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ANEMIAS DURING PREGNANCY By Osama M. Warda, MD Professor of OB/GYN Mansoura University

Anemias during pregnancy warda [compatibility mode]

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Page 1: Anemias during pregnancy warda [compatibility mode]

ANEMIAS DURING PREGNANCY

By

Osama M. Warda, MD

Professor of OB/GYN

Mansoura University

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Definition :

Anemia means reduction below normal of either red blood cells (RBCs) count, or hemoglobin percentage, or both leading to deficient oxygen carrying capacity of the blood.

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During pregnancy; anemia is diagnosed if:RBCs count is less than 3.5 millions/ cc OR,Hemoglobin content less than 10 gm/dL , orHematocrit value is less than 30 %

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Incidence:

Anemia is the most common medical complication in pregnancy. More than 50% of all pregnant women suffer anemia during pregnancy.

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Iron deficiency anemia is the most common type, followed by blood loss due to obstetric cause, and anemia due to chronic infection.

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Anemia Pregnancy Inter-relations:A]. Effect of anemia on pregnancy ( mother &

fetus):

1- Increased incidence of PreeclampsiaPreeclampsia--eclampsiaeclampsia, especially with iron deficiency anemia and megaloblastic anemia (mechanism unknown). PE

PA

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megaloblastic anemia (mechanism unknown).

abruptionplacentalIncreased incidence of -2(accidental hemorrhage).

neonatal, and stillbirthsIncreased incidence of -3.deaths

.laborpretermIncreased incidence of -4

PASBNDPL

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Anemia Pregnancy Inter-relations:

B]. Effect of pregnancy anemia:

Aggravation of the pre-existing anemia occurs due to;

1- Expansion of the maternal plasma volume

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1- Expansion of the maternal plasma volume (hyderemia; hemodilution) .

2- Fetal utilization of substrates necessary for building up of hemoglobin molecules.

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Classification (types) of Anemia:According to RBCs indices*; anemia

may be classified into 3 main types:

:CYTIC ANEMIA-CROICHROMIC M-O[I]. HYP

1-Iron deficiency anemia (most common).

CIMCH

MCHCMCV

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1-Iron deficiency anemia (most common).

2-Thalassemia (certain types).

3-Chronic infections (eg . glomerulonephritis, pyelonephritis).

4-Chronic lead poisoning.

5- Vitamin B6 deficiency.

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Classification (types) of Anemia:

CYTIC ANEMIA:-CROACHROMIC M-RE[II].HYP

1-Folic acid deficiency anemia.

2-Vitamin B12 deficiency anemia.

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[III]. NORMOCHROMIC NORMOCYTIC ANEMIA:

1-Hemorrhagic anemia (due to blood loss).

2-Hemolytic anemias; (a) thalassemia, (b) sickle cell anemia, (c) spherocytosis, and (d) G6PD deficiency

3- Hypoplastic (aplastic) anemia.

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IRON DEFICIENCY ANEMIA

It is the most common type of anemia encountered during pregnancy.

Physiological Role of iron during pregnancy:

1-Enters the haem portion of hemoglobin & myohemoglobin.

2-Respiratory enzymes as cytochrome oxidase enzyme.

3-Placental enzymes

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3-Placental enzymes

4-Fetal hematopoeisis.

Metabolism of iron during pregnancy:

� Normal diet supplies 14 mg of iron per day.

� Only 1-2 mg ( 10-15% of dietary iron) is absorbed depending on iron stores (ferritin-apoferritin system).

� Iron is absorbed in the 'ferrous' state in the presence of vitamin C. Phytate & phosphate decrease iron absorption .

� Haem iron of red meat & liver is rapidly absorbed than vegetable iron in apple, spinache, and other vegetables.

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IRON DEFICIENCY ANEMIA cont.;

� Daily requirement of iron during pregnancy:

The daily requirement of the pregnant lady is 4 mg of elemental iron .

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� The TOTAL requirement during pregnancy is about 1000 mg of elemental iron calculated by the Council on Food and Nutrition as follows;

To compensate for external iron loss…….= 170 mg

To allow expansion of maternal cell……..= 450 mg

Iron for fetal needs ………………………. =270 mg

Iron in placenta and cord ………………….= 90 mg

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IRON DEFICIENCY ANEMIA cont.;Etiology of iron deficiency anemia during pregnancy:

[A]. Decrease intake of iron:

1- Poor diet.

2- Extensive morning sickness

[B]. Diminished absorption of iron:

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[B]. Diminished absorption of iron:

1- Lack of vitamin C and proteins.

2- Increased phosphate & phytates.

3- Decreased gastric acidity & use of antacids.

4- Malabsorption syndromes, and parasitic infestations.

[C]. Increased iron demands during pregnancy:

1- Multiple pregnancy

2- Hemorrhage with pregnancy

3- Multi-parity

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IRON DEFICIENCY ANEMIA cont.;

Clinical Picture:S y m p t o m s:

General; pallor, tiredness, easy fatigability.Cardiovascular; Dyspnea on exertion, palpitation, anginal pains, swelling of lower limbs,

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palpitation, anginal pains, swelling of lower limbs, and other low cardiac output symptoms.Gastrointestinal; anorexia, nausea, vomiting, constipation.Nervous System; lack of concentration, numbness and tingling, headaches.

S i g n s:General; pallor, glassy tongue, brittle nailsCardiovascular; haemic murmurs over the procordium on auscultation.

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IRON DEFICIENCY ANEMIA cont.;Investigations:

Peripheral blood ( complete blood count; CBC):[A].

Findings suggestive of diagnosis include;1-Microcytic hypochromic anemia ( ie, reduced indices)2- Anisocytosis (ie, different sizes of RBCs)3- Piklocytosis (ie, different shapes of RBCs)4-Normal reticulocytic count (ie, 0.5%- 1.5%)

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4-Normal reticulocytic count (ie, 0.5%- 1.5%)5-Normal platelet & leukocyte counts

:Blood chemistry[B].

Findings suggestive of diagnosis include;1- Decreased serum iron less than 60µg/ dl (normal 90-150 µg / dl)

2-Decreased serum ferritin 3-Increased serum iron binding capacity more than 300 µg%

4-Increased free erythrocyte proto-porphyrin.

Bone marrow biopsy (seldom done):[C].

There is absence of stainable iron in bone marrow.

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Treatment of iron deficiency anemia during pregnancy:

. Prophylactic Treatment:[A]

Every pregnant woman needs iron supplementation during pregnancy; the earlier the better ( but NOT earlier than 14 weeks pregnancy)

Oral iron supplementation to ALL pregnant ladies after

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Oral iron supplementation to ALL pregnant ladies after 16 weeks gestation as 60-80 mg of elemental iron per day; can be obtained from;

200 mg ferrous fumarate, OR

300 mg ferrous sulfate, OR

550 mg ferrous gluconate, PLUS

1000mg vitamin C ( to help absorption) and 2mg folic acid (to help hematopoeisis).

Antacids lower the absorption of iron from the stomach.

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Treatment of iron deficiency anemia during pregnancy:

Active Treatment:[B].Active management of anemia depends on 2 main factors; severity of anemia, and the duration of pregnancy.

weeks:30 -16Pregnancy ). 1(

Oral ferrous sulfate 300mg t.d.s----------- HB ↑ 1gm/monthweeks with severe anemia:30 Pregnancy after ).2(

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weeks with severe anemia:30 Pregnancy after ).2(parenteral iron therapy Intramuscular ( 250mg every other day) orIntravenous infusion in a crystalloid solution (eg ferrous succinate; ferosac®: 1amp in 100 ml of dextrose 5% every other day).

weeks pregnancy and hemoglobin less 35 Anemia after ). 3(gm/dl:6 than

These patients should receive transfusion of packed RBCs (or whole blood if packed RBCs are not available).

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Folic Acid Deficiency Anemia

Folic acid deficiency causes megaloblastic anemiawhich accounts for 3% of cases of anemia during pregnancy.

Folic acid metabolism during pregnancy:

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Folic acid metabolism during pregnancy:

� Pregnancy is associated with negative folate balance.

� Folic acid & iron play a central role in nutrition & DNA synthesis

� Folate requirements are increased during pregnancy for the growing fetus, placenta, maternal RBCs, and uterine hypertrophy. Folate requirement in normal pregnant lady are 200-300 µg/ day.

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Folic Acid Deficiency Anemia; cont.;

Etiology of folic acid deficiency anemia:

1-The causes are the same as those of iron deficiency anemia , plus the following:

2- Anti-convulsion therapy (eg, pregnant

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2- Anti-convulsion therapy (eg, pregnant epileptic patient on epanutin®).

3- Antipyretic therapy.

4- Chronic hemolysis.

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Folic Acid Deficiency Anemia; cont.;

Investigations for folate deficiency:Peripheral blood:[A].

The findings suggestive of diagnosis:1-Macrocytic hyperchromic anemia (MCV increased)2-Hypersegmented polymorphs

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2-Hypersegmented polymorphs3-Elevated reticulocytic count.

[B]. Blood chemistry:1-Decreased plasma folate level; the finding of a serum folate <2ng/ ml [+] red cell folate <150 ng /ml, is diagnostic.2-Increased urinary form-imino-glutamic acid (FIGLU); this finding differentiate folate deficiency from vitamin B12 deficiency.

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Folic Acid Deficiency Anemia; cont.;

Hazards of folate deficiency during pregnancy

Increased incidence of the following;

1- Neural tube defects (NTDs)

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2- Cleft lip and cleft palate.

3- Intrauterine growth restriction (IUGR)

4-Megaloblastic anemia.

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Folic Acid Deficiency Anemia; cont.;

Treatment of folic acid deficiency anemia during preg.:

Prophylactic measures:[A].

Vitamin supplements containing 400 µg of folic acid orally per day are now recommended for all

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orally per day are now recommended for all women of childbearing age and during pregnancy.

Active treatment:[B].

� Mild cases; Oral 5 mg folic acid per day

� Severely anemic patients near delivery; Exchange transfusion with packed RBCs followed by parenteral folic acid therapy (1mg/IM/day/ for 1 week).

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Vitamin B 12 Deficiency Anemia

Etiology :

� It is also called pernicious anemia. It is a very rare type of megaloblastic anemia during pregnancy, since the daily

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during pregnancy, since the daily requirement of vitamin B12 during pregnancy is only 1 µg.

� Vitamin B12 deficiency is usually due to intrinsic factor deficiency in the stomach; (sub-acute combined degeneration).

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Vitamin B 12 Deficiency Anemia, cont

Diagnosis:

bloodPeripheral

will show the same picture as folate deficiency anemia except for normal

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deficiency anemia except for normal reticulocytic count ( elevated in folate deficiency).

;Blood chemistry

there is low plasma vitamin B12 level . A serum level less than100 pg/ ml is diagnostic of vitamin B12 deficiency.

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Vitamin B 12 Deficiency Anemia, cont

Treatment:

: Mild cases

250 µg of parenteral (IM) cyancobolamin/ month. Oral preparations of vitamin B12 have unreliable absorption

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Oral preparations of vitamin B12 have unreliable absorption

properties & are inadequate for long term therapy.

; Severely anemic patients near deliveryExchange transfusion with packed RBCs followed by parenteral cyancobolamine ( 100 µg /IM/day/

for 1 week ).

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Normochromic Normocytic Anemias

Hemorrhagic Anemia:[A].

It is the 2nd common type of anemia during pregnancy following iron deficiency anemia.

Causes: acute or chronic blood loss in

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Causes: acute or chronic blood loss in obstetrics;

Early: abortion, ectopic pregnancy, vesicular mole.

Late: placenta previa, accidental hemorrhage.

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Normochromic Normocytic Anemias

:AnemiasHemolytic[ B]. According to results of Coomb's test, they are classified into:

( ie, positive Coomb's test): this may ;A)Immune hemolytic anemiasbe isoimmune OR autoimmune;

B).Non-immune hemolytic anemias; (ie, negative Coomb's test):

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B).Non-immune hemolytic anemias; (ie, negative Coomb's test):this may be due to:

(a). Intracorpuscular causes ( ie, chronic hemolytic anemia);- Hemoglobinopathies as thalassemias, sickle cell anemia-Cell wall defect as spherocytosis, elliptocytosis- Enzymatic defect as G-6- PD deficiency, pyruvate kinase

deficiency. (b). Extra-corpuscular causes as;

Preeclampsia-eclampsiaProsthetic heart valvesMalarial infection.

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Normochromic Normocytic Anemias

Clinical features of chronic hemolytic anemias:

1-Pallor with jaundice.

2- Mongoloid facies.

3-Splenomegaly and hepatomegaly.

4- (±) Hemic murmur over the heart.

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4- (±) Hemic murmur over the heart.

Laboratory features of chronic hemolytic anemias:

1-Normochromic Normocytic (except with thalassemia it is microcytic hypochromic).

2-Reticulocytosis (reticulocyte count > 2%)

serum bilirubin.indirectElevated -3

4-Shortened life span of RBCs (by isotope chromium 51).

5-Erythroid hyperplasia of the bone marrow.

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Management of pregnancies

complicated by Thalassemias:

with the aid of a hematologist)[A]. MATERNAL: (

--No specific therapy for β-thalassemia minor during pregnancy; as the outcome for both the mother & the fetus is satisfactory.

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mother & the fetus is satisfactory.

1- Blood transfusion is rarely indicated except for hemorrhage.

2- Prophylactic folic acid supplementation is strongly indicated.

3- Proper treatment of infections.

4- Iron chelating agents (eg, Desferal®).

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Management of pregnancies

complicated by thalassemias:

:[B]. FETALThe fetal management in patients with thalassemia or sickle cell disease is concerned with the fetal risk of acquiring the disease.Management consists of:1- Genetic counseling.to determine the fetal risks by Mendelian laws.

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1- Genetic counseling.to determine the fetal risks by Mendelian laws.2- Antenatal diagnosis of thalassemias & sickle cell anemia may be achieve via one of the following techniques:

(a) Chorionic villus sampling, (b) Early amniocentesis between 7-11 weeks gestation, (c) Cordocentesis through percutaneous umbilical blood sampling

(PCUBS), or(d) Fetoscopy with cord blood sampling.

3. Termination of pregnancy is considered if the fetus is severely affected.4. Reassurance of pregnancies if the fetus is not affected or mildly affected.

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Management of pregnancies complicated by the SS -disease:

:[A]. PREGNANCY1- Very close observation (frequent antenatal visits, or hospital). 2- Folic acid supplementation ( 2mg orally / day). 3- .

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3- Eradication of asymptomatic bacteruria & pyelonephritis. 4- Guard against pneumonia and heart failure.5- Prophylactic blood transfusion.6- Management of crisis by:

Oxygenation Hydration (iv fluid therapy)Blood transfusion Heparinization for the thrombotic cricis

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Management of pregnancies complicated by the SS -disease:

[B]. DELIVERY: (managed as cardiac patients)1-Comfortable but not sedated.2-Blood ready for transfusion.3-Vaginal delivery is preferred, and CS for obstetrical

indication only.4-Regional anesthesia is better than general anesthesia.

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4-Regional anesthesia is better than general anesthesia.5-Replace blood loss adequately.

[C]. CONTRACEPTION:� Tubal sterilization is indicated even if the parity is very low.� Combined oral contraceptives are contraindicated

(↑thrombosis)

� Intrauterine contraceptive device (IUCD) is contraindicated(↑infection).

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