Chapter Ill Material & Methods

I I t

L .. ---·-- . -- - - .

II

•

MATERIAL AND METHODS

The present study was carried out in B.J. Medical College, Civil Hospital,

Ahmedabad from 2004 to October 2009. It was a cross sectional study and study

subjects comprised of outdoor and indoor patients of Civil Hospital and their

relatives. Adolescent subjects comprised of first year nursing students of Civil

Hospital and school girls from high school of east Ahmedabad. Patients and their

relatives were from the State of Gujarat and neighbouring states.

Subjects were randomly selected by stratified sampling method for the study.

Females from 10 to 49 years of age were divided in to three groups (strata) i.e.

adolescents, adult pregnant and adult nonpregnant females and samples were

randomly drawn from each strata. To study the prevalence and other

epidemiological features of nutritional anemia in study population females already

diagnosed of having anemia from outside were excluded. Subjects were from all

communities and from all socio-economic classes, from rural or urban areas,

having different levels of education and either students, housewives or working

females.

Exclusion Criteria :

1. Females below 10 years and above 49 years of age.

2. Females having other medical disease like Hypertension, Diabetes,

Thyroid disorders or any major systemic disease.

3. Females on any regular drug therapy .

33

4. In pregnant patients, patients having any high risk factor like multiple

pregnancy, diagnosed fetal anomaly, grand multipara, uterine

anomaly, bad obstetric history, liquor abnormality were also excluded.

5. Patients having gynec pathologies like fibroid, adenomyosis, ovarian

tumours were also excluded.

6. Adolescent pregnant patients were excluded as adolescent period

and pregnancy both increase the chances of anemia.

Total 800 females were screened out of which 550 were adult females and 250

were adolescent girls. Among 550 adult females 350 were pregnant and 200 were

non pregnant. The anemia was diagnosed by clinical examination and confirmed

by hemoglobin estimation. Hb estimation was done by Cyanmeth-hemoglobin

method and WHO criteria were used to diagnose anemia as follows:-

For Adult females and adolescents< 12.0 gm%.

For Adult pregnant females< 11.0 gm%.

Total 497 were diagnosed to suffer from anemia (62.12%). 52 subjects having

other types of anemia like hemolytic anemia (malaria, drug induced), hemorrhagic

anemia (hookworm, piles, menorrhagia) hemolytic anemia (Thalassemia, Sickle

Cell Disease) and aplastic anemia were further excluded as the aim was to study

the health hazards of nutritional anemia only. These other types of anemias were

diagnosed by history, clinical examination and necessary investigations.

34

Total 445 females were having nutritional anemia i.e. 55.62% prevalence in the

screened population. Nutritional cause was investigated by doing laboratory

investigations in the form of serum iron, total iron binding capacity (TIBC) and

peripheral smear in all cases. Serum ferritin was done in all adolescent girls and

75% of adult females. Serum folic acid and serum vitamin 812 estimations were

done only in subjects having either severe anemias (Hb<7.0g%), or clinical

features of these vitamins deficiencies or detection of megaloblasts on peripheral

smear examination. Limitation in carrying out these special investigations in all the

subjects was due to financial constraints as these investigations were not done in

Civil Hospital Pathology Department and getting them done in private laboratory

involved high cost.

Total 445 subjects of nutritional anemia were studied in the present study by

dividing them in 2 groups. Group-1 of adolescent girls and Group-11 of adult

females.

To compare the health related hazards control subjects were taken in respective

groups. They were also taken randomly by stratified sampling method. Controls

were nonanemic females and in the same age group, residence, community and

similar socio-economic status. They were selected from patients' relatives in adult

females and colleague students in adolescent girls. The relatives in adult group

were daughter, sister, sister in law, daughter in law, mother and mother in law who

usually accompany the patients. Controls were taken of the same number in each

group for proper comparison.

35

Group-1: Adolescent girls between the age 10 to 19 years.

Group-1 A : Anemic subjects

Group-1 B : Controls

Group-11: Adult Females between the Age> 19 to 49 years

Group-1:

Group-11:

Group II A : Anemic subjects

II A-1 Pregnant patients

II A-2 Non pregnant females

Group II B: Controls

II B-1 Pregnant patients

II B-2 Non pregnant females

Total 216 adolescent girls were studied in this group. 108 in each

sub group I A and I B.

Total 674 adult females were studied in this group, 337 in each

sub group II A and group II B. Among 337 of each sub group II-A

and 11-B 228 were pregnant and 109 were non pregnant adult

females.

The study subjects were evaluated as per predesigned performa. To study the

spectrum of nutritional anemia in 445 anemic subjects epidemiological features

were analysed first. The detailed history was taken including age, religion,

education, residence and economic status of the family. Modified Prasad

Criteria 154 was used for classifying them in different economical class. They were

36

divided in three classes from six of Prasad classification. Their number in the

family i.e. birth order was noted. In adult females, whether they were housewives

or working was noted. Each anemic subject was assessed for the awareness

regarding anemia and dietary rich sources of iron and folic acid. Whether they

were knowing their Hb or not was also checked. Detailed dietary history was taken

keeping in mind about quality, quantity and iron and folic acid components of diet.

Menstrual history was taken in detail. Regularity of the periods, number of days of

bleeding and amount of flow was asked.- As mentioned earlier cases of

menorrhagia were excluded as menorrhagia and anemia has cause and effect

relationship, making it difficult to establish which occurred first in a particular

female.

In married females the obstetric history was taken in detail. Gravidity, parity, full

term delivery, preterm deliveries and abortions were noted. History of any obstetric

complications in past pregnancies were elicited.

Further study was carried out for assessment of health related hazards in these

nutritional anemic subjects and compared with appropriate controls. Adolescent

subjects were analyzed separately from the adult subjects by dividing them into

Gr.l and Gr.ll for health related hazards.

General health was assessed by weight and height examination and body mass

index (BMI) was calculated by the standard formula i.e. BMI = Kg/M2 • Symptoms

of anemia like weakness, tiredness, dizziness, headache, irritability was checked

by asking leading questions.

37

History of infections like respiratory infection, urinary tract infections, genital tract

infections and gastrointestinal tract infections in last five years was elicited in

details by asking subjects themselves or their relatives and checked by available

records. History of repeated infections was also checked.

Physical capacity was assessed by asking their efficiency to do work at home or at

the job place. Diminished efficiency or any limitation to do routine work was

recorded. For housewives doing three of five home tasks i.e. cooking, sweeping

the house, washing cloths, cleaning utensils and miscellaneous household work

without fatigue was considered normal. For working women their job + one

household task and for adolescent girls study + one household task without any

limitation was considered normal.

Cognitive performance by IQ testing was assessed by asking them to answer a

standard set of 40 questions taken from the I Q tests questions prepared by

vocational guidance institute Government of Gujarat.155 Four points was given for

each correct answer and total score was calculated. Score below 40 was

considered as poor IQ, 40 to 80 as average IQ, 80 to 120 as good IQ and 120 to

160 as genius. Time required to complete the 40 questions was also noted in full

minutes. For illiterate patients mathematical questions were not asked. English

translation of complete document with 50 questions (40 were used) is given at the

end in Annexure I.

In pregnant subjects obstetric outcome was assessed by following them till delivery

and six weeks postpartum. Maternal morbidity was assessed. Puerperal pyrexia

including puerperal sepsis, post partum hemorrhage (PPH), congestive cardiac

38

failure (CCF), wound complications and failure of lactation were recorded in

anemic as well as control subjects.

Perinatal morbidity was recorded. Cases of birth asphyxia, prematurity, intra

uterine growth restriction, neonatal sepsis and other neonatal complications were

recorded. Perinatal deaths in the form of still births and neonatal deaths were

analysed for cause of death in both anemic as well as control subjects.

Treatment: Counselling was done to all445 anemic subjects regarding dietary rich

sources of iron and folic acid and to change their dietary habits. As iron deficiency

was found on investigation, in all anemic subjects iron was administered to all .

Patients with mild anemia were treated by oral iron ferrous sulphate 200 mg tablets

which contains 60 mg elemental iron. Patients with moderate anemia were treated

by either oral iron or parenteral iron followed by oral iron particularly when Hb was

less than 8 gm%. Iron sucrose intravenously was used for parenteral iron therapy.

Iron sucrose is safe and gives rapid rise of Hb. Its dose is considered by the

formula. Weight (in kg) x Hb deficit in gram (12 actual Hb) x 0.24 + 500 mg. 100mg

IN was given on alternate days diluted in 100 ml of normal saline.

Folic acid 0.5 mg was given to all pregnant patients and 5 mg to subjects with folic

acid deficiency.

Anemic subjects with severe anemia were directly treated with blood transfusion in

the form of packed cell volume, number of PCVs were determined by her original

Hb and aim was to raise the Hb to at least 9 gm%. One unit of packed cells raises

the Hb by approximately 1 to 1.5 gm%.

39

----------------------------------------

Statistical analysis was done in terms of percentage, Chi square test, Z test and P

values were obtained for statistical significance using Epi Info software as

mentioned in results under individual table.

PROFORMA : NUTRITIONAL ANEMIA

Date: OPD/Indo. No. Residence: Rural/Urban Sr. No.

Name: Age: Education: UE/Pri/Sec/Grad/PG

Religion : Hindu I Mus I Christ /Others Occupation : S.E.Status :

M/H : Menarche : PaMP : LMP :

No. of pads H/o. clots

OIH:

Contraception :

Gen.Health : Weight : Height: BMI:

Diet : VegiNon Veg. Calories : Adequate I nonadequate

Iron rich foods: Cereals I pulses I fruits I green vegetables I Jaggery

Non-veg.

F .A. Rich : Green vegetables

Food habits :

Awareness : About anemia & Diet : Yes I No

About their Hb: Yes I No

Her No. in the family :

40

Work efficiency : Student : Normal/ Reduced

At work place : Normal/ Reduced

At home : Normal/ Reduced

Complaints: Fatigue ,Weakness,Dizziness,Breathlessness,Headache,Others

H/0 Infections : UTI : one episode /more Genital tract : one episode /more

IQ score:

Investigations:

RTI : one episode /more

Time required :

Hb: Se. Iron :

MCV:

G I tract : one episode /more

TIBC:

MCH: MCHC: Peri.Smear : MP

Se.Ferritin Se.Folate Se. Vitamin 812

Others Stool Urine

Other anemias : Malaria I worms I piles I Congenitai/Hemolytical

Obst. Outcome : Mother : Sepsis I CCF I Wound gap I death I others

New Born : M/F Wt.

Treatment : Oral iron I iron + Folic Acid

Parenteral iron I Parent iron + Oral

PCV.

Follow up:

Remarks:

Maturity Complication:

41

Chapter IV Results

,

RESULTS

Table No.1 :Age distribution of anemic subjects

Age in years No. of subjects No. of subjects

Total(%) Adolescent Adult

10-19 108 - 108 (24.3)

20-29 - 168 168 (37.7)

30-39 - 98 98 (22.0)

40-49 - 71 71 (16.0)

108 337 445 (100.0)

More than 1/3rd of anemic subjects were in third decade (37.7 %) , more or less

1/4th of subjects (24.3%) were in the second decade, while less than 1/4th (22.0%)

were in the 4th decade. Mean age of study subjects was 27.19 ± 9.5. At 95 %

Confidence limit Confidence interval was 8.57 to 45.81.

Table No. 2 : Educational Status

Education Adolescents ( % ) Adults (%) Total (%)

Graduate or post - 62 (18.4) 62 (13.9)

graduate

High school 73 (67.6) 79 (23.4)

152 (34.2) HSC/SSC passed

Primary School 35 (32.4) 126 (37.4) 161 (36.2)

Illiterate - 70 (20.8) 70 (15.7)

Total 108 (100.0) 337 (100.0) 445 (100.0)

The education in adolescents was HSC or SSC in 2/3rd of subjects (67.6 %), while

more or less 1/3rd (32.4%) were studying in schools. One third of adult subjects

42

(37.4%) were having primary school education, while less than 1/41h (23.4%) were

having HSC/SSC level education. Anemia was prevalent in all, adolescent and

adult anemic subjects irrespective of their education.

Table No. 3 : Residence

Residence Adolescents(%) Adults(%) Total(%)

Rural 22 (20.4) 137 (40.6) 159 (35.7)

Urban 86 (79.6) 200 (59.4) 286 (64.7)

Total 108 (100.0) 337 (100.0) 445 (100.0)

Nearly 2/3rd (64.7%) of anemic subjects coming to civil Hospital were from urban

areas while more than 1/3rd (35.7%) of anemic subjects were from rural areas. As

per census of India 2001, 72.2 % of population resides in rural area while 27.8 %

stay in urban areas. Rural:urban ratio in present study is different from the last

census of 2001, because the Civil Hospital is a tertiary care teaching hospital in

the state of Gujarat and the patients are mainly from urban areas (>80%). In the

school and nursing students overall 15 % were from rural areas.

Table No. 4 : Different Communities

Community Adolescents(%) Adults(%) Total(%)

Hindu 90 (83.3) 252 (74.8) 342 (76.8)

Muslim 12 (11.1) 68 (20.2) 80 (18.0)

Christian 6 (5.6) 17 (5.0) 23 (5.2)

Total 108 (100.0) 337 (100.0) 445 (100.0)

43

More than 3/41h (76.8%) number of anemic subjects were hindus, while less than

1/41h (18.0%) were muslims. It is matching with the distribution of various

communities as per census of 2001. As per census of India 2001, 80.5 % are

hindus, 13.5 % are muslims and 2.3 % are christians. Thus religion had no

influence on prevalence of nutritional anemia. All subjects other than Muslim and

Christian like Sindhis and Sikhs were included in Hindus.

Table No. 5 : Diet

Diet Adolescents (%) Adults(%) Total(%)

Vegetarian 82 (75.9) 231 ( 68.5) 313 (70.3)

Non-vegetarian 26( 24.1) 106 (31.5) 132 (29.7)

Total 108 (100.0) 337 (100.0) 445 (100.0)

More than 2/3rd (70.3%) anemic subjects were purely vegetarian. Only less than

1/3rd (29.7%) were taking mixed diet, hence labeled as non-vegetarians. On

detailed analysis it was found that all these 132 (26+1 06) non-vegetarian subjects

were consuming less than one non-vegetarian meal per week.

According to the 2006 survey 156 40 % of population in India is vegetarian. In this

study vegetarians were more than non-vegetarians not matching with the national

data at large because the state of Gujarat is having more vegetarians than other

states.

44

-- ---------------------

Table No. 6 : Occupation

Occupation Adolescents (%) Adults(%) Total(%)

Student 108 (100.0) 108 (24.3)

Housewife - 157 (46.6) 157 (35.3)

Working

Office type table work - 84 (24.9) 84 (18.9)

Labourer - 96 (28.5) 96 (21.5)

Total 108 (100.0) 337 (100.0) 445 (1 00.0)

Nutritional anemia was prevalent in all types of females - students, working and

housewives. More than 40 % of anemic subjects were working in present study,

while female working population at large is 25.6 % as per census 2001. As the

anemic subjects were more from urban areas where most of the females also

work, the working anemic subjects were more than the census 2001.

Table No. 7 : Economic status of 445 anemic subjects

Modified Prasad Classification

Socia Economic Class Adolescents(%) Adults (%) Total(%)

Upper 16 ( 14.8) 42 (12.5) 58 (13.0)

Middle 28 (25.9) 80 (23.7) 108 (24.3)

Lower 64 (59.3) 215 (63.8) 279 (62.7)

Total 108 (100.0) 337 445 (1 00.0)

Only three main categories were taken from original six classes of Prasad

classification. Most of the anemic subjects were from lower socioeconomic (SE)

group (62.7%), while approximately 1/4th (24.3%) were from middle SE group. It

shows that economic status of subjects play a role in nutritional anemias. Lower

45

SE group included 154 (34.6%) below poverty line (BPL) and 125 (28.1%) poor

economic class subjects. As per Planning Commission of India population below

poverty line reported is 27% in 2005.

Table No. 8 : Birth Order

Birth order Adolescents(%) Adults(%) Total(%) 1st 33 (30.6) 63 (18.7) 96 (21.6)

2nd 31 (28.7) 75 (22.3) 106 (23.8)

3rd 24 (22.2) 97 (28.8) 121 (27.2)

41h or more 20 (18.5) 102 (30.3) 122 (27.4)

Total 108 (100.0) 337 (100.0) 445 (1 00.0)

Birth order is not showing any important correlation with anemic subjects in the

present study. Nutritional anemia was prevalent whether the study subject was a

first child in the family or second, third, fourth or more in number in her family.

Fig. No. 9 : Knowledge regarding anemia, diet and their Hb

9 A : Knowledge about anemia and dietary sources of iron & folic acid

Category Adolescents ( % ) Adults (%) Total (%)

Not knowing 79 (73.1) 206 (61.1) 285 (64.0)

Knowing 29 (26.9) 131 (38.9) 160 (36.0)

Total 108 (100.0) 337 (100.0) 445 (100.0)

Chi Square 5.14 p = 0.023

Overall 64% females (285 out of total 445) had no knowledge about anemia and

dietary rich sources of iron. This was statistically significant. (P < 0.05). It was more

in adolescents (73.1 %) than in adult subjects (61.1 %).

46

9 8 : Knowledge about their Hb

Category Adolescents ( % ) Adults (%) Total (%)

No 92 (85.2) 229 (68.0) 321 (72.1)

Yes 16 (14.2) 108 (32.0) 124 (27.9)

Total 108 (100.0) 337 (1 00.0) 445 (1 00.0)

Chi Square 12.08 P = 0.0005

Overall 72.1% females ( 321 out of total 445) were not knowing their own Hb. This

was statistically significant. (P < 0.05). It was quite more in adolescent group

(85.2%) as compared to adults (68.0%). This may be due to adult females might

have undergone Hb estimation during their past pregnancies.

Table No. 10 : Degrees of anemia

Degree Hb level Adolescents.(%) Adults (%) Total (%)

Mild Nonpregnant 10 to <12.0 g% 57 (52.8) 67 (19.9) 245 (55.0)

Pregnant 10 to <11.0 g% - 121(35.9) -

Moderate 7 to <10 g% 47 (43.5) 113 (33.5) 160 (36.0)

Severe < 7.0 g% 4 (3.7) 36 (10.7) 40 (9.0)

Total 108 (100.0) 337 (1 00.0) 445 (100.0)

Mild anemia is found in more than 50% cases in both the groups. While severe

anemia is more common in adult group. Most of these (33 out of 36) were

pregnant subjects. In moderate anemia group there were 36 patients (out of total

160 subjects) were having Hb less than 8.0 Gm%.

47

Other Investigations :

Fig. No. 1 : Serum iron values

Se.iron ug/dl

80 .--·-----------. --------------------------------- -----l 70 •• !

6o 1~~~ • I so"~$·~~~!"~*'~ ! 40 ~~. ~~~ ~~~. ~ fi~" ' 30 ~·Vi • .. l~,. ~ ' ~· .... . . . I r"". • • ~-· •• • • •••

+ •• • • • • ··~· • + I 20 • • • • • i

1o I • l

0+---------------~----------------,-------~ 0 100 200 300 400 500

• no. of subjects

Fig.No.1 shows scatter diagram of serum iron values in 445 anemic subjects

Serum iron was ranging from 24 to 68 ).lg/dl in adolescents and 20 to 54 ).lg/dl in

adult subjects (normal range 60-150 ).lg/dl).

TIBC was ranging from 360 to 500 ).lg/dl in adolescents and 380 to 590 ).lg/dl in

adults subjects (normal range 250 to 350 ).lQ/dl). Peripheral smear was done in all

cases and showed microcytic hypochromic ( iron deficiency ) or dimorphic anemia

( iron +folic acid deficiency) picture.

48

Se.Ferritin ug/1

90 80 70 60 50 40 30 #. 20 •••

10

•

!~ Fig. No. 2 : Serum Ferritin values

• •

•

0 ~--~----~----~---,-----,--------~~--~ 0 50 100 150 200 250 300 350 400

• No. of subjects

Fig. No.2 shows scatter diagram of serum ferritin values. It was done in total 362

subjects - all adolescents and 75% of adult subjects. In both the groups it was

ranging from 8 to 80 ug/1. In most of them it was less than 30 ug/1.

Serum Folate and serum Vitamin 812 was done in 71 subjects who were having

either severe anemia or clinical features of their deficiencies or megaloblasts

detected on peripheral smear. 31 anemic subjects were having low folate levels

ranging from 1.2 to 3.0 ng/ml, while Vitamin B 12 levels were in normal range

except three cases they were marginally low ( 190-200 pg/ml ).

Table No. 11 : Symptoms

Leading questions regarding symptoms of anemia like tiredness, weakness,

dizziness, feeling of chromic ill heath were asked to the anemic subjects as well as

controls.

49

------------------ --------

11 A : Adolescents

Symptoms Gr I A. Anemic Gr I B. Controls (%) subjects (%)

Present 64 (59.3) 24 (22.2)

Absent 44 (40.7) 84 (77.8)

Total 108 (100.0) 108 (100.0)

Chi Square 30.6 P = 0.0000

11 B: Adults

Symptoms Gr II A. Anemic Gr II B. Controls (%) subjects(%)

Present 266 (78.9) 114 (33.8)

Absent 71(21.1) 223 (66.2)

Total 337 (100.0) 337 (100.0)

Chi Square 59.1 P = 0.0000

The symptoms were present in 330 (7 4.1%) of anemic subjects (64 adolescents +

266 adults) while they were present in only 138 (31. 0%) of controls. (24

adolescents +114 adults) . Comparing both the groups of anemic subjects with

appropriate controls this was statistically significant (P<0.05) .

Table No. 12 : Weight

12 A : Adolescents

Weight in Kgs. Gr I A. Anemic subjects ( % ) Gr I B. Controls ( % )

~40 37 (34.3) 35 (32.4)

41-50 64 (59.3) 63 (58.3)

51-60 6 (5.5) 8 (7.4)

61-70 1 (0.9) 2 (1.9)

Total 108(100.0) 108(100.0)

Chi Square o.68 P = 0.8

50

------------ ----------

12 B: Adults

Weight in Kgs. Gr II A. Anemic subjects ( % ) Gr II B. Controls ( % )

~40 39 (11.6) 38 (11.3)

41-50 44 (13.1) 44 (13.1)

51-60 124 (36.8) 120 (35.6)

61-70 82 (24.3)) 86 (25.5)

> 70 48 (14.2) 49 (14.5)

Total 337 ( 100.0) 337 ( 100.0)

Chi Square 0.18 P = 0.9

There was no significant difference (P > 0.05) in anemic subjects and controls as

far as the weight was concerned in both adolescents as well as adult groups. In

Gr I of adolescent subjects there was no student of > 70 Kg weight.

Table No. 13 : Body Mass Index (BMI)

13 A : Adolescents

Body Mass Index ( BMI) Gr I A. Anemic subjects ( % ) Gr I B. Controls ( % )

< 18.50 Kg/M2 31 (28.7) 26(24.1)

18.5 - 24.99 Kg/M2 59 (54.6) 61 (56.5)

~ 25.00 Kg/M2 18 (16.7) 21 (19.4)

Total 108 ( 100.0) 108 ( 100.0)

Chi Square 0. 7 p =0.7

13 B: Adults

Body Mass Index ( BMI) Gr II A. Anemic subjects ( % ) Gr II B. Controls ( % )

< 18.50 Kg/M2 40 (11.9) 38(11.3)

18.5 - 24.99 Kg/M2 151 (44.8) 143 (42.4)

~ 25.00 Kg/M2 146 (43.3) 156 (46.3)

Total 337 ( 100.0) 337( 100.0)

Chi Square 0.6 P = 0.7

51

There was no significant difference (P > 0.05) in anemic subjects and controls as

far as BMI was concerned in both the groups. BMI categories were made

according to WH0157. BMI of< 18.50 Kg/M2 are considered underweight, 18.50 to

24.99 Kg/M2 are considered normal and .:::_ 25.00 Kg/M2 are considered overweight.

This means that anemia can still be there even if other nutrition is not affected.

Table No. 14: Physical Performance

14 A: Adolescents

Gr I A. Anemic subjects ( % ) Gr I B. Controls ( % )

Reduced Capacity 70 ( 64.8) 44(40.7)

Normal 38 ( 35.2) 64 ( 59.3)

Total 108 ( 100.0) 108(100.0)

Chi Square = 12.56 p = 0.0004

14 B: Adults

Gr II A. Anemic subjects ( % ) Gr II B. Controls (%)

Reduced capacity 217 (64.4) 174(51.6)

Normal 120 (35.6 ) 163(48.4)

Total 337( 100.0) 337 ( 100.0)

Chi Square = 11.26 p = 0.0008

In both the groups physical capacity was reduced in anaemic subjects as

compared to controls which was statistically significant (P < 0.05) . In adult group

physical capacity was reduced even in 51.6% of control group. This may be due to

physiological changes of pregnancy in pregnant subjects of the group (228 of 337).

52

Table No. 15 : Infections in last 5 years

15 A : Adolescents

Category Gr I A. Anemic subjects (%) Gr I B. Controls (%)

No infection 4 ( 3.7) 25 ( 23.1 )

One episode 78 ( 72.2) 66 ( 61.1 )

> 1 episode 26 ( 24.1 ) 17 ( 15.8)

Total 108 (100.0) 108 (100.0)

Chi Square= 17.57 p = 0.00003

15 8: Adults

Category Gr II A. Anemic subjects(%) Gr II B. Controls(%)

No infection 36 ( 10.7) 78 ( 23.2)

One episode 211 (62.6) 198 ( 58.7)

> 1 episode 90(26.7) 61(18.1)

Total 337 (100.0) 337 (100.0)

Chi Square = 18.62 p = 0.00002

Infection in last 5 years was assessed by eliciting histories and by checking

available records in anemic subjects as well as controls. In Group I of anemic

adolescents 104 (78+26) had one or more episodes of infection while only 83

adolescents of control group (66+17) had history of infections in last 5 years.

In Group-11 of adults 311 anemic subjects had one or more episodes of infection as

against 259 subjects of controls. In both the groups this was statistically significant

(P< 0.05). In adolescents respiratory and gastrointestinal tract infections were

common while in adults genital tract and urinary tract infections were common. In

pregnant anemic subjects respiratory tract infections was also common.

53

Table No. 16: I Q Testing

16 A : Adolescents

Score Gr I A. Anemic subjects ( % ) Gr I B. Controls ( % )

40 31 (28.7) 18(16.7)

> 40-80 66 ( 61.1 ) 59 ( 54.6)

> 80-120 8(7.4) 18 ( 16.7)

> 120-160 3 ( 2.8) 13 ( 12.0)

Total 108(100.0) 108 ( 100.0)

Chi Square = 13.94 p = 0.003

16 B: Adults

Score Gr II A. Anemic subjects ( % ) Gr II B. Controls (%)

40 98 ( 29.1 ) 52 ( 15.5)

> 40-80 206 ( 61.1 ) 200 ( 59.3)

> 80-120 22 ( 6.5) 56 ( 16.6)

> 120-160 11 ( 3.3 29 ( 8.6)

337 ( 100.0) 337 ( 100.0)

Chi Square = 15.54 p = 0.0014

I Q score obtained in both the groups were low in anemic subjects as compared to

controls & this was statistically significant (P < 0.05).

Anemic subjects were slow in completing the test. Time required in anemic

subjects ranged from 17 to 24 minutes with mean of 20.99 ±. 2.8 minutes ( 95 %

Confidence interval 18.19 to 23.79 ), while in controls it ranged from 13 to 21

minutes with mean of 16.0 .:t 3.78 minutes (95 % Confidence interval 12.22 to

19.78) On applying the 'Z' test for comparison of anemic subjects with controls

for IQ test time it was statistically significant . P < 0.05 , Z = 43.85.

54

Table No. 17: Pregnant patients Maternal Outcome

Pregnant anemic subjects Controls Complications

Gr li.A.1 Gr II.B.1

Post partum hemorrhage 14 6

Congestive cardiac failure 4 0

Puerperal pyrexia 24 6

(includes sepsis)

Wound complications 8 2

Lactation failure 7 3

Total 57 (44) 17 (12)

Chi Square = 20.85 p = 0.00001

Total 44 patients of nutritional anemia had some obstetric complications as against

12 patients of control group. Total number of complications are more as some

patients had more than one complication. This was statistically significant

(P < 0.05).

Complications occurred because anemic subjects who were on treatment either

delivered before treatment was over or they suffered more blood loss during

delivery. Post partum hemorrhage (PPH) is common in anemic subjects as

myometrial oxygenation may be poor, resulting in atony of uterus and PPH.

Moreover moderate amount of blood loss can be detrimental to anemic patients.

Congestive cardiac failure occurred in patients of severe anemia in 2 during

labour, in 1 postpartum and in 1 when she was given Packed cells.

There was no case of maternal mortality in anemic subjects as well as controls in

present study.

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Table No. 18 : Perinatal Outcome

18 A : Perinatal Morbidity

Pregnant anemic subjects Controls Complications Gr II.A.1 Gr 11.8.1

Birth asphyxia 18 8

Prematurity 22 7

IUGR 25 10

Neonatal Sepsis 8 2

Others 4 2

Total 77 (68) 31 (26)

Chi Square= 17.66 p = 0.00003

Total 68 babies in anemic subjects and 26 babies in control group had one or more

complications. This was statistically significant (P < 0.05) As some of the newborns

had more than one complication total No. of complications is more than the

number of babies. Different complications were nearly 2 to 3 times more common

in anemic subjects as compared to controls.

18 B : Perinatal Mortality

Pregnant anemic subjects Controls

Gr II.A.1 Gr 11.8.1

SB (Intrapartum) 3 1

Neonatal Death 8 4

11 5

Cause of Death Prematurity 4 2 Severe birth asphyxia 5 3 Septicemia 2 0

Total 11 5

Chi Square = 2.33 p = 0.13

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Perinatal deaths were more than double in anemic subjects as against controls but

this was statistically not significant.(P > 0.05) Neonatal deaths were common and

prematurity and severe birth asphyxia were the common causes.

Table No. 19: Treatment

Treatment Failure Side effects

Oral Iron 369 31( 8.4%) 108 ( 29.3%)

Parenteral Iron 36 + 31 - 2

Packed cells 40 - 2

Folic acid 235 - -

All patients of mild anemia were treated by oral iron ferrous sulphate 200 mg tablet

per day. Patients having moderate anemia with Hb more than 8 gm% were also

treated by oral tablets but dose was increased to two tablets I per day. Parenteral

iron in the form of intravenous iron sucrose was given to the patients of moderate

anemia whose original Hb was less than 8 gm% ( 36) and 31 subjects in whom

oral iron therapy failed to raise their Hb at the end of 4 weeks.

Blood transfusion in the form of Packed cells was given to 40 anemic subjects

whose Hb was < 7 gm% i.e. severe anemia.

Folic acid tablets were given to all pregnant patients as supplements 0.5 mg/day

and 5 mg/day was given to all the 31 subjects having their deficiencies. Three

patients of Vit B 12 deficiency were treated by Vit B 12 JIM injections.

108 patients on oral therapy had side effects in the form of gastric upset,

constipation, diarrhoea.

57

- -~-----------

Two patients on parenteral iron therapy had side effects of whom one had

induration at injection site and other developed minor allergic reaction to IV iron

sucrose. Two patients of blood transfusion had complications. One had CCF and

other had pyrexic reaction both were tackled effectively.

58