Anemia in Pregnancy

Usman ali 08-202 Batch-K

Definition

Anemia - insufficient Hb to carry out O2 requirement by

tissues.

WHO definition : Hb conc. 11 gm %

CDC definition : Hb conc. < 11gm % in 1st and 3rd trimesters and < 10.5 gm% in 2nd trimester

For developing countries : cut off level suggested is 10 gm %

- WHO technical report Series no. 405, Geneva 1968

Centre for disease control, MMWR 1989;38:400-4

Magnitude of Problem

Globally, is about 30 %

In developing countries & Pakistan incidence is around 40 – 90%.

Responsible for 40% of maternal deaths in third world countries.

Important cause of direct and indirect maternal deaths

- Vitere FE Adv Exp Med Biol 1994;352:127

Clinical FeaturesPallor of skin

Edema

PlatynychiaKoilonychia PlatynychiaKoilonychia

Glossitis

Stomatitis

Tachycardi

a

Soft ejectionsystolic murmur

Signs

Physiological

Pathological

Causes of Anaemia

Nutritional

Haemorrhagic

Haemolytic

Early Pregnancy

2.5 mg / day

32 to 40 weeks

6.8 mg / day

TOTAL800 – 1000

mg

20 to 32 weeks

5.5 mg / day

RBC =500mgFetus+Placenta =450mgThird stage blood loss=200mgTotal = 1150mg

Iron Requirement During Pregnancy

R.B.C. 4.5 – 4.7 million/cu mm

TIBC 300 – 360 μg / dL

S. Ferritin level 30 μg / Lit

Erythropoietin 15.20 U / Lit

MCH 27 – 33 pg

PCV 32 – 40 %

Normal Levels

Laboratory Diagnosis of Anaemia

IDA Thalassemia Chronic Diseases

Serum Iron Decreased Normal / Increased Decreased

TIBC Increased Normal Decreased or N

Transferrin

Saturation

Decreased N or Increased N or Decreased

Serum Ferritin Decreased N or Increased N

Marrow Iron Decreased / absent

N or Increased N

Therapeutic test with oral iron

Rise in Hb No rise in Hb No rise

Reason For Increased Incidence Of Anemia

Poor pre-pregnancy iron balance due to – untreated systemic diseases & menstrual disorders

Improper supplementation of iron in pregnancy ( late registration and poor follow up)

Repeated childbearing

Lack of awareness and illiteracy

Low socioeconomic status and poor hygiene

Chronic malnutrition

Poor availability of iron due to predominantly veg diet, diet low in calories but rich in phytates. Food and religious taboos

GI infections and infestations (e.g. Kala azar, worm infestations)

Reason For Increased Incidence Of Anemia

Management Options

Pre – pregnancy :

Treat the cause before conception

Pre-pregnancy balanced diet, education and health

support.

Build up iron stores during adolescent phase

Oral Iron Therapy Ideal dose – 100mg per day (prophylactic)

Ferrous gluconate, ferrous fumarate, ferrous succinate, ferrous sulphate, ferrous ascorbate citrate

Rise in Hb – 0.8 gm / dl / week

Side effects -G I upset most common

Pt. compliance not guaranteed

Ineffective in pts with worm infestations

Inconclusive evidence on benefit of controlled release Iron preparation

Iron salts are dissociated into bivalent or trivalent iron salts

Diffuses as free iron ions through the upper part of the gastrointestinal mucosa

Taken up by transferrin and incorporated into ferritin.

For binding to ferritin and transferrin ferrous iron has to be converted into ferric iron by oxidation

Highly reactive free radicals are produced during this process

All ionic iron including carbonyl iron are absorbed similarly

• Borbolla JR. Cicero RE, Dibilox MM, Sotres RD et al.. Rev Mex Pediatr 2000; 67(2): 63-67

• Heubers KA, Brittenham GM, Csiba E, Finch CA. J Lab Clin Med 1986 ; 108 ; 473-8.

Absorption of Ferrous SaltsUncontrolled Passive Absorption

Parenteral Therapy : Traditional Indications

Intolerance to oral iron

Poor compliance to oral iron

Gastrointestinal disorders

Malabsorption syndromes

Rapid blood loss

Inability to maintain iron balance (haemodialysis)

Patient donating large amount of blood for auto-transfusion programme

? Pregnant women with severe IDA, presenting late in pregnancy

Parenteral Therapy : Traditional Indications

The

World Health Organisation states…

‘transfusion should be

prescribed ONLY for

conditions for which there

is NO OTHER TREATMENT’

Diagnosis of Folate Deficiency Anemia (FDA)

Special considerations in diagnosis

• FDA is suspected when the expected response

to adequate iron therapy is not achieved

• Macrocytosis can occur in pregnancy in absence

of FDA

• If FDA + IDA present, it will be masked by IDA

• Definitive diagnosis – Bone marrow aspirate

Megaloblastic Anemia- Diagnostic Problems

HB estimation

Peripheral smear

MCV estimation

Serum folate

Red cell folate

FIGLU estimations

Marrow aspirate

Management of FDA

Strong case for routine prophylaxis

Prophylaxis with anti convulsants

Continue routine oral therapy for

hemolytic anaemia

Parenteral therapy for severe deficiency

Worm Infestations

Common cause of anaemia in developing countries

Most common – hookworm infestation, Round worm, whip worm, etc.

Oral iron therapy becomes ineffective

Treatment by antihelminthics is a must

Treatment

Mebendazole : 100mg twice daily for three days

Pyrantel pamoate : 10mg / kg in single dose.

Albendazole : 400mg once a day for three days

Hemoglobinopathies

A collective term for the inherited disorders of Hb synthesis

Disorders of globin synthesis e.g. Thalassemia

Structural Hb variants e.g. Sickle cell anemia, HbC

Thalassemia

Genetic disorders; lack or sed synthesis of globin chains

Two types : & thalassemia

chains encoded by 2 pairs of genes on chromosome 16

chains encoded by single pair of genes on chromosome 11

thalassemia more common and presents as either °(major) or + (minor)

Diagnosis of Thalassemia

Hb estimations

Peripheral smear

sed MCV

sed MCH

HbA2 ( 22)

Sickle Cell Disease Structural Hb variant

Exists in homo & heterozygous forms

Under hypoxic conditions, HbS polymerizes, gels or crystallizes.

hemolysis of cells, & thrombosis of vessels in various organs

In long standing cases, multiple organ damage.

Take Home Message

Anaemia although preventable is a global problem

Anaemia still is the commonest cause of maternal mortality

and morbidity in spite of easy diagnosis and treatment

Anaemia can be due to a number of causes,

including certain diseases or a shortage of iron, folic

acid or Vitamin B12.

The most common cause of anemia in pregnancy is

iron deficiency.

Iron therapy is best given orally

The youth need to be educated about diet, sanitation and personal hygiene

Hookworm infestation should be treated

Pregnant women should be given Iron and folate supplements

Take Home Message

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