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ANEMIA IN PREGNANCY

Dr Anahita Chauhan
Associate Professor & Unit Head Seth G S Medical College & KEM Hospital Honorary Consultant, Saifee & St. Elizabeth Hospital

Background
Anaemia is the commonest medical disorder during pregnancy Greek meaning without blood Iron deficiency anaemia is the most common type of anaemia during pregnancy NFHS 2003-06: 57.9% of pregnant women 25% direct maternal deaths

Definitions of Anemia in Pregnancy


WHO - Hemoglobin concentration <11gm/dl & hematocrit of <33% CDC definition- Hb <11gm/dl during the first and third trimesters and <10.5gm/dl in th second trimester (to allow for the physiological fall due to hemodilution in second trimester) FOGSI - a cut off of 10 gm/dl for India

Classification Based on Severity


ICMR Mild Moderate Severe Very severe 10 11 gm/dl 7 10 47 <4 decompensated WHO 9 11 gm/dl 7-9 <7

Causes of Anemia in Pregnancy


Physiological anemia Nutritional anemia IDA, megaloblastic Anemia of chronic illness Blood loss Hemolysis and hemolytic anemias Hemoglobinopathies Other hereditary anemias Aplastic anemia

Increased Iron Demands


1000mg extra elemental iron required in pregnancy
Cannot be met by diet alone

Undernutrition compounds the problem

Normal Reference Ranges


Hematological index MCV (PCV/ RBC) Reference range 75 98 fl

MCH (Hb)
MCHC TIBC Fe/ TIBC ratio

25 31 pg
32 36% 325 400 / 100ml 30%

Morphological Classification
By the size of the RBCs Macrocytic anemia (MCV > 100)

Normocytic anemia (80 < MCV < 100)


Microcytic anemia (MCV < 80)

Clinical Features - Symptoms


Mild anemia is usually asymptomatic

Moderate anemia - weakness, fatigue, exhaustion, loss of appetite, indigestion, giddiness, breathlessness Severe anemia - palpitations, tachycardia, breathlessness, increased cardiac output, cardiac failure, generalised anasarca, pulmonary edema

Clinical Features - Signs


Pallor Nail changes Cheilosis, Glossitis, Stomatitis Edema Hyperdynamic circulation (short & soft systolic murmur) Fine crepitations

Effects of Anemia on Mother


Antepartum Preterm labor Pre eclampsia Sepsis IUGR Intrapartum Uterine inertia PPH Cardia failure

Effects of Anemia on Mother


Postpartum
Puerperal sepsis Subinvolution Pulmonary embolism Failure of lactation Delayed wound healing Cardiac failure

Fetal Effects
Prematurity and LBW IUGR IUFD Increased perinatal mortality Iron Deficiency Anemia due to lower iron stores can cause poor mental performance or behavioral abnormalities in later life

Diagnosis Baseline/ Presumptive


Haemoglobin Measurement Peripheral blood smear Reticulocyte count Hematocrit Blood indices
MCV, MCHC, MCHC

Stool Examination Urine Examination Proteins, LFT, RFT

Therapeutic Trial of Iron


Oral iron therapy Increase in reticulocytes in 5 7 days Rise in Hb at a rate of 2-4 gm/dl every 3 weeks till normal If no response or incomplete response, do additional tests

Diagnosis - Additional
Serum Fe Total iron binding capacity Serum Ferritin

Saturation
Hb electrophoresis

Bone marrow examination

Lab findings in IDA


Hb < 11 gm/dl Peripheral smear - microcytic, hypochromic MCV and MCHC are low Serum iron is low - < 50 gm/dl (N 60 -175) TIBC is increased - > 400 gm/dl Tests of iron stores Serum ferritin is < 12 gm/dl (N 40-200) Stainable iron in the bone marrow is reduced

Newer investigations
Serum transferrin receptors
Transferrin receptor/ ferritin index

Reticulocyte indices
automated counting of reticulocytes, count of <26pg/ cell is a strong predictor of IDA Reticulocyte production index

Red cell zinc protoporphyrin level

IDA
Severity MCV S Ferritin TIBC S Iron Variable Decreased Decreased Increased Decreased

ACD
Mild Normal/ decreased Normal/ increased Decreased Decreased +

Thalass-emia
Mild Decreased Normal Normal Normal +

Sidero-blastic
Variable Normal/ decreased Increased Normal Increased +

Marrow iron -

IDA
Population
RDW MCV Serum iron Ferritin TIBC Hb electrophoresis

Beta thal
Greeks, Italians
Normal Low Normal Normal Normal Increased HbA2

All
High Low Decreased Decreased Increased Normal

Mentzer Index
Calculation that may (or may not) be useful in differentiating thalassemia minor from IDA Mentzer Index = MCV/RBC Count <13 Thalassemia minor >13 Iron Deficiency Useful in children

Folic Acid Deficiency Anemia


Deficiency of folate or B12 Anticonvulsants, oral contraceptives, sulfa drugs, and alcohol can decrease absorption of folate from meals

Folate is essential for normal growth and development Coexists with IDA

Diagnosis
Macrocytes on peripheral smear Hypersegmentation of neutrophils Pancytopenia

Low Hb and high MCV


Megablastosis on bone marrow

Serum folate <3ng/ ml

Prevention
Dietary advice and modification Iron supplementation of adolescent & non pregnant women Treatment of hookworm Infestation Iron supplementation in pregnant women Food fortification Antenatal care for early recognition

Management of Anemia
Oral Iron Therapy

Prophylactic Iron therapy- 100mg elemental iron daily with 500 mcg of folic acid
Deworming of all anemic patients Treatment of Anemia- 200mg of elemental iron & folate 5mg/d

Iron Requirement in Pregnancy


2.5mg /day in early pregnancy

5.5mg /day from 20 -32 weeks


6 8 mg/ day after 32 weeks Average 4 mg/ day

Side effects of Oral iron


Nausea Vomiting Constipation Abdominal cramping Diarrhoea The tablet can be given with meals or different brand may be tried

Reasons for Failure to Respond


Non compliance Concomitant folate deficiency Continuous loss of blood through hookworm infestation or bleeding haemorrhoids Co-existing infection Faulty iron absorption Inaccurate diagnosis Non iron deficiency microcytic anaemia

New Therapeutic Alternatives


The side effects of older Iron preparations & their poor compliance even on providing free tablets are the most important reasons of failure of anaemia control programmes
Newer preparations are better tolerated, have less side effects with better compliance Carbonyl Iron Iron ascorbate

Merits of New Preparations


Outstanding GI Tolerance in contrast to 20% severe side effects with conventional therapy Very safe with no poisoning even in high doses
No interaction with food stuffs

The newer preparations are delicious with nonmetallic taste and dont stain the patients teeth Hence the compliance is very high

Parenteral Iron therapy


Indicated when the pregnant woman is unable to take iron due to side effects or is non compliant Its main advantage is certainty of administration

Rise in hemoglobin is similar to oral iron (upto 1gm per wk)

Preparation & dosage


Iron Dextran IM and IV high molecular wt stable complexes release iron slowly, can cause anaphylaxis Iron citrate sorbitol IM less stable, rapid release of iron

Iron sucrose IV intermediate stability, rapid metabolism hence readily available iron. Since they do not form biological polymers, there are no reactions

Precaution
Oral Iron to be suspended 48 hours before parenteral therapy Emergency measures like inj hydrocortisone adrenaline, oxygen cylinder to be kept ready Look for reaction while giving infusion

Dose calculation
Older preparations: each 1ml = 50mg elemental iron

0.3 x Wt in lb x (100 Hb%) + 500


Iron sucrose: each ml = 20mg elemental iron

Dose: 200mg slow IV alternate day


0.24 x wt in kg x (target Hbpt Hb) + 500

Disadvantages
Pain Nausea, vomiting, headache Skin discolouration Abscess formation Fever Lymphadenopathy Allergic reaction Anaphylaxis

Blood Transfusion
Severe anemia, especially after 36 weeks

Hemorrhage
Associated infections Packed cells preferred

Exchange transfusion rare

Use of Erythropoetin
Used in severe anemia & renal failure for significant increase in Hb and to avoid blood transfusion Gynaecological surgeries - preop use of erythropoietin and Iron Dextran has been shown to avoid the need for blood tranfusion later

Dosage Regimen Erythropoetin


Inj erythropoetin can be given subcut or iv 100-15 iu/kg On day 1, 3 & 5 along with parenteral iron or day 1, 3 & 5 6000units s/c erythropoetin and iron dextran 100mg deep im daily for 5 day

First dose given after subcut sensitivity test


Adrenaline, hydrocortisone, oxygen to be kept ready Produces 3gm% rise in Hb over a 2wk period

Management in Labor
Make patient comfortable, oxygen

Sedation and analgesia


Prevent cardiac failure Aim to deliver vaginally Antibiotics Cut short second stage Active management of third stage

Clinical Case Scenarios


A primigravida presents at 28 wks of gestation with pallor, hemoglobin 7.8g%, no other medical comorbidity, good functional status. Most pragmatic first line therapy in cases with assured compliance would be a. blood transfusion b. parenteral iron c. oral iron d. oral plus parenteral iron Answer: c

Clinical Case Scenarios


Foodstuff with highest available iron is a. Red meat b. Figs c. Groundnut d. Soyabean

Answer b

Clinical Case Scenarios


A lady at 32 weeks gestation with hemoglobin 8.9, red cell width is increased, taking iron supplements. Least likely situation is a. non compliance b. intestinal parasites c. thalassemia trait d. anti epileptic medication Answer: c

Clinical Case Scenarios


Single most important set of investigations in a recently diagnosed case of anaemia in pregnancy is a. Red cell indices b. Retic count and peripheral smear c. Iron studies d. Hemoglobin electrophoresis Answer: b

Clinical Case Scenarios


G5P2L0A2 at 35 weeks gestation in early preterm labor. Hb is 8.8g%. All can be part of management except a. Steroids b. Frusemide c. Blood transfusion d. Intra partum antibiotics Answer: c

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