anaemia dr. rajkumar ppt
TRANSCRIPT
ANAEMIA: ANAEMIA: PreventablePreventable, ,
Yet a Problem!!Yet a Problem!!
DR. R. RAJKUMAR M.D., D.M.DR. R. RAJKUMAR M.D., D.M.
CONSULTANT MEDICAL ONCOLOGIST CONSULTANT MEDICAL ONCOLOGIST
MADURAI MEDICAL COLLEGEMADURAI MEDICAL COLLEGE
ANAEMIA: ANAEMIA: PreventablePreventable, ,
Yet a Problem!!Yet a Problem!!
DR. R. RAJKUMAR M.D., D.M.DR. R. RAJKUMAR M.D., D.M.
CONSULTANT MEDICAL ONCOLOGIST CONSULTANT MEDICAL ONCOLOGIST
MADURAI MEDICAL COLLEGEMADURAI MEDICAL COLLEGE
DefinitionDefinition
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
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
Degree Hb% Haematocrit (%)
Moderate 7-10.9 24-37%
Severe 4-6.9 13-23%
Very Severe <4 <13%
Degree Hb% Haematocrit (%)
Moderate 7-10.9 24-37%
Severe 4-6.9 13-23%
Very Severe <4 <13%
WHO Classification of Anaemia WHO Classification of Anaemia
Magnitude of ProblemMagnitude of ProblemMagnitude of ProblemMagnitude of Problem
Globally, is about 30 %Globally, is about 30 %
In developing countries & In developing countries & India, incidence is around India, incidence is around 40 – 90%.40 – 90%.
Responsible for 40% of Responsible for 40% of maternal deaths in third world maternal deaths in third world countries.countries.
Important cause of direct and Important cause of direct and indirect maternal deathsindirect maternal deaths
- Vitere FE Adv Exp Med Biol 1994;352:127- Vitere FE Adv Exp Med Biol 1994;352:127
Globally, is about 30 %Globally, is about 30 %
In developing countries & In developing countries & India, incidence is around India, incidence is around 40 – 90%.40 – 90%.
Responsible for 40% of Responsible for 40% of maternal deaths in third world maternal deaths in third world countries.countries.
Important cause of direct and Important cause of direct and indirect maternal deathsindirect maternal deaths
- Vitere FE Adv Exp Med Biol 1994;352:127- Vitere FE Adv Exp Med Biol 1994;352:127
Infection
Lack of Concentration
Weakness
Irritability
Palpitation
Fatigue
Dizziness
SymptomsSymptoms
Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features
Pallor of skin And m/m
Edema
PlatynychiaKoilonychia PlatynychiaKoilonychia
Glossitis
Stomatitis
Tachycardi
a
Soft ejectionsystolic murmur
SignsSigns
Physiological
Pathological
Causes of Anaemia Causes of Anaemia Causes of Anaemia Causes of Anaemia
Nutritional
Haemorrhagic
Haemolytic
Nutritional
Haemorrhagic
Haemolytic
Iron RequirementIron Requirement
Iron Absorption Iron Absorption 11 Amount of iron in the
body Amount of iron in the
body
Iron Loss
Skin
Urine
Feces
Menstruation
1-2mg/d1-2mg/d
20-30mg/c20-30mg/c
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 PregnancyIron Requirement During Pregnancy
HbHb 13.5 – 14 gm %13.5 – 14 gm %
R.B.C.R.B.C. 4.5 – 4.7 million/cu mm4.5 – 4.7 million/cu mm
Serum IronSerum Iron 50 – 150 μg / dL50 – 150 μg / dL
TIBCTIBC 300 – 360 μg / dL300 – 360 μg / dL
Transferrin saturationTransferrin saturation 25 – 50 %25 – 50 %
S. Ferritin levelS. Ferritin level 30 μg / Lit30 μg / Lit
Red Cell protoporphyrinRed Cell protoporphyrin 30 μg / dL30 μg / dL
ErythropoietinErythropoietin 15.20 U / Lit15.20 U / Lit
MCVMCV 76 – 100 fL76 – 100 fL
MCHMCH 27 – 33 pg27 – 33 pg
MCHCMCHC 33.37 gm / dL33.37 gm / dL
PCVPCV 32 – 40 %32 – 40 %
Normal LevelsNormal Levels
Laboratory Diagnosis of AnaemiaLaboratory Diagnosis of Anaemia
IDAIDA ThalassemiaThalassemia Chronic DiseasesChronic Diseases
Serum IronSerum Iron Decreased Decreased Normal / Increased Normal / Increased DecreasedDecreased
TIBCTIBC IncreasedIncreased NormalNormal Decreased or NDecreased or N
TransferrinTransferrin
SaturationSaturation
DecreasedDecreased N or IncreasedN or Increased N or DecreasedN or Decreased
Serum FerritinSerum Ferritin DecreasedDecreased N or IncreasedN or Increased NN
Marrow IronMarrow Iron Decreased / Decreased / absentabsent
N or IncreasedN or Increased NN
Therapeutic test with Therapeutic test with oral ironoral iron
Rise in HbRise in Hb No rise in HbNo rise in Hb No riseNo rise
National Nutrition Anaemia Prophylaxis Programme (NNAPP 1971 - 72)
National Nutrition Anaemia Prophylaxis Programme (NNAPP 1971 - 72)
Anaemia continues – Major health problem
Nutritional Anaemia :Major Health ProblemsNutritional Anaemia :
Major Health Problems
FS + FA
Pregnancy
Lactating mothers
Family planning acceptors
Children – 1 to 11 years
Reason For Increased Reason For Increased Incidence Of AnemiaIncidence Of Anemia
Reason For Increased Reason For Increased Incidence Of AnemiaIncidence Of Anemia
Poor pre-pregnancy iron balance due to – Poor pre-pregnancy iron balance due to – untreated systemic diseases & menstrual untreated systemic diseases & menstrual disorders disorders
Improper supplementation of iron in pregnancy Improper supplementation of iron in pregnancy ( late registration and poor follow up)( late registration and poor follow up)
Repeated childbearingRepeated childbearing
Lack of awareness and illiteracyLack of awareness and illiteracy
Poor pre-pregnancy iron balance due to – Poor pre-pregnancy iron balance due to – untreated systemic diseases & menstrual untreated systemic diseases & menstrual disorders disorders
Improper supplementation of iron in pregnancy Improper supplementation of iron in pregnancy ( late registration and poor follow up)( late registration and poor follow up)
Repeated childbearingRepeated childbearing
Lack of awareness and illiteracyLack of awareness and illiteracy
Low socioeconomic status and poor hygieneLow socioeconomic status and poor hygiene
Chronic malnutritionChronic malnutrition
Poor availability of iron due to predominantly Poor availability of iron due to predominantly veg diet, diet low in calories but rich in phytates. veg diet, diet low in calories but rich in phytates. Food and religious taboosFood and religious taboos
GI infections and infestations GI infections and infestations (e.g. Kala azar, worm infestations)(e.g. Kala azar, worm infestations)
Low socioeconomic status and poor hygieneLow socioeconomic status and poor hygiene
Chronic malnutritionChronic malnutrition
Poor availability of iron due to predominantly Poor availability of iron due to predominantly veg diet, diet low in calories but rich in phytates. veg diet, diet low in calories but rich in phytates. Food and religious taboosFood and religious taboos
GI infections and infestations GI infections and infestations (e.g. Kala azar, worm infestations)(e.g. Kala azar, worm infestations)
Reason For Increased Reason For Increased Incidence Of AnemiaIncidence Of Anemia
Reason For Increased Reason For Increased Incidence Of AnemiaIncidence Of Anemia
IUGR
IUD IUH
CCFCCF
INFECTIONINFECTION
PRETERM LABOUR
PRETERM LABOUR
PIHPIH
Medical DisorderMedical Disorder
Complications - PregnancyComplications - PregnancyComplications - PregnancyComplications - Pregnancy
Instrumental delivery
PPH
FoetalDistressCCF
MATERNALPERINATAL
MorbidityMortality
Complications - LabourComplications - LabourComplications - LabourComplications - Labour
Management Options Management Options Management Options Management Options
Pre – pregnancy :
Treat the cause before conception
Pre-pregnancy balanced diet, education
and health support.
Build up iron stores during adolescent
phase
Pre – pregnancy :
Treat the cause before conception
Pre-pregnancy balanced diet, education
and health support.
Build up iron stores during adolescent
phase
Oral Iron
Blood transfusionParenteral
Injectable IronInjectable IronHuman Recombinant
Erythropoietin
Modalities of ManagementModalities of ManagementModalities of ManagementModalities of Management
100 mg elemental Iron ------- ↑ 0.18 gm % day100 mg elemental Iron ------- ↑ 0.18 gm % day
Iron stores poor
-ve-ve
Iron absorption
↓ Bioavailability
of Iron
-ve-ve-ve-ve
Phosphate phytate
Worm infestation
Oral IronOral IronOral IronOral Iron
Oral Iron Therapy Oral Iron Therapy Oral Iron Therapy 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
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
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.
• 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 SaltsAbsorption of Ferrous SaltsUncontrolled Passive AbsorptionUncontrolled Passive Absorption
Fe+2Fe+2
Fe+2Fe+2
Dissociation
Passive diffusion
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2 Fe+2
Gut Lumen Mucosal Cell Blood
Ferritin
Iron salts
Fe+3
Free Radical
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2Fe+2
Fe+2
Fe+3
Free Radical
Transferrin
Incorporation into Hb
↑ Hb – 0.21 gm %
Fractionated Irondextran[Iron hydroxide dextran
complex]
Les s
Les s
Les
s Les
s
Parenteral TherapyParenteral Therapy
100 mg elemental Iron
Anaphylactic Anaphylactic reactionreaction
Anaphylactic Anaphylactic reactionreaction
I.M. I.V.
Parenteral Therapy : Parenteral Therapy : Traditional IndicationsTraditional IndicationsParenteral Therapy : Parenteral Therapy :
Traditional IndicationsTraditional Indications
Intolerance to oral iron Intolerance to oral iron
Poor compliance to oral iron Poor compliance to oral iron
Gastrointestinal disorders Gastrointestinal disorders
Malabsorption syndromesMalabsorption syndromes
Rapid blood loss Rapid blood loss
Intolerance to oral iron Intolerance to oral iron
Poor compliance to oral iron Poor compliance to oral iron
Gastrointestinal disorders Gastrointestinal disorders
Malabsorption syndromesMalabsorption syndromes
Rapid blood loss Rapid blood loss
Inability to maintain iron balance Inability to maintain iron balance (haemodialysis)(haemodialysis)
Patient donating large amount of blood Patient donating large amount of blood for auto-transfusion programmefor auto-transfusion programme
? Pregnant women with severe IDA, ? Pregnant women with severe IDA, presenting late in pregnancypresenting late in pregnancy
Inability to maintain iron balance Inability to maintain iron balance (haemodialysis)(haemodialysis)
Patient donating large amount of blood Patient donating large amount of blood for auto-transfusion programmefor auto-transfusion programme
? Pregnant women with severe IDA, ? Pregnant women with severe IDA, presenting late in pregnancypresenting late in pregnancy
Parenteral Therapy : Parenteral Therapy : Traditional IndicationsTraditional IndicationsParenteral Therapy : Parenteral Therapy :
Traditional IndicationsTraditional Indications
TheThe
World Health OrganisationWorld Health Organisation states…states…
‘‘transfusion should be transfusion should be
prescribed prescribed ONLYONLY for for
conditions for which there conditions for which there
is is NONO OTHER TREATMENT’ OTHER TREATMENT’
Diagnosis of Folate Deficiency Diagnosis of Folate Deficiency Anemia (FDA)Anemia (FDA)
Diagnosis of Folate Deficiency Diagnosis of Folate Deficiency Anemia (FDA)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
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 AnemiaMegaloblastic Anemia- Diagnostic Problems- Diagnostic ProblemsMegaloblastic AnemiaMegaloblastic Anemia- Diagnostic Problems- Diagnostic Problems
HB estimationHB estimation
Peripheral smearPeripheral smear
MCV estimationMCV estimation
Serum folate Serum folate
Red cell folateRed cell folate
FIGLU estimationsFIGLU estimations
Marrow aspirateMarrow aspirate
HB estimationHB estimation
Peripheral smearPeripheral smear
MCV estimationMCV estimation
Serum folate Serum folate
Red cell folateRed cell folate
FIGLU estimationsFIGLU estimations
Marrow aspirateMarrow aspirate
Management of FDAManagement of FDAManagement of FDAManagement of FDA
Strong case for routine prophylaxis
Prophylaxis with anti convulsants
Continue routine oral therapy for
hemolytic anaemia
Parenteral therapy for severe deficiency
Strong case for routine prophylaxis
Prophylaxis with anti convulsants
Continue routine oral therapy for
hemolytic anaemia
Parenteral therapy for severe deficiency
Worm InfestationsWorm 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
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
HemoglobinopathiesHemoglobinopathies
A collective term for the inherited disorders A collective term for the inherited disorders of Hb synthesisof Hb synthesis
Disorders of globin synthesis e.g. Disorders of globin synthesis e.g. Thalassemia Thalassemia
Structural Hb variants e.g. Sickle cell Structural Hb variants e.g. Sickle cell anemia, HbCanemia, HbC
A collective term for the inherited disorders A collective term for the inherited disorders of Hb synthesisof Hb synthesis
Disorders of globin synthesis e.g. Disorders of globin synthesis e.g. Thalassemia Thalassemia
Structural Hb variants e.g. Sickle cell Structural Hb variants e.g. Sickle cell anemia, HbCanemia, HbC
ThalassemiaThalassemia
Genetic disorders; lack or Genetic disorders; lack or sed synthesis of globin sed synthesis of globin chainschains
Two types : Two types : & & thalassemia thalassemia
chains encoded by 2 pairs of genes on chains encoded by 2 pairs of genes on chromosome 16chromosome 16
chains encoded by single pair of genes on chains encoded by single pair of genes on chromosome 11chromosome 11
thalassemia more common and presents as eitherthalassemia more common and presents as either °(major) or °(major) or ++ (minor) (minor)
Genetic disorders; lack or Genetic disorders; lack or sed synthesis of globin sed synthesis of globin chainschains
Two types : Two types : & & thalassemia thalassemia
chains encoded by 2 pairs of genes on chains encoded by 2 pairs of genes on chromosome 16chromosome 16
chains encoded by single pair of genes on chains encoded by single pair of genes on chromosome 11chromosome 11
thalassemia more common and presents as eitherthalassemia more common and presents as either °(major) or °(major) or ++ (minor) (minor)
Diagnosis of ThalassemiaDiagnosis of Thalassemia
Hb estimationsHb estimations
Peripheral smearPeripheral smear
sed MCVsed MCV
sed MCHsed MCH
HbAHbA2 2 (( 2 222))
Hb estimationsHb estimations
Peripheral smearPeripheral smear
sed MCVsed MCV
sed MCHsed MCH
HbAHbA2 2 (( 2 222))
Diagnostic Strategy for Thalassemias
Hb Electrophoresis + CBC
Abnormal band
Normal No action
MCV MCH
Quantitative Hb electrophoresis
Raised Hb A2
B Thalassemia
Normal
sed Examine partners blood
? X Thalassemia
DNA analysis for x gene defects
Sickle Cell DiseaseSickle Cell Disease
Structural Hb variantStructural Hb variant
Exists in homo & heterozygous Exists in homo & heterozygous formsforms
Under hypoxic conditions, HbS Under hypoxic conditions, HbS polymerizes, gels or crystallizes.polymerizes, gels or crystallizes.
hemolysis of cells, & hemolysis of cells, & thrombosis of vessels in thrombosis of vessels in various organsvarious organs
In long standing cases, In long standing cases, multiple organ damage.multiple organ damage.
Structural Hb variantStructural Hb variant
Exists in homo & heterozygous Exists in homo & heterozygous formsforms
Under hypoxic conditions, HbS Under hypoxic conditions, HbS polymerizes, gels or crystallizes.polymerizes, gels or crystallizes.
hemolysis of cells, & hemolysis of cells, & thrombosis of vessels in thrombosis of vessels in various organsvarious organs
In long standing cases, In long standing cases, multiple organ damage.multiple organ damage.
Take Home MessageTake 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
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, The youth need to be educated about diet,
sanitation and personal hygienesanitation and personal hygiene
Hookworm infestation should be treatedHookworm infestation should be treated
Pregnant women should be given Iron and Pregnant women should be given Iron and
folate supplementsfolate supplements
The youth need to be educated about diet, The youth need to be educated about diet,
sanitation and personal hygienesanitation and personal hygiene
Hookworm infestation should be treatedHookworm infestation should be treated
Pregnant women should be given Iron and Pregnant women should be given Iron and
folate supplementsfolate supplements
Take Home MessageTake Home Message