anemia in pregnancy by dr usman ali
TRANSCRIPT
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
THANK
YOU