Anaemia in pregnancy - types,diagnosis and management

anemia different types in pregnancy

1. ANAEMIA IN PREGNANCY - 1

2. Def/Degree Commonest cause Prevalence Consequences Requirement Screening Clinical Diagnosis Aetiology Laboratory diagnosis Prevention Treatment Labour

3. Definition Anemia is a condition where the red blood cell number or their oxygen-carrying capacity is insufficient to meet physiologic needs, and is conventionally taken as a hemoglobin ( Hb ) value that is less than two standard deviation (SD) below the median value for healthy matched population by age, sex, altitude, smoking, and pregnancy status

4. Degree World Health Organisation (WHO) Anemia in pregnancy as Hb values less than 11gm/ dl Mild : 10 to 10.9 Moderate : 7 to 9.9 Severe : less than 7 Anemia in postpartum females is defined as Hb less than 10 g/dl

5. CAUSES PHYSIOLOGICAL IRON DEFICIENCY HEREDITARY RED CELL DISORDERS-HEMOGLOBINOPATHIES(THALASEMIA,SICKLE CELL ANEMIA),RED CELL MEMBRANE DISORDERS(SPHEROCYTOSIS,ELLIPTOCYTOSIS) OTHER DEFICIENCIES-MEGALOBLASTIC ANEMIA DUE TO VITAMIN B12,FOLATE DEFICIENCY) AUTOIMMUNE HEMOLYTIC ANEMIA HYPOTHYROIDISM,CHRONIC KIDNEY DISEASE

6. Consequences

7. CONSEQUENCES Placental abruption (adjusted odds ratio [ aOR ] 1.36 with mild anemia, 1.98 with moderate anemia, 3.35 with severe anemia) Preterm birth ( aOR 1.08 with mild anemia, 1.18 with moderate anemia, 1.36 with severe anemia) Severe postpartum hemorrhage ( aOR 1.45 with mild anemia, 3.53 with moderate anemia, 15.65 with severe anemia) Maternal shock ( aOR 1.50 for moderate anemia, 14.98 for severe anemia) Maternal intensive care unit (ICU) admission ( aOR 1.08 with moderate anemia, 2.88 for severe anemia)

8. Screening first trimester (or at booking) 24–28 weeks and at 36 weeks of gestation

9. Causes- Physiologic (dilutional) Plasma volume increases by 40-50% The RBC mass also increases, but to a lesser extent (approximately 15 to 25 percent)

10. Causes-iron deficiency Globally, the commonest cause for anemia in pregnancy is IDA ( Iron Deficiency Anaemia ) Iron Deficiency (ID) : total content of iron in the body Iron Deficiency Anaemia (IDA): ID is severe enough to reduce erythropoiesis

11. Prevalence

12. Requirement

13. Requirement The average daily requirement of iron has been calculated as 0.8 mg/d in the first trimester and increases to 7.5 mg/day in the third trimester Average daily iron absorption from Indian diet varies from 0.8 mg/d to 4.5 mg/d depending on the type of staple used

14. History & Examination SYMPTOMS- Fatigue Alopecia Pica Restless leg syndrome SIGNS- Pallor, koilonychia, atrophic tongue papillae, glossitis and stomatitis

15. SYMPTOMS AND SIGNS Severe cases -congestive cardiac failure such as dyspnoea,orthopnea , edema, Examination shows raised Jugular Venous Pulse and pulmonary crepts

16. RISK FACTORS Pre-pregnancy menorrhagia Pre-pregnancy anemia Frequent child births, Worms infestation Gastrointestinal blood loss

17. Laboratory tests IDA Mean Corpuscular Volume (< 80 fl ) Mean Corpuscular Hemoglobin ( < 27 pg ) Red Cell Distribution Width Peripheral Smear ID Serum Ferritin ( < 30 mcg/dl )

18. Prevention Counselling on diet and nutrition Deworming( single dose albendazole 400 mg / mebendazole 500 mg ) after first trimester.

19. Prevention Universal prophylaxis IFA supplementation of 100 mg elemental iron and 500 μg of folic acid every day for at least 180 days starting after the first trimester at 14–16 weeks of gestation for all non-anemic pregnant women followed by the same dose for 180 days postpartum

20. Treatment Depends on Severity of anaemia Stage of pregnancy Obstetric risks of the patient Non obstetric co morbidities Methods Oral Parenteral Blood Transfusion

21. Oral Iron Therapy Maximum dose absorbed is only 100 to 200 mg No superiority of one iron salt/preparation over another Avoid enteric coated and delayed release preparations Take oral iron empty stomach or 1 h after meals for better absorption preferably with vitamin C rich product such as orange juice or guava

22. GI side effects nausea, constipation, diarrhea, indigestion, and metallic taste Ferric salts have a superior GI tolerability than Ferrous salts at the cost of reduced iron absorption Reducing the frequency, content of oral iron and changing it to an alternative preparation or taking the iron with meals may be employed to reduce GI side effects

23. Assessing response to oral iron Reticulocyte hb content ( as early as 3 days) Hb by I gm ( 2 weeks) & by 2 gm (4 weeks) Sub optimal rise Check compliance Reconfirm diagnosis Indication for parenteral iron

24. Treatment completion Once the Hb is in normal range, 100–200 mg/day of iron should continue for at least 3 months and at least 6 weeks postpartum to replenish the stores 60–100 mg/d oral iron should continue for at least 3–6 months postpartum

25. Parenteral Iron Intramuscular Iron-not used at present due to tissue staining and is painful Intravenous Iron

26. Intravenous Iron ID is confirmed by serum ferritin Informed Consent Resuscitative facilities Vitals to be monitored No test dose required Transient symptoms Single/ multiple

27. Ganzoni ‘s equation

28. Postpartum anaemia Poor QOL and depression 60–100 mg/d oral iron should continue for at least 3–6 months postpartum Hb should within 48 h of delivery

29. Postpartum anaemia treatment Mild anaemia : oral iron 100 to 200 mg for next 3 months Moderate anaemia : IV iron preparations Severe anaemia : blood transfusion before discharge follow up CBC with serum ferritin should be considered before discontinuation of iron therapy at 3 to 6 months

30. Role of Transfusion Risks : RBC allo -immunization, volume overload and fetal hemolytic disease. A threshold Hb < 7 g/dl for transfusion Decision for transfusion is individualized

31. In Labour Delivery where transfusion facility is available Intravenous access and cross matched blood Active management of third stage of labour

32. Prevention of other causes of anemia F olic acid  – Folic acid supplementation is routinely recommended to prevent neural tube defects.(5mg/day) Vitamin B12  – For individuals who consume a strict vegetarian diet or those with anatomic reasons to develop vitamin B12 deficiency ( eg , Roux-en-Y or biliopancreatic bariatric surgery), the importance of supplemental oral vitamin B12 should be emphasized.

33. Sickle cell disease (SCD)   Transfusion in individuals with SCD; G enetic counseling for those with SCD or sickle cell trait. Managing acute complications

34. Thalassemia  Transfusion in certain individuals G enetic counseling P renatal testing for thalassemia A Managing iron overload

35. Autoimmune hemolytic anemia (AIHA) Transfusions Immunosuppressive therapies ( eg , glucocorticoids) A ttention to possible anemia in the neonate due to autoantibodies that cross the placenta

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