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1. Anemia &Malaria in pregnancy By Girma A (CI) MODULATOY Dr Alferid A ( Ass’t Prof.of OBGYN)

2. Contents of presentation Introduction Anemia in pregnancy Incidence and cause of anemia in pregnancy Effects of anemia in pregnancy Iron deficiency anemia Malaria in pregnancy Diagnosis Prinicple of treatement and managements Reference

3. General objectives At the end of the lesson Identify common type of anemia during pregnancy and its principle of of management. Discribe effects of anemia during pregnanacy and its prevention applying preventive methods of malaria for prgnanat mothers

4. Introduction Pregnancy induces physiological changes that often confuse the diagnosis hematological disorders One of the most significant changes blood volume expansion with a disproportionate plasma volume increase resulting in a normally decreased hematocrit.

5. The modest fall in hemoglobin levels during pregnancy is caused by a relatively greater expansion of plasma volume compared with the increase in red cell volume The disproportion between the rates at which plasma and erythrocytes are added to the maternal circulation is greatest during the second trimester. Late in pregnancy, plasma expansion essentially ceases while hemoglobin mass continues to increase. After delivery, the hemoglobin level fluctuates and then rises to and usually exceeds the nonpregnant level. .

6. Hemoglobin concentration at term averages 12.5 g/dL, and in approximately 5 percent of women, it is below 11.0 g/dL The total iron content of normal adult women ranges from 2.0 to 2.5 g .the iron stores of normal young women are only about 300 mg (Pritchard and Mason, 1964).

7. Pregnant women are susceptible to hematological abnormalities . include chronic disorders hereditary anemias, immunological thrombocytopenia, malignancies, (leukemias and lymphoma). pregnancy-induced demands iron-deficiency & megaloblastic anemias. Pregnancy may also unmask underlying hematological disorders compensated hemolytic anemias caused by hemoglobinopathies or red cell membrane defects. Any hematological disease may first arise during pregnancy (autoimmune hemolysis or aplastic anemia).

8. ANEMIA IN PREGNANCY Defined as hemoglobin concentration < 12 g/dL in nonpregnant women <10 g/dL during pregnancy or the puerperium. CDC(1998)defined as in iron-supplemented pregnant women using a cutoff of the 5th percentile 11 g/dL in the first and third trimesters 10.5 g/dL in the second trimester

9. Anemia in pregnancyWHO definition Stage of pregnancy Anemic if less than : (g/dl) FIRST TRIMESTER 11.0 Second trimester 10.5 THIRD TRIMESTER 11.0

10. Incidence and Causes of Anemia The frequency of anemia during pregnancy depends primarily on preexisting iron states and prenatal supplementation. ( ACOGA, 2008) 22 % Chinese women were anemic in the first trimester. ( Ren and colleagues 2007) Hemoglobin levels at term averaged 12.7 g/dL vs 11.2g/dl among women who took supplemental iron compared with those who did not. ( Taylor and associates 1982) 20 % of women with normal prenatal hemoglobin levels had postpartum anemia that was caused by hemorrhage at delivery (Bodnar and associates 2001)

11. C ontribution to maternal death from bleeding or infection. In Africa anemia accounts for 11% of all maternal deaths its pevalence 10-15% in developed countries 42-65% in developing countries

12. Causes of Anemia during Pregnancy Common causes 85% of anemia Physiologic anemia & Iron deficiency A.Acquired Iron-deficiency anemia Anemia caused by acute blood loss Anemia of inflammation or malignancy  Megaloblastic anemia  Acquired hemolytic anemia Aplastic or hypoplastic anemia malaria & HIV

13. cause cont--- B. Hereditary   Thalassemias   Sickle-cell hemoglobinopathies   Other hemoglobinopathies   Hereditary hemolytic anemias

14. The amount of iron passing from mucosal cells in to the body is determined by the rate of erythropoiesis and the state of body iron store

15. Iron Requirements In a singleton gestation, the maternal need for iron averages close to 1000 mg. 300 mg is for the fetus and placenta 500 mg for maternal hemoglobin mass expansion 200 mg that is shed normally through the gut, urine, and skin.

16. T he total amount of 1000 mg considerably exceeds the iron stores of most women and results in iron-deficiency anemia unless iron supplementation is given Most iron is used during the latter half of pregnancy, the iron requirement becomes large after midpregnancy and averages 6 to 7 mg/day (Pritchard and Scott, 1970) hemoglobin concentration below 11.0 g/dL, especially late in pregnancy, should be considered abnormal and usually due to iron deficiency rather than due to hypervolemia of pregnancy.

17. Effects of Anemia on Pregnancy Slightly increased risk of preterm birth with midtrimester anemia (Klebanoff and co-workers (1991) The risk of low birthweight, preterm birth, and SGA infants(Ren and colleagues (2007) Incidence of preterm delivery and low birthweight was increased as the severity of anemia increased(Kidanto and co-workers (2009) Evidence that maternal anemia influences placental vascularization by altering angiogenesis during early pregnancy(Kadyrov and co-workers (1998)

18. Iron Deficiency Anemia The two most common causes of anemia during pregnancy and the puerperium Iron deficiency & acute blood loss. The first pathologic change to occur in iron deficiency anemia is the depletion of bone marrow, liver, and spleen iron stores. The serum iron level falls, as does the saturation of transferrin. The total iron-binding capacity rises, because this is a reflection of unbound transferrin. A falling hemoglobin and hematocrit follow.

19. Then Microcytic hypochromic RBCs are released into the circulation. If combined with folate or vitamin β12 deficiency, normocytic and normochromic RBCs are observed on the peripheral blood smear

20. Malaria in pregnancy Itis a significant public health concern globally, particularly in areas where the disease is endemic. Risks to both the mother and the fetus, including severe anemia, spontaneous abortion, stillbirth, premature delivery, and low birth weight

21. The pathogenesis of malaria in pregnancy is characterized by the following key points: Increased susceptibility : .This is due to changes in acquired cellular immunity and the expression of unique variant surface antigens (VSA) by the Plasmodium falciparum parasite that can sequester in the placenta. Placental sequestration: The P. falciparum parasite can sequester in the placenta, leading to heavy infiltration of infected red blood cells in the intervillous spaces. placental insufficiency

22. pathogenesis cont-- Inflammatory response : particularly monocyte infiltrates, predisposes the mother to anemia and the fetus to growth restriction. Severity and timing : The severity depends on the level of pre-existing immunity, with first-time pregnant women (primigravidae) being more susceptible. Adverse outcomes : can lead to abortion, stillbirth, preterm delivery, and low birth weight.

23. The risk of malaria infection is higher during pregnancy due to the changes in the immune system and the presence of the placenta, which provides new sites for parasites to bind Malaria infection is most frequent between 13-16 weeks of pregnancy, declining towards term. In areas with high malaria transmission, women often develop immunity to severe disease, but the parasite still targets the placenta, increasing the risk of adverse outcomes during pregnancy

24. The World Health Organization (WHO) recommends a package of interventions to prevent and treat malaria in pregnancy The use of insecticide-treated bed nets Intermittent preventive treatment (IPTp) with sulfadoxine-pyrimethamine (SP), Effective case management IPTp is particularly important in areas with moderate to high malaria transmission, where it has been shown to reduce the risk of adverse outcomes

25. In low transmission areas, where women generally have no immunity to malaria, the disease is more likely to result in Severe malaria disease Maternal anemia Premature delivery, or fetal loss IPTp is recommended, but the focus is on prompt and effective case management

26. The WHO recommends that : IPTp be given at each routine antenatal care visit, starting as early as possible in the second trimester, and that it should be part of routine antenatal care in moderate and high transmission areas The use of IPTp has been shown to reduce the risk of adverse outcomes, including maternal anemia and low birth weight

27. Diagnosis Histroy and P/E Lab. investiation Classical morphological evidence of iron-deficiency anemia erythrocyte hypochromia and microcytosis is less prominent Moderate iron-deficiency anemia during pregnancy usually is not accompanied by obvious morphological changes in erythrocytes. Serum ferritin levels, lower than normal

28. Treatment and prevention of anemia in pregnancy Supplementation with iron and folat e 120 mg elemental iron and 1 mg folic acid are optimal daily dosages needed to prevent anemia When anemia is already present 180 mg elemental iron and 2mg folic acid per day. Treatment should continue for at least another 2 or 3 months to build up iron stores If a woman cannot take oral iron preparations, then parenteral therapy is given. ferrous sucrose has been shown to be safer than iron-dextran (ACOG 2008)

29. 2. Dietary modification Increase consumption of hem iron food stuff Increase consumption of regular foods (if the above is not possible) Enhancing bioavailability of ingested iron

30. 3. Food fortification Adds little to the price of food Selective fortification of widely consumed food Promising controlling deficiencies Require industrial infrastructure

31. Malaria control 5. Control of other parasitic infections like hook worm, schistosomiasis and gardiasis

32. Transfusion The following factors must be taken in to account: Stage of pregnancy Evidence of cardiac failure Presence of infection Obstetric history Anticipated delivery Hgb leve

33. Reference Williams obestetric 23 edition ( 252_300) Gabbe 7th ediction (14-20) Up to date 23edition Malaria in pregnanacy Jhpiego (2023 :12) Malaria journal of Biomedial (2017:467)

34. Thank you !!