Anemia during pregnancy/types/causes/prevention and management

It's normal to have mild anemia when you are pregnant. But you may have more severe anemia from low iron or vitamin levels or from other reasons. Anemia can leave you feeling tired and weak. If it is severe but goes untreated, it can increase your risk of serious complications like preterm delivery

1. Mrs Babitha MathewMSc OBG Assistant professor CON, NMC, Muvattupuzha Anemia in pregnancy

2. ANAEMIA IN PREGNANCY Definition: By WHO Hb. < 11 gm /dl (or haematocrit <32%) Mild anaemia -------- 10 -10.9 gm /dl Moderate anaemia--- 7-10 gm /dl Severe anaemia-------- < 7gm /dl Very severe anaemia-- < 4gm/dl

3. Physiological Pathological Nutritional deficiency anaemias - Iron deficiency (90%) - Folate deficiency - Vit. B12 deficiency - protein deficiency Infections : Malaria/Hookworm/UTI/TB Hemorrhagic –acute/chronic blood loss Bone marrow insufficiency – Aplastic (radiation, Drugs) Chronic diseases- R enal or neoplasm Genetic/ Haemoglobinopathies : Thalassaemias , hemolytic COMMON ANEMIAS IN PREGNANCY

4. PHYSIOLOGICAL ANAEMIA Plasma volume 50% (by 34weeks) but RBC mass only 25% Disproportionate increase in plasma vol , RBC vol. and hemoglobin mass during pregnancy CRITERIA Hb = 10 gm% RBC = 3.2 million/mm 3 PCV = 32% Peripheral smear showing normal morphology of RBC with central pallor

5. IRON DEFICIENCY ANEMIA

6. Causes of anemia Deficient intake & absorption inadequate diet low socioeconomic status loss of appetite antacids, H2 blockers, proton pump inhibitors Hyperemesis Presence of phosphates & phytates in diet Achlorhydria & vit.C deficiency 2 . Increased demand Multiple pregnancy teenage pregnancy

7. 3. Excessive loss Repeated pregnancies Prolonged lactation Prior menorrhagia Hookworm infestation Malaria, bleeding piles, dysentery through sweat-15mg/ mth 4. Chronic illness 5. Asymptomatic bacteriuria 6. Prepregnant health status 7. Blood loss at delivery

8. Clinical Features of Anaemia in Pregnancy Symptoms Signs Weakness Pallor . Lassitude , tiredness , exhaustion Glossitis . Indigestion Stomatitis . Loss of appetite Oedema Palpitation Hypoproteinaemia . Breathlessness Soft systolic murmur in mitral area due to hyperdynamic circulation Giddiness / dizziness Fine crepitations at lung bases. Swelling feet eye lids ( peripheral ) Pale nails . Platynychia . Koilonychia Generalized anasarca. Tenderness in sternum . Blackouts in front of eyes on sudden standing Hepatic –splenic enlargement . Symptoms of congestive cardiac failure

9. Investigation-objectives To find degree of anemia Type of anemia Cause of anemia

10. Diagnosis of Iron Deficiency Anaemia Characteristics IDA Hb gm % < 10 PCV < 30% Mean corpuscular volume(MCV) <75 Mean corpuscular HB (MCH) <25pg Mean corpuscular Hb Conc. (g/dl) (MCHC) <30 PBF(peripheral Blood Film ) Microcytic Hypochromic Serum Iron (ug/dl) < 30 Total iron binding capacity (ug/dl ) >400 Transferrin Saturation < 10% Serum Ferritin (mcg / dl ) <30 Serum Transferrin Receptors increased Red Blood Cell < 4 million/mm3

11. To find the cause of anemia Examination of stool Urine examination X-ray chest-TB Fractional test meal analysis of gastric juice-pernicious Sr.Protein - hypoprotenemia Bonemarrow - hypoplastic anemia, kala-azar (ID- bonemarrow normoblastic )

12. EFFECTS OF Anaemia IN PREGNANCY ANTEPARTUM Pre eclampsia Intercurrent infection Cardiac failure Preterm labour APH INTRAPARTUM PPH Cardiac failure Shock POSTPARTUM Puerperal sepsis Subinvolution Failing lactation Puerperal venous thrombosis Pulmonary embolism

13. Baby IUGR Prematurity Increased risk of IDA early infancy Still births Congenital malformations ↑ in Neonatal deaths/ Perinatal mortality Intra uterine deaths(severe maternal anoxemia ) Abnormal Social and Emotional behaviour

14. MANAGEMENT PROPHYLACTIC

15. Prevention of Anemia Proper spacing between two children – 2 years Regular screening for anemia. Hb - Ist visit,30 th wk & 36 th wk Avoid / Reduce smoking / alcohol consumptions S upplementary iron- 200 mg ferrous sulphate with 1 mg folic acid daily Treat hookworm infestation, dysentery, malaria, UTI, bleeding piles

16. Dietary advice Fortification of ready-to-eat food with iron Use iron utensils for cooking Don’t discard water used for vegetable and rice cooking Sources- liver, meat, egg, green vegetables, green peas, figs, beans, whole wheet , green plantain, onion stalks, jaggery

17. CURATIVE

18. 1) Hospitalization Hb< 7.5 gm /DL Associated obstetrical-medical complication with moderate degree anemia

19. 2. General Treatment Diet Improve Appetite- Acid Pepsin Eradicate sepsis – Antibiotic therapy Therapy to treat the cause

20. 3. Specific therapy Depends on: severity of anemia duration of pregnancy Associated complicating factors

21. Oral Iron Therapy Indications mild to moderate Anemia plenty of time before EDD Dose - 200 mg ferrous sulphate tid Rate of improvement - increase Hb by 0.7 gm / wk Reticulocytosis with in 10 days Side effects - nausea , vomiting , epigastric burning , constipation, abdominal cramps and diarrhoea.

22. Iron preparations available IRON PREPARATION Ferrous Fumerate Ferrous Gluconate Ferrous Sulphate

23. Parenteral Therapy Route – total dose infusion Intramuscular route Indications Contraindications of oral therapy Not co operative during last 8-10 wks with severe anemia Preparations  Iron Sorbitol Injection – given deep IM after sensitivity test –rapid absorption owing to molecular wt., associated with pain and skin discoloration at the site of injection .Total calculated dose is given over 2 weeks of duration.

24. Paenteral Iron Therapy ---- Iron Dextran – can be given IM / IV route after sensitivity test . It has minimal side effects ,as it is highly fractionated low molecular salt . Iron Sucrose – can be given as single / repeat dose in Iv drip. Parenteral therapy will take 4-6 weeks to reach their optimal effect.

25. Anemia and blood Transfusion -- When Hb is < 5gm % and or pt is near term and obstetrical haemorrhage . Digitilisation and Lasix therapy may be given to control CHF or to prevent its precipitation. PCV transfusion , if available is preferred than Whole Blood . Recombinant Erythropietin can be used along with parenteral iron therapy to the patients having chronic renal disease complicating pregnancy and to non responders to oral / parenteral iron therapy.

26. Folic Deficiency Anaemia --- Folic acid is needed in higher doses during pregnancy because of the increased cell replication , taking place in fetus , uterus and bone marrow.

27. Causes Inadequate Diet Excessive Cooking Intestinal Malabsorption ( Sprue ) Syndrome . Twin Pregnancy Multigravida Hook Worm Infestation GIT Diseases Bleeding Piles Haemolytic Conditions Malaria And Other Infections . Anti Folate Medications Like Anti Epileptics , Anti Cancer

28. complications Maternal PIH Abruptio placenta Preterm labour Fetal fetal neural tube defects abortion IUGR premature / small for date fetus poor folate level in newborn

29. Folic Acid Deficiency Anaemia -- Symptoms Asymptomatic loss of appetite vomiting Diarrhoea unwell with unexplained fever Signs Pallor Bleeding points on skin Enlarged spleen and liver neuropathy.

30. Diagnosis Of folic Acid Deficiency Anaemia Characteristics Normal range Folic acid deficiency Hb 11-15gm% <11 gm% MCV 75-96 > 100 Mean corpuscular HB Conc. 32-35 Normal PBF Normocytic Normochromic Megalobastic , neutropenia , thrombocytopenia, hypersegmentation of neutrophills , macrocytic erythrocytes Serum Folate >3 <3 microgm /dl Red cell Folate >150 ng / ml < 80 microgram/dl Serum Iron 60-120 ug/dl Normal Serum lactate dehydogenase HomoCysteine Increased Increased Bone marrow Megaloblastic erythropoiesis

31. Treatment WHO recommends 800ug / day in pregnancy and 600ug / day during lactation period . eat more green leafy vegetables ( palak , maithi , brocoli ) and liver and kidneys . Treatment 5mg folic acid / day for > 4 weeks . Response is observed by fall in LDH level in 3-4 days and increase in reticulocyte count in 5-8 days.

32. CYANOCOBALAMIN (VIT .B12 ) DEFICIENCY daily requirement - 3ug Gastric mucosal atrophy following long term use of H2 inhibitor and Proton pump inhibiting anta acid will result in deficiency of intrinsic factor and decreased absorption of Vit B12 .

33. Clinical findings are same as in folic deficiency Vit B12 level is lower in the blood ( < 90ug / L) TREATMENT- Parenteral(I/M) Vit B-12 250ug / month is the treatment.

34. MEGALOBLASTIC ANEMIA(PS) MEGALOBLASTIC ANEMIA(BM)

35. HAEMOGLOBINOPATHIES Each molecule of normal Hb is composed of 4 subunits , with a single heam group and 4 species specific globin chains . 2 pairs of globin chains ( 2 alpha & 2 Beta chains ) are attached to the Pyrole rings to make normal Hb .

36. HAEMOGLOBINPATHIES Sickle cell disease Sickle cell anaemia (most common & severe) Sickle cell beta thalassemia , Haemoglobin SC disease Thalassemia - Alpha thalassaemia . - Beta thalassaemia : . Major . Minor

37. Sickle cell Hemoglobinopathies Valine substituted for glutamic acid at 6 th position on β chain of Hb molecule Common variants - SS ( sickle cell anemia) - SA ( sickle cell trait) Hb SS Hb SA Cell trait Homozygous Heterozygous HbS 70 – 90%, rest HbF 10 – 40%, 40-60% HbA Hb (g/dl) 6 - 9 13 -15 Life expectancy 30 yrs normal Propensity for sickling ++++ + (O 2 falls < 40%)

38. SIGNS & SYMTOMS Vaso -occlusive complications a) Painful episodes-most common(50%) b) Acute chest syndrome(20%) c) Strokes d) Renal insufficiency e) Splenic sequestration f) Proliferative retinopathy g) Priapism h) Spontaneous abortion i ) Bone pains, leg ulcers, Osteonecrosis

39. Complications maternal a) acute painful sickling crisis b) preeclampsia& hellp c) Pyelonephritis puerperal sepsis d) Thromboembolism e) Cardiac dysfunction perinatal complications a) miscarriage & preterm delivery b) IUGR c) IUD d) isoimmunization DIAGNOSIS Hb solubility test-specific, cheap, rapid and simple. Sickling test Hb electrophoresis

40. MANAGEMENT Preconceptional councelling Folic acid-5 mg should be given OD preconceptually and throughout the pregnancy ACE inhibitors & angiotensin receptor blockers stopped before conception Early detection and treatment of malaria and infections

41. Multidisciplinary approach Routine BP measurement and urinalysis to detect hypertension and proteinuria Retinal screening/ fundoscopy for proliferative retinopathy Screening for iron overload (serum ferritin) Antibiotic prophylaxis-penicillin/erythromycin Termination planned for homozygous state

42. Low dose Aspirin from 12 wks of gestation Thromboprophylaxis with LMWH NSAIDS between 12 to 28 weeks Fluid and oxygen therapy(oxygen saturation > 95%) in painful crisis BT indicated only during complications like acute anemia/ACS/twin pregnancies, preeclampsia, septicemia, renal failure Iron therapy to be given if there is evidence of iron deficieny

43. Vaccine : H influenza type b, conjugated menigococcal C vaccine, peneumococcal vaccine & Hepatitis-B vaccine Timing of deliver : 38 -40 wks of gestation either by induction of labour /elective CS Factors to be avoided favouring sickling - Dehydration - Hypotension - Hypothermia - Acidosis - High conc. of HbS

44. CS is preferred over vaginal delivery when labour is not progressing well. Continuous FHR monitoring due to increases rate of still births/abruption/ compromosed placental reserve Adequate fluid therapy to avoid dehydration Counseling the parents regarding partner screening for carrier detection. Contraceptives Porgesterone only pill Injectable contraceptives LNG-IUS Barrier methods Sterilization

45. THALASSAEMIAS The synthesis of globin chain is partially or completely suppressed resulting in reduced Hb. content in red cells, which then have shortened life span. TYPES: - Alpha thalassaemia . - Beta thalassaemia : Major & Minor Microcytic haemolytic anaemias Reduced synthesis of one or more of polypeptide globin chains. .

46. Alpha thalassaemia . Major- pregnancy results in prematurity & nonimmune hydrops Major trait – iron & folic acid supplementation Higher transfusion requirements in pregnancy worsen haemosiderosis & cardiac failure

47. Beta thalassemia major genetic defect where the red cell survival time is reduced Severe anemia in early childhood Lead to progressive hepatosplenomegaly , impaired growth, anemia, CCF, infections Beta thalassemia minor Don’t require iron supplementation during pregnancy Blood transfusion

48. CLINICAL FEATURES Usually asymptomatic Weakness, fatigue, exhaustion, loss of appetite, indigestion, giddiness, breathlessness Palpitations, tachycardia, breathlessness, increased cardiac output, cardiac failure, generalised anasarca, pulmonary edema Pallor Nail changes Cheilosis , Glossitis , Stomatitis Edema Hyperdynamic circulation (short & soft systolic murmur) Fine crepitation s

49. Women with hemoglobinopathy should be offered oral iron therapy if serum ferritin <30 mcg/L Referral to secondary/tertiary care to be done if Severe anemia Significant symptoms Late gestation(34 wks) Failure to respond to oral iron TREATMENT

50. WHO - 60 mg Elemental iron + 400 micro gram Folic acid / day up to 3 months postpartum husband’s blood is tested for abnormality Councelled for risk of offspring

51. ANAEMIA ASSOC. WITH CHRONIC INFECTIONS / DISEASE Common in developing countries Poor response to Haematinics unless primary cause is treated Worm infestations is common ( Diagnosed by stool examination ) Urinary tract inf , & asymptomatic bacteriuria in preg . is assoc. with refractory anaemia Chronic renal disorders = due to erythropoietin def.

52. PREVENTION Dietary advice and modification(red meat/ poultry/fish) Germination and fermentation of cereals and legumes improve the bioavailability of iron in food Green peas/Whole wheat/Green vegetables/ Jaggery Iron supplementation of adolescent girls & non pregnant women A nutritious diet in a pregnant woman should be providing about 40 mg elemental iron daily.

53. Food fortification Fortification of staple food like wheat flour which is technically simple Fortification of curry powder, salt and sugar, dried and liquid milk Fortification of infant foods Fortification of complimentary foods

54. Identifying the etiology and treat accordingly Deworming with mebendazole / albendazole / levamisole Treated with recombinant Erythropoietin for renal disease. ATT to a patients with tuberculosis Antibiotics to treat UTI according to sensitivity TREATMENT

55. Treatment of hookworm Infestation, malaria,TB Avoidance of Hypoxia, Acidosis, Infection, Dehydration Stress , Exercise, Extreme, Temperature Avoidance of frequent child birth. Supplemented Viamin -C (250-500mg/day) with iron Adequate treatment for any infection like UTI

56. Early detection of falling Hb level, levels should be estimated at 1 st A/N visit, 30 th & finally 36 th week Mandatory monthly screening for anemia should be done in all antenatal clinics(especially at booking and at 28 wks with FBC) Screening and effective management of obstetric and systemic problems in all pregnant women

57. Aplastic Anaemia Bone marrow aplasia / hypoplasia means arrest of production of all blood elements like RBC, WBC and platelets PBF shows Pancytopenia . It can develop following bone marrow function depression by radiations , chemotherapy , industrial chemicals , drugs and viral infections . Repeated Whole blood transfusion , prednisolon , erythropoietin , nutrients , bone marrow transplantation Pluripotent stem cell therapy is indicated.

58. Thalassaemia If mother has Thalassaemia Trait , husband should be investigated for Trait .If both partners are positive for trait , prenatal diagnosis for foetal is indicated . There is 1: 4 chances of fetus being Thallassaemia major . Therapeutic termination of pregnancy is indicted in such situation . If foetus is has normal Hb Or Trait only Pregnancy can be continued and mange the anaemia by blood transfusion as per need.

59. SicKle Cell Haemoglobinopathy O.1- 1.0 % in west African and American blacks . RBC have abnormal HB called HbS, having faulty Beta chains in Hb, results from a single Beta chain substitution of glutamic acid by Valine at colon 6 of Beta globin chain . When HbS is exposed to low O2 tension ,Hb precipitates in long crystals , cell become elongated and sickle shape . Red cell membrane changes make these abnormal shaped cells more fragile –life span reduces resulting in anaemia .

60. signs

61. Management options : Blood transfusion S ymptomatic anaemia Hb < 6.0g% at 36weeks / close to delivery Hb < 10.0g% in Placenta Praevia for elective CS

62. Thank you and have a nice day