Anemia in Pregnancy

Anemia in Pregnancy

1. ANEMIA IN PREGNANCY BY A.RAMANA PRIYA

2. What is Anaemia ? Anaemia is defined as reduction in circulating haemoglobin mass below the critical level. The normal haemoglobin ( Hb ) is 12-14 gm%. WHO has accepted up to 11 gm% as the normal haemoglobin level in pregnancy. Therefore any haemoglobin level below 11gm in pregnancy should be considered as anaemia

3. What is the Incidence of Anaemia ? Anaemia in pregnancy is present in very high percentage of pregnant women in India. Exact data is not available about the prevalence of nutritional anaemia. However according to WHO, the prevalence of Anaemia in pregnancy in south East Asia is around 56 %. In India incidence of anaemia pregnancy has been noted as high as 40-80%.

4. IRON REQUIREMENT IN PREGNANCY Total iron requirement is 1000 mg. Fetus and placenta -- 300 mg ↑ in red cell mass – 500 mg Basal loss – 200 mg Average requirement is 4-6mg/day. 2.5 mg/day in early pregnancy 5.5 mg/day from 20-32 weeks 6-8 mg/day from 32 weeks onwards

5. How will you classify anaemia ? Anaemia is often classified as Mild degree (9-11 gm %) Moderate (7-9 gms %) Severe (4-7 gm %) Very severe (<4gm %) It is also classified according to Haematocrit (PCV) %.

6. Maternal Risk Factors Antenatal Period -Poor weight gain -Preterm labour -PIH -Placenta Previa -PROM Postnatal Period -Postnatal sepsis -Sub involution -Embolism Intranatal Period -Dysfunctional Labour - Intranatal -Hemorrhage -Shock -Cardiac Failure - Anaethesia risk What are the maternal risk factors ?

7. Fetal and Neonatal Risk Factors Prematurity Low birth weight Poor apgar score Foetal distress Neonatal Anaemia What are the fetal and neonatal risk factors ?

8. What are the Causes of anaemia ? Physiological Nutritional: Iron deficiency Folate &/or Vit B12 deficiency Dimorphic Hemorrhagic: Acute or Chronic Hemoglobinopathies Hemolytic: Congenital or acquired Aplastic anaemia

9. What are the Clinical presentation of anaemia ? Symptoms Fatigue Loss of appetite Digestive upset Dyspnoea Palpitation Signs Pallor Pale nails Koilonychias Pale Tongue Severe Case - Oedema

10. What are the Investigations? CBC Pheripheral Smear – Hypochromic Microcytosis Poikilocytosis Anisocytosis MCV, MCH, MCHC TIBC Serum Iron Serum Ferritin Free erythrocyte protoporphyrin Bone marrow examination Urine examination Stool examination Serum protein

11. Special tests Serum Folate RBC folate Serum Vit B12 Serum Bilirubin Coombs test HB electrophoresis NESTROF test Red cell osmotic fragility

12. What are the propylactic measures can be taken? Routine screening for anaemia for adolescent girls from school days Encouraging iron rich foods Fortification of widely consumed food with iron Providing iron supplementation from school days Annual screening for those with risk factors

13. PREVENTION OF IRON DEFICIENCY Prophylaxis of non-pregnant women – 60 mg of elemental iron daily for 3 months. Iron supplementation during pregnancy. Routine iron supplementation is debatable in western countries It has to be given in non-industrialized countries W.H.O RECOMMENDATION: Universal oral iron supplementation for pregnant women (60 mg of elemental iron and 400 µg of folic acid) for 6 months in pregnancy and additional of 3 months post-partum where the prevalence is more than 40%.

14. PREVENTION OF IRON DEFICIENCY (Contd.) MINISTRY OF HEALTH, GOVT. OF INDIA RECOMMENDATION: [CSSM] 100 mg of elemental iron with 500 µg of folic acid in second half of pregnancy for atleast 100 days. 2 injections of iron dextran (250 mg each) given IMI at 4 weeks interval with TT injection. Treatment of hook worm infestation Single albendazole (400 mg) or mebendazole (100 mg x BD x 3 days) Change in defecation habits and avoidance of walking bare footed.

15. What are the iron rich food? Pulses,cereals,jaggery,beet root,green leafy vegetables,meat,liver,egg,fish,legumes,dry beans

16. What are the effects of anemia on pregnancy? MOTHER PREGNANCY- Cardiac failure at 30-34 wks of pregnancy Increased susceptibility to infection Preterm labour Preeclampsia LABOUR- Uterine inertia Post partum haemorrhage Cardiac failure shock

17. Puerperium Cardiac failure Puerperal sepsis Subinvolution Failing lactation Chronic ill health,backache FETUS&NEONATE Prematurity IUGR Increased perinatal death Decreased iron stores in neonate

18. How will you manage anemia? ORAL IRON THERAPY Safe,inexpensive and effective way to administer iron National nutritional anemia prophylaxis program suggest 60 milligrams of elemental iron and 500 micrograms of folic acid daily However it is suggested that 120 milligram of elemental iron and 1 milligram of folicacid are the optimum daily dose needed

19. SALT TABLET ELEMENTAL IRON Ferrous sulfate 200mg 60mg[30%] Ferrous fumarate 200mg 66mg[33%] Ferrous gluconate 320mg 36mg[12%] Ferrous succinate 100mg 35mg[35%] Ferric ammonium citrate 125mg 25mg[17-22%] Ferrous ascorbate ------ 100mg Carbonyl iron ------- 90mg Sodium feredetate ------- 231mg Hb preparation 2.1g [0.33%]

20. SIDE EFFECTS OF ORAL IRON UPPER GI TRACT Nausea,gastric discomfort,loss of apetite,staining of teeth LOWER GI TRACT Constipation,diarrhoea,flatulance

21. PARENTRAL IRON THERAPY Preparation Iron sucrose-Imax S[100mg/5ml], orofer s[50mg /2.5ml] Iron sorbital citric acid complex- jectocos Iron dextran-imferon

22. Intramuscular iron 0.5ml test dose should be given 75/100mg/day is given daily on alternate days Given deep Im by Z- techniue to prevent skin staining Side effects- painful,discolouration,injection abscess

23. INTRAVENOUS IRON Formula-0.66*% deficit of Hb *wt in kg=mg of iron Total dose in mg/50=ml of imferon Total dose is given in normal saline COMPLICATION Local- thrombophlebitis at IV site Systemic- malaise,fever,arthralgia,utricaria lymphadenopathy

24. BLOOD TRANFUSION Indicated insevere anemia at any GA,moderate anemia beyond 36wks and when there is a failure of response to iron therapy,severe hemorrhage like APH,PPH,rupture uterus,cesarean section,first trimester hemorrhage,thalassemiasand sickling disorders in pregnancy

25. ADVERSE REACTIONS Tranfusion reaction Infection Volume overload Others like hypothermia,citrate toxicity,hyperkalemia,hypocalcemia and rarely air embolism

26. MANAGEMENT DURING LABOUR First stage – Comfortable position Adequate analgesia Arrangement for oxygen, Digitalization maybe required in cardiac failure due to severe anaemia Antibiotic prophylaxis

27. MANAGEMENT DURING LABOUR (Contd.) Second stage – Cut short by forceps application. Active management of third stage During puerperium Adequate rest Iron and folate therapy for 3 months Infection if any should be treated energetically Careful watch for puerperal sepsis, failing lactation; sub involution of uterus and thromboembolism

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