ANEMIA IN PREGNANCY-1(1).pptxrrrrrrrrrrrr

fafa

1. ANEMIA IN PREGNANCY Dr Noor Nakiwunga Lecturer IUIU

2. Anemia in pregnancy is Hb of less than 11g/dl (Hct < 33%) in the first and third trimesters and less than 10.5g/dl (Hct < 32%) in the second trimester(ACOG & WHO) Anemia is the commonest medical condition in pregnancy. The two commonest causes of anemia in pregnancy and puerperium are iron deficiency and acute blood loss. WHO estimates that over 40 percent of pregnant women globally have anemia

3. Classification Normocytic, normochromic anaemia ( Chronic disease, aplastic, endocrine dysfunction, haemolytic, haemorrhagic anemias) Microcytic, hypochromic anaemia (iron deficiency, sideroblastic, thalassemia, lead poisoning and anaemia of chronic disease) Macrocytic, normochromic (folic acid deficiency and vit. B12 deficiency)

4. Causes of anemia in pregnancy • Increased demands of iron • Diminished intake of iron • Diminished absorption • Disturbed metabolism due to infections including asymptomatic bacteriuria • Pre-pregnant health status • Excess demand: Multiple pregnancy, S.I.P.I and the demand of iron which accompanies the natural growth before the age of 21

5. Clinical features Weakness Malaise Fatigue Headache Poor concentration Dyspnea Increased cardiac output causing palpitations, Angina intermittent claudication of the legs Symptoms of cardiac failure.

6. Effects of anemia on pregnancy and outcomes To mother Placenta abruption Increased risk of PPH Increased risk of sepsis Cardiac failure Increased risk of maternal mortality To the baby Increased risk of preterm birth Low birth weight Small for gestation age infants Impaired psychomotor and mental development in infants esp those born to iron deficient mothers.

7. Physiological anemia in pregnancy Pregnancy causes a state of hydraemic plethora. There is disproportionate increase of plasma volume during pregnancy leading to apparent reduction of RBC, hemoglobin and hematocrit value i.e., Plasma vol. increases by app. 45-50% Total red blood cell vol. increases by 20-30% (due to an increase in circulating Erythropoietin 50% increase)

8. Because Plasma vol. increase is 3 times greater than the RBC vol. increase, the net result is a decrease in total RBC, HCT and Hb. This results in Hemodilution which is maximal at 28-34wks. Increased iron requirements to 1g per day (300mg for placenta &fetus, 500mg mother & 200mg excreted)

9. Iron deficiency anemia. Iron stores in non pregnant women are generally marginal due to menstrual blood loss and thus iron loss. Usual menses loss is app 12-15mg of Elemental iron Iron requirements increase ;during pregnancy by about 1000mg over the usual iron stores of 2-2.5g in adult women. The need for iron begins early in the 2 nd half of pregnancy increasing from an additional 0.8mg/day In early pregnancy to 7.5mg/day by term.

10. The amount iron needed by the fetus, placenta and to replace usual maternal losses is an obligatory requirement that is met regardless of the cost to maternal iron stores. Even if the mother has low iron levels and is anemic the fetus will usually not suffer because the placenta continues to transport iron to meet fetal needs. Even with adequate nutrition 10-20% of pregnant women will develop Iron deficiency

11. Note; With very severe iron deficiency the fetus may have decreased RBC vol. Hb, iron stores and cord ferritin levels and an increased risk of iron deficiency during infancy. Iron deficiency anemia is ass. With an increased risk of low birth weight, preterm Birth and perinatal mortality

12. Diagnosis CBC Serum ferritin levels < 10-15mg/l confirm iron deficiency anemia . Note; S. ferritin is an acute phase reactant and may be falsely high in the presence of an infection. Total iron binding capacity and serum iron often fall during pregnancy as well as in IDA hence not useful test

13. MANAGEMENT Management is by treatment and prevention Due to increased demand dietary supplement is not enough Daily supplementation of 30-60mg of iron and 400micrograms of folic acid (provided by Ferrous sulphate 150mg, Ferrous Gluconate 300mg, Ferrous Fumarate 100mg daily) Iv ferrous sucrose (5-10mg weekly) can be given in women who don’t tolerate oral medication

14. Prevention of Anemia in pregnancy Child births spacing ↔ at least 2 years Supplementary iron therapy: Daily administration of 300 mg of FeSO4 (containing 60 mg of elemental iron) along with 1 mg folic acid Dietary prescription: A realistic balanced diet, rich in iron Deworming Adequate treatment for helminthiasis,malaria,dysentry,bleeding piles, UTI Early detection: Hb level should be estimated at 1 st antenatal visit, at 30th & finally at 36th wk .

15. Acute blood loss anemia Common in early pregnancies( abortion, hydatiform mole and ectopic pregnancies) Most common in postpartum from obstetrical hemorrhage. Transfusions are not recommended for Hb above 7g/dl, hemodynamically stable and able to ambulate and is not septic. Instead, iron therapy is given for at least 3 months or intravenous ferric carboxymaltose given weekly.

16. Anemia due to chronic disease Women with chronic disease may develop anemia for the 1 st time during pregnancy. Causes include; CRD, IBD, HIV, Cancer etc In pts with CRD recombinant Erythropoietin is considered. One worrisome side effect is HTN which is already prevalent in women with Renal disease.

17. Megaloblastic Anemia X- sed by blood and bone marrow abnormalities from impaired DNA synthesis. May be 2ndary to folic acid deficiency or Vit. B12 def. Folic acid deficiency is common in women who don’t consume fresh green leafy vegs, legumes or animal protein. As folate def. and anemia worsen, anorexia often becomes intense and further aggravates the dietary def. Excessive alcohol ingestion also causes or contributes to folate def.

18. In non preg women the folic acid requirement is 50-100mcg/day. During pregnancy the requirement increases and 400mcg/day is recommended. Early morphological changes usually include neutrophils that are hyper segmented and newly formed erythrocytes that are macrocytic. Note; Fetus and placental extract folate from maternal circulation so effectively that the fetus is not anemic despite severe maternal anemia however there is increased risk of neural tube defects

19. Pregnant women should receive 400mcg of folic acid daily. For women who previously had an baby with a neural tube defect should receive about 4mg of folic acid preconceptionally and throughout pregnancy

20. Vitamin B12 deficiency; Example is Addison's pernicious anemia … Absence of intrinsic factors that allow for B12 reabsorption in the gut. Autoimmune common in women over 40yrs Seen in women who have had gut pathology or resection or those with Crohn disease. Those who have undergone total gastrectomy require 1000mcg of vit. B12 given IM monthly.

21. Haemolytic anaemia Pregnancy induced hemolysis. Autoimmune hemolysis Drug induced hemolysis Paroxysmal nocturnal Hemoglobinuria Severe Pre eclampsia and eclampsia (HELLP Syndrome) Acquired Haemolytic Anemia is due to exotoxin of clostridium perfringes or Group A β hemolytic streptococci

22. Read Sickle cell anemia in pregnancy Aplastic anemia Thalassemia

23. QUESTIONS??? THANK YOU FOR LISTENING!