Anemia in pregnancy by Sunil Kumar Daha

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1. Anemia and pregnancy Sunil Kumar Daha

2. Anemia: Haemoglobin level below 12gm/dl normally and 10mg/dl at any time during pregnancy or puerperium 20% of maternal deaths in 3 rd world countries Introduction

3. CAUSES IN PREGNANCY At pregnancy demand of iron iron intake absorption Disturbed metabolism

4. SYMPTOMS Exhaustion Anorexia Indigestion Palpitation Dyspnoea Swelling of legs

5. SIGNS: Pallor with evidence of glossitis and stomatitis Edema of legs due to hypoproteinemia or associated pre- eclampsia Systemic murmur in mitral area due to physiological mitral incompetence Crepitations due to pulmonary oedema

6. CLASSIFICATION Physiological anemia of pregnancy Pathological Deficiency anemia Iron deficiency Folic acid deficiency Vitamin B12 deficiency Protein deficiency

7. CONTD…. Hemorrhagic Acute (in early months/APH) Chronic (Hook worm infestation , bleeding piles) Hereditary Thalassemia Sickle cell Hereditary haemolytic anemia

8. Bone marrow insufficiency ( hypoplasia / aplasia ) Anemia of infection (Malaria, T.B.) Chronic disease (Renal/neoplasm)

9. Physiological anemia

10. PHYSIOLOGICAL ANEMIA IN PREGNANCY

11. Diagnostic criteria (2 nd half of pregnancy) Hb – <10 gm% RBC – 3.2 per cubic millimeter (4.2 – 5.4 × 106 /µl) PCV – 32% (37% - 48%) Peripheral smear – Normocytic , normochromic

12. TREATMENT  If there are signs suggestive of fetal hypoxemia  red cell transfusion Resolve by six weeks postpartum since plasma volume has returned to normal by that time

13. Is the most common cause along with acute blood loss. Is due to increase iron demand Fe stores being constant or depleted in pregnant state is the cause. IRON DEFICIENCY ANEMIA

14. CRITERIA FOR IRON DEFICIENCY ANEMIA Hb - <10gm% RBC - <4 million per cubic mm PCV - <30% MCHC - <30% PBS: microcytic and hypochromic (not seen in moderate) reduced serum ferritin level and increased TIBC

15. COMPLICATION OF ANEMIA During pregnancy: Pre- eclampsia Intercurrent infection Heart failure at 30-32 weeks of pregnancy Pre-term labour During labour : Post partum haemorrhage Cardiac failure Shock

16. Puerperium : Puerperal sepsis Sub involution Prolactation Puerperal venous thrombosis Pulmonary embolism Effects on baby: Low birth weight babies IUFD due to maternal anoxemia

17. PROPHYLAXIS Avoid frequent child birth Supplementary iron therapy Dietary prescription Treat the underlying cause Early detection of Hb level .

18. CURATIVE Hospitalization: If Hb level at or < 9 gm/dl . General treatment: Diet : protein, iron, vitamins Acid pepsin : after meal to improve appetite and facilitate digestion Antibiotics : If septic focus Therapy for underlying diseases

19. Specific therapy: to restore Hb and iron reserve. Two types of iron therapy Oral Parenteral

20. ORAL THERAPY Ferrous gluconate , fumarate , succinate , sulphate Ferous sulphate is the widely used Regimen: 1 tab TDS with or after meal in a day Maximum tablet per day is up to 6/day till blood picture is normal Maintenance dose: 1 tablet for 100 days following delivery

21. Points to consider while on therapy: Epigastric pain, nausea, vomiting, diarrhea and constipation Absorption reduced by anta-acids, oxalates &phosphates Absorption increased by ascorbate, lactate and amino acids Contraindications: Severe oral intolerance Severe anemia in advanced pregnancy

22. PARENTERAL THERAPY Intravenous: Drugs: Iron Dextran : TDI = 0.3 × W(100-Hb%) mg of elemental iron W= wt. in pounds, Hb % = percentage concentration of Hb Additional 50% for partial replenishment. Iron sucrose : TDI = 2.3 × W × D +500 ; where W= wt. in kg before pregnancy, D= Hb (target-actual), 500= 500mg for body store

23. PROCEDURES Patient is admitted in the morning for infusion Required iron is mixed in 500ml of normal saline Drips is to be 10 drops/min in 1 st 20 mins Drips increased to 40 drops/min thereafter If rigors, hypo-tension or chest pain seen call it a quit.

24. INTRAMUSCULAR THERAPY Iron dextran Iron sorbitol citric acid complex in dextrin 50mg elemental iron per ml contained in both Total required dose calculated previous formula: Oral iron suspended 24 hrs prior to therapy to avoid reaction

25. Problems with IM Injection is painful Staining of the skin Fever Lymphadenopathy Headache Nausea Vomiting Allergic reactions

26. Blood transfusion If anemia is due to blood loss , combat PPH Severe anemia in later months of pregnancy(beyond 36 weeks to improve anemic state and oxygen carrying capacity of blood patient goes into labour ) Refractory anemia: anemia not responding to either oral or parenteral therapy inspite of correct typing

27. Management during labour First stage: Make the patient lie in bed and make her comfortable Arrange for oxygen inhalation Strict asepsis Second stage Asepsis maintained Low forceps or vaccum delivery IV methergin 0.2mg following delivery of anterior shoulder Methergin ( methylergometrine ): Active management of the 3rd stage of labor (as means to promote separation of the placenta and to reduce blood loss).

28. Third stage: Should be more attentive. Significant amount of blood loss should be replenished by fresh packed cell transfusion Danger of post partum overloading to heart should be avoided Puerperium Prophylactic antibiotic Continuation of antianemic therapy given before delivery till patient restores her normal clinical and hematological states Even in normal cases, iron therapy continued for at least 3 months following delivery Patient should be warned of the danger of recurrence in subsequent pregnancies .

29. Megaloblastic anemia

30. CAUSES OF B12 DEFICIENCY Vegetarian diet Gastritis Gasterectomy Ileal bypass Chron’s disease Drugs: Metformin , PPI

31. CAUSES OF FOLIC ACID DEFICIENCY Inadequate intake Increased demand Decreased absorption Abnormal demand (infection, hemorrhagic state, hemolytic state) Failure of utilization (anti epileptics, infection) Decreased storage (hepatic disorder, vitamin C deficiency) Iron deficiency anemia.

32. CLINICAL FEATURES Insidious onset usually First revealed in last trimester or acutely in early puerperium Anorexia or protracted vomiting Occasional diarrhea Unexplained fever associated

33. HEMATOLOGICAL FINDINGS of MbA 1.Hb <10 gm% 2. Peripheral blood smear, 2 or more features seen: Neutrophil hypersegmentation (5 or >lobes) Macrocytosis and anisocytosis Giant polymorphs Megaloblasts Howell-Jolly bodies Buffy coat smear more diagnostic 3. MCV >100micro cube, MCH >33 pg, MCHC- normal

34. 4. Associated leukopenia and thrombocytopenia 5. Serum iron normal or high, TIBC decreased 6. Serum folate <3mg/ml ,(in non-pregnant 2.8-8 ng /ml normal) 7.Serum vit B12 <90pg/ml (normal- 300pg/ml) 8. BM- megaloblastic erythropoiesis

35. COMPLICATIONS OF MEGALOBLASTIC ANEMIA Abortion Dysmaturity Prematuirity Abruptio placentae Fetal malformation (cleft palate, NTD )

36. PROPHYLAXIS All reproductive age group woman given 400 micro gm of folic acid Additional 4mg given where demand is high (like in multiple pregnancy, anti- convulsants , hemoglobinopathies , woman with NTD infants)

37. MANAGEMENT Daily administration of folic acid 4mg orally Continued for at least 4 weeks following delivery

38. APLASTIC ANEMIA Rarely seen in pregnancy Immunologically mediated or autosomal recessive inheritance Marked decrease in marrow stem cells

39. COMPLICATIONS Hemorrhage Infection Diagnosis: Blood: anemia, leukopenia , thrombocytopenia Bone marrow: Hypocellular

40. MANAGEMENT Repeated blood transfusion to maintain HCT>20 Granulocyte transfusion to combat infection Platelet transfusion to control hemorrhage Glucocorticoids in some In severe cases: Bone marrow or stem cell transplantation

41. References Williams Obstetrics, 24 th Edition DC Dutta’s Textbook of Obstetrics, 7 th Edition