Anemia_Pregnancy Sept.08 2.ppthcxxjchfskoh

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1. BY: Dr. K.S.K JUSUBY: Dr. K.S.K JUSU
Department of O&G- SCSDepartment of O&G- SCS
Anemia in PregnancyAnemia in Pregnancy

2. Case 1Case 1

Mrs. A. N. is a 28-year-old woman in her second Mrs. A. N. is a 28-year-old woman in her second
trimester of pregnancy with her first child, and trimester of pregnancy with her first child, and
though her pregnancy had been progressing though her pregnancy had been progressing
normally, recently she has noticed that she normally, recently she has noticed that she
tires very easily and is short of breath from tires very easily and is short of breath from
even the slightest exertion. She also has even the slightest exertion. She also has
experienced periods of light-headedness, experienced periods of light-headedness,
though not to the point of fainting. Other though not to the point of fainting. Other
changes she has noticed are cramping in her changes she has noticed are cramping in her
legs, and the fact that her tongue is sore. legs, and the fact that her tongue is sore.

3. Upon examining, she has tachycardia, pale Upon examining, she has tachycardia, pale
gums and nail beds, and her tongue is gums and nail beds, and her tongue is
swollen. Given her history and the findings on swollen. Given her history and the findings on
her physical exam, she is suspected to be her physical exam, she is suspected to be
anemic and a sample of her blood is orderes anemic and a sample of her blood is orderes
for examination. for examination.

4. Table 1. Blood Sample Results
Red Blood Cell Count 3.5 million/mm
3
Hemoglobin (Hb) 7 g/dl
Hematocrit (Hct) 30%
Serum Iron low
Mean Corpuscular Volume (MCV) low
Mean Corpuscular Hb Concentration
(MCHC)
low
Total Iron Binding Capacity in the
Blood (TIBC)
high

5. 
A diagnosis of anemia due to iron A diagnosis of anemia due to iron
deficiency is made and oral iron deficiency is made and oral iron
supplements prescribed. Her symptoms supplements prescribed. Her symptoms
are eliminated within a couple of weeks are eliminated within a couple of weeks
and the remainder of her pregnancy and the remainder of her pregnancy
progresses without difficulty.progresses without difficulty.

6. Case 2Case 2

A 35 year old woman is seen for easy fatigue A 35 year old woman is seen for easy fatigue
for many months. She is now 24 weeks for many months. She is now 24 weeks
pregnant with her 3rd child in 3 years. She pregnant with her 3rd child in 3 years. She
does not see any obstetrician and does not does not see any obstetrician and does not
take any vitamins. Lately, she has developed a take any vitamins. Lately, she has developed a
taste for eating ice (craving to taste ice, soil taste for eating ice (craving to taste ice, soil
etc). She has no other complaint. Family and etc). She has no other complaint. Family and
past history are negative. She does not smoke past history are negative. She does not smoke
or drink. Physical examination is positive for or drink. Physical examination is positive for
pale conjunctiva, mild spooning of nails, and a pale conjunctiva, mild spooning of nails, and a
II/VI systolic murmur at left lower sternal II/VI systolic murmur at left lower sternal
border. Stools are negative for occult blood.border. Stools are negative for occult blood.

7. Labs:Labs:

Complete blood count (CBC)Complete blood count (CBC)
- Hb 7.1 gm/dl, Hct 23% - Hb 7.1 gm/dl, Hct 23%
- WBC 5,400/mm3 (differential is normal) - WBC 5,400/mm3 (differential is normal)
- Platelets 450,000/mm3- Platelets 450,000/mm3
- Mean Corpuscular volume (MCV) is 74 fl - Mean Corpuscular volume (MCV) is 74 fl
(normal 85-95 fl) (normal 85-95 fl)
- Red cell Distribution Width (RDW) is - Red cell Distribution Width (RDW) is
17.1% (normal 13-15). 17.1% (normal 13-15).

8. Defination of Anemia during Defination of Anemia during
Preg.Preg.

Hemoglobin below 11gm/dl in 1Hemoglobin below 11gm/dl in 1
stst
and and
33
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trimester and below 10.5gm/dl in trimester and below 10.5gm/dl in
second trimester.second trimester.

9. WHOWHO

11gm/dl or less11gm/dl or less

By this standard, 50% of women not on By this standard, 50% of women not on
hematinics become anemic.hematinics become anemic.

10. IncidenceIncidence
Anaemia may affect 10% of pregnancies
in developed countries and is
considerably commoner in developing
countries, where it is a major source of
maternal morbidity
and a contributor to mortality.
Up to 56% of all women living in
developing countries are anaemic (Hb <
11 g/dl) due to infestations.

11. ClassificationClassification

PhysiologicPhysiologic

Pathologic: Pathologic:
a. Deficiency: Iron, Folic A., Vitamin B12a. Deficiency: Iron, Folic A., Vitamin B12
b. Hemorrhagic: APH, Hookwormb. Hemorrhagic: APH, Hookworm
c. Hereditary: Thalassemia, Sickle, H. Hemolytic c. Hereditary: Thalassemia, Sickle, H. Hemolytic
AnemiaAnemia
d. Bone Marrow Insufficiency: Aplastic Anemiad. Bone Marrow Insufficiency: Aplastic Anemia
e. Infections: Malaria, TBe. Infections: Malaria, TB
f. Chronic Renal Diseases or Neoplasm.f. Chronic Renal Diseases or Neoplasm.

12. Concept of Physiologic AnemiaConcept of Physiologic Anemia

Disproportionate increase in plasma Disproportionate increase in plasma
vol, RBC vol. and hemoglobin mass vol, RBC vol. and hemoglobin mass
during pregnancyduring pregnancy

Marked demand of extra iron during Marked demand of extra iron during
pregnancy especially in second pregnancy especially in second
trimestertrimester

14. Criteria for Physiologic AnemiaCriteria for Physiologic Anemia

Hb: 10gm%Hb: 10gm%

RBC: 3.2 million/mm3RBC: 3.2 million/mm3

PCV: 30%PCV: 30%

Peripheral smear showing normal Peripheral smear showing normal
morphology of RBC with central pallormorphology of RBC with central pallor

16. Significance of HypervolemiaSignificance of Hypervolemia
1. To meet the demands of the enlarged uterus 1. To meet the demands of the enlarged uterus
with its greatly hypertrophied vascular system.with its greatly hypertrophied vascular system.
2. To protect the mother, and in turn the fetus, 2. To protect the mother, and in turn the fetus,
against the deleterious effects of impaired against the deleterious effects of impaired
venous return in the supine and erect positions.venous return in the supine and erect positions.
3. To safeguard the mother against the adverse 3. To safeguard the mother against the adverse
effects of blood loss associated with parturition.effects of blood loss associated with parturition.

17. 
Normal hemoglobin by gestational age Normal hemoglobin by gestational age
in pregnant women taking iron in pregnant women taking iron
supplementsupplement

12 wks12 wks 12.2 [11.0-13.4]12.2 [11.0-13.4]

24wks24wks 11.6 [10.6-12.8]11.6 [10.6-12.8]

40 wks40 wks 12.6 [11.2-13.6]12.6 [11.2-13.6]

19. Most common causes of Most common causes of
AnemiaAnemia

Iron loss : sweat, repeated pregnancy, Iron loss : sweat, repeated pregnancy,
hookworm infestation and malariahookworm infestation and malaria

Faulty absorption mechanism : due to Faulty absorption mechanism : due to
high incidence of intestinal infestation, high incidence of intestinal infestation,
there is intestinal hurrythere is intestinal hurry

Faulty diet habit : rich carbohydrate Faulty diet habit : rich carbohydrate
and high phosphate reduce absorption and high phosphate reduce absorption
of ironof iron

20. Factors lead to develop AnemiaFactors lead to develop Anemia

Increase iron demandIncrease iron demand

Diminished intake of ironDiminished intake of iron

Disturbed metabolismDisturbed metabolism

Pre-pregnancy health statusPre-pregnancy health status

Excess demandExcess demand

21. Iron Deficiency AnaemiaIron Deficiency Anaemia

Symptoms: lassitude, weakness, Symptoms: lassitude, weakness,
anorexia, palpitation, dyspneaanorexia, palpitation, dyspnea

Signs: Pallor, glossitis, soft systolic Signs: Pallor, glossitis, soft systolic
murmur in mitral area due to murmur in mitral area due to
physiologic mitral incompetencephysiologic mitral incompetence
Degree: Mild: 8-10gm%Degree: Mild: 8-10gm%
Moderate: 7-8gm% Moderate: 7-8gm%
Severe: <7gm% Severe: <7gm%

22. pallorpallor

23. Conjunctival PallorConjunctival Pallor

24. KoilonychiaKoilonychia

25. Smooth TongueSmooth Tongue

26. Interpretation of plasma Iron Interpretation of plasma Iron
IronIron TIBCTIBC FerritinFerritin
Iron deficiency Iron deficiency
anemiaanemia
DecreasDecreas
ee
IncreaseIncreaseDecreaseDecrease
Anemia of Anemia of
chronic diseasechronic disease
DecreasDecreas
ee
DecreasDecreas
ee
IncreaseIncrease
PregnancyPregnancy IncreaseIncreaseIncreaseIncreaseNormalNormal

27. Normal Iron Requirements
Iron requirement for normal pregnancy is 1gm
200 mg is excreted
300 mg is transferred to fetus
500 mg is need for mother
Total volume of RBC inc is 450 ml
1 ml of RBCs contains 1.1 mg of iron
450 ml X 1.1 mg/ml = 500 mg
Daily average is 6-7 mg/day

28. TreatmentTreatment
Prophylactic: Supplement Fe – 60 mg: Supplement Fe – 60 mg
elemental Fe with Folic elemental Fe with Folic
AcidAcid

Curative: 200mg FeSo4 3 times daily till Curative: 200mg FeSo4 3 times daily till
Hb level becomes normal, then Hb level becomes normal, then
maintenance dose of 1 tab for maintenance dose of 1 tab for
100 days 100 days

29. Megaloblastic AnemiaMegaloblastic Anemia

Due to impaired DNA synthesis, derangement Due to impaired DNA synthesis, derangement
in Red Cell maturationin Red Cell maturation

It may be due to Def. of VitB12 or Folic Acid or It may be due to Def. of VitB12 or Folic Acid or
both.both.

Megaloblastic anemia in pregnancy is almost Megaloblastic anemia in pregnancy is almost
always due to Folic Acid def.always due to Folic Acid def.

Vit B12 def is rare in Pregnancy becoz its need Vit B12 def is rare in Pregnancy becoz its need
is less in amount and amount is met with any is less in amount and amount is met with any
diet that contains animal products. diet that contains animal products.

30. Sign and symptomsSign and symptoms

Insidious onset, mostly in last trimesterInsidious onset, mostly in last trimester

Anorexia and occasional diarrhoeaAnorexia and occasional diarrhoea

Pallor of varying degreePallor of varying degree

Ulceration in mouth and tongueUlceration in mouth and tongue

Hemorrhagic patches under the skin Hemorrhagic patches under the skin
and conjunctivaand conjunctiva

Enlarged liver and spleenEnlarged liver and spleen

31. Angular CheilosisAngular Cheilosis

32. Blood valuesBlood values

Hb<10gm%Hb<10gm%

Hypersegmentation of neutrophilsHypersegmentation of neutrophils

MegaloblastMegaloblast

MCV>100micrometer3MCV>100micrometer3

MCH>33pg, but MCHC is NormalMCH>33pg, but MCHC is Normal

Serum Fe is Normal or high TIBC is lowSerum Fe is Normal or high TIBC is low

33. TreatmentTreatment

ProphylacticProphylactic
- all woman of reproductive age should - all woman of reproductive age should
be given 400mcg of folic acid dailybe given 400mcg of folic acid daily

CurativeCurative
-daily administration of Folic acid 4mg -daily administration of Folic acid 4mg
orally for at least 4 wks following orally for at least 4 wks following
deliverydelivery

34. Sickle cell HemoglobinopathySickle cell Hemoglobinopathy

Hbs comprises 30-40% total HbHbs comprises 30-40% total Hb

There is substitution of Lysine for glutamic acid There is substitution of Lysine for glutamic acid
at the sixth position of B chain of Hbat the sixth position of B chain of Hb

Red cells in oxygenated state behave normally, Red cells in oxygenated state behave normally,
but in deoxygenated state it aggregates, but in deoxygenated state it aggregates,
polymerises and distort red cells to sickle. polymerises and distort red cells to sickle.

These cells are more fragile and increased These cells are more fragile and increased
destruction leads to hemolysis, anemia and destruction leads to hemolysis, anemia and
jaundice.jaundice.

36. Effects on pregnancyEffects on pregnancy

Increase incidence of abortion, Increase incidence of abortion,
prematurity, IUGR and Fetal loss.prematurity, IUGR and Fetal loss.

Perinatal mortality is high.Perinatal mortality is high.

Incidence of pre-eclampsia, postpartum Incidence of pre-eclampsia, postpartum
hemorrhage and infection is increased.hemorrhage and infection is increased.

37. ManagementManagement

Careful antinatal supervisionCareful antinatal supervision

Air travelling in unpressurised aircraft Air travelling in unpressurised aircraft
to be avoided.to be avoided.

Prophylatically Folic A. 1gm daily.Prophylatically Folic A. 1gm daily.

Regular blood transfusion at approx. in Regular blood transfusion at approx. in
6 weeks interval6 weeks interval

40. My ReferencesMy References

44. Thank YouThank You