ANEMIA IN PREGNANCY

1
ANEMIA IN PREGNANCY
2

• Dr Anahita Chauhan
• Associate Professor Unit Head
• Seth G S Medical College KEM Hospital
• Honorary Consultant,
• Saifee St. Elizabeth Hospital

3
Background

• Anaemia is the commonest medical disorder during
  pregnancy
• Greek meaning without blood
• Iron deficiency anaemia is the most common type
  of anaemia during pregnancy
• NFHS 2003-06 57.9 of pregnant women
• 25 direct maternal deaths

4
Definitions of Anemia in Pregnancy

• WHO - Hemoglobin concentration lt11gm/dl
  hematocrit of lt33
• CDC definition- Hb lt11gm/dl during the first and
  third trimesters and lt10.5gm/dl in th second
  trimester (to allow for the physiological fall
  due to hemodilution in second trimester)
• FOGSI - a cut off of 10 gm/dl for India

5
Classification Based on Severity
ICMR WHO
Mild 10 11 gm/dl 9 11 gm/dl
Moderate 7 10 7 - 9
Severe 4 7 lt7
Very severe lt4 decompensated
6
Causes of Anemia in Pregnancy

• Physiological anemia
• Nutritional anemia IDA, megaloblastic
• Anemia of chronic illness
• Blood loss
• Hemolysis and hemolytic anemias
• Hemoglobinopathies
• Other hereditary anemias
• Aplastic anemia

7
Increased Iron Demands

• 1000mg extra elemental iron required in pregnancy
• Cannot be met by diet alone
• Undernutrition compounds the problem

8
Normal Reference Ranges
Hematological index Reference range
MCV (PCV/ RBC) 75 98 fl
MCH (Hb) 25 31 pg
MCHC 32 36
TIBC 325 400 µ/ 100ml
Fe/ TIBC ratio 30
9
Morphological Classification

• By the size of the RBCs
• Macrocytic anemia (MCV gt 100)
• Normocytic anemia (80 lt MCV lt 100)
• Microcytic anemia (MCV lt 80)

10
Clinical Features - Symptoms

• Mild anemia is usually asymptomatic
• Moderate anemia - weakness, fatigue, exhaustion,
  loss of appetite, indigestion, giddiness,
  breathlessness
• Severe anemia - palpitations, tachycardia,
  breathlessness, increased cardiac output, cardiac
  failure, generalised anasarca, pulmonary edema

11
Clinical Features - Signs

• Pallor
• Nail changes
• Cheilosis, Glossitis, Stomatitis
• Edema
• Hyperdynamic circulation (short soft systolic
  murmur)
• Fine crepitations

12
Effects of Anemia on Mother

• Antepartum
• Preterm labor
• Pre eclampsia
• Sepsis
• IUGR
• Intrapartum
• Uterine inertia
• PPH
• Cardia failure

13
Effects of Anemia on Mother

• Postpartum
• Puerperal sepsis
• Subinvolution
• Pulmonary embolism
• Failure of lactation
• Delayed wound healing
• Cardiac failure

14
Fetal Effects

• Prematurity and LBW
• IUGR
• IUFD
• Increased perinatal mortality
• Iron Deficiency Anemia due to lower iron stores
  can cause poor mental performance or behavioral
  abnormalities in later life

15
Diagnosis Baseline/ Presumptive

• Haemoglobin Measurement
• Peripheral blood smear
• Reticulocyte count
• Hematocrit
• Blood indices
• MCV, MCHC, MCHC
• Stool Examination
• Urine Examination
• Proteins, LFT, RFT

16
Therapeutic Trial of Iron
17
Diagnosis - Additional

• Serum Fe
• Total iron binding capacity
• Serum Ferritin
• Saturation
• Hb electrophoresis
• Bone marrow examination

18
Lab findings in IDA

• Hb lt 11 gm/dl
• Peripheral smear - microcytic, hypochromic
• MCV and MCHC are low
• Serum iron is low - lt 50 µgm/dl (N 60 -175)
• TIBC is increased - gt 400 µgm/dl
• Tests of iron stores
• Serum ferritin is lt 12 µgm/dl (N 40-200)
• Stainable iron in the bone marrow is reduced

19
Newer investigations

• Serum transferrin receptors
• Transferrin receptor/ ferritin index
• Reticulocyte indices
• automated counting of reticulocytes, count of
  lt26pg/ cell is a strong predictor of IDA
• Reticulocyte production index
• Red cell zinc protoporphyrin level

20
IDA ACD Thalass-emia Sidero-blastic
Severity Variable Mild Mild Variable
MCV Decreased Normal/ decreased Decreased Normal/ decreased
S Ferritin Decreased Normal/ increased Normal Increased
TIBC Increased Decreased Normal Normal
S Iron Decreased Decreased Normal Increased
Marrow iron -
21
IDA Beta thal
Population All Greeks, Italians
RDW High Normal
MCV Low Low
Serum iron Decreased Normal
Ferritin Decreased Normal
TIBC Increased Normal
Hb electro- phoresis Normal Increased HbA2
22
Mentzer Index

• Calculation that may (or may not) be useful in
  differentiating thalassemia minor from IDA
• Mentzer Index MCV/RBC Count
• lt13 Thalassemia minor
• gt13 Iron Deficiency
• Useful in children

23
Folic Acid Deficiency Anemia

• Deficiency of folate or B12
• Anticonvulsants, oral contraceptives, sulfa
  drugs, and alcohol can decrease absorption of
  folate from meals
• Folate is essential for normal growth and
  development
• Coexists with IDA

24
Diagnosis

• Macrocytes on peripheral smear
• Hypersegmentation of neutrophils
• Pancytopenia
• Low Hb and high MCV
• Megablastosis on bone marrow
• Serum folate lt3ng/ ml

25
Prevention

• Dietary advice and modification
• Iron supplementation of adolescent non pregnant
  women
• Treatment of hookworm Infestation
• Iron supplementation in pregnant women
• Food fortification
• Antenatal care for early recognition

26
Management of Anemia

• Oral Iron Therapy
• Prophylactic Iron therapy- 100mg elemental iron
  daily with 500 mcg of folic acid
• Deworming of all anemic patients
• Treatment of Anemia- 200mg of elemental iron
  folate 5mg/d

27
Iron Requirement in Pregnancy

• 2.5mg /day in early pregnancy
• 5.5mg /day from 20 -32 weeks
• 6 8 mg/ day after 32 weeks
• Average 4 mg/ day

28
Side effects of Oral iron

• Nausea
• Vomiting
• Constipation
• Abdominal cramping
• Diarrhoea

The tablet can be given with meals or different
brand may be tried
29
Reasons for Failure to Respond

• Non compliance
• Concomitant folate deficiency
• Continuous loss of blood through hookworm
  infestation or bleeding haemorrhoids
• Co-existing infection
• Faulty iron absorption
• Inaccurate diagnosis
• Non iron deficiency microcytic anaemia

30
New Therapeutic Alternatives

• The side effects of older Iron preparations
  their poor compliance even on providing free
  tablets are the most important reasons of failure
  of anaemia control programmes
• Newer preparations are better tolerated, have
  less side effects with better compliance
• Carbonyl Iron
• Iron ascorbate

31
Merits of New Preparations

• Outstanding GI Tolerance in contrast to 20
  severe side effects with conventional therapy
• Very safe with no poisoning even in high doses
• No interaction with food stuffs
• The newer preparations are delicious with
  non-metallic taste and dont stain the patients
  teeth
• Hence the compliance is very high

32
Parenteral Iron therapy

• Indicated when the pregnant woman is unable to
  take iron due to side effects or is non compliant
• Its main advantage is certainty of administration
  
• Rise in hemoglobin is similar to oral iron (upto
  1gm per wk)

33
Preparation dosage

• Iron Dextran IM and IV high molecular wt stable
  complexes release iron slowly, can cause
  anaphylaxis
• Iron citrate sorbitol IM less stable, rapid
  release of iron
• Iron sucrose IV intermediate stability, rapid
  metabolism hence readily available iron. Since
  they do not form biological polymers, there are
  no reactions

34
Precaution

• Oral Iron to be suspended 48 hours before
  parenteral therapy
• Emergency measures like inj hydrocortisone
  adrenaline, oxygen cylinder to be kept ready
• Look for reaction while giving infusion

35
Dose calculation

• Older preparations each 1ml 50mg elemental
  iron
• 0.3 x Wt in lb x (100 Hb) 500
• Iron sucrose each ml 20mg elemental iron
• Dose 200mg slow IV alternate day
• 0.24 x wt in kg x (target Hbpt Hb) 500

36
Disadvantages

• Pain
• Nausea, vomiting, headache
• Skin discolouration
• Abscess formation
• Fever
• Lymphadenopathy
• Allergic reaction
• Anaphylaxis

37
Blood Transfusion

• Severe anemia, especially after 36 weeks
• Hemorrhage
• Associated infections
• Packed cells preferred
• Exchange transfusion rare

38
Use of Erythropoetin

• Used in severe anemia renal failure for
  significant increase in Hb and to avoid blood
  transfusion
• Gynaecological surgeries - preop use of
  erythropoietin and Iron Dextran has been shown
  to avoid the need for blood tranfusion later

39
Dosage Regimen Erythropoetin

• Inj erythropoetin can be given subcut or iv
  100-15 iu/kg
• On day 1, 3 5 along with parenteral iron or
  day 1, 3 5 6000units s/c erythropoetin and iron
  dextran 100mg deep im daily for 5 day
• First dose given after subcut sensitivity test
• Adrenaline, hydrocortisone, oxygen to be kept
  ready
• Produces 3gm rise in Hb over a 2wk period

40
Management in Labor

• Make patient comfortable, oxygen
• Sedation and analgesia
• Prevent cardiac failure
• Aim to deliver vaginally
• Antibiotics
• Cut short second stage
• Active management of third stage

41
Clinical Case Scenarios

• A primigravida presents at 28 wks of gestation
  with pallor, hemoglobin 7.8g, no other medical
  comorbidity, good functional status. Most
  pragmatic first line therapy in cases with
  assured compliance would be
• a. blood transfusion
• b. parenteral iron
• c. oral iron
• d. oral plus parenteral iron
  Answer c

42
Clinical Case Scenarios

• Foodstuff with highest available iron is
• a. Red meat
• b. Figs
• c. Groundnut
• d. Soyabean
• Answer b

43
Clinical Case Scenarios

• A lady at 32 weeks gestation with hemoglobin 8.9,
  red cell width is increased, taking iron
  supplements. Least likely situation is
• a. non compliance
• b. intestinal parasites
• c. thalassemia trait
• d. anti epileptic medication
• Answer c

44
Clinical Case Scenarios

• Single most important set of investigations in a
  recently diagnosed case of anaemia in pregnancy
  is
• a. Red cell indices
• b. Retic count and peripheral smear
• c. Iron studies
• d. Hemoglobin electrophoresis
• Answer b 

45
Clinical Case Scenarios

• G5P2L0A2 at 35 weeks gestation in early preterm
  labor. Hb is 8.8g. All can be part of management
  except
• a. Steroids
• b. Frusemide
• c. Blood transfusion
• d. Intra partum antibiotics
• Answer c