ANEMIA y Anemia is a sign, not a disease of dynamic process.

World Health Organization y 2 billion people 30% of the world s population are anemic, mainly due to iron deficiency. Anemia y Is a major killer. y Iron deficiency anemia is the most common medical disorder during pregnancy. y In pregnancy, it is one of the leading causes of maternal mortality in developing countries. y It affects both mother and fetus. Causes: Physiological y Disproportionate increase of plasma volume apparent reduction of RBC, Hb & Hct. Acquired y Nutritional y Iron deficiency anemia (60%) y Macrocytic anemia (10%) due to deficiency of folic acid and/or vitamin B12 y Dimorphic and protein deficiency anemic (30%) in extreme malnutrition Hemorrhagic o Infections  Acute (eg. Malaria)  Chronic (eg. Tuberculosis) o Genetic Conditions (eg. Thalassemia, sickle cell) o Enzyme disorders (eg. Sideroblastic anemia) o Anemia of Chronic Disease (eg. Malignancy, Chronic Renal Failure) Criteria for Physiologic Anemia y Hb: 10gm% y RBC: 3.2 million/mm3 y PCV: 30% y Peripheral smear showing normal morphology of RBC with central pallor Significance of Hypervolemia 1. To meet ht demands of the enlarged uterus with its greatly hypertrophied vascular system. 2. To protect the mother, and in turn the fetus against the deleterious effects of impaired venous return in the supine and erect positions. 3. To safeguard the mother against the adverse effects of blood loss associated with parturition

IDA Associated with 115,000 of the 510,000 maternal deaths (22%) and 591,000 of the 2, 464,000 perinatal deaths (24%) occurring annually around the world National Family Health Survey (NFHS-3) reveals the prevalence of anemia to be 7089% in children, 70% in pregnant women and 24% in adult men Definition of Anemia in Pregnancy WHO Hb conc <11gm/dl & Hct < 33% CDC Hb conc <11gm/dl & Hct <33% during the 1st trimester and Hb conc <10.5gm/dl Hct <32% during the 2nd trimester CDC Definition Pregnancy Trimester First Second Third

Hemoglobin 11.0 10.5 11.0

Hematocrit 33.0 32.0 33.0

Normal Iron Requirements Iron requirement for normal pregnancy is 1gm o 200mg is excreted o 300mg is transferred to fetus o 500mg is need for mother Total Volume of RBC increase is 450mL o 1 ml of RBCs contains 1.1mg of iron o 450mL x 1.1 mg/ml = 500mg Daily Average is 6-7 mg/day Iron Requirements Early Pregnancy 2.5 mg/day

20-32 weeks 5.5 mg/day

32-40 weeks 6.8 mg/day

Overall needs are about 2-4.8 mg iron/day Must consume 20-48 mg of dietary iron to absorb this quantity of iron daily. Average vegetarian diet provide 10-15 mg iron/day Amount of iron absorbed from diet+iron mobilized from stores, is usually insufficient to meet the demands. Therefore, iron supplementary during pregnancy is recommended universally even in non anemic women

MATERNAL ANEMIA: A PREVENTABLE KILLER

INCREASED REQUIREMEN TS

DECREASE D ABSORPTI ON

CAUSES OF IDA

POOR DIET

INCREASED BLOOD LOSS

Anemia: Etiologies Inadequate Dietary Intake Poor nutrition Chronic alcoholism Decreased consumption of animal protein and ascorbic acid Increased Iron Demands Multiparity Diarrhea, HV/AIDS and UTI Recurrent Infections Tuberculosis, Amoebiasis, Giardiasis, Roundworm Other Infectious Disease Inadequate GIT Absorption Malabsorption syndrome Certain drugs/foods

Blood Loss Hookworm Infestation Malaria Bleeding piles and gums Surgery Gastrointestinal Bleeding Trauma Dialysis

Effects of Anemia on Fetus PROM

IUGR IUFD Prematurity Abnormal Trophoblast Invasion Fetal programming and disease of newborn: behavioral abnormalities, poor performance on Bayley Mental Development Index, increased cognitive function Neonatal anemia Adult HT associated with low birth weight and high ration of placenta to birth weight If maternal oxygenation is 98-100%, the fetus gets around 70% of O2 with decrease fetal Hb, fetus can compensate. As the maternal Hb drops, fetal hypoxia develops, which leads to stimulation of fetal erythropoiesis Increased viscosity of blood due to raised PCV, sluggish circulation End artery thrombosis Failure of the organs, supplied by these vessels

Severe Anemia

Fetal Hypoxia

Prolonged Period

Short Duration

Neurological Deficit

IQ less, Slow Learner

Fetal Hypoxia leads to an increase in the cord blood EPO. Cord blood EPO correlates with perinatal brain damage.

Maternal Effects of Anemia y Behavioral Changes o (Irritability)

y y y y y y y y y

Loss of Appetite, indigestion, etc. due to low performance of each organ Increased morbidity and mortality due to PIH, APH, PPH, if associated CCF at 30-32 weeks, intrapartum and post partum Reduced immune function o Infection, ante-partum and puerperal sepsis Negative thermoregulation Increased risk of blood transfusion Preterm labor Sub involution Failing lactation Pulmonary Venous; thrombosis and embolism due to thrombophlebitis.