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Anemia in Pregnancy

Isharyah Sunarno

Introduction
Anemia: Hb concentration < normal,
according to the GA or sex
Hb < 11 gr% in 1st & 3rd trimester
Hb < 10.5 gr% in 2nd trimester
Hb < 12 gr% in non pregnant
Hb < 7 gr% in severe anemia
Hb < 4 gr% in extreme severe anemia

Introduction
Anemia:
Iron deficiency anemia
Vit. B12 & folic acid deficiency
anemia
Haemoglobinopathy anemia
Erythropoetin deficiency anemia

Introduction
Iron deficiency anemia
Fe demand is higher than Fe loss
in one day
Unbalanced diet
Permanent iron deficiency
erythropoesis disturbance.

Introduction
Vit. B12 & folic acid deficiency
anemia
Macrositic-hyperkrom
CS: mild jaundice, BW,
neurological deficit, dan glocitis or
other epithelial damage.
Confirmed with Vit. B12 or folic
acid in serum and erythrocite.

Introduction
Haemoglobinopathy anemia
Haemoglobinopathy : hemoglobin
protein component synthesis
disturbance
Result:
Alteration in hemoglobin synthesis
normal polypeptide chain synthesis
velocity

Introduction
Haemoglobinopathy anemia
Single amino acid chain
Whole amino acid chain
Major cause : erythrocite
destruction, erythrocite life-span,
hemolysis

Introduction
Haemoglobinopathy anemia
Accompanied by : abnormal
eryhtrocite morphology,
transportation function,
deteriorating oxygen transfer,
erythropoesis compensatoric with
reticulosytosis & bone marrow
hyperplasia.

Introduction
Erythropoetin deficiency anemia
Ineffective arythropoesis caused
by : absolute erythropoetin
deficiency or inadequate
erythropoetin reaction (relative).
Erythropoetin deficiency major
cause of anemia in CRF.
Normochromic -normocytic.

Introduction
3 phases of iron deficiency :
Phase 1 : iron reserve depletion
ferritin level
Phase 2 : erythropoesis
disturbance transferrin
saturation because TIBC while
iron serum

Introduction
Phase 2 :
Erythrocite protoporphyrin concent.
Protoporphyrin : heme precursor in
erythrocite if available Fe is not
enough for heme synthesis.
Hb concent. normal or tend to
Serum sTfR .

Introduction
Phase 3 :
Microcytic-hypochrom
Retyculocite in Hb
Ferritin level

Introduction
SKRT (2004) in Indonesia:
prevalence of anemia in
pregnancy: 50,5%
USA: 6%

Introduction
WHO according to representative
national survey (1993 2005) :
42% pregnant women were anemia
Non-malaria area : 60% caused by
iron deficiency
Malaria area : 50% caused by iron
deficiency

Introduction
SKRT (1994) : prevalence of
nutritional anemia in
pregnancy in South Sulawesi
Province : 76,17%.
Iron deficiency anemia is the
most common nutritional
problem in the world

Introduction
World Health Day (April 7th, 2003)
WHO: iron deficiency anemia
1 out of 10 risk factors of major
health problem
40% of maternal death in developing
countries anemia in pregnancy

Patophysiology
Mature eryhtroid progenitor
need Fe for Hb synthesis

Lab
Parameters to measure Fe
status :
Fe plasma or serum
Transferrin & transferrin
saturation
Transferrin receptor
Ferritin

Introduction
Anemia ~ pregnancy outcome ??
Anemia risk of preterm & LBW
Iron reserve LBW & oxydative
damage
Diet supply neonates & placental
size
Micronutrient supply neonates &
placental size

Patophysiology
Anemia involved :
erythrocite count and / or
Hb concent.

Loss of blood oxygen transfer


capacity

Management

Iron Deficiency anemia

pallor

Conjunctival
Pallor

Koilonychi
a

Smooth Tongue

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

Treatment
Prophylactic: Supplement Fe 60
mg
elemental Fe with Folic Acid
Curative: 200mg FeSo4 3 times
daily till Hb level becomes normal,
then maintenance dose of 1 tab for
100 days

Megaloblastic Anemia

Angular Cheilosis

Treatment
Prophylactic
- all woman of reproductive
age should be given 400mcg of
folic acid daily
Curative
-daily administration of Folic
acid 4mg orally for at least 4
wks following delivery

Hemoglobinopathy

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

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

Management
History and physical examination is sufficient
to exclude serious disease (e.g pregnant or
lactating women, adolescents)
- CURE ANEMIA
History and/or physical examination is
insufficient (e.g old men, postmenopausal
women)
- FIND ETIOLOGY OF ANEMIA AND CURE
(CAUSAL TREATMENT)

Benzidine test
Gastroscopy
Colonoscopy
Gynaecological examination

ORAL IRON ABSORPTION


TEST
1. baseline serum iron level
2. 200 - 400 mg of elemental iron
orally
3. serum iron level 2-4 hours after
ingestion

SIDEROBLASTIC ANEMIAS
HEREDITARY DISORDERS (rare)
SYNONIM FOR MDS (RA,RAES)
DISTURBANCES IN INTRACELLULAR
IRON METABOLISM
HIGHER SIDEROBLASTS NUMBER
IN BONE MARROW
CORRECT OR HIGHER IRON
CONCENTRATION

Anaemia prophylaxis/control programme for


pregnant women

Programmes for prevention and


management of anaemia in
pregnancy
In India : an attempt was made to
identify all pregnant women and
give them 100 tablets containing
60mg of iron & 500g of folic acid
In hospital settings, screening for
anaemia and iron-folate therapy in
appropriate doses and route of
administration for the prevention
and management of anaemia have
been incorporated as an essential
component of antenatal care

Management of anaemia
in pregnancy
Hb

< 5 g/dL

Constitute 5- 10 % of anaemic women


Admission and intensive care preferably
in secondary or tertiary care institutions
to ensure maternal and fetal salvage

Hb 5 to 7.9g/dL
Constitute 10 to 20% anaemic women
Screen for systemic/obstetric problems
and infections
If she has no other systemic or obstetric
problems give her IM iron therapy

Effect of IM iron dextran on Hb & birth weight


Group

No.

No.

Hb < 8g/dl untreated

443

2530 + 651

IM iron from 20 weeks

76

2890 + 428

IM iron from 28 weeks

105

2734 + 416

Following initial successful trials by Dr Menon, Dr Bhatt and


others, IM iron dextran injections were widely used in
medical college hospital settings
on out patient basis ;
between 10-30 % report side effects fever, arthralgia or
myalgia .
However IM iron dextran injections never reached primary
health care settings

IM IRON SORBITOL COMPLEX


Initial trials by Dr Menon showed promising results but it
was not widely used because
1/3rd of the drug gets excreted in urine and higher dose of
is required
It was more expensive
Advantages
Side effects are mild: nausea, metallic taste in the tongue
and giddiness; all these respond readily to symptomatic
treatment

Impact of IM iron sorbital on Maternal Hb & birthweight(NFI)


Maternal Hb (g/dl)
I - < 8.0

Birth weight(g)
97

2577+378.3

II - 8.0 11.0

645

2796+394.7

III - > 11.0

103

2921+418.1

Total

845

2786+4055

All women who had IM iron


therapy

340

2805+379.3

NFI study showed that IM iron sorbital therapy is feasible in


primary care institutions. Mean Hb rose and there was
significant improvement in birth weight. BUT majority of
women who received 900 mg of iron sorbital had Hb levels
around 10 g/dl and birth weight was lower than the birth
weight in non-anaemic women.
It would appear that 1500mg of iron sorbital citric acid
complex would be required for optimal results .

Side effects of IM iron sorbitol citric acid complex


Metallic taste in the mouth

32.4%

Nausea/vomiting

15.3%

None had muscle or joint pain which is commonly


seen with iron dextran injections
Nausea and vomiting was treated with anti-emetics.
It maybe worth while to initiate its use in medical
colleges and later at smaller hospitals

IM iron therapy
IM iron therapy mainly iron dextan was used mainly
in some medical colleges and rarely at district
hospitals. It never reached primary health care level
There were problems in ensuring continuous supply
of drugs even at medical colleges
Some women found it difficult to come to OPD daily
for ten days for IM injections
With iron dextran women who developed trouble
some side effects like arthralgia wanted to discontinue;
Iron sorbital citric acid complex was associated with
fewer and milder side effects but
this drug has not

Strategy for prevention of anaemia in pregnancy


health and nutrition education to improve over all
dietary intakes and promote consumption of iron
and folate-rich foodstuffs- possible through NRHMs
health and nutrition days
dietary diversification inclusion of iron folate rich
foods as well as food items that promote iron
absorption- possible with proper linkages with
National Horticultural Mission
introduction of iron and iodine-fortified salt
universally to improve iron intake- possible with
NIN technology
Opportunity: Affordable & sustainable interventions
to improve iron and folate intake of the entire
family and prevent anaemia are readily available .

Strategy for prevention of anaemia in pregnancy


focus on Hb estimation for detection and treatment of
anemia in adolescent school girls as a part of school health
check possible through school health system
focus on Hb estimation in girls / women who are married,
for detection and treatment of anemia prior to pregnancycan be attempted through coordination with AWW
screening all pregnant women for anemia-Possible using
filter paper technique
providing one tablet of IFA to prevent any fall in Hb levels
in non anaemic pregnant women- possible through NRHM
Opportunity:All these interventions are feasible& affordable
for the individual and health system. With universal coverage
and monitored supplementation it is possible to ensure that
non anaemic women do not become anaemic

Strategy for management of anaemia in pregnancy


iron folate oral medication at the maximum tolerable dose
throughout pregnancy for women with Hb between 8 10.9g/dL
possible through convergence between AWW and ANM
IM iron therapy for women with Hb between 5 and 7.9 g/dL if
they do not have any obstetric or systemic complication- possible
with urban & rural PHCs taking the major responsibility
hospital admission and intensive personalised care for women
with haemoglobin less than 5 g/dl- possible with referral to tertiary
care centres using of emergency transport funds and ASHA
screening and effective management of obstetric and systemic
problems in anaemic pregnant women possible in hospitals
improvement in health education to the community to promote
utilisation of available care possible through AWW, ASHA, ANM
and PRI
Opportunity:All these interventions are feasible& affordable
for the individual and health system.

Opportunities for prevention, detection and


management of anemia in pregnant women
India
currently has
the
necessary infrastructure ,
manpower, technology for this task
Indians are rational and responsive; peoples institutions
are in place for providing the necessary community support
Prevention, detection and appropriate management
of
anemia in pregnant women and preventing the adverse
consequences of anaemia on the mother child dyad is
feasible under NRHM and its urban counterpart
The country should take this opportunity to show case
how it can cope with a major challenge to maternal and
child health effectively within a short time