case presentation on anemia in pregnancy slideshare

Anemia in Pregnancy

• Symptoms and Signs |
• Diagnosis |
• Treatment |
• Key Points |
• Iron Deficiency Anemia in Pregnancy |
• Prevention |
• Folate Deficiency Anemia in Pregnancy |
• Hemoglobinopathies in Pregnancy |

Normally during pregnancy, erythroid hyperplasia of the marrow occurs, and red blood cell (RBC) mass increases. However, a disproportionate increase in plasma volume results in hemodilution (hydremia of pregnancy): hematocrit (Hct) decreases from between 38% and 45% in healthy women who are not pregnant to about 34% during late single pregnancy and to 30% during late multifetal pregnancy. The following hemoglobin (Hb) and Hct levels are classified as anemic:

1st trimester: Hb

2nd trimester: Hb

3rd trimester: Hb

If Hb is < 11.5 g/dL at the onset of pregnancy, women may be treated prophylactically because subsequent hemodilution usually reduces Hb to < 10 g/dL. Despite hemodilution, oxygen-carrying capacity remains normal throughout pregnancy. Hct normally increases immediately after birth.

Anemia occurs in up to one third of women during the 3rd trimester. The most common causes are

Iron deficiency

Folate deficiency

Obstetricians, in consultation with a perinatologist, should evaluate anemia in pregnant Jehovah's Witness patients (who are likely to refuse blood transfusions) as soon as possible.

Symptoms and Signs of Anemia in Pregnancy

Early symptoms of anemia are usually nonexistent or nonspecific (eg, fatigue, weakness, light-headedness, mild dyspnea during exertion). Other symptoms and signs may include pallor and, if anemia is severe, tachycardia or hypotension.

Anemia increases risk of

Preterm delivery

Low birth weight

Postpartum maternal infections

Diagnosis of Anemia in Pregnancy

Complete blood count (CBC), followed by testing based on mean corpuscular value (MCV) value

Diagnosis of anemia begins with CBC; usually, if women have anemia, subsequent testing is based on whether the MCV is low ( < 79 fL) or high ( > 100 fL):

For microcytic anemias: Evaluation includes testing for iron deficiency (measuring serum ferritin) and hemoglobinopathies (using hemoglobin electrophoresis). If these tests are nondiagnostic and there is no response to empiric treatment, consultation with a hematologist is usually warranted.

For macrocytic anemias: Evaluation includes serum folate and vitamin B12 levels.

For anemia with mixed causes: Evaluation for both types is required.

Treatment of Anemia in Pregnancy

Treatment to reverse the anemia

Transfusion as needed for severe symptoms or fetal indications

Treatment of anemia during pregnancy is directed at reversing the anemia (see below).

Transfusion is usually indicated for any anemia if severe constitutional symptoms (eg, light-headedness, weakness, fatigue) or cardiopulmonary symptoms or signs (eg, dyspnea, tachycardia, tachypnea) are present; the decision is not based on the Hct.

Pearls & Pitfalls

Hemodilution occurs during pregnancy, but oxygen-carrying capacity remains normal throughout pregnancy.

The most common causes of anemia during pregnancy are iron deficiency and folate acid deficiency.

Anemia increases risk of preterm delivery and postpartum maternal infections.

Treat the cause of the anemia if possible, but if patients have severe symptoms, transfusion is usually indicated.

Iron Deficiency Anemia in Pregnancy

About 95% of anemia cases during pregnancy are iron deficiency anemia . The cause is usually

Inadequate dietary intake (especially in adolescent girls)

A previous pregnancy

The normal recurrent loss of iron in menstrual blood (which approximates the amount normally ingested each month and thus prevents iron stores from building up) before the woman became pregnant

Diagnosis of Iron Deficiency Anemia in Pregnancy

Measurement of serum iron, ferritin, and transferrin

Typically, Hct is ≤ 30%, and MCV is < 79 fL. Decreased serum iron and ferritin and increased serum transferrin levels confirm the diagnosis of iron deficiency anemia.

Treatment of Iron Deficiency Anemia in Pregnancy

Usually ferrous sulfate 325 mg orally once a day

One 325-mg ferrous sulfate tablet taken midmorning is usually effective. Higher or more frequent doses increase GI adverse effects, especially constipation, and one dose blocks absorption of the next dose, thereby reducing percentage intake.

About 20% of pregnant women do not absorb enough supplemental oral iron; a few of them require parenteral therapy. The iron deficit may be calculated, and the iron can often be replaced over one or two infusions. Hct or Hb is measured weekly to determine response. If iron supplements are ineffective, concomitant folate deficiency should be suspected.

Neonates of mothers with iron deficiency anemia usually have a normal Hct but decreased total iron stores and a need for early dietary iron supplements.

Prevention of Iron Deficiency Anemia in Pregnancy

Although the practice is controversial, iron supplements (usually ferrous sulfate 325 mg orally once a day) are usually given routinely to pregnant women to prevent depletion of body iron stores and prevent the anemia that may result from abnormal bleeding or a subsequent pregnancy.

Folate Deficiency Anemia in Pregnancy

Folate deficiency increases risk of neural tube defects and possibly fetal alcohol syndrome . Deficiency occurs in 0.5 to 1.5% of pregnant women; megaloblastic macrocytic anemia is present if deficiency is moderate or severe.

Rarely, severe anemia and glossitis occur.

Diagnosis of Folate Deficiency Anemia in Pregnancy

Measurement of serum folate

Folate deficiency is suspected if CBC shows anemia with macrocytic indices or high RBC distribution width (RDW). Low serum folate levels confirm the diagnosis.

Treatment of Folate Deficiency Anemia in Pregnancy

Severe megaloblastic anemia may warrant bone marrow examination and further treatment in a hospital.

Prevention of Folate Deficiency Anemia in Pregnancy

Hemoglobinopathies in pregnancy.

During pregnancy, hemoglobinopathies, particularly sickle cell disease , Hb S-C disease , and beta- and alpha- thalassemia , can worsen maternal and perinatal outcomes. Genetic screening genetic screening for some of these disorders is available.

Preexisting sickle cell disease, particularly if severe, increases risk of the following:

Maternal infection (most often, pneumonia , urinary tract infections [UTIs] , and endometritis )

Pregnancy-induced hypertension

Heart failure

Pulmonary infarction

Fetal growth restriction

Anemia almost always becomes more severe as pregnancy progresses. Sickle cell trait increases the risk of UTIs but is not associated with severe pregnancy-related complications.

Treatment of sickle cell disease during pregnancy is complex. Painful crises should be treated aggressively. Prophylactic exchange transfusions to keep Hb A at ≥ 60% reduce risk of hemolytic crises and pulmonary complications, but they are not routinely recommended because they increase risk of transfusion reactions, hepatitis, HIV transmission, and blood group isoimmunization. Prophylactic transfusion does not appear to decrease perinatal risk. Therapeutic transfusion is indicated for the following:

Symptomatic anemia

Severe bacterial infection

Severe complications of labor and delivery (eg, bleeding, sepsis)

Hb S-C disease may first cause symptoms during pregnancy. The disease increases risk of pulmonary infarction by occasionally causing bony spicule embolization. Effects on the fetus are uncommon but, if they occur, often include fetal growth restriction.

Sickle cell–beta-thalassemia is similar to Hb S-C disease but is less common and more benign.

Alpha-thalassemia does not cause maternal morbidity, but if the fetus is homozygous, hydrops and fetal death occur during the 2nd or early 3rd trimester.

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ANAEMIA IN PREGNANCY

Sep 03, 2014

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ANAEMIA IN PREGNANCY. Presenter: Dr Anshuman Raheja Moderator: Dr Medha Mohta. University College of Medical Sciences &amp; GTB Hospital, Delhi. www.anaesthesia.co.in. email: [email protected]. Anaemia

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ANAEMIA IN PREGNANCY Presenter: Dr Anshuman Raheja Moderator: Dr Medha Mohta University College of Medical Sciences & GTB Hospital, Delhi www.anaesthesia.co.in email: [email protected]

Anaemia Quantitative or qualitative reduction of Hb or circulating RBCs or both in circulation resulting in reduced oxygen carrying capacity of blood to organs and tissues. Anaemia in pregnancy Hb conc. <11 gm/dl or Hct < 0.33 in 1st & 3rd trimester Hb conc. <10.5 gm/dl or Hct < 0.32 in 2nd trimester In developing countries, limit brought down to 10 gm/dl Prevalence in India = 65 to 75 % (WHO)

Classification of anaemia Based on • Etiology • Morphology • Severity

Classification based on etiology • Physiological anaemia • Acquired anaemia • Nutrition: Iron deficiency, folate deficiency, vit.B12 deficiency anaemia • Infections: Malaria, hookworm infestation • Haemorrhagic: Acute / chronic blood loss • Bone marrow suppression: Aplastic anaemia, drugs • Renal disease • Genetic: Haemoglobinopathies • Sickle cell disease • Thalassemia

Classification based on morphology • Microcytic : Iron deficiency anaemia, thalassemia • Normocytic : haemolysis, acute blood loss, bone marrow disease. • Macrocytic : folate deficiency, vit. B12 deficiency.

Classification based on severity of Anaemia WHO CATEGORIES Category Severity Hb(gm%) 1 Mild 10 – 10.9 2 Moderate 7 – 9.9 3 Severe <7.0

Severity of Anaemia ICMR CATEGORIES Category Severity Hb levels gm % 1 Mild 10 – 10.9 2 Moderate 7 – 10.0 3 Severe <7.0 4 Very severe <4.0

Severity of Anaemia Severity Hb (gm%) Mild 8-10 Moderate 6.5-8 Severe <6.5 Clinically used in developing countries

Importance of topic ??? Anaemia in pregnancy • The commonest haematological disorder that may occur in pregnancy • Severe anaemia can increase morbidity and mortality in mother as well as baby

Complications of anaemia During Pregnancy - Pre eclampsia (due to malnutrition or hypoproteinemia) - Intercurrent infection (diminished resistance to infection) - Cardiac failure (at 30-32wks of pregnancy) - Preterm labour

During Labour - PPH - Cardiac failure - Shock During Puerperium • Puerperal sepsis • Subinvolution • Failing lactation • Puerperal venous thrombosis • Pulmonary embolism

Effects on baby Amount of Fe transferred to fetus is uneffected even if mother suffers from Fe deficiency Moderate to severe anaemia may cause - IUGR - prematurity - low foetal store of Fe/vitB12/folate - increased risk of anaemia/nutritional disorder in early infancy - still births - congenital malformations - ↑ in neonatal deaths/perinatal mortality by 2-3 fold when Hb < 8gm% and 8 – 10 fold when Hb< 5gm%

Role of Anaesthesiologist Anaesthetic management • Anaemic patient for LSCS • Anaemic patient for non-obstetric surgery Critical care management • Cardiac failure • Haemorrhage with shock • Pulmonary embolism

Physiological Anaemia of Pregnancy

Physiological anaemia of pregnancy Blood volume ↑45% Plasma volume ↑55% RBC volume ↑30% Hct ↓30% Hb ↓10.5-11

Criteria for Physiological anaemia • Hb = 10 gm% • RBC = 3.2 million/mm3 • PCV = 30% • Peripheral smear showing normal morphology of RBC with central pallor

Physiology and Pathophysiology Related to Anaemia

Oxygen Transport Oxygen is carried in blood in two forms: • Oxyhaemoglobin – 1 g fully oxygenated Hb carries 1.31 ml oxygen – 20 ml/100ml of arterial blood • Physical solution in plasma (dissolved) - 0.3 ml/100 ml of arterial blood at a PaO2 of 100 mmHg Oxygen content: Volume of oxygen carried in 100 ml of blood Arterial O2 content (CaO2)= (1.31 x Hb x SaO2) + (0.003 x PaO2)

Oxygen flux: Amount of oxygen leaving left ventricle per minute in arterial blood CO x arterial O2 sat x Hb conc. X 1.31 Oxygen delivery: Amount of oxygen that reaches systemic capillaries each minute DO2 =CO x CaO2 x 10 Compensatory mechanism in chronic anaemia • Increase in Cardiac Output

Oxygen consumption: Important determinant of adequacy of tissue oxygenation VO2=CO X (CaO2-CvO2) X 10 = 230-250 ml/min • Oxygen extraction ratio: Fraction of oxygen delivered to capillaries that is taken up into tissues . O2ER = VO2 / DO2 = 25% Compensatory mechanism in chronic anaemia • Increase in oxygen extraction ratio

Normal values of oxygen in arterial and Venous blood Normal range for oxygen transport parameters

. Compensatory mechanism Increase in 2-3 DPG leading to rightward shift of ODC Oxygen haemoglobin dissociation curve

Compensatory mechanisms • ↑ Cardiac output • ↑ Oxygenextractionratio • ↑ 2-3 DPG leading to shift of O2Hb dissociation curve to right • Decrease in blood viscosity → improved tissue blood flow • Release of erythropoietin → stimulates erythroid precursors in bone marrowto produce RBCs

Iron Deficiency Anaemia

Iron Deficiency Anaemia • Most common cause • Iron stored as S.ferritin & Hemosiderin. Adult male Adult female Stores 1000mg 300 – 500mg Losses 1mg/day 2mg/day • Daily iron requirement 2.5mg – early pregnancy. 5.5mg – from 20 to 22 wks 6 to 8mg – 32 wks onwards

Sources of iron lossmg lost Obligatory iron loss 180 ± 20 Increased red cell mass 400 ± 200 Foetal iron 270 ± 70 Placenta and cord 100 ± 70 Blood loss at delivery 150 ± 100 Total loss 1100 ± 460 TOTAL REQUIREMENT 800-900mg(4-6mg/d)

Haematological parameters Normal values 2nd half of Fe deficiency pregnancy anaemia Plasma iron (μg/dl) 60-120 65-75 <30 S.Ferritin (μg/l) 20-30 15 <12 TIBC (μg/dl) 300-350 300-400 >400 Transferrin saturation (%) 30 <16 <15 MCV (fl) 75-100 75-95 <75 MCH (pg) 27-32 26-31 <25 MCHC (%) 32-36 30-35 <30

How to investigate a case of Anaemia History • Asymptomatic • Fatigue, dyspnoea on exertion • Nausea, loss of appetite, constipation, indigestion • H/o bleeding (DUB, malena, haematuria) • Palpitation • H/o drug intake: salicylates, anticonvulsants chloramphenicol & cytotoxic drugs alcohol • H/o previous surgery in gut

Examination GPE - Pallor of skin & mucous membranes, glossitis, stomatitis, Koilonychia, mouth soreness, pedal edema, generalised anasarca, JVP ↑ Resp. system - Tachypnoea - Basal crepts CVS - Tachycardia, strong peripheral pulses with wide pulse pressure - Functional cardiac murmur (Ejection murmur) CNS - Mental disturbance, features of SACD

Investigations Complete haemogram including : Hb, Hct, RBC count, WBC count – TLC, DLC, Platelet count Peripheral smear - Cell size - Hb content - Anisocytosis, Poikilocytosis - Nuclear segmentation of neutrophils RBC indices – MCV,MCH,MCHC Reticulocyte count Iron supply studies – S.Iron, TIBC, S.Ferritin Urine analysis Stool examination for presence of ova, cyst

Other investigations Blood grouping Urea, creatinine S. bilirubin Thyroid hormones S. proteins Marrow examination – aspirate & biopsy ECG Hb electrophoresis

Management Prevention • Avoidance of frequent child birth. • Dietary prescription. • Adequate treatment for any infection. • Early detection of falling Hb level, levels should be estimated at 1st A/N visit, 30th & finally 36th week. • Supplementary Fe therapy (60mg elemental Iron three times a day). • National Anaemia Control Programme (NACP) : all pregnant women to be screened for anaemia. Non anaemic women would get iron (100mg) and folate (500ug) and those with anaemia should get 2 tablets daily.

Pregnancy <30wks Pregnancy 30-36wks Pregnancy >36wks IDA FA def. Parenteral Oral FA I/M iron I/V iron IDA FA def. Oral iron Oral FA Intolerance or Non-compliance I/M iron I/V iron Blood transfusion TREATMENT OF ANAEMIA IN PREGNANCY

Oral Iron Therapy Ferrous sulphate tablets 200mg (60mg elemental iron) X 3 times a day along with folate Hb rise : 0.7gm%/wk Drawbacks: - Intolerance - Unpredictable absorption rate - Non Compliant patient - Long time for improvement

Parenteral Iron Therapy Indications: - Failure to oral therapy - Non compliant patient - Case seen for 1st time during last 8-10 wks with severe anaemia Routes: IV, IM Hb rise : 0.7 – 1gm%/wk

IV Iron Therapy Iron Dextran 2ml ampoule containing 50 mg/ml elemental iron Total dose infusion (TDI) Deficit of iron calculated & total amount required to correct deficit is administered in 100ml saline in single setting I/V infusion slowly over several hours Dose = 0.3 X wt(100 – Hb%) or (deficiency in Hb X 250) + 50% =mg of iron Given @10 drops/min X 30 min. (diluted in normal saline or 5% dextrose) → no reaction → ↑ to 45 drops/min

Side effects: • Anaphylactoid reaction • Chest pain, rigors, chills, fall in BP, dyspnoea, haemolysis Treatment: • Stop infusion. • Give antihistaminics, corticosteroids & epinephrine Fe sucrose complex • Safe, effective, less side-effects • Low allergenic effect due to slow release of iron from the complex

IM Iron Therapy • Iron Sorbitol Citrate (Jactofer) • Iron Dextran (imferon) Oral iron should be suspended at least 24 hrs prior to therapy to avoid reaction. Drawbacks: - Painful injection (less with jactofer) - Chances of abscess formation & discolouration of skin over injection site

Blood Transfusion • Task force 1996, 2006 – No uniform transfusion trigger Decision to transfuse blood should be based on • Needs and risk of developing complications of inadequate oxygenation • Both clinical and haematological grounds Hb > 10gm/dl – transfusion rarely indicated.

BLOOD TRANSFUSION Patient factorsType of surgery Preg Preg Elective Emergency <36wks > 36wks C/S C/S -Hb ≤ 5gm% - Hb ≤ 6gm% - with H/o -assess without CHF without CHF APH,PPH, according -Hb 5-7gm%,if -Hb 6-8gm%,if previous to situation CHF, hypoxia, CHF,hypoxia, LSCS infections infections Hb 8 – 10 gm%, confirm BG & cross-matching Hb <8 gm%, 2 units to be kept ready in OT

Precautions during transfusion : Packed RBC to be preferred Addition of diuretics may be helpful If not urgent, blood should be transfused at least 48hrs before surgery for ; - restoration of intravascular fluid volume & blood viscosity - restoration of depleted 2,3 DPG content in stored blood

Blood Volume to be transfused: = normal blood volume x Hb% rise needed Hb% of transfused blood Normal Hb% of whole blood = 10 – 13gm% Hb% of packed cells = 18 – 23gm% Blood volume = 70 – 80ml/kg

Choice of Anaesthesia Depends on • Severity and type of anaemia • Extent of physiological compensation • Concomitant medical conditions • Type and nature of procedure • Anticipated blood loss

Anaesthetic Concerns Main anaesthetic concerns in chronic anaemia : • To minimize factors interfering with O2 delivery • Prevent any increase in O2 consumption • To optimize PO2 in arterial blood

Avoid hypoxia • Preoxygenation with 100% O2 • O2 supplementation in peri and postoperative period • Difficult airway cart • High FiO2, low conc. of volatile agents • Avoid and treat conditions that ↑O2 demand – fever, shivering, acute massive blood losses • N2O → cautious use in B12/folate deficiency

Minimize drug induced ↓ in CO Titrated doses of anaesthetic agents to prevent precipitous fall in CO Careful positioning, left uterine displacement Mild tachycardia and wide pulse pressure may be physiological

Avoid factors leading to left shift of ODC • Avoid hyperventilation → hypocapnia → respiratory alkalosis, ↓ CO • Avoid hypothermia - normal core body temperature, warm fluids Monitoring • Adequacy of perfusion and oxygenation of vital organs • Routine monitoring with temperature & urine output monitoring ± CVP, IBP, ABG analysis, serial Hb & HCT.

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Patient Case Presentation

Patient  Overview

M.J. is a 25-year-old, African American female presenting to her PCP with complaints of fatigue, weakness, and shortness of breath with minimal activity. Her friends and family have told her she appears pale, and combined with her recent symptoms she has decided to get checked out. She also states that she has noticed her hair and fingernails becoming extremely thin and brittle, causing even more concern. The patient first started noticing these symptoms a few months ago and they have been getting progressively worse. Upon initial assessment, her mucosal membranes and conjunctivae are pale. She denies pain at this time, but describes an intermittent dry, soreness of her tongue.

Vital Signs:

Temperature – 37 C (98.8 F)

HR – 95

BP – 110/70 (83)

Lab Values:

Hgb- 7 g/dL

Serum Iron – 40 mcg/dL

Transferrin Saturation – 15%

Medical History

• Diagnosed with peptic ulcer disease at age 21 – controlled with PPI pharmacotherapy
• IUD placement 3 months ago – reports an increase in menstrual bleeding since placement

Surgical History

• No past surgical history reported

Family History

• Diagnosis of iron deficiency anemia at 24 years old during pregnancy with patient – on daily supplement
• Otherwise healthy
• Diagnosis of hypertension – controlled with diet and exercise
• No siblings

Social History

• Vegetarian – patient states she has been having weird cravings for ice cubes lately
• Living alone in an apartment close to work in a lower-income community
• Works full time at a clothing department store

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A study on anemia and its risk factors among pregnant women attending antenatal clinic of a rural medical college of West Bengal

Anuradha sinha.

1 Department of Pathology, Purulia Government Medical College, Purulia, West Bengal, India

Moumita Adhikary

2 Department of Microbiology and Pathology, Rampurhat Government Medical College, Rampurhat, West Bengal, India

Jyoti P. Phukan

Sonal kedia.

3 Department of Anesthesiology and Gynecology and Obstetrics, Ramakrishna Mission Seva Pratishthan, Kolkata, West Bengal, India

Tirthankar Sinha

Background:.

Anemia is the commonest nutritional deficiency disorder in the world, particularly in developing countries. Though anemia is easily treatable and largely preventable disease if timely detected, it still continues to be significantly prevalent among pregnant women.

The aim of this study was to measure the extent of anemia in pregnancy and to assess the association of risk factors with anemia.

Study Design:

Hospital-based cross-sectional descriptive study.

Materials and Methods:

A total of 200 women were selected among pregnant women attending antenatal clinic. Sampling was done by selecting every fifth woman visiting antenatal clinic within the duration of two months on alternate days. Data were collected using a predesigned, pretested semi-structured schedule. Hemoglobin concentrations were also recorded for each patient. Data were analyzed using Chi-square test and 'T' test of significance. A value of P < 0.05 was considered significant.

We found overall prevalence of anemia to be 90% among pregnant women. Most of the anemic patients (60.5%) belong to moderate severity according to the World Health Organization classification. Three factors namely socioeconomic status, gravida and time of 1 st antenatal visit were significantly associated with prevalence of anemia in pregnancy ( P < 0.05).

Conclusion:

In this study, a high prevalence of anemia was found in pregnant women. Low socioeconomic status, multigravida and delayed visit to antenatal clinic were significantly associated with anemia in pregnancy. So, awareness and education programs should be generated to make people come to know about anemia, its complications during pregnancy and ways to prevent it.

Introduction

Anemia has been recognized as the most common form of nutritional deficiency worldwide, particularly in developing countries like India. Though anemia is easily treatable and preventable disease, it continues to be significantly associated with pregnancy. Diminished intake and increased demand, excess demand in case of multigravid woman and altered metabolism along with the background characteristics like low socioeconomic status, illiteracy, early age of marriage associated with increase in susceptibility to infectious diseases like hookworm infestations may serve to be the underlying factors associated with prevalence of anemia during pregnancy. According to the World Health Organization (WHO) prevalence of anemia among pregnant women varies from 14% in developed countries to 65%–75% in India.[ 1 ] In women, anemia may become the underlying cause of maternal mortality and perinatal mortality.[ 2 ]

Hemoglobin value <11 g/dL is defined as anemia in pregnancy by WHO.[ 3 ] Anemia in pregnancy can be further divided as mild, moderate and severe anemia for hemoglobin level 10.0–10.9 g/dL, 7–9.9 g/dL and severe <7 g/dL.[ 4 ]

Various studies showed an association between anemia and maternal mortality.[ 5 , 6 , 7 ] Apart from maternal mortality, anemia in pregnancy may result in intrauterine growth retardation, low birth weight, still-birth, and neonatal death.[ 8 , 9 , 10 , 11 ]

In view of low dietary deficiency of iron and folic acid, and high prevalence of anemia among pregnant women, India started the National Nutritional Anemia Prophylaxis Program (NNAPP) to prevent anemia among pregnant women.[ 12 ] Through this program 100 mg of ferrous iron and 500 mcg folic acid tablets distributed to pregnant woman through Urban Family Welfare Centers in urban areas and Primary Health Centers in rural areas. Despite of these preventive measures, anemia in pregnant women is still very much prevalent in India.[ 12 , 13 ]

The key for safe motherhood is reduction of maternal anemia. The risk factors of anemia particularly during pregnancy are multifactorial and complex.[ 14 ] So, knowledge of these risk factors and compliance of respondents towards implemented government program is very much essential to prevent anemia and its consequences.

Primary health care physicians are the first contact physician in the community who can play a very important role in identification and treatment of anemia.[ 15 ] Many issues associated with anemia can be assessed and modified at the primary care level such as dietary habits, multi parity etc.

Hence, this study was undertaken with the following aims and objectives:

• To determine the magnitude of anemia in pregnant women according to severity among study population, and
• To find out association of anemia with different socio-demographic factors.

Materials and Methods

Study subjects and study area.

This cross-sectional study was conducted in a rural teaching hospital of West Bengal, India for a duration of 2 months. This rural medical college is situated in a backward area of western West Bengal which caters mainly economically poor population. Data collected from 200 pregnant women (Cases). Every fifth patient was taken attending antenatal clinic (ANC) and first patient was selected randomly. A consent form was filled by each participant.

Inclusion and exclusion criteria

Inclusion criteria.

Pregnant women attending ANC who filled the consent form having their Hemoglobin (Hb) report. Confirmation of pregnancy was done by either urinary pregnancy test and/or by pelvic ultrasonography.

Exclusion criteria

Unwilling pregnant women and who did not have hemoglobin report with them were excluded from the study.

Ethical consideration

The study was approved by the institutional ethics committee before commencing the study. The study was done as a part of the Indian Council of Medical research short-term studentship program (ICMR-STS). It was obtained on 21/03/2012.

Data collection

Data were collected from every participant using a predesigned, pretested semi-structured schedule. Sociodemographic particulars and data regarding reproductive behavior were collected. Socioeconomic status was determined based on Tendulkar's committee poverty line where the income of less than rupee 673 per month was considered as low socio-economic status. Hemoglobin level is also recorded from the available investigation report. All hemoglobin levels estimated by the cyanmethemoglobin method.

Statistical analysis

Chi-square test and 'T' test of significance were used to show any association between risk factors and severity of anemia. A 'P' value <0.05 was considered statistically significant to show an association between the particular risk factor and severity of anemia.

Results and Observations

In our study, 200 pregnant women were included. The demographic characteristics of the pregnant women were shown in Table 1 . The most common age group in our study was 20-30 years (54.5%) and majority were of low socioeconomic status (58%) [ Table 1 ]. Maximum numbers of study subjects were Hindu (94.5%).

Distribution of pregnant women according to variable characteristics ( n =200)

Among the pregnant women, 90% suffered from anemia; majority had moderate anemia (60.5%), followed by mild anemia (29%). Only 1 woman was suffering from severe anemia while the rest had no anemia [ Table 2 ].

Distribution of severity of anemia among pregnant women according to WHO criteria

Hb=Hemoglobin

Association of anemia with low socioeconomic status was found to be 63.93%, 51.72% and 35% for severe and moderate, mild and no anemia respectively [ Table 3 ] which was statistically significant [P = 0.03]. However, no significant association of severity of anemia with the educational status of the pregnant women was detected.

Distribution of pregnant women according to socio economic status with respect to severity of anemia ( n =200)

χ 2 =7.002, P =0.030 (S). S=Significant

Also, severity of anemia is associated with time of first antenatal visit which is statistically significant [ Table 4 ]. However, severity of anemia with respect to age and religion were not significant.

Distribution of pregnant women according to time of 1 st antenatal visit with respect to severity of anemia ( n =200)

χ 2 =27.549, P =<0.001 (S). S=Significant

Anemia in pregnancy is a major health issue in India. The reason being low socioeconomic status, less dietary intake of iron and folic acid, short spacing of multiple pregnancies, excessive bleeding during labor, infections like malaria and hookworm infestations.[ 16 ]

In West Bengal, National Family Health Survey-3 found the prevalence of anemia among pregnant women of age group 15–49 years to be 62.6%.[ 17 ] This is less than our study, where we found it to be 90%; which is similar to other Indian studies done by Lokare et al ., Gautam et al ., Toteja et al . and ICMR Taskforce Multicenter Study[ 12 , 18 , 19 , 20 ] On the contrary, few recent studies done in African continent found the prevalence of anemia in pregnant women as low as 25.8% to 37.6%.[ 21 , 22 ] This variation may be due to various socio-demographic and comorbid conditions. Also, as our study participants are mainly poor from tribal population with low socioeconomic status, therefore the prevalence of anemia during pregnancy may be remarkably high.

Majority of cases in our study had moderate anemia (60.5%), mild anemia (29.0%) and one case of severe anemia which was found to be similar to Vindhya et al ., Mahamud et al ., Sarala V et al .[ 15 , 21 , 23 ]

There was no association found between age group and religion with anemia unlike Viveki et al . who found higher maternal anemia for age group above 26 years.[ 24 ] Studies done in Aurangabad city and New Delhi in India showed that severity of anemia decreases with higher per capita income, which is similar to our study.[ 12 , 19 ]

Time of ANC visit also plays an important role in reducing maternal anemia. 1 st Trimester visit with prescription of proper diet, iron and folic acid supplements have reduced severe anemia remarkably in our study which is like study done by Mangla et al .[ 25 ]

Still a remarkably high prevalence of anemia among pregnant women showed that anemia is endemic in this region irrespective of age, religion, education status, occupation etc., Various socio-cultural problems like taking vegetarian diet, having tea after food, open field defecation predisposing women to hook worm infestation and other associated infections may serve as important factor behind high prevalence of anemia in the pregnant women. Age of marriage didn't show any association with respect to severity of anemia in this study suggesting that multiple pregnancies, heavy menstrual blood loss or multiple abortions because of some false cultural belief like the desire to have a boy child may be the reasons behind high prevalence of anemia. Thus, gravida showed a significant association with severity of anemia.

In our study, we found that majority of pregnant women did not consume the minimum number of iron and folic acid tablets. This suggested lack of compliance or low efficacy of government policies to provide regular supplementation. Also lack of motivation and education towards utility of supplementation may be the cause to serve high prevalence of anemia. However mere use of this supplementation during pregnancy cannot solely serve the purpose, as other etiologies like hookworm infestations, malarial infection and other infections may be an issue which needs to be taken under consideration.

Limitations of the study

The study was conducted with a small sample size in a hospital which increases the possibility of error. If it would have been a longitudinal study rather than cross-sectional, then a better association between anemia and its risk factors could have been assessed. Mother's status of anemia could not be traced at different trimesters of pregnancy because of short duration of the study period. No test was done, or report was checked to find out any infectious disease like hookworm infestation or malaria and others to serve as etiology behind anemia. Morphology of red blood cell was also not recorded, which could help us to find its etiology.

Recommendations

Based on our study, we have the following recommendations to prevent and/or decrease the severity of anemia among pregnant women:

• Awareness and Education programs should be generated to make people come to know about anemia, its complications, and ways to prevent it.
• Especially adolescent girls should be educated to make them aware of the upcoming problem if not taken care since the same age.
• Woman of childbearing age should be motivated to take the required supplementation before conceiving and to continue with it till breastfeeding the baby.
• Education of the male partner regarding the complications of the disease and the utility of the supplementary diet during pregnancy may help the pregnant woman a lot to execute these policies in her daily life.
• To add support to supplementation food fortification with essential vitamins and minerals may serve the purpose. Iron fortification may be used in commonly used food like salt and sugar to build up iron stores and such things should be easily accessible and affordable by the common people. Mere cooking of food in cast iron utensil may reduce the severity of anemia.
• Advertisement programs should be generated to draw the attention of policymakers as anemia is one of the major global problems.

In summary, this study revealed a high prevalence of anemia in pregnancy, irrespective of age, religion, education status and occupation. Anemia is found to be endemic in this region, due to various unfavorable socio-demographic factors. As we all know, prevention is better than cure, therefore, these findings may help our policymakers and health care providers to change policies, add new strategies and educates the society to save from maternal anemia.

Financial support and sponsorship

Indian Council of Medical Research – Short Term Studentship (ICMR-STS).

Conflicts of interest

There are no conflicts of interest.

• Preferences

ANEMIA IN PREGNANCY - PowerPoint PPT Presentation

ANEMIA IN PREGNANCY

India contributes to 80% of maternal deaths of south asia where anemia is responsible for 40% of cases directly or indirectly. anemia is the most common medical disorder during pregnancy. – powerpoint ppt presentation.

• Most Common Nutritional Disorder in the World
• Incidence 40 to 60 of pregnant women in India
• Commonest Medical(hematological) disorder during pregnancy
• 25 of direct maternal deaths
• Responsible for 40 of maternal deaths in third world countries.
• India contributes to 80 of maternal deaths due to anemia in South Asia
• Quantitative or qualitative reduction of Hb or circulating RBCs or both resulting in a reduced oxygen carrying capacity of blood to organs and tissues
• Woman Hct 33 or Hb 11g/dl 1st 3rd trimester and Hct 32 or Hb 10.5 g / dl in 2nd trimester(CDC/WHO)
• Physiological
• Nutritional deficiency anaemias
• - Iron deficiency (90)
• - Folate deficiency
• - Vit. B12 deficiency
• Infections Malaria/Hookworm/UTI
• Hemorrhagic acute/chronic blood loss
• Bone marrow- Aplastic anemia
• Renal diseases
• Genetic/Haemoglobinopathies
• - Thalassaemias
• Plasma volume 50 (by 34weeks) but RBC mass only 25
• Disproportionate increase in plasma vol, RBC vol. and hemoglobin mass during pregnancy
• CRITERIA FOR PHYSIOLOGICAL ANAEMIA
• RBC 3.2 million/mm3
• Peripheral smear showing normal morphology
• of RBC with central pallor
• IRON REQUIREMENTS DURING PREGNANCY
• Maternal req. of total Iron -1000mg
• 500 mg ? Maternal Hb. Mass expansion
• 300 mg ? Fetus Placenta
• 200mg ? Shed through gut., urine skin
• 2.5mg /day in early pregnancy
• 5.5mg /day from 20 -32 weeks Average 4 mg/ day
• 6 8 mg/ day after 32 weeks
• Increases from 1-2mg in 1st trimester to 6-8 mg in 3rd trimester
• Absorption of iron depends upon
• Amount of iron in the diet
• Bioavailability of iron
• Physiological requirements
• Iron sources are two types
• Haem iron(5) hemoglobin and myoglobin from red meat, poultry and fish
• Nonhaem iron(95) fibers, green vegetables
• Pre eclampsia
• Intercurrent infection
• Cardiac failure
• Preterm labour
• INTRAPARTUM
• Puerperal sepsis
• Subinvolution
• Failing lactation
• Puerperal venous thrombosis
• Pulmonary embolism
• Prematurity
• Increased risk of IDA early infancy
• Still births
• Congenital malformations
• ? in Neonatal deaths/Perinatal mortality
• Intra uterine deaths(severe maternal anoxemia)
• Abnormal Social and Emotional behaviour
• EFFECT OF PREGNANCY IN ANAEMIA
• Pt. Mildly anemic progresses to marked Anaemia
• Pt. Who is severely anemic becomes symptomatic by the end of 2nd trimester
• IDA IN PREGNANCY
• Hook worm infestation
• Blood loss Menorrhagia 20-30
• Increase demand for iron particularly in 2nd 3rd trimester
• Higher risk with morning sickness
• Aspirin/NSAIDS
• Multiple pregnancies
• Intolerance for red meat
• Low dietary intake (Vegetarians, Vit. C Calcium)
• Malabsorption (Hypo-or achlorohydria)
• Losses can increase with colorectal cancer, polyps
• Prelatent(Depletion)
• Stores are depleted without a change in hematocrit or serum iron levels .
• Reduced stored iron e.g. serum ferritin with normal hemoglobin
• Latent(iron deficient erythropoisis)
• Serum iron drops and the TIBC increases without a change in the hematocrit.
• Reduced stored and transport iron
• Increased erythrocyte protoporphyrin concentration
• Detected by a routine check of the transferrin saturation.
• Associated with erythrocyte microcytosis and hypochromia.
• Stage of deficiency of stored, transport and functional iron
• Reduction of hemoglobin and serum ferritin
• Low serum transferrin saturation
• Iron deficiency attracts medical attention most commonly at this stage.
• Loss of appetite
• Palpitations
• Dyspnea on exertion
• Ankle swelling
• Paresthesia
• Leukoplakia
• Cold intolerance
• irritability
• Heart murmurs
• Increased JVP
• Tachycardia
• Postural hypotension
• Dryness or roughness of the skin
• Koilonychia
• Dry cracked lips Brittle hair
• DIAGNOSIS OF IDA
• Low hemoglobin
• Low serum ferritinlt15 mcg/dl
• Microcytic hypochromic in absence of chronic diseases/hemoglobinopathies
• Low serum iron content(lt 30mcg/dL)
• Low PCV, MCV, MCH, MCHC
• High TIBC gt 400 mcg/dl
• Increased ZPP (gt40 mmol/mole heme)
• Low transferrin saturation(lt15)
• Increased serum transferrin(gt350mg/dL)
• Increased serum soluble transferrin binding receptors(gt 8 mg/L)
• increased serum neopterin concentration
• Haematocrit
• RBC Indices
• Peripheral blood
• Urine for haemturia(RM/CS)
• Stool examination
• Hb electrophoresis
• X-ray Chest(PA View)
• Serum iron lt 50 µgm/dl
• TIBC is increased - gt 400 µgm/dl
• Serum ferritin is lt 12 µgm/dl
• Serum transferrin saturationlt20
• Red cell Zinc Protoporphyrin
• Stainable iron in the bone marrow is reduced-Gold Standard
• Serum transferrin receptor(TfR) Increased
• Bone marrow examination.
• Reticulocyte hemoglobin conc. Count of lt26pg/ cell
• Trial of iron therapy-diagnostic therapeutic
• Anaemic gravidas 120 240mg / per day
• Supplementation with folic acid Vit C.
• Ferrous sulphate 300mg TID daily after meals X 12 months
• Therapeutic results after 3 weeks rise in Hb level of 0.8gm/dl/ week with good compliance
• Rise in Hb at a rate of 2-4 gm/dl every 3 weeks till normal
• Hb conc. is normal after 6 wks of therapy
• INDICATORS OF IRON THERAPY RESPONSE
• Increase in Reticulocyte count (Increases 3-5 days after initiation of therapy )
• Increase in Hb levels. Hb increases 0.3 to 1 g/ week
• Epithelial changes (esp tongue nail ) revert to normal
• ORAL IRON THERAPY
• WHO 60 mg elemental iron 250 ug FA OD/BD.
• Govt. of India 100 mg Fe 500 ug FA during 2nd half of pregnancy X 100 days.
• - Intolerance
• - Unpredictable absorption rate.
• - Not suitable for patients with GI diseases/ significant bleeding
• - Non Compliant patient.
• - Long time for improvement
• Side effects
• Nausea Vomiting
• Gastric irritation
• Constipation
• Abdominal cramp
• Response to therapy
• - Sense of well being/Increased appetite.
• - Increase in Hb approximately 2gm per every 3-4 wk
• - Reticulocytosis with in 5-10 days
• - hematocrit returning to normal
• Enteric coated/sustained release preparations to be avoided as they are carried past duodenum limiting absorption
• Once hemoglobin is normal therapy is continued for further 3 months /at least 6 wks postpartum to replenish stores.
• Absorption helped by vitamin-C(take the tablets with glass of orange juice)
• Take before or after 1 hr of meal
• Don't take tea/coffee/milk
• Calcium based antacids will reduce the absorption
• NEW THERAPEUTIC ALTERNATIVES
• CARBONYL Iron
• Iron ascorbate
• Outstanding GI Tolerance
• Very safe with no poisoning even in high doses
• No interaction with food stuffs
• Delicious with non-metallic taste and dont stain the patients teeth
• Compliance is very high
• INDICATIONS
• Failure to oral iron therapy.
• Non compliance/intolerance to oral iron
• 1st time seen during last 8-10 wks with severe anemia
• Malabsorbtion/IBD
• Small bowel resection
• When hemorrhage is likely to continue
• C/I to blood transfusion
• Combination with recombinant human erythropoietin
• C/I to oral therapy
• Intravenous preparation
• Iron dextran (Imferon)
• Iron sucrose
• Sodium ferric gluconate (ferrlecit)
• Intramuscular preparation
• Iron Sorbitol Citrate in dextrin(Jectofer)
• Iron Dextran (imferon)
• Iron dextran 50 mg/mL. Iron sucrose 20 mg/mL. Ferric gluconate 12.5 mg/mL
• Contraindications
• h/o anaphylaxis to parenteral iron therapy
• 1st trimester of pregnancy
• Active acute/chronic infection
• Chronic liver diseases
• - Certainty of admission.
• - Hb rises _at_1gm/wk.
• Disadvantage
• Nausea and Vomiting
• Metallic taste on tongue
• Iron Dextran (1ml contains 50mg elemental iron 1amp2ml)
• Dose 100 mg IM OD/AD till the total dose over
• Painful injection (less with jactofer).
• Skin discoloration
• Local abscess
• Allergic reaction
• Fe over load.
• Category C drug
• Gluteal sarcoma
• Test dose needed
• Can be given in primary care set up
• Absolute reticulocyte count increases in 7 days
• Hemoglobin increases within 1-2 wks
• Whole dose can be given in single setting
• Repeated Injections
• Total dose infusion
• - Anaphylactic reaction.
• - Chest pain, rigors, chills, fall in BP, dyspnoea, hemolysis.
• Stop infusion.
• Give antihistaminics, corticosteroids epinephrine.
• IRON DEXTRAN
• Colloidal solution of ferric oxyhydroxide complexed with polymersised dextran
• Advantage patients total iron requirement is given in one administration
• Higher rate of adverse effects like delayed hypotension/ arthralgia/abdominal pain
• Test dose is necessary
• Patients should be monitored 1 hr following a test dose of 25 mg
• Can given as IV infusion with rate less than 50 mg/min
• Category B drug
• TDI TOTAL DOSE INFUSION
• I/V (IRON DEXTRAN)
• TDI(Normal Hb - Patients Hb) X Blood Volume(65ml/kg)X3.4
• TDI (Normal Hb Pt. Hb) X Wt in Kg X 2.211000
• TDI10  (target Hb-actual Hb )  (0.24  bodywei ght ) 0/500
• Dose given I/V by slow push 100mg / day or the entire dose given in 500 ml N/S slow I/V infusion over 1-6 hours
• FERRIC GLUCONATE COMPLEX IN SUCROSE
• Given as IV injection/infusion
• Standard dose of 125 mg may be given IV injection over 10 min
• Rate should be lt 12.5mg/min
• Dose can be repeated if ferritin lt 100ng/ml or saturation lt 20
• Can be safely given to Dextran sensitive patients
• Commonly used in chronic kidney diseases
• MW 34,000-60,000 D
• Iron hydroxide sucrose complex in water
• Each ml contains 20 mg of Fe
• After IV administration it dissociates into iron sucrose
• T 1/2 is 6hrs
• Total iron deficit Body weight x (Target Hb Actual Hb) x 2.4 Iron stores mg
• Administered 100 mg IV over 5 minutes, thrice weekly until 1000 mg
• 200mg max dose per Sitting
• Rate of administration should not more than 20 mg/min
• Infusion 50 mg to be injected slowly over 2 minutes, wait for 2-3 min ,then give another 50 mg over 2 min
• 100mg-200 mg to be diluted with 100ml NS, infuse at least 15 min
• Marked increase in reticulocyte count expected in 7-14 days
• Advantages of IRON SUCROSE over others
• All iron preparations were capable of causing tissue peroxidation except iron sucrose
• Less oxidative injury
• Less risk of tissue parenchymal injury by free iron.
• Higher availability for erythropoiesis than iron Dextran
• IV iron supplementation increases the erythropoiesis 5 times
• Safe in dextran sensitive patients
• Minimal side effects
• The Hb rise will be evident in as early as 5 days
• IV iron sucrose is safe effective
• Iron sucrose is given both bolus push infusion
• Total dose administered in multiple infusions
• Needs a set up where anaphylactic reaction can be managed.
• Iron III Carboxymaltose (FERRINJECT)
• Ferric hydroxide carbohydrate complex which allows for control delivery of iron within cells of the RES (primarily bone marrow) and subsequently delivery to the iron binding proteins ferritin and transferin
• Dose Single dose of 1000 mg over 15 minutes (maximum 15mg/kg by injection or 20 mg/kg by infusion)
• IRON III ISOMALTOSE(MONOFER)
• Strongly bound iron in spheroid iron-carbohydrate particle providing slow release of bioavailale iron to iron binding proteins
• Rapidly up taken by RES and little risk of free iron for tissue damage
• Dose 1000 mg in a single infusion
• Erythropoietic response seen within days
• Serum ferritin returns to normal by 3 wks
• FERUMOXYTOL
• USA FDA approved this drug in 2009 for iron replacement in patients with IDA CKD
• No test dose required
• Can be given as large dose (510 mg/vial) in lt20 Seconds in single settings
• No significant side effects
• Not approved in Europe
• 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
• Decision based on
• Needs and risk of developing complications of inadequate oxygenation
• Both clinical and hematological grounds
• Indications
• Severe anemia, especially after 36 weeks
• Risk of further hemorrhage
• Associated infections
• Imminent cardiac compromise
• Patient factors Type of surgery
• Preg Preg Elective Emergency
• lt36wks gt 36wks C/S C/S
• -Hb 5gm - Hb 6gm - with H/o -assess
• without CHF without CHF APH,PPH, according
• -Hb 5-7gm,if -Hb 6-8gm,if previous to situation
• CHF, hypoxia, CHF, hypoxia, LSCS
• Infection infection
• Hb 8 10 gm, confirm BG cross-matching
• Hb lt8 gm, 2 units to be kept ready in OT
• Consideration for delivery in well equipped hospital.
• Avoid sympathetic stimulation and hyperventilation prevent rightward shift of ODC.
• Supplemented with oxygen therapy
• Prophylactic forceps/Vaccum to cut short 2nd stage
• Decreased blood loss by active management of 3rd stage of labors.
• Avoid maternal stress, patient can go into CHF.
• PPH should be emergently treated(uterotonics)
• Pre oxygenation is mandatory with 100 O2
• Oxygen supplementation should be given in peri and postoperative periods
• Blood arrangements prior to surgery is must
• Airway maintenance to prevent fall of PO2 due to airway obstruction
• Hyperventilation to be avoided to minimize respiratory alkalosis
• General/spinal anaesthesia can be given after platelet count and excluding h/o spontaneous hemorrhage.
• Incidence 0.2 5
• Caused by folic acid deficiency Vit B12 deficiency
• Pathophysiology
• Preg. Causes 20 -30 fold increase in Folate requirement (150-450 microgram / day ) to meet needs of fetus placenta.
• Placenta transports folate actively to fetus even if the mother is deficient.
• Vit.B12 deficiency Occurs in patients with gastrectomy , ileitis, ileal resection, pernicious anaemia, intestinal parasites
• Folic acid reduced to DHFA then THFA, used in nucleic acid synthesis, is required for cell growth division.
• So more active tissue reproduction growth more dependant on supply of folic acid.
• So bone marrow and epithelial lining are therefore at particular risk.
• Coexists with IDA
• Folic acid deficiency more likely if
• . Woman taking anticonvulsants.
• . Multiple pregnancy.
• . Hemolytic anemia, thalassemia cleft palate
• -Increased MCV ( gt 100 fl)
• -Peripheral smear - Macrocytosis, hypochromia
• - Hypersegmented neutrophils(gt 5 lobes)
• - Neutropenia
• - Thrombocytopenia
• -Low Serum folate level.(lt3ng/ ml)
• -Low RBC folate (lt20 ng/ml)
• Insidious onset, mostly in last trimester
• Anorexia and occasional diarrhea
• Pallor of varying degree
• Ulceration in mouth and tongue
• Enlarged liver and spleen
• Hemorrhagic patches under the skin and conjunctiva
• Macrocytic Megaloblastic Anemia
• Peripheral neuropathy
• Subacute combined degeneration of the Spinal cord
• Hypersegmentation of neutrophils
• Megaloblast, Howell-Jolly bodies
• MCV gt 100 fl
• MCH gt 33pg, but MCHC is Normal
• Serum Fe is Normal or high, TIBC is low
• Serum Vit B12 levels lt 100 pg /ml
• Radio active Vit B12 absorption test (Schilling Test)
• Replace iron and treat underlying disease.
• Oral route is preferred for replacement.
• Response can be followed by retic. increase in 1-2 weeks (5-7 days)
• Hb response to treatment
• half normal by a month
• returns to normal by 2-4 months
• Replacement therapy is prolonged by 6-12 months to replenish stores of iron.
• 1000 microgram Parenteral Cyanocobalamin every wk X 6 weeks
• Prophylactic All woman of reproductive age should be given 400mcg of folic acid daily
• Curative Daily administration of Folic acid 4mg orally up to at least 4 wks following delivery
• Sickle cell disease
• Sickle cell anaemia (most common severe)
• Sickle cell beta thalassemia,
• Haemoglobin SC disease
• Thalassemia
• - Alpha thalassaemia.
• - Beta thalassaemia
• Valine substituted for glutamic acid at 6th position on ß chain of Hb molecule
• Common variants - SS ( sickle cell anemia)
• - SA ( sickle cell trait)
• SIGNS SYMTOMS
• Vaso-occlusive complications
• a)Painful episodes-most common(50)
• b) Acute chest syndrome(20)
• d) Renal insufficiency
• e) Splenic sequestration
• f) Proliferative retinopathy
• g) Priapism
• h) Spontaneous abortion
• i) Bone pains, leg ulcers, Osteonecrosis
• Complications related to hemolysis
• a) Anemia (Hct 15 30)
• b) Cholelithiasis
• c) Acute aplastic episodes
• Infectious complications
• a) Streptococcus pneumonia sepsis
• b) E.coli sepsis
• c) Osteomyelitis
• Hb solubility test-specific, cheap, rapid and simple.
• Sickling test
• Hb electrophoresis,
• Multidisciplinary approch
• Routine BP measurement and urinalysis to detect hypertension and proteinuria
• Retinal screening/fundoscopy for prliferative retinopathy
• Screening for iron overload(serum ferritin)
• Screening for PAH by echocardiography
• Antibiotic prophylaxis-penicillin/eruthromycin
• Termination planned for homozygous state
• Folic acid-5 mg should be given OD preconceptually and throughout the pregnancy
• Hydroxurea if taking should be stopped 3 months prior conception
• ACE inhibitors angiotensin receptor blockers stopped before conception
• Early detection and treatment of malaria and infections
• Low dose Aspirin from 12 wks of gestation
• Thromboprophylaxis with LMWH
• NSAIDS between 12 to 28 weeks
• Fluid and oxygen therapy(oxygen saturation gt 95) in painful crisis
• BT indicated only during complications like acute anemia/ACS/twin pregnancies, preeclampsia, septicemia, renal failure
• Goals Hb gt 8gm/dl HbA gt 40 of total Hb
• Iron therapy to be given if there is evidence of iron deficieny
• Vaccine H influenza type b, conjugated menigococcal C vaccine, peneumococcal vaccine Hepatitis-B vaccine
• Timing of deliver 38 -40 wks of gestation either by induction of labour/elective CS
• Factors to be avoided favouring sickling
• - Dehydration
• - Hypotension
• - Hypothermia
• - High conc. of HbS
• CS is preferred over vaginal delivery when labour is not progressing well.
• Continuous FHR monitoring due to increases rate of still births/abruption/compromosed placental reserve
• Counseling the parents regarding partner screening for carrier detection.
• Contraceptives
• Porgesterone only pill
• Injectable contraceptives
• Barrier methods
• Sterilization
• The synthesis of globin chain is partially or completely suppressed resulting in reduced Hb. content in red cells,which then have shortened life span.
• - Beta thalassaemia Major Minor
• Microcytic haemolytic anaemias
• Reduced synthesis of one or more of polypeptide globin chains.
• Higher transfusion requirements in pregnancy worsen haemosiderosis cardiac failure.
• Usually asymptomatic
• Weakness, fatigue, exhaustion, loss of appetite, indigestion, giddiness, breathlessness
• Palpitations, tachycardia, breathlessness, increased cardiac output, cardiac failure, generalised anasarca, pulmonary edema
• Nail changes
• Cheilosis, Glossitis, Stomatitis
• Hyperdynamic circulation (short soft systolic murmur)
• Fine crepitations
• Women with hemoglobinopathy should be offered oral iron therapy if serum ferritinlt30 mcg/L
• Referral to secondary/tertiary care to be done if
• Severe anemia
• Significant symptoms
• Late gestation(34 wks)
• Failure to respond to oral iron
• WHO - 60 mg Elemental iron 400 micro gram Folic acid / day up to 3 months postpartum
• GOI - 60 mg elemental Iron 500 mcg Folic acid as Prophylactic supplementation x 100 days in 2nd trimester up to 3 months postpartum
• Common in developing countries
• Poor response to Haematinics unless primary cause is treated
• Worm infestations is common ( Diagnosed by stool examination )
• Urinary tract inf, asymptomatic bacteriuria in preg. is assoc. with refractory anaemia
• Chronic renal disorders due to erythropoietin def.
• Identifying the etiology and treat accordingly
• Deworming with mebendazole/albendazole/levamisole
• Treated with recombinant Erythropoietin for renal disease.
• ATT to a patients with tuberculosis
• Antibiotics to treat UTI according to sensitivity
• Dietary advice and modification(red meat/ poultry/fish)
• Germination and fermentation of cereals and legumes improve the bioavailability of iron in food
• Green peas/Whole wheat/Green vegetables/Jaggery
• Iron supplementation of adolescent girls non pregnant women
• A nutritious diet in a pregnant woman should be providing about 40 mg elemental iron daily.
• Food fortification
• Fortification of staple food like wheat flour which is technically simple(USA)
• Fortification of curry powder, salt and sugar, dried and liquid milk(SA)
• Fortification of infant foods (INDIA)
• Fortification of complimentary foods (USA)
• Treatment of hookworm Infestation, malaria,TB
• Avoidance of Hypoxia, Acidosis, Infection, Dehydration Stress , Exercise, Extreme, Temperature
• Avoidance of frequent child birth.
• Supplemented Viamin-C (250-500mg/day) with iron
• Adequate treatment for any infection like UTI
• Early detection of falling Hb level, levels should be estimated at 1st A/N visit, 30th finally 36th week
• Mandatory monthly screening for anemia should be done in all antenatal clinics(especially at booking and at 28 wks with FBC)
• Screening and effective management of obstetric and systemic problems in all pregnant women

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You might even have a presentation you’d like to share with others. If so, just upload it to PowerShow.com. We’ll convert it to an HTML5 slideshow that includes all the media types you’ve already added: audio, video, music, pictures, animations and transition effects. Then you can share it with your target audience as well as PowerShow.com’s millions of monthly visitors. And, again, it’s all free.

About the Developers

PowerShow.com is brought to you by  CrystalGraphics , the award-winning developer and market-leading publisher of rich-media enhancement products for presentations. Our product offerings include millions of PowerPoint templates, diagrams, animated 3D characters and more.