CONTINOUS MEDICAL EDUCATION BY DR NAZ

1. ANEMIA IN PREGNANCY
DR SHABNAM NAZ
ASSISTANT PROFESSOR
OBGYN
CMC,SMBBMU LARKANA

2. definition
A pathological condition in which the oxygen
carrying capacity of red blood cells is insufficient
to meet the body ‘s needs
WHO recommends the HB% should not fall below
11g/dl at any time during pregnancy
CDC refer the value of 10.5 g /dl

3. PREVALANCE-
40% of world ‘s population
(35%non-preg 51%pregnant)
56% in Pakistan
MORTALITY
40-60% IN Pakistan
18% in industerlised countries

4. PHYSIOLOGICAL CHANGES IN BLOOD
DURING PREGNANCY
 Plasma volume increased 50%
 Red cell mass increased 25%
 Fall in Hb conc:, haematocrit & red cell
count .
 MCV increased secondary to erythropoiesis
 MCHC remains stable
 Sr: iron and ferritin decrease
 TIBC increased

5. Severity of anemia
Severity Percentage hemoglobin
values
MILD 13 10-10.9 mg/dl
MODERATE 57 7-10mg/dl
SEVERE 12 <7mgldl
VERY SEVERE Decompanseted <4mg/dl

6. Degrees of anemia

7. CLASSIFICATION of ANEMIA
 Physiologic
 Pathologic:
a. Deficiency: Iron, Folic A., Vitamin B12
b. Hemorrhagic: APH, Hookworm
c. Hereditary: Thalassemia, Sickle, H. Hemolytic
Anemia
d. Bone Marrow Insufficiency: Aplastic Anemia
e. Infections: Malaria, TB
f. Chronic Renal Diseases or Neoplasm.

8. IRON DEFICIENCY
ANEMIA

9. IRON ABSORBTION
 Dietary iron (heme and non heme)
- heme-animal blood flesh viseras
-Non heme-cerels, seeds, vegetables, milk eggs.
 Factors increases iron absorbtion
 Heme iron
 Proteins
 Meat
 Ascorbic acid
 Fermentation

10.  Ferrous iron
 Gastric acidity
 Alcohol
 Low iron stores
 Increase erethropiioetic activity(hight altitue,bleeding)
FACTROS DECREASES IRON ABSORBTION
 Phytates
 Calcium
 Tennins, tea, coffee, herbal drinks
 Fortified iron supplements

11. IRON LOSS
PHYSIOLOGIC FACTORS
 Desquamation of cells( intestine, skin)
 Menstruation
 Delivery
 Lactation
PATHOLOGIC FACTORS
 Hookworms /other helmentis
 Bleeding from GIT
 Allergies
 Occult blood loss, excess menses,APH

12. Iron requirement in pregnancy
 Adult woman absorption-2mg/day
 Total iron requirement during pregnancy-900mg
DEMANDS
 EXPANSION OF RBC-500 -600mg
 FETUS AND PLACENTA-300mg
DAILY IRON REQUIREMENTDURING PREGANCY 4mg
Early pregnancy – 2.5mg
20-32wksof pregnancy- 5.5mg
>32wks of pregnancy6-8mg
Iron absorption rate 10%

13. PREVENTION OF IRON DEFICIENCY
1.Iron supplementation during pregnancy
According to WHO 60 mg elemental iron and 250mg folic acid
daily for 6 months and additional 3 months in postpartum
period in low prevalence countries
2.Treatment of hookworm infestation
Single dose of albendazole 400mg stat
Or mebendazole 100mg BD for 3 days
3.Improvements of dietary habits
Iron rich food
Cook food in iron utensils

14. Prevention continue…..
4.Social services
Improvement in sanitation
Personal hygiene
Better education of female regarding diet
Contraception
5.Food fortification
Iron fortified salt like iodine salt

15. Concept of Physiologic Anemia
 Disproportionate increase in plasma vol, RBC vol. and
hemoglobin mass during pregnancy
 Marked demand of extra iron during pregnancy
especially in second trimester

16. Physiologic anemia in pregnancy

17. Criteria for Physiologic Anemia
 Hb: 10gm%
 RBC: 3.2 million/mm3
 PCV: 30%
 Peripheral smear showing normal morphology of RBC
with central pallor

19. Significance of Hypervolemia
 . To meet the 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.

20.  Normal hemoglobin by gestational age in
pregnant women taking iron supplement
 12 wks 12.2 [11.0-13.4]
 24wks 11.6 [10.6-12.8]
 40 wks 12.6 [11.2-13.6]

22. FACTORS LEAD TO DEVELOP ANEMIA
 Physiological hamodilution
Increase iron demand
Diminished intake of iron
 Disturbed metabolism
 Pre-pregnancy health status
 Excess demand

23. SIGNS AND SYMPTOMS OF ANEMIA
Symptoms
 fatigue,
 Headache
 Faintness
 Breathlessness
 Palpitation
 Intermittent claudication

24. SIGNS
 Palar of skin , conjunctiva, mucous membrane
 Tachycardia high volume pulse
 Ankle edema
 Cardiac failure
 Systolic flow murmur
Specific signs of iron deficiency
koilonychias, brittle nails atrophy of papilla of tongue
Angular stomatisis, brittle hair, palmmer winson
syndrome

25. koilonychia

26. Smooth tounge

27. Angular cheilosis

28. EFFECTS OF ANEMIA ON PREGNANCY
MATERNAL EFFECTS
 Preterm labour
 Anasarca
 CCF
 Pulmonary edema
 PPH
 P-Sepsis
 Failing lactation
 Sub involution of uterus
 thromboembolism

29.  Maternal mortality in 3rd trimester ,during labour ,delivery
,immediately after delivery ,during peurperium due to
heart failure and pulmonary embolism .
FETAL EFFECTS
 Pre-term birth
 SGA
 Infection
 Anemia
 Low iron store
 High peri-natal mortality

30. DIAGNOSIS OF IRON DEFICIENCY ANEMIA
1.Hb%-
practical cheap early performed method
2.Blood cell indices
-differentiated b/w iron deficiency and thalasemia

31. Red cell indices in iron deficiency and
thalasemia
characteristics calculation Normal range Iron deficiency Thalasemia
MCV(fl) PCV/RBC 75-96 Reduced Very reduced
MCH(pg) Hb/RBC 27-33 Reduced Very reduced
MCHC(g/dl) Hb /PCV 32-35 Reduced Normal or
slightly reduced
HbF(%) hbF/HbA/100 <2% normal Raised
HbA2(%) HbA2/HbA/100 2-3% Normal or Raised
raised
FEP(microgram/ ____ <35 >50 Normal
dl
Red cell width High Normal

32. 3.Serum ferritin –reflect iron store
Normal level 15-300microgram /L
Level <12 microgram/L indicate iron deficiency
4.TIBC-serum iron decreased and TIBC increased
Transferin saturation can be estimated from serum iron
and TIBC
Reduce transferin saturation indicate deficient iron
supply to tissues.
Serum iron 60-120 mcg/dl
TIBC-300-350mcg/dl

33. 5.Free erythropoietin receptors
Help to differentiate b/w iron deficiency and thalasemia
6.Serum transfferin receptors
Appear to be specific and sensitive marker of iron
deficiency in pregnancy, its level increased in iron
deficiency, but not routinely available.
7.Bone marrow aspiration
When no response and for diagnosis of aplastic anemia
and kalzar

34. bone marrow aspiration
high cellularity mild to moderate erythroid
hyperplasia
(25-35%; N 16 – 18%)
polychromatic and pyknotic cytoplasm of
erythroblasts is
vacuolated and irregular in outline
(micronormoblastic erythropoiesis)absence
of stainable iron
8.Stool examination-consequently for 3 days

35. 9.Urine examination- for occult blood
shistosomiasis in shistosomiasis prevalent
countries.
10.Blood film for MP
11.Sputum examination /x-ray (TB)
12.RFT
13.Serum protein(hypo proteienemia)

36. Iron. Deficiency—Diagnoses
Microphotograph of bone
marrow staining for iron.
Iron is stained blue and it
is mainly in the
macrophages (lower left

37. Categorizing iron deficiency anemia
category Serum ferritin Hb% Diagnosis
One >12mcg/dl >11g/dl Normal no iron deficiency
Two <12mcg/dl >11g/dl Storage iron depletion
Three <12mcg/dl <11g/dl Iron deficiency
Four >12mcg/dl <11gdl Other cause of anemia

38. Treatment of iron deficiency anemia
 Medical treatment
 Oral iron
 Parenteral iron
 Blood transfusion
 Recombinant erythropoietin

39. ORAL IRON
 PROPHYLAXIS -100mg(elemental iron)+0.5 folic acid /day
 THERAPUTIC -180mg elemental iron/day
Raise of Hb-0.3-0.8g/wk
To improve compliance
1. Give drug less frequently then daily
2. Change brand
3. Give with meal or decrease dose.
If no improvement
Another preparation as carbonyl iron
Blood transfusion

40. Oral iron
DISAADVANTAGES
 Intolerance to medication
 Unpredictable absorption
 Non compliance
SIDE EFFECTS
 Abdominal cramps
 Constipation
 Distaste
 Nausea vomiting

41. Oral iron
INDICATORS OF RESPONSE TO THERAPY
 Improvements in symptoms
 Increase reticulocyte count in 5-10 days
 Increase in Hb% 0.8g/dl/week
REASONS OF FAILURE
 Inaccurate diagnosis
 Non compliance
 Continues blood loss

42. PARENTERAL IRON THERAPY
Available forms
 Iron dextran (oral and i/v infusion)
 Iron poly maltose(sucrofer rubiject)
 Iron sucrose
DOSE
(Normal Hb-patient’s Hb) x weight(kg)x2.21 +1000=
(14-7) x65kg x 2.21+1000=2005mg
Precautions
 Should be given in hospital setup by doctor
 Inj :hydrocortisone, epinephrine, and oxygen should be
available.

43. Total dose infusion
Total dose iron replacement in 2nd and 3rd trimester in
which
total deficit is calculated and given as single infusion
which
take 3-6 hrs to complete.
Various preparations are available
Dextran( imferon)withdrawn b/c of high incidence of
anaphylaxis

44. PARENTRAL IRON THERAPY
I/M-ROUTE
 Iron sorbitol citrate (jactosol /jectofer)
Advantages
 low mol:wt:
 Rapid absorption
Dose and technique
 50mg test dose then 100mg i/m
 Z technique

45. Precautions
Stop oral iron to avoid toxic effect
Disadvantages
 Nausea vomiting
 Headache
 Fever
 Allergic reaction
 Lymph adenopathy
 Tattooing of skin
 Severe anaphylaxis

46. Parenteral iron therapy continue..
INTRAVENOUS IRON
Indication
 Non compliant
 GI problems
 Pregnancy >32-36wks
Advantages
 Certainty of its administration
 Raise Hb/wk(rapid raise)
 Alternate to blood transfusion when oral treatment
fails.

47. ERETHROPOETIN
Recombinant erythropoietin
 Anemia of chronic renal failure
 Autologous production of blood in normal individuals
 Severe postpartum anemia(life saving)
 Where blood transfusion avoided as in jehovah witnesses
BLOOD TRANSFUSION
(pc) preferred
 Severe anemia
 Pregnancy beyond 36 wks
 Blood loss e.g. ; APH,PPH,
 Pts not responding to oral and parental treatment
EXCHANGE TRANSFUSION
 Very rare in sever anemia

48. Obstetrical treatment
 Frequent A/N visits
 Caution in use of steroids and beta mimetics in p.t.l
 Prop up, oxygen
 Sedation
 Adequate analgesia
 Assisted delivery in second stage
 AMTSL
 Breast feeding
 Contraception for 2 years
 Continue iron for 3 months

49. Obstetrical treatment
Antenatal care
 More frequent visit
 Detect and manage complication as heart failure PTL
 Fetal monitoring for growth and well being

50. Obstetrical treatment
Management in labour
 Comfortable position (prop up)
 Sedation
 Analgesia
 In pre term beta mimetics and corticosteroids used
carefully to avoid risk of pulmonary edema
 Antibiotic prophylaxis
 Oxygen in dyspnoic patients
 Digitalization and cardiac support in cardiac failure.

51. Obstetrical treatment
Second stage management
 Shortened by instrumental delivery
Third stage
 AMTSL except in severe anemic for fear of cardiac failure
Puerperium
 Adequate rest
 Iron and folate therapy for 3 months
 Treatment of any infections
 Pediatric opinion
 Effective contraception.(at least 2 years till iron store
recover)

52. Megaloblastic Anemia's
 A form of anemia characterized by the presence of large,
immature, abnormal red blood cell progenitors in the
bone marrow
 95% of cases are attributable to folic acid or vitamin B12
deficiency

53. Static Test for Folate/B12 Status
Folate
 Measured in whole blood (plasma and cells) and then
in the serum alone
 Difference is used to calculate the red blood cell folate
concentration (may better reflect the whole folate
pool)
 Can also test serum in fasting patient
B12
 Measured in serum

54. Functional Tests for
Macrocytic Anemia's
 Homocysteine: Folate and B12 are needed to convert
homocysteine to methionine; high homocysteine may
mean deficiencies of folate, B12 or B6
 Methylmalonic acid measurements can be used along
with homocysteine to distinguish between B12 and
folate deficiencies (↑ in B12 deficiency)
 Schilling test: radiolabeled cobalamin is used to test
for B12 malabsorption

55. Pernicious Anemia
A macrocytic, megaloblastic anemia caused by a deficiency of
vitamin B12.
 Usually secondary to lack of intrinsic factor (IF)
 May be caused by strict vegan diet
 Also can be caused by ↓gastric acid secretion, gastric
atrophy, H-pylori, gastrectomy, disorders of the small
intestine (celiac disease, regional enteritis, resections),
drugs that inhibit B12 absorption including neomycin,
alcohol, colchicine, metformin, pancreatic disease

56. Symptoms of
Pernicious Anemia
 Paresthesia (especially numbness and tingling in
hands and feet)
 Poor muscular coordination
 Impaired memory and hallucinations
 Damage can be permanent

57. Vitamin B12 Depletion
 Stage I—early negative vitamin B12 balance
 Stage II—vitamin B12 depletion
 Stage III—damaged metabolism: vitamin B12 deficient
erythropoiesis
 Stage IV—clinical damage including vitamin B12 anemia
 Pernicious anemia—numbness in hands and feet; poor
muscular coordination; poor memory; hallucinations

58. Causes of Vitamin B12 Deficiency
 Inadequate ingestion
 Inadequate absorption
 Inadequate utilization
 Increased requirement
 Increased excretion
 Increased destruction by antioxidants

59. Treatment of B12 Deficiency
 Before 1926 was incurable; until 1948 was treated with
liver extract
 Now treatment consists of injection of 100 mcg of vitamin
B12 once per week until resolved, then as often as
necessary
 Also can use very large oral doses or nasal gel
 MNT: high protein diet (1.5 g/kg) with meat, liver, eggs,
milk, milk products, green leafy vegetables

60. Folic Acid Deficiency
 Tropical sprue; pregnancy; infants born to deficient
mothers
 Alcoholics
 People taking medications chronically that affect folic acid
absorption
 Malabsorption syndromes

61. Causes of Folate Deficiency
 Inadequate ingestion
 Inadequate absorption
 Inadequate utilization
 Increased requirement
 Increased excretion
 Increased destruction
 Vitamin B12 deficiency can cause folate deficiency
due to the methylfolate trap

62. Methylfolate Trap
In the absence of B12,
folate in the body exists as
5-methyltetrahydro-folate
(an inactive form)
B12 allows the removal of
the 5-methyl group to
form THFA

63. Stages of Folate Depletion and
Deficiency
 Stage I—early negative folate balance (serum depletion)
 Stage II—negative folate balance (cell depletion)
 Stage III—damaged folate metabolism with folate-
deficient erythropoiesis
 Stage IV—clinical folate deficiency anemia

64. Diagnosis of Folate Deficiency
 Folate stores are depleted after 2-4 months on
deficient diet
 Megaloblastic anemia, low leukocytes and platelets
 To differentiate from B12, measure serum folate, RBC
folate (more reflective of body stores) serum B12
 High formiminoglutamic acid (FIGLU) in the urine also
diagnostic

65. Other Nutritional Anemia's
 Copper deficiency anemia
 Anemia of protein-energy malnutrition
 Sideroblastic (pyridoxine-responsive) anemia
 Vitamin E–responsive (hemolytic) anemia

66. Hemolytic Anemia
 Oxidative damage to cells—lysis occurs
 Vitamin E is an antioxidant that seems to be
protective.
 This anemia can occur in newborns, especially
preemies.

67. Non nutritional Anemia's
 Sports anemia (hypochromic microcytic transient
anemia)
 Anemia of pregnancy: dilutional
 Anemia of inflammation, infection, or malignancy
(anemia of chronic disease)
 Sickle cell anemia
 Thalassemia's

68. SUMMARY
 Anemia is most common medical disorder of pregnancy
with significant maternal ND fetal implications
 Iron deficiency is major cause of anemia in pregnancy
 Diagnosis should be establish during nd before pregnancy
so to treat timely to prevent complications
 Screening for iron deficiency in pregnancy is simple

69. THANK YOU