1. ANEMIA IN PREGNANCY

2. INTRODUCTION Most common complication of pregnancy in developing countries Important cause of maternal death Incidence – 40-90% in India

3. DEFINITION Anemia is defined as low hemoglobin concentration resulting in decrease in oxygen carrying capacity of blood. WHO -11 gm% FOGSI – 10 gm%

4. HEMATOLOGICAL CHANGES DURING PREGNANCY Plasma volume Increases by 40-45% Red cell mass Increases by 15- 20% Disproportionate increase b/w the plasma volume and red cell mass results in physiological anemia of pregnancy (Hb 10gm%,PCV 30, RBC count- 3.2mill,PS)

5. CLASSIFICATION PHYSIOLOGICAL ANEMIA OF PREG PATHOLOGICAL 1. Deficiency anemia iron/folic acid/vitamin B12/protien deficiency 2 Hemorrhagic Acute /chronic 3Hemolytic Familial-sickle cell anemia Acquired –malaria, severe infection 4Bone marrow insufficiency-radiation /drugs/infection 5Hemoglobinopathies

6. Physiology of iron absorption and erythropoiesis ERYTHROPOIESIS Bone marrow Pronormoblast  normoblasts  reticulocyte  mature non-nucleated erythrocytes Requires good nutrition- Mineral- Fe. Cu, Cobalt Vitamins – vitamin B12, folic acid,vitamin C Protein- supply amino acid Erythropoietin – stimulate stem cells in BM

7. Contd.. ABSORPTION In the duodenum. Fe2+ Factors affecting absorption Apoferritin / transferrin Excretion

8. Contd… Iron requirement non pregnant female- 1.4 – 2.5 mg/day In pregnancy- 3.5-4 mg/day should be absorbed In pregnancy Absorption increases up to 10%

9. IRON DEFICIENCY ANEMIA CAUSES Poor intake of dietary iron/faulty diet Poor absorption- only 10% is absorbed normally. in pregnancy 4-6mg of iron should be absorbed daily so diet should contain at least 40-60 mg of iron. Increased demand during pregnancy Continuous loss of blood

10. Contd.. Increased demand during pregnancy Fetus and placenta300 mg Maternal Hb mass expansion500 mg Loss in urine/gut/skin200 mg Loss at delivery150 – 200mg lactation150- 200 mg

11. Factors contributing to anemia in pregnancy Increased demand Diminished intake Disturbed metabolism Pre-existing anemia Excess demand- multiple preg/ rapid recurring/ young mothers

12. Clinical features Mild- no symptoms Severe Associated with multigravida/ less spacing/ Multiple pregnancy/chronic illness- uti,worm infestation symptoms- lethargy,palpitation,giddy,DOE Signs – pallor, glossitis,edema, ESM ---cardiac failure

13. INVESTIGATIONS Degree of anemia Hb,PCV, RBC count Mild -8-10 gm%, moderate- 6.5- < 8 gm% Severe - <6.5 gm% Type of anemia Peripheral smear, hematological indices, S.iron, TIBC,S. ferritin, S. bilirubin, %saturation

14. BLOOD PICTURE IN Fe DEFICIENCY ANEMIA FINDINGS- Non- pregnant Pregnancy with anemia Hb>14<10 gm% PCV42%<30% MCHC34<30% MCV87< 75um3 MCH29< 25 pg S. Iron50-150<30 ug/100ml S.Ferritin20-30<10 ug /L TIBC300-350>400 ug/100 ml % saturation30% < 10%

15. CONTD.. Find cause of anemia Stool exam/ urine exam Special- x- ray chest/FTM/S.protein / osmotic fragility/Hb electrophoresis Bone marrow- not done routinely-unresponsive/ aplastic anemia/ L.D bodies

16. COMPLICATIONS OF SEVERE ANEMIA DURING PREGNANCY PET,infection,cardiac failure,PTL DURING LABOR PPH,cardiac failure, shock PUERPERIUM Sepsis, sub involution, failing lactation,venous thrombosis,pulmonary embolism, delayed healing BABY- LBW due to PTL, IUGR

17. TREATMENT PROPHYLACTIC Counselling - avoid frequent child births Supplement iron + folic acid Proper diet Deworming Treat probable disease causing anemia Periodic checking of Hb - (1 st,28,36)

18. Contd.. CURATIVE Depends on the degree of anemia and period of gestation General treatment Diet Treat any underlying cause Vitamin C to improve absorption To eradicate any septic foci-antibiotics

19. SPECIFIC THERAPY ORAL THERAPY PARENTERAL THERAPY Oral Ferrous preparation – Draw backs- intolerance/unpredictable absorption/difficult replacing iron stores Improve in 3 weeks 0.7gm/100ml/week Response indicators Contraindications to oral therapy

20. PARENTERAL THERAPY ROUTES Intravenous ( REPEATED INJ / TDI ) Intramuscular Indications Advantage- fix up iron store as well Rise in Hb is 0.7-1 gm/100ml/week

21. CONTD… INTRAVENOUS ROUTE Repeated injections - not in use TDI- deficit calculated and the total amount of iron required to correct the deficit is administered in a single sitting i/v infusion Iron dextran-1ml contain 50mg elemental iron Advantages Limitations

22. Contd.. Estimation of total iron requirement 0.3x W (100-Hb%) mg of elemental iron W = patients weight in pounds.Hb= observed Hb in %.Additional 50% for replenishing iron stores 2.4xwt(kg)x(15-hb of pt)+1000gm Pre-requisites Drip rate and administration

23. Contd... Intramuscular therapy Iron – dextran Iron sorbitol citric acid complex in dextrin (jectofer) I ml=50mg of elemental iron Oral iron to be suspended at least 24hours prior to therapy Procedure/draw backs

24. Contd… Indications for blood transfusion To correct anemia due to blood loss and to combat PPH Patients with severe anemia in later weeks >36 weeks of pregnancy Refractory anemia Associated infection

25. Contd… Fresh blood Packed cells Advantages Precautions Drawbacks – PTL, CF,reaction EXCHANGE TRANSFUSION

26. Contd… Management during labor First stage Patient in bed Pain relief Oxygen inhalation Strict asepsis Second stage Cut short second stage Prophylactic methergin -0.2 mg/ lasix

27. Contd… Third stage Blood transfusion if excess blood loss. strict asepsis Puerperium Patient in bed Antibiotics Hematinics Blood transfusion contraindicated in puerperium just to have rapid improvement of anemic state

28. MEGALOBLASTIC ANEMIA Deranged red cell maturation with the production of abnormal precursors in the bone marrow (due to impaired DNA synthesis) known as megaloblasts. Causes Folic acid deficiency due to: Incidence- 0.5 – 3 % > in multi > in multiple preg

29. Contd… Clinical features –anorexia/ diarrhea Pallor,glossitis,pet/hsm/hemorrhagic patches Investigation- Hb 100um3/mch>33pg/ mchc normal TC /platelets/B12/s.folate/s. fe/ s bilirubin raised/ bone marrow Complications Treatment- prophylaxis/curative

30. Contd… Dimorphic anemia Anemia from protein deficiency Hemoglobinopathies sickle cell anemia Thalassemia