Anaemia in pregnancy Anaemia is one of the most common disorders affecting humans in the world. The WHO defines anaemia as Haemoglobin (Hb)< 11g/dl. Chronic anaemia results in the sense of well-being; fatigue, stress, decrease in work capacity. Anaemia in pregnancy, is associated with an increased risk of maternal and fetal morbidity and mortality.

Physiological changes in pregnancy Healthy pregnancy and puerperium are associated with a marked physiological changes in the circulating blood; increase in blood volume and alteration in the factors involved in haemostasis. These changes have relevance to the most potential and hazardous haematological problems of pregnancy& delivery. What are they???

Physiological changes Blood volume; Plasma volume Red blood mass Hypervolemia state, modifies the response to hypotension in the first half of pregnancy and the blood loss at delivery. Vaginal delivery;? ml Caesarean section? ml

Causes Inadequate intake of nutrition Excess blood loss Abnormal demand malabsorption

Iron deficiency anaemia Hb concentration decrease MCV MCH MCHC All can be calculated from RBC, Hb,Packed cell volume. These tests give basic guide to a diagnosis in pregnancy.

MCV, the most sensitive indicator of underlying Iron deficiency, decrease Hypochromia, and MCHC appear with more severe degree of Iron defiency. Serum ferritin Total Iron binding capacity

Management Confirm diagnosis; history, examination and investigation Treatment depends on the degree of anemeia and ?????

Treatment Nutrition Iron therapy, various forms, depends on Compliance of the woman Associated GIT symptoms Availability of medication Cost

Oral Iron, ferrous fumerate, ferrous sulphate Does depends on level of HB Supplement folic acid Give proper instructions Care if on throxine, calcium,

Injectable/ parentral Iron therapy Intramuscular Intravenous infusion

The following statements about oral iron prophylaxis during pregnancy are correct: Gastric side effects are does-related. Iron absorption during the first trimester of pregnancy is decreased compared with non-pregnant state. Non-compliance of the mother occurs in less than 10%. Oral maternal iron prophylaxis is recognized to be associated with an increase in MCV

Iron deficiency anaemia in pregnancy MCHC and MCV are low There is usually chronic blood loss Blood transfusion is indicated if the Hb is <9gm/dl. There is increase risk of Pre-eclampsia. There is no proven danger of teratogencity from Iron therapy.

A clinical scenario A 25 years old gravida 2with a normal past obstetric history, is found to have a Hb of 10gm/dl at 32 weeks of gestation. The Hb at booking(12 weeks) was 12gm/dl and she has not taken Iron supplements during this pregnancy. Full investigation shows a MCH of 32 and a MCV of 86FL. The blood film shows some polychromasia and microcystic.

These findings are diagnostic of Iron deficiency anaemia The MCV is a better guide to the presence of Iron deficiency anaema than is Hb level. Should iron deficiency occur late in a prgnancy, parentral Iron will raise the hb faster than oral iron

Haemoglobinpathies Sickle cell disease Is the name given to a group of inherited blood conditions which include: Sickle cell anaemia, Sickle cell beta thalasemia, Haemoglobin SC disease. The most common and severe is Sickle cell anaemia

What causes sickle cell anaemia Inherited disorder of the Hb structure

Antenatal care Sickle cell trait (HbSA) , may have UTI and microscpic haematuria’ Sicle cell anameia Bad obstetric history Painful crises Jaundice Anaemia Deformed pelvis Increase rate of operative deliveries; CS avascular necrosis of the hip

Diagnosis Hb electrophoresis, not specific, Hb D, G Sickling test, not specific, HbC Hb memphis. Hb solubility test, specific, cheap, rapid and simple. reticulocytes

Combination; HbSS and pregnancy hazardous Mother Infection Anaemia Heart failure Painful crises Embolism/ stroke Pulmouary hypertension Renal dysfunction Retinal disease Leg ulcers Choliothesis

Antenatal follow-up Mother MSU Blood pressure Dip stick Renal function Liver function Complete blood picture Will they have Iron deficiency anaemia????

Fetal monitoring USS for viability <9 weeks USS, first trimester 11-14 weeks USS detailed anomaly at 20 weeks Biometry every 4 weeks.

What to give Folate, because ?? Asprin , how much??? Heparin, what kind??

In pregnancy Avoid Hypoxia Acidosis Infection Dehydration Stress Exercise Extreme Teperature

Treatment Multi-disciplenary approach Supportive measures Rehydration Analgesics Blood transfusion, keep Hb S level<40% Keep Hb A level >60%

Further Readings Management of sickle cell Disease in pregnancy.Guideline No 61 July 2011 www.evidence.nhs.uk www.rcog.org.uk/Guidelines

Maternal sickle cell disease The spontaneous miscarriage is increased The incidence of proteinuric hypertension increased. The incidence of spontaneous delivery is increased. The incidence of small for gestational age is unchanged. The presence of sickle cell disease in the fetus can not be diagnosed.

Sickle cell disease There is failure of formation of the beta chain of polypeptide. Hb level rarely fall below 9gm/dl. Iron deficiency anaemia is usual Crises is unlikely to occur the trait.

Perinatal mortality rates are adversely affected by: Alpha Thalasemia minor HbSS Beta Thalasmia minor HbSC Sickle cell thalasemia Sickle cell trait