1. Anemia in Pregnancy- An Overview Session 1.1

2. What is Anaemia
A condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet the body’s physiological requirements
These vary by age, sex, altitude, smoking habits, and during pregnancy
Anemia is defined as hemoglobin concentration below established cut-off levels in the blood
Iron deficiency anemia is most common and it can be prevented and treated
In Rajasthan every second pregnant woman is anemic (NFHS-4)

3. What is Anaemia
Anemia is associated with increased maternal mortality and morbidity
22% maternal deaths can be attributed to Anaemia directly or indirectly
Rajasthan government is committed to address anemia in pregnancy
Reducing anemia by 3% per year through Anemia Mukt Bharat is one of the important initiatives of Government of India
Prevalence of anaemia in pregnant women (15-49 yrs) in Rajasthan is 40-50% (NFHS 4)

4. Top and Bottom Five Districts of Rajasthan in Anemia Prevalence According to NFHS 4, (2015-16)
Top 5 Districts
Bottom 5 Districts
Hanumangarh (20.3%)
Jhunjhunu (27.7%)
Dausa (28.6%)
Jaipur (30.0%)
Sawai Madhopur (30.8%)
Banswara (68.7%)8.7%)
Baran (69.5%)
Jhalawar (69.6%)
Chittaurgarh (71.6%)
Udaipur (73.5%)

5. Symptoms and Signs of Anaemia during Pregnancy
Easy fatigability
Swelling over feet or all over body
Breathing difficulty, breathlessness
Brittle nails
Flat nails
Pica
Tingling, numbness
Palpitation
Oedema over body
Pallor-conjunctiva, tongue, nails
Koilonychia or platynychia
Rapid pulse
Glossitis
Hyperdynamic circulation
Hepato-spleenomegaly
Later pulmonary oedema or CHF

6. Causes of Anaemia Low Iron Stores Dietary Iron Loss Maternal Anaemia
During pregnancy in anemic mothers
Poor iron stores from infancy, childhood deficiencies and adolescent anemia
Inappropriate complementary feeding practices
Excessive consumption of ‘Iron Inhibitors’ (tea, coffee, calcium-rich foods) and low intake of ‘Iron Enhancers’ (Vitamin C etc.)
Low bioavailability of dietary iron
50% population consumes less than required iron
Decreased intake of folate, vitamin B 12
Due to parasitic load (malaria, intestinal worms)
Poor environmental sanitation, unsafe drinking water and inadequate personal hygiene
Chronic illness like TB, HIV
Heavy menstruation
Increased iron requirement due to tissue, blood formation and energy requirement during pregnancy
Iron loss from post-partum haemorrhage
Teenage pregnancy
Repeated pregnancies with less than 2 years interval
Note: During pregnancy physiological anemia occurs due to disproportionate rise in plasma volume, RBC haemoglobin mass with increased demand of extra iron

7. Effects of Anaemia on Woman and Fetus
Pregnant Woman
Foetus
Abortions (12-28%)
Increased risk of infections
Pre ‐eclampsia/eclampsia
Preterm labor
Premature rupture of membranes (PROM)
Placental abruption
PPH
Puerperal sepsis
Maternal deaths (30%)
Foetal death (7-10%)
Asphyxia
Low birth weight
Intra uterine growth restriction (IUGR)
Prematurity (5 times more in iron deficiency anemia)

8. Public Health Implications of Anemia
Reduced physical development
Impact on pregnancy outcomes
Reduced cognitive development
Economic impact
Decreased work output and work capacity
About 20 % of maternal deaths are caused by Anemia worldwide
Neural tube defects, infants of low birth weight and still births
Anemic pregnant women are more prone to increased morbidity and there is a three times greater incidence of premature delivery in severely anemic women
Diminished concentration, disturbance in perception, delayed psychomotor development
Impaired language and motor skills
Diminished IQ equivalent to a 5–10 point
In the WHO/World Bank rankings, iron deficiency anemia is the third leading cause of DALYs lost for females aged 15–44 years and 1.18 % of Gross Domestic Product (GDP) loss

9. Kushal Mangal Karyakaram-Programme Overview

10. Introduction: Kushal Mangal Karyakaram
Launched on 11th July 2015
Objectives
To generate community awareness about planned conception & care during pregnancy.
To ensure early detection and management of complications in pregnancy.
To establish a mechanism for screening, tracking, line listing and follow up of every HRP(PMSMA,SMD)
To provide Quality ANC care to all pregnant women
To ensure Assured Ambulance Availability for every HRP.
To ensure planned institutional delivery at appropriate facility through PND.
To ensure special Post natal Care & follow up of HRP up to 42 days.

11. Kushal Mangal Karyakram components
HRP management and care
Planned conception
HRP Tracking
HRP Follow up
HRP counselling and help desk (104)
HRP escort
Assured ambulance availability
Planned institutional deliveries of HRP
Postpartum care of mother & new born

12. 1. Planned conception & care during pregnancy
To generate community awareness
To reduce the possibility of Anaemia in adolescents
Marriage not before than 18 years
Avoid first conception before 20 years
Minimum 03 years difference between two pregnancies
Avoid pregnancy after 35 years

13. 2. Screening, tracking, line listing of every HRP
Definition :- A high risk pregnancy is one in which some condition puts the mother, foetus or both at higher risk during or after pregnancy for a variety of reasons
To identify HRP at right time, ensure registration of every pregnant women within 12 weeks
Ensure at least 4 ANC visits
If any signs of HRP is found during visit, send her immediately to medical officer/specialist at nearest FRU for further treatment and follow up

14. A. Based on previous pregnancy history of High Risk Conditions
More than 4 earlier pregnancies
H / O PIH (Pre-eclampsia and eclampsia)
Previous Caesarean Section/Any Uterine surgery
H /O repeated spontaneous abortion upto three times
Previous LBW baby delivery (Pre term delivery/ IUGR baby
Conceived after long periods of infertility / Artificial reproductive technique
Previous early neonatal death / still birth / birth asphyxia
H/O of previous complicated delivery
History of APH / PPH
HIV positive
History of Active TB / Leprosy
H/O of Diabetes / Heart disease / Kidney diseases

15. B. Based on current pregnancy history of High Risk Conditions
History (Obstetric)
1st pregnancy below 18 yrs and above 35 years
Any pregnancy above 40 yrs
Post dated pregnancy (More than 7 days from EDD)
Excess pain in abdomen during 1st trimester
Decrease/no fetal movement
General Examination
Height <140cm
Weight gain per month after 1st trimester <500gm and more than 3kg
BP more than 140/90 (Pregnancy Induced Hypertension)
Abdominal Examination
Over distended/unusual larger size
Premature contraction
Screening tests / Lab Investigation
Pregnant woman with Malaria/Any high fever
Hepatitis B positive/Jaundice
Rh negative pregnant woman
Severe anaemia (<7gm/ dl)
Pregnancy with HIV positive /RTI/STI
History of Thalassemia/Sickle Cell Disease/Rh negative mother
PV Examination
Bleeding PV
Foul smelling vaginal discharge
Premature Rupture of Membrane/Leaking

16. Conditions Requiring Referral
Conditions requiring immediate referral
Excess pain in abdomen during 1st trimester
No foetal movement
Bleeding PV
Premature Rupture of Membrane/Leaking
Conditions requiring referral for confirmation
Decrease foetal movement
BP more than 140/90
Over distended/unusual larger size
Severe anaemia (<7gm/ dl)
Foul smelling vaginal discharge

17. C. Based on Physical examination
Swelling:
If swelling appears in the evening and goes until morning, then it is a common symptom.
Swelling on face, Hands, abdominal skin & vulva are common.
If swelling is associated with high blood pressure, heart disease, Anaemia & proteinuria, refer her to medical officer after line listing
if nonpitting edema indicates hypothyroidism or filariasis, send immediately to medical officer for further investigation
2. Blood pressure:
Measure blood pressure in every visit
If blood pressure reading is greater than or equal to 140/90 mm Hg in two consecutive readings with a gap of 4 hours, then check for Urine Albumin, if its positive then categorize the female as a case of Pre-eclampsia. Mark the case as HRP & refer her to MO after line listing.

18. Cont. Weight Measurement – Normal wt gain during pregnancy is 9-11 Kg
If the average wt gain per month is less than 2 kg, it indicates poor nutrition. She should be advised to take 4-5 meals per day
Increased wt gain(>3kg/per month) indicates pre-eclampsia, multiple pregnancy, diabetes.
Height Measurement –
PW whose height is less than 140 cm can have a contracted pelvis and might require LSCS for delivery. So she should be referred to higher centre after marking as HRP & line listing

19. D. Based on Investigation
Haemoglobin estimation
A PW whose Hb is less than 7 is considered to be suffering from severe anaemia. These PW should be marked as HRP and referred to higher centre after line-listing and appropriate treatment can be started like BT/iron sucrose etc.
A PW whose HB is between 7 to 8.9 gm% is referred to Higher centre for IV iron sucrose therapy. This PW will be registered in table B of KMK (HRP) register in CHC and PHC.
If the PW has Hb 9-11gm% then give her a total of 360 IFA Tablets to be taken one tablet twice a day. Check her HB status after 1 month if it doesn’t increase then refer to higher centre for further management.

20. E. Abdominal Examination
Perform abdominal examination to find out the Gestational age, foetal development, foetal lie, presentation & FHR
Mostly foetal lie is longitudinal with cephalic presentation any presentation apart from this is abnormal and should be marked as HRP (after 8th Month of Pregnancy) and referred to MO after line listing
Normal FHR is 120 to 160. If the FHR is less than 120 or more than 160 it should be marked as HRP & referred to higher centre after line listing.
If the health worker is doubtful about any of the above conditions and is indecisive she/he can ask for the opinion of MO

21. HRP assured ambulance availability:
HRP Follow up:
ANMs are doing monthly and weekly follow up of HRP mother
Follow up of services by daily call back from 104 call centre state help desk
HRP assured ambulance availability:
Assured referral transport services for all HRP pregnant women
Planning institutional deliveries of HRP:
Identification of appropriate health facility and birth preparedness during Prasuti Niyojan Diwas & Surakshit Matratva Diwas

22. Post partum care of mother and newborn:
Follow up home visits by ANMs & ASHAs
Referral for complications and management
Counselling for birth spacing

23. ANM Training Module and Guideline
KMK Toolkit
Program Guidelines
ANM Training Module and Guideline
HRP Register
KMK Matrix
HRP Strategy Hexagon
HRP Stickers

24. Anemia Mukt Bharat Strategy
Reduction in morbidity and mortality due to anemia
Impact
To reduce anemia prevalence by 3 percent per annum in all age groups (children, adolescents, pregnant women and women of reproductive age)
To increase the proportion of eligible target beneficiaries who consumed IFA tablet as per protocol by 50% (by NFHS-5)
Output
- To increase community knowledge and risk perception through improved social support
- Health facility managers competent to deliver services and ensure uninterrupted supplies for prevention and management of anemia
Process
Outcome

25. Six Interventions Prophylactic Iron Folic Acid Supplementation
Periodic deworming of children, adolescent and pregnant women
Intensified year-round behavior change communication
Testing anaemia using digital methods and point of care treatment
Mandatory provision of iron and folic acid fortified foods in public health programs
Addressing non-nutritional causes of anaemia in endemic pockets with special focus on malaria, haemoglobinopathies and flurosis

26. Thank you

27. Screening, Classification and Prophylaxis of Anemia
Session 1.2

28. When to do Haemoglobin Test in Pregnancy?
Minimum 4 times during pregnancy at every ANC visit or more frequently if required
14-16 weeks
20-24 weeks
26-30 weeks
30-34 weeks

29. Screening Methods for Haemoglobin Estimation
PoC diagnostics: Sahli’s hemoglobinometer/color scale/digital hemoglobinometer
Semiautoanalyser/photo calorimeter should be available at all high load facilities

30. Methods of Diagnosis Colour scale (Hemocheck)
The Blood drop is taken on a strip and is matched with a colour scale.
Sahli’s hemoglobinometer
The Blood is mixed with N/10 HCl in the hemoglobinometer and color is matched with the comparator glass.

31. Methods of Diagnosis (Cont.)
Haemocue
The Blood drop filled microcuvette is placed in the cuvette holder & pushed to its measuring position.
After seconds the hemoglobin value of the sample is displayed and recorded

32. Anaemia Classification Based on Haemoglobin Level
Level of haemoglobin
Degree of anemia
11 gm% or more
Normal
gm%
Mild anemia
gm%
Moderate anemia
Less than 7 gm%
Severe anemia

33. Anaemia Classification Based on MCV
Microcytic (less than 80)
Iron deficiency
Thalassemia
Anaemia of chronic disease
Sideroblastic
Lead poisoning
Copper deficiency
Normocytic (80-100)
Early iron def.
Acute blood loss
Sickle cell disease
Bone marrow disease
CRF
Hypothyroidism
Macrocytic (More than 100)
Vitamin B12 deficiency
Folic acid deficiency
Liver disease
Alcohol use
Myelodysplastic syndromes
To understand how MCV is key in determining etiology of anaemia.
To emphasize that while traditional teaching approaches anaemia based on a reticulocyte count, this needs advanced laboratory expertise (ie ability to accurately read a peripheral smear) and would result in all iron non responsive patients needing to be referred to a district hospital or higher.

34. Prevention of Anemia during Pregnancy- Prophylaxix Iron Folic Acid Supplementation
Drug
Dose and regimen
Tablet Folic Acid
500 micrograms once a day after confirmation of pregnancy in 1st trimester to avoid anemia and congenital malformation
Tablet Albendazole
400 mg orally once only for deworming in second trimester after 4th month of pregnancy by DOTS
Prophylactic IFA
From 14 weeks onwards, 1 tablet once daily for 180 days and then 180 days postpartum
Vitamin B12
15 mcg once a day
Vitamin C
100 mg once a day

35. Important Counseling Points for Iron Supplementation
IFA tablets should not be consumed with tea, coffee, milk or calcium tablets as these reduce the absorption of iron
Encourage the woman to take plenty of fruits and vegetables containing vitamin C (e.g. mango, guava, orange and sweet lime), as these enhance the absorption of iron
Don’t take iron tablets on empty stomach 
Cook food in iron utensils if available to increase iron uptake
Any kind of infection reduces iron uptake, wash hands before eating food and after going to toilet for improved hygiene and prevention from infection
There are some harmless mild side effects of iron tablets which resolve spontaneously

36. Common Side-effects of Iron Tablets Intake
Epigastric discomfort–nausea, diarrhoea or constipation
Dark stools due to excretion of unabsorbed iron in stools
Metallic taste
Side effects are not universal, not frequent (less than 1%) and never lead to any adverse event (disability or death)
They happen most when IFA is taken for the first time, since the body may find it little difficult to digest and disappear once IFA is regularly used for a few days or weeks

37. Prevention of Anemia-Diet Counselling