Dr Nik Ahmad Nik Abdullah Jabatan O&G Hospital Kota Bharu

OUTLINE

Introduction Physiological changes during pregnancy Nutritional requirements in pregnancy Causes of anemia in pregnancy Symptoms and Signs of anemia Approach to anemia in pregnancy Effect of anemia on pregnancy Management

Introduction

INTRODUCTION

Definition:

a condition of low circulating haemoglobin (Hb) in which the Hb concentration has fallen below a threshold lying at two standard deviation below the median of a healthy population at the same age, sex and stage of pregnancy However, this is only a statistical definition & not easily understandable & practical

INTRODUCTION

WHO Definition

A pregnant mother is considered to be anemic if her Hb level is less than 11g/dl (7.45 mmol/l) & Hct < 0.33

CDC definition : Hb conc < 10.5 d/dL during second trimester

INTRODUCTION

However, many studies in tropical or developing countries use 10 g/dl as the threshold which defines anemia

(Tee

et al, 1984).

INTRODUCTION

It is further classified as:

Mild: Moderate: Severe: Very severe:

10 - 10.9 grams/dl 7 - 10 grams/dl 4 - 6.9 grams/dl less than 4grams/dl

WHO Calcification

EPIDEMIOLOGY

Overall : 40% of world population

35% for non-pregnant women 51% for pregnant women 3-4x higher in non-industrialised countries

Affect 18% in industrialized countries Affect between 35-75% in non-industrialised countries (average : 56%)

EPIDEMIOLOGY

Prevalence in central-asia

Nearly of the global total anemic women

from Indian subcontinent (in India alone ~ 88%)

EPIDEMIOLOGY
Factors affecting anaemia in pregnancy among rural mothers in Kelantan

Mal J Nutr 3:83-90, 1997

Physiological changes during pregnanacy

Amount of iron (mg)
Iron costs Foetal iron Umbilical cord and placental iron Maternal blood loss Obligatory losses Expansion of maternal red cell mass Total 270 90

150 230 450 1190

Nett costs Contraction of maternal red cell mass postpartum Nett total (b) Total requirement (c) 1040 Adapted from AMA (1968)

Physiologic anemia of pregnancy

Plasma volume increases 50-70 %

Beginning by the 6th wk

RBC mass increases 20-35 %

Beginning by the 12th wk

Disproportionate increase in plasma volume over RBC volume---Hemodilution

Despite erythrocyte production there is a physiologic fall in the hemoglobin and hematocrit readings

Physiological changes during pregnanacy

This iron requirement is distributed unequally over the 40 weeks of a normal pregnancy.

first 20 weeks of pregnancy are about the same as for a non-pregnant woman.
The expansion in maternal red cell mass occurs maximally between weeks 20 and 25 of gestation, after which the daily iron requirements to maintain this mass remain constant at about 3-4 mg.

Physiological changes during pregnanacy

However, the total iron requirements continue to increase after week 25 up to week 36 due to the needs of the placenta and the foetus.

The total iron needs near the end of the second and third trimesters are about 3.5 mg/day and 7 mg/day, respectively

(Bothwell, 1995).

Physiological changes during pregnanacy

Physiological changes during pregnanacy

As pregnancy continues,

Serum iron

Serum total iron binding capacity (TIBC)

Both changes are due to the increased plasma vol

Plasma & tissue ferritin - whether given haematinics or not Insensible losses of iron ~ approx 1 mg/day

4 mg/day of iron absorbed daily from diet

If women enters pregnancy with depleted iron stores, the efx of iron deficiency will develop

Causes of anaemia in pregnancy

Deficiency of o iron o folic acid o vitamins o protein

o o o o o

Nutritional anaemia

Hemolytic anaemia

Thalassaemia Drug-induced

Aplastic anaemia

Chronic blood loss

Repeated abortion Closely space pregnancy Menorrhagia Bleeding gums, ulcer or piles Worm infestation

Drug-induced Idiopathic

Myeloproliferative disorders

Causes of anaemia in pregnancy

Pathological anaemia of pregnancy is mainly due to iron deficiency (IDA)

Over 90% of anemia due to red cell iron deficiency assoc with depleted iron stores & deficient intake Infection will inhibit iron binding from the stores into Hb.

Folate defiency :

Minor component & assoc with poor diet

Vit B12 deficiency :

Rarely causes anemia in pregnancy Addisonian pernicious anemia : doesnt usually occur in the reproductive years & usually assoc with infertility

Causes of anaemia in pregnancy

Unless the dietary intake is above average, the requirement is unlikely to be met
Nutrition

Blood loss

Physiological changes during pregnanacy

FACTORS AFFECTING THE IRON STATUS IN A PREGNANT WOMAN

Absorption. Dietary Habits. Defective in Iron Absorption Loss

FACTORS AFFECTING THE IRON STATUS IN A PREGNANT WOMAN

Iron absorption :

Dietary iron (haem & non-haem)

Haem iron contained food : animal blood, flesh & viscera

Absorption in normal women : 15-30% but in IDA up to 50%

Non-haem iron contained food : cereal, seeds, vege, milk

Enhancers of absorption

Haem iron, proteins, meat, ascorbic acid, fermentation, ferrous iron, gastric acidity, alcohol, low iron stores, increased erythropoietic activity

Inhibitors of iron absorption

Phytates, calcium, tannins, tea & coffee, herbal drinks, fortified iron supplements

CAUSES OF HIGH PREVALENCE OF IDA

Dietary habits

Low bio-availability diet (cereals, roots & tubers) Assoc with poverty ~ in non-industrialised countries Assoc with pica ~ ingestion of various substances having no dietary value Pregnancy complicated with hyperemesis

CAUSES OF HIGH PREVALENCE OF IDA

Defective iron absorbtion

Worm infestation, amoebiasis & giardiasis

Other courses of IDA

Iron loss

Pathological factors

Hookworm & other helminths infestation Haemorrhage from GIT Allergies Occult blood loss

Clinical features
General symptoms and signs of anaemia

Asymptomatic
SYMPTOMS Lethargy Weakness Dyspnoea Palpitation Headache Dizziness

SIGNS Pallor Tachycardia Bounding pulse Cardiomegaly Systolic murmur Angular stomatitis Koilonychia Pica syndrome

Investigation

ANAEMIA IN PREGNANCY : IRON DEFICIENCY - Diagnosis

Hb concentration : (late!)

Initially by iron stores serum iron Hb Simple non-invasive practical test available Hb < 10.5 g/dL in 2nd & 3rd trimesters ~ abnormal & require further Ix

ANAEMIA IN PREGNANCY : IRON DEFICIENCY - Diagnosis

Red cell indices :

Higher proportion of young large RBC may mask the efx of iron def on MCV (mean corpuscular vol) in preg + establish anemia

This is due to increased drive to erythropoesis

In pregnancy, small physiological increase in red cell size

Average : 4 fL but may increase to 20 fL

MCV is a poor indicator may be normal in iron def

ANAEMIA IN PREGNANCY : IRON DEFICIENCY - Diagnosis

Women with iron def anaemia prior to preg,

Will quickly develop florid anaemia in pregnancy MCV, MCH (mean corpuscular Hb) & MCHC (mean corpuscular Hb concentration) MCV < 80 fl, MCH < 27 pg ~ in IDA

ANAEMIA IN PREGNANCY : IRON DEFICIENCY - Diagnosis

Ferritin

High molecular weight glycoprotein In healthy adult female (non-pregnant) Circulates at levels : 15 300 g/L Level 12 g/L indicates IDA Important in pregnancy In development of iron def : serum ferritin 1st abn lab test

Hb & ferritin estimations ~ used clinically to categories the pts into normal & abnormal iron stores

ANAEMIA IN PREGNANCY : IRON DEFICIENCY - Diagnosis

Nutritional

Iron in food occurs in two forms, haem iron and non-haem iron.

Approximately 40% of the iron in meat products is haem iron;

60% of the iron in meat and all the iron in plant foods is non-haem iron. The absorption by the body of the two types of iron differs, with about 2% to 20% of non-haem iron, and about 20% of haem iron, being absorbed.

Food Source

Serving Size (oz.)

Iron (mg)

Beef, liver Beef, corned Beef, lean ground; 10% fat *Beef, round *Beef, chuck *Beef, flank Chicken, breast w/out bone Chicken, leg w/bone Chicken, liver Chicken, thigh w/ bone Cod, broiled Flounder, baked Pork, lean ham *Pork, loin chop Salmon, pink canned Shrimp, 10 - 2 1/2 inch Tuna, canned in water Turkey, dark meat Turkey, white meat

3.0 3.0 3.0 3.0 3.0 3.0 3.0 2.0 3.0 2.3 3.0 3.0 3.0 3.0 3.0 1.1 3.5 3.0 3.0

7.5 2.5 3.9 4.6 3.2 4.3 0.9 0.7 7.3 1.2 0.8 1.2 1.9 3.5 0.7 0.5 1.0 2.0 1.2

Food
Cashew nuts Pumpkin seeds Tahini/Sesame seeds Sunflower seeds Molasses Licorice Marmite (fortified) Apricots (dried) Raisins Avocado Prunes Kelp (cooked) Nori (cooked) Parsley (raw) Potato, with skin (cooked) Spinach (cooked) Broccoli (cooked) Brussels sprouts (cooked) Some breakfast cereals (fortified)

Serving
2 tbsp 2 tbsp 2 tbsp 2 tbsp 1 tbsp 50 g 5g 1/4 cup 1/4 cup 1/2 1/4 cup 1/2 cup 1/2 cup 50 g 1 medium 1/2 cup 1/2 cup 1/2 cup 100 g 1/2 cup 1/2 cup 2 tbsp 1 slice 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup

Iron content (mg)

1.0 2.5 1.2 1.1 3.3 4.4 1.8 1.5 1.1 1.0 0.9 42.0 20.9 4.7 2.7 1.5 1.0 0.9 10 (approx) 2.0 1.6 1.2 0.9 0.5 6.2 4.4 3.4 3.2 2.5 2.2 2.2 1.8 1.7 1.5 1.2 0.

Textured Vegetable Protein (TVP) (cooked) Barley, whole (cooked) Wheat germ Bread, whole wheat Rice, brown (cooked) Tofu Soybeans (cooked) Garbanzo beans (cooked) Lentils (cooked) Navy beans (cooked) Pinto beans (cooked) Lima beans (cooked) Tempeh (cooked) Split peas (cooked) Kidney beans (cooked) Peas (cooked) Baked beans (cooked)

Approach to anemia in pregnancy

Iron Supplementation in Pregnancy

Safety: Unintentional overdosing, hemochromatosis, GI symptoms
Compliance: Prescribed Fe supps taken correctly by 70%, not at all by 10% Recommendation: Evidence is insufficient to recommend for or against Routine iron supplementation during pregnancy.

Iron Supplementation in Pregnancy

Fe deficiency is common in pregnancy Fe supps maintain Hgb levels during pregnancy.

Percentage of iron absorbed declines as the amount given increases.

High does increase side effects and decrease compliance. Recommendation: Small dose (30mg) after 12 weeks for all pregnant women.

Cochrane Review of 20 Trials1999

Iron supplementation appears to prevent low haemoglobin at birth or at six weeks post-partum. Iron supplementation had no detectable effect on any substantial measures of either maternal or fetal outcome.

Centers for Disease Control. Recommendations to prevent and control iron deficiency in the United States.
MMWR.1998;47:1-36.

No conclusive evidence for benefit of universal iron supplementation

Recommend 30 mg/d starting at first prenatal visit because many women have reduced Fe stores with pregnancy For Tx of low hct or hbg: 60-120 mg/d

If no response evaluate mean cell volume and serum ferritin

Recommendations for Routine Iron Supplementation in Pregnancy

Yes IOM - NAS (1990) No Maybe Not enough evidence US preventive Services Task Force (1993) Cochran Review (1999)

Nat'l Perinatal US Surgeon Epi Proj. General Oxford (1988) USPHS Ex. Panel on Prenatal care (1989)

FASEB (1991)

CDC (1998)

Supplement

** For the non-anaemic patient 30 mg of ferrous iron daily is considered adequate for supplementation.
Treatment 100mg of ferrous

Oral supplements of iron

Ferrous Sulfate (200mg), Elemental Iron (65mg),

Supplement

Side efx of oral iron administration

Related to the quantity given Rare side efx with daily dose to 100 mg & delay introduction till 16 wks gestation Most common complaint : constipation

Other c/o nausea, vomiting, diarrhoea, abd cramping Usually overcome easily with slow release preparation but not all iron is released at all & expanses

However, most women can tolerate cheaper preparation + folic acid

IM injection of 1000 mg iron :

Preparation :

Iron dextran (Imferon) ~ IM / IV Iron sorbitol citrate (Jectofer) ~ IM only

For those whom add iron cant be given by oral route either by non-compliance & unacceptable side efx Disadvantage : painful injection & skin staining, + anaphylaxis IM injection ~ less side efx

Iron deficit is calculated as :

Elemental Iron need (mg) = (Normal Hb-Pts Hb) x weight (kg) x 2.21 + 100

Mx of IDA

With adequate treatment,

An increase of Hb of 0.8g/ dL/ week (1.0 g/ dL/wk in non-pregnant women) in absence of other abnormalities. The response is similar with iron given orally or parenterally. If there is no enough time to achieve reasonable Hb for delivery or symptomatic, transfusion with all its hazards should be considered.

Mx of IDA

Blood transfusion

Rarely indicated except severe anaemia regardless of gestation & to replenish blood loss due to APH / PPH Disadv : transfusion reaction, infectious disease

Mx of IDA

FIRST VISIT
High risk factors

Other risk factors

Poor socio-economic

Past history
Post-partum haemorrhage, multiparity, short gap between Pregnancies Heavy periods

Blood donation - current status, recent or Immigrant Vegetarian recent history Previous iron deficiency diet

MCV, Hb, Hct

Criteria:
Hb < 10.5gm% Action: Management as per established protocols for investigation of anaemia in Pregnancy (including serum ferritin assay).

Criteria:
Hb=10.5-11.5 gm% And the presence of one major or two or more of any risk factors. Action: Specific dietary advice: Iron supplementation: at least 30mg/day of Elemental Iron Reassess at 28 weeks.

Criteria:
Hb>11.5 gm% and no risk factors present. Action: General Preventative dietary advice Iron supplementation is not required.

SUBSEQUENT EARLY ANTENATAL CARE

Assess:

Diet. Presence of nausea, vomiting. Compliance: in those women prescribed iron supplementation

ANAEMIA IN PREGNANCY : IRON DEFICIENCY maternal risks

In iron def women,

May take > 1 year for Hb to return to pre-preg level.

If iron supplement given, Hb pre-preg state by 5-7 days after delivery

Blood loss is greater at delivery

Due to effect iron def on neuromuscular transmission & myometrial contraction

ANAEMIA IN PREGNANCY : IRON DEFICIENCY Fetal risks

Children with iron deficiency,

Behavioral abnormalities related to changes in the concentration of chemical mediators in the brain Cognitive skills poor performance which can be improved with iron supplements in some

In utero,

Iron def results in low birthweight infants Iron supplements - prevention of adult hypertension (origin in fetal life due to LBW)

Summary

pregnant mother is considered to be anaemic if her Hb level is less than 11g/dl (7.45 mmol/l) & Hct < 0.33. Over 90% of anaemia due to red cell iron deficiency assoc with depleted iron stores & deficient intake Hb & ferritin estimations ~ used clinically to categorise the pts into normal & abnormal iron stores

No conclusive evidence for benefit of universal iron supplementation.