ANEMIA FREE

PREGNANCY

DEFINITION OF ANEMIA
Deficiency in the oxygen-carrying capacity of
the blood due to a diminished erythrocyte
mass.
May be due to:
Erythrocyte loss (bleeding)
Decreased Erythrocyte production
low erythropoietin
Decreased marrow response to erythropoietin
Increased Erythrocyte destruction (hemolysis)

MEASUREMENTS OF ANEMIA
Hemoglobin = grams of hemoglobin per 100 mL of
whole blood (g/dL)
Hematocrit = percent of a sample of whole blood
occupied by intact red blood cells
RBC = millions of red blood cells per microL of whole
blood
MCV = Mean corpuscular volume
If > 100 Macrocytic anemia
If 80 100 Normocytic anemia
If < 80 Microcytic anemia

RDW = Red blood cell distribution width

= (Standard deviation of red cell volume mean cell volume)

100
Normal value is 11-15%
If elevated, suggests large variability in sizes of RBCs

LABORATORY DEFINITION OF ANEMIA

Hb:
Women: <12.0
Men: < 13.5

Hct:
Women: < 36
Men: <41

SYMPTOMS OF ANEMIA
Decreased oxygenation

Exertional dyspnea
Dyspnea at rest
Fatigue
Bounding pulses
Lethargy, confusion

Decreased volume

Fatigue
Muscle cramps
Postural dizziness
syncope

SPECIAL CONSIDERATIONS IN
DETERMINING ANEMIA
Acute Bleed

Drop in Hgb or Hct may not be shown until 36 to 48

hours after acute bleed (even though patient may be
hypotensive)

Pregnancy

In third trimester, RBC and plasma volume are

expanded by 25 and 50%, respectively.
Labs will show reductions in Hgb, Hct, and RBC
count, often to anemic levels, but according to RBC
mass, they are actually polycythemic

Volume Depletion

Patients who are severely volume depleted may not

show anemia until after rehydrated

IRON DEFICIENCY ANEMIA

IRON DEFICIENCY ANEMIA KOILONYCHIA

IRON DEFICIENCY ANEMIA LAB

FINDINGS
Serum Iron
LOW (< 60 micrograms/dL)

Total Iron Binding Capacity (TIBC)

HIGH ( > 360 micrograms/dL)

Serum Ferritin
LOW (< 20 nanograms/mL)
Can be falselynormal in inflammatory states

Prevalence of anaemia Source: WHO

Global Developed Developing
Children<5 yrs 43
Children > 5yrs 37
Men
18
Women
35
Pregnant
59
Women

India
Urban Rural
12
51
60 70
7
46
50 60
3
26
35
45
11
47
50
60
14
51
65
75

About one third of the global population ( over 2 billion

persons ) are anaemic .
Anaemia is the most common nutritional deficiency disorder
in the world
Prevalence of anaemia is higher in developing countries
Prevalence of anaemia in India is very high in all groups of
the population

ANAEMIA IN PREGNANCY ASIAN COUNTRIES

90

80

70

60

50

40

30

20

WHO 1992

10

0
Bangladesh

China

India

Indonesia

Malay sia

My anm ar

Nepal

Pakistan

Philippines

Singapore

Srilanka

Thailand

Prevalence of anaemia is high in South Asia. Even among South Asian countries
prevalence of anaemia in pregnancy is highest in India.

Trends in prevalence of anaemia in pregnant women in India

YEAR

AUTHOR

PLACE

PREVALENCE %

1975

Sood et al

Delhi

80

1982

Prema

Hyderabad

75

1987

Agarwal et al

Bihar & UP

87

1989

Christian et al

Chandrapur, Panchmahal

87,88

1988-92

Agarwal et al

Rural Varanasi

94

1989

ICMR

11 states

87

1994

Sheshadri

Baroda

74

2000

NFHS 2

All India

52.0?

99- 2000

ICMR

11 states

84.6

2002-04

DLHS 2

All districts

90.4

2006

NNMB

8 states

70.3

2007

MFHS 3

All India

57.9?

Over 70 % of pregnant women in India are anaemic. There has been no decline
in anaemia in the last three decades

Prevale nce of Anae m ia (%){DLHS 2003}

Pe r c e n ta g e

100%
80%
60%
40%
20%
0%
preschool
children

adolescent girls

pregnant w omen

Group

severe

moderate

mild

no anaemia

Anaemia begins in
childhood, worsens
during adolescence in girls and gets
aggravated during pregnancy

Source: NNMB 2003

Among the southern states, prevalence of anaemia in pregnancy is lower in

Kerala and Tamil Nadu -?due to better access to health care

Anaemia pregnant women, India

(Age between 15 - 44 years)
Source : DLHS2

DLHS 2 showed that over 90% of pregnant women are anaemic both in urban
and in rural areas

Prevalence of anaem ia in children, adolescent

girls and pregnant w om en from 3 surveys
100
80
60
40
20
0
NNMB

ICMR

DLHS NNMB ICMR

Pregnant w omen
Normal

DLHS NNMB DLHS

Adolescent girls
Mild

Moderate

Children
Severe

Source NNBM

Majority of children, adolescents, adult men& women are anaemic.

Anaemia antedates pregnancy& gets aggravated during pregnancy. Maternal
anaemia results in poor iron stores in foetus
Prevalence anaemia in children is high because of poor iron stores, low iron
content of breast milk and complementary foods.
There is thus an intergenerational self perpetuating vicious cycle of anaemia
in all age groups

Prevalence of anaemia in adolescent girls & pregnant

women by education & standard of living index
80
60
40

Education

Education

High

Medium

Low

>10yrs

0-9 yrs

Illiterate

High

Standard of living
index

Adolescent girls

Source: Ref 7.11.1.6

Medium

Low

>10yrs

0-9 yrs

Illiterate

20

Standard of living
index

Pregnant women
Severe Moderate

Prevalence of anaemia is high even in high income

groups and among well educated pregnant women

Why is anemia so common

Major causes of anemia

Inadequate iron, folate intake due to low vegetable
consumption and perhaps low B12 intake
Poor bioavailability of dietary iron from the fibre,
phytate rich Indian diets
Chronic blood loss
Increased requirement of iron during pregnancy

Time trends in intake of iron, folic acid and vitamin C in rural and urban areas
(c/day) (NNMB)
Nutrients

NNMB
Rural

Urban

197579

1988-90 1996-97 2000-01 2004-05 1975-79 1993-94

Iron (mg)

30.2

28.4

24.9

17.5

14.8

24.9

18.96

Vit C

37

37

40

51

44

40

42

Folic
acid

153

62

52.3

Dietary intake of iron and folate are less than 50% of the RDA
Bioavailability of iron from phytate and fibre rich Indian diets is
only 3 %

Time trends in intake of iron (mg / day) in different groups

Age group

1975-79

1996-97

2000-01

2004-05

19

20

12.2

18

19

12.1

21

21

15.4

20

21

12.9

25

26

16.7

22

22

15.3

Adult males

26

27

17.5

Adult females(NPNL)

21

22

17.1

12
11.5
13.3
13
16.4
13.4
19.6
13.8

Pregnant women

20

23

14

14

Lactating women

23

23

14.6

14.7

10-12
13-15
16-17

Iron intake is low in all age groups and does not increase in pregnancy; there
has been no increase in iron intake over 3 decades

Why is anaemia in pregnancy a cause of grave

concern

Indias share in global maternal deaths

INDIA

It is estimated that globally there are over 5 lakh maternal deaths every year.
There are about 1 to 1.2 lakh maternal deaths in India every year
India with 16% global population
deaths in the world

accounts for 20-25 % % of all maternal

Prevalence of Iron deficiency anemia in South Asia%

Country

Children Women
< 5 years 15-49 years

Pregnant
women

Maternal deaths
from anemia

Afghanistan

65
55
81

61
36
55

74
68

2600
<100

75
65

51
62

87
63

22000
760
25,560

Bangladesh
Bhutan
India
Nepal
South Asia
Region Total
World Total

50,000

About half the deaths from anaemia in the world

occur in South Asian countries. India accounts for
over 80% of deaths due to anaemia in South Asia

CAUSES OF MATERNAL MORTALITY

SRS-1998
Toxemia
8%

Others
8%

Hemorrhage
30%

Obst. Lab
10%
Abortion
9%

Sepsis
16%

Anemia
19%

Anaemia directly causes 20% of maternal deaths and indirectly accounts for
another 20% of maternal deaths.These figures have remained unchanged in
the last five decades

CONSEQUENCES OF ANAEMIA IN PREGNANCY

8-11 g/dL: easy fatigability, poor work capacity

5-7.9 g/dL: impaired immune function, increased
morbidity due to infections
<5 g/dL: compensated stage: increased morbidity and
maternal mortality due to inability to withstand even
small amount of bleeding during pregnancy /delivery and
increased risk of infections
<5 g/dL: decompensated stage about 1/3rd develop
severe congestive cardiac failure and many with
congestive failure succumb either during pregnancy or
during labour
There is 8 to 10 fold increase in MMR when the Hb is <5
g%

Effect of maternal hemoglobin level on birth weight and perinatal

mortality ( Prema 1982)
Effects on

Hemoglobin (g/dL)
<5

5-7.9

8-10.9

11.0

Mean birth weigh(g)

2,400

2,530

2,660

2,710

Perinatal mortality
(rate/1000 live births)

500

174

76

55

Maternal anaemia is associated with poor

intrauterine growth and increased risk of preterm
births resulting in increase low birth weight rates.
This in turn results in higher perinatal morbidity and
mortality, higher IMR and poor growth trajectory in
infancy, childhood and adolescence. A doubling of low
birthweight rate and 2 to 3 fold increase in the
perinatal mortality rates is seen when the Hb falls
<8 g%

IMMUNE STATUS OF ANAEMIC PREGNANT WOMEN

There is a fall in T and B cell count when maternal

Hb is below < 11 g/dL
The fall in T and B cell counts are significant when
Hb is <8g/dL
There is no alterations in lymphocyte transformation
or in cell mediated immunity
Prevalence of morbidity due to infections
including asymptomatic bacteriuria is higher in
anaemic pregnant women
Higher morbidity rates might contribute to the
higher low birth-weight rates in anaemic pregnant
women

TREATMENT

MANAGEMENT OF IDA
Blood transfusion if heart failure
is eminent
IV or IM iron in pregnant women
Oral iron 3-5 mg Fe/kg/day
Treat underlying cause
Dietary education

UNTOWARD EFFECTS OF ORAL IRON

PREPARATIONS
Gastrointestinal side-effects such as epigastric
discomfort, nausea, vomiting, constipation, and
diarrhoea
The frequency of these side-effects is directly related
to the dose of iron or % of elemental iron in tablet
Iron consumed with a meal is better tolerated than
when it is taken on an empty stomach
Although the amount of iron absorbed is reduced
Liquid preparations may cause blackening of teeth
and makes faeces black due to formation of iron
sulfide and metallic taste

LIMITATIONS OF CURRENT
ORAL IRON THERAPY

 .Large number of iron salts is available in market

In clinical practice oral iron supplementation
commonly used are Fe sulfate, Fe fumarate
These conventional iron preparations are cheap
But have more gastrointestinal intolerance

DRAWBACKS OF CONVENTIONAL
DOSAGE FORM
Poor patient compliance, increased chances of
missing the dose of a drug with short half-life for
which frequent administration is necessary
The unavoidable fluctuations in drug concentration
may lead to under medication or over medication
A typical peak-valley plasma concentration time
profile is obtained which makes attainment of steadystate condition difficult
The fluctuations in drug levels may lead to
precipitation of adverse effects especially of a drug
with small therapeutic index whenever over
medication occur
Dusane Abhijeet Ratilal et al/ IJRAP 2011, 2(6)
1701-1708

The major reason for the failure of iron

therapy is non-compliance due to
the side-effects caused by an
excessively high initial dose of iron.

THE SOLUTION

Use
of
Slow-release
preparations instead of
conventional iron

BENEFITS OF MODIFIED DRUG DELIVERY

SYSTEM
Decrease in dosing frequency
Reduced peak to trough ratio of drug in systemic
circulation
Reduced rate of rise of drug concentration in
blood
Sustained and consistent blood level within the
therapeutic window
Enhanced bioavailability
Customized delivery profile
Reduced side effects
Improved patient compliance
Dusane Abhijeet Ratilal et al/ IJRAP 2011, 2(6)
1701-1708

THANK YOU