pallor

Conjunctival Pallor

Koilonychia

ANAEMIA IN
PREGNANCY

ANAEMIA IN PREGNANCY
Commonest medical disorder in pregnancy
Out of estimated 160 million deliveries
occurring annually in the world, approx
6,00,000 women die from the complications of
pregnancy & child birth (W.H.O 1996).
Anaemia is responsible for 40-60% of maternal
deaths in developing countries. It also increases
perinatal mortality and morbidity rates (W.H.O
1997).

DEFINITION
Anaemia is a condition of low circulating haemoglobin
in which haemoglobin concentration has fallen below
the threshold lying at two standard deviations below
the median value for a healthy matched population.
W.H.O defines anaemia in pregnancy as haemoglobin
concentration of less than 11 g/dl and haematocrit of
less than 0.33.
The cut-off point suggested by the United States
Centers for disease control is 10.5 gm/dl in the second
trimester.

SEVERITY OF ANAEMIA
ICMR describes four grades of anaemia depending
upon the haemoglobin levels as shown:
Grades of Anaemia

Haemoglobin Value (g/dl)

Mild

9-10.9

Moderate

7-9

Severe

<7

Very Severe

<4

ERYTHROPOIESI
S

Confined to the bone marrow in adults

RBCs are formed through stages of pronormoblast normoblast reticulocytes
mature non-nucleated arithrocyte.
After a life span of 120 days RBCs degenerate
and haemoglobin is broken down into
haemosiderin and bi-pigment.

ERYTHROPOIESIS (Contd.)
For proper erythropoiesis adequate nutrients
are needed:
1.Minerals: Iron, traces of copper, cobalt and
zinc.
2.Vitamins: Folic Acid, Vitamin B12, Vitamin C,
Pyridoxine and riboflavin
3.Proteins: For synthesis of globin moiety.
4.Hormones: Androgens and thyroxine.

ERYTHROPOIETIN
Erythropoietin is a hormone produced by kidneys
(90%) and the liver (10%)
Increased secretion occurs during pregnancy due to
placental lactogen and progestrone.
Eryhtropoietin increases red cell volume by
stimulating stem cells in the bone marrow.
In addition to common deficiency of folic acid and
iron, there is a growing body of evidence to
implicate vitamin A in nutritional anaemia.

HAEMATOLOGICAL CHANGES IN
PREGNANCY
Characteristic

Normal Adult
Women

32-34 Weeks
Gestation

Increased /
Decreased

Plasma volume (ml)

2600

3850

1250 in

Red cell mass (ml)

1400

1640-1800*

Increased

Haemoglobin (g/dl)

12-14

11-12

Decreased

4-5

3-4-5

Decreased

0.36-0.44

0.32-0.36

Decreased

Mean corpuscular volume

80-97

70-95

Decreased

Mean corpuscular haemoglobin (pg)

27-33

26-31

Decreased

Mean corpuscular haemoglobin concentration (%)

32-36

30-35

Decreased

Serum Iron (g/dl)

60-175

60-75

Decreased

Total Iron Binding Capacity (g/100ml)

300-350

350-400

Increased

30

15

Decreased

1.5-2.0

4.0

Increased

Red Blood Cells (10*6 /mm*3)

Packed cell volume

Percentage Saturation (%)

Requirements of iron (mg/day)

Mean corpuscular haemoglobin = MCH

Packed cell volume = PCV
Mean corpuscular haemoglobin concentration = MCHC
Mean corpuscular volume =
MCV
Total iron binding capacity = TIBC

PREVALENCE OF
ANAEMIA IN
PREGNANCY

Overall prevalence 40% of worlds

population
Prevalence of anaemia is 3-4 times
higher in developing countries. Average
prevalence being 56%.
In industrialized countries approx 18% of
women are anaemic during pregnancy.
In India alone the prevalence of anaemia
in pregnancy is as high as 88% (W.H.O

CLASSIFICATION OF ANAEMIA IN
PREGNANCY
ACQUIRED:
Iron deficiency anaemia
Anaemia caused by blood loss
Acute (APH)
Chronic (Hook worm infestation, bleeding piles etc.)
Megaloblastic anaemia (Vitamin B12 and folic acid
deficiency)
Acquired hemolytic anaemia
Aplastic or hypo-plastic anaemia

CLASSIFICATION (Contd.)
HERIDITARY:
Thalassemias
Sickle cell haemoglobinopathies
Other haemoglobinopathies
Hereditary hemolytic anaemias (RBC
membrane defects, spherocytosis)

IRON DEFICIENCY ANAEMIA

It is the commonest type of anaemia in

pregnancy.
Food iron is made up of two pool
Haem Iron Pool
Non- Haem Iron Pool
Haem Iron Pool includes all food containing
iron as haem molecules, such as animal flesh
and viscera. Its absorption is 15-30%, but it can
increase to 50% in iron deficiency state. Its
absorption is usually not affected by inhibitors.

IRON DEFICIENCY ANAEMIA (Contd.)

Non-Haem Iron Pool includes cereals, vegetables,
milk and eggs. Its absorption can be increased by
enhancers and decreased by inhibitors.
Enhancers of absorption of Haem iron- proteins,
meat, ascorbic acid, ferrous iron, gastric acidity,
alcohol, low iron stores, increased erythropoietic
activity.
Inhibitors of iron absorption: Phytates, calcium,
tannins, tea & coffee.

CAUSES OF INCREASED
PREVALENCE OF I.D.A
Dietary habits: Consumption of low-bio availability diet
Food Fadism
Defective iron absorption due to intestinal infections,
hook worm infestation, amoebiasis, giardiasis.
Increased iron loss: Frequent pregnancies, menorrhagia,
hook worm infestation, chronic malaria, excessive
sweating, piles.
Repeated and closely spaced pregnancies and prolonged
period of lactation.

Symptoms
Lack of
Concentratio
n

Irritabilit
y

Infectio
n
Palpitati
on

Fatigu
e
Weakne
ss

Dizzines
s

Clinical Features
Pallor of skin
And m/m

Soft ejection
systolic
murmur

Edema

Signs
Platynychia
Platynychia
Koilonychia
Koilonychia

Tachycard
ia
Glossitis
Stomatitis

IRON REQUIREMENT IN PREGNANCY

Total iron requirement is 1000 mg.
Fetus and placenta -- 300 mg
in red cell mass 500 mg
Basal loss 200 mg
Average requirement is 4-6mg/day.
2.5 mg/day in early pregnancy
5.5 mg/day from 20-32 weeks
6-8 mg/day from 32 weeks onwards

PREVENTION OF IRON DEFICIENCY

Prophylaxis of non-pregnant women 60 mg of

elemental iron daily for 3 months.
W.H.O RECOMMENDATION: Universal oral
iron supplementation for pregnant women (60
mg of elemental iron and 250 g of folic acid)
for 6 months in pregnancy and additional of 3
months post-partum where the prevalence is
more than 40%.

PREVENTION OF IRON DEFICIENCY

(Contd.)
MINISTRY OF HEALTH, GOVT. OF INDIA
RECOMMENDATION: 100 mg of elemental iron with
500 g of folic acid in second half of pregnancy for
atleast 100 days. 2 injections of iron dextran (250 mg
each) given IMI at 4 weeks interval with TT injection.
Treatment of hook worm infestation
Single albendazole (400 mg) or mebendazole (100 mg x
BD x 3 days)
Change in defecation habits and avoidance of walking
bare footed.

PREVENTION OF IRON DEFICIENCY

(Contd.)
Improvement of dietary habits and improving bio
availability of food iron
Iron fortification of food.
Iron utensils for cooking
Iron rich foods are- liver, meat, egg, green vegetables
grean peas ,beans ,whole wheat , onionstallks ,
jaggery etc

EFFECTS OF ANAEMA IN PREGNANCY

Mother :
low output- due to inadequate tissue
oxygenation, increase cardiac failure
(more likely if reqirement for excessive
blood flow )
PPH
Predisposes to infection
Risk of thrombo-embolism
Delayed general physical recovery esp
after c. section
Preterm labour

Cont.
hypoxic encephalopathy
Obstetrical shock
Puerperal sepsis
subinvolution of uterus
failing lactation
puerperal venous thrombosis
pulmonary embolism

Fetus:

IUGR
Preterm birth
LBW
Depleted Fe store
Delayed Cognitive function.

INVESTIGATIONS

Haemoglobin estimation
Peripheral
blood
smear

microcytosis,
hypochromia anisocytosis, poykilocytosis and
target cells
RBC indices MCV, MCH, MCHC, MCV is
the most sensitive indicator
Serum ferritin first abnormal laboratory test
Transferrin saturation second to be affected
FEP third test to become abnormal
Serum transferrin receptor best indicator

INVESTIGATIONS (Contd.)
Bone marrow examination no response to treatment
after 4 weeks of therapy
Aplastic anaemia
Diagnosis of kala-azar
Urine examination
Stool examination for three consecutive days
Other tests RFT, LFT, chest x-ray, sputum
examination, etc.
For response haemoglobin and PBS,
reticulocyte count

MANAGEMENT OF IRON DEFICIENCY

ANAEMIA
AIM
To correct iron deficiency
To restore iron reserve
To correct associated complicating factor
CHOICE OF THERAPY
Depends on severity of anaemia
Duration of pregnancy
Associated complicating factor

MANAGEMENT (Contd.)
GENERAL TREATMENT
Dietary advice
Treatment of associated
complicating factor
IRON THERAPY
Oral
Parenteral

ORAL IRON THERAPY

For women presents in mid trimester or early third
trimester
For treatment more than 180 mg of elemental
iron/day is required
To minimize side effects, start with low dose
Treatment is continued till blood picture becomes
normal, thereafter maintenance of one tablet daily
for 3 months to replenish iron stores

INDICATIONS OF RESPONSE TO
THERAPY

Sense of well being

Improved outlook of patient
Increased appetite
haemoglobin, haematocrit, reticulocytosis within
5-10 days
If no significant clinical or haematological
improvement within 3 weeks, diagnostic reevaluation is needed.

INDICATIONS OF
RESPONSE TO THERAPY
(Contd.)
RATE OF IMPROVEMENT:
After a lapse of few days haemoglobin concentration
is expected to rise at a rate of 0.7 g/dl/week.
CAUSES OF FAILURE OF ORAL THERAPY
Incorrect diagnosis
Malabsorption syndrome
Presence of chronic infection
Continuous loss of iron
Poor patient compliance
Concomitant folate deficiency.

PARENTRAL IRON THERAPY

INDICATIONS:
Intolerance to oral iron
Poor patient compliance
Unpredictable absorption
Patient near term
ADVANTAGE
No added advantage over oral iron
except for certainty of its
administration.

PARENTRAL IRON THERAPY (Contd.)

PARENTERAL IRON THERAPY
Intra muscular
Intra venous
Two preparations Iron dextran IM/IV
Iron sorbitol citrate IM
IRON DEFICIT
Elemental iron needed (mg) = (Normal Hb
Patients Hb) x Weight (kg) x 2.21 + 1000

PARENTRAL IRON THERAPY (Contd.)

Simple method is to give 250 mg elemental iron for
each gm of HB below normal & then it will be 250xpt
value. Another 50 % is to be added to replenish store.
Oral Iron should be stopped atleast 24 hrs prior to
therapy to avoid toxic reaction.
Iron injections are given daily or on alternate day by
deep IMI using Z technique.
I.V. ROUTE
Total dose in fusion (TDI) Dose calculated by
same formula

PRE-REQUISITES FOR TDI:

Correct diagnosis of iron deficiency anaemia.
Adequate supervision in hospital setting.
Facility for management of anaphylactic reaction.
Sensitivity test done by 1ml test dose prior to infusion:
If no reaction iron dextran is diluted in normal saline or 5%
dextrose and given over 4-6 hrs.
If total dose is more than 2500 mg infusion is given in 2
doses on consecutive days.
Look for reaction Chest pain, rigor chills, hypotension,
dyspnoea, haemolysis & anaphylactic reaction.

INDICATION OF BLOOD
TRANSFUSION

Severe anaemia beyond 36

weeks
Refractory anaemia
To correct anaemia due to blood
loss
Associated infection

MANAGEMENT DURING LABOUR

First stage Comfortable position
Adequate analgesia and sedation
Arrangement for oxygen,
Digitalization maybe required in cardiac failure
due to severe anaemia
Antibiotic prophylaxis
Tocolytics &steroids should be given with
caution to prevent pulmonary edema in case of
preterm labour

MANAGEMENT DURING LABOUR

(Contd.)
Second stage
-strict asepsis to be maintained
- propped up positions
- Cut short second stage by forceps application.
Active management of third stage
-avoid use of methargin, use oxytocin or
prostoglandin

 During puerperium
Adequate rest
Iron and folate therapy for 3 months
Infection if any should be treated energetically
Careful watch for puerperal sepsis, failing
lactation; sub involution of uterus and
thromboembolism
To avoid postpartum overloading of the
heart,administer
IV frusemide 20mg.
-appropriate and effective contraceptive therapy
depends on needs

FOLATE DEFICIENCY ANAEMIA

At cellular level
Folic acid reduced to Dihydrofolicacid then
Tetrahydro-folicacid . (THF) c is required for cell
growth & division.
So more active tissue reproduction & growth more
dependant on supply of folic acid.
So bone marrow and epithelial lining are therefore
at particular risk.

Causes
Inadequate dietary intake
Extra demand-mainly due to
- Multiple pregnancy
-Hemolytic anemias
worminfestation,malaria,hemorrhoids,infectio
ns
Decreased absorption-celiac disorders
Drugsantiepileptic drugs-Phenytoin
sodium,primidone etc
Diminished storage
IDA

Clinical features
Two cardinal symptoms-macrcytic megaloplastiv
anemia and glossitis
Other symptoms- anorexia, protracted vomiting,
diarrhea, unexplained fever, hemorrhagic patches
under the skin and conjunctiva, hepatosplenomegaly
Few cases-periperal neuropathies.

FOLATE DEFICIENCY ANAEMIA

Diagnosis: Increased MCV ( > 100 fl)
Peripheral smear: - Macrocytosis, hypochromia

- Hypersegmented
neutrophils
(> 5 lobes)
- Neutropenia
- Thrombocytopenia
Low Serum folate level.
Low RBC folate.

FOLATE DEFICIENCY ANAEMIA

Daily folate requirement for :
Non pregnant women -- 50 -100
microgram
Pregnant woman -------- 300-400
microgram
Usually folic acid present in diets like
fresh fruits and vegetables and
destroyed by cooking.

Management of FDA
Strong case for routine prophylaxis
Prophylaxis with anti convulsants
Continue routine oral therapy for

hemolytic anaemia
Parenteral therapy for severe deficiency

Cont.
WHO recommendation-prophylaxis
800microgram- AN period
600micogram lactation
Treatment:
5mg/daily-4wks(high risk)
Parentral therapy-for gastric
intolerance or late in pregnancy

complications

Abortion ,preterm labour and IUGR

Abruptio placenta
Pre-eclampsia
Fetal anomalies-harelip,cleft
palate,NFD

THANK YOU