Downloaded 105 times
Uploaded byMulovi Nzyoki
Anaemia in pregnancy
Anemia in pregnancy, defined as an Hb level below 11 g/dL in the first and last trimester and below 10.5 g/dL in the second trimester, affects 30-50% of pregnant women, primarily due to iron deficiency. The condition poses significant risks to both maternal and fetal health, including increased mortality and morbidity rates, low birth weight, and preterm delivery. Management includes dietary interventions, oral iron supplements, and, in severe cases, parenteral iron therapy or blood transfusions.
More Related Content
Similar to Anaemia in pregnancy
Anaemia in pregnancy
- 1.
- 2. Introduction • Anaemia inpregnancy is defined as an Hb <11g/dl in the first and last trimester and less than 10.5g/dl in the second trimester. • Commonest medical disorder in pregnancy • 30-50% of women become anemic during pregnancy, with iron deficiency being the most common form of anemia accounting for more than 90% of the cases. Hemoglobin Level 1st trimester < 11g/dl 2nd trimester <10.5g/dl 3rd trimester < 11g/dl
- 3. Causes • Increased bloodloss – acute – APH, PPH – Chronic- hookworm infestation, PUD, menorrhagia • Nutritional – Low intake- vegans, socio-ecomonic factors – Reduced absorption- malabsorption syndrome, dairy products • Reduced formation – Aplastic anemia – Medication – zidovudine, cancer chemo • Increased destruction (hemolytic anemia) – Hereditary – hemoglobinopathies, membranopathies, enzymopathies – Acquired – immune (AIHA), non immune (paroxysmal nocturnal hemoglobinuria) – Mechanical damage- malaria, HIV
- 4. Physiologic changes inpregnancy • During pregnancy there is an increase in total blood volume by 30-40%. The increase in plasma volume is usually higher than the HB level increase resulting in dilution. • Iron requirements increase rapidly in the second (4-5mg/day)and third trimester(>6mg/day) due to fetal growth, however iron absorption in the gut is not sufficient to meet this increased demand. Thus iron balance depends on maternal iron stores during this period.
- 6. Impact of anemia MaternalFetal Fatigue, Low birth weight Increased risk of PPH Small for gestational age Increased risk of sepsis Increased risk of peri-natal morbidity and mortality Risk of CCF Increased incidence of diabetes and cardiac disease later in life Increased risk of preterm labor Increased risk of preterm delivery
- 7. IMPACT OF UNTREATED ANEMIA IN PREGNANCY FETALHEALTH •Perinatal morbidity& mortality (low APGAR scores) •Increased incidence of diabetes & cardiac disease later in life •Small for gestational age •Iron deficiency in the first few months of life MATERNAL HEALTH •Increased risk of PPH •Increased risk of sepsis •Increased risk of CCF PREGNANCY OUTCOME •2 times increased risk of preterm delivery •3 times increased risk of low birth weight •Possible placental abruption NB. There is little information regarding the Hb thresholds below which mortality increases
- 8. Epidemiology • Iron deficiencyis the most common form of malnutrition in the world, affecting more than 2 billion people globally i.e. 1/3 of the world’s population. (source WHO) • Anemia in pregnancy is highly prevalent in less-developed countries (40-75%) compared to 18-20% in developed countries. (source RCOG) • Responsible for 40% of maternal mortality in the 3rd world
- 9.
- 10. Risk factors Pregnancy Postpartum Multiplepregnancy Iron deficiency during pregnancy Low socio-economic status Delivery by CS Multiparity Placenta previa Short period between pregnancies Assisted vaginal delivery Dietary factors PPH Pre-pregnancy BMI Other risk factors: •Malaria •HIV/ AIDS
- 11.
- 12. Detailed History – DietaryHx – Obs/Gyn Hx – Drug Hx – Social Hx – Duration of symptoms if any
- 13. Signs and symptoms SymptomsSigns Fatigue Pallor Palpitations Edema Breathlessness Glossitis , stomatitis, angular cheilitis Dizziness, Fainting Soft Systolic murmur in mitral area due to hyper-dynamic circulation Headache
- 14. Investigations • Full bloodcount – Hemoglobin levels – PCV – Red cell Indices- MCV, MCHC, MCH (routinely done as part of antenatal profile. NICE recommends Hemogram at booking and at 28wks gestation) • Peripheral blood film- allows characteristics of the RBC to be observed. Hypochromic microcytic cells may be seen. Abnormal RBC morphology will also be seen.
- 15. Other investigations • SerumFerritin – Serum ferritin is a stable glycoprotein which accurately reflects iron stores in the absence of inflammatory change. It is the first laboratory test to become abnormal as iron stores decrease and it is not affected by recent iron ingestion. – It is generally considered the best test to assess iron-deficiency in pregnancy, although it is an acute phase reactant and levels will rise when there is active infection or inflammation. – Serum ferritin should be checked prior to starting iron in patients with known haemoglobinopathy. • Serum Iron and Total Iron Binding Capacity (TIBC)- lack sensitivity and specificity due to diurnal variations and recent ingestion of iron.
- 16. Investigations cont. • Stoolfor Ova & Cysts • Stool for occult blood • Bone marrow – considered the gold standard for assessment of iron stores. Is however invasive and impractical unless cause of anemia can’t be identified by simpler means.
- 17. Trial of IronTherapy • Is both diagnostic and therapeutic. • It should be considered as the first line diagnostic test for normocytic or microcytic anaemia. An increase in Hb must be demonstrated at 2 weeks, otherwise further tests are needed.
- 18. Hemoglobin level Mild anemia9 – 10.9 g/dl Moderate anemia 7.0 – 8.9 g/dl Severe anemia < 7.0 g/dl Very severe anemia < 4.0 g/dl
- 19. Management of IronDeficiency Anemia
- 20.
- 21. • The amountof iron absorption depends upon the amount of iron in the diet, its bioavailability and physiological requirements. • Haem iron is only found in meat, chicken and fish, and is easily absorbed. • Non-haem iron is also found in plant foods, such as vegetables, cereals , beans and lentils, but is not absorbed as well by the body. Absorption may be enhanced by vitamin C. Germination and fermentation of cereals and legumes improve the bioavailability of non-haem iron by reducing the content of phytate.
- 22. • All womenshould be counseled regarding diet in pregnancy including details of iron rich food sources and factors that may inhibit or promote iron absorption and why maintaining adequate iron stores in pregnancy is important.
- 23.
- 24. • Once womenbecome iron deficient in pregnancy it is not possible to ensure repletion through diet alone and oral supplementation is needed. • Ferrous iron salts are the preparation of choice. The oral dose for iron deficiency anemia should be 100-200mg of elemental iron daily. • Available ferrous salts include ferrous fumarate, ferrous sulphate and ferrous gluconate
- 25. How to takeIron Supplements • Women should be counseled as to how to take oral iron supplements correctly. • This should be on an empty stomach, 1 hour before meals, with a source of vitamin C (ascorbic acid) such as orange juice to maximize absorption. Other medications or antacids should not be taken at the same time.
- 26. Indications for Ironsupplementation • Women with a Hb <11.0 g/dl in the 1st trimester or < 10.5g/dl thereafter should be offered trial of iron therapy unless they are known to have a hemoglobinopathy. • In the presence of known haemoglobinopathy, serum ferritin should be checked and women offered therapeutic iron replacement if the ferritin is <30 µg/l. • Secondary care should be considered if: – Anemia is severe (<7g/dl) – Significant symptoms – Advanced gestation (>34 weeks)
- 27. Response to oralIron therapy • The hemoglobin concentration should rise by 2 g/dl after 3–4 weeks. Failure to do so is usually due to poor compliance, misdiagnosis, continued blood loss, or malabsorption. • Iron supplementation should be continued for three months after correction of anemia to replenish iron stores. • For nausea and epigastric discomfort, preparations with lower iron content should be tried. Slow release and enteric coated forms should be avoided.
- 28.
- 29. Parenteral Iron Therapy •Parenteral iron should be considered from the 2nd trimester onwards and postpartum period in women with iron deficiency anemia who fail to respond to or are intolerant of oral iron. • Associated with faster increases in Hb and better replenishment of iron stores in comparison with oral therapy. • Fewer post partum transfusions have been reported in those treated with IV iron.
- 30. Parenteral Iron preparations •Iron III carboxymaltose • iron sucrose e.g venofer • Iron dextran
- 31. Dose calculation • Severalformulas exist. The commonest is Nakao’s formula. Iron needed(mg) = (target HB-current HB) X Body weight X 2.4
- 32. Precautions to takewith Parenteral Iron Therapy • Administer in a facility with capacity to handle any severe anaphylactic or allergic reaction. • Start oral iron only after 5 days after the last injection of parenteral iron. • Only use in proven cases of iron deficiency anemia. • Shouldn’t be administered more than 3 times per week.
- 33. Contraindications to parenteralIron Therapy • History of anaphylaxis or reactions to parenteral iron therapy • First trimester of pregnancy • Active acute or chronic infection • Chronic liver disease
- 34.
- 35. Indications for Transfusionduring pregnancy • HB <7g/dl • HB <8g/dl & gestation >36 wks • Moderate or severe anemia in patient with heart disease or severe resp. disease • Placenta previa with HB < 10g/dl • those who develop severe reactions to both oral and parenteral iron.
- 36. Management of Anemicpatient in labor • If Hb is <8g/dl tranfuse • If Hb is <10 g/dl have blood available for transfusion • Active management of 3rd stage of labor (AMTSL)
- 37. Prevention • Universal ironsupplementation in pregnancy from the second trimester. • Nutritional counseling on rich sources of iron. • Intermittent prophylactic therapy and insecticide treated nets given in Malaria endemic zones. (SP given after 16 wks and 4 wks thereafter) • Deworming with mebendazole 500mg stat in the 2nd trimester.