Download to read offline
![4
• E.g (iron dextran):
• The total elemental Fe required in an anemic patient
weighing 100 kg with Hb 50% is calculated as follows:
• 0.3 × 100 (100 –50) = 3/10 × 100 × 50 = 1500 mg. Add
50% = 750 mg.
• Total elemental iron = 2250 mg.
Iron (ferrous) Sucrose:
2.4 × W × D + 500 [W = Weight (kg) before pregnancy; D
= Hb (Target– Actual) g/dL; 500 mg for body store].
• It is given IV, 100 mg (at a time) in 100 mL normal saline
over 15 minutes.
• Can also be given as 200mgs in 200mls N.S per dose](https://image.slidesharecdn.com/anaemiainpregnancyppt3-250903092826-0ad3776c/75/ANAEMIA-IN-PREGNANCY-ppt-3-ppt-educational-purpose-x-23-2048.jpg)
ANAEMIA IN PREGNANCY ppt (3).ppt educational purpose x
- 1. ANAEMIA IN PREGNANCY DR.NAJJEMBAAMINAH MBChB,MMED Obs/Gyn
- 2. OUTLINE • Introduction • Classification •Why anaemia in Pregnancy • Iron deficiency Anaemia • Megaloblastic anaemia
- 3. Introduction • Anemia isthe commonest hematological d/o in pregnancy • Others: Rh isoimmunization & blood coagulation d/o. • 30% of reproductive aged women are anaemic • 40% of pregnant mothers world wide • Overwhelming majority of anaemia in reproductive aged women is due to absent or low iron stores.
- 4. Definitions • Anemia definedas a Hb concn. < 11 g/dL (HCT < 33%) in 1st & 3rd or a Hb concn. < 10.5 g/dL (HCT < 32%) in 2nd Trimester (CDC) • Postpartum – Hemoglobin <10 g/dL (approximate hematocrit <30 percent) (WHO)
- 5. Classification of Anaemia Physiological Pathological Physiological Anaemia: – In pregnancy blood volume increases by approx.50% & RBC mass by approx.33%. – This relatively greater increase in plasma volume →lower haematocrit but does not truly represent anemia. – There is also associated low serum iron,↑ iron binding capacity & ↑ rate of iron absorption as found in iron deficiency anemia.
- 6. Sub-Classification of PathologicalAnemia Reduced production. • Marrow failure syndromes (congenital/ acquired). • Nutrition deficiencies (Iron, Folate , B12,Protein,anaemia of chronic infection-TB) Bleeding.(frank loss of blood)- • Acute :-Obstetrics (APH, PPH), Trauma • Chronic:- Warm infestations (Hook worm), Neoplasms, PUD, Piles. Hemolysis. • Hereditary (membrane-spherocytosis, Hb-SCD, thalassemia, enzymes defects-G6PD) • Acquired(immune mediated-HDN, None Immune-infections- Malaria, drugs).
- 7. However two commonesttypes of anemia— deficiency anemia and hemorrhagic anemia
- 8. Why Dev’t ofanaemia in pregnancy • Increased demands of iron • Diminished intake of iron • Diminished absorption • Disturbed metabolism due to infections including asymptomatic bacteriuria • Pre-pregnant health status • Excess demand: Multiple pregnancy, S.I.P.I and the demand of iron which accompanies the natural growth before the age of 21
- 9. IRON DEFICIENCY ANAEMIA •95% of anemias in pregnancy reflects increased demands for iron. • The total body iron consists mostly of (1) iron in hemoglobin (2) iron stored as ferritin & hemosiderin in reticuloendothelial cells in bone marrow, the spleen, and parenchymal cells of the liver • Small amounts of iron exist in myoglobin, plasma & various enzymes.
- 10. IRON DEFICIENCY ANAEMIA •The absence of hemosiderin in bone marrow indicates that iron stores are depleted. • This finding is both diagnostic of anemia & an early sign of iron deficiency. • Subsequent events are a decrease in serum iron, an increase in serum total iron-binding capacity & anemia
- 11. Iron Deficiency anaemiacont. • In the 1st half of pregnancy iron requirements are not significantly ↑sed & therefore absorbed iron from food meets the basal loss of 1mg/d • However, in 2nd half of pregnancy, iron requirements ↑se due to expansion of RBC mass & rapid growth of the fetus • The ↑ RBC mass & a greater Hb mass requires approx. 500 mg of iron. • The iron needs of the fetus averages 300 mg. • Thus, the additional amount of iron needed due to pregnancy approx. 800 mg. • pregnancy increases a woman's iron requirements to approximately 3.5 mg/d
- 12. Clinical Findings: Symptoms: • Easyfatiguability • headache • General weakness • Anorexia &indigestion • Palpitation • Dyspnea • Giddiness • Swelling of the legs. Signs: • Tachy cardia • Angular stomatitis & glossitis • koilonychia • pallor • Lower limb edema +/- soft systolic murmur in the mitral area • Gallop rhythm • Crepitations at the base of the lungs due to congestion.
- 13. Laboratory Findings Hb<9 gm/dl or less should be subjected to a full hematological screen Degrees of anemia: • Mild -8 - 10 gm/dl • Moderate - < 8 - 7 gm/dl • Severe - < 7 gm/dl Peripheral blood smear suggest microcytic hypochromic anemia Reticulocyte count may be slightly raised Hematological indices:MCHC,MCV,MCH,PCV,RBCs
- 14. Laboratory Findings A typicalIDA shows the following blood values: • Hemoglobin -< 10 gm/dl • RBCs - < 4 million/mm3 • PCV- < 30% • MCHC- < 30%, • MCV - < 75 μ3 • MCH -< 25 pg. • Serum iron < 30 μg/100 mL • Total iron binding capacity > 400 μg/100 mL, • % saturation is 10% or less & Serum ferritin < 30 μg/L.
- 15. Investigate the causeof anaemia: • Stool analysis and occult blood (FOB) • Urinalysis • bone marrow study: • Hb Electrophoresis
- 16. Complications of anaemiain pregnancy: • Antepartum: Pre-eclampsia ,Intercurrent infection, heart failure at 30–32 weeks of pregnancy ,IUGR, Preterm labor, chronic fetal hypoxia, Low birth weight,IUFD,low amniotic fluid vol. • Intrapartum: Postpartum hemorrhage, cardiac failure and Shock • Pueperium: Puerperal sepsis,Subinvolution,Poor lactation, Puerperal venous thrombosis & Pulmonary embolism • New born: prematurity,neonatal anaemia, neurological sequelae: Mental retardation, Cerebral palsy
- 17. PROGNOSIS • Prompt improvementfollowing early detection and RX • Tendency for anemia to recur in subsequent pregnancy. • In severe and neglected cases→ prematurity with its hazards, Neonatal anaemia.
- 18. Prevention of Anaemiain pregnancy • Child births spacing ↔ at least 2 years • Supplementary iron therapy: Daily administration of 300 mg of FeSO4 (containing 60 mg of elemental iron) along with 1 mg folic acid • Dietary prescription: A realistic balanced diet, rich in iron • Deworming • Adequate treatment for helminthiasis,malaria,dysentry,bleeding piles, UTI • Early detection: Hb level should be estimated at 1st antenatal visit, at 30th & finally at 36th wk.
- 19. Treatment: Curative Choice oftherapy depends on: • Severity of anemia • Duration of pregnancy (time available before delivery). • Associated complicating factors.
- 20. IRON THERAPY: Oraltherapy Parenteral therapy • Oral therapy Preparations: ferrous gluconate, ferrous fumarate or ferrous succinate. • RX duration: Approx.3 months after Hb normalise in order to replenish iron stores • Hemoglobin levels should increase by at least 0.3 g/dL/wk • C/I to oral therapy: Intolerance to oral iron, Severe anemia in advanced pregnancy.
- 21. Parenteral Treatment • Intravenousroute: (i) Repeated injections (ii) Total dose infusion (TDI) • Intramuscular route Indications of parenteral therapy: • C/I of oral therapy as previously mentioned. • Patient not cooperative to take oral iron. The expected rise in Hb concentration after parenteral therapy is 0.7 - 1 g/dL per week
- 22. Parenteral Rx I.VRoute Total dose infusion (TDI): • The compound used is iron dextran compound, or iron (ferrous) sucrose. • Estimation of the total requirement: formula for iron dextran is: • 0.3 × W (100–Hb%) mg of elemental iron. Where W = patient’s weight in kg. Hb% = observed Hb concn. in %. • Additional 50% is to be added for partial replenishment of the body store iron.
- 23. 4 • E.g (irondextran): • The total elemental Fe required in an anemic patient weighing 100 kg with Hb 50% is calculated as follows: • 0.3 × 100 (100 –50) = 3/10 × 100 × 50 = 1500 mg. Add 50% = 750 mg. • Total elemental iron = 2250 mg. Iron (ferrous) Sucrose: 2.4 × W × D + 500 [W = Weight (kg) before pregnancy; D = Hb (Target– Actual) g/dL; 500 mg for body store]. • It is given IV, 100 mg (at a time) in 100 mL normal saline over 15 minutes. • Can also be given as 200mgs in 200mls N.S per dose
- 24. Intramuscular therapy: • Iron-dextran(Imferon) • Iron-sorbitolcitric acid complex in dextrin (Iron sorbitol complex—Jectofer) NB: Oral iron should be suspended at least 24 hours prior to parenteral therapy to avoid reaction.
- 25. BLOOD TRANSFUSION: Indications: • To correct anemia due to blood loss & to combat PPH • Severe anemia in later months of pregnancy (beyond 36 wks)—to improve hemodynamic status before labour • Refractory anemia: Anemia not responding to either oral or parenteral therapy despite correct typing. • Associated infection
- 26. Megaloblastic Anaemia • Dueto deficiency of vit.B 12 or Folic Acid or both • Commonest is Folate deficiency • Derangement in red cell maturation with the production of megaloblasts in the bone marrow due to impaired DNA synthesis • Required Folate in pregnancy atleast 400 mcg/d of folic acid is recommended • Folic acid absorption/metabolism can be impaired by the use of OCs, pyrimethamine, Fansidar (sp), primidone, phenytoin,barbiturates or alcohol
- 27. Clinical Features ofMegaloblastic anaemia Symptoms: • Anorexia • protracted vomiting • Occasional diarrhea • Constitutional symptom like unexplained fever is often associated • Sore mouth or tongue On examination: • Pallor • glossitis (1/3rd of cases) • Hemorrhagic patches under the skin & conjunctiva • Enlarged liver & spleen
- 28. Haematological & otherblood values: Hemoglobin level <10 gm/dl Peripheral thin film: Hypersegmentation of neutrophils, Macrocytosis & anisocytosis ,Giant polymorphs Megaloblasts, Howell- Jolly bodies. MCV > 100 μ3 MCH >33 pg MCHC is normal Associated leucopenia & thrombocytopenia
- 29. Blood values cont. Serumiron is normal or ↑,iron binding capacity is low Serum folate < 3 ng/mL (NR 2.8-8) Serum vitamin B12 level < 90 pg/mL (NR 300 pg/mL) Serum bilirubin—may be ↑ Bone marrow—shows megaloblastic erythropoeisis.
- 30. Complications of MegaloblasticAnemia • Abortion • Prematurity • Abruptio placentae • Fetal malformation (cleft palate, neural tube defects). • There is association between pre- conceptional folate deficiency & neural tube defects
- 31. PREVENTION • Daily supplimentationof 400mcg of folic acid • Especially in: multiple pregnancy, patient having anticonvulsant therapy, hemoglobinopathies or associated chronic infection • Previous history of children with neural tube defects should receive preconceptional folate supplimentation
- 32. Treatment • Specific therapyincludes—daily administration of folic acid 4 mg orally until at least 4 weeks following delivery. • Supplementation of 1 mg of folic acid daily along with iron & nutritious diet can improve pregnancy induced megaloblastic anemia by 7 to 10 days.
- 33. Response is evidencedby -sense of well being &increased appetite -increase in reticulocyte, leukocyte & thrombocyte count (iii) rise in hemoglobin level. Folic acid should never be given without supplemental iron EXCEPT in Haemoglobinopathies. Supplementary I.M vitamin B12 100 μg daily or on alternate days if response to folic acid alone is not adequate. Ascorbic acid 100 mg tablet thrice daily enhances the action of folic acid by converting it into folinic acid.
- 34. Read; • Sickle cellanemia in pregnancy • Aplastic anemia • Thalassemia
Editor's Notes
- #3 The physiological anaemia is normocytic and normochromic in type. Global and regional variations in prevalence reflect socioeconomic status and associated nutritional defficiencies Iron deficiency anaemia remains a formidable problem
- #5 Iron demand increases to 3mg/day in first trimester,4-5 mg/day in 2nd trimester,6mg/day in 3rd trimester.
- #8 the demand of iron during pregnancy is markedly increased. An adequate balanced diet contains not more than 18–20 mg of iron and assuming that the absorption rate is increased by two folds (20%), the demand is hardly fulfilled. ii) Women with rapidly recurring pregnancy, within 2 years following the last delivery, need more iron to replenish deficient iron reserve
- #11 This need outstrips the 1 mg/d of iron available from the normal diet and must be met by supplementation of at least 40 mg/d of elemental iron (10% of which is absorbed).
- #12 due to physiological mitral incompetence
- #18 , should be prescribed which should be within the reach of the patient and should be easily digestible. The foods rich in iron are liver, meat, egg, green vegetables, green peas, figs, beans, whole wheat and green plantains, onion
- #20 Drawbacks: (1) Intolerance—the intolerance is evidenced by epigastric pain, nausea, vomiting and diarrhea or constipation. It may be related to increased dose of iron or to some preparation. To avoid intolerance, it is preferable to start the therapy with a smaller dose—one tablet daily and then to increase the dose to a maximum three tablets a day. If such a procedure fails to stop the symptoms, an alternate preparation may be prescribed.
- #21 Cases seen for the first time during the last 8–10 weeks with severe anemia. The main advantage of parenteral therapy is the certainty of its administration to correct the hemoglobin deficit and to fix up the iron store. The expected rise in hemoglobin concentration after parenteral therapy is 0.7 to 1 g/100 mL per week.
- #22 Limitations: (1) As the maximum hemoglobin response does not appear before 4 to 9 weeks, the method is unsuitable if at least 4 weeks time is not available, to raise the hemoglobin to a safe level of 10 g% before delivery. Thus, it is mostly suitable during 30–36 weeks of pregnancy where the patient is unwilling or unable to complete the course of intramuscular injections (2) Previous history of reaction to parenteral therapy is contraindicated for its use.
- #23 Both the preparations contain 50 mg of elemental iron in one milliliter. Total dose to be administered is calculated as that previously mentioned in intravenous therapy. Total dose of iron sorbitol complex is to be adjusted because of its 30% excretion Procedure of injections: After an initial test dose of 1 mL, the injections are given daily or on alternate days in doses of 2 mL intramuscularly. To prevent dark staining of the skin over the injection sites and to minimize pain, the injections are given with a two inch needle deep into the upper outer quadrant of the buttock using a ‘Z’ technique (pulling the skin and subcutaneous tissues to one side before inserting the needle). An additional precaution is to inject small quantity of air or saline down the needle before withdrawing it.
- #25 The quality and quantity of blood: The blood to be transfused should be relatively fresh, properly typed, grouped and cross matched. Only packed cells are transfused. The quantity should be between 80–100 mL at a time. To allow time for circulatory readjustment, transfusion should not be repeated within 24 hours. The primary concern is not only to correct anemia but also to make the patient fit to withstand the strain of labor and blood loss following delivery. Advantages of blood transfusion: (1) Increases oxygen carrying capacity of the blood (2) Hemoglobin from the hemolysed red cells may be utilized for the formation of new red cells (3) Stimulates erythropoiesis. (4) Supplies the natural constituents of blood like proteins, antibodies, etc. (5) Improvement is expected after 3 days. Precautions: Utmost precautions are to be taken to minimize reaction and over loading of the heart. (1) Antihistaminic (Phenargan 25 mg) is given intramuscularly (2) Diuretics (Frusemide 20 mg) is given intramuscularly at least 2 hours prior to transfusion to produce negative fluid balance (3) The drip rate should be about 10 drops per minute (4) To observe carefully the pulse, respiration and crepitations in the base of lungs.
- #27 Features of pre-eclampsia