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Anemia in pregnancy safemotherhood
This document discusses anemia in pregnancy. It defines anemia and notes that about half of all pregnant women worldwide are anemic. Causes of anemia in pregnancy include iron deficiency, other nutritional deficiencies, infection, and blood loss. Untreated anemia can lead to complications for both mother and baby like preterm delivery and low birth weight. Screening and treatment of anemia is important. Oral iron supplementation is usually first line treatment for iron deficiency anemia in pregnancy.
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Anemia in pregnancy safemotherhood
- 1. ANEMIA IN PREGNANCY Dr Rohayatibt. Mohd Baharin 1
- 2. Content Introduction Causesof Anemia Clinical Features and complication Investigations IDA Management 2
- 3. What is Anemia? Disorder by which the body is depleted of RBC to carry adequate oxygen to tissues In pregnant lady normal Haemoglobin level is ≥ 11 gm% Anemic women is unable to tolerate an equivalent amount of blood loss as those without anemia. 3
- 4. ANEMIA A BALANCE OFBOTH PRODUCTION AND LOSS!
- 5. INTRODUCTION Most commonmedical disorder in pregnancy Affects nearly ½ of all pregnant women in the world 1 52% in developing countries 23% in the developed world High demand for iron and other vitamins is increased due to physiological burden of pregnancy. Due to inability to meet the required level for these substances either as a result of dietary deficiencies or infection 2 1. WHO database 1998-2005 2. Van den Broek N. The Cytology of Anaemia in Pregnancy in West Africa Tropical Doctor. 1996;26:5–7
- 6. Local study reportedthat The overall prevalence of anemia 35% (SE 0.02) if the cut off level is 11 g/dL and 11 % (SE 0.03) if the cut-off level is 10 g/dL. The majority was of the mild type. The prevalence was higher in the teenage group, Indians followed by Malays and Chinese Grandmultiparas and from urban residence are at risk too Jamaiyah Hanif et al - Asia Pac J Clin Nutr 2007;16 (3):527-536
- 7. PHYSIOLOGICAL CHANGES IN PREGNANCY Bloodvolume begins to increase in week 6 of gestation and reaches approximately 50% more at 3rd trimester Red cell mass increases as much as 25% above pre-pregnancy levels The plasma volume increase is proportionally greater than the increase in red blood cell mass resulting haemodilution
- 9. Severe anaemiais associated increased risk of maternal and child mortality Population group Prevalence of anaemia Population affected Percent 95% CI Number (million) 95% CI Preschool-age children 47.4 45.7–49.1 293 283–303 School-age children 25.4 19.9–30.9 305 238–371 Pregnant women 41.8 39.9–43.8 56 54–59 Non-pregnant women 30.2 28.7–31.6 468 446–491 Men 12.7 8.6–16.9 260 175–345 Elderly 23.9 18.3–29.4 164 126–202 Total population 24.8 22.9–26.7 1620 1500–1740 Global anaemia prevalence and number of individuals affected Worldwide prevalence of anaemia 1993-2005 –WHO report 2007
- 10. C DIAGNOSIS PHYSIOLOGICAL ANAEMIA OLOGICALANAEMIA Hb = 10 gm% RBC = 3.2 million/mm3 PCV = 30% Peripheral smear showing normal morphology
- 11. HAEMATOLOGICAL CHANGES Elevated erythropoietin levelsincrease the total red cell mass by the end of the second trimester but haemoglobin concentrations never reach pre-pregnancy levels. A normal pregnancy creates a demand for about 1000 mg of additional iron.(60 mg elemental iron or 300 mg ferrous sulfate per day). Serum iron falls during pregnancy whilst transferrin and total iron binding capacity rise.
- 12. IRON REQUIREMENT IN PREGNANCY Maternal req. of total Iron -1000mg 500 mg Maternal Hb. Mass expansion 300 mg Fetus & Placenta 200mg Shed through gut., urine & skin 2.5mg /day in early pregnancy 5.5mg /day from 20 -32 weeks Average 4 mg/ day 6 – 8 mg/ day after 32 weeks Increases from 1-2mg in 1st trimester to 6-8 mg in 3rd trimester
- 13. Absorption of irondepends upon a) Amount of iron in the diet b) Bioavailability of iron c) Physiological requirements
- 14. CLINICAL FEATURES OF ANAEMIA SYMPTOMS Fatigue Weakness Headache Loss of appetite Dysphagia Palpitations Dyspnea on exertion SIGNS Glossitis Stomatitis Heart murmurs Increased JVP Tachycardia Tachypnea Postural hypotension Pallor Dryness or roughnessof the skin Koilonychia Dry & cracked lips & Brittle hair
- 15. AETIOLOGY OF ANAEMIA Physiological Acquire Iron deficiency anaemia (IDA) Nutritional deficiency – miconutrient deficiency B12,Folate,Riboflavin, copper Chronic infection – TB, Inflammatory – SLE, RA, multiple myeloma Blood loss – GIT bleeding, abnormal uterine bleeding Blood disorder Abnormal RBC synthesis - Haemoglobinopathies Excessive RBC destruction - BM depression Others - malignancy
- 16. EFFECT ANAEMIA TO PREGNANCYOUTCOME Preterm delivery (Scholl et al, 1994) Low birth weight (Cogswell et al, 2003) Placental abruption and increased peripartum blood loss (Arnold et al, 2009).
- 17. Complications IF Untreated PPH HYPOVOLEMIC SHOCK! HEART FAILURE FETAL IUGR INCREASED RISK OF INFECTION DELAY WOUND HEALING
- 18. INVESTIGATIONS Basic investigations Full bloodcount BFMP Stool ova & cysts Specific test Peripheral blood film Total Iron Study Total Iron binding capacity Total ferritin Total transferrin Vitamins assay Folic acid Vitamin B1, B12 Ascorbic acid Hb Electrophoresis Bone marrow aspiration Lupus anticoagulant antibody Rheumatoid factor antibody LE cells Others – LFT,Renal profile sputum AFB
- 19. Normal red cellmorphology
- 20.
- 21. IDA Target cells Sickle cells Poikiolocytosis Stomatocytes Acanthocytes OvalocyteSpherocytes Nucleated RBC
- 22. IRON RICH FOODS Dark-green leafy vegetables, such as watercress and curly kale Iron-fortified cereals wholegrain eg brown rice Beans, peas, soya bean Nuts, peanut butter Meat and fish Oatmeal Spinach Apricots prunes Raisins
- 23. IRON ABSORPTION Occurspredominantly in the duodenum and upper jejunum Whatever the mechanism of iron uptake, normally only about 10% of the elemental iron entering the duodenum is absorbed. Absorption increases markedly with iron deficiency In contrast, iron overload reduces but does not eliminate absorption
- 24. Physiologic ironrequirements are 3 times higher in pregnancy 1 Approximately 1200 mg must be acquired from the body iron store or diet Approximately 15% of dietary iron is absorbed Additional iron requirement reaches a peak toward the end of 3rd trimester 4-6 mg/day. 2 The additional iron is derived from both the stores and increased absorption 1. Bothwell, T.H. (2000) American Journal Clinical Nutrition 72, 257S-264S 2. Tapiero, H., Gaté, L., Tew, K.D. (2001) Biomedicine and Pharmacotherapy 55, 324-332
- 25. The serumferritin level is the best measure of the size of iron stores ( non-pregnant storage~ 300mg) During pregnancy estimated calculated Fe storage is 800 mg ( the average woman must absorb 500 mg more iron) With adequate iron stores, less absorption of iron require during the first trimester. Absorption is accelerated only after there has been a substantial fall in the size of the iron store
- 26. Week of gestation HB(g/L) Serum ferritin (μg/L) Iron store2 (mg) Absorptio n (%) 12 127 43.8 350 7.2 24 116 11.1 88 36.3 36 116 5.4 43 66.1 IRON ABSORPTION IN PREGNANCY Data from Barrett et al. (1994).
- 27. Prevent Iron absorption Tea and coffee Calcium, found in dairy products such as milk Antacids (medication to help relieve indigestion) Proton pump inhibitors (PPIs), which affect the production of acid in your stomach Some wholegrain cereals contained phytic acid Lagi oriii…..
- 28. MANAGEMENT OF ANAEMIA INPREGNANCY MEDICAL Iron and vitamin supplement Parenteral iron Others – depends on aetiology OBSTETRIC Antepartum Intrapartum Postpartum
- 29. Management For purposes ofmanagement, the following classification of anaemia can be used. (WHO. 1992) Management of anemia in pregnant mother with thalassemia minor is according to severity of anaemia. 29 Severe anaemia Haemoglobin < 7 gm% Moderate anaemia Haemoglobin 7 – < 9gm% Mild anaemia Haemoglobin 9 – < 11gm%
- 30. IRON DEFICIENCY ANEMIA Commonest anemia in pregnancy Physiological iron requirements are 3x higher in pregnancy, with increasing demand as pregnancy advances Inadequate dietary supplement Ineffective absorption Increased iron loss
- 31. DIAGNOSIS OF IRON DEFICIENCYANAEMIA Low haemoglobin Low serum ferritin < 12 mcg/dl Microcytic & hypochromic in the absence of chronic diseases / haemoglobinopathies Low serum iron content (< 30mcg/dL) Low PCV, MCV, MCH, MCHC High TIBC > 400 mcg/dl
- 32. Haemoglobin ( g/dl) Diagnosis 1 >12 > 11 Normal, IDA excluded 2 < 12 > 11 Storage iron depletion 3 < 12 < 11 Iron deficiency anaemia 4 > 12 < 11 Other causes of anaemia Categorization of women using Haemoglobin and serum ferritin
- 33. TREATMENT OF IRON DEFICIENCYANAEMIA Full blood count and MCV value is considered a good screening tool for IDA Mild-moderate 70–100μg/L Severe type < 20–30μg/L Many patients do not respond adequately to oral iron therapy due to: ingestion Side effects
- 35. HOW TO TAKEIRON TABLETS? 35
- 36. Indication of parenteraliron Cannot tolerate side effects of oral iron Suffers from inflammatory bowel disease Patient does not comply Patient near term
- 37. TYPE OF PARENTERALIRON Intravenous preparation Iron (II) hydroxide dextran ( Imferon ) Iron (III) hydroxide dextran ( Cosmofer) Iron sucrose (Venofer) Intramuscular preparation Iron (II or III ) Dextran type Iron dextran: 50 mg/mL. Iron sucrose: 20 mg/mL. Ferric gluconate: 12.5 mg/mL
- 38. INDICATION FOR PARENTERAL IRON Failure to oral iron therapy. Non compliance/intolerance to oral iron 1st time seen during last 8-10 wks with severe anemia Mal-absorbtion/IBD Small bowel resection When hemorrhage is likely to continue Contraindication to oral or blood transfusion Combination with recombinant human erythropoietin
- 39. CONTRAINDICATION PARENTERAL IRON Historyof anaphylaxis to parenteral iron therapy 1st trimester of pregnancy Active acute/chronic infection Chronic liver diseases ADVANTAGES : Certainty of admission. Hb rises @1gm/wk. DISADVANTAGES : Nausea and Vomiting Metallic taste on tongue
- 40. Blood transfusion ???? Should be avoided unless indicated Indication Severely ( asymptomatic ) Hb < 6 gm% not in failure not responsive to parenteral iron Severe anaemia with heart failure Hb < 8 gm % at term or in early labour Actively antepartum/postpartum bleeding
- 41. Recommendation for IDA Iron supplementation decreases the prevalence of maternal anemia at delivery. LEVEL A IDA associated with an increased risk of low birth weight, preterm delivery, and perinatal mortality. Severe anaemia with maternal Hb ≤ 6 g/dL associated with abnormal fetal oxygenation non-reassuring fetal heart rate patterns reduced amniotic fluid volume, fetal cerebral vasodilatation fetal death. LEVEL B . ACOG July 2008 (ACOG practice bulletin; no. 95).
- 42. All pregnantwomen should be screened for anemia Those with IDA should be treated with supplemental iron, in addition to prenatal vitamins. Patients with anemia other than iron deficiency anemia should be further evaluated. Failure to respond to iron therapy should prompt further investigation and may suggest incorrect diagnosis coexisting disease malabsorption noncompliance blood loss LEVEL C Anemia in pregnancy. American College of Obstetricians and Gynecologists (ACOG); 2008 Jul. 7 p. (ACOG practice bulletin; no. 95).
- 43. ANTENATAL MANAGEMENT Routinescreening of anaemia For prophylaxis with Hb> 11 gm% , iron and vitamin supplement to be taken weekly basis If Hb < 11gm%, Ferrous fumurate 200 mg bd on daily basis Elemental iron dose content per tablet Preparation Elemental iron (mg/tablet) Fe fumurate 200mg 60 mg Fe gluconate 250 mg (Iberet) 105 mg Fe sulphate (Obimin) 30 mg
- 44. MANAGEMENT OF OTHER TYPEOF ANAEMIA Chronic diseases eg PTB, Renal diseases, connective tissue diseases (SLE,RA) Haemolytic anaemia Aplastic anaemia Bone marrow diseases Multidisciplinary approach and treatment depend on the causative factors
- 45. OBSTETRIC MANAGEMENT : 1.FETAL ASSESSMENT Fundal height Serial symphysio-fundal height
- 46. Ultrasonograph forfetal growth OBSTETRIC MANAGEMENT :1. FETAL ASSESSMENT
- 47.
- 49. 2. TIME ANDMODE OF DELIVERY In the absence of fetal or maternal complication Aim for vaginal delivery Wait for spontaneous onset of labor Induction of labour in the presence of obstetric indications Optimise maternal health prior to labour Correct anaemia before elective delivery
- 50. 3. ANAEMIA INLABOUR To transfuse if Hb< 8 gm% and transfer to hospital with specialist Blood taken GXM at least 2 units and transfusion require In the event of advance labour where transfer is not possible, specialist input is require regarding the need for transfusion Oxytocin prophylactically postpartumlly with pitocin infusion 40 unit at 40 drops/min for 4-8 hours
- 51. 4. POSTNATAL PERIOD Continue oral iron supplement if Hb> 7 gm% Parenteral iron indicated if Hb bet 6-7 gm% provided asymptomatic and not in heart failure Blood transfusions may be inappropriate in the absence of continued / massive bleeding Dietary and Contraception advise Once the Hb is in the normal range, treatment continued for 3 months and at least until 6 weeks postpartum to replenish iron stores 1. Parker, J., Thompson, J., Stanworth, S. (2009) International Journal of Obstetric Anesthesia 18, 309-313
- 52. Severity of Anemia Hb level (g/dL) Managementaccording period of gestation (weeks <12 12-28 29-35 ≥ 36 Normal (white tag) ≥ 11gm% Heamatinic supplement (to be taken weekly) - Ferrous fumarate 400 mg - Folic 5 mg - Vitamin Bco 1 tablet - Vitamin C 100 mg Option: - Other preparation of supplement 52
- 53. Severity of Anemia Hb level (g/dL) Managementaccording period of gestation (weeks <12 12-28 29-35 ≥ 36 Mild (green tag) 9.0 – <11.0 Asymptomatic Lab Investigation: - - Full blood count - Stool ova and cyst (Optional) Haematinics - Ferrous fumarate 400 mg daily/200 mg bd - Folic 5 mg daily - Vitamin Bco 1 tab daily - Vitamin C 100 mg daily Option: Other preparation of supplement Refer to MO & HO for assessment. If patient is anemic and symptomatic on follow up, refer to FMS. 53
- 54. Severity of Anemia Hb level (g/dL) Managementaccording period of gestation (weeks <12 12-28 29-35 ≥ 36 Moderate (yellow tag) 7.0 – <9.0 gm% Laboratory investigation: - Peripheral blood film (PBF) - Serum Ferritin - TIBC - Serum folate and Vitamin B12 if blood film suggest macrocytic anaemia - Hb electrophoresis if haemoglobinopathy is suspected - BFMP (if indicated) - Stool ova and cyst (optional) *Repeat FBC 2 weekly. 54
- 55. Severity of Anemia Hb level (g/dL) Managementaccording period of gestation (weeks <12 12-28 29-35 ≥ 36 Moderate (yellow tag) 7.0 – <9.0 gm% Haematinics Ferrous fumarate 400 mg bd Folic 5 mg daily Vitamin Bco 1 tab daily Vitamin C 100 mg daily Option: Other preparation of supplement Continue oral heamatinics If poor compliance, not tolerating orally or fail to increase Hb level. Patient should be counselled for parenteral treatment. (option I/M or I/V) If patient symptomatic refer hospital Refer to Hospital. 55
- 56. Severity of Anemia Hb level (g/dL) Managementaccording period of gestation (weeks <12 12-28 29-35 ≥ 36 Severe (red tag) < 7.0 gm% Refer to Hospital Refer to Hospital Refer to Hospital Refer to Hospital 56
- 57. Moderate Anemia Patientswith Hb between 7 – <9 gm%. Full blood count should be performed and patient counseled regarding diet and hematinics If the patient is not reliable or is unable to tolerate oral therapy, iron dextran therapy is indicated either by intramuscular injection or by IV infusion in divided doses. Iron dextran therapy by intramuscular injection can be given in the health clinic, after test dose 0.5ml given by a Medical Officer. During this therapy, oral iron should be omitted. After the completion of iron dextran therapy, oral hematinics may be continued. Reassess patients’ general condition and haemoglobin level 2 weeks later. Cases which do not respond to treatment should be referred to FMS/ hospital for further management. 57
- 58. Severe Anemia Patientwith Hb < 7 gm% *Refer case to hospital for management Assess the patient for reliability and compliance. If the patient is asymptomatic and compliant to all medications before 32 weeks, oral therapy is sufficient. If the patient is asymptomatic and not compliant to all medications after 2nd trimester, parenteral iron (Iron Sucrose or Dextran) is indicated. If the patient is symptomatic and clinically pale, blood transfusion is necessary. NOTE: All cases of cardiac failure and intrauterine growth retardation must be referred to hospital for further management. 58
- 59. Dextran Formula tocalculate the amount of iron dextran to be given: (Normal Hb – patient’s Hb in gm%) x body weight (kg) x factor* + 500 mg = ______ mg of elemental iron One ampoule of iron dextran (2ml) contains 50 mg of elemental iron per ml (100 mg). Test Dose IM 0.5ml (undiluted solution) to be given by a doctor in the hospital or clinic (with adequate resuscitation equipment). Iron dextran to be given under supervision by doctor. *factor - for iron dextran = 0.24 (*Factors vary depend - for iron sucrose = 2.4 on drug preparation) 59
- 60. THANK YOU FOR YOURATTENTION