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ANEMIA IN PREGNANCY the expectant mothers
- 1. ANEMIA IN PREGNANCY Prof.Joseph Mlay
- 2. OUTLINE Introduction Physiologicalchanges in Pregnancy Pathogenesis Etiology Clinical Presentation Investigations Management & Treatment
- 3. INTRODUCTION Anemia isthe reduction in the level of hemoglobin below 12g/dl or hematocrit below 37% or reduction in the total number of erythrocytes in non-pregnant women. It is defined as a hemoglobin concentration of less than 11g/dl in pregnant women in the 1st and 3rd trimesters and less than 10.5g/dl in the 2nd trimester. (WHO) It is the most common disorder affecting pregnant women. Incidence is particularly high in underdeveloped countries. It’s a major contributing factor in maternal and perinatal mortality.
- 4. CONT… In thedeveloped countries maternal and perinatal mortality has dropped because of:- a. Improved living conditions/standards b. Improved nutrition c. Small and spaced families d. Elimination of grand multiparity e. Widespread use of contraception
- 5. CONT… Besides maternalmorbidity and mortality Anemia is associated with A. Significant mortality during and following pregnancy B. Increases the chances of infection & hemorrhage C. It plays a role in venous thrombosis and pulmonary embolism D. It predisposes to decompensation in mothers with cardiac and respiratory disease E. It is an important factor in delayed general physical recovery postpartum recovery especially after caesarian section and in women of high parity and low socio-economic status
- 6. PHYSIOLOGICAL CHANGES INPREGNANCY 1. In normal pregnancy there is plasma volume expansion which begins in the first trimester and it reaches a plateau between 16 & 24 weeks. The increase of plasma volume is about 1,500 mls in a singleton pregnancies to 2,000 mls in twin pregnancies ( between 40%-50%). A small increase in the amniotic fluid may occur in association with A. Placental insufficiency B. Fetal growth retardation or possibly C. With Folate deficiency
- 7. CONT… Pregnancy inducedplasma volume expansion (hypervolemia) has several important functions a) To meet the demands of the enlarged uterus with its greatly hypertrophied vascular system b) To protect the mother, and in turn the fetus, against deleterious effects of impaired venous return in the supine and erect positions c) To safeguard the mother against the adverse effects of blood loss associated with parturition.
- 8. Mean hemoglobin concentrations and 5thand 95th percentiles for healthy pregnant women taking Iron supplements
- 9. CONT.. 2. Throughout pregnancythere is gradual linear increase in total red cell mass due to increased erythrocyte production (possibly due to increased erythropoietin due to placental lactogen). An increase of between 18%-32%. 3. The relative increase of plasma volume in excess of red cell mass causes physiological hemodilution and the hemoglobin is reduced to about 11g/dl or hematocrit of 37%. Lower values than this are not due to physiological changes alone. NB: hemoglobin of 10g/dl or hematocrit of 35% are generally taken as criteria for diagnosis of pregnancy Anemia.
- 10. PATHOGENESIS Anemia occurswhen erythropoiesis is impaired or when the bone marrow is unable to make up for an abnormal loss/destruction of erythrocytes by hemorrhage/hemolysis. Anemia in pregnancy is usually due to defective erythropoiesis most of the time due to Iron or Folate deficiency or both. Vitamin B12 deficiency may be important in some tropical countries. Chronic hemorrhage can also contribute to Iron deficiency.
- 11. ETIOLOGY Iron deficiencyAnemia Anemia from acute blood loss Anemia associated with chronic disease (CKD, Pyelonephritis) Megaloblastic anemia (folate deficiency & Vitamin B12 deficiency) Hemoglobinopathies ( Sickle-cell hemoglobinopathies, Thalassemias) Hemolytic anemias caused by inherited erythrocyte defects (Spherocytosis, red cell enzyme deficiencies) Infections ( Malaria, UTI’s, Hookworm infestation, schistosomiasis) NB: in 3rd world countries anemia is a complication of Malnutrition, prolonged lactation, too frequent pregnancies
- 12. ETIOLOGY (IRON DEFICIENCYANEMIA) Iron deficiency anemia – usually iron is stored in the body in the tune of 1000mg excluding blood loss during delivery. The iron demand during singleton pregnancy is divided into: 300mg for the fetus and placenta, 500 mg for maternal increase in red blood cell mass and 200mg for basal losses (excretion through skin, gut and urine). Because of amenorrhea for nine months there is a reserve of about 360mg of iron. Some women will enter pregnancy with depleted stores because diseases like menorrhagia, malaria, UTI’s etc. The requirements of iron in twin pregnancies is doubled.
- 13. CONT.. Iron deficiencyanemia at the start of pregnancy signifies already depleted iron stores. This reflects a. Dietary lack b. Chronic blood loss c. Intestinal bleeding from hookworm infestation, schistosomiasis infection or hemorrhoids d. Repeated attacks of malaria infection e. Chronic urinary tract infection and other chronic infections which cause poor utilization of iron by the marrow f. Malignancies g. Impaired absorption due to either lack of cofactor (vitamin C) or formation of insoluble compunds like iron phytates. h. Or simply the start of pregnancy with deficiency
- 14. CLINICAL PRESENTATION Fatigue Giddiness Breathlessness The severity of the symptoms is dictated by the level of hemoglobin ON EXAMINATION o The patient will look restless with gross pallor (scleral, palmor) o The tongue will look pale with disappearance of tongue papillae (i.e glossitis) o The pulse will be raised o The pulse pressure will be wide o Splint hemorrhage of nail bed, finger clubbing o Hyperdynamic murmurs May be in failure (edema of lower extremities) Look for enlarged lymph nodes may indicate infection or neoplasia Splenomegaly maybe present in cases of Tropical splenomegaly syndrome or Chronic Myeloid Leukemia.
- 15. INVESTIGATIONS Full bloodPicture – will show low Hb, low hematocrit, low MCV, low MCHC,low MCH Serum Ferritin – levels lower than 15 ug/L confirm Iron deficiency Anemia.
- 16. MANAGEMENT & TREATMENT It has been proven that routine iron supplementation reduces the incidence of pregnancy induced anemia and improves the hemoglobin concentration, hematocrit and red cell count even in women on good diet. In communities where iron deficiency is common women should take iron supplements throughout pregnancy. Special attention must be kept on women with 1. Grandmultiparity 2. Multiple pregnancy 3. Previous history of anemia 4. Abnormal bleeding before conception 5. Those women who book late o NB: even when overt anemia doesn’t occur pregnancy inevitably reduces iron stores unless supplementation is given.
- 17. CONT… The therapeuticlevels of iron to be taken daily is 100mg provided with the daily dose of folic acid of 350ug.
- 18. CONT… The treatmentof well established anemia during pregnancy is aimed at 1. Correcting the anemia by the last month of pregnancy and replenishing iron stores Oral replacement therapy is the preferred method, but the choice of method depends on three things A. Severity of the anemia B. Gestational age C. Presence of additional complications Usually when anemia in pregnancy is secondary to iron deficiency, oral iron can be tried. If effective the treatment should continue for 3-6 months postpartum to replenish the iron stores.
- 19. CONT… Severe anemiain early pregnancy calls for full investigation to minimize the delay in starting the appropriate treatment. Note that the assimilation of oral iron and parenteral iron is the same in ideal conditions For treatment of existing anemia with oral iron it is advised to double the prophylactic dose Parenteral route can be used if the oral route is ineffective The main advantage of the parenteral route is the certainty of its administration and when given in total dose intravenously (total dose of parenteral iron in mg is calculated by the formula 1.4 x W x D. W is weight in kilograms and D is the percent deficiency of hemoglobin concentration below 14.8 g/dl)
- 20. CONT… Blood transfusioncan be considered 1. When there is severe anemia near term 2. In the presence of other complications needed like placenta previa 3. When emergency surgery is to be done in patients with severe anemia
- 21. EFFECTS OF IRONDEFICIENCY IN PREGNANCY There are anemia compensatory changes which occur in the circulation in an attempt to maintain adequate tissue oxygenation 1. Plasma volume and cardiac output rises 2. Peripheral resistance falls by vasodilation & neovascularization 3. Velocity of blood flow increases 4. Red cells tend to produce 2,3- Biphosphogluconate (2,3-BPG) which shifts the oxygen dissociation curve to the left which leads to oxygen being released at a lower partial pressure
- 22. MEGALOBLASTIC ANEMIA ANDFOLIC ACID DEFICIENCY In non-pregnant subjects the minimum daily requirement of folic acid is about 50 ug. The requirements in pregnancy rise to 350-400 ug per day. Causes of folate deficiency 1. Inadequate intake 2. Multiple pregnancy 3. Intestinal malabsorption 4. Gluten sensitivity 5. Drugs i.e Anticonvulsants 6. Chronic hemolysis like SCD, B-Thalassemia 7. Chronic infection
- 23. CLINICAL PRESENTATION Megaloblasticanemia in pregnancy runs a more acute, sometimes fulminant course than does iron deficiency anemia within some patients: - Obvious anemia and dyspnoea - Tongue is usually sore or acutely painful with papillary flattening, it may be smooth perhaps “mapped” with dark red patches - Apthous ulceration of the tongue and mouth is common - The liver and spleen may be enlarged - Retinal and subcutaneous petechial hemorrhage may be present due to reduced platelet formation - There may be protracted vomiting - Anorexia is prominent - Other obstetric complications may include: APH, Abruptio Placenta, prematurity, abortion and fetal malformation - NB: regardless of maternal folate deficiency the fetus will still extract enough folic acid from the mother.
- 24. HEMATOLOGICAL FEATURES Withfolate deficiency there is - Reduced serum folate - Hypersegmentation of neutrophils after which the blood film will show anisocytosis and macrocytosis - Other features are giant polymorphs and erythrocytes showing Howell-Jolly bodies - Folic acid deficiency also leads to neutropenia - There is a fall in the red cell count NB: Serum B12 assay should be done to rule out Vitamin B12 deficiency.
- 25. MANAGEMENT Folic acidshould be given routinely as prophylaxis in pregnancy and in particular to women in - Multiple pregnancy - Hemoglobinopathies - And women on anticonvulsants - Or previous history of megaloblastic anemia The daily recommended dose is 350ug for replacement. When megaloblastosis is diagnosed oral folic acid in the dose of 2.5mg daily is recommended. Hematological response is observed after 5-7 days with raised reticulocyte count.
- 26. DIFFERENTIALS Other causesof Anemia which are not discussed here are 1. Hemolytic anemia due to inherited red cell disorders - Congenital spherocytosis - Red cell enzyme defects - Hemoglobinopathies - Sickle cell syndromes (HbSS, HbSC, HbAS) 2. Thalassemias 3. Aplastic anemias 4. Leukemia & Hogkin’s disease