Anemia in pregnancy, prevention, diagnosis and management.

1. ANAEMIA IN
PREGNANCY
Mohammad AmirMohammad Amir
Final Year MBBSFinal Year MBBS
JJM Medical College. DavangereJJM Medical College. Davangere

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

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

4. SEVERITY OF ANAEMIASEVERITY OF ANAEMIA
 ICMR describes four grades of anaemia depending uponICMR describes four grades of anaemia depending upon
the haemoglobin levels as shown:the haemoglobin levels as shown:
Grades of AnaemiaGrades of Anaemia Haemoglobin Value (g/dl)Haemoglobin Value (g/dl)
MildMild 9-10.99-10.9
ModerateModerate 7-97-9
SevereSevere < 7< 7
Very SevereVery Severe < 4< 4

5. ERYTHROPOIESISERYTHROPOIESIS
 Confined to the bone marrow in adultsConfined to the bone marrow in adults
 RBCs are formed through stages of pro-normoblast –RBCs are formed through stages of pro-normoblast –
normoblast – reticulocytes – mature non-nucleatednormoblast – reticulocytes – mature non-nucleated
arithrocyte.arithrocyte.
 After a life span of 120 days RBCs degenerate andAfter a life span of 120 days RBCs degenerate and
haemoglobin is broken down into haemosiderin and bi-haemoglobin is broken down into haemosiderin and bi-
pigment.pigment.

6. ERYTHROPOIESIS (Contd.)ERYTHROPOIESIS (Contd.)
 For proper erythropoiesis adequate nutrients are needed:For proper erythropoiesis adequate nutrients are needed:
1.1. Minerals: Iron, traces of copper, cobalt and zinc.Minerals: Iron, traces of copper, cobalt and zinc.
2.2. Vitamins: Folic Acid, Vitamin B12, Vitamin C,Vitamins: Folic Acid, Vitamin B12, Vitamin C,
Pyridoxine and riboflavinPyridoxine and riboflavin
3.3. Proteins: For synthesis of globin moiety.Proteins: For synthesis of globin moiety.
4.4. Hormones: Androgens and thyroxine.Hormones: Androgens and thyroxine.

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

8. HAEMATOLOGICALHAEMATOLOGICAL
CHANGES INCHANGES IN
PREGNANCYPREGNANCYCharacteristicCharacteristic Normal AdultNormal Adult
WomenWomen
32-34 Weeks32-34 Weeks
GestationGestation
Increased /Increased /
DecreasedDecreased
Plasma volume (ml)Plasma volume (ml) 26002600 38503850 1250 in1250 in
Red cell mass (ml)Red cell mass (ml) 14001400 1640-1800*1640-1800* IncreasedIncreased
Haemoglobin (g/dl)Haemoglobin (g/dl) 12-1412-14 11-1211-12 DecreasedDecreased
Red Blood Cells (10*6 /mm*3)Red Blood Cells (10*6 /mm*3) 4-54-5 3-4-53-4-5 DecreasedDecreased
Packed cell volumePacked cell volume 0.36-0.440.36-0.44 0.32-0.360.32-0.36 DecreasedDecreased
Mean corpuscular volumeMean corpuscular volume 80-9780-97 70-9570-95 DecreasedDecreased
Mean corpuscular haemoglobin (pg)Mean corpuscular haemoglobin (pg) 27-3327-33 26-3126-31 DecreasedDecreased
Mean corpuscular haemoglobin concentration (%)Mean corpuscular haemoglobin concentration (%) 32-3632-36 30-3530-35 DecreasedDecreased
Serum Iron (µg/dl)Serum Iron (µg/dl) 60-17560-175 60-7560-75 DecreasedDecreased
Total Iron Binding Capacity (µg/100ml)Total Iron Binding Capacity (µg/100ml) 300-350300-350 350-400350-400 IncreasedIncreased
Percentage Saturation (%)Percentage Saturation (%) 3030 1515 DecreasedDecreased
Requirements of iron (mg/day)Requirements of iron (mg/day) 1.5-2.01.5-2.0 4.04.0 IncreasedIncreased
Mean corpuscular haemoglobin = MCH Packed cell volume = PCVMean corpuscular haemoglobin = MCH Packed cell volume = PCV
Mean corpuscular haemoglobin concentration = MCHC Mean corpuscular volume =Mean corpuscular haemoglobin concentration = MCHC Mean corpuscular volume =
MCV Total iron binding capacity = TIBCMCV Total iron binding capacity = TIBC

9. PREVALENCE OFPREVALENCE OF
ANAEMIA INANAEMIA IN
PREGNANCYPREGNANCY
 Overall prevalence – 40% of world’s populationOverall prevalence – 40% of world’s population
 Prevalence of anaemia is 3-4 times higher in developingPrevalence of anaemia is 3-4 times higher in developing
countries. Average prevalence being 56%.countries. Average prevalence being 56%.
 In industrialized countries approx 18% of women areIn industrialized countries approx 18% of women are
anaemic during pregnancy.anaemic during pregnancy.
 In India alone the prevalence of anaemia in pregnancy is asIn India alone the prevalence of anaemia in pregnancy is as
high as 88% (W.H.O Global Database 1997).high as 88% (W.H.O Global Database 1997).

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

11. CLASSIFICATION (Contd.)CLASSIFICATION (Contd.)
HERIDITARY:HERIDITARY:
 ThalassemiasThalassemias
 Sickle cell haemoglobinopathiesSickle cell haemoglobinopathies
 Other haemoglobinopathiesOther haemoglobinopathies
 Hereditary hemolytic anaemias (RBC membrane defects,Hereditary hemolytic anaemias (RBC membrane defects,
spherocytosis)spherocytosis)

12. IRON DEFICIENCYIRON DEFICIENCY
ANAEMIAANAEMIA
 It is the commonest type of anaemia in pregnancy.It is the commonest type of anaemia in pregnancy.
 Food iron is made up of two poolFood iron is made up of two pool
–Haem Iron PoolHaem Iron Pool
–Non- Haem Iron PoolNon- Haem Iron Pool
 Haem Iron Pool includes all food containing iron asHaem Iron Pool includes all food containing iron as
haem molecules, such as animal flesh and viscera. Itshaem molecules, such as animal flesh and viscera. Its
absorption is 15-30%, but it can increase to 50% inabsorption is 15-30%, but it can increase to 50% in
iron deficiency state. Its absorption is usually notiron deficiency state. Its absorption is usually not
affected by inhibitors.affected by inhibitors.

13. IRON DEFICIENCYIRON DEFICIENCY
ANAEMIA (Contd.)ANAEMIA (Contd.)
 Non-Haem Iron Pool includes cereals, vegetables, milkNon-Haem Iron Pool includes cereals, vegetables, milk
and eggs. Its absorption can be increased by enhancersand eggs. Its absorption can be increased by enhancers
and decreased by inhibitors.and decreased by inhibitors.
 Enhancers of absorption: Haem iron, proteins, meat,Enhancers of absorption: Haem iron, proteins, meat,
ascorbic acid, ferrous iron, gastric acidity, alcohol, lowascorbic acid, ferrous iron, gastric acidity, alcohol, low
iron stores, increased erythropoietic activity.iron stores, increased erythropoietic activity.
 Inhibitors of iron absorption: Phytates, calcium, tannins,Inhibitors of iron absorption: Phytates, calcium, tannins,
tea & coffee.tea & coffee.

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

15. IRON REQUIREMENT INIRON REQUIREMENT IN
PREGNANCYPREGNANCY
Total iron requirement is 1000 mg.Total iron requirement is 1000 mg.
 Fetus and placenta -- 300 mgFetus and placenta -- 300 mg
 ↑↑ in red cell mass – 500 mgin red cell mass – 500 mg
 Basal loss – 200 mgBasal loss – 200 mg
Average requirement is 4-6mg/day.Average requirement is 4-6mg/day.
 2.5 mg/day in early pregnancy2.5 mg/day in early pregnancy
 5.5 mg/day from 20-32 weeks5.5 mg/day from 20-32 weeks
 6-8 mg/day from 32 weeks onwards6-8 mg/day from 32 weeks onwards

16. PREVENTION OF IRONPREVENTION OF IRON
DEFICIENCYDEFICIENCY
 Prophylaxis of non-pregnant women – 60 mg of elementalProphylaxis of non-pregnant women – 60 mg of elemental
iron daily for 3 months.iron daily for 3 months.
 Iron supplementation during pregnancy.Iron supplementation during pregnancy.
– Routine iron supplementation is debatable in westernRoutine iron supplementation is debatable in western
countriescountries
– It has to be given in non-industrialized countriesIt has to be given in non-industrialized countries
– W.H.O RECOMMENDATION:W.H.O RECOMMENDATION: Universal oral ironUniversal oral iron
supplementation for pregnant women (60 mg ofsupplementation for pregnant women (60 mg of
elemental iron and 250 µg of folic acid) for 6 months inelemental iron and 250 µg of folic acid) for 6 months in
pregnancy and additional of 3 months post-partumpregnancy and additional of 3 months post-partum
where the prevalence is more than 40%.where the prevalence is more than 40%.

17. PREVENTION OF IRONPREVENTION OF IRON
DEFICIENCY (Contd.)DEFICIENCY (Contd.)
– MINISTRY OF HEALTH, GOVT. OF INDIAMINISTRY OF HEALTH, GOVT. OF INDIA
RECOMMENDATION:RECOMMENDATION: 100 mg of elemental iron with100 mg of elemental iron with
500 µg of folic acid in second half of pregnancy for atleast500 µg of folic acid in second half of pregnancy for atleast
100 days. 2 injections of iron dextran (250 mg each) given100 days. 2 injections of iron dextran (250 mg each) given
IMI at 4 weeks interval with TT injection.IMI at 4 weeks interval with TT injection.
 Treatment of hook worm infestationTreatment of hook worm infestation
– Single albendazole (400 mg) or mebendazole (100 mg x BD xSingle albendazole (400 mg) or mebendazole (100 mg x BD x
3 days)3 days)
– Change in defecation habits and avoidance of walking bareChange in defecation habits and avoidance of walking bare
footed.footed.

18. PREVENTION OF IRONPREVENTION OF IRON
DEFICIENCY (Contd.)DEFICIENCY (Contd.)
 Improvement of dietary habits and improving bioImprovement of dietary habits and improving bio
availability of food ironavailability of food iron
 Iron fortification of food.Iron fortification of food.

19. EFFECTS OF ANAEMIA ONEFFECTS OF ANAEMIA ON
PREGNANCYPREGNANCY
 Maternal effects:Maternal effects:
ANTE NATALANTE NATAL INTRA NATALINTRA NATAL POST NATALPOST NATAL
Poor weight gainPoor weight gain Dysfunctional labourDysfunctional labour Puerperal SepsisPuerperal Sepsis
Preterm labourPreterm labour Haemorrhage & shock Sub-involutionHaemorrhage & shock Sub-involution
Pre-eclampsiaPre-eclampsia Cardiac failureCardiac failure EmbolismEmbolism
Abruptio placentaeAbruptio placentae
Inter current infectionsInter current infections
PROMPROM

20. EFFECTS OF ANAEMIA ONEFFECTS OF ANAEMIA ON
PREGNANCY (Contd.)PREGNANCY (Contd.)
 Fetal effects:Fetal effects:
– Risk of pre-maturityRisk of pre-maturity
– IUGR, LBW, poor apgar scoreIUGR, LBW, poor apgar score
– Depleted iron store in neonates and anaemia inDepleted iron store in neonates and anaemia in
infancy periodinfancy period
– High prevalence of failure to thrive and poorHigh prevalence of failure to thrive and poor
intellectual development.intellectual development.
– Cardiovascular morbidity and mortality in adult lives.Cardiovascular morbidity and mortality in adult lives.

21. INVESTIGATIONSINVESTIGATIONS
 Haemoglobin estimationHaemoglobin estimation
 Peripheral blood smear – microcytosis, hypochromiaPeripheral blood smear – microcytosis, hypochromia
anisocytosis, poykilocytosis and target cellsanisocytosis, poykilocytosis and target cells
 RBC indices – ↓MCV, ↓MCH, ↓MCHC, MCV is theRBC indices – ↓MCV, ↓MCH, ↓MCHC, MCV is the
most sensitive indicatormost sensitive indicator
 ↓↓ Serum ferritin – first abnormal laboratory testSerum ferritin – first abnormal laboratory test
 ↓↓ Transferrin saturation – second to be affectedTransferrin saturation – second to be affected
 ↑↑ FEP – third test to become abnormalFEP – third test to become abnormal
 ↑↑ Serum transferrin receptor – best indicatorSerum transferrin receptor – best indicator

22. INVESTIGATIONS (Contd.)INVESTIGATIONS (Contd.)
 Bone marrow examination – no response to treatment afterBone marrow examination – no response to treatment after
4 weeks of therapy4 weeks of therapy
– Aplastic anaemiaAplastic anaemia
– Diagnosis of kala-azarDiagnosis of kala-azar
– Urine examinationUrine examination
– Stool examination – for three consecutive daysStool examination – for three consecutive days
– Other tests – RFT, LFT, TSP A:G, chest x-ray,Other tests – RFT, LFT, TSP A:G, chest x-ray,
sputum examination, etc.sputum examination, etc.
– For response – haemoglobin and PBS, reticulocyteFor response – haemoglobin and PBS, reticulocyte
countcount

23. MANAGEMENT OF IRONMANAGEMENT OF IRON
DEFICIENCY ANAEMIADEFICIENCY ANAEMIA
AIMAIM
 To correct iron deficiencyTo correct iron deficiency
 To restore iron reserveTo restore iron reserve
 To correct associated complicating factorTo correct associated complicating factor
CHOICE OF THERAPYCHOICE OF THERAPY
 Depends on severity of anaemiaDepends on severity of anaemia
 Duration of pregnancyDuration of pregnancy
 Associated complicating factorAssociated complicating factor

24. MANAGEMENT (Contd.)MANAGEMENT (Contd.)
GENERAL TREATMENTGENERAL TREATMENT
 Dietary adviceDietary advice
 Treatment of associated complicating factorTreatment of associated complicating factor
IRON THERAPYIRON THERAPY
 OralOral
 ParenteralParenteral

25. ORAL IRON THERAPYORAL IRON THERAPY
 For women presents in mid trimester or early thirdFor women presents in mid trimester or early third
trimestertrimester
 For treatment more than 180 mg of elemental iron/day isFor treatment more than 180 mg of elemental iron/day is
requiredrequired
 To minimize side effects, start with low doseTo minimize side effects, start with low dose
 Treatment is continued till blood picture becomes normal,Treatment is continued till blood picture becomes normal,
thereafter maintenance of one tablet daily for 3 months tothereafter maintenance of one tablet daily for 3 months to
replenish iron storesreplenish iron stores

26. INDICATIONS OF RESPONSEINDICATIONS OF RESPONSE
TO THERAPYTO THERAPY
 Sense of well beingSense of well being
 Improved outlook of patientImproved outlook of patient
 Increased appetiteIncreased appetite
 ↑↑ haemoglobin, haematocrit, reticulocytosis within 5-10haemoglobin, haematocrit, reticulocytosis within 5-10
daysdays
If no significant clinical or haematological improvementIf no significant clinical or haematological improvement
within 3 weeks, diagnostic re-evaluation is needed.within 3 weeks, diagnostic re-evaluation is needed.

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

28. PARENTRAL IRON THERAPYPARENTRAL IRON THERAPY
INDICATIONS:INDICATIONS:
 In tolerance to oral ironIn tolerance to oral iron
 Poor patient compliancePoor patient compliance
 Unpredictable absorptionUnpredictable absorption
 Patient near termPatient near term
ADVANTAGEADVANTAGE
 No added advantage over oral iron except for certainty ofNo added advantage over oral iron except for certainty of
its administration.its administration.

29. PARENTERAL IRON THERAPYPARENTERAL IRON THERAPY
Intra muscularIntra muscular
Intra venousIntra venous
Two preparations – Iron dextran – IM/IVTwo preparations – Iron dextran – IM/IV
 Iron sorbitol citrate – IMIron sorbitol citrate – IM
IRON DEFICITIRON DEFICIT
Elemental iron needed (mg) = (Normal Hb – Patient’s Hb) xElemental iron needed (mg) = (Normal Hb – Patient’s Hb) x
Weight (kg) x 2.21 + 1000Weight (kg) x 2.21 + 1000
PARENTRAL IRON THERAPYPARENTRAL IRON THERAPY
(Contd.)(Contd.)

30. PARENTRAL IRON THERAPYPARENTRAL IRON THERAPY
(Contd.)(Contd.)
Simple method is to give 250 mg elemental iron for each gmSimple method is to give 250 mg elemental iron for each gm
of haemoglobin below normal. Another 50 % is to be addedof haemoglobin below normal. Another 50 % is to be added
to replenish store.to replenish store.
Oral IronOral Iron should be stopped atleast 24 hrs prior to therapyshould be stopped atleast 24 hrs prior to therapy
to avoid toxic reaction.to avoid toxic reaction.
Iron injections are given daily or on alternate day by deepIron injections are given daily or on alternate day by deep
IMI using ‘Z’ technique.IMI using ‘Z’ technique.
I.V. ROUTEI.V. ROUTE
 Total dose in fusion (TDI) – Dose calculated by sameTotal dose in fusion (TDI) – Dose calculated by same
formulaformula

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

32. INDICATION OF BLOODINDICATION OF BLOOD
TRANSFUSIONTRANSFUSION
 Severe anaemia beyond 36 weeksSevere anaemia beyond 36 weeks
 Refractory anaemiaRefractory anaemia
 To correct anaemia due to blood lossTo correct anaemia due to blood loss
 Associated infectionAssociated infection

33. MANAGEMENT DURINGMANAGEMENT DURING
LABOURLABOUR
 Iron and folate therapy for 3 monthsIron and folate therapy for 3 months
 Infection if any should be treated energeticallyInfection if any should be treated energetically
 Careful watch for puerperal sepsis, failing lactation; subCareful watch for puerperal sepsis, failing lactation; sub
involution of uterus and thromboembolisminvolution of uterus and thromboembolism
 First stage – Comfortable positionFirst stage – Comfortable position
– Adequate analgesiaAdequate analgesia
– Arrangement for oxygen,Arrangement for oxygen,
– Digitalization maybe required in cardiac failure due toDigitalization maybe required in cardiac failure due to
severe anaemiasevere anaemia
– Antibiotic prophylaxisAntibiotic prophylaxis

34. MANAGEMENT DURINGMANAGEMENT DURING
LABOUR (Contd.)LABOUR (Contd.)
 Second stage – Cut short by forceps application.Second stage – Cut short by forceps application.
 Active management of third stageActive management of third stage
 During puerperiumDuring puerperium
– Adequate restAdequate rest
– Iron and folate therapy for 3 monthsIron and folate therapy for 3 months
– Infection if any should be treated energeticallyInfection if any should be treated energetically
– Careful watch for puerperal sepsis, failing lactation;Careful watch for puerperal sepsis, failing lactation;
sub involution of uterus and thromboembolismsub involution of uterus and thromboembolism

35. THANK YOUTHANK YOU