1. ANAEMIA: Preventable,
Yet a Problem!!
DR. R. RAJKUMAR M.D., D.M.
CONSULTANT MEDICAL ONCOLOGIST
MADURAI MEDICAL COLLEGE
2. Definition
♦
Anemia - insufficient Hb to carry out O2 requirement
by tissues.
♦
WHO definition : Hb conc. < 11 gm %
♦
CDC definition : Hb conc. < 11gm % in 1st and 3rd
trimesters and < 10.5 gm% in 2nd trimester
♦
For developing countries : cut off level suggested is
10 gm %
- WHO technical report Series no. 405, Geneva 1968
Centre for disease control, MMWR 1989;38:400-4
3. WHO Classification of Anaemia
Degree
Hb%
Moderate
7-10.9
24-37%
Severe
4-6.9
13-23%
Very Severe
<4
Haematocrit (%)
<13%
4. Magnitude of Problem
♦
Globally, is about 30 %
♦
In developing countries &
India, incidence is around
40 – 90%.
♦
Responsible for 40% of
maternal deaths in third world
countries.
♦
Important cause of direct and
indirect maternal deaths
- Vitere FE Adv Exp Med Biol 1994;352:127
9. Iron Requirement During Pregnancy
Early
Pregnancy
20 to 32
weeks
32 to 40
weeks
6.8 mg / day
5.5 mg / day
2.5 mg / day
TOTAL
800 – 1000 mg
RBC
=500mg
Fetus+Placenta
=450mg
Third stage blood loss =200mg
Total
=
1150mg
11. Laboratory Diagnosis of Anaemia
IDA
Thalassemia
Chronic Diseases
Serum Iron
Decreased
Normal / Increased
Decreased
TIBC
Increased
Normal
Decreased or N
Transferrin
Decreased
N or Increased
N or Decreased
Serum Ferritin
Decreased
N or Increased
N
Marrow Iron
Decreased /
absent
N or Increased
N
No rise in Hb
No rise
Saturation
Therapeutic test with Rise in Hb
oral iron
12. Nutritional Anaemia :
Major Health Problems
National Nutrition Anaemia Prophylaxis
Programme (NNAPP 1971 - 72)
Pregnancy
FS + FA
Lactating mothers
Family planning acceptors
Children – 1 to 11 years
Anaemia continues – Major health problem
13. Reason For Increased
Incidence Of Anemia
♦
Poor pre-pregnancy iron balance due to –
untreated systemic diseases & menstrual
disorders
♦
Improper supplementation of iron in pregnancy
( late registration and poor follow up)
♦
Repeated childbearing
♦
Lack of awareness and illiteracy
14. Reason For Increased
Incidence Of Anemia
♦
Low socioeconomic status and poor hygiene
♦
Chronic malnutrition
♦
Poor availability of iron due to predominantly
veg diet, diet low in calories but rich in phytates.
Food and religious taboos
♦
GI infections and infestations
(e.g. Kala azar, worm infestations)
17. Management Options
Pre – pregnancy :
♦ Treat the cause before conception
♦ Pre-pregnancy balanced diet, education
and health support.
♦ Build up iron stores during adolescent
phase
19. Oral Iron
100 mg elemental Iron ------- ↑ 0.18 gm % day
-ve
Phosphate
phytate
Iron absorption
-ve
↓ Bioavailability
of Iron
Iron stores poor
-ve
Worm
infestation
20. Oral Iron Therapy
♦
Ideal dose – 100mg per day (prophylactic)
♦
Ferrous gluconate, ferrous fumarate, ferrous
succinate, ferrous sulphate, ferrous ascorbate citrate
♦
Rise in Hb – 0.8 gm / dl / week
♦
Side effects -G I upset most common
♦
Pt. compliance not guaranteed
♦
Ineffective in pts with worm infestations
♦
Inconclusive evidence on benefit of controlled release
Iron preparation
21. Absorption of Ferrous Salts
Uncontrolled Passive Absorption
♦ Iron salts are dissociated into bivalent or trivalent iron salts
♦ Diffuses as free iron ions through the upper part of the
gastrointestinal mucosa
♦ Taken up by transferrin and incorporated into ferritin.
♦ For binding to ferritin and transferrin ferrous iron has to be
converted into ferric iron by oxidation
♦ Highly reactive free radicals are produced during this process
♦ All ionic iron including carbonyl iron are absorbed similarly
•
Borbolla JR. Cicero RE, Dibilox MM, Sotres RD et al.. Rev Mex Pediatr 2000; 67(2): 63-67
•
Heubers KA, Brittenham GM, Csiba E, Finch CA. J Lab Clin Med 1986 ; 108 ; 473-8.
22. Gut Lumen
Iron
salts
Mucosal Cell
Blood
Fe+3
Free Radical
Ferritin
Dissociation
Fe+2
Fe+2
Fe+2
Fe
Fe+2
Transferrin
Fe+2
+2
Fe+3
Fe+2
Free Radical
Passive diffusion
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2
Incorporation into
Hb
23. Parenteral Therapy
I.V.
I.M.
100 mg
elemental Iron
Anaphylactic
reaction
Anaphylactic
reaction
Fractionated Irondextran
[Iron hydroxide dextran complex]
Les
s
Les
s
↑ Hb – 0.21 gm %
24. Parenteral Therapy :
Traditional Indications
♦
Intolerance to oral iron
♦
Poor compliance to oral iron
♦
Gastrointestinal disorders
♦
Malabsorption syndromes
♦
Rapid blood loss
25. Parenteral Therapy :
Traditional Indications
♦
Inability to maintain iron balance
(haemodialysis)
♦
Patient donating large amount of blood
for auto-transfusion programme
♦
? Pregnant women with severe IDA,
presenting late in pregnancy
27. Diagnosis of Folate Deficiency
Anemia (FDA)
Special considerations in diagnosis
• FDA is suspected when the expected response
to adequate iron therapy is not achieved
• Macrocytosis can occur in pregnancy in absence
of FDA
• If FDA + IDA present, it will be masked by IDA
• Definitive diagnosis – Bone marrow aspirate
29. Management of FDA
♦ Strong case for routine prophylaxis
♦ Prophylaxis with anti convulsants
♦ Continue routine oral therapy for
hemolytic anaemia
♦ Parenteral therapy for severe deficiency
30. Worm Infestations
♦ Common cause of anaemia in developing countries
♦ Most common – hookworm infestation, Round
worm, whip worm, etc.
♦ Oral iron therapy becomes ineffective
♦ Treatment by antihelminthics is a must
Treatment
♦ Mebendazole : 100mg twice daily for three days
♦ Pyrantel pamoate : 10mg / kg in single dose.
♦ Albendazole : 400mg once a day for three days
31. Hemoglobinopathies
A collective term for the inherited disorders
of Hb synthesis
♦ Disorders of globin synthesis e.g.
Thalassemia
♦ Structural Hb variants e.g. Sickle cell
anemia, HbC
32. Thalassemia
♦
Genetic disorders; lack or ↓ sed synthesis of globin
chains
♦
Two types : α & β thalassemia
♦
α chains encoded by 2 pairs of genes on
chromosome 16
♦
β chains encoded by single pair of genes on
chromosome 11
♦
β thalassemia more common and presents as either
β °(major) or β + (minor)
34. Diagnostic Strategy for Thalassemias
Hb Electrophoresis + CBC
Abnormal band
MCV
MCH
Quantitative Hb
electrophoresis
Raised Hb A2
B Thalassemia
Normal
No action
Examine partners blood
↓sed
Normal
?X
Thalassemia
DNA analysis
for x gene
defects
35. Sickle Cell Disease
♦
Structural Hb variant
♦
Exists in homo & heterozygous
forms
♦
Under hypoxic conditions, HbS
polymerizes, gels or crystallizes.
♦
∴ hemolysis of cells, &
thrombosis of vessels in
various organs
♦
In long standing cases,
multiple organ damage.
36. Take Home Message
♦ Anaemia although preventable is a global problem
♦ Anaemia still is the commonest cause of maternal mortality
and morbidity in spite of easy diagnosis and treatment
♦ Anaemia can be due to a number of causes,
including certain diseases or a shortage of iron, folic
acid or Vitamin B12.
♦ The most common cause of anemia in pregnancy is
iron deficiency.
♦ Iron therapy is best given orally
37. Take Home Message
♦
The youth need to be educated about diet,
sanitation and personal hygiene
♦
Hookworm infestation should be treated
♦
Pregnant women should be given Iron and
folate supplements
