Anemias during pregnancy warda [compatibility mode]
ANEMIAS DURINGPREGNANCYByOsama M. Warda, MDProfessor of OB/GYNMansoura University
Definition:Anemia means reduction below normal ofeither red blood cells (RBCs) count, orhemoglobin percentage, or both leading todeficient oxygen carrying capacity of the blood.9 May 2013 Osama wardaDuring pregnancy; anemia is diagnosed if:RBCs count is less than 3.5 millions/ cc OR,Hemoglobin content less than 10 gm/dL , orHematocrit value is less than 30 %
Incidence:Anemia is the most common medicalcomplication in pregnancy. More than 50% ofall pregnant women suffer anemia duringpregnancy.9 May 2013 Osama wardaIron deficiency anemia is the most commontype, followed by blood loss due to obstetriccause, and anemia due to chronic infection.
Anemia Pregnancy Inter-relations:A]. Effect of anemia on pregnancy ( mother &fetus):1- Increased incidence of PreeclampsiaPreeclampsia--eclampsiaeclampsia,especially with iron deficiency anemia andmegaloblastic anemia (mechanism unknown). PEPA9 May 2013 Osama wardamegaloblastic anemia (mechanism unknown).abruptionplacentalIncreased incidence of-2(accidental hemorrhage).neonatal, andstillbirthsIncreased incidence of-3.deaths.laborpretermIncreased incidence of-4PASBNDPL
Anemia Pregnancy Inter-relations:B]. Effect of pregnancy anemia:Aggravation of the pre-existing anemiaoccurs due to;1- Expansion of the maternal plasma volume9 May 2013 Osama warda1- Expansion of the maternal plasma volume(hyderemia; hemodilution) .2- Fetal utilization of substrates necessary forbuilding up of hemoglobin molecules.
Classification (types) of Anemia:According to RBCs indices*; anemiamay be classified into 3 main types::CYTIC ANEMIA-CROICHROMIC M-O[I]. HYP1-Iron deficiency anemia (most common).CIMCHMCHCMCV9 May 2013 Osama warda1-Iron deficiency anemia (most common).2-Thalassemia (certain types).3-Chronic infections (eg . glomerulonephritis,pyelonephritis).4-Chronic lead poisoning.5- Vitamin B6 deficiency.
Classification (types) of Anemia:CYTIC ANEMIA:-CROACHROMIC M-RE[II].HYP1-Folic acid deficiency anemia.2-Vitamin B12 deficiency anemia.9 May 2013 Osama warda[III]. NORMOCHROMIC NORMOCYTIC ANEMIA:1-Hemorrhagic anemia (due to blood loss).2-Hemolytic anemias; (a) thalassemia, (b) sickle cellanemia, (c) spherocytosis, and (d) G6PD deficiency3- Hypoplastic (aplastic) anemia.
IRON DEFICIENCY ANEMIAIt is the most common type of anemia encountered duringpregnancy.Physiological Role of iron during pregnancy:1-Enters the haem portion of hemoglobin & myohemoglobin.2-Respiratory enzymes as cytochrome oxidase enzyme.3-Placental enzymes9 May 2013 Osama warda3-Placental enzymes4-Fetal hematopoeisis.Metabolism of iron during pregnancy:Normal diet supplies 14 mg of iron per day.Only 1-2 mg ( 10-15% of dietary iron) is absorbed dependingon iron stores (ferritin-apoferritin system).Iron is absorbed in the ferrous state in the presence ofvitamin C. Phytate & phosphate decrease iron absorption .Haem iron of red meat & liver is rapidly absorbed thanvegetable iron in apple, spinache, and other vegetables.
IRON DEFICIENCY ANEMIA cont.;Daily requirement of iron during pregnancy:The daily requirement of the pregnant lady is 4 mgof elemental iron .9 May 2013 Osama wardaThe TOTAL requirement during pregnancy is about1000 mg of elemental iron calculated by the Councilon Food and Nutrition as follows;To compensate for external iron loss…….= 170 mgTo allow expansion of maternal cell……..= 450 mgIron for fetal needs ………………………. =270 mgIron in placenta and cord ………………….= 90 mg
IRON DEFICIENCY ANEMIA cont.;Etiology of iron deficiency anemia during pregnancy:[A]. Decrease intake of iron:1- Poor diet.2- Extensive morning sickness[B]. Diminished absorption of iron:9 May 2013 Osama warda[B]. Diminished absorption of iron:1- Lack of vitamin C and proteins.2- Increased phosphate & phytates.3- Decreased gastric acidity & use of antacids.4- Malabsorption syndromes, and parasitic infestations.[C]. Increased iron demands during pregnancy:1- Multiple pregnancy2- Hemorrhage with pregnancy3- Multi-parity
IRON DEFICIENCY ANEMIA cont.;Clinical Picture:S y m p t o m s:General; pallor, tiredness, easy fatigability.Cardiovascular; Dyspnea on exertion,palpitation, anginal pains, swelling of lower limbs,9 May 2013 Osama wardapalpitation, anginal pains, swelling of lower limbs,and other low cardiac output symptoms.Gastrointestinal; anorexia, nausea, vomiting,constipation.Nervous System; lack of concentration, numbnessand tingling, headaches.S i g n s:General; pallor, glassy tongue, brittle nailsCardiovascular; haemic murmurs over theprocordium on auscultation.
IRON DEFICIENCY ANEMIA cont.;Investigations:Peripheral blood ( complete blood count; CBC):[A].Findings suggestive of diagnosis include;1-Microcytic hypochromic anemia ( ie, reduced indices)2- Anisocytosis (ie, different sizes of RBCs)3- Piklocytosis (ie, different shapes of RBCs)4-Normal reticulocytic count (ie, 0.5%- 1.5%)9 May 2013 Osama warda4-Normal reticulocytic count (ie, 0.5%- 1.5%)5-Normal platelet & leukocyte counts:Blood chemistry[B].Findings suggestive of diagnosis include;1- Decreased serum iron less than 60µg/ dl (normal 90-150 µg / dl)2-Decreased serum ferritin3-Increased serum iron binding capacity more than 300 µg%4-Increased free erythrocyte proto-porphyrin.Bone marrow biopsy (seldom done):[C].There is absence of stainable iron in bone marrow.
Treatment of iron deficiency anemiaduring pregnancy:. Prophylactic Treatment:[A]Every pregnant woman needs iron supplementationduring pregnancy; the earlier the better ( but NOTearlier than 14 weeks pregnancy)Oral iron supplementation to ALL pregnant ladies after9 May 2013 Osama wardaOral iron supplementation to ALL pregnant ladies after16 weeks gestation as 60-80 mg of elemental ironper day; can be obtained from;200 mg ferrous fumarate, OR300 mg ferrous sulfate, OR550 mg ferrous gluconate, PLUS1000mg vitamin C ( to help absorption) and 2mg folic acid (tohelp hematopoeisis).Antacids lower the absorption of iron from the stomach.
Treatment of iron deficiency anemiaduring pregnancy:Active Treatment:[B].Active management of anemia depends on 2 main factors;severity of anemia, and the duration of pregnancy.weeks:30-16Pregnancy).1(Oral ferrous sulfate 300mg t.d.s----------- HB ↑ 1gm/monthweeks with severe anemia:30Pregnancy after).2(9 May 2013 Osama wardaweeks with severe anemia:30Pregnancy after).2(parenteral iron therapyIntramuscular ( 250mg every other day) orIntravenous infusion in a crystalloid solution (eg ferroussuccinate; ferosac®: 1amp in 100 ml of dextrose 5% everyother day).weeks pregnancy and hemoglobin less35Anemia after).3(gm/dl:6thanThese patients should receive transfusion of packed RBCs (orwhole blood if packed RBCs are not available).
Folic Acid Deficiency AnemiaFolic acid deficiency causes megaloblastic anemiawhich accounts for 3% of cases of anemiaduring pregnancy.Folic acid metabolism during pregnancy:9 May 2013 Osama wardaFolic acid metabolism during pregnancy:Pregnancy is associated with negative folatebalance.Folic acid & iron play a central role in nutrition & DNAsynthesisFolate requirements are increased during pregnancyfor the growing fetus, placenta, maternal RBCs, anduterine hypertrophy. Folate requirement in normalpregnant lady are 200-300 µg/ day.
Folic Acid Deficiency Anemia; cont.;Etiology of folic acid deficiency anemia:1-The causes are the same as those of irondeficiency anemia , plus the following:2- Anti-convulsion therapy (eg, pregnant9 May 2013 Osama warda2- Anti-convulsion therapy (eg, pregnantepileptic patient on epanutin®).3- Antipyretic therapy.4- Chronic hemolysis.
Folic Acid Deficiency Anemia; cont.;Investigations for folate deficiency:Peripheral blood:[A].The findings suggestive of diagnosis:1-Macrocytic hyperchromic anemia (MCV increased)2-Hypersegmented polymorphs9 May 2013 Osama warda2-Hypersegmented polymorphs3-Elevated reticulocytic count.[B]. Blood chemistry:1-Decreased plasma folate level; the finding of a serumfolate <2ng/ ml [+] red cell folate <150 ng /ml, isdiagnostic.2-Increased urinary form-imino-glutamic acid (FIGLU);this finding differentiate folate deficiency fromvitamin B12 deficiency.
Folic Acid Deficiency Anemia; cont.;Hazards of folate deficiency during pregnancyIncreased incidence of the following;1- Neural tube defects (NTDs)9 May 2013 Osama warda2- Cleft lip and cleft palate.3- Intrauterine growth restriction (IUGR)4-Megaloblastic anemia.
Folic Acid Deficiency Anemia; cont.;Treatment of folic acid deficiency anemia duringpreg.:Prophylactic measures:[A].Vitamin supplements containing 400 µg of folic acidorally per day are now recommended for all9 May 2013 Osama wardaorally per day are now recommended for allwomen of childbearing age and during pregnancy.Active treatment:[B].Mild cases; Oral 5 mg folic acid per daySeverely anemic patients near delivery; Exchangetransfusion with packed RBCs followed byparenteral folic acid therapy (1mg/IM/day/ for 1week).
Vitamin B12 Deficiency AnemiaEtiology :It is also called pernicious anemia. It is avery rare type of megaloblastic anemiaduring pregnancy, since the daily9 May 2013 Osama wardaduring pregnancy, since the dailyrequirement of vitamin B12 duringpregnancy is only 1 µg.Vitamin B12 deficiency is usually due tointrinsic factor deficiency in the stomach;(sub-acute combined degeneration).
Vitamin B12 Deficiency Anemia, contDiagnosis:bloodPeripheralwill show the same picture as folatedeficiency anemia except for normal9 May 2013 Osama wardadeficiency anemia except for normalreticulocytic count ( elevated in folatedeficiency).;Blood chemistrythere is low plasma vitamin B12 level . Aserum level less than100 pg/ ml isdiagnostic of vitamin B12 deficiency.
Vitamin B12 Deficiency Anemia, contTreatment::Mild cases250 µg of parenteral (IM) cyancobolamin/ month.Oral preparations of vitamin B12 have unreliable absorption9 May 2013 Osama wardaOral preparations of vitamin B12 have unreliable absorptionproperties & are inadequate for long term therapy.;Severely anemic patients near deliveryExchange transfusion with packed RBCs followedby parenteral cyancobolamine ( 100 µg /IM/day/for 1 week ).
Normochromic Normocytic AnemiasHemorrhagic Anemia:[A].It is the 2nd common type of anemia duringpregnancy following iron deficiency anemia.Causes: acute or chronic blood loss in9 May 2013 Osama wardaCauses: acute or chronic blood loss inobstetrics;Early: abortion, ectopic pregnancy,vesicular mole.Late: placenta previa, accidentalhemorrhage.
Normochromic Normocytic Anemias:AnemiasHemolytic[ B].According to results of Coombs test, they are classified into:( ie, positive Coombs test): this may;A)Immune hemolytic anemiasbe isoimmune OR autoimmune;B).Non-immune hemolytic anemias; (ie, negative Coombs test):9 May 2013 Osama wardaB).Non-immune hemolytic anemias; (ie, negative Coombs test):this may be due to:(a). Intracorpuscular causes ( ie, chronic hemolytic anemia);- Hemoglobinopathies as thalassemias, sickle cell anemia-Cell wall defect as spherocytosis, elliptocytosis- Enzymatic defect as G-6- PD deficiency, pyruvate kinasedeficiency.(b). Extra-corpuscular causes as;Preeclampsia-eclampsiaProsthetic heart valvesMalarial infection.
Normochromic Normocytic AnemiasClinical features of chronic hemolytic anemias:1-Pallor with jaundice.2- Mongoloid facies.3-Splenomegaly and hepatomegaly.4- (±) Hemic murmur over the heart.9 May 2013 Osama warda4- (±) Hemic murmur over the heart.Laboratory features of chronic hemolytic anemias:1-Normochromic Normocytic (except with thalassemia it ismicrocytic hypochromic).2-Reticulocytosis (reticulocyte count > 2%)serum bilirubin.indirectElevated-34-Shortened life span of RBCs (by isotope chromium 51).5-Erythroid hyperplasia of the bone marrow.
Management of pregnanciescomplicated by Thalassemias:with the aid of a hematologist)[A]. MATERNAL: (--No specific therapy for β-thalassemia minorduring pregnancy; as the outcome for both themother & the fetus is satisfactory.9 May 2013 Osama wardamother & the fetus is satisfactory.1- Blood transfusion is rarely indicatedexcept for hemorrhage.2- Prophylactic folic acid supplementation isstrongly indicated.3- Proper treatment of infections.4- Iron chelating agents (eg, Desferal®).
Management of pregnanciescomplicated by thalassemias::[B]. FETALThe fetal management in patients withthalassemia or sickle cell disease is concernedwith the fetal risk of acquiring the disease.Management consists of:1- Genetic counseling.to determine the fetal risks by Mendelian laws.9 May 2013 Osama warda1- Genetic counseling.to determine the fetal risks by Mendelian laws.2- Antenatal diagnosis of thalassemias & sickle cell anemia may beachieve via one of the following techniques:(a) Chorionic villus sampling,(b) Early amniocentesis between 7-11 weeks gestation,(c) Cordocentesis through percutaneous umbilical blood sampling(PCUBS), or(d) Fetoscopy with cord blood sampling.3. Termination of pregnancy is considered if the fetus is severelyaffected.4. Reassurance of pregnancies if the fetus is not affected or mildlyaffected.
Management of pregnanciescomplicated by the SS-disease::[A]. PREGNANCY1- Very close observation (frequent antenatal visits, orhospital).2- Folic acid supplementation ( 2mg orally / day).3- .9 May 2013 Osama warda3- Eradication of asymptomatic bacteruria & pyelonephritis.4- Guard against pneumonia and heart failure.5- Prophylactic blood transfusion.6- Management of crisis by:OxygenationHydration (iv fluid therapy)Blood transfusionHeparinization for the thrombotic cricis
Management of pregnanciescomplicated by the SS-disease:[B]. DELIVERY: (managed as cardiac patients)1-Comfortable but not sedated.2-Blood ready for transfusion.3-Vaginal delivery is preferred, and CS for obstetricalindication only.4-Regional anesthesia is better than general anesthesia.9 May 2013 Osama warda4-Regional anesthesia is better than general anesthesia.5-Replace blood loss adequately.[C]. CONTRACEPTION:Tubal sterilization is indicated even if the parity is very low.Combined oral contraceptives are contraindicated(↑thrombosis)Intrauterine contraceptive device (IUCD) is contraindicated(↑infection).