ANAEMIA IN PREGNANCY

1. BY
A.RAMANA PRIYA

2.  What is Anaemia ?
Anaemia is defined as reduction in circulating
haemoglobin mass below the
critical level.
 The normal haemoglobin (Hb) is 12-14 gm%.
 WHO has accepted up to 11 gm% as the normal
haemoglobin level in pregnancy.
Therefore any haemoglobin level below 11gm
in pregnancy should be considered as anaemia

3.  Anaemia in pregnancy is present in very high
percentage of pregnant women in India.
 Exact data is not available about the prevalence
of nutritional anaemia. However according to
WHO, the prevalence of Anaemia in pregnancy in
south East Asia is around 56 %.
 In India incidence of anaemia pregnancy has
been noted as high as 40-80%.

4. Total iron requirement is 1000 mg.
 Fetus and placenta -- 300 mg
 ↑ in red cell mass – 500 mg
 Basal loss – 200 mg
Average requirement is 4-6mg/day.
 2.5 mg/day in early pregnancy
 5.5 mg/day from 20-32 weeks
 6-8 mg/day from 32 weeks onwards

5.  Anaemia is often classified as
Mild degree (9-11 gm %)
Moderate (7-9 gms %)
Severe (4-7 gm %)
Very severe (<4gm %)
 It is also classified according to Haematocrit
(PCV) %.

6. Antenatal Period
-Poor weight gain
-Preterm labour
-PIH
-Placenta Previa
-PROM Postnatal Period
-Postnatal sepsis
-Sub involution
-Embolism
Intranatal Period
-Dysfunctional Labour
-Intranatal
-Hemorrhage
-Shock
-Cardiac Failure
-Anaethesia risk
What are the maternal risk factors ?

7. • Prematurity
• Low birth weight
• Poor apgar score
• Foetal distress
• Neonatal Anaemia
What are the fetal and neonatal risk factors ?

8.  Physiological
 Nutritional: Iron deficiency
Folate &/orVit B12 deficiency
Dimorphic
 Hemorrhagic: Acute or Chronic
 Hemoglobinopathies
 Hemolytic: Congenital or acquired
 Aplastic anaemia

9. Symptoms
 Fatigue
 Loss of appetite
 Digestive upset
 Dyspnoea
 Palpitation
Signs
Pallor
Pale nails
Koilonychias
PaleTongue
Severe Case - Oedema

10.  CBC
 Pheripheral Smear – Hypochromic
Microcytosis
Poikilocytosis
Anisocytosis
 MCV, MCH, MCHC
 TIBC
 Serum Iron
 Serum Ferritin
 Free erythrocyte protoporphyrin
 Bone marrow examination
 Urine examination
 Stool examination
 Serum protein

11.  Serum Folate
 RBC folate
 SerumVit B12
 Serum Bilirubin
 Coombs test
 HB electrophoresis
 NESTROF test
 Red cell osmotic fragility

12.  Routine screening for anaemia for adolescent
girls from school days
 Encouraging iron rich foods
 Fortification of widely consumed food with iron
 Providing iron supplementation from school days
 Annual screening for those with risk factors

13.  Prophylaxis of non-pregnant women – 60 mg of elemental
iron daily for 3 months.
 Iron supplementation during pregnancy.
 Routine iron supplementation is debatable in western
countries
 It has to be given in non-industrialized countries
 W.H.O RECOMMENDATION: Universal oral iron
supplementation for pregnant women (60 mg of elemental
iron and 400 µg of folic acid) for 6 months in pregnancy
and additional of 3 months post-partum where the
prevalence is more than 40%.

14.  MINISTRY OF HEALTH, GOVT. OF INDIA
RECOMMENDATION: [CSSM] 100 mg of elemental iron with
500 µg of folic acid in second half of pregnancy for atleast 100
days. 2 injections of iron dextran (250 mg each) given IMI at 4
weeks interval with TT injection.
 Treatment of hook worm infestation
 Single albendazole (400 mg) or mebendazole (100 mg x BD x 3
days)
 Change in defecation habits and avoidance of walking bare
footed.

15.  Pulses,cereals,jaggery,beet root,green leafy
vegetables,meat,liver,egg,fish,legumes,dry
beans

16.  MOTHER
 PREGNANCY-
1. Cardiac failure at 30-34 wks of pregnancy
2. Increased susceptibility to infection
3. Preterm labour
4. Preeclampsia
 LABOUR-
1. Uterine inertia
2. Post partum haemorrhage
3. Cardiac failure
4. shock

17.  Puerperium
1. Cardiac failure
2. Puerperal sepsis
3. Subinvolution
4. Failing lactation
5. Chronic ill health,backache
 FETUS&NEONATE
1. Prematurity
2. IUGR
3. Increased perinatal death
4. Decreased iron stores in neonate

18.  ORAL IRONTHERAPY
1. Safe,inexpensive and effective way to
administer iron
2. National nutritional anemia prophylaxis
program suggest 60 milligrams of elemental
iron and 500 micrograms of folic acid daily
3. However it is suggested that 120 milligram of
elemental iron and 1 milligram of folicacid are
the optimum daily dose needed

19. SALT TABLET ELEMENTAL
IRON
Ferrous sulfate 200mg 60mg[30%]
Ferrous fumarate 200mg 66mg[33%]
Ferrous gluconate 320mg 36mg[12%]
Ferrous succinate 100mg 35mg[35%]
Ferric ammonium
citrate
125mg 25mg[17-22%]
Ferrous ascorbate ------ 100mg
Carbonyl iron ------- 90mg
Sodium feredetate ------- 231mg
Hb preparation 2.1g [0.33%]

20.  SIDE EFFECTS OF ORAL IRON
A. UPPER GITRACT
Nausea,gastric discomfort,loss of apetite,staining
of teeth
A. LOWER GITRACT
Constipation,diarrhoea,flatulance

21.  PARENTRAL IRONTHERAPY
 Preparation
Iron sucrose-Imax S[100mg/5ml],orofer s[50mg
/2.5ml]
Iron sorbital citric acid complex-jectocos
Iron dextran-imferon

22.  Intramuscular iron
1. 0.5ml test dose should be given
2. 75/100mg/day is given daily on alternate days
3. Given deep Im by Z-techniue to prevent skin
staining
4. Side effects-painful,discolouration,injection
abscess

23.  INTRAVENOUS IRON
1. Formula-0.66*% deficit of Hb*wt in kg=mg of iron
2. Total dose in mg/50=ml of imferon
3. Total dose is given in normal saline
 COMPLICATION
Local-thrombophlebitis at IV site
Systemic-malaise,fever,arthralgia,utricaria
lymphadenopathy

24.  BLOODTRANFUSION
1. Indicated insevere anemia at any GA,moderate
anemia beyond 36wks and when there is a
failure of response to iron therapy,severe
hemorrhage likeAPH,PPH,rupture
uterus,cesarean section,first trimester
hemorrhage,thalassemiasand sickling disorders
in pregnancy

25.  ADVERSE REACTIONS
1. Tranfusion reaction
2. Infection
3. Volume overload
4. Others like hypothermia,citrate
toxicity,hyperkalemia,hypocalcemia and rarely
air embolism

26.  First stage – Comfortable position
 Adequate analgesia
 Arrangement for oxygen,
 Digitalization maybe required in cardiac failure
due to severe anaemia
 Antibiotic prophylaxis

27.  Second stage – Cut short by forceps application.
 Active management of third stage
 During puerperium
 Adequate rest
 Iron and folate therapy for 3 months
 Infection if any should be treated energetically
 Careful watch for puerperal sepsis, failing lactation; sub
involution of uterus and thromboembolism