My presentation at the International critical care in obstetrics, Pune, 20th July 2013.

1. Severe Anemia in India:
Pregnancy adds fuel to fire
Dr Ajay Dhawle

2. Dr Ajay S Dhawle
MD (PGIMER, Chandigarh)
DNB (CMC Ludhiana)
Fellowship in Perinatology (Diwakars Global
Hospital, Bangalore)
FMF, Uk accredited sonologist
Associate Professor, OBG, JNMC, Sawangi-Meghe, Wardha
drajaysd@gmail.com
7620679506

3. My (failed)attempts at Google search….

4. Where’s the fire?

6. Anemia in pregnancy
• Definition
• Classification
• India and Anemia: made for each other
• Physiological changes during pregnancy
• Myth - busting
• Effect of Anemia on pregnancy
• Summary

7. Definition
• Definition:
“Quantitative or qualitative reduction of Hb or
circulating RBCs or both resulting in decreased O2
carrying capacity”
• WHO –
Hemoglobin <11gm/dl & hematocrit <33%
Postpartum Hb < 10 gm/dl
• CDC definition-
First and third trimesters : Hb <11gm/dl
Second trimester <10.5gm/dl
- WHO. (2001) Iron deficiency anaemia: assessment, prevention and control, Geneva
- Dowdle, W. (1989) Centers for Disease Control: CDC Criteria for anemia in children and
childbearing-aged women. Morbidity and Mortality Weekly Report 38, 400–404.

8. Classification
ICMR WHO
Mild 10 – 11 gm/dl 9 – 11 gm/dl
Moderate 7 – 10 7 - 9
Severe 4 – 7 <7
Very severe <4 decompensated

9. Indian women are anemic to start with…
• A vicious circle…
• Thus an Indian girl invariably enters her reproductive
career in an iron depleted state
Poverty
Malnutrition
Early marriages
Poor spacing
Anemic
mothers
Anemic
infants/
children
Parasites
Education
Gender bias

11. Where do we stand today?
• Anemia prevalence: (NFHS 3: 2005-06)
20-80% amongst pregnant women
56% of adolescent girls, 30% boys
79% of children (increasing trend compared to NFHS 2; 1998-99)
• Anemia as a cause of maternal deaths: 15-20%
• Indirect cause: ~20%

12. Physiological changes during pregnancy
• A state of hemodilution
• Rise in RBC mass < Plasma
• Protects agianst:
Decreased venous return
Peripartum blood loss
• Meets nutritional and
metabolic demands

13. Blood volume
• Plasma volume increases rapidly up to 10% above
baseline by 7 weeks of gestation, and plateaus by 32
weeks at 45–50%
• Pregnancies complicated by growth restriction :lower
mean maternal plasma volume increase
• Obstetric outcomes and birth weights are correlated with
the amount of plasma volume expansion

14. Respiration
• Oxygen consumption increases by 30–50 mL/min (2/3rd
covers additional maternal requirements & 1/3rd is for
the developing fetus)
• The increase in oxygen consumption is associated with a
40% increase in ventilation secondary to a progressive
rise in tidal volume of 200 mL
• Decrease in maternal alveolar and arterial pCO2
• A state of chronic respiratory alkalosis with a
compensatory metabolic acidosis.

15. Cardiovascular changes
• Increased heart rate (as the SVR decreases)
• Decreased time for ventricular filling & atrial emptying
• Increased chances of pulmonary edema, esp in rate
dependant conditions (MS)
• Midtrimester BP fall (BP = CO. SVR)
• CO rises in the first trimester, and peaks by the end of
the second trimester by ~ 30–50% of non-pregnant
values (3.5–6.0 L/min)
• SV increases by 8 weeks of gestation, reaching a plateau
at 16–20 weeks (+32% mid-pregnancy values)
The heart has to work very hard during pregnancy

16. Peripartum changes
• Each contraction expels 300–500 mL of blood into the
maternal circulation, increasing venous return and
therefore CO by up to 30%.
• Maternal pain, anxiety, valsalva and positioning also have
profound effects on CO in labour
• Autotransfusion of approximately 500 mL of blood from
the uterus back to the heart, relief of vena caval
compression from the gravid uterus & fluid shifts from
the extra to the intravascular compartment
• CO (+59%), heart rate and stroke volume (+71%) all rise
within the first 10 min of delivery and remain elevated at
1 hr

19. Increased needs during Pregnancy
Increased iron requirement (1000-1200mg)
• For fetal and placental growth : 300 mg
• Maternal RBC mass expansion : 500 mg
• Peripartum blood loss : 180 mg
• Lactation : 180 mg
Iron saved due to Amenorrhoea : 200 mg
Iron requirement increases from a 0.8 mg/day in the first
trimester to 6 to 7 mg/day in the second half of
pregnancy
Mukherji J. Iron deficiency anemia in pregnancy. Rational Drug Bull. 2002;12:2–5.

20. Anemic Myths
• Mild anemia does not have any great significance
• Dietary modification is enough for treating mild anemia
• Baby will not be affected by mild anemia. It will take
what is necessary from the mother
• Baby will grow BLACK / BIG due to the Fe tabs
• Iron injections are very dangerous
• Delayed cord clamping results in increased need for
phototherapy.

21. Effects of Anemia on Pregnancy

24. Fetal & Neonatal effects
• Depleted maternal stores: inadequate fetal stores:
anemia in the first year of life
• Behavioral abnormalities & cognitive dysfunction :
changes in chemical mediators
• Poor performance on the Bayley Mental Development
Index
• Prophylaxis of iron deficiency during pregnancy may have
an important role in the prevention of adult hypertension
• Both developmental delays and cognition can be
improved with treatment

25. Summary
• Preeclampsia
• Prematurity
• Intercurrent infections
• PPH/ uterine atony/
subinvolution
• Abruptio
• Cardiac failure
• Puerperal sepsis
• Maternal deaths
• Low birth weight/ SGA
• Poor APGARs at 1
min, fetal distress
• Stillbirths
• Anemia in first year
• Behavioral abnormalities
• Cognitive dysfunction
• Adult onset HTN

26. A Dream worth Dreaming?

27. Thank you