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Anemia in pregnancy
1. Syed Awais ShahSyed Awais Shah
08-18908-189
Anemia in PregnancyAnemia in Pregnancy
2. Case 1Case 1
• Mrs.Khan. is a 28-year-old woman in her secondMrs.Khan. is a 28-year-old woman in her second
trimester of pregnancy with her first child, andtrimester of pregnancy with her first child, and
though her pregnancy had been progressingthough her pregnancy had been progressing
normally, recently she has noticed that she tiresnormally, recently she has noticed that she tires
very easily and is short of breath from even thevery easily and is short of breath from even the
slightest exertion. She also has experiencedslightest exertion. She also has experienced
periods of light-headedness, though not to theperiods of light-headedness, though not to the
point of fainting. Other changes she has noticedpoint of fainting. Other changes she has noticed
are cramping in her legs, and the fact that herare cramping in her legs, and the fact that her
tongue is sore.tongue is sore.
3. • Upon examining, she has tachycardia, paleUpon examining, she has tachycardia, pale
gums and nail beds, and her tongue is swollen.gums and nail beds, and her tongue is swollen.
Given her history and the findings on herGiven her history and the findings on her
physical exam, she is suspected to be anemicphysical exam, she is suspected to be anemic
and a sample of her blood is ordered forand a sample of her blood is ordered for
examination.examination.
4. Table 1. Blood SampleTable 1. Blood Sample ResultsResults
Red Blood Cell CountRed Blood Cell Count 3.5 million/mm3.5 million/mm33
Hemoglobin (Hb)Hemoglobin (Hb) 7 g/dl7 g/dl
Hematocrit (Hct)Hematocrit (Hct) 30%30%
Serum IronSerum Iron lowlow
Mean Corpuscular Volume (MCV)Mean Corpuscular Volume (MCV) lowlow
Mean Corpuscular Hb ConcentrationMean Corpuscular Hb Concentration
(MCHC)(MCHC)
lowlow
Total Iron Binding Capacity in theTotal Iron Binding Capacity in the
Blood (TIBC)Blood (TIBC)
highhigh
5. • A diagnosis of anemia due to ironA diagnosis of anemia due to iron
deficiency is made and oral irondeficiency is made and oral iron
supplements prescribed. Her symptomssupplements prescribed. Her symptoms
are eliminated within a couple of weeksare eliminated within a couple of weeks
and the remainder of her pregnancyand the remainder of her pregnancy
progresses without difficulty.progresses without difficulty.
6. Anemia during Pregnancy.Anemia during Pregnancy.
• ’’’’Hemoglobin levels below 11gm/dl in 1Hemoglobin levels below 11gm/dl in 1stst
and 3and 3rdrd
trimester and below 10.5gm/dl intrimester and below 10.5gm/dl in
second trimester.’’second trimester.’’
7. IncidenceIncidence
• Anaemia may affect 18% of pregnanciesAnaemia may affect 18% of pregnancies
in developed countries and is considerablyin developed countries and is considerably
commoner in developing countries, wherecommoner in developing countries, where
it is a major source of maternal morbidityit is a major source of maternal morbidity
and a contributor to mortality.and a contributor to mortality.
• Up to 56% of all women living inUp to 56% of all women living in
developing countries are anaemic (Hb <developing countries are anaemic (Hb <
11 g/dl) due to infestations.11 g/dl) due to infestations.
8. Degree of AnaemiaDegree of Anaemia
Mild: 8-10gm%Mild: 8-10gm%
Moderate: 7-8gm%Moderate: 7-8gm%
Severe: <7gm%IronSevere: <7gm%Iron
9. ClassificationClassification
• PhysiologicPhysiologic
• Pathologic:Pathologic:
a. Deficiency: Iron, Folic A., Vitamin B12a. Deficiency: Iron, Folic A., Vitamin B12
b. Hemorrhagic: APH, Hookwormb. Hemorrhagic: APH, Hookworm
c. Hereditary: Thalassemia, Sickle, H. Hemolytic Anemiac. Hereditary: Thalassemia, Sickle, H. Hemolytic Anemia
d. Bone Marrow Insufficiency: Aplastic Anemiad. Bone Marrow Insufficiency: Aplastic Anemia
e. Infections: Malaria, TBe. Infections: Malaria, TB
f. Chronic Renal Diseases or Neoplasm.f. Chronic Renal Diseases or Neoplasm.
10. Concept of Physiologic AnemiaConcept of Physiologic Anemia
• Disproportionate increase in plasma vol,Disproportionate increase in plasma vol,
RBC vol. and hemoglobin mass duringRBC vol. and hemoglobin mass during
pregnancypregnancy
• Marked demand of extra iron duringMarked demand of extra iron during
pregnancy especially in second trimesterpregnancy especially in second trimester
11.
12. Criteria for Physiologic AnemiaCriteria for Physiologic Anemia
• Hb: 10gm%Hb: 10gm%
• RBC: 3.2 million/mm3RBC: 3.2 million/mm3
• PCV: 30%PCV: 30%
• Peripheral smear showing normalPeripheral smear showing normal
morphology of RBC with central pallormorphology of RBC with central pallor
13.
14. Significance of HypervolumiaSignificance of Hypervolumia
1. To meet the demands of the enlarged uterus1. To meet the demands of the enlarged uterus
with its greatly hypertrophied vascular system.with its greatly hypertrophied vascular system.
2. To protect the mother, and in turn the fetus,2. To protect the mother, and in turn the fetus,
against the deleterious effects of impairedagainst the deleterious effects of impaired
venous return in the supine and erect positions.venous return in the supine and erect positions.
3. To safeguard the mother against the adverse3. To safeguard the mother against the adverse
effects of blood loss associated with parturition.effects of blood loss associated with parturition.
15. • Normal hemoglobin by gestational age inNormal hemoglobin by gestational age in
pregnant women taking iron supplementpregnant women taking iron supplement
• 12 wks12 wks 12.2 [11.0 - 13.4]12.2 [11.0 - 13.4]
• 24wks24wks 11.6 [10.6 - 12.8]11.6 [10.6 - 12.8]
• 40 wks40 wks 12.6 [11.2 - 13.6]12.6 [11.2 - 13.6]
16. Most common causes ofMost common causes of
AnemiaAnemia
• Iron loss : sweat, repeated pregnancy,Iron loss : sweat, repeated pregnancy,
hookworm infestation and malariahookworm infestation and malaria
• Faulty absorption mechanism : due toFaulty absorption mechanism : due to
high incidence of intestinal infestation,high incidence of intestinal infestation,
there is intestinal hurrythere is intestinal hurry
• Faulty diet habit : rich carbohydrate andFaulty diet habit : rich carbohydrate and
high phosphate reduce absorption of ironhigh phosphate reduce absorption of iron
17. Factors lead to develop AnemiaFactors lead to develop Anemia
• Increase iron demandIncrease iron demand
• Diminished intake of ironDiminished intake of iron
• Disturbed metabolismDisturbed metabolism
• Pre-pregnancy health statusPre-pregnancy health status
• Excess demandExcess demand
18. Remember…..!Remember…..!
Iron deficiency anemia is the mostIron deficiency anemia is the most
common micronutrient deficiency in thecommon micronutrient deficiency in the
world…world…
Most common hematological disorderMost common hematological disorder
during pregnancyduring pregnancy
19. Iron Deficiency AnaemiaIron Deficiency Anaemia
• Symptoms: lassitude, weakness, anorexia,Symptoms: lassitude, weakness, anorexia,
palpitation, dyspneapalpitation, dyspnea
• Signs: Pallor, glossitis, soft systolic murmur inSigns: Pallor, glossitis, soft systolic murmur in
mitral area due to physiologic mitralmitral area due to physiologic mitral
incompetenceincompetence
• deficiency can be classified asdeficiency can be classified as
• severe ID when the serum ferritin level is belowsevere ID when the serum ferritin level is below
20–30 μg/L and20–30 μg/L and
• mild-moderate ID if the serum ferritin level ismild-moderate ID if the serum ferritin level is
below 70–100 μg/Lbelow 70–100 μg/L
24. Normal Iron RequirementsNormal Iron Requirements
• Iron requirement for normal pregnancy is 1gmIron requirement for normal pregnancy is 1gm
200 mg is excreted200 mg is excreted
300 mg is transferred to fetus300 mg is transferred to fetus
500 mg is needed for mother500 mg is needed for mother
• Total volume of RBC inc is 450 mlTotal volume of RBC inc is 450 ml
1 ml of RBCs contains 1.1 mg of iron1 ml of RBCs contains 1.1 mg of iron
450 ml X 1.1 mg/ml = 500 mg450 ml X 1.1 mg/ml = 500 mg
• Daily average is 6-7 mg/dayDaily average is 6-7 mg/day
25. DiagnosisDiagnosis
• Full blood count and MCV value allowing theFull blood count and MCV value allowing the
diagnosis of microcytic anaemia is considered adiagnosis of microcytic anaemia is considered a
good screening tool for IDA.good screening tool for IDA.
26. Treatment OptionsTreatment Options
• Oral Iron TherapyOral Iron Therapy
• Intravenous Iron TherapyIntravenous Iron Therapy
• Blood TransfusionBlood Transfusion
• Recombinant Human ErythropoietinRecombinant Human Erythropoietin
(rHuEPO) Therapy (rHuEPO) Therapy
27. Oral Iron TherapyOral Iron Therapy
• ProphylacticProphylactic: Supplement Fe – 60 mg elemental Fe: Supplement Fe – 60 mg elemental Fe
with 500mcg folic Acid daily.with 500mcg folic Acid daily.
• CurativeCurative: 200mg FeSo4 3 times daily till: 200mg FeSo4 3 times daily till
Hb level becomes normal, thenHb level becomes normal, then
maintenance dose of 1 tab formaintenance dose of 1 tab for
100 days100 days
• widely used worldwide, the effectiveness of oral iron iswidely used worldwide, the effectiveness of oral iron is
largely compromised by lack of absorption, poorlargely compromised by lack of absorption, poor
compliance, increased adverse effects (up to 56%), andcompliance, increased adverse effects (up to 56%), and
discontinuation of treatment (up to 20%)discontinuation of treatment (up to 20%)
28. IV TherapyIV Therapy
• Available Preparations of IronAvailable Preparations of Iron
• Ferric gluconate, Iron sucrose, Iron dextran, andFerric gluconate, Iron sucrose, Iron dextran, and
Ferric carboxymaltoseFerric carboxymaltose
• iron sucrose appears to be a safe and effectiveiron sucrose appears to be a safe and effective
alternative form of treatment that is able toalternative form of treatment that is able to
rapidly restore iron stores in pregnant andrapidly restore iron stores in pregnant and
postpartum women with IDA postpartum women with IDA
29. Blood TransfusionBlood Transfusion
• Does not treat the cause of anaemiaDoes not treat the cause of anaemia
• Doesn’t treat the non hematological effects ofDoesn’t treat the non hematological effects of
Iron DeficiencyIron Deficiency
• The indications for transfusion in anaemia inThe indications for transfusion in anaemia in
pregnancy are broadlypregnancy are broadly
divided into three groups:divided into three groups:
■■ Duration of pregnancy <36 weeksDuration of pregnancy <36 weeks
■■ Duration of pregnancy >36 weeksDuration of pregnancy >36 weeks
■■ Elective Caesarean sectionElective Caesarean section
30.
31. How to calculate average IronHow to calculate average Iron
requirement in an adult patientrequirement in an adult patient
• Total Dose (mg) = 50 { 0.0442 Bwt (Hbt -Total Dose (mg) = 50 { 0.0442 Bwt (Hbt -
Hbo) + (0.26 Bwt) }Hbo) + (0.26 Bwt) }
OROR
Total Dose (mg) = 2.4 Bwt (15 - Hbo) + 500Total Dose (mg) = 2.4 Bwt (15 - Hbo) + 500
32. Megaloblastic AnemiaMegaloblastic Anemia
• Due to impaired DNA synthesis, derangement inDue to impaired DNA synthesis, derangement in
Red Cell maturationRed Cell maturation
• It may be due to Deficiency of VitB12 or FolicIt may be due to Deficiency of VitB12 or Folic
Acid or both.Acid or both.
• Megaloblastic anemia in pregnancy is almostMegaloblastic anemia in pregnancy is almost
always due to Folic Acid deficiency.always due to Folic Acid deficiency.
• Vit B12 def is rare in Pregnancy because itsVit B12 def is rare in Pregnancy because its
need is less in amount and amount is met withneed is less in amount and amount is met with
any diet that contains animal products.any diet that contains animal products.
33. Sign and symptomsSign and symptoms
• Insidious onset, mostly in last trimesterInsidious onset, mostly in last trimester
• Anorexia and occasional diarrhoeaAnorexia and occasional diarrhoea
• Pallor of varying degreePallor of varying degree
• Ulceration in mouth and tongueUlceration in mouth and tongue
• Hemorrhagic patches under the skin andHemorrhagic patches under the skin and
conjunctivaconjunctiva
• Enlarged liver and spleenEnlarged liver and spleen
34. Blood valuesBlood values
• Hb<10gm%Hb<10gm%
• Hypersegmentation of neutrophilsHypersegmentation of neutrophils
• MegaloblastMegaloblast
• MCV>100flMCV>100fl
• MCH>33pg, but MCHC is NormalMCH>33pg, but MCHC is Normal
• Serum Fe is Normal or high TIBC is lowSerum Fe is Normal or high TIBC is low
35. TreatmentTreatment
• ProphylacticProphylactic
- all woman of reproductive age should be- all woman of reproductive age should be
given 400mcg of folic acid dailygiven 400mcg of folic acid daily
• CurativeCurative
-daily administration of Folic acid 4mg-daily administration of Folic acid 4mg
orally for at least 4 wks following deliveryorally for at least 4 wks following delivery
36. Sickle cell HemoglobinopathySickle cell Hemoglobinopathy
• HbS comprises 30-40% total HbHbS comprises 30-40% total Hb
• There is substitution of Lysine for glutamic acidThere is substitution of Lysine for glutamic acid
at the sixth position of B chain of Hbat the sixth position of B chain of Hb
• Red cells in oxygenated state behave normally,Red cells in oxygenated state behave normally,
but in deoxygenated state it aggregates,but in deoxygenated state it aggregates,
polymerises and distort red cells to sickle.polymerises and distort red cells to sickle.
• These cells are more fragile and increasedThese cells are more fragile and increased
destruction leads to hemolysis, anemia anddestruction leads to hemolysis, anemia and
jaundice.jaundice.
37.
38. Effects on pregnancyEffects on pregnancy
• Increase incidence of abortion,Increase incidence of abortion,
prematurity, IUGR and Fetal loss.prematurity, IUGR and Fetal loss.
• Perinatal mortality is high.Perinatal mortality is high.
• Incidence of pre-eclampsia, postpartumIncidence of pre-eclampsia, postpartum
hemorrhage and infection is increased.hemorrhage and infection is increased.
39. ManagementManagement
• Careful antinatal supervisionCareful antinatal supervision
• Air travelling in unpressurised aircraft toAir travelling in unpressurised aircraft to
be avoided.be avoided.
• Prophylatically Folic A. 1gm daily.Prophylatically Folic A. 1gm daily.
• Regular blood transfusion.Regular blood transfusion.
