Dr. Rabi Narayan SatpathyAsst. professorDept. of Obst. & gynaecologySCB MEDICAL College, CuttackMob-09861281510
Major Public Health Problem Most Preventable Cause Still the Leading Cause
Developing Countries: World 9 out of 11 pt are anemic.population: 5-6 billion Every second preg. Woman 2 billion anemic 4 out of 10 pre school MAGNITUDE OF THE PROBLEM India: Highest prevalence 87% preg women 10% severe anemia 1 in 5 maternal deaths
ANNUAL MATERNAL DEATHS - GLOBALLY TOTAL 500,000 India South Asia Rest South Asia Rest India75% : Hemorrhage ; Abortion ; Eclampsia ; Sepsis ; Obs. Labour.ANAEMIA : Direct cause contributes 20% Indirect cause further 20%
Fe++ Fe++ Fe++ Iron Metabolism – Fe++ Fe++ The Concept Fe++Fe++ Fe++ Is it Very Confusing !!!
EXTERNAL IRON EXCHANGE Non-haem Iron Haem Iron Inorganic Organic Inhibitors •Phytates.Fascilitators Efficient •Tannin. independent of•Ascorbate •Antacid duodenal pH•Gastric pH •P-pump inhibitors•Citrate Competitors•AA •Pb. •Mn. •Zn. C Luminal Cell of Duodenum & CFe++ JejunumFerrousMore soluble FerritinAcidic duodenal pH PLASMA TRANSFERIN
Normal men 1 mg/dayMenstruating females 2 mg/day Pregnant women 4.8 mg/day Adolescent 1-2 mg/day
INTERNAL IRON EXCHANGE (IRON CYCLE) Bone marrow erythroid cells RBC Transferrin – 120 days Iron Complex R-E system Transferrin Haemosiderin receptor (Stable) can’t be mobilizedGut Liver Ferritin
Demand by fetus Net utilisation is 800 mg Twin. IronAbsorption Increase << Bioavailability of iron is decreased. Inadequate calorie intake < 2,000 Kcal/day. Increase in plasma & RBC volume.
Age group < 20 yrs. Low SE status. Literacy. Parity > 2. Sparing 2 yrs. Malnutrition. Vegetarian diet – mostly cereal & pulse. Worm infestation. Unemployment of women, poverty.
Reliable, Cost effective, Easy Indicator of Anemia WHO standardisation of Anemia g/dl g/l PCV Mild < 11 < 110 Moderate 6.5-8 70-109 24-37 Severe < 6.5 40-69 13-23Very severe <4 < 40 < 13
Decrease Hb Anemia Story Behind Negative Iron Balance. Iron deficient erythropoiesis. Iron Deficiency Anemia (IDA).
Normal Negative Iron deficient Iron deficiency iron balance erythropoiesis anemia BM Iron Stores Hb% S. Ferritin 50-200 ( g/l) <15 TIBC 300-360 > 400 ( g/dl) S. Iron 50-150 N ( g/dl)Saturation 30-50 N (%) RBC Nprotophyrin RBC Microcytic N Nmorphology hypochromatic
Degree of SymptomsAnemiaMild Mod Irritabilit y Fatigue Severe Weaknes Dizziness s
Vulnerable Groups Problems Maximum Iron required Infant (4-24m) equivalent to adult dose Worm infestation, UTI, Growing girl child epistaxis, pelvic infection, chronic malaria, tuberculosis Puberty menorrhagia, Adolescent girl infection, malnutrition
Non-haem IronHaem Iron EggOrgan meats. Diary products.Poultry. Dried beans, peas.Fish. Dark green leafyOysters. vegetablesBeef. (spinach, mustardPork. greens). People who are iron deficientsesame seeds Nuts & absorbs 10 times more than normal subjects. Vit. C → Citrus fruits, lemon, tomatoes. Cooking in cast iron pans & utensils.
Respect to girl child.Education of girl child.Equal rights.Mid-day meal programmes.Personal hygiene.Marriage after 18.Safe abortion.Worm infestation.Malaria.
National Nutritional Anemia Prophylaxis Programme (NNAPP) Aims at Universal Oral Iron Supplementation of All Pregnant Women 60 mg/ 100 mg/ 120 mgAs Recommended by WHO & implemented by GOI 100 mg of Iron x 100 days
1st trimester 2nd trimester 3rd trimester < 11 g/dl 9 – 11 g/dl 200 mg 200 mgElemental Iron Elemental IronReassessment Monitoring on 2nd & 3rd Maintenance Therapy < 9 g/dl Lab. Test: CBC (PS), Iron Studies, BM studies, Opinion of Hematologist IDA: 200 mg Elemental Iron Monitoring
IUGR CCF PIH INFECTIONIUD IUH Medical PRETERM Disorder LABOUR
Iron & Ascorbic Acid.Vit. C enhances the absorption of iron.Fewer side effects.Better tolerated.Good bioavailability.
Small Iron Particles - 5 mFerric hydroxidepolymaltose complex. Slow absorption.Expensive. Good bioavailabilityBioavailability Least GI side effectcontroversial. Environment stability. Seems to be promising in rise of Hb status.
PROBLEMS WITH ORAL IRON Gastric irritation Diarrhea Constipation Free Radical Generation
If a child consumes 3 adult iron tablets,acute fatal iron poisoning can occur.
Highly controversial.High side effects & adverse reaction.Should have hematology consultation. I.V. (TDI) / I.M. Iron Dextran (Imferon) Recent: IV Sodium ferric gluconate. Iron sucrose. Used with recombinant erythropoietin therapy.
??? to raise Hb in last trimester Acute blood loss. Preparation of cesarean. Obstetric complications.
It is paradoxical but true,that anaemia ispreventable condition,however due to itsmultifactoral origin wecould not conquer it andeven today it remains oneof the major cause ofmaternal mortality.
DREAMING PREGNANT WOMAN FREE OFNUTRITIONAL ANEMIAKeep the lamp of knowledge burning to achievethe vision. Only the vision will ignite the billionsouls. Ignited soul is the most powerful resourcemaking dream to reality. A. P. J. Abdul Kalam