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ANAEMIA: Preventable,
Yet a Problem!!

DR. R. RAJKUMAR M.D., D.M.
CONSULTANT MEDICAL ONCOLOGIST
MADURAI MEDICAL COLLEGE
Definition
♦

Anemia - insufficient Hb to carry out O2 requirement
by tissues.

♦

WHO definition : Hb conc. < 11 gm %

♦
...
WHO Classification of Anaemia
Degree

Hb%

Moderate

7-10.9

24-37%

Severe

4-6.9

13-23%

Very Severe

<4

Haematocrit (...
Magnitude of Problem
♦

Globally, is about 30 %

♦

In developing countries &
India, incidence is around
40 – 90%.

♦

Res...
Symptoms

Irritability

Lack of
Concentration

Fatigue

Infection
Palpitation

Weakness
Dizziness
Clinical Features
Pallor of skin
And m/m

Soft ejection
systolic
murmur

Edema

Signs
Platynychia
Platynychia
Koilonychia
...
Causes of Anaemia
Physiological
Pathological
♦

Nutritional

♦

Haemorrhagic

♦

Haemolytic
Iron Requirement

Iron Absorption

∝

1
Amount of iron in the
body
Skin

Iron Loss

Urine

1-2mg/d

Feces
Menstruation

20...
Iron Requirement During Pregnancy

Early
Pregnancy

20 to 32
weeks

32 to 40
weeks
6.8 mg / day

5.5 mg / day

2.5 mg / da...
Normal Levels
Hb

13.5 – 14 gm %

R.B.C.

4.5 – 4.7 million/cu mm

Serum Iron

50 – 150 μg / dL

TIBC

300 – 360 μg / dL

...
Laboratory Diagnosis of Anaemia
IDA

Thalassemia

Chronic Diseases

Serum Iron

Decreased

Normal / Increased

Decreased

...
Nutritional Anaemia :
Major Health Problems
National Nutrition Anaemia Prophylaxis
Programme (NNAPP 1971 - 72)
Pregnancy
F...
Reason For Increased
Incidence Of Anemia
♦

Poor pre-pregnancy iron balance due to –
untreated systemic diseases & menstru...
Reason For Increased
Incidence Of Anemia
♦

Low socioeconomic status and poor hygiene

♦

Chronic malnutrition

♦

Poor av...
Complications - Pregnancy
IUGR

CCF
PIH

IUD

INFECTION

Medical
Disorder

PRETERM
LABOUR

IUH
Complications - Labour
PPH
Instrumental
delivery

MATERNAL
PERINATAL

CCF

Foetal
Distress

Morbidity
Mortality
Management Options
Pre – pregnancy :

♦ Treat the cause before conception
♦ Pre-pregnancy balanced diet, education
and hea...
Modalities of Management

Oral Iron

Parenteral

Injectable Iron

Blood
transfusion

Human Recombinant
Erythropoietin
Oral Iron
100 mg elemental Iron ------- ↑ 0.18 gm % day
-ve

Phosphate
phytate

Iron absorption
-ve
↓ Bioavailability
of I...
Oral Iron Therapy
♦

Ideal dose – 100mg per day (prophylactic)

♦

Ferrous gluconate, ferrous fumarate, ferrous
succinate,...
Absorption of Ferrous Salts
Uncontrolled Passive Absorption
♦ Iron salts are dissociated into bivalent or trivalent iron s...
Gut Lumen
Iron
salts

Mucosal Cell

Blood

Fe+3

Free Radical
Ferritin

Dissociation

Fe+2
Fe+2

Fe+2

Fe

Fe+2

Transferr...
Parenteral Therapy
I.V.

I.M.
100 mg
elemental Iron
Anaphylactic
reaction

Anaphylactic
reaction

Fractionated Irondextran...
Parenteral Therapy :
Traditional Indications
♦

Intolerance to oral iron

♦

Poor compliance to oral iron

♦

Gastrointest...
Parenteral Therapy :
Traditional Indications
♦

Inability to maintain iron balance
(haemodialysis)

♦

Patient donating la...
The

World Health Organisation
states…

‘ transfusion should be
prescribed ONLY for
conditions for which there is
NO OTHER...
Diagnosis of Folate Deficiency
Anemia (FDA)
Special considerations in diagnosis

• FDA is suspected when the expected resp...
Megaloblastic Anemia
- Diagnostic Problems
♦

HB estimation

♦

Peripheral smear

♦

MCV estimation

♦

Serum folate

♦

R...
Management of FDA
♦ Strong case for routine prophylaxis
♦ Prophylaxis with anti convulsants
♦ Continue routine oral therap...
Worm Infestations
♦ Common cause of anaemia in developing countries
♦ Most common – hookworm infestation, Round

worm, whi...
Hemoglobinopathies
A collective term for the inherited disorders
of Hb synthesis
♦ Disorders of globin synthesis e.g.

Tha...
Thalassemia
♦

Genetic disorders; lack or ↓ sed synthesis of globin
chains

♦

Two types : α & β thalassemia

♦

α chains ...
Diagnosis of Thalassemia
♦

Hb estimations

♦

Peripheral smear

♦

↓ sed MCV

♦

↓ sed MCH

♦

HbA2 (α 2δ 2)
Diagnostic Strategy for Thalassemias
Hb Electrophoresis + CBC
Abnormal band

MCV
MCH
Quantitative Hb
electrophoresis
Raise...
Sickle Cell Disease
♦

Structural Hb variant

♦

Exists in homo & heterozygous
forms

♦

Under hypoxic conditions, HbS
pol...
Take Home Message
♦ Anaemia although preventable is a global problem
♦ Anaemia still is the commonest cause of maternal mo...
Take Home Message
♦

The youth need to be educated about diet,
sanitation and personal hygiene

♦

Hookworm infestation sh...
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Anaemia dr. rajkumar ppt

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Anaemia dr. rajkumar ppt

  1. 1. ANAEMIA: Preventable, Yet a Problem!! DR. R. RAJKUMAR M.D., D.M. CONSULTANT MEDICAL ONCOLOGIST MADURAI MEDICAL COLLEGE
  2. 2. Definition ♦ Anemia - insufficient Hb to carry out O2 requirement by tissues. ♦ WHO definition : Hb conc. < 11 gm % ♦ CDC definition : Hb conc. < 11gm % in 1st and 3rd trimesters and < 10.5 gm% in 2nd trimester ♦ For developing countries : cut off level suggested is 10 gm % - WHO technical report Series no. 405, Geneva 1968 Centre for disease control, MMWR 1989;38:400-4
  3. 3. WHO Classification of Anaemia Degree Hb% Moderate 7-10.9 24-37% Severe 4-6.9 13-23% Very Severe <4 Haematocrit (%) <13%
  4. 4. Magnitude of Problem ♦ Globally, is about 30 % ♦ In developing countries & India, incidence is around 40 – 90%. ♦ Responsible for 40% of maternal deaths in third world countries. ♦ Important cause of direct and indirect maternal deaths - Vitere FE Adv Exp Med Biol 1994;352:127
  5. 5. Symptoms Irritability Lack of Concentration Fatigue Infection Palpitation Weakness Dizziness
  6. 6. Clinical Features Pallor of skin And m/m Soft ejection systolic murmur Edema Signs Platynychia Platynychia Koilonychia Koilonychia Tachycardi a Glossitis Stomatitis
  7. 7. Causes of Anaemia Physiological Pathological ♦ Nutritional ♦ Haemorrhagic ♦ Haemolytic
  8. 8. Iron Requirement Iron Absorption ∝ 1 Amount of iron in the body Skin Iron Loss Urine 1-2mg/d Feces Menstruation 20-30mg/c
  9. 9. Iron Requirement During Pregnancy Early Pregnancy 20 to 32 weeks 32 to 40 weeks 6.8 mg / day 5.5 mg / day 2.5 mg / day TOTAL 800 – 1000 mg RBC =500mg Fetus+Placenta =450mg Third stage blood loss =200mg Total = 1150mg
  10. 10. Normal Levels Hb 13.5 – 14 gm % R.B.C. 4.5 – 4.7 million/cu mm Serum Iron 50 – 150 μg / dL TIBC 300 – 360 μg / dL Transferrin saturation 25 – 50 % S. Ferritin level 30 μg / Lit Red Cell protoporphyrin 30 μg / dL Erythropoietin 15.20 U / Lit MCV 76 – 100 fL MCH 27 – 33 pg MCHC 33.37 gm / dL PCV 32 – 40 %
  11. 11. Laboratory Diagnosis of Anaemia IDA Thalassemia Chronic Diseases Serum Iron Decreased Normal / Increased Decreased TIBC Increased Normal Decreased or N Transferrin Decreased N or Increased N or Decreased Serum Ferritin Decreased N or Increased N Marrow Iron Decreased / absent N or Increased N No rise in Hb No rise Saturation Therapeutic test with Rise in Hb oral iron
  12. 12. Nutritional Anaemia : Major Health Problems National Nutrition Anaemia Prophylaxis Programme (NNAPP 1971 - 72) Pregnancy FS + FA Lactating mothers Family planning acceptors Children – 1 to 11 years Anaemia continues – Major health problem
  13. 13. Reason For Increased Incidence Of Anemia ♦ Poor pre-pregnancy iron balance due to – untreated systemic diseases & menstrual disorders ♦ Improper supplementation of iron in pregnancy ( late registration and poor follow up) ♦ Repeated childbearing ♦ Lack of awareness and illiteracy
  14. 14. Reason For Increased Incidence Of Anemia ♦ Low socioeconomic status and poor hygiene ♦ Chronic malnutrition ♦ Poor availability of iron due to predominantly veg diet, diet low in calories but rich in phytates. Food and religious taboos ♦ GI infections and infestations (e.g. Kala azar, worm infestations)
  15. 15. Complications - Pregnancy IUGR CCF PIH IUD INFECTION Medical Disorder PRETERM LABOUR IUH
  16. 16. Complications - Labour PPH Instrumental delivery MATERNAL PERINATAL CCF Foetal Distress Morbidity Mortality
  17. 17. Management Options Pre – pregnancy : ♦ Treat the cause before conception ♦ Pre-pregnancy balanced diet, education and health support. ♦ Build up iron stores during adolescent phase
  18. 18. Modalities of Management Oral Iron Parenteral Injectable Iron Blood transfusion Human Recombinant Erythropoietin
  19. 19. Oral Iron 100 mg elemental Iron ------- ↑ 0.18 gm % day -ve Phosphate phytate Iron absorption -ve ↓ Bioavailability of Iron Iron stores poor -ve Worm infestation
  20. 20. Oral Iron Therapy ♦ Ideal dose – 100mg per day (prophylactic) ♦ Ferrous gluconate, ferrous fumarate, ferrous succinate, ferrous sulphate, ferrous ascorbate citrate ♦ Rise in Hb – 0.8 gm / dl / week ♦ Side effects -G I upset most common ♦ Pt. compliance not guaranteed ♦ Ineffective in pts with worm infestations ♦ Inconclusive evidence on benefit of controlled release Iron preparation
  21. 21. Absorption of Ferrous Salts Uncontrolled Passive Absorption ♦ Iron salts are dissociated into bivalent or trivalent iron salts ♦ Diffuses as free iron ions through the upper part of the gastrointestinal mucosa ♦ Taken up by transferrin and incorporated into ferritin. ♦ For binding to ferritin and transferrin ferrous iron has to be converted into ferric iron by oxidation ♦ Highly reactive free radicals are produced during this process ♦ All ionic iron including carbonyl iron are absorbed similarly • Borbolla JR. Cicero RE, Dibilox MM, Sotres RD et al.. Rev Mex Pediatr 2000; 67(2): 63-67 • Heubers KA, Brittenham GM, Csiba E, Finch CA. J Lab Clin Med 1986 ; 108 ; 473-8.
  22. 22. Gut Lumen Iron salts Mucosal Cell Blood Fe+3 Free Radical Ferritin Dissociation Fe+2 Fe+2 Fe+2 Fe Fe+2 Transferrin Fe+2 +2 Fe+3 Fe+2 Free Radical Passive diffusion Fe+2 Fe+2 Fe+2 Fe+2 Fe+2 Fe+2 Fe+2 Fe+2 Fe+2 Fe+2 Incorporation into Hb
  23. 23. Parenteral Therapy I.V. I.M. 100 mg elemental Iron Anaphylactic reaction Anaphylactic reaction Fractionated Irondextran [Iron hydroxide dextran complex] Les s Les s ↑ Hb – 0.21 gm %
  24. 24. Parenteral Therapy : Traditional Indications ♦ Intolerance to oral iron ♦ Poor compliance to oral iron ♦ Gastrointestinal disorders ♦ Malabsorption syndromes ♦ Rapid blood loss
  25. 25. Parenteral Therapy : Traditional Indications ♦ Inability to maintain iron balance (haemodialysis) ♦ Patient donating large amount of blood for auto-transfusion programme ♦ ? Pregnant women with severe IDA, presenting late in pregnancy
  26. 26. The World Health Organisation states… ‘ transfusion should be prescribed ONLY for conditions for which there is NO OTHER TREATMENT’
  27. 27. Diagnosis of Folate Deficiency Anemia (FDA) Special considerations in diagnosis • FDA is suspected when the expected response to adequate iron therapy is not achieved • Macrocytosis can occur in pregnancy in absence of FDA • If FDA + IDA present, it will be masked by IDA • Definitive diagnosis – Bone marrow aspirate
  28. 28. Megaloblastic Anemia - Diagnostic Problems ♦ HB estimation ♦ Peripheral smear ♦ MCV estimation ♦ Serum folate ♦ Red cell folate ♦ FIGLU estimations ♦ Marrow aspirate
  29. 29. Management of FDA ♦ Strong case for routine prophylaxis ♦ Prophylaxis with anti convulsants ♦ Continue routine oral therapy for hemolytic anaemia ♦ Parenteral therapy for severe deficiency
  30. 30. Worm Infestations ♦ Common cause of anaemia in developing countries ♦ Most common – hookworm infestation, Round worm, whip worm, etc. ♦ Oral iron therapy becomes ineffective ♦ Treatment by antihelminthics is a must Treatment ♦ Mebendazole : 100mg twice daily for three days ♦ Pyrantel pamoate : 10mg / kg in single dose. ♦ Albendazole : 400mg once a day for three days
  31. 31. Hemoglobinopathies A collective term for the inherited disorders of Hb synthesis ♦ Disorders of globin synthesis e.g. Thalassemia ♦ Structural Hb variants e.g. Sickle cell anemia, HbC
  32. 32. Thalassemia ♦ Genetic disorders; lack or ↓ sed synthesis of globin chains ♦ Two types : α & β thalassemia ♦ α chains encoded by 2 pairs of genes on chromosome 16 ♦ β chains encoded by single pair of genes on chromosome 11 ♦ β thalassemia more common and presents as either β °(major) or β + (minor)
  33. 33. Diagnosis of Thalassemia ♦ Hb estimations ♦ Peripheral smear ♦ ↓ sed MCV ♦ ↓ sed MCH ♦ HbA2 (α 2δ 2)
  34. 34. Diagnostic Strategy for Thalassemias Hb Electrophoresis + CBC Abnormal band MCV MCH Quantitative Hb electrophoresis Raised Hb A2 B Thalassemia Normal No action Examine partners blood ↓sed Normal ?X Thalassemia DNA analysis for x gene defects
  35. 35. Sickle Cell Disease ♦ Structural Hb variant ♦ Exists in homo & heterozygous forms ♦ Under hypoxic conditions, HbS polymerizes, gels or crystallizes. ♦ ∴ hemolysis of cells, & thrombosis of vessels in various organs ♦ In long standing cases, multiple organ damage.
  36. 36. Take Home Message ♦ Anaemia although preventable is a global problem ♦ Anaemia still is the commonest cause of maternal mortality and morbidity in spite of easy diagnosis and treatment ♦ Anaemia can be due to a number of causes, including certain diseases or a shortage of iron, folic acid or Vitamin B12. ♦ The most common cause of anemia in pregnancy is iron deficiency. ♦ Iron therapy is best given orally
  37. 37. Take Home Message ♦ The youth need to be educated about diet, sanitation and personal hygiene ♦ Hookworm infestation should be treated ♦ Pregnant women should be given Iron and folate supplements

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