Anaemia in pregnancy


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Anaemia in pregnancy

  1. 1. ANAEMIA IN PREGNANCY Desabandu Dr. G.H.K.K. Gunawardana M.B.B.S.,M.S.(Obs & Gyn), F.R.C.O.G.,F.C.O.C.(S.L ) Consultant Obstetrician and Gynaecologist Teaching Hospital, Peradeniya.
  2. 2.  A common and world wide problem that deserves more attention. Over half of the pregnant women in the world are anaemic. For many developing countries prevalence rate is up to 75% (WHO) Not only it is common it is often severe. In developed countries the average prevalence is 18% (WHO)
  3. 3. Prevalence of anaemia in pregnant women by WHO region, 1998
  4. 4. Contribute significantly to maternal mortality and morbidity. WHO estimates that anemia contributed to approximately 20% of the maternal deaths worldwide in 1995 in combination with maternal haemorrage.
  5. 5. WHO Definition Haemoglobin concentration <11.0g/dl in the first half of the pregnancy and <10.5g/dl in the second half. It is further divided in to, Mild 10.0-10.9 g/dl Moderate 7.0 - 9.9 g/dl Severe <7.0 g/dl
  6. 6. Causes of Anaemia in Pregnancy  Nutritional anaemias – Iron deficiency Folate deficiency B12 deficiency  Chronic blood loss – Haemorroids, GI bleeding  Short birth intervals  Infections – HIV Malaria  Haemotological conditions – Leukemia Sickle cell disease Thalasaemia
  7. 7. Normal Physiological Changes in Pregnancy Plasma volume expands by 46-55% Red cell volume expands by 18-25% Haemodilution “Physiological Anaemia of Pregnancy” not considered abnormal unless the levels fall too low.
  8. 8. Effects of Anaemia in Pregnancy Increased risk of abortions Increased risk of premature labour Increased risk of IUGR Increased risk of mortality following PPH Increased risk of puerperal sepsis
  9. 9. Risk Factors Associated with:  Twin or multiple pregnancy  Poor nutrition, especially multiple vitamin deficiencies  Smoking, which reduces absorption of important nutrients  Excess alcohol consumption, leading to poor nutrition  Any disorder that reduces absorption of nutrients  Use of anticonvulsant medications
  10. 10. Screening Clinical inspection of conjunctiva for the presence of pallor -simple -but low sensitivity except when Anaemia is severe
  11. 11. Diagnostic Procedures  Haemoglobin level  Haemotacrit  Erythrocyte indices  Blood picture  Serum ferritin All pregnant women should have at least one Hb measurement during the cause of pregnancy.
  12. 12. Signs and Symptoms May not have obvious symptoms unless the cell counts are very low.  Common Symptoms:  Tiredness, weakness or fainting.  Paleness-skin, lips, nails, palms  Breathlessness  Occasional Symptoms:  Headache  Nausea  Inflamed, sore tongue  Palpitations or an abnormal awareness of the heartbeat  Forgetfulness  Jaundice (rare)  Abdominal pain (rare)
  13. 13. Iron Deficiency Anaemia The most common type of anemia in pregnancy. Responsible for 95% of anemia of pregnancy. Causes -poor dietary intake -hookworm, schistosoma infestations
  14. 14. Diagnosis of Fe Deficiency Anaemia Low Hb Low MCV, MCH, MCHC Blood picture – RBCs microcytic hypochromic with anisocytosis and poikilocytosis Reduced S. Ferritin level Hypochromic Microcytic Anaemia
  15. 15. Treatment for Fe Deficiency Anaemia  Oral iron supplementation is the first line of management  A high iron diet should be recommended where possible.  Parenternal iron therapy carry a risk of anaphylactic reaction. Their use should be reserved only for severe cases.  Treatment depends on - The type and severity of anemia. - Duration of pregnancy - Complication of pregnancy
  16. 16. Available Fe Preparations Elemental Tablet Iron Ferrous sulphate 200mg 65mg Ferrous gluconate 300mg 35mg Ferrous fumerate 300mg 65mg Choice of preparation depends on cost and side effects.
  17. 17. Adverse Effects of Fe Supplements Lead to poor compliance GI irritation - Nausea and vomiting - Epigastric pain Long term therapy cause - Constipation - Dark stools
  18. 18. Ways to overcome poor compliance Take the iron with or after food  Start with a low dose and increase gradually Change the preparation e.g.- liquid preparation
  19. 19. Parenternal Fe Therapy Indications Reserve for use when oral Fe therapy fails due to intolerance When quick response needed e.g. Late pregnancy Continuing blood loss Malabsorption Poor patients compliance
  20. 20. IM Fe Therapy Preparations - Iron sorbitol - Iron dextran - Lesser chance of anaphlaxis and toxicity
  21. 21. Adverse Effect of IM Fe Therapy Very pain painful, muscle necrosis can occur o Staining of skin o Headache, dizziness, disorientation o Nausea, vomiting, metallic taste in mouth o Arrhythmias
  22. 22. IV Fe Therapy Preparation used – Iron dextran Not unpleasant Given as an infusion Anaphylaxis can occur Other side effects Headache, malaise, fever, nausea, vomiting, arthralgia, urticaria
  23. 23. Blood Transfusion Indication Severe Anaemia presenting in the latter part of pregnancy Packed cells are given with mid transfusion frusemide Should be cautious on cardiac failure
  24. 24. Folate deficiency Folate deficiency in pregnancy is often associated with iron deficiency since both folic acid and iron are found in the same types of foods. Megaloblastic Anaemia Low Hb Low reticulocyte count Hyper segmented neutrephils Macrocytes High MCV
  25. 25. Vitamin supplements containing 400 mcg of folic acid are now recommended for all women of childbearing age and during pregnancy. These supplements are needed because natural food sources of folate are poorly absorbed and much of the vitamin is destroyed in cooking.
  26. 26. Vitamin B12 deficiency  Women who are vegans (who eat no animal products) are most likely to develop vitamin B12 deficiency.  Including animal foods in the diet such as milk, meats, eggs, and poultry can prevent vitamin B12 deficiency.  Strict vegans usually need supplemental vitamin B12 by injection during pregnancy.
  27. 27. Prevention of Nutritional Anaemia in Pregnancy  Good pre-pregnancy nutrition not only helps prevent anemia, but also helps build other nutritional stores in the mother's body.  Eating a healthy and balanced diet during pregnancy helps maintain the levels of iron and other important nutrients needed for the health of the mother and growing baby
  28. 28. Strategies Education about nutrition, food preparation and dietary modification Prophylactic administration of haematanics Access to family planning information, education and services
  29. 29. Dietary Education  Food that enhance Fe absorption Food that contain Vit C Family of citrus- lemon, lime, oranges Raw vegetables  Food that decrease Fe absorption Tea Antacids Methyldopa Calcium
  30. 30. Haem iron, which is well absorbed and is contained in foods of animal origin. Non-haem iron, which is poorly absorbed and is contained in foods of plant origin. Haem Fe absorption is not affected by presence of food. Presence of haem iron in food enhance the absorption of non-haem iron.
  31. 31. Good food sources of iron include the following:  meats - beef, pork, lamb, liver, and other organ meats  poultry - chicken, duck, turkey, liver (especially dark meat)  fish - shellfish, including oysters, sardines, and anchovies  leafy greens of the cabbage family, such as broccoli, turnip greens, and collards, spinach  legumes, such as green peas dry beans and peas, such as pinto beans, black-eyed peas, and canned baked beans  yeast-leavened whole-wheat bread and rolls  iron-enriched white bread, pasta, rice, and cereals
  32. 32. Food sources of Folate include the following: leafy, dark green vegetables dried beans and peas citrus fruits and juices and most berries fortified breakfast cereals enriched grain products
  33. 33. Prophylactic Administration of Haematanics  Iron absorbed from dietary sources, along with mobilized iron stores, is usually insufficient to meet iron requirements during pregnancy  WHO recommends routine oral supplementation of 60 mg elemental iron plus 400 mcg folic acid daily for 6 months during pregnancy in areas where the prevalence of anemia in pregnancy is < 40%. In areas where the prevalence of anemia in pregnancy is > 40%, it recommends the same dosages for 6 months and continuing for 3 months postpartum.
  34. 34. References British Medical Bulletin 67:149-160 (2003) Anaemia and micronutrient deficiencies Reducing maternal death and disability during pregnancy ITO Textbook Chapter 2: Management of Iron Deficiency Anemia in Pregnancy and the Postpartum-Christian Breymann