regarding anaemia in pregnancy effects of anaemia on pregnancy

1. Anaemia in pregnancy

2. Definition
• Anemia - insufficient Hb to carry out O2
requirement of the tissues.
• WHO definition : Hb conc.  11 gm %
• CDC definition : Hb conc. < 11gm % in 1st and
3rd trimesters and < 10.5 gm% in 2nd trimester
• ICMR def: Hb <10 gm %

3. Degree Hb% Haematocrit (%)
Moderate 7-10.9 24-37%
Severe 4-6.9 13-23%
Very Severe <4 <13%
WHO Classification of Anaemia

4. • Grading –
– Mild Hb between 8-11 gm %
– Moderate Hb between6.5 -<8 gm %
– Severe Hb less than 6.5 %
• Classification
 Nutritional
 Due to increased blood loss
 Due to haemolysis
 Others

5. Nutritional
a) Iron deficiency
b) Folate deficiency
c) Vitamin B12 deficiency
Due to increased blood loss
hookworm infestation common
 Due to haemolysis
haemoglobinopathies , malaria
Others

6. Nutritional anaemia( etiology )
Iron def
• Inadequate
food intake
• Poor
bioavailabilit
y of iron
intraditional
indian diet
Folate def
• Folic acid water
soluble & heat labile
, destroyed on
cooking
• Folate rich food
uncommon and
expensive
• Average diet folate
deficent
Vit B12 def
• Rarer
inadequat
e intake
in veggies
• Poor
absorptio
n

7. Iron requirement
• Total iron loss in pregnancy – 1230 mg
Fetus 300 mg
Placenta 50 mg
Increased red cell mass 410 mg
Basal losses 220 mg
Maternal blood loss at delivery 250 mg
• Total iron conserved -410 mg
• Net requirement in pregnancy -800 mg

8. Early
Pregnancy
2.5 mg / day
32 to 40
weeks
6.8 mg / day
TOTAL
800 – 1000 mg
20 to 32
weeks
5.5 mg / day
RBC =500mg
Fetus+Placenta =450mg
Third stage blood loss =200mg
Total = 1150mg
Iron Requirement During Pregnancy

9.  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
Absorption of Ferrous Salts
Uncontrolled Passive Absorption

10. Fe+2
Fe+2
Fe+2
Fe+2
Dissociation
Passive diffusion
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2 Fe+2
Gut Lumen Mucosal Cell Blood
Ferritin
Iron
salts
Fe+3
Free
Radical
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2
Fe+3
Free
Radical
Transferrin
Incorporation
into Hb

11. PATHOPHYSIOLOGY OF IRON DEF
ANEMIA
• Divided into 3 stages depending on
– Time
– Course
– extent of iron def.
• Depletion of iron stores
• Deficient erythropoiesis
• Frank iron deficiency anaemia

12. •Depletion of iron stores-earliest manifestation
Storage forms of iron –ferritin & haemosiderin
Determined by measuring
serum ferritin level in blood
Haemosiderin level in bone marrow
•Deficient erythropoiesis
Iron def. leads to accumulation of protoporphyrins that
cannot be converted to Hb
Serum iron & saturation of transferrin reduced
 protoporphyrins level sensitive marker of iron def.
erythropoiesis .
Determined by lab tests
•Frank iron deficiency anaemia
Microcytosis
Hypochromia
Low HB level

13. Folate & Vit B12 def
Folate & b12 essentialfor DNA synthesis
Def. leads to deficient DNA synthesis
Nuclear maturation lags behind cytoplasm
Megaloblastic erythropoiesis

14. Clinical features
• Symptoms
– Insidious in onset ,nonspecific in nature
– Fatigue ,anorexia, lassitude, breathlessness,dyspnoea
– Inadvanced stages-generalised oedema, heart failure
• Signs
– Pallor, oedema, haemic murmur, koilonychia, brittle
hair,glossitis, angular stomatitis
– Jaundice,spleenomegaly
• Signs and symptoms of underlying chronic illness such
as renal disease ,T.B. etc

15. Infectio
n
Lack of
Concentration
Weakness
Irritability
Palpitatio
n
Fatigue
Dizziness
Symptoms

16. Pallor of skin
And m/m
Edema
Platynychia
Koilonychia
Glossitis
Stomatitis
Tachycard
ia
Soft ejection
systolic
murmur
Signs

17. Conjunctival Pallor

18. pallor

19. Koilonychia

20. Smooth Tongue

21. Effects of anaemia
Maternal effects
More prone to
 Intercurrant infections
 Preterm labour
 PIH
 Obstetric shock
 Abruptio placentae
 CCF
Fetal effects
At risk of
 Prematurity
 still birth
 Neonatal anaemia
 IUGR

22. Management
• History
Age
Parity
Diseases –hookworm
infestation,ch illness ,malaria
Dietetic history
Ch bleeding -bleeding
disorders,prior
menorraghia,prior use of IUCD,
Previous obstetric
historymultiple preg&
abortion
Race- certain races suffer from
haemoglobinopathies
&hereditary anemias
History & clinical
exam to rule out
predisposing
factors &
underlying
conditions

23. Investigations
• Blood indices
• Urine examination
• stool examination
• Bone marrow examination
• BUN/Serum Creatinine
• Chest Xray
• SPECIAL Investigations

24. Blood indices
 Haemoglobin
 Mild -8-11gm%
 Moderate 6.5-8gm%
 Severe <6.5 gm%
 RBC count-
 Normal >3.2 million/cumm
 Decreased in anaemia
 PCV
 Normal >37-47%
 Decreased in anaemia<32%
 MCV
 Normal >78-92 cu microns million/cumm
 Low value in m icrocytic anaemia
 High value ( 110-140 cu microns) in maicrocytic anaemia (
 MCHC –( most sensitive index of Iron def anaemia )
 Normal -26-30 %
 Decreased in iron def .anaemia
 Normal value in megaloblastic anaemia .
 Peripheral smear

25. Peripheral smear
Typical Findings Include
• Microcytic & hypochromic cells
– Iron def anaemia
• Macrocytic cells,hypersegmented neutrophils >5 lobes
– Folate /Vit.B12 def
• Schisto/aniso&poikilocytes
– Hemolytic anaemia
• Sickle cells
– sickle cell anaemia
• Decreased platelets may be seen
• Target cells
– in Thalassemia
• Parasites such asplasmodium /Leishmania

26. Investigations
• Urine examination
– Evidence of
– haematuria /Ch.renal
disease
• Stool examination
– Parasites,(Ova ,hookworm)
– Occult blood
– Steatorrhoea
•Blood examination
BUN/S.creatinine-
to rule out renal disease
•Bone marrow
examination
Incase of
refractory/atypical
anaemia
•Chest Xray
To rule out T.B.

27. Special investigations
Iron def. anaemia
1. S. Ferritin 40-160 ng /dl
(abnormal <20ng/dl)
2. S. Iron 65-165µg/dl
Decreased in anaemia
3. S.iron binding capacity-TIBC
300-360µg/dl
Value increased with severity of anaemia
4. Transferrin saturation
35-50%--normal
Decreased to less than 20 % in anaemia
5. RBC protoporphyrin
30-µg/dl
Value doubled or tripled in Iron def anaemia

28. Laboratory Diagnosis of Anaemia
IDA Thalassemia Chronic Diseases
Serum Iron Decreased Normal /
Increased
Decreased
TIBC Increased Normal Decreased or N
Transferrin
Saturation
Decreased N or Increased N or Decreased
Serum Ferritin Decreased N or Increased N
Marrow Iron Decreased /
absent
N or Increased N
Therapeutic test
with oral iron
Rise in Hb No rise in Hb No rise

29. Management Options
Pre – pregnancy :
• Build up iron stores during adolescent phase
• Treat the cause before conception
• Pre-pregnancy balanced diet, education and health
support.

30. Management
• Choice of therapy depends on –
– Severity of Anemia
– Duration of pregnancy
– Associated factors
• Dietary advice
• Prophylactic supplementation
• Iron therapy

31. • Dietary advice
– Iron rich foods :eggs,liver,shrimps
,cereals,beans,green leafy vegetables (spinach,
coriander,fenugreek)
– Folate rich foods:yeast, meat,liver, legumes,
broccolli,asparagus,mushrooms,milk,cheeses,eggs

32. • Prophylactic supplementation
– Iron-60mgof elemental iron/day
– Folate -5mg /day
• Iron therapy
– Oral
– Parenteral
• IV
• IM