The document emphasizes the urgent need for improving hemoglobin levels in pregnant women through comprehensive strategies addressing iron deficiency anemia (IDA) in India, such as prophylactic iron supplementation and public awareness campaigns. It highlights alarming statistics from the National Family Health Survey showing increased anemia rates across various demographic groups, particularly children and pregnant women. Additionally, it discusses treatment approaches, including the use of specific iron preparations like ferrous ascorbate, and the importance of addressing both nutritional and non-nutritional causes of anemia.

1. Is the NEED of TODAY
Dr. Sharda Jain
Gynaecologist to focuss on
*12 gm Haemoglobin
at Delivery
* Which Oral preparation in IDA
Anemia Free India

2. 2018 AMB
Anemia +Kuposhan in vulnerable groups
6X6X6
strategy
Six target
beneficiaries
Six
interventions
Six
institutional
mechanisms

3. Important Highlights
• Prophylactic Iron and Folic Acid Supplementation in all six target age groups.
• Intensified year-round Behaviour Change Communication (BCC) Campaign for:(a)
improving compliance to IFA and deworming, (b) enhancing appropriate infant and young child
feeding practices, (c) encouraging increase in intake of iron-rich food through diet and/or
fortified foods (d) ensuring delayed cord clamping .
• Testing and treatment of anaemia, using digital methods and point of care treatment, with
special focus on pregnant women and school-going adolescents.
• Addressing non-nutritional causes of anaemia
in endemic pockets with special focus on malaria, hemoglobinopathies and fluorosis

4. Important Highlights
• Management of moderate to severe anaemia in pregnant women
undertaken by administration of IV Iron FCM / Sucrose/Blood
transfusion.
• Providing incentives to the ANM for identification and follow-up of
pregnant women with severe anaemia in high priority districts (HPDs).
• Training and orientation of all Doctors /Medical Officers and front line-
workers on newer Maternal Health and Anaemia Mukt Bharat guidelines.
• Field level awareness by ASHAs through community mobilization
activities and IEC and BCC activities

5. Following 2021 National Family Health
Survey 2019-2021 INTENSIFIED

6. ANAEMIA : its prevalence across age and
gender group has increased.
Aneamia has increased by 2-9% among
children -67, Adol-59
Pregnant -52 ,women-57 and men-25/31
National Family health survey 5 (NFHS-5)
2021

7. The largest spike is seen in
children between
6months and 59 months,
67.1 % are Anaemic ,
DELHI -69 %

8. In rural India , 68.3%
children are Anaemic ,
while the urban India
its stands at 64.2 %
according to NFHS-5

9. The Second highest increase in
adolescent girls
15 and 19YEARS ,
59% in NFHS 5.
rural areas (60.1 %)
V/S urban areas (56.5%)

10. All womenbetween the ages of
15 and 49 years reported a four % increase
in incidence of Anaemia
57%

11. PREGNANCY : The % of
pregnant women between
the ages of 15 and 49 years
who are anemic
 52.2%
2019 – 21

12. MEN , between the ages of 15 and 49 – up to 25%
younger men , between 15 and 19 increase to 31%

13. WHO. The global prevalence of anaemia in 2011. Geneva: World Health Organization;2015.
Anemia affects around 2 billion children and women globally
INDIA USP
:anaemia/
Malnutrition
Anemia: A Global Burden

14. Work performance
Child development
School PerformanceIQ
Child mortality
Maternal mortality
Perinatal mortality
Other factors
A new conceptual model of IDA and its effects.
Tissue Iron
Deficiency (mild)
Moderate&
Severe
Anemia

15. DEFINITION OF ANAEMIA
Greek word – LACK OF BLOOD
• Decrease in no. of RBC’s, or
• Decrease in Hb, or
• Decrease in oxygen carrying capacity of Hb molecule
• BRAIN -20% of total oxygen

16. weakness
&
fatigue

17. • SYMPTOMS AND SIGNS WHICH
WE IGNORE DARK KNUCKES
• IMPLICATION ON MOTHER AND FETUS
ARE WELL KNOWN TO OUR OBSTETRICIAN AND GYNAECOLOGIST

19. HB –CUT OFFS
• WHO recommendation (2001)
Hb concentration should not fall below 11.0g/dL (Hct < 33%) anytime
during pregnancy
*Mild 10-10.9g/dL * Moderate 7 - 9.9g/dL
*Severe <7g/dL * Very Severe <4g/dL
INDIAN DOCTORSshould aim at 12 gm
in pregnancy too to save
Life from 2-5 % ACUTE BLD Loss & PPH
GOI HB 8 GM% AT LSCS

20. 18- 20% Direct , another 20% Indirect deaths
Nothing is more expensive than a missed opportunity! –TOTREAT
just bcz of our callous Attitude & NO Policy of RED FLAG Aproach
ANEMIA DEATHS : UNCHANGED FOR 5 DECADES

21. Anaemia
Death
Beyond numbers!
For every maternal death, there are 30 more who ‘almost died’.

22. TREND IN LAST 70 YEARS
1964 90%
2000 88 %
2021 52 %

23. Source: India Development and Participation by Jean Dreze and Amartya Sen, OUP 2002
ANAEMIA IN PREGNANCY - 2002

24. National Family Health survey 4 MoHFW 2021
Anemia in Women: Declined in most states from NFHS-3 to
NFHS-4,but still remains high
Anaemia among Children and Adults NFHS 4 (2015-16) NFHS 5(2)
Urban (%) Rural (%) Total (%) Total (%)
Non-pregnant women age 15-49 years
(<12.0 g/dl)
51.0 54.3 53.2 57.2
Pregnant women age 15-49 years
(<11.0 g/dl)
45.7 52.1 50.4 52..2
All women age 15-49 years 50.8 54.2 54.1 59.1
National Family Health Survey - 5 (2021) data

25. ANAEMIA
FREE
INDIA
IDIA
INCREASE In anemia NOT ACCEPTABLE that too
>50 % -------2047 < 5 %

26. Diagnosis of Iron Deficiency Anemia

27. There is long list of causes of IDA
Physiological
- INFANCY
- ADOLESCENCE IN GIRLS
- PREGNANCY
- Regular blood donation
- Being an elite athlete
Blood Loss
- Digestive tract :Malignancy, IBD, Ulcers
- Gynecological loss
- Surgery
- Hematuria, Epistaxis, Hemoptysis
- Hemodialysis
Malabsorption
- Gastrectomy
- H. Pylori
- Gut resection, atrophic gastritis,
- Bypass gastric surgery
- Proton pump inhibitors,H2 antagonists
-Parasite infestation
IDA associated with chronic diseases
- Chronic heart failure
- Cancer
- Chronic kidney disease
- Rheumatoid arthritis
- Obesity
- Inflammatory bowel diseases
Lancet 2016; 387: 907–16

29. REVIVE PB Smear + Don,t forget hemolytic
• Complete Blood Count with peripheral smear examination
(Type of Anemia ) macro/micro/normo/dimorphic /hemolytic
/pancytopenia.
it is good to do digital HB
& counsel on Rx before
patients leaves the clinic

30. CBC PARAMETERS
PARAMETER UNITS NORMAL RANGE
HEMOGLOBIN gm/dl 11.5 -15.0
TOTAL LEUCOCYTE COUNT cu/mm 4000 -10500
DLC P_L_E_M_B_ %
R.B.C.COUNT million/cum 4.5 – 6.0
PLATELET COUNT lakhs/cum 1.50 -4.00
P.C.V. % 37 – 47
M.C.V. fl 78 – 94
M.C.H. pg 27 – 32
RDW H% 10 – 15
M.C.H.C. g/dl(%) 32 – 38
ESR mm/1st hr 00 – 15
PERIPHERAL SMEAR

31. IDA VERSUS THALASEMIA
MENTZER’S INDEX
MCV/ RBC
< 14 THALASEMMIA
> 14 IDA

32. CBC PARAMETERS IDA THALASSEMIA
RBC count < 5 million/ml >5 million /ml
RDW >14 <14
Mentzer’s Index >14 <14
MCV
MCH
MCHC NORMAL

33. Approach to a pregnant woman presenting with IDA
Stable Patient
History, examination and investigations to find out the severity
type, and cause of anemia CBC with P/S, serum iron studies,
serum folate vit B12, HPLC, KFT, LFT, urine routine and
microscopy, stool examination.
USG for fetal biometry and growth
CAUSES OF CHRONIC ANEMIA Nutritional anemia Pernicious
anemia Hemoglobinopathies ,Intrinsic red blood cell deficiency,
Metabolic disorders, Infections Chronic blood loss,
Malabsorption syndromes
Treat according to the severity. cause of anemia and the
gestational age

34. Unstable patient
Approach to a pregnant woman presenting with ANEMIA
Comprehensive history, general physical examination, systemic examination, per abdomen
examination, per speculum and per vaginam , indicated. Relevant investigations CBC with P/S, KFT.
LFT, Serum electrolytes, Urine examination. and culture, USG abdomen and pelvis
Early pregnancy Late pregnancy
Hemorrhagic shock
Acute ruptured ectopic pregnancy
Abortion complications
Molar pregnancy
Ruptured corpus luteum cyst
Nonhemorrhagic shock
Septic shock
Pyelonephritis
Neurogenic shock
Ovarian torsion
Cardiogenic shock
Heart disease
Anaphylactic shock
Hemorrhagic shock
Abruptio placentae
Placenta pravia
Uterine rupture
Broad ligament hematoma
Nonhemorrhagic shock
Septic shock:
Chorioamnionitis
Pyelonephritis
Neurogenic shock
Ovarian torsion
Cardiogenic shock
Heart disease
Anaphylactic shock
Treatment according to the cause

35. Management Of
Anaemia in Pregnancy

36. Hb ≥ 11 g%
Hb < 11 g%
CBC *, **,***
Prophylactic IFA
(60 mg+0.5 mg) 1 tab OD
* MCV< 80 MCH< 27
Mentzer index < 13 (MCV/RBC count)
do HPLC to R/O Thalassemia
** MCV> 100 do serum Vit B12 and
folic acid add supplements accordingly
Start therapeutic IFA
(60 mg+0.5 mg) 1 tab BD with
counselling on how to take iron
and calcium tabs
Dietary counselling
Investigate
CBC with PS
If Hb< 10 g/dl Serum Ferritin, Vit
B12, Folic acid (if available)
Repeat Hb after 1 month
Hb improves by
≥ 1 g/dl
Hb < 1 g/dl or
no increase
Continue oral
iron therapy and
repeat Hb after
1 month
Serum Ferritin < 15
Microcytic
hypochromic
Mentzer index > 13
Hb ≥ 11 g%
Consider parenteral
Iron therapy Iron
sucrose/ FCM
Serum Ferritin < 15
Other deficiencies
Vit B12 < 200
Folic acid < 4
Add Inj vit B12 1000 µg
IM and Tab 1000 µg BD ±
Tab Folic acid 5 mg OD
Serum Ferritin > 15
Other deficiencies
Vit B12 < 200
Folic acid < 4
Consider parenteral Iron
therapy and add Inj vit B12
1000 µg IM and Tab 1000 µg
BD ± Tab Folic acid 5 mg OD
Hb ≥ 11 g%
Continue oral iron
therapy for 3 mths.
Repeat Hb as per
protocol
Repeat Hb after
4 weeks
Continue oral iron
therapy for 3 mths.
Repeat Hb as per
protocol
Hb estimation at registration, 28-30 wks. and 36 wks. of pregnancy

37. RED FLAG SIGN
• GET CBC / HB-PCV  3 TIMES IN PREGNANCY
• HB AT 20 WEEKS  10 gmOR LESS  INJECTABLE IRON THERAPY
• REFACTORY ANEMIA  THINK B12
 EXCLUDE THALASSEMIA

38. <10gm at 20 wks injectable FCM
(red flag )

39. Consider parenteral Iron therapy
If no improvment &
Serum Ferritin > 15 + Other deficiencies is noted
Vit B12 < 200
Folic acid < 4
Hb < 10 g%
Add Inj vit B12 1000 µg IM or Tab 1000 µg BD or NASAL B2
± Tab Folic acid 5 mg OD
Continue oral iron therapy for 3 mths
Repeat Hb as per protocol

40. LEARN TT OF ANAPHYLAXIS

41. 2ND PART

42. Is the NEED of TODAY
Dr. Sharda Jain
Gynaecologist to focus
** Which Oral preparation in IDA
Anemia Free India

43. Management Of IDA With Oral Iron Therapy +
others

44. FERROUS SULPHATE
IS GREAT

45. DOCTORS in GOVT Sector  Must emphasize that
GOI Supply of Iron is NO INFERIOR to market tab.

46. WHICH IRON confuses Doctors
in Private Practice -as market is
flooded with >300 preparations
EXPERTS
Must settle this confusion
too

47. 47
Absorption from Ferrous Ascorbate can be as high
as 70 % in Iron deficiency anemia patients
Key:
iron-depleted stores (IDS),
normal Fe status (NIS),
Fe deficiency without anemia (IDWA),
Fe deficiency anemia (IDA)
Biol Trace Elem Res. 2013 Dec;155(3):322-6. doi: 10.1007/s12011-013-9797-2. Epub 2013 Aug 27.

48. My Experience :GOVT supply is great
Ferrous Ascorbate is good

49. 49
Study On Ferrous Ascorbate - PRIDE Study
 Significantly more patients became non-anemic by treatment with ferrous ascorbate (93.33%) than with
carbonyl iron (46.66%).
 Ferrous ascorbate replenished ferritin stores to a greater extent than carbonyl iron.
Hb increase of 5 g/dl vs. 2.8 g/dl in 60 days
IJOG 2005; 8(4):23-30

50. Study On Ferrous Ascorbate - PRIDE Study
50
Rapid rise in Hb % by 5.03 within 60 days
IJOG 2005; 8(4):23-30

51. 51
Study on Ferrous Ascorbate – HERS Trial
N = 1461
The results show that at a dose of 1 tablet daily was effective in treating anemia, with rapid
increase in hemoglobin (mean: 2.37 g/ dl; 95%C.I.: 2.25 - 2.49) within 45 days, and was well
tolerated. The maximum increase of 3.60g/dl (95%C.I.: 3.07-4.13) was observed in those
with baseline hemoglobin less than 6g/dl.
Max 3.6 g/dl rise in 45 days
HERS study Group. IJGO 2005

52. Right Ratio For More Benefits
Right Ratio Of Iron And Ascorbic Acid Is Necessary To Form Stable Ferrous Ascorbate Complex Yielding
High Efficacy And Favourable Tolerability

53. Lets Compare Other Iron Salts With
Ferrous Ascorbate

54. Reported % Absorption Elemental Iron

55. Deworming

56. •Anthelminthic medication in pregnant women with
anaemia after 12 weeks of pregnancy
•Drug of choice is single dose Mebendazole 100mg BD
for 3 days
OR Albendazole 400mg
WHO

57. COUNCELLING ON DIET
WHAT TO TAKE WHAT NOT TO TAKE MEDICATION TIMING DEWORMING

61. DO NOT FORGET
SOYABIN
PEANUTS
PROTEIN PREP -40%

62. SOURCES OF IRON
Green leafy vegetables
Legumes, Nuts
Jaggery , Dried Fruits
Meat , Liver ,
Poultry , Fish
SOURCES OF FOLIC ACID
Green leafy vegetables
Legumes, Nuts
Milk , Fruits
Meat , Liver , Eggs

63. DIET --- IRON AND PROTEINS

64. Food Fortification

68. Arise Awake !
And Stop not untill
the goal is reached