ANEMIA IN PREGNANCY BY DR SHASHWAT JANI

1. ANAEMIA IN
PREGNANCY
Dr. SHASHWAT JANIDr. SHASHWAT JANI
M.S. ( OBS - GYNM.S. ( OBS - GYN ))
Diploma in Advanced laparoscopy.Diploma in Advanced laparoscopy.
Assistant Professor , Sheth V. S. General Hospital.Assistant Professor , Sheth V. S. General Hospital.
Smt. N.H.L. Municipal Medical college, Ahmedabad.Smt. N.H.L. Municipal Medical college, Ahmedabad.
Mobile : +91 99099 44160.Mobile : +91 99099 44160.
E- mail : drshashwatjani@gmail.comE- mail : drshashwatjani@gmail.com

2. 
Commonest haematological dsCommonest haematological ds

40-60% maternal deaths in developing40-60% maternal deaths in developing
countriescountries

Death b/o cardiac failure, haemorrhage,Death b/o cardiac failure, haemorrhage,
infection, pre-eclampsiainfection, pre-eclampsia

3. DefinitionDefinition

Condition of low circulating Hb in whichCondition of low circulating Hb in which
Hb concentration has fallen below aHb concentration has fallen below a
threshold lying at 2 standard deviationthreshold lying at 2 standard deviation
below the median of a healthy populationbelow the median of a healthy population
of same age, sex, stage of pregnancyof same age, sex, stage of pregnancy

WHOWHO

ICMR categorises anaemia depending onICMR categorises anaemia depending on
Hb levelHb level

4. Classification of AnaemiaClassification of Anaemia

PhysiologicalPhysiological

PathologicalPathological

5. Causes of pathological anaemiaCauses of pathological anaemia
DeficiencyDeficiency
anaemiaanaemia
HaemorrhagicHaemorrhagic
anaemiaanaemia
Acute, chronicAcute, chronic
HereditaryHereditary
anaemiaanaemia
Bone marrowBone marrow
insufficiency –insufficiency –
aplasia, hypoaplasia, hypo
Anaemia ofAnaemia of
infection-infection-
malaria, TBmalaria, TB
Chronic ds-Chronic ds-
renalrenal

6. Concept of physiological anaemiaConcept of physiological anaemia
IncreaseIncrease
•Plasma volumePlasma volume
•TIBCTIBC
•IRON requirementIRON requirement
DecreaseDecrease
•HbHb
•Red cellRed cell
•PCVPCV
•MCVMCV
•MCHMCH
•MCHCMCHC
•S.IronS.Iron
•%Saturation%Saturation

7. Iron requirementIron requirement
Menstruating females 1-2mg per dayMenstruating females 1-2mg per day
Pregnant females 1.5-2.5mg per dayPregnant females 1.5-2.5mg per day
Children 1mg per dayChildren 1mg per day
An adequate diet contains 15mg of iron, 10% ofAn adequate diet contains 15mg of iron, 10% of
which is absorbed.which is absorbed.

8. Total iron requirement in pregnancyTotal iron requirement in pregnancy

Total requirement: 700-1400mgTotal requirement: 700-1400mg

Average 4mg/day increases toAverage 4mg/day increases to
6.6mg/day in last few weeks6.6mg/day in last few weeks

2.5mg/d early 12.5mg/d early 1stst
trimestertrimester

5.5mg/d 20-32wk5.5mg/d 20-32wk

6-8mg/d >32wk6-8mg/d >32wk

Diet provides 14mg iron (5-15%)Diet provides 14mg iron (5-15%)
absorbed i.e. 1-2mg absorbedabsorbed i.e. 1-2mg absorbed

9. Iron distribution on pregnancyIron distribution on pregnancy

Basal iron 280mgBasal iron 280mg

Expansion red cell mass 570mgExpansion red cell mass 570mg

Fetal transfer 200-350mgFetal transfer 200-350mg

Placenta 50-150mgPlacenta 50-150mg

Blood loss 100-250mgBlood loss 100-250mg

10. Iron distribution in bodyIron distribution in body

Total iron 3-5gTotal iron 3-5g

Iron in Hb 2/3Iron in Hb 2/3rdrd
of total iron i.e. 2.3 - 3.3gof total iron i.e. 2.3 - 3.3g

Storage iron (ferritin, hemosidrin) 1gStorage iron (ferritin, hemosidrin) 1g

Essential iron (myoglobin, enzymes) 0.5gEssential iron (myoglobin, enzymes) 0.5g

Plasma iron 3-4mgPlasma iron 3-4mg

11. Iron absorptionIron absorption

Inorganic ironInorganic iron
((dietary iron, ferric form)dietary iron, ferric form)

Cereals, seeds, veg, milk, eggCereals, seeds, veg, milk, egg

Abs ↑ by enhancers haem,Abs ↑ by enhancers haem,
protein, ascorbic acid, alcoholprotein, ascorbic acid, alcohol

Abs ↓ by inhibitors fibre,Abs ↓ by inhibitors fibre,
phytic acid, calcium, tannin,phytic acid, calcium, tannin,
tea, coffee, chocolatetea, coffee, chocolate

Absorption varies 2-100%Absorption varies 2-100%

Haem ironHaem iron
((ferrous form)ferrous form)
Derived from Hb,Derived from Hb,
myoglobinmyoglobin
Animal blood, flesh, visceraAnimal blood, flesh, viscera
,,
N. Absorption 15-30%N. Absorption 15-30%
Iron deficiency 50-90%Iron deficiency 50-90%
Not affected by inhibitorsNot affected by inhibitors

13. ErythropoiesisErythropoiesis

For erythropoiesis minerals, vitamins,For erythropoiesis minerals, vitamins,
protein, hormones are neededprotein, hormones are needed

Minerals : iron, copper, cobaltMinerals : iron, copper, cobalt

Protein : erythropoietinProtein : erythropoietin

Vitamins: folic acid, vit B12, vit C, vit B6,Vitamins: folic acid, vit B12, vit C, vit B6,
riboflavinriboflavin

Hormones : androgens, thyroxinHormones : androgens, thyroxin

14. Causes of iron deficiency anaemiaCauses of iron deficiency anaemia

Faulty dietary habitsFaulty dietary habits

Defective iron absorption d/t intestinal inf.Defective iron absorption d/t intestinal inf.

↑↑ iron lossiron loss

↑↑ iron demandiron demand

↓↓ intake of ironintake of iron

Pre-pregnancy health statusPre-pregnancy health status

15. Clinical FeaturesClinical Features

S/S are d/t anaemia itself or ds causingS/S are d/t anaemia itself or ds causing

Symptoms:Symptoms: fatigue, weakness, lassitudefatigue, weakness, lassitude,, musclemuscle
weakness, palpitation, syncope, angina, dyspnoea,weakness, palpitation, syncope, angina, dyspnoea,
pedal edemapedal edema

Signs :Signs :pallor, edema ,nail changes, tachycardia,pallor, edema ,nail changes, tachycardia,
↑pulse pressure↑pulse pressure

16. Systemic changesSystemic changes
CVSCVS :: Effect of hypoxia on heart ; high cardiac output stateEffect of hypoxia on heart ; high cardiac output state
(dyspnoea on exertion is common, in severe anaemia –on(dyspnoea on exertion is common, in severe anaemia –on
rest)rest)
Haemic murmur –mid systole murmurHaemic murmur –mid systole murmur
ventricular dilatationventricular dilatation
heart failureheart failure
Very severe anaemia can ppt heart failure in pt with normal heartVery severe anaemia can ppt heart failure in pt with normal heart
ECG:ECG: changes may occur with Hb <6g/dlchanges may occur with Hb <6g/dl
normal QRS Wavenormal QRS Wave
depression of ST segmentdepression of ST segment
Flattening / inversion of T WaveFlattening / inversion of T Wave

17. • CNS:CNS: Faintness, giddiness, headache, tinnitus, lackFaintness, giddiness, headache, tinnitus, lack
of concentration, drowsiness, tingling, numbnessof concentration, drowsiness, tingling, numbness
• Eyes :Eyes : pallor, retina –pale,pallor, retina –pale,
papillodema –rarepapillodema –rare
• Reproductive :Reproductive : menstrual disturbance (non –menstrual disturbance (non –
pregnant )pregnant )
• Renal disturbance:Renal disturbance: slight proteinuriaslight proteinuria
• GIT:GIT: anorexia, glossitis, stomatitis, constipationanorexia, glossitis, stomatitis, constipation

19. Effect of anaemia on pregnancyEffect of anaemia on pregnancy
Mild anaemiaMild anaemia
No effect exceptNo effect except
↓iron store↓iron store
ModerateModerate
anaemiaanaemia
•↑↑weakness,weakness,
•Lack of energy,Lack of energy,
Fatigue,Fatigue,
•Poor workPoor work
performanceperformance
SevereSevere
anaemiaanaemia
•Poor outcomePoor outcome
•PalpitationPalpitation
•TachycardiaTachycardia
•BreathlessnessBreathlessness
•Cardiac failureCardiac failure

20. InvestigationInvestigation
↓↓Hb conc. is late featureHb conc. is late feature
Red cell indicesRed cell indices::
Non pregnant -↓MCV is earliest featureNon pregnant -↓MCV is earliest feature
Pregnancy –MCV is not sensitivePregnancy –MCV is not sensitive
indicatorindicator
↓↓MCVMCV
↓↓MCHMCH
↓↓MCHCMCHC
S.FerritinS.Ferritin; stored iron; stored iron
normal 15-300normal 15-300μμg/lg/l
<12<12μμg/L indicate iron deficiencyg/L indicate iron deficiency
not affected by recent ironnot affected by recent iron
ingestioningestion
S.IronS.Iron : S.Iron <60: S.Iron <60μμg/dl (60-120g/dl (60-120μμg/dl)g/dl)
TIBC >350TIBC >350μμg/dl (300-g/dl (300-
350350μμg/dl)g/dl)
Transferrin sat. <15% (30%)Transferrin sat. <15% (30%)
Indicate iron deficiency anaemiaIndicate iron deficiency anaemia
Free erythrocyte protoporphyrin: ↑Free erythrocyte protoporphyrin: ↑
Serum transferrin receptorSerum transferrin receptor::
sensitive and specific markersensitive and specific marker
cellular iron statuscellular iron status
level ↑ in cellular iron deficiencylevel ↑ in cellular iron deficiency
Bone marrowBone marrow : no response to therapy after 4: no response to therapy after 4
wkwk
diagnosis of aplastic anaemiadiagnosis of aplastic anaemia
kala azarkala azar
Depleted store: ↓ferritinDepleted store: ↓ferritin
Iron deficiency with no anaemia:Iron deficiency with no anaemia:
↓↓ferritinferritin
↓↓transferrin sat.transferrin sat.
↑↑FEPFEP
Anaemia with iron deficiency:Anaemia with iron deficiency:
↓↓Hb, red cell indicesHb, red cell indices
↓↓transferrin sat.transferrin sat.
↑↑TIBC, FEPTIBC, FEP

21. Normal Blood FilmNormal Blood Film

22. MICROCYTESMICROCYTES

23. HYPOCHROMIAHYPOCHROMIA

24. COMPLICATIONCOMPLICATION
DuringDuring
PregnancyPregnancy
•Pre-eclampsiaPre-eclampsia
•IntercurrentIntercurrent
infectioninfection
•Heart failureHeart failure
•PretermPreterm
deliverydelivery
LabourLabour
•PPHPPH
•Heart failureHeart failure
•ShockShock
•DystociaDystocia
PuerperiumPuerperium
•P.sepsisP.sepsis
•Sub involutionSub involution
•FailingFailing
lactationlactation
•P. venousP. venous
thrombosisthrombosis

25. 
Risk period:Risk period: 30-32wk pregnancy30-32wk pregnancy
During laborDuring labor
Immediately following deliveryImmediately following delivery
Puerperium (7-10days)Puerperium (7-10days)

Fetal complication:Fetal complication: LBWLBW
IUDIUD
Preterm babyPreterm baby
SGASGA
↑↑Perinatal morbidity& mortalityPerinatal morbidity& mortality
IUGRIUGR

26. TREATMENTTREATMENT

PROPHYLACTIC:PROPHYLACTIC:
--Avoidance of frequent child birthAvoidance of frequent child birth
-Dietary prescription-Dietary prescription
-Food fortification-Food fortification
-Supplement iron therapy-Supplement iron therapy::
100mg elemental iron100mg elemental iron + 500+ 500μμg folate forg folate for
minimum 100 Daysminimum 100 Days

27. CurativeCurative
• Choice of therapy depend onChoice of therapy depend on
• Duration of pregnancyDuration of pregnancy
• Severity of anaemiaSeverity of anaemia
• Associated complicated factorAssociated complicated factor
• Iron therapyIron therapy
--oraloral
- parentral- parentral

28. 
WHOWHO ;;30-60 mg/d normal iron store30-60 mg/d normal iron store
120-240mg/d no iron store120-240mg/d no iron store
Oral ironOral iron Elemental doseElemental dose
Ferrous sulphateFerrous sulphate 6565
F.Sulphate(exsiccated)F.Sulphate(exsiccated) 6565
Ferrous gluconateFerrous gluconate 3636
Ferrous fumarateFerrous fumarate 6767

29. 
Ferrous sulphateFerrous sulphate is cheap,is cheap,
Rest are expansive but have less epigastric discomfort,Rest are expansive but have less epigastric discomfort,
nausea, vomitingnausea, vomiting

Slow release preparationSlow release preparation::
expansive, no S/E.expansive, no S/E.
Much iron not released, unabsorbed, excretedMuch iron not released, unabsorbed, excreted
unchangedunchanged
↑↑dose required to achieve given responsedose required to achieve given response

Rate of improvement:Rate of improvement:
evident in 3wk, Hb rise 0.7-1g/dl/wkevident in 3wk, Hb rise 0.7-1g/dl/wk

30. 
Drawback :Drawback : IntoleranceIntolerance
unpredictable abs. rateunpredictable abs. rate
S.iron restored but difficult to replenishS.iron restored but difficult to replenish
iron storeiron store

Response to therapy:Response to therapy: sense of well beingsense of well being
↑↑AppetiteAppetite
Improved outlookImproved outlook
haematologically improv.haematologically improv.

Causes of failure:Causes of failure: Improper typing, def.Improper typing, def.
absorption,absorption,
failure to take iron, infectionfailure to take iron, infection
conc. Blood loss, folate def.conc. Blood loss, folate def.

31. Parentral iron therapyParentral iron therapy

IVIV // IMIM

DoseDose : 0.3: 0.3 x wt (lb) (100-Hb%)x wt (lb) (100-Hb%)

(Hb – pt Hb)(Hb – pt Hb) x wt (kg) x2.21+1000x wt (kg) x2.21+1000

250mg250mg elemental iron for each g below N.elemental iron for each g below N.

IntravenousIntravenous;; eliminate repeated & painful IM inj.eliminate repeated & painful IM inj.
T/t completed in a dayT/t completed in a day
TDI & UndilutedTDI & Undiluted

32. 
TDI:TDI:-- Diluted in a lt of isotonic saline or 5% dextroseDiluted in a lt of isotonic saline or 5% dextrose
-Maximum conc. used-Maximum conc. used 2.5g/lt/d2.5g/lt/d dilutentdilutent
-@15 drops/ min then 45-60 drops/min (over in-@15 drops/ min then 45-60 drops/min (over in
4- 5hr)4- 5hr)

S/E:S/E:,, chills, ↓BP chest pain, rigor, hemolysis,chills, ↓BP chest pain, rigor, hemolysis,
anaphylactic reactionanaphylactic reaction

Stop infusionStop infusion :: anti H, steroids, adrenalineanti H, steroids, adrenaline

Undiluted preparationUndiluted preparation:: given in single dosegiven in single dose
Test dose: 0.5ml iron dextran diluted with 4-5ml of pt.Test dose: 0.5ml iron dextran diluted with 4-5ml of pt.
blood given slowlyblood given slowly

Therapeutic dose:Therapeutic dose: up to 5ml slow@ 1ml/minup to 5ml slow@ 1ml/min

33. 
IntramuscularIntramuscular

Iron dextran:Iron dextran: colloid of ferric hydroxide with dextrancolloid of ferric hydroxide with dextran
Inj. Site should never be massagedInj. Site should never be massaged

Iron sorbitol citrate:Iron sorbitol citrate: small molecule, rapidlysmall molecule, rapidly
cleared from body.cleared from body.
30%excreted unchanged30%excreted unchanged
S/E;S/E; Headache, nausea, vomiting, if givenHeadache, nausea, vomiting, if given
simultaneously with ironsimultaneously with iron
DOSE;DOSE; 1.5 mg/kg1.5 mg/kg

Parentral ironParentral iron C/IC/I : H/O Allergy –asthma: H/O Allergy –asthma
H/O previous reactionH/O previous reaction

34. Iron Dextran: Adverse Reactions
�Dose related: arthralgia, backache, chills,
dizziness, moderate to high fever,headache, malaise, myalgia,
�Increased incidence of these effects with
total dose infusions
�Onset is 24-48 hours after administration
�Effects subside within 3-4 days

35. Sodium Ferric Gluconate
(Ferrlicit): Dose
�Give 10ml (125mg elemental iron) during
a total of 8 consecutive dialysis sessions
for a total dose of 1000mg elemental iron

36. Sodium Ferric Gluconate
Administration
�Dilute 2ml test dose (25mg elemental iron) in 50ml
normal saline and give over 60 minutes
�Dilute 10ml (125mg elemental iron) in 100ml normal
saline and give over 60 minutes (2.1mg/min)
�Undiluted as a slow IV injection at a rate up to
12.5mg/min

37. Adverse Reactions
�Hypotension/flushing
�Associated with rapid administration
�Not associated with hypersensitivity reactions
�Resolves within 1-2 hours
�Symptoms:
abdominal pain, diarrhea, vomiting leading to
pallor or cyanosis, lassitude, drowsiness,
hyperventilation due to acidosis, & CV collapse

38. Iron Sucrose (Venofer): Dose
�

39. Iron Sucrose (Venofer):
Monitoring
�Hematologic and hematinic factors
– Hb, Hct, serum ferritin, transferrin saturation
– because transferrin values increase rapidly after IV
administration, serum iron values may be reliably
obtained 48 hours after dosing
�Experienced in > 5% of patients:
– hypotension
– cramps/leg cramps
– nausea
– headache
– vomiting
– diarrhea

40. 
If no time to achieve reasonable Hb conc.If no time to achieve reasonable Hb conc.
BLOOD TRANSFUSIONBLOOD TRANSFUSION

PACKED RED CELL PREFERREDPACKED RED CELL PREFERRED

41. ANC CARE
<30WK 30-36WK >36WK
IRON DEF FOLIC ACID DEF
ORAL IRON
INTOLERANCE/
NON COMLIANCE
IM/ IV
FOLIC ACID
IRON DEF FOLIC ACID DEF
PARENTRAL
IM/IV
ORAL FOLATE
BLOOD
TRANSFUSION

42. MANAGEMENT IN LABORMANAGEMENT IN LABOR

11stst
stage: -stage: - comfortable positioncomfortable position
- pain relief- pain relief
-oxygen ready-oxygen ready
-digitalisation may be required-digitalisation may be required
-avoid drugs causing tachycardia-avoid drugs causing tachycardia
-antibiotic prophylaxis-antibiotic prophylaxis
-blood to kept ready (cross-blood to kept ready (cross
match)match)

43. 2nd stage:2nd stage: more stressfulmore stressful
-↑ chance of CCF-↑ chance of CCF
- shorten by forceps/ vacuum- shorten by forceps/ vacuum
3rd stage:3rd stage: active managementactive management
4th stage:4th stage: stage of monitoring, PPHstage of monitoring, PPH
treated energitically as thesetreated energitically as these
pt tolerate bleeding poorlypt tolerate bleeding poorly

44. Megaloblastic anaemiaMegaloblastic anaemia

Derangement in RBC maturation, withDerangement in RBC maturation, with
production in BM of abn. Precursor k/asproduction in BM of abn. Precursor k/as
megaloblast d/t impaired DNA synthesismegaloblast d/t impaired DNA synthesis

Deficiency of ; folate, vitamin B12 or bothDeficiency of ; folate, vitamin B12 or both

Vit B12 def. rare in pregnancyVit B12 def. rare in pregnancy

Anaemia nearly b/oAnaemia nearly b/o folic acidfolic acid defdef

45. Causes of Folic acid deficiencyCauses of Folic acid deficiency
• Inadequate intake:Inadequate intake:
nausea, anorexianausea, anorexia
dietary insufficiencydietary insufficiency
excess cooking destroys FAexcess cooking destroys FA
AlcholicAlcholic
• Increased demand:Increased demand:
pregnancy ( 400pregnancy ( 400μμg)g)
lactationlactation

46. 
↓↓ AbsorptionAbsorption
intestinal absorption syndromeintestinal absorption syndrome

Abnormal demandAbnormal demand::
twin pregnancytwin pregnancy
infectioninfection
haemorraghic statushaemorraghic status

Failure of utilisationFailure of utilisation
anticonvulsant therapyanticonvulsant therapy
infectioninfection

↓↓ storagestorage::
liver dsliver ds
vit C defvit C def

47. 
Folic acid absorbed in duodenum,Folic acid absorbed in duodenum,
jejunumjejunum

Function :Function : methylation of homocysteine tomethylation of homocysteine to
methiononemethionone
synthesis of pyrimidinesynthesis of pyrimidine

Incidence 0.5- 3%Incidence 0.5- 3%
↑↑ in multiparain multipara
↑↑multiple pregnancymultiple pregnancy
Plasma folate falls as pregnancy advances,Plasma folate falls as pregnancy advances,
becomes ½ of non pregnant valuebecomes ½ of non pregnant value

48. VITAMIN BVITAMIN B1212 DEFICIENCYDEFICIENCY

Synthesis by certain micro-organismsSynthesis by certain micro-organisms

2 active metabolic forms2 active metabolic forms
methycobalaminemethycobalamine
adenosylcobalamineadenosylcobalamine

Absorption occur in Distal duodenumAbsorption occur in Distal duodenum

Dietary source:Dietary source:
meat, fish, egg, milkmeat, fish, egg, milk

Not destroyed by cookingNot destroyed by cooking

49. Clinical features in megaloblasticClinical features in megaloblastic
anaemiaanaemia

Insidious, last trimester or puerperiumInsidious, last trimester or puerperium

Anorexia, vomitingAnorexia, vomiting

Unexplained fever’Unexplained fever’

Glossitis, Haemorraghic patch (skin)Glossitis, Haemorraghic patch (skin)

S/s of pre-eclampsiaS/s of pre-eclampsia

Numbness or paresthesia in extremityNumbness or paresthesia in extremity
(vit B12 def)(vit B12 def)

50. Investigation of megaloblastic anaemiaInvestigation of megaloblastic anaemia

Red cell indices:Red cell indices: Hb <10g/dlHb <10g/dl
MCV >96flMCV >96fl
MCH >33pgMCH >33pg
MCHC normalMCHC normal

Sr enzyme Methymalonic acid & homocysteineSr enzyme Methymalonic acid & homocysteine
level are raised in Vit B12 def., in folic acid def.level are raised in Vit B12 def., in folic acid def.
only homocysteine is ↑.only homocysteine is ↑.

51. 
Plasma folate: limited diagnostic valuePlasma folate: limited diagnostic value

Red cell folate: body tissue levelRed cell folate: body tissue level

↑↑FIGLU excretion in urineFIGLU excretion in urine

↓↓Sr. folate (<3ng/dl) & red cell folateSr. folate (<3ng/dl) & red cell folate
(<150ng/dl) diagnostic of folic acid(<150ng/dl) diagnostic of folic acid
deficiencydeficiency

PS: macrocyte, hypersegmentedPS: macrocyte, hypersegmented
neutrophil, neutropenia,neutrophil, neutropenia,
thrombocytopeniathrombocytopenia

52. Macrocytic anemiaMacrocytic anemia
The RBC are almost as large as the lymphocyte. Note
the hypersegmented neurotrophil. There are fewer
RBCs.

53. Effect of folic acid deficiencyEffect of folic acid deficiency
Effect on pregnancyEffect on pregnancy
•AbortionAbortion
•Growth retardationGrowth retardation
•Abruptio placentaAbruptio placenta
•Pre -eclampsiaPre -eclampsia
Effect on fetusEffect on fetus
•Neural tube defectNeural tube defect
•AbortionAbortion
•SGASGA
•Pre termPre term

54. TreatmentTreatment

Prophylactic :Prophylactic : Dietary habitDietary habit
- avoid over-cooking- avoid over-cooking
-food fortification-food fortification
WHO: Pregnancy 800WHO: Pregnancy 800μμgg
Lactation 600Lactation 600μμgg
Non pregnant 400Non pregnant 400μμgg

Treatment :Treatment : Folic acidFolic acid 5mg oral /d till 4 wk5mg oral /d till 4 wk
in puerperiumin puerperium
Parenteral cyanocobalamine 250Parenteral cyanocobalamine 250μμgg
im every monthim every month

55. HaemoglobinopathiesHaemoglobinopathies

Defect in synthesis of globin chain of HbDefect in synthesis of globin chain of Hb

Eg . Thalassemia, sickle cell anaemia,Eg . Thalassemia, sickle cell anaemia,
Hb E, Hb DHb E, Hb D
DIAGNOSIS:DIAGNOSIS:
Hb electrophoresisHb electrophoresis
Molecular techniqueMolecular technique

56. SICKLE CELL ANAEMIASICKLE CELL ANAEMIA

Structural abn. Of globin synthesisStructural abn. Of globin synthesis

A.A. substitution at 6A.A. substitution at 6thth
position glutamateposition glutamate
replacing valine.replacing valine.

Sickling favouredSickling favoured byby acidosis, dehydration, coolingacidosis, dehydration, cooling
Sickle ds
HOMOZYGOUS
HbSS
HETEROZYGOUS
HbAS
HbSC

57. Hb CHb C
•LYSINE for GLUTAMICLYSINE for GLUTAMIC
ACIDACID
•Less solubleLess soluble
•Haemolytic anaemiaHaemolytic anaemia
•Normal / near normal HbNormal / near normal Hb
•Undiagnosed butUndiagnosed but ± massive± massive
sickling in pregnancysickling in pregnancy
Hb ASHb AS
•No detectable abn.No detectable abn.
•Not anaemic underNot anaemic under
additional pregnancy stressadditional pregnancy stress
•Crisis in extreme conditionCrisis in extreme condition
•↑↑ incidence pre eclampsiaincidence pre eclampsia

58. 
DiagnosisDiagnosis:: Refractory hypochromic anaemiaRefractory hypochromic anaemia
-Identified by sickling test-Identified by sickling test
-Persistent leucocytosis-Persistent leucocytosis
-↑S.Iron-↑S.Iron
- Electrophoresis- Electrophoresis
Effect on pregnancyEffect on pregnancy
• AbortionAbortion
• PrematurityPrematurity
• Fetal loss (placentalFetal loss (placental
infarct)infarct)
• Pre eclampsia,Pre eclampsia,
• PPH,PPH,
• InfectionInfection
↑↑Maternal morbidityMaternal morbidity
•InfectionInfection
•Cardiovascular stressCardiovascular stress
•Sickle cell crisesSickle cell crises
•CerebrovascularCerebrovascular
•Pul . InfarctPul . Infarct
•EmbolismEmbolism

59. MANAGEMENTMANAGEMENT

?role of BM Transfusion?role of BM Transfusion

Induction of HbF : -Induction of HbF : - HydroxyureaHydroxyurea
- Pulse butyrate therapy- Pulse butyrate therapy

Labor : -Labor : -Adequate HydrationAdequate Hydration
-Avoid Hypoxia-Avoid Hypoxia

Post natal: -Post natal: -AntibioticAntibiotic
-Hydration-Hydration
-Contraception (avoid IUCD)-Contraception (avoid IUCD)

60. ThalassemiaThalassemia

Common genetic disorderCommon genetic disorder

↓↓rate of globin synthesisrate of globin synthesis

Two typeTwo type
αα ThalassemiaThalassemia
ββ ThalassemiaThalassemia

61. αα ThalassemiaThalassemia

D/t gene deletionD/t gene deletion

4 types:4 types:
1gene mut1gene mut..
•No clinical/ labNo clinical/ lab
abn.abn.
•Silent carrierSilent carrier
2 gene mut2 gene mut
•αα thalassemiathalassemia
minorminor
•UnrecognisedUnrecognised
3 gene mut3 gene mut
•HbHHbH
•One functionalOne functional
GeneGene
•Hb unstable d/tHb unstable d/t
ββ44 tetramer ortetramer or
Hb Bart(Hb Bart(γγ44))
•HaemolyticHaemolytic
anaemiaanaemia
All 4 geneAll 4 gene
•NONO
functionalfunctional
genegene
•IncompatibleIncompatible
with lifewith life
•HydropicHydropic
fetusfetus
•Severe preSevere pre
eclampsiaeclampsia
Abn. Red cell indices: ↓MCV, MCH; MCHCAbn. Red cell indices: ↓MCV, MCH; MCHC NormalNormal

62. ββ thalassemiathalassemia

ββ thalassemia majorthalassemia major (Cooley anaemia)(Cooley anaemia)
homozygoushomozygous
Erythropoietin ineffectiveErythropoietin ineffective
HepatospleenomegalyHepatospleenomegaly

ββ thalassemia minor :thalassemia minor : heterozygousheterozygous

Hb ↓/ NHb ↓/ N

Hb AHb A22(( αα22ζζ2)/ Hb F2)/ Hb F

63. MANAGEMENTMANAGEMENT
αα ThalassemiaThalassemia
•Iron & folate ANCIron & folate ANC
•Parentral iron C/IParentral iron C/I
•IF Hb not adequate at termIF Hb not adequate at term
blood transfusionblood transfusion
•Pt with HbH –N. lifePt with HbH –N. life
expectancy, daily folateexpectancy, daily folate
suppl., pregnancy- 5mg/dsuppl., pregnancy- 5mg/d
ββ thalassemiathalassemia
Major : folate suppl.Major : folate suppl.
Iron C/IIron C/I
Minor : oral Iron & folateMinor : oral Iron & folate
parentral iron C/Iparentral iron C/I

64. THANK
THANK
YOU...!!!
YOU...!!!