Anemia is a condition in which the number of red blood cells and/OR their oxygen-carrying capacity is insufficient to meet the body’s physiological needs.

1. ANEMIA MANAGEMENT
DR NIRANJAN CHAVAN
23/12/2023
FOGSI RUN CME
RAIPUR / BILASPUR

2. Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital
President, MOGS (2022-2023)
Joint Treasurer, FOGSI (2021-2025)
Organising Secretary, AICOG Mumbai 2025
Treasurer, AFG (2023-2024)
Member Oncology Committee, SAFOG (2021-2023)
Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses
Editor-in-Chief, FEMAS, JGOG & TOA Journal
74 publications in International and National Journals with 182 Citations
National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-
2022)
Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16)
Member, Oncology Committee AOFOG (2013-2015)
Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at
L.T.M.G.H (2010-16)
Member, Managing Committee IAGE (2013-17), (2018-20), (2022-2023)
Editorial Board, European Journal of Gynaec. Oncology (Italy)
Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery
(AMAS) at LTMGH (2018-19)
DR. NIRANJAN CHAVAN
MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP,
DIPLOMA IN ENDOSCOPY (USA)

3. “Iron Deficiency Anemia is a Global Pandemic!”
– Steven Magee

4. DEFINITION
Anemia is a condition in which the number of red blood cells and/OR their oxygen-
carrying capacity is insufficient to meet the body’s physiological needs.

6. CLASSIFICATION OF ANEMIA -
BASED ON CLINICAL PICTURE-
• Iron deficiency anemia.
• Megaloblastic anemia.
• Pernicious anemia.
• Hemorrhagic anemia.
• Hemolytic anemia.
• Thalassemia anemia.
• Sickle cell anemia.
• Aplastic anemia.

7. • Iron deficiency anemia-
• Excessive loss of iron
• Women are at risk - for menstrual blood and growing fetus
• Megaloblastic anemia-
• Less intake of vitamin B12 and folic acid.
• Red bone marrow produces abnormal RBC e.g. cancer
drugs
• Pernicious anemia-
• Inability of stomach to absorb vitamin B12 in small
intestine
• Hemorrhagic anemia-
• Excessive loss of RBC through bleeding, stomach ulcers,
menstruation

8. • Hemolytic anemia-
• RBC plasma membrane rupture, may be due to
parasites, toxins, antibodies
• Thalassemia-
• Less synthesis of hemoglobin. Found in population
of Mediterranean sea
• Sickle cell anemia-
• Hereditary blood disorder, characterized by red
blood cells that assume an abnormal, rigid, sickle
shape
• Aplastic anemia-
• Destruction of red bone marrow
• Caused by toxins,gamma radiation

9. CLASSIFICATION OF ANEMIAAS
PER SEVERITY
According to ICMR (Indian Council of Medical Research)
Mild – 8-11 g/dl
Moderate- 5-8 g/dl
Severe- less than 5 g/dl

10. CLASSIFICATION OF ANEMIA -
MORPHOLOGICAL

12. CLASSIFICATION - WOMEN IN
REPRODUCTIVE AGE GROUP

14. GLOBAL PREVALENCE
• In 2019, global anaemia prevalence was 29.9% in women of reproductive.
age(WRA), equivalent to over half a billion women aged 15-49 years.
• Prevalence was 29.6% in non-pregnant women of reproductive age, and 36.5% in
pregnant women.
• WRA are one of the groups most at risk of anemia, due to their physiological
processes.
• There has been little progress in reducing the anemia burden among WRA over the
past two decades, with prevalence actually increasing in some South Asian and sub-
Saharan African countries.

15. GLOBAL PREVALENCE OF ANEMIA
IN WOMEN OF REPRODUCTIVE AGE
GROUP

16. AGE-WISE PREVALENCE IN
INDIA

17. ANEMIA – A PUBLIC HEALTH
CHALLENGE
• Identifying effective drivers of anemia reduction,
including programs and policies, and understanding
how they contribute to improvements in anemia
among WRA, is pivotal for creating a framework
that countries can follow to improve the health and
well-being of their populations.

18. ANEMIA IN PREGNANCY
• Anemia in pregnancy is one of the most important factors
related to maternal morbidity and mortality.
• It reduces a woman’s ability to tolerate intra- or post-
partum blood loss.
• New World Health Organization suggest that worldwide,
30% of pregnant women were anemic in 2023.
• The most common cause of anemia in pregnancy is
nutritional.
• NFHS 5 data shows an increase in the prevalence of
anaemia in all women by 4%, 1.8% in pregnant women
and a increase by 4 % in non-pregnant women.

19. MECHANISM OF DEVELOPMENT
OF ANAEMIA

21. SIGNS OF ANAEMIA
• Brittle nails
• Koilonychia (spoon shaped nails)
• Atrophy of the papillae of the tongue
• Angular stomatitis
• Brittle hair
• Dysphagia and Glossitis
• Plummer Vinson/Kelly Patterson

23. DETERMINANTS OF ANEMIA
• Adequate dietary diversity, especially consumption of
iron-rich foods is a vital determinant of the micronutrient
status of individuals.
• Diversity in diet during the reproductive years are highly
correlated with improved health and nutrition outcomes
for both women and their children.
• National and/or regional-level fortification policies and
programs determine households’ and individuals’ access
to fortified foods.

24. • The proximal maternal characteristics of BMI and age at pregnancy were also
associated with observed changes in anemia prevalence
• Women who were underweight (BMI < 18.5 kg/m2) had consistently higher
odds of anemia compared to women who had a BMI higher than 18.5 kg/m2
• Increased maternal age at pregnancy was associated with a significant decline in
anemia

25. • Increase in household wealth and maternal
educational attainment were most strongly
associated with a decrease in WRA anemia
prevalence
• Higher educational attainment was also protective
against anemia
• Increased access to improved sanitation, and a
reduction in the proportion of the population
practicing open defecation, were also identified as
strong drivers of improvement.
• Residence in urban areas was also found to be
protective against the risk of anemia.

26. ANEMIA – CLINICALAPPROACH

27. INVESTIGATIONS
• Complete Hemogram
• All blood routine examination
• Peripheral smear
• Reticulocyte count
• MCV, MCH, MCHC
• Sr. Iron, TIBC, Sr. ferritin
• Urine routine examination
• Stool routine examination
• Blood grouping

29. TO CALCULATE IRON DEFICIT

30. TREATMENT OF ANAEMIA
• Oral iron provides an inexpensive and effective
means of restoring iron balance in a patient with
iron deficiency without complicating comorbid
conditions.
• Numerous oral iron formulations are available as
discussed in the next slide.

32. ORAL IRON PREPARATIONS

33. INTRAVENOUS PREPARATIONS
• IV iron is appropriate for patients who are unable to tolerate
gastrointestinal side effects of oral iron.
• Older individuals, pregnant women (who already have
gastrointestinal symptoms related to the pregnancy), and
individuals with existing gastrointestinal disorders that may
exacerbate oral iron side effects
• Those with severe/ongoing blood loss (eg, telangiectasias,
varices)
• Gastric surgery (bypass, resection) that reduces gastric acid may
severely impair intestinal absorption of oral iron
• Malabsorption syndromes (celiac disease, Whipple's disease,
bacterial overgrowth) may limit absorption of oral iron

34. PARENTERAL IRON PREPARATION

35. A total of 100 women received a FCM infusion for IDA, with pre-infusion Hb and serum
ferritin levels and post-FCM infusion Hb and serum ferritin levels available for 100 women.
The findings of this prospective study support previous prospective evidence that FCM
treatment in pregnancy and postpartum is likely to be safe and effective.

36. • The need to increase
• Awareness,
• Reach and
• Discussion led to
• Times of Anemia
• A medico magazine that highlighted.
• A framework for managing care customization.
• An analysis of mass customization in service sectors.
• Care customization compared to personalized medicine and patient-centered
care.
• The available options for treatment of various types of anemia.

38. • The theme for 1st World Congress of Anemia (WCA)
“Iron Deficiency Anemia and strategies for its prevention”
• WCA 2021 witnessed an august audience of 9450+ doctors globally.
• Associations across segments and boundaries joined hands to create awareness on
various facets of anemia.

39. The theme for 2nd World Congress of Anemia (WCA)
“Iron Deficiency Anemia and tools for effective prevention & control “

40. WORLD CONGRESS OF ANAEMIA 2024
UPCOMING!!

41. Adapted from: Geisser P. Port J Nephrol Hypert. 2009;23(1):11-6.
Friedrisch JR, et al. Rev Bras Hematol Hemoter. 2015;37(6):400–405.
FCM is an iron complex consisting of a ferric hydrochloride core stabilized by a
carbohydrate shell.
FCM
01 Dextran-free parenteral iron
02
Offers rapid and high-dose
replenishment of depleted iron stores
FCM: Ferric carboxymaltose.
Ferric Carboxymaltose as a Therapy in Iron-Deficiency
Anemia

42. FCM has low immunogenic potential, which
shields it from a high risk of anaphylactic
reactions.
The design of FCM permits controlled
delivery of iron preventing the release of
large amounts of iron into the serum.
Permits large doses of FCM (15 mg/kg;
maximum of 1000 mg/infusion) in a
single rapid (15-minute) session. Model for the proposed molecular structure of ferric
carboxymaltose.
Adapted from: AusPAR.TGA. Availaible at: chrome-
extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.tga.gov.au/sites/default/fi
les/auspar-ferric.pdf. Accessed on 25 Aug 2023
Friedrisch JR, et al. Rev Bras Hematol Hemoter. 2015;37(6):400–405. AusPAR: Australian public assessment record; FCM: Ferric carboxymaltose;
Ferric Carboxymaltose Permits the Administration of Large
Doses

43. FCM Dosing
Weight (kg) Hb levels (g/dL) FCM dose (mg)
≥ 66kg 8 to <9 1,000 mg followed by 500 mg
9 to <11 1,000 mg only
< 66 kg 8 to <9 500 mg weekly x 3 weeks
9 to <11 500 mg weekly x 2 weeks
Mahapatra PC, Gupte S, Malhotra N, et al. Ferric Carboxymaltose for the Treatment of Anemia during Antenatal and Postpartum Period: Expert Opinion. J South Asian Feder Obst Gynae 2022;14(3):292–301.

44. FCM: Ferric carboxymaltose.
FCM in a dose of 1000 mg administered during 12–24 weeks can provide a
substantial improvement in iron status.
FCM may be administered in the late second or early third trimester. If
administered in the third trimester, it should be done at least 2 weeks before the
expected date of delivery.
Mahapatra PC, et al.. J. South Asian Fed. Obstet. Gynecol.. 2022;14(3):292‒301.
Optimal Timing of FCM Administration

45. Summary of Previously Reported PROMISE Study
A retrospective, observational, real-world study of 1800 patients with IDA
Data of 1800
women patients
with IDA
Assessed the efficacy and safety of
intravenous (IV) FCM in adolescents
and adults with IDA
Real-world study
Trivedi P, et al. Obstet Gynecol Int. 2022;2022:5759740. FCM: Ferric carboxymaltose; IDA: Iron-deficiency anemia; PROMISE: Progesterone in Recurrent Miscarriages.
PROMISE study

46. Comparison of FCM With Other Iron Treatments for Anemia
in Indian Pregnant Women
FCM: Ferric carboxymaltose; Hb: Hemoglobin; IDA: Iron-deficiency anemia; IS: Iron sucrose; ISr: Iron sorbitol.
At 6 weeks, almost two times more
increase in hemoglobin was noted in the
FCM group compared to the ISr group.
Patil KA, et al. Int J Reprod Contracept Obstet Gynecol. 2022;11(10):2692‒2698.
Adapted from: Patil KA, et al. Int J Reprod Contracept Obstet Gynecol. 2022;11(10):2692‒2698.
• Mean hemoglobin and mean serum
ferritin levels at 2 weeks and 6 weeks
in the FCM group were significantly
higher compared to the IS as well as
the ISr groups.
A FCM single 1000 mg injection is a crucial treatment for correcting anemia and restoring
iron stores in pregnant women experiencing moderate-to‒severe anemia in the late second
or third trimester.
n=150
24 to 34 weeks of gestation with IDA Hb
between 6.5 g/dL and <9.0 g/dL

47. Charmila A, et al. India. J Blood Med. 2022;13:303‒313.
A retrospective, observational, and real-world study to assess the efficacy and safety of
FCM in adolescents and adults with IDA across 269 centers in India; n=1800 with IDA.
Conducted between 01 January 2021 and 31 December 2021.
FCM: Ferric carboxymaltose;; IDA: Iron-deficiency anemia.
FCM efficiently, safely, and quickly corrects moderate-to‒severe anemia in Indian patients in a short span of 4
weeks.
98.3% of the subjects had moderate-
(77.5%) to‒severe (20.8%) anemia, which
responded to FCM within 4 weeks.
Multicenter Efficacy and Safety Study of FCM in IDA

48. CI: confidence interval; FCM: Ferric carboxymaltose; Hb: Hemoglobin; IDA: Iron-
deficiency anemia; PPA: Postpartam anema; IS: Iron sucrose; IV: Intravenous.
Sharma N and colleagues1
Hol KV and colleagues2
A prospective comparative study
July 2015 to July 2016
A prospective comparative study
January 2013 to December 2013
Hb IS
group,
Mean
FCM
group,
Mean
Difference between
mean
Mild anemia group (Hb 9‒11 gm%)
Baseline 9.83 9.94 Not significant t = 1.358
DF = 58, p-value =
0.180 (95% CI = -
0.5196 to 0.09959)
6 weeks 12.14 12.46
Mean difference 2.31 2.52
Moderate anemia group (Hb 7‒11 gm%)
Baseline 7.75 7.74 Not significant t = 1.023
DF = 38, p-value =
0.313 (95% CI = -
0.4765 to 0.1565)
6 weeks 12.36 12.47
Mean difference 4.58 4.74
Fixed-dose IS and FCM are equally effective and safe for the
treatment of IDA in postpartum patients.
Parameter Group A (IS) Group B (FCM)
Mean difference in
increase in Hb
(g%)
1.68 3.14
Mean difference in
increase in
ferritin (ng/dL)
113.80 125.91
FCM was very effective in improving Hb concentration as well as in
the early replenishment of iron stores in patients with PPA.
Hb and serum ferritin were repeated 14 days posttransfusion
1. Sharma N, et al. J Obstet Gynaecol India. 2017;67(4):253–257.
2. Hol KV, et al, Int J Reprod Contracept Obstet Gynecol.2015;4:669–673.
Comparative Efficacy and Safety Study of IS vs. FCM for IDA
in PPA Patients

49. A comparative study to evaluate the safety and efficacy of IV FCM and iron sucrose in the treatment
of postpartum IDA
Conducted between October 2013 to June 2015
Hb levels IS group FCM group T statistic p-value
Mean ± SD Mean ± SD
Pretreatment 7.93±0.69 8.01±0.55 -0.878 0.381
Post
treatment
12.08±1.17 12.70±1.04 -3.674 <0.001
Hb
difference
3.92 ± 1.12 4.68 ± 0.96 -4.827 <0.001
Comparison of hemoglobin levels among the two groups.
FCM causes a faster and higher replenishment of iron stores and correction of Hb levels than IS; hence, it
can be considered a first-line drug for postpartum IDA.
Joshi SD, et al. Int J Reprod Contracept Obstet Gynecol. 2016;5:2566-2570.
FCM: Ferric carboxymaltose; Hb: Hemoglobin;
IDA: Iron deficIS: Iron sucrose; IV: Intravenous.
There was a significant rise of
Hb in the FCM group
compared to Iron sucrose:
4.68 g/dL and 3.92 g/dL
respectively (p<0.001) after 1
month.
Comparative Study of Efficacy and Safety of IV FCM vs. Iron
Sucrose in Treatment of Postpartum IDA

50. What Makes Ferric Carboxymaltose a Better Choice in
Pregnancy
1. Jose A, et al. BMC Pregnancy Childbirth. 2019;19(1):54
2. Pasricha SR, et al. The Lancet. 2023; 401 (10388):1595–1609
FCM: Ferric carboxymaltose; QoL: Quality of life.
FCM offers the advantage of large
dose administration per sitting,
which translates to better patient
compliance owing to:1
In pregnancy, FCM has been
demonstrated to improve QoL scores and
fatigue levels when compared with
standard parenteral iron therapy.1
FCM is also reported to provide a rapid
elevation of Hb levels in pregnancy.1,2
Fewer number of hospital visits
Lesser discomfort to the patient due to needle
pricks

51. FOGSI Recommendations for FCM
Compared to other
parenteral iron
preparations, FCM has
several advantages: It has
fewer side effects, single
high-dose administration is
possible, and it can reduce
the frequency of hospital
visits.
Among the various preparations of
parenteral iron supplementation, FCM was
found to be possibly better than other
parenteral iron supplementation products.
FCM is a dextran-free IV iron preparation
that allows rapid administration of high
doses of iron (up to 1000 mg iron in 15 min).
FCM administration in postpartum has been
found to be safe and effective in improving
the mean hemoglobin level.
FOGSI general clinical practice recommendations management of iron deficiency anemia in pregnancy. Available at:
https://www.fogsi.org/wp-content/uploads/2017/07/gcpr-recommendation-ida.pdf. Accessed on 25 August 2023.
FCM: Ferric carboxymaltose; FOGSI: Federation of Obstetric
and Gynaecological Societies of India; IV: Intravenous

52. In a Nutshell
IDA is the most common cause of anemia during pregnancy.
FCM has demonstrated therapeutic efficacy for conditions
associated with absolute or functional iron deficiency either with
or without anemia..
Studies confirm the safety, efficacy, and tolerability profile of FCM.
Treatment aspects of IDA include lifestyle changes, supplementation,
dietary modifications, transfusion, and pharmacotherapy.
FCM is reported to be effective in treating IDA as well as PPA
in women.
FCM: Ferric carboxymaltose; IDA: Iron-deficiency anemia;
PPA: Post-partum anemia.
Compared to other parenteral iron preparations, FCM has several advantages: It has fewer side
effects, single high-dose administration is possible, and it can reduce the frequency of hospital visits.

53. TAKE HOME MESSAGES
• From 2019, there has been adoption of anemia reduction among WRA, as an official
target indicator for the second sustainable development goal (SDG2.2 - Malnutrition)
• Anemia in pregnancy is one of the most important factors related to maternal
morbidity and mortality
• Oral iron provides an inexpensive and effective means of restoring iron balance in a
patient with iron deficiency without complicating comorbid conditions
• IV iron is appropriate for patients who are unable to tolerate gastrointestinal side
effects of oral iron
• FCM treatment in pregnancy and postpartum is likely to be safe and effective.

54. REFERENCES
• Global burden of disease study 2017.Lancet.2018 nov.10;392(10159)
• WHO Global Database on Anemia.Geneva, World Health Organization 2008.
• https://anemiamuktbharat.info
• niti.gov.in/content/anemia-alert-government
• Pavlov AD, Morshchakova EF, Rumyantsev AG. Erythropoiesis, Erythropoietin, Iron.
Moscow: GEOTAR-Media; 2011. 304 p
• Radzinsky VE, editor. Guide to Outpatient Care in Obstetrics and Gynecology. 2nd ed.,
Revised, and additional. Moscow: GEOTAR-Media; 2014. 944 p
• A teenage girl as a patient. Endocrine gynecology of physiological pubertal: Optimal
correction minimum. In: Kuznetsova IV, editor. Information Bulletin. Moscow: Editorial
staff of the magazine Status Praesens; 2014. 20 p
• Kagamimori S, Fujita T, Naruse Y, Kurosawa Y, Watanabe M. A longitudinal study of serum
ferritin concentration during the female adolescent growth spurt. Annals of Human Biology.
1998;15:413-419

55. THANK YOU!