Anemia in pregnancy Diagnosis clinical signs and symptoms and treatment of iron deficiency anemia

1. Anemia in
Pregnancy
Dr . MADHURI
Post graduate-3rd
year
AIMSR , Chittoor

2. Approach to a case of anemia in
pregnancy
 Clinical and laboratory assessment for
severity of anemia
 Typing of anemia
 Identification of the etiology of anemia
 Determining the predisposing and
precipitating factors of anemia

3. Clinical evaluation
History :
Symptoms of anemia vary with type and severity of
anemia
 Fatigue
 Weakness
 Headache
 Loss of appetite
 Dysphagia
 Palpitations
 Dyspnea on exertion
 Ankle swelling
 Paresthesia
 Leukoplakia
 Cold intolerance
 irritability

4.  History of passing worms in the stool
 Bleeding per rectum
 Haematuria
 Hyperemesis
 Malabsoroptin
 Chronic diseases like tuberculosis
 Malaria
 Bleeding diathesis
 Excessive menstrual blood loss
 Obstetric hemorrhages and infections
 Detailed h/o dietary intake of iron
containing foods and
vegetables,hematinics
 h/o intake of drugs causing bonemarrow
failure

5. General physical examination
Signs of anemia
 Pallor of mucous membranes and nailbeds
 Koilonychia or platynychia
 Cheliosis
 Angular stomatitis
 Glosssy tongue with atrophy of lingual paillae
 Dryness of skin and briittle hair
Cardiac decompensation signs such as
 Tachycardia
 Tachypnoea
 Increased JVP
 Heart murmurs (systolic murmur)
 Postural hypotension
 Ankle edema

6. Stages of iron deficiency
anemia
Iron deficiency can be divided into three
stages
1.Depletion of iron stores
2.Iron deficient erythropoises
3.Frank iron deficiency anemia

7. Diagnosis of iron deficiency
anemia
1.Hemoglobin estimation
To be checked at
Booking visit
24-28 weeks
36 weeks og gestation
MOHFW has recommended minimum of
four Hb estimations
Hb alone is not parameter to diagnose iron
deficiency anemia as there is hemodilution
in pregnancy

8. Iron studies
 Serum ferritin levels decrease,andit is
more specific and marker for for iron
deficiency aemia,
 Best test for confirmation of iron
deficiency anemia.
 Ferritin value >100ng/dl indicates
adequate iron stores
 Low iron levels
 Elevated total iron binding capacity
 Trasferrin saturation calculated by
dividing serum iron /TIBC which
decreases.

9. Markers in different stages of
anemia

10. RBC INDICES
 Good indicator of iron deficiency
 MCV(80-90fl)-decreases
 MCH(27-32pg)-decreases
 MCHC(34-37g/dl)-decreases
 Red cell distribution width(RDW)
increases
 Reticulocyte count increases

11. Peripheral blood smear
 Single most important tool in the
diagnosis for typing of anemia
 Differential RBC morphology like
microcytic, hypochromic, anisocytosis,
poikilocytosis seen in IDA
 Presence of parasites like malaria
,kala azar,toxic granules in case of
chronic infection.

12. Peripheral smear picture in iron deficiency anemia

13. Other investigations
 Stool examination for occult
blood,ova,parasites and cysts
 Urine analysis
 Blood urea ,serum creatinine,serum protein
 Liver function tests
 In peripheral smear look for any ova or
parasites

14. Advanced tests
 Free erythrocyte protoporphyrin(FEP)
Level increases
 Soluable serum transferrin
receptor(sTfR)Rises
 Zinc protoporphyrin :last step of
hemoglobin production
 Ferrous protoporphyrin+globin to make
Hb ,when there is lack of iron zinc
replaces iron to produce ZPP
 Bone marrow biopsy
 Mentzer index: it is MCV/RBC count
(millions/ul) >13 in IDA,<13 In

15. TREATMENT OF IDA
 Anaemic gravidas need120 –240mg /
per day
 Supplementation with folic acid + Vit C.
 Ferrous sulphate 300mg TID daily after
meals X 12 months
 Therapeutic results after 3 weeks – rise
in Hb % level of 0.8gm/dl/ week with
good compliance
 Rise in Hb at a rate of 2-4 gm/dl every 3
weeks till normal
 Hb conc. is normal after 6 wks of therapy

16. Prophylactic measures for iron
deficiency anemia
 Increase in dietary iron
 Green leafy vegetables
 Sprouts
 Meat
 Liver
 Iron supplementation
 60-100mg elemental iron
 With 400-500mcg folic acid
 For atleast 100 days,preferably 6 months
 From 14 weeks or from when nausea
subsides
 100 days postpartum

17. Parasite control measures in
endemic areas
 To be given in second trimester
 Hookworm infestation
 Albendazole 400 mg single dose
 Mebendazole 500 mg single dose or
100mg twice daily for 3 days
 Malaria Chemoprophylaxis in endemic
areas

18. Recommendations for the
administration of oral iron
 Best taken on empty stomach
 Early in the morning or
 2 hrs after food
 Iron salts not be given with food
 Vitc,orange juice and lemon juice increase iron
absorption
 Absorption is impaired is phytates , tannates
,and phosphtes(in tea and coffee)
Factors that inhibit the absorption of iron salts
 Milk and dairy products ,eggs ,cereals
 Calcium supplementation
 Antacids
 H2 receptor blockers , proton pump inhibitors
 Certain antibiotics(quinolones)

19. Oral iron therapy
 Ferrous sulphate more cheap and and
suitable for more patients
 Govt of india
 Ferrous sulphate 100 mg elemental
iron along with 500mcg of folic acid
 Ferrus fumarate,gluconate and
succinate have less GI side effects
and can be used in pts who cant
tolerate ferrous sulphate

21. Side effects of oral iron therapy
 Approximately 30% or more of women will
have gastrointestinal symptoms
 Nausea
 Constipation or diarrhea
 Epigastric distress
 Vomiting
 Women should is reassured that the side
effects will subside10-14 days of continuous
usage.
 Alternate dosing can be tried
 Constipation may occur but can be relieved

22.  NEW THERAPEUTIC ALTERNATIVES
 • CARBONYL Iron
 • Iron ascorbate
ADVANTAGES
 a) Outstanding GI Tolerance
 b) Very safe with no poisoning even in
high doses
 c) No interaction with food stuffs
 d) Delicious with non-metallic taste and
don’t stain the patients’ teeth
 e) Compliance is very high

23. Response to therapy
 Per week with adequate replacement
An increase in reticulocyte
count,increases 7-10 days after the
start of therapy.
 Hb level increases by0.3-1g/dl
1g/dl is expected after 2 weeks
and2g/dl after 1 month

24. Parenteral iron therapy
INDICATIONS:
a) Failure to oral iron therapy.
b) Non compliance/intolerance to oral iron
c) 1 st time seen during last 8-10 wks with
severe anemia
d) Malabsorbtion /IBD
e) Small bowel resection
f) When hemorrhage is likely to continue
g) C/I to blood transfusion
h) Combination with recombinant human
erythropoietin
i) C/I to oral therapy

25. Indications:
 Unresponsive to oral iron
 Noncompliance
 Intolerance to oral iron
 Proven malabsorption(inflammatory
bowel disease)
 Requirement for rapid Hb
response(late third trimester)
 If Hb is 7-9 g/dl after 20 weeks
gestation (govt of india
recommendation)
 As a substitute to blood tranfusion.

26. Intramuscular preparation
a) Iron Sorbitol Citrate in dextrin(Jectofer)
b) Iron Dextran (imferon)
 Iron dextran: 50 mg/mL.
 Iron sucrose: 20 mg/mL.
 Ferric gluconate: 12.5 mg/m
Intravenous preparation
 a) Iron dextran (Imferon)
 b) Iron sucrose
 c) ferric carboxy maltose

27.  Oral iron should be discontinued before
24 hrs of giving parenteral iron and after
giving for should stop for 4 weeks
atleast
 Because receptor sites are
choked,leading to an increased risk of
toxicity from free circulation.
Dose calculation
 Ganzoni’s formula
total iron dose required(mg)=2.4x(target
hb-actual hb in g/dl)x prepregnancy
wt+replenishment of stores

28.  Contraindications
 a) h/o anaphylaxis to parenteral iron
therapy
 b) 1 st trimester of pregnancy
 c) Active acute/chronic infection
 d) Chronic liver diseases
 Advantages: -
 Certainty of admission.
 Hb rises @1gm/wk.
 Disadvantage
 a) Nausea and Vomiting
 b) Metallic taste on tongue

29. Intramuscular Route
 Iron Dextran (1ml contains 50mg elemental iron &
1amp=2ml)
 Dose : 100 mg IM OD/AD till the total dose over
Drawbacks:
a) Painful injection (less with jectofer).
b) Skin discoloration
c) Local abscess
d) Allergic reaction
e) Fe over load.
f) Category C drug
g) Gluteal sarcoma
h) Test dose needed Advantage Can be given in primary
care set up
Absolute reticulocyte count increases in 7 days Hemoglobin
increases within 1-2 wks .Whole dose can be given in single
setting

30.  a) Repeated Injections
 b) Total dose infusion
Side effects: -
 Anaphylactic reaction.
 Chest pain, rigors, chills, fall in BP,
dyspnoea, hemolysis.
 Treatment:
 a) Stop infusion.
 b) Give antihistaminics, corticosteroids
& epinephrine

31.  IRON DEXTRAN
 First generation iron preparation for
intravenous administration
 a) Colloidal solution of ferric oxyhydroxide
complexed with polymersised dextran
 b) Advantage : patients total iron
requirement is given in one administration
 c) Higher rate of adverse effects like
delayed hypotension/ arthralgia/abdominal
pain
 d) Test dose is necessary
 e) Patients should be monitored 1 hr
following a test dose of 25 mg
 f) Can given as IV infusion with rate less
than 50 mg/min

32. IRON SUCROSE
 Second generation intravenous iron
preparation
 Effectively increases serum ferritin levels
safe with fewer side effects
 The dose is 200-300 mg /day,which can
be repeated every 3-4 days
 Total dose should be not more than
600mg/week
 After IV administration it dissociates into
iron & sucrose
 T 1/2 is 6hrs
 Category B drug

33. IRON SUCROSE INFUSION
 Add 200mg of iron sucrose to 100 ml of
0.9% normal saline and infuse over at
least 30 minutes
 On completion flush with 50 ml of
normal saline
 Brown staining of skin may occur due to
leakage at injection site.any burning or
swelling stop immediately.
 Patient should be observed for 30
minutes after administration
 Side effects:metallic

34.  Advantages of IRON SUCROSE over others
 a) All iron preparations were capable of causing
tissue peroxidation except iron sucrose
 b) Less oxidative injury
 c) Less risk of tissue parenchymal injury by free
iron.
 d) Higher availability for erythropoiesis than iron
Dextran
 e) IV iron supplementation increases the
erythropoiesis 5 times
 f) Safe in dextran sensitive patients
 g) Minimal side effect

35.  The Hb rise will be evident in as early
as 5 days
 IV iron sucrose is safe & effective
 Iron sucrose is given both bolus push
& infusion
 Disadvantage
 a) Total dose administered in multiple
infusions
 b) Needs a set up where anaphylactic
reaction can

36. NEWEST FAST ACTING IV
MOLECULES
Ferric carboxy maltose:
a) Ferric hydroxide carbohydrate
complex which allows for control delivery
of iron within cells of the RES (primarily
bone marrow) and subsequently delivery
to the iron binding proteins ferritin and
transferin
 b) T1/2 : 16 hr c)
 Dose : Single dose of 1000 mg over 15
minutes (maximum 15mg/kg by
injection or 20 mg/kg b

37. IRON III ISOMALTOSE(MONOFER)
 a) Strongly bound iron in spheroid iron-
carbohydrate particle providing slow
release of bioavailale iron to iron binding
proteins
 b) Rapidly up taken by RES and little
risk of free iron for tissue damage
 c) Dose : 1000 mg in a single infusion
 d) Erythropoietic response seen within
days
 e) Serum ferritin returns to normal by 3
wk

38. FERUMOXYTOL
 USA FDA approved this drug in 2009 for
iron replacement in patients with IDA &
CKD
 No test dose required
 Can be given as large dose (510
mg/vial) in <20
 Seconds in single settings
 No significant side effects
 Not approved in EuropeSeconds in
single settings

39. FAILURE TO RESPOND
 Non compliance
 Concomitant folate deficiency
 Continuous loss of blood through
hookworm infestation or bleeding
haemorrhoids
 Co-existing infection
 Faulty iron absorption
 Inaccurate diagnosis
 Non iron deficiency microcytic anaemia

40. BLOOD TRANSFUSION
 Decision based on
 Needs and risk of developing
complications of inadequate
oxygenation
Both clinical and hematological grounds
Indications
 a) Severe anemia, especially after 36
weeks
 b) Risk of further hemorrhage
 c) Associated infections
 d) Imminent cardiac compromis

41. Indications of packed cell
transfusion
 Hb<5g/dl at any gestational age
 Hb <7g/dl in late third trimester
 Women with severe anemia in labour
 Severe anemia with decompensation
 Acute hemorrhage

42. MANAGEMENT DURING LABOUR
 Consideration for delivery in well equipped
hospital.
 Avoid sympathetic stimulation and
hyperventilation; prevent rightward shift of
ODC.
 Supplemented with oxygen therapy
 Prophylactic forceps/ Vaccum to cut short 2 nd
stage
 Decreased blood loss by active management
of 3rd stage of labors.
 Avoid maternal stress, patient can go into CHF.
 PPH should be emergently treated(uterotonics