2. Definition
• The qualitative definition of anemia is decreased oxygen carrying
capacity of blood due to decraese in amount of RBC’s or Hb or both.
• Quantitaively,As per WHO recommendation, anemia is
diagnosed when Hb<11gm/dl and PCV<33%.
-First trimester – Hemoglobin <11 g/dL (approximately equivalentto
a hematocrit <33 percent)
-Second trimester – Hemoglobin <10.5 g/dL(approximate
hematocrit <31 or 32 percent)
-Third trimester – Hemoglobin level <11 g/dL(approximate
hematocrit <33 percent)
3. Classifiaction of anemia
HERIDITARY:
1) THALASSEMIA
2) SICKLE-CELL HEMOGLOBINOPATHIES
3) HERIDITARY HEMOLYTIC ANAEMIAS
4) OTHER HEMOGLOBINOPATHIE
ACQUIRED:
1) IDA
2) DIMORPHIC ANAEMIA – ANAEMIA DUE TO IRON AND FOLIC ACID
DEFICIENCY
3) ANAEMIA CAUSED BY ACUTE BLOOD LOSS
4) ANAEMIA OF INFLAMMATION/MALIGNANCY
5) MEGALOBLASTIC ANAEMIA
6) ACQUIRED HEMOLYTIC ANAEMIA
7) APLASTIC /HYPOPLASTIC ANAEMIA
4. Causes in
pregnancy
• Increased demand
• Diminished intake of iron-faulted diet habits, nausea, vomiting
and reduced appetite
• Disturbed metabolism- faulty absorption, depressed
erythropoiesis and infections.
• Pregnancy competes for folic acid, vitamin B12 and proteins-
polymorphism
• Excess or abnormal demand as in younger age(<21),
multiple pregnancy, repeated pregnancy with lesser gap in
between
5. Increased iron requirement during
pregnancy
• Total cost of one pregnancy is about 1000 mg which is not met by a
normal Indian diet.
Fetus and placenta – 300mg
For maternal Hb expansion – 500mg
Basal loss – 200mg
During delivery – 400mg
Total need – 1400 mg
Due to cessation of menstruation and contraction of expandedblood
volume after delivery amounts to 400mg, therefore net Iron req is
approx 1000mg
8. Investigations to diagnose type of
anaemia
• Blood indices:
1) RBC count: ( normal = > 3.2 million/cu.cm)
a) decreased in anaemia
2) PCV falls below 32%
3) MCV ( n= 78-92 mcm3):
a) microcytic- iron deficiency anaemia
b) macrocytic anaemia- folate deficiency
4) MCHC- MOST SENSITIVE INDICATOR OF IDA ( N= 26-
30% , DECREASED IN IDA)
9. Peripheral
Smear
• Microcytic and hypochromic cells – IDA
• Macrocytic cells – Folate or Vit B12 def
• Normocytic cells – Early nutritional defeciency
• Schisto/Aniso and poikilocytes – Hemolytic Anemia
• Sickle cell – in SCA
• Wbc hypersegmented – Megaloblastic anemia
• Target cells – Thalassemia
• Platelet may be decreased.
10.
11. To diagnose aetiology
• Urine R/M
• Urine C/S
• Stool examination
• Bone marrow Examination
• Chest X ray
• RFT
• Serum protein
• Osmotic fragility
• Electrophoresis
12. SPECIAL
INVESTIGATIONS
• TO CONFIRM DIAGNOSIS AND SEVERITY OF
IDAANAEMIA
1) S.FERRITIN: N: 40-60 ng/Dl , decreased to < 20 ng/ml .
2) SERUM IRON: N= 65-165 mcg/ Dl . Decreased in ida
3) SERUM TIBC: N= 300-360 mcg/Dl.Increases as severity
increases
4) % saturation of transferrin: 35-50%. DECREASED TO <
20%.
5) RBC PROTOPORPHYRIN : 30 mcg/Dl . In IDA it is
doubled/ tripled.
13. Tests to ensure response to therapy
1) Increase in Hb.
2) Retic count increases.
3) PBS- decrease in all types of abnormal
cells
16. MANAGEMENT OF IRON DEFICINECY
ANAEMIA IN PREGNANCY
• A) PROPHYLACTIC THERAPY
• B) CURATIVE THERAPY
• 1) ORAL IRON THERAPY
• 2) PARENTERAL IRON
THERAPY
• C)BLOOD TRANSFUSION
17. PROPHYLACTIC
THERAPY
• AVOID FREQUENT CHILD BIRTHS( MINIMUM GAP 2
YRS)
• SUPPLEMENT IRON TABLETS
• EARLY DETECTION OF FALLING Hb LEVELS AT-
1. FIRST ANTENATAL VISIT
2. 30 TH WEEK
3. 36 TH WEEK
18. FOOD BASED
STRATEGIES
1) DIETARY MODIFICATION / IMPROVEMENT:
• NET IRON DEMAND IN PREGNANCY IS 840 mg.
• IRON REQUIREMENTS DECREASE DURING 1ST
TRIMESTER BUT INCREASE TO 4-6mg/d IN SECOND
TRIMESTER AND 10mg/d IN LAST 6-8 WKS OF
PREGNANCY
19. • DIET RICH IN IRON:
A) RICH : LIVER, EGG YOLK , MEAT , DRY BEANS , DRY
FRUITS , WHEAT GERMS AND YEAST
B) MEDIUM:MEAT, CHICKEN , FISH , SPINACH ,BANANA,
APPLE.
C) POOR: MILK AND MILK PRODUCTS( CALCIUM),
ROOT VEGETABLES
AVOID TAKING THIS WITH IRON- PHYTATES(CEREALS),
TANNINS( TEA-COFFEE), CALCIUM
ENHANCE ABSORPTION: HEME, ASCORBIC ACID, FERROUS
IRON.
20. FOOD
FORTIFICATION
• SODIUM IRON DIETHYLENE DIAMINE TETRA ACETIC ACID
(NaFeEDTA) IS FREQUENTLY USED OWING TO
EFFECTIVENESS IN DIET RICH IN PHYTATES LIKE SUGAR,
CURRY POWDER , SOY SAUCE ETC.
• MICRONISED GROUND FERRIC PYROPHOSPHATE IS USED TO
FORTIFY RICE IN INDIA.
• BIOFORTIFICAITON IS A RECENT APPROACH IN WHEAT,
BEANS , MAIZE ETC.
DOUBLE FORTIFIED IRON SALT CONSUMPTION IN PREGNANT
FEMALES ALONG WITH IFA IS FOUND HELPFUL, ADDING 93 mg
IRON OVER 6 MON OF SUPPLEMENTATION
22. CURATIVE
THERAPY
• A) ORAL IRO THERAPY:
• Hb RISES BY 0.7-1 gm/wk
• 180-200 mg ORAL IRON (3 TAB/DAY) AND 1mg FOLIC
ACID TILL RETIC COUNT IS NORMAL( EARLIEST
PARAMETER TO CHANGE AFTER GIVING ORAL IRON)
• THEN MAINTAINENCE DOSE OF 1 TAB/DAY
THROUGHOUT PREGNANCY AND 100 DAYS AFTER
PREGNANCY
23. PARENTERAL IRON THERAPY:
INDICATION : ( ADVANTAGEOUS IN CERTAININTY
OF ADMINISTRATION)
1) ON HEMO/PERITONEAL DIALYSIS
2) MALABSORPTION SYNDROME
3) SEVERE ANAEMIA PREGNANT FEMALES( AS PER WHO,
Hb=)
RISE OF Hb IN PARENTERAL IRON= ORAL IRON.
24. • PARENTERAL IRON FORMS:
MOST USED: IRON DEXTRAN, IRON SORBITOL
IT REPLACED IRON SUCROSE AND IRON
CARBOXYMALTOSE DUE TO DECREASED SIDE EFFECTS
AND ANAPHYLACTIC RISK.
25. IRON
DEXTRAN
DOSE AND ROUTE:
TEST DOSE OF 50 mg IM 24 HRS BEFORE 1ST DOSE FOLLOWED BY 100 mg OD
DEEP IM BY Z TECHNIQUE .
ADR OF IM ROUTE:
1. PAIN AT INJECTION SITE
2. RISK OF ABSCESS
FORMATION
3. SKIN STAINING
4. ARTHRALGIA
5. FEVER
6. LYMPHADENOPATHY
ADR OF IV
ROUTE- RISK
OF SEVERE
ANAPHYLAXIS
26. IRON
SUCROSE
• DOSE AND ROUTE:
200-300 mg /DOSE , 2-3 TIMES PER WEEK IV, MAX 600
mg/WEEK.
UNDILUTED 200 mg SLOW IV AT
20 mg/MIN AFTER TEST DOSE
OF
20 mg OVER 1-2 MIN
IV INFUSION 200
mg DILUTED IN
MAX 200 ml
NORMAL SALINE
OVER 15-20 min.
27. IRON
CARBOXYMALTOSE
• DOSE AND ROUTE:
1) UNDILUTED SLOW IV PUSH AT 100mg/MIN
OR
2)INFUSION OF 1000mg OVER 15 min. CONC OF INFUSION
>/= TO 2mg/mL.
• NO NEED OF TEST DOSE AND IT SHOULD BE
DILUTED IN NORMAL SALINE.
28. TOTAL IRON REQUIREMENT OF
PARENTERAL IRON
Required dose in mg = (2.4* body wt( kg) * Hb DEFICIT( g/dl)
* pre pregnancy wt(kg))+ 1000 mg for replenishment stores.
31. • ONE UNIT OF BLOOD RAISES Hb LEVELS BY 0.8-1g%
WITHIN 24 HRS.
• Hb AT TIME OF DELIVERY SHOULD BE ATLEAST 7 gm%
32. OVERVIEW OF MANAGEMENT OF IDA
IN PREGNANCY
IRON
DEFICIENCY
ANAEMIA
FOLIC ACID
DEFICIENCY
PREGNANCY< 30 WKS ORAL-------> IM/IV
IF
INTOLERANT/NON
- COMPLIANT
ORAL FOLATE
THERAPY
PREGNANCY 30-36 WK IM/IV
PARENTERAL
IRON
ORAL FOLATE
THERAPY
PREGNANCY > 36 WK BLOOD TRANSFUSION
• IN DIMORPHIC ANAEMIA , BOTH IRON AND FOLIC
ACID IN THERAPEUTIC DOSES.
33. Management during labour
1. Close monitoring
2. Watch for dystocia and prolonged labour.
3. Forceps to shorten stage ii
4. Follow active management in 3rd stage of labour.
5. PPBC transfusions , SOS
6. WATCH FOR PPH.
34. REFERENC
ES
• FOGSI GENERAL CLINICAL PRACTICE
RECOMMENDATIONS FOR MANAGEMENT OF IDA IN
PREGNANCY
• HOLLAND AND BREWS TEXTBOOK OF OBSTETRICS
