TREATMENT OF ANEMIA IN PREGNANCY

1. TREATMENT OF
ANEMIA IN
PREGNANCY

2. Prophylactic Measures
1. Avoidance of frequent childbirths- A minimuminterval of 2 years, if not
3, to replenish the lost iron during childbirthprocess and lactation. This
can be achievedby proper family planning.
2. Supplementary Iron Therapy- Only 20% of pregnant women have iron
stores of 500 mg which is the minimumessential for pregnancy and
about 40% have virtually no iron stores. Therefore, iron supplementation
during pregnancy is essential even with a balanced diet after the
patient becomes free from nausea. Daily administration of 200 mg
ferrous sulphate (containing 60 mg elemental iron) and 1 mg folic acid
is an effective prophylaxis. Tea should be avoided within 1 hour of
taking iron tablet.

3. 3. Dietary prescription – A realistic balanced diet,rich in iron and protein should
be prescribed which should be withinthe patient’s reach and should be easily
digestible. The foods rich in iron are liver, meat, egg, green vegetables, figs,
beans, whole wheat and jaggery etc. Iron utensils should be preferably used for
cooking and water used in rice and vegetable cooking shouldn’t be discarded.
4. Adequate treatment- Of any underlyinghookworminfestation,dysentery,
malaria, bleedingpiles and UTI.
5.Early detection of falling hemoglobin level is to be made. Hemoglobin should
be estimated at the first antenatal visit, at the 30th week and finally at 36th week.

5. Curative Measures
Treatment must be preceded by an accurate diagnosis of the cause and type
of anemia.
◦ Hospitalisation-Ideally all patients having hemoglobin level9g/100 ml or less
should be admitted for investigationand treatment.But due to high
prevalence and inadequate hospital beds, an arbitrary hemoglobin level of
7.5 g/ 100 ml may be considered for hospitalisation. Associated obstetrical-
medical complication evenwith moderate degreeof anemia.
◦ General treatment-
1. Diet
2. To improve appetiteand facilitatedigestion, preparation of acid pepsin
maybe giventhrice daily after meals.
3. To eradicate even a mimimal septic focus by appropriate antibiotictherapy.
4. Effectivetherapy to cure the disease contributingto the cause of anemia.

6. Specific Therapy
Principle- to raise the hemoglobin level as near to normal as possible and to
restore the iron reserve before the patientgoes in labor.
Choice of therapy depends on-
1. Severity of anemia
2. Time availablebefore delivery
3. Associated complicating factors
Iron therapy-
1. Oral therapy
2. Parenteral therapy

7. Oral therapy
◦ Iron is best absorbed in the ferrous form.
◦ Available preparations- ferrous gluconate, ferrous fumarate or ferrous
succinate.
◦ Widely used- ferrous sulphate
◦ Fersolate tablet contains 325 mg ferrous sulfate which contains 60 mg of
elemental iron, trace of copper and manganese.
◦ Initial dose in one tablet to be given thrice daily 30 minutes before meals. If
larger dose is necessary (maximum 6 tablets a day), it should be gradually
stepped up in 2 to 3 days.
◦ Treatment continued till blood picture becomes normal; thereaftera
maintenance dose of 1 tablet daily is to be continued for at least 100 days
following deliveryto replenish the iron stores.

8. Drawbacks-
1. Intolerance:Epigastric pain, nausea, vomiting, diarrhoea or constipation. To avoid,
start the therapy with a smaller dose (1 tab daily) and then increase the dose to a
maximum of 3 tablets a day. If ineffective , switch preparations.
2. Unpredictable response rate: Various factors affect iron absorption and utilisation,
hence can’t be instilled confidentlywhen rapid response is needed. Antacids,
oxalates and phytates reduce absorption while ascorbic acid, lactate and various
amino acids increase its absorption .
3. With the therapeutic dose: serum iron may be restored but there is difficulty
replenishing the iron store.
Response of therapy is evidencedby-
1. Sense of well-being.
2. Increased appetite
3. Improvedoutlook of the patient
4. Hematological examination

9. Rate of improvement – shouldbe evident within 3 weeks of therapy. Hemoglobin rises at
the rate of 0.7g /dl every week after 3 weeks of starting oral therapy.
Causes of failure of improvement-
1. Improper typing of anemia
2. Defective absorption due to GIT disorders
3. Non- compliance or improper consumption
4. Concurrent blood loss as in hookworm infestationor bleeding piles
5. Inhibition of erythropoiesis by infection
6. Co-existent folate deficiency
Contraindications of oral therapy-
1. Intolerance
2. Severe anemia in advanced pregnancy

10. Parenteral therapy
◦ Intravenous route: Repeated injections, Total Dose Infusion(TDI)
◦ Intramuscular route
Hemoglobin rises at the rate of 0.7 to 1g /100 ml/ week.
TDI- Total amount of iron required to correct the deficit is calculated and administeredin
a singlesitting intravenous infusion. The compounds used are iron sucrose, sodium ferric
gluconate or iron dextran.
Iron sucrose is safe, effective and has less side effects.
Advantages
Limitations: Maximum hemoglobin response doesn’t appear before 4 to 9 weeks, thus
method is unsuitable if atleast 4 week’s time js not available to raise hemoglobin to a
safe level of 10g/ dl before delivery. Most suitable during 30-36 weeks of pregnancy.

11. ◦ Iron (ferrous) sucrose (20mg elemental iron /ml) 100mg /dose, usually one dose daily for
10 days.
◦ Sodium ferric gluconate complex 125mg/dose usually one dose/ day usually8 doses
needed (12.5mg elemental iron /ml).
Estimationof total requirement for iron dextran
0.3 X W (100-Hb%) mg + 50% (for partial replenishment of the body iron store)
W- weight of patient in pounds
Prerequisites for infusion

12. Intramuscular therapy
Compounds used-
◦ Iron sucrose (20mg/ml)
◦ Sodium ferric gluconate complex (12.5mg elemental iron/ml)
◦ Iron dextran ( Imferon) ( 50mg/ml)
Procedure of injections-
To prevent dark staining of skin over the injectionsites and to minimise pain, injections are
given with a 2 inch needle deep into the upper outer quadrant of the buttock using a ‘Z’
technique.
An additional precaution is to inject small quantity of salinedown the needle before
withdrawing it. This will prevent even a small drop of solutionto come beneath the skin
surface to stain it.
Drawbacks

13. Blood transfusion
Indications:
◦ Anemia correction due to blood loss and to combat postpartumhemorrhage
◦ Patient with severe anemia seen in later months of pregnancy ( beyond 36 weeks)– to
improve anemic state before patient goes into labor.
◦ Refractory anemia
◦ Associated infection
Quality and quantity of blood:
1. Relatively fresh, properly typed, grouped and cross-matched. Only packedcells are
transfused.
2. Quantity should be between 80 and 100 ml at a time.
3. To allow for circulatory readjustment transfusion shouldn’t be repeated within 24 hours.

14. Advantages of blood transfusion
1. Increases Oxygen carrying capacity
2. Hemoglobin from hemolysed red cells may be utilised for the formation of new red cells.
3. Stimulates erythropoiesis
4. Supplies the natural constituents of blood like proteins, antibodies etc.
5. Improvement is expected after 3 days.
Precautions:
1. Antihistaminic is given intramuscularly. (Phenergan 25mg)
2. Diuretics given intramuscularlyatleast 2 hours prior to produce negative fluid balance.
3. The drip rate should be about 10 drops per minute
4. The pulse,respiration and crepitations in the base of lungs should be observed.
Drawbacks:
1.Premature labor due to blood reaction.
2.Increased chance of cardiac failure with pulmonary edema because of overloading of
heart.
3.Transfusiomreaction.

15. Management During Labor
◦ First stage:
1. The patient should be in bed and lie in a position comfortable to her.
2. Arrangements for oxygen inhalation to be kept ready to increase maternal blood
oxygenation and diminish the risk of fetal hypoxia.
3. Strict asepsis
◦ Second stage:
1. Asepsis maintained
2. Prophylactic low forceps or vacuum delivery to shorten the duration of second stage
3. Injection oxytocin 10 IU IM should be given soon following the delivery of the baby.
◦ Third stage:
1. Significant blood loss should be replenished by fresh packed cell transfusion.

16. Puerperium
1. Prophylactic antibiotics to prevent infection
2. Predelivery antianemic therapy should be continuedfor atleast 3 months following
delivery or till the patient restores her normal clinical and hematological states.
3. Patient shouldbe warned of the danger of recurrence in subsequent pregnancies.