Obgyn_Anemia_in_Pregnancy_for_UG_class.ppt
- 2. Learning Objectives Diagnose anemia in pregnancy Learn the effect on mother & fetus Learn S/S in pregnancy Learn prevention of anemia Learn supplementation of oral iron during pregnancy Management of anemia during pregnancy Labor & Delivery management National anemia control program Post partum contraception
- 3. Background Information Commonest medical disorder in pregnancy Prevalence in India varies between 50-70% Prevalence in USA is 2-4% Nutritional anemia (Fe deficiency) is commonest It is important contributor to maternal & perinatal morbidity & mortality as a direct or indirect cause
- 4. Definition - Anemia A condition where circulating levels of Hb are quantitatively or qualitatively lower than normal Non pregnant women Hb < 12gm% Pregnant women (WHO) Hb < 11 gm% Haematocrit < 33% Pregnant women (CDC) Hb <11 gm% 1st &3rd Trimester 2nd trimester Hb < 10.5 gm%
- 5. ICMR Anemia Severity Classification Hb values Mild 10.0-10.9 gm% Moderate 7-9.9 Severe <7 Very Severe <4
- 6. Causes of Anemia in Pregnancy Nutritional / Iron deficiency anemia Pre-pregnancy poor nutrition very important Besides Iron, folate and B12 deficiency also important Chronic blood loss due to parasitic infections – Hookworm & malaria Multiparity Multiple pregnancy Acute blood loss in APH, PPH Recurrent infections (UTI) - anemia due to impaired erythropoiesis Hemolytic anemia in PIH Hemoglobinopathies like Thalassemia, sickle cell anemia Aplastic anemia
- 7. Patho-physiology of Nutritional Anemia in Pregnancy Augmented erythropoiesis in pregnancy Blood volume increases 40-45% in pregnancy Increase in plasma is more as compared to red cell mass leading to hemodilution & decrease in Hb level Iron stores are depleted with each pregnancy Too soon & too many pregnancies result in higher prevalence of iron deficiency anemia
- 8. Extra Iron Requirement & Loss During Pregnancy Due to cessation of menses & contraction of blood volume after delivery conservation of iron is around 400 mg
- 9. Factors Required for Erythropoiesis Proteins for synthesis of Globin Mineral – Iron for synthesis of heme Hormones – Erythropoietin (produced from Kidney, stimulates stem cells in Bone Marrow), Thyroxine, Androgens Trace elements – Zinc (also important for protein synthesis & Nucleic acid metabolism), Cobalt, Copper Vitamins – Vit B12 required for synthesis of RNA in early stage, Folic acid (Vitamin 9) required in later stage for DNA synthesis Vitamin C necessary for conversion of folic acid to folinic acid, it enhances absorption of iron from small intestine Pyridoxine B6 useful adjuvant in erythropoiesis Vitamin A required for cell growth, differentiation & maintenance of integrity of epithelium, immune function
- 10. Pharmaco-kinetics of Iron / daily requirement Normal diet contain about 14 mg of iron Absorption of iron is 5-10% (1- 2 mg) & 3-4% in pure veg diet Additional daily iron demand in early pregnancy 2-3 mg/day In late pregnancy 6-7 mg/day So daily supplement of 40-60 mg of elemental iron is required during pregnancy Folic acid requirement is also increased 400-600 mcg/day In strict veg Vit B 12 is also deficient
- 12. Clinical Presentation Depends on severity of anemia High risk women – adolescent, multiparous, multiple pregnancy, lower socio economic status Mild anemic - asymptomatic Symptoms – pallor, weakness, fatigue, dyspnoea, palpitation, swelling over feet & body Signs – pallor, facial puffiness, raised JVP, tachycardia, tachypnea, crepts in lung bases, hepato-splenomegaly, pitting oedema over abdominal wall & legs Haemic murmur, cardiac failure Glossitis, stomatitis, chelosis, brittle hair
- 14. Effect of Anemia on Pregnancy & Mother Higher incidence of pregnancy complications APH (abruptio placentae, preterm labor) Predisposed to infections like – UTI, puerperal sepsis Increased risk to PPH Subinvolution of uterus Lactation failure Maternal mortality – due to CHF, Cerebral anoxia, Sepsis, Thrombo-embolism
- 15. Effect of Anemia on Fetus & Neonate Higher incidence of abortions, preterm birth, IUGR IUD Low APGAR at birth Neonate more susceptible for anemia & infections Higher Perinatal morbidity & mortality Anemic infant with cognitive & affective dysfunction
- 16. Most Critical Period 28-30 weeks of pregnancy In labor Immediately after delivery Early Puerperium CHF (Failure to cope up with pregnancy induced cardiac load)
- 17. Work Up of Pregnancy with Anemia Detailed H/o – age, parity, diet, chronic bleeding, worm infestation, malaria, race etc Examination Pallor Glossitis Splenomegaly – hemolytic anemia Jaundice – hemolytic anemia Purpura – bleeding disorder Evidence of chronic disease – Renal , TB Anasarca & signs of cardiac failure in severe cases
- 18. Investigation Severity of anemia – Hb & Haematocrit, at first visit, 28-30 weeks & 36 weeks Type of anemia – GBP microcytic, macrocytic, dimorphic, normocytic, hemolytic, pancytopenia Bone marrow activity – reticulocyte count (N .2-2%), higher bone marrow activity is seen in hemolytic anemia following acute blood loss iron def anemia on treatment Cause of anemia – by various investigations
- 19. GBP - Stained with Leishman stain Normal smear – Normocytic (Normal size RBC), normochromic (Normal colour RBC) Iron deficiency – Microcytic (small RBC), hypochromic (pale RBC), anisocytosis (variation in size), poikilocytosis (variation in shape), with or without target cells Malarial parasites can be seen Aplastic anemia shows low/no counts Sickle cells can be demonstrated Toxic granules can be seen Abnormal Blast cells seen in Leukemia Target cells in Thalassemia Bone marrow aplastic anemia Malarial parasite Blast cells Fe def anemia Target cells Thalassemia Toxic granules
- 20. Red Cell Indices RBC count – decreases in anemia (N 3.2 million/cu mm) PCV - < 32%, (N37-47%) MCV – low in Fe def anemia, microcytic MCH - decreases MCHC – decreases, one of the most sensitive indices (N26-30%)
- 21. Special Investigations Serum Ferritin – abnormal if < 20 ng/ml (N 40-160 ng/dl), assess iron stores Serum Iron – N 65-165 ug/dl, decreases in Fe def anemia Serum Iron binding capacity – 300-360 ug/dl, increases with severity of anemia Percentage saturation of transferrin – 35-50%, decreases to less than 20% in fe def anemia RBC Protoporphyrin – 30ug/dl, it doubles or triples in Fe def anemia ( substrate to bind with Fe, can not be converted into Hb in Fe def))
- 22. Differentiation between iron deficiency anemia & Thalassemia 9diminished synthesis of Hb b chains in Thalassemia) Investigations Normal values Fe Def Anemia Thalassemia MCV 75-96 fl reduced V reduced MCH 27-33pg reduced V reduced MCHC 32-35 gm/dl reduced N or reduced HbF <2 % normal Raised HbA2 2-3% N or reduced Raised >3.5% Serum Iron 60-120 ug/dl reduced Normal Serum Ferritin 15-300 ug/L reduced Normal TIBC 300-350 ug/dl Raised Normal Bone iron stores reduced Normal Free erythrocyte protoporphyrin (FEP) <35 ug/dl >50 Normal
- 23. Other Investigations Urine examination – RBC & Casts Stool examination – occult blood, ova Bone marrow examination – refractory anemia X-Ray chest – Pulmonary TB BUN/Serum creatinine – Renal disease
- 24. Treatment for Iron Deficiency Anemia Improving diet rich in iron & fruits & leafy vegetables Treat worm infections, maintain general hygiene Food fortification with iron & genetic modification of food Iron & folic acid supplementation in young girls & during pregnancy Heme iron better, present in animal food & is better absorbed Iron absorption enhanced by citrous fruits, Vit C Avoid tea, coffee, Ca, phytates, phosphates, oxalates, egg, cereals with iron
- 25. Iron Rich Foods Green leafy vegetables-chana sag, sarson ka sag, chauli. Sowa, salgam Cereals - wheat, ragi, jowar, bajra Pulses-sprouted pulses Jaggery Animal flesh food - meat, liver Vit C - lemon, orange, guava, amla, green mango etc.
- 26. Iron supplementation in Pregnancy 60 mg elemental iron & 400 ug of folic acid daily during pregnancy and 3 months there after In anemia therapeutic doses are 180-200 mg /d Route of administration depends on, severity of anemia, Gest age, compliance & tolerability of iron Various preparations – fumarate, gluconate, succinate, sulfate, ascorbate Carbonyl iron better tolerated Oral iron can have side effects like nausea, vomiting, gastritis, diarrhoea, constipation Iron supplementation not recommended in first trimester Higher incidence of miscarriage Birth defects Bacterial infection (bacteria grow after taking iron from supplementation)
- 27. Oral Iron Hb 8-11 gm%, early preg Contraindication to Oral Iron Therapy Intolerance to oral iron Severe anemia in advanced pregnancy Non compliant Failure to Respond Inaccurate diagnosis Faulty absorption Continuous blood loss Co-existant infection Concomitant folate deficiency Indicators of response to therapy Feeling of well being Improved look of patient Better appetite Rise in Hb .5-.7 gm/dl per week (starts after 3 weeks) Reticulocytosis in 7-10 days
- 28. Parenteral Iron Transfusion Iron sucrose for parenteral use Dose calculated - Wt in Kg x iron deficit x 2.2 + 1000 mg for iron stores Response - by increase in Hb level 1g/week Increase in Reticulocyte count with in 5-10 days Clinical symptoms improve
- 29. Indications for Blood Transfusion Severe anemia first seen after 36 weeks of pregnancy Anemia due to acute blood Loss – APH & PPH Associated Infection Patient not responding to oral or parenteral therapy Anemic & symptomatic pregnant women (dyspneic, with heart failure etc) irrespective of gestational age
- 30. Management of Labor Labor should be supervised Proper counseling & consent to be taken Blood (whole & packed) kept cross matched Women nursed in propped up position Intermittent O2 to be given Precaution to prevent infection & blood loss Strict aseptic precautions & minimal P/V exams Prophylactic antibiotic can be given Patent iv line but fluids are avoided In decompensated patient diuretic given
- 31. Second & Third Stage of Labor Second stage cut short by forceps or ventouse Active management of 3rd stage of labour to be done Oxytocics, P/R misoprostol can be given after delivery of fetus Injection methergin iv contraindicated Even normal blood loss may be tolerated poorly in anemic patient IV Frusemide given after delivery to decrease cardiac load
- 32. Post Natal Care & Contraception Early ambulation is encouraged Hematinics are continued for 3-6 months Watch for subinvolution , puerperal sepsis, CHF, thrombo-embolism & lactation failure Avoid pregnancy at least for 2 years LAM, barrier contraception, POP after 3 weeks, IUCD or permanent sterilization
- 33. Anaemia Mukt Bharat (AMB PROGRAM)
- 37. Age group Dose and Regime for IFA supplementation 6 – 59 months of age -Biweekly, 1 ml Iron and Folic Acid syrup -Each ml of Iron and Folic Acid syrup containing 20 mg elemental Iron + 100 mcg of Folic Acid -Bottle (50ml) to have an ‘auto-dispenser’ and information leaflet as per MoHFW guidelines in the mono-carton 5- 10 years children -Weekly, 1 Iron and Folic Acid tablet -Each tablet containing 45 mg elemental Iron + 400 mcg Folic Acid, sugar-coated, pink color School going adolescent girls and boys, 10-19 years of age and Out of school adolescent girls 10-19 years age -Weekly, 1 Iron and Folic Acid tablet -Each tablet containing 60 mg elemental iron + 500 mcg Folic Acid, sugar-coated, blue color
- 38. Women of reproductive age (non- pregnant, non-lactating) 20-49 years Weekly, 1 Iron and Folic Acid tablet Each tablet containing 60 mg elemental Iron + 500 mcg Folic Acid, sugar- coated, Red color All women in the reproductive age group in the pre-conception period and up to the first trimester of the pregnancy are advised to have 400 mcg of Folic Acid tablets, daily Pregnant women and lactating mothers (0-6 months child) -Daily, 1 Iron and Folic Acid tablet starting from the fourth month of pregnancy ( second trimester), continued throughout pregnancy (minimum 180 days during pregnancy) and to be continued for 180 days, post- partum -Each tablet containing 60 mg elemental Iron + 500 mcg Folic Acid, sugar- coated, Red color
- 39. Pregnant woman is considered anemic when her Hb is below (unit gm/dl) A. 12 B. 11 C. 10 D. 9
- 40. Most common cause of anemia in pregnancy in India is A. Nutritional anemia B. Parasitic anemia C. Aplastic anemia D. Thalassemia
- 41. Iron deficiency anemia can be diagnosed earliest by which laboratory test A. Hb% B. Serum ferritin C. Serum iron D. RBC protoporphyrin
- 42. Response to anemia management by oral Fe therapy in pregnancy can be assessed earliest by A. Increase in Hb% B. Increase in reticulocyte count C. GBP D. Increase in S ferritin
- 43. Which complication is not common in Pregnancy with anemia A. PIH B. Preterm labour C. GDM D. Puerperal sepsis