ANAEMIA IN ANAEMIA IN PREGNANCYPREGNANCY

Desabandu Dr. G.H.K.K. GunawardanaDesabandu Dr. G.H.K.K. GunawardanaM.B.B.S.,M.S.(Obs & Gyn), M.B.B.S.,M.S.(Obs & Gyn), F.R.C.O.G.,F.C.O.C.(S.L )F.R.C.O.G.,F.C.O.C.(S.L )Consultant Obstetrician and Consultant Obstetrician and GynaecologistGynaecologistTeaching Hospital,Teaching Hospital,Peradeniya.Peradeniya.

A common and world wide problem A common and world wide problem that deserves more attention.that deserves more attention.

Over half of the pregnant women in Over half of the pregnant women in the world are anaemic.the world are anaemic.

For many developing countries For many developing countries prevalence rate is up to 75% (WHO)prevalence rate is up to 75% (WHO)

Not only it is common it is often Not only it is common it is often severe.severe.

In developed countries the average In developed countries the average prevalence is 18% (WHO)prevalence is 18% (WHO)

Prevalence of anaemia in pregnant Prevalence of anaemia in pregnant

women by WHO region, 1998women by WHO region, 1998

Contribute significantly to maternal Contribute significantly to maternal mortality and morbidity.mortality and morbidity.

WHO estimates that anemia WHO estimates that anemia contributed to approximately 20% of contributed to approximately 20% of the maternal deaths worldwide in the maternal deaths worldwide in 1995 in combination with maternal1995 in combination with maternal

haemorrage.haemorrage.

WHO DefinitionWHO Definition

Haemoglobin concentration <11.0g/dl Haemoglobin concentration <11.0g/dl in the first half of the pregnancy and in the first half of the pregnancy and <10.5g/dl in the second half.<10.5g/dl in the second half.

It is further divided in to,It is further divided in to,

Mild 10.0-10.9 g/dlMild 10.0-10.9 g/dl

Moderate 7.0 - 9.9 g/dlModerate 7.0 - 9.9 g/dl

Severe <7.0 g/dlSevere <7.0 g/dl

Causes of Anaemia in Causes of Anaemia in PregnancyPregnancy

Nutritional anaemias – Iron deficiencyNutritional anaemias – Iron deficiency Folate deficiencyFolate deficiency B12 deficiencyB12 deficiency Chronic blood loss – Haemorroids, GI Chronic blood loss – Haemorroids, GI

bleedingbleeding Short birth intervalsShort birth intervals Infections – HIVInfections – HIV MalariaMalaria Haemotological conditions – LeukemiaHaemotological conditions – Leukemia Sickle cell diseaseSickle cell disease ThalasaemiaThalasaemia

Normal Physiological Normal Physiological Changes in PregnancyChanges in Pregnancy

Plasma volume expands by 46-55%Plasma volume expands by 46-55%Red cell volume expands by 18-25%Red cell volume expands by 18-25%

HaemodilutionHaemodilution

““Physiological Anaemia of Pregnancy”Physiological Anaemia of Pregnancy”

not considered abnormal unless the not considered abnormal unless the levels fall too low.levels fall too low.

Effects of Anaemia in Effects of Anaemia in PregnancyPregnancy

Increased risk of abortionsIncreased risk of abortionsIncreased risk of premature labourIncreased risk of premature labourIncreased risk of IUGRIncreased risk of IUGRIncreased risk of mortality following Increased risk of mortality following

PPH PPHIncreased risk of puerperal sepsisIncreased risk of puerperal sepsis

Risk FactorsRisk FactorsAssociated with: Associated with: Twin or multiple pregnancy Twin or multiple pregnancy

Poor nutrition, especially multiple vitamin Poor nutrition, especially multiple vitamin deficiencies deficiencies

Smoking, which reduces absorption of important Smoking, which reduces absorption of important

nutrients nutrients Excess alcohol consumption, leading to poor Excess alcohol consumption, leading to poor

nutrition nutrition Any disorder that reduces absorption of nutrients Any disorder that reduces absorption of nutrients Use of anticonvulsant medications Use of anticonvulsant medications

ScreeningScreening

Clinical inspection of conjunctiva for Clinical inspection of conjunctiva for the presence of pallorthe presence of pallor

-simple-simple

-but low sensitivity-but low sensitivity

except when Anaemia is severeexcept when Anaemia is severe

Diagnostic ProceduresDiagnostic Procedures

Haemoglobin levelHaemoglobin level HaemotacritHaemotacrit Erythrocyte indicesErythrocyte indices Blood pictureBlood picture Serum ferritinSerum ferritin

All pregnant women should have at least All pregnant women should have at least one Hb measurement during the cause of one Hb measurement during the cause of pregnancy.pregnancy.

Signs and SymptomsSigns and SymptomsMay not have obvious symptoms unless the cell counts are May not have obvious symptoms unless the cell counts are

very low. very low. Common SymptomsCommon Symptoms:: Tiredness, weakness or fainting. Tiredness, weakness or fainting. Paleness-skin, lips, nails, palms Paleness-skin, lips, nails, palms BreathlessnessBreathlessness Occasional SymptomsOccasional Symptoms:: Headache Headache Nausea Nausea Inflamed, sore tongue Inflamed, sore tongue Palpitations or an abnormal awareness of the Palpitations or an abnormal awareness of the heartbeat heartbeat Forgetfulness Forgetfulness Jaundice (rare) Jaundice (rare) Abdominal pain (rare) Abdominal pain (rare)

Iron Deficiency AnaemiaIron Deficiency Anaemia

The most common type of anemia The most common type of anemia in pregnancyin pregnancy. .

Responsible for 95% of anemia of Responsible for 95% of anemia of pregnancy.pregnancy.

Causes Causes -poor dietary intake-poor dietary intake -hookworm, schistosoma -hookworm, schistosoma infestationsinfestations

Diagnosis of Fe Deficiency Diagnosis of Fe Deficiency AnaemiaAnaemia

Low HbLow HbLow MCV, MCH, MCHCLow MCV, MCH, MCHCBlood picture – RBCs microcytic Blood picture – RBCs microcytic hypochromic with anisocytosis and hypochromic with anisocytosis and

poikilocytosispoikilocytosisReduced S. Ferritin levelReduced S. Ferritin level

Hypochromic Microcytic AnaemiaHypochromic Microcytic Anaemia

Treatment for Fe Deficiency Treatment for Fe Deficiency AnaemiaAnaemia

Oral iron supplementation is the first Oral iron supplementation is the first line of management line of management

A high iron diet should be A high iron diet should be recommended where possible.recommended where possible.

Parenternal iron therapy carry a risk of Parenternal iron therapy carry a risk of anaphylactic reaction. Their use should anaphylactic reaction. Their use should be reserved only for severe cases.be reserved only for severe cases.

Treatment depends on Treatment depends on - The type and severity of anemia.- The type and severity of anemia. - Duration of pregnancy- Duration of pregnancy - Complication of pregnancy- Complication of pregnancy

Available Fe PreparationsAvailable Fe Preparations

ElementalElemental TabletTablet Iron IronFerrous sulphate 200mg 65mgFerrous sulphate 200mg 65mgFerrous gluconate 300mg 35mgFerrous gluconate 300mg 35mgFerrous fumerate 300mg 65mgFerrous fumerate 300mg 65mg

Choice of preparation depends on Choice of preparation depends on cost and side effects.cost and side effects.

Adverse Effects of Fe SupplementsAdverse Effects of Fe Supplements

Lead to poor complianceLead to poor complianceGI irritationGI irritation - Nausea and vomiting- Nausea and vomiting - Epigastric pain- Epigastric painLong term therapy causeLong term therapy cause - Constipation- Constipation - Dark stools- Dark stools

Ways to overcome poor complianceWays to overcome poor complianceTake the iron with or after foodTake the iron with or after food Start with a low dose and increase Start with a low dose and increase

gradually gradually Change the preparationChange the preparation

e.g.- liquid preparatione.g.- liquid preparation

Parenternal Fe TherapyParenternal Fe Therapy

IndicationsIndicationsReserve for use when oral Fe Reserve for use when oral Fe

therapy fails due to intolerancetherapy fails due to intoleranceWhen quick response neededWhen quick response needed

e.g. Late pregnancye.g. Late pregnancyContinuing blood lossContinuing blood lossMalabsorptionMalabsorptionPoor patients compliancePoor patients compliance

IM Fe TherapyIM Fe Therapy

PreparationsPreparations

- Iron sorbitol- Iron sorbitol- Iron dextranIron dextran

- Lesser chance of anaphlaxis and Lesser chance of anaphlaxis and toxicitytoxicity

Adverse Effect of IM Fe TherapyAdverse Effect of IM Fe TherapyVery pain painful, muscle necrosis can Very pain painful, muscle necrosis can

occuroccur

o Staining of skinStaining of skino Headache, dizziness, disorientationHeadache, dizziness, disorientationo Nausea, vomiting, metallic taste in Nausea, vomiting, metallic taste in

mouthmoutho Arrhythmias Arrhythmias

IV Fe TherapyIV Fe Therapy

Preparation used – Iron dextranPreparation used – Iron dextran

Not unpleasantNot unpleasantGiven as an infusionGiven as an infusion

Anaphylaxis can occurAnaphylaxis can occurOther side effectsOther side effectsHeadache, malaise, fever, nausea, Headache, malaise, fever, nausea,

vomiting, arthralgia, urticariavomiting, arthralgia, urticaria

Blood Transfusion

IndicationIndicationSevere Anaemia presenting in the Severe Anaemia presenting in the

latter part of pregnancylatter part of pregnancyPacked cells are given with mid Packed cells are given with mid

transfusion frusemidetransfusion frusemideShould be cautious on cardiac Should be cautious on cardiac

failurefailure

Folate deficiency

Folate deficiency in pregnancy is Folate deficiency in pregnancy is often associated with iron often associated with iron deficiency since both folic acid and deficiency since both folic acid and iron are found in the same types of iron are found in the same types of foods.foods.

Megaloblastic Anaemia Megaloblastic Anaemia

Low Hb

Low reticulocyte count

Hyper segmented neutrephils

Macrocytes

High MCV

Vitamin supplements containing 400 Vitamin supplements containing 400 mcg of folic acid are now mcg of folic acid are now recommended for all women of recommended for all women of childbearing age and during pregnancy. childbearing age and during pregnancy.

These supplements are needed These supplements are needed because natural food sources of folate because natural food sources of folate are poorly absorbed and much of the are poorly absorbed and much of the vitamin is destroyed in cooking. vitamin is destroyed in cooking.

Vitamin B12 deficiencyVitamin B12 deficiency

Women who are vegans (who eat no Women who are vegans (who eat no animal products) are most likely to animal products) are most likely to develop vitamin B12 deficiency.develop vitamin B12 deficiency.

Including animal foods in the diet such as Including animal foods in the diet such as milk, meats, eggs, and poultry can prevent milk, meats, eggs, and poultry can prevent vitamin B12 deficiency.vitamin B12 deficiency.

Strict vegans usually need supplemental Strict vegans usually need supplemental vitamin B12 by injection during pregnancy.vitamin B12 by injection during pregnancy.

Prevention of Nutritional Prevention of Nutritional Anaemia in PregnancyAnaemia in Pregnancy

Good pre-pregnancy nutrition not only Good pre-pregnancy nutrition not only helps prevent anemia, but also helps build helps prevent anemia, but also helps build other nutritional stores in the mother's other nutritional stores in the mother's body. body.

Eating a healthy and balanced diet during Eating a healthy and balanced diet during pregnancy helps maintain the levels of pregnancy helps maintain the levels of iron and other important nutrients needed iron and other important nutrients needed for the health of the mother and growing for the health of the mother and growing babybaby

StrategiesStrategiesEducation about nutrition, food Education about nutrition, food

preparation and dietary modificationpreparation and dietary modificationProphylactic administration of Prophylactic administration of

haematanicshaematanicsAccess to family planning Access to family planning

information, education and servicesinformation, education and services

Dietary EducationDietary Education

Food that enhance Fe absorptionFood that enhance Fe absorption Food that contain Vit CFood that contain Vit C Family of citrus- lemon, lime, orangesFamily of citrus- lemon, lime, oranges Raw vegetablesRaw vegetables

Food that decrease Fe absorptionFood that decrease Fe absorption Tea Tea AntacidsAntacids MethyldopaMethyldopa CalciumCalcium

Haem iron, which is well absorbed and Haem iron, which is well absorbed and is contained in foods of animal origin.is contained in foods of animal origin.

Non-haem iron, which is poorly Non-haem iron, which is poorly absorbed and is contained in foods of absorbed and is contained in foods of plant origin.plant origin.

Haem Fe absorption is not affected by Haem Fe absorption is not affected by presence of food.presence of food.

Presence of haem iron in food enhance Presence of haem iron in food enhance the absorption of non-haem iron.the absorption of non-haem iron.

Good food sources of iron include the Good food sources of iron include the following:following:

meats - beef, pork, lamb, meats - beef, pork, lamb, liverliver, and other organ meats, and other organ meats

poultry - chicken, duck, turkey, liver (especially dark meat)poultry - chicken, duck, turkey, liver (especially dark meat)

fish - shellfish, including oysters, sardines, and anchoviesfish - shellfish, including oysters, sardines, and anchovies

leafy greens of the cabbage family, such as broccoli, leafy greens of the cabbage family, such as broccoli, turnip greens, and collards,turnip greens, and collards, spinach spinach

legumes, such as green peas dry beans and peas, such as legumes, such as green peas dry beans and peas, such as pinto beans, black-eyed peas, and canned baked beanspinto beans, black-eyed peas, and canned baked beans

yeast-leavened yeast-leavened whole-wheat breadwhole-wheat bread and rolls and rolls

iron-enriched white bread, pasta, rice, and iron-enriched white bread, pasta, rice, and cereals cereals

Food sources of Folate Food sources of Folate include the followinginclude the following::

leafy, dark green vegetables leafy, dark green vegetables dried beans and peas dried beans and peas citrus fruits and juices and most citrus fruits and juices and most

berries berries fortified breakfast cereals fortified breakfast cereals enriched grain products enriched grain products

Prophylactic Administration of Prophylactic Administration of HaematanicsHaematanics

Iron absorbed from dietary sources, along Iron absorbed from dietary sources, along with mobilized iron stores, is usually with mobilized iron stores, is usually insufficient to meet iron requirements during insufficient to meet iron requirements during pregnancypregnancy

WHO recommends routine oral WHO recommends routine oral supplementation of 60 mg elemental iron supplementation of 60 mg elemental iron plus 400 mcg folic acid daily for 6 months plus 400 mcg folic acid daily for 6 months during pregnancy in areas where the during pregnancy in areas where the prevalence of anemia in pregnancy is prevalence of anemia in pregnancy is

< 40%. In areas where the prevalence of < 40%. In areas where the prevalence of anemia in pregnancy is > 40%, it anemia in pregnancy is > 40%, it recommends the same dosages for 6 months recommends the same dosages for 6 months and continuing for 3 months postpartum. and continuing for 3 months postpartum.

ReferencesReferences

BritishBritish Medical Bulletin Medical Bulletin 67:149-160 (2003) 67:149-160 (2003) Anaemia and micronutrient deficiencies Anaemia and micronutrient deficiencies Reducing maternal death and disability Reducing maternal death and disability

during pregnancyduring pregnancy

ITO Textbook ITO Textbook www.irontherapy.orgwww.irontherapy.org Chapter 2: Management of Iron Deficiency Chapter 2: Management of Iron Deficiency

Anemia in Pregnancy and the Anemia in Pregnancy and the Postpartum-Postpartum-Christian BreymannChristian Breymann