DR. RABI NARAYAN SATAPATHYASST.PROFESSORDEPT. OF OBST.& GYNAECOLOGYSCB MEDICAL COLLEGE, CUTTACKMOB-09861281510EMAIL-drrabisatpathy@gmail.com

ANAEMIA PREVENTION

Defined as :

Reduction in the circulating red cell mass and corresponding decrease in haemoglobin mass and oxygen carrying capacity of blood

WHO : Hb level PCV

g/dl g/L %

Mild < 11 < 110

10 g/dl ( developing countries)

Moderate 6.5 - 8 70 – 109 24-37

Severe < 6.5 40 - 69 13-23

Very Severe < 40 < 13

GLOBAL POPULATION - 4.4 BILLION

ANEMIA - 1.3 BILLION ( 30%)

DEVELOPING COUNTRIES – 1.2 BILLION

WORLD

51%DEVELOPED

18%

DEVELOPING 56%

ASIA-60%

EASTERN-37%

S.EASTERN-63%

SOUTHERN-75%

WESTERN-50%

ANAEMIA IN PREGNANCY - ASIAN COUNTRIES

WHO 1992

0

10

20

30

40

50

60

70

80

90

Bangladesh China India Indonesia Malay sia My anmar Nepal Pakistan Philippines Singapore Srilanka Thailand

BANGLADESH

CHINA

INDIA

INDONES IA

MALAYSIA

MYANMAR

NEPAL

PAKISTAN

PHILIPPINES

SPORE

SRILANKA

THAILAND

INDIA

ANNUAL MATERNAL DEATHS - GLOBALLY

SOUTH ASIA

TOTAL 500,000

75% : Haemorrhage ; Abortion ; Eclampsia ; Sepsis ; Obs. Labour.

ANAEMIA : Underlying cause in 20%

WHO 1991

0

5

10

15

20

25

30

FOGSI 1982 RG. India 1986 Bara &Sengupta 1992

Kamla Jayram1992

RG India 1992

MATERNAL DEATHS DUE TO ANAEMIA Indian Data

8.517.8

5.97.5

19

19

12.2

17.24 18.2

17.98

10.10

ICMR-29.9

Registrar general 1999 : 17.3%

FW Year Book 1989-90: 17.8%

16.814.3

MATERNAL DEATHS DUE TO ANAEMIA

PREVALENCE OF ANAEMIA

URBAN : 40 – 50 % 46 %

RURAL : 50-70% 54%

H.W.ENDEMIC : 90 %

( National Family Health Survey – 2 1998-1999)

Incidence : 50% in general population

M : F is 1 : 4

India : highest prevalence 80% females suffering from it

1 in 5 maternal deaths are due to it

FOGSI-WHO Study:

of the maternal deaths due to anaemia 64.4% : Hb < 8gm%

21.6% : Hb<5gm%

CONQUERING ANAEMIA : major thrust issue

In an era Where both diagnosis and treatment are

EASY EFFECTIVE

INEXPENSIVE

ANAEMIA

the most preventable cause

Is still the leading indirect cause

Among the most freedoms that we can have is the freedom from avoidable ill-health and from

escapable mortality

Amartya Sen

CAUSES

NUTRITIONAL : IRON DEFICIENCY FOLIC ACID DEFICIENCY

HAEMORRHAGIC: WORM INFESTATION ANTECEDENT PREGNANCY

HAEMOLYTIC : HAEMOGLOBINOPATHIES DRUG REACTIONS

INFESTATION : MALARIAL PARASITES

APLASTIC ANAEMIA

If left Untreated ……………

Abruptio placentae

Intercurrent infection

PROM

Preterm Labour

Heart Failure

Uterine inertia PPH peurperal sepsis

lactational failure periphral venous

thrombosis pulmonary embolism

Perinatal Morbidity …………………..

Prematurity

IUGR

Congenital Anomalies

Intrauterine Death

Birth Asphyxia

Infection

The competency and skill of the modern obstetrician is assessed not by the conduct of delivery or performance of Caesarean Section but by the smartness exhibited in managing medical disorders complicating

pregnancy & the high risk problems

Crux of the problem ?

Anemia/Anaemia ?

Oral / parenteral ?

Ferrous Sulphate/Ferrous Glycine Sulphate / Iron Polymaltose Complex /Carbonyl Iron ?

Definition ?

Supplementation Dosage Schedule ?

Daily ?

Once weekly ?

Twice weekly ?

In pregnancy ?

Minimal Iron Stores in Males & Females

M 800 – 1000 mg F 400 – 600 mg

At Birth

Adolescence – Adulthood

RBC : 2 – 2.5 mg Tissues : 200 mg Circulation : 3 mg Exfoliation : 1 mg/day

PREGNANCY

Addl. Req. – 800-1000mg 1st trimester - .8 mg/day 2nd & 3rd trimester - 6.3 mg/day peurperium & - 1.3 mg/day

lactation

Daily req. - 2 – 4.8 mg/day

Consume - 20 – 40 mg/day 10-15 mg/day

(veg)

+ phytates of cereals

DYNAMICS OF IRON ABSORPTION

INTESTINES PLASMA CELL

Haem syhthesis

APOFERRITIN

AUTOPHAGOCYTOSIS

PHAGOSOME

PATHWAY OF IRON METABOLISMDIETARY IRON

( 14 + 4 mg 1 day, 6mg / 1000 kcal )

INTESTINAL MUCOSA(Absorption 1 mg / day )

PLASMA IRON( Pool about 3 mg, turnover 10x / day )

OBLIGATORY LOSS

( 1mg / d : Male 2mg / d : Female )

RETICULO - ENDOTHELIUM POOL( 25 mg / day )

INTERSITIAL FLUID

TISSUES( Myoglobin and enzymes . About 6 mg / day )

FERRITIN STORES

ERYTHROID MARROW( uptake about 25 mg / day )

CIRCULATING RBC’s( Pool about 2100 mg daily

turnover 18 mg )

STAGES IN DEVELOPMENT OF IRON DEFICIENCY

NORMAL DEPLETION OF IRON STORES WITHOUT

ANAEMIA

IRON DEFICIENCY ANAEMIA

HAEMOGLOBIHAEMOGLOBIN IRONN IRON

STORAGE STORAGE (AVAILABLE ) (AVAILABLE ) IRONIRON

TISSUE ( NON- TISSUE ( NON- AVAILABLE ) AVAILABLE ) IRONIRON

IRON DEFICIENCY IS NOT

SYNONYMOUS WITH

IRON DEFICIENCY ANAEMIA

Hb. Conc. - not a very sensitive index

Latent & Early Iron Deficiency Anaemia - normal blood picture

Serum Iron

TIBC

Serum Ferritin

Not Feasible

M : 40-340 ng/ml F : 14-150 ng/ml

<30 ng/ml – absent iron stores

<12mg/ml - critical

Best Compromise

Peripheral smear Hb.conc.

Electronic counter-Most sensitive

Sahli’s Method

Pale Hypochromia Microcytosis

Polychromatic BasophilicStippling

Target cells

Macrocytosis (oval) Hypersegmented Neutrophils Fully Haemoglobinised RBC

Sickle cells

PERCENTAGE OF WOMEN WITH ANAEMIA

NATIONAL FAMILY HEALTH SURVEY-2 1998-99

MILD

MODE- RATE

SEVERE

0

5

10

15

20

25

30

35

40

15-19 20-24 25-29 30-34 35-39

0

5

10

15

20

25

30

35

40

illiterate literate

mild

moderate

severe

LITERACY

NATIONAL FAMILY HEALTH SURVEY-2 1998-99

Build Iron Stores …………..

Respect Girl child

Primary Education

Mid-Day Meal Schemes

Food Fortification

Early detection via good ANC

Hospitalisation & Treatment

Avoid prolonged & Difficult Labour

Post- Partum period – Close watch

Girl Child

Pregnancy Related

PROBLEMS OF A GIRL CHILD

WORM INFESTATIONS

BLEEDING GUMS AND DIATHESIS

EPISTAXIS

CHRONIC UTI

PELVIC INFECTION

MENSTRUATION

CHRONIC MALARIA

TUBERCULOSIS

Gender Specific Prescription

Respect Girl child

Primary Education

Mid-Day Meal Schemes

Food Fortification : WHEAT

SALT

DOUBLE FORTIFICATION

( IODINE & IRON)

Early detection via good ANC

Hospitalisation & Treatment

Avoid prolonged & Difficult Labour

Post- Partum period – Close watch

Anaemia may antedate pregnancyIt may be aggravated by pregnancy

OrThe accidents of labour may perpetuate it

Age/Sex group Haemoglobin < g/dl

Haematocrit < %

Children 6mths.-5yrs. 11.0 33

Children 5-11yrs 11.5 34

Children 12-13yrs. 12.0 36

Non-pregnant women 12.0 36

Pregnant women 11.0 33

Men 13.0 39

HAEMOGLOBIN AND HAEMATOCRIT CUT OFFS TO DEFINE ANAEMIA IN PEOPLE LIVING AT SEA

LEVEL

From WHO/UNICEF/UNU,1997

RISK FACTORS FOR ANAEMIA IN PREGNANCY

Age group < 20 yrs. / > 30 yrs.

Lower socio-economic status

Literacy

Parity >2

Spacing < 2 yrs.

Calorie Intake < 80% of expected

History of Worm Infestation ( last 6 mths.)

Malnutrition ( BMI < 18.5 )

Vegetarian Diet

Unemployment of women

IRON PREPARATION

FERROUS SULPHATE : least expensive best absorbed

FERROUS GLUCONATE

FERROUS FUMARATE

SUSTAINED RELEASE PREPARATION claim – less side effects

Diet restrictions : Cereal diet, Wheat, Tannin, Nuts & Pulses

MOLECULAR IRON

ELEMENTAL IRON

FERROUS SULPHATE

200 60

FERROUS GLUCONATE

300 36

FERROUS FUMARATE

200 65

SUSTAINED RELEASE

350 105

IRON POLYMALTOSE COMPLEX

STRUCTURE : FERRIC HYDROXIDE POLYMALTOSE COMPLEX

ANALOGUS TO FERRITIN

PROTEIN LIGAND REPLACED BY MALTOSE

CAPSULE CONTAIN 100mg elemental iron

CLAIM :

FOOD : NO INTERFERENCE WITH ABSORPTION

DECREASE G.I. SYMPTOMS

BIOAVAILABILITY SAME AS FERROUS

NEGLIGIBLE FREE RADICALS

CARBONYL IRON

“CARBONYL” : MANUFACTURING PROCESS

VAPOURISED IRON PENTACARBYL CONTROLLED HEATING

UNCHARGRD ELEMENTAL IRON

SOLUBILISATION DEPENDS ON GASTRIC ACID PRODUCTION

ONLY SOLUBILISED FRACTION IS ABSORBED

NON-COMPLIANCE

MEDICAL FACTORS

SOCIO-CULTURAL FACTORS

COLOUR

TASTE

SIDE EFFECTS : NAUSEA

ABD. DISCOMFORT CONSTIPATION DIARRHOEA

PARENTERAL THERAPY

INTOLERANCE TO SIDE EFFECTS OF ORAL IRON

IBD / PEPTIC ULCER

NON COMPLIANCE

IRON MALABSORPTION (documented)

NEAR TERM

ROUTE : I M / IV IRON DEXTRAN COMMONLY USED

~ 100 mg IM DAILY TILL CALCULATED DRUG IS GIVEN

~ SHOLUD BE INITIATED PRIOR TO 20 WEEKS FOR

OPTIMUM OUTCOME

“Parenteral route can provide greater amount of iron than the oral route & erythropoiesis can be increased 6-8

times over the basal levels after parenteral iron as compared to 3-4

times after oral iron”

Hillman & Anderson 1969 Vol 46 / No.2 / 1996

DRAWBACKS

PAIN & STAINING

MYALGIA

ARTHRALGIA

INFECTION ABSCESS

HOSPITALISATION / REGULAR VISITS

I.V. - ONE SHOT

BETTER COMPLIANCE

National Nutritional Anemia Prophylaxis Programme (NNAPP )

Launched in the 4th five year plan - report 1989

60mg. Iron +50 mcg FA/day X 100 days

1. Anemia Prevalence was the same – consumed 88.1% did not consume 87.6%

2. >50 tablets – better Hb% as compared to those >25 tablets

3. Erratic supply : 19% pregnant women 17% lactating women

4. Education co mponent- weak / absent

We will plan our work

And

Work our plans

With

Dedication

IRON PROPHYLAXIS

PATIENT COMPLIANCE

SMOOTH DISTRIBUTION

60 / 120 mg / day

WESTERN – 60/mg day

DEVELOPING –

start pregnancy with depleted iron stores poor nutrition infection 120 mg /dayinfestation

GUIDELINES - IRON SUPPLEMENTATION TO PREGNANT WOMEN

Prevalence of anaemia in pregnancy Dose Duration

< 40% 60 mg iron 6 mths in 400 Folic acid pregnancy

> 40% 60 mg iron 6 mths in 400 Folic acid pregnancy 3mths pp

TRANSFERRIN RECEPTOR ( TfR )

RECENT ADVANCES IN DIAGNOSIS

Transmembrane protein

Binds transferrin & bound iron

Reduction in iron supply – increased TfR synthesis

Inproportion to the decrease in Iron

Differentiate between tissue iron deficiency & anaemia due to haemodilution

FOLATE & FOLIC ACID

TWO DISTINCT ROLES IN PREGNANCY :

PREVENTION OF ANAEMIA IN LATE PREGNANCY

ROLE IN EMBRYOGENESIS IN RELATION TO NEURAL TUBE DEFECTS

BIRTH DEFECTS :

Neural tube defects (Scott et al 1990; 1994)

Orofacial clefts (Tolarova & Harris 1995 )

IUGR (Baumslag et al 1970)

FOLIC ACID

400 mcg of Folic acid /day ideally for two or three months before

conception

400mcg. to be continued throughout pregnancy & lactation

Fortification Options : Cereals Fruit Juices

Bread

No significant associated risk

Fetal origin of Adult Disease Reduction in intrauterine nutrition

Impaired intrauterine development

Affect CVS / Pancreas in adult life

;BARKER’S HYPOTHESIS 1990BARKER’S HYPOTHESIS 1990

WOMEN : POORNUTRITION LOW SOCIOECONOMIC STATUS DEVELOPING COUNTRIES

ROUTINE SUPPLEMENTATION IN PREGNANCY Great Britain

PREVENTION : TWO SCHOOLS OF THOUGHTS

Scandinavian countries

WOMEN AT RISK

LOWER SOCIO-ECONOMIC GROUPS

MULTIPARAS

MALABSORPTION SYNDROME

We have to wait till the evening to know how glorious the day has been.

Sophocles (2000yrs. ago)

INFESTATIONS

Ankylostoma Duodenale ( Hookworm )

Ascaris lunbricoides ( Roundworm )

Trichuris trichura ( Whipworm )

Enterobus vermicularis (Threadworm )

Strongyloidosis

Cestodes ( Tapeworm )

Trematodes ( Fluke )

ANAEMIA CAUSED BY HOOKWORMS

Complementary parasite control measures in pregnancy

Hookworms : Endemic prevalence rate 20-30% antihelminthic - second trimester

Highly endemic – prevalence rate > 50% repeat third trimester

Mebendazole 500 mg single dose / 100 mg twice daily x 3d

FDAC

Pyrantel Palmoate 10mg/kg single dose, FDAC best to repeat for two consecutive days

Levamisole 2.5 mg/kg single dose, FDX best to repeat for two consecutive days

Albendazole 400 mg single dose FDX

WORM INFESTATION

ANTIHELMINTHIC

FOOTWEAR

IMPROVE SANITATION

PERSONAL HYGIENE

SAFE WATER

MALARIA

ANAEMIA : Haemolysis

Suppression of erythropoiesis

MALARIA PROPHYLAXIS

Endemic

First & second Pregnancies

First visit – Curative antimalarials

Antimalarial prophylaxis

HAEMOGLOBINOPATHIES

THALASSEMIA

SICKLE CELL ANAEMIA

? IRON SUPPLEMENTATION

Serum Ferritin levels are significantly raised in pregnant women with Sickle Cell Disease

AKINYANJU (1987):

“…..clear need should be established before iron supplementation in haemoglobinopathic patients ”

TURNBULL ( 1989 )

Thalassemia Minor : Prophylactic oral iron therapy - has a role Parenteral Iron should not be given

CONSENSUS

Asses iron status of all haemoglobinapathically anaemic pregnant women

Wiser to avoid routine prophylaxis

Therapeutic dose given where required

APLASTIC ANAEMIA (AA)

3 SUBSETS OF PATIENTS WITH APLASTIC ANAEMIA

PREGNANCY INDUCED AA

PREGNANCY ASSOCIATED AA

TRANSIENT MARROW SUPRESSION INDUCED BY PREGNANCY

PRE-EXISTING AA CAUTIONED

MANAGEMENT STAGE OF PREGNANCY AT WHICH PANCYTOPENIA DEVELOPS & ON MAINTAINING MOTHERS BLOOD COUNT

LYMPHOCYTE GLOBULIN

MARROW TRANSPLANT

Today, analysis of causes of maternal deaths is almost a futile exercise. Researchers and intellectuals all over the world are now joining together to draft the preventive measures

Dr. S. Dasgupta

International Nutritional Anaemia Consultative Group ( INACG )

Guidelines:

• to provide clear and simple recommendations

• to address both ~ prevention of anaemia ~ and treatment of anaemia

• to integrate recommendations for the use of ~ anti-malarials

~ antihelminthic

An Effective Control Programme

Population group Benefit Children behavioural & cognitive development

child survival

Adolescents cognitive development

better iron stores for later pregnancies

Pregnant women Decreased - low birth weight & their infants - perinatal mortality - maternal mortality - obstetrical complications

All individuals Improved fitness and work capacity Improved cognition

INTERVENTIONAL ARRAY

Iron supplementation

Food based interventions

Helminth control

Malaria control

Reproductive and Obstetric Interventions

Target Groups for Iron supplementation :

Based on : likelihood of iron deficiency public health benefits

Priority groups : Pregnant & Post-partum women Children 6-24 mths of age

High prevalence of anaemia

Women of reproductive age Pre-school children School-age children Adolescents

Selecting and Prioritising Interventions

Epidemiology of anaemia in the area

Available infrastructures

Community opinion and priorities

PROPHYLAXIS MANDATORY

SECOND TRIMESTER ONWARDS

ORAL IRON – Tab / Liquid

FERROUS SALTS – Sulphate/Gluconate/Succinate

SUSTAINED RELEASE PREPARATION - No Significant advantage

HAEMOGLOBIN PREPARATIONS 1gm Hb preparation - 3.4 mg iron

Preparations contain - 10 gm = 20-30 mg

Do not discontinue once the Haemoglobin level normalises – Iron stores start building up only after that –continue iron therapy for 3-4 mths after Hb. Level has come to normal.

Key Points

Contd………….

Vitamin C

Folic Acid - 350 mcg

Deworming

Prophylaxis against Malaria

Dietary Advice

Sanitation & Hygiene

THANK YOU