ANEMIA IN PREGNANCY
Dr Anahita Chauhan
Associate Professor & Unit Head Seth G S Medical College & KEM Hospital Honorary Consultant, Saifee & St. Elizabeth Hospital
Background
Anaemia is the commonest medical disorder during pregnancy Greek meaning without blood Iron deficiency anaemia is the most common type of anaemia during pregnancy NFHS 2003-06: 57.9% of pregnant women 25% direct maternal deaths
Definitions of Anemia in Pregnancy
WHO - Hemoglobin concentration <11gm/dl & hematocrit of <33% CDC definition- Hb <11gm/dl during the first and third trimesters and <10.5gm/dl in th second trimester (to allow for the physiological fall due to hemodilution in second trimester) FOGSI - a cut off of 10 gm/dl for India
Classification Based on Severity
ICMR Mild Moderate Severe Very severe 10 11 gm/dl 7 10 47 <4 decompensated WHO 9 11 gm/dl 7-9 <7
Causes of Anemia in Pregnancy
Physiological anemia Nutritional anemia IDA, megaloblastic Anemia of chronic illness Blood loss Hemolysis and hemolytic anemias Hemoglobinopathies Other hereditary anemias Aplastic anemia
Increased Iron Demands
1000mg extra elemental iron required in pregnancy
Cannot be met by diet alone
Undernutrition compounds the problem
Normal Reference Ranges
Hematological index MCV (PCV/ RBC) Reference range 75 98 fl
MCH (Hb)
MCHC TIBC Fe/ TIBC ratio
25 31 pg
32 36% 325 400 / 100ml 30%
Morphological Classification
By the size of the RBCs Macrocytic anemia (MCV > 100)
Normocytic anemia (80 < MCV < 100)
Microcytic anemia (MCV < 80)
Clinical Features - Symptoms
Mild anemia is usually asymptomatic
Moderate anemia - weakness, fatigue, exhaustion, loss of appetite, indigestion, giddiness, breathlessness Severe anemia - palpitations, tachycardia, breathlessness, increased cardiac output, cardiac failure, generalised anasarca, pulmonary edema
Clinical Features - Signs
Pallor Nail changes Cheilosis, Glossitis, Stomatitis Edema Hyperdynamic circulation (short & soft systolic murmur) Fine crepitations
Effects of Anemia on Mother
Antepartum Preterm labor Pre eclampsia Sepsis IUGR Intrapartum Uterine inertia PPH Cardia failure
Effects of Anemia on Mother
Postpartum
Puerperal sepsis Subinvolution Pulmonary embolism Failure of lactation Delayed wound healing Cardiac failure
Fetal Effects
Prematurity and LBW IUGR IUFD Increased perinatal mortality Iron Deficiency Anemia due to lower iron stores can cause poor mental performance or behavioral abnormalities in later life
Diagnosis Baseline/ Presumptive
Haemoglobin Measurement Peripheral blood smear Reticulocyte count Hematocrit Blood indices
MCV, MCHC, MCHC
Stool Examination Urine Examination Proteins, LFT, RFT
Therapeutic Trial of Iron
Oral iron therapy Increase in reticulocytes in 5 7 days Rise in Hb at a rate of 2-4 gm/dl every 3 weeks till normal If no response or incomplete response, do additional tests
Diagnosis - Additional
Serum Fe Total iron binding capacity Serum Ferritin
Saturation
Hb electrophoresis
Bone marrow examination
Lab findings in IDA
Hb < 11 gm/dl Peripheral smear - microcytic, hypochromic MCV and MCHC are low Serum iron is low - < 50 gm/dl (N 60 -175) TIBC is increased - > 400 gm/dl Tests of iron stores Serum ferritin is < 12 gm/dl (N 40-200) Stainable iron in the bone marrow is reduced
Newer investigations
Serum transferrin receptors
Transferrin receptor/ ferritin index
Reticulocyte indices
automated counting of reticulocytes, count of <26pg/ cell is a strong predictor of IDA Reticulocyte production index
Red cell zinc protoporphyrin level
IDA
Severity MCV S Ferritin TIBC S Iron Variable Decreased Decreased Increased Decreased
ACD
Mild Normal/ decreased Normal/ increased Decreased Decreased +
Thalass-emia
Mild Decreased Normal Normal Normal +
Sidero-blastic
Variable Normal/ decreased Increased Normal Increased +
Marrow iron -
IDA
Population
RDW MCV Serum iron Ferritin TIBC Hb electrophoresis
Beta thal
Greeks, Italians
Normal Low Normal Normal Normal Increased HbA2
All
High Low Decreased Decreased Increased Normal
Mentzer Index
Calculation that may (or may not) be useful in differentiating thalassemia minor from IDA Mentzer Index = MCV/RBC Count <13 Thalassemia minor >13 Iron Deficiency Useful in children
Folic Acid Deficiency Anemia
Deficiency of folate or B12 Anticonvulsants, oral contraceptives, sulfa drugs, and alcohol can decrease absorption of folate from meals
Folate is essential for normal growth and development Coexists with IDA
Diagnosis
Macrocytes on peripheral smear Hypersegmentation of neutrophils Pancytopenia
Low Hb and high MCV
Megablastosis on bone marrow
Serum folate <3ng/ ml
Prevention
Dietary advice and modification Iron supplementation of adolescent & non pregnant women Treatment of hookworm Infestation Iron supplementation in pregnant women Food fortification Antenatal care for early recognition
Management of Anemia
Oral Iron Therapy
Prophylactic Iron therapy- 100mg elemental iron daily with 500 mcg of folic acid
Deworming of all anemic patients Treatment of Anemia- 200mg of elemental iron & folate 5mg/d
Iron Requirement in Pregnancy
2.5mg /day in early pregnancy
5.5mg /day from 20 -32 weeks
6 8 mg/ day after 32 weeks Average 4 mg/ day
Side effects of Oral iron
Nausea Vomiting Constipation Abdominal cramping Diarrhoea The tablet can be given with meals or different brand may be tried
Reasons for Failure to Respond
Non compliance Concomitant folate deficiency Continuous loss of blood through hookworm infestation or bleeding haemorrhoids Co-existing infection Faulty iron absorption Inaccurate diagnosis Non iron deficiency microcytic anaemia
New Therapeutic Alternatives
The side effects of older Iron preparations & their poor compliance even on providing free tablets are the most important reasons of failure of anaemia control programmes
Newer preparations are better tolerated, have less side effects with better compliance Carbonyl Iron Iron ascorbate
Merits of New Preparations
Outstanding GI Tolerance in contrast to 20% severe side effects with conventional therapy Very safe with no poisoning even in high doses
No interaction with food stuffs
The newer preparations are delicious with nonmetallic taste and dont stain the patients teeth Hence the compliance is very high
Parenteral Iron therapy
Indicated when the pregnant woman is unable to take iron due to side effects or is non compliant Its main advantage is certainty of administration
Rise in hemoglobin is similar to oral iron (upto 1gm per wk)
Preparation & dosage
Iron Dextran IM and IV high molecular wt stable complexes release iron slowly, can cause anaphylaxis Iron citrate sorbitol IM less stable, rapid release of iron
Iron sucrose IV intermediate stability, rapid metabolism hence readily available iron. Since they do not form biological polymers, there are no reactions
Precaution
Oral Iron to be suspended 48 hours before parenteral therapy Emergency measures like inj hydrocortisone adrenaline, oxygen cylinder to be kept ready Look for reaction while giving infusion
Dose calculation
Older preparations: each 1ml = 50mg elemental iron
0.3 x Wt in lb x (100 Hb%) + 500
Iron sucrose: each ml = 20mg elemental iron
Dose: 200mg slow IV alternate day
0.24 x wt in kg x (target Hbpt Hb) + 500
Disadvantages
Pain Nausea, vomiting, headache Skin discolouration Abscess formation Fever Lymphadenopathy Allergic reaction Anaphylaxis
Blood Transfusion
Severe anemia, especially after 36 weeks
Hemorrhage
Associated infections Packed cells preferred
Exchange transfusion rare
Use of Erythropoetin
Used in severe anemia & renal failure for significant increase in Hb and to avoid blood transfusion Gynaecological surgeries - preop use of erythropoietin and Iron Dextran has been shown to avoid the need for blood tranfusion later
Dosage Regimen Erythropoetin
Inj erythropoetin can be given subcut or iv 100-15 iu/kg On day 1, 3 & 5 along with parenteral iron or day 1, 3 & 5 6000units s/c erythropoetin and iron dextran 100mg deep im daily for 5 day
First dose given after subcut sensitivity test
Adrenaline, hydrocortisone, oxygen to be kept ready Produces 3gm% rise in Hb over a 2wk period
Management in Labor
Make patient comfortable, oxygen
Sedation and analgesia
Prevent cardiac failure Aim to deliver vaginally Antibiotics Cut short second stage Active management of third stage
Clinical Case Scenarios
A primigravida presents at 28 wks of gestation with pallor, hemoglobin 7.8g%, no other medical comorbidity, good functional status. Most pragmatic first line therapy in cases with assured compliance would be a. blood transfusion b. parenteral iron c. oral iron d. oral plus parenteral iron Answer: c
Clinical Case Scenarios
Foodstuff with highest available iron is a. Red meat b. Figs c. Groundnut d. Soyabean
Answer b
Clinical Case Scenarios
A lady at 32 weeks gestation with hemoglobin 8.9, red cell width is increased, taking iron supplements. Least likely situation is a. non compliance b. intestinal parasites c. thalassemia trait d. anti epileptic medication Answer: c
Clinical Case Scenarios
Single most important set of investigations in a recently diagnosed case of anaemia in pregnancy is a. Red cell indices b. Retic count and peripheral smear c. Iron studies d. Hemoglobin electrophoresis Answer: b
Clinical Case Scenarios
G5P2L0A2 at 35 weeks gestation in early preterm labor. Hb is 8.8g%. All can be part of management except a. Steroids b. Frusemide c. Blood transfusion d. Intra partum antibiotics Answer: c
