ANEMIA IN PREGNANCY

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ANEMIA IN PREGNANY AND ROLE OF PARENTERAL IRON
THERAPY
Dr SUSANTA KUMAR BEHERA SENIOR
RESIDENT DEPARTMENT OF O G MKCG MEDICAL
COLLEGE BRAHMAPUR, ODISHA INDIA
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• Most Common Nutritional Disorder in the World
• Incidence 40 to 60 of pregnant women in
  India
• Commonest Medical(hematological) disorder during
  pregnancy
• 25 of direct maternal deaths
• Responsible for 40 of maternal deaths in third
  world countries.
• India contributes to 80 of maternal deaths due
  to anemia in South Asia

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Pregnancy Most dangerous journey of mankind
Anemia begins in childhood, worsens during
adolescence in girls and gets aggravated during
pregnancy
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• Quantitative or qualitative reduction of Hb or
  circulating RBCs or both resulting in a reduced
  oxygen carrying capacity of blood to organs and
  tissues
• Woman Hct 33 or Hb 11g/dl 1st 3rd
  trimester and Hct 32 or Hb 10.5 g / dl in 2nd
  trimester(CDC/WHO)

Gm ICMR WHO
Mild 10 11 10-10.9
Moderate 7 10 7-9.9
Severe 4 7 lt7
Very severe lt 4
5
COMMON ANEMIAS IN PREGNANCY

• Physiological
• Acquired
• Nutritional deficiency anaemias
• - Iron deficiency (90)
• - Folate deficiency
• - Vit. B12 deficiency
• Infections Malaria/Hookworm/UTI
• Hemorrhagic acute/chronic blood loss
• Bone marrow- Aplastic anemia
• Renal diseases
• Genetic/Haemoglobinopathies
• - SCD
• - Thalassaemias

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PHYSIOLOGICAL ANEMIA
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• Plasma volume 50 (by 34weeks) but RBC
  mass only 25
• Disproportionate increase in plasma vol, RBC
  vol. and hemoglobin mass during pregnancy
• CRITERIA FOR PHYSIOLOGICAL ANAEMIA
• Hb 10 gm
• RBC 3.2 million/mm3
• PCV 30
• Peripheral smear showing normal morphology
• of RBC with central pallor

8

• IRON REQUIREMENTS DURING PREGNANCY
• Maternal req. of total Iron -1000mg
• 500 mg ? Maternal Hb. Mass expansion
• 300 mg ? Fetus Placenta
• 200mg ? Shed through gut., urine skin
• 2.5mg /day in early pregnancy
• 5.5mg /day from 20 -32 weeks Average 4
  mg/ day
• 6 8 mg/ day after 32 weeks
• Increases from 1-2mg in 1st trimester to 6-8 mg
  in 3rd trimester

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• Absorption of iron depends upon
• Amount of iron in the diet
• Bioavailability of iron
• Physiological requirements
• Iron sources are two types
• Haem iron(5) hemoglobin and myoglobin from red
  meat, poultry and fish
• Nonhaem iron(95) fibers, green vegetables

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NORMAL IRON CYCLE
Duodenum
Dietary iron
(average, 1 - 2 mg
Utilization
Utilization
per day)
Plasma
(TIBC)

transferrin
(3 mg)
Bone
Muscle
marrow
(myoglobin)
(300 mg)
Circulating
(300 mg)
erythrocytes
Storage


(hemoglobin)
iron
(Ferritin)
(1,800 mg)
Sloughed mucosal cells
Desquamation/Menstruation
Other blood loss
(average, 1 - 2 mg per day)
Reticuloendothelial
Liver
macrophages
(1,000 mg)
Iron loss
(600 mg)
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FACTORS THAT MODIFY IRON ABSORPTION
HemegtFe2gtFe3 Physical State
Vagotomy, pernicious anemia H2 receptor blockers, calcium-based antacids High Gastric pH
Crohns disease, Celiac disease Intestinal Structure disruption
Phytates, tannins Inhibitors
Cobalt, Lead, Strontium Competitors
Ascorbate, Citrate, Amino acids, Iron deficiency Facilitators
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EFFECTS OF ANAEMA IN PREGNANCY

• ANTEPARTUM
• Pre eclampsia
• Intercurrent infection
• Cardiac failure
• Preterm labour
• APH
• PIH
• INTRAPARTUM
• PPH
• Cardiac failure
• Shock

• POSTPARTUM
• Puerperal sepsis
• Subinvolution
• Failing lactation
• Puerperal venous thrombosis
• Pulmonary embolism

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• Baby
• IUGR
• Prematurity
• Increased risk of IDA early infancy
• Still births
• Congenital malformations
• ? in Neonatal deaths/Perinatal mortality
• Intra uterine deaths(severe maternal anoxemia)
• Abnormal Social and Emotional behaviour
• EFFECT OF PREGNANCY IN ANAEMIA
• Pt. Mildly anemic progresses to marked Anaemia
• Pt. Who is severely anemic becomes symptomatic by
  the end of 2nd trimester

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• IDA IN PREGNANCY
• Grandmulti
• Hook worm infestation
• Blood loss Menorrhagia 20-30
• Increase demand for iron particularly in 2nd
  3rd trimester
• Higher risk with morning sickness
• Aspirin/NSAIDS
• Multiple pregnancies
• Intolerance for red meat
• Low dietary intake (Vegetarians, Vit. C
  Calcium)
• Malabsorption (Hypo-or achlorohydria)
• Losses can increase with colorectal cancer,
  polyps

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STAGES OF IRON DEFICIENCY

• Prelatent(Depletion)
• Stores are depleted without a change in
  hematocrit or serum iron levels .
• Reduced stored iron e.g. serum ferritin with
  normal hemoglobin
• Latent(iron deficient erythropoisis)
• Serum iron drops and the TIBC increases without a
  change in the hematocrit.
• Reduced stored and transport iron
• Increased erythrocyte protoporphyrin
  concentration
• Detected by a routine check of the transferrin
  saturation.

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• Frank IDA
• Associated with erythrocyte microcytosis and
  hypochromia.
• Stage of deficiency of stored, transport and
  functional iron
• Reduction of hemoglobin and serum ferritin
• Low serum transferrin saturation
• Increased erythrocyte protoporphyrin
  concentration
• Iron deficiency attracts medical attention most
  commonly at this stage.

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CLINICAL FEATURES

• SYMPTOMS
• Fatigue
• Weakness
• Headache
• Loss of appetite
• Dysphagia
• Palpitations
• Dyspnea on exertion
• Ankle swelling
• Paresthesia
• Leukoplakia
• Cold intolerance
• irritability

• SIGNS
• Glossitis
• Stomatitis
• Heart murmurs
• Increased JVP
• Tachycardia
• Tachypnea
• Postural hypotension
• Pallor
• Dryness or roughness of the skin
• Koilonychia
• Dry cracked lips Brittle hair

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• DIAGNOSIS OF IDA
• Low hemoglobin
• Low serum ferritinlt15 mcg/dl
• Microcytic hypochromic in absence of chronic
  diseases/hemoglobinopathies
• Low serum iron content(lt 30mcg/dL)
• Low PCV, MCV, MCH, MCHC
• High TIBC gt 400 mcg/dl

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• Increased ZPP (gt40 mmol/mole heme)
• Low transferrin saturation(lt15)
• Increased serum transferrin(gt350mg/dL)
• Increased serum soluble transferrin binding
  receptors(gt 8 mg/L)
• increased serum neopterin concentration

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PENCIL CELLS
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INVESTIGATIONS

• Haematocrit
• RBC Indices
• - Low MCV
• - Low MCH
• - Low MCHC
• - Low PCV
• Peripheral blood
• Urine for haemturia(RM/CS)
• Stool examination
• Hb electrophoresis
• X-ray Chest(PA View)

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• Serum iron lt 50 µgm/dl
• TIBC is increased - gt 400 µgm/dl
• Serum ferritin is lt 12 µgm/dl
• Serum transferrin saturationlt20
• Red cell Zinc Protoporphyrin
• Stainable iron in the bone marrow is reduced-Gold
  Standard
• Serum transferrin receptor(TfR) Increased
• Bone marrow examination.
• Reticulocyte hemoglobin conc. Count of lt26pg/
  cell
• LFT, RFT
• Trial of iron therapy-diagnostic therapeutic

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• TREATMENT
• Anaemic gravidas 120 240mg / per day
• Supplementation with folic acid Vit C.
• Ferrous sulphate 300mg TID daily after meals X
  12 months
• Therapeutic results after 3 weeks rise in Hb
  level of 0.8gm/dl/ week with good compliance
• Rise in Hb at a rate of 2-4 gm/dl every 3 weeks
  till normal
• Hb conc. is normal after 6 wks of therapy

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• INDICATORS OF IRON THERAPY RESPONSE
• Increase in Reticulocyte count (Increases 3-5
  days after initiation of therapy )
• Increase in Hb levels. Hb increases 0.3 to 1 g/
  week
• Epithelial changes (esp tongue nail ) revert to
  normal

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Pregnancy gt36wks
Pregnancy lt30wks
Pregnancy 30-36wks
IDA FA def.
Oral iron Oral FA Intolerance
or Non-compliance I/M iron I/V
iron
IDA FA def. Parenteral Oral
FA I/M iron I/V
iron
Blood transfusion
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• ORAL IRON THERAPY
• WHO 60 mg elemental iron 250 ug FA OD/BD.
• Govt. of India 100 mg Fe 500 ug FA
  during 2nd half of pregnancy X 100 days.
• Drawbacks
• - Intolerance
• - Unpredictable absorption rate.
• - Not suitable for patients with GI
  diseases/ significant bleeding
• - Non Compliant patient.
• - Long time for improvement

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• Side effects
• Nausea Vomiting
• Gastric irritation
• Constipation
• Abdominal cramp
• Diarrhoea
• Response to therapy
• - Sense of well being/Increased
  appetite.
• - Increase in Hb approximately 2gm
  per every 3-4 wk
• - Reticulocytosis with in 5-10 days
• - hematocrit returning to normal
• .

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• Enteric coated/sustained release preparations to
  be avoided as they are carried past duodenum
  limiting absorption
• Once hemoglobin is normal therapy is continued
  for further 3 months /at least 6 wks postpartum
  to replenish stores.

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IRON SUPPLEMENTS
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Taking iron tablets

• Absorption helped by vitamin-C(take the tablets
  with glass of orange juice)
• Take before or after 1 hr of meal
• Don't take tea/coffee/milk
• Calcium based antacids will reduce the
  absorption

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• NEW THERAPEUTIC ALTERNATIVES
• CARBONYL Iron
• Iron ascorbate
• ADVANTAGES
• Outstanding GI Tolerance
• Very safe with no poisoning even in high doses
• No interaction with food stuffs
• Delicious with non-metallic taste and dont stain
  the patients teeth
• Compliance is very high

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PARENTRAL THERAPY

• INDICATIONS
• Failure to oral iron therapy.
• Non compliance/intolerance to oral iron
• 1st time seen during last 8-10 wks with severe
  anemia
• Malabsorbtion/IBD
• Small bowel resection
• When hemorrhage is likely to continue
• C/I to blood transfusion
• Combination with recombinant human erythropoietin
• C/I to oral therapy

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• Intravenous preparation
• Iron dextran (Imferon)
• Iron sucrose
• Sodium ferric gluconate (ferrlecit)
• Intramuscular preparation
• Iron Sorbitol Citrate in dextrin(Jectofer)
• Iron Dextran (imferon)
• Iron dextran 50 mg/mL. Iron sucrose 20 mg/mL.
  Ferric gluconate 12.5 mg/mL

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• Contraindications
• h/o anaphylaxis to parenteral iron therapy
• 1st trimester of pregnancy
• Active acute/chronic infection
• Chronic liver diseases
• Advantages
• - Certainty of admission.
• - Hb rises _at_1gm/wk.
• Disadvantage
• Nausea and Vomiting
• Metallic taste on tongue

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• IM ROUTE
• Iron Dextran (1ml contains 50mg elemental iron
  1amp2ml)
• Dose 100 mg IM OD/AD till the total dose over
• Drawbacks
• Painful injection (less with jactofer).
• Skin discoloration
• Local abscess
• Allergic reaction
• Fe over load.
• Category C drug
• Gluteal sarcoma
• Test dose needed
• Advantage
• Can be given in primary care set up
• Absolute reticulocyte count increases in 7 days
• Hemoglobin increases within 1-2 wks
• Whole dose can be given in single setting

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• I/V Route
• Repeated Injections
• Total dose infusion
• Side effects
• - Anaphylactic reaction.
• - Chest pain, rigors, chills, fall in BP,
  dyspnoea, hemolysis.
• Treatment
• Stop infusion.
• Give antihistaminics, corticosteroids
  epinephrine.

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• IRON DEXTRAN
• Colloidal solution of ferric oxyhydroxide
  complexed with polymersised dextran
• Advantage patients total iron requirement is
  given in one administration
• Higher rate of adverse effects like delayed
  hypotension/ arthralgia/abdominal pain
• Test dose is necessary
• Patients should be monitored 1 hr following a
  test dose of 25 mg
• Can given as IV infusion with rate less than 50
  mg/min
• Category B drug

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• TDI TOTAL DOSE INFUSION
• I/V (IRON DEXTRAN)
• TDI(Normal Hb - Patients Hb) X Blood
  Volume(65ml/kg)X3.4
• 100
• TDI (Normal Hb Pt. Hb) X Wt in Kg X 2.211000
• TDI10  (target Hb-actual Hb )  (0.24  bodywei
  ght ) 0/500
• Dose given I/V by slow push 100mg / day or the
  entire dose given in 500 ml N/S slow I/V
  infusion over 1-6 hours

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• FERRIC GLUCONATE COMPLEX IN SUCROSE
• Given as IV injection/infusion
• Standard dose of 125 mg may be given IV injection
  over 10 min
• Rate should be lt 12.5mg/min
• Dose can be repeated if ferritin lt 100ng/ml or
  saturation lt 20
• Can be safely given to Dextran sensitive patients

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IRON SUCROSE

• Commonly used in chronic kidney diseases
• MW 34,000-60,000 D
• Iron hydroxide sucrose complex in water
• Given as IV injection/infusion
• Each ml contains 20 mg of Fe
• After IV administration it dissociates into iron
  sucrose
• T 1/2 is 6hrs
• Category B drug

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• Total iron deficit Body weight x (Target Hb
  Actual Hb) x 2.4 Iron stores mg
• Administered 100 mg IV over 5 minutes, thrice
  weekly until 1000 mg
• 200mg max dose per Sitting
• Rate of administration should not more than 20
  mg/min
• Infusion 50 mg to be injected slowly over 2
  minutes, wait for 2-3 min ,then give another 50
  mg over 2 min
• 100mg-200 mg to be diluted with 100ml NS, infuse
  at least 15 min
• Marked increase in reticulocyte count expected
  in 7-14 days

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• Advantages of IRON SUCROSE over others
• All iron preparations were capable of causing
  tissue peroxidation except iron sucrose
• Less oxidative injury
• Less risk of tissue parenchymal injury by free
  iron.
• Higher availability for erythropoiesis than iron
  Dextran
• IV iron supplementation increases the
  erythropoiesis 5 times
• Safe in dextran sensitive patients
• Minimal side effects

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• The Hb rise will be evident in as early as 5
  days
• IV iron sucrose is safe effective
• Iron sucrose is given both bolus push infusion
• Disadvantage
• Total dose administered in multiple infusions
• Needs a set up where anaphylactic reaction can be
  managed.

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NEWEST FAST ACTING IV MOLECULES

• Iron III Carboxymaltose (FERRINJECT)
• Ferric hydroxide carbohydrate complex which
  allows for control delivery of iron within cells
  of the RES (primarily bone marrow) and
  subsequently delivery to the iron binding
  proteins ferritin and transferin
• T1/2 16 hr
• Dose Single dose of 1000 mg over 15 minutes
  (maximum 15mg/kg by injection or 20 mg/kg by
  infusion)

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• IRON III ISOMALTOSE(MONOFER)
• Strongly bound iron in spheroid iron-carbohydrate
  particle providing slow release of bioavailale
  iron to iron binding proteins
• Rapidly up taken by RES and little risk of free
  iron for tissue damage
• Dose 1000 mg in a single infusion
• Erythropoietic response seen within days
• Serum ferritin returns to normal by 3 wks

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• FERUMOXYTOL
• USA FDA approved this drug in 2009 for iron
  replacement in patients with IDA CKD
• No test dose required
• Can be given as large dose (510 mg/vial) in lt20
  Seconds in single settings
• No significant side effects
• Not approved in Europe

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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

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BLOOD TRANSFUSION

• Decision based on
• Needs and risk of developing complications of
  inadequate oxygenation
• Both clinical and hematological grounds
• Indications
• Severe anemia, especially after 36 weeks
• Risk of further hemorrhage
• Associated infections
• Imminent cardiac compromise

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• Patient factors
  Type of surgery
• 
  
• Preg Preg
  Elective Emergency
• lt36wks gt 36wks
  C/S C/S
• -Hb 5gm - Hb 6gm - with
  H/o -assess
• without CHF without CHF
  APH,PPH, according
• -Hb 5-7gm,if -Hb 6-8gm,if previous
  to situation
• CHF, hypoxia, CHF, hypoxia,
  LSCS
• Infection infection
• Hb 8 10 gm, confirm BG cross-matching
• Hb lt8 gm, 2 units to be kept ready in OT

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MANAGEMENT DURING LABOUR

• Consideration for delivery in well equipped
  hospital.
• Avoid sympathetic stimulation and
  hyperventilation prevent rightward shift of ODC.
• Supplemented with oxygen therapy
• Prophylactic forceps/Vaccum to cut short 2nd
  stage
• Decreased blood loss by active management of 3rd
  stage of labors.
• Avoid maternal stress, patient can go into CHF.
• PPH should be emergently treated(uterotonics)

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ANAETHETIC CONSIDERATIONS

• Pre oxygenation is mandatory with 100 O2
• Oxygen supplementation should be given in peri
  and postoperative periods
• Blood arrangements prior to surgery is must
• Airway maintenance to prevent fall of PO2 due to
  airway obstruction
• Hyperventilation to be avoided to minimize
  respiratory alkalosis
• General/spinal anaesthesia can be given after
  platelet count and excluding h/o spontaneous
  hemorrhage.

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MEGALOBLASTIC ANAEMIA

• Incidence 0.2 5
• Caused by folic acid deficiency Vit B12
  deficiency
• Pathophysiology
• Preg. Causes 20 -30 fold increase in Folate
  requirement (150-450 microgram / day ) to meet
  needs of fetus placenta.
• Placenta transports folate actively to fetus even
  if the mother is deficient.
• Vit.B12 deficiency Occurs in patients with
  gastrectomy , ileitis, ileal resection,
  pernicious anaemia, intestinal parasites

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FOLATE DEFICIENCY ANAEMIA

• Folic acid reduced to DHFA then THFA, used in
  nucleic acid synthesis, is required for cell
  growth division.
• So more active tissue reproduction growth more
  dependant on supply of folic acid.
• So bone marrow and epithelial lining are
  therefore at particular risk.
• Coexists with IDA

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• Folic acid deficiency more likely if
• . Woman taking anticonvulsants.
• . Multiple pregnancy.
• . Hemolytic anemia, thalassemia cleft palate
• Diagnosis
• -Increased MCV ( gt 100 fl)
• -Peripheral smear - Macrocytosis, hypochromia
• - Hypersegmented neutrophils(gt 5
  lobes)
• - Neutropenia
• -
  Thrombocytopenia
• -Low Serum folate level.(lt3ng/ ml)
• -Low RBC folate (lt20 ng/ml)

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CLINICAL FEATURES

• Insidious onset, mostly in last trimester
• Anorexia and occasional diarrhea
• Pallor of varying degree
• Ulceration in mouth and tongue
• Glossitis
• Enlarged liver and spleen
• Hemorrhagic patches under the skin and
  conjunctiva
• Macrocytic Megaloblastic Anemia
• Peripheral neuropathy
• Subacute combined degeneration of the Spinal cord

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DIAGNOSIS

• Hb lt 10gm
• Hypersegmentation of neutrophils
• Megaloblast, Howell-Jolly bodies
• MCV gt 100 fl
• MCH gt 33pg, but MCHC is Normal
• Serum Fe is Normal or high, TIBC is low
• Serum Vit B12 levels lt 100 pg /ml
• Radio active Vit B12 absorption test (Schilling
  Test)

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MEGALOBLASTIC ANEMIA(PS)
MEGALOBLASTIC ANEMIA(BM)
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TREATMENT

• Replace iron and treat underlying disease.
• Oral route is preferred for replacement.
• Response can be followed by retic. increase in
  1-2 weeks (5-7 days)
• Hb response to treatment
• half normal by a month
• returns to normal by 2-4 months

60

• Replacement therapy is prolonged by 6-12 months
  to replenish stores of iron.
• 1000 microgram Parenteral Cyanocobalamin every wk
  X 6 weeks
• Prophylactic All woman of reproductive age
  should be given 400mcg of folic acid daily
• Curative Daily administration of Folic acid 4mg
  orally up to at least 4 wks following delivery

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HAEMOGLOBINPATHIES

• Sickle cell disease
• Sickle cell anaemia (most common severe)
• Sickle cell beta thalassemia,
• Haemoglobin SC disease
• Thalassemia
• - Alpha thalassaemia.
• - Beta thalassaemia
• .
  Major
• .
  Minor

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SICKLE CELL ANAEMIA

• Valine substituted for glutamic acid at 6th
  position on ß chain of Hb molecule
• Common variants - SS ( sickle cell anemia)
• - SA (
  sickle cell trait)

Hb SS Hb SA
Cell trait Homozygous Heterozygous
HbS 70 90, rest HbF 10 40, 40-60 HbA
Hb (g/dl) 6 - 9 13 -15
Life expectancy 30 yrs normal
Propensity for sickling (O2 falls lt 40)
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• SIGNS SYMTOMS
• Vaso-occlusive complications
• a)Painful episodes-most common(50)
• b) Acute chest syndrome(20)
• c) Strokes
• d) Renal insufficiency
• e) Splenic sequestration
• f) Proliferative retinopathy
• g) Priapism
• h) Spontaneous abortion
• i) Bone pains, leg ulcers, Osteonecrosis

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• Complications related to hemolysis
• a) Anemia (Hct 15 30)
• b) Cholelithiasis
• c) Acute aplastic episodes
• Infectious complications
• a) Streptococcus pneumonia sepsis
• b) E.coli sepsis
• c) Osteomyelitis
• DIAGNOSIS
• Hb solubility test-specific, cheap, rapid and
  simple.
• Sickling test
• Hb electrophoresis,

65

• MANAGEMENT
• Multidisciplinary approch
• Routine BP measurement and urinalysis to detect
  hypertension and proteinuria
• Retinal screening/fundoscopy for prliferative
  retinopathy
• Screening for iron overload(serum ferritin)
• Screening for PAH by echocardiography
• Antibiotic prophylaxis-penicillin/eruthromycin
• Termination planned for homozygous state

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• Folic acid-5 mg should be given OD
  preconceptually and throughout the pregnancy
• Hydroxurea if taking should be stopped 3 months
  prior conception
• ACE inhibitors angiotensin receptor blockers
  stopped before conception
• Early detection and treatment of malaria and
  infections
• Low dose Aspirin from 12 wks of gestation

67

• Thromboprophylaxis with LMWH
• NSAIDS between 12 to 28 weeks
• Fluid and oxygen therapy(oxygen saturation gt 95)
  in painful crisis
• BT indicated only during complications like
  acute anemia/ACS/twin pregnancies, preeclampsia,
  septicemia, renal failure
• Goals Hb gt 8gm/dl HbA gt 40 of total Hb
• Iron therapy to be given if there is evidence of
  iron deficieny

68

• Vaccine H influenza type b, conjugated
  menigococcal C vaccine, peneumococcal vaccine
  Hepatitis-B vaccine
• Timing of deliver 38 -40 wks of gestation
  either by induction of labour/elective CS
• Factors to be avoided favouring sickling
• - Dehydration
• - Hypotension
• - Hypothermia
• - Acidosis
• - High conc. of HbS

69

• CS is preferred over vaginal delivery when labour
  is not progressing well.
• Continuous FHR monitoring due to increases rate
  of still births/abruption/compromosed placental
  reserve
• Counseling the parents regarding partner
  screening for carrier detection.
• Contraceptives
• Porgesterone only pill
• Injectable contraceptives
• LNG-IUS
• Barrier methods
• Sterilization

70
THALASSAEMIAS

• The synthesis of globin chain is partially or
  completely suppressed resulting in reduced Hb.
  content in red cells,which then have shortened
  life span.
• TYPES
• - Alpha thalassaemia.
• - Beta thalassaemia Major Minor
• Microcytic haemolytic anaemias
• Reduced synthesis of one or more of polypeptide
  globin chains.
• Higher transfusion requirements in pregnancy
  worsen haemosiderosis cardiac failure.

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CLINICAL FEATURES

• Usually asymptomatic
• Weakness, fatigue, exhaustion, loss of appetite,
  indigestion, giddiness, breathlessness
• Palpitations, tachycardia, breathlessness,
  increased cardiac output, cardiac failure,
  generalised anasarca, pulmonary edema
• Pallor
• Nail changes
• Cheilosis, Glossitis, Stomatitis
• Edema
• Hyperdynamic circulation (short soft systolic
  murmur)
• Fine crepitations

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TREATMENT

• Women with hemoglobinopathy should be offered
  oral iron therapy if serum ferritinlt30 mcg/L
• Referral to secondary/tertiary care to be done
  if
• Severe anemia
• Significant symptoms
• Late gestation(34 wks)
• Failure to respond to oral iron

73

• WHO - 60 mg Elemental iron 400 micro gram
  Folic acid / day up to 3 months postpartum
• GOI - 60 mg elemental Iron 500 mcg Folic acid
  as Prophylactic supplementation x 100 days in 2nd
  trimester up to 3 months postpartum

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ANAEMIA ASSOC. WITH CHRONIC INFECTIONS / DISEASE

• Common in developing countries
• Poor response to Haematinics unless primary cause
  is treated
• Worm infestations is common ( Diagnosed by stool
  examination )
• Urinary tract inf, asymptomatic bacteriuria in
  preg. is assoc. with refractory anaemia
• Chronic renal disorders due to erythropoietin
  def.

75
TREATMENT

• Identifying the etiology and treat accordingly
• Deworming with mebendazole/albendazole/levamisole
• Treated with recombinant Erythropoietin for renal
  disease.
• ATT to a patients with tuberculosis
• Antibiotics to treat UTI according to sensitivity
  

76
PREVENTION

• Dietary advice and modification(red meat/
  poultry/fish)
• Germination and fermentation of cereals and
  legumes improve the bioavailability of iron in
  food
• Green peas/Whole wheat/Green vegetables/Jaggery
• Iron supplementation of adolescent girls non
  pregnant women
• A nutritious diet in a pregnant woman should be
  providing about 40 mg elemental iron daily.

77

• Food fortification
• Fortification of staple food like wheat flour
  which is technically simple(USA)
• Fortification of curry powder, salt and sugar,
  dried and liquid milk(SA)
• Fortification of infant foods (INDIA)
• Fortification of complimentary foods (USA)

78

• Treatment of hookworm Infestation, malaria,TB
• Avoidance of Hypoxia, Acidosis, Infection,
  Dehydration Stress , Exercise, Extreme,
  Temperature
• Avoidance of frequent child birth.
• Supplemented Viamin-C (250-500mg/day) with iron
• Adequate treatment for any infection like UTI

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• Early detection of falling Hb level, levels
  should be estimated at 1st A/N visit, 30th
  finally 36th week
• Mandatory monthly screening for anemia should be
  done in all antenatal clinics(especially at
  booking and at 28 wks with FBC)
• Screening and effective management of obstetric
  and systemic problems in all pregnant women

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THANK Q