ANAEMIA IN PREGNANCY

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ANAEMIA IN PREGNANCY

• BY
• Dr. Shumaila Zia

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ANAEMIA IN PREGNANCY

• Commonest medical disorder.
• High incidence in underdeveloped countries
• Increased Maternal morbidity mortality
• Increased perinatal mortality

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ANAEMIA IN PREGNANCY

• Definition By WHO
• Hb. lt 11 gm /dl
• (or haematocrit lt32).
• Mild anaemia -------- 9 -10.9 gm /dl
• Moderate anaemia--- 7-8.9 gm /dl
• Sever anaemia-------- lt 7gm /dl
• Very sever anaemia-- lt 4gm/dl

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ETIOLOGY

• There are 3 main causes
• 1- Erythrocyte production (hypo
  proliferative anemia )
• . Fe deficiency
• . Folic acid
• . Vitamin B12
• 2- RBC destruction
• 3- RBC loss
• 90 anemia in pregnancy is due to Fe
  deficiency

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Physiological changes in pregnancy

• Plasama volume 50 (by 34weeks)
• But RBC mass only 25
• Results in haemodilution
• 
  Hb
• 
  Haematocrit
• 
  RBC count
• No change in MCV or MCH
• 2-3 fold increase in Fe requierment.
• 10-20 Fold increase in folate requirement

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Common Anaemias in pregnancy

• Common types
• Nutritional deficiency anaemias
• - Iron deficiency
• - Folate deficiency
• - Vit. B12 deficiency
• Haemoglobinopathies
• - Thallassemias
• - SCD
• Rare types
• - Aplastic
• - Autoimmune hemolytic
• - Leukemia
• - Hodgkins disease
• - Paroxysmal nocturnal haemoglobinurea

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IRON DEFICIENCY ANAEMIA

• Iron required for fetus and placenta -------
  500mg.
• Iron required for red cell increment -------
  500mg
• Post partum loss
  --------- 180mg.
• Lactation for 6
  months - 180mg.
• Total requirement
  -------1360mg
• 350mg subtracted (saved as a result of
  amennorrhoea)
• So actual extra demand ----------------------1000m
  g
• Full iron stores --------------------------------1
  000mg

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ETIOLOGY OF IRON DEFICIENCY ANAEMIA

• Depleted iron stores dietary lack, chronic
  renal failure, worm infestation, chronic
  menorrhagia
• Chronic infections ( like malaria)
• Repeated pregnancies
• - with interval lt 1 year
• - blood loss at time of delivery
• - multiple pregnancy.
• CLINICAL FEATURES
• Symptoms usually in severe anaemia
• - Fatigue
• - Giddiness
• - Breathlessness

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EFFECTS OF ANAEMA IN PREGNANCY

• . Mother
• High output Cardiac failure (more likely if
  precelampsia present. inadequate tissue
  oxygenation increase requirments for excessive
  blood flow )
• PPH
• Predisposes to infection
• Risk of thrombo-embolism
• Delayed general physical recovery esp after c.
  section
• Fetus . IUGR
• . Preterm birth
• . LBW
• . Depleted Fe store
• . Delayed Cognitive function.

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INVESTIGATIONS

• Hb
• Haematocrit
• RBC Indices
• - Low MCV
• - Low MCH
• - Low MCHC
• - Low PCV
• Peripheral blood picture
• Microcytic Hypochromic
  anaemia .

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INVESTIGATIONS

• Serum iron decreased (lt12 micro mol / l)
• Total iron binding capacity TIBC in non-pregnant
  state is 33 saturated with iron .when serum iron
  level fall ,lt15 ofTIBC saturated.by fall in
  saturation,the TIBC INCREASED.
• S. ferritin In healthy adults ferritin circulate
  in plasma in range of 15_300 pg/l. in iron
  deficiency anemia it is the first test to become
  abnormal.

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• Serum transferrin receptor(TfR) present on all
  cells as transmembrane protien that binds
  transferrin iron and transfer it to cell
  interior. Increased in iron def. anemia.
• Bone marrow examination.
• RFTS/LFTS.
• Urine for haemturia.
• Stool examination for ova ,cyst and occult blood.

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MANAGEMENT

• Objectives
• 1- To achieve a normal Hb by end of
  pregnancy
• 2- To replenish iron stores
• Two ways to correct anaemia
• I- Iron supplementation . Oral
  Fe
• 
  . Parenteral Fe
• II- Blood transfurion
• Choice of method
• It depends on three main factors
• Severity of the anaemia
• Gestational Age.
• Presence of additional risk factor

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MANAGEMENT

• Recommended supplementation for non-anaemiac 30
  - 60mg /day of elemental iron
• Anaemic gravidas 120 240mg / per day
• In tolerance to iron tablets enteric coated
  tablet / liquid suspension
• Supplementation with folic acid Vit C.
• Therapeutic results after 3 weeks rise in Hb
  level of 0.8gm/dl/ week with good compliance.
• Treatment continued in the postpartum period to
  fill the stores

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MANAGEMENT

• Severe anaemia (Hb lt 8gm/dl)- preferably
  parenteral theraphy in the form of I/M or I/V
  iron
• - I/M ( Iron sorbitol) with Z
  technique
• - I/V (iron sucrose)
• Iron neede
• (Normal Hb Pt. Hb) Wt in Kg2.211000)

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MANAGEMENT

• Dose given I/M or 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
• Marked increase in reticulocyte count expecred
  in 7-14 d
• Blood transfusion
• may be required to treat severe anaemia near term
  or when some other complication such as placenta
  praevia present.
• Gross anaemia
• Packed red cells transfusion (Under cover of loop
  diuretic)
• Exchange transfusion (Under cover of loop
  diuretic)

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MANAGEMENT

• Side effect of Fe Oral therapy
• . G. I upset.
• . Constipation.
• . Diarrhoea.
• Parentral
• - skin discolouration
• - local abscess
• - allergic reaction
• - Fe over load.

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MEGALOBLASTIC ANAEMIA

• Complicates upto 1 of pregnancies
• Characterized by
• - RBC with high MCV
• - White blood cells with altered morphology
• (hypersegmented neutrophils).
• Usually caused by
• - Folate deficiency may occur
  after exposure
• to sulfa drugs or hydroxyurea
• - Vitamin B12 deficiency

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FOLATE DEFICIENCY ANAEMIA

• At cellular level
• Folic acid reduced to Dihydrofolicacid then
  
• Tetrahydro-folicacid . (THF) e 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.

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FOLATE DEFICIENCY ANAEMIA

• Folic acid deficiency more likely if
• . Woman taking anticonvulsants.
• . Multiple pregnancy.
• . Hemolytic anemia thalasemia H.spherocytosis
• Maternal risk
• Megaloblastic anemia
• Fetal risk
• Pre-conception deficiency cause
  neural tube defect and cleft
  palate etc.

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FOLATE DEFICIENCY ANAEMIA

• Diagnosis Increased MCV ( gt 100 fl)
• Peripheral smear - Macrocytosis, hypochromia

- Hypersegmented
neutrophils (gt 5
lobes) -
Neutropenia -
Thrombocytopenia Low Serum folate
level. Low RBC folate.
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FOLATE DEFICIENCY ANAEMIA

• Daily folate requirement for
• Non pregnant women -- 50 -100 microgram
• Pregnant woman -------- 300-400 microgram
• Usually folic acid present in diets like fresh
  fruits and vegetables and destroyed by cooking.
• Folate deficiency
• - 0.5-1.0mg
  folic acid/day
• If F/Hx. of neural tube defect
• - 4mg folic
  acid/day.

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Vitamins B12 Deficiency

• It is rare
• Occurs in patients with gastrectomy , ileitis,
  illeal resection, pernicious anaemia, intestinal
  parasites.
• Diagnosis
• Peripheral smear
• Vitamin B12 level lt 80 pico g/ml
• Treatment of B12 Deficiency
• Vit B12 1mg I/M weekly for 6 weeks.

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HAEMOGLOBINOPATHIES.

• Normal adult Hb. after age of 6 month,
• HbA---97, HbA2---(1.5-3.5), HbF2--lt1.
• 4 Globin chains associated with haem complex.
• Hb. A 2 alpha 2 beta globin chains.
• Hb.A2 2alpha2 delta globin chains.
• Hb.F 2 alpha 2 gamma globin chains.
• Hb. synthesis is controlled by genes.
• Alpha chains by 4 gene,2 from each parent.
• Beta chains by 2 genes ,1 from each parent.

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HAEMOGLOBINOPATHIES

• DEFINITION
• Inherited disorders of haemoglobin.
• Defect may be in
• - Globin chain synthesis------thallas
  semia.
• - Structure of globin chains-sickle
  cell disease.
• Hb.abnormalities may be
• - Homozygous inherited from both
  parents.
• (Sufferer of disease)
• - Hetrozygous inherited from one
  parent.
• (Carrier/trait of disease)

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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

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Beta thallassemia minor

• Beta Thallassemia trait
• Heterozygous inheritance from one parent.
• Most frequent encountered variety.
• Partial suppression of the Hb. synthesis.
• Mild anaemia.
• Investigations Hb----around 10 g/dl.
• Red cell indices low MCV.
• low MCH.
• normal MCHC.
• Diagnostic test Hb. Electrophoresis.

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Beta Thallassemia Minor

• Management
• Same as normal woman in pregnancy.
• Frequent Hb. Testing.
• Iron folate supplements in usual dose.
• Parenteral iron should be avoided. because of
  iron overload.
• If not responded ---I/M folic acid.
• blood transfusion close to time of delivery.

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Beta Thallassaemia Major

• Homozygous inheritance from both parents.
• Sever anaemia.
• Diagnosed in paediatric era.
• T/m is blood transfusion.
• ALPHA THALASSAEMIA
• Both heterozygous homozygous forms exist.
• Alpha thallassaemia trait.
• HbH disease.
• Alpha thallassaemia major.

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SICKLE CELL SYNDROME.

• Autosomally inherited .
• Structural abnormality.
• HbS - susceptible to hypoxia, when oxygen
  supply is reduced.
• Hb precipitates makes the RBCs rigid sickle
  shaped.
• Heterozygous----HbAS.
• Homozygous-----HbSS.
• Compound heterozygous---HbSC etc.

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Sickle Cell Disease (SCD)

• Sickeling crises frequently occurs in pregnancy,
  puerperium in state of hypoxia like G/A and Hag.
• Increased incidance of abortion and still birth
• growth restriction, premature birth and
  intrapartum fetal distress with increased
  perinatal mortality.
• Sickle cell trait(carrier state)
• Does not pose any significance clinical
  problems

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SCD

• Diagnosis
• - Hb. Electrophoresis
• - Sickledext test is screening test
• Management
• - No curative Tx.
• - only symptomatic
• - Well hydration, effective analgesia,
  prophylactic
• antibiotics, O2 inhalation, folic acid,
  oral iron
• supplement (I/V iron is C/I), blood
  transfusion

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Management During labour

• Comfortable Position
• Adequate analgesia
• O2 inhalation
• Low threshold of assisted delivery
• Avoid ergometrine
• Prophylactic antibiotics
• Continue iron folate therapy for 3 mo after
  delivery
• Appropriate contraceptive advice