Definition: according to who, anaemia in pregnancy is present when the haemoglobin concentration in the peripheral blood is 11gm/1OOml or less
Classification:
A- physiological anaemia of pregnancy
B- pathological
Pathological
1 -deficiency anaemia
· Iron deficiency
· Folic acid deficiency
· Vitamin B12 deficiency
· Dimorphic (Both iron and folic/vit-131 2 deficiency)
· Protein deficiency.
2 -Haemorrhagic
· Acute- Following bleeding in early months or APH
· Chronic- Hookworm infestation, bleeding piles etc.
3. Hereditary
· Thalassemias
· Sickle cell haemoglobinopathies
· Hereditary haemolytic anaemias
4. Anaemia of chronic infection - HIV, malaria and tuberculosis
5. Chronic renal disease or neoplasm
6. Bone marrow insufficiency- Aplasia or hypoplasia due to malignancy, radiation and drugs Degree of anaemia
· Mild - hb% level between 9-11 gm%
· Moderate- between 7-9 gm%
· Severe - less than 7gm%
Iron deficiency anaemia is the most common anemia in pregnancy.
Clinical features:
· Symptoms:-
1. Lassitude and feeling of exhaustion or weakness.
2. Anorexia and indigestion
3. Palpitation caused by ectopic beats and dyspnoea.
4. Giddiness and
5. Swelling of legs
· On examination:-
1. Pallor of varying degrees.
2. Glossitis and somatitis
3. Edema of legs
4. Koilonychia
5. Soft systolic murmur 'haemic murmer' may be heared.
6. Crepitations at the base of lungs may be heared due to congestion.
Investigation
The following investigations are to be done-
1. Haematological indices- hb%, total red cell count, pcv,mcv,mch,mchc.
2. Peripheral blood film/smear
3. Serum iron, total iron binding capacity, saturation percentage and serum ferritin.
4. Examination of stool.
5. Complete examination of urine and culture
6. Estimation of serum protein in hypoproteinaemia
7. Hba2 (in chronic cases)
Treatment
· Prophylactic
· Curative
Prophylactic treatment in cludes:
1. Avoidance of frequent child-births:-minimum interval between pregnancies should be atleast 2 years.
2. Supplementary iron therapy: -daily administration of 335mg of ferrous sulphate containing 100 mg of elemental iron along with 0.5 mg folic acid daily for 100 days is quite effective.
3. Dietary prescription:- a balanced diet rich in iron, vitamins, minerals and protein should be prescribed.
4. Adequate treatment should be done to eradicate hookworm infestation, dysentery, malaria, bleeding piles and uti.
5. Early detection of falling hb % level should be made, hb % level should be estimated at first anc visit, at 28th -30th and 36th week
Curative treatment:
1. Hospitalisation:
All patients with hb% level of 7 or less should be hospitalised for investigations and treatment.
2. Specific treatment:
Choice of treatment depends on severity of anaemia, duration of pregnancy and associated complicating factors.
· Iron therapy: oral and parenteral therapy
· Blood transfusion: Iron therapy:
Oral route:
- fersolate tab containing 100 mg of elemental iron is given, once/twice/thrice a day according to severity of anaemia.
- Response of therapy is evidenced by sense of well being, increased appetite, improved outlook of the pt and rise in Hb%.
- Reticulocytosis within 7-10 days of therapy.
- Improvement should be evident within three weeks of therapy. The haemoglobin level is expected to rise atthe rate of about 0.7 gm/dl perweek
-parenteral route:
· Intravenous
· Intramuscular
-repeated injections and total dose infusion(tdi)
· Indications of parenteral therapy are- contraindications of oral therapy, patient seen for the first time during the last 8-10 weeks and non- complaint patients to take oral iron.
· The expected rise in haemoglobin concentration after parenteral therapy is 0.7-1gm/dl per week
Iintravenous -total dose infusion (tdi)-
-the deficit of iron is first calculated and the total amount of iron required is administered by a single intravenous infusion. The compound used is iron sucrose (acog-2008).
- formula used for iron sucose:
Total iron dose(mg)= 2.3 x w x d+500 {w=wt in kg , d= hb% deficit,(target -actual), 500mg for body store}.
-example, the total elemental iron required for an anaemic patient having hb 8gm% weighing 50 kg is calculated as- 2.3 x 50 x 3 + 500= 845 mg. It is given iv, 100mg in 100ml normal saline over 15 minutes.
Intramuscular therapy:
-iron dextran and iron-sorbitol-citric acid complex are used.
-total dose to be administered is calculated as in i.v therapy and given repeated injections i.m in buttocks using "z" technique.
Blood transfusion
- Blood transfusion in anaemia of pregnancy is very much limited.
- Less than 36 weeks of pregnancy.
- Indications are-to correct anaemia due to bloodloss like in aph and to combat post-partum haemorrhage.
- Patient with severe anaemia seen beyond 36 weeks of pregnancy. -
- Refractory anaemia..
- Only packed cells are to be transfused.
Management during labour First stage:
- The patient should be on bed and should lie in position comfortable to her.
- Arrangements for oxygen inhalation-are to be kept ready.
- Strict asepsis is to be maintained to minimize puerperal infection.
Second stage:
- Asepsis is maintained.
- Prophylactic low forceps or vacuum delivery may be done to shorten the duration of second stage of labour.
- Restricted fluid to be given
Third stage:
- one should be very vigilant during the third stage.
- oxygen inhalation to be given accordingly.
- restricted i.v fluids.
- active management of third stage must be done by giving 10 units of oxytocin intramuscularly (inj. methergin should be avoided)
- significant amount of blood loss should be replenished by giving packed cell transfusion. Puerperium:
-prophylactic antibiotics are given to prevent infections.
-iron therapy should be continued for at least 3 months following delivery;
-patient should be warned of the danger of recurrence in subsequent pregnancies.
Govt of india is providing iron tablet free of cost to all antenatal women containing, 100mg of elemental iron and 0.5 mg of folic acid.
Mohfw goi 2013
Guidelines for control of iron deficiency anaemia
Pregnant women and lactating mothers
Iron and folic acid tablets are being distributed through sub-centres, primary health centres (phcs), community health centres (chcs) and district hospitals (dhs) to all pregnant women and lactating mothers.
Implementation
Provision of IFA tablets to pregnant women will be during routine antenatal visits at subcentre/ PHC/CHC/DH. ASHA to ensure provision of IFA supplements to pregnant women who are not able to come for regular antenatal checkups through home visits. She will also monitor compliance of IFA tablets consumption through weekly house visits.
Pregnant and Lactating Women
Screening of all pregnant women for anaemia at sub- centre/VHND/outreach/PHC level can be done by Sahli's haemoglobinometer or by Standard Hb Colour Scale. Therapeutic dose of oral IFA supplementation can be initiated even on clinical signs and symptoms, however, such cases must be referred for confirmation of degree of anaemia through Hb testing and for further management as per Table.
Haemoglobin Level of facility Therapeutic regimen Level Sub-centre Hb level between 9-11 gm/dl
9-11 gm/dl Signs and symptoms • 2 IFA tablets (1 in the morning and 1 in the (generalised evening) per day for at least 100 days (at least
weakness, giddiness, 200 tablets of IFA).
breathlessness, etc.) • Hb levels should preferably be
reassessed at
Clinical examination monthly intervals. If on testing, Hb has come (pallor eyelids, tongue, up to normal level, discontinue the treatment. nail beds, palm, etc.) • If it does not rise in spite of the administration
Confirmation by of 2 tablets of IFA daily and dietary laboratory testing supplementation, refer the woman to the next higher health facility for further management.
7-9 gm/di PHC/CHC Hb level between 8-9 gm/dl
Signs and symptoms • Before starting the treatment, the
woman
(generalised should be investigated to defect the cause of weakness, giddiness, anaemia. -
BPeathlessness, etc.) • Oral IFA supplementation as for Hb level
Clinical examination 9-11 gm/dl. Hb testing to be done every (pallor of eyelids, month.
tongue, nail beds, •Depending on the response to treatment, palm, etc.) same course of action as prescribed for Hb Confirmation by level between 9-11 gm/dl.
laboratory testing • Hb level between 7-8 gm/dl
• Before starting the treatment, the woman should be investigated to diagnose the cause of anaemia.
• Injectable IM iron preparations (parenteral iron) should be given if iron deficiency is found to be the cause of anaemia.
• IM iron therapy in divided doses along with oral folic acid daily if women do not have any obstetric or systemic complication; repeat Hb after 8 weeks: If the woman has become non- anaemic, no further medication is required: if Hb level is between 9-11 gm/dl, same regimen of oral IFA prescribed for this range
• If woman with Hb between 7-8 gm/dl comes to PHC/CHC in the third trimester of pregnancy, refer to FRU/MC for management.
Multiple dose regime
Intramuscular (IM) - Test dose of 0.5 ml given deep IM and woman observed for 1 hour. Iron dexfran or iron sorbitol citrate complex given
as 100 mg (2 ml) deep IM in gluteal region daily. Recommended dose is 1500-2000 mg
(IM in divided doses) depending upon the body weight and Hb level. If parental iron therapy is contradicted e.g. in CHF, H/O allergy, asthma,eczema; Haemochromatosis, liver cirrhosis, rheumatoid arthritis and acute liver cirrhosis, rheumatoid arthritis and acute renal failure etc, refer the woman to FRU/MC
<7 gm/dl FRU/DH/MC Hb level between 5-7 gm/dl
Signs and symptoms • Continue parenteral iron therapy as
for Hb
(generalized, level between 7-8 gm/dl. Hb testing to
be
weakness, giddiness done after 8 weeks
breathlessness, etc.) • If the woman becomes non-anaemic,
no
Clinical examination further medication is required.: if Hb
level is
(pallor eyelids, tongue, between 9-11 gm/dl, same regimen of oral nail beds, palm, etc.) IFA prescribed for this range Confirmation by
• Depending on the further response to laboratory testing treatment, same course of action as prescribed for Hb level between 9-11 gm/dl Hb levels less than 5 gm/dl
• Refer patient to higher center for further management preparation:
• Evidence for injectable IV sucrose under Randomised Control Trial of GOI
• Immediate hospitalization irrespective of period of gestation in hospitals where round- the-clock specialist care is available for intensive personalized care and decision for blood transfusion (packed cell transfusion)
Pre-requisites for parenteral therapy
• Should be given under proper supervision
• After test dose only
• Close monitoring required
• Inj. Adrenaline, Hydrocortisone and oxygen to be available for management of anaphylactic reactions.
• Cardiopulmonary resuscitation facility to be available.
• Other indications for parenteral iron therapy are poor compliance or intolerance to oral iron therapy.
Post-partum/post-ncital period
If the woman is non-anaemic in post-partum period, prophylactic regime (1 tablet per day for 100 days) should be given.
Precautions for oral therapy
• Intake of doses as per regime, should be taken regularly and must complete the treatment
• Ideally, tablets should be taken on empty stomach for better absorption. In case of gastritis, nausea, vomiting etc., advise to take one hour after meal or at night
• If constipation occurs, advise to drink more water and add roughage to diet
• IFA tablets should not be consumed with tea, coffee, milk or calcium tablets
• IFA treatment should always supplemented with diet rich in iron, vitamins (particularly Vitamin C), protein, minerals and other nutrients e.g. Green leafy vegetables, whole pulses, jaggery, meat, poultry and fish, fruits and black gram, groundnuts, ragi, whole grains, milk, eggs, meat and nuts, etc.
Megaloblcistic anaemia
Megaloblastic anaemia is characterized by blood and bone marrow abnormalities from impaired DNA synthesis in which there is derangement in red cell maturation and production of abnormal precusors cells known as megaloblasts.
It is caused by deficiency of vitamin B-12, folic acid or both.
· Vitamin B-12deficiency is rare in pregnancy so megaloblastic anaemia is mainly due to deficiency of folic acid.
· Incidence varies from 0.5 to 3%.
· More common in multiparae, 5 times more than in primigravidae and in multiple pregnancy (8 fold increase than in singleton).
Causes: Common causes of Vit B-12 are:
1. Strict vegetarian diet
2. Gastritis
3. Gastrectomy
4. Heal bypass
5. Crohn's disease
6. Drugs- metformin and proton pump inhibitors
7. Addisonian pernicious anaemia
8. Megaloblastic anaemia of malabsorption syndrome. Causes of folic acid deficiency are:
1. Inadequate intake
2. Increased demand as in pregnancy
3. Abnormal demand in case of infection and haemorrhage
4. Diminished absorption in malabsorption syndrome
5. Failure of utilization- pt on anticonvulsant therapy
6. Diminished storage- hepatic disorders
7. Associated with iron deficiency anaemia.
· When anaemia fails to improve with iron therapy addition of folic acid should be tried before proceeding for a detailed investigation.
Clinical features:
Specific to megaloblastic anaemia are:
1. The onset is usually insidious and is first revealed in the last trimester or acutely in early puerperium
2. Anorexia or protracted vomiting
3. Occasional diarrhea
4. Neurological symptoms like paraesthesias and numbness of extrimities.
5. Constitutional symptom like unexplained fever is often associated.
6. Haemorrhagic patches under the skin and conjunctiva
7. Hepatomegaly and spleenomegaly
Haematological findings:
1. Hyper-segmentation of the neutrophils 5 or more lobes, megaloblasts, howell- jolly bodies, giant polymorphs, macrocytosis and anisocyfosis.
2. Mcv is more than 1000, mch is high > 33pg, but mchc is normal
3. Serum iron is normal or highand iron binding capacity is low.
4. Associated leucopenia and thrombocytopenia.
5. Serum folate is below 3ng/ml (n-3-8)
6. Serum vitb-l2 level is below 9opg/rnl(n-300)
7. Bone marrow shows megaloblasticerythropoisis
Complications:
1. Abortion
2. Dysmaturity
3. Prematurity
4. APH
5. Fetal malformation like cleft lip, harelip, neural tube defects.
Prophylactic therapy:
All woman of reproductive age should be given 400 µg of folic acid and additional amount 4mg should be given in situations where demand is high.
Women with previous history of having babies with neural tube defects should be given 4mg of folic acid daily 1 month before conception till 12th week of pregnancy.
Curative:
1. Daily administration of 4mg folic acid orally and continued forfour weeks following delivery.
2. Supplementation of 1 mg of folic acid with iron and nutritious diet.
3. Supplementary intramuscular injection of vit B daily or alternate day may be added when response to folic acid alone is not adequate.
References
No references available