ANAEMIA: Preventable, Yet a Problem

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ANAEMIA Preventable, Yet a Problem!!
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Definition

• Anemia - insufficient Hb to carry out O2
  requirement by tissues.
• WHO definition Hb conc. ? 11 gm
• CDC definition Hb conc. lt 11gm in 1st and
  3rd trimesters and lt 10.5 gm in 2nd trimester
• For developing countries cut off level
  suggested is 10 gm
• - WHO technical report Series no. 405,
  Geneva 1968
• Centre for disease control, MMWR
  198938400-4

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WHO Classification of Anaemia

• Degree Hb Haematocrit ()
• Moderate 7-10.9 24-37
• Severe 4-6.9 13-23
• Very Severe lt4 lt13

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Magnitude of Problem

• Globally, is about 30
• In developing countries India, incidence is
  around 40 90.
• Responsible for 40 of maternal deaths in third
  world countries.
• Important cause of direct and indirect maternal
  deaths
• - Vitere FE Adv Exp Med Biol 1994352127

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Symptoms
Irritability
Lack of Concentration
Fatigue
Infection
Palpitation
Weakness
Dizziness
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Clinical Features
Pallor of skin And m/m
Soft ejection systolic murmur
Edema

• Signs

Platynychia Koilonychia
Tachycardia
Glossitis Stomatitis
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Causes of Anaemia
Physiological
Pathological

• Nutritional
• Haemorrhagic
• Haemolytic

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Iron Requirement
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Iron Requirement During Pregnancy
32 to 40 weeks
20 to 32 weeks
6.8 mg / day
Early Pregnancy
5.5 mg / day
2.5 mg / day
RBC 500mg FetusPlacenta 450mg Third stage
blood loss 200mg Total 1150mg
TOTAL 800 1000 mg
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Normal Levels
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Laboratory Diagnosis of Anaemia
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Nutritional Anaemia Major Health Problems
National Nutrition Anaemia Prophylaxis Programme
(NNAPP 1971 - 72)
Anaemia continues Major health problem
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Reason For Increased Incidence Of Anemia

• Poor pre-pregnancy iron balance due to
  untreated systemic diseases menstrual disorders
  
• Improper supplementation of iron in pregnancy (
  late registration and poor follow up)
• Repeated childbearing
• Lack of awareness and illiteracy

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Reason For Increased Incidence Of Anemia

• Low socioeconomic status and poor hygiene
• Chronic malnutrition
• Poor availability of iron due to predominantly
  veg diet, diet low in calories but rich in
  phytates. Food and religious taboos
• GI infections and infestations
  (e.g. Kala azar, worm infestations)

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Complications - Pregnancy
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Complications - Labour
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Management Options

• Pre pregnancy
• Treat the cause before conception
• Pre-pregnancy balanced diet, education and health
  support.
• Build up iron stores during adolescent phase

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Modalities of Management
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Oral Iron
100 mg elemental Iron ------- ? 0.18 gm day
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Oral Iron Therapy

• Ideal dose 100mg per day (prophylactic)
• Ferrous gluconate, ferrous fumarate, ferrous
  succinate, ferrous sulphate, ferrous ascorbate
  citrate
• Rise in Hb 0.8 gm / dl / week
• Side effects -G I upset most common
• Pt. compliance not guaranteed
• Ineffective in pts with worm infestations
• Inconclusive evidence on benefit of controlled
  release Iron preparation

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Absorption of Ferrous Salts
Uncontrolled Passive Absorption

• Iron salts are dissociated into bivalent or
  trivalent iron salts
• Diffuses as free iron ions through the upper part
  of the gastrointestinal mucosa
• Taken up by transferrin and incorporated into
  ferritin.
• For binding to ferritin and transferrin ferrous
  iron has to be converted into ferric iron by
  oxidation
• Highly reactive free radicals are produced during
  this process
• All ionic iron including carbonyl iron are
  absorbed similarly

• Borbolla JR. Cicero RE, Dibilox MM, Sotres RD et
  al.. Rev Mex Pediatr 2000 67(2) 63-67
• Heubers KA, Brittenham GM, Csiba E, Finch CA. J
  Lab Clin Med 1986 108 473-8.

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Mucosal Cell
Blood
Gut Lumen
Fe3
Iron salts
Free Radical
Ferritin
Dissociation
Transferrin
Fe2
Fe2
Fe2
Fe3
Fe2
Fe2
Fe2
Free Radical
Passive diffusion
Fe2
Fe2
Fe2
Fe2
Fe2
Fe2
Fe2
Fe2
Fe2
Fe2
Fe2
Incorporation into Hb
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Parenteral Therapy
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Parenteral Therapy Traditional Indications

• Intolerance to oral iron
• Poor compliance to oral iron
• Gastrointestinal disorders
• Malabsorption syndromes
• Rapid blood loss

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Parenteral Therapy Traditional Indications

• Inability to maintain iron balance
  (haemodialysis)
• Patient donating large amount of blood for
  auto-transfusion programme
• ? Pregnant women with severe IDA, presenting
  late in pregnancy

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TheWorld Health Organisation
states

• transfusion should be prescribed ONLY for
  conditions for which there is NO OTHER TREATMENT
  

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Diagnosis of Folate Deficiency Anemia (FDA)

• Special considerations in diagnosis
• FDA is suspected when the expected response
• to adequate iron therapy is not achieved
• Macrocytosis can occur in pregnancy in
  absence
• of FDA
• If FDA IDA present, it will be masked by
  IDA
• Definitive diagnosis Bone marrow aspirate

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Megaloblastic Anemia- Diagnostic Problems

• HB estimation
• Peripheral smear
• MCV estimation
• Serum folate
• Red cell folate
• FIGLU estimations
• Marrow aspirate

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Management of FDA

• Strong case for routine prophylaxis
• Prophylaxis with anti convulsants
• Continue routine oral therapy for hemolytic
  anaemia
• Parenteral therapy for severe deficiency

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Worm Infestations

• Common cause of anaemia in developing countries
• Most common hookworm infestation, Round worm,
  whip worm, etc.
• Oral iron therapy becomes ineffective
• Treatment by antihelminthics is a must
• Treatment
• Mebendazole 100mg twice daily for three days
• Pyrantel pamoate 10mg / kg in single dose.
• Albendazole 400mg once a day for three days

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Hemoglobinopathies

• A collective term for the inherited disorders
  of Hb synthesis
• Disorders of globin synthesis e.g. Thalassemia
• Structural Hb variants e.g. Sickle cell anemia,
  HbC

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Thalassemia

• Genetic disorders lack or ?sed synthesis of
  globin chains
• Two types ? ? thalassemia
• ? chains encoded by 2 pairs of genes on
  chromosome 16
• ? chains encoded by single pair of genes on
  chromosome 11
• ? thalassemia more common and presents as either
  ?(major) or ? (minor)

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Diagnosis of Thalassemia

• Hb estimations
• Peripheral smear
• ?sed MCV
• ?sed MCH
• HbA2 (? 2?2)

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Diagnostic Strategy for Thalassemias
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Sickle Cell Disease

• Structural Hb variant
• Exists in homo heterozygous forms
• Under hypoxic conditions, HbS polymerizes, gels
  or crystallizes.
• ? hemolysis of cells, thrombosis of vessels in
  various organs
• In long standing cases, multiple organ damage.

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Take Home Message

• Anaemia although preventable is a global problem
• Anaemia still is the commonest cause of maternal
  mortality and morbidity in spite of easy
  diagnosis and treatment
• Anaemia can be due to a number of causes,
  including certain diseases or a shortage of
  iron, folic acid or Vitamin B12.
• The most common cause of anemia in pregnancy
  isiron deficiency.
• Iron therapy is best given orally

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Take Home Message

• The youth need to be educated about diet,
  sanitation and personal hygiene
• Hookworm infestation should be treated
• Pregnant women should be given Iron and folate
  supplements

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Concept Dr. Duru Shah

• Editors
• Dr. Sangeeta Agrawal
• Dr. Reena Wani

• Contributors
• Dr Duru Shah
• Dr. Sarita Bhalerao
• Dr. Manisha Bandgar

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We acknowledge the efforts of our

• Coordinators
• Dr. Sangeeta Agrawal - Central
• Dr. Narendra Malhotra - North
• Dr. Hema Divakar - South
• Dr. P. C. Mahapatra - East
• Dr. Uday Thanawala - West
• In bringing the FOGSI YOUTH EXPRESS to your
  city.

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This Youth Express Has Been Possible Due To The
Educational Grant From

• Charak Pharma Pvt. Ltd
• CIPLA Ltd.
• Emcure Pharmaceuticals Ltd
• GlaxoSmithKline Pharmaceuticals Limited
• Glenmark Pharmaceuticals Ltd.
• Metropolis Health Services (India) Pvt.Ltd.
• Organon India Ltd
• Roche Pharmaceuticals Ltd.
• Sandoz Private Limited
• USV Limited
• Wyeth Limited