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ANEMIA IN PREGNANCY

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Title: ANEMIA IN PREGNANCY


1
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
2
  • 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

3
Pregnancy Most dangerous journey of mankind
Anemia begins in childhood, worsens during
adolescence in girls and gets aggravated during
pregnancy
4
  • 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

6
PHYSIOLOGICAL ANEMIA
7
  • 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

9
  • 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

10
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)
11
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
12
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

13
  • 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

14
  • 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

15
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.

16
  • 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.

17
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

18
  • 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

19
  • 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

20
PENCIL CELLS
21
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)

22
  • 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

23
  • 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

24
  • 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

25
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
26
  • 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

27
  • 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
  • .

28
  • 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.

29
IRON SUPPLEMENTS
30
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

31
  • 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

32
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

33
  • 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

34
  • 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

35
  • 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

36
  • 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.

37
  • 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

38
  • 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

39
  • 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

40
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

41
  • 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

42
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43
  • 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

44
  • 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.

45
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)

46
  • 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

47
  • 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

48
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

49
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

50
  • 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

51
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)

52
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.

53
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

54
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

55
  • 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)

56
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

57
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)

58
MEGALOBLASTIC ANEMIA(PS)
MEGALOBLASTIC ANEMIA(BM)
59
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

61
HAEMOGLOBINPATHIES
  • Sickle cell disease
  • Sickle cell anaemia (most common severe)
  • Sickle cell beta thalassemia,
  • Haemoglobin SC disease
  • Thalassemia
  • - Alpha thalassaemia.
  • - Beta thalassaemia
  • .
    Major
  • .
    Minor

62
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)
63
  • 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

64
  • 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

66
  • 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.

71
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

72
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

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  • 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.

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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

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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.

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  • 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)

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  • 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
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