anaemia in pregnancy-hm
DESCRIPTION
MANAGING ANEMIATRANSCRIPT
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Dr Nik Ahmad Nik AbdullahJabatan O&G
Hospital Kota Bharu
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OUTLINE Introduction Physiological changes during
pregnancy Nutritional requirements in pregnancy Causes of anemia in pregnancy Symptoms and Signs of anemia Approach to anemia in pregnancy Effect of anemia on pregnancy Management
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INTRODUCTION Definition:
a condition of low circulating haemoglobin (Hb) in which the Hb concentration has fallen below a threshold lying at two standard deviation below the median of a healthy population at the same age, sex and stage of pregnancy
However, this is only a statistical definition & not easily understandable & practical
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INTRODUCTION WHO Definition
A pregnant mother is considered to be anemic if her Hb level is less than 11g/dl (7.45 mmol/l) & Hct < 0.33
CDC definition : Hb conc < 10.5 d/dL during second
trimester
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INTRODUCTION However, many studies in tropical or
developing countries use 10 g/dl as the threshold which defines anemia
(Tee et al, 1984).
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INTRODUCTION It is further classified as:
Mild: 10 - 10.9 grams/dl
Moderate: 7 - 10 grams/dl
Severe: 4 - 6.9 grams/dl
Very severe: less than 4grams/dl
WHO Calcification
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EPIDEMIOLOGY Overall : 40% of world population
35% for non-pregnant women
51% for pregnant women
3-4x higher in non-industrialised countries Affect 18% in industrialized countries Affect between 35-75% in non-industrialised
countries (average : 56%)
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EPIDEMIOLOGY Prevalence ↑ in central-asia
Nearly ½ of the global total anemic women
from Indian sub-continent (in India
alone ~ 88%)
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EPIDEMIOLOGYFactors affecting anaemia in pregnancy among rural mothers in Kelantan
Mal J Nutr 3:83-90, 1997
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Physiological changes during pregnanacy
Amount of iron (mg)
Iron costs Foetal iron 270 Umbilical cord and placental iron 90
Maternal blood loss 150 Obligatory losses 230 Expansion of maternal red cell mass 450 Total 1190
Nett costs Contraction of maternal red cell mass postpartum Nett total (b)
Total requirement (c) 1040
Adapted from AMA (1968)
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Physiologic anemia of pregnancy
Plasma volume increases 50-70 % Beginning by the 6th wk
RBC mass increases 20-35 % Beginning by the 12th wk
Disproportionate increase in plasma volume over RBC volume----Hemodilution
Despite erythrocyte production there is a physiologic fall in the hemoglobin and hematocrit readings
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Physiological changes during pregnanacy This iron requirement is distributed
unequally over the 40 weeks of a normal pregnancy.
first 20 weeks of pregnancy are about the same as for a non-pregnant woman.
The expansion in maternal red cell mass occurs maximally between weeks 20 and 25 of gestation, after which the daily iron requirements to maintain this mass remain constant at about 3-4 mg.
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Physiological changes during pregnanacy
However, the total iron requirements continue to increase after week 25 up to week 36 due to the needs
of the placenta and the foetus.
The total iron needs near the end of the second and third trimesters are about 3.5 mg/day and 7 mg/day, respectively
(Bothwell, 1995).
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Physiological changes during pregnanacy
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Physiological changes during pregnanacy As pregnancy continues,
Serum iron ↓
Serum total iron binding capacity (TIBC) ↑ Both changes are due to the increased plasma vol
Plasma & tissue ferritin ↓ - whether given haematinics or not
Insensible losses of iron ~ approx 1 mg/day
4 mg/day of iron absorbed daily from diet
If women enters pregnancy with depleted iron stores, the efx of iron deficiency will develop
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Causes of anaemia in pregnancy Nutritional anaemiaDeficiency of o irono folic acido vitaminso protein
Chronic blood losso Repeated abortiono Closely space pregnancyo Menorrhagiao Bleeding gums, ulcer or
pileso Worm infestation
Hemolytic anaemia Thalassaemia Drug-induced
Aplastic anaemia Drug-induced Idiopathic
Myeloproliferative disorders
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Causes of anaemia in pregnancy Pathological anaemia of pregnancy is mainly due to iron
deficiency (IDA) Over 90% of anemia due to red cell iron deficiency assoc with
depleted iron stores & deficient intake Infection will inhibit iron binding from the stores into Hb.
Folate defiency : Minor component & assoc with poor diet
Vit B12 deficiency : Rarely causes anemia in pregnancy Addisonian pernicious anemia : doesn’t usually occur in the
reproductive years & usually assoc with infertility
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Causes of anaemia in pregnancy Unless the dietary intake is above
average, the requirement is unlikely to be met
Blood loss
NutritionPhysiological
changes during
pregnanacy
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FACTORS AFFECTING THE IRON STATUS IN A PREGNANT WOMAN
Absorption. Dietary Habits. Defective in Iron Absorption Loss
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FACTORS AFFECTING THE IRON STATUS IN A PREGNANT WOMAN Iron absorption :
Dietary iron (haem & non-haem) Haem iron contained food : animal blood, flesh & viscera
Absorption in normal women : 15-30% but ↑ in IDA up to 50% Non-haem iron contained food : cereal, seeds, vege, milk
Enhancers of absorption Haem iron, proteins, meat, ascorbic acid, fermentation,
ferrous iron, gastric acidity, alcohol, low iron stores, increased erythropoietic activity
Inhibitors of iron absorption Phytates, calcium, tannins, tea & coffee, herbal drinks,
fortified iron supplements
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CAUSES OF HIGH PREVALENCE OF IDA Dietary habits
Low bio-availability diet (cereals, roots & tubers)
Assoc with poverty ~ in non-industrialised countries
Assoc with pica ~ ingestion of various substances having no dietary value
Pregnancy complicated with hyperemesis
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CAUSES OF HIGH PREVALENCE OF IDA Defective iron absorbtion
Worm infestation, amoebiasis & giardiasis
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Other courses of IDA Iron loss
Pathological factors Hookworm & other helminths infestation Haemorrhage from GIT Allergies Occult blood loss
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Clinical features
General symptoms and signs of anaemia
Asymptomatic
SYMPTOMS Lethargy Weakness Dyspnoea Palpitation Headache Dizziness
SIGNS Pallor Tachycardia Bounding pulse Cardiomegaly Systolic murmur Angular stomatitis Koilonychia Pica syndrome
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Investigation
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ANAEMIA IN PREGNANCY :IRON DEFICIENCY - Diagnosis Hb concentration : (late!)
Initially by ↓ iron stores → ↓ serum iron → Hb ↓
Simple non-invasive practical test available
Hb < 10.5 g/dL in 2nd & 3rd trimesters ~ abnormal & require further Ix
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ANAEMIA IN PREGNANCY :IRON DEFICIENCY - Diagnosis Red cell indices :
Higher proportion of young large RBC – may mask the efx of iron def on MCV (mean corpuscular vol) in preg + establish anemia This is due to increased drive to erythropoesis
In pregnancy, small physiological increase in red cell size Average : 4 fL but may increase to 20 fL
MCV is a poor indicator – may be normal in iron def
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ANAEMIA IN PREGNANCY :IRON DEFICIENCY - Diagnosis
Women with iron def anaemia prior to preg, Will quickly develop florid anaemia in
pregnancy ↓ MCV, ↓ MCH (mean corpuscular Hb) &
↓ MCHC (mean corpuscular Hb concentration)
MCV < 80 fl, MCH < 27 pg ~ in IDA
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ANAEMIA IN PREGNANCY :IRON DEFICIENCY - Diagnosis Ferritin
High molecular weight glycoprotein
In healthy adult female (non-pregnant) Circulates at levels : 15 – 300 μg/L Level ≤ 12 μg/L indicates IDA
Important in pregnancy In development of iron def : ↓ serum ferritin – 1st abn lab
test
Hb & ferritin estimations ~ used clinically to categories the pts into normal & abnormal iron stores
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ANAEMIA IN PREGNANCY :IRON DEFICIENCY - Diagnosis
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Nutritional
Iron in food occurs in two forms, haem iron and non-haem iron.
Approximately 40% of the iron in meat products is haem iron;
60% of the iron in meat and all the iron in plant foods is non-haem iron.
The absorption by the body of the two types of iron differs, with about 2% to 20% of non-haem iron, and about 20% of haem iron, being absorbed.
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Food Source Serving Size (oz.) Iron (mg)
Beef, liver 3.0 7.5
Beef, corned 3.0 2.5
Beef, lean ground; 10% fat 3.0 3.9
*Beef, round 3.0 4.6
*Beef, chuck 3.0 3.2
*Beef, flank 3.0 4.3
Chicken, breast w/out bone 3.0 0.9
Chicken, leg w/bone 2.0 0.7
Chicken, liver 3.0 7.3
Chicken, thigh w/ bone 2.3 1.2
Cod, broiled 3.0 0.8
Flounder, baked 3.0 1.2
Pork, lean ham 3.0 1.9
*Pork, loin chop 3.0 3.5
Salmon, pink canned 3.0 0.7
Shrimp, 10 - 2 1/2 inch 1.1 0.5
Tuna, canned in water 3.5 1.0
Turkey, dark meat 3.0 2.0
Turkey, white meat 3.0 1.2
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Food Serving Iron content (mg)
Cashew nuts 2 tbsp 1.0
Pumpkin seeds 2 tbsp 2.5
Tahini/Sesame seeds 2 tbsp 1.2
Sunflower seeds 2 tbsp 1.1
Molasses 1 tbsp 3.3
Licorice 50 g 4.4
Marmite (fortified) 5 g 1.8
Apricots (dried) 1/4 cup 1.5
Raisins 1/4 cup 1.1
Avocado 1/2 1.0
Prunes 1/4 cup 0.9
Kelp (cooked) 1/2 cup 42.0
Nori (cooked) 1/2 cup 20.9
Parsley (raw) 50 g 4.7
Potato, with skin (cooked) 1 medium 2.7
Spinach (cooked) 1/2 cup 1.5
Broccoli (cooked) 1/2 cup 1.0
Brussels sprouts (cooked) 1/2 cup 0.9
Some breakfast cereals (fortified) 100 g 10 (approx)
Textured Vegetable Protein (TVP) (cooked) 1/2 cup 2.0
Barley, whole (cooked) 1/2 cup 1.6
Wheat germ 2 tbsp 1.2
Bread, whole wheat 1 slice 0.9
Rice, brown (cooked) 1/2 cup 0.5
Tofu 1/2 cup 6.2
Soybeans (cooked) 1/2 cup 4.4
Garbanzo beans (cooked) 1/2 cup 3.4
Lentils (cooked) 1/2 cup 3.2
Navy beans (cooked) 1/2 cup 2.5
Pinto beans (cooked) 1/2 cup 2.2
Lima beans (cooked) 1/2 cup 2.2
Tempeh (cooked) 1/2 cup 1.8
Split peas (cooked) 1/2 cup 1.7
Kidney beans (cooked) 1/2 cup 1.5
Peas (cooked) 1/2 cup 1.2
Baked beans (cooked) 1/2 cup 0.
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Approach to anemia in
pregnancy
Approach to anemia in
pregnancy
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Iron Supplementation in Pregnancy
Safety: Unintentional overdosing, hemochromatosis, GIsymptoms
Compliance: Prescribed Fe supps taken correctlyby 70%, not at all by 10%
Recommendation: Evidence is insufficient to recommend for or againstRoutine iron supplementation during pregnancy.
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Iron Supplementation in Pregnancy
• Fe deficiency is common in pregnancy
• Fe supps maintain Hgb levels during pregnancy.
• Percentage of iron absorbed declines as the amount given increases.
• High does increase side effects and decrease compliance.
• Recommendation: Small dose (30mg) after 12 weeks for all pregnant women.
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Cochrane Review of 20 Trials- 1999
• “Iron supplementation appears to prevent low haemoglobin at birth or at six weeks post-partum.”
• “Iron supplementation had no detectable effect on any substantial measures of either maternal or fetal outcome.”
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Centers for Disease Control. Recommendations to prevent and control
iron deficiency in the United States. MMWR.1998;47:1-36.
• No conclusive evidence for benefit of universal iron supplementation
• Recommend 30 mg/d starting at first prenatal visit because many women have reduced Fe stores with pregnancy
• For Tx of low hct or hbg: 60-120 mg/d– If no response evaluate mean cell volume and serum
ferritin
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Yes No Maybe Not enough evidence
IOM - NAS (1990)
Nat'l Perinatal Epi Proj. - Oxford
US Surgeon General (1988)
US preventive Services Task Force (1993)
FASEB (1991)
USPHS Ex. Panel on Prenatal care (1989)
Cochran Review (1999)
CDC (1998)
Recommendations for Routine Iron Supplementation in Pregnancy
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Supplement ** For the non-anaemic patient 30 mg of
ferrous iron daily is considered adequate for supplementation.
Treatment 100mg of ferrous
Oral supplements of iron Ferrous Sulfate (200mg), Elemental Iron (65mg),
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Supplement Side efx of oral iron administration
Related to the quantity given
Rare side efx with ↓ daily dose to 100 mg & delay introduction till 16 wks gestation
Most common complaint : constipation Other c/o nausea, vomiting, diarrhoea, abd cramping Usually overcome easily with slow release preparation –
but not all iron is released at all & ↑ expanses However, most women can tolerate cheaper preparation
+ folic acid
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IM injection of 1000 mg iron : Preparation :
Iron dextran (Imferon) ~ IM / IV Iron sorbitol citrate (Jectofer) ~ IM only
For those whom add iron can’t be given by oral route either by non-compliance & unacceptable side efx
Disadvantage : painful injection & skin staining, + anaphylaxis IM injection ~ less side efx
Iron deficit is calculated as :Elemental Iron need (mg) =
(Normal Hb-Pts’ Hb) x weight (kg) x 2.21 + 100
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Mx of IDA With adequate treatment,
An increase of Hb of 0.8g/ dL/ week (1.0 g/ dL/wk in non-pregnant women) – in absence of other abnormalities.
The response is similar with iron given orally or parenterally.
If there is no enough time to achieve reasonable Hb for delivery or symptomatic, transfusion with all its hazards should be considered.
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Mx of IDA Blood transfusion
Rarely indicated except severe anaemia regardless of gestation & to replenish blood loss due to APH / PPH
Disadv : transfusion reaction, infectious disease
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Mx of IDA
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FIRST VISITHigh risk factors
Blood donation - current orrecent historyPrevious iron deficiency
Other risk factors
Poor socio-economicstatus, recentImmigrant Vegetariandiet
Past history
Post-partumhaemorrhage,multiparity, shortgap betweenPregnanciesHeavyperiods
MCV, Hb, Hct
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Criteria:Hb < 10.5gm%Action:
Management asper established protocols for investigation of anaemia in Pregnancy(including serum ferritin assay).
Criteria:Hb=10.5-11.5 gm%And the presence ofone major or two or more of any riskfactors.Action:Specific dietaryadvice: Iron supplementation:at least 30mg/day of ElementalIron Reassess at 28weeks.
Criteria:Hb>11.5 gm% and
no risk factors
present.
Action:
General
Preventative
dietary advice Iron
supplementation is
not required.
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SUBSEQUENT EARLY ANTENATAL CARE Assess:
Diet. Presence of nausea, vomiting. Compliance: in those women prescribed iron
supplementation
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ANAEMIA IN PREGNANCY :IRON DEFICIENCY – maternal risks In iron def women,
May take > 1 year for Hb to return to pre-preg level.
If iron supplement given, Hb ≈ pre-preg state by 5-7 days after delivery
Blood loss is greater at delivery Due to effect iron def on neuromuscular transmission
& myometrial contraction
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ANAEMIA IN PREGNANCY :IRON DEFICIENCY – Fetal risks Children with iron deficiency,
Behavioral abnormalities – related to changes in the concentration of chemical mediators in the brain
Cognitive skills – poor performance which can be improved with iron supplements in some
In utero, Iron def results in low birthweight infants Iron supplements - prevention of adult
hypertension (origin in fetal life due to LBW)
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Summary pregnant mother is considered to be anaemic if her
Hb level is less than 11g/dl (7.45 mmol/l) & Hct < 0.33.
Over 90% of anaemia due to red cell iron deficiency assoc with depleted iron stores & deficient intake
Hb & ferritin estimations ~ used clinically to categorise the pts into normal & abnormal iron stores
No conclusive evidence for benefit of universal iron supplementation.
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