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continous medical education b ydr naz


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definition A pathological condition in which the oxygen carrying capacity of red blood cells is insufficient to meet the body ‘s needs WHO recommends the HB% should not fall below 11g/dl at any time during pregnancy CDC refer the value of 10.5 g /dl

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PREVALANCE- 40% of world ‘s population (35%non-preg 51%pregnant) 56% in Pakistan MORTALITY 40-60% IN Pakistan 18% in industerlised countries


PHYSIOLOGICAL CHANGES IN BLOOD DURING PREGNANCY Plasma volume increased 50% Red cell mass increased 25% Fall in Hb conc:, haematocrit & red cell count . MCV increased secondary to erythropoiesis MCHC remains stable Sr: iron and ferritin decrease TIBC increased

Severity of anemia :

Severity of anemia Severity Percentage hemoglobin values MILD 13 10-10.9 mg/dl MODERATE 57 7-10mg/dl SEVERE 12 <7mgldl VERY SEVERE Decompanseted <4mg/dl

Degrees of anemia:

Degrees of anemia


CLASSIFICATION of ANEMIA Physiologic Pathologic: a. Deficiency: Iron, Folic A., Vitamin B12 b. Hemorrhagic: APH, Hookworm c. Hereditary: Thalassemia, Sickle, H. Hemolytic Anemia d. Bone Marrow Insufficiency: Aplastic Anemia e. Infections: Malaria, TB f. Chronic Renal Diseases or Neoplasm.

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IRON ABSORBTION Dietary iron (heme and non heme) - heme-animal blood flesh viseras -Non heme-cerels, seeds, vegetables, milk eggs. Factors increases iron absorbtion Heme iron Proteins Meat Ascorbic acid Fermentation

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Ferrous iron Gastric acidity Alcohol Low iron stores Increase erethropiioetic activity(hight altitue,bleeding) FACTROS DECREASES IRON ABSORBTION Phytates Calcium Tennins, tea, coffee, herbal drinks Fortified iron supplements


IRON LOSS PHYSIOLOGIC FACTORS Desquamation of cells( intestine, skin) Menstruation Delivery Lactation PATHOLOGIC FACTORS Hookworms /other helmentis Bleeding from GIT Allergies Occult blood loss, excess menses,APH

Iron requirement in pregnancy:

Iron requirement in pregnancy Adult woman absorption-2mg/day Total iron requirement during pregnancy -900mg DEMANDS EXPANSION OF RBC-500 -600mg FETUS AND PLACENTA-300mg DAILY IRON REQUIREMENTDURING PREGANCY 4mg Early pregnancy – 2.5mg 20-32wksof pregnancy- 5.5mg >32wks of pregnancy6-8mg Iron absorption rate 10%


PREVENTION OF IRON DEFICIENCY 1.Iron supplementation during pregnancy According to WHO 60 mg elemental iron and 250mg folic acid daily for 6 months and additional 3 months in postpartum period in low prevalence countries 2.Treatment of hookworm infestation Single dose of albendazole 400mg stat Or mebendazole 100mg BD for 3 days 3.Improvements of dietary habits Iron rich food Cook food in iron utensils

Prevention continue…..:

Prevention continue….. 4.Social services Improvement in sanitation Personal hygiene Better education of female regarding diet Contraception 5.Food fortification Iron fortified salt like iodine salt

Concept of Physiologic Anemia:

Concept of Physiologic Anemia Disproportionate increase in plasma vol, RBC vol. and hemoglobin mass during pregnancy Marked demand of extra iron during pregnancy especially in second trimester

Physiologic anemia in pregnancy:

Physiologic anemia in pregnancy

Criteria for Physiologic Anemia:

Criteria for Physiologic Anemia Hb: 10gm% RBC: 3.2 million/mm3 PCV: 30% Peripheral smear showing normal morphology of RBC with central pallor

Significance of Hypervolemia:

Significance of Hypervolemia . To meet the demands of the enlarged uterus with its greatly hypertrophied vascular system. 2. To protect the mother, and in turn the fetus, against the deleterious effects of impaired venous return in the supine and erect positions. 3. To safeguard the mother against the adverse effects of blood loss associated with parturition.

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Normal hemoglobin by gestational age in pregnant women taking iron supplement 12 wks 12.2 [11.0-13.4] 24wks 11.6 [10.6-12.8] 40 wks 12.6 [11.2-13.6]


FACTORS LEAD TO DEVELOP ANEMIA Physiological hamodilution Increase iron demand Diminished intake of iron Disturbed metabolism Pre-pregnancy health status Excess demand


SIGNS AND SYMPTOMS OF ANEMIA Symptoms fatigue, Headache Faintness Breathlessness Palpitation Intermittent claudication

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SIGNS Palar of skin , conjunctiva, mucous membrane Tachycardia high volume pulse Ankle edema Cardiac failure Systolic flow murmur Specific signs of iron deficiency koilonychias, brittle nails atrophy of papilla of tongue Angular stomatisis, brittle hair, palmmer winson syndrome



Smooth tounge:

Smooth tounge

Angular cheilosis:

Angular cheilosis


EFFECTS OF ANEMIA ON PREGNANCY MATERNAL EFFECTS Preterm labour Anasarca CCF Pulmonary edema PPH P-Sepsis Failing lactation Sub involution of uterus thromboembolism

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Maternal mortality in 3 rd trimester ,during labour ,delivery ,immediately after delivery ,during peurperium due to heart failure and pulmonary embolism . FETAL EFFECTS Pre-term birth SGA Infection Anemia Low iron store High peri-natal mortality


DIAGNOSIS OF IRON DEFICIENCY ANEMIA 1.Hb%- practical cheap early performed method 2.Blood cell indices -differentiated b/w iron deficiency and thalasemia

Red cell indices in iron deficiency and thalasemia:

Red cell indices in iron deficiency and thalasemia characteristics calculation Normal range Iron deficiency Thalasemia MCV(fl) PCV/RBC 75-96 Reduced Very reduced MCH(pg) Hb/RBC 27-33 Reduced Very reduced MCHC(g/dl) Hb /PCV 32-35 Reduced Normal or slightly reduced HbF(%) hbF/HbA/100 <2% normal Raised HbA2(%) HbA2/HbA/100 2-3% Normal or raised Raised FEP(microgram/dl ____ <35 >50 Normal Red cell width High Normal

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3.Serum ferritin –reflect iron store Normal level 15-300microgram /L Level <12 microgram/L indicate iron deficiency 4.TIBC- serum iron decreased and TIBC increased Transferin saturation can be estimated from serum iron and TIBC Reduce transferin saturation indicate deficient iron supply to tissues. Serum iron 60-120 mcg/dl TIBC-300-350mcg/dl

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5.Free erythropoietin receptors Help to differentiate b/w iron deficiency and thalasemia 6.Serum transfferin receptors Appear to be specific and sensitive marker of iron deficiency in pregnancy, its level increased in iron deficiency, but not routinely available. 7.Bone marrow aspiration When no response and for diagnosis of aplastic anemia and kalzar

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bone marrow aspiration high cellularity mild to moderate erythroid hyperplasia ( 25-35%; N 16 – 18% ) polychromatic and pyknotic cytoplasm of erythroblasts is vacuolated and irregular in outline ( micronormoblastic erythropoiesis ) absence of stainable iron 8.Stool examination-consequently for 3 days

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9.Urine examination- for occult blood shistosomiasis in shistosomiasis prevalent countries. 10.Blood film for MP 11.Sputum examination /x-ray (TB) 12.RFT 13.Serum protein (hypo proteienemia)

Iron. Deficiency—Diagnoses:

Iron. Deficiency—Diagnoses Microphotograph of bone marrow staining for iron. Iron is stained blue and it is mainly in the macrophages (lower left

Categorizing iron deficiency anemia:

Categorizing iron deficiency anemia category Serum ferritin Hb% Diagnosis One >12mcg/dl >11g/dl Normal no iron deficiency Two <12mcg/dl >11g/dl Storage iron depletion Three <12mcg/dl <11g/dl Iron deficiency Four >12mcg/dl <11gdl Other cause of anemia

Treatment of iron deficiency anemia:

Treatment of iron deficiency anemia Medical treatment Oral iron Parenteral iron Blood transfusion Recombinant erythropoietin


ORAL IRON PROPHYLAXIS -100mg(elemental iron)+0.5 folic acid /day THERAPUTIC - 180mg elemental iron/day Raise of Hb-0.3-0.8g/wk To improve compliance Give drug less frequently then daily Change brand Give with meal or decrease dose. If no improvement Another preparation as carbonyl iron Blood transfusion

Oral iron:

Oral iron DISAADVANTAGES Intolerance to medication Unpredictable absorption Non compliance SIDE EFFECTS Abdominal cramps Constipation Distaste Nausea vomiting

Oral iron:

Oral iron INDICATORS OF RESPONSE TO THERAPY Improvements in symptoms Increase reticulocyte count in 5-10 days Increase in Hb% 0.8g/dl/week REASONS OF FAILURE Inaccurate diagnosis Non compliance Continues blood loss


PARENTERAL IRON THERAPY Available forms Iron dextran (oral and i/v infusion) Iron poly maltose(sucrofer rubiject) Iron sucrose DOSE (Normal Hb-patient’s Hb) x weight(kg)x2.21 +1000= (14-7) x65kg x 2.21+1000=2005mg Precautions Should be given in hospital setup by doctor Inj :hydrocortisone, epinephrine, and oxygen should be available.

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Total dose infusion Total dose iron replacement in 2 nd and 3 rd trimester in which total deficit is calculated and given as single infusion which take 3-6 hrs to complete. Various preparations are available Dextran( imferon)withdrawn b/c of high incidence of anaphylaxis


PARENTRAL IRON THERAPY I/M-ROUTE Iron sorbitol citrate (jactosol /jectofer) Advantages low mol:wt: Rapid absorption Dose and technique 50mg test dose then 100mg i/m Z technique

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Precautions Stop oral iron to avoid toxic effect Disadvantages Nausea vomiting Headache Fever Allergic reaction Lymph adenopathy Tattooing of skin Severe anaphylaxis

Parenteral iron therapy continue..:

Parenteral iron therapy continue.. INTRAVENOUS IRON Indication Non compliant GI problems Pregnancy >32-36wks Advantages Certainty of its administration Raise Hb/wk(rapid raise) Alternate to blood transfusion when oral treatment fails.

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ERETHROPOETIN Recombinant erythropoietin Anemia of chronic renal failure Autologous production of blood in normal individuals Severe postpartum anemia(life saving) Where blood transfusion avoided as in jehovah witnesses BLOOD TRANSFUSION (pc) preferred Severe anemia Pregnancy beyond 36 wks Blood loss e.g. ; APH,PPH, Pts not responding to oral and parental treatment EXCHANGE TRANSFUSION Very rare in sever anemia

Obstetrical treatment:

Obstetrical treatment Frequent A/N visits Caution in use of steroids and beta mimetics in p.t.l Prop up, oxygen Sedation Adequate analgesia Assisted delivery in second stage AMTSL Breast feeding Contraception for 2 years Continue iron for 3 months

Obstetrical treatment:

Obstetrical treatment Antenatal care More frequent visit Detect and manage complication as heart failure PTL Fetal monitoring for growth and well being

Obstetrical treatment:

Obstetrical treatment Management in labour Comfortable position (prop up) Sedation Analgesia In pre term beta mimetics and corticosteroids used carefully to avoid risk of pulmonary edema Antibiotic prophylaxis Oxygen in dyspnoic patients Digitalization and cardiac support in cardiac failure.

Obstetrical treatment:

Obstetrical treatment Second stage management Shortened by instrumental delivery Third stage AMTSL except in severe anemic for fear of cardiac failure Puerperium Adequate rest Iron and folate therapy for 3 months Treatment of any infections Pediatric opinion Effective contraception.(at least 2 years till iron store recover)

Megaloblastic Anemia's :

Megaloblastic Anemia's A form of anemia characterized by the presence of large, immature, abnormal red blood cell progenitors in the bone marrow 95% of cases are attributable to folic acid or vitamin B 12 deficiency

Static Test for Folate/B12 Status:

Static Test for Folate/B12 Status Folate Measured in whole blood (plasma and cells) and then in the serum alone Difference is used to calculate the red blood cell folate concentration (may better reflect the whole folate pool) Can also test serum in fasting patient B12 Measured in serum

Functional Tests for Macrocytic Anemia's:

Functional Tests for Macrocytic Anemia's Homocysteine: Folate and B12 are needed to convert homocysteine to methionine; high homocysteine may mean deficiencies of folate, B12 or B6 Methylmalonic acid measurements can be used along with homocysteine to distinguish between B12 and folate deficiencies ( ↑ in B12 deficiency) Schilling test: radiolabeled cobalamin is used to test for B12 malabsorption

Pernicious Anemia:

Pernicious Anemia A macrocytic, megaloblastic anemia caused by a deficiency of vitamin B 12. Usually secondary to lack of intrinsic factor (IF) May be caused by strict vegan diet Also can be caused by ↓gastric acid secretion, gastric atrophy, H-pylori, gastrectomy, disorders of the small intestine (celiac disease, regional enteritis, resections), drugs that inhibit B12 absorption including neomycin, alcohol, colchicine, metformin, pancreatic disease

Symptoms of Pernicious Anemia:

Symptoms of Pernicious Anemia Paresthesia (especially numbness and tingling in hands and feet) Poor muscular coordination Impaired memory and hallucinations Damage can be permanent

Vitamin B12 Depletion:

Stage I—early negative vitamin B 12 balance Stage II—vitamin B 12 depletion Stage III—damaged metabolism: vitamin B 12 deficient erythropoiesis Stage IV—clinical damage including vitamin B 12 anemia Pernicious anemia—numbness in hands and feet; poor muscular coordination; poor memory; hallucinations Vitamin B 12 Depletion

Causes of Vitamin B12 Deficiency:

Causes of Vitamin B 12 Deficiency Inadequate ingestion Inadequate absorption Inadequate utilization Increased requirement Increased excretion Increased destruction by antioxidants

Treatment of B12 Deficiency:

Treatment of B12 Deficiency Before 1926 was incurable; until 1948 was treated with liver extract Now treatment consists of injection of 100 mcg of vitamin B12 once per week until resolved, then as often as necessary Also can use very large oral doses or nasal gel MNT: high protein diet (1.5 g/kg) with meat, liver, eggs, milk, milk products, green leafy vegetables

Folic Acid Deficiency:

Folic Acid Deficiency Tropical sprue; pregnancy; infants born to deficient mothers Alcoholics People taking medications chronically that affect folic acid absorption Malabsorption syndromes

Causes of Folate Deficiency:

Causes of Folate Deficiency Inadequate ingestion Inadequate absorption Inadequate utilization Increased requirement Increased excretion Increased destruction Vitamin B12 deficiency can cause folate deficiency due to the methylfolate trap

Methylfolate Trap:

Methylfolate Trap In the absence of B12, folate in the body exists as 5-methyltetrahydro-folate (an inactive form) B12 allows the removal of the 5-methyl group to form THFA

Stages of Folate Depletion and Deficiency:

Stages of Folate Depletion and Deficiency Stage I—early negative folate balance (serum depletion) Stage II—negative folate balance (cell depletion) Stage III—damaged folate metabolism with folate-deficient erythropoiesis Stage IV—clinical folate deficiency anemia

Diagnosis of Folate Deficiency:

Diagnosis of Folate Deficiency Folate stores are depleted after 2-4 months on deficient diet Megaloblastic anemia, low leukocytes and platelets To differentiate from B12, measure serum folate, RBC folate (more reflective of body stores) serum B12 High formiminoglutamic acid (FIGLU) in the urine also diagnostic

Other Nutritional Anemia's:

Other Nutritional Anemia's Copper deficiency anemia Anemia of protein-energy malnutrition Sideroblastic (pyridoxine-responsive) anemia Vitamin E–responsive (hemolytic) anemia

Hemolytic Anemia:

Hemolytic Anemia Oxidative damage to cells—lysis occurs Vitamin E is an antioxidant that seems to be protective. This anemia can occur in newborns, especially preemies.

Non nutritional Anemia's:

Non nutritional Anemia's Sports anemia (hypochromic microcytic transient anemia) Anemia of pregnancy: dilutional Anemia of inflammation, infection, or malignancy (anemia of chronic disease) Sickle cell anemia Thalassemia's


SUMMARY Anemia is most common medical disorder of pregnancy with significant maternal ND fetal implications Iron deficiency is major cause of anemia in pregnancy Diagnosis should be establish during nd before pregnancy so to treat timely to prevent complications Screening for iron deficiency in pregnancy is simple

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