ANEMIA IN PREGNANCY
INTRODUCTION:
- Commonest haematological disorder occur in pregnancy
- Prevalance in pregnant women –
- Developed:14 %
- Developing countries:51%
- India:65-75%
- 80 % leading to maternal deaths
DEFINITION:
Reduction in circulating Hb mass
- < 12g/dl in non-pregnant women
- < 10g/dl in pregnant women
CDC:Anaemia in iron supplemented pregnant Woman
- Hct 33% & Hb 11g/dl – 1st & 3rd trimester
- Hct 32% & Hb 10.5 g / dl – 2nd trimester
WHO GRADING OF ANEMIA:
| Mild | 10g/dl |
| Moderate | 7- 10 g/dl |
| Severe | < 7 g/dl |
ICMR GRADING:
| Mild | 10 – 10.9 g/dl |
| Moderate | 7 – 9.9 g/dl |
| Severe | < 7 g/dl |
| Very Severe | < 4 g/dl |
HEMATOLOGICAL CHANGES IN PREGNANCY:
PHYSIOLOGICAL ANEMIA OF PREGNANCY:
- Plasma volume : 40-50%
- RBC mass:30 %
- As a result Hb concentration decreases by 2g/dl
- Decreased Hb concentration is due to haemodilution
Criteria of Physiological Anemia
- Hb 10 gm %
- RBC 3.2 million cells / cu mm
- PCV 32%
- Peripheral Smear – Normal morphology
IRON Requirements during Pregnancy:
- Maternal req. Of total Iron -1000mg
- 500 mg →Mat. Hb. Mass expansion
- 300 mg → Fetus & Placenta
- 200mg → Shed through gut urine, skin
IRON DEFICIENCY ANEMIA:
Development:
- Depletion of Iron stores
- Iron deficient erythropoiesis
- Frank Iron deficiency Anemia
Symptoms:
- Fatigue
- Weakness
- Headache
- Loss of appetite
- Dysphagia
- Palpitations
- Dyspnea on exertion
- Ankle swelling
- Paresthesias
- Leukoplakia
Examination:
- pallor
- glossitis and stomatitis
- Edema of legs
- soft systolic murmur
- Crepitations
INVESTIGATIONS:
Degree of anemia
- Hemoglobin
- Total RBC
- PCV
Type of anemia:
- Peripheral blood smear
- Hematological indices
Cause of anemia:
- Examination of stool(helminthic)
- Examination of urine(protein, sugar and pus cells)
COMPLICATIONS:
DURING PREGNANCY:
- Preeclampsia
- Intercurrent infection
- Heart failure(30–32 weeks)
- Preterm labor
DURING LABOR:
- Uterine inertia
- Postpartum hemorrhage
- Cardiac failure
- Shock
PUERPERIUM:
- Puerperal sepsis
- Subinvolution
- Poor lactation
- Puerperal venous thrombosis
- Pulmonary embolism
TREATMENT:
- Supplementary iron therapy:Daily administration of 200 mg of ferrous sulfate & 1 mg folic acid
- With oral iron therapy, rise in Hb% can be seen after 3 weeks
- Dietary prescription
- Early detection of falling hemoglobin level(30th week and 36th week)
- Hospitalization:Hb
IRON THERAPY:
- Oral therapy
- Parenteral therapy:Intravenous route
- Repeated injections
- Total dose infusion (TDI)
- Intramuscular route
MEGALOBLASTIC ANEMIA:
CAUSES OF FOLIC ACID DEFICIENCY IN PREGNANCY:
Inadequate intake :
- Nausea, vomiting and loss of appetite.
- Dietary insufficiency
Increased demand:
- Increased maternal tissue
- Multiple pregnancy
- Growing fetus
- Intestinal malabsorption syndrome
- Infection
- Hemorrhage
- Failure of utilization due to anticonvulsant drugs
Diminished storage:
- Hepatic disorders
- Hyperhomocysteinemia
- vitamin C de!ciency.
- Iron deficiency anemia
INCIDENCE:
- 0.5% to 3%.
- More common in multiparae & multiple pregnancy
CLINICAL FEATURES:
- Onset insidious
- First revealed in last trimester
- Acutely manifested in early puerperium
- Anorexia or protracted vomiting
- Occasional diarrhea
- Unexplained fever
- Pallor
- glossitis
- Hemorrhagic patches under the skin and conjunctiva
- Enlarged liver and spleen
- preeclampsia
INVESTIGATIONS:
- Hemoglobin level
Stained blood film:
- Hypersegmentation of the neutrophils (5 or more lobes)
- Macrocytosis and anisocytosis
- Giant polymorphs
- Megaloblasts
- Howell-Jolly bodies
- MCV > 100 μ3.
- MCH>33 pg
- MCHC is normal
- Associated leukopenia and thrombocytopenia
- Serum iron is normal or high
- Low TIBC
- Red cell folate < 3 ng/mL
- Serum vitamin B12 level < 90 pg/mL
- Serum bilirubin—may be raised
- Bone marrow—shows megaloblastic erythropoiesis.
COMPLICATIONS:
- Miscarriage
- Dysmaturity
- Prematurity
- Abruptio placentae
- Fetal malformation (cleft lip, cleft palate, neural tube defects).
TREATMENT:
- 400 μg of folic acid daily
Additional amount (4 mg):
- Multiple pregnancy
- Patient having anticonvulsant therapy
- Hemoglobinopathies or associated chronic
Specific therapy:
- Daily administration of folic acid 4 mg orally 4 weeks following delivery
- Supplementary IM vitamin B12 100 μg daily
- Ascorbic acid 100 mg tablet thrice daily
DIMORPHIC ANEMIA:
- Dietary inadequacy
- Intestinal malabsorption
- Deficiency of both iron and folic acid or vitamin B12
- The red cells become macrocytic or normocytic and hypochromic or normochromic
- Treatment consists of prescribing both iron and folic acid
APLASTIC ANEMIA:
- Immunologically mediated or may be an autosomal recessive inheritance
- Complications in pregnancy are hemorrhage and infection
Diagnosis:
- Blood values—Anemia, leukopenia and thrombocytopenia.
- Bone marrow—markedly hypocellular
Management:
- Specific therapy:granulocyte transfusion to combat infection and platelet transfusion to control hemorrhage
- Glucocorticoid therapy
- bone-marrow or stem cell transplantation
Exam Important
- According to WHO, anemia in pregnancy is diagnosed, when hemoglobin is less than 11.0 gm%
- In pregnancy, Iron + folic acid anemia is common in India
- With oral iron therapy, rise in Hb% can be seen after 3 weeks
- Pre-eclampsia, Intercurrent infection & Heart failure complications are likely to increase in a case of severe anemia during the pregnancy
- As per WHO, anemia is considered to exist in pregnancy, if the hemoglobin level is below
- Type of anemia in pregnancy is Microcytic hypochromic
- Cord cutting should be delayed in Sever anemia
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