ANEMIA IN PREGNANCY - IDA: CHANGING CONCEPT

1. ANEMIA IN PREGNANCY - IDA: CHANGING CONCEPT Dr Veena Agrawal M.S., MICOG, WHO Fellow (USA) Professor & HOD, Obst. & Gynecology, G. R. Medical College Core faculty of human Genetics, Jiwaji University Gwalior, M.P. Dr Sonali Agrawal DGO Consultant Agrawal Hospital & Research Centre Gwalior, M.P. India

2. Anemia is a sign, not a disease of dynamic process

3. World Health Organization World Health Organization 2 billion people - >30% of the world's population are anemic, mainly due to iron deficiency

4. Anemia – a major killer • Incidence is about 50% in general population, (in India 80%). • Iron deficiency anemia is the most common medical disorder during pregnancy. • In pregnancy, it is one of the leading causes of maternal mortality in developing countries. • It affects both mother and fetus.

5. PREVALENCE OF anemiain India Available studies on prevalence of nutritional anemia show that: • 65% infant and toddlers, • 60% 1-6 years of age, • 88% adolescent girls (3.3% has hemoglobin <7 gm./dl; severe anemia) and • 85% pregnant women (9.9% having severe anemia) • prevalence higher in lactating than pregnant women The most common is iron deficiency anemia.

6. Causes: • Physiological - disproportionate ↑se of plasma volume apparent reduction of RBC, Hb & Hct. Picture is normochromic normocytic. • Acquired: • Nutritional • Iron deficiency anemia (60%), • Macrocytic anemia (10%) due to def of folic acid and/or vitamin B12 • Dimorphic and protein deficiency anemia (30%) in extreme malnutrition

7. Causes of Anemia • Hemorrhagic • acute blood loss, • chronic (hook worm, bleeding piles) • Infections   • Acute (e.g., malaria) • Chronic (e.g., tuberculosis) • Genetic conditions (e.g., thalassemia, sickle cell)    • Enzyme disorders (e.g., sideroblastic anemia) • Anemia of chronic disease (e.g., malignancy, chronic renal failure

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

9. Significance of Hypervolemia 1. 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.

10. IDA • 12th most important risk factor for all mortality globally. • 9th most important risk factor for the global burden of disease. • associated with 115,000 of the 510,000 maternal deaths (22%) and 591,000 of the 2,464,000 perinatal deaths (24%) occurring annually around the world. Mason, Rivers and Helwig Food and Nutrition Bulletin 26: 57-162, 2005..

11. 1/3 world’s population suffers from anemia, mostly iron deficiency anemia. • India continues to have a very high prevalence. • National Family Health Survey (NFHS-3) reveals the prevalence of anemia to be 70-80% in children, 70% in pregnant women and 24% in adult men.

12. Definition of Anemia in Pregnancy • WHO-Hb conc <11gm/dl & Hct < 33% • CDC definition-Hb con <11gm/dl & Hct < 33% during the 1st trimester & < 10.5 gm/dl Hct < 32% during the 2nd trimester • Absolute iron deficiency is defined as ferritin <200 µg/L with or without iron saturation <20%,

13. CDC definition:

14. Factors required for erythropoiesis • Proteins (erythropoietin) • Minerals (iron) • Trace elements: (Zinc, Cobalt, Copper etc) • Vitamins: Folic acid, Cyanocobalamin (B12), Vitamin C, Pyridoxine (B6), Riboflavin, Vitamin A • Hormones: Androgens & Thryoxine Letsky E. 1995 Prasad AS. J. Am. Coll. Nutr. 1996

15. Anemia • Acc to ICMR • Mild 10-11mg% • Moderate 7-10.9mg% • Severe 4 - 6.9mg% • Very severe <4mg%

16. Irondeficienterythropoiesis Irondeficiencyanemia Irondepletion Normal Storage iron Transport iron Erythorin iron Marrow iron 2-3+ 0 trace 0 0 Plasma ferritin (µg/l) 100±60 < 20 10 <10 35±15 Normal Normal Microcytic hypochromic Transferrin saturation(%) Iron absorption Normal ± + +

17. Normal Levels

18. Requirement of Iron

19. Iron Requirements in Pregnancy

20. Normal Iron Requirements • Iron requirement for normal pregnancy is 1gm 200 mg is excreted 300 mg is transferred to fetus 500 mg is need for mother • Total volume of RBC inc is 450 ml 1 ml of RBCs contains 1.1 mg of iron450 ml X 1.1 mg/ml = 500 mg • Daily average is 6-7 mg/day

21. Iron Requirement - Pregnancy

22. Overall needs are about 2 to 4.8 mg iron/day. • Must consume 20 to 48 mg of dietary iron to absorb this quantity of iron daily. • Average vegetarian diet provide 10-15 mg iron/day. • Amount of iron absorbed from diet+iron mobilized from stores, is usually insufficient to meet the demands. • Therefore, iron supplementation during pregnancy is recommended universally even in non anemic women.

23. Maternal Anemia: A Preventable Killer

25. Anemia: Etiologies • Inadequate dietary intake • Poor nutrition • Chronic alcoholism • Decreased consumption of animal protein and ascorbic acid   • Increased iron demands • Multiparity • Diarrhea, HIV/ AIDS and • UTI • Recurrent Infections- Tuberculosis, Amoebiasis , Giardiasis, Roundworm • other infectious diseases • Inadequate GIT absorption • Malabsorption syndromes • Certain drugs/foods   • Blood loss • Hookworm infestation • Malaria • Bleeding piles &gums • Surgery • Gastrointestinal bleeding • Trauma • Dialysis

26. Major Causative Factor in India for IDA? Low Iron Intake or Low Iron Absorption Haemolysis due to malaria worm infestations (hookworm) Multiparity

27. Effects of Anemia on Pregnancy Pathophysiology - Fetus

28. Fetal Effects • Mild and moderate anemia may not show significant effects. • Iron is actively transported across the placenta. • Fetal iron and ferritin levels > maternal levels 3 times

29. Effects of Anemia on Fetus • PROM, • IUGR, • IUFD, • Prematurity, • Abnormal trophoblast invasion • Fetal programming & disease of newborn:behavioral abnormalities, poor performance on Bayley Mental Development Index, decreased cognitive function. • Neonatal anemia • Adult HT associated with low birth weight & high ratio of placenta to birth weight. • (Barker DJP, Bull AR, et all BMJ 1990; 301:259-262)

30. If maternal oxygenation is 98 – 100 %, • The fetus gets around 70 % of O2, with fetal Hb. Fetus can compensate. • As the maternal Hb. drops, fetal hypoxia develops, which leads to stimulation of fetal erythropoiesis • Increased viscosity of blood due to raised PCV. sluggish circulation • End artery thrombosis • Failure of the organs, supplied by these vessels.

31. Increased PCV • Brain damage • Necrotising enterocolitis • Hypoglycemia • Hypocalcemia • Hyperbilirubinimia • RDS At Birth Hb – 18 to 20 gms %, PCV – 55 to 60 %

32. Severe Anemia Fetal hypoxia Prolonged period Short duration Neurological deficit IQ less, slow learner Fetal hypoxia leads to an increase in the cord blood EPO. Cord blood EPO correlates with perinatal brain damage.

33. Production of uterine contraction stimulating hormones (estrogen, connexin) and inhibition of IGF, an anabolic hormone

34. Maternal Effects of Anemia • Behavioral changes, irritability. • Loss of appetite, indigestion, etc. due low performance of each organ. • Increased morbidity and mortality due to PIH, APH, PPH, if associated. • C CF at 30-32 wks, intra- partum & post-partum. • Reduced immune function - infection, ante-partum and puerperal sepsis. • Negative thermoregulation • Increased risk of blood transfusion • Preterm Labor • Sub involution • Failing lactation • Pulmonary Venous: thrombosis & embolism, due to thrombophlebitis.

35. ANTENATAL CAREAs a routine - No difference Registration Counseling Regular check up weight, B.P., Hb%, urine Prevention of complications Immunizations

36. Care in addition to routine ANC • H & P of Anemia • Investigate for • Grade of anemia • Type • Severity of IDA • cause • Tx of anemia • Tx the cause of anemiaie. deworming, Antimalarial

37. Intrapartum Managementif patient comes in labor • Individuals who MUST present in labor room • Skilled Birth attendant's • Anesthesiologist • Pediatrician • Nursing Staff • “Extra Hands” • Informed consent

38. Things that should be available: • US Machine • Cardiotocographic machine • Blood transfusion facility • Neonatal resuscitative measures

39. Things that should be done: • IV Line should be patent • Bl arranged - PCV • Monitor pt for sign of CCF esp. immediately postpartum • Early cord clamping • No methergin • Cut shirt 2nd stage labor • IV Diuretic • Antibiotics

40. Postpartum Management • Monitor patient for sign of CCF • Antibiotics • Otherwise same

41. Clinical Feature of Anemia Symptoms: • Mild anemia; usually asymptomatic • Moderate anemia - weakness, fatigue, exhaustion, loss of appetite, indigestion, giddiness, breathlessness • Severe anemia-palpitation, tachycardia, breathlessness, Increased cardiac output, CHF, general anasarca, pulmonary edema Sharma J.B. Progress in Obst. & Gynae. (Studd) 2003.

42. Clinical Features of Anemia Signs: • Pallor • Nail changes – Koilonychia • Angularcheilosis, Glossitis, Stomatitis • Oedema • Hyperdynamic circulation (short and soft systolic murmur) • Fine crepts Sharma J.B. Progress in Obst. & Gynae. (Studd) 2003.

43. What lab tests should be done?

44. What is level • Type • cause

45. Anemia? Production? Survival/Destruction? The key test is the …..

46. The Reticulocyte Count(Kinetic Approach) • ↑ reticulocytes (>2-3% or 100,000/mm3 total) are seen in bl loss and hemolytic processes, although up to 25% of hemolytic anemia's will present with a normal count.

47. EVALUATION OF IRON STATUS • Hb Measurement & Haematocrit • Peripheral smearwill often reveal many diagnostic clues • Reticulocyte count • Serum ferritinmost sensitive tool. Values < 10mcg/L indicate absence of stored iron, <20 or <15 µg/L indicate depleted iron stores • Transferrin saturation (TSAT), should be above 16% with normal being 30% • Soluble serum transferrin receptors (sTfR)(>45 nM/Ldenote IDA), TSAT <20%, serum ferritin <100 ng/mL & % of hypochromic RBC’s >10% indicate absolute ID,

48. RBC indices-little diagnostic value unless the MCV is below 70fl • Serum iron- decreased in a variety of states including iron deficiency, inflammation & stress. Varies tremendously from morning to evening and from day to day. value < 0.5mg/L indicate anemia, normal range :0.80 to 1.80 mg/L • Total iron binding capacityis very specific for iron deficiency (near 100%) but has poor sensitivity (<30%). • Iron saturation(Fe/TIBC x 100) can be decreased below 16% in both anemia of chronic disease and iron deficiency

49. Tests used in Diagnosing Iron Deficiency Anemia (IDA)

50. Specific tests for etiology of the anemia • Urine & stool examination • Test for malaria • Rarely- Endoscopic or barium studies of the GI tract, bone marrow examination • Exclude other causes of hypochromic microcytic anemia • Anemia of chronic disease • Thalassaemia trait • Sideroblastic anemia