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ANLMIA IN kLGNANC ANLMIA IN kLGNANC

Makmur sitepu
Divisi Fetomaternal
Departemen Obstetric & Gynaecologi
FK-USU
8ackground 8ackground
W W Anaem|a |s the commonest med|ca| d|sorder dur|ng Anaem|a |s the commonest med|ca| d|sorder dur|ng
pregnancy pregnancy
W W Greek mean|ng "w|thout b|ood" Greek mean|ng "w|thout b|ood"
W W Iron def|c|ency anaem|a |s the most common type Iron def|c|ency anaem|a |s the most common type
of anaem|a dur|ng pregnancy of anaem|a dur|ng pregnancy
W W NInS 2003 NInS 2003 06 S79 of pregnant women 06 S79 of pregnant women
W W 2S d|rect materna| deaths 2S d|rect materna| deaths
ef|n|t|ons of Anem|a |n regnancy ef|n|t|ons of Anem|a |n regnancy
W W WnC WnC nemog|ob|n concentrat|on 11gm]d| nemog|ob|n concentrat|on 11gm]d|
hematocr|t of 33 hematocr|t of 33
W W CC def|n|t|on CC def|n|t|on nb 11gm]d| dur|ng the f|rst and nb 11gm]d| dur|ng the f|rst and
th|rd tr|mesters and 10Sgm]d| |n th second th|rd tr|mesters and 10Sgm]d| |n th second
tr|mester (to a||ow for the phys|o|og|ca| fa|| due to tr|mester (to a||ow for the phys|o|og|ca| fa|| due to
hemod||ut|on |n second tr|mester) hemod||ut|on |n second tr|mester)
W W ICGSI ICGSI a cut off of 10 gm]d| for Ind|a a cut off of 10 gm]d| for Ind|a
Hb Hb 13.5 13.5 - - 14 gm % 14 gm %
R.B.C. R.B.C. 4.5 4.5 - - 4.7 miIIion/cu mm 4.7 miIIion/cu mm
Serum Iron Serum Iron 50 50 - - 150 g / dL 150 g / dL
TIBC TIBC 300 300 - - 360 g / dL 360 g / dL
Transferrin saturation Transferrin saturation 25 25 - - 50 % 50 %
S. Ferritin IeveI S. Ferritin IeveI 30 g / Lit 30 g / Lit
Red CeII protoporphyrin Red CeII protoporphyrin 30 g / dL 30 g / dL
Erythropoietin Erythropoietin 15.20 U / Lit 15.20 U / Lit
MCV MCV 76 76 - - 100 fL 100 fL
MCH MCH 27 27 - - 33 pg 33 pg
MCHC MCHC 33.37 gm / dL 33.37 gm / dL
PCV PCV 32 32 - - 40 % 40 %
NormaI LeveIs NormaI LeveIs
C|ass|f|cat|on 8ased on Sever|ty C|ass|f|cat|on 8ased on Sever|ty
ICMk WnC
M||d 10 11 gm]d| 9 11 gm]d|
Moderate 7 10 7 9
Severe 4 7 7
Very severe 4 decompensated
Causes of Anem|a |n regnancy Causes of Anem|a |n regnancy
W W hys|o|og|ca| anem|a hys|o|og|ca| anem|a
W W Nutr|t|ona| anem|a Nutr|t|ona| anem|a IA mega|ob|ast|c IA mega|ob|ast|c
W W Anem|a of chron|c |||ness Anem|a of chron|c |||ness
W W 8|ood |oss 8|ood |oss
W W nemo|ys|s and hemo|yt|c anem|as nemo|ys|s and hemo|yt|c anem|as
W W nemog|ob|nopath|es nemog|ob|nopath|es
W W Cther hered|tary anem|as Cther hered|tary anem|as
W W Ap|ast|c anem|a Ap|ast|c anem|a
Increased Iron emands Increased Iron emands
W W 1000mg extra e|ementa| |ron requ|red |n pregnancy 1000mg extra e|ementa| |ron requ|red |n pregnancy
W W Cannot be met by d|et a|one Cannot be met by d|et a|one
W W Undernutr|t|on compounds the prob|em Undernutr|t|on compounds the prob|em
Fe
+2
Fe
+2
Fe
+2
Fe
+2
Dissociation
Passive diffusion
Fe
+2
Fe
+2
Fe
+2
Fe
+2
Fe
+2
Fe
+2
Gut Lumen
MucosaI CeII BIood
Ferritin
Iron
saIts
Fe
+3
Free RadicaI
Fe
+2
Fe
+2
Fe
+2
Fe
+2
Fe
+2
Fe
+2
Fe
+2
Fe
+3
Free RadicaI
Transferrin
Incorporation into
Hb
Iron Requirement Iron Requirement
!ron Absorption !ron Absorption MM
1 1
Amount of iron in the
body
Amount of iron in the
body
Iron Loss
Skin
Urine
Feces
Menstruation
12mg/d 12mg/d
2030mg/c 2030mg/c
Early
Pregnancy
2.S mg / day
32 to 40 weeks
6.8 mg / day
TOTAL
800 - 1000 mg
20 to 32 weeks
S.S mg / day
RBC =S00mg
Fetus+Placenta =4S0mg
Third stage blood loss =200mg
Total = 11S0mg
Iron Requirement During Pregnancy Iron Requirement During Pregnancy
Norma| keference kanges Norma| keference kanges
nemato|og|ca| |ndex keference range
MCV (CV] k8C) 7S 98 f|
MCn (nb) 2S 31 pg
MCnC 32 36
1I8C 32S 400 ] 100m|
Ie] 1I8C rat|o 30
Morpho|og|ca| C|ass|f|cat|on Morpho|og|ca| C|ass|f|cat|on
W W 8y the s|ze of the k8Cs 8y the s|ze of the k8Cs
W W Macrocyt|c anem|a (MCV 100) Macrocyt|c anem|a (MCV 100)
W W Normocyt|c anem|a (80 MCV 100) Normocyt|c anem|a (80 MCV 100)
W W M|crocyt|c anem|a (MCV 80) M|crocyt|c anem|a (MCV 80)
C||n|ca| Ieatures C||n|ca| Ieatures Symptoms Symptoms
W W M||d anem|a |s usua||y asymptomat|c M||d anem|a |s usua||y asymptomat|c
W W Moderate anem|a Moderate anem|a weakness fat|gue exhaust|on weakness fat|gue exhaust|on
|oss of appet|te |nd|gest|on g|dd|ness breath|essness |oss of appet|te |nd|gest|on g|dd|ness breath|essness
W W Severe anem|a Severe anem|a pa|p|tat|ons tachycard|a pa|p|tat|ons tachycard|a
breath|essness |ncreased card|ac output card|ac breath|essness |ncreased card|ac output card|ac
fa||ure genera||sed anasarca pu|monary edema fa||ure genera||sed anasarca pu|monary edema
C||n|ca| Ieatures C||n|ca| Ieatures S|gns S|gns
W W a||or a||or
W W Na|| changes Na|| changes
W W Che||os|s G|oss|t|s Stomat|t|s Che||os|s G|oss|t|s Stomat|t|s
W W Ldema Ldema
W W nyperdynam|c c|rcu|at|on (short soft systo||c nyperdynam|c c|rcu|at|on (short soft systo||c
murmur) murmur)
W W I|ne crep|tat|ons I|ne crep|tat|ons
R


CCF CCF
!FECTO! !FECTO!
PRETERN
LABOR
PRETERN
LABOR
P P
Nedical
isorder
Nedical
isorder
CompIications CompIications - - Pregnancy Pregnancy CompIications CompIications - - Pregnancy Pregnancy
nstrumental
delivery
PP
Foetal
istress
CCF
NATER!AL
PER!ATAL
Norbidity
Nortality
CompIications CompIications - - Labour Labour CompIications CompIications - - Labour Labour
Lffects of Anem|a on Mother Lffects of Anem|a on Mother
W W Antepartum Antepartum
W W reterm |abor reterm |abor
W W re re ec|amps|a ec|amps|a
W W Seps|s Seps|s
W W IUGk IUGk
W W Intrapartum Intrapartum
W W Uter|ne |nert|a Uter|ne |nert|a
W W n n
W W Card|a Card|a fa||ure fa||ure
Lffects of Anem|a on Mother Lffects of Anem|a on Mother
ostpartum ostpartum
W W uerpera| seps|s uerpera| seps|s
W W Sub|nvo|ut|on Sub|nvo|ut|on
W W u|monary embo||sm u|monary embo||sm
W W Ia||ure of |actat|on Ia||ure of |actat|on
W W e|ayed wound hea||ng e|ayed wound hea||ng
W W Card|ac fa||ure Card|ac fa||ure
Ieta| Lffects
W W rematur|ty and L8W rematur|ty and L8W
W W IUGk IUGk
W W IUI IUI
W W Increased per|nata| morta||ty Increased per|nata| morta||ty
W W Iron ef|c|ency Anem|a due to |ower |ron stores can Iron ef|c|ency Anem|a due to |ower |ron stores can
cause poor menta| performance or behav|ora| cause poor menta| performance or behav|ora|
abnorma||t|es |n |ater ||fe abnorma||t|es |n |ater ||fe
|agnos|s 8ase||ne] resumpt|ve
W naemog|ob|n Measurement
W er|phera| b|ood smear
W ket|cu|ocyte count
W nematocr|t
W 8|ood |nd|ces
MCv MCPC MCPC
W Stoo| Lxam|nat|on
W Ur|ne Lxam|nat|on
W rote|ns LI1 kI1
1herapeut|c 1r|a| of Iron 1herapeut|c 1r|a| of Iron
% Cra| |ron therapy
% Increase |n ret|cu|ocytes |n S 7 days
% k|se |n nb at a rate of 24 gm]d| every 3 weeks
t||| norma|
% If no response or |ncomp|ete response do
add|t|ona| tests
|agnos|s |agnos|s Add|t|ona| Add|t|ona|
W W Serum Ie Serum Ie
W W 1ota| |ron b|nd|ng capac|ty 1ota| |ron b|nd|ng capac|ty
W W Serum Ierr|t|n Serum Ierr|t|n
W W Saturat|on Saturat|on
W W nb e|ectrophores|s nb e|ectrophores|s
W W 8one marrow exam|nat|on 8one marrow exam|nat|on
Lab f|nd|ngs |n IA Lab f|nd|ngs |n IA
W W Pb 11 gm/dl Pb 11 gm/dl
W W erlpheral smear erlpheral smear mlcrocyLlc hypochromlc mlcrocyLlc hypochromlc
W W MCv and MCPC are low MCv and MCPC are low
W W Serum lron ls low Serum lron ls low 30 30 gm/dl (n 60 gm/dl (n 60 173) 173)
W W 1l8C ls lncreased 1l8C ls lncreased 400 400 gm/dl gm/dl
W W 1esLs of lron sLores 1esLs of lron sLores
Serum ferrlLln ls 12 Serum ferrlLln ls 12 gm/dl (n 40 gm/dl (n 40 200) 200)
SLalnable lron ln Lhe bone marrow ls reduced SLalnable lron ln Lhe bone marrow ls reduced
Newer |nvest|gat|ons Newer |nvest|gat|ons
W W Serum transferr|n receptors Serum transferr|n receptors
W W 1ransferr|n receptor] ferr|t|n |ndex 1ransferr|n receptor] ferr|t|n |ndex
W W ket|cu|ocyte |nd|ces ket|cu|ocyte |nd|ces
auLomaLed counLlng of reLlculocyLes counL of auLomaLed counLlng of reLlculocyLes counL of
26pg/ cell ls a sLrong predlcLor of luA 26pg/ cell ls a sLrong predlcLor of luA
8eLlculocyLe producLlon lndex 8eLlculocyLe producLlon lndex
W W ked ce|| z|nc protoporphyr|n |eve| ked ce|| z|nc protoporphyr|n |eve|
IA AC 1ha|assem|a S|derob|ast|c
Sever|ty Var|ab|e M||d M||d Var|ab|e
MCV ecreased Norma|]
decreased
ecreased Norma|]
decreased
S Ierr|t|n ecreased Norma|]
|ncreased
Norma| Increased
1I8C Increased ecreased Norma| Norma|
S Iron ecreased ecreased Norma| Increased
Marrow |ron + + +
IA 8eta tha|
opu|at|on A|| Greeks Ita||ans
kW n|gh Norma|
MCV Low Low
Serum |ron ecreased Norma|
Ierr|t|n ecreased Norma|
1I8C Increased Norma|
nb e|ectro
phores|s
Norma| Increased nbA2
Mentzer Index Mentzer Index
W W Ca|cu|at|on that may (or may not) be usefu| |n Ca|cu|at|on that may (or may not) be usefu| |n
d|fferent|at|ng tha|assem|a m|nor from IA d|fferent|at|ng tha|assem|a m|nor from IA
W W Mentzer Index MCV]k8C Count Mentzer Index MCV]k8C Count
W W 13 13 1ha|assem|a m|nor 1ha|assem|a m|nor
W W 13 13 Iron ef|c|ency Iron ef|c|ency
W W Usefu| |n ch||dren Usefu| |n ch||dren
Io||c Ac|d ef|c|ency Anem|a
W ef|c|ency of fo|ate or 812
W Ant|convu|sants ora| contracept|ves su|fa drugs
and a|coho| can decrease absorpt|on of fo|ate from
mea|s
W Io|ate |s essent|a| for norma| growth and
deve|opment
W Coex|sts w|th IA
Mega|ob|ast|c Anem|a
|agnost|c rob|ems
Mega|ob|ast|c Anem|a
|agnost|c rob|ems
W n8 est|mat|on
W er|phera| smear
W MCV est|mat|on
W Serum fo|ate
W ked ce|| fo|ate
W IIGLU est|mat|ons
W Marrow asp|rate
W n8 est|mat|on
W er|phera| smear
W MCV est|mat|on
W Serum fo|ate
W ked ce|| fo|ate
W IIGLU est|mat|ons
W Marrow asp|rate
|agnos|s |agnos|s
W W Macrocytes on per|phera| smear Macrocytes on per|phera| smear
W W nypersegmentat|on of neutroph||s nypersegmentat|on of neutroph||s
W W ancytopen|a ancytopen|a
W W Low nb and h|gh MCV Low nb and h|gh MCV
W W Megab|astos|s on bone marrow Megab|astos|s on bone marrow
W W Serum fo|ate 3ng] m| Serum fo|ate 3ng] m|
revent|on revent|on
W |etary adv|ce and mod|f|cat|on
W Iron supp|ementat|on of ado|escent non pregnant
women
W 1reatment of hookworm Infestat|on
W Iron supp|ementat|on |n pregnant women
W Iood fort|f|cat|on
W Antenata| care for ear|y recogn|t|on
Management of Anem|a
W W Cra| Iron 1herapy Cra| Iron 1herapy
W W rophy|act|c Iron therapy rophy|act|c Iron therapy 100mg e|ementa| |ron 100mg e|ementa| |ron
da||y w|th S00 mcg of fo||c ac|d da||y w|th S00 mcg of fo||c ac|d
W W eworm|ng eworm|ng of a|| anem|c pat|ents of a|| anem|c pat|ents
W W 1reatment of Anem|a 1reatment of Anem|a 200mg of e|ementa| |ron 200mg of e|ementa| |ron
fo|ate Smg]d fo|ate Smg]d
Iron kequ|rement |n regnancy Iron kequ|rement |n regnancy
W W 2Smg ]day |n ear|y pregnancy 2Smg ]day |n ear|y pregnancy
W W SSmg ]day from 20 SSmg ]day from 20 32 weeks 32 weeks
W W 6 6 8 mg] day after 32 weeks 8 mg] day after 32 weeks
W W Average 4 mg] day Average 4 mg] day
The tabIet can be given with meaIs or The tabIet can be given with meaIs or
different brand may be tried different brand may be tried
S|de effects of Cra| |ron S|de effects of Cra| |ron
W W Nausea Nausea
W W Vom|t|ng Vom|t|ng
W W Const|pat|on Const|pat|on
W W Abdom|na| cramp|ng Abdom|na| cramp|ng
W W |arrhoea |arrhoea
keasons for Ia||ure to kespond keasons for Ia||ure to kespond
W W Non comp||ance Non comp||ance
W W Concom|tant fo|ate def|c|ency Concom|tant fo|ate def|c|ency
W W Cont|nuous |oss of b|ood through hookworm Cont|nuous |oss of b|ood through hookworm
|nfestat|on or b|eed|ng haemorrho|ds |nfestat|on or b|eed|ng haemorrho|ds
W W Co Co ex|st|ng |nfect|on ex|st|ng |nfect|on
W W Iau|ty |ron absorpt|on Iau|ty |ron absorpt|on
W W Inaccurate d|agnos|s Inaccurate d|agnos|s
W W Non |ron def|c|ency m|crocyt|c anaem|a Non |ron def|c|ency m|crocyt|c anaem|a
New 1herapeut|c A|ternat|ves New 1herapeut|c A|ternat|ves
W W 1he s|de effects of o|der Iron preparat|ons the|r 1he s|de effects of o|der Iron preparat|ons the|r
poor comp||ance even on prov|d|ng free tab|ets are poor comp||ance even on prov|d|ng free tab|ets are
the most |mportant reasons of fa||ure of anaem|a the most |mportant reasons of fa||ure of anaem|a
contro| programmes contro| programmes
W W Newer preparat|ons are better to|erated have |ess Newer preparat|ons are better to|erated have |ess
s|de effects w|th better comp||ance s|de effects w|th better comp||ance
W W Carbony| Iron Carbony| Iron
W W Iron ascorbate Iron ascorbate
Mer|ts of New reparat|ons Mer|ts of New reparat|ons
W W Cutstand|ng GI 1o|erance |n contrast to 20 severe Cutstand|ng GI 1o|erance |n contrast to 20 severe
s|de effects w|th convent|ona| therapy s|de effects w|th convent|ona| therapy
W W Very safe w|th no po|son|ng even |n h|gh doses Very safe w|th no po|son|ng even |n h|gh doses
W W No |nteract|on w|th food stuffs No |nteract|on w|th food stuffs
W W 1he newer preparat|ons are de||c|ous w|th non 1he newer preparat|ons are de||c|ous w|th non
meta|||c taste and don't sta|n the pat|ents' teeth meta|||c taste and don't sta|n the pat|ents' teeth
W W nence the comp||ance |s very h|gh nence the comp||ance |s very h|gh
arentera| Iron therapy arentera| Iron therapy
W W Ind|cated when the pregnant woman |s unab|e to Ind|cated when the pregnant woman |s unab|e to
take |ron due to s|de effects or |s non comp||ant take |ron due to s|de effects or |s non comp||ant
W W Its ma|n advantage |s certa|nty of adm|n|strat|on Its ma|n advantage |s certa|nty of adm|n|strat|on
W W k|se |n hemog|ob|n |s s|m||ar to ora| |ron (upto 1gm k|se |n hemog|ob|n |s s|m||ar to ora| |ron (upto 1gm
per wk) per wk)
reparat|on dosage
W W Iron extran IM and IV Iron extran IM and IV h|gh mo|ecu|ar wt stab|e h|gh mo|ecu|ar wt stab|e
comp|exes re|ease |ron s|ow|y can cause anaphy|ax|s comp|exes re|ease |ron s|ow|y can cause anaphy|ax|s
W W Iron c|trate sorb|to| IM Iron c|trate sorb|to| IM |ess stab|e rap|d re|ease of |ess stab|e rap|d re|ease of
|ron |ron
W W Iron sucrose IV Iron sucrose IV |ntermed|ate stab|||ty rap|d |ntermed|ate stab|||ty rap|d
metabo||sm hence read||y ava||ab|e |ron S|nce they do metabo||sm hence read||y ava||ab|e |ron S|nce they do
not form b|o|og|ca| po|ymers there are no react|ons not form b|o|og|ca| po|ymers there are no react|ons
recaut|on recaut|on
W W Cra| Iron to be suspended 48 hours before Cra| Iron to be suspended 48 hours before
parentera| therapy parentera| therapy
W W Lmergency measures ||ke |n[ hydrocort|sone Lmergency measures ||ke |n[ hydrocort|sone
adrena||ne oxygen cy||nder to be kept ready adrena||ne oxygen cy||nder to be kept ready
W W Look for react|on wh||e g|v|ng |nfus|on Look for react|on wh||e g|v|ng |nfus|on
ose ca|cu|at|on
W C|der preparat|ons each 1m| S0mg e|ementa| |ron
03 x WL ln lb x (100 Pb) + 300
W Iron sucrose each m| 20mg e|ementa| |ron
W ose 200mg s|ow IV a|ternate day
W 024 x wt |n kg x (target nbpt nb) + S00
|sadvantages |sadvantages
W a|n
W Nausea vom|t|ng headache
W Sk|n d|sco|ourat|on
W Abscess format|on
W Iever
W Lymphadenopathy
W A||erg|c react|on
W Anaphy|ax|s
8|ood 1ransfus|on
W W Severe anem|a espec|a||y after 36 weeks Severe anem|a espec|a||y after 36 weeks
W W nemorrhage nemorrhage
W W Assoc|ated |nfect|ons Assoc|ated |nfect|ons
W W acked ce||s preferred acked ce||s preferred
W W Lxchange transfus|on rare Lxchange transfus|on rare
Use of Lrythropoet|n Use of Lrythropoet|n
W W Used |n severe anem|a rena| fa||ure for s|gn|f|cant Used |n severe anem|a rena| fa||ure for s|gn|f|cant
|ncrease |n nb and to avo|d b|ood transfus|on |ncrease |n nb and to avo|d b|ood transfus|on
W W Gynaeco|og|ca| surger|es Gynaeco|og|ca| surger|es preop use of preop use of
erythropo|et|n and Iron extran has been shown to erythropo|et|n and Iron extran has been shown to
avo|d the need for b|ood tranfus|on |ater avo|d the need for b|ood tranfus|on |ater
osage keg|men Lrythropoet|n
W W In[ In[ erythropoet|n erythropoet|n can be g|ven can be g|ven subcut subcut or |v 100 or |v 100 1S 1S |u |u]kg ]kg
W W Cn day 1 3 S a|ong w|th Cn day 1 3 S a|ong w|th parentera| parentera| |ron or day 1 3 |ron or day 1 3
S 6000un|ts s]c S 6000un|ts s]c erythropoet|n erythropoet|n and |ron and |ron dextran dextran 100mg 100mg
deep deep |m |m da||y for S day da||y for S day
W W I|rst dose g|ven after I|rst dose g|ven after subcut subcut sens|t|v|ty test sens|t|v|ty test
W W Adrena||ne hydrocort|sone oxygen to be kept ready Adrena||ne hydrocort|sone oxygen to be kept ready
W W roduces 3gm r|se |n roduces 3gm r|se |n nb nb over a 2wk per|od over a 2wk per|od
Management |n Labor Management |n Labor
W W Make pat|ent comfortab|e oxygen Make pat|ent comfortab|e oxygen
W W Sedat|on and ana|ges|a Sedat|on and ana|ges|a
W W revent card|ac fa||ure revent card|ac fa||ure
W W A|m to de||ver vag|na||y A|m to de||ver vag|na||y
W W Ant|b|ot|cs Ant|b|ot|cs
W W Cut short second stage Cut short second stage
W W Act|ve management of th|rd stage Act|ve management of th|rd stage