anaemia prevention dr rabi
TRANSCRIPT
DR. RABI NARAYAN SATAPATHYASST.PROFESSORDEPT. OF OBST.& GYNAECOLOGYSCB MEDICAL COLLEGE, [email protected]
ANAEMIA PREVENTION
Defined as :
Reduction in the circulating red cell mass and corresponding decrease in haemoglobin mass and oxygen carrying capacity of blood
WHO : Hb level PCV
g/dl g/L %
Mild < 11 < 110
10 g/dl ( developing countries)
Moderate 6.5 - 8 70 – 109 24-37
Severe < 6.5 40 - 69 13-23
Very Severe < 40 < 13
GLOBAL POPULATION - 4.4 BILLION
ANEMIA - 1.3 BILLION ( 30%)
DEVELOPING COUNTRIES – 1.2 BILLION
WORLD
51%DEVELOPED
18%
DEVELOPING 56%
ASIA-60%
EASTERN-37%
S.EASTERN-63%
SOUTHERN-75%
WESTERN-50%
ANAEMIA IN PREGNANCY - ASIAN COUNTRIES
WHO 1992
0
10
20
30
40
50
60
70
80
90
Bangladesh China India Indonesia Malay sia My anmar Nepal Pakistan Philippines Singapore Srilanka Thailand
BANGLADESH
CHINA
INDIA
INDONES IA
MALAYSIA
MYANMAR
NEPAL
PAKISTAN
PHILIPPINES
SPORE
SRILANKA
THAILAND
INDIA
ANNUAL MATERNAL DEATHS - GLOBALLY
SOUTH ASIA
TOTAL 500,000
75% : Haemorrhage ; Abortion ; Eclampsia ; Sepsis ; Obs. Labour.
ANAEMIA : Underlying cause in 20%
WHO 1991
0
5
10
15
20
25
30
FOGSI 1982 RG. India 1986 Bara &Sengupta 1992
Kamla Jayram1992
RG India 1992
MATERNAL DEATHS DUE TO ANAEMIA Indian Data
8.517.8
5.97.5
19
19
12.2
17.24 18.2
17.98
10.10
ICMR-29.9
Registrar general 1999 : 17.3%
FW Year Book 1989-90: 17.8%
16.814.3
MATERNAL DEATHS DUE TO ANAEMIA
PREVALENCE OF ANAEMIA
URBAN : 40 – 50 % 46 %
RURAL : 50-70% 54%
H.W.ENDEMIC : 90 %
( National Family Health Survey – 2 1998-1999)
Incidence : 50% in general population
M : F is 1 : 4
India : highest prevalence 80% females suffering from it
1 in 5 maternal deaths are due to it
FOGSI-WHO Study:
of the maternal deaths due to anaemia 64.4% : Hb < 8gm%
21.6% : Hb<5gm%
CONQUERING ANAEMIA : major thrust issue
In an era Where both diagnosis and treatment are
EASY EFFECTIVE
INEXPENSIVE
ANAEMIA
the most preventable cause
Is still the leading indirect cause
Among the most freedoms that we can have is the freedom from avoidable ill-health and from
escapable mortality
Amartya Sen
CAUSES
NUTRITIONAL : IRON DEFICIENCY FOLIC ACID DEFICIENCY
HAEMORRHAGIC: WORM INFESTATION ANTECEDENT PREGNANCY
HAEMOLYTIC : HAEMOGLOBINOPATHIES DRUG REACTIONS
INFESTATION : MALARIAL PARASITES
APLASTIC ANAEMIA
If left Untreated ……………
Abruptio placentae
Intercurrent infection
PROM
Preterm Labour
Heart Failure
Uterine inertia PPH peurperal sepsis
lactational failure periphral venous
thrombosis pulmonary embolism
Perinatal Morbidity …………………..
Prematurity
IUGR
Congenital Anomalies
Intrauterine Death
Birth Asphyxia
Infection
The competency and skill of the modern obstetrician is assessed not by the conduct of delivery or performance of Caesarean Section but by the smartness exhibited in managing medical disorders complicating
pregnancy & the high risk problems
Crux of the problem ?
Anemia/Anaemia ?
Oral / parenteral ?
Ferrous Sulphate/Ferrous Glycine Sulphate / Iron Polymaltose Complex /Carbonyl Iron ?
Definition ?
Supplementation Dosage Schedule ?
Daily ?
Once weekly ?
Twice weekly ?
In pregnancy ?
Minimal Iron Stores in Males & Females
M 800 – 1000 mg F 400 – 600 mg
At Birth
Adolescence – Adulthood
RBC : 2 – 2.5 mg Tissues : 200 mg Circulation : 3 mg Exfoliation : 1 mg/day
PREGNANCY
Addl. Req. – 800-1000mg 1st trimester - .8 mg/day 2nd & 3rd trimester - 6.3 mg/day peurperium & - 1.3 mg/day
lactation
Daily req. - 2 – 4.8 mg/day
Consume - 20 – 40 mg/day 10-15 mg/day
(veg)
+ phytates of cereals
DYNAMICS OF IRON ABSORPTION
INTESTINES PLASMA CELL
Haem syhthesis
APOFERRITIN
AUTOPHAGOCYTOSIS
PHAGOSOME
PATHWAY OF IRON METABOLISMDIETARY IRON
( 14 + 4 mg 1 day, 6mg / 1000 kcal )
INTESTINAL MUCOSA(Absorption 1 mg / day )
PLASMA IRON( Pool about 3 mg, turnover 10x / day )
OBLIGATORY LOSS
( 1mg / d : Male 2mg / d : Female )
RETICULO - ENDOTHELIUM POOL( 25 mg / day )
INTERSITIAL FLUID
TISSUES( Myoglobin and enzymes . About 6 mg / day )
FERRITIN STORES
ERYTHROID MARROW( uptake about 25 mg / day )
CIRCULATING RBC’s( Pool about 2100 mg daily
turnover 18 mg )
STAGES IN DEVELOPMENT OF IRON DEFICIENCY
NORMAL DEPLETION OF IRON STORES WITHOUT
ANAEMIA
IRON DEFICIENCY ANAEMIA
HAEMOGLOBIHAEMOGLOBIN IRONN IRON
STORAGE STORAGE (AVAILABLE ) (AVAILABLE ) IRONIRON
TISSUE ( NON- TISSUE ( NON- AVAILABLE ) AVAILABLE ) IRONIRON
IRON DEFICIENCY IS NOT
SYNONYMOUS WITH
IRON DEFICIENCY ANAEMIA
Hb. Conc. - not a very sensitive index
Latent & Early Iron Deficiency Anaemia - normal blood picture
Serum Iron
TIBC
Serum Ferritin
Not Feasible
M : 40-340 ng/ml F : 14-150 ng/ml
<30 ng/ml – absent iron stores
<12mg/ml - critical
Best Compromise
Peripheral smear Hb.conc.
Electronic counter-Most sensitive
Sahli’s Method
Pale Hypochromia Microcytosis
Polychromatic BasophilicStippling
Target cells
Macrocytosis (oval) Hypersegmented Neutrophils Fully Haemoglobinised RBC
Sickle cells
PERCENTAGE OF WOMEN WITH ANAEMIA
NATIONAL FAMILY HEALTH SURVEY-2 1998-99
MILD
MODE- RATE
SEVERE
0
5
10
15
20
25
30
35
40
15-19 20-24 25-29 30-34 35-39
0
5
10
15
20
25
30
35
40
illiterate literate
mild
moderate
severe
LITERACY
NATIONAL FAMILY HEALTH SURVEY-2 1998-99
Build Iron Stores …………..
Respect Girl child
Primary Education
Mid-Day Meal Schemes
Food Fortification
Early detection via good ANC
Hospitalisation & Treatment
Avoid prolonged & Difficult Labour
Post- Partum period – Close watch
Girl Child
Pregnancy Related
PROBLEMS OF A GIRL CHILD
WORM INFESTATIONS
BLEEDING GUMS AND DIATHESIS
EPISTAXIS
CHRONIC UTI
PELVIC INFECTION
MENSTRUATION
CHRONIC MALARIA
TUBERCULOSIS
Gender Specific Prescription
Respect Girl child
Primary Education
Mid-Day Meal Schemes
Food Fortification : WHEAT
SALT
DOUBLE FORTIFICATION
( IODINE & IRON)
Early detection via good ANC
Hospitalisation & Treatment
Avoid prolonged & Difficult Labour
Post- Partum period – Close watch
Anaemia may antedate pregnancyIt may be aggravated by pregnancy
OrThe accidents of labour may perpetuate it
Age/Sex group Haemoglobin < g/dl
Haematocrit < %
Children 6mths.-5yrs. 11.0 33
Children 5-11yrs 11.5 34
Children 12-13yrs. 12.0 36
Non-pregnant women 12.0 36
Pregnant women 11.0 33
Men 13.0 39
HAEMOGLOBIN AND HAEMATOCRIT CUT OFFS TO DEFINE ANAEMIA IN PEOPLE LIVING AT SEA
LEVEL
From WHO/UNICEF/UNU,1997
RISK FACTORS FOR ANAEMIA IN PREGNANCY
Age group < 20 yrs. / > 30 yrs.
Lower socio-economic status
Literacy
Parity >2
Spacing < 2 yrs.
Calorie Intake < 80% of expected
History of Worm Infestation ( last 6 mths.)
Malnutrition ( BMI < 18.5 )
Vegetarian Diet
Unemployment of women
IRON PREPARATION
FERROUS SULPHATE : least expensive best absorbed
FERROUS GLUCONATE
FERROUS FUMARATE
SUSTAINED RELEASE PREPARATION claim – less side effects
Diet restrictions : Cereal diet, Wheat, Tannin, Nuts & Pulses
MOLECULAR IRON
ELEMENTAL IRON
FERROUS SULPHATE
200 60
FERROUS GLUCONATE
300 36
FERROUS FUMARATE
200 65
SUSTAINED RELEASE
350 105
IRON POLYMALTOSE COMPLEX
STRUCTURE : FERRIC HYDROXIDE POLYMALTOSE COMPLEX
ANALOGUS TO FERRITIN
PROTEIN LIGAND REPLACED BY MALTOSE
CAPSULE CONTAIN 100mg elemental iron
CLAIM :
FOOD : NO INTERFERENCE WITH ABSORPTION
DECREASE G.I. SYMPTOMS
BIOAVAILABILITY SAME AS FERROUS
NEGLIGIBLE FREE RADICALS
CARBONYL IRON
“CARBONYL” : MANUFACTURING PROCESS
VAPOURISED IRON PENTACARBYL CONTROLLED HEATING
UNCHARGRD ELEMENTAL IRON
SOLUBILISATION DEPENDS ON GASTRIC ACID PRODUCTION
ONLY SOLUBILISED FRACTION IS ABSORBED
NON-COMPLIANCE
MEDICAL FACTORS
SOCIO-CULTURAL FACTORS
COLOUR
TASTE
SIDE EFFECTS : NAUSEA
ABD. DISCOMFORT CONSTIPATION DIARRHOEA
PARENTERAL THERAPY
INTOLERANCE TO SIDE EFFECTS OF ORAL IRON
IBD / PEPTIC ULCER
NON COMPLIANCE
IRON MALABSORPTION (documented)
NEAR TERM
ROUTE : I M / IV IRON DEXTRAN COMMONLY USED
~ 100 mg IM DAILY TILL CALCULATED DRUG IS GIVEN
~ SHOLUD BE INITIATED PRIOR TO 20 WEEKS FOR
OPTIMUM OUTCOME
“Parenteral route can provide greater amount of iron than the oral route & erythropoiesis can be increased 6-8
times over the basal levels after parenteral iron as compared to 3-4
times after oral iron”
Hillman & Anderson 1969 Vol 46 / No.2 / 1996
DRAWBACKS
PAIN & STAINING
MYALGIA
ARTHRALGIA
INFECTION ABSCESS
HOSPITALISATION / REGULAR VISITS
I.V. - ONE SHOT
BETTER COMPLIANCE
National Nutritional Anemia Prophylaxis Programme (NNAPP )
Launched in the 4th five year plan - report 1989
60mg. Iron +50 mcg FA/day X 100 days
1. Anemia Prevalence was the same – consumed 88.1% did not consume 87.6%
2. >50 tablets – better Hb% as compared to those >25 tablets
3. Erratic supply : 19% pregnant women 17% lactating women
4. Education co mponent- weak / absent
We will plan our work
And
Work our plans
With
Dedication
IRON PROPHYLAXIS
PATIENT COMPLIANCE
SMOOTH DISTRIBUTION
60 / 120 mg / day
WESTERN – 60/mg day
DEVELOPING –
start pregnancy with depleted iron stores poor nutrition infection 120 mg /dayinfestation
GUIDELINES - IRON SUPPLEMENTATION TO PREGNANT WOMEN
Prevalence of anaemia in pregnancy Dose Duration
< 40% 60 mg iron 6 mths in 400 Folic acid pregnancy
> 40% 60 mg iron 6 mths in 400 Folic acid pregnancy 3mths pp
TRANSFERRIN RECEPTOR ( TfR )
RECENT ADVANCES IN DIAGNOSIS
Transmembrane protein
Binds transferrin & bound iron
Reduction in iron supply – increased TfR synthesis
Inproportion to the decrease in Iron
Differentiate between tissue iron deficiency & anaemia due to haemodilution
FOLATE & FOLIC ACID
TWO DISTINCT ROLES IN PREGNANCY :
PREVENTION OF ANAEMIA IN LATE PREGNANCY
ROLE IN EMBRYOGENESIS IN RELATION TO NEURAL TUBE DEFECTS
BIRTH DEFECTS :
Neural tube defects (Scott et al 1990; 1994)
Orofacial clefts (Tolarova & Harris 1995 )
IUGR (Baumslag et al 1970)
FOLIC ACID
400 mcg of Folic acid /day ideally for two or three months before
conception
400mcg. to be continued throughout pregnancy & lactation
Fortification Options : Cereals Fruit Juices
Bread
No significant associated risk
Fetal origin of Adult Disease Reduction in intrauterine nutrition
Impaired intrauterine development
Affect CVS / Pancreas in adult life
;BARKER’S HYPOTHESIS 1990BARKER’S HYPOTHESIS 1990
WOMEN : POORNUTRITION LOW SOCIOECONOMIC STATUS DEVELOPING COUNTRIES
ROUTINE SUPPLEMENTATION IN PREGNANCY Great Britain
PREVENTION : TWO SCHOOLS OF THOUGHTS
Scandinavian countries
WOMEN AT RISK
LOWER SOCIO-ECONOMIC GROUPS
MULTIPARAS
MALABSORPTION SYNDROME
We have to wait till the evening to know how glorious the day has been.
Sophocles (2000yrs. ago)
INFESTATIONS
Ankylostoma Duodenale ( Hookworm )
Ascaris lunbricoides ( Roundworm )
Trichuris trichura ( Whipworm )
Enterobus vermicularis (Threadworm )
Strongyloidosis
Cestodes ( Tapeworm )
Trematodes ( Fluke )
ANAEMIA CAUSED BY HOOKWORMS
Complementary parasite control measures in pregnancy
Hookworms : Endemic prevalence rate 20-30% antihelminthic - second trimester
Highly endemic – prevalence rate > 50% repeat third trimester
Mebendazole 500 mg single dose / 100 mg twice daily x 3d
FDAC
Pyrantel Palmoate 10mg/kg single dose, FDAC best to repeat for two consecutive days
Levamisole 2.5 mg/kg single dose, FDX best to repeat for two consecutive days
Albendazole 400 mg single dose FDX
WORM INFESTATION
ANTIHELMINTHIC
FOOTWEAR
IMPROVE SANITATION
PERSONAL HYGIENE
SAFE WATER
MALARIA
ANAEMIA : Haemolysis
Suppression of erythropoiesis
MALARIA PROPHYLAXIS
Endemic
First & second Pregnancies
First visit – Curative antimalarials
Antimalarial prophylaxis
HAEMOGLOBINOPATHIES
THALASSEMIA
SICKLE CELL ANAEMIA
? IRON SUPPLEMENTATION
Serum Ferritin levels are significantly raised in pregnant women with Sickle Cell Disease
AKINYANJU (1987):
“…..clear need should be established before iron supplementation in haemoglobinopathic patients ”
TURNBULL ( 1989 )
Thalassemia Minor : Prophylactic oral iron therapy - has a role Parenteral Iron should not be given
CONSENSUS
Asses iron status of all haemoglobinapathically anaemic pregnant women
Wiser to avoid routine prophylaxis
Therapeutic dose given where required
APLASTIC ANAEMIA (AA)
3 SUBSETS OF PATIENTS WITH APLASTIC ANAEMIA
PREGNANCY INDUCED AA
PREGNANCY ASSOCIATED AA
TRANSIENT MARROW SUPRESSION INDUCED BY PREGNANCY
PRE-EXISTING AA CAUTIONED
MANAGEMENT STAGE OF PREGNANCY AT WHICH PANCYTOPENIA DEVELOPS & ON MAINTAINING MOTHERS BLOOD COUNT
LYMPHOCYTE GLOBULIN
MARROW TRANSPLANT
Today, analysis of causes of maternal deaths is almost a futile exercise. Researchers and intellectuals all over the world are now joining together to draft the preventive measures
Dr. S. Dasgupta
International Nutritional Anaemia Consultative Group ( INACG )
Guidelines:
• to provide clear and simple recommendations
• to address both ~ prevention of anaemia ~ and treatment of anaemia
• to integrate recommendations for the use of ~ anti-malarials
~ antihelminthic
An Effective Control Programme
Population group Benefit Children behavioural & cognitive development
child survival
Adolescents cognitive development
better iron stores for later pregnancies
Pregnant women Decreased - low birth weight & their infants - perinatal mortality - maternal mortality - obstetrical complications
All individuals Improved fitness and work capacity Improved cognition
INTERVENTIONAL ARRAY
Iron supplementation
Food based interventions
Helminth control
Malaria control
Reproductive and Obstetric Interventions
Target Groups for Iron supplementation :
Based on : likelihood of iron deficiency public health benefits
Priority groups : Pregnant & Post-partum women Children 6-24 mths of age
High prevalence of anaemia
Women of reproductive age Pre-school children School-age children Adolescents
Selecting and Prioritising Interventions
Epidemiology of anaemia in the area
Available infrastructures
Community opinion and priorities
PROPHYLAXIS MANDATORY
SECOND TRIMESTER ONWARDS
ORAL IRON – Tab / Liquid
FERROUS SALTS – Sulphate/Gluconate/Succinate
SUSTAINED RELEASE PREPARATION - No Significant advantage
HAEMOGLOBIN PREPARATIONS 1gm Hb preparation - 3.4 mg iron
Preparations contain - 10 gm = 20-30 mg
Do not discontinue once the Haemoglobin level normalises – Iron stores start building up only after that –continue iron therapy for 3-4 mths after Hb. Level has come to normal.
Key Points
Contd………….
Vitamin C
Folic Acid - 350 mcg
Deworming
Prophylaxis against Malaria
Dietary Advice
Sanitation & Hygiene
THANK YOU