Download - Anemia in pregnancy rns
Dr. Rabi Narayan Satpathy
Asst. professor
Dept. of Obst. & gynaecology
SCB MEDICAL College, Cuttack
Mob-09861281510
MMajor Public Health Problemajor Public Health Problem
MMost Preventable Cause ost Preventable Cause Still the Leading CauseStill the Leading Cause
MAGNITUDE OF THE PROBLEMMAGNITUDE OF THE PROBLEM
WorldWorld
population:population: 5-6 billion5-6 billion
2 billion anemic2 billion anemic
Developing Countries:Developing Countries:
9 out of 11 pt are anemic.9 out of 11 pt are anemic.
Every second preg. WomanEvery second preg. Woman
4 out of 10 pre school4 out of 10 pre school
India:India:
Highest prevalenceHighest prevalence
87% preg women87% preg women
10% severe anemia10% severe anemia
1 in 5 maternal deaths1 in 5 maternal deaths
ANNUAL MATERNAL DEATHS - ANNUAL MATERNAL DEATHS - GLOBALLYGLOBALLY TOTAL 500,000TOTAL 500,000
75%75% : Hemorrhage ; Abortion ; Eclampsia ; : Hemorrhage ; Abortion ; Eclampsia ; Sepsis ; Obs. Labour. Sepsis ; Obs. Labour.
ANAEMIAANAEMIA : Direct cause contributes 20% : Direct cause contributes 20%
Indirect cause further 20%Indirect cause further 20%
Iron Metabolism – Iron Metabolism – The ConceptThe Concept
Iron Metabolism – Iron Metabolism – The ConceptThe Concept
FeFe++++
FeFe++++
FeFe++++
FeFe++++
FeFe++++
FeFe++++
FeFe++++
FeFe++++
Is it Very Confusing !!!Is it Very Confusing !!!Is it Very Confusing !!!Is it Very Confusing !!!
EXTERNAL IRON EXCHANGEEXTERNAL IRON EXCHANGENon-haem IronNon-haem Iron
InorganicInorganic
Haem IronHaem Iron
OrganicOrganic
Fascilitators Fascilitators •AscorbateAscorbate•Gastric pHGastric pH•CitrateCitrate•AAAA
InhibitorsInhibitors•Phytates.Phytates.•Tannin.Tannin.•AntacidAntacid•P-pump inhibitors P-pump inhibitors
CompetitorsCompetitors•Pb.Pb.•Mn. Mn. •Zn.Zn.
Efficient Efficient independent of independent of duodenal pHduodenal pH
Luminal Cell of Duodenum & Luminal Cell of Duodenum & JejunumJejunum
FerritinFerritin
CC
Fe++Fe++
Ferrous Ferrous
More solubleMore soluble
Acidic duodenal pHAcidic duodenal pH
CC
PLASMA TRANSFERINPLASMA TRANSFERIN
Normal men 1 mg/day
Menstruating females 2 mg/day
Pregnant women 4.8 mg/day
Adolescent 1-2 mg/day
INTERNAL IRON EXCHANGEINTERNAL IRON EXCHANGE(IRON CYCLE)(IRON CYCLE)
Transferrin – Transferrin –
Iron ComplexIron Complex
Transferrin – Transferrin –
Iron ComplexIron Complex
Bone marrow erythroid cellsBone marrow erythroid cells
RBCRBC
R-E systemR-E system
Liver Liver
FerritinFerritin
Gut Gut
Recycling
Recycling
release of Iron
release of Iron
120 days120 days
Transferrin Transferrin receptorreceptor
Haemosiderin Haemosiderin (Stable) can’t be (Stable) can’t be
mobilizedmobilized
Iron Iron Absorption Absorption
IncreaseIncrease
Demand by fetusDemand by fetus Net utilisation is 800 mgNet utilisation is 800 mg Twin. Twin.
Bioavailability of iron is Bioavailability of iron is decreased.decreased.
Inadequate calorie Inadequate calorie intake < 2,000 Kcal/day.intake < 2,000 Kcal/day.
Increase in plasma & Increase in plasma & RBC volume.RBC volume.
<<<<
Age group < 20 yrs.Age group < 20 yrs. Low SE status.Low SE status. Literacy.Literacy. Parity > 2.Parity > 2. Sparing Sparing 2 yrs. 2 yrs. Malnutrition.Malnutrition. Vegetarian diet – mostly cereal & pulse.Vegetarian diet – mostly cereal & pulse. Worm infestation.Worm infestation. Unemployment of women, poverty.Unemployment of women, poverty.
NutritionalNutritional
Fe.Fe. Folic.Folic. BB1212..
Combined.Combined.
Blood lossBlood loss
Acute.Acute. Abortion.Abortion. Ectopic.Ectopic. Molar.Molar. AbruptioAbruptio Previa.Previa. Coagulopathies.Coagulopathies.
Chronic.Chronic. Hookworm.Hookworm.
Causes Contd…..Causes Contd…..
Hemolytic anemiasHemolytic anemias
Congenital.Congenital. Hemoglobinopathies.Hemoglobinopathies. Thalassemia.Thalassemia. Sickle cell anemia.Sickle cell anemia.
Acquired.Acquired. Malaria.Malaria. Autoimmune disease.Autoimmune disease.
Aplastic Anemias/ Aplastic Anemias/ HypoplasticHypoplastic
Chronic systemic Chronic systemic disease.disease.
Bone marrow depression.Bone marrow depression. Renal disease.Renal disease. Endocrine disorder.Endocrine disorder. Malignancy.Malignancy. Viral infection.Viral infection.
Reliable, Cost effective, Reliable, Cost effective, Easy Indicator of AnemiaEasy Indicator of Anemia
g/dlg/dl g/lg/l PCVPCV
Mild Mild < 11< 11 < 110< 110
Moderate Moderate 6.5-86.5-8 70-10970-109 24-3724-37
Severe Severe < 6.5< 6.5 40-6940-69 13-2313-23
Very severeVery severe < 4< 4 < 40< 40 < 13< 13
WHO standardisation of AnemiaWHO standardisation of Anemia
Decrease Hb Anemia
Story Behind
Negative Iron Balance.Negative Iron Balance.
Iron deficient erythropoiesis.Iron deficient erythropoiesis.
Iron Deficiency Anemia (IDA).Iron Deficiency Anemia (IDA).
BM Iron BM Iron StoresStores
Hb%Hb%
Normal Normal Negative iron Negative iron balancebalance
Iron deficient Iron deficient erythropoiesiserythropoiesis
Iron deficiency Iron deficiency anemiaanemia
S. Ferritin S. Ferritin ((g/l)g/l) 50-20050-200
<15<15
TIBC TIBC ((g/dl)g/dl) 300-360300-360 > 400> 400
S. Iron S. Iron ((g/dl)g/dl) 50-15050-150 N N
Saturation Saturation (%)(%) 30-5030-50 NN
RBC RBC protophyrinprotophyrin N N
RBC RBC morphologymorphology N N N N Microcytic Microcytic
hypochromatichypochromatic
Lack
of
Conce
ntrati
on
Degree of Degree of AnemiaAnemia
SymptomsSymptoms
Weakness
Fatigue
Dizzines
s
Irritability
ModMild
Severe
Vulnerable GroupsVulnerable Groups Problems Problems
Infant (4-24m)Infant (4-24m) Maximum Iron required Maximum Iron required equivalent to adult doseequivalent to adult dose
Growing girl childGrowing girl childWorm infestation, UTI, Worm infestation, UTI, epistaxis, pelvic infection, epistaxis, pelvic infection, chronic malaria, tuberculosischronic malaria, tuberculosis
Adolescent girlAdolescent girl Puberty menorrhagia, Puberty menorrhagia, infection, malnutritioninfection, malnutrition
Diet.
Fortification.
Social factors.
Infection control.
Haem IronHaem Iron
Organ meats.Organ meats.
Poultry.Poultry.
Fish.Fish.
Oysters.Oysters.
Beef.Beef.
Pork.Pork.
Non-haem IronNon-haem Iron
EggEgg
Diary products.Diary products.
Dried beans, peas.Dried beans, peas.
Dark green leafy Dark green leafy vegetables (spinach, vegetables (spinach, mustard greens).mustard greens).
Nuts & sesame seedsNuts & sesame seeds People who are iron deficient absorbs 10 People who are iron deficient absorbs 10 times more than normal subjects.times more than normal subjects.
Vit. C Vit. C → → Citrus fruits, lemon, tomatoes.Citrus fruits, lemon, tomatoes.
Cooking in cast iron pans & utensils. Cooking in cast iron pans & utensils.
Iron fortification of:Iron fortification of:Cereals.Cereals.Bread.Bread.Pasta.Pasta.
Double fortification of salt.Double fortification of salt. Iodine & Iron.Iodine & Iron.
Food vehicles.Food vehicles.
Respect to girl child.Respect to girl child.
Education of girl child.Education of girl child.
Equal rights.Equal rights.
Mid-day meal programmes.Mid-day meal programmes.
Personal hygiene. Personal hygiene.
Marriage after 18.Marriage after 18.
Safe abortion.Safe abortion.
Worm infestation.Worm infestation.
Malaria.Malaria.
National Nutritional Anemia Prophylaxis Programme (NNAPP)
Universal Oral Iron Supplementation of All Pregnant Women
60 mg/ 100 mg/ 120 mg
100 mg of Iron x 100 days
Aims at
As Recommended by WHO & implemented by GOI
1st trimester 2nd trimester 3rd trimester
< 11 g/dl
200 mg Elemental Iron
Reassessment on 2nd & 3rd
9 – 11 g/dl
200 mg Elemental Iron
MonitoringMaintenance
Therapy
< 9 g/dl
Lab. Test: CBC (PS), Iron Studies, BM studies, Lab. Test: CBC (PS), Iron Studies, BM studies, Opinion of HematologistOpinion of Hematologist
IDAIDA:: 200 mg Elemental Iron200 mg Elemental Iron
MonitoringMonitoring
IUGR
IUD IUH
CCF
INFECTION
PRETERM LABOUR
PIH
Medical Disorde
r
Supplement FormsSupplement FormsSupplement FormsSupplement Forms
Elemental IronElemental Iron
Ferrous saltsFerrous salts 60 mg 60 mg(Sulphate, Ascorbate, Citrate,(Sulphate, Ascorbate, Citrate,Lactate, Carbonate)Lactate, Carbonate) Ferrous fumarateFerrous fumarate 65 mg65 mg Ferrous gluconateFerrous gluconate 36 mg36 mg Sustained releaseSustained release 105 mg105 mg
Polysaccharide iron complexPolysaccharide iron complex Carbonyl ironCarbonyl iron
Iron & Ascorbic Acid.Iron & Ascorbic Acid.
Vit. C enhances the absorption of iron.Vit. C enhances the absorption of iron.
Fewer side effects.Fewer side effects.
Better tolerated.Better tolerated.
Good bioavailability.Good bioavailability.
Ferric hydroxide Ferric hydroxide polymaltose complex.polymaltose complex.
Expensive.Expensive.
Bioavailability Bioavailability controversial.controversial.
Small Iron Particles - 5Small Iron Particles - 5mm
Slow absorption.Slow absorption.
Good bioavailability Good bioavailability
Least GI side effect Least GI side effect
Environment stability.Environment stability.
Seems to be promising in Seems to be promising in rise of Hb status.rise of Hb status.
Constipation
Diarrhea
Gastric irritation
PROBLEMS WITH ORAL IRON
Free Radical Generation
If a child consumes 3 adult iron tablets, If a child consumes 3 adult iron tablets, acute fatal iron poisoningacute fatal iron poisoning can occur. can occur.
Highly controversial.Highly controversial.High side effects & adverse reaction.High side effects & adverse reaction.Should have hematology consultation.Should have hematology consultation.
I.V. (TDI)I.V. (TDI) // I.M.I.M.
Iron Dextran (Imferon)Iron Dextran (Imferon) Recent:Recent:
IV Sodium ferric gluconate.IV Sodium ferric gluconate. Iron sucrose.Iron sucrose. Used with recombinant erythropoietin therapy.Used with recombinant erythropoietin therapy.
Acute blood loss.Acute blood loss.
Preparation of cesarean.Preparation of cesarean.
Obstetric complications.Obstetric complications.
??? to raise Hb in last trimester??? to raise Hb in last trimester
Requirement: 400 Requirement: 400 g/dayg/day Megaloblastic anemia.Megaloblastic anemia.
S. folate.S. folate. RBC folateRBC folate Macrocytosis.Macrocytosis.
Rich in:Rich in: Bananas, fruits, green leafy Bananas, fruits, green leafy
vegetable, yeast.vegetable, yeast. Periconception, pregnancy, Periconception, pregnancy,
lactation.lactation.
Rich source:Rich source: Diary products.Diary products. Animal products.Animal products. Egg.Egg. Fish oil.Fish oil.
RDA – 2.4 RDA – 2.4 g/day.g/day.
It is paradoxical but It is paradoxical but true, that anaemia is true, that anaemia is preventable condition, preventable condition, however due to its however due to its multifactoral origin we multifactoral origin we could not conquer it could not conquer it and even today it and even today it remains one of the remains one of the major cause of major cause of maternal mortality.maternal mortality.
DREAMING DREAMING PREGNANT WOMANPREGNANT WOMAN
FREE OF FREE OF NUTRITIONAL NUTRITIONAL
ANEMIAANEMIAKeep the lamp of knowledge burning to achieve Keep the lamp of knowledge burning to achieve the vision. Only the vision will ignite the billion the vision. Only the vision will ignite the billion souls. Ignited soul is the most powerful resource souls. Ignited soul is the most powerful resource making dream to reality.making dream to reality.
A. P. J. Abdul KalamA. P. J. Abdul Kalam