ANAEMIA: Preventable, Yet a Problem!!

Definition

Anemia - insufficient Hb to carry out O2 requirement by tissues. WHO definition : Hb conc. 11 gm %

CDC definition : Hb conc. < 11gm % in 1st and 3rd trimesters and < 10.5 gm% in 2nd trimester
For developing countries : cut off level suggested is 10 gm %
- WHO technical report Series no. 405, Geneva 1968 Centre for disease control, MMWR 1989;38:400-4

WHO Classification of Anaemia

Degree Hb% Haematocrit (%)

Moderate Severe Very Severe

7-10.9 4-6.9 <4

24-37% 13-23% <13%

Magnitude of Problem

Globally, is about 30 % In developing countries & India, incidence is around 40 90%. Responsible for 40% of maternal deaths in third world countries. Important cause of direct and indirect maternal deaths
- Vitere FE Adv Exp Med Biol 1994;352:127

Symptoms
Lack of Concentration

Irritability

Infection
Palpitation

Fatigue

Weakness
Dizziness

Clinical Features
Soft ejection systolic murmur
Pallor of skin And m/m

Edema

Signs
Tachycardia Glossitis Platynychia Koilonychia

Stomatitis

Causes of Anaemia

Physiological
Pathological
Nutritional

Haemorrhagic
Haemolytic

Iron Requirement

Iron Absorption

1 Amount of iron in the body

Skin Urine 1-2mg/d

Iron Loss

Feces
Menstruation 20-30mg/c

Iron Requirement During Pregnancy

32 to 40 weeks Early Pregnancy 2.5 mg / day TOTAL 800 1000 mg RBC Fetus+Placenta Third stage blood loss Total =500mg =450mg =200mg = 1150mg 20 to 32 weeks 5.5 mg / day 6.8 mg / day

Normal Levels
Hb R.B.C. 13.5 14 gm % 4.5 4.7 million/cu mm

Serum Iron
TIBC Transferrin saturation

50 150 g / dL
300 360 g / dL 25 50 %

S. Ferritin level
Red Cell protoporphyrin Erythropoietin MCV MCH MCHC PCV

30 g / Lit
30 g / dL 15.20 U / Lit 76 100 fL 27 33 pg 33.37 gm / dL 32 40 %

Laboratory Diagnosis of Anaemia

IDA Serum Iron TIBC Transferrin Saturation Serum Ferritin Decreased N or Increased N Decreased Increased Decreased Thalassemia Normal / Increased Normal N or Increased Chronic Diseases Decreased Decreased or N N or Decreased

Marrow Iron

Decreased / absent

N or Increased
No rise in Hb

N
No rise

Therapeutic test with Rise in Hb oral iron

Nutritional Anaemia : Major Health Problems

National Nutrition Anaemia Prophylaxis Programme (NNAPP 1971 - 72)
Pregnancy FS + FA Lactating mothers Family planning acceptors Children 1 to 11 years Anaemia continues Major health problem

Reason For Increased Incidence Of Anemia

Poor pre-pregnancy iron balance due to untreated systemic diseases & menstrual disorders Improper supplementation of iron in pregnancy ( late registration and poor follow up)

Repeated childbearing
Lack of awareness and illiteracy

Reason For Increased Incidence Of Anemia

Low socioeconomic status and poor hygiene

Chronic malnutrition
Poor availability of iron due to predominantly veg diet, diet low in calories but rich in phytates. Food and religious taboos GI infections and infestations (e.g. Kala azar, worm infestations)

Complications - Pregnancy
IUGR
PIH IUD IUH Medical Disorder
PRETERM LABOUR

CCF
INFECTION

Complications - Labour PPH

Instrumental delivery

CCF

Foetal Distress

MATERNAL PERINATAL

Morbidity Mortality

Management Options
Pre pregnancy :

Treat the cause before conception Pre-pregnancy balanced diet, education

and health support.

Build up iron stores during adolescent

phase

Modalities of Management

Oral Iron

Parenteral

Blood transfusion

Injectable Iron

Human Recombinant Erythropoietin

Oral Iron
100 mg elemental Iron ------- 0.18 gm % day
Iron absorption Phosphate phytate

-ve
Bioavailability of Iron

Worm infestation

Iron stores poor

Oral Iron Therapy

Ideal dose 100mg per day (prophylactic) Ferrous gluconate, ferrous fumarate, ferrous succinate, ferrous sulphate, ferrous ascorbate citrate Rise in Hb 0.8 gm / dl / week Side effects -G I upset most common Pt. compliance not guaranteed Ineffective in pts with worm infestations

Inconclusive evidence on benefit of controlled release Iron preparation

Absorption of Ferrous Salts

Uncontrolled Passive Absorption
Iron salts are dissociated into bivalent or trivalent iron salts

Diffuses as free iron ions through the upper part of the gastrointestinal mucosa
Taken up by transferrin and incorporated into ferritin.

For binding to ferritin and transferrin ferrous iron has to be converted into ferric iron by oxidation
Highly reactive free radicals are produced during this process

All ionic iron including carbonyl iron are absorbed similarly

Borbolla JR. Cicero RE, Dibilox MM, Sotres RD et al.. Rev Mex Pediatr 2000; 67(2): 63-67 Heubers KA, Brittenham GM, Csiba E, Finch CA. J Lab Clin Med 1986 ; 108 ; 473-8.

Gut Lumen
Iron salts

Mucosal Cell
Fe+3

Blood

Free Radical
Transferrin
Fe+2

Ferritin

Dissociation

Fe+2

Fe+2 Fe+2

Fe+2 Fe+2

Fe+2

Fe+3

Passive diffusion
Fe+2 Fe+2 Fe+2 Fe+2 Fe+2 Fe+2

Free Radical
Fe+2
Fe+2

Fe+2

Fe+2

Incorporation into Hb

Parenteral Therapy
I.M. I.V.

100 mg elemental Iron

Anaphylactic reaction Anaphylactic reaction

Hb 0.21 gm %
Fractionated Irondextran [Iron hydroxide dextran complex]

Parenteral Therapy : Traditional Indications

Intolerance to oral iron

Poor compliance to oral iron Gastrointestinal disorders Malabsorption syndromes Rapid blood loss

Parenteral Therapy : Traditional Indications

Inability to maintain iron balance (haemodialysis)

Patient donating large amount of blood for auto-transfusion programme ? Pregnant women with severe IDA, presenting late in pregnancy

The

World Health Organisation

states

transfusion should be
prescribed ONLY for conditions for which there is NO OTHER TREATMENT

Diagnosis of Folate Deficiency Anemia (FDA)

Special considerations in diagnosis

FDA is suspected when the expected response

to adequate iron therapy is not achieved

Macrocytosis can occur in pregnancy in absence

of FDA

If FDA + IDA present, it will be masked by IDA

Definitive diagnosis Bone marrow aspirate

Megaloblastic Anemia - Diagnostic Problems

HB estimation Peripheral smear MCV estimation Serum folate

Red cell folate

FIGLU estimations Marrow aspirate

Management of FDA
Strong case for routine prophylaxis
Prophylaxis with anti convulsants

Continue routine oral therapy for

hemolytic anaemia
Parenteral therapy for severe deficiency

Worm Infestations
Common cause of anaemia in developing countries Most common hookworm infestation, Round

worm, whip worm, etc.

Oral iron therapy becomes ineffective Treatment by antihelminthics is a must

Treatment
Mebendazole : 100mg twice daily for three days Pyrantel pamoate : 10mg / kg in single dose. Albendazole : 400mg once a day for three days

Hemoglobinopathies
A collective term for the inherited disorders of Hb synthesis

Disorders of globin synthesis e.g. Thalassemia

Structural Hb variants e.g. Sickle cell anemia, HbC

Thalassemia

Genetic disorders; lack or sed synthesis of globin chains Two types : & thalassemia chains encoded by 2 pairs of genes on chromosome 16 chains encoded by single pair of genes on chromosome 11 thalassemia more common and presents as either (major) or + (minor)

Diagnosis of Thalassemia

Hb estimations Peripheral smear

sed MCV
sed MCH

HbA2 ( 22)

Diagnostic Strategy for Thalassemias

Hb Electrophoresis + CBC Abnormal band MCV MCH Normal sed No action Examine partners blood

Quantitative Hb electrophoresis Raised Hb A2

Normal

?X Thalassemia

B Thalassemia

DNA analysis for x gene defects

Sickle Cell Disease

Structural Hb variant

Exists in homo & heterozygous forms

Under hypoxic conditions, HbS polymerizes, gels or crystallizes. hemolysis of cells, & thrombosis of vessels in various organs In long standing cases, multiple organ damage.

Take Home Message

Anaemia although preventable is a global problem Anaemia still is the commonest cause of maternal mortality

and morbidity in spite of easy diagnosis and treatment

Anaemia can be due to a number of causes,

including certain diseases or a shortage of iron, folic acid or Vitamin B12.

The most common cause of anemia in pregnancy is

iron deficiency.
Iron therapy is best given orally

Take Home Message

The youth need to be educated about diet, sanitation and personal hygiene Hookworm infestation should be treated Pregnant women should be given Iron and folate supplements

Concept Dr. Duru Shah

Contributors
Dr Dr. Dr.

Editors :
Dr.

Duru Shah Sarita Bhalerao Manisha Bandgar

Sangeeta Agrawal Reena Wani

Dr.

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