anaemia in pregnancy.ppt

35
ANAEMIA IN PREGNANCY BY Dr. Shumaila Zia

Upload: umar-dhani

Post on 26-Oct-2014

1.177 views

Category:

Documents


5 download

TRANSCRIPT

Page 1: Anaemia in Pregnancy.ppt

ANAEMIA IN PREGNANCY

BY

Dr. Shumaila Zia

Page 2: Anaemia in Pregnancy.ppt

ANAEMIA IN PREGNANCY

Commonest medical disorder. High incidence in underdeveloped countries Increased Maternal morbidity & mortality Increased perinatal mortality

Page 3: Anaemia in Pregnancy.ppt

ANAEMIA IN PREGNANCY

Definition: By WHO

Hb. < 11 gm /dl

(or haematocrit <32%).

Mild anaemia -------- 9 -10.9 gm /dl

Moderate anaemia--- 7-8.9 gm /dl

Sever anaemia-------- < 7gm /dl

Very sever anaemia-- < 4gm/dl

Page 4: Anaemia in Pregnancy.ppt

ETIOLOGY

There are 3 main causes:

1- Erythrocyte production: (hypo proliferative anemia )

. Fe deficiency

. Folic acid

. Vitamin B12

2- RBC destruction:

3- RBC loss:

90% anemia in pregnancy is due to Fe deficiency

Page 5: Anaemia in Pregnancy.ppt

Physiological changes in pregnancy

• Plasama volume 50% (by 34weeks)• But RBC mass only 25% • Results in haemodilution : • Hb

Haematocrit

RBC count No change in MCV or MCH2-3 fold increase in Fe requierment.10-20 Fold increase in folate requirement

Page 6: Anaemia in Pregnancy.ppt
Page 7: Anaemia in Pregnancy.ppt

Common Anaemias in pregnancyCommon types: Nutritional deficiency anaemias

- Iron deficiency

- Folate deficiency

- Vit. B12 deficiency Haemoglobinopathies:

- Thallassemias

- SCD

Rare types:

- Aplastic

- Autoimmune hemolytic

- Leukemia

- Hodgkin’s disease

- Paroxysmal nocturnal haemoglobinurea

Page 8: Anaemia in Pregnancy.ppt

IRON DEFICIENCY ANAEMIA

Iron required for fetus and placenta ------- 500mg.Iron required for red cell increment ------- 500mg Post partum loss --------- 180mg. Lactation for 6 months - 180mg. Total requirement -------1360mg350mg subtracted (saved as a result of

amennorrhoea)So actual extra demand ----------------------1000mgFull iron stores --------------------------------1000mg

Page 9: Anaemia in Pregnancy.ppt

ETIOLOGY OF IRON DEFICIENCY ANAEMIA Depleted iron stores – dietary lack, chronic renal failure,

worm infestation, chronic menorrhagiaChronic infections: ( like malaria) Repeated pregnancies : - with interval < 1 year - blood loss at time of delivery - multiple pregnancy.

CLINICAL FEATURES Symptoms usually in severe anaemia - Fatigue - Giddiness - Breathlessness

Page 10: Anaemia in Pregnancy.ppt

EFFECTS OF ANAEMA IN PREGNANCY

. Mother : High output Cardiac failure (more likely if precelampsia

present. inadequate tissue oxygenation increase requirments for excessive blood flow )

PPH Predisposes to infection Risk of thrombo-embolism Delayed general physical recovery esp after c. section Fetus: . IUGR

. Preterm birth

. LBW

. Depleted Fe store

. Delayed Cognitive function.

Page 11: Anaemia in Pregnancy.ppt

INVESTIGATIONS

Hb Haematocrit RBC Indices: - Low MCV

- Low MCH - Low MCHC - Low PCV Peripheral blood picture : Microcytic Hypochromic anaemia .

Page 12: Anaemia in Pregnancy.ppt

Serum iron decreased (<12 micro mol / l)

Total iron binding capacity :TIBC in non-pregnant state is 33% saturated with iron .when serum iron level fall ,<15% ofTIBC saturated.by fall in saturation,the TIBC INCREASED.

S. ferritin :In healthy adults ferritin circulate in plasma in range of 15_300 pg/l. in iron deficiency anemia it is the first test to become abnormal.

INVESTIGATIONS

Page 13: Anaemia in Pregnancy.ppt

Serum transferrin receptor(TfR) : present on all cells as transmembrane protien that binds transferrin iron and transfer it to cell interior. Increased in iron def. anemia.

Bone marrow examination.RFTS/LFTS.Urine for haemturia.Stool examination for ova ,cyst and occult

blood.

Page 14: Anaemia in Pregnancy.ppt

MANAGEMENT

Objectives: 1- To achieve a normal Hb by end of pregnancy 2- To replenish iron stores Two ways to correct anaemia: I- Iron supplementation . Oral Fe . Parenteral Fe II- Blood transfurion Choice of method: It depends on three main factors:

Severity of the anaemiaGestational Age.Presence of additional risk factor

Page 15: Anaemia in Pregnancy.ppt

MANAGEMENTRecommended supplementation for non-anaemiac

30 - 60mg /day of elemental ironAnaemic gravidas 120 –240mg / per dayIn tolerance to iron tablets – enteric coated tablet /

liquid suspensionSupplementation with folic acid + Vit C.Therapeutic results after 3 weeks – rise in Hb %

level of 0.8gm/dl/ week with good compliance.Treatment continued in the postpartum period to

fill the stores

Page 16: Anaemia in Pregnancy.ppt

MANAGEMENT

Severe anaemia: (Hb < 8gm/dl)- preferably parenteral theraphy in the form of I/M or I/V iron

- I/M : ( Iron sorbitol) with “Z” technique

- I/V : (iron sucrose)Iron neede =

(Normal Hb – Pt. Hb)* Wt in Kg*2.21+1000)

Page 17: Anaemia in Pregnancy.ppt

MANAGEMENT

Dose given I/M or I/V by slow push 100mg / day or the entire dose given in 500 ml N/S slow I/V infusion over 1-6 hours

Marked increase in reticulocyte count expecred in 7-14 d

Blood transfusion: may be required to treat severe anaemia near term or when

some other complication such as placenta praevia present. Gross anaemia

Packed red cells transfusion (Under cover of loop diuretic)

Exchange transfusion (Under cover of loop diuretic)

Page 18: Anaemia in Pregnancy.ppt

MANAGEMENT

Side effect of Fe Oral therapy:

. G. I upset.

. Constipation.

. Diarrhoea.

Parentral:

- skin discolouration

- local abscess

- allergic reaction

- Fe over load.

Page 19: Anaemia in Pregnancy.ppt

MEGALOBLASTIC ANAEMIAComplicates upto 1% of pregnanciesCharacterized by :

- RBC with high MCV

- White blood cells with altered morphology

(hypersegmented neutrophils).

Usually caused by :

- Folate deficiency may occur after exposure

to sulfa drugs or hydroxyurea

- Vitamin B12 deficiency

Page 20: Anaemia in Pregnancy.ppt

FOLATE DEFICIENCY ANAEMIAAt cellular level

Folic acid reduced to Dihydrofolicacid then

Tetrahydro-folicacid . (THF) e is required for cell growth & division.

So more active tissue reproduction & growth more

dependant on supply of folic acid.

So bone marrow and epithelial lining are therefore at particular risk.

Page 21: Anaemia in Pregnancy.ppt

FOLATE DEFICIENCY ANAEMIA

Folic acid deficiency more likely if. Woman taking anticonvulsants.. Multiple pregnancy.. Hemolytic anemia; thalasemia

H.spherocytosis Maternal risk: Megaloblastic anemia Fetal risk: Pre-conception deficiency cause neural

tube defect and cleft palate etc.

Page 22: Anaemia in Pregnancy.ppt

FOLATE DEFICIENCY ANAEMIA

Diagnosis: Increased MCV ( > 100 fl)

Peripheral smear: - Macrocytosis, hypochromia

- Hypersegmented neutrophils (> 5 lobes) - Neutropenia - Thrombocytopenia

Low Serum folate level. Low RBC folate.

Page 23: Anaemia in Pregnancy.ppt

FOLATE DEFICIENCY ANAEMIA

Daily folate requirement for : Non pregnant women -- 50 -100 microgram Pregnant woman –-------- 300-400 microgram Usually folic acid present in diets like fresh fruits

and vegetables and destroyed by cooking.

Folate deficiency: - 0.5-1.0mg folic acid/day

If F/Hx. of neural tube defect - 4mg folic acid/day.

Page 24: Anaemia in Pregnancy.ppt

Vitamins B12 DeficiencyIt is rare

Occurs in patients with gastrectomy , ileitis, illeal resection, pernicious anaemia, intestinal parasites.

Diagnosis:Peripheral smearVitamin B12 level < 80 pico g/ml

Treatment of B12 Deficiency: Vit B12 1mg I/M weekly for 6 weeks.

Page 25: Anaemia in Pregnancy.ppt

HAEMOGLOBINOPATHIES.

Normal adult Hb. after age of 6 month,HbA---97%, HbA2---(1.5-3.5%), HbF2--<1%.4 Globin chains associated with haem complex.Hb. A = 2 alpha +2 beta globin chains.Hb.A2= 2alpha+2 delta globin chains.Hb.F = 2 alpha+ 2 gamma globin chains.Hb. synthesis is controlled by genes.Alpha chains by 4 gene,2 from each parent.Beta chains by 2 genes ,1 from each parent.

Page 26: Anaemia in Pregnancy.ppt

HAEMOGLOBINOPATHIESDEFINITION: Inherited disorders of haemoglobin.Defect may be in:

- Globin chain synthesis------thallassemia.

- Structure of globin chains-sickle cell disease.Hb.abnormalities may be:

- Homozygous = inherited from both parents.

(Sufferer of disease)

- Hetrozygous = inherited from one parent.

(Carrier/trait of disease)

Page 27: Anaemia in Pregnancy.ppt

THALASSAEMIAS

The synthesis of globin chain is partially or completely suppressed resulting in reduced Hb. content in red cells,which then have shortened life span.

TYPES:

- Alpha thalassaemia.

- Beta thalassaemia:

. Major

. minor

Page 28: Anaemia in Pregnancy.ppt

Beta thallassemia minor

Beta Thallassemia traitHeterozygous inheritance from one parent.Most frequent encountered variety.Partial suppression of the Hb. synthesis.Mild anaemia.

Investigations: Hb----around 10 g/dl. Red cell indices: low MCV.

low MCH.

normal MCHC.Diagnostic test: Hb. Electrophoresis.

Page 29: Anaemia in Pregnancy.ppt

Beta Thallassemia Minor

Management:Same as normal woman in pregnancy.Frequent Hb. Testing.Iron & folate supplements in usual dose.Parenteral iron should be avoided. because of

iron overload.If not responded ---I/M folic acid. blood transfusion close to time of delivery.

Page 30: Anaemia in Pregnancy.ppt

Beta Thallassaemia Major

Homozygous inheritance from both parents.Sever anaemia.Diagnosed in paediatric era.T/m: is blood transfusion.

ALPHA THALASSAEMIA:Both heterozygous & homozygous forms exist.Alpha thallassaemia trait.HbH disease.Alpha thallassaemia major.

Page 31: Anaemia in Pregnancy.ppt

SICKLE CELL SYNDROME.

Autosomally inherited .Structural abnormality.HbS - susceptible to hypoxia, when oxygen

supply is reduced.Hb precipitates & makes the RBCs rigid &

sickle shaped.Heterozygous----HbAS.Homozygous-----HbSS.Compound heterozygous---HbSC etc.

Page 32: Anaemia in Pregnancy.ppt

Sickle Cell Disease (SCD)

Sickeling crises frequently occurs in pregnancy, puerperium &in state of hypoxia like G/A and Hag.

Increased incidance of abortion and still birth

growth restriction, premature birth and intrapartum fetal distress with increased perinatal mortality.

Sickle cell trait:(carrier state)

Does not pose any significance clinical problems

Page 33: Anaemia in Pregnancy.ppt

SCD

Diagnosis:

- Hb. Electrophoresis

- Sickledext test is screening testManagement:

- No curative Tx.

- only symptomatic

- Well hydration, effective analgesia, prophylactic

antibiotics, O2 inhalation, folic acid, oral iron

supplement (I/V iron is C/I), blood transfusion

Page 34: Anaemia in Pregnancy.ppt
Page 35: Anaemia in Pregnancy.ppt

Management During labour

Comfortable PositionAdequate analgesiaO2 inhalationLow threshold of assisted deliveryAvoid ergometrineProphylactic antibioticsContinue iron &folate therapy for 3 mo after

deliveryAppropriate contraceptive advice