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

ANEMIA DEFISIENSI BESI PADA

KEHAMILAN

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

Irritability

Lack of
Concentration

Fatigue
Infection
Palpitatio
n

Weakness
Dizziness

Clinical Features
Pallor of skin
And m/m

Soft ejection
systolic
murmur

Edema

Signs
Platynychia
Platynychia
Koilonychia
Koilonychia

Tachycardia
Glossitis
Stomatitis

Causes of Anaemia
Physiological
Pathological

Nutritional

Haemorrhagic

Haemolytic

Iron Requirement
Iron Absorption

1
Amount of iron in the
body
Skin

Iron Loss

Urine

1-2mg/d

Feces
Menstruation

20-30mg/c

Iron Requirement During Pregnancy

32 to 40
weeks
Early
Pregnancy

TOTAL
800 1000
mg

20 to 32
weeks

6.8 mg / day

5.5 mg / day

2.5 mg / day
RBC
=500mg
Fetus+Placenta
=450mg
Third stage blood loss
=200mg
Total
=

Normal Levels
Hb

13.5 14 gm %

R.B.C.

4.5 4.7 million/cu mm

Serum Iron

50 150 g / dL

TIBC

300 360 g / dL

Transferrin saturation

25 50 %

S. Ferritin level

30 g / Lit

Red Cell protoporphyrin

30 g / dL

Erythropoietin

15.20 U / Lit

MCV

76 100 fL

MCH

27 33 pg

MCHC

33.37 gm / dL

PCV

32 40 %

Laboratory Diagnosis of Anaemia

IDA

Thalassemia

Chronic Diseases

Serum Iron

Decreased

Normal / Increased

Decreased

TIBC

Increased

Normal

Decreased or N

Transferrin

Decreased

N or Increased

N or Decreased

Serum Ferritin

Decreased

N or Increased

Marrow Iron

Decreased /
absent

N or Increased

No rise in Hb

No rise

Saturation

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

IUD

CCF
PIH

INFECTION

Medical
Disorder

PRETERM
LABOUR

IUH

Complications - Labour
PPH
Instrumental
delivery

MATERNAL
PERINATAL

CCF

Foetal
Distress

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

Injectable Iron

Blood
transfusion

Human Recombinant
Erythropoietin

Oral Iron
100 mg elemental Iron ------- 0.18 gm % day
-ve

Phosphate
phytate

Iron absorption
-ve

Bioavailability
of Iron
Iron stores poor

-ve

Worm
infestation

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.

Parenteral Therapy
I.V.

I.M.
100 mg
elemental Iron
Anaphylactic
reaction

Anaphylactic
reaction

Fractionated Irondextran
[Iron hydroxide dextran
complex]

Les
s

Les
s

Hb 0.21 gm %

Parenteral Therapy :
Traditional Indications

Intolerance to oral iron

Poor compliance to oral iron

Gastrointestinal disorders

Malabsorption syndromes

Rapid blood loss