MBChB IV-Anemia in pregnancy

DR. T. NHEMACHENA 2009/09/08

Anemia in Pregnancy-Objectives
To know the normal physiological hematological changes in pregnancy. To define anemia in pregnancy To list the common causes of pregnancy anemia To know the investigations to confirm the diagnosis of the different types of anemia To be able to manage pregnancy anemia

Anemia: Objectives
Definition: WHO (Hb<11g/dL)vs CDC(<10.5g/dL), HCT< 30%. Causes: acquired vs congenital Clinical features Pathogenesis Diagnosis: IDA/Folate/B12/HbSS. Management

Physiological Changes in Pregnancy

Plasma volume progressively during normal pregnancy (50% by 32-34 wks) and positively correlated to birth weight of baby 50%PV v 18%RCM Hb, Hct and red cell count (hemodilution). No change in MCV/MCH Pregnancy causes a 2-3fold in Fe++ ,& a 1020-foldin folate requirements. Change in coagulation systems physiological hypercoagulable state

Physiological Changes
Where is iron absorbed in the GIT & in what form is it absorbed? In pregnancy, additional demands for iron represent:
Fetus+ placenta RBC increase Postpartum bleeding/lactation Loss thru gut, urine & skin 500mg 500mg 180mg 200mg

Causes of anemia in Pregnancy

Acquired Hereditary IDA Hemoglobinopathy Folate deficiency HbSS/HbSC Acute blood loss Thalassemias AIDS/Hodgkins disease Drug-induced hemolytic anemia Leukemia/Aplastic anemia Nutritional B12 deficiency

Consequence of Anemia in pregnancy

20% of maternal deaths in Africa esp after obstetric hemorrhage physical work capacity maternal morbidity (PPH, puerperal sepsis, thrombo-embolism). risk of pre-term birth fetal morbidity & mortality An association with LBW

Management of Anemia in pregnancy

Determine etiology of anemia

IDA
Most common cause of pregnancy anemia(75%-90%). Most pts present 3rd trimester when Fe demands reach their peak(1-2mg/day non-pregnant,2.5mg/day 1st trimester,6.6mg/day 3rd trimester). IDA common in pregnancy because many enter it with depleted Fe stores (MBL,PEM-inadequate diet, previous recent pregnancies). Multiple pregnancy IDA. Blood loss at delivery IDA in puerperium Birth spacing & avoidance of teenage pregnancies allow deposition of Fe stores after pubertal growth spurt or a previous pregnancy

IDA-Presentation/Prevention
Revise Haematology/ Internal medicine Lectures for Clinical Presentation Prevention of IDA:1998-WHO/UNICEF recommend routine supplements (60mg Fe & 400g folate daily to all pregnant women for 6/12 & extending to 3/12 postpartum in areas with a high prevalence(>40%) of anemia

Investigations IDA
Visualization of peripheral blood smear RBC indices MCV;MCH;MCHC(<30)- All NB. Hb estimation alone is unreliable. Serum Fe <12mol/l, TIBC saturation<15%, serum ferrritin<12g/l Stool /Urine for M/C/S

Treatment of IDA
Dietary advice-red meat/fish/green leafy vegetables/avocadoes Fe therapy-oral vs parenteral(I.M. or I.V.) vs blood transfusion. NB Jehovah Witnesses- Blood substitutes/ parenteral Fe/Recombinant erythropoetin. Moderate reticulocytosis in 7-10 days confirms a satisfactory response.

Folate-deficiency Anemia
Normal dietary folate inadequate to prevent megaloblastic changes in the BM in~25% pregnant women. Incidence- function of SES & the nutrition of the population. FDA-more likely if pt on AEDs, or has hematological conditions like hemolytic anemiaHS/thalassemia;intestinal malabsorption/gluten sensitivity/overcooking of fresh green vegetables/excessive alcohol consumption, grand multiparity with short intervals between pregnancies

FDA
FDA =macrocytic anemia with megaloblastic change in the BM NB a MCV can be a feature of normal pregnancy. Confirm by (serum &) RBC folate levels PMN hypersegmentation, megaloblasts & Howell-Jolly bodies in peripheral blood smear;neutropenia/thrombocytopenia NB: All women planning a pregnancy are advised to take 400g of folate 3/12 before & 3/12 after conception to risk of NTDs & other fetal abnormalities (MRC Vitamin Study Research Group-1991). Pts with FDA or with a prev fetus with NTD or those on AEDs to take 5mg /day thru-ot pregnancy.

Vitamin B12 deficiency

Megaloblastic anemia due to B12 deficiency is very rare. May be seen in vegans, pts who had partial or total gastrectomies, Crohns disease or ileal resection or in Addisonian pernicious anemia. If suspected serum B12 levels. Treatment:100g of B12 weekly.

Aplastic anemia/Leukemia
These 2 conditions are rarely seen during pregnancy. Aplastic anemia characterized by anemia, thrombocytopenia & agranulocytosis with a markedly hypocellular BM. Drugs, chemicals, infection, irradiation, leukemia & immunological disorders ay trigger it.Rx inlude repeated transfuions of rbc, plts & granlocytes. Steroids have a role as well as BM transplantation. In acute leukemia chemoRx should continue as appropriately chosen drugs are well tolerated by the mother & fetus without evident teratogenic effects.

Acquired Hemolytic anemias

Auto-immune hemolytic anemia-possibly due to warm-active or cold-active autoantibodies or both. May either be primary or secondary to a CT disease, infection, chronic inflammatory disease or drugs. Both DCT & indirect Coombs tests are +ve. Rx: Corticosteriods are effective

Acquire Hemolytic Anemias(H.A.s)

Drug-induced H.A.-usually resolve with withdrawal of the drug causing hemolysis. Examples of drugs that may induce hemolysis includemethyldopa/penicillins/cephalosporins/rifampicin and thiopental; antimalarials in women with G6PD deficiency. Other acquired H.A.s may be due to PET/Eclampsia/HELLP syndrome as well as with septic shock.

Haemoglobinopathies
Sickle-cell Hemoglobinopathies include: 1. Sickle-cell anemia(HbSS disease) 2. Sickle-cell hemoglobin C disease (HbSC) 3. Sickle-cell beta Thalassemia. These are autosomally inherited with substitution of glutamic acid by valine in the -chain.

Sickle-cell Haemoglobinopathies
Factors responsible for sickling include: Hypoxia due to poor oxygenation/circulation Acidosis Dehydration/Cooling Severe infections General anaesthesia

Complications of Sickle-cell Effect on Pregnancy

Fetal- incidence of miscarriage, preterm birth, IUGR, PNMR by 4-6 fold. Incidence of PPH,PET, & infection. Maternal mortality- due to infection, CVA & sickling crises (MM up to 25%pulmoary infarction, CCF,embolism).

Effect of Pregnancy on Sicklecell Disease

chance of crises: 1. Hemolytic crisis-: Hemolysis with rapidly developing anemia + jaundice, WCC + fever. 2. Painful crisis: Due to vaso-occlusion of various organs[bones-osteonecrosis, kidney,liver/spleen,heart] capillary thrombosis infarction.

Sickle cell Disease: Management

Preconceptional Counseling Antepartum period:Folate supplements, avoid airtravel.Fe only if anemic/blood transfusion-keep hct >25% & [Hb-S]<50%,screen for UTI Intra-partum.As for anemia. Avoid dehydrationEpidural anesthesia ideal.C/s for obstetric indications. Postpartum: Prophylactic antibiotics Contraception: Consider BTL given the short life span. COC Pill is contraindicated (TED risk). IUCD is contraindicated- risk of infection.I7-MPA incidence of sickling crises. Barrier method is ideal