anaemia in pregnancy
DESCRIPTION
o&g update course 2012 hospital segamatTRANSCRIPT
ANAEMIA COMPLICATING PREGNANCY
DR:HUSSEIN H AKL
O&G SPECIALIST
HOSPITAL SEGAMAT
Definition
¨ Anemia - insufficient Hb to carry out O2 requirement
to the 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 - insufficient Hb to carry out O2 requirement
to the 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
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
Degree Hb% Haematocrit (%)
Moderate 7-10.9 24-37%
Severe 4-6.9 13-23%
Very Severe <4 <13%
Degree Hb% Haematocrit (%)
Moderate 7-10.9 24-37%
Severe 4-6.9 13-23%
Very Severe <4 <13%
WHO Classification of Anaemia WHO Classification of Anaemia
Magnitude of ProblemMagnitude 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
¨ 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
Infection
Lack of Concentration
Weakness
Irritability
Palpitation
Fatigue
Dizziness
SymptomsSymptoms
Clinical FeaturesClinical Features
Pallor of skin And m/m
Edema
PlatynychiaKoilonychia PlatynychiaKoilonychia
Glossitis
Stomatitis
Tachycardia
Soft ejectionsystolic murmur
Signs
IRON DEFICIENCY ANEMIA
¨ GENERAL ANEMIA’S SYMPTOMS:
•FATIGABILITY
•DIZZENES
•HEADACHE
•SCOTOMAS
•IRRITABILITY
•ROARING
•PALPITATION
•CHD, CHF
pallor
Conjunctival Pallor
Koilonychia
¨ ¨
CHARACTERISTICS SYMPTOMS
•GLOSSITIS, STOMATITIS• DYSPHAGIA ( Plummer-Vinson syndrome)
•ATROPHIC GASTRITIS
•DRY, PALE SKIN
•SPOON SHAPED NAILS, KOILONYCHIA,
•BLUE SCLERAE
•HAIR LOSS
•PICA (APETITE FOR NON FOOD SUBSTANCES SUCH AS AN ICE, CLAY)
•SPLENOMEGALY (10%)
•INCREASED PLATELET COUNT
Physiological
Pathological
Causes of Anaemia Causes of Anaemia
¨ Nutritional
¨ Haemorrhagic
¨ Haemolytic
¨ Nutritional
¨ Haemorrhagic
¨ Haemolytic
Common Anaemias in pregnancy
Common 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
Iron RequirementIron Requirement
Iron Absorption 11 Amount of iron in the
body Amount of iron in the
body
Iron Loss
Skin
Urine
Feces
Menstruation
1-2mg/d1-2mg/d
20-30mg/c20-30mg/c
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 MCH
¨ 2-3 fold increase in Fe requierment.
¨ 10-20 Fold increase in folate requirement
Criteria for Physiologic Anemia
¨ Hb: 10gm%
¨ RBC: 3.2 million/mm3
¨ PCV: 30%
¨ Peripheral smear showing normal morphology of RBC with central pallor
Significance of Hypervolemia
1. To meet the demands of the enlarged uterus with its greatly hypertrophied vascular system.
2. To protect the mother, and in turn the fetus, against the deleterious effects of impaired venous return in the supine and erect positions.
3. To safeguard the mother against the adverse effects of blood loss associated with parturition.
¨ Normal hemoglobin by gestational age in pregnant women taking iron supplement
¨ 12 wks 12.2 [11.0-13.4]
¨ 24wks 11.6 [10.6-12.8]
¨ 40 wks 12.6 [11.2-13.6]
Early Pregnancy
2.5 mg / day
32 to 40 weeks
6.8 mg / day
TOTAL800 – 1000
mg
20 to 32 weeks
5.5 mg / day
Iron Requirement During PregnancyIron Requirement During Pregnancy
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 -------1360mg
¨ 350mg subtracted (saved as a result of amennorrhoea)
¨ So actual extra demand ----------------------1000mg
¨ Full iron stores --------------------------------1000mg
Hb 13.5 – 14 gm %
R.B.C. 4.5 – 4.7 million/cu mm
Serum Iron 50 – 150 μg / dL
TIBC 300 – 360 μg / dL
Transferrin saturation 25 – 50 %
S. Ferritin level 30 μg / Lit
Red Cell protoporphyrin 30 μg / dL
Erythropoietin 15.20 U / Lit
MCV 76 – 100 fL
MCH 27 – 33 pg
MCHC 33.37 gm / dL
PCV 32 – 40 %
Normal LevelsNormal Levels
ETIOLOGY OF IRON DEFICIENCY ANAEMIA
Depleted iron stores – dietary lack, chronic renal failure, worm infestation, chronic menorrhagia
Chronic infections: ( like malaria)
Repeated pregnancies :
- with interval < 1 year
- blood loss at time of delivery
- multiple pregnancy.
IRON DEFICIENCY ANEMIA¨ ETIOLOGY:
–CHRONIC BLEEDING
•MENORRHAGIA
•PEPTIC ULCER
•STOMACH CANCER
•ULCERATIVE COLITIS
•INTESTINAL CANCER
•HAEMORRHOIDS
–DECREASED IRON INTAKE
–INCREASED IRON REQUIRMENT (JUVENILE AGE, PREGNANCY, LACTATION)
CLINICAL FEATURES
Symptoms usually in severe anaemia
- Fatigue
- Giddiness
- Breathlessness
EFFECTS OF ANAEMA IN PREGNANCY
¨ . Mother :
– High output- due to inadequate tissue oxygenation, increase cardiac failure (more likely if reqirement 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.
IUGR
IUD ABORTION
CCFCCF
INFECTIONINFECTION
PRETERM LABOUR
PRETERM LABOUR
PIHPIH
Medical DisorderMedical Disorder
Complications - PregnancyComplications - Pregnancy
Instrumental delivery
PPH
FoetalDistressCCF
MATERNALPERINATAL
MorbidityMortality
Complications - LabourComplications - Labour
Laboratory Diagnosis of AnaemiaLaboratory Diagnosis of Anaemia
IDA Thalassemia Chronic Diseases
Serum Iron Decreased Normal / Increased Decreased
TIBC Increased Normal Decreased or N
Transferrin
Saturation
Decreased N or Increased N or Decreased
Serum Ferritin Decreased N or Increased N
Marrow Iron Decreased / absent
N or Increased N
Therapeutic test with oral iron
Rise in Hb No rise in Hb No rise
¨ 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
¨ 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.
BLOOD AND BONE MARROW SMEAR
¨ BLOOD:¨ microcytosis, hipochromia, anisocytosis
poikilocytosis
¨ BONE MARROW¨ high cellularity ¨ mild to moderate erythroid hyperplasia (25-35%;
N 16 – 18%) ¨ polychromatic and pyknotic cytoplasm of
erythroblasts is vacuolated and irregular in outline (micronormoblastic erythropoiesis)
¨ absence of stainable iron
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 anaemia
Gestational Age.Presence of additional risk factor
National Nutrition Anaemia Prophylaxis Programme (NNAPP 1971 - 72)
National Nutrition Anaemia Prophylaxis Programme (NNAPP 1971 - 72)
Anaemia continues – Major health problem
Nutritional Anaemia :Major Health ProblemsNutritional Anaemia :
Major Health Problems
FS + FA
Pregnancy
Lactating mothers
Family planning acceptors
Children – 1 to 11 years
Reason For Increased Incidence Of Anemia
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
¨ 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
¨ 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)
¨ 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)
Reason For Increased Incidence Of Anemia
Reason For Increased Incidence Of Anemia
Management Options Management Options
Pre – pregnancy :
¨ Treat the cause before conception
¨ Pre-pregnancy balanced diet, education
and health support.
¨ Build up iron stores during adolescent
phase
Pre – pregnancy :
¨ Treat the cause before conception
¨ Pre-pregnancy balanced diet, education
and health support.
¨ Build up iron stores during adolescent
phase
Oral Iron
Blood transfusionParenteral
Injectable IronInjectable IronHuman Recombinant
Erythropoietin
Modalities of ManagementModalities of Management
100 mg elemental Iron ------- ↑ 0.18 gm % day100 mg elemental Iron ------- ↑ 0.18 gm % day
Iron stores poor
-ve-ve
Iron absorption
↓ Bioavailability
of Iron
-ve-ve-ve-ve
Phosphate phytate
Worm infestation
Oral IronOral Iron
Oral Iron Therapy 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
¨ 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
¨ 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
¨ 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.
• 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.
Absorption of Ferrous SaltsAbsorption of Ferrous SaltsUncontrolled Passive AbsorptionUncontrolled Passive Absorption
Fe+2Fe+2
Fe+2Fe+2
Dissociation
Passive diffusion
Fe+2
Fe+2
Fe+3
Fe+2
Fe+3
Gut Lumen Mucosal Cell Blood
Ferritin
Iron salts
Fe+3
Free Radical
Fe+2
Fe+2
Fe+2
Fe+2
Fe+2Fe+2
Fe+2
Fe+3
Free Radical
Transferrin
Incorporation into Hb
↑ Hb – 0.21 gm %
Fractionated Irondextran[Iron hydroxide dextran complex]
Les s
Les s
Les
s Les
s
Parenteral TherapyParenteral Therapy
100 mg elemental Iron
Anaphylactic reaction
Anaphylactic reaction
I.M. I.V.
Parenteral Therapy : Traditional IndicationsParenteral Therapy :
Traditional Indications
¨ Intolerance to oral iron
¨ Poor compliance to oral iron
¨ Gastrointestinal disorders
¨ Malabsorption syndromes
¨ Rapid blood loss
¨ Intolerance to oral iron
¨ Poor compliance to oral iron
¨ Gastrointestinal disorders
¨ Malabsorption syndromes
¨ Rapid blood loss
IRON DEFICIENCY ANEMIACURE
¨ PARENTERAL IRON SUBSTITUTION
¨ Bad oral iron tolerance (nausea, diarrhoea)
¨ Negative oral iron absorption test
¨ Necessity of quick management (CHD, CHF)
¨ 50 - 100 mg daily
¨ I.v only in hospital (risk of anaphilactic shock)
¨ I.m in outpatient department
¨ iron to be injected (mg) = (15 - Hb/g%/) x body weight (kg) x 3
¨ TDI(in mg)=2.3xWxD+500
¨ 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
¨ 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
Parenteral Therapy : Traditional IndicationsParenteral Therapy :
Traditional Indications
The
World Health Organisation states…
‘transfusion should be
prescribed ONLY for
conditions for which there
is NO OTHER TREATMENT’
FOLATE DEFICIENCY ANAEMIA
At cellular level
Folic acid reduced to Dihydrofolicacid then
Tetrahydro-folicacid . (THF) c 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.
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.
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.
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.
Vitamins B12 Deficiency
¨ It is rare
Occurs in patients with gastrectomy , ileitis, illeal resection, pernicious anaemia, intestinal parasites.
¨ Diagnosis:
–Peripheral smear
–Vitamin B12 level < 80 pico g/ml¨ Treatment of B12 Deficiency:
¨ Vit B12 1mg I/M weekly for 6 weeks.
Diagnosis of Folate Deficiency Anemia (FDA)
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
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 ProblemsMegaloblastic Anemia- Diagnostic Problems
¨ HB estimation
¨ Peripheral smear
¨ MCV estimation
¨ Serum folate
¨ Red cell folate
¨ FIGLU estimations
¨ Marrow aspirate
¨ HB estimation
¨ Peripheral smear
¨ MCV estimation
¨ Serum folate
¨ Red cell folate
¨ FIGLU estimations
¨ Marrow aspirate
Management of FDAManagement of FDA
¨ Strong case for routine prophylaxis
¨ Prophylaxis with anti convulsants
¨ Continue routine oral therapy for
hemolytic anaemia
¨ Parenteral therapy for severe deficiency
¨ Strong case for routine prophylaxis
¨ Prophylaxis with anti convulsants
¨ Continue routine oral therapy for
hemolytic anaemia
¨ Parenteral therapy for severe deficiency
Worm InfestationsWorm 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
¨ 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
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
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.
HAEMOGLOBINOPATHIES
DEFINITION:
¨ Inherited disorders of haemoglobin.
¨ Defect may be in:
- Globin chain synthesis------thalassemia.
- 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)
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
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)
¨ 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)
Beta thalassemia minor
¨ Beta Thalassemia trait
¨ Heterozygous 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.
Beta Thalassemia 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.
Beta Thalassaemia 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 thalassaemia trait.
¨ HbH disease.
¨ Alpha thalassaemia major.
Diagnosis of Thalassemia
¨ Hb estimations
¨ Peripheral smear
¨ sed MCV
¨ sed MCH
¨ HbA2 ( 22)
¨ Hb estimations
¨ Peripheral smear
¨ sed MCV
¨ sed MCH
¨ HbA2 ( 22)
Diagnostic Strategy for Thalassemias
Hb Electrophoresis + CBC
Abnormal band
Normal No action
MCV MCH
Quantitative Hb electrophoresis
Raised Hb A2
B Thalassemia
Normal
sed Examine partners blood
? X Thalassemia
DNA analysis for x gene defects
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.
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
Sickle Cell DiseaseSickle 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.
¨ 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.
SCD
¨ Diagnosis:
- Hb. Electrophoresis
¨ Management:
- 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
Management During labour
¨ Comfortable Position
¨ Adequate analgesia
¨ O2 inhalation
¨ Low threshold of assisted delivery
¨ Avoid ergometrine
¨ Prophylactic antibiotics
¨ Continue iron &folate therapy for 3 mo after delivery
¨ Appropriate contraceptive advice
Take Home MessageTake 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
¨ 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
¨ 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
¨ 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
Take Home MessageTake Home Message
Thank YouThank You
Egypt