Practical Obstetrics & Gynecology Nirmala Saxena, Jyoti Sinha
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Obstetrics

Anemia—A Public Health Issue1

Shyam V Desai,
Nikhil S Jani
Nutritional deficiency anemias are uncommon in the developed countries because of better nutritional because of better nutritional standards, widespread antenatal care and pregnancy supplementation with oral iron compounds, vitamins and dietetic supplementation with oral iron compounds, vitamins and dietetic supplements. However anemia continues to be widely prevalent in the underdeveloped countries of Asia and Africa contributing to a raised maternal mortality and perinatal loss. (Krishna Menon 1965, Reinhardt 1978, Sood SK 1989). Infact the incidence of anemia is believed to be the highest in the South-East Asian countries.
 
 
Definition
According to the WHO standards, anemia is said to be present during pregnancy when the hemoglobin concentration in the peripheral blood is 11 g/dl or less. However a case can be made for lowering the standards to 10 g/dl in the tropics (Paintin 1962).
 
Dimensions of the Problem
Physiological changes in pregnancy contribute to hemodilution and an increase in the circulating blood volume leading to lowering in the levels of circulating hemoglobin. However undernutrition, poverty, poor sanitation, multiparity with poor spacing of births, prevalence of helminthic infestations and parasitic infections including malaria contribute to widespread prevalence of anemia throughout the underdeveloped world.
2 The global prevalence of anemia was around 30 percent in 1980. Out of a global population of 4.4 billion people, 1.3 billion were anemic, out of these 1.2 billion inhabited the countries comprising the underdeveloped world. The women most likely to be affected or those belonging to the lower income groups residing in rural areas and the urban slums.
 
Causes of Anemia
In India, diets which are predominantly vegetarian and lacking in animal proteins, rich in phytates, and low in ascorbic acid contents, the bioavailibility or iron is poor, this coupled with poor iron absorption contributes to widespread prevalence of anemia. The added factor of parasitic infections further aggravates the problem.
Nutritional deficiencies also contribute to folate deficiency in the diets which contribute to the occurrence of dimorphic anemia. The demands of pregnancy further add to enhance its intensity and medical complications arising therefrom.
 
Clinical Features
Women with mild anemia may go through pregnancy and delivery without noticeable clinical effects, however those suffering from more severe forms of the disease may suffer from tiredness, lassitude, general weakness, dizziness, headache, and even breathlessness. As the severity of anemia increases, maternal symptoms get aggravated and the incidence of maternal morbidity and perinatal complications markedly increase. Anemic heart failure, susceptibility to infections and the inability to withstand blood loss contribute to the adverse pregnancy outcome.
 
Diagnosis of Anemia
Relying on clinical features alone to detect anemia during pregnancy may delay diagnosis and contribute to loss of valuable time in initiating treatment. It is therefore mandatory 3to perform a Hb estimation at the very first visit. All women with hemoglobin levels lower than 10.0 g percent should be further investigated particularly if they do not respond to oral hematinics within six weeks.
 
Investigations Recommended
These include the following.
Iron deficiency anemia is diagnosed by the following tests.
  1. Examination of a peripheral smear for red blood cell morphology-microcytosis, poikilocytosis, and hypochromasia and vacoulation indicate iron deficiency. Large red blood cells are seen in folate deficiency, however dimorphic anemia due to nutritional deficiencies is far more prevalent in our country.
  2. Mean corpuscular hemoglobin concentration (MCHC) less than 30 percent.
  3. Serum iron concentration less than 60 mg/dl.
  4. Saturation of transferring less than 15 percent.
  5. Serum ferritin less than 12 mg/dl.
Folate deficiency is diagnosed on the basis of the following tests.
  1. Peripheral smear shows dimorphic RBCs.
  2. Serum folate levels less than 3.0 ng/dl.
  3. Red blood cell folate level less than 80 mg/dl.
 
THE CASE FOR PRESCRIBING PROPHYLACTIC ORAL IRON TO ALL PREGNANT WOMEN
Although in many Western countries, obstetricians believe that the daily diets of pregnant women can provide for the increased demand posed by pregnancy and therefore shy away from prescribing oral iron supplements. However the experience in underdeveloped countries is different and teaches us the importance of prescribing oral iron supplements routinely to all pregnant women.
A large controlled clinical trial in the Philippines clearly showed that pregnant women receiving oral iron throughout 4pregnancy maintained their hemoglobin levels. Anemic pregnant women on larger therapeutic doses of oral iron supplements showed an increase in their hemoglobin levels. Whereas those women who were not prescribed oral iron supplements registered a progressive decline in their hemoglobin values as pregnancy progressed. All pregnant women on oral iron medication had satisfactory iron reserves at the end of pregnancy. Considering that anemia contributes directly or indirectly to a third of all adverse pregnancy outcomes. The case for prescribing oral iron supplement throughout pregnancy rests on firm ground.
 
Management of Anemia in Pregnancy
Anemia management during pregnancy should be based upon the severity of anemia, the gestation maturity, presence of medical or obstetric complications, and the facilities available for taking care of any emergency complications.
  1. Mild anemia (Hb levels between 8.0-10.5 g/dl) All cases of mild anemias seen early in pregnancy should be treated with oral iron supplements, folic acid, vitamin B12, ascorbic acid 100 mg/daily and protein supplements, the hemoglobin should be periodically reassessed and parenteral iron therapy considered for selected cases not showing appropriate response to oral therapy, or in advanced stages of pregnancy.
  2. Moderately severe anemia (Hb levels between 5.0 to 8.0 g/dl) About 20 percent of pregnant women fall into this category, after excluding infections and other medical problems, these patients should be considered for parenteral iron therapy. The drug of choice is iron-dextran complex. This can be administered by the intravenous dose as total dose infusion therapy or as intramuscular injections. The monumental work undertaken by Bhatt RV (1960) is worth mentioning. In a large series of 8000 cases treated with total dose perentral infusion of iron dextran complex, not only was the anemic status of the treated patients improved, but in a long term follow-up study, it was shown that whereas 5only 30 percent of the treated patients had Hb levels of less than 10 g/dl in contrast to 80 percent in the nontreated group. This fact establishes the long term benefits of parenteral iron therapy in severely anemic pregnant subjects.
  3. Severely anemic subjects (Hb less than 5.0 g/dl) These patients should be hospitalised. They are prone to undergo congestive cardiac failure and infections.
In patients not in circulatory failure, fresh blood transfusion is worth consideration, in case of failure or imminent labor, consider partial exchange transfusion or transfusion of packed cells. If bleeding complicates pregnancy, fresh whole blood transfusion is indicated. Later parenteral iron therapy/oral iron therapy may follow.
Simultaneously attention to diet, control of infections with antibacterials and anthelmintics to eliminate intestinal parasites requires consideration.
 
Conclusions
  1. Anemia is widely prevalent in India. It’s incidence is higher amongst women in the lower socioeconomic group, rural women and those living in urban slums.
  2. Nutritional deficiency, poverty, illiteracy, religious taboos, multiparity and poorly spaced pregnancies, worm infestations, malaria, and untreated chronic infections perpetuate this problem.
  3. Anemic mothers tend to suffer from preterm deliveries, give birth to low birth weight babies, they are prone to congestive failure, shock following hemorrhage and postpartum psychosis. Anemia is directly or indirectly implicated in 2/3 of all maternal morbidity and mortality.
  4. Perinatal morbidity is high because of a higher incidence of low birth weight babies, intrauterine growth retarded babies, anemic babies, anemic babies with poor iron reserves, susceptible to infections, metabolic disorders and birth trauma.
6BIBLIOGRAPHY
  1. Bhatt RV. Pregnancy at Risk Current Concepts, 4th edition, Jaypee Brothers  2001.
  1. Krishna Menon MK. Observations on anaemia in pregnancy. Journal of Obstetrics and Gynaecology of India 1965;15:127-46.
  1. Paintin D. The rise of the total red cell volume in pregnancy. Journal of Obstetrics and Gynaecology of the British Commonwealth, 1962;69:719-23.
  1. Reinhardt MC. Maternal anaemia in Abidjan : its influence on placenta and newborns. Helvetica Paediatrica Acta 1978;33(Supplement, 41): 43-63.
  1. Sood SK, et al. Nutritional anaemia in pregnancy and its health implications with special reference to India. Ann Acad of Med Sci 1989;25:41-50.