Treatment of Anemia In Pregnancy- Indian Guidelines

Anemia is a major problem in women of child bearing age in developing countries with effects that may be deleterious to mothers and fetuses.

Over one third of the world’s population suffers from anemia, mostly iron deficiency anemia. India continues to be one of the countries with very high prevalence. National Family Health Survey (NFHS-3) reveals the prevalence of anemia to be 70-80% in children, 70% in pregnant women and 24% in adult men. Prevalence of anemia in India is nearly two thirds of the pregnant women because of low bioavailability diet, defective absorption & chronic blood loss due to hook worm infestation & malaria and rapidly successive multiple pregnancies. Iron deficiency anemia is responsible for 95% of the anemias during pregnancy.

In India, anemia is directly or indirectly responsible for 40 percent of maternal deaths due to haemorrhage, cardiac failure ,infection & preeclampsia . India contributes to about 80 per cent of the maternal deaths due to anemia in South Asia. There is 8 to 10-fold increase in MMR when the Hb falls below 5 g/dl. Maternal anemia is associated with increased perinatal morbidity & mortality rates consequent to IUGR, preterm births, low iron stores and cognitive & affective dysfunction in the infant. India was the first developing country to take up a National Programme to prevent anemia among pregnant women and children. The National Anemia Prophylaxis Programme of iron and folic acid distribution to all pregnant women in India through the primary health care system was evolved and implemented from 1972. In order to tackle this public health problem, a multipronged 12 x 12 initiative has also been launched in the country. The initiative is targeted at all adolescents across the country with the aim for achieving hemoglobin level of 12 gm% by the age of 12 years by 2012.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Anemia In Pregnancy. Following are the major recommendations :

Anemia is defined as a decrease in the oxygen carrying capacity of the blood due to decrease in amount of RBCs or haemoglobin or both.

I. When To Suspect / Recognize?

 WHO - Hemoglobin -11gm/dl or less

-Mild 8-11 gm/dl

-Moderate 5-7 gm/dl

-Severe below 5 gm/dl

 ICMR categories

-Mild 10-10.9 gm/dl

-Moderate 7-10 gm/dl

-Severe below 7gm/dl

-Very severe(decompensated) below 4gm/dl

 RBC<3.2million

 PCV<33%

II. Incidence Of The Condition In Our Country

 Incidence- About one third of the global population(over 2 billion) are anemic

 CDC-Up to 56% of all women in India are anemic (Hb < 11 g/dl)

 NNMB, DLHS and ICMR surveys showed that over 70 percent of pregnant women are anemic

The World Health Organization (WHO) estimates that 42% of all women, and 65-75% of pregnant women in our country are anemic. In India, the second National Family Health Survey in 1998–1999 (NFHS-II) showed that 54% of rural women of childbearing age were anemic compared with 46% of women in urban areas. Kerala has only a 23% prevalence of anemia compared with 62% in many northeastern states of India.

III. Differentioal Diagnosis

 Nutritional

 Hemorrhagic

 Hemoglobinopathies

 Bone marrow disorder

 HIV

 Drug induced

 Tuberculosis

 Inherited disorders

 Anemia caused by inflammation, malignancy, chronic diseases & autoimmune disorders

IV. Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria

Complete medical history and Physical examination is very important.

*Situation 1: At Secondary Hospital/ Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited

a) Clinical Diagnosis:

Symptoms: 1. Weakness

2. Easy fatiguability

3. Lassitude

4. Dizziness or vertigo especially when standing

5. Headache

6. Irritability

7. Indigestion, loss of appetite

8. Breathlessness

9. Palpitations

10. Generalized swelling

11. Symptoms due to cause of anemia like yellowing of skin & mucous membranes, bleeding from rectum etc.

Signs:

1. Pallor

2. Icterus

3. Glossitis, stomatitis

4. Koilonychia

5. Tachycardia, systolic murmurs, bounding pulse

6. Fine crepitations at lung bases

7. Splenomegaly

8. Hepatomegaly

9. Edema

b)Investigations:

 Hb%

 PCV

 Peripheral smear for immature cells, type of anemia and MP.

 Urine routine and microscopy, Urine C/S if required

 Stool for Routine and microscopy

 USG abdomen

c) Treatment:

Although there are several different forms of anemia, this health profile will only address the three most common: iron-deficiency anemia, vitamin B12 anemia and folic acid deficiency.

Non-drug treatment

 Awareness/ Education

 Improvement of dietary habits-diet rich in Vit C, protein and iron, cooking in iron utensils, avoiding tea & coffee intake with meals & overcooking

 Food Fortification

 Social services such as improvement of sanitation & personal hygiene for eradication of helminthiasis

 Annual screening for those with risk factors

 Routine screening for anaemia & providing iron supplementation for adolescent girls from school days

Iron rich foods: Pulses, cereals, jaggery, Beet root, Green leafy vegetables, nuts, meat, liver, poultry, Egg, fish, legumes, dry beans, and dry fruits viz: dates, figs, apricots etc .

Drug treatment: Prophylaxis WHO recommendation

 60mg elemental iron and 0.25mg folic acid daily

 To be given for 6 months in countries with prevalence <40% & additional 3 months postpartum where the prevalence >40%

Government of India recommendation

 100mg elemental iron and 0.5mg folic acid daily

 To be given in the second half of pregnancy and lactation for at least 100 days Ferrous sulphate is least expensive and best absorbed form of iron. It also allows more elemental iron absorbed per gram administered. If for some reason, this is not tolerated, then ferrous gluconate & fumarate are the next choice for iron therapy.

Treatment of Iron deficiency has included:

 Oral iron

 Parenteral iron

 Blood transfusion

 Oral Iron

- First line therapy

- 200mg FeSo4 (60mg elemental iron)2- 3 times daily in conjunction with folic acid.

- If patient is non-compliant to oral therapy or if there is gastritis, then reduce doses & give it after meals or change over to ascorbic acid/ carbonyl iron or parenteral therapy.

- Diagnostic reevaluation if there is no significant clinical or haematological improvement within 3 weeks.

Parenteral Therapy:

Indications:

- Hb less than 7g/dl and pregnancy >30 weeks

- Malabsorption Syndrome

- Incapacitating side effects with oral iron

Preparations:

- Iron sucrose -

Iron dextran

- Iron sorbitol citrate

Total iron deficit (mg) = Amount of iron deficit + amount of iron to replenish stores Amount of iron deficit (mg) = (Hb target- Hb initial)gm/dl x Body wt (Kg) × 2.2 + Stores

Or

( 100-Hb initial)% x Body wt (Pounds) x 0.3 + Stores

where

Stores (mg) = 50% of deficit or approx 1000mg

Iron Sucrose Complex is considered to show a significant improvement of Hb and iron stores in pregnant women.

The target Hb may be taken as 11gm% for the Indian population according to WHO guidelines.

 Deworming necessary :

- Albendazole 400 mg single dose

- Mebendazole 500 mg single dose or 100 mg twice daily for 3 days

- Levamisole 2.5 mg/kg single dose, best if a second dose is repeated on next 2 consecutive days

- Pyrantel 10 mg/kg single dose, best if dose is repeated on next 2 consecutive days

- To prevent recurrence, patients should be advised to use footwear, improve sanitation, and personal hygiene.

 Malaria prophylaxis in endemic area to be treated.

Treatment of Folic Acid/ Vitamin B12 deficiency

 Tab. Folic acid 5 mg daily

Prophylactic - all woman of reproductive age should be given 400mcg of folic acid daily.

Preventive daily or intermittent iron or iron+folic acid supplementation taken by women during pregnancy reduces anaemia in mothers. There is evidence that taking iron or iron and folic acid daily or intermittently has a similar effect in reducing anaemia at term and improving haemoglobin concentrations in the mother.

 Vitamin B12 deficiency:

Oral preparation of Vitamin B12 (not very effective)

In Moderate cases- 1000mcg of Parenteral Cynocobalamine every month

In Severe cases 1000mcg/day for 1 week, following by weekly for 1 month

Referral criteria:

 Hb less than 5 gm% in all trimesters, less than 7gm% if >36weeks

 Cases not responding to treatment

 Associated with medical disorders eg:leukaemias/ other obstetric complications

 Haemolysis or evidence of bone marrow suppression

 Other types of anemia(Sickle cell anemia, Thalasemia)

 Level II USG to rule out fetal complication/ compromise by CVS/ Amniocentesis .

 If any of the below suspected, as the below are common in pregnancy:

- Maternal risks during Antenatal period: Poor weight gain, preeclampsia, eclampsia, placenta previa, accidental haemorrhage, premature rupture of membranes, pre term labour, cardiac failure etc.

- Maternal risks during Intranatal period: Dysfunctional labour, accidental hemorrhage, shock, anesthesia risk, cardiac failure, if signs of respiratory distress

- Maternal risks during Postnatal period: Postnatal sepsis, sub involution, embolism, PPH (primary, secondary).

Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available

A) Clinical Diagnosis: Same as situation 1

B)Investigations:

 Same as situation 1, in addition

 CBC with peripheral smear

 Reticulocyte count

 Red cell indices

 LFT, RFT, LDH

 Coombs Test

 Iron studies

- serum iron

- serum iron binding capacity

- serum ferritin

 Hb electrophoresis

 Bone marrow aspiration/ Biopsy

C)Treatment: Same as situation 1

 Confirm iron deficiency anaemia

 Treatment of IDA includes :

 Oral iron,

 Parenteral iron,

 Recombinant erythropoietin and

 Blood transfusion

 Inj. Iron Dextran (50 mg / ml elemental iron) 2 cc IM on alternate day after test dose x 10 injections by Z technique.

 Blood Transfusion

Packed cells to be transfused.

Indications

- Hb < 7 gm/dl & POG > 36 weeks

- Hb < 6 gm/dl & POG < 36 weeks

- CHF due to anaemia(exchange transfusion)

- Replenish blood loss due to APH/PPH

-Not responding to oral & parenteral therapy

 Diagnosis & management of sickle cell disease, Haemoglobinopathies, Pancytopenia in cases not responsive to iron.

 Manage congestive cardiac failure/ PIH / Placenta Previa if associated/ where indicated.

Megaloblastic Anemia

 VitB 12 or Folic Acid Supplementation

Labour Management:

Oxygen and other measures to deal with heart failure and PPH to be kept ready.

 To cut short second stage by Outlet forceps/vacuum delivery of fetus.

 To routinely employ active management of third stage of labour.

 LSCS only for Obstetric Indications .

Postpartum Management:

 Iron should be continued till the patient restores her normal clinical & haematological state & for an additional 3 months for store replenishment.

 Dietary advice

 Effective method of contraception as per WHO guidelines & should not conceive for atleast 2 years giving time for iron stores to recover.

 Sterilization is preferred if the family is complete.

Resources Required For One Patient/ Procedure (Patient Weight 60 Kgs)

(Units to be specified for human resources, investigations, drugs, and consumables and equipment. Quantity to also be specified)

Situation	Human resources	Investigations	Drugs and consumables	Equipment
1. At Secondary Hospital/ Non-Metro situation Optimal Standards of Treatment in Situations where technology and resources are limited	Obstetrician Physician Pathologist Lab technician House keeping	Hb% PCV RBC Peripheral smear Urine routine and microscopy Stool for Routine and Microscopy	Gloves x 10 pairs Drapes for delivery/Caesarean Suture materials Foleys catheter Urobag Venflons Drip sets IVFluids Antiseptics, Compatible blood/packed cells	Stethoscope BP apparatus Pulse oximeter USG machine ECG monitors Lab equipment Labour room, CTG Labour couch Delivery/Caesarean tray Vacuum apparatus Boyles appar OT table Light source Oxygen Suction Baby warmer
2. At Super Specialty Facility in Metro location where higher-end technology is available	Obstetrician Pathologist Anaesthetist Neonatologist Intensivist Nurses x 5 OT technician Lab technician Porters House keeping	CBC Peripheral blood smear Reticulocyte count Urine routine and microscopy Stool for Routine and Microscopy Iron studies LFT,RFT,LDH Coombs Test Hb electrophoresis Bone marrow aspiration/ Biopsy	Gloves x 15 pairs Drapes for delivery/Caesarean Suture materials Foleys catheter Urobag CVP line Arterial line Venflons Drip sets IVFluids Epidural anaesthesia kit General anaesthesia kit Drugs to manage cardiac failure , PPH	Stethoscope BP apparatus Pulse oximeter USG machine ECG Lab equipment Automated cell counter Biochemistry analyser Labour room, CTG Labour couch Delivery tray Caesarean tray Vacuum apparatus Boyles apparatus OT table Light source Oxygen Suction ICU bed Syringe pumps Baby warmer

Guidelines developed by

- Dr. Lavanya.R ( Dept. of OBG, Narayana Hrudayalaya) Karnataka,

- Dr. Sharath Damodhar( HOD, Dept. of Haemotology, Narayana Hrudayalaya) Karnataka,

- Dr.Basavaraju Narasimhaiah, DGO, Tumkur Government Hospital, Karnataka,

V. Further Reading / References

 Cochrane Database of Systematic Reviews 2007

 Medscape J Med. 2008; 10(12): 283.

 DeMayer EM, Tegman A. Prevalence of anaemia in the World.World Health Organ Qlty 1998; 38 : 302-16.

 WHO. 2004. Micronutrient deficiency: Battling iron deficiency anaemia: the challenge. Available from: http://www.who.int/nut/ida.htm, accessed on April 24, 2008.

 Ezzati M, Lopus AD, Dogers A, Vander HS, Murray C. Selected major risk factors and global and regional burden of disease. Lancet 2002; 360 : 1347-60.

 IIPS National Family Health Survey 1998-99 (NFHS-2): Available from: http://www.nfhsindia.org/india2.html;accessed on September 24, 2008.

 IIPS. National Family Health Survey 2005-06 (NFHS-3): Available from: http://mohfw.nic.in/nfhsfactsheet.htmb accessed on September 24, 2008.

 DLHS on RCH. Nutritional status of children and prevalence of anaemia among children, adolescent grils and pregnant women 2002-2004. Available from: http://www.rchindia.org/nr_india.htm 2006, accessed on September 24, 2008.

 Toteja GS, Singh P. Micronutrient profile of Indian population.New Delhi: Indian Council of Medical Research; 2004.

 National Nutrition Monitoring Bureau (NNMB). 2002 .NNMB Micronutrient survey. Hyderabad: National Institute of Nutrition.

 Maternal Mortality in India 1997-2003, Registrar General of India. Available from: http://www.censusindia.net/, accessed on December 15, 2008.

 Breymann C. Iron deficiency and anemia in pregnancy: Modern aspects of diagnosis and therapy. Blood Cells Mol Dis 2002; 29: 506-16.

 Practical guide to High Risk Pregnancy and Delivery; Fernando Arias, 2nd edition; chap-3, pg245-262.

 Williams Obstetrics, Eds Cunningham FG, Gant NF, Leveno KJ et al. 22nd Edn. 2005.