Anaemia in Pregnancy

Questions that remains unanswered in anaemia in pregnancy-particularly when preconception blood tests were not carried out in resource poor countries?

Q.1. what, according to conventional list of investigations in the context of Anaemia at booking (initial) visit of pregnant women? Say a woman reporting for first time at about 8-10 Weeks of gestation in a private clinic? To remember, that she has no premarital / pre-conceptional haematological & viral screening.

My ans. Should we, limit lists of lab tests 1) Hb% only in resource poor countries? Or ask for 2) Hb% & PCV? Or 3) Hb%, PCV, Ferritin, 4) also add Thalassaemia Screening   5) add TIBC    & 6) add RBC indices too.  We are also aware of the fact as iron store diminishes when anaemia(less blood in body) last. But in practice, we seldom order for all these tests in initial visit: If we do so, I am afraid the couple will have to go back to their home without any tests at all.   But, honestly speaking what is in our back of mind? Factors that limit such detailed blood tests are (in fact we are compromising) are:-Firstly, Cost, in the context of rural West Bengal is prohibitive. B) We also know that she may not come to us before two months time.  C) We should think that repeated venepuncture for blood examinations are disliked by many even by the poorest of poor. D) We also have to take into consider that as per norms of medicine we have to ask for many other Lab tests which we cannot just avoid.

Then, what tests on the day of initial visit if no financial constraint, keeping in mind nopreconceptional counseling was done?  At booking visit. The following are the tests that should ideally be done at booking visit. Therefore, admittedly we have to curtail our list of tests and make some compromise. Such list of investigations as ordered in booking visit is exhaustive:-Blood: - Laboratory documentation   of medical fitness for pregnancy e.g. PPBS, HBA1_c, Viral screen, Urine RE & C/S; Ultrasonography, Thalassaemia. This is addition to doctor’s visit, transportation charges, hidden expenses like, Tiffin & lunch.

Q2. Global view about routine Fe suppl to all preg women? Does this policy do well to healthy nonanaemic nonveg affluent preg women: But does routine supplementation in pregnancy can cause harm to the woman concerned?

This is a longstanding debate, particularly   in the industrialized    countries where most of the pregnant women are not anemic at initial few visits. They may decline to ingest Fe unnecessarily. Should it be universal or selective in our country? Can we do harm to a pregnant women by administering Fe to woman who is fee sufficient? The advantages of routine Fe suppl without assessing her Fe status.

 I know valid Points in favour of routine suppl after 16 weeks are: - 1) Adequate foetal iron store particularly in the liver, is ensured, 2) routine Fe suppl might prevent adult hypertension, if foetus gets adequate quantum of iron supply throughout pregnancy. Foetal iron supply line, as we know is through maternal transferrin. This maternal transferrin level is not always related to maternal iron stores.  Th maternal transferrin which trapped by the placenta like iodine trapping by thyroid)àstore in gestational period 3) Additionally, if a preg women is sub clinically Fe deficient à  she may give birth to a neonate with poor Fe storeà who  may fail  catch up later as he/she grows up as child. Such children are often termed by the hematologist colleagues as “iron deficient in the absence of anemia “.Prevalence of such children is not uncommon in India. Such toddler may develop behavioral disorders, development of anemia in first few years of life as breast milk contain minimal Fe. Such children born with minimal Fe store in liver may later develop cognitive disorders.

What harm can occur if Hb% is high? Can it induce PIH by inducing haemo-concentration? High maternal HB is mostly associated with poor preg outcome. Therefore Obstetrician often orders for PCV in cases where one is suspecting onset of PIH (prediction of PIH).

Q3. Large size of Placenta is not good: - Placenta might have work hard & increased in size to trap more transferrin from maternal blood.

Q6. Time to confess:-How many of us order or assess Transferrin & TIBC before initiation of Ry of pregnant anemic mother??Should we therefore estimate of Transferrin saturation in all pregnant women as it is key factor in delivering the Fe to placenta? Serum iron level and TIBC reflect estimate of transferrin saturation. The sequence of events, as we knowà loss of marrow/ stores of Feà decrease in circulating Ferritin (latent anaemia)à peripheral reflection s anaemia   clinically known as anemia.

Q.2. Should we initiate iron therapy in a pregnant mother without investigating her? Investigations are quite costly in underdeveloped countries?

Ans. should we initiate iron therapy in a pregnant mother without investigating her? Investigations are quite costly?

Q.3. should we initiate straight  to iron supplementations if anaemia is diagnosed first time in first trimester or go for dietary adjuments in first trimester ve to substatantiate that the women is concerned is suffering from Fe deficiency anemia. That costs only about 1500/-. Thereafter, if mild  anaemia in first trimester à may be corrected with dietary iron only iron rich food  The question of drugs i.e. Fe supplementation should be beer be deferred from 2nd trimester onwards,

But if the degree of anemia is of moderate to severe anaemia in first trimester (Proved to be Fe deficiency by investigation) has to be treated with oral Fe.

What is done at UK? UK guidelines on the management of iron deficiency in pregnancy-British Committee for Standards in Hematology mentions that Women with a Hb < 110g/l up until 12 weeks or <105g/l beyond 12 weeks should be offered a trial of therapeutic iron replacement.

Q. What are the clinical situations when we have to transfuse pack cellsRBC) in anemic pregnant who has no bleeding episodes. To put in other way, at what Hb% level the and what gestational age one women should ideally be advised PCV transfusion to improve tissue oxygenation & combat infections or congestive failure?

Q. Should we routinely supplement Vitamin B12 to all pregnant women of India in addition to FeSO4? The exact role played by Vitamin B12 in haematopoisis?

Ans: - “Vitamin B12 deficiency rarely causes anemia in pregnancy”   -Source: “High Risk Pregnancy “-Ed David James, ELSEVIER; Ed.4^th. pp. 683,

But what about vegans? –They are deficiency of vit B12 in most cases.

Q. What are the clinical examples of “iron-deficiency induced tissue malfunction due to compromised function of iron –dependent enzymes of the body?

Q. As age of marriage is on the rise therefore we are recently having women Chr Renal diseases in preg. IS it safe to administer r-Erythropoietin in pregnancy? Your experience please?

Q. What are the drugs that can lead to autoimmune anemia in pregnancy? Have seen cases of Chr anemia out of LDA intake for long time?

Q. What is the common Chr, medical diseases in India which leads to aneamia? – Hook worm infestations, poor nutrition, poor cooking habits, less protein intake,