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,

Anaemia in pregnancy :-List of investigations in resource poor countries in pregnancy period at first booking vist

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,

Diagnosis of Toxoplasmosis organisms in pregnancy period. The ever existing dilemma.

Diagnosis of Active Toxoplasmosis in Pregnancy:-A ever existing dilemma:-Obstetricians are often confused once IgG titer is high & raised IgM-more so if there is demonstrable foetal anomaly Sonologically at a later date:--It is difficult to confer some abnormalities of foetus, God forbid if appear later in this case, that whether such abnormalities (if at all appear in this case) - were due either to CMV or to Rubella with certainty: There may be other causes of CM of foetus.

Reasons are:--Firstly, in our country CMV IgG antibodies are as high in 95% +ve of all women of child bearing age. Though presence of IgG antibody do not guarantee against re-infection. Secondly :-One cant equate cong malformations due to  re-infection as re-infection rate is quite high in our country and in such cases a low IgM antibodies have less predictive value( in re-infection cases-I mean).What, then  is solution? Therefore, molecular methods of diagnosis are more relevant.

Please do not equate presence of  IgM means acute maternal / foetal infection:- Mere presence of high titers of IgG Rubella /IgG CMV in pregnancy do not always mean that the  concerned foetal abnormities were due to acute  viral infection acquired in the pregnancy. At best one can suspect acute viral infection, if IgM is very high. Because in most cases prepregnancy serological status remain unknown to us. Such high titers of antibody might have present earlier i.e. prior to pregnancy. Only an avidity case can prove whether the viral infection was recent or not.

What is meant by avidity test of antibodies? The terms avidity or “functional affinity” imply to quantify the net antigen –binding force/ capability of population of antibodies. IgG antibody affinity is now commonly done in many centres if India nowadays. This will diagnose the and differentiate between reactivation, re-infection, or primary infection. The high avidity rules out recent infection of less than 4 months even if IgM abs is present.  Therefore low avidity is not an absolute indication of recent infection. High avidity with 10% positive predictive value to rule out acute infection.

Polyp-small tumours in the inner wall of womb causing distressing excessive bleeding -Is hysteroscopy ideal for unmarried girls?

 Hysteroscopy for unmarried women –the rationality? A) What is what her age is? If menorrhagia is considerable and there is no systemic cause then hysteroscopy is ideal to remove the tumours from inner lining of womb. If refuges for hysteroscopy then traditional curettage –which, however may miss some polyps. But another issue is what is the etiology of polyp -Hyperoestrogenic? If PCOS- Then lifelong follow up e.g. -lipid, Breast, Metabolic disorder.

Prevention of preterm Labour

Cervical weakness: Threatened Preterm Labour: Prevention of preterm labour: Why we at al put a stitch? We have to make our conscious clear and accountable to Medl science as to ‘On which indication we are banking upon before contemplating on STITICH”. Broadly speaking the indications of Prophylactic Cerclage:-are of tree types: - Prophylactic Cerclage are of three types:-

 A) First & possibly commonest indication is Symptom Oriented : Dependent –“Guided”-but  unsupported by USG features ( new appearance of “Whites symptoms in preg ”  which increase as weeks passes , & Mild abd “cramps in tummy-which was absent earlier and unassociated with constipation & UTI”).

Secondly:-history oriented Cerclage: - in the form past one or two spont midtrimeser pregnancies whether no definite cause could be ascertained with certainty .Again supported by USG but unsupported by USG findings.

C) More scientific :- i.e. Sonologically documented serial USG confirmed progressive cervical changes: In such cases irrespective of parity and symptoms if there is serial USG confirmed progressive cervical changes then one can consider put prophylactic stitches. On the whole repeated HSG, SIS, Trial Transfer & Hysteroscopy are more becoming indication of stitch in the era of 21st. century,

 So far as multiple pregnancies there is no sound and valid initiation of putting a Cerclage as cervical tissue integrity is not comprised in any way. In fact there is no documentation that cervical structural & functional capacity is compromised in multiply preg in any way. Whatever the defect is there is limited to cleavage of embryo and or release of any oocytes from poly-ovular follicles. In fact. Cerclage can initiate PTL,

 But in case of already existing cong abnormality of uterus, yes, hopefully there is rationality off strengthen Cx. More so if she had repeated insult in Cx in the form of HSG/Hysteroscopy etc.

Prevention of pregnancy after unprotected sex

There are two issues bestowed on the Dr. Chunduri: - . Firstly to provide alternative form of EC (Emergency Contraceptive) urgently preferably by 72 hrs, Secondly, possibly the most omitted by our profession is to counsel strongly for ongoing contraception.

A)   U may directly talk to local medicine shop owner (if U are kind enough) by handing over mobile phone of your patient to shop keeper & enquire which brand of ECP (emergency contraceptive Pill) is available at his shop.

B)  How sympathetic doctor is ? Having said that this problem of non-availability of the desired brand of EC drugs at uncommon areas is not uncommon in Resorts, Sea sides, Hilly resorts, Forest houses and islands in particulars. If such brand is not available one can ask the couple to go a nearby shop if available and hand over her mobile to shop keeper and insist on some other high dose LNG pill like Pill 72, EC-2, No –Preg, Pill-72, Preventol,Unwanted-72E-Pill,Unwanted 72(as suggested by Dr Patel & others), I-Pill, Preventol.etc.

C) Holiday is over but te hidden anxiety is there more so in wife or girl friend:-What is the way out? When she come back from resort or at home UPI (unprotected Intercourse) she can be fitted with T-Cu-IUD within 7 days of such intercourse, if no such high dose LNG is available. I think enough time is allowed by WHOM-no panicky for local nonavailibilty. Efficacy of Cu T 380 A will be good even at 120 hrs & acceptable.

D) Wife/ Girlfriend :- If denies to be fitted with Devices the other three tablets of EC are available. Such   Tab are e.g. . . . Mifepristone(50 mg)  , Ulipristal tab and age -old High or low dose Pill 2 tab BD or 4 tab per dose 12 hrs apart wit due antiemetics .

E) I have missed the last Bus/ train? What is the last option? Last option is oral MTP drugs that too after confirmation of UTP and exclusion of EP by serum Prog & possibly demonstration of GSD in Ut cavity. This is unacceptable by most of us, possibly couple too prior to ingestion of Medl Ab tablets. Opinion of Forum members Pl,

Part II. Most forgotten part:-Operation successfully done but who will take care of “Dressing of the wound?” Ongoing contraception either by “Quick Stared Method r “Late start of OCP/ IUCD after initiation of mens after UPI. Pl do counsel that,

If desied and known brands of emergency contraceptives tablets ( post coital Pills-ie. drugs to be taken are not availabaille local market-What are the options left n by female partner after unprecedented sex to prevent unwanted prenancy)

There are two issues bestowed on the Droctor.: - . Firstly to provide alternative form of EC (Emergency Contraceptive) urgently preferably by 72 hrs, Secondly, possibly the most omitted by our profession is to counsel strongly for ongoing contraception.

A)   U may directly talk to local medicine shop owner (if U are kind enough) by handing over mobile phone of your patient to shop keeper & enquire which brand of ECP (emergency contraceptive Pill) is available at his shop.

B)  How sympathetic doctor is ? Having said that this problem of non-availability of the desired brand of EC drugs at uncommon areas is not uncommon in Resorts, Sea sides, Hilly resorts, Forest houses and islands in particulars. If such brand is not available one can ask the couple to go a nearby shop if available and hand over her mobile to shop keeper and insist on some other high dose LNG pill like Pill 72, EC-2, No –Preg, Pill-72, Preventol,Unwanted-72E-Pill,Unwanted 72(as suggested by Dr Patel & others), I-Pill, Preventol.etc.

C) Holiday is over but te hidden anxiety is there more so in wife or girl friend:-What is the way out? When she come back from resort or at home UPI (unprotected Intercourse) she can be fitted with T-Cu-IUD within 7 days of such intercourse, if no such high dose LNG is available. I think enough time is allowed by WHOM-no panicky for local nonavailability. Efficacy of Cu T 380 A will be good even at 120 hrs & acceptable.

D) Wife/ Girlfriend :- If denies to be fitted with Devices the other three tablets of EC are available. Such   Tab are e.g. . . . Mifepristone(50 mg)  , Ulipristal tab and age -old High or low dose Pill 2 tab twice daily  or 4 tab per dose 12 hrs apart wit due antiemetics .

E) I have missed the last Bus/ train? What is the last option? Last option is oral MTP drugs that too after confirmation of UPI(unprotected sexual Intercourse) and exclusion of EP by serum Prog & possibly demonstration of GSD in Ut cavity. This is unacceptable by most of us, possibly couple too prior to ingestion of Medl Ab tablets. Opinion of Forum members Pl,

Part II. Most forgotten part:-Operation successfully done but who will take care of “Dressing of the wound?” Ongoing contraception either by “Quick Stared Method r “Late start of OCP/ IUCD after initiation of mens after UPI. Pl do counsel that,