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CLASSIFICATION
PHYSIOLOGICAL ANEMIA
PATHOLOGICAL
CLASSIFICATION
Haemorrhagic - Acute - Chronic- hook worm ,piles hemolytic - familial - sickle cell anemia - acquired- malaria, severe infection
Aplastic Hemoglobinopathies
s.ferritin
14.8gm% 5 million/mm3 39- 42% 27-32pg 75-100cu micron 32-36% 60-120 micro g 300-350 micro g 30% 20-30 mig/L
11-14gm% 4-4.5 million/mm3 32-36% 26-31pg 75-95 cu micron 30-35% 65- 75 micro g 300-400micro g < 16% 15mig/L
PHYSIOLOGAL ANEMIA
Hb- 10gm% RBC- 3.2 million/c.mm PCV- 30% RBC morphology normal with central pallor Expected Hb%= Hb%<12 wks 2gms%
ERYTHROPOISES
Pronormoblassts- normoblasts- reticulocytesRBC Life span 120 days Nutrients required Minerals- Fe, Cu, Co Vitamins- B12, folic acid, vit C B12 for RNA, FA- DNA Vit C folinic acid to folic acid Proteins- for globin moiety Erythropoitin
Increased demand Diminished intake Disturbed metabolism-presence of infection Pre-pregnant health status Excess demand i) multiple pregnancy ii)rapidly recurring pregnancy iii) Teen age pregnancy Polymorphism
Clinical features
Symptoms: lassitude, weakness, anorexia, indigestion, palpitation dyspnoea, giddiness, swellings of limbs PALLOR, glossitis, stomatitis Edema- hypoproteinemia/ PIH Hemic murmur crepitations
INVESTIGATIONS
Degree of anaemia
HB% RBC count PCV Mild- 8- 10gm% Moderate- 8-7gm% Severe- < 7gm%
TYPE OF ANAEMIA
Peripheral blood smear Microcytic hypochromic cells Hematological indices- MCV, MCH,MCHC S.fe - <30mig/dl TIBC-400mig/dl %age saturation- <10% S.ferritin- <15mig/L S.bilirubin normal
Cause of anaemia
Stool for ova& cyst Urine CXR Bone marrow study- nonresponse to treatment, hypoplastic anaemia, kalaazar D.D : -infection -nephritis/preeclampsia -Hemoglobinopathies
COMPLICATIONS
PREGNANCY
Preeclampsia Intercurrent infection CCF Preterm labour LABOUR uterine inertia, PPH, CCF, shock PUERPERIUM sepsis, subinvolution, failure of lactation, dvt, pulmonary embolism
DANGER PERIODS
30-32 WEEKS LABOUR IMMEDIATELY AFTER DELIVERY 7-10 DAYS AFTER DELIVERY BABY LBW IUD MMR 20%
PREVENTION
FAMILY PLANNING SUPPLIMENTATION DIET TREATMENT OF INFECTION Hb % estimation at Ist visit, 30 wks,36wks
CURATIVE
Hb< 7.5g to be admitted Associated medical or obs complication with moderate anemia General treatment Diet Improve appetite Antibiotic Effective therapy
CHOICE OF THERAPY
SEVERITY OF ANAEMIA DURATION OF PREGNANCY ASSOCIATED COMPLICATIONS
ORAL THERAPY
Best absorbed in ferrous form Ferrous sulphate, fumarate,succinate 200mg, 60mg elemental 1 tid,max-6/day Maintainance dose 1 od for 100days Draw backs; 1. intolerance, 2. unpredictable absorption rate,3.stores not replinished easily Response to treatment
ORAL THERAPY
Rate of improvement : should be evident with in 3 wks. 0.7gm/wk Causes for failure of improvement: 1. Improper typing 2. Defective absorption 3. Poor compliance 4. Concurrent blood loss 5. Infection 6. Coexistant folate deficiency Contraindications: intolerance, severe anemia
PARENTERAL THERAPY
INTRAVENOUS: I.REPEATED INJECTIONS II. TDI INTRAMUSCULAR INDICATIONS: 1. C.I. to oral therapy 2. Non co-operative pt 3. Last 8-10 wks with severe anemia Advantage : stores replinished early Rate of improvement: 0.7-1gm/wk
TDI
Iron dextran Advantages: 1.eliminates repeated painful injections 2.Treatment completed in single day 3.Less costly Limitations : 1.max response 4-9wks 2.h/o reaction Estimation: 0.3xW(100-Hb%)+50%
IM therapy
Iron dextran Iron sorbital citrate Oral therapy should be suspended atleast 24hrs before Test dose Z technique Draw backs: 1) painful, 2) abcess, 3) reactionfever, headache, lymphaedenopathy, allergy
BLOOD TRANSFUSION
INDICATIONS Blood loss anaemia Severe anemia >36wks Refactory anaemia Associated infection Packed cells Advantages 1.increase in o2 carrying capacity 2. substrate for hemopoises 3.stimulates erythropoises 4.Improvement in 3 days
BLOOD TRANSFUSION
Precautions: 1. antihistaminics 2. diuretics, 3. drip rate 10/min, 4. pulse,r.r., creps Drawbacks: 1. preterm labour, 2. CCF, 3.reaction EXCHANGE TRANSFUSION CCF, SURGERY, HCT<13%
MANAGEMENT OF LABOUR
IST STAGE: bed rest,o2 inhalation,asepsis II STAGE: cut short ii stage by forceps, iv methergin III STAGE: packed cell trans fusion, Puerperium : antibiotics, continue hemotherapy, counseling about next pregnancy
MEGALOBLASTIC ANAEMIA
There is derangement in RBC maturation with production of abnormal precursors (megaloblasts) due to impaired DNA synthesis Normal requirement= 3microgm Causes: 1. temperate, 2. tropical, 3.addsonian pernicious 3. malabsorption addsonian is due to lack of IF
Inadequate Intake: emesis, dietary, cooking Daily requirement- 50-100microgm, during pregnancy- 400 microgm Diminished absorption Abnormal demand; twins,infection, bleeding Failure of utilisation Diminished stores Iron defficiency anaemia
Clinical features
Pallor,glossitis,hemorrhagic patches, hepatosplenomegaly, PIH Hyper segmented neutrophils, macrocytosis,gaint polymorphs, megaloblasts, ^mcv,^mch, Pancytopenia folate,<3ng/ml S.B12<90pg/ml BM- megaloblastic erythropoises
COMPLICATIONS
Abortion, IUGR, preterm, abruption, malformation( NTD). TREATMENT Folic acid 4mg daily , till 4 months after delivery
Pathophysiology: deoxygenated state hb aggregates polymerises & distort RBC to sickle Blocks micro circulation Ppted by infection, acidosis, hypoxia & cooling Decreases life span Increased destruction- hemolysis, anemia, jaundice
DIAGNOSIS
Refactory hypochromic anemia Sickling test Persistent reticulosis High fasting fe Electrophoresis Effects on pregnancy: abortion, IUGR,fetal loss Maternal death ^ to 25% due to pulmanary infarction, CCF, embolism Effects on disease- hemolytic crisis, painful crisis
MANAGEMENT
PRECONCEPTIONAL COUNSELLING During pregnancy- anc, avoid air travelling, folate 1mg daily, fe tobe restricted, B.T. at 6 monthly intervals,hydroxyurea During labour- o2, avoid anoxia, fluids, antibiotic, Contraception- sterilisation, barrier ideal
THALASSEMIA SYNDROMES
Basic defect is reduced rate of synthesis of globin synthesis RBC with deficient Hb content Deficient erytropoises, hemolysis, ultimately anemia Alfa, beta minor / major