Anemia

Anemia is characterized by a decrease in the number of red blood cells, a decrease in hemoglobin content, or both. The normal hemoglobin concentration is 12-15 gm%.

Types of Anemia

• Physiological anemia of pregnancy
• Pathological
  1. Deficiency anemia
• Iron deficiency
• Folic acid deficiency
• Vitamin B12 deficiency
  1. Hemorrhagic anemia
• Acute- following bleeding in early months.
• Chronic- hookworm infestation, bleeding piles, etc.
  1. Hemolytic anemia
• Sickle cell anemia
• Acquired- malaria, severe infection, etc.
  1. Bone marrow insufficiency eg aplastic anemia
  2. Hemoglobinopathies

The most common of the various causes is dietary insufficiency.

Nutritional deficiency Anemia

Anemia from iron deficiency. Anemia of this sort arises when the body does not have enough iron to make enough hemoglobin. This is a protein found in red blood cells. It is responsible for transporting oxygen from the lungs to the rest of the body. The blood cannot carry enough oxygen to tissues throughout the body in iron-deficiency anemia.

Iron deficiency is the most common cause of anemia in pregnancy.

• Folate anemia Folate is a nutrient found naturally in meals such as green leafy vegetables. The body needs folate, a type of B vitamin, to make new cells, including healthy red blood cells.
• Women require more folate during pregnancy. However, they do not always get enough from their food. When this happens, the body is unable to produce enough normal red blood cells to carry oxygen to all tissues. Folic acid refers to synthetic folate supplementation. Folate deficiency has been linked to birth problems such as neural tube abnormalities (spina bifida) and low birth weight.
• Deficiency of vitamin B12. Vitamin B12 is required by the body to build healthy red blood cells. When a pregnant woman's diet is deficient in vitamin B12, her body is unable to manufacture enough healthy red blood cells. Women who do not consume meat, poultry, dairy products, or eggs are more likely to develop a vitamin B12 deficiency, which may contribute to birth malformations such as neural tube abnormalities and may result in preterm labor.
• Anemia can also be caused by blood loss during and after delivery.

Requirements

• During a normal pregnancy, a woman loses approximately 800mg of iron as follows:
• Fetus: 300mg
• Placenta: 50mg
• Increased red cell mass: 410mg
• Blood loss: 220mg
• Maternal blood loss at delivery: 250mg
• Total 1230mg
• From this is subtracted the total amount of iron that is conserved due to a cessation of menses and contraction of the expanded blood volume after delivery which amounts of 410 mg. This net iron expenditure is approximately 800mg.
• The food and nutrition board of the National Academy of Sciences makes the following recommendations.
• Iron: 3.5mg/day
• Folic acid: 800 mcg/day (antenatal), 600 mcg/day
• Vitamin B12: 3 mg/day

Clinical Features

Signs:

• The patient has a pale appearance (conjunctiva, mucosal membrane, nail beds, and soles of the feet), as well as mild glossitis.
• Glossitis, koilonychia, brittle hair, and angular stomatitis are symptoms of iron deficiency.
• Severe anemia can cause edema of the lower limbs or anasarca, cardiac dilatation, a murmur at the heart, and heart failure.
• Splenomegaly and jaundice can occur in conjunction with hemolytic anemia.

Symptoms:

• The signs of anemia's beginning are subtle and non-specific in nature.
• In the early stages, patients frequently complain of weariness, anorexia, dyspnoea, nausea, vomiting, lassitude, and dyspnea.
• Some women may experience pica.
• Loss of appetite, dyspnea, palpitation on exercise, diarrhea, and swelling of the face and feet may occur in severe instances.

Investigation

• Blood: HB, CBC, PCV, RBC, ESR, peripheral smear, parasite.
• Urine and stool routine examination
• LFT, RFT, BUN
• Investigation for other specific types of anemia.

Effect of Anemia/ Complications

• Maternal
  • During pregnancy:
    • Preeclampsia due to malnutrition and hypoproteinaemia.
    • Intercurrent infection
    • Heart failure at 30-32 weeks of pregnancy
    • Preterm labor
  • During labor
• Uterine inertia
• Postpartum hemorrhage
• Cardiac failure could be caused by increased cardiac output.
• Obstetric shock
  • Puerperium:
• Puerperal sepsis
• Sub involution
• Failing lactation
• Puerperal venous thrombosis
• Pulmonary embolism.
• Fetal:
• Low birth weight
• Intrauterine death due to severe maternal anoxemia
• Stillbirth
• Increased neonatal death

Management

Anemic patients require special care during both the prenatal and intranasal periods. With early and sufficient treatment, the prognosis of most anemias (especially those caused by dietary factors) is very good. This patient's care necessitates a thorough history, examination, investigation, and, finally, therapy. Management of nutritional anemia entails the following steps:

1. Prevention/ prophylactic
2. Treatment/ curative

Prophylaxis

1. Avoiding multiple pregnancies: the minimum delay between pregnancies should be at least two years. So, guidance on proper family planning strategies.
2. Dietary management should include a realistically balanced diet high in iron and protein. Iron-rich foods include liver, beef, eggs, green vegetables, green pea beans, whole wheat, and so on. Iron utensils should be used for cooking rather than being tossed.
3. Supplemental iron therapy: Once the patient is nausea-free, supplementing iron should become routine. A daily dose of 60 mg iron with 1mg folic acid is an extremely efficient preventative measure.
4. Other possible causes of anemia should be treated appropriately. Hookworm infestation, diarrhea, malaria, hemorrhage, UTI, and so on.
5. Early detection of hemoglobin deficiency. Hemoglobin levels should be measured at the first antenatal visit, then again at the 28th and 36th weeks.

Treatment/ Curative

Anemia is not an illness, but rather a symptom of another condition. A proper diagnosis of the etiology of anemia and the type of hemoglobin must precede treatment.

• Hospitalization: Women with hemoglobin levels less than 10 gm/dL should be admitted for evaluation and treatment, however, this may not be possible.
• Diet: A nutritious, well-balanced diet high in protein, iron, and vitamins.
  • Tonic medication must provide effective therapy to cure the disease contributing to the cause of anemia in order to restore appetite and digestion.
• Specific therapy: The goal is to get the hemoglobin level as close to normal as feasible. The type of therapy used is determined by the severity of the anemia, the length of the pregnancy, and the accompanying complication factors.
  • Iron therapy: Fersolate tablet 200mg ferrous sulfate contains 1gm (60mg) elemental iron and is administered twice daily with or after meals. If a higher dose is required, a maximum of 6 pills per day can be administered. The treatment should be continued until the blood picture returns to normal, and then a maintenance dose of one tablet daily should be taken for at least three months after delivery to replace the iron stores.
  • Parenteral iron therapy: The indications are
    - Intolerance to oral iron
    - Chronic blood loss
    - Malabsorption
    - When a rapid response is required in late pregnancy
    - Hemoglobin between 5-8 gm%

A daily dose of 100 mg (2ml) is given intramuscularly to the buttock muscles. An extra 500 milligrams of iron may be given to replace the body's iron stores.

• Folic acid therapy: I/M folic acid at 1mg/day for 7 days in megaloblastic anemia.
• Vitamin B12 therapy: In the event of a vitamin B12 shortage, 250 mg of cyanocobalamin is given I/m once a month.
• As a last option, blood transfusions and packed cell transfusions should be administered slowly and carefully.
• With each unit of blood, provide 40 mg I/V of frusemide.

Management During Labor

First Stage of Labor

• The patient should be placed in bed and raised up on her left side.
• For pain treatment, light analgesics should be administered.
• A plan for oxygen inhalation should be kept on hand in order to boost the oxygenation of the maternal blood and thereby reduce the danger of fetal hypoxia.
• To avoid puerperal infection, strict asepsis must be maintained.

Second Stage of Labor

Wait for standard delivery; do not rush delivery.

Third Stage of Labor

Active control of the third stage of labor to avoid blood loss. During the third stage, one must be extremely vigilant. Significant blood loss should be replenished as soon as possible.

Note: Check Hb and PCV for an anemic mother with minimal blood loss. If a blood transfusion is required, the packed cell should be utilized to avoid heart overload.

Management During Puerperium

• The patient should be lying down.
• Any infection should be discovered and treated as soon as possible.
• Iron and folate therapy should be continued for up to three months, and family planning should be advised.
• Advice on proper diet, rest, and infection-prevention measures.

Nursing considerations in general for pregnant clients with anemia include:

• Nutritional intake and status evaluation
• Examine for signs of weariness, pallor, sore tongue, anorexia, nausea and vomiting, stomatitis, infection, and extreme pain (due to veno-occlusive crisis).
• Examine and track hematologic laboratory data.
• Encourage the customer to consume iron and folic acid-rich foods such as green leafy vegetables, fish, meat, poultry, eggs, and legumes.
• Teach how to prepare food to avoid iron and folic acid loss (steaming with a small amount of water)
• Encourage the consumption of vitamin C-rich foods for iron absorption. Emphasize a fiber- and fluid-rich diet to avoid constipation (side effect of iron intake)
• In order to avoid urinary tract infections, it is also important to practice excellent cleanliness.
• Instruct a client to avoid others who are infected, as they may be susceptible to illness as well.
• Teach the client to look for indicators of preterm labor and to observe and monitor fetal well-being.
• Allow the client to rest as much as possible while still offering emotional support.