7a anemia and other common problems 13-sept 2011

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Anaemia during Pregnancy and in the Postpartum period

Maternal Health DivisionMinistry of Health & Family

WelfareGovernment of India

BEMoC - Presentation 7 (a)

Session 7a

ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD



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Session Objectives

To be able to:

• Diagnose Anaemia & Malaria

• Treat Anaemia & Malaria

• Prevent Anaemia & Malaria

Refer cases of Severe Anaemia to FRU

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Anaemia




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Anaemia in Pregnancy

Definition

Anaemia is defined as Hb level < 11gm% in pregnancy or immediate post partum period.

Anaemia is grouped as (ICMR Classification)

• Mild (10-11gm %)

• Moderate (7-9.9 gm %)

• Severe (4 – 6.9gm %)

• Very severe (<4 gm %)




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Diagnosis of anaemia and its severity

Symptoms & signs Probable Diagnosis (ICMR Classification)

Haemoglobin >11 g/dlNo pallor

No clinical Anaemia

Hemoglobin 10-10.9 g/dl Mild Anaemia

Haemoglobin 7-9.9g/dlORPalmar or conjunctival pallor

Moderate Anaemia

Haemoglobin 4-6.9 g/dlAND/ ORSevere palmar and conjunctival pallor or any pallor with any of the following:* >30 breaths/minute* Easy fatiguability* Breathlessness at rest

Severe Anaemia

Haemoglobin <4 g/dlAND/ OR as severe anemia

Very Severe Anaemia




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Management

Depends on :

• Severity of anaemia

• Gestational age

Iron administered either orally or parentally requires a minimum period of 4 - 6 wks to raise the Hb to normal levels

Nutritional counselling for iron rich food(like jaggery, spinach etc)




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Management

For prophylaxis: 1 IFA tablet (with 100 mg elemental iron and 0.5 mg folic acid) once daily for 100 days starting after the 1st trimester.

Mild to Moderate anemia : • IFA tabs (100 mg elemental iron + 0.5 mg folic acid) twice daily

and to be continued during postpartum period. • Administer parenteral iron preparation if there is non compliance /

intolerance to oral iron. Moderate and Severe anaemia: May receive antihelminthic drugs

(Tab. Mebendazole 100 mg bd for 3 days or Tab. Albendazole 400 mg single dose) especially in hookworm endemic areas during 2nd/3rd trimesters of pregnancy.

Severe anemia : • Refer to FRU for further investigations & treatment. • This woman might need a blood transfusion.




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Management- Mild & Moderate Anaemia

Give IFA tablet (with 100 mg elemental iron and 0.5 mg folic acid) twice daily for 100 days & to be continued in post partum period for 3 months.

Counsel the woman on the need for compliance with treatment.

Nutritional Counselling for Iron Rich Food

• Administer parenteral iron preparation if there is non compliance / intolerance to oral iron.

Give LLINs if you are in a malaria-endemic zone.

Give the woman an antihelminthic for deworming (Tab. Mebendazole 500 mg stat , or Albendazole 400 mg stat), especially if you are in a hookworm-endemic area.




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Management – Mild & Moderate anaemia

Reassess after one month. If Hb level increases continue treatment If no improvement refer to FRU for further management If the woman of mild & moderate anemia reports in labour

• Conduct the delivery with emphasis on AMTSL

• Monitor her for 48 hours

• Check Hb level after 3 days

• Prescribe I tab (100 mg) of IFA twice daily for 6 months post partum

• Reassess her in the next postnatal visit at 6 weeks & refer to FRU if no improvement




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Management – Severe anaemia

Should ideally be managed in a CEmOC facility where blood transfusion facility is available

Refer her to FRU at the earliest If she reports in first stage of labor and there is

sufficient time or post partum refer her to FRU If she reports in active labor with delivery imminent,

• Conduct the delivery with minimal possible blood loss (AMTSL)

• Monitor the vital signs intensively during the delivery• Refer urgently to FRU after stabilizing her condition

Follow up the woman in two weeks to check the clinical progress, test results and compliance with treatment of double dose of iron (1 tablet twice a day) for 6 months postpartum.




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Counselling – Diet & Rest

Reassure the mother that she can eat normal food ; these will not harm the breast fed baby

Diet to be rich in iron & fibre Discuss about food taboos especially against food that are

nutritionally healthy Talk to family members like mother in law , husband to encourage

them to ensure that the woman easts enough & avoids heavy physical work

Take care of the mother so that she can take care of the baby Counselling on diet especially for adolescent mother IFA Supplementation Women with normal Hb are advised to take 1 IFA tablet daily for 3

months If Hb below 11 gm%, advise her to take 2 IFA tabs daily and repeat

Hb after 1 month Family support specially for girl child Rest to the Mother

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Malaria




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Screening and prophylaxis of malaria during pregnancy

No prophylaxis is recommended but insecticide treated bed nets/LLIN be given on priority basis to the all pregnant women in vulnerable population

High malaria endemic areas: Routine testing & screening for malaria on the 1st ANC & in each month by RDK tests even if she does not manifest any malaria symptoms

Non endemic areas: All clinical suspected cases (as per NVBDCP guidelines) should preferably be investigated for malaria by RDK

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Treatment in 1st Trimester




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Treatment: Uncomplicated Malaria

P. vivaxChloroquine base to be

given as under:

Day 1 4 tabs @10mg/kg


Day 3 2 tabs@5 mg/kg

P. falciparum Quinine (as tablets) 10

mg. quinine salt/kg. body weight 3 times daily for 7 days.




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Treatment: Severe and complicated malaria

Parenteral Quinine is the drug of choice in first trimester Loading dose :

• 20 mg/kg. body weight on admission (I.V. infusion in 5% Dextrose/ dextrose saline over a period of 4 hours)

• May not be given if the patient has already received quinine or if clinician feels inappropriate.

Maintenance dose: • 10 mg./kg. bw 8 hourly• infusion rate should not exceed 5 mg salt/kg bw per hour

NEVER give bolus injection of Quinine Parenteral Quinine given for minimum of 48 hours & once the patient tolerates

oral therapy, follow-up treatment is as under:• Quinine 10 mg./kg. bw three times a day to complete a course of 7 days

PLUS• Clindamycin 10mg./kg. bw 12 hrly should be given for 7 days

If Parenteral Quinine to be given after 48 hours, reduce dose to 7 mg/kg body weight 8 hourly.

Parenteral Treatment should be given for a minimum of 24 hours once started If Quinine unavailable, artemisin derivatives may be used

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Treatment of Malaria in 2nd & 3rd Trimesters




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TREATMENT:

P. vivaxChloroquine base to be

given as under:



Day 3 2 tabs@5 mg/kg

P. falciparum ACT to be given as

under:

1st day

2nd day

3rd day

AS 4 tabs 4 tabs 4 tabs

SP 3 tabs Nil Nil

AS- artesunate 50 mgSP-Sulfadoxine 500 mg + Pyrimethamine 25 mg




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Treatment: Severe and complicated malaria

Parenteral artemisin derivatives preferred in 2nd & 3rd trimesters. To be given as under:

• Artesunate 2.4 mg/kg bw iv or im given on admission then at 12

hours & 24 hours, then once a day Care should be taken to dilute artesunate powder in 5%

Sodium bicarbonate provided in the pack

• Artemether 3.2 mg/kg body weight im given on admission then 1.6

mg/kg bw per day

• Α-βArteether 150 mg daily im for 3 days




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Side effects of Quinine

Metallic taste Nausea Tinnitus Hypoglycaemia

Note: Pregnant women should not take quinine on an

empty stomach and should eat regularly, while on quinine treatment

No special diet is needed Primaquine is contraindicated during pregnancy.




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Key Messages

Prophylaxis of anaemia

Management of Anaemia

Management of Complicated and Uncomplicated Anaemia in First, Second & Third Trimesters

Referral of Severe Anaemia Cases




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Case Studies

Case Study Number 23 on page number 88 & 89 of Trainees Hands Book

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Thank you

7a anemia and other common problems 13-sept 2011

Health & Medicine

Transcript of 7a anemia and other common problems 13-sept 2011