Anemia in Pregnancy: MCV, Iron and TIBC

• Total iron requirement during pregnancy is 1000mg
• RBC's require 500mg of iron (450 x 1.1), RBC volume increases by 450ml in pregnancy
• The fetus requires 300mg of iron
• 250mg of iron is excreted via urine, sweat, etc
• Iron is actively transported from mother to fetus
• Iron supplementation is mandatory during pregnancy
• Approximate daily iron requirement is 4-6 mg/day
• Daily dose of iron is 40-60 mg, only 10% of dietary iron is actually absorbed

Daily Iron Requirements by Trimester

• First Trimester (T1): 0.8mg/day
• Third Trimester (T3): 7.5mg/day

Disease Burden of Anemia

• 50% of females in India are anemic
• Anemia is responsible for half of global deaths
• Anemia is a major indirect cause of maternal mortality

Anemia Mukt Bharat Programme details:

• Also known as I-NIPI (Intensified National Iron Plus Initiative)
• Launched in 2018 to provide free iron and folic acid (IFA) tablets to all women

Each Tablet (Red Pill) Contains

• 60mg of elemental iron (Ferrous Sulphate)
• 500mcg of Folic Acid: which is the RDA in pregnancy

6x6x6 Programme comprises of

• 6 beneficiaries: pregnant and non-pregnant women of reproductive age
• 6 Interventions
• 6 institutional methods

Interventions for Anemia Prevention

• Digital hemoglobinometer: Screening
• IFA tablets: Prevention.
  • Pregnant female: 400mg Albendazole (in 2nd trimester)
  • Non-pregnant: 400mg Albendazole (Bi-annually)
• Deworming
• Delayed cord clamping
• Food fortification
• Addressing other causes of anemia

IFA Tablets Details

• Non-pregnant females (20-49 yrs): 1 pill/week
• If pregnancy is planned: Only folic acid taken to prevent NTD, ideally started 1 month prior to conception Pregnant females:
  • First 3 months: Folic acid
  • 4th month onwards: Iron + Folic acid/Red pill(Prevention)
    • Dose: 1 tablet/day
    • Duration: Throughout pregnancy + 180 days after delivery (to replenish iron stores)

Correct methods of consuming IFA tablets

• Ideal time: 2 hours after meals
• A minimum of 2 hours gap between IFA tablet & Calcium tablets
• Should not be taken along with tea/milk

Anemia definitions based on Hemoglobin Levels:

• Normal Hemoglobin levels is > 11 gm%
• Anemia is defined when Hemoglobin levels are < 11 gm%

Physiological vs Pathological Anemia

Physiological Anemia

• Hemoglobin: > 11 gm%
• Hemodilution: Plasma volume increases by 40-50%, RBC volume increases by 20-30%
• Decreased Hb concentration (maximum in T2)
• Peripheral smear: Normocytic normochromic

Pathological Anemia

• Hemoglobin: < 11 gm%
• Due to underlying pathological conditions
• Peripheral smear: Microcytic hypochromic indicates Iron deficiency anemia, Macrocytic indicates Folic acid deficiency

Causes of Anemia

• Physiological: Hemodilution
• Pathological:
  • Acquired – Nutritional deficiencies (most common), Hemolytic anemia, Anemia of chronic disease, Aplastic anemia
  • Inherited – Thalassemia (Western India), Sickle cell anemia (Central India), Inherited hemolytic anemia, Other hemoglobinopathies

Noteworthy points about anemia.

• Physiological anemia is the most common cause of anemia in pregnancy
• Iron deficiency anemia (IDA) is the most common pathological cause of anemia in pregnancy

Definitions as per WHO

• Anemia: <11g/dl
  • Mild: 10-10.9g/dl
  • Moderate: 7-9.9g/dl
  • Severe: <7g/dl

Definitions as per ICMR

• Additional category: very severe anemia is when Hb < 4g/dl.

CDC guidelines for Hemoglobin Levels by Trimester are:

• 1st Trimester: <11gm/dl
• 2nd Trimester: < 10.5 gm/dl
• 3rd Trimester: <11gm/dl

Maternal Effects of Anemia (Antenatal)

• Placentomegaly to compensate for poor fetal oxygenation
• Preterm labor (PTL) / PROM secondary to maternal stress
• Infections
• Congestive heart failure (CHF) secondary to severe anemia
• Pregnancy-induced hypertension secondary to placentomegaly
• Abruptio placenta/APH secondary to folic acid deficiency

Maternal Effects of Anemia

• Intranatal causes: uterine inertia, maternal exhaustion
• Postnatal causes: PPH, Subinvolution of uterus, Sepsis, Venous thromboembolism, Postpartum depression, Poor wound healing, CHF Most common time that these complications might arise: Immediately postpartum due to a maximum increase in cardiac output

Fetal Effects of Anemia

• Fetus derives iron from the mother against concentration gradient, hence maternal anemia leads to fetal anemia
  • Prematurity/preterm labor
  • Low birth weight

Clinical Aspects related to History Taking

• Fatigue/lethargy/light headedness
• Progressive dyspnea
• Palpitations: Rule out heart disease
• Orthopnea
• Edema
  • Physiological: Relieved by rest
  • Pathological: Protein deficiency
• Loss of appetite
• Passage of worms in stool
• Bleeding tendencies like Hematuria/hematemesis

Past History Considerations

• Chronic diseases (Rheumatoid arthritis/CKD/CLD)
• Pica, Tuberculosis, Hyperemesis gravidarum

Menstrual History

• History of menorrhagia
• Assess amount of blood loss (Based on number of sanitary pads used)

Previous Pregnancy Considerations

• Use of parenteral iron
• Blood transfusions
• Repeated abortions

Physical Examination for pallor

Sites assessed:

• Conjunctiva
• Oral mucosa
• Nail bed
• Palmar crease
• Vaginal mucosa

Nail signs to check for:

• Koilonychia (Distorted nails): IDA

• Koilonychia (Distorted nails): IDA

• Yellowish discoloration indicating Hemolytic anemia

• Glossitis/Cheilosis could indicate Folic acid deficiency

Things to consider w/ JVP

• JVP is normal in pregnancy
• Measured in semi-reclined position (45°)

• 8 cm of H2O (3 cm above clavicle): marker of CHF

• Leg ulcers indicate sickle cell anemia
• Lymph node enlargement Rules out chronic diseases (TB, malignancy)

Laboratory Diagnosis

Indian Guidelines (MOHFW) recommends and indicates importance

• Hb checked 4 times during each antenatal visit
• Screening is indicated if Hemoglobin levels are: Hb < 11 gm%

Diagnostic Tests to conduct and utilize

• Complete Blood Count + Reticulocyte count
• Peripheral smear
• Hb electrophoresis (Suspected sickle cell anemia/ thalassemia)

International Guidelines

• Hb is checked twice
  • 1st antenatal visit
  • 24-28 weeks of gestation

Diagnostic Testing and RBC Indices

• Mentzer Index = MCV / RBC count
  • Use: differentiate between IDA & Thalassemia < 13: Thalassemi

  • 13: IDA

Mean Corpuscular Volume (MCV)

• Normal range in pregnancy: 75-100 fL (Average: 80-85)
• Use: differentiate between microcytic & macrocytic anemia

Volume categories

mcv < 75 fL (microcytic anemia)

• IDA (MCHC < 30%)
• Thalassemia
• Sideroblastic anemia (Lead poisoning)
• Anemia of chronic disease (Or normocytic normochromic)

mcv > 100 fL (macrocytic anemia)

• Vit B12 deficiency
• Folic acid deficiency
• Anemia of liver disease
• Thyrotoxicosis

Noteworthy Markers of IDA is

• Most sensitive RBC index: MCHC

• Normal during pregnancy: 34-37%.

• IDA: < 30%.

• Most sensitive/earliest/best marker: Serum ferritin which also is the storage form of Iron

Normal Serum ferritin (iron) values

• 20-200 mcg/L: Normal iron stores

• < 20: Depletion of iron stores

• < 10: IDA Serum iron: < 40 mcg/dl is indicative of IDA

• TIBC > 410 if IDA

• Transferrin Saturation is normal at 25-50% and < 10% in cases of IDA

• IDA vs Anemia of chronic disease: Differentiated by serum hepcidin.

• Bone marrow biopsy is an invasive method for IDA

  • Absence of stainable iron is IDA
  • It is the gold standard method

Explore anemia during pregnancy, focusing on MCV levels, iron deficiency, and the Anemia Mukt Bharat Programme. Key topics include iron requirements, transport mechanisms, and IFA tablet recommendations. Learn about TIBC and transferrin saturation.