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ANAEMIA IN PREGNANCYANAEMIA IN PREGNANCY
Commonest medical disorder in pregnancyCommonest medical disorder in pregnancy
Out of estimated 160 million deliveries occurring annuallyOut of estimated 160 million deliveries occurring annually
in the world, approx 6,00,000 women die from thein the world, approx 6,00,000 women die from thecomplications of pregnancy & child birth (W.H.O 1996).complications of pregnancy & child birth (W.H.O 1996).
Anaemia is responsible for 40Anaemia is responsible for 40--60% of maternal deaths in60% of maternal deaths indeveloping countries. It also increases perinatal mortalitydeveloping countries. It also increases perinatal mortalityand morbidity rates (W.H.O 1997).and morbidity rates (W.H.O 1997).
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DEFINITIONDEFINITION
Anaemia is a condition of low circulating haemoglobin inAnaemia is a condition of low circulating haemoglobin inwhich haemoglobin concentration has fallen below thewhich haemoglobin concentration has fallen below the
threshold lying at two standard deviations below thethreshold lying at two standard deviations below themedian value for a healthy matched population.median value for a healthy matched population.
W.H.O defines anaemia in pregnancy as haemoglobinW.H.O defines anaemia in pregnancy as haemoglobinconcentration of less than 11 g/dl and haematocrit of lessconcentration of less than 11 g/dl and haematocrit of less
than 0.33.than 0.33. The cutThe cut--off point suggested by the United States Centersoff point suggested by the United States Centers
for disease control is 10.5 gm/dl in the second trimester.for disease control is 10.5 gm/dl in the second trimester.
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ERYTHROPOIESISERYTHROPOIESIS
Confined to the bone marrow in adultsConfined to the bone marrow in adults
RBCs are formed through stages of proRBCs are formed through stages of pro--normoblastnormoblast
normoblastnormoblast reticulocytesreticulocytes mature nonmature non--nucleatednucleatedarithrocyte.arithrocyte.
After a life span of 120 days RBCs degenerate andAfter a life span of 120 days RBCs degenerate andhaemoglobin is broken down into haemosiderin and bihaemoglobin is broken down into haemosiderin and bi--
pigment.pigment.
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ERYTHROPOIESIS (Contd.)ERYTHROPOIESIS (Contd.)
For proper erythropoiesis adequate nutrients are needed:For proper erythropoiesis adequate nutrients are needed:
1.1. Minerals: Iron, traces of copper, cobalt and zinc.Minerals: Iron, traces of copper, cobalt and zinc.
2.2. Vitamins: Folic Acid, Vitamin B12, Vitamin C,Vitamins: Folic Acid, Vitamin B12, Vitamin C,Pyridoxine and riboflavinPyridoxine and riboflavin
3.3. Proteins: For synthesis of globin moiety.Proteins: For synthesis of globin moiety.
4.4. Hormones: Androgens and thyroxine.Hormones: Androgens and thyroxine.
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ERYTHROPOIETINERYTHROPOIETIN
Erythropoietin is a hormone produced by kidneys (90%) andErythropoietin is a hormone produced by kidneys (90%) and
the liver (10%)the liver (10%)
Increased secretion occurs during pregnancy due toIncreased secretion occurs during pregnancy due toplacental lactogen and progestrone.placental lactogen and progestrone.
Eryhtropoietin increases red cell volume by stimulatingEryhtropoietin increases red cell volume by stimulatingstem cells in the bone marrow.stem cells in the bone marrow.
In addition to common deficiency of folic acid and iron,In addition to common deficiency of folic acid and iron,there is a growing body of evidence to implicate vitaminthere is a growing body of evidence to implicate vitamin
A in nutritional anaemia.A in nutritional anaemia.
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PREVALENCE OF ANAEMIAPREVALENCE OF ANAEMIA
ACCORD
ING TO AGEACCORD
ING TO AGEAGE %
OFWOME
N WITH
ANY
ANEMIA
MILD
AMEMIA
MODRAT
E
ANEMIA
SEVERE
ANEMIA
NO. OF
ANEMIA
15-19 56 36.2 17.9 1.9 7,117
20-24 53.8 34.8 17.6 2.0 14,580
25-29 51.4 34.8 13.7 1.9 15,965
30-34 50.5 34.8 13.7 1.9 13,595
35-49 50.5 35.1 13.6 1.9 28,426
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Anaemia Among Women
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PREVALENCE OF ANAEMIAPREVALENCE OF ANAEMIA
IN PREGNANCYIN PREGNANCYOverall prevalenceOverall prevalence 40% of worlds population40% of worlds population
Prevalence of anaemia is 3Prevalence of anaemia is 3--4 times higher in developing4 times higher in developingcountries. Average prevalence being 56%.countries. Average prevalence being 56%.
In industrialized countries approx 18% of women areIn industrialized countries approx 18% of women areanaemic during pregnancy.anaemic during pregnancy.
In India alone the prevalence of anaemia in pregnancy is asIn India alone the prevalence of anaemia in pregnancy is ashigh as 88% (W.H.O GlobalDatabase 1997).high as 88% (W.H.O GlobalDatabase 1997).
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CLASSIFICATION OFCLASSIFICATION OF
ANAEMIA IN PREGNANCYANAEMIA IN PREGNANCYACQUIRED:ACQUIRED:
Iron deficiency anaemiaIron deficiency anaemia
Anaemia caused by blood lossAnaemia caused by blood loss Acute (APH)Acute (APH)
Chronic (Hook worm infestation, bleeding piles etc.)Chronic (Hook worm infestation, bleeding piles etc.)
Megaloblastic anaemia (Vitamin B12 and folic acidMegaloblastic anaemia (Vitamin B12 and folic aciddeficiency)deficiency)
Acquired hemolytic anaemiaAcquired hemolytic anaemia
Aplastic or hypoAplastic or hypo--plastic anaemiaplastic anaemia
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CLASSIFICATION (Contd.)CLASSIFICATION (Contd.)
HERIDITARY:HERIDITARY:
ThalassemiasThalassemias
Sickle cell haemoglobinopathiesSickle cell haemoglobinopathiesOther haemoglobinopathiesOther haemoglobinopathies
Hereditary hemolytic anaemias (RBC membrane defects,Hereditary hemolytic anaemias (RBC membrane defects,
spherocytosis)spherocytosis)
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HAEMATOLOGICALHAEMATOLOGICALCHANGES IN PREGNANCYCHANGES IN PREGNANCY
CharacteristicCharacteristic Normal AdultNormal Adult
WomenWomen
3232--34 Weeks34 Weeks
GestationGestation
Increased /Increased /
DecreasedDecreased
Plasma volume (ml)Plasma volume (ml) 26002600 38503850 1250 in1250 in
Red cell mass (ml)Red cell mass (ml) 14001400 16401640--1800*1800* IncreasedIncreased
Haemoglobin (g/dl)Haemoglobin (g/dl) 1212--1414 1111--1212 DecreasedDecreased
Red Blood Cells (10*6 /mm*3)Red Blood Cells (10*6 /mm*3) 44--55 33--44--55 DecreasedDecreased
Packed cell volumePacked cell volume 0.360.36--0.440.44 0.320.32--0.360.36 DecreasedDecreased
Mean corpuscular volumeMean corpuscular volume 8080--9797 7070--9595 DecreasedDecreased
Mean corpuscular haemoglobin (pg)Mean corpuscular haemoglobin (pg) 2727--3333 2626--3131 DecreasedDecreased
Mean corpuscular haemoglobin concentration (%)Mean corpuscular haemoglobin concentration (%) 3232--3636 3030--3535 DecreasedDecreased
Serum Iron (g/dl)Serum Iron (g/dl) 6060--175175 6060--7575 DecreasedDecreased
Total Iron Binding Capacity (g/100ml)Total Iron Binding Capacity (g/100ml) 300300--350350 350350--400400 IncreasedIncreased
Percentage Saturation (%)Percentage Saturation (%) 3030 1515 DecreasedDecreased
Requirements of iron (mg/day)Requirements of iron (mg/day) 1.51.5--2.02.0 4.04.0 IncreasedIncreased
Mean corpuscular haemoglobin = MCH Packed cell volume = PCVMean corpuscular haemoglobin = MCH Packed cell volume = PCV
Mean corpuscular haemoglobin concentration = MCHC Mean corpuscular volume = MCVMean corpuscular haemoglobin concentration = MCHC Mean corpuscular volume = MCV
Total iron binding capacity = TIBCTotal iron binding capacity = TIBC
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IRONDEFICIENCYIRONDEFICIENCY
ANAEMIAANAEMIA It is the commonest type of anaemia in pregnancy.It is the commonest type of anaemia in pregnancy.
Food iron is made up of two poolFood iron is made up of two pool
Haem Iron PoolHaem Iron PoolNonNon-- Haem Iron PoolHaem Iron Pool
Haem Iron Pool includes all food containing iron asHaem Iron Pool includes all food containing iron ashaem molecules, such as animal flesh and viscera. Itshaem molecules, such as animal flesh and viscera. Itsabsorption is 15absorption is 15--30%, but it can increase to 50% in30%, but it can increase to 50% iniron deficiency state. Its absorption is usually notiron deficiency state. Its absorption is usually notaffected by inhibitors.affected by inhibitors.
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IRONDEFICIENCYIRONDEFICIENCY
ANAEMIA (Contd.)ANAEMIA (Contd.)NonNon--Haem Iron Pool includes cereals, vegetables, milkHaem Iron Pool includes cereals, vegetables, milk
and eggs. Its absorption can be increased by enhancersand eggs. Its absorption can be increased by enhancers
and decreased by inhibitors.and decreased by inhibitors.Enhancers of absorption: Haem iron, proteins, meat,Enhancers of absorption: Haem iron, proteins, meat,
ascorbic acid, ferrous iron, gastric acidity, alcohol, lowascorbic acid, ferrous iron, gastric acidity, alcohol, lowiron stores, increased erythropoietic activity.iron stores, increased erythropoietic activity.
Inhibitors of iron absorption: Phytates, calcium, tannins,Inhibitors of iron absorption: Phytates, calcium, tannins,tea & coffee.tea & coffee.
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CAUSES OF INCREASEDCAUSES OF INCREASED
PREVALENCE OF I.D.APREVALENCE OF I.D.ADietary habits: Consumption of lowDietary habits: Consumption of low--bio availability dietbio availability diet
Food FadismFood Fadism
Defective iron absorption due to intestinal infections,Defective iron absorption due to intestinal infections,hook worm infestation, amoebiasis, giardiasis.hook worm infestation, amoebiasis, giardiasis.
Increased iron loss: Frequent pregnancies, menorrhagia,Increased iron loss: Frequent pregnancies, menorrhagia,hook worm infestation, chronic malaria, excessivehook worm infestation, chronic malaria, excessivesweating, piles.sweating, piles.
Repeated and closely spaced pregnancies and prolongedRepeated and closely spaced pregnancies and prolongedperiod of lactation.period of lactation.
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CLINICAL FEATURES
SIGNS:
a)PALLOR b)GLOSSITIS c)ULCERATION IN MOUTH
c)SOFT SYSTOLIC MURMUR IN MITRAL AREAd)CREPITATIONS AT BASE OF LUNG
SYMPTOMS:
LASITTUDE,WEAKNESS,EXHAUSTION,ANOREXIA,GIDDINESS,DYSPNOEA
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IRON REQUIREMENT INIRON REQUIREMENT IN
PREGNANCYPREGNANCYTotal iron requirement is 1000 mg.Total iron requirement is 1000 mg.
Fetus and placentaFetus and placenta ---- 300 mg300 mg
in red cell mass in red cell mass 500 mg500 mgBasal lossBasal loss 200 mg200 mg
Average requirement is 4Average requirement is 4--6mg/day.6mg/day. 2.5 mg/day in early pregnancy2.5 mg/day in early pregnancy
5.5 mg/day from 205.5 mg/day from 20--32 weeks32 weeks
66--8 mg/day from 32 weeks onwards8 mg/day from 32 weeks onwards
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SEVERITY OF ANAEMIASEVERITY OF ANAEMIA
ICMR describes four grades of anaemia depending uponICMR describes four grades of anaemia depending uponthe haemoglobin levels as shown:the haemoglobin levels as shown:
Grades of AnaemiaGrades of Anaemia Haemoglobin Value (g/dl)Haemoglobin Value (g/dl)
MildMild 99--10.910.9
ModerateModerate 77--99
SevereSevere < 7< 7
Very SevereVery Severe < 4< 4
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EFFECTS OF ANAEMIA ONEFFECTS OF ANAEMIA ON
PREGNANCYPREGNANCYMaternal effects:Maternal effects:
ANTE NATALANTE NATAL INTRA NATAL INTRA NATAL POST NATAL POST NATAL
Poor weight gainPoor weight gain Dysfunctional labourDysfunctional labour Puerperal SepsisPuerperal Sepsis
Preterm labourPreterm labour Haemorrhage & shock SubHaemorrhage & shock Sub--involutioninvolution
PrePre--eclampsiaeclampsia Cardiac failure Cardiac failure Embolism Embolism
Abruptio placentaeAbruptio placentaeInter current infectionsInter current infections
PROMPROM
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EFFECTS OF ANAEMIA ONEFFECTS OF ANAEMIA ON
PREGNANCY (Contd.)PREGNANCY (Contd.)Fetal effects:Fetal effects:
Risk of preRisk of pre--maturitymaturity
IUGR, LBW, poor apgar scoreIUGR, LBW, poor apgar scoreDepleted iron store in neonates and anaemia inDepleted iron store in neonates and anaemia in
infancy periodinfancy period
High prevalence of failure to thrive and poorHigh prevalence of failure to thrive and poorintellectual development.intellectual development.
Cardiovascular morbidity and mortality in adult lives.Cardiovascular morbidity and mortality in adult lives.
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PREVENTION OF IRONPREVENTION OF IROND
EFICIENCYD
EFICIENCY Prophylaxis of nonProphylaxis of non--pregnant womenpregnant women 60 mg of elemental60 mg of elemental
iron daily for 3 months.iron daily for 3 months.
Iron supplementation during pregnancy.Iron supplementation during pregnancy.
Routine iron supplementation is debatable in westernRoutine iron supplementation is debatable in westerncountriescountries
It has to be given in nonIt has to be given in non--industrialized countriesindustrialized countries
W.H.O RECOMMENDATION:W.H.O RECOMMENDATION: Universal oral ironUniversal oral ironsupplementation for pregnant women (60 mg ofsupplementation for pregnant women (60 mg ofelemental iron and 250 g of folic acid) for 6 monthselemental iron and 250 g of folic acid) for 6 monthsin pregnancy and additional of 3 months postin pregnancy and additional of 3 months post--partumpartum
where the prevalence is more than 40%.where the prevalence is more than 40%.
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PREVENTION OF IRONPREVENTION OF IROND
EFICIENCY (Contd.)D
EFICIENCY (Contd.) MINISTRY OF HEALTH, GOVT. OF INDIAMINISTRY OF HEALTH, GOVT. OF INDIA
RECOMMENDATION:RECOMMENDATION: 100 mg of elemental iron with100 mg of elemental iron with500 g of folic acid in second half of pregnancy for atleast500 g of folic acid in second half of pregnancy for atleast
100 days. 2 injections of iron dextran (250 mg each) given100 days. 2 injections of iron dextran (250 mg each) givenIMI at 4 weeks interval with TT injection.IMI at 4 weeks interval with TT injection.
Treatment of hook worm infestationTreatment of hook worm infestation
Single albendazole (400 mg) or mebendazole (100 mg x BD
xSingle albendazole (400 mg) or mebendazole (100 mg x BD
x3 days)3 days)
Change in defecation habits and avoidance of walking bareChange in defecation habits and avoidance of walking barefooted.footed.
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PREVENTION OF IRONPREVENTION OF IROND
EFICIENCY (Contd.)D
EFICIENCY (Contd.) Improvement of dietary habits and improving bioImprovement of dietary habits and improving bio
availability of food ironavailability of food iron
Iron fortification of food.Iron fortification of food.
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INVESTIGATIONSINVESTIGATIONS
Haemoglobin estimationHaemoglobin estimation
Peripheral blood smearPeripheral blood smear microcytosis, hypochromiamicrocytosis, hypochromia
anisocytosis, poykilocytosis and target cellsanisocytosis, poykilocytosis and target cellsRBC indicesRBC indices MCV, MCH, MCHC, MCV is theMCV, MCH, MCHC, MCV is the
most sensitive indicatormost sensitive indicator
Serum ferritin Serum ferritin first abnormal laboratory testfirst abnormal laboratory test
Transferrin saturation Transferrin saturation second to be affectedsecond to be affected
FEP FEP third test to become abnormalthird test to become abnormal
Serum transferrin receptor Serum transferrin receptor best indicatorbest indicator
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INVESTIGATIONS (Contd.)INVESTIGATIONS (Contd.)
Bone marrow examinationBone marrow examination no response to treatment afterno response to treatment after4 weeks of therapy4 weeks of therapy
Aplastic anaemiaAplastic anaemiaDiagnosis of kalaDiagnosis of kala--azarazar
Urine examinationUrine examination
Stool examinationStool examination for three consecutive daysfor three consecutive days
Other testsOther tests RFT, LFT, TSP A:G, chest xRFT, LFT, TSP A:G, chest x--ray,ray,sputum examination, etc.sputum examination, etc.
For responseFor response haemoglobin and PBS, reticulocytehaemoglobin and PBS, reticulocyte
countcount
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MANAGEMENT OF IRONMANAGEMENT OF IROND
EFICIENCY ANAEMIAD
EFICIENCY ANAEMIAAIMAIM
To correct iron deficiencyTo correct iron deficiency
To restore iron reserveTo restore iron reserve To correct associated complicating factorTo correct associated complicating factor
CHOICE OF THERAPYCHOICE OF THERAPY
Depends on severity of anaemiaDepends on severity of anaemia
Duration of pregnancyDuration of pregnancy
Associated complicating factorAssociated complicating factor
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MANAGEMENT (Contd.)MANAGEMENT (Contd.)
GENERAL TREATMENTGENERAL TREATMENT
Dietary adviceDietary advice
Treatment of associated complicating factorTreatment of associated complicating factorIRON THERAPYIRON THERAPY
OralOral
ParenteralParenteral
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ORAL IRON THERAPYORAL IRON THERAPY
For women presents in mid trimester or early thirdFor women presents in mid trimester or early thirdtrimestertrimester
For treatment more than 180 mg of elemental iron/day isFor treatment more than 180 mg of elemental iron/day isrequiredrequired
To minimize side effects, start with low doseTo minimize side effects, start with low dose
Treatment is continued till blood picture becomes normal,Treatment is continued till blood picture becomes normal,thereafter maintenance of one tablet daily for 3 months tothereafter maintenance of one tablet daily for 3 months toreplenish iron storesreplenish iron stores
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INDICATIONS OF RESPONSEINDICATIONS OF RESPONSE
TO THERAPYTO THERAPY Sense of well beingSense of well being
Improved outlook of patientImproved outlook of patient
Increased appetiteIncreased appetite
haemoglobin, haematocrit, reticulocytosis within 5 haemoglobin, haematocrit, reticulocytosis within 5--1010daysdays
If no significant clinical or haematological improvementIf no significant clinical or haematological improvementwithin 3 weeks, diagnostic rewithin 3 weeks, diagnostic re--evaluation is needed.evaluation is needed.
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INDICATIONS OF RESPONSEINDICATIONS OF RESPONSE
TO THERAPY (Contd.)TO THERAPY (Contd.)RATE OF IMPROVEMENT:RATE OF IMPROVEMENT:
After a lapse of few days haemoglobin concentration isAfter a lapse of few days haemoglobin concentration isexpected to rise at a rate of 0.7 g/dl/week.expected to rise at a rate of 0.7 g/dl/week.
CAUSES OF FAILURE OF ORAL THERAPYCAUSES OF FAILURE OF ORAL THERAPY
Incorrect diagnosisIncorrect diagnosis
Malabsorption syndromeMalabsorption syndrome
Presence of chronic infectionPresence of chronic infection
Continuous loss of ironContinuous loss of iron
Poor patient compliancePoor patient compliance
Concomitant folate deficiency.Concomitant folate deficiency.
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PARENTRAL IRON THERAPYPARENTRAL IRON THERAPY
INDICATIONS:INDICATIONS:
In tolerance to oral ironIn tolerance to oral iron
Poor patient compliancePoor patient complianceUnpredictable absorptionUnpredictable absorption
Patient near termPatient near term
ADVANTAGEADVANTAGE
No added advantage over oral iron except for certainty ofNo added advantage over oral iron except for certainty ofits administration.its administration.
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PARENTERAL IRON THERAPYPARENTERAL IRON THERAPY
Intra muscularIntra muscular
Intra venousIntra venousTwo preparationsTwo preparations Iron dextranIron dextran IM/IVIM/IV
Iron sorbitol citrateIron sorbitol citrate IMIM
IRONDEFICITIRONDEFICIT
Elemental iron needed (mg) = (Normal HbElemental iron needed (mg) = (Normal Hb Patients Hb) xPatients Hb) xWeight (kg) x 2.21 + 1000Weight (kg) x 2.21 + 1000
PARENTRAL IRON THERAPYPARENTRAL IRON THERAPY
(Contd.)(Contd.)
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PARENTRAL IRON THERAPYPARENTRAL IRON THERAPY
(Contd.)(Contd.)Simple method is to give 250 mg elemental iron for each gmSimple method is to give 250 mg elemental iron for each gmof haemoglobin below normal. Another 50 % is to be addedof haemoglobin below normal. Another 50 % is to be added
to replenish store.to replenish store.Oral IronOral Iron should be stopped atleast 24 hrs prior to therapyshould be stopped atleast 24 hrs prior to therapyto avoid toxic reaction.to avoid toxic reaction.
Iron injections are given daily or on alternate day by deepIron injections are given daily or on alternate day by deep
IMI using Z technique.IMI using Z technique.I.V. ROUTEI.V. ROUTE
Total dose in fusion (TDI)Total dose in fusion (TDI) Dose calculated by sameDose calculated by same
formulaformula
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INDICATION OF BLOODINDICATION OF BLOOD
TRANSFUSIONTRANSFUSION Severe anaemia beyond 36 weeksSevere anaemia beyond 36 weeks
Refractory anaemiaRefractory anaemia
To correct anaemia due to blood lossTo correct anaemia due to blood lossAssociated infectionAssociated infection
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MEGALOBLASTIC ANAEMIA
DEARRANGEMENT IN RED CELL MATURATION
IMPAIRED DNA SYNTHESIS
EITHER VIT B 12 OR FOLIC ACID DEFICIENY ADDISONIAN PERNICIOUS ANAEMIA DUE TO
DEFFECTIVE B 12 ABSORPTION
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FOLIC ACIDDEFICIENY
CAUSES:-
INADEQUATE INTAKE
INCREASED DEMAND DUE TO:a)d maternal tissueb)product of conception
DIMINISHED ABSORPTION
ABNORMAL DEMAND:a)twins b)infection
c)haemorrhagic states
FAILURE OF UTILISATION