Iron metabolosm and anemia in pregnancy

Total iron content in the body is 38mg/kg and 70% of them are found in the hemoglobin and 30% in tissues.Iron loss from the body is not under regulation. Usual losses are in the form of menstrual loss and epithelial desquamation from the gut and skin. These losses amount to about 2mg/day. The iron balance is maintained by the iron absorption. Iron absorption is regulated by the amount of iron stores and the rate of erythropoiesis.

Iron absorption takes place at duodenum. Organic heme iron is well absorbed where as inorganic non-heme iron is poorly absorbed. Phytates, phosphates and tannin inhibit iron absorption. This factor has to be born in mind when dietary advice is given to the patient.

In pregnancy placental lactogen stimulates the erythropoietin secretion and produces bone marrow hyperplasia. This results in linear gradual increase in red cell mass, which reaches the peak of about 25% increase by 32-34 weeks of POA. This increase in red cell mass is enhanced by iron and folate supplementation.

Plasma volume too increases by about 40% and the net result is dilution of blood and dilutional (relative/physiological) anemia despite of increase in red cell mass. This factor has to be in mind when interpreting the Hb levels (normal is about 10-11g/dl) and hematocrit levels (normal is about 35%) in pregnancy.

Iron loss via menstrual blood (about 360mg) is saved during pregnancy. But the fetus totally depends on maternal circulation for its iron need (about 500mg). Also the need of iron is increased during pregnancy due to the increased red cell production (by about 500mg) and storage for future lactation (by about 180mg). Additional loss (of about 180mg) will occur at the time of partus. Hence, maternal intake has to be adequate to meet the net iron loss of 1000mg during pregnancy. Therefore in pregnancy iron requirement increase by about 3.6mg/day. Iron absorption is increased in pregnancy and iron supplementation in pregnancy will show good response.

Anemia in pregnancy

Anemia is a common medical disorder in pregnancy. The situation is worse in developing countries due to the poor nutritional status. Though anemia is associated with maternal mortality and morbidity, effective management can prevent most of them.

Inadequate erythropoiesis due to iron, folate and vitamin B12 deficiency and chronic blood loss are the commonest causes for anemia in pregnancy. Leukemia, sickle cell disease, thalassemia, myelodysplasias and hemolytic anemia are rare conditions but need to be born in mind while assessing the patients.

Effects of anemia in pregnancy

•     Increased risk of abortion
•     Increased risk of premature labour
•     Increased risk of intra uterine growth restriction (IUGR)
•     Lethargy
•     Ill health
•     Dyspepsia
•     Heart failure
•     Worsening of heart diseases
•     Bad prognosis following post partum hemorrhage (PPH)  and maternal death
•     Increased risk of puerperal sepsis

Intrauterine contraceptive device (IUCD)

Intrauterine contraceptive device is a device placed within the uterus in order to prevent pregnancy.Intrauterine contraceptive devices stimulate a non-inflammatory macrophage reaction and this effect is further enhance by the Copper content of it. In addition the progesterone releasing variety converts the endometrium unsuitable for implantation. As the end result sperm transportation in the upper female genital tract, ovum transport and fertilization are inhibited and implantation is impaired. These together make intrauterine contraceptive device as a very efficient method of contraception. But fertilization can occur in the fallopian tube. Efficacy of the intrauterine contraceptive device is increased when it is medicated with Copper and/or progesterone; the surface area is large and proper insertion high up in the uterus. The efficacy rate of the currently popular intrauterine contraceptive devices are about 99%. This is suitable for spacing and limitation of family. Since insertion of intrauterine contraceptive device is difficult in nullipara this is not suitable for delaying the first child.

Side effects

Abnormal menstrual bleeding, per vaginal discharge, lower abdominal cramps, back pain and infections leading to pelvic inflammatory disease are some side effects commonly seen with intrauterine contraceptive devices. Improper insertion may leads to perforation of the uterine wall usually at the time of insertion (use pull out method). Patient with uterine rupture may present with severe abdominal pain and per vaginal bleeding.Risk of perforation is during post partum when the uterus is soft. Removal of intrauterine contraceptive device is mandatory in this event. Ectopic pregnancy is a well established entry in intrauterine contraceptive device usage. When a patient complain about abnormal bleeding with abdominal pain while intrauterine contraceptive device is in situ, it is necessary to exclude ectopic pregnancy.

Contraindications for IUCD

• Known or suspected pregnancy
• Pelvic inflammatory disease
• Heart diseases - valvular or septal lesion
• Abnormal uterine bleeding
• Uterine abnormalities
• Confirmed or suspected malignancy of genital tract

As a routine intrauterine contraceptive device is perfect to be inserted at the time of menstruation since it rules out pregnancy, negotiation through cervix is easy and slight bleeding at the time of insertion goes unnoticed. Post partum intrauterine contraceptive device should be inserted after 6 weeks from delivery, but now newer devices are available, which can be inserted immediately after delivery. If the woman gets pregnant while in intrauterine contraceptive device she should be immediately referred to a specialist Obstetrician for the removal of intrauterine contraceptive device and further management.

Woman should be advised on the following:

• Bleeding per vagina for few days after insertion is normal
• First few menstrual cycles may be abnormal
• Lower abdominal pain and back pain may occur with menstruation. If disturbing can take analgesia.
• Always check for the presence of the thread especially after menstruation. Report to the clinic immediately if the thread is not felt.

The currently used intrauterine contraceptive devices can keep insitu for about 6-8 years. After insertion the woman should be reviewed frequently for two visits and later annually.

Post coital contraception with intrauterine contraceptive device

Intrauterine contraceptive device inserted within 72 hours of unprotected sexual intercourse can act as contraceptive method and prevents pregnancy.