Foetal outcome in pregnant women with anaemia

Background: Anaemia in pregnancy is one of the most important and common public health problems not only in India but also in most of the South East Asian countries. Anaemia is the most common nutritional deficiency disorder in the world. There is predominance of iron deficiency anaemia (nutritional anaemia). In pregnancy, it is one of the leading causes responsible for adverse foetal outcome. Objective: To find out the situation and causes of anaemia in pregnant women at MMIMSR during the study period with special reference to the severity of the disease and to find out foetal outcome in pregnant women with anaemia. Methods: The study was conducted in Department of Obstetrics and Gynaecology, MMIMSR, Mullana, Ambala(India). The study was carried out between the period of october 2012 to September 2014.A total of 200 cases of moderate and severe anaemia were included in the study on the basis of simple random sampling method and 200 cases of non anaemic subjects were included to serve as controls for the anaemic group, during the study period. Hb gm/dl was taken as criteria for deciding anaemia cases and also to classify them according to the severity. Cases were classified according to WHO criteria. Results: Out of 200 cases of anaemia, 70% were moderately anaemic (Hb 7 – 9.9gm/dl) and 30% were severly anaemic (Hb < 7gm/dl). Microcytic hypochromic type of anaemia (82.5%) was more prevalent suggesting nutritional inadequacies as cause of anaemia. Adverse foetal outcome in the form of preterm birth (17%), still birth (3.5%), low birth weight babies (27.5%), neonatal morbidity (23.3%) was more in the anaemic group than non anaemic controls. Conclusion: Anaemia in pregnancy has adverse foetal outcome in the form of decreased birth weight, increased perinatal morbidity and mortality.


Introduction
Anaemia in pregnancy is one of the most important and common public health problems not only in India but also in most of the South East Asian countries.About 16% to 40% of maternal deaths occur due to anaemia.Anaemia also increases maternal morbidity significantly.Most of the pregnant patients presenting to outpatient department have iron deficiency anaemia.Along with physiological causes, social causes are also responsible for anaemia during pregnancy like early age at marriage, teenage pregnancy, ill spacing between two pregnancies and poor supplementation of iron, malnutrition, endemic diseases like malaria and worm infestations.Standards laid by WHO suggest haemoglobin below 11 gm/dl as anaemia.According to standards laid down, incidence of anaemia during pregnancy in India ranges from 65% to 75%. 1 The prevalence of anaemia all over the world is 51% and is as high as 87.5% amongst pregnant women in India. 2 Anaemia, the most preventable cause that can improve perinatal health.

Aim
To study outcome of pregnancy in cases of Moderate and Severe Anaemia.Objectives Anaemia in pregnancy is one of the most important and common public health problems not only in India but also in most of the South East Asian countries.Anaemia is the most common nutritional deficiency disorder in the world.WHO has estimated that prevalence of anaemia in pregnant women is 14 per cent in developed and 51 per cent in developing countries and 65-75 percent in India. 1 The high prevalence of anaemia is recognized to be contributory to under nutrition of the foetus and infant mortality.Adverse effects of anaemia on the foetus 1. Foetal growth restriction (FGR).2. Preterm birth.3. Intrauterine foetal deaths due to severe placental insufficiency.The incidence of still birth and preterm births have been found to decrease if iron therapy has been administered before 30 weeks of gestation.4. Long term effects: Studies have shown that severe anaemia in the mother may result in behavioural abnormalities in children and reduced cognitive skills and impaired schooling later.This is said to be due to deficiency of chemical mediators in the foetal brain as a result of maternal iron deficiency.In view of high prevalence of anaemia in pregnancy and its serious adverse consequences on both mother and baby, prevention and management of anaemia has become a very high priority in obstetric and public health practice.So, present study was carried out to observe the effects of anaemia on foetal outcome and its prevalence.

Material and methods
The present study was conducted in Department of Obstetrics and Gynaecology, MMIMSR, Mullana, Ambala.The study was carried out between the periods of October 2012 to September 2014.The objectives of the study were a) To find out the situation and causes of anaemia in pregnant women at MMIMSR during the study period with special reference to the severity of the disease.b) To find out the perinatal outcome.

Inclusion criteria
• A total of 200 cases of moderate and severe anaemia were included in the study on the basis of simple random sampling method and 200 cases of non anaemic subjects were included to serve as controls for the anaemic group, during the study period.
• Hbgm/dl was taken as criteria for deciding anaemia cases and also to classify them according to the severity.• Hbgm/dl was taken as criteria for deciding anaemia cases and also to classify them according to the severity.Antenatal women with moderate anaemia (Hb-7-9.9gm/dl)Antenatal women with severe anaemia (Hb < 7gm/ dl).Antenatal women with moderate and severe anaemia otherwise having no other medical problem.

Exclusion criteria
Antenatal women with no anaemia (Hb ≥11gm/dl) Antenatal women with mild anaemia (Hb-10-10. This table shows that mean PCV was 27.0% in the moderate anaemic group and 19.2% in the severely anaemic group. The mean MCV was 76.0fl in the moderately anaemic and 61.8fl in the severely anaemic group.
 The mean MCH was 22.37pg in the moderately anaemic and 17.91pg in the severely anaemic group. The mean MCHC was 27.4% in the moderately anaemic and 25.1% in the severely anaemic group. This shows that MCV, MCH and MCHC are all reduced in iron deficiency anaemia, which is the commonest type of anaemia in pregnancy. The mean S. Iron was 59.74 mg/dl in the moderately anaemic and 60.15 mg/dl in the severely anaemic group. The mean S. TIBC was 447.44 mg/dl in the moderately anaemic and 477.20 mg/dl in the severely anaemic group.This shows that as the iron stores decrease in iron deficiency anaemia, serum total iron binding capacity increases.95% of babies in the non anaemic group had normal Apgar score at birth and only 5% had birth asphyxia while 19.2% of babies in the anaemic group showed evidence of birth asphyxia -12.4% mildly asphyxiated, 2.6% moderately asphyxiated and 4.2% severely asphyxiated.Thus, anaemia in pregnancy is associated with lower Apgar score at birth.The overall perinatal mortality was 4% in the anaemic group and 1% in the control group.Thus, anaemia in pregnancy is associated with poor perinatal outcome.Lone FW et al 22 concluded that there was a 3.7 and 4 times greater risk of intrauterine foetal death and preterm delivery and among the anaemic women than the non-anaemic women.

Table -10: Table showing NICU admissions in the babies
In the present study, that the incidence of low birth weight babies (< 2.5 kg) was 27.5% in anaemic subjects (table no-8) as against 17% in the non anaemic subjects.This is comparable to the study conducted by Toshina V 11 , where 29.6% babies had low birth weight in anemic cases.
Similarly, in the study conducted by Meda N et al 21 , incidence of low birth weight (< 2.5 kg) was 21%.Sarin AR 10 , El Guindi W et al 12 and Geelhoed Det al 13 also concluded that maternal anaemia leads to higher incidence of low birth weight babies.
Ali AA et al 14 concluded that, the risk of LBW was 2.5 times higher in women with mild/moderate anaemia and 8.0 times higher in women with severe anaemia.
Bondevik GT et al 16  The perinatal mortality was 4% in the cases and 1% in the control group.Therefore, efforts need to be directed not only to correct anaemia but to prevent anaemia in the entire women folk of the country.Proper antenatal care is the basic requirement for prevention, early detection and treatment of anaemia.Adequate Iron and folic acid supplementation during pregnancy in iron deficient mothers improves iron status during pregnancy and postpartum period, thus providing some protection against iron deficiency in the subsequent pregnancy.Ensuring maternal iron sufficiency during gestation is the most cost effective method of preventing perinatal iron deficiency and related morbidities.

Conclusion
From the present study under discussion, it is concluded that anaemic antenatal cases suffering from moderate and severe anaemia carried adverse effects on foetal outcome in the form of decreased birth weight, increased perinatal morbidity and mortality.
(HS) 85% of anaemic women had symptoms suggestive of anaemia.The common symptoms were weakness/ fatiguability in 75%, dyspnoea/ palpitations in 37% and pedal edema in 20% of anaemic cases.97% of the control group were asymptomatic and only 3% had pedal edema due to associated gestational hypertension.Table -4: Relationship of grade of anaemia with different mean blood parameters = 0.318; P < 0.001 (HS) N * = Number of babies born live in the cases 28.5% of babies in the anaemic group had NICU admissions as against only 10% in the control group.248; P = 0.013 (HS) N*= Number of babies born live in the cases  The above table shows that neonatal morbidity was 23.3% in the anaemic group as against only 5% in the control group. The major causes of neonatal morbidity in the anaemic group were Meuconium Aspiration Syndrome (MAS) and Respiratory Distress Syndrome (RDS).Thus, anaemia in pregnancy leads to increase in neonatal morbidity.Table -12: Table showing perinatal mortality in the study subjectsPerinatal mortality Cases (N = 200) Controls (N = 200) 189; P = 0.024 (S)

Table - 6: Table showing the foetal outcome in the study subjects Foetal outcome Cases (N=200) Controls (N=200) No. of cases % No. of cases %
 Maximum cases had microcytic hypochromic anaemia accounting for 82.5% of cases. Dimorphic anaemia was present in the balance 17.5% of the cases.

Table - 7: Table showing the neonatal complications in the study subjects Complication Cases (N=200) Controls (N=200) No. of cases % No. of cases %
17% of the babies in anaemic group were preterm as against only 4% in the control group. 7.5% of babies in anaemic group and 5% in the control group had IUGR. 3.5 % of the babies were still born in anaemic group.
CC = 0.208; P = 0.059 (NS) ENND -Early Neonatal Death   0.5% of babies in anaemic group and 1% in the control group had early neonatal death. One baby in the anaemic group had congenital anomaly (Anencephaly).

Table - 8: Distribution of birth weight in the babies of study subjects Birth Weight (Kg) Cases (N=200) Controls Moderate Severe Total % N=200 %
It is evident from the above table that the incidence of low birth weight babies (< 2.5 kg) is more -27.5% in anaemic women as against 17% in non anaemic women.

Table - 9: Table showing analysis of Apgar score at 1 min
CC = 0.307; P < 0.001 (HS) N * = Number of babies born live in the cases.
18 in severe anaemia.In the study conducted by Agarwal V, mean PCV was 21.6% in moderate and 14.9% in severe anaemia.These findings are comparable with the observations of Awasthi A et al25, Preterm 9.5%, and IUD 6.5%.Similarly, Ali AA et al18concluded that there were 3.3% still births in anaemic group.Sifakis S et al 9 studied that anaemia with haemoglobin levels less than 6 gm/dl was associated with poor pregnancy outcome.Prematurity, spontaneous abortions, low birth weight, and foetal deaths were complications of severe maternal anaemia.Similarly, Sarin AR 10 also concluded that maternal anaemia was associated with poor foetal outcome.
24scussionMajority of study subjects in the present study belonged to the age group of 20-29 years, 79% in cases and 82% in the controls group (table no-1).This is comparable to the study conducted byKhandait DW et al (2001)15; in which 70% of the cases belonged to 20-29 years age group.Studies conducted by Malhotra P et al5and Sanha H et al 6 also concluded similar results.In the present study, 85% of anaemic women had symptoms suggestive of anaemia.The common symptoms were Weakness / Fatiguebility in 75%, Dyspnoea / Palpitations in 37%, Loss of Appetite in 28% and Pedal Edema in 20% cases.Malaria, fever, UTI, TB and visual blackouts were present in 1.5% cases.(tableno-3)SharmaJB 4 studied that anaemic patients complain of weakness, exhaustion and lassitude, indigestion and loss of appetite.Palpitation, dyspnoea, giddiness, edema and rarely anasarca and even congestive cardiac failure can occur in severe cases.In the present study, (table no-4) the mean PCV, MCV, MCH, MCHC and S. Iron and S.TIBC are comparable that to that studied by Agarwal V.24In the present study mean PCV was 27% in moderate anaemia and 19.
20udied that severe anaemia was associated with a significantly increased risk of low birth weight.Sangeeta VB et al19concluded that there was 2.8 times increased risk of low birth weight among cases.Bakhtiar UJ et al20found that the risk of low birth weight was 1.8 times more in anaemic mothers.The common symptoms were easy fatiguability followed by dyspnoea and palpitations, loss of appetite and pedal edema.This is statistically highly significant.Out of 200 cases of anaemia, 70% were moderately anaemic and 30% were severly anaemic.The mean PCV, MCV, MCH, MCHC and RBC count are all reduced in anaemia patients indicating that iron deficiency is the commonest type of anaemia in pregnancy.The mean S. Iron was 59.74 mg/dl in moderate anaemia and 60.15 mg/dl in the severely anaemic group.The mean S.TIBC was 447.44 mg/dl in moderate anaemia and 477.20 mg/dl in the severely anaemic group.This shows that as iron stores decrease in iron deficiency anaemia, serum total iron binding capacity increases.Microcytic hypochromic anaemia was the commonest type of anaemia (82.5%).The neonatal morbidity was 23.3% in the anaemic group and 5% in the control group with meconeum aspiration as the leading cause.This is statistically highly significant.