Anemia and its management

Leaning objectives
1. To understand the diagnosis and classification of anemia in various population groups
2. To study the causes and consequences of anemia especially in pregnancy
3. To demonstrate the measures for prophylaxis of anemia in various population groups
4. To demonstrate the management of anemia in pregnancy
5. To understand the dietary sources of iron for dietary counselling

What is anemia?
Anaemia is a condition in which the number of red blood cells or the haemoglobin
concentration within them is lower than normal, resulting in decreased capacity of the blood
to carry oxygen to the body’s tissues (1). The optimal haemoglobin concentration needed to
meet physiologic needs varies by age, sex, elevation of residence, smoking habits and
pregnancy status.
(1). World Health Organization. Anaemia [Internet]. [cited 2022 Jul 28]. Available from: https://www.who.int/health-
topics/anaemia

Symptoms

• The manifestations of anemia vary by its severity and range from fatigue, weakness,
dizziness and drowsiness to impaired cognitive development of children and increased
morbidity.
• Anemia in pregnancy is associated with post-partum haemorrhage, neural tube defects,
low birth weight, premature births, stillbirths and maternal deaths.
Sign
Diagnosis and classification of anemia
Table: Hemoglobin levels to diagnose anemia (g/dl)
No Anemia
Population anemia Mild Moderate Severe
Children 6 – 59 months of age ≥11 10 – 10.9 7 – 9.9 <7
Children 5 – 11 years of age ≥11.5 11 – 11.4 8 – 10.9 <8
Children 12 – 14 years of age ≥12 11 – 11.9 8 – 10.9 <8
Non-pregnant women (15 years age & ≥12 11 – 11.9 8 – 10.9 <8
above)
Pregnant women ≥11 10 – 10.9 7 – 9.9 <7
Men (15 years of age & above) ≥13 11 – 12.9 8 – 10.9 <8

Source: WHO- Nutritional Anemia: Tools for Effective Prevention and Control, 2017

Methods for hemoglobin estimation

1. Laboratory methods: Automated hematology analyzers
It uses venous blood sample. Also used to assess other hematological parameters like
complete blood count, differential WBC count, RBC profile etc.
2. Point-of-care devices: Digital hemoglobinometers – HemoCue 201 & HemoCue 301
Uses capillary blood. Used for hemoglobin estimation at field level.
Resource: Anemia Mukt Bharat. Course for medical officers, staff nurses, ANMs, teachers,
ASHAs & AWWs on Anemia Mukt Bharat. Test and treat anemia; Testing for anemia part-2.
[video]. 2021 Sep 15. Available from: https://youtu.be/dFfkYsowGns
Causes of anemia
Causes of anemia can be broadly classified as:

Nutrition
Iron deficiency
Vitamin A, B2, B6, B12, C, D, E,
folate and copper deficiencies
Protein energy malnutrition

Infectious Genetic
Malaria, TB, HIV, parasitic Sickle cell disorders, α- and β-
infestations thalassemias, G6PD deficiency
Anemia of chronic
inflammation
Anemia in pregnancy
• Anaemia during pregnancy has been associated with poor maternal and birth outcomes,
including premature birth, low birth weight and maternal, perinatal and neonatal
mortality.
• Postpartum anaemia is associated with decreased quality of life, including increased
tiredness, breathlessness, palpitations and infections.
• Women who have anaemia postpartum may also be at greater risk of postpartum
depression.

Prophylaxis of anemia
Age group IFA prophylaxis Deworming
Children 6–59 Each ml contains 20 mg 400 mg Albendazole
months of age elemental iron + 100 mcg folic
acid Biannual
12–24 months (½ tablet)
1ml biweekly 24–59 months (1 tablet)
Children 5–9 years Contains 45 mg elemental iron 400 mg Albendazole
of age + 400 mcg folic acid
1 tablet biannually
Weekly 1 pink tablet
School-going Contains 60 mg elemental iron 400 mg Albendazole
adolescent girls + 500 mcg folic acid
and boys (10–19 1 tablet biannually
years of age) Weekly 1 blue tablet
Out-of-school
adolescent girls
(10–19 years of
age)
Women of Contains 60 mg elemental iron 400 mg Albendazole
reproductive age + 500 mcg folic acid
(20–49 years) 1 tablet biannually
(non-pregnant,
Weekly 1 red tablet
non-lactating)
Pregnant women Contains 60 mg elemental iron 400 mg Albendazole
and lactating + 500 mcg folic acid
mothers 1 tablet, after 1st
Daily 1 red tablet starting trimester, preferably
(of 0–6 months
from 2nd trimester, continued during 2nd trimester
child)
throughout pregnancy, to be
continued 180 days post-
partum.

Note: Prophylaxis with iron should be withheld in case of acute illness (fever, diarrhoea, pneumonia,
etc.), and in a known case of thalassemia major/history of repeated blood transfusion. In case of SAM
children, IFA supplementation should be continued as per SAM management protocol.

Treatment of anemia in children (6–59 months)

Anemia (Hb <11 g/dl)

Mild and moderate anemia Severe anemia

(7-10.9 g/dl) (Hb <7 g/dl)

Refer urgently
Children 6-12 Children 1-3 Children 3-5
to FRU/DH*
months years years
(6 to 10.9 kg) (11-14.9 kg) (15-19.9 kg)

Provide 1 ml Provide 1.5 Provide 2ml

IFA syrup ml syrup IFA syrup
daily for 2 daily for 2 daily for 2
months months months

Management of anemia in pregnancy

Hemoglobin level Oral iron (IFA tablet) IV iron
If haemoglobin is 60 mg elemental iron + • Anemia detected late in
10–10.9 g/dl 500 mcg folic acid) pregnancy
(Mild anemia) • Poor compliance to oral IFA
Twice daily • Hb not improving with oral IFA
 IV Iron Sucrose
If haemoglobin is 60 mg elemental iron +
or
7–9.9 g/dl (moderate 500 mcg folic acid
Ferric Carboxy Maltose
anemia)
Twice daily

If haemoglobin is Managed by medical officer at

5.0–6.9 g/dl (severe PHC/CHC/FRU/DH.
anemia)
IV Iron Sucrose
or
Ferric Carboxy Maltose

If hemoglobin is <5 Immediate hospitalization

g/dl (severe anemia)

Dietary counselling

Iron absorption Iron absorption

enhancers inhibitters

Dietary sources of iron

Veg (Non-heme iron) Non-veg (Heme iron)

• Green leafy vegetables 1. Organ meat
• Nuts 2. Poultry
• Pulses
Resource: Anemia Mukt Bharat. Test, Treat and Talk T3 anemia camp: Talk on iron and
vitamin C rich food. Test and treat anemia; Testing for anemia part-2. [video]. 2021 Sep 16.
Available from: https://youtu.be/o7LGhdlHxdc

Additional reading

1. World Health Organization. Nutritional anaemias: tools for effective prevention and
control [Internet]. [cited 2022 Jul 17]. Available from: https://www.who.int/publications-
detail-redirect/9789241513067

2. Anemia Mukt Bharat. Intensified National Iron Plus Initiative (I-NIPI). Operational
guidelines for programme managers. [Internet]. [cited 2022 Jul 17]. Available from:
https://anemiamuktbharat.info/resources/
 Antenatal care

Leaning objectives

1. Demonstrate proper history taking and examination for ANC patients

2. Identify high risk pregnancies
3. Demonstrate the screening method to identify high risk cases among the antenatal
mothers attending antenatal OPD in primary care settings and community
4. Study the prenatal advices given as a part of ANC care
5. Study the important national programmes for pregnant women (JSY and JSSK)

Antenatal care (ANC) can be defined as the care provided by skilled health-care professionals
to pregnant women and pregnant adolescent girls in order to ensure the best health conditions
for both mother and baby during pregnancy.

Objectives of antenatal care

The objectives of antenatal care are:
1. To promote, protect and maintain the health of the mother during pregnancy;
2. To detect "high-risk" cases and give them special attention;
3. To foresee complications and prevent them;
4. To remove anxiety and dread associated with delivery;
5. To reduce maternal and infant mortality and morbidity;
6. To teach the mother elements of child care, nutrition, personal hygiene, and
environmental sanitation;
7. To sensitize the mother to the need for family planning, including advice to cases
seeking medical termination of pregnancy; and
8. To attend to the under-fives accompanying the mother.

Components of antenatal care

1. Early registration of pregnancy – within 12 weeks

2. No of antenatal visits
Ideal: Once a month during the first 7 months; twice a month during the next month;
and once a week thereafter, if everything is normal.

Minimum: 4 ANC visits

• 1st visit - within 12 weeks, preferably as soon as the pregnancy is suspected, for
registration of pregnancy and first antenatal check-up
• 2nd visit - between 14 and 26 weeks
• 3rd visit - between 28 and 34 weeks
• 4th visit - between 36 weeks and term

3. History to be asked during antenatal visits

 • Record the date of 1st day of last menstrual period (LMP) and calculate the
expected date of delivery (EDD) by adding 9 months and 7 days to the LMP
and the period of gestation (POG)
• Complications during any previous pregnancy/ confinement that may have
bearing on the present pregnancy
• Symptoms indicating complications, e.g., fever, persistent vomiting, abnormal
vaginal discharge or bleeding, palpitation, easy fatigability, breathlessness at rest
or on mild exertion, generalized swelling in the body, severe headache and
blurring of vision, burning micturition, decreased or absent foetal movements etc.
• History of any current systemic illness, e.g., hypertension, diabetes, heart disease,
tuberculosis, renal disease, epilepsy, asthma, jaundice, malaria, reproductive tract
infection, STD, HIV/ AIDS etc.
• Family history of hypertension, diabetes. tuberculosis, and thalassaemia. Family
history of twins or congenital malformation
• History of drug allergies and habit-forming drugs.

4. Examinations to be done during antenatal visits

General physical examination: Pallor, pulse, respiratory rate, edema, blood pressure,
weight gain (9 – 11 kg during pregnancy or around 2kg every month after the first
trimester), breast examination.

Resource: Dr. Vikram. How to see pallor in general examination [Internet]. 2011 Nov
2. Video. Available from: https://youtu.be/TRcI8Lrt6b4

Abdominal examination:

• Measurement of fundal height

12 weeks - Uterine fundus just palpable per abdomen
24 weeks – Fundus at the level of the umbilicus
36 weeks - Fundus felt at the level of xiphisternum
 • Fetal parts, multiple pregnancy, fetal lie and presentation, fetal movements
(Leopold maneuvour)
• Fetal heart sounds
• Inspection of abdominal scar or any other relevant abdominal findings

Resource: Medicine Decoded. How to do obstetric examination? Leopold Maneuvers

[Internet]. 2022 May 28. Video. Available from: https://youtu.be/rx_yn_cN8gg

5. Investigations to be done during antenatal visits

• Hemoglobin
• Blood grouping, Rh typing
• Urine for albumin and sugar
• HIV, HBsAg, VDRL
• USG
• Screening for GDM by 75g oral glucose & measuring plasma glucose 2 hour
after ingestion. Twice in pregnancy – at first antenatal contact and at 24–28
weeks POG

Reference: Ministry of Health and Family Welfare. Screening for Syphillis during pregnancy – technical and
operational guidelines. National Health Mission. New Delhi. 2014 Sep. Available from:
http://nhm.gov.in/images/pdf/programmes/maternal-health/guidelines/Syphilis_Doc_Low-res_5th_Jan.pdf

Reference: Ministry of Health and Family Welfare. National guidelines for diagnosis and management of
Gestational Diabetes Mellitus. National Health Mission. New Delhi. 2014 Dec. Available from:
http://nhm.gov.in/images/pdf/programmes/maternalhealth/guidelines/National_Guidelines_for_Diagnosis_&_
Management_of_Gestational_Diabetes_Mellitus.pdf

6. High risk pregnancy

● Elderly primi (30 years and over)

● Short statured primi (140 cm and below) – high risk of cephalo-pelvic
disproportion
● Elderly grandmultipara – high risk for PPH
● Malpresentations, viz breech, transverse lie, etc.
● Antepartum haemorrhage, threatened abortion
● Pre-eclampsia and eclampsia
● Anaemia
● Twins, hydramnios
● Previous still-birth, intrauterine death, manual removal of placenta
● Prolonged pregnancy (14 days-after expected date of delivery)
● History of previous caesarean or instrumental delivery
● Pregnancy associated with general diseases, viz. cardiovascular disease, kidney
disease, diabetes, tuberculosis, liver disease, malaria, convulsions, asthma, HIV,
RTI, STI, etc.
● Treatment for infertility
● Three or more spontaneous consecutive abortions
7. Prenatal advice
Nutritional advice
• Well balanced diet consisting of a variety of food – cereals, pulses, milk &
dairy products, fresh/ seasonal fruits & vegetables, green leafy vegetables,
nuts, dal, for non-vegetarians egg, fish & meat.
• Consume 1 extra meal a day
• Iron rich foods – Refer to chapter on anemia
• Extra fluids

Advice for adequate rest

• 8 hours sleep at night and 2 hours rest during the day
• Lie on left side
• Avoid hard work such as lifting heavy weights

Warning signs during pregnancy

• headache
• blurring of the vision
• bleeding or discharge per vagina
• decreased/ absent fetal movements

8. Specific health protection

 Prophylaxis and treatment of anemia during pregnancy: Refer to chapter on anemia
and its management

Calcium supplementation: Oral calcium tablets to be taken twice a day (total 1g

calcium/day) starting from 14 weeks of pregnancy up to six months post-partum.
(Each calcium tablet should contain 500 mg elemental calcium and 250 IU vitamin
D3)

Reference: Ministry of Health and Family Welfare. National guidelines for calcium supplementation during
pregnancy and lactation. National Health Mission. New Delhi. 2014. Available from:
http://nhm.gov.in/images/pdf/programmes/maternal-
health/guidelines/National_Guidelines_for_Calcium_Supplementation_During_Pregnancy_and_Lactation.pdf

Tetanus prophylaxis
● 2 doses of Td vaccine – 1st dose at first ANC contact, and 2nd dose after 1 month.
● For a woman who has received Td during a previous pregnancy within the last 3
years, one booster dose will be sufficient.
● No pregnant woman should be denied Td, if she is seen late in pregnancy.
● Dose and route: 0.5 ml IM into the deltoid

9. Essential Obstetric Care

● Institutional delivery
● Skilled attendance at delivery

10. Emergency Obstetric Care

● Operationalizing First Referral Units
● Operationalizing PHCs and CHCs for round the clock delivery services

Janani Suraksha Yojana (JSY)

Conditional cash transfer scheme

Objective: To reduce maternal and neonatal mortality by promoting institutional delivery.

Eligibility:
LPS States All pregnant women delivering in Government health centres like Sub-
centre, PHC/CHC/ FRU / general wards of District and state Hospitals or
accredited private institutions
HPS States BPL pregnant women, aged 19 years and above, upto 2 live births.
All SC and ST women delivering in a government health centre like Sub-
centre, PHC/CHC/ FRU / general ward of District and state Hospitals or
accredited private institutions
Reference: Ministry of Health and Family Welfare. Janani Suraksha Yojana. National Health Mission. New Delhi. Available
from: https://nhm.gov.in/WriteReadData/l892s/97827133331523438951.pdf

Janani Shishu Suraksha Karyakram (JSSK)

Objective: to eliminate out-of-pocket expenses for both pregnant women and sick infants.

Beneficiaries:
• Pregnant women – antenatal complications, delivery, post-natal complications
• Sick newborns and infants (upto 1 year of age)
• Those accessing public health institutions

Benefits:
• absolutely free and no expense delivery, including caesarean section
• free diagnostics, drugs, diet for 3 days for normal delivery and 7 days for C-section,
blood wherever required, transport from home to institution, between facilities in case
of referral and drop back home
• exemption from user charges.

Reference: Ministry of Health and Family Welfare.Guidlines for Janani – Shishu Suraksha Karyakram (JSSK). National
Health Mission. New Delhi. Available from:
http://nhm.gov.in/images/pdf/programmes/jssk/guidelines/guidelines_for_jssk.pdf

Additional reading

1. Park K. Park’s Textbook of Preventive and Social Medicine. 25th ed. Pages 575-583

2. WHO recommendations on antenatal care for a positive pregnancy experience

[Internet]. [cited 2022 Jul 18]. Available from: https://www.who.int/publications-
detail-redirect/9789241549912

3. DC Dutta’s textbook of obstetrics, 8th edition. Pages 106-116, 255, 303-312, 326-333
Post-natal care

Leaning objectives
1. To study the components of postnatal care for the mother and newborn
2. To identify maternal complications in the postnatal period
3. To identify danger signs in the mother and the newborn in the postnatal period

Objectives of postnatal care

1. To prevent complications of the postpartum period;
2. To provide care for the rapid restoration of the mother to optimum health;
3. To check adequacy of breast-feeding;
4. To provide family planning services; and
5. To provide basic health education to mother/family.

Complications of postnatal period

 1. Puerperal sepsis - infection of the genital tract, characterized by any ≥2 of the
following signs and symptoms: (i)Fever >38° C; (ii)Abnormal, foul smelling vaginal
discharge (iii)Lower abdominal pain (iv)Subinvoluted, tender and soft uterus.
2. Thrombophlebitis
3. Secondary hemorrhage – excessive bleeding from the genital tract 24 hours after
delivery upto 6 weeks postpartum
4. Anemia in postpartum period – hemoglobin level <12 g/dl
5. Urinary tract infection – Fever >380° C with chills, burning and frequent micturition
with abdominal pain
6. Mastitis and breast abcess – painful tender breast with erythema

Postnatal visits
1. Home-based post-natal care (HBPNC): by ASHA workers

Home delivery – on days 0, 3, 7, 14, 21, 28, 42 (7 visits)

Institutional normal delivery – on days 3, 7, 14, 21, 28, 42 (6 visits)
LSCS – on days 7, 14, 21, 28, 42 (5 visits)

2. History taking and examination

• History of warning signs in mother or newborn

• History of difficulty in passing urine or stools
• Breastfeeding history and assess signs of good attachment
• Examination of mother – pulse, BP, respiratory rate, temperature, breast examination,
abdominal examination for involution of uterus, check for excessive bleeding PV or
abnormal lochia. Look for warning signs.
• Examination of mother – weight, pulse, respiratory rate, look for signs of difficulty in
breathing, jaundice, examination of the cord. Look for warning signs.

3. IFA and calcium supplementation for 6 months after delivery

4. Post-natal counselling

Breast feeding advice

• Early initiation of breast feeding within 1 hour of birth

• No pre-lacteal feeds
• Exclusive breast feeding till 6 months of age
• Burping after every feed
• Complementary feeding to be started at 6 months
• Breast feeding to be continued up to 2 years or beyond
For details refer to module on breastfeeding and complementary feeding

Advice on keeping the baby warm

• Dry the baby immediately after birth

• Skin-to-skin contact with the mother (Kangaroo mother care) – refer to reading
material 2
• Cover the baby in clean dry cloth, cover the head with cap
• Initiate breastfeeding within 1 hour of birth
 • Do not bathe the baby until at least 24 hours after birth

Danger signs in newborn

• Meiconium not passed in 24 hours

• Urine not passed by 48 hours
• Fast breathing >60 breaths/min
• Severe chest indrawing, grunting
• Fever of low body temperature
• Convulsions
• Bleeding, redness or pus at the umbilicus
• 10 or more pustules or a big boil/abscess
• Jaundice in first 24 hours of life, palms and soles are yellow
• Lethargic, unconscious or poor cry
• Baby not feeding well
• Diarrhoea with blood in stools

Danger signs in mother

• Excessive vaginal bleeding
• Foul smelling lochia
• Convulsions
• Fast/ difficult breathing
• Fever and weakness
• Severe abdominal pain
• Breast engorgement

Contraceptive advice
• For spacing the next birth or for limiting the family size
• Lactational amenorrhoea
• IUD and conventional (non-hormonal) contraceptives are the choices during the first
6 months following delivery. Oral pills should be avoided in a lactating mother as
they suppress lactation.
For details refer to module on contraception

Other advice

• Hygiene – wash hands with soap and water before feeding, changing baby’s diapers,
or cleaning the baby. Maintain perineal hygiene of the mother.
• Nutritional advice for mother – nutritious food intake to meet the need for extra
calories for lactation & plenty of oral fluids
• Avoid strenuous physical activity
• Cord care – keep cord clean and dry
• Immunization of baby – BCG, OPV-0, Hep B-0 before discharge from hospital.
Refer to module on Immunization for more details.

Additional reading

1. Park K. Park’s Textbook of Preventive and Social Medicine. 26th ed. Jabalpur:
Banarsidas Bhanot; c2021. Page 582 - 593
2. Ministry of Health and Family Welfare. Trainees’ handbook for training of medical
officers in pregnancy care and management of common obstetric complications.
National Health Mission. Kangaroo Mother Care – Page 61

3. Ghai Essential Paediatrics, 8th Edition Page 8–9, 148–150