Problem Based Learning: Anaemia

Anemia is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet the body’s physiological requirements, which vary by age, sex, altitude, smoking habits, and during pregnancy.

Here are some problems related to anemia:

1. Problem: 

A poor anemic woman of gravida 3, and in the 3rd trimester of pregnancy has attended PHC for the 1st time. Her Hb% is 7.5 gm/dl, weight is 50 kg. How will you manage?

1.Solution:

As we can see from the case history, the risk factors we can recognize are:

• Moderate anemia
• Poverty, lack of nutrition
• Multigravida
• Lack of health-seeking behavior
• Not taken antenatal care

Investigations for the cause of anemia:

• History
• Cause of blood loss if any
• Diet practices
• Lab investigations: Complete hemogram(CBC & ESR), Stool examination for hookworms & occult blood, Iron saturation (TIBC), Serum ferritin levels. 

Management:

• A pregnant mother should have a minimum of 11 gm/dl of hemoglobin.
• Here, the woman is having only 7.5 gm/dl of hemoglobin.
• Hence, anemia should be corrected immediately by parental iron therapy.

Treatment plan for moderate anemia in pregnancy:

Calculation of Iron requirement in mg:

= (Normal Hb%➖ Patient's Hb%) ✖ Weight in kg ✖ 2.21➕ 1000

= (11-7.5) ✖ 50 ✖ 2.21 ➕ 1000

= 3.5 ✖ 50 ✖ 2.21➕ 1000

= 386.75 ➕ 1000

= 1386.75 (to round up to 1400 mg)

Hence, iron requirement is 1400 mg.

Inferon (100 mg) is given IM daily for 15 days.

Oral treatment is continued for 3 months after Hb% has returned to normal.

Assessment of hemoglobin periodically.

Preventive measures: 

The woman is advised to 

• Take more iron rich foods: Green leafy vegetables, jaggery, etc.
• Attend supplementary nutrition programmes at Anganwadi (ICDS).
• Take antenatal care (ANC).
• Take Albendazole 400 mg.
• Health education regarding anemia & it's complications.
• Improvement of socioeconomic problems.
• Plan for institutional delivery.
• Plan for undergoing tubectomy.

2. Problem:

What are the anatomic sites to be examined for detecting pallor?

2. Solution:

• Lower palpebral conjunctiva
• Tongue and oral mucosa
• Nails
• Palms of hands

3. Problem:

What are the advices to be given to a recipient taking the IFA tablet?

3. Solution:

• The IFA tablet should be consumed after meals to avoid gastric discomfort and nausea.
• Black stools may be passed after consuming IFA tablets.
• One can experience loose stools or constipation for some time but this will settle after some days.
• Do not take the tablets with tea, coffee or milk as these may interfere with absorption of iron.
• Do not take Calcium tablets at the same time as calcium inhibits absorption of iron.
• Pregnant or lactating women must consume the tablets daily.

4. Problem:

What are the contraindications for IFA prophylaxis?

4. Solution:

Prophylaxis with iron should not be given in case of

• Acute illness (fever, acute diarrhea, pneumonia, etc.)
• Severe acute malnutrition (SAM)
• Known case of hemoglobinopathy
• History of repeated blood transfusion.

5. Problem:

What are the measures to prevent anaemia in children?

5. Solution:

Besides the supplementation, the following measures should be taken simultaneously as long-term measures to prevent IDA in children:

• Exclusive breastfeeding promotion for the first 6 months of life.
• Adequate & appropriate complementary feeding with iron-rich foods till 2 years of age.
• Different variety of foods rich in absorbable vitamins and minerals to be included. 
• To increase the bioavailability of iron in usual diets altering the meal patterns. 
• Diagnosis, treatment & prevention of parasitic infections.
• Screening of target groups for moderate/severe anaemia and referring these cases to an appropriate health facility.

6. Problem:

How will you manage mild & severe anemia in pregnancy at PHC?

6. Solution:

7. Problem:

What are the doses of IFA for different age groups for prophylaxis of anemia?

7. Solution:

8. Problem:

What are the doses of Albendazole for different age groups for deworming?

8. Solution:

9. Problem:

What are the foods which enhance the absorption of iron & inhibit iron absorption?

9. Solution:

Enhancers of  the iron absorption:

1. Haem iron: present in meat, poultry, fish, and seafood.
2. Ascorbic acid or vitamin C: present in fruits, juice, potatoes and some other tubers and other vegetables such as green leaves, cauliflower, and cabbage.
3. Fermented or germinated food.

Inhibitors of iron absorption:
1. Cereal bran, cereal grains, high-extraction flour, legumes, nuts, and seeds.
2. Tea, coffee, cocoa, herbal infusions in general, certain spices (e.g. oregano).
3. Calcium, particularly from milk and milk products.