Evaluation of Risk Factors and Treatment of Peri-Partum Anemia

Iron deciency anemia (IDA) in pregnancy, i.e., prepartum anemia, is associated with premature birth, low birth weight, and small for gestational age of the newborn and is furthermore closely associated with the occurrence of anemia after delivery of a child, i.e., in the postpartum period .Post partum anemia is a common problem throughout the world. Through this study, aim of the work (frequency of post partum anemia and risk factors for its development) & objectives was done. The study showed that percentage of antepartum anemia was about 64.3% this percentage postpartum increased to about 65.4% and 13.6% of those with antepartum normal hemoglobine level became anemic and there were 12.5% anemic improved postpartum and became normal. The major causes of postpartum anemia are prepartum iron deciency/anemia in combination with excessive blood losses at delivery. Post partum anemia is not affected by demographic data, obstetric history, ante-partum u/s and partum history. Antepartum hemorrage was not signicantly associated with postpartum anemia. The more the estimated blood loss during labor the more the postpartum anemia. Through follow up of post partum anemia cases and treated it according type of anemia (oral, intravenous, folate supplementation and blood transfusion) Outcome of treatment of anemia after 8 weeks 61.02 % is improved & 38.98% is not improved. Conclusion: The major causes of postpartum anemia are prepartum iron deciency/anemia in combination with excessive blood losses at delivery. The study showed that percentage of antepartum anemia was about 64.3% this percentage postpartum increased to about 65.4% and 13.6% of those with normal antepartum hemoglobine level became anemic postpartum and there were 12.5% anemic improved postpartum and became normal.


Introduction
An adequate iron status is essential for an uncomplicated course of pregnancy, a normal development of the fetus, and maturity of the newborn (1).
Iron de ciency anemia (IDA) in pregnancy, i.e., prepartum anemia, is associated with premature birth, low birth weight, and small for gestational age of the newborn and is furthermore closely associated with the occurrence of anemia after delivery of achild, i.e., in the postpartum period (1).
Postpartum iron de ciency and anemia are associated with an impaired quality of life from a physical and a psychological point of view and constitutes a signi cant health problem both in developed and developing countries (2) Anemia after the delivery of a child (postpartum anemia) is a common problem throughout the world (3).
It has been estimated that of the ~500,000 maternal deaths occurring each year on a global scale in association with delivery, 20% are caused by peripartum hemorrhage and anemia (4,5).
Postpartum anemia is closely connected with the presence of anemia in pregnancy prior to delivery (prepartum anemia (10), which inevitably will be aggravated after delivery due to blood losses (2).
In the Western countries, the prevalence of prepartum anemia in the third trimester is markedly lower in women who have taken iron supplements during pregnancy compared with non-supplemented women. The major causes of postpartum anemia are prepartum iron de ciency/anemia in combination with excessive blood losses at delivery (10, 2).
In Europe, in selected series of healthy women after normal delivery, the prevalence of anemia (hemoglobin level <11 g/dL) 1 week postpartum is 14% in women who have taken iron supplements in pregnancy vs. 24% in non-supplemented women. In developing countries, the prevalence of postpartum anemia is considerably higher, in the range of 70%-80% (10).

Page 3/16
The post-partum period is de ned as the period during which conditions return to the non-pregnant states (6).
Some studies have focused on iron administration to prevent anemia and the results obtained during pregnancy (7).
However, in Japan, it is conventionally reported that anemia will be alleviated by the 30th day post-partum recommends dietary therapy rather than prescribing iron tablets for p.o. administration when the hemoglobin level is between 9 and 11 g/dL and mean corpuscular volume (MCV) is between 85 and 100 μm 3 . If anemia is not alleviated by the 30th day postpartum, this will impede a full recovery from the delivery and will complicate child care, resulting in increases in fatigue (8).

Aim of the work
The aim of the study is to know the percentage of post-partum anemia and what are the risk factors for its development.

Patients And Methods
This study was a prospective cross section observational study, conducted at Obstetrics and Gynecology department, during the period (from September 2018 to March 2019).
Population in patients around 6000 in one year delivered.

Per partum blood transfusion.
Steps of performance: The study includes the patients who deliver (within two weeks after delivery).
All patients were undergone the following Consent was taken from all patients Complete history taking, history of iron supplementation during pregnancy.
History of antepartum hemorrhage.
Complete clinical examination.
On admission and within two weeks after delivery, 3ml of blood was withdrawn by venipuncture into dry plastic tube containing Edeta solution.
Hemoglobin (HB) concentration, hematocrit value (HCV), and other indices(mean corpuscular hemoglobin or MCH, mean corpuscular hemoglobin concentration or MCHC, and mean corpuscular volume or MCV) was determined in laboratory using automated counters.
Cases of PPA diagnosed at Level of hemoglobin concentration <11gm/dl Case with PPA was compared with cases without PPA as regarding HB before delivery.
Estimated blood loss during labor.
Cases who need treatment were given oral or intravenous iron .,plus folic acid and vitamin B12 according to the type of anemia and cases with hemoglobin less than 6gm/dl were given blood transfusion .
Follow up CBC was done 8 weeks after delivery STATISTICAL ANALYSIS All data were collected, tabulated and statistically analyzed using SPSS 20.0 for windows (SPSS Inc., Chicago, IL, USA) and MedCalc 13 for windows (MedCalc Software bvba, Ostend, Belgium). Quantitative data were expressed as the mean ± SD & median (range), and qualitative data were expressed as absolute frequencies (number) & relative frequencies (percentage).

Results
Sample size 361 case the study showed postpartum anemia 236 case percentage of postpartum anemia is 65.4%.
The study showed that percentage of antepartum anemia was about 64.3% this percentage postpartum increased to about 65.4% and 13.6% of those with antepartum normal hemoglobin level became anemic and there were 12.5% anemic improved postpartum and became normal.
The major causes of postpartum anemia are prepartum iron de ciency/anemia in combination with excessive blood losses at delivery.
Post-partum anemia is not affected by demographic data, obstetric history , ante-partum u/s and partum history .
Antepartum hemorrhage was not signi cantly associated with postpartum anemia. The more the estimated blood loss during labor the more the postpartum anemia .Through follow up of post-partum anemia cases and treated it according type of anemia(oral , intravenous , folate supplementation and blood transfusion ) Outcome of treatment of anemia after 8 weeks 61.02 % is improved &38.98 % is not improved.

Discussion
Iron de ciency anemia (IDA) in pregnancy, i.e., prepartum anemia, is associated with premature birth, low birth weight, and small for gestational age of the newborn and is furthermore closely associated with the occurrence of anemia after delivery of achild, i.e., in the postpartum period (1).
Postpartum iron de ciency and anemia are associated with an impaired quality of life from a physical and a psychological point of view and constitutes a signi cant health problem both in developed and developing countries (9) the study showed percentage of postpartum anemia is 64.3% ,absence of postpartum anemia is 35.7% & showed that postpartum anemia is not affected by demographic data( age ,residence) In Europe, in selected series of healthy women after normal delivery, the prevalence of anemia (hemoglobin level <11 g/dL) 1 week postpartum is 14% in women who have taken iron supplements in pregnancy vs. 24% in non-supplemented women( 10). In unselected series of women who have not taken iron supplements, the prevalence of anemia (hemoglobin level <11 g/dL) 48 h after delivery is approximately 50% (2).
Postpartum anemia is closely connected with the presence of anemia in pregnancy prior to delivery (prepartum anemia which inevitably will be aggravated after delivery due to blood losses (2).
The study showed percentage of types of postpartum anemia The study showed that cases with postpartum anemia had a mean antepartum HB at 10.45 g/dl and cases without postpartum anemia had a mean antepartum HB at 12.39 and cases with antepartum anemia was signi cantly associated with postpartum anemia & percentage of antepartum anemia was about 64.3% this percentage postpartum increased to about 65.4% and 13.6% of those with antepartum normal hemoglobin level became anemic and there were 12.5% anemic improved postpartum and became normal In a Danish series in 1991 of iron-supplemented women after a normal singleton pregnancy and delivery (11), the mean hemoglobin concentration 1 week postpartum was12.7 g/dL (95% CI 10.2-14.7), whereas non-supplemented women had a mean hemoglobin of 11.8 g/dL (95% CI 9.7-13.9) The study showed percentage of types of antepartum anemia Studies on healthy Scandinavian pregnant women without iron de ciency, singleton pregnancy, and living at sea level (11,12,13 ,14) have shown that in late third trimester, the fth percentile for the hemoglobin concentration is 11-11.1 g/dL and the lower reference value of the 95% con dence interval (CI), corresponding to the 2.5th percentile, is 10.8g/dL.
The study showed that antepartum hemorrhage was not signi cantly associated with post-partum anemia The study showed that the more the estimated blood loss during labor the more the postpartum anemia.
In a Dutch study ( 15) comprising 367 women with vaginal deliveries and a low risk of postpartum hemorrhage ,blood losses within 1 h of delivery of placenta were measured by a gravimetric method.
In New South Wales blood losses >500 ml were observed in 13.1% of deliveries. Among deliveries in Norway in 1999-2004, severe obstetric hemorrhage >1,500 ml within 24 h postpartum occurred in 1.1% (17).
Postpartum hemorrhage occurs in 4-6% of all deliveries (18) but there are considerable discrepancies between blood losses estimated by midwifes/obstetricians and true blood losses.
This study showed that 71.18% treated by oral iron, 25.42% treated by IV iron, 3.38% treated by blood transfusion & outcome of treatment of anemia after 8 weeks 61.02% is improved & 38.98% is not improved.
In women taking 66 mg ferrous iron/day during pregnancy, anemia (hemoglobin level <11 g/dL) at 1 week postpartum was observed in 14% vs. in 22% of women taking placebo tablets (20,11). Eight weeks postpartum, anemia (hemoglobin level <12.1 g/dL) was observed in 6%-8% of women who had been taking iron vs. 16% in women taking placebo (11,20,21). Oral iron therapy should be the rst therapeutic option in women having slight-to-moderate IDA with hemoglobin levels of 9.5-12 g/dL.
Such high doses of iron should preferably be administered between meals as a sustained release iron preparation in order to optimize absorption and reduce gastrointestinal side effects (23). Following treatment for 2 weeks, the therapeutic response should be checked by measurement of hemoglobin. In order to keep the solution stable, iron sucrose should be dissolved in a maximum of 200 ml isotonic saline, infused over a minimum of 30 min ; repetitive doses should be administered with a minimum of 3-days interval ( 22). At profound anemia with hemoglobin level of <6 g/dl, blood transfusion should be considered (23).

Conclusion
The major causes of postpartum anemia are pre-partum iron de ciency/anemia in combination with excessive blood losses at delivery.