RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.
Annexure-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1. / NAME OF CANDIDATE & ADDRESS (IN BLOCK LETTER) / Dr. SMRUTHI.C.RAJPG IN OBSTETRICS & GYNAECOLOGY
BMC & RI
BANGALORE
2. / NAME OF THE INSTITUTION / BANGALORE MEDICAL COLLEGE &
RESEARCH INSTITUTE,
BANGALORE : 560002
3. / COURSE OF STUDY & SUBJECT / M.S. IN OBSTETRICS AND GYNAECOLOGY
4. / DATE OF ADMISSION TO COURSE / 18-06-2013
5. / TITLE OF THE TOPIC / “A PROSPECTIVE STUDY OF SEVERE ANEMIA IN PREGNANCY AND ITS OUTCOME AND MANAGEMENT IN A TERTIARY CARE CENTRE”
6. BRIEF RESUME OF THE INTENDED WORK:
6.1 NEED FOR THE STUDY:
Anemia is a global problem. Its prevalence in India is about 60%1 and may increase to 80% during pregnancy2. It is a major and preventable public health problem in developing world. Anemia directly or indirectly contributes to a significant proportion 40-60% of maternal deaths in developing countires3.Anemia in pregnancy is a condition with effects that may be deleterious to mother and fetus both.
The World Health Organisation (WHO) defines anemia in pregnancy as a hemoglobin(Hb) concentration of less than 11g% and HCT < 0.334. The cut off point suggested by centers for disease control (CDC) USA is 10.5g% in the second trimester5,6.The Indian Council of Medical Research (ICMR) categorizes anemia as mild(10-10.9g%), moderate(7.0-10.0g%), severe(<7.0g%) and very severe(<4.0g%).
Effects of anemia in pregnancy are not much in mild and moderate anemia but severe anemia contributes to the major effects. During pregnancy it may cause Pre eclampsia, Abruptio placentae, preterm labour, Cardiac failure, Infections, Death. During labor it may cause Uterine inertia, Post partum hemorrhage, Cardiac failure, Shock, Death. During puerperium complications like Sepsis, Sub involution, Failing lactation, Venous thrombosis, Pulmonary embolism may be seen Fetal outcomes like Preterm birth7, Small for gestational age, IUGR, Low APGAR score, Intra uterine death/ still birth are also likely.
Anemia in pregnancy is one of the most common medical disorders in India. The factors responsible for anemia in pregnancy should be identified and eradicated. Conquering anemia is an achievable goal. If we cannot have blood banks in every district, we can atleast try and build a blood bank in every woman’s body8. Owing to high prevalence of anemia in India this study is designed to determine the outcome of severe anemia in pregnancy.
6.2 REVIEW OF LITERATURE.
Riffat Jaleel et al studied 51 pregnant women admitted for delivery and having severe anemia and compared with 108 non anemic women of similar demographic features. Maternal and perinatal complications were observed, frequency of anemia was 69.9% and that of severe anemia was 4.8%. post partum hemorrhage occurred in 9.8% as compared to 0.9%of controls. Preterm birth was seen in 23.5% cases and 10.2% controls. 29.6% babies were low birth weight and 27.8% were small for gestational age as compared to 14.5% and 8.2% of controls , respectively.
In a study conducted by El Guindi W et al, a retrospective study comparing two groups pregnant women 111 with Hb <8g%, 111 with Hb >10g%. In the anemic group iron deficiency was the most common cause of anemia(92.7%). Maternal anemia was found to be significantly associated with more frequent preterm births(29.2% v/s 9.2%) and increased low birth weight (2933g v/s 3159g)
Geelhoed D et al conducted a Cohort study in two district hospitals, incliding 157 pregnant women exposed to severe anemia (Hb<8.0g%) and 152 non exposed pregnant women (Hb >=10.9g%) . Exposed women had an increased risk of maternal death (5/157 v/s o/152) perinatal mortality was increased with exposure to Hb< 7g% and low birth weight was increased with exposure to Hb<6g%.9
In a study conducted by Naushaba Rizwan et al, a total of 1225 women were studied, 688 were in the anemic group and 537 were in the non anemic group. The prevalence of anemia was 56.1% . Risk of preterm delivery was higher in anemic group 56.25% (95% CL: 0.05-0.09). Risk of abruptio placentae was 6.4% (95% CL: 2.1-9.6). Similarly there was a high risk of retained placenta 1.3% (95% CL: 0.7-16.4), PPH 4.1% (95% CL: 1.9-16.2) respectively. There was a high risk of low birth weight 14.0% (95% CL: 1.2-2.7), perinatal mortality 2.3% (95% CL: 0.5-2.4), low APGAR score at one minute 8.9%, at 5 min 10.0%, respectively. The risk of intrauterine death also high among anemic women 2.3% (95% CL: 0.9-6.9)10.
In a study conducted by Justine A. Kavle et al, published in J Health Popul Nutr. 2008 June; 26(2): 232–240. Association between Anemia during Pregnancy and Blood Loss at and after Delivery among Women with Vaginal Births in Pemba Island, Zanzibar, Tanzania In bivariate analyses, increased blood loss at childbirth and postpartum was strongly associated with the severity of maternal anemia at enrollment (p=0.02) and at 32 weeks gestation (p=0.03) The change in hemoglobin concentration from recruitment to 36 weeks gestation was not associated with total blood loss.11
6.3 AIMS AND OBJECTIVES OF STUDY:
1. To determine the association between severe anemia and maternal outcome.
2. To determine the association between severe anemia and perinatal outcome.
7. MATERIALS & METHODS:
7.1 SOURCE OF DATA:
7.1 Study design:
Prospective study
7.2 Study area :
VVH and Bowring & Lady Curzon Hospital, BMCRI, Banglore.
7.3 Inclusion criteria:
1. All pregnant women admitted for delivery and having <7g% of Hb%
2. Singleton pregnancies.
3. Patients giving written consent for the study.
7.4 Exclusion criteria:
1. Pregnant women with mild to moderate anemia(Hb 7-10.9 g%)
2. Multiple pregnancies.
3. Severe anemia in pregnancy with other co morbidities like PIH, Gestational diabetes mellitus, Sickle cell disease, RHD, Hemoglobinopathies,Thyroid disorders, hepatobiliary disorders and placenta previa.
4. Pregnant women who have not given written consent for the study.
7.5 Study population:
Pregnant women attending OPD in VVH and Bowring & Lady Curzon Hospital, BMCRI, Banglore.
7.6 Sampling method:
All pregnant women attending OPD in Vani Vilas and Bowring and Lady Curzon Hospital, BMCRI, Bangalore.
7.7 Methodology for data collection:
This study will be conducted in Department of Obstetrics and Gynaecology in Vani Vilas Hospital and Bowring and Lady Curzon Hospital, BMCRI, Bangalore from Nov 2013 to May 2015, satisfying the inclusion and exclusion criteria. All pregnant women having Hb% < 7g%attendind OPD in Vani Vilas Hospital and Bowring and Lady Curzon Hospital , BMCRI , Bangalore. Were taken up for study. The control group were all pregnant women having Hb% >=11g% attending OPD at the same two above mentioned hospitals. After thorough history taking, appropriate investigations will be sent , the patients will be followed throughout pregnancy and their outcome and management will be studied and compared with those with the control group.
7.8 Methodology for data analysis:
Descriptive statistics will be presented as mean and percentage. Appropriate test of significance will be done to analyse the data and data will be presented in charts, table formats based on the ease of understanding.
7.8 Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so please describe briefly.
Yes, investigations required are
1. Complete hemogram
2. Packed cell volume
3. Peripheral smear
4. Serum Ferritin
5. Stool for occult blood
6. Stool for ova and cyst
7. Urine routine.
7.9 Has ethical clearance has been obtained from your institution in case of 7.8?
Yes.
8. List of references
1. Schwartz WJ, Thurnau GR. Iron deficiency anemia in pregnancy. Clin Obstet Gynecol 1995;38:443-54.
2. World HealthOrganization.WHO Global Database.Geneva:WHO,1997
3. Manjari Matah, Partha Mukherjee,Arti Matah, Preeti Matah; Anemia in pregnancy, Pankaj Desai, Narendra Malhotra, Duru Shah; Practice and Principles of obstetrics And Gynaecology for Post Graduates, 3rd edition; Sec(2) 7: 69.
4. Riffat Jaleel and Ayesha Khan. Severe anemia and adverse pregnancy outcome. Journal of Surgery Pakistan(international) 13(4)oct – dec 08
5. World Health Organization. Report of a WHO Group of Experts on Nutritional Anemias. Technical series no. 503. Genava:WHO,1972.
6. Hematological disorders.Cunningham, Levena, Bloon, Haulth, Rouse, Spong; Williams Obstetrics 23rd edition: ch 51: 1079
7. El Guindi W, Pronost J, Carles G, Largeaud M, El Gareh N, Montoyo Y, Arbeille P. Service de Gynecologie –Obstetrique, Centre Hoapitalier Frank Joly, 97320 Saint-Laurent-du-Maoni,Guyane, France.
8. Asima Mukhopadhyay, Neeraja Bhalta. Anemia; Ian Donald’s Practical Obstetrics Problems 6th edition, ch 8:155.
9. Geelhoed D, Agadzi F, Visser L, Albordepppey E, ASare K, O’Rourke P et al.; Severe anemia in pregnancy in rural Ghana: a case-control study of causes and management. Acta Obstet Gynecol Scand.2006;85(10):1165-71.
10. Naushaba Rizwan, Syed Farhan Uddin and Firdous Mumtaz. Maternal Anemia Impact on Maternal and Perinatal Outcome. An Observational Study at University Hospital of Sindh. Int.J.Med.Med.Sci. ISSN:2167-0404 vol3(1):328-331.
11. Justine A. Kavle, Rebecca J.Stoltzfus, Frank Witter, James M.Tielsch, Sabra S Khalfan and Laura E. Caulfield. J Health Popul Nutr. 2008 June;26(2):232-240.
1