---

Iron Requirements During Pregnancy & NIPI / Anemia Mukt Bharat

---

PART 1: IRON DEMANDS DURING PREGNANCY

Why Pregnancy Sharply Increases Iron Needs

1. Expansion of maternal red cell mass - Plasma volume expands by ~50%, and red cell mass expands by ~450 mL, requiring ~450 mg of iron purely for new hemoglobin synthesis.
2. Fetal demands - Iron is actively transported across the placenta to the fetus regardless of maternal iron stores. This unidirectional transport prioritizes the fetus, meaning the mother goes deficient first.

---

Total Iron Requirement in Pregnancy

Source: Goodman & Gilman's, Table 45-3 - Iron Requirements for Pregnancy

---

Trimester-by-Trimester Daily Requirements

---

Iron Absorption Physiology

• Only ~10% of dietary iron is absorbed under normal circumstances.
• This is why the daily supplementation dose is 40-60 mg elemental iron - even though the daily need is 4-7.5 mg, you must give ~10x that amount to actually absorb enough.
• Heme iron (from meat/blood) is absorbed much better (~25-30%) than non-heme iron (~3-8%).
• Ascorbic acid (Vitamin C) enhances non-heme iron absorption.
• Phytates, tannins (tea), calcium, and phosphates inhibit non-heme iron absorption.
• Absorption occurs primarily in the duodenum and upper jejunum via the DMT1 (divalent metal transporter) system.

---

Mechanism of Iron Transfer to Fetus

• Transferrin (the iron-carrying plasma protein) delivers iron to transferrin receptors on the placental syncytiotrophoblast.
• Iron is internalized, released, and re-exported across the placenta via ferroportin.
• This active system ensures the fetus gets iron even when maternal stores are depleted - the mother becomes iron-deficient before the fetus does.
• Iron stores in infants are set during the last trimester (fetal iron loading), which is why preterm babies are highly vulnerable to iron deficiency.

---

Consequences of Iron Deficiency in Pregnancy

---

PART 2: ANEMIA MUKT BHARAT (AMB) & INTENSIFIED NIPI

Background and Timeline

---

The Red IFA Tablet (Given in Pregnancy)

• 60 mg of elemental iron (as ferrous sulphate)
• 500 mcg (0.5 mg) of folic acid - this is the RDA for pregnancy

Note: Your notes state 40-60 mg - the current AMB standard tablet contains 60 mg elemental iron for pregnant women.

---

The 6 x 6 x 6 Strategy

---

Dimension 1: 6 BENEFICIARIES (Target Groups)

Your notes mention "pregnant females and non-pregnant females of reproductive age" - the full programme actually covers all 6 groups including children and adolescents.

---

Dimension 2: 6 INTERVENTIONS

---

Dimension 3: 6 INSTITUTIONAL MECHANISMS (Delivery Platforms)

1. Anganwadi Centres (AWC/ICDS)
2. Schools (through WIFS - Weekly Iron Folic Acid Supplementation)
3. Primary Health Centres (PHC)
4. Community Health Centres (CHC)
5. Sub-centres/ANM (Auxiliary Nurse Midwife)
6. Hospitals/Medical Colleges

---

IFA Supplementation by Age Group

---

Intervention Details

1. Digital Haemoglobinometer (Screening)

• Used for point-of-care Hb testing, especially at ANM level, schools, and anganwadis.
• Enables rapid, accurate field diagnosis without a laboratory.
• Grading of anemia in pregnancy:
  • Normal: Hb ≥ 11 g/dL
  • Mild: 10-10.9 g/dL
  • Moderate: 7-9.9 g/dL → IV iron sucrose
  • Severe: < 7 g/dL → blood transfusion

2. IFA Tablets (Prevention + Treatment)

• The backbone of the programme.
• Must be taken with water (not milk or tea, which inhibit absorption).
• Best taken at night or between meals to reduce GI side effects (nausea, constipation).

3. Deworming with Albendazole

Important: Albendazole is contraindicated in the 1st trimester (teratogenic risk during organogenesis). It is given only from the 2nd trimester in pregnancy.

4. Delayed Cord Clamping

• AMB recommends delayed cord clamping for at least 3 minutes (some guidelines say 60 seconds minimum for term infants) after delivery.
• Allows placental blood to transfuse back to the neonate: increases neonatal blood volume by ~30% and iron stores by ~50 mg.
• Reduces risk of neonatal iron deficiency anemia, especially important in resource-limited settings.
• Evidence from Creasy & Resnik's supports this practice, noting it improves hematocrit at 2 hours of age without adverse effects on resuscitation.

5. Food Fortification

• Mandatory fortification of staple foods distributed through government platforms: PDS rice/wheat, midday meal grains, ICDS complementary foods.
• Targets the population that cannot rely on supplementation compliance alone.
• Reduces the baseline iron deficiency burden in the general population.

6. Addressing Other Causes of Anemia

• Malaria - causes hemolysis; treated with antimalarials
• Haemoglobinopathies - sickle cell disease, thalassemia (endemic in tribal belts)
• Fluorosis - chronic fluoride toxicity causes anemia in endemic areas
• Vitamin B12/folate deficiency - causes megaloblastic anemia
• Infection and inflammation - causes anemia of chronic disease

---

Why Folic Acid is Combined with Iron

• Neural tube defects (NTDs) - folic acid prevents spina bifida and anencephaly when taken periconceptionally and in early pregnancy.
• Megaloblastic anemia - folate deficiency in pregnancy causes macrocytic anemia; combined with iron deficiency creates a "dimorphic anemia."
• 500 mcg is the RDA during pregnancy (higher than the normal adult RDA of 400 mcg).
• Iron alone cannot treat megaloblastic anemia; folate alone cannot treat IDA - the combination covers both.

---

Key Numbers to Remember (Exam Quick Recap)

---

• Goodman & Gilman's Pharmacological Basis of Therapeutics, Tables 45-3 and 45-4 (Iron requirements in pregnancy)
• Park's Textbook of Preventive and Social Medicine - Anaemia Mukt Bharat Strategy and NIPI
• Creasy & Resnik's Maternal-Fetal Medicine - Iron kinetics in pregnancy
• AMB Official PIB Release
• AMB Training Modules, Ministry of Health