Dr.

Waled abohatab
Turkish Board MD
Nasser Medical Complex
Physiological changes in the
blood, iron metabolism and folic
acid during pregnancy
 Increase in blood volume.
 Physiological dilution of blood due to
discrepancy in the increase between
plasma volume and red cell mass.
 Increase iron requirements.
 Increase iron absorption from
duodenum and jejunum.
 Increase folic acid requirements
 Definition
 By Who:Hb concentration less than
11gm/dl,the cut off point is 10.5 gm/dl in
2nd trimester.
 The value that is lower than the threshold
of two standard deviation below median
value for a healthy matched population.
 Pathologic anemia is the most common
medical disorder in pregnancy.
 Incidence: in non-industrialized countries
it’s responsible for 40-60%of maternal
deaths,
 In industrialized countries 18%of women
are anemic during pregnancy.
 Types of anemia
1. Iron deficiency anemia:microcytic
anemia.
2. Folate deficiency :macrocytic anemia.
3. Hemolytic anemia:
a. Hemoglobinopathies:AR
i. Sickle cell anemia.
ii. Thalassemia
b. G6PD deficiency-X-linked
c. Congenital spherocytosis.
***screening for anemia in pregnancy:Hb
level at booking visit,28,34wks.
 Diagnosis
1. History.
2. Examination.
3. Investigations:
a. Hb level.
b. Blod film-red cell indices:
-MCV:75-99fl.
-MCH:27-31pg
-MCHC:32-36gm/dl
c. Reticulocyte count:1-2%
d. Others: serum ferritin:15-300ug/L
serum iron:13-27umol/L
TIBC:45-72umol/L
urine ax, stool ax.
Hb electrophoresis
folic acid level>2.5ng/ml
Iron Deficiency Anemia:
A. Maternal Risks:
 Normal requirements.
 Why requirements increase in
pregnancy?
 How to achieve these requirements?
 Risk factors for developing IDA.
 1st ferritin level will decrease, then
serum iron and finally Hb level.
Iron Deficiency Anemia
 Effects of IDA on body Functions:
a. Impair muscle fxn.
b. Impair neurotransmitter activity.
c. Impair exercise tolerance.
d. Impair epithelial changes.
e. Alteration in GI fxn.
 Response to blood loss in pregnancy
 B. Fetal risks:
 How does the fetus obtain iron?
 Iron transportation.
 If maternal iron stores are depleted:
1. Anemia in first year of life.
2. Behavioral abnormalities.
3. Poor performance.
4. Development delays.
 Diagnosis:

a) Hb concentration.
b) Red cell-indices
**why MCV is a poor indicator of IDA in
pregnancy??
c) Seum iron&TIBC.
**both are not reliable indicator of IDA
why?
d) Zinc protoporphyrin
e) Ferritin.
f) Transferrin receptor.
 Prevention of iron deficiency.

 Prophylactic iron supplementation

 Who are the candidates??
 Its use is controversial.
 Goal of prophylactic iron
supplementation.
 S/E of iron supplementation.
 Concerns about iron prophylaxis:
a. Poor pregnancy outcome.
b. Increase production of free radicals
 Management of IDA.
1. Oral iron:
 Dose: elemental 100-200mg/day,ferrous
sulfate 200mg q 8hrs=195mg elemental
iron/day.
 We should continue until Hb normalizes and
should be followed be prophylactic or
maintenance doses until 3 months
postpartum.
 S/E
 How to decrease S/E.
 Response.
 If no response: what will cause unsuccessful
treatment??
 Management of IDA.
2. Parenteral iron.
 Advantaged over oral.
 Preparations:
a. Iron dextran:ferric
hydroxide(50mg/ml)
b. Iron sucrose:complex(20mg/ml)
3. Blood transfusion.
 Only indicated if severe anemia beyond
36wks.
4. Recombinant human erythropoietin
 Labor and delivery.

 No specific recommendations.
 X-matching.

 Postnatal
 Continue iron for at least 3 months in
patients with clear evidence of IDA.
 2. Folate Deficiency
A. Maternal risks.
 Folate deficiency>>>megaloblastic anemia.
 Folate decreases as pregnancy advances
reaching ½ of non-pregnant values at term why?

a. Decrease intake because of loss of appetite.

b. Increase plasma clearance of folate by kidneys.
c. Transfer of folate from mother to fetus.
d. Uterine hypertrophy and expanded red cell
mass.
 Sources of folate.
 It’s heat labile.
 Body stores.
 Incidence:0.2-5%.
 Past and current requirements of folate
B. Fetal risks.
 If folate deficient mother>>>increase
risk of megaloblastic anemia.
 Assn btwn periconceptional folic acid
deficiency and:harelip,cleft palate,NTD.
C. Diagnosis.
a. Blood film:macrocytosis,hypersegmented
neutrophils.
b. Retics count.
c. Hb level.
d. Red cell folate assay
e. BM examination: large erythroblasts,
D. Management options.
1. prepregnancy:400ug.day-prevent
NTD,fortified food.
2. Prenatal:
a) Prophylactic.
 Should be given with iron:200-300ug/day.
 Concern:risk of vit B12 def. why?
 Risk of vit B12 in pregnancy is low why?
b) Management of established folate deficiency.
 Once anemia is established treatment is more
difficult why?
 Rx:folic acid 5mg/day continued for several
wks postpartum
c) Anti-convulsants and folic acid.
d) Disorders that may affect folate
requirements:
 Hemolytic anemias.
 Thalassemia trait.

3. Labor and delivery.

4. Post natal.