ANEMIA IN

PREGNANCY
Dr. Ima Indirayani, Dr. ObGyn, Sp.OG
Prevalence of Anemia

■ 1/5 of maternal mortality worldwide (Berger J et al,2011)

■ Global : 40-50%
South East Asia : 48%
( W.H.O, 2005)
Definition of Anemia

■ A pathological condition in which the oxygencarrying capacity of red blood cells is

insufficient to meet the body’s need
■ Diagnosis of anemia in pregnancy :

1 st Trimester < 11 gr/dl

2 nd Trimester < 10.5 gr/dl

3 rd Trimester < 11 gr/dl

CDC 1998
Definition of Anemia

■ According to WHO definition of anemia, if Hb < 11 gr/dl or haemotocrit < 32 %

Mild anemia < 9 – 10.9 gr/dl

Moderate anemia < 7 – 8.9 gr/dl

Severe < 4 - 7 gr/dl

Very severe anemia < 4 gr/dl

Etiology of Anemia
■ Physiological anemia in Pregnancy
■ Pathological:
1. Deficiency :
- Iron deficiency Anemia
- Folic acid deficiency
- Vit. B12
- Protein deficiency
2. Haemorrahagic
- Acute : bleeding during early pregnancy or APH
- Chronic : worm infection, GI tract bleeding, bleeding piles, Gastro-
intestinal tract bleeding.
Etiology of Anemia
3. Hereditary
- Thalassemia
- Sickle cell Haemoglobinopathies
- Hereditary haemolytic anemias
4. Bone Marrow Insufficiency
5. Anemia of Infection
6. Chronic disease (Renal disease) or Malignancy (neoplasma)
Glossitis
PHYSIOLOGICAL ANEMIA IN
PREGNANCY
 Etiological Physiological Anemia
Component Change
Plasma volume ↑ by 50%
Red cell mass ↑ by 25%
Hemoglobin concentration ↓
Hematocrit ↓
Red cell count ↓
Sr. iron ↓
Sr. ferritin ↓
Sr. TIBC ↑ (increase plasma volume)

Dispropotional increased of plasma volumes to the red cell mass cause haemadilution
 physiological anemia in pregnancy
Physiological anemia in pregnancy
INVESTIGATION FINDINGS

■ Hb ↓, 𝑯𝒂𝒆𝒎𝒂𝒕𝒐𝒄𝒓𝒊𝒕 ↓, 𝑹𝒆𝒅 𝑩𝒍𝒐𝒐𝒅 𝑪𝒐𝒖𝒏𝒕 ↓,

𝑴𝑪𝑽 𝒂𝒏𝒅 𝑴𝑪𝑯𝑪 𝒏𝒐𝒓𝒎𝒂𝒍, 𝒑𝒆𝒓𝒊𝒑𝒉𝒆𝒓𝒂𝒍 𝒃𝒍𝒐𝒐𝒅 𝒔𝒎𝒆𝒂𝒓 ∶ 𝒏𝒐𝒓𝒎𝒂𝒍 𝒎𝒐𝒓𝒑𝒉𝒐𝒍𝒐𝒈𝒚
■ 𝒂𝒏𝒅 𝒄𝒆𝒏𝒕𝒓𝒂𝒍 𝒑𝒂𝒍𝒍𝒐𝒓 𝒐𝒇 𝒓𝒆𝒅 𝒃𝒍𝒐𝒐𝒅 𝒄𝒆𝒍𝒍
IRON DEFICIENCY ANEMIA
Iron requirement increase in pregnancy due to
expanding red cell mass and fetal requirement.
 FACTORS INFLUENCING IRON
ABSORPTION
• Maximum absorption : duodenum
• gastric acid and Vitamin C increased iron
• Haem iron (meat, poultry, fish,seafood) is absorbed better
than non-haem iron.
• Iron in eggs is poorly absorbed due to phosphates present
in yolk sac
• Tea, coffee, foods derived from grains (contain phytates),
dairy product will reduce iron absorption.
• GI disease that affect absorption will inhibit iron
absorption.
 IRON DEFICIENCY ANEMIA (IDA)
DIAGNOSIS
Hypochromic microcytic anemia
↓MCV
FBC ↓ MCHC
↑RDW
Hematocrit < 33%
Hypochromic microcytic anemia
FBP Pencil cells
Target cells
Sr Ferritin ↓ ( <12ng/mL)
Sr TIBC ↑
Sr iron ↓
Sr transferrin ↓
MANAGEMENT OF IDA

■ The clinical severity of the anemia from haemoglobin levels, symptoms, compliance
and gestational age determine the types of therapy for the patient
■ If oral iron is not tolerated due to the side effect, other routes of iron supplement
should be considered.
■ Parenteral iron therapy is indicated in severe malabsoprtion or non-compliance due
to intolerance of oral iron.
ORAL IRON FOR PROPHYLAXIS
■ Dietary iron intake is not enough, even in developed countries
■ Recommended to start oral iron as early as 10 weeks of
gestations.

■ Routine supplementation recommended by WHO :

■ Developed country : 30-40mg of elemental iron/day
■ Developing country : 60mg of elemental iron /day

Milman et al, 2012

ORAL IRON : TREATMENT

■ Dietary changes alone are insufficient to correct iron deficiency anaemia

and iron supplements are necessary.
■ Ferrous iron salts are the preparation of choice.

■ The oral dose for iron deficiency anaemia should be 100-200mg of

elemental iron daily
British Committee for Standards in Haematology ,2011
ORAL IRON

NAME OF DRUG IRON ELEMENTAL INCREMENT OF HB SIDE EFFECT

Fe Fumarate 65 mg GI side effects (30%):
• Nausea
Obimin 30 mg 0.8 mg/dl/week • Vomiting
• Constipation
Iberet-folic 105 mg • Abdominal cramp
PARENTERAL IRON

■ Indicated in severe malabsoprtion, non- compliance/severe intolerance to oral

therapy/excessive iron loss.
■ Faster and higher increase in Hb and body iron stores compared to oral iron
■ Especially useful for rapid correction in 3rd trimester

Milman et al, 2012

PARENTERAL IRON
NAME OF DRUG IRON ELEMENTAL ROUTE SIDE EFFECT

IRON DEXTRAN EACH VIAL IV OR IM IM:

100 MG/ 2ML • Skin discoloration,
late abscess,
formation,subcutan
eous atrophy.
IV :
Dyspnoea,chills and
rigors,
hypotension,chest
pain,
headache,anaphylactic
reactions, metallic
taste of the mouth.

Dosage (mg)= 0.66x weight (kg)x (14-pt Hb in g/dl)+500mg

PARENTERAL IRON
NAME OF DRUG IRON ELEMENTAL ROUTE SIDE EFFECT

IRON SUCROSE EACH VIAL IV Dyspnoea

20 MG/ ML • Hypotension
WITH INCREMENT OF • Muscles cramp
HB : • Dry mouth
• Diarhoea
0.16 g/dL/ day • Headache
• Nausea and
1.12 g/dL/ week vomiting
 PARENTERAL IRON
NAME OF DRUG IRON ELEMENTAL ROUTE SIDE EFFECT

IRON SUCROSE EACH VIAL IV Dyspnoea

20 MG/ ML • Hypotension
WITH INCREMENT OF • Muscles cramp
HB : • Dry mouth
• Diarhoea
0.16 g/dL/ day • Headache
• Nausea and
1.12 g/dL/ week vomiting

Elemental iron needed = (target Hb-pt Hb) x weight(kg) x 0.24 +500mg

 ORAL VS PARENTERAL IRON
■ Randomized trial of the use of oral iron versus intravenous iron sucrose for
postpartum anemia, women treated with parenteral iron had significantly higher Hb
level on day 5 and 14 compare with women on oral iron. However, by day 40 there
was no significant difference between the hemoglobin level of two groups.
ACOG, Obstet Gynecol 2008

■ Most of the practitioner used iron sucrose in cases of severe anemia (Hb level
<7g/dl).
■ Iron sucrose is efficient, safe and helped to avoid blood transfusion.
■ Commonest side effect of oral iron that contibuted to non-compliance are gastritis,
constipate and diarrhoa.
IJIFM, Hema Divankar,2012
BLOOD TRANSFUSION
MANAGEMENT OF LABOUR

■ The aim is to deliver baby vaginally

■ The second stage is more stressful as the patient is more likely to go into cardiac
failure if she is severely anemic
■ Active management of third stage, anticipating postpartum haemorrhage
■ During puerperium, excessive exertion should be avoided and iron therapy must be
continued for at least 3 months.
IJOG,2005
FOLAT DEFICIENCY ANEMIA
VIT B12 DEFICIENCY
WORM INFECTION
HAEMOGLOBINOPATHIES
SICKLE CELL SYNDROME
 TERIMA KASIH
JAZAKUNULLAH KHYRAN KATSIRAN