ANEMIA IN PREGNANCY.

PRESENTERS:
ODEKINA OJIMA-OJO FAITH – BHU/14/01/01/0162
NICODEMUS YALSOM – BHU/14/01/01/0099
UWODI ELEOJO GIFT – BHU/14/04/07/0006
NEV TERNA FELIX – BHU/14/01/01/0075
OBASI MICHAEL NNACHI – BHU/14/01/01/0053

MODERATORS- DR.IDOKO/DR.UBANYI
OUTLINE
• INTRODUCTION
• DEFINITON
• CLASSIFICATION
• CASE PRESENTATION
• EPIDEMIOLOGY
• LITERATURE REVIEW
• HOME VISIT
• PREVENTION
• CONCLUSION
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INTRODUCTION
• Anaemia in pregnancy is a common problem in developing countries
and a major cause of morbidity and mortality.
• 20% of maternal deaths in Africa have been attributed to anaemia
• Women often become anaemic during pregnancy because of increase
in demand for iron and other vitamins due to the physiologic burden
of pregnancy; extra burden in tropical Africa due to the endemicity of
malaria
• Anemia has a significant impact on the health of the foetus and
mother, hence shouldn’t be treated with kidgloves.

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DEFINITION…
• Anaemia in pregnancy is the haemoglobin concentration of less than
11g/dl
• WHO

• However,in the developing countries and sub-Saharan Africa anaemia

is defined when the haemoglobin concentration is less than 10 g/dl or
packed cell volume less than 30%

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CLASSIFICATION
• Generally classified into two types:
1. PATHOLOGICAL ANEMIA IN PREGNANCY
2. PHYSIOLOGICAL ANEMIA IN PREGNANCY

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PATHOLOGICAL ANEMIA IN
PREGNANCY
• 1) DEFICIENCY Anaemia; e.g. iron, folate, vitamin B12, protein
• 2) HEMORRHAGIC:
• ACUTE haemorrhagic following bleeding in early months of pregnancy
or APH
• CHRONIC haemorrhagic following hookworm infestations, GI bleeding
• OTHERS:
• HEREDIATARY anaemia; e.g. haemoglobinopathies, hereditary
haemolytic anaemia
• BONE marrow insufficiency e.g. radiation, suppressant drugs
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• ANEMIA of infection e.g. malaria, tuberculosis
• CHRONIC diseases as in nephropathies and neoplastic diseases

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PHYSIOLOGICAL ANEMIA
• During pregnancy erythroid hyperplasia of the marrow occurs, and
red blood cell mass increases. However a disproportionate increase in
plasma volume results in hemodilution(hydremia of pregnancy).
• Haematocrit decreases from 38-45% in healthy women who are not
pregnant to about 34% in late pregnancy

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CASE PRESENTATION
• I present Dorcas JOHN, a 31 year old Irugwe, Christian woman, who is a
hairstylist, separated and lives in Tudun wada, Jos.
• She is a P5 + 1, 5alive woman. Last menstrual period was September, 2020
• She presented to this facility 1month ago with unconsciousness of a few
minutes duration.
• Patient was apparently well until around noon on the 10th of January when she
started experiencing dizziness and weakness which was severe enough to stop
her from her activities and call her friends for support.
• Prior to this, she experienced episodes of recurrent bleeding which started on
the 3rd of December then stopped, but she experienced another episode on
the 3rd of January.
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CASE PRESENTATION CONTD…….
• The bleeding could not be quantified but she said she continuously
used pads and thrusts and had to change them frequently cause it got
heavily soaked. It was associated with fleshy materials and pain which
she described as labour pains. The blood was bright red.
• There is a positive history of yellowish vaginal discharge associated
with vulva itchiness.
• Before presentation to this facility, she has sought for help on account
of the bleeding in a health facility where a diagnosis of complete
abortion was made and she was placed on antibiotics. Symptoms
however re-occurred leading to the unconsciousness

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CASE PRESENTATION CONTD…….
• Her index pregnancy was undesired and spontaneously achieved, it was
confirmed by ultrasound scan. 1st confinement was 14 years ago (2007) and
she was delivered of a live male neonate at term by spontaneous vaginal
delivery in the hospital. Birth weight was 2.5kg
• Her 2nd pregnancy was desired and spontaneously achieved, it was
confirmed by ultrasound scan. It was 11 years ago (2010)She delivered of a
live female neonate at term in the hospital. She cant recall the birth weight.
• Her 3rd pregnancy was desired and spontaneously achieved, it was
confirmed by ultrasound scan. It was 9 years ago (2012) and she was
delivered of a live male neonate at home via spontaneous vaginal delivery
at home, She had an episode of PPH Birth weight unknown.
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CASE PRESENTATION CONTD…….
• Her 4th pregnancy was desired and spontaneously achieved, confirmed by
ultrasound scan. 4th confinement was 6 years ago (2015) she was delivered of a
live female neonate at term via spontaneous vaginal delivery in the hospital.
Birth weight unknown.
• Her 5th pregnancy was desired and spontaneously achieved, confirmed by
ultrasound scan. 5th confinement was 4 years ago (2017) she was delivered of a
live male neonate at term via spontaneous vaginal delivery in the hospital. Birth
weight unknown.
• Her 6th and last pregnancy was undesired and spontaneously achieved, she was
unaware of the pregnancy up until the onset of her bleeding where was scanned
and a diagnosis of complete abortion made. She was then placed on antibiotics
and Flagyl
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CASE PRESENTATION CONTD…….
• She attained menarche at the age of 14, she has a regular cycle of 28 days with
a duration of 4-5 days. No menorrhagia, no dyspareunia, dysmenorrhoea.
• She is aware of contraceptives and uses implants and condoms
• She is unaware of pap smear.

• She has been admitted several times in the past for malaria, typhoid, low
blood pressure. She is not a known sickle cell disease, hypertension, asthmatic
nor seizure disorder patient
• She has been transfused in the past and has not had any significant surgical
procedure done.

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CASE PRESENTATION CONTD…….
• There is a positive history of diabetes mellitus in the father. However,
no family history of sickle cell disease, hypertension, asthma or
seizure disorder. No family history of twinning

• She is currently separated from her husband on account of lack of

support from him. Husband is a mechanic. She is a hair dresser
• She does not smoke or take tobacco in any form, neither does she
take alcohol.
• She has no known drug allergy

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CASE PRESENTATION CONTD…….
• On presentation to this facility, she was resuscitated and placed on
oxygen. She was also transfused about 2 pints of blood and placed on
some I.V. fluids.
• On ultrasound scan she was found to have had an incomplete
abortion and a manual vacuum aspiration was carried out after which
she was observed and then discharged.

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CASE PRESENTATION CONTD…….
• In summary…….
• I have presented a Para 5 + 1, 5 alive woman who presented
unconscious after episodes of blood loss per vaginum, has been
resuscitated and managed for severe anaemia, she has been
discharged and is currently doing better.

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CASE PRESENTATION CONTD…….
• On examination…..
• A woman, conscious and alert, not ill looking, not in any obvious
respiratory distress, anicteric, slightly pale, acynosed. No peripheral
lymphadenopathy. No finger clubbing, no koilonychia, no leuchonychia, no
splinter haemorrhages , capillary refill was not delayed .

• Her abdomen was full, moves with respiration, symmetrical, presence of

striae distensae, no scarification marks. Umbilicus was inverted
• No areas of tenderness, No organomegaly or masses on palpation
• Bowel sounds were heard
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CASE PRESENTATION CONTD…….
• She had a respiratory rate of 16CPM, chest wall was symmetrical, and
moved equally on respiration. Trachea is centrally placed, equal chest
expansion, tactile fremitus was felt and normal
• Resonance is normal upon percussion of all lung fields, lung sounds are
clear in all lobes bilaterally.

• Pulse rate of 61BPM- normal rhythm, no elevated jugular venous

pressure, external chest is normal in appearance with no heaves or
thrills. Apex beat not visible but palpable at the 5th IC MCL.
• 1st and 2nd heart sounds heard, no murmurs
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EPIDEMIOLOGY
Global estimates of the prevalence of anaemia, all women of
reproductive age, 15-49 years, 2011

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Global estimate of the prevalence of anaemia in
pregnant women ages 15-49 years, 2011

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DISTRIBUTION
• Anaemia in pregnancy is one of the leading causes of maternal and
perinatal mortality worldwide.
• The World Health Organization (WHO) estimates that anaemia affects
over half of all pregnant women in developing countries.
• WHO reports the prevalence of anaemia in women of reproductive
age in sub-Saharan Africa to be 57.1%, but this varies between
regions, with the in Central and West Africa (61%) and the lowest
level reported in Southern Africa (34%) in 2011.

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• Recent estimates puts the prevalence anaemia in pregnancy in Nigeria
at 60.0% , and about 7.0% are severely anaemic.
• Rural women (62%) are more likely to be anaemic than urban women
(54%).
• By state, anaemia prevalence ranges from a low of 36% in Adamawa
to a high of 74% in Sokoto.
(Nigeria 2018 Demographic & Health survey key findings)

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DETERMINANTS/RISK FACTORS
HOST FACTORS:
• Pregnant women (15-49 years)
• Nutritional deficiency;
Iron deficiency in 95% of cases
 Folate & vitamin B12 deficiency in 0.5-1.5% of cases
• Multiparity with inadequate spacing (<2years)
• Haemoglobinopathies (Thalassemia & Sickle cell anaemia)
• Maternal education
• Chronic diseases; Cardiac, Renal, Malignancies
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AGENT FACTORS:
• Late Ante-natal care booking

• Infections;
Malaria
Helminths (hookworm infestation)
HIV/AIDS

ENVIRONMENTAL FACTORS:
• Low socioeconomic status
• Rural dwellers
• Religious factors
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DETERRENTS
• Early registration for Ante-natal care (ANC) clinic
• Effective control of malaria during pregnancy
• Provision of hematinic to all pregnant women, especially in
government-owned health facilities
• Intensified health education to pregnant women during ANC to
improve knowledge on preventive health and nutrition.

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LITERATURE REVIEW
INTRODUCTION

Anaemia affects a quarter of the global population, including 293

million (47%) children younger than 5 years and 468 million (30%)
non-pregnant women. In addition to anaemia's adverse health
consequences, the economic effect of anaemia on human capital
results in the loss of billions of dollars annually (Balarajan,
Ramakrishnan, Özaltin, Shankar, Subramanian 2011).
Anaemia in pregnancy, defined as a haemoglobin concentration
<11g/dL, affects more than 56 million women globally, two thirds
of them being from Asia (Goodewardene 2012).

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The World Health Organization’s (WHO) recommendation is that
anaemia in pregnancy is present when the haemoglobin
concentration in the peripheral blood is 11g/dL or less. However,
from practical experience in tropical obstetrics, it is generally
accepted that anaemia in pregnancy exists when the haemoglobin
concentration is less than 10g/dL or the packed cell volume (PCV) is
less than 30 percent (Agboola 2006).
This literature review examines the common aetiology, prevalence of
anaemia especially in the tropics. It also explores the risk groups of
anaemia in pregnancy, effects of anaemia in the mother and fetus,
prevention and management strategies and the role of sickle cell
disease in pregnancy.

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 AETIOLOGY
Unlike Hypertensive diseases in pregnancy, anaemia in
pregnancy lacks a standard classification based on aetiology
and pattern. Chowdhury, Rahman, Moniruddin (2014)
classifies anaemia grossly into two types; Pathological
anaemia in pregnancy and physiological anaemia in
pregnancy. Pathogical anaemia is further sub classified into
deficiency anaemia (iron, folate, vitamin B12 and protein
deficiencies) and hemorrhagic anaemia. Haemorraghic
anaemia is caused by acute(bleeding in early pregnancy and
APH) and chronic haemorrhagic conditions due to infections,
hereditary, bone marrow insufficiency and chronic diseases.
This classification provides the closest approach to a
standardized manner of classifying anaemia in pregnancy.
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The mechanism of physiological anaemia is due to hemo-
dilution and water retention effect of progesterone (Jadhav 2019).
Normally during pregnancy, erythroid hyperplasia of the marrow
occurs, and red blood cell (RBC) mass increases. However, a
disproportionate increase in plasma volume results in
hemodilution (hydremia of pregnancy): hematocrit (Hct) decreases
from between 38% and 45% in healthy women who are not
pregnant to about 34% during late single pregnancy and to 30%
during late multifetal pregnancy (Friel 2020).

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Despite decades of public health interventions, anaemia in
pregnancy remains a major health problem worldwide,
with an estimated 41.8% of pregnant women being
diagnosed with anaemia at some point in their gestation
according to the WHO. At least half of the cases of
anaemia in pregnant women are assumed to be due to iron
deficiency, with folate or vitamin B12 deficiency, chronic
inflammatory disorders, parasitic infections like malaria,
and certain inherited disorders accounting for the remaining
cases (Gupta, Gadipudi 2018).

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In terms of pattern, anaemia due to pregnancy related
conditions such as abortion, antepartum hemorrhage and
postpartum hemorrhage are usually as a result of blood
loss. Anaemias resulting from acute blood loss during
pregnancy usually have evident aetiologies, since external
blood loss usually occurs and symptoms are sudden.
These disorders can include multiple trauma and
spontaneous splenic rupture, as well as disorders of
gastrointestinal, pulmonary or urinary tract, which may or
may not be related to obstetric conditions (E. Obeagu, G.
Obeagu 2018). These are most likely to cause severe
anaemia especially among women of the higher
socioeconomic class who are not as susceptible to severe
anaemia due to chronic infections and malnutrition.
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All literature cited previously agree on the main cause of anaemia in
pregnancy being iron deficiency. Breymann (2015) states that the
stages of iron deficiency are “depletion of iron stores, iron-deficient
erthropoiesis without anaemia and iron deficiency anaemia, the
most pronounced form of iron deficiency”. Other causes are
common in the tropics especially malaria as shown in a cross
sectional study conducted by Ssentongo et al between 2012 and
2017 in several countries in Sub-Saharan Africa which aimed to
establish the association of malaria and HIV to the increased
prevalence of anaemia in pregnancy and it was concluded that
malaria was associated with increased prevalence of anaemia in
pregnancy but malaria-HIV coinfection prevalence was too low to
determine their association to low haemoglobin levels.

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Hookworm infection is among the major causes of anaemia in
poor communities, but its importance in causing maternal
anaemia is poorly understood, and this has hampered effective
lobbying for the inclusion of anthelmintic treatment in maternal
health packages. Evidence indicates that increasing hookworm
infection intensity is associated with lower haemoglobin levels in
pregnant women in poor countries. There are insufficient data to
quantify the benefits of deworming, and further studies are
warranted (Brooker, Hotez, Bundy 2008). An epidemiological
study in 1995 highlighted the paradox presented to public health
workers that an estimated one-third of all pregnant women in
developing countries were infected with hookworm (Bundy et al
1995).

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 PREVALENCE
A WHO report in 2014 showed that anaemia affects more than half
a billion reproductive age women globally. From this, 38% of the
anaemic women were pregnant (Global Nutrition targets 2025 -
anaemia policy relief). This report shows a similar prevalence from
a previous report by the WHO in 2008 based on data collected from
1993-2005 which estimated that 460 million women of
reproductive age are anaemic with 2/3 of them being in Asia also
concurring with a study by Goodewardene in 2012 about the
distribution of anaemia associated with pregnancy in Asia as
compared to the rest of the world. The report also gives the
worldwide prevalence of anaemia in pregnancy (albeit with an
upper threshold of 11g/dL) as 42% ranging from 6% in North
America to as high as 75% in The Gambia.

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Referring to a study conducted in Turkey for the Turkish Journal of
Obstetrics and Gynaecology by Öztürk et al in 2017, prevalence of
anaemia detection in pregnant women who presented in the first
trimester was 20% with 11g/dL as an upper threshold. In this
study, this rate was seen as in par with that in developed nations.
Bringing it closer to home, a study conducted in Kenya between
2016 and 2019 by Odhiambo and Sartorius showed that the overall
estimated number of pregnant women with anaemia increased by
90.1% from 155,539 cases in 2016 to 295,642 cases 2019. In a
study by Mohamed Ag Ayoya et al (2012) in the West and Central
African region, the prevalence of anaemia among pregnant and non-
pregnant women is higher than 50 % and 40 %, respectively, in all
countries. Within countries, this prevalence varies by living setting
(rural v. urban), women's age and education.

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Several studies related to anaemia in pregnancy have been
carried out in Nigeria. Across the six geographical zones,
prevalence of anaemia ranged from 23.7%-88.7%. A crosssectional
survey conducted in 4 northern Nigerian states (Jigawa, Katsina,
Zamfara and Yobe) revealed that the prevalence of anaemia among
pregnant women ranged from 61.2 to 88.7%. These high
prevalences have been attributed to a relatively low utilization of
Iron-Folic Acid supplementation, despite high awareness and high
coverage (Oladipo et al 2005, Nigerian Demographic and Health
Survey 2013). Several studies, in Abeokuta and in Oyo reveal
prevalence of 72.8% and 58% respectively. The high prevalence has
been likened to low education and socioeconomic status (Oladipo et
al 2005, Onoh et al 2014, Idowu et al 2005, Owolabi et al 2011). In
a study conducted at Federal Teaching Hospital in Abakaliki,
Ebonyi State, prevalence among pregnant women was 58% (Onoh
et al 2014).

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Prevalence of anaemia in pregnancy in the North Central
region of Nigeria is demonstrated by a study conducted by Bassi
et al in Bingham University Teaching Hospital, published in 2016.
Prevalence of anaemia according to this study in BHUTH was
43.5% with the commonest form being mild anaemia. Reduced
ANC visits and increasing age where significant factors associated
with anaemia in pregnancy from this study. Nevertheless, data
from this study was obtained using WHO’s threshold of 11g/dL.
This indicated that majority of cases of anaemia in pregnancy
were within WHO’s definition of mild anaemia (<10.9-10.0g/dL)
and the tropical definition of anaemia gives the upper threshold at
10.0g/dL meaning that majority of women were not anaemic by
tropical standards.

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 Risk Groups & Risk Factors (Prevalence)
Factors associated with anaemia in pregnancy are gestational
age at booking, educational status, socioeconomic class,
parity, inter-pregnancy drugs and use of insecticide treated
nets (Muguleta et al 2013). In a study done among pregnant
women at the Amino Kano Teaching Hospital, the prevalence of
anaemia was 64.7% in those from the low socioeconomic class as
compared to 14.9% and 12.5% among the middle class and high
class respectively. This is because the women in the low
socioeconomic class lacked adequate level of education and had
financial constraints and may not be able to afford good maternal
health services and therefore more prone to effects of poor
nutrition, malaria, diarrheal disease and chronic infections (Nwizu
et al 2011).

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Parity is said to be associated with prevalence of anaemia in
women with higher parity showing higher prevalence. In a study
conducted by Adewara et al in 2014, 85.3% of all grand
multiparous women and 65.5% of all primigravida women had
varying degrees of anaemia, showing a correlation between
anaemia and parity. However, in a study conducted by Judith et
al in 2008 among pregnant women in Uduoi district in India, the
prevalence of anaemia among women of low parity was 51.6% and
women of high parity was 38.4% thereby being in contrast to the
earlier stated study. Idowu et al (2005) puts the prevalence of
anaemia in pregnant women in Abeokuta at 69.7% for the
primigravida and 59% for multigravida. Gamble et al (2006)
explains this by stating that malaria which is a major cause of
anaemia in pregnant women in endemic regions is more severe
among the primigravida.

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A review of studies conducted in Sub-Saharan African countries
also found that there is a higher (26%) risk of severe anaemia in
pregnant women secondary to malaria infection. Malaria infection
is responsible for one in ten cases of severe anaemia in pregnant
women (Guyatt et al 2001).
In a study carried out on pregnant women in University of Uyo
Teaching Hospital, the prevalence of anaemia among women of
<2years inter pregnancy interval was 64% and 48.5% in women
of ≥ 2 years inter pregnancy interval (Olatubosun et al 2014).
Hence, short interval between pregnancies, delays the mother’s
recovery from the effects of previous pregnancies thus increasing
the risk of maternal depletion syndrome. Since the foetal demand
is met first, the mother is left with further depleted iron stores at
the end of one pregnancy takes almost two years to be
replenished (Adinma et al 2002).

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Another risk factor for anaemia in pregnancy could be
marital status of the woman. To support this statement, a
study done in the Aminu Kano Teaching Hospital gives the
prevalence of anaemia in pregnant women who were single and
divorced as 66.7% while the prevalence of anaemia in married
women was 16.0%. It was therefore concluded that single or
divorced women had a two-fold increased risk compared to those
who were married (Nwizu et al 2011).

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 MATERNAL ANAEMIA AND OUTCOMES
In a population-based study, the diagnosis of anaemia in
pregnancy carries a higher risk of peri-partum, intra-partum,
and post-partum complications for the mother, and a higher
risk of preterm birth for the infant (Beckert et al 2019). This
retrospective study was focused on California live births from
2007-2012. Results from the study showed that anaemic mothers
were more likely to be diagnosed with hypertension, diabetes,
placental abruption, or chorioamnionitis, or require a blood
transfusion or admission to the intensive care unit. Infants born
to anaemic mothers were more likely to be born preterm (8.9%
versus 6.5%), but not more likely to suffer morbidities associated
with prematurity (Beckert et al 2019).

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A set of studies on the issues of outcome of anaemia in
pregnancy in both the mother and fetus showed that anaemia
or iron deficiency during pregnancy is associated with intrauterine
growth retardation, premature birth, low birth weight, increased
labor time, higher risk of infection, elevated maternal and prenatal
mortality, muscle dysfunction, and low physical capacity (Allen
2000, Ronnenberg et al 2004, Rahmati et al 2017, Suryanarayana
et al 2017, Lin et al 2018). On the contrary, a study conducted by
Stephen et al from 2013-2015 and published in 2018 to
determine prevalence of anaemia in pregnancy in Northern
Tanzania found little to no association of anaemia to adverse
outcomes in pregnancy but the pitfall of this study is that it was
based on laboratory diagnosis of anaemia and not clinical
assessment.

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In a study of four Southern African countries, maternal anaemia
was highly associated with childhood anaemia in all the four
countries after controlling for the individual and community level
factors. In addition, the results have also demonstrated that
community-level maternal anaemia exhibits a strong association
with childhood anaemia in Mozambique (Ntenda et al 2018).
Individual-level factors showed that with an increase in infant’s
age the risk of childhood anaemia decreases in all the four
countries. The presence of fever two weeks prior to data collection
and history of stunting (in Malawi, Mozambique and Namibia),
residing in poorest households (for Malawi) appeared to increase
the risk of childhood anaemia. For community-level factors,
communities with a high percentage of women perceiving distance
to the health facility as a big problem exacerbated adverse effects
of maternal anaemia on childhood anaemia (Ntenda et al 2018).

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Malaria in pregnancy remains a risk factor. Pregnant women
are especially susceptible to malaria infection. Without existing
immunity, severe malaria can develop requiring emergency
treatment, and pregnancy loss is common. In semi-immune
women, consequences of malaria for the mother include anaemia
while stillbirth, premature delivery and foetal growth restriction
affect the developing foetus (Rogerson 2017).
Folic acid deficiency, especially at the time of conception, is
strongly correlated with increased neural tube defects (De-Regil et
al 2010). Low maternal RBC folate is also associated with LBW,
and an increased risk for SGA (Van Uitert et al 2013). Maternal
vitamin B12 (cobalamin) status affects fetal growth and
development. Low cobalamin is associated with an increased fetal
risk of low lean mass and excess adiposity, increased insulin
resistance, and impaired neurodevelopment (Rush et al 2014).

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 PREVENTION/MANAGEMENT EFFORTS
The most common nutritional deficiency is Iron deficiency
anaemia. Iron deficiency (ID) and iron deficiency anemia (IDA) are
global health concerns associated with adverse perinatal effects.
Despite efforts taken at the international level, there is no
consensus on unified prevention/treatment strategies, largely
stemming from inconsistencies of outcome reporting
(Malinowski et al 2019). Pankajkumar et al (2017) conducted an
interventional study which involved exploring the impact of
educational intervention regarding anaemia and its preventive
measures among pregnant women of which only 30% of 100
women selected for the study having baseline knowledge regarding
treatment of anaemia with that number increasing to 64% after a
45 minute educational intervention. The study focused mainly on
nutrition during preconception.

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The burden of malaria and anaemia in pregnancy remains high
despite the availability of proven efficacious antenatal care
interventions. Sub-optimal uptake of the interventions may be
due to inadequate active participation of pregnant women in their
antenatal care (Ampofo et al 2018). The study followed a
hypothesis that providing opportunities for pregnant women to
improve upon active participation in their antenatal care through
malaria and anaemia point-of-care testing would improve
adherence to ANC recommendations and interventions and lead to
better pregnancy outcomes. Nevertheless, although its potential
was evident, this study found no significant beneficial effect of
women participating in their malaria and haemoglobin tests on
pregnancy outcomes. Exploring factors influencing health worker
compliance to health intervention implementation and patient
adherence to health interventions within this context will
contribute in future to improving intervention effectiveness.
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Screening for iron-deficiency anaemia is recommended in every
pregnant women, and should be done by serum ferritin-level
screening in the first trimester and regular hemoglobin checks at
least once per trimester. In the case of iron deficiency with or
without anaemia in pregnancy, oral iron therapy should be given
as first-line treatment. In the case of severe iron-deficiency
anaemia, intolerance of oral iron, lack of response to oral iron, or
in the case of a clinical need for rapid and efficient treatment of
anaemia (e.g., advanced pregnancy), intravenous iron therapy
should be administered (Breymann et al 2017). Also, as increasing
numbers of countries embrace malaria elimination as a goal, the
special needs of the vulnerable group of pregnant women and
their infants should not be overlooked (Rogerson 2017).

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Rogerson (2017) on the management of malaria in pregnancy
gives preventive measures such as insecticide treated nets and in
some African settings, intermittent preventive treatment which is
typically given at onset of fetal quickening and a second dose 4
weeks later. Prompt management of maternal infection is key,
using parenteral artemisinins for severe malaria, and artemisinin
combination treatments (ACTs) in the second and third trimesters
of pregnancy.
Because of the significant consequences of folate deficiency on
neural tube development, folate supplementation is a standard
component of antenatal care in the United States and Canada (De
Wals et al 2007). The WHO recommends folate
supplementation for pregnant women, 400 μg per day from
early pregnancy to 3 months postpartum.

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 SICKLE CELL ANAEMIA IN PREGNANCY
Patients with SCA have numerous acute and chronic medical
problems, which collectively contribute to life-threatening
morbidity, early mortality, and annual domestic medical costs
exceeding $1.1 billion (Lanzkron et al 2013, Therrell et al 2015,
Powers et al 2005, Kauf et al 2009). More than 75% of the global
burden of SCA occurs in sub-Saharan Africa (Piel et al 2013),
where scarce health resources and inadequate awareness among
health care providers and the general public contribute to
shocking rates of early mortality. With few data from neonatal
screening programs, and virtually no prospective natural history
studies, true mortality rates are unknown, but an estimated 50%
to 90% of infants born with SCA in sub-Saharan Africa die before
their fifth birthday (Grosse et al 2011, WHO 2010).

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Women with SCA face the significant challenges of pregnancy and
its perinatal complications (Lesage et al 2015). Pregnancy in
women with sickle-cell disease (SCD) is associated with
increased adverse outcomes. Findings on the association
between SCD and adverse pregnancy outcomes are conflicting,
and the results do not address whether these associations are
similar in both low- and high-income countries according to a
study by T.K Boafor et al (2016). Results showed that SCD was
associated with intrauterine growth restriction, perinatal mortality
and low birth weight. SCD was also associated with an increased
risk of pre-eclampsia, maternal mortality and eclampsia. Studies
by Oteng-Ntim et al (2015), Lesage et al (2015) among others
report similar findings.

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Specific management program and protocols are essential for
better outcome of pregnancy in women with sickle cell disease
(Singh et al 2019). The same study concluded that hospitals
should have a clear protocol for management of pregnancy
with sickle cell disease. A multi-disciplinary team should be
appointed comprising of obstetricians along with hematologists.
However, recent advanced techniques and achievement in fields of
prenatal and preimplantation genetic diagnosis, proper antenatal
care with strict vigilance has led to good maternal and fetal
outcomes in cases of sickle cell anemia. Pre-eclampsia and
eclampsia are associated with maternal complications and
protocols for early detection and management should be instituted
from basic health care level for good maternal and perinatal
outcome (Singh et al 2019).

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 CONCLUSION
There was a reduction in the prevalence and severity of anaemia
in the last 15 years. The two-pronged strategy of increasing iron
intake (dietary diversification and use of iron-fortified iodized salt)
in all the population and testing, and detecting and treating
pregnant women with anaemia will accelerate the pace of
reduction in anaemia (Kalaivani et al 2016).
More research effort should also be put into a standardized
classification of anaemia in pregnancy as well as universal health
coverage as a means of reducing financial restraints among the
lower socioeconomic class thereby also reducing the burden of
anaemia in pregnancy in general and promoting health seeking
behavior.

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CLINICAL FEATURES
• Many women with anaemia in pregnancy would only be discovered
at routine estimation of PCV or haemoglobin at booking. Some
women however would have symptoms.
• Common symptoms include;
- Dizziness
- Headaches
- Faiting attacks
- Breathlessness
- Easy fatiguebility
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• Signs include;
- pallor
- jaundice
- Signs of hyperkinetic circulation (tachycardia, wide pulse pressure ,
cardiac murmurs)
- Koilonychia in iron deficiency aaemia

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COMPLICATIONS
• Preterm labour
• Increased incidence of post partum hemorrhage
• Increased susceptibility to infection
• Worsening of anaemia after blood loss during delivery
• Low birth weight of the child. Growth retardation of the fetus
• Neural tube defects

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HOME VISIT
• She is a hairstylist who is separated from her husband and currently stays with her
parent.
• She has an estimated income of 6,000-18,000 per month.
General surrounding; clean and suggesting a typical low class setting in Nigeria . There
was a refuse dump beside the house.
Living room;
- one three-seat sofa with a wooden chair, T.V. , a center table , drum and her hair
dressing tools.
- There was no ceiling
- Floor was covered with a rug
- One window
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HEALTH EDUCATION
1. On pap smear
2. Anaemia (cause of her symptoms, encouraged her to take more
vegetables and fruits)

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PREVENTION
PREVENTION
• PRIMORDIAL
• PRIMARY
• SECONDARY
• TERTIARY

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PRIMORDIAL PREVENTION
• Sustained advocacy in tackling Micronutrient Deficiency at National
and International Policy levels is prerequisite to attainment of
Millennium Development Goals 4 and 5.
• Laws that encourage Antenatal care for all pregnant women.
• Implementing laws on routine screening of all pregnant women for
Iron deficiency.

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PRIMORDIAL PREVENTION
• Laws that provides special antenatal care for pregnant women with
co-morbid conditions putting them at risk of developing Iron
deficiency.
• Advocacy programs on Health Awareness to all pregnant women by
every member of the health sector.

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PRIMARY PREVENTION
• Women are to start oral low-dose (30mg per day) supplements of Iron
at the first Antenatal visit.
• Encourage women to eat Iron-rich foods and foods that enhances Iron
absorption.
• Pregnant women should eat food with high Folic acid, such as dried
beans, dark green leafy vegetables, wheat germ and orange juice.

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PRIMARY PREVENTION
• Pregnant women should eat foods with high vitamin-C, such as citrus
and fresh, raw vegetables.

• Antenatal counselling on importance and how to maintain normal

Iron levels all through pregnancy.

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SECONDARY PREVENTION
• Screen for Anemia at the first Antenatal/booking visit.
• Screen for other Iron deficiency predisposing conditions in pregnant
women.
• Early treatment of Iron deficiency if Hb. concentration <9.Og/dl OR
PCV <120mg.
• Blood transfusion for pregnant women with Iron deficiency states to
prevent complications.

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TERTIARY PREVENTION
• Maternal resuscitation.
• Blood transfusion to perfuse baby and prevent intrauterine demise
and asphyxia.
• If above age of viability, blood transfusion and immediate delivery of
fetus should be done by the safest possible means.
• Fetal resuscitation after birth.

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TERTIARY PREVENTION
• Restriction of further damage to other organs in both mother and
fetus.

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CONCLUSION
• Iron deficiency remains the most important cause of anemia in
pregnancy in developing countries.
• Hence, it contributes to increased risks of Low Birth Weight,
Prematurity, And Maternal Morbidity cannot be underscored.
• It Should Be A Matter Of National Concern.

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REFERENCES
• Anaemia in pregnancy: a survey of pregnant women in Abeokuta,
Nigeria: - OA Idowu, CF Mafiana, and Dapo Sotiloye
• Textbook of obstetrics and gynaecology for medical students: 2nd
edition: pages 336-340:- Akin agboola

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