Iron deficiency Anemia in

Pregnancy
Dr Amna Usman
FCPS II Trainee(R1)
Case :
A 35 year old female came to Emergency. She is gravida 3 para 2+0, NKCM
at 24 weeks of gestation now. She has not seen any obstetrician yet .Now she
has come with complain of fatigue and dizziness.She is also giving history of
eating ice.She has no other complaint. Physical examination is positive for pale
conjunctiva, mild spooning of nails and systolic murmur at left lower sternal
border.
CBC :
Hb:8.1g/dl
Hct:23%
MCV :74fl
MCH:24pg
MCHC: 30/dl
WBC:5,400/mm3
Plt: 268000/L
Definition : Anemia is defined as heamoglobin two standard deviations below
the mean for a healthy age matched population. It is a condition in which the number of red
blood cells or their oxygen carrying capacity is insufficient to meet the physiological needs
of individual.

1s trimester less than 11g/dl

2nd trimester less than 10.5g/dl
3rd trimester less than 10.5g/dl
Postpartum less than 10g/dl
 Classification of Anemia
• Physiological anemia .
• Nutritional anemia :

Iron deficiency
Folate deficiency
Vitamin B12 deficiency
• Haemoglobinopathies
Thalassemia
Sickle cell anemia
• Aplastic anemia
• Acute Blood Loss
 Pysiological changes occuring in pregnancy

• During pregnancy, maternal plasma volume gradually expands by 50%.

• The total increase in red blood cells is 25%.
• This relative hemodilution produces a fall in Hb concentration, thus presenting a picture
of iron deficiency anemia.
• Most of the rise takes place before 32-34 weeks of gestation.
 Iron Deficiency Anemia

• Most common cause of anemia in pregnancy.

• During pregnancy approximately 1250mg is needed for fetus, placenta and delivery.
• It is a significant problem worldwide, affecting 50% of pregnant women( 56% in
developing and 18% in developed countries).
Symptoms and Signs
 Consequences of Iron deficiency anemia
Maternal: Fetus:
Fetus is protacted from the effects of iron
• Maternal susceptibility to infection deficiency by upregulation of placental
iron transport proteins.
• Poor work performance
• Emotional instability Infant:
Increases the risk of iron deficiency in first
Pregnancy outcome : 3 months of life.
• Low birth weight babies
• Preterm delivery
• Placental abruption
 Diagnosis
• Trial of Iron : It should be the first diagnostic test for women with a check for Hb increase at
2 weeks .

• CBC :
Low Hb, MCV,MCH and MCHC.
BLOOD FILM: Microcytic Hypochromic Red cells characteristic pencil cells
• Serum Ferritin: It is a stable glycoprotein which accurately reflects iron stores . It
is not affected by recent iron ingestion . It is the best test to assess iron deficiency in
pregnancy . As it is the acute phase reactant so levels will raise during active infection or
inflammation . Concurrent CRP measurement is helpful.
Serum ferritin levels below 15 µg/L is diagnostic of iron deficiency and a level below
30 µg/L should also prompt treatment.(specificity 98% , sensitivity 75%).

• Serum iron and TIBC : Affected by factors like recent ingestion and
infection
 Management
The daily recommended intake of iron for pregnant women is 30 mg .
Dietry Advice :
Diet rich in iron
Oral iron :
• Once women become iron deficient in pregnancy, dietary changes alone
are insufficient to correct iron deficiency and iron supplements are
necessary.
• Its an effective, safe and cheap way to replace iron.
• Ferrous iron salts are the preparation of choice.
• The oral dose for iron deficiency anemia is 100-200 mg of elemental iron
daily.
 Response to Oral iron
• In anemic women, repeat Hb after 2 weeks of treatment, Once Hb is in normal
range, continue for a further 3 months and atleast 6 weeks postpartum to
replenish iron stores.
• In non anemic women, repeat Hb and serum ferritin after 8 weeks of treatment
to confirm response.

Side effects : Iron salts may cause gastric irritation and upto a third of
patients may develop dose limiting side effects, including nausea and epigastric
discomfort.
Intravenous Iron : Consider it from 2nd trimester onwards and in postpartum period.
The dose of parenteral iron is calculated on the basis of prepregnancy weight, aiming for a
target Hb of 11g/dl.
Indications :
• Absolute non compliance or intolerance to oral iron therapy.
• Proven malabsorption.
Contraindications :
• History of anaphylaxis or reactions to parenteral iron.
• First trimester of pregnancy.
• Active acute or chronic infection.
• Chronic liver disease.
Parenteral Iron preparations:
• Iron sucrose ( requires multiple infusions)
• Iron III carboxymaltose (single dose administration)
• Iron III isomaltoside (single dose administration).

Blood Transfusion :
• Unstable vital signs.
• Severe anemia with maternal Hb<6g/dl.
Reference:
•Dewhurst's text book of obstetrics and gynecology.
•SOGP guidelines.