ANAEMIA IN

PREGNANCY

DR P AO
Definition by WHO

Anaemia in Pregnancy:
Hb level below 10.5g/dl.
 In pregnancy – haemoglobin concentration of 11g/dl.
The cut off point for disease control Centre is 10.5g
%.

The levels used as per NDoH outline;

 Hb level: 8.0 – 9.9g/dl
 Hb level: < 8.0g/dl
 No record
Overview

 Anaemia is the commonest medical problem

associated with pregnancy.
 Causes are multifactorial
 Prior to pregnancy 8-10% of Western women are
iron deficient.
 PNG?
 At PMGH 33% of women have Hb of <10g%/dl at
booking
 On the coast the prevalence is as high as 40 – 50%
in women
 Haemoglobin
Succinyl-CoA Glycine

5 aminolevulinic acid

porphobilinogen
iron protophophyrin
globin
heme
Haemoglobin

Heme globin

iron protophophyrin Amino acid

transferrin CO2 bilirubin

erythroblast Bilirubin glucoronid

Erythrocyte
Normal are:
 Biconcave disk
 7.5µm in diameter with
edges thicker than the
centre of the cell.
 2.0µm thick at the edges.
 The biconcave increase the
surface area.
 It bend or fold around it’s
thin centre.
Erythrocyte
 Bone marrow microenvironment
 Heme components
 Globin components (α2 and β2 chains)
 Vitamin B12 and folate (DNA synthesis)
 Hormones such as Erythropoietin
Causes of Anaemia

Accelerated
Loss

Defective production
Inadequate
RBC or Hb structure in anaemia erythropoietin
the marrow production

Decreased
Production
Accelerated Losses
 Acute Blood Loss
 Haemorrhage
 Hemolytic anaemia
 Hereditary
 Membrane defects
 Enzyme defect
 Haemoglobinopathy
 Sickling
 Thalasemia

 Acquired
 Parasitic infections eg: malaria
 Drugs
 Autoimmune reaction
Defective RBC or Hb production in the marrow
 Irondeficiency
 Folate Deficiency
 Vitamin B12 Deficiency
 Inadequate dietary intake of essential nutrients
Inadequate Production of Erythropoietin
 Renal disease

Decreased Red Cell Production

 Aplastic anaemia
In Pregnancy…
 Plasma volume increases by 30 – 50%
 Highest level of increase is at around 34 weeks (1.2L to
1.6L)
 Bigger babies and multiple pregnancy may will
increase further.
 Red cell mass increase about 18% without iron
suppliment but may increase up to 30% if
supplementation taken.
 Mechanism? Na+ and water retention from
stimulation of angiotension renin system
 Erythropoietin stimulation by HPL and PG
In Pregnancy…
 The increase in blood volume and hemostatic
changes prepare the body for blood loss during
delivery.
 In trying to do so, the above changes may result in
haemodilution

Physiological Anaemia in Pregnancy.

In Pregnancy…the commonest cause of Anaemia are;
 Iron deficiency Anaemia (46%)
 Iron and Folate Deficiency Anaemia (24%)
 Folate Deficiency (19%)
 Malaria (8%)
Iron Deficiency Anaemia in Pregnancy

Iron Metabolism
Transferred
bound to
Absorbed
diet transfer
into the gut
protein
transferrin

Store as To the
ferritin/ marrow for
hemosiderin erythropoiesi
s or
Iron deficiency
 Women have half the total iron store .
 Total iron store for women is 2 – 2.5gms
 Normal iron store – only 10 -20% of ingested iron is absorbed
 Daily requirement is 3.5mg and increases to 6-7mg in late pregnancy
 Total iron required for pregnancy is 1000mgs
 500mgs for increased Red Cell Mass
 300mgs for fetal use
 200mgs for normal losses

 The 300gms for the fetus is transferred late in pregnancy

Iron Deficiency
 Adequate iron is transferred to the fetus despite low
stores in the mother by active transport.
 Fetal Hb has no relation to the maternal Hb
 Women not anaemic in the beggining of pregnancy
and without supplementation have a significant
reduction of Hb, serum ferritin and transferrin by
term.
 Goal of the supplements is to maintain or restore iron
store.
Causes of Iron Deficiency Anaemia in pregnancy
 Increased demands
 Increased red cell mass
 Fetal demands
 PoorDiet
 Blood loss
 Hookworm infection
 GI; varices, peptic ulcer
 In the presence of underlying gut malignancies
Maternal /Fetal Risk with iron Deficiency
Maternal
 Impaired muscle function.
 Impaired neurotransmission
activity
 Impaired exercise tolerance
 Epithelial changes
 Alteration in GI function
Fetal
 Decreased fetal iron store
 IUGR
 Low birth weight
 Development delay in iron
deficient infants
 Iron deficiency in the first
year of life
 Behavioral abnormalities
Management of Iron deficiency in Pregnancy
 Prophylactic iron should be given before the
deficiency
 Iron – oral, intramuscular and intravenous forms
available
 Treatment should continue into the post partum
period.
 Dietary advance .
Folate
 Folate is essential for DNA synthesis

Folic acid dihydrofolate Tetrahydrofolate

 Tetrahydrofolate is fundamental to cell growth and

division.
 The more active a tissue is in reproduction and
growth, the more dependent it is on the efficient
turnover and supply of folate coenzymes.
Folate
 Body store of folate found in the liver – 10mg.
 If the reserve is low, the body stays for 4 -5 months
before symptomatic anaemia develops
 Food; greens, fruits, .
 WHO requirements for daily intake;
 Prenatal = 800µg
 Antenatal = 400µg
 Lactation = 600µg
Folate deficiency
 Complicates 1/3 of all pregnancies
 Incidence is higher in multiple pregnancies
 Megaloblastic anaemia in pregnancy is almost
always secondary to folate deficiency rather than
vitamin B12.
 Advancing pregnancy ing folate
 Increase plasma clearance by the kidneys
 Reduced apetite
 Transfer from mother to fetus (800µg by term)
 Uterine hyperplasia
 Expending red cell mass
Folate deficiency

Matermal Risks: Fetal Risk:

 Increase risk of Neonatal
 Megaloblastic anaemia
megaloblastic anaemia in
neonates of folate deficient
mothers
 Harelip, cleft palate and
neural tube defect
Management of Folate Deficiency

Prenatal Pophylaxis
 In countries were megaloblastic anaemia is common
and nutritional anaemia
 200 -300µg daily
 Risk: women with underlying Vitamin B12
deficiency.

Established Folate Deficiency

 If diagnosed prenatally – folic acid 5mg dly through
postpartum
Anaemia secondary to Malaria ( 8%)
 Sequestration of parasitized red cells in the spleen
 Folate and Fe+ deficiency: Fe+ is not lost but folate
deficiency may result from destruction of RBCs
 Dys-erythropoiesis: Red cell production is
impaired.? Blockage of small venules and hence
slow release of reticulocytes from bone marrow
Management of Anaemia in Pregnancy

ANAEMIA PROPHYLAXSIS
 Ferrous sulphate (200mg) daily and folic acid 5mg
weekly or fefol 1 tab daily
 Give standard treatment for malaria in areas were
there is prevalence of malaria
 Hb to be done at booking, at 28-32 weeks and after
36 weeks.
Management of Anaemia in Pregnancy

TREATMENT FOR ESTABLISHED ANAEMIA

All should receive
 Extra iron and folic acid, fefol 1tb bd or folic acid
5mg daily for 2-3 months
 Albendazole 100mg stat.
 ?? A standard course of antimalarials
 Imferon 1gm (imi/ iv infusion)
 Transfusion ( pack cells if required)
 Family spacing/ completion
 Diet advice upon discharge.
Anaemia postpartum
 Fefolfor at least 1 -3 months
 Family planning and spacing.
Reference
 High Risk Pregnancy Management Options. D.K James, P.J Steer,
C.P Weiner and B Gonik. 3rd Ed 2005.

 Harrisons Principle of Internal Medicine. 17th Ed. CD ROM

 Manual of Standard Management (O&G). Mola G (ed). 6th Ed

2010.

 Collection of PBL Seminar;

 Haematology - Anaemia in Pregnancy
 Regulation of Haemopoiesis
 Biosynthesis and Regulation of Heme in Hb
 Iron and iron balance
 Hemolysis
 Overview of Blood Cells - Erythrocyte