ANAEMIA

IN
PREGNANCY
 INTRODUCTION
Anaemia is one of the most frequent complications related to pregnancy. The
word implies a decrease in the oxygen-carrying capacity of the blood. It is
known that there is a large increase in plasma volume relative to red cell mass in
almost all pregnancies & it accounts for “physiologic anaemia”.This alterations
have been known for centuries & the term “plethora gravidarum” from medieval
ages indicates this condition.
It is the most common nutritional deficiency disorders affecting the
pregnant woman, the prevalence in developed countries is 14%, in developing
countries is 51% & in India it varies from 65%-75%.
Anaemia is the 2nd most common cause of maternal death in India &
contributing to about 80% of the maternal deaths caused by anaemia in South-
East Asia & is also an established risk factor for intrauterine growth retardation,
leading onto poor neonatal health & perinatal death.
 WHAT IS ANAEMIA?
• Anaemia is defined as qualitative & quantitative reduction in circulating
haemoglobin mass below the critical level and deficiency of R.B.C. in the
peripheral blood circulation.
• The normal haemoglobin(Hb) is 12-14 gm%(avg.).
The normal range for haemoglobin is 13.5-17.5(male) & 12.0-15.5(female).
The normal R.B.C. count 5 million/100 ml of blood(avg.).
The normal range for R.B.C. is 4.5-5.5 million/100 ml of blood(male) & 3.8-
4.2 million/100 ml of blood(female).
• WHO has accepted up to 11 gm% as the normal haemoglobin level in pregnancy.
Therefore any haemoglobin level below 11gm% in pregnancy should be
considered as anaemia.
 WHAT IS THE INCIDENCE
OF ANAEMIA?
• Anaemia in pregnancy is present in very high
percentage of pregnant women in India.
• Exact data is not available about the prevalence of
nutritional anaemia. However according to WHO,
The prevalence of Anaemia in pregnancy in South-
East Asia is around 56%.
• In India incidence of anaemia in pregnancy has
been noted as high as 40-80%.
 TYPES OF ANAEMIA IN
PREGNANCY
• Iron deficiency anaemia
• Folic acid deficiency anaemia
• Other deficiency anaemia
 IRON DEFICIENCY
ANAEMIA
It is the most common type of anaemia in pregnancy. About 80% of
pregnant woman generally suffers from this type. Factors contributing
to this state includes poor iron absorption during pregnancy. The most
usual clinical symptoms of this type are lathergy, fatigue, headache,
paresthesia, burning sensation of the tounge which appears in severe
cases after the 20th week of gestation. Glossitis, pallor & inflammation
of lips(cheilitis) are clinical signs of this type. In more severe cases
retinal bleeding, conjunctivitis, trachicardia & splenomegali may be
present. In this conditions Mean Corpuscular Volume(MCV) is often
decreased. There is decreased iron stores in the bone-marrow. The
laboratory evaluation of iron deficiency anaemia is quite difficult
because of the physiologic hydremia of pregnancy.
 IRON REQUIREMENT IN
PREGNANCY
• Total iron requirement is 1000 mg.
Foetus and placenta---300 mg.
Increase in red cell mass---500 mg.
Basal loss---200 mg.
• Average requirement is 4-6 mg/day.
2.5 mg/day in early pregnancy
5.5 mg/day from 20-32 weeks
6-8 mg/day from 32 weeks onwards
 FOLIC ACID DEFICIENCY
ANAEMIA
• It causes megaloblastic type of anaemia that is the second in occurance
as a cause for nutritional deficiency anaemia in pregnancy. Insufficient
level of folic acid may lead to the manifestations noted in megaloblstic
anaemia. Folic acid must be provide in the diet(green vegetables, fruits
like lemons, melon & meat). The absorption happens in the proximal
jejunam. Increased folic acid requirement seen in pregnancy because of
the increased demand of foetal growth and maternal erythropoiesis. The
higher level of eastrogen & progesterone during pregnancy seem to have
an inhibitory effect on folate absorption. Symptoms are general anaemia
with roughness of the skin & glossitis. MCH & MCHC are usually
normal whereas MCB is increased. A low serum level(less than 3gm/L)
may occur. During pregnancy folic acid requirement is 0.82-1.0mg.
Folate deficiency effects about 60-95% of pregnant woman .
 OTHER DEFICIENCY
ANAEMIA
• Hemic nutrients, trace elements(minerals), vitamins & proteins are
necessary for growth & maintainance of various bodily functions of the
mother and foetus. nutritional anaemia may be an important problem in
poor & undeveloped countries. Deficiency in some minerals may cause
anaemia in rare cases . Severe phosphorus deficiency can cause
haemolytic anaemia,, zinc deficiency can cause sickle cell anaemia &
thalassemia. Vit B12 deficiency is clinically important because of its role
in metabolism of folate through the production of active FH4. Serum B12
levels are depressed during pregnancy. It may lead to a type of
megaloblastic anaemia. Anaemia has been associated with protein
deficiency in pregnancy which can cause kwashiorkor; is a characteristic,
normochromic & hormocytic anaemia associated with decreased
erythropoiesis & reduced iron intake.
WHAT ARE THE CAUSES OF
ANAEMIA IN PREGNANCY?
• Physiological
• Nutritional
Iron deficiency
Folate &/or Vit B12 deficiency
Dimorphic
• Hemorrhagic
Acute or Chronic
• Hemoglobinopathies
• Distinguised metabolism
• Hemolytic
Congenital or acquired
• Aplastic Anaemia
 HOW WILL YOU CLASSIFY
ANAEMIA?
• Anaemia is often classified as
Mild (9-11 gm%)
Moderate (7-9 gm%)
Severe (4-7 gm%)
Very severe (<4 gm%)
• It is also classified according to Haematocrit(PCV)%
 WHAT ARE THE CLINICAL
PRESENTATION OF ANAEMIA?
Symptom
Signs
s
Fatigue &
vertigo Pallor

Weakness Pale Nails

Loss of
appetite Koilonychias
Digestive
Pale Tounge
upset
Dyspnoea

Palpitation
WHAT ARE THE EFFECTS OF
ANAEMIA IN PREGNANCY?
• Mother during pregnancy
Cardiac failure at 30-34 weeks of pregnancy
Increased susceptibility to infection
Preterm labour
Preeclampsia
• Labour
Uterine inertia
Post partum haemorrhage
Cardiac failure
Shock
WHAT ARE THE MATERNAL
RISK FACTORS?
Antenatal Period Intranatal Period Postnatal Period
Poor weight gain Dysfunctional labour Anasthesia risk
Preterm labour Intranatal infection Postnatal sepsis
PIH Haemorrhage Sub involution
Placenta previa Shock Embolism
PROM Cardiac failure
 WHAT IS FOETAL AND
NEONATAL RISK?

• Prematurity
• Low birth weight
• Poor apgar score
• Foetal distress
• Neonatal Anaemia
 WHAT ARE THE
INVESTIGATIONS?
• CBC
• Peripheral smear--------Hypochromic, Microcytosis, Poikilocytosis,
Anisocytosis
• MCV,MCH,MCHC
• TIBC
• Serum Iron
• Serum Ferritin
• Free erythrocyte protoporphyrin
• Bone marrow examination
• Urine examination
• Stool examination
• Serum protein
 Special tests

• Serum folate
• R.B.C. folate
• Serum Vit B12
• Serum Bilirubin
• Coombs test
• HB electrophoresis
• NESTROF test
• Red cell osmotic fragility
WHAT ARE THE PROPYLACTIC
MEASURES CAN BE TAKEN?
• Routine screening for Anaemia for adolescent girls
from school days.
• Encouraging iron rich foods.
• Fortification of widely consumed food with iron.
• Providing iron supplementation from school days.
• Annual screening for those with risk factors.
 THERAPUTICS

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