ANEMIA IN PREGNANCY

BY DR. KAMIL
 Introduction
2

A global public health problem

Definition of Anemia during Pregnancy.
 WHO: 11gm/dl or less
 CDC(1990) defined anemia as:
 Less than 11 g/dL in the first and third trimesters and
 Less than 10.5 g/dL in the second trimester
More prevalent in pregnant women and young children.
Prevalence in pregnancy varies considerably
 Affects nearly half of all pregnant women in the world:
 52% in developing countries .
 23% in the developed world.
 Introduction; contd…
3

The most common causes of anemia are deficiencies of iron and other micronutrients,
General mechanisms
 Decreased hgb production
 Poor nutrition,
 Faulty absorption mechanism:
 High incidence of intestinal infestation,
 Faulty diet habit : Rich carbohydrate & high phosphate reduce absorption of iron.
 Increased hgb loss (usually bleeding)
 Repeated pregnancy,
 hookworm disease, and schistosomiasis.
 Increased destruction of RBC
 Malaria,
 Iron Metabolism in Pregnancy
4
Normal body iron content — 3 to 4 grams:-
 Hgb(70% — ~2 grams + proteins(29% (myoglobin, cytochromes, & catalase) -
400 mg + Iron bound to transferrin in plasma(0.2% — 3 to 7 mg
 The remainder is storage iron in the form of ferritin or hemosiderin.
Iron requirement for normal pregnancy is 1,000 mg.
 500 mg to increase the maternal RBC mass
 400 mg transported to the fetus, and
 300 mg to compensate for the normal (obligatory) daily loss
Thus, needs to absorb an average of 3.5 mg/day of iron.
 Increase remarkably during the third trimester to 6 to 7 mg/day.
 Iron Metabolism in Pregnancy; contd…
5
 If body iron stores are normal, only about 10 percent of ingested iron is absorbed,
most of which remains in the mucosal cells or enterocytes until sloughing leads to
excretion in the feces (1mg/day).
Iron absorption in the duodenum is limited to its ferrous (divalent)
state, the form found in iron supplements.
Ferric (trivalent) iron from vegetables must first be converted to the
divalent state by ferric reductase.
Iron is transported actively across the placenta, and fetal iron & ferritin
levels are 3 X higher than maternal levels.
 Adequate iron transport despite severe maternal iron deficiency.
 Etiologic:
Pathologic:
 Deficiency:
 Iron, Folic A., Vitamin B12
 Hemorrhagic: APH, Hookworm

 Hereditary:
 Thalassemia's, Sickle,
 Hemolytic Anemia
 Bone Marrow Insufficiency: Aplastic Anemia

 Infections: Malaria, TB

 Chronic Renal Diseases or Neoplasm.

 Based on RBC morphology:-
Size (Microscopic; based on MCV):
Normocytic
Microcytic
Macrocytic

Color
Normochromic
Hypochromic
 Microcytic (MCV < 80 fl)
Iron Deficiency
Anemia of Chronic Disease
Thalassemias
Hemoglobinopathies
Sideroblastic Anemia
 Normocytic (MCV 80-100 fl)

Acute blood loss

Anemia of chronic disease
Early iron deficiency
Hemoglobinopathies
Primary marrow disorders
Combined deficiencies
Increased destruction
Chronic renal insufficiency
 Macrocytic (MCV>100 fl)
Folic acid deficiency
Vitamin B-12 defficiency
Liver disease
Ethanol abuse
Hemoglobinopathies
Metabolic disorders
Primary marrow disorders
Increased destruction
 Iron Deficiency Anemia
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The most common cause of anemia in gravid

women,
~ 75 % of anemias that occur during pregnancy

Degree: Mild: 8-10gm%

Moderate: 7-8gm%
Severe: <7gm%
 CAUSES OF INCREASED PREVELANCE
Poor intake
Diet deficiency in iron containing foods
vomiting in pregnancy
 Poor absorption
presence of phosphates, phytates
Ferric iron in the gut instead of ferrous form
Lack of vitamin C
 Increased utilization
Demand of pregnancy more if it is multiple pregnancy
 Excessive iron loss
Repeated pregnancies specially at short interval
Menorrhagia prior to pregnancy
Hookworm infestation
Chronic malaria
 Pregnancy tends to interfere with maternal erythropoiesis
by competing for the available raw materials such as folic
acid ViB 12 and protines apart from Iron
 Clinical Findings

 The symptoms may be vague and nonspecific,

including
 pallor, easy fatigability, headache, palpitations,
tachycardia, and dyspnea.
 Angular stomatitis, glossitis, and koilonychia
(spoon nails) may be present in long-standing
severe anemia.
Pica
 Iron deficiency anaemia diagnosis

Symptoms and Signs:

Blood film
 RBC size N or ↓
 Hypochromic

 Anaesocytosis + +

 Poikilocytosis + +

 White cells N
Haematological values
 Hb ↓
 MCV ↓
 MCHb ↓
 MCHbC ↓
 Serum iron ↓
 Serum ferritin ↓
 Serum folate N
 Elevated total iron-binding capacity (TIBC),
 Marrow -↓ Iron stores
 Treatment
17
Depends on Degree of anaemia, Duration of pregnancy and
Cause of iron deficiency:
Oral:
 200mg elemental iron daily till Hb level becomes normal,
 Continue therapy for about 3 months after corrected
 Hemoglobin levels should increase by at least 0.3 g/dL/wk
 Best absorbed in ferrous/reduced form from empty stomach.
 Administering ascorbic acid at the time of iron treatment…

 Available iron preparations:-

 Ferrous sulfate 325 mg (65 mg elemental iron),
 Ferrous gluconate 325 mg (35 mg elemental iron), and
 Ferrous fumarate 325 mg (107 mg elemental iron).
 Treatment; contd…
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Parenteral Iron therapy:

If intolerance of, or refractoriness to, oral iron. In most
cases of moderate iron deficiency anemia,
Intramuscular (i.m.) or i.v. preparation.
Risks of anaphylactic reaction, muscle necrosis, &
phlebitis
 After a 0.5-mL test dose, iron dextran can be
administered IM or IV at a rate not to exceed 100
mg/d of elemental iron.
 Prevention
19
 Family spacing
 Dietary precautions
 Adequate treatment of underlying infections and infestations
 Iron supplements
 To raise or maintain the maternal hemoglobin level, AND to maintain or restore normal
maternal iron levels
 Rarely needs to be started before 20 weeks.
 Taking iron before 20 weeks can worsen the nausea and vomiting of pregnancy.
 Prophylactic: Supplement Fe – 60 mg daily elemental Fe with Folic Acid 400 μg.
 Continue for 3 months postpartum
 Vitamin C may enhance absorption
 Do not take iron with milk or antacids
 Calcium impairs absorption
 Megaloblastic Anemia
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Impaired DNA synthesis  deranged RBC maturation
Complicates up to 1% of pregnancies
Megaloblastic anemia in pregnancy is almost always due to Folic Acid
def.
 It may be due to Def. of VitB12 or Folic Acid or both.
 Is common where nutrition is inadequate.
 ~70% of folate-deficient Pts also lack iron stores
Vit B12 def. is rare in Pregnancy because its need is less in amount and
amount is met with any diet that contains animal products.
 In the nonpregnant women the minimum daily intake of folate
necessary for adequate hematopoiesis and to maintain store is
180microg/day increases to 140micG/day during pregnancy

However during pregnancy daily requirement is increased as

compared to nonpregnant women even it is more for multiple
pregnancy
 In addition patients with chronic hemolytic anemia like sickle cell
anemia need further more folic acid supplementation to meet
increased demand imposed due to increased hematopoiesis
 Megaloblastic Anemiacontd;…
22
Folate deficiency:-
 Stored in liver sufficient for 6 wks
 Hyper segmented neutrophils (more than 5% of neutrophils having five or more
lobes) appear after 7 weeks
 RBC folate is reduced after 18 weeks, and
 Anemia occurs after 20 weeks.
 Characterized by:-
 Increased MCV
 WBCs with altered morphology (hypersegmented neutrophils).
 Extreme anemia often is associated with leukocytopenia and thrombocytopenia.
 Megaloblastic Anemia: contd…
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TREATMENT:-
 Folate
deficiency responds to 0.5 to 1.0 mg folate orally
per day,
 Response to folate:
Reticulocytosis within 3 days

Hematocrit level may rise by 1% daily after 1 week of treatment.

Carries a good prognosis if adequately treated.

 B 12 deficiency requires vitamin B 12, 1 mg intramuscularly, weekly

for 6 weeks.
 Megaloblastic Anemia: contd…
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PREVENTION: Women contemplating pregnancy should be
advised:-
A daily folic acid supplement
 0.4 mg/day if there is no family history of neural tube defect
 4 mg/day if there is a family history of NTD starting before conception &
continuing throughout the first trimester.
 In
contrast, vitamin B 12 deficiency is rare, because very little of the
body's stores is used each day.
 Patients who have had a gastrectomy, ileitis, or ileal resection, or who have
pernicious anemia, pancreatic insufficiency, or intestinal parasites eventually may
become vitamin B 12 deficient.
 Dimorphic Anemia

More prevalent in low socio-economic groups of tropics due to

poor diet sources, faulty dietic habits, Intestinal malabsorbtion
There is both deficiency of Iron, folic acid, and protein
 The peripheral smear shows features of both Irone and folate
deficiency
Bone marrow shows predominantly of macrocytic
 Complications of anemia during pregnancy

Severity of complications depends on severity of anemia

Maternal complications
 Congestive high output heart failure
 Intolerance to hemorrhage such as PPH
 High infection rates including puerperal sepsis

Fetal complications
 Fetalgrowth restriction
 Preterm labor and prematurity
 READING ASSIGNMENT

THALASSEMIA
 HEMOLYTIC ANEMIA
 APLASTIC ANEMIA
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