PREGNANCY WITH PALLOR

Presented by:
Ashir Farooq (09)
Ayesha Sajid (11)
Learning Objectives
Definition and types of anemia
Differential diagnosis
Examination and Investigations
Risk factors, aetiology and complications
Antenatal care
Management plan
Anemia

• DEFINITION
- Pathological condition in which the oxygen carrying capacity of RBCs is
inadequate to meet the body's demand according to age, sex, altitude, ethnicity and
pregnancy status.

- According to the World Health Organization (WHO), anemia is defined as (Hb)

levels <12.0 g/dL in women and <13.0 g/dL in men.
Anemia in Non-Pregnant Anemia in Pregnant (WHO)
(WHO)
 Hb level <11 g/dL and Hct <33%
 Hb level <12.0 g/dL
• Hb < 11 g/dl in 1st trimester
• Mild  11.0–11.9 g/dL • Hb < 10.5 g/dl in 2nd and 3rd
• Mod  8.0–10.9 g/dL trimesters
• Severe  <8.0 g/dL • Hb < 10 g/dl in postpartum period
 Physiological Changes In Pregnancy
Plasma Volume RBC Mass
Expansion
50% 25%

This leads to physiological hemodilution with Hb and hematocrit.

Normally pregnancy has:
• 2–3-fold increase in iron requirements
• 10–20-fold increase in folate requirements in pregnancy.
 Anemia in pregnant woman thus defined at a lower Hb than non-pregnant
woman
Effects of anemia
Maternal effects Fetal Effects

Maternal death Fetal death

Infection Neural tube defect (folate def.)

Pre-eclampsia (Fe def.) Low birth weight

Cardiac failure (high output) IUGR

Pre-term labor Anemia in infancy

PPH Prematurity
Types of Anemia

Nutritional types Haemoglobinopathies

• Iron deficiency
 Thalassemia
• Folic acid deficiency
 Sickle cell disorder
• Vit B12 deficiency
Assessment of Anemia
Iron Deficiency Anemia
• Most common type of anemia in pregnancy. 90%
• Early pregnancy daily iron requirement = 4mg, last few weeks = 6.6mg
• Women who become anemic in pregnancy are mostly those with reduced iron stores,
not those who don’t take iron supplements.
• Full iron stores are 750 – 1000 mg of iron. Enough to sustain 1 pregnancy independently
Risk factors for Iron deficiency anemia:
• Multiparity
• Malnourished woman
• Poor care during pregnancy
• Non compliance to iron during pregnancy
• Worm infestation with bleeding history
• Heavy menstrual bleeding
Causes of Iron deficiency anemia
Clinical Features of Iron Def Anemia
• Symptoms: • Signs
▫ Mild anemia
- Asymptomatic ▫ Mild anemia
- diagnosed on routine clinical tests • no signs
▫ Moderate ▫ Inc. severity
- inc. weakness • pallor
- lack of energy
• Systolic murmur in mitral area
- fatigue
- poor performance at work ▫ Severe
- loss of appetite
 congestive cardiac failure and
▫ Severe generalized edema
- palpitation
- breathlessness
- later proceed to cardiac failure
Investigations:
• Complete blood picture (complete CP)
▫ Haemoglobin estimation
▫ RBC count
▫ Hematocrit
▫ RBC indices

• Peripheral blood film picture

▫ Microcytic hypochromic anemia

• Serum iron/ total iron binding capacity (TIBC)

▫ Serum iron concentration of adult non-pregnant woman lies between 13-
27µmol/l. there is fall in serum iron concentration and percentage
saturation of TIBC in pregnancy, but the serum levels <12µmol/l of iron &
15% of TIBC saturation indicates anemia during pregnancy.
• Serum ferritin:
▫ Gives better picture of stored iron. In development of
iron deficiency anemia reduction in serum ferritin is
the first test to become abnormal.

• Other tests:
▫ Transferrin saturation
▫ Bone marrow examination
Management:
Management of iron deficiency during pregnancy has two aspects i.e;
i. Treatment of established iron deficiency anemia.
ii. Prevention of iron deficiency in non-anemic women.

i. Established iron deficiency anemia

▫ Objectives of treatment during pregnancy are;
▫ 1.Achieve normal Hb level by last month of pregnancy.
▫ 2.To replenish iron stores
▫ The treatment options are the iron therapy and blood transfusion. The former
fulfills both the objectives, while latter can satisfy the first objective only but
provides readymade Hb and proves life saving in emergency situations.
▫ Selection of treatment modality depends upon 3 main factors i.e; severity of
anemia, duration of gestation and presence of additional complications of
pregnancy like bleeding etc.
• Iron therapy
1.Oral iron ( ferrous sulphate, ferrous fumarate):
 Oral iron ( ferrous sulphate, ferrous fumarate)
 Oral iron is given upto 28 weeks of gestation
 Recommended dose: 100-200mg/day
 Vit C aids absorption so advised to take with orange juice
 Iron isn’t given in 1st trimester because of its teratogenic effects. It is
given from the start of 2nd trimester with vit C.
2. Parenteral iron:
 Iron sucrose(venofer)
 It is indicated when there is absolute non-compliance or intolerance to oral iron
therapy or proven malabsorption.
 In cases of severe IDA, parenteral iron preparations can also be given
 After 28 weeks of gestation, if woman comes with iron deficiency anemia parenteral
iron is given for 3 weeks.
3. Blood transfusion: Indications:
i.Hb <6g/dl
ii. For women who are at term
iv. Moderate and severe anemia in patient with known heart disease or severe respiratory
disease
v. Placenta previa with Hb <10g/dl
vi. Patient who develops severe side effect to both oral and parenteral iron therapy

4. Treat the associated cause

5. Dietary advice:
 red meat, poultry, fish, green leafy vegetables, beans, lentils, beetroot
Megaloblastic Anemia
• From Folic acid or Vitamin B12 deficiency

• Folic acid deficiency more common, since B12 has high stores
in body
Folic Acid deficiency
• For cell growth and division
• Daily req. inc. from
400micrograms in non-
pregnant state to 800
micrograms in pregnant
state
• Req. increased in iron deficiency
patients
• Significance:
 Intrauterine growth retardation
 Placental abruption
 Pre-eclampsia
 Folic acid deficiency in neonate
 NEURAL TUBE DEFECT
High Risk Groups
❖High risk groups include women:
➢Previous child affected with neural tube defects
➢Diabetes
➢Sickle cell disease
➢BMI> 35
➢anti-epileptics
• Causes of deficiency:

▫ Dietary deficiency – fail to consume fruits and vegetables, live

and kidneys. Prolonged cooking destroys vitamin

▫ Poor absorption from GIT

▫ Increased demand – multiple pregnancies, hookworms,

chronic malaria
• Clinical Features: • Examination:

▫ Runs acute and fulminant course ▫ Tongue shows papillary flattening /

▫ Some pt. asymptomatic & smooth tongue
▫ Tongue mapped with dark red
diagnosis made on routine
patches
clinical tests
▫ Aphthous ulcers of tongue and
▫ When symptomatic – nausea, mouth
vomiting, diarrhea, loss of ▫ Bleeding spots in skin due to dec.
appetite, soreness and pain in platelet count
tongue, unexplained fever, ▫ Retinal hemorrhages
breathlessness ▫ Hepatomegaly
▫ polyneuropathy
• Investigations:
▫ Full blood count – Hb low, MCV and MCH raised, MCHC
normal

▫ Peripheral film – macrocytosis, hyper segmentation of

neutrophils, neutropenia, thrombocytopenia

▫ Plasma/ red cell folate concentration – decreased

• Treatment: • Prophylaxis:

▫ Folate therapy – 5mg folic acid/day ▫ Daily folate intake – 8oo ug

throughout pregnancy for women taking antenatal period
anticonvulsants or suffering from hemolytic ▫ 3 months before conception
diseases ▫ 600 ug – lactation
▫ Vitamin C, folic acid and iron given in ▫ Prophylaxis continued for 6
combination months during pregnancy and 3
▫ Blood transfusion requirement rare, only done after
in case of severe megaloblastic anemia after
week 36 of gestation
▫ Diet: dark green leafy vegetables, citrus fruits,
juices, dried beans, breads and cereals fortified with
folic acid.
 Vitamin B12 deficiency
• Synthetized by microorganisms, animals, humans
• Found in meat, fish, eggs, milk
• NOT IN PLANTS
• Uncommon since vitamin not destroyed by over cooking
• Ample stores in body
• Deficiency seen in pt. with Pernicious anemia and Topical Sprue
• Clinical picture similar to Folic Acid Deficiency Anemia
• In B12 deficiency, serum B12 low & Methyl Malonic acid raised
• Treatment:

▫ Requirement met by any diet containing animal products e.g. milk, eggs,
yogurt, salmon

▫ Parenteral cyanocobalamin 250ug i/m every month

Management plan for anemia
• Screening:
▫ Hemoglobin estimations –
most common and cost effective
▫ Test performed at booking visit
and again at 28 & 36 weeks of
gestation
• Evaluation:
▫ If Hb below 11g/dl, further evaluation
needed to find out type of anemia, its
cause and contributory factors.
▫ Take detailed history, carry out thorough
examination and investigation.
• HISTORY: • EXAMINATION:

▫ H/O tiredness, easy fatiguability, ▫ Rapid pulse

breathlessness and palpitations on ▫ Pallor in palmer caresses, nails,
routine work mucosa of lower lid and mouth
▫ W/ Folic Acid Def. Complain of oral ▫ Spoon shaped nail deformity –
discomfort koilonychia
▫ Dietary intake ▫ Folic acid def. – sore tongue, and
▫ Obstetric history aphthous ulcers
▫ H/O oof hemolytic disease e.g. ▫ Mild systolic murmur
malaria ▫ Hepatomegaly
▫ Hookworm infestation ▫ Generalized edema
▫ Hemorrhoids
▫ Family history in mother/sisters
▫ Menstrual history
▫ GI disease w/ malabsorption
• Antenatal Care:

▫ In pt. w/ Anemia, more frequent visits required

▫ Aim of treatment to achieve normal Hb by last month of pregnancy, so
woman can withstand hemorrhage at time of delivery
▫ In suspected hemoglobinopathies, fetal cells obtained, via Cordocentesis, chronic
villus sampling and amniocentesis and sent for Genetic defect testing
▫ If major type of hemoglobinopathy present, termination offered
▫ Fetal monitoring of fetal growth, as babies born to mothers with anemia tend to
be small
Thank You