14 Anemia Pregnancy

ANEMIA IN PREGNANCY
Laston Kastom
BscBMS(RH),Dip.Clin.Med
World Health Organization
Anemia – a major killer
Iron deficiency anemia is the most common
medical disorder during pregnancy.

In pregnancy, it is one of the leading causes of
maternal mortality in developing countries.

It affects both mother and fetus.
General Causes of anaemia:
Physiological - disproportionate ↑se of plasma
volume apparent reduction of RBC, Hb & Hct.
Picture is normochromic normocytic.
Acquired:
Nutritional
Iron deficiency anemia (60%),
Macrocytic anemia (10%) due to def of folic acid
and/or vitamin B12
Dimorphic and protein deficiency anemia (30%) in
extreme malnutrition
Causes of Anemia
Hemorrhagic
acute blood loss,
chronic (hook worm, bleeding piles)
Infections
 Acute (e.g., malaria)
 Chronic (e.g., tuberculosis)
Genetic conditions (e.g., thalassemia, sickle cell)
Enzyme disorders (e.g., sideroblastic anemia)
Anemia of chronic disease (e.g., malignancy, chronic
renal failure
Criteria for Physiologic Anemia
Hb: 10gm%
RBC: 3.2 million/mm3
PCV: 30%
Peripheral smear showing normal morphology of
RBC with central pallor
Significance of Hypervolemia
1. To meet the demands of the enlarged uterus
with its greatly hypertrophied vascular system.
2. To protect the mother, and in turn the fetus,

against the deleterious effects of impaired
venous return in the supine and erect positions.
3. To safeguard the mother against the adverse

effects of blood loss associated with parturition.
Definition of Anemia in Pregnancy
Anaemia is a sign and not a disease
WHO-Hb conc <11gm/dl & Hct < 33%
CDC definition-Hb con <11gm/dl & Hct < 33% during
the 1st trimester & < 10.5 gm/dl Hct < 32% during the
2nd trimester
Absolute iron deficiency is defined as ferritin <200
µg/L with or without iron saturation <20%,
CDC definition:
Pregnancy
Hemoglobin Hematocrit
Trimester
First 11.0 33.0
Second 10.5 32.0
Third 11.0 33.0
Classes of Anemia
Mild 10-11mg%
Moderate 7-10.9mg%
Severe 4 - 6.9mg%
Very severe <4mg%
Factors required for erythropoiesis
• Proteins (erythropoietin)
• Minerals (iron)
• Trace elements: (Zinc, Cobalt, Copper etc)
• Vitamins: Folic acid, Cyanocobalamin (B12), Vitamin C, Pyridoxine
(B6), Riboflavin, Vitamin A
• Hormones: Androgens & Thryoxine

Letsky E. 1995
Prasad AS. J. Am. Coll. Nutr. 1996
Normal Iron Requirements
Iron requirement for normal pregnancy is 1gm
200 mg is excreted
300 mg is transferred to fetus
500 mg is need for mother
Total volume of RBC inc is 450 ml

1 ml of RBCs contains 1.1 mg of iron
450 ml X 1.1 mg/ml = 500 mg
Daily average is 6-7 mg/day

Normal Levels
Hb 13.5 – 14 gm %
R.B.C. 4.5 – 4.7 million/cu mm

Serum Iron 50 – 150 μgm / dL
TIBC 300 – 360 μgm / dL
Transferrin saturation 25 – 50 %
S. Ferritin level 30 μg / Lit
Red Cell protoporphyrin 30 μg / dL
Erythropoietin 15.20 U / Lit
MCV 76 – 100 L
MCH 27 – 33 pg
MCHC 33.37 gm / dL
PCV 32 – 40 %
Maternal Anemia
Etiologies in Pregnancy
 Inadequate dietary intake  Inadequate GIT absorption
 Poor nutrition  Malabsorption syndromes
 Chronic alcoholism  Certain drugs/foods
 Decreased consumption of  Blood loss

animal protein and ascorbic  Hookworm infestation
acid  Malaria
 Increased iron demands  Bleeding piles &gums
 Multiparity  Surgery
 Diarrhea, HIV/ AIDS and  Gastrointestinal bleeding
 UTI  Trauma
 Recurrent Infections-  Dialysis
Tuberculosis, Amoebiasis ,
Giardiasis, Roundworm
 other infectious diseases
Low Iron Intake or Low Iron
Absorption
Haemolysis due to malaria
worm infestations (hookworm)
Multiparity
Clinical Feature of Anemia
Symptoms:
Mild anemia; usually asymptomatic
Moderate anemia - weakness, fatigue,
exhaustion, loss of appetite, indigestion,
giddiness, breathlessness
Severe anemia-palpitation, tachycardia,
breathlessness, Increased cardiac output, CHF,
general anasarca, pulmonary edema
Sharma J.B. Progress in Obst. & Gynae. (Studd) 2003.

Clinical Features of Anemia
Signs:
Pallor
Nail changes – Koilonychia
Angular cheilosis, Glossitis, Stomatitis
Oedema
Hyperdynamic circulation (short and soft systolic
murmur)
Fine crepts
Sharma J.B. Progress in Obst. & Gynae. (Studd) 2003.

Effects of Anemia on Pregnancy
Pathophysiology - Fetus
Effects of Anemia on Fetus
• PROM,
• IUGR,
• IUFD,
• Prematurity,
• Abnormal trophoblast invasion
• Fetal programming & disease of newborn:
behavioral abnormalities, decreased cognitive function.
• Neonatal anemia
• Adult HT associated with low birth weight & high ratio of
placenta to birth weight.
•(Barker DJP, Bull AR, et all BMJ 1990; 301:259-262)
• If maternal oxygenation is 98 – 100 %,
• The fetus gets around 70 % of O2, with fetal Hb.
Fetus can compensate.
• As the maternal Hb. drops, fetal hypoxia develops,
which leads to stimulation of fetal erythropoiesis
• Increased viscosity of blood due to raised PCV.
sluggish circulation
• End artery thrombosis
• Failure of the organs, supplied by these vessels.
Severe Anemia
Fetal hypoxia
Prolonged period Short duration
Neurologic IQ less,
al deficit slow
learner
etal hypoxia leads to an increase in the cord blood EPO
ord blood EPO correlates with perinatal brain damage

Maternal Effects of Anemia
Reduced immune function -
• Behavioral changes, infection, ante-partum and
irritability. puerperal sepsis.
• Loss of appetite, Negative thermoregulation
indigestion, etc. due low Increased risk of blood
performance of each transfusion
organ. • Preterm Labor
• Increased morbidity and • Sub involution
mortality due to PIH, APH, • Failing lactation
PPH, if associated. • Pulmonary Venous:
• C CF at 30-32 wks, intra- thrombosis & embolism, due
partum & post-partum. to thrombophlebitis.
What is level
Type
cause
FULL BLOOD COUNT
HGB
HCT
RBC MORPHOLOGY/INDICES
RETICULOCYTE COUNT
RBC indices - little diagnostic value unless the
MCV is below 70fl
Serum iron - decreased in a variety of states
including iron deficiency, inflammation & stress.
Varies tremendously from morning to evening and
from day to day. value < 0.5mg/L indicate anemia,
normal range :0.80 to 1.80 mg/L
Total iron binding capacity is very specific for iron
deficiency (near 100%) but has poor sensitivity
(<30%).
Iron saturation (Fe/TIBC x 100) can be decreased
below 16% in both anemia of chronic disease and
iron deficiency
The Reticulocyte Count
(Kinetic Approach)
↑ reticulocytes (>2-3% or 100,000/mm3 total) are seen in

bl loss and hemolytic processes, although up to 25% of
hemolytic anemia's will present with a normal count.
Specific tests for etiology of the anemia
•Urine & stool examination

• Test for malaria
• Rarely- Endoscopic or barium studies of the
GI tract, bone marrow examination
Exclude other causes of hypochromic
microcytic anemia
•Anemia of chronic disease

• Thalassaemia trait
• Sideroblastic anemia
Mild and Moderate
Nutrition
Control of infestation
Control of infection
Iron and Folic acid supplement
Economic reforms
Education
Cultural reforms
Infrastructure development, etc.
Severe Anemia
Management depends on the time at hand.
If diagnosis:
 Preconception - oral, if not tolerated, parenteral
 First & second trimester - oral + parenteral
 Third trimester - parenteral + blood transfusion by PCV
 Late in third trimester and/ labor, blood transfusion by
PCV nasal O2, B T, digitalization and ICU
management with team approach.
Clinical condition
Associated risk factors
World Health Organization
‘Transfusion should be
prescribed ONLY for conditions
for which there is NO OTHER
TREATMENT’
Blood Transfusion:
• Indications-
• Severe Anemia in third trimester, CCF in pregnancy,
Acute hemorrhage or hemolysis in pregnancy.
• Jehovah’s Witness who refuse blood transfusion due to
religious beliefs.
• S/E of BT-
• HIV, Hepatitis B, C, malaria, rubella, etc.
• Transfusion reaction
• Risk of incorrect cross - matching and transfusion
negative impact on immune system.
• .
Prevention
Dietary modification
Iron supplementation of adolescent & non pregnant
female
Tx of Hookworm infestation
Control of malaria
Iron supplementation in pregnant Women
Food fortification
Antenatal care for early recognition
Optimal birth spacing
Eat foods that are:
Rich in iron - liver, beef, whole-grain breads
cereals, eggs, dark green vegetables and dried fruit.
High in folic acid, such as wheat germ, beans,
peanut butter, oatmeal, mushrooms, collards,
broccoli, beef liver and asparagus.
High in vitamin C, such as citrus fruits and fresh,
raw vegetables. Vitamin C makes iron absorption
more efficient.
Take prenatal vitamin and mineral supplements,
especially folic acid.
Dietary components Absorption
Calcium (Dairy products) 

Meat, fish,
Phytate poultry,
(grain sea-food
products) 

Polyphenols 
(Tea, spices, vegetables)
Vitamin C 
CONCLUSION
Proper antenatal care and awareness programmes for
prevention of anemia.
Adequate iron / folic acid prophylaxis in all antenatal
cases.
Early detection and timely referral to tertiary centers.
Management to be decided depending upon the cause of
anemia, type of anemia and severity of anemia.
Logical use of blood and blood components.
Proper intrapartum and postpartum care.
Motivation of the patient for acceptance of any
contraceptive method.
FOR LISTENING

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ANEMIA IN PREGNANCY

Iron deficiency anemia is the most common

medical disorder during pregnancy.

maternal mortality in developing countries.

2. To protect the mother, and in turn the fetus,

3. To safeguard the mother against the adverse

• Hormones: Androgens & Thryoxine

Total volume of RBC inc is 450 ml

Daily average is 6-7 mg/day

R.B.C. 4.5 – 4.7 million/cu mm

 Chronic alcoholism  Certain drugs/foods

 Decreased consumption of  Blood loss

Sharma J.B. Progress in Obst. & Gynae. (Studd) 2003.

Sharma J.B. Progress in Obst. & Gynae. (Studd) 2003.

Prolonged period Short duration

ord blood EPO correlates with perinatal brain damage

↑ reticulocytes (>2-3% or 100,000/mm3 total) are seen in

•Urine & stool examination

•Anemia of chronic disease

Calcium (Dairy products) 

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