Anaemia in Pregnancy 2

Anaemia in Pregnancy
By
Professor John Ikimalo

Introduction
• Anaemia in pregnancy occur world wide. It is a public health
problem in women of reproductive age in developing
countries where nutrition is generally poor, malaria is
endemic, acute and chronic infections are common.
• Affects 14 to 60% of pregnancies
Definition
Anaemia is defined by the value of haemoglobin (Hb).
The World Health Organization defines anaemia in pregnancy as
haemoglobin (Hb) concentration of less than 11g/dl.
The severity of anaemia in pregnancy can generally be
considered as :
Very severe < 4g/dl
Severe < 7g/dl
Moderate 7-8.9g/dl
Mild 9-10.9g/dl
Classification
• Physiological anaemia in pregnancy
• Pathological
i. Deficiency anaemia (isolated or combined)
 Iron
 Folic acid
 Vit B
12
 Protein
ii. Haemorrhagic
 Acute haemorrhage – Abortions, ectopic pregnancies, H.mole APH,
PPA, Uterine rupture
 Chronic haemorrhage – bleeding haemorrhoids, hookworm infestation
Classification contd.
iii. Hereditary
 Sickle cell disease - SS
 Other haemoglobinopathies - SC
 Thalassemias
 G6 – 6 – PD deficiency
iv. Haemolytic
 Intrinsic causes – Red blood cell membrane or metabolic defects
 Extrinsic causes – Acquired immune haemolytic anaemia and
microangiopathic haemolytic anaemia
v. Bone marrow insufficiency
 Hypoplastic or aplastic from radiation or drug (Aspirin, indomethacin)
vi. Infections
 Malaria, tuberculosis
 Other bacterial infection
vii. Chronic diseases
 Neoplasia
 Renal
 Liver cirrhosis
viii. Socio-economic – poverty, illiteracy, high parity, status of women – girl child
For red blood cell formation (Erythropoiesis), iron, folic acid, VitC, Vit
B6, erythropoietin, zinc, copper, cobalt, androgens and thyroxin are
required in adequate amount.
Increase in the demand, inadequate supply, inadequate reserve of any
of these will lead to anaemia.
In pregnancy, plasma volume ↑ 50%, RBC volume ↑ 25-30%
Physiological anaemia is normocytic and normochromic
There is ↓Hb, ↓Haematocrit, ↓Serum iron values, ↓Iron binding
capacity, ↑Absorption
Effect of Anaemia in Pregnancy
Maternal Foetus
• Weakness, fatigue, poor work • Small for date (IUGR)
performance • Preterm birth, low birth weight
• Abruptio placenta • Low Apgar’s score – asphyxia
• Preterm labour • Infection
• Infections • Cognitive and affective
• Cardiac failure dysfunctions
• Uterine inertia • Iron deficiency anaemia
• Shock • IUCD / Still birth
• Subinvolution • Neonatal death
• Failing lactation
• Venous thrombosis
• Pulmonary embolism
Effect of Pregnancy on Anaemia
Aggravation of symptoms
Iron Deficiency Anaemia
• Commonest type of anaemia in pregnancy
• 4-6mg of iron is absorbed daily – Ferrous form in duodenum and
jejunum.
• Since only 10% is absorbed, then 40-60mg required daily. More absorbed
in heme form.
• Sources of iron – Liver, meat, poultry, fish, egg, yolk, green vegetables,
nuts milk and milk production
• Stored in the reticuloendothelial cells in liver, spleen, bone marrow,
hepatocytes and myocytes
• Demand for iron increases as pregnancy advances.
Cause of Iron Deficiency
• Dietary habits
• Faulty iron absorption - ↑VitC and HCL, ↓Phytates, Phosphorus, tea
• Increase iron loss – bile, urine, faeces, sweat
• Infection / infestations – bacteria, hookworm, malaria
• Poor iron reserve pre pregnancy
• Teenage pregnancy
• Non practice of active management of 3rd stage of labour
Megaloblastic Anaemia
• DNA synthesis affected
• Derangement of red cell maturation
• Production of abnormal precursors (megaloblasts) in the bone
marrow
• Found in the circulation as macrocytes
• Caused by Folic acid or Vit B12 deficiency
Folic Acid Deficiency
• Absorption - duodenum / jejunum
• Requirement in pregnancy 300mg/day, lactating woman, 150mg/day
• At cellular level, reduced to dihydrofolic acid and then tetrahydrofolic acid
(Folinic acid)
• Essential for cell growth and division (prevents neural tube defect, cleft lip
and palate)
• Sources - green vegetables, beans, yeast, liver, kidney, fruits, cereals, nuts
• Destroyed by boiling or steaming
• Stored in the liver and other tissues but low, 10mg
Causes of Deficiency
• Reduced dietary intake - poverty
• Prolonged cooking
• Malabsorption - G.I disease
• Liver disorders
• Chronic alcoholism
• Anti-folates - phenytoin, primidone
• Infection / infestations
Vitamin B12 (Cobalamin)
- Rare or uncommon
- Daily requirement 5-15 micrograms - absorption unchanged in pregnancy
- Source - only in animal products, meat and dairy products
- Smoking reduce B12 levels
- Preferential transfer to the foetus
- Addisonian pernicious anaemia (intrinsic factor deficiency) cause infertility
- Stored in liver
- Sources - liver, kidney, meat, fish, egg, milk and cheese
Diamorphic Anaemia
- In the tropical countries, deficiency of both iron and folic acid are
commonly seen - nutritional anaemia.
- Blood film show macrocytic or normocytic, normochromic or
hypochromic picture.
- Treatment is with both iron and folic acid supplementation, fruits and
green vegetables.
Other Causes of Anaemia
● Haemoglobinopathies / Sickle Cell Disease
● Haemolytic anaemia
● Aplastic anaemia
● Malaria
● HIV
Detailed lectures on these will follow.
Clinical Features
Presentation depends on the degree of anaemia- no symptoms initially
Symptoms Signs
● Tiredness, fatigue, lassitude ● Palor (conjunctiva, tongue, buccal

● Dizziness, headache, irritability mucosa, palm, nail beads)
● Breathlessness, palpitation, ● Glossitis (red smooth)
giddiness ● Spoon shaped nail (koilonychia)
● Swollen legs, bleeding, pica ● Slim, long limbs, bossing forehead (SS
anaemia)
● Jaundice, pedal oedema, dyspnoea,
soft systolic murmur
● splenomegaly
Investigations
First Line Second line
● Full Blood Count (FBC), HB included ● Chest X ray (TB)

● Blood film, malaria parasite ● Bone marrow aspiration- sternum
● Red cell morphology iliac crest
● LFT, E/U/CR ● Serum iron
● HB Genotype Full urinalysis, M/C/S, ● Iron binding capacity
shistosomiasis ● Serum proteins (hypoproteinemia)
● Stool for microscopy (hookworm
ova)
Management
 Detailed history and clinical examination
. Mx depends on the cause, degree of anaemia and gestational age

 Principle - Find the cause and treat it, correct anaemia before term or
labour
Treatment
● Oral Haematinics
○ Ferrous sulphate, ferrous gluconate, ferrous fumarate, ferrous succinate
(200mg tabs contain 60 mg element Fe)
○ Folic acid
● Other Vitamins
○ Vit B and C
● Parenteral Haematinics
○ IM Iron (eg. imferon, Jectofer)
○ IV, Iron dextran, Iron Sorbitol Citrate- over hours and monitored
○ Dose of elemental iron = deficit (i.e normal HB - pt. Hb)x wt (kg)x
2.21+1000
○ No haematological advantage over oral. Both raise Hb by 0.8g/dh per
week
Treatment cont.
● Blood transfusion
○ Required in severe anaemia, anaemic heart failure, acute blood loss,
moderate/severe anaemia in labour
○ Packed cell (Hb increases by 0.7-1g/dh)
○ Whole blood
○ Blood transfusion with diuretics - furosemide, ethacrynic acid (to prevent
circulatory overload)
○ Exchange blood transfusion - rarely done these days
● Prophylactic broad spectrum antibiotics

Prevention
● Prophylaxis - supplementation in pregnancy (Fe 200 mg + Folic acid 5mg daily)
● Hb check in pregnancy at booking, 28wks, 32wks and at term
● Treat worm infestation- Albendazole 400mg stat, Mebendazole 100mg
bd x 3 days
● Improve dietary habits (table salt fortified with iron)
● Improve sanitation and personal hygiene
● Improve female literacy
● Prevent teenage pregnancy, high parity and space childbirth -
contraceptive use
● Health education
Conclusion
● The commonest medical disorder in pregnancy
● Increase maternal and fetal morbidity and mortality
● Nutritional deficiency, malaria, infections/infestations and
haemoglobinopathies are commonest causes
● Management is to identify the cause, treat and correct the anaemia with
supplementation.
● Preventive measures are cheap and easy to achieve.

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Anaemia in Pregnancy

Professor John Ikimalo

● Tiredness, fatigue, lassitude ● Palor (conjunctiva, tongue, buccal

● Full Blood Count (FBC), HB included ● Chest X ray (TB)

. Mx depends on the cause, degree of anaemia and gestational age

● Prophylactic broad spectrum antibiotics

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