Anemia in Pregnancy

Mrs Samia Abu Aishia

The anemia
Anemia: is reduction in the oxygen carrying capacity of the blood, which may be due to: A reduced number of red blood cells. A low concentration of hemoglobin. A combination of both.

Physiological haemodilution of pregnancy:

During

pregnancy the blood volume increases, the increase in the plasma volume is greater than the increase in the red mass. This has the following effects: The blood become less viscous which may help to reduce cardiac workload and make perfusion of the placental easier.

There

are fewer red blood cells in each liter of blood, which means that the hemoglobin concentration is reduced. These changes result in an obvious anemia but as this represents a normal pregnancy state they should not be regarded as pathological

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.

Defination of Anemia during Preg.

Hemoglobin

below 11gm/dl in 1st and 3rd trimester and below 10.5gm/dl in second trimester.

The effect of anemia

Mother Reduced enjoyment of pregnancy and motherhood due to fatigue. Fetus/baby Higher prenatal mortality if maternal Hb is less than 8g/dl

Reduced resistance to infection caused by impaired cell mediated immunity.

Increased risk of intrauterine hypoxia and growth retardation

Predisposition to post partum hemorrhage

An increase in sudden infant death when maternal Hb is less than 10g/dl

Potential threat to life. Problem caused by treatment.

Classification
Physiologic Pathologic:
a. Deficiency: Iron, Folic A. c. Hereditary: Thalassemia, Sickle,

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
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 average is 6-7 mg/day

Total

Daily

Iron Deficiency Anaemia:

It

is the most common form of anemia. During pregnancy approximately 1400mg iron is needed for: The increase in the number of the red blood cells. The fetus and the placenta. Replacement of daily loss (about 1mg/day) through stool, urine and skin. Replacement of blood lost at delivery.

Causes of iron deficiency anemia:

Reduced

intake or absorption of iron or protein or both (iron is stored in combination with ferritin which is a protein). Dietary deficiency and gastro intestinal disturbances such as morning sickness. Excess demand such as multiple pregnancies. Blood loss, from menorrhagia before conception, bleeding hemorrhoids, ante partum or post partum

Prevention:
Accurate

medical, obstetric and social history. Health education about the sources of iron and ways in which absorption can be increased. Oral iron preparation given prophylactically consist of one of the iron salts.

Investigation:
A

low Hb concentration only indicates that the women are anemic; iron deficiency is microytic that is producing a small red cell.

Management:
Oral

iron: Side effect of oral iron: stool may turn black. Nausea and epigastric pain. Diarrhea or constipation. Parenteral iron IM or IV is contra-indicated for women who have liver or renal disorder. Blood transfusion: is used to raise the Hb level quickly if delivery is expected shortly.

Folic acid deficiency:

Folic

acid is needed for the increased cell growth of both mother and fetus. Folic acid is found in leafy green vegetables but is destroyed easily by prolonged boiling or steaming and by the addition of alkaline such as bicarbonate of soda. Anemia is more likely to be found towards the end of pregnancy when the fetus is growing rapidly. Also more common during winter when folic acid is more difficult to obtain, and in areas of social, economic, and nutritional deprivation.

Causes of folic acid deficiency anemia:

Reduced

dietary intake, as a result of overcooking. Reduced absorption for instance in celiac disease. Interfere with utilization, such as anticonvulsants, alcohol. Excessive demand

Prevention:
Advising

pregnant women on correct selection and preparation of foods, which are high in folic acid. Folic acid may be prescribed prophylactic for women at incrsed risk. Those with a multiple pregnancy.

Investigation:
In

folic acid deficiency the red blood cells are reduced in number but enlarged in size macrocytic or megaloblastic

Management:
folic

acid is available in oral and intramuscularly form. The usually daily dose being between 5 and 15 mg in divided doses. Side effects are rare but anorexia nausea and flatulence have been noted.

Complication of the folic acid deficiency in pregnancy: Infection.

Placental

separation(abruption

placenta) Bleeding. Possible congenital abnormalities such as neural tube defect.

Thalassaemia:
The

basic defect is reduced rate of globin chain synthesis resulting in either alpha or beta chains being missing. This leads to haemolysis and in adequate hemoglobin content. The severity of the condition depends on whether the child has inherited abnormal gene from one parent or from both.

Thalassaemia intermediate and minor produce: Similar to iron deficiency in that

the Hb, MCV, and MCH are lowered. A deficiency in iron is not a problem because red cell are broken more rapidly than the normal and the iron is stored for future use. Treatment folic acid supplement.

Thalassaemia minor:
The

child inherits abnormal genes from both parents. Rapid red cell breakdown produces severe anemia. Worst from (alpha thalassaemia major), this condition is incompatible with extra uterine life. Beta thalassaemia in early childhood although the use of frequent blood transfusion increases the possibility of survival to childbearing age. Accumulation of iron in the body due to break down of red cells from donated must be removed by the chelating agent desferrioxaine

Pregnant woman with Thalassaemia major:

Shared

care from an obstetrician and a hematologist in specialist center. Mother will need to increase her dietary intake of folic acid and to take folic acid supplement through pregnancy. Repeated blood transfusion may be required. The midwife has vital role in supporting the woman and in

Sickle cell anemia:

In

this condition defective genes produce abnormal heamoglobin beta chain; the resulting Hb is call Hbs In sickle cell trait (Hbas): only one abnormal gene has been inherited. In sickle cell disease (Hbss): abnormal genes have been inherited from both parents.

Leads

to low oxygen tension and cause heamolsed and anemia develop. Sickle cell trait: is usually asymptomatic. The blood appears normal, although the sickle screening test is positive There is no anemia even under the additional stress of

Sickle cell anemia

Women

with sickle cell anemia may be sub fertile. Those who do become pregnant may already have organ damage, due to sickling crises, which may occur whenever oxygen concentration is low, during anesthesia, illness, cold, at high altitude or pregnancy. Infarction leads to pain due to accumulation of red cells sickle and blocking small blood vessels. Emboli may threaten life. (Shortened life span for17 days) lead to hemolytic

Antenatal care:
Screening

of the high risk women and those who are diagnosed. Monitoring of pregnancy is performed at regular intervals under supervision of obstetricians and hematologist. During pregnancy avoid situation, which may precipitate a crisis such as cold, stress, dehydration, hypoxia and infection. Regular monitoring of the Hb concentration is required throughout

Treatment

may include 3-4 unit blood transfusion every 6 weeks to maintain an adequate Hb level. Role of midwife is to identify preventive measures as well as to provide social and psychological support

Intrapartum:
During

labor well hydration, iv fluids given prophylactic antibiotic and effective analgesia (epidural and oxygen therapy). Monitoring for the fetus closely for signs of distress The sickle cell test doses not yield positive results until the age of 3-4 month of fetal Hb (hbf) recedes. A positive test dose not distinguish between sickle cell trait and sickle cell anemia, therefore all children showing positive result should be investigated and followed up by the hematologist.

Postnatal care:
Prevention

of puerperal sepsis. Antibiotic cover is continued throughout postnatal periods.

Nursing Care for Women With Anemias During Pregnancy

Teach woman which foods are high in iron and folic acid Teach woman how to take supplements Do not take iron supplements at the same time when drinking milk Do not take antacids with iron When taking iron, stools will be dark green to black The woman with sickle cell disease requires close medical and nursing care Teach her to prevent dehydration and activities that cause hypoxia Teach her to avoid situations where exposure to infections are more likely Teach her to promptly report any signs of infections