Anemia in Pregnancy

Detty Nurdiati
Dept of Obstetric & Gynecology
Faculty of Medicine, Gadjah Mada University
Dr. Sardjito Hospital. Yogyakarta

Cycle: Nutrition, Health
and their Consequences

Higher
mortality
rate

Impaired
immunity

Impaired mental
development
Increased risk
of adult
chronic
disease

Baby
Elderly

Reduced capacity to
care for baby

Untimely / inadequate
weaning

Low Birth Weight

Frequent
infections

Malnourished
Inadequate
catch up
growth

Inadequate
fetal nutrition
Inadequate
food,
health
& care

Inadequate
food, health
& care

Infection
e.g. malaria

Anemia

Anemia

Woman
Malnourished

Child Stunted
Reduced
mental
capacity

Pregnancy
Low Weight Gain
Micronutrient deficiencies

Adolescent
Stunted

Higher maternal mortality
Inadequate food, health & care

Reduced mental capacity

Inadequate
food, health &
care

Objectives     Understand the physiological changes of the blood in pregnancy Know the maternal and effect of anemia Understand the cause of anemia in pregnancy Be able to detect and manage anemia antenatally .

.

Physiological Changes      Blood volume normally ↑ 36%  max being reached at 34 weeks Plasma volume ↑ 47-50% Red cell mass ↑ 17-25% Relative hemodilution throughout the pregnancy Reaches its maximum between 28-34 weeks .

RBC The MCV ↑ secondary to erythropoiesis These indices decrease progressively in IDA Serum iron & ferritin ↓ secondary to ↑ utilization Total iron-binding capacity ↑ . Hct.Physiological Changes  Consequent of hemodiltuion ↓ in   MCV and MCHC remains stable     Hb.

Physiological Changes  Iron requirement ↑      Iron absorption ↑ moderately Folate requirements ↑   Due to expanding red cell mass & fetal requirements 2.5 mg/day in trim 1 to 6. uterus and expanded maternal and red cell mass No major effect on B12 stores.6 mg/day in trim 3 700-1400 mg total pregnancy Due to the fetus. placenta. although levels ↓ (preferential active transport to fetus) .

1997 .Dietary Iron Requirements Throughout the Life Cycle Required iron intake (mg Fe/1000 kcal) Pregnancy 12 10 Men Women 8 6 4 2 0 0 10 20 30 Age (years) 40 50 60 70 Stoltzfus.

Anemia  Definition:   A pathological condition in which the oxygencarrying capacity of RBC in insufficient to meet the body’s need Diagnosis is based on the Hb concentration:   WHO: < 11g/dL at any time during pregnancy Clinicians:   Trim I and III : < 11 g/dL Trim II : < 10.5 g/dL .

Incidence   The commonest medical disorder of pregnancy 30-50% of pregnant women   90% iron deficiency 5% folate deficiency .

Clinical Features   Often asymptomatic Diagnosis being made on routine screening  Estimating the Hb concentration   The beginning of pregnancy and Again later in pregnancy .

Consequences of Maternal Anemia       Maternal deaths Reduced transfer of iron to fetus Low birth weight Neonatal mortality Reduced physical capacity Impaired cognition .

drugs. retained placenta. blood and fluids There is no evidence that high levels of Hb are Enkin et al 2000. birth canal laceration Primary factors affecting outcome:   Rapid intervention to prevent exsanguination Availability of skilled provider.  . abruption. Mahomed 2000a. atony.Anemia and Obstetrical Hemorrhage  Anemia does not cause obstetrical hemorrhage Etiology of obstetric hemorrhage    Early pregnancy: Abortion complications Mid/late pregnancy to delivery: Previa. beneficial in withstanding a hemorrhagic event.

5 10 3.5 0 < 65 > 65 Pregnancy hemoglobin concentration (g/L) Llewellyn-Jones. 1985 .Severe Anemia and Maternal Mortality (Malaysia) 20 Maternal deaths / 1000 live births 15.

Pregnancy Hemoglobin and Low Birth Weight % Low birth weight 15 13. 1981 .4 11 130 140 5 0 80 90 100 Lowest pregnancy hemoglobin concentration (g/L) Garn et al.8 11..9 9 110 120 11.7 10 8.5 9.

hypochromic anemia because of the reduced of MCV and MCHC Significant iron demands during pregnancy    Secondary to expanding red cell mass and fetal requirements Can only be met by a limited increase in iron absorption and by the utilization of iron stores If the iron stores already depleted  anemia will develop rapidly. .Iron Deficiency Anemia   Microcytic.

ferritin levels fall Decreased Hb concentration is a late event in iron deficiency anemia .Iron Deficiency Anemia    The total iron-binding capacity (TIBC) increases secondary to the increased plasma volume and the serum iron falls As iron demands exceed during the pregnancy.

the impairment of cognitive development and behaviour of babies .Concequences  The impaired function of iron-dependent enzymes    causes alterations in muscle neurotransmitter activity and epithelial changes throughout the body The basis explanation for the apparent link between IDA and preterm delivery. infection medical intervention during labour and postpartum hemorrhage Fetal perspective   Increased risk of preterm delivery and IUGR Increased risk the low neonatal iron status.

which is not affected by pregnancy The concentration of <12 ug/L is diagnostic .Diagnosis   ID can be present in the absence of anemia and other parameter of the full blood count that usually give a clue to this (reduced MCV and MCHC) are not accurate during pregnancy The diagnosis test for ID is   a ferritin concentration.

should be used in preference Vit C aids the iron absorption 40% increased of side effect.Treatment  Oral iron replacement      Effective if there is enough time  maximum increase HB: 0.8 g/dL per week Recommended dose: 120-240 of elemental iron per day Ferrous salts are absorted better than ferric salts. mainly gastrointestinal  effect on compliance .

Treatment  Intramuscular Iron   Intravenous iron    Iron sucrose is licensed for total dose iron replacement in the trim 2 and 3. but can also be used to increase the autologous production of blood in normal individuals . More effective & less side effect Blood transfusion    Iron sorbitol injection has a low molecular  rapid absorption Towards the end of pregnancy Rapid increase of Hb concentration but not iron stores Erythropoietin  Mainly used for the anemia associated with erythropoietin deficiency in CRF.

Prevention  Prevention before pregnancy    Balanced diet in the absence of ongoing blood loss Identification and treatment of IDA prior to pregnancy Prevention during pregnancy   Routine iron supplementation 60 mg/day elemental iron Improvement in hematological indices .

Folate Deficiency  Increase of folate requirements because of   Plasma folate    the increased cell replication that is taking place in the fetus. uterus and bone marrow (increase red cell mass) decrease during pregnancy Reaching half non pregnant levels by term Folate deficiency causes a megaloblastic anemia .

Concequences  Fetal perspective:    Clear link  preconceptual folate deficiency and NTD All women planning a pregnancy should take 400 ug/day folic acid  the first 12 weeks the neural tube is closed Maternal perspective:   Anemia Involvement of tissues with high rates of cell turnovers. in particular mucous membranes  the folate deficiency can be exacerbated by malabsorption if the gut mucosa is affected .

Diagnosis  Outside pregnancy   In pregnancy    Macrocytic of folate deficiency anemia is diagnosed by an increased of MCV the MCV is increased May be masked by co-existing iron deficiency leading to reduced MCV. Examining the blood film may be useful  bone marrow aspiration .

Treatment    Severe folate deficiency is extremely rare But if it happened. the treatment is difficult due to poor folate absorption from the affected gastrointestinal tract 5 mg oral pteroglutamic acid daily or parenteral folate can be used .

Prevention   400 ug/day for the prevention of NTD by 36% 5 mg/day could reduce the risk of NTD by 85% .

Vitamin B12 Deficiency     Rare during the reproductive years Absorption unchanged by pregnancy Actively transported across the placenta to the fetus Management   Should be optimized prior to conception Virtually all animal products will supply enough vit B12 .