ANAEMIA DURING PREGNANCY

INTRODUCTION
Anaemia is the commonest medical disorder in pregnancy.
Anemia is a frequent condition during pregnancy, particularly among women from
developing countries who have insufficient iron intake to meet increased iron needs of both
the mother and the fetus.
Anaemia in pregnancy continues to be major health problem in many developing countries, it
is associated with increased rate of maternal and perinatal mortality, premature delivery, low
birth weight and other adverse outcomes, it is the most common pregnancy complication
worldwide.

DEFINITION
Anaemia in pregnancy is a HB concentration is less than 11g/dl (7.45mmol/l) and a
haematocrit of less than 0.33.
- According to WHO
Proposes a cut-off point 10.5g/dl during the second trimester.
-CDC (Centers for disease control)
This is a measure of the concentration of the RBC pigment haemoglobin in whole blood,
expressed as grams per 100ml (dl) of whole blood.
- M . C. Bansal
Anemia may be defined as a reduction in red blood cell (RBC) mass or blood haemoglobin
concentration.

INCIDENCE:
Anemia in pregnancy ranges widely from 40-80% compared to 10-20% in the developed
countries.
In Nepal 15-49 years women 36% exhibiting anemia and among pregnant women 2 out of 5
women are anemic. (DHS 2007).
Anemia is responsible for 20% of maternal deaths in the third world countries/ developing
countries.

PREVELANCE OF ANEAMIA IN PREGNANCY

It is estimated that about 51% of pregnancy women worldwide will suffer some degree of
anaemia during pregnancy. HB levels of 9-11g/dl is considered mild anaemia.
*pregnancy by itself will aggravate any already existing anaemia.

CAUSES DURING PREGNANCY

The woman, who has got sufficient iron reserve and is on a balanced diet, is unlikely to
develop anemia during pregnancy in spite of an increased demand of iron. But if the iron
reserve is inadequate or absent, the factors which lead to the development of anemia during
pregnancy are:
INCREASED DEMAND OF IRON: The demand of iron during pregnancy is markedly
increased. An adequate balanced diet contains not more than 18-20mg of iron and assuming
that the absorption rate is increased by two folds (20%), the demand is hardly fulfilled.
DIMINISHED INTAKE OF IRON: Apart from socioeconomic factors, faulty dietetic
habits, loss of appetite and vomiting in pregnancy are responsible factors.
DISTURBED METABOLISM: Apart from the faulty absorption mechanism just described,
pregnancy depresses the erythropoitic function of the bone marrow. Presence of infection
markedly interferes with the erythropoiesis; one should not even ignore the presence of
asymptomatic bacteriuria.
PRE PREGNANT HEALTH STATUS: majority of the women actually start pregnancy on
a pre-existing anemia state or a least with inadequate iron reserve. It is the state of the stored
iron which largely determines whether or not and how soon a pregnant woman will become
anemic
EXCESS DEMAND: Multiple pregnancy- increased the iron demand by two folds
Women with rapidly recurring pregnancy- within two years following the last delivery, need
more iron replenish deficient iron reserve.
The demand of iron which accompanies the natural growth before the age of 21 should not be
under-estimated, specially where teenage pregnancies are quite prevalent. At the age of 17,
the additional demand is estimated to be about 270mg during the course of pregnancy; the
requirement is, however brought down to nil at the age of 21.
Another important problem posed by anemia in pregnancy is its polymorphism. Pregnancy
tends to interfere with maternal erythropoiesis by competing for the available raw materials
such as folic acid, vitamin B12 proteins, apart from iron.

CLASIFICATION AND TYPES OF ANAEMIA

A-physiological of anaemia
B-nutritional anaemia
C-haemorrhagic anaemia
D-haemolytic anaemia
E-microangiopathic haemolytic anaemic
F-acquired immune haemolytic anemia
G-haemolytic anemia associated with haemoglobinopathies
H-aplastic anemia
A-PHYSIOLOGICAL OF ANAEMIA
During pregnancy the plasma volume increases more than the increase in the R.B.C volume
resulting in hydraemia and physiological anemia (blood picture is normal )
B-NUTRITIONAL ANAEMIA

1, Iron deficiency anemia

2, Megaloblastic anemia
1, IRON DEFICIENCY ANEMIA
It is the commonest nutritional deficiency in pregnancy followed by folate deficiency anemia.
It may either be due to increased iron loss or decreased iron absorption.
2, MEGALOBLASTIC ANEMIA
In megaloblastic anemia, DNA replication is affected. There is derangement of red cell
maturation with production of abnormal precursors known as megaloblasts which can be due
to deficiency of folate or vitamin B12 .
C-HAEMORRHAGIC ANAEMIA
Repeated blood loss during pregnancy , as with antepartum haemorrhage , or GIT bleeding.
D-HAEMOLYTIC ANAEMIA
E-MICROANGIOPATHIC HAEMOLYTIC ANAEMIC
Occurs in some patients with severe pre-eclampsia, eclampsia, thrombotic thrombocytopenic
purpura and hemolytic uremic syndrome.
F-ACQUIRED IMMUNE HEMOLYSTIC ANEMIA
Antibodies of the IgG type agients red cell antigens are present in collagen vascular disease
G-HAEMOLYTIC ANEMIA ASSOCIATED WITH HAEMOGLOBONOPATHIES
Abnormal haemoglobin synthesis:
_ Sickle cell anemia
_Beta thalassemia
H-APLASTIC ANEMIA
Extremely rare and the mortality rate is about 30%
SEVERITY OF ANEMIA
category Anemia severity Haemoglobin level(g/dl)
1 Mild 10-10.9
2 Moderate 7-10
3 Severe <7
4 Decompensated <4

EFFECTS OF ANEMIA ON PREGNANCY

 A- MATERNAL EFFECTS

*MILD ANEMIA : In effects on pregnant and labour mother will have low
iron stores
*MODERATE ANEMIA: increased weakness, lack of energy, fatigue and poor work
performance.
*SEVERE ANEMIA: Associated with poor outcome increased incidence of pre -term
labour, pre- eclampsia and sepsis.
RISK
The risk periods when the patient may even die suddenly are:o At about 30-32 weeks of
pregnancy. o During labour.
Immediately after delivery. o Any time in the puerperium specially 7-10 days following
delivery due to pulmonary embolism

B- FETAL EFFECTS
-Decreased iron stores due to depletion of maternal stores
-High risk for an adverse perinatal outcome (inceased perinatal mortality )
EFFECTS ON BABY
o Amount of iron transferred to the fetus is unaffected even if the mother suffers from
iron deficiency anemia.
o There is increased incidence of low birth weight babies with its incidental hazards.

o Intra uterine death due to severe maternal anoxaenmia.

o The sum of effect is increased perinatal loss.

SIGNS
There may be no signs, especially in mild and moderate cases.
- Pallor,
-glossitis and stomatitis may be present.
In severe cases oedema and systolic murmur can be found.
SYMPTOMS
There may be no symptoms, especially in mild and moderate anemia. Patient may complain
of -weakness
-exhaustion
- loss of appetite
Palpation and dyspnoea
Generalised anasarca and congestive heart failure in severe cases.
DIAGNOSIS / INVESTIGATION
CBP( complete blood picture) including Hb% and haematocrit value
-Serum iron
-Peripheral blood smear: To study the morphology of the red cells gives a better idea, about
type of anemia, hematological indices MCHC, MCV and MCH is based on the value of Hb
estimation, total red cells count, and PCV.
- HB electrophoresis; for diagnosis of inherited anemia
MANAGEMENT OF ANEMIA
DURING PREGNANCY:
PREVENTION: proper antenatal care. Iron supplementation using oral iron preparations.
Proper diet rich in iron and vitamin C
TREATMENT
ORAL IRON THERAPY: In mid trimester or early 3rd trimester. Haemoglobin rises from 0.3
to 1.0g per week, and this is reflected in a significant elevation in Hb/Ht values 2 to 3 weeks
after initiation of treatment.
DIETARY PRESCRIPTION: A realistic balanced diet, rich in iron and protein should be
prescribed which should be within the reach of the patient. The foods rich in iron are liver,
meat, egg, green vegetables, green peas, figs beans, whole wheat and green plantains, onion
etc.

IRON REQUIRMENTS IN PREGNANCY

THE REQUIREMENT ARE
1, Basal iron ,280mg
2, Expansion of red cell mass , 570mg
3, For transfer of the fetus 200-350mg
4, For placenta , 50-150mg
5, Blood loss at delivery , 100-250mg
PARENTRAL IRON THERAPY: For women with severe anemia in late 3 rd trimester or
those with poor compliance for oral therapy. Iron dextran is used.
BLOOD TRANSFUSION (packed cells are preferred):
Very rarely required in patients with severe anemia beyond 36 weeks, associated infection, to
compensate blood loss due to antepartum haemorrhage and in patients not responding to iron
therapy.
DURING LABOUR
FIRST STAGE: Oxygen should be ready if dyspnoea develops. Antibiotic prophylaxis.The
patient should be in bed and should lie in a position comfortable to her. o Arrangements for
oxygen inhalation are to be kept ready to increase the oxygenation of the maternal blood and
thus diminish the risk of fatal hypoxia. o Strict asepsis is to be maintained to minimize
puerperal infection.
SECOND STAGE: Shortened if necessary to avoid maternal exhaustion.
 Asepsis is maintained.
 Prophylactic low forceps or vacuum delivery may be done to shorten the second
stage.
 Provide oxygen inhalation to increase the oxygenation of the maternal blood and thus
diminish the risk of fatal hypoxia
 Prepare for active management of third stage.
THIRD STAGE: Active management of third stage of labour .
 Active management should be done except in very severe anemia for fear of cardiac
failure ( any postpartum haemorrhage must be treated as these patients tolerate
bleeding very poorly).
 One should be very vigilant during third stage.
 Significant amount of blood loss should be replenished by fresh packed cell
transfusion.
 The danger of postpartum overloading of the heart should be avoided.
IMMEDIATELY AFTER DELIVERY.
Any time in the puerperium specially 7-10 days following delivery due to pulmonary
embolism. Effects on baby Amount of iron transferred to the fetus is unaffected even if the
mother suffers from iron deficiency anemia.
There is increased incidence of low birth weight babies with its incidental hazards. o Intra
uterine death due to severe maternal anoxaenmia. o The sum of effect is increased perinatal
loss.
DURING PUERPERIUM
There is increased chance of:
1.Puerperal sepsis
2.Sub-involution
3.Failing lactation
4.Puerperal venous thrombosis
5.Pulmonary embolism
Risk periods The risk periods when the patient may even die suddenly are:o At about 30-32
weeks of pregnancy.
-Adequate rest, iron and folate therapy for at least 3 months.
-Any infection should be promptly treated.

COMPLICATIONS OF ANEMIA
A. DURING PREGNANCY:
 Pre-eclampsia may be related to malnutrition and hypoproteinaemia.
 Intercurrent infection—not only does anemia diminish resistance to infection, but also
any pre existing lesion, if present will flare up. It should be noted that the infection
itself impairs erythropoiesis by bone marrow depression.
 Heart failure at 30-32 weeks of pregnancy. oPreterm labour.
B. DURING LABOUR
 Uterine inertia: - is not a common associate on the contrary the labour is short because
of a small baby and multiparity.
 Post partum hemorrhage is a real threat – The patient tolerates badly even a minimal
amount of blood loss.
 Cardiac failure may be due to accelerated cardiac output which occurs during labour
or immediately following delivery.
 Shock – even a minor traumatic delivery without bleeding may produce shock or a
minor hypoxia during anesthesia which may be lethal.

CURATIVES
HOSPITALIZATION: - Ideally all patients having hemoglobin level 9 gm/100 ml/ or less
should be admitted for investigation and treatment. But due to high prevalence of anemia and
inadequate hospital beds, an arbitrary hemoglobin level of 7.5 mg% may be considered.
GENERAL TREATMENT :-
 Diet – A realistic balanced diet rich in proteins, iron and vitamins and which is easily
assailable is prescribed.
 To improve the appetite and facilitate digestion, preparation containing acid pepsin
may be given thrice daily after meals.
 To eradicate even a minimal septic focus by appropriate antibiotic therapy.
 Effective therapy to cure the disease contributing to the cause of anemia