ANEMIA
The iron is recycled carried by the
 When the number of red blood or
concentrations of hemoglobin are low a
person is said to have anemia.
Hemoglobin is a protein
(metalloprotein) inside the RBCs that
contains iron and transports.
 These cells are manufactured in the
bone marrow and have a life
expectancy of approximately four
months.
 To produce red blood cells, body needs
(among other things) iron, vitamin B12
and flic acid. If there is a lack of one or
more of these ingredients, anemia will
develop.
Kidney Liver
Erythroprotein Iron
Bone Marrow
(Red Blood Cells)
Oxygen = Energy
RBC Lifecycle
 Erythroblast is the earliest identified
erythrocytes wigth deep blue cytoplasm
and large open nuckeus
 After 7 days both the cytoplasm and
nucleus will change dramatically. In the
process of maturation and division the
cells become dense and smaller
 The cytoplasm begins to fill up with hgb,
turning the cells from blue to red.
 The new red cell is now ready to enter
the cell
 After 120 days, macrophage recognize
the erythrocytes as too old and remove
them from the circulation. 1.2 cells%
are removed every day.
 HEME is detoxified by the macrophage.
plasma by the transferrin in the m
arrow taken up by erythroblast and
used to make a new red cell.
 The heme ring opens up and catabolize
bilirubin
 Indirect bilirubin is insoluble bilirubin is
brought to the liver to convert it in a
soluble form known as direct bilirubin
 Direct bilirubin is excreted into the bile
Anemia During Pregnancy
 Hemoglobin below 11gm/dl in 1st and
3rd trimester and below 10.5 gm/dl in
second trimester
Incidence
 Anemia may affect 10% of pregnancies
in developed countries and is
considerably commoner in developing
countries, where it is a major source of
maternal morbidity and a contributor to
mortality.
 Up to 56% of all women living in
developing countries are anemic (Hb <
11g /dl) due to infestations
Classification
o Pathologic:
o A. Deficiency: Iron Folic A., Vitamin B12
o B. Hemorrhagic: Hookworm
o C. Hereditary: Thalassemia, Sickle,
Hemolytic Anemia
o D. Bone Marrow Insufficiency: Aplastic
Anemia
o E. Infectious: Malaria, TB
o Chronic Frenal Disease or Neoplasm
Causes of anemia during pregnancy
 The demand for iron and other vitamins
is increased.
 The mother must increase her
production of red blood cells and, in
 addition, the fetus and placenta need
their own supply of iron, which can only
be obtained from the mother.
 In order to have enough RBC for the
fetus, the body starts to produce more
red blood cells and plasma
 Loss of blood due to bleeding from
hemorrhoids or stomach ulcers
 Anemia is more common in women
who have pregnancies close together
and also women carrying twins or
triplets
Iron Deficiency Anemia
Factors that cause IDA
Symptoms of anemia during pregnancy
 The first symptoms will be tiredness
and paleness
 Palpitations – the awareness of the
heartbeat, breathlessness and
dizziness c an occur, though they
are unusual.
 If the anemia is severe (less than 6g
of hemoglobin per deciliter of
blood), it may cause chest pain
(angina or headaches)
 Lethargy – sluggishness, apathy a
feeling of laziness
Signs and Symptoms
 Malaise – a vagur feeling thatine is
not well
 Dyspnea – difficult or labored
breathing
 Poor concentration
 Palpitations – unpleasant irregular
and/or forceful beating of the heart
 Sensitivity to cold temperature
How is anemia diagnosed
 Blood test will measure the patient’s
RBC and levels of hemoglobin, If the
levels are low the patient has anemia
 The blood test will also reveal whether
the blood cells have an unusual shape,
color or size
 Patients with iron deficiency have
smaller and pale red blood cells
compared to healthy individuals. A
patient with a vitamin deficiency will
have fewer and larger red blood cells.
 Most common anemia of pregnancy,
complicating 15% - 25%
 When hemoglobin level is below
12mg/dl, hematocrit under 33%, iron
deficiency is suspected.
 Heavy menstrual flows
 Diet low in iron
 Unwise weight-reducing programs
 Women who were pregnant less than 2
years before the current pregnancies
 Low socio-economic levels
 Iron is made available to the body by
absorption from the duodenum to the
blood stream after it is ingested. It is
bound to transferrin for transport liver,
spleen and bone marrow it is
incorporated into hemoglobin
 Symptoms: lassitude, weakness,
anorexia, palpitation, dyspnea
 Signs: Pallor, glossitis, soft systolic
murmur in mitral area due to
physiologic mitral incompetence
Findings
 Hematocrit (33%), hgb ( 12mg/dl)
 Serum transferrin – under 100 mg /dl
 Transferrin saturation level – under 5%
 Serum iron under 30 ug/dl
 Mean corpuscular hemoglobin – under
30
 Serum iron is a test that measures how
much iron is in your blood Iron: 60-170
mcg/dl
 Transferrin saturation 20-50% it is the
ratio of serum iron and total iron-
binding capacity, multiplied by 100.
 (MCH), is the average mass of
hemoglobin per red blood cell in a
sample of blood.
 Increase iron binding – over 400 ug/dl
 Pica
 Extreme fatigue
 Poor exercise tolerance
Management
 Iron supplement w/food (60mg)
 Diet high In iron andf vitamins
 Ferrous sulfate or Ferrous gluconate
 Take it with fruit juices or vit C
supplement
 Increase roughage in the diet
 Dextran – IM or IV
Folic-Acid Deficiency Anemia
 Folic acid or folacin, one of B vitamins is
necessary for the normal formation of
RBC
 Prevents neural tube defects
 1-5% in pregnancy
 Multiple pregnancy
 Hemolytic diseases
 Hydantoin – anticonvulsant
 Taking oral contraceptives
 Megaloblastic anemia (enlarged RBC)
 Increase mean corpuscular
 Most apparent in the 2nd trimester
 Can lead to miscarriage or abruptio
placenta
 Increase intake of folacin rich food
(green leafy veg. oranges, dried beans
Sickle Cell Anemia
 Inherited hemolytic anemia
 Caused by abnormal amino acid In the
beta chain of hemoglobin
 Sickle cell hemoglobin (Hbs) abnormal
amino acid replaces the amino acid
valine
 Non-sickling hemoglobin (Hbc) –
substituted for amino acid lysine
 RBC are irregular or sickle-shaped – ot
cannot carry as much hgb
 With o2 tension decrease( high
altitudes or blood hormones more
viscid – cells clump due to irregular
shape
O2 tension decrease
Blood becomes more viscid
Cells clump
Vessel blockage
Decrease blood flow to organs
Effects on pregnancy
 Increase incidence of abortion
prematurity, IUGR and fetal loss
 Perinatal mortality is high
 Incidence if pre-eclampsia, postpartum
hemorrhage and infection is increased.
Assessment
 Hemoglobin level of 6.8 mg / 100 ml –
decrease O2 to the fetus
 Sickle cell crisis – decrease 5-6mg/100
ml in few hours
 Increase bilirubin – cannot conjugate
the bilirubin released from so many RBC
so quickly destroyed
 Fetal health
 UTZ at 16-24 weeks AOG to assess UGR
 NST or UTZ – weekly at 30 weeks AOG
 Blood flow velocity – measures blood
flow through the uterus and placenta if
BFV is reduced, the chance of IUGR is
increased.
 Urinalysis (clean- catch)
 Monitor the diet to make sure that
there is a sufficient amount of folic acid
intake
 Assess lower extremities every prenatal
visit for varicosities and pool in for
blood in the leg veins
Therapeutic Management
 Periodic exchange transfusion
throughout the pregnancy – to prevent
sickle cell crisis
Crisis
 Control pain
 O2 administration
 IVF (hypotonic) (0.45 saline) – to
remove increase volume
 Intake of Folic acid and folic acid
supplement (to build new RBC)
 8 glasses or fluids/day
 Limited long periods of standing
 No iron supplement `
Cardiovascular Disorders and
Pregnancy
 A woman with cardiovascular disease
needs a team approach to care during
pregnancy, combining the talents of an
internist, obstetrician and nurse
 Pregnancy taxes the circulatory system
of every woman, w/o cardiac disease,
because both the blood volume and
cardiac output increased approximately
30%
 Because if the increased blood flow past
valves, functional (innocent) or
transient murmurs can be heard in
many women during a usual pregnancy.
Heart palpitations on sudden exertion is
normal in pregnancy neither of disease
is symptoms is a sign of cardiovascular
disease, but merely an indication of the
normal physiologic adjustment to
pregnancy.
 The danger of pregnancy in a woman
with cardiac disease occurs primarily
because of the increase in circulatory
volume
 The most dangerous time for a woman
is in weeks 28 to 32, just after the blood
vol. peaks
 A woman’s heart may become so
overwhelmed but the increase in blood
volume toward the end of pregnancy
that her cardiac output falls to the point
that vital organs (including the
placenta) are no longer perfused
adequately
 Hemodynamic changes during
pregnancy
 Cardiac output
 Increase in CO starts at 5 wk. AOG,
reaches a maximum at 30-34 wk. (40%
increase over the prepregnant value
and remains elevated till term
 During labor, it increases by 20 % with
uterine contractions immediately
following delivery CO increases further
by 15-20%
 Mechanism for increase CO
Increase stroke volume = 27%
Increase heart rate = 17%
Increase in intravascular volume
 Peripheral resistance
- resistance to the passage of blood
A left sided heart failure
through the small blood vessels,
especially the arterioles
 Vascular resistance is a term used to
define the resistance to floe that must
be overcome to push blood through the
circulatory system
 The resistance offered by the
vasculature of the lungs is known as the
pulmonary vascular resistance (PVR)
Classification of Heart Disease
Class 1
 Uncompromised. Woman have no
ordinary limitation of physical activity.
Ordinary physical activity causes no
discomfort. They have no symptoms of
cardiac insufficiency and no anginal pain
 Can expect normal pregnancy and birth
Class 2
 Slightly uncompromised. Women have
slight limitation of physical activity
causes excessive fatigue, palpitation
and dyspnea or anginal pain
 Can expect normal pregnancy and birth
Class 3
 Markedly compromised. Women have
a moderate to marked limitation of
physical activity. During less than
ordinary activity, they experience
excessive fatigue, palpitation, dyspnea
or anginal pain
 Can complete a pregnancy by
maintaining almost CBR
Class 4
 Severely Compromised. Women are
unable to carry out and physical activity
w/o experiencing discomfort. Even at
rest they experience symptoms of
cardiac insufficiency or anginal pain.
 The left ventricle cannot move the
volume of blood forward that it has
received by the eft atrium form the
pulmonary circulation
 The heart becomes so overwhelmed it
fails to function. The reason fir the
failure is most often at the level of the,
mitral valve
 The normal physiologic tachycardia of
pregnancy shortens diastole (atrial
contraction) and decreases the time
available for blood to flow across this
valve.
 The inability of the mitral valve to push
blood forward causes back pressure on
the pulmonary circulation, causing it to
become distended
 Systemic blood pressure decreases in
the face if lowered cardiac output, and
pulmonary hypertension occurs
 When pressure in the pulmonary vein
reaches a point of about 25mmhg, fluid
begins to pass form the pulmonary
capillary membranes into the interstitial
spaces surrounding the alveoli and then
 into the alveoli themselves (pulmonary
edema)

Blood dumps back to the

LA

To the pulmonary vein to

the pulmonary capillary
beds

Volume exceeds to the

interstitial spaces and
alveoli

Alveoli Dyspnea
/pulmonary Orthopnea
edema hypoxia Causes of Left sided Heart failure

 Paroxysmal Nocturnal Dyspnea

 Elevated Pulmonary Capillary Wedge
 Pulmonary Congestion
microhemorrhage Rust colored
sputum - Cough

- Crackles

- wheezes
Decrease Fatigue
systemic BP Weakness - Blood-Tinged Sputum
Dizziness
- Tachypnea

- Restlessness
SNS – increase heart rate
Vasoconstriction - Confusion
Na and H2o retention - Orthopnea

- Tachycardia

- Exertional Dyspnea

- Fatigue
- Cyanosis
 As the oxygen saturation of the blood
decreases from dysfunction of the
alveoli, chemoreceptors stimulate the
resp center to increase resp rate.
 At first this is noticeable only on
exertion, then finally with rest also
 A woman experiences increased
fatigue, weakness and dizziness
(specifically from lack of oxygen in brain
cells)
 As pulmonary edema becomes severe a
woman cannot sleep in any position in
except with her chest and head
elevated (orthopnea)
 Elevating her chest allows fluid to settle
to the bottom of her lungs and frees
space for gas exchange
 She may also notice paroxysmal
nocturnal dyspnea – suddenly waking at
night short of breath. This occurs
because heart action is more effective
when she is at rest
 If mitral stenosis is present it is so
difficult for blood to leave the left
atrium that a secondary problem of
thrombus formation can occur form
non circulating blood. A woman may
need to be prescribed an anticoagulant
to prevent t his
 If coarctation of aorta is causing the
difficulty, dissection of the aorta from
high BP from trying to push blood past
the constriction can occur, In this
instance, a woman may be prescribed
antihypertensives to control blood
pressure, diuretics to reduce blood
volume, and beta- blockers to improve
ventricular filling
 If an anticoagulant us required, heparin
is the DOC for early pregnancy because
it does not have teratogenic effects, as
does sodium warfarin (coumadin)
 Warfarin can be used after 12 week but
a woman will then be returned to
heparin therapy during the last month
of pregnancy if the fetus will not
develop a coagulation disorder at birth.
A woman with right sided heart failure
 It occurs when the output ofIncrease
the rightvolume or
ventricle is less than the blood volume
pressure to distensible
received by the atrium fromorgans
the vena
cava Liver – hepatomegaly
 Back pressure from this results - jugular
in distention
congestion of the systemic venous - splenomegaly
circulation and decreased cardiac
output to the lungs
 Blood pressure decreases in theIncrease
aorta pressure to
because less blood is reaching it;
the peritoneal cavity
pressure is high in the vena cava from
back pressure of blood;
 Both jugular venous distention andAnasarca
Increase pressurewt.
to
increased portal circulation occur the capillarygain
 The liver and spleen become distended.
Liver enlargement can cause extreme
dyspnea and pain in a pregnant woman
Leak of fluid in to
because the enlarged liver, as it is edema
the ITS
pressed upward by the enlarged uterus,
puts extreme pressure on the
diaphragm
 Fluid also moves form the systemic
circulation into lower extremity
interstitial spaces
 Distention of abdominal vessels can
lead to exudate of fluid form the vessels
into the peritoneal cavity
 Women who have an uncorrected
anomaly *(right to left atrial or atrial
ventricular septal defect with an
accompanying pulmonary stenosis) of
this type may be advised not to become
pregnant. If they do become pregnant,
 they can expect to be hospitalized for
the last part of pregnancy
 They need oxygen administration to
ensure fetal growth

Blood are not pump

forward

Blood dumps back to the

systemic circuit

Organ dysfunction

Deactivation of
aldosterone

Additional fluid
retention
 Left sided Heart Failure
 Fatigue
 Increase Peripheral Venous Pressure
 Ascites
 Enlarged Liver and Spleen
 May be secondary to chronic pulmonary
problems
 Distended Jugular Veins
 Anorexia and Complaints of GI Distress
 Weight Gain
 Dependent Edema
Assessment of a Woman with Cardiac Disease
 Health history to document her pre
pregnancy cardiac status
 Ask about her level of exercise
performance
 Ask If she normally has a cough or
edema. Instruct women with cardiac
disease always to report coughing
during pregnancy, because pulmonary
edema form heart failure may first
manifest itself as a simple cough
 Edema of pregnancy induced
hypertension usually begins after week
20
 Other symptoms will probably also be
present: irregular pulse, rapid or
difficult respirations, and perhaps chest
pain or exertion
 Record a baseline blood pressure, pulse
rate and respiratory rate in either sitting
or lying position at the first prenatal
visit.
 Making comparison assessments for
nail bed filling (should be 5 secs) and
jugular venous distention
 For additional cardiac assessment, a
woman may need a electrocardiogram
(ECG) chest radiograph, or
echocardiogram done at periodic points
in pregnancy
Fetal Assessment
 Cardiac failure can affect fetal growth at
the point at which maternal blood
pressure becomes insufficient to
provide an adequate supply of blood
and nutrients to the placenta
 For this reason, the infants of women
with severe heart disease tend to have
low birth weights because not enough
nutrients can be furnished to them
 A poor perfusion level may also lead to
an acidotic fetal environment if the
blood flow becomes inadequate for
carbon dioxide exchange
 Preterm labor also may occur
 An infant may not respond well to labor
(evidenced by late deceleration
patterns on a fetal heart monitor)
Nursing Interventions
 Promote Rest
 Promote Healthy Nutrition
 Educate Regarding Medication
 Educate Regarding Avoidance of
Infection
 Be prepared for Emergency Actions
 During Labor and Birth
- Monitor fetal heart rate and uterine
contractions during labor in all women
with heart disease
- Assess a woman’s blood pressure,
pulse and respirations frequently. A
rapidly increasing pulse rate (100 beats
per minute) is an indication that a heart
is pumping ineffectively and has
increased its rate in an effort to
compensate. Advise a woman to
assume side-lying position to reduce the
possibility of supine hypotension
syndrome
- if she has a pulmonary edema, it may
be necessary for her to have her chest
and head elevated (semi-fowlers
position)
 - women with extreme heart disease antibodies against the invading
need oxygen during labor to substance
compensate for the added oxygen  The Rh factor exists as a portion of the
required because of the increased red blood cell, so these maternal
exertion needed for labor antibodies cross the placenta and cause
The anesthetic of choice during labor rbc destruction (hemolysis) of fetal rbc
for women with heart disease is an cells
epidural, because this can make both  A fetus can become so deficient in red
labor and birth less taxing blood cells that sufficient oxygen
- if an epidural anesthetic is used, low transport to body cells cannot be
forceps or a vacuum extractor can be maintained
used for birth.  This conditioned is termed hemolytic
disease of the newborn or
Rh Incompatibility erythroblastosis fetalis
 Approximately 15% of white and 10% of
AFRICAN Americans in the United States
are missing the Rh (D factor in their
blood or have a Rh-negative blood type.
 Rh Incompatibility occurs when a Rh-
negative mother (one negative for a D
antigen or one with a dd genotype)
carries a fetus with an Rh+ blood type
(DD or Dd genotype)
 As the placenta separates after birth of
 For such a situation to occur, the father
the first child, there is an active
of the child must either be homozygous
exchange of fetal and maternal blood
(DD) or heterozygous (Dd) Rh-positive
form damaged villi
 If the father of the child is homozygous
 Therefore, most of the maternal
(DD) for the factor, 100% of the
antibodies formed against the Rh-
couple’s children will be Rh-positive
positive blood are formed during
(Dd)
pregnancy but in the first 72 hours after
 If the father is heterozygous for the
birth, making them a threat to a second
trait, 50% of their children can be
pregnancy
expected to be Rh positive (Dd)
 Because people who have Rh-positive
Assessment
blood have a protein factor that Rh-
 All women with Rh negative blood
negative people do not, when an Rh-
should have a n anti D antibody titer
positive fetus begins to grow inside an
done at a first pregnancy visit
Rh-negative mother who is sensitized, t
 If the first results are normal or the titer
is as though her body is being invaded
is minimal (normal is 0, a ratio below1-8
by a foreign agent
is minimal), the test will be repeated at
 Her body reacts in the same manner, it
week 28 of pregnancy if this is also
would if the invading factor were a
normal, no therapy is needed.
substance such as a virus she forms
 If a woman’s antibody titer is elevated
at a first assessment (1-16) or greater),
 showing Rh sensitization, the well being
of the fetus in this potentially toxic
environment will be monitored every 2
weeks (or more often) by Doppler
velocity of the fetal middle cerebral
artery, a technique that can predict
when anemia is preset or fetal
 If the artery velocity remains high, a
fetus is not developing anemia and
most likely is a Rh-negative fetus. Of the
reading is low, it means fetus is in
danger and immediate birth will be
carried out providing the fetus is near
term.
 If not near term, efforts to reduce the
number of antibodies in the woman or
replace damaged red blood cells in the
fetus are begun
 Therapeutic Management
 To reduce the number of maternal Rh
(D) antibodies being formed, Rh (D)
immune globulin (RhIG) a commercial
preparation of passive Rh (D) antibodies
against the Rh factor, is administered to
women who are Rh negative at 28
weeks of pregnancy
 These cannot cross the placenta and
destroy fetal red blood cells because
the antibodies are not the IgG class, the
only type that crosses the placenta.
 RhIG is given again by injection to the
mother in the first 72 hours after birth
of an Rh positive child to further
prevent the woman form forming
antibodies
 Because RhIG is passive antibody
protection it is transient and in 2 weeks
to 2 months. The passive antibodies are
destroyed. Only those few antibodies
that were formed during pregnancy are
left.
 After birth the infant’s blood typewill be
determined form a sample of the cord
blood.
 If it is Rh positive Coombs’ negative
indicating that a large number of
antibodies are not present in the
mother the mother will receive the
RhIG injection.
Intrauterine Transfusion
 To restore fetal red blood cells, blood
transfusion can be performed on the
fetus in utero. This is done by injecting
red blood cells. By amniocentesis
technique, directly into a vessel in the
fetal cord or depositing them in the
fetal abdomen where they migrate into
the fetal circulation
 Blood used for transfusion in utero is
either the fetus own type (determined
by percutaneous blood sampling or
group O negative if the fetal blood type
is unknown. From 75 to 150 Ml of
washed red cells are used, depending
on the age of the fetus
 After deposition of the blood in the
cord or abdomen, the cannula is
withdrawn and a woman is urge to rest
for approximately 30 mins while fetal
heart sounds and uterine activity are
monitored.
 The mother receives an RhIG injection
after the transfusion to help reduce
increased sensitization form any blood
that might have been exchanged.
Transfusion is some times done only
once during pregnancy, or it may be
repeated as often as every 2 weeks
