ANEMIA IN PREGNANCY

INTRODUCTION: Anemia is a commonest haematological disorder that may occur in

pregnancy. According to standard laid down by WHO, anemia in pregnancy is present when
the haemoglobin concentration in peripheral blood is 11g/dl or less. During pregnancy
plasma volume expands (maximum around 32weeks) resulting in haemoglobin dilution. For
this reason, haemoglobin level below 10g/dl at any time during pregnancy is considered
anaemia (WHO,1993; CDC,1990). Hb level ≤9g/dl requires detailed investigations and
appropriate treatment. Anemia is responsible for 20% of maternal death in the third world
country.

RELATED ANATOMY AND PHYSIOLOGY:

RBCs (erythrocytes) carry oxygen to the cell and help transport carbon dioxide back to the
lungs. RBCs also assist with acid base balance. They contain carbonic anhydrase, an enzyme
that join CO2 to water to form carbonic acid. This acid dissociates to form bicarbonate and
hydrogen ions, which diffuse out of the RBCs. The production of erytrhrocytes is termed as
erythropoiesis. Erythrocytes arise from nucleated cell called hematopoietic stem cells.
Immature erythrocytes leave the bone marrow via veins in the marrow and enter to the
general circulation as nucleated reticulocytes. Then they travel to the spleen where they
undergo conditioning and evolve into mature erythrocytes before being release into general
circulation.

During pregnancy, the blood volume is markedly raised during pregnancy. The blood volume
starts to increase from about 6th weeks, expands rapidly up to 40-50% above non-pregnant
level at 30-32 weeks whereas the RBC mass is increased to the extent of 20-30%. The
disproportionate increase in plasma and RBC volume produces a state of haemodilution.

PRINCIPAL BLOOD CHANGE DURING PREGNANCY:

Nonpregnant Pregnancy Total Change

near term increment
Blood volume(ml) 4000 5500 1500 +30-40%

Plasma volume(ml) 2500 3750 1250 +40-50%

Red Cell Volume(ml) 1400 1750 350 +20-30%

Total haemoglobin(g) 475 560 85 +18-20%

Haematocrit (whole body) 38% 32% Diminished

 Normal blood value in pregnant and non-pregnant state

Non-pregnant Second half pregnancy

Haemoglobin (Hb) 14.8 gm/100ml 11-14 gm/100 ml
Red blood cell (RBCs) 5 million/cumm (mm3) 4-4.5 million/cumm (mm3)
Packed cell volume (PCV) 39-40% 32-36%
[Hemocrit]
Mean corpuscular 27-32 micro micron 26-31 pg
haemoglobin (MCH) (pictogram-pg)
Mean corpuscular volume 75-100cubic micron (µ3) 75-95 µ3
(MCV)
Mean corpuscular 32-36 % 30-35%
haemoglobin concentration
(MCHC)
Serum iron 60-100µg/100ml 65-75µg/100ml
Total iron binding capacity 300-350µg/100ml 300-400µg/100ml
(TIBC)
Saturation % 30% less than 16%
(serum iron: TIBC)
Serum ferritin 20-30µg/L (mean) 15mg/L

CLASSIFICATION:

1. Physiological anemia in pregnancy:

2. Pathological
A. Deficiency anemia
 Iron deficiency
 Folic acid deficiency
 Vitamin B12 deficiency
 Protein deficiency
B. Haemorrhagic
 Acute: Following bleeding in early month or APH
 Chronic: Hookworm infestation, bleeding piles
C. Hereditary
 Thalassemia
 Sickle cell hemoglobinopathies
 Hereditary haemolytic anemia
D. Bone marrow insufficiency
E. Anaemia due to infection (malaria, tuberculosis)
F. Chronic disease(renal) or neoplasm.
Identification data:

Name: Priya Singh

Age:28 years

Address:25/1A Narkeldanga road, P.O-Kankurgachi, P.S-Fulbagan.

Bed No-10

Reg No-4882249

Ward-C. B Antenatal Road

Date of Admission-14.12.20

Under Doctor-Dr.Bal

Unit-I

GPAL-G3 L3 A0

LCB-4 years

Case-Pregnancy with anemia.

Subjective data:
Past medical history: Nothing Significant
Past surgical history: Nothing Significant
Present medical history: Nothing Significant
Present surgical history: Nothing Significant

Present complaint: She noted that leg oedema gradually increased for last 2 weeks
associated with lethargy, dyspnoea and pallor subsequently. Then she visited nearest health
centre on 14.12.20and they referred to N.R.S.M.C.H., Kolkata.

Diet- Non –veg.

Breakfast: Chapati, vegetables and tea.

Lunch: Rice, dal, vegetables, fish/egg.

Dinner: Rice, dal, vegetables, milk.

Remark: She do not take balanced diet. Her diet deficient of iron and protein.

She takes adequate diet. No harmful cultural practice is present

Socio-economic history:

Type of family: Joint; Total family member: 5; Adult: 3; Children: 2

Education: Husband—XII, Wife—VI

Occupation: Husband—Business, Wife--Housewife

Family income: 6,000/-pm; Earning member: 1

Type of house: Pucca; Own house.

Source of drinking water: Municipality supplied tap water.

Personal history:

Married for: 9 yr.

Habit: Nothing significant Addiction: No

Any allergy: Nil

Infertility treatment: Not done, Contraceptive history: Not used

Menstrual History-

Age of menarchy-14 years

Duration-4 days

Cycle-28+-days

Flow-Normal

Obstetric history-

Past obstetric history: She is third gravida.

Present obstetric history:

LMP-13.05.20

EDD-20.02,21

Booked: At N.R.S.M.C.H.
Any problem during pregnancy: 1st trimester: Nausea, vomiting.

2nd trimester: Nothing significant

3rd trimester: Oedema in leg and lethargy. Total weight gain: 8 kg.

Immunization: 2 doses inj. T.T. taken.

Any iron tablet: 100 IFA tablet taken

Any other treatment: Tab. Calcium 1 tab OD, Tab. Albendazole (400mg) 1 tab stat taken

Parity-P3+0

Gravida-3rd

History of child birth-Vaginal delivery

Family planning method-

Physical assessment done:

Date: 18.12 .20 Time: 10am

Emotional status:
Emotional status: Anxious but co-operative
Central nervous system: Conscious, Oriented
Level of consciousness
Gait/Appearance: Normal

Respiratory system:

Chest movement: Bilateral equal movement present

Respiratory pattern: Dyspnoea, rate 30/min
Air entry: Bilaterally equal
Crepitus-Present
Cough: Nil.

Cardio-vascular system:

Cardio-vascular rhythm: Tachycardia,

Blood pressure: 110/80 mmHg
Pulse rate: 90 beats /min
Peripheral pulse: Radial- Present
Brachial pulse-present
Popliteal- present

Heart sound: S1-S2: present

Any abnormal sound: Not present
Neck-vein distension: Not present
Clubbing of finger: not present

Gastro-intestinal system:

Mouth: Stomatitis and Glossitis present.

Tongue: Moist
Teeth: Clean
Oral ulcer: Nil
Peristalsis: present
Abdominal tenderness: Not present
Liver: Not palpable
Nausea: Not present
Vomiting: Not present
Bowel: Passed

Musculoskeletal system:
Joint: Tenderness not present
Swelling: Not present

Integumentary system:

Skin: Intact
Pallor: Present
Nail bed: CRT˃3sec.
Edema: Present in leg
Periphery: cold
Temperature: 97°F
Scalp: Clean
Eyes: No discharge present
Nose: No discharge present
Ear: No discharge present

Genitourinary system:

Voiding pattern: Normal

Amount- Normal
Urine colour: Straw
Sedimentation: Nil

Concept of physiological anemia:

In pregnancy there is disproportionate increase in plasma volume, RBC volume and

haemoglobin mass. In addition there is marked demand of extra iron during pregnancy
specially in the second half. Even an adequate diet cannot provide the extra demand of iron.
Thus there always remains a physiological iron deficiency state during pregnancy. There is
not only fall in haemoglobin and hemocrit value but there is also associated low serum iron,
increase iron binding capacity and increase rate of iron absorption. Thus, the fall in
haemoglobin concentration during pregnancy is due to combined effect of hemodilution and
negative iron balance.

CAUSES OF ANEMIA DURING PREGNANCY:

In book In patient
Before pregnancy:
*Faulty dietetic habit: There is no deficiency of iron in diet 
but diet is rich in carbohydrate, High phytates in gut reduce
absorption of iron.

*faulty absorption mechanism: High prevalence of

intestinal infestation, there is intestinal hurry which reduces 
the iron absorption. Another cause is hypochlorhydria.

*Iron loss:
-More iron is lost through sweat
-repeated pregnancy at short interval
-Excessive blood loss during menstruation
-Hookworm infestation
-Chronic malaria
-Bleeding piles and dysentery.

During pregnancy:

*Increased demand of iron: Before pregnancy, the

recommended dietary allowance of iron is 30mg/day. For
pregnant women, it is 38mg/day. The highest requirement of
iron is in the first and third trimester. S ICMR and Ministry of
health recommend for iron supplement containing 100mg of
iron /day for at least 100days.

*Diminished intake of iron: Apart from socio-economic

factors, faulty dietetic habits, loss of appetite and vomiting in
pregnancy are responsible factors.

*Diminished absorption: Acid environment in duodenum

helps iron absorption. On the other hand, intake of antacid, H2
blocker, proton pump inhibitors inhibit iron absorption.

*Disturbed metabolism: Presence of infection markedly

interferes with erythropoiesis.

*Pre-pregnant habit status: Majority of the tropics, actually

start pregnancy on a pre-existing anemic state.

*Excess demand: multiple pregnancy, Recurrent pregnancy,

the demand of iron which accompanies the natural growth
before the age of 21.

Iron deficiency anemia

The clinical features depend more on degree of anemia than anything else. In the majority,
the patient has got no symptom and the entity is detected accidentally during examination.
However, the following features may develop slowly.

Clinical Features:

A. Symptoms

In book In patient
 Lassitude, feeling of weakness or exhaustion 

 Anorexia and indigestion 

 Palpitation
 Giddiness
 Dyspnoea 
 Swelling of legs 

B. On examination:

In book In patient
*Pallor on varying degree 

*Glossitis and stomatitis 

*Enema of the leg 

*A soft systolic murmur may be heard in the mitral area.

*Crepitation may be heard at the base of the lung due to

congestion 

Investigation:
The patient’s haemoglobin level is 9gm/dl should be subjected to a full of haematological
investigation. The objectives of investigations are to ascertain:

 Degree of anemia
 Type of anemia
 Cause of anemia

*To note degree of anemia 14.12.20

Hb%; total RBC; Packed cell volume Hb-5.4gm/dl; WBC-7900cumm;
neutron-63; lympho-27; esino-06;
mono-04; baso-00; Platelet-2lacs;
PCV-14.3

15.12.20
*To ascertain type of anemia Hb-7.4 gm/dl
-peripheral blood smear Serum Iron-24.8 μg/dl
-Calculation of MCHC, MCV & MCH Serum TIBC-294.5 μg/dl
(A typical iron deficiency anemia shows Hb-<10
gm.,
RBC-<4million/mm3, PCV-<30%, MCHC-<30%,
MCV-<25pg.
!6.12.20
*Other blood values Hb-7gm/dl
-Serum iron <30 µg/100ml.
-Total iron binding capacity >400µg/100ml 18.12.20
-%saturation 10% or less Hb-7.7 gm/dl, RBC-3.7*106/μL
-Serum ferritin level <30µm /L ,HCT-27.8%,MCV-75.1 fl,MCH-
20.8pg,MCHC-27.7gm/dl,WBC-7.9*103
*To find out cause of anemia μL,Plt-390*103 μL
-Examination of stool for ova, parasites Transferrin saturation-5.1%
-Urine test –presence of protein, sugar or pus cell.
Serum Iron-32.9 μg/dl
*Bone marrow study: This is not done as a routine Serum TIBC-638 μg/dl
test.
- 20.12.20
MCV-103.6 m3; MCH-33.3pg;
MCHC-32.2%

DIFFERENTIAL DIAGNOSIS:

Apart from iron deficiency, other causes are infection, nephritis and pre-eclampsia,
hemoglobinopathies.
Complications of anaemia during pregnancy:

In book In patient
During pregnancy:
No complication is arising at
1). Pre-eclampsia may be related to malnutrition and present.
hypoproteinaemia.
2). Intercurrent infection anemia diminishes resistance
to infection and if any pre-existence lesion is present, will
flare up. The infection itself impair erythropoiesis by bone
marrow depression.
3). Heart failure at 30-32 weeks of pregnancy.
4). Preterm labour.

During Labour:
1. Uterine inertia
2. Postpartum haemorrhage
3. Cardiac failure
4. Shock

Puerperium:
1. Puerperal sepsis
2. Subinvolution
3. Poor lactation
4. Puerperal Venous thrombosis
5. Pulmonary embolism

Effect of baby:
1. Low birth weight baby with incidental hazard
2. Intrauterine death due to maternal anoxia.

Prognosis:

 Maternal- Anemia either directly or indirectly contributes to about 20% of maternal

deaths in the third world countries. If it detect early and proper treatment is instituted,
anemia improves promptly.
 Foetal- If detected early and treatment started promptly, the fetal prognosis is not too
bad. Baby born at term of a severely anemic mother will not be anemic at birth. But as
there is little or no iron reserve, anemia develops subsequently.

Treatment:
  Prophylactic
 Curative

In book In patient
Prophylactic treatment:
1). Avoidance of frequent child birth: A minimum interval
between two childbirth should be at least 2 years.

2). Supplementary iron therapy: Supplementary iron should The patient has taken IFA 1
be a routine after the patient become free from nausea of tablet daily from 4 month
pregnancy. Daily administration of 200mg of ferrous sulphate of pregnancy.
(containing 60mg of elemental iron with 1mg folic acid.)

3). Dietary prescription: Diet rich in iron and protein and The patient is advised for
easily digestible. The food rich in iron are green leafy high iron and protein diet
vegetable, fig, green peas, jiggery, whole grain, liver, meat and i.e. Deep green leafy
egg. Iron utensils should be used for cooking water used in vegetables, figs, whole
cooking should not discarded. wheat, jiggery and egg etc.

4). Adequate treatment: Eradication of hookworm infestation,

dysentery, malaria, bleeding piles and urinary tract infection. Tab. Albendazole 1 tab HS
given.

5). Haemoglobin level should be estimated at 1st antenatal

visit, at 30th and 36th week. Haemoglobin level is
estimated at 28th week. And
Hb-7.7gm%
Curative: Treatment must be preceded by an accurate
diagnosis of the cause of anemia and type of anemia.
1). Hospitalization: Ideally Hb level ≤9mg/dl should be
admitted in hospital. But due to high prevalence and inadequate
hospital beds, an arbitrary Hb level of 7.5 gm/dl may be
considered, when patient should be hospitalized.
 General treatment: She is advised for high iron
-Diet: A realistic balanced diet rich in iron and protein and protein diet.
which is easily available and digestible.
-To improves appetite and digestion by prescribing acid
pepsin thrice daily
-To eradicate minimum infection by antibiotic..
-effective therapy to cure the disease for contributing
cause of anemia.

 Specific therapy:
Choice of therapy depends on: (1) severity of anemia,
(2) Duration of pregnancy, (3) Associated complicating
factors.
IRON THERAPY: As the patient is having
Iron is best absorbed in ferrous form. The preparation available severe anemia, oral iron
are ferrous gluconate, ferrous fumarate, or ferrous succinate. treatment is
Ferrous sulphate is widely used. Ferrous tablet contains 200mg contraindicated. Because of
ferrous sulphate which contains 60mg elemented iron. The unpredictable and
initial dose 1 tablet thrice daily maximum 6 tablet daily with or utilization of absorption.
after meal. The treatment should be continued till the blood
picture becomes normal. There after maintenance dose of one
tablet daily.

Drawback: (1) Intolerance: The intolerance is evidenced by

epigastric pain, nausea, vomiting and diarrhoea or constipation.
To avoid intolerance, it is preferable to start therapy with low
dose—one tablet then increase the dose.

(2 Unpredictable absorption rate: Antacid, oxalates and

phosphates will reduce absorption whole ascorbic acid, lactate
and various amino acid enhance absorption.

Contraindication of iron therapy:

(1) Intolerance of oral iron, (2) Severe anemia in advanced
pregnancy.

PARENTERAL THERAPY:
-Intravenous route: Iron dextran or iron sucrose.

-Intramuscular therapy: -a) Iron dextran (imferon)

b). Iron-sorbitolcitric acid complex in dextrin
(jectofer)

Indication of Parenteral therapy:

-Contraindication of oral therapy
-Patient is not cooperative to take oral therapy
-Case seen for the first time during the last 8-10 weeks with
severe anemia.

The advantage of Parenteral therapy is the certainty of its

administration to correct the haemoglobin deficit and to fix up
the iron store.

Intravenous route:
 Total dose infusion: The deficit of iron is first
calculated and the total amount of iron required to
correct the deficit by a single sitting intravenous
infusion. The iron dextran compound or iron(ferrous)
sucrose is used. Iron sucrose is safe , effective and les
side effect.

Advantages: (1) It eliminates repeated painful

injections, (2) Single sitting treatment so earliest
 discharge from hospital, (3) It is less costly.

Limitations: (1) The maximum haemoglobin response

does not appear before 4-9 weeks; the therapy is
unsuitable if at least 4 weeks’ time is not available.
(2) Previous history of reaction to Parenteral therapy.

Estimation of total requirement:

Iron dextran: One such formula is-

 0.3×W (100-Hb%)
(Where W=weight of patient in pound and Hb%=
observed haemoglobin concentration in percentage)
Additional 50% is to be added foe partial replenishment
of the body store iron.

Example: The total elemental iron required in an

anaemic patient weighing 100 Ib with haemoglobin
50%

0.3×100(100-50) =0.3×5000=1500mg add 50%=750mg

=1500+750=2250mg elemental iron is required.

 Iron Sucrose:
Total iron dose= 2.3×W×D+500 [W=in kg,
D=Hb(target-actual) g/dl] It is given IV, 100mg (at a
time) in 100ml normal saline over 15 minutes.

Prerequisites: (1) Correct diagnosis of true iron deficiency (2)

Adequate supervision (3) Facilities for management of
anaphylactic reaction.

Intramuscular therapy: The compound used are:

 Iron dextran (Imferon)
 Ironsorbitolcitic acid complex in dextrin (Jectofer)
Both preparations contain 50 mg elemental iron in 1 ml. Total
iron should be calculated as previously mentioned in
intravenous therapy. Oral iron should be suspended at least 24
hrs prior to therapy to avoid reaction.

Procedure of injection: After an initial test dose of 1 ml are

given daily on alternate day. To prevent dark staining of the
skin over the injection site and to minimize pain, the injection
are given with a two inch needle deep into the upper outer
quadrant of the buttock using a “Z” technique (pulling the skin
and subcutaneous tissue to one side before inserting the
needle). An additional precaution is to inject small quantity of
air or saline down the needle before withdrawing it. This
procedure prevents even a slight drop of the solution to come Now the patient is 28
beneath the skin surface so as to stain it. weeks of pregnancy. So,
she has been treated with
fresh blood transfusion one
Place of blood transfusion: packet daily, for three days
Indication: -1) To correct anaemia due to blood lose from 16 .12.20 to18.12.20.
and to combat PPH. After three days i.e.,
2). Patient with severe anemia seen in later pregnancy 18.12.20, her hb-7.7 gm/dl
(beyond 36 weeks). The primary concern is not only to
correct anemia but also to make the patient fit to
withstand the strain of labour and blood lose following
delivery.
3). Refractory anaemia: Anaemia is not responding to
oral or parenteral therapy.
4). Associated infection.

MANAGEMENT DURING LABOR

First stage:

The following are the special precautions that are to be taken when an anemic patient goes
into labor:
 The patient should be in bed and should lie in a position comfortable to her.
 Arrangements for oxygen inhalation is to be kept ready to increase the oxygenation of
the maternal blood and thus diminish the risk of fetal hypoxia.
 Strict asepsis is to be maintained to minimize puerperal infection.
 Continuous FHS monitoring
 Vitals monitoring. And maintain hydration and nutrition.
 Assurance to mother.

Second stage:

 Place on labor table in suitable position

 Asepsis is maintained.
 Prophylactic low forceps or vacuum delivery may be done to shorten the duration
of second stage.
 Intramuscular oxytocin 10 IU should be given soon following the delivery of the
baby.
 vitals of mother and FHS monitoring by CTG
 Prior Inform pediatrician about labor.
 O2 inhalation if needed.

Third stage:
  One should be very vigilant during the third stage.
Significant amount of blood loss should be replenished by fresh packed cell
transfusion after taking the usual precautions mentioned earlier.
 The danger of postpartum overloading of the heart should checked by monitoring
vitals, urine out put, pulse, respiratory rate and pattern and be avoided.
 Vitals should checked frequently (15 mins), Close supervision of other and baby.
 Maintain hygiene, hydration and nutrition.
 Initiation of breast feeding.
 Rest and support.
 Records all events properly.

Puerperium:

 Prophylactic antibiotic to prevent infection

 Predelivery antianemia therapy should be continued till the patient restores her normal
clinical and haematological state. Even in normal case, iron therapy should be
continued for at least 3 months following delivery.
 Patient should be warned of the danger of recurrence of subsequent delivery.
 Asepsis should maintained.
 Adequate rest and nutrition should assure
Hb estimation with supplementation of iron & folic acid, and others supplementation
should continue up to 6 months.