What is Anemia?

⚫ A decreased amount of red

blood cells or hemoglobin in
the body. These components
play a huge role in carrying
oxygen throughout the body.
Presence of low RBCs or
hemoglobin, body won’t
receive enough oxygen to
function properly.
⚫ Commonest medical disorder
in pregnancy
⚫ It is important contributor to
maternal & perinatal
morbidity & mortality as a
direct or indirect cause
⚫ A condition where
circulating levels of Hb
are quantitatively or
qualitatively lower than
normal

❖ Non pregnant women Hb < 12gm%

❖ Pregnant women (WHO) Hb < 11 gm%
Haematocrit < 33%
❖ Pregnant women (CDC) Hb <11 gm%
1st&3rd Trimester
2nd trimester Hb < 10.5 gm%
Causes of Anemia in Pregnancy

⚫ Nutritional / Iron deficiency anemia

⚫ Pre-pregnancy poor nutrition very important
⚫ Besides Iron, folate and B12 deficiency are also important
⚫ Chronic blood loss due to parasitic infections – Hookworm
& malaria
⚫ Multiparity
⚫ Multiple pregnancy
⚫ Acute blood loss in APH, PPH
⚫ Recurrent infections (UTI) - anemia due to impaired
erythropoiesis
⚫ Hemolytic anemia in PIH
⚫ Hemoglobinopathies like Thalassemia, sickle cell anemia
⚫ Aplastic anemia is rare
 Pathophysiology of Nutritional Anemia in
Pregnancy

⚫ Augmented erythropoiesis in pregnancy

⚫ Blood volume increases 40-45% in pregnancy

⚫ Increase in plasma is more as compared to red
cell mass leading to hemodilution & decrease in
Hb level

⚫ Iron stores are depleted with each pregnancy

⚫ Too soon & too many pregnancies result in higher
prevalence of iron deficiency anemia
Extra Iron Requirement & Loss During
Pregnancy
During pregnancy Total 800-
1000 mg extra iron is required
400-500 mg 250 mg iron
300 mg for lost during
for
Fetus & 50 delivery
increased
mg for
red cell 220 mg
Placenta
mass basal losses

Due to cessation of menses & contraction of blood volume after

delivery conservation of iron is around 400 mg
Absorption of Iron / daily requirement
⚫ Normal diet contain about 14
mg of iron
⚫ Absorption of iron is 5-10%
(1-2 mg) & 3-4% in pure veg
diet
⚫ Additional daily iron demand
in early pregnancy 2-3
mg/day
⚫ In late pregnancy 6-7 mg/day
⚫ So daily supplement of 40-60
mg of elemental iron is
required during pregnancy
⚫ Folic acid requirement is also
increased 400-600 ug/day
⚫ In strict veg Vit B 12 is also
deficient
⚫ Depends on severity of anemia Assessment
⚫ High risk women – adolescent,
multiparous, multiple pregnancy,
lower socio economic status
⚫ Mild anemic - asymptomatic
⚫ Symptoms – pallor, weakness,
fatigue, dyspnoea, palpitation,
swelling over feet & body
⚫ Signs – pallor, facial puffiness,
raised Jugular vein, tachycardia,
tachypnea, crepitations in lung
bases, hepato-splenomegaly,
pitting edema over abdominal wall
& legs
⚫ cardiac murmurs, cardiac failure
⚫ Glossitis, stomatitis, chelosis,
brittle hair
Most Critical Period

⚫ 28-30 weeks of
pregnancy
⚫ In labor
⚫ Immediately after
delivery
⚫ Early Puerperium

⚫ CHF
(Failure to cope up
with pregnancy
induced cardiac load)
Treatment for Iron Deficiency
Anemia
⚫ Improving diet rich in iron &
fruits & leafy vegetables
⚫ Treat worm infections,
maintain general hygiene
⚫ Food fortification with iron &
genetic modification of food
⚫ Iron & folic acid
supplementation in young
girls & during pregnancy
⚫ Heme iron better, present in
animal food & is better
absorbed
⚫ Iron absorption enhanced by
citrous fruits, Vit C
⚫ Avoid tea, coffee, Ca,
phytates, phosphates,
oxalates, egg, cereals with
iron
*Iron-rich foods
✓lean red meat, poultry, and fish
✓leafy, dark green vegetables (such
as spinach, broccoli, and kale)
✓iron-enriched cereals and grains
✓beans, lentils, and tofu
✓nuts and seeds
✓eggs
Iron supplementation in
Pregnancy
⚫ 60 mg elemental iron & 400 ug ⚫ Iron supplementation is not
of folic acid daily during recommended in first
pregnancy and 3 months there trimester
after
 Higher incidence of
⚫ In anemia therapeutic doses
are 180-200 mg /d miscarriage
⚫ Route of administration  Birth defects
depends on, severity of  Bacterial infection
anemia, Gest age, compliance (bacteria grow after
& tolerability of iron taking iron from
⚫ Various preparations – supplementation)
fumarate, gluconate,
succinate, sulfate, ascorbate
⚫ Oral iron can have side effects
like nausea, vomiting,
gastritis, diarrhoea,
constipation
Oral Iron
⚫ Hb 8-11 gm%, early preg ⚫ Indicators of response
⚫ Contraindication to Oral to therapy
Iron Therapy  Feeling of well being
 Intolerance to oral iron  Improved look of
 Severe anemia in patient
advanced pregnancy  Better appetite
 Non compliant  Rise in Hb .5-.7 gm/dl
⚫ Failure to Respond per week (starts after 3
weeks)
 Inaccurate diagnosis
 Reticulocytosis in 7-10
 Faulty absorption days
 Continuous blood loss
 Co-existant infection
 Concomitant folate
deficiency
 Parenteral Iron Transfusion

⚫ Iron sucrose for parenteral

use
⚫ Dose calculated - Wt in Kg x
iron deficit x 2.2 + 1000 mg
for iron stores
⚫ Response - by increase in
Hb level 1g/week
⚫ Increase in Reticulocyte
count with in 5-10 days
⚫ Clinical symptoms improve
 Indications for Blood Transfusion

⚫ Severe anemia first seen

after 36 weeks of pregnancy
⚫ Anemia due to acute blood
Loss – APH & PPH
⚫ Associated Infection
⚫ Patient not responding to
oral or parenteral therapy
⚫ Anemic & symptomatic
pregnant women (dyspneic,
with heart failure etc)
irrespective of gestational
age
 Folic Acid Deficiency
Anemia

⚫ Pregnant women need to get

enough folic acid. The vitamin
is important to the growth of
the fetus's spinal cord and
brain. Folic acid deficiency
can cause severe birth defects
known as neural tube defects.
The Recommended Dietary
Allowance (RDA) for folate
during pregnancy is 600
micrograms (µg)/day.
Folic Acid Deficiency
Anemia

⚫ A decrease in RBC’s due to

a lack of B9 vitamin called
folate (or folic acid)
⚫ When there isn’t enough folic acid, the
RBC’s are formed unusually large and
don’t work right
⚫ Can co-exist with Vitamin B12 deficiency
⚫ A megaloblastic anemia
⚫ Folate stores are small and can be
depleted within 4 months
 Causes of Folic Acid Anemia

⚫ Inadequate dietary
intake
⚫ Excessive alcohol
intake
⚫ Pregnancy
⚫ Certain
medications
⚫ Diseases of
absorption
⚫ Inherited condition
 Clinical Manifestations of
Folic Acid Deficiency Anemia

⚫ The same as a Vitamin B12 Deficiency (except no

neuro symptoms)
⚫ Fatigue, headache, pale skin, sore mouth and
smooth, sore tongue, decreased appetite,
irritability, diarrhea, curly, graying hair, decreased
skin color pigment, infertility, worsening of heart
disease or heart failure
 How is Folic Acid
Deficiency Anemia How is Folic Acid
Diagnosed? Deficiency Anemia
Managed?
⚫ Folic Acid levels
⚫ CBC • Identify and treat the
⚫ Rarely a bone marrow cause of the folate
exam deficiency
• Replace folate in the
diet or with
supplements
• Prefer PO, IM only
with malabsorption
• Decrease alcohol
consumption
• Supplements before
and during
pregnancy
What Nursing Interventions are useful for
Folic Acid Deficiency Anemia?

⚫ Advise patient to eat

folate rich foods-
Green, leafy
vegetables, liver, fresh
fruits, cereals, meats,
yeast
⚫ Inspect skin, mucous
membranes and tongue
⚫ Inspect for jaundice
⚫ Hair for premature
graying
Vitamin B12 Deficiency
Pathophysiology
⚫ Vit B12 absorption is unaltered during pregnancy
⚫ Tissue uptake is increased → Decreased serum B12
⚫ Recommended B12 intake – 3 microgram /day.

CAUSES of Vit B12 deficiency

⚫ Strict Vegetarian diet
⚫ Use of proton pump inhibitors
⚫ Metformin
⚫ Gastritis
⚫ Gastrectomy
⚫ Ileal bypass
⚫ Crohn’s
⚫ H. Pylori infection
  DIAGNOSIS

Serum Vit B12 levels ,100 pg /ml

Radio active Vit B12 absorption test ( Schilling
Test )

Treatment
⚫ 1000 microgram parenteral cyanocobalamin
every wk * 6 weeks
⚫ Pernicious Anaemia – Oral Vit B12
⚫ Total Gastrectomy – 1000 microgram Vit B12 im
every month.
⚫ Partial gastrectomy – Ser. Vit B12 levels
measured.
What is Megaloblastic Anemia?

Anemia with very large, immature,

incompletely developed RBC’s.

The RBC’s do not function properly and die early

Caused by folic acid or vitamin B12 deficiency
Caused by alcohol abuse, chemotherapy, leukemia,
drugs, genetic conditions, chemicals
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