Anemia in Pregnancy

Rajeev Ojha

Case 1
 Mrs.

A. N. is a 28-year-old woman in her second trimester of pregnancy with her first child, and though her pregnancy had been progressing normally, recently she has noticed that she tires very easily and is short of breath from even the slightest exertion. She also has experienced periods of light-headedness, though not to the point of fainting. Other changes she has noticed are cramping in her legs, and the fact that her tongue is sore.

 Upon

examining, she has tachycardia, pale gums and nail beds, and her tongue is swollen. Given her history and the findings on her physical exam, she is suspected to be anemic and a sample of her blood is orderes for examination.

Table 1. Blood Sample Results Red Blood Cell Count Hemoglobin (Hb) Hematocrit (Hct) Serum Iron Mean Corpuscular Volume (MCV) 3.5 million/mm3 7 g/dl 30% low low

Mean Corpuscular Hb Concentration low (MCHC) Total Iron Binding Capacity in the Blood (TIBC) high

A

diagnosis of anemia due to iron deficiency is made and oral iron supplements prescribed. Her symptoms are eliminated within a couple of weeks and the remainder of her pregnancy progresses without difficulty.

Case 2
A

35 year old woman is seen for easy fatigue for many months. She is now 24 weeks pregnant with her 3rd child in 3 years. She does not see any obstetrician and does not take any vitamins. Lately, she has developed a taste for eating ice (craving to taste ice, soil etc). She has no other complaint. Family and past history are negative. She does not smoke or drink. Physical examination is positive for pale conjunctiva, mild spooning of nails, and a II/VI systolic murmur at left lower sternal border. Stools are negative for occult blood.

Labs:
 Complete

blood count (CBC) - Hb 7.1 gm/dl, Hct 23% - WBC 5,400/mm3 (differential is normal) - Platelets 450,000/mm3 - Mean Corpuscular volume (MCV) is 74 fl (normal 85-95 fl) - Red cell Distribution Width (RDW) is

Defination of Anemia during Preg.
 Hemoglobin

below 11gm/dl in 1st and 3rd trimester and below 10.5gm/dl in second trimester.

WHO
 11gm/dl

or less

 By

this standard, 50% of women not on hematinics become anemic.

Incidence
 Anaemia

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 anaemic (Hb < 11 g/dl) due to infestations.

Classification
 Physiologic  Pathologic:
a. Deficiency: Iron, Folic A., Vitamin B12 b. Hemorrhagic: APH, Hookworm c. Hereditary: Thalassemia, Sickle, H. Hemolytic Anemia d. Bone Marrow Insufficiency: Aplastic Anemia e. Infections: Malaria, TB f. Chronic Renal Diseases or Neoplasm.

Concept of Physiologic Anemia
 Disproportionate

increase in plasma vol, RBC vol. and hemoglobin mass during pregnancy  Marked demand of extra iron during pregnancy especially in second trimester

Criteria for Physiologic Anemia
 Hb:

10gm%  RBC: 3.2 million/mm3  PCV: 30%  Peripheral smear showing normal morphology of RBC with central pallor

Significance of Hypervolemia
1. To meet the demands of the enlarged uterus with its greatly hypertrophied vascular system. 2. To protect the mother, and in turn the fetus, against the deleterious effects of impaired venous return in the supine and erect positions. 3. To safeguard the mother against the adverse effects of blood loss associated with parturition.

 Normal

hemoglobin by gestational age in pregnant women taking iron supplement 12.2 [11.0-13.4] 11.6 [10.6-12.8] 12.6 [11.2-13.6]

 12

wks  24wks  40 wks

Most common causes of Anemia
 Iron

loss : sweat, repeated pregnancy, hookworm infestation and malaria  Faulty absorption mechanism : due to high incidence of intestinal infestation, there is intestinal hurry  Faulty diet habit : rich carbohydrate and high phosphate reduce absorption of iron

Factors lead to develop Anemia
 Increase

iron demand  Diminished intake of iron  Disturbed metabolism  Pre-pregnancy health status  Excess demand

Iron Deficiency Anaemia
Symptoms: lassitude, weakness, anorexia, palpitation, dyspnea  Signs: Pallor, glossitis, soft systolic murmur in mitral area due to physiologic mitral incompetence
  Degree:

Mild: 8-10gm% Moderate: 7-8gm% Severe: <7gm%

pallor

Conjunctival Pallor

Koilonychia

Smooth Tongue

Interpretation of plasma Iron
Iron Iron deficiency anemia Anemia of chronic disease Pregnancy Decreas e Decreas e Increas e TIBC Increas e Decreas e Increas e Ferritin Decreas e Increase Normal

Normal Iron Requirements
 Iron

requirement for normal pregnancy is

1gm 200 mg is excreted 300 mg is transferred to fetus 500 mg is need for mother

Total volume of RBC inc is 450 ml 1 ml of RBCs contains 1.1 mg of iron 450 ml X 1.1 mg/ml = 500 mg Daily average is 6-7 mg/day

Treatment
 Prophylactic:

Acid  Curative: 200mg FeSo4 3 times daily till Hb level becomes normal, then maintenance dose of 1 tab for 100 days

Supplement Fe – 60 mg elemental Fe with Folic

Megaloblastic Anemia
 Due

to impaired DNA synthesis, derangement in Red Cell maturation  It may be due to Def. of VitB12 or Folic Acid or both.  Megaloblastic anemia in pregnancy is almost always due to Folic Acid def.  Vit B12 def is rare in Pregnancy becoz its need is less in amount and amount is met with any diet that contains animal products.

Sign and symptoms
 Insidious

trimester  Anorexia and occasional diarrhoea  Pallor of varying degree  Ulceration in mouth and tongue  Hemorrhagic patches under the skin and conjunctiva  Enlarged liver and spleen

onset, mostly in last

Angular Cheilosis

Blood values
 Hb<10gm%  Hypersegmentation  Megaloblast  MCV>100micrometer3  MCH>33pg,

of neutrophils

but MCHC is Normal  Serum Fe is Normal or high TIBC is low

Treatment
 Prophylactic

- all woman of reproductive age should be given 400mcg of folic acid daily  Curative -daily administration of Folic acid 4mg orally for at least 4 wks following delivery

Sickle cell Hemoglobinopathy
 Hbs

comprises 30-40% total Hb  There is substitution of Lysine for glutamic acid at the sixth position of B chain of Hb  Red cells in oxygenated state behave normally, but in deoxygenated state it aggregates, polymerises and distort red cells to sickle.  These cells are more fragile and increased destruction leads to hemolysis, anemia and jaundice.

Effects on pregnancy
 Increase

incidence of abortion, prematurity, IUGR and Fetal loss.  Perinatal mortality is high.  Incidence of pre-eclampsia, postpartum hemorrhage and infection is increased.

Management
 Careful

antinatal supervision  Air travelling in unpressurised aircraft to be avoided.  Prophylatically Folic A. 1gm daily.  Regular blood transfusion at approx. in 6 weeks interval

My References

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