Anemia in

Pregnancy

Mrs Samia Abu Aishia

The anemia
Anemia: is reduction in the oxygen carrying
capacity of the blood, which may be due
to:
A reduced number of red blood cells.
A low concentration of hemoglobin.
A combination of both.
Physiological haemodilution of
pregnancy:
During pregnancy the blood volume
increases, the increase in the plasma
volume is greater than the increase in the
red mass. This has the following effects:
The blood become less viscous which
may help to reduce cardiac workload and
make perfusion of the placental easier.
There are fewer red blood cells in each
liter of blood, which means that the
hemoglobin concentration is reduced.
These changes result in an obvious
anemia but as this represents a normal
pregnancy state they should not be
regarded as pathological
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.
Defination of Anemia during Preg.
Hemoglobin below 11gm/dl in 1st and 3rd
trimester and below 10.5gm/dl in second
trimester.
 The effect of anemia
Mother Fetus/baby

Reduced enjoyment of pregnancy and Higher prenatal mortality if maternal Hb

motherhood due to fatigue. is less than 8g/dl

Reduced resistance to infection caused by Increased risk of intrauterine hypoxia and

impaired cell mediated immunity. growth retardation

Predisposition to post partum hemorrhage An increase in sudden infant death when

maternal Hb is less than 10g/dl

Potential threat to life.

Problem caused by treatment.

Classification
Physiologic
Pathologic:
a. Deficiency: Iron, Folic A.
c. Hereditary: Thalassemia, Sickle,
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

Iron Deficiency Anaemia:
It is the most common form of anemia.
During pregnancy approximately 1400mg
iron is needed for:
The increase in the number of the red blood
cells.
The fetus and the placenta.
Replacement of daily loss (about 1mg/day)
through stool, urine and skin.
Replacement of blood lost at delivery.
Lactation
Causes of iron deficiency anemia:
Reduced intake or absorption of iron or
protein or both (iron is stored in combination
with ferritin which is a protein). Dietary
deficiency and gastro intestinal disturbances
such as morning sickness.
Excess demand such as multiple pregnancies.
Blood loss, from menorrhagia before
conception, bleeding hemorrhoids, ante
partum or post partum hemorrhage.
Prevention:
Accurate medical, obstetric and social
history.
Health education about the sources of
iron and ways in which absorption can be
increased.
Oral iron preparation given
prophylactically consist of one of the iron
salts.
Investigation:
A low Hb concentration only indicates
that the women are anemic; iron
deficiency is microytic that is producing a
small red cell.
Management:
Oral iron: Side effect of oral iron: stool
may turn black. Nausea and epigastric
pain. Diarrhea or constipation.
Parenteral iron IM or IV is contra-
indicated for women who have liver or
renal disorder.
Blood transfusion: is used to raise the Hb
level quickly if delivery is expected
shortly.
Folic acid deficiency:
Folic acid is needed for the increased cell growth
of both mother and fetus.
Folic acid is found in leafy green vegetables but is
destroyed easily by prolonged boiling or steaming
and by the addition of alkaline such as
bicarbonate of soda.
Anemia is more likely to be found towards the
end of pregnancy when the fetus is growing
rapidly.
Also more common during winter when folic acid
is more difficult to obtain, and in areas of social,
economic, and nutritional deprivation.
Causes of folic acid deficiency
anemia:
Reduced dietary intake, as a result of
overcooking.
Reduced absorption for instance in celiac
disease.
Interfere with utilization, such as
anticonvulsants, alcohol.
Excessive demand
Prevention:
Advising pregnant women on correct
selection and preparation of foods, which
are high in folic acid.
Folic acid may be prescribed prophylactic
for women at incrsed risk. Those with a
multiple pregnancy.
Investigation:
In folic acid deficiency the red blood cells
are reduced in number but enlarged in size
macrocytic or megaloblastic
Management:
folic acid is available in oral and
intramuscularly form.
The usually daily dose being between 5
and 15 mg in divided doses.
Side effects are rare but anorexia nausea
and flatulence have been noted.
Complication of the folic acid
deficiency in pregnancy:
Infection.
Placental separation(abruption placenta)
Bleeding.
Possible congenital abnormalities such as
neural tube defect.
Thalassaemia:
The basic defect is reduced rate of globin
chain synthesis resulting in either alpha or
beta chains being missing. This leads to
haemolysis and in adequate hemoglobin
content.
The severity of the condition depends on
whether the child has inherited abnormal
gene from one parent or from both.
Thalassaemia intermediate and
minor produce:
Similar to iron deficiency in that the Hb,
MCV, and MCH are lowered.
A deficiency in iron is not a problem
because red cell are broken more rapidly
than the normal and the iron is stored for
future use.
Treatment folic acid supplement. 
Thalassaemia minor:
The child inherits abnormal genes from both
parents.
Rapid red cell breakdown produces severe
anemia.
Worst from (alpha thalassaemia major), this
condition is incompatible with extra uterine life.
Beta thalassaemia in early childhood although the
use of frequent blood transfusion increases the
possibility of survival to childbearing age.
 Accumulation of iron in the body due to break
down of red cells from donated must be removed
by the chelating agent desferrioxaine
Pregnant woman with
Thalassaemia major:
Shared care from an obstetrician and a
hematologist in specialist center.
Mother will need to increase her dietary
intake of folic acid and to take folic acid
supplement through pregnancy.
Repeated blood transfusion may be required.
The midwife has vital role in supporting the
woman and in maintaining links with other
department such as hematology, social work.
Sickle cell anemia:
In this condition defective genes produce
abnormal heamoglobin beta chain; the
resulting Hb is call Hbs
In sickle cell trait (Hbas): only one
abnormal gene has been inherited.
In sickle cell disease (Hbss): abnormal
genes have been inherited from both
parents.
Leads to low oxygen tension and cause
heamolsed and anemia develop.
Sickle cell trait: is usually asymptomatic.
The blood appears normal, although the
sickle screening test is positive
There is no anemia even under the
additional stress of pregnancy.
Sickle cell anemia
Women with sickle cell anemia may be sub
fertile.
Those who do become pregnant may already
have organ damage, due to sickling crises,
which may occur whenever oxygen
concentration is low, during anesthesia,
illness, cold, at high altitude or pregnancy.
Infarction leads to pain due to accumulation
of red cells sickle and blocking small blood
vessels. Emboli may threaten life. (Shortened
life span for17 days) lead to hemolytic
anemia.
Antenatal care:
Screening of the high –risk women and those
who are diagnosed.
Monitoring of pregnancy is performed at
regular intervals under supervision of
obstetricians and hematologist.
During pregnancy avoid situation, which
may precipitate a crisis such as cold, stress,
dehydration, hypoxia and infection.
Regular monitoring of the Hb concentration
is required throughout pregnancy.
Treatment may include 3-4 unit blood
transfusion every 6 weeks to maintain an
adequate Hb level.
Role of midwife is to identify preventive
measures as well as to provide social and
psychological support
Intrapartum:
During labor well hydration, iv fluids given
prophylactic antibiotic and effective analgesia
(epidural and oxygen therapy).
Monitoring for the fetus closely for signs of
distress
The sickle cell test doses not yield positive results
until the age of 3-4 month of fetal Hb (hbf)
recedes.
A positive test dose not distinguish between sickle
cell trait and sickle cell anemia, therefore all
children showing positive result should be
investigated and followed up by the hematologist.
Postnatal care:
Prevention of puerperal sepsis.
Antibiotic cover is continued throughout
postnatal periods.
 
Nursing Care for Women With Anemias
During Pregnancy
 Teach woman which foods are high in iron and folic acid
 Teach woman how to take supplements
◦ Do not take iron supplements at the same time when drinking
milk
◦ Do not take antacids with iron
◦ When taking iron, stools will be dark green to black
 The woman with sickle cell disease requires close medical and
nursing care
◦ Teach her to prevent dehydration and activities that cause
hypoxia
◦ Teach her to avoid situations where exposure to infections are
more likely
◦ Teach her to promptly report any signs of infections