Anemia in pregnancy

By Mengistu Lopiso, MD

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• Level of Hgb is affected by sex, race, pregnancy & iron supplement.
• During early & late pregnancy, Hgb level with good iron store is 11mg/dl or
higher.
• CDC defined anemia as:
Hgb level less than 11mg/dl in the 1st & 3rd trimester ,
Less 10.5mg/dl for 2nd trimester pregnancy.

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Causes of anemia
I)Common causes :(95 %)
Physiological anemia
Iron deficiency anemia ( IDA)

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Effects of anemia on pregnancy
• Spontaneous abortion
• Still birth
• IUGR
• Preterm delivery
• LBW
• Angina pectoris or CHF
• Infection

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Mechanism of IDA
• >75% of all anemia in pregnancy is caused by IDA.
• Causes: 1. majority Nutritional(  intake)
2.  absorption
3.  loss
4.  demand
.

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Evaluation of anemia
• Sign and symptom of anemia
Symptom:
 Weakness/vertigo/dizziness
 Fatigue/ easily irritability
Restless leg syndrome
Labored breathing /palpitation
Pica (abnormal craving )
Difficulty of swallowing

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Signs :
 Increase PR/BP
Pallor (skin /conjunctiva)
Glositis(inflamed tongue)
Spooning of nails(koilonychia)/blue sclera
Functional systolic ejection murmur
Investigations:
 Hgb/ Hct determination (race, trimester of
pregnancy)

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Treatment of IDA in pregnancy
 Specific treatment :
i) oral iron therapy
One iron tablet/three time/day recommended
One tablet of ferrous sulfate daily provide prophylaxis, it contains 60mg of
elemental iron (10% of it will be absorbed).

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iv) blood transfusion : rarely indicated,
Severe anemia (<5mg/dl), preparing for delivery or surgical intervention.
Poor response to available iron therapy
CHF secondary to severe anemia
Acute blood loss with hemodynamic instability
One unit blood raise Hb/Hct (0.8-1mg/ 3%)/unit of blood
respectively.
Packed RBC is preferred to whole blood if there is no associated
hypovolemia.

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Other type anemia
1)Folate deficiency:( <5ng/ml)
Water soluble vitamin, found in green vegetable , peanuts and liver
Folate store in the liver is sufficient for 6wks,
During pregnancy folate deficiency is common cause of megaloblatic
anemia where as vit B12 is rare.

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• Daily requirement for non-pregnant is 50 microgram during pregnancy raise
to 3-4x.
• Clinical megaloblastic rarely occurs before third TM, if the patient had risk
develop mild anemia.
• Serum folate/RBC folate best test to detect folate deficiency before
megaloblastosis develops.
• Most non –prescription prenatal vitamin have 0.8mg as compared to
prescription requiring preparations (1mg of folic acid) but the amount is
more than adequate to treat or prevent folate deficiency.

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• Women with multiple gestation, frequent conception, hemoglobinopaties,
receiving anticonvulsants, requires 1mg folic acid supplement daily.
• If women folate deficient reticulocyte count will be depressed, after three
days treatment reticulocytosis usually occur.
• Hct level may rise as much as 1%/ day after one week of folate replacement.
• If patient do not develop reticuloctosis after one week of folate replacement
appropriate test for IDA should performed.

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•Malaria in pregnancy

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 Gametocytes taken by mosquitoes  zygote  ookinate
in gut cells  sporozoites in salivary gland   
Sporozoits

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Placental malaria
• Unique features is the ability of PF- parasitized erythrocytes to sequester within
the intervillous space of the placenta

• Placental infection may be detected even in the absence of peripheral parasitemia

in mothers.

• Xized by sequestration & multiplication of the parasites

• Pregnancy-induced immune suppression may also account for the more severe
disease.

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CLINICAL MANIFESTATIONS
• In areas of Stable Transmission:
Most infections are asymptomatic, but
The mother at risk for anemia and the fetus is at risk for LBW
• For women residing in mesoendemic areas, or for women returning
to a holo-endemic area:
Febrile illness,
Severe symptomatic disease,
Preterm birth, and
Death of mother or fetus

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• PF is associated with:
High levels of parasitemia since it invades RBC of all ages;
Occasionally, >50% of RBC are infected.
• The C/F of malaria are nonspecific & variable &frequent symptoms
include:
Chills, sweats, fever
Headache, myalgias, fatigue,
Nausea, abdominal pain,
Vomiting, diarrhea,
Jaundice, and cough.

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• Compared to nonpregnant women, pregnant women experience
more severe disease,
Hypoglycemia:
Respiratory complications (pulmonary edema, ARDS).
Anemia is a common complication.

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DIAGNOSIS:
Should be considered in any febrile woman who:
 Resided in a malarious region, or
 Traveled to a malarious region even if briefly or only transit.
Women may have placental parasites with out peripheral parastemia, &
hence, B/F would be -ve.
The diagnosis is made by histological examination after delivery.

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OUTCOME
• Adverse maternal & perinatal outcomes associated with malaria
during pregnancy include:
Miscarriage
IUGR/SGA infant
Preterm birth
LBW (<2500 g at birth)
Perinatal death
Congenital infection
Maternal anemia
Maternal death

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Treatment and prevention of malaria in
pregnancy
• TREATMENT:
Malaria in pregnancy is dangerous for both the mother and the fetus.
Pregnant women with malaria must be treated promptly with an effective
antimalarial agent.
The newer the drug, the more likely it is to be effective, but fewer data will be
available on safety in pregnancy.

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Uncomplicated P. falciparum :
• 1st TM
Quinine + clindamycin
Artesunate + clindamycin 7days
 If the only RX available
 If other regimen failed
• 2nd & 3rd TM
ACT(link)
Artesunate + clindamycin
Quinine + clindamycin

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•  PV, PO, PM, and P. knowlesi
 Seldom kills, but can be a cause of significant morbidity in pregnancy.
• Non-falciparum malaria may be treated as:
P. Vivax &P. Ovale (chloroquine-sensitive)
Chloroquine :
 1000 mg salt PO immediately, followed by 500 mg salt PO at 6, 24, and 48 hours.

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Chloroquine-resistant P. vivax:
Mefloquine
 750 mg salt orally as initial dose, followed by 500 mg salt orally given 6-12 hours after
initial dose 
 Quinine
 650 mg salt PO TID 3 to 7 days
• Following RX; non-pregnant patients are treated with primaquine to
prevent PV & PO.
• Primaquine is contraindicated in pregnancy:
It can cause hemolytic anemia in individuals with G6PD deficiency &
Fetal G6PD status is uncertain.

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PREVENTION
• Major tools for prevention include:
Chemoprophylaxis
Mosquito avoidance
Case management
• Chemoprophylaxis:
Pregnant travelers advised to defer travel to malarias areas .
For who cannot defer travel, chemoprophylaxis is recommended.
Pregnant women living in endemic areas benefit from chemoprophylaxis
against malaria

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MANAGEMENT OF PREGNANCY
In severe malaria, fetal assessment recommended, as NRFHB tracings and
IUGR are common.
AFV decreases during febrile periods and tends to normalize with
defervescence.
Assuming available resources, a reasonable program of surveillance consists
of:
 Serial ultrasound examinations for assessment of fetal growth and amniotic fluid.

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