ANAEMIA IN PREGNANCY

 MBCHB V

PRESENTED BY:

DR. F.X. ODAWA

ANAEMIA IN PREGNANCY

 An expectant mother is considered to

have anaemia if her HB level is < 10g/dl.
(WHO: <11g/dl)
 During pregnancy plasma volume
expands by 46-50% whereas red cell
mass increases by 18-25 %. This leads
to haemodilution hence the lower level
taken for HB during pregnancy.
 Normal ranges: Female: 12-16g/dl
 Male: 13-18g/dl

 Anaemia is the most common medical

disorder to occur in pregnant women
particularly in developing countries but
its prevalence varies from region to
region.
 It is a major contributor to
maternal morbidity and mortality and is
also associated with perinatal mortality.
 Causes

Are multifactorial and include:

1) Nutritional deficiencies of iron and
folate
- Poor dietary intake
- Poor absorption
- Increased nutrient loss and demand
- Methods of cooking
- Dietary habits
Causes Cont…

- Prohibitive costs
- Some food taboos for pregnant women

NB: Absorption of iron is affected by the

high phytate content in many grains
based diets in the tropics.
2). Malaria infestation

 With its attendant haemolysis increases

folate demand leading to megaboblastic
anaemia.

 Natural acquired immunity is lowered in

pregnancy leading to excessive
destruction of RBCs in some cases.
3). Hookworm infestation:

 Chronic parasite infection affects millions

of women of reproductive age in
developing countries.
 Lives in the duodenum - the site of
optimal iron absorption, therefore
interfering with the latter by their
attachments to the duodenal mucosa
besides sucking blood from the patient
(0.05 – 0.1ml per worm/ day), and leads
to iron deficiency.
4) Other helminthes and parasites e.g
E. histolytica

5) Haemoglobinopathes e.g. sickle cell

disease (SCD), thalasaemia and glucose
6-phosphate dehydrogenase deficiency.
 SCD is the most common inherited
anaemia in the world.
 The anaemia in SCD is related to the
shortened red cell survival (average 17
days) so that these patients suffer from a
chronic haemolytic process reflecting
itself in the form of a crisis in the mother
and IUGR in the foetus. The steady state
HB in SCA is between 6-10%.
6). Chronic diseases e.g. TB, HIV,
Brucellosis, scistosomiasis, UTI, chronic
liver and renal dx, and protein deficiency.
7) Demands of pregnancy parse;

Extra demands to the haemolytic factors

(increased red cell mass plus demands of
the growing foetus = increase in the total
number of rapidly dividing cell leads to
increased requirement of folic acid).
 Clinical Features
 Characteristically insidious in onset
 Presentation usually non-specific and depends
on the severity of anaemia, duration of disease
and causative factors.
 Diagnosis depends on history, physical
examination and various lab tests done based
on aetiological factors.
 In the early stages it may only be detected by
routine HB estimation in the ANC.
Symptoms include:

- General weakness, malaise, fatigue,

lethergy or lassitude
- Dizziness
- Dyspnoea on slight excertion
- Breathlessness
- Swelling of legs feet and face (oedema)
Signs include:

 palour (conjunctiva, tongue, palms and nail

beds, sole of the feet etc),
 jaundice (or tingue of),
 Moderate tachycardia at rest,
 Haemic murmur,
 low grade fever without obvios cause is
common plus or minus hepatosplenomegaly in
haemolytic anaemia e.g. of malaria (endemic)
and SCD,
 Orthorpnoea and other signs of cardiac
failure e.g. engorged neck veins in the
semi-upright position, congestion of lung
bases, enlarged tender liver, increased
pulse pressure, and may be present in
very severe cases
 Albuminuria is common
 In the terminal phase acute pulmonary
oedema may supervene and cerebral
anoxia may produce excitement and
mental confusion followed by loss of
consciousness.
 Investigations
 H’gram + PBF+ BS for MPs
 Stool: O/C
 Hb electrophoresis/ sickling test
 LFTs for serous proteins as in chronic liver
disease and hypoproteinaemia
 U/Es + Cr + U.A to rule out underlying nephrosis
 CXR- to r/o intercurrent chronic chest infection
Sequale of Anaemia in pregnancy

 CCF= death in pregnancy or soon after

delivery or during labour
 Low resistance = infections e.g.
pneumonias, puerperal sepsis etc
 IUGR
 Late abortions (20 – 28 wks)
 Premature labour
 IUFD/ neonatal death (perinatal death)
due to intrapartum asphyxia

 Infantile anaemia 2-3 months post

delivery due to deficient iron storage in
the last trimester.
Treatment

 Mainly directed at the cause

 Supportive care is similarly important

e.g. administration of haematinics or
blood transfusion or both – depending on
the degree of anaemia and the
gestational age at the time of diagnosis.
General Measures

 Protein intake- Should be adequate – at

least 100grams per /day, 50% of which
should preferably be animal protein
 Chronic diarrhoeas – should be treated
as they interfere with folic acid and B12
absorption
 Hookworm – should be treated with
non-toxic antihelminthics
Specific treatment

1). Oral iron therapy; in Fe def. anaemia of

moderate degree in the first and second
trimester

2). Parenteral iron therapy; in more severe

cases particularly those seen for the first time
near term to achieve quicker response as well
as for those not able to tolerate oral Fe due to
gastric symptoms and also those not
responding due to malabsorption.
3). Suplementary Folic Acid
4). Malaria treatment – when confirmed or
suspected
5). Steroid therapy – in excessive
haemolysis
6). Vit. B12 – for megaloblastic anaemia
unresponsive to folic acid or when B12
def.is confirmed
7).Cardiac failure - treated appropriately with
antifailure regime (digoxine, aminophyline, O2
etc
8). Blood transfusion – for impending CCF,
patient in labour with severe anaemia
- watch for overload
- Packed RBCs is preferred
- Transfuse slowly (not more than 500mls
in at least 6-8 hrs
Mx of labour and the
puerperium in severe anaemia
 Labour and the first 2wks of the
puerperium are the periods of greatest
danger to the anaemic mother.
 Most deaths occur in the first 12hrs after
delivery
 O2 should be delivered in labour by
mask to reduce the risk of foetal
asphyxia
 Aseptic techniques to be employed due to
decreased immunity
 2nd stage should be shortened by
assisted vacuum extraction or low forceps
delivery
 Antibiotic prophylaxis in the puerperium
 Specific treatment for anaemia to
continue for at least 6wks after delivery
(puerperium) to accelerate recovery
 Finally before discharge warn the mother
of possibility of recurrence in subsequent
pregnancies therefore to present as
soon as they become pregnant for
prophylaxis
Prevention

a) Correct faulty dietary habits e.g.

overcooking vegetables and meat
(important sources of folic acid)
b) Increase production and consumption
of foods which contain the raw
materials of erythropoesis.
c) Antimalarial prophylaxis
d) Reduction of hookworm loads
e) Prophylactic medication – haematinics
f) Early detection of anaemia in
pregnancy by screening all pregnant
women (ANP) – first and last visits
 These measures will lead to a
reduction in loss of maternal and
infant lives from anaemia and also
reduce cost of hospitalization and
treatment
 Conclusion

 Prevention of anaemia is difficult in

developing countries due to its
multfactorial origin:
- Poor SES
- Poor health facilities
- Socio-cultural factors
- Poor utilization and scarcity of FP and
ANC services
 However prophylactic use of haematinics
and antimalarials has reduced the
severity of anaemia in the tropics.