ANAEMIA IN

PREGNANCY

Presented by,
Ms. komal Dhulap
4th year BSc nursing.
INTRODUCTION
 Anemia is a most common Haematological disorder that may occur in pregnancy, and it’s
responsible for 20% of maternal death’s in country.
 The who ( world Health Organization) has accepted Upto 11gm% as the normal level of
Haemoglobin in pregnancy.
 Therefore Any haemoglobin level below 11gm% In pregnancy should be considered As
Anemia.
 In 2019, anaemia prevalence was 29.9% in women of reproductive age.
 Its responsible for significant high metarnal and fetal mortality rate Throughout the country.
DEFINITION
Anemia in pregnancy is defined as a hemoglobin concentration is less than 11 gm / dl

Classification
Mild : 9- 10.9 mg /dl
Moderate : 7.8 – 9 mg / dl
Severe : < 7 mg / dl
Very severe : < 4 mg / dl
 CLASSIFICATION OF ANEMIA
Pathological anemia
Deficiency
Anemia
Haemorrhagic
• Iron deficiency anemia
anemia
• Folic acid deficiency Hereditary
• Vitamin B 12 deficiency • Acute haemorrhage
anemia Bone marrow
• Protein deficiency • Chronic hemborrhage insufficiency Haemolytic
• Thalassemia
• Sickle cell anemia • Hypoplasia disorder
• Hemoglobinopathies • Leukaemia • Autoimmune
• Hereditary anemia • Lymphoma haemolysis
• Drug induced G6PD
deficiency
• SLE, HELLP
SYNDROME
 Physiological anemia

 During pregnancy , maternal plasma volume gradually expand by 50% , An increase

of approximately about 1200 ml by term.
 Most of the rise takes place before 32 to 36 weeks of gestation And there after there is
relatively little change.
 The total increase in red blood cell is about 25 % , approximately 300 ml that Occur
later in pregnancy. This relative hemodilution produces fall in haemoglobin
concentration. Thus presenting the picture of iron deficiency Anemia.
 However it has been found that , these changes are physiological alterations Of
pregnancy Necessary for the development of fetus.
CAUSES OF ANEMIA IN PREGNANCY
BEFORE PREGNANCY
• Faulty dietetics habits
• Faulty absorption mechanism
• Iron loss
DURING PREGNANCY
• Increased demand of iron
• Diminished intake of iron
• Diminished Absorption
• Disturbed metabolism
• Prep regnant health status
• Excess demand
INVESTIGATIONS
 The patient having a haemoglobin level 9 gm% or less should be subjected to a full
Haematological investigation.
 Degree of Anemia – this require examination of hb, total RBC count, determination
of packed cell volume.
 Type of Anemia –

Peripheral blood smear – to examine morphology of RBC

Haematological indices – calculation of MCHC, MCV, MCH. (MCHC is the
most sensitive index of iron deficiency Anemia.
 To find out cause of anemia

Stool examination – this should be done as routine basis especially in tropics, to detect Helminthic
infestation.
Urine examination – to detect presence of protein, sugar and puss cell.
 Other investigation –

1. X ray in suspected tuberculosis

2. Estimation of serum protein in hypoproteinaemia
3. Osmotic fragility in hereditary Spherocytosis Or Hemoglobinopathies disorder.
4. Fractional test for meal analysis of gastric juice to find out alchorhydria in pernicious Anemia.
 Bone marrow studies –

1. The cases who are not responding to therapy according to Haematological typing.
2. To diagnose hypoplastic Anemia.
3. To diagnose kala azar by detecting LD bodies. ( Leishman-donovan body)
IRON DEFICIENCY ANEMIA

 Iron deficiency Anemia is thought to be the most common cause of anemia globally.
 It is a common type of Anemia in which blood lacks adequate healthy red blood cells.
It is due insufficiency iron.
 The daily iron requirement for a healthy women is 1.3 mg, which can be acquired
through a diet rich in iron to 3 mg / day.
 In pregnancy, this requirement rises to 3 mg / day, further increasing to 7 mg / day
after 32 weeks and folic acid is 50 -400 πg/ day.
IRON DEFICIENCY ANEMIA ASSOCIATED WITH,

 Reduced intake of iron due to gastric malabsorption or dietary deficiency.

 Short interval between pregnancy.
 Chronic infection such as malaria and HIV.
 Chronic blood loss eg. Menorrhagia and gastric ulcer.
 Multiple pregnancy.
ON EXAMINATION
1. Pallor skin, evidence of glossitis and Stomatiti.
2. Edema of the leg due to hypoproteinemia.
3. A soft systolic murmur may be heard, due to mitral incompetence.
4. Crepitation may be heard at the bade of the lung due to congestion.
5. Koilonychia.
PROPHYLACTIC TREATMENT
Only 20 % pregnant women’s have iron store of 500 mg which is minimum essential for
pregnancy.
 Avoidance of frequent childbirth, a minimum interval between pregnancy should be
at least 2 year.
 Supplementary therapy – daily administration of 200 mg of ferrous sulfate along with
1 mg folic acid.
 Adequate treatment – should be initiated to eradicate hookworm infestation,
dysentery, malaria, piles, urinary tract infection.
 Early detection of falling haemoglobin level is to be made.
CURATIVE TREATMENT AND MANAGEMENT
 Treatment of severe anemia must be preceded by an accurate diagnosis of the cause
and type.
 Women having HB level of 7.5 gm /dl or ideally anyone with HB less than 10 gm/ dl
and those with associated obstetrical medical complication should be Hospilized.
 Balanced diet – a diet which is rich in protein, iron and vitamin should be adviced.
 Antibiotic therapy – appropriate antibiotic therapy to eradicate even minimal septic
focus.
 Effective therapy – to cure the disease contributing to the cause of anemia.
 Iron therapy – to rise hemoglobin level and restore the iron.
 Vitamin B complex – to improve the appetite and facilitate digestion.
 Treatment of severe anemia must be preceded by an accurate diagnosis of the cause
and type.
 Women having HB level of 7.5 gm /dl or ideally anyone with HB less than 10 gm/ dl
and those with associated obstetrical medical complication should be Hospilized.
 Balanced diet – a diet which is rich in protein, iron and vitamin should be adviced.
 Antibiotic therapy – appropriate antibiotic therapy to eradicate even minimal septic
focus.
 Effective therapy – to cure the disease contributing to the cause of anemia.
 Iron therapy – to rise hemoglobin level and restore the iron.
 Vitamin B complex – to improve the appetite and facilitate digestion.
ORAL IRON THERAPY
 Tablet ferosulfate 300mg ( ferrous sulphate 60mg elemental iron).
 Initial dose 1 tablet 3 time a day 1 hour before meal.
 Maintenance dose 1 tablet daily for at least 100 days following delivery.
 HB should be rise by 2.0 gm / dl every 3- 4 weeks with start of an oral iron therapy.
 Side effect – Intolerance

Unpredictable absorption rate.

Response of therapy evidenced by –
 Sense of well being.
 Increased appetite
 Rise in HB level
 Haematocrit value returning to normal level
 (Note: if no significant improvement is evident clinically, and Haematologically
within 3 weeks, diagnostic revaluation is needed.
 Within 3 weeks of therapy the hemoglobin concentration is expected to rise at the
rate of about o. 7 gm /100 ml / week
Causes of failure of improvement.
 Improper typing of Anemia
 Malabsorption
 Patient fails to take iron.
 Chronic blood loss.
 Inhibition of erythropoiesis by infection
 Co-existence of folate deficiency.

Contraindication of oral therapy

1. Intolerance of iron by orally.
2. Severe Anemia in advanced pregnancy.
PARENTERAL THERAPY

Intravenous route

 Iron sucrose (20 mg / ml) 100 mg / dose once daily for 10 day’s.
 Sodium ferric Gluconate complex 125mg / dose once in daily usually for 8 days.

Indications
1. If oral therapy is contraindicated.
2. Patient is not cooperative to take oral iron.
3. Cases seen for the first time during the last 8-10 weeks with severe Anemia.
 Limitations – 1. Method is unsuitable if at least 4 weeks time is not available to rise
haemoglobin.
2. Previous history of reaction to parenteral therapy.
 Prerequisites – 1. Correct diagnosis of true iron deficiency Anemia.

2. Adequate supervision.
3. Facilities for management of anaphylactic reaction.
 Procedure -

1. Injection should dilute with 500 ml 0.9 % saline

2. Take Precautions like those blood transfusion are to be taken both prior to and during
the infusion process.
3. The drip rate should be 10 drops per minute during first 20 minutes and thereafter it’s
increase to 40 drops per minute.
 Intramuscular route
1. Injection iron sucrose 20 mg/ml
2. Injection sodium ferric Gluconate complex 12.5mg/ ml.
3. Injection iron dextran 50 mg / ml.
Gluteus Medius
 Procedure –
 After initial test dose of 1 ml, the injection are given daily or an alternate days in dose
of 2ml Imtremuscularly.
To prevent dark staining of the skin Over the injection site and minimize pain.
The injection are given with a 2 inch needle deep into the upper outer quadrant of the
buttocks.
 Drawbacks –

1. The injection are painful.

2. Risk of abscess formation and discoloration of the skin over injection
site.
3. Pyrexia, Lymphadenopathy , headache, nausea, vomiting and allergic
reactions are infrequent, Hypotension, arthralgia and abdominal pain.
 Blood transfusion

 Indication-

1. Patient with severe Anemia.

2. Refractory Anemia.
3. Associated infection.
 The quality and quantity of blood.

1. The blood should be fresh, properly grouped and cross matched.

2. Only packed cells are transfused.
3. The quantity should be 80- 100 ml at a time. Should not repeat within 24 hours.
 Advantages of blood transfusion.

1. Increased oxygen carrying capacity of the blood.

2. Stimulate erythropoiesis.
3. Supplies natural constituents of blood like protein, antibodies etc. Drawbacks
 Precautions

1. Antihistamine should be given. ( inj phenergan 25 mg IM)

2. Diuretic should be given at least 2 hour prior to the transfusion.
3. Drip rate should be about 10 drops /minute. And careful observation.
 Exchange blood transfusion

 Indications

1. Cardiac failure due to severe Anemia.

2. Cases of sever Anemia requiring surgeries.
3. Sever Anemia near term.
 Drawbacks.

1. Large quantity of fresh blood is required.

2. Chance of serum hepatitis is more.
COMPLICATIONS OF ANEMIA IN PREGNANCY
During pregnancy
 Pre-eclampsia
 Intercurrenr infection
 Heart failure
 Preterm labor
During labor
 Uterine inertia
 Postpartum hemorrhage
 Cardiac failure
 Shock
 Puerperium

 Puerperal sepsis.
 Poor lactation
 Subinvolution
 Puerperal venous thrombosis
 Poor wound healing.

Risk period

 About 30 – 32 weeks of pregnancy

 During labor
 Immediately following 7-8 day of delivery.
MANAGEMENT DURING LABOR
First stage

 Patient should be on the bed in comfortable position.

 Oxygen therapy
 Strict asepsis.

Second stage

 Prophylactic low forceps or vacuum delivery

may be done to shorten the duration of second stage.

 Injection oxytocin 10 IU IM should be given.
 Third stage

 Replenish the significant amount of blood loss.

 Prevention of postpartum overloading of the heart.

Puerperium

 Prophylactic antibiotics.
 Predelivery Antiemetic therapy.
 Education regarding Anemia and measures of contraception.
REFERENCES
 DC Dattas, Textbook of obstetrics, 9th edition page no. 245 to 252.
 Myles Textbook for midwives, 17th edition page no 378 to 384.
 Nima bhaskar, Textbook of midwifery and obstetrical nursing, page no 380 to 384.