Anemia in pregnancy

Presenters :
Jill Ganatra
Kondamadugula Gaurav Reddy

Tutor:
Dr. Ntuyo Peter
Objectives
Definition
Epidemiology
Classification
Etiology
Risk factors
Complications
Management
Definition
• According to WHO guidelines, Hb concentration in a pregnant woman
of less than 11.0g/dl is considered as anemia.
• In the second trimester the cut off hemoglobin level is 10.5g/dl.
• Grading:
mild anemia: 8-10.9 g/dl
moderate anemia: 7-7.9 g/dl
severe anemia: < 7 g/dl
Epidemiology
• From the global burden of disease study, there has been a slight
decrease in the prevalence of anemia from 43% to 38% among
pregnant women compared to 33% to 29% in non-pregnant women
between 1995 and 2011. This prevalence translates to about 32 million
pregnant women with anemia globally.
• The prevalence of anemia in pregnancy was 24.7%, majority of these
deaths were in northern Uganda, which is a region recovering from
decades of war.
• The anemia in this region was majorly due to iron deficiency anemia
either because of not being on Iron supplementation or not being
dewormed
Classification
• Anemia in pregnancy can be classified according to WHO guidelines or
Etiologically as:
Physiological
Pathological
Physiological classification
• In pregnancy both the plasma volume and red blood cell volume
increases, which leads to a fall in hemoglobin and hematocrit values.
• This concept is known as hemodilution.
• In the second half of pregnancy the nutritional demand of the fetus
increases because of which the iron demand also increases which is
not sufficed by the normal diet of the mother.
• This combination of reduce in hemoglobin and increase iron demand
causes anemia which is normocytic and normochromic.
• Here the peripheral blood film will show normal size and shape of
RBC, but the patient will be having central pallor.
Pathological classification
• Deficiency: Iron deficiency anemia
folic acid deficiency
vitamin B12 deficiency
protein deficiency
• Hemorrhagic: Acute blood loss
Chronic blood loss
Trauma
• Hereditary: Sickle cell anemia
Thalassemia
• Infection: malaria
tuberculosis
Etiology cont…
• Iron deficiency anemia:
During pregnancy iron deficiency anemia is caused by:
Increased iron demands: Fetoplacental growth
Fetal RBC production
Expanding maternal blood volume
Preparation for lactation
Diminished iron intake: Loss of appetite
Vomiting in pregnancy
Inflammatory bowel disease
Gastric bypass
Cont…
Excess iron demand: Multiple pregnancies
Short interpregnancy intervals
Teenage pregnancies
Infections
Impaired iron metabolism
Chronic blood loss
Symptoms of IDA
SYMPTOMS.
Lassitude and feeling of exhaustion or weakness
Anorexia
Indigestion
Palpitation by ectopic beats
Dyspnea
Giddiness
Swelling of legs
Megaloblastic anemia
• In megaloblastic anemia, there is derangement in red cell
maturation with the production in the bone marrow of abnormal
precursors known as megaloblasts due to impaired DNA synthesis.
• Megaloblastic anemia in pregnancy is almost always due to folic acid
deficiency. The daily requirement of Vit B12 in non-pregnant
condition is 2 μg and during pregnancy is 3 μg. This amount is met
with any diet that contains animal products. Only the strict
vegetarians, may need supplementation.
Folic acid deficiency
• Pernicious anemia of pregnancy
• Associated with diets low in animal proteins, fresh green leafy vegetables and
legumes
• Caused by: Increased demand
Inadequate intake
Diminished absorption
Iron deficiency anemia
• Causes: Anorexia, unexplained fevers, vomiting, occasional diarrhea
DIAGNOSIS
Low RBC folate levels, macrocytic RBC, increased MCV and MCHC, hyper segmented
neutrophils on peripheral smear
Complications of Folic acid deficiency
• Miscarriage
• Dysmaturity
• Prematurity
• Placental abruption
• Fetal malformation (cleft lip, cleft palate, neural tube defects).
Vitamin B12 deficiency
Causes macrocytic anemia
Due to absence of intrinsic factor required for dietary vitB12
absorption.
In mothers who had partial or total gastrectomy, Crohn disease, obese
patients taking proton pump inhibitors, ileal resection and bacterial
overgrowth.
Dimorphic anemia:

• This is the most common type of anemia met with in the tropics. It is
related to dietary inadequacy or intestinal malabsorption. As such,
anemia results from deficiency of both iron and folic acid or vitamin
B12. The red cells become macrocytic or normocytic and hypochromic
or normochromic.
Hemoglobinopathies
Sickle cell anemia:
Sickle cell hemoglobinopathies are hereditary disorders. It is caused by a point
mutation in the β globin gene on chromosome II. There is increased incidence
of miscarriage (25%), prematurity, IUGR and fetal loss. Perinatal mortality is
high. Incidence of preeclampsia, postpartum hemorrhage and infection is
increased. Increased maternal morbidity is due to infection (UTIs),
cerebrovascular accident and sickle cell crisis. Maternal death is increased up to
25% due to pulmonary infarction, acute chest syndrome, congestive heart
failure and embolism.
This sickling phenomenon is precipitated by infection, acidosis, dehydration,
hypoxia and cooling. The cells have got shorter life span and are more fragile.
Increased destruction leads to hemolysis, anemia and jaundice.
Platelet disorders
• Gestational thrombocytopenia: Is mainly the physiological fall resulting from hemodilution of
normal pregnancy and increased platelet destruction.
• Immune (idiopathic) thrombocytopenic purpura (ITP): Is due to accelerated destruction of
antibody coated platelets in the spleen and other reticuloendothelial systems. Antibodies are of
IgG, IgM and IgA types. Patients may present with skin bruisingFetus and the neonate may be
affected due to transplacental carriage of IgG antibodies. Thrombocytopenia in the fetus when
severe may cause intracranial hemorrhage especially during labor.
• Management: Objective is to maintain platelet count more than 50,000/μL.
• During pregnancy: (b) Platelet transfusion is indicated when there is clinically significant
bleeding. (c) Splenectomy—as this may be the site of antibody production or red cell
sequestration (c) Platelet transfusion—as a temporary measure. (d) In a patient with thrombotic
thrombocytopenic purpura plasma exchange should be done
• During labor: Vaginal route is the preferred method as severe thrombocytopenia is rarely
encountered.
Risk factors
Obstetric factors: Multiple gestation
Frequent pregnancies
Ruptured uterus
History of postpartum hemorrhage
Hydatidiform mole
Nutritional factors: Inadequate dietary intake
Malabsorption syndrome
Pica
Chronic bleeding: Epistaxis
Rectal and vaginal bleeding
Hookworm infestation
Sickle cell anemia which is common in Africans
Socioeconomic factors: Ignorance about use of available foods
Poverty
Religion
Alcohol
Beliefs and superstitions
Complications
• During Pregnancy: The following complications are likely to increase:
Preeclampsia may be related to malnutrition and hypoproteinemia.
Intercurrent infection—Not only does anemia diminish resistance to
infection, but also any pre-existing lesion, if present, will flare up.
It should be noted that the infection itself impairs erythropoiesis by
bone marrow depression.
Heart failure at 30–32 weeks of pregnancy.
Preterm labor
.
• During Labor:
Uterine inertia is not a common associate, on the contrary the labor is
short because of a small baby and multiparity.
Postpartum hemorrhage is a real threat. Patient tolerates
even a minimal amount of blood loss.
Cardiac failure may be due to accelerated cardiac output which occurs
during labor or immediately following delivery. As the blood in the uterine
circulation is squeezed in the general circulation, it puts undue strain on the
weak heart already compromised by hypoxia.
Shock—Even a minor traumatic delivery without bleeding may produce
shock or a minor hypoxia during anesthesia which may be lethal.
Treatment
• Prophylaxis
All pregnant women should receive ferrous and folic acid daily from 12 weeks.
Continue supplementation until 6months after delivery.
• If Hb >7 g/dL
Give combination of ferrous and folic acid once daily(Fe-200mg+400mcg)
Review the mother every 2 weeks (Hb should rise by 0.7-1 g/dL per week)
• Emphasize a realistic balanced diet rich in proteins, iron, and vitamins, e.g. beans,
peas, millet, sorghum, peanuts, red meat, liver, dark green vegetables, fortified foods,
Bananas.
• Treat malaria presumptively with SP and follow up
• De-worm the patient with mebendazole 500 mg single dose in 2nd and 3rd trimesters
• Prevention/Health Education / mother selfcare
Explain the possible causes of anemia
Advise on nutrition and diet: mother should increase consumption of
foods rich in iron and vitamins
Instruct patient to use medication as prescribed, and the dangers of
not complying
Advise on side effects of iron medicines (e.g. darkened stools)
Instruct patient to come every 2 weeks for follow-up
References
• Uganda clinical guidelines 2023
• DC Dutta’s Textbook of obstetrics 8th edition
• WHO guidelines