Anemia in Pregnancy

Obstetrics
Anemia in pregnancy
Introduction
Aneamia defined as an Hb level <110 g/L at booking ; heamodilution will result in further
drops during pregnancy and subsequent reduction in oxygen –carrying capacity.In the
second and third trimesters the diagnostic level for anemia is an Hb<105g/L postpartum
the level 100g/L.
The normal physiological change of an increase in plasma volume causes haemodilution in
a pregnant woman. Although the red cell mass increases, plasma volume increases
disproportionately, resulting in a lowering of the haemoglobin (Hb) to approximately 115
g/L. The National Institute for Health and Care Excellence (NICE) advises that women
should be offered screening for anaemia at booking and at 28 weeks of gestation
Aetiology
Iron-deficiency anaemia accounts for the majority of cases of anaemia that are identified
and is characterized by low mean cell volume (MCV). It is usually caused by nutritional
deficiency or low iron stores resulting from previous pregnancy or previous heavy
menstrual blood loss. Physiological requirements for iron in pregnancy are three times
higher than in non-pregnant menstruating women and iron requirement increases as
pregnancy advances.
Less common causes
•Folic acid deficiency.
•Sickle cell disease.
•Haemoglobin sickle-C (HbSC).
•Beta thalassaemia (more common in patients from Southeast Asia, Southern Europe and
Africa).
•Vitamin B12 deficiency.
•Chronic haemolysis (hereditary spherocytosis).
•Paroxysmal nocturnal haemoglobinuria.
•Leukaemia.
Obstetrics
•Gastrointestinal bleeding.
•Coeliac disease.
•Parasitic diseases (eg, hookworm, schistosomiasis
Presentation
Anemia in pregnancy may be asymptomatic. However, the following symptoms are most
common:
•Fatigue
•Dyspnoea
•Dizziness
The patient may appear pale.
Investigations
•Hb.
•MCV: if ≤76 then the probable cause is iron deficiency but, if lower than concomitant with
other signs of anaemia and a raised red blood cell count, this suggests possible B2-
thalassaemia (estimate HbA2 and use Hb electrophoresis).
•Normal MCV (76-96 fl) with low Hb is typical of pregnancy.
•Ferritin is not required as a routine test. A two-week trial of oral iron with a subsequent
improvement in Hb level confirms the diagnosis of iron deficiency.However, it should be
checked in women with haemoglobinopathy or where the cause is in doubt.
Management .
Routine iron replacement in pregnancy is not recommended in the UK.
Women with known haemoglobinopathy should have serum ferritin checked and be
offered oral supplements if their ferritin level is low (<30 μg/L).
Women with unknown haemoglobinopathy status with a normocytic or microcytic
anaemia, should start a trial of oral iron and haemoglobinopathy screening should be
offered
Obstetrics
Non-anaemic women at increased risk of iron deficiency should have a serum ferritin
checked early in pregnancy and be offered oral supplements if ferritin is low.
Women with established iron-deficiency anaemia should be given 100-200 mg
•Referral to a haematologist should be considered if there are significant symptoms and/or
severe anaemia (Hb<70 g/L) or late gestation (>34 weeks) or if there is failure to respond to
a trial of oral iron
Thalassaemias
Inherited blood disorders with reduced or absent production of alpha or beta chains of the
globin content of haemoglobin (Hb).
Women who are carriers of thalassaemia may be asymptomatic when not pregnant but
more anaemic than usual during pregnancy.
MCV ≤80 fl requires investigation, with an HbA2 ≥3.5% being positive for B2-thalassaemia.
In these cases, the father of the child should be tested and the couple offered genetic
counselling.
Chorionic villus sampling in the first quarter of pregnancy and fetal cord blood sampling
under ultrasound guidance in the second quarter
Sickle cell anemia

Genetic defect causes production of abnormal Hb with a red blood cell life of ≤15 days. In a
sickle cell crisis, red blood cell destruction causes severe haemolytic anaemia and bone
pain. The most common form is haemoglobin S but this mainly affects people from East and
West Africa.
Where suspected, women should receive folate supplementation of 5 mg per day. FBC
should be routinely checked at 20, 28 and 32 weeks.
Iron supplements are not needed unless serum iron and ferritin levels are reduced. If given
routinely, iron supplementation causes iron overload leading to haemochromatosis.
If Hb falls below 60 g/L, or there is a fall of 20 g/L from baseline, a transfusion is considered.
Complications of sickle cell anaemia in pregnancy
Obstetrics
Spontaneous abortion can occur in up to 25% of women affected by sickle cell anaemia
with 15% approximate perinatal mortality also often associated with preterm delivery and
low birth weight (30% ≤2500 g).
Stillbirth rates of 8-10% have been seen and thorough antenatal fetal testing is required to
assess growth, including ultrasound of the umbilical artery.
Sickle cell crisis, stroke and pulmonary embolism are further complications which may
occur.
Frequent urinary tract infections are common and require prompt treatment.
Pregnancy-associated hypertension is also thought to be more common.
Complications
Women with anemia in pregnancy have been shown to have a higher risk of:
Maternal death.
Fetal death.
Premature delivery.
Low birth-weight babies.
Cardiac failure.
Their babies having subsequent developmental problems.
Poor work capacity/performance.

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Obstetrics

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