ANEMIA IN

PREGNANCY
VIVIEN YEO FEN FEN
Klinik Kesihatan Masjid Tanah
 Introduction
• Anemia is the most common medical disorder in
pregnancy.
• Pregnancy causes 2-3 fold increase in requirement
of iron and 10-20 fold increase in folate
requirement.
 Definition
In pregnancy, the Centers for Disease Control and
Prevention and the World Health Organization define
anemia as:

1st Trimester 2nd Trimester 3rd Trimester

Hemoglobin (g/dL) < 11 < 10.5 < 11

Hematocrit (%) < 33 < 32 < 33

 WHO Recommendation
• Daily oral iron and folic acid supplementation with
30 mg to 60 mg of elemental iron and 400 µg (0.4
mg) folic acid is recommended for pregnant
women to prevent maternal anemia, puerperal
sepsis, low birth weight, and preterm birth.

• The equivalent of 60 mg of elemental iron is 300 mg ferrous sulfate

heptahydrate, 180 mg ferrous fumarate or 500 mg of ferrous gluconate.
• Folic acid should be commenced as early as possible (ideally before
conception) to prevent neural tube defects.
 Types of Anemia in Pregnancy

1. Iron-deficiency anemia
2. Folate-deficiency anemia
3. Vitamin B12 deficiency
 Iron-Deficiency Anemia
• Iron-deficiency anemia is the most common type
of anemia during pregnancy, contributing to about
95% of anemia cases related to pregnancy.
• This type of anemia typically occurs when the body
doesn’t have enough iron to produce adequate
amounts of hemoglobin.
 Folate-Deficiency Anemia
• Folate refers to folic acid, a water-soluble vitamin
that can help prevent neural tube defects during
pregnancy.
• It is commonly taken as a supplement by pregnant
women. It can also be found in fortified foods such
as cereals, leafy vegetables, bananas, melons and
legumes.
• A diet lacking folic acid leads to a reduced number
of red blood cells in the body, thus causing
deficiency.
Vitamin B12 Deficiency Anemia
• Vitamin B12 is also one of the essential vitamins
for our body to have to help with the production of
red blood cells.
• Women who don’t eat meat, poultry, dairy
products, and eggs have a greater risk of
developing vitamin B12 deficiency.
 Risk of Anemia in Pregnancy
• Have two pregnancies close together
• Pregnant with twins or more
• Vomiting frequently due to morning sickness
• Do not consume enough iron
• Have a heavy pre-pregnancy menstrual flow
Clinical Signs & Symptoms
 Effects of Anemia in Pregnancy
FETUS MOTHER
• Neural tube defect • Susceptibility to infection
• Pre-term birth • Heart failure
• Low birth weight • Postpartum depression
• Mental impairment
• Delayed growth
 Treatment
Prenatal Vitamins available in PKDAG:
1. Iberet Folic-500
2. Zincofer
3. Separate Hematinics
 Iberet Folic-500
Contents
Ferrous Sulfate 525mg (105mg elemental iron)
Vit B1 6mg
Vit B2 6mg
Vit B6 5mg
Vit B12 25mcg
Vit C 500mg
Niacinamide 30mg
Ca pantothenate 10mg
Folic acid 800mcg

Indication/Uses • Iron-deficiency anemia

• Megaloblastic anemia where there is an associated deficiency of
vitamins C and B-complex particularly in pregnancy

Administration • May be taken with or without food:

Swallow whole, do not chew/crush

Side Effects • Rare, occasionally with nausea, vomiting, constipation or diarrhea,

gastric pain at high doses.
 Iberet Folic-500
Drug Interactions • Absorption inhibited by magnesium trisilicate, antacids or
cholestyramine
• With concomitant use of alcohol, toxic delirium and lactic acidosis have
been noted
• With concomitant use of niacin and nicotine, flushing and dizziness
have been reported
• With concomitant use of quinolone anti-infective agents (e.g.
Ciprofloxacin, Norfloxacin, Ofloxacin), will result in decreased serum
and urine concentration of quinolone
• Ferrous Sulfate may interfere with the absorption of Tetracycline
• Pyridoxine is noted to have effects on dopamine, drug interaction are
possible. Drug interaction with Levodopa is noted, but can be avoided
if Levodopa is given combination with Decarboxylase inhibitor
• Prothrombin time is decreased when ascorbic acid is used
concomitantly with anticoagulants

Food • Eggs inhibit iron absorption

Interactions • Coffee and tea consumed inhibit iron absorption
 Zincofer
Contents Ferrous Fumarate 350mg (115mg elemental iron)
Cyanocobalamin 5mcg
Folic acid 1mg
Ascorbic acid 75mg
Pyridoxine HCl 1.5mg
Zinc Sulfate 55mg

Indication/Uses • Iron-deficiency anemia

• Nutritional deficiency anemia
• Prophylaxis against iron-deficiency and megaloblastic anemia
during 2nd and 3rd trimester of pregnancy
Administration • May be taken with or without food
Side Effects • Gastro-intestinal disorders including gastro-intestinal discomfort,
anorexia, nausea, vomiting, constipation, diarrhoea
• Darkening of the stools may occur
• Rarely allergic reactions may occur
 Zincofer
Drug Interactions • Absorption inhibited by antacids, cholestyramine and trientine
• Co-trimoxazole, chloramphenicol, sulphasalazine, aminopterin,
methotrexate, pyrimethamine or sulphonamides may interfere with
folate metabolism
• Neomycin may alter the absorption of iron
• Iron reduces the absorption of penicillamine
• Iron compounds impair the bioavailability of fluoroquinolones,
levodopa, carbidopa, thyroxine and bisphosphonates
• Absorption of both iron and antibiotic may be reduced if Zincofer is
given with tetracycline
• Serum levels of anticonvulsant drugs may be reduced by administration
of folate
• Oral chloramphenicol delays plasma iron clearance, incorporation of
iron into red blood cells and interferes with erythropoiesis
• Administration of oral iron may increase blood pressure in patients
receiving methyldopa

Food • Eggs inhibit iron absorption

Interactions • Coffee and tea consumed decrease iron bioavailability
Suggestion of Administration
*May switch to separate hematinics if non-tolerable

Hb Level Suggestion of Vitamin Dose Recommendation

<10 T. Iberet Folic-500 1 tab. OD or BD (max)

10-12 C. Zincofer 1 cap. OD

 Separate Hematinics
Hematinics Function
T. Ferrous Fumarate 200mg To replenish iron store
T. Vitamin B Complex To help your body to utilize energy through
metabolism of carbohydrate, protein & fat
T. Ascorbic Acid 500mg To increase iron absorption
T. Folic Acid 5mg To help reduce risk of neural tube defects and
to help produce normal red blood cells &
prevent anemia
 Counseling Points
• Ferrous Fumarate should be taken with empty stomach
To enhance its absorption
However, iron supplements can cause stomach cramps,
nausea, and diarrhea in some people. May need to take iron
with a small amount of food to avoid this problem.
• Recommend to take iron tablets with orange juice
To enhance its absorption
• Common side effect of iron tablet:
Constipation: Recommend to take more fruits and vegetables
Black stools
• Interaction with antacids and diary products
Recommend to space time interval if taking antacid
Not to take milk or coffee while taking iron tablet
 Parenteral Iron Therapy
• Oral iron therapy is used as first-line to treat anemia in
pregnancy as it is cheap, effective and will correct anemia in
most pregnant women, especially if treatment is started early.
• However, up to 10% of patients taking oral iron therapy can
have significant compliance issues. About a third of women
also suffer from significant gastrointestinal upset and side
effects which make them intolerant of oral iron.

• Examples of parenteral iron formulations in PKDAG:

 Iron Dextran (Cosmofer®)

Iron dextran SHOULD NOT be administered concurrently with oral iron

preparation as the absorption of oral iron is reduced
 Calculation For IV Iron Dextran (Cosmofer®)
Total iron deficit [Body weight (kg) x [Target Hb- Actual Hb (g/L) x 0.24*] + mg
(mg) iron for iron stores

*Factor 0.24 = 0.0034 x 0.07 x 1000

(Iron content of Hb 0.34%, Blood volume=7% of body weight,
1000 is the coversion from g to mg)

Total volume of Total iron deficit (mg)/ 50 (mg/ml)

IV Dextran to be
administered 1vial iron dextran = 100mg = 2ml
(ml) Concentration iron dextran = 50mg/ml

Administration Normal dosing method: 100-200mg iron dextran (2-4ml)

schedule administered 2-3 times per week depending on haemoglobin
level

For rapid delivery of iron, iron dextran can be administered as

total dose infusion up to a total replacement dose
corresponding to 20mgiron/kg body weight.
PREVENTION OF ANEMIA
 REFERENCES
• PKDAG Pharmacy Bulletin Issue 1, 2017
• American Society of Hematology. (2020). Retrieved from:
https://www.hematology.org/education/patients/anemia/p
regnancy
• Talaulikar, V.S. (2020). Anemia In Pregnancy. Retrieved
from:
https://www.glowm.com/Critical_current_issue/page/25
• Johnson, T.C. (2018). Anemia In Pregnancy. Retrieved from:
https://www.webmd.com/baby/guide/anemia-in-
pregnancy#3
• Product Leaflet (Iberet-Folic, Zincofer, Cosmofer)