Anaemia in Pregnancy

Anaemia in Pregnancy
3 April 2014
Learning Objectives
• Recognise physiological haematological changes in
pregnancy
• Identify the causes and symptoms of anaemia in

pregnancy
• Recognise the potential complications of untreated

anaemia in pregnancy
• Familiarise with the treatment of iron deficiency in

pregnancy
Case Study
• 26yo, 3rd pregnancy, 28 weeks
• Tiredness and fatigue; occasional headaches

and dizziness
• Denies any similar symptoms during previous

pregnancies
Case Study
• PMHx: nil significant
• Diet: normal
• Meds: folic acid

Case Study
• Examination
– Pallor
– BP = 120/70mmHg
– HR = 110bpm
– Soft systolic murmur
– The rest of the examination - unremarkable
Case Study
• Investigations
– FBC:
• Hb = 94g/L
• Ht = 0.29
• MCV = 70fL
• WCC = 11.2, normal differential
• Plt = 430 x 10^9/L
• Microcytic, hypochromic RBC
– Iron studies
• Iron = 5µmol/L
• TIBC = 99µmol/L
• Trans sat = 10%
• Ferritin = 10nmol/L
– B12/folate - N
Case Study
• ? treatment
Physiological Changes in
Pregnancy
• Hypercoagulable
– Estrogen & Vascular stasis
– Increased risk for thromboembolic disease
• Increase in fibrinogen, all coagulation factors except II, V, XII
• Fall in protein S and sensitivity to APC
• Fall in platelets and factor XI and XIII
• Plasma volume increases 50-100% (greatest increase
between 6-24weeks of gestation)
– Relative anemia (“physiologic”)
• RBC increases 25-40%

• Increase in WBC
Physiological Changes Pregnancy
Blood volume ↑
Plasma volume ↑
RBC volume ↑
Hct ↓
Hb ↓
Reference Range Haematological
Parameters
The Institute of Laboratory Medicine (Sydpath). Pathology Results in Normal Pregnancy. World
Wide Web, 2005
Anaemia of Pregnancy - Definition
• WHO: Hb < 110 g/L in the 1st and 3rd trimester
or <105g/L in the second trimester
• Affects
– 52% pregnant women from undeveloped or
developing countries
– 20% pregnant women from industrialized nations
• Increased risk with progression of pregnancy

Lee A I, Anaemia of pregnancy, Hematol Oncol Clin N Am 25, 2011
Classification
• Physiological anaemia
• Acquired anaemia
 Nutrition: Iron deficiency, folate deficiency, vit.B12
deficiency anaemia
 Infections: Malaria, hookworm infestation
 Haemorrhagic: Acute / chronic blood loss
 Bone marrow suppression: Aplastic anaemia, drugs
 Renal disease
• Genetic: Haemoglobinopathies
 Sickle cell disease
 Thalassemia
Classification based on
morphology
• Microcytic : Iron deficiency anaemia,
thalassaemia
• Normocytic : haemolysis, acute blood loss,

bone marrow disease.
• Macrocytic : folate deficiency, vit. B12

deficiency.
Iron Requirements
• Average: approximately 4.4 mg/day in

pregnancy
• 0.8mg/day in the first trimester
• 7.5 mg/day in the second trimester – due to

fetal growth
Risks Factors for Iron Deficiency in
Pregnancy
• Poor appetite or poor nutrition
• Nausea, vomiting - hyperemesis gravidarum
• Second pregnancy in less than 2 years
• Chronic illness
• Preexisting iron deficiency - untreated

B12/folate
• B12 and folate levels fall during pregnancy, due to a
shift from the serum to tissue stores
• Folic acid requirement for the nonpregnant woman is

50 to 100 μg per day; in pregnancy: 150 μg (red cell
mass in the mother increases and increased fetal
growth - cell proliferation)
• True vitamin B12 deficiency in pregnancy is rare
• More often folate deficiency

Importance
• Severe anaemia can increase morbidity

and mortality in mother as well as baby
Complications - Mother
- Pre eclampsia (due to malnutrition or

hypoproteinemia)
- Reduced resistance to infections
- Cardiac failure (at 30-32wks of pregnancy)
- Preterm labour
Complications - Baby
- IUGR
- Prematurity
- Increased risk of anaemia/nutritional disorder
in early infancy
- Still births
- Congenital malformations (folate deficiency)
- ↑ in neonatal deaths/perinatal mortality by 2-
3 fold when Hb < 80g/L and 8 – 10 fold when
Hb< 50g/L
How to Investigate a Case of Anaemia
History
• Asymptomatic
• Fatigue, dyspnoea on exertion
• Nausea, loss of appetite, constipation,
indigestion
• H/o bleeding (DUB, malena, haematuria)
• Palpitation
• Medication: salicylates, anticonvulsants,
chloramphenicol & cytotoxic drugs
• Alcohol
• H/o previous bowel surgery
Examination
• Pallor
• Nail changes
• Cheilosis, Glossitis, Stomatitis
• Oedema
• Hyperdynamic circulation (short & soft systolic
murmur)
• Fine crepitations
Investigations
• FBC
• Peripheral blood smear
• Reticulocyte count
• ELFT’s
• B12/folate and iron studies
• Haemolytic screen
• Hb electrophoresis
• Stool Examination
• Bone marrow
Management
• Depending on the cause
– Iron supplementation
– B12/folate (usually folate, rarely B12)
– Steroids if haemolysis
– Transfusions
–…
Iron Deficiency - Management
• Sources of dietary iron: meat, poultry and fish (2-3
times more absorbable than plant-based iron foods
and iron-fortified foods)
• Vitamin C enhance absorption; orange juice
• Vegetarians should be encouraged to eat foods high

in iron, such as, tofu, beans, lentils, spinach, whole
wheat breads, peas, dried apricots, prunes and
raisins
Level of Treatment Duration of Follow-up of
Anaemia Treatment treatment
Hb - N Daily po 65mg e.g. FGF Until N levels FBC and ferritin level at
Ferritin < 30 Consider 100mg in the postpartum 28 weeks and 36
3rd trimester weeks
Hb 95 -110 g/L 100-200mg daily e.g. Throughout Check the FBC within 2
Ferritin < 15 Fefol, FGF or pregnancy; check FBC - 4 weeks of initiating
Ferrogradumet and ferritin 6 weeks treatment, at 28 weeks
postpartum gestation, and
at 36 weeks gestation.
Hb < 95 g/L Po 200mg elemental Review for ongoing Individualised

iron daily; consider iron management management
infusion according to the
gestation and the
clinical situation
Anaemia in pregnancy, clinical Guidelines, King Edward Memorial Hospital, Perth WA

Level of Treatment Duration of Follow-up of
Anaemia Treatment treatment
Hb <85 If acute blood loss, Individualised

immediate cardiac management
compromise -
transfusion
Po or iron infusion –
depending on the
clinical scenario
Postpartum Transfusion Individualised
Hb < 70 g/L management

Case Study
• Treatment
– Iron infusion – Ferrinject 1000mcg over 30min
– Continue folic acid
– Recheck iron studies in 4-6 weeks; if still low iron
stores – repeat iron infusion
B12 Deficiency - Management
• Women on a vegetarian diet – B12 levels checked
early in pregnancy and B12 supplements
• If B12 deficiency - Cobalamin 1000mcg daily for 1

week followed by cobalamin 1000mcg of monthly
injections
• In strict vegans - recommended 3 monthly injections

of Cobalamin 1000 mcg

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• Identify the causes and symptoms of anaemia in

• Recognise the potential complications of untreated

• Familiarise with the treatment of iron deficiency in

• 26yo, 3rd pregnancy, 28 weeks

• Tiredness and fatigue; occasional headaches

• Denies any similar symptoms during previous

• PMHx: nil significant

• Meds: folic acid

• RBC increases 25-40%

• Increased risk with progression of pregnancy

• Normocytic : haemolysis, acute blood loss,

• Macrocytic : folate deficiency, vit. B12

• Average: approximately 4.4 mg/day in

• 0.8mg/day in the first trimester

• 7.5 mg/day in the second trimester – due to

• Nausea, vomiting - hyperemesis gravidarum

• Second pregnancy in less than 2 years

• Preexisting iron deficiency - untreated

• Folic acid requirement for the nonpregnant woman is

• True vitamin B12 deficiency in pregnancy is rare

• More often folate deficiency

• Severe anaemia can increase morbidity

- Pre eclampsia (due to malnutrition or

- Reduced resistance to infections

- Cardiac failure (at 30-32wks of pregnancy)

• Vitamin C enhance absorption; orange juice

• Vegetarians should be encouraged to eat foods high

Hb < 95 g/L Po 200mg elemental Review for ongoing Individualised

Anaemia in pregnancy, clinical Guidelines, King Edward Memorial Hospital, Perth WA

Hb <85 If acute blood loss, Individualised

Anaemia in pregnancy, clinical Guidelines, King Edward Memorial Hospital, Perth WA

• If B12 deficiency - Cobalamin 1000mcg daily for 1

• In strict vegans - recommended 3 monthly injections

Anaemia in pregnancy, clinical Guidelines, King Edward Memorial Hospital, Perth WA

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