ANEMIA

IN
PREGNANCY

PREPARED BY:
Aashma Bidari
M.Sc. Nursing 1st year
4th Batch, KUSMS
 Objectives

General Objective: At the end of teaching

learning session, students will be able to
explain about anemia in pregnancy
 Specific objectives

At the end of teaching learning session, students will be

able to:
- define anemia
- define anemia in pregnancy
- state grading of anemia in pregnancy
- state the classification of anemia
- explain the physiological anemia of pregnancy
- explain erythropoiesis
- enlist iron and folic acid requirement in pregnancy
- state folate deficiency anemia
- state vitamin B-12 deficiency anemia
- define iron deficiency anemia
- elaborate the causes of anemia
- enlist the sign and symptoms of anemia
- state the effects of anemia on mother and baby
- explain the prophylactic management of anemia
in pregnancy
- describe the curative management of anemia in
pregnancy
- discuss the management of anemia in pregnancy
- state aplastic anemia
- state sickle cell anemia
- state thalessemia
 INTRODUCTION

• Commonest medical disorder in pregnancy.

• It is responsible for significant high maternal and
fetal mortality rate worldwide.
• In 2011, World Health Organization (WHO)
reported that the global prevalence of anemia for
all women of reproductive age was 29.4%, with
38.2% in pregnant women and 29.0% in non-
pregnant women
 DEFINITION
• According to WHO Anemia is a
condition in which the number of
red blood cells or the haemoglobin
concentration within them is lower
than normal.
• Haemoglobin concentration
needed to meet physiologic needs
varies by age, sex, elevation of
residence, smoking habits and
pregnancy status.
 Anemia in pregnancy

• Anemia in pregnancy is defined as

haemoglobin (Hb) concentration is less
than 11 g/dl.
CLASSIFICATION
 CLASSIFICATION OF ANEMIA

1.Physiological Anemia
2.Pathological Anemia
✔ Deficiency anemia
• Iron deficiency
• Folic acid deficiency
• Vitamin B12 deficiency
✔ Hemorrhagic
• Acute—following bleeding in early months of pregnancy or
APH
• Chronic—hookworm infestation, bleeding piles, etc.
✔Hereditary
• Thalassemias, Sickel cell
anemia, other
hemoglobinopathies
✔Bone marrow insufficiency
• hypoplasia or aplasia due to
radiation
• Drugs or severe infection.
✔Anemia of infection (malaria,
tuberculosis, kala-azar)
✔Chronic disease (renal or
neoplasm)
✔Hematologic malignancy
• leukemias, lymphomas
✔Hemolytic
• SLE, HELLP syndrome, autoimmune
hemolysis
 Physiological anemia of
pregnancy

• During pregnancy, maternal plasma volume gradually

expands by 40- 50% (maximum around 32 weeks). The
total increase in red blood cells is 20%.
• There is relatively fall in the level of hemoglobin and
hematocrit during pregnancy.
• In addition there is marked demand of extra iron
during pregnancy especially in the second half.
• Thus, there always remains a physiological iron
deficiency state during pregnancy.
 Erythropoiesis
• In adults, erythropoiesis is confined to the
bone marrow.
• Red cells are formed through stages of
pronormoblasts-normoblasts-
reticulocytes- to nature nonnucleated
erythrocytes.
• The average life- span of red cells is about
120 days after which the RBC’s degenerate
and the haemoglobin are broken into
hemosiderin and bile pigment.
• For proper erythropoiesis, adequate
nutrients are needed. These are minerals,
vitamins, proteins and hormones.
• Inadequate reserve or increased demand or
deficient supply of any of the constituents
interferes with the normal erythropoiesis.
 Iron requirements in
pregnancy
During pregnancy approximately 1,500
mg iron is needed for:-
- Increase in maternal
haemoglobin (400-500mg)
-
The fetus and placenta (300-400 mg)
-
Replacemet of daily loss through urine,
stool and skin (250mg)
-
Replacement of blood lost at
delivery (200mg)
-
Lactation (1mg/day)
Iron and folic acid requirement in
pregnancy

Elemental iron- 30 mg to 60 mg
Folic acid- 400 µg (0.4 mg)

It is recommended for pregnant

women to prevent maternal
anemia, puerperal sepsis, low
birth weight, and preterm birth of
babies.
 Folate-deficiency anemia

• Folate is the vitamin found naturally in certain

foods like green leafy vegetables.
• The body needs folate to produce new cells,
including healthy red blood cells.
• During pregnancy, women need extra folate
which is not enough from their diet.
• Thus, body can't make enough normal red blood
cells.
• Man made supplements of folate are needed
which are called folic acid.

• Folate deficiency can directly contribute to certain

types of birth defects, such as neural tube
abnormalities (spina bifida) and low birth weight.
 Vitamin B12 deficiency

• The body needs vitamin B12 to form healthy red

blood cells. Lack of vitamin B12 can cause
inadequate production of healthy red blood cells. 

• Women who don't eat non-veg diet have a greater

risk of developing vitamin B12 deficiency, which may
contribute to birth defects, such as neural tube
abnormalities, and could lead to preterm labor.
 IRON DEFICIENCY ANEMIA

• It occurs when the body doesn't have enough iron to

produce adequate amounts of hemoglobin.

• In iron-deficiency anemia, the blood cannot carry

enough oxygen to tissues throughout the body.

• Iron deficiency is the most common cause of anemia

in pregnancy.
• About 95% of pregnant women with anemia have
iron deficiency type.
• A pregnant woman is said to be anemic if her
haemoglobin is less than 10 gm/dl.
 CAUSES
Before pregnancy:
• Faulty dietetic habit
• Faulty absorption mechanism
• Iron loss
- Repeated pregnancies
- Excessive blood loss during
menstruation 
- Hookworm infestation
- Chronic malaria, chronic blood loss
During pregnancy
• Increased demands of iron
• Diminished intake of iron
• Diminished absorption
• Disturbed metabolism
• Pre-pregnant health status
• Excess demand
 Symptoms

• Fatigue or weakness
• Anorexia and indigestion
• Palpitation caused by ectopic beats, dyspnea,
giddiness and swelling of the legs.
On examination:
• Evidences of glossitis and stomatitis.
• Edema of the legs
• Soft systolic murmur
• Crepitations may be heard
 Effects of anemia on the
mother

During pregnancy
• Preeclampsia may be related to
malnutrition and hypoproteinemia. 
• Intercurrent infection
• Heart failure at 30–32 weeks of
pregnancy. 
• Preterm labor
During labor:
• Uterine inertia
• Postpartum hemorrhage 
• Cardiac failure
• Shock
Puerperium
• Puerperal sepsis
• Subinvolution
• Poor lactation
• Puerperal venous thrombosis 
• Pulmonary embolism.
 Effects to fetus/ baby

• Intrauterine hypoxia and 

growth retardation
• Prematurity
• LBW
• Anemia a few months after 
birth due to poor stores
• Increased risk of perinatal 
morbidity and mortality
 Management

Prophylactic/ prevention
• Avoidance of frequent child-births
• Supplementary iron therapy: 200 mg of ferrous
sulfate (containing 60 mg of elemental iron) along
with 1 mg folic acid
• Provide albendazole: Single dose 0f albendazole
400 mg stat should be administered to prevent
from hookworm infestation.
• Dietary prescription 
• Hygiene and sanitation: Improvement of
sanitation and personal hygiene with frequent
hand washing.
• Adequate treatment to eradicate hookworm
infestation, dysentery, malaria, bleeding piles,
and urinary tract infection.
• Early detection of falling hemoglobin level. Hb
level should be estimated at the first antenatal
visit, at the 30th week and finally at 36th week.
 Curative/ Treatment

Mild anemia (Hospitalization):

• Ideally hemoglobin level 9
gm/100 mL or less should be
admitted.
• But due to high prevalence of
anemia and inadequate
hospital beds, hemoglobin
level of 7.5 gm/dL should be
hospitalized.
Identity the cause of the anemia
General treatment:  
• Diet: A realistic balanced diet rich in proteins,
iron and vitamins. 
• To improve the appetite and digestion,
preparation containing acid pepsin may be given
thrice daily after meals.
• Frequent follow up visits with blood test.
• Effective therapy to cure the disease contributing
to the cause of anemia.
 Specific therapy

IRON THERAPY:
• Fersolate tablet contains 325 mg ferrous sulfate
which contains 60 mg of elemental iron.
• 1 tablet to be thrice daily 30 minutes before
meals.
• Maintenance dose: 1 tablet daily continue for at
least 100 days following delivery.
 Moderate anemia

General treatment same as above

• Iron therapy: Initial dose: 1 tablet to be thrice
daily 30 minutes before meals.
• large dose (max. 6 tablets a day), stepped up
gradually in 3–4 days. Continue till hb becomes
normal.
• Maintenance dose: 1 tablet daily continue for at
least 100 days following delivery.
 Severe anemia

• General treatment: same

• Iron therapy: Maximum 6 tablets a day can
be administered, stepped up gradually in 3–4
days. Continue till hb becomes normal.
• Parenteral therapy is given if there is
contraindications of oral therapy. Cases seen
for the first time during the last 8–10 weeks
with severe anemia.
 Intravenous route:
• Sodium ferric gluconate 12.5 mg/dose one dose/day,
usually 8 doses needed (12.5 mg elemental iron/mL). 
• Iron (ferrous) Sucrose: (20 mg elemental iron/mL) 100
mg/dose, usually one dose daily for 10 days.
• Formula:  0.3 × W (100–Hb%) mg of elemental iron.
• Where, W = patient’s weight in pounds. Hb% = observed
hemoglobin concentration in percentage. Additional 50%
is to be added for partial replenishment of the body store
iron.
Intramuscular therapy:
• Iron sucrose (20 mg/ml)      
• Iron-dextran (Inferon) (50
mg/ml)  
• Sodium ferric gluconate
complex 12.5 mg elemental
iron/mL
Blood transfusion:
Folate deficiency
• Seen in 5% cases of anemia
in pregnancy.
• Associated with hemolytic
anemia, hemoglobinopathies
poor nutrition.
• A dose of 5 mg oral folic acid
daily is recommended for
correction of anemia. 
In cases of vitamin B12 deficiency, prophylactic
therapy:
• 400 µg of folic acid daily.
• Additional amount (4 mg) given where the demand is
high. Such as: multiple pregnancy, patient having
anticonvulsant therapy, hemoglobinopathies
• Women, who have infants with neural tube defects,
should be given 4 mg of folic acid daily beginning 1
month before conception to about 12 weeks of
pregnancy. 
Curative:
• Specific therapy includes—daily administration of
folic acid 4 mg orally which should be continued
for at least 4 weeks following delivery.
• Supplementation of 1 mg of folic acid daily along
with iron and nutritious diet can improve
pregnancy induced megaloblastic anemia by 7–10
days.
 Management during
labour
First stage:
• The patient should be in bed and
should lie in a position comfortable to
her.
• An arrangement for oxygen inhalation
is to be kept ready to increase the
oxygenation of the maternal blood and
thus diminish the risk of fetal hypoxia.
• Strict asepsis is to be maintained to
minimize puerperal infection. 
Second stage: 
• Asepsis is maintained. 
• Prophylactic low forceps or
vacuum delivery may be done
to shorten the duration of
second stage. 
• Intravenous methergine 0.2 mg
should be given soon following
the delivery of the baby. 
Third stage: 
• Significant amount of blood
loss should be replenished by
fresh packed cell transfusion. 
• The danger of postpartum
overloading of the heart
should be avoided. 
 Puerperium

• Prophylactic antibiotics. 
• Predelivery therapy should be
continued till the patient restores her
normal clinical and hematological
states. 
• Iron therapy should be continued for
at least 3 months following delivery.
• Warn patient for danger of recurrence
in subsequent pregnancies.
 APLASTIC ANEMIA

• It is rarely seen in pregnancy.

• There is marked decrease in the marrow stem cells.
• Exact cause is unknown.
• It may be immunologically mediated or may be an
autosomal recessive inheritance.
• In about 30% of cases, anemia improves once
pregnancy is terminated.
• The significant complications in pregnancy are
hemorrhage and infection.
 SICKLE CELL ANEMIA

• Sickle cell anemia is a disease in

which body produces abnormally
shaped red blood cells.
• Cells are shaped like a crescent or
sickle.
• The cells also get stuck in blood
vessels, blocking blood flow. 
• This can cause pain and organ
damage.
 THALESEMIA SYNDROMES

• Thalesemia syndrome are genetic

disorders of the blood.
• The basic defect is reduced rate of 
haemoglobin chain synthesis.
• This leads to  ineffective
erythropoisis and increased 
hemolysis. The syndrome are of 
two types:
• The alpha and beta thalesemia
depending on  the globin chain
synthesis affected.
 Summary

• Anemia in pregnancy is the most

commonly occurring disorder during
pregnancy, Iron deficiency anemia is
the commonest. Every women who
are pregnant must screen for anemia
and must take treatment as soon as
possible along with foods rich in iron.
Timely prevention and treatment of
anemia helps to prevent complication
to mother and baby.
 Assignment

• What do you mean by iron deficiency

pregnancy?
• How iron deficiency anemia can be
prevented and treated
 REFERENCES
• Dutta DC. Textbook of obstetrics. 9th edition. New Delhi,
India: Jaypee brothers’ medical publishers; 2018. 245 to
256 p.
• Myles, “textbook of midwies”, 6th edition, Elvester (Ltd),
2014. 273-275 p.
• Tuitui R. Manual of midwifery I. 6th edition. Vidyarthi
pustak bhandar; 2009. 298 to 313 p.
• WHO. The global prevalence of anaemia in 2011.
Geneva, Switzerland: WHO; 2015. Available from:
https://
apps.who.int/iris/bitstream/handle/10665/177094/978
9241564960_eng.pdf