Anemia in Pregnancy

Section objectives:
1. Over view of Anemia
2. Describe physiologic changes during pregnancy
3. List the causes and risk factor of anemia
4. Classify anemia
5. Describe the complication of anemia
6. Explain the management and prevention of anemia
 Introduction
• Commonest medical disorder in pregnancy
• Pregnant mothers are at high risk b/s of increase
demand.
• Associated with preterm labor &LBW( 3x)
• Anemia in pregnancy is highly prevalent in less-
developed countries (40-75%) compared to 18-20% in
developed countries. (source RCOG)
 Epidemiology
 Iron deficiency anemia is common affecting all
population.
 Iron deficiency is the most common form of malnutrition
in the world, affecting more than billion people globally
i.e. 1/3 of the world’s population. (source WHO)
 WHO estimate that anemia contribute approximately 20
% maternal deaths worldwide(1995 report)
 Anemia in pregnancy
Anemia in pregnancy defined as when Hgb in :
• 1st trimester : < 11g/dl
• 2nd trimester :<10.5g/dl
• 3rd trimester :<11g/dl
 Physiologic changes in pregnancy
• During pregnancy there is an increase in total

by blood volume by 50 %.
• Red cell volume (30%) but there is disproportion in rise
of plasma volume and red cell resulting in
physiological hemodilution.
• This result in fall in hemoglobin percent by 2gm/ dl in
later half of pregnancy.

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 Anemia in pregnancy…Cont’d

• Iron requirements increase rapidly in the 2nd (4-

5mg/day)and 3rd trimester(>6mg/day) due to fetal
growth
• However iron absorption in the gut is not sufficient to
meet this increased demand.
• Thus iron balance depends on maternal iron stores
during this period
• Pregnancy anemia mostly due to deficiency of iron
and folic acid
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 Anemia in pregnancy …Cont’d
Iron requirement in pregnancy
Required for mg
• Red cell expansion 450 – 500
• Fetus and placenta 400
• Blood loss at delivery 100 – 200
• External iron loss 300
• Total requirement 1280 – 1400
• Iron saved due to amenorrhea 300
• Net requirement 950 – 1100

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 Causes
• The causes of anemia can be classified in three groups.
1. Blood loss
• acute – APH, PPH
• Chronic-hookworm infestation, PUD, menorrhagia
2. Low RBC production
• Aplastic anemia
• Medication – zidovudine, cancer chemotherapy
3. High RBC destruction
• Acquired – immune (AIHA), non immune (paroxysmal
nocturnal hemoglobinuria)
• Mechanical damage- malaria
 Risk factors
• Pregnancy • Delivery by CS 
• Postpartum • Placenta previa
• Multiple pregnancy • Assisted vaginal
• Short period between delivery
pregnancies • Pre-pregnancy BMI
• Multiparity Other risk factors:
• Iron deficiency during • Malaria
pregnancy • HIV/ AIDS
• low socio-economic
status
 Classification of anemia
Anemia in pregnancy can be due to the following
1. Nutritional deficiency (iron ,folic acid deficiency)
2. Blood loss (hemorrhagic)-
- bleeding during pregnancy (APH)
- hook warm infestation
3. Increased break down of RBC (hemolytic)
- malaria , sickle cell disease and thalassemia
4. Decrease production of RBC
- A plastic anemia

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 Iron deficiency anemia
Cause
1. Poor absorption
• increase PH of gastric juice
• lack of vitamin C
2. Increased utilization
• Demand of pregnancy more in multiple pregnancy
3. Excessive iron loss (repeated px, menorrhagia prior to
px ,hook warm infection and chronic malaria)

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 Folic acid deficiency anemia

Folic acid is an essential cofactor in

• nucleic acid synthesis in all cells

• for the increase in cell growth of both the mother and

fetus

• but there is physiological decrease in serum folate

level in pregnancy.  
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 Cause

• reduced dietary in take

• reduced absorption
• interference with utilization drug such as
- anticonvulsant
- sulphonamide and alcohol
• excessive demand and loss

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 C/F
- pallor
- anorexia
-nausea
- mental depression
-vomiting
- diarrhea

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 Complications

Fetal Maternal

• spontaneous abortion • CHF

• puerperal sepsis
• IUGR
• pulmonary edema
• preterm delivery
• delayed wound healing

• increase risk of infection

• Still birth
• Neonatal – anemia
• low birth weight

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 How we can evaluate anemia?
I)Sign and Symptom of anemia
a) Symptom:
*Weakness/dizziness
*Fatigue/ easily irritability
*Restless leg syndrome
*Labored breathing /palpitation
*Pica (abnormal craving )
*Difficulty of swallowing

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 …Cont’d
b) Signs :
*Increase PR
*Pallor (skin /conjunctiva)
*Glositis(inflamed tongue)
*Spooning of nails/blue sclera

II) Investigations:
a) Hb/ Hct determination (race, trimester of
pregnancy)
 ……Cont’d

b) Peripheral smear
Micro cytic-hypo chromic erythrocytes in the
peripheral smear
o Low serum iron (less than 60mg/dl)

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 Treatment of IDA in pregnancy
A)Specific treatment :
i) oral iron therapy : mild Hgb 8.7-10g/dl
* one iron tablet/three time/day recommended
* iron preparations with elemental iron.
#ferrous gluconate,325mg (37-39mg)
#ferrous sulfate, 325mg (60-65mg)
# ferrous fumerate,325mg( 107mg)
* one tablet of ferrous sulfate daily provide
prophylaxis, it contains 60mg of elemental iron (10%
of it will be absorbed.
 Cont’d…
* response of treatment is increase in Hb 1g/4wks or Hct
by 3%/ 4 wks treatment if response is unsatisfactory
look for other causes of anemia.
ii) Parenteral therapy: (for moderate Hbg 6.6-8.6g/dl)
# indicated:
*non-compliant patient
* unable to take po medication( PUD)
*Severe anemia (requiring blood transfusion)
* build iron store before delivery(avoiding transfusion)
#iron dextran, gluconate & sucrose
*iron dextran is associated with anaphylactic rxn(0.6-
2.3%) not commonly recommended practice
 Conti.…
* intravenous therapy in pregnancy primarily deals with
iron sucrose.
*patient finishing course of treatment received a mean of
1000mg elemental iron.
* Hb increases an average of 1.6g/dl from the beginning
of to the end rose another o.8g/dl.
*ferritin level increase from 2.9ng/ml to 122.8ng/ml by
the end of therapy ( decrease only to mean 109.4ng/ml 2
weeks later.
Total iron deficit= body wt(kg)x (target Hb- initial Hb)
x0.24 + 500mg(10mg/kg)
 Cont’d…
iii) blood transfusion : rarely indicated,
* severe anemia (<5g/dl),preparing for delivery or
surgical intervention.
*poor response to available iron therapy
* congestive heart failure secondary to severe anemia
*acute blood loss with hemodynamic instability
* anemia's following sickle cell/beta-thallasmeia
* one unit blood raise Hb/Hct (0.8-1g/ 3%/unit of
blood respectively.
* packed RBC is preferred to whole blood if there is
no associated hypovolumia.
 Cont’d…
B) ante partum/postpartum treatment :
i) ante partum management
* high risk pregnancy/frequent visit
* iron therapy based on patient condition
* strong nutritional advice ( iron rich)
* prepare and plan for delivery
ii) intra-partum management:
* position / oxygen supplement
* control pain/ reduce anxiety
 Cont’d…
* avoid fluid overload ( risk of CHF)
* shorten second stage of labor
*avoid excessive blood loss/ prevent PPH
* first 72 hrs after deliver risk CHF is very high due to
auto transfusion from closure of placenta bed, follow
up controlling IV-fluid is very important.
* determine Hb/Hct level after delivery and treat her
accordingly
 Other type anemia
Folate deficiency:( <5ng/ml)
*water soluble vitamin, found in green
vegitable,peanuts and liver.
* during pregnancy folate deficiency is common cause
of megaloblatic anemia as vit B12 is rare.
 Cont’d...
• Women with multiple gestation, frequent conception
receiving anticonvulsants, requires 1mg folic acid
supplement daily.
• If women folate deficient reticulocyte count will be
depressed, after three days treatment reticulocytosis
usually occur.
• Hct level may rise as much as 1%/ day after one week of
folate replacement.
• If patient do not develop reticuloctosis after one week
folate replacement appropriate test for IDA should
performed.
Prevention of anemia
– improve diet and dietary habit
– prevent and treat hook warm
– child spacing by f/p
– iron supplementation to all pregnant women
– folic acid supplementation
– iron fortification of staple diet
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• THANK YOU