Anemia in

pregnanc
y
Tapiwa Maoni
Antonio Machado
Ackson Kawamba
Rudo Masendeke
Shaneela Somanje
Outline
1. Brief outline of the definition, manifestation and complications of the disease
2. Burden and trends of disease
1. Global
2. Malawi
3. Risk and protective factors for acquisition and progression of the disease.
4. Diagnostic methods for the disease
1. Feasibility of and challenges in implementing the available diagnostic methods in
Malawi.
5. Available disease prevention strategies and activities of the disease
1. Current strategies employed by the Malawi government to prevent the disease.
What are the goals of the Malawi government in implementing the strategies?
2. Feasibility of and challenges in implementing the other strategies in Malawi
6. Available disease treatment strategies and activities
1. Current strategies employed by the Malawi government to treat the disease. What
are the goals of the Malawi government in implementing the strategies?
2. Feasibility of and challenges in implementing the other strategies in Malawi
7. Ability to suggest public health interventions that are feasible and affordable reduce
the burden of disease in Malawi
8. Summary
Introduction
Anemia during pregnancy is a significant public
health concern, especially in developing
countries. It is defined as a hemoglobin
concentration of less than 11.0 g/dL at any
gestational age.
The World Health Organization (WHO) classifies
anemia in pregnancy as
●Mild- 10.0- 10.9 g/dL
●Moderate- 7.0-9.9 g/dL
●Severe - <7.0 g/dL
●Very severe - <4.0 g/dL
Introduction continued
Anemia can manifest asymptomatically or with signs and
symptoms such as exertional dyspnea, fatigue, headache,
dizziness, palpitations, conjunctival pallor, palmar pallor, yellowing
of the skin and eyes, paling of the stool, enlarged spleen,
koilonychia, and fainting.
Complications can be maternal or fetal. These include;
●severe anemia, cerebral malaria, pulmonary edema, infections,
necrosis of real tubules, preterm labor and PPH(maternal)
●preterm birth, neural tube defects, low birth weight, miscarriages,
intrauterine growth restriction (IUGR), intrauterine fetal death
(IUFD), and placental abruption(fetal)
Burden
Globally, anemia is estimated to affect 37% of pregnant
women, with the highest prevalence in the WHO regions of
Southeast Asia (48.7%) and Africa (46.3%).
In Malawi, the prevalence rates are reported between 38.8%
and 72% for all anemia (Hb < 11.0 g/dL) and 3.6% − 4% for
severe anemia (Hb<7.0 g/dL).
Risk Factors: Infectious
Diseases

Nutritional Anemia Socioeconomic

Deficiencies Factors

Reproductive
factors
 Nutritional • Iron Deficiency: The most common cause of anemia
Deficiencies: in pregnancy, often due to inadequate dietary intake
or increased demand during pregnancy.
• Folate and Vitamin B12 Deficiency: Contributes to
megaloblastic anemia, common where diets lack
sufficient fruits, vegetables, and animal products.

Infectious • Malaria: Highly prevalent in Malawi, it causes

hemolysis and contributes significantly to anemia.
Diseases: • HIV/AIDS: Associated with anemia due to chronic
disease and treatment side effects.
• Helminth Infections: Intestinal worms, particularly
hookworm, can cause chronic blood loss leading to
anemia
Reproductive • High Parity: Multiple pregnancies in quick
Factors: succession can deplete iron stores.
• Teenage Pregnancy: Increased risk due to higher
nutritional demands during adolescence.
• Short Inter-Pregnancy Interval: Insufficient time
to replenish iron stores between pregnancies.

Socioeconomic
Factors • Poverty: Limits access to nutrient-rich foods and
healthcare.
• Cultural Practices: Dietary restrictions during
pregnancy can contribute to nutritional
deficiencies.
Protective factors

Supplementation
Adequate Malaria Education
nutrition Prevention and
Health
Awareness
Diagnostic Methods for Anemia in Pregnancy
 Feasibility and Challenges in Implementing Diagnostic
Methods in Malawi

Feasibility: Challenges
1. Basic Hb 1. Infrastructure: Lack of
Measurement:Feasible in laboratories and diagnostic
most healthcare facilities, even equipment in rural areas.
in rural areas, using portable
devices like Hemocue. 2. Skilled Personnel: Shortage of
2. Peripheral Blood Smear: trained laboratory technicians,
especially in peripheral areas.
Feasible in district hospitals
and larger health centers with 3. Cost: High costs of certain
laboratory capacity. diagnostic tests like serum ferritin,
3. CBC and Serum Ferritin: limiting widespread use.
More feasible in urban or 4. Supply Chain Issues: Inconsistent
referral hospitals but availability of reagents and
challenging in rural and
resource-limited settings. equipment maintenance,
Available disease
treatment
strategies
MANAGEMENT OF ANAEMIA IN
PREGNANCY
●Treat the underlying cause
●Check FBC and treat according to the result

If Hb < 7 g/dL, especially if symptomatic, then blood

transfusion
●Transfuse rapidly if anaemia due to acute blood loss
● Transfuse slowly if chronic anaemia (Consider use of
diuretics as necessary to reduce risk of congestive
cardiac failure due to sudden circulatory overload)
● Treat with folate and FeFol 325 mg PO BD and recheck
Hb in 2-4 wks.
Management cont.…
● If MCV < 80, then send blood for iron studies (ferritin,
TIBC and % saturation) if available.
● If MCV 80-93, then send blood for peripheral smear
and consult haematologist as needed
● If MCV ≥ 94, then treat for folate or vitamin B12
deficiency
Management cont'd
●Treat malaria and schistosomiasis if indicated
●Treat with albendazole 400mg once on an empty
stomach.
●Treat with iron titrating up to reduce side effects
●Hemolytic anemia (coombs test, treat with
corticosteroids and stop drugs if drug induced)
Management conti….
● If Folate deficiency: folate 1-4 mg PO OD.
● Vitamin B12 deficiency, vitamin B12 1000 mcg
IM/week for 4 weeks, then 1,000 mcg IM monthly or
until deficiency is corrected
● If hemolytic anemia, then send blood for direct and
indirect Coombs tests.
● Treat with corticosteroids.
● Drug-induced (methyldopa, penicillin, cephalosporin)
is treated by stopping the offending medication
Available disease prevention
strategies
● Daily oral iron and folic acid supplementation is recommended
as part of the antenatal care.
● Preventive deworming using single-dose albendazole (400 mg)
or mebendazole (500 mg) is recommended as a public health
intervention for pregnant women.
● In malaria-endemic areas in Africa, intermittent preventive
treatment with sulfadoxine-pyrimethamine (IPTp-SP) is
recommended for all pregnant women
● PITC in high HIV prevalence areas with retesting recommended
in the third trimester
Strategies employed by the Malawi
Government
● Improving access to healthcare: Ensuring that pregnant women
have access to regular check-ups to identify and treat anemia
early on.
● Nutrition education: Educating women on healthy eating habits
and the importance of iron-rich foods can help prevent anemia as
part of ANC
● Iron and folic acid supplementation: Providing monthly
supplements to pregnant women to prevent anemia.
● HIV test and treat strategy
● Infection control using mass drug administration: Preventing and
treating infections such as malaria and hookworm
Goals for the strategies
● To reduce the the risk of maternal puerperal infections
● To reduce the risk of low-birth-weight neonates
● To reduce the risk of very preterm birth
● To improve overall maternal and newborn outcomes
Challenges faced
● Side effects of drugs including nausea, vomiting,
weakness and dizziness have been reported
● SP of poor quality
● SP resistance in some plasmodium falciparum
● Drug stock outs at some ANC facilities
● Some women still have less than the minimum
number of ANC visits
● Overall poor ANC uptake
● Socio-demographic factors of mother negatively
impact ANC
Public Health
Interventions
 In 2016, the World
Health Organization
introduced the new
“2016 WHO ANC
Model”

New model
recommended a
minimum of eight ANC
visits with healthcare
workers as research
shows improved
pregnancy outcomes
Iron and folic acid supplements
●Daily oral iron and folic
supplementation
●30mg to 60mg of elemental iron
● 0.4mg of folic acid is
recommended
Iron folate supplementation of pregnant
women Strengthen in Ntchisi District,
Malawi
●45% of pregnant women in Malawi anaemic, only 33% take iron
tablets for a minimum of 90 days
●Health facility has limited access to iron folate supplements
●Consumer demands low due to side effects, poor acceptability,
associated myths, forgetfulness, and frustration of taking
medication daily
Landmark Malawi trial boosts iron levels in
pregnant women
●World-first study exploring
new ways to fight anaemia in
developing countries
●Single infusion of ferric
carboxymaltose can
significantly reduce iron
deficiency in pregnant women,
compared with daily tablets
●Study showed significant
reduction of iron deficiency in
pregnant women, compared to
daily iron supplement currently
recommended by the WHO
Prevention of malaria during
pregnancy
●In areas of malaria
transmission, highly
effective preventive
interventions are required

1. Intermittent preventive
therapy
2. Insecticide-treated nets
Intermittent preventive therapy (IPT)

●Most promising preventive approach using

anti-malarial drugs in pregnancy

●WHO recommends in areas of high

transmission, IPT with preferably one-dose
anti-malarial drug be given

●Studies in Kenya and Malawi have shown a

beneficial impact on maternal and infant
health with the use of sulfadoxine-
pyrimethamine
Intermittent preventive therapy (IPT)

●Wide-scale IPT programming in Malawi has found

strong acceptance with the regimen distributed in
antenatal clinics

●Consistently achieved coverage levels >80% for the

first dose

●Dosing schedule of at least two doses with SP being

given at the first and second ANC visit after quickening
Insecticide treated nets

●Reduce the human-vector contact

●Studies in Kenya indicated that

women who were protected by
insecticide-treated bed nets every
night in the first four pregnancies
delivered approximately 25%
fewer babies who were either
small for gestational age or born
prematurely
Preventive anthelmintic treatment
●Preventive chemotherapy (deworming), using single
dose albendazole (400mg) or mebendazole (500mg)

●Recommended as a health intervention in pregnant

women after the first trimester living in area where both
1. Baseline prevalence of hookworm and/or T. trichiura
infection is 20% or more
2. Anaemia is a severe public health problem, with
prevalence of 40% or higher
Malaria and Helminth Co-Infection
Malaria and Helminth Co-Infection
during Pregnancy in Sub-Saharan
Africa : A Systematic Review and
Meta-Analysis
●Uganda had a burden of helminthic infection in
pregnancy (70%), which was higher than Cameron and
Malawi combined (22%)

●Hookworm (48%), Ascaris lumbricoides (37%), and

Trichuris trichiura (15%), respectively, were the pooled
estimates of the most prevalent helminths associated
with unintended pregnancy complications in SsA
Summary
●Anaemia in pregnancy is a major public health problem
in developing countries
●In sub-Saharan Africa, this is generally as a result of
nutritional deficiencies, particularly iron
●Malawi struggling to achieve WHO recommendations to
combat anaemia in pregnancy
●Public health interventions should follow a multisectoral
approach in dealing with this burden
 References
[1] https://www.webmd.com/baby/anemia-in-pregnancy

[2] https://my.clevelandclinic.org/health/diseases/23112-anemia-during-
pregnancy

[3] https://www.hematology.org/education/patients/anemia/pregnancy

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5954959/

[5]https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-
depth/anemia-during-pregnancy/art-20114455