2. OBJECTIVES
At the end of this session should be able to:
1. Define what is anaemia in pregnancy
2. Describe why women are at risk of anaemia
during pregnancy.
3. Outline various ways of classifying anaemia.
4. Outline maternal and fetal complications of
anaemia in pregnancy.
5. Describe the management of anaemia during
labour.
6. Describe strategies for prevention of anaemia in
pregnancy.
3. DEFINITION OF ANAEMIA
• According to WHO Anaemia in pregnancy is
any Hb level <11g/dl ( or hematocrit <33%)
4. PREDIPOSING FACTORS FOR ANAEMIA IN
PREGNANCY
1. Physiological changes in pregnancy
– Increase in maternal blood volume
– Iron demands increases for the growing fetus and
placenta
2. Rapid growth during adolescence leading to increase needs
for iron
3. Delivery at short interval (less than 3 years)
4. Chronic infection including TB,HIV/AIDS
5. Regular menstrual blood loss
6. Other factors:
– Poor diet of low bioavailability(iron and folate)
– Frequent parasitic infections(Hookworms and
5. CLASSIFICATION OF
ANAEMIA
Severity Classification
1. Mild anaemia: Hb 9 g/dl-10.9 g/dl
2. Moderate anaemia:hb 7.1 g/dl-8.9 g/dl
3. Severe anaemia: 5 g/dl-7.0 g/dl
4. Very severe anaemia: hb less than 5 g/dl
NB in pregnant women Hb < 8.5 is severe
anaemia
7. GENERAL FEATURES OF
SEVERE ANAEMIA
I. SYMPTOMS
• Tiredness/general body weakness
• Shortness of breaths, exertional dyspneoa
• Headache,
• Dizziness,
• Palpitations
• Paroxysmal nocturnal dyspneoa
• Oedema
8. General feature cont….
II. SIGNS
• Pallor
• Signs of heart failure
– Tachycardia (HR > 100/min),
– Dyspneoa
– Elevated jugular venous pressure,
– Tachypneoa,
– Basal crepitations,
– Enlarged and tender liver
9. INVESTIGATIONS
1. Hb levels
2. Stool analysis: for worm ova, blood cells
3. Blood slide: Malarial parasites
4. Urinalysis – Rbc in urine
5. Sickling test and hb electrophoresis
11. Management of anaemia during
pregnancy
Management of mild/moderate anaemia (Hb 8.5 up to 11 g/dl)
in pregnancy
• Treat the cause if determined
Give the following medicines
• Full course of treatment of malaria if patient is positive for
malaria
• Combined ferrous sulphate 200mg+ folic acid 0.25 mg twice
daily for three months
• Anthelminthics e.g. mebendazole from second trimester
• Hb measurement is recommended every 2 weeks until Hb
reached 11
• For non responding patient should consider other
investigation i.e. bone marrow aspiration
12. Management cont…
For severe anaemia ( <Hb 8.5 g/dl) in pregnancy
• It depend on gestation age of pregnancy
• Before 36 weeks GA and if the patient not in
cardiac failure the treatment should be as for
moderate anaemia ( but if Hb 8.5-.7 g/dl)
13. Management cont..
Anaemia in failure and anaemia after 36 weeks
GA with or without failure ( Hb <8.5 g/dl)
• Treat the course if determined
• Give blood transfusion
• Continue with combined iron and folic acid up
to 3 months after delivery
• Follow up the patient every 2weeks until Hb
11 g/dl.
14. Management cont..
General considerations
• At dispensary level these patient should be referred to
the facilities with blood transfusion services.
• Admit the patient for investigations
• Nurse patient in propped up position
• Give frusemide 80-120mg iv, this will reduce
pulmonary congestion
• Administer oxygen if dyspnoec
• Catheterized the patient
• Avoid any form of iv fluid
15. How to give BT
• Transfuse packed cell only slowly -1 unit in four
hours
• Only RBC should be transfused and plasma should be
discard.
• It recommended to transfused only one unity of
blood in 24hours
• During transfusion,Monitor :pulse rate, blood
pressure, temperature, and respiratory rate hourly,
auscultate both lungs hourly for crepitations,
observe for other possible transfusion reactions
16. Management of severe anaemia in
labour
First stage
• Monitor labour in prop up position
1. Administer IV diuretics – frusemide 80mg
2. Give intermittent oxygen if available
3. Insert urethral catheter
Reduce movements during labour
4. Obtain blood for Hb, grouping & cross matching if possible
5. Do not give IV fluids
17. Management cont…..
Second stage
1. Assist 2nd stage of labour with vacuum:
To prevent excessive pushing
2. Reduce blood loss
– Avoid – Episiotomy
18. Management cont…
Third stage
1. Active management of 3rd stage: To limit
postpartum blood loss
a. Give oxytocin 10 IU im immediately after
delivery of the baby.
b. Controlled cord traction
c. Uterine massage
19. Management cont…..
AFTER DELIVERY
• Physiological Changes
Autotranfusion as result of;
Uterine vessels shut down and Closure of the
arteriovenous (AV) shunts at the placental beds
from the 3rd stage of labour.
Such changes may lead to increased workload →
Cardiac failure
Critical time - within 12 hours after delivery.
20. Management cont….
Essentials of management after delivery
AVOID IV fluids in any forms even Blood
Transfusion within the first 24 hours after
delivery
Close observation - ensure that no PPH
Input output charting
Cont diuretics and catheterization
21. COMPLICATIONS OF
ANAEMIA IN PREGNANCY
• Maternal complications
• Heart failure
• Preterm labour
• Maternal death
• Iron deficiency anaemia leads to
• Koilonychia, atrophic glossitis, fatty change in the
heart
• Pseudo-pre eclampsia
22. Complications cont…
• PSEUDO-PRE ECLAMPSIA
Severe anaemia may present with features of pre-eclampsia.
– High blood pressure, Protenuria and Oedema
• Can be differentiated from normal pre-eclampsia by:
– Low diastolic BP in severe anaemia, DBP is always raised
in pre-eclampsia
• Wide pulse pressure
– In severe anaemia all three signs disappear with slight rise
in haematocrit following treatment
23. Complications cont…
2. Fetal complications
i. IUFD,
ii. Abortion
Due to poor O2 supply to the placental tissues
iii. Premature delivery
iv. Low birth weight
v. Anaemia as a result of depleted iron stores during
infancy
24. Indications of blood transfusions
• Very severe anaemia ,Hb <5g/dl
• Anemia with congestive heart failure
• If hb <8.5g/dl at gestation age > 36weeks
before onset of labour.
• Acute hemorrhage
25. Preventions of anaemia in pregnancy
Strategies
1. Screening during antenatal clinic visits
2. Iron and folate: supplementation and fortification.
3. Give mebendazole 500mg single dose
4. Malarial disease control: presumptive therapy, ITN.
5. Advice on appropriate diet
6. Treat other underlying causes
7. Family planning – child spacing
26. NOTE
• Oral iron
Hb increases by about 0.1 – 0.2 g/dl per day or over 2
g/dl over 3 – 4 weeks
• One unit of blood increases Hb level by 0.5 – 1
g/dl
