Anaemia in Pregnancy Update April 2019

2. What is considered anaemia in pregnancy?
Diagnosis?
How to manage?
ANAEMIA IN PREGNANCY

3. Sarawak data - % of mothers with anemia at 36 weeks,
2014-2015

4. What is anaemia in pregnancy?
Definition (British Committee of Standards in Haematology):
Pregnancy Haemoglobin,
Hb (g/dL)
1st trimester <11
2nd and 3rd trimester <10.5
Postpartum <10
Severity Haemoglobin,
Hb (g/dL)
Mild 9.1-11
Moderate 7-9
Severe <7
Screening for anaemia:
During booking
20-24 weeks of gestation
36 weeks of gestation

5. Why anaemia occurs in pregnancy?
• Causes:
Anaemia in pregnancy is not a complete diagnosis! A cause must be
identified to ensure effective treatment.
95% of anaemia in pregnancy is due to iron deficiency anaemia.
However, other causes must be explored if patient is not responding to
haematinics (after ensuring patient is compliant to haematinics)

6. Types of Anaemia
Microcytic (MCV <80fl)
Hypochromic (MCH <27pg)
Normocytic (MCV 80-100fl) Macrocytic (MCV >100fl)
• Iron Deficiency Anemia
• α-/β-thalassemia
• Anaemia of chronic
disease
• Bleeding from
gastrointestinal tract
• Hookworm infestation
• Acute blood loss
• Anaemia of chronic
disease
• Haemolytic anaemia
• Dilutional anaemia
• Vit. B12 deficiency
 Pernicious anaemia
 Gastric bypass
surgery
 Vegetarian
• Folate deficiency
• Hypothyroidism
• Alcoholism
*MCV: mean corpuscular volume
*MCH: mean corpuscular haemoglobin

7. • Features suggestive of iron deficiency anaemia:
Previous or early booking haemoglobin, MCV and MCH normal
Microcytic hypochromic anaemia
Mentzer index = MCV(fL) : RBC (10x6/L) >13
• Confirmatory test for iron deficiency anaemia:
Serum ferritin <15ng/mL
Treatment should be considered if level <30ng/mL, as this level indicates
early iron depletion

8. Mentzer Index = MCV(fL) : RBC (10x6/L) >13
IDA vs Thalassaemia
IDA Thalassaemia
MCV (fL) ↓ ↓
RBC (10x6/L) ↓ =
Mentzer Index = ↓ (<13)

9. • General Rules of Iron Supplement
Requirement:
Prophylaxis: ~60mg elemental
iron/day
Treatment: ~100-200mg
elemental iron/day
Types of Iron Supplement Elemental Iron
Ferrous Fumarate 200mg 65mg
Ferrous Sulphate 200mg 65mg
Ferrous Gluconate 300mg 35mg
Iberet-Folic (Ferrous Sulphate 525mg)
* Containing vitamin C, Folic acid 800mcg etc.
105mg
Zincofer (Fe fumarate 300mg, 1mg FA, B12, B6) 115mg
Maltofer (ferric hydroxide polymaltose) 100mg
Obimin (Ferrous Fumarate/ Sulphate)
*Containing vitamin A 3000 IU, vitamin C, vitamin D
200/400iu, folic acid 1mg, calcium carbonate 100mg etc.
30mg
Iron Dextran (IM or IV) (Eg: Cosmofer) 50mg/mL
Iron Sucrose (IV) (Eg: Venofer) 20mg/mL

10. Management
• Prevention
Dietary advices:
Haem iron: red meat, fish, poultry (2-3x easier absorption)
Vitamin C enhances iron absorption
Avoid iron absorption inhibitors: tea, coffee (tannins), cereals (phytates) and
calcium.
WHO recommends prophylactic iron supplement with 30-60mg
elemental iron daily throughout pregnancy.
Explore more on compliance and tolerance to iron supplement.
Correct way of taking iron supplement: on empty stomach, 1 hour
before meals, with a source of vitamin C. Avoid taking together with
antacids.

11. Management
• Treatment
Treat empirically by increasing the dose of iron supplement to treatment
dose (trial of iron therapy is simultaneously diagnostic and therapeutic).
A rise in haemoglobin (about 1g/dL per week) should be demonstrable
by 2 weeks and confirms iron deficiency.
Once haemoglobin is normalised, treatment should be continued for a
further 3 months and at least until 6 weeks postpartum to replenish iron
stores.

12. Management
• Treatment
If no response to oral iron supplement, to proceed with further workup according
to types of anaemia:
Microcytic hypochromic: Peripheral blood film (not routinely required to confirm microcytic
hypochromic anaemia unless the classical features of IDA are absent), serum iron + ferritin, Hb
electrophoresis  DNA analysis, stool for occult blood, stool for ova and cyst.
Macrocytic: Peripheral blood film, serum folate, serum B12, thyroid function test (if clinically
suspected).
Referral to family medicine specialist (FMS) or O&G specialist:
1. Symptomatic anaemia
2. Severe anaemia (Hb <7g/dL)
3. Failure to respond to iron supplement

13. Management
• Treatment
Indications for parenteral iron:
Only for CONFIRMED IDA and
Failure to respond to oral iron
Non-compliant/tolerant of oral iron
Malabsorption of iron
Contraindications for parenteral iron:
History of allergic reaction or anaphylaxis to parenteral iron
1st trimester
Acute or chronic infection
Chronic liver disease

14. Management
• Treatment
Blood transfusion
Greater scrutiny before blood transfusion due to potential dangers of blood transfusion such as
transfusion-induced sensitization to red cell antigens, allergic reaction or anaphylaxis, transfusion-
related infection.
Blood transfusion should be only reserved for:
Severe anaemia with Hb <6g/dL
Hb <8g/dL and >36 weeks
Risk of bleeding (eg: severe anaemia in labour, placenta praevia before caesarean section, placental
abruptio)
Significant symptomatic anaemia
Cardiac compromise
Moderate and severe anaemia in patient with known heart disease or respiratory disease
Patients who develop severe side effects to both oral and parenteral iron therapy

15. Case scenarios

16. 17 year-old primigravida booked at 28
weeks POG. Booking haemoglobin
noted to be 7.4g/dL.

17. MCV 67 fl
MCH 26 pg
Mx?

18. 2 weeks later (30 wks POG)
Hb- 8.0 g/dL
Mx?

19. Compliant,Tolerable
Sr. Ferritin: 12 ng/mL
Mx?

20. Anaemia Action Plan

21. In conclusion
• IDA is the most frequent cause of anaemia in pregnant women
• Dietary measures are inadequate to prevent IDA
• ALL pregnant women should be given ~60 mg/day of iron supplements
prophylactically regardless of iron status
• Treatment of IDA should aim at replenishing body iron deficits and preventing
low iron stores in the newborn baby

22. In conclusion
• Treating and preventing IDA can improve national productivity by 20% and
reduce maternal mortality!
• consider other causes of anaemia if there’s lack of response to iron therapy
• CONSIDER EARLY RECOURSETO PARENTERAL IRON IF UNABLETO
TOLERATE / NON-COMPLIANTTO ORAL IRONTHERAPY
• CONSIDER PARENTERAL IRON IN NON-PREGNANT PATIENTS WITH LOW
HB