Anemia in pregnancy is defined as a hemoglobin level below 11g/dL in the first trimester and below 10.5g/dL in the second and third trimesters by WHO guidelines. Common causes include iron deficiency, thalassemia, folate or B12 deficiency, worm infestation, and hemorrhage. Symptoms include weakness, fatigue, palpitations, and shortness of breath. Diagnosis involves blood tests to determine hemoglobin levels, red blood cell counts and indices, and iron, folate, and B12 levels. Treatment depends on hemoglobin levels and includes oral iron supplements, intravenous iron, folic acid, B12 injections, and blood transfusions in severe or symptomatic

1. ANEMIA IN
PREGNANCY
Nurul Fatimah binti Ramli
Obstetric & Gynaecology Department
Hospital Selayang

2. Anemia in pregnancy
1. Definition
2. Common causes
3. Physiological changes in pregnancy
4. Signs and symptoms
5. Diagnosis
6. Management and complication

3. Definition
• WHO defines anemia in pregnancy as a Hb <11g/dl
• In the UK Guidelines, anemia in pregnancy is Hb <11g/dl in 1st trimester,
Hb <10.5 g/dl in 2nd and 3rd trimester and Hb <10g/dl postpartum

4. Physiological changes in pregnancy
Marked physiological changes in composition of the blood in healthy
pregnancy.
• Increased total blood volume
• Hemostatic changes

5. • Plasma volume increases progressively by at least 50% throughout normal pregnancy.
• Increase in total RBC 20-30% helps provide the extra oxygen demand of both
mother and fetus
• Because of the expansion in plasma volume is greater than the increase in red cell
mass, there is a fall in hemoglobin concentration, hematocrit and red cell count.
(hemodilution)
• Despite this hemodilution, there is usually no change in mean corpuscular volume
(MCV) or mean corpuscular hemoglobin concentration (MCHC).

6. Common causes
• Iron deficiency anemia
• Haemoglobinopathy – thalassemia
• Megaloblastic anemia – B12 and folic acid deficiency
• Worm infestation – hookworms, etc
• Hemorrhage from GI tract – hemorrhoids
• Chronic medical disorders

7. Signs and symptoms
• Weakness, fatigue
• Palpitation
• Shortness of breath
• Chest pain
• Dizziness
• Pallor
• Glossitis, angular stomatitis, koilonychia – seen in IDA patient
• Soft systolic murmur – can be heard in severe anemia

8. Diagnosis
- all patients with anemia should be investigated to determine the underlying cause
• Full diet history
• Family history of haemoglobinopathies
• Previous obstetric history – especially birth interval
• Infections – eg. Malaria, helminthic infestations
• HIV status

9. • Investigations
- FBC with red cell indices, MCV
 80-100 fL: normocytic
< 80 fL: microcytic
> 100: macrocytic
- Full blood picture
- Iron studies (serum ferritin, iron and TIBC): serum ferritin used to confirm IDA
(<12)
- Folate and B12 levels – megaloblastic anemia
- Hb analysis, only when indicated
- Stool examination

11. Management
• Hb <6g/dl (severe): at any gestational age
PC transfusions with IV frusemide 20mg in between transfusion
• Hb 6-8 g/dl (moderate)
< 37 weeks
- asymptomatic: hematinics/ parenteral iron therapy
- Symptomatic: consider blood transfusion
 > 37 weeks: consider blood transfusion

12. • Check Hb 1 month after commence of hematinics
 Hb increased : cont oral hematinics
Hb not increase: check result of investigation
- IDA confirmed: start parenteral iron therapy
- IDA not confirmed: investigate for other causes of anemia
Parenteral iron therapy
- Only after IDA has been confirmed
- Preferred if patient not compliance or intolerance to oral iron therapy or no increase
in Hb
- Can be given IM/IV

13. Total dose (mg Fe) – Hb in g/l:
• (Body weight (kg) x (target Hb - actual Hb) (g/l) x 0.24) + mg iron for iron stores
• A test dose must always be administered
- 25mg in 100ml of NS and infused slowly over 15-20 mins and observed for an hour
• Recheck Hb 2 weeks after IV iron dose

14. Antenatal care
• FBC is assessed on booking visit, 20 weeks, 28 weeks and at least once more
at 36 weeks
• Patients with anemia may require more frequent reviews
• Look for complications of anemia, monitor fetal growth
• Dietary advise (enhancers and inhibitors of iron absorption)

15. Post partum and care in the puerperium
• Hematinics must be continued for at least 3 months
• Hb should be maintained at least 10g/dl
• Contraception and spacing of at least 2 years before subsequent pregnancy.
This will enable iron stores to be replenished.

16. • Megaloblastic anemia
- Folic acid 5mg daily and,
- Injection of vit B12 (cyanocobalamine) 1000mcg weekly for 3 doses
• Thalassemia
- Folic acid 5mg daily
- Hb should be maintained above 8g/dl

17. Complications
- Bleeding
- SGA
- IUGR in severe anemia
- Preterm labour
- Higher perinatal mortality

18. THANK YOU