By Dr. Ravi Prakash

1. Anaemia in
Pregnancy
Dr. Ravi Prakash
JR-III
Dept. of Community Medicine
Katihar Medical College

2. DEFINITION
• Anemia is a condition in which
the haemoglobin content of
blood is lower than normal as a
result of a deficiency of one or
more essential nutrients,
regardless of the cause of such
deficiency. (WHO)

3. Anemia in pregnancy
• Iron is critical to the health of a pregnant
mother & her unborn child. A woman need
more iron during pregnancy because the
foetus and placenta both need additional
iron.
• Anemia in pregnancy is defined as
haemoglobin (Hb) concentration is less
than 11 g/dl.

4. Epidemiology
• Iron deficiency is the most common form of malnutrition in
the world, affecting more than 2 billion people globally i.e.
1/3 of the world’s population. (source WHO)
• Anemia in pregnancy is highly prevalent in developing
countries with 2/3rd of pregnant woman suffered with it.
• Pregnant woman (aged 15-49 yrs) who are anaemic
constitutes 45.7% in urban area, 52.1% in rural and 50.3% as
total (NFHS-4)

5.  Anaemia during pregnancy is responsible for
20% of all maternal death directly and
indirectly accounts for another 20% of
maternal death.
 Maternal mortality rate shows a steep
increase when maternal haemoglobin level
fall below 5.0g/dl.

6. Risk factors
Pregnancy Postpartum
Multiparity Iron deficiency during pregnancy
Short period between pregnancies Delivery by CS
Low socio-economic status Placenta previa
Dietary factors Assisted vaginal delivery
PPH
Other risk factors:
•Malaria
•HIV/ AIDS

7. Causes
• Increased blood loss
– acute – APH, PPH
– Chronic- hookworm infestation, PUD, menorrhagia
• Nutritional
– Low intake- vegans, socio-ecomonic factors
– Reduced absorption- malabsorption syndrome, dairy products
• Reduced formation
– Aplastic anemia
– Medication – zidovudine, cancer chemo
• Increased destruction (hemolytic anemia)
– Hereditary – hemoglobinopathies, membranopathies, enzymopathies
– Acquired – immune (AIHA), non immune (paroxysmal nocturnal
hemoglobinuria)
– Mechanical damage- malaria, HIV

8. Physiologic changes in pregnancy
• During pregnancy there is an increase in total blood volume
by 30-40%. The increase in plasma volume is usually higher
than the Hb level increase resulting in dilution.
• Iron requirements increase rapidly in the second (4-
5mg/day) and third 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.

9. CLASSIFICATION
• Mild :
• Moderate :
• Severe :
10- 10.99 gm/dl
7- 9.99 gm/dl
< 7 gm/dl

10. CLASSIFICATION OF ANEMIA
1.Physiological Anemia
2.Pathological Anemia
• Iron deficiency
• Folic acid deficiency
• Vitamin B12 deficiency
3. Hemorrhagic Anemia
• Acute—following bleeding in early months of
pregnancy or APH
• Chronic—hookworm infestation, bleeding piles, etc.

11. 4. Hemolytic anemia
• Familial—congenital jaundice, sickel cell
anemia, etc.
• Acquired—malaria, severe infection, etc
5.Bone marrow insufficiency
• Hypoplasia or aplasia due to radiation,
drugs or severe infection.
6.Hemoglobinopathies
• Abnormal structure of one of the globin
chains of the hemoglobin molecule, ex-
sickle cell disease

12. Signs and symptoms
Symptoms Signs
Fatigue Pallor
Palpitations Edema
Breathlessness Glossitis , stomatitis, angular
cheilitis
Dizziness, Fainting Soft Systolic murmur in mitral
area due to hyper-dynamic
circulation
Headache

13. Detailed History
– Dietary Hx
– Obs/Gyn Hx
– Drug Hx
– Social Hx
– Duration of symptoms if any

14. Investigations
• Full blood count
– Hemoglobin levels
– PCV
– Red cell Indices- MCV, MCHC, MCH
• Peripheral blood film- allows characteristics of the
RBC to be observed. Hypochromic microcytic cells
may be seen. Abnormal RBC morphology will also be
seen.

15. Other investigations
• Serum Ferritin
– Serum ferritin is a stable glycoprotein which accurately reflects
iron stores in the absence of inflammatory change. It is the first
laboratory test to become abnormal as iron stores decrease
and it is not affected by recent iron ingestion.
– It is generally considered the best test to assess iron-
deficiency in pregnancy, although it is an acute phase
reactant and levels will rise when there is active infection or
inflammation.
• Serum Iron and Total Iron Binding Capacity (TIBC)-
-lack sensitivity and specificity due to diurnal variations
and recent ingestion of iron.

16. cont..
• Stool for Ova & Cysts
• Stool for occult blood
• Bone marrow – considered the gold standard
for assessment of iron stores.
However it is an invasive and impractical
unless cause of anemia can’t be identified
by simpler means.

17. MATERNAL MORTALITY
Its prevalence in the poorest countries contributes to instability and
often is the result of denial of basic human rights.
Major causes






Haemorrhage (29%)
hypertension (8%)
anaemia (19%)
puerperal sepsis (16%)
obstructed labour (10%) and
abortion related deaths (9%)
Anaemia is not only an important cause of death but also an aggravating factor
in haemorrhage, sepsis and pregnancy induced hypertension.

18. IRON DEFICIENCY ANEMIA
• About 95% of pregnant women with
anemia have iron deficiency type.

20. Causes
1. DIETARY HABITS
•Consumption of low bioavailability diet
•Low level of enhancers of absorption and High level of Inhibitors
of iron absorption
2. DEFECTIVE IRON ABSORPTION
•
•
High prevalence of intestinal infestation
Hypochlorhydria (due to malnutrition)
3. IRON LOSS
•
•
•
Hookworm infestation
Menorrhagia
Haemorrhoids

21. DURING PREGNANCY
1. INCREASED DEMAND
• During first 20 weeks of pregnancy daily iron requirement – same as for
the non pregnant women.
• At about 20 weeks and thereafter iron requirement increases from
0.8mg to 7.5 mg/day.
2. DIMINISHED INTAKE OF IRON
• Anorexia and vomiting
3. EXCESS DEMAND
•
•
Multiple pregnancy (2 folds)
Rapidly recurring pregnancy within 2 years
Teenage pregnancy

22. Impact of anemia
Maternal Fetal
Fatigue, Low birth weight
Increased risk of PPH Small for gestational age
Increased risk of sepsis Increased risk of peri-natal
morbidity and mortality
Risk of CCF Increased incidence of
diabetes and cardiac
disease later in life
Increased risk of preterm labor Increased risk of preterm
delivery

23. IMPACT OF
UNTREATED
ANEMIA IN
PREGNANCY
FETAL HEALTH
•Perinatal morbidity&
mortality (low APGAR
scores)
•Increased incidence of
diabetes & cardiac
disease later in life
•Small for gestational age
•Iron deficiency in the
first few months of life
MATERNAL
HEALTH
•Increased risk
of PPH
•Increased risk
of sepsis
•Increased risk
of CCF
PREGNANCY OUTCOME
•2 times increased risk of
preterm delivery
•3 times increased risk of
low birth weight
•Possible placental abruption

24. MANAGEMENT
• Avoidance of frequent childbirths
• Supplementary iron therapy
• Dietary advice
• Adequate treatments to
eradicate illnesses likely to
cause anemia
• Early detection of falling
hemoglobin level

25. • Women having haemoglobin level of 7.5
g/dl and associated with obstetrical
medical complications must be
hospitalized.
•
•
•
•
•
Following therapeutic measures are to be
instituted:
Diet
Antibiotic therapy
Blood transfusion
Iron therapy which may be oral/ parental
Oral iron: daily dose 120- 180 gm is given.

26. • Treatment of Iron Deficiency Anemia – Oral
60 mg elemental iron + 500mcg Folate per day
• Oral Iron is the treatment of choice
• Consider Parenteral Iron Therapy – if oral
iron cannot be tolerated, patient non-
compliant, or patient comes late in pregnancy
• Blood transfusion is rarely
required

27. • The amount of iron absorption depends upon the
amount of iron in the diet, its bioavailability and
physiological requirements.
• Haem iron is only found in meat, chicken and fish, and
is easily absorbed.
• Non-haem iron is also found in plant foods, such as
vegetables, cereals , beans and lentils, but is not
absorbed as well by the body. Absorption may be
enhanced by vitamin C. Germination and fermentation
of cereals and legumes improve the bioavailability of
non-haem iron by reducing the content of phytate.

28. Haem iron more readily absorbed
DIETARY ADVICE?

29. • All women should be counseled regarding diet
in pregnancy including details of iron rich food
sources and factors that may inhibit or
promote iron absorption and why maintaining
adequate iron stores in pregnancy is
important.

30. How to take Iron Supplements
• Women should be counseled as to how to
take oral iron supplements correctly.
• This should be on an empty stomach, 1 hour
before meals, with a source of vitamin C
(ascorbic acid) such as orange juice to
maximize absorption.
• Other medications or antacids should not
be taken at the same time.

31. Indications for Iron
supplementation
• All pregnant Women should be offered.
• In the presence of known haemoglobinopathy, serum
ferritin should be checked and women offered
therapeutic iron replacement if the ferritin is <30 µg/l.
• Secondary care should be considered if:
– Anemia is severe (<7g/dl)
– Significant symptoms
– Advanced gestation (>34 weeks)

32. Response to oral Iron
therapy
• The hemoglobin concentration should rise by 2 g/dl
after 3–4 weeks. Failure to do so is usually due to
poor compliance, misdiagnosis, continued blood
loss, or malabsorption.
• Iron supplementation should be continued for
three months after correction of anemia to
replenish iron stores.
• For nausea and epigastric discomfort, preparations
with lower iron content should be tried. Slow
release and enteric coated forms should be
avoided.

33. Parenteral Iron Therapy
• Parenteral iron should be considered from the 2nd
trimester onwards and postpartum period in
women with iron deficiency anemia who fail to
respond to or are intolerant of oral iron.
• Associated with faster increases in Hb and better
replenishment of iron stores in comparison with
oral therapy.

34. Parenteral Iron preparations
• iron sucrose (I/V)
• Iron dextran (I/M & I/V)
• Iron sorbitol complex- jectofer (I/M)

35. Indications for Transfusion during
pregnancy
• HB <7g/dl
• HB <8g/dl & gestation >36 wks
• Moderate or severe anemia in patient with
heart disease or severe resp. disease
• Placenta previa with HB < 10g/dl

36. Contraindications to parenteral Iron
Therapy
• History of anaphylaxis or reactions to parenteral
iron therapy
• First trimester of pregnancy
• Active acute or chronic infection
• Chronic liver disease

37. Management of Anemic patient in
labor
• If Hb is <8g/dl - tranfuse
• If Hb is <10 g/dl have blood available for
transfusion.
• Active management of 3rd stage of labor (AMTSL)

38. Prevention
• Universal iron supplementation in pregnancy from the
second trimester.
• Nutritional counseling on rich sources of iron.
• Deworming with mebendazole 500mg stat in the 2nd
trimester.

39. •
Heam Iron Polypeptide
Heme iron is found in foods that contained hemoglobin.
Heme Iron is extracted from hemoglobin, a naturally
occurring iron source found in red meat and poultry
Heme iron sources used, do not contain common
allergens, such as milk or wheat products, gluten, or
significant amounts of oils or fats
• Unlike traditional iron supplements like ferrous sulfate,
it is readily absorbed by the body and is generally free of
side-effects like heartburn and constipation
NEW ASPECT OF ANEMIA
MANAGEMENT

41. FOLIC ACID DEFICIENCY ANEMIA
(MEGALOBLASTIC ANEMIA):-
•Folic acid deficiency anemia happens
when body does not have enough folic
acid.
•Deficiency of folic acid can cause
placental abruption, neural tube defect
and congenital cardiac septal defects

42. VITAMIN B 12 DEFICIENCY
• Vitamin B12deficiency, also known
as hypocobalaminemia, refers to
low blood levels of vitamin B 12.
• Deficiency is most likely in
vegetarians who eat no animal
product.

43. CONCLUSION
• Anemia in pregnancy is the most commonly
occurring disorder during pregnancy, so every
mother who are pregnant must screen for anemia
and must take treatment as soon as possible
along with foods rich in iron and also must have
family support and care throughout pregnancy.

44. Preventive policy
 Nutritional supplementation through ICDS Scheme
for the pregnant woman.
 Food fortification – addition of ferric orthophosphate
to salt.
 National Nutritional Anaemia Prophylaxis
Programme – Pregnant women (those have Hb level
<8g/dl) are also the beneficiary under this
programme.
 Under this scheme one tablet of iron and folic
acid given containing 60mg elemental iron and

45. Poshan Abhiyan

46. Growth Monitoring & Promotion
Management of Acute Malnutrition
Breastfeeding
• Within 1 hour of delivery
• Continued till 6 months
MonitoringMechanisms
Complementary Feeding
Antenatal Check-ups
Institutional Deliveries
4
• Children 0-6 years
• Weight and Height
• SAM and MAM Children
Anaemia
• Initiated at 6 months of age
• Children
• Adolescent Girls
• Mothers
5
6
7
8
9
10

47. Deworming
Diarrhoea Management
Calcium Supplement
• Children from 6 to 59 months
• Adolescent Girls
• Women of reproductive Age
• Pregnant Women
Service Delivery andInterventions
Immunisation
Vitamin A Supplementation
Iron and Folic Acid
11
• Children till 1 year of age
• Actions Taken at State &
District Level
Food Fortification
• Children from 6 to 59 months
12
13
14
15
16
17
• Pregnant Women (360
Tablets)
• Children 1 to 19 years
• February & August every year
• Oral rehydration Solution
• Zinc Supplementation

48. Anaemia Mukt Bharat

51.  Pregnant Women and Lactating Mothers
(of 0-6 months child)
Daily, 1 Iron and Folic Acid tablet starting from the fourth
month of pregnancy (that is from the second trimester),
continued throughout pregnancy (minimum 180 days during
pregnancy) and to be continued for 180 days, post-partum
Each tablet containing 60 mg elemental Iron + 500 mcg Folic
Acid, sugar-coated and red-colour.

52. References..
 Park’s Text book of Preventive & Social Medicine.
 Community medicine with Recent advances by A.H.Suryakantha
 Textbook of Community Medicine by Sunder Lal, Adarsh, Pankaj.
 D. C. Dutta’s Textbook of Obstetrics
 https://anemiamuktbharat.info/

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