This document discusses anaemia in pregnancy, which is a widespread problem globally. Over half of all pregnant women worldwide are anaemic, with rates as high as 75% in some developing countries. Anaemia can significantly contribute to maternal mortality and morbidity. The most common cause of anaemia in pregnancy is iron deficiency, responsible for 95% of cases. Treatment involves oral iron supplementation, though parenteral iron may be used in severe cases. Diet and supplementation with iron, folic acid and vitamin B12 are important to prevent and treat nutritional anaemia during pregnancy.

1. ANAEMIA IN PREGNANCY
Desabandu Dr. G.H.K.K. Gunawardana
M.B.B.S.,M.S.(Obs & Gyn),
F.R.C.O.G.,F.C.O.C.(S.L )
Consultant Obstetrician and Gynaecologist
Teaching Hospital,
Peradeniya.

2.  A common and world wide problem
that deserves more attention.
Over half of the pregnant women in
the world are anaemic.
For many developing countries
prevalence rate is up to 75% (WHO)
Not only it is common it is often
severe.
In developed countries the average
prevalence is 18% (WHO)

3. Prevalence of anaemia in pregnant
women by WHO region, 1998

4. Contribute significantly to maternal
mortality and morbidity.
WHO estimates that anemia contributed
to approximately 20% of the maternal
deaths worldwide in 1995 in combination
with maternal
haemorrage.

5. WHO Definition
Haemoglobin concentration <11.0g/dl in
the first half of the pregnancy and
<10.5g/dl in the second half.
It is further divided in to,
Mild 10.0-10.9 g/dl
Moderate 7.0 - 9.9 g/dl
Severe <7.0 g/dl

6. Causes of Anaemia in Pregnancy
 Nutritional anaemias – Iron deficiency
Folate deficiency
B12 deficiency
 Chronic blood loss – Haemorroids, GI bleeding
 Short birth intervals
 Infections – HIV
Malaria
 Haemotological conditions – Leukemia
Sickle cell disease
Thalasaemia

7. Normal Physiological Changes in
Pregnancy
Plasma volume expands by 46-55%
Red cell volume expands by 18-25%
Haemodilution
“Physiological Anaemia of Pregnancy”
not considered abnormal unless the levels fall
too low.

8. Effects of Anaemia in
Pregnancy
Increased risk of abortions
Increased risk of premature labour
Increased risk of IUGR
Increased risk of mortality following
PPH
Increased risk of puerperal sepsis

9. Risk Factors
Associated with:
 Twin or multiple pregnancy
 Poor nutrition, especially multiple vitamin deficiencies
 Smoking, which reduces absorption of important
nutrients
 Excess alcohol consumption, leading to poor nutrition
 Any disorder that reduces absorption of nutrients
 Use of anticonvulsant medications

10. Screening
Clinical inspection of conjunctiva for the
presence of pallor
-simple
-but low sensitivity
except when Anaemia is severe

11. Diagnostic Procedures
 Haemoglobin level
 Haemotacrit
 Erythrocyte indices
 Blood picture
 Serum ferritin
All pregnant women should have at least one Hb
measurement during the cause of pregnancy.

12. Signs and Symptoms
May not have obvious symptoms unless the cell counts are very low.
 Common Symptoms:
 Tiredness, weakness or fainting.
 Paleness-skin, lips, nails, palms
 Breathlessness
 Occasional Symptoms:
 Headache
 Nausea
 Inflamed, sore tongue
 Palpitations or an abnormal awareness of the
heartbeat
 Forgetfulness
 Jaundice (rare)
 Abdominal pain (rare)

13. Iron Deficiency Anaemia
The most common type of anemia in
pregnancy.
Responsible for 95% of anemia of
pregnancy.
Causes
-poor dietary intake
-hookworm, schistosoma
infestations

14. Diagnosis of Fe Deficiency
Anaemia
Low Hb
Low MCV, MCH, MCHC
Blood picture – RBCs microcytic
hypochromic with anisocytosis and
poikilocytosis
Reduced S. Ferritin level
Hypochromic Microcytic Anaemia

15. Treatment for Fe Deficiency
Anaemia
 Oral iron supplementation is the first line
of management
 A high iron diet should be recommended
where possible.
 Parenternal iron therapy carry a risk of
anaphylactic reaction. Their use should be
reserved only for severe cases.
 Treatment depends on
- The type and severity of anemia.
- Duration of pregnancy
- Complication of pregnancy

16. Available Fe Preparations
Elemental
Tablet Iron
Ferrous sulphate 200mg 65mg
Ferrous gluconate 300mg 35mg
Ferrous fumerate 300mg 65mg
Choice of preparation depends on cost
and side effects.

17. Adverse Effects of Fe Supplements
Lead to poor compliance
GI irritation
- Nausea and vomiting
- Epigastric pain
Long term therapy cause
- Constipation
- Dark stools

18. Ways to overcome poor compliance
Take the iron with or after food
 Start with a low dose and increase
gradually
Change the preparation
e.g.- liquid preparation

19. Parenternal Fe Therapy
Indications
Reserve for use when oral Fe therapy
fails due to intolerance
When quick response needed
e.g. Late pregnancy
Continuing blood loss
Malabsorption
Poor patients compliance

20. IM Fe Therapy
Preparations
- Iron sorbitol
- Iron dextran
- Lesser chance of anaphlaxis and toxicity

21. Adverse Effect of IM Fe Therapy
Very pain painful, muscle necrosis can
occur
o Staining of skin
o Headache, dizziness, disorientation
o Nausea, vomiting, metallic taste in mouth
o Arrhythmias

22. IV Fe Therapy
Preparation used – Iron dextran
Not unpleasant
Given as an infusion
Anaphylaxis can occur
Other side effects
Headache, malaise, fever, nausea,
vomiting, arthralgia, urticaria

23. Blood Transfusion
Indication
Severe Anaemia presenting in the
latter part of pregnancy
Packed cells are given with mid
transfusion frusemide
Should be cautious on cardiac failure

24. Folate deficiency
Folate deficiency in pregnancy is often
associated with iron deficiency since
both folic acid and iron are found in
the same types of foods.
Megaloblastic Anaemia
Low Hb
Low reticulocyte count
Hyper segmented neutrephils
Macrocytes
High MCV

25. Vitamin supplements containing 400 mcg
of folic acid are now recommended for
all women of childbearing age and during
pregnancy.
These supplements are needed because
natural food sources of folate are poorly
absorbed and much of the vitamin is
destroyed in cooking.

26. Vitamin B12 deficiency
 Women who are vegans (who eat no animal
products) are most likely to develop vitamin
B12 deficiency.
 Including animal foods in the diet such as milk,
meats, eggs, and poultry can prevent vitamin
B12 deficiency.
 Strict vegans usually need supplemental vitamin
B12 by injection during pregnancy.

27. Prevention of Nutritional
Anaemia in Pregnancy
 Good pre-pregnancy nutrition not only helps
prevent anemia, but also helps build other
nutritional stores in the mother's body.
 Eating a healthy and balanced diet during
pregnancy helps maintain the levels of iron and
other important nutrients needed for the health
of the mother and growing baby

28. Strategies
Education about nutrition, food
preparation and dietary modification
Prophylactic administration of
haematanics
Access to family planning information,
education and services

29. Dietary Education
 Food that enhance Fe absorption
Food that contain Vit C
Family of citrus- lemon, lime, oranges
Raw vegetables
 Food that decrease Fe absorption
Tea
Antacids
Methyldopa
Calcium

30. Haem iron, which is well absorbed and is
contained in foods of animal origin.
Non-haem iron, which is poorly absorbed
and is contained in foods of plant origin.
Haem Fe absorption is not affected by
presence of food.
Presence of haem iron in food enhance
the absorption of non-haem iron.

31. Good food sources of iron include the
following:
 meats - beef, pork, lamb, liver, and other organ meats
 poultry - chicken, duck, turkey, liver (especially dark meat)
 fish - shellfish, including oysters, sardines, and anchovies
 leafy greens of the cabbage family, such as broccoli, turnip
greens, and collards, spinach
 legumes, such as green peas dry beans and peas, such as pinto
beans, black-eyed peas, and canned baked beans
 yeast-leavened whole-wheat bread and rolls
 iron-enriched white bread, pasta, rice, and cereals

32. Food sources of Folate include
the following:
leafy, dark green vegetables
dried beans and peas
citrus fruits and juices and most berries
fortified breakfast cereals
enriched grain products

34. Prophylactic Administration of
Haematanics
 Iron absorbed from dietary sources, along with
mobilized iron stores, is usually insufficient to
meet iron requirements during pregnancy
 WHO recommends routine oral supplementation of
60 mg elemental iron plus 400 mcg folic acid daily
for 6 months during pregnancy in areas where the
prevalence of anemia in pregnancy is
< 40%. In areas where the prevalence of anemia in
pregnancy is > 40%, it recommends the same
dosages for 6 months and continuing for 3 months
postpartum.

35. References
British Medical Bulletin 67:149-160 (2003)
Anaemia and micronutrient deficiencies
Reducing maternal death and disability during
pregnancy
ITO Textbook
www.irontherapy.org
Chapter 2: Management of Iron Deficiency Anemia
in Pregnancy and the Postpartum-Christian
Breymann