This document discusses anaemia in pregnancy, including its definition, causes, types, diagnosis, and management. It defines anaemia in pregnancy as a hemoglobin level below 11 g/dL in the first trimester and below 10.5 g/dL in the second and third trimesters. The most common cause is iron deficiency anaemia, which can be diagnosed based on microcytic, hypochromic blood and a low serum ferritin level below 15 ng/mL. Treatment involves oral iron supplementation, with increased doses for deficiency and continued supplementation postpartum. Parenteral iron or blood transfusion may be considered for non-response or severe cases. Regular screening and treatment of anaemia can help improve health outcomes for

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