2. OUT LINES
• Review of Hematopoiesis and iron metabolism
• Heamatoligic changes in pregnancy
• causes of anemia in pregnancy
• Diagnosis and clinical management of anemia during
pregnancy and prevention
2
ATAKLTI S
2/7/2024
3. INTRODUCTION
Hematopoiesis
• Development of blood cells and other formed elements
• Sites vary throughout development
Fetal: yolk sac, liver, spleen
Pediatric: axial and appendicular skeleton
Adult: axial skeleton (sternum and pelvis)
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5. Fig. Formation of the multiple different blood cells from the original
pluripotent hematopoietic stem cell (PHSC) in the bone marrow.
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6. Fig. Genesis of normal red blood cells (RBCs) and characteristics of
RBCs in different types of anemias.
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7. HEMATOLOGIC CHANGES in pregnancy
Plasma Volume
• During a singleton pregnancy, maternal
plasma volume gradually expands by
approximately 50% (1000 mL).
• The total RBC mass also increases, but
only by approximately 300 mg (25%), and
this starts later in pregnancy.
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9. Cont…
• The plasma volume
increase approximately 47 percent (1,200 to 1,300
ml)begin to increase by 6 weeks
expands at a steady pace until it plateaus at 30 weeks'
gestation
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11. Cont..
• Erythrocyte mass
begins to increase at about 10 weeks gestation.
the initial slope of this increase is slower
continues to increase progressively until term
without plateauing.
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13. Cont…
Erythropoietin
• increase two- to threefold,
starting at 16 weeks
• it is responsible for moderate erythroid hyperplasia
in the bone marrow,
• mild elevations in the reticulocyte count.
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14. Fig. Function of the erythropoietin mechanism to increase production
of red blood cells when tissue oxygenation decreases.
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15. Iron Metabolism in Pregnancy
• Iron absorption from the duodenum is limitted to its
ferrous (divalent) state found in iron supplements.
• Ferric (trivalent) iron from vegetable food sources
converted by ferric reductase to the divalent state.
• If body iron stores are normal,
only 10 percent of ingested iron is absorbed,
most of which remains in the mucosal cells or enterocytes
until sloughing leads to excretion in the feces (1 mg/day)
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16. Cont…
• if the need increased the fraction of iron absorbed
increases.
• After absorption iron is released from the
enterocytes into the circulation, where it is carried
bound to transferrin to the liver, spleen, muscle,
and bone marrow.
• In those sites, iron incorporated into
hemoglobin (75 percent of iron), and
myoglobin, or stored as ferritin and
hemosiderin
2/7/2024 ATAKLTI S 16
18. Cont..
Internal iron exchange.
• 80% of iron is recycled from broken-down red cell -15-
20mg/d
• from the diet 1 mg/d is required in men,
1.4 mg/d in women.
• in case of blood loss, dietary iron deficiency, or
inadequate iron absorption, up to 40 mg/d of iron can be
mobilized from stores.
2/7/2024 ATAKLTI S 18
19. Cont…
• Daily Loss of Iron.
excretes 0.6 milligram each day, mainly into the feces.
For a woman, additional menstrual loss long-
term iron loss to an average of about 1.3 mg/day
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20. Cont…
• the average red cell life span is 120 days
0.8–1.0% of red cells turn over each day.
• At the end of its life span, undergoes
phagocytosis.
the globin and other proteins are returned to the amino
acid pool, and
• the iron is shuttled back to the surface of the RE cell,
where it is presented to circulating transferrin. It is the
efficient and highly conserved recycling of iron
2/7/2024 ATAKLTI S 20
21. Cont…
• Iron requirements of pregnant mother
are increased by 1,000 mg.
• 500 mg used to increase the maternal RBC mass (1 ml
of erythrocytes contains 1.1 mg iron),
• 300 mg transported to the fetus, and
• 200 mg to compensate for the normal daily iron losses
• average absorption 3.5 mg/day of iron but is not constant
during the second and third trimester about 6 to 7 mg/day.
2/7/2024 ATAKLTI S 21
23. Cont…
• iron requirements of the fetus
receives its iron through active transport, primarily during
the last trimester.
• Iron is transported actively across the
placenta, and fetal iron & ferritin levels are 3 X
higher than maternal levels.
• Adequate iron transport despite severe maternal iron deficiency
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24. Anemia in pregnancy
• is a reduction in the concentration
of erythrocytes or hemoglobin in
blood.
•According to the World Health
organization (WHO), 20% to 52%
of pregnant women are anemic.
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25. Hgb/ Hct cutoff point:
• Hgb (g/dL) and Hct (percentage) levels below 11 g/dL and
33%, respectively, in the 1st & 3rd trimester
• Hgb (g/dL) and Hct (percentage) levels below 10.5 g/dL
and 32%, respectively, in the second trimester
Dependent on RBC mass and plasma volume
• Values decrease if RBC mass decreases or plasma
volume increases
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26. Hemoglobin Values in Pregnancy
WEEKS'
GESTATION
MEAN
HEMOGLOBIN
(G/DL)
FIFTH PERCENTILE
HEMOGLOBIN
(G/DL)
12 12.2 11.0
16 11.8 10.6
20 11.6 10.5
24 11.6 10.5
28 11.8 10.7
32 12.1 11.0
36 12.5 11.4
40 12.9 11.9
From U.S. Department of Health and Human Services:
Recommendations to prevent and control iron deficiency in the United
States. MMWR 47:1, 1998
2/7/2024 ATAKLTI S 26
27. Anemia classification
Anemias may be categorized by based
on
• the underlying causative mechanism:
decreased RBC production, increased
RBC destruction, and blood loss
• RBC morphology,
• or by whether they are inherited or
acquired
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28. Anemia Characterized by Mechanism
A-Decreased red blood cell production
• Iron, vitamin B12, Folic acid deficiency anemia
• Anemia associated with bone marrow disorders
• Anemia associated with bone marrow suppression
• Anemia associated with low levels of erythropoietin
• Anemia associated with hypothyroidism
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29. B-Increased red blood cell
destruction
Inherited hemolytic anemias
— Sickle cell anemia
— Thalassemia major
— Hereditary spherocytosis
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34. Cont…
III) Rare causes:
*B-thalassemia major
*A-thalassemia
*vit B 12 deficiency
*syndrome of chronic hemolysis
*hereditary spherocytosis
*paroxysmal nocturnal heamoglobunuria
*hematologic malignancies/ GI- bleeding
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35. Functional Causes of anemia
1)Inadequate diet:
*iron,folate or vit B 12 deficiency.
2)Malabsorbtion syndrome:
* pregnancy/ GI-disease/ food /drugs
3) Blood loss:
* hemorrhage/helementic infestation.
4)Increase red cell destruction:
* heamolysis
2/7/2024 ATAKLTI S 35
36. lClassification by Mean Corpuscular Volume
Microcytic (MCV less than 80 fL)
• Iron deficiency anemia
• Thalassemias
• Anemia of chronic disease
• Sideroblastic anemia
• Anemia associated with copper deficiency
• Anemia associated with lead poisoning
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38. …….Cnt
Normocytic (MCV 80–100 fL)
• Hemorrhagic anemia
• Early iron deficiency anemia
• Anemia of chronic disease,
• Anemia associated with bone marrow suppression
• Anemia associated with chronic renal insufficiency
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39. …..Normocytic
• Anemia associated with endocrine dysfunction
• Autoimmune hemolytic anemia
• Anemia associated with hypothyroidism or
hypopituitarism
• Hereditary spherocytosis
• Hemolytic anemia associated with paroxysmal nocturnal
hemoglobinuria
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40. Macrocytic (MCV greater than 100 fL)
• Folic acid, vitamin B12 deficiency anemia
• Drug-induced hemolytic anemia (eg, zidovudine)
• Anemia associated with liver disease
• Anemia associated with ethanol abuse
• Anemia associated with acute myelodysplastic
syndrome
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41. Physiologic Anemia
• Observed in healthy pregnant woman
• Greatest during late 2nd to early 3rd trimester (lowest Hgb
at 28 to 36wks)
• Nearer to term Hgb increases
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42. Physiologic Anemia
• Criteria for Physiologic Anemia
• Hb: 10gm%
• RBC: 3.2 million/mm3
• PCV: 30%
• Peripheral smear showing normal morphology of RBC with central
pallor
42
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43. Iron Deficiency Anemia
• defined as abnormal values on biochemical test results ,
• Approximately 75% of anemias that occur during
pregnancy are secondary to iron deficiency
• absent bone marrow iron stores as determined by a bone
marrow iron smear
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44. Mechanism of IDA
• In adult women ,iron store are located in bone marrow,
liver &spleen in the form of ferritin.
• Ferritin constitute 25% (500mg) of 2g iron store found in
normal women.
• 65 % iron is in circulating RBC, if dietary intake is poor,
pregnancy interval is too short or there is bleeding IDA
readily &rapidly developed.
2/7/2024 ATAKLTI S 44
45. Cont…
• The first pathologic change to occur is depletion of iron
store.
• Serum iron falls, as does the % saturation
transferitin,TIBC rises as reflection of unbound
transfertin.
• Falling Hb/Hct follws,microcytic hypo-chromic RBC are
released in to circulation.
• If IDA is combined with folate deficiency, macrocytic
normochromic or megaloblastic RBCs are observed in
peripheral blood smear.
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46. Cont…
• Most women enter pregnancy,inadeqately to meet
demand of pregnancy.
• Approximately 1000mg is needed, 500mg to support
expanding RBC mass and 300mg for the fetus and
placenta.
• on average daily iron need is 6-7mg as opposed to
1mg/day in non pregnant condition.
2/7/2024 ATAKLTI S 46
47. Cont…
• During the last 6-8 wks of pregnancy the need increase to
10mg/day.
• Conditions with placental implantation may induce chronic
blood loss and increase further iron requirement.
• Plasma volume increase is higher than RBC mass,
physiological heamodillution mother is protected from
RBC mass loss as much as 1000ml.
• deliveries accompanied by blood loss>1000 ml develops
symptoms of anemia.
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48. Diagnosis of IDA
• In non-pregnant women anemia is Hb concentration of <
12g/dl.
• Because of physiological dilution other Hb cut of
considered during pregnancy.
• CDC propose Hb of 11g/dl as lower normal during first &
last trimester of pregnancy with recommended lower limit
of 10.5 g/dl (second trimester pregnancy)
• CBC,MCV, MCHC is first step for the positive differential
diagnosis
2/7/2024 ATAKLTI S 48
49. Contiii…
• The gold standard for evaluating iron store bone marrow
biopsy(routinely can not be used).
• Serum ferritin indirectly reflect iron store.
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52. The spectrum of iron deficiency
a,depletion,
• when stored iron is low
b,iron deficient erythropoiesis,
• when both stored and transport iron are low
c,iron deficiency anemia,
• stored, transport, and functional iron are low
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55. Prevalence, Etiologies, and Risk
Factors
• In US 21.55/ 1000 women Hgb < 10g/dl
• Up to 56% of all women living in developing countries are
anaemic (Hb < 11 g/dl) due to infestations
• Teenaged mothers had the highest prevalence of anemia
in pregnancy of all races
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56. ……Prevalence
Ethiopia:
• mild to moderate anaemia (30.4%),
• iron deficiency (49.7%) and
• iron deficiency anaemia (17%)
• severe anaemia is rare (0.9%)
Ethiop.J.Health Dev. 2008;22(3)
Iron Deficiency Anaemia among Women of Reproductive Age in
Nine Administrative Regions of Ethiopia
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57. Risk factors IDA
• diet poor in iron-rich foods,
• diet poor in iron absorption enhancers
• diet rich in foods that diminish iron absorption,
• pica (eating nonfood substances such as clay
or laundry starch)
• gastrointestinal disease affecting absorption;
• heavy menses;
• short interpregnancy interval; and blood loss
2/7/2024 ATAKLTI S 57
58. evaluation of anemia
I)Sign and symptom of anemia
a) symptom:
*weakness/vertigo/dizziness
*fatigue/ easily irritability
*restless leg syndrome
*labored breathing /palpitation
*pica (abnormal craving )
*difficulty of swallowing (pvs)
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59. Cont…
b) signs :
*Increase PR/BP
*Pallor (skin /conjunctiva)
*glositis(inflamed tongue)
*spooning of nails/blue sclera
* functional systolic ejection murmur
2/7/2024 ATAKLTI S 59
60. Cont…
• Cheilosis and koilonychia are signs of advanced tissue
iron deficiency.
• The diagnosis of iron deficiency is typically based on
laboratory results
2/7/2024 ATAKLTI S 60
61. III) Investigations:
a) Hb/ Hct determination (race, trimester of pregnancy)
i)First trimester pregnancy:
* Hb <(11g/dl)/Hct <33%
ii) Second trimester pregnancy:
*Hb < (10.5g/dl)/ Hct < 32 %
iii) Third trimester pregnancy:
*Hb < (11g/dl )/ Hct < 33%
iv)For black women (0.8g/dl / 2%) lower cut off point
respectively.
2/7/2024 ATAKLTI S 61
62. Cont…
B)Pheriperal smear :
i) normocytic normocromic ( anemia of chronic illness)
ii) Micorcytic hypochromic (IDA)
iii) Macrcytic normochromic (megaloblastic anemia)
iv) Look for hemolysis.
C) RBC indices: part of CBC test
i)MCV: reflect the size of RBC,mesured directly by machine.
* normal value ( 80-100 femtoliter)
*MCV below lower limit (microcytic anemia)
*MCV b/n normal limit (normocytic anemia)
*MCV above upper limit (macrocytic anemia)
2/7/2024 ATAKLTI S 62
63. Cont…
ii) MCH( Hb/ RBC count) : reflect Hb content in
RBC.
* normal value (27-31 picogram/cell)
* MCH lower than lower limit ( hypochromic A)
*MCH with in normal range (normochromic A)
* MCH grater than upper limit ( hyperchromic
A)
iii) MCHC ( Hb/ Hct) : reflect Hb content of RBC.
* normal value ( 32-36 grams/deciliter)
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64. what abnormal results mean
• Normcytic /normchromic A caused by sudden
loss, sepsis ,tumor, long term disease or aplastic
anemia.
• Microcytic/hypochromic anemia cause by IDA,
lead poisoning or thalasemia.
• Microcytic/normchromic A result from
lack(deficiency) of hormones erythropoietin from
renal failure
• Macrocytic/normochromic A results from
chemotherapy, folate or vit B 12 deficiency.
2/7/2024 ATAKLTI S 64
65. Cont…
D) Iron studies
i)Feritin : measuring feritin level has got high sensitivity and
specificity.
*≤ 45ng/ml ( probable IDA)
*≥ 100ng/ml( no IDA)
*46- 99ng/ml ( request TIBC,transferitin saturation &
serum iron level)
** if TIBC increases, serum iron decreases, transfertin
saturation decreases type anemia is IDA.
** if TIBC deceases, serum iron increased, transfertin
saturation decreases IDA less likely evaluate other
causes of anemia
2/7/2024 ATAKLTI S 65
66. Cont…
E) If no IDA/do Hb typing
i) HbA2 < 3.5 %
*DNA testing for alpha globulin abnormalities &
diagnose alpha- thalasmeia
*counseling determine carrier status of father if
mother is confirmed, father positive for alpha- thalasemia
prenatal diagnosis recommended.
ii) Hb A2≥ 3.5 % : beta-thalaseima, counseling determine
carrier status of father if the mother is confirmed carrier,
father positive for beta-thalasmia prenatal diagnosis
recommended.
2/7/2024 ATAKLTI S 66
67. Cont…
f) Reticulocyte count: ( < 28pg associated with IDA)
* elevated count associated with heamolysis
*LDH/bilurubin level determination to rule in
heamolysis.
* rule out occult blood loss
*Hb- electrophoresis to rule out
heamglobulinopaties.
2/7/2024 ATAKLTI S 67
68. Cont…
G) Investigation for secondary
anemia
* CBC /bone marrow studies ( look for
malignancies)
* febrile work up( rule out infection)
* work up to look for chronic blood loss (S/E, stool
for occult blood ,special GI-studies renal studies)
* work up to look for rare causes (thalasmeias,
sickle cell anemia, hereditary spherocitosis,
heamoglobinopaties)
2/7/2024 ATAKLTI S 68
69. Who should be screened for anemia during
pregnancy?
• All pregnant women
• Anemic ones should be treated with supplemental iron, in
addition to prenatal vitamins
• Anemia other than iron deficiency anemia should be
further evaluated
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70. Prevention of IDA
• Preventing adolescent pregnancies,
• reducing the total number of pregnancies,
• increasing the time between pregnancies
• exclusive breastfeeding
• dietary improvement,
• fortification of foods with iron,
• iron supplementation, & helminthes control
2/7/2024 ATAKLTI S 70
71. Iron supplementation
• Currently, routine iron supplementation is
controversial.
• Most American obstetricians favor the
practice,
• whereas those in Europe generally consider it
unnecessary.
• A recent Cochrane review concluded the
evidence for either a beneficial or harmful
effect on pregnancy outcome is inconclusive.
2/7/2024 ATAKLTI S 71
72. Cont…
• unsupplemented patient, not always, is
frequently significantly iron deficient at term.
• Romslo et al. demonstrated that
unsupplemented women who are not anemic
at the beginning of gestation have a
significant drop in hemoglobin concentration,
serum iron, serum ferritin, and transferrin
saturation by term
2/7/2024 ATAKLTI S 72
75. Cont…
• For iron replacement therapy, up to 300 mg of elemental
iron per day is given, usually as three or four iron tablets
(each containing 50–65 mg elemental iron) given over the
course of the day.
• The goal of therapy in individuals with iron-deficiency
anemia is not only to repair the anemia, but also to
provide stores of at least 0.5–1.0 g of iron. Sustained
treatment for a period of 6–12 months after correction of
the anemia will be necessary to achieve this.
2/7/2024 ATAKLTI S 75
76. Cont…
• Ideally, oral iron preparations should be taken on an
empty stomach, since foods may inhibit iron absorption.
2/7/2024 ATAKLTI S 76
77. Enhancers of iron absorption
haem iron, present in meat, poultry, fish, and
seafood;
ascorbic acid or vitamin C, present in fruits,
juices, potatoes and some other tubers, and other
vegetables such as green leaves, cauliflower, and
cabbage; and
some fermented or germinated food and
condiments, cooking, (reduces the amount of
phytates)
2/7/2024 ATAKLTI S 77
78. Inhibitors of iron absorption
phytates, present in cereal bran, cereal grains,
high-extraction flour, legumes, nuts, and seeds;
food with high inositol content
iron-binding phenolic compounds (tannins); foods that
contain the most potent inhibitors resistant to the
influence of enhancers include tea, coffee, cocoa, herbal
infusions in general, certain spices (e.g. oregano), and
some vegetables
calcium, particularly from milk and milk products.
2/7/2024 ATAKLTI S 78
79. Possible side-effects
Epigastric discomfort, nausea, diarrhoea, or constipation
Faeces may turn black
All iron preparations inhibit the absorption of
tetracyclines, sulphonamides, and trimethoprim. Thus,
iron should not be given together with these agents
High-dose vitamin C supplements should not be taken
with iron tablets, because this would likely cause
epigastric pain.
2/7/2024 ATAKLTI S 79
80. Iron treatment response
-Reticulocytosis may be 7–10 days
-increase in Hgb and Hct levels in subsequent weeks
(10-14 days)
Failure to respond due to:
• incorrect diagnosis,
• coexisting disease,
• malabsorption,
• noncompliance, or blood loss
2/7/2024 ATAKLTI S 80
81. indications for transfusion
• Seldom indicated
• an operative delivery must be performed on a patient
with anemia
• hypovolemia from blood loss coexists
2/7/2024 ATAKLTI S 81
82. …transfusion
• trauma caused by instrumented delivery,
• uterine atony,
• placenta previa,
• retained products of conception
• placental abruption, and coagulopathy (eg, the syndrome
of hemolysis, elevated liver enzymes, and low platelet
count [HELLP]).
2/7/2024 ATAKLTI S 82
83. …transfusion
Severe anemia with maternal Hgb levels less than 6
associated with
• abnormal fetal oxygenation, resulting in NRFHRP,
reduced amniotic fluid volume, fetal cerebral
vasodilatation, and fetal death
• maternal transfusion should be considered for fetal
indications in cases of severe anemia
2/7/2024 ATAKLTI S 83
84. PARENTERAL IRON
INDICATIONS
• cannot tolerate or will not take modest doses of oral iron
• malabsorption syndrome and severe iron deficiency
anemia
• intravenous iron had significantly higher Hgb levels on
days 5 and 14 than women treated with an oral
supplement, by day 40 there was no significance differnce
2/7/2024 ATAKLTI S 84
86. Iron tolerance test
• A useful test in the clinic to determine the
patient's ability to absorb iron .
Two iron tablets are given to the patient on an
empty stomach, and the serum iron is measured
serially over the subsequent 2 hours.
Normal absorption will result in an increase in the
serum iron of at least 100 g/dL.
If iron deficiency persists despite adequate
treatment, it may be necessary to switch to
parenteral iron therapy
2/7/2024 ATAKLTI S 86
87. criteria for referral
• Underlying medical condition causing anemia
• Underlying hematologic condition causing anemia
• Concern of possible need for bone marrow biopsy to
establish diagnosis
• Nutritional deficiency (dietary counseling)
2/7/2024 ATAKLTI S 87
88. Complications of IDA
• It is still not certain whether anemia results in an
increased risk for poor pregnancy outcome.
• in early pregnancy is associated with preterm delivery
and low birth weight.
2/7/2024 ATAKLTI S 88
89. CONT…
• Scholl and Hediger concluded that anemia diagnosed in
early pregnancy is associated with preterm delivery and
low birth weight.
• In the study, women with iron deficiency
anemia had twice the risk of preterm delivery
and three times the risk of delivering a low-
birth-weight infant.
• Preterm labor, however, is a multifactorial
problem, and there were many confounders in
this study.
2/7/2024 ATAKLTI S 89
90. CONT…
Sifakis and Pharmakides observed that hemoglobin
concentrations less than 6 g/dl are associated with
preterm birth, spontaneous abortion, low birth weight,
and fetal deaths
2/7/2024 ATAKLTI S 90
91. CONT…
• Nevertheless, a mild to moderate anemia did not
appear to have any significant .
• Conversely increased risk of stillbirth and growth-
restricted infants in women with hemoglobin
concentrations greater than 14.6 g/dl at their prenatal
visit
2/7/2024 ATAKLTI S 91
92. CONT…
• In developing nations, severe anemia is a major
cause of maternal morbidity and mortality
2/7/2024 ATAKLTI S 92
93. CONT…
Iron deficiency anemia during pregnancy:
• an increased risk of low birth weight, preterm delivery,
and perinatal mortality
Severe anemia Hgb levels less than 6 g/dL:
• NRFHRP,
• reduced amniotic fluid volume
• fetal cerebral vasodilatation, and fetal death
2/7/2024 ATAKLTI S 93
94. Megaloblastic Anemia
• During pregnancy, folate deficiency is the most common cause
of megaloblastic anemia.
• The daily folate requirement in the nonpregnant state is
approximately 50 mcg, but this rises at least fourfold during
gestation.
• Complicates up to 1% of pregnancies.
94
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95. Megaloblastic Anemia: contd…
• Megaloblastic anemia in pregnancy is almost always due
to Folic Acid deficiency.
• It may be due to Def. of VitB12 or Folic Acid or both.
• Is common where nutrition is inadequate.
• ~70% of folate-deficient Pts also lack iron stores
• Vit B12 def is rare in Pregnancy because its need is less
in amount and amount is met with any diet that contains
animal products
95
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96. Megaloblastic Anemiacontd…
• Folate defficiency:-
– Stored in liver sufficient for 6 wks
• Hypersegmented neutrophils (more than 5% of neutrophils having five
or more lobes) appear after 7 weeks
• RBC folate is reduced after 18 weeks, and
• Anemia occurs after 20 weeks.
– Characterized by:-
• Increased MCV
• WBCs with altered morphology (hypersegmented neutrophils,
anisocytosis, and poikilocytosis).
• Extreme anemia often is associated with leukocytopenia and
thrombocytopenia.
96
2/7/2024 ATAKLTI S
97. Megaloblastic Anemia: contd…
• PREVENTION: Women contemplating pregnancy should
be advised:-
– A daily folic acid supplement
• 0.4 mg/day if there is no family history of neural tube defect
• 4 mg/day if there is a family history of NTD starting before conception &
continuing throughout the first trimester.
– In contrast, vitamin B 12 deficiency is rare, because very little of the
body's stores is used each day.
97
2/7/2024 ATAKLTI S
99. Megaloblastic Anemia: contd…
• TREATMENT:-
• Folate deficiency responds to 0.5 to 1.0 mg folate orally per day,
• Response to folate:
• Reticulocytosis within 3 days
• Hematocrit level may rise by 1% daily after 1 week
of treatment.
• Carries a good prognosis if adequately treated.
• B 12 deficiency requires vitamin B 12, 1 mg intramuscularly, weekly
for 6 weeks.
99
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100. THALASSEMIAS
• All are inherited as an autosomal recessive trait.
• Mediterranean basin, Middle East, Africa, Asia, & India.
• Aetiology: due to a defect in the rate of globin chain synthesis.
– Homozygous—thalassaemia major: Defect in both beta chains
• Usually fatal before pregnancy age group.
• Decreased or no production of Hgb A
• Hgb F 60-90%
– Heterozygous— Thalassaemia minor: Defect in one chain
• Commonest thalassaemia.
• Beta-Thalassaemia minor is the more serious especially if combined with any
other abnormal Hb such as S or C.
• Mild hypochromic microcytic anemia
• Normal life expectancy
100
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102. Thalasamias; contd…
• Ghosh and coinvestigators reported their experience
caring for 26 Chinese women who were at risk to deliver a
fetus with homozygous α-thalassemia.
• Six of the 26 fetuses were affected. In two of the six
cases, progressive fetal ascites appeared before 24
weeks’ gestation. These pregnancies were terminated
and the diagnoses confirmed.
• In the remaining four patients, there was evidence of
intrauterine growth restriction by 28 weeks’ gestation. At
later gestational ages, an increase in the transverse
cardiac diameter was seen in the affected fetuses. Woo
and colleagues77
102
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103. Thalasamias; contd…
• Diagnosis:
• Globin chain synthesis studies.
• Occasionally mild anaemia (MCV↓, MCH↓, MCHC=)
• May present with severe anemia at 4-6 months
• Splenomegaly, Jaundice.
• Pain from bone infarcts (later in life—ulcers of legs).
• Treatment
• Transfusions
• She should receive folic acid supplementation, but not iron
supplementation unless iron deficiency is diagnosed, also.
• Prevent stress if possible (e.g. hypoxia).
• Treat infections early.
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104. Sickle cell anemia
• Autosomal recessive disorder of haemoglobin.
• HbS (commonest): Middle East, Africa, USA, Caribbean & southern
Europe.
• HbC: Ghana, HbE: South-East Asia, HbD: Punjab.
• Abnormally shaped blood cells do not flow smoothly Can
clog small blood vessels
• Increased maternal and perinatal morbidity and mortality.
• Pregnancy can cause a crisis
• Massive erythrocyte destruction and vessel occlusion
• Occlusion can occur in vessels that supply placenta
• Can lead to preterm birth, growth restriction, & fetal demise
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105. Sickle cell anemia; contd…
• Stillbirth rates of 8% to 10% have been described in
patients with sickle cell disease.
• Studies showed abnormal systolic/diastolic ratios for the
uterine or umbilical arteries in 88% of patients with
hemoglobin SS compared with 7% with hemoglobin AS
and 4% with hemoglobin AA.
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106. Sickle cell anemia; contd…
• Although maternal mortality is rare in patients
with sickle cell anemia, maternal morbidity is
significant. Infections are common, occurring
in 50% to 67% of women with hemoglobin SS.
• Pulmonary infection and infarction are also
common. Patients with sickle cell anemia should
receive pneumococcal vaccine before pregnancy.
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107. Sickle cell anemia; contd…
• Haematology
• Low Hb.
• Sickling and target cells on blood film.
• Electrophoresis shows abnormal Hb patterns.
• Treatment
• Detect early.
• Oxygen and fluids are given continuously throughout labor
• Folic acid prophylactically 1–2mg/day.
• Transfusion of red blood cells.
• Diuretic.
• Antibiotics.
• If crisis: Hydrate, serial Hb , Antibiotics.
• Consider exchange transfusion.
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