The document discusses anemia during pregnancy, defining it as hemoglobin levels below certain thresholds and detailing its common causes, including iron deficiency and physiological changes in plasma volume. Complications for both mothers and fetuses are highlighted, with diagnostic methods and management strategies outlined, such as dietary advice and iron supplementation. Treatment options vary from oral iron to blood transfusions, addressing different levels of severity in anemia.

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Dilayhu B.
ANEMIA DURING PREGNANCY

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Definition
 Anemia in pregnancy
- Hgb< 11gm/dl(WHO)
- Hgb<11gm/dl (hematocrit of <
33%) in the first or third
trimester or a Hgb<10.5 g/dL
(hematocrit < 32%) in the
second trimester.(CDC)

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Causes of Anemia During Pregnancy
 Common causes—85% of anemia
 Physiologic anemia
 Iron deficiency
Nutrition
Short inter px interval
 Uncommon causes
 Folic acid deficiency
 Hemoglobinopathies -Sickle cell
disease
 Gastrointestinal bleeding

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Physiologic consideration
 Hgb, Hct and RBC count fall
during pregnancy due to the
disproportionate increase in
plasma vol(40-50%) with respect
to the red cell mass(18-30%)
 18% without Fe supplementation,
30% with Fe supplementation

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 In adult women, iron stores are located in the
bone marrow, liver and spleen in the form of
ferritin.
 Ferritin constitutes approximately 25 percent
(500 mg) of the 2-g of iron stores found in the
normal woman.
 Approximately 65 percent of stored iron is located
in the circulating RBCs.
 If the dietary iron intake is poor, the interval
between pregnancies is short, or the delivery is
complicated by hemorrhage, iron deficiency
anemia readily and rapidly develops.

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 The first pathologic change to occur in iron deficiency
anemia is the depletion of bone marrow, liver, and
spleen iron stores.
 The serum iron level falls, as does the percentage
saturation of transferrin.
 The total iron-binding capacity rises, because this is a
reflection of unbound transferrin. A falling
hemoglobin and hematocrit follow.
 Microcytic hypochromic RBCs are released into the
circulation. If iron deficiency is combined with folate
or vitamin β12 deficiency, normocytic and
normochromic RBCs are observed on the peripheral
blood smear

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Iron metabolism
 The iron requirements of gestation are about 1,000
mg.
 - 500 mg used to ↑ the maternal RBC mass
 - 300 mg transported to the fetus
 - 200 mg to compensate for the normal daily iron
losses by the mother.
 Thus, the normal expectant woman needs to absorb an
average of 3.5 mg/day of iron.
 In actuality, the iron requirements are not constant
but increase remarkably during the third trimester
to 6 to 7 mg/day.
 A normal average diet supplies 14mg of elemental
iron each day of which 1.2mg(5-15%) is absorbed
 Heme & Nonheme Fe sources/ Enhancers & inhibitors

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Classification
 Physiological anemia of pregnancy
 Pathological
A. Deficiency(Nutritional) anemia - commonest
- Iron - Folic acid – Vitamin B12
B. Blood loss
- Acute(For e.g. following APH)
- Chronic (Hook worm infestation, bleeding
piles)
C. Hereditary
- Thalasemia - Hemoglobinopathies
D. Bone marrow insufficiency (Hypoplasia or
aplasia)
E. Anemia of infection (Malaria, tuberculosis)
F. Chronic illness(Renal , neoplasm)

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hyperchromic a. Anemia
 mean corpuscular hemoglobin concentration
(MCHC) is greater than normal.
 The red blood cells are darker staining than
normal.
 hypochromic a. Anemia
 hemoglobin is deficient and mean
corpuscular hemoglobin concentration is less
than normal.
 microcytic a. Anemia marked by abnormally
small red blood cells.

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 normochromic a. Anemia in which the
red blood cells contain the normal
amount of hemoglobin.
 normocytic a. Anemia in which the size
and hemoglobin content of red blood
cells remain normal.

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Diagnosis
Clinical
 symptoms – depend on severity
and mimic minor complaints of
pregnancy
 Signs- pallor in skin, mucous
membrane, and nail beds

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Complications
 Fetal
- IUGR
- abortion
-increased PMR
 Maternal
- CHF
- Poor wound healing

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Diagnosis…
Laboratory
 Hb & Hct – preceded by depletion of iron store &
reduction in serum iron
 RBC indices(MCV, MCH, MCHC)- are more sensitive
indicators of iron deficiency. The earliest effect
of Fe def is a ↓ in cell size(MCV).
 Hypochromicity and a fall in MCHC only appears in
a more serious degree of Fe depletion
 ↓ Serum iron level and↑ total iron binding
capacity
 Serum ferritin level
 BM aspiration – Most reliable but invasive
 Dx of underlying cause(S/E, CXR, Hb
electrophoresis)

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 A serum iron concentration less than 60 mg/dl with less than 16
percent saturation of transferrin is suggestive of iron deficiency.
 An increase in iron-binding capacity is not reliable, because 15
percent of pregnant women without iron deficiency show an
increase in this parameter.
 If a patient has been iron deficient for an extended period of time,
her serum iron level can rise before she has depleted her iron
stores.
 The ferritin level indicates the total status of her iron stores.
 Serum ferritin levels normally decrease minimally during
pregnancy.
 However, a significantly reduced ferritin concentration is
indicative of iron deficiency anemia and is the best parameter to
judge the degree of iron deficiency.
 Ferritin levels are variable and can change 25 percent from one day
to the next

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Complications
 Fetal: spontaneous abortion, preterm
delivery, low birth weight, intrauterine
growth restriction, stillbirth,
 Maternal: congestive heart failure and
pulmonary edema especially in labour and
postpartum period, postpartum
hemorrhage, puerperal sepsis, delayed
wound healing, apathy, increased risk of
other infections like tuberculosis
 Neonatal: anemia of infancy

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Managment
Prevention
 ANC - Examine for anemia at booking,
b/n 24-26wks, b/n 32-34wks & just
before term
- Dietary advice
- Rx of hook worm, malaria,
diarrheal illness
- prophylactic
supplementation- FeFol 1tab/d
 Active 3rd
stage management

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Management…
Treatment
 Rx underlying cause
 Iron deficiency anemia
- Oral iron dose
- Parental iron
 Blood transfusion

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Management…
Iron treatment
 Oral Iron
- 108 mg of elemental iron in three divided doses
given until Hgb of 11gm%. Then 60mg PO BID
throught pregnancy
- Fe Rx should continue for 2-3 mo to build up Fe
stores
- First 3-5 days syptoms improve then Hgb ↑ by
0.8mg/dl/wk whenever oral or parentral Fe Rx
- S/E – GI upset, nausea, vomiting, intolerance,
constipation
 Parentral Iron

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 Iron should be taken 30 minutes before meals to allow
maximum absorption.
 However, when taken in this manner, dyspepsia and nausea
are more common. Therapy, therefore, must be
individualized to maximize patient compliance.
 For those patients who are noncompliant or are unable to
take oral iron and are severely anemic, intravenous iron can
be given.
 Parenteral iron is indicated in those who cannot or will not
take oral iron therapy and are not anemic enough to require
transfusion
 Iron dextran comes in a concentration of 50 mg/ml. It can be
given intramuscularly or intravenously, although
intramuscular injection is very painful

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Elemental Iron Available from Common
Generic Iron Preparations
PREPARATION
ELEMENTAL IRON
(MG)
Ferrous gluconate 325 mg 37–39
Ferrous sulfate 325 mg 60–65
Ferrous fumarate 325 mg 107

21. Indications for blood transfusion
 Indicated when there is no time to achieve
reasonable Hb concentration before delivery,
surgery or at the time of abortion
 presence of congestive heart failure
 severe anemia with hemoglobin of<4.4 gm/dl ?/
Hct< 14%
 anemia with sepsis and renal failure
 anemic patient with hemoglobin of <6-7gm/dl
seen for the first time in labour, abortion or in
the last 4 weeks of pregnancy.
 Packed RBC should be used.

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Expected response
 An effective regimen for the treatment of uncomplicated
iron deficiency with oral iron preparations should lead to the
following responses:
 If pagophagia (pica for ice) or restless leg syndrome is
present, it often disappears almost as soon as oral or
intravenous iron therapy is begun, well before there are any
observable hematologic changes such as reticulocyte
response.
 The patient will note an improved feeling of well-being
within the first few days of treatment.
 In patients with moderate to severe anemia, a modest
reticulocytosis will be seen, maximal in approximately 7 to
10 days. Patients with mild anemia may have little or no
reticulocytosis.

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 The hemoglobin concentration will rise slowly, usually
beginning after approximately one to two weeks of
treatment, and will rise approximately 2g/dL over the
ensuing three weeks.
 The hemoglobin deficit should be halved by approximately
one month, and the hemoglobin level should return to
normal by six to eight weeks.
 Typically, papillation of the tongue is decreased in patients
with iron deficiency and can be used as a gauge of duration
of symptoms.
 Classically, loss of papillae begins at the tip and lateral
borders, and moves posteriorly and centrally.
 Following iron repletion, a rapid correction (weeks to
months) is observed.

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Folic Acid Deficiency
 In the past, this condition was referred to as pernicious
anemia of pregnancy.
 It usually is found in women who do not consume fresh
green leafy vegetables, legumes, or animal protein.
 As folate deficiency and anemia worsen, anorexia often
becomes intense, further aggravating the dietary deficiency.
 In some instances, excessive ethanol ingestion either causes
or contributes to folate deficiency.
 During pregnancy, requirements are increased, and 400
g/day is recommended
 The earliest biochemical evidence is low plasma folic acid
concentrations.

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 Early morphological changes usually include neutrophils
that are hypersegmented and newly formed erythrocytes
that are macrocytic.
 With preexisting iron deficiency, macrocytic erythrocytes
cannot be detected by measurement of the mean
corpuscular volume
 The treatment of pregnancy-induced megaloblastic anemia
should include folic acid, a nutritious diet, and iron.
 As little as 1 mg of folic acid administered orally once daily
produces a striking hematological response.
 By 4 to 7 days after the beginning of treatment, the
reticulocyte count is increased, and leukopenia and
thrombocytopenia are corrected.

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 Vitamin B12 Deficiency
 Megaloblastic anemia during
pregnancy caused by lack of vitamin
B12, that is, cyanocobalamin, is
exceedingly rare. In Addisonian
pernicious anemia, a lack of intrinsic
factor results in failure to absorb
vitamin B12. It is an extremely
uncommon