This document discusses anemia in pregnancy, defining it as a hemoglobin level below 11g/dL in the first trimester, 10.5g/dL in the second trimester, and 11g/dL in the third trimester. It classifies anemias based on their cause into reduced red blood cell production, increased red blood cell destruction, or increased blood loss. The most common anemias in pregnancy are nutritional deficiencies of iron, folic acid, and vitamin B12, as well as hemoglobinopathies like sickle cell disease and thalassemias. Prevention is key and involves health education, administration of hematinics and antimalarial prophylaxis, and insecticide treated nets. Treatment

1. ANEMIA IN
PREGNANCY
AISHA ISHAQ
HOUSE OFFICER
DEPARTMENT OF OBSTETRICS AND
GYNAECOLOGY
MAITAMA DISTRICT HOSPITAL
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2. OUTLINE
• INTRODUCTION
• DEFINITION
• CLASSIFICATION
• PATHOPHYSIOLOGY
• COMMON ANEMIAS IN PREGNANCY
• MANAGEMENT
• PREVENTION
• CONCLUSION 2

3. INTRODUCTION
• COMMONEST HEMATOLOGICAL DISORDER IN PREGNANCY
• HIGH INCIDENCE IN UNDERDEVELOPED COUNTRIES
• • RESPONSIBLE FOR SIGNIFICANT HIGH MATERNAL MORBIDITY AND MORTALITY
AND INCREASED FETAL MORTALITY RATE WORLDWIDE
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4. DEFINITION
• DEFINED BY THE VALUE OF HAEMOGLOBIN- WHEN THE BLOOD HAEMOGLOBIN
VALUE IS LESS THAN THE FIFTH PERCENTILE OF THE DISTRIBUTION OF HB IN A
HEALTHY REFERENCE POPULATION BASED ON THE STAGE OF PREGNANCY
• WHO DEFINES IT AS HAEMOGLOBIN CONCENTRATION IN THE PERIPHERAL
BLOOD IS <11G/DL(33%) IN THE FIRST TRIMESTER, 10.5G/DL(32%) IN THE
SECOND TRIMESTER AND 11G/DL(33%) IN THIRD TRIMESTER
• IN THE TROPICS, HB <10G/DL (OR PCV OF LESS THAN 30%) IS ACCEPTABLE
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5. CLASSIFICATION
1. REDUCED RBC
PRODUCTION
2. INCREASED RBC
DESTRUCTION
3. INCREASED BLOOD LOSS
A) NUTRITIONAL ANEMIA :
IRON DEFICIENCY, FOLIC
ACID DEFICIENCY, VITAMIN
B12 DEFICIENCY
A) INHERITED HEMOLYTIC
ANEMIAS- SICKLE CELL
ANEMIA THALASSAEMIA
MAJOR, HEREDITARY
SPHEROCYTOSIS
A) ACUTE BLOOD LOSS-
ABORTION, ECTOPIC
PREGNANCY, APH, RETAINED
PLACENTA WITH
PPH,RUPTURED UTERUS
B) SYSTEMIC DISEASES :
CHRONIC RENAL FAILURE,
TUBERCULOSIS
B) ACQUIRED HEMOLYTIC-
AUTOIMMUNE HEMOLYTIC
ANEMIA, HEMOLYTIC ANEMIA
ASS WITH MALARIA
B) CHRONIC BLOOD LOSS-
HOOKWORM INFESTATION,
HAEMORRHOIDS, PUD,
SCHISTOSOMIASIS
C) BONE MARROW
INFILTRATION :
MALIGNANCIES
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6. CLASSIFICATION
4. BASED ON MEAN CORPUSCULAR VOLUME
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MICROCYTIC
(MCV<80FL)
NORMOCYTIC(MCV 80-
100FL)
MACROCYTIC
(MCV>100FL)
IRON DEFICIENCY
ANEMIA
HEMORRHAGIC
ANEMIA
FOLIC ACID
DEFICIENCY
THALASSEMIAS ANEMIA OF CHRONIC
DISEASE
ANEMIA ASS WITH B12
DEFICIENCY
ANEMIA OF CHRONIC
DISEASE
AUTOIMMUNE
HEMOLYTIC ANEMIA
DRUG INDUCED
HEMOLYTIC ANEMIA
SIDEROBLASTIC
ANEMIA
ANEMIA ASS WITH
BONE MARROW
SUPPRESSION
ANEMIA ASS WITH
LIVER DISEASE
ANEMIA ASS WITH HEREDITARY

7. PATHOPHYSIOLOGY
1. PHYSIOLOGICAL ANEMIA OF PREGNANCY
• PLASMA VOLUME INCREASES BY :
- EXPANDS RAPIDLY TO UPTO 40-50% AND RED BLOOD CELL VOLUME
EXPANDS BY 20%
- BECAUSE THE EXPANSION IN PLASMA VOLUME IS HIGHER THAN
THAN THE INCREASE IN RED BLOOD CELL VOLUME, THERE IS FALL IN HB
CONCETRATION
2. INCREASE DEMAND OF IRON
• WEIGHT GAIN IN PREGNANCY
• FETUS AND THE PLACENTA
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8. PATHOPHYSIOLOGY
3. FAULTY DIETETIC HABITS LIKE OVERCOOKING WHICH
DESTROYS NUTRITIONAL VALUE, PROBLEMS OF STORAGE
AFTER COOKING, FOOD CONSUMED THAT ARE LESS
NUTRITIOUS WHICH REDUCE IRON ABSORPTION
4. FAULTY ABSORPTION MECHANISM- BECAUSE OF HIGH
PREVALENCE OF INTESTINAL INFESTATION, THERE IS
INTESTINAL HURRY WHICH REDUCES THE IRON ABSORPTION
4. INCREASED SUSCEPTIBILITY TO MALARIA- INTERFERES WITH
ABSORPTION AND UTILIZATION OF NUTRIENTS
5. SHORT PREGNANCY INTERVAL- WOMEN START ANOTHER
PREGNANCY AT A TOO FREQUENT INTERVAL WHILE NOT GIVING
THE BODY TIME TO REPLENISH ITS DEPLETED STORES
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9. COMMON ANEMIAS IN PREGNANCY
• COMMON TYPES- 1. NUTRIONAL DEFICIENCY ANEMIA
-IRON DEFICIENCY
- FOLATE DEFICIENCY
- VITAMIN B12 DEFICIENCY
2. HAEMOGLOBINOPATHIES
- SICKLE CELL DISEASE
- THALASSAEMIAS

10. IRON DEFICIENCY ANEMIA
• IRON DEFICIENCY CAN BE DEFINED AS ANEMIA WITH BIOCHEMICAL EVIDENCE OF
IRON DEFICIENCY BASED ON THE FOLLOWING LAB FINDINGS- SERUM FERRITIN,
SERUM IRON, TOTAL IRON BINDING CAPACITY
• ETIOLOGY- DEPLETED IRON STORES( DIETARY LACK, WORM INFESTATION,
CHRONIC MENORRHAGIA), CHRONIC INFECTIONS(MALARIA), REPEATED
PREGNANCY(SHORT INTERPREGNANCY INTERVAL, BLOOD LOSS AT DELIVERY)
• DIAGNOSIS- LAB RESULTS ARE CHARACTERISTICS OF MICROCYTIC,
HYPOCHROMIC ANEMIA WITH EVIDENCE OF DEPLETED IRON STORES, LOW
PLASMA IRON LEVELS, HIGH TIBC, LOW SERUM FERRITIN LEVELS
• IRON DEFICIENCY ANEMIA DURING PREGNANCY HAS BEEN ASS WITH INCREASED
RISK OF LOW BIRTH WEIGHT,PRETEM DELIVERY AND PERINATAL MORTALITY AND
SHOULD BE TREATED WITH IRON SUPPLEMENTATION IN ADDITION TO PRENATAL
VITAMINS
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11. MACROCYTIC ANEMIA
• MACROCYTIC ANEMIA MAYBE MEGALOBLASTIC OR NON MEGALOBLASTIC BASED ON
THE BONE MARROW FINDINGS
• CAUSES OF MEGALOBLASTIC INCLUDE FOLATE AND VIT B12 DEFICIENCY
• MACROCYTIC ANEMIA IS CHARACTERIZED BY AN MCV GREATER THAN 100FL
• ETIOLOGY- INADEQUATE INTAKE, INCREASED DEMAND, ABNORMAL DEMAND,VIT B12
IS ENCOUNTERED IN WOMEN WHO HAD PARTIAL OR TOTAL GASTRIC RESECTION,
CROHN’S DISEASE, ,STRICT VEGETARIAN DIET
• DIAGNOSIS- LAB RESULTS ARE CHARACTERISTICS OF MACROCYTIC ANEMIA WITH
EVIDENCE OF HYPER SEGMENTED NEUTROPHILS, LOW SERUM FOLATE LEVEL, LOW
VIT B12 LEVEL
• TREATMENT- FOLIC ACID AND IRON SUPPLEMENTATION, VIT B12 GIVEN
INTRAMUSCULAR IN VIT B12 DEFICIENCY
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12. HAEMOGLOBINOPATHIES
• SICKLE CELL ANEMIA
- SCD IS AN AUTOSOMAL INHERITED GENETIC CONDITION WHERE ABNORMAL
HB(HBS) CONTAINS BETA GLOBIN CHAINS WITH AN AMINO ACID SUBSTITUTION THAT
RESULTS IN IT PRECIPITATING WHEN IN REDUCED STATE. THE RED BLOOD CELLS
BECOME SICKLE SHAPED AND OCCLUDE SMALL BLOOD VESSELS
- THERE IS SEVERE ANEMIA, CHRONIC HYPERBILIRUBINEMIA, PREDISPOSITION TO
TO INFECTION, VASO-OCCLUSIVE COMPLICATIONS INCLUDING ACUTE CHEST
SYNDROME AND CHRONIC KIDNEY DISEASE
- DIAGNOSIS – RETICULOCYTE COUNT,SICKLING TEST, HEMOGLOBIN
ELECTROPHORESIS
- MANAGEMENT- PRE-PREGNANCY OPTIMIZATION AND EDUCATION ON RISK ON
PREGNANCY, HIGH DOSE FOLATE SUPPLEMENTS, LOW DOSE ASPIRIN, CRISES(
ADEQUATE HYDRATION, OXYGEN, ANALGESIA, SCREEN AND TREAT INFECTIONS,
BLOOD TRANSFUSION, FETAL MONITORING)
- COMPLICATIONS- MATERNAL: INCREASED RISK OF CRISES, MISCARRIAGE, PRE
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13. HAEMOGLOBINOPATHIES
• THALASSEMIA
- COMMONEST GENETIC BLOOD DISORDERS
- THE DEFECTS IS A REDUCED PRODUCTION OF NORMAL HB AND THE SYNDROMES ARE
DIVIDED INTO ALPHA AND BETA TYPES, DEPENDING ON WHICH GLOBIN CHAIN IS AFFECTED
- IN ALPHA THALASSEMIA MINOR, THERE IS DELETION OF ONE OF THE TWO NORMAL ALPHA
GENES REQUIRED FOR HB PRODUCTION. AFFECTED INDIVIDUAL IS CHRONICALLY ANEMIC BUT
HAS LOW RISK OF OBSTETRICS COMPLICATIONS
- IN BETA THALASSEMIA, IT RESULTS FROM DEFECTS IN NORMAL PRODUCTION OF THE BETA
CHAINS. BETA THALASSEMIA MINOR IS A HETEROZYGOUS INHERITANCE FROM ONE PARENT,
PRESENTS WITH LOW MCV, LOW MCH, NORMAL MCHC AND IRON SUPPLEMENTS SHOULD BE
GIVEN AND PARTNERS SHOULD BE SCREENED
- HOWEVER IN BETA THALASSEMIA MAJOR- HOMOZYGOUS INHERITANCE FROM BOTH
PARENTS, SEVERE ANEMIA AND TREATMENT IS BLOOD TRANSFUSION
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14. MANAGEMENT
• PRINCIPLES OF MANAGEMENT
- IDENTIFICATION OF CAUSE OF ANEMIA
•HISTORY AND CLINICAL EXAMINATION
•INVESTIGATION
-TREATMENT OF ANEMIA BY THE MOST APPROPRIATE METHOD
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15. CLINICAL PRESENTATION
• ASYMPTOMATIC
- DETECTED ONLY ON ROUTINE ESTIMATION OF PCV OR HB AT BOOKING
•SYMPTOMATIC
- EASY FATIGABILITY, WEAKNESS, DIZZINESS, FAINTING ATTACKS, HEADACHE,
WEAKNESS, FAINTING ATTACKS, BREATHLESSNESS ,SWOLLEN LEGS, SYMPTOMS
OF PREDISPOSING CONDITION
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16. CLINICAL EXAMINATION
• GENERAL PHYSICAL EXAMINATION
- GENERAL STATUS: POORLY OR WELL NOURISHED
-ASSESS PALLOR, JAUNDICE, HAIR FLUFFINESS, DELAYED CAPPILARY REFILL,
KOILONYCHIA, PEDAL EDEMA
. CVS EXAMS- PULSE RATE FOR TACYCARDIA, BP FOR NORMALITY; LOW(SHOCK)
OR RISE(PREECLAMPSIA), JVP MAY BE RAISED, HEART SOUNDS
. RESP SYSTEM- TACHYPNEA, CREPITATIONS AT THE LUNG BASES
. ABD EXAM- TENDER HEPATOMEGALLY
. OTHER SYSTEMS FOR ETIOLOGY AND COMPLICATIONS
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17. INVESTIGATIONS
• TO ASCERTAIN DEGREE OF ANEMIA, TYPE OF ANEMIA, CAUSE OF ANEMIA
• HEMATOLOGICAL- FULL BLOOD COUNT, RETICULOCYTE COUNT,, BLOOD FILM
FOR MALARIA, BLOOD FILM FOR RED CELL MORPHOLOGY, HB
ELECTROPHORESIS, BLOOD GROUP AND RHESUS FACTOR, COMB
TEST(DIRECT AND INDIRECT),SERUM FOLATE, SERUM B12, IRON STUDIES, BM
ASPIRATION
• MICROBIOLOGICAL( STOOL MICROSCOPY, URINE MC/S, MANTOUX , SPUTUM
ACID FAST BACILLI
• RADIOLOGICAL- ABDOMINAL USS, CHEST XRAY
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18. TREATMENT
• METHOD OF TREATMENT DEPENDS ON GA, SEVERITY OF ANEMIA,
SYMPTOMATOLOGY, CO-MORBIDITY, ONGOING BLOOD LOSS
• GENERAL TREATMENT
- ADEQUATE NUTRITION
- TREATMENT OF UNDERLYING CAUSE( ANTIMALARIAL, ANTIBIOTICS,
ANTIHELMENTHIC, ANTIRETROVIRAL)
. SPECIFIC TREATMENT
- HEMATINIC (ORAL AND PARENTERAL)
- BLOOD PRODUCTS
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19. TREATMENT
• MILD ANEMIA- <37WKS ( IRON THERAPY, FOLIC ACID), AT TERM AND LABOR (
BLOOD TRANSFUSION)
• MODERATE ANEMIA- <34WKS (IRON THERAPY), >34WKS( BLOOD
TRANSFUSION)
• SEVERE ANEMIA - BLOOD TRANSFUSION IRRESPECTIVE OF GA
• ORAL IRON FORMULATION
A) FERROUS SULPHATE 200MG TDS
B) FERROUS FUMARATE 200MG
C) FERROUS GLUCONATE 300MG TDS
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20. TREATMENT
• PARENTERAL IRON MAY BE INDICATED IF THERE IS : -
- NON COMPLIANCE WITH ORAL IRON
- MALABSORPTION SYNDROME
- INTOLERABLE SIDE EFFECTS
- SEVERE IRON DEFICIENCY
• INDICATIONS OF BLOOD TRANSFUSION:
- SEVERE ANEMIA
- CO-MORBIDITY( SEPSIS, RENAL FAILURE, HAEMORRHAGE)
- GA CLOSE TO TERM , GOING FOR SURGERY OR IN LABOR IRRESPECTIVE OF
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21. COMPLICATIONS
• EFFECTS ON THE MOTHER- HEART FAILURE(GENERALIZED EDEMA,
TACHYCARDIA, ABNORMAL HEART SOUNDS), SHOCK, PREDISPOSITION TO PIH
AND PRETERM LABOR, REDUCED IMMUNITY TO INFECTION, INCREASED
MORTALITY RATE
• EFFECTS ON THE FETUS-ABORTION, INTRAUTERINE GROWTH RESTRICTION,
INTRAUTERINE FETAL DEATH, PREMATURITY, LOW BIRTH WEIGHT, INCREASED
RISK OF PERINATAL MORBIDITY AND MORTALITY
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22. PREVENTION
• GOOD EDUCATION ON HOW TO IMPROVE THEIR HEALTH WELLBEING AND
IMPORTANCE OF PROPHYLACTIC HAEMATINICS AND ANTIMALARIAL
• ENCOURAGE FAMILY PLANNING
• ENCOURAGE TO COME FOR ROUTINE ANC
• DISCOURAGE HARMFUL PRACTICES LIKE FOOD TABOO
• GOOD HEALTH FACILITIES AND TRAINED PERSONNEL
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23. CONCLUSION
• ANEMIA REMAINS A DIRECT AND INDIRECT CAUSE OF MATERNAL MORBIDITY
AND MORTALITY PARTICULARLY IN DEVELOPING COUNTRIES
• PREVENTION IS KEY TO CURTAILING THE NUMEROUS HAZARDS OF ANEMIA IN
PREGNANCY
• HEALTH EDUCATION, ADMINISTRATION OF HAEMATINICS AND ANTIMALARIAL
PROPHYLAXIS AND USE OF INSECTICIDE TREATED NETS REMAINS EFFECTIVE
IN THE PREVENTION AND MANAGEMENT OF ANEMIA
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24. REFERENCES
• TEXTBOOK OF OBSTETRIC AND GYNAECOLOGY BY AKIN AGBOOLA
• TEXTBOOK OF OBSTETRICS BY 10 TEACHERS
• COMPREHENSIVE OBSTETRICS IN THE TROPICS
• DC DUTTA TEXTBOOK OF OBSTETRICS
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25. THANK YOU
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