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ANEMIA IN
PREGNANCY
Dr.Akebom Kidanemariam.
( MD,Assistant professor of Gynecology and Obestetrics, Mekelle University college of health sciences)
Learning Objectives
• INTRODUCTIONS
• DEFINITION
• EPIDEMIOLOGY
• CAUSES OF ANEMIA(Physiologic, Iron deficiency )
• SCREENING DURING PREGNANCY
• CLINICAL PRESENTATION
• EFFECTS OF ANEMIA
• EVALUATION OF ANEMIA
• MANAGEMENT
INTRODUCTION
• Pregnant women are susceptible to several hematological
abnormalities
• Pregnancy induced physiological changes often confuse diagnosis
• Anemia in pregnancy is a global health problem.
• Most common hematologic abnormality
DEFINITION
• A decrease in the oxygen-carrying capacity of the blood and is best characterized
by a reduction in hemoglobin concentration
• First trimester – HGB<11 g/dL ( HCT <33 %)
• Second trimester – HGB <10.5 g/dL ( HCT <32 %)
• Third trimester – HGB <11 g/dL (HCT <33 %)
• Postpartum – HGB <10 g/dL ( HCT<30 %)
EPIDEMIOLOGY
• Over 40 percent of pregnancies are complicated by anemia(WHO)
• Africa - 46%
• EDHS 2016 - 41% Variations in socioeconomic status
• Americas - 19 %
• Majority of anemia in reproductive-age females is due to low or absent iron stores
- IDA( world's most common anemia)
CAUSES OF ANEMIA DURING PREGNANCY
Common Causes: 85% of
Anemia
Physiologic anemia
Iron deficiency
Uncommon Causes
Folic acid deficiency
Vitamin B12 deficiency
Hemoglobinopathies
• Sickle cell disease
• Hemoglobin SC
• β-Thalassemia minor
Bariatric surgery
Gastrointestinal bleeding
Rare Causes
Hemoglobinopathies
• β-Thalassemia major
• α-Thalassemia
Syndromes of chronic hemolysis
• Hereditary spherocytosis
• Paroxysmal nocturnal hemoglobinuria
Hematologic malignancy
PHYSIOLOGIC ANEMIA/DILUTIONAL
Iron deficiency Anemia/Iron metabolism
• RDA; 27mg
• Absorption ; duodenum and upper jejunum
via DMT1on enterocytes
• Non - heme ferrous iron(FE2+)
• Regulated by Hepcidine
• No specific mechanism for excreation
• Storage ; BM, liver, and spleen in the form
of ferritin, 25% (500 mg) of the 2 g of iron
stores
• 65% of stored iron - circulating RBCs
Iron deficiency
• Abnormal value on biochemichal test results or
• Increase in Hemoglobin concentration of > 1g/dl after iron treatment or
• Absent bonemarrow iron stores on bone marrow smear
• Specterum of iron deficiency
Iron depletion(low stored iron) → Iron deficient erythropoiesis(low
stored and transport iron) → Iron deficiency anemia( low stored
,transport and functional iron)
Iron deficiency Anemia
• The first pathologic change to occur in iron deficiency anemia is the depletion of
bone marrow, liver, and spleen iron stores.
• Over a period of a few weeks, the serum iron level falls, as does the percentage
saturation of transferrin.
• The total iron-binding capacity rises simultaneously with the fall of iron.
• A falling hemoglobin and hematocrit follow within 2 weeks.
• Microcytic hypochromic RBCs are released into the circulation
Iron deficiency Anemia
• Most common pathologic cause of anemia in pregnancy
• Iron deficiency is a widespread phenomenon
• The prevalence of iron deficiency during pregnancy is higher
Iron deficiency Anemia
• Factors that contribute to iron deficiency in this population:
Insufficient dietary iron
Blood loss from previous pregnancies and/or menstruation
Short interpartum interval
Conditions that preclude adequate iron intake or impair iron
absorption( nausea and vomiting of pregnancy, inflammatory bowel
disease, bariatric surgery)
Iron deficiency Anemia
• Iron requirements increase dramatically through out pregnancy
Function Requirement
Increased red blood cell mass 450 mg
Fetus and placenta 360 mg
Vaginal delivery 190 - 250 mg
Lactation 1 mg/day
Iron deficiency Anemia
• Iron requirments during pregnancy
First trimester ~1 to 2 mg/day of iron is needed
Second trimeste ~ 4 to 5 mg/day
Third trimester ~ 6 mg/day
SCREENING DURING PREGNANCY
• Screening for anemia during pregnancy is universally accepted
• First prenatal visit with a complete blood count (CBC)
• Reasonable to screen all pregnant individuals for iron deficiency, even if not
anemic( FIGO 2023)
• Repeat screening with a CBC at week 24 to 28.
Individuals at high risk
• Previous diagnosis of iron deficiency
• Diabetes
• Smoking
• HIV infection
• Inflammatory bowel disease
• Multiparas ,(IPI <6 months)
• History of AUB
• BMI above or below the normal range
• Vegetarian or vegan diet
• Symptoms such as restless legs
syndrome or pica, especially
pagophagia (ice craving)
• Decreased access to health care
Screening for iron deficiency anemia
• A ferritin level
<30 ng/mL [<30 mcg/L]), this is sufficient to confirm the diagnosis of iron
deficiency.
 ≥30 ng/mL are sufficient to eliminate the possibility of iron deficiency in
the majority of cases.
• Borderline serum ferritin (30 to 40 ng/mL)( DM,CKD, Collagen vascular disease)
- APR
• Borderline ferritin levels - testing of a full set of iron studies
Screening for iron deficiency anemia
• Transferrin saturation (TSAT);
< 16 % without inflammation
< 20 % with inflammation
• Iron supplements can falsely elevate the TSAT
 peaks at approximately four hours after an oral dose.
•
Clinical Presentation
• Depends on severity of anemia
• The most usual clinical symptoms of iron-deficiency anemia are lethargy and
fatigue, although they are also seen in normal pregnancy
• Mild anemic - asymptomatic
• Symptoms – pallor, weakness, fatigue, dyspnoea, palpitation, swelling over feet &
body
• Signs – pallor, facial puffiness, raised JVP, tachycardia, tachypnea, crepts in lung
bases, hepato-splenomegaly, pitting oedema over abdominal wall & legs
• Haemic murmur, cardiac failure
• Glossitis, stomatitis, chelosis, brittle hair
Effect of Anemia on Pregnancy & Mother
• Higher incidence of pregnancy complications
• PET, abruptio placentae, preterm labor
• Predisposed to infections like – UTI, puerperal sepsis
• Increased risk to PPH
• Subinvolution of uterus
• Lactation failure
• Maternal mortality – due to
• CHF,
• Cerebral anoxia,
• Sepsis,
• Thrombo-embolism
Effect of Anemia on Fetus & Neonate
• Higher incidence of abortions, preterm birth, IUGR
• IUD
• Low APGAR at birth
• Neonate more susceptible for anemia & infections
• Higher Perinatal morbidity & mortality
• Anemic infant with cognitive & affective dysfunction
EVALUATION OF ANEMIA
• Detailed H/o – age, parity, diet, chronic bleeding, worm infestation, malaria, race
• Physical Examination
• Pallor
• Glossitis
• Splenomegaly – hemolytic anemia
• Jaundice – hemolytic anemia
• Purpura – bleeding disorder
• Evidence of chronic disease – Renal , TB
• Anasarca & signs of cardiac failure in severe cases
EVALUATION OF ANEMIA
• CBC
RBC count – decreases in anemia (N 3.2 million/cu mm)
MCV – low in Fe def anemia, microcytic
MCH - decreases
MCHC – decreases, one of the most sensitive indices (N26-30%)
• Serum Iron studies
• Urine examination – RBC & Casts
• Stool examination – occult blood, ova
• Bone marrow examination – refractory anemia
• X-Ray chest – Pulmonary TB
• BUN/Serum creatinine – Renal disease
MANAGEMENT
• Prevention of iron deficiency ;
 Supplemental oral iron 27 to 30 mg daily throughout
pregnancy(CDC,ACOG)
 60 mg once every other day
 Improving diet rich in iron
 Treat worm infections, maintain general hygiene
 Food fortification with iron & genetic modification of food
Iron indices in pregnancy and Iron deficiency
Test Normal values Iron deficiency anemia
Plasma iron level 40 - 175 micrograms/dl Decreased
Plasma total iron binding capacity 216 - 400 micrograms/dl Increased
Transferrin saturation 16 -60% < 16%
Serum ferittin level >10 micrograms/dl Decreased
Free erythrocyte protoporphyrin
level
< 3 micrograms/g
Iron deficiency – Microcytic (small RBC), hypochromic (pale RBC), anisocytosis (variation in size),
poikilocytosis (variation in shape), with or without target cells
IRON RICH FOODS
• Green leafy vegetables-chana sag,
sarson ka sag, chauli. Sowa, salgam
• Cereals - wheat, ragi, jowar, bajra
• Pulses-sprouted pulses
• Jaggery
• Animal flesh food - meat, liver
• Vit C - lemon, orange, guava, amla,
green mango etc.
MANAGMENT
• Oral iron
• Iv iron - A test dose is strongly recommended, used in 2nd & 3rd
trimesters only
• Transfussion
Elemental Iron Available From Common Generic Iron
Preparations
Ferrous gluconate 325 mg 37–39mmg
Ferrous sulfate 325 mg 60–65mg
Ferrous fumarate 325 mg 107 mg
 Iron absorption enhanced by citrous fruits, Vit C
 Avoid tea, coffee, Ca, phytates, phosphates, oxalates, egg, cereals with iron
 Maximum absorption in empty stomach
Parenteral Iron Administration
Medication Dose Preparation
Iron dextran Total dose (mL) = 0.0442
(desired Hb − observed
Hb)
× LBW + (0.26 × LBW),
100 mg/dose maximum
50 mg elemental
iron/mL
Iron sucrose 100 mg/dose, usually 1
dose/
day, usually 10 doses
needed
20 mg elemental
iron/mL
Sodium ferric
gluconate
complex
125 mg/dose, usually 1
dose/
day, usually 8 doses
needed
12.5 mg of
elemental
iron/mL
Oral vs IV iron
Assessing response to treatment
• Reticulocytosis after approximately one week,
• Increase in the hemoglobin level of at least 1 g/dL within two to three weeks
• Increase in serum ferritin into the normal range, typically within three weeks
•
Assessing response to treatment
• Check the hemoglobin level and reticulocyte count two to three weeks after
starting therapy of oral iron
 Good response = continue through out pregnancy
 Not good/ not tolerable= changes to increase tolerability/ change
to IV iron
MACROCYTIC ANEMIA( MCV > 100fl)
• Megaloblastic
 Folate deficiency
 Vitamine B 12
 Pernicious anemia
• Non megaloblastic
 Alcholism
 Liver disease
 Meyelodysplasias
 Aplastic anemia
 Hypothyroidism
 Increased reticulocyte count
Folic Acid Deficiency Anemia
• Second in occurrence as a cause for nutritional deficiency anemia of pregnancy
after iron deficiency anemia.
• During pregnancy, folate deficiency is the most common cause of megaloblastic
anemia.
Folic Acid Deficiency Anemia
Folate
• Necessary for appropriate DNA
synthesis and amino acid production
• Common sources are green
vegetables, fruits (lemons, melons),
and meats (liver, kidney),peanuts and
liver
• The absorption happens in the
proximal jejunum
• RDA- 50 µg,( ↑ 4 fold in pregnancy)
• Stored primarily in the liver and are
usually sufficient for 6 weeks.
• After 3 weeks of a diet deficient in
folate, the serum folate level falls.
• Two weeks later, hypersegmentation
of neutrophils occurs.
• After 17 weeks without folic acid
ingestion, RBC folate levels drop.
• In the next week, a megaloblastic bone
marrow develops
Folic Acid Deficiency Anemia
• Etiology
 Decreased intake (poor nutrition)
 Impaired absorption
 Increased folic acid requirements( f
fetal growth and maternal
erythropoiesis)
 Higher levels of estrogen and
progesterone(inhibitory effect on
folate absorption)
• Symptoms
• General anemia symptoms
• Roughness of the skin
• Glossitis
Folic Acid Deficiency Anemia
• Diagnosis
Normochromic macrocytic erythrocyte
precursors
Abnormal nuclear–cytoplasmic
appearance
MCH and MCHC are usually normal
 Hypersegmented neutrophils
 Serum / RBC folate < 4ng/ml
 Neutropenia and Thrombocytopenia
• Pregnancy adverse effects
Increased incidences( in experimental
animals)
prematurity
fetal death,
 hypertension,
placental abruption
 fetal malformations.
Folic Acid Deficiency Anemia
• Prenatal vitamins that contain 0.8 mg
or 1 mg of folic acid are more than
adequate to prevent and treat folate
deficiency.
• Women with:
 Significant hemoglobinopathies
 Taking anticonvulsant
 Carrying a multiple gestation
 Frequent conception
 > 4 mg folic acid(reduce the risk of
recurrent NTDs)
Vitamin B12 deficiency
• unusual
• Causes during pregnancy
Strict vegetarian diet
 Use of proton pump inhibitors
 Metformin
 Gastritis
 Gastrectomy
 Ileal bypass
 Crohn disease
 Sprue
 Helicobacter pylori infection
Vitamin B12 deficiency
• Cobalamin is found only in animal
products
• The daily minimum required intake is
6 to 9 µg.
• Total body stores are 2 to 5 mg
• one-half of this is stored in the liver.
• Abundant vitamin B12 stores in the
body
• It takes several years for a clinical
vitamin B12 deficiency to develop.
• For cobalamin to be absorbedan
individual needs;
(1) acid-pepsin in the stomach,
(2) intrinsic factor secreted by
(3) pancreatic proteases
(4) Intact ileum with receptors
Vitamin B12 deficiency
• Evaluation of methylmalonate and homocysteine levels to distinguish
folate deficiency from vitamin B12 deficiency.
• Treatment
Without neurologic involvement
- Hydroxocobalamin(IM): 1 mg three times a week for 2 weeks then
1mg every 2/3 months
With neurologic involvement
- Hydroxocobalamin(IM): 1 mg daily on alternate days then 1mg q 1
months
Management of other anemias
• Sickle cell disease (SCD)- Transfusion in individuals with SCD; genetic
counseling for those with SCD or sickle cell trait
• Thalassemia - Transfusion in certain individuals; genetic counseling; prenatal
testing for thalassemia A
• Hereditary hemorrhagic telangiectasia (HHT)-Intravenous iron
• Autoimmune hemolytic anemia (AIHA)-Transfusions, glucocorticoids, or
intravenous immune globulin if needed
4/7/2024 42
By. Dr. AKEBOM(MD,GYNOBS SPECIALIST)
THANK YOU

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ANEMIA IN PREGNANCY by Dr. Akebom Kidanemariam

  • 1. ANEMIA IN PREGNANCY Dr.Akebom Kidanemariam. ( MD,Assistant professor of Gynecology and Obestetrics, Mekelle University college of health sciences)
  • 2. Learning Objectives • INTRODUCTIONS • DEFINITION • EPIDEMIOLOGY • CAUSES OF ANEMIA(Physiologic, Iron deficiency ) • SCREENING DURING PREGNANCY • CLINICAL PRESENTATION • EFFECTS OF ANEMIA • EVALUATION OF ANEMIA • MANAGEMENT
  • 3. INTRODUCTION • Pregnant women are susceptible to several hematological abnormalities • Pregnancy induced physiological changes often confuse diagnosis • Anemia in pregnancy is a global health problem. • Most common hematologic abnormality
  • 4. DEFINITION • A decrease in the oxygen-carrying capacity of the blood and is best characterized by a reduction in hemoglobin concentration • First trimester – HGB<11 g/dL ( HCT <33 %) • Second trimester – HGB <10.5 g/dL ( HCT <32 %) • Third trimester – HGB <11 g/dL (HCT <33 %) • Postpartum – HGB <10 g/dL ( HCT<30 %)
  • 5. EPIDEMIOLOGY • Over 40 percent of pregnancies are complicated by anemia(WHO) • Africa - 46% • EDHS 2016 - 41% Variations in socioeconomic status • Americas - 19 % • Majority of anemia in reproductive-age females is due to low or absent iron stores - IDA( world's most common anemia)
  • 6. CAUSES OF ANEMIA DURING PREGNANCY Common Causes: 85% of Anemia Physiologic anemia Iron deficiency Uncommon Causes Folic acid deficiency Vitamin B12 deficiency Hemoglobinopathies • Sickle cell disease • Hemoglobin SC • β-Thalassemia minor Bariatric surgery Gastrointestinal bleeding Rare Causes Hemoglobinopathies • β-Thalassemia major • α-Thalassemia Syndromes of chronic hemolysis • Hereditary spherocytosis • Paroxysmal nocturnal hemoglobinuria Hematologic malignancy
  • 8. Iron deficiency Anemia/Iron metabolism • RDA; 27mg • Absorption ; duodenum and upper jejunum via DMT1on enterocytes • Non - heme ferrous iron(FE2+) • Regulated by Hepcidine • No specific mechanism for excreation • Storage ; BM, liver, and spleen in the form of ferritin, 25% (500 mg) of the 2 g of iron stores • 65% of stored iron - circulating RBCs
  • 9. Iron deficiency • Abnormal value on biochemichal test results or • Increase in Hemoglobin concentration of > 1g/dl after iron treatment or • Absent bonemarrow iron stores on bone marrow smear • Specterum of iron deficiency Iron depletion(low stored iron) → Iron deficient erythropoiesis(low stored and transport iron) → Iron deficiency anemia( low stored ,transport and functional iron)
  • 10. Iron deficiency Anemia • The first pathologic change to occur in iron deficiency anemia is the depletion of bone marrow, liver, and spleen iron stores. • Over a period of a few weeks, the serum iron level falls, as does the percentage saturation of transferrin. • The total iron-binding capacity rises simultaneously with the fall of iron. • A falling hemoglobin and hematocrit follow within 2 weeks. • Microcytic hypochromic RBCs are released into the circulation
  • 11. Iron deficiency Anemia • Most common pathologic cause of anemia in pregnancy • Iron deficiency is a widespread phenomenon • The prevalence of iron deficiency during pregnancy is higher
  • 12. Iron deficiency Anemia • Factors that contribute to iron deficiency in this population: Insufficient dietary iron Blood loss from previous pregnancies and/or menstruation Short interpartum interval Conditions that preclude adequate iron intake or impair iron absorption( nausea and vomiting of pregnancy, inflammatory bowel disease, bariatric surgery)
  • 13. Iron deficiency Anemia • Iron requirements increase dramatically through out pregnancy Function Requirement Increased red blood cell mass 450 mg Fetus and placenta 360 mg Vaginal delivery 190 - 250 mg Lactation 1 mg/day
  • 14. Iron deficiency Anemia • Iron requirments during pregnancy First trimester ~1 to 2 mg/day of iron is needed Second trimeste ~ 4 to 5 mg/day Third trimester ~ 6 mg/day
  • 15. SCREENING DURING PREGNANCY • Screening for anemia during pregnancy is universally accepted • First prenatal visit with a complete blood count (CBC) • Reasonable to screen all pregnant individuals for iron deficiency, even if not anemic( FIGO 2023) • Repeat screening with a CBC at week 24 to 28.
  • 16. Individuals at high risk • Previous diagnosis of iron deficiency • Diabetes • Smoking • HIV infection • Inflammatory bowel disease • Multiparas ,(IPI <6 months) • History of AUB • BMI above or below the normal range • Vegetarian or vegan diet • Symptoms such as restless legs syndrome or pica, especially pagophagia (ice craving) • Decreased access to health care
  • 17. Screening for iron deficiency anemia • A ferritin level <30 ng/mL [<30 mcg/L]), this is sufficient to confirm the diagnosis of iron deficiency.  ≥30 ng/mL are sufficient to eliminate the possibility of iron deficiency in the majority of cases. • Borderline serum ferritin (30 to 40 ng/mL)( DM,CKD, Collagen vascular disease) - APR • Borderline ferritin levels - testing of a full set of iron studies
  • 18. Screening for iron deficiency anemia • Transferrin saturation (TSAT); < 16 % without inflammation < 20 % with inflammation • Iron supplements can falsely elevate the TSAT  peaks at approximately four hours after an oral dose. •
  • 19. Clinical Presentation • Depends on severity of anemia • The most usual clinical symptoms of iron-deficiency anemia are lethargy and fatigue, although they are also seen in normal pregnancy • Mild anemic - asymptomatic • Symptoms – pallor, weakness, fatigue, dyspnoea, palpitation, swelling over feet & body • Signs – pallor, facial puffiness, raised JVP, tachycardia, tachypnea, crepts in lung bases, hepato-splenomegaly, pitting oedema over abdominal wall & legs • Haemic murmur, cardiac failure • Glossitis, stomatitis, chelosis, brittle hair
  • 20. Effect of Anemia on Pregnancy & Mother • Higher incidence of pregnancy complications • PET, abruptio placentae, preterm labor • Predisposed to infections like – UTI, puerperal sepsis • Increased risk to PPH • Subinvolution of uterus • Lactation failure • Maternal mortality – due to • CHF, • Cerebral anoxia, • Sepsis, • Thrombo-embolism
  • 21. Effect of Anemia on Fetus & Neonate • Higher incidence of abortions, preterm birth, IUGR • IUD • Low APGAR at birth • Neonate more susceptible for anemia & infections • Higher Perinatal morbidity & mortality • Anemic infant with cognitive & affective dysfunction
  • 22. EVALUATION OF ANEMIA • Detailed H/o – age, parity, diet, chronic bleeding, worm infestation, malaria, race • Physical Examination • Pallor • Glossitis • Splenomegaly – hemolytic anemia • Jaundice – hemolytic anemia • Purpura – bleeding disorder • Evidence of chronic disease – Renal , TB • Anasarca & signs of cardiac failure in severe cases
  • 23. EVALUATION OF ANEMIA • CBC RBC count – decreases in anemia (N 3.2 million/cu mm) MCV – low in Fe def anemia, microcytic MCH - decreases MCHC – decreases, one of the most sensitive indices (N26-30%) • Serum Iron studies • Urine examination – RBC & Casts • Stool examination – occult blood, ova • Bone marrow examination – refractory anemia • X-Ray chest – Pulmonary TB • BUN/Serum creatinine – Renal disease
  • 24. MANAGEMENT • Prevention of iron deficiency ;  Supplemental oral iron 27 to 30 mg daily throughout pregnancy(CDC,ACOG)  60 mg once every other day  Improving diet rich in iron  Treat worm infections, maintain general hygiene  Food fortification with iron & genetic modification of food
  • 25. Iron indices in pregnancy and Iron deficiency Test Normal values Iron deficiency anemia Plasma iron level 40 - 175 micrograms/dl Decreased Plasma total iron binding capacity 216 - 400 micrograms/dl Increased Transferrin saturation 16 -60% < 16% Serum ferittin level >10 micrograms/dl Decreased Free erythrocyte protoporphyrin level < 3 micrograms/g Iron deficiency – Microcytic (small RBC), hypochromic (pale RBC), anisocytosis (variation in size), poikilocytosis (variation in shape), with or without target cells
  • 26. IRON RICH FOODS • Green leafy vegetables-chana sag, sarson ka sag, chauli. Sowa, salgam • Cereals - wheat, ragi, jowar, bajra • Pulses-sprouted pulses • Jaggery • Animal flesh food - meat, liver • Vit C - lemon, orange, guava, amla, green mango etc.
  • 27. MANAGMENT • Oral iron • Iv iron - A test dose is strongly recommended, used in 2nd & 3rd trimesters only • Transfussion
  • 28. Elemental Iron Available From Common Generic Iron Preparations Ferrous gluconate 325 mg 37–39mmg Ferrous sulfate 325 mg 60–65mg Ferrous fumarate 325 mg 107 mg  Iron absorption enhanced by citrous fruits, Vit C  Avoid tea, coffee, Ca, phytates, phosphates, oxalates, egg, cereals with iron  Maximum absorption in empty stomach
  • 29. Parenteral Iron Administration Medication Dose Preparation Iron dextran Total dose (mL) = 0.0442 (desired Hb − observed Hb) × LBW + (0.26 × LBW), 100 mg/dose maximum 50 mg elemental iron/mL Iron sucrose 100 mg/dose, usually 1 dose/ day, usually 10 doses needed 20 mg elemental iron/mL Sodium ferric gluconate complex 125 mg/dose, usually 1 dose/ day, usually 8 doses needed 12.5 mg of elemental iron/mL
  • 30. Oral vs IV iron
  • 31. Assessing response to treatment • Reticulocytosis after approximately one week, • Increase in the hemoglobin level of at least 1 g/dL within two to three weeks • Increase in serum ferritin into the normal range, typically within three weeks •
  • 32. Assessing response to treatment • Check the hemoglobin level and reticulocyte count two to three weeks after starting therapy of oral iron  Good response = continue through out pregnancy  Not good/ not tolerable= changes to increase tolerability/ change to IV iron
  • 33. MACROCYTIC ANEMIA( MCV > 100fl) • Megaloblastic  Folate deficiency  Vitamine B 12  Pernicious anemia • Non megaloblastic  Alcholism  Liver disease  Meyelodysplasias  Aplastic anemia  Hypothyroidism  Increased reticulocyte count
  • 34. Folic Acid Deficiency Anemia • Second in occurrence as a cause for nutritional deficiency anemia of pregnancy after iron deficiency anemia. • During pregnancy, folate deficiency is the most common cause of megaloblastic anemia.
  • 35. Folic Acid Deficiency Anemia Folate • Necessary for appropriate DNA synthesis and amino acid production • Common sources are green vegetables, fruits (lemons, melons), and meats (liver, kidney),peanuts and liver • The absorption happens in the proximal jejunum • RDA- 50 µg,( ↑ 4 fold in pregnancy) • Stored primarily in the liver and are usually sufficient for 6 weeks. • After 3 weeks of a diet deficient in folate, the serum folate level falls. • Two weeks later, hypersegmentation of neutrophils occurs. • After 17 weeks without folic acid ingestion, RBC folate levels drop. • In the next week, a megaloblastic bone marrow develops
  • 36. Folic Acid Deficiency Anemia • Etiology  Decreased intake (poor nutrition)  Impaired absorption  Increased folic acid requirements( f fetal growth and maternal erythropoiesis)  Higher levels of estrogen and progesterone(inhibitory effect on folate absorption) • Symptoms • General anemia symptoms • Roughness of the skin • Glossitis
  • 37. Folic Acid Deficiency Anemia • Diagnosis Normochromic macrocytic erythrocyte precursors Abnormal nuclear–cytoplasmic appearance MCH and MCHC are usually normal  Hypersegmented neutrophils  Serum / RBC folate < 4ng/ml  Neutropenia and Thrombocytopenia • Pregnancy adverse effects Increased incidences( in experimental animals) prematurity fetal death,  hypertension, placental abruption  fetal malformations.
  • 38. Folic Acid Deficiency Anemia • Prenatal vitamins that contain 0.8 mg or 1 mg of folic acid are more than adequate to prevent and treat folate deficiency. • Women with:  Significant hemoglobinopathies  Taking anticonvulsant  Carrying a multiple gestation  Frequent conception  > 4 mg folic acid(reduce the risk of recurrent NTDs)
  • 39. Vitamin B12 deficiency • unusual • Causes during pregnancy Strict vegetarian diet  Use of proton pump inhibitors  Metformin  Gastritis  Gastrectomy  Ileal bypass  Crohn disease  Sprue  Helicobacter pylori infection
  • 40. Vitamin B12 deficiency • Cobalamin is found only in animal products • The daily minimum required intake is 6 to 9 µg. • Total body stores are 2 to 5 mg • one-half of this is stored in the liver. • Abundant vitamin B12 stores in the body • It takes several years for a clinical vitamin B12 deficiency to develop. • For cobalamin to be absorbedan individual needs; (1) acid-pepsin in the stomach, (2) intrinsic factor secreted by (3) pancreatic proteases (4) Intact ileum with receptors
  • 41. Vitamin B12 deficiency • Evaluation of methylmalonate and homocysteine levels to distinguish folate deficiency from vitamin B12 deficiency. • Treatment Without neurologic involvement - Hydroxocobalamin(IM): 1 mg three times a week for 2 weeks then 1mg every 2/3 months With neurologic involvement - Hydroxocobalamin(IM): 1 mg daily on alternate days then 1mg q 1 months
  • 42. Management of other anemias • Sickle cell disease (SCD)- Transfusion in individuals with SCD; genetic counseling for those with SCD or sickle cell trait • Thalassemia - Transfusion in certain individuals; genetic counseling; prenatal testing for thalassemia A • Hereditary hemorrhagic telangiectasia (HHT)-Intravenous iron • Autoimmune hemolytic anemia (AIHA)-Transfusions, glucocorticoids, or intravenous immune globulin if needed 4/7/2024 42 By. Dr. AKEBOM(MD,GYNOBS SPECIALIST)