pathological condition in which the oxygen carrying capacity of red blood cells is insufficient to meet the body ‘s needs The world health organization uses haemoglobin Concentration to define anaemia, below 120 g/l in nonpregnant Women and 110 g/l in pregnancy. Anaemia in pregnancy is defined as first trimester haemoglobin (Hb) less than 110 g/l second/third trimester Hb less than 105 g/l postpartum Hb less than 100 g/l PREVALANCE- 40% of world ‘s population (35% non-preg 51%pregnant) 56% in Pakistan MORTALITY 40-60% IN Pakistan 18% in industerlised countries Reason of anemia during pregnancy Physiological hamodilution Increase iron demand Diminished intake of iron--- bcs of nvp Disturbed metabolism Pre-pregnancy health status Excess demand. (Twin) During pregnancy, iron requirements increase (due to expanding red cell mass and increasing fetal requirements)by 2.5 mg/day in the first trimester to 6.6 mg/day in the third trimester. There is an increase in iron absorption from the gastrointestinal tract during pregnancy. Folic acid requirements also increase in pregnancy due to increased red cell mass and the expanding feto–placental unit. Vitamin B12 decreases in pregnancy (205–1025 pg/ml to 30–510 pg/ml in pregnancy). Despite lower concentrations, there is rarely, if ever, evidence of biochemical vitamin B12 deficiency. gastrointestinal issues affecting absorption short inter-pregnancy interval  Other : parasitic diseases micronutrient deficiencies genetically inherited hemoglobinopathies TYPES OF ANAEMIA DURING PREGNANCY Physiologic Pathologic: 1 . Hereditary causes Thalassaemias , Sickle Cell. Haemoglobinopathies , Haemolytic anaemias , other type ofHaemgobinopathies. 2 .Acquired Causes A . Nutritional---Iron deficiency anaemia ( microcytic hypocromic anaaemia , Folate deficiency anaemia ( megaloblastic anaemia ) , Vit B12 Deficiency anaemia ( Megaloblastic anaemia ) B . Anaemia due to bone marrow failure ( aplstic / hypo plastic anaemia ). C . Anaemia secondary to inflammation , chronic disease , malignancy. D . Anemia due to acute / chronic blood loss. E . Acquire hemolytic anemia. IRON ABSORBTION Dietary iron (heme and non heme) - heme-animal blood flesh viseras -Non heme-cerels, seeds, vegetables, milk eggs. Factors increases iron absorbtion Heme iron Proteins Meat Ascorbic acid Fermentation Ferrous iron Gastric acidity Alcohol Low iron stores Increase erethropiioetic activity(hight altitue,bleeding) FACTROS DECREASES IRON ABSORBTION Phytates Calcium Tennins, tea, coffee, herbal drinks Fortified iron supplements IRON LOSS PHYSIOLOGIC FACTORS Desquamation of cells( intestine, skin) Menstruation Delivery Lactation PATHOLOGIC FACTORS Hookworms /other helmentis Bleeding from GIT Allergies Occult blood loss, excess menses,APH Pharmaco-kinetics of Iron Normal diet contain about 14 mg of iron Absorption of iron is 5-10% Additional daily iron demand in early pregnancy 2-3 mg/day In late pregnancy 6-7 mg/day So daily su

1. ANEMIA IN PREGNANCY
DR SHABNAM NAZ
PROFESSOR
OBGYN
CMC,SMBBMU LARKANA

2. DEFINITION
• A pathological condition in which
the oxygen carrying capacity of
red blood cells is insufficient to
meet the body ‘s needs
• The world health organization
uses haemoglobin Concentration
to define anaemia, below 120 g/l
in nonpregnant Women and 110
g/l in pregnancy.
Anaemia in pregnancy is
defined as
• first trimester
haemoglobin (Hb) less than
110 g/l
• second/third trimester Hb
less than 105 g/l
• postpartum Hb less than
100 g/l
PREVALANCE-
40% of world ‘s population
(35% non-preg 51%pregnant)
56% in Pakistan
MORTALITY
40-60% IN Pakistan
18% in industerlised countries

3. PHYSIOLOGICAL CHANGES IN
BLOOD DURING PREGNANCY
• Plasma volume increased
50%
• Red cell mass increased
25%
• Fall in Hb conc:, haematocrit &
red cell count .
• MCV increased secondary to
erythropoiesis
• MCHC remains stable
• Sr: iron and ferritin decrease
• TIBC increased---

4. • Reason of anemia during pregnancy
• Physiological hamodilution
Increase iron demand
Diminished intake of iron--- bcs of nvp
• Disturbed metabolism
• Pre-pregnancy health status
• Excess demand. (Twin)
• During pregnancy, iron requirements increase (due to
expanding red cell mass and increasing fetal
requirements)by 2.5 mg/day in the first trimester to 6.6
mg/day in the third trimester.
• There is an increase in iron absorption from the
gastrointestinal tract during pregnancy.
• Folic acid requirements also increase in pregnancy due to
increased red cell mass and the expanding feto–placental
unit.
• Vitamin B12 decreases in pregnancy (205–1025 pg/ml to
30–510 pg/ml in pregnancy). Despite lower
concentrations, there is rarely, if ever, evidence of
gastrointestinal
issues affecting
absorption
short inter-
pregnancy interval
 Other :
parasitic diseases
micronutrient
deficiencies
genetically inherited
hemoglobinopathies

5. SEVERITY/ DEGREE OF
ANEMIA

6. TYPES OF ANAEMIA DURING PREGNANCY
• Physiologic
• Pathologic:
• 1 . Hereditary causes
• Thalassaemias , Sickle Cell.
Haemoglobinopathies , Haemolytic
anaemias , other type
ofHaemgobinopathies.
• 2 .Acquired Causes
• A . Nutritional---Iron deficiency anaemia
• ( microcytic hypocromic anaaemia ,
Folate deficiency anaemia (
megaloblastic anaemia ) , Vit B12
Deficiency anaemia ( Megaloblastic
anaemia )
B . Anaemia due to bone
marrow failure ( aplstic /
hypo plastic
anaemia ).
C . Anaemia secondary
to inflammation , chronic
disease ,
malignancy.
D . Anemia due to acute
/ chronic blood loss.
E . Acquire hemolytic
anemia.

7. CONCEPT OF PHYSIOLOGIC
ANEMIA
• Disproportionate increase in plasma
vol, RBC vol. and hemoglobin mass
during pregnancy
• Marked demand of extra iron during
pregnancy especially in second
trimester
• Significance of Hypervolemia
• To meet the demands of the enlarged
uterus with its greatly hypertrophied
vascular system.
2. To protect the mother, and in turn the
fetus, against the deleterious effects of
impaired venous return in the supine
and erect positions.
3. To safeguard the mother against the
adverse effects of blood loss associated
with parturition

8. CRITERIA FOR PHYSIOLOGIC
ANEMIA
• Hb: 10gm%
• RBC: 3.2 million/mm3
• PCV: 30%
• Peripheral smear showing
normal morphology of RBC
with central pallor

9. IRON DEFICIENCY ANEMIA

10. • IRON ABSORBTION
• Dietary iron (heme and non
heme)
- heme-animal blood flesh viseras
-Non heme-cerels, seeds, vegetables, milk eggs.
• Factors increases iron absorbtion
• Heme iron
• Proteins
• Meat
• Ascorbic acid
• Fermentation Ferrous iron
• Gastric acidity
• Alcohol
• Low iron stores
• Increase erethropiioetic activity(hight
altitue,bleeding)
FACTROS DECREASES IRON ABSORBTION
• Phytates
• Calcium
• Tennins, tea, coffee, herbal drinks
• Fortified iron supplements

11. IRON LOSS
PHYSIOLOGIC FACTORS
• Desquamation of cells( intestine, skin)
• Menstruation
• Delivery
• Lactation
PATHOLOGIC FACTORS
• Hookworms /other helmentis
• Bleeding from GIT
• Allergies
• Occult blood loss, excess menses,APH

12. • Pharmaco-kinetics of Iron
• Normal diet contain about 14 mg of iron
• Absorption of iron is 5-10%
• Additional daily iron demand in early pregnancy 2-3 mg/day
• In late pregnancy 6-7 mg/day
• So daily supplement of 40-60 mg of elemental iron is required
• during pregnancy
• Pregnancy results in an increased iron requirement of 1200 mg for
• the entirety of pregnancy and this must be met through nutritional
• changes and supplementation, where necessary.
• Iron is required by the fetus and the mother as the maternal
• erythrocyte mass increases from 350 ml to 450 ml

13. CAUSES OF IRON DEFICIENCY

14. • The most common cause of anaemia is iron deficiency.
the most likely cause of treatment failure is non -
compliance.
• menstrual blood loss is the most common cause of
deficiency and iron-deficiency anaemia in
premenopausal women, account for 20–30% of cases
iron-deficiency anaemia worldwide.
• In postmenopausal women, the most common cause
anaemia is blood loss from the GIT.

15. SYMPTOMS & SIGNS
 Classic symptoms of iron
deficiency and iron-
deficiency anaemia
include:
 Fatigue
 weakness
 Irritability
 hair loss
 poor concentration

16. SIGNS of ANEMIA
SIGNS
• Palar of skin , conjunctiva, mucous
membrane
• Tachycardia high volume pulse
• Ankle edema
• Cardiac failure
• Systolic flow murmur
Specific signs of iron deficiency
• koilonychias, brittle nails atrophy of
papilla of tongue,Angular stomatisis,
brittle hair, palmmer winson syndrome

17. EFFECTS OF ANEMIA ON PREGNANCY
MATERNAL EFFECTS
• Preterm labour
• Anasarca
• CCF
• Pulmonary edema
• PPH
• P-Sepsis
• Failing lactation
• Sub involution of uterus
• Thromboembolism
• Maternal mortality in 3rd trimester ,during
labour ,delivery ,immediately after delivery
,during peurperium due to heart failure and
pulmonary embolism
.
FETAL EFFECTS
Pre-term birth
SGA
Infection
Anemia
Low iron store
High peri-natal mortality

18. ADVERSE MATERNAL AND FETAL OUTCOMES
• Mild anemia
The conclusions of
several studies
chronic mild anemia
can lead to a normal
course of pregnancy
and to a labor
without any adverse
consequences.
Moderate to severe anemia
A strong association has been found between
moderate to severe anemia at 28 weeks of gestation
and the severity of intra‐ and postpartum hemorrhage,
which cause 23% of maternal deaths.
preterm delivery, low birth weight infants, or maternal
morbidity, except in cases of severe anemia.
suboptimal fetal outcome; however, data supporting
this concept are not clear
Fetal iron needs will be compromised when maternal
iron stores are suboptimal.
altered or limited iron supply in utero, during key
windows of development, may lead to adaptive
responses that permanently impact metabolic or
developmental programming and the developing brain
The relationship between anemia and perinatal
mortality is still unclear

19. • Optimisation of haemoglobin in the antenatal
period
• 1. Screening of anaemia
• 2. Diagnosis of anaemia
• 3. Management of normocytic or microcytic anaemia

20. SCREENING DURING PREGNANCY
• Routine screening for iron deficiency anemia in asymptomatic women
may or may not be conducted since there is still a lack of sufficient
evidence to develop a recommendation for this procedure.
• However, the most important institutions include in their guidelines
that:
Screening
• At booking
• At 28 weeks.
• Women with multiple pregnancies repeat full blood count at 20–24
weeks.
• Women with additional risks for anemia should have individualized
plans
• Unselected screening with routine use of serum ferritin is generally
not recommended although individual centers with a particularly high
prevalence of at‐risk women may find this useful.

21. DIAGNOSIS OF ANEMIA
• If a woman is anaemic, several possible blood tests may be indicated
: FBC----Hb% practical cheap early performed method
Blood cell indices differentiated b/w iron deficiency and thalasemia
blood film---- morphology of rbc ,reticulocytes,abnormal cells,m.p
haematinics (ferritin, B12, folate)
haemolysis screen (LDH, retics, DCT, haptoglobin).

22. RED CELL INDICES IN IRON
DEFICIENCY AND THALASEMIA
characteristic calculation Normal range Iron Thalasemia
MCV(fl) PCV/RBC 75-96 Reduced Very reduced
MCH(pg) Hb/RBC 27-33 Reduced Very reduced
MCHC(g/dl) Hb /PCV 32-35 Reduced Normal or
slightly
reduced
HbF(%) hbF/HbA/100 <2% normal Raised
HbA2(%) HbA2/HbA/10
0
2-3% Normal or
raised
Raised
FEP(microgra
m/dl
____ <35 >50 Normal
Red cell width High Normal

23. • Fbc. Low hb
• red cell indices reduced MCV ,reduced MCH.,reduced MCHC
• Peripheral blood film -- --Morphology: Microcytic- hypochromic red cells .
Serum ferritin ---marker of iron stores
 normal range 50–150
 Iron deficiency. & Iron-deficiency anaemia less 15-30
 TIBC-increased---- normal level TIBC-300-350mcg/dl TIBC is not routinely
checked in all women as it is an unreliable indicator of availability of iron to the
tissues. This is because of wide fluctuation in TIBC levels due to recent ingestion
of iron, diurnal rhythm and other factors such as infection.
 When acute or chronic inflammation, hepatocellular damage and some
malignancies are present
 transferrin saturation may be a more useful investigation for assessing iron
deficiency.
 A transferrin saturation of less than 16% is indicative of insufficient iron supply
for erythropoiesis
Serum iron 60-120 mcg/dl
investigations for diagnosis Iron deficiency anemia

24. Free erythropoietin receptors----Help to differentiate b/w iron deficiency and
thalasemia
.Serum transfferin receptors----Appear to be specific and sensitive marker of
iron deficiency in pregnancy, its level increased in iron deficiency, but not
routinely available.
.Bone marrow aspiration ----When no response and for diagnosis of aplastic
anemia and kalzar
bone marrow aspiration .
 high cellularity mild to moderate erythroid hyperplasia (25-35%; N 16 –
18%)
 polychromatic and pyknotic cytoplasm of erythroblasts is
 vacuolated and irregular in outline
 (micronormoblastic erythropoiesis)absence of stainable iron
Stool examination-consequently for 3 days
Urine examination- for occult blood shistosomiasis in shistosomiasis prevalent
countries.
.Sputum examination /x-ray (TB)
.RFT

26. NICE GUIDELINE RECOMMENDATIONS
• women with HMB may
under diagnose iron
deficiency in women
because it advocates a
full blood count but not
serum ferritin as part of
the routine assessment
• NICE guidelines on antenatal care
advocate screening for anaemia at
booking and at 28 weeks of
gestation.
• During pregnancy anaemia is best
assessed using serum ferritin.
Ferritin rises initially and then
gradually declines as pregnancy
continues so that by 32 weeks
levels are 50% less than
prepregnancy levels. Treatment
should be instigated when levels
fall below 30 mcg/l.
• For women with a postpartum
blood loss of greater than 500 ml
and those with uncorrected
antenatal anaemia, a full blood
count should be taken within 48
hours of delivery

27. • FIGO - RECOMMENDATIONS
• Delaying the time at which the umbilical
is clamped after delivery has a significant
impact on the net amount of blood and,
iron stores transferred to the neonate at
• Referral to secondary care should be
considered if:
1) there are significant symptoms and/or
severe anemia (hemoglobin <7.0 g/dL)
2) late gestation (>34 weeks)
3) failure to respond to a trial of oral iron.
• Women with anemia may require additional
precautions for delivery including
 delivery in a hospital setting
 available intravenous access
 active management of the third stage of
labor
 and preparation for excess bleeding
• Suggested hemoglobin
cutoffs are less than
10.0 g/dL for delivery in
hospital and less than
9.5 g/dL for delivery in an
obstetrician‐led unit.
• Women with hemoglobin
less than 10.0 g/dL in the
postpartum period should be
given 100–200 mg elemental
iron for 3 months.

28. • All women should be given dietary information to maximize iron
intake and absorption.
• Routine iron supplementation for all women in pregnancy is
recommended, according to the health policies of the countries,
especially in areas with a high prevalence of anemia.
• The minimum dosage should be 30 mg of elemental iron a day.
• Once iron-deficiency anaemia has occurred it is not possible to
reverse these changes through an increase in dietary intake alone.
• In addition to iron replacement, an important component of the
management is investigating and treating the underlying cause or
causes

29. TREATMENT OF IRON
DEFICIENCY ANEMIA
• Medical treatment
• Oral iron
• Parenteral iron
• Blood transfusion
• Recombinant erythropoietin

30. ORAL IRON SUPPLEMENTATION
• First-line management of iron
deficiency and iron-deficiency
anaemia is oral iron
supplementation containing
ferrous ions, which is inexpensive
and effective.
• Adults with iron deficiency
anaemia, including pregnant
women, are advised to ingest 100–
200 mg elemental iron a day in
two to three divided doses and
100 mg daily for iron deficiency
• Iron supplements that contain iron
in its ferrous form are better
absorbed
• To maximize absorption, iron
tablets should be taken at night or
at least 1 hour prior to food.
• substances that inhibit absorption
such as tannins ,tea coffee,and
milk should be avoided
• fruit juice containing ascorbic
acid taken in conjunction with iron
supplements increases their
absorption.
• The adverse effects of oral iron
therapy can limit compliance and
include nausea, vomiting,
constipation, dark stools and
abdominal discomfort as a result
of free radical-mediated mucosal
luminal damage
DISAADVANTAGES
• Intolerance to medication
• Unpredictable absorption
• Non compliance

31. • Following commencement
of oral iron therapy a
further
• full blood count and serum
ferritin level should be
undertaken three to four
weeks later (2 weeks in
pregnancy) to assess
response to treatment.
• Hb should rise by 20 g/l
every three to four weeks or
1.2 g/l/day.
• Once Hb and serum ferritin
levels are normal treatment
should be continued for
three months.
• If Hb falls below normal
reinvestigation should be
considered along with re-
provision of iron
supplementation
INDICATORS OF RESPONSE TO THERAPY
• Improvements in symptoms
• Increase reticulocyte count in 5-10
days
• Increase in Hb% 0.8g/dl/week
REASONS OF FAILURE
• Inaccurate diagnosis
• Absorption problem malabsorption
synd
• Non compliance

32. PARENTERAL IRON THERAPY
• If response to oral therapy is
inadequate parenteral therapy
should be considered.
• Non compliant pt
• GI problems
• Pregnancy >32-36wks
Advantages
• Certainty of its administration,Raise
Hb/wk(rapid raise),Alternate to blood
transfusion when oral treatment fails.
During pregnancy its use is
contraindicated in the first trimester.
• Parenteral iron results in rapid
repletion of iron levels (up to 20 g/l
in seven days) making it an
appropriate choice before major
surgery.
DOSE
(Normal Hb-patient’s Hb) x weight(kg)x2.21
+1000=
(14-7) x65kg x 2.21+1000=2005mg
Within bone marrow, parenteral iron results
in 4.5–7.8 times the normal production of
erythrocytes compared with the 2.5–3.5
times normal production associated with
oral iron therapy.

33. • A variety of preparations are
available, including
 iron dextran
iron sucrose
iron carboxymaltose
iron isomaltoside.
Carboxymaltose and
sucrose have similar
efficacy; however,
carboxymaltose achieves
this efficacy with fewer
injections and shorter
infusion duration times.
The adverse effects associated
with parenteral iron include
hypotension, malaise, nausea,
vomiting, arthralgia and
abdominal pain.
Adverse effects are more
common with iron dextran and
less commonly associated with
the administration of iron sucrose
and iron carboxymaltose.
For women with HMB,
parenteral iron has been shown to
improve quality of life more than
oral iron therapy, and is more
effective at replenishing iron
stores

34. • Precautions
• It is generally safe and
associated with fewer
adverse effects than oral
preparations, although
anaphylaxis has been
reported.
• Should be given in hospital
setup by doctor
• Inj :hydrocortisone,
epinephrine, and oxygen
should be available.
• during an infusion and for
30 minutes afterwards,
patients must be
for signs of
total dose infusion
• Total dose iron replacement in
2nd and 3rd trimester in which
total deficit is calculated and
given as single infusion which
take 3-6 hrs to complete.
• Various preparations are
available f(erinject. )
• Dextran(imferon)withdrawn b/c
of high incidence of
anaphylaxis

35. BLOOD TRANSFUSION
 adverse outcomes associated with
transfusion, including
 fluid overload
 Anaphylaxis
 allergic reaction
 acute lung injury
 infection
 in women of childbearing age,
potential sensitisation of red cell
antigens
BLOOD TRANSFUSION. Preferred. Pcv
Indications.
Severe anemia
Pregnancy beyond 36 wks
Blood loss e.g. ; APH,PPH,
Pts not responding to oral and parental
treatment
management of major obstetric
haemorrhage,
those who are haemodynamically unstable or
 with organ function compromise.
Each unit of packed red blood cells
transfused should raise the Hb by 10 g/l.
The need for additional iron
supplementation can be determined once the
woman has been stabilized.

36. ERETHROPOETIN INDICATIONS.
Recombinant erythropoietin
• Anemia of chronic renal failure
• Autologous production of blood in normal individuals
• Severe postpartum anemia(life saving)
• Where blood transfusion avoided as in jehovah witnesses

37. OBSTETRICAL TREATMENT
ANTENATAL CARE
• More frequent visit
• Detect and manage
complication like heart failure
PTL
• Fetal monitoring for growth and
well being
• In pre term beta mimetics and
corticosteroids used carefully to
avoid risk of pulmonary edema
MANAGEMENT IN LABOUR
Ist stage
• Fluid restriction
• if need of augmentation
use conc oxytocin
• Comfortable position (prop
up)
• Sedation
• Analgesia
• Antibiotic prophylaxis
• Oxygen in dyspnoic patients
• Digitalization and cardiac
support in cardiac failure.

38. SECOND STAGE MANAGEMENT
• Shortened by instrumental delivery
THIRD STAGE
• AMTSL except in severe anemic for fear of cardiac
failure
PUERPERIUM
• Adequate rest
• Iron and folate therapy for 3 months
• Treatment of any infections
• Pediatric opinion
• Effective contraception.(at least 2 years till iron store
recover)
• Vte risk acessment

39. PREVENTION OF IRON DEFICIENCY
1.Iron supplementation during pregnancy
According to WHO 60 mg elemental iron
and 250mg folic acid daily for 6 months
and additional 3 months in postpartum
period in low prevalence countries
2.Treatment of hookworm infestation
Single dose of albendazole 400mg stat
Or mebendazole 100mg BD for 3 days
3.Improvements of dietary habits
Iron rich food
Cook food in iron utensils
4.Social services
• Improvement in sanitation
• Personal hygiene
• Better education of female
regarding diet
• Contraception
5.Food fortification
Iron fortified salt like iodine salt

40. case study. A 28year old woman para 5 at 23
weeks of gestation presents feeling tired and dizzy.
A full blood count is taken and the results are:
Hb = 10.0 g/dl
MCV = 74 fl
Platelets = 205 (109)
She is found to have a ferritin level of 9 g/dl
so ferrous sulfate treatment, 200 mg bd (twice-
daily) begins. She re attends the clinic 6 weeks
later and her Hb is 8.0 g/dl.
What are the diagnostic possibilities and the
possible solutions?
Diagnostic possibility She is not taking her iron tablets
due to noncompliance or side effects.
solution. Talk about risks of anaemia in pregnancy to
encourage tablet taking (anaemia has been linked with
preterm delivery and fetal growth restriction,
Try to reduce adverse effects (nausea, vomiting,
heartburn, diarrhoea) by reducing the dose, changing
the tablet iron preparation, changing to liquid
preparation of iron, or discussing the option of
intravenous iron
Diagnostic possibility She is not
absorbing the iron
Advise her to take the iron with orange
juice, as vitamin C aids iron absorption.
The orange juice should be taken on an
empty stomach as this improves
absorption Consider investigation of
malabsorption
She is actively bleeding Has she had any
episodes of clinical bleeding?
Consider stool samples for faecal occult
bloods (can get false positive faecal
occult bloods if the woman is taking
iron tablets), midstream urine (MSU) for
haematuria andendoscopy (if clinically
indicated)

41. SUMMARY
• Anemia is most common medical disorder of
pregnancy with significant maternal ND fetal
implications
• Iron deficiency is major cause of anemia in
pregnancy
• Diagnosis should be establish during nd before
pregnancy so to treat timely to prevent
complications
• Screening for iron deficiency in pregnancy is simple

42. THANK YOU