The document discusses anemia in pregnancy, highlighting its prevalence, causes, symptoms, and classifications, including physiological and pathological types. It addresses the impact of anemia on maternal and fetal health, treatment protocols, and complications, as well as the importance of iron therapy and dietary management. Prophylactic measures and specific treatments for various forms of anemia are also outlined, emphasizing the need for early detection and comprehensive management during pregnancy and postpartum.

1. Anemia and pregnancy
Sunil Kumar

2.  Anemia: Haemoglobin level below 12gm/dl normally
and 10mg/dl at any time during pregnancy or
puerperium
 20% of maternal deaths in 3rd world countries
Introduction

3. CAUSES IN PREGNANCY
At pregnancy
 demand of iron
 iron intake
 absorption
 Disturbed metabolism

4. SYMPTOMS
 Exhaustion
 Anorexia
 Indigestion
 Palpitation
 Dyspnoea
 Swelling of legs

5. SIGNS:
 Pallor with evidence of glossitis and stomatitis
 Edema of legs due to hypoproteinemia or associated
pre-eclampsia
 Systemic murmur in mitral area due to physiological
mitral incompetence
 Crepitations due to pulmonary oedema

6. CLASSIFICATION
 Physiological anemia of pregnancy
 Pathological
 Deficiency anemia
 Iron deficiency
 Folic acid deficiency
 Vitamin B12 deficiency
 Protein deficiency

7. CONTD….
 Hemorrhagic
 Acute (in early months/APH)
 Chronic (Hook worm infestation , bleeding
piles)
 Hereditary
 Thalassemia
 Sickle cell
 Hereditary haemolytic anemia

8.  Bone marrow insufficiency (hypoplasia/
aplasia)
 Anemia of infection (Malaria, T.B.)
 Chronic disease (Renal/neoplasm)

10. PHYSIOLOGICAL ANEMIA IN
PREGNANCY
Disproportionate increase in plasma volume, RBC
volume, Hb mass
Extra demand of iron especially in 2nd half.
physiological iron deficient state
Hb concentration, HCT value, serum iron,
TIBC
Net Result: Fall in Hb concentration is due to combined
effect of haemodilution and –ve Fe++ balance.

12. Diagnostic criteria (2nd half of
pregnancy)
 Hb – <10 gm%
 RBC – 3.2 per cubic millimeter (4.2 – 5.4 ×
106 /µl)
 PCV – 32% (37% - 48%)
 Peripheral smear – Normocytic, normochromic

13. TREATMENT
 If there are signs suggestive of fetal hypoxemia
red cell transfusion
 Resolve by six weeks postpartum since plasma
volume has returned to normal by that time

14.  Is the most common cause along with acute blood
loss.
 Is due to increase iron demand
 Fe stores being constant or depleted in pregnant
state is the cause.
IRON DEFICIENCY ANEMIA

15. CRITERIA FOR IRON DEFICIENCY
ANEMIA
 Hb - <10gm%
 RBC - <4 million per cubic mm
 PCV - <30%
 MCHC - <30%
 PBS: microcytic and hypochromic (not seen
in moderate)
 reduced serum ferritin level and increased
TIBC

16. COMPLICATION OF ANEMIA
During pregnancy:
 Pre-eclampsia
 Intercurrent infection
 Heart failure at 30-32 weeks of pregnancy
 Pre-term labour
During labour:
 Post partum haemorrhage
 Cardiac failure
 Shock

17. Puerperium:
 Puerperal sepsis
 Sub involution
 Prolactation
 Puerperal venous thrombosis
 Pulmonary embolism
Effects on baby:
 Low birth weight babies
 IUFD due to maternal anoxemia

18. PROPHYLAXIS
 Avoid frequent child birth
 Supplementary iron therapy
 Dietary prescription
 Treat the underlying cause
 Early detection of Hb level.

19. CURATIVE
 Hospitalization: If Hb level at or < 9 gm/dl.
 General treatment:
 Diet: protein, iron, vitamins
 Acid pepsin: after meal to improve appetite and
facilitate digestion
 Antibiotics: If septic focus
 Therapy for underlying diseases

20.  Specific therapy: to restore Hb and iron reserve. Two
types of iron therapy
• Oral
• Parenteral

21. ORAL THERAPY
 Ferrous gluconate, fumarate, succinate, sulphate
 Ferous sulphate is the widely used
 Regimen:
• 1 tab TDS with or after meal in a day
• Maximum tablet per day is up to 6/day till blood
picture is normal
• Maintenance dose: 1 tablet for 100 days following
delivery

22.  Points to consider while on therapy:
 Epigastric pain, nausea, vomiting, diarrhea and
constipation
 Absorption reduced by anta-acids, oxalates
&phosphates
 Absorption increased by ascorbate, lactate and
amino acids
 Contraindications:
 Severe oral intolerance
 Severe anemia in advanced pregnancy

23. PARENTERAL THERAPY
Intravenous:
Drugs:
 Iron Dextran: TDI = 0.3 × W(100-Hb%)mg of elemental
iron
W= wt. in pounds, Hb% = percentage concentration of
Hb
Additional 50% for partial replenishment.
 Iron sucrose: TDI = 2.3 × W × D +500; where W= wt. in
kg before pregnancy, D= Hb(target-actual), 500= 500mg
for body store

24. PROCEDURES
 Patient is admitted in the morning for infusion
 Required iron is mixed in 500ml of normal saline
 Drips is to be 10 drops/min in 1st 20 mins
 Drips increased to 40 drops/min thereafter
 If rigors, hypo-tension or chest pain seen call it a

25. INTRAMUSCULAR
THERAPY
 Iron dextran
 Iron sorbitol citric acid complex in dextrin
 50mg elemental iron per ml contained in both
 Total required dose calculated previous formula:
 Oral iron suspended 24 hrs prior to therapy to
avoid reaction

26. Problems with IM
 Injection is painful
 Staining of the skin
 Fever
 Lymphadenopathy
 Headache
 Nausea
 Vomiting
 Allergic reactions

27. Blood transfusion
1. If anemia is due to blood loss, combat PPH
2. Severe anemia in later months of pregnancy(beyond
36 weeks to improve anemic state and oxygen
carrying capacity of blood patient goes into labour)
3. Refractory anemia: anemia not responding to either
oral or parenteral therapy inspite of correct typing

28. Management during labour
 First stage:
 Make the patient lie in bed and make her comfortable
 Arrange for oxygen inhalation
 Strict asepsis
 Second stage
 Asepsis maintained
 Low forceps or vaccum delivery
 IV methergin 0.2mg following delivery of anterior
shoulderMethergin(methylergometrine): Active management of the 3rd stage of labor (as
means to promote separation of the placenta and to reduce blood loss).

29.  Third stage:
 Should be more attentive.
 Significant amount of blood loss should be replenished
by fresh packed cell transfusion
 Danger of post partum overloading to heart should be
avoided
 Puerperium
 Prophylactic antibiotic
 Continuation of antianemic therapy given before delivery till
patient restores her normal clinical and hematological
states
 Even in normal cases, iron therapy continued for at
least 3 months following delivery

30. Abnormal precussors (megaloblasts)
Impaired DNA synthesis in RBC in bone marrow
vit B12/ folate/ both deficiency
Megaloblastic anemia

31. CAUSES OF B12
DEFICIENCY
 Vegetarian diet
 Gastritis
 Gasterectomy
 Ileal bypass
 Chron’s disease
 Drugs: Metformin, PPI

32. CAUSES OF FOLIC ACID
DEFICIENCY
 Inadequate intake
 Increased demand
 Decreased absorption
 Abnormal demand (infection, hemorrhagic state,
hemolytic state)
 Failure of utilization (anti epileptics, infection)
 Decreased storage (hepatic disorder, vitamin C
deficiency)
 Iron deficiency anemia.

33. CLINICAL FEATURES
 Insidious onset usually
 First revealed in last trimester or acutely in early
puerperium
 Anorexia or protracted vomiting
 Occasional diarrhea
 Unexplained fever associated

34. HEMATOLOGICAL FINDINGS of
MbA
1.Hb <10 gm%
2. Peripheral blood smear, 2 or more features seen:
- Neutrophil hypersegmentation (5 or >lobes)
- Macrocytosis and anisocytosis
- Giant polymorphs
- Megaloblasts
- Howell-Jolly bodies
 Buffy coat smear more diagnostic
3. MCV >100micro cube, MCH >33 pg, MCHC-
normal

35. 4. Associated leukopenia and thrombocytopenia
5. Serum iron normal or high, TIBC decreased
6. Serum folate <3mg/ml,(in non-pregnant 2.8-8 ng/ml
normal)
7.Serum vit B12 <90pg/ml (normal- 300pg/ml)
8. BM- megaloblastic erythropoiesis

36. COMPLICATIONS OF
MEGALOBLASTIC ANEMIA
 Abortion
 Dysmaturity
 Prematuirity
 Abruptio placentae
 Fetal malformation (cleft palate, NTD)

37. PROPHYLAXIS
 All reproductive age group woman given 400 micro
gm of folic acid
 Additional 4mg given where demand is high (like
in multiple pregnancy, anti-convulsants,
hemoglobinopathies, woman with NTD infants)

38. MANAGEMENT
 Daily administration of folic acid 4mg orally
 Continued for at least 4 weeks following delivery

39. APLASTIC ANEMIA
 Rarely seen in pregnancy
 Immunologically mediated or autosomal recessive
inheritance
 Marked decrease in marrow stem cells

40. COMPLICATIONS
 Hemorrhage
 Infection
Diagnosis:
 Blood: anemia, leukopenia, thrombocytopenia
 Bone marrow: Hypocellular

41. MANAGEMENT
 Repeated blood transfusion to maintain
HCT>20
 Granulocyte transfusion to combat infection
 Platelet transfusion to control hemorrhage
 Glucocorticoids in some
 In severe cases:
Bone marrow or stem cell transplantation

42. References
1. Williams Obstetrics, 24th Edition
2. DC Dutta’s Textbook of Obstetrics, 7th Edition