1) Anaemia is common in pregnancy due to physiological haemodilution which exceeds the increased production of red blood cells. The most common cause is iron deficiency. 2) Regular antenatal iron supplementation is important to prevent anaemia in pregnancy and its clinical effects like fatigue, risk of postpartum hemorrhage, and risk of poor pregnancy outcomes. 3) Oral iron therapy is the first-line treatment for iron deficiency anaemia in pregnancy, with a daily dose of 30-60mg of elemental iron recommended. Intravenous iron may be used if oral iron is not tolerated or compliance is an issue.

1. Anaemia in Pregnancy
Assessor : Dr NgYee Ling
26 July 2020 Nur Asyikin

2. What happens in pregnancy
• Physiological expansion of plasma volume
- from 1st trimester and plateaues by 3rd trimester
- which exceeds the increased production of red blood cells and haemoglobin.
• Results in haemodilution fall in Hb during pregnancy
• Most common cause of anaemia in pregnancy = iron deficiency

3. Causes of anemia in pregnancy
• Nutritional aneia- Iron deficiency, folate deficiency, B12 deficiency
• Chronic blood loss – hemorrhoids, GI Bleeding
• Short birth intervals
• Infection- HIV, Malaria
• Hematological conditions- Leukemia, Sickle cell disease,Thalassaemia

4. Threshold for Anaemia
• First trimester : <11.0 g/dL
• Second trimester & third trimester : <10.5 g/dL
• Postpartum : 10.0 g/dL
Regular antenatal iron
supplementation is important
to prevent Anaemia in pregnancy

5. Clinical effects
• Maternal fatigue poorer QoL increased risk of postpartum depression
• Risk of postpartum hemorrhage
- (due to impaired uterine contractility due to reduced availability of oxygen)
• Risk of maternal mortality (if severe anaemia)

6. Pregnancy outcome
• High risk of perinatal and neonatal mortality
• Low birth weight
• Premature birth
• Low Apgar score
• Potential neurodevelopmental impairment in the fetus
- impaired motor, cognition and language development

8. Clinical symptoms and signs
SYMPTOMS
- Fatigue
- Dizziness
- Headache
- Palpitations
- Restless legs
- Irritability
- Poor concentration
- Hair loss
SIGNS
- Pallor
- Weakness
- Dyspnoea

9. LaboratoryTesting
• low Hb, MCV, MCH and MCHC
• low serum ferritin is diagnostic of iron deficiency in pregnancy
(<30microgram/L)
• Iron studies if necessary (transferrin,TIBC, serum Iron)
• Haemoglobin concentration (at booking and at around 28 weeks’ gestation)

10. Oral IronTherapy
• Oral Iron preparations : effective, cheap and safe way to replace iron
• A trial of iron therapy for simultaneous diagnostic and therapeutic purposes
• A rise in Hb should be demonstrable by 2 weeks and supports the diagnosis of
iron deficiency
• Women who are haemoglobinopathy carriers should have serum ferritin testing
prior to iron administration
- to confirm concomitant iron deficiency and exclude iron overload

11. Management of Iron Deficiency
• Dietary advice
- daily iron intake from food = 10 mg (10–15% is absorbed)
- Capacity for absorption is enhanced in pregnancy but physiological iron
requirements increases
- from 1–2 mg to 6 mg per day as pregnancy advances
- In iron deficient women, repletion through diet alone is not possible and oral
supplementation is needed

12. How to take Oral Iron Supplements?
• Daily folic acid (400 µg) is required < 12 weeks’ gestation neural tube defects.
• 40–80 mg every morning is suggested, checking Hb at 2–3 weeks to ensure an adequate
response
- Why morning? - Hepcidin levels are lowest in the morning
• Oral iron supplementation should be taken on an empty stomach
- Why? absorption is reduced/promoted by the same factors that affect absorption of dietary non-
haem iron
• Compliance and intolerance = the usual factors limiting efficacy.
- Iron salts may cause gastric irritation, nausea and epigastric discomfort
- For nausea and epigastric discomfort - alternate day dosing or lower iron content should be tried

13. Iron Supplement in pregnancy women
• WHO Guideline
• Daily oral iron and folic acid supplementationis recommended as part of the antenatal
care to reduce the risk of low weight, maternal anemia and iron deficiency
• Dose- 30-60mg of elemental iron per day
• 400mcg of folic acid per day
• Malaysia Guideline
• Malaysia clinical practice guideline 2007
• Malaysia Perinatal care Manual
• 100mg elemental iron /day

14. Preparation Elemental iron content ( mg/tablet)
Obimin 30mg ferrous sulphate
Ferrous Fumarate 200mcg 60mg ferrous fumarate
Iberet 105 mg ferrous sulphate
Zincofer 115 mg ferrous fumarate
Maltofer 100mg ferric hydroxide polymaltose
Iron dextran ( IM or IV ) 50 mg /ml
Iron sucrose ( IV) 20 mg / ml

15. Intravenous iron therapy
• Advantages :Achieved Hb target, Fewer side effects
• Indication :
• when there is absolute noncompliance
• with, or intolerance of, oral iron therapy or proven
• malabsorption or when a rapid Hb response is required.
• Contraindication :
• history of anaphylaxis or serious
• reactions to parenteral iron therapy
• first trimester of pregnancy,
• active acute or chronic bacteraemia
• Decompensated liver disease
• Adverse Effects :
• Hypophosphataemia (particularly ferric carboxymaltose)
• Haemosiderin skin staining ( due to extravasation)

16. How to calculate?

18. Postpartum Anaemia
• Hb <100 g/l (However, clinical assessment is necessary for every patient)
• When should Hb be repeated?
• Women with blood loss >500 ml
• Uncorrected anaemia detected in the antenatal period
• Those with anaemic symptoms postnatally
• Oral iron should be offered to
• Women with Hb <100 g/l within 48 h of delivery, and
• Haemodynamically stable, either
• Asymptomatic, or mildly symptomatic

19. Thank you