notes for post-graduates, medical students & midwifes

1. ANAEMIA IN PREGNANCY
DATO’ Dr.ARUKU NAIDU
MD(UKM), FRCOG(UK),CU(JCU), AM
Consultant O&G &
urogynaecologist, Hospital Ipoh
www.aruku-naidu.blogspot.com

2. Causes of Maternal Death, 1997and 2007
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32.3% potentially stand
a better chance if they
DON’T have Anemia

3. Prevalence of anemia
World 47% 42% 30%
Malaysia 32% 38% 30%
Pre-school children Pregnant women
Non-pregnant women during
child bearing age
WHO Global Database on Anemia,2008

4. Anemia
Hemoglobin (Hb) or hematocrit (Hct) value less than the fifth
percentile of the distribution of Hgb or Hct in a healthy reference
population based on the stage of pregnancy1.
1st Trimester 2nd Trimester 3rd Trimester
Hemoglobin (g/dL) < 11 < 10.5 <11
Hematocrit (%) < 33 < 32 < 33

5. Anaemia in pregnancy
 WHO 1992 – prevalence 55.9% among expected mothers
 Significantly higher in 3rd trimester than in 1st & 2nd trimester
 Anaemia affect health of mother,  risk should haemorrhage
occur
 Major cause of maternal mortality is postpartum haemorrhage
 Anaemic women unable to tolerate the same amount of blood
loss
 Routinely check Hb at booking, 28, 32 & 36 weeks

6. Anaemia in pregnancy
 Haemodilution - Plasma volume
increase exceeds the rise in red cell
mass
 Symptoms – tiredness, breathlessness,
giddiness, palpitations, swelling of feet
& ankles
 Signs – pallor, glossitis, oral fissures,
splenomegaly

7. Sign & Symptoms of Anaemia
HEADACHES
COLD
HANDS &
FEET
WEAKNESS,
FATIGUE,
SHORTNESS OF
BREATH
DIZZINESS
PALE SKIN

8. Causes of anaemia
 Nutritional anaemia – deficiency of iron, folic acid
& vitamin
 Chronic blood loss – repeated abortion, closely
spaced pregnancies, bleeding gums, ulcers, piles,
menorrhagia, worm infestation
 Hemolytic anaemia –thalassaemia,malaria or drug-
induced
 Aplastic anaemia- drug-induced or idiopathic
 Myeloproliferative disorder

9. The most frequent nutritional
disorder
How many suffer from iron deficiency anemia?
2 billion people
1/3rd of the world’s population
Milman N, Anemia still a major health problem in many parts of the world, Ann Hematol(2011) 90:369–377

10. Prepartum iron deficiency
anemia (IDA)
 Among fertile, non-
pregnant women,
∼40% have ferritin of
≤30 μg/L
 Prepartum IDA
predisposes to
postpartum IDA
Milman N ,Prepartum anemia:prevention and treatment, Ann Hematol(2008) 87:949–959
Test Level Remarks
Serum Ferritin (ug/L) < 30 Low iron status
< 15 Iron deficiency

11. Iron requirement in pregnancy
Milman N Ann Hematol 2006; 85(9):559-565
* RNI Malaysia 2005 , National Coordinating Committee on Food and Nutrition (NCCFN),Ministry of Health Malaysia
100mg/day iron for all women*
9x higher
Iron
requirement
during
pregnancy

12. Common causes of Anaemia

13. Iron deficiency anemia (IDA)
 Hemoglobin concentration is a poor indicator of iron stores –
final stage in the disease spectrum of iron deficiency
 Serum ferritin is a more sensitive indicator of iron deficiency1
1. Milman N ,Prepartum anemia:prevention and treatment, Ann Hematol(2008) 87:949–959
Test Level Remarks
Serum Ferritin (ug/L) < 30 Low iron status
< 15 Iron deficiency

14. WHO Iron Defiency Aaemia, 2001
Company Confidential © 200X Abbott
Criteria for Assessing
Anemia
Test Age Gender Deficiency value
Hemoglobin (g/dL) 0.5 - 10 M-F <11
11 - 15 M <12
F <11.5
> 15 M <13
F <12
Pregnancy <11
Hematocrit (%) 0.5 - 4 M-F <32
5 - 10 M-F <33
11 - 15 M <35
F <34
> 15 M <40
F <36
- Hemoglobin test - a test that measures hemoglobin which is a protein in the blood that carries oxygen
- Hematocrit test - the percentage of red blood cells in your blood by volume
- Hemoglobin and hematocrit levels usually aren't decreased until the later stages of iron
deficiency(anemia)
- Anemia was further categorized into 3 level; mild 9-11g/dL,moderate 7-9 g/dL and severe <7g/dL.

15. Classification
 Severe anaemia: less than 6.9g/dl
 Moderate anaemia: 7.0 to 8.9g/dl
 Mild anaemia: 9.0 to 11.0g/dl

16. Prevention of anaemia in
pregnancy
 Daily requirement – 100 mg elemental iron with 300
µg folic acid
 To prevent anaemia, all mothers routinely given
Ferrous Fumarate 200 mg daily and Folic acid 5 mg
daily
 Iron rich-foods –
 Animal – red meat, fish
 Plant – dark green leafy vegetables, beans

17. Food that are rich in iron
Only 10% to 15% of dietary
iron is being absorbed.
IDA – Treatment & Management
*Women with iron deficiency in
pregnancy should not
attempt to correct it through
means of diet alone.
*Mayo Clinic. Iron deficiency anemia. Treatments and drugs.(accesses 7 Sept 2010)

18. Investigation
 Hb,TWDC,platelet count
 Urine FEME
 BFMP
 Stool for ova & cysts
 Peripheral blood film

19. Further test
 Full blood picture
 Renal function test
 Hematocrit
 Urine for C&S
 Serum ferritin, serum iron and total iron
binding capacity (TIBC)
 Serum folate, vit B12
 Hb electrophoresis if hemoglobinopathy is
suspected

20. Management - <36 weeks with
mild to moderate anaemia
 Investigation
 Counselling on diet
 Tab.ferrous fumarate 200 mg daily
 Tab.folic acid 5 mg daily
 Tab. Vit. B Co 2 tabs daily
 Tab. Vit C 100 mg daily

21. Management - <36 weeks
 Assess the compliance & reliability
 If reliable patient – oral therapy sufficient
 If not reliable or unable to tolerate oral
therapy – iron dextran therapy by im
injection or total dose infusion (TDI)
 Repeat Hb after 2 weeks to assess response

22. Management->36 weeks
 Booked for hospital delivery
 Counselled about diet & oral therapy
 Iron dextran therapy
 Severe anaemia may need blood transfusion – 1
pint of blood raises Hb by 0.7 g/dl, give packed
cells covered with diuretics to  risk of
overloading
 Should deliver in hospital, prevent PPH
 Blood available during labour

23. Iron deficiency anaemia
 During pregnancy -  demand for
iron for red cell volume, for uterus
& fetus and for lactation
 Factors for IDA
 Reduced iron intake – poor diet,
excessive morning sickness
 Diminished absorption -  gastric
acidity, dietary imbalance,lack of vit.C
 Abnormal demands- multiple
pregnancy, poor spacing, multiparity,
prev.history of haemorrhage

24. Iron deficiency anaemia -
Diagnosis
 FBP showed microcytic,
hypochromic anaemia
 Serum iron and serum
ferritin are low
 Total iron binding
capacity (TIBC) 

25. IDA During pregnancy
Annet J.C. Roodenburg. Iron supplementation during pregnancy. Eur J Obstet & Gynecol & Reproductive Biology 61 (1995) 65-71
Linsay H Allen. Anemia and iron deficiency: Effects on pregnancy outcome. Am J Clin Nutr 2007; 71(suppl)
Milman N ,Prepartum anemia:prevention and treatment, Ann Hematol(2008) 87:949–959
Paul Preziosi et al. Effect of iron supplementation on the iron status of pregnant women: consequences for newborns. AM J Clin Nutr 1997; 66: 1178-82

26. Iron deficiency anaemia
Treatment
 250 mg iron raises Hb by 1g/dl
 Tab. Ferrous Fumarate 200 mg ODs
and Folic acid 5 mg daily
 Treat UTI or worm infestation
 Advise on dietary intake
 Failure to respond or non-
compliance can give parenteral iron
either repeated intramuscular
injection or total dose infusion

27. Oral iron treatment
 WHO recommendation 120 mg/day elemental iron
 RNI Malaysia 2005 recommendation 100mg/day elemental iron
 High-dose iron therapy
 preferably administered as sustained release iron preparations
 to optimize absorption and reduce GI side effects
Milman N ,Prepartum anemia:prevention and treatment, Ann Hematol(2008) 87:949–959
RNI Malaysia 2005, National Coordinating Committee on Food and Nutrition (NCCFN), Ministry of Health Malaysia

28. Treatment of IDA in pregnancy
In women with slight to moderate IDA
(Hb 90–105 g/L)
Rx : oral ferrous iron of ∼100 mg/day
Hb checked after 2 weeks
Increase > 10g/l
Continue oral iron
Milman N ,Prepartum anemia:prevention and treatment, Ann Hematol(2008) 87:949–959

29. Dosage and Administration
29

30.  Solution for injection can be administered by an intravenous drip
infusion or by a slow intravenous injection of which the
intravenous drip infusion is the preferred route of administration,
as this may help to reduce the risk of hypotensive episodes.
Dosage & Administration
Dosage & Administration

31. Intramuscular injection (used by Klinik Kesihatan):
 Attributed by the pH neutral solution, can be administered as a series
of undiluted intramuscular injections up to 100mg iron.
 Iron Dextran must be given by deep intramuscular injection to
minimise the risk of subcutaneous staining. It should be injected only
into the upper outer quadrant of the buttock. A 20 - 21 gauge needle
at least 50 mm long should be used for normal adults. For obese
patients the length should be 80 - 100 mm whereas for small adults a
shorter and smaller needle (23 gauge x 32 mm) is used.
Dosage & Administration Intramuscular
Dosage & Administration
Deep I/M Z- technique Inject air / saline before withdrawing

32. Other Intramuscular injection
therapy
The compounds used in intramuscular therapy are:
1. Iron-dextran (Imferon)
2. Iron- sorbitol-citric acid complex in dextrin(Jectofer)
( Both contain 50mg of elemental iron in one milliliter)
Total dose is calculated as in i/v therapy .
• Dose of iron sorbitol complex is to be adjusted because of its
30% excretion in urine.
• Oral iron should be suspended at least 24 hours prior to I /M
therapy to avoid reaction.

33. Iron dextran therapy
Total Dose Infusion
 Must be given in premises with
emergency facilities
 All TDI must have a test dose,
even tough is may not be full
prove & watch for 30 mins
 Must watch for ADR during &
after ( delayed) after TDI
 Keep resus trolley standby,
hydrocortisone standby

34.  Due to the tightly bound iron complex, CosmoFer® can be
administered as Total dose infusion (TDI) with up to 20 mg/kg
administered over 4-6 hours in one single infusion.
Dosage & Administration
Dosage & Administration

35. Iron dextran therapy
 Adverse reaction
 Pruritus
 Bronchospasm
 Hypotension
 Anaphylaxis
 Arthritis
 Contraindication
 Thalassaemia
 Known allergy to iron dextran

36. Post-partum Anemia
1. Jamaiyah Haniffet al.Anemia in pregnancy in Malaysia:a cross-sectional survey.Asia Pac J Clin Nutr
2007;16(3): 527-536.
“More than 80 percent of maternal
deaths are caused by
haemorrhage,…… Most of these
deaths are preventable when there is
access to adequate reproductive
health service”
1

37. Post partum anemia
 Severe postpartum anemia is a complication of 5% of deliveries1
 Following delivery, women lose some amount of iron through
breastfeeding and lactation
 IDA has been associated with impaired cognitive function and
behavioral disturbances in postpartum women
 Mother’s iron status should be evaluated prior
to discharge to monitor postpartum anemia
1. Bodnar LM,et,al. Who should be screened for postpartum anemia? An evaluation of current recommendations. Am J
Epidemiol. 2002 Nov

38. Post partum anemia
 Iron deficiency persists beyond the 4-6 weeks postpartum period
 12% of women are iron deficient up to 12 months after delivery
 8% of women are iron deficient 13-24 months after delivery
 Iron supplementation should continue after delivery if iron status
remains low or while the mother is breastfeeding1
1. Bodnar LM,et,al. Who should be screened for postpartum anemia? An evaluation of current recommendations. Am J
Epidemiol. 2002 Nov

39. Haemoglobinopathies
 Defects in globin structure or
synthesis leading to hemolytic
anaemia
 Eg. Thalassaemia, sickle cell
disease
 Diagnosis by electrophoresis
 Treatment - Tab Folic acid 15
mg daily, blood transfusion

40. In conclusion
 IDA is the most frequent form of anaemia in pregnant women
 Dietary measures are inadequate to reduce the frequency of
prepartum IDA
 Pregnant women should be given 100mg/day iron regardless of
ID status in 2nd and 3 rd trimester, prophylactically
 Treatment of IDA should aim at replenishing body iron deficits
 Treating and preventing IDA can improve national productivity
by 20% and reduce maternal mortality

41. THANK YOU
DATO’ Dr.ARUKU NAIDU
MD(UKM), FRCOG(UK),CU(JCU). AM(MAL)
Pakar Perunding O&G & urogynaecologist, Hospital Ipoh
aruku.naidu.blogspot.com