Anemia in Pregnancy

Rajeev Ojha
 Case 1
 Mrs. A. N. is a 28-year-old woman in her
second trimester of pregnancy with her
first child, and though her pregnancy had
been progressing normally, recently she
has noticed that she tires very easily and
is short of breath from even the slightest
exertion. She also has experienced periods
of light-headedness, though not to the
point of fainting. Other changes she has
noticed are cramping in her legs, and the
fact that her tongue is sore.
 Upon examining, she has tachycardia, pale
gums and nail beds, and her tongue is
swollen. Given her history and the findings
on her physical exam, she is suspected to
be anemic and a sample of her blood is
orderes for examination.
Table 1. Blood Sample Results

Red Blood Cell Count 3.5 million/mm3

Hemoglobin (Hb) 7 g/dl

Hematocrit (Hct) 30%

Serum Iron low

Mean Corpuscular Volume (MCV) low

Mean Corpuscular Hb Concentration
low
(MCHC)
Total Iron Binding Capacity in the
high
Blood (TIBC)
A diagnosis of anemia due to iron
deficiency is made and oral iron
supplements prescribed. Her
symptoms are eliminated within a
couple of weeks and the remainder
of her pregnancy progresses without
difficulty.
 Case 2
A 35 year old woman is seen for easy
fatigue for many months. She is now 24
weeks pregnant with her 3rd child in 3
years. She does not see any obstetrician
and does not take any vitamins. Lately,
she has developed a taste for eating ice
(craving to taste ice, soil etc). She has no
other complaint. Family and past history
are negative. She does not smoke or drink.
Physical examination is positive for pale
conjunctiva, mild spooning of nails, and a
II/VI systolic murmur at left lower sternal
border. Stools are negative for occult
blood.
 Labs:
 Complete blood count (CBC)
- Hb 7.1 gm/dl, Hct 23%
- WBC 5,400/mm3 (differential is
normal)
- Platelets 450,000/mm3
- Mean Corpuscular volume (MCV) is
74 fl
(normal 85-95 fl)
- Red cell Distribution Width (RDW) is
 Defination of Anemia during
Preg.
 Hemoglobin below 11gm/dl in 1st and
3rd trimester and below 10.5gm/dl in
second trimester.
 WHO
 11gm/dl or less

 Bythis standard, 50% of women not

on hematinics become anemic.
 Incidence
 Anaemia may affect 10% of
pregnancies in developed countries
and is considerably commoner in
developing countries, where it is a
major source of maternal morbidity
and a contributor to mortality.
 Up to 56% of all women living in
developing countries are anaemic
(Hb < 11 g/dl) due to infestations.
 Classification
 Physiologic
 Pathologic:
a. Deficiency: Iron, Folic A., Vitamin B12
b. Hemorrhagic: APH, Hookworm
c. Hereditary: Thalassemia, Sickle, H. Hemolytic
Anemia
d. Bone Marrow Insufficiency: Aplastic Anemia
e. Infections: Malaria, TB
f. Chronic Renal Diseases or Neoplasm.
 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
 Criteria for Physiologic
Anemia
 Hb: 10gm%
 RBC: 3.2 million/mm3
 PCV: 30%
 Peripheral smear showing normal
morphology of RBC with central
pallor
Significance of Hypervolemia

1. 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.
 Normal hemoglobin by gestational
age in pregnant women taking iron
supplement

 12 wks 12.2 [11.0-13.4]

 24wks 11.6 [10.6-12.8]
 40 wks 12.6 [11.2-13.6]
 Most common causes of
Anemia
 Iron loss : sweat, repeated
pregnancy, hookworm infestation
and malaria
 Faulty absorption mechanism : due
to high incidence of intestinal
infestation, there is intestinal hurry
 Faulty diet habit : rich carbohydrate
and high phosphate reduce
absorption of iron
 Factors lead to develop
Anemia
 Increaseiron demand
 Diminished intake of iron
 Disturbed metabolism
 Pre-pregnancy health status
 Excess demand
 Iron Deficiency Anaemia
 Symptoms: lassitude, weakness,
anorexia, palpitation, dyspnea
 Signs: Pallor, glossitis, soft systolic
murmur in mitral area due to
physiologic mitral incompetence

 Degree: Mild: 8-10gm%

Moderate: 7-8gm%
Severe: <7gm%
pallor
Conjunctival Pallor
Koilonychia
Smooth Tongue
Interpretation of plasma Iron

Iron TIBC Ferritin

Iron deficiency Decreas Increas Decreas

anemia e e e
Anemia of Decreas Decreas Increase
chronic e e
disease
Pregnancy Increas Increas Normal
e e
 Normal Iron Requirements
 Iron requirement for normal pregnancy is
1gm
200 mg is excreted
300 mg is transferred to fetus
500 mg is need for mother

 Total volume of RBC inc is 450 ml

1 ml of RBCs contains 1.1 mg of iron
450 ml X 1.1 mg/ml = 500 mg

 Daily average is 6-7 mg/day

 Treatment
 Prophylactic:Supplement Fe – 60 mg
elemental Fe with Folic
Acid
 Curative: 200mg FeSo4 3 times
daily till
Hb level becomes normal,
then
maintenance dose of 1 tab
for
100 days
 Megaloblastic Anemia
 Due to impaired DNA synthesis,
derangement in Red Cell maturation
 It may be due to Def. of VitB12 or Folic
Acid or both.
 Megaloblastic anemia in pregnancy is
almost always due to Folic Acid def.
 Vit B12 def is rare in Pregnancy becoz its
need is less in amount and amount is met
with any diet that contains animal
products.
 Sign and symptoms
 Insidious onset, mostly in last
trimester
 Anorexia and occasional diarrhoea
 Pallor of varying degree
 Ulceration in mouth and tongue
 Hemorrhagic patches under the skin
and conjunctiva
 Enlarged liver and spleen
Angular Cheilosis
 Blood values
 Hb<10gm%
 Hypersegmentation of neutrophils
 Megaloblast
 MCV>100micrometer3
 MCH>33pg, but MCHC is Normal
 Serum Fe is Normal or high TIBC is
low
 Treatment
 Prophylactic
- all woman of reproductive age
should be given 400mcg of folic acid
daily
 Curative
-daily administration of Folic acid
4mg orally for at least 4 wks
following delivery
Sickle cell Hemoglobinopathy
 Hbs comprises 30-40% total Hb
 There is substitution of Lysine for glutamic
acid at the sixth position of B chain of Hb
 Red cells in oxygenated state behave
normally, but in deoxygenated state it
aggregates, polymerises and distort red
cells to sickle.
 These cells are more fragile and increased
destruction leads to hemolysis, anemia
and jaundice.
 Effects on pregnancy
 Increase incidence of abortion,
prematurity, IUGR and Fetal loss.
 Perinatal mortality is high.
 Incidence of pre-eclampsia,
postpartum hemorrhage and
infection is increased.
 Management
 Careful antinatal supervision
 Air travelling in unpressurised
aircraft to be avoided.
 Prophylatically Folic A. 1gm daily.
 Regular blood transfusion at approx.
in 6 weeks interval
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