Anemia during pregnancy

Anemia During Pregnancy
Prof .Mahmoud Zakherah,MD
Prof. Obstertris and Gynecology
mszakhera@yahoo.com

• Intended Learning Objectives (ILOs)
-Definition of anemia during pregnancy
-Classification and clinical types of anemia
-Treatment of common types of anemia
during pregnancy

Introduction
• Anemia is the commonest medical disorder
in pregnancy.
• Nutritional anemia is the commonest type
of anemia.
• Iron deficiency is the commonest type of
nutritional anemia.

Introduction
• WHO reported that 56% of women in
developing countries are anemic.
• 50-90% of pregnant women are anemic.

Definition of Anemia during
Pregnancy
• Hemoglobin below 11gm/dl in 1st
and 3rd
trimester and below 10.5gm/dl in second
trimester
• Hemoglobin below 11gm/dl (WHO)
• HB below 7 gm/dl = severe anemia
• Serum ferritrin of 15 ug/dl
•

By this standard, 50% of women
not on hematinics become
anemic.

Incidence
• Anemia 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

Effect of anemia on pregnancy
• 16 % of maternal deaths in India are due
to anemia.
• Early onset anemia =more and severe
complications

Effect of anemia on pregnancy
• MATERNAL
o Inertia
o PPH
o Heart failure
• FETAL
o IUGR-LBW
o Abortion -pre-term
labor
o low APGAR score
o Neurological and
mental impairment

Effects of pregnancy on anemia
• Increased iron demands
• Hemodilution
• Aggravated pre existing anemia

Types of anemia
• Physiologic anemia
• Pathologic anemia

Physiologic anemia
Concept of Physiologic Anemia

Physiologic anemia
• Disproportionate increase in plasma
volume, RBC vol. and hemoglobin mass
during pregnancy (Dilutional or physiologic
Anemia)
• Marked demand of extra iron during
pregnancy especially in second trimester

Criteria for Physiologic Anemia
• Hb: 10gm%
• RBC: 3.2 million/mm3
• Peripheral smear showing normal
morphology of RBC with central pallor
• Plasma volume increased more than RBCs
(HEMODILUTION )

• 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]

Physiologic Anemia of Pregnancy

‫ر‬ُ ‫بري‬ِ‫ري‬‫خ‬َ‫ِب‬ ‫ل‬ْ‫خ‬‫ا‬ ‫ف‬ُ ‫طري‬ِ‫ري‬ ‫َل‬ّ‫ِط‬‫ل‬‫ا‬ ‫و‬َ‫ِب‬ ‫ه‬ُ ‫و‬َ‫ِب‬ ‫ق‬َ‫ِب‬ ‫َل‬َ‫ِب‬‫خ‬َ‫ِب‬ ‫ن‬ْ‫خ‬ ‫م‬َ‫ِب‬ ‫م‬ُ ‫َل‬َ‫ِب‬‫ع‬ْ‫خ‬ ‫ي‬َ‫ِب‬ ‫ل‬َ‫ِب‬ ‫أ‬َ‫ِب‬

Physiologic anemia
• Pregnancy-induced hypervolemia has several
important functions:
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.

Types of anemia
• Nutritional anemia
Iron deficiency anemia
Megaloplastic anemia
 Folic acid defiency
 Vit B12 deficiency (pernicious anemia)
• Hemolytic anemia
 Hemoglobinopathies as thalassemia, sickle
cell anemia
 HELLP syndrome

Types of anemia
• Hemorrhagic anemia due to blood loss.
• Due to chronic diseases Renal diseases
• Bone Marrow Insufficiency: Aplastic
Anemia
• Infection Hookworm infections -TB -
Malaria

Iron deficiency anemia
• The commonest type
• Causes
 Increased demands
 Decreased intake
 Deficient absorbion
Diagnosis Blood picture
hypochromic microcystic anemia

Causes
1-Increased demands
• 1000 mg 500 RBCs expansion
300 fetus and placenta
200 growing uterus
150gm saved by amenorrhea so the need is
------850mg

• Increased demands
o Normal pregnancy
o Short spaced pregnancies
o Multiple pregnancy

2-Decreased intake .poverty ----
3-Iron stores DEPLETION
4-Deficient absorption Malabsorption
syndromes

The amount of iron absorbed from diet,
together with that mobilized from stores,
is usually insufficient to meet the
maternal demands imposed by
pregnancy

Diagnosis
• Clinical
History
lassitude, weakness, anorexia, palpitation, dyspnea
examination
Pallor, glossitis, soft systolic murmur in mitral area
due to physiologic mitral incompetence

• Laboratory
CBC red cell indices HB HT
Serum ferritrin serum iron
Serum ferritrin is the best indicator of
bonr marrow stores

Degree of anemia
Mild: 8-10gm%
Moderate: 7-8gm%
Severe: <7gm%

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 of iron deficiency
anemia
PROPHYLAXIS
Ferous gluconate 300mg orally/day
Supplement Fe – 60 mg elemental Fe with Folic
Acid
DIET rich iron green vegetables

TREATMENT ( Curative)
Iron Therapy
 ORAL Ferrous Gluconate 300mg
3 times /day
Ferrous sulfate 325 bid-tid
 PARENTRAL IV OR IM

Blood transfusion In severe anemia
(HB<7gm/DL
NB Restore iron stores
Target is tissues

•(‫الداكن‬ ‫)اللحم‬ ‫الدواجن‬
(‫والتمر‬ ‫والزبيب‬ ‫والتين‬ ‫والخوخ‬ ‫)المشمش‬ ‫المجففة‬ ‫الفواكه‬ •
‫الكاملة‬ ‫الحبوب‬ •
•‫الرخرى‬ ‫واللحوم‬ ‫الكبد‬
‫يمكنك‬ ‫آمنة‬ ‫البحرية‬ ‫المأكول ت‬ ‫من‬ ‫أنواع‬ ‫على‬ ‫)تعرف‬ ‫البحرية‬ ‫المأكول ت‬ •
(‫الحمل‬ ‫أثناء‬ ‫تأكل‬ ‫أن‬
‫الورقية‬ ‫الداكنة‬ ‫الخضراء‬ ‫الخضر‬ ‫من‬ ‫وغيرها‬ ‫واللفت‬ ‫القرنبيط‬ ،‫السبانخ‬ •
‫الجلد‬ ‫مع‬ ‫المشوية‬ ‫البطاطا‬ •
‫والبازلء‬ ‫الفول‬ •
‫والبذور‬ ‫المكسرا ت‬ •

Nutritional anemia
Iron deficiency anemia
Megaloplastic anemia
 Folic acid defiency
 Vit B12 deficiency (pernicious
anemia)

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 because the needs
are less and the amount is met with any diet that
contains animal products.

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

• Nutritional anemia
•Hemolytic anemia
 Hemoglobinopathies as thalassemia,
sickle cell anemia
 HELLP syndrome

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 they aggregate, polymerise
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 antenatal supervision
• Air travelling in unpressurised aircraft to be
avoided.
• Prophylactically Folic A. 1gm daily.
• Regular blood transfusion at approximately
6 weeks interval

Anemia during pregnancy

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