ANEMIA IN PREGNANCY

Anemia is defined as a decrease in the oxygen carrying capacity of the blood due to decrease in amount of RBCs or haemoglobin or both.

The definition of anaemia in pregnancy is Hb levels of:

<110g/l in the first trimester

<105 g/l in the second and third trimesters

<100 g/l in the postpartum period.

Severity

Mild anaemia --------      9 -10.9 gm /dl

      Moderate anaemia---             7-8.9 gm /dl

      Sever anaemia--------              <  7gm /dl

      Very sever anaemia--     < 4gm/dl

 90% anemia in pregnancy is due to  Fe deficiency

 5% folate deficiency anemia  

Common types:

1.Nutritional deficiency anaemias

        - Iron deficiency          

        -  Folate deficiency

        -  Vit. B12 deficiency

2.Haemoglobinopathies: 

        - Thallassemias            

        - SCD

3.Rare types:

        - Aplastic                      

        - Autoimmune hemolytic

        - Leukemia                    

        - Hodgkin’s disease

        - Paroxysmal nocturnal haemoglobinurea

Prevalence of anemia in developing countries  is nearly two thirds of the pregnant women because of low bioavailability diet, defective absorption & chronic blood loss due to hook worm infestation & malaria and rapidly successive multiple pregnancies. Iron deficiency anemia is responsible for 95% of the anemias during pregnancy.

Symptoms:

1. Weakness

2. Easy fatiguability

3. Lassitude

4. Dizziness or vertigo especially when standing

5. Headache

6. Irritability

7. Indigestion, loss of appetite

8. Breathlessness

9. Palpitations

10. Generalized swelling

11. Symptoms due to cause of anemia like yellowing of skin & mucous membranes, bleeding from rectum etc.

Signs:

1. Pallor

2. Icterus

3. Glossitis, stomatitis

4. Koilonychia

5. Tachycardia, systolic murmurs, bounding pulse

6. Fine crepitations at lung bases

7. Splenomegaly

8. Hepatomegaly

9. Edema

Maternal complication

Iron deficiency may contribute to maternal morbidity through effects on immune function with increased susceptibility or severity of infections, poor work capacity and performance and disturbances of postpartum cognition and emotions .

It doesn’t cause PPH but worsen the severity of PPH and need of transfusion after delivery.

Fetal complications

The fetus is relatively protected from the effects of iron deficiency by upregulation ofplacental iron transport proteins (Gambling et al, 2001) but evidence suggests that maternal iron depletion increases the risk of iron deficiency in the first 3 months of life.

Investigations:

Hb%

PCV

Peripheral smear for immature cells, type of anemia and MP.

Urine routine and microscopy, Urine C/S if required

Stool for Routine and microscopy

USG abdomen

Screening for anemia

NICE guidelines recommend that women are screened for anaemia at

booking and again at 28 weeks gestation.

All women should be given advice regarding diet in pregnancy with details of

foods rich in iron along with factors that may promote or inhibit the absorption

of iron. This should be backed up with written information. Dietary changes

alone are not sufficient to correct an existing iron deficiency in pregnancy and

iron supplements are necessary.

Treatment:

Non-drug treatment

1.     Awareness/ Education

2.     Improvement of dietary habits-diet rich in Vit C, protein and iron, avoiding tea & coffee intake with meals .

3.     Social services such as improvement of sanitation & personal hygiene for eradication of helminthiasis

4.     Routine screening for anaemia & providing iron supplementation for adolescent girls from school days

Iron rich foods: Pulses, cereals, jaggery, Beet root, Green leafy vegetables, nuts, meat, liver, poultry, Egg, fish, legumes, dry beans, and dry fruits viz: dates, figs, apricots etc .

Drug treatment: Prophylaxis

WHO recommendation

60mg elemental iron and 0.25mg folic acid daily

Ferrous sulphate is least expensive and best absorbed form of iron. It also allows more elemental iron absorbed per gram administered. If for some reason, this is not tolerated, then ferrous gluconate & fumarate are the next choice for iron therapy.

Treatment of anemia in the antenatal period (Fe deficiency)

If at booking Hb <110 g/l : Start on a trial of oral iron.

The necessary dose is 100-200mg of elemental iron daily.

Women should be counselled as to how to take oral iron supplementation

correctly. This should be on an empty stomach, 1 hour before meals, with a

source of vitamin C to maximise absorption. Other medications or antacids,

tea or coffee should not be taken at the same time.

Women with a norman Hb but a low MCV should have their ferritin checked

and if ferritin is <30µ/l, oral iron should be commenced.

Repeat Hb levels 3 weeks after commencement of iron therapy (this should fit

in with 15-16 week antenatal appointment) and a rise in Hb should be

demonstrated. If there is no rise in Hb despite compliance with therapy serum

ferritin should be checked and concomitant causes of the anaemia need to be

excluded.

If at Booking Hb <90 g/l Oral iron - 200mg elemental iron in divided

doses/day should be commenced and follow up as above.

If at Booking Hb <70g/l send an urgent referral to joint

obstetric/haematology clinic to investigate further and make management

plan. Do not offer blood transfusion unless symptomatic or currently actively

bleeding. Consider total dose IV iron infusion .

200mg of elemental iron / day (N.B. if 200mg ferrous sulphate used, need

3-4 tablets/day) if taken correctly will give a rise in Hb of 20g/l every 3

weeks.

Once Hb is within the normal range, treatment should be continued for a

further 3 months.

Parenteral iron can be considered from the second trimester onwards

and during the third trimester for women with confirmed iron deficiency

who fail to respond to or are intolerant of oral iron. Intravenous iron is

the appropriate treatment for those patients with active inflammatory

bowel disease where oral preparations are not tolerated or contraindicated.

Management of Labour and Delivery

With effective management of anaemia antenatally, anaemia at delivery is

usually avoided. If this occurs, all measures must be taken to avoid blood

loss at delivery:

Deliver in consultant unit

IV access and Group and screen on admission

Active management of third stage of labour

In the event of a PPH prompt active management is required to stop

Bleeding

Consider the use of prophylactic syntocinon infusion.

Postnatal FBC and serum ferritin on day 1 and iron replacement as

below.

Contraindications to IV iron therapy.

First trimester of pregnancy

Previous hypersensitivity to IV iron

Anaemia not attributable to iron deficiency

Iron Overload

Acute infection/inflammation

Clinical or biomedical evidence of liver damage

Asthma

Acute renal failure

Active Rheumatoid Arthritis

Indications:

- Hb less than 7g/dl and pregnancy >30 weeks

- Malabsorption Syndrome

- Incapacitating side effects with oral iron

Preparations:

- Iron sucrose

- Iron dextran

- Iron sorbitol citrate

Total iron deficit (mg) = Amount of iron deficit + amount of iron to replenish stores

Amount of iron deficit (mg) = (Hb target- Hb initial)gm/dl x Body wt (Kg) × 2.2 + Stores

Or

( 100-Hb initial)% x Body wt (Pounds) x 0.3 + Stores

where

Stores (mg) = 50% of deficit or approx 1000mg

Iron Sucrose Complex is considered to show a significant improvement of Hb and iron stores in pregnant women.

Deworming necessary :

- Albendazole 400 mg single dose

- Mebendazole 500 mg single dose or 100 mg twice daily for 3 days

- Levamisole 2.5 mg/kg single dose, best if a second dose is repeated on next 2 consecutive days

- Pyrantel 10 mg/kg single dose, best if dose is repeated on next 2 consecutive days

- To prevent recurrence, patients should be advised to use footwear, improve sanitation, and personal hygiene.

Malaria prophylaxis in endemic area to be treated.