ANAEMIA IN PREGNANCY - DR. F.X.
ODAWA
• An expectant mother is considered to have anaemia if
her HB level is < 10g/dl (WHO: <11g/dl)
• During pregnancy plasma volume expands by 46-50%
whereas red cell mass increases by 18-25 %. This leads to
haemodilution hence the lower level taken for HB during
pregnancy.
• Normal ranges: Female: 12-16g/dl; Male:13-18g/dl
• Anaemia is the most common medical disorder to occur
in pregnant women particularly in developing countries
but its prevalence varies from region to region.
• It is a major contributor to maternal morbidity and
mortality and is also associated with perinatal mortality.
Causes
Are multifactorial and include:
1)Nutritional deficiencies of iron and folate
• Poor dietary intake
• Poor absorption
• Increased nutrient loss and demand
• Methods of cooking
• Dietary habits
• Prohibitive costs
• Some food taboos for pregnant women
NB: Absorption of iron is affected by the high phytate content
in many grains based diets in the tropics.
2). Malaria infestation
• With its attendant haemolysis increases folate demand
leading to megaboblastic anaemia.
• Natural acquired immunity is lowered in pregnancy
leading to excessive destruction of RBCs in some cases.
3). Hookworm infestation:
• Chronic parasite infection affects millions of women of
reproductive age in developing countries.
• Lives in the duodenum - the site of optimal iron
absorption, therefore interfering with the latter by their
attachments to the duodenal mucosa besides sucking
blood from the patient (0.05 – 0.1ml per worm/ day),
and leads to iron deficiency.
4) Other helminthes and parasites e.g E. histolytica
5) Haemoglobinopathes e.g. sickle cell disease (SCD),
thalasaemia and glucose 6-phosphate dehydrogenase
deficiency.
• SCD is the most common inherited anaemia in the world.
• The anaemia in SCD is related to the shortened red cell
survival (average 17 days) so that these patients suffer
from a chronic haemolytic process reflecting itself in the
form of a crisis in the mother and IUGR in the foetus.
The steady state HB in SCA is between 6-10%.
6). Chronic diseases e.g. TB, HIV, Brucellosis, scistosomiasis,
UTI, chronic liver and renal dx, and protein deficiency.
7) Demands of pregnancy per se
• Extra demands to the haemolytic factors - increased red
cell mass plus demands of the growing foetus = increase
in the total number of rapidly dividing cell leads to
increased requirement of folic acid.
Clinical Features
• Characteristically insidious in onset
• Presentation usually non-specific and depends on the
severity of anaemia, duration of disease and causative
factors.
• Diagnosis depends on history, physical examination and
various lab tests done based on aetiological factors.
• In the early stages it may only be detected by routine HB
estimation in the ANC.
Symptoms include:
• General weakness, malaise, fatigue, lethergy or lassitude
• Dizziness
• Dyspnoea on slight excertion
• Breathlessness
• Swelling of legs feet and face (oedema)
Signs include:
• pallor (conjunctiva, tongue, palms and nail beds, sole of
the feet etc),
• jaundice (or tinge of),
• Moderate tachycardia at rest,
• Haemic murmur,
• low grade fever without obvious cause is common plus or
minus hepatosplenomegaly in haemolytic anaemia e.g. of
malaria (endemic) and SCD,
• Orthorpnoea and other signs of cardiac failure e.g.
engorged neck veins in the semi-upright position,
congestion of lung bases, enlarged tender liver, increased
pulse pressure, and may be present in very severe cases
• Albuminuria is common
• In the terminal phase acute pulmonary oedema may
supervene and cerebral anoxia may produce excitement
and mental confusion followed by loss of consciousness.
Investigations
• H’gram + PBF+ BS for MPs
• Stool: O/C
• Hb electrophoresis/ sickling test
• LFTs for serous proteins as in chronic liver disease and
hypoproteinaemia
• U/Es + Cr + U.A to rule out underlying nephrosis
• CXR- to r/o intercurrent chronic chest infection
Sequale of Anaemia in pregnancy
• CCF= death in pregnancy or soon after delivery or during
labour
• Low resistance = infections e.g. pneumonias, puerperal
sepsis etc
• IUGR
• Late abortions (20 – 28 wks)
• Premature labour
• IUFD/ neonatal death (perinatal death) due to Prevention
intrapartum asphyxia • Correct faulty dietary habits e.g. overcooking vegetables
• Infantile anaemia 2-3 months post delivery due to and meat (important sources of folic acid)
deficient iron storage in the last trimester. • Increase production and consumption of foods which
contain the raw materials of erythropoesis.
Treatment • Antimalarial prophylaxis
• Mainly directed at the cause • Reduction of hookworm loads
• Supportive care is similarly important e.g. administration • Prophylactic medication – haematinics
of haematinics or blood transfusion or both – depending • Early detection of anaemia in pregnancy by screening all
on the degree of anaemia and the gestational age at the pregnant women (ANP) – first and last visits
time of diagnosis. • These measures will lead to a reduction in loss of
maternal and infant lives from anaemia and also reduce
General Measures cost of hospitalization and treatment
• Protein intake- Should be adequate – at least 100grams
per /day, 50% of which should preferably be animal Conclusion
protein • Prevention of anaemia is difficult in developing countries
• Chronic diarrhoeas – should be treated as they interfere due to its multfactorial origin:
with folic acid and B12 absorption o Poor SES
• Hookworm – should be treated with non-toxic o Poor health facilities
antihelminthics o Socio-cultural factors
o Poor utilization and scarcity of FP and ANC
Specific treatment services
1). Oral iron therapy; in Fe def. anaemia of moderate degree • However prophylactic use of haematinics and
in the first and second trimester antimalarials has reduced the severity of anaemia in the
2). Parenteral iron therapy; in more severe cases particularly tropics.
those seen for the first time near term to achieve quicker
response as well as for those not able to tolerate oral Fe due
to gastric symptoms and also those not responding due to
malabsorption.
3). Suplementary Folic Acid
4). Malaria treatment – when confirmed or suspected
5). Steroid therapy – in excessive haemolysis
6). Vit. B12 – for megaloblastic anaemia unresponsive to folic
acid or when B12 def.is confirmed
7).Cardiac failure - treated appropriately with antifailure
regime (digoxine, aminophyline, O2 etc
8). Blood transfusion – for impending CCF, patient in labour
with severe anaemia
• watch for overload
• Packed RBCs is preferred
• Transfuse slowly (not more 500mls in at least 6-8 hrs)

Mx of labour and the puerperium in severe anaemia

• Labour and the first 2wks of the puerperium are the
periods of greatest danger to the anaemic mother.
• Most deaths occur in the first 12hrs after delivery
• O2 should be delivered in labour by mask to reduce the
risk of foetal asphyxia
• Aseptic techniques to be employed due to decreased
immunity
• 2nd stage should be shortened by assisted vacuum
extraction or low forceps delivery
• Antibiotic prophylaxis in the puerperium
• Specific treatment for anaemia to continue for at least
6wks after delivery (puerperium) to accelerate recovery
• Finally before discharge warn the mother of possibility of
recurrence in subsequent pregnancies therefore to
present as soon as they become pregnant for prophylaxis