Anemia in

Pregnancy

DEFINITION of
Anemia in Pregnancy

WHO Definition:

Hb < 11 gm/dL

CDC Definition:

1st trimester: < 11 gm/dL

2nd trimester: < 10.5 gm/dL
3rd trimester: < 11 gm/dL

In Malaysia, a Hb > 10 gm/dL is considered normal although normal

values do not exist in Malaysia.
Mild Anemia

Moderate
Anemia

Severe
Anemia

Hb 8 - 10

Hb 6 - 8

Hb < 6

Physiological Considerations

The disproportionate rise in plasma volume ( 50%) compared to red

cell volume ( 30%) leads to a physiological haemodilution.

Hb concentration, HCT and red cell count fall due to haemodilution.

Iron requirements during pregnancy is around 950 - 1100mg, which is

required for:

red cell expansion

fetus and placenta

blood loss at delivery

external iron loss (sweat, urine, faeces)

Causes
Iron deficiency
Lack of production Folic acid deficiency
Protein deficiency
of blood
Combined deficiency

Blood loss

Haemorrhage during pregnancy

Hookworm infestation

Increased
breakdown of
RBCs

Malaria
Sickle cell disease
Haemoglobinopathies

Decreased
production

Aplastic anemia
Myelosuppression

Iron Deficiency Anemia in

Pregnancy
Poor Intake

Diet deficient in iron-containing foods

Vomiting in pregnancy

Poor
Absorption

Presence of phosphates, phytates

Increased pH of gastric juice (achlorhydria)
Ferric irons in the gut instead of ferrous form
Lack of Vitamin C

Increased
Utilisation

Demands of pregnancy more if multiple

pregnancy

Excessive
Iron Loss

Repeated pregnancies, especially at short

intervals
Menorrhagia prior to pregnancy
Hookworm infestation
Chronic malaria

Clinical Features
Symptoms

Fatigue
Lassitude
Anorexia
Breathlessness on
exertion
Dizziness
Headache
Insomnia
Palpitations

Signs

Pallor of skin and

mucus membranes
Tachycardia
Edema
Glossitis
Stomatitis
Koilonychia
Soft systolic
ejection murmur

Maternal and Fetal Consequences

Inability to withstand haemorrhage (PPH)

Susceptibility to infection

Development of heart failure if severe anemia

Stillbirths

Preterm labour

The neonate will not be anaemic at birth, but if there is little or no

reserve iron, anemia develops rapidly in neonatal period.

Low birth weight infants.

Investigations
Investigations

Justification

Full blood count

Diagnosis and severity

Full blood picture

Helps identify the type of anemia

Serum ferritin
Serum iron and TIBC

To identify iron deficiency if blood film

shows microcytic hypochromic anemia

Folate and Vit B12

If blood film shows macrocytic anemia

Haemoglobin
electrophoresis

If haemoglobinopathy is suspected from the

full blood picture

Stool ova and cyst

Helminthic infestation is a common cause of

chronic blood loss

Stool for occult blood

Identifies chronic upper GI bleed as a cause

Urine analysis

If chronic urinary tract infection is

suspected

Bone marrow studies

In selected cases if necessary

Treatment

To achieve a normal Hb by the end of the

pregnancy.

To replenish iron stores.

This can be done by:

Oral iron therapy

Parenteral iron therapy

Blood transfusion

Oral Iron Therapy

Haematinics

T.
T.
T.
T.

Ferrous fumarate 200mg OD

Folic acid 5mg OD
Vitamin C 50mg OD
B Complex 1/1 OD

The preferred route of administration of iron is oral (ferrous sulfate, ferrous

gluconate, ferrous fumarate).

There is significant rise in Hb concentration by 0.1 - 0.2 gm/dL/day starting

from the second week of treatment (approximately 0.8 gm/dL/week), leading
to a 2 gm/dL rise over a period of 3 - 4 weeks.

Side effects: nausea, vomiting, constipation, abdominal cramping, diarrhoea.

It is advisable to encourage mothers to take oral iron with orange juice as it

increases the absorption of iron.

Parenteral Iron Therapy

Indications

Intolerance to oral iron

Poor compliance to oral iron

Iron dextran (Imferon) - It is more widely used, and can be given both IV or IM.

1 ampule of Imferon (2mls) = 100mg of elemental iron.

Dosages can be calculated from the following formula: -

(14.8 - Hb) X 3 X weight (kg) + 500 / 100

The preferred site for IM is upper and outer quadrant of the buttock deep into the
gluteal muscle. A test dose should be given. If no adverse effect, further
administration of parenteral iron therapy can be given. The adverse effects are:
fever, myalgia/arthralgia, or arthritis.

The main advantage of IV therapy is the certainty of its administration to correct

the Hb deficit and to fix up the iron store. It eliminates repeated and painful IM
injections and the treatment is completed in a day, at the maximum two. However,
adverse effects might occur, such as severe anaphylactoid reactions, peripheral
vascular flushing, tachycardia, hypotension and syncope.

There would be a rise in Hb in 3 weeks time.

Blood Transfusion
Indications

Hb < 8 or POA > 36 weeks

Hb < 6
Fail to respond to oral iron and
parenteral iron therapy
Those who require surgery

Blood transfusion is prescribed only for conditions for which there is no other
treatment.

Adverse effects:

Mild: Mild hypersensitivity: allergic, urticarial reactions.

Moderate: Severe urticarial reactions, febrile non-hemolytic reactions, possible

bacterial contamination, pyrogens.

Severe: Acute intravascular hemolysis, bacterial contamination and septic

shock, fluid overload, anaphylactic reactions, and transfusion-associated lung
injury.

Delayed complications: tranfusion-transmitted infections (Hep B, Hep C, HIV),

delayed hemolytic reaction, post-tranfusion purpura, or graft-vs-host disease.

Megaloblastic Anemia

It is the second most common cause of nutritional

anemia - contributing to 3-4% of all anemias seen
in pregnancy.

More common in multiparae and in multiple

gestation.

Diagnosis: Macrocytosis ( MCV), peripheral smear

shows macrocytic normochromic erythrocytes,
decrease in serum folate.

Management: Daily administration of folic acid 5mg

orally will lead to a rapid recovery, as evidenced by
reticulocytosis within a week.

End.