ANAEMIA AND PREGNANCY

DR DOHBIT SAMA
OBS/GYN
HGOPY-FMBS

PLAN
1.

Introduction and Definition

2. Physiopathology
3. Iron Deficiency anaemia
4. Clinical presentation
5. Management
6. Complications
7. Conclusion

INTRODUCTION
An

important maternal problem during

pregnancy
A hemoglobin level of less than 10g/dl should
be investigated and treated.
All efforts made to avoid blood transfusion and
its related complications
Every delivery and the postpartum entail blood
loss

INTRODUCTION 2
An

anaemic woman is therefore at increased

jeopardy
Pregnancy increases the blood volume by
50% and the red cell mass at about 25%
This physiologic hydremia (hemodilution) will
lower the hematocrit

PHYSIOPATHOLOGY
Nutritional

anaemia is the most common form

Results from deficiency of iron, folic acid, or
vitamin B12
Pernicious anaemia due to vitamin B12
deficiency is very rare.
Aplastic anaemia
Drug-induced hemolytic anaemias

IRON DEFICIENCY
Responsible

for 95% of anaemias during

pregnancy
Total iron: 70% (1700mg) in Hemoglobin and
30% (300mg) stored as ferritin and
hemosiderin in RE cells in bone marrow,
spleen, and parenchymal cells of the liver
Small amounts exist in myoglobin, plasma,
and various enzymes

IRON DEFICIENCY 2

Hemosiderin contains 37% more iron than does

ferritin.
Its absence in bone marrow will indicate depletion of
iron stores of the body
This is diagnostic of anaemia and one of the earliest
signs of iron deficiency
This will be followed by a decrease in serum iron and
an increase in serum total iron-binding capacity and
anaemia

IRON DEFICIENCY 3

In the 1st half of pregnancy, iron requirements may

not be much.
Iron from food; 10-15mg/day is sufficient to cover the
basal loss of 1mg/day
In the 2nd half of pregnancy, there is expansion of red
blood cell mass and the rapid growth of the foetus
Increase in RBC and HB mass require 500mg of iron
The iron need of the foetus is 300mg.

IRON DEFICIENCY 4

Total iron requirement is 800mg, cannot be got from

diet alone, iron supplementation must be given.
Pregnancy increases a womans Fe requirements to
approximately 3.5mg/day
This need can be met by iron supplements
exceeding 40mg/day of elemental iron
Iron deficiency anaemia if severe will lead to IUGR
and preterm labour.

CLINICAL FINDINGS
The

symptoms may be vague and non

specific: pallor, fatigability, palpitations,
tachycardia, and dyspnoea.
Angular stomatitis, glossitis, and koilonychia
may be present in long-standing severe
anaemia

LABORATORY FINDINGS
Low

Hb level, could drop to 3g/dl, RBC of

2,5M/L
Microcytic RBC MCV<79fL and hypochromic
Low erythrocyte count, Plt increased, WBC
are normal
Occasional hypersegmented neutrophils are
seen
Serum iron levels are less than 60g/dL

LAB FINDINGS 2
Total

Fe binding capacity increased to 350500/dL

Transferrin saturation less than 16%
Serum ferritin concentration < 10g/dL
The amount of stainable iron (hemosiderin)
in the marrow aspirate is a reasonably
accurate indication of stored Fe

DIFFERENTIAL DIAGNOSIS
Anaemia

due to chronic disease or

inflammatory process (RA)
In Thalassemia trait, there is normal serum
iron levels, stainable iron in the marrow, and
elevated levels of hemoglobin A2

COMPLICATIONS
Angina

pectoris or congestive heart failure

Sideropenic dysphagia

PREVENTION
During

the course of pregnancy and the

puerperium, at least 60mg/day of elemental
iron should be prescribed to prevent anaemia

TREATMENT
Oral

Iron therapy, 300mg Fe sulfate,

containing 60mg of elemental Fe, about 10%
is absorbed, is given 3 times daily
Treatment continued for 3 months after
restoration of Hb level, to replenish Fe stores
Weekly Hb increase should be at least
0.3g/dL/wk

TREATMENT 2
Parentheral

Fe if intolerance or refractoriness
to oral iron (Imferon)
Weekly dose of 250mg of elemental Fe

FOLIC ACID DEFICIENCY ANAEMIA

Common where nutrition is inadequate

Bone marrow studies show an incidence of 25-60%,
Peripheral blood examination shows a lower
incidence
Incidence in the USA is 0.5-15%
Minimum daily intake to maintain adequate
hematopoiesis is 50g
This is increased during pregnancy to 800ug

FOLIC ACID DEFICIENCY ANAEMIA 2

More

common in multiple pregnancy and

multigravid patients.
May recur in subsequent pregnancies
FA absorption can be impaired during the use
of oral contraceptives, pyrimethamine,
trimethoprim-sulfamethoxazole, primidone,
phenytoin, or barbiturates, jejunal bypass
surgery, malabsorption syndrome sprue

FOLIC ACID DEFICIENCY ANAEMIA 3

F

A is necessary for the DNA synthesis of

erythropoiesis, sicklers need folate
Dg usually made late in pregnancy or in the
puerperium
Usually suspected when anaemia fails to
respond to iron therapy
Low birth weight known to be associated.

FOLIC ACID DEFICIENCY ANAEMIA 4

Its

association with placenta abruption,

spontaneous abortion, PEC, neural tube
defects is not universally accepted

CLINICAL FINDINGS
Are

nonspecific: lassitude, anorexia, nausea

and vomiting, diarrheoa, depression.
Pallor often is not marked, rarely a sore
mouth or tongue may be present.
An accompanying UTI is common
Occasionally purpura may be a clinical
manifestation

LABORATORY FINDINGS
Similar

to pernicious anaemia, due to B12

deficiency, which is rare in women of child
bearing age
Megaloblastic anaemia in pregnancy almost
always implies folate deficiency
Hb may be as low as 4-6g/dL, RBC <2M/l in
severe cases
Leukocytopenia and thrombocytopenia

LABORATORY FINDINGS 2
The

RBC are macrocytic, MCV>100fL,

Megaloblastic changes are present in the
marrow.
In pregnancy, macrocytosis can be
concealed by associated Fe deficiency and
thalassemia.
Peripheral white cells are hypersegmented

LABORATORY FINDINGS 3

75% of folate deficiency patients have >5% of

neutrophils with 5 or more lobes but this may also be
true for 25% of normal pregnant patients
Urinary excretion of formiminoglutamic acid (Figlu) is
Dg but levels are abnormal only in severe cases
Bone marrow aspirate, good hematologic response
to folate
Serum Fe and vitamin B12 levels ahould be normal

TREATMENT

1-5mg/day orally or parentherally for several weeks

Maximum hematologic response, replacement of
body stores, and daily requirements
The Ht should rise by 1% daily from day 5-6 of
therapy
The reticulocyte count should elevate after 3-4 days
of therapy

PROGNOSIS

Good if adequately treated

Usually mild anaemia except if associated with
multifoetal pregnancy, systemic infection or
hemolytic disease like sickle cell
Usually disappears after delivery, may recur in
subsequent pregnancy
Fe and Folate are given in pregnancy because 70%
of folate deficient patients also lack Fe stores.

APLASTIC ANAEMIA
Rare

in pregnancy
May be secondary to exposure to certain
marrow toxic substances like CAF,
phenylbutazone, mephenytoin, alkylating
chemotherapeutic agents, and insecticides
In most cases, no obvious case is detected

APLASTIC ANAEMIA 2
Idiopathic

cases may have spontaneous

remission following delivery but may recur in
subsequent pregnancies, suggesting an
immune mechanism
The anaemia is rapid
Dg criteria are pancytopenia and empty bone
marrow on biopsy examination
Increase risk of infection and haemorrhage

COMPLICATIONS
Increased

foetal wastage
Prematurity
IU foetal demise
Increased maternal morbidity and death

TREATMENT
Avoidance

of toxic agents
Prednisolone 10-20mg, 4 times daily
Transfusion of packed RBC and platelets
In some cases TOP may be necessary
Bone marrow tansplantation if remission
does not occur
Infection treated agressively

DRUG INDUCED HEMOLYTIC ANAEMIA

Individuals

with inborn errors of metabolism

G6PD, catalase and glutathione deficiency
The traits are X-linked, 12% black males and
3% black females

CLINICAL FINDINGS
Decreased

G6PD activity in 1/3 of patients in

the 3rd trimester, increasing the risk of
hemolytic episodes
About 2/3 of the patients will have Ht of less
than 30%
Sulfonamides (oxidant drug)
Risk of foetal hemolysis, hydrops foetalis and
foetal death

CLINICAL FINDINGS 2
Some

toxic substances include:

sulfonamides, nitrofurans, antipyretics, some
analgesics, sulfones, vitamin K analogues,
uncooked fava beans, some antimalarials,
naphthalene, and nalidixic acid
Specific lab tests include glutathione stability
test and cresyl blue dye reduction test

TREATMENT
Immediate

discontinuation of any suspected

medication
Treatment of intercurrent illness
Blood transfusion where indicated.

CONCLUSION
Anaemia

in pregnancy is a major risk of

maternal death
Iron prophylaxis should be initiated at first
visit and continued in the postpartum period
Adequate investigations should be carried
out to determine the aetiology
Preparation for delivery MUST correct any
existing anaemia.

THANK YOU

MERCI