Anemia with

pregnancy
L/RADWA RASHEEDY

Information must be obtained:

Definition
Incidence
Physiological adaptation of hematological
system in pregnancy
Etiology
Clinical picture
Diagnosis
Effect of anemia on pregnancy
Effect of pregnancy on anemic patient
management

Definition
WHO definition: anemia in pregnancy is a Hb
concentration of < 11 g/ dl and a haematocrit of <
. 33 %, at any trimester in pregnancy
Centers for disease control (CDC): proposed a
. cut- off point 10.5 g /dl during 2nd trimester

: Incidence

Anemia is the commonest medical disorder in

. pregnancy
About 50% of pregnant women worldwide will
. suffer some degree of anemia in pregnancy

Physiological adaptation of
hematological system in pregnancy
Plasma volume increases by 10 to 15 percent at 6
to 12 weeks of gestation ,expands rapidly until 30
to 34 weeks, after which there is only a modest
rise
Red blood cell mass begins to increase at 8 to 10
weeks of gestation and steadily rises by 20 to 30
percent (250 to 450 mL) above nonpregnant
levels by the end of pregnancy in women taking
iron supplements
Among women not on iron supplements, the red
cell mass may only increase by 15 to 20 percent
Erythrocyte life span is slightly decreased during
normal pregnancy

A greater expansion of plasma volume relative to

the increase in hemoglobin mass and erythrocyte
volume is responsible for the modest fall in
hemoglobin levels (ie, physiological or dilutional
anemia of pregnancy) observed in healthy
pregnant women

Iron requirements in pregnancy: 4-6 mg/day of

absorbed iron. Because absorption is less than
10% at least 40-60 mg of iron should be available
in the diet, so iron supplementation is a necessity
in all pregnant women

: Etiology

: Nutritional anemia
Iron Deficiency anemia: is the commonest nutritional-
deficiency anemia in pregnancy followed by foliate
deficiency anemia. It may either be due to increased
. iron loss or decreased iron absorption
Megaloblastic anemia: which can be due to deficiency -
of foliate or vitamin B 12

: Hemorrhagic anemia
due to severe or repeat blood loss as in APH, or GIT
. bleeding
.

:Haemolytic anemia

Microangiopathic hemolytic anemia: e.g. some patients -

. with severe PE, eclampsia, TTP
Acquired immune hemolytic anemia: antibodies against -
. red cell are present in collagen vascular diseases

Hemolytic anemia associated with haemoglobinopathies: due to abnormal Hb synthesis; as

. in cases of sickle cell anemia, and Beta thalassemia

: Aplastic anemia
Extremely rare and the mortality rate is about 30%

Effect of anemia on
pregnancy

:Maternal
Mild anemia: No effect on pregnancy and labour. Mother will have
. low iron stores
Moderate anemia: Increased weakness, lack of energy, fatigue
. and poor work performance
Severe anemia: Associated with poor outcome as; increased PTL,
PE and sepsis
Fetal and neonatal: Increased perinatal morbidity and
: mortality, related to

. Decreased iron stores: due to depletion of maternal stores-

High risk for an adverse perinatal outcome (preterm labour,. IUGR)

Effect of pregnancy on
anemia
more decrease in hemoglobin level with increase
gestational age (dilutional)
Delay in diagnosis of anemia as S&S of it mimic
some normal in pregnancy as easy fatigability,
dyspnea

: Clinical picture
Mild cases: asymptomatic
Moderate cases: Exaggerated symptoms of normal
. pregnancy: weakness, exhaustion, and dyspnea
: Severe anemiaa) Pallor, glossitis , stomatitis and koilonychias
b) Rarely, high output heart failure may occur in
. severe cases

Anemia is one of the major signs of disease. It

is never normal and its cause(s) should
. always be sought
The workup should be directed towards answering
the following questions
?Is the patient bleeding (now or in the past)
Is there evidence for increased RBC destruction
?(hemolysis)
?Is the bone marrow suppressed
?Is the patient iron deficient? If so, why
Is the patient deficient infolic acidor vitamin B12?
?If so, why

:Diagnosis
HB

CBC
less than 11 gm/dl &HTC less than 33%
==== diagnosis of anemia
Look for abnormality in MCV

MCV bet 80 -97f MCV more 97 f

MCV less 80 f

Normocytic anemia

Macrocytic anemia

Microcytic anemia

hemglobinopathy

Foleate def

severe iron
, deficiency

the anemia of
chronic disease

Vit B12 def

alpha or beta
thalassemia minor

Aplastic anemia

the anemia of
chronic disease

Reticulocyte count
Anemia with a high reticulocyte count reflects an
increased erythropoietic response to continued
hemolysis or blood loss

low reticulocyte count is strong evidence for

deficient production of RBCs (ie, a reduced marrow
response to the anemia
infection like parvovirus , chemotherapy ,aplastic
, ====anemia

Anemia with a high reticulocyte count either due to

hemolysis or blood loss to DD
Increased indirect bilirubin & LDH
And blood film showing shistocytes indicating
hemolysis
:To diagnose cause of hemolysis
HB electrophoresis ==== thalassemia &sickle- 1
cell anemia
S test for immune hemolytic anemia 2= coomb

:If suspect nutritional anemia

Iron def=== ferritin level ,s iron ,TIBC
RBC foleate level , vitB12 level

management
:Management during pregnancy
Prevention: Proper antenatal care. Iron supplementation using oral iron
. preparations. Proper diet rich in iron and vitamin C
: o Treatment
: Oral iron therapy. In mid trimester or early 3rd trimester
Hemoglobin rises from 0.3 to 1.0 g per week, and this is reflected in a
. significant elevation in Hb/Ht values 2 to 3 weeks after initiation of treatment
Parentral iron therapy: Iron dextran is used. ForWomen with severe anemia in late 3rd trimester
. Those with poor compliance for oral therapy

Blood transfusion (Packed cells are preferred): Very

rarely required in patients with
Severe anemia beyond 36 weeks
Associated infection
To compensate blood loss due to antepartum
hemorrhage
Patients not responding to iron therapy

Management during labour

. First stage: Oxygen should be ready if dyspnea develops. Second stage: Shortened if necessary to avoid maternal exhaustionThird stage: Active management should be done except in verysevere anemia for fear of cardiac failure (any post-partum hemorrhage
. must be treated as these patients tolerate bleeding very poorly)
: Management during puerperium
. Adequate rest, iron and foliate therapy for at least 3 months. Any infection should be promptly treated-