AnAemia in Pregnancy

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AnAemia in Pregnancy

• Dr. Yasir Katib
• MBBS, FRCSC
• Perinatologest

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Objectives

• Normal changes in blood physiology during
  pregnancy
• Different causes of anemia (history and
  investigations)
• Effects of anemia on the mother and the fetus
• Managing anemia in pregnancy (from prevention to
  treatments)

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Introduction

• A normochromic, normocytic anemia may occur from
  the 78th week of gestation
• (physiological anemia)
• Hb should not fall to
• lt11.0 g/dl in the 1st trimester
• lt10.5 g/dl in the 2nd and 3ed trimesters

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Anemia and Pregnancy
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Introduction

• Puerperium
• HB fluctuates for a few days
• Then rise to higher (non-pregnant) level

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Introduction

• Pregnancy requires an iron intake of
• 2.5 mg/day early
• 3.07.5 mg/day required in the third trimester
• An average diet supplies around 250 µg/day of
  folate
• Requirements increase to around 400 µg/day during
  pregnancy

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Introduction

• Folate deficiency most commonly due to lack of
  folate-rich vegetables such as broccoli and peas,
  which is often linked to social deprivation.
• Folate deficiency is more common in
• multiple pregnancy
• frequent childbirth
• adolescent mothers

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Introduction

• The body stores around 3 mg of B12, with a daily
  dietary requirement of 3µ g/day
• The only B12 source is animal foodstuffs thus,
  vegetarians and vegans are most at risk of
  dietary deficiency

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Iron deficiency anemia

• It is the most common cause of anemia in
  pregnancy worldwide
• Maternal iron requirements increase in pregnancy
  because of the requirements of
• Fetus
• Placenta
• Maternal red cell mass

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Iron deficiency anemia

• Hb as the sole means of diagnosing anemia is not
  a sensitive test although this is often used as
  the first indicator in clinical practice
• Serum ferritin is the most sensitive single
  screening test to detect adequate iron stores
  Using a cutoff of 30 micrograms/liter has a
  sensitivity of 90

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Clinically

• This is often asymptomatic
• However the following are most common
• Fatigue
• Dyspnoea
• The patient may also appear pale

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Investigations

• Hb 11.0g/dl
• MCV if 76fl then probable cause is iron
  deficiency, but if lower than concomitant with
  other signs of anemia and RBC count raised, then
  suggests possible B2-thalassaemia (Hb
  electrophoresis)
• Normal MCV (76-96fl) with low Hb is typical of
  pregnancy
• Serum ferritin 10-50g/dl needs monitoring and
  lt10g/dl requires treatment

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Management

• Routine Iron and folate supplementation with
  normal Hb
• Raised or maintained the serum iron and ferritin
  levels and serum and red-cell folate levels
• Resulted in a reduction of women with a
  hemoglobin level below 10 g/dl or 10.5 g/dl in
  late pregnancy
• However, no detectable effects on rates of
• caesarean section
• Preterm delivery
• Low birth weight
• Admission to neonatal unit
• Stillbirth and neonatal deaths

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Management

• Iron supplementation with iron deficiency anemia
• Evidence was inconclusive on the effects of
  treating iron deficiency anaemia in pregnancy
  because of the lack of good quality trials
• There is an absence of evidence to indicate the
  timing of, and who should be receiving, iron
  supplementation during pregnancy
• Severe maternal iron deficiency is associated
  with premature delivery and low birth weight

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Recommendations

• Pregnant women should be offered screening for
  anemia.
• Screening should take place
• Early in pregnancy (at the first appointment)
• And at 28 weeks
• Hemoglobin levels outside the normal range for
  pregnancy (that is, 11 g/dl at first contact and
  10.5 g/dl at 28 weeks) should be investigated and
  iron supplementation considered if indicated

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Recommendations

• Supplementation can be achieved with 3060 mg of
  iron/day, which produces few side effects
• Side effects are mainly seen with replacement
  (200 mg/day) therapy
• Furthermore, supplementation of more than 200
  mg/day will not produce a supra-normal hemoglobin
  (Hob) or haematocrit (HCT)

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Recommendations

• Iron absorption is maximized when combined with
  ascorbic acid such as taking the iron supplements
  with
• fresh orange juice
• vitamin C preparation
• Therapy failure occurs in
• malabsorption
• when loss exceeds intake
• but is most commonly due to poor compliance

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Recommendations

• There are also liquid oral iron preparations and
  parenteral therapy
• Parenteral therapy is useful in
• malabsorption
• failed compliance
• But otherwise does not produce a faster response
  than oral iron and side effects are common

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Thalassaemia

• Inherited blood disorders with reduced or absent
  production of alpha or beta chains of the globin
  content of haemoglobin.
• Carriers of thalassaemia, may be asymptomatic
  when not pregnant but more anemic than usual
  during pregnancy
• MCV 80fl requires investigation with an HbA2
  3.5 being positive for B2-thalassaemia

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Sickle-cell Anemia

• Genetic defect causes production of abnormal
  hemoglobin with a red blood cell life of 15 days
• Mainly affects people from East and West Africa
• Where suspected, women should receive folate
  15mg/day with frequent Hb counts
• If Hb falls 6g/dl, need transfusion

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Sickle-cell Anemia

• Use of regular prophylactic transfusions reduced
  number of transfusions required, but was
  associated with more pain crises
• May give prophylactic antibiotics during
  childbirth and afterwards

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Sickle-cell Anemia

• Screening may be based on
• higher risk
• An ethnic group
• Or on laboratory method
• To all pregnant women

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Sickle-cell Anemia

• Complications
• Fetal
• Spontaneous abortion
• PTL
• Low birth weight
• Perinatal mortality
• Maternal
• UTI
• PIH

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Summery

• Pre-conceptional counseling
• 1st visit screening
• Supplementation prevention
• Prenatal screening
• Follow up
• Laboratory
• Ultrasound