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Anemia In Pregnancy
Definition:
Hb = 10 gm/dl or less
Hct = 35%
Incidence:
< 5% of pregnant ladies
Significance:
Fetal Morbidity & Mortality
Infection rate
Decompensation in mothers w/ Cardiac or Pulmonary
dis
Exacerbate the effect of Hemorrhage
Delays recovery in the Post Partum period
General Symptoms of Anemia :
1- Lethargy.
2- Tiredness.
3- Headache.
4- Dizziness.
5- Dyspnea.
6- Dysphagia. IDA
7- Palpitation: b/c blood volume in pregnancy physiological
tachycardia.
8-

risk of Hge during pregnancy & labor

** These symptoms are found in any pregnant woman

but in anemic patients these symptoms will be more
severe.
Signs:
1- Pallor in palms, nail bed, mucus membrane and
conjuctiva.
2- Cyanosis.
3- Splenomegaly.
4- In severe anemia:
Heart failure
Lower limb edema.

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General Causes of Anemia in Pregnancy :

Requirements Multiple pregnancy
frequency of pregnancy ( < 2 y
apart)

Intake

poor diet
Hyperemesis gravidarum esp in early

pregnancy

storage

liver disease

Abnormal absorption d/t changes in the GIT

Chance of Hemorrhage

Clinical classification:
1- Iron deficiency anemia.
85%
2- Megaloblastic anemia.
3- Secondary anemia (2%):
- Chronic infections specially pyelonephritis.
- Recurrent bleeding.
- Malignancy.
4- Hemolytic anemia:
- SCD (3.5%).
- Thalassemia.
5- Aplastic anemia, which is rare these days.

Physiological Anemia in Pregnancy:

** Hematological changes in Pregnancy:
plasma volume by 40% w/ a platue at 28 w
RBC mass
by 32% w/ a platue at 30 w
total Hb mass by 15%
This will lead to Hemodilution
~ Hb = 11 g/dl , but not less than 10mg/dl.
& Hct = 37%
During 1st 48 hr post partum Hemodilution
circulation

After
After

B/c interstitial fluid enters

1st 48 hr post partum Hemoconcentration

6-8 w post partum Back to normal

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Iron Deficiency Anemia

# This is the most common type of anemia in pregnancy
(80%).
Normal Physiology of Iron:
Iron Requirements:
average adult = 4-5 gm
In pregnancy = an extra 1gm

Iron Sources:
1- Red meat, liver and kidneys.
2- Green leaves and vegetables.
3- Fruits like Banana.

Iron Absorption:
Site = Upper small intestine = duodenum &
jejunum
Amount = 1/10th dietary iron

Iron Storage:
Site = RES
Amount = 30%
Form = Hemosiderine

Iron Excretion:
Route = urine, feces, menstrual bl, skin
desquamation
Amount = 1mg/day

Importance of Iron in Pregnancy:

RBC mass
350 mg needed
Uterus & its contents 350 mg for fetus, 100 mg for placenta
Loss of iron during delivery & in lochia 150 mg
Lactation
150 mg
Causes:
A. demand and requirement in pregnancy
B. Intake: appetite , vomiting.
C. Storage Multiple pregnancies

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D. Improper Metabolization & Utilization.

E. Abnormal absorption.

# Note
The iron loss starts with depletion of iron stores
~ iron serum levels (10 gm/dl)
~ iron binding capacity (16)
~ morphologic changes in RBCs microcytic hypo
chromic.

Investigations:
1- CBC (microcytic hypo chromic).
2- Serum iron- (NL= 34-150).
3- Serum ferritin- (NL = 6-31)
4- TIBC
5- Bone marrow if needed
Recommendation:
1- Adequate diet rich in iron = 15 mg/day
2- Iron prophylaxis.

Ferrous SO4 200 mg twice daily

Start giving pregnant women after 1st trimester (12
weeks), because:
1- There will be enough iron storage for the 1 st
trimester.
2- In the 1st trimester there is N/V and the iron irritates
the stomach causing more N/V. so some patients will
stop taking it.
3- There is less N/V in the 2nd trimester onwards

Treatment:
Depends on severity of anemia and gestational age:
1- In late 3rd trimester & severe anemia (<6)
~ blood transfusion (packed RBCs).
Then continue with iron supplement.
B/c if she goes into labor and develops PPH, she will
collapse & die.
B/c the effect of iron therapy will not appear before 4-6
weeks.
~ to anticipate the complications after delivery
2- Any stage of pregnancy & severe anemia
~ transfuse her first to make her feel healthier
then continue with iron supplement.
3- Moderate anemia (6-8gm/dl)

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iron therapy., & no transfusion

Types of iron therapy:

Oral :
most commonly used
Forms: * ferrous sulphate (cheapest)
* ferrous fumarate
* ferrous gluconate.
Dose: 200-300 mg 2-3x daily.
Hb by 1g/dl/ month
S.E: N/V and constipation.
Parentral:
In case of no response to oral iron or advanced
pregnancy
Dose: 250 mg every other day
Hb by 1g/dl/ for each dose
Forms:
A. IV infusion:
Iron dose is put in 1-liter NS & slowly
infused.
Hydrocortisone and antihistamine must
be ready
B/c the patient may develop anaphylactic
shock.
B.

IM injection:
3 Z- shaped injections every week
SE: * Very painful.
* staining of the injection site in the
buttock
esp in fair color women
* abscess formation.

How to follow the patient?

Hb level

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After 4-6 weeks
b/c it takes 4-6 weeks to notice a change in Hb.
Reticulocyte count
After 10 days from starting iron we
if 3% or more responding to the iron therapy.

Megaloblastic anemia
# due to folic acid rather than B12.
# Its also more commonly found in association with iron deficiency
anemia.
Folic Acid Physiology:
Diet rich in folic acid:
1- Animal liver and meat,
2- Green vegetables (dont cook it).
3- Peanuts.

Requirements:
WHO recommend to give folic acid 300 g throughout
pregnancys prophylaxis

Absorption site:
upper 1/3 of small intestine

Results of Folic acid Deficiency

1- Abruptio placenta.
2- Neural tube defect.
3- Spina bifida
4- Anencephaly,
5- P.E.T.
~ any patient w/ past Hx of this we advise her to
take folic acid & multiple vitamins.

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Causes :
Requirements Multiple pregnancy
Multiparity
frequency of pregnancy ( < 2 y apart)

Utilization

Analgesics
ABC e.g Furadantin used for UTI.
Contraceptive pills
Methetroxate
Phenytoin.

Intake

poor diet
Hyperemesis gravidarum esp in early pregnancy

storage

liver disease

Abnormal absorption d/t changes in the GIT

Resection of upper GIT
Chance of Hemorrhage

Presentation:

develops in late pregnancy or post partum period

b/c it takes about 18 w of folate deficient diet to predispose
anemia.
12345678-

Pallor.
Glossitis
Oral fissures
Edema of ankle & feet
Vomiting & diarrhea
Splenomegaly
Check forBP & proteinuria.
Check for neural tube defect esp.if mother has
polyhydramnios.

Investigations
1- CBC:

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Megaloblastic (macrocytosis).
Anisocytosis
Giant cells
Howell Jolly bodies
Thrombocytopenia
Neutropenia
Hyper-segmented neutrophils.

2- Serum folate (NL= 3-17).

3- B12 levels (NL= 5-10).
4- Bone marrow biopsy Megaloblastic Erythropoiesis

Treatment of folic acid anemia:

1- Correct the patients diet.
2- Folic acid supplement:
5 mg twice daily orally. ( 350 g/ day)
10 mg ample injection once daily for a month.
3- Iron supplements
4- Vit B12 Prophylaxis**one injection every month
Till pregnancy is over
5- Blood transfusion In severe anemia
then followed with folic acid
treatment.
How to follow the patient?
Reticulocyte count

respond very fast

It should within 1 week after oral or

injection

# Note**
If the patient has vitamin B12 deficiency (pernicious
anemia) and you give her folic acid, Hb levels will improve
but later on she will develop sub acute combined
degeneration of the spinal cord.
So, if you diagnose megaloblastic anemia give folic acid +
vitamin B12.
Then after pregnancy is over you investigate for pernicious
anemia by
** schilling test
** radio-isotopes which is harmful to the fetus.

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Prophylaxis:
Prophylactic folic acid w/ iron in the combined pill = 0.5
mg/day

Hemoglobinopathies
Pathology:
- Alteration in the amino acid structure of the polypeptide
chain
e.g. HbS Sickle cell disease
HbC Hemolytic anemia
- Impaired production of orchains
ka Thalassemia
Clinical Manifestations depends on:
1- Type of Hb present
2- Relative proportion , depending on inheritance
i.e. Homo or Hetero zygous

Sickle Cell Disease

These patients dont conceive easily and if they become pregnant:
1- Abortion rate.
2- infection incidence
3- perinatal mortality
4- Premature labor.
5- IUGR.
6- IUFD
On the mother side, the stress of pregnancy and the disease itself cause:
1- incidence of hemolytic crises.
2- incidence of painful crises.
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3- UTI infection ( pyelonephritis) is common in these
patients esp. in sickle cell trait rather than disease.
4- HTN
5- HSM
6- Leg ulceration
7- If the mother develop hypoxia, dehydration or acidosis
its going to affect the baby.

Management:
1- Avoid risk factors
2- Avoid iron b/c 1- Serum iron
2- TIBC

Hemosiderosis

3- Folic acid supplements 15mg/day from the beginning

of pregnancy until 6 weeks post
partum to maintain Hb around 910 gm/dl.
4- Rx Embolisms Heparin
5- Rx infections Abc
6- During surgery ( C section) plenty of O2
not to develop hypoxia and vaso-occlusive crises as a result of
anesthesia

7- Rx Crisis *
*
*
*
*

Admit the patient.

Re-hydration by IVF
Analgesics
Rx Acidosis.
Blood transfusion when needed (Hb<5)

even though it should be avoided not to develop atypical

Ab.

* Exchange blood transfusion when needed.

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Thalassemia
Management:
1- Folic acid supplements
2- Blood transfusion depending on Hb

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