ANEMIA DURING

PREGNACY
PREPARED BY- Dr. Ebrahim Seid(OBGYN R1 resident)
Moderated by-Dr.Zelele (assistant prop. OBGYN)
Objective
• To know management of ANEMIA DURING PREGNACY

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Outline

Introduction

Type of anemia

Clinical feature

Diagnosis

management
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 Introduction

• Anemia is one of the commonest medical disorder present globally.

• Anemia is Hgb below the 5th percentile value (12.0 g/dl)

Hgb <11 g/dL /hematocrit <33% in the first or third trimester
 Hemoglobin <10.5 g/dL or hematocrit < 32% in the second
trimester
 Anemia is risk for LBW, preterm birth, and perinatal mortality.
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 Cont..
Hematocrit Values in Pregnancy
5th centile 50th 75th

1st triminister 33 37.5 41.2

2nd trimister 30.5 35.7 39.2
predelivery 30.7 36.5 40.5

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Cont...
• Hemoglobin
transporting O2 from the lungs to the various body organs & CO2

Heme group(consists iron ion) &4 globin chains.

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 Classification of anemia
 Physiological anemia of
pregnancy
 Pathological
 IDA (isolated or combined)
 Folic acid deficiency
 Vitamin B12 deficiency
 Anemia of chronic diseases

 Hemorrhagic  Acute: bleeding in early months or APH

 Chronic: Hookworm infestation, bleeding piles,

 Hereditary  Thalassemia
 Sickle cell hemoglobinopathies
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 Hereditary hemolytic anemias
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Physiological anemia due to pregnancy
Physiological hemodilution
Disproportionate ↑ in plasma volume & RBC mass

Average blood volume expansion is 40% to 50% reach to peak GA 30 to 34 weeks

Without iron supplementation, RBC mass ↑ about 18% by term & 30% with iron

supplement.

physiologic anemia of pregnancy reaches a nadir at 30-34wks.

RBC mass continues to ↑ after 30 weeks when the plasma volume expansion has

plateaued.
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 Negative iron balance during pregnancy
 Around 1000 mg of iron is required during pregnancy.
500mg used to increase RBC volume
300mg transfer to the fetus
200mg composite daily iron loss by mother(about 0.8 mg/day)
 Additional requirement of about 2 to 5 mg iron every day.

50% of pregnant women are anemic, NCNC anemia.

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 Iron absorbed from diet + mobilized from the stores => insufficient to
meet the maternal demands in pregnancy
 Require additional 20–30mg of elemental iron

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Pathologic Anemia During Pregnancy

A. Microcytic Anemia: MCV<80fl

Iron deficiency anemia
 Thalassemia and
 Anemia of chronic illness

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Iron deficiency anemia

 75% of anemia that occurs during pregnancy

 Iron stores are located in the bone marrow, liver, and spleen in the
form of ferritin
 ferritin 25% (500 mg)& 65% of stored iron in the circulating RBCs.

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Cont..
 Two types of iron are present in food
I. Heme
found principally in animal products(meat, poultry &fish)
its absorption is unaffected by other dietary constituents
II. NonHeme Iron(88%)
found mainly in plant products, iron salt
absorption influenced by
o its solubility in the upper part of the small intestine
o the composition of the meal

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Cont..

 Meat & ascorbic acid-rich fruits and vegetables, a increase iron absorption

 Milk ,tea and coffee decreased absorption NonHeme Iron

 The average total dietary iron absorption

 men is about 6% (0.8mg/day)&
women in their childbearing years, 13%(1.3 mg/day)

 Lactating women, <0.3 mg/day is lost in human milk

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Cont..

 Iron depletion is generally described in 3 stages of progressively increasing

severity
depletion of iron stores ( low serum ferritin level)
impaired hemoglobin production
iron deficiency anemia

 Goal for iron nutrition during pregnancy is simply to avoid progression

beyond low iron stores
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Cont..

 Impaired hemoglobin production

 insufficient supply of iron to develop RBCs
 Low Fe/TIBC & MCV
 Hemoglobin in normal range

 IDA: Low ferritin Fe/TIBC , MCV& hemoglobin

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Causes of iron deficiency anemia

 Increased demand,increased loss OR decreased intake

 Nutritional causes

 Anemia due to blood loss

Acute

o Acute blood loss (APH, PPH)

Chronic

o Hookworm infestation,
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Risk factors IDA

Prior history of menorrhagia (loss Increased frequency of blood

> 80 ml of blood per month) donation
 Multiple gestations Chronic blood loss due to
short inter pregnancies hookworm infestation,
 the delivery is complicated by schistosomiasis

hemorrhage Chronic infection (e.g. malaria)

Vegetarian diet, low in meat. Chronic aspirin use.

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Clinical features IDA
 Loss of appetite, digestive upset

Fatigue/SOB ,palpitation

 Lightheadedness, tinnitus, headache

 Nocturnal leg cramps

Oral and nasopharyngeal symptoms SIGN

 pica  PR,pallor,systolic murmur &Pedal

edema

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DDX of IDA

 Thalassemia

 Anemia of Chronic Disease(20% -30%)

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Thalassemia

 Impaired or defective production of one or more normal globin

peptide chains.
 Ineffective erythropoiesis, hemolysis and varying degrees of anemia

 Classified into two types: α or β-thalassemia.

 Serum iron concentration & bone marrow iron stores are normal

 Increased proportions of Hb F & Hb A2

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Anemia of Chronic Disease

 CKD , hypothyroidism, malignancies (Leukemia, lymphoma, myeloma)

 chronic inflammation
cytokines restrict erythropoiesis and shorten red cell lifespan
Hepcidin - inhibits iron exporting activity from enterocytes

 Reduction in both the lifespan of existing RBCs & new RBCs

production to replace dying RBCs.

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Blood index IDA Thalassemia CIA

Peripheral smear mchc mchc NCNC /mchc(

Serum iron ↓ Normal or high Normal
TIBC High ↕ ↓

Percentage saturation Reduced < 16% Normal or high > 16%

Serum ferritin ↓ ↕ ↕

Hemoglobin pattern ↕ Abnormal ↕

Hb F & Hb A2 ↕ Abnormal ↕

Red cell width High Normal ↕

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 Investigations
• CBC Peripheral Smear

•
•

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 • Serum Iron Studies
Blood parameter Normal value Value IDA

Serum transferrin levels 200–360 mg/dl >360 mg/dl

Serum iron concentration 60–175 μgm/dl < 60 μgm/dl

Transferrin saturation 25%–60% < 25%

Ferritin levels 50–145 ng/ml < 30 ng/m

Serum protoporphyrin 30–70 μgm/dl > 70 μgm/dl

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Cont..
 Stool Examination
 parasitic infestation(3x)
occult stool test
 U/A
pus cells/occult blood or schistosomes

 Indications of bone marrow examination

No response to any treatment even after 4 weeks
Suspected aplastic anemia
Kala-azar
Sideroblastic anemias
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Degree of anemia and possible treatment options
Degree of
HB level Immediate action
anemia

> = 11 gm/dl Normal Iron-folate prophylactic dose

Therapeutic iron dose + peripheral RBC morphology and

9 -10.9 gm/dl Mild
RBC indices

Therapeutic iron dose + peripheral RBC morphology and

7 – 8.9 gm/dl Moderate
RBC indices, close follow up

Referral to a hospital for complete investigation and

<7 gm/dl Severe possible blood transfusion; continue therapeutic iron
dose then after

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 Cont..

Oral Supplement Elemental Iron

Ferrous fumarate 106 mg/tablet
Ferrous sulfate 65 mg/tablet
Ferrous gluconate 28–36 mg/tablet
Iron dextran 50 mg / ml

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Cont..
 Compliance and Side Effects iron supplement
GI side effects, namely constipation &nausea
Iron appears to be best tolerated when administered at bedtime.
Antacids impair iron absorption

 If anemia prevalence among pregnant women of <20%, 120 mg of

elemental iron & 2.8 mg folic acid once weekly.

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Cont..
 Indicators for showing response to iron therapy
↑in the reticulocyte count (2% to 16%)-3days
↑in hemoglobin levels-1wk
Epithelial changes (especially in tongue and nails) revert to normal
ferritin levels rise-1moth

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 Causes of failure to oral iron
therapy
 Lack of patient compliance
 Incorrect diagnosis (presence of
 Persistent blood loss (hookworm)
non-ID microcytic anemia)
 Ineffective release of iron from a
 Faulty absorption of iron
particular preparation
 Presence of chronic infection
 Concomitant folate defi ciency
 Loss of iron from the body

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Indications for use of parenteral iron therapy

Intolerance to oral form of iron

NO respond for oral treatment.

Non-compliance on part of the patient

IBD aggravated by oral iron therapy.

unable to absorb iron orally.

Patients near term (32–36 weeks of pregnancy).

 Risk for anaphylactic reactions

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Prevention of IDA

 Recommend daily iron supplement during ANC started 12wks GA

30 mg of elemental iron if normal preconception Hgb
preconception Hgb low , 60 - 100 mg/day

 Po vs IV, IV iron correct Hgb fast ,no other difference.

 Malaria Prophlaxis:

 dewarming:
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 Macrocytic Anemia :MCV >100 fL
megaloblastic anemia NON megaloblastic anemia
 folate deficiency  alcoholism, liver disease
 vitamin B12 deficiency  Myelodysplasia
 pernicious anemia(Chronic atrophic autoimmune  aplastic anemia
gastritis)  hypothyroidism
 Increased reticulocyte count
 AZT, Metformin, Methotrexate, Valproic acid, PPI..

• MCV >115fL, folic acid or vitamin B12 deficiencies.

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Megaloblastic Anemia in pregnancy

 Derangement in red cell maturation due to impaired DNA synthesis.

 Slowing of the nuclear division cycle relative to the cytoplasmic

maturation cycle.
 Macrocytic red blood cells and hyper segmented neutrophils
 deficiency disease caused by lack of either vitamin B12 or folate or both

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 A. Folic acid deficiency Anemia during pregnancy

 The synthetic form of the naturally occurring B9 vitamin, folate.

 Folate-rich food sources are citrus fruits, dark-green leafy vegetables,

nuts, and liver.
 Folic acid available in multivitamins, prenatal vitamins, fortify foods
& as a pure folic acid supplement.
 Fortification food provides -163μg folic acid/day
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Cont..

 Folate stores are located primarily in the liver and are usually sufficient for 6
weeks.
 Folate deficiency is the most common cause of megaloblastic anemia during
pregnancy .
 Due to
Daily folate requirement ↑(50-100µgX4)
Fetal demands ↑
↓in the gastrointestinal absorption
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Cont..
 The fetus & placenta effectively extract folate from maternal
circulation.
 In sever cases pancytopenia can occur
 Cause for unexplained thrombocytopenia

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Cont..

 Cause for Folic acid deficiency

 Nutritional deficiency(dark green leafy vegetables & liver)

Extensive jejunal resection, gastrectomy, and Crohn disease

 Hemolytic anemias; malignancy; and some antifolate drugs
IDA→ depressed bone marrow → iron therapy → hyperplastic
marrow → increased need for folic acid → extra folic acid is not
supplemented→ ineffective erythropoiesis → nonresponsive to
simple iron therapy alone
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B. Vitamin B12 deficiency

• Cobalamin is found only in animal products, and the daily minimum

required intake is 6 to 9 µg.

• B/c of the abundant vitamin B12 stores in the body, it takes several
years for a clinical vitamin B12 deficiency to develop.

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Cont..
 Causes of Vitamin B12 Deficiency
Strict vegetarian diet
Use of proton pump inhibitors
 Metformin(10-30%)
Gastrectomy ,Ileal bypass , Crohn disease
 Gastritis , H-pylori infection

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• Clinical features
Anemia symptoms +

Neuropsychiatric deficits (VB12)

o paraesthesia, numbness, memory loss, ataxia,depression, irritability &

impaired cognition.

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Ix

 CBC
Anemia

MCV >100 fL , MCH >33 pg, MCHC is normal

Mild leukopenia and/or thrombocytopenia

Low reticulocyte count

 Determination of the levels of vitamin B12 & Folate

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Peripheral morphology of megaloblastic anemia

• Hypersegmented neutrophils
>5 lobes in at least 5% of neutrophils or

 a single cell showing six or more lobes is a cardinal feature.

• Target cells-suggestive of liver disease.

• Macro-ovalocytes & hypersegmented neutrophils-B12, folate, or

copper deficiency; or drug
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 methylmalonate & homocysteine level

Increased methylmalonate and folate levels indicate vitamin B12 deficiency.

Normal methylmalonate and increased homocysteine levels indicate folate deficiency

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Treatment

• Improve functional status of the patient by correcting the anemia

• Correct existing and prevent further neuropsychiatric manifestations

• Identify and treat the underlying cause

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treatment of vitamin B12 (Cobalamin) deficiency

• Cyanocobalamin (Vitamin B12) 1000micrograms (1mg), IM

Every day for one week then Every week for four weeks.
If hemoglobin has not normalize, continue weekly until it gets
normal.
If the underlying disorder persists, 1mg every month for the rest of
the patient's life.

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Treatment of folate deficiency

 Folic acid, 1 to 5mg P.O., daily for 1-4 months, or until complete
hematologic recovery.
 Vitamin B12 level should be checked before giving folic acid
alone
 If vitamin B12 can‘t be checked, both Folic acid & vitamin B12
should be started at the same time.
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Hemolytic anemia

• Shortened survival of circulating RBCs due to their premature

destruction.
↑ reticulocyte count

↑ LDH & bilirubin,

↓ haptoglobin,

spherocytes on the peripheral blood smear.

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 Cont..
Intrinsic RBC defects Extrinsic RBC defects Intravascular destruction
of CBC
 Enzyme  Liver disease  Microangiopathic ( TTP,
deficiencies(G6PD)  Hypersplenism HUS, HELLP syndrome)
 Hemoglobinopathies  Infections (malaria)  ABO incompatibility
(thalassemias)  Autoimmune hemolytic  Infections (malaria)
 Membrane defects anemia DIC
 IV immune globulin infusion  Snake bites

• V..V
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 Anemia In HELLP syndrome

 Hemolysis confirmed with at least 2 of the findings

Peripheral smear with schistocytes and burr cells

Serum bilirubin >1.2 mg/dl

Low Hb(<25mg/dl) or LDH> 2x the upper level of the normal.

 Severe anemia with hemoglobin <8 to 10 g/dl depending on the

pregnancy stage, unrelated to blood loss.

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Cont..

 bccnvmv
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Reference

1. Barbara L. Hoffman, John 0. Schorge, Lisa M. Halvorson, Cherine

A. Hamid, Marlene M. Corton, Joseph I. Schaffer, Williams
Gynecology 4th edition, 2020

2. DC Dutta, DC Dutta’s Textbook of Obstetrics,8th edition, 2015

3. Philip Samuels, Hematologic Complications of Pregnancy, Gabe's

Obstetrics 8th edition ,2022,959-966
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3. UpToDate 2023

4. ACOG Practice Bulletin, Anemia in Pregnancy 2021

5. Richa Saxena Bedside Obstetrics And Gynecology 2010

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