Anemia in

pregnancy

Update 1/11/2014

Juliana Mohd Basuni

definition defined as a decrease in the amount of red blood cells

(RBCs) or the amount of hemoglobin in the blood.Anemia". http://www.merriam-webster.com/. Retrieved 7 July 2014.

Stedman's medical dictionary (28th ed. ed.). Philadelphia: Lippincott Williams & Wilkins. 2006. p. Anemia.

ISBN 9780781733908.

It can also be defined as a lowered ability of the blood

to carry oxygen. Hematology : clinical principles and applications (3. ed. ed.). Philadelphia: Saunders. 2007. p. 220.

ISBN 9781416030065.

Hemoglobin in red blood cells is an oxygen-

carrying protein that binds oxygen through its iron

component.

Hemoglobin transports oxygen to most cells in the

body for the generation of energy.

When hemoglobin levels are low less oxygen

reaches the cells to support the body’s activities

Normal physiological changes

in pregnancy

Plasma volume (50%)

Red cell mass ( 18 – 25 % depending on iron status)

Physiologic dilution which is greatest at 32 weeks

gestation

WHO definition anemia in pregnancy

Anaemia as defined by the World Health Organization as

haemoglobin levels of ≤ 11 g/dl. UNICEF/UNU/WHO. Iron deficiency anemia: assessment, prevention, and control. Geneva, World

Health Organization, 2001

HCT < 32%

gestation Hb

1st Trimester <11.0g/L

2nd Trimester < 10.5g/L

3rd Trimester < 11.0g/L

prevalence varies

considerably because of differences in

socioeconomic conditions, lifestyles and health-

seeking behaviors across different cultures.

Anaemia affects nearly half of all pregnant

women in the world:

52% in developing countries

23% in the developed world UNICEF/UNU/WHO. Iron deficiency anemia: assessment, prevention, and control.

Geneva, World Health Organization, 2001

Prevalence

WHO Global Database on Anemia 2008

Preschool children Pregnant women Non pregnant

women during

child bearing age

world 47% 42% 30%

malaysia 32% 38% 30%

classifcation

Severity of anemia Hb concentration in pregnant women g/dL

Treatment

Mild 8 – 11 Oral haematinics or paranteral iron therapy.

Moderate 6.0 – 8 Depending on period of gestation < 36 weeks gestation

Treat with oral haematinics or paranteral iron therapy.

If symptomatic admit to hospital.

> 36 weeks gestation

Paranteral iron in therapy.

Consider blood transfusion.

Severe < 6 Blood transfusion with 2 units packed cells.

problems Anaemia is one of the most prevalent nutritional

deficiency problems affecting pregnant women . Thangaleela T, Vijayalakshmi P. Prevalence of anaemia in pregnancy. Indian J Nutr Diet

1994;31:26-32

The high prevalence of iron and other micronutrient efficiencies among women during pregnancy in developing countries is of concern and maternal anaemiais still a cause of considerable maternal & perinatal morbidity and mortality

Cutner A, Bead R, Harding J. Failed response to treat anaemia in pregnancy: reasons and evaluation. J Obstet Gynecol 1999;suppl.:S23-7

one of the world's leading causes of disability

one of the most serious global public health problems.

Anemia effects

Problems in postpartum period

Uterine Atony

PPH

Mortality ( 20% )

Depression

Emotional instability

Stress

Lower cognitive performance tests

Iron deficiency anaemia:

Requirements in pregnancy : 900 mg

Daily iron requirement in pregnancy : 4mg

2.5 mg/day in early pregnancy 6 – 8 mg/day from 32 weeks onwards

Absorption of iron is <10%, so an average of 40 mg dietary iron is required daily

? Iron is important vital for all living organisms because

it is essential for multiple metabolic

processes, including oxygen

transport, DNA synthesis, and

electron transport.

Causes

Insufficient intake/ insufficient production ; nutrition , spacing , blood disease

Increase loss : bleeding/ hemolysis , infestation , renal disease

Increase demand : placenta , fetus , red blood cells expansion

Causes

Causes

Poor nutrition

Deficiencies of iron and other micronutrients

Malaria

Hookworm disease

Schistosomiasis

HIV infection

Haemoglobinopathies are additional factors

Van den Broek NR, White SA, Neilson JP. The relationship between asymptomatic

human immunodeficiency virus infection and the prevalence and severity of anemia

in pregnant Malawian women. Am J Trop Med Hyg 1998;59:1004-7

symptoms

signs

Ix FBC FBP Peripheral Blood Smear Reticulocyte count

Serum Ferritin

UFEME , Stool Ova cyst

TIBC , Serum Iron

Hb Electrophoresis if required

Serum Folate /B12 if required

Management

Prevention of Anemia

Women should be encouraged to undergo a pre-natal check up for early detection and treatment of iron deficient anemia.

Proper spacing between two children

( contraceptions )

Having a well balanced diet rich in iron from adolescence.

Regular screening for anemia.

Fortification of ready-to-eat food with iron

Avoid / Reduce smoking / alcohol consumptions

Management for IDA

Dietary advice : 10 – 15% absorption

management

Iron preparations

Treatment

Treatment Iron Deficiency Anemia:

Treatment: 60 mg of elemental Fe (iron) orally every 6 to 12 hours (e.g. 2 to 4 times per day)

Prophylaxis: 60 mg of elemental Fe (iron) orally every day.

Recommended Daily Intake

Men: 8 mg elemental Fe (iron) orally once daily

Women: 18 mg elemental Fe (iron) orally once daily

Pregnant women: 27 mg elemental Fe (iron) orally once daily

Lactating women: 9 mg elemental Fe (iron) orally once daily

Parenteral & Oral Iron Products - GlobalRPh

Parenteral indications

Parenteral dosage

Iron Dextran ( Imferon / Cosmofer )

IM

Dose :

0.0442 x ( Desired Hb – Current Hb ) x Weight ( kg ) + 0.26 x Weight ( kg)

Iron Sucrose ( Venofer )

IV

Dose :

Prepregnancy Weight ( kg ) x Target Hb – Current Hb ) x 0.24 + 500mg

Cosmofer can also be given in IV route

Management options : Blood

transfusion

Symptomatic anaemia Hb < 6.0g% at 36weeks /close to delivery

Hb < 10.0g% in Placenta Praevia for elective CS

management

Treat infections

Treat worm infestations :

Albendazole 400mg/ Mebendazole500mg

Treat Schistosomiasis : Praziquantel

Treat Malaria :

Chloroquine/Hydroxychloroquine

Management optionsThalassaemia Syndromes

Conclusions Screen anemia in pregnancy at booking

Rule out for thallasemia is necessary

Supplementation with iron

Dietary advice

Noted the contraindications of iron therapy

Continue supplemantation through postpartum until cessation of lactation

Thank you