AnAemia in PregnancyAnAemia in Pregnancy

Dr. Yasir KatibDr. Yasir Katib

MBBS, FRCSCMBBS, FRCSC

PerinatologestPerinatologest

ObjectivesObjectives

Normal changes in blood physiology Normal changes in blood physiology during pregnancyduring pregnancy

Different causes of anemia (history Different causes of anemia (history and investigations) and investigations)

Effects of anemia on the mother and Effects of anemia on the mother and the fetusthe fetus

Managing anemia in pregnancy (from Managing anemia in pregnancy (from prevention to treatments) prevention to treatments)

Introduction Introduction

A normochromic, normocytic anemia may occur from the 7–8th week of gestation

(physiological anemia)Hb should not fall to

<11.0 g/dl in the 1st trimester<10.5 g/dl in the 2nd and 3ed trimesters

Anemia and PregnancyAnemia and Pregnancy

IntroductionIntroduction

PuerperiumPuerperiumHB fluctuates for a few daysHB fluctuates for a few days

Then rise to higher (non-pregnant) Then rise to higher (non-pregnant) levellevel

IntroductionIntroduction

Pregnancy requires an iron intake of2.5 mg/day early 3.0–7.5 mg/day required in the third

trimester An average diet supplies around 250

μg/day of folateRequirements increase to around

400 μg/day during pregnancy

IntroductionIntroduction

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 pregnancyfrequent childbirthadolescent mothers

IntroductionIntroduction

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

Iron deficiency anemiaIron deficiency anemia

It is the most common cause of anemia in pregnancy worldwide

Maternal iron requirements increase in pregnancy because of the requirements ofFetus Placenta Maternal red cell mass

Iron deficiency anemiaIron 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%

ClinicallyClinically

This is often asymptomaticThis is often asymptomatic

However the following are most However the following are most commoncommon::

Fatigue Fatigue Dyspnoea Dyspnoea

The patient may also appear paleThe patient may also appear pale

InvestigationsInvestigations

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 <10g/dl requires treatment

ManagementManagement

Routine Iron and folate supplementation with Routine Iron and folate supplementation with normal Hbnormal 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

ManagementManagement

Iron supplementation with iron deficiency anemiaIron 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

RecommendationsRecommendations

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

RecommendationsRecommendations

Supplementation can be achieved with 30–60 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)

RecommendationsRecommendations

Iron absorption is maximized when combined with ascorbic acid such as taking the iron supplements withfresh orange juice vitamin C preparation

Therapy failure occurs inmalabsorption when loss exceeds intakebut is most commonly due to poor

compliance

RecommendationsRecommendations

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

ThalassaemiaThalassaemia

Inherited blood disorders with reduced or Inherited blood disorders with reduced or absent production of alpha or beta absent production of alpha or beta chains of the globin content of chains of the globin content of haemoglobinhaemoglobin. .

Carriers of thalassaemiaCarriers of thalassaemia, may be , may be asymptomatic when not pregnant but asymptomatic when not pregnant but more anemic than usual during more anemic than usual during pregnancypregnancy

MCV ≤ 80fl requires investigation with an MCV ≤ 80fl requires investigation with an HbA2 ≥ 3.5 being positive for B2-HbA2 ≥ 3.5 being positive for B2-thalassaemia thalassaemia

Sickle-cell AnemiaSickle-cell Anemia

Genetic defect causes production of Genetic defect causes production of abnormal hemoglobin with a red blood abnormal hemoglobin with a red blood cell life of ≤15 dayscell life of ≤15 days

Mainly affects people from East and Mainly affects people from East and West AfricaWest Africa

Where suspected, women should Where suspected, women should receive folate 15mg/day with frequent receive folate 15mg/day with frequent Hb countsHb counts

If Hb falls ≤ 6g/dl, need transfusionIf Hb falls ≤ 6g/dl, need transfusion

Sickle-cell AnemiaSickle-cell Anemia

Use of regular Use of regular prophylactic prophylactic transfusionstransfusions reduced number of reduced number of transfusions required, but was transfusions required, but was associated with more pain crises associated with more pain crises

May give May give prophylactic antibioticsprophylactic antibiotics during childbirth and afterwardsduring childbirth and afterwards

Sickle-cell AnemiaSickle-cell Anemia

Screening may be based on higher risk

An ethnic group Or on laboratory method

To all pregnant women

Sickle-cell AnemiaSickle-cell Anemia

Complications Complications FetalFetal1.1. Spontaneous abortionSpontaneous abortion2.2. PTLPTL3.3. Low birth weightLow birth weight4.4. Perinatal mortalityPerinatal mortalityMaternalMaternal 1.1. UTIUTI2.2. PIHPIH

SummerySummery

Pre-conceptional counselingPre-conceptional counseling11stst visit screening visit screeningSupplementation & preventionSupplementation & preventionPrenatal screeningPrenatal screeningFollow up Follow up

LaboratoryLaboratoryUltrasoundUltrasound