Anemia in Pregnancy: Rabika Fatima Rabia Saleem Almina Rehman

ANEMIA IN PREGNANCY
Rabika Fatima
Rabia Saleem
Almina Rehman
WHAT IS
ANEMIA?
• Anemia occurs when the

number of red blood cells or
their oxygen carrying
capacity is insufficient to
meet the physiological
needs of an individual,
which vary based on age,
gender, or pregnancy status.
PHYSIOLOGIC ANEMIA OF
PREGNANCY
• During pregnancy the plasma volume of the mother increases by 40% -

45% by term. Most of this occurs before gestational week 32 – 34.
• The maternal red blood cell mass also increases by 30% by term
• The difference between the rate of increase of the RBC mass and
plasma volume causes hemodilution resulting in physiological anemia.
ANEMIA IN PREGNANCY
• A full blood count measurement is taken as a part of

antenatal care
• It allows identification of women with existing anemia
and early initiation for the treament of the anemia.
• Anemia in pregnancy is defined as a hemoglobin of
less than 110 g/L (11 mg/dL) in the 1st trimester, less
than 105 g/L (10.5 mg/dL) in the 2nd trimester and
3rd trimester, and less than 100g/L (10 mg/dL) in the
postpartum period.
TYPES OF ANEMIA
• Microcytic – MCV < 80 µm³

• Iron deficiency
• Thalassemia
• Normocytic - MCV 80 – 100 µm³
• Sickle Cell
• Macrocytic – MCV >100 µm³
• Folate deficiency
• B12 deficiency
IRON DEFICIENCY ANEMIA
• Iron deficiency anemia is the most common type in

pregnancy
• It is characterized by microcytic, hypochromic red blood
cells
• Risk factors
• Increased requirement of iron during pregnancy
• Impaired absorption
• Chronic bleeding
• Investigations
• Serum ferritin levels will be low
• Increase in total iron binding capacity
• Low serum iron
• The iron requirement for an average
pregnancy is approximately 1000 mg
iron
IRON REQUIREMENTS IN • There is an increase in maternal
PREGNANCY hemoglobin – 400-500 mg
• The fetus and placenta require 300-400mg
• Replacement of daily loss through urine
stool and skin – 250 mg
MANAGEMENT
• Encourage women to have green leafy

vegetables, meat and poultry
• Daily supplementation of 30mg elemental
iron (one iron ferrous sulphate tablet 325mg
has 60mg elemental iron) and 0.4mg(400
micrograms) folic acid
• Parenteral iron in those unable to tolerate
oral preparations
• Vitamin C increases absorption of iron
THALESSEMIA
• Autosomal recessive disorder; impaired production of α and β

globin chain, resulting in RBC with inadequate Hb content.
• Although the effected person is chronically anemic, this condition
rarely produces obstetric complications except in case of severe
blood loss.
• Diagnosis:
• It is Suspected in presence of microcytic anemia with normal
MCHC
• Hb-Electrophoresis – definitive diagnosis
ALPHA AND BETA THALESSEMIA
• Αlpha Thalassemia - Defect in the normal production of alpha

globin chains
• Silent Carrier: One gene deletion; Asymptomatic
• αtrait: Two gene deletion; Mild anemia
• HbH Disease: Three gene deletions; Severe hemolytic anemia
• Hb Bart Disease: Four gene deletion; Incompatible with life
• Beta thalassemia - Defect in the normal production of beta globin
chains
• Β Minor: One defective gene: mildly anemic with low mean
corpuscular volume(MCV).
• Β Major: Two defective genes : Transfusion dependent
COMPLICATIONS
• Maternal
• α - Thalassemia major can cause fetal hydrops and preecelampsia
• β - Thalassemia major females who survive childhood are usually sterile
• Fetal
• α - Thalassemia major can cause fetal hydrops; polyhydramnios, preterm
delivery, stillbirth
• β - Thalassemia major results in severe anemia, the child shows failure to thrive
and may die during childhood
MANAGEMENT
• Check ferritin in early pregnancy. Iron supplements only if iron

deficient.
• Folic acid 5mg daily
• If the mother has thalassemia, the partner needs screening: If positive;
couple needs counseling about risk of pregnancy and prenatal
diagnosis should be offered.
• If both partners have beta thalassemia minor there is a 1:4 chance the
fetus could have eta thalassemia major which is associated with
profound anemia in post natal life
• Thalassemia major detected in 1st trimester of pregnancy by chorion
villus sampling
• Can be detected in 2nd trimester of pregnancy by cordocentesis (fetal
cord blood)
SICKLE CELL ANEMIA
• Its an autosomal recessive mutation in beta

chain of hemoglobin
• Characterized by abnormal hemoglobin S
molecule; valine substitution for glutamic acid
at 6th position
• HbS polymerizes when deoxygenated.
Polymers aggregate into sickle cells which
occlude small blood vessels.
SICKLE CELL SCREENING
• Women should be seen antenatally to receive information about affects sickle cell
and how to improve outcomes.
• They should also be encouraged to have the hemoglobinopathies status of their
partners determined
• They should avoid precipitating factors of sickle cell crisis such as exposure to
extreme temperature, dehydration and over-exertion.
• Invasive testing can be done to detect the status of the fetus if both parents are
carriers
SICKLE CELL TRAIT
• It is heterozygous for hemoglobin S (HbAS)

• What it causes
• Asymptomatic bacteriuria
• Increased UTI
• This is because patient with SCA are hypo splenic and are more prone to
infections in particular from encapsulated bacteria such as N.meningitides,
S.pneumoniae and H.influenzae
• Pregnancy outcome isn’t changed
• No fetal complications
SICKLE CELL DISEASE
• Sickle cell disease is homozygous for hemoglobin S (HbSS)
• Mothers are at increased risk of:
• Severe anemia • Preterm labor • Acute chest syndrome; (fever,
chest pain, tachypnea, one pain,
• Miscarriage • Central vein thrombosis elevated WBCs)
• Pre eclampsia • Deep vein thrombosis
• Increase incidence of sickle cell crisis which that results in episodes of severe pain, typically effecting
bones and chest.
• Crisis in pregnancy is precipitated by hypoxia, stress infection and hemorrhage
• Fetal complications:
• Fetal growth restriction
• Prematurity
• Stillbirth
MANAGEMENT
• High dose folate(5mg daily)

• Low dose aspirin(75mg daily)
• SICKLE CELL CRISES:
• Prompt treatment and adequate hydration
• Adequate oxygenation to avoid hypoxia and acidosis
• Narcotic analgesics for sickle cell crisis (NSAIDS; ibuprofen,
diclofenac) or, weak opioid
• Screen for infection and Antibiotic for UTI (Penicillin)
• Blood transfusion(leukocyte depleted)
• Heparin for prophylaxis against thrombosis
• Serial US of fetal growth
• Folate supplementation (iron supplementation only if lab
evidence of iron deficiency)
FOLATE DEFICIENCY ANEMIA
• Common in 5% pregnancy
• Characterized by macrocytic, hyper segmented neutrophils
• Risk factors
• Poor nutritional status
• Hemolytic anemias
• Hemoglobinopathies
• Drugs (Anti-epileptics, antibiotics, anti-cancer)
DIAGNOSIS
• Increase in:
• MCV>100 µm³
• MCHC (mean corpuscular hemoglobin concentration)
• Plasma homocysteine
• Decrease in:
• Serum folate levels
• RBC folate level
MANAGEMENT
• Management:
• Folic acid 1-3mg/d orally
• Iron supplementation
• weekly measurement of reticulocyte count and hematocrit
• Folic acid is given preconception and in early pregnancy
to reduce risk of Neural tube defects
• Dosage increased in women with high risk of NTDs:
• Patients on anti-convulsants
• Previous child with NTDs
• Hematological disorders
EFFECTS OF
ANEMIA ON
THE MOTHER
• Reduced resistance to infection due

to impaired cell medated immunity
• Reduced ability to withstand
postpartum hemorrhage
• Strain of labor may cause cardiac
failure
• Predisposition to preterm labor due
to associated malnutrition
• Fatigue
• Potential threat to life
EFFECTS OF ANEMIA ON THE
FETUS
• Intrauterine hypoxia and growth retardations

• Prematurity
• Low birth weight
• Anemia in first few month post birth due to
poor stores
• Increased risk of preinatal morbidity and
mortality
THANK YOU

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ANEMIA IN PREGNANCY

• Anemia occurs when the

• During pregnancy the plasma volume of the mother increases by 40% -

• A full blood count measurement is taken as a part of

• Microcytic – MCV < 80 µm³

• Iron deficiency anemia is the most common type in

• Encourage women to have green leafy

• Autosomal recessive disorder; impaired production of α and β

• Αlpha Thalassemia - Defect in the normal production of alpha

• Check ferritin in early pregnancy. Iron supplements only if iron

• Its an autosomal recessive mutation in beta

• It is heterozygous for hemoglobin S (HbAS)

• High dose folate(5mg daily)

• Reduced resistance to infection due

• Intrauterine hypoxia and growth retardations

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