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ANEMIA IN PREGNANCY

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ANEMIA IN PREGNANCY

INTRODUCTION:
  • Commonest haematological disorder occur in pregnancy
  • Prevalance in pregnant women –
  • Developed:14 %  
  • Developing countries:51%       
  • India:65-75% 
  • 80 % leading to maternal deaths
DEFINITION:
Reduction in circulating Hb mass     
  • < 12g/dl in non-pregnant women
  • < 10g/dl in pregnant women

CDC:Anaemia in iron supplemented pregnant Woman

  • Hct 33% & Hb 11g/dl – 1st & 3rd trimester
  • Hct 32% & Hb 10.5 g / dl – 2nd trimester
WHO GRADING OF ANEMIA:
Mild 10g/dl
Moderate 7- 10 g/dl
Severe  < 7 g/dl

ICMR GRADING:

Mild 10 – 10.9 g/dl
Moderate 7 – 9.9 g/dl
Severe < 7 g/dl
Very Severe < 4  g/dl

HEMATOLOGICAL CHANGES IN PREGNANCY:

PHYSIOLOGICAL ANEMIA OF PREGNANCY:
  • Plasma volume : 40-50%
  • RBC mass:30 %
  • As a result Hb concentration decreases by 2g/dl
  • Decreased Hb concentration  is due to haemodilution

Criteria of Physiological Anemia

  • Hb 10 gm %
  • RBC 3.2 million cells / cu mm
  • PCV 32%
  • Peripheral Smear – Normal morphology
IRON Requirements during Pregnancy:
  • Maternal req. Of total Iron -1000mg
  • 500 mg →Mat. Hb. Mass expansion
  • 300 mg → Fetus & Placenta
  • 200mg → Shed through gut urine, skin

IRON DEFICIENCY ANEMIA:

Development:

  • Depletion of Iron stores
  • Iron deficient erythropoiesis
  • Frank Iron deficiency Anemia

Symptoms:

  • Fatigue
  • Weakness
  • Headache
  • Loss of appetite
  • Dysphagia
  • Palpitations
  • Dyspnea on exertion
  • Ankle swelling
  • Paresthesias
  • Leukoplakia

Examination:

  • pallor
  • glossitis and stomatitis
  • Edema of legs
  • soft systolic murmur
  • Crepitations

INVESTIGATIONS:

Degree of anemia

  • Hemoglobin
  • Total RBC
  • PCV

Type of anemia:

  • Peripheral blood smear
  • Hematological indices

Cause of anemia:

  • Examination of stool(helminthic)
  • Examination of urine(protein, sugar and pus cells)

COMPLICATIONS:

DURING PREGNANCY:

  • Preeclampsia
  • Intercurrent infection
  • Heart failure(30–32 weeks)
  • Preterm labor

DURING LABOR:

  • Uterine inertia
  • Postpartum hemorrhage
  • Cardiac failure
  • Shock

PUERPERIUM:

  • Puerperal sepsis 
  • Subinvolution
  • Poor lactation
  • Puerperal venous thrombosis 
  • Pulmonary embolism

TREATMENT:

  • Supplementary iron therapy:Daily administration of 200 mg of ferrous sulfate & 1 mg folic acid
  • With oral iron therapy, rise in Hb% can be seen after 3 weeks
  • Dietary prescription
  • Early detection of falling hemoglobin level(30th week and 36th week)
  • Hospitalization:Hb

IRON THERAPY:

  • Oral therapy
  • Parenteral therapy:Intravenous route
  • Repeated injections 
  • Total dose infusion (TDI) 
  • Intramuscular route
MEGALOBLASTIC ANEMIA:

CAUSES OF FOLIC ACID DEFICIENCY IN PREGNANCY:

Inadequate intake :

  • Nausea, vomiting and loss of appetite.
  • Dietary insufficiency

Increased demand:

  • Increased maternal tissue
  • Multiple pregnancy
  • Growing fetus
  • Intestinal malabsorption syndrome
  • Infection
  • Hemorrhage
  • Failure of utilization due to anticonvulsant drugs

Diminished storage: 

  • Hepatic disorders
  • Hyperhomocysteinemia
  • vitamin C de!ciency.
  • Iron deficiency anemia
INCIDENCE:
  • 0.5% to 3%.
  • More common in multiparae & multiple pregnancy
CLINICAL FEATURES:
  • Onset insidious
  • First revealed in last trimester 
  • Acutely manifested in early puerperium
  • Anorexia or protracted vomiting
  • Occasional diarrhea
  • Unexplained fever 
  • Pallor
  • glossitis
  • Hemorrhagic patches under the skin and conjunctiva 
  • Enlarged liver and spleen
  • preeclampsia
INVESTIGATIONS:
  • Hemoglobin level

Stained blood film:

  • Hypersegmentation of the neutrophils (5 or more lobes)
  • Macrocytosis and anisocytosis
  • Giant polymorphs
  • Megaloblasts
  •  Howell-Jolly bodies
  • MCV > 100 μ3. 
  • MCH>33 pg
  • MCHC is normal 
  • Associated leukopenia and thrombocytopenia 
  • Serum iron is normal or high
  • Low TIBC
  • Red cell folate < 3 ng/mL
  • Serum vitamin B12 level < 90 pg/mL
  • Serum bilirubin—may be raised 
  • Bone marrow—shows megaloblastic erythropoiesis.
COMPLICATIONS:
  • Miscarriage 
  • Dysmaturity 
  • Prematurity
  • Abruptio placentae
  • Fetal malformation (cleft lip, cleft palate, neural tube defects).
TREATMENT:
  • 400 μg of folic acid daily

Additional amount (4 mg):

  • Multiple pregnancy
  • Patient having anticonvulsant therapy
  • Hemoglobinopathies or associated chronic

Specific therapy:

  • Daily administration of folic acid 4 mg orally 4 weeks following delivery
  • Supplementary IM vitamin B12 100 μg daily
  • Ascorbic acid 100 mg tablet thrice daily
DIMORPHIC ANEMIA:
  • Dietary inadequacy
  • Intestinal malabsorption
  • Deficiency of both iron and folic acid or vitamin B12
  • The red cells become macrocytic or normocytic and hypochromic or normochromic
  • Treatment consists of prescribing both iron and folic acid
APLASTIC ANEMIA:
  • Immunologically mediated or may be an autosomal recessive inheritance
  • Complications in pregnancy are hemorrhage and infection

Diagnosis: 

  • Blood values—Anemia, leukopenia and thrombocytopenia. 
  • Bone marrow—markedly hypocellular

Management:

  • Specific therapy:granulocyte transfusion to combat infection and platelet transfusion to control hemorrhage
  • Glucocorticoid therapy
  • bone-marrow or stem cell transplantation

Exam Important

  • According to WHO, anemia in pregnancy is diag­nosed, when hemoglobin is less than 11.0 gm%
  • In pregnancy, Iron + folic acid anemia is common in India
  • With oral iron therapy, rise in Hb% can be seen after 3 weeks
  • Pre-eclampsia, Intercurrent infection & Heart failure complications are likely to increase in a case of severe anemia during the pregnancy 
  • As per WHO, anemia is considered to exist in pregnancy, if the hemoglobin level is below 
  • Type of anemia in pregnancy is Microcytic hypochromic
  • Cord cutting should be delayed in  Sever anemia
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