BY Dr. Milal Al-Jeborry

2021

To know physiological changes in blood during pregnancy.

To understand definition, types and aetilogy of anemia in pregnancy.

To know how to diagnose and treat various types of anemia in pregnancy.

Iron deficiency anaemia is a significant problem

worldwide, affecting 50% of pregnant women (56% in developing and 18% in developed countries).

Incidence is lower in developed countries due to :-

1.Better living slandered & nutrition. 2.Smaller & better- spaced families. 3.Wide spread use of oral contraception which

usually decrease menstrual loss.

Plasma volume increase by 20% by 15 weeks & 50% by 30-34 weeks (1250 ml).

RBC increase by 14% (180 ml) without supplementation iron & 28 %( 350 ml) when extra iron & folic acid given.R.B.C mass will increase due to increase erythropoietin (possibly due to HPL).

Because there is greater increase in plasma volume than of the RBC this will lead to hemodilution & physiological anemia.

(MCV) which increases by about 4–6 fL, secondary to greater numbers of larger

young red cells from the increase in red cell mass.

↑ white cell count: ↑ neutrophils, ↑ monocytes, ↓ lymphocytes

Mild thrombocytopenia with no impairment of platelet function.

Prothrombotic state predominantly due to increases

in FVIII, vWF, fibrinogen and reduction in protein S.

Serum folate levels fall by around half, due to a twofold increase in folate requirements

but red cell folate levels are relatively spared.

Functional vitamin B12 levels change very little

The British Society of Haematology

(BSH) and the US Centers for Disease Control and Prevention (CDC) use

a value of less than 11.0 g/L in the

first trimester

but less than 10.5 g/L in the second and third Trimesters.

Postpartum anaemia

is defined as Hb less than 10.0 g/L

1.↓ ability to withstand the effects of obstetric hemorrhage.

2. Severe anemia predispose to infection. 3. It may ↑ risk of thrombo –embolism. 4. It predispose to decompensation in mother

with cardiac or respiratory disease. High output cardiac failure is likely when Hb < 5g%.

5. Delayed physical recovery especially after c/s & in multipara.

There may also be a link between iron deficiency, low birthweight and preterm

delivery but this is, as yet, unproven

On the other hand, the effects of maternal iron deficiency anemia on the fetus are negligible & the baby has normal cord blood Hb level

as preferential delivery of iron is facilitated by upregulation of placental transferrin.

80% of anemia in pregnancy is IDA.

In non- pregnant women iron requirement is 1 mg/day. During pregnancy there is ↑ iron requirement about 3.5 mg/day.

Fetus, placenta: 500mg iron

Increase RBC mass 500mg

Postpartum blood loss: 180 mg

Lactation for 6 months: 180 mg

Total requirement: 1360 mg iron. From this 350 mg may save as a result of amenorrhea of pregnancy, so the actual demand during pregnancy is 1000 mg.

1. Poor intake of iron in diet or poor absorption of iron.

2. Chronic menorrhagia. 3. Intestinal bleeding due to hemorrhoids or

hookworms infestation. 4. Insufficient interval for replenishment between

pregnancies. 5. Poor utilization of iron by the bone marrow due

to severe or chronic infection. Clinical features: Tiredness, breathlessness, palpitation, fainting. In

severe case the patient may looks pale.

1. Hb, pcv% decrease. 2. Blood film: hypochromic microcytic 3. B.M exam .special stain, absence of iron. 4. Serum iron decrease 5. I.B.C increase 6. Serum ferritin decrease below 15 μg/L is

diagnostic. I.D.A.: serum iron decrease, I.B.C increase, serum

ferritin decrease. Infection: serum iron decrease, I.B.C increase,

serum ferritin increase

The British Committee for Standards in Haematology (BCSH) suggest the following.

A trial of oral iron should be the first ‘diagnostic test’ for women with a normocytic or microcytic anaemia,

with a check for Hb increase at 2 weeks.

1. Prevention:-iron prophylaxis esp. for: patient with high parity, multiple pregnancies, history of anemia or menorrhagia.

A pregnant woman need only one tablet of iron per day for prophylaxis which usually combined with folic acid in the same tablet (100 mg elemental iron +350ug folic acid) as soon as they are free from nausea & vomiting of early pregnancy.

Depend on:

A. severity of anemia

B.Nearness to term

C.Other complications like placenta previa.

Treatment:-

1. Oral iron

2. Injectable iron

3. Blood transfusion.

Anemia in early pregnancy is treated with oral iron. One tablet of ferrous sulfate or gluconate or fumarate 3 times /day after meals & the treatment continue for 3-6 months postpartum to full the stores.

10-20% of patients undergo GIT symptoms such as nausea, vomiting, constipation, abdominal cramps & diarrhea, treatment by ↓ the dose or by giving the pill with the meals rather than after meals.

rarely indicated in : a. Patient have severe iron deficiency anemia (Hb <

8 g/dl, & a few weeks before the expected date of delivery.

b. patient can not absorb iron (malabsorption syndrome ).

c. patient develop incapacitating S/E with oral iron. S/E of parenteral iron: 1. 2% of patients develop acute systemic reaction

such as hemolysis, hypotension & circulatory collapse.

2. Causes dark staining of the skin & inflammation at the site of injection.

Calculate iron deficit using one of the following formula:-

1. Normal Hb –patient Hb× weight (Kg) ×2.2 +1000 =mg of iron needed.

2. 250 mg elemental iron for each 1 gm Hb below the normal.

Parenteral iron may be given by a deep I.M injection as iron dextran (imferon) or iron sorbitol (jectofer). Each of these contains 50 mg of iron per ml & the patient given a daily injection of 2 ml until satisfactory response is established.

Iron dextran (but not sorbitol) may also be given by (total – dose I.V infusion), this method may be useful for women with severe anemia & who are unlikely to attend for a series of injections. The patient is admitted to the hospital for 6 hours & one litter of normal saline containing the calculated dose of iron dextran is administered by slow I.V drip.

Follow up: reticulocytes, Hb. newer preparations such as iron carboxymaltose, which is given as a single dose over 15 min, produces a faster response (approximately 1.0 g/L improvement per week) 3. Blood transfusion:- May be required for treatment of severe anemia near term or

when some other complication such as placenta previa.

5 % of anemia. Folic acid requirement: Non pregnant: 50 ug/ day. Pregnant: 350-400 ug /day. Causes of folate deficiency: 1. Inadequate dietary intake. 2. Poor absorption (intestinal malabsorption). 50% of

cases e.g. gluten sensitivity; typical recurrence of megaloblastic anemia in successive pregnancies.

3. Epileptic with anticonvulsant drugs. 4. Multiple pregnancies. 5. Chronic hemolysis from any cause such as sickle cell

disease or B-thalassemia. 6. Impaired utilization of folic acid by B.M e.g.

infection.

Presentation is acute; tongue is painful with papillary flattening, opthous ulceration of tongue, mouth. May be vomiting, anorexia, diarrhea, little or no weight gain or even weight loss during pregnancy.

Regardless the severity of maternal folate depletion, the fetus obtains enough folic acid for its own requirement & cord blood folate level being higher than the maternal value at the time of delivery.

1. Blood film: hyper segmentation of neutrophils, macrocytes, neutropenia, and thrombocytopenia.

2. Decrease RBC folate, decrease serum folate.

3. B.M.: megaloblast erythropoisis, disordered granulopoisis, impaired thrombopoisis.

4. Serum B12 level.

B12 ↓ is rare occur in vegetarian, gluten enteropathy involving the ileum.

A- Prevention:- folic acid supply for:

Multiple pregnancies, hemoglobinopathy, anticonvulsant therapy, previous history of megaloblastic anemia.

Patients at increased risk of folate deficiency should take 5 mg of folate daily as prophylaxis during pregnancy.

Those with established folate deficiency should take 5 mg three times daily

1. Oral folic acid 5mg three times daily. 2. I.M folate: A. impaired absorption of folate. B. when there is severe

vomiting. 3. Treatment of any infection. 4. Blood transfusion when Hb < 6 gm/dl. When

Hb < 4 gm/dl then exchange blood transfusion.

5. B12 ↓ rare treated by weekly injection of vit. B12 1000 ug, should be given as well as folic acid until after delivery.

A- Acquired: infection, toxin, poison. B- Congenital: 1. Spherocytosis & elliptocytosis: autosomal

dominmant, neonatal jaundice. No significant maternal effects during pregnancy. Folic acid supplementation double the dose. 2. Enzyme defects Haemolytic anemia:- G6PD ↓ (sex-linked recessive). Neonatal jaundice. Hemolytic crisis: sulphonamide, synthetic

analogues of vitamin k & nitrofurantoin.

Hb A → ᾳ2 B2 (95% OF Hb).

Hb F →ᾳ2ᴕ2 (1% OF Hb.

Hb A2→ᾳ2 delta2

Sickle –cell; syndrome:

Autosomal inherited, affecting the blacks.

Hbs; abnormality in B chain

Homozygous → Hbss (sickle –cell disease)

Heterozygous →Hbs (sickle-cell trait)

Usually fatal in childhood, so rare in pregnant woman. Low Hb (5-9 g/dl).↑ incidence of crisis during pregnancy, labour & puerperium& may be precipitated by hypoxia, infection, acidosis& dehydration.

↑ abortion, stillbirth, prematurity IUGR.

Screening by sickledex test; while definitive diagnosis by Hb electrophoresis.

1. Avoid hypoxia, dehydration & acidosis.

2. Treatment of any infection.

3. Repeated blood transfusion throught pregnancy decrease the likelihood of crisis. The aim is Hb 10 g/dl.

4. Therapeutic doses of folic acid.

5. Avoid iron

There is partial or complete suppression of either B or ᾳ chain

B thalassemia major (homozygous)

B thalassemia minor (heterozygous)

ᾳ thalassemia major or minor.

Bthalassemia minor affect meditrian, Hb 10 g%, hypochromic microcytic anemia.

No ↑ in RBC mass in pregnancy

Diagnosis:

Hb electrophoresis

Treatment:

1. Folic acid supplementation.

2. Avoid iron.

3. Blood transfusion sometime necessary.

THANK YOU