ANAEMIA IN PREGNANCY
‫منى قاسم محمود‬.‫د‬.‫م‬.‫ ا‬
Learning Objectives
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Diagnose anemia in pregnancy
Learn the effect on mother & fetus
Learn S/S in pregnancy
Learn prevention of anemia
Learn supplementation of oral iron during pregnancy
Management of anemia during pregnancy
Labor & Delivery management
Post partum contraception
Background Information
 Commonest medical disorder in pregnancy
 Prevalence in India varies between 50-70%
 Prevalence in USA is 2-4%
 Nutritional anemia (Iron deficiency) is commonest
 It is important contributor to maternal & perinatal
morbidity & mortality as a direct or indirect cause
Definition - Anemia
 A condition where circulating levels of Hb are
quantitatively or qualitatively lower than normal
 Non pregnant women
Hb < 12gm%
 Pregnant women (WHO)
Hb < 11 gm%
Haematocrit
< 33%
 Pregnant women (CDC)
Hb <11 gm%
1st Trimester
2nd trimester
Hb < 10.5 gm%
ICMR Anemia Severity Classification
Hb values
Mild
Moderate
Severe
Very Severe
10.0-10.9 gm%
7-9.9
<7
<4
Causes of Anemia in Pregnancy
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Nutritional / Iron deficiency anemia
Pre-pregnancy poor nutrition very important
Besides Iron, folate and B12 deficiency also important
Chronic blood loss due to parasitic infections – Hookworm & malaria
Multiparity
Multiple pregnancy
Acute blood loss in APH, PPH
Recurrent infections (UTI) - anemia due to impaired erythropoiesis
Hemolytic anemia
Hemoglobinopathies like Thalassemia, sickle cell anemia
Aplastic anemia is rare
Patho-physiology of Nutritional Anemia in
Pregnancy
 Augmented erythropoiesis in pregnancy
 Blood volume increases 40-45% in pregnancy
 Increase in plasma is more as compared to red cell mass
leading to hemodilution & decrease in Hb level
 Iron stores are depleted with each pregnancy
 Too soon & too many pregnancies result in higher
prevalence of iron deficiency anemia
Extra Iron Requirement & Loss During
Pregnancy
During pregnancy Total 800-1000
mg extra iron is required
300 mg for
Fetus & 50
mg for
Placenta
250 mg iron
lost during
400-500 mg
delivery
for increased
red cell mass 220 mg basal
losses
Due to cessation of menses & contraction of blood volume after delivery
conservation of iron is around 400 mg
Clinical Presentation
 Depends on severity of anemia
 High risk women – adolescent, multiparous, multiple
pregnancy, lower socio economic status
 Mild anemic - asymptomatic
 Symptoms – pallor, weakness, fatigue, dyspnoea,
palpitation, swelling over feet & body
 Signs – pallor, facial puffiness, raised JVP, tachycardia,
tachypnea, crepts in lung bases, hepato-splenomegaly,
pitting oedema over abdominal wall & legs
 cardiac failure
 Glossitis, stomatitis, chelosis, brittle hair
Investigation
 Hb, CBC
 Blood film
 Iron study (ferritin ) level
 Hb- electrophoresis
Red Cell Indices
 PCV - < 32%, (N37-47%)
 MCV – low in Fe def anemia, microcytic
 MCH - decreases
 MCHC – decreases, one of the most sensitive indices
(N26-30%)
Special Investigations
 Serum Ferritin – abnormal if < 20 ng/ml (N 40-160 ng/dl),
assess iron stores
 Serum Iron – N 65-165 ug/dl, decreases in Fe def anemia
 Serum Iron binding capacity – 300-360 ug/dl, increases with
severity of anemia
 Percentage saturation of transferrin – 35-50%, decreases to
less than 20% in iron deficiency anemia
Differentiation between iron deficiency anemia & Thalassemia
diminished synthesis of Hb b chains in Thalassemia)
Investigations Normal values
75-96 fl
MCV
27-33pg
MCH
32-35 gm/dl
MCHC
<2 %
HbF
2-3%
HbA2
Serum Iron
60-120 ug/dl
Serum Ferritin
15-300 ug/L
300-350 ug/dl
TIBC
Bone iron stores
Free erythrocyte
protoporphyrin
(FEP)
<35 ug/dl
Thalassemia
reduced
V reduced
reduced
V reduced
reduced
N or reduced
normal
Raised
N or reduced Raised >3.5%
reduced
Normal
reduced
Normal
Raised
Normal
reduced
Normal
>50
Normal
Fe Def Anemia
Other Investigations
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Urine examination – RBC & Casts
Stool examination – occult blood, ova
Bone marrow examination – refractory anemia
X-Ray chest – Pulmonary TB
BUN/Serum creatinine – Renal disease
Effect of Anemia on Pregnancy & Mother
 Higher incidence of pregnancy complications
PET, abruptio placentae, preterm labor
 Predisposed to infections like – UTI, puerperal sepsis
 Increased risk to PPH
 Lactation failure
 Maternal mortality – due to
 CHF,
 Cerebral anoxia,
 Sepsis,
 Thrombo-embolism
Effect of Anemia on Fetus & Neonate
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Higher incidence of abortions, preterm birth, IUGR
IUD
Low APGAR at birth
Neonate more susceptible for anemia & infections
Higher Perinatal morbidity & mortality
Anemic infant with cognitive & affective dysfunction
Treatment for Iron Deficiency Anemia
 Improving diet rich in iron &
fruits & leafy vegetables
 Treat worm infections,
maintain general hygiene
 Food fortification with iron &
genetic modification of food
 Iron & folic acid
supplementation in young girls
& during pregnancy
 Heme iron better, present in
animal food & is better
absorbed
 Iron absorption enhanced by
citrous fruits, Vit C
 Avoid tea, coffee, Ca,
phytates, phosphates,
oxalates, egg, cereals with iron
Iron Rich Foods
 Green leafy vegetables
 Animal flesh food - meat, liver
 Vit C - lemon, orange.
Iron supplementation in Pregnancy
 60 mg elemental iron & 400 ug of folic
acid daily during pregnancy and 3
months
there
after
,
In
anemia
therapeutic doses are 180-200 mg /d
 Route of administration depends on,
severity
of
anemia,
Gest
age,
compliance & tolerability of iron
 Oral iron can have side effects like
nausea, vomiting, gastritis, diarrhoea,
constipation
 Iron supplementation
not recommended in
first trimester
 Higher
incidence
miscarriage
defects
,
of
Birth
Parenteral Iron Transfusion
 Iron sucrose for parenteral
use. Response - by increase
in Hb level 1g/week
 Increase in Reticulocyte
count with in 5-10 days
 Clinical symptoms improve
Indications for Blood Transfusion
 Severe anemia first seen after 36
weeks of pregnancy
 Anemia due to acute blood Loss –
APH & PPH
 Patient not responding to oral or
parenteral therapy
 Anemic & symptomatic pregnant
women (dyspneic, with heart failure
etc) irrespective of gestational age
Management of Labor
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Labor should be supervised
Proper counseling & consent to be taken
Blood (whole & packed) kept cross matched
Women nursed in propped up position
Intermittent O2 to be given
Precaution to prevent infection & blood loss
Strict aseptic precautions & minimal P/V exams
Prophylactic antibiotic can be given
Patent iv line but fluids are avoided
In decompensated patient diuretic given
Second & Third Stage of Labor
 Second stage cut short by forceps or ventouse
 Active management of 3rd stage of labour to be done
 Oxytocics, P/R misoprostol can be given after delivery of fetus
 Even normal blood loss may be tolerated poorly in anemic
patient
 IV Frusemide given after delivery to decrease cardiac load
Post Natal Care & Contraception
 Early ambulation is encouraged
 Hematinics are continued for 3-6 months
 Watch for subinvolution , puerperal sepsis, CHF, thromboembolism & lactation failure
 Avoid pregnancy at least for 2 years
Contraception ; barrier contraception, POP after 3 weeks,
IUCD or permanent sterilization
Sickle cell anaemia
Inherited disorder of Hb synthesis
Female in pregnacy had higher mortality
rate.
Painful crises
Bad obstetrical history
Anemia and jaundice.
Complications in pregnancy
Infection, Anemia
Heart failure
Painful crises
Pul. Embolism
Stroke
Hypertension
Renal failure
Gall stone
Recurrent pregnancy loss
Treatment
Multidisplinary team.
Follow up of fetal growth and blood
pressure
Give folic acid
Blood transfusion
Admission in case of crises
Hypothyroidism and hyperthyroidism in
pregnancy
Thyroid gland in pregnancy
 Thyroid gland increases in size by 10% during
pregnancy in iodine-replete countries and by 20–
40% in iodine-deficient areas , Production of T4
and T3 increases by 50% during pregnancy
 •Daily iodine requirement increases by 50% during
pregnancy, •10–20% of all pregnant women in the
1st trimester of pregnancy are TPO or TgAb +ve
and euthyroid
Hypothyroidism in pregnancy
2–3%
of
apparently
healthy,
non-
pregnant women of childbearing age
have elevated serum TSH
•An estimated 0.3–0.5% would have
overt hypothyroidism
•Prevalence is higher in areas of iodine
insufficiency
Causes of hypothyroidism
Iodine deficiency
Hashimoto's thyroiditis
Atrophic autoimmune thyroiditis
Post-radioablation
Post-thyroidectomy
Complications of hypothyroidism
Increased risk of premature birth
Increased risk of fetal death
Low birth weight
Miscarriage
Impaired fetal neurocognitive development
Gestational hypertension
Diagnosis of hypothyroidism
TSH >2.5 mIU/L with decreased FT4
concentration
TSH >10.0 mIU/L, irrespective of FT4
(Subclinical hypothyroidism – TSH
between 2.5 and 10 mIU/L with a normal
FT4)
Treatment of hypothyroidism
Multidisplinary team
L-thyroxine
LT4 dose requires adjustment due to
increased demand as pregnancy
progresses
Hyperthyroidism in pregnancy
Graves' disease, the most common cause of
autoimmune hyperthyroidism in pregnancy,
occurs in 0.1–1% (0.4% clinical and 0.6%
subclinical) of all pregnancies
Gestational
hyperthyroidism
(transient
hyperthyroidism) occurs in approximately
1–3% of all pregnancies
Causes of hyperthyroidism
Graves' disease
Gestational
hyperthyroidism
hyperthyroidism)
hCG-induced thyrotoxicosis
Toxic multinodular goitre
Toxic adenoma
Factitious thyrotoxicosis
Silent thyroiditis
Struma ovarii
(transient
Diagnosis of hyperthyroidism
Suppressed or undetectable serum TSH
(<0.1mIU/L)
Elevated FT4
Complications of hyperthyroidism
Miscarriages
Pregnancy-induced hypertension
Prematurity
Low birth weight
Intrauterine growth restriction
Stillbirth
Thyroid storm
Maternal congestive heart failure
Fetal hyperthyroidism
Neonatal hyperthyroidism
Excessive amounts of ATDs can cause
fetal and neonatal hypothyroidism
High titres of serum TRAb between 22 and
26 weeks’ gestation are risk factors for
fetal or neonatal hyperthyroidism
Treatment
Multidisplinary team (Carbimazole, PTU)
FT4 and TSH should be monitored
approximately every 2–6 weeks
The primary goal is a serum FT4 at or
moderately above the normal reference range
Discontinuation of all ATD therapy is feasible in
20–30% of patients in the last trimester of
gestation
In women with high levels of TRAb values, ATD
therapy should be continued until delivery
INDICATION AND TIME OF THYROIDECTOMY
Allergies/contraindications to ATDs
Requiring large doses of ATDs
Not adherent to drug therapy
2nd trimester is optimal time
Renal disease in pregnancy
Physiological changes in pregnancy
 Increase in the GFR and renal plasma flow (30-50% by T2 persist
till term)
 Fall in serum creatinine (by 20-30%)
 Increased protein excretion= 300mg/24hrs upper limit. PCR
30mg/mmol
 Physiological hydronephrosis=
 increase in size of kidney by 1.5cm
 Dilatation of renal pelvis and ureter occurs R>L
Smooth muscle relaxation due to progesterone effect. Gravid uterus
dextrorotation to right
Chronic or preexisting renal disease
CKD is rare in pregnant patients, affecting
0.15% of pregnancies, and most patients
have early stages of CKD.
In the general population, diabetes
mellitus and hypertension are the
commonest causes of CKD.
Complications during pregnancy
Miscarriage
Gestational Hypertension in 50%
PET
IUGR and caesarean section
PTD
Fetal death (with urea >20-25 mmol/l 10%)
Management
 Pre pregnancy counselling essential and use effective
contraception
 In sever cases we can terminate the pregnancy
 Role of aspirin in prevention of PET
 Diagnosing superimposed PET
 Monitoring of fetal growth and wellbeing