CASE OF ANAEMIA IN PREGNANCY
NAME – Vasanthamma
AGE – 30 years
ADDRESS – Nelamangala
OCCUPATION – Housewife
(PCI– Rs. 750)
RELIGION – Hindu
HUSBAND’S NAME – Bailanjappa
AGE – 35 years
OCCUPATION – Coolie
INCOME – Rs. 3300/month
SE STATUS – Upper Lower class
G3P2L2 comes with 8 months of amenorrhea
PRESENTING COMPLAINS – Easy fatigability since 2 months
HISTORY OF PRESENTING COMPLAINTS:
 Patient presents with 8 months of amenorrhea with easy fatigability since 2 months.
Previously, the patient was able to do her household work, but for the past 2 months, she
gets tired even with minimal work. On walking about 50 m, patient complains of
fatigability, giddiness, blurring of vision which is relived on rest.
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No history of increased bleeding during menses prior to pregnancy.
No history of exertional dyspnea, palpitation, PND, pedal edema or giddiness.
No history of bleeding or leak PV.
No history of bleeding PR or malena.
No history of passing worms in the stools.
No history of fever with chills and burning micturation.
No history of cough with expectoration, hemoptysis, evening rise of temperature or
contact with a known case of tuberculosis.
 No history of drug intake (anti-malarial drugs or aspirin).
 No history of any yellowish discolouration of skin and sclera.
 Not a known diabetic or hypertensive.
OBSTETRIC HISTORY:
Married Life – 13 years, Non-consanguinous
Obstetric index – G3P2L2A0
No.
G1
DELIVERY
FTND, Government
Hospital
G2
FTND, Government
Hospital
BABY AT BIRTH
Cried soon after birth,
Male, 3.2 kg, Breast fed 3
years
Baby cried soon after
birth, Female, 3 kg,
Breast fed – 2 ½ years
LMP – 02/11/2006
EDD – 09/07/2007
PRESENT PREGNANCY
T1
 No history of nausea, vomiting or weakness.
PRESENT AGE
12 years
10 years
COMMENTS
Post partum period – normal
Booked & Immunized
Had 3 ANC visits + TT + IFA
Post partum period – normal
Booked & Immunized
Had 3 ANC visits + TT + IFA
 No urinary symptoms
 No drug intake
 No history of craving for abnormal food (pica)
T2
 Quickening in 5th month
 1st ANC visit – 20 weeks, given TT & IFA tablets (consumed)
T3
 Fetal movements present
 No leak or bleed PV
 No h/o pain abdomen
CONTRACEPTIVE HISTORY:
No history of using any contraceptive methods.
MENSTRUAL HISTORY:
Age of Menarche – 13 years
Past Cycles – Regular 30 days cycles with flow lasting 5 days, normal quantity, no pain or passing
of clots.
LMP – 02/11/2006
FAMILY HISTORY:
No history of congenital anomalies or twinning, DM, HTN
PAST HISTORTY:
No history of Tuberculosis, Epilepsy, Asthma, DM, HTN
No history suggestive of any cardiac ailments.
No history of previous surgeries, blood transfusions.
PERSONAL HISTORY:
Diet – Mixed
Appetite – Good
Sleep – Sound
Bowel & Bladder – Regular
Habits – Nil
DIET HISTORY:
Consumes – 2100 kcal/day
Required – 2400 kcal/day
Deficit – 300 kcal/day
GENERAL PHYSICAL EXAMINATION:
Patient is 30 year old, moderately built and nourished, conscious, alert & cooperative.
Pulse
BP
RR
Temperature
– 84/min, regular, good volume
– 110/68 mm of Hg
– 14/min, regular
– Patient is afebrile
Pallor
– Present
Icterus
– Absent
Cyanosis
– Absent
Clubbing
– Absent
Clubbing
– Absent
Edema
– Absent
Lymphadenopathy
– Absent
Thyroid
Breasts
Spine
– Normal
– Normal
– Normal
Height
Weight
BMI
– 146 cm
– 56 kg
– 26.27
SYSTEMIC EXAMINATION:
CVS – S1 S2 heard, No murmurs.
RS – NVBS heard, no basal crepts.
CNS – NAD.
PA – NAD
OBSTETRIC EXAMINATION:
INSPECTION:
 Abdomen is uniformly distended, globular in shape

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

Umbilicus everted, hernial orifices normal
Flanks do not appear to be full
Stria gravidarum and linea nigra present
No scars over the abdomen
PALPATION:
 Abdominal circumference – 76 cm
 Symphysio-fundal height – 28 cm (corresponds to 32 weeks)
 FUNDAL GRIP – Soft, broad & non-ballotable, suggestive of Breech
 LATERAL GRIP
Knob like structures on the right side suggestive of limb buds
Uniform resistance on the left side suggestive of spine
 1ST PELVIC GRIP – Smooth, hard, ballotable mass suggestive of head
 2ND PELVIC GRIP – Fingers converge, head not engaged.
 Uterus is relaxed
 Fetal age = 28*8/7 = 32 weeks
 Fetal weight = (28-12)*155 = 2480 gm
AUSCULTATION:
 Fetal Heart sounds heard along the left spino-umbilical line
 142/min, regular, rhythmic
DIAGNOSIS:
30 years old G3P2L2A0 with 32 weeks of gestation, moderate anemia probably Iron deficiency, not
in labour with no clinical signs of failure.
DISCUSSION
ANEMIA – Decrease in the oxygen carrying capacity of the blood due to the decrease in the total
circulating RBC or Hb or both for that particular age, sex & physiological state.
CLASSIFICATION (BASED ON ETIOLOGY)
1. Physiological
2. Pathological
a. Nutritional – Deficiency of Fe, Folate, Vit. B12, Protein deficiency, Dimorphic
Anemia.
b. Hemorrhagic
i. Acute – Bleeding, APH
ii. Chronic – Hookworm infestation (loss of 0.05ml/day), Piles
c. Hemolytic – Sickle Cell Anemia
d. Hemoglobinopathies
e. Aplastic Anemia – Radiation, drugs, etc.
f. Anemia of Infections – Malaria, Kala afar
g. Anemia of Chronic diseases
GRADING OF ANEMIA (ICMR)
WHO
INDIA
MILD
9 – 11 gm/dl
8 – 10 gm/dl
MODERATE
7.1 – 9 gm/dl
6.5 – 8 gm/dl
SEVERE
≤ 7 gm/dl
≤ 6.5 gm/dl
As per WHO anemia in pregnancy is
< 11 gm% in T1 & T2
< 10.5 gm% in T3
INVESTIGATIONS
AIM

To confirm the presence of anemia

To know the
o Degree
o Type
o Cause
1. BLOOD FOR Hb% ESTIMATION
a. Sahli’s Acid Hematin Method
i. Capillary blood from left hand ring finger, don’t sqeeze
ii. Spirit used not betadine as latter doesn’t vaporize & dilutes the blood
giving wrong results
iii. 20 cc of blood sample → Tube →dilute with 0.2 ml N/10 HCl → 10 min &
then match the colour
b. Other methods
i. Talliquist’s (using blotting paper) – used in rural areas
ii. Cyanmethhemoglobin method (best)
iii. CuSO4 method
iv. Alkaline hematin method
2. URINE FOR
a. ALBUMIN
i. Heat coagulation
ii. Heliar’s Test
iii. Esbach’s Test
b. SUGAR
i. Benedict’s Test – 5 ml Benedict’s reagent → heat to remove impurities →
add urine & heat → compare
c. MICROSCOPY – If pyuria, send for Culture & Sensitivty
CAUSES OF ANEMIA IN UTI
Progesterone → relaxation of urethral muscle → retrograde flow → UTI
 Infection causes decreased Fe absorption
 Ascending pyeitis → pyelonephritis
 Toxins released – lysis of RBC’s.
3. Peripheral Smear
a. Iron deficiency – Microcytic hypochromic anemia with anisocytosis, target cells/
b. B12/Folate deficiency – Macrocytic normochromic anemia with megaloblasts,
Howell – Jolly bodies (disfigured RBC’s)
c. Dimorphic Anemia – Fe & Folate deficiency
d. Malaria/kala azar (with Leishman’s stain) – Haemo-parasites
e. Hemolytic – Sickle shaped RBC, Increased Reticulocyte count, Increased fragility
f. Anemia of chronic diseases & hemorrhage – Normocytic normochromic
4. BLOOD INDICIES
INDEX
MCV
MCH
MCHC
NORMAL
75 – 100 μg
27 – 32 pg
28 – 32 %
Fe deficiency
↓ <75 μg
↓ <25 pg
↓ <30%
B12/Folate deficiency
↑
Normal
↓
5. HEMATOCRIT VALUE
Normal female
Pregnancy
Anemia in Pregnancy
→ 35 – 45%
→ 30 – 37%
→ <30%
6. STOOL FOR OVA, CYST & OCCULT BLOOD
a. Hookworm – ova
b. Giardia lamblia
c. Ascariasis – bile stained
d. Occult blood – Benzidine test
Treat the anemia 1st because, if anti-helminthic drugs are given 1st, the parasites
are killed and retained for a longer time, the raw area left longer which further
bleeds (↓healing in anemia) aggravating anemia
7. IRON PROFILE
NORMAL
Serum Fe
60 – 120 μg/dl
TIBC
300 – 350 μg/dl
Serum ferittin
15 – 200 μg/dl
% saturation
20 – 45%
8. BONE MARROW BIOPSY – in case of
a.
b.
MANAGEMENT
Fe deficiency
< 30 μg/dl
>400 μg/dl
<15 μg/dl
<10%
Refractory anemia
Aplastic anemia
PREVENTIVE MEASURES:
1. Food/salt fortification with Iron (Jaggery).
2. Screening of adolescent girls & give Fe supplementation.
3. Control & treatment of malaria, UTI, hookworm infestation, piles.
4. Maintain minimum 2 years gap between successive pregnancies.
THERAPEUTIC MEASURES:
1. ORAL IRON
a.
b.
Prophylactic
i. T1 – not given as
 It may be teratogenic.
 Aggravates morning sickness.
 Hemodilution occurs only after 20th week.
ii. T2 onwards – 100 tablets of FeSO4 200 mg – 60 mg elemental Fe, 500 µg
Folic Acid
 Prevents progression of latent anemia to overt anemia.
 Meets increased requirements of Fe during pregnancy.
 Bioavailability of Fe during pregnancy is 20% - thus only 12 mg of
iron is absorbed.
iii. If the mother has normal Hb%, then need for prophylaxis is determined on
basis of Serum Ferritin levels
 If normal, then ½ the dose is given.
 If it is less, then full dose is given.
Therapeutic – when Iron deficiency is confirmed.
i. Start with 1 tablet/day
3 tablets/day (to prevent gastric
irritation).
ii. Take immediately after meal to reduce gastric irritation though should be
ideally consumed ½ hour before meal.
iii. To check compliance
 Ask for blackening of stools.
 Ask for gastric symptoms.
 Ask to show empty packets.
iv. Preparations
 Ferrous ascorbate (best, Vitamin C increases absorption).
 Ferrous sulphate – Cheapest and widely used (FERSOLATE).
 Ferrous fumarate – Commercial preparation, less gastric sideeffects
c. Side Effects – Nausea, Vomiting, Staining of teeth, Constipation.
2. PARENTERAL IRON
a. Indications
i. Intolerance/non-compliance to oral iron.
ii. Poor absorption (achlorhydria).
b. Preparations
i. Iron dextran (IMFERON – 100 mg in 1 ampoule) IM or IV.
ii. Iron sorbital citrate (JECTOFER – 75 mg) only IM – excreted by kidney
(thus avoid in renal disease).
iii. Iron sucrose
(Deep IM – upper outer quadrant of gluteal region – Z technique)
iv. Formula
 0.3 × weight (lb) × (100-Hb%) + 50% dose for stores
(1 amp → 2 ml & 1 ml → 50 mg elemental Iron)
 4.4 × weight (kg) × (14 – Hb%) + 500 mg for pregnancy
[Suspend Oral Fe <24 hours before injection to avoid reaction]
v. TDI – Total Dose of Iron IV Fe for cases of painful IM injection (1 sittingi).
It takes 4 – 9 weeks for Hb% to increase, 8 – 10 drops/min over 6 hours
after test dose.
3. BLOOD TRANSFUSION
a. Indications
i. Severe anemia – <7 gm%
ii. >36 weeks when no time to act.
iii. Severe anemia due to acute hemorrhage.
iv. Thalessemia.
b. 1 unit increases Hb% by 1 gm%.
c. Reactions
i. Immune – Anaphylaxis, Acute/delayed hemolysis.
ii. Non-immune – Infections, Hypothermia, citrate toxicity, DIC.
(Obstetric problem – patient goes into labour)
SIGNS OF IMPROVEMENT
1. Sense of well being with an increased appetite
a.
b.
Due to release of endorphins in brain
Phagocytic activity of neutrophils require peroxidase enzyme which requires Fe
for catalysis.
c. Increased Oxygen carrying capacity shifts anaerobic to aerobic respiration.
2. Hb% increases (rate of 0.7 mg/100 ml/week).
3. Reticulocyte Count increases (stained with cresyl blue).
INDICATIONS FOR GIVING FeSO4 TABLETS AS SUGGESTED BY THE WHO:
1. Pregnancy.
2. 1st 6 months after Delivery.
3. After inserting Copper T.
4. After Tubectomy.
NOTE:
1. Why is it called Physiological Anemia?
2.
3.
4.
5.
6.
7.
a. Occurs in every women.
b. Can’t prevent even with Iron supplementation.
Management is based on severity of anemia and duration of pregnancy.
a. Mild – Fe supplementation.
b. Moderate (7-9 mg)
i. If delivery is within the next 4 weeks – Blood Transfusion.
ii. If delivery is not within the next 4 weeks – Fe Supplementation.
c. Severe – Blood Transfusion.
Obstetric Management – when patient is in labour
a. Not in failure.
b. In failure – Take Physician’s help.
Hb% estimation in pregnancy
a. 1st ANC visit.
b. 28th week.
c. 36th week.
Raise in Hb%
a. Oral Fe – 0.7 g/dl/week.
b. Parenteral – 0.7 – 1 g/dl/week.
Situations in Obstetrics where we get Pulmonary Edema
a. Anemia.
b. PIH.
c. Any Cardiac disease.
d. Tocolytic use.
e. Thyrotoxicosis
Obstetric Management
a. 1st Stage
i. Monitor Pulse, BP, RS, CVS, fluids, start a wide bore IV line and draw
blood for investigations.
ii. Strict asepsis, IV started.
iii. Left lateral position or propped up if in failure.
iv. Keep Oxygen ready.
v. Monitor uterine contractions.
vi. Monitor fetus and mother + partogram.
b. 2nd Stage
i. Cut short the 2nd Stage.
ii. IV Methergin (CI if in failure).
c. 3rd Stage
i. Clamping the cord
1. Not in failure – early clamping.
2. In failure – Late clamping.
ii. Replenish blood loss by transfusion if severe anemia.
iii. Active Management.
iv. Episiotomy suture.
d. Peurperium
i. Continue Parenteral Antibiotics for 2-3 days/
ii. Early ambulation (DVT).
iii. Discharge by 7 days.
8. Test dose for
a. IM – Few drops of deep IM, wait for a fem minutes, if no reaction, then full dose is
given.
b. IV – Take 0.5 ml in a 5 ml syringe, pass into the vein and pull 5 ml blood and inject
the same into vein and look for reaction.
9. Blood Loss with Worm Infestation per day
a. Necator amaricans – 0.03 ml/worm/day
b. Ankylostoma duodenale – 0.20 ml
Fe REQUIREMENT DURING PREGNANCY:
1. Expansion of RBC
→ 400 mg
2. Fetus & placenta
3. Basal losses
→ 300 mg
→ 200 mg
Total
→ 900 mg ~ 1 gm + 300 mg lost during delivery.