2. Anemia:- is a common medical disorder
in pregnancy
• WHO estimate that 40% of pregnant women worldwide are anemic.
• WHO define anemia in pregnancy as hemoglobin less than 11 g/dl.
• Center of disease control define anemia in pregnancy as hemoglobin
less than 11g/dl in first and third trimester , and less than 10.5g/dl in
second trimester .
4. •Physiological changes :-
• Plasma volume increase 50%
• Red cell mass increase 25%
• Hb , haematocrit ,RBC count fall due to haemodilution
• MCV increase due to erythopoiosis
• MCHC remains stable,
• Total iron binding capacity increases.
5. • Serum iron and ferritin concentration decreases due to increased
utilization.
Iron requirements increase from 2.5 mg /day in 1st trimester to
6.6mg.day.
iron absorption moderately increase .
folate requirement increase.
6.
7.
8. Screening for anemia
• By routine estimation of Hb concentration by FBC at the
begging of pregnancy and later at the start of 3rd trimester and
the term.
• Its advantage that its cheap & simple
• But it lacks specificity and low Hb count does not reveal the
cause of anemia
9. Why screening is important during pregnancy?
• Severe anemia during pregnancy increases your risk of
premature birth, having a low birth weight baby and postpartum
depression
10. Common and important type of anemia
during pregnancy
• Iron deficiency anemia
• Megaloblastic anemia
• Sickle cell anemia
• Thalassemia
12. Diagnosis:
• Iron deficiency can present without anemia (reduced MCV,
MCH ) those are not as accurate and unreliable in pregnancy.
• Transferrin and iron transporter protein increase to deliver more
iron for tissue .
• Ferritin concentration <15 μg/dl is diagnostic for iron
deficiency ( not affected by pregnancy) but elevated in active
infection and inflammation.
13. 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.
• A serum ferritin level below 15μg/L is diagnostic of iron deficiency
• In those women at high risk of iron deficiency but who are not yet anaemic,
ferritin levels should be checked and oral iron started in those with ferritin
below 30 μg/L.
14. • What are the risk factors for iron deficiency anemia during
pregnancy?
• Have two closely spaced pregnancies
• Multigravida
• hyperemesis gravidar
• don’t consuming enough iron
• Have a heavy pre-pregnancy menstrual flow
• Have a history of anemia before pregnancy
15. Complication of iron deficiency anemia
• Maternal:
• impaired function of iron depending enzymes
• Increase risk of preterm delivery ,postpartum hemorrhage with
increased chance of blood transfusion
16. Fetal complication
• Increased risk of preterm delivery & IUGR.
• May affect neonatal iron status, cognitive development, and
behavior of babies
17. Treatment:
• The principles of treating iron deficiency are as follows:
• 1- establish cause.
• 2- correct deficiency.
• 3- replenish iron stores.
18. Iron deficiency in pregnancy cannot be corrected
through diet alone so iron supplementation is
necessary.
• Iron supplementation can be given by :
• Oral.
• Intramuscular.
• Intravenous .
19. • The optimal dose has not yet been established but the current.
recommendation in the UK is 100–200 mg elemental iron daily with
Hb level checked in 2 weeks.
Oral iron supplement
20. • Non‐anaemic women with low serum ferritin (<30μg/L) should be started
on 65mg of elemental iron daily with a repeat Hb and ferritin in 8 weeks.
• Postpartum women with Hb below 10g/dL who are haemodynamically
stable with minimal symptoms should be offered 100–200mg elemental
iron daily for 3 months to replenish iron stores.
21. Adverse effects of Iron therapy
1. nausea.
2. Vomiting
3. constipation
4. occasionally diarrhea (reduced by taking tablets after meals).
5. Abdominal pain
22.
23. If there is no response to oral supplement or intolerance start IV
supplement
• Intravenous iron preparations have no license for use in the first
trimester.
• They are relatively contraindicated in patients with chronic liver
disease or active infection.
• The risk of anaphylaxis is exceedingly rare but other non‐allergic
reactions occur in around 1 in 200 000.
Intravenous
24. • IM supplement
• Intramuscular iron is rarely used as it is painful.
• However, women whose Hb is less than 10 g/dL should deliver in
hospital , have intravenous access, a group and save available, and
active management of the third stage of labour to minimize bleeding.
25. Erythropoietin:
• Used in the following situations:
1. Erythropoietin deficient anemia(chronic renal failure)
2. Severe or progressing iron-deficiency anemia
3. Placenta previa (or placenta accreta)
4. Preoperative and postoperative patients
5. Autologous blood donation
6. Hemoglobinopathies.
7. Can be use in sever postpartum anemia .
26. Prevention and prophylaxis for IDA:
• advice on iron‐rich foods and factors that aid or increase absorption.
• Identification and treatment of iron deficiency prior to pregnancy.
• The recommended daily iron intake for pregnant women is 30 mg.
27. Megaloblastic anemia
• The marrow is usually hypercellular and the anemia is based on
ineffective erythropoiesis.
28. Common cause of megaloblastic anemia :
I. Folic acid deficiency
II. Vitamin B.12 deficiency
29. Folic acid
o It a vitamin which is water soluble, necessary for the production of
the RBC, WBC and platelets.
o the human body needs about 100-150 µg daily.
o It is absorbed in the Duodenum and Jejunum.
30. FOLATE DEFICIENCY
• Significant folate requirement in pregnancy due to increased
cell replication( fetus ,uterus, bone marrow).
• Folate concentration decreases throughout pregnancy.
• Folate deficiency causes megaloblastic anemia around 5% of
anemia.
31. Clinical feature :
• Persistent fatigue.
• Weakness lethargy.
• Pale skin.
• Shortness of breath.
• Irritability.
32. Cause of folic acid deficiency :
1. Increase demand (pregnancy)
2. Decrease intake (poor diet)
3. Decrease absorption (celiac disease)
4. Increase RBC production ( chronic hemolysis)
5. Alcoholism.
34. Diagnosis:
• Signs and symptom
• CBC (increase in MCV and MCH) .
• Serum folic acid ( normal range is 2.7 to 17 ng/ml) below the normal
range.
• Diagnosis is by examining blood film +/- bone marrow aspirate
35. • There is clear links between folate deficiency and NTD and
other anomalies .
• 400 μg/day should be taken 3 month prior pregnancy and
same dose continue till the end of 1st trimester ( N T is closed)
in a normal pregnant woman.
• may lead to malabsorption and exacerbate anemia.
36. Treatment
• 5mg folic acid daily .
.
• High risk group ( hemolytic anemia ,women taking
anticonvulsant drugs ) should be kept on 5mg daily oral folate
throughout pregnancy.
37. Vitamin B12 deficiency
• it is rare , associated with infertility.
• Vitamin B12 absorption is not affected by pregnancy,
38. Cause of B-12 deficiency :
• Insufficient intake
• Pernicious anemia
• Pancraetic insufficiency
• inflammatory bowel disease.
39. Clinical feature
• Fatige
• Lethergy
• headaches
• Pale skin
• Glove and stocking paraesthesiae
• Loss of ankle reflex
• Optic atrophy
40. Diagnosis :
• Clinical feature
• CBC ( not useful in pregnancy )
• Decrease level of vit.b12
• Both homocysteine and methymalonic acid increase
41. Treatment
• Diet containing animal products.
• Single IM injection of 1000 mg of vit.B12 weekly until anemia
improves .
43. Thalassemia
• Defect Hb synthesis either in alpha subunit or beta subunit
• Clinically classified into
1- minor(carrier)
2-intermedia
3-major(lifelong transfusion dependent)
44. Alpha thalassemia
• Patient with one or two alpha subunit deletion have a normal
pregnancy outcome.
• Carrier having microcytic hypochromic no evidence of anemia
• While 3 subunit deletion ranging from asymptomatic to transfusion
dependent , jaundice, hepatosplenomegaly , growth restriction
• Prophylactic folic acid 5mgday given.
• Anemia worsen by infections
45. Beta thalassemia
• Defect in B chain synthesis
• RBC destruction in spleen and bone marrow
• Major forms having splenomegaly skeletal deformities
• Only small number of successful pregnancies were reported
• During preganancy folic acid support is important
• Chelating agents are discontinued
• Fetal IUGR and oligohydromnia are common
46. Sickle cell anemia
• Preexisting sickle cell disease increases the risk of the following
• 1-infections (UTI , pneumonia…..)
• 2-pregnancy induced hypertension
• 3-HF
• 4-PE
• 5-preterm delivery
• 6- elampsia
47. management of sickle cell disease
• High dose folic acid
• Aspirin
• Rehydration during crises
• Antibiotics
• Analgesic
48. Reference
• OBSTETRICS by ten teachers 20th edition
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7477519/
• Dewhurst’s Textbook of OBSTETRICS & GYNAECOLOGY 9th edition
Anemia is defined as a decrease in the quantity of circulating red blood cells (RBC), represented by a reduction in hemoglobin concentration (Hb), hematocrit (Hct), or RBC count
90% of them have iron deficiency anemia
Folate deficiency about 5% and he almost always is the of megaloblastic anemia
Most common type of anemia
Iron deficiency can be present without anemia (reduced MCV, MCH, and MCHC ) those are not as accurate and unreliable in pregnancy
Iron and total iron binding capacity (TIBC) unhelpful as they are affected by factor such as recent iron ingestion and infection .
Transferrin and iron transporter protein increase to deliver more iron for tissue .
Ferritin concentration <15 μg/dl is diagnostic for iron deficiency ( not affected by pregnancy) but elevated in active infection and inflammation.
● In those women at high risk of iron deficiency but who are not yet anaemic, ferritin levels should be checked and oral iron started in those with ferritin below 30 μg/L.
Maternal:
1- that cause alteration in the function of muscle ,neurotransmitter activity
For most women oral replacement is the best option because it is effective, safe and inexpensive and can be started in primary care.
first week following initiation of iron therapy, there is often no rise in hemoglobin level but reticulocytosis is observed. Hemoglobin level usually starts rising in the second week . Hb rise by around 2g/dL every 3–4 weeks and treatment should continue for at least 3 months after Hb has normalized and until at least 6 weeks post partum.
To maximize absorption, patients should take tablets with orange juice on an empty stomach, avoid tea and coffee for an hour either side of the tablet and not take with other medications, especially antacids. However, if side effects do occur and lowering the dose does not help, it may be appropriate to take tablets with meals despite the reduction in absorption.
The older intravenous preparations do not raise Hb levels quicker than correctly taken oral iron. However, newer preparations such as iron carboxymaltose, which is given as a single dose over 15min, produces a faster response (approximately 10g/L improvement per week) so may be particularly beneficial for those women who present late in pregnancy.
There are several different iron preparations available and choice should be based on dose of elemental iron and side‐effect profile (Table 12.3). Around 10–20% of patients experience gastrointestinal side effects, which are mostly dose related.
patients who fail to respond to oral iron or who are truly intolerant we can use intravenous iron :
due to concerns that oxidative free radicals could cause toxicity to placental membranes.
The older intravenous preparations do not raise Hb levels quicker than correctly taken oral iron. However, newer preparations such as iron carboxymaltose, which is given as a single dose over 15min, produces a faster response (approximately 10g/L improvement per week) so may be particularly beneficial for those women who present late in pregnancy.
Intramuscular iron is rarely used as it is painful, has variable absorption and can cause permanent skin stain ing if not given correctly.With optimum care most women will no longer be anaemic at the point of delivery.
However, women whose Hb is less than 100 g/L should deliver in hospital (<95 g/L in an obstetrician‐led unit), have intravenous access, a group and save available, and active management of the third stage of labour to minimize bleeding.
Treated by :
Diets containing animal products
Single IM injection 1000 Mg VIT B12 weekly until anemia improve
