Anemia in pregnancy

1. Anaemia in Pregnancy
Assessor : Dr NgYee Ling
26 July 2020 Nur Asyikin

2. What happens in pregnancy
• Physiological expansion of plasma volume
- from 1st trimester and plateaues by 3rd trimester
- which exceeds the increased production of red blood cells and haemoglobin.
• Results in haemodilution fall in Hb during pregnancy
• Most common cause of anaemia in pregnancy = iron deficiency

3. Causes of anemia in pregnancy
• Nutritional aneia- Iron deficiency, folate deficiency, B12 deficiency
• Chronic blood loss – hemorrhoids, GI Bleeding
• Short birth intervals
• Infection- HIV, Malaria
• Hematological conditions- Leukemia, Sickle cell disease,Thalassaemia

4. Threshold for Anaemia
• First trimester : <11.0 g/dL
• Second trimester & third trimester : <10.5 g/dL
• Postpartum : 10.0 g/dL
Regular antenatal iron
supplementation is important
to prevent Anaemia in pregnancy

5. Clinical effects
• Maternal fatigue poorer QoL increased risk of postpartum depression
• Risk of postpartum hemorrhage
- (due to impaired uterine contractility due to reduced availability of oxygen)
• Risk of maternal mortality (if severe anaemia)

6. Pregnancy outcome
• High risk of perinatal and neonatal mortality
• Low birth weight
• Premature birth
• Low Apgar score
• Potential neurodevelopmental impairment in the fetus
- impaired motor, cognition and language development

8. Clinical symptoms and signs
SYMPTOMS
- Fatigue
- Dizziness
- Headache
- Palpitations
- Restless legs
- Irritability
- Poor concentration
- Hair loss
SIGNS
- Pallor
- Weakness
- Dyspnoea

9. LaboratoryTesting
• low Hb, MCV, MCH and MCHC
• low serum ferritin is diagnostic of iron deficiency in pregnancy
(<30microgram/L)
• Iron studies if necessary (transferrin,TIBC, serum Iron)
• Haemoglobin concentration (at booking and at around 28 weeks’ gestation)

10. Oral IronTherapy
• Oral Iron preparations : effective, cheap and safe way to replace iron
• A trial of iron therapy for simultaneous diagnostic and therapeutic purposes
• A rise in Hb should be demonstrable by 2 weeks and supports the diagnosis of
iron deficiency
• Women who are haemoglobinopathy carriers should have serum ferritin testing
prior to iron administration
- to confirm concomitant iron deficiency and exclude iron overload

11. Management of Iron Deficiency
• Dietary advice
- daily iron intake from food = 10 mg (10–15% is absorbed)
- Capacity for absorption is enhanced in pregnancy but physiological iron
requirements increases
- from 1–2 mg to 6 mg per day as pregnancy advances
- In iron deficient women, repletion through diet alone is not possible and oral
supplementation is needed

12. How to take Oral Iron Supplements?
• Daily folic acid (400 µg) is required < 12 weeks’ gestation neural tube defects.
• 40–80 mg every morning is suggested, checking Hb at 2–3 weeks to ensure an adequate
response
- Why morning? - Hepcidin levels are lowest in the morning
• Oral iron supplementation should be taken on an empty stomach
- Why? absorption is reduced/promoted by the same factors that affect absorption of dietary non-
haem iron
• Compliance and intolerance = the usual factors limiting efficacy.
- Iron salts may cause gastric irritation, nausea and epigastric discomfort
- For nausea and epigastric discomfort - alternate day dosing or lower iron content should be tried

13. Iron Supplement in pregnancy women
• WHO Guideline
• Daily oral iron and folic acid supplementationis recommended as part of the antenatal
care to reduce the risk of low weight, maternal anemia and iron deficiency
• Dose- 30-60mg of elemental iron per day
• 400mcg of folic acid per day
• Malaysia Guideline
• Malaysia clinical practice guideline 2007
• Malaysia Perinatal care Manual
• 100mg elemental iron /day

14. Preparation Elemental iron content ( mg/tablet)
Obimin 30mg ferrous sulphate
Ferrous Fumarate 200mcg 60mg ferrous fumarate
Iberet 105 mg ferrous sulphate
Zincofer 115 mg ferrous fumarate
Maltofer 100mg ferric hydroxide polymaltose
Iron dextran ( IM or IV ) 50 mg /ml
Iron sucrose ( IV) 20 mg / ml

15. Intravenous iron therapy
• Advantages :Achieved Hb target, Fewer side effects
• Indication :
• when there is absolute noncompliance
• with, or intolerance of, oral iron therapy or proven
• malabsorption or when a rapid Hb response is required.
• Contraindication :
• history of anaphylaxis or serious
• reactions to parenteral iron therapy
• first trimester of pregnancy,
• active acute or chronic bacteraemia
• Decompensated liver disease
• Adverse Effects :
• Hypophosphataemia (particularly ferric carboxymaltose)
• Haemosiderin skin staining ( due to extravasation)

16. How to calculate?

18. Postpartum Anaemia
• Hb <100 g/l (However, clinical assessment is necessary for every patient)
• When should Hb be repeated?
• Women with blood loss >500 ml
• Uncorrected anaemia detected in the antenatal period
• Those with anaemic symptoms postnatally
• Oral iron should be offered to
• Women with Hb <100 g/l within 48 h of delivery, and
• Haemodynamically stable, either
• Asymptomatic, or mildly symptomatic

19. Thank you