Management of Anemia in Pregnancy, Labour and puerperium

Anemia in Pregnancy:
Anemia is the commonest hematological disorder that may occur in pregnancy.
According to the standard laid down by WHO 1993, anemia in pregnancy is present when
the hemoglobin concentration in the peripheral blood is 11gm /100 ml or less. During
pregnancy plasma volume expands (maximum around 32 weeks) resulting in
hemoglobin dilution. For this reason, hemoglobin level below 10 gm/dl at any time
during pregnancy is considered anemia. Hb level at or below 9gm/dl requires details
investigations and appropriate treatment.
Anemia is a reduction in the oxygen carrying capacity of the blood which may be caused
by a decrease in red blood cells production or reduction in hemoglobin concentration
in the blood or combination of both.
Incidence:
o Incidence of anemia in pregnancy ranges widely from 40-80% compared to 1020% in the developed countries.
o In Nepal 15-49 years women 36% exhibiting anemia and among pregnant women
2 out of 5 women are anemic. (DHS 2007).
o Anemia is responsible for 20% of maternal deaths in the third world countries/
developing countries.
Classification:
The anemia may be classified in various ways;
Physiological anemia of pregnancy
Pathological
o Deficiency anemia: Iron deficiency anemia, Folic acid deficiency anemia, Vit.
B12 deficiency anemia and Protein deficiency anemia.
o Hemorrhagic anemia: Acute- following bleeding in early months or APH and
Chronic- hookworm infestation, bleeding piles etc.
o Hereditary: Thalassemias: sickle cell hemoglobinopathies and other
hemoglobinopathies, hereditary hemolytic anemia (RBC membrane defects
spherocytosis).
o Bone marrow insufficiency: Hypoplasia or aplasia due to radiation, drugs
(aspirin, indomethacin).
o Anemia of infection( malaria, TB)
o Chronic disease ( Renal ) or Neoplasm
However, the obstetricians are more concerned with two common types of anemia;
o The deficiency anemia
o Hemorrhagic anemia

Physiology of anemia in pregnancy:

During pregnancy, the blood volume is markedly increased. The blood volume starts to
increase from about 6th week, expands rapidly thereafter to maximum 40-50% above the
non pregnant level at 30-32 weeks. The rate of increase of plasma almost parallels to
that of blood volume but maximum is reached to the extent of 50% and RBC is increased
to the extent of 20-30%.
There is disproportionate increase in plasma volume, RBC volume and hemoglobin mass
during pregnancy. In addition, there is marked demand of extra iron during pregnancy
especially in the second half. Even an adequate diet can not provide the extra demand of
iron. Thus, there always remains a physiological iron deficiency state during pregnancy.
As a result there is not only a fall in hemoglobin concentration and hematocrit value in
the second half of pregnancy but there is also associated low serum iron, increased iron
binding capacity and increased rate of iron absorption as found in iron deficiency
anemia. Thus, the fall in the hemoglobin concentration during pregnancy is due to
combined effect of haemodiluation and negative iron balance.

Principle blood changes during pregnancy

Non
pregnancy near
total
Contents
pregnant
term
increment
Change
blood volume(ml)
4000
5500
1500 +30-40%
Plasma volume(ml)
2500
3750
1250 +40-50%
Red cell volumeml)
1400
1750
350 +20-30%
Total Hb (gm)
475
560
85 +18-20%
Hematocrit (whole
body)
38%
32%
Diminished

Normal blood values in non pregnant and pregnan

state
Contents
hemoglobin
RBC

Non pregnant
14.8gm/100ml
5 million/cumm

2nd half Pregnancy

11-14gm/100ml
4-4.5million/mm3

packed cell volume or HCT

Mean corpuscular Hb(MCH)
Mean corpuscular
volume(MCV)
Mean ,, Hb
concentration(MCHC)
Serum Iron
Total iron binding capacity
saturation%

39-42%
27-32micromicro(pg)

32-36%
26-31pg

75-100cu. Micron

75-95 cu. Micron

32-36%
60120microngram/100ml
300350microngram/100ml
30%

30-35%
6575microngram/100ml
300400microngram/100ml
16%

Criteria of physiological anemia

The lower limit of physiological anemia during the second half of pregnancy should
fulfill the following hematological values:
o Hb 10gm%
o RBC 3.2 million/mm3
o PCV 30%
o Peripheral smear showing normal morphology of the RBC with central pallor.
Causes of Anemia:
Iron deficiency anemia is very much prevalent amongst women of child bearing age
especially in the under privileged sector. In a healthy individual, a daily intake of dietary
iron 15mg can replenish the daily loss of about 1.5mg of iron assuming an absorption rate
of 10%. But especially with low socioeconomic group, the daily requirement is likely to
be more because of the following;
Faulty dietetic habit: there is no deficiency of iron in the diet but the diet is in rich
carbohydrate. High phosphate and phytic acid help in the formation of insoluble
iron phosphate in the gut, thereby reducing the absorption of iron.
Faulty absorption mechanism: because of high prevalence of intestinal infestation,
there is intestinal hurry, which reduces the iron absorption.
Iron loss:
o More iron is lost through sweat to the extent of 15 mg per month.
o Repeated pregnancy at short intervals along with a prolonged period of
lactation puts a serious strain on the iron reserve. It has been estimated
that a normal healthy woman with adequate diet takes about two years
to replenish about 1000 mg of iron lost during childbirth and lactation
o Excessive blood loss during menstruation which is left untreated and
uncared for

o Hookworm infestation with consequent blood depletion to the extent

of 0.5 -2 mg of iron daily

o Chronic malaria, chronic blood loss due to bleeding piles and

dysentery also cause iron deficiency anemia.
Causes during pregnancy
The woman, who has got sufficient iron reserve and is on a balanced diet, is unlikely to
develop anemia during pregnancy in spite of an increased demand of iron. But if the iron
reserve is inadequate or absent, the factors which lead to the development of anemia
during pregnancy are:
Increased demand of iron: the demand of iron during pregnancy is markedly
increased. An adequate balanced diet contains not more than 18-20mg of iron and
assuming that the absorption rate is increased by two folds (20%), the demand is
hardly fulfilled.
Diminished intake of iron: apart from socioeconomic factors, faulty dietetic
habits, loss of appetite and vomiting in pregnancy are responsible factors.
Disturbed metabolism: apart from the faulty absorption mechanism just
described, pregnancy depresses the erythropoitic function of the bone marrow.
Presence of infection markedly interferes with the erythropoiesis; one should not
even ignore the presence of asymptomatic bacteriuria.
Pre pregnant health status: majority of the women actually start pregnancy on a
pre-existing anemia state or a least with inadequate iron reserve. It is the state of
the stored iron which largely determines whether or not and how soon a pregnant
woman will become anemic.
Excess demand:
oMultiple pregnancy- increased the iron demand by two folds
oWomen with rapidly recurring pregnancy- within two years following the last
delivery, need more iron replenish deficient iron reserve.
oThe demand of iron which accompanies the natural growth before the age of 21
should not be under-estimated, specially where teenage pregnancies are quite
prevalent. At the age of 17, the additional demand is estimated to be about
270mg during the course of pregnancy; the requirement is, however brought
down to nil at the age of 21.
oAnother important problem posed by anemia in pregnancy is its polymorphism.
Pregnancy tends to interfere with maternal erythropoiesis by competing for
the available raw materials such as folic acid, vitamin B12 proteins, apart
from iron

Iron deficiency Anemia

Iron deficiency in women is usually due to blood loss resulting from excessive
menstruation, post partum hemorrhage or iron deprivation form previous pregnancy.
About 95% of pregnant woman with anemia have the iron deficiency.

Clinical Features:
The clinical features depends more on the degree of anemia than anything else. In the
majority, the patients have got on symptom and the entity is detected accidentally during
examination. However, the following features may develop slowly.
Symptoms:
o Lassitude and feeling of exhaustion or weakness may be the earliest
manifestation.
o The other features are anorexia and indigestion; palpitation caused by ectopic
beats, dyspnoea, giddiness and swelling of the legs.
On Examination:
oThere is pallor of varying degrees; evidence of glossitis and stomatitis
oOedema of the legs may be due to hypoproteinemia or associated pre- eclampsia
oA soft systolic murmur may be heard in the mitral area due to physiological mitral
incompetence
oCrepitations may be heard at the base of the lungs due to congestion.
Investigations:
The patient having a hemoglobin level 9 gm % or less should be subjected to a full
hematological investigation. The objectives of investigation are to ascertain:
Degree of anemia:
This requires hematological examination which includes estimation of Hb, Total RBC
counts, packed cell volume. All these help not only to identify the physiological
anemia but also to note the degree of pathological anemia.
7-11 mild, less than 7 is severe. (national medical standard Vol. III)
Type of anemia: peripheral blood smear
To study the morphology of the red cells gives a better idea, about type of anemia,
hematological indices MCHC, MCV and MCH is based on the value of Hb
estimation, total red cells count, and PCV.
Cause of anemia:

Examination of stool to detect helminthes infestation (particularly hookworm)

infestation, urine examination for the presence of protein, sugar and pus cells.
When definite diagnosis as to the cause of anemia can not be made with the above,
further investigations may be directed according to the clinical findings. This may
necessitate x-ray chest in suspected pulmonary tuberculosis, fractional test meal
analysis of gastric juice to find out achlorhydria in pernicious anemia. Bone marrow
study can be done if cases not responding to therapy according to hematological
typing, to diagnose kala- azar and hypoplastic anemia.
Treatmentaa
In the tropics, majority of cases with iron deficiency anemia in pregnancy have a low
socioeconomic status. The anemia is either pre-existing or is aggravated during
pregnancy.
Prophylaxis:
Avoidance of frequent child-birth:
A minimum interval between pregnancies should be at least two years to replenish the
lost iron during child-birth process and lactation.
Supplementary iron therapy:
Even with a well balanced diet, supplementary iron should be a routine after the patient
becomes free from nausea of pregnancy. Daily administration of 200mg of ferrous
sulphate along with 1mg folic acid is a quite effective. Tea and calcium should be avoided
within one hour of taking iron tablet.
Dietary prescription:
A realistic balanced diet, rich in iron and protein should be prescribed which should be
within the reach of the patient. The foods rich in iron are liver, meat, egg, green
vegetables, green peas, figs beans, whole wheat and green plantains, onion etc.
Adequate treatment Should be instituted to eradicate hookworm infestation, dysentery,
malaria, bleeding piles and urinary tract infection
Early detection of falling hemoglobin level is to be made. Hb level should be estimated
at the first antenatal visit, at the 30th and finally at 36th week.
Curatives
Anemia is not a disease but a sign of an underlying disorder. Treatment must be preceded
by an accurate diagnosis of the cause of anemia and type of anemia.
1.Hospitalization: - Ideally all patients having hemoglobin level 9 gm/100 ml/ or less
should be admitted for investigation and treatment. But due to high prevalence of anemia

and inadequate hospital beds, an arbitrary hemoglobin level of 7.5 mg% may be
considered.
2.General treatment :o Diet A realistic balanced diet rich in proteins, iron and vitamins and which is
easily assailable is prescribed.
o To improve the appetite and facilitate digestion, preparation containing acid
pepsin may be given thrice daily after meals.
o To eradicate even a minimal septic focus by appropriate antibiotic therapy.
o Effective therapy to cure the disease contributing to the cause of anemia.
3.Specific Therapy
The main principle is to raise the hemoglobin level as near to normal as possible. The
choice of therapy depends on severity of anemia, duration of pregnancy and associated
complicating factors.
a.Iron Therapy
--Oral therapythe initial dose of ferrous sulphate is 1 tab (200 mg) which containing
60mg of elemental iron thrice daily after meals, if larger dose necessary maximum 6 tbls
a day can be given but it should be stepped up gradually in 3-4 days.
Maintenance dose of 1 tab daily is to be continued for at least 100 days following
delivery to replenish the iron stores.
Contraindications of oral therapy
o Intolerance to oral iron.
o Severe anemia in advanced pregnancy. Considering the unpredictable absorption
and utilization following oral therapy.
Therapy
o Intravenous
Total dose infusion (TDS: the deficit of iron is first calculated and total amount of
iron required to correct the deficit is administered by a single sitting intravenous
infusion. The compound used is iron dextran compound, 1ml of which contains
50gm element iron and one ampoule contains 2ml or 10ml.
Estimation of the total requirement
0.3x wt (100-Hb %) mg of element iron. where W = pts weight in pounds. Hb%=
observed hemoglobin concentration percentage. Additional 50% is to be added for
partial replenishment of the body store iron.
Eg. 0.3x100(100-50)= 3/10x100x50 =1500mg add 50% = 750mg
Total element iron required 2250mg.
Procedure
o The patient is admitted in the morning for infusion.
o The required iron is mixed with 500ml of 0.9% saline. If the required
amount of iron is more than 50ml (1ml= 50 mg of iron), then the total
dose is to be infused on two consecutive days, infusing half the total
amount in each day.

o Precautions like those of blood transfusion are to be taken both prior to

and during the infusion process.
o The drip rate should be 10 d/ min during first 20 min and thereafter is
increased to 40 d/min.
o Intramuscular
Iron -dextran (imferon)
Iron- sorbitol- citric acid complex in dextrin (iron sorbitol complex-jectofer).
Both the preparations contain 50mg of element iron in 1 ml. total dose to be
administered is calculated as IV therapy. Oral iron should be suspended at least 24 hrs
prior to therapy to avoid reaction.
b.Blood transfusion
The indications of blood transfusion
1.To correct anemia due to blood loss and to combat postpartum hemorrhage.
2.Patient with severe anemia seen in later months of pregnancy (beyond 36 weeks) to
improve the anemic state and oxygen carrying capacity of blood before the patient
goes into labour. The primary concern is not only to correct anemia but also to
make the patient fit to withstand the strain of labour and blood loss following
delivery.
3.Anemia not responding to either oral or parenteral therapy in spite of correct typing.
Management during labour
First stage
o The patient should be in bed and should lie in a position comfortable to her.
o Arrangements for oxygen inhalation are to be kept ready to increase the
oxygenation of the maternal blood and thus diminish the risk of fatal hypoxia.
o Strict asepsis is to be maintained to minimize puerperal infection.
Second stage
o Asepsis is maintained.
o Prophylactic low forceps or vacuum delivery may be done to shorten the second
stage.
o Provide oxygen inhalation to increase the oxygenation of the maternal blood and
thus diminish the risk of fatal hypoxia
o Prepare for active management of third stage.
Third stage
o Active management of third stage of labour.
o One should be very vigilant during third stage.
o Significant amount of blood loss should be replenished by fresh packed cell
transfusion.
o The danger of postpartum overloading of the heart should be avoided.
Puerperium

o Prophylactic antibiotics are given to prevent infection.

o Pre-delivery antianemic therapy should be continued till the patient restores
normal hematological stage.
o Even in an otherwise normal case, iron therapy should be continued for at least 3
months following delivery.
o Patient should be warned of the danger of recurrence in subsequent pregnancies.
Complications of severe Anemia
A.During Pregnancy:oPre-eclampsia may be related to malnutrition and hypoproteinaemia.
oIntercurrent infectionnot only does anemia diminish resistance to infection, but
also any pre existing lesion, if present will flare up. It should be noted that the
infection itself impairs erythropoiesis by bone marrow depression.
oHeart failure at 30-32 weeks of pregnancy.
oPreterm labour.
B.During labour:-

o Uterine inertia: - is not a common associate on the contrary the labour is short
because of a small baby and multiparity.

o Post partum hemorrhage is a real threat The patient tolerates badly even a
minimal amount of blood loss.
o Cardiac failure may be due to accelerated cardiac output which occurs during
labour or immediately following delivery.
o Shock even a minor traumatic delivery without bleeding may produce shock or
a minor hypoxia during anesthesia which may be lethal.
During Puerperium
There is increased chance of:1.Puerperal sepsis
2.Sub-involution
3.Failing lactation
4.Puerperal venous thrombosis
5.Pulmonary embolism
Risk periods
The risk periods when the patient may even die suddenly are:o At about 30-32 weeks of pregnancy.
o During labour.

o Immediately after delivery.

o Any time in the puerperium specially 7-10 days following delivery due to
pulmonary embolism.
Effects on baby
Amount of iron transferred to the fetus is unaffected even if the mother suffers from iron
deficiency anemia.
o There is increased incidence of low birth weight babies with its incidental
hazards.
o Intra uterine death due to severe maternal anoxaenmia.
o The sum of effect is increased perinatal loss.
Megaloblastic Anemia
In megaloblastic anemia, there is derangement in red cell maturation with the
production in the bone marrow of abnormal precursors known as megaloblast due
to impaired DNA synthesis. Thus it may be regarded as deficiency disease caused
by lack of either vit. B12 or folate or both. Vitamin B12 deficiency is rare in
pregnancy. Vit. B12 is first bound to intrinsic factor which is secreted by the
gastric parital cells. Thereafter it is absorbed in the distal ileum. Megaloblstic
anemia in pregnancy is almost always due to folic acid deficiency. The daily
requirement of vit. B12 in non pregnant condition is 2 micro gram and during
pregnancy is 3microgram. This amount is met with any diet that contains animal
products. Only the strict vegans, may need supplementation. Vit.B12 deficient
megaloblastic anemia is seen in women with gastrectomy or ileal resection or
with pernicious anemia.
Folic Acid Deficiency Anemia:
The folic acid deficiency during pregnancy is caused by:

Inadequate intake due to: nausea, vomiting and loss of appetite, dietary insufficiency (
sources- green leafy vegetables, cauliflower, spinach, liver, kidney)

Increased demand due to: increased maternal tissue including RBC volume,
developing product of conception. Daily requirement of folic acid in a non pregnant
woman is 50-100microgramm/day and during pregnancy is increased to
400microgram/day.

Diminished absorption: intestinal malabsorption syndrome is responsible for its

recurrence in subsequent pregnancies.

Abnormal demand: Twins, infection- reduces the life span of the RBC and hence
increases the demand of folic acid to replenish the red cells. Hemorrhagic states such
as peptic ulcer, hookworm infestation, hemorrhoids and the hemolytic states such as
chronic malaria sickle cell anemia or thalassaemias, lead to increased erythroposis

and exhaustion of the available supply of folic acid resulting in megaloblastic

erythroposis.

Failure of utilization: this associated with anticonvulsant drugs used in epilepsy or

with presence of infection

Diminish storage- this is associated with hepatic disorders and vit.C deficiency.

Iron deficiency anemia: correction of anemia by iron therapy alone ma aggravate folic
acid deficiency.

Clinical features;
o The onset is usually insidious and is first revealed in the last triminister or may be
acutely manifested in early puerperium.
o Anorexia or protracted vomiting
o Occasional diarrhea
o Unexplained fever is often
On Examination:
o Pallor of varying degree.
o Ulceration in the mouth (glossitis) and tongue
o Hemorrhagic patches under the skin and conjunctiva
o Enlarged liver and spleen which may be difficult to palpate due to an enlarged gravid
uterus.
o Features of pre-eclampsia may be present.
Hematological examination and other blood values: