ANEMIA IN PREGNANCY

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Anaemia in pregnancy

• Dr.Isaac Makanda
• MD,Mmed

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Objectives of the session

• Define anaemia in pregnancy
• Describe the magnitude of anaemia in pregnancy-
  globally and in Tanzania
• Explain the underlying causes of anaemia,
• Describe the clinical presentation, complications
  and the management of anaemia in pregnancy

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Outline

• Definitions
• Magnitude of the problem
• Factors contributing to anaemia in pregnancy
• Types of anaemia
• Clinical presentation
• Complications of anaemia in pregnancy
• Management

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Definitions- (WHO)

• Anaemia in pregnancy is defined as Hblt11g/dl
• Moderate Hb 7.0-10.9)
• Severe anaemia Hblt7g/dl
• Very severe anaemia Hblt4g/dl

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Magnitude of the problem

• Anaemia in pregnancy is highly prevalent
• Developing countries 56, developed countries
  -18, Africa 50-60

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Magnitude in Tanzania

• Anaemia is a very common complication of
  pregnancy
• According to the Demographic and Health survey
  (DHS 2005)
• 58 of pregnant women were anaemic
• Studies in DSM
• 57 DHS 2021
• prevalence among pregnant women at booking was
  60
• Among primigravida 75 (Massawe et al 1996,1999)

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Magnitude Contd

• Anaemia is the number one reason for admissions
  during the antenatal period in several
  hospitals in Tanzania.
• Contributes directly and indirectly to maternal
  morbidity and mortality

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Factors contributing to the high prevalence of
anaemia in pregnancy

• Increased nutritional demand for
• Growing foetus and placenta
• Increased maternal Red blood cell mass
• Nutrients include mainly iron, and folic acid,
  and other vitamins
• Plasma volume increases by 50, and RBC mass
  25.This leads to haemodilution which reaches
  maximum about 32-34 weeks of gestation.

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Underlying factors contd..

• This so called physiological or dilutional
  anaemia is not pathological and is of no
  significance in well fed women
• Inadequate dietary intake nutritional deficiency
• Poor diet lacking essential nutrients for
  haemopoesis- i.e iron and folic acid
• Poor appetite- e.g excessive vomiting
• Acute chronic infections
• Inadequate absorption (malabsorption this is rare)

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• Excessive iron loss ( blood loss)
• parasitic infestations- mainly hookworm,
  schistosmiasis
• heavy menstrual loss prior to pregnancy
• Malaria
• -pregnancy women are more susceptible to
  malaria especially during first pregnancy

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Factors contd..

• Chronic nutrient depletion
• High parity especially frequent closely
  spaced births
• Multiple pregnancy- increased demand of
  nutrients (iron,folic acid vit B
• Underlying infections e.g UTI,HIV,TB

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Aetiological types

• Often multi-factorial
• Iron deficiency
• Folic acid deficiency
• Combined deficiencies
• Haemolytic anaemia - due to malaria
• Anaemia of chronic infections- e.g
  HIV/AIDS,pyelonephritis TB etc
• Hemoglobinopathies, eg sickle cell anaemia

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What happens

• With anaemia,there is reduced number of
  circulating red blood cells (RBC) leading to
  reduced oxygen-carrying capacity which is
  insufficient to meet physiological needs,which
  consequently will vary by age, sex,
  altitude,smoking,and pregnanct status.
• Hemoglobin concentration is the most common
  hematological assessment method used to define
  anemia

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Physiological anaemia of pregnancy

• During pregnancy,maternal plasma volume expands
  by 50 an increase of approximately 1.200mls by
  term.
• Most of the increase takes place by 32nd to 33rd
  weeks gestation and thereafter there is
  relatively little change
• The total increase in red blood cell is
  approximately 25 about 300mls which occur late
  in pregnancy.

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Physiological anaemia of pregnancy.

• This relative haemo-dilution produces a fall in
  haemoglobin concentration, thus presenting a
  picture of iron deficiency
• These changes have been found to be a
  physiological alteration of pregnancy necessary
  for the development of the fetus

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Erythropoesis

• In adults,erythropoiesis is confined to the bone
  marrow.red blood cells are formed through stages
  of pronromoblasts? normoblasts?Reticulocytes?natur
  e nonnucleated erythrocytes
• The average life-span of red cells is about 120
  days after which they degenerate and the
  haemglobin are broken into haemosiderinand bil
  pigment

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Iron requirements in pregnancy

• Approximately 1,500 mg of iron is needed during
  pregnancy for
• Increase in maternal haemoglobin (400-500mg),
• The fetus and placenta (300-400mg),
• Replacement of daily loss through urine,stool,and
  skin (250mg),
• Replacement of blood loss at delivery(200mg)

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Iron and folic acid requirement in pregnancy

• Elemental iron -30 to 60mg /day
• Folic acid -400µg(0.4mg)
• It is recommended for pregnant women to prevent
  maternal anaemia, puerperal sepsis ,low birth
  weight ,and pretem births

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Clinical presentation

• Anaemia may be asymptomatic and symptoms appear
  when the anaemia is already severe
• Symptoms and signs are not very specific
• The general complaints are fatigue, and
  listlessness, dizziness, palpitations,dyspnoea,
  orthopnoea,
• Signs include pallor of the conjunctiva, tongue,
  buccal mucosa, palms, nail beds etc,
  tachycardia,tachypnoea, gallop rhythm

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Signs contd..

• Pallor of the mucous membranes, and palms
• May have angular stomatitis,glossitis, reflecting
  chronic nutrient depletion especially vitamins
• Koilonychia in long standing severe anaemia of
  iron deficiency type
• May be jaundiced

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Complications of anaema in pregnancy

• MOTHER
• Severe anaemia may cause cardiac failure and
  death
• Dangerous time is during labour when there is
  increased work of the heart
• After delivery when shunting of the blood from
  placental bed results in volume overload
• Reduced tolerance to blood loss. Minimal blood
  loss may precipitate hypovolaemia and collapse

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Complications contd..

• Reduced resistance to infection especially during
  the puerperium, and thus susceptible to puerperal
  infections
• Decreased work capacity
• Poor ability to lactate

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Complications contd..

• FOETUS
• Abortion
• Premature delivery
• Intrauterine growth retardation
• Stillbirth
• Thus anemia in pregnancy causes increased
  maternal morbidity and mortality and perinatal
  morbidity and mortality

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Management of anaemia in pregnancy

• Diagnosis
• Thorough history taking is very important
  enquire about the symptoms
• History of any of the possible underlying
  factors- e.g dietary history, hookworm
  infestations ( sanitary environment at home),
  malaria, etc
• Social economic situation- education level income
  and employment status,housing status,
  environmental sanitation etc

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Diagnosis contd

• Clinical Examination
• -General examination
• -Systemic examination

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Clinical examination

• Signs includes( depending on severity)
• Tachycardia, gallop rhythm
• Raised JVP
• Puffiness
• Tachypnoea
• Basal crepitations

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Diagnosis contd..

• Thorough examination of the Cardiovascular and
  respiratory system
• aim is to exclude heart failure
• Abdominal examination- exclude liver enlargement
  and tenderness and spleen enlargement

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Diagnosis contd..

• Investigations-establish the cause
• Full blood count and RBC indices
• Haemoglobin-determine the severity of anaemia
• -peripheral blood smear
• -Red cell indices- microcytosis, hypochromia-
  reflects iron deficiency anaemia.
• - Megaobablastic- folic acid deficiency
• Blood slide for malaria parasites

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Investigations contd..

• Stool analysis
• Urine analysis
• Sickling test if indicated
• Bone marrow if indicated
• Other tests as dictated by the clinical condition

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Treatment

• Depends
• on underlying cause
• Gestation age at diagnosis
• Severity of anaemia

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Treatment contd..

• Screen all pregnant women for anaemia
• Operational cut off level for referral for
  investigations and treatment in Tanzania is
  Hblt8.5g/dl
• This should not be confused with the definition
  of anaemia!
• Referral is from a primary level e.g health
  centre and dispensary to a higher level of care (
  district regional or consultatnt hospital

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Treatment contd..

• NOTE
• About 18-20 of pregnant women have Hb lt8.5
  at booking
• Deterioration of Hb level if appropriate
  treatment is not instituted
• The objective of treatment is to correct anemia
  before term and before they go into labour

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Prophylaxis

• All pregnant women
• Iron- ferrous sulphate 1 tablet twice a day
• Folic acid 1 tablet once a day
• Intermittent presumptive treatment (IPT) for
  malaria with SP three during pregnancy
• De-worming once during the second trimester

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TREATMENT contd

• lt36 weeks moderate anaemia- oral treatment of
  underlying cause
• Including iron, folic acid, malaria treatment,
  and de-worming if indicated.
• Consider parentral iron if oral treatment is not
  tolerated, monitor Hb response
• Treat any other infection

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Treatment contd..

• Severe at any gestation- is an emergency admit
• Thorough history and examination
• Exclude cardiac failure
• Give blood transfusion-
• Precautions-give diuretic before transfusion
• Transfuse slowly
• NB blood transfusion may precipitate cardiac
  failure

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Treatment contd..

• Moderate anaemia gt 36 weeks
• Admit
• Investigate
• Quickly correct anaemia
• May need transfusion if operative delivery is
  anticipated
• ( Individualize treatment)

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Treatment Contd

• Very Severe anaemia in Cardiac failure is an
  obstetric emergency
• Transfusion is necessary and urgent
• Use packed cells or sediment cell and discard the
  serum
• Give a fast acting diuretic- e. g furosemide or
  ethacranic acid before transfusion

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Severe anaemia in labour.

• Nurse in a propped up position
• If in labour assist the second stage of labour
• Avoid ergometrine

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Severe anaemia in labour

• Nurse patient in propped position
• Give oxygen 2-2.5 littres/min.
• Draw blood for grouping/cross match.
• Give morphine to allay anxiety
• Catheterize
• Give furusemide 40-80mg to decongest the heart
• Assist second stage with vaccum or forceps

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Cont.

• Do active management of the third stage of labour
  
• Ie give oxytocine immediatelly after delivery.
• Deliver the placenta by controlled cord traction
• Inspect placenta for complete ness

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• Inspect for tears perineum/cervix
• Continue massaging the uterus
• Transfuse-packed cell volume 24 hrs post
  delivery slowly for 4hrs .

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Indications of urgent Blood Transfusion

• Very severe anaemia in heart failure
• Very severe anaemia with evidence of hypoxia
  (respiratory distress)
• Very severe anaemia with evidence of continuing
  bleeding

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cont

• Mother whose Hb is below 7g/dl before a caesarean
  section
• The Hb is below 7g/dl and the mother gt36 weeks of
  GA

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Prevention

• Anaemia in pregnancy is preventable!
• Early booking antenatal care
• Early clinical diagnosis investigations and
  treatment
• Provide prophylaxis to all women
• Malaria treatment and IPT
• Give nutritional education
• Family planning reduce frequent births and
  nutrient depletion

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Prevention contd..

• General environmental measures
• Control malaria, and hookworm
• Promote and ensure adequate nutrition to all
  women in reproductive age
• Promote adequate food production and thus
  household food security at national level

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• END

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Home work

• Mention fetal complication of anaemia in
  pregnancy.
• Discuss managent of a woman with severe anaemia
  in labour
• Discuss prevention of anaemia in pregnancy.