An outline on how to approach the problem of pregnancy anaemia from a clinical standpoint. Specially presented for the benefit of students and primary care physicians.

1. HERE’S A
LOW DOWN
ON
ANAEMIA IN
PREGNANCY
brought to you by
Associate Professor Dr Hanifullah Khan
!1

2. Objectives of this
presentation
•
To define & classify anaemia in pregnancy
•
To highlight the importance of anaemia in
pregnancy
•
To clinically identify anaemia in pregnancy
•
To outline the management
!2

3. Definition of
anaemia
A reduction in circulating
Hb mass below the
critical level can be
caused by multiparity
!3

4. Definition
•
A reduction in circulating Hb mass below the
critical level
•
•
•
Normal Hb between 12-14g%
WHO has accepted up to 11g% as normal
However in many developing countries the lower
limit is often accepted as 10g%
WHO 2007
!4

5. Definition -trimester specific
•
Haemoglobin level :
1st Trimester : < 11g/dL
2nd Trimester : < 10.5 g/dL
3rd Trimester : < 11g/dL
!5

6. Physiology
Haematological changes in
pregnancy
!6

7. Physiology
•
Haematological changes in pregnancy - geared
towards maternal & feral well-being, especially
during delivery
•
Physiological changes - raised serum transferrin &
Fe binding capacity
!7

8. Iron
•
•
Pregnancy - additional demand of 1000
mg of iron
Entering pregnancy with low maternal
iron stores - anaemia
= 300 mg
FeSO4 / 60mg
elemental Fe
daily
Fe supplementation may have to be instituted
Anemia resulting from inadequate iron supplementation
may result in obstetric complications like preterm
delivery and late miscarriages
Tan EK, Tan EL. Best Practice & Research Clin Obstet Gynaecol 2013
!8

9. Plasma volume
•
Plasma volume increases 30–50% in pregnancy
about 1200–1300 mls
•
This increase is higher in
Multigravidas
Twin pregnancy - can be as high as 70%
Tan EK, Tan EL. Best Practice & Research Clin Obstet Gynaecol 2013
!9

10. Blood volume
•
Increased volume necessary
to allow for increased blood flow to organs (uterus, kidney)
to counter blood loss at delivery
•
Beginning 7/52, peak increase around 30-34/52
•
At its maximum, intravascular volume is increased
to about 45% above normal levels = 1-2 L extra
Tan EK, Tan EL. Best Practice & Research Clin Obstet Gynaecol 2013
!10

11. RBCs
•
Increased RBC production (by erythropoietin)
•
18-25% rise above non-pregnant levels
Both plasma and red cell mass !
are increased in pregnancy
Tan EK, Tan EL. Best Practice & Research Clin Obstet Gynaecol 2013
!11

12. Dilutional anaemia
Increase in blood components
RBCs increase
18-25%
Plasma vol. increase
30-50%
The disproportionate increase results in a falling Hb as pregnancy
advances
anaemia most noticeable 30-34/52
Haematocrit also falls - decreased blood viscosity
Necessary to allow for easier blood flow
!12

13. Why should anaemia be
avoided in pregnancy?
This explains the risks of being pregnant with anaemia
!13

14. Summary
of
complica.ons
Complica)ons
•
Maternal
è Inability
to
withstand
haemorrhage
è
Risk
of
PPH
•
è Risk
of
Infec)on
è Risk
of
cardiac
failure
Fetal
!
è
è
è
è
Hypoxia
IUGR
Spontaneous
abor)on
Cogni)ve
delay
Nur Filzah, Toh Yee Shih, Beatrice Leong. CUCMS 2012
14

15. Maternal risks
•
During Antenatal period –
Poor weight gain, Preterm labour, PIH, placenta previa, APH,
eclampsia, PROM
•
During labour –
Dysfunctional labour, PPH, shock, anesthesia risk, cardiac failure
•
Maternal risk during postnatal period –
Postnatal sepsis, sub involution, embolism
!15

16. Fetal/Neonatal Risks
•
Complications include
Prematurity, low birth weight, poor Apgar score, fetal distress,
neonatal distress requiring prolonged resuscitation &
neonatal anemia
•
Infants with anemia have
Higher prevalence of failure to thrive, poorer intellectual
developmental milestones, and higher rates of morbidities
and neonatal mortalities than infants without anemia.
!16

17. Classification
Basic division of the causes of anaemia
!17

18. Summary
of
causes
of
anaemia
Physiological
anaemia
Causes
Excessive
RBC
Loss
Blood
Loss
placenta
praevia
abrup.on
prior
menorrhagia
Inadequate
RBC
Produc)on
Increased
RBC
destruc)on
(haemolysis)
extrinsic
-­‐
Infec.on,
medica.ons
in.nsic
-­‐
thalassaemia
18
iron
deficiency
folic
Acid
deficiency
anaemia
of
chronic
disease
thalassemia

19. Blood loss
Current pregnancy
Blood loss leading to anaemia
may occur in the index
pregnancy or in the past
•
Placenta praevia is the most obvious &
dramatic cause during the pregnancy
•
Concealed abruptio may also be a
cause
In the past
•
Inability to recover from recurrent
blood loss is a consequence of poor
pregnancy spacing
Other causes
•
•
•
•
•
Going into pregnancy with a prior
history of menorrhagia is another
cause
!19
Worm infestation (Hookworm)
•
Previous abortions
Haemorrhoids
•
PPH - anaemia in a subsequent
pregnancy
GIT blood loss - ulcer disease or drug
induced
Trauma

20. Increased destruction of
RBCs
•
Common causes & Type of haemolytic
anaemia in pregnancy
RBC destruction is called
haemolysis - this may occur
intra- or extravascularly
Condition
Thalassemia
G6PD deficiency
•
haemolytic anaemia can also
be inherited or acquired
Type
inherited
Pre-eclampsia
Hepatitis
Blood transfusion
NSAIDs
Malaria
!20
acquired

21. Decreased production of
RBCs
•
This may result either from a
lack of a necessary
component or defective stem
cell production
Common causes & RBC
features
Condition
RBCs
Fe deficiency
Chronic diseases
microcytic,
hypochromic
Nutritional anaemia is one of
the most common causes
Thalassemia
Vitamin B12 deficiency megaloblastic
!21

22. Nutritional Anaemia
i. Iron deficiency
ii. Folate deficiency
iii. B12 deficiency
Bone marrow failure
Nutritional
•
One of the most common causes of anaemia
Poor dietary intake or malabsorption causes this
•
Mainly due to iron & folate deficit. B12 deficiency is rare in
pregnancy
•
Folate requirement increased 2x in pregnancy - normal body
stores only last 4 months
Folate deficiency exacerbated by haemolysis - e.g. in thalassaemia, malaria
In cases of anaemia, taking a detailed
dietary history is very important!
!22

23. Nutritional anaemia - Fe deficiency
•
Fe deficiency - the commonest
cause of nutritional anaemia
usually as a result of poor diet
Sources of iron - meat (liver in particular),
vegetables, dairy products
•
Fe demand increases in pregnancy about 1g of iron required during a
normal pregnancy
1. Anaemia occurs because
2. depleted iron stores because of poor
diet
!23
Hook
worm
infestation is
another cause of
iron deficiency
anaemia in the
tropics

24. Physiological anaemia
•
A state of haemodilution - due to the greater
increase in plasma volume compared to red cells
•
êHct & êHb
•
Peripheral blood - normochromic and normocytic
red cells
•
Physiological haematological changes require
≅ 3/52 post-delivery to revert to normal
!24

25. How dilution anaemia comes about
•
A disproportionate increase of plasma volume
during pregnancy
Leading to apparent reduction of RBC, Hb & haematocrit
value
•
Hb is consequently reduced
•
The dilution picture is normochromic & normocytic
This is the so called physiological anaemia
!25

26. Graphical presentation of
haematological changes in pregnancy
50
40
C
h
a
n
g
e
(%)
30
Plasma
Volume
Blood
Volume
Red Cell
mass
Haematocrit
20
10
0
-10
20
10
20
30
40
Weeks of pregnancy
Oliver E, Olufunto K. www.intechopen.com
!26

27. How do we identify
anaemia in clinical practice
!27

28. Strategy for assessment
•
When faced with a patient with anaemia in
pregnancy, the investigation begins with
the taking of a detailed history
a relevant physical examination
concludes with the appropriate investigations
•
It is necessary to determine causal factors prior to
initiating treatment
!28

29. History
!29

30. In the beginning…
•
Begin history taking by having a list of possible causes in mind
This list will guide the investigator on the important questions to ask the patient
•
Include symptoms of anaemia, their severity and features of
complications, and include questions of possible aetiologies
•
Since nutritional anaemia is widely prevalent, all patients have also
to be investigated in detail on their diet, habits and lifestyle
Not only do we need to know the foods that the patient eats, but also those that
she avoids
•
It is not uncommon for anaemic mothers to have more than 1
cause for her problem, especially so where nutrition is concerned
!30

31. Presentations
•
Many patients are asymptomatic
Most commonly, anaemia is identified from routine antenatal
testing
•
If they are symptomatic, then this usually means
that the anaemia is not mild
!31

32. What are you thinking?
•
This G3 P2 was noted to have
an Hb of 10 g% at 32 weeks
gestation
•
She is now being investigated
managed for anaemia in
pregnancy
•
Hb on booking at 9 weeks was
12.1 g%
What do you think?
!32

33. Patients with low Hb on booking
•
Important to be aware of physiological anaemia
•
Late booking blood may show haemodilution when
in fact there is no anaemia
•
The best Hb reading is one taken prepregnancy
•
The next best alternative is an early pregnancy one
Prior to the entrenched haematological changes
!33

34. Symptomatic patients
•
Many of the symptoms of
anaemia are non-specific
Fatigue, weakness, dyspnoea
The differential
diagnoses !
in such patients include:!
Headache, syncope attack
!
Palpitation, reduce effort
tolerance
•
•
•
Notice that these are
very similar to
symptoms caused by
other conditions
•
•
•
!34
Cardiac disease
Respiratory distress
Anxiety & Anxiety disorders
Gastric symptoms
Anaemia

35. Prepregnancy anaemia
•
Duration of the complaints - establish clearly if they
were present before this pregnancy
•
Any past history of haematinics prescription and
blood transfusions indicates a preexisting condition
!35

36. History of haemorrhage
•
Any haemorrhage? – ante, intra, and post
•
Past treatment of anaemia must be sought during these times
•
Miscarriages and past menstrual loss - can be associated with
significant amounts of bleeding
•
A common non-reproductive source of bleeding is the
gastrointestinal tract
Passage of black, tarry stools, use of analgesic drugs (NSAIDs), history of
peptic ulcer disease
•
Dark-coloured urine & yellowness of the eyes - indicate haemolysis
!36

37. Chronic Fe depletion
•
Multiparous patients - frequent, poorly spaced
pregnancies might indicate an inability to
adequately recover from delivery blood loss
•
Medical histories, including medications used, may
suggest a premorbid condition
e.g.the use of anticoagulant medication in cardiac disorders
!37

38. Family & Heredity
•
Family members - any with blood disorders?
•
Genetic preponderance suggested by - easy
bleeding, anaemia in pregnancy, splenectomy,
jaundice and gallstones
•
Rare conditions such as thrombocytopaenia,
bleeding disorders & collagen disease - gum
bleeding, easy bruising, joint pains & skin & facial
rashes
!38

39. Physical
examination
!39

40. Aims of examination
•
Confirm the presence of anaemia
•
The extent of the anaemia
•
Look for evidence of possible causes.
!40

41. General examination
•
General inspection - note body habitus
•
See if the patient is comfortable
•
If she needs to be propped up - might suggest
decompensation
•
Check BP
!41

42. Mucosa & others
•
Check for pallor & jaundice
•
jaundice could be an indicator of haemolysis
•
Angular cheilosis, palmar erythema & koilonychia
suggest chronic anaemia and malnourishment
•
Leg edema - if severe suggests cardiac
decompensation (has to be differentiated from
pregnancy edema)
!42

43. Signs of haemolytic anaemia
•
jaundice
•
heart murmur
•
increased heart rate
•
enlarged spleen
•
enlarged liver
!43

44. Other systems
•
Cardiovascular & respiratory system assessment to rule out decompensation & concurrent disease
•
Chronic anaemia may lead to bounding pulses,
cardiomegaly and systolic murmurs
•
Rounding off the abdominal examination is the
search for liver and spleen enlargement
!44

45. Uterus
•
Establish fetal well-being
•
Maternal anaemia, if severe, can lead to fetal
growth restriction
A uterus that is smaller than dates
Oligohydramnios
!45

46. Investigations
Many clinicians tend to order
investigations in a
blunderbuss manner
Investigations for anaemia
may be divided into basic &
specific
It is more appropriate to think
& order the relevant
investigations
!46

47. Basic investigations - FBC
•
A full blood count (FBC)
Hb, WBC, platelet counts PCV
•
Red cell indices - size and colour
MCV, MCHC, MCH - small (microcytic), normal (normocytic)
or large (macrocytic) sized and if they are of normal colour
(normochromic) or pale (hypochromic)
!47

48. Basic investigations - PBF
!48

49. Specific investigations
!49

50. Thank you
!50