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Anemia in PregnancyDetty NurdiatiDetty Nurdiati
Dept of Obstetric & GynecologyFaculty of Medicine, Gadjah Mada University
Dr. Sardjito Hospital. Yogyakarta
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Higher mortality
rate
Impaired mental development
Increased risk of adult chronic disease
Baby
Impaired immunity
Cycle: Nutrition, Health and their Consequences
Untimely / inadequate weaning
Frequent infections
Inadequate food, health
& careInadequate food,
health& care
Reduced capacity to care for baby
Inadequate fetal nutrition
Baby Low Birth Weight
Inadequate catch up growth
Child
Elderly Malnourished
Anemia
AnemiaInfectione.g. malaria
Reduced mental capacity
Inadequate food, health &
care
Reduced mental capacityInadequate food, health & careHigher maternal mortality
PregnancyLow Weight Gain
Micronutrient deficiencies
WomanMalnourished
Adolescent Stunted
Child StuntedAnemia
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Objectives
Understand the physiological changes of the blood in pregnancyblood in pregnancy
Know the maternal and effect of anemia
Understand the cause of anemia in pregnancy
Be able to detect and manage anemia Be able to detect and manage anemia antenatally
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Physiological Changes
Blood volume normally 36% max being reached at 34 weeks
Plasma volume 47-50% Red cell mass 17-25%
Relative hemodilution throughout the pregnancy
Reaches its maximum between 28-34 weeks
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Physiological Changes
Consequent of hemodiltuion in Hb, Hct, RBC
MCV and MCHC remains stable The MCV secondary to erythropoiesis These indices decrease progressively in IDA
Serum iron & ferritin secondary to Serum iron & ferritin secondary to utilization
Total iron-binding capacity
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Physiological Changes
Iron requirement Due to expanding red cell mass & fetal requirements Due to expanding red cell mass & fetal requirements
2.5 mg/day in trim 1 to 6.6 mg/day in trim 3
700-1400 mg total pregnancy
Iron absorption moderately Folate requirements
Due to the fetus, placenta, uterus and expanded maternal Due to the fetus, placenta, uterus and expanded maternal and red cell mass
No major effect on B12 stores, although levels (preferential active transport to fetus)
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Dietary Iron RequirementsThroughout the Life Cycle
Required iron intake(mg Fe/1000 kcal)
Pregnancy
4
6
8
10
12
Men
Women
Pregnancy
0
2
0 10 20 30 40 50 60 70
Stoltzfus, 1997
Age (years)
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Anemia
Definition: A pathological condition in which the oxygen-
carrying capacity of RBC in insufficient to meet the bodys need
Diagnosis is based on the Hb concentration: WHO: < 11g/dL at any time during pregnancy
Clinicians: Trim I and III : < 11 g/dL
Trim II : < 10.5 g/dL
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Incidence
The commonest medical disorder of pregnancypregnancy
30-50% of pregnant women 90% iron deficiency
5% folate deficiency
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Clinical Features
Often asymptomatic
Diagnosis being made on routine screening Estimating the Hb concentration The beginning of pregnancy and
Again later in pregnancy
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Consequencesof Maternal Anemia
Maternal deaths
Reduced transfer of iron to fetus Reduced transfer of iron to fetus
Low birth weight
Neonatal mortality
Reduced physical capacity Reduced physical capacity
Impaired cognition
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Anemia and ObstetricalHemorrhage
Anemia does not cause obstetrical hemorrhage Anemia does not cause obstetrical hemorrhage Etiology of obstetric hemorrhage Early pregnancy: Abortion complications Mid/late pregnancy to delivery: Previa, abruption,
atony, retained placenta, birth canal laceration
Primary factors affecting outcome:Primary factors affecting outcome: Rapid intervention to prevent exsanguination Availability of skilled provider, drugs, blood and fluids
There is no evidence that high levels of Hb are beneficial in withstanding a hemorrhagic event.Enkin et al 2000; Mahomed 2000a.
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Severe Anemia andMaternal Mortality (Malaysia)
20Maternal deaths / 1000 live births
15.5
3.5
10
20
0
Llewellyn-Jones, 1985
< 65 > 65Pregnancy hemoglobin concentration (g/L)
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Pregnancy Hemoglobinand Low Birth Weight
13.815 13.8
11.59.7 8.9 9
11.4 11
0
5
10
15
80 90 100 110 120 130 140
% L
ow
bir
th w
eig
ht
80 90 100 110 120 130 140
Lowest pregnancy hemoglobin concentration (g/L)
Garn et al., 1981
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Iron Deficiency Anemia
Microcytic, hypochromic anemia because of the reduced of MCV and MCHCthe reduced of MCV and MCHC
Significant iron demands during pregnancy Secondary to expanding red cell mass and fetal
requirements
Can only be met by a limited increase in iron absorption and by the utilization of iron stores
If the iron stores already depleted anemia will develop rapidly.
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Iron Deficiency Anemia
The total iron-binding capacity (TIBC) increases secondary to the increased plasma volume and secondary to the increased plasma volume and the serum iron falls
As iron demands exceed during the pregnancy, ferritin levels fall
Decreased Hb concentration is a late event in iron deficiency anemiadeficiency anemia
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Concequences
The impaired function of iron-dependent enzymes causes alterations in muscle neurotransmitter activity and causes alterations in muscle neurotransmitter activity and epithelial changes throughout the body
The basis explanation for the apparent link between IDA and preterm delivery, infection medical intervention during labour and postpartum hemorrhage
Fetal perspectiveIncreased risk of preterm delivery and IUGR Increased risk of preterm delivery and IUGR
Increased risk the low neonatal iron status, the impairment of cognitive development and behaviour of babies
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Diagnosis
ID can be present in the absence of anemia and other parameter of the full blood count and other parameter of the full blood count that usually give a clue to this (reduced MCV and MCHC) are not accurate during pregnancy
The diagnosis test for ID is The diagnosis test for ID is a ferritin concentration, which is not affected by
pregnancy
The concentration of
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Treatment
Oral iron replacementEffective if there is enough time maximum Effective if there is enough time maximum increase HB: 0.8 g/dL per week
Recommended dose: 120-240 of elemental iron per day
Ferrous salts are absorted better than ferric salts, should be used in preference
Vit C aids the iron absorption 40% increased of side effect, mainly
gastrointestinal effect on compliance
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Treatment
Intramuscular Iron Iron sorbitol injection has a low molecular rapid Iron sorbitol injection has a low molecular rapid
absorption Intravenous iron
Iron sucrose is licensed for total dose iron replacement in the trim 2 and 3.
More effective & less side effect Blood transfusion
Towards the end of pregnancy Towards the end of pregnancy Rapid increase of Hb concentration but not iron stores
Erythropoietin Mainly used for the anemia associated with erythropoietin
deficiency in CRF, but can also be used to increase the autologous production of blood in normal individuals
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Prevention
Prevention before pregnancy Balanced diet in the absence of ongoing blood loss
Identification and treatment of IDA prior to pregnancy
Prevention during pregnancy Routine iron supplementation 60 mg/day elemental Routine iron supplementation 60 mg/day elemental
iron
Improvement in hematological indices
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Folate Deficiency
Increase of folate requirements because of the increased cell replication that is taking place in
the fetus, uterus and bone marrow (increase red cell mass)
Plasma folate decrease during pregnancy
Reaching half non pregnant levels by term
Folate deficiency causes a megaloblastic anemia
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Concequences
Fetal perspective:Clear link preconceptual folate deficiency and Clear link preconceptual folate deficiency and NTD
All women planning a pregnancy should take 400 ug/day folic acid the first 12 weeks the neural tube is closed
Maternal perspective: Maternal perspective: Anemia Involvement of tissues with high rates of cell
turnovers, in particular mucous membranes the folate deficiency can be exacerbated by malabsorption if the gut mucosa is affected
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Diagnosis
Outside pregnancy Macrocytic of folate deficiency anemia is
diagnosed by an increased of MCV
In pregnancy the MCV is increased
May be masked by co-existing iron deficiency May be masked by co-existing iron deficiency leading to reduced MCV.
Examining the blood film may be useful bone marrow aspiration
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Treatment
Severe folate deficiency is extremely rare
But if it happened, the treatment is difficult due to poor folate absorption from the affected gastrointestinal tract
5 mg oral pteroglutamic acid daily or parenteral folate can be usedparenteral folate can be used
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Prevention
400 ug/day for the prevention of NTD by 36%
5 mg/day could reduce the risk of NTD by 85%
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Vitamin B12 Deficiency
Rare during the reproductive years
Absorption unchanged by pregnancy
Actively transported across the placenta to the fetus
Management Should be optimized prior to conception Should be optimized prior to conception
Virtually all animal products will supply enough vit B12
