Anaemia In Pregnancy

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Introduction

Anemia is a condition in which blood has a lower than-normal amount of red blood cells or hemoglobin. Anemia in pregnancy is a decrease in the total red blood cells or hemoglobin in the blood
during pregnancy.
Anaemia is the most common complication of pregnancy in sub-Saharan Africa. It is a diminution below normal of the total circulating haemoglobin mass.
World Health Organization definition of anaemia:

  • Haemoglobin concentration less than 11 g/dL or a hematocrit less than 33% in peripheral blood

For practical purposes in developing and tropical countries a haemoglobin concentration of 10 g/dL or hematocrit of 30% is taken as cut off. Below these levels there may be adverse fetal and maternal outcomes:

Classification

  • Mild- PCV 25-29%
  • Moderate- PCV 20-24%
  • Severe- PCV <20%

Clinical presentation

This varies and depends on the severity. It may be asymptomatic or symptomatic

Symptoms

  • Generalised weakness
  • Lassitude
  • Easy fatigability
  • Headaches
  • Dyspnea on mild exertion
  • Ankle swelling

Signs

  • Pallor
  • Jaundice may or may not be present
  • Pedal edema
  • Tachypnea
  • Tachycardia
  • Haemic murmurs
  • Pseudo-toxaemia
    • Systolic hypertension, edema and albuminuria
  • There may, or may not be clinical evidence of causative pathology
    • Sickle cell facies, urinary tract symptoms, etc.
  • Hepatomegaly: not invariable
  • Splenomegaly: not invariable
  • Anaemic heart failure in extreme cases

Differential diagnoses

  • Nutritional deficiencies: Iron, folic acid, protein, vitamin C; trace elements, and rarely vitamin B12
  • Physiological demands of pregnancy
  • Excessive red cell haemolysis as in malaria, haemoglobinopathies
  • Infections: urinary tract infection, HIV/AIDS, Hookworm infestation
  • Antepartum haemorrhage
  • Bone marrow pathologies
  • Miscellaneous: e.g. bleeding duodenal ulcer.

Complications

Maternal Abortion

  • Cardiac failure
  • Reduced ability to tolerate blood loss at delivery
  • Reduced ability to tolerate anaesthesia
  • Diminished resistance to infection
  • Preterm labour. Precipitate labour may occur
  • Death

Foetal

  • Spontaneous abortion
  • Intrauterine growth restriction.
  • Intrauterine fetal death
  • Still birth
  • Prematurity
  • Risk of developing anaemia within 2 – 3 months of birth if mother suffered iron deficiency anaemia

Investigations

  • Haematocrit
  • Haemoglobin concentration
  • White blood cell count and differentials
  • Blood picture
  • Reticulocyte count
  • Blood smear
  • Midstream urine: microscopy, culture and sensitivity
  • Stool analysis: ova, cysts, parasites, occult blood
  • Group and cross-match blood
  • VDRL
  • Haemoglobin genotype
  • Blood Group
  • HIV screening.
  • Urinalysis and culture.
  • Ultrasound scan (e.g. of abdomen, pelvis).
  • Bone marrow biopsy if bone marrow involvement is suspected

Treatment objectives

  • Correct hematocrit.
  • Treat underlying cause(s)
  • Fetal surveillance:
    • of growth and wellbeing to exclude IUGR and intrauterine asphyxia

Correction of hematocrit:

1. Oral haematinics

For mild and moderate anaemia –
Ferrous sulfate

  • 200 mg daily and folic acid 5 mg daily
  • Vitamin C (ascorbic acid)
    100 mg three times daily.

2. Parenteral iron:

Indicated in

  • Mild to moderate anaemia, near term
  • Malabsorption of oral iron, or when it causes serious gastroenteritis

Administration:

  • Calculate haemoglobin deficit
  • For each 1 g/dL deficit, 250 mg of iron dextran injection is required
  • Additionally, 50% of the total calculated is added onto the deficit value to take care of the iron stores
  • Administer by deep intramuscular injection into the gluteal muscle, by slow intravenous injection or by intravenous Infusion (after a
    negative test dose)
Intramuscular injection
  • 250 mg daily; after a negative test dose of 25 mg
Intravenous

If the total calculated dose of iron dextran is less than 1,500 mg it can be given over 8 hours in one litre of sodium chloride 0.9%. If greater than 1,500 mg, it should be given in divided doses daily, not exceeding 1,500 mg/day
Antihistamine (chlorphenamine injection), epinephrine and hydrocortisone injection must be available:

  • iron dextran could cause severe anaphylaxis

3. Blood transfusion 

  • Consider as from the 37 week for mild anaemia and from the 32 week for moderate anaemia
  • Usually, packed cells under furosemide cover

Indications:

  • Severe anaemia irrespective of gestational age
  • Cardiac failure
  • Moderate anaemia detected in labour or during an abortion, or co-existing with other conditions such as sepsis, renal failure, haemorrhage or eclampsia

Prevention

  • Counselling on contraception; adequate spacing of pregnancies.
  • Malaria prophylaxis in pregnancy.
  • Chemoprophylaxis against helminthiasis.
  • Prompt and appropriate treatment of febrile illnesses in pregnancy
  • Improvement of the socioeconomic status of the people
  • Provision of accessible and affordable maternity care facilities

 

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