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Anemia in Pregnancy

Article  in  Annals of the New York Academy of Sciences · February 2000

DOI: 10.1111/j.1749-6632.2000.tb06223.x · Source: PubMed


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2 authors, including:

Stavros Sifakis
Mitera Hospital, Heraklion, Crete, Greece


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Anemia in Pregnancy
Department of Obstetrics and Gynecology, University Hospital of Heraklion,
University of Crete, Heraklion, Greece

ABSTRACT: Anemia is one of the most frequent complications related to preg-

nancy. Normal physiologic changes in pregnancy affect the hemoglobin (Hb),
and there is a relative or absolute reduction in Hb concentration. The most
common true anemias during pregnancy are iron deficiency anemia (approxi-
mately 75%) and folate deficiency megaloblastic anemia, which are more com-
mon in women who have inadequate diets and who are not receiving prenatal
iron and folate supplements. Severe anemia may have adverse effects on the
mother and the fetus. Anemia with hemoglobin levels less than 6 gr/dl is asso-
ciated with poor pregnancy outcome. Prematurity, spontaneous abortions, low
birth weight, and fetal deaths are complications of severe maternal anemia.
Nevertheless, a mild to moderate iron deficiency does not appear to cause a sig-
nificant effect on fetal hemoglobin concentration. An Hb level of 11 gr/dl in the
late first trimester and also of 10 gr/dl in the second and third trimesters are
suggested as lower limits for Hb concentration. In an iron-deficient state, iron
supplementation must be given and follow-up is indicated to diagnose iron-
unresponsive anemias.


Anemia is one of the most frequent complications related to pregnancy. The word
implies a decrease in the oxygen-carrying capacity of the blood and is best charac-
terized by a reduction in hemoglobin concentration. This may be either relative or
absolute. It is known that there is a larger increase in plasma volume relative to red
cell mass in almost all pregnancies, and it accounts for “physiologic anemia.” These
alterations have been known for centuries, and the term “plethora gravidarum” from
medieval ages indicates this condition. However, it is still an open question to what
extent this “hydremia” is physiologic or pathologic.
There are two contrasting medical philosophies covering this problem. Accord-
ing to the first, it is preferable to prevent pregnant women from developing too low
hemoglobin concentrations. According to another point of view the “physiologic
anemia” is of great importance for normal fetal growth and should be passively ob-
served. Moreover, the relationship between a successful outcome of pregnancy and
this normal expansion in maternal plasma volume has been noted.1 This controversy
is reflected in the recommendations from the World Health Organization on the op-
timal hemoglobin (Hb) concentrations or hematocrit (Hct) level. Thus, in 1965 a
WHO expert committee suggested that 10 gm/dl should be accepted as the lower
limit of the physiologic adjustments made during pregnancy.2 However, three years

aAddress for correspondence: Stavros Sifakis, 22 Apolloniou Rodiou Str., 71305, Heraklion
Crete, Greece. Phone: 0030 81 212915; fax: 0030 81 392759.


later another WHO scientific group recommended that when Hb values are lower
than 11 gr/dl anemia should be considered to exist in pregnant women, and diets
must be supplemented with medical iron.3


The plasma volume starts to increase at about 6 weeks of pregnancy in a healthy

woman.4 This increase, which is disproportionately greater than the corresponding
changes on the red cell mass, accounts for the physiologic fall in the Hb concentra-
tion during pregnancy. As a consequence, there is a significant reduction in arterio-
venous oxygen extraction at the heart and an important increase of the oxygen-
carrying capacity of the pregnant woman, despite the fall in the Hb level.
The increase in plasma volume is about 1,250 ml at term, a total increase of about
48% above the nonpregnant state. This is the result of an initial rapid rise, followed
by a slower rise after the 30th week of pregnancy. Several studies demonstrate the
positive correlation between the weight of the newborn and the increase in the plas-
ma volume.1,5–8 It seems that the increase in plasma volume is an indication of nor-
mal growth of the fetus and one of the hallmarks of a successful pregnancy.
As regards the red cell mass, it also increases although, in contrast to the plasma
volume, it does so more slowly. The total increase is about 18% or 250 ml at term.
After stimulation with iron supplements, however, the red cell mass may reach 400
ml—a total increase of about 30% compared with the nonpregnant state. Similar to
the plasma volume, the increased red cell mass is linked to fetal growth, although
probably to a lesser degree.


Because of the normal physiologic changes in pregnancy that affect the hemat-
ocrit and certain other parameters, such as hemoglobin, reticulocytes, plasma fer-
ritin, and unsaturated iron-binding capacity, diagnosing true anemia, as well as
determining the etiology of anemia, is challenging. The most common anemias are
iron-deficiency anemia and folate deficiency megaloblastic anemia. These anemias
are more common in women who have inadequate diets and who are not receiving
prenatal iron and folate supplements. Other less common causes of acquired anemia
in pregnancy are aplastic anemia and hemolytic anemia. In addition, anemias such
as thalassemia and sickle cell disease can have an impact on the health of the mother
and fetus.
As was stated above, the most frequent causes of true or absolute anemia are nu-
tritional deficiencies. Frequently, these deficiencies are multiple, and the clinical
presentation may be complicated by attendant infections, generally poor nutrition,
or hereditary disorders such as hemoglobinopathies.9,10 However, the fundamental
sources of nutritional anemia embody insufficient intake, inadequate absorption, in-
creased losses, expanded requirements, and insufficient utilization of hemopoietic
nutrients. Approximately 75% of all anemias diagnosed during pregnancy are due to
iron deficiency. Significant deficiency of iron leads to characteristic hypochromic,
microcytic erythrocytes on the peripheral blood smear. Other causes of hypochromic

anemias, even rare, must be considered, including hemoglobinopathies, inflamma-

tory processes, chemical toxicity, malignancy, and pyridoxine-responsive anemia.
However the greater percentage of the remaining cases of anemia in pregnancy other
than the iron-deficiency type consists of the megaloblastic anemia of pregnancy due
to folic acid deficiency and, to a lesser extent, to vitamin B12 deficiency. Anemia
caused by deficiencies of other vitamins or elements does not commonly occur in
Nutritional anemia is not a broad-based problem in the populations of developed
countries. It is nevertheless a problem for many individuals in these countries, and it
is certainly a major health problem in poor, underdeveloped countries. Pregnant
women as well as menstruating women and children make up the segment of the
population in third-world countries—and even in the United States and Europe—
that is affected by nutritional deficiency, sometimes accompanied by frank anemia.11
In conclusion, the investigation of acquired anemias during pregnancy is very im-
portant, considering that inadequate nutrition and nutritional deficiencies have an
adverse impact on pregnancy outcome, without excluding a priori other, less com-
mon types of anemia.


Obviously, severe anemia has adverse effects on the mother and the fetus. There
is also evidence that less severe anemia is associated with poor pregnancy outcome.
Major maternal complications directly related to anemia are not common in women
with a hemoglobin level greater than 6 gr/dl. However, Hb levels even lower may
lead to significant morbidity in pregnant women, such as infections, increased hos-
pital stays, and other general health problems.10
A lot of symptoms and signs may accompany this clinical state, to a variable de-
gree. The commonest of these are headache, fatigue, lethargy, paresthesia, and the
clinical signs of tachycardia, tachypnea, pallor, glossitis, and cheilitis. In more se-
vere cases, especially in pregnant women with hemoglobin levels less than 6 gr/dl,
significant life-threatening problems secondary to high-output congestive heart fail-
ure and decreased oxygenation of tissues, including heart muscle may be encoun-
tered. Such conditions are rare as a result of nutritional deficiency anemias, at least
in developed countries or when the pregnant woman receive iron supplementations.
However, severe iron deficiency anemia or methemorragic anemia may be presented
by complications of pregnancy, such as placenta previa or abruptio placenta, opera-
tive delivery and post partum hemorrhage.12 These conditions if untreated by iron
supplementation or blood transfusion may lead to severe complications.


There are a lot of indications that severe maternal anemia in pregnancy is associ-
ated with poor pregnancy outcome and that the cause of this association has yet to
be elucidated.10 Moreover, what effects the maternal anemia has on the fetus are not
well defined; however, several reports in the literature associate the reduction in he-
moglobin level with prematurity, spontaneous abortions, low birth weight, and fetal

deaths. Some authors believe that even a mild reduction in Hb level (8–11 gr/dl) may
produce a predisposition to these conditions; in contrast, other authors support a di-
rect relationship between anemia and fetal distress only when the maternal Hb levels
re less than 6 gr/dl.13
It is important to know what effect the iron status of the mother has on the iron
status of the fetus for definitive and correct conclusions about management. There
are controversial opinions about this: some investigators found that levels of mater-
nal iron exert little effect on that of the neonate at birth.14 On the other hand, studies
of cord blood serum iron levels have shown a direct relationship between maternal
and fetal iron levels.15 Additionally, when serum ferritin is used as an indicator of
iron status, it was found that babies born to mothers who did not take iron supple-
ments during pregnancy had reduced iron stores at birth.16,17 Most authors agree that
only severe anemia may have direct adverse effects on the fetus and neonate and that
a mild to moderate maternal iron deficiency does not appear to cause a significant
effect on fetal hemoglobin concentration.15
There are several reports that correlate the anemia during pregnancy with prema-
turity and low-birthweight infants, indicating a direct relationship between low birth
weight and low maternal Hb level.18–20 In a large epidemiologic study, it was shown
that the risk of a preterm delivery was increased by 20% in pregnancies with Hb lev-
els between 10 and 11 gr/dl and by 60% in pregnancies with Hb levels between 9 and
10 gr/dl. Below 9 gr/dl, the risk was more than doubled, tripled, and so on for each
fall of 1 gr/dl.21 In the same study, no correlation was found between maternal Hb
levels and growth retardation. In another large epidemiologic study, perinatal mor-
tality was found to be tripled when the maternal Hb levels fell below 8 gr/dl in com-
parison with Hb levels above 11 gr/dl.22 In addition, Garn et al.23 demonstrated an
association between low maternal Hb levels and poor pregnancy outcomes such as
prematurity, low birth weight, fetal death, and other medical abnormalities with in-
creasing complication rates when there were lower maternal Hb concentrations.
Nevertheless, all these reports are strong indications of an adverse effect of maternal
anemia on fetal growth and pregnancy outcome. Nevertheless, it would be better, at
least in cases of mild to moderate maternal anemia, to characterize these simply as
possible risk factors rather than as an adequate evaluation indicating an obvious ad-
verse impact on the fetus. Moreover, it is important to stress that low maternal Hb
levels are often associated with other pathologic conditions, so it is difficult to be
sure whether maternal anemia per se causes or even contributes directly to the in-
creased mortality and morbidity rates. In other words, low Hb levels are often a sec-
ondary phenomenon caused by antecedent infections or chronic illnesses that in turn
may lead to severe complications during pregnancy that do not fundamentally de-
pend on the hematologic profile of the pregnant woman.



There are conflicting views on the optimal Hb concentrations during pregnancy.

One of the reasons for this is that the prepregnant hematologic state of the woman is
rarely known, and this, to a large extent, determines the hematologic reactions dur-
ing pregnancy. Thus, one important parameter is the knowledge of normal nonpreg-

nant Hb variation. Another point is the use of ±2 SD as limits for the variation of
Hb levels during pregnancy. Finally, it is best to consider what is known about the
physiological changes in plasma volume and in red cell mass during pregnancy that
lead to physiological anemia.
In the nonpregnant state, Hb and Hct values are more indicative of the plasma vol-
ume than of the red cell mass in women. It is possible that individual factors influ-
ence the plasma volumes from consistently high to average or low.4 There is also
often a gradual transition from normal iron stores to slight or moderate iron deficien-
cy anemia during which the symptoms are inconspicuous. Two-thirds or more of
healthy women of reproductive age in several countries have been found to have
scanty or absent iron stores.24 This situation may have not consequences in a non-
pregnant state but during pregnancy such women are at a variable risk of developing
frank anemia.
The normal variations of Hb and Hct values in a nonpregnant state are wide. In
one study, however, which is in close agreement with the results of many others,25
young, healthy, nonpregnant women have the following values: Hb: 12.3 ± 0.9 gr/dl
(range, 11.4–14.3 gr/dl); Hct: 38% ± 3 (range: 34–45%).
It is important to ask, however, what is the optimal (or normal) Hb level for preg-
nant women and what is the lower limit of normal variation? This is a very difficult
problem for which there are lot of conflicting views and strong discrepancies. Nev-
ertheless, there is fairly good agreement among several investigators that the lower
limit of normal physiologic variation of Hb levels is about 10 gr/dl.23,26,27 This low-
est value occurs in weeks 25 and 26 with a mean Hb value of 11.4 gr/dl, making the
lower (± 2 SD) limit 9.8 gr/dl,26 a figure very close to the lower limits of 10 gr/dl
and 10.4 gr/dl of two other reports.23,27
In the other trimesters of pregnancy, an Hb level of 11 gr/dl in the late first tri-
mester and of 10 gr/dl in the third trimester are suggested as lower limits for Hb con-
centration. Koller et al. investigated the optimal Hb levels in iron-supplemented
pregnant women and created a diagram based on the results of uncomplicated preg-
nancies resulting in healthy, normal neonates.26 This pregnant population routinely
used iron supplementation of 100 to 200 mg Fe per day (both doses have about the
same effect on Hb levels).28 According to the results of this study, it is remarkable
that supplements had very little influence on the Hb levels before 25 weeks of ges-
tation, although from that time on, these levels increased gradually compared with
those of nonsupplemented women. Other authors supported that the difference at
term between Hb levels in pregnant women with or without iron supplementation
will be about 1 gr/dl.29,30
About of 3% pregnant women have Hb levels below the lower limit of 10 gr/dl in
the second trimester,26,31 whereas the corresponding number in the third trimester is
1%.31 The decrease in Hb concentration is positively correlated with the prepregnan-
cy Hb value.24 The low values (10 to 11 gr/dl) often show no drop in value, howev-
er.28 This may be explained by considering that these low values indeed represent
iron deficiency anemia that reacts rapidly to iron supplementation with hemoglobin
production, thus preventing a further drop in Hb concentration. It is remarkable that
this “resistance” to further decrease in Hb levels also appears in pregnant women
without iron supplementation. It may represent a physiologic “adaptation” to preg-
nancy in order to keep the Hb concentration at sufficient levels for placental perfu-
sion.24Another explanation is that women with low prepregnancy Hb levels may

have larger plasma volumes than the women with higher Hb levels, and as a conse-
quence they do not experience the plasma expansion that appears at early stages of


Iron-Deficiency Anemia
The majority of all anemias diagnosed during pregnancy are characterized as iron-
deficiency anemias. It is estimated that about 80% of pregnant women at term who
do not use iron supplementation have hemoglobin concentrations less than 11 gr/dl.13
The increased fetal need for iron as well as a number of other factors constitute the
iron-deficiency profile of the pregnant woman and the need for supplementation.
The factors contributing to that state include poor iron absorption during pregnancy,
multiple gestations or successive gestations less than two years apart, adolescent
pregnancy, and any associated chronic blood loss, as well as decreased amounts of
total body iron before the pregnancy.
The most usual clinical symptoms of iron-deficiency anemia are lethargy and fa-
tigue, although they are also seen in normal pregnancy. Other symptoms are head-
ache, paresthesia, burning sensation of the tongue, and pica, which is the ingestion
of substances with no dietary value and appears in severe cases of anemia after the
twentieth week of gestation. Glossitis, pallor, and inflammation of the lips (cheilitis)
are clinical signs of iron deficiency, whereas koilonychia and “spooning” nails are
less common findings. In cases of severe anemia, retinal bleeding, conjunctivitis, ta-
chypnea or tachycardia, and splenomegaly may be presented. Nevertheless, these
signs are rarely seen in developed countries because of the rarity Hb levels of 5 or
6 gr/dl. Some authors support a correlation of iron-deficiency anemia with defects
in cellular immunity and decreased defense to bacteria by white blood cells,32 but it
is not clear whether this immune depression associated with anemia, predisposes a
person to infection.33
The laboratory evaluation of iron-deficiency anemia is quite difficult because of
the physiologic hydremia of pregnancy and the subsequent changes in the values of
the main hematologic parameters. Moreover, a differential diagnosis must be done
between the hypochromic microcytic anemia of iron deficiency and other hypochro-
mic anemias such as hemoglobinopathies or anemias induced by chemicals or in-
flammatory processes or malignancies. In these conditions the mean corpuscular
volume (MCV) is often decreased, although it is the rule in iron-deficiency ane-
mia.34 The expected increase in the red blood cell mass after week 20 of gestation
will not observed if iron stores are depleted. The serum iron levels decline as preg-
nancy advances for the reasons presented above. Values < 30 g/dl are usually diag-
nostic of iron deficiency, but the best indicator for this is the measurement of serum
ferritin (normal values in pregnancy: 55–70 µg/l). Additionally, quite a good indica-
tion is the transferrin saturation, which in iron deficiency is < 15%. Some authors
consider the unsaturated iron-binding capacity (UIBC) an important marker of iron
deficiency states, when it takes values > 400 µg/dl.35 The earliest tissue indicator of
an iron-deficient state is decreased iron stores in the bone marrow, but aspiration in
pregnancy is usually not indicated.

Therapy of Iron-Deficiency Anemia and Iron Supplementation

Most clinicians advocate iron supplementation in pregnant women. Others be-
lieve that supplementation has no value when hemoglobin levels are equal to or
greater than 10 gr/dl. They believe that there is no need for extra therapy, on the
grounds that hemodilution during pregnancy is an important physiologic adaptation,
important for adequate uteroplacental circulation.36 In an iron-deficient state, how-
ever, iron supplementation must be given, and follow-up is indicated to diagnose
iron-unresponsive anemias. Reticulocytosis is normally observed 10 days after the
initiation of iron therapy. The increased demand for iron and the hemodilution dur-
ing pregnancy may mask the response to iron supplementation. It is self-evident that
other causes of anemia have been excluded. In these cases iron supplementation
should continue throughout pregnancy, and it can be accomplished with a variety of
agents. Oral preparations containing elemental salt are the most commonly em-
ployed, whereas ferous sulfate compounds are the least expensive and have been
demonstrated to be efficacious for iron supplementation. It should be taken three or
four times daily in a dosage of 30–60 mg for a conservative dosage to 200–300 mg
per day in the iron-deficient state. Nausea, vomiting, diarrhea, and constipation are
the most common side effects of the ingestion of oral iron. The sustained release cap-
sules, iron compounds that are slowly absorbed, and syrups may reduce some of the
intolerance and increase patient compliance. Patients with severe iron deficiency
anemia who cannot tolerate oral administration or who demonstrate noncompliance
with the oral administration of iron, can be treated with intramuscular (i.m.) or in-
travenous (i.v.) administration. Additionally, parenteral therapy is preferred when
rapid replenishment of iron stores is necessary. However, the hematologic response
to the i.m. or i.v. route of therapy is no more rapid than that of the response to oral
iron, and adverse effects including fatal anaphylaxis can be observed due to imme-
diate or delayed reactions to iron dextran. It is more likely to appear when oral iron
and parenteral iron are given concomitantly; therefore, this combination is not indi-
cated. A test dose is strongly recommended before the first parenteral administra-
tion. A formula for the dose of iron needed to restore hemoglobin is the following37:
patient’s Hb ( gr ⁄ dl ) × 100
elemental iron (mg) = 0.3 × weight (lbs) × 100 = ----------------------------------------------------------------------- .
The side effects of such a route of iron administration include discomfort at the in-
jection site, skin staining, malaise, and metallic taste. Moderate reactions of hyper-
pyrexia, lymphadenopathy, and phlebitis occur in 1–2% of patients, whereas
anaphylaxis may occur in about 0.5% of them.

Folic Acid Deficiency Anemia

Folic acid deficiency causes a megaloblastic type of anemia that is second in oc-
currence as a cause for nutritional deficiency anemia of pregnancy after iron defi-
ciency anemia. Folates and especially their derivative formyl FH4 are necessary for
appropriate DNA synthesis and amino acid production. Insufficient levels of folic
acid may lead to the manifestations noted in megaloblastic anemia.38 Folic acid must
be provided in the diet: common sources are green vegetables, fruits (lemons, mel-
ons), and meats (liver, kidney). The absorption happens in the proximal jejunum.

The etiology of folic acid deficiency is variable and decreased intake is associated
with poor nutrition and impaired absorption as well as increased folic acid require-
ments seen in pregnancy because of the increased demands of fetal growth and ma-
ternal erythropoiesis. Additionally, the higher levels of estrogen and progesterone
during pregnancy seem to have an inhibitory effect on folate absorption The symp-
toms of folic acid deficiency are those of general anemia plus roughness of the skin
and glossitis. The erythrocyte precursors are morphologically larger (“macrocytic”),
and an abnormal nuclear–cytoplasmic appearance as well as normochromic and
macrocytic findings are diagnostic criteria for megaloblastic anemia. MCH and
MCHC are usually normal, whereas the large MCV is helpful in differentiation of
this anemia from physiologic changes of pregnancy or iron-deficiency anemia. For
MCV, the presence of increased serum iron and transferrin saturation are also help-
ful. Neutropenia and thrombocytopenia are the results of abnormal maturation in
granulocytes and thrombocytes. A low serum level (<3 g/l) may occur early in folic
acid deficiency.
The daily requirement in a nonpregnant state is at least 0.4 mg. In pregnancy or
increased growth states, such as during infancy and adolescence, however, the re-
quirements are increased to 0.8–1.0 mg.39,40 It is possible that multiple gestations or
short intervals between pregnancies increase folate requirements further. It has been
reported that folate deficiency affects about 60 to 95% of untreated women at term.13
However, true megaloblastic anemia due to folic acid deficiency is uncommon, al-
though megaloblastic changes produced by this state are not uncommon. Half of the
pregnant women with this type of anemia present before delivery with the remaining
cases being detected puerperally. The majority of folic acid deficiencies during preg-
nancy appear in the third trimester.13 Severe folic acid deficiency in experimental an-
imals has been linked to an increased appearance of pregnancy abnormalities such
as prematurity, fetal death, hypertension, placental abruption, or fetal malforma-
tions. A direct relationship of these outcomes with iron deficiency in humans has not
been proven.38 The fetus seems to have the ability to sustain stable hemoglobin and
folate levels even in cases of obvious or severe maternal folate deficiency anemia. It
is possible that the fetus removes folic acid from maternal circulation even in her
deficit state. Thus, the infants in such cases are not anemic and appear unaffected.
However, it has been found that megaloblastic anemia in pregnancy may be accom-
panied by smaller blood volume40 and may be related to fetal growth retardation in
some cases.41 On the other hand, when there are no signs of anemia, the effects of
folic acid deficiency are controversial or unclear. Nevertheless, the majority of phy-
sicians consider folate supplementation useful, especially for those at risk for devel-
oping deficiency states. Intake of 0.5 mg to 1 mg two or three times daily orally is
generally adequate. A response to therapy within 48–72 hours can be expected as
reticulocytes and platelets increase. A neutrophilic response can be observed within
2 weeks. If there are low serum iron levels, the existence of concomitant iron defi-
ciency anemia is possible.42 In these cases serum iron levels may be elevated and
erythropoiesis will not be efficient.

Other Deficiency Anemias in Pregnancy

Hemic nutrients, trace elements, vitamins, and proteins are necessary for growth
and maintenance of various bodily functions, especially for the hematologic system

functions of the mother, fetus, and newborn. They are vital in facilitating the metab-
olism of amino acids, carbohydrotes, and fat and are therefore involved in anemias.
The increased nutritional requirements during pregnancy commonly result in inade-
quate dietary intake. Nutritional anemia is not a very common problem in developed
countries, except for iron-deficiency or folic acid deficiency anemia. However, ane-
mia caused by deficiencies in a number of iron, folic acid, vitamins, and proteins
may be an important problem in poor, underdeveloped countries.
Except for iron deficiency, which is responsible for the great majority of anemias
diagnosed during pregnancy, deficiencies in some other minerals may account for
some cases of anemias in rare cases. Severe phosphorus deficiency can cause
hemolytic anemia because of adenosine triphosphate depletion in the red cells with
subsequent osmotic fracture.13 Moreover, severe copper deficiency has been charac-
terized to iron supplementation.43 Zinc deficiency has been noted in patients with
sickle cell anemia and thalassemia. However, there is no evidence that this deficien-
cy causes worsening of anemia.44
Of the water-soluble vitamins, folic acid deficiency accounts for a large pregnan-
cy which is megaloblastic in type. Except for folic acid, vitamin B12 deficiency is
clinically important because of its role in the metabolism of folate through the pro-
duction of active FH4. When serum B12 levels are depressed during pregnancy, it
may lead to a type of megaloblastic anemia which exists in common with folic acid–
related anemia in 98% of megaloblastic anemias at pregnancy.45 Other B complex
vitamin–related anemias are almost never seen in pregnancy. Though rare, vitamin
B6 (pyridoxine) deficiency is noted during pregnancy by a decrease to about 75% of
normal levels. A relationship between this deficiency and hypochromic microcytic
anemia has been reported.43 Another hypochromic-type anemia has been noted in
80% of pregnant women with ascorbic acid (vitamin C) deficiency (scurvy). The in-
teraction of ascorbic acid and iron metabolism is regarded as the etiologic reason for
this anemia.13 Of the fat-soluble vitamins (A, D, E, K), vitamin A deficiency has
been shown by some investigators to produce an anemia similar to iron-deficiency
A mixed pattern of anemias has been associated with protein deficiency in preg-
nancy. The increasing needs of the mother and the demands from the fetus increase
protein requirements from about 45 g in the nonpregnant state. Protein deficiency is
not uncommon in a great part of the world, and anemia associated with kwashiorkor
is a characteristic normochromic and hormocytic anemia43 that is associated with
decreased erythropoiesis and reduced iron intake.46
A variety of anemias are associated with chronic ingestion of alcohol. Alcohol
decreases folate levels through a direct effect on folate metabolism, and poor dietary
intake leading to nutritional deficiency is common in these pregnant women. There-
fore alcohol-related anemia may present with microcytic red cells or normochromic
and macrocytic cells, with an increased number of ring sideroblasts.43


Significantly higher Hb levels have been found in pregnancies complicated by fe-

tal growth retardation and perinatal distress.47,48 A number of important reports have
also demonstrated a correlation between high maternal Hb levels in the first and sec-

ond trimester with pregnancy complications including low birth weight, preterm
birth, pregnancy-induced hypertension, and intrauterine death of unknown
cause.27,49 Murphy et al. showed that the frequency of hypertension in primiparas
ranged from 7% with Hb values under 10.5 gr/dl to 42% with Hb concentrations over
14.5 gr/dl.27 Garn et al. found that fetal death was 2.6 times more frequent with ma-
ternal Hb levels around 14 gr/dl than when it was around 8 gr/dl.23
It is probably that the explanation for the development of these complications is
the failure of the pregnancy to induce sufficient hemodilution, a major adjustment of
normal pregnancy. This failure may be caused by faulty implantation or by inade-
quate genetic endownment. Moreover, a number of studies have shown that abnor-
mally high maternal Hb levels probably impair the uteroplacental circulation by
raising the whole-blood viscosity.50,51 It is known that the major component of
whole-blood viscosity is the concentration of Hb/Ht.52
Garn et al. found that Hb values of 11 gr/dl (Ht 34) for blacks and Hb 12 gr/dl
(Ht 36) for whites are the optimum values for pregnant women, whereas Hb values
of 13 gr/dl (Ht 41) are the upper border values for an optimal outcome.23 A practical
conclusion is that an Hb value of 13 gr/dl or higher in the second trimester should be
a cause for concern.


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