American Journal of

Obstetrics and Gynecology

EDITORS: GEORGE IV. KOSMAK, M.D., AND Hmo E~HRENFEST, M.D.

Editorial Comment

Anemia in Pregnancy

A LTHOUGH almost a full century has passed since Walter Charming

of Boston first described anemia in pregnancy, prior to the last
ten years the progress of knowledge was essentially limited to deserip-
tive and nosologic studies of this condition. Investigators were, for the
most part, so thoroughly imbued wit,h the belief in a positive etiologic
agent, a ntaterips nao&, that an untold amount of time and energy was
devoted to the search for the hypothetic toxin which, elaborated by the
product of conception, resulted in the development. of anemia. The in-
troduction of liver therapy in pernicious anemia a decade ago by Minot
ushered in a virtual renaissance of fruitful research in the field of
hematology. The work of Whigple, Minot, (~‘ast.le, and their various
associates established in a quantitative way the relationship of food,
digestion, and absorption to blood formation. It therefore became ob-
vious that t,he best method of attacking the problem of anemia in preg-
nancy would be by the study of these factors in pregnant women.
Early observers had demonstrated that there were different types of’
anemia in pregnancy, many of them dependent on well-established causes
for anemia, such as hemorrhage, sepsis, nephritis, and the like. Two
distinct types, however, remained associated with I-JO obvious cause. Onr
of these was morphologically similar to addisonian pernicious anemia,
the other to simple hypochromic anemia. 111 1928 there was recorded
the first successful treatment of a case of pernicious anemia of preg-
nancy with liver by Deschamps and Fropez. Two gears later an un-
equivocal demonstration of t.he successful treat.mcnt of hypoehromi,
anemia of pregnancy with iron in adequate dosage was lmblished 1)~.
Strauss. Following these reports many investig,ators have established
beyond question that in t,he absence of complicat,ions, pernicious anemia
of pregnancy may be relieved by liver therapy and hyI)oehromie anemia
of pregnancy by iron therapy, provided th,at irk each instance a~& ade.,
qzcate unzozant of liver or iron be employed. It has been shown that t.htl
mere administration of some liver or so~zt! iron is not sufficient. F,nough
687
688 AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY

must be given, and by the appropriate route, for the individual case. In
this respect neither pernicious nor hypochromic anemia in pregnancy
differs from’similar types of anemia in the nonpregnant.
The nature of the deficiency state resulting in addisonian pernicious
anemia has been somewhat elucidated. A substance, to be found in
liver, kidney, brain, placenta. and perhaps ot,her organs, is necessary for
norma hematopoiesis in man. This substance is apparently elaborated
through the interaction of an enzyme-like factor found in normal hu-
man gastric juice and a substance present in the average human dietary.
It has been shown that the gastric factor is not any of the common
ferments of gastric juice. The dict’ary factor is frequentI>- associatctl
with foods rich in the vit,amin B complex, although no1 t,o hc identified
with any of the known ljnrificd componcnt,s of this vitamin. Evidence
has further been produced which suggests that dist,urbances of intcstina I
absorption may result in a virtual dcficicncy of the product, of inter-
action of the gastric and food factors.
Studies of pernicious anemia of prcgnanc;v 1)~ Strauss have shown
that the condition. may result from a temporary suppression of secrt~iion
of Castle’s gastric factor, from a lack of the dietary factor or from :I
combination of these two. Although defective absorption has not been
demonstrated to be etiologically related to pernicious anemia of preg-
nancy, it seemsprobable that this does play a ri3e in some cases.
Simple hypochromic anemia in nonpregnant individuals has been
shown to be associated with a deficiency of available iron. This defi-
ciency may result from an inadequat,e intake of iron, from impaired
absorption or from loss from the body. The high incidence of gastric
anacidity in patients with hypochromic anemia has suggest,ed that t,his
or some associated gastrointestinal defect results in malabsorption of
iron. Pregnant. women wit,11 hypochromic anemia have been shown to
have a high incidence of gastric anacidity; many have partaken, not
only during pregnancy, but frequent,ly over a period of years, of diets
low in iron content. Further, attention has been directed to the obvious
fact that all the blood-forming materials which enter into the fetal or-
ganism are derived from the mother. This is comparable, as far as t,he
maternal body economy is concerned, lo chronic hlood loss.
Pernicious anemia is relatively rare in pregnancy in the temperate
zone. When it occurs it may be controlled by liver therapy, preferably
administered parenterally. Its prevention in many instances is to be
achieved by the administration of a diet rich in foods containing the
vitamin B complex such as meat and other proteins.
Moderate degrees of hypochromic anemia are common in pregnancy,
!l?hex.is reason to believe that an adequate dietary for the pregnant
woman will eliminate many of these cases. However, proper food is frc-
quently costly and dietary habits of a lifetime are altered with difficulty.
Hence, it should be of great interest to all concerned with maternal wel-
 EDITORIAL COMMENT tip9

fare to note that the daily administration of as little as 0.5 gm. (79$ gr. 1
of ferrous sulphate to women during the last four months of gestation
has prevented the development of hypochromic anemia in a large series
of casesin spite of the fact that most of these women partook of diets
which were considered inadequate. Onr of every four women of it con-
trol, untreated group of pregnant women developed hppochromic anrtuia
with less than 70 per cent hemoglobin.
The conclusions that may be drawn From the studies t,hat have been
outlined are of practical significance. ilnemias occur in pregnancy, not
as a result of mysterious hypothetic tosins but from the same types of
mechanism as produce similar anemias in the nonpregnant. The t real -
ment must thus he, not the termination of pregnancy, but the cxhibitiotl
of the proper, IFOUP~, therapeutic agents. Hypochromic anemia in
pregnancy is to be prevcntcd by the use of some simple iron salt, in
adequate amount, and the employment of diets containing n(~r(l~~i~t(~
amounts of blood-building matcrinls.

WILLIAM BLAIR-BELL
T IS with deep sorrow that we record the death, at the age of 65,
I on January 25, of Professor Blair-Bell, t,he d.istinguished English
gynecologist, author, editor, and research worker. He was well known
in t,his country and was made an honorary member of the American
Gynecological Society in 1923 after having been its oTscia1 guest
speaker at the annual meeting in IY22. Professor Blair-Bell made
numerous outstanding contributions to the liter.ature of his specialty,
but his chief efforts were devoted to two problems-the physiology of
the ductless glands and the treatment of cancer by chemical agent’s
His American colleagues may well acknowledge Blair-Bell’s genius,
a man to whom they owe tribute for the monunnent.al services which
make his eventful career an outstanding one in Anglo-Americau
medicine.