* CPC *

ANEMIA
IN PREGNANCY
Department of
GYNAECOLOGY & OBSTETRICS
Presented by :
Abdullah Junaid Tariq
Afifa Roy
Farjad Naveed Ahmad

10009
10014
10021

HISTORY
By :
Abdullah Junaid
Tariq

PATIENTS PROFILE
Name : Zohra Kashif
Husbands Name : Kashif Hussain
Age : 21 yrs
Married for : 1 year
Resident of : Fatehgarh, Sialkot
Mode of Admission : Admitted through OPD
Date of Admission : 8/09/15
GPA : Primigravida
LMP : 25/12/14
EDD : 2/10/15

PRESENTING COMPLAINTS
Gestational amenorrhea ---- 36 weeks
Shortness of breath & Lethargy ---- 2
months

HISTORY OF PRESENT ILLNESS

Dates back to 36 weeks, when my patient was in
her usual state of health
Then she missed her periods and confirmed her
pregnancy by investigations.
Two months ago, she developed
breathlessness, which was aggravated on exertion e.g
climbing stairs, doing the routine household work.
Breathlessness was not associated with fever, cough,
wheezing, chest pain, palpitations or edema feet
It was relieved by rest.
She also experienced fatigue, after performing routine
activities.

Systemic Inquiry
Alimentary system : No history of nausea,
vomiting, diarrhea, constipation or
abdominal pain/cramping
Genitourinary system : No history of
burning micturition, increased urinary
urgency & frequency
Central Nervous system : No history of
vertigo, headache or convulsions
Musculoskeletal system : No history of
joint, bone or muscular pain

TRIMESTER HISTORY
She conceived spontaneously
1st TRIMESTER :
She confirmed her pregnancy by Urine Test.
Nausea and vomiting were present
No history of burning micturition or increased
urinary frequency/urgency
No per vaginal bleeding
Folic acid & calcium supplements were taken
1st Antenatal Care Visit : 6/03/15
Dating scan was done at that time

 2nd TRIMESTER :
Fetal movements (quickening) were felt at 5
months and were normal
Calcium supplements were taken
Iron supplements were prescribed but she did not
take those, due to poor compliance and tolerance.
Nausea & vomiting settled
No burning micturition or increased urinary
frequency/urgency
Anomaly scan was done at 20 weeks
Blood pressure was normal

 3rd TRIMESTER :
She developed breathlessness & easy
fatigability
Blood pressure was normal
CBC was done (Hb was 8 g/dl)
Fetal well-being scan was done
No history of burning micturition or
increased urinary frequency/urgency
No per vaginal bleeding

MENSTRUAL HISTORY
o Age of Menarche : 12 years
o LMP : 25th December 2014
o Duration of Menstrual Period : 7/28
o Pattern : Regular
o Flow : Average / Heavy
o Dysmenorrhea : Present
o Dyspareunia : Present
o Vaginal Discharge : Absent
o Inter-Menstrual Bleeding : Absent
o Post-Coital Bleeding : Absent
o No history of Contraceptive use
o Pap smear was not done

PAST HISTORY
No history of TB, Hepatitis B/C, DM,
Asthma, Malaria, Thalassemia,
Hypertension, IHD, GI diseases
No previous hospitalisations or operations
No history of trauma

FAMILY HISTORY
No history of Diabetes Mellitis, IHD, TB,
Asthma, Hypertension, Thalassemia,
Leukemia
No history of chronic diseases and
gynaecological malignancies in the family

DRUG/ALLERGIC HISTORY
Patient was allergic to parenteral iron.
No other drug allergies, food allergies or
seasonal allergies were noted.

PERSONAL HISTORY

She had normal eating and sleeping habits

Urinary & bowel habits were normal
She had no addictions
She had gained some weight

SOCIOECONOMIC HISTORY
Patient belongs to a middle class family
Her husband is a factory employee
She lives in a joint family system, in her
own house
Basic life facilities are met with ease

CLINICAL
EXAMINATION

GENERAL PHYSICAL EXAMINATION

A pale looking, young lady, sitting on the
bed, well oriented in time, place and
person, intelligently answering the
questions.

VITALS :
Pulse : 85/min (regular)
Blood Pressure : 130/85 mmHg
Temperature : 98.6F
Respiratory rate : 16/min

No clubbing, koilonychia, leukonychia.

Palms were pale
Lower conjunctiva was pale
Jaundice was not present
Oral hygiene was normal
Thyroid was normal
Accessible lymph nodes were not palpable
No edema feet

ABDOMINAL EXAMINATION
Inspection :
Abdomen was symmetrically protuberant, with no scar marks,
visible veins or pulsations.
Striae gravidarum were present
Palpation :
Abdomen was soft and non tender
Symphysiofundal height was 36 cm with longitudinal lie and
cephalic presentation.
Fetal head was 5/5th palpable
There were no palpable contractions ; Liquor was adequate
Auscultation :
Fetal heart rate was normal (140/min)

 CARDIOVASCULAR EXAMINATION :
S1 + S2 + 0
No added sounds
No distended neck veins
RESPIRATORY EXAMINATION :
Normal vesicular breathing with no
added
sounds

INVESTIGATIONS
By :
Afifa Roy

COMPLETE BLOOD PICTURE

BLOOD GROUP & Rh FACTOR

SERUM ALT & URIC ACID

OTHER INVESTIGATIONS
Random Blood Glucose 90 mg/dl
(Normal = < 140
mg/dl)
HbsAg Negative
Anti - HCV Negative
Urine examination Normal
Peripheral blood film Microcytic
hypochromic
anemia

DIFFERENTIAL DIAGNOSIS
(Microcytic Anemia)

Iron deficiency anemia

Thalassemia minor
Sideroblastic anemia
Lead poisoning
Anemia of chronic disease

PROVISIONAL DIAGNOSIS
Iron Deficiency Anemia

MANAGEMENT

 GENERAL TREATMENT :
Bed rest
Proper diet
SPECIFIC TREATMENT :
2 units of blood were transfused to the
patient

LITERATURE
REVIEW
(ANEMIA IN PREGNANCY)
By :
Farjad Naveed Ahmad

DEFINITION
By WHO :
Hb < 11 gm /dl
(or Hematocrit <33%)
GRADING :
Mild anemia
Moderate anemia
Severe anemia
Very Severe anemia

9 -10.9 gm /dl
7-8.9 gm /dl
< 7gm /dl
< 4gm/dl

INCIDENCE
Commonest medical disorder
Highest incidence in underdeveloped
countries
In Pakistan, 56% of the pregnant women
are affected
Increased maternal morbidity & mortality
Increased perinatal mortality

TYPES OF ANEMIAS IN PREGNANCY

Common types :
Nutritional deficiency anemias
- Iron deficiency
- Folate deficiency
- Vit. B12 deficiency
Hemoglobinopathies:
- Thalassemias
- Sickle cell disease

Rare types:
-

Aplastic anemia
Autoimmune hemolytic anemia
Polycythemia rubra vera
Leukemia
Hodgkins disease
Paroxysmal Nocturnal Hemoglobinurea

ETIOLOGY OF ANEMIA IN PREGNANCY

There are 3 main causes :
1- Decreased Erythrocyte Production :
Nutritional deficiency anemias
2- RBC Destruction :
Hemoglobinopathies
3- RBC Loss :
Hemorrhage due to any cause during pregnancy
4- Volume Homeostasis :
Physiological anemia in pregnancy

VOLUME HOMEOSTASIS
(PHYSIOLOGICAL ANEMIA IN PREGNANCY)
Plasma volume increases by 50% (32-34
weeks)
But RBC mass increases only 25%
resulting in Hemodilution
Decreased Hb, Hematocrit & RBC count

MANAGEMENT PLAN
SCREENING :
Hb estimation on 1st antenatal care visit and
then at 28 & 36 weeks
EVALUATION :
History Symptoms
Clinical examination Signs
Investigations Red cell indices, RBC count,
platelet count & peripheral blood film

CLINICAL FEATURES
Symptoms usually appear in severe anemia
- Fatigue
- Giddiness
- Breathlessness

 TREATMENT of the cause of anemia.

The aim is to achieve a normal Hb level by
the last month of pregnancy.
Fetal and Maternal monitoring

COMPLICATIONS OF ANEMIA
In the Mother :
High output Cardiac Failure
Inadequate tissue oxygenation leads to progressively increased
cardiac output
Pre-eclampsia
PPH
Infection
Delayed general physical recovery esp. after C. Section
In the Fetus :
Low birth weight
IUGR (Intra Uterine Growth Restriction)
Depleted iron stores
Cognitive & affective dysfunction.

IRON DEFICIENCY
ANEMIA

 In 90% of pregnant women, anemia is due to

Iron Deficiency
Iron demand increases during pregnancy
Iron required for fetus and placenta = 500mg.
Iron required for red cell increment = 500mg
Postpartum loss =180mg.
Lactation for 6 months = 180mg.
Total requirement = 1360mg
360mg saved as a result of amenorrhoea
Total increase in iron demand = 1000mg

ETIOLOGY OF IRON DEFICIENCY ANEMIA

CAUSES :
1)

Insufficient intake :
Diet low in iron (vegan diet)
Malnutrition
Pica

2)

Defective iron absorption :

Ameobiasis, giardiasis, Vit. C deficiency, high gastric pH
gastric or bariatric surgery, diet containing iron
absorption inhibitors e.g coffee, tea, tannins etc

3)

Increased iron loss :

Repeated pregnancies, menorrhagia,
hookworm infection, schistosomiasis,
chronic malaria, excessive sweating, blood loss
due to hemorrhoids etc

CLINICAL FEATURES
Symptoms :
Mild anemia :
Asymptomatic

Moderate anemia :
Headache,weakness, fatigue,
anorexia, indigestion
Severe anemia = Palpitations, breathlessness

 Signs :
Mild anemia :
No signs
Moderate anemia :
Pallor, systolic murmur,
rapid pulse
Severe anemia = Koilonychia, hepatomegaly
generalized edema

INVESTIGATIONS
Hemoglobin estimation : < 11g/dl
Peripheral blood film : Microcytosis
Hypochromia
Anisocytosis
Poikilocytosis
Pencil shaped cells

Peripheral Blood Film in IDA

Red cell indices :

Serum Ferritin : < 15 ug/dl

Transferrin saturation : < 15 %
Total iron binding capacity : <15 %
Serum transferrin receptor : Increased
Free erythrocyte protoporphyrin :
Increased
Bone marrow examination : Blue granules
of stainable iron in the erythroblasts

Bone Marrow Examination

OTHER INVESTIGATIONS
RFTs & LFTs
Stool examination for occult blood &
malarial parasite
Urine examination for UTI and
Schistosomiasis

MANAGEMENT OF IDA
Has two aspects :
1) Treatment of established Iron Deficiency
Anemia
2) Prevention of Iron deficiency in NonAnemic women

TREATMENT OF IDA
SELECTION OF TREATMENT :
Depends upon
Severity of anemia
Duration of gestation
Additional obstetric complications e.g
Placenta Praevia

A. IRON THERAPY
. Oral Iron :
.
.

.
.
.

Mild to Moderate Anemia, during first two trimesters (upto 28

weeks)
Preparations :
- Ferrous Sulfate
- Ferrous Gluconate
- Ferrous Fumarate
- Carbonyl Iron
Ferrous Sulfate 325mg (65mg of elemental iron) t.i.d
To promote absorption, pt. should avoid tea and coffee, and
may take Vit. C (500units) with the iron pill.
Side effects (dose related) include Nausea, Vomiting,
Constipation, Abdominal cramping and Diarrhea

Parenteral Iron :

Mild to Moderate Anemia, between 28 and 36

weeks
or
Gestation < 28 weeks in whom oral iron has
proved ineffective due to poor compliance or
tolerance

Preparations :
1) IM - Iron Sorbitol (fewer side effects) ---- Z Technique
2) IV - Iron Sucrose or
Ferric Carboxymaltose injection
(Injectafer) 15mg/kg body wt.
)

Side effects :
Skin discoloration , abscess formation, allergic reaction, iron overload

 Blood transfusion :
Anemia beyond 36 weeks
If oral & parenteral therapy has failed
Excessive hemorrhage e.g APH
Under cover of loop diuretic (Furosemide)
Packed cells are preferred during
pregnancy, as whole blood can cause
transfusion reactions, pre-term labour and
overloading of heart.

PROPHYLAXIS
Iron supplements : Elemental iron
30-60mg/day for 6
months
during pregnancy &
continued for 3 months
postpartum
Treatment of infections : Hookworm
infections
Dietary advice : Food rich in iron, avoid
tea

IRON RICH FOODS