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Anemia in Pregnancy Chowdhury S1, Rahman M2, Moniruddin ABM3

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Anemia in Pregnancy Chowdhury S1, Rahman M2, Moniruddin ABM3 Review Article Anemia in Pregnancy Chowdhury S1, Rahman M2, Moniruddin ABM3 Abstract Classification of anemia in pregnancy Anemia is the commonest hematological disorder that Grossly classified into two types4: occurs in pregnancy. According to the recent standard laid down by ‘WHO’, anemia is present when the Hemoglobin (A) Pathological anemia in pregnancy. (Hb) concentration in the peripheral blood is 11 gm/dl or less. The most common cause of anemia in pregnancy is (B) Physiological anemia in pregnancy. lack of iron. Less often, it is caused by folic acid deficiency. (A) Pathological Anemia is further sub-classified into In some populations, 80% of pregnant women are anemic. Those most at risk are women from low socio-economic 1. Deficiency Anemia, e. g., groups and teenagers. Anemia is diagnosed by estimating the hemoglobin concentration and examining a peripheral blood -Iron deficiency smear for the characteristic red blood cell changes. Iron -Folic acid deficiency and folate supplementation is indicated during pregnancy to prevent the complications. -B12 deficiency -Protein deficiency Key words : Erythropoiesis, Puerperium, APH, PPH, ANC, LBW, IUD. 2. Hemorrigic: Acute hemorrhagic: Following bleeding in early month of Introduction pregnancy or APH Anemia is a lack of functioning red blood cells (RBCs) that Chronic hemorrhagic: as by hookworm infestation, GI leads to a lack of oxygen-carrying ability, causing unusual (gastrointestinal) bleeding. 1 complications during life time . These RBCs are produced in 1. Hereditary: the bone marrow. They have a life expectancy of about 120 Thalassemias – Haemolobinopathies. days. Among other things, the body needs iron, vitamin B12 & folic acid for erythropoiesis. If there is a lack of one or more Hereditary hemolytic anemia – RBCs defects. of these ingredients or there is an increased loss of RBCs, anemia develops. Any patient with a Hb of less than 11 2. Bone Marrow insufficiency: as by radiation, marrow suppressant drugs. gm/dl to 11.5 gm/dl at the start of pregnancy will be treated as anemic. The reason is that as the pregnancy progresses, 3. Anemia of infection – as by malaria tuberculosis the blood is diluted and the woman will eventually become 4. Chronic diseases : as in nephropathies & neoplastic anemic. The dilution of blood in pregnancy is a natural disorders. process and starts at approximately at the eighth week of pregnancy and progresses until the 32nd to 34th week of It is noteworthy that obstetricians are concerned with two pregnancy2. common types of anemia. They are : 5. Deficiency anemia, Incidence 6. Haemorrhagic anemia 3 In tropical countries, the incidence of anemia in pregnancy It has been found there is increased prevalence of anemia in is about 40-80%. pregnancy in tropical countries. In developed countries, it ranges between 10-20%. This is due to It is responsibe for 20% of maternal death in developing countries. a. Faulty dietary habit, b. Faulty absorption mechanism, 1. Corresponding Author: Salma Chowdhury MBBS, DGO c. More iron loss due to sweating and repeated pregnancy Senior Consultant (Gynae) at short interval; prolonged period of lactation, Central Police Hospital, Rajarbag, Dhaka d. Infection : Chronic malaria, tuberculosis, Email: [email protected] e. Excess demand of iron : pregnancy is an iron deficit 2. Mizanur Rahman MBBS, FCPS state. Associate Professor of Surgery Faridpur Medical College, Faridpur (B) Physiological Anemia 3. ABM Moniruddin MBBS, FCPS During pregnancy there is disproportionate increase in Professor of Surgery plasma volume upto 50%, RBC 33% and Hb 18-20% mass. City Medical College, Itahata, Gazipur In addition there is marked demand of extra iron during 2014 Volume 26 Number 01 49 REVIEW ArticLE pregnancy especially in the second half of pregnancy. Differential Diagnosis of deficiency anemias in So, physiological anemia is due to combined effect of pregnancy:6 hemodialution & negative iron balance. - Infection, Criteria of Physiological Anemia include5 - Nephritis, - Hb% - 10 gm r less, - Hemoglobinnopathies. - R.B.C – 3.5 million/mm3, Treatment of anemia in Pregnancy:7 - P.C.V – 30%, - Prophylactic - PBF – Normal morphology with central pallor. - Curative Prophylaxis includes Clinical features of iron deficiency Anemia depends more on - Avoidance of frequent child birth by proper family the degree of anemia. Symptoms of anemia include lassitude, planning method. feeling of exhaustion, weakness, anorexia, indigestion, Dietary prescription: Realistic balanced diet rich in iron and palpitation, swelling legs Signs of anemia include pallor, portion like liver, meat, eggs, green vegetable etc. Adequate glossitis, Stomatitis, edema legs, soft systolic murmur in treatment should be instituted to eradicate hook worm mitral area. Investigations are done to detect the degree of infestation, control of dysentery, malaria, nephropathies & anemia, the type of anemia the cause of anemia. excision of bleeding piles. Hb level should be estimated at the 1st ANV and 30th and finally at 36th week. To ascertain the degree of anemia one must look for Hb%, RBC count, PCV (Packed Cell Volume). Mild anemia means Curative treatment: Hb- 8-10 gm%; Moderate- less than 7-8 gm%; Severe – Less - Hospitalisation, if Hb level is below 7.5 gram percent. than 7 gm%. General treatment: To determine type of anemia one must examine the PBF - Diet – balanced diet rich in protein, vitamins and iron (Peripheral Blood Film), hematological indcies like MCV, - Antibiotic for infective focuses, if any. MCH, MCHC, etc. Specific Therapy as needed: A typical iron deficiency anemia shows the flowing blood - Oral, values: - Parental, - Hb-less than 10 gm% - Blood transfusion. - RBC – less 4 million/ mm3 Depending on - PCV – less than 30% - Severity of anemia, - MCHC – Less than 30% - Duration of pregnancy, - MCV – less than 75% micro mole m3 (meter cube) - Associate complicating factor. - MCH- less than 25 pg. Iron Therapy: Serum iron is usally below 30 micro gram/ 100 ml. Total iron Parenteral – binding capacity increases to 400 micro gram/100ml. Serum ferritin falls below 15 micro gm/L. 1. Intravenous, a. Total dose infusion, To find out the cause of anemia, the physician should carefully follow the basic protocols. b. Multidose infusion, - History taking, 2. Intramuscular: - Iron dexran, - Physical examination, - Iron sorbital. - Routine examination of stool to detect helminthes or occult blood, Estimation of total requirement: - Urine is examined for the protein, sugar and pus cells, 0.3 X W ( 100-Hb%) gm of elemental iron + addition of 50%. - X ray chest in suspected cases of pulmonary tuberculosis; Improvement is expected withon 3-4 weeks. but in case not responding to therapy, bone marrow study Advantage of blood transfusion:8 should be undertaken. - Increased O2 carrying capacity, - Blood for PBF & malarial parasites, - Hb from heamolysed RBC, - Kidney function tests like BUN & s. creatinine, etc. - Stimulating by erythropoietin, 50 2014 Volume 26 Number 01 REVIEW ArticLE - Supplies natural content of blood antibodies, In 3rd stage- - Improvement is expected after 3 days. - Active management. Precaution: Prophylactic antibiotic to prevent infection - To prevent circulatory over load, - Iron therapy for at least 3 months following delivery. - Antihistamine for allergic episodes, Risk periods: - Diuretic injection 20 mg Frusemide, - At 30-32 weeks of pregnancy, - Careful observation of respiration & crepitations at the - During labor, lung bases. - Immediately following delivery. Place of blood transformation : Prognosis:10 Indications: Maternal aspect- - To correct blood loss, 1. If detected early & proper treatment is instituted, anemia - To combat PPH, improves promptly; - Beyond 36 weeks and severe anemia, refectory anemia. 2. Substantial chances of recurrence in next pregnancy, Quality and quantity of blood: 3. Contributes to about 2-% maternal death in developing countries. - Fresh and properly typed, grouped and cross matched; only PCV are transfused. Fetal aspects- - Quantity 80-100 ml at a time interval after 24 hours for - Baby born at term from severely anemic mother will not circulating readjustment. be anemic at birth. But there is little or no reserved iron. So anemia develops at neonatal period, Complications of severe anemia:9 - Preterm labour, During pregnancy- - LBW (Low Birth Weight), - Pre-eclampisa, - IUD (Intra-Uterine Death). - Recurrent infection, Discussion - Heart failure, The most common cause of anemia in pregnancy is iron - Preterm labour, deficiency. It usually occurs due to low iron stores prior to pregnancy. The growing fetus depletes what stores there are During labor- and takes priority for any iron available. It is important to - Uterine inertia, remember that increased iron requirements continue after the birth of the baby due to blood loss and breastfeeding. Less - PPH, often, anemia in pregnancy is caused by folic acid deficiency. - Cardiac failure, In certain populations, pregnancy can be complicated by sickle cell trait and anemia, as well as thalassaemias11. - Shock. These diseases, in which the red blood cells are abnormal, During puerperium: present special problems in pregnancy. In some populations, as many as 80% of pregnant women are anemic. They are - Puerperal sepsis, generally women from lower socio-economic groups in - Sub-involution, developing countries as well as pregnant teenagers. Women who experienced heavy periods and those who became - Failing lactation. pregnant soon after the birth of a
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