Anemia

Anemia during pregnancy is defined as a haemoglobin level of 11 mg/dl or less (hematocrit of <33%) except during the second trimester when the cut-off point is reduced to 10.5 mg/dl. It is said to be severe if the haemoglobin is less than 8gm/dl in pregnant mothers

Incidence and causes

- It affects approximately 5- 50% of pregnant women in tropics and < 2% mothers in developed countries. It is more severe in tropics. It is the leading cause of indirect maternal mortality and morbidity. Anaemia is the most common haematological abnormality during pregnancy.

- The majority are nutritional anaemia. Iron deficiency anaemia accounts for 80-95% of nutritional anaemia during pregnancy. Other causes of anaemia are not common during pregnancy.

How nutritional anaemia will occur?

The requirement of iron during pregnancy is around 1000mg (450mg for red blood cells and uterine muscle, 270 mg for foetal iron, 170-200 mg for daily loss and 90 mg for placenta). There are additional needs for blood loss during delivery (190 mg) and lactation (1mg/day).

Assuming the stores are adequate a pregnant woman average daily dietary requirement is 3.5 mg/day. Failure to meet this demand eventually ends up in anaemia. The sequence of events in the development of frank anaemia is depletion of the stores followed by deficient production of RBC and finally reduction in the number of RBC, which results in decreased hematocrit. This leads to pallor and decrease of circulating haemoglobin resulting oxygen deficiency for cellular activities.

The predisposing factors for iron deficiency anaemia are the following:

Inadequate intake of iron: food taboos, poor dietary habit, low socioeconomic status.
Low store at the beginning of pregnancy: short interval between pregnancies, excess menstrual flow, hookworm infestation.
Blood loss during pregnancy: early and late pregnancy bleeding, hookworm.
Increased demand: multiple pregnancies, chronic infections.
Presence of hookworm infection.

Complications

Anemia is associated with adverse pregnancy outcome on the mother, fetus and neonate.

Fetal: spontaneous abortion, preterm delivery, low birth weight, intrauterine growth restriction and stillbirth.
Maternal: congestive heart failure and pulmonary edema especially in labor and the postpartum period, postpartum hemorrhage, puerperal sepsis, delayed wound healing, apathy, increased risk of other infections like tuberculosis.
Neonatal: anemia of infancy.

Treatment

It depends on the cause, severity and the gestational age.

Iron deficiency anemia: Ferrous sulfate 300mg containing 60 mg elemental iron of which 10% is absorbed, three times per day, orally; Continue treatment for 3months after the hemoglobin concentration returned to normal (laboratory facility ) or sign and symptom improved. Alternatives are ferrous fumarate and ferrous gluconate. Send her for follow up with weekly hemoglobin and reticulocyte determination.
Underlying causes, if any (like hook worm, malaria and chronic illnesses), other than nutritional deficiency, should also be treated.
If the condition becomes worse, refer the client for further investigation and treatment.