Anemia and its implications in pregnancy

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Anemia, a condition characterized by a deficiency in the number or quality of red blood cells, affects millions of women worldwide, particularly during pregnancy. This summary aims to provide a concise overview of anemia in women, with a special focus on its implications during pregnancy.

Anemia is a prevalent global health concern, affecting approximately a quarter of the world's population, with women being disproportionately affected. There are various types of anemia, including iron-deficiency anemia, the most common type worldwide, caused by inadequate iron intake or absorption. Other types include vitamin B12 deficiency anemia, caused by insufficient absorption of vitamin B12, and folic acid deficiency anemia, caused by inadequate intake of folic acid.

During pregnancy, women are at increased risk of developing anemia due to physiological changes such as expansion of blood volume and increased iron requirements to support fetal growth and development. Iron-deficiency anemia is particularly common during pregnancy and can have serious consequences for both the mother and the developing fetus if left untreated.

The symptoms of anemia in women can vary depending on the severity and type of anemia but often include fatigue, weakness, pale skin, shortness of breath, and dizziness. Diagnosis typically involves blood tests to measure hemoglobin levels and assess the underlying cause of anemia.

Treatment of anemia in women, especially during pregnancy, aims to correct the underlying cause and replenish depleted iron stores. This often involves iron supplementation, either orally or intravenously, along with dietary changes to increase iron intake. In some cases, blood transfusions may be necessary, particularly in severe or life-threatening cases of anemia.

Prevention of anemia in women, particularly during pregnancy, is crucial and can be achieved through adequate nutrition, including a diet rich in iron, vitamin B12, and folic acid. Prenatal vitamins containing these nutrients are often recommended for pregnant women to help prevent anemia and support healthy fetal development.

In addition to nutritional interventions, other strategies for preventing anemia in women include early detection and treatment of underlying medical conditions that can lead to anemia, such as gastrointestinal disorders or chronic diseases.

In conclusion, anemia is a significant health issue affecting women worldwide, with pregnant women being particularly vulnerable due to increased iron requirements. Early detection, proper diagnosis, and timely intervention are essential in managing anemia in women, especially during pregnancy, to prevent complications and promote maternal and fetal health

1. Prof. Waseem Talib MCPS, FCPS, FIMSA Professor of Gynecology Lahore Medical & Dental College Lahore , Pakistan Advanced Certification in Assisted Reproductive Techniques Fellow International society of Minimally Invasive Surgery Anemia

2. Magnitude of the Problem Affects more than 2 billion people globally Accounts for over 30% of the world’s population Most common health problem in Africa and South East Asia WHO . Micronutrient deficiency, prevention and control guidelines. Geneva: WHO 2015

3. Anemia in Pregnancy Iron Deficiency Anemia (IDA) is the commonest anemia in pregnancy In Pakistan IDA is followed by folate and then Vit . B12 deficiency anemia in pregnant women Prevalence is seen to vary between 48.2% to 55.3% Yajnik CS et al. Vitamin B12 deficiency and hyperhomocysteinemia in rural and urban Indians. J. Assoc Physicians India. 2016;54 : 775-82

4. Definition of Anemia in Pregnancy WHO defines anemia in pregnancy as: Hemoglobin of < 11 gm/ dl (7.45 mmol /l) Hematocrit of < 33% Postpartum hemoglobin of <10 gm/ dl

5. Physiological Changes in Pregnancy that contribute to anemia Plasma volume ↑ by 1250 ml Red Cell Mass ↑ by 250 ml MCV↑ by 4-6fl Von Willibrand factor, factor VII, VIII and X ↑ Protein S↓ Protein C and factor IX remain unchanged Neutrophilia and leucocytosis APTT is shortened

6. Impacts of Anemia in Mothers Responsible for 40% maternal deaths in Asia & Africa Direct deaths 25% Indirect deaths CCF Heamorrhage Infection Pre eclampsia If Hb falls to < 5 gms / dl, it results in 8-10 fold increase in maternal mortality

7. Impacts of Anemia in Infants Increased perinatal morbidity and mortality due to Preterm delivery Low birth weight infants SGA infants Low iron stores Cognitive and affective dysfunction Lower mental development

8. Severity of Anemia Severity of Anemia Hb Concentration (gm/d l) ICMR 2006 Hb Concentration (gm/dl) WHO 2011 MILD 8.0-10.9 10-10.9 MODERATE 5-7.9 7.0-9.9 SEVERE <5 4.0-6.9 VERY SEVERE <4

9. Factors Affecting Iron Stores in Pregnancy (Iron Loss) Physiological Factors Basal losses from desquamation from intestines and skin Previous Menstruation Previous Delivery Previous Lactation Pathological Factors Hookworm and other helminths Haemorrhage from GIT Allergies Occult blood losses

10. Causes of IDA in Low Income Countries Dietary habits Defective iron absorption Increased loss of iron due to intestinal infections Multiparity

11. Factors Affecting Iron Stores in Pregnancy (Iron Absorption) Dietary Iron Enhancers of Absorption Haem iron Proteins, amino acids Meat Ascorbic acid Fermentation Ferrous iron Gastric acidity Alcohol Low iron stores Increased erythropoietin activity (high altitude, haemolysis , bleeding) Inhibitors of Iron Absorption Phytates Calcium Tannins Tea and coffee Herbal drinks, milk Fortified iron supplements Multivitamin

12. Iron Requirements in Pregnancy Varies with maternal body weight In a typical singleton pregnancy about 1000 mgs of iron is required in total; 300 mgs for fetus and placenta 500 mgs for maternal red cell mass expansion 200 mgs for basal losses e.g. shedding of cells from GIT, skin and urinary tract

13. Iron Requirements in Pregnancy Daily iron requirement increases to 5-6 mg / day in 2 nd and 3 rd trimester Absorption is usually 10% At least 50-60 mg of iron should be available in the diet Diet alone is insufficient in providing this amount and hence the need for iron supplementation

14. Clinical Features of IDA (Symptoms) Skin Pallor Cold skin Yellowish discoloration Eyes Pallor Respiratory Shortness of breath Muscular Weakness Intestinal Changed stool color Central Symptoms Fatigue Dizziness Fainting Blood vessels Low blood pressure Heart Palpitation Rapid heart rate (tachycardia) Chest pain Angina Heart attack in severe anemia Abdominal Spleen enlargement Liver enlargement

15. Signs of Anemia Pallor – conjunctiva, tongue, plate, nail, palm, Koilonychia Dryness and roughness of skin Brittle hair Glossitis , stomatitis Pedal oedema Raised JVP Tachycardia, collapsing pulse Postural hypotension Tachycardia, haemic murmur (soft systolic murmur) Respiratory system (chest), tachypnoea , fine crepitations at bases of lungs Abdominal examination may reveal hepato splenomegaly

16. Investigations Hb measurement Peripheral blood film Reticulocyte count Hematocrit Blood indices Serum iron < 30 µ g/ dl TIBC > 400 µ g/ dl Serum ferritin Transferrin saturation

17. Aim of Treatment Establish cause of anemia Correct deficiency Replenish iron stores

18. Treatment Oral iron therapy Parenteral iron therapy Blood transfusion Whole blood Packed cells

19. Oral Iron Therapy Route of choice First line therapy Absorbed in ferrous form Available as ferrous sulphate , ferrous fumarate , ferrous succinate etc Daily iron supplementation along with folate therapy has to be given

20. Indicators of Response to Therapy Feeling of well being Improved look Better appetite Increased reticulocyte count Improvement should be evident within 3 weeks of therapy

21. Reasons for Failure to Respond to Oral Therapy Inaccurate diagnosis Faulty absorption Non compliance Continuous blood loss Inhibition of erythropoiesis by co-existing infection Concomitant folate deficiency Presence of chronic infection Aplastic anemia Myelodysplastic syndrome

22. Indications for Parenteral Iron Therapy Intolerance to oral iron Poor compliance Malabsorption No response to oral iron in 2 weeks IDA in 3 rd trimester

23. Parenteral Iron Therapy Only indicated when a pregnant woman is unable to take oral iron due to side effects or non compliance

24. Contraindications to Parenteral Iron Non IDA Hemoglobinopathies Liver cirrhosis H/o severe asthma, eczema or atopic allergies 1 st trimester of pregnancy

25. Dose Calculation of Parenteral Iron Formulae Hb deficit (15-patient’s Hb ) x weight (kg) x 2.3 + 500-1000 (for stores) 250 g x Deficiency of Hb% (simplest formula), for e.g., if a woman has 8 g/dl Hb, the iron requirement will be 15-8 x 250 = 1750 mg of iron 0.23 x body weight (kg) x (150-patient Hb in g/L) + 500 0.3 x body weight in pounds x Hb deficit + 500

26. Route of Administration Intramuscular (I/M) Intravenous (I/V)

27. Intramuscular A dose of 100 mgs/ day Confirmed diagnosis of IDA Oral therapy to be stopped 48 hours before parenteral therapy to avoid toxicity Steroids, adrenaline and oxygen should be available Disadvantages Skin discolouration Abscess formation Nausea and vomiting Headache Fever

28. Intravenous Iron Therapy Iron dextran Iron sucrose Iron isomaltoside Ferric carboxymaltose

29. Intravenous Iron Therapy Iron Dextran is cheaper Associated with severe anaphylactic reactions Total Dose Imferon (TDI)

30. Iron Sucrose More expensive than iron dextrans Associated with less side effects Cannot be given as a bolus Given as 200 mgs I/V 2-3 times per week till requirement is complete

31. Iron Sucrose Gives higher rise in serum ferritin as compared to oral therapy Significant Hb rise compared to oral iron therapy

32. I/V iron (cont’d) Ferric carboxymaltose is now the treatment of choice. Approved by FDA for use in postpartum anemia initially, but can now be used in pregnancy Better tolerated Significant improvement in haemoglobin upto 1g/dl/week. Iron isomaltoside is also used

33. Other Treatments Erythropoietin Blood transfusion Severe anemia first seen near term (after 36 weeks) or in labor Anemia due to blood loss, e.g., APH or PPH Associated infection Patients not responding to oral or parenteral iron therapy Hemoglobinopathies

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