Treatment for Anemia If you are anemic during your pregnancy, you may need to start taking an iron supplement and/or folic acid supplement in addition to your prenatal vitamins. Your doctor may also suggest that you add more foods that are high in iron and folic acid to your diet.

1. ANEMIA-MANAGEMENT OF ANEMIA IN
PREGNANCY
MUKESH SAH, MD
POST GRADUATE MEDICAL INTERN
GOODSAM MEDICAL CENTER

4. PREVALENCE OF ANEMIA AMONG WOMEN
(NDHS 2016)

5. Anemia in pregnancy
■ Anemia is the commonest hematological disorder that
may occur in pregnancy.
■ Anemia is condition in which the number of red blood
cells or their oxygen-carrying capacity is insufficient to
meet the physiological needs of the individual, which
consequently will vary by age, sex, altitude, smoking and
pregnancy status. (WHO 2013)

6. Anemia in pregnancy
■ Anemia in pregnancy is defined as hemoglobin
concentration of less than 11g/dl. (James et al 2011)

7. Classification
Physiological
anemia in
pregnancy Pathological
anemia

8. Pathological
 Deficiency anemia of pregnancy (isolated or combined)
• Iron deficiency
• Folic acid deficiency
• Vitamin B12 deficiency
• Protein deficiency
 Hemorrhage
• Acute: following bleeding in early months or APH
• Chronic: Hookworm infestation, bleeding piles etc.

9. Cont….
 Hereditary
• Thalassemia
• Sickle cell anemia
• Other hemoglobinopathies
• Hereditary hemolytic anemia
 Bone marrow insufficiency
 Anemia of infection (malaria, tuberculosis)
 Chronic disease (renal) or neoplasm.

10. Physiological anemia of pregnancy (1/3)
■ During pregnancy the maternal plasma volume gradually
expands by 50% or an increase of approximately 1200
ml by term.
■ The total increase in RBCs is 25%, or approximately 300
ml.
■ This relative haemodilution produces a fall in Hb
concentration, which reaches its lowest level during the
second trimester in pregnancy and then rises again in
the third trimester.

11. Physiological anemia of pregnancy (2/3)
■ These changes are not pathological but are considered
to represent a physiological alteration of pregnancy
necessary for the development of the fetus.

12. Physiological anemia of pregnancy (3/3)

14. During pregnancy (1/2)
■ The women who has got sufficient iron reserve and is on
a balanced diet, is unlikely to develop anemia during
pregnancy in spite of an increased demand of iron. But if
the iron reserve is inadequate or absent.
■ The factors which lead to the development of anemia
during pregnancy are:
• Increased demands of iron

15. During pregnancy (2/2)
• Diminished intake of iron
• Disturbed metabolism
• Pre-pregnancy health status
• Excess demand: Multiple pregnancy, women with rapidly
recurring pregnancy, within 2 years following the last
pregnancy, teenage pregnancy

16. Iron deficiency anemia
■ It is most common type of anemia in pregnancy.
■ It is defined as a condition in which there are no
mobilizable iron stores and compromised supply to body
tissues.
■ During pregnancy iron deficiency increase the risk of
sepsis, maternal mortality, perinatal mortality and low
birth weight.

17. Iron deficiency is associated with:
■ Reduced intake of iron due to gastric malabsorption,
gastric surgery or dietary deficiency.
■ Short intervals between pregnancies.
■ Chronic infection such as malaria or human
immunodeficiency virus (HIV)
■ Chronic blood loss, e.g. menorrhagia or gastric ulcer
■ Hemorrhage
■ Secondary cause to medical disorders
■ Multiple pregnancy

18. Clinical manifestation
■ Irritability and depression
■ Breathlessness, poor memory, muscle aches
■ Palpitations , exhaustion or weakness, anorexia,
■ indigestion, swelling legs.
■ Pallor, dyspnea, giddiness
■ Glossitis and stomatitis, edema of legs

20. ■ Celiac disease- A disease in which the small intestine is hypersensitive to gluten, leading
to difficulty in digesting food.
- Eating gluten ( a protein found in wheat, barley and rye) triggers an immune response in
small intestine.
- Overtime, this reaction damages small intestines lining and prevents absorption of some
nutrients.
■ Pernicious anemia- It is a condition in which the body cant make enough healthy red
blood cells because it doesn’t have enough vitamin-12, vitamin B-12 is a nutrient found
in some foods.
- It is caused by an inability to absorb the vitamin B-12 needed for your body to make
enough healthy red blood cells.
- Impaired instrinsic factor production due to autoimmune destruction of parietal cells,
which secretes IF.
■ Biguanides- prevent the production of glucose in the liver.
- Groups of oral type 2 diabetes drugs that work by preventing the production of glucose
in liver, improving the body’s sensitivity towards insulins.

21. Investigation
■ History collection
■ Physical examination
■ Full blood count testing is the recommended method for
diagnosing anemia in pregnancy.
■ In setting where full blood count testing is not available
onsite hemoglobin testing with hemoglobinometer is
recommended over the use of hemoglobin color scale as
the method for diagnosing anemia in pregnancy.

24. ■ The patient having a hemoglobin level 9 gm% or less
should be subjected to a full hematological investigations.
The objectives of investigations are to ascertain:
 Degree of anemia.
 Types of anemia.
 Causes of anemia.
■ To ascertain the degree of anemia one must look for Hb%,
RBC count, PCV (Packed Cell volume). Mild anemia means
Hb- 8-10 gm%; Moderate- less than 7-8 gm%; Severe –
less than 7 gm%.

25. Complication
■ During pregnancy: Intercurrent infection, heart failure,
preterm labor.
■ During labor: uterine inertia, postpartum hemorrhage,
cardiac failure, shock.
■ Puerperium: puerperal sepsis, sub-involution, failing
lactation, puerperal venous thrombosis, pulmonary
embolism.

26. Effects on baby
■ Amount of iron transferred to the fetus is unaffected even
if the mothers suffers from iron deficiency anemia. So,
the neonate does not suffer from anemia at birth.
■ There is increased incidence of low birth weight babies
with its incidental hazards.
■ Intrauterine death-due to severe maternal anoxemia.
■ The sum effect is increased perinatal loss.

27. Management of anemia
■ Treatment of iron-deficiency anemia in pregnancy
increases the hematological parameters so, in
pregnancy women with mid-to-moderate anemia this
intervention could prevent the need for interventions
at a later stage that could prove more dangerous for the
mother and her baby.
■ In developing countries, where it is not possible, it is
advisable to give iron and folate routinely to all pregnant
women.

28. Prophylactic (1/2)
■ Daily oral iron and folic acid supplementation with 30mg
to 60mg of elemental iron and 400μg (0.4mg) of folic acid
is recommended for pregnant women to prevent
maternal anemia, puerperal sepsis, low birth weight and
pre-term birth.

29. Prophylactic (2/2)
■ Intermittent oral iron and folic acid supplementation with
120mg of elemental iron and 2800μg (2.8mg) of folic acid
once weekly is recommended for pregnant women to
improve maternal and neonatal outcomes if daily iron is
not acceptance due to side-effects, and in populations
with an anemia prevalence among pregnant women of
less than 20%.

30. Curative prophylaxis includes:
■ Avoidance of frequent child birth by proper family
planning method.
■ Dietary prescription: Realistic balanced diet rich in iron
and portion like liver, meat, eggs, green vegetable etc.
Adequate treatment should be instituted to eradicate
hook worm infestation, control of dysentery, malaria,
nephropathies & excision of bleeding piles. Hb level
should be estimated at the 1st ANC and 30th and finally
at 36th week.

31. Curative treatment (1/3)
■ Hospitalization: if Hb level is below 7.5 gm%
■ General treatment:
 Diet –balanced diet rich in protein, vitamins and iron
- Antibiotic for infective focuses, if any.

32. Curative treatment (2/3)
■ Specific Therapy as needed:
• Oral, Parenteral, Blood transfusion is given depending on
severity of anemia, duration of pregnancy, Associate
complicating factor.
• Oral- ferrous gluconate, ferrous fumarate, ferrous
succinate.

33. Curative treatment (3/3)
• Parenteral therapy:
 Intravenous route-iron dextran or iron (ferrous) sucrose.
Iron sucrose is safe, effective and has less side effects.
 Intramuscular therapy- iron dextran (imferon), iron
sorbitol.

34. Indication of parenteral therapy
■ Contraindications of oral therapy.
■ Patient not cooperative to take oral iron.
■ Cases seen for the first time during the last 8-10 weeks
with severe anemia.

35. Blood transfusion
■ The indications are:
 To correct anemia due to loss and to combat postpartum
hemorrhage.
 Patient with severe anemia seen in later months of
pregnancy (beyond 36 weeks)
 Refractory anemia: Anemia not responding to either oral
or parenteral therapy in spite of correct typing.
 Associated infection.

36. Folic acid deficiency
■ Folic acid deficiency anemia is the lack of folic acid in the
blood.
■ Folic acid is part of the vitamin B complex.
■ In pregnancy it is necessary for effective cell growth
and synthesis of RNA and DNA and a deficiency is
associated with neural tube defects in the fetus.
■ Low level of folic acid can cause megaloblastic anemia
with this condition, red blood cells are larger than normal.

37. Causes
■ Multiple pregnancy
■ Poor diet
■ Drink alcohol- this makes it harder for intestines to
absorb folate.
■ Stomach problems- celiac disease.

38. Clinical manifestation
■ Fatigue, lack of energy
■ Shortness of breathing
■ Headaches
■ Pale skin
■ Palpitation
■ Weight loss or not feeling hungry
■ Ringing in ears.

39. Investigation
■ CBC (complete blood count) test to measure the number
and appearance of red blood cells.
■ In case of lack of folate, red blood cells look large and
immature.

40. Management
■ The average daily folate requirement rise in pregnancy
from 50-400 μg/day
■ Although this can usually be met through a healthy diet,
women are encourage to take prophylactic folic acid 400
μg/day (0.4mg) routinely in the first trimester, which
should be increase to 5 mg if the women also taking
antiepileptic drugs or other drugs affecting folate
metabolism.

41. Complication
■ Low birth weight baby
■ Hemorrhage
■ Premature baby
■ Fetal death.
■ Neural tube defects in fetus

42. Vitamin B12 deficiency anemia (1/3)
■ Vitamin B12 deficiency anemia occurs when a lack of
vitamin B12 causes the body to produce abnormally
large red blood cells that can't function properly.
■ Deficiency of vitamin B12 also produces a megaloblastic
anemia is rare because the body draws on its stores.
Deficiency is most likely in vegans, who eat no animal
products at all, and should therefore take vitamin B12
supplements during pregnancy

43. Vitamin B12 deficiency anemia (2/3)
■ Vitamin B12 deficiency is rare, particularly in pregnancy.
■ As vitamin B12 plays as important role in new tissue
development, deficiency can be associated with infertility
and repeated miscarriage. It is also seen in women
generally aged >40 years as pernicious anemia and
related to a lack of intrinsic factor in the stomach.
Pernicious anemia is extremely rare in pregnancy.

44. Vitamin B12 deficiency anemia
(3/3)
■ Vitamin B12 is only found in foodstuffs from animals and
is absorbed via the terminal ileum, thus it can also occur
as a result of malabsorption and insufficient dietary
intake.

45. Risk of developing vitamin B12
deficiency
■ Elderly women (due to prevalence of gastric atrophy).
■ Vegetarian diet, particularly vegan diets.
■ Previous gastric/ileac resection, or history of coeliac
disease, inflammatory bowel disease.
■ Prolonged use of proton pump inhibitors, H2 receptor
antagonists and biguanides (may interfere with
absorption of B12 over time).

46. Clinical manifestations
• Extreme tiredness, lack of energy.
• A sore and red tongue, mouth ulcers.
• Muscle weakness.
• Disturbed vision.
• Psychological problems, which may include depression
and confusion.
• Problems with memory, understanding and judgment.

47. Preventing and treating vitamin
B12 deficiency
■ Vitamin B12 supplements are for vegetarians and vegan
women in pregnancy and lactation with recommended
daily intake 6mcg/day.
■ As the etiology of vitamin B12 deficiency is generally
absorptive, the recommended form of treatment is
parenteral vitamin B12.

48. Cont…..
■ Hydroxycobalamin or cyancobalamin 1000mcg/ 1ml
given by intramuscular injection, once weekly for 3
weeks.
■ If treatment received for vitamin B12 deficiency during
the pregnancy, vitamin B12 levels should be reassessed
2 months post-partum to confirm if the levels have
returned to the normal ranges.

49. Haemoglobinopathies (1/4)
■ This term describes inherited conditions where the
hemoglobin in abnormal.
■ Haemoglobin consists of a group of four molecules, each
of which has a haemo unit made up of an iron porphyrin
complex and a protein or globin chain. A total of 97% of
adult Hb (HbA) has two α-and two 𝛿-chains.
■ Fetal Hb (HbF) has two α-and two γ-chains; by 6 months
of age this has been replaced by adult haemoglobin.

51. Haemoglobinopathies (2/4)
■ The type of globin chain is genetically determined.
■ Defective genes lead to the formation of abnormal
haemoglobin; this may be as a result of impaired globin
synthesis (thalassemia syndromes) or from structurally
abnormality of globin (hemoglobin variations such as
sickle cell anemia)

52. Haemoglobinopathies (3/4)
■ As this condition is inherited, and in the homozygous
form can be fatal, screening of the population at risk
should be carried out.
■ Blood is examined by electrophoresis, which detects the
different types of haemoglobin.

53. Haemoglobinopathies (4/4)
■ Prospective parents who are known to have (or carry
genes for) abnormal haemoglobin need genetic
counseling in order to help them make an informed
decision regarding contraception, pregnancy and
prenatal diagnostic program

55. Sickle cell disease (1/3)
■ Sickle cell disease is refers to a groups of disorders arising from
defective genes that produce abnormal Hb molecules (Hbs).
■ It is caused by point mutation in the B globin gene on chromosome
II
■ Gene mutation-when homozygous the individual has sickle cell
anemia. She has small quantity of fetal hemoglobin (HbF).

56. Sickle cell disease (2/3)
■ Sickle cell-B thalassemia- is observed when one B
chain gene carries the sickle cell mutation. Pregnancy
outcome is similar to sickle cell anemia.
■ Sickle cell trait: Hb-S compromise 30-40% of the total
hemoglobin, the rest being Hb-A, Hb-F. if the husband is
a carrier, there is 25% chance that the infant will be
homozygous sickle cell disease and 5-%-sickle cell trait.
As such, pre-conceptional counseling should be done to
know whether the husband also carries the trait or not.

57. Sickle cell disease (3/3)
■ The patient will require iron supplementation. As a
concentration of Hb-s is low, crisis is rare but can occur
extreme hypoxia. Hematuria and urinary infection are
quite common.
■ Sickle cell disease: Homozygous sickle cell disease
(Hb-ss) is transmitted equally by males and females.
Partner must be tested. Termination of pregnancy is an
option if a fetus is diagnosed to have major
hemoglobinopathy.

58. Effects on pregnancy
■ There is increase incidence of abortion, prematurity,
IUGR, fetal loss.
■ Prenatal mortality is high
■ Incidence of pre-eclampsia and infection is increased.
■ Increased maternal mortality is due to infection,
cerebrovascular accident and sickle cell disease.

59. Effects on disease
■ Hemolytic crisis: it is due to hemolysis with rapidly
developing anemia along with jaundice.
■ Painful (vaso-occlusive) crisis: it is due to vascular
occlusion of the various organs by capillary thrombosis
resulting in infarction.

60. MANAGEMENT

61. Pre-conceptional counselling:
• Prenatal identification of homozygous state of the
disorder is an indication for early termination of the
pregnancy, if the parents desire.
• Folic acid should be increased to 5 mg/day and iron
chelation discontinued 3-6months prior to conception
due to possible teratogenicity.

62. During pregnancy
• The women presenting with sickle cell anemia is at risk
of experiencing a sickle cell crisis secondary to infection,
pre-eclampsia, miscarriage, IUGR, still birth and possible
maternal death.
• Folic acid should be increased to 5mg/day if not done so
pre-conceptually, and iron supplements only given if
indicated by serum ferritin results.
• Iron supplements only given if indicated by serum ferritin
results.
• Regular blood transfusion at approximately 6 weeks
interval is given

63. During labor
• Oxygen therapy might be required to maintain adequate
oxygenation and improve cardiac function.
• Prophylactic antibiotics may be considered to reduce
infection.
• A prolonged labor should be avoided and active
management or caesarean section may be advised
depending on the women’s health

64. During postnatal period:
• Prophylactic antibiotics and thromboprophylaxis should
continue.
• Early mobilization is encouraged.
• The women should be advised about subsequent
pregnancies.

65. Contraceptive:
• Sterilization should be considered even with low parity
because of the short life span of the patient.
• Oral pill is contraindicated as it might aggravate risk of
thromboembolism.
• Intrauterine device is contraindicated for fear of infection.
• Barrier method of contraceptive is ideal

66. Thalassemia syndromes
■ Thalassemia is an inherited (genetic) blood disorder. It
happens when mutated genes affect the body’s ability to
make healthy haemoglobin.
■ There are different types of thalassemia, depending on
which part of the haemoglobin is affected.
■ Haemoglobin is made up of matching chains of proteins:
the alpha chains and the beta chains.

67. Alpha thalassemia (1/2)
■ A mutation in the alpha haemoglobin chains causes
alpha thalassemia. The alpha chains are produced by
four genes.
■ Mutation of one genes-there is no clinical or laboratory
abnormalities. Subject remains as a silent carrier.
■ Mutation in two of the four genes: α-thalassemia
minor. It often goes unrecognized and pregnancy is well
tolerated.

68. Alpha thalassemia (2/2)
■ Mutation in three of the four genes: this condition is
called hemoglobin H disease.
■ Mutation in all four genes:α-thalassemia major (Hb
Bart’s syndrome). The fetus dies either in utero or soon
after birth. this is an important cause of non-immune fetal
hydrops and perinatal death.

69. Beta thalassemia
■ A mutation in the beta haemoglobin chains causes beta
thalassemia. The beta chains are produced by two genes
• if one gene is mutated, it results in symptoms of usually
very mild anemia (beta thalassemia trait). It may also
cause a more complex set of anemia symptoms, ranging
from mild to severe (beta thalassemia intermedia).
• If both genes are mutated, it results in the more serious
beta thalassemia major (Cooley’s anemia)

70. Management (1/3)
■ Pre-conception care is important and genetic counselling
is required, especially if there is inter-marriage of
cousins. There is 1 in 4 chance of a baby inheriting a
major condition if both parents are carriers.
■ In early pregnancy diagnostic test are offered to the
women, consisting of DNA analysis of chorionic villi and
fetal blood sampling. Termination of pregnancy should be
done if the fetus is adversely affected.

71. Management (2/3)
■ In thalassemia major oral and iv iron therapy is
contraindicated.
■ If the women have thalassemia major she is at risk of
pre-term labor, which might be iatrogenic, as well as both
maternal and fetal hypoxia in labor.
■ If the women has bone deformities, caesarean section
may be necessary.

72. Management (3/3)
■ There should be continuous fetal monitoring of blood
pressure and fluid balance. Due to the risk of
hemorrhage, it would be wise for the midwife to facilitate
active management of the third stage of labor.
■ During postnatal period, the women should be observed
for signs of infection and hemorrhage and if any wound
should be inspected for signs of poor healing.

73. ASSIGNMENT
■ Write about nursing management of anemia in
pregnancy.

74. References
■ DC Dutta’s “textbooks of obstetrics including perinatology and contraception. 7th
edition.Page no. 260-274
■ Myles textbooks for midwives, sixteen edition page no:273-276

75. References
■ https://www.webmd.com/a-to-z-guides/folic-acid-deficiency-anemia#1
■ https://www.hopkinsmedicine.org/healthlibrary/conditions/hematology_and_blood
_disorders/anemia_of_folate_deficiency_85,P00089
■ https://www.kemh.health.wa.gov.au/~/media/Files/Hospitals/WNHS/For%20healt
h%20professionals/Clinical%20guidelines/OG/WNHS.OG.VitaminB12DeficiencyMa
nagement.pdf
■ https://www.nhs.uk/conditions/vitamin-b12-or-folate-deficiency-anaemia/causes/
■ https://www.babycentre.co.uk/a1026605/thalassaemia-in-pregnancy