Anemia in PregnancyCHAPTER 1

Patient was a booked antenatal case in some private hospital in Sonipat since 4 months amenorrhea.

She got all her routine antenatal investigations done at 5 months amenorrhea and diagnosed with moderate hemoglobin.

She was non compliant with oral iron tablets and was transfused 6 doses of iron sucrose and with that her hemoglobin improved.

Again at 8 month of pregnancy she, became symptomatic and was referred to Lok Nayak Hospital (LNH) in view of severe anemia.

She was admitted to labor room after her general, physical and abdominal examination.

Her blood sample [full blood count (FBC), blood group cross match, liver function test, kidney function test, serum electrolytes] was taken and patient was evaluated. She was diagnosed with moderate anemia with microcytic hypochromic picture in peripheral smear.

She was shifted to clean maternity ward, to be investigated and evaluated for the cause of anemia.

Pregnancy was confirmed, at home by urine pregnancy test when she was overdue by 10 days.

She had no history of any bleeding or discharge per vaginum, pain lower abdomen, fever with rashes, bladder and bowel symptoms, self-medication or radiation exposure.

Folic acid (FA) was started once her pregnancy test came positive after she consulted in local dispensary. Her FA intake was occasional.

She reported mild symptoms of morning sickness and managed with dietary modification.

Ultrasonography was done in first trimester that showed positive cardiac activity.

Quickening felt at around 5 months. Iron and calcium started. FA not taken. Two doses of tetanus toxoid were received.

Blood and urine test were done and patient was diagnosed with moderate anemia. As she was noncompliant due to nausea and vomiting, i.e. intolerance after oral iron, injectable iron (six doses) was transfused. Her anemia got corrected. There is no history of any blood transfusion.2

Level II ultrasound was done in fifth month of pregnancy and was normal.

No history of breathlessness, easy fatigability, burning micturition, blood from any orifices, passage of worms in stools, swelling over feet, bleeding or leaking per vaginum or increased blood sugar was there.

She visited antenatal clinic thrice and her blood pressure was normal on all visits.

She was intolerant to oral iron. FA not taken. Calcium intake was normal.

She had breathlessness and fatigability at eighth month of amenorrhea. She was investigated and diagnosed with severe anemia.

She was referred to LNH in view of severe anemia and nonavailability of blood bank in dispensary.

G1—booked at Ambedkar hospital at 2 months amenorrhea, had preterm intrauterine demise (IUD) at 8 months, delivered by induction of labor 10 years back. Baby was female,1.8 kg birth weight, history of diabetes mellitus or hypertension was there, no morphological abnormality was detected in baby. Breast suppression was given, postnatal period was uneventful. Discharged in satisfactory condition on postpartum day 3.

G2—booked at LNH at four months amenorrhea. She had preterm lower segment cesarean section (LSCS) in view of severe preeclampsia with moderate hemoglobin with poor bishops score eight years back, baby was female 2 kg birth weight, admitted in nursery for 6 days. No history of PPH or any blood loss (surgical). Two units of packed cell transfused post-LSCS in view of severe anemia. SRC out on day 2, complete stitch removal on day 10. Uneventful postpartum period. Baby six months breastfed, is alive and healthy with normal milestones, immunized till date.

G4—present pregnancy.

Menarche—14 years of age

LMP—13/10/2016

Estimated date of delivery (EDD)—20/07/2017

No history of dysmenorrhea, menorrhagia.

She is a housewife with normal bowel and bladder pattern with normal sleep pattern.

Nonvegetarian, nonalcoholic and no other addictions.

Patient takes approximately 2200 kcal.

Her protein intake is approximately 60 g.

Gestational carrier (GC)—good

Weight—65 kg.

Height—150 cm.

Body mass index (BMI)—28.8 kg/m² [according to prepregnancy weight]

Pallor—present, clinically 7-8 g%.

Icterus—absent.

Cyanosis—absent.

Clubbing—absent.3

Pedal edema—absent.

Pulse rate—90/min, regular, rhythmic, no radioradial or radiofemoral delay.

Blood pressure (BP)—110/80 mm Hg in right arm in sitting.

Respiratory rate—16/min.

Thyroid—normal

Lymph nodes—not palpable.

Abdomen is uniformly distended with all quadrants moving with respiration.

Linea nigra and stria gravidarum present, transverse scar of previous LSCS present.

Umbilicus is central and everted, no herniation observed.

Fundal height—30 weeks

Symphysio fundal height—28 cm

Abdominal girth—31.5 inches

Fundal grip—a soft broad ballotable structure felt at fundus, suggestive of breech

Lateral grip—smooth and curved structure felt on right lateral side of abdomen, suggestive of back

Multiple nobby parts felt on left side, suggestive of limbs

Pelvic grips—a hard, globular and smooth structure is felt on palpation, suggestive of head, was freely mobile and not engaged.

External genitalia—normal

No bleeding and no leaking observed.

Os closed

Cervix long

No abnormal discharge or bleeding observed.

Hemoglobin (Hb)—8 g%

Hematocrit (Hct)—30%

Mean corpuscular volume (MCV)—74 fL

Mean corpuscular hemoglobin (MCH)—24 pg

Mean corpuscular hemoglobin concentration (MCHC)—29%

Peripheral smear shows microcytic hypochromic red blood cells (RBCs) rest unremarkable

Nestroft—negative

High performance liquid chromatography (HPLC)—normal

Stool ova and cyst—not observed, no occult blood seen

Serum protein—6 g%

Lactate dehydrogenase (LDH)—320 IU/L

First trimester <11.0 g/L

Second and third trimesters <10.5 g/L

Postpartum period <10.0 g/L.²

First and third trimesters—Hb <11 g/dL, Hct <33%

Second trimester—Hb <10.5 g/dL, hematocrit <32%.⁴

Severe hemoglobin Hb <7 g/dL

Very severe hemoglobin Hb <4 g/dL.⁵

Non-pregnant female (15–49 years of age)—Hb <12 g%.⁶

Pregnant women (15–49 years of age)—Hb <11 g%.⁶

Iron deficiency anemia—dietary/chronic blood loss/worm infestation

Megaloblastic anemia—vitamin B₁₂ and folic acid deficiency

Anemia of inflammation or malignancies, e.g. chronic renal disease, tuberculosis, etc.

Aplastic or hypoplastic anemia

Drug induced, e.g. alkylating agents like vincristine, chloramphenicol, anticonvulsants especially primidone, quinine, alpha methyldopa, etc.

Anemia caused by acute blood loss—postpartum hemorrhage (PPH)/ectopic/abortions, etc.

Thalassemia

Sickle cell hemoglobinopathy and hemoglobinopathies

Hereditary hemolytic anemia.

Symptoms—fatigue, weakness, headache, dizziness, palpitations, irritability, poor concentration, hair loss.

Signs—pallor, tachycardia, dyspnea, glossitis, stomatitis, restless leg syndrome, pica.^9–11

↓Hb and Hct

↓MCV

↓MCH

↓MCHC.

Earliest laboratory marker to become abnormal

Best test for iron deficiency anemia (IDA) with cut off of 30 µg/L.¹² The values <15 µg/L indicates severe deficiency.

Sensitivity was 92% and specificity 98%.¹³

Serum ferritin initially rises followed by gradual fall till 32 weeks, slight increase is observed in third trimester.

In trial of iron therapy first we measure serum ferritin and rule out hemolysis with Nestroft.

If negative a trial of iron preparation either oral or injectable depending on period of gestation was given.5

Response to therapy was assessed by demonstrating a rise in Hb after 2 weeks. It is both diagnostic and therapeutic.

If no improvement is observed in Hb by 2 weeks, one should rule out other causes.³

Foods rich in calcium

Tannins in tea

Phytates in cereals.

Heme iron

Ferrous iron

Ascorbic acid

Low iron stores.

Decrease immunity with increased susceptibility to infections¹⁵

Decrease work capacity and performance¹⁶

Postpartum emotional and cognition disturbances.¹⁷

Relatively unaffected.¹⁸

Impaired psychomotor and/or mental development.

Social emotional behaviour of infant is negatively affected.¹⁹

Mothers should be advised to take food rich in iron

Due to very high requirement of iron, iron and folic acid should be given to all pregnant patients as prophylaxis to prevent anemia

To optimize absorption of iron, its intake should be spaced properly with meals rich in phytats, tannins, calcium

Maternal iron requirements are approximately 1000 mg in singleton pregnancies (500 mg for maternal hemoglobin, 300 mg for placenta and fetus, and 200 mg that is shed normally through gut, urine and skin)

Approximately 10 mg iron is absorbed from food, i.e. 15% of dietary iron

Pregnant women iron requirements are thrice as high as menstruating women²³

Iron absorption increases by three-fold with progressive gestation, with iron requirements increasing from 1–2 mg to 6 mg per day in third trimester²⁴

The main sources of dietary heme iron are from nonvegetarian foods like red meats, fish and poultry

Heme iron is 2- to 3-fold readily absorbed than nonheme iron sources which contributes approximately 95% of dietary iron²⁵

Vitamin C markedly enhances iron absorption from non-heme foods²⁶

Germinated and fermented food decreases phytate thereby improving bioavailability of nonheme iron

Tea and coffee (tannins) if taken with a meal or shortly after it decreases iron absorption

Deworming should be done in all patients

• Tablet albendazole 400 mg single dose
• Tablet mebendazole 500 mg single dose or 100 mg twice daily for 3 days.

In pregnancy increased iron demands cannot be fulfilled by dietary changes alone and hence iron supplements are required

Ferrous iron salts cheap, effective, and safer way to replace iron and are the preparation of choice. The effective oral dose should be 100–200 mg of elemental iron daily.

Preferably empty stomach

At least 1 hour prior meals

Along with vitamin C

Avoid other drugs like antacids.6

All antenatal women should have a FBC taken at the booking and at 28 weeks [National Institute of Health and Clinical excellence (NICE), 2008]²⁷

Trial of therapeutic iron replacement should be offered to women with a Hb <11 g% until 12 weeks or <10.5 g% beyond 12 weeks

In a women with hemoglobinopathy trial of iron therapy can be offered if the ferritin is <30 µg/L

The patient who are intolerant to oral iron, i.e. having excessive nausea and vomiting, lot of upper gastrointestinal (GI) discomfort to the extent patient avoid taking oral iron. Such patients are advised to take iron tablets after meals

To be given for 6 months in countries with prevalence <40% and additional 3 month postpartum where the prevalence >40%.

Inter-conceptional anemia

Frequent pregnancies ≤1 year interval in between

Vegetarians

Teenagers

Women with bleeding disorders

Known hemoglobinopathy.

Increased sense of well being

Increase in work capacity

Improvement of other symptoms.

Reticulocyte count—increase up to 5% in 5–7 days.

Hb—increase @ 0.8–1 g/dL/week after 2–3 weeks.

RBCs indices—improvement in MCV/MCH/MCHC after 2–3 weeks.

Peripheral smear—normocytic normochromic picture in 6–8 weeks.

Poor compliance to oral iron

Intolerance to oral iron therapy

Lack of response

Postpartum hemoglobin

Women with GI disorders that hampers oral iron absorption

Proven malnutrition.

Hypersensitivity to parenteral iron therapy

First trimester of pregnancy

Noniron deficiency hemoglobin

Active acute or chronic infection

Chronic liver disease.

It facilitates controlled delivery of iron within the cells of the reticuloendothelial system

Followed by delivery to the iron binding proteins ferritin and transferrin.

The dose to be calculated on the basis of prepregnancy weight, with a target Hb of 11 g/mL.

Written informed consent should be there regarding potential side-effects.

[2.4 × (target Hb–actual Hb) × prepregnancy weight (kg)] + 10 mg/kg for stores replenishment.¹

Iron (mg)–{weight (kg) × (14 – Hb) × (2.145)

Pregnancy <34 weeks

• Hb <5 g/dL with/without signs of cardiac failure or hypoxia
• 5–7 g/dL—in presence of impending heart failure.

Pregnancy >34 weeks

• Hb <7 g/dL even without signs of cardiac failure or hypoxia
• Severe anemia with decompensation.

Anemia not due to hematinic deficiency

• Hemoglobinopathy or bone marrow failure syndromes
• Hematologist should always be consulted.

Acute hemorrhage

• Always indicated if Hb <6 g/dL
• If the patient become hemodynamically unstable due to ongoing hemorrhage.

Hb <7 g/dL (in labor)

Decision of blood transfusion depends on medical history or symptoms.

Anemia with signs of shock/acute hemorrhage with signs of hemodynamic instability

Hb <7 g/dL (postpartum): Decision of blood transfusion depends on medical history or symptoms.

Patient was a booked antenatal case of same hospital

She complained of easy fatigability and breathlessness on exertion since 1 month

No history of any blood loss from any site

No history of any cardiac illness in present or past

No history of any respiratory disorders

No complains of any bleeding or leaking per vaginum.

She was admitted to the labor room after her general and abdominal examinations.

Her blood samples [full blood count (FBC), blood group cross match, liver function test, kidney function test, serum electrolytes] was taken and patient was evaluated. She was diagnosed with moderate anemia with macrocytic normochromic picture in peripheral smear.

She was shifted to clean maternity ward, investigated and evaluated for the cause of anemia.

Pregnancy was confirmed, at home by urine pregnancy test when she was overdue by 20 days

No intake of folic acid in first trimester. Rest unremarkable.

Amenorrhea continued and patient develops gradual onset weakness, fatigability, and breathlessness over a period of 1 month

Her iron intake was occasional, folic acid not taken.

Married since 11 years

Non-consanguinous marriage.

G1—was a supervised pregnancy at LNH, had full-term emergency LSCS in view of fetal distress, 9 years back

G2—was a supervised pregnancy at LNH, had full-term vaginal delivery, 4 year back

Baby was male, 2.6 kg birth weight, cried after birth

Died at 6 month of age due to drowning

G3—spontaneous abortion

G4—present pregnancy.

Menarche—14 years of age

LMP—17/09/2016

Estimate date of death delivery (EDD)—24/06/2017.

No history of dysmenorrhea, menorrhagia.9

Patient takes approximately 1,700 kcal as per 24 hour recall method.

Her protein intake is approximately 40 g. Her calorie deficit was 500 kcal and her protein deficit was 20 g. Diet modification to include increase protein and calories explained.

GC—good

Weight—50 kg

Height—150 cm

BMI—22.2 kg/m

Pallor—present, clinically 7–8 g%

Rest unremarkable

Systemic examination—unremarkable.

Fundal height—32 weeks

Symphysio fundal height—30 cm

Abdominal girth—32.3 inches

Grips—unremarkable.

Hb—7.2 g%

Hct—24%

Mean corpuscular volume (MCV)—106 fl

Mean corpuscular hemoglobin (MCH)—21 pg

Mean corpuscular hemoglobin concentration (MCHC)—27%.

Nestroft—negative

HPLC—normal.

Serum B₁₂ level <100 pg/mL suggest B₁₂ deficiency.

Serum folate level <2 ng/mL suggests folate deficiency anemia.

Fasting serum folate level <6 µg/L and RBC folate <165 µg/L are diagnostic of folate deficiency.

Alcohol abuse

HIV infection

Certain inherited disorders

Atrophic gastritis and achlorhydria

Pernicious hemoglobin

Pancreatic insufficiency

Zollinger-Ellison syndrome

Inflammatory bowel syndrome

Tropical sprue

Blind loop syndrome

Drugs that affect DNA, such as chemotherapy drugs

Leukemia

Myelodysplastic syndrome

Myelofibrosis

The anticonvulsant drug dilantin.

Weakness, fatigue

Gastrointestinal—loss of appetite, weight loss, nausea, constipation

Neurological—numbness, pain, tingling, and burning in a patient's hands and feet stocking or glove neuropathy.

Lemon color complexion

Palpitations, glossitis

Hyperpigmentation of skin and abnormal hair pigmentation

Peripheral neuropathy, psychosis, abnormal gait, speech impairment, loss of propioceptive and vibratory senses

Weight loss, abdominal distension, diarrhea, and steatorrhea.

Daily 400 µg of folic acid.⁴⁰

Daily vitamin B₁₂ 2.6 μg.

Hypothyroidism

Liver disease

Myelodysplasia

Hydroxyurea

Alcoholism

Lesch-Nyhan syndrome

Homocystinuria.

Maternal vitamin B₁₂ status affects fetal growth and development.

Low cobalamin increases risk of fetal low lean mass and excess adiposity, increased insulin resistance and impaired neurodevelopment.

Maternal risks include fatigue, pallor, tachycardia, poor exercise tolerance and suboptimal work performance.

Depleted blood reserves during delivery may increase the need for blood transfusion, preeclampsia, placental abruption, cardiac failure and related death.

Oral: 1000 μg of vitamin B₁₂, daily should be given to patient with serum levels to be monitored to ensure adequate repletion.

Sublingual: For patients with absorption disorder, i.e. bariatric surgery, steatorrhea, malabsorption syndromes.

Parenteral: Non-responders and patients with neurological features.

Increased sense of well being

Improved working capacity

Improvement of glossitis

Improvement of depigmentation

Improvement of neurological symptoms.

Decrease in LDH levels by 3–4 days

Increase in reticulocyte count by 5–7 days

Increase in hemoglobin 0.8–1 g/dL/week

Peripheral smear shows normocytic normochromic RBCs.

She was a booked antenatal case in government hospital, Najafgarh, New Delhi

She had breathlessness since 2 months. It was gradual in onset and increased progressively

She had palpitations since 1 month

She had weakness which was gradual in onset and markedly increased since 10 days

She had no history of any cardiac disorder in present or past

She had no history of any respiratory illness in present or past

She had no history of bleeding per vaginum or blood loss from any other orifices.

She was admitted to labor room after her general physical and abdominal examination which showed severe pallor, PR 100/min, RR 18/min, hemic murmur on cardiovascular system (CVS) examination with bilateral chest clear and presence of abdominal wall edema with pedal edema, rest unremarkable.

She was evaluated again in labor room, propped up, oxygen saturation done (100%), continued oral intake with monitoring of vitals, input, output, chest auscultation to detect earliest symptoms and signs of cardiorespiratory failure.

Intermittent oxygen by mask continued.

Fetal monitoring continued as routine (NST at admission, DFMC, intermittent auscultation)

Her blood samples [full blood count (FBC), blood group cross match, liver function test, kidney function test, serum electrolytes] was taken and patient was evaluated. She was diagnosed with severe anemia with microcytic hypochromic picture in peripheral smear.

All other reports normal except serum proteins 5 g/dL.

Patient was evaluated and investigated and diagnosed with severe hemoglobin not in failure.

ABO Rh—B+

Hb—5.1 g/dL

Hct—14.9%

MCV—57 Fl

MCH—14.8 pg

MCHC—26.1%

RDW—16.7

TLC—14900/cumm

Platelet—1.69/cumm12

Serum total bilirubin—1.6

Aspartate transaminase (AST)—10

Alanine transaminase (ALT)—22

Serum proteins—5 g/dL

Blood urea—22 mg/dL

Serum creatinine—1.2 mg/dL

Prothrombin time (PT)—14.4

International normalized ratio (INR)—1.12

Hepatitis B surface antibody (HBsAg)—Nonreactive

Venereal disease research laboratory (VDRL)—nonreactive

Human immunodeficiency virus (HIV)—nonreactive.

Amenorrhea continued.

She was intolerant to oral iron. FA not taken. Calcium intake was normal.

She had breathlessness and fatigability at eighth month of amenorrhea. She was investigated and diagnosed with severe anemia.

She was referred to LNH in view of severe anemia and nonavailability of blood bank in Najafgarh hospital.

G1—was a supervised pregnancy at LNH, had full-term emergency LSCS in view of Naval Physical and Oceanographic Laboratory (NPOL) distress, 10 years back. Baby was female, 2.8 kg birth weight 6 months breastfed. SRC out on day 2rd, stitch removal on day 7. Discharged satisfactory on day 7th.

G2—diagnosed with unruptured left tubal ectopic pregnancy. Treated medically at LNH, 7 year back.

G3—present pregnancy.

GC—good

Weight—50 kg

Height—150 cm

BMI—22.2

Pallor—present, clinically 3–4 g%

Icterus—absent

Cyanosis—absent

Clubbing—absent

Pedal edema—present

Pulse rate—104/min, regular, rhythmic, no radioradial or radiofemoral delay

BP—110/80 mm Hg in right arm in sitting

Respiratory rate—22/min

Cardiovascular examination—S1, S2 normal, hemic murmur heard.

Fundal height—40 weeks

Symphysiofundal height—34 cm

Abdominal girth—35.46 inches

Presentation—cephalic.13

Patient should be propped up

Intermittent oxygen should be given

High-risk consent

The patient should be in bed preferably in position comfortable to her

Send urgent hemogram with BGCM

Arrange and transfuse adequate packed cell

Intermittent chest auscultation

Strict asepsis should be followed

Fluid restriction (IV fluid)

Watch for symptoms and sign of cardiac failure.

Partogram to be maintained

Concentrated oxtytocin should be given if required.

Active management of third stage of labor (AMSTL)

Avoid postpartum hemorrhage (PPH).

Avoid any genital trauma. Prophylactic episiotomy to be given, if required.

Patient should be kept in observation for at least 6 hours postpartum

Prophylactic antibiotics can be considered to prevent sepsis

Iron and folic acid should be continued 6 month postpartum

Contraception advice

Barrier methods

POPs

Sterilization if family completed.

Malnutrition as part of nutritional anemia

Hypertensive disorders

Deranged blood sugars/hyperglycemias

Infections

Liver diseases

Renal diseases

Nutritional deficiency

Malabsorption

Septicemia

Nonspecific: Dietary protein supplementation irrespective of cause is the most common way of treatment.

Specific: Treating underlying cause.