1. ANEMIAS DURING
PREGNANCY
By
Osama M. Warda, MD
Professor of OB/GYN
Mansoura University

2. Definition:
Anemia means reduction below normal of
either red blood cells (RBCs) count, or
hemoglobin percentage, or both leading to
deficient oxygen carrying capacity of the blood.
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During pregnancy; anemia is diagnosed if:
RBCs count is less than 3.5 millions/ cc OR,
Hemoglobin content less than 10 gm/dL , or
Hematocrit value is less than 30 %

3. Incidence:
Anemia is the most common medical
complication in pregnancy. More than 50% of
all pregnant women suffer anemia during
pregnancy.
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Iron deficiency anemia is the most common
type, followed by blood loss due to obstetric
cause, and anemia due to chronic infection.

4. Anemia Pregnancy Inter-relations:
A]. Effect of anemia on pregnancy ( mother &
fetus):
1- Increased incidence of PreeclampsiaPreeclampsia--eclampsiaeclampsia,
especially with iron deficiency anemia and
megaloblastic anemia (mechanism unknown). PE
PA
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megaloblastic anemia (mechanism unknown).
abruptionplacentalIncreased incidence of-2
(accidental hemorrhage).
neonatal, andstillbirthsIncreased incidence of-3
.deaths
.laborpretermIncreased incidence of-4
PA
SB
ND
PL

5. Anemia Pregnancy Inter-relations:
B]. Effect of pregnancy anemia:
Aggravation of the pre-existing anemia
occurs due to;
1- Expansion of the maternal plasma volume
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1- Expansion of the maternal plasma volume
(hyderemia; hemodilution) .
2- Fetal utilization of substrates necessary for
building up of hemoglobin molecules.

6. Classification (types) of Anemia:
According to RBCs indices*; anemia
may be classified into 3 main types:
:CYTIC ANEMIA-CROICHROMIC M-O[I]. HYP
1-Iron deficiency anemia (most common).
CI
MCH
MCHC
MCV
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1-Iron deficiency anemia (most common).
2-Thalassemia (certain types).
3-Chronic infections (eg . glomerulonephritis,
pyelonephritis).
4-Chronic lead poisoning.
5- Vitamin B6 deficiency.

7. Classification (types) of Anemia:
CYTIC ANEMIA:-CROACHROMIC M-RE[II].HYP
1-Folic acid deficiency anemia.
2-Vitamin B12 deficiency anemia.
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[III]. NORMOCHROMIC NORMOCYTIC ANEMIA:
1-Hemorrhagic anemia (due to blood loss).
2-Hemolytic anemias; (a) thalassemia, (b) sickle cell
anemia, (c) spherocytosis, and (d) G6PD deficiency
3- Hypoplastic (aplastic) anemia.

8. IRON DEFICIENCY ANEMIA
It is the most common type of anemia encountered during
pregnancy.
Physiological Role of iron during pregnancy:
1-Enters the haem portion of hemoglobin & myohemoglobin.
2-Respiratory enzymes as cytochrome oxidase enzyme.
3-Placental enzymes
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3-Placental enzymes
4-Fetal hematopoeisis.
Metabolism of iron during pregnancy:
Normal diet supplies 14 mg of iron per day.
Only 1-2 mg ( 10-15% of dietary iron) is absorbed depending
on iron stores (ferritin-apoferritin system).
Iron is absorbed in the 'ferrous' state in the presence of
vitamin C. Phytate & phosphate decrease iron absorption .
Haem iron of red meat & liver is rapidly absorbed than
vegetable iron in apple, spinache, and other vegetables.

9. IRON DEFICIENCY ANEMIA cont.;
Daily requirement of iron during pregnancy:
The daily requirement of the pregnant lady is 4 mg
of elemental iron .
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The TOTAL requirement during pregnancy is about
1000 mg of elemental iron calculated by the Council
on Food and Nutrition as follows;
To compensate for external iron loss…….= 170 mg
To allow expansion of maternal cell……..= 450 mg
Iron for fetal needs ………………………. =270 mg
Iron in placenta and cord ………………….= 90 mg

10. IRON DEFICIENCY ANEMIA cont.;
Etiology of iron deficiency anemia during pregnancy:
[A]. Decrease intake of iron:
1- Poor diet.
2- Extensive morning sickness
[B]. Diminished absorption of iron:
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[B]. Diminished absorption of iron:
1- Lack of vitamin C and proteins.
2- Increased phosphate & phytates.
3- Decreased gastric acidity & use of antacids.
4- Malabsorption syndromes, and parasitic infestations.
[C]. Increased iron demands during pregnancy:
1- Multiple pregnancy
2- Hemorrhage with pregnancy
3- Multi-parity

11. IRON DEFICIENCY ANEMIA cont.;
Clinical Picture:
S y m p t o m s:
General; pallor, tiredness, easy fatigability.
Cardiovascular; Dyspnea on exertion,
palpitation, anginal pains, swelling of lower limbs,
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palpitation, anginal pains, swelling of lower limbs,
and other low cardiac output symptoms.
Gastrointestinal; anorexia, nausea, vomiting,
constipation.
Nervous System; lack of concentration, numbness
and tingling, headaches.
S i g n s:
General; pallor, glassy tongue, brittle nails
Cardiovascular; haemic murmurs over the
procordium on auscultation.

12. IRON DEFICIENCY ANEMIA cont.;
Investigations:
Peripheral blood ( complete blood count; CBC):[A].
Findings suggestive of diagnosis include;
1-Microcytic hypochromic anemia ( ie, reduced indices)
2- Anisocytosis (ie, different sizes of RBCs)
3- Piklocytosis (ie, different shapes of RBCs)
4-Normal reticulocytic count (ie, 0.5%- 1.5%)
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4-Normal reticulocytic count (ie, 0.5%- 1.5%)
5-Normal platelet & leukocyte counts
:Blood chemistry[B].
Findings suggestive of diagnosis include;
1- Decreased serum iron less than 60µg/ dl (normal 90-150 µg / dl)
2-Decreased serum ferritin
3-Increased serum iron binding capacity more than 300 µg%
4-Increased free erythrocyte proto-porphyrin.
Bone marrow biopsy (seldom done):[C].
There is absence of stainable iron in bone marrow.

13. Treatment of iron deficiency anemia
during pregnancy:
. Prophylactic Treatment:[A]
Every pregnant woman needs iron supplementation
during pregnancy; the earlier the better ( but NOT
earlier than 14 weeks pregnancy)
Oral iron supplementation to ALL pregnant ladies after
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Oral iron supplementation to ALL pregnant ladies after
16 weeks gestation as 60-80 mg of elemental iron
per day; can be obtained from;
200 mg ferrous fumarate, OR
300 mg ferrous sulfate, OR
550 mg ferrous gluconate, PLUS
1000mg vitamin C ( to help absorption) and 2mg folic acid (to
help hematopoeisis).
Antacids lower the absorption of iron from the stomach.

14. Treatment of iron deficiency anemia
during pregnancy:
Active Treatment:[B].
Active management of anemia depends on 2 main factors;
severity of anemia, and the duration of pregnancy.
weeks:30-16Pregnancy).1(
Oral ferrous sulfate 300mg t.d.s----------- HB ↑ 1gm/month
weeks with severe anemia:30Pregnancy after).2(
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weeks with severe anemia:30Pregnancy after).2(
parenteral iron therapy
Intramuscular ( 250mg every other day) or
Intravenous infusion in a crystalloid solution (eg ferrous
succinate; ferosac®: 1amp in 100 ml of dextrose 5% every
other day).
weeks pregnancy and hemoglobin less35Anemia after).3(
gm/dl:6than
These patients should receive transfusion of packed RBCs (or
whole blood if packed RBCs are not available).

15. Folic Acid Deficiency Anemia
Folic acid deficiency causes megaloblastic anemia
which accounts for 3% of cases of anemia
during pregnancy.
Folic acid metabolism during pregnancy:
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Folic acid metabolism during pregnancy:
Pregnancy is associated with negative folate
balance.
Folic acid & iron play a central role in nutrition & DNA
synthesis
Folate requirements are increased during pregnancy
for the growing fetus, placenta, maternal RBCs, and
uterine hypertrophy. Folate requirement in normal
pregnant lady are 200-300 µg/ day.

16. Folic Acid Deficiency Anemia; cont.;
Etiology of folic acid deficiency anemia:
1-The causes are the same as those of iron
deficiency anemia , plus the following:
2- Anti-convulsion therapy (eg, pregnant
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2- Anti-convulsion therapy (eg, pregnant
epileptic patient on epanutin®).
3- Antipyretic therapy.
4- Chronic hemolysis.

17. Folic Acid Deficiency Anemia; cont.;
Investigations for folate deficiency:
Peripheral blood:[A].
The findings suggestive of diagnosis:
1-Macrocytic hyperchromic anemia (MCV increased)
2-Hypersegmented polymorphs
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2-Hypersegmented polymorphs
3-Elevated reticulocytic count.
[B]. Blood chemistry:
1-Decreased plasma folate level; the finding of a serum
folate <2ng/ ml [+] red cell folate <150 ng /ml, is
diagnostic.
2-Increased urinary form-imino-glutamic acid (FIGLU);
this finding differentiate folate deficiency from
vitamin B12 deficiency.

18. Folic Acid Deficiency Anemia; cont.;
Hazards of folate deficiency during pregnancy
Increased incidence of the following;
1- Neural tube defects (NTDs)
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2- Cleft lip and cleft palate.
3- Intrauterine growth restriction (IUGR)
4-Megaloblastic anemia.

19. Folic Acid Deficiency Anemia; cont.;
Treatment of folic acid deficiency anemia during
preg.:
Prophylactic measures:[A].
Vitamin supplements containing 400 µg of folic acid
orally per day are now recommended for all
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orally per day are now recommended for all
women of childbearing age and during pregnancy.
Active treatment:[B].
Mild cases; Oral 5 mg folic acid per day
Severely anemic patients near delivery; Exchange
transfusion with packed RBCs followed by
parenteral folic acid therapy (1mg/IM/day/ for 1
week).

20. Vitamin B12 Deficiency Anemia
Etiology :
It is also called pernicious anemia. It is a
very rare type of megaloblastic anemia
during pregnancy, since the daily
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during pregnancy, since the daily
requirement of vitamin B12 during
pregnancy is only 1 µg.
Vitamin B12 deficiency is usually due to
intrinsic factor deficiency in the stomach;
(sub-acute combined degeneration).

21. Vitamin B12 Deficiency Anemia, cont
Diagnosis:
bloodPeripheral
will show the same picture as folate
deficiency anemia except for normal
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deficiency anemia except for normal
reticulocytic count ( elevated in folate
deficiency).
;Blood chemistry
there is low plasma vitamin B12 level . A
serum level less than100 pg/ ml is
diagnostic of vitamin B12 deficiency.

22. Vitamin B12 Deficiency Anemia, cont
Treatment:
:Mild cases
250 µg of parenteral (IM) cyancobolamin/ month.
Oral preparations of vitamin B12 have unreliable absorption
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Oral preparations of vitamin B12 have unreliable absorption
properties & are inadequate for long term therapy.
;Severely anemic patients near delivery
Exchange transfusion with packed RBCs followed
by parenteral cyancobolamine ( 100 µg /IM/day/
for 1 week ).

23. Normochromic Normocytic Anemias
Hemorrhagic Anemia:[A].
It is the 2nd common type of anemia during
pregnancy following iron deficiency anemia.
Causes: acute or chronic blood loss in
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Causes: acute or chronic blood loss in
obstetrics;
Early: abortion, ectopic pregnancy,
vesicular mole.
Late: placenta previa, accidental
hemorrhage.

24. Normochromic Normocytic Anemias
:AnemiasHemolytic[ B].
According to results of Coomb's test, they are classified into:
( ie, positive Coomb's test): this may;A)Immune hemolytic anemias
be isoimmune OR autoimmune;
B).Non-immune hemolytic anemias; (ie, negative Coomb's test):
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B).Non-immune hemolytic anemias; (ie, negative Coomb's test):
this may be due to:
(a). Intracorpuscular causes ( ie, chronic hemolytic anemia);
- Hemoglobinopathies as thalassemias, sickle cell anemia
-Cell wall defect as spherocytosis, elliptocytosis
- Enzymatic defect as G-6- PD deficiency, pyruvate kinase
deficiency.
(b). Extra-corpuscular causes as;
Preeclampsia-eclampsia
Prosthetic heart valves
Malarial infection.

25. Normochromic Normocytic Anemias
Clinical features of chronic hemolytic anemias:
1-Pallor with jaundice.
2- Mongoloid facies.
3-Splenomegaly and hepatomegaly.
4- (±) Hemic murmur over the heart.
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4- (±) Hemic murmur over the heart.
Laboratory features of chronic hemolytic anemias:
1-Normochromic Normocytic (except with thalassemia it is
microcytic hypochromic).
2-Reticulocytosis (reticulocyte count > 2%)
serum bilirubin.indirectElevated-3
4-Shortened life span of RBCs (by isotope chromium 51).
5-Erythroid hyperplasia of the bone marrow.

26. Management of pregnancies
complicated by Thalassemias:
with the aid of a hematologist)[A]. MATERNAL: (
--No specific therapy for β-thalassemia minor
during pregnancy; as the outcome for both the
mother & the fetus is satisfactory.
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mother & the fetus is satisfactory.
1- Blood transfusion is rarely indicated
except for hemorrhage.
2- Prophylactic folic acid supplementation is
strongly indicated.
3- Proper treatment of infections.
4- Iron chelating agents (eg, Desferal®).

27. Management of pregnancies
complicated by thalassemias:
:[B]. FETAL
The fetal management in patients with
thalassemia or sickle cell disease is concerned
with the fetal risk of acquiring the disease.
Management consists of:
1- Genetic counseling.to determine the fetal risks by Mendelian laws.
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1- Genetic counseling.to determine the fetal risks by Mendelian laws.
2- Antenatal diagnosis of thalassemias & sickle cell anemia may be
achieve via one of the following techniques:
(a) Chorionic villus sampling,
(b) Early amniocentesis between 7-11 weeks gestation,
(c) Cordocentesis through percutaneous umbilical blood sampling
(PCUBS), or
(d) Fetoscopy with cord blood sampling.
3. Termination of pregnancy is considered if the fetus is severely
affected.
4. Reassurance of pregnancies if the fetus is not affected or mildly
affected.

28. Management of pregnancies
complicated by the SS-disease:
:[A]. PREGNANCY
1- Very close observation (frequent antenatal visits, or
hospital).
2- Folic acid supplementation ( 2mg orally / day).
3- .
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3- Eradication of asymptomatic bacteruria & pyelonephritis.
4- Guard against pneumonia and heart failure.
5- Prophylactic blood transfusion.
6- Management of crisis by:
Oxygenation
Hydration (iv fluid therapy)
Blood transfusion
Heparinization for the thrombotic cricis

29. Management of pregnancies
complicated by the SS-disease:
[B]. DELIVERY: (managed as cardiac patients)
1-Comfortable but not sedated.
2-Blood ready for transfusion.
3-Vaginal delivery is preferred, and CS for obstetrical
indication only.
4-Regional anesthesia is better than general anesthesia.
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4-Regional anesthesia is better than general anesthesia.
5-Replace blood loss adequately.
[C]. CONTRACEPTION:
Tubal sterilization is indicated even if the parity is very low.
Combined oral contraceptives are contraindicated
(↑thrombosis)
Intrauterine contraceptive device (IUCD) is contraindicated
(↑infection).

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