1. Anaemia in pregnancy
Anaemia is one of the most common disorders affecting humans in the world.
The WHO defines anaemia as Haemoglobin (Hb)< 11g/dl.
Chronic anaemia results in the sense of well-being; fatigue, stress, decrease in work capacity.
Anaemia in pregnancy, is associated with an increased risk of maternal and fetal morbidity and mortality.

2. Physiological changes in pregnancy
Healthy pregnancy and puerperium are associated with a marked physiological changes in the circulating blood; increase in blood volume and alteration in the factors involved in haemostasis.
These changes have relevance to the most potential and hazardous haematological problems of pregnancy& delivery.
What are they???

3. Physiological changes
Blood volume;
Plasma volume
Red blood mass
Hypervolemia state, modifies the response to hypotension in the first half of pregnancy and the blood loss at delivery.
Vaginal delivery;? ml
Caesarean section? ml

4. Causes Inadequate intake of nutrition Excess blood loss
Abnormal demand
malabsorption

5. Iron deficiency anaemia
Hb concentration decrease
MCV
MCH
MCHC
All can be calculated from RBC, Hb,Packed cell volume.
These tests give basic guide to a diagnosis in pregnancy.

6. MCV, the most sensitive indicator of underlying Iron deficiency, decrease
Hypochromia, and MCHC appear with more severe degree of Iron defiency.
Serum ferritin
Total Iron binding capacity

7. Management Confirm diagnosis; history, examination and investigation
Treatment depends on the degree of anemeia and ?????

8. Treatment Nutrition Iron therapy, various forms, depends on
Compliance of the woman
Associated GIT symptoms
Availability of medication
Cost

9. Oral Iron,
ferrous fumerate, ferrous sulphate
Does depends on level of HB
Supplement folic acid
Give proper instructions
Care if on throxine, calcium,

10. Injectable/ parentral Iron therapy
Intramuscular
Intravenous infusion

11. The following statements about oral iron prophylaxis during pregnancy are correct:
Gastric side effects are does-related.
Iron absorption during the first trimester of pregnancy is decreased compared with non-pregnant state.
Non-compliance of the mother occurs in less than 10%.
Oral maternal iron prophylaxis is recognized to be associated with an increase in MCV

12. Iron deficiency anaemia in pregnancy
MCHC and MCV are low
There is usually chronic blood loss
Blood transfusion is indicated if the Hb is <9gm/dl.
There is increase risk of Pre-eclampsia.
There is no proven danger of teratogencity from Iron therapy.

13. A clinical scenario
A 25 years old gravida 2with a normal past obstetric history, is found to have a Hb of 10gm/dl at 32 weeks of gestation. The Hb at booking(12 weeks) was 12gm/dl and she has not taken Iron supplements during this pregnancy. Full investigation shows a MCH of 32 and a MCV of 86FL. The blood film shows some polychromasia and microcystic.

14. These findings are diagnostic of Iron deficiency anaemia
The MCV is a better guide to the presence of Iron deficiency anaema than is Hb level.
Should iron deficiency occur late in a prgnancy, parentral Iron will raise the hb faster than oral iron

15. Haemoglobinpathies Sickle cell disease
Is the name given to a group of inherited blood conditions which include:
Sickle cell anaemia,
Sickle cell beta thalasemia,
Haemoglobin SC disease.
The most common and severe is Sickle cell anaemia

16. What causes sickle cell anaemia
Inherited disorder of the Hb structure

17. Antenatal care
Sickle cell trait (HbSA) , may have UTI and microscpic haematuria’
Sicle cell anameia
Bad obstetric history
Painful crises
Jaundice
Anaemia
Deformed pelvis Increase rate of operative deliveries; CS
avascular necrosis of the hip

18. Diagnosis Hb electrophoresis, not specific, Hb D, G
Sickling test, not specific, HbC Hb memphis.
Hb solubility test, specific, cheap, rapid and simple.
reticulocytes

19. Combination; HbSS and pregnancy hazardous
Mother
Infection
Anaemia
Heart failure
Painful crises
Embolism/ stroke
Pulmouary hypertension
Renal dysfunction
Retinal disease
Leg ulcers
Choliothesis

20. Antenatal follow-up Mother MSU Blood pressure Dip stick Renal function
Liver function
Complete blood picture
Will they have Iron deficiency anaemia????

21. Fetal monitoring USS for viability <9 weeks
USS, first trimester weeks
USS detailed anomaly at 20 weeks
Biometry every 4 weeks.

22. What to give Folate, because ?? Asprin , how much???
Heparin, what kind??

23. In pregnancy Avoid Hypoxia Acidosis Infection Dehydration Stress
Exercise
Extreme Teperature

24. Treatment Multi-disciplenary approach Supportive measures Rehydration
Analgesics
Blood transfusion, keep Hb S level<40%
Keep Hb A level >60%

25. Further Readings
Management of sickle cell Disease in pregnancy.Guideline No 61 July 2011

26. Maternal sickle cell disease
The spontaneous miscarriage is increased
The incidence of proteinuric hypertension increased.
The incidence of spontaneous delivery is increased.
The incidence of small for gestational age is unchanged.
The presence of sickle cell disease in the fetus can not be diagnosed.

27. Sickle cell disease
There is failure of formation of the beta chain of polypeptide.
Hb level rarely fall below 9gm/dl.
Iron deficiency anaemia is usual
Crises is unlikely to occur the trait.

28. Perinatal mortality rates are adversely affected by:
Alpha Thalasemia minor
HbSS
Beta Thalasmia minor
HbSC
Sickle cell thalasemia
Sickle cell trait