1. By: Ahmad Harith Zabidi Azhar Nik Muhammad Farhan Zulkifli Shahrizam Tahir Ahmad Nadzmi Mahfuz

2.  Progressive increase in plasma volume up till 32-34 weeks, (50%)  Progressive increase in Red cell mass, although the pregnancy, (25%)  Max physiological anemia occur at 32-34 weeks gestation.  MCV, MCHC stay constant, i.e. dilutional anemia  Proressive fall in platelet count, low platelets only if Platelets are < 100 or pathologically reduced count. 5- 10% will be 100-150*109 /l  There is 2-3 fold increase in iron requirements in pregnancy.  Hypercoagulable state.

3.  Lower limit Hb normal values:-  Non-pregnant 11.5 – 12 g/dl  Pregnant, change with gestation, but generally 10.5 g/dl  Clinical features:  Mostly detected on routine testing  Tiredness  Lethargy  Dizziness  fainting

4.  Resulting in decreased heme production.  The commonest in pregnancy  Increased demand by the developing fetus, lead to increased absorption and increased mobilization from stores.  All pregnant woman should be screened.  Elemental iron 30 mg daily recommended for all pregnant woman.

5.  Stores are depleted  Poor iron intake  Poor absorption  Utilization is reduced  Increased demand:  Multiple gestations  Chronic blood loss  Hemolysis  A lot of patients start pregnancy with already depleted stores.  Menorrhagia  Inadequate diet  Previous recent pregnancy  Conception while lactating

6.  IDA is more common in multiple pregnancies.  Blood loss at delivery will further increase maternal anemia, so it is not only a problem confined to pregnancy period.

7.  Fetal effects:  Increased IUGR  Preterm birth

8.  Iron deficiency Anemia:  As it is the commonest, it is always presumed to be the diagnosis, but it should always be confirmed.  Changes in the indices as follows: ▪ MCV reduced ( < 80 ) ▪ MCH,MCHC reduced ▪ RDW > 15% ▪ RBCs are microcytic and hypochromic. ▪ Serum iron fall, < 12 mmol/l (normally falls in pregnancy). ▪ Total iron binding capacity increased, ▪ Saturation <15% indicate anemia ▪ Serum ferritin fall

9.  Resulting in decreased Hb production.  Second commonest n pregnancy  The normal dietary folate intake is inadequate to prevent megaloblastic changes in bone marrow in 25% of pregnancy ladies.  Prevalence varies according to:  Social class  Nutritional status

10.  Factors increasing the risk of FDA:  Anticonvulsant therapy ( phenytoin, phenobarbitol)  Chronic Hemolytic anemias ( e.g., Sickle Cell disease)  Thalassemia  Hereditary spherocytosis  Frequent pregnancies

11.  Fetal effects:  Increased IUGR  Preterm birth  NTD

12.  Folate Deficiency  MCV increased (>100)  RDW > 15 %  RBCs are macrocytic.  Megaloblastic changes in the bone marrow  Reduced serum and red cell folate.  Peripheral smear may show hypersegmented neutrophils.

13.  Routine iron supplement, as demand is rarely met by normal iron intake.  Oral supplementation is not without side effects:  Constipation  Metallic taste  Diarrhea  Nausea and vomiting

14.  alternate routes are available:  IV  IM  The maximum rate of rise in Hb is around 1g/dl/week.  Severe anemia diagnosed in the later stages of pregnancy may need transfusion.

15.  Folate intake and supplementation preconception and 1 st trimester:  i) routine: Preconception advice for all women is to take folate supplement of 0.4 mg/day to reduce the risk of NTD,  ii) this will increase to 5mg/day in cases of previous NTD baby, or in case of taking of anti- folate medications.

16.  Thank You