1. AnAemia in Pregnancy Dr. Yasir Katib MBBS, FRCSC Perinatologest

2. Objectives Normal changes in blood physiology during pregnancy Normal changes in blood physiology during pregnancy Different causes of anemia (history and investigations) Different causes of anemia (history and investigations) Effects of anemia on the mother and the fetus Effects of anemia on the mother and the fetus Managing anemia in pregnancy (from prevention to treatments) Managing anemia in pregnancy (from prevention to treatments)

3. Introduction A normochromic, normocytic anemia may occur from the 7 – 8th week of gestation (physiological anemia) Hb should not fall to <11.0 g/dl in the 1 st trimester <10.5 g/dl in the 2 nd and 3ed trimesters

4. Anemia and Pregnancy

5. Introduction Puerperium HB fluctuates for a few days HB fluctuates for a few days Then rise to higher (non-pregnant) level Then rise to higher (non-pregnant) level

6. Introduction Pregnancy requires an iron intake of 2.5 mg/day early 3.0 – 7.5 mg/day required in the third trimester An average diet supplies around 250 μg/day of folate Requirements increase to around 400 μg/day during pregnancy

7. Introduction Folate deficiency most commonly due to lack of folate-rich vegetables such as broccoli and peas, which is often linked to social deprivation. Folate deficiency is more common in multiple pregnancy frequent childbirth adolescent mothers

8. Introduction The body stores around 3 mg of B12, with a daily dietary requirement of 3μ g/day The only B12 source is animal foodstuffs; thus, vegetarians and vegans are most at risk of dietary deficiency

9. Iron deficiency anemia It is the most common cause of anemia in pregnancy worldwide Maternal iron requirements increase in pregnancy because of the requirements of Fetus Placenta Maternal red cell mass

10. Iron deficiency anemia Hb as the sole means of diagnosing anemia is not a sensitive test although this is often used as the first indicator in clinical practice Serum ferritin is the most sensitive single screening test to detect adequate iron stores Using a cutoff of 30 micrograms/liter has a sensitivity of 90%

11. Clinically This is often asymptomatic However the following are most common: Fatigue Fatigue Dyspnoea Dyspnoea The patient may also appear pale

12. Investigations Hb ≤ 11.0g/dl MCV : if ≤ 76fl then probable cause is iron deficiency, but if lower than concomitant with other signs of anemia and RBC count raised, then suggests possible B2-thalassaemia (Hb electrophoresis) Normal MCV (76-96fl) with low Hb is typical of pregnancy Serum ferritin 10-50g/dl needs monitoring and <10g/dl requires treatment

13. Management Routine Iron and folate supplementation with normal Hb Raised or maintained the serum iron and ferritin levels and serum and red-cell folate levels Resulted in a reduction of women with a hemoglobin level below 10 g/dl or 10.5 g/dl in late pregnancy However, no detectable effects on rates of caesarean section Preterm delivery Low birth weight Admission to neonatal unit Stillbirth and neonatal deaths

14. Management Iron supplementation with iron deficiency anemia Evidence was inconclusive on the effects of treating iron deficiency anaemia in pregnancy because of the lack of good quality trials There is an absence of evidence to indicate the timing of, and who should be receiving, iron supplementation during pregnancy Severe maternal iron deficiency is associated with premature delivery and low birth weight

15. Recommendations Pregnant women should be offered screening for anemia. Screening should take place Early in pregnancy (at the first appointment) And at 28 weeks Hemoglobin levels outside the normal range for pregnancy (that is, 11 g/dl at first contact and 10.5 g/dl at 28 weeks) should be investigated and iron supplementation considered if indicated

16. Recommendations Supplementation can be achieved with 30 – 60 mg of iron/day, which produces few side effects Side effects are mainly seen with replacement (200 mg/day) therapy Furthermore, supplementation of more than 200 mg/day will not produce a supra- normal hemoglobin (Hob) or haematocrit (HCT)

17. Recommendations Iron absorption is maximized when combined with ascorbic acid such as taking the iron supplements with fresh orange juice vitamin C preparation Therapy failure occurs in malabsorption when loss exceeds intake but is most commonly due to poor compliance

18. Recommendations There are also liquid oral iron preparations and parenteral therapy Parenteral therapy is useful in malabsorption failed compliance But otherwise does not produce a faster response than oral iron and side effects are common

19. Thalassaemia Inherited blood disorders with reduced or absent production of alpha or beta chains of the globin content of haemoglobin. Inherited blood disorders with reduced or absent production of alpha or beta chains of the globin content of haemoglobin. Carriers of thalassaemia, may be asymptomatic when not pregnant but more anemic than usual during pregnancy Carriers of thalassaemia, may be asymptomatic when not pregnant but more anemic than usual during pregnancy MCV ≤ 80fl requires investigation with an HbA2 ≥ 3.5 being positive for B2- thalassaemia MCV ≤ 80fl requires investigation with an HbA2 ≥ 3.5 being positive for B2- thalassaemia

20. Sickle-cell Anemia Genetic defect causes production of abnormal hemoglobin with a red blood cell life of ≤15 days Genetic defect causes production of abnormal hemoglobin with a red blood cell life of ≤15 days Mainly affects people from East and West Africa Mainly affects people from East and West Africa Where suspected, women should receive folate 15mg/day with frequent Hb counts Where suspected, women should receive folate 15mg/day with frequent Hb counts If Hb falls ≤ 6g/dl, need transfusion If Hb falls ≤ 6g/dl, need transfusion

21. Sickle-cell Anemia Use of regular prophylactic transfusions reduced number of transfusions required, but was associated with more pain crises Use of regular prophylactic transfusions reduced number of transfusions required, but was associated with more pain crises May give prophylactic antibiotics during childbirth and afterwards May give prophylactic antibiotics during childbirth and afterwards

22. Sickle-cell Anemia Screening may be based on higher risk An ethnic group Or on laboratory method To all pregnant women

23. Sickle-cell Anemia ComplicationsFetal 1. Spontaneous abortion 2. PTL 3. Low birth weight 4. Perinatal mortality Maternal 1. UTI 2. PIH

24. Summery Pre-conceptional counseling Pre-conceptional counseling 1 st visit screening 1 st visit screening Supplementation & prevention Supplementation & prevention Prenatal screening Prenatal screening Follow up Follow up Laboratory Laboratory Ultrasound Ultrasound