Anemia of pregnancy

Notes
  • See the subtopic “Anemia, overview” in this publication for further details
  • In normal pregnancy the RBC mass increases and total plasma volume tend to increase
  • However, the plasma volume usually increases more than RBC mass leading to hydremia of pregnancy (or hemodilution of pregnancy)
  • Statistics: global prevalence of anemia among pregnant women is 41.8%; prevalence of anemia among pregnant women in Kenya is 55.1% (and 46.4% among non-pregnant women)

##Categorization of anemia based on HB concentration:

  • Anemia- below 10gm/dl
  • Mild anemia - 8 to 10gm/dl
  • Moderate anemia - 6 to 7gm/dl
  • Severe anemia - 4 to 5gm/dl
  • Very severe anemia - below 4gm/dl

##Risks associated with anemia in pregnancy:

  • Severe anemia is associated with abortion, premature labor, and intrauterine fetal death (IUFD)
  • Very severe anemia endangers the life of the mother

##Causes of anemia in pregnancy:

  • Iron and folate deficiency from nutritional deficiency (majority of cases)
  • Hemolysis as a result of malaria infection
  • Loss of blood from causes like helminths (mainly hookworm)
  • Sickle cell disease
Symptoms
  • It may be asymptomatic
  • Fatigue
  • Irritability
  • Edema
  • Paleness of the skin, tongue, lips, conjunctiva and nail beds
  • Jaundice (yellowing of the skin and eyes)
  • Koilonychia (in iron deficiency) - spoon nails
  • Apnea
  • Dizziness
  • Poor ability to exercise
  • Pica (tendency to eat stone chips, ice, paper, wax, grass etc.)
  • Changed stool color
  • Confusion
  • Loss of consciousness
  • Intermittent claudication of the legs
  • Thirst
  • Hypotension
  • Palpitations
  • Tachycardia
  • Splenomegaly
  • In severe anemia, there can be fainting, shock, chest pain, angina and heart attack
  • A short, soft, apical, “haemic” systolic murmur
Diagnosis
  • Complete Blood Count including RBC count, hemoglobin concentration, MCV and RDW that facilitate calculations of hematocrit, MCH, and MCHC
  • Thin blood film examination for cell morphology and blood parasites especially malaria
  • Urinalysis
  • Stool for ova of helminths and occult blood
  • Bone marrow
  • Sickling test/HB Electrophoresis
  • Flow cytometry (to measure the size of RBCs)
Differential
  • Low LDL Cholesterol (Hypobetalipoproteinemia)
Prevention
  • Routine antenatal visits and review
  • Oral iron and folic acid prophylactic doses throughout pregnancy
  • Malaria prophylaxis and encouragement of the use of long lasting insecticide treated nets (LITNs)
  • Balanced diet

##IFAS implementation in Kenya:

  • Iron and Folic Acid Supplementation (IFAS) for pregnant women is one of the interventions that has been recommended by WHO and implemented by the Ministry of Health to reduce anemia, risks of low birth weight, neural tube defects in pregnancy and improve overall pregnancy outcome.
  • It is implemented through Focused Antenatal Care (FANC)
  • IFAS recommends administration of a fixed-dose combination tablet or capsule of elemental iron 60mg + folic acid 0.4mg ONCE Daily from conception to delivery for all women.
Management
  • Treat the underlying cause(s) such as malaria, helminths, and iron /folic acid deficiencies (refer to specific diseases for further details)
  • Mild anemia – oral iron and folic acid
  • For moderate anemia - oral iron and folic acid PLUS iron dextran injection
  • Severe anemia - oral iron and folic acid PLUS iron dextran injection PLUS blood transfusion
  • Very severe anemia – Resuscitation PLUS oral iron and folic acid PLUS iron dextran injection PLUS blood transfusion
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