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Anemia is a condition in which blood has a lower than-normal amount of red blood cells or hemoglobin. Anemia in pregnancy is a decrease in the total red blood cells or hemoglobin in the blood
Anaemia is the most common complication of pregnancy in sub-Saharan Africa. It is a diminution below normal of the total circulating haemoglobin mass.
World Health Organization definition of anaemia:
- Haemoglobin concentration less than 11 g/dL or a hematocrit less than 33% in peripheral blood
For practical purposes in developing and tropical countries a haemoglobin concentration of 10 g/dL or hematocrit of 30% is taken as cut off. Below these levels there may be adverse fetal and maternal outcomes:
- Mild- PCV 25-29%
- Moderate- PCV 20-24%
- Severe- PCV <20%
This varies and depends on the severity. It may be asymptomatic or symptomatic
- Generalised weakness
- Easy fatigability
- Dyspnea on mild exertion
- Ankle swelling
- Jaundice may or may not be present
- Pedal edema
- Haemic murmurs
- Systolic hypertension, edema and albuminuria
- There may, or may not be clinical evidence of causative pathology
- Sickle cell facies, urinary tract symptoms, etc.
- Hepatomegaly: not invariable
- Splenomegaly: not invariable
- Anaemic heart failure in extreme cases
- Nutritional deficiencies: Iron, folic acid, protein, vitamin C; trace elements, and rarely vitamin B12
- Physiological demands of pregnancy
- Excessive red cell haemolysis as in malaria, haemoglobinopathies
- Infections: urinary tract infection, HIV/AIDS, Hookworm infestation
- Antepartum haemorrhage
- Bone marrow pathologies
- Miscellaneous: e.g. bleeding duodenal ulcer.
- Cardiac failure
- Reduced ability to tolerate blood loss at delivery
- Reduced ability to tolerate anaesthesia
- Diminished resistance to infection
- Preterm labour. Precipitate labour may occur
- Spontaneous abortion
- Intrauterine growth restriction.
- Intrauterine fetal death
- Still birth
- Risk of developing anaemia within 2 – 3 months of birth if mother suffered iron deficiency anaemia
- Haemoglobin concentration
- White blood cell count and differentials
- Blood picture
- Reticulocyte count
- Blood smear
- Midstream urine: microscopy, culture and sensitivity
- Stool analysis: ova, cysts, parasites, occult blood
- Group and cross-match blood
- Haemoglobin genotype
- Blood Group
- HIV screening.
- Urinalysis and culture.
- Ultrasound scan (e.g. of abdomen, pelvis).
- Bone marrow biopsy if bone marrow involvement is suspected
- Correct hematocrit.
- Treat underlying cause(s)
- Fetal surveillance:
- of growth and wellbeing to exclude IUGR and intrauterine asphyxia
Correction of hematocrit:
1. Oral haematinics
For mild and moderate anaemia –
- 200 mg daily and folic acid 5 mg daily
- Vitamin C (ascorbic acid)
100 mg three times daily.
2. Parenteral iron:
- Mild to moderate anaemia, near term
- Malabsorption of oral iron, or when it causes serious gastroenteritis
- Calculate haemoglobin deficit
- For each 1 g/dL deficit, 250 mg of iron dextran injection is required
- Additionally, 50% of the total calculated is added onto the deficit value to take care of the iron stores
- Administer by deep intramuscular injection into the gluteal muscle, by slow intravenous injection or by intravenous Infusion (after a
negative test dose)
- 250 mg daily; after a negative test dose of 25 mg
If the total calculated dose of iron dextran is less than 1,500 mg it can be given over 8 hours in one litre of sodium chloride 0.9%. If greater than 1,500 mg, it should be given in divided doses daily, not exceeding 1,500 mg/day
Antihistamine (chlorphenamine injection), epinephrine and hydrocortisone injection must be available:
- iron dextran could cause severe anaphylaxis
3. Blood transfusion
- Consider as from the 37 week for mild anaemia and from the 32 week for moderate anaemia
- Usually, packed cells under furosemide cover
- Severe anaemia irrespective of gestational age
- Cardiac failure
- Moderate anaemia detected in labour or during an abortion, or co-existing with other conditions such as sepsis, renal failure, haemorrhage or eclampsia
- Counselling on contraception; adequate spacing of pregnancies.
- Malaria prophylaxis in pregnancy.
- Chemoprophylaxis against helminthiasis.
- Prompt and appropriate treatment of febrile illnesses in pregnancy
- Improvement of the socioeconomic status of the people
- Provision of accessible and affordable maternity care facilities