King Khalid University Hospital Department of Obstetrics & Gynecology Course 481 Anaemia in Pregnancy Anaemia in Pregnancy

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.

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???

Physiological changes Blood volume; Blood volume; Plasma volume Plasma volume Red blood mass 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

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

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

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

Management Confirm diagnosis; Confirm diagnosis; history, examination and investigation history, examination and investigation Treatment depends on the degree of anemeia, symptomatology and gestational age Treatment depends on the degree of anemeia, symptomatology and gestational age

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

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

Injectable/ parentral Iron therapy Intramuscular Intramuscular Intravenous infusion Intravenous infusion

A clinical scenario A clinical scenario A 25 years old gravida 2 with 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. A 25 years old gravida 2 with 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.

1. These findings are diagnostic of Iron deficiency anaemia 2. The MCV is a better guide to the presence of Iron deficiency anaema than is Hb level. 3. Should iron deficiency occur late in a pregnancy, parenteral Iron will raise the Hb faster than oral iron

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

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

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

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

Combination; HbSS and pregnancy risks  Mother Infection Infection Anaemia Anaemia Heart failure Heart failure Painful crises Painful crises Embolism/ stroke Embolism/ stroke Pulmonary hypertension Pulmonary hypertension Renal dysfunction Renal dysfunction Retinal disease Retinal disease Leg ulcers Leg ulcers Choliothesis Choliothesis

Antenatal follow-up Mother Mother MSU MSU Blood pressure Blood pressure Dip stick Dip stick Renal function Renal function Liver function Liver function Complete blood picture Complete blood picture

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

What to give Folate Folate Aspirin Aspirin Heparin Heparin

In pregnancy Avoid Hypoxia Hypoxia Acidosis Acidosis Infection Infection Dehydration Dehydration Stress Stress Exercise Exercise Extreme Temperature Extreme Temperature

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

Maternal sickle cell disease The spontaneous miscarriage is increased The spontaneous miscarriage is increased The incidence of proteinuric hypertension increased. The incidence of proteinuric hypertension increased. The incidence of premature delivery is increased. The incidence of premature delivery is increased. The presence of sickle cell disease in the fetus can not be diagnosed. The presence of sickle cell disease in the fetus can not be diagnosed.

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

Perinatal mortality rates are adversely affected by: Alpha Thalassemia minor Alpha Thalassemia minor HbSS HbSS Beta Thalassemia minor Beta Thalassemia minor HbSC HbSC Sickle cell thalassemia Sickle cell thalassemia Sickle cell trait Sickle cell trait