1. Haematological disorders

2. Anemia
Definition ;
is a condition in which the number of red blood cells or their oxygen-carrying capacity is insuffcient to meet the physiological needs of the individual, which consequently will vary by :
age,
sex,
altitude
, smoking
and pregnancy status

3. -In its severe form, it is associated with ;
-fatigue,
- weakness,
- dizziness
- drowsiness
-pregnant women and children being particularly vulnerable
-Anaemia in pregnancy is defined as a haemoglobin (Hb) concentration of less than 11 g/dl

4. Physiological anaemia of pregnancy
increase of blood plasma in pregnancy causes a state of haemodilution (see Chapter 9). -On laboratory testing, the Hb values decline, reaching the lowest in the second trimester followed by a gradual rise in the third trimester.
This situation is not pathological unless the Hb reduces to such an extent that iron deficiency anaemia results.

5. Iron deficiency anaemia
the most common cause of anemia globally and is defined by trimester,
Anaemia defined by trimester
Trimester Serum ferritin concentration Haemoglobin1<30 µg/l<11 g/dl 2 and 3 <30 µg/l <10.5 g/dl
-The daily iron requirement for a healthy woman is 1.3 mg, which can be acquired through a diet rich in iron and folate.
-In pregnancy this requirement rises to 3 mg per day, further increasing to 7 mg per day after 32 weeks
-Prophylactic antenatal iron supplementation is no longer ,the woman is at risk of developing iron deficiency anaemia.

6. Iron deficiency is associated with:
reduced intake of iron due to gastric malabsorption, gastric surgery or dietary deficiency
short intervals between pregnancies
chronic infection such as malaria or human immunodeficiency virus (HIV)
chronic blood loss, e.g. menorrhagia or gastric ulcer
haemorrhage
secondary cause to medical disorders
multiple pregnancy.

7. Iron deficiency interferes with body functions, leading to:
tiredness
irritability and depression
breathlessness
poor memory
muscle aches
palpitations
cardiac failure
maternal exhaustion in labour

8. poor recovery from blood loss at the birth and during the postnatal period.
-Routine serum blood samples should be taken from healthy pregnant women at intervals during the antenatal period according to local protocols for the early identification of anaemia.
-When anaemia is identified serum ferritin should be measured as an indication of the level of stored iron.
-It is recommended that women with known anaemia be screened at every antenatal appointment .

9. -Borderline anaemia
can be managed in the community setting, however severe or chronic cases should be referred to a consultant-led maternity unit as should those women who are symptomatic
-The initial treatment is with iron tablets, such as Pregaday®, one tablet per day for 2 weeks.
-The woman should be advised to take the tablet 1 hour before food with orange juice, which contains ascorbic acid (vitamin C) to aid absorption of the iron.
- Unfortunately many brands of oral iron tablets have unpleasant gastric side-effects which reduce maternal compliance in taking them.

11. -Serum Hb estimation is undertaken after 2 weeks, and if the Hb appears to be rising, the woman should continue taking the
iron tablets.
However, if the Hb does not rise or there is intolerance or poor compliance, the woman should be referred to a haematology clinic for further management.
Additional investigations may be undertaken to determine the cause of the anaemia and other oral iron, such as ferrous sulphate (200 mg 2–3 times daily) may be prescribed

12. If there is still intolerance to oral iron, then parenteral iron injections will be offered.
These injections, however, are uncomfortable and can cause iron staining on the skin, so the z- track injection method should be used.
Blood transfusion is used only in extreme cases during pregnancy
If the anaemia persists then the woman should be assessed regarding her risk for haemorrhage.

13. -An IVI should be sited in labour and blood samples taken for full blood count (FBC) and for group and save.
The FBC results should be reviewed before the woman either eats or drinks.
-The midwife should be alert for signs of maternal exhaustion during labour with active management of the third stage of labour being undertaken, and all perineal trauma should be sutured to minimize the effects of blood loss at the time of the birth.

14. -In the postnatal period the woman with anemia is at risk of :
*infection,
*postpartum hemorrhage,
* depression
*poor wound healing.
The midwife should observe and support her accordingly and ensure that a FBC blood sample is taken to identify further treatment requirements.

15. -Contraceptive advice should be given for adequate spacing of pregnancies along with dietary advice and a follow-up appointment.
The FBC will also need repeating at the 6 week postnatal examination.