Anaemia in Pregnancy

Anaemia means a reduction in oxygen carrying capacity or in quantity of red blood cells.

This may be due to:
> A reduction in number of the red blood cells
> A low concentration haemoglobin
> A combination of both
Degrees
Mild – 80% = 11 g/dl – 12.5 g/dl
Moderate – 70% = 8-10.3
Severe – 60% = 7 g/dl and below
OR
Mild – 9.0g/dl
Moderate – 7.8g/dl
Severe – 6g/dl

Table of Contents

Causes

Social and economic factors;

Ignorance about utilization of food
Poverty unable to buy the high protein foods
Native medicine
Unstable country / Insecurity
Beliefs – cultural superstition which forbid women from taking certain foods for example chicken and eggs

Obstetrical causes

Frequent child bearing
Repeated haemodilution
Multiple pregnancy due to high fetal demand
Hyperemesis gravidarum leading to poor absorption of Vitamin B12
Abortions, ruptured ectopic, PPH, APH, and heavy periods

Medical causes

Frequent attacks of malaria
Hookworm infestation
Infections such as septicaemia, TB
Sickle cell anaemia
Drugs like Chloramphenical

Types of Anaemia

Physiological anaemia.
Nutritional anaemia.
Aplastic anaemia.
Haemorrhagic anaemia.
Haemolytic anaemia.
Pernicious anaemia.

Physiological anaemia: This is the type of anaemia that occurs during pregnancy due to haemo-dilution that occurs during pregnancy where the blood plasma is increased by 25-30%.
Nutritional anaemia: This is the type brought about about by poor diet whereby there may be deficiency in:
> Folic acid which is responsible for the RBC development bringing about megoblastic anaemia, (Immature Red blood cells)
> Iron deficiency anaemia which is due to the increased fetal demand from the 28th week of pregnancy or due to excessive morning sickness, vitamin B12 and vitamin c deficiency with lack of protein leading to pernicious anaemia.
Aplastic anaemia: This is due to the damage of the red bone marrow caused by prolonged use of chloramphenical depressing the bone marrow
> Radiation where insufficient protection from the x-rays was not provided
> Diseases such as cancer and leukaemia
> Poison from insecticides
Haemorrhagic anaemia: This when there is increased blood loss as may occur in the following cases
> Frequent child bearing that the mother does not get time to regain her haemoglobin levels
> Worm infestation such as hookworms
> Abortions, PPH and APH
> Ruptured ectopic pregnancy
> Trauma and accidents
> Haematemesis and haemoptysis
Haemolytic anaemia: This is when there is increased blood destruction due to:
> Infections such as septicaemia, Pyelonephritis and Bacterial Streptococcus
> Diseases for example malaria
> Mis-crossmatched transfusion
> Sickle cell disease – big spleen disease
> Drugs for example primaquine
Pernicious anaemia
This is when the intrinsic factor is missing leading to mal absorption of vitamin B12. It may occur in the following conditions:
> Diseases of the stomach for example cancer
> Hyperemesis gravidarum
> Surgical operations for example gastrectomy. However, this condition rarely occurs during child bearing age

Signs and symptoms

On history taking

Patient gives history of general body weakness
Dizziness
Faintness
Palpitations
Loss of appetite (Anorexia)
Headaches
Breathlessness
History of heavy bleeding may be there

On Examination

Pale mucus membranes and conjunctiva for example gums, kips, tongue, soles of the feet and palms of the hands
Distention of the jugular veins
In severe cases oedema of the ankles, feet or it may be generalized
On abdominal palpation, there may be enlarged spleen and liver
Jaundice

Laboratory Tests
Haemoglobin level will be low below 12.5 g/dl

Diagnosis

Based on three factors:

History taken from the patient about her home including the surrounding
diet, parity and hygiene.
Examination of the patient to detect pale mucus membranes and venous return for example oedema of the upper limbs, wedding rings and puffiness of the face
on the abdomen during auscultation
Investigations: Investigations carried out

(a) . Haemoglobin estimation that any haemoglobin of 10 g/dl or below is regarded as anaemia
(b) . Packed cell volume (Normal is 40%)
(c) . Blood film – thick to identify the shape, maturity and consistency, thin red blood
cells.
(d) . BS for malarial parasites
(e) . Sickling test to exclude abnormal cells
(f) . Blood film for the thin:

Microcytosis and hypochromia for iron deficiency
Megaloblastic cells – Normochromic for vitamin B12 and folic deficiency
Sickle cell disease
Target cells
Reticulocytes for haemolysis whether its going on mainly in the spleen, whether it is a mixture of no. 1 and 2 which will be indicating nutritional
anaemia

(g) . Coombs test for haemolytic anaemia to see whether the mother s developing
antibodies against the red blood cells. Usually gets recurrent anaemia.
(h) . Bone marrow – to confirm the shape of the cells
(i) . Urinalysis for protein indicating damage to the kidney. Microscopic – for put
cells in case of severe pyenehiritis

(j) . Stool for intestinal parasites, the commonest is hookworm anaemia
(k) . Haemoglobin: Electrophoresis to confirm SCD

Effects of anaemia on pregnancy and labour

General body fatigue with tiredness, breathlessness, palpitations and headache.
Placental insufficiency due to lack of oxygen may lead to:
> Intra-Uterine Fetal Death – intra uterine fetal death
> Small for dates
> Neonatal death
> Abortion and premature labour
Post partum haemorrhage
Stress of labour may not be tolerated by a very anaemic and even minor blood loss may be fatal
Fetal and maternal distress leading to instrumental delivery
May go into heart failure
More likely to have venous thrombosis
Less resistance to infection
Poor lactation

Management

Will depend on the severity of the grade of anaemia, stage of gestation and investigation or cause.

Early pregnancy with mild or moderate anaemia in a maternity centre and hospital
A mother with mild or moderate anaemia treated as an out patient.

Put the mother in bed
Take history from the mother concerning the type of diet way of living and her surrounding to know the cause of anaemia
Carry out general examination for degree of anaemia by use of a tallquist book
The midwife is only allowed to treat mild and moderate anaemia in early pregnancy
The condition is managed according to the cause
If no clinical examination the haemoglobin is found to be below 60% is sent to the hospital for investigations

Active Treatment
For a mother with haemoglobin of 60% and above may be treated with the following:-

Where malaria is common, the mother is given three doses of Fansidar 960 mgs tablets.
Mebendazole 200 mgs bd x 3 days for hookworm
Iron therapy of ferrous Sulphate and folic acid then review after 2 months, ferrous sulphate 200 mgs bd, forric acid 5 mgs od
NB. In the maternity centre moderate anaemia in late pregnancy, refer to hospital.

In the hospital

Admit in the hospital in Antenatal ward
Take history about the diet, environment and hygiene
Observations – temperature, Pulse, Respirations and blood pressure taken
Any underlying cause will be treated accordingly
The mother is given routine nursing care
Proper hygiene
Given a high protein diet

Severe anaemia in early pregnancy and late pregnancy
In maternity Centre – refer to hospital please

In Hospital
The mother is admitted and history taken
Observations and investigations carried out
Patient is resuscitated immediately with:
(a) Blood transfusion or parenteral iron dextran (Inferon) infusion if blood is not available. (N.B Total dose of inferno is given slowly and only in severe anaemia nearly to the time of delivery, and after delivery, should be transfused with packed cells under Lasix.)
Dueretics are given for example lasix 120 mg IV
The patient with severe anaemia should be nursed propped up in bed and
given all the care of a very ill patient.
Mouth should be given special attention as stomatitis and glossitis are common in anaemia patients diet – high protein diet with green vegetables plus fresh fruit
Strict fluid balance chart, observe for signs of impending cardiac failure which are raising pulse and respirations. Should report breathlessness if the patient has tuberculosis
N.B. IV inferon – 5 ampoules of 250 mgs each in 100 mls of dextrose 5% or normal saline 500mls.

Prevention of anaemia

Good antenatal care – by detecting anaemia and malaria early and treat them.
Health education about diet, personal hygiene, environmental, sanitation by proper use of latrines
Protection against malaria
Reduce blood loss in 3rd stage even after by good management of all the stages of labour
Replace proteins at least during lactation by giving extra protein
Administration of extra Iron and folic acid
To carry out the routine examination of blood for haemoglobin

Advice to the mother

Explain to the mother the reason why she has become anaemic, dangers of
anaemia and how to prevent it.
Rest to avoid overworking
Diet and types of food
Advise the mother to take any treatment ordered regularly
The need to prevent mosquitoes to avoid malaria
To avoid frequent child bearing (family planning)
To deliver in the hospital

In labour

Good management of 3rd stage of labour to prevent much blood loss
Administration of iron during puerperium

On discharge
Tell the mother to report immediately when they become pregnant in order to receive appropriate prophylactic treatment of iron therapy