2. Anaemia in pregnancy
Important History
Symptoms
• Possible chief complaint
- Anaemic symptoms (eg. SOB, lethargy, palpitation, etc)
- Planned admission for blood transfusion
IDA:
- HOPI:
1. Booking haemoglobin:
• Normal: indicate that patient is not anaemic prior to
pregnancy
• Low: ask for symptoms of chronic blood loss before
pregnancy (menorrhagia, chronic GI blood loss, worm
infestation)
2. Whether prophylactic oral iron supplement (haematinics) was
given?
• T. ferrous fumarate 200mg od
• T. folic acid 5mg od
• T. vitaminc Bco 1/1 od
• T. vitamin C 1/1 od
3. Hb trend during pregnancy, ask patient when Hb starts to
drop?
4. Any treatment given when the Hb starts to drop?
• escalate the oral iron to therapeutic dose (a diagnosis of
IDA is presumed)
- T. ferrous fumarate 400-800mg/day (in 2 divided
doses)
- Repeat the FBC 4 weeks later
5. How is the treatment response? (whether Hb improves?)
• If Hb improves after therapeutic iron treatment is
started
- The diagnosis of IDA is confirmed
• If Hb remains low
- Check compliance
✓ Forgetfulness to take medication
✓ Side effects (GI upset, constipation, vomiting)
- Check whether method of oral iron intake is correct or
not?
✓ Empty stomach (2 hours before or after meal)
✓ Should not take it with coffee and tea (impair iron
GI absorption)
✓ Take it with vitamin C (enhance iron GI absorption)
- Blood investigation is indicated to ascertain the
diagnosis of IDA
• Any further treatment escalation?
• Any admission for blood transfusion / parenteral iron
during pregnancy?
• Diet history eg. vegetarian (IDA), family history of
anaemia (thalassaemia)
• Monitoring of complication of anaemia in pregnancy:
- symptoms of placenta abruption (abdominal pain / PV bleeding)
- Regular fetal growth scan to rule out IUGR
Physical Examination
- Look for signs of IDA:
o Conjunctival pallor, Glossitis, angular stomatitis,
koilonychias
**post-cricoid webs(plummer vinson syndrome)
- Per abdomen to look for abdominal tenderness for AP- Uterus smaller than date (IUGR)
Complete examination by:
- Speculum exam: PV bleeding for AP
Investigation
Mother Fetus
Blood:
1. FBC: to confirm HCMC
2. FBP: to confirm morphology of rbc such as
target cell and pencil cell
3. Iron studies:
✓ Serum ferritin (to confirm IDA if the
levels < 15, threshold levels to start
treatment is < 30)
✓ Serum Iron & TIBC (not reliable to
reflect iron storage)
✓ Tsat [Formula = (serum iron x
100)/TIBC], IDA is likely if the level <
20%
Serial u/s of
fetus tro iugr
✓ Hb electrophoresis (beta thal)
✓ DNA analysis (a thal)
Management
Treatment of IDA:
1. Oral iron in therapeutic dose
2. Repeat FBC 1 month later to assess the response
3. If there is slow /no response of Hb improvement,
• Increase the dose further but still within 100-200mg
elemental iron dosage
• If it is due to suboptimal compliance due to side effect,
change to other type oral iron tablet which has lower
side effect profile, eg Iberet
• Parenteral iron
4. Parenteral Iron (eg. Venofer, Cosmofer, Avofer)
• Dose: there is a specific formula to calculate
• When do you consider parenteral iron?
- Failed oral iron treatment due to non-compliance,
side effects
- Contraindication to oral iron treatment eg. GI
malabsorption problems eg. inflammatory bowel
disease
5. Blood transfusion
• Symptomatic of anaemia
• Hb levels < 8 at term
6. Any other relevant management?
• Dietary: high iron diet (eg. spinach, liver, red meat, etc)
• Watchout for placenta abruption (association with
anaemia in pregnancy)
• Monitor fetal growth because there is risk of IUGR
• Intrapartum:
- send GSH/GXM to standby blood product if she
remain anaemic at time of delivery
- Prevention of PPH by active 3rd stage management,
prophylactic uterotonic agents (oxytocin use after
delivery)• Postpartum:
- Assess Hb post-partum (target 10 g/dl and above)
✓ If < 10, therapeutic iron treatment and reassess FBC 2-4
weeks later. Consider blood transfusion if Hb < 7-8 or
patient has anaemic symptoms
✓ If > 10, prescribe prophylactic iron supplement for 3 months
to replenish iron storage
• Monitor for lochia loss
• Effective contraception:
✓ Ensure good pregnancy spacing and thus it allows time for
Hb to recover
✓ avoid method that can trigger bleeding problem
✓ eg. copper IUCD
Discussion
1) what cause her hb to keep dropping despite of having
enough hematinin and compliance
- so tanya pasal diet hx and also workout for thalassemia
(kna tanya dalam family hx )
2) what are the effect of anemia to pregnancy
- placental abruption – APH
- IUGR
- PIH/Pre-eclampsia
- Cardiac failure
- Preterm labour
3) What is the Cut off value
o 1st trimester – 11 g/dL
o 2nd & 3rd trimester – <10.5 g/dL
o Post-partum – <10 g/dL
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