Management of Anaemia in Pregnancy InTech Open

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234 Anemia, occurring at 24 26 weeks This is termed physiological anaemia of pregnancy see Fig 1. This dilution picture is often normochromic and normocytic Occasionally physiologic. anaemia can also be associated with a physiologic macrocytosis MCV increases to 120fl. although average at term is 104 fl, In pregnancy there is an additional demand of about 1000 mg iron equivalent to 60 mg. elemental iron or 300 mg ferrous sulphate daily While the transferrin and total iron binding. capacity rises the serum iron falls Thus women who enter pregnancy in an iron deficient. state are then unable to meet the demands of pregnancy by diet alone and require. supplementation It takes approximately 2 3 weeks after delivery for these haematologic. changes to revert to pre pregnancy status,a 20 Volume. e 10 Red Cell,0 Haematocrit,10 20 30 40,Weeks of pregnancy. Fig 1 Graphical representation of haematological changes in pregnancy. www intechopen com,Management of Anaemia in Pregnancy 235.
3 Epidemiology of anaemia in pregnancy, Anaemia has been found to be associated with poverty and underdevelopment and is one. of the most common disorders globally The incidence of anaemia varies from place to place. even within the same country and depends on the socioeconomic status and level of. development The World Health Organization reports anaemia among the top ten most. important contributors to global ill health and deaths It estimated that about a third of the. world s population of 7 billion have haemoglobin levels below the WHO criteria for. diagnosis of anaemia The majority of these persons reside in Sub Saharan Africa and South. Pregnant women are particularly considered to be the most vulnerable group because of the. additional demands that are made on maternal stores during pregnancy The average. global prevalence of anaemia in pregnancy is reported to be 51 Like anaemia in the. general population the prevalence of anaemia in pregnancy varies from 17 in Europe to 52. and 60 respectively in Africa and Asia In sub Saharan Africa it is estimated that 20 of. maternal deaths are associated with anaemia It is also a major risk factor for infant iron. deficiency which has been shown to be associated with adverse behavioural and cognitive. development of children and low birth weight which is one of the main risk factors for. infant mortality,4 Definition of anaemia, The term anaemia refers to the reduction in the oxygen carrying capacity of the blood due. to fewer circulating red blood cells than normal or a reduction in the concentration of. haemoglobin The deficiency may occur as a result of a reduction in the production or an. increased loss of erythrocytes, Anaemia is said to occur when the haemoglobin content of blood is below the normal range. expected for the age and sex of the individual provided that the presence of pregnancy. the state of hydration of the individual and the altitude have been taken into account While. several authorities and experts accepts the lower limits of normal haemoglobin. concentration as 12g dl in women and 14g dl in men WHO accepts up to 11gm percent as. the normal haemoglobin level in pregnancy Thus any haemoglobin level below 11gm in. pregnancy by WHO standard should be considered as anaemia However in most of the. developing countries the lower limit is often accepted as 10 g dl because a large percentage. of pregnant women in this setting with haemoglobin level of 10 g dl tolerate pregnancy. labour and delivery very well and with good outcome. The centre for disease control USA defined anaemia as a hemoglobin Hgb or hematocrit. Hct value less than the fifth percentile of the distribution of Hgb or Hct in a healthy. reference population,5 Classification of anaemia, Anaemia can be classified as physiological eg pregnancy according to the aetiology Table. 1 and red blood cell morphology Table 2, Classification based on red cell morphology classifies anaemia based on the size and shape.
of the red blood cell normocytic MCV80 90fl macrocytic MCV 100fl microcytic. MCV 80fl as well as pigmentation hypochromic normochromic hypochromic Table 2. www intechopen com,236 Anemia,Blood loss, i Antepartum haemorrhage eg placenta praevia abruptio. ii Intrapartum haemorrhage,i Hookworm infestation,ii Bleeding hemorrhoids. iii Peptic Ulcer Disease,B Nutritional Anaemia,i Iron deficiency. ii Folate deficiency,iii B12 deficiency,C Bone marrow failure. a Aplastic anaemia,b Isolated secondary failure of erythropoiesis.
c Drugs eg Chloramphenicol Zidovudine,D Haemolytic. a Inherited,i Haemoglobinopathies eg Sickle cell disorders. Thalassemia, ii Red cell Membrane defects eg Hereditary spherocytosis. elliptocytosis, iii Enzyme deficiencies eg G6PD deficiency Pyruvate kinase. defeciency,b Acquired,i Immune Haemolytic anaemias eg autoimmune.
alloimmune drug induced,ii Non Immune Haemolytic anaemias. a Acquired membrane defects eg,Paroxysmal nocturnal Haemoglobinuria. b Mechanical damage eg Microangiopathic haemolytic anaemia. iii Secondary to systemic disease eg renal diseases liver disease. iv Infections Malaria Sepsis HIV, Table 1 Classification of anaemia based on aetiology. www intechopen com,Management of Anaemia in Pregnancy 237. A Hypochromic Microcytic,Iron deficiency,Thalassemia.
Sideroblastic anemia,Anaemia of chronic disorders,Lead poisoning. B Macrocytic,Folic acid deficiency,Vitamin B12 deficiency. Liver disease,Chronic Obstructive Pulmonary Disease. Myelodysplastic syndromes,Blood loss anemia,C Normocytic Normochromic. Autoimmune haemolytic anaemia,Systemic Lupus Erythomatosis.
Collagen vascular disorders,Hereditary spherocytosis. Haemoglobinopathies,Bone marrow failure,Malignancies. Myelodysplasia,Blood loss anemia,Anemia of chronic disease. Table 2 Morphological Classification of Anemia and causes. The classifications are not necessarily independent of each other as the cause of the anaemia. could be multifactorial, Anaemia can be classified according to severity as mild moderate severe and very severe. Table 3 Following the diagnosis and possible cause s of anaemia in the pregnant woman. management as regards the need for blood transfusions or not will depend on the severity. as well as rapidity of development of anaemia,Degree of Severity Haemoglobin level g dl.
Normal haemoglobin level 11g dl,Mild Anaemia 9 11g dl. Moderate 7 9g dl,Severe 4 7g dl,Very severe 4g dl, Table 3 Classification of Anaemia by degree of severity. www intechopen com,238 Anemia,6 Aetiology, The causes of anaemia in the general population are generally same for anaemia in. pregnancy The causes of anaemia in pregnancy are often multifactorial In developing. countries the major causes of anaemia in pregnancy are nutritional deficiencies infections. and infestations haemorrhage and haemoglobinathies Anaemia is also seen also in some. chronic medical disorders like renal and hepatic diseases. 6 1 Nutrition, In many regions of the world nutritional deficiency is the major cause of anaemia in. pregnancy The World health Organization WHO estimates that about half of all. pregnant women globally suffer from nutritional anaemia Nutritional anaemia is mainly. due iron and folate deficiency in diet Diseases that cause poor dietary intake or. malabsorption of these nutrients will also result in nutritional anaemia. Iron deficiency is the commonest cause of nutritional anaemia in both developing and. industrialized countries and is usually as a result of poor diet Sources of iron include. meat liver in particular vegetables and dairy products The demand for iron increases in. pregnancy as it is required by both mother and fetus for growth and development In. developing countries the already depleted iron stores as a result of poor diet too early too. many and too frequent pregnancies are unable to cope with the requirement of 1000mg of. iron required during a normal pregnancy The resultant effect is iron deficiency anaemia. Hook worm infestation is another cause of iron deficiency anaemia in the tropics. The folic acid requirement is also increased two fold in pregnancy Normal body stores can. only last for 3 4 months Folate deficiency in pregnancy often develops as a result of poor. dietary intake which is often the case in developing countries as well as excess utilization. Sources of folate include liver egg yolk and leafy green vegetables Folate deficiency results. in ineffective erythropoesis, Folate deficiency can be further exacerbated in pregnant women with hemoglobinopathies.
as well as in those residing in areas of high malaria endemicity as increased haemolysis. leads to high red cell turnover and increased folate demand. Vitamin B12 is rare during pregnancy as the daily requirement is as low as 3 5 g and liver. stores last for as long as 2 years,6 2 Infections, Pregnant women are more prone to infections as a result of depressed immunity Anaemia. due to infections is usually as a result of products from the infecting organisms causing ill. health fever red cell destruction and or reduced red cell production Bacterial infections. used to be a leading cause of anaemia however in the tropics and developing countries. malaria and more recently HIV AIDS are leading contributors to anaemia in pregnancy. 6 3 Malaria, Malaria infection is a leading cause of anemia in the tropics both in pregnant and non. pregnant individuals Malaria induced anaemia is more profound in pregnancy as the. susceptibility to malaria is greater in the primigravidae Anaemia resulting from malarial. infection is caused by the destruction of infected and uninfected red blood cells as well as. bone marrow suppression Red blood cells infected with malaria parasites also accumulate. www intechopen com,Management of Anaemia in Pregnancy 239. and sequester in the placenta Macrophages and cytokines e g Tumor necrosis factor. Interferon and interleukin 1 enhance red cell destruction splenic clearance capacity and. depress bone marrow erythropoesis Concurrent micronutrient deficiencies infection with. HIV hookworm infestation or other chronic inflammatory states will worsen anaemia in. these persons,6 4 HIV AIDS, Anaemia is the most common haematological complication of the Human. Immunodeficiency Virus HIV infection and may be consequent upon the effects of the. virus itself or treatment with various drugs The mechanisms of HIV induced anaemia occur. through three mechanisms of decreased red blood cell production increased red cell. destruction and ineffective production of red blood cells The aetiology of HIV associated. anaemia is multifactorial and may include the infiltration of the bone marrow by tumour or. infection bone marrow suppression by the virus itself the use of myelosuppressive drugs. like Zidovudine or drugs that prevent the utilization of folate like cotrimoxazole Other. aetiologies include decreased production of erythropoietin red cell destruction as a result of. autoantibodies to red blood cells and nutritional deficiencies Nutritional deficiencies could. occur as a result of reduced intake due to difficult in swallowing as a result of oropharnygeal. thrush malabsorption or increased catabolism as a result of ill health and associated fever. from various infections Apart from iron and folate deficiency other reported vitamin. deficiencies in HIV infection include vitamin B12 vitamin B6 and vitamin A. 6 5 Haemoglobinopathies, Haemoglobinopathies are inherited disorders affecting haemoglobin structure Sickle cell.
disorders or synthesis thalassemias They are usually seen in individuals from Africa the. Middle East the Mediterranean Asia and the Far East The haemoglobinopathies that cause. anaemia in pregnancy are sickle cell disorders HbSS HbSC and HBS thalassemia. Haemoglobinopathies cause a chronic haemolytic anaemia In sickle cell disorders the. abnormal haemoglobin S sickles in hypoxic states predisposing the structurally damaged. cells to early destruction hence affected persons are chronically anaemic Folate demands. are increased and concurrent infections will worsen anaemia. 6 6 Haemorrhage, Acute blood loss as result of ectopic pregnancy antepartum haemorrhage and abortions are. common causes of anaemia in pregnancy Chronic blood loss from worm infestations. gastrointestinal ulcers and hemorrhoids results in depletion of iron stores and ineffective. erythropoesis,6 7 Red cell aplasia, This is a rare cause of anaemia in pregnancy and results from a selective failure of. erythropoesis In most cases the cause is unknown The identified causes of pure red cell. aplasia include autoimmune diseases e g SLE drugs and infection with parvovirus B19. 7 Risk factors for anaemia in pregnancy, Pregnant women in developing countries of sub Saharan Africa South America and South. East Asia are at particular risk of anaemia in pregnancy as a result of poverty malnutrition. www intechopen com,240 Anemia, and depleted iron stores from too early too many and too frequent pregnancies. Irrespective of race and economic situation the prevalence of anemia in pregnancy is. highest amongst teenage mothers A recent report by Scholl estimates that in a low income. setting rates of iron deficiency anemia are 1 8 in the first trimester 8 2 in the second. Management of Anaemia in Pregnancy health care delivery system cultural beliefs poor nutrition illiteracy gender inequality teenage pregnancies and high parity Other factors such as infections and infestations ultimately cause anaemia and increase morbidity and mortality in pregnant women and their offspring Anaemia during pregnancy is a well known risk for unfavourable pregnancy

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