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Effect of anemia on pregnancy. Symptoms of anemia during pregnancy
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Effect of anemia on pregnancy
Severe or untreated iron-deficiency anemia during pregnancy can increase the incidence of following complications in pregnancy:
- Complications to the fetus
- Intrauterine fetal growth restriction
- Low-birth-weight baby
- A preterm birth
- Neonatal anemia
- Impaired psychomotor/mental development of a child
- Complications to the mother:
- Mother may need in blood transfusion (in severe cases)
- Increase risk for hemorrhage in labor and postpartum
- Postpartum depression
- Increased susceptibility of maternal organism to infections
Untreated folate deficiency, as well as vitamin B12 deficiency, can increase risk of having a:
- Preterm or low-birth-weight baby
- Baby with a serious birth defect of the spine or brain (neural tube defects).
Effective management is needed to prevent adverse maternal and pregnancy outcomes, including the need for red cell transfusion.
There is ambiguous information regarding the Hb threshold below which mortality increases, but it is known that severe anemia is associated with a doubling of the maternal death risk. Severe anemia with maternal Hb levels less than 70 g/L has been associated with abnormal fetal oxygenation resulting in nonreassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilatation, and fetal death. Thus, maternal transfusion should be considered for fetal indications.
Effect of Pregnancy on anemia
Pregnancy is characterized by an increased need of the mother's body in iron, folates, vitamins due to the growing fetus and placenta. Thus, the pregnant women are at a higher risk of developing anemia due to excess blood that the body produces in order to help provide nutrients for the baby, and because of the increased demand for iron. The woman, suffering from anemia before pregnancy already has lack of the level of stored iron, and in pregnancy she has significant risk for progressive worsening of the course of anemia.Symptoms of anemia during pregnancy
The most common symptoms of anemia during pregnancy are:
- Pale skin, lips, and nails
- Feeling tired or weak
- Dizziness
- Shortness of breath
- Rapid heartbeat
- Trouble concentrating
Diagnosis
The diagnosis of iron deficiency anemia is based on chief complaints, data of thoroughly taken history, estimation of objective status, data of laboratory research. At the objective inspection, the pallor of skin and mucous membranes is marked. On heart auscultation the muffled I tone and slight “anemic” systolic murmur on the apex and pulmonary artery are marked.
On history taking special attention is paid to feature of nutrition, state of gastrointestinal system, past illnesses, number and the course of pregnancies in her anamnesis, multiple pregnancies, bleedings at previous deliveries and in postpartum period, the duration of lactation, and availability of occupational hazards.
The basic laboratory indexes allowing to diagnose the state of iron deficiency are the level of hemoglobin, color index, quantity of erythrocytes and reticulocytes, hematocrit and serous iron.
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Lab tests:
· CBC (Complete Blood Count) below 110g/l at booking and below 105g/l at 28 weeks indicates anemia. There is often a low MCV (microcytic), low MCH (hypochromic) anemia with iron deficiency, although microcytic hypochromic anemia can also indicate hemoglobinopathies.
· Serum ferritin. This is the first laboratory test to become abnormal in iron deficiency and is the most useful and easily available parameter for assessing iron deficiency (< 30 microgm/L). Serum Ferritin is not performed routinely unless there is a lack of response to (2-3 weeks) trial of oral iron, or before IV iron administration, or to assess response to treatment.
· Other tests like serum iron, total iron binding capacity lack sensitivity and specificity and hence are not recommended in routine diagnosis.
Three degrees of iron deficiency anemia are distinguished depending on degree of deficiency: mild, moderate, severe (Table 20).
Table 21
Classification of Iron Deficiency Anemia
| Hematological indexes | Norm | Mild degree of anemia | Moderate degree of anemia | Severe degree of anemia |
| Hemoglobin (g/L) | 140 — 111 | 110 — 91 | 90 — 81 | < 80 |
| Erythrocytes (mln/mL) | 4. 6-3. 5х1012 | 3. 5-3. 2х1012 | 3. 2-2. 8х1012 | < 2. 8х1012 |
| Reticulocytes | 7 — 19 | 20 — 35 | > 35 | |
| Color index | 0. 85 — 1. 05 | 0. 85 — 0. 8 | 0. 85 — 0. 8 | < 0. 8 |
| Serous iron (mcg/%) | 160 — 81 | 80 — 71 | 70 — 60 | < 60 |
| Hematocrit (%) | 40 — 36 | 35 — 31 | 30 — 21 | < 21 |
Management
Maternal iron requirements average 1000 mg/d. Because many pregnant women lack sufficient iron stores, iron supplementation may be included in prenatal care. Primary prevention for average-risk populations includes adequate intake of dietary iron and oral, low-dose (30 mg/d) iron supplements early in pregnancy. Suggested prophylaxis for IDA in high-risk populations is 60 to 100 mg of elemental iron daily.
All pregnant women should be screened for anemia, and those with iron deficiency anemia should be treated with supplemental iron, in addition to prenatal vitamins.
A routine antenatal check-up with blood examination before 10 weeks of pregnancy is carried out in patients form the group of higher risk of IDA. The revealing of the 3 degree of anemia in early stages of pregnancy may be an indication for medical abortion. After 12 weeks of pregnancy the question of therapeutic abortion should be solved individually depending on age of pregnant, data of anamnesis and concomitant obstetric and extragenital pathology. In other cases pregnancy should be prolonged till the term of delivery, the examination of blood should be carried out regularly, and treatment should be administered to prevent a progressive anemia.
Patients with Hb concentration ≥ 110 g/L and the serum ferritin concentration > 20 µg/L usually not need in iron medication, but need in accurate regular screen for anemia and a diet enriched with iron. A varied diet of iron-rich foods and foods that enhance iron absorption (meats and ascorbic acid-rich fruits) should be recommended to the patient. Items that inhibit absorption of iron (tea, coffee, whole-grain cereals, particularly bran, unleavened whole-grain breads, and dried beans) should be consumed separately from iron-rich foods.Pregnants with a mild degree of anemia are usually treated at the out-patient department, in antenatal clinic. When the Hb concentration is between 90 and 109 g/L and the serum ferritin concentration is between 12 and 20 µg/L, or the Hb concentration is ≥ 110 g/L and the ferritin concentration is ≤ 20 µg/L, supplemental iron should be administered by 30 mg daily.
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60-120 mg of supplemental iron should be administered by mouth when the Hb concentration is between 90 and 109 g/L and the ferritin concentration is < 12 µg/L. The Hb concentration should be evaluated at subsequent prenatal visits. Oral iron supplementation should demonstrate a rise in Hb concentration after 2-3 weeks of intake. If there has been no improvement in Hb in 2 -3 weeks further investigations should be made to consider other causes of anemia including folate deficiency. If the hemoglobin concentration is normal for that stage of pregnancy, lower the supplemental iron dose should be declined to 30 mg of iron per day.
Medical treatment at the in-patient department is indicated in the following cases:
· anemia of a moderate and severe degree (in the late terms of pregnancy);
· inefficiency of out-patient therapy;
· presence of accompanying extragenital pathology;
· presence of obstetric complications. (table 21)
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