Anemia in Pregnancy Approach

Scenario.: A 30 yo female G3P2 at 20 weeks of gestation presented to your Clinic for antenatal follow up. Her Hemoglobin concentration was found to be 90 gm/l. She is pale and complaining of fatigue and dizziness. Gives history of long standing anemia.

– History – 

• CC: (take SOCRATES hx if applicable)
  • Onset: first time? When? Sudden\gradual? Continuous\intermittent? Getting better\worse?
  • Severity: affecting ADL?
• Associated sx:
  • Constitutional: fever, chills, night sweats, loss of appetite?
  • Anemia: fatigue, exercise intolerance, dizziness, headache, pica, hemolysis (jaundice, itching)?
  • Bleeding: nose bleeds, vomiting\coughing up blood, change in color or blood in urine\stool, PV bleeding, easy bruising?
  • CVS: chest pain, SOB, PND, palpitations?
  • Preeclampsia: headache, visual changes, epigastric pain, N\V, lower limb swelling?

• Obstetric Hx:
  • Gravida? Para? Abortions? Living?
    • If prev: mode of delivery? Fetal\maternal complications?
  • LMP? Due date?
  • Last US: when? Results? Singleton or multiple gestation?
  • Screening: GBS, GDM, rubella immunization, blood type\Rh immunization?

• Gynecological Hx:
  • Menstrual Hx: age of menarche? Regular\heavy\painful periods? Intermenstrual bleeding?
  • Contraception use, IUCD?
  • Gynecological procedures, IVF\induction of ovulation?

• PMHx:
  • Diseases:
    • Chronic ds (HTN, DM\GDM, DLP)
    • Cardiac, thyroid, renal\autoimmune ds
    • Hematological ds, malignancy
    • Gyn (fibroids, endometriosis)
  • Medications: abx, steroids, anticoagulants, folate, irone, herbal
  • Surgery, blood transfusions, hospitalization, trauma
  • Allergies

• FMHx:
  • Similar complaint?
  • Same diseases as in PMHx?

• Social Hx:
  • Occupation, marital status, children?
  • Smoking, alcohol, recreational drugs?
  • Travel Hx
  • Diet (red meat, fruits), exercise

 

---

– Physical Exam –

• WIPE, blah blah, chaperone
• Vital signs: pulse, BP, temperature
• General inspection: weight, distress, pallor, bruises, jaundice, scratch marks, petechiae\purpura
• Hands: pallor, koilonychia
• Eye: conjunctival pallor, scleral jaundice
• Mouth: angular stomatitis, bleeding gums, swollen tongue
• Neck: LN, JVP
• Chest: murmur, shifted apex, lung crepitations
• Abdomen: same old stuff
• Pelvic exam: cervix and uterus

 

– Investigations –

• CBC: hgb, Hct, RBC count, MCV, MHC, retics, WBC, blood type
• Peripheral blood smear
• Iron, serum ferritin, TIBC
• If necessary: stool analysis, Hgb electrophoresis, US

 

– Management –

“most likely it will be iron deficiency anemia”

• Oral iron: 200-300 mg of ferrous sulphate per day
  • Take on an empty stomach, with vit C to enhance absorption, avoid tea\coffee
  • S\E: GI -> abdominal pain, N\V, diarrhea\constipation
• Blood transfusion: in advanced GA (at labor) or hemodynamically unstable (severe anemia <7g\dL)
• Folate:
  • Prophylaxis: 0.4-5 mg of oral folate per day 3 mo prior conception until 12 wks of gestation
  • Treatment: 5 mg of oral folate per day until complete hematological recovery

 

– Complications –

• Iron deficiency anemia: preterm, lower birth weight, IUGR
• Folate deficiency anemia: NTD, IUGR, spontaneous miscarriage

 

– Definitions –

• Physiological anemia in pregnancy: w\ normal pregnancy, blood volume increases, which results in a concomitant hemodilution. Although RBC mass increases during pregnancy, plasma volume increases more, resulting in a relative anemia. This results in a physiologically lowered Hb level, Hct value, and RBC count, but it has no effect on the MCV
• Anemia in pregnancy: hemoglobin below 11 g/dL (Hematocrit less than 33%) in the first and third trimester, and hemoglobin less than 10.5 g/dL (Hematocrit less than 32%) in the second trimester. According to the CDC, severe anemia is hemoglobin less than 7 g/dL

 

---

Download the PDF version: here