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


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