INDIAN JOURNAL OF COMMUNITY HEALTH / VOL 32 / ISSUE NO 03 / JUL - SEP 2020 [Hematological Profile of…] | Sharma A et al

ORIGINAL ARTICLE
Hematological Profile of Women in Pregnancy in a Hilly District of Himachal
Pradesh
Anuj Sharma1, Jai Gopal Vohra2, Manisha Behal3, Sneha Bansal4
1
Professor, Department of Pathology, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal
Pradesh; 2Assistant Professor, Department of Community Medicine, Maharishi Markandeshwar Medical College
and Hospital, Solan, Himachal Pradesh; 3Professor, Department of Obstetrics and Gynecology, Maharishi
Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh; 4Assistant Professor, Department of
Community Medicine, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh
Abstract Introduction Methodology Results Conclusion References Citation Tables / Figures
Corresponding Author
Dr J G Vohra, Assistant Professor, Dept. of Community Medicine, Maharishi Markandeshwar
Medical College and Hospital, Solan, Himachal Pradesh
E Mail ID: [email protected]
Citation
Sharma A, Vohra JG, Behal M, Bansal S. Hematological Profile of Women in Pregnancy in Hilly District of
Himachal Pradesh. Indian J Comm Health. 2020;32(3): 506-511.
Source of Funding: Nil Conflict of Interest: None declared
Article Cycle
Received: 02/08/2020; Revision: 16/08/2020; Accepted: 29/08/2020; Published: 30/09/2020
This work is licensed under a Creative Commons Attribution 4.0 International License.
Abstract
Introduction: Anemia during pregnancy is a major public health problem throughout the world, especially in the
developing countries. Anemia during pregnancy can lead to morbidity and mortality in mother as well as fetus.
Anemia cannot be diagnosed only clinically; several blood tests are required for complete characterization. Aim
of the present study was to know the prevalence of Anemia during pregnancy in District Solan of Himachal
Pradesh, classify its types and determine the effect of pregnancy on hematological parameters in Anemia.
Material and Methods: In the present study Hematological parameters of 150 pregnant females in advanced
pregnancy (of gestational age 32 to40 weeks) were analyzed and the results were compared with 90 age matched
control cases. Results: The pregnant study group exhibited statistically significant lower values of haemoglobin,
PCV, MCV, MCHC and lymphocyte and platelets while neutrophil and total WBC counts were significantly elevated.
Conclusion: Hematological parameters are a simple and cost-effective investigation which can aid in early
recognition of anemia during pregnancy and thereby improve the outcome of pregnancy.
Keywords
Anemia; Hemoglobin; Pregnancy
Introduction also affects the growth and development of child.
Anemia is defined as decreased hemoglobin or red This affects directly and indirectly the family income
cells mass and is the most common hematological and GDP of the nation.
disorder seen in pregnancy. Anemia during Fetuses are at risk of preterm deliveries, low birth
pregnancy can lead to morbidity and mortality in weights, morbidity and perinatal mortality due to the
mother as well as fetus. Anemia during pregnancy is impairment of oxygen delivery to placenta and fetus.
one of the major factors of Low Birth Weight babies Thus, routine screening tests for anemia are
in the Indian context, which results in subsequent recommended in pregnant women. (1) WHO has
infections in early infancy. In mothers this is an estimated the prevalence of Anemia in pregnant
indirect cause of infection/sepsis during child birth, women as 14% in developed, 51% in developing
Post-Partum Hemorrhage and maternal mortality. It countries and 65-75% in India. About one third of the

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global population (over 2 billion) is anemic. differential leucocyte count (DLC), platelet count,
Prevalence of Anemia in all the groups is higher in blood indices, haematocrit (HCT), peripheral blood
India as compared to other developing countries.(2) smear, reticulocyte count also some biochemical
In most developing countries, Anemia in pregnancy tests like Vitamin B12 and Serum ferritin which have
makes an important contribution to maternal important diagnostic role.(1)
mortality and morbidity.(3)It is a startling fact that Aims & Objectives
about half of the global maternal deaths due to
1. To know the prevalence of Anemia in pregnancy
Anemia occur in South Asian countries.(4) In India
in the hill region of Solan (Himachal Pradesh).
16% of maternal deaths are due to Anemia. (5)
2. To assess different hematological parameters
The lower limit of normal range of Hb is reduced
for anemia in pregnant and non-pregnant
during pregnancy as the plasma volume increases
women.
producing a fall in the Hb level. Throughout normal
3. To classify the morphologic types of anemia in
pregnancy, blood volume expands by an average of
pregnant females in order to differentiate
50% compared with the nonpregnant state. This
physiological from pathological anemia of
rapid expansion of blood volume starts in the first
pregnancy based on these hematological
trimester. (6) Plasma volume increases more than
parameters.
does red cell mass, which produces hemodilution
and a declining hemoglobin concentration during the Material & Methods
first half of pregnancy. This is known as the Study Type: It was a Cross sectional study.
physiologic anemia of pregnancy. (7) Criteria of Study Population: Antenatal cases coming to the
Physiological Anemia include Hb 10 gm%, RBC 3.2 Obstetrical and Gynecology department of
million/cmm, PCV 30% and PBF with normal Maharishi Markandeshwar Medical College, who
morphology (normocytic normochromic).(8) have given the consent to be enrolled in the study
Hemoglobin concentration of < 11.0 g/dl is and meet the criteria of the inclusion. For the Control
commonly taken as indicator of anemia in the Non-Pregnant women of reproductive age group
pregnancy.(3)According to W.H.O guidelines, mild accompanying the patients to the department have
anemia is defined as Hb between 10.0-10.9 g/dL, also been included.
moderate anemia as 7.0-9.9 g/dl and severe anemia Study Population: The study subjects.
as <7 g/dl.(9)Anemia can be classified in a variety of The study subjects attending Obstetrics and
ways, based on the morphology of RBCs, underlying Gynecology clinic of the tertiary care health facility
etiologic mechanisms, and discernible clinical of Solan district of Himachal Pradesh hospital
spectra. The diagnosis of Anemia in pregnancy is fulfilling the inclusion criteria.
difficult to establish based on clinical picture alone; Inclusion Criteria:
yet it is important that treatment should be initiated 1) All pregnant women reporting to department of
early because of the high morbidity and mortality Obstetrics MMMCH with age group: 18-35 years,
associated with anemia during pregnancy.(10 Gestational age: 8th to 40th weeks, primipara or
)Microcytic hypochromic Anemia resulting from iron multipara, Single ton pregnancy.
deficiency is the most frequent form of Anemia 2) The subjects who give the informed consent to
followed by folate deficiency and combined iron and be enrolled in the study voluntarily.
folate deficiency.(11,12) WHO data indicates that Exclusion Criteria:
iron deficiency Anemia is a significant problem 1) Nonconsenting study participants
throughout the world ranging from 1% (average of 2) Obesity
14%) in the industrialized countries to an average of 3) Diabetes
56% (ranging from 35-75%) in developing countries. 4) Any complication of pregnancy like APH, PIH,
The most common causes include; nutritional Preterm labour
deficiencies of iron, parasitic diseases such as 5) Multiple pregnancies
Malaria and hookworm and hemoglobinopathies 6) Pregnant women with history of smoking
such as Sickle cell disease.(13) A number of cigarettes, tobacoo use, alcohol or narcotic use
diagnostic tests are currently available in assessing 7) Age less than 18 yrs and more than 35 years
Anemia in pregnant women such as hemoglobin 8) History of any chronic illness
concentration (Hb), total leucocyte count (TLC),
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INDIAN JOURNAL OF COMMUNITY HEALTH / VOL 32 / ISSUE NO 03 / JUL - SEP 2020 [Hematological Profile of…] | Sharma A et al
9) Liver, kidney and/or heart disease, Diabetes, and macrocytic anemia (dimorphic) 8 (10.67%), and
chronic hypertension, severe sepsis or history of macrocytic anemia 3 (4%). Mean hemoglobin values
menorrhagia or blood loss in last 12 months were10.91 g/dL and 12.80 g/dL respectively in
Study Duration: 6 Months pregnant females and non-pregnant controls. The
Ethical Approval: From Institutional Ethical values were significantly lower in pregnant women
Committee vide approval letter number in comparison to control group. Mean RBC count,
MMM&CH/IEC/17/62. PCV, MCV and MCHC and platelet count
Consent: Written informed Consent was obtained were significantly lower and Mean WBC count and
from the study subject in the approved format. neutrophilic count significantly higher in pregnant
Methodology: The study was carried out on the women in comparison to non-pregnant women.
women visiting the department of Obstetrics & There was a significantly lower platelet count during
Gyaenecology of Maharishi Markandeshwar Medical pregnancy as compared to non pregnant controls.
College and Hospital, Solan as a part of routine [Table 1]
antenatal checkup/ treatment and included both Discussion
pregnant and non pregnant females. The blood
The present study was conducted in hospital setting
samples were collected in EDTA vials. A detailed
of Maharishi Markandeshwar Medical College and
history taking and clinical examination of subjects
hospital, Solan, which is a tertiary hospital catering
after taking informed consent from each participant.
to the needs of mostly the rural areas of the hilly
The hematological parameters studied included
state of Himachal Pradesh. In the present study, half
Hemoglobin (Hb), Red blood cell (RBC) count,
of the women were found to be Anemic. In the NFHS
Hematocrit (PCV - packed cell volume), Mean
4 (2015-16) also, 50.5% of pregnant women were
Corpuscular volume(MCV), Mean Corpuscular
found to be Anemic in rural parts of Himachal
hemoglobin (MCH), Mean corpuscular hemoglobin
Pradesh, which matches with our study results.(14)
concentration (MCHC), Total Leucocyte count (TLC),
Mean hemoglobin value in our study was 10.91 g/dL
Differential Leucocyte count (DLC), Platelet count
in pregnant females which was close to national
and Peripheral smear (PBF). The Hb, RBC count, PCV,
average of 10.93 g/dL as highlighted by Bharati et al
RBC indices, TLC, DLC, and Platelet count were
in their survey on Zone-wise and State-wise
estimated using Automated Blood cell counter and
distribution of Mean Hb. They also stated that
PBF stained by Leishman’s stain examined under
women from Himachal Pradesh have lower
microscope for the accurate morphological type of
prevalence (<40%) of Anemia than the other states.
anemia.
The difference in our prevalence vs theirs (50% vs
Statistical Analysis: A database of findings of both
40%) might be due to our study group being
groups in the form of master chart was prepared. All
predominantly rural and local area differences.(15)
values were expressed as Mean±SD. All results were
Our study carried out in the high altitude region also
analyzed statistically using unpaired Student ‘t’-test
showed relatively higher mean Hb, RBC count and
in SPSS software version 20.
PCV than many other Indian studies carried out in
Results the plains.(16,17,18,19)
In the present study 50% of the total pregnant Distribution in our study as per degree of severity of
females studied at our antenatal clinic were anemic anemia was mild anemia (46.67%), moderate
with mean Hb 10.91 g/dl. The anemic pregnant anemia (50.67%) and severe anemia (2.66%)
females were categorized into mild, moderate and showing that mild and moderate anemia constituted
severe according to WHO criteria. It was observed majority of anemia cases. Our study showed results
that 35 (46.67%) had mild anemia, 38 (50.67%) were similar to other studies in finding moderate anemia
moderately anemic, while 2 (2.66%) had severe as commonest during pregnancy however severe
anemia. (Figure 1). Based on PBF picture five anemia cases were minimal in our study.(1,10) Our
morphologic types of anemia were diagnosed in study also corroborates with the ICMR data showing
anemic pregnant women (Figure 2). The most relative prevalence of mild, moderate, and severe
common was microcytic hypochromic 29 (38.67%), anemia as 13%, 57% and 12% respectively in India.(8)
followed by normocytic normochromic 25 (33.33%), The most common morphologic type of Anemia in
normocytic hypochromic 10 (13.33%), microcytic our study was microcytic hypochromic type. Such

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INDIAN JOURNAL OF COMMUNITY HEALTH / VOL 32 / ISSUE NO 03 / JUL - SEP 2020 [Hematological Profile of…] | Sharma A et al
picture of microcytic hypochromic type is classical of was found to be statistically significant (p<0.001).
Iron Deficiency Anemia which is globally prevalent Lymphocyte count decreases during pregnancy
and the most common type of Anemia of pregnancy. through first and second trimesters, increases during
In a study by Panigrahi et al peripheral smear the third trimester.(21)
examination showed 63% of subjects with Anemia Large cross-sectional studies in pregnancy of healthy
had microcytic hypochromic anemia indicative of women have shown that the platelet count
iron deficiency anemia, and 21.2% subjects with decreases during pregnancy, particularly in the third
early stages of iron deficiency reflected by trimester, termed as “gestational
normocytic hypochromic picture.(20) In the present thrombocytopenia”. (17,21) Although there was no
study microcytic hypochromic and normocytic case of gestational thrombocytopenia in our study
hypochromic picture together constituted more than but a significantly lower platelet count during
half of the morphologic types of Anemia indicating pregnancy as compared to non pregnant controls
iron deficiency being the cause in half of pregnant was another finding which correlated well with other
study group. These findings indicate that the Iron studies.(17)
deficiency Anemia is the leading cause of anemia but Conclusion
there were other causes as well such as physiologic
Anemia is one of the major Public Health Problems
Anemia of pregnancy (normocytic normochromic)
of the country and Anemia in pregnancy contributes
and macrocytic Anemia. Physiologic Anemia of
to significant morbidity and mortality in a developing
pregnancy (normocytic normochromic) constituted
country like India especially in rural set up. In our
33.3% of cases in our study group. Red Cell formation
study also we have Anaemia in half of the Antenatal
is affected by food and other essential materials such
cases. Severe Anaemia is in 2.66 % of the Anaemic
as vitamin B-12 and folic acid which has a bearing on
Antenatal mothers. Mild and Moderate Antenatal
the process of red blood cell formation. Macrocytic
cases are 46.67% and 50.67% respectively.
Anemia or Megaloblastic Anemias results due to lack
Hematological parameters can be easily performed
of vitamin B12 or folic acid. Deficiency of folic acid is
and monitored during pregnancy and when carefully
the most valid reason for megaloblastic Anemia in
interpreted, these parameters can aid in early
pregnancy, since vitamin B12 is stored adequately in
recognition of type of Anemia and differentiating
the body for many years. Singh et al reported the
physiological from pathological causes of Anemia.
incidence of megaloblastic Anemia as 6.25% and in
Microcytic Hypochromic and normocytic
the our study incidence was 4%.(10)
hypochromic Anaemia are in 38.67% and 13.33%
On comparison of red cell parameters between
respectively, which indicate classical of Iron
pregnant and non-pregnant women, it was found
Deficiency Anemia and early Iron deficiency
that the differences in mean hemoglobin
Anaemia. Iron deficiency Anaemia and the Folic acid
concentration, RBC count, PCV, MCV and MCHC
deficiency is taken care of by distribution of IFA
were statistically significant. We justify this
tablets to Antenatal mothers under National Health
difference by the fact that women Pregnant womenl
Programme. Dietary intake of Iron is to be also
mother requires the micronutrients and the
encouraged with the locally available food that
proximate food components, for the growing fetus,
increases the bioavailability of Iron like Amla, citrus
for the growth of various body parts, body fluids etc.
fruits etc.
required for the newborn. Our results were similar to
other studies which also found significant Recommendation
differences between the above hematological Anaemia in Pregnant women in this rural hilly region
parameters.(16,17,18,19) of Himachal Pradesh is a matter of concern and
White cell count is increased in pregnancy with a requires proper attention. Nutrition Education in the
typical reference range of 6 × 10(9)–16 × VHND by the AWW and ASHA needs to be
10(9)/L.(21)In our study also, total WBC count (TLC) strengthened. Distribution of IFA to be monitored
was found to be significantly higher during strictly by the health administrators for compliance.
pregnancy with neutrophils contributing significantly The investigation for Anaemia in Antenatal mothers
to this increase. Out of other white cells, Eosinophil needs to be monitored and analyzed by health
and monocyte count differences were not managers.
statistically significant, but lymphocyte difference
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INDIAN JOURNAL OF COMMUNITY HEALTH / VOL 32 / ISSUE NO 03 / JUL - SEP 2020 [Hematological Profile of…] | Sharma A et al
iron nutrition. Am J Clin Nutr. 2000 Jul;72(1 Suppl):272S-
Limitation of the study 279S. doi: 10.1093/ajcn/72.1.272S. PMID:
As the study subjects are drawn from the women 10871593.[PubMed].
attending Obs. & Gyn. department of a tertiary 8. Sharma JB, Shankar M. Anemia in Pregnancy. JIMSA 2010
Oct-Dec;23(4):253-60.
health care facility, it does not represent the women
9. World Health Organisation (WHO). Haemoglobin
as a whole of the State of Himachal Pradesh, but it concentrations for the diagnosis of anaemia and
helps us to draw some conclusions. assessment of severity. Vitamin and Mineral Nutrition
Information System. Geneva, World Health Organization,
Relevance of the study 2011.Available at
The study helped us to assess the prevalence of http://apps.who.int/iris/bitstream/10665/85839/3/WHO_
anaemia, its grade and its types, though limited to NMH_NHD_MNM_11.1_eng.pdf?ua=1
10. Singh P, Singh S, Topesh. Hematological parameters in
women attending medical college OPD, it helps us to
anaemic pregnant women attending the antenatal clinic of
find out some associated factors and draw some tertiary care hospital. Int J Res Health Sci 2014 Oct
limited recommendations as explained. 31;2(4):981-6.
11. Peña-Rosas JP, De-Regil LM, Dowswell T, Viteri FE.
Authors Contribution Intermittent oral iron supplementation during pregnancy.
AS: The Principal investigator and he drafted the Cochrane Database Syst Rev. 2012 Jul 11;7(7):CD009997.
manuscript of the study; JGV: is the Corresponding doi: 10.1002/14651858.CD009997. Update in: Cochrane
Database Syst Rev. 2015;(10):CD009997. PMID: 22786531;
author and co-investigator. He also participated in
PMCID: PMC4053594.[PubMed]
writing the manuscript and doing data analysis; MB: 12. Seshadri S. Prevalence of micronutrient deficiency
Prof Obstetrics, co-investigator, Collection of data particularly of iron, zinc and folic acid in pregnant women in
and helping in writing Manuscript; SB: Statistical data South East Asia. Br J Nutr. 2001 May;85 Suppl 2:S87-92.
analysis and processing data. PMID: 11509095.[PubMed].
13. Vanderjagt DJ, Brock HS, Melah GS, El-Nafaty AU, Crossey
Acknowledgement MJ, Glew RH. Nutritional factors associated with anaemia in
pregnant women in northern Nigeria. J Health Popul Nutr.
We acknowledge the support given by Dr Kiranjeet
2007 Mar;25(1):75-81. PMID: 17615906; PMCID:
Kaur, Principal of the Maharishi Markandeshwar PMC3013266.[PubMed].
Medical College and Hospital (MMMCH). We are also 14. State Fact Sheet Himachal Pradesh - National Family Health
thankful to the study subjects who willingly Survey – 4 2015 -16 available from:
consented to participate in the study. http://www.rchiips.org/nfhsAccessed July 12, 2020.
15. Bharati P, Som S, Chakrabarty S, Bharati S, Pal M.
References Prevalence of anemia and its determinants among
1. Shah AR, Patel ND, Shah MH. Hematological parameters in nonpregnant and pregnant women in India. Asia Pac J Public
anaemic pregnant women attending the antenatal clinic of Health. 2008;20(4):347-59. doi:
rural teaching hospital. Innovative Journal of Medical and 10.1177/1010539508322762. PMID: 19124329.[PubMed].
Health Science 2012 Sep-Oct;2(5):70-3. 16. Das S, Char D, Sarkar S, Saha TK, Biswas S. Study of
2. De Mayer EM, Tegman A. Prevalence of anemia in the Hematological Parameters in Pregnancy. IOSR Journal of
World. World Health Organ Qlty1998;38:302-16. Dental and Medical Sciences 2013 Nov-Dec;12(1):42-4.
3. Nutritional anaemias. Report of a WHO scientific group. 17. PurohitG, Shah T, HarsodaJM. Hematological profile of
Geneva, World Health Organization, 1968. (WHO Technical normal pregnant women in Western India. Sch. J. App. Med.
Report Series, No. 405). Available at Sci. 2015 Sept;3(6A):2195-9.
http://whqlibdoc.who.int/trs/WHO_TRS_405.pdf 18. Chaudhari SJ, BodatRK. Are there any difference in
4. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ; haematological parameters in pregnant and non-pregnant
Comparative Risk Assessment Collaborating Group. women? Ntl J of Com-munity Med 2015; 6(3):429-432.
Selected major risk factors and global and regional burden 19. Verma A, Chaudhary H. Study of Haematological
of disease. Lancet. 2002 Nov 2;360(9343):1347-60. doi: Parameters in AdvancedPregnancy. International Journal of
10.1016/S0140-6736(02)11403-6. PMID: Recent Trends in Science and Technology 2013;7(1):16-9.
12423980.[PubMed]. 20. Panigrahi A, Sahoo PB. Nutritional anemia and its
5. AbouZahr C, Royston E. Maternal mortality: A global epidemiological correlates among women of reproductive
factbook. Geneva: World Health Organisation, 1991. age in an urban slum of Bhubaneswar, Orissa. Indian J Public
6. PRITCHARD JA. CHANGES IN THE BLOOD VOLUME DURING Health. 2011 Oct-Dec;55(4):317-20. doi: 10.4103/0019-
PREGNANCY AND DELIVERY. Anesthesiology. 1965 Jul- 557X.92415. PMID: 22298143.[PubMed].
Aug;26:393-9. doi: 10.1097/00000542-196507000-00004. 21. Ramsay M. Normal hematological changes
PMID: 14313451.[PubMed]. duringpregnancy and the puerperium. In: Pavord S and
7. Yip R. Significance of an abnormally low or high hemoglobin HuntB, Eds. The Obstetric Hematology Manual. Cambridge:
concentration during pregnancy: special consideration of Cambridge University Press, 2010; p 3-5.

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Tables
TABLE 1 HEMATOLOGICAL PARAMETERS OF PREGNANT AND NON PREGNANT FEMALES
Hematological Pregnant Women Non pregnant Women Level of
Parameters (N=150) (N=90) Significance
(Unit) Mean±SD Mean±SD (p value)
RBC count(millions/cmm) 4.17±0.54 4.71±0.36 < 0.001
PCV (%) 32.64±4.12 37.21±2.61 < 0.001
MCV (fL) 79.16±9.26 81.56±2.53 < 0.05
MCH (pg) 27.43±6.46 27.94±1.19 > 0.05
MCHC (g/dL) 33.34±1.81 34.35±1.28 < 0.001
TLC (x103/µL) 10.09±2.29 7.82±1.68 < 0.001
Neutrophils(%) 70.86±6.93 64.24±6.41 < 0.001
Lymphocytes (%) 24.05±6.55 30.58±6.11 < 0.001
Monocytes (%) 2.70±1.18 2.59±1.18 > 0.05
Eosinophils (%) 2.04±0.96 2.05±0.81 > 0.05
Basophils (%) 0.36±0.48 0.57±0.50 < 0.05
Platelets (Lac/cmm) 2.51±0.73 2.76±0.71 < 0.05

Figures
FIGURE 1 DEGREE OF ANEMIA FIGURE 2 MORPHOLOGIC TYPES OF ANAEMIA

Microcytic Hypochromic
Normocytic Normochromic
Mild Anemia Normocytic Hypochromic
Moderate Anemia Dimorphic
Severe Anemia
Macrocytic

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