GROUP 3

PRESENTATION

ANAEMIA IN PREGNANCY

1
 GENERAL OBJECTIVE

At the end of the lesson student

midwives should be able to:
1. Acquire sufficient knowledge on
Anaemia in pregnancy and be able to
nurse a pregnant woman with
Anaemia.

2
 SPECIFIC OBJECTIVES

At the end of the lesson student

midwives should be able to:
1.Define Anaemia
2.Explain the causes and predisposing
factors of anaemia in Pregnancy
3.List the signs and symptoms of
Anaemia
4.Describe how anaemia in pregnancy
is diagnosed
3
 SPECIFIC OBJECTIVES
5.State the effects of Anaemia in
pregnancy
6.Outline the management of Anaemia
in pregnancy
7.Explain the prevention of Anaemia in
pregnancy.

4
 DEFINITION
1. Anaemia is a reduction in the
oxygen carrying capacity of the
blood; this may be caused by
decrease in red blood cell production,
or reduction in haemoglobin count of
blood or a combination of both
(Myles, 2003). OR

5
 CAUSES OF ANAEMIA
1. Changes during pregnancy
• Haemoglobin concentration decreases during
pregnancy because of physiological changes
but not below 10.5g/dl.

• Average iron requirement is 4mg/day,

increasing as pregnancy advances.

• Normal diet contains up to 25mg/day but only

10% is absorbed.

• Stores do fall during pregnancy because of high

demands. 6
 CAUSES OF ANAEMIA CONT’D
2. Increased demand due to
pregnancy
• This is the most common cause of
anaemia in pregnancy.

• The fetus takes some thing like 300mg of

iron from the mother.

• A further 700mg is needed by mother’s

own expanded blood volume, the
placenta, and the growing uterine
muscle. 7
CAUSES OF ANAEMIA CONT’D
• This means that there is usually a negative
balance as the normal diet only affords
some 25mg of iron daily to the mother and
only 10% of iron in the diet is actually
absorbed.

• Folic acid and vitamin B 12 are equally on

demand, and if the intake is not increased,
deficient will occur.

• Multiple pregnancy increases the demand

on the mother’s resources further. 8
 CAUSES OF ANAEMIA CONT’D
3. Deficiency in dietary intake
• To manufacture normal red blood cells the
body requires protein, iron, folic acid, and
vitamin B12.

• Therefore, deficiency can be due to;

a. Lack of the right food or inadequate food
b. Poor appetite of the pregnant woman
c. Malabsoption due to chronic diarrhea or
vomiting. 9
 CAUSES OF ANAEMIA CONT’D
4. Acute or chronic blood loss
• The woman might start the pregnancy
already lacking iron.

• This might be because of heavy menstrual

flows or bleeding in past pregnancies.

• These past pregnancies, which very often

follow each other very closely, might have
been complicated by ante partum or
postpartum haemorrhage or haemorrhoids
which will cause further loss. 10
CAUSES OF ANAEMIA CONT’D
• Further blood loss might be caused by
hook­worm infestation.

• Each worm is capable of extracting up

to 0.05 ml of blood per day.

• In heavy infections the patient could

have up to 1000 worms.

• Therefore check the stool of every

pregnant woman for hookworm.
11
CAUSES OF ANAEMIA CONT’D
• If you have no laboratory facilities
and you are working in an area
where hook­worm is endemic you can
give one dose of Vermox
(mebendazole) 500mg tablet stat to
deworm each woman in pregnancy
after 20 weeks.

12
CAUSES OF ANAEMIA CONT’D
5. Increased red cell destruction
• When red cells grow old, they are
destroyed in the spleen and the liver.

• In -some pathological conditions

where red cells have a strange
shape, such as in sickle-cell
disease, this destruction is
accelerated and the cells have a
shortened life, especially when the
oxygen in the blood is low. 13
CAUSES OF ANAEMIA CONT’D
• As pregnancy advances the large
uterus prevents the lungs inflating
fully which leads to lower, oxygen
concentration in the blood and cell
destruction is increased.

• Infection with falciparum malaria

also leads to destruction and
hemolysis of the red cells.

14
 CAUSES OF ANAEMIA CONT’D
• Folic acid is therefore used to replace
the destroyed cells.

• You should give these women extra

folic acid throughout pregnancy and
also give malaria prophylaxis.

15
 TYPES OF ANAEMIA

1. Physiological Anaemia:
• During pregnancy, iron is required
for the extra Hb in the increased
blood volume of 45%, RBCs only
increase by 25% (hydraemia of
pregnancy).

• This causes dilution of the RBCs

making blood less viscosity .
16
 TYPES OF ANAEMIA
• The decrease in blood viscosity
possibly helps to reduce the cardiac
output and makes perfusion of the
placental bed easier.

• This dilution of blood will also

decrease the Hb concentration in
the blood, this occurs between 12-
32 weeks of gestation.
17
TYPES OF ANAEMIA CONT’D
2. Iron Deficiency Aneamia
• During pregnancy, there is increased
demand of iron which is not met.

• The reduction in iron may be due to:

reduced dietary intake due to poor eating
habits, cooking Customs, food taboos etc.

• Reduced absorption due to gastro

intestinal problems e.g. diarrhea and
vomiting. 18
TYPES OF ANAEMIA CONT’D

• Infections e.g., dysentery, hookworm

infestation and malaria.

• Reduced intake of vitamin C.

19
TYPES OF ANAEMIA CONT’D
3. Folic Acid Deficiency Aneamia.
• This is needed for RBC maturation for
both fetus and mother.

• However, there is usually a

physiological decrease in this
substance which may be caused by;

- Reduced dietary intake.

20
TYPES OF ANAEMIA CONT’D

• Multiple pregnancy due to increased

fetal demand.

• Intake of certain oral drugs interferes

with the utilization of folic acid e.g.
sulphonamides, anticoagulants,
anticonvulsants, coffee and tea and
alcohol

21
 TYPES OF ANAEMIA
CONT’D
4. Sickle cell Anaemia and
thalasseamia.
• This is an inherited autosomal
recessive disease resulting in normal
production of abnormal globin chain
and this will cause severe hemolysis
(10-12 days) resulting in severe
anaemia.

22
 TYPES OF ANAEMIA
CONT’D
• In relationship to pregnancy this will
be worsen because of the high
demand by the fetus for iron and
folate also worsen by physiological
anaemia which occurs during
pregnancy and may complicate
pregnancy to abortion or intra
uterine fetal death.

23
 TYPES OF ANAEMIA CONT’D
5. Vitamin B 12 Deficiency
Anaemia
• Vitamin B12 and folic acid
deficiencies are characterized by the
production of abnormally large RBCs
called megaloblasts.

• Because these cells are abnormal,

many are sequestered (trapped)
while still in the bone marrow, and
their rate of release is decreased. 24
TYPES OF ANAEMIA CONT’D
• Some of these cells actually die in
the bone marrow before they can be
released into the circulation

• This results in megaloblastic anemia.

• A deficiency of vitamin B12 can occur

in several ways, i. e

25
 TYPES OF ANAEMIA
CONT’D
• Inadequate dietary intake is rare but
can develop in strict vegetarians who
consume no meat or dairy products.

• Faulty absorption from the

gastrointestinal tract is more
common.

• This occurs in conditions such as

Crohn’s disease. 26
 SIGNS AND SYMPTOMS OF ANAEMIA

• A drop in haemoglobin level deprives

the tissues of adequate oxygen.

• The symptoms of anaemia are infact

symptoms of oxygen lack. (CBoH,
2002). These include the following;
1.Weakness
2.Tiredness
3.Dizziness
27
 SIGNS AND SYMPTOMS OF
ANAEMIA CONT’D
4. Breathlessness on exertion
5. Heart palpitation
6. Paresthesia in fingers and toes
7. Headache
8. Apathy
9. Increases heart rate
10. Restlessness
11.Air hunger
28
 SIGNS AND SYMPTOMS OF
ANAEMIA CONT’D
On examination
1. Pallor of the skin, mucus membranes,
palms of hands and conjunctivae.

2. There may be oedema.

3. Tachycardia

4. Examination with stethoscope reveals

systolic heart murmurs 29
 DIAGNOSIS OF ANAEMIA

• In order to be able to diagnose anaemia in

pregnancy it is extremely important to first
obtain a very accurate and complete history from
the woman.
1. Personal or social history is obtained in order
to know where the woman lives.

• If it’s in high altitude and conditions common are

bilharzias, malaria and whether she lives in dry
area where worm infestation and diet deficiency
are common.

• Ask about the age, parity, occupation and home

30
condition
 DIAGNOSIS OF ANAEMIA
CONT’D
2. Previous pregnancies-spacing of
children, date of last pregnancy and
how long she breastfed, any
Complications and mode of delivery.

3. Present pregnancy- the LMP,

calculation of gestation age, any
complications like varicosities, ante
partum hemorrhage.
31
 DIAGNOSIS OF ANAEMIA
CONT’D
4. Dietary history-find out how food is
prepared and how it is stored,
availability of food, any food taboos.

5. Ask about her suffering from

diseases like malaria, bilharzia and
worms.

6. Physical examination-check for

pallor, any systemic infections 32
 DIAGNOSIS OF ANAEMIA
CONT’D
Investigations
• Blood for Hb estimation and a low Hb
indicates the woman is anaemic.

• In Zambia women with haemoglobin

estimations below 5g per 100 ml should be
considered anemic and managed as follows:

• Hb above 9g/dl: Follow up regularly in the

antenatal clinic and double the normal dose
of folic acid 10 mg per day) and the normal
33
dose of ferrous sulphate (600 mg per day).
 DIAGNOSIS OF ANAEMIA
CONT’D
• Hb below 9g/dl: in the last 4 weeks
of pregnancy, together with those
with an Hb below 7g/dl at any stage
of pregnancy, should be admitted to
hospital for blood transfusion
followed by a total dose of iron
infusion.

34
 DIAGNOSIS OF ANAEMIA
CONT’D
7g above
• Admit to a hospital where usually a
total dose infusion of iron (as Inferon)
will be given (if the pregnancy is less
than 36 weeks) and the woman will
be discharged on the regimen above.

35
 EFFECTS OF ANAEMIA

A). ON THE MOTHER

1. Maternal death due to multiple organ
failure such as heart failure and renal
failure.

• This may come about due to increased

cardiac workload to compensate for the
reduced haemoglobin as well as
insufficient nutritional supply to the heart.
36
 EFFECTS OF ANAEMIA CONT’D

2. Renal failure is due to reduced blood

flow to the kidneys.

3. Abortions usually in the second

trimester caused by Heamolysis of
parasitized cells which eventually
lead to anaemia

4. Premature labour
37
EFFECTS OF ANAEMIA CONT’D

5. Post partum haemorrhage due to

reduced platelets count

6. Puerperal sepsis as a result of

reduced immunity due to low
immunoglobulin.

7. Venous thrombosis due to reduced

mobility
38
EFFECTS OF ANAEMIA CONT’D

B) ON THE FETUS
1. Intra uterine fetal death due to
insufficient nutrients and oxygen

2. Intra uterine growth retardation due

to inadequate nutrients to the fetus.

3. Fetal distress due to insufficient

oxygen.
39
EFFECTS OF ANAEMIA CONT’D

4. Low birth weight as a result of

reduced nutrient supply.

5. Asphyxia due to insufficient oxygen.

6. Prematurity due to reduced oxygen

and Nutrients.

06/03/2025 MPONDA M. CHILONGA MIDWIFERY SCHO 40

OL
MANAGEMENT OF ANAEMIA
• The management of anaemia is
dependent on its severity and stage
of pregnancy and labour

1. Moderate 7.0 to 10.9 g/dl

2. Severe 4 to 6.9 g/dl

3. Very severe less than 4.09 g/dl 41

 MANAGEMENT OF ANAEMIA CONT’D

Antenatally (Moderate anaemia 7.0 to 10.9

g/dl )
• Health education on diet is given.
• Taking of medications like folic acid, ferrous
sulphate, IPT with Fansidar at 16 weeks and
Vermox
• Physical examination to rule out haemorrhoids
or epistaxisis or malnutrition

42
 MANAGEMENT OF ANAEMIA
CONT’D
• Encourage the woman to have enough
rest.

• Malaria sample should be done and if

positive then treated or if negative
prophylaxis should given.

• Hb estimation has to be done and

repeated each visit to assess if the
client is improving or not 43
 MANAGEMENT OF ANAEMIA CONT’D

Antenatally
Severe to very severe anaemia in
pregnancy; (4g/dl below or 4 to 6.9
g/dl).

• The clients with severe anaemia or

Hb below 7g/dl are admitted to
hospital for specialised care.

44
 MANAGEMENT OF ANAEMIA
CONT’D
Aims of care;
a) Prevent complications

b) Prolong the pregnancy until the

fetus is mature and delivered alive
and health baby.

c) Receive blood transfusion

45
 MANAGEMENT OF ANAEMIA
CONT’D
• Hb estimation and grouping/cross match
for transfusion to prevent renal failure.

• Other samples will be collected such as

blood slide, stool for microscope to rule out
the present of malaria and worm
infestation respectively

• Intra venous fluid should be commenced

awaiting blood transfusion to promote
increased blood volume e.g. Normal saline 46
 MANAGEMENT OF ANAEMIA
CONT’D
Observations;
• Do vital signs of Temperature, Pulse,
Respiration and blood pressure.

• A rise in vital signs will indicate

impending cardiac failure.

47
 MANAGEMENT OF ANAEMIA
CONT’D
• Breathlessness and disturbing cough
is due to pulmonary congestion,
reduced Blood Pressure is due to
reduced Hb.

• Record intake and output of fluids

especially if patient has oedema, and
is on diuretics or is on blood
transfusion
48
 MANAGEMENT OF ANAEMIA
CONT’D
• Full history should be taken to rule out
chronic illness such as sickle cell
anaemia or Tb or any other familiar or
chronic illness

• Full examination to identify early signs

of chronic illness and malnutrition

• The woman should be on bed rest to

prevent cardiac failure 49
 MANAGEMENT OF ANAEMIA
CONT’D
• Monitor maternal and fetal well being and
provide kick chart to woman to record in
order to monitor, fetal wellbeing.

• Monitor for any contractions, abnormal

vaginal discharge and rupture of membranes.

• Monitor for maternal and fetal distress.

• Prescribed Ferrous sulphate 200mg TDS and

Folic Acid 10mg once are given daily
50
 MANAGEMENT OF ANAEMIA
CONT’D
Exercise
• Encourage minimal exercises to prevent deep
vein thrombosis and stress on the heart.

Nutrition
• Encourage foods rich in iron e.g. green leafy
vegetables to boost the Hb.

• Provide a diet rich in protein to boost the

immunity, and roughage to prevent
constipation
51
 MANAGEMENT OF ANAEMIA
CONT’D
Management during labour
Severe anaemia
1st stage of labour
• Psychological care: Reassure the
mother about her condition; explain
about the investigations and
treatment being given to relieve
anxiety.
• Explain and involve the caretaker in
the care of the patient 52
 MANAGEMENT OF ANAEMIA
CONT’D
Position
• Prop up patient in bed for easy
breathing and lung expansion.

• Encourage patient to lie on her side

avoid supine position because it can
aggravate supine hypotension
syndrome.

53
 MANAGEMENT OF ANAEMIA
CONT’D
• Ensure that oxygen is commenced
of 6-8l/m to prevent maternal and
fetal distress
• Commence iv therapy of normal
saline, or ringers lactate.
• Record intake and output of fluids
especially if patient has oedema and
is on diuretics or is on blood and take
the blood sample urgently grouping/
x-match so that the client can be 54
 MANAGEMENT OF ANAEMIA
CONT’D
• Encourage the women to take a lot of
glucose fluid to enhance labor and to
prevent maternal exhaustion.

• Ensure that there is strictly

monitoring of progress of labour,
fetal wellbeing and maternal
wellbeing.

55
 MANAGEMENT OF ANAEMIA
CONT’D
2nd stage of labour
• Ensure that oxygen is commenced of 6-
8l/m to prevent maternal and fetal distress.

• Collect samples of Hb, grouping and cross

match urgently

• Client should continue on intra venous fluid

or blood and monitor intake and output
strictly to avoid over load or under load.
56
 MANAGEMENT OF ANAEMIA
CONT’D
• Position the client in any other
position that is comfortable for
delivery but avoid lithotomy position
to prevent worsening dyspnoea and
supine hypotension

• Avoid excessive bleeding by avoiding

episiotomy that can lead to excessive
bleeding resulting into severe
condition of anaemia. 57
 MANAGEMENT OF ANAEMIA
CONT’D
3rd stage of labour ( severe
anaemia)

• Active management of the third

stage of labour should be done to
avoid excessive bleeding which may
worsen the condition

58
 MANAGEMENT OF ANAEMIA
CONT’D
• Give oxytocin 10 iu stat and maintain
on IV line of oxytocin to prevent
bleeding and help in sustain the
contraction hence minimize bleeding

• Perform cord control traction when

delivering the placenta to avoid
retaining membrane or placenta
tissue which may lead to severe
bleeding. 59
 MANAGEMENT OF ANAEMIA
CONT’D
• Encourage early lactation to promote
uterus contraction to prevent
bleeding

• Encourage the mother to message

the uterus to sustain uterine
contraction

06/03/2025 MPONDA M. CHILONGA MIDWIFERY SCHO 60

OL
 MANAGEMENT OF ANAEMIA
CONT’D
• Collect blood samples and maintain
on intra venous fluid while waiting for
transfusion

• Ensure all procedures are done

aseptically to avoid infection since
they are prone to infections

61
 MANAGEMENT OF ANAEMIA
CONT’D
• Keep on monitoring the per vaginal
bleeding ¼ hourly for an 1 hour to
ensure that the woman does not
develop post partum haemorrhage.

• Encourage to have enough rest till

she is transfused and the condition
has improved.

62
 MANAGEMENT OF ANAEMIA
CONT’D
During pueperium with severe anaemia.
• The main aim is to control anaemia
and prevent infection.

• Admit the client for further

management if the client has severe
anaemia

• Collect blood for Hb, grouping and

cross matching. 63
 MANAGEMENT OF ANAEMIA
CONT’D
• Commerce the client on intra venous
fluids while awaiting blood
transfusion.

• Palpate the uterus if well contracted

to rule out uterine atone which may
be the cause of bleeding leading to
anaemia.

• Check the type of lochia to rule out 64

 MANAGEMENT OF ANAEMIA
CONT’D
• Examine the perineum for any tear or
broken episiotomy which mighty be
bleeding leading to anaemia.

• Ask the client about anaemia during

pregnancy or bleeding during
pregnancy

• Ask the mother about history of

delivery if there was severe bleeding. 65
 MANAGEMENT OF ANAEMIA
CONT’D
• Interview her on how many pads
she is changing in a day.
Encourage the patient to
• Take a balanced diet rich in iron,
folate and vitamin 12.
• Encourage breast feeding
• Provide treatment for malaria,
worms and give folic acid and
ferrous sulphate
 PREVENTION OF ANAEMIA
1. Instruct the community on proper
dietary habits.

• Each family should have a vegetable

garden, and green vegetables
should not be overcooked as this
destroys the folic acid.

67
 PREVENTION OF ANAEMIA
CONT’D
2. Encourage the mother to practice
child spacing so that there is time
between each pregnancy for her to
replenish her body resources.

3. Teach proper disposal of faeces to

avoid hookworm infestation, where
possible people should wear shoes all
the time.
68
 PREVENTION OF ANAEMIA
CONT’D
4. Conduct mass campaigns to
eradicate hookworm and control of
malaria.

5. Prevent or treat ante partum and

postpartum haemorrhage
adequately.

69
 PREVENTION OF ANAEMIA
CONT’D
6. In the meantime give the following
supplements to each woman through­
out the pregnancy:
– Ferrous sulphate 200 mg three times a
day
– Folic acid 5 mg daily.

7. Give Fansidar after sixteen weeks of

gestation period and continue every
fourth week( times three doses) 70
 PREVENTION OF ANAEMIA
CONT’D
8. Reduce hookworm by deworming all
pregnant women after 20 weeks.

9. Detect the anaemia early and give

adequate treatment.

10. Encourage mothers to sleep under

treated mosquito nets.
 SUMMARY

• We have come to the end of our discussion

on anaemia in pregnancy and it is a common
problem in most developing countries and a
major cause of morbidity and mortality
especially in malaria endemic areas.

• In pregnancy, anaemia has a significant

impact on the health of the fetus as well as
that of the mother.

• Most of maternal deaths in Africa have been

attributed to anaemia. 72
 REFERENCES

• CBOH (2002) Intergrated Technical

Guidelines for Frontline
Healthworkers, 2nd Edition, Lusaka,
Zambia.
• CBOH (2003) Malaria During
Pregnancy Facilitator’s Guide, 4th
Edition, Lusaka, Zambia.
• De Mayer, E M. (1989) Preventing
and Controlling Iron Deficiency
Anaemia Through Primary Health
Care. Geneva: WHO. 73
 REFERENCES….Cont…

• Frazer M.D. and Cooper M. A. (2005).

Myles Text Book for Midwives, 14th
Edition, Churchill Livingstone, Elsevier Ltd.

• Harrison K A, Ibezlako P A.(1973) Maternal

Anaemia and Fetal Birth weight. J Obst
Gynaecol Br common wealth.

• Harrison KA. (1975)Maternal Mortality

and Anaemia in Pregnancy. West African
Med J. 74
 REFERENCES….Cont…

• Massawe F, Evans R and Kagimba,

(2005) Gynaecology and
Obstetrics, African Medical
Research Foundation, Nairobi, Kenya.

• Fleming A F. (1989) Tropical

Obstetrics and Gynaecology/
Anaemia in Pregnancy in Tropical
Africa. Trans R Soc Trop Med Hyg.
75