Anemia Complicating Pregnancy - NTRUHS MBBS Exam Answer

Clinical Data Interpretation

(i) DIAGNOSIS AND HOW TO DIAGNOSE

Diagnosis

• Mild: Hb 10-10.9 g%
• Moderate: Hb 7-9.9 g%
• Severe: Hb < 7 g% (this patient qualifies)
• Very severe (dangerous): Hb < 4 g%

How to Diagnose

• Dietary history - low iron/folate intake, vegetarian diet
• Parity and inter-pregnancy interval (repeated pregnancies deplete iron stores)
• Menstrual history - prior menorrhagia
• Symptoms - fatigue, exertional dyspnea, palpitations, ankle swelling
• Worm infestation, malaria exposure (causes of hemolytic/hookworm anemia)
• Socioeconomic status

• Pallor - conjunctival, palmar, nail bed, tongue (most reliable in pregnancy)
• Koilonychia (spoon-shaped nails) - IDA
• Angular cheilosis, glossitis - IDA/B12/folate deficiency
• Jaundice - hemolytic anemia
• Edema, cardiac failure signs (decompensated severe anemia)
• Splenomegaly - hemolytic/thalassemia
• Fundal examination - fetal growth assessment

• Complete Blood Count (CBC): Hb, PCV, MCV, MCH, MCHC, RBC count
• Peripheral Blood Smear (PBS): Microcytic hypochromic (IDA), macrocytic (B12/folate), sickle cells, target cells
• Reticulocyte count

• Serum ferritin < 12 µg/L (most sensitive for iron stores)
• Serum iron - decreased (<60 µg/dL)
• TIBC - increased (>360 µg/dL)
• Transferrin saturation - decreased (<16%)

• Urine R/E - rule out infection, hematuria
• Stool for ova and parasites - hookworm infestation
• Serum B12 and folate - if macrocytic picture
• Hb electrophoresis - if thalassemia/sickle cell suspected
• Peripheral smear for MP - if malaria endemic area
• Blood group and Rh typing
• Serum bilirubin - if hemolysis suspected

(ii) PREVENTIVE METHODS

1. Antenatal Prophylaxis (Primary Prevention)

• All pregnant women: 100 mg elemental iron + 500 µg folic acid daily from 1st trimester (as early as possible, ideally before 16 weeks) until 6 months postpartum
• Government of India: Janani Suraksha Yojana and NRHM provide IFA tablets free

2. Pre-Pregnancy Measures

• Treat existing anemia before conception
• Adequate inter-pregnancy interval (minimum 2-3 years) to replenish iron stores
• Treat menorrhagia in non-pregnant state
• Iron supplementation during adolescence (Anaemia Mukt Bharat programme)

3. Dietary Measures

• Encourage iron-rich foods: green leafy vegetables, jaggery, horse gram, meat, fish, eggs, liver
• Vitamin C-rich foods alongside iron-containing meals (enhances absorption)
• Avoid tea/coffee with meals (tannins inhibit iron absorption)
• Avoid phytate-rich foods (wheat bran, raw legumes) taken simultaneously with iron

4. Treatment of Infections

• Deworming: Single dose Albendazole 400 mg in 2nd trimester (after 1st trimester) - under National Deworming Day programme
• Malaria prophylaxis in endemic areas
• Treatment of urinary tract infections

5. Early Booking and Regular ANC

• Register pregnancy early at PHC/CHC
• Minimum 4 ANC visits (WHO recommends 8+)
• Routine Hb estimation at booking and at 28-30 weeks
• Early detection and treatment of moderate anemia to prevent severe anemia at term

6. Birth Spacing

• Family planning counseling
• Adequate spacing (>2 years) between pregnancies

(iii) MANAGEMENT OF LABOUR IN ANEMIA COMPLICATING PREGNANCY

General Principles

1. Correct anemia before/during labour if possible
2. Minimize blood loss during and after delivery
3. Prevent and promptly treat complications

A. BEFORE LABOUR (Antenatal Optimization)

• Hb < 7 g% before 36 weeks: Admit to hospital, investigate cause, and give:
  • IV Iron sucrose (preferred in 2nd and 3rd trimester): 200 mg slow IV infusion on alternate days up to total calculated dose
  • Target to raise Hb by at least 2-3 g% before term
• Blood transfusion if Hb < 5 g% (or <7 g% near term with inadequate time for IV iron to work):
  • Packed Red Blood Cells (PRBC) preferred over whole blood
  • Transfuse slowly (2-4 hrs per unit) to prevent pulmonary edema
  • Give frusemide (furosemide) 20 mg IV mid-transfusion to prevent cardiac failure
  • Exchange transfusion if very severe anemia (Hb <4 g%) in cardiac failure

B. DURING LABOUR

• Continuous maternal vital signs monitoring (pulse, BP, SpO2, respiratory rate)
• IV access - large bore IV cannula
• Blood grouping and cross-matching ready; blood should be available
• Foetal heart rate monitoring
• Keep fluid balance chart

• Liberal use of episiotomy to shorten second stage
• Outlet/low-cavity forceps or vacuum delivery to cut short second stage (if indicated)
• Avoid prolonged pushing - increases cardiac strain

C. DURING DELIVERY

• Minimize blood loss - careful technique
• Active management of third stage of labour (AMTSL):
  • Oxytocin 10 IU IM immediately after baby delivery (drug of choice)
  • Controlled cord traction
  • Uterine massage after placenta delivery
  • Do NOT give ergometrine (methylergometrine) - it causes vasoconstriction and can precipitate acute cardiac failure in severe anemia
• Inspect placenta and membranes for completeness

D. POSTPARTUM MANAGEMENT

• Blood transfusion if significant intrapartum blood loss or Hb drops further
• Continued iron therapy: IV/oral iron for 3-6 months postpartum to replenish stores
• Monitor for PPH (higher risk in anemic patients - uterine atony from poor myometrial function)
• Monitor for cardiac failure (pulmonary edema)
• Breastfeeding: Encourage - oxytocin release helps uterine involution
• Family planning counseling before discharge

E. COMPLICATIONS TO WATCH FOR

Summary Table for Quick Revision

Examiner's Note: Anemia is the most common medical disorder complicating pregnancy in India, with iron deficiency accounting for >80% of cases. Severe anemia (Hb <7 g%) is an indirect cause of maternal mortality. The threshold for blood transfusion in pregnancy is Hb <6 g% (or <8 g% near term/in labour), though clinical judgment based on symptoms is equally important.