Anemia In Pregnancy clerking template for Obstetrics MBBS

 2. Anaemia in pregnancy

Important History

Symptoms

Possible chief complaint

- Anaemic symptoms (eg. SOB, lethargy, palpitation, etc)

- Planned admission for blood transfusion

IDA:

- HOPI:

1. Booking haemoglobin:

Normal: indicate that patient is not anaemic prior to

pregnancy

Low: ask for symptoms of chronic blood loss before

pregnancy (menorrhagia, chronic GI blood loss, worm

infestation)

2. Whether prophylactic oral iron supplement (haematinics) was

given?

T. ferrous fumarate 200mg od

T. folic acid 5mg od

T. vitaminc Bco 1/1 od

T. vitamin C 1/1 od

3. Hb trend during pregnancy, ask patient when Hb starts to

drop?

4. Any treatment given when the Hb starts to drop?

escalate the oral iron to therapeutic dose (a diagnosis of

IDA is presumed)

- T. ferrous fumarate 400-800mg/day (in 2 divided

doses)

- Repeat the FBC 4 weeks later

5. How is the treatment response? (whether Hb improves?)


If Hb improves after therapeutic iron treatment is

started

- The diagnosis of IDA is confirmed

If Hb remains low

- Check compliance

Forgetfulness to take medication

Side effects (GI upset, constipation, vomiting)

- Check whether method of oral iron intake is correct or

not?

Empty stomach (2 hours before or after meal)

Should not take it with coffee and tea (impair iron

GI absorption)

Take it with vitamin C (enhance iron GI absorption)

- Blood investigation is indicated to ascertain the

diagnosis of IDA

Any further treatment escalation?

Any admission for blood transfusion / parenteral iron

during pregnancy?

Diet history eg. vegetarian (IDA), family history of

anaemia (thalassaemia)

Monitoring of complication of anaemia in pregnancy:

- symptoms of placenta abruption (abdominal pain / PV bleeding)

- Regular fetal growth scan to rule out IUGR


Physical Examination

- Look for signs of IDA:

o Conjunctival pallor, Glossitis, angular stomatitis,

koilonychias

**post-cricoid webs(plummer vinson syndrome)

- Per abdomen to look for abdominal tenderness for AP- Uterus smaller than date (IUGR)



Complete examination by:

- Speculum exam: PV bleeding for AP



Investigation

Mother Fetus

Blood:

1. FBC: to confirm HCMC

2. FBP: to confirm morphology of rbc such as

target cell and pencil cell

3. Iron studies:

Serum ferritin (to confirm IDA if the

levels < 15, threshold levels to start

treatment is < 30)

Serum Iron & TIBC (not reliable to

reflect iron storage)

Tsat [Formula = (serum iron x

100)/TIBC], IDA is likely if the level <

20%

Serial u/s of

fetus tro iugr

Hb electrophoresis (beta thal)

DNA analysis (a thal)



Management

Treatment of IDA:

1. Oral iron in therapeutic dose

2. Repeat FBC 1 month later to assess the response

3. If there is slow /no response of Hb improvement,

Increase the dose further but still within 100-200mg

elemental iron dosage

If it is due to suboptimal compliance due to side effect,

change to other type oral iron tablet which has lower

side effect profile, eg Iberet

Parenteral iron


4. Parenteral Iron (eg. Venofer, Cosmofer, Avofer)

Dose: there is a specific formula to calculate

When do you consider parenteral iron?

- Failed oral iron treatment due to non-compliance,

side effects

- Contraindication to oral iron treatment eg. GI

malabsorption problems eg. inflammatory bowel

disease


5. Blood transfusion

Symptomatic of anaemia

Hb levels < 8 at term

6. Any other relevant management?

Dietary: high iron diet (eg. spinach, liver, red meat, etc)

Watchout for placenta abruption (association with

anaemia in pregnancy)

Monitor fetal growth because there is risk of IUGR

Intrapartum:

- send GSH/GXM to standby blood product if she

remain anaemic at time of delivery

- Prevention of PPH by active 3rd stage management,

prophylactic uterotonic agents (oxytocin use after

delivery) Postpartum:

- Assess Hb post-partum (target 10 g/dl and above)

If < 10, therapeutic iron treatment and reassess FBC 2-4

weeks later. Consider blood transfusion if Hb < 7-8 or

patient has anaemic symptoms

If > 10, prescribe prophylactic iron supplement for 3 months

to replenish iron storage

Monitor for lochia loss

Effective contraception:

Ensure good pregnancy spacing and thus it allows time for

Hb to recover

avoid method that can trigger bleeding problem

eg. copper IUCD



Discussion

1) what cause her hb to keep dropping despite of having

enough hematinin and compliance

- so tanya pasal diet hx and also workout for thalassemia

(kna tanya dalam family hx )

2) what are the effect of anemia to pregnancy

- placental abruption – APH

- IUGR

- PIH/Pre-eclampsia

- Cardiac failure

- Preterm labour

3) What is the Cut off value

o 1st trimester – 11 g/dL

o 2nd & 3rd trimester – <10.5 g/dL

o Post-partum – <10 g/dL

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