Postpartum Anaemia

Postpartum anaemia is a haemoglobin below 10 g/dL in the first week after birth, or below 12 g/dL from 6 weeks onward (below 7 g/dL is severe). It results from blood loss at birth, iron deficiency carried over from pregnancy, folate or vitamin B12 deficiency, malaria, hookworm, HIV, sickle cell disease and chronic infection. It affects a large share of Kenyan women after birth, and it matters because it causes fatigue, infection, poor lactation, depression and slow recovery.

• Risk factors: antenatal anaemia, postpartum haemorrhage, caesarean section, multiple pregnancy, short birth interval, malaria, hookworm, poor diet, adolescent age.
• Iron stores take 3 to 6 months to rebuild after birth.
• IV iron corrects haemoglobin faster than oral iron.

Women have tiredness, breathlessness on effort, palpitations, dizziness, headache, pallor of the conjunctivae and palms, poor concentration and low mood. Severe anaemia causes heart failure, fainting and poor milk production.

• Pallor, tachycardia, systolic flow murmur, ankle oedema in severe cases.
• Koilonychia, angular stomatitis and glossitis in long standing iron deficiency.
• Differential diagnosis: ongoing blood loss, sickle cell disease, thalassaemia, malaria, haemolysis, folate or vitamin B12 deficiency, anaemia of chronic disease, HIV related anaemia, hypothyroidism, postpartum thyroiditis, peripartum cardiomyopathy.
• Complications: heart failure, infection, postpartum depression, reduced milk supply, poor bonding, thromboembolism, blood transfusion reactions, delayed wound healing.

The approach is haemoglobin measurement with tests to find the cause.

• Full blood count with red cell indices; blood film for hypochromic microcytic cells, sickle cells or malaria parasites; malaria rapid test.
• Serum ferritin below 30 micrograms/L confirms iron deficiency (below 100 micrograms/L with inflammation); transferrin saturation below 20 percent.
• Serum folate and vitamin B12 where macrocytosis is present; reticulocyte count.
• Stool microscopy for hookworm eggs; HIV test; haemoglobin electrophoresis if sickle cell disease or thalassaemia is suspected.

The principle is to restore haemoglobin and iron stores with iron, treat the cause, and transfuse only when symptomatic or severely anaemic.

• Supportive: iron rich diet (meat, fish, beans, green leafy vegetables) with vitamin C rich fruit; avoid tea and coffee within 1 hour of iron tablets; rest; continue breastfeeding; mosquito net use; hand washing and footwear against hookworm.
• Pharmacological: haemoglobin 7 to 10 g/dL: ferrous sulphate 200 mg (65 mg elemental iron) oral 12-hourly between meals for 3 months, then once daily until ferritin is above 30 micrograms/L; for intolerance, 200 mg oral once daily or on alternate days; IV iron for haemoglobin below 8 g/dL, oral intolerance, poor absorption or need for a rapid rise: iron sucrose 200 mg IV in 100 mL sodium chloride 0.9 percent over 30 minutes on alternate days for 3 to 5 doses (total 600 to 1000 mg), or ferric carboxymaltose 15 mg/kg IV over 15 minutes as a single dose (maximum 1000 mg); folic acid 5 mg oral once daily for 4 months if folate is low; cyanocobalamin 1000 micrograms IM daily for 7 days, then weekly for 4 weeks, then monthly for 3 months for vitamin B12 deficiency; albendazole 400 mg oral as a single dose for hookworm; artemether-lumefantrine 4 tablets (each 20 mg and 120 mg) oral at 0, 8, 24, 36, 48 and 60 hours for malaria.
• Procedures: transfusion of packed red cells, 1 unit IV over 3 to 4 hours, then reassess before a second unit, for haemoglobin below 7 g/dL, or below 8 g/dL with chest pain, heart failure or ongoing bleeding.
• Special groups: women with sickle cell disease take folic acid 5 mg oral once daily long term and iron only when ferritin is low, with transfusion decided with a haematology specialist; women who decline transfusion have early IV iron with ferric carboxymaltose 15 mg/kg (maximum 1000 mg) and treatment of the bleeding source.
• Red flags: haemoglobin below 7 g/dL, breathlessness at rest, chest pain, syncope, ongoing heavy bleeding, fever with pallor, dark urine and jaundice.
• Follow-up: haemoglobin at 2 weeks (a rise of 1 g/dL or more confirms response), at 6 weeks and at 3 months; ferritin at 3 months; continue iron for 3 months after haemoglobin is normal; review spacing of births and contraception.