Severe Anaemia in Pregnancy

Severe anaemia in pregnancy is haemoglobin below 7 g/dL, and very severe anaemia is below 5 g/dL. Causes include iron deficiency, malaria, hookworm, sickle cell disease, HIV, haemorrhage, folate and B12 deficiency and chronic disease, often several together. It contributes to maternal death through heart failure and haemorrhage, and causes preterm birth, stillbirth and low birth weight.

• Risk factors: poor diet, untreated malaria, hookworm, HIV, short pregnancy interval, multiple pregnancy.
• Haemoglobin below 5 g/dL carries a high risk of heart failure.
• Cause is found and treated while the mother is stabilised.

Women have marked pallor, fatigue, breathlessness, palpitations, dizziness and ankle swelling, with tachycardia, flow murmur and signs of heart failure. Check respiratory rate, pulse, blood pressure, jugular venous pressure and liver size.

• Pulse above 100 per minute, respiratory rate above 24 per minute.
• Crackles and oedema in heart failure.
• Differential diagnosis: malaria, sickle cell crisis, haemorrhage, haemolysis, aplastic anaemia, leukaemia, HIV related marrow failure, peripartum cardiomyopathy.
• Complications: heart failure, hypoxia, shock, preterm birth, stillbirth, postpartum haemorrhage, infection, maternal death.

The approach is rapid blood tests, cause finding and cardiac assessment.

• Haemoglobin (point of care), full blood count, film, reticulocytes, ferritin, folate, B12.
• Malaria test, stool for hookworm eggs, HIV test, sickling test or electrophoresis, urea, creatinine, liver enzymes, group and cross-match.
• ECG and echocardiography if breathless or oedematous; chest X-ray with shielding.
• Ultrasound for gestation, growth and placenta.

The principle is to stabilise, transfuse when indicated, treat the cause and prepare for safe delivery.

• Supportive: admit; sit upright; oxygen 4 to 6 L/min if saturation is below 95 percent; monitor pulse, respiratory rate and fluid balance; avoid IV fluid overload; deliver in a facility with blood.
• Pharmacological: transfuse packed red cells slowly, 1 unit (about 300 mL) over 3 to 4 hours, with furosemide 20 mg IV before the second unit if there are signs of heart failure; ferric carboxymaltose 15 mg/kg (maximum 1000 mg) IV over 15 minutes, or iron sucrose 200 mg IV on alternate days to 1000 mg, if no transfusion is needed after 13 weeks; ferrous sulphate 200 mg oral 8-hourly for 3 months; folic acid 5 mg oral daily; artesunate 2.4 mg/kg IV at 0, 12 and 24 hours then daily for severe malaria, or artemether-lumefantrine 4 tablets (20 mg and 120 mg each) oral at 0, 8, 24, 36, 48 and 60 hours for uncomplicated malaria; albendazole 400 mg oral single dose after 13 weeks; oxytocin 10 IU IM immediately after delivery of the baby; tranexamic acid 1 g IV over 10 minutes for any bleeding above 500 mL.
• Procedures: transfusion for haemoglobin below 5 g/dL regardless of symptoms, below 7 g/dL with heart failure, hypoxia or active bleeding, and below 8 g/dL after 36 weeks; vaginal delivery with shortened second stage is preferred.
• Special groups: sickle cell disease uses top up or exchange transfusion; women with heart failure are sat up and given oxygen with diuretics during transfusion.
• Red flags: heart failure, haemoglobin below 5 g/dL, confusion, chest pain, bleeding, fever above 38 degrees Celsius, reduced fetal movements.
• Follow-up: haemoglobin daily in hospital and at 2 weeks after discharge; iron for 3 months after normal and for 3 months postpartum; contraception counselling.