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Iron Deficiency Anemia in Pregnancy

Discuss about the Anemia in Pregnancy.

Erythroid hyperplasia of the bone marrow alongside a reduction in the mass of RBCs is normal during pregnancy. However, an unchecked increase in the volume of plasma results in dilution of blood (hemodilution) a condition referred to as hydremia of pregnancy (Balgir, 2015). Additionally, the percentage of red blood cells in the blood (HCT) also reduces the range of 38 and 45% in healthy women to about 34% during single pregnancies and 30% of instances of multifetal pregnancy (McClure et al., 2014). Iron deficiency is the single most common micronutrient deficiency in the world and a major cause of anemia. Anemia in pregnancy is therefore characterized by a hemoglobin count of <10g/DL and an HCT of <30%. The oxygen carrying capacity of the RBCs tends to remain normal despite hemodilution during pregnancy though (Esen, 2017). This paper presets anemia as a common health complication to most women in the third trimester of pregnancy. Most common causes are an iron deficiency and foliate deficiency.

Iron deficiency anemia accounts for up to 95% of cases of anemia in pregnancy. Also known as microcytic anemia it is caused by inadequate dietary intake of iron during pregnancy (Koura et al., 2012). Malabsorption of iron from the gastrointestinal tract can also result in Iron deficiency anemia. Still, gastrointestinal tract surgery can result in blood loss leading anemia since 2ml of blood contains 1mg of iron. Normal recurrent loss of blood during menstruation also results in loss of iron given the amount of iron lost roughly approximates the amount that is ingested in a month, hence reducing the buildup of iron stores in the body. The clinical presentation of iron deficiency anemia includes but is not limited to, inflammation of the tongue (glossitis), inflammation of the lips(cheilitis), sensitivity to cold, weakness and fatigue. According to Kassebaum (2016), Iron Deficiency is the leading cause of anemia in pregnant women. The world is focusing on reducing cases of anemia among women of the reproductive age by 2025 as part of its nutritional target (World Health Organization, 2014). One in four pregnancies in Europe is affected by iron deficiency anemia (McLean et al., 2009 and Scholl, 2010). The world health organization estimates that in 2011, the prevalence of anemia stood at 38% among pregnant women. According to Stevens et al.,(2013). This figure translates to roughly 32 million women worldwide.

Megaloblastic Anemia

Also called macrocytic anemia, it is characterized by large RBCs which are fragile and easily destroyed. It is majorly attributed to two factors essential in the synthesis of red blood cells. Obse et al., (2013) contend that insufficient dietary intake of folic acid and cobalamin is the major risk factors for megaloblastic anemia. Cobalamin deficiency can result from a failure by the gastric mucosa to secrete intrinsic factors for the absorption of cobalamin from the GIT. Gastrointestinal surgery may also lead to the loss of intrinsic factor-secreting gastric mucosal cells. In some instances, hereditary defects in cobalamins utilization are also implicated. Folic acid deficiency, on the other hand, results majorly from poor dietary intake of folic acid. It can also result from malabsorption syndromes, drugs that inhibit folic acid absorption, alcohol abuse, and hemodialysis. These factors lead to a reduction in erythropoiesis. Scholl (2015) and  Pavord et al., (2012) contend that with the decline in erythropoietic activity, iron stores are depleted, reduced and eventually depleted, resulting in anemia. Deficiencies in vitamin B 12 and folate still remain the leading cause of megaloblastic anemia since the consequence of ineffective hematopoiesis is major on RBCs as much as it affects other cell lines. According to Achebe et al., (2017) universal supplements such as folate and cobalamins are vital in care of mothers with megaloblastic anemia

Options of care, collaboration, and consultation with other health providers

There is a need for collaborative approach by all heath care providers right from the clinician or doctor, to the laboratory personnel where the diagnosis is done to the nurses who implement the care and treatment plan. Key among these is the diagnosis.

  • Diagnosis of Iron Deficiency Anemia

Bone marrow aspirate staining is the gold standard for defining iron deficiency anemia. The bone marrow aspirate is then viewed under a microscope; the absence of staining on the field demonstrates a lack of iron for erythropoietic activity. Gale et al., (1963). This approach, however, has a disadvantage of being intrusive so it cannot be applied to routine practice. The use of different biomarkers other than this provides a better alternative for determining iron status. According to Pavord et al., (2012) serum levels of ferritin are the most reliable method. As a routine, therefore, Iron deficiency anemia is diagnosed by measuring the levels of iron, ferritin, and transferrin in the serum. It is usually characterized by an HCT of <30% and an MCV <79fL. Decreased levels of iron and ferritin in the serum and increased levels of transferrin in the serum is a confirmatory diagnosis

  • Diagnosis of Megaloblastic anemia

Options of care, collaboration, and consultation with other health providers

A complete blood count and a peripheral smear form the basis for diagnosis. The peripheral smear usually shows anisocytosis and poikilocytosis- characteristic of, macrocytic anemia and enlarged oval RBCs (macro-ovalocytes). Reticulocytopenia and neutrophils with hyper segmentations also indicate megaloblastic anemia. Definitive diagnosis, however, carried out by the measurement of folate in serum. A Complete Blood Count that shows anemia with indices consistent with macrocytic anemia or high red blood cells distribution width(RDW) usually indicates folate deficiency.  The confirmatory diagnosis is low levels of folate in the serum.

Perinatal and maternal outcomes can potentially worsen if hemoglobinopathies, such as sickle cell disease, α-thalassemia, and Hemoglobin S-C Disease are not detected and treated. Fetuses which are chronically exposed to iron deficiency anemia are likely to be born underweight (Lone et al., 2004) due to effects on fetal intrauterine growth Gaillard et al., (2014). Preexisting sickle cell anemia increases the maternal susceptibility to infections majorly pneumonia, inflammation of the endometrium (endometritis) and UTIs (Urinary tract infections).  The leading cause of maternal death in the UK is maternal sepsis, affecting 5 in 10000 pregnancies.  It may also predispose the mother to conditions such as pulmonary infarction heart failure and pregnancy-induced hypertension. It has also been determined to result in restriction of fetal growth and preterm delivery. Iron deficiency anemia (IDA) was also the most common cause of anemia-related disability in 2013 (Kassebaum, 2016) contends that the leading cause of anemia related disability in 2013 was iron deficiency anemia. (Cantwell et al., 2011) also, contends that the risk of maternal mortality secondary to hemorrhage is increased in mothers with iron deficiency anemia. The severity of most anemia cases also tends to increase with the progression of the pregnancy hence posing serious health risks to both mother and fetus. Although the risk of UTIs is increased in mothers with sickle cell trait it is not commonly implicated in severe pregnancy-related complications. Hb S-C disease may also present during pregnancy. With it comes increased the risk of pulmonary infarction due to occasional embolization of the bony spicule. Fetal effects are less common but when present may include restriction of fetal growth.α-Thalassemia is not likely to cause maternal morbidity but results in fetal death if the fetus is homozygous for α-Thalassemia. The fetus is not likely to make it beyond the early third semester. According to Congdon et al., (2012), cognitive development and growth can suffer long term impairments among infants that are in-utero exposed to iron deficiency anemia. Beck et al., (2010) argue that chronic fetal exposure to iron deficiency anemia could potentially increase the risk of pre-term delivery by up to double. This makes detection and treatment of iron deficiency anemia a top priority for policymakers and healthcare providers globally (World Health Organization, 2011).

Anemia Associated Risks in Pregnancy

Adequate dietary intake of iron and iron supplementation through medicines is the principle prevention mechanism for iron deficiency in pregnant mothers. All pregnant mothers need to be started on aloe oral dose of about 30 mg/day of iron supplementing drugs (Masukume et al., 2015). It is also vital to integrated iron rich foods like beef and selected vegetables from the onset of pregnancy as well foods that enhance the absorption of iron. Pregnant mothers also need to be screened for iron deficiency anemia in good time if they are from populations that are at high risk of iron deficiency (Nguyen et al., 2016). In such populations, higher doses of iron supplement such as 60-100 mg per day may help achieve prophylaxis against iron deficiency anemia.

If a pregnant mother is confirmed to have iron deficiency anemia by diagnosis, the treatment regimen is quite similar to iron deficiency in postpartum mothers, non-pregnant women, postmenopausal or premenopausal women (Pavord et al., 2012). The marked difference is the t they are administered with additional iron together with a combination of prenatal vitamins. Dietary counseling is also recommended. Another course that is recommended is taking a measurement of the Complete Blood Count consistently to monitor the iron levels in the hemoglobin of the pregnant mother (Onyeneho et al., 2016). According to the Center for Disease Control, screening of the mother during the first prenatal visit is essential. The IOM recommends that mothers from high-risk populations be screened at the beginning of every trimester and postpartum for one to one and a half months. While universal supplementation of iron is recommended by both the CDC and the WHO, the American Department of Defense decries the lack of sufficient evidence to support the same (Daru et al., 2015). Studies reveal that the supplementation of iron for pregnant mothers before depletion of iron stores which has become a common practice among clinicians may also be implicated in severe fetal and maternal health outcome (Congdon et al., 2012 and Siu, 2015).

According to Koura et al., (2012), infant anemia correlates with maternal anemia. The potential of delaying the clamping of the umbilical cord has been found to have potential to improve the iron levels in infants born at complete term. Also, it is beneficial for improving the hematocrit levels in infants born to anemic mothers. Although this comes along with a possible increase in the risk of hyperbilirubinaemia by about 12% studies reveal that it is rarely ever as serious as to require exchange transfusion or phototherapy-making it safe to apply (Gebreamlak, Dadi, & Atnafu, 2017). The study revealed that delaying cord clamping has the effect of raising the concentration of hemoglobin especially in infants born to anemic mothers at ages between 2-3 months and lowers the risk of developing anemia for the infant. This practice may be especially beneficial to countries where tea is high occurrences of fetal anemia.

It may be important for mothers to continue taking prenatal vitamins inclusive of iron supplements during breastfeeding in order to reduce the risk of postpartum anemia. According to Oppenheimer (2012), postpartum screening is essential for monitoring of iron and hemoglobin status even post- delivery. According to WHO a hemoglobin level<10.5g/dl and HCT<32% would be an indication of anemia even postpartum. McClure et al., (2014) also denote that postpartum anemia is a leading cause of postnatal depression and depression in last trimester Yilmaz et al., (2017), which could adversely affect the emotional wellbeing of the mother and the child as well.

Other adverse effects associated with postpartum anemia include fatigue and exhaustion beyond the expected normal, insufficient milk syndrome and poor quality of milk (Christides et al., 2016). Also important is to increase dietary intake of foods rich in iron after delivery. Although this may take a longer time to achieve desired iron levels as compared to taking iron supplements, iron is still better absorbed by the body from dietary sources in the GIT (Obse, Mossie, & Gobena, 2013). The bioavailability of iron from supplement sources is less than that absorbed from dietary sources (Sharp, 2015). When designing a care plan for a postpartum mother who had intrapartum iron deficiency anemia, it is critical to ensure the iron levels remain up. Given the fact that delivery itself is associated with a lot of blood loss, such a mother must be screened to find out if she is in need of a blood transfusion to forestall a fall in hemoglobin.  

Conclusion

As covered in this paper, anemia in pregnancy affects 5 in every 10000 pregnant women totaling to about 32 million women globally. For this reason, the world health organization intends to cut by half the prevalence of iron deficiency anemia among women of reproductive age (which accounts for up to 98% of all cases of anemia in pregnancy) by the year 2025.Understanding the etiology and clinical presentation of iron deficiency anemia is critical for both clinicians and health policy makers alike if this target is to be achieved. There is also need for more research into the benefits and adverse effects of the use of iron supplements for mothers on maternal and fetal health if real strides are to be made towards this same goal.

References

Achebe, M. M., &Gafter-Gvili, A. (2017). How I treat anemia in pregnancy: iron, cobalamin, and folate. Blood, 129(8), 940-949. doi:10.1182/blood-2016-08-672246

Balgir, R. S. (2015). Prevalence of hemolytic anemia and hemoglobinopathies among the pregnant women attending a tertiary hospital in central India. Thalassemia Reports, 5(1), 16-20. doi:10.4081/thal.2015.464

Bayesian Statistical Modelling 2nd edition by P. CONGDON. (2007). Biometrics, 63(3), 976-977. doi:10.1111/j.1541-0420.2007.00856_12.x

Christides, T., Wray, D., McBride, R., Fairweather, R., & Sharp, P. (2015). Iron bioavailability from commercially available iron supplements. European Journal Of Nutrition, 54(8), 1345-1352. doi:10.1007/s00394-014-0815-8

Daru, J., Moores, R., Dodds, J., Rayment, J., Allard, S., & Khan, K. S. (2015). Non-anaemic iron deficiency in pregnancy: the views of health service users and health care professionals. Transfusion Medicine, 25(1), 27-32. doi:10.1111/tme.12184

Gaillard, R., Eilers, P. C., Yassine, S., Hofman, A., Steegers, E. P., &Jaddoe, V. V. (2014). Risk Factors and Consequences of Maternal Anaemia and Elevated Haemoglobin Levels during Pregnancy: a Population-Based Prospective Cohort Study. Paediatric& Perinatal Epidemiology, 28(3), 213-226. doi:10.1111/ppe.12112

Gale Encyclopedia of Medicine (Book Review).(2000). American Libraries, 31(5), 63.

Kassebaum, N. J., Lozano, R., Lim, S. S., & Murray, C. J. (2017).Setting maternal mortality targets for the SDGs--reply. Lancet, 389(10070), 697-698.

Masukume, G., Khashan, A. S., Kenny, L. C., Baker, P. N., Nelson, G., & null, n. (2015). Risk Factors and Birth Outcomes of Anaemia in Early Pregnancy in a Nulliparous Cohort.Plos ONE, 10(4), 1-15. doi:10.1371/journal.pone.0122729

Nguyen, P. H., Young, M., Gonzalez-Casanova, I., Pham, H. Q., Nguyen, H., Truong, T. V., & ... Ramakrishnan, U. (2016). Impact of Preconception Micronutrient Supplementation on Anemia and Iron Status during Pregnancy and Postpartum: A Randomized Controlled Trial in Rural Vietnam. Plos ONE, 11(12), 1-16. doi:10.1371/journal.pone.0167416

Onyeneho, N. G., I'Aronu, N., Chukwu, N., Agbawodikeizu, U. P., Chalupowski, M., & Subramanian, S. V. (2016). Factors associated with compliance to recommended micronutrients uptake for prevention of anemia during pregnancy in urban, peri-urban, and rural communities in Southeast Nigeria. Journal Of Health, Population & Nutrition, 351-17. doi:10.1186/s41043-016-0068-7  

Pavord, S., Myers, B., Robinson, S., Allard, S., Strong, J., & Oppenheimer, C. (2012).UK guidelines on the management of iron deficiency in pregnancy. British Journal OfHaematology, 156(5), 588-600. doi:10.1111/j.1365-2141.2011.09012.x

Gebreamlak, B., Dadi, A. F., &Atnafu, A. (2017). High Adherence to Iron/Folic Acid Supplementation during Pregnancy Time among Antenatal and Postnatal Care Attendant Mothers in Governmental Health Centers in AkakiKality Sub City, Addis Ababa, Ethiopia: Hierarchical Negative Binomial Poisson Regression. Plos ONE, 12(1), 1-11. doi:10.1371/journal.pone.0169415

McClure, E. M., Meshnick, S. R., Mungai, P., Malhotra, I., King, C. L., Goldenberg, R. L., & ... Dent, A. E. (2014). The Association of Parasitic Infections in Pregnancy and Maternal and Fetal Anemia: A Cohort Study in Coastal Kenya. Plos Neglected Tropical Diseases, 8(2), 1-8. doi:10.1371/journal.pntd.0002724

Obse, N., Mossie, A., &Gobena, T. (2013). MAGNITUDE OF ANEMIA AND ASSOCIATED RISK FACTORS AMONG PREGNANT WOMEN ATTENDING ANTENATAL CARE IN SHALLA WOREDA, WEST ARSI ZONE, OROMIA REGION, ETHIOPIA. Ethiopian Journal Of Health Sciences, 23(2), 165-173.

Y?lmaz, E., Y?lmaz, Z., Çakmak, B., Gültekin, ?. B., Çekmez, Y., Mahmuto?lu, S., & ... Küçüközkan, T. (2017).Relationship between anemia and depressive mood in the last trimester of pregnancy. Journal Of Maternal-Fetal & Neonatal Medicine, 30(8), 977-982. doi:10.1080/14767058.2016.1194389

Esen, U. I. (2017). Iron deficiency anaemia in pregnancy: The role of parenteral iron. Journal Of Obstetrics &Gynaecology, 37(1), 15-18. doi:10.1080/01443615.2016.1180505

Koura, G. K., Ouedraogo, S., Le Port, A., Watier, L., Cottrell, G., Guerra, J., & ... Garcia, A. (2012). Anaemia during pregnancy: impact on birth outcome and infant haemoglobin level during the first 18 months of life. Tropical Medicine & International Health, 17(3), 283-291. doi:10.1111/j.1365-3156.2011.02932.x

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