Prevention and management of anemia in the reproductive period and pregnancy

VIDEO 8

Women of reproductive age (WRA) are one of the groups most at risk of anemia, due to their physiological processes. There has been little progress in reducing the anemia burden among WRA over the past two decades, with prevalence actually increasing in some South Asian and sub-Saharan African countries. More recent estimates from WHO indicate that, globally, the prevalence of anemia among WRA has increased between 2011 and 2016, from 30% to 33%. The high global burden of anemia continues to underline the need for tailored approaches and target interventions on an individual basis.

BACKGROUND

The global prevalence of anemia is 24.3%, making it one of the most common diseases worldwide. It is estimated that there are 1.92 billion people with anemia globally, 2/3 of whom have it due to iron deficiency, which is the most common reason for anemia^1,2. The World Health Organization (WHO) estimates that 37% of non-pregnant and 30% of pregnant women worldwide suffer from anemia³.

Uses of iron

Iron is essential in the form of hemoglobin, which is responsible for oxygen transport. Iron is also an essential component in the electron transport chain for the generation of ATP. Iron likewise plays an important part in DNA synthesis. Thus, iron is integral to the maintenance of normal body functions⁴.

Burden of anemia in the mother and fetus

Maternal anemia correlates with adverse maternal and perinatal outcomes. It increases the risk of preterm birth (RR 1.56; 95% CI, 1.25–1.95)⁵. Anemia at the time of delivery is significantly associated with Cesarean section (OR 1.30; 95% CI, 1.13–1.49), blood transfusion (OR 5.48; 95% CI, 4.57–6.58), macrosomia (OR 1.23; 95% CI, 1.12–1.35), large-for-gestational age (LGA) (OR 1.29; 95% CI, 1.20–1.39), low 5-min Apgar score (OR 2.21; 95% CI, 1.84–2.64), and NICU admission (OR 1.28; 95% CI, 1.04–1.57). The association of anemia at birth with LGA is presumably due to the high iron demands of a rapidly growing LGA fetus⁶. Maternal anemia during organogenesis stage, on the other hand, results in small-for-gestational-age fetuses⁷. Fetal growth restriction, due to fetal programming, may result in long-term chronic diseases such as obesity, hypertension and metabolic syndrome in later life⁸. A more disturbing effect of anemia is seen in fetal brain development due to its effect on the development of the hippocampus. Cognitive, socioemotional and psychological functions are adversely affected by anemia⁹.

Prevention of anemia

Anemia is prevented by identifying and changing modifiable risk factors, nutritional interventions, iron supplementation and lifestyle changes. A recently published meta-analysis identifies risk factors associated with anemia in pregnancy. Parasitic and malarial infections, tea or coffee after meals, low intake of meat and vegetables, being underweight, second and third trimesters of pregnancy, multiple pregnancy, multiparity, big family size, short pregnancy intervals, low socio-economic income, rural residence, no antenatal care and history of menorrhagia prior to pregnancy all correlate positively with maternal anemia. Iron supplementation and being obese or overweight are found to be protective¹⁰. Additional risk factors for anemia are adolescent pregnancy, being a female endurance athlete, being vegetarian, obesity, prolonged use of proton-pump inhibitors, poor sanitation and weak immune system. Consuming iron-rich food and those that are high in folate, vitamin B6 and vitamin C also prevent anemia¹¹. The WHO recommends iron supplementation for prevention¹².

Screening for anemia

The majority of guidelines recommend screening for anemia in pregnancy¹³.

Diagnosis of anemia

Anemia in pregnancy is diagnosed using the following hemoglobin levels: < 110 g/L in the first and third trimesters and < 105 g/L in the second trimester. The cut-offs for anemia are lower in pregnancy compared to the non-pregnant female due to the effects of physiologic anemia¹⁴.

Management of anemia

Management of anemia depends on etiology. The common causes of anemia in pregnancy are iron deficiency anemia and other nutritional deficiencies, chronic blood loss from heavy menstrual bleeding, thalassemia and acute blood loss during delivery. Iron deficiency anemia is diagnosed when the hemoglobin and hematocrit are low, the mean corpuscular volume is < 80 fl, and serum ferritin is < 30 ng/mL^15,16. Chronic blood loss is often diagnosed from history. Thalassemia is suspected when hemoglobin and hematocrit are low, the mean corpuscular volume is < 80 fl, serum ferritin is usually normal and hemoglobin electrophoresis is low (in the case of Beta thalassemia) or genetic studies confirm the presence of alpha thalassemia¹⁵. Acute blood loss during delivery may be due to genital tract trauma and lacerations, uterine atony and placenta accreta spectrum disorders. Less often, causes of anemia are chronic diseases, blood dyscrasia and liver disease. Iron deficiency anemia is treated with higher doses of iron orally, intravenously when anemia is more severe and/or the side effects of oral iron therapy cannot be tolerated, and by blood transfusion for the severe forms that need faster treatment¹¹.

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