4.1 Iron deficiency anaemia

Anaemia is defined as a haemoglobin (Hb) level below 11 g/dl during the first and third trimester and below 10.5 g/dl during the second trimester.

Pre-existing anaemia due, for example, to nutritional deficiency or malaria may be aggravated by pregnancy.

Anaemia increases the risk of intrauterine growth restriction and preterm birth. It increases vulnerability in the event of haemorrhage, particularly postpartum haemorrhage.

4.1.1 Diagnosis

• Clinical signs: pallor of the conjunctivae, mucous membranes, palms, and the soles of the feet; fatigue, dizziness, tachycardia, heart murmur.
• Signs of serious illness: intense pallor, impaired consciousness, dyspnoea, Hb level below 7 g/dl.
• Measure Hb level using HemoCue.

4.1.2 Treatment

ferrous sulfate/folic acid (co-formulated tablet containing 200 mg ferrous sulfate equivalent to 65 mg elemental iron + 400 micrograms folic acid a Citation a. 200 mg ferrous sulfate (65 mg elemental iron) + 400 micrograms folic acid tablets may be replaced by 185 mg ferrous fumarate (60 mg elemental iron) + 400 micrograms folic acid tablets. ) PO: 1 tablet 2 to 3 times daily until Hb level rises to normal, then change to preventive treatment [1] Citation 1. World Health Organization. Guideline: Daily iron and folic acid supplementation in pregnant women. Geneva. 2012.
http://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf (Chapter 1, Section 1.2.5).
Addition of ascorbic acid (vitamin C) PO, 500 mg once daily, improves iron absorption.

In areas where hookworm is endemic, add an anthelmintic treatment as of the second trimester (Chapter 1, Section 1.2.5).

In areas where malaria is endemic, add intermittent preventive (Chapter 1, Section 1.2.5) or curative (Section 4.3.1) antimalarial treatment, depending on the malaria test result.

In the event of severe anaemia:

• Transfusion is indicated in the following cases:
  • Less than 36 weeks LMP:
    • Hb ≤ 5 g/dl, even if there are no signs of decompensation
    • Hb > 5 g/dl and < 7 g/dl if there are signs of decompensation or sickle cell disease or severe malaria or serious bacterial infection or pre-existing heart disease
  • 36 weeks LMP or over:
    • Hb ≤ 6 g/dl, even if there are no signs of decompensation
    • Hb > 6 g/dl and < 8 g/dl if there are signs of decompensation or sickle cell disease or severe malaria or serious bacterial infection or pre-existing heart disease
• In the third trimester:
  • Arrange for delivery in a CEmONC facility.
  • Given the risk of haemorrhage and rapid decompensation during delivery, be prepared for transfusion for any woman whose Hb is < 7 g/dl, even if anaemia is relatively well-tolerated.