4.1 Iron deficiency anaemia

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

Pregnancy aggravates pre-existing anaemia due, for example, to nutritional deficiency or malaria.

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

4.1.1 Diagnosis

– Pallor of the conjunctivae, mucous membranes, palms, and the soles of the feet; fatigue, dizziness, tachycardia, heart murmur.
– Signs of serious illness: intense pallor, lethargy, dyspnoea, haemoglobin below 7 g/dl.
– Measure haemoglobin 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 acid1 ) PO: 2 to 3 tablets/day in 2 or 3 divided doses until haemoglobin level rises to normal, then change to preventive treatment1 (Chapter 1, Section 1.2.5).
Addition of vitamin C PO (500 mg/day) improves iron absorption.

In areas where hookworm is endemic, add a single dose 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.

For severe anaemia in the third trimester:

Arrange for delivery in a CEmONC facility.
Ensure active management of third stage of labour and if required, uterine exploration/manual removal in case of postpartum haemorrhage, or possible transfusion.

Given the risk of haemorrhage and rapid decompensation during delivery, be prepared for transfusion for any woman whose haemoglobin is below 7 g/dl, even if anaemia is relatively well-tolerated.

Ref Notes
1 200 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.