Clinical Transfusion

8. Obstetric Anaemia

Introduction

Maternal anaemia is a common condition. According to the World Health Organization, pregnancy anaemia and postpartum anaemia is very frequent across the world, and confers a number of health risks to mother and child [1]. Maternal symptoms and signs include fatigue, paleness and cardiovascular strain, reduced mental and physical performance and increased risk for blood transfusion [2, 3]. Thyroid and immune functions may also be affected [2, 4]. The most frequent type of obstetric anaemia is iron deficiency anaemia (IDA), both worldwide and in developed countries, in spite of decades of guidelines and recommendations on prevention and treatment [1, 2, 5]. Iron is needed for many physiological processes in the body, and observational studies indicate that iron deficiency during pregnancy may independently cause cognitive or behavioural abnormalities in the child [6-8]. Other causes include other nutritional deficiencies, infectious diseases and genetic red cell disorders [9]. Peri- and postpartum haemorrhage may induce or aggravate anaemia postpartum.  Prevention and treatment, especially iron is widely available, but not applied sufficiently. Severe anaemia may require transfusion, particularly if there is also a significant blood loss at delivery. 

Why Obstetric Anaemia is Important

  • Maternal deficiency of iron is by far the most frequent cause of obstetric anaemia
  • Maternal anaemia is frequent despite knowledge, guidelines and widely available treatment
  • Maternal anaemia is thought to be the most frequent cause of maternal death
  • Anaemia during pregnancy increases the risk of induction of labour or caesarean section
  • Anaemia during pregnancy increases the risk of postpartum anaemia
  • Pregnancy IDA (iron deficiency anemia) is linked to a number of harmful effects on the foetus, including intrauterine growth restriction, death in utero, infection, preterm delivery and neurodevelopmental damage, which may be irreversible [6-8, 10]
  • Failure to treat maternal IDA may carry over to the next pregnancy

Pregnancy Anaemia

From the sixth week of gestation

Hormones induce haemodynamic changes. Even though there is an increase in red cell mass, plasma volume increases relatively more [11]. Therefore, obstetric anaemia is defined by specific haemoglobin limits, which are lower than in non-pregnant women. The increased red cell production increases iron needs, which frequently leads to iron depletion, as women in the fertile age often have marginal iron stores [2].

Definitions of pregnancy anaemia differ:

WHO definition: Haemoglobin < 11 g/dL in first and last trimester, and < 10.5 g/dL in the second trimester [5]. BCSH guidelines: Haemoglobin < 11g/dL in first trimester, < 10.5 g/dL in second and third trimesters [12]

Mild anaemia during pregnancy

May not harm mother or child, but a haemoglobin level below 9 g/dL is associated with a 2-3 fold increased risk for intrauterine growth restriction, which in severe cases may lead to intrauterine foetal death [2].

Pregnancy IDA (Iron Deficiency Anemia)

is by far the most frequent type [9, 9, 13], and is seen in approximately 25% of pregnant women, even in highly industrialized countries, and ethnicity and age are strongly associated with anaemia prevalence [14, 15]. Prevalence of anaemia during pregnancy shows a large geographical variation caused by environmental, socio-economic and hereditary factors: Europe and North America 17-31%, South-East Asia 44-53% and Africa 53-61%. Approximately 20% of who have haemoglobin levels below 8/dL, and Iron deficiency is the most common cause, as the vast majority of women have iron stores too low to meet the cumulative needs of pregnancy and delivery [5, 5, 16].

Multiple other acquired aetiologies exist:

Folate deficiency, vitamin B12 deficiency, parasitic infestation (malaria, hookworm), bacterial infection, autoimmune haemolytic anaemia, toxic/aplastic anaemias, haematological malignancies and PNH [2, 9].

Diagnosis is essential

should be adapted to the geographic region due to the different treatment and prognosis. Clinical and laboratory investigation should at least look for iron and folate deficiency and rule out infection, malignancies and hereditary disorders [2, 17].

Prevention:

IDA can be prevented by taking 15-60 mg of iron diet daily [18] (or 2-3 times per week, which reduces the side effects [19]), though not all countries recommend this [17].

Other types of anaemia

Treatment should target the underlying disease or condition.

Blood transfusion

Carries a number of risks including volume overload and should only be used for acute bleeding, haematological conditions and severe cases of refractory anaemia, where low haemoglobin levels or insufficient physiological compensation are thought to cause an imminent risk for mother or foetus [17].

Treatment

For ID and manifest IDA higher dosage, between 65-200 mg of elemental iron is required [18]. This frequently induces significant gastro-intestinal side effects, resulting in low compliance rates: Inflammation and intestinal malfunction severely limits absorption. If oral iron is not feasible or effective, intravenous iron can induce repletion of iron stores within 1-2 days and normalisation of haemoglobin levels in 1-3 weeks, and can be used from the second. Trimester onwards, provided that blood and iron physiology is otherwise normal [12, 20].

Postpartum Anaemia

Definition:

Haemoglobin < 10 d/dL [17]

Prevalence:

If postpartum anaemia is defined as a Hb < 10 g/dL, the prevalence 30% or higher [17], if defined as < 11g/dL, the prevalence is up to 50%, with no iron intake during pregnancy. With routine intake of iron during pregnancy, postpartum anaemia has been recorded in 14% [21].

Aetiologies:

Postpartum haemorrhage alone or in combination with pregnancy iron deficiency is a common cause of postpartum anaemia. Other aetiologies: see pregnancy anaemia above.

 

 

Postpartum haemorrhage (PPH)

can be defined > 500 ml of blood loss within 24 hours after delivery [22]. PPH is seen in approximately 18% of all deliveries. Severe PPH, defined as blood loss of > 1000 ml, is seen in 4-5% of deliveries, and PPH > 2500 ml is seen in 0.4% of births [23, 24]. Normally 500 mg of iron is stored in the liver, corresponding to formation of the erythrocytes in 1 litre of blood. If the haemorrhage is severe or there is a pre-existing pregnancy ID or IDA, the blood loss at delivery will almost invariably lead to postpartum IDA.

Prevention:

Treating anaemia during pregnancy and managing obstetric haemorrhage reduces the risk of postpartum IDA, see pregnancy anaemia above, and guidelines for the management of obstetric haemorrhage [25].

Treatment

• The majority of obstetric anaemia cases can be prevented or treated based on their aetiology (e.g. by supplementing iron or folate or treating the underlying disease), if diagnosed in time. Oral iron supplementation is the gold standard for the treatment of IDA, and intravenous iron can be used where oral iron is not feasible or effective, from second trimester in pregnancy and onwards [26].

• Red cell transfusion is given in approximately 2% of all deliveries [27], and should be reserved for the treatment of major haemorrhage and severe anaemia with cardiac incompensation, where other treatment options are insufficient, as the clinical effect of red cell transfusion on common anaemia symptoms does not outweigh its risks and costs [28, 29]

Relevant guidelines available

  1. UK guidelines on the management of iron deficiency in pregnancy Sue Pavord, Bethan Myers, Susan Robinson, Shubha Allard, Jane Strong, Christina Oppenheimer 2012
  2. Cochrane reviews on the treatment of IDA after pregnancy Markova V, Norgaard A, Jørgensen KJ, Langhoff-Roos J 2015
  3. Cochrane reviews on the treatment of IDA during pregnancy Pena-Rosas JP, De-Regil LM, Dowswell T, Viteri FE 2012
  4. Patient Blood Management Guidelines: Module 5 Obstetrics and Maternity National Blood Authorities of Australia 2015
  5. Postpartum Hemorrhage guidelines Dahlke JD, Mendez-Figueroa H, Maggio L, Hauspurg AK, Sperling JD, Chauhan SP, Rouse DJ 2015

Some examples of practical tools to support implementation:

Management of anaemia in pregnancy/postpartum period. 

http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/2/b2.23.pdf
 

Training material with links

BloodSafe elearning on Postpartum haemorrhage 

bloodsafelearning.org.au/course/postpartum-haemorrhage-pph/

  1. World health organization: The global prevalence of anaemia in 2011 Juan Pablo Peña-Rosas, Lisa Rogers and Gretchen A Stevens 2015
  2. Iron Deficiency Anemia in Pregnancy. Breymann C. 2015
  3. Anemia--still a major health problem in many parts of the world! Milman N 2011
  4. Evaluation of iodine, iron, and selenium in biological samples of thyroid mother and their newly born babies. Kazi TG, Kandhro GA, Sirajuddin, Afridi HI, Baig JA, Shah AQ, Wadhwa SK, Khan S, Kolachi NF, Shaikh HU 2010
  5. Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System McLean E, Cogswell M, Egli I, Wojdyla D, de BB 2009
  6. Impact of Fetal-Neonatal Iron Deficiency on Recognition Memory at 2 Months of Age Geng F, Mai X, Zhan J, Xu L, Zhao Z, Georgieff M, Shao J, Lozoff B 2015
  7. Why iron deficiency is important in infant development. Beard JL 2008
  8. Long-lasting neural and behavioral effects of iron deficiency in infancy Lozoff B, Beard J, Connor J, Barbara F, Georgieff M, Schallert T 2006
  9. Anemia in pregnancy Horowitz KM, Ingardia CJ, Borgida AF 2013
  10. On the safety of intravenous iron, evidence trumps conjecture Auerbach M, Adamson J, Bircher A, Breymann C, Fishbane S, Gafter-Gvili A, Gasche C, Gilreath J, Grazzini G, Henry D, Liumbruno G, Locatelli F, Macdougall I, Munoz M, Rampton D, Rodgers G, Shander A 2015
  11. Postpartum hemorrhage and transfusion of blood and blood components. Jansen AJ, van Rhenen DJ, Steegers EA, Duvekot JJ 2005
  12. UK guidelines on the management of iron deficiency in pregnancy Pavord S, Myers B, Robinson S, Allard S, Strong J, Oppenheimer C 2012
  13. Postpartum anemia I: definition, prevalence, causes, and consequences Milman N 2011
  14. WHO Global Database on Anaemia WHO 2016
  15. Changes in hematologic indices in caucasian and non-caucasian pregnant women in the United States Harm SK, Yazer MH, Waters JH: 2012
  16. Prevalence of maternal anaemia and its predictors: a multi-centre study Barroso F, Allard S, Kahan BC, Connolly C, Smethurst H, Choo L, Khan K, Stanworth S 2011
  17. UK guidelines on the management of iron deficiency in pregnancy Pavord S, Myers B, Robinson S, Allard S, Strong J, Oppenheimer C 2012
  18. Daily oral iron supplementation during pregnancy Pena-Rosas JP, De-Regil LM, Dowswell T, Viteri FE 2012
  19. Intermittent oral iron supplementation during pregnancy Pena-Rosas JP, De-Regil LM, Dowswell T, Viteri FE 2012
  20. Treatment of Iron Deficiency in Women. Breymann C, Romer T, Dudenhausen JW 2013
  21. Prepartum anaemia: prevention and treatment. Milman N 2008
  22. WHO recommendations for the prevention and treatment of Postpartum haemorrhage WHO 2012
  23. Postpartum haemorrhage in nulliparous women: incidence and risk factors in low and high risk women. A Dutch population-based cohort study on standard (> or = 500 ml) and severe (> or = 1000 ml) postpartum haemorrhage. Bais JM, Eskes M, Pel M, Bonsel GJ, Bleker OP 2004
  24. How we manage the haematological aspects of major obstetric haemorrhage. Allard S, Green L, Hunt BJ 2013
  25. Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines Dahlke JD, Mendez-Figueroa H, Maggio L, Hauspurg AK, Sperling JD, Chauhan SP, Rouse DJ 2015
  26. Treatment for women with postpartum iron deficiency anaemia. Markova V, Norgaard A, Jorgensen KJ, Langhoff-Roos J 2015
  27. Severe postpartum haemorrhage and mode of delivery: a retrospective cohort study Holm C, Langhoff-Roos J, Petersen KB, Norgaard A, Diness BR 2012
  28. Transfusion policy after severe postpartum haemorrhage: a randomised non-inferiority trial Prick BW, Jansen AJ, Steegers EA, Hop WC, Essink-Bot ML, Uyl-de Groot CA, Akerboom BM, van AM, Bloemenkamp KW, Boers KE, Bremer HA, Kwee A, van Loon AJ, Metz GC, Papatsonis DN, van der Post JA, Porath MM, Rijnders RJ, Roumen FJ, Scheepers HC, Schippers DH 2014
  29. Cost-effectiveness of red blood cell transfusion vs. non-intervention in women with acute anaemia after postpartum haemorrhage. Prick BW, Duvekot JJ, van der Moer PE, van GN, van der Salm PC, Jansen AJ, van Rhenen DJ, Mol BW, Uyl-de Groot CA 2014
  30. Daily oral iron supplementation during pregnancy. Pena-Rosas JP, De-Regil LM, Dowswell T, Viteri FE: 2012
  31. Patient Blood Management Guidelines National Blood Authorities of Australia 2013
Astrid Norgaard

Astrid Norgaard

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The content of this resource has been developed and reviewed by members of the ISBT Clinical Transfusion Working Party and should be used at the discretion of healthcare professionals utilising this clinical resource. The authors or the International Society of Blood Transfusion cannot accept legal responsibility for the content of this resource.