Anaemia in pregnancy

If there is any clinical condition where caregivers are very proactive in management, it is ANAEMIA IN PREGNANCY. The reality is that whether the patient has anaemia or not, she is routinely placed on HAEMATINICS, which are blood building supplements. The fact is that the clinician knows that the haemodynamics of pregnancy results in the dilution of the amount of circulating red blood cellsavailable and that they will be blood loss during delivery irrespective of how the baby comes out.

What then is anaemia?

It is defined as when there is a decrease in the number of red blood cells or when the quantity of HAEMOGLOBIN in the red blood cell is less than normal. Anaemia may also be defined in relation to decreased OXYGEN-BINDING ability of haemoglobin molecule due to DEFORMITY or lack of quantitative production in some deficiencies.

For starters the RED BLOOD CELL is a bi-concave shaped cell without a NUCLEUS. Its main function is to carry oxygen from the lungs to all the tissues in the body and convey back carbon dioxide to the lungs for expulsion to the environment for processing by the green plants. Inside the red blood cell is this complex molecule; haemoglobin which is made up of HAEM, a complex compound molecule made of PORPHYRINS and a protein component known as GLOBIN. In the central core of the molecule is positively charged IRON ion which facilitates the loose binding of oxygen molecule. The life span of an average red blood cell is one hundred and twenty days. After which they are destroyed be the reticular-endothelial system; very prominent in the SPLEEN. Both the HAEM and the GLOBIN are recycled.

Under what conditions can one become anaemic? This is best summarized in what can be described as red blood cell KINETICS. These cells are produced in the fatty component of the BONE MARROW. They are one of the derivatives of the STEM CELL known as MEGAKARIOCYTE which give rise to other cellular components of blood. The production of red cells is stimulated by ERYTHROPOIETIN which in turn is produced in the KIDNEY. Other building blocks for this highly specialized cell are IRON and FOLIC ACID.

Thus anaemia can result from failure of the stem cells to proliferate, that is increase in number and differentiate. By differentiation of cells we mean the process of transformation of primitive or progenitorcells to highly specialized cells that perform SPECIFIC functions and lose their ability to divide. Secondly, anaemia can result from rapid destruction of red blood cells in certain condition; the commonest in our environment being the sickle cell disorder and so many that cannot be listed here.

The third common cause of anaemia is in cases of ACUTE blood loss like during surgery, severe trauma like in road traffic accident and bleeding disorders like in HAEMOPHILIA. We also have CHRONIC or slow bleeding like in hookworm infestation; bleeding chronic duodenal ulcer etc.

Of primary concern to Diagnosis today is NUTRITIONAL IRON DEFICIENCY anaemia in pregnancy. This is so common among our expectant mothers; that in certain communities, not being anaemic during pregnancy is an exception to the norm. This condition is also very common in children. In as much as haemodilution and Malaria infection are very serious contributory factors to anaemia in pregnancy, by and large the taking care of nutritional iron deficiency goes a long way in solving the challenge of anaemia in pregnancy

To the ever busy care giver the Diagnosis of anaemia is done through a simple approach; by conducting a FULL BLOOD COUNT (FBC). This may involve reporting on the number of red blood cells and the level of haemoglobin. The first result the care giver gets is the PACKED CELL VOLUME (PCV). This is expressed as a percentage of red blood cells compared to the total blood volume. As a gold standard, any value less than 30 per cent is defined as anaemia especially if in addition the haemoglobin level is below 11g/dl. In areas where there are facilities, microscopy to estimate the size of red cell and calculation of mean capsular haematocrit concentration etc can be done. In a rural setting with large pool of expectant mothers; a functional centrifuge, capillary tubes and a PCV scale could make a lot of difference even in a Primary Health Centre manned by a doctor.

A pregnant woman with anaemia, just like the one with Malaria may be completely asymptomatic. In its common presentation, they may report the feelings of weakness, fatigue and poor concentration.Quite too often the care giver may just overlook it simply because all the symptoms can be explained on the bases of apathy of pregnancy. Sometimes to the embarrassment of the care giver when the patient says,” Dr I don’t think that I have enough blood in my body,” that the clinician may take a second look at the eye lids and mucus membranes and start to order for tests. It is not uncommon that you see a pregnant woman WALK into your consulting room with a PCV of 10 per cent and argues with you when you suggest admission for iron therapy by intravenous route.

In practice, the management of anaemia in pregnancy is through routine iron salt administration through the oral route. The common formulations available are ferrous sulfate, ferrous fumarate and ferrous gluconate. The main draw back with ferrous sulfate is that on the release of the iron component, the combination of sulfate and hydrogen forms a strong acid and could lead to abdominal discomfort. These days the fumarate and gluconate formulations are becoming popular because on release of iron the resultant acids are ORGANIC and weak acids.

Following the so called IRON-BLOCK theory, and depending on the available receptor sites in the intestine the body can only absorb a maximum of 6mg of IRON irrespective of the quantity swallowed in a day. ASCORBIC acid, better known as Vitamin C helps to increase the quantity of iron absorbed from the intestine. The excess and unabsorbed iron are oxidized and passed out in stool, BLACK in colour.

Thus in severe cases of anaemia in pregnancy it may be necessary to give inject able iron either INTRAMUSCULARLY or through INTRAVENOUS line. There are some Primary Health Centers  who do this routinely with other vitamins irrespective whether the patient is receiving oral iron supplements or not. This is good especially where due to resource constraint, dietary variety a challenge is.

Finally the empirical treatment of malaria should also be paramount in managing this category of patients. All in all, Diagnosis feels that we have done well in this sphere of maternal care in being proactive.