Early symptoms of anemia are usually nonspecific such as fatigue, weakness, light-headedness, mild dyspnea during exertion.

Other symptoms and signs may include pallor of the eyelids, tongue, nail beds, and palms, spoon-shaped nails (koilonychia), and oedema.

The restless leg syndrome during pregnancy and pica (an eating disorder to lick or eat non-food items, such as gypsum, chalk, soil, ice or paper) are also prevalent symptoms in pregnant women.

Tachycardia, hypotension and even congestive cardiac failure can occur in severe cases.

Anemia increases risk of preterm delivery. Postpartum anaemia is associated with decreased quality of life, including increased tiredness, breathlessness, palpitations and infections. Women who have postpartum anemia may also experience greater stress and depression and may be less responsive towards their infants.

References-

www.msdmanuals.com/professional/gynecology-and-obstetrics/

medind.nic.in/jav/t10/i4/javt10i4p253.pdf

www.fogsi.org/wp-content/uploads/2017/07/gcpr-recommendation-ida.pdf

The common causes of anemia during pregnancy are nutritional disorders and infections. Among nutritional disorders iron deficiency is the most common cause of anaemia globally. Other conditions such as folate, vitamin B12 and vitamin A deficiency, chronic inflammation, parasitic infections, and inherited disorders can all cause anemia.

Causes of nutritional anaemia in women:

• Insufficient quantity of iron-rich foods and, and low bioavailability of dietary iron (non-haem iron from plant sources)
• Less quantity of iron enhancers (foods rich in vitamin C such as citrus fruits) in the diet
• Excessive quantity of iron inhibitors in diet, especially during mealtimes (such as tea, coffee; calcium-rich foods)
• Iron loss during menstruation
• Poor iron stores from infancy, childhood deficiencies and adolescent anaemia
• Iron loss from post-partum haemorrhage
• Increased iron requirement during pregnancy
• Teenage pregnancy
• Repeated pregnancies with less than 2 years’ interval
• Iron loss due to parasite load (e.g., malaria, intestinal worms)
• Poor environmental sanitation and unsafe drinking water

Iron deficiency anaemia (IDA): Among women, iron deficiency prevalence is higher than among men due to menstrual iron losses and the extreme iron demands of a growing foetus during pregnancies, which are approximately two times the demands in the non-pregnant state. There is substantial increase in iron requirement during pregnancy that ranges from 0.8mg per day in the first trimester to 7.5mg per day in the third trimester.

IDA occurs when the body doesn’t have enough iron to produce adequate amounts of haemoglobin. Low bio-availability of iron in food, inadequate intake of iron rich food and iron enhancers, and excess consumption of iron inhibitors can contribute to iron deficiency anemia.

Folate deficiency anaemia– Folate is a type of B vitamin needs to produce new cells including healthy red blood cells. During pregnancy, women need extra folate and when they don’t get enough from diet, it results in to anemia. Folate deficiency can directly contribute to certain types of birth defects such as neural tube abnormalities (spina bifida). A diet low in fresh fruits, vegetables, and fortified cereals is the main cause of folate deficiency.

Vitamin B12 deficiency can also lead to anaemia during pregnancy which may contribute to birth defects such as neural tube abnormalities, and could lead to preterm labor. Folate deficiency and vitamin B-12 deficiency can often be found together.

Helminthic infestation (such as hookworm) is associated with IDA due to chronic intestinal blood loss.

Malaria causes anaemia by rupturing RBCs and suppressing production of RBCs. Malaria in pregnancy increases the risk of maternal anaemia, stillbirth, spontaneous abortion, LBW and neonatal deaths.

Sickle cell disease and thalassemia are inherited disorders of haemoglobin result in recurrent haemolytic anaemia. 

Infections: Certain chronic diseases, such as cancer, HIV/AIDS, rheumatoid arthritis, Crohn’s disease and other chronic inflammatory diseases can interfere with the production of RBCs, resulting in chronic anaemia. Kidney failure can also cause anaemia

In developing countries early onset of childbearing, high number of births, short intervals between births, and poor access to antenatal care and iron supplementation also contribute to occurrence of anemia during pregnancy.

References-

nhm.gov.in/images/pdf/programmes/wifs/guidelines/

www.fao.org/tempref/docrep/fao/005/y8346m/y8346m06.pdf

Diagnosis of anemia during pregnancy is done by the symptoms, clinical signs and investigations.

Investigations-

 (a)Hemoglobin estimation (Hb)– Haemoglobin estimation is the most practical method of diagnosing anemia. Compulsory haemoglobin estimation by Cyanmeth-haemoglobin method by using Semi-autoanalyser or photo calorimeter at 14-16 weeks, 20-24 weeks, 26-30 weeks and 30-34 weeks of pregnancy for all pregnant mothers (minimum four Hb estimations) is indicated under routine antenatal checkups. The interval between one haemoglobin estimation and another should have a minimum of four weeks.

Hemoglobin cut off for anemia during pregnancy (ICMR-1989)

 (b) Mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean cell hemoglobin concentration (MCHC), red cell distribution width (RDW), reticulocyte Hb content, % hypochromic cells, and peripheral blood smear are used to detect type of anemia. Peripheral blood should be examined for malarial parasites also.

(c)To rule out refractory anemia, urine should be checked for albumin, sugar and deposits. If deposits are more than 4-6 cells, then urine culture should be done. In areas where schistosomiasis is prevalent, urine examination for occult blood and schistosomes can be performed.

(d)Serum ferritin is a sensitive indicator of IDA in pregnant women. Concentration below 30μg/L, indicates early iron depletion.

(e)Soluble transferrin receptor (sTFR)- Its levels are increased in iron deficiency anemia

(f)Serum iron and total iron binding capacity (TIBC) are the other independent indicators of iron stores or availability.

(g)Bone marrow examination is only indicated in cases where there is no response to iron therapy after 4 weeks or for diagnosis of Kala-azar or in suspected aplastic anemia.

(h)Stool examination -As worm infestations are common causes of anemia, stool examination for ova and cysts should be done consecutively for 3 days in all cases.

References–

www.msdmanuals.com/professional/gynecology-and-obstetrics/pregnancy

www.fogsi.org/wp-content/uploads/2017/07/gcpr-recommendation-ida.pdf

As the need for iron increases during pregnancy, prophylactic oral iron therapy is given to all pregnant women with normal laboratory values. All pregnant women at 14-16th week (second trimester) should be given one tablet of Albendazole 400mg – single dose. In the anemic mother management and form of therapeutic iron supplementation depend on the duration of pregnancy and severity of anemia.

Supplementation- Interventions as suggested by Ministry of Health and Family Welfare Government of India:

(i) At 14-16 weeks –

First Hb estimation should be done at 14-16th week pregnancy during antenatal visit: 

• If the Hb is more than 11 gms, prophylactic doses of IFA tablets are given.

• If the Hb is 7.1-10.9 gms%, therapeutic doses of IFA tablets are given.

• If the Hb is less than 7 gms%, she has to be referred to CEmONC centres (Comprehensive Emergency Obstetric and New Born Care Services) for blood transfusion and further management.

(Prophylactic dose: Tab.IFA (100 mg of iron with 0.5mg of folic acid) once daily for 100 days.

Therapeutic dosage: Tab.IFA twice daily for 100 days.

(ii) At 20-24 weeks- Second Hb estimation has to be done between 20 and 24 weeks of gestation for all pregnant mothers.

• If the Hb is more than 11 gms, give prophylactic dose of IFA tablets.

• If the Hb is 9-10.9 gms%, give therapeutic dose of IFA tablets.

• If haemoglobin level is between 7.1 to 8.9 gm/dl. Intravenous (IV) Iron sucrose infusion should be given.

• If the Hb is less than 7 gms%, she has to be referred to CEmONC centres for blood transfusion and further management.

(iii) At 26-30 weeks– Third Hb estimation has to be done between 26 and 30 weeks of gestation for all pregnant mothers. For ante-natal mothers infused with iron sucrose infusion during 20-24 weeks, Hb estimation has to be done after one month.

• If the Hb is more than 11 gms, assure and counsel to continue with prophylactic dose of IFA tablets.

• If the Hb is 9-10.9 gms%, assure and counsel the mother for further improvement of Hb% and continue with therapeutic dose of IFA tablets.

• If the Hb is 7.1 -8.9 gms%

• For mothers who received iron sucrose infusion, give two top up doses of 100 mgs of Iron sucrose infusion with 2-4 days’ interval between each infusion.
• For mothers who had not received injection iron sucrose earlier during current pregnancy, give four doses of iron sucrose injection (100 mg in 100 ml of normal saline infused over 20 -30 minutes once a day x 4 days over a period of 2 weeks with 2-4 days of interval between each infusion)

• If the Hb is less than 7 gms%, she has to be referred to CEmONC centres for blood transfusion and further management.

(iv) At 30-34 weeks

All antenatal mothers have to be subjected to Hb estimation at 30-34 weeks irrespective of mode of management of anaemia previously.

• If the Hb is more than 11 gms, assure and counsel to continue with prophylactic dose of IFA tablets

• If the Hb is 9-10.9 gms%, assure and counsel the mother for further improvement of Hb% and continue with therapeutic dose of IFA tablets.

• If the Hb checked at 30-34 weeks does not improve (still less than 9 gms%), refer to higher institution for blood transfusion and further management.

Vitamin supplementation– Vitamin B12 and Vitamin C supplementation is also given along with iron supplementation.

Diet counselling-All the mothers should be encouraged to take iron rich foods and avoid coffee and tea just after meals.  

References-

apps.who.int/iris/bitstream/handle/10665/

www.nrhmtn.gov.in/guideline/RGPMA.pdf

www.nhmmp.gov.in/WebContent/MPTast/MaternalHealth/

Anaemia is a multi-factorial disorder that requires a multi-pronged approach for its prevention. As most women start their pregnancy with low iron stores and anaemia, preventive interventions should start early in life specially with adolescent girls and women in child bearing age. Good nutrition is the best way to prevent anemia.

Nutrition education programmes should be strengthened in the community/ health care facilities with the objective to improve the amount and bioavailability of iron in Indian diet. Family should be made aware about the different plans to meet the requirement of iron rich foods, role of iron inhibitors and enhancers in the diet with changing dietary habits according to various cultural, agricultural and socio-economic environment in the country.

Preventive measures include nutrition education about increase iron intake through food-based approaches namely- dietary diversification, food fortification with iron, iron supplementation; and improved health services and sanitation.

 (i) Diet diversification–

With the diet diversification consumption of iron in the diet can be increased with adopting following measures:

(a) Promotion of eating foods rich in iron such as green leafy vegetables, lentils, eggs, nuts and seeds, beans, lean red meat, fruits like banana, melon.

Some common sources of iron are– Chickpea (Chana Sag), Spinach (Palak), Amaranth (Kantewali Chaulai), Onion Stalks (Pyaz ki kali), Mustard Leaves (Sarson ka sag), Fenugreek Leaves (Methi), Mint (Pudina), Lentil (Dal), Soyabean, Bengal Gram (Whole Kala chana), Gingelly Seeds (Til), Black Gram Dal, (Urad Dal), Pumpkin (Seethaphal), Plantain Green (Kuchcha Kela), Water Melon (Tarbooz), Mutton (Gosht).

(b) By increasing use of enhancers such as ascorbic acid (vitamin C) in the diet to enhance iron absorption. Some of the rich sources of vitamin C are guava, orange, lemon, cabbage, green leafy vegetables, amla, bell peppers, kiwi, melons.

(c) By encouraging the use of a number of common household processing methods such as germination, malting, and fermentation which can enhance iron absorption by increasing the vitamin C content; and by lowering the tannin and phytic acid content, or both.

(d) Addition of a small portion of meat, poultry, or fish will increase the total iron content as well as the amount of bio-available iron.

(e) To encourage the consumption of tea, coffee, chocolate, or herbal teas at times other than with meals as these substances prevents abortion of iron from the gut.

(ii) Food fortification refers to the addition of micronutrients to processed foods so as to improve the nutritional quality of the food supply and provide a public health benefit with minimal risk to health. Iron fortified Iodized Salt (double fortified salt) has been approved by the Government of India as Food fortification to prevent IDA.

(iii)Supplementation- Interventions implemented by Ministry of Health and Family Welfare

The National Iron+ Initiative is an attempt to prevent IDA comprehensively across all life stages. There are age specific interventions with iron and folic Acid supplementation (IFA) and deworming for improving the haemoglobin levels and reducing the prevalence of anaemia for all age groups including children 6-59 months, 5 – 10 years, adolescent girls and boys (11-19 years), pregnant and lactating women and women in reproductive age group (20 – 49 years).

• Adolescents 11–19 years receive weekly dose of 100 mg elemental iron and 500 mcg folic acid with biannual de-worming in school itself.
• Women in reproductive age group (20–49 Years): ASHA provides IFA supplementation with 100 mg elemental iron and 500 mcg of folic acid throughout the calendar year, i.e., 52 weeks, each year and albendazole (400 mg) tablets for biannual de-worming during doorstep distribution of contraceptives.
• Pregnant and lactating women are provided with 100 mg of elemental iron and 500 mcg of folic acid daily for 100 days during routine antenatal visits at subcentre/ PHC/CHC/DH followed by same dose for 100 days in the post-partum period.

Long Lasting Insecticide Nets (LLINs) are also provided to pregnant women.

Oral antihelminthic treatment can also be given to pregnant women in the second trimester to control worm infestation.

Pradhan Mantri Surakshit Matritva Abhiyan: The programme aims to provide assured comprehensive and quality antenatal care, free of cost, universally to all pregnant women on the 9^th of every month, that will also help in reducing prevalence of anemia in pregnant mothers.

Programmes and Schemes of other Ministries:

Integrated Child Development Services (ICDS) Scheme by Ministry of Women and Child Development (MWCD) provides supplementary nutrition (600 Kcal and 18–20 grams of protein) to pregnant and lactating mother.

Sabla is a scheme of MWCD, where supplementary nutrition is provided to adolescent girls (AGs) in the form of take home rations (THR) or hot cooked meals. Under this scheme, each AG will be given at least 600 calories and 18–20 grams of protein and the recommended daily intake of micronutrients for 300 days in a year.

Swacch Bharat Mission by improving environmental sanitation along with other factors such as provision of safe drinking water, personal hygiene, better education and alleviation of poverty can prevent anemia in general population.

National Nutrition Mission is launched under the oversight of the Ministry of Women and Child Development in March 2018 with the aim to reduce anaemia among young children, adolescent girls and women of reproductive age (15–49 years) by one third of NFHS4 levels by 2022.

References-

www.fogsi.org/wp-content/uploads/2017/07/gcpr-recommendation-ida.pdf

medind.nic.in/jav/t10/i4/javt10i4p253.pdf,

www.who-seajph.org/article.asp?issn=2224-

nhm.gov.in/images/pdf/programmes/wifs/guidelines/

pib.nic.in/newsite/PrintRelease.aspx?relid=71725

pib.nic.in/newsite/PrintRelease.aspx?relid=137953