Anaemia in Pregnancy

Anemia or anaemia, is derived from a Greek word which means "without blood", it is a deficiency of red blood cells and/or hemoglobin which occurs either due to the reduced production, an increased loss of red blood cells or excessive blood cell destruction. Hemoglobin (the oxygen-carrying protein in the red blood cells) has to be present to ensure adequate oxygenation of all body tissues and organs. Anaemia results in a reduced ability of blood to transfer oxygen to the tissues. Iron deficiency & folate deficiency anaemia commonly affects pregnant women

      Anemia is common in pregnancy & it has been described as the second leading cause of maternal death. According to WHO guidelines, anaemia during pregnancy is considered when the haemoglobin level < 11.0 gm in pregnancy, but as per the Indian standard it is considered when haemoglobin level < 10.5 gm. Any patient with a haemoglobin of less than 11 gm/dl to 11.5 gm/dl at the start of pregnancy will be treated as anaemic. The reason is that as the pregnancy progresses, the blood is diluted and the woman will become anaemic. The dilution of blood in pregnancy is a natural process and starts at approximately the eighth week of pregnancy and progresses until the 32nd to 34th week of pregnancy. Hence, anaemia during pregnancy usually occurs in the later stages of pregnancy when the foetus is becoming bigger, heavier and has more blood circulating in his or her body, therefore requiring greater red cell and blood production on the part of the mother. A woman's normal haemoglobin level in pregnancy is 11.5-15g/dl

      During pregnancy, women should be especially aware of the symptoms of anemia, as an adult female loses an average of two milligrams of iron daily. Therefore, she must intake a similar quantity of iron in order to make up for this loss. Additionally, a woman loses approximately 500 milligrams of iron with each pregnancy, compared to a loss of 4-100 milligrams of iron with each period.

      To produce red blood cells, the body needs (among other things) iron, vitamin B12 and folic acid. If there is a lack of one or more of these ingredients, anaemia shall develop. A key component of Safe Motherhood is the eradication of anemia during pregnancy.

REQUIREMENT OF IRON -

 The recommended daily intake of iron for an adult woman is 18mg per day. During pregnancy, though, this increases to 27mg per day due to the rise in maternal blood volume.

Iron requirements during pregnancy are as follows:

·         1st Trimester - 0.8mg daily

·         2nd Trimester - 4 to 5mg daily

·         3rd Trimester - 6mg daily

      The total iron requirement for a normal pregnancy in an average size woman is approximately 1,000mg

INCIDENCE -

      India continues to hold the dubious distinction of being one of the countries with the highest prevalence of anaemia during pregnancy. Its prevalence according to WHO is 74.3%. In some populations, 80% of pregnant women are anaemic. Roughly 47% of non-pregnant women and 60% of pregnant women have anemia worldwide. It is estimated that 200 women die each year in pregnancy and childbirth due to anaemia related complications. One in five that is 20% of all maternal deaths are attributed to anaemia during pregnancy.

CLASSIFICATION

      There are several different types of anemia. The most common are iron deficiency anemia, megaloblastic anemia (caused by lack of vitamin B) and anemia of chronic disease.

      In the morphological approach, anemia is classified by the size of red blood cells. If the cells are smaller than normal, the anemia is said to be microcytic; if they are normal size, normocytic; and if they are larger than normal, the anemia is classified as macrocytic. Microcytic anemia is often the result of iron deficiency. Megaloblastic anemia is the most common cause of macrocytic anemia. Megaloblastic anemia is due to the deficiency of either vitamin B12 or folic acid or both.

ANAEMIA

Fig: Classification of anaemia

RISK FACTORS

   A pregnant female carries the maximum risk of developing anaemia. It is observed that 10-15% of pregnant women will develop it, compared to 3-4% of women who aren't pregnant develop anaemia.

1. Heavy periods prior to pregnancy.
2. Inadequate gap between pregnancies.
3. Women from low socio-economic groups and teenagers.
4. Frequent nausea & vomiting due to morning sickness
5. Women carrying more than one child in the womb.
6. Poor nutrition.

Etiology of the disease

Anemia in pregnancy in women is multifactorial in etiology.

- Lack of iron.

- Folic acid deficiency.

- Vitamin deficiencies.

- Repeated pregnancies at short intervals.

- Pregnancy carrying twins or triplets.

- Dietary deficiency.

- Worm infestations.

- Certain chronic conditions 
- Bleeding disorders.

- Infections.

- Hereditary conditions.

- Malabsorption.

Clinical features

      Anemia goes undetected in many people, and symptoms can be vague. If the woman is otherwise healthy, she will rarely have any symptoms of anaemia unless her haemoglobin is below 8g/dl. However, clinical features of anemia include:

·         General weakness, fatigue & exhaustion.

·         Pallor and palpitation.

·         Dizziness.

·         Fainting

·         Breathlessness on exertion (in severe cases).

·         Chest pains (in severe cases)

·         Rapid heart beat.

·         Headaches.

·         Confusion, personality changes& depression.

·         Slow healing.

·         Abdominal pain.

·         Weight loss & loss of appetite

·         Loss of sex drive.

·         Generalized swelling of body.

·         Sometimes even heart failure can occur.

·         Low blood pressure

·         Numbness and tingling in the hands and feet

·         Smooth shiny tongue and tenderness of the skin at the corners of the mouth in advanced cases of iron deficiency anaemia.

Investigations

Apart from the clinical symptoms, anaemia is usually detected during antenatal screening by the following investigations:-

1. Haemogram includes haemoglobin %, red cell count, Hb conc, MCV & peripheral blood film to know the type of deficiency.
2. More specific test like S. Ferritin and TIBC levels may be required to define the exact cause of anaemia.
3. Iron deficiency anaemia can be confirmed by measuring the amount of storage iron as well as the levels of iron binding proteins in the blood.
4. Diagnosis of folate deficiency is confirmed by estimating the red blood cell folate levels.
5. Reticulocyte count which is a nearly direct measure of the bone marrow's capacity to produce new red blood cells, and is thus the most used method of evaluating the problem of production of RBCs.
6. Other screening blood tests that might identify the cause of fatigue are serum glucose, ESR, serum iron, RBC folate level, serum vitamin B12, renal function tests (e.g. serum creatinine) and electrolytes.

Blood tests are usually performed again between the 24th and 28th week of pregnancy, as it is more likely that a woman will develop anemia later in pregnancy.

COMPLICATIONS

Possible complications of anaemia are:-

Maternal Complications-

·         Premature labour.

·         Increased susceptibility to infection.

·         Likelihood of postpartum transfusion.

·         Reduced physical and mental performance.

·         Difficulty in breathing, palpitations and angina.

·         Severe anemia may result in death from hypoxia and heart failure.

·         Brittle or rigid fingernails.

·         Cold intolerance.

·         Maternal mortality.

Foetal/Infant Complications-

• Intrauterine growth retardation (poor development of baby).
• Low birth weight.
• Impaired physical growth.
• Can be born with neural-tube defects, such as spina bifida.
• Fetal mortality or still birth.
• Damaging the brain of the fetus, which could cause a possible permanent impairment in mental ability of school children and adolescents.
• Increases the child's risk of developing anemia during infancy.

General Management

      Treatment depends on the cause and severity of the anemia. After examining the expectant mother, necessary supplements required for the treatment of anaemia shall be advised.

      If anaemia is caused by lack of iron, it is treated with iron supplements like ferrous fumerate, glycerate, glycinate or ferrous sulphate tablets. These supplements should not be taken more than twice daily, since the side effects of iron are stomach upsets, bad taste, black stools and constipation which are problematic in pregnancy. Hence, the iron supplements should be taken with meals and should be avoided at bedtime to limit the side effects. If the anaemia is due to folic acid deficiency, it is treated with folic acid supplements (1 to 5 mg once a day). Vitamin C supplements to be given to aid in absorption of iron.

      In severe anemia (Hb < 6.0 gms) blood transfusion may also be needed to prevent risk of heart failure. Mild exercise should be done every day. Second hand smoke to be avoided. Exposure to lead and other toxic metals such as aluminum, cadmium and mercury should be minimised.

Diet and anemia

      Most cases of anemia will respond well to nutritional therapy. Adequate intake of healthy and balanced diet with plenty of iron-rich, folic acid & vitamin rich foods such as lean red meat, green leafy vegetables, whole grains, cereals, nuts, sardines, dried fruit, dried beans, dried apricots, dried prunes, dried raisins, almonds, molasses and spinach should be taken. In extreme cases of anemia, consumption of beef liver, oysters, lamb or chicken may be introduced.

      Absorption of iron from food is enhanced if the intake of vitamin C is adequate. Dietary sources of vitamin C include citrus fruits and juices, tomatoes, broccoli and cauliflower. Dietary sources of Vitamin B12 include liver, meats, eggs, tuna, salmon, mackerel and cheese. Good food sources of folic acid include green leafy vegetables, beans, lentils, orange juice and grains. Folic acid supplementation can mask vitamin B12 deficiency, so always vitamin B12 should be taken with folic acid.

      Absorption of iron from food is reduced by certain substances such as calcium, vitamin E, zinc, antacids, wheat bran, chocolates, ice cream, soft drinks, tea, alcohol, caffeine, etc. Hence these substances should be avoided with food. Foods high in Oxalic acid should also be avoided as Oxalic acid interferes with iron absorption. Foods such as almonds, cashews, chocolate, kale, rhubarb, sorrel, spinach, Swiss chard and most nuts and beans are high in oxalic acid.

Complementary Therapies- 
HERBAL TREATMENT:- 
Various herbs are useful in the treatment of anaemia. The following herbal therapies can be taken for one to three months and then reassessed.

1) Blackstrap molasses, also known as pregnancy tea (1 tbsp. per day in a cup of hot water), is a good source of iron, B vitamins, minerals, and is also a very gentle laxative.

2) Spirulina, or blue-green algae, has been used successfully to treat both microcytic and macrocytic anemias. Dose is 1 helping tsp. per day.

3) Alfalfa (Medicago sativa), dandelion (Taraxacum officinale) root or leaf, burdock (Arctium lappa), and yellowdock (Rumex crispus) have long been used to fortify and cleanse the blood. For mild cases of anemia, they may help bring levels of hemoglobin into normal range. Dosage is 1 tbsp. per cup of water. Simmer roots for 20 minutes and leaves for 5 minutes. A single herb, or a combination of these four herbs, may be used.

4) Gentian ( Gentiana lutea) is often used to stimulate the digestive system & to help in easy absorption of iron and other nutrients. Add 1 tsp. powdered dried rhizome to 3 cups of water. Take 1 tbs. about a half hour before eating.

5) Other herbs that can be used in the treatment of anemia include bilberry, burdock root, cherry, chive, dog guai, goldenseal, grape skins, hawthorn berry, horsetail, mullein, parsley, nettle, Oregon grape root, pau d'arco, red raspberry, shepherd's purse, watercress, and yellow dock root.

Ayurvedic Treatment-

Add a teaspoon of turmeric to a cup of plain yogurt. Eat this mixture on an empty stomach in the morning or afternoon.

Reflexology: When working on your hands or feet, focus on the spleen and liver reflex points.

Juice Therapy: Focus on vegetables that are high in iron. Blend it with juices high in Vitamin C.

Homoeopathic Management

      Homeopathy is ideal for pregnant women as it is a gentle, safe, rapid & highly effective system of medicine. Homeopathy in pregnant females is not harmful to their unborn child and it works with their bodies natural defences. There are remedies given to combat the tiredness & to boost the energy. Homeopathy offers a number of remedies that may be helpful in treating anemia. Homeopathy considers anemia as the symptomatic result of some other underlying condition and will treat that condition.

      Before prescribing a remedy, homeopaths should take into account a person's constitutional type and then accordingly determine the most appropriate treatment for each individual. Indications of some of the commonly used homoeopathic medicines are as follows:-

Ferrum metallicum is the essential remedy for anaemia from almost any cause, but will not cure every case of anaemia; careful individualization is necessary. Ferrum shall be indicated when there is appearance of plethora followed by paleness or earthiness of the face and puffiness of the extremities. Mucous membranes are pale. Patient is robust, chilly, oversensitive & easily exhausted. Vomiting of food after eating may occur. In very stubborn cases sometimes Ferrum phosphoricum may serve better than Ferrum metallicum. Schuessler recommends first Calcarea phosphorica, then Ferrum phosphoricum.

Ferrum Phos follows Calcarea phos. as soon as improvement of the general health sets in. There is a want of red blood in the system. This remedy, by its power of attracting oxygen, colors the new blood-cells red and enriches them after they have been supplied by Calcarea phos.

Pulsatilla is the great antidote to Iron, and hence is indicated in the anaemic condition produced by large or continued doses of it. The system is relaxed and worn out; patient is chilly & still feels better in the fresh air, suffers from gastric derangements. Chloro-anaemic, peevish women with dizziness on rising & absence of thirst. Slow phlegmatic temperament; after failure of iron and China. Cyclamen, which is similar in many respects, differ from Pulsatilla in dreading the fresh air.

Cinchona is the chief remedy for anaemia resulting from loss of fluids, as in lactation or haemorrhage, or from all exhausting discharges, long-lasting diarrhoea, and sexual excesses and loss of semen. The quality of the blood is actually poorer in cases calling for Cinchona. Symptoms are oversensitivity, chilliness, exhaustion, heaviness of the head, loss of sight, fainting, ringing in the ears, pale sallow complexion, sour belching, poor digestion and bloated abdomen. The patient is sensitive to draughts of air yet wants to be fanned.

Natrum muriaticum is one of the best remedies in anaemic conditions due to loss of fluids, especially in women who suffer from chronic diseases with a dead, dirty-looking skin. There is paleness, and, in spite of the fact that the patient eats well, there is emaciation. Attacks of throbbing headache and dyspnoea, especially on going up stairs. Constipation, depression of spirits and consolation aggravates. With these symptoms there is much palpitation, fluttering and intermittent action of the heart. The hypochondriasis in these cases is marked. Dry mouth and lips & tendency to cold sores.

Chininum arsenicosum is sometimes prescribed for anaemia

Acetic acid suits anaemic nursing women, with waxy skin and thirst.

Calcarea carbonica is useful in anaemic and debilitated conditions. Indicated in psoric, scrofulous or tubercular diathesis and the general symptoms of the drug are disgust for meat, craving for sour and indigestible things, swelling of abdomen, vertigo and palpitation on going upstairs. Patient is in a state of worry. Constantly imagining calamities.

 Calcarea phos indicated in anaemia in excessive child- bearing females. This remedy acts by supplying new blood cells. Pains and cramps dependent on anaemic conditions. Waxy appearance of the skin due to anaemia. Constant headache and ringing in ears. A constitutional remedy in cases where nutrition is manifestly defective.

Alumina is indicated in anemia from improper nourishment with abnormal craving for indigestible substances, such as slate pencils, chalk, etc.

Nux vomica may be indicated in anaemic conditions when due to gastro-intestinal derangements.

Arsenicum indicated in cases of pernicious anaemia or in anaemias due to a malarial of toxic influence. Indications are excessive prostration, violent and irregular palpitation, marked appetite for acids and brandy, extreme anxiety and rapid emaciation. Irritable stomach with intense thirst.

Helonias is an excellent remedy for anaemia and chlorosis. Suits especially in anaemia from prolonged haemorrhage in women enervated by indolence and luxury, or such as are worn out with hard work; they are too tired to sleep and the strained muscles burn and ache. Characteristic modality is that the patient is better when the attention is engaged. Anaemia is associated with disturbances in the urinary and sexual organs. Tired, anaemic females with backache require Helonias.

Aletris F indicated when debility of females from protracted illness; no organic disease. Power and energy of mind and body are weakened. Patients are tired, dull, heavy & confused.

Secale produces a progressive general anaemia. It is shown by the peculiar cachexia of anaemia, pale, bloodless, jaundiced color. By its effect on the blood corpuscles it produces a general anaemia, threatening not only the life of a part, but vitiating the whole life of the bodily economy. It is a sort of a mechanical anaemia.

Kali carbonicum is one of the most important remedies in anaemia, weak heart, sweats backache, especially with female complaints.

Picric ac. indicated when anaemia is coupled with mental overload

Sepia indicated in Chloro-anaemia with irritability and complete aversion to her usual household duties; pelvic congestion.

MIASMATIC BACKGROUND-

Anaemia been a functional disease is psoric in nature.

PROGNOSIS

   As long as the anaemia is treated and corrected, there should be no problem.

Prevention

      By far the best "cure" for anaemia is prevention.

1) Since nutritional deficiency is the commonest cause of anaemia. A diet rich in iron, vitamins and folic acid is required.

2) Worm infestation can be prevented by washing hands properly, washing vegetables, fruits thoroughly before cooking or eating & not passing stools in open /unhygienic areas.

3) Spacing childbirth- At least 2 yrs interval is needed to replenish the iron store depleted during pregnancy.

4) Taking oral iron tablets regularly from 4th month of pregnancy.

5) It is routinely advised to women planning pregnancy to take folic acid supplement for the first 12 weeks of pregnancy and preferably starting before conception. This reduces the risk of spinal cord defects (spina bifida) developing in the foetus.

6) Avoid drugs that can have adverse effects on your gastrointestinal system and avoid excessive alcohol intake if one or both of these are the cause of your anemia.

7) Severe anemia is greatly reduced in patients who have received regular malaria prophylaxis during pregnancy.

8) Women to visit the antenatal clinic as soon as they know they are pregnant. They should take their iron folate tablets daily throughout their pregnancy and even six weeks after delivery.

9. Pregnant women should obtain malaria and de-worming treatments to ensure that their babies develop well.

REFERENCES -

1. Therapeutics- Practical Homoeopathic Therapeutics by Dewey W.A.
2. Therapeutics- ABC Manual of Materia Medica and Therapeutics (therap part) by Clarke G. H.
3. Therapeutics- Twelve Tissue Remedies Comprising of Theory,
4. Therapeutics, Applications, Materia Medica and Complete Repertory of Tissue Remedies [Therap Part] by Boericke & Dewey.
5. Gynaecology- Dawn.
6. www.pregnancy-info.net/diet
7. www.alternativehealth.co.nz/cancer/Anemia
8. www.netdoctor.co.uk/diseases/facts/anaemiapregnancy
9. www.health24.com/Woman/Common_conditions/