Anemia during the Pregnancy: The Management and Outcomes Depending on the Etiology

Background: Anemia is the most common hematological abnormality in pregnant women. The main cause of anemia in pregnancy and puerperium is the deficiency of iron. Iron requirements increase during pregnancy, and a failure to maintain sufficient levels of iron may result in adverse maternal-fetal consequences. Antenatal iron deficiency anemia (IDA) must be adequately and safely treated to avoid complications during the pregnancy. Other causes of anemia in pregnancy require early diagnosis and precise therapy.

Aim. Establishment of algorithms for management of pregnancy, delivery and postpartum period in different types of anemia is crucial to pregnancy outcomes. We have been optimizing strategies for the management of pregnant patients with anemia.

Results: From 2012 to 2014 we observed 1284 pregnant women aged 19-44 years. 312(24,3%) of them had decreased hemoglobin (Hb) during the pregnancy. IDA was diagnosed in 267(85,6%), myeloprolyferative neoplasms (MPN) –18(5,8%), hemoglobinopathies –7(2,2%), hematological malignancies (MHD) in remission –6(1,9%), folic acid or B12 deficiency –5(1,6%), paroxysmal nocturnal hemoglobinuria (PNH) –4(1,3%), aplastic anemia (AA) –3 (1%), myelodysplastic syndrome (MDS) –2(0,6%). Hb level was below 90 g/l in 58(18,6%) patients. The most of anemia cases were identified during the pregnancy -187(59,9%), others existed before that. For IDA diagnosis we used the serum ferritin level, ratio of serum iron and total iron-binding capacity and transferrin. 88 (33%) of IDA patients had already had IDA during their lifespan. IDA was treated with ferric carboxymaltose intravenously weekly after the first trimester of pregnancy in Hb up to 90 g/l (the course summary dose –1500-2000 mg). In other cases we administered ferric (III) hydroxide polymaltosate per os (100-200 mg daily during 1-3 months). Hb was normalized by delivery in 216 (80,9%) patients. We have analyzed the outcomes of pregnancy in IDA. The most common complaint was impaired physical performance (91%). Spontaneous miscarriages were registered in 2(0,8%) cases. We did not observe a neonatal mortality. 242 (90,6%) pregnancies ended up with a birth of full-term healthy infants without birth defects. Preterm birth occurred in 23(8,6%) cases, IDA persisted in 19 (82,6%) of them. 38(14,3%) of patients with IDA in third trimester reported maternal and fetal complications, such as chronic placental insufficiency (36,8%), fetal growth retardation syndrome and low birth weight for gestational age (57,9%), placental abruption (5,3%), postpartum hemorrhage (10,5%). IDA was diagnosed in 14(5,3%) neonates and 26(9,8%) women noted the reduced lactation. Anemia in postpartum period was registered in 43(16,2%) patients. Also we have analyzed outcomes of 44 pregnancies in women with non-IDA anemia. The majority of them were patients remained in complete or partial remission of MHD, MPN, AA, PNH, MDS, who underwent the special treatment. Some of them required special treatment during the pregnancy (interferon in MPN, eculizumab in PNH). The non-severe types of hemoglobinopathies required observation and supportive care until postpartum period. Macrocytic anemia with folic or B12 deficiency was successfully treated with folic acid or cyanocobàlamin. The level of Hb by delivery was below 110 g/l in 32(72,7%) non-IDA women (blood transfusion required 2 patients). 40(90,9%) of pregnancies ended up with a birth of full-term infants. Preterm birth occurred in 4(9,1%) cases. In our study exposure to special therapy was not associated with congenital anomalies, and no spontaneous miscarriages were registered. The fetal growth retardation syndrome and low birth weight registered in 3(6,8%) patients. No hemorrhagic complications during labor or postpartum period have been observed.

Conclusion: Despite the regular antenatal observation, maternal anemia is still high. Anemia during pregnancy is a diverse group of disorders with varied pathophysiology, treatment options and overall prognosis. IDA is the most frequent anemia reason. We have concluded that the prognosis for pregnant women timely treated for IDA is similar to that of healthy women. Mothers with persistent IDA reported different pregnancy complications. The modern IDA treatment approaches allow the majority of patients to achieve the effect in shortest time. Another anemia reasons require diagnosis and special treatment of underlying disease.