FIGURE 56-3 This peripheral blood smear from a women with iron-deficiency anemia contains many scattered microcytic and hypochromic red cells with characteristic central pallor. These exhibit moderate anisopoikilocytosis, namely, varying sizes and shapes including occasional elliptocytes, which can be oval or pencil-shaped. (Reproduced with permission from Werner Cl, Richardson Dl, Chang SY, et al (eds): Perioperative Considerations. In Williams Gynecology Study Guide, 3rd ed. New York, McGrawHill Education, 201o6: Photo contributor: Dr. Weina Chen.) he initial evaluation of a pregnant woman with moderate anemia includes measurements of hemoglobin, hematocrit, and red cell indices; careful examination of a peripheral blood smear; a sickle-cell preparation if the woman has African origin; and evaluation of serum iron or ferritin levels, or both (Appendix p. 1255). Serum ferritin levels normally decline during pregnancy, and levels < 10 to 15 mg/L confirm iron-deficiency anemia.
When pregnant women with moderate iron-deficiency anemia are given adequate iron therapy, a hematological response is detected by an elevated reticulocyte count. The rate of rise of hemoglobin concentration or hematocrit is typically slower than in nonpregnant women due to the increasing and larger blood volumes during pregnancy.
Routinely in pregnancy, daily oral supplementation with 30 to 60 of iron and 400 �g of folic acid is recommended (World Health Organization, 2012). A Cochrane review found that intermittent oral iron supplementation may also be appropriate (Pena-Rosas, 2015). For iron-deficiency anemia, resolution and restitution of iron stores can be accomplished with simple iron salts that provide approximately 200 mg daily of elemental iron. hese include ferrous sulfate, fumarate, or gluconate. If a woman cannot or will not take oral iron preparations, then parenteral therapy is given. Although both are administered intravenously, ferrous sucrose is safer than iron-dextran (American College of Obstetricians and Gynecologists, 2017a; Camaschella, 2015; Shi, 2015). Hemoglobin and ferritin levels show equivalent rises in women treated with either oral or parenteral iron therapy (Breymann, 2017; Daru, 20r16).
In early pregnancy, anemia caused by acute blood loss is common with abortion, ectopic pregnancy, and hydatidiform mole. Postpartum, anemia commonly stems from obstetrical hemorrhage. Massive hemorrhage demands immediate treatment as described in Chapter 41 (p. 788). If a moderately anemic woman-defined by a hemoglobin value of approximately 7 g/dL-is hemodynamically stable, is able to ambulate without adverse symptoms, and is not septic, then blood transfusions are not indicated. Instead, oral iron therapy is given for at least 3 months (Kraft, 2005) .
• Anemia Associated with Chronic Disease
Various disorders, such as chronic renal insuiciency, cancer and chemotherapy, human immunodeficiency virus (HIV) infection, and chronic inflammation result in moderate and sometimes severe anemia, usually with slightly hypochromic and microcytic erythrocytes. It is the second most common form of anemia worldwide (Weiss, 2005).
During pregnancy, women with chronic disorders may develop anemia for the first time. In those with preexisting anemia, it may be intensified as plasma volume expands. Causes include chronic renal insuiciency, inlammatory bowel disease, and connective-tissue disorders. Others are granulomatous infections, malignant neoplasms, rheumatoid arthritis, and chronic suppurative conditions.