Low blood count when pregnant

Anemia in Pregnancy: Causes, Symptoms, and Treatment

Written by Jen Uscher

Types of Anemia During Pregnancy

Several types of anemia can develop during pregnancy. These include:

Iron-deficiency anemia
Folate-deficiency anemia
Vitamin B12 deficiency

Here's why these types of anemia may develop:

Iron-deficiency anemia. This type of anemia occurs when the body doesn't have enough iron to produce adequate amounts of hemoglobin. That's a protein in red blood cells. It carries oxygen from the lungs to the rest of the body.

In iron-deficiency anemia, the blood cannot carry enough oxygen to tissues throughout the body.

Iron deficiency is the most common cause of anemia in pregnancy.

Folate-deficiency anemia. Folate is the vitamin found naturally in certain foods like green leafy vegetables A type of B vitamin, the body needs folate to produce new cells, including healthy red blood cells.

During pregnancy, women need extra folate. But sometimes they don't get enough from their diet. When that happens, the body can't make enough normal red blood cells to transport oxygen to tissues throughout the body. Man made supplements of folate are called folic acid.

Folate deficiency can directly contribute to certain types of birth defects, such as neural tube abnormalities (spina bifida) and low birth weight.

Vitamin B12 deficiency. The body needs vitamin B12 to form healthy red blood cells. When a pregnant woman doesn't get enough vitamin B12 from their diet, their body can't produce enough healthy red blood cells. Women who don't eat meat, poultry, dairy products, and eggs have a greater risk of developing vitamin B12 deficiency, which may contribute to birth defects, such as neural tube abnormalities, and could lead to preterm labor.

Blood loss during and after delivery can also cause anemia.

Risk Factors for Anemia in Pregnancy

All pregnant women are at risk for becoming anemic. That's because they need more iron and folic acid than usual. But the risk is higher if you:

Are pregnant with multiples (more than one child)
Have had two pregnancies close together
Vomit a lot because of morning sickness
Are a pregnant teenager
Don't eat enough foods that are rich in iron
Had anemia before you became pregnant

Symptoms of Anemia During Pregnancy

The most common symptoms of anemia during pregnancy are:

Pale skin, lips, and nails
Feeling tired or weak
Dizziness
Shortness of breath
Rapid heartbeat
Trouble concentrating

In the early stages of anemia, you may not have obvious symptoms. And many of the symptoms are ones that you might have while pregnant even if you're not anemic. So be sure to get routine blood tests to check for anemia at your prenatal appointments.

Risks of Anemia in Pregnancy

Severe or untreated iron-deficiency anemia during pregnancy can increase your risk of having:

A preterm or low-birth-weight baby
A blood transfusion (if you lose a significant amount of blood during delivery)
Postpartum depression
A baby with anemia
A child with developmental delays

Untreated folate deficiency can increase your risk of having a:

Preterm or low-birth-weight baby
Baby with a serious birth defect of the spine or brain (neural tube defects)

Untreated vitamin B12 deficiency can also raise your risk of having a baby with neural tube defects.

Tests for Anemia

During your first prenatal appointment, you'll get a blood test so your doctor can check whether you have anemia. Blood tests typically include:

Hemoglobin test. It measures the amount of hemoglobin -- an iron-rich protein in red blood cells that carries oxygen from the lungs to tissues in the body.
Hematocrit test. It measures the percentage of red blood cells in a sample of blood.

If you have lower than normal levels of hemoglobin or hematocrit, you may have iron-deficiency anemia. Your doctor may check other blood tests to determine if you have iron deficiency or another cause for your anemia.

Even if you don't have anemia at the beginning of your pregnancy, your doctor will most likely recommend that you get another blood test to check for anemia in your second or third trimester.

Treatment for Anemia

If you are anemic during your pregnancy, you may need to start taking an iron supplement and/or folic acid supplement in addition to your prenatal vitamins. Your doctor may also suggest that you add more foods that are high in iron and folic acid to your diet.

In addition, you'll be asked to return for another blood test after a specific period of time so your doctor can check that your hemoglobin and hematocrit levels are improving.

To treat vitamin B12 deficiency, your doctor may recommend that you take a vitamin B12 supplement.

The doctor may also recommend that you include more animal foods in your diet, such as:

meat
eggs
dairy products

Your OB may refer you to a hematologist, a doctor who specializes in anemia/ blood issues. The specialist may see you throughout the pregnancy and help your OB manage the anemia.

Preventing Anemia

To prevent anemia during pregnancy, make sure you get enough iron. Eat well-balanced meals and add more foods that are high in iron to your diet.

Aim for at least three servings a day of iron-rich foods, such as:

lean red meat, poultry, and fish
leafy, dark green vegetables (such as spinach, broccoli, and kale)
iron-enriched cereals and grains
beans, lentils, and tofu
nuts and seeds
eggs

Foods that are high in vitamin C can help your body absorb more iron. These include:

citrus fruits and juices
strawberries
kiwis
tomatoes
bell peppers

Try eating those foods at the same time that you eat iron-rich foods. For example, you could drink a glass of orange juice and eat an iron-fortified cereal for breakfast.

Also, choose foods that are high in folate to help prevent folate deficiency. These include:

leafy green vegetables
citrus fruits and juices
dried beans
breads and cereals fortified with folic acid

Follow your doctor's instructions for taking a prenatal vitamin that contains a sufficient amount of iron and folic acid.

Vegetarians and vegans should talk with their doctor about whether they should take a vitamin B12 supplement when they're pregnant and breastfeeding.

Health & Pregnancy Guide

Getting Pregnant
First Trimester
Second Trimester
Third Trimester
Labor and Delivery
Pregnancy Complications
All Guide Topics

Anemia in Pregnancy | Cedars-Sinai

ABOUT CAUSES DIAGNOSIS TREATMENT NEXT STEPS

What is anemia?

Anemia is when your blood has too few red blood cells. Having too few red blood cells makes it harder for your blood to carry oxygen or iron. This can affect how cells work in nerves and muscles. During pregnancy, your baby also needs your blood.

Who is at risk for anemia during pregnancy?

Women are more likely to get anemia during pregnancy if they:

Are strict vegetarians or vegans. They are at greater risk of having a vitamin B12 deficiency.
Have celiac disease or Crohn's disease, or have had weight loss surgery where the stomach or part of the stomach has been removed

Women are more likely to get iron-deficiency anemia in pregnancy if they:

Have 2 pregnancies close together
Are pregnant with twins or more
Have vomiting often because of morning sickness
Are not getting enough iron from their diet and prenatal vitamins
Had heavy periods before pregnancy

What causes anemia during pregnancy?

You can get several kinds of anemia during pregnancy. The cause varies based on the type.

Anemia of pregnancy. During pregnancy, the volume of blood increases. This means more iron and vitamins are needed to make more red blood cells. If you don't have enough iron, it can cause anemia. It's not considered abnormal unless your red blood cell count falls too low.
Iron-deficiency anemia. During pregnancy, your baby uses your red blood cells for growth and development, especially in the last 3 months of pregnancy. If you have extra red blood cells stored in your bone marrow before you get pregnant, your body can use those stores during pregnancy. Women who don't have enough iron stores can get iron-deficiency anemia. This is the most common type of anemia in pregnancy. Good nutrition before getting pregnant is important to help build up these stores.
Vitamin B-12 deficiency. Vitamin B-12 is important in making red blood cells and protein. Eating food that comes from animals, such as milk, eggs, meats, and poultry, can prevent vitamin B-12 deficiency. Women who don't eat any foods that come from animals (vegans) are most likely to get vitamin B-12 deficiency. Strict vegans often need to get vitamin B-12 shots during pregnancy.
Folate deficiency. Folate (folic acid) is a B vitamin that works with iron to help with cell growth. If you don't get enough folate during pregnancy, you could get iron deficiency. Folic acid helps cut the risk of having a baby with certain birth defects of the brain and spinal cord if it's taken before getting pregnant and in early pregnancy.

What are the symptoms of anemia during pregnancy?

You may not have clear symptoms of anemia during pregnancy unless your cell counts are very low. Symptoms may include:

Pale skin, lips, nails, palms of hands, or underside of the eyelids
Feeling tired
Sensation of spinning (vertigo) or dizziness
Labored breathing
Rapid heartbeat (tachycardia)
Trouble concentrating

The symptoms of anemia can be like other health conditions. Always see your healthcare provider for a diagnosis.

How is anemia during pregnancy diagnosed?

Your healthcare provider will check for anemia during your prenatal exams. It's usually found during a routine blood test. Other ways to check for anemia may include other blood tests such as:

Hemoglobin. This is the part of blood that carries oxygen from the lungs to tissues in the body.
Hematocrit. This measures the portion of red blood cells found in a certain amount of blood.

How is anemia during pregnancy treated?

Treatment will depend on your symptoms, age, and general health. It will also depend on how severe the condition is.

Treatment for iron deficiency anemia includes taking iron supplements. Some forms are time-released. Others must be taken several times each day. Taking iron with a citrus juice, such as orange, can help your body absorb it better. Taking antacids may make it harder for your body absorb to iron. Iron supplements may cause nausea and cause stools to become dark greenish or black in color. They may also cause constipation.

What are possible complications of anemia during pregnancy?

If you have anemia during pregnancy, your baby may not grow to a healthy weight, may arrive early (preterm birth), or have a low birth weight. Also being very tired may keep you from recovering as quickly after birth.

Can anemia during pregnancy be prevented?

Good nutrition before pregnancy not only helps prevent anemia, but it also helps build other nutritional stores in your body. Eating a healthy, balanced diet before and during pregnancy helps keep up your levels of iron and other important nutrients needed for your growing baby.

Good food sources of iron include:

Meats. Beef, pork, lamb, liver, and other organ meats.
Poultry. Chicken, duck, turkey, and liver, especially dark meat.
Fish. Shellfish, including (fully cooked) clams, mussels, and oysters are good. So are sardines and anchovies. The FDA recommends that pregnant women eat 8 to 12 ounces per week of fish that are lower in mercury. These include salmon, shrimp, pollock, cod, tilapia, tuna (light canned), and catfish. Don't eat fish with high levels of mercury, such as tilefish from the Gulf of Mexico, shark, swordfish, and king mackerel. Limit white (albacore) tuna to only 6 ounces per week.
Leafy greens of the cabbage family. These include broccoli, kale, turnip greens, and collards.
Legumes. Lima beans and green peas; dry beans and peas, such as pinto beans, black-eyed peas, and canned baked beans.
Yeast-leavened whole-wheat bread and rolls
Iron-enriched white bread, pasta, rice, and cereals

Experts recommend all women of childbearing age and all women who are pregnant take vitamin supplements with at least 400 micrograms of folic acid. Folate is the form of folic acid found in food. Good sources are:

Leafy, dark green vegetables
Dried beans and peas
Citrus fruits and juices and most berries
Fortified breakfast cereals
Enriched grain products

Key points about anemia in pregnancy

Anemia is a condition of too few red blood cells.
Four kinds of anemia can happen during pregnancy: anemia of pregnancy, iron deficiency anemia, vitamin B-12 deficiency, and folate deficiency.
Anemia may cause your baby to not grow to a healthy weight. Your baby may also arrive early (preterm birth) or have a low birth weight.
Anemia is usually found during a routine blood test for hemoglobin or hematocrit levels.
Treatment depends on the type of anemia and how bad it is.
Good nutrition is the best way to prevent anemia during pregnancy.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

Know the reason for your visit and what you want to happen.
Before your visit, write down questions you want answered.
Bring someone with you to help you ask questions and remember what your provider tells you.
At the visit, write down the name of a new diagnosis and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
Know why a new medicine or treatment is prescribed and how it will help you. Also know what the side effects are.
Ask if your condition can be treated in other ways.
Know why a test or procedure is recommended and what the results could mean.
Know what to expect if you do not take the medicine or have the test or procedure.
If you have a follow-up appointment, write down the date, time, and purpose for that visit.
Know how you can contact your provider if you have questions.

Medical Reviewer: Irina Burd MD PhD

Medical Reviewer: Donna Freeborn PhD CNM FNP

Medical Reviewer: Heather M Trevino BSN RNC

The norm of a complete blood count during pregnancy. Hemoglobin, platelets, hematocrit, erythrocytes and leukocytes during pregnancy. Clinical blood test during pregnancy. Hematological changes during pregnancy.

A normal pregnancy is characterized by significant changes in almost all organs and systems to adapt to the requirements of the fetoplacental complex, including changes in blood tests during pregnancy.

Blood test norms during pregnancy: summary of the article

Significant hematological changes during pregnancy are physiological anemia, neutrophilia, mild thrombocytopenia, increased blood clotting factors and decreased fibrinolysis.
By 6-12 weeks of gestation, plasma volume increases by approximately 10-15%. The fastest rate of increase in plasma volume occurs between 30 and 34 weeks of gestation, after which plasma volume changes little.
Red blood cell count begins to increase at 8-10 weeks of gestation and by the end of pregnancy increases by 20-30% (250-450 ml) of the normal level for non-pregnant women by the end of pregnancy A significant increase in plasma volume relative to the increase in hemoglobin and red blood cell volume leads to moderate decrease in hemoglobin levels (physiological anemia of pregnancy), which is observed in healthy pregnant women.
Pregnant women may have a slightly lower platelet count than healthy non-pregnant women.
The neutrophil count begins to rise in the second month of pregnancy and stabilizes in the second or third trimester, at which time the white blood cell count. The absolute number of lymphocytes does not change.
The level of some blood coagulation factors changes during pregnancy.

This article describes the hematological changes that occur during pregnancy, the most important of which are:

Increased plasma volume and decreased hematocrit
Physiological anemia, low hemoglobin
Elevated white blood cells during pregnancy
Neutrophilia
Moderate thrombocytopenia
Increase in procoagulant factors
Fibrinolysis reduction

Tests mentioned in the article

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Plasma volume

By 6-12 weeks of pregnancy, the volume of blood plasma increases by about 10-15%. The fastest rate of increase in plasma volume occurs between 30 and 34 weeks of gestation, after which plasma volume changes little. On average, plasma volume increases by 1100-1600 ml per trimester, and as a result, plasma volume during pregnancy increases to 4700-5200 ml, which is 30 to 50% higher than plasma volume in non-pregnant women.

During pregnancy, plasma renin activity tends to increase, while the level of atrial natriuretic peptide decreases slightly. This suggests that the increase in plasma volume is caused by insufficiency of the vascular system, which leads to systemic vasodilation (dilation of blood vessels throughout the body) and an increase in vascular capacity. Since it is the volume of blood plasma that initially increases, its effect on the renal and atrial receptors leads to opposite effects on the hormonal background (a decrease in plasma renin activity and an increase in natriuretic peptide). This hypothesis is also supported by the observation that an increase in sodium intake does not lead to a further increase in plasma volume.

Plasma volume immediately decreases after delivery, but rises again 2-5 days later, possibly due to increased aldosterone secretion occurring at this time. Plasma volume then gradually decreases again: 3 weeks postpartum, it is still elevated by 10-15% of the normal level for non-pregnant women, but usually returns to normal by 6 weeks postpartum.

Red blood cells during pregnancy, ESR during pregnancy

The number of red blood cells begins to increase at 8-10 weeks of gestation and by the end of pregnancy increases by 20-30% (250-450 ml) of the normal level for non-pregnant women, especially in women taking drugs iron during pregnancy. Among pregnant women who did not take iron supplements, the number of red blood cells may increase by only 15-20%. The lifespan of red blood cells decreases slightly during a normal pregnancy.

The level of erythropoietin during normal pregnancy increases by 50% and its change depends on the presence of pregnancy complications. An increase in plasma erythropoietin leads to an increase in the number of red blood cells, which partially provide for the high metabolic oxygen requirements during pregnancy.

In women not taking iron supplements, mean red cell volume decreases during pregnancy and averages 80-84 fl in the third trimester. However, in healthy pregnant women and in pregnant women with moderate iron deficiency, the average volume of erythrocytes increases by about 4 fl.

ESR increases during pregnancy, which has no diagnostic value.

Anemia in pregnancy, hemoglobin in pregnancy, hematocrit in pregnancy, low hemoglobin in pregnancy

Decreased hemoglobin in pregnancy

pregnant), which is observed in healthy pregnant women. The biggest difference between the growth rate of blood plasma volume and the number of red blood cells in the maternal circulation is formed during the end of the second, beginning of the third trimester (a decrease in hemoglobin usually occurs at 28-36 weeks of pregnancy).

The hemoglobin concentration rises due to the cessation of the increase in plasma volume and the continuation of the increase in the amount of hemoglobin. Conversely, the absence of physiological anemia is a risk factor for stillbirth.

Anemia in pregnancy

Defining anemia in pregnant women is difficult because it consists of pregnancy-related changes in plasma volume and red blood cell count, physiological differences in hemoglobin concentration between women and men, and the frequency of iron supplementation during pregnancy.

The Centers for Disease Prevention and Control defined anemia as hemoglobin levels less than 110 g/L (hematocrit less than 33%) in the first and third trimesters and less than 105 g/L (hematocrit less than 32%) in the second trimester.
WHO defined anemia in pregnancy as a decrease in hemoglobin less than 110 g/l (11 g/dl) or hematocrit less than 6.83 mmol/l or 33%. Severe anemia in pregnancy is determined by a hemoglobin level of less than 70 g/l and needs medical treatment. Very severe anemia is defined as a hemoglobin level of less than 40 g/L and is a medical emergency due to the risk of congestive heart failure.

Women with hemoglobin values below these levels are considered anemic and should undergo routine tests (CBC with peripheral blood smear evaluation, reticulocyte count, serum iron, ferritin, transferrin). If no abnormalities were found during the examination, then hemoglobin reduced to a level of 100 g / l can be considered physiological anemia with a wide variety of factors affecting the normal level of hemoglobin in a particular person.

Chronic severe anemia is most common among women in developing countries. A decrease in maternal hemoglobin below 60 g / l leads to a decrease in the volume of amniotic fluid, vasodilation of the cerebral vessels of the fetus and a change in the heart rate of the fetus. It also increases the risk of preterm birth, miscarriage, low birth weight and stillbirth. In addition, severe anemia (hemoglobin less than 70 g/l) increases the risk of maternal death. There is no evidence that anemia increases the risk of congenital malformations of the fetus.

Severe chronic anemia is usually associated with insufficient iron stores (due to insufficient dietary intake or intestinal worm infestations), folate deficiency (due to insufficient intake and chronic hemolytic conditions such as malaria). Thus, prevention of chronic anemia and improvement of pregnancy outcome is possible with the use of nutritional supplements and the use of infection control measures.

Administering blood and packed red cell transfusions (where safe blood transfusion is available) is a reasonable aggressive treatment for severe anemia, especially if there are signs of fetal hypoxia.

Signs of physiological anemia of pregnancy disappear 6 weeks after delivery, when plasma volume returns to normal.

Iron requirement

In a singleton pregnancy, the iron requirement is 1000 mg per pregnancy: approximately 300 mg for the fetus and placenta and approximately 500 mg, if any, to increase hemoglobin. 200 mg is lost through the intestines, urine and skin. Since most women do not have an adequate supply of iron to meet their needs during pregnancy, iron is usually prescribed as part of a multivitamin, or as a separate element. In general, women taking iron supplements have a 1 g/dL higher hemoglobin concentration than women not taking iron.

Folate requirements

The daily folate requirement for non-pregnant women is 50-100 micrograms. An increase in the number of red blood cells during pregnancy leads to an increase in the need for folic acid, which is provided by increasing the dose of folic acid to 400-800 mcg per day, to prevent neural tube defects in the fetus.

Platelets during pregnancy

In most cases, the platelet count during uncomplicated pregnancy remains within the normal range for non-pregnant women, but it is also possible for pregnant women to have lower platelet counts compared to healthy non-pregnant women. The platelet count begins to rise immediately after childbirth and continues to increase for 3-4 weeks until it returns to normal values.

Thrombocytopenia in pregnancy

The most important obstetrical change in platelet physiology during pregnancy is thrombocytopenia, which may be associated with pregnancy complications (severe preeclampsia, HELLP syndrome), drug disorders (immune thrombocytopenia) or may be gestational thrombocytopenia.

Gestational or occasional thrombocytopenia is asymptomatic in the third trimester of pregnancy in patients without prior thrombocytopenia. It is not associated with maternal, fetal, or neonatal complications and resolves spontaneously after delivery. 99/l. The white blood cell count drops to the reference range for non-pregnant women by the sixth day after delivery.

Pregnant women may have a small number of myelocytes and metamyelocytes in the peripheral blood. According to some studies, there is an increase in the number of young forms of neutrophils during pregnancy. Lobe bodies (blue staining of cytoplasmic inclusions in granulocytes) are considered normal in pregnant women.

In healthy women during uncomplicated pregnancy, there is no change in the absolute number of lymphocytes and there are no significant changes in the relative number of T- and B-lymphocytes. The number of monocytes usually does not change, the number of basophils may decrease slightly, and the number of eosinophils may increase slightly.

Coagulation factors and inhibitors

During normal pregnancy, the following changes in clotting factor levels occur, leading to physiological hypercoagulation:

Due to hormonal changes during pregnancy, the activity of total protein S antigen, free protein S antigen and protein S is reduced.
Activated protein C resistance increases in the second and third trimesters. These changes have been identified in first-generation tests using pure blood plasma (i.e., not lacking factor V), but this test is rarely used clinically and is of only historical interest.
Fibrinogen and factors II, VII, VIII, X, XII and XIII are increased by 20-200%.
Von Willebrand factor rises.
Increased activity of fibrinolysis inhibitors, TAF1, PAI-1 and PAI-2. The level of PAI-1 also increases markedly.
Levels of antithrombin III, protein C, factor V and factor IX most often remain unchanged or increase slightly.

The end result of these changes is an increase in the tendency to thrombosis, an increase in the likelihood of venous thrombosis during pregnancy and, especially, in the postpartum period. Along with contraction of the myometrium and an increase in the level of decidual tissue factor, hypercoagulability protects the pregnant woman from excessive bleeding during labor and delivery of the placenta.

APTT remains normal during pregnancy but may decrease slightly. Prothrombin time may be shortened. Bleeding time does not change.

The timing of normalization of blood clotting activity in the postpartum period may vary depending on factors, but everything should return to normal within 6-8 weeks after delivery. The hemostasiogram should not be assessed earlier than 3 months after delivery and after lactation is completed to exclude the influence of pregnancy factors.

The influence of acquired or inherited thrombophilia factors on pregnancy is an area for research.

Postpartum period

Hematological changes associated with pregnancy return to normal 6-8 weeks after delivery. The rate and nature of the normalization of changes associated with pregnancy, specific hematological parameters are described above in the section on each parameter.

Hematological complications during pregnancy

Iron deficiency anemia.
Thrombocytopenia.
Neonatal alloimmune thrombocytopenia.
Acquired hemophilia A.
Venous thrombosis.
Rh and non-Rh alloimmunization. For diagnosis, an analysis is carried out for Rh antibodies and anti-group antibodies.
A manifestation of a previously unrecognized coagulation disorder, such as von Willebrand disease, most commonly manifests in women during pregnancy and childbirth. For screening for von Willebrand disease, an assay is given to assess platelet aggregation with ristocetin.
Aplastic anemia.