Asymptomatic Severe Anemia in Pregnancy: A Call for Standardized Preconception Care

by Dr. Lashantè Stubb

Objective: To raise awareness on the importance of preconception care and nutrient supplementation preconception in a Bahamian healthcare system.

 

Case Report: A 20 year old gravida 1 para 0 at 26+3 weeks with no known medical illnesses presented for a routine antenatal visit. On review of the patient's labs, it was discovered that she had a hemoglobin of 6.3 g/dL and hematocrit of 31.6%. The previous hemoglobin was 6.7g/dL and pre-pregnancy hemoglobin was 11.3 g/dL. The patient denied a history of shortness of breath, fatigue, weakness, dizziness, chest pains or palpitations. Vitals and O2 saturation was normal. She admitted to fetal movements, but denied any vaginal bleeding and denied gush of fluids. On physical examination, mucous membranes were pink and moist. No spooning of the nail beds were noted. Pulses were normal, with normal capillary refill. Normal heart sounds were auscultated, no added sounds or murmurs were noted. No glossitis was noted. The abdomen was gravid and non tender. The fetal back was facing the maternal left with a cephalic presentation. Symphyseal fundal height was 20 cm and the fetal heart rate was in the 140s. The patient was provided a course of hematinics. The hemoglobin was repeated 2 weeks later and the hemoglobin increased to 8.6 g/dL . The hemoglobin steadily increased over the course of the pregnancy. The patient delivered a live male infant full term without complications.

 

Discussion:  In developing countries, iron deficiency anemia is a major healthcare concern. Recent publications have deemed iron deficiency anemia a major global health problem. In most cases of severe anemia, the patient often experiences symptoms. In this instance, the patient is more likely to seek medical attention and the anemia treated. However, there are some cases of severe anemia that are asymptomatic. As a result, these cases go untreated for an extended period of time and are often only discovered incidentally. While a dilutional anemia is common in pregnancy, iron deficiency anemia is the most common cause of anemia in pregnancy in developing countries. Severe anemia in pregnancy is associated with adverse effects for both the mother and the developing fetus. There is also an increased risk of maternal mortality. Severe anemia requiring transfusion also increases the risk for transfusion reactions, RBC allo-immunization,  fetal hemolytic disease as well as fluid overload. Further studies have shown that there are also long-term adverse effects on the child later in life. Preconception care is not routinely offered in the public setting in the Bahamas. Furthermore, there are no studies exploring preconception care in The Bahamas. While the benefits of preconception care are well laid out in clinical practice, preconception care is still lacking. Preconception care can provide a means by which nutritional deficiencies(as well as other ailments) are discovered and treated. This in turn decreases materna morbidity and contributes to better long term health outcomesfor the child.

 

Conclusion:  It is important to emphasize preconception care and remove barriers to preconception care. Further studies should be done to assess how the implementation of standard accessible preconception care in developing countries can lead to the amelioration of reversible causes of anemia and nutritional deficienciesin pregnancy.