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How to manage low haemoglobin in pregnancy?

Thursday, 07 August 2003
Answered by: Puneet Bedi
Consultant in Obstetrics and Gynaecology
Apollo Hospital
New Delhi
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Q. I am pregnant for the second time, 7th month is running and expected date of delivery is after 2 months. My Hb levels are low for the fast few months and maintaining steady at 6.2 to 6.7. I have been taking the iron supplements and veg diet. My diet I am following as per my doctor. I do not have any symptoms of any weakness or giddiness. My gynaecologist has suggested blood transfusion to increase the Hb levels. I have gained around 5 kgs after pregnancy and according to doctor the babys growth is good. (5.3 and 59 kgs, age 30 years) My question is inspite of such heavy medication what could be reason that my Hb level is not going up? Can I take blood transfusion at this stage, my husband has already identified known donors and blood is ready at the blood bank. What should be the quantity to boost my Hb levels? Is it safe at this stage of pregnancy?

A.  Haemoglobin (Hb) can be a little low at this stage of pregnancy due to water retention, which normally occurs during mid-pregnancy (haemodilution). But 6 to 7 g is very low and if you are already on iron it is obvious that the anaemia is not due to iron deficiency anaemia! You must urgently get tests to exclude other causes of anaemia. You must get tests (Hb electrophoresis) to exclude Thalassaemia - a common cause in India for anaemia during pregnancy and this anaemia will not respond to iron. If you got anaemic in the first pregnancy as well, you are even more likely to be Thalassaemia carrier. This is a disorder in which you might never know that you are thalassaemic. It is very important to check if you are a carrier of Thalassaemia; if you are, you must get your husband's thalassaemia status checked as well. (by Hb electrophoresis, which is a blood test) If both of you are carriers only then it is a problem. Please get these tests urgently. If only you are a carrier, it is not too bad as only you will have anaemia during pregnancy, but if both of you are carriers you will have to exclude the unborn baby from being affected with Thalassaemia which is a serious illness in children as not enough blood is being made (you have a one in four chances of having an affected child if you are both carriers and no chance at all if only you are a carrier you do not have to worry even if you both are carriers we can do a prenatal diagnosis and prevent an abnormal baby form being born but these test must be done immediately! (As soon as possible - Hb electrophoresis). It can be done at any good laboratory and is only a blood test, though the report may take a few days. Regarding you query about the advisability of a blood transfusion, well if it has to be given, safe blood properly tested for all possible infections should be used as always, barring the complications known of a blood transfusion, but the increase in the haemoglobin will be about one gram per unit of blood given and will be temporary and may need to be repeated. But it is more important to find out the cause of anaemia and rule out Thalassaemia. I cannot overstress the need to exclude Thalassaemia and if you are both carriers check the fetus for a possible Thalassaemia major. As soon as possible. I do not want to scare you but it is a distinct possibility in your case! Even at this stage the fetus can be diagnosed (by fetal placental biopsy and / or fetal blood sampling. (Any doctor who says otherwise is probably not aware of all the facilities available in the country these days!) I know that I may be scaring you but it is very important. And if no thalassaemia is found, then get all tests done to find out other causes of anaemia and take suitable treatment like worm disinfestation, malabsorption, chronic diarrhoea, piles, etc and treat the cause. But all these conditions or any other similar condition will only bother you, while thalassaemia will affect the baby for a life time. Blood transfusion if required and if given under good supervision and safe blood can be given in pregnancy. It may be required to increase your haemoglobin and treat your symptoms like weakness and lethargy. But it is more important to find out the cause! Please sort it out and in consultation with your treating physician. Since your husband is a regular donor at the red cross it is unlikely that he would be a carrier of thalassaemia, so you should be reassured but, still please get the tests done!

A.  Haemoglobin (Hb) can be a little low at this stage of pregnancy due to water retention, which normally occurs during mid-pregnancy (haemodilution). But 6 to 7 g is very low and if you are already on iron it is obvious that the anaemia is not due to iron deficiency anaemia! You must urgently get tests to exclude other causes of anaemia. You must get tests (Hb electrophoresis) to exclude Thalassaemia - a common cause in India for anaemia during pregnancy and this anaemia will not respond to iron. If you got anaemic in the first pregnancy as well, you are even more likely to be Thalassaemia carrier. This is a disorder in which you might never know that you are thalassaemic. It is very important to check if you are a carrier of Thalassaemia; if you are, you must get your husband's thalassaemia status checked as well. (by Hb electrophoresis, which is a blood test) If both of you are carriers only then it is a problem. Please get these tests urgently. If only you are a carrier, it is not too bad as only you will have anaemia during pregnancy, but if both of you are carriers you will have to exclude the unborn baby from being affected with Thalassaemia which is a serious illness in children as not enough blood is being made (you have a one in four chances of having an affected child if you are both carriers and no chance at all if only you are a carrier you do not have to worry even if you both are carriers we can do a prenatal diagnosis and prevent an abnormal baby form being born but these test must be done immediately! (As soon as possible - Hb electrophoresis). It can be done at any good laboratory and is only a blood test, though the report may take a few days. Regarding you query about the advisability of a blood transfusion, well if it has to be given, safe blood properly tested for all possible infections should be used as always, barring the complications known of a blood transfusion, but the increase in the haemoglobin will be about one gram per unit of blood given and will be temporary and may need to be repeated. But it is more important to find out the cause of anaemia and rule out Thalassaemia. I cannot overstress the need to exclude Thalassaemia and if you are both carriers check the fetus for a possible Thalassaemia major. As soon as possible. I do not want to scare you but it is a distinct possibility in your case! Even at this stage the fetus can be diagnosed (by fetal placental biopsy and / or fetal blood sampling. (Any doctor who says otherwise is probably not aware of all the facilities available in the country these days!) I know that I may be scaring you but it is very important. And if no thalassaemia is found, then get all tests done to find out other causes of anaemia and take suitable treatment like worm disinfestation, malabsorption, chronic diarrhoea, piles, etc and treat the cause. But all these conditions or any other similar condition will only bother you, while thalassaemia will affect the baby for a life time. Blood transfusion if required and if given under good supervision and safe blood can be given in pregnancy. It may be required to increase your haemoglobin and treat your symptoms like weakness and lethargy. But it is more important to find out the cause! Please sort it out and in consultation with your treating physician. Since your husband is a regular donor at the red cross it is unlikely that he would be a carrier of thalassaemia, so you should be reassured but, still please get the tests done!

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