Anemia in Pregnancy — Diagnosis & Management
Anemia in pregnancy affects over 50% of Indian pregnant women — among the highest rates globally. It is the second leading cause of maternal mortality in India (after haemorrhage). The Government of India's Anemia Mukt Bharat (AMB) strategy, launched in 2018, targets anemia reduction through IFA supplementation, deworming, fortified foods, and IV iron therapy at sub-centre level.
WHO and Government of India definitions of anemia in pregnancy:
- Hb < 11 g/dL in 1st and 3rd trimester
- Hb < 10.5 g/dL in 2nd trimester (physiologic haemodilution)
- Hb < 7 g/dL = severe anemia
- Hb 7-9.9 g/dL = moderate anemia
- Hb 10-10.9 g/dL (or 10-10.4 in 2nd trimester) = mild anemia
India's prevalence: 50-60% of pregnant women are anaemic (NFHS-5). Severe anemia (Hb < 7) affects 5-7% — major contributor to maternal death from postpartum haemorrhage, heart failure, infection.
- Iron deficiency (most common, 60-70%): Poor dietary intake, vegetarian diet (low bioavailability), repeated pregnancies, menstrual loss before pregnancy, hookworm infestation
- Folate deficiency (15-20%): Increased demand in pregnancy, poor intake, no periconceptional folic acid
- Vitamin B12 deficiency: Strict vegetarian diet, no supplementation
- Haemoglobinopathies: Sickle cell trait/disease, thalassemia — high in tribal areas
- Acute blood loss: Antepartum haemorrhage, abortion
- Chronic disease: TB, malaria, chronic kidney disease
- Malaria: Endemic areas — haemolysis
Daily IFA (100 mg elemental iron + 500 mcg folic acid): All pregnant women from first ANC visit, daily for 100 days during pregnancy, continued for 180 days postpartum. Take on empty stomach with citrus juice (vitamin C enhances absorption). Avoid with milk/tea (calcium/tannins inhibit absorption).
Albendazole 400 mg: Single dose in 2nd trimester — deworming to reduce hookworm-related iron loss.
Treatment of mild-moderate anemia: Double dose IFA (1 tablet BD) for 90 days, then recheck Hb. If Hb improves by ≥ 1 g/dL, continue single IFA. If no improvement, evaluate for other causes (thalassemia, B12 deficiency, chronic disease).
Weekly IFA for adolescents (10-19 years): Weekly 1 tablet x 52 weeks — prevents anemia before pregnancy. School-based distribution.
IV iron therapy (Anemia Mukt Bharat 2018): Indications:
- Hb 6-9 g/dL in 2nd/3rd trimester — IV Iron Sucrose at sub-centre level
- Oral iron intolerance or non-response
- Severe anemia close to term
Iron sucrose regimen: 200 mg in 100 mL NS over 15-30 min on alternate days, total dose calculated by Ganzoni formula: Total iron (mg) = Body weight (kg) x (Target Hb - Actual Hb) x 2.4 + 500 mg depot. Or simpler: 200 mg IV on Day 1, 3, 5, 7, 9 — total 1000 mg over 2 weeks.
Ferric Carboxymaltose (FCM): Single large-dose IV iron — 1000 mg in 100 mL NS over 15 min, repeat after 7 days if needed. Faster than iron sucrose, increasingly used in Indian facilities.
Blood transfusion indications: Hb < 7 g/dL at any time, OR Hb < 8 g/dL with symptoms (dyspnoea, palpitations, heart failure), OR Hb < 9 g/dL at term with anticipated haemorrhage. Use packed red cells, cross-matched. Transuse slowly with monitoring to avoid circulatory overload in pregnancy.
Launched in 2018 under NHM, targets reducing anemia prevalence by 3% per year across 6 beneficiary groups: children 6-59 months, children 5-9 years, adolescents 10-19 years, women of reproductive age, pregnant women, lactating women.
Six interventions under AMB:
- Prophylactic IFA supplementation
- Deworming (Albendazole 400 mg — children > 1 year, biannually)
- Iron-fortified foods (rice, wheat, salt)
- IV iron sucrose for moderate anemia in pregnancy (at PHC level)
- Behaviour change communication — dietary diversification, delayed cord clamping
- Addressing non-nutritional causes — malaria, hookworm, haemoglobinopathies
Anemia in pregnancy is one of India's largest public health challenges and a major contributor to maternal mortality. For UPSC CMS aspirants, Hb cutoffs, IFA supplementation, IV iron therapy, and AMB strategy are highly testable topics.