Anemia is a condition characterized by reduced red blood cell (RBC) levels in blood . The hemoglobin (a protein) in red blood cells are responsible for binding and carrying oxygen to various parts of the body; so, lack of RBC in the blood leads to symptoms like tiredness and fatigue  resulting from low oxygen supply. Pregnant women are more at risk of developing this condition due to certain body changes occurring during this time . There are several different types of anemia with the iron deficiency form being most prevalent among expectant mothers.
What are the types of anemia in pregnancy?
Iron deficiency anemia
As the name suggests, this type occurs when you do not get enough iron from your daily diet. Iron is an essential component for producing hemoglobin .
Vitamin B-12 deficiency anemia
Vitamin B12 deficiency can also hamper RBC production, especially during pregnancy. Vegan and vegetarian women are more likely to develop this type of anemia .
Pernicious anemia: Sometimes, abnormal immune reaction can lead to loss of certain stomach cells responsible for producing the intrinsic factor. It results in a malignant condition named pernicious anemia due to major vitamin B12 deficiency as the intrinsic factor is responsible for absorbing the vitamin in the intestine . It is quite rare among pregnant women.
Folic acid deficiency anemia
Resulting from a lack of folic acid or folate (a type of B vitamin) , this type of anemia produces abnormally large RBCs, known as megalocytes or megaloblasts. As a result, it is often referred to as megaloblastic anemia .
Various inherited or genetic disorders can also lead to certain forms of anemia such as sickle cell anemia and aplastic anemia in pregnancy .
What are the risk factors of anemia during pregnancy?
- Carrying twins or triplets
- Getting pregnant soon after giving birth to one child 
- Teenage pregnancy
- Severe morning sickness causing excessive vomiting 
- History of anemia before conceiving
- Poor diet (low in iron and vitamins)
- Excessive pre-pregnancy menstrual flow
- History of hemorrhoids or stomach ulcers
Causes and Pathophysiology of Iron Deficiency Anemia in Pregnancy
The blood volume in your body increases by 50% during pregnancy to support the growth of your baby. So naturally, your body needs more iron, especially during the second and third trimesters, to produce enough hemoglobin for the additional blood to carry oxygen and essential nutrients to the fetus as well as different parts of your body, . Failure to get enough iron to meet these requirements can make you anemic .
Is anemia a sign of pregnancy?
Although most women develop mild anemia while pregnant, it cannot be considered a sign of pregnancy as it is usually not diagnosed until the late second or third trimester and can lead to certain complications if left unattended.
What are the signs and symptoms of anemia during pregnancy?
You may experience the following symptoms in addition to weakness and fatigue caused by anemia:
- Dizziness 
- Low body temperature
- Numb feeling in your hands and feet 
- Leg cramps
- Irregular, rapid heartbeat
- Pale skin
- Shortness of breath 
- Difficulty concentrating
- Spoon-shaped nails (koilonychias), pica (craving for unusual, often inedible items like dirt and paper) and sore mouth with cracked corners (iron deficiency anemia) 
- Hallucination, paranoia, dementia and schizophrenia (B12 deficiency anemia) 
Dietary Measures for Preventing Anemia during Pregnancy
- Following a healthy diet containing ample amounts of dark green leafy vegetables (spinach, parsley, kale), legumes (green peas, lima beans) red meat, liver, fish (shellfish, sardines) and poultry products (especially dark meat) as these are rich in iron 
- Including plenty of folic acid rich foods, like avocado, orange, leafy vegetables and dried beans, in your daily diet 
- Eating lots of vitamin C rich foods including fresh raw vegetables and citrus fruits
- Consuming lots of high fiber foods such as whole grain breads, cereals as well as fruits and vegetables rich in fiber 
- Taking prenatal multivitamins and iron supplements regularly before and during pregnancy
Using cast iron pots for cooking is beneficial as it boosts the iron content in your food by around 80% . The above dietary changes are also recommended for those with mild to moderate anemia for preventing further deterioration of the condition. Avoid having tea or coffee with your meals as they affect your body’s iron absorption capacity .
Anemia during Pregnancy Diagnosis
It is usually detected during your routine prenatal check-up as regular blood tests are performed from the first trimester to look for such abnormalities. Additional tests may be used for confirming the diagnosis and differentiating it from other conditions with similar symptoms :
- Peripheral blood smear 
- Complete blood count (hemoglobin and hematocrit) 
- Serum ferritin index 
Anemia during Pregnancy Treatment and Management
Oral iron supplements are most commonly used for managing pregnancy anemia as most cases are triggered by iron deficiency . Over-the-counter iron supplements such as Floradix are often prescribed for this purpose  as your body needs at least 27mg iron every day throughout pregnancy . Taking the pills with citrus fruit juices (e.g. orange juice) helps with the iron absorption, while taking them with dairy products, calcium supplements and antacids  hampers the absorption process .
Folic acid supplements may also be prescribed if your doctor suspects folate deficiency .
Doing light exercise or prenatal yoga every day can help to manage the symptoms . Make sure to consult your physician regarding the safety of exercising while pregnant.
There are no natural remedies for anemia apart from having lots of fresh fruits, leafy vegetables and fruit juices every day.
Managing Severe Anemia
Severe cases call for complete bed rest accompanied by a proper diet and necessary nutritional supplementations. Hospitalization for intravenous/intramuscular iron administration or blood transfusion may be necessary in case the iron deficiency is too severe to be compensated by diet and oral supplements . Transfusion may also be necessary for treating some genetic forms of anemia.
Are there any side effects of the supplements?
Iron supplements may lead to the following side effects:
- Diarrhea or constipation 
- Dark green or blackish stool color 
These side effects may be avoided by taking the tablets with some food or starting with low dosages and gradually increasing it over time . Contact your physician if you have the above side effects.
Possible Complications of Anemia while Pregnant
In most cases, it does not affect the baby or have any serious outcomes. However, untreated and severe cases may result in:
- Higher risk of preterm labor
- Postpartum depression 
- Having a baby with lower than normal birth weight 
- Developmental delay
Risks to the baby
Anemia during Pregnancy Incidence
The incidence statistics show it to affect around one-third of all pregnant women in the third trimester .
Anemia ICD-9 and ICD-10 Codes
The ICD-9 codes 280-285  are used for indicating anemia while its ICD-10 codes are D50-D64 .
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