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Referral and warning signs
When to refer
Severe anaemia (Hb <=7) or heart failure signs. Unresponsive to oral iron. Anaemia late in pregnancy/labour. Sickle cell disease.
Red flags
- Hb <= 7 g/dL
- Signs of heart failure
- Severe pallor
- Associated heavy bleeding
Signs and symptoms
- General symptoms of anaemia (fatigue, weakness, pallor, dyspnoea, dizziness, palpitations).
- Glossitis, stomatitis (nutritional deficiency).
- Leg oedema.
- Signs of heart failure in severe cases (engorged neck veins, dyspnoea at rest, hepatomegaly, ascites, gallop rhythm).
Risk factors
- Iron deficiency (poor diet, increased demand, blood loss).
- Folate deficiency.
- Infections/Infestations (Malaria, Hookworm, HIV/AIDS, UTI).
- Haemoglobinopathies (Sickle Cell Disease).
- Chronic bleeding.
- Multiple pregnancy.
- Short interpregnancy interval.
Diagnosis
Clinical assessment
Suspected based on symptoms and signs (especially pallor). Assess severity based on clinical signs and Hb level.
Investigations
- Haemoglobin (Hb) estimation: Confirms diagnosis and severity (Mild 10-10.9, Moderate 7-9.9, Severe <7 g/dL).
- Peripheral Blood Smear: Assess RBC morphology (microcytic, macrocytic, normocytic), check for malaria parasites.
- Stool analysis: Ova & Cysts (hookworm).
- Consider Hb Electrophoresis if Sickle Cell suspected.
- HIV test.
- Urinalysis (check for UTI).
Diagnostic criteria
Hb <11 g/dL (or <10.5 g/dL in 2nd trimester).
Management
Non-pharmacological management
- Dietary Counseling: Emphasize balanced diet rich in iron, folate, protein, vitamins.
- Treat underlying causes (Malaria, Hookworm, UTI, HIV).
- Advise on child spacing (>2 years interval).
Pharmacological treatment
- Prophylaxis (All pregnant women): Ferrous Sulphate (~60mg elemental Fe) + Folic Acid (400mcg) combination tablet, 1 tablet daily from 12 weeks until 6 months postpartum. (LOC: HC2)
- Treatment (Hb >7 g/dL): DOUBLE DOSE Iron + Folic Acid (1 tablet PO BID/TID). Treat underlying cause (Malaria, Deworming - Mebendazole 500mg in 2nd/3rd tri). Review Hb q2wks. Refer if no improvement. (LOC: HC2)
- Severe Anaemia (Hb <=7 g/dL) or Signs of Heart Failure: Refer URGENTLY to Hospital for likely transfusion. (LOC: HC4)
- Anaemia at Term (>36 weeks) or During Labour: Refer to well-equipped facility. (LOC: HC4)
- Sickle Cell Disease with Anaemia: Refer for specialist ANC/delivery. Folic Acid 5mg daily. (LOC: HC4)
Monitoring
Monitor Hb levels during treatment. Monitor clinical symptoms. Assess adherence. Monitor fetal well-being.
Complications
- Maternal: Preterm labour, PPH, Cardiac failure, Infection risk, Poor lactation.
- Fetal/Neonatal: IUGR, LBW, Prematurity, Fetal hypoxia, Stillbirth/Neonatal death.
Prevention
- Routine iron and folic acid supplementation.
- Malaria prevention (IPTp-SP, ITNs).
- Deworming.
- Good nutrition.
- Child spacing.
Patient education
- Explanation of anaemia and risks.
- Importance of taking supplements and managing side effects.
- Dietary advice.
- Need to treat underlying causes.
- Follow-up importance.
- Danger signs.
Uganda-specific notes
Extremely common, major morbidity/mortality contributor. Multifactorial. Routine supplementation, IPTp-SP, deworming key. Empirical treatment common due to limited diagnostics.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.2.1