Understand the link between Pregnancy and Anaemia

The total blood volume increased in pregnancy by about 45% . While the volume of blood has increased, the number of red blood cells often don’t increase to match that volume. This condition is anaemia.

The haemoglobin level in women should range between 12 to 16 g/dl. According to the classification of World Health Organization (WHO), pregnant women with haemoglobin levels less than 11.0 g/dl in the first and third trimesters and less than 10.5 g/dl in the second trimester are considered anaemic.

What are the needed haemoglobin ranges in pregnancy?

It's interesting to note that the levels vary. Have a look:

• When not pregnant: 12 to 15.8 g/dl  
• 1st trimester of pregnancy: 11.6 to 13.9 g/dl 
• 2^nd trimester of pregnancy: 9.7 to 14.8 g/dl 
• 3^rd trimester of pregnancy: 9.5 to 15 g/dl 

The Importance of Managing Anaemia in Pregnancy

Red blood cells carry oxygen from our lungs to the rest of our bodies, from the brain to our toes Then, they make the return trip, taking carbon dioxide back to our lungs to be exhaled. Haemoglobin is the most important component of red blood cells. It is composed of a protein called heme, which binds oxygen. In the lungs, oxygen is exchanged for carbon dioxide.

What could be making me anaemic in pregnancy?

Several types of anaemia can develop during pregnancy. These include:

• Iron-deficiency anaemia
• Folate-deficiency anaemia
• Vitamin B12 deficiency

Here's more:

• Iron-deficiency anaemia. This type of anaemia occurs when the body doesn't have enough iron to produce adequate amounts of haemoglobin, which is a protein in red blood cells. It carries oxygen from the lungs to the rest of the body.

In iron-deficiency anaemia, the blood cannot carry enough oxygen to tissues throughout the body.Iron deficiency is the most common cause of anaemia in pregnancy.

For this condition, your doctor will give you iron supplements. Here are three golden rules for taking those:

• If possible, take your iron tablets when your stomach is empty.
• Don't take iron with antacids. 
• Take iron tablets with vitamin C. Vitamin C improves the absorption of iron.

Folate-deficiency anaemia. Folate is the vitamin found naturally in certain foods like green leafy vegetables A type of B vitamin, the body needs folate to produce new cells, including healthy red blood cells.

Folate deficiency leads to certain types of birth defects, such as neural tube abnormalities (spina bifida) and low birth weight.

Your doctor will prescribe a Folic acid tablet. That is the man-made version of the vitamin, folate. Make sure you take the supplement to help your unborn baby's brain, skull and spinal cord develop properly to avoid development problems (called neural tube defects) such as spina bifida

Folic acid can also be combined with:

• ferrous fumarate and ferrous sulphate (to treat iron deficiency anaemia).
• other vitamins and minerals (as a multivitamin and mineral supplement).

Folic acid supplement is not suitable for some people: 

• If you had an allergic reaction to folic acid or any other medicine in the past.
• have low vitamin B12 levels (vitamin B12 deficiency anaemia) or pernicious anaemia.
• have a stent in your heart (and have been given the go-ahead for pregnancy by a doctor).
• Vitamin B12 deficiency. The body needs vitamin B12 to form healthy red blood cells. When a pregnant woman doesn't get enough vitamin B12 from their diet, their body can't produce enough healthy red blood cells. Women who don't eat meat, poultry, dairy products, and eggs have a greater risk of developing vitamin B12 deficiency, which may contribute to birth defects, such as neural tube abnormalities, and could lead to preterm labour.

You are at increased risk of developing any of the above 3 types of anaemia during pregnancy if you:

• Have two closely spaced pregnancies
• Are pregnant with more than one baby
• Are vomiting frequently due to morning sickness
• Don't consume enough iron-rich foods
• Have a heavy pre-pregnancy menstrual flow
• Have a history of anaemia before your pregnancy

How much Hb is required for normal delivery?

There is no one level that has been stated as the needed level for normal birth. But, if the hb is below 11, women will face more challenges in keeping their strength during all stages of labour. 

Here is another eye-opening fact: In one large study, pregnant women with haemoglobin less than 10 g/dl, had babies with birth weight of 2.6kg, while pregnant women with higher haemoglobin level (>10 g/dl), considered as normal gave birth to heavier and normal babies (3.3 kg).

How can I raise my haemoglobin level quickly?

During pregnancy, you need 27 milligrams of iron a day.

Firstly, supplements that are prescribed by your doctor are important. In some cases, just a prenatal vitamin that has an iron component is fine. If your doctor feels you need more, (s)he might recommend a separate iron supplement. 

Secondly, good nutrition with iron-rich foods is needed. Dietary sources of iron include lean red meat, poultry and fish. Other options include iron-fortified breakfast cereals, dark green leafy vegetables, dried beans and peas. 

The iron from animal products, such as meat, is most easily absorbed. To enhance the absorption of iron from plant sources and supplements, pair them with a food or drink high in vitamin C — such as orange juice, tomato juice or strawberries. If you take iron supplements with orange juice, avoid the calcium-fortified variety. Although calcium is an essential nutrient during pregnancy, calcium can decrease iron absorption.

Can anaemia in pregnancy harm my baby?

Severe iron deficiency anaemia during pregnancy increases the risk of premature birth. It is also associated with having a low birth weight baby and postpartum depression.

The Role of Diet in Managing Anaemia in Pregnancy

Eating well can help you raise iron levels. Here are some ground rules before we move to the foods.  

To increase Iron levels:

• Unlock Iron (reduce phytates) in the food sources:

• By germination or sprouting of grains, legumes, nuts and seeds
• By fermentation of grains, legumes, vegetables

To absorb the iron:

• Don’t have any coffee or tea with meals.
• Include Vitamin C + Iron for better absorption
• Don’t have calcium rich foods with your Iron rich foods.

Good sources of iron include:

• Pulses like masoor dal, moong dal, and urad dal
• Fresh green leafy vegetables, such as cabbage, spinach, spring onions, colocassia and chawli leaves.
• Dried vegetables like lotus stem, karonda and sundakai in pickles.
• Mushrooms, beetroot and onion stalks
• Millets like bajra, samai has as porridge, cheela, upma
• Cauliflower leaves (that wrap around the vegetable)
• Raw banana as a veggie
• Soybean
• Pomegranate, sitaphal, watermelon, peaches
• Seeds, such as sunflower or sesame seeds
• Dried prunes, raisins (kishmish), figs and apricots  (soak and have)
• Chhole and rajma
• Sesame seeds (til), almonds, garden cress, piyal seeds (chironji), cashewnuts and almonds.
• Pumpkin, sesame, hemp and flaxseed, poppy seeds (khus-khus)

For absorption of iron, get your Vitamin C from:

• Kiwi fruit
• Oranges
• Potatoes
• Cauliflower
• Broccoli
• Tamarind chutney
• Karonda pickle
• Amchur or mango powder

Natural Ways to Increase Iron During Pregnancy

• Eat iron-rich foods cooked in iron vessels. 
• Have Vitamin C for better absorption of iron in the body so citrus fruits or the Indian gooseberry (amla) could be of immense help. 
• Calcium does not support iron absorption, so try to maintain a gap between milk intake and your iron-rich meals. 
• Breathing exercises (pranayama) like anulom vilom  and nadi shodhan help to improve blood circulation and thereby fight anaemia. 
• Yoga helps facilitate better functioning of the heart. This can help improve the haemoglobin levels in the body. Get into a daily yoga routine with asanas like trikonasana, marjariasana and utkatasana.

Ayurveda tips for Pregnancy Anaemia

• ‍Turmeric And Triphala: Mix the powder of Turmeric and Triphala, take it twice a day with honey or ghee in unequal proportion. Triphala is a rich source of iron and aids the absorption of iron. ‍
• Amla Powder: 1 tsp of Amla powder along with honey everyday after food. Amla is rich in calcium, vitamin C and iron. ‍
• Liquorice Powder: 1tsp of liquorice powder along with honey before food everyday. Liquorice is a rich source of iron. ‍
• Ragi / Millet: Prepare a halwa (in cow ghee, fry the coarse flour of ragi, add jaggery and water, adjust the consistency) helps to relieve anemia. 

A nutritionist-prescribed diet plan for Anaemia in Pregnancy.

Meal 1: On rising

Timing: 10-15 minutes after waking up

Meal Options

Herbal Tea to kick start metabolism (½ glass of water, boil it, add ½ tsp of cumin/ carom seeds and boil for 3 minutes, strain and then have the tea, it will be slightly bitter to taste).

Almonds (2-3) + Dried apricots (unsweetened, unsulfured) (2-3)

Dried figs (2-3) + Walnuts (2)

Notes

Soak the nuts and dry fruits overnight. This way the absorption of them will be better. Peel the skin off the almonds before consuming (the skin has a compound called tannins which prevents its absorption).

‍Meal 2: Breakfast

Meal Options

Spinach paratha with vegetable chutney 

Ragi dosa with ghee + peanut chutney

Moong dal chilla with mint-coriander chutney

Daliya with vegetables 

Scrambled eggs (made with 2 whole eggs) / Omelette (add finely chopped vegetables like onion, tomato, etc) 

Poha with some groundnuts, green peas 

30 min post breakfast

1 medium citrus fruit (orange, sweet lime, kiwi)

Meal 3: Midmorning

Meal Options

Lemonade

Kokum sherbet 

Meal 4: Lunch

2 millet roti + green leafy vegetable + raita/ salad (use colourful vegetables like cucumber, carrots, beetroot, broccoli, sweet corn, lettuce, tomato, onion, etc)

1 bowl of brown rice + egg curry (2 white + 1 yolk) + carrot-beetroot salad

1 bowl of brown rice + sardine fish curry (2-3 pcs) + salad

Meal 5: Evening Snacks

Steamed sprouts with lemon juice, coriander leaves - 1 bowl

Spinach soup with ½ lemon squeezed- 1 bowl

Meal 6: Dinner

Bajra + moong dal + green peas khichdi (cooked softly) with some ghee with green chutney (blanched spinach with basic seasoning can be ground to make a chutney, can use any other leafy vegetable similarly)

Dal khichdi / Palak khichdi with ghee

Notes:

Some iron-food sources to include:

• Bajra (pearl millet)
• Dried figs (1-2 slices)
• Spinach, beetroot greens
• Steamed sprouts
• Oily fishes like Indian salmon, anchovies, sardines
• Garden cress seeds (halim seeds)
• Unsweetened almond butter
• Beans and peas (Lima beans, chickpeas, black-eyed peas)

Some tips to boost your iron levels:

• Have lemon juice / citrus fruits/ a piece of amla along with the iron rich foods or after the iron supplement. The vitamin C will promote iron absorption.
• Use cast iron pots and pans for cooking.
• Do not have the iron and calcium supplement together.