Anemia is a concern in pregnancy and is usually addressed with iron supplementation. Its linkage to postpartum hemorrhage has been of concern because those who are anemic are likely to expire more rapidly once blood loss occurs.
Dating back to the early 2000s the evidence was firmly mixed. While suspicion of a connection was evident, it was clear that there were many questions and unknowns. In an article published in 2000 byThe American Journal of Clinical Nutrition, discussing current knowledge on anemia and pregnancy, it was argued that a link between anemia and subsequent maternal mortality could not be proven because they could both be caused by another factor, like PPH. In other words, it was unclear whether anemia or PPH came first.
Moreover, the focus on the relationship between anemia and maternal mortality rather than anemia and PPH in these early studies highlights another intertwining factor in the relationship between anemia, PPH, and maternal mortality - the specific role of anemia. Did anemia increase the risk of PPH or did it only increase the risk of mortality from PPH? This was a question implicitly asked throughout studies in the early 2000s. It was suspected that anemia made a woman less able to withstand the blood loss associated with childbirth, even at levels below PPH. As the World Health Organization quotes in a 2004 document on the subject of anemia and childbirth, “Even a blood loss of 100 ml can cause circulatory shock and death.” This idea was supported by studies that showed no difference in risk of PPH across anemic and nonanemic pregnant women, but found a statistically significant increase in the use of blood transfusions in the anemic group.
Studies from 2008 and onwards are beginning to show that anemia may have adirect effect on the risk of PPH. In a study published in theJournal of Health, Population and Nutritionin 2008, a strong association was found between moderate-to-severe anemia at 28 weeks gestation and a higher severity of blood loss at delivery and postpartum, after adjusting for confounding factors like labor and delivery variables and socioeconomic status that made evidence “inconclusive” in the early 2000s. The investigators attributed this association to the following:
Decreased uterine blood flow or low uterine muscle strength may contribute to inefficient uterine contractions and contribute to blood loss, potentially mediated by low body iron stores (serum ferritin <100 μg/L) and, therefore, iron-deficiency anaemia. Our data are consistent with this latter hypothesis.
Another study published in theJournal of Surgery Pakistanin 2008, found a similar association, calling it causal. They postulated that the biological mechanism for this causal relationship involved the impaired transport of hemoglobin and oxygen to the uterus and tissue enzyme and cellular dysfunction. These are both caused by iron-deficiency anemia and lead to impaired myometrial contractility and atonic uterus, the main cause of PPH.
In addition, there is increasing evidence showing that the risk of PPH increases with the degree of anemia. A study published in 2012 in theInternational Journal of Gynecology & Obstetricslooked at the role of nitric oxide (NO) in increasing the risk of PPH. Nitric oxide is a molecule that causes relaxation and vasodilation of muscle and increases 7.5-fold with moderate-to-severe iron-deficiency anemia. They found that women with mild anemia - which does not cause a rise in NO - did not have an increased risk of PPH, but for women with moderate-to-severe anemia, which does cause a rise in NO, their risk for PPH did increase (after adjusting for confounders). Another study found that women with PPH who had to undergo a hysterectomy to save their life were significantly more likely to have severe anemia and higher blood loss compared to women with PPH who did not need to undergo a hysterectomy. A systematic review, published in theAnnals of the New York Academy of Sciences last year, showed a dose-response relationship between severity of anemia and PPH incidence. These studies are pointing to a potential direct and dose-response relationship between anemia and PPH.
Jean M. Bouquet, DO, is an Assistant Professor of Family Medicine and Co-Director of the Urban Underserved Track at the Rocky Vista University College of Osteopathic Medicine. He is the founder of the Bouquet Speculum, an innovative and FDA-cleared medical device that helps to screen women for cervical cancer. Dr. Bouquet also started the Cure Cervical Cancer nonprofit. The following blog post was written by Dr. Bouquet about his journey to creating the Bouquet Speculum.
Dr. Daniel Kimani is a trained and licensed medical officer in Kenya, holding a Bachelor of Medicine & Surgery, and a post-graduate certificate on basic oncology training. Dr. Kimani is the founder of the Global Cancer Care and Research Institute, and is an expert in clinical colposcopy — a procedure to examine the cervix, vagina, and vulva.