Anemia during pregnancy continues to be a major public health problem worldwide, particularly in developing countries such as India, where it contributes significantly to maternal and perinatal morbidity and mortality. According to the World Health Organization (WHO), anemia in pregnancy is defined as hemoglobin concentration  < 11 grams/dl , while severe anemia is defined as hemoglobin levels < 7 grams/dl^.[1]Pregnancy is associated with physiological hemodilution due to expansion of plasma volume, which may aggravate pre-existing anemia and reduce oxygen-carrying capacity^.[2] Severe anemia compromises oxygen delivery to maternal tissues and the developing fetus, resulting in adverse maternal and fetal outcomes^.[3]

Maternal complications associated with severe anemia include preterm labour, postpartum hemorrhage, puerperal sepsis, cardiac failure, increased need for blood transfusion, and maternal mortality^.[3,4] Fetal complications include intrauterine growth restriction, low birth weight, prematurity, birth asphyxia, and increased perinatal mortality^.[4,5]

Despite various national initiatives such as the National Iron Plus Initiative and intensified antenatal care services, the prevalence of anemia in pregnancy remains high due to poor nutritional status, inadequate antenatal care, low socioeconomic pregnancy conditions, and poor compliance with iron supplementation^.[6,7]

Therefore, the present study was undertaken to prospectively evaluate the fetomaternal outcomes among pregnant women with severe anemia.

Objectives:

• To assess the fetomaternal outcomes in pregnancies complicated by severe anemia
• To identify the maternal complications associated with severe anemia
• To evaluate neonatal outcomes among women with severe anemia
• To determine the need for blood transfusion and critical care support in pregnant women with severe anemia.

MATERIALS AND METHODS

Study Design: Prospective observational study

Study Setting: Department of Obstetrics and Gynecology at a tertiary care teaching hospital

Study Duration: March 2024 -August 2024

Study Population: Pregnant women presenting to the antenatal outpatient department (OPD) or labour ward and diagnosed with severe anemia were enrolled in the study.

Inclusion Criteria:

• Pregnant women with a hemoglobin level of <7 g/dL.
• Gestational age between 28 and 40weeks.
• Antenatal women who provided written informed consent to participate in the study

Exclusion Criteria:

• Known hemoglobinopathies, chronic systemic illnesses, such as renal or cardiac disease.
• Acute obstetric hemorrhage.

Sample Size:

A total of 50 antenatal women with severe anemia were included in the study

Data Collection: Data collection was commenced only after approval from the Institutional Ethics Committee, written informed consent was obtained from all the participants before their enrollment in the study, each participant underwent a detailed clinical evaluation including:

Demographic profile: age, parity, socioeconomic status

Antenatal care status: booked/unbooked Clinical examination findings, laboratory investigations, including hemoglobin estimation, peripheral smear, additional tests where feasible

Management Protocol: Patients received appropriate management based on clinical condition:
Statistical Analysis: SPSS 26.0 was used for analysis, results were expressed in terms of percentages, mean, and standard deviation.

RESULTS

Table 1. Age Distribution

Majority of the severe anemia cases belonged to the 20-24 years age group 64% (n= 32).

Table 2. Residence

The majority of women with severe anemia were from rural areas 72% (n= 36).

Table 3. Educational Status

Most women were illiterate (44%), followed by those with primary education (36%).

Table 4. Socioeconomic Status

The majority women of with severe anemia belonged to the lower socioeconomic class 60% (n=30).

Table 5. Booking status

Out of the 50 women, 68% (n=34) were unbooked

Table 6. Gravidity

The majority of women were multigravida 68% (n=34)

Table 7. Gestational Age at Admission

Most women with anemia were admitted between 32and 36+6 weeks of gestational age52%(n=26).

Table 8. Severity of Anemia

Most women had severe anemia 90%(n=45) while 10% had severe anemia.

Table 9. Blood transfusion Requirements

Most women 40% (n =20) received 2 units of blood transfusion.

Table 10. Mode of Delivery

In the present study 56% women delivered by vaginally, while 24% underwent assisted vaginal delivery.

Table 11. Birth Weight

Most newborns 44 % (n=22) had a birth weight of 2.0-2.49kg.

Table 12. Gestational Age at Delivery

In the present study 64%(n=32) of deliveries were preterm.

Table 13. Maternal and Fetal outcomes among Women with severe anaemia

In the present study, postpartum hemorrhage was the most common maternal complication, occurring in 7 (14%) of women, followed by preeclampsia in 6 (12%) NICU admission was required for 14 (28%) of newborns, while 12 (24%) of newborns had a low Apgar score.

DISCUSSION
The present study demonstrated that severe anemia during pregnancy is associated with significant adverse maternal and neonatal outcomes. A large proportion of women in our study were unbooked and had received inadequate antenatal care. Similar observations have been reported by Singh S, Kaur K et al.who found that inadequate antenatal care and delayed diagnosis contributed significantly to severe anemia _[2]

Postpartum hemorrhage was one of the common maternal complications observed in the present study. similar findings have been reported by Cheng et al^{, [6,12].} Severe anemia reduces the physiological reserve of pregnant women and may predispose them to poor tolerance of blood loss during delivery^.[3]. The high requirement for blood transfusion observed in the present study is comparable to findings reported by CLIP India Trial ^[5].

Preterm labour and low birth weight were among the major fetal complications identified. Maternal anemia leads to chronic fetal hypoxia and impaired placental function, resulting in restricted fetal growth and premature delivery which is comparable with the Rahman et al study ^[4,9]. In a large systematic analysis, reported a significant association between maternal anemia and adverse birth outcomes including low birth weight and preterm birth^.[4,7]

The increased incidence of NICU admission and newborn with low Apgar were  observed in the present study is also consistent with previous reports indicating that severe maternal anemia adversely affects neonatal survival and immediate postnatal adaptation^.[5,9,10]

Overall, the findings of the present study support existing evidence that severe anemia remains an important and preventable contributor to adverse fetomaternal outcomes. Early diagnosis through routine antenatal screening and timely management with iron therapy and blood transfusion where indicated can substantially improve maternal and neonatal health outcomes. ^[8,9,11]

CONCLUSION:

Severe anemia during pregnancy is associated with significant adverse maternal and neonatal outcomes, including preterm labour, postpartum hemorrhage, increased blood transfusion requirement, low birth weight, prematurity, NICU admission, and increased perinatal morbidity. The findings of this prospective observational study highlight that women from lower socioeconomic backgrounds and those with inadequate antenatal care are at greater risk of developing severe anemia and its associated complications, early detection through routine antenatal screening, prompt correction of anemia with Iron therapy and blood transfusion when indicated, appropriate nutritional counseling, and timely referral to tertiary care centers can substantially improve maternal and  neonatal outcomes. Strengthening antenatal care services, improving community awareness regarding maternal nutrition and iron supplementation, and ensuring early identification and management of severe anemia should remain public health priorities for reducing maternal and neonatal morbidity and mortality.

Conflict of interest: The authors declare that there is no conflict of interest regarding the publication of this article.

Funding: No external funding was received for this study.

Ethical Approval: The study was approved by the institutional Ethics Committee.

REFERENCES

1. World Health Organization. Global prevalence of anemia in 2019. Geneva: WHO; 2021.
2. Singh S, Kaur K. Maternal outcomes in cases of severe anemia in labour(IJRCOG,2018)
3. Bhutta et al./Global Network study(BJOG,2019),Prospective multi-county cohort.
4. Rahman MM, Abe SK, Rahman MS, et al. Maternal anaemia and adverse birth outcomes: a systematic review and meta-analysis. Lancet Glob Health. 2016;4(10): e736-e743.
5. CLIP India Trial(BMC Pregnancy and Childbirth,2022.. ‘
6. Shi H et al.(JAMA Network Open,2022)
7. Government of India. National Iron Plus Initiative: Guidelines for Control of Iron Deficiency Anemia. New Delhi: Ministry of Health and Family Welfare; 2013.
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