Anemias in Pregnancy

The following is reprinted from The Brewer Medical Diet for Normal and High-Risk Pregnancy, published in 1983. Although it was written 20 years ago, I believe that the principles presented here apply just as well to pregnancies today.

If after reading this explanation of anemia from Gail and Dr. Brewer, you and your midwife decide that you need some kind of iron supplementation, I recommend the Floradix supplement over any other iron supplements.

At your first prenatal visit, a sample of your blood is drawn and analyzed for many different conditions. If the volume of red blood cells in your circulation [hematocrit] is less than 36 percent and/or the hemoglobin (the red pigment inside the cells that carries oxygen) level is reduced below 12 grams per 100 milliliters of blood, you are likely to be told that you are anemic.

Some anemias are nutritional. Some are not. The nutritional anemias far outweigh the nonnutritional. Williams Obstetrics, the standard textbook used in American medical schools, lists thirteen different types of anemias. The correct treatment depends on which type or types you have. All too often, an accurate diagnosis is not made; a pregnant woman with a low hemoglobin/hematocrit reading is given a prescription for some iron and folic acid supplements as a prenatal care routine, then retested at the next visit.

If your first blood test indicates that you are anemic (and there has been no laboratory error), you should request that your doctor fully evaluate your condition. This is done by:

If your nutrition up to the time of conception has not been the best, you need to start improving your diet at once as outlined in Chapters 2 and 3 [see the "Physiology" page and the "Vegetarian" page of this website]. Because several essential nutrients are required to manufacture red blood cells, merely adding iron and folic acid pills to a poor diet is unlikely to bring you into the pink of condition. Furthermore, large doses of iron can irritate the lining of your gastrointestinal tract, causing nausea, vomiting, abdominal cramps, and constipation. Under these circumstances, you are likely to lose your appetite, aggravating your undernutrition even more. If you iron supplements make you sick to your stomach or turn your stool black, you have exceeded the dose that's right for you. Turn instead to the foods that contain iron and the other substances necessary to red blood cell formation, such as red meats, eggs, liver, molasses, whole wheat, seafood, green leafy vegetables, nuts, and legumes.

If your nutrition satisfies the requirements for pregnancy, or has been corrected to do so, and your hemoglobin/hematocrit reading still shows anemia, you may have any of a number of other medical diseases or conditions that produce anemia. Your doctor or midwife may refer you to an internist for consultation.

In the usual course of events, your hemoglobin/hematocrit will not be assessed again until about four weeks before delivery. If you were not anemic at the start of pregnancy and you have been following our diet faithfully throughout pregnancy, your values should be somewhat lowered from what they were at the beginning. This is due to the dilutional effect of the markedly expanded plasma volume in your bloodstream. Your red blood cells are simply surrounded with more water than before as your body prepares for labor and the likelihood that you will experience some blood loss at that time. The expanded blood volume is also essential to maintaining optimal perfusion of your placenta during these last few weeks of pregnancy, when your baby requires so much more in terms of nutrition than was the case in the first half of pregnancy.

Agnes Higgins, director of the Montreal Diet Dispensary, and numerous other investigators have reported that when mothers are documented to be on adequate pregnancy diets, the lowest hemoglobin/hematocrit values are consistently associated with the largest babies: hematocrits of 30 go along with the 11-pounders, 31 with the babies who weigh 10 pounds at birth, 32 with those at 9 pounds, and so on. The reason is that the larger blood volumes transport more nutrients to the placenta per given amount of time than do smaller blood volumes. And the babies benefit from the extra nutrition as evidenced by their improved growth.

By the same token, a rising hematocrit/hemoglobin value in the last weeks of pregnancy should be a red flag, alerting you that something is amiss with your nutrition or that you have developed some other medical complication requiring diagnosis and treatment. Rising hematocrit/hemoglobin values indicate that the water compartment of your bloodstream is shrinking, placing both you and your baby at extreme risk for complications such as intrauterine growth failure, abruption of the placenta, metabolic toxemia of late pregnancy, fetal distress during labor, and going into shock after delivery.

In our practice, we start worrying when the hematocrit reaches 38 in the last month of pregnancy (hemoglobin is generally one-third that of hematocrit). The only exceptions to this policy are women who live at high altitudes and those who have been taking extra iron in addition to following a high-quality diet. High altitudes induce the body to produce more red blood cells to compensate for the reduced concentration of oxygen in the atmosphere. Eating exeptionally well and taking extra vitamin-mineral-food-extract supplements may also stimulate the bone marrow to produce more red cells.

We order an SMA blood chemistry test to determine whether the blood proteins are normal and whether the liver and kidneys are also functioning normally. Most often, when the hematocrit is up, the proteins are down because of a problem in the mother's dietary pattern. In late pregnancy, for instance, a ten-day to two-week bout with a severe flu can interrupt your good nutrition (because of nausea, vomiting, diarrhea, and the general malaise that makes you feel disinclined to eat), resulting in these internal changes in your circulating clood supply. Even just cutting down on your sodium intake for a couple of weeks can reduce the amount of blood in your circulation. Likewise, excess perspiration causes losses of water and sodium, which must be replaced in order to keep your blood volume expanded to you8r level of pregnancy need.

The only corrective measure to be taken if your hemoglobin/hematocrit values are rising because of problems with your diet is to get back on our diet immediately. These changes can be reversed only if you step up your protein and calories, take salt to taste, drink to thirst, and rest when you are tired.

It is ironic that many low-risk hospital birthing rooms and most out-of-hospital birthing centers and home birth practitioners "risk out" mothers whose hematocrits fall below 34! That is, the mothers on good diets whose blood volumes are the most expanded and who present the least chance of any complications at delivery are labeled "high-risk" and denied the birth experience they have worked so hard for.

The confusion in the minds of medical professionals arises from observations made over the years in poorly nourished mothers with low hemoglobin/hematocrit values toward the end of pregnancy who did indeed suffer an extraordinarily high rate of complications. They are truly anemic, not just appearing so because of a well-expanded blood volume. They are exceptionally high-risk--not because their hematocrit is below 34, but because of their profound malnutrition.

In other words, excluding those with anemias due to medical diseases, there are two kinds of women who show up with low hemoglobin/hematocrit at the ninth month of pregnancy: the well-nourished and the poorly nourished. Treating them both as though they were at the same level of risk is not in the best interest of the patients. Careful evaluation of both low and high hemoglobin/hematocrit toward the end of pregnancy is indicated in every case.