Table Of ContentAN INVESTIGATION INTO THE TYPE, INCIDENCE, AND
PROPHYLAXIS OP GESTATIONAL ANAEMIA IN AN
INDUSTRIAL POPULATION, BASED ON A STUDY OP
AETIOLOGICAL PACTORS AND NORMAL BLOOD VALUES
IN PREGNANCY.
BY
T .0 .P.D.LAWSON, MB.Ch.B. D.OBst. R.C.O.G. D.P.H.
MEDICAL OPPICER OP HEALTH AND SCHOOL MEDICAL
OPPICER, COUNTY BOROUGH OP DUDLEY.
LATE ASSISTANT MEDICAL OPPICER OP HEALTH,
STAPPORDSHIRE COUNTY COUNCIL.
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Chapter I. Introduction.
Chapter II. C lassificatio n and A etiology of
Anaemia of Pregnancy.
Chapter III. Pernicious Anaemia of Pregnancy.
Chapter IV. Normal Haem atological Values in
Non-Pregnant and Pregnant Women,
and C rite ria of Anaemia of Pregnancy.
Chapter V. Present In v estig atio n .
Chapter VI. R esu lts.
Chapter V II. D iscussion.
Chapter V III. Summary.
CHAPTER I.
In tro d u ctio n :
Anaemia associated w ith the pregnant sta te is now
generally accepted as a c lin ic a l_ e n tity , and although
its incidence has been variously sta te d , i t is
undoubtedly a common condition which has been widely
recognised fo r many years. Nasse in 1836 was the f ir s t
to observe th at the number of red blood corpuscles was
reduced in the pregnant woman, but nearly a century was
to pass before the subject received the in te re st it
deserved. Indeed, u n til the turn of the century, l i t t l e
in te re st in the condition was aroused, and even as
recently as 1929 Galloway (a) could find only ninety
references re la tiv e to the subject, and a ll but ten of
these, d ealt w ith the pernicious v ariety . Henderson (1902)
stated th at the anaemia of pregnancy was a subject which
up t i l l th at time had received l i t t l e a tte n tio n , and
observed th at the lite ra tu re was very scanty, ch iefly
continental, and of a remote date. We are, however,
indebted to him fo r a summary of the chief contributions
p rio r to the beginning of th is century.
Oaseaux (1850) considered th at the pregnant sta te
was one e sse n tia lly analogous to ch lo ro sis, and believed
i t should be treated as such, but W illcocks (1881)
disagreed w ith th is theory. He showed th at the blood
p ictu re in pregnancy d iffered from th a t of chlorosis in
th a t, w hile the haemoglobin was reduced in both
conditions, the red blood c e lls were dim inished in number
only and were not impoverished as in ch lo ro sis. He
referred also to the increase in the w ater content of
the plasma. Spiegelberg and G scheidlin (1872), in an
exam ination of pregnent dogs reported a sim ilar increase
in the w ater content of the blood and also a dim inution
of the red blood corpuscles, and Becquerel and Rodier
(188^.) in a study of nine cases, confirmed these findings.
Lusk (1882) described the anaemia of pregnancy as a
condition of "serous plethora", w ith a dim inution of red
blood corpuscles and an increase in the w ater content of
the blood. He a ttrib u te d these changes to the demand
of the foetus on the m aternal system . P lay fair (1893),
refe rrin g to the deductions drawn by Caseaux, concluded
th at "the general blood sta te is tending to poverty and
anaemia? Charming f ir s t drew a tten tio n to the condition
in America in 181^2 and other contributions were recorded
by Kiswisch (I8I4.8), Scanzoni (1867), Lebert (1876) and
Cabot (1900).
With the turn of the century, the anaemia of
pregnancy began to receive wider recognition and more
frequent reference to the condition began to appear in
the lite ra tu re . In one such reference, Given (1906)
stated th at so fa r as he could discover, no E nglish
observer up t i l l th at tim e, had investigated the
haematology of pregnancy and the puerperium . While
th is may be true of the English lite ra tu re , i t certain ly
did not apply to Scotland, where Henderson (1902) had
already published h is "observations on the M aternal
Blood a t Terra and during the Puerperium ," from the
Glasgow Royal M aternity H ospital, He dem onstrated a
f a ll in haemoglobin, red blood corpuscles and a lowered
colour index during pregnancy. In America, Thomson (190^-)
published the resu lts of a sim ilar study, and Blumenthal
in Germany (1907) recorded his observations on a series
of cases. Gram (1920) pointed out th at it was probably
not generally known th at the blood of pregnant women had
a lower content of haemoglobin than th at of other normal
women, but he stated th at th is observation had already
been made by Andral in 1814-5. Alder in 192I4. commented
th at the anaemia of pregnancy was so common th at i t was
surp risin g how l i t t l e was known about i t . In th is
country, however, real in te re st in the subject was
stim ulated by the publicatio n in 1919 of a paper e n title d
"The Severe Anaemia of Pregnancy and the Post-Partum
S tate" by O sier, who is credited w ith the f ir s t re a l
contribution to the E nglish lite ra tu re . In sp ite of
th is increasing in te re st in the subject, no large scale
in v estig atio n s had as yet been carried out, and no
records were available of s ta tis tic a l studies of a large
se rie s of cases. The reason, however, for th is apparent
lack of in te re st in a common malady was probably the
m ildness of the symptoms produced, and the com parative
ra rity of serious com plications. As Whitby (1932)
observed, "anaemia of its e lf , severe enough to be an
alarm ing symptom, is in th is country, so rare a
com plication of pregnancy, th a t the subject has been
l i t t l e stu d ied ."
A fter the end of the f ir s t world war, anaemia of
pregnancy began to occupy a p o sitio n of ever increasing
prominence in the lite ra tu re , both in th is and in many
other countries, u n til a t the present time a vast and
varied lite ra tu re has accum ulated, dem onstrating the
wide prevalence of the condition. Many contributions
from well-known a u th o ritie s, and other workers, in th is
fie ld , have appeared. These w ill be referred to la te r.
That a wide in te re st in the subject became evident at
th is tim e was probably due to the 19114. - 1918 War w ith
its afterm ath of poverty, m alnutrition and lowered
standards of liv in g . L arge-scale in v estig atio n s of the
h ealth standards of the population were carried out, and
i t was n atu ral th a t these in v estig atio n s should include
the health of the expectant mother on whom must depend
the health of the future generation. Anaemia of
pregnancy, th erefo re, came to be widely studied and
much valuable inform ation has been obtained regarding
the aetiology, incidence and sev erity of the condition,
not only at th is period, but also during the recent
world war which offered a valuable opportunity fo r
comparison w ith pre-w ar in v estig atio n s. One would
mention esp ecially , in th is connection, a publication
of the M edical Research Council, "Haemoglobin Levels in
Great B ritain in 19k3 by the Committee on Haemoglobin
Surveys." This publication emphasized the need fo r a
continual check of the nation*s h ealth , pointing out,
in p a rtic u la r, th at there were s t i l l too many women
w ith haemoglobin values below the normal le v e l. I t w ill
be the object of the present in v estig atio n to attem pt
a post-w ar study of the hypochromic or iron-deficiency
anaemia of pregnancy and to draw a comparison w ith
re su lts published in th is country both before and
during the recent war.
Although th is increased in te re st in the subject,
and the publication of d etailed re su lts have g reatly
increased our knowledge of the condition, many facto rs
concerning the anaemia of pregnancy are s t i l l obscure
and co n tro v ersial. A lder, as already quoted, commented
on our lack of knowledge, and Irving in America (1935)
stated th at exam ination of the lite ra tu re revealed a
divergence and confusion of opinion regarding c la s s ific a
tio n , cause and treatm ent. This statem ent is amply
borne out when one attem pts to compare re su lts
published by various workers in th is and other co u n tries.
Among other things, th is sta te of a ffa irs is undoubtedly
due to the many d iffe re n t standards and c rite ria of
anaemia employed in c lin ic a l in v estig atio n s. Further
reference w ill be made to th is aspect of the subject la te r.
At the moment it may be said th at u n til an in tern atio n al
standard of haemoglobinometry has been estab lish ed and
d e fin ite haem atological c rite ria fo r the anaemia of
pregnancy accepted, no comparison of re su lts can be
attem pted With a re lia b le degree of accuracy. In sp ite
of th is, however, a study of the lite ra tu re , leaves no
doubt as to the prevalence and frequency of the anaemia
of pregnancy. I t is generally agreed also by a ll
au th o ritie s on the subject, th at the predominant anaemia
of pregnancy is the secondary or hypochromic type which
w ill form the subject of the present study.
I t w ill be seen from the foregoing, th at anaemia
associated w ith pregnancy is by no means a recent
discovery, although its recognition has only been acclaim ed
in com paratively recent years. Indeed, Brindeau and
Theodoiides (1935) quote reference to the subject in the
works of H ippocrates. Since the tim e of Nasse, however,
in te re st in the condition has stead ily increased, and
the lite ra tu re enriched by many valuable contributions,
which have helped to c la rify many of the more obscure
and controversial p o in ts. N evertheless, it would appear
th at the subject demands an in te re st even g reater than
th at at present shown. Although Nasse*s o rig in a l
observations were made in 1836, i t is in te re stin g to
read a century la te r in the T ransactions of the
Edinburgh O b stetrical Society th at "u n til 1919 when
O sier made his survey, there was no publication of note
in th is country, and even now, textbooks on o b ste trics
or haematology devote very l it t le space to th is su b ject.
(Stevenson 1938).
