CLINICAL CASE PRESENTATIONAnemia in Pregnancy

AHMED FARRASYAH BIN MOHD KUTUBUDIN071303511

BATCH 24 GROUP A2

Patient’s Profile

Name : Azizah Bt SulaimanAge: 33 years oldRace : MalayOccupation : HousewifeAddress : Bukit Limau,Melaka Parity index : G3P2POG : 31weeks + 3 daysLMP : 10/12/12EDD : 17/9/13DOA : 15/7/13DOE : 17/7/13

Chief Complaint

• Referred from KK Cheng due to low hemoglobin level (9.2 g/dl)

History of presenting illness

• Patient was found to be anaemic when she went for her booking on 26/2/2013

• She was then started on oral iron, folic acid, vitamin c and vitamin b complex.

• However, when she went for antenatal check up on 15/7/2013,at 30 weeks of gestation,she was told again that her Hb level was low (9.2g/dl).She was then referred to MGH.

• There is no lethargy,shortness of breath,palpitation,dizziness,syncopal attack or headache.no bleeding/leaking PV,no abdominal contraction and fetal movement is good

• Upon arrival at MGH,she was sent to labor room where USG&CTG was done and found to be normal

• Blood and urine sample was taken for investigations

• She was later sent to the ward• Patient is currently well but worried that her

condition will affect her baby.

History of presenting pregnancy

• Unplanned pregnancy• Confirmed by urine pregnancy test and USG at 10

weeks amenorrhea at KK Cheng• Booking & dating scan was done at the same time• Blood test non-reactive for HIV,Hepatitis B&C and

syphilis• Urine investigation normal• Blood group B+• Hemoglobin level on 1st antenatal check up was

low(10g/dl)• She received iron,folic acid,vitamin c and vitamin b

complex• Advised to take iron rich food

• Quickening felt at 5 months of gestation.

• Fetal scan in 2nd trimester was normal

• Fetal movement was well appreciated

• No MGTT done

Past Obstetric history

2008

term baby,NSVD,anemia,2.7kg(G),6/12

2009

term baby,NSVD,3.3kg(B),6/12

Past Gynecological History

Nil

Menstrual History

Attained menarche at 11 years old.Regular cycle with normal flow for 7 days of 28-30 days cycle

11(7/30)

No dysmenorrhea , no menorrhagiaNo contraception usedNo history of pap smear

Past medical & surgical history

Nil

Family history

Youngest of 3 siblings.All family

members are healthy.

Personal History

She takes normal balance diet in small amount.

No loss of appetite

No loss of weight

Normal sleeping pattern

Normal bowel & bladder habit

Non-smoker and do not consume alcohol

No known drug allergy

Socioeconomic history

Married for 6 years.

Staying with husband and 2 childrens.

Monthly family income is RM 3000

Summary

33 years old G3P2 at 31 weeks + 3 days POG referred from KK Cheng due to anemia in pregnancy with current hemoglobin

level of 9.2g/dl.She is currently well

General Physical Examination

• Patient alert,cooperative,comfortably lying on the bed.• She is small built and moderately nourished.BMI 21.8 kg/m2• There is pallor of nail bed but no koilonychia/platynychia• Vital signs :• pulse rate : 78 beats /min, regular rhythm,normal volume• BP : 120/70 mmhg• RR: 20 breath/min• temperature : 37 C• Eyes: There is pallor of lower palpebral conjunctiva,no icterus• Mouth : there is pallor, no sublingual icterus, oral hygiene is fair,

no glossitis&stomatitis• Neck : no obvious neck swelling,no cervical lymphadenopathy• Breast : no lumps,no nipple discharge/retraction• Lower limbs : no pedal oedema

Abdominal Examination

InspectionAbdomen is uniformly distendedFlanks are fullLinea nigra,striae gravidarum and albican

are seenUmbilicus is centrally placed and invertedAll quadrants move equally with respirationNo obvious fetal movemantHernial orifices are intact

Palpation

Clinical fundal height is at 30 weeks POGSymphysiofundal height is corresponding to 28 weeks POGFundal grip : soft ,broad mass non-ballotable = fetal buttockMaternal right : curved broad surface = fetal backMaternal left : irregular knob like structure = fetal limbs2nd pelvic grip : hard globular mass = fetal headAuscultationFetal heart sound heardSystemic examination : nothing significantsummary: singleton pregnancy, longitudinal lie ,cephalic

presentation with head 5/5th palpable

investigations

1. FBC

• Hb 92.0 g/L (120.0-150.0)

• MCV 73 fl (83-101)

• MCH 24.1 pg ( 27.0- 32.0)

• MCHC 33.0 g/dl (31.5-34.5)

2. peripheral smear

- microcytic hypochromic anaemia

3. iron/TIBC

iron 31.1 umol/L (6.6-26)

TIBC 74.4 umol/L (60.8-76.6)

4. Serum ferritin 8.11 ng/mL (13-150)

5.Hb analysis results pending

6.TAS- parameters corresponding to POG

DISCUSSION

• Definition• low circulating haemoglobin in which

haemoglobin concentration has fallen below the threshold level of 2 standard deviations below the median value for healthy matched population.

- Hb concentration of < 11g/dl or hematocrit level <0.33 (WHO)

- Hb concentration <10 g/dl (hospital protocol)

Causes of anaemia in pregnancy

1) Lack of production of blood• Iron,folic acid,protein,combined deficiency2) Blood loss (acute/chronic)• Bleeding during pregnancy • Hookworm infestation3) Increased RBC breakdown• Malaria• Sickle cell disease• haemoglobinopathies4) Decreased RBC production• Aplastic anaemia• myelosuppression

Pathophysiology of Anaemia in Pregnancy

1 Haemodilution during pregnancy• Increase in blood volume during

pregnancy beginning at 8 weeks and reaching its peak at 32 to 36 weeks of pregnancy. This involves disproportionate rise in plasma volume compared to red cell volume (plasma increase estimated around 50% while red cell volume around 30%)

• This causes a general physiological fall in Hb levels in later half of pregnancy

2 Iron Deficiency anaemia in pregnancy

• Poor Intake – diet deficiency, vomiting

• Poor Absorption – presence of phosphate, increased pH of gastric juice, ferric ions in gut, lack of vitamin C

• Excessive iron loss – repeated pregnancies, menorrhagia, hookworm infestations, chronic malaria

• Total iron requirement is 1000mg (fetus and placenta=300mg, increase in red cell mass=500mg, basal loss=200mg). Average requirement is 4-6mg/day (2.5mg/day in early pregnancy, 5.5mg/day from 20-32 weeks, 6-8mg/day from 32 weeks onwards)

Clinical features

symptoms signs

FatigueLassitudeAnorexia Breathless on exertionDizzinessHeadacheInsomniaPalpitationDyspepsia

PallorkoilonychiaTachycardiaPedal oedemaGlossitisStomatitissoft systolic murmur in mitral areaBasal crepitation

Effects on pregnancy

ANTENATAL INTRANATAL POSTNATAL

Poor weight gainPreterm laborPre-eclampsiaAbruptio placentaIntercurrent infectionsPROM

Dysfunctional laborSepsisHemorrhage and shockCardiac failure

Puerperal sepsisSub-involutionembolism

Diagnosis

1) FBC- Hb level2) Peripheral blood smear3) RBC indices-MCV is the most sensitive indicator4) Reticulocyte count5) Decrease Serum ferritin -1st abnormal laboratory test6) Decrease transferrin saturation – 2nd

7) Increase free erythrocyte protoporphyrin(FEP)-3rd

8) Increase serum transferrin receptor – best indicator9) Bone marrow examination10) Stool examination11) Hb electrophoresis – HbA2 for thalassemia

Prevention

• Iron tablet 200mg (60 elemental iron) and 500 mcg folic acid daily during the last 100 days of pregnancy

• Hb estimation at least 4 times in pregnancy

- at 1st antenatal visit

- 24-26 weeks pog

- 32-34 weeks pog

- before term

“ Oral iron given reduced the risk of being anemic in 2nd trimester,and Hb and ferritin level are higher (WHO)”

Management

• Aim : Hb at least 10g/dl at term

1 Oral iron therapy

- ferrous sulfate,ferrous fumarate/ ferrous

gluconate

- dose : 200 mg tds

- expectation : reticulocyte count rises within 5-10 days, rise in Hb by 0.1-0.2g/dl/day starting from 2nd week.Hb rises 2g/dl after 3 -4 weeks

2 Parenteral iron therapy- Iron dextran (Imferon)- 100 mg of

elemental iron in 2ml ampoule route :im/iv- Iron sorbitol single im,not exceed 100mg

Blood transfusion

• Transfusion should be considered in a woman at or above 34 weeks pog with Hb< 7g/dl

Transfusion should be done before developing very severe anemia(<5g/dl) as it is usually associated with imminent heart failure and increase risk of mortality (WHO)

RED CELL TRANSFUSION IN ANEMIA IN PREGNANCY

• POG <3 6 weeks – Hb level <5g/dl even w/out clinical signs of cardiac failureand hypoxia

• POG>36 weeks – Hb 6/below

• Intrapartum (just before delivery) –

Hb <8 g/dl requires cross matching of 2 unit of blood and made it available

• Elective LSCS-

group screen and hold is recommended

REFERENCES

• Obstetric today 1st edition

• WHO guidelines for treatment of IDA in pregnancy

• MGH Protocol