CLINICAL CASE PRESENTATION

Anemia in Pregnancy

AHMED FARRASYAH BIN MOHD KUTUBUDIN

071303511
BATCH 24 GROUP A2
Patient’s Profile
Name : Azizah Bt Sulaiman
Age: 33 years old
Race : Malay
Occupation : Housewife
Address : Bukit Limau,Melaka
Parity index : G3P2
POG : 31weeks + 3 days
LMP : 10/12/12
EDD : 17/9/13
DOA : 15/7/13
DOE : 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 menorrhagia
No contraception used
No 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
Inspection
Abdomen is uniformly distended
Flanks are full
Linea nigra,striae gravidarum and albican
are seen
Umbilicus is centrally placed and inverted
All quadrants move equally with respiration
No obvious fetal movemant
Hernial orifices are intact
Palpation

Clinical fundal height is at 30 weeks POG

Symphysiofundal height is corresponding to 28 weeks POG
Fundal grip : soft ,broad mass non-ballotable = fetal buttock
Maternal right : curved broad surface = fetal back
Maternal left : irregular knob like structure = fetal limbs
2nd pelvic grip : hard globular mass = fetal head
Auscultation
Fetal heart sound heard
Systemic examination : nothing significant
summary: 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 deficiency
2) Blood loss (acute/chronic)
• Bleeding during pregnancy
• Hookworm infestation
3) Increased RBC breakdown
• Malaria
• Sickle cell disease
• haemoglobinopathies
4) 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

Fatigue Pallor
Lassitude koilonychia
Anorexia Tachycardia
Breathless on exertion Pedal oedema
Dizziness Glossitis
Headache Stomatitis
Insomnia soft systolic murmur in mitral
Palpitation area
Dyspepsia Basal crepitation
Effects on pregnancy

ANTENATAL INTRANATAL POSTNATAL

Poor weight Dysfunctional Puerperal

gain labor sepsis
Preterm labor Sepsis Sub-involution
Pre-eclampsia Hemorrhage embolism
Abruptio and shock
placenta Cardiac failure
Intercurrent
infections
PROM
Diagnosis
1) FBC- Hb level
2) Peripheral blood smear
3) RBC indices-MCV is the most sensitive indicator
4) Reticulocyte count
5) Decrease Serum ferritin -1st abnormal laboratory test
6) Decrease transferrin saturation – 2nd
7) Increase free erythrocyte protoporphyrin(FEP)-3rd
8) Increase serum transferrin receptor – best indicator
9) Bone marrow examination
10) Stool examination
11) 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