CBC How to read

Prepared by
Dr.Hesham Abd Elaziz
Elmahalla gen. hosp. Egypt
+2 01069241551
If you don't use it
you lose it !
Contents
 1- What is CBC
 2- Why CBC
 3- Parameters of CBC
 4-What is normal ,what is abnormal
 5-diagnostic possibilities
 6-How CBC can direct management
CBC is an inexpensive
maneuver
Can help us in diagnosing
1-Blood diseases
2-Bone marrow conditions
3-Other organ abnormalities
CBC can diagnose
1-Anaemia
2- Bone marrow suppression
3-Nutritional deficiencies
4-Thrombocytopenia
5-Autoimmune conditions
6-Infections and infestations
7-Haemoglobinopathies
8- Response to treatment
Blood
Components
Blood is made
of two major
components
plasma and
cells
The plasma consists of
water, plasma proteins
(albumin , globulin and
fibrinogen), and other
constituents
Cells of the blood
include the
1-Erythrocytes
2-Leukocytes
3-Platelets
What does
CBC
analyze ?
1- RBCs
2- hemoglobin
3-reticulocytes
4-haematocrit
5- mean corpuscular volume
6- mean corpuscular hemoglobin
7-mean corpuscular hemoglobin
concentration
8-Differential WCCs count
9- Platelets
The most important
values is
1-Haemoglobin
2-MCV
3-Reticulocytes
4-Leukocytic count
5-Platelets
 RBCs count in female 4.1-5.4
million/cmm

Decreased in Increased in
 1-Iron deficiency  1-PE
 2-Chronic blood loss
 2-OHSS
 3- Haemolysis
 4-Bone marrow
 3-CHF , hypoxia
suppression smokers
 5-Chronic liver  4-Highlanders
disease  5- Polycythemia vera
 6-Leukaemia
 malignancy
 7-Hyperthyroidism
1-Increased RBCs count &
High Hb & haematocrit
&High risk for pre-eclampsia
investigate for PE
1-Albumine in urine
2-MCV
3-Uric acid
4-Liver function tests
5-Renal function tests
1-Increased RBCs count &
Hb
haematocrit
High risk for OHSS
investigate for OHSS
1-Leukocytic count
2-Serum albumin
3-Kidney function tests
4-Coagulation profile
Normal Hb in female 12-16 gm/dl

Decreased in Increased in
 1- Iron deficiency  1- PE
anemia
 2-Thalassemia  2- OHSS
 3-Chronic liver  3- Hypoxia,
disease
 4-Haemolysis
smokers, CHF
 5-Hyperthyroidism  4- Polycythemia
 6-Malignancy vera
 7-leukaemia
Haemoglobin
1-Pre-operative preparation
>9.5g/dl
2-Before bloody operations : 11g/dl
3-Pre-operative for placenta
praevia / accreta 12g/dl
4-Blood transfusion : if Hb is 7gms
or less
 Haematocrit (PCV) in women 37-47%
in pregnant 33-44%

Decrease in Increase in
 1- Anaemia  1-PE
 2-Blood loss  2- OHSS
 3-Chronic liver  3-CHF
disease  4-Smokers
 4- Hyperthyroidism
 5-Dehydration
 5-Haemolysis
 6-Leukaemia
 6-Polycythaemia
 7- Malignancy
vera
 8-Thymus  7-Hyperspenism
hypofunction
Rule of 3
RBCs x 3 = Haemoglobin
Haemoglobin x 3 = haematocrit
If haematocrit
>45 % severe OHSS
(Patient should be hospitalized)
>55% critical OHSS
Leukocytic count > 25.000/cmm
(Refere the patient to ICU)
Reticulocytes :
These are the immature red
cells
If the cause of anaemia in the bone
marrow , reticulocytes
If the the cause of anaemia outside
bone marrow ,reticulocytes
Normal levels are 0.5-1.5%
 Reticulocytes
Decreased in Increased in
 1-Aplastic anaemia  1-Haemolytic anaemia
 2-Megaloplastic  2-Pregnancy
anaemia
 3-Recent Hge
 3-Anaemia of chronic
disease  4-Response to
 4-Cirrhosis treatment
 5-Radiation  5-Thalassaemia
 6-Decreased ACTH  6-Hypoxia
and pituitary  7-Leukaemia
hormones
Indices
1- (MCV) mean corpuscular volume
2- (MCH) mean corpuscular
hemoglobin
3- (MCHC) the mean corpuscular
haemoglobin concentration
4- (RDW) red cell distribution width
MCV means volume of red blood
cells = cytic
MCV = Hct / RBCs
Normal values are 80 -100 fl.
<80fl microcytic anaemia
>100fl macrocytic anaemia
MCV <72fl without heterogenecity
is a sensitive and specific test for
thalassaemia trait
The MCV can be normal
with a low hemoglobin if
the patient is
hypovolemic or has had a
recent blood loss
MCV <80 fl in microcytic
cells as:
1-Iron deficiency
2-Thalassemia
3-Chronic disease
4- Lead poisoning
5- Porphyria
MCV < 80 fl (microcytic)
1- test ferritin
2- exclude haemoglobinopathies
Iron supplementation if
indicated oral or parenteral
CBC after 2wks
Iron is continued 3ms after
Haemoglobin became normal
MCV 80-100 fl(normocytic)
If Hb 8.5gm/dl or less
*CBC/m and
*test ferritin , folate , B12 and
reticulocytes
If normal : CBC /month
If abnormal give supplementation
MCV >100 fl (macrocytic)
caused by
1-Megaloblastic anaemia
2-Folate or Vitamin B12 deficiency
3-Liver disease
4-Post-splenectomy
5-Chemotherapy
6-Hypothyroidism
MCV > 100 fl (macrocytic)
Investigate B12 , Folate
Liver function tests
Thyroid function tests
CBC / month
give folic acid 5 mg /d orally
If low B12 give B12 supplementation
If normal B12
Investigate reticulocytes
?referal
 MCV<80fl (microcytic)
X = MCV – (Hb X5) - 3.5
 If
X is  IfX is
positive negative
 Iron  Thalassaemi
deficiency a is
anaemia is suggested
suggested
MCH: is the average weight of
hemoglobin per red cells
Give the colour of the cells = chromic
Most macrocytic are normochromic
Most microcytic are hypochromic
except chronic disease
MCH = Hb / RBCs x100
Normal level is 27 -32pg
Decreased in microcytic anaemia
Increased in macrocytic anaemia
MCHC:
is the average concentration of
hemoglobin per erythrocyte
Normal levels =32-36%
MCHC = Hb / Hct x10
MCHC in
1- Iron deficiency
2- Thalassaemias
Normal levels of MCHC
are 32 -36 %
RDW:
Measures the variation of red
blood cell volume
It is used in conjunction with MCV
to determine if anaemia is due to
mixed cause or a single cause
RDW = anisocytosis
In microcytes RDW raised with Fe
defeciency , in thalassaemia ,not
Normal levels are 11.5-14.5%
 Causes of anaemia by MCV
Microcytic=<80fl Normocytic = 80-100fl= Macrocytic >100fl=
= < 7micron 7-8micron >8.3micron

1- Sideroplastic 1- Acute blood 1- Megaloplastic

loss -B12 deficiency
2- Fe
2- Haemolytic -Folic acid
deficiency anaemia deficiency
3- 2- Nonmegaloplastic
3- Sickle cell
Thalassaemia -Pregnancy
disease -Reticulocytosis
4-Haemoglobin
4- -Liver disease
opathies
Haemoglobinop -Alcohol
5-Chronic -3-Hypothyriodism
athies
infections
 Microcytic anaemia
MCV<80fl= Serum iron TIBC Bone marrow
<7micron perls stain

Iron Decreased Increased 0

deficiency
anaemia
Chronic Decreased Decreased ++
infections
Thalassaemia Increased Normal ++++
Haemoglobin Normal Normal ++
opathies
Lead Normal Normal ++
poisoning
Sideroplastic Increased Normal ++++
 Iron deficiency anaemia

Iron related Normal Fe deficiency

tests a
S. Ferritin (p 33-270
mol/L) <33
TIBC(ug/dl) 300-340 >400
S. Iron (ug/dl) 50-150 <30
Saturation % 30-50 <10
Bone marrow ++ Absent
 Iron deficiency anaemia

1-Microcytic MCV< 80fl RBC <7u

2-Hypochromic MCH <27pg
MCHC <30%
3-Reticulocytes >2%
4-S.ferritin < 30pmol/l
5-TIBC >400 ug/dl
6-Serum iron <30ug/dl
7-Bone marrow stain Absent
8-Response to treatment Excellent
Macrocytic anaemia MCV>100fl
1-Megaloplastic anaemia
Folic acid deficiency
B12deficiency
2- Non megaloplastic
Haemoglpbinopathies
Hypothyroidism
Drugs as immunosuppressant
anticonvulsants
Treatment of IDA
I-dietary iron(heme & non-
heme)
II- Oral iron (tablets & syrups)
III- Parenteral iron(IV&IM)
IV- Erythropoietin
V- Blood transfusion
II- Oral iron
Elemental iron 100 to 200 mg/d
until Hb becomes normal
then prophylactic doses
30-120mg
3 months postpartum to
replenish iron stores
 III-parenteral iron
It is permittible from the 2nd trimester
and postpartum period when :
1- Non-compliance with, or
intolerance to oral iron therapy
2- Malabsorption
Dose (mg) : Body wight (kg) X Hb
deficit(in grm) X 0.24 + 500mg to
replinish iron store
 3-Ertthropoietin

Indications:
1-Chronic renal failure
2-Religion indications
 IV-Blood transfusion
No cut of levels
The indications should consider
clinical and haematological points
Transfusion is rarely indicated in the
stable patient when Hb is >10 g/dl and
is almost always indicated when <6
g/dl
MCV>110fl
Consider folic acid and
B12 deficiency
MCV=100-110fl
Consider other causes
of
Megaloplastic anaemia
 Folic acid supplementation
1- Prophylactic of NTD and some
congenital anomalies(?heart) started 4-8
wks before &first12 wks after pregnancy
Dose: 400-500µg/d
5mg/d is recommended in
1- History of NTD
2- Epileptic drugs
3- Obesity & DM
4- Multiple pregnancy
2-folic acid deficiency anemia (5%)
Prevention : 400-500µg/d
Treatment: 1-5mg/d up to 3times /d 12wks
before pregnancy and 1st trimester
Normocytic anaemia
1-Chronic disease
2-Early iron deficiency anaemia
3-Heamoglobinopathies
4-1ry bone marrow disorder
5-Combined deficiencies
6-Haemolysis
7-Anaemia of investigations (ICU)
Anaemia of chronic
disease
1-Thyroid disease
2-Malignancy
3-Collagen vascular disease
*Rheumatoid arthritis
*SLE
*Poly arteritis nodosa
*Chronic infections as
HIV , Osteomylitis,TB
*Renal failure
Dimorphic anaemia
1-Folic acid deficiency
combined
with Fe deficiency as
pregnancy
2-B12and Fe deficiency
3- Iron deficiency and
haemolysis
RDW is increased very much
Leukocytic count:
1- Neutrophils
2- Bands
3- Eosinophils
4-Monocytes
5- Lymphocytes
Two types of WBCs
A-Granuloctes
1-Neutrophils 50-70%
2-Eosinophils 1-5%
3-Basophils up to 1%
B-Agranulocytes
1-Lymphocytes 20-40%
2-Monocytes 1-6%
The change of a number of
cells depends on the function
1-In bacterial infections ,
Neutrophils are mostly affected
2-In viral infections ,Lymphocytes
are mostly affected
3-In parasitic infestations ,
Eosinophils are mostly affected
Leukocytic count
1- Normal level 4.000-11.000/cmm
2- In pregnancy 6.000-15.000
/cmm
3- Leukocytosis in pregnancy
> 15.000/cmm
4-Chorio-amnionitis WCC
> 15.000 /cmm
5-Critical OHSS WCC
>25.000 /cmm
Bands:
Immature neutrophils which are
released after injury or
inflammation
An increase in the release of
immature cells is known as a
shift to the left
Normal level ranges from
0 – 4%
Neutrophils:
The function of neutrophils is
to destroy and ingest bacteria
Neutrophils arrive first at the
site of inflammation , their
numbers will greatly
immediately after an injury or
during the inflammatory
process
Neutrophils life span is 10hrs (n:45-74%)

Increase in Decrease in
 1-Inflammation  1-Viral infections
 2-Hypersplenism
 2- Bacterial  3-Agranulocytosis
infections causing drugs as:
Carbamazipine
 3Corticosteriod
 Clozapine
 4-Necrosis  Colchicine
from burns and  Carbimazole
MI  4-Bone marrow failure
 5-Stress
Eosinophils: found in skin ,the
airway and blood stream
Increase in allergic , inflammatory
reactions and parasite infestations
Normal blood levels range from
0 -7 %
.
Basophils: Called basophils
when found in the blood
Called Mast cells when found in
the tissues ( GIT , RT and the skin)
They contain heparin and histamine
Basophils may contribute to
preventing clotting in
microcirculation
Basophils
Normal level is 0-2%
Increase in
1-Allergy
2-Viral infections
3-Inflammatory disorders
4-Lymphoma
5-Radiation exposure
6-Leukaemia
 Monocyte counts 2-10%
Increase in Decrease in
 1- Bacterial  1-Acute infection
infections (TB)  2-Corticosteroids
 2-Auto-immune  3-Leukaemia
disease
 3-Leukaemia
 4-Hodgkin’s
disease
Lymphocytes : normal range20-40%

Increase in Decrease in
 1-Viral  1- Viral infection
 2- HIV
infection  3- Post-
 2-Chronic chemotherapy
bacterial  4- Whole body
radiation
infection  5- Bone marrow
 3-Lymphoma failure
Three types of
lymphocytes
1- B lymphocytes
(humoral immunity)
antibody formation
2- T lymphocytes
(cellolar immunity)
For viral infections
3- Natural killer cells
Platelets counts 150.000-400.000/cmm

Thrombocytosis Thrombocytopenia
>400.000/cmm <150.000/cmm
 1-Menstruation
 1-Pregnancy
 2-Gestational
 2-Infections thrombocytopenia
 3-Inflammation  3- PE

 4-Trauma  4-HELLP syndrome

 5-Severe haemorrhage
 5-Arthritis 6-DIC
 6-Atheletics  7 - ITP
 7-Malignancy  8-Aplastic anemia
 9-Drug-induced
 8-
Postsplenectomy  10-Leukaemia
The values have to fit the clinical
Life span of platelets is 7-
10ds
Consider in
Low dose aspirin therapy
NSAIDs therapy
And in platelets therapy
Thrombocytopaenia in pregnancy
1-Gestational thrombocytopaenia
Mild , seen in 2nd and 3rd trimester
2-Associated with PIH syndromes
as HELLP , PIH , PE
And super imposed PE
3-Auto-immune (ITP)
mostly seen in 1st trimester
4-HIV
I-Pregnancy specific
Gestational thrombocytopenia 75%
(7% of pregnancies)
Preeclampsia/Eclampsia &HELLP
syndrome 20%
Acute fatty liver Autoimmune
Disseminated Intravascular Coagulopathy
(DIC): Placental abruption ,IUFD &
Septicemia
Severe obstetrical hemorrhage with
excessive fluid infusion(dilutional
coagulopathy)
II-Pregnancy-associated
1-Spurious result (EDTA) Blood smear±
Citrate
2-Autoimmune Disease
Immune Thrombocytopenia Purpura (ITP) 4%
Antiphospholipid antibodies (APS &SLE )
Acquired Glanzman's disease(↓ function) rare
3- Thrombotic microangiopathies (TTP)
4- Viral infection :( Hep C, CMV, EBV, AIDS)
5- Aplastic anemia & Megaloblastic anaemia
6-Drug exposure
7-Allergic reaction
8- Irradiation
9- Inherited thrombocytopenia
 Gestational thrombocytopoaenia
7% of all pregnancies

5 criteria
1- Mild thrombocytopenia
2- Mostly >100,000/mL, rarely <70,000/ml)
3- No history of thrombocytopenia
outwith pregnancy
4- Occurs late in gestation (normal )
5- No fetal/neonatal thrombocytopenia
Postpartum resolution (6 weeks)
(No Treatment is Required)
 ITP (Immune thrombocytopaenic purpura
Idiopathic Thrombocytopenic Purpura:
Probably autoimmune ↓platelet lifespan
No pathognomonic signs, symptoms, or tests
Diagnosis by exclusion ,however 4 associations:
Persisten€t thrombocytopenia (<100,000/ml )
Normal €or ↑ bone marrow megakaryocytes
Exclusion of other systemic disorders or drugs
causing thrombocytopenia
Absence of splenomegaly
May be indistinguishable from mild form
gestational thrombocytopenia at late pregnancy
 Treatment of ITP in pregnancy

It is considerable at platelet count

<50,000/ml.
Pridnisonlone (Hostacortin H 5mg , Suluprid
5& 20mg ) from 5mgX2/d up to 1 mg/kg/day
Most likely continued throughout pregnancy.
In refractory disease, high-dose intravenous
immunoglobulin is given
If still no response Splenectomy with CS
(technically difficult) to increase platelets
 Treatment of ITP in pregnancy

Dexametasone : (Epidrone)
Before delivery : 8-24 mg iv /day
during a period of 4-6 days.
During labor :high doses of
cortisone may be used:
16 mg iv Dexametasone or
200 mg hydrocortisone
hemisuccinate
 ITP in pregnancy
Fetal & neonatal thrombocytopenia
are common in the following situations:
1-The mother has had a splenectomy and/or
has ITP refractory to splenectomy
II-The mother's platelet count has been
<50,000/ml at some time during the pregnancy
and/or had a platelet count <100,000/ml at the
time of delivery .
III-An older sibling has had neonatal
thrombocytopenia
 ITP in pregnancy
Effect on the foetus and neonate
Platelet-associated IgG antibodies can cross
the placenta and cause severe fetal-neonatal
thrombocytopenia (<50,000/ml ) in 12%
Intracranial hemorrhage as the consequence
of labor and delivery 1%..
There is no clinical characteristic or laboratory
test that will accurately predict fetal platelet
count, and there is no instantanious correlation
between fetal and maternal platelet counts
In HELLP
Low platelets
*Class 1 (at higher risk)<50.000/cmm
*Class II 50.000-100.000/cmm
*Class III 100.000-150.000/cmm
In thrombocytopaenia
1- Platelets below 75.000 contra-indicate
spinal prick
2-CS can be embarked at the level of
50.000/cmm
3-25.000/cmm or more , permits vaginal
delivery
4-Platelet transfusion at 40.000/cmm
5-Give one unit of platelets for 6units of
packed RBCs
6-Every one unit of platelets increases count
by 10.000/cmm
How to investigate platelets
1-Blood film
2-Bone marrow biopsy
3-Infection screen (HIV,HCV)
4-Liver function tests
5-LDH
6-Serum B12,folate
7-Coagulation profile
8-CRP
Conditions that may
enhance platelet function
1-Atherosclerosis
2-Diabetes
3-Smoking and
4-Hypercholesterolaemia
 Investigations of a case of
anaemia
1-Haematinics
Folic acid , B12 , S. ferritin
2-Thyroid function tests
3-Blood film , bone marrow
biopsy
(haemolytic , sideroplastic)
Investigations of a case of
anaemia
4-Hb electrophoresis
(Thalassaemia , Sickle cell)
5-Bilirobin : (haemolysis)
6-Iron studies
Serum Fe , transferrin ,
TIBC, ferritin ,
transferrin saturation,
soluble transferrin receptor
 Investigations to confirm
haemolysis

1-Increased un-conjugated
bilirubin
2-Increased LDH
3-Increased urinary
urobilinogen
4- Reticulocytosis
 Investigations to confirm
haemolysis
5-Increased urinary
haemosiderine
6-Decreased
hepatoglobulin
7-Haemoglobinuria
Search En

1. Which blood cells and blood

elements are included in a CBC
test?
A.Red blood cells (also called
erythrocytes)
B. White blood cells
C. Platelets
D. All of the above
2. What do white blood cells do?
A. Carry oxygen from the lungs
B. Carry waste products from
the cells
C. Fight infection
D. Help stop bleeding by
forming clots
E. All of the above
3. What do red blood cells do?
A. Carry oxygen from the lungs
B. Carry carbon dioxide, a waste
product, from the cells
C. Fight infection
D. Help stop bleeding by forming
clots
E. All of the above
F. A and B
4. What do platelets do?
A. Carry oxygen from the
lungs
B. Carry waste products from
the cells
C. Fight infection
D. Help stop bleeding by
initiating clots E. All of the
above
5. What is haematocrit?
A. sometimes fatal blood
disease
B. The portion of red blood cells
compared with total blood
volume
C. A blood pressure measuring
device
D. A medicine that helps stop
bleeding
6. What are neutrophils?
A. Immature red blood
cells
B. A type of white blood
cell
C. A type of platelet
D. A type of bacteria
7. What is severe neutropenia?
A.An absolute neutrophil count
of less than 500
B. An ANC of less than 1.000
C. An ANC of less than 50
D. An ANC of less than 25
8. Which is a symptom of
anaemia?
A. Itching
B. Nausea
C. Fever
D. Fatigue
9. What is the name of the
decreased platelets?
A.Thrombocytopenia
B. Thromboangiitis
C. Thrombocythemia
10-Which of the following
conditions can be ruled
out
by normal CBC
1-*B12 deficiency
2-*Folate deficiency
3-*Bacterial infection
4-*Viral infection
5-*Iron infection
11- What statements are
true about WBC
1-It is more useful than
absolute count of each cell type
2-*It may be normal in neutropenia
3-*It may be normal in lymphcytosis
4-It will be elevated in all infections
12- What would be appropriate action
in neutrophil count<1.0x1000.000/ml
1-Repeat neutrophil count after
4-8wks
2-*Consider medicatin effect
3-*Look for other blood abnormalities
4-Urgent referal to all patients
5-*Urgent referal if the
patient is feverish or unwell
13- What of the statements
about neutrophil shift to left
are true
1-*The cells are less mature
2-*Can be produced to
infection
3-?Does not occur with
inflammation
4-*The cells can show toxic
granulation
14- What of the following
statements is true about
thalassaemia
1-*Often presents with
microcytisis
2-Frritin level is usually
low
3-CRP is usually raised
15- A reticulocytosis is
usually present in which
conditions
1-*Blood loss
2-*Haemolysis
3-Thalassaemia
4-Pregnancy
16-Which of the following
factors may contribute to
thrombocytopenia
1-*Autoimmune disease
2-*Viral infection
3- *Pregnancy
4-Smoking
17- A neutriphilia an occur
in which conditions
1-*Heavy exercise or stress
2-*Pregnancy
3-*MI
4-?Viral infection
18 - What is true about
lymphocytopenia
1-It usually due to acute
infections as EBV
2- May be due to smoking
3-*Can be seen late in HIV
infection
4- *Can be related to
radiation
 Prepared by
Hesham Abd Elaziz
Elmahalla gen. hosp.
+2 01069241551