Hematological Disorders in Pregnancy

1. A complete blood cell count is typically obtained at the initiation of prenatal care. This test is
important as an indicator of general nutritional status. In the pregnant population, anemia can best
be defined as which of the following?
(A) high total iron binding capacity
(B) a genetic defect in ferritin synthesis
(C) low folic acid
(D) a hemoglobin below 11 g/dL
(E) low plasma volume

2. What hemoglobin value is used to define anemia in the second trimester of pregnancy?
a. 9.5 g/dL
b. 10.0 g/dL
c. 10.5 g/dL
d. 11.0 g/dL
e. 8.0 gr/dL

3. Your patient has microcytic anemia with a hemoglobin of 9 and normal iron stores. What is
the most likely diagnosis?
(A) folate deficiency
(B) vitamin B12 deficiency
(C) thalassemia
(D) vitamin B6 deficiency
(E) acute blood loss

A 22-year-old patient presents with a hematocrit of 31% at 28 weeks’ gestation. Her mean
corpuscular volume (MCV) is 105, her mean corpuscular hemoglobin (MCH) is 33, and her mean
corpuscular hemoglobin concentration (MCHC) is 36. Serum iron is 100 mg/dL. There is no evidence
of abnormal bleeding.

4. Which of the following is the best diagnosis?

(A) normocytic, normochromic anemia
(B) normal
(C) macrocytic anemia
(D) microcytic anemia
(E) hemolysis

5. The most likely cause of anemia in this patient is which of the following?
(A) gastrointestinal (GI) bleeding
(B) G6PD deficiency
(C) iron deficiency
(D) folic acid deficiency
(E) pernicious anemia

6. Which of the following adverse pregnancy outcomes is associated with anemia in pregnancy?
a. Stillbirth
b. Preeclampsia
c. Preterm birth
d. All of the above
e. None of the above

7. What is the maternal iron requirement in pregnancy for a typical singleton gestation?
a. 500 mg
b. 800 mg
c. 1000 mg
d. 1200 mg

8. Your patient is diagnosed with severe iron-deficiency anemia at 34 weeks’ gestation, for which
you recommend ferrous sulfate supplementation three times daily. If you repeat a complete blood
count one week after starting iron therapy, what would you expect to see if she is compliant with
taking her iron?
a. A 20% rise in her hematocrit
b. An elevated reticulocyte count
c. An increase in red cell distribution width
d. An increase in the mean corpuscular volume

9. In patients with sickle-cell disease, in which of the following conditions do red cells assume the
shape shown in the peripheral smear below?

Reproduced with permission from Longo DL: Atlas of hematology and analysis of peripheral
blood smears. In Longo DL, Fauci AS, Kasper DL, et al (eds): Harrison’s Principles of
Internal Medicine, 18th ed. New York, McGraw-Hill, 2012, Figure e17-12.

a. Hyperglycemia
b. Low oxygen tension
c. Dietary protein deficiency
d. Administration of certain antibiotics

10. An infant born with hemoglobin H disease will have which of the following red cell types present
at birth?
a. Hemoglobin A
b. Hemoglobin H (β4 )
c. Hemoglobin Bart (ϒ4)
d. All of the above
11. You see a 23-year-old woman, who is known to have beta thalassaemia major. She underwent
splenectomy at the age of 7. Her platelet count is 660 × 10 3/L at booking.
What antenatal thromboprophylaxis is recommended?
Options
A. Low-dose aspirin 75 mg/day.
B. LMWH.
C. Low-dose aspirin 75 mg/day and LMWH.
D. LMWH for 6 weeks postnatally.
E. UFH.

12. You see a 30-year-old para 1 in the antenatal clinic. She is found to have a platelet count of 85 ×
109/L on routine screening at 28 weeks’ gestation. This is her second pregnancy; her first child was
delivered at term by caesarean section for breech presentation. She reports good fetal movements
and has no history of bruising or bleeding.
Which of the following conditions could not explain her thrombocytopenia?
Options
A. Alloimmune thrombocytopenia.
B. Gestational thrombocytopenia.
C. Immune thrombocytopenic purpura.
D. Preeclampsia.
E. Antiphospholipid syndrome.

13. You are caring for a pregnant patient with known idiopathic thrombocytopenic purpura who is
currently 29 weeks pregnant. Her platelet count returns at 21,000/μL. Which of the following
treatments would you consider as first-line therapy?
a. Splenectomy
b. Azathioprine
c. Corticosteroids
d. Intravenous immune globulin

14. A 32-year-old G3P2 presents at 38 weeks’ gestation complaining of mild fever and headache. Her
temperature is 38.1oC, blood pressure measures 152/94 mmHg, and her heart rate is 112 beats per
minute. Her laboratory results demonstrate a hematocrit of 21%, platelet count of 17,000/μL, and
her creatinine is 1.4 mg/dL. A peripheral smear is performed, which demonstrates schistocytes.
What is the most likely underlying cause of her clinical presentation?
a. Severe preeclampsia
b. Idiopathic thrombocytopenic purpura
c. Endothelial damage due to an underlying infection
d. Elevated levels of large von Willebrand factor multimers

15. What is the most appropriate treatment for the patient in Question 56–31?
a. Plasmapheresis
b. Labor induction
c. Magnesium sulfate infusion
d. All of the above

16. You see a 30-year-old who is at 17 weeks in her third pregnancy and who presents with a
threatened miscarriage. Her blood group is A Rhesus negative. She had surgical management of
miscarriage in her second pregnancy and anti-D immunoglobulin was not given. Screening for red
cell antibodies shows an anti-D antibodies level of 7 IU/ml. The bleeding has now settled, the
pregnancy is ongoing and she is pain free.
What is your most appropriate next step?
Options
A. Referral to fetal medicine unit.
B. Repeat anti-D level in 4 weeks.
C. Repeat anti-D level in 2 weeks.
D. Offer anti-D immunoglobulin.
E. Kleihauer–Betke test.

17. You see a 28 year old in your antenatal clinic. She is 17 weeks into her third ongoing pregnancy.
Her first pregnancy ended in a spontaneous miscarriage at 13 weeks and, in her second pregnancy,
she gave birth to an anaemic baby who required exchange transfusion. Anti-E antibodies were
detected at her initial screening in this pregnancy.
What is your most appropriate next step?
Options
A. Noninvasive fetal genotyping using maternal blood.
B. Determine paternal E antigen status.
C. Obtain maternal anti-E level.
D. Obtain fetal haemoglobin level by cordocentesis.
E. Monitor fetal middle cerebral artery peak systolic velocity.