‫‪Anemia‬‬

‫‪Prepared by‬‬
‫زينب محمد عبد الرحيم‬
‫ياسمين ماجد عدنان‬
‫نور الهدى جعفر احمد‬ ‫‪Supervised by‬‬
‫سجى عماد محمد‬ ‫د‪.‬رغد ليث‬
‫مريم محمد حسين‬
‫سجى جمال سعدون‬
‫انس زكي عيد الكريم‬
‫هدى الثقلين علي حسين‬
‫زينب وليد فخري‬
‫اسامه محمد وحاد‬
Introduction
• Mature red cell is a circular, biconcave disc containing
pigmented protein called hemoglobin and is bound by the cell
membrane.

• On a peripheral blood smear, they appear as pale red cells with

central one -third pallor (where the upper and lower membrane
surfaces closely meet).

• The advantages of the characteristic morphology of the RBCs

are:

• The young, healthy red cells are quite flexible and highly
deformable so that they can easily pass through extremely
narrow capillary beds and splenic sinusoids.

• Provides greater surface area compared to volume which

allows considerable alterations in the cell volume. Thus they
can resist hemolysis to certain extent
Introduction
• Normal Parameters of Red Cell

• Size: The size of normal RBCs ranges from 6.7 to 7.7 µm

in diameter.

• Life span: The average life span of normal RBC is 110-120

days.
ANEMIA
• Anemia is defined as the decrease below normal of the
hemoglobin concentration, erythrocyte count or hematocrit.

• Anemia is not a disease but it is the expression of

underlying disease and from the treatment point of view, it
is necessary to identify the cause of anemia.

• Anemia may be absolute, when there is decreased red blood

cell (RBC) mass, or relative, when associated with a higher
plasma volume.

• Relative anemia may occur in the third trimester of

pregnancy due to hemodilution (spurious anemia). But the
term anemia is conventionally used for absolute anemia.
Classification of Anemia /1.Etiological classification
• Based on the cause and the underlying mechanisms of
production of anemia (Table below)
Classification of Anemia /2.Morphological classification
• It is based on:

• (1) red cell size (normocytic, microcytic, or

macrocytic), and

• (2) degree of hemoglobinization, reflected by the

color of red cells (normochromic or hypochromic).
Classification of Anemia /2.Morphological classification
• Microcytic hypochromic anemia is characterized by red
blood cells smaller than normal and the central pallor more
than normal 1/3.

• It shows reduced MCV (< 80 fL) and reduced MCHC ( 30

gm/dL).

• It is usually due to decreased hemoglobin synthesis ( e.g.

iron deficiency anemia and thalassemia).
Classification of Anemia /2.Morphological classification
• Normocytic normochromic anemia is characterized by
normal red cell size as well as central pallor.

• It shows a normal MCV ( 82-100 fL) and normal MCHC ( 33-

36 gm/dL).

• This type may be seen during acute blood loss.

Classification of Anemia /2.Morphological classification
• Macrocytic normochromic anemia is characterized by red
cells larger than normal.

• They have increased MCV (> 100 fL) and normal MCHC and
are due to defective maturation of erythroid precursors in
the bone marrow.

• This type of anemia is commonly found with deficiency of

vitamin B12 and folic acid
Clinical Features of Anemia
Irrespective of the cause, anemia when severe, presents with
certain clinical features. The symptoms depend on four main
factors:

• Speed of onset of anemia: Rapidly progressive anemia causes

more symptoms than that of gradual onset. This is because
there is less time for adaptation in the cardiovascular system.

• Severity of anemia: Mild anemia produces no symptoms

compared to significant symptoms in severe anemia.

• Age of the patient: Young patients can tolerate anemia better

than elderly.

• Underlying illness: The disease which caused the anemia. In

anemia, the lowered oxygen content of the circulating blood
leads to tissue hypoxia. General clinical features are either
due to tissue hypoxia or compensatory mechanisms
Clinical Features of Anemia
1.Due to tissue hypoxia:

• Nonspecific symptoms: Weakness, malaise and easy

fatigability due to hypoxia of muscles.

• Dyspnea on mild exertion: It is due to the lowered

oxygen content of the circulating blood.

• Pallor: Patients appear pale due to deficiency of red

colored hemoglobin which is better appreciated in the
conjunctiva, mucous membrane of tongue and nail beds.
Pallor associated with icterus is suggestive of a
hemolytic anemia.

• CNS: Patients of severe anemia may complain of

headache, vertigo, tinnitus and lack of concentration.
Clinical Features of Anemia
2. Due to compensatory mechanisms:

• Cardiac features: Dyspnea on mild exertion, palpitation,

tachycardia and cardiac murmur occur due to
compensatory mechanisms. The resulting increase in the
cardiac output may cause congestive cardiac failure.
Treatment / Management
• Management depends primarily on treating the
underlying cause of anemia.

• 1) Anemia due to acute blood loss - Treat with IV

fluids, crossmatched packed red blood cells, oxygen.
Always remember to obtain at least two large -bore
IV lines for the administration of fluid and blood
products.

• Maintain hemoglobin of > 7 g/dL in a majority of

patients. Those with cardiovascular disease require a
higher hemoglobin goal of > 8 g/dL.
Treatment / Management
2 ) A n emi a d u e t o n u t ritional d ef iciencies: O r al / IV i r o n, B 1 2 , an d
f o l ate.

• O r al s u p plementation o f i r o n i s b y f ar t h e mo s t co mmo n met h o d o f

i r o n r ep l etion. Th e d o s e o f i r o n ad mi n istered d ep en ds o n t h e
p at ient's ag e, cal culated i r o n d ef i cit, t h e r at e o f co r r ection
r eq u ired, an d t h e ab i lity t o t o lerate s i d e eff ects . Th e mo s t co mmo n
s i d e eff ects i n cl ude met al lic t as t e an d g as t rointes tinal s i d e eff ects
s u ch as co n s tipation an d b l ack t ar r y s t o ols . F o r s u ch i n d ividuals,
t h ey ar e ad v is ed t o t ak e o r al i r o n ev er y o t h er d ay, i n o r d er t o ai d
i n i mp r oved G I ab s o rption. Th e h emo g lobin w i l l u s u ally n o r malize
i n 6 - 8 w eek s , w i t h an i n cr eas e i n r et iculocyte co u n t i n j u s t 7 - 1 0
d ays .

• I V i r o n may b e b en eficial i n p at ients r eq u iring a r ap i d i n cr ease i n

l ev els . P at i ents w i t h acu t e an d o n g oing b l o od l o s s o r p at i ents w i t h
i n t olerable s i d e eff ects ar e can d idates f o r I V i r o n.
Treatment / Management

3) Anemia due to defects in the bone

marrow and stem cells: Conditions such
as aplastic anemia require bone marrow
transplantation.
Treatment / Management

4) Anemia due to chronic disease: Anemia in the setting

of renal failure, responds to erythropoietin.
Autoimmune and rheumatological conditions causing
anemia require treatment of the underlying disease.
Treatment / Management
• 5 ) Anemia due to increased red blood cell destruction:

• Hemolytic anemia caused by faulty mechanical valves will need replacement.

• Hemolytic anemia due to medications requires the removal of the offending drug.

• Persistent hemolytic anemia requires splenectomy.

• Hemoglobinopathies such as sickle anemia require blood transfusions, exchange

transfusions, and even hydroxyurea to decrease the incidence of sickling.

• DIC, which is characterized by uncontrolled coagulation and thrombosis, requires

the removal of the offending stimulus. Patients with life -threatening bleeding
require the use of antifibrinolytic agents.
Prognosis
• The prognosis for anemia depends on the cause of anemia.

• Nutritional replacements of (iron, B 12, folate) should

begin immediately.

• In iron deficiency, replacements must continue for at least

three months after the normalization of iron levels, in
order to restore iron stores. Usually, nutritional
deficiencies have a good prognosis if treated early and
adequately.

• Anemia, due to acute blood loss, if treated and stopped

early, has a good prognosis.
Complications
• Anemia, if undiagnosed or left untreated for a prolonged
period of time can lead to multiorgan failure and can even
death.

• Pregnant women with anemia can go into premature labor

and give birth to babies with low birth weight. Anemia
during pregnancy also increases the risk of anemia in the
baby and increased blood loss during pregnancy.

• Complications are more predominant in the older

population due to multiple comorbidities. The
cardiovascular system is the most commonly affected in
chronic anemia.
Complications
• Severe iron deficiency is associated with restless
leg syndrome and esophageal webs.

• Severe anemia from a young age may lead to

impaired neurological development in the form of
cognitive, mental, and developmental delays. These
complications are unlikely to be amenable to
medical management.
Summary
• Anemia is defined as the decrease below normal of the hemoglobin concentration,
erythrocyte count or hematocrit.

• Anemias are classified morphologically into normocytic, microcytic and macrocytic

depending on the size of the RBCs and hypochromic or normochromic depending on the
hemoglobin content.

• Anemia is classified etiologically as due to impaired production, increased destruction

and blood loss.

• The symptoms of anemia are either due to the hypoxia or the compensatory mechanism.
References
1. Nayak, R., Rai, S., & Gupta, A. ( 2011). Essentials in hematology and clinical pathology
(pp. 10-30). JP Medical.

2. Adamson JW, Longo DL. Anemia and polycythemia. Harrison's Principles of Internal
Medicine. 15th ed. New York, New York: McGraw -Hill; 2001. Vol 1.: 348-354.

3. Oliveira MA, Osorio MM, Raposo MC. Socioeconomic and dietary risk factors for
anemia in children aged 6 to 59 months. J Pediatr (Rio J). 2007 Jan-Feb Epub 2007 Jan
12. 83(1):39-46.