HematologicalDisorders

hemoglobin
A concentration below
1. 56-1. would
which of the following thresholds
indicate anemia in an iron-supplemented
pregnant woman in any trimester?

a. 9.0 g/dL b. 9.5 g/dL c. 10.0g/dL d. 10.5

gldL
2. 56-2. What is the most common cause of
antepartum anemia in pregnant women?
a. Thalassemia
b. Iron deficiency
c. Folic acid deficiency
d. Anemiaof chronic disease
3. 56-3. A19-year-old primigravida at 29
weeks' gestation is noted to have anemia
with a hemoglobin concentration of 8 g/dL.
The peripheral blood smear below is
obtained. Which of the following laboratory
findings are likely to accompany this
condition?
 Rnhn weh Ymsn om utkr Didrs of tnm mtaheen. In Lkhimn
MAA 1.ShnU(
Wilhans Hmatoy, Nth d Nu lock, McCiraw-Hl

a. Decreased serum ferritin level

b. Elevated mean corpuscular volume
c. Decreased total iron binding capacity
d. Positive sickle-cell screen (Sickledex) result
564. For the patient described in Question 56
3, what is the most appropriate initial treatment?
a. Red cell transfusion
b. Folicacid, 4 mg orally daily
c. Hydroxyurea, 1 g orally daily
d. Elemental iron, 200 mg orally daily
56-5. Of medical conditions associated with
anemia of chronic disease, which is most
frequently encountered in pregnancy?
a. Crohn disease
b. Hodgkin lymphoma
c. Chronic renal insufficie

d. Systemic lupus erythematosus

56-6. A 36-year-old G3P2 at 18 weeksfound to
gestation reports extreme fatigue and is
hemoglobin concentration of 7.5 g/dL.
be have a
volume is
The erythrocyte mean corpuscular
markedly elevated and measures 124 fL. A
shown
peripheral blood smear is obtained and is
here. What is the most likely etiology?

Reroduod wah pmisson fom GrocnR: Folate, cohalamin, and megaloblastic anemia
in Lichtmn MA Kipps TJ, Sdipuhn U (ads): Williams Hcmtology, 8th d. New York.
MoGitaw-Hil, 2010, Figure 41-12A

a. Iron deficiency
b. Vitamin B, deficiency
c. Folic acid deficiency
d. Vitamin B, deficiency
2. 56-7. All EXCEPT which of the following
statements regarding autoimmune hemolytic
anemia in pregnancy are true?
1.Pregnancy can accelerate hem
2.The direct Coombs test is usually
positive.
 3.The indirect Coombs test is usually
positive.
4.The cause of aberrant antibody
production originates from fetal
microchimerism.

8 56-8. Pregnant women with paroxysmal

nocturnal hemoglobinuria are at increased
risk for which of the following?
a. Renal failure
b. Venous thrombosis

c. Maternal mortality
d. Allof the above
9. 56-9. What is the typical inheritance
pattern of the mutation in the spectrin gene
that results in hereditary spherocytosis?
a. Mitochondrial
b. X-linked dominant

c. Autosomal dominant
d. Autosomal recessive
 10 56-10. The following image demonstrates
the appearance of spherocytes using
scanning electron microscopy. In addition to
identifying erythrocytes with this
appearance, what other laboratory finding
helps confirm the diagnosis of hereditary
spherocytosis?

a. Low serum haptoglobin level

b. Elevated serum bilirubin level
c. Increased erythrocyteosmotic fragility
d. Increased serum level of fibrin split products
56-11. Which of the following statements is
true regarding women who are heterozygous for
the glucose-6- phosphate dehydrogenase
mutation?

1.Infectionsin pregnancy can precipitate

hemolysis.
2.Some degree of protection against malaria is
conferred.
25% d. 4% States?
b. 1%
a. among Placenta
Placental
56-13. abruption previaStillbirth
d. polycythemia
c.complications
a.vera? 56-12.
8%
c. Coagulopathy b. 4.All
3.Lyonization
activity.
enzyme
African-American What Which of
the
is has ofabove
the results
been the
prevalence
following
associated in
women a
variable
of pregnancy
in
sickle-cell with
the degree
United
trait of
 Intrnal
Reproduced
blood
Matnome
cough, 56-15.
condition?whichchest cell Hyperglycemia
d. c. b. a. sncats
usth
56-14.
under cells
deficiency
Dietary
protein Low prmason
|Sh Ln
Longo
Administration ad
disease Now DL
fhm
VarkFaac1
radiograph Long which may
Mir-Hl AS
DL
of and Oxygen Kapr In
the A DL,
Als
ofbmtology assume
2012. d patients
al
22-year-old
increasing
presents Fure
(ods)

following Harisn's
cl7-12 and
of
analysis
Princaples the
tension ofpaph
is of of the with
obtained. with following
certain following
ardyspnea.
e primigravida sickle-cell
precipitantscomplaintsantibiotics
conditions?
All The configuration
EXCEPT disease,
with
following of
of fever,
this sickle red
 Marrow
emboliAtelectasis
d. Infection
b. a.
ed.decreased. 17.56-17. Coagulopathy
16.
c.
sickle-cell
c. b. anemia? Pulmonary
a. with red is hypertension c.failure
Renal
d. complications?
d. following
b.maternal
a. anemia
56-16.
Risk RateGestation accurate Cardiomyopathy
Perinatal All
cell
of
of of transfusions Which
the are
fetal-growth Pregnant
red mortality
duration regarding at
above
cell increased
of
ation the women
is for the
rate following
restrictionincreased. pregnant
use risk
is with
decreased. of for
prophylactic
statements sickle-cell
which
is women

is of
the
globin
ent 56-21.
Which of a, withglobin
Women
56-20. C.
following?
theofbeen Intrauterine
c. devicewomen 56-18.
a. choices
aa/--b. d.
abruption
Placental
Gestational b. a. 56-19. sterilization
d.Surgical b.
Urinary
Preeclampsia Combination Depot
homozygous associated
genotypes with mayWhich
Sickle-cell
medroxyprogesterone
with a-/aa tract
oresis sickle-cell help
diabetes
a which
withof with oral of
sis he a-la- C. a are infections prevent the
t-thalassemia? trait
an
following at contraceptive following
d.aa/aa risk increased
(hemoglobin disease?
painful
of
would to
ß have the contraceptive
iafindings risk acetate crises
be following -a pills
offspring AS)
most for
in
on which has
emic
oids
nectomy
roscopic
d. c. b. treatment
immune 56-23.
of Immune
preeclampsia
coagulopathy
Consumptive
the Gestational
a.thrombocytopenia b. a. 56-22.
thrombocytopenia
pregnancy?
d. c.Severe in
s zathioprine following 4.Hemoglobin
3.Hemoglobin
hemoglobin
fetal
1.Hemoglobin
2.Hemoglobin
hemoglobin hemoglobin
level hemoglobin
level
When What
thrombocytopenic
is
indicated is
the the
greater A2 greater A2 A2 A2
most most
hrombocytopenic
purpura? greater greater less less
appropriate in common than than than than
pregnancy, than
purpura than 2% 1%; 1%;
2%
cause 3.5%; fetal normal
3.5%;
initialwhich
G of normal
fetal fetal
of
 24.56-24. Which of the following
management strategies is recommended to
detect fetal thrombocytopenia in women
whohave chronic immune
thrombocytopenic purpura?
a. Cordocentesis
b. Scalp sampling
c. Cesarean delivery
d. None of the above

25. 56-25. Most cases of thrombocytosis in

which the platelet count exceeds 1
million/uL are caused by which of the
following conditions?
a. Malignancy
b. Iron deficiency
C. Autoimmune conditions

d. Essentialthrombocytosis
26.56-26. Although there is considerable
clinical overlap between thrombotic
thrombocytopenic purpura (TTP) and
hemolytic uremicsyndrome (HUS), these
entities can be distinguished by all
EXCEPT which of the following?
1.HUS has more renal dysfunction.
 28. 27.
d.
thrombocytopenia
Moderate important.
c.thrombocytopenic
findings
a.favors
TTP? conditions
severe 56-28. transfusion
Platelet
d.
thrombocytopenic
c. b.purpura? 56-27.
thrombotic
treatment
for
gulation
hemolysis
Severe
Mild b. Anticoagulation a. 3.TTP2.HUS
ked Plasmapheresis
Intravenous 4.All
aberrations.
neurologic
isseminated preeclampsia Because What statements more is
ase Which is seen
very is frequently
immunoglobulin the primarily
ofdifferent, the
purpura are
the fromtreatment cornerstone
intravascular true.
tion following
thrombotic has
(TTP)
differentiating in
associatedadults.
of(1VIG) of
the
clinical is
two
 Willebrand 56-31. Uterotonics
ofepisiotomy
Avoiding
d.
Desmopressin
C. b. reduced risk
a. 56-30. C.fashion?
a.Hemophilia
deficiency56-29. A,
reased
3.Increased
2.Decreased
1.Increased e
thOperative
vels
ctor levels
factor X-linked
Autosomal
for
following
Pregnancy excessive
by In
factor all women dominant in
factor factorfactorfactor vaginal EXCEPT dominant factor
changes
(vWF)
physiology hemorrhage
affected
VIIl VIII VI,
VIII VIII delivery b.
to which d. characterized
X-linked
levels; levels; levels? is
and and factor Autosomal
by inherited
results at
hemophilia
decreased
vWF vWF of
delivery
reased VIIl the recessive
levels in by
levels and in following? recessive
which can A, what a
vWF vWF von severe
bethe
 gestation?
a. 56-3. Preterm
Preeclampsia
d. birth c. b.pregnancy?
anemia in
a. 56-2. a. 56-1.
500 Stillbirth pregnancy? Preterm generally
All 9.5 Fetal-growth
Hematological
Disorders restriction d. encountered
pregnancy-related
abruption
Placental birtha.Willebrand
b. 56-32.
mg What of Which
hemorrhage
Postpartum c.
g/dL What
b. the
800 isabove b.
the of 10.hemoglobin
0
mg the Although
maternal good
c. following g/dL
100O c. value
disease,
in
mg iron 10.5 up in
adverse is
requirement
d. g/dL used complications
tomay bewomen
pregnancy
200 I d.
pregnancy
11.0
to 50which
mg define percent
in g/dL
pregnancy
outcomes
anemia ofwho
outcomes
the have
in of
for the following
is such
associated second von
typical a
trimester cases? are
singleton with

of
56-4. A22-year-old Gl presents to your office at 32 weeks' gestation. Routine
laboratory assessment reveals a hemoglobin of 8 gdL with a mean corpuscular
volume of 81 fL. Asa part of the work-up for her anemia, a peripheral smear is
performed, which is shown. What is the most likely diagnosis?

Reeodxd wich permon fn Tne (1. Rathsndn DL. Charg sy.

Sed ed. No ork.

a. Iron-deficiency anemia
b. Acute blood loss anemia
C. Anemia of chronic disease
d. Anemia resulting from folate deficiency

56-5. 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

6. 56-6. A36-year-old G3P3 is postoperative day 3follow-ing arepeat cesarean

delivery with a 2-liter estimated blood loss due to lysis of adhesions. She reports
feeling well and denies dizziness or palpitations when ambulating. Her blood
pressure is 100/60 mmHg, her pulse is 92 beats per minute, and her postpartum
hemoglobin is stable at 7.2 g/dL. Which of the following would you advise based on
her clinical status?
1. Transfusion of 2 units of blood
2. Repeat a complete blood count emergently
3. Three months of iron supplementation at discharge
4. All of the above

7. 56-7. You are caring for a 29-year-old G1 who suffers from long-standing type 1
diabetes and is currently 28 weeks pregnant. Her baseline creatinine at the
beginning of pregnancy was 1.5 mg/dl. Her third- trimester complete blood count
reveals a hematocrit of 19% with a ferritin of 150 ng/mL. She reports overall feeling
wellexcept for mild fatigue, and her vitals are as follows: pulse 82 beats per minute,
bloodpressure 128/78 mmHg, and temperature 36.8C. What is the best next course
of action for this patient?
 a. Consult nephrology
b. Admit to the
hospital for observation
c. Administer
recombinant erythropoietin
d. Allof the above

56-8. A39-year-old G2P1 at 22 weeks' gestation

complains of extreme fatigue. Laboratory
evaluation reveals a hemoglobin of 7.3g/dL, platelet
of 102,000/uL, and a mean corpuscular count
volume
for further evaluation and is shown below. of 122 fL. Aperipheral smear is performed
is she most likely to complain of? Based on the findings, what additional symptom

Reprudoced wirh pcrmision fom CteroR Fobre. cohalamin, and negalohlastx anc mi
In Lichtan MA, Kpps T}. Selo U leda): Wlums Hematdogy. 8th ed Nw Yoc
McGtaw-Hdl, 2010. hpee 1-12A

a. Dry skin
b. Anorexia
c. Hair loss
d. Excessive perspiration

9. 56-9. Which of the following is not acause of vitamin B, deficiency encountered in

pregnancy?

a. Crohn disease
b. Ulcerative colítis
c. History of Roux-en-Y gastric bypass

d. Prior ileal resection following trauma

10. 56-10. One of your patients was recently diagnosed with mononucleosis while 20
weeks pregnant. Three weeks after her diagnosis, she complains that her fatigue is
worsening rather than improving, although she denies shortness of breath or
palpitations. Laboratory evaluation reveals a hemoglobin of 6.8 mg/dL and a
positive direct Coombs test. What treatment could you consider offering?

a. Iron supplementation
b. Monoclonal antibody therapy
c. Intravenous immunoglobulin infusion
d. None of the above are indicated
 above the ofAll d.
ased. stillbirth
are restriction,
and fetal-growth preeclampsia, labor,preterm Ratofes c.
pregnancy. continued
in should
be therapy Steroid b.
infection. hemorrhage
and are risks major The a.
pregnancy? condition
in regarding
this true What
is
Diamond-Blackfan
anemia.
historyof wigestation
tah weeks' 12womanat pregnant faocaring
r are You56-14.
dehydrogenase
Glucose-6-phosphate d.
isomerase phosphate Glucose c.
kinase Pyruvate b.
Ankyrin a.
mutation? the carrier
homozZygous
of isa that fetus ain
fetalis hydrops result
in deficiencies
can enzymeerythrocyte following the Whiof
ch 56-13.
inheritance germlinedemonstrate not doesdeficiency This 4.
50% 3.
25% 2.
0% 1.
2B, S6
Fgure
MkGrw-HlL.
2014, Yark New d.
Obssetrics,
24th dlams diorders.
InHematologcal
(ods): al etSlRonm
. KJ. Lorno Cunningham
Fi, fpermiion
rom Reproducad
with
disease? the carry not doeshusband assuming
her offspring, her this
he
wil schance the is What below. shownspherocytes isdemonstrating micrograph to pass
electron pregnancy.
Her diagnosed
prior
to was whideficiency,
ch
spherocytosis
todue hereditary 25-weeks-pregnant spectrin
haspatient Your 56-12. 12.
Surgery infectiontransfusions, precipitated above the ofAll 4.
thromboses or: by Often 3.
venous
intervals irregular suffer patients
Hemogl
develops
at obinuria ofhalf Almost 2.
nocturnal paroxysmal regarding hemoglobinuria? 1.
truefollowingis the Whiofch 56-11. 11.
 Preeclampsia b.
Stillbirth a.
pregnancy? disease
insickle-cell context
of
increased
the in complications
not is obstetric following the Whiofch 56-19. 19.
20% 10%d. c.5% b.2%a.
echocardiographic
findings? these
implied
by
complication the sufferpatientssickle-cell centage
of per- What mmHg.
pressure
55of systolicventricular right dilation,
anda atrial right artery,
pulmonary
dilated
demonstratesa echocardiogram
which routine ordera Youanemia.
sickle-cell wigestation
th weeks' 26-year-old
17at G1 foacaring
r are You56-18. 18.
antibiotics certain
Administrationof d.
deficiency protein Dietary C.
tension oxygen Low b.
Hyperglycemia a.
el7-12. Figure Mcirzw-Hill,
2012. York. New cd. 18tMedicine,
h Intctnal
Principlesof Harrison's ,
ed a DlaLKasper LongoAS, Fauci permision
from Dl.Longo smcars.
In
Reptoduccd
with blood eral
periph analysis
of and
below? smearperipheral the shown
in shape theassume
cells reconditions
d do following the whiofch disease,
insickle-cell witpatients
h 56-17.
In
1/576 1/392d. 1/144c. b.
1/48 a.
sickle-cell having ofinfant's
risk their disease?
would
be what origin, and race their Based trait.
on
sickle the carriers
of are they unsure
if are they butdisease, sickle-cell
pregnancy. considering are who couple American Neither
has them
of
African ancaring
for are Yo56-16.
u
above the None
of d.
heparin andAspirin C.
alone Heparin b.
alone Aspirin a.
clot noapolycythemia
nd vera with woman pregnant? noW who history
is
consider
afor you would therapy What 56-15.
 Marrow
emboli d. Infection
Atelectasis
c. b. a. pain
baseline56-21. is
obtained.fever,
56-22. pressure
110/68 d. c. b. a. sickleWhat56-20.
Preterm
labor Unpredictable Decreased
Increased No 7
23. 4. 3.
Supplemental Opioids
only 1.
2. typical weeks
cough, change crisesshould
entation
Iron a.
b.demonstrates
decrease Outside
Her 56-23. Supplemental of A Gestational
Fetal-growth diabetes
restriction d. c.
actic All Supplemental A You
baseline 21-year-old 21-year-old
24%. of along.
except joint risk risk in inyou are
her pregnancy the
her pregnancy ofYou pain mmHg. Hersickle risk in in She
tell caring
hematocrit pregnancy contextof
risk a are which temperature pregnancy her
reports
hematocrit primigravida and oxygen, oxygen,opioids
oxygenand G1 in for
red of caring What crises. is pregnancy regarding
having increasing of admitted a
cell she the intravenous pregnancy?30-year-old a
is for is Her remote
sion following intravenous the is
of
25% is a
atypically with hematocrit a her
pain 23%. sickle-cell shortness best
37.5°C, at
and 27 history
risk
crisis sickle-cell treatment pregnant
her are hydration, weeks' of
heart
Whichadmitted
precipitants hydration, is maternal of
this most patient of 21%, a
of breath. gestation patient
crisis
pregnancy? recent disease based rate
the every opioids, which
who 102 sickle-cell as
following The and on with
a
of
presents beats with child,
complete 3-4 is this opioids
and her is
currently following just hemoglobin
months condition? presentation? per intense complications but
interventions blood slightly
with minute, none
blood chest
complaints transfusion lower
for 16 lower since SC
count weeksa radiograph and disease
pain leg such that
may pregnant. blood than and
crisis. of time.
as who
her back
is
 d. c. b. a.results
Hemoglobin
emoglobin Hemoglobin
Hemoglobin 56-28.
is 27. 26. 25. 24.
compatible Which d.
Parvovirus
infection
syndrome
c.Turner
b. a.
None isfetal has
56-27. d. c.
Hemoglobin red
b. a.A 56-26. unreported
a. founddescent,
Hemoglobin the weeks'20 Hemoglobin All AsymptomaticSpontaneous
abortion
bacteruria
56-25. mortality
Perinatal
birthweight
d. C.pregnancy?
b.Low a. 56-24. d. c.
A2 hydrops been Hemoglobin cell -a/-ab. None
Prophylactic
A2 A2 A2 most of
2.5%, 3.5%, 2.5%, the
more
3.5%, the of theof uncomplicated gestation. You types An although
a-Thalassemia of
with
following likely Which
hemoglobin above with are above infant commonly
-a/aa in these
hemoglobin
hemoglobin Bart Bart present women
moglobin B-thalassemia explanation H
elevatedperforming (B) hemoglobin ofantibiotic
disease Both (Y) born c, the wil
hemoglobin at --/aa
thus birth? with in ofminor followingdecrease
F she womenAfrican
F F middle administration
F
3% 1% 19% for far and an hemoglobin d.
3% minor? anatomical H is
the except her --/-a descent. disease her
electrophoresis cerebral of more complications
observed husband African risk
for common of
mild H Which and
artery survey disease crisis
descent,
hemoglobin
hydrops?anemia. are
of in is
velocities. of ona the women associated
Asian will
explains
23-year-oldOn have following
descent. Bart
ultrasound,
Which of
which thisdisease both with
genotypes,
observation? sickle-cell
of Her Asian
primigravida of
the you the are
pregnancy and
following following rare
observe which African trait
or
at is
in
 disease?
a. 56-34. Co-dominance c.
d. Mosaicism a.
10% 56-33.
Lyonization b.
None d.induction
Plasmapheresis Labor
C. b. a. 56-32. d. c.
Magnesium preeclampsia
presentation?
b.Severeperformed, headache.
a.clinicalplatelet Corticosteroids
rate56-31. Azathioprine
Splenectomy
d. c. b. a. purpura 56-30.
of pregnancies?
percentage
a. of
All Endothelial
Elevated ldiopathic Intravenous 56-29.Thrombocytopenia,
th e
b. of is 1%b.
What of
30% the What the What 112 following
count A
above 32-year-old
beats Her
who You 3%
c. is above determines sulfate levels which
50% the isthrombocytopenic
damage temperatureof isare c.
the 17,000/ per immune treatments 5%
incidence of demonstrates
currentlycaring
d. infusion most minute. d.
large due
70% the G3P2 10%
appropriate L, globulin for
of von to 29
factor an is
Herpresents would a
postpartum and 38.1°C, pregnant
weeks defined
Willebrand underlying purpura schistocytes.laboratory
her
VIl you
pregnant.
treatment creatinine blood at as
activity consider patient
38 a
hemorrhage factor infection pressure weeks' platelet
What results Her with
level for is as
multimers 14 platelet
first-line count
in the demonstrateis gestation known
mg/dL.
the measures
in women patient
most <150,000/ul,
women therapy? count
idiopathic
complaining
A
affected in likely 152/94
peripheral
Question a returns
with hematocrit
underlying thrombocytopenic
von with mmHg, complicates
smear of at
56-31? 21,000/uL.
Willebrand hemophilia ofand mild
cause 21%, is fever
her what
of heart and Which
A? her