Transcript anaemia in pregnancy - Rawalpindi Medical College

ANAEMIA IN
PREGNANCY
A common
problem of underresourced world
Dr. Humaira Bilqis
Senior Registrar
Gynae/Obs Unit I
Holy Family Hospital, Rawalpindi
DEFINITION
 Hb
concentration of <11g/dL during first
trimester OR <10.5 g/dL during second
and third trimesters of pregnancy (CDC)
 Decrease
in Hb, red cell count or
hematocrit lower than the threshold of
2SD below the median value for a healthy
matched population
Ref: High Risk Pregnancy: Management Options. James et al. 4 th ed. 2011
IMPORTANCE

Incidence 42% worldwide

13% maternal deaths in developing world

Diagnosis and treatment both neglected..
Ref: High Risk Pregnancy: Management Options. James et al. 4 th ed. 2011
WHY DIAGNOSIS A DILEMMA?
TYPES OF
ANAEMIA
Physiological
Anaemia of
pregnancy
Dietary
Deficiency
Anaemias
Haemoglobin_
opathies
Blood loss
Anaemia
Haemolytic
Anaemias
Anaemia
of Chronic
Ailments
HEMOLYTIC ANAEMIAS
Characterized by accelerated premature
red cell destruction
Abnormalities
in Hb structure
Intrinsic
Causes
Abnormalities
of red cell
membrane
Abnormalities
of red cell
metabolism
Haemolytic
Anaemia
Autoimmune
Extrinsic
Causes
DIC
TTP
HEREDITARY
SPHEROCYTOSIS
IN PREGNANCY
(Minkowski–
Chauffard
syndrome)
INCIDENCE
1
in 2000 births in Northern Europe
 Rare
in pregnancy
INHERITANCE
Autosomal
dominant
70%
INHERITANCE
Autosomal
recessive
De novo
mutations
25%
5%
STRUCTURE OF RED CELL
RED CELL MEMBRANE PROTEINS
WHAT HAPPENS IN
SPHEROCYTOSIS
Spectrin
PRESENTATION
 Severe
disease---------Diagnosed early in
life. Neonatal icterus requiring exchange
transfusion
 Moderate disease-----Diagnosed later
 Intermittent jaundice triggered by fatigue,
cold, emotional stress or pregnancy
 Anaemia of varying severity
 Splenomegaly
 Mild disease------Remains undiagnosed
CLINICAL FEATURES
Asymptomatic---------------Fulminant
hemolytic anaemia
 Anaemia
 Jaundice
 Abdominal
pain (due to splenomegaly)
EXAMINATION
 GPE
•
•
Signs of anaemia
Jaundice
 Abdominal
•
•
Examination
Splenomegaly
Signs of cholecystitis
INVESTIGATIONS
LABORATORY
 Mild
to moderate
anemia
 Increased MCHC
 Reticulocytosis
 Spherocytes on
peripheral blood
smear
 Hyperbilirubinemia
 Increased
LDH
 Abnormal osmotic
fragility test
HAEMATOLOGICAL FEATURES
Hallmark is the MICROSPHEROCYTE on
peripheral smear
INVESTIGATIONS (Contd)
RADIOLOGY
 Splenomegaly
 Cholelithiasis
DIFFERENTIAL DIAGNOSIS
Other causes of anaemia
• non_haemolytic
• haemolytic
Other causes of jaundice
Other causes of splenomegaly
DIFFICULTIES IN DIAGNOSIS
 Co-inheritance
of other haematological
disorders
beta thallasaemia trait
sickle cell disease
 Co-existance
deficiencies
 Obstructive
of Iron, folate or vitamin B12
jaundice
COMPLICATIONS
MATERNAL
 Haemolytic crisis
 Aplastic crisis (with Parvovirus infection)
 Cholecystitis
 Cholelithiasis with biliary tract
complications
 Problems of multiple blood transfusions
 Splenic rupture
COMPLICATIONS (Contd)
FETAL
 First trimester miscarriages
 IUGR
 PPROM
 Preterm delivery
 Inherited disorder
 Hydrops fetalis
COMPLICATIONS (Contd)
NEONATAL
 Neonatal
jaundice – requiring exchange
transfusion
 Anemia
PROBLEMS SPECIFIC TO
PREGNANCY
Maintaining haemoglobin throughout
pregnancy
 Increased risk of splenic rupture during
pregnancy
 Increased risk of haemorrhage
 Risk of damage to enlarged spleen during
delivery or C-Section

MANAGEMENT IN
PREGNANCY
 Treatment
 Folate
is mainly supportive
supplementation
 Anaemia
correction
MANAGEMENT (Contd)
 Measures
to prevent splenic rupture
 Post-delivery
 Neonatal
thromboprophylaxis
evaluation for HS inheritance
MANAGEMENT (Contd)
 Advice
regarding:
Life long folate supplementation
Splenectomy after delivery
Periodic ultrasound evaluation of gall
bladder every 3-5 yrs
Laparoscopic cholecystectomy if gall
stones are present
SPLENECTOMY DURING
PREGNANCY
CONTROVERSIAL
Can be considered in second trimester
PRENATAL DIAGNOSIS
 Not
required
 Can
be considered only for families
having severe disease pattern on their
own request
 Chorionic
villous biopsy/ cordocentesis
LITERATURE REVIEW

Newly diagnosed patients with a family history of HS,
typical clinical features (splenomegaly) and
laboratory investigations (spherocytes, raised MCHC,
increase in reticulocytes) do not require any
additional tests. Guidelines for the Diagnosis and Management of
Hereditary Spherocytosis.The British Committee for Standards in
Haematology. Published September 2011

During pregnancy some non-splenectomised HS
patients develop sufficiently severe anaemia to need
blood transfusion. Guidelines for the Diagnosis and Management
of Hereditary Spherocytosis.The British Committee for Standards in
Haematology. Published September 2011
LITERATURE REVIEW (Contd)

Splenectomy is an independent risk factor for
preterm delivery. Pregnancy outcome in women following
splenectomy. Gershovitz M,Sergienko R,Friedler JM,Wiznitzer
A,Zlotnik A,Sheiner E. J Womens Health (Larchmt). Aug
2011;20(8)1233-7

Splenectomy as a second-line option in cases of
refractory severe ITP in pregnancy. Splenectomy
during pregnancy: treatment of refractory immune
thrombocytopenic purpura. Mahey R,Deep S,Chumbe
S,Kriplani,Bhatla N. BMJ Case Reports 2013
LITERATURE REVIEW (Contd)

Splenectomy should be carried out on maternal
indication if there is poor or no response to
medical treatment, or if medical treatment is
hazardous to the mother. We feel that the strong
warnings against surgical treatment of ITP during
pregnancy should be revised. Splenectomy during
pregnancy: an option in the treatment of autoimmune
thrombocytopenic purpura.Gottlieb P, Axelsson O,Bakos
O,Rastad J. BJOG, April 1999, Vol 106(4),373-375
LITERATURE REVIEW (Contd)

Pregnancy may precipitate hemolytic anemia but
maternal morbidity and fetal outcome seem more
favorable after splenectomy than before
splenectomy. Pregnancy and hereditary spherocytosis.
Report of 8 patients and a review. Paior A,Lehoczky D,Szakacs
Z. Arch Gynecol Obstet. 1993;253(1):37-42.
CONCLUSION
 Never
treat every anaemic patient with
iron without proper workup
 Review
the diagnosis if no response with
initial iron therapy
 Multidisciplinary
approach should be
adopted
 Genetic
counseling of the affected
families should be done
q
Questions?