Scenario.: A 30 yo female G3P2 at 20 weeks of gestation presented to your Clinic for antenatal follow up. Her Hemoglobin concentration was found to be 90 gm/l. She is pale and complaining of fatigue and dizziness. Gives history of long standing anemia.
– History –
- CC: (take SOCRATES hx if applicable)
- Onset: first time? When? Sudden\gradual? Continuous\intermittent? Getting better\worse?
- Severity: affecting ADL?
- Associated sx:
- Constitutional: fever, chills, night sweats, loss of appetite?
- Anemia: fatigue, exercise intolerance, dizziness, headache, pica, hemolysis (jaundice, itching)?
- Bleeding: nose bleeds, vomiting\coughing up blood, change in color or blood in urine\stool, PV bleeding, easy bruising?
- CVS: chest pain, SOB, PND, palpitations?
- Preeclampsia: headache, visual changes, epigastric pain, N\V, lower limb swelling?
- Obstetric Hx:
- Gravida? Para? Abortions? Living?
- If prev: mode of delivery? Fetal\maternal complications?
- LMP? Due date?
- Last US: when? Results? Singleton or multiple gestation?
- Screening: GBS, GDM, rubella immunization, blood type\Rh immunization?
- Gravida? Para? Abortions? Living?
- Gynecological Hx:
- Menstrual Hx: age of menarche? Regular\heavy\painful periods? Intermenstrual bleeding?
- Contraception use, IUCD?
- Gynecological procedures, IVF\induction of ovulation?
- Chronic ds (HTN, DM\GDM, DLP)
- Cardiac, thyroid, renal\autoimmune ds
- Hematological ds, malignancy
- Gyn (fibroids, endometriosis)
- Medications: abx, steroids, anticoagulants, folate, irone, herbal
- Surgery, blood transfusions, hospitalization, trauma
- Similar complaint?
- Same diseases as in PMHx?
- Social Hx:
- Occupation, marital status, children?
- Smoking, alcohol, recreational drugs?
- Travel Hx
- Diet (red meat, fruits), exercise
– Physical Exam –
- WIPE, blah blah, chaperone
- Vital signs: pulse, BP, temperature
- General inspection: weight, distress, pallor, bruises, jaundice, scratch marks, petechiae\purpura
- Hands: pallor, koilonychia
- Eye: conjunctival pallor, scleral jaundice
- Mouth: angular stomatitis, bleeding gums, swollen tongue
- Neck: LN, JVP
- Chest: murmur, shifted apex, lung crepitations
- Abdomen: same old stuff
- Pelvic exam: cervix and uterus
– Investigations –
- CBC: hgb, Hct, RBC count, MCV, MHC, retics, WBC, blood type
- Peripheral blood smear
- Iron, serum ferritin, TIBC
- If necessary: stool analysis, Hgb electrophoresis, US
– Management –
“most likely it will be iron deficiency anemia”
- Oral iron: 200-300 mg of ferrous sulphate per day
- Take on an empty stomach, with vit C to enhance absorption, avoid tea\coffee
- S\E: GI -> abdominal pain, N\V, diarrhea\constipation
- Blood transfusion: in advanced GA (at labor) or hemodynamically unstable (severe anemia <7g\dL)
- Prophylaxis: 0.4-5 mg of oral folate per day 3 mo prior conception until 12 wks of gestation
- Treatment: 5 mg of oral folate per day until complete hematological recovery
– Complications –
- Iron deficiency anemia: preterm, lower birth weight, IUGR
- Folate deficiency anemia: NTD, IUGR, spontaneous miscarriage
– Definitions –
- Physiological anemia in pregnancy: w\ normal pregnancy, blood volume increases, which results in a concomitant hemodilution. Although RBC mass increases during pregnancy, plasma volume increases more, resulting in a relative anemia. This results in a physiologically lowered Hb level, Hct value, and RBC count, but it has no effect on the MCV
- Anemia in pregnancy: hemoglobin below 11 g/dL (Hematocrit less than 33%) in the first and third trimester, and hemoglobin less than 10.5 g/dL (Hematocrit less than 32%) in the second trimester. According to the CDC, severe anemia is hemoglobin less than 7 g/dL