7 Hematology During Pregnancy Flashcards
Maternal blood volume increases by an average of _______above the nonpregnant level.
40% to 50%
Plasma volume begins to rise early in pregnancy, with most of the escalation taking place in the second trimester and prior to week ______ of gestation.
week 32 of gestation
Erythropoietin levels increase throughout pregnancy, reaching approximately _____% of their prepregnancy levels at term
150%
The overall effect of these changes in most women is a slight ________ in hemoglobin concentration, which is most pronounced at the end of the ____________ trimester and slowly improves approaching term.
Slight drop in hemoglobin concentration
Second trimester
TRUE OR FALSE
In general, white cell counts drop during pregnancy with the occasional appearance of myelocytes or metamyelocytes in the blood.
FALSE
In general, white cell counts rise during pregnancy with the occasional appearance of myelocytes or metamyelocytes in the blood.
During labor and the early puerperium, there is a rise in the leukocyte count.
INCREASE, SAME OR DECREASE
C-reactive protein concentration:
Erythrocyte sedimentation rate (ESR):
Von Willebrand factor (VWF), fibrinogen, and factors VII, VIII, and X :
Factors II, V, IX, XI, and XII:
Factor XIII:
Levels of protein C and antithrombin:
Total and free protein S:
Plasminogen activator inhibitor type I and type II:
C-reactive protein concentration: INCREASE
Erythrocyte sedimentation rate (ESR): INCREASE
Von Willebrand factor (VWF), fibrinogen, and factors VII, VIII, and X : INCREASE
Factors II, V, IX, XI, and XII: SAME
Factor XIII:DECREASE
Levels of protein C and antithrombin: SAME
Total and free protein S: INCREASE
Plasminogen activator inhibitor type I and type II: INCREASE
Definition of anemia
First and third trimesters:
Second trimester:
First and third trimesters: less than 110 g/L
Second trimester:less than 105 g/L
Iron requirements
Normal pregnancy:
Fetus and the placenta:
Expansion of the maternal red cell mass:
Lost via excretion:
Normal pregnancy: 1 g
* Fetus and the placenta: 300 mg
*Expansion of the maternal red cell mass: 500 mg
*Lost via excretion: 200 mg
TRUE OR FALSE
There is no correlation between the hemoglobin of the fetus and that of the mother
TRUE
There is no correlation between the hemoglobin of the fetus and that of the mother
The ingestion of nonnutritive substances, is said to be more common among iron-deficient pregnant women than among other populations with iron deficiency
Pica
Folate requirements in pregnancy are roughly twice those in the nonpregnant state
800 mcg/day
Anemia related to folate deficiency most often presents in the ________ trimester and responds to folate supplementation with reticulocytosis within 24–72 hours
third trimester
Vitamin B12 (cobalamin) deficiency during pregnancy is rare, in part because deficiency of this vitamin leads to _______________
Infertility
Serum cobalamin levels are known to (rise or fall) during pregnancy.
fall
TRUE OR FALSE
Because of the changes in coagulation factor levels, D-dimer, and platelet count during pregnancy, the normal range for tests routinely used to diagnose DIC in a nonpregnant state cannot be extrapolated directly to DIC in pregnancy.
TRUE
Because of the changes in coagulation factor levels, D-dimer, and platelet count during pregnancy, the normal range for tests routinely used to diagnose DIC in a nonpregnant state cannot be extrapolated directly to DIC in pregnancy.
Complications of pregnancy that lead to DIC include
Placental abruption, a retained dead fetus, and amniotic fluid embolism
In normal women and in patients with types 1 and 2 (but not type 3) VWD, levels of factor VIII and VWF rise during pregnancy, with the most pronounced increase in the ______ trimester.
Third trimester
TRUE OR FALSE
Prophylactic administration of VWF-containing factor concentrates at delivery is necessary in patients with type 1 and type 2 VWD
FALSE
Prophylactic administration of VWF-containing factor concentrates at delivery is often unnecessary in patients with type 1 and type 2 VWD
However, the risk of postpartum hemorrhage is significant (13–29%) because levels fall rapidly after birth.
In type 1 VWD patients, factor VIII levels should be tested not only late in the third trimester but also for________weeks postpartum.
1–2 weeks postpartum.
In VWD, risk of bleeding appears to be minimal when factor VIII levels are greater than ______U/dL
Greater than 50 U/dL
Type 3 VWD patients require infusion of a plasma-derived VWF-containing concentrate at delivery
Give the dose
40–80 IU/kg, followed by doses of 20–40 IU/kg daily for 1 week and then tapered over the next few weeks
Coagulation Factor Deficiencies
Baseline factor levels should be tested at the first visit during pregnancy and again in the ________ trimester
third trimester
TRUE OR FALSE
Factor IX levels generally do not rise during pregnancy.
TRUE
Factor IX levels generally do not rise during pregnancy.
The commonest site of bleeding in newborns with severe hemophilia and has the highest potential for long-term serious sequelae.
Cranial hemorrhage
Associated with habitual hemorrhagic abortions and postpartum hemorrhage.
Deficiency of factor XIII
Recommendations for conditions such as congenital afibrinogenemia, hypofibrinogenemia, and dysfibrinogenemia
IV fibrinogen replacement (using cryoprecipitate or fibrinogen concentrate) to maintain a level of 60–100 mg/dL during pregnancy and for 6 weeks postpartum
Condition that is asymptomatic and is said to occur later in pregnancy and be less severe than ITP.
Gestational thrombocytopenia
Gestational thrombocytopenia occurs in the____________ trimesters, with platelet counts rarely falling below _______× 109/L
Second and third trimesters
70 × 109/L
**No past history of low platelets, except perhaps with previous pregnancies, the platelet count returns to normal after delivery, and there is no association with fetal thrombocytopenia
Management of ITP in pregnancy
Less than 10 × 109/L:
30–50 × 109/L without bleeding:
10–30 × 109/L in later trimesters or in the presence of bleeding:
Less than 10 × 109/L: YES regardless of trimester
30–50 × 109/L without bleeding: NO treatment
10–30 × 109/L in later trimesters or in the presence of bleeding: YES
Splenectomy for ITP in pregnancy is best done in the ________ trimester if platelet counts are extremely low and unresponsive to treatment.
Second trimester
Maternal platelet counts of greater than_______ × 109/L usually are safe for both vaginal and cesarean delivery.
50 × 109/L
In most cases, spinal anesthesia should not be used if the platelet count is less than ______ ×109/L.
75 ×109/L
Fewer than _____% of babies born to mothers with ITP have platelet counts less than 20 × 109/L
5%
TRUE OR FALSE
In eclampsia and HELLP, thrombosis is more of an issue than is bleeding
TRUE
In eclampsia and HELLP, thrombosis is more of an issue than is bleeding
TRUE OR FALSE
Some data suggest that maternal recovery from the HELLP syndrome is accelerated by administration of IV dexamethasone; however, a meta-analysis demonstrated no clear advantage to the use of glucocorticoids to decrease maternal or perinatal morbidity or mortality.
TRUE
Some data suggest that maternal recovery from the HELLP syndrome is accelerated by administration of IV dexamethasone; however, a meta-analysis demonstrated no clear advantage to the use of glucocorticoids to decrease maternal or perinatal morbidity or mortality.
Another rare disorder that can present in the third trimester with severe liver dysfunction, but thrombocytopenia, if present, is generally mild and does not require treatment
Acute fatty liver of pregnancy
Recommendations for anticoagulation among pregnat patients with paroxysmal nocturnal hemoglobinuria
Prophylactic or intermediate-dose low-molecular-weight heparin (LMWH) antepartum and for 6 weeks postpartum
Factors specific to pregnancy that increase the risk of VTE
Obstruction of venous return by the gravid uterus, acquired prothrombotic changes in hemostatic proteins, and venous atonia caused by hormonal factors
Cesarean section (especially emergency), obesity, and increasing age
Approximately 80% of deep vein thromboses in pregnancy occur in the
Iliofemoral veins on the left
The commonest abnormalities associated with VTE in pregnancy
Factor V Leiden and the prothrombin gene mutation
The initial test of choice in pregnant women suspected with VTE
Compression ultrasonography
Recommended for all pregnant women when there is suspicion of pulmonary embolism
V/Q or CTPA
The anticoagulant of choice because they do not cross the placenta and have a lower risk of osteoporosis and heparin-induced thrombocytopenia
LMWHs
Based on the Chest guidelines, all women with prior history of VTE should be offered
Prophylactic or intermediate-dose LMWH for 6 weeks
For pregnant women with a low risk of recurrence (eg, a single VTE with a transient risk factor unrelated to pregnancy or estrogen use)
Surveillance is recommended antepartum
Those with higher risk for VTE
Prophylactic or intermediate dose LMWH before delivery
Recommendations for those with no prior VTE
Higher risk of VTE (Factor V Leiden or prothrombin 20210 homozygotes or compound heterozygotes with a family history of VTE):
Factor V Leiden or prothrombin 20210 homozygotes or compound heterozygotes without a family history of VTE:
No personal history of VTE with any other thrombophilia and a family history of VTE:
Women with lower risk thrombophilias and no personal or family history of VTE:
Higher risk of VTE (Factor V Leiden or prothrombin 20210 homozygotes or compound heterozygotes with a family history of VTE): prophylactic or intermediate-dose LMWH antepartum and postpartum prophylaxis with prophylactic or intermediate-dose LMWH for 6 weeks
Factor V Leiden or prothrombin 20210 homozygotes or compound heterozygotes without a family history of VTE: postpartum prophylaxis with prophylactic or intermediate-dose LMWH for 6 weeks
No personal history of VTE with any other thrombophilia and a family history of VTE: surveillance antepartum; postpartum prophylaxis with prophylactic or intermediate-dose LMWH for 6 weeks
Women with lower risk thrombophilias and no personal or family history of VTE: surveillance antepartum and postpartum
Patients with two or more episodes of VTE:
Treated throughout pregnancy and the puerperium
Women who meet the criteria for antiphospholipid antibody syndrome
Antepartum prophylactic or intermediate-dose UFH or prophylactic LMWH and low-dose aspirin throughout pregnancy
TRUE OR FALSE
Treatment of VTE in pregnancy should be with full-dose LMWH.
TRUE
Treatment of VTE in pregnancy should be with full-dose LMWH.
Heparin is usually discontinued ______hours before induction; however, women deemed to be at very high risk of recurrent VTE can then receive IV heparin up to_____hours before delivery.
24 hours
4–6 hours
TRUE OR FALSE
Heparins and warfarin are safe postpartum even when breastfeeding.
TRUE
Heparins and warfarin are safe postpartum even when breastfeeding.
For pregnant and breastfeeding women, fondaparinux and oral direct acting oral anticoagulants are relatively contraindicated.
TRUE OR FALSE
With Hodgkin Lymphoma, neither the histology nor the outcome of patients who present during pregnancy is worse than that of other patients
TRUE
With Hodgkin Lymphoma, neither the histology nor the outcome of patients who present during pregnancy is worse than that of other patients
Fetal risks of chemotherapy are greatest in the first trimester during the period of organogenesis, with _________ and ____________ carrying the largest risk.
Folate antagonists and antimetabolites
In HL, in some cases, radiotherapy may be a feasible alternative in the ____________ trimesters of pregnancy
Second and third trimester
In HL, if chemotherapy is indicated, it should be delayed until the _________ trimester; however, single-agent ______________ has been given in the first trimester with a low incidence of fetal abnormalities
Second trimester
Vinblastine
TRUE OR FALSE
Compared with Hodgkin lymphoma, other lymphomas are less frequent in pregnancy, tend to present with a higher stage disease, and have a poorer prognosis.
TRUE
Compared with Hodgkin lymphoma, other lymphomas are less frequent in pregnancy, tend to present with a higher stage disease, and have a poorer prognosis.
TRUE OR FALSE
Rituximab has not been associated with abnormalities of the newborn when given in the first, second, or third trimester
TRUE
Rituximab has not been associated with abnormalities of the newborn when given in the first, second, or third trimester
Acute leukemias make up nearly ______% of the total followed by ______________, which comprises an additional 10%; chronic lymphocytic leukemia is extremely rare
90%
Chronic myeloid leukemia
The anthracycline of choice in pregnant patients with AML
Doxorubicin
TRUE OR FALSE
For patients who require chemotherapy postpartum, breastfeeding is recommended.
FALSE
For patients who require chemotherapy postpartum, breastfeeding is not recommended to avoid exposure of the newborn to cytotoxic drugs in the breast milk.
Treatment options for pregnant women with CML
Interferon-α, hydroxyurea, leukapheresis, and busulfan
When antifungal therapy is required, _______________ may be the drug of choice because there have been no reports of teratogenicity with this agent.
Amphotericin
Of all the myeloproliferative neoplasms,________ has the highest proportion of affected women of childbearing age
ET
In ET, if cytoreductive therapy becomes necessary, ___________ is the drug of choice
Interferon-α
Patients with ET with a thrombotic episode (peripheral or placental) during pregnancy should receive
LMWH at therapeutic doses and oral anticoagulant therapy (PT international normalized ratio, 2–3) for at least 6 weeks postpartum
Patients with sickle cell anemia should receive at least_______ mg of folate per day
1 mg of folate per day
In Sickle cell anemia, Prophylactic transfusions are suggested in those with
History of severe sickle cell anemia–related complications before pregnancy or if there are additional features of high-risk pregnancy or new sickle cell anemia–related complications during pregnancy
Patients with β-thalassemia minor generally tolerate pregnancy well; however, doses of at least________ mg/ day of folate PO
4 mg/ day of folate
In thalassemia, during pregnancy, regular transfusions are recommended to keep the hemoglobin level at _______ mg/dL, and transfusion requirements often increase compared with prepregnancy values.
10 mg/dL
