In a non-pregnant woman, anaemia is defined as 12 weeks to birth Immediately post birth Hb <100 g/L Hb <110g/L Hb <105 g/L

- 1st trimester (0-12 wks) = Hb 12 weeks to birth = Hb <105 g/L - Immediately post birth = Hb <100 g/L

Anaemia in Pregnancy Flashcards by David Houghton

What is the definition of anaemia in women?

1 - <200 g/L Haemoglobin (Hb)
2 - <160 g/L Haemoglobin (Hb)
3 - <140 g/L Haemoglobin (Hb)
4 - <120 g/L Haemoglobin (Hb)

4 - <120 g/L Haemoglobin (Hb)

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In a non-pregnant woman, anaemia is defined as <120 g/L Haemoglobin (Hb). Match the cut off to the trimester in a pregnant woman with anaemia?

1st trimester (0-12 wks)
>12 weeks to birth
Immediately post birth

Hb <100 g/L
Hb <110g/L
Hb <105 g/L

1st trimester (0-12 wks) = Hb <110g/L
> 12 weeks to birth = Hb <105 g/L
Immediately post birth = Hb <100 g/L

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Typically what 2 timepoints do pregnant women have their FBC taken which would identify if anaemia was present?

1 - 10-12 and 28 wks
2 - 10-12 and 18 wks
3 - 16 and 28 wks
4 - 18 and 32 wks

1 - 10-12 and 28 wks

additional FBC at 20 and 40 weeks if patient is high risk

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What is the prevalence of anaemia in the UK?

1 - 2.4%
2 - 24%
3 - 45%
4 - >60%

2 - 24%

Lower income countries this is 50%
due to:
- nutritional deficiencies (iron)
- infectious diseases (malaria)
- variant Hb (sickle cell disease)
- thalassaemic disorder

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Do iron levels fall first or does anaemia occur first?

iron levels drop first
pregnant women can be iron deficient and have a normal Hb

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What maternal symptoms can present in suspected anaemia in pregnancy?

1 - fatigue/weakness
2 - pallor / jaundice
3 - dizziness
4 - increased risk of infection
5 - palpitations
6 - all of the above

6 - all of the above

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Anaemia can have detrimental effects on the mother. Which of the following is NOT one of these?

1 - Post partum haemorrhage
2 - Puerperal sepsis
3 - Increased mortality (< 70g/L)
4 - Myocardial infarction

4 - Myocardial infarction

increased mortality was shown in lower income countries
puerperal sepsis is due to a genital tract infection

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Anaemia can have detrimental effects on the foetus. Which of the following is NOT one of these?

1 - large birth weight
2 - Pre-term birth
3 - Perinatal death
4 - neuro-developmental impairment

1 - large birth weight
- typically causes low birth weight

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During pregnancy their is a physiological increase in plasma volume by what %?

1 - 3-5%
2 - 10-15%
3 - 20-30%
4 - 30-50%

4 - 30-50%
- referred to as dilution anaemia

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During pregnancy their is a physiological increase in RBCnumber by what %?

1 - 2-3%
2 - 20-30%
3 - 30-40%
4 - 30-50%

2 - 20-30%
- RBCs increase to supply placenta and foetus

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Does hematocrit, a % by volume of red cells in your blood increase or decrease pregnancy?

decreases
please increases by 30-50% and RBCs only increases by 20-30%

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As the RBC number increases, the expecting mother requires an increase in haematinics, nutrient for RBCs development. Which of the following is NOT a haematinic?

1 - iron
2 - folic acid
3 - vit B12
4 - vitamin A
5 - vitamin D

4 - vitamin A
- good for eyes but not a haematinic

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Iron is one haematinic that is required in pregnancy for erythropoiesis and iron dependent enzymes including those in foetal and placental tissue. Which trimester is this particularly important in?

1 - 1st
2 - 2nd
3 - 3rd

3 - 3rd
- important for growth of baby in 1st 4-6months
- Increased maternal erythropoiesis to help with this

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What is the iron requirement in a non-pregnant women?

1 - 1-2mg/day
2 - 5-10mg/day
3 - 25-50mg/day
4 - >100mg/day

1 - 1-2mg/day
- typically consume 10mg/day, but only 10-15% absorbed = 1-2mg

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What is the iron requirement in a pregnant women towards the end of pregnancy?

1 - 2mg/day
2 - 6mg/day
3 - 25mg/day
4 - 100mg/day

2 - 6mg/day
- mothers should be consuming aprox 27mg of iron/day

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Does the absorption of iron capacity increase or decrease in pregnancy?

increases in pregnancy

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In pregnancy as the demand for iron increases, which of the following forms of iron decreases first?

1 - transport iron
2 - erythropoiesis iron
3 - storage iron

3 - storage iron
- once iron stores are used the pregnant women becomes anaemic

All women are at risk of pregnancy in anaemia, however, which of the following may have a greater risk of anaemia in pregnancy?

1 - nutritional (vegetarian, vegan)
2 - multiparty with short inter-pregnancy interval (<1y)
3 - socio-economic factors
4 - teenagers
5 - late antenatal support
6 - medications e.g. Anticoagulants
7 - Menorrhagia
8 - Women who decline transfusion e.g. Jehovah’s witness
9 - all of the above

9 - all of the above

Our diets contain 2 forms of iron,

heme iron (meats) = Fe2+ iron is already bound to haemoglobin
non-heme iron (vegetables) = Fe3+ as not bound to haemoglobin

Once digested, all iron converted into Fe2+. Is heme or non-heme iron easier to absorb?

heme iron is absorbed better
this is why vegetarians and vegans are at increased risk of anaemia

Which vitamin helps with the absorption of iron?

1 - vitamin D
2 - vitamin C
3 - vitamin A
4 - vitamin K

2 - vitamin C

tannins in tea and coffee inhibit iron absorption

If a woman becomes iron deficient in pregnancy what should they be advised to do?

1 - increase iron in diet
2 - have iron infusions
3 - blood transfusions
4 - take iron supplements

4 - take iron supplements

ferrous sulphate or fumarte

Increased folate is also required in pregnancy, which of the following is NOT a good source of folate?

1 - garlic
2 - green vegetables
3 - nuts / seeds / legumes
4 - citrus / mango / banana
5 - avocado
6 - eggs

1 - garlic

All of the following are causes of anaemia in pregnancy, but which is the most common cause?

1 - physiological dilutional
2 - iron deficiency
3 - haematinic deficiency (folate)
4 - haemolysis, Elevated Liver Enzymes, Low platelets (HELLP syndrome)
5 - blood loss (puerperium)

2 - iron deficiency

Some patients may have anaemic causing conditions such as:

Haemoglobinopathies: Sickle cell anaemia, thalassaemia
Bone marrow failure
Haemolytic anaemias e.g. hereditary spherocytosis

In addition to check and making sure patients iron levels are ok, what other marker associated with iron do we need to measure and consider giving if it is low?

1 - transferrin
2 - ferritin
3 - feroportin
4 - hepcidin

2 - ferritin
- stores iron in tissues

if <30ug/L may need to start oral iron supplementation

Which of the following is NOT an instruction given to patients when advising them to take iron supplements? 1 - every morning 2 - with tea or coffee 3 - empty stomach 4 - maximum once a day

2 - with tea or coffee - this can reduce iron absorption

When giving patients oral iron, what is the target of elemental iron (iron that is available for absorption) that patients should be taking? 1 - 4-8mg 2 - 4-80mg 3 - 40-80mg 4 - 80-120mg

3 - 40-80mg

Which of the following molecules negatively regulates iron absorption, and is lowest in the mornings? 1 - hepcidin 2 - ferritin 3 - vitamin D 4 - vitamin C

1 - hepcidin

Which of the following is NOT a common adverse effect of oral iron supplements? 1 - constipation 2 - diarrhoea 3 - nausea 4 - dark stool

2 - diarrhoea

In women who have been identified as anaemic, they should continue on oral iron supplementation throughout pregnancy and then during breast feeding for how long? 1 - whole time breastfeeding 2 - until a total of 6 weeks post-partum 3 - until they want to stop 4 - until Hb levels are above 120g/L

2 - until a total of 6 weeks post-partum - may still be breastfeeding, but just stop after 6 weeks total post partum

If a patient is iron deficient, are over the counter iron supplements sufficient to raise iron levels enough?

- no

When trying to identify if a patient is iron deficient we can look at MCV which will be microcytic anaemia (<80fl). Which 2 of the following could cause this in pregnancy? 1 - iron deficiency (reduced MCV) 2 - haemoglobinopathies (sickle cell) (reduced MCV) 3 - increased MCV

3 - increased MCV - this happens in pregnancy, but in anaemia in pregnancy this is likely to go down

In pregnancy, does mean corpuscular haemoglobin (MCH), a measurement of the amount of haemoglobin in red blood cell go up of down?

- goes up - BUT can go down if patient is iron deficient or have haemoglobinopathies (sickle cell)

If a patient has a low Hb (<70g/L) and are between 34-40 wks and/or are not responding to iron supplementation, who should they be referred to? 1 - GP 2 - haematologist 3 - obstetrics 4 - gynaecologist

3 - obstetrics - need to check iron compliance

Intravenous iron can be considered in patients with iron deficiency anaemia who are not responding to iron supplements. But which trimester must they not be given? 1 - 1st 2 - 2nd 3 - 3rd

1 - 1st

Intravenous iron can be considered in patients with iron deficiency anaemia who are not responding to iron supplements. Which of the following is NOT an indication for oral transfusion? 1 - Non-compliance with or intolerance of oral iron 2 - Malabsorption 4 - Patient choice 3 - rapid correction of anaemia is required e.g. Hb<70g/L or close to term

4 - Patient choice - More women achieved target Hb and maintained Hb with Fewer side effects with iron transfusion

Intravenous iron can be considered in patients with iron deficiency anaemia who are not responding to iron supplements. Which of the following is NOT a contraindication for oral transfusion? 1 - Anaphylaxis/serious reactions 2 - Third trimester 3 - Active infection 4 - Decompensated liver disease

2 - Third trimester - 1st trimester is contraindicated Disadvantages of iron transfusion: - Rare instances of anaphylaxis - Hypophosphataemia - Extravasation and skin staining - Cost and administration

B12 is another important haematinics for erythropoiesis. Which of the following is NOT a cause of low B12? 1 - vegan diets 2 - normal diet 3 - inflammatory bowel disease 4 - physiological effect 5 - surgery

2 - normal diet - physiological low B12 typically occur in the 3rd trimester

Which 2 of the following are symptoms of a patient with low B12? 1 - paraesthesia neuropathy causing pins and needles) 2 - pallor 3 - macrocytosis (small TBCs) 4 - bruising

1 - paraesthesia neuropathy causing pins and needles) 3 - macrocytosis (small TBCs)

If a patient has confirmed low vitamin B12, how should they be treated? 1 - iron and folic acid supplementation 2 - multivitamin over the counter 3 - hydroxycobalamin injection (IM) 4 - all of the above

3 - hydroxycobalamin injection (IM) - 3 injections given - check 2 months post natal by GP

Pregnancy and lactation are associated with increased folate requirements, malabsorption, diet and medication can all cause low folate. How much folate should a pregnant woman be advised to take? 1 - 400ucg daily until term 2 - 1mg daily until term 3 - 5mg daily until term 4 - 10mg daily until term

3 - 5mg daily until term - pregnant women not folate deficient take 400ucg daily until term - reduces the risk of neural tube defects

Women with anaemia are at higher risk of post partum haemorrhage. What cut off of Hb, should women be advised to give birth in an obstetrician led unit? 1 - Hb <70g/L 2 - Hb <80g/L 3 - Hb <100g/L 4 - Hb <120g/L

3 - Hb <100g/L Group and save and crossmatch Active management of third stage (removal of placenta to reduce risk of PPH)

What is the definition of post-partum anaemia? 1 - <200 g/L Haemoglobin (Hb) 2 - <160 g/L Haemoglobin (Hb) 3 - <140 g/L Haemoglobin (Hb) 4 - <100 g/L Haemoglobin (Hb)

4 - <100 g/L Haemoglobin (Hb) - give oral iron if no active bleeding - check FBC 48h post delivery - if severe symptoms give iron transfusion - may need blood transfusion