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m4 obgyn > Anemia in pregnancy > Flashcards

Anemia in pregnancy Flashcards

1
Q

Lab values of anemia in pregnancy

A

1st trimester: <11.0 g/dl
2nd trimester: <10.5 g/dl
3rd trimester: <10.0 g/dl

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2
Q

Physiology changes in pregnancy

A

Total intravascular volume increases by 50%
Total RBC mass expands by 25%
-> Greater increase in blood volume than increase of RBC mass causes haemodilution (esp in 3rd trimester)
-> Physiological anemia
Total daily iron absorption from gut increases to 20%

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3
Q

Classifications of anemia in pregnancy

A
  1. Iron deficiency**
  2. Megaloblastic
    - vit B12 def
    - folate def
  3. Hemolytic anemia
    a) congenital
    - thalessemia**
    - sickle cell anemia
    - hereditary spherocytosis
    b) acquired
    - infection
    - drugs
    - autoimmune
  4. Refractory anemia or Anemia of jolly
    Mild bone marrow suppression occurring only during pregnancy, reverts to normal after pregnancy
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4
Q

Causes of anemia in pregnancy

A
  1. Decrease intake/absorption
    - Poor diet: Lack of iron, folate, vit B12
    - Vomiting
    - Drugs decreasing absorption of iron
    - GI disease/surgery (eg. peptic ulcer disease)
  2. Decreased production
    - Renal failure
    - Chronic infection
    - Bone marrow disorder/suppression
  3. Increased destruction
    - Hemolytic anemia:
    Thalessemia
    Sickle cell anemia
    MAHA (DIC, TTP, Eclampsia)
    AIHA
    G6PD
  4. Blood loss
    - Injuries/trauma
    - Menorrhagia
    - Antepartum/postpartum haemorrhage
    - BGIT
  5. Increased demand:
    - Multiple pregnancy, repeated pregnancy
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5
Q

Clinical presentations of anemia in pregnancy

A

Pallor
SoBoE
Palpitations
Giddiness
Fatigue/weakness/poor concentration
Chest pain
Irritability
Hair loss (Fe def)
Tongue discomfort/Disturbance of
taste
Pruritus
Ankle edema

Any bleeding sources? GIT, menstrual

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6
Q

Complications of anemia in pregnancy

A

Mother
- Mortality!
- Peripartum blood loss
- Increased susceptibility to infection
- Post-partum depression

Fetus
- Preterm delivery
- Low birth weight
- Perinatal mortality
- Reduce brain maturity

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7
Q

What to look out for in FBC in anemia in pregnancy?

A

=DONE AT BOOKING and at 28 WEEKS=
1. Hb Level?
2. Microcytic vs normocytic vs macrocytic?
3. RDW and retic count

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8
Q

What is the most common type of anemia in pregnancy?

A

Iron deficiency anemia

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9
Q

What test to confirm iron def anemia?

A

Iron panel with ferritin

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10
Q

Why is there increased iron requirement in pregnancy?

A

Increased red cell mass
Increase in muscle mass (particularly uterine
muscle)
Demands of fetus and placenta

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11
Q

Risk factors of IDA in pregnant woman

A
  • Ethnicity (African)
  • Teenage pregnancy
  • Low socioeconomic class
  • Poor absorption
  • Heavy menses
  • Short interpregnancy interval
  • Multiparity
  • Postpartum hemorrhage
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12
Q

Management options for Iron Def Anemia

A
  1. Lifestyle changes – Eat more leafy greens, beans, red meat, seafoods etc
  2. Oral iron supplementations
  3. Parenteral iron
  4. Blood transfusion
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13
Q

Oral iron supplementations

A

First line
- Hb > 6.5 before 36 weeks
- Max daily dose 200g to prevent GI upset
- Taken at night or 1h before food
- Fruit juice containing ascorbic acid increases absorption
- Avoid milk, caffeine, tea
- Hb should increase within 2 weeks of PO iron

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14
Q

Side effects of oral iron supplementation

A

GI S/E
- constipation, diarrhoea, N/V, abdo pain, dark stools

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15
Q

Indication for parenteral iron

A
  • Intolerance to oral iron
  • Malabsorption
  • Anaemia diagnosed AFTER 36 weeks
    *near term, need to replace quickly + compliance issue
  • Hb <6.5 g/dL

CONTRAINDICATED in 1st trimester

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16
Q

Use of parenteral iron is contraindicated in

A

First trimester

17
Q

Side effect of parenteral iron

A

Headache, N/V, diarrhoea skin discoloration, anaphylaxis

18
Q

Indication for blood transfusion

A
  • Hypovolemia from blood loss (antepartum haemorrhage)
  • Haemolytic crisis
  • Hb <6g/dL (abnormal fetal
    oxygenation, fetal distress/death)
19
Q

Thalassemia in pregnancy

A

Autosomal recessive condition
Genetic defect causes partial or complete suppression of synthesis in either alpha or beta globulin chain, resulting in reduced haemoglobin production in red blood cells

20
Q

Types of alpha thalassemia

A

Alpha thal:
HbA genes x4 on chromosome 16 codes for 2 alpha chains

  • Defect in 1 gene: Alpha thal minima: asymptomatic, not anemic
  • Defect in 2 genes: Alpha thal minor: MILD anemia
  • Defect in 3 genes: Haemoglobin H disease (appears healthy at birth then develops haemolytic anemia): MODERATE-SEVERE anemia
  • Defect in 4 genes: Hydrops fetalis with Hb Bart’s (4 gamma): INCOMPATIBLE with extra-uterine life
21
Q

Types of beta thalassemia

A

Beta thal:
HBb/HbE/HbF genes x2 on chromosome 11 codes for 2 beta chains

  • Defect in 1 gene: Beta thal minor: asymptomatic, mild anemia
  • Defect in 2 genes: Beta thal major: does not reach childbearing age
22
Q

Investigations to do for microcytic anemia (thal)

A

FBC
- Microcytic, hypochromic anemia
- Mentzer’s index < 13

Iron panel TRO Fe def
- Fe, Ferritin, transferrin, TIBC (normal in thal)

PBF
- Target cells (thal)
- HbH inclusion bodies (alpha thal)

Hb electrophoresis**
- Diagnostic for beta thal
- Screening for alpha thal (single gene deletion may be missed out)

Genotyping for alpha thal

23
Q

Mother is thalassemia carrier/ has thalassemia, what investigation should be done next?

A

Screen father

24
Q

If father is found to be a carrier, what should be done?

A

Genetic counselling + prenatal diagnosis

25
Q

How to make a prenatal diagnosis in a foetus with suspected thalassemia?

A

Screening for thalassemia:
- 1st trimester: Chorionic villus sampling
- 2nd trimester: Fetal cord blood sampling

*weigh risk and benefits of screening -> invasive test -> risk of miscarriage present

26
Q

Management of thalassemia

A
  • Folic acid, vit C supplement
  • Iron supplements if concomitant Fe def
  • Blood transfusion if severe
  • Screen father
  • Genetic counselling and prenatal diagnosis
27
Q

Megaloblastic anemia in pregnancy

A

Vit b12 and folate deficiency
- Macrocytic hyperchromic anemia
- Increase incidence in vegetarian (b12), bariatric surgery, coeliac disease, IBD
- Pernicious anemia: autoantibody interfere with absorption of b12
- Neuropsychiatric changes with B12 def
- Neural tube defect with folate def (folic acid supplementation during pregnancy)
- Confirm with b12 and folate panel

28
Q

Neural tube defect is due to

A

Folate deficiency
Mx by giving folic acid supplementation

29
Q

Lab findings to suggest iron def anemia picture

A

FBC
- Microcytic, hypochromic anemia
- Mentzer’s index > 13
- High RDW

Iron panel
- Low serum Fe
- Low ferritin (fe stores)
- Low transferrin
- High TIBC (measures the ability of the blood to attach to Fe and transport it around the body; TIBC high as ferritin low)

m4 obgyn (41 decks)

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