CH 34 Hematologic Disorders in Pregnancy

Question 1

Iron deficiency Anemia patho

Answer 1

in second half of pregnancy, iron requirements increase due to expansion of RBC mass and rapid growth of the fetus (requiring 500 mg of iron) and the fetus needs 300 mg on average meaning 800 mg of additional iron needed in 2nd half of pregnancy exceeding the 1 mg/d of iron available from a normal diet (need 3.5 mg/d)

Question 2

Iron makeup in body

Answer 2

iron in hemoglobin (70% or 1700mg in a 56kg woman) and iron stored as ferritiin and hemosiderin in reticuloendothelial cells in bone marrow, the spleen, and parenchymal cells of liver. Small amounts of iron in in myoglobin, plasma, and various enzymes

Question 3

Iron deficiency Anemia prevention

Answer 3

women with hx of iron deficiency anemia, give at least 60 mg/d of elemental iron to prevent anemia during pregnancy and puerperium

Question 4

Iron deficiency Anemia symptoms and signs

Answer 4

pallor, easily fatigability, HA, palpitations, tachycardia, and dyspnea. If severe: angular stomatitis, glossitis, and koilonychia (spoon nails)

Question 5

Iron deficiency Anemia labs

Answer 5

hematocrit <33%, hemoglobin may fall as low as 3 g/dL, red blood cell count rarely below 2.5 x 10^6mm^3. Red cells are hypochromic and microcytic. Serum ferritin falls to < 15 ug/dL and transferrin falls to <16%, low reticulocyte count, increased platelet count, normal WBC count. Bone marrow biopsy shows lack of stainable iron in marrow macrophages and erythroid precursors

Question 6

Iron deficiency Anemia complications

Answer 6

intrauterine growth retardation and preterm birth, increased risk of postpartum depression, angina pectoris, CHF, sideropenic dysphagia (patterson kelly syndrome/plummer vinson syndrome: dysphagia, esophageal web, atrophic glossitis), reduced fetal oxygenation, abnormal fetal heart tracing, low amniotic fluid volume, and intrauterine fetal demise

Question 7

oral iron therapy for Iron deficiency Anemia

Answer 7

ferrous sulfate 300 mg (with 60 mg of elemental iron) TID. If not tolerated, give ferrous fumarate or gluconate. Continue for 3 months even after hemoglobin values return to normal. Give on empty stomach. Taking with citrus juice or ascorbic acid aids in absorption

Question 8

Parenteral iron therapy for Iron deficiency Anemia

Answer 8

give when oral iron is not tolerated. Iron dextran given IM or IV. Do 0.5 ml test dose first. If given IM, must be done in upper outer quadrant of buttocks. Associated risks: anaphylactic reaction, muscle necrosis, fever, phebitis

Question 9

Erythropoietin for Iron deficiency Anemia

Answer 9

given with IV iron may shorten time to targeted hematologic indices than IV iron alone. Particularly better for women in 3rd trimester

Question 10

blood transfusion for Iron deficiency Anemia

Answer 10

reserved for women with coexisting issues such as operative delivery or postpartum hemorrhage or women with evidence of active bleeding or hemoglobin <7 due to increased risk of obstetrical and fetal complications in women with anemia of this severity.

Question 11

thromboembolism patho

Answer 11

increased risk during pregnancy and peurperium due to being hypercoagulable states (virchow’s triad: circulatory stasis, vascular damage, and hypercoagulability)

Question 12

superficial thrombophlebitis

Answer 12

will present with tenderness, pain, or erythema along a vein. palpable cord is sometimes present. diagnose with compression US. Treat with compression stockings, ambulation, leg elevation, local heat, and analgesic meds

Question 13

Deep vein thrombosis

Answer 13

half occur in antepartum and other half postpartum. attributed to prolonged bedrest. 80% occur in LT lower leg due to compression of left iliac vein by the right iliac artery as it branches to aorta

Question 14

thromboembolism clinical findings

Answer 14

lower extremity tenderness, swlling, color changes, and palable cord. Homan’s sign (pain from passive dorsiflexion of the foot) may be present. extremity may be pale and cool with decreased pulses due to reflex arterial spasm

Question 15

thromboembolism diagnosis

Answer 15

US with duplex and color doppler US. IF not detected but high suspicion, use MRI

Question 16

thromboembolism treatment

Answer 16

anticoagulation, bed rest, analgesia. once symptoms have abated (7-10 days) ambulate with ted hose. Start anticoagulation with unfractionated heparin or low molecuar weight heparin. in postpartum, pt can transition to warfarin (NOT during pregnancy). Therapy should be total of 3-6 months

Question 17

Pulmonary Embolism clinical findings

Answer 17

has signs of DVT first, but may not be apparent. dyspnea, pleuritic chest pain, apprehension, cough, syncope, and hemoptysis, tachypnea, tachycardia

Question 18

PE prevention

Answer 18

women at high risk should be given prophylactic anticoagulation.

Question 19

PE labs and imaging

Answer 19

arterial blood gas, CXR, and ECG. VQ scans, CT

Question 20

PE diagnosis

Answer 20

high probability VQ scans indicative of PE. Gold standard is pulmonary artery catheterization with angiography but is used less frequently due to invasive nature

Question 21

PE treatment

Answer 21

anticoagulation (heparin or couamdin). First line during pregnancy is adjusted dose unfractionated heparin or low molecular weight heparin. Therapeutic anticoagulation should be continued for 4-6 months to prevent recurrence. May use vena cava filter