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Essay 367 - anaemia in pregnancy

Essay 367 - anaemia in pregnancy Posted by Farrukh G.

A 25 year old woman has been referred to the antenatal clinic at 18 weeks gestation because her haemoglobin concentration is 8.1g/dl. (a) Discuss your initial assessment [8 marks]. (b) Discuss her treatment options given that she has iron deficiency anaemia [6 marks]. (c) Discuss your intra-partum and post-natal care given that she goes into spontaneous labour at 38 weeks gestation and her Hb at 37 weeks was 8.4g/dl [6 marks].

Answer to Essay 367 - anaemia in pregnancy Posted by preetiba rani V.

a)  The incidence of anaemia in pregnancy is around 30% - 50% with Iron Deficiency Anaemia being the commonest (90%)

My assessment will begin with detail history taking. I will ask her regarding symptoms such as tiredness, fainting episodes and dizziness eventhough majority of women will be asymptomatic.  I will also probe into her menstrual history prior to her pregnancy that can point to heavy menstrual loss which could be the cause of her anaemia. Other on going loss such as per rectal bleeding need to be ascertained as haemorrhoids are common in pregnancy.  History of passing worm in her stools and pruritus ani will point towars helminth infestations that can also lead to anaemia. I will also ask regarding history of chronic illness such as autoimmune or renal diseases.  Family and personal history of blood disorders or blood transfusion will point towards hemoglobinopathies.  A detail enquiry regarding her diet is also essential as this can also lead to anaemia especially if she is a vegetarian ( where she could have Vitamin B12 deficiency anaemia)

Clinical examination will reveal pallor.  I will also look for signs of chronic anaemia such as koilonychia, angular stomatitis and glossitis.  Presence of an enlarged liver or spleen will point towards hematological conditions such as Thallasaemia and in rare instances malignancies such as leukaemia.  If history is suggestive a proctoscope examination should be performed to look for haemorrhoids.

Other parameters in a Full Blood Count results should be looked into such as Mean Cell Volume (MCH), Mean Cell haemoglobin (MCH) and Mean Cell Haemoglobin Concentration (MCHC).  Reduced MCV and MCHC will point towards hypochromic microcytic anaemia.  Where else macrocytosis may point towards folate deficiency.  Serum ferritin should be sent as a reading of < 12ug/L is diagnositc of Iron Deficiency Anaemia.  A rise in TIBC can be expected.  A peripheral blood film should be taken to study the morphology of the cells which can reveal folate deficiencies or hemoglobinopathies.  Microscopy examination of the stool can be done if the history is suggestive of helminth infestations

 

b)  Treatment options for this woman would be oral iron therapy, intramuscular iron or intravenous iron

Oral iron therapy is the first line of treatment as it is cheap and widely available. A recommended dose of 120 - 240mg of elemental iron per day should be given,  This can cause a raise in her haemoglobin (Hb) of 0.8g/dL per week.  Ferrous salt has beeted absorption than ferric salt and hence it is more preferable.  However, the main problem with oral iron therapy is the side effect mainly involving gastrointestinal system such as nausea and vomiting (occuring in 40% of women).  This leads to non compliance.  An alternative can be a slow releasing iron preparations which has lesser side effect profiles but has lesser absorption.

Intramuscular iron can be given if the woman is unable to tolerate the oral therapy due to it's side effect profile.  Iron sorbitol can be given deep intramuscularly for 2 weeks.  This therapy is associated with pain at injection sites and also requires multiple injections which is not desirable for most women.

The other option would be intravenous iron.  This method has fewer side effects compared to oral therapy and also causes a rapid rise in Hb concentration.  However this needs the womanto be on IV cannula and  to have daily trips to the hospital for a few days

 

c)  This woman is at increase risk of post partum haemorrhage during delivery.  Therefore, I will ensure that her blood is taken for group and save.  Active 3rd stage management is important to prevent primary PPH.  Routine use of 5 units of slow intravenous oxytocin will ensure a well contracted uterus.  Control cord traction  must be performed to minimize blood loss.  Care should be taken to look for any genital tract trauma and repair done to secure hemostasis.  

Post natal period care should be taken to assess the ongoing losses such as monitoring blood pressure and pulse rate and also the pad.  Any excessive loss in lochia must be immediately reported.  Oral iron therapy should be continued and the woman reassessed after 6-8 weeks post partum.  Persistence of anemia should prompt further investigations and hence referral to a physician must be made

Kb Posted by saini K.
A)
KB Posted by saini K.

a) I will ask for detailed history including any effect on QOL like weakness, easy fatiqueability, and shortness of breath. I will further enquire about any presence of recurrent fever with chills and rigor, chronic cough, dysuria/hematuria to exclude infection like malaria,TB,UTI. Any chronic blood loss like bleeding gums, piles, worm infestation or any bleeding disorder like easy bruiseability, ecchymosis, petechia. Any chronic diarrhea or altered bowel habit may indicate malabsortion syndrome. Any medical problem like chronic renal disease, any immunosuppressive therapy or medication causing hemolysis. Any history of repeated blood transfusion in self and family. Her menstrual history prior to pregnancy including duration, amount of bleeding, clots and obstetric history for parity, close gap between pregnancy, any APH/PPH or blood transfusion in last pregnancy. Social history like lower social economic status, dietry habit, alcohol or smoking.I will examine her degree of pallor, BMI, any other signs of nutritional deficient like stomatitis, glossitis,Chelosis, lymphadenopathy, nail clubbing/koilonychia and peripheral neuropathy and abdominal examination for any hepatospleenomegaly. I will review her FBC report for MCH/MCH/MCHC for type of anemia. According to finding I will consider sending serum ferritin/TIBC, red cell Folate/Vit B12 , Hb electrophoresis to find out cause of anemia. I will test urine and stool for occult blood, ova/cyst.

b)

I will inform consultant obstetrician and anesthetist. I will set up IV plug and send for group crossmatch. I will keep her in propped up position and give oxygen by face mask. I will continuously monitor her BP,HR,RR,SPO2 and ECG monitoring and frequent auscultation of lung bases for any signs of cardiac decompensation due to increased cardiac preload during labour and strict input/output charting. Encourage epidural analgesia. I will consider to cutshort second stage of labour by assisted instrumental delivery to avoid cardiorespiratory distress. The third stage of labour should be actively managed to avoid blood loss since she might not able to tolerate even small amount of blood loss. Avoid ergortamine as it may precipitate cardiac failure due to sudden increase in preload. Meticulous hemostasis for vaginal laceration and episiotomy.

Postnatally I will continue HR,BP,RR,SPO2 monitoring closely as she is at increased risk of cardiac decompenation immediately after delivery due to increased cardiac load. Start her on thromboprophylaxis like TEDS, adequate hydration, early ambulation and LMWH according to risk factors. I will discuss with her contraceptive option before discharge. I will offer her either progesterone only pill, depot provera, implanon or LNG IUS 4 weeks after delivery if breastfeeding. Cupper IUCD not suitable for her as it may be associated with menorrhagia. I will further advice her to continue therapeutic dose of oral iron therapy till Hb level > 12gm/dl and to continue till 3 months after that to restore store. She is at increased risk of P.sepsis and subinvolution of uterus, I will advise her to seek medical advice if any symtoms like fever,foul smelling vaginal discharge,pain abdomen,GI symtoms etc.

 

 

 

KB Posted by saini K.

please ignore previous answer, answer to question ( B) is missing

 

a) I will ask for detailed history including any effect on QOL like weakness, easy fatiqueability, and shortness of breath. I will further enquire about any presence of recurrent fever with chills and rigor, chronic cough, dysuria/hematuria to exclude infection like malaria,TB,UTI. Any chronic blood loss like bleeding gums, piles, worm infestation or any bleeding disorder like easy bruiseability, ecchymosis, petechia. Any chronic diarrhea or altered bowel habit may indicate malabsortion syndrome. Any medical problem like chronic renal disease, any immunosuppressive therapy or medication causing hemolysis. Any history repeated blood transfusion in self and family. Her menstrual history prior to pregnancy including duration, amount of bleeding, clots and obstetric history for parity, close gap between pregnancy, any APH/PPH or blood transfusion in last pregnancy. Social history like lower social economic strata, dietry habit, alcohol or smoking.

I will examine her degree of pallor, BMI, any other signs of nutritional deficient like stomatitis, glossitis,Chelosis, lymphadenopathy, nail clubbing/koilonychia and peripheral neuropathy and abdominal examination for any hepatospleenomegaly. I will review her FBC report for MCH/MCH/MCHC for type of anemia. According to finding I will consider sending serum ferritin/TIBC, red cell Folate/Vit B12 , Hb electrophoresis to find out cause of anemia. I will test urine and stool for occult blood, ova/cyst.

b)

Treatment is administration of iron either by oral or parentral route. Route depends whether she can tolerate oral iron, compliance, any malabsorption syndrome. The preferred route is oral. She should be given therapeutic dose of 200 mg elemental iron daily. Oral therapy is easy, cheap and similar efficacy as parentral route. However, associated with nausea,vomiting,gastritis, diarrhea/constipation. i will give parentral iron therapy if poor oral intolerance, nomcompliance, malabsorption syndrome. Various forms available are iron dextran, iron sorbital, iron sucrose and iron gluconate. Iron dextran can be given either IM or IV route whereas iron sorbital only IM route and iron sucrose and gluconate as IV route. IM route may be associated with pain in injection site,abcess formation, myalgia, anaphylactic reaction. Iron sucrose is rarely associated with anaphylactic reaction but it is expensive. Asessment of reponse to therapy done by clinically and hematological indices. She will start feeling better and Hb level rises by 0.8 to 1 gm/dl per week, reticulocyte count increases within 5-7 days.

c)

I will inform consultant obstetrician and anesthetist. I will set up IV plug and send for group crossmatch. I will keep her in propped up position and give oxygen by face mask. I will continuously monitor her BP,HR,RR,SPO2 and ECG monitoring and frequent auscultation of lung bases for any signs of cardiac decompensation due to increased cardiac preload during labour and strict input/output charting. Encourage epidural analgesia. I will consider to cutshort second stage of labour by assisted instrumental delivery to avoid cardiorespiratory distress. The third stage of labour should be actively managed to avoid blood loss since she might not able to tolerate even small amount of blood loss. Avoid ergortamine as it may precipitate cardiac failure due to sudden increase in preload. Meticulous hemostasis for vaginal laceration and episiotomy.

Postnatally I will continue HR,BP,RR,SPO2 monitoring closely as she is at increased risk of cardiac decompenation immediately after delivery due to increased cardiac load. Start her on thromboprophylaxis like TEDS, adequate hydration, early ambulation and LMWH according to risk factors. I will discuss with her contraceptive option before discharge. I will offer her either progesterone only pill, depot provera, implanon or LNG IUS 4 weeks after delivery if breastfeeding. Cupper IUCD not suitable for her as it may be associated with menorrhagia. I will further advice her to continue therapeutic dose of oral iron therapy till Hb level > 12gm/dl and to continue till 3 months after that to restore store. She is at increased risk of P.sepsis and subinvolution fo uterus, I will advise her to seek medical advice if any symtoms like fever,foul smelling gavinal discharge,pain abdomen,GI symtoms etc.

 

 

 

Posted by Christa R.

 

a)

Anaemia is a common problem during pregnancy.  The anaemia may be asymptomatic, however symptoms may be present indicating more severe disease or poor tolerance of the condition.  I would therefore firstly enquire about symptoms of fatigue, lethargy, weakness, palpitations/ noticeable fast heart rate and SOB, all of  which are features of anaemia.  I would enquire about symptoms of bleeding/ blood loss, specifically any history of gastritis, vaginal or rectal bleeding.  I would enquire about possible melaena indicating GIT bleeding.    I would ask about any personal health problems such as coeliac disease or inflammatory bowel disease which could cause anaemia secondary to malabsorption.  I would ask about any personal or family history of haemaglobinopathies i.e. thalassaemia or sickle cell disease.  I would enquire any history of renal disease or SLE, since renal disease can result in defective EPO production and anaemia.  I would enquire about the lady’s diet.  A vegan or vegetarian diet may be deficient in iron, folate or B12.  I would finally ask about any other chronic medical condition, since anaemia can present with chronic disease.

I would examine for signs of pallor or jaundice.  I would check BMI and identify if underweight or significantly overweight. I would identify the presence of any rash (malar butterfly rash of SLE) along with evidence of glosittis, and angular chelitis which may indicate vitamin deficiency.  I would assess for hepatosplenomegaly and peripheral oedema (nephropathy).  If concerns over GIT bleeding I may perform a PR examination.

Investigations would include FBC to assess mean cell volume (macrocytosis or microcytosis) which may help point towards the aetiology of the  anaemia.  The haematocrit and mean cell haemoglonin concentration would also be assessed.  A blood film would assess for evidence of haemolysis as would LDH and bilirubin levels.  Blood film may also identify the presence of parasitaemia which can cause anaemia. .  I would assess iron stores by means of ferritin levels, which are the most reliable indicator of iron deficiency as well as complete iron studies. (including total iron binding capacity).    I would perform screening for haemaglobinopathies i.e. thalassaemia or sickle cell disease.  I would perform baseline renal function and liver function tests.  If any vaginal bleeding present I would arrange an ultrasound scan to look for placental location and fetal growth + LV.

 

 b)

Iron supplementation may help to improve iron levels.  In the first instance this may be trialled with oral iron (ferrous salts such as ferrous sulphate), unless known malabsorption such as from inflammatory bowel disease.  The down side of such treatment is GIT side effects which can result in poor compliance .  The aim of the therapy is to increase HB by 0.8g/dL/week.  Vitamin C taken simultaneously may help with the iron absorption.  This would be advised by taking the iron with fresh orange juice or other vitamin C containing products.  Alternatively it can be achieved with Vitamin C supplementation, although this is not routinely recommended.

If oral iron is not tolerated then parenteral preparations can be given.  Intramuscular iron is an option (iron sorbitol) however it may be painful and tattoo the skin at the injection sites and with repeated injection this may be undesirable..  IV iron (e.g iron sucrose) can increase iron levels more rapidly that other preparations.  There is however a small risk of allergic reactions and anaphylaxis.  It also requires cannulation which is invasive.  If iron levels are profoundly low or associated with renal disease then erythropoietin may be considered.   Finally, there may be a role for folic acid supplementation to help with erythropoiesis.

 

c)

Intrapartum management will involve early IV access with blood taken for repeat baseline FBC and cross matching (2-4 units).  The anaesthetist and consultant obstetrician should be informed of the lady’s admission.  If delivery is necessary via C/S, then good intra-operative management of haemostatis and the possibility of cell salvage may help to minimise the risk of worsening postpartum anaemia.  Active management of the 3rd stage with initial 5IU of syntocinon followed by a prophylactic syntocinon infusion will help to reduce the risk of PPH secondary to uterine atony.  Careful assessment of uterine cavity at C/S to check empty and assessment for completeness of placenta should also be performed.  Prompt repair of perineal trauma should be performed.  Postpartum assessment of pulse, BP and PV loss should be performed at least 4 hourly.  If heavy lochia or signs of haemodynamic compromise, here should be senior obstetrician input for assessment and advice .  A postpartum FBC should be performed to assess the need for postpartum transfusion.  Iron therapy should be continued for a minimum of 6 weeks at which time a repeat FBC will be performed.  Postpartum investigations of anaemia may be necessary i.e endoscopy.  Breast feeding should not be discouraged

 

 

 

essay 367 Posted by sujata B.

 

Essay   367
 
 
 
I willask a detailed history regarding any factors suggestive of anaemia prior to pregnancy ex. menorrhagia,whether she is from a poor socioeconomic background.
 and whwther she had been tested for anaemia  before pregnancy. I would also look into her records to see if she was screened for haemoglobinopathies
 at her bookin visit.I will ask her if she had received dietary advice on Iron Rich foods and factors which may infuence their absorption.
I will ask her if she is on folic acid.I would examine her - look for pallor, odema if any, ascultate for any haemic murmur. I will plapate her abdomen -to note if the growth is corresponding to the period of pregnancy.I will do furthur investigations like a FBC,which would include MCV.
,MCHC,MCH and Peripheral smear. I will do Hb Electrophoresis if it has not been done earlier. I would also do her serum Ferretin.
 
Regarding  her treatment options-I will refer her to a dietician to give her dietary advice and will ensure that she is aware that tea ,cofee(tannins) would 
decrease absorption of iron . I would tell her to take the iron1hr before a meal with Vit C as it would enhance it's absorption.I will start her on Oral Iron A dose of 100 to 200 mg daily if her S. ferretin us <30mcg/dl. I will recheck her Hb after 2 weeks and refer her to a secondary centre if there has been no rise or if she is intorelant to oral iron.I will advice her to continue taking her folic acid.If her Hb contonues to be low I will advice her to plan her delivery in an obstetric unit with facilities even for cell salvage..If her haemoglobonopathy status is positive she will be explained about the possible ned for blood transfusion at the time of delivery.Oral iron would be madicines in the ferrous salts,as absorbtion would be better.I will givher parenteral iron(iron sucrose) if she is unable to tolerate oral iron and if her Haemoglobonopath status is negative.
 
 
In the intrapartum phase I will have an early I/V access, group and save. I will will ensure that she has an active management of the 3rd stage of labor and be prepared for any event like PPH.Postnatally I will recheck her Hb and if still low will consider oral or parenteral iron.I will consider blood transfusion only if she has any risk factors like risk for cardiac decompensation. I will advice on continuing the treatment for 3 months.I will request the neonatologist to assesss the baby. I will discharge her after giving her dietary advice , information leaflets on diet and will also give contraceptive advice.Essay   367
 
 
 
assay 367 Posted by huaida A.

A 25 year old woman has been referred to the antenatal clinic at 18 weeks gestation because her haemoglobin concentration is 8.1g/dl. (a) Discuss your initial assessment [8 marks]. (b) Discuss her treatment options given that she has iron deficiency anaemia [6 marks]. (c) Discuss your intra-partum and post-natal care given that she goes into spontaneous labour at 38 weeks gestation and her Hb at 37 weeks was 8.4g/dl [6 marks

A/

 

First I  would take a history to assess her symptom severity  and to identify the causative factor  .                 
  
       Would inquire about whether the woman is vegetarian or not as they are commonly depleted in iron .also  would inquire about any febrile illness specially if the woman came from area endemic with malaria as this  may  cause hemolytic anemia .would ash about history of worm infestation such as pin worm and    hook   worm that lead to iron deficiency anemia. Would ask about history of hemoglobinapathy such as sickle cell disease or thalaseamias   .examination of the pulse may show collapsing pulse . heart examination may reveal hemic murmurs plus or minus gallob rythm                                                                                             ..                                                                                                                                           .    
                            
,I would examine the the abdomen for hepatosplenomegally which is common in hemolysis and leukemia.
Would assess the fundal height and confirm  the viability by ultrasound .
Then would request investigations to find out the cause.
CBC and peripheral blood picture help in differentiating different types  of anemia., hypochromia and microcytosis indicate iron deficiency anemia, and this could be supported by measuring serum ferritin level, while macrocytosis woud suggest vit B or folic defeciency,
Poikilocytosis and anisocytosis suggest hemolytic
Hb electrophoresis would be requested if the history and the ethenic group suggest it,s presence
Stool general to detect occult blood. 
B/
The options are either iron supplementation or blood transfusion.
If her symptoms are not severe and as she is still far from date of delivery ,iron supplementation would the option of choice , this can be supplemented in form of iron sulfate , howevere  this type of iron associated with more GIT side effect.
iron gluconate has better  side effect profile
Slow releasing  iron is another option for those who cannot  tolerate iron sulfate 
for those with poor compliance  with oral iron injectable  forms would be an option
Iron supplement whether orally or parenterally   it takes time  to improve the Hb.  (3-4 weeks) needed to elevate the Hb 1- 2 gram /dl
The second option is the blood transfusion , if the woman symptoms are so severe as in case of impending heart failture then packed cell volume transfusion would be the right option.
C/
Intrapartum , she  would be consider as a  high risk delivery,she is at risk of fetal distress, at risk of maternal exhaustion  and hence delayed second stage of labour,which in turn may necessitate  instrumental delivery.Continous CTG is needed and the woman should be counselled about this.
Also she is at risk of postpartum hemorrhage .
Blood  sample for grouping and  safe should be taken . Large iv line should be fixed early.If she refuse blood transfusion this should be documented clearly in her note  ,&,should be counselld about transfusion of other blood component as well as usage of cell salvage.
Active management of third stage of labour is mandatory ,using intravenous syntometrin   after delivery of the anterior shoulder or intramuscularly at time of head crowning, in addition to this controlled cord traction helps in reducing the risk of postpartum hemorrhage.Blood loss should be estimated accuratlly and if more than 500 cc or if compromises the hemodynamic status of the woman should be replaced by packed cell  volume
In the postpartum period she at risk of DVT so risk of thromboembolism should be assessed continously.
 
She would have low immunity which would make he vulnerable  to infections such as postpartum endometritis , and delivery wound infection ,so,prophylactic antibiotic would guard her against these complication.
She should offer  postpartum iron and multivitamines.postpartum contraception that result  in irregular bleeding or causing menorrhgia should be avoided and other options should be discussed with woman before discharge .She should be given an appointment as 6 weeks postpartum.  As she is iron deficient her breast milk would be also deficient in iron so  an advice from the neonatologist  is important regarding the neonate feeding.
 
 
 
 
 
 
essay 367..anaemia in pregnancy Posted by shazard S.

 

Essay 367- my answer

(a)

Firstly obtain a history. Symptoms of anaemia include dizziness, headaches, fatigue and palpitations. Detirmine the effect of these symptoms on her quality of life. Regarding her diet, vegetarians are pre-disposed to anaemia in pregnancy. Assess her attitude (refusal or acceptance) toward blood transfusion if transfusion becomes necessary. A history of haematemesis, haematochezia or maleena stool indicate blood loss through the gastro-intestinal (GI) tract. Regarding her past obstetric history, multi-parity and interpregnancy intervals less than 1 year are associated with iron deficiency. Prior outcomes such as low birth weight and preterm delivery are associated with anaemia. Obtain a menstrual history. Menorrhagia is associated with iron deficiency. Elicit a past medcal history. Auto-immune conditions such as SLE and pernicious anaemia pre-dispose to anaemia in pregnancy. A history of haemoglobinopathy (sickle cell disease and thalassaemia)are recognized causes of anaemia. Renal disease is associated with anaemia. Past surgical history of small bowel resection may result in malabsorbtion. Note any haematinics currently used and tolerance of side effects. On examination, pale mucous membranes and tachycardia may be a consequence of anaemia. Calculate her BMI. Malabsorbtion syndromes may be associated with a BMI<18.5kg/m2 (under weight). Angular stomatitis indicates iron deficiency. A beefy red tongue (glossitis) suggests B12 deficiency. On abdominal examination measure her symphysio-fundal height. Uterine fibroids may be present if large for dates. Regarding investigations, a complete blood count (CBC) with red cell indices, renal function tests, serum ferritin and a Haemoglobin electrophoresis should be done initially.

(B)

Treatment should start with oral iron supplementation. Dosage required is 100-200mg daily. Advise that it be taken on an empty stomach at least 1 hour prior to meals. Advise that absorption is enhanced with vitamin C and inhibited by phyates (cereal) and tannins(coffee/tea). Side effects of oral iron include nausea and constipation.Arrange consultation with the dietician to appropriately supplement her diet with green leafy vegetables and meat. If no improvement in haemoglobin concentration despite 3-4 weeks of compliance with oral iron administer iron sucrose intravenously. Administer intravenous iron sucrose if side effects of oral iron limit compliance (nausea and constipation). Intra-venous iron achieves a quicker rise in haemoglobin concentration and replenishment of iron stores. Counsel regarding risk of anaphylaxis and administer in a setting with facilities and staff trained in management of anaphylaxis. Blood transfusion is appropriate if iron supplementation has failed. Blood transfusion increases haemoglobin concentration immediately. Administer blood transfusion if Hb falls below 6g/dl or if symptoms affect quality of life. Counsel regarding risks of transfusion reaction and blood borne infection. Blood transfusion is less cost effective than iron supplementation and subject to availability.

(C)

Anemia requires additional precautions in labour. Delivery should occur in a consultant lead unit. Inform the senior midwife. Establish intravenous access and take bloods for CBC and to be grouped and saved. Review her antenatal notes regarding documentation of refusal or acceptance of blood transfusion if required. Ensure adequate analgesia and hydration. Recognise that anaemia reduces her tolerance of blood loss. Anaemia is a risk factor for post partum haemaorrhage. Therefore ensure active management of the third stage and meticulous haemostasis of vaginal laceration repair. Regarding post-natal care, anaemia is a risk factor for venous thrombo-embolism (VTE). Perform a risk assessment for VTE and administer appropriate thromboprohylaxis. Repeat her Hb within 48 hours of delivery. Offer oral iron supplementation, 100-200mg daily for the next 3 months. Arrange follow up in three months with her general practitioner or district midwife to repeat her CBC and serum ferritin. Advise effective contraception and to delay pregnancy by at least one year.

Posted by gouthaman S.

 

History  includes  the  effect  of  anemia  on  working performance,Quality  of  life,fatigue,palpitations,dizziness,dyspnoea.Since  anemia  predisposes  to  infections  due  to impaired  immunity H|O  urinary tract infections,vaginal discharge  are  enquired.Risk  factors  predisposing  to  anemia  including  parity,interpregnancy  interval,menorrhagia,chronic  illness  renal, celiac  disease  are  enquired.Ethnicity,family  history  of  hemoglobinopathies,social  factors,previous  blood  transfusion  are  reviewed.Dietary  pattern   and  screening  reports  of  hemoglobinopathies  if  done  are  reviewed  and  FBC  report  with  red  cell  indices  are  reviewed  for  type  of  anemia.

Examination  includes assessment  of  BMI,pallor,presence  of angularstomatitis,

Glossitis,Koilonychia  indicating  chronic  anemia.PR,BP,CVS  ,RS  are  checked.Perabdominal  examination  is  done  for  hepatosplenomegaly   which  is  present  in  chronic  malaria, hemoglobinopathies.

First line  diagnostic  test  is  commencement  of  oral  iron  with 100-200mg  of  elemental  iron  with  anemia  after having  ruled  out  hemoglobinopathies. Appointment  for  followup  is  arranged  after  2  weeks  with  serum  ferritin,blood  film,FBC.,screening  results  if  not  performed  earlier.Written  information  is  provided.TIBC,Serum  transferrin  and  serum  iron  not  useful  due  to  diurnal  variation.

B)Treatment  options  include  oral,parenteral   iron  preparations along  with  appropriate  diet  advice.Oral  iron  with  elemental  iron  100-200mg per  day  is  commenced  .It  is  effective  ,safe,easy  to  administer,cost  effective.  Ferrous  preparation  is  given  for  better  absorption.All  types  are  equally  effective.Slow  release ,enteric  coated  preparation  avoided.Side  effects  are  explai ned  including   epigastric discomfort,nausea.She  is  advised  to  take  in  empty  stomach  with vit C orange juice  and   avoiding  other  medications.Improvement  is  assessed    after  2  weeks(0.8 gm per week increase) Oral  tablets  should  be  kept  out  of  reach  for  children.If  normal  HB  is  attained  therapy  is  given  for  3  months  and 6weeks postpartum.

 

Diet  rich  in  iron(meat,poultry,fish,green vegetables} is  advised  with  avoidance  of  intake  of  tannates(coffee,tea}  and  intake  of  phytates.Smoking  cessation advised.  Parenteral  therapy  is   given  if  noncompliance,no  improvemement  in. HB. Parenteral therapy  is  more  effective,quicker  in  improving  HB.IM  and  IV iron  preparations  are  available.IV  iron  sucrose  preferred since  it  avoids pain, staining. Dose  is  calculated  with  prepregnancy  BMI   and  aim for  HB 11gm%.Staff  dealing  with anaphylaxis  should  be  present while  giving  parenteral  therapy. .Written  information  is  provided.Newer  preparation iv carboxymaltose  can  be  given  as  single  dose  but costly  with  limited  availability.

Blood  transfusion  is  reserved  only  for  ongoing  bleeding,cardiac compromise,acute  replacement.

c) Care  should  be  under   obstetrician led unit since HB is less than 9.5gms%.

Plan  of  care should  be  made including  for  management  of PPH.

Intravenous access is  made.Blood  is  sent  for  group  and  save  .Adequate  analgesia  for  pain  relief  is  offered.Vitals PR,BP   monitored       and  progress of  labour   with  partogram.Fetal  monitoring done  every 30min in first stage and 15 min in second stage.Vaginal  operative  delivery  is  done  if  maternal  exhaustion,fetal distress or  cardiac  compromise  .Active  management  of  third  stage  with  im  oxytocin 10u is given. . If  prolonged  labour,instrumental delivery 2-3 hrs  of  oxytocin iv infusion given . She  is  monitored for  blood  loss. Prophylactic  antibiotic  is  given  if  taken for LSCS.    Postpartum    HB is  checked  within  48  hrs of  delivery.Oral  elemental  iron  100-200mg  is  started if  tolerant  and  given   for  3  months.Personal hygiene  to  avoid  infection  is stressed  along  with  dietary  advice.Risk  assessment  for  thromboprophylaxis is  done  and  early  mobilization,hydration   encouraged.  Baby  is  assessed  for  wellbeing  since  prone  for  lowbirth  weight. Contraceptive  advice  given. . Breast  feeding  is  encouraged. Postnatal  review  is  explained , documented and  appointment  for  followup  given  after  6-8  weeks.FBC  and  serum  ferritin  are  repeated  after  3  months  for  assessing  improvement.

Answer 367 Posted by Jyoti B.
Obtain a history from the patient regarding symptoms of anaemia like fatigue,Headache, palpitations,breathlesnes.History of diarrhoea or features of malabsorption. Bleeding per rectum, or per vaginum, or any haematamesis.Take any history of easy bruisability,previous blood transfusion,family history of haemoglobinopathies. Ask about her diet,especially prone to anaemia if vegetarian,alcoholic.If on iron tablets currently or in the past,it's compliance and side effects like nausea,epigastic Pain,altered bowel habits. Enquire if she noticed any worms in her stools.In her menstrual history ask about history of menorrhagia which may have caused anaemia.In her obstetric history ask about her parity,time of last child birth as multiparty(>3)and interval between childbirth<1 year predisposes to anaemia . Any history of iron tablet intake,preterm birth,or iugr in previous babies which indicated anaemia in previous pregnancies. Know if any belief against blood transfusion. On examination, we take the BMi of the patient,<18.5, predisposis the patient to anaemia,look for features of malnutrition, look for glossitis or angular stomatitis which indicate vitamin b deficiency.Check the patients vitals to look for any tachycardia.examine any pallor,pedal Edema.Lookfor any crepts in the chest which may indicate heart failure.Per abdominal confirm the fundal height, look for any organomegaly especially spleenomegaly which may point to haemoglobinopathies or any chronic liver disease. Initial investigations include, full blood count with RBCindices ,a peripheral smear for type of anaemia,malarial parasite.Baseline renal function test and liver function test with s. proteins to rule out any chronic disease.Serum ferritin and Hb electrophoresis.urine routine and microscopy, stroll for ova and cyst to rule out infection. B) First line of management of iron deficiency anaemia is by oral iron tablets which are in ferrous or ferric salt preparation in a dose so that elemental iron intake is 100-200mg per day.Advice the patient to take iron tablets on empty stomach/1hr prior to meals preferably with citric juices like orange or lemon juices which are goof sources of vitamin c which enhances absorption.Sense of well being ,improvement of symptoms, rise in reticulocytes is seen in about 1week and rise of Hb by1gm/week seen after 2weeks.the treatment should continue for atleast 3 months to built up iron and replenish stores.If patient faces side effects like nausea, epgastric pain, constipation Lower the iron dose or change the iron salt. Parental iron can be started in patients who cannot tolerate oral iron or are non compliant or those who have a proven malabsorption syndrome.Containdication includes any active acute or chronic infection,chronic liver disease or anaphylaxis to parental iron.Parentral iron can be given as iron dextran, iron sucrose.Newer alternatives include iron ,iron isomaltoside. Iron sucrose has high bioavailability and low chances of anaphylaxis but cannot be given as total dose infusion like iron dextran.Parentral iron should be given in a hospital setting due to possibility of anaphylactic reaction SCBUand oral iron should be withheld prior to treatment with Parentral iron.The rise of Hb and iron stores is faster with Parentral iron due to high bioavailability. Alone with treatment of iron deficiency anaemia diet of the patient should also be taken care of to include more green leafy veditables,sources rich in proteins.if malnourished dietician referral can be taken to improve diet.If alcoholic, include steps for detoxification. C) This patient should be delivered in a consultant led unit .Review her antenatal notes regarding acceptance of blood transfusion.. An intravenous line should be secured and blood should be sent for blood grouping and cross match.Maintain adequate hydration and analgesia and look for any symptoms of heart failure during labour.Active management of the 3 rd stage to reduce blood loss and be aware that these patients are more prone to post partum haemorrhage.Strict watch on vitals and note for any symptoms of heart failure immediatly post delievery. Post partum anaemic patients are more prone to infection,check for any unhealthy Lochia or infected episiotomy and commence antibiotic early.Hb to be repeated 48hrs post delievery,.Start oral iron therapy at a dose of 100-200mg per day for 3 months, advice high protien diet.hb to be checked after 2 weeks to check rise of haemoglobin by 1-2gm/week.Inform midwife and GP of the patient to check for compliance and correction of anaemia and diet. Ensure effective contraception in form of oral contraceptive pill and advice to delay pregnancy for atleast 1 year.
Answer to essay 367 Posted by uzma sultana M.

A] The initial assesment of the patient  , Take a detail history of symptoms such as felling of Tiredness, Giddiness, fatiuge and lethargy.  History of previous pregnancies and spacing,  menstrual history of oligomenorrhoea, polymenorrhoea, menorrhagia,  any history of fibroids which could have resulted in menorrhagia and worsened her anaemia  , intermenstrual bleeding if there is risk of chlamydia and gonorrhoea as infections are common in anaemia  , report of last cervical smear to rule out cervical malignancies,  family history of Haemoglobinopathies,  any  previous history of  blood transfusion,   any bleeding per rectum for haemorrhoides,  any blood in stool if patient has history of peptic or duodenal ulcer, any post coital bleeding if there is cervical erosion or growth such as polyp,   Her diet history , if she is an vegetarian , if she is a smoker , alcoholic and on any recreational drug  , if she has a history of chronic renal disease,  and contraception history if she had levanorgestrel iud inserted which would have caused irregular vaginal bleeding. any history of passing worms in stool and any anal itching  .

  Coming to examination part  ,check for pallor in the conjunctiva,tongue, Kilonychia in nails, ascultate lungs and heart for murmers, palpate abdomen for any masses and for hepatospleenomegaly ,  do a cervical examination for erosion and polyp and any malignant growth. proctoscopy for haemorrhoides. 

Investigations will be CBC, MCV, MCHC, MCH all these levels will be decreased, Serum Ferritin , IF >25 microgram% then it is diagnostic of Iron deficiency. If no history of haemoglobinopathy no need to screen them, Renal function test and liver function test,  stool analysis for occult blood and ova or cyst. peripheral smear not neccesarry in iron deficiency anaemia.

B] The patient is advised high protein diet,   Smoking and  alcohol cessation,   Since she is still 18 weeks pregnant there is time to built up her iron provided she complys with her drugs   . Oral iron preparation of 120-240mg elementary iron in the ferrous form  Because it absorbs better than ferric form,  this treatment is less costly,   give it along with VIT C as it absorbs better and less gastointestinal side effects ,  preferably on empty stomach along with orange juice  , Most of the patients dont comply with this because of side effects such as nausea, vomiting, constipation and dark coloured stools.    Oral preparation helps to increase her haemoglobin  by 0.8 grm per week,  check her haemoglobin level after 2 weeks,    Next option is injectables such as Sorbitol injection,   deep IM ,   it helps to built her haemoglobin quickly,    the side effect is,    it causes injection site pain and tatooing,     Other option is IV Dextran infusion  given in hospital setup   , This has better compliance but risk of anaphylaxis,  now a days isomaltoside  is given because less side effects,    If her haemoglobin is very low about 6 grm she can have blood transfusion  but this has transfusion risk  , If there is Endstage renal disease she can be given Recombinant erythropoietin  .Information leaflet will be provided.

c]  Since she is anaemic she has to deliver in a consultant led unit,   Labour is monitored closely   , Bp, pulse checked every 30 minutes, input and output chart  maintained,  Caeserean setion is only for obstetric reasons,   After counselling about the risks ,  An IV line is set blood taken for group and crossmatch,   she will labour in left lateral position to prevent aorto caval compression with adequate  analgesia of her choice  , second stage is cut short with operative vaginal delivery   and active management of 3 rd stage by giving 10 units of syntocinon im.    This reduces blood loss and prevents post partum Haemorrhage, volume over load is prevented because risk of going into heart failure,    The fetus is monitored continiously by CTG to check fetal distress, as there is increase risk of IUGR  , Post nataly  the patient is encouraged to breast feed,   advised on high protien diet,   maintain hygiene because risk of infection with foul smelling lochia,   continue with her haematincs,   contraceptive advice,   and review after 6-8 weeks for CBC and serum ferritin   , Information leaflet is provided and contact number given.

Srija Posted by Srija C.

 

 

(a) Discuss your initial assessment [8 marks].

History is taken regarding her dietary details to know if she is vegetarian as vegans can become iron deficient.

She is asked if she is suffering from fatigue, head ache, breathlessness and poor concentration which are the symptoms of iron deficiency anaemia and how is she is coping with her symptoms. She should asked about her ethnic status to know if she has come from areas where certain haemoglobinopathies are prevalent. She should be asked about previous anaemia before pregnancy due to heavy menstrual bleeding. Recent history of bleeding from hemorrhoids, epistaxis or bleeding gums should be taken.

Obstetric history is important as multiparty and short pregnancy interval are associated with iron deficiency anaemia. 

Examination is undertaken to identify pallor. Pulse is recorded as tachycardia is common in case of anaemia. Abdominal examination is done to measure the uterine size and multiple pregnancy should be excluded by ultrasound scaning. Multiple pregnancy is risk factor for the development of iron deficiency anaemia. 

Investigations include FBC and low Hb, Low haematocrit, low MCV, low MCHC suggest iron deficiency. Presence of microcytic hypo chromic RBC (pencil cells) on blood film suggests iron deficiency. Serum ferritin level is measured which is the first laboratory finding to become abnormal in iron deficiency anaemia and levels below 15μg/l suggests iron depletion in pregnancy. 

 

 

(b) Discuss her treatment options given that she has iron deficiency anaemia [6 marks].

 

She should be provided with dietary advice which should include details of Haem iron and non Haem iron. ( Haem iron is 2-3 times more absorbed than non Haem iron.) She should be advised to avoid phytates ( present in cereals) and tannins ( coffee and tea) which inhibit iron absorption.

 

Once the woman is iron deficient diet alone is not sufficient to restore iron stores in pregnancy . The recommended dose of elemental iron is  100-200mg per day. Ferrous salts (ferrous fumarate, ferrous sulphate and ferrous gluconate) are better absorbed than ferric saltsHigher doses should not be given as absorption is saturated and side effects are increased.  She should be advised to take oral iron supplements on an empty stomach, 1 hour before meals, with a source of vitamin C  (ascorbic acid) such as orange juice to maximise absorption If she develops side effects such as nausea and epigastric discomfort, dose of the iron should be titrated to minimize side effects.

If she cannot tolerate oral iron or compliance is a doubt parenteral iron is indicated. Iron sucrose has a higher availability for erythropoiesis than iron dextran but its use is limited by total dose that can be administered in one infusion requiring multiple infusions. Newer preparations iron III carboxymaltose and Iron III isomaltoside aim to overcome this problem with single dose administration in an hour or less. Parenteral iron is contraindicated in case of previous anaphylaxis, acute or chronic infection and in the presence of chronic liver disease.

 

(c) Discuss your intra-partum and post-natal care given that she goes into spontaneous labour at 38 weeks gestation and her Hb at 37 weeks was 8.4g/dl [6 marks].

Her delivery should be in obstetrician's lead unit.

 

She should be asked if she has any concerns regarding blood transfusion in case to make alternative arrangements.

 

Venous access should be secured and blood should be grouped and saved.

 

Third stage should be managed actively to reduce the risk of post partum hemorrhage.

 

Hb should be checked 48 hours after the delivery.

 

If Hb is less than 10 g/ dl she should be prescribed elemental iron 100-200mg daily for 3 months with a repeat

FBC and ferritin at the end of therapy

Essay 367 iron def anaemia Posted by MONA V.
A ) Initial assessment   a)   A  detailed history  is taken  about symptoms of anemia like fatigue,palpitations ,dizziness and effect on quality of life. Obstetric history is taken for parity,  frequent childbirth , short pregnancy intervals predisposing to iron deficiency anemia.   Chronic infections like recurrent urinary tract infections , worm infestations lead to anemia and should be treated .  Review her antenatal hemoglobinopathy results if any, enquire ethnicity , previous blood transfusions to assess for thalasssemia or sickle cell disease causing anemia. Chronic blood loss due to bleeding hemorrhoids may cause anemia and  asked for.   Complex social factors like migration ,poor diet may predispose to anaemia.  General examination for pallor, angular stomatis  koilonychia which point to chronic anemia. Blood pressure BMI is noted as under weight women may be anaemic. Abdominal exam for liver spleen enlargement in hemolytic anaemia is done.   Investigations include red blood indices peripheral blood film to look for type of anaemia. First line investigation is trial of oral iron for two weeks wherby improvement suggests iron deficiency anaemia. If hemoglobonipathy known serum  ferritin cheched   and oral iron given only if less than 30 ug/l .  If  status unknown  send hemoglobinopathy screen as soon as possible , serum ferritin and start oral iron. Follow up after 2 weeks with results.   b) Oral elemental iron 100 – 200 mg per day is continued in case of iron deficiency anemia with correct  instructions .like taking tablet before meals,  preferably with orange juie.  Advice to keep tablets away from reach of children. Advise about diet iron rich foods like green vegetables , meats and regular intake of  iron supplements . If nausea ,epigastric  pain lower dose tried.  Avoid enteric coated preparations.  Parenteral intravenous iron sucrose can be given if intolerance, non compliance to oral iron or no response. Total dose calculated as per weight and iron deficit.  Patient is given written information about possible risks like preterm labor, abruption  and intentions about blood transfusion if needed  during labor documented. Blood reserved only for cardiac compromise , bleeding . Once hemoglobin normal iron for 3 months . c) Place of delivery should be  obstetrician led unit as hemoglobin is < 95g/L       due to increased risk of peripartum blood loss.  Intravenous access secured , blood taken for group and save .Alert blood bank  as major post partum hemorrhage is a complication.   Labor progress is monitored by partogram  .Avoid fliud bolus which will precipitate cardiac failure She is offered pain relief ,epidural not contraindicated.  Fetal heart ausculated intermittently . Oxytocin augmentation can be done after assessing for cephalopelvic disproportion. Active management of third stage is done . by prophylactic oxytocics , controlled cord traction. Post partum hemorrhage managed aggressively .  Thromboprophylaxis given as per risk assement  .Encourage early ambulation, hydration as thrombosis common.  Encourage breast feeding as more chance of lactation failure .  Look for fever  puerperal sepsis and treat with broad spectrum antibiotic.  Contraception advice given as repeated pregnancy worsen anaemia. Reassess Hb after 48 hours as uncorrected anemia or if blood loss . continue oral iron 3 months.
essay 367 iron def anaemia Posted by MONA V.

 

please ignore the above answer  due to technical errors

A ) Initial assessment

 

a)   A  detailed history  is taken  about symptoms of anemia like fatigue,palpitations ,dizziness and effect on quality of life. Obstetric history is taken for parity,  frequent childbirth , short pregnancy intervals predisposing to iron deficiency anemia.   Chronic infections like recurrent urinary tract infections , worm infestations lead to anemia and should be treated .  Review her antenatal hemoglobinopathy results if any, enquire ethnicity , previous blood transfusions to assess for thalasssemia or sickle cell disease causing anemia. Chronic blood loss due to bleeding hemorrhoids may cause anemia and  asked for.   Complex social factors like migration ,poor diet may predispose to anaemia.  General examination for pallor, angular stomatis  koilonychia which point to chronic anemia. Blood pressure BMI is noted as under weight women may be anaemic. Abdominal exam for liver spleen enlargement in hemolytic anaemia is done. 

Investigations include red blood indices peripheral blood film to look for type of anaemia. First line investigation is trial of oral iron for two weeks wherby improvement suggests iron deficiency anaemia. If hemoglobonipathy known serum  ferritin cheched   and oral iron given only if less than 30 ug/l .  If  status unknown  send hemoglobinopathy screen as soon as possible , serum ferritin and start oral iron. Follow up after 2 weeks with results.

 

b)      Oral elemental iron 100 – 200 mg per day is continued in case of iron deficiency anemia with correct  instructions .like taking tablet before meals,  preferably with orange juie.  Advice to keep tablets away from reach of children. Advise about diet iron rich foods like green vegetables , meats and regular intake of  iron supplements . If nausea ,epigastric  pain lower dose tried.  Avoid enteric coated preparations.  Parenteral intravenous iron sucrose can be given if intolerance, non compliance to oral iron or no response. Total dose calculated as per weight and iron deficit.  Patient is given written information about possible risks like preterm labor, abruption  and intentions about blood transfusion if needed  during labor documented. Blood reserved only for cardiac compromise , bleeding . Once hemoglobin normal iron for 3 months .

c)      Place of delivery should be  obstetrician led unit as hemoglobin is < 95g/L

       due to increased risk of peripartum blood loss.  Intravenous access secured , blood taken for group and save .Alert blood bank  as major post partum hemorrhage is a complication.   Labor progress is monitored by partogram  .Avoid fliud bolus which will precipitate cardiac failure    She is offered pain relief ,epidural not contraindicated.  Fetal heart ausculated intermittently . Oxytocin augmentation can be done after assessing for cephalopelvic disproportion. Active management of third stage is done . by prophylactic oxytocics , controlled cord traction. Post partum hemorrhage managed aggressively .  Thromboprophylaxis given as per risk assement  .Encourage early ambulation, hydration as thrombosis common.  Encourage breast feeding as more chance of lactation failure .  Look for fever  puerperal sepsis and treat with broad spectrum antibiotic.  Contraception advice given as repeated pregnancy worsen anaemia. Reassess Hb after 48 hours as uncorrected anemia or if blood loss . continue oral iron 3 months.

 

Posted by Nabila A.

Enquiry  is made to identify the risk factors   for anemia…diet ,menorrahgia previous anemia , multiparity,interval  from the previous pregnancy, known  haemoglobinopathy. Symptoms ,their severity although nonspecific   should be asked to assess  its effect  on her quality of life …fatiguibility ,irritability.palpitations ,breathlessness.History of any vaginal bleeding  is taken.

General physical examination  is done to  note BMI,pallor ,pulse B.P.Abdominal examination  is done to find  for the symphsiofundal height  and whether it corresponds to the dates.

F ull blood count  with haemoglobin estimation  including Red cell indices should be done E xclude haemoglobinopathy.In the absence of haemoglobinopathy , microcytic hypochromic or normocytic anemia  is  indicative of iron deficiency anemia.Serum ferritin  is   indicated only if  the woman is diagnosed to have hemoglobinopathy ,prior to parenteral iron replacement or with  risk factors for iron depletion.

Once iron deficiency occurs it is difficult to replenish the stores with diet alone

Treatment options include oral iron replacement therapy .It is both diagnostic as well as therapeutic .If  hem oglobin improves in 2 weeks with iron replacement therpy  then it is diagnostic of iron deficiency anemia.Various oral  ferrous salts( ferrous  fumarate, ferrous sulphate , ferrous gluconate) are available.Ferrous salts are better thon ferric salts.The recommended  dose for treatment is 100- 200 mg  elemental iron daily.Oral iron therapy has various side effects….gastric discomfort ,nausea vomiting,altered bowel habit either diarrhea or constipation .These are  dose related and are responsible for the non compliance .Dose can be reduced to  decrease the side effects.Dose should be titrated  accordingly .Oral preparations  should be taken empty stomach for better absorption.Vitamin c increases its absorption.Tannins in tea and phytate sin cereals decrease its absorption.

If oral iron is not tolerated,non compliance or fails to improve haemoglobin levels  by 2 gm in 3-4 weeks ..parenteral iron  is also another option .It  can be administered  by intramuscular injection (iron  sucrose) or intravenous route (iron dextran).Newer preparations ironIII  carboxymaltose or iron III isomaltoside  are available in which total dose     is administered in one hour by infusion.

Use of recombinant human erythropoietin  is still to be established in routine clinical practice  and should be used only in research context.

She should be   referred for the specialist obstetrician care if  severe symptoms or failure to respond to  iron replacement.She is at risk of  having low birth weight baby,risk of premature labour and PPH.

Delivery  should be conducted in  the consultant led unit .Additional precautions to be be made to prevent  blood loss.Venous access  as well as group and save done If required advice from haematologist  should be sort.Active management of third stage should be done.Good hemostasis  maintained if operative delivery is indicated  .Any lacerations should be promptly stitched.In case of haemodynamically stable ,asymptomatic..ther is little evidence of benefit of blood transfusion.  oral iron replacement is recommended for 3 months FBC and Serum ferritin repeated thereafter.

In case of PPH,blood transfusion is  considered  depending on the hemodynamic status ,amount of ongoing bleeding  and history (anemia unresponsive to treatment).

Advice for effective contraception alongwith education about importance of diet and birth spacing should be given.Support for breastfeeding given.Follow up planned to repeat the haemoglobin levels and referral to physician

 

essay367 Posted by R S.

 

a:-

Most of the time anaemia is asymtomatic. My intital assesment starts with history.I would enquire about her current symptoms,like tiredness, fatigue, pallor, dizziness. Enquire about her parity as well. if this pregnancy is first or 2nd or 3rd, because consicutive pregnancies & lactation can depleted the iron stores from the body. Further proceed to enquire about any bleeding problem like, mentrual irregularities like menorragia, dysfunctional uterine bleeding, any haemoglobinopathys, any upper GI ulcers also responsible for iron deficiency anaemia. Enquire about rectal bleeding to exclude, hamhorrides, any rectal carcinoma(rare), any rectal polyps & ulcerative colitis .Inaddition asked about helminthic infections.Any chronic illness like renal impairment. I would also asked the ethenic groups, like south east asians & african community has haemoglobinopathys and iron deificiency anaemia. I must asked about her diet either shes vagan. After that i would examine for kholinychia, onchylosis, brittle nails, pallor for iron deficency anaemia.I would evalute the investigation, fall in MCV,MCH,MCHC, indicate iron deficency anaemia.Gold standard test is serum ferratin test if its less than 12ug/l then it confirmed the iron deficiency anaemia. TIBC & SERUM IRON is unreliable indicator because wide flucctuation of recent ingetion of iron & infection.Zinc protoporphyrine is increases when iron is low.ZPP has not been affected by haemodilution. however has good sensitivity and specificity. this test is expensive and not performed widely.Soluble Transferrin Receptors increases in iron deficiency anaemia but again expensive test. Bone Marrow Iron test is too invasive so it only performed when there is not identifiable cause of iron deficency anaemia.

b:- Pt should informed about iron deficiency anaemia. Let her informed the option of treatment. Pt should encourage her heam iron i-e haemoglobin & myoglobin includes red meat, poultry & fish, has better absorption than Non-heam products should be taken with vit:c where it provides better absorption however phytates in cereals, tannins in tea & calcium rich food causes less absorption.Oral irons is safe and cheap option. There are ferrous iron and ferric salts. but ferrous iron is better than ferric salts. In moderate to sever iron deficiency anaemia 100-200mg iron should commenced. Parentral iron is fastest way to replinish iron. Iron dextran( cosmofer) can be given i/m mostly. Can be injected on altenative buttocks & its painful too.Can be able to adminster total dose over 4-6 hours. The major side effect could be muscle staining which could be permenant. Iron sucrose(venofer) widely used, total i/v dose no more than 20mg, can be repeated up to 3 times a week. Can cause anaphylactoid reaction. Iron maltose(ferinject) and iron maltoside(monofer) are fast acting iron preprations which can be given as a total dose in once off for correcting iron deficency anaemia.

c:- Delivery should be in hospital setting, where in case of any complication prompt treatment should be given. intravenous access, blood grouping and save. Clear evidence from RCT supports active management of 3rd stage of labour. After delivery should administer intramuscularly syntocinon and ergometrin to minimized the blood loss. inaddition if there is instumental delivery or prolonged labour i/v infusion of high doses of syntocinonshould be continuded for uterine contraction. If uterotonics are not avaialble than misoprostol may be useful as alternative.In postpartum repeat Hb, continue for oral iron for 3 months or may be given fast acting iron prepration. Followup maintain with in 3 months , if anaemia persistant then refer her to physian. Advise for contraception for future pregnancy.

Anaemia in Pregnancy Posted by A H.

(a) In the history, I will ask about menorrhagia, which will predispose to pre-pregnancy anaemia. I will ask her parity and the age of her last child. Multiparity, especially if the interpregnancy interval is short will predispose to anaemia. If her last child is less than one year old and she breast fed, this will also predispose to anaemia.

She will be asked about her diet. A vegan or vegetarian diet will predispose to iron deficiency, folate deficiency, and B-12 deficiency anaemia. Chronic conditions like renal failure and autoimmune disease will be enquired.

I will check her booking blood reports to identify any haemoglobinopathy, for example sickle cell disease and thalassemia.

The mucus membranes will be examined for pallor and jaundice. The abdomen will be palpated for enlarged liver or spleen and for a large for dates uterus which may indicate fibroids.

Blood will be taken for full blood count and red cell indices (MCV, MCH, MCHC) will be noted. Serum ferritin, B-12 and red cell folate concentrations will be requested.

An ultrasound will be requested if necessary to determine position and size of fibroids. Stool will be sent for parasistology and occult blood.

(b) The firstline treatment is is oral iron, commonly ferrous sulphate. Ferrous preparations are more readily absorbed than ferric . The haemoglobin (Hb) should rise by 0.8gms/dl/week. Gastrointestinal side effect mainly nausea and constipation, is experienced by about 40% of patients. Extended release preparations may be used instead to reduce this risk. The patient will be advised to take it with fresh orange juice as Vitamin C enhances absorption.

Intramuscular injections can be used if she does not tolerate tablets or if absorption is poor. Treatment will have to be given over two weeks. The main drawback is it is extremely painful and it causes staining at the injection site.

Intravenous iron is the most effective. Tolerability and absorption issues will be absent. The main problem is anaphylaxis which may be experiencd by a small number of patients. She will have to be admitted for intravenous access an the infusion will take about 4 hours.

Blood tranfusion will be necessary if iron therapy is not effective. The main problem is anaphylaxis and prion infection.

c)An intravenous access will be inserted and at least 2 unts crossmathed blood or packed cells requested. Blood will be transfused as soon as it is available, as her haemoglobin need to be optimised if emergency caesarean becomes necessary and reduce complications of massive blood loss.

Anaemia predisposes to uterine atony and postpartum haemorrhage. She will therefore be counselled for active management of the third stage.If there is uterine atony an oxytocic infusion will be commenced.and she will be closely monitored. Other interventions for uterine atony will be employed early. Repair of episiotomy and lacerations will be done promptly.

She will be counselled to use effective contraception to avoid falling pregnant before the cause of anaemia is found and treated. She will be referred to the appropriate specialist and/or haematologist to treat the cause of anaemia and optimise her haemoglobin before the next planned pregnancy

anemia in preg Posted by shraddha G.

 

A)     Detailed history has to be taken regarding the symptoms of anaemia viz; fatigue, dizziness, irritability, poor concentration, headache, dyspnea and palpitations. Enquire about the passage of worms in stool, pruritis ani (suggestive of helminth infestation), blood in stools, piles, altered bowel habits (suggests malabsorption syndrome). Ask about the history of pica, i.e. craving to eat chalk, mud which is due to iron deficiency. Ask about any chronic disease as renal disease/ failure may lead to erythropoietin deficiency and anemia of chronic disease. Ask about the menstrual pattern and if she had excessive blood loss in menses in her previous menstrual cycles. Ask for her parity and birth interval as multiparity (P>=3) and low birth interval < 1year leads to iron deficiency anemia. Dietary history has to be taken as strict vegans may be Vitamin B12 deficient. Ask if history of multiple blood transfusion is there in the family, suggestive of hemoglobinopathy which are hereditay. History of bony pain which exacerbate on dehydration, low oxygen conditions suggests sickcle cell disease.

Thorough general examination must be done. Look for pallor in the lower conjunctiva, nail-bed, palmar creases. Look for the hydration status, pulse as she may have tachycardia due to hyperdynamic circulation, petechiae, ecchymosis , gum bleed may suggests, Idiopathic thrombocytopenic purpura, coagulopathy or dengue infection . Examine and look for the signs of chronic anemia such as koilonychia ,cheliosis, glossitis and stomatitis. Systemic examination include CVS , ejection systolic murmur heard in mitral area  due to hyperdynamic circulation,on  per abdomen examination hepato-splenomegaly may be there and indicate malaria, or hemoglobinopathy like thalassemia. Plot the symphysio-fundal height , if correspond to gestational age as there is risk of IUGR and LBW.

FBC should be done and study the red cell indices. Low MCV,MCH and MCHC suggests iron deficiency anaemia while high MCV suggests megaloblastic  anaemia and folic acid deficiency. Red cell alloantibodies, Hb electrophoresis to screen for hemoglobinopathies. Coagulation profile to screen for coagulopathies. Get the peripheral blood film to indicate type of anemia. In Iron deficiency anemia  microcytic, hypochromic cells seen and “pencil cells”. Serum Ferritin is measured which is the first parameter to disturb in iron deficiency. Serum ferritin less than 12 ug/L is diagnostic of iron deficiency anaemia. Also study TIBC, reticulocyte count ,serum Vit.B12 and Serum iron.  Obstetric ultrasound should be done for anomalies and if foetal growth and amniotic fluid corresponds to gestational age.

 

B)      Investigate  her serum ferritin to estimate the iron stores. Serum ferritin less than 12 ug/L is diagnostic of iron deficiency anaemia. At 18 week gestation, there is sufficient time to build up Hb till time of delivery. So, oral iron supplementation is prescribed with 120-240 mg elemental iron per day. With oral iron, 0.8 gm/dl rise in Hb occurs in a week. Ferrous salts are better absorbed than the ferric  salts. Oral preparation of Ferrous fumarate, ferrous gluconate and ferrous sulphate are available with little variation in elemental iron. Ask her to take the iron one hour before meal empty stomach with fresh orange juice as vitamin C aids in better absorption of iron. Sustained release tablets of iron should be avoided as  iron is released from them after passage through first part of duodenum where optimal absorption of iron occurs. GI side effects such as nausea,vomiting,malabsorption are common with iron and elemental iron should be then decreased. If still intolerance or non compliance is there, shift to parentral iron therapy.

Iron sucrose is the drug of choice for parentral iron therapy as it has higher bioavailability than iron dextran.It raises haemoglobin faster and also replete the iron stores.But disadvantage is multiple infusion, anaphylaxis risk. Newer preparation of iron sucrose, Cosmofer is now licensed for total dose replacement in second and third trimester in asingle infusion and takes 4-6 hours to complete.Newer preparation of iron III carboxymaltose and iron III isomaltoside overcome this problem and single dose can be administered in one hour or less.

 

C)      At 37 week when her Hb was 8.4 gm/dl she should be offered blood transfusion for the rapid rise in Hb and discuss about the mode of birth and place of delivery with consultant obstetrician. She should have delivery in obstetrician led unit under the supervision of consultant obstetrician. In labour a venous access should be set and send serum for group & save as she is at high risk of PPH.  Electronic foetal monitoring should be done as their foetus are IUGR or LBW and may be compromised during labour, so need to be timely recognised. Active management of labour is recommended and augmentation by amniotomy or syntocinon is suggested to decrease the duration of labour and hence blood loss. Active management of III stage of labour is recommended as they are at high risk of PPH due to uterine atony and placenta is delivered by CCT after 10 units of syntocinon injection intramuscularly. Thus duration of III stage is decreased from 15 minutes to 5 minutes and blood loss is also decreased. If she has bled more than 500ml she may need whole blood transfusion

Postnatally get her Hb done after 48 hours of delivery and prescribe 100-200 mg elemental iron for 3 months and repeat serum ferritin and FBC at the end of therapy to ensure repletion of iron stores.

Posted by FAUZIA  T.

(A) I will take a detailed history from the woman. I will ask her if she feels tired , dizzy, fatigue or has palpitations.Ask the woman if she was having heavy menstrual bleeding before her getting pregnant .Her past obstetric history- multiparity and the interpregnancy interval. If she is multiparous, to know whether she had a history of postpartum haemorrhage or had a low birth weight baby.

Family history of haemoglobinopathies., her ethnic origin.Her past medical history to know if she is suffering from renal disease or SLE, malabsorption.Her recent cervical smear history, her personal history to know her socioeconomic group. I will also ask if she smokes, takes alcohol .Her past surgical history to know if there was resection of the small intestines.Any history of bleeding per rectum and bleeding gums

Examination-general examination to see for pallor, koilonychia, angular stomatitis,pale beefy tongue.

P/A- palpate for any masses, splenomegaly, hepatomegaly, fundal height if corresponding to the gestational age.P/s- to see if cervix is healthy.

Investigations include full blood count, Red cell indices that is MCV, MCHC and haematocrit. haemoglobin electrophoresis, Stool analysis, G6PD .Serum ferritin level.

(B)-The treatment options are- Firstly I will give her the dietary advice and refer her to dietitian.Start her on Oral Iron which should be 100-200 mgm daily of elemental iron. I will advice her to take iron 1 hour before food in empty stomach and if possible to take vit c with it for better absorption. I will also tell the woman about the side effects like gastrointestinal disturbances.if the woman is non complaint or she cannot tolerate the oral iron then I will refer her to secondary centre for IV iron therapy. Another option is IM iron but it is very painful and there is staining of the skin.

(C)-Intrapartum care- woman should be advised to deliver in Obstetric unit. Blood should be sent for FBC, group and save and IV access. Also i will see if the woman is willing for blood transfusion if indicated . Risk of pph is there so active management of the third stage of labour should be done which includes early cord clamping and administration of oxytocin and controlled cord traction. Woman should be assessed for the risk of Venous thromboembolism .

Postpartum -if there is no active bleeding and woman is asyptomatic, she should  be advised for oral iron and should be reviewd after 3 months. Contraception should be advised to the woman before discharge from the hospital.

 

Essay 367 answer.from liza Posted by Liza S.

 

(A)Initial  assessment.
Iron  deficiency  anaemia considered to be most common cause of anaemia in pregnancy.
I will ask the history that she has any feeling of tiredness or weakness(which is the most common symptom)any dizziness ,headache, shortness of breath during exertion, which are effecting her quality of life ,her  dietary  in- take habit(to identify poor iron intake) should be asked .I will ask the menstrual history  that did she has a heavy periods before she become pregnant. Regarding  her  obstetric history I will ask that how many children she has and what is time difference  between  two pregnancy, as short interval in pregnancy nearly one year can be a contributing  factor in anaemia . I will ask the drug history that she is taking any anti-inflammatory treatment   like , aspirin  ,corticosteroids .I will ask about  the medical history that did she has any recent illness H/O which might suggest underlying gastrointestinal bleeding like altered bowel habit, weight loss or any per-rectum bleeding H/O.  Any travelling H/O to the   tropic   region (can have malaria or parasites which cause anaemia).I will ask  the family H/O iron deficiency anaemia (which may indicate inherited disorder of iron deficiency),any haematological  disorders e.g  thalassemia .Examination .on general  examination I will look for skin and lips which may be pale looking, nail changes  to be looked (may be spoon shaped) inflamed tongue ,ulceration at the angles of mouthshould be looked also ,Examination  of the heart and chest for signs of heart failure  like  tachycardia or murmurs  may  present if severe anaemia present . Per  abdomen  examination I will  look  for  any any  masses  or there may  be Hepatosplenomegaly   if  malaria or haemoglobinopathy  is the cause of anaemia. Regarding Investigation  Full blood count including red cell indicces show low Hb , low mean cell volume, and  low  mean cell haemoglobin and mean cell haemoglobin concentration. A  blood  film may confirm  presence of  microcytic hypochromic  red cells and characteristic “ pencil cells “,however microcytic  hypochromic  indices may  also occur in haemoglobinopathies.  Serum  Ferritin levels will accurately  reflects iron stores in the absence of inflammatory changes and it is first laboratory test to become abnormal as iron stores decreased and consider the best test to assess iron deficiency anaemia. other test like serum iron and total iron binding capacity are unreliable indicators in pregnancy as levels are affected by recent ingestion, also ZINC protoporphyrin (ZPP) levels are used in pregnancy but now a days rarely performed but have greater sensitivity and specificity for iron depletion .ZPP increases when iron availability decreases.
B---Treatment  Options
I will educate her regarding diet which may improve her iron stores and anaemia .Advise her to get enough  iron  at least three serving a day of iron rich food such as lean meat, poultry ,fish  green vegetables(spinach ,broccoli) along food rich in vitamin C like citrus fruits and juices which can help the body absorb more iron. Avoid tea and coffee with a meal or shortly after as they inhibit iron absorption. This should be consolidated by the provision of an information leaflet in the appropriate language. Dietary changes are sometimes insufficient to correct her anaemia and iron supplement are necessary .Ferrous iron salt oral preparation are the first line of treatment in a dose of 100-200mg in elemental iron daily, advise the women to take oral iron treatment with empty stomach/one hour before  meals ,with a source of vitamin C(ascorbic acid)to maximize absorption and other medications or antacid should not be taken at the same time. But if she cannot tolerate oral treatment like constipation , diarrhoea ,nausea and epigastric  discomfort ,then after  full counselling  of risk and benefit with informed consent ,PARENTERAL iron therapy is another treatment  option for her .I/V iron Sucrose is used for parenteral iron therapy, it will give the faster increase in Hb and better replenishment of iron stores  but not  suitable in patient with H/o anaphylaxis or reaction to parenteral  therapy ,active acute/chronic infection. Another options is intramuscular preparation is low molecular weight iron dextran, more effective than oral treatment ,and after test dose can be administered in primary care, but its use is limited due to pain and permanent skin staining at the site of injection.
C-
This women with this low Hb requires  additional precautions  for delivery .Delivery  should be in a consultant  led  hospital. Intravenous access  with blood  group and save to be done, and  plans  to deal  with excessive bleeding  in  anaemic  patient  with protocol of the hospital should be followed, and  in case of need of blood transfusion  with view of patient refusal or acceptance  should be documented .Active management  of the  third stage as a method of decreasing  postpartum blood loss with intramuscular syntometrine/syntocinon  should  be done and in the presence of additional  risk  factors such as prolonged labour or instrumental  delivery ,an  i/v  infusion of  high dose syntocinon  continued for 2-4 hours to maintain uterine contraction. If  she has postpartum haemorrhage or symptoms of anaemia  post natally  then  her  Hb should  be checked  within 48 hours  of delivery . otherwise if  she is asymptomatic  and haemodynamically  stable with Hb  less  than 10g/dl ,and  advise  to follow up GP  and should be offered elemental  iron  100-200mg daily for 3 months  with the repeat  Full blood count  at the end of treatment  to ensure the Hb and iron stores  are improved .
 
 
 
Posted by Lola B.

By Lola:

a) I will take a history, asking her abour her past obstetric history -- how many pregnancies she has had before and the spacing, the mode of deliveries, if she breastfed and for how long. Her menstrual history is asked, especially with regard to the presence of menorrhagia and irregular bleeding. Ask about any recent PV bleeding in this current pregnancy. Aks abour her diet -  if she is a vegan, and adequacy of iron intake from foods. Ask about past medical history like caeliac diease which will lead to folate deficiency. Ask about any other bleeding tendencies like PR bleeding, haematuria, gum bleeding. Ask for signs and symptoms of anaemia, like hsortness of breath, palpitations, giddiness. Ask about personal or family history of bleeding tendencies, haemoglobinopathies like thalassaemia. Ask also for history of haemoglobinopathies is her partner. 

On examination, her BMI, BP, PR, SpO2 are checked. Check for pallor. Heart is auscultated for murmurs. Abdomen is palpated for fundal height. Further examintion will be guided by history -  like a speculum examination if PV bleed is reported, and per rectal examination if PR bleeding is reported.

I will perform a full blood count to look at the MCV, CH, MCHC, total whites and platelets. If platelts are <50x109/L, a clotting profile is done. A peripheral blood film is done. A Hb electrophoresis for b thal and a thal gene probe is done. 

b) Iron can be administered orally in the form of tablets. It raises the Hb by 1g/dL per month. It is convenient, east and cheap. However compliance can be an issue. It causes side effects like constipation.

Parenteral Iron can be given in an IV dosing every 1 monthly. It is a one time dosing thus higher compliance. But it is more invasive and more costly.

Blood transfusion can be given. 1 unit of packed cells raises the Hb by 1g/dL. This is more invasive albeit a quicker way to raise the Hb levels. There are adverse reactions from transfusion, like anaphylaxis, transfusion fever, infections and haemolytic reactions.

c) She requires 1:1  midwifery care in a consultant obstetrician led unit. She needs to be on constant EFM. FBC will be performed upon arrival in the ward. Clotting profile is done if plts <50x109/L. Blood is screened for antibodies and crossmatched 2 untis on standby. Casesheets are perused to check for any standing orders in labour. The consultant is informed. A multidisciplinary team care involving the anaesthetiest, midwife, neonatologist and haemotologist is ideal. 

Epidural is allowed if plts >50x109/L. She needs close monitoring of her parameters (BP, PR, SpO2) continuously. Care is taken to ensure adequate hydration, by a fluid balance chart. Episiotomy is done only when clinically indication. There should be active management of the 3rd stage. IV ergometrine is given upon delivery of the placenta. This is followed by a continuous infusion of a syntocinon drip. 

Postnatally, she is monitored closely, parameters every 15 mins for the 1st 2 hours. A pad chart is put up to monitory PV loss. She is advised on compliace to oral iron therapy, especially if she is breastfeeding. She is counselling about pregnancy spacing and contraception advice is given before home.

ans Posted by Yingjian C.

a)

From patient’s history, I would ask if she has any current symptoms of anemia such as breathlessness, giddiness, fatigue. I would ask for any current or recent bleeding: vaginally, from stools or in urine and if she has any abdominal pain. I will ask if she has any past history of anemia (hemoglobinopathies or coagulation disorders), any blood transfusions, any known iron deficiency or nutrional deficiency such as folate. I will ask her past obstetric history: any anemia or antepartum haemorrhage in pregnancy, any hydrops in previous pregnancies. I will ask how many children she has, when was her last delivery, mode of deliveries for her pregnancies, any postpartum haemorrhage. I will ask if she is taking any iron supplements, any folic acid, if she is a vegetarian which may suggest a nutrional cause of her anemia. I would ask her social circumstances, is she smokes, takes alcohol or recreational drugs. I would ask if she has any family history of anemia or blood transfusion. I will ask if she has recent travel history to malaria endemic areas or any jaundice.

From her physical exam, I would check for pallor (subconjunctival, palmar creases) and jaundice. I will check her blood pressure, heart rate, oxygen saturation. I will check her weight: if she looks thin and malnourished. I will palpate her abdomen for masses such as hepatosplenomegaly, I will check for any uterine tenderness and uterine size equivalent to dates. I will check for any per vaginal bleeding and rectal examination if she complains of melena or rectal bleeding.

I would send off blood tests for full blood count to check her haemoglobin, platelets and MCV (microcytic or macrocytic anemia). I would check her serum iron panel  and thalassemia screening for hemoglobinopathies. If suspected to have thalassemia, I would also check her husband for full blood count and thalassemia screen.  I will send a renal panel or liver function test if she has jaundice. I will send a group cross match if she needs blood transfusion if she is symptomatic for anemia.

 

b) I will investigate and treat any underlying cause for her iron deficiency anemia: if it is nutrional: I would refer her to a dietician and encourage her to take red meat or spinach; if due to blood loss, I would investigate and stop the source of the bleeding. I will given her iron supplements: she may have hard black stools and explain that she needs to take it for at least a few months. If she is symptomatic for anemia I will admit her for intravenous iron transfusion or blood transfusion. I will repeat her full blood count 4-6 weeks later. I will advise the patient to return if any symptoms of anemia such as giddiness or breathlessness.

 

c) Intrapartum, she will be admitted to a maternity unit with blood transfusion services available. I will ask if she has symptoms of anemia. I will repeat her full blood count, take group cross match and set 2 large bore intravenous cannulas on her arm. I will monitor her blood pressure, heart rate, oxygen saturation, fluid input/output, blood losss continuously on modified early obstetric warning chart. She will have 1:1 midwife care and continuous electronic fetal monitoring. If patient is symptomatic for anemia on admission, I will transfuse her with 1 pack of packed red cells. Multidisciplinary team management is important: with midwives, anesthetist, consultant obstetrician, haematologist and blood bank. She can have epidural for analgesia if not thrombocytopenic. I will monitor blood loss at delivery. If patient declines any blood transfusion in pregnancy and heavy blood loss is expected for any operative delivery, I will inform anesthetist and for intraoperative cell salvage needed. There should be active management of the third stage of labour with early cord clamping, oxytocin infusion and controlled cord traction to deliver placenta.

Postnatally, patient will be monitored inpatient for postpartum haemorrhage or symptoms of anemia. If blood loss was heavy during delivery, I will repeat a full blood count postpartum. Patient will continue to take iron supplements, blood transfusion can be considered if she is symptomatic, havinh continued bleeding and hemoblobin drops further. I will explain to patient regarding her iron deficiency anemia and need to optimise her haemoglobin before next pregnancy. I would monitor her vital parameters 4 hourly.  

 

 

Posted by Ravi B.
I would first determine her parity and the time since her last pregnancy as multiparity and pregnancy interval of less than a year are associated with iron deficiency anaemia. I would ask about symptoms of anaemia like dizziness, shortness of breadth, chest pain, fatigue, headaches and palpitations and determine how she is affected by her condition. History of any menorrhagia and Gynaecological conditions such as uterine fibroids prior to pregnancy is also important as these may point to iron deficiency anaemia. Any coexisting medical conditions such as sickle cell disease, thalassemia and gastrointestinal diseases like inflammatory bowel disease and pernicious anaemia is also important since this would guide treatment for the type of anaemia specific to the condition. Any family history of hemoglobinapathies is also important so the patient can be appropriately screened and investigated. Assessing her risk for thromboembolism is also important at this initial visit so that antenatal thromboprophylaxis can be started if necessary. Screening for other causes of macrocytic anaemia like vegetarian diet without adequate vitamin B12 replacement, alcoholism, symptoms of hypothyroidism is necessary as this would guide investigation and treatment. Examination would entail measurement of her pulse as hypothyroid patients can be bradycardic and iron deficiency anemic patients can be tachycardic. Pale mucous membranes, angular stomatitis and beefy red tongue are also signs of anaemia. I would also assess of her body mass index and look for signs of liver disease like jaundice and  hepatomegaly on abdominal examination.  Initial investigations would include a full blood count, haemoblobin electrophoresis, serum ferritin, serum B12 and folate if indicated by history. B) Oral iron sulphate or fumerate at a dose of 100 - 200mg daily should be started. I would advise her that this should be taken 1hr beforemeals on an empty stomach and with orange juice as this increases absorption. This form of treatment should increase haemoblobin levels about 3-4g/dl after 3-4 weeks once there is no ongoing losses. She should be advised that diet alone does not provide enough iron and only a small percentage of dietary intake is absorbed. I would advise her of the side effects of oral iron and titrate dosage as necessary to decrease side effects. Parenteral iron is another option if she cannot tolerate oral iron due to its side effects of nausea and vomiting. This form of iron cannot be taken if patient has any infection or liver disease. I would advise her that blood transfusion is not necessary at this time, but may be necessary at term if she is still anaemic. C) This woman should have a an intravenous access with full blood count and a group and save when she presents in labour. Her management should be in a consultant led unit under the care of a senior midwife. She should have active management of the third stage of labour with use of uterotonics, early cord clamping and controlled cord traction. I would recheck her haemoblobin 48hrs after once there was no heavy vaginal bleeding prior to this. I would reassess her risk for thromboembolism and prescribe thromboprophylaxis  if necessary. I would also prescribe oral iron replacement for three months with a recheck of full blood count and serum ferritin levels at her family physician.
answer Posted by Shivamalar  V.

@ I will ask number of previous pregnancy, the interval between last pregnancy and current pregnancy ( if < 1 year increase risk for iron deficiency anemia), past history of anaemia, any recent blood loss,history of haemoglobinopaty and if she is vegetarian as these carries risk to anemia in pregnancy. I woul ask her is she has any symptom related to her anaemia such as palpitations, dyspnoea, increasing lethargy and do a clinical examination to assess presence of pallor, check her pulse rate. i would also palpate the fundus as anaemia in pregnancy has a risk for fetal growth retardation. I would look at her booking Hg count to see if she was anaemic  (11.0g/dl) and would despatch serum ferritin level to check her iron storage level. Ferritin would be the first blood marker to be low in iron deficiency anaemia.If haemoglobin status is unknown I would cousel and concent the patient and partner for electrophoresis. I would administer her with oral Iron tablet (100-200mg/day)  and repeat her Hg level 2 week later. This can be diagnostic and therapeutic in iron deficiency anaemia. Even if haemoglobin status is unknown this method can be used while awaiting the result.

(b) Treatment option includes dietry supplement with high haem containing food, oral or parentral iron replacement. Dietry replacement may not be able to replace the iron adequately as only 15% of dietry iron is absorbed which contains about 1-2mg of iron. Oral iron replacement should ideally be 100-200mg daily for 3 months and hg should be repated within 48 hours after delivery. Oral replacement therapy should be taken in empty stomach and 1 hour before meal and ideally better absortion if taken together with vit C containing food or drink. Oral treatment may give side effect such as nausea, vomiting and constipation or diarrhoea. Patient may not be able to tolerate medications well. Together with this plus other circumstances like malnutrition,and no improvement with oral tablet may be an indication for parentral iron replacement. This can be given over several hours in day unit over several infusion. It is faster replacement of iron and should be done in conjunction with local haematologist advice. 

 

(C) Patietn who has anaemia during pregnancy should deliver in hospital (hg <10.5g/dL) or under consultant based team care (if hg <10g/dL). She should have Intravenous plug set in labour and group and save sent. She should have active 3rd stage management in labour. These steps are taken to reduce the risk of postpartum haemorrhage wihich is highly related to anemia in pregnancy. Patitn should continue iron tablet for 3 months and Hg should be checked after that to see improvement in her blood count. Before disharging patient should be counselled regarding appropriate contraception and breastfeeding should be encouraged despite being on oral iron tablet.