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MRCOG PART 2 SBAs and EMQs

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answer 367

answer 367 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.