Obstetrics & Gynecology - 2014

CASE PRESENTATION & CASE REVIEW

CASE ONEPRESENTER:Dr. T.KIAK

CASE SUMMARY

Regina Anthony is a 30 years old Gravida 3 Para 2 at 27 weeks gestation who is admitted for dizziness, GBW, swollen limbs and Paleness of 3 months duration seeking further management

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ID: ｧ Name: Regina Anthonyｧ Age/Sex: Female 30ｧ Marital Status:Marriedｧ Origin: Magarima , Hela Provｧ Occupation: Subsistence Farmerｧ Religion: Revivalｧ Next of Kin: Nephewｧ DOA: 16th of September 2014ｧ ROA: A&E-Referral Caseｧ Information: Patient (Pidgin)

Background:ｧ Un-booked Motherｧ Multiparity (P2G3)ｧ LCB 1 year ago ｧ K: 3/28 Regular Cyclesｧ LMP: End of February 2014ｧ Quickening: Early July 2014ｧ Gestational Age: 29/40ｧ EDD: Early December 2014ｧ Not on Family Planning

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Presenting Complaintsｧｧ Dizzinessｧｧ Generalized Body Weakness 3/12mothsｧｧ Swollen limbs & abdomenｧｧ Pale

History of Presenting Complaint

The above patient was unwell since she got pregnant but did not seek help until now. She complained of dizziness when walking long distance and developed general body weakness and fatigue when climbing mountain. She also realized a lump was developing from abdomen with lower limbs swelling. Her relatives also noticed that she appeared pale. She developed these signs and symptoms 3 months ago and decided to seek help. Pt Admitted taking anti-retro treatment since June and hubby was also on treatment. Treatment include 300mg lamivudine and Efavirenz 600mg tablets. She was referred to MGH for further management

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Specific Interrogation

2nd hospital admission,1st at Nearest Health CenterNo history of PV BleedingNo history of TraumaNo history of recent travelNo history of cough or night sweats

Past Obstetric & Gynecology History

Denies any STI historyNo history of Miscarriages or stillbirthsPrevious deliveries were vaginal birth1st child died after 2/12 months from NNS2nd child died after 1/12 months from NNS both delivered @ MHGHDenies any complication during birth

Past Medical History

Previous hospital admission was due to chronic diarrhoea for a monthNo family history of TB, HNT ,DM or Asthma

Family History

3rd born in the family of 5All siblings are alive and wellBoth parents are alive and well

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Social History

She is the 3rd wife , husband has 2 other wives but both are divorced Husband is self-employedWife subsistence FarmerWas a smoker but quite a year ago

Drug and Food History

No known allergies to food or drug

General Examination

ｧ Melanesian Female appears sick-looking and puffy face, wasted, pale and in mild distress.

Vitalsｧ Temperature: 37 ‘C , BP: 90/60 mmHg, PR: 80/min, RR: 20/min

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GIT/ABDOMENｧｧ Pale nail with koilonychaiｧｧ Pallor conjuntivaeｧｧ Oral thrustｧｧ No Spleenomegalyｧｧ Gravidae uterus with abdominal oedemaｧｧ Symphysis Fundal Height (SFH) 27cmｧｧ Cephalic, singleton and Longitudinal Lieｧｧ Adequate Liqor Volumeｧｧ FMF with FHR of 142bpm

USS: ｧｧ Placenta Fundal Posterior, BPD/FL: 29 weeks, AFI: 11cm

No significant Finding in other system

Provisional Diagnosis: Severe Anemia in Pregnancy 2nd to Retro-Infection

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Plan of Management

1.Full Blood Investigationa. FBC/UECb. Blood Film: MCV, MCH, MCHCc. VDRL/ Widalsd. MPSe. PICT- after counselingf. Pack-Cells 2 units

2.Conservative Management• Cortrimazole 500mg oral BD, Albendazole 2tab oral

stat, Fefol 2 tabs oral BD.• Continue 6 Hourly Fetal Heart Rate Monitoring• Continue 6 Hourly maternal Observations• Consult HIV Clinic for Follow-Up with Anti-Retro

Treatment

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Follow-Up

Blood ResultsFBC

ｧｧ WCC: 5600/mm 3 RBC: 2.13ｧｧ Lymp: 22 % HB: 7.1gm/dlｧｧ Mono: 7% HCT: 21.1 %ｧｧ Neut: 77% Plt: 11,

Blood Filmｧｧ MCV: 98.9 flｧｧ MCH: 33.1 pgｧｧ MCHC: 33.5

PICT- PositiveWidals No ReagentMPS Negative

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PREVALENCEWHO estimates that 2 billion people—over 30% of the world’s population—are anemic, although prevalence rates are variable because of differences in socioeconomic conditions, lifestyles,food habits, and rates of communicable and noncommunicable diseases.

Nearly half of all pregnant women suffer from anemia: 52% in low-resource countries and 23% in high-resource regions. Every second pregnant woman and about 40% of preschool children are anemic in developing countries.

Iron deficiency is the most prevalent cause of anemia, with iron deficiency being the most common form of anemia in more than 90% of the cases

Individuals who are deficient in iron are also deficient in other important micronutrients, although this important correlation is often overlooked by the medical profession and almost always unthought-of by the public at large.

CASE REVIEW: Anemia in Pregnancy

Definition - Hemoglobin of <11gm/dl in first & third trimester and below 10.5gm/dl in 2nd trimester

Classification according to Severity

mild 10-11 gm/dl

Moderate 7-10gm/dl

Severe 4-7 gm/dl

Very severe <4 gm/dl

Classification according to Etiology: Physiologic Vs Pathologic

Concept of Physiologic Anemia - disproportionate increase in plasma volume , RBC & Hemoglobin mass during pregnancy

Criteria for physiologic anemia

Hb:10gm%, RBC: 3.2million/mm3, PCV: 30%

Peripheral Smear showing normal morphology of RBC with central pallor

The most common causes of Pathological anemia in pregnancy include.

1. Deficiency : Iron, Folic Acid, Vit B12

2. Hemorrhagic: Ante-partum Hemorrhagic

3. Hereditary: Thalassemia, Sickle Cell Anemia, Hemolytic Anemia

4. Bone Marrow Insufficiency: Aplastic Anemia

5. Infection: Malaria, TB, Viral Infection includes HIV

6. Chronic Renal Disease

The simplest approach to the differential diagnoses of Pathological Anemia is to differentiate anemias by the mean corpuscular volume (MCV), measured in fL.

MCV less than 80 fL or microcytic anemia etiologies are Thalassemia Iron deficiency Anemia of chronic disease

MCV 80-100 fL or normocytic anemia etiologies are: Hemorrhagic anemia Anemia of chronic disease Anemia associated with bone marrow suppression Anemia associated with chronic renal insufficiency Anemia associated with endocrine dysfunction Autoimmune hemolytic anemia Anemia associated with hypothyroidism or hypopituitarism

MCV greater than 100 fL or macrocytic anemia etiologies are: Folic acid deficiency anemia Vitamin B-12–deficiency anemia Drug-induced hemolytic anemia (eg, zidovudine) Anemia associated with reticulocytosis Anemia associated with liver disease

Microcytic anemia

Iron Deficiency: Anemia accounts for 75-95% of the causes of anemia in pregnant woman-

Common Causes: poor diet, Multiparity, Menorrhagia

Symptoms: ill health, fatigue, loss of appetite, headache, restless leg syndrome, dysnoea, palpitation

Exam: Paler, Pale nail, koilonychias, pale tongue, oedema

Investigation: Low Hb, RBC, PCV, MCH, MCV

Blood film shows hypochromic microcystic

Low serum iron, ferritin, High Total Iron Binding Capacity

Macrocytic Anemia

Caused by def in folic acid & Vit B12. An increase MCV(>100 fl) can be suggestive of folate & B12 deficiency

Deficiency in folate can cause megaloblastic anaemia which is found in 5% of pregnancies. Anaemia is more likely to be found later in pregnancy due to the rapidly growing fetus, and primarily occurs as a result of reduced dietary intake or poor absorption. Folic acid is important for nucleic acid formation & inadequate level lead to reduction in cell proliferation - Risk of Neuro-tube defect (NTD)

Vitamin B12 deficiency is uncommon in pregnancy but it is required for synthesis of new DNA the demand in pregnancy increases by up to ten times.

Causes

Poor diet- Gastrointestinal upset & Oral antibiotic decrease absorption

Lack of Vit C - hepatic disease- decrease storage

Multiparity, RH incompatibility -increase demand

Symptoms: anorexia, Pallor, enlarged spleen & Liver

Investigation: decrease Hb, RBC, PCV, increase MCV

Blood film show megaloblastic cell & hyper-segmented neutrophile

Managementfolate can be found in green leafy vegetables, legumes and orange juice.Women at risk of folate deficiency (e.g. multiple pregnancy, haemolytic anaemia) should take 5 mg of folic acid throughout the pregnancyTreatment: Intramuscular Cobalamin 1000mcg daily for 1 wk followed by Cobalamin 1000mcg of monthly injections for vitamin B12 deficiency

Other Causes of Anemia

Microangiopathic anaemia can be seen in pregnancy conditions such as preeclampsia, eclampsia, HELLP syndrome, and with thrombotic thrombocytopenia purpure. Autoimmune haemolytic anaemia occurs up to four times more frequently in pregnancy.

Infectious causes of Anemia

Infectious cause of anemia are more common in low resource countries. Anemia can be caused by infections such as parvovirus B-19, cytomegalovirus (CMV), HIV, hepatitis viruses, Epstein-Barr virus (EBV), malaria, babesiosis, bartonellosis, hookworm infestation, and Clostridium toxin.

It has serious short- and long-term consequences during pregnancy and beyond. The anemic condition is often worsened by the presence of other chronic diseases as stated earlier.Untreated anemia also leads to increased morbidity and mortality from these chronic conditions as well. It is surprising that despite these chronic conditions (such as malaria, tuberculosis, and HIV) often being preventable, they still pose a real threat to public health

Chronic infections and disorders as causes of anemia

PathophysiologyThe exact pathophysiologic mechanism by which anemia is caused in

chronic inflammatory conditions is unknown.1. A common factor may be the contribution of hepcidin, a polypeptide

hormone. Chronic inflammatory conditions lead to release of cytokines from the reticuloendothelial system as a part of cell-mediated immunity.In response to these cytokines, mainly interleukin 6 (IL-6),the liver produces increased amounts of hepcidin, which in turn prevents release of iron from its stores. The process is mediated by blocking iron channels (such as ferroportin). Inflammatory cytokines also appear to influence other important aspects of iron metabolism, such as decreasing ferroportin expression, and possibly directly suppressing erythropoiesis by decreasing the ability of the bone marrow to respond to erythropoietin.

2. The propensity to infections is also thought to be caused by altered cellular immunity due to iron deficiency.

Short-term risks of anemia

Antepartum: Prone to infections, preterm labor, left ventricular failure.Intrapartum: Heart failure, postpartum hemorrhage, shock.Postpartum: Heart failure, puerperal sepsis, uterine sub-involution, increased cesarean delivery morbidity.Fetus: Increased stillbirth and morbidity and mortality due to intrauterine growth restriction, prematurity & sepsis.

Long-term risks of anemia

Anemia leads to debilitating physical (tiredness, lethargy, reduced exercise tolerance, dyspnea, dizziness, anginal pain, and palpitation) and mental (impaired cognitive function) symptoms, both of which negatively affect quality of life.In terms of the effect of anemia on HIV, some studies strongly suggest that adverse pregnancy events (such as low birth weight, stillbirth, preterm birth, and intrauterine growth restriction) are worsened in the presence of anemia. Moreover,mother-to-child transmission (MTCT) of HIV may be increased. HIV infection in pregnancy also increases anemia-related maternal deaths. Anemic condition, in turn, can result in HIV disease progression

Chronic conditions/diseases associated with anemia

Infections:Malaria, HIV, tuberculosis, osteomyelitis, bacterial endocarditis, pulmonary abscess.

Parasitic infestations: Hookworm, ascaris, schistosomiasis

Chronic noninfectious diseases: Diabetes, rheumatoid arthritis, Systemic Lupus Erythematosus, Crohn’s disease, ulcerative colitis,chronic liver disease, cirrhosis, hemoglobinopathies

Malignancy: Carcinoma, sarcoma, lymphoma, myeloma

Anemia is often worsened by chronic communicable and noncommunicable diseases, the most important being malaria, HIV,tuberculosis, and diabetes. When anemia occurs in pregnancy it not only results in poor pregnancy outcome in the short term but, in the long term, it also leads to worsening of these chronic conditions,reduced work capacity, and an impaired cognitive developmentof the child. A joint social and political approach is necessary to control anemia in pregnancy, as it represents a life-threatening but preventable cause of maternal and childhood morbidity and mortality

References:

1. http://emedicine.medscape.com/article/261586-overview

2. Raja Gangopadhyaya, Mahantesh Karoshia, Louis Keithb: Anemia and pregnancy: A link to maternal chronic diseases:International Journal of Gynecology and Obstetrics 115 Suppl. 1 (2011) S11–S15

3. WHO, Centers for Disease Control and Prevention Atlanta. Worldwide prevalenceof anaemia 993–2005. www.who.int.http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf. Published 2008.

4. Nemeth E, Rivera S, Gabayan V, Keller C, Taudorf S, Pedersen BK, et al. IL-6mediates hypoferremia of inflammation by inducing the synthesis of the ironregulatory hormone hepcidin. J Clin Invest 2004;113(9):1271–6.

5. Haurani FI. Hepcidin and the anemia of chronic disease. Ann Clin Lab Sci 2006;36(1):3–6