Slide 1
ANAEMIA IN PREGNANCY Dr. Kiran Jabeen 4th Yr PGT, Obs/Gynae Unit
I Holy Family Hospital
Patients ProfileMrs XYZ
Age 18 years
Education Matric
Married for 10 months
MOA OPD
DOA 29-12-2014 (1st antenatal visit)
Primigravida
R/O Hassanabdal
Non consanguineous
Non Booked
Reason for AdmissionGestational Amenorrhoea 34+3 weeks LMP
30-04-2014 EDD 06-02-2015
For evaluation and correction of anaemia and gestational
hypertension
History of Present PregnancySpontaneous, planned conception
Progressive pallor, noticed over last 4 years, markedly
increased during pregnancy
1st trimester
Uneventful
Took haematinics from GP due to easy fatigability and pallor
History of Present Pregnancy (contd)2nd trimester
Remained admitted in Medical deptt, HFH in 6th month of
pregnancy due to severe anaemia (Hb 4.6g/dL)
Extensive workup for anaemia was done, diagnosed as Hereditary
Spherocytosis
9 RCCs were transfused
Discharged at Hb 7.4g/dL
During workup, also diagnosed as HCV positive
No history of Menorrhagia or bleeding from any siteChronic
diarrhoea, vomiting, weight loss, fever, pica, passage of worms in
stoolDiagnosed bleeding/clotting disorderDocumented raised BP prior
to or during pregnancy
Systemic InquiryCardiovascular system History of palpitations,
shortness of breath on exertion Urinary system Burning micturition
with increased frequency and lower abdominal pain
Gastrointestinal system No history of nausea, vomiting,
diarrhoea, weight loss
Systemic Inquiry (contd)Respiratory system No history of cough,
asthma, allergy, tuberculosis
Musculoskeletal system No history of arthralgia, rash, muscular
pain or weakness
Past HistoryHistory of jaundice 5 years back with enlarged liver
and spleen. Patient remained admitted in some private hospital (no
record available)
Never investigated for anaemia properly. She was advised
multiple haematinics by GPs but didnt respond to iron therapy
Surgical history not significant
Family History No known family history of anaemia, bleeding or
any other hereditary disorder
Drug History No history of any regular medication prior to or
during pregnancy except haematinics
Personal HistoryNon smoker, non addictNormal sleep and
appetiteNo known allergy
Socioeconomic History Lower middle class
Examination
Pulse 88/min
BP 170/90mmHg
Temp 98.6 F
Pallor ++
Jaundice MildOedema +ve
Thyroid Not enlarged
Lymph nodes Not palpable
Koilonychia Absent
Abdominal ExaminationInspection
Protuberant abdomen with central everted umbilicus
Striae+, no dilated veins, scar marks, visible pulsations
A prominent mass visible separate from gravid uterus over left
side of the abdomen
Examination (contd)Palpation
SFH 34cmsLie Longitudinal Presentation Cephalic
Spleen was palpated as firm, elongated, regular andimmobile
mass, overlapping the uterus upto22cms below left costal margin,
notches werepalpable
Liver not palpable
Examination (contd)PercussionDull note over spleen
AuscultationFetal heart rate 138/min
Systemic Examination Examination of cardiovascular, respiratory
and musculoskeletal system was unremarkableInvestigationsBlood
group A+ve
Complete blood count
Hb 8.6g/dL TLC 8700/mm3 Plt 252,000/mm3 MCV 68.4 fL MCH 28 pg
MCHC 34.2 g/dL (N)
Peripheral film Spherocytes
Reticulocytes 3%
Investigations (contd)STB 2.4 mg/dL
Direct bilirubin 0.6 mg/dL
Indirect bilirubin 1.8 mg/dL
ALT 43 u/L
Serum LDH 779 U/L
Uric acid 6.7 mg/dL
Investigations (contd)Coombs test (direct and indirect)
Negative
Antinuclear antibodies Negative
PT/aPTT Normal
Osmotic fragility Increased
Peripheral smear
Osmotic fragility testNormal
Abnormal
Investigations (contd)BSF 85mg/dl
2 hrs PP 104mg/dl
HBsAg Negative
Anti HCV Ab Positive (by ELISA)
Urine R/E Numerous pus cells Proteins +Urine C/S No growth
Investigations (contd)Ultrasound AbdomenSpleen grossly enlarged
measuring 23cms approx.
Investigations (contd)Fetal scan
Single alive fetusLongitudinal/CephalicBiparietal diameter 83.5
mm/33wksFemur Length 57.2 mm/30wksPlacenta FundoposteriorAFI
17.3cmsNo gross fetal anomaly seen
Investigations (contd) Umbilical artery doppler
SD Ratio 2.81 RI 0.64 Reduced end diastolic flow
Risk factorsSevere anaemia due to hereditary spherocytosis
Marked splenomegaly
Gestational hypertension
Intrauterine growth restriction
Urinary tract infection
HCV positive
ManagementDuring her hospital stay, fetomaternal surveillance
was done.Medical advice was sought on repeated occasions for
optimal management
Tab. Folic acid 5mg once a day
Tab. Methyldopa 250mg 3 times a day
Cap. Cefixime 400mg once a day (5days)
Management (contd)Maternal Surveillance
Serial CBC
4-hourly BP monitoring
Daily proteinuria monitoring
Fetal Surveillance
Daily CTG, fetal kick count charting
BPP
2-weekly growth scan
Management (contd)4 units of RCCs were transfused due to
repeated falls in Hb
General care and advice to avoid any abdominal trauma that may
lead to injury to enlarged spleen
Surgical consultation was sought and splenectomy was decided to
be done after the delivery because of the huge size and
complications associated with splenectomy
Labour And DeliveryInduction of labour was done at 38 weeks due
to high risk pregnancy and reduced fetal movements
Labour was monitored vigilantly, taking care to avoid external
pressure to abdomen
Type II (late) decelerations were found during early labour
Emergency lower segment caesarean section done
Operative findingsPeritoneal fluid yellowish in colour
Massive splenomegaly, spleen visible through Pfannenstiel
incision over most of the upper segment of uterus
OutcomeMale baby, 2.2 kg, APGAR 8/10, 9/10
Transferred to nursery
Developed deep jaundice up to legs after 24 hours
Phototherapy was given
Further workup was strongly advised but the attendants did not
agree
Discharged on strong request on 3rd day of life
Post operative periodRemained stable
I/V Antibiotics
Thromboprophylaxis
Had normal post operative recovery and got discharged on request
on 2nd post-op day
Counselled for follow up, contraception and surgical evaluation
for splenectomy
Follow upContact details taken at time of discharge
Did not come for follow up inspite of detailed counselling
