Which one is it?
This type of anemia can cause hydrops fetalis.
Alpha thalassemia
That's why genetic counseling is important, especially in SE Asians, Africans, Middle Easterns, and Indians
T or F: pregnant patients with sickle cell disease have an increased risk of alloimmunization.
True!
There are increased differences in common antigens with having had multiple blood donors ex. Rh variants. It is recommended to check for this at the 1st prenatal visit, and if negative, at 24-28 weeks gestation, and when admitted for delivery. The recommendation to give RhoGAM are otherwise the same.
A patient comes in for an IOB in her 2nd trimester and has never been seen before. What Hgb and Hct level would concern you for anemia?
Hgb <10.5g/dL, Hct <32%
In the 1st and 3rd trimester, Hgb <11g/dL, Hct <33%
T or F: for pregnant patients with sickle cell disease, hydroxyurea can be used.
False!
Animal studies have shown that it can cause fetal harm so is not recommended. Pain crisis should be treated with opioids, especially in the third trimester when NSAIDs should also be avoided.
Demographics: which population has the highest risk of anemia in pregnancy?
Teens!
Other high risk populations include African Americans and those with low socioeconomic status.
A patient comes in for an IOB and you draw a CBC, which shows an MCV of 78. What test is most specific and sensitive for iron deficiency anemia?
Ferritin <10mg/dL
normal ferritin can point to physiologic anemia of pregnancy, whereas increased ferritin can point to anemia of chronic disease.
T or F: Anemia in pregnancy can cause increased birth weight.
False!
There is also a risk for preterm delivery and perinatal mortality. And fun fact, increased risk of maternal postpartum depression.
Why is the Hgb and Hct expected to be lower in pregnancy?
Blood volume increases by 50% (~1000ml) whereas RBC mass only increases by 25% (~300ml), causing physiologic anemia.
T or F: sustained release and enteric-coated PO iron supplements are more effective.
False!
They are actually poorly dissolved. PO options include ferrous fumurate, ferrous sulfate, and ferrous gluconate. These should be dosed as every other day or MWF to also increase effectiveness while decreasing GI symptoms
For African American patients, you should lower the anemia cutoff by ____ for Hgb and _____ for Hct.
Hgb: 0.8g/dL
Hct: 2%
A patient comes in for an IOB and you draw a CBC, which shows an MCV of 117. What are you concerned about?
folate deficiency --> neural tube defects
alcoholism --> fetal alcohol syndrome
vitamin B12 deficiency
T or F: Decreased amniotic fluid volume can be caused by severe anemia defined by Hgb <6g/dL
True!
This level can also cause nonreassuring FHTs, fetal cerebral vasodilation, and fetal death.
A patient with sickle cell disease comes in after having a positive pregnancy. What types of prenatal diagnostic tests do you do any when?
10-13 weeks, chorionic villus biopsy
15-16 weeks, amniocentesis
>20 weeks, fetal blood sampling but with increased risk of fetal loss
What is the recommended daily elemental iron intake during pregnancy?
27mg, which is present in most PNVs
Typical diet only provides 15mg of elemental iron
For patients who had anemia in pregnancy, what is the recommendation for postpartum management?
Continue PNVs or iron supplementations for 6-8 weeks.
T or F: All women with sickle cell disease should be treated with iron supplementation
False!
These patients have chronic hemolysis and repeated blood transfusions, so they have adequate or even high iron stores. Only recommend iron supplements if ferritin is low.
In which trimester is iron most important for the fetus? Why?
Iron-dependent neurogenesis is at its peak, and decreased availability can cause neurocognitive deficits. This should ideally be corrected by PO iron before 30 weeks gestation, but if not, IV iron should be used to speed up correction.
After starting PO iron treatment for IDA, you should expect a minimum rise in Hgb by ____ after ____ weeks of treatment.
>1g/dL, 3 weeks
Some medical societies recommend rechecking a CBC after 3-4 weeks to assess response to tx and need for IV options
What groups of pregnant patients are candidates for IV iron treatment? Name at least 2.
Women who have had total gastrectomy require _______mcg of monthly intramuscular vitamin B12.
1000 mcg
T or F: A pregnant patient has an MCV >100. Your next step is to start folate supplementation.
False!
You should check B12 and folate levels since starting on folate can masks B12 deficiency. This can be seen in vegans, pts with IBD, Celiac, hx of bariatric surgery, thyroid disease, and other autoimmune diseases
When should you screen for anemia during the course of pregnancy?
First prenatal visit, and again at 24-28 weeks gestation. Some even recommend 3-4 weeks after initiating treatment.
During pregnancy, daily folic acid requirements increase from ____ mcg to _______mcg. What is the recommended dose to account for this change?
50mcg --> 400 mcg
1g daily folate
Remember that some patients require 4g daily supplementation (ex: previous hx of NTD in either parent or previous pregnancy)