Infectious Cause of Anemia in Pregnancy

1. Obstetrics & Gynecology - 2014
CASE PRESENTATION & CASE REVIEW
CASE ONE
PRESENTER:
Dr. T.KIAK

2. CASE SUMMARY
Cont…
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

3. 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:
Cont…
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

4. Presenting Complaints
ｧDizziness
ｧGeneralized Body Weakness 3/12moths
ｧSwollen limbs & abdomen
ｧPale
History of Presenting Complaint
Cont…
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

5. Specific Interrogation
2nd hospital admission,1st at Nearest Health Center
No history of PV Bleeding
No history of Trauma
No history of recent travel
No history of cough or night sweats
Past Obstetric & Gynecology History
Denies any STI history
No history of Miscarriages or stillbirths
Previous deliveries were vaginal birth
1st child died after 2/12 months from NNS
2nd child died after 1/12 months from NNS both
delivered @ MHGH
Denies any complication during birth
Cont…
Past Medical History
Previous hospital admission was due
to chronic diarrhoea for a month
No family history of TB, HNT ,DM or
Asthma
Family History
3rd born in the family of 5
All siblings are alive and well
Both parents are alive and well

6. Social History
She is the 3rd wife , husband has 2 other wives but both
are divorced
 Husband is self-employed
Wife subsistence Farmer
Was 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
Cont…

7. GIT/ABDOMEN
ｧPale nail with koilonychai
ｧPallor conjuntivae
ｧOral thrust
ｧNo Spleenomegaly
ｧGravidae uterus with abdominal oedema
ｧSymphysis Fundal Height (SFH) 27cm
ｧCephalic, singleton and Longitudinal Lie
ｧAdequate Liqor Volume
ｧFMF with FHR of 142bpm
USS:
ｧPlacenta Fundal Posterior, BPD/FL: 29 weeks, AFI: 11cm
No significant Finding in other system
Cont…
Provisional Diagnosis: Severe Anemia in Pregnancy 2nd to Retro-Infection

8. Plan of Management
1.Full Blood Investigation
a. FBC/UEC
b. Blood Film: MCV, MCH, MCHC
c. VDRL/ Widals
d. MPS
e. PICT- after counseling
f. 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
Cont…

9. Follow-Up
Blood Results
FBC
ｧWCC: 5600/mm 3 RBC: 2.13
ｧLymp: 22 % HB: 7.1gm/dl
ｧMono: 7% HCT: 21.1 %
ｧNeut: 77% Plt: 11,
Blood Film
ｧMCV: 98.9 fl
ｧMCH: 33.1 pg
ｧMCHC: 33.5
PICT- Positive
Widals No Reagent
MPS Negative
Cont…

10. CASE REVIEW: Anemia in Pregnancy
PREVALENCE
WHO 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.

11. 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

12. 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

13. 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

14.  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

15.  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.

16. 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
Management
folate 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 pregnancy
Treatment: Intramuscular Cobalamin 1000mcg daily for 1 wk followed by
Cobalamin 1000mcg of monthly injections for vitamin B12 deficiency

17. 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.

18. Infectious causes of Anemia

19. Chronic infections and disorders as 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

20.  Pathophysiology
The 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.

21. 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

22. 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

23. 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

24. 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