Professional Documents
Culture Documents
Anemia in Women
Anemia in Women
Peggy Mancuso, Ph.D., CNM
Peggy Mancuso, Ph.D., CNM
2 2
What is blood?
What is blood?
Plasma (60%)
Plasma (60%)
Water
Water
WBCs
WBCs
RBCs
RBCs
Platelets
Platelets
3 3
Erythrocyte Development
Erythrocyte Development
1.
1.
Stem cell
Stem cell
2.
2.
Early RBC progenitor
Early RBC progenitor
3.
3.
Late RBC progenitor
Late RBC progenitor
4.
4.
Pronormoblast
Pronormoblast
5.
5.
Basophilic normoblast
Basophilic normoblast
6.
6.
Polychromatophil
Polychromatophil
7.
7.
Orthochromatic normoblast
Orthochromatic normoblast
8.
8.
Reticulocyte (large cell)
Reticulocyte (large cell)
9.
9.
Mature RBC
Mature RBC
4 4
What are reticulocytes?
What are reticulocytes?
Adolescent RBCs
Adolescent RBCs
1.
1.
Erythropoietin from kidneys
Erythropoietin from kidneys
2.
2.
Bone marrow responds
Bone marrow responds
3.
3.
Reticulocytes are produced
Reticulocytes are produced
4.
4.
Released into circulation
Released into circulation
Accelerated RBC production more reticulocytes
Accelerated RBC production more reticulocytes
!
!
5 5
What accelerates RBC production?
What accelerates RBC production?
1.
1.
Hemolysis
Hemolysis
2.
2.
Blood loss
Blood loss
3.
3.
Hemoglobin S disease
Hemoglobin S disease
4.
4.
Cancer
Cancer
5.
5.
Pregnancy
Pregnancy
6.
6.
Iron replacement in iron deficiency
Iron replacement in iron deficiency
anemia
anemia
6 6
What if reticulocytes are
What if reticulocytes are
decreased?
decreased?
Normal
Normal
1
1
-
-
2% of RBCs are reticulocytes
2% of RBCs are reticulocytes
Decreased when bone marrow is not
Decreased when bone marrow is not
making RBCs
making RBCs
Iron deficiency
Iron deficiency
Aplastic anemia
Aplastic anemia
Chronic infection
Chronic infection
2 alpha chains
2 alpha chains
2 beta chains
2 beta chains
Each chain has heme molecule
Each chain has heme molecule
Abnormal hemoglobin
Abnormal hemoglobin
8 8
Types of Hemoglobin (Hb)
Types of Hemoglobin (Hb)
Fetal hemoglobin
Fetal hemoglobin
Hb F
Hb F
Hb A
Hb A
Adult hemoglobin
Adult hemoglobin
Hb A with glucose
Hb A with glucose
3
3
-
-
6 % normal
6 % normal
Hb S
Hb S
Equilibrium occurs
Equilibrium occurs
Microcytic
Microcytic
Normocytic
Normocytic
Macrocytic
Macrocytic
80
80
-
-
100 (107) fl/L
100 (107) fl/L
80
80
-
-
83 low normal
83 low normal
15 15
Mean Corpuscular Hemoglobin
Mean Corpuscular Hemoglobin
(MCH)
(MCH)
Average weight for each RBC
Average weight for each RBC
Picograms
Picograms
26
26
-
-
34 pg
34 pg
Not used as much as others
Not used as much as others
16 16
Mean Corpuscular Hemoglobin
Mean Corpuscular Hemoglobin
Concentration (MCHC)
Concentration (MCHC)
Average hemoglobin
Average hemoglobin
concentration
concentration
31 g/
31 g/
-
-
37 dL
37 dL
17 17
Red Cell Distribution Width
Red Cell Distribution Width
(RDW)
(RDW)
Coefficient of
Coefficient of
variation of red cells
variation of red cells
Anisocytosis
Anisocytosis
Iron deficiency
Iron deficiency
Chronic disease
Chronic disease
Increased serum ferritin
Increased serum ferritin
Iron overload
Iron overload
Inflammatory diseases
Inflammatory diseases
Alcoholism
Alcoholism
21 21
Iron Indices
Iron Indices
Transferrin
Transferrin
20
20
-
-
50%
50%
22 22
Red Blood Cell Folate
Red Blood Cell Folate
Diagnose macrocytic anemia
Diagnose macrocytic anemia
Low folate
Low folate
Folate deficiency
Folate deficiency
Pancytopenia ?
Pancytopenia ?
Low RBC folate
Low RBC folate
Maturational defect in
Maturational defect in
cells
cells
25 25
Classification of Anemia by Etiology
Classification of Anemia by Etiology
Increased RBC loss
Increased RBC loss
Blood loss
Blood loss
RBC destruction
RBC destruction
Extrinsic (mechanical
Extrinsic (mechanical
cardiac valve)
cardiac valve)
Combination of above
Combination of above
26 26
Classification by RBC
Classification by RBC
Morphology
Morphology
Size
Size
Normochromic
Normochromic
Hypochromic
Hypochromic
27 27
Microcytic Anemias
Microcytic Anemias
Iron deficiency
Iron deficiency
Thalassemia
Thalassemia
Anemia of chronic disease
Anemia of chronic disease
28 28
Macrocytic Anemias
Macrocytic Anemias
Megaloblastic
Megaloblastic
Vitamin B
Vitamin B
-
-
12 deficiency
12 deficiency
Folate deficiency
Folate deficiency
Non megaloblastic
Non megaloblastic
Chemotherapy
Chemotherapy
Liver disease
Liver disease
Reticulocytosis
Reticulocytosis
Myxedema
Myxedema
-
-
chronic hypothyroidism
chronic hypothyroidism
29 29
Normocytic Anemias
Normocytic Anemias
Acute blood loss
Acute blood loss
Anemia of chronic disease
Anemia of chronic disease
Infection
Infection
Medications
Medications
30 30
Signs and Symptoms of Anemia
Signs and Symptoms of Anemia
Often asymptomatic
Often asymptomatic
Systolic murmur
Systolic murmur
Hypotension
Hypotension
Glossitis
Glossitis
Chilitis
Chilitis
31 31
Signs and Symptoms of Anemia
Signs and Symptoms of Anemia
Dry skin
Dry skin
Thin hair
Thin hair
Pallor
Pallor
Nail ridges
Nail ridges
Pale conjunctiva
Pale conjunctiva
32 32
Microcytic Anemia
Microcytic Anemia
Iron Deficiency Anemia
Iron Deficiency Anemia
Most common anemia
Most common anemia
33 33
Normal Iron Metabolism
Normal Iron Metabolism
Ferritin: stored iron
Ferritin: stored iron
Stimulates RBC
Stimulates RBC
production
production
36 36
Lab Findings
Lab Findings
B12 Folate Iron Chronic
Disease
Hgb
Hct
MCV /
MCH /
MCHC /
Size
macrocytic macrocytic microcytic normocytic
37 37
Lab Values
Lab Values
Smear
Smear
Hypochromic
Hypochromic
Microcytic
Microcytic
Anisocytosis
Anisocytosis
Ani
Ani
Poikilocytosis
Poikilocytosis
Poikolo
Poikolo
<15 mcg/L
<15 mcg/L
TIBC
TIBC
Rises
Rises
Serum iron
Serum iron
<30 mcg/dL
<30 mcg/dL
MCV
MCV
<80
<80
MCHC
MCHC
<30
<30
RDW
RDW
Elevated
Elevated
39 39
Evaluation of Iron Status
Evaluation of Iron Status
Serum Ferritin
Serum Ferritin
Increase
Increase
Systemic inflammation
Systemic inflammation
Infection
Infection
Liver disease
Liver disease
40 40
Evaluation of Iron Status
Evaluation of Iron Status
Transferrin Saturation
Transferrin Saturation
Menstrual
Menstrual
GI
GI
Increased requirements
Increased requirements
Pregnancy or lactation
Pregnancy or lactation
43 43
Differential Diagnosis
Differential Diagnosis
Anemia of chronic disease
Anemia of chronic disease
More microcytosis
More microcytosis
Duration = 3 months
Duration = 3 months
Will respond in 10
Will respond in 10
-
-
21 days
21 days
Ferrous sulfate preferred
Ferrous sulfate preferred
Adverse effects
Adverse effects
GI complaints
GI complaints
45 45
Comparison of Oral Products
Comparison of Oral Products
Product % Iron Daily dose Fe/day
Ferrous
sulfate
20% 325mg tid 195mg
Ferrous
fumarate
33% 200mg tid 198mg
Ferrous
gluconate
11% 600mg tid 198mg
46 46
Administration of Oral Iron
Administration of Oral Iron
Empty stomach if no
Empty stomach if no
GI distress
GI distress
Administer with meat,
Administer with meat,
fish, or Vitamin C
fish, or Vitamin C
foods
foods
Keep out of reach of
Keep out of reach of
children
children
47 47
Parenteral Iron Therapy
Parenteral Iron Therapy
(Iron Dextran)
(Iron Dextran)
Noncompliance or malabsorption
Noncompliance or malabsorption
Single dose IV
Single dose IV
Dose: 500
Dose: 500
-
-
3000 mg
3000 mg
Heme iron
Heme iron
Deep green
Deep green
vegetables
vegetables
Iron
Iron
-
-
fortified cereals
fortified cereals
49 49
Parenteral Iron Therapy
Parenteral Iron Therapy
(Iron Dextran)
(Iron Dextran)
Side effects
Side effects
-
-
anaphylaxis
anaphylaxis
Arthralgia
Arthralgia
Myalgia
Myalgia
Flushing
Flushing
Malaise
Malaise
Fever
Fever
Allergy/anaphylaxis
Allergy/anaphylaxis
Give test dose: 25mg (0.5ml)
Give test dose: 25mg (0.5ml)
50 50
Follow
Follow
-
-
Up
Up
Repeat CBC 2
Repeat CBC 2
-
-
4 weeks after therapy
4 weeks after therapy
initiated
initiated
If no response
If no response
Decreased erythropoietin
Decreased erythropoietin
53 53
Clinical Findings
Clinical Findings
Signs and symptoms of anemia
Signs and symptoms of anemia
Labs
Labs
1.
1.
Low serum iron
Low serum iron
2.
2.
Low TIBC
Low TIBC
3.
3.
Normal or increased serum ferritin
Normal or increased serum ferritin
Dialysis
Dialysis
1.
1.
Low folate
Low folate
GI blood loss
GI blood loss
1.
1.
Positive guaiac
Positive guaiac
54 54
Further Lab Findings
Further Lab Findings
1.
1.
Hct rarely below 25%
Hct rarely below 25%
(Except with renal failure)
(Except with renal failure)
2.
2.
MCV normal or slightly low
MCV normal or slightly low
3.
3.
RBC morphology normal
RBC morphology normal
4.
4.
Reticulocytes normal/low
Reticulocytes normal/low
5.
5.
Serum ferritin normal/low
Serum ferritin normal/low
6.
6.
Serum iron low
Serum iron low
7.
7.
Transferrin saturation very low
Transferrin saturation very low
55 55
Common Features
Common Features
Hypo
Hypo
-
-
proliferative
proliferative
bone marrow
bone marrow
Low serum
Low serum
erythropoietin
erythropoietin
56 56
Goals of Therapy
Goals of Therapy
Increase Hct to target
Increase Hct to target
30% to 36%
30% to 36%
Decrease morbidity
Decrease morbidity
and mortality
and mortality
Decrease transfusion
Decrease transfusion
requirements
requirements
57 57
Erythropoietin
Erythropoietin
50
50
-
-
100U/kg TIW, IV or SC
100U/kg TIW, IV or SC
Reduce dose when:
Reduce dose when:
1.
1.
HCT approaches 36%
HCT approaches 36%
2.
2.
HCT increases > 4 points in 2 weeks
HCT increases > 4 points in 2 weeks
Increase dose when:
Increase dose when:
1.
1.
Hct does not increase > 5
Hct does not increase > 5
-
-
6 points after 8
6 points after 8
weeks
weeks
2.
2.
Hct is below target
Hct is below target
58 58
Side Effects
Side Effects
Hypertension (25%)
Hypertension (25%)
Arthralgia
Arthralgia
Nausea
Nausea
59 59
Factors Decreasing Response
Factors Decreasing Response
to Therapy
to Therapy
Iron deficiency
Iron deficiency
Blood loss
Blood loss
Infection
Infection
60 60
Iron Supplementation with
Iron Supplementation with
Erythropoietin
Erythropoietin
May be PO or IV
May be PO or IV
Normal cells
Normal cells
Hypochromic cells
Hypochromic cells
Coarse basophilic
Coarse basophilic
stippling
stippling
Elevated lead levels
Elevated lead levels
63 63
Symptoms Chronic Toxicity:
Symptoms Chronic Toxicity:
Serum Lead 25
Serum Lead 25
-
-
50 mcg/dl
50 mcg/dl
Dark line (lead
Dark line (lead
sulfide)
sulfide)
Microcytes
Microcytes
Acanthocytes
Acanthocytes
Target cells
Target cells
67 67
Thalassemia
Thalassemia
Alpha and beta thalassemia
Alpha and beta thalassemia
Genetic mutations
Genetic mutations
Occur in areas where malaria was
Occur in areas where malaria was
endemic
endemic
68 68
Alpha Thalassemia
Alpha Thalassemia
China, Philippines
China, Philippines
Malaysia, Thailand,
Malaysia, Thailand,
Cambodia, Laos,
Cambodia, Laos,
Vietnam, Burma,
Vietnam, Burma,
India, Sri Lanka,
India, Sri Lanka,
African and American
African and American
blacks
blacks
69 69
Alpha Thalassemia
Alpha Thalassemia
Silent carrier
Silent carrier
Thalassemia minor
Thalassemia minor
Hemoglobin H disease
Hemoglobin H disease
Hydrops fetalis
Hydrops fetalis
Microcytosis
Microcytosis
Hypochromic
Hypochromic
Aniso/poilokocytosis
Aniso/poilokocytosis
Iron studies normal
Iron studies normal
Remember may have a combination of
Remember may have a combination of
anemias!
anemias!
73 73
Alpha Thalassemia Minor in
Alpha Thalassemia Minor in
Pregnancy
Pregnancy
Non
Non
-
-
black
black
5
5
-
-
10%
10%
Microcytosis
Microcytosis
Hypochromia
Hypochromia
Targeting
Targeting
Misshapen red cells
Misshapen red cells
Hgb electrophoresis
Hgb electrophoresis
5
5
-
-
30% Hgb H
30% Hgb H
75 75
Symptoms of Hb H Disease
Symptoms of Hb H Disease
Hepatosplenomegaly
Hepatosplenomegaly
Gallstones
Gallstones
Transfusion
Transfusion
-
-
dependent
dependent
Milder in blacks
Milder in blacks
Anemia worse during pregnancy
Anemia worse during pregnancy
Refer to physician
Refer to physician
Counseling needed
Counseling needed
76 76
Alpha Thalassemia Major
Alpha Thalassemia Major
No alpha globin
No alpha globin
genes are normal
genes are normal
Hydrops fetalis
Hydrops fetalis
present
present
Does not survive
Does not survive
77 77
Beta Thalassemia
Beta Thalassemia
Point mutations rather than large deletions
Point mutations rather than large deletions
Beta0 or Beta+
Beta0 or Beta+
Alpha chains unstable
Alpha chains unstable
People of Mediterranean origin
People of Mediterranean origin
Greeks 1:10
Greeks 1:10
Italians 1:10
Italians 1:10
Asians 1:25
Asians 1:25
Homozygous B0 or B+
Homozygous B0 or B+
<10% Hgb A
<10% Hgb A
Thalassemia
Thalassemia
intermedia
intermedia
Mild Homozygous B+
Mild Homozygous B+
Heterozygous B0
Heterozygous B0
Heterozygous B+
Heterozygous B+
80
80
-
-
95% Hgb A
95% Hgb A
79 79
Thalassemia Major
Thalassemia Major
Severe hemolytic anemia
Severe hemolytic anemia
Regular transfusion program
Regular transfusion program
Iron overload (hemosiderosis) common
Iron overload (hemosiderosis) common
Shortened life span
Shortened life span
80 80
Thalassemia Intermedia
Thalassemia Intermedia
Blacks may have milder clinical course
Blacks may have milder clinical course
Refer to physician for care
Refer to physician for care
81 81
Thalassemia Minor
Thalassemia Minor
Heterozygotic
Heterozygotic
Lifelong microcytic,
Lifelong microcytic,
hypochromic anemia
hypochromic anemia
Severe anemia
Severe anemia
unusual
unusual
May be asymptomatic
May be asymptomatic
Splenomegaly?
Splenomegaly?
82 82
Thalassemia Minor
Thalassemia Minor
MCV<80
MCV<80
MCH<26
MCH<26
Abnormal peripheral smear
Abnormal peripheral smear
Elevated Hgb F?
Elevated Hgb F?
No treatment needed
No treatment needed
83 83
Thalassemia Minor
Thalassemia Minor
If pregnant, screen father of baby
If pregnant, screen father of baby
Genetic referral if father has
Genetic referral if father has
hemoglobinopathy
hemoglobinopathy
If coexistent iron deficiency
If coexistent iron deficiency
Drugs or Toxins
Drugs or Toxins
Ringed sideroblasts present in marrow
Ringed sideroblasts present in marrow
(Nucleated, immature RBC with iron granules)
(Nucleated, immature RBC with iron granules)
Hgb 6
Hgb 6
-
-
10
10
Microcytic, normochromic or normocytic,
Microcytic, normochromic or normocytic,
normochromic
normochromic
86 86
B
B
12
12
and Folate Deficiency
and Folate Deficiency
Macrocytic Anemias
Macrocytic Anemias
87 87
Vitamin B
Vitamin B
12
12
Only source is diet
Only source is diet
3
3
-
-
5 years before deficiency apparent
5 years before deficiency apparent
Pernicious anemia
Pernicious anemia
Gastrectomy
Gastrectomy
89 89
Vitamin B
Vitamin B
12
12
Deficiency
Deficiency
Decreased absorption of B
Decreased absorption of B
-
-
12
12
Fish tapeworm
Fish tapeworm
Surgical resection
Surgical resection
Cohn's disease
Cohn's disease
Pancreatic deficiency
Pancreatic deficiency
Inadequate intake (rare)
Inadequate intake (rare)
90 90
Clinical Findings
Clinical Findings
Weakness
Weakness
Weight loss
Weight loss
Beefy red tongue
Beefy red tongue
(glossitis)
(glossitis)
Numbness
Numbness
Ataxia
Ataxia
Memory loss
Memory loss
Pallor
Pallor
Paresthesias
Paresthesias
Decrease reflexes
Decrease reflexes
Depression
Depression
Decreased vibration
Decreased vibration
or position sense
or position sense
91 91
Diagnosis
Diagnosis
MCV 110
MCV 110
-
-
140
140
MCV may be normal in presence of
MCV may be normal in presence of
another microcytic anemia
another microcytic anemia
Macro
Macro
-
-
ovalocytes, multi
ovalocytes, multi
-
-
lobed neutrophils
lobed neutrophils
Diagnosed through serum B
Diagnosed through serum B
-
-
12<100 pg/L
12<100 pg/L
Shilling test
Shilling test
Decreased absorption of B
Decreased absorption of B
-
-
12
12
Differentiate from folate deficiency
Differentiate from folate deficiency
92 92
B
B
12
12
Deficiency
Deficiency
Gradual development over 1
Gradual development over 1
-
-
3 years
3 years
Treatment (Cyanocobalamin)
Treatment (Cyanocobalamin)
LD: 100mcg/d IM x 3
LD: 100mcg/d IM x 3
-
-
5 days
5 days
MD: 100mcg IM q2
MD: 100mcg IM q2
-
-
4 weeks
4 weeks
93 93
B
B
12
12
Deficiency
Deficiency
Response rate
Response rate
50
50
-
-
100 mcg
100 mcg
Dietary deficiency most common cause
Dietary deficiency most common cause
Diagnosis
Diagnosis
1
1
-
-
5 months
5 months
Treatment
Treatment
1mg/day po x 2
1mg/day po x 2
-
-
3 weeks
3 weeks
96 96
Causes of Folate Deficiency
Causes of Folate Deficiency
Dietary deficiency
Dietary deficiency
Decrease absorption
Decrease absorption
Topical sprue
Topical sprue
Drugs
Drugs
Phenytoin, Sulfas Phenytoin, Sulfas
97 97
Causes of Folate Deficiency
Causes of Folate Deficiency
Increased requirement
Increased requirement
Pregnancy
Pregnancy
Dialysis
Dialysis
Inhibition of reduction to active form
Inhibition of reduction to active form
Methotrexate
Methotrexate
98 98
Other Causes of Macrocytosis
Other Causes of Macrocytosis
HIV treated with zidovudine
HIV treated with zidovudine
Hypothyroidism
Hypothyroidism
Mild macrocytosis
Mild macrocytosis
Alcoholism
Alcoholism
Diminished strength
Diminished strength
Splenic infarction
Splenic infarction
High altitude
High altitude
102 102
Symptoms
Symptoms
Generally asymptomatic
Generally asymptomatic
History of bladder/kidney infections
History of bladder/kidney infections
May confuse diagnosis of other coexisting
May confuse diagnosis of other coexisting
anemia
anemia
Diagnosed by Hb electrophoresis
Diagnosed by Hb electrophoresis
34
34
-
-
54% Hb S
54% Hb S
Sickledex positive
Sickledex positive