Hematologic Disorders in Pregnancy

Ma. Lourdes Coloma

Iron supplementation!
o Regardless of anemia status, daily oral
supplementation with

30-60mg elemental iron

400ug folate
o Diet is not adequate

Iron replacement
o Anemia resolution and restitution of iron
stores can be accomplished with simple
iron compounds like

Ferrous sulfate

Better absorption

Ferrous fumarate

Ferrous gluconate

Which all provide 200mg daily

elemental iron

Anemia
CDC: two most common causes of anemia during
pregnancy and the puerperium are:
o IDA
o Acute blood loss

IRON DEFICIENCY ANEMIA [IDA]

CDC defined anemia in iron supplemented
pregnant women using a cutoff of the 5th
percentile
o 11g/dL in 1st and 3rd trimester
o 10.5g/dL in 2nd trimester
-

Course in pregnancy
o Manifested by an appreciable drop in
hemoglobin concentration
o Exacerbated in the 3rd trimester as
additional iron is needed to augment
maternal hemoglobin and for transport to
the fetus
o Need > Supply, fetus will become more
anemic FALSE!
o Amount of iron diverted to the fetus,
similar in a normal and in an iron
deficient mother

The newborn infant of a severely

anemic mother does not suffer
from iron deficiency anemia

Classic morphological evidence in IDA

o Microcytic hypochromic
o Less prominent in the pregnant woman
compared with that in the non-pregnant
woman
o Serum ferritin levels, however, are lower
than normal
o No sustainable bone marrow iron

Evaluation of moderate anemia in a gravida

o Measurement of Hgb, Hct, RBC indices
o Careful examination of a peripheral
blood smear
o A sickle cell preparation if the woman is
of African origin
o Measurement of serum iron or ferritin
levels or both

Serum Ferritin
o Levels normally decline during
pregnancy
o <10-15 mg/L confirm IDA

Parenteral iron

If a woman cant or wont take

oral iron preparations

Ferrous sucrose safer than iron

dextran

Equivalent increases in Hgb

levels in women treated with
either oral or parenteral iron
therapy

Assessing treatment
o When iron therapy is adequate

Elevated reticulocyte count

o Rate of increase of Hgb concentration or
Hct typically is slower than in nonpregnant women due to the increasing
and larger blood volumes during
pregnancy

ALPHA THALASSEMIA
Suspect when iron supplementation fails to
increase hemoglobin
The relative frequency of a thalassemia minor,
Hgb H disease and Hgb Bart disease varies

remarkable among racial groups

All of these variants are encountered in Asians

GESTATIONAL THROMBOCYTOPENIA
Normal pregnancy may be a physiological
decrease in platelet concentration (<150,000/uL)
o Usually evident in the 3rd trimester
o Predominant due to hemodilution
o Increased splenic mass characteristic of
normal pregnancy may be contributory
o Platelet life span is unchanged in normal
pregnancy

Diagnosis by exclusion

OB SETTINGS
Severe preeclampsia syndrome
Massive hemorrhage with transfusions
Consumptive coagulopathy from placental
abruption
Sepsis syndrome or amniotic fluid embolism
Hemolytic anemias
SLE and APAS
Hypoplastic or aplastic anemia
Viral infection, drugs and allergic reactions
IMMUNE THROMBOCYTOPENIC PURPURA
Usually caused by a cluster of IgG antibodies
directed against one or more platelet
glycoproteins
o Antibody coated platelets are destroyed
prematurely in the reticuloendothelial
system[spleen]
o Probably mediated by autoantibodies
directed at platelet-associated
immunoglobulins [PAIgG, PAIgM,
PAIgA]
-

Course in pregnancy
o No evidence that pregnancy increased
the risk of relapse in women with
previously diagnosed ITP or worsens
thrombocytopenia in women with active
disease
o No pattern, variable
o Usual for women who have been in
clinical remission for several years to
have recurrent thrombocytopenia during
pregnancy
o From [?] closer surveillance, [?]
hyperestrogenemia

Therapy
o Considered if platelet count is <30,00050,000/uL
o Primary treatment

IVIg

Corticosteroids [prednisone]

Fetal and Neonatal Effects

o Platelet associated IgG antibodies cross
the placenta

May cause thrombocytopenia in

the fetus-neonate

Fetal death from hemorrhage

occurs occasionally

Severely thrombocytopenic
fetus is at increased risk for
intracranial hemorrhage with
labor and delivery