May 2014 Case Discussion: Low Hb

Consider Jyoti… Jyoti is a 26 yo G3 P0 currently 28 weeks gestation who presents to you for follow up of her 28 week blood test performed by your colleague You note that a Hb only was performed on this occasion; result 109 g/L (normal g/L) On checking her notes the previous CBP performed at 12 weeks was 110g/L and showed a hypochromic microcytic red cell picture, with target cells & elliptocytes which was also highlighted in the comment from the laboratory Only standard pregnancy investigations results are filed in her notes and recorded in her pregnancy hand held record What else would you like to know ?

Further Information: From your consultation and review of her notes you discover: Jyoti is of Nepalese origin No follow up testing was performed at 12 weeks. However, your colleague did advise her to commence some iron which she has been taking irregularly, but generally a few times a week What is your differential diagnosis? Would you like to perform any further tests?

You further decide to : repeat her full CBP perform iron studies perform thalassaemia screening Further Tests…

Jyoti returns for explanation of the follow up bloods you performed: CBP: Hb 109g/L normochromic, normocytic picture, normal platelets & WBC iron studies: Ferritin 23ng/L (15-150) Iron35nmol/L (8-27) H Transferrin sat37% (10-35) H Transferrin3.73g/L ( ) thalassaemia screening: nil evidence of deletion form of alpha thalassaemia Normal level of HbA2 7 HbF did not suggest beta thalassaemia trait How do you explain Jyoti’s results through this pregnancy? What are the important learning points from this case? Further information…

In iron deficiency, microcytosis can precede anaemia Abnormal cell morphology commonly seen in haemoglobinopathies such as target cells, elliptocytes, poikolocytes, frequently occur in iron deficiency Investigations may include: Iron studies, B12, folate, Hb electrophoresis & alpha thalassaemia gene testing Test partner if woman positive for thalassaemia Take Home Messages…