Quiz megaloblastic anemia upto rh sensi

• Megaloblastic Anemia


  A group of hematologic diseases caused by impaired DNA synthesis resulting in blood and bone marrow abnormalities

  
• Causes of Megaloblastic Anemia

  • Deficiency in folic acid (vitamin b9)
  • Deficiency in vitamin b12
  • Disturbance in folic acid metabolism

  
• Types of Megaloblastic Anemia

  • Folic Acid Deficiency Anemia/ Pernicious anemia
  • Vitamin B12 Deficiency/ Addison Pernicious Anemia

  
• Folic Acid Deficiency Anemia

  Folic acid is necessary for the normal formation and nutrition of red blood cells. Deficiency in folic acid leads to the formation of large and immature blood cells that have shorter life span than normal red blood cells.

  
• Folic acid deficiency usually develops in women whose diet consists mostly of meat products and those who do not eat fresh green leafy vegetables. Women who have folic acid deficiency during pregnancy are more at risk of giving birth to babies with neural tube defects like spina bifida.
• Effects of Folic Acid Deficiency on Pregnancy

  • Abortion
  • Abruptio placenta
  • Neural tube defects in fetus

  
• Predisposing Factors for Folic Acid Deficiency Anemia

  • Poor nutrition
  • Multiple pregnancies
  • Successive pregnancies

  
• Management of Folic Acid Deficiency Anemia


  1. Folic acid supplementation of 1 mg/day accompanied by oral iron

  2. Vitamin supplements containing 400 micrograms of folic acid are now recommended for all women of childbearing age and during pregnancy

  
• Food Sources of Folate

  • Leafy, dark green vegetables
  • Dried beans and peas
  • Citrus fruits and juices and most berries
  • Fortified breakfast cereals
  • Enriched grain products
• Vitamin B12 Deficiency Anemia


  Addison Pernicious Anemia is a very rare type of anemia caused by an uncommon auto immune disorder that leads to failure to absorb vitamin B12 because of lack of intrinsic factor. Onset is usually at 40 years of age and unless treated, it may lead to sterility.

  
• Causes of Vitamin B12 Deficiency Anemia


  • Total gastrectomy- treated with monthly IM injection of 1000 ug of cyanocobalamine
  • Crohn's disease
  • Ilial resection
  • Bacterial over growth in the large intestine

  
• Signs and Symptoms of Vitamin B12 Deficiency Anemia

  • Weak muscles
  • Numb or tingling feeling in hands and feet
  • Trouble walking
  • Nausea
  • Decreased appetite
  • Weight loss
  • Irritability
  • Lack of energy or tiring easily (fatigue)
  • Diarrhea
  • Smooth and tender tongue
  • Fast heart rate

  
• Sickle Cell Anemia


  A recessive inherited hemolytic anemia caused by an abnormal amino acid in the beta chain of hemoglobin. The disease is characterized by sickling of the RBC in the presence of decreased oxygenation. Majority of the RBCs are irregular or sickle-shaped so cannot carry as much hemoglobin as normally-shaped RBCs.

  
• When oxygen tension becomes reduced, as happens at high altitudes, or blood becomes more viscid than usual (dehydration), the sickle-shaped cells tend to clump because of the irregular shape. This clumping can result in vessel blockage with reduced blood flow to organs. The cells will undergo hemolysis leading to severe anemia.

  
• Risk Factors for Sickle Cell Anemia

  • Significant blood loss...surgery, trauma etc.
  • Illness (at risk for this due to spleen function being affected)
  • Climbing or flying to high altitudes
  • Keeping continued stress (physical or mental)
  • Low fluid intake (dehydrated)
  • Elevated temperature.....fever, strenuous exercise (extreme temperature changes like cold weather or cold water....like swimming in cold can lead cells to sickle)

  
• Signs and Symptoms of Sickle Cell Anemia

  • Pain (very severe)...back, joints, chest etc. comes in episodes
  • Anemic: RBC dying too soon: fussiness, tired, tachycardia, jaundice or pale (for dark skinned patients assess mucous membranes), delayed growth, shortness of breath
  • Infection risk: spleen recycles old RBCs and helps us fight infection by filtering out foreign invaders... sickled RBCs become trapped in spleen and this leads it to swell and not work properly.....at risk for infection, especially pneumonia (needs pneumococcal vaccine and flu, meningococcal...some patients need a splenectomy.
  • Stroke: if sickled RBCs stick together and block blood flow to the brain. blood supply is limited to the brain leading to a decrease in brain blood supply...can cause mental and physical disabilities. NEURO checks very important.
  • Eye problems: vision issues due to the blockage of blood flow to eye vessels from sickled cells (needs eyes checked regularly)
  • Risk for abnormal clotting due to an increase in blood coagulation: at risk for DVT
  • Leg ulcers (older children and adults): lack of blood flow...painful and very slow healing.

  
• Management of Sickle Cell Anemia

  1. Focus on hydration

  2. Oxygen, pain

  3. At risk for infection

  4. Monitor respiratory status

  5. Neuro checks

  6. At risk for acute chest syndrome
• Prevention of Future Sickle Cell Anemia Crisis Episodes

  1. Medications

  2. Blood transfusions

  3. Pain: opioids around the clock (PRN not the best at this time until crisis over

  4. IV fluids and oral fluid: dilutes blood and helps kidney function (blood flow is being limited because RBCs are sticking together)

  5. Oxygen: remember RBCs are stressed because of the lack of 'oxygen... this helps with alleviating the sickling

  6. Penicillin: prevents infection or other antibiotics to treat (some MDs will order some patients to take prophylactic doses of PCN to prevent infection because their risk).... if patient develops acute chest syndrome due to pneumonia may be ordered antibiotics.

  7. Blood transfusion to replace RBCs and helps with anemia and increases oxygen levels in the body.. or multiple transfusions watch for iron overload

  8. Bedrest

  9. Educate about preventing infection (needs vaccines to be up-to-date, hand hygiene, avoid extreme weather and physical activities, mental/physical stress, staying hydrated, avoiding smoking, high altitudes)

  10. Keep extremities elevated and extended to prevent swelling and helps blood flow

  11. Remove restrictive clothing because it decreases perfusion

  12. Warm compresses (not cold leads to sickling) for painful areas

  13. Folic acid administration: helps make RBCs..NOT iron... this doesn't help with this type of anemia but can actually build up in the body causing toxicity and harm to organs

  14. Hydroxyurea: this helps actually treat cancer, but it will help with SCA in that it will help create fetal hemoglobin. This helps decrease sickling episodes and this protein is present at first until 5-6 months of age, which is why babies don't start showing signs and symptoms until after then. It will also help with anemia (decreasing the need for blood transfusions)

  
• Thyroid disorders affect four times more women than men
• Physiologic Changes in Pregnancy

  Maternal thyroid volume increases 10-30% in pregnancy, especially in 3rd trimester, as a result of increased blood volume and extracellular fluid. An enlarged thyroid gland in isolation is not an indication for screening for thyroid disease if no other clinically relevant history, symptoms, or signs are present.
• Changes in TSH (thyroid stimulating hormone) during Pregnancy

  1. Decreased in early pregnancy due to 3-hCG weakly stimulating TSH receptors causing increased T4 (thyroxine) levels. Estrogen stimulates higher levels of thyroid-binding globulin that transport thyroid hormone in the blood.

  2. In late first trimester, reduce lower reference range by 0.4mU/L and reduce upper reference range by 0.5mU/L if local reference ranges are unavailable.

  3. After first trimester, use non-pregnant reference ranges as TSH increases due to increased production of placental deiodinase.
• Maternal transfer of T4 to fetus is necessary for fetal brain development. 30% of umbilical cord T4 is maternally derived.
• Pregnant women require 220 micrograms of iodine per day, and lactating women require 290 micrograms per day. Majority of women in US have sufficient intake.
• How Pregnancy Normally Affects Thyroid Function

  • HCG is similar to TSH and mildly stimulates the thyroid to produce more thyroid hormone
  • Increased estrogen produces higher levels of thyroid binding globulin, also known as thyroxine binding globulin, a protein that transports thyroid hormone in the blood.
• Hyperthyroidism or Maternal Thyrotoxicosis


  The second most common endocrine disorder of pregnancy, due to the elevated level of thyroxine which causes fast metabolism in the body resulting in low birth weight infant. Usually caused by Graves' disease where the immune system makes an antibody called thyroid-stimulating immunoglobulin (TSI), sometimes called TSHR receptor antibody, which mimics TSH and causes the thyroid to make too much thyroid hormone.

  
• Signs and Symptoms of Hyperthyroidism

  • Tachycardia
  • Enlarged thyroid gland
  • Exophthalmos
  • Weakness
  • Sweating
  • Failure to gain weight normally
• Thyroid Storm


  A major complication of hyperthyroidism manifested by high fever, tachycardia, severe dehydration and occasional cardiac decompensation.
• Diagnostic Procedures for Hyperthyroidism

  1. Low TSH and Increased free T4

  2. TSHR test. This test detects even tiny amounts of TSH in the blood and is the most accurate measure of thyroid activity available. Generally, below-normal levels of TSH indicate hyperthyroidism. However, low TSH levels may also occur in a normal pregnancy, especially in the first trimester, due to the small increase in thyroid hormones from HCG.

  3. T3 and T4 test. If TSH levels are low, another blood test is performed to measure T3 and T4. Elevated levels of free T4-the portion of thyroid hormone not attached to thyroid-binding proteins-indicate hyperthyroidism.
• Hyperthyroidism


  Condition that causes the thyroid to make too much thyroid hormone, usually caused by Graves' disease
• Signs and Symptoms of Hyperthyroidism

  • Tachycardia
  • Enlarged thyroid gland
  • Exophthalmos
  • Weakness
  • Sweating
  • Failure to gain weight normally
• Thyroid Storm


  A major complication of hyperthyroidism manifested by high fever, tachycardia, severe dehydration and occasional cardiac decompensation
• Diagnostic procedure for Hyperthyroidism

  1. Low TSH and Increased free T4

  2. ISHI test to detect tiny amounts of TSH in the blood

  3. T3 and I4 test to measure T3 and T4 levels

  4. TSI test to detect presence of TSI antibodies
• Hyperthyroidism Management

  • Medical treatment with thiomide drugs like propylthiouracil and methimazole until euthyroid
  • Thyroidectomy - surgical removal of thyroid gland during 2nd trimester of pregnancy
• Hyperthyroidism Treatment

  1. Follow free T4 and total T3 every 2 to 4 weeks until titrated to high normal range

  2. PTU: 100 to 600mg divided TID in first trimester

  3. PTU: 100 to 600mg divided TID or Methimazole 5 to 30mg divided into BID after first trimester
• Hyperthyroidism Complications

  • Preeclampsia
  • Heart Failure
  • Abortion
  • Stillbirth
  • Low birth weight

  
• Effects of Hyperthyroidism on Fetus

  • Rapid heart rate leading to heart failure
  • Early closure of soft spot in skull
  • Poor weight gain
  • Irritability
  • Enlarged thyroid that can interfere with breathing
• Hypothyroidism


  Caused by very low thyroxine levels that cause slow metabolism, resulting in stillbirth and infertility
• Hypothyroidism Symptoms

  • Cold intolerance
  • Muscle cramps
  • Weight gain
  • Edema
  • Dry skin
  • Hair loss
  • Prolonged relaxation of deep tendon reflexes
• Hypothyroidism Management

  Thyroxine Replacement Therapy
• Hypothyroidism Treatment


  1. Follow TSH every 4 to 6 weeks and titrate to lower reference limit

  2. Levothyroxine: 1 to 2 mcg/kg daily, typically 100 micrograms daily

  3. Avoid T3 compounds