Haematological problems in obstetric patients

Haematological problems in obstetric patients

Sep 19, 2016 1
haematology,o&g,onthepods

James talks to Dr Shafqat Inam, Haematology Advanced Trainee, about an approach to haematological problems in obstetric patients.

Summary Writer:  Antonia Clarke

Editor:  Bruce Way

Interviewee:  Shafqat Inam

About Dr Shafqat Inam

Shafqat Inam is currently a Haematology Registrar at Royal Prince Alfred Hospital and Concord Hospital, and Associate Lecturer at the University of Sydney. He studied medicine at the University of New South Wales and completed his junior medical officer and basic physician training at Royal Prince Alfred Hospital. He has a particular interest in research and medical education.

Haematological problems in obstetric patients

With Dr Shafqat Inam, Haematology Advanced Trainee at Royal Prince Alfred Hospital, New South Wales, Australia

Introduction

Certain haematological conditions are unique to pregnancy and in approaching these conditions, consideration must be given to the mother and child.

What are the physiological changes in pregnancy?

  • Dilutionalanaemia – becomes more pronounced in the 2nd and 3rd trimesters
  • Iron deficiency anaemia
  • Thrombocytopaenia – this can be a benign finding (gestational thrombocytopaenia) or a feature of pre-eclampsia and HELLP syndrome
  • Thrombotic complications e.g. DVT, PE

Case 1

You are a junior doctor working in the Emergency Department and you are asked to review a woman who is 12 weeks into her third pregnancy – she presents with a sore and swollen leg.

  • History for suspected DVT/PE
    • Time course of the symptoms
    • Provoking factors other than pregnancy e.g. recent immobilisation
    • Ask for symptoms suggestive of PE e.g. shortness of breath, chest pain
  • Examination for suspected DVT/PE
    • Oxygen saturations and heart rate
      • Remember that a mild resting tachycardia can be a common finding in pregnancy as well as a subjective feeling of dyspnoea
    • Unilateral swelling, warmth and tenderness (often more common in the left leg due to compression of the left iliac vein by the uterus)
    • Examine the chest for any features of PE
  • A D-dimer is often not useful as it can be elevated in pregnancy
  • Lower limb Doppler US is the definitive test for DVT
  • If there is suspicion for a proximal thrombus not picked up on ultrasound, a CT or MR venogram may be indicated
  • If there are symptoms of PE, the choices are:
    • V/Q scan: more radiation to the foetus, but less to the mother’s breasts
    • CTPA: more radiation to the mother’s breasts, but less to the foetus
      • Radiation risks should be discussed with the patient but generally the importance of diagnosis outweighs the radiation risk
  • Anticoagulation: low molecular weight heparin e.g. enoxaparin is often used and can be monitored via anti-Xa levels
    • Warfarin is contraindicated due to the effect on the foetus
    • It is important to also consider anticoagulation during the period of delivery (remember to withhold LMWH 24 hours prior to an epidural)
    • NOACs are not currently recommended for treatment of DVT/PE in pregnancy

Case 2

You are a junior doctor helping out in the antenatal clinic. You see a woman for a routine visit at 9 weeks. Her Hb is 88g/L.

  • Dilutionalanaemia
    • Cut-off for Hb is usually 110g/L in the first trimester, and 105g/L in later trimesters
  • Consider the differential causes of anaemia
    • Microcytic anaemia: iron deficiency anaemia or thalassaemia
      • These are the more common causes of anaemia in the pregnant population
      • Three times the normal amount of iron is required in pregnancy
    • Normocytic anaemia: haemolysis or chronic disease
    • Macrocytic anaemia: vitamin B12 or folate deficiency
  • History
    • Assess for symptoms of anaemiae.g. fatigue, dyspnoea
    • Assess if there are any contributing conditions to anaemia e.g. diet, previous menorrhagia
  • Iron studies: look for a decreased ferritin level, raised transferrin and decreased transferrin saturation
  • Oral iron supplements – this can cause gastrointestinal disturbance; or
  • Intravenous iron infusion – this rapidly improves iron deficiency
    • Repeat a full blood count and iron studies 2-3 months following iron infusion to assess response
  • Interpretation of tests must account for the physiological changes that occur in pregnancy
  • There are certain conditions unique to pregnancy e.g. pre-eclampsia, which can present with thrombocytopaenia, and require specialist input

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Tags: #DVT,#haematological problems in obstetric patients,#haematology,#obstetrics and gynaecology,#pregnancy,#pregnant patient

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