Anemia

Published on 31/05/2015 by admin

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Chapter 11 Anemia

INTRODUCTION

Description: Anemia is a reduction below normal in the oxygen-carrying capacity of the blood as reflected by the hemoglobin or hematocrit values. Women are at higher risk because of menstrual blood loss.
Prevalence: More than 20% of women, 50% to 60% of pregnant women.
Predominant Age: Reproductive most common for women.
Genetics: Hemoglobinopathies such as sickle cell disease, thalassemia, and others are associated with anemia.

ETIOLOGY AND PATHOGENESIS

Causes: Abnormalities of production (e.g., iron deficiency, chronic disease, chemotherapy, radiation). Abnormalities of destruction or loss (e.g., hemorrhage, hemolysis, sickle cell disease).
Risk Factors: Excessive blood loss (menorrhagia), poor diet, pica, malabsorption, chronic disease, endocrinopathy (thyroid). Smokers have slightly higher hemoglobin values (0.5 to 1.0 g/dL).

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Asymptomatic
• Fatigue, palpitations, dyspnea, exhaustion (late signs)
• Ice craving, spooning or ridging of fingernails (iron-deficiency anemia)
• Sore mouth or dysphagia (B12 or iron-deficiency anemia)
• Joint and bone pain (sickle cell anemia)

DIAGNOSTIC APPROACH

• Differential Diagnosis: See illustration.
• Associated Conditions: Stomatitis, ridging and spooning of fingernails, hypersegmented polymorphonuclear neutrophils (megaloblastic anemia).

Workup and Evaluation

Laboratory: Mean corpuscular volume, reticulocyte count, blood smear, iron studies, hemoglobin electrophoresis; others based on individual patient—serum iron, total iron binding capacity, serum ferritin.
Imaging: No imaging indicated.
Special Tests: Bone marrow analysis (not necessary for the majority of patients).
Diagnostic Procedures: Laboratory evaluation.

Pathologic Findings

Based on underlying cause.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, diet counseling, control of menstrual abnormalities.
Specific Measures: Based on cause.
Diet: Adequate iron (7 to 12 mg/day) and folate (1 to 5 mg/day).
Activity: No restriction.
Patient Education: Diet counseling; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP001 (Nutrition During Pregnancy).

Drug(s) of Choice

Iron supplements (ferrous sulfate 300 to 350 mg PO three times daily) for 6 to 12 months or longer. (Parenteral iron may be given to patients with severe anemia or to those who do not comply with oral therapy.)
For pernicious anemia—vitamin B12 100 mg intramuscularly (IM) monthly. (Treatment of megaloblastic anemia resulting from B12 deficiency with folate will reverse anemia, but progressive and irreversible neurologic damage may result. B12 levels should always be checked if this is suspected.)
Precautions: Anaphylaxis may occur with parenteral iron.
Interactions: Ascorbic acid increases absorption of iron.

FOLLOW-UP

Patient Monitoring: Normal health maintenance, periodic evaluation of blood count.
Prevention/Avoidance: Good diet, control of excessive menstrual blood loss.
Possible Complications: Progressive and irreversible neurologic damage may result with untreated vitamin B12 deficiency.
Expected Outcome: Generally good response to iron therapy (iron-deficiency type).

MISCELLANEOUS

Pregnancy Considerations: Anemia more common in pregnancy.
ICD-9-CM Codes: 285.9 (others based on cause).

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REFERENCES

Level III

Hillman RS, Rinder HM, Ault KA. Hematology in Clinical Practice. New York: McGraw-Hill, 2005.

De Gruchy GC. Clinical Hematology in Medical Practice. London: Blackwell Publishing, 1989.

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