Pregnant mother with Anaemia

History
Basic Info & Introduction
Mrs MN Keshala is 26 years old pregnant mother from Kotahena. This is her 2nd pregnancy. From her first preg-
nancy she has a boy of 4 years old. She has no occupation
LMP - 2021/ 10/15
EDD by dates - 2022/ 07/ 22
EDD by scan - 2022/ 07/ 30
POA - 34W + 4 ( on 20th June 2022 )

PC
Admitted as requested for a blood transfusion following a detection of low Hb level at routine clinic visit

HPC
Pre conceptional
planned pregnancy,
FA suppliments taken since 2 months prior to conception,
Previosly vaccinated for Rubella

T1
Pregnancy was dignosed with urine HCG test following a period of amenorrhoea
Booking vist at 8W POA antenatal clinic in the area. FBC, PPBS, UFR, Blood grouping VDRL, HIV done. Hb - 9mg/dl
Hematinics started
Poor compliance to oral Iron therapy due to side effects such as nausea, vomiting, excessive sweating etc noted
on assessment
No other investigations done.
Dating scan performed at 12W POA, No abnormalities detected
No Hx of bleeding PV, Excessive vomiting or hospital admissions.

T2
Hematinics were started soon after booking visit
Tetanus toxoid given
Upon inquiring mother confirmed that quickening was felt at ????
USS done at 22W POA, No abnormalities detected.
No Hx of Bleeding PV & hospital admissions
Complains about a mild headache, diziness & fatiguability

T3
OGTT done at 28W POA, No GDM
USS done at 29W POA, No abnormalities detected.
USS done at 34W POA, SLF, CP, Placenta not low

What has been done so far

Compliance for oral Iron therapy was poor.
Patient complains gradual onset progressive persistent mild headache since 20W POA & associated with nausea
& vomiting when it is severe. Headache is resolved by steam inhalation but after some time it will develop again.
Patient also compains about a gradual onset progressive fatiguability associted with occasional dizzines.
Resolves after taking meals but develops again.

Serial HB monitoring done during clinc visits.

Hb was maintained around 9mg/dl
Last time it has reduced upto 8mg/dl
Plan to give blood transfusions now

Ddx
Dietary intake of Irons & vitamin A rich was not reduced & revealed that she takes three main meals with a
protein rich food upon inquiring. Does not eat mutton or beef. Only eats Fish, chicken & Eggs.
No symptoms of worm infection. Regulary takes antiheminthic treatments.
No hx of LOW, symptoms of distant mets, recurrent infections
No family Hx of Thalassemia or other haemoglobinopathies.
No Hx of Jaundice & symptoms of haemolysis.
No symptoms suggestive of chronic blood loss.

Past Obs Hx
P1 - Pregnancy was complicated by anaemia & two episodes of seizures.
Anaemia was mx with blood transfusions.
No hx of FGR.
Delivered at 41W POA with vaginal delivery assisted by forceps.
Baby had bilateral club foot. Initially mx via cast
Then opted for surgery. Now the child can walk normally & 4 years of age.
Mother complains about hyperactivity of the child

Past Gyn Hx
Mensturation - Reguar cycles, 28/4, Normal flow
Contraception - IUD loop was inserted after the deliery of first child. Removed the loop in July 2021 ( LMP in Oct
2021)
No Hx of gynaecological infection
Cervical smear not done
No hx of gynaecological surgeries

PMHx & PSHx

There is a past hx of seizure. 1st at the age of 17y & then 2 episodes during the 1 pregnancy at 32W POA.
Aura was present. She had felt a chest pain before the onset of seizure.
Generalized tonic clonic seizre, Lasted for less than 1 minute, mouth deviated to ???
Admitted to hospital soon after the 1st episode & developed a another episode in the hospital
Started on antiepileptics ( carbamazapine, Lamotrigeine ) continued about 1 1/2 years.
EEG done, MRI done,
followed up at clinc for 1 1/2 years. Then discharged from the clinic.

Psy Hx
Unremarkable

Family Hx
DM DM

No family Hx of seizures

4 years
old

Social Hx
Lives with husband & 1 st child in a single story rented house ( Rs.11000/month)
Mother & father lives closeby & has good extended family support
Husband works at China harbour as a supervisor & income is adequate for their needs
Nearest hospital??
Educated upto??

Examination
General examination
Conjunctival pallor is present
There is no angular stomatitis or glossitis, No koilonychia, No ankle oedema
several dental caries were present

Obs
Inspection
Abdomen asymetrically enlarged more towards right side
Striae gravidarum & linea nigra is present.
Palpation
SFH - 34cm compatable with gestational age.
Two fetal poles were palpable - Hard ballotable mass in suprapubic area & soft boggy mass towards epigastric
right hypochondrum &right lumbar & umbilicus region.
Longitudinal lie
cephalic presentation
Head is not engaged
Fetal back is in right side
Liquor is adequate
Estimated fetal weight is around 2.5kg

Auscultation
Fetal heart sound is audible through pinnard

Summary
26y old pregnant mother presented with low Hb level Hb at 34W+2 POA
Low Hb level detected in booking visit at 8W POA.
Started on DDI therapy & poor compliance to the therapy noted.
No abnormality in USS
First pregnancy was also complicated by anaemia & needed blood transfusions as well. Also she had two
episodes of GTC seizures during first pregnancy. Not on antiepileptics Tx now.
Forcep delivery & child had bilateral club foot which surgically corrected later. Now the child can walk normally.
There is a family Hx of DM
examination revealed conjunctival pallor & several dental caries.
Single pregnancy, SFH 34cm, longitudinal lie, cephalic presentation, head is not engaged, Liquor is adequate,
Estimated fetal weight 2.5kg, can hear the fetal heart sounds.

Plan
Iv Iron sucrose200mg in 100ml 0.9% saline - Infusion over 2 hours, Every other day ( EOD) 3 doses
Keep vein open for reactions
Omit oral Iron
FA 5mg/d
IM B12 1000 micrograms EOD 6 doses
review with FBC in 2/52