CLINICAL FEATURES: (1) The onset is usually insidi- aus and is first

revealed in the last trimester or may be acutely manifested in early

puerperium, (2) Anorexia ar protracted. vomiting, (3) Occasional diarrhea
and (4) Constitutional symptom like unexplained fever is often ociated.
On examination: (1) Pallor of varying degree, (2) Ulceration in the mouth (glossitis)
and tongue (one-third Cases), (3) Hemorrhagic patches under the skin and con-
unctiva, (4) Enlarged liver and spleen which may be dif- cult to palpate due to an
enlarged gravid uterus and (5) Features of pre-eclampsia may be present (two and
half mes increased).
Hematological examination and other blood values: Hemoglobin level is
usually below 10g%. Stained mod film: Presence of any two of the following
features the peripheral blood, but more often seen in buffy coat parations, are
diagnostic:a Hypersegmentation of the neutrophils (5 or more lobes),
macrocytosis and socytosis, giant polymorphs, megaloblasts, Howell-Jolly
bodies. (3) MCV is more than 100 μ3. WICH is high (more than 33 pg), but
MCHC is normal. Associated leukopenia and thrombocytopenia. (5) iron is
normal or high and iron binding capacity (6) Red cell folate is below 3 ng/mL
(normal non- mant level being 2.8-8 ng/mL). (7) Serum vitamin level is below
90 pg/mL (normal levels 300 pg/mL). Serum bilirubin-may be raised and (9)
Bone mar- shows megaloblastic erythropoiesis.
COMPLICATIONS:
appetite, (ii) increase in reticulocyte, leukocyte and thrombocyte count and (iii) rise
in hemoglobin level. Folic acid should never be given without supplemental iron.
Supplementary intramuscular vitamin B12 100 μg daily or on alternate days may
be added when response to folic acid alone is not adequate. Ascorbic acid 100 mg
tablet thrice daily enhances the action of folic acid by converting it into folinic
acid.
DIMORPHIC ANEMIA
This is the most common type of anemia met with in the tropics. It is related to dietary
inadequacy or intestinal malab- sorption. As such, anemia results from deficiency of
both iron and folic acid or vitamin B12. While there is polydeficiency state, the
hematological findings or the bone marrow picture usually show predominance of one
deficiency. The red cells become macrocytic or normocytic and hypochromic or
normochromic
a are mentioned before. The following are the al complications in megaloblastic anemia:
Mis- e. Dysmaturity, Prematurity, Abruptio tae and Fetal malformation (cleft lip, cleft
pal-Fig. 20.2). Bone marrow picture is predominantly megalobl- neural tube defects).
There is association between ceptional folate deficiency and neural tube
PROPHYLACTIC THERAPY: All woman of reproductive uld be given 400 ug of
folic acid daily. Additional (4 mg) should be given in situations where the nd is
high. Such conditions are: multiple preg- patient having anticonvulsant therapy,
hemo- pathies or associated associated chronic infection or Women, who have
infants with neural tube should be given 4 mg of folic acid daily begin- month
before conception to about 12 weeks of
WE: Specific therapy includes-daily adminis- of folic acid 4 mg orally which should be ed
for at least 4 weeks following delivery. mementation of 1 mg of folic acid daily along
and nutritious diet can improve pregnancy- megaloblastic anemia by
7-10 days. Response enced by-(i) sense of well-being and increased
astic as the folic acid is required for the development of the umber of red cell
precursors. The treatment consists of prescrib- bing both the iron and folic acid in
therapeutic doses.
APLASTIC ANEMIA
It is rarely seen in pregnancy. There is marked decrease in the marrow stem cells.
Exact cause is unknown. It recessive in immunologically mediated or may be an
autosomal recessive inheritance. In about 30% of cases, anemia improves once
pregnancy is terminated. The significant complications in pregnancy are hemorrhage
and infection.
Diagnosis: Blood values-Anemia, leukopenia and throm- bocytopenia. Bone marrow-markedly
hypocellular.
Management: Repeated blood transfusions are given to maintain hematocrit level above 20.
Specific therapy may be needed, e.g. granulocyte transfusion to combat infection and
platelet transfusion to control hemorrhage. Glucocorticoid therapy may be helpful in some
patients. In a severe case of aplastic anemia, bone-marrow or stem cell transplantation is
effective. Vaginal delivery is always preferred.
Anemia due to chronic diseases, infections or neoplasms is of hypochromic microcytic
type. Serum iron level is low,

HEMOGLOBINOPATHIES
Hemoglobin is a conjugated protein which contains a globin fraction bound to 4 heme moieties. There are
4 polypeptide chains within the globin fraction-namely alpha, beta, gamma
and delta. Composition of a normal adult hemoglobin HbA (a, B2)= 96.98%, HbF (a2 Y2) = 0.5-
0.8% and HbA, 1.5-3.7%. In normal fetal hemoglobin, the beta chains replaced by two gamma
chains (a2 y2). The last two vari constitute not more than 5% in normal human adults.
=
Hemoglobinopathies are inherited specific biochemi disorders (quantity or quality) within
the polypeptide cha of globin fraction. Two common varieties are met. Sickle disease is
inherited structural abnormality involvingprim