Orientation of Medical Officers on Anaemia during Pregnancy, Rajasthan Case Exercises on Anaemia during Pregnancy Session 2.2

Case 1 22 years old Geeta, primigravida comes to your OPD at CHC with 7 months amenorrhoea with complaints of weakness, lethargy and breathlessness on little work since 15 days. Question: What will you do next?

Case 1 contd. Possible Response Prompts Take history- LMP, current obstetric history, geographic location of residence, socio- economic background, dietary intake, previous H/O any blood transfusion (BT), H/O taking supplements in this pregnancy General examination- Pallor, oedema, vitals According to her LMP she is 27 weeks pregnant, not residing in malaria endemic zone, no H/O BT, coming first time for ANC and has not taken any supplements O/E-pallor+, pedal oedema +, pulse 98/min, temperature-370 C, respiratory rate 22/min, and BP is 110/70 mm Hg Question: What investigations will you advice?

Case 1 contd. Possible Response Prompts Since she is coming for the first time, I will advise Hb, urine for protein, sugar and AFB, OGTT, HIV, HBsAg, syphilis, blood group Besides this since she is looking pale so I will advise for peripheral smear (PS) for MP, TLC, DLC, Platelets, MCV, Peripheral smear for RBC morphology (if available) Her Hb is 8 gm%, urine albumin, sugar-nil. Rest reports awaited. O/E-pallor +, pedal oedema +, pulse 98/min, temperature-370 C, respiratory rate 22/min, and BP is 110/70 mm Hg Question: What is your probable diagnosis? Answer: Moderate anaemia Question: How will you proceed to manage this case?

Case 1 contd. Response: Management of moderate anemia: Tablet Albendazole 400 mg stat by DOTS Start Injection Iron sucrose regime Counselling on her condition, diet, hand hygiene, safe drinking water Counselling on importance of adhering and completing treatment Counselling on institutional delivery Result: Great! Correct response.

Case 2 Reena, 28 years old second gravida, comes to your PHC for her third follow up ANC visit. She was diagnosed with anemia as her Hb level was 10 gm% during her second ANC visit and was advised to take tablet IFA twice a day. Question: What will you do next?

Case 2 contd. Possible Response Prompts Ask for compliance Perform general examination for pallor, oedema, vitals Perform abdominal examination for appropriate growth of fundal height (foetal growth) She says she is taking the advised tablets regularly. O/E-pallor +, pedal oedema +, pulse 98/min, temperature-370 C, respiratory rate 22/min, and BP is 110/70 mm Hg Her fundal height is according to her gestational age Question: What investigations will you advice? Haemoglobin is 9 gm% Repeat her Hb. Question: What are the possibilities of fall in Hb? What will you do next?

Case 2 contd. Possible Response: Since she is not responding to oral iron therapy, possibilities are: Non compliance Unresponsive to iron absorption I will refer her to higher facility for further evaluation to rule out other causes of anemia and further management accordingly Result: Great! Correct response.

Case 3 Meena, 4th gravida comes to you at the district hospital for her 1st ANC visit with her sister. She is 8 months pregnant. She is complaining of extreme weakness, swelling over body, breathlessness, giddiness since 1 month. Question: What will you do next?

Case 3 contd. Possible Response Prompts Take history- LMP, past and current obstetric history, spacing between pregnancies, geographic location of residence, socio- economic background, dietary intake, previous H/O any blood transfusion (BT), H/O taking supplements in this pregnancy General examination- Pallor, oedema, vitals According to her LMP she is 36 weeks pregnant, not residing in malaria endemic zone, no H/O BT, coming first time for ANC and has not taken any supplements O/E-pallor ++, oedema + over face hands and feet, pulse 110/min, temperature-370 C, respiratory rate 28/min, and BP is 110/70 mm Hg Question: What investigations will you advice?

Case 3 contd. Possible Response Prompts Since she is coming for the first time, I will advise Hb, urine for protein, sugar and AFB, OGTT, HIV, HBsAg, syphilis, blood group Besides this since she is looking pale so I will advise for peripheral smear (PS) for MP, TLC, DLC, Platelets, MCV, Peripheral smear for RBC morphology (if available) Her Hb is 5 gm%, urine albumin and sugar-nil. Rest reports awaited. O/E-pallor +, pedal oedema +, pulse 98/min, temperature-370 C, respiratory rate 22/min, and BP is 110/70 mm Hg Question: What is your probable diagnosis? Answer: Severe anaemia Question: How will you proceed to manage this case?

Case 3 contd. Possible Response: I will manage her as for severe anemia: Admit her and inform Meena and her attendant/family about her condition and its effects on her and the baby’s well-being and need for blood transfusion Take blood for grouping and cross matching Arrange blood and start transfusion Give tablet Albendazole 400 mg stat by DOTS Counsel her on need to complete the treatment, diet, hand hygiene, safe drinking water Counsel her on institutional delivery Result: Great! Correct response.

Thank you