haematological evaluation of anemia - bsog · haematological evaluation of anemia sitalakshmi s ......
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HAEMATOLOGICAL
EVALUATION OF ANEMIASitalakshmi S
Professor and Head
Department of Clinical Pathology
St John’s medical College, Bangalore
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Learning Objectives
Laboratory tests for the evaluation of anemia
Classification of anemia
Common causes of anemia in OB and Gyn practice
Case discussion
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What is anemia?
Sign?
Clinical finding?
Laboratory finding?
Disease?
Pointer to a systemic disease?
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The first step in any diagnosis:
physical examination
determining its cause
A detailed medical, personal, and dietary history :
Any family or personal history of anemia
A history jaundice, or enlarged spleen
Heavy menstrual bleeding in women
Any signs of internal bleeding.
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Of all the diagnostic tests available, complete blood count is one of the
single most valuable tools in assessing the general health of the body.
Provides a snap shot of the hematopoietic system at a specific point in
time.
It is a valuable indicator of disease, either local or systemic
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Complete Blood Count (CBC)
a panel of tests that measures RBC,WBC and platelets.
For diagnosis of anemia, the CBC provides critical information on:
the size, volume, and shape of RBC
Hemoglobin
Anemia is when Hb is
< 11 g/dL for pregnant women
< 12 g/dL for non-pregnant women
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CBC
The CBC includes
quantitative evaluation of erythrocytes, leukocytes and
platelets and
Qualitative - microscopic examination of the blood film to
detect morphological abnormalities that provide valuable
insight to various disease conditions.
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Components of CBC
RBC parameters
Platelet parameters
WBC parameters - Scattergram
Reticulocyte count
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Parameters…
RBC parameters RBC count
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW
Reticulocyte
Nucleated RBC
WBC parameters
WBC count
Differential
Platelet parameters
Platelet count
MPV
PDW
PCT
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All the routine tests have been automated and new tests
have been developed.
Currently available automated analysers make it possible to
process several hundreds of blood specimens a day.
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All automated hematology analyzers in addition to
enumerating the CBC results generate:
red cell histograms
platelet histograms and
white cell histograms or scattergrams
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The RBC and platelet histograms depict the cell sizing data
in graphic form by plotting relative cell number versus size
(volume)
whereas scattergrams are two- dimensional or three-
dimensional plots of multiparameter data obtained for the
DLC.
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Red cell Indices
mean cell volume (MCV)
mean corpuscular hemoglobin (MCH)
and mean cell hemoglobin concentration (MCHC)
help us to classify an anemia as:
regenerative (blood loss or hemolysis) or
nonregenerative (production defect)
often giving us insight to the etiology
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25-75 fl 200-250 fl
Erythrocyte (RBC) Histogram
RBC size: 80-95 fl
RBC detection: between 25 and 250 fl
Distribution curves are separated by flexible
discriminators: RL & RU
RL RU
RBCPLT
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MCV
MCV (mean corpuscular volume)
The average volume of RBC
Hct
= 10 (fl)
RBC count (m/µL)
e.g. Hct= 40%
RBC=5.0 (m /µL)
MCV= 40/5.0 10 = 80 fl
NR= 80-96 fl
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MCH
MCH (mean corpuscular hemoglobin)
The average content of Hb in average RBC.
It is directly proportional to the amount of Hb and RBC size.
Hb
RBC count (m/µL)
10 (pg)MCH =
e.g. Hb = 14 g/dl
RBC = 4 (m/µL)
MCH= 14/4 10
= 35 pg
NR= 27-32 pg
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MCHC
MCHC (mean corpuscular hemoglobin concentration)
Express the average concentration of hemoglobin per unit volume of
RBC.
It defined as the ratio of the weight of hemoglobin to volume of RBC.
Hb (g/dl)
Hct (%)
100 (%)MCHC=
e.g. Hb = 14 g/dl
Hct = 45 %
MCHC 14/45 100 = 31%
NR= 32-36%
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RDW and HDW
The new additions to the CBC profile which have
useful clinical application.
Red cell distribution width (RDW) – an indicator of the
degree of anisocytosis
Hemoglobin distribution width ( HDW) - is a red cell
parameter that measures anisochromia which along with MCV and
RDW are useful in the differential diagnosis of microcytic anemia.
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RDW
RDW - coefficient of variation of the red blood cell
distribution histogram.
Quantitative measure of variation in RBC size
(anisocytosis)
RDW is elevated in:
iron deficiency anemia
RDW is normal in microcytic anemia of thalassemia.
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RBC - Histogram Distribution Width
Reference range less than 16 %
200 250 fl
100 %
RDW – CV is equivalent to
68,26 % of the distribution curve
RDW-CV
RDW – SD standerd devation at 20 %
of the distrubution curve
Reference range: 37 - 46 fl200 250 fl
100%
RDW-SD
.
20%
68.26%
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Red cell indices in Anemia
Anemia associated with thalassemia minor:
low MCV, a normal RDW, and elevated HDW
Iron deficiency anemia:
Low MCV, an increase in both RDW and HDW
Marrow regeneration as in haemolytic anemias :
elevated MCV, RDW and HDW.
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The severity of anemia is categorized by:
Mild anemia Hb 9.5g/dl
Moderate anemia Hb 7.0 - 9.5 g/dL
Severe anemia Hb below 7.0 g/dL
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Peripheral smear Reticulocyte smear
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Reticulocyte Count
Reticulocyte count is the percent of immature RBCs
Normal levels 0.5 - 2%
Corrected reticulocyte count compares anemic to non-anemic
counterparts to assess response as reticulocyte count may
overestimate response
Corrected Reticulocyte Count = % Retic X HCT/45
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Reticulocyte Correction Factor
RPI = % reticulocytes X HCT/45 X 1/Correction Factor
Normal RPI =1
RPI < 2 Hypoproliferative anemia
RPI greater than/equal 2 Hyperproliferative Disorder
Hematocrit Correction Factor
40-45 1
35-39 1.5
25-34 2
15-24 2.5
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CLASSIFICATION OF ANEMIAS
Anemias may also be classified functionally into:
Hypoproliferative (when there is a proliferation defect)
Ineffective (when there is a maturation defect)
Hemolytic (when there is a survival defect)
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FUNCTIONAL CLASSIFICATION OF ANEMIAS
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Kinetic Approach
Decreased RBC production
Lack of nutrients (B12, folate, iron)
Bone Marrow Suppression
Increased RBC destruction
Inherited and Acquired Hemolytic Anemias
Blood Loss
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Morphological Approach
Microcytic (MCV < 80)
Reduced iron availability
Reduced heme synthesis
Reduced globin production
Normocytic ( 80 < MCV < 100)
Macrocytic (MCV > 100)
Liver disease, B12, folate
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MORPHOLOGICAL CLASSIFICATION OF
ANEMIAS
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NORMOCYTIC NORMOCHROMIC ANEMIAS
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MICROCYTIC HYPOCHROMIC ANEMIAS
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MACROCYTIC ANEMIAS
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Case 1
A 72 year old
lady has the
CBC findings
shown..
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Case 1
What test would you order for this
patient?
A-Hemoglobin Electrophoresis
B-Retic count
C-Stool for occult blood
D-B12 Assay
E-Bone marrow biopsy
Peripheral Blood smear:
RBCs are hypochromic & microcytic
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Case 1
Two questions:
What is your diagnosis?
What is the next step for this patient?
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Case 1
Answers
Question 1
Likely Iron Deficiency Anemia
Question 2
Colonoscopy
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Iron Deficiency Anemia: Peripheral Smear
Microcytosis &, Hypochromic RBCs
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Iron Deficiency Anemia
Low Retic Count
High RDW
Low iron level
High TIBC
Low ferritin
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Degrees of Iron Deficiency
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Tests for Assessing Iron Status
Serum iron
Total iron binding capacity (TIBC)
Transferrin saturation = serum iron/TIBC x 100
Serum ferritin
Serum transferrin receptor (sTfR)/serum ferritin
[R/F ratio]
Reticulocyte haemoglobin content
Stainable iron in bone marrow
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Case 2
A 28 year old lady G2P1
16 weeks gestation has
become progressively more
fatigued at the end of the day.
This has been going on for
months.
In the past month she has noted
paresthesia with numbness in the
feet.
A CBC demonstrates the findings
shown.
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Case 2
A peripheral blood smear (the slide is representative of this condition) shows red blood cells displaying macro- ovalocytosis and neutrophils with hypersegmentation.
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Case 2
Which of the following tests would be most useful to determine the
etiology?
A. Hemoglobin electrophoresis
B. Reticulocyte count
C. Stool for occult blood
D. Vitamin B12 assay
E. Bone marrow biopsy
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Case 2
Questions:
• What is the diagnosis from these findings?
• How do you explain the neurologic findings?
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Case 2
Answers:
Question 1
This is a macrocytic (megaloblastic) anemia. The neurologic findings
suggest vitamin B12 deficiency (pernicious anemia).
Question 2
The B12 deficiency leads to degeneration in the spinal cord (posterior and
lateral columns).
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Case 3
24 year old lady presented at 34 weeks of gestation with headache, vomiting and epigastric pain of acute onset. On examination she had anemia and jaundice.
Investigations
Hb 5.6g/dl
TC 22000/cmm
DC N 86 L 5 Bd 3 Myelo 2 meta 4 NRBC 7/100 WBC
Platelet count 40.000/cmm
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Case 3
Peripheral smear:
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Case 3
Biochemical investigations:
Serum bilirubin 2 .5 mg
Conjugated 0.8
AST 786 IU/L ALT 1030 IU/L
Alkaline phosphatase: 240
PT 13 sec C 12 sec INR 1
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Case 3
HELLP syndrome
Acute fatty liver of pregnancy
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1- Abnormalities of RBC interior
a. Enzyme defects
b. Hemoglobinopathies & Thalassemia M
2-RBC membrane abnormalities
a. Hereditary spherocytosis, elliptocytosis etc
b. Paroxysmal nocturnal hemoglobinuria
c. Spur cell anemia
3- Extrinsic factors
a. Hypersplenism
b. Antibody : immune hemolysis
c. Traumatic & Microangiopathic hemolysis
d. Infections , toxins , etc
Hereditary
Acquired
A Very Simple Classification of Hemolytic Anemias
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Laboratory Evaluation of Hemolysis
Extravascular Intravascular
HEMATOLOGIC
Routine blood film
Reticulocyte count
Bone marrow
examination
Polychromatophilia
Erythroid
hyperplasia
Polychromatophilia
Erythroid
hyperplasia
PLASMA OR SERUM
Bilirubin
Haptoglobin
Plasma hemoglobin
Lactate dehydrogenase
Unconjugated
, Absent
N/
(Variable)
Unconjugated
Absent
(Variable)
URINE
Bilirubin
Hemosiderin
Hemoglobin
0
0
0
0
+
+ severe cases
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Acute Myeloblastic Leukemia Aplastic anemia
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A logical stepwise approach in the context of clinical presentation
selection of appropriate laboratory tests to support the clinical
suspicion
Arrive at the correct diagnosis