OB-GYN-L Messages for July, 2007: Re: low hgb

Re: low hgb

From: Barbara Nicol

blnicol@ix.netcom.com

Tue Jul 31 11:39:35 2007

This sounds like an acute anemia; think about occult blood loss vs hemolysis. Hemolysis would be the diagnosis from the smear (but a hemoccult is an easy test to do.) Have you/they checked a bili? Retic count? There are a number of tests that even the smallest of hospitals should be able to run or send which would aid in diagnosis of the anemia.

The DDx of acute hemolysis is covered in many texts, but there are some diagnoses you will want to exclude before delivery if possible. Just frex, what about favism (G6PD deficiency)? Causes hemolysis, can be triggered by drugs or fava beans, and could cause an acute drop in HGB as you see here. G6PD deficiency can affect your medical management - you'd like to know if she has it. Have you, perhaps, treated her for a UTI recently with, say, Septra? Were favas in season about a month ago? (Yeah, I know, zebra - but the point is: do think about the DDx of hemolysis - and think about what might affect your choice of meds during or after delivery.)

Anyway, I'd suggest calling the hematologist and ask which tests she wants before any potential confounding transfusions - probably she would be glad to have them sent before seeing the patient. This is for 2 reasons (1) you will quite possibly need to transfuse even for a routine blood loss during delibery and, once you do, a lot of your blood tests will be meaningless. (2) the pediatrician needs to know as much as you do if it's a genetic disorder. Of course, you may have already done these tests, and just not reported them in your summary.

I also note that there are some mushrooms - Gyromitra - that can cause hemolysis, seizures, and coma, as well as a number of toxic chemicals. Again, a zebra, but this is an odd enough case that it's worth asking if there's a potential occupational or culinary toxic exposure.

If the baby's doing okay (good testing/growth) I think that these are good reasons to do a brief workup first before rushing to delivery. Obviously you will have blood available for the patient at the time, and with a symptomatic anemia, I think a transfusion before induction of labor is a reasonable idea to discuss with her. Transfusions are not risky compared to further blood loss with a Hgb this low, and if they clear her symptoms then you have also made your diagnosis for the neuro stuff. I would not be at all surprised to discover that she is neurologically just fine when her Hgb is up in the 9 or 10 range.

good luck!

Barb Nicol, M.D.

-----Original Message----- >From: Joe Cutchin <forcep@intercom.net>
>Sent: Jul 31, 2007 7:33 AM
>To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
>Subject: Re: low hgb
>
>Vicki: Where is she from orginally? I think there is a wierd Hb disease
>in the carribean that manifests like this. Maybe Ef knows of it. It has
>been published . Joe C
>
>babycatchers@aol.com wrote:
>> I wanted to see if any of you had any ideas on a case that we have now.
>>
>> For those of you who do not know, I am a CNM in practice (5 Years) with
>> 2 OB/GYNS in a small rural hospital.
>>
>> 26 yo G3 P2 35 5/7 weeks. 3rd pregnancy in 5 years.
>> First 2 pregnancies she was anemic, but not severely. On PNV, FE, folic
>> acid and vit C. This pregnancy she has been anemic, but holding at
>> about 10. Then about a month ago her hgb tanked and she started having
>> bizarre symptoms.
>> About 3 weeks ago she started having intermittent one sided numbness,
>> slurred speech, confusion, disorientation and headaches. She would have
>> an 'attack' that would last a couple of hours and then she would be
>> fine. She said that she could 'sleep it off'. My first thought was
>> migraines, but that doesn't explain the other symptoms. I was alone in
>> the office that day.
>> I called ER and the ER doc thought it was a panic attack and to have
>> her come in when she had symptoms. In the office PEARL, grips equal
>> bilat, symmetric movement, A & OX3, reflexes 2+, neg Babinski, HR 90s, R
>> rate 30s, BP 92/50.(This is not THAT kind of patient). When she went
>> into the ER about 3 days later, they diagnosed it as 'hyperventilation'
>> and let her go home. Saw our OB that Thursday and was fine.
>> On Friday afternoon she was found unconscious on her living room floor.
>> No real idea of how long she had been there with the 2 other kids in the
>> house. She was brought here- unresponsive to pain/anything- CT neg. We
>> flew her out to the University Center. She was unconscious for about 30
>> hours and then gradually started to wake up. They did a repeat CT
>> (without contrast), labs and they tried to do an MRI which failed- for
>> whatever reason.
>> Hgb there was 6 something. They thought the neuro symptoms were 'complex
>> partial migraines"- has anyone heard of such an animal?
>> They sent her back to us last week to get 3 time a week IV FE infusion
>> and monitoring. Baby is doing good- so far.
>>
>> I did the infusion last night because outpatient refused to do it
>> because she is pregnant and the OB nurses needed some reassurance before
>> they would do it on their own. The Hgb was 8.1, MCV was 32, and plt 161,
>> WBC 11.4. The diff showed tear drop shaped cells, ovoid shaped cells and
>> another one I can't remember.
>> The OBs and I have discussed it and they like to know what you guys
>> think about some of these strange things.
>> Theory #1- Two separate problems that the pregnancy stressed her body
>> enough to bring out symptoms this time.
>> Theory #2- one of the funk-y thalasemia things that may have induced
>> some vasulititis.
>> Theory #3- well, we haven't really gotten there yet.
>>
>> She is to follow up with the Hematologist this week, but they want us to
>> deliver her.
>> The last time they sent one of these unknown patients back, she had a
>> seizure at delivery and we had to chopper her back up there. That was
>> about 2 months ago, so we are a little gun shy.
>> Naturally she wants me for delivery. I delivered the other ones. The OB
>> doesn't have a problem sitting at the desk and waiting in case anything
>> happens, but I just want to know what to be ready for.
>>
>> Thanks for your ideas.
>> Vicki
>>
>> Vicki Smith, CNM, MSN
>> West Virginia
>> Changing the world one baby at a time.
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