Dr Zhuo Lin Ng1, Dr Adam Morton1
1Mater Hospital Obstetric Medicine Department, Brisbane, Australia
Biography:
Dr Zhuo Lin Ng (Jolene) is a nephrology fellow who is currently pursuing her obstetric medicine fellowship / SOMANZ certification in Brisbane, QLD Australia.
Abstract:
Erythropoeitin (EPO) levels rise 2-4-fold in pregnancy as a physiological compensatory rise to stimulate red cell mass in response to the increase in plasma volume. EPO resistance or hypo-response is well described in pregnancy, as well as in chronic kidney disease, and other conditions with normal renal function including nephrotic range proteinuria, congestive cardiac failure, active autoimmune or inflammatory states, autonomic neuropathy, restrictive eating disorders and cyclosporin therapy in non-pregnant individuals.1
We report a case of a 28-year-old primigravida with multifactorial anaemia characterized by both reduced erythropoietin production and response requiring erythropoietin stimulating agent (ESA) supplementation during pregnancy. Her past medical history was significant for poorly controlled type 1 diabetes mellitus diagnosed at age 15 (early pregnancy HBa1c 9.7%) complicated by autonomic neuropathy, nephropathy, hypothyroidism, coeliac disease, and chronic hypertension.
The woman developed intractable nausea and vomiting which progressively worsened in second trimester secondary to gastroparesis. Inadequate oral intake and medication intolerance necessitated a nasojejunal tube at week 30. She subsequently developed superimposed pre-eclampsia at 32 weeks gestation with fetal growth restriction.
Haemoglobin fluctuated between 82-88 g/L with negative haemolytic screen, normal B12 and folate and urine protein:creatinine ratio 227 mg/mmol following IV 2000 mg ferric carboxymaltose therapy administered 2 weeks earlier. Serum EPO level was 17.4 mIU/L, lower than the level predicted for the degree of anaemia in a non-pregnant individual (normal range 43.3-242IU/l) 2. Darbepoietin Alfa 40 mcg subcutaneous weekly was commenced with limited response. Haemoglobin at time of delivery at 35 weeks + 2 days gestation was 91 g/L.
Previous case reports have described reduced EPO levels in pregnancy with mildly abnormal renal function.3 ESA therapy is a useful adjunct in the management of maternal anaemia to reduce need for blood transfusions, though its efficacy may be limited in inflammatory and chronic cardiorenal conditions.
Keywords
anaemia, erythropoeitin
References
1. Ahn SH and Garewal HS. Low erythropoietin level can cause anemia in patients without advanced renal failure. Am J Med 2004; 116: 280-281. 2004/02/19. DOI: 10.1016/j.amjmed.2003.09.047.
2. Vogeser M and Schiel X. Serum erythropoietin concentrations in patients with anemia–preliminary hemoglobin-related reference ranges. Clin Lab 2002; 48: 595-598. 2002/12/06.
3. Morton A. Absent erythropoietin response to anaemia with mild to moderate chronic kidney disease in pregnancy. Nephrology (Carlton) 2021; 26: 205. 2020/09/08. DOI: 10.1111/nep.13779.