Dr Sagun Banjade1, Dr Jessica Gehlert
1Flinders Medical Centre
Biography:
I am Sagun Banjade who is Obstetric Medicine Registrar at Flinders Medical Centre. I have completed FRACP in General Medicine and looking at enhancing my knowledge and skills in looking after women in their pregnancy.
Abstract:
Pregnancy induced haemolytic anaemia is a rare condition that can be diagnosed when all other causes of haemolysis have been excluded in the gravid state and resolves postpartum. Adverse pregnancy outcomes are often related to presentation in first and second trimester and lower haemoglobin (Hb) nadir [1-3].
We present a case of haemolytic anaemia during a woman’s third pregnancy; first pregnancy was complicated by PET/HELLP and second pregnancy by anaemia, with no clear rise in markers of haemolysis. During this pregnancy, she presented in third trimester (31/40) with symptoms of anaemia with Hb nadir of 77 g/L. This was macrocytic anaemia with macrocytosis worsening as the pregnancy progressed (98.4 – 110.3fL). Further markers of haemolysis included undetectable haptoglobin, elevated LDH (peak 289 U/L) and reticulocytosis (149 x 10^9/L – 232x 10^9/L). Blood film showed macrocytosis and occasional nucleated red cells. Bilirubin was persistently normal (< 3 – 3 µmol/L). Direct Antiglobulin Test was negative. Investigations of anaemia included initial iron deficiency (ferritin 29ug/L) which responded to oral replacement, normal active B12, normal folate, normal ADAMTS 13 and negative autoimmune screen. She required 2 units of packed red blood cells transfusion to maintain Hb above 75. A month after blood transfusion, Hb started reducing with concurrent decrease in haptoglobin. She developed acute kidney injury with peak Creatinine of 91 µmol/L. She was treated with Prednisolone 25 mg daily and her Hb stabilised at 86g/L before delivery. Post delivery her prednisolone was ceased. There was an initial drop in Hb to the nadir of 71g/L but has continued to improve with most recent Hb of 88g/L (Day 8 PostNatal). Haptoglobin has normalised and reticulocyte count is improving. Renal function has normalised.
Prompt recognition and work up of haemolytic anaemia in pregnancy is important. Treatment with steroids is likely to improve maternal/fetal outcomes.
Keywords
Haemolytic anaemia, low haptoglobin
References
1. Murakhovskaya I, Anampa J, Nguyen H, Sadler V, Billett HH. Pregnancy-associated autoimmune hemolytic anemia: meta-analysis of clinical characteristics, maternal and neonatal outcomes. Blood. 2021 Nov 23;138:1959.
2. Gupta M, Kala M, Kumar S, Singh G, Chhabra S, Sen R. Idiopathic hemolytic anemia of pregnancy: a diagnostic dilemma. Journal of Hematology. 2015 Jan 4;3(4):118-20.
3. Fattizzo B, Bortolotti M, Fantini NN, Glenthøj A, Michel M, Napolitano M, Raso S, Chen F, McDonald V, Murakhovskaya I, Vos JM. Autoimmune hemolytic anemia during pregnancy and puerperium: an international multicenter experience. Blood. 2023 Apr 20;141(16):2016-21.