4. Normal physiology & structure of Hb
Globular protein contain Heme + Globin
▶ Accounts for > 95% of protein in RBC
▶ Main functions: transportation of respiratory gases. It carries ~ 98.5% of all O2
▶ Concentration of Hb in the Blood: Measured as g/dl (grams per deciliter, or
per 100 ml)
▶ Average values:
▶ Male: 14-18 g/dl
▶ Female: 12-16 g/dl
▶ Infants: 14-20 g/dl
5. Haematological indices
▶ Mean corpuscular volume (MCV): The average size of the red blood cells
expressed in femtoliters (fl).
▶ Normal value: 80-95 femtoliters (10-15 liters) abbreviated fl.
▶ - Macrocytic anemias– larger than normal cells
▶ - Normocytic anemia (MCV = 80-95 fl) – cells are normal in volume.
▶ - Microcytic anemias– cells are smaller than normal.
▶ Mean corpuscular Hb (MCH):
▶ The average amount of hemoglobin inside a RBC expressed in picograms (pg).
▶ Normal value: 27-33 pg (10-12 gram)
▶ - Normochromic
▶ - Hypochromic
▶ - Hyperchromic
7. Metabolism of iron
(Adapted from Bothwell TH,
Charlton RW, Cook JD, Finch
CA: In Iron Metabolism in Man.
Oxford, UK: Blackwell Scientific,
1979, p 24.)
10. Fate of Components of Heme
Source: Dr.Ahmed Alshafei Lecture
• Iron(Fe+3)
▶ - transported in blood attached to transferrin protein
▶ - stored in liver
▶ * attached to ferritin or hemosiderin protein
▶ - in bone marrow, iron is used for hemoglobin synthesis
• Biliverdin (green) is converted to bilirubin (yellow)
▶ - bilirubin is secreted by liver into bile
▶ * converted to urobilinogen then stercobilin (brown
feces) by bacteria of large intestine
pigment in
▶ * if urobilinogen is reabsorbed from intestines into blood is
converted to a yellow pigment, urobilin and excreted in urine
12. Definition of IDA
▶ Anemia is defined as a reduction in the oxygen-carrying capacity of
the blood caused by a diminished erythrocyte mass.
▶ Iron deficiency anemia develops when body stores of iron drop too low
to support normal red blood cell (RBC) production. Inadequate dietary
iron, iron absorption, bleeding, or loss of body iron in the urine may
be the cause.
▶ HGB<13.5 g/dL (men) <12 (women)
▶ HCT<41% (men) <36 (women)
▶ a ferritin concentration of more than 100 ng/mL (100 mg/L)
effectively rules out iron deficiency, and a ferritin of less than 15
ng/mL (15 mg/L) rules in iron deficiency.
▶ More common in women as a result of menstrual losses
14. RFs of IDA in Pregnancy
▶ Pregnant with more than one child
▶ Two pregnancies close together
▶ Vomiting a lot because of morning sickness
▶ Teenager who is pregnant
▶ Not enough foods that are rich in iron
▶ Heavy periods before pregnancy
Source : http://www.webmd.com/baby/guide/anemia-in-pregnancy
19. S & S
▶ Symptoms of anemia (eg, easy fatigability, tachycardia,
palpitations and tachypnea on exertion)
▶ Skin and mucosal changes (eg, smooth tongue, brittle
nails, spooning of nails [koilonychia], and cheilosis) in
severe iron deficiency
▶ Dysphagia resulting from esophageal webs (Plummer-
Vinson syndrome) may occur in severe iron deficiency
▶ Pica (ie, craving for specific foods [eg, ice chips, lettuce]
often not rich in iron) is frequent
Source: Chapter 103. Iron Deficiency and Other Hypoproliferative Anemias
21. Investigations
Useful tests include the following:
▶ Complete blood count
▶ Peripheral blood smear
▶ Serum iron, total iron-binding capacity (TIBC), and serum ferritin
▶ Evaluation for hemosiderinuria, hemoglobinuria, and pulmonary hemosiderosis
▶ Hemoglobin electrophoresis and measurement of hemoglobin A2 and fetal
hemoglobin
▶ Reticulocyte hemoglobin content
Source: http://emedicine.medscape.com/article/202333-overview
22. Investigations
Tests useful for establishing the etiology of iron deficiency anemia and excluding
or establishing a diagnosis of another microcytic anemia include the following:
▶ Stool testing
▶ Incubated osmotic fragility testing
▶ Measurement of lead in tissue
▶ Bone marrow aspiration
Source: http://emedicine.medscape.com/article/202333-overview
23. Investigations
CBC results in iron deficiency anemia include the following:
▶ Low mean corpuscular volume (MCV)
▶ Low mean corpuscular hemoglobin concentration (MCHC)
▶ Elevated platelet count (>450,000/µL) in many cases
▶ Normal or elevated white blood cell count
Source: http://emedicine.medscape.com/article/202333-overview
24. Investigations
Peripheral smear results in iron deficiency anemia are as follows:
▶ RBCs are microcytic and hypochromic in chronic cases
▶ Platelets usually are increased
▶ In contrast to thalassemia, target cells are usually not present, and
anisocytosis and poikilocytosis are not marked
▶ In contrast to hemoglobin C disorders, intraerythrocytic crystals are not seen
Source: http://emedicine.medscape.com/article/202333-overview
25. Investigations
Results of iron studies are as follows:
▶ Low serum iron and ferritin levels with an elevated TIBC are diagnostic of iron
deficiency
▶ A normal serum ferritin can be seen in patients who are deficient in iron and
have coexistent diseases (eg, hepatitis or anemia of chronic disorders)
Source: http://emedicine.medscape.com/article/202333-overview
27. Management
▶ Symptomatic elderly patients with severe iron-deficiency anemia and
cardiovascular instability may require red cell transfusions.
▶ Younger individuals can be treated more conservatively with iron replacement.
▶ For the majority of cases of iron deficiency (pregnant women, growing children
and adolescents, patients with infrequent episodes of bleeding, and those with
inadequate dietary intake of iron), oral iron therapy will suffice. For patients with
unusual blood loss or malabsorption, specific diagnostic tests and appropriate
therapy take priority. Once the diagnosis of iron-deficiency anemia and its cause is
made, There are three major therapeutic approaches.
1 RED CELL TRANSFUSION:
2 ORAL IRON THERAPY
3PARENTERAL IRON THERAPY: saccharated ferric oxide (SFO) and cideferron (CF), for
those who are not tolerated with oral iron therapy.
Source: Harrison’s Principles of Internal Medicine 17th edition
29. Complications
▶ Effects of Anemia in Pregnant Women
Pregnant women with significant anemia may have an increased risk for poor pregnancy outcomes,
particularly if they are anemic in the first trimester.
▶ Complications from Anemia in Children and Adolescents
In children, severe anemia can impair growth and motor and mental development. Children may
exhibit a shortened attention span and decreased alertness. Children with severe iron-deficiency
anemia may also have an increased risk for stroke.
▶ Effects of Anemia in the Elderly
Anemia is common in older people and can have significantly more severe complications than
anemia in younger adults. Effects of anemia in the elderly include decreased strength and increased
risk for falls. Anemia may have adverse effects on the heart and increase the severity of cardiac
conditions, including reducing survival rates from heart failure and heart attacks. Even mild anemia
may possibly lead to cognitive impairment or worsen existing dementia.
▶ Iron Overload
Source: http://www.umm.edu/patiented/articles/what_symptoms_of_anemia_000057_4.htm#ixzz2P9eHzfYJ
31. Prevention
Good food sources of iron include the following:
▶ Meats--beef, pork, lamb, liver, and other organ meats
▶ Poultry--chicken, duck, turkey, liver (especially dark meat)
▶ Fish--shellfish, including clams, mussels, oysters, sardines, and anchovies
▶ Leafy greens of the cabbage family, such as broccoli, kale, turnip greens, and
collards
▶ Legumes, such as lima beans and green peas; dry beans and peas, such as
pinto beans, black-eyed peas, and canned baked beans
▶ Yeast-leavened whole-wheat bread and rolls
▶ Iron-enriched white bread, pasta, rice, and cereals
Source: https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P02428
32. Prevention
Vitamin supplements containing at least 400 micrograms of folic acid are now
recommended for all women of childbearing age and during pregnancy. Food
sources of folate include the following:
▶ Leafy, dark green vegetables
▶ Dried beans and peas
▶ Citrus fruits and juices and most berries
▶ Fortified breakfast cereals
▶ Enriched grain products
Source: https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P02428
34. Differential Diagnosis
Microcytic anemia resulting from other causes
▶ Thalassemia
▶ Anemia of chronic disease
▶ Sideroblastic anemia
▶ Lead poisoning
Source: Quick Medical Diagnosis & Treatment Book
