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Anemia

Anemia is common among women, in both the obstetric and the primary care settings. It is not a disease in and of itself, but it indicates the presence of an underlying disorder, such as an occult malignancy, nutritional deficiency, or bleeding, that must be sought out.

Anemia is a decline in erythrocyte mass from any etiology and is generally defined as a hematocrit or hemoglobin value that is two standard deviations below the mean for a given population. Specifically, in women, a hemoglobin value less than 12 g/dL (or less than approximately 11 g/dL in pregnancy) is generally considered consistent.

Detection and Screening

Anemia may be detected by screening asymptomatic patients or by diagnosing those presenting with signs and symptoms. Symptoms arise from tissue hypoxia and compensatory adjustments of the cardiopulmonary system.

Recommendations for screening asymptomatic women vary. The American College of Obstetricians and Gynecologists recommends hemoglobin testing for high-risk groups of all ages. Recent Centers for Disease Control and Prevention recommendations include screening nonpreg-nant women of childbearing age every 5-10 years in the absence of risk factors or annually if risk factors exist. Risk factors include vegetarian or fad diets, adolescence, menorrhagia and other bleeding (eg, postoperative, postpartum), low socioeconomic status, alcohol abuse, a history of a chronic illness or gastrectomy, or a history of closely spaced and multiple pregnancies. The U.S. Preventive Services Task Force recommends screening in pregnancy only. In pregnancy, the American College of Obstetricians and Gynecologists suggests a complete blood count and determination of the mean corpuscular volume for patients who are at increased risk for a and beta thalassemia. If the mean corpuscular volume is abnormally low in the absence of iron deficiency, hemoglobin electrophoresis should be performed; if this test excludes the diagnosis of [3 thalassemia, performance of a DNA probe may be required to evaluate for a thalassemia.

For women of childbearing age only, the presumptive diagnosis of iron deficiency can be made in the absence of factors suggesting other causes, and therapy with 60-120 mg/d of elemental iron can be initiated. However, if the hemoglobin value is less than 9 g/dL at the time of diagnosis, or if after 4 weeks of therapy there is no response.

Microcytic Anemias

Iron-Deficiency Anemia

Iron deficiency is estimated to affect 11% of reproductive-age women. In 50% of these women, the deficiency is enough to make them anemic. In pregnancy, as many as one third of women may have iron deficiency by the third trimester. Its presence reflects a dietary deficiency, malab-sorption, or excess loss of iron and mandates a search for the underlying cause. Among postmenopausal women, the presence of an occult (gastrointestinal) malignancy must be

Thalassemia

Normal hemoglobin consists of two pairs of polypeptide (globin) chains attached to a heme. Diminished production of one of the major globin chains results in thalassemia, an inherited spectrum of disorders ranging from subtle erythrocyte changes to life-threatening disease.

b-Thalassemia predominantly affects people of Mediterranean, African, Southeast Asian, Hispanic, Indian, Pakistani, 

Macrocytic Anemias

Anemias that are associated with macrocytosis (a mean corpuscular volume of >100 fL) include those from liver disease, alcoholism, hypothyroidism, certain drug exposures, megaloblastic anemia, myelodysplasias, preleukemia, or 

Megaloblastic Anemias

Megaloblastic anemias are typically associated with either B12 or folate deficiency. B12 deficiency rarely results from poor dietary intake, except in vegans, because sources are ubiquitous and storage is prolonged. More commonly, it is because of altered coupling with intrinsic factor (ie, pernicious anemia or gastrectomy), impaired transport to the ileum because of bacterial overgrowth or parasites, or malabsorption because of ileitis or ileal resection. Presenting 

Sickle Cell Disorders

In contrast to thalassemia syndromes, which result from a quantitative defect in globin synthesis, sickling disorders are qualitative disorders that result in increased erythrocyte rigidity and formation of "sickled" cells under conditions of decreased oxygen tension. The heterozygous state (hemoglobin AS or trait) usually is not associated with symptoms

Anemia of Chronic Disease

Anemia of chronic disease is seen in association with a variety of disease states, especially chronic renal disease and connective tissue disease. It is best treated by control of the underlying disorder. Anemia associated with renal

Coagulopathies

Bleeding Diatheses

An evaluation for a bleeding disorder may be indicated in situations such as menorrhagia, easy bruising, or otherwise-unexplained obstetric or surgical hemorrhage. A recent study revealed the incidence of an inherited bleeding disorder to be 17% in women with menorrhagia and a normal pelvic examination. A careful history and physical examination may help elucidate the cause of abnormal bleeding. Attention should be directed to prior

Predisposition to Thrombosis

The term "thrombophilia" refers to a predisposition for thrombosis as a result of defined familial or acquired disorders of hemostasis regulation. It is important to recognize the presence of such conditions to provide appropriate prevention and treatment for the patient, as well as for asymptomatic relatives. Patients with thrombosis and no easy explanation for its occurrence must be evaluated for an inherited defect of a coagulation factor. Hereditary disorders include the factor V Leiden mutation (causing activated protein C resistance); protein C, S, and antithrombin III