Interpret Anemia Lecture Notes 2023-2024 PDF
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Helwan University
2024
Shady Estfanous
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Summary
These lecture notes cover the topic of interpreting anemia. It provides information about signs and symptoms, diagnosis, and treatment. The material is suitable for fourth-level pharmacy undergraduate students at Helwan University, 2023-2024 academic year. These notes may also be useful for medical professionals seeking review notes.
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# Interpret Anemia ## "This is the day that the LORD has made; let us rejoice and be glad in it." Psalm 118:24 ## Theoretical Part (Lecture 2) **For Pharm D Undergraduate** **Fourth Level Pharmacy Students** **2023-2024** *Shady Estfanous, Msc., PhD Lecturer, Biochemistry and Molecular Biology...
# Interpret Anemia ## "This is the day that the LORD has made; let us rejoice and be glad in it." Psalm 118:24 ## Theoretical Part (Lecture 2) **For Pharm D Undergraduate** **Fourth Level Pharmacy Students** **2023-2024** *Shady Estfanous, Msc., PhD Lecturer, Biochemistry and Molecular Biology Faculty of Pharmacy, Helwan University* *[email protected] +201285315688* ## Signs and Symptoms 1. Asymptomatic 2. Tachypnea * > 20 respirations in 1 minute * 13 respirations in 30 seconds 3. Dyspnea on Exertion 4. Paller of nails and conjunctivae * An image of two children with pale nails and conjunctivae 5. Lack of concentration * An image of a boy writing on a table, looking tired and distracted 6. Easily Fatiguability * An image of a young woman sleeping ## How to diagnose Anemia from CBC ? | | Ref. Range | Ref. Range | Unit | | |---|---|---|---|---| | Haemoglobin | 11.5-16 | 13-17 | g/dl | | | Hematocrit | 34-44 | 40-50 | % | | | Red cell count | 3.8-5.4 | 4.5-6.2 | x10<sup>6</sup>/uL | | | MCV | 78-96 | 78-96 | fL | **Mean Corpuscular Volume (MCV):** average volume each RBC | | MCH | 26-32 | 26-32 | pg | **Mean Corpuscular Hemoglobin (MCH):** average amount of Hb in each RBC | | MCHC | 31-36 | 31-36 | g/dL | **Mean Corpuscular Hemoglobin Conc. (MCHC):** average conc of Hb in each RBC | | RDW | 11.5-14.5 | 11.5-14.5 | % | | | Platelet Count | 150-450 | 150-450 | x10<sup>3</sup>/uL | | | T.L.C | 4-11 | 4-11 | x10<sup>3</sup>/uL | | * ↓Hgb, ↓Hct, ↓RBC Symptoms: Fatigue, vertigo, breath shortness, chest pain, palpitation, Pale appearance* **RBC indices measure the size, shape, and quality of RBC.** **RBC distribution width (RDW):** %size variation between RBC ## RBC Indices * **MCH = Hb (g/dL) x 10 / RBC count (millions/mm<sup>3</sup>)** * **MCHC = Hb (g/dL) x 100 / Hct%** * **MCV = Hct% x 10 / RBC count (millions/mm<sup>3</sup>)** ## For Leisure **When Hb is normal** **Rule of Three can be used to determine if the pt is overhydrated or dehydrated?** * **Multiply Hb by 3** * < Hct ± 3 Dehydrated * = Hct ± 3 Normal * >Hct ± 3 Overhydrated ## Classify Anemia according MCV (80-100) - <80 Microcytic Anemia - 80-100 Normocytic Anemia - >100 Macrocytic Anemia ## Classify Anemia according MCV (<80fL) ### Iron Deficiency Anemia (IDA) #### Fe Metabolism: Iron Law | | First Rule | Second Rule | Third Rule | Fourth Rule | |---|---|---|---|---| | | Fe Not always Friendly | Not found alone inside body | Body always carry, transform iron in Ferric form | To transfer across membranes must be in ferrous form | | | Excess leads to free radicals | But bonds to protein (Hgb, transferrin, ferritin, haptoglobin,...) | Except Hgb ferrous form (one pocket empty to carry O2) | So oxidized Hgb (Methemoglobin) is danger | | | Fe+3 + O-- ↔ Fe+2 + O2 | | | | #### Fe in Food - Non-heme Fe+3 * Duodenal cytochrome b (Dcytb) * Ca (Milk) * Tannins * Vit C * Citrus (acid liberate fe+3) - heme Fe+2 * Animal-based foods - Beef, liver, chicken, turkey, duck, shrimp * Heme carrier protein 1 * FLVCR * Heme-Fe carrier (Hemopexin) * By heme oxidase * Heme Fe Absorption → 15-35%. * Non-heme iron → 2-20%. * Heme Fe gives red meats their characteristic color * Non-heme Fe is not associated with specific food colors. #### Fe Storage: | | Ferritin | Hemosiderin | |---|---|---| | | Circulates in blood in small amount | Do Not circulates | | | Present in all tissues cell → Majority of iron store → Easily available for HgB synthesis | Present in macrophages of RES → Minority of Fe stores → Less available for Hgb synthesis | | | Fe content (20%)(4500 Fe/ molecule)→ Colorless and unstainable | Fe content (37%) →Positive Fe Stain | | | Water soluble conjugated protein | Water insoluble Fe-protein complex | #### Fe Metabolism: 1. Fe+3 Bloodstream * Not sensitive, High False-ve 2. Total iron-binding capacity (TIBC) 250-380μg% 250-450μg% * Amount of Fe available to be attached to TF * Indirectly measurement of TF (Xss Fe → adsorbed Mg hydroxy carbonate) * Add Xss fe→ remove unbound → det. Fe conc 3. Transferrin Saturation 15-50% 12-45% * Amount of Fe bound to TF as % 4. Ferritin 24-336µg/L 11-307µg/L * Storage form of Fe in body, Each molecule store 4000 Fe atom * +ve Acute phase reactants sequesters Fe to reduce that available to tumor cells or pathogens Non-Specifically elevated in inflammation #### Fe Metabolism: * Body not posses any mechanisms for removing Fe But Recycling * Means of Fe loss: blood loss, menstruation, shed intestinal cells, Sweat * An image showing a detailed schematic of iron metabolism in humans. #### Fe Metabolism: * Pt who need frequent blood transfusion → Fe overload → ↑hepcidin → Fe unload from ferritin → accumulate in different organs cause organ damage in form called **hemosiderin** * TTT by **Fe-chelating agent** as **Deferoxamine** * Desferal® * An image of the Deferoxamine drug. #### Causes: * Inadequate intake→ PUD, hernia, gastritis as in aspirin & NSAID use * ↑Fe requirement as in Pregnancy, Blood loss as in mensuration. #### Labs: * **RDW ↑** Anisocytosis * **Serum Fe ↓** * **% Saturation ↓** * **TIBC ↑** * **Ferritin ↓** #### Labs * An image of the transferrin which is a protein that binds to iron in the blood. * Normal Transferrin * ↑ TF with ↓ Fe * An image of a red blood cell with iron (Fe) bound to transferrin. ## Specific Manifestation of IDA * flattened, concave, spoon like shape (koilonychia) * An image of a hand showing a flattened, concave spoon like shape * dry, brittle, and split easily. (Onychoschizia) * An image of a hand with dry, brittle, and split nails * Brittle hair * An image of a hand with brittle hair * Smooth thin tongue * An image of a woman sticking out her tongue which is smooth and thin. * Atrophic Glossitis * An image of a woman sticking out her tongue which is smooth and thin. * Angular stomaitis * An image of a woman's mouth showing angular cheilitis or angular stomatitis * 16% Pagophagia= Ice craving → Type of pica (desire to eat non-nutritional items such as dirt or paper). * An image of a child eating ice * help people to feel more alert & mentally sharp * Restless legs syndrome * An image of a pair of legs doing nighttime twitching * Fall in dopamine → urge to move or shake the legs to find relief especially at night. * An image of a person having a tic, particularly in one leg. ## For Leisure | | BRITTLE NAILS | NAIL PITS, DEPRESSIONS | HORIZONTAL RIDGES | VERTICAL RIDGES | YELLOW NAILS | PALE NAILS || UNEVEN RED LINES | BLACK LINES UNDER NAILS | NAIL CLUBBING | |---|---|---|---|---|---|---|---|---|---|---|---| | | * poor nutrition, especially low vitamin A, vitamin C or biotin hypothyroidism* | * psoriasis, alopecia, areata, داء الثعلبة* | * zinc deficiency, diabetes, kidney conditions * | * common with aging, iron deficiency anemia* | *diabetes, hypothyroidism, psoriasis, nail fungus*| * anemia, metabolic disorders* | | *lupus, connective tissue disease* | *result of injury, endocarditis, melanoma* | *CVS Dz, inflammatory bowel disease, liver diseases, pulmonary diseases, AIDS* | | **Image** | An image of a finger nail with brittle edges. | An image of a finger nail with nail pits, depressions. | An image of a finger nail with horizontal ridges. | An image of a finger nail with vertical ridges. | An image of a finger nail with yellow color. | An image of a pale finger nail. | | An image of red finger nail with uneven red lines. | An image of a black line underneath a finger nail. | An image of a finger nail with Nail Clubbing. | ## Main Treatment "**معرفه السبب اهم من العلاج ؟؟؟ انا عندى انيميا ليه ؟؟؟؟**" *Treat Main etiology→ Menorrhagia, Meterohagia, Blood Loss, malabsorption (Celiac dz)* #### مثال 1: * Pt with CBC clinical features of IDA * & with high eosinophile count in WBC differential count * Anklystoma (Hookworm) * ttt by : Mebendazole or Albendazole * An image of a children's medication called Bendax. * An image of a children's medication called Verm. * An image of a person using a syringe. This is probably an image of a nurse administering medicine. #### مثال 2: * Pt with CBC clinical features of IDA & ↓ in plt count & ↑↑↑ in WBC * Afraid from Leukemia (BM cancer) #### مثال 3: * Pt with CBC clinical features of IDA & ↓ in plt count & ↑or ↓ lymphocytes (WBC) * Aplastic anemia or Lymphoma (lymphatic system cancer) #### مثال 4: * Pt with CBC clinical features of IDA & did gastric bypass, gastric sleeve (achlorhydria) * Not treated with oral iron supplements #### مثال 4: * Old menopause ♀ Pt with CBC clinical features of IDA & has mensural bleeding * Afraid from Uterine or cervix cancer #### مثال 5 : * Old ở Pt with CBC clinical features of IDA & has decrease in body wight severely * Afraid from colon or stomach cancer #### مثال 6: * Pt with CBC clinical features of IDA & has hepatocellular carcinoma (HCC) * Afraid from esophageal Varices دوالى المريء #### مثال 7: * Pt with CBC clinical features of IDA & may has blood loss as in (hemorrhoids بوصير , inflammatory bowl disease) * FOBT = Faecal Occult Blood Test= Most commonly used test for bowel cancer screening=can↑↑ in hemorrhoids, Ulcers, crohn disease. * For Leisure: Fecal Calprotectin=produced by neutrophils so used to differentiate between inflammatory & non-inflammatory bowel disease #### مثال 7: * An image of a commercial home fecal occult blood test called ScheBo M2-PK Quick. ## Main Treatment * Mild Anemia * Hgb ≥ 10 gm% * Oral Fe Supplements * Moderate Anemia * Hgb ≥ 8 gm% * Parenteral (IM or IV) * Severe Anemia * Hgb < 8 gm% * Decompensated Anemia * Hgb < 4 gm% * PRBC transfusion *Iron supplement → Not only correct anemia but build up Fe stores. Total amount of Oral Fe need (mg)= Body weight \* Fe deficit Maximum dose per day = 200mg divided in 2 or 3 doses Take with orange or lemon juice & Avoid Tannins Ca++* **Example:** IDA 70Kg with Hgb 8 → Fe need= 70 \* (14-8) \* 4.4 = 1540 mg ## Main Treatment * **Oral Fe Supplements** * **FEROSE-F** * An image of a drug called FEROSE-F. * **Ferrous sulphate.... 150 mg** (*≈ elemental Iron... 47 mg*) * An image of a drug called Hæma-Caps. * **Ferrous Fumarate tab 350 mg** (*≈ 115 mg elemental iron*) * An image of a drug called FEROSAC. * An image of a drug with the description: "بيعمل امساك جامد" * **Parenteral Supplements** * **Haemojet** * An image of a drug called Haemojet * **CosmoFer®** * An image of a drug called CosmoFer. * An image of a drug called Iron(III)-hydroxide dextran complex * **IV administration** * Iron Dextran ONLY CAN BE given BOTH IV & IM * *As any other heavy metals → very slowly only in hospital → anaphylactic shock +100 ml NS infused/3h* ## Main Treatment **In pregnant Anemic Women** * **First Trimester** → No Fe Supplementation * **Last trimester at week 28** → PRBC even if she is moderate anemic not severe * anemia ↓ blood flow to uterus | Uterine contraction ↑↑↑ risk of **Atonic Postpartum Hemorrhage** * **To follow up if the** * **Diagnosis is right** → Rets after 4 days * **Treatment is going Ok** → CBC after 2 weeks → Hgb ↑↑ by 1gm/dL * An image of a pregnant woman. ## Classify Anemia according MCV (<80fL) **2- Thalassemia (Mediterranean) انيميا البحر المتوسط** #### Causes: * **HbA →** Most Common type in adult → 2a & 2ẞ globulins. * Inherited mutation leads to defect in production of globulins **Amount** * **If in a-globulins (4gene)→** a-Thalessemia →Less Common * **If in B-globulins (2gene)→** B-Thalessemia →More Common autosomal recessive (Minor&Major). * **Xss a-globulins→** No stable tetramers→ precipitate→ premature cell death. #### Labs: * **ΔΔ with IDA ** * **Confirmatory Test** **Electrophoresis** * **RDW ↑** * **History ↑** * **Treatment** * **Mentzer's index (MI)=MCV/RBC (in millions)** * **Thalassemia <13** * **BUT IN IDA >13** * Continuous blood transfusion or BM transplant ## Classify Anemia according MCV (< 80fL) **3- Anemia Chronic Disease ACD ** #### Causes: * Patient with long time inflammatory disease (malignancy, infections, DM, RA, Cancer, * Endocrine disorders (Hypo (thyroidism, adrenalism, gonadism)) * Inflammatory cytokines (IL-6, IL-10, TNF-α) → ↓ Fe homeostasis #### Labs: * **RDW ↔** * **Serum Fe ↓** * **Hepcidin ↑** * **History ↑** * **% Saturation ↓** * **TIBC ↑** * **Ferritin ↑** * **TTT: ** * Underlining condition * Parenteral iron * Parenteral EPO * **TF with ↓ Fe** * An image of a red blood cell with iron (Fe) bound to transferrin. ## Classify Anemia according MCV (<80fL) **4- Sideroblastic Anemia** #### Causes: * Accumulation of Fe in RBC mainly * Acquired: Lead poisoning Alcoholism Vit B6 Pyridoxine deficiency * As all interfere with heme synthesis →↑ Fe accumulation * Congenital inherited (less common) →**X-linked recessive** in **ALA synthase (PLP cofactor)** * "الدهانات القديمة معموله من الرصاص في البيوت القديمة" * ***ttt BAL dimercaprol*** #### Confirmatory Tests: * **Blood Pb level** * **PBS (Peripheral Blood Smear)** #### Labs: * **RDW ↑** * **% Saturation ↑** * **Serum Fe ↑** * **Ferritin ↑** * **TIBC ↓** * **Basophilic Stippling التنقير** * **Sideroblasts >5granules** * **RNA staining Not specific** * **Fe staining Prussian blue Must confirm in BM biopsy** ## Classify Anemia according MCV (>100) **Macrocytic Anemia Megaloblastic Anemia** * **Store last 3-5 yrs** * **Vit B12 (Cobalamin) Deficiency in** #### Why? * **Absorption need intrinsic Factor (IF)** * produced by Parietal cells & acid to liberate * **Malabsorption as in gastritis, Bariatric Surgery جراحات السمنه** * **Ab # IF or parietal cells (Pernicious anemia)** * An image of a drug box containing Vitamin B12. * An image of a drug box containing Methyltechno, a brand of cyanocobalamin medicine. * An image of a drug box containing Depovit B12, a brand of Vitamin B12 medicine. #### Defect in DNA Synthesis * ↑liver disease progression * **Store last 4 months** * **Folic Acid (Vit B9)** * **Methotrexate MTX** * **Trimethoprim** * **Both Folic acid antagonist** * **Animal & diary products** * **Inadequate intake** * ↑ demands * **Green Leafy fresh Vegetables** * **Pregnancy** * "نص جرام يوميا في اول 3 شهور الحمل " ## Classify Anemia according MCV (>100) **Vit B12 (Cobalamin) Macrocytic Anemia Folic Acid (Vit B9)** **How to differentiate between them?** * **Serum conc → OK but not ideal due to variability in measurement methods** * **Vit 9** * **Folic Acid** * **THF** * **Vit B12** * **Protein** * **Methionine** * **SAM** * **5-Me-THF** * **Homocysteine** * **↑CVD & Thrombosis** * **Lipid** * **Methyl Malonyl Co-A (MMA)** * **☐ Vit B12** * **Succinyl Co-A** * **SAH** * **Krebs cycle** ## Classify Anemia according MCV (>100) **Vit B12 (Cobalamin) Macrocytic Anemia Folic Acid (Vit B9)** * **Confirmatory Diagnosis:** **PBS: Hypersegmented (≥ 6 lobs) neutrophils → Pathognomonic (diagnostic) to megaloblastic anemia** **How to differentiate between them ?** * **Serum conc of folic acid & Vit B12** * **Homocysteine ↑** * **Methylmalonic acid (MMA) ↔** * **Non megaloblastic Macrocytic anemia** * **Alcoholic Liver disease & Hypothyroisidsm → macrocytosis BUT NO megaloblasts but due to ↑ cholesterol content of RBC & toxic to BM precursor** ## Classify Anemia according MCV (>100) **Vit B12 (Cobalamin) Macrocytic Anemia Folic Acid (Vit B9)** * **Both** Hematological as pancytopenia & Neurological manifestation * **Only** Hematological manifestation as pancytopenia **Neurological manifestations of Vit B12:** * **3P's** * **Peripheral Neuropathy** * **Spastic paraplegia شلل نصفى تشنجي** * **posterior cord syndrome → Loss of deep sensation with delayed reflex** ## Important Note Good to Know "!!!!50% of who takes Metformin develop VitB12 deficiency!!!!!" * **Cidophage** * An image of a drug box containing Cidophage. * **CONTROLOC®** * An image of a drug box containing CONTROLOC®. * **C-Retard** * An image of a drug box containing C-Retard. * An image of a drug box containing Glucophage. * **Perloc** * An image of a drug box containing Glucophage. * **Vitacisd C** * An image of a drug box containing Vitacisd C. * **→ Interferes with Ca++dependent membrane action responsible for Vit B12 intrinsic factor absorption in the terminal ileum. ** * **→ Taking Vit B12 (1µg) & Ca++ (1gm) supplements as a preventive measure** * **VitB12 need acid medium to be absorbed → long term treatment with PPI ↓ Fe. Vit B12, Ca++** * **Vitamin C supplements. ↓ available amount of vitamin B-12 in your body → take VitC 2-3h after taking a vitamin B-12 supplement.** ## Labs help to identify the type of Anemia called "Reticulocyte Index (RI)" * **Bone marrow (Myeloid Stem Cells)** * **normalblast** * **proniormoblast** * **polychromatic erythrocyte** * **orthochromatic erythrocyte** * **reticulocyte** * **erythrocyte** * **Maturation process in bone marrow** * **Peripheral blood** * **Retic = Immature RBC that sent to bloodstream to matured within spleen within 2d** * **= Still contain rRNA that can be stained by methylene blue.** * **= determined as % of RBC** * **NV: adult: 0.5% to 2.5% infants 2% to 6%** * **↓ Production RI <3%** * “عندى انيميا و المصنع مزودش شغله ليه؟ ملحقش ولا مفيش فلوس المصنع شغال بس السوق بيبلع البضاعه فالمصنع زود الانتاج \ نشتری مواد بناء ولا واحد امر من الدوله و لا الاجهزه بتاعته بايظة” * **↑ destruction ≥3%** * **Blood loss <1 week ** * **Nutritional** * **Hormonal (EPO)** * **↓BM function** * **Blood loss > 1 week** * **Hemolysis** ## Classify Anemia according MCV (80-100) **Normocytic Anemia** * **Corrected Reticulocyte Index (RI)** * **<3%** * **Non-Regenerative Anemia** * **Non Reticulocytosis** * {{{ BM Not Response }}} * Early stage (IDA OR ACD) * ESRF (↓EPO) * Malignancy * Aplastic Anemia * **>3%** * **Regenerative Anemia** * **Reticulocytosis** * {{{ BM Response }}} * Hemolytic Disease *"بطريقة ما ... مش عليكوا ... هيصوا ©"* *"علشان تعرف ان ال normocytic دي جايه من IDA بس هي مستعبطه ومش ظاهره microcytic \ IDA غالبا أيضا normocytic hypochromic anemia لو لقيته قلي يعنى MCHC شوف )MCV80("* ## Normocytic Anemia RI>3% Hemolytic Disease * **Common Labs for any hemolytic anemia:** * **1:↑ Unconjugated (Indirect) bilirubin** * **↑ LDH2 (Lactate dehydrogenase Blood isoform)** * **↑ Free Hb in Blood → ↑Hburia → Hp prevent hemoglobinuria (Haptoglobin)** * **Hp is plasma protein produced by liver ... get rid of free Hb to loss of Fe by Hb uptake by engulfment by WBC macrophage so its level↓** ## Hemolysis disease is been confirmed but which type ??? **Immune mediated** * **Alloimmune hemolysis** * **Autoimmune hemolysis** * **Drug induced** * **Distinguished Direct Comb's Test (Direct antiglobulin test) (DAT) ??** * **Rh &/or ABO incompatibility** * An image of a vial with the description "1200000 I.U RL Retarpen AITO SANDOZ". ## Normocytic Anemia RI>3% Hemolytic Disease **Immune mediated** **Non-Immune mediated** * **Direct Coombs test / Direct antiglobulin test** * **Positive test result** * **Blood sample from a patient with immune mediated haemolytic anaemia: antibodies are shown attached to antigens on the RBC surface.** * **The patient's washed RBCs are incubated with antihuman antibodies (Coombs reagent).** * **RBCs agglutinate: antihuman antibodies form links between RBCs by binding to the human antibodies on the RBCs.** * An image shows how a Direct Coombs test is performed. * **المصيبة حصلت** * **Immune mediated hemolytic anemia** ## Note for Leisure: **المصيبة ممكن تحصل** * **Indirect Coombs test → we test for the antibodies that not bind to RBC but more likely to bind to transfused RBC** * **1- Identify the presence of anti-D after the 1st pregnancy of Rh+ mother.** * **→ If -ve test → Safe for 72 hours to give anti-Rh → Ab production.** * **Indirect Coombs test / Indirect antiglobulin test** * **Positive test result** * **Recipient's serum is obtained, containing antibodies (Ig's).** * **Donor's blood sample is added to the tube with serum.** * **Recipient's Ig's that target the donor's red blood cells form antibody-antigen complexes.** * **Anti-human Ig's (Coombs antibodies) are added to the solution.** * **Agglutination of red blood cells occurs, because human Ig's are attached to red blood cells.** * **An image of a drug called Rhophylac.** * **2- Cross Matching before blood transfusion one of blood compatibility test** ## Normocytic Anemia RI>3% Hemolytic Disease **Non-Immune mediated** * **Then Exclude disease one by one** * **1-Glucose 6P DH deficiency** * “في التناول الطعام البدائل ايراني LAVE المكي بقولك ايه يا دكتور الواد اكل فول ©©” ## Normocytic Anemia RI>3% Hemolytic Disease **Non-Immune mediated** * **Then Exclude disease one by one** * **1-Glucose 6P DH deficiency Favism انيميا الفول** * **➤ G6PDH → HMP Shunt → ↑ NADPH → regenerate glutathione (antioxidant).** * **X-linked recessive, Not fully dominant (with 1 allele ½ of her blood diseased).** * **More common in younger African American children.** * **➤ Confirmed:** * **G6P level not checked during hemolytic crisis or taking sulfa drugs (False Negative)** * **PBS: Heinz Bodies &/or Bitten cells** * **Heinz Bodies: Hb ppt in RBC** * An image shows Heinz bodies in red blood cells. * “هو دة اللى أأأكل الجبنة” * **Bitten Cells: Macrophages eat the Heinz bodies** * An image shows Bitten Cells in red blood cells. ## Classify Anemia according MCV (<80fL) **2-Sickle Cell Anemia فقر الدم المنجلي** * **Autosomal- recessive, Not fully dominant.** * **Defect only in the shape not amount of B-globulin HbA** * **Infant → No symptoms → Only if HbF has been replaced by Hb.** * **Confirmed:** * **Genotypes BABA BABS BSBS** * **(Normal) (Sickle-cell trait) (Sickle-cell anemia)** * **Electrophoresis** * **+** * **Sample loaded** * **Electrophoresis direction** * (Hb-A) * (Hb-S) * **An image of a stained blood sample showing different types of Hemoglobin.** * **PBS: Sickle cell RBC.** * **An image of sickle cell RBCs.** * **Only supportive ttt** * **Transfusion++ Hydroxyurea anticancer as it found to ↑ HbF 🙂** ## فيه بعض الناس بتقسم ال hemolytic anemia بطريقه تانية * **Corpuscular** * **RBC interior abnormalities** * **Enzyme deficiency as in Favism or pyruvate kinase deficency** * **Hemoglobinopathies as in Sickle cell anemia** * **RBC membrane abnormalities** * **Hereditary spherocytosis (autosomal recessive), Paroxysmal nocturnal hemoglobinuria PNH** * **Extra-Corpuscular** * **Hypersplenism (Extravascular)** * **Ab: immune hemolysis** * **Mechanical Trauma:** * **MAHA (MicroAngiopathic Hemolytic Anemia in mechanical prosthetic heart valves)** * **Infections, toxins as snake venom, ....etc** ## Measuring HbA1C in Guess Individuals who have **WHAT** * **↓ RBC turn over** * **IDA, Megaloblastic Anemia** * **↑ RBC turn over** * **Pregnancy → ↑EPO → Emergency erythropoiesis** * **Hemolytic, Sickle cell, Thalassemia** * **False increased** * "هو اللي خلق ال Hb مخلقش بروتين تأنى في الدم يحصله glycosylated شفت على ال albumin" ## Glycosylated Albumin (Fructosamine) * **N.V.** 175-280mmol/L * **Diabetic (controlled)** <421 mmol/L * **Life Span= 14-21d** * **Short term glucose control** * **لئيمة . WHO** * *Test for undiagnosed T2DM at first prenatal visit in those with risk factor for T2DM, using standard diagnostic criteria.* * *In women with no history of diabetes, screen for GDM at 24-28 gestation week, using OGTT.* * *A 75-g OGTT is done at 24-28 weeks of gestation, with plasma glucose measurement fasting and at 1h and 2 h.* ## Thus far GOD has helped us 1 Samuel 7:12 ## Thank You * An image of a dove flying in the sky with a sign that has the word "Thank You" on it.
