Etiopathological Spectrum of Anaemias in Women of Reproductive Age Group Attending Rrmch

“ETIOPATHOLOGICAL SPECTRUM OF ANAEMIAS IN WOMEN OF REPRODUCTIVE AGE GROUP ATTENDING RRMCH, BANGALORE”

By

Dr. MITIKA SHRIVASTAVA

Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka,

In partial fulfilmentof the requirements for the degree of

DOCTOR OF MEDICINE

IN

PATHOLOGY

Under the guidance of

Dr. T .RAJARAM

Professor and Head of the department

DEPARTMENT OF PATHOLOGY

RAJARAJESWARI MEDICAL COLLEGE AND HOSPITAL,

BANGALORE

2014

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA

DECLARATION BY THE CANDIDATE

I hereby declare that this Dissertation entitled“ETIOPATHOLOGICAL SPECTRUM OF ANAEMIAS IN WOMEN OF REPRODUCTIVE AGE GROUP ATTENDING RRMCH, BANGALORE” is a bonafide and genuine research work carried out by me under the guidance of Dr. T. Rajaram.,Professor and Head of the Department, Department of Pathology,Rajarajeswari Medical College and Hospital, Bangalore.

The dissertation has not formed the basis for the award of any degree to me previously by any other University.

Date:

Place:Bangalore

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled“ETIOPATHOLOGICAL SPECTRUM OF ANAEMIAS IN WOMEN OF REPRODUCTIVE AGE GROUP ATTENDING RRMCH, BANGALORE”is a bonafideresearch work done byDr. MITIKA SHRIVASTAVA, Post Graduate student, in Department of Pathology, RajarajeawariMedical College and Hospital, Bangalore. It was done under my guidance in partial fulfilment of the requirementfor the M.D. in Pathologydegree examination of Rajiv Gandhi University of health Science to be held in 2014.

Date:

Place: Bangalore

ENDORSEMENT BY THE HEAD OF DEPARTMENT

This is to certify that the dissertation entitled “ETIOPATHOLOGICAL SPECTRUM OF ANAEMIAS IN WOMEN OF REPRODUCTIVE AGE GROUP ATTENDING RRMCH, BANGALORE” is a bonafide research work done by Dr. Mitika Shrivastava, PostGraduate Student, in Department of Pathology, Rajarajeswari Medical College and Hospital,Bangalore, underthe guidance and supervision of Dr. T. Rajaram., Professor and head of the department, Department ofPathology, Rajarajeswari Medical College and Hospital, Bangalore, in partial fulfilment ofthe regulations for the M..D. in Pathology degree examination of Rajiv Gandhi University of Health Science to be held in 2014.

ENDORSEMENT BY THE HEAD OF THE INSTITUTION

This is to certify that the dissertation entitled “ETIOPATHOLOGICAL SPECTRUM OF ANAEMIAS IN WOMEN OF REPRODUCTIVE AGE GROUP ATTENDING RRMCH, BANGALORE” is a bonafide research work done by Dr. Mitika Shrivastava, PostGraduate Student, in Department of Pathology, Rajarajeswari Medical College and Hospital,Bangalore, underthe guidance and supervision of Dr. T. Rajaram., Professor and head of the department, Department ofPathology, Rajarajeswari Medical College and Hospital, Bangalore, in partial fulfilment ofthe regulations for the M..D. in Pathology degree examination of Rajiv Gandhi University of Health Science to be held in 2014.

Dr. H. Rangappa

Dean,

Rajarajeswari Medical College and Hospital, Bangalore

Date :

Place: Bangalore

AKNOWLEDGMENTS

Thanking is a pleasant job, but nonetheless difficult when one sincerely tries to put it in words. These humble words of expression of gratitude cannot wholly convey my feelings.

I express my deep sense of gratitude to my respected teacher and guide Dr. T.Rajaram, Professor and Head, Department of Pathology, Rajarajeswari MedicalCollege and Hospital, Bangalore who has been the propelling force and inspiration for this dissertation / research work.

I am indebted to Dr. JyothiA.Raj, Associate Professor, Department of Pathology, whose encouragement, supervision and support helped me at every step of my dissertation.

It gives me enormous pleasure to express my sincere and heartfelt gratitude to Dr. Usha Ramachandra, Principal and Professor of Pathology for her support and guidance.

I express my heartfelt thanks to the Dr. D.L.Ramachandra Medical Director, Dr. H. Rangappa Additional Medical Director, Dr (Gen) S.C. Godara, Dean of the Hospital, Dr. K.M. Govindaraju, Medical Superintendent and Administrative officers of Rajarajeswari Medical College and Hospital for providing the necessary facilities during my study without which this task could not have been accomplished.

I express my thanks to the Chairman and the Management of Rajarajeswari Medical College and Hospital,Bangalore.

My sincere thanks to Dr. Sharmila P.S and Dr.Mahanthachar V, Professors of Pathology, Dr. SushmaT.A,Associate Professor of Pathology, Dr. K. Shashikala and Dr.Shwetha J, Assistant Professors of Pathology and Dr.Latha V, Blood Bank Officer, for their encouragement , guidance and support during my postgraduate course.

I would like to thank my colleagues Dr. Nikitha, Dr.Ankur, Dr. Paul, Dr. Dhaval,Dr. Amit, Dr. Jeena for their help and support.

I am grateful to the patients who despite their suffering cooperated in completing the project.

My sincere thanks to the Technical Staff of Department of Pathology, Rajarajeswari Medical College and Hospital, Bangalore.

I thank Dr. Rahul Jain, my Husband for his unlimited love, faith and encouragement.

I thank my in – laws and brother for their kind support.

My deepest gratitude to my parents for their constant help, support, encouragement and motivation. It is to them that I dedicate this dissertation.

Above all I am thankful for the divine blessings of GOD.

Dr.Mitika Shrivastava

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE.

COPY RIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall have the rights to preserve, use and disseminate this dissertation in print or electronic format for academic/research purpose.

© Rajiv Gandhi University of Health Sciences, Karnataka

LIST OF ABBREVIATIONS

Hb - Haemoglobin

BMI - Body mass index

WHO - World Health Organisation

Yrs - Years

MCV - Mean Corpuscular Volume

RDW - Red Cell Distribution Width

HMP - Hexose Mono Phosphate

IDA - Iron Deficiency Anaemia

CLL - Chronic Lymphocytic Leukaemia

RNA - Ribonucleic Acid

NFHS - National Family Health Survey

CDC - Centers for Disease Control and Prevention

HIV - Human Immunodeficiency Virus

NSAIDS - Nonsteroidal anti - inflammatory drug

MCHC - Mean Corpuscular Haemoglobin Concentration

TLC - Total Leucocyte Count

PCV - Packed Cell Volume

EDTA - Ethylene Diamine Tetra Acetic Acid

AHG - Anti Human Globins

Hct - Haematocrit

ANOVA - Analysis of Variance

IPD - In Patient Department

OPD - Out Patient Department

RRMCH - Rajarajeswari Medical College and Hospital

AIDS - Acquired Immunodeficiency Syndrome

SD - Standard Deviation

WBC - White Blood Cell

ABSTRACT

Background and objectives of the study

Anaemia is the common problem among the reproductive age group of women in our country. The major cause is nutritional, on which extensive studies and published works are available. The pregnant and non pregnant women can have non nutritional causes of anaemia. The small possible number of haemoglobinopathies among them also need to be identified. The aim is to identify and evaluate cases of anaemia among this group and to find out the proportion of nutritional anaemias and hemolytic anaemias among this group.

Methodology

1000 cases of reproductive age group women with low hemoglobin were included. All the hematological parameters including RDW were obtained through analyzer. Peripheral smear stained with Leishman’s stain was evaluated for morphology. The cases suggestive of hemolytic anaemia were evaluated by Coombs’ test and Haemoglobin electrophoresis. Bone marrow aspiration was performed wherever required.

Results

Out of 1000 cases of anaemia, 798 cases (79.8%) were diagnose to have microcytic hypochromic anaemia, 76 cases (7.6%) had macrocytic anaemia, 66 cases (6.6%) had normocytic normochromic anaemia and 60 cases (6%) had dimorphic anaemia. Out of 798 cases of microcytic hypochromic anaemia, 4 cases were found to be Coombs’ reactive and out of 66 cases of normocytic normochromic anaemia were found to have sickle cell anaemia.

Conclusion

Out of 1000 anaemic women identified, 994 cases were found to have nutritional anaemia and only 6 cases were diagnosed to have haemolytic anaemia. Hence, the cause of anaemia in women is non nutritional in very few.

(KEY WORDS – Haemoglobinopathies, RDW, Coombs’ test)

CONTENTS

Sl.No. / Title / Page No.
1 / INTRODUCTION / 1
2 / AIMS AND OBJECTIVES / 5
3 / REVIEW OF LITERATURE / 6
4 / MATERIAL AND METHODS / 29
5 / RESULTS / 39
7 / DISCUSSION / 66
8 / SUMMARY / 75
9 / CONCLUSION / 77
10 / REFERENCES / 78
ANNEXURE
PROFORMA
KEY TO MASTR CHART
MASTER CHART / 90
91
92

LIST OF TABLES

Table No. / Title / Page No.
Table - 1 / Age distribution of patients studied / 39
Table - 2 / Number and percentage of women with mild, moderate and severe anaemia / 40
Table - 3 / Age distribution in mild, moderate and severe anaemia / 41
Table - 4 / Distribution of patients according to peripheral smear examination / 43
Table - 5 / Age wise distribution of peripheral smear / 44
Table - 6 / Correlation of peripheral smear with severity of anaemia / 46
Table - 7 / Distribution of cases according to MCV / 48
Table - 8 / Correlation of MCV with severity of anaemia / 49
Table - 9 / Distribution of cases according to MCH / 50
Table - 10 / Distribution of cases according to MCHC / 51
Table - 11 / Distribution of cases according to haematocrit / 52
Table - 12 / Distribution of cases according to Total RBC count / 53
Table - 13 / Distribution of cases according to Red cell distribution width / 54
Table - 14 / Correlation of RDW with severity of anaemia / 55
Table - 15 / Correlation of RBC count with severity of anaemia / 56
Table - 16 / Comparison of various variables according to severity of anaemia / 57
Table - 17 / Correlation of various Red cell indices with peripheral smear / 58
Table - 18 / Results of Coombs’ test / 58
Table - 19 / Bone marrow results / 59
Table - 20 / Electrophoresis positive cases / 60
Table - 21 / Age wise distribution of anaemic cases in comparison with other studies / 69
Table - 22 / Percentage distribution of degree of anaemia in comparison with other studies / 70
Table - 23 / Percentage of anaemia cases with reduced MCV in comparison to other studies / 71
Table - 24 / Percentage of anaemia cases with increased MCV in comparison to other studies / 72
Table - 25 / Sensitivity of RDW in comparison with other studies / 73

LIST OF GRAPHS

Graph No. / Title / Page No.
Graph - 1 / Age distribution of patients studied / 39
Graph - 2 / Number and percentage of women with mild, moderate and severe anaemia / 40
Graph - 3 / Age distribution in mild, moderate and severe anaemia / 41
Graph - 4 / Distribution of patients according to peripheral smear examination / 43
Graph - 5 / Age wise distribution of peripheral smear / 44
Graph - 6 / Correlation of peripheral smear with severity of anaemia / 46
Graph - 7 / Distribution of cases according to MCV / 48
Graph - 8 / Correlation of MCV with severity of anaemia / 49
Graph - 9 / Distribution of cases according to MCH / 50
Graph - 10 / Distribution of cases according to MCHC / 51
Graph - 11 / Distribution of cases according to haematocrit / 52
Graph - 12 / Distribution of cases according to Total RBC count / 53
Graph - 13 / Distribution of cases according to Red cell distribution width / 54
Graph - 14 / Correlation of RDW with severity of anaemia / 55
Graph - 15 / Correlation of RBC count with severity of anaemia / 56

LIST OF FIGURES

Figure No / Title / Page No.
1. / Mindray BC 3000 semiautomated hematology analyser / 61
2. / Microcytic Hypochromic Anaemia showing microcytes
and a small lymphocyte / 61
3. / Microcytic Hypochromic Anaemia showing many Target cells. / 62
4. / Microcytic Hypochromic Anaemia exhibiting marked anisopoikilocytosis., tear drop cells and target cells / 62
5. / Macrocytic Anaemia showing macrocytes and ovalocytes / 63
6. / Macrocytic Anaemia showing macrocytes,
A hypersegmented neutrophil and a small lymphocyte for comparison with RBC’S / 63
7. / Dimorphic Anaemia showing macrocytes, microcytes and a small lymphocyte for comparision with RBC’S. / 64
8. / Dimorphic Anaemia showing macrocytes and microcytes. / 64
9. / Haemoglobin alkaline electrophoresis report showing presence of HbS haemoglobin / 65
10. / Bone marrow aspirate shows megaloblasts and mitosis / 65

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