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Case Summary: Iron Deficiency Anemia
Patient: 33-year-old breastfeeding woman from Baglung, mother of four children.
Presenting complaints
She presented to the Medicine OPD with:
- Dizziness
- Loss of appetite
- Generalized weakness, fatigue and malaise
- Shortness of breath on exertion
Symptoms had persisted for approximately 6 months after her most recent delivery.
Relevant history
- History of prolonged postpartum vaginal bleeding for 2-3 weeks after delivery, eventually controlled with medication.
- She also reported excessive postpartum bleeding after an earlier delivery, requiring hospital admission and oral haematinics after discharge.
- She was non-compliant with oral haematinic therapy.
- Vegetarian diet and a farming-dependent family, suggesting possible low dietary iron intake.
- No significant family history, alcohol use, or smoking history.
Examination findings
- Pale appearance
- Thin build and short stature
- Glossitis
- Angular stomatitis
- Koilonychia
- Pulse: 110/min (tachycardia)
- BP: 110/70 mmHg
- Respiratory rate: 20/min
- Soft systolic flow murmur on cardiac auscultation
- Other systemic examinations were within normal limits.
Investigations
- Hemoglobin: 7 g/dL
- PCV, MCV, MCH and MCHC: decreased
- Peripheral blood smear: microcytic hypochromic anemia with anisopoikilocytosis
- RDW: increased
- Serum ferritin: low
- TIBC: high
- Reticulocyte count: increased
- Total and direct bilirubin: normal
- CBC, TC and DC: within normal limits
- Stool examination: no parasites detected
- Chest X-ray: normal
- ECG: decreased R-R interval, consistent with tachycardia
- Blood group: A positive
Diagnosis
Severe iron deficiency anemia, most likely due to chronic iron depletion from postpartum blood loss, compounded by inadequate dietary iron intake and poor adherence to iron supplementation.
Management advised
The diagnosis of iron deficiency anemia was made, and she was advised to take oral haematinic/iron supplementation. Follow-up should assess adherence, symptomatic improvement, hemoglobin response, and restoration of iron stores.
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Detailed Case Summary
Patient profile
A 33-year-old breastfeeding mother of four, residing in Baglung, presented to the Medicine Outpatient Department with symptoms suggestive of anemia. She belonged to a farming-dependent family, was vegetarian, and had no history of smoking or alcohol use. There was no significant personal or family history of chronic illness or hematological disease.
Chief complaints
The patient complained of:
- Dizziness
- Loss of appetite
- Generalized weakness and easy fatigability
- Malaise
- Shortness of breath on exertion
These symptoms had been present for six months, beginning after the birth of her fourth child.
History of present illness
Following her most recent delivery, the patient experienced prolonged per-vaginal bleeding for 2-3 weeks. The bleeding was later controlled with medication, but the prolonged blood loss likely depleted her iron stores. She had also experienced excessive postpartum vaginal bleeding after her first home delivery, for which she was admitted to a nearby hospital and discharged with oral haematinic medication.
Although oral haematinics had been prescribed previously, she admitted that she was not compliant with treatment. Her vegetarian diet may have further contributed to inadequate iron intake, as non-heme iron from plant sources is less readily absorbed than heme iron from animal foods.
General physical examination
The patient was thin-built and of short stature. She appeared pale, supporting clinically significant anemia. Features characteristic of chronic iron deficiency were present:
- Pallor: due to reduced hemoglobin concentration
- Glossitis: inflamed or smooth tongue
- Angular stomatitis: fissuring/inflammation at the angles of the mouth
- Koilonychia: spoon-shaped nails, a classic feature of long-standing iron deficiency
Vital signs and systemic examination
- Pulse rate: 110 beats/minute, indicating tachycardia
- Blood pressure: 110/70 mmHg
- Respiratory rate: 20 cycles/minute
- Cardiovascular examination: soft systolic murmur on auscultation, likely a functional flow murmur caused by anemia
- Other systemic examinations: within normal limits
The tachycardia, exertional dyspnea, and systolic flow murmur can be explained by compensatory increased cardiac output in response to reduced oxygen-carrying capacity of blood.
Laboratory investigations
The investigations showed findings typical of iron deficiency anemia:
| Investigation | Finding | Interpretation |
|---|---|---|
| Hemoglobin | 7 g/dL | Severe anemia |
| PCV | Decreased | Reduced red-cell volume |
| MCV | Decreased | Microcytosis |
| MCH/MCHC | Decreased | Hypochromia due to reduced hemoglobin content |
| Peripheral blood smear | Microcytic, hypochromic RBCs with anisopoikilocytosis | Typical morphology of iron deficiency anemia |
| RDW | Increased | Variable RBC size, common in iron deficiency |
| Serum ferritin | Low | Indicates depleted body iron stores |
| TIBC | High | Increased transferrin production in iron deficiency |
| Reticulocyte count | Increased | Marrow response to anemia/iron therapy or recent blood loss |
| Bilirubin | Normal | Does not support hemolysis |
| TC/DC | Within normal limits | No major leukocyte abnormality/infection suggested |
| Stool routine examination | No parasites detected | Hookworm or other intestinal parasites less likely |
| Chest X-ray | Normal | No apparent cardiopulmonary cause of dyspnea |
| ECG | Decreased R-R interval | Consistent with sinus tachycardia |
| Blood group | A positive | Recorded for clinical purposes |
Interpretation of hematological findings
This is a microcytic hypochromic anemia. The combination of low hemoglobin, reduced MCV/MCH/MCHC, increased RDW, low serum ferritin, and increased TIBC confirms iron deficiency anemia. Serum ferritin is a useful indicator of iron stores, while increased TIBC reflects an increase in circulating transferrin in iron deficiency. These findings are consistent with standard pathology descriptions of iron depletion and iron deficiency anemia in Robbins & Kumar Basic Pathology.
Probable etiological factors
The anemia is most likely multifactorial:
- Chronic blood loss due to prolonged postpartum bleeding after the fourth delivery.
- Previous obstetric blood loss, as she reported excessive bleeding after her first delivery.
- Increased iron requirements during repeated pregnancies and lactation.
- Inadequate dietary intake of bioavailable iron, as she is vegetarian.
- Poor adherence to prescribed oral haematinics, preventing replacement of depleted iron stores.
- Low socioeconomic and nutritional risk suggested by dependence on farming.
Final diagnosis
Severe iron deficiency anemia secondary to postpartum blood loss, inadequate iron intake, repeated pregnancies, and non-compliance with oral iron supplementation.
Management plan
The patient was advised to take oral haematinic therapy, particularly oral iron supplementation. Her treatment should also include:
- Counseling regarding adherence to therapy.
- Iron-rich dietary advice, including legumes, lentils, green leafy vegetables, beans, fortified cereals, nuts, seeds, and vitamin C-containing foods to enhance non-heme iron absorption.
- Avoiding tea, coffee, and calcium-rich foods close to the time of taking iron, as they can reduce absorption.
- Monitoring hemoglobin and reticulocyte response after starting treatment.
- Continuing iron therapy after hemoglobin improves in order to replenish body iron stores.
- Assessment for continued menstrual or postpartum blood loss and gynecological causes if bleeding persists or recurs.
- Consideration of parenteral iron or transfusion if there is clinical instability, failure to tolerate oral therapy, failure to respond, or need for rapid correction.
WHO has published a postpartum iron guideline supporting iron supplementation in postpartum women. A recent systematic review of pregnancy and postpartum iron-deficiency anemia guidance is indexed as PMID 37424100.
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