Pregnant & Confused

I'll be 34w pregnant tomorrow [06/06/11] and about a month ago had a phone call from the bloods nurse at the maternity telling me that my MCH was low [25.8] and that I might have thalassemia [nothing was explained about what it was] and that myself and my partner needed to come in and have it tested. I happened to be admitted for hyperemesis gravidarum [extreme pregnancy sickness which requires me to take anti-emetics every day to stop me vomiting] about a fortnight later and unbeknown to me they'd retaken my MCH and it was now at 24.6. I went in last week and had the bloods done that they'd scheduled me for. When I phoned at the start of the week for my results I was told that my MCH was not tested it was just full iron studies that were done [I'm not sure why, the bloods nurse even asked why I was there and I told her!]. The nurse proceeded to tell me that my partner was fine [MCH 30.3] and that I needed iron ASAP because all my results came back low. Now as I have absolutely no knowledge about any of this I'm probably not giving you a lot or the best information right now!!!

She did say my iron stores are at 3.5% and that my ferritin is at 5. She told me that my hemoglobin was low but didn't give me the number and said that they hadn't done the MCH but that my last result was 24.6.

I've been extremely short of breath, like gasping, like my ribcage is too tight since Tuesday and when maternity asked me to come in and have it checked they found all my obs [and heart traces, lungs clear] to be normal and said it was because my iron was so low and would ease when I'd had some iron. I can't take iron tablets because of the hyperemesis so they decided to give me venofer instead. I had my first injection on Friday and was told it would take a couple of days to kick in. I'm due my 2nd injection tomorrow [Monday]. My breathing hasn't eased at all. I don't know if it's related to the iron, no-one has told me anything I don't even know if I'm a carrier of thalassemia!! No-one has explained my results to me or told me what it means!! All they have said is that I need iron ASAP in case I go into labour as the blood loss could be fatal to both me and my baby.

Does anyone understand any of this and could anyone shed any light?!

Hi Yinarii,

I would say that iron deficiency is at least part, if not all of the problem. Your iron stores are quite low and this is not unusual during pregnancy. In addition to the IV iron, you should also be trying to eat an iron rich diet, as much as your condition allows. To determine if thal minor may also be involved, you would need at least the results of a complete blood count (CBC). MCH alone cannot explain things, as it is low in both thal minor and iron deficiency. MCV, RDW, RBC count and other values are included in the CBC. If you have had a CBC, please ask for the results. Also, find out your Hb level. Are you also taking folic acid? This is an absolute must during all pregnancies. If you have not had a CBC, please request one now. These iron injections do normally work for iron deficiency but you should be aware that red blood cells take time to produce and iron deficiency cannot immediately correct the deficiency. Iron is needed to make new red blood cells, but the anemia will take some time to clear. Have you ever been known to be anemic before this pregnancy?

I would also ask any of the moms here if they've had to deal with hyperemesis gravidarum during pregnancy and if they have any advice on how to deal with it.

I've had hyperemesis gravidum all three times and just had to tough it out as none of the medicines made any difference at all. It does ease after 4-5 months usually.
However my sisters used Zofran and it helped them alot. See if you can get it prescribed. I couldnt even though I had to be hospitalised several times for fluids b/c I just couldnt keep anything down.
In my case for the low Hb they first tried iron then B12. Neither helped .But once it was found I was thal minor they transfused.
If they suspect thal they should have had a HB electrophoresis done  shouldnt they?
Zahra

The results of a CBC would indicate whether or not an electrophoresis should also be done, so I hope we can see some of those values. Zahra, was your iron actually measured as low when they gave you iron or was it based solely on low Hb?

Zahra I'm already on zofran [have been from about 11w pregnant] and even though I'm on it I still get periods of vomiting, it's constant nausea but the vomiting is a lot better on the zofran - my last hospitalisation was a few weeks ago.

Andy I have the CBC results from April when I was first called with the MCH being 25.8, my MCV was 80.. no RDW results listed on here but the RBC was 4.19 and the HB was 10.8 - there is also an HCT that is lost at .336  and WCC which is high at 12.6... I'm just listing them because I have no idea what they are and if they are relevant!! As I said I don't have the results here for anything more recent all I know is that my MCH had gone down to 24.6 two weeks ago when I was admitted.

Apparently they were supposed to send a leaflet out about thalassemia but I never got anything hence my asking you guys who probably know more than they do anyway!!! I just thought the breathlessness might have started improving today but no such luck.

Yinarii,

An MCV of 80 is high for either iron deficiency or thal minor, and is in the normal range. Even when thal minor and iron deficiency are found together, a much lower MCV would be expected. The RBC is also normal. In your blood reports are there any comments about the blood itself? Such as RBC MORPHOLOGY-Microcyctic or monochromatic references? Thal minors usually have some abnormal red blood cells and this will normally be included as an observation with the CBC results.

If there is some question if thal minor is present, you should do as Zahra suggested and have a hemoglobin electrophoresis test done. This will clear things up in most cases. It may be that this is just iron deficiency, assuming there is no folate deficiency.

Yea the nurse said my MCV is just in the low normal range [their cutoff, I don't know if it's different per hospital or region, is 78]. I don't have the original, just the numbers the nurse read out to me on the phone. They haven't explained any of my results just telling me that I needed iron asap [I'm due for my 2nd venofer injection tomorrow and then a month wait to have my blood retested].

Thanks for all your help Andy!!

Also this isn't my region but I wonder if this has something to do with them looking at the MCH rather than the MCV?

http://www.ncbi.nlm.nih.gov/pubmed/19958202

Ideally both MCV and MCH should be tested, along with the rest of a CBC. The suggestion in the article is that if the cost of testing is a big factor, and in testing thousands or perhaps even millions of people in a population, cost is a prohibitive factor, that the MCH would be a better choice than MCV. A CBC would not be done, unless the MCH suggested thal trait. China has a huge problem with thalassemia and has been taking steps to reduce and eventually eliminate the births of thal majors. This has already been done in Hong Kong, where there are no longer thal majors being born. By testing women, they can do follow up testing to confirm thal trait and identify carriers. I do not know if they are prohibiting marriage of two carriers, but at the least, it gives potential parents the knowledge that they are carriers so they can make informed decisions.

Your MCH is definitely low, while the MCV is on the low end of normal or very high end of thal trait. However, your iron levels show deficiency, which is enough to explain your low Hb and HCT. In fact, with low iron, the MCH and MCV would both be expected to be lower, so the results are puzzling. And if thal minor was also present, the MCV would be expected to be much lower.
The post at http://www.thalassemiapatientsandfriends.com/index.php/topic,3480.msg35538.html#msg35538 shows what to expect with either or both in combination. Your iron is very low and it does need to be treated. If you don't have a history of anemia, thal trait is less likely. The anemia is definitely exacerbated by the hyperemesis gravidum, which results in a loss of nutrients. Considering you are pregnant and have hyperemesis gravidum, it's almost surprising your Hb isn't even lower, since your iron is so low. I would think that without correction, your Hb would probably drop more during the pregnancy. Without further test information, it's not possible to make a conclusion, but it does seem unlikely that thalassemia trait is also involved.

I really appreciate all the information Andy, for someone who doesn't have thal you are very knowledgeable!! I have always had anemia issues - I used to pass out consistently on a monthly basis when I had my periods growing up and had iron tablets throughout my first pregnancy but I think with my first pregnancy I wasn't as mature or perhaps more naive about finding out and understanding what was going on in my body because I was so excited about being pregnant. This time I've been more involved in my pregnancy because of having the HG etc. My mum and sister have both had anemia issues throughout their lives and my sister was diagnosed about a month ago with vit B12 def. which now requires injections for life to keep her right. My mum had to have a hysterectomy a few months ago because of the effect the bleeding had - again with fainting a lot etc.

It's good to have some more information, it's a shame the hospital couldn't have explained the results to me the way you have!!!

Actually, now that you mention you family history, there is enough anemia that I think you should ask for a hemoglobin electrophoresis test to determine if you might have thal trait. Often when you see similar problems in the same family, thal trait becomes more likely. Family history is often used to help diagnose thal. It may turn out to be another type of anemia, but it should be investigated.

Hmmmm I know that when the nurse first mentioned my MCH being low and I'd googled it [not that I could understand most of it because it all seemed very medical!] but it seems that my sisters vit b12 issue is like the opposite and apparently the vit b12 def. means you have high MCH! I will def ask my MW tomorrow!!! Thanks Andy!!

Yinarii,

When you talk to your doctor ask if the CBC showed anything unusual about the characteristics of your blood, like large red blood cells (B-12 or pernicious anemia) or small pale red blood cells (thal trait, iron deficiency). Was your B-12 level tested as normal?