“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 fulfilment of 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
i
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:
Dr. Mitika Shrivastava
Postgraduate student,
Department of Pathology
Rajarajeswari Medical College and
Hospital, Bangalore.
Place: Bangalore
ii
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 bonafide research work
done by Dr. MITIKA SHRIVASTAVA, Post Graduate student, in Department of
Pathology, Rajarajeawari Medical College and Hospital, Bangalore. It was done under
my guidance in partial fulfilment of the requirement for the M.D. in Pathology degree
examination of Rajiv Gandhi University of health Science to be held in 2014.
Date:
Dr. T. Rajaram
Professor and Head of the department of
Pathology,
Rajarajeswari Medical College and
Hospital, Bangalore.
Place: Bangalore
iii
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, Post Graduate Student, in Department of
Pathology, Rajarajeswari Medical College and
Hospital, Bangalore, under the
guidance and supervision of Dr. T. Rajaram., Professor and head of the department,
Department of Pathology, Rajarajeswari Medical College and Hospital, Bangalore, in
partial fulfilment of the regulations for the M..D. in Pathology degree examination of
Rajiv Gandhi University of Health Science to be held in 2014.
Dr. T. Rajaram
Professor and Head,
Department of Pathology,
Rajarajeswari Medical College
And Hospital, Bangalore.
Date:
Place: Bangalore
iv
Date:
Place: Bangalore
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, Post Graduate Student, in Department of
Pathology, Rajarajeswari Medical College and
Hospital, Bangalore, under the
guidance and supervision of Dr. T. Rajaram., Professor and head of the department,
Department of Pathology, Rajarajeswari Medical College and Hospital, Bangalore, in
partial fulfilment of the 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
v
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
Medical College and Hospital, Bangalore who has been the propelling force and
inspiration for this dissertation / research work.
I am indebted to Dr. Jyothi A .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.
vi
My sincere thanks to Dr. Sharmila P.S and Dr. Mahanthachar V, Professors
of Pathology, Dr. Sushma T.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
Date :
Place : Bangalore
vii
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.
Dr. Mitika Shrivastava
Date:
Place: Bangalore
© Rajiv Gandhi University of Health Sciences, Karnataka
viii
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
ix
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
x
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
xi
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)
xii
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
90
KEY TO MASTR CHART
91
MASTER CHART
92
xiii
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
40
anaemia
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
69
studies
xiv
Table - 22
Percentage distribution of degree of anaemia in comparison with
70
other studies
Table - 23
Percentage of anaemia cases with reduced MCV in comparison to
71
other studies
Table - 24
Percentage of anaemia cases with increased MCV in comparison to
72
other studies
Table - 25
Sensitivity of RDW in comparison with other studies
xv
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
40
severe anaemia
Graph - 3
Age distribution in mild, moderate and severe anaemia
Graph - 4
Distribution
of
patients
according
to
peripheral
41
smear
43
examination
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
xvi
LIST OF FIGURES
Figure No
Title
Page No.
1.
Mindray BC 3000 semiautomated hematology analyser
61
2.
Microcytic Hypochromic Anaemia showing microcytes
61
and a small lymphocyte
3.
Microcytic Hypochromic Anaemia showing many Target cells.
62
4.
Microcytic
62
Hypochromic
Anaemia
exhibiting
marked
anisopoikilocytosis., tear drop cells and target cells
5.
Macrocytic Anaemia showing macrocytes and ovalocytes
63
6.
Macrocytic
63
Anaemia
A hypersegmented neutrophil
showing
and
a
macrocytes,
small lymphocyte
for
comparison with RBC’S
7.
Dimorphic Anaemia showing macrocytes, microcytes and a small
64
lymphocyte for comparision with RBC’S.
8.
Dimorphic Anaemia showing macrocytes and microcytes.
64
9.
Haemoglobin alkaline electrophoresis report showing presence of
65
HbS haemoglobin
10.
Bone marrow aspirate shows megaloblasts and mitosis
xvii
65