Chronic posthemorrhagic anemia: causes, symptoms, diagnosis, treatment

Chronic posthemorrhagic anemia develops as a result of prolonged, recurring, minor bleeding and is the main cause of iron deficiency conditions.

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Causes of chronic posthemorrhagic anemia

The following pathological conditions may be the causes of repeated minor bleeding:

1. Diseases of the gastrointestinal tract: erosive and ulcerative lesions of the gastrointestinal tract, polyposis, diaphragmatic hernia, mucosal duplication, diverticulosis and others.
2. Helminthiases: trichuriasis, hookworm disease, ascariasis.
3. Tumors (including glomus tumors).
4. Kidney diseases: chronic glomerulonephritis, urolithiasis.
5. Lung diseases: Zehlen-Gellerstedt syndrome (pulmonary hemosiderosis).
6. Liver diseases: cirrhosis with the development of portal hypertension syndrome, liver failure.
7. Uterine bleeding: menorrhagia of various origins, dysfunctional uterine bleeding, endometriosis, uterine fibroids, and others.
8. Pathology of the hemostasis system: hereditary and acquired thrombocytopathy, coagulopathy, vasopathies.
9. Iatrogenic blood loss: frequent blood sampling for research, blood loss during extracorporeal treatment methods (hemodialysis, plasmapheresis).

In neonates of the first week of life, the most common cause of chronic posthemorrhagic anemia is fetomaternal transfusions. Fetomaternal transfusions are diagnosed in approximately 50% of pregnant women, but significant volumes of fetal blood loss (> 30 ml) are detected in 1% of cases. Fetomaternal transfusions are considered the only cause of true iron deficiency anemia in neonates. The diagnosis is based on the detection of fetal erythrocytes in the mother's bloodstream and an elevated level of fetal hemoglobin. The Kleinhauer-Betke test is used for diagnosis, based on the phenomenon of HbA washout from erythrocytes in a citrate-phosphate buffer. After appropriate processing of the mother's peripheral blood smear, erythrocytes with HbF (fetal erythrocytes) are visible as bright red, while erythrocytes with HbA (i.e. maternal) are visible as pale cellular shadows.

Chronic posthemorrhagic anemia in newborns can also be caused by postpartum hemorrhages and repeated blood sampling for laboratory tests. Postpartum hemorrhages in internal organs and the brain develop as a result of obstetric birth trauma and disorders in the hemostasis system (hereditary and acquired coagulopathy, thrombocytopenia, DIC syndrome), as well as against the background of perinatal pathology (asphyxia, intrauterine and acquired infections).

Chronic posthemorrhagic anemia is characterized by slow development. Children tolerate chronic blood loss relatively easily. The child's body, thanks to compensatory mechanisms, adapts more easily to chronic blood loss than to acute blood loss, despite the fact that the total amount of blood lost can be significantly greater.

When studying the kinetics of erythrons, it was found that in chronic posthemorrhagic anemia, the proliferative activity of erythrons decreases, ineffective erythropoiesis increases, and the lifespan of erythrocytes shortens. Compensation for anemia (taking into account the transition to a lower level of peripheral blood indices) is achieved by expanding the hematopoiesis platform. As a result of chronic blood loss, the iron depot is constantly depleted and sideropenia develops. Due to iron deficiency, various hypovitaminoses (B, C, A) develop; the metabolism of microelements is disrupted (the concentration of copper in erythrocytes decreases, the level of nickel, vanadium, manganese, and zinc increases).

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Symptoms of chronic posthemorrhagic anemia

Depends on the severity of anemia. With a hemoglobin level of 90-100 g/l, children feel satisfactory and anemia may remain unnoticed for a long time.

The clinical picture of chronic posthemorrhagic anemia is equivalent to that of iron deficiency anemia. Children complain of weakness, dizziness, tinnitus, loss of appetite, and decreased tolerance to physical activity. The skin is pale with a waxy tint or porcelain-pale. The mucous membranes are pale. Dry and rough skin, angular cheilitis, smoothed papillae of the tongue, soft and brittle nails and hair are characteristic. Puffiness of the face and pastosity of the shins are possible. Some patients have subfebrile condition. The borders of the heart are shifted to the left, systolic murmur, tachycardia, and a "whirring top" murmur are heard in the jugular veins. Blood pressure may decrease moderately.

Clinical picture of chronic posthemorrhagic anemia in newborns: pale skin and mucous membranes, moderate tachycardia with a soft systolic murmur at the apex of the heart, tachypnea. The liver and spleen may be enlarged due to the development of extramedullary hematopoiesis foci in them. In this case, if posthemorrhagic anemia is caused by hemorrhage into the abdominal organs (adrenal glands, liver, spleen), then the clinical picture may be two-stage - moderate signs of anemia are replaced on the 3-5th day of life due to a sharp increase in hematoma and rupture of organs, the development of the clinical picture of posthemorrhagic shock and the clinical picture of obstruction or adrenal insufficiency.

Diagnosis of chronic posthemorrhagic anemia

In the clinical blood analysis, hypochromic normo- or moderately hyperregenerative anemia is observed. Microcytosis, anisocytosis, poikilocytosis are observed. Leukopenia with relative lymphocytosis is characteristic.

The serum iron level is reduced, the total and latent iron-binding capacity of the serum are increased, and the transferrin saturation coefficient is reduced.

On the ECG, the amplitude of the P and T waves is reduced, signs of impaired myocardial nutrition.

Having diagnosed chronic posthemorrhagic anemia, it is very important to find out its cause. The direction and nature of examinations are determined individually, taking into account clinical and anamnestic data. All patients, regardless of the anamnestic data and clinical picture, must have their feces examined five times for helminth eggs.

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Treatment of chronic posthemorrhagic anemia

Treatment is primarily aimed at eliminating the source of bleeding and restoring iron balance.

The patient's diet is enriched with products containing increased amounts of iron, vegetables, and fruits. The amount of protein in the diet is increased by 0.5-1 g/kg of the patient's weight compared to the age norm.

In chronic posthemorrhagic anemia, indications for blood transfusions are established based on the general condition of the patient and clinical symptoms: resistance to iron therapy, pronounced progression of anemia (Hb < 70 g / l, Ht < 0.35 l / l), the appearance of cardiopulmonary failure with symptoms of hypoxia, insufficiency of compensatory and regulatory mechanisms. In newborns with chronic posthemorrhagic anemia, transfusions of red blood cells (10-15 ml / kg) are indicated at a Hb level of < 100 g / l in the 1st week of life and below 81-90 g / l thereafter.

Treatment with iron preparations and vitamin therapy is prescribed.

Forecast

In chronic posthemorrhagic anemia, the prognosis depends on the treatment options for the underlying disease, the timeliness of prescribing iron preparations, and the rationality of the regimen and diet.

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