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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA ANNEXURE II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1. Name of Candidate Dr. PRASHANTH. R and S/O RUDRAPPA. D, Address #215, 15TH WARD, (in block letters) OPP. BASAVESHWARA TEMPLE, THALI ROAD, ANEKAL, BANGALORE. PIN-562106 2. JJM Medical College, Name of Institution Davangere, Karnataka. PIN-577004 3. Course of study and subject Post-Graduate, MD in Pathology 4. Date of admission to course 5. Title of the Topic: 29.5.2012 “CLINICO-HEMATOLOGICAL PROFILE OF NEONATAL ANEMIA” 1 6. Brief resume of the intended work 6.1 Need for the study Anemia is a disorder characterized by an abnormally low red cell mass; in clinical practice, “hemoglobin concentration” is assumed to reflect the circulating red cell mass, and an abnormally low hemoglobin concentration defines the anemic state.1 The expected ranges of hematocrit, hemoglobin concentration, and erythrocyte count undergo considerable changes during fetal life and after birth.2 Neonatal anemia is defined by a hemoglobin or hematocrit concentration of greater than two standard deviations below the mean for postnatal age.3 The causes of neonatal anemia are blood loss during prenatal, perinatal and postnatal period, intrinsic red blood cell destruction and decreased red cell production. Diagnosis of neonatal anemia in most studies is considered when hemoglobin is below 13 g/dl.4,5,6,7 Anemia in the newborn period is often a complex problem owing to the normal variation in hematological parameters, and also because, in no other period of life, anemia is known to occur due to such varied causes.5 This necessitates the need to take up the study on neonatal anemia. 6.2 Review of Literature The newborn period can be characterized as one of transition, during which the neonate leaves the relative hypoxic in-utero environment and emerges into an altered physiological setting. To effectively make the transition, the modification of several organ systems must take place. The hematologic system of the newly born exemplifies this process. Hematopoiesis in the fetus and neonate is in a constant state of flux and evolution as the newborn adapts to a new milieu. Review of the data on the extensive research undertaken to define neonatal hematologic norms suggests the extreme variation with advancing age in what is defined as normal, thereby making the identification of abnormal problematic.3 The mean hemoglobin concentration of cord blood has been reported in various studies to range from 15.7 g/dl to 17.9 g/dl. Approximately 95% of all values fall between 13.7 g/dl and 20.1 g/dl.5 The differential diagnosis of non-physiologic neonatal anemia is extensive and includes not only many of the causes of anemia seen in older patients, but also many unique to the fetus and newborn associated with pregnancy, labor and delivery. Classifying anemia into categories of RBC loss, including hemorrhage and hemolysis, and inadequate erythrocyte production provides a useful framework for the evaluation, diagnosis, and treatment of the anemic neonate.8 2 A classification according to the cause of anemia is as follows1,3,4,9,10: I. Secondary to decreased production: 1. Congenital red cell aplasia (Diamond-Blackfan anemia) 2. Infection- acquired (bacterial sepsis) - congenital (rubella) 3. Nutritional deficiencies (e.g., Iron deficiency) 4. Congenital leukemia 5. Physiologic anemia or anemia of prematurity II. Secondary to increased destruction 1. Immune hemolytic anemia -Rh, ABO or minor group incompatibility -Maternal autoimmune hemolytic anemia -Drug induced hemolytic anemia 2. Infection- acquired (bacterial sepsis) - congenital (rubella, disseminated herpes) 3. Vitamin E deficiency 4. Red cell membrane disorders -Hereditary spherocytosis -Hereditary elliptocytosis -Other rare disorders (e.g., hereditary stomatocytosis) 5. Thalassemia syndromes -α thalassemia -gamma thalassemia 6. Unstable hemoglobinopathies III. Secondary to blood loss 1. Occult hemorrhage prior to birth or during delivery -Feto-maternal -Twin-to-twin -Feto-placental 2. Obstetric accidents, malformations of placenta or cord 3. Internal hemorrhage -Intracranial -Ruptured liver/spleen 4. Iatrogenic blood loss 3 The most common causes of anemia present at birth are hemorrhage and hemolysis secondary to isoimmunization. After 24 hours of age, external or internal hemorrhage and non-immune hemolytic disorders are more common.4 The establishment of an accurate diagnosis is essential to directing the appropriate therapeutic interventions. Given the diverse etiology of neonatal anemia, a systematic approach to diagnosis is often required as follows3,4,10: 1. History: - Appropriate data vary with the patient’s age, but often include maternal antenatal, obstetric and delivery history, the estimated gestational age at birth, the chronologic age, the infant’s diet, and details of any previous anemia, blood loss, transfusions, medications, and illnesses, as well as the family history of anemia, jaundice, splenectomy. 2. Physical examination: - The physical examination should evaluate the general health, growth and development, skin for pallor, jaundice. Identification of any dysmorphic features, abnormal masses, or skin lesions can aid the diagnosis. The patient also should be assessed for hepatosplenomegaly, cardiovascular function, and lymphadenopathy. 3. Laboratory investigations: - It is beneficial to proceed with investigation in a stepwise manner. The first step should be to establish a diagnosis of anemia by hemoglobin or hematocrit estimation. The initial laboratory evaluation includes a complete blood count (CBC) with RBC indexes, a reticulocyte count, and evaluation of the peripheral blood smear. The results of the preliminary tests, combined with information from the history and physical examination, should dictate the need for further tests, such as determining maternal and neonatal blood grouping, analysis of serum bilirubin, direct Coombs test, sepsis work up (CRP, cultures or titres) and other relevant investigations (osmotic fragility test, Hb electrophoresis, specific enzyme assays, bone marrow aspiration, etc.). 4 6.3 Objectives of the study 1. To study the hematological profile of neonatal anemia which includes hematological parameters obtained by automated cell counter, reticulocyte count, blood grouping (ABO and Rh), direct Coombs test and peripheral blood smear examination. 2. To study the clinical features in various causes of neonatal anemia. 7. Materials and methods 7.1 Source of data This study will be undertaken on neonates referred to the Department of Pathology, JJM Medical College, Davangere for investigations, during the period July 2012 to June 2014. (Two years’ study) 7.2 Method of collection of data (including sampling procedure, if any) Case samples will be selected consecutively as and when they present with anemia. All cases will be subjected to detailed clinical examination. Venous blood sample will be collected under aseptic precautions in vials containing approximately 1.5 mg/ml EDTA anticoagulant and subjected to investigations for hematological parameters- hemoglobin, hematocrit, total and differential WBC count, RBC indices, platelet count, RDW, MPV, in automated cell counter (Sysmex XT-1800i 5-part analyzer), reticulocyte count, blood grouping, direct Coombs test, peripheral blood smear examination after staining with Leishman’s stain using the standard protocol. Other investigations (like Hb electrophoresis, biochemical investigations like serum total, direct and indirect bilirubin, osmotic fragility, bone marrow aspirate examination, etc.) will be done only if indicated. C-reactive protein, Hematologic scoring system of Rodwell and Tudehope11,12 will be assessed in cases of anemia associated with neonatal sepsis. 5 Statistical analysis: Pattern of anemia will be presented as frequency & percentage proportions. Average levels of different hematological parameters will be compared within various causes of neonatal anemia using Analysis of variance (ANOVA) & Student t- test. Categorical data will be analyzed by Chi-square test. Sample size: 100 Inclusion criteria: Neonates (age– 28 days and less) clinically diagnosed as anemia with hemoglobin level of 13 g/dl or less. Exclusion criteria: Neonates with severe bleeding manifestations; and Neonates with hemoglobin level more than 13 g/dl. 7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly. Yes Venous blood sample for investigations like hemoglobin, hematocrit, reticulocyte count, direct Coombs test, RBC indices, blood grouping, peripheral blood smear and other relevant investigations only when indicated. Bone marrow examination only if clinically indicated. 7.4 Has ethical clearance been obtained from your institution in case of 7.3? Yes. 6 8. List of references 1. Blanchette VS, Zipursky A. Assessment of anemia in newborn infants. Symposium on perinatal hematology. Clin Perinatol 1984; 11(2): 489-510. 2. Christensen RD, Ohis RK. Anemias unique to the newborn period. In: Greer JP, Foerster J, Rodgers GM, Paraskevas F, Glader B, Arber DA et.al., editors. Wintrobe’s clinical hematology, Vol. 1, 12th ed. Philadelphia: Lippincott Williams and Wilkins; 2009. p. 1247-1260. 3. Bizzaro MJ, Colson E, Ehrenkranz RA. Differential diagnosis and management of anemia in the newborn. Pediatr Clin N Am 2004; 51: 1087-1107. 4. Kulkarni ML. Common neonatal problems. In: Manual of neonatology. New Delhi: Jaypee; 2000. p. 363-368. 5. Lokeshwar MR, Singhal T, Shah N. Anemia in the newborn. Symposium on hematology-II (Neonatal Hematology). Ind J Pediatr 2003; 70: 893-902. 6. Kumara S, Gupta AK, Dadhich JP. Anemia in neonates. In: Gupte S, editor. R A P Neonatology – 2, Spl. Vol. 5. New Delhi: Jaypee; 2000. p. 212-229. 7. Kumari S, Saxena A, Monga D, Malik A, Kabra M, Kurray RM. Significance of cord problems at birth. Ind Pediatr 1992; 29: 301-303. 8. Gallagher PG. Hematology of the newborn. In: Young NS, Gerson SL, High KA. Clinical hematology. Philadelphia: Elsevier Mosby; 2006. p. 911-919. 9. Christou HA. Anemia. In: Cloherty JP, Eichenwald EC, Hansen AR, Stark AR, editors. Manual of neonatal care. 7th ed. Philadelphia: Lippinott Williams & Wilkins; 2012. p. 563-571. 10. Luchtman-Jones L, Wilson DB. The blood and hematopoietic system, part 1, Hematologic problems in the fetus and neonate. In: Martin RJ, Fanaroff AA, Walsh MC, editors. Fanaroff and Martin’s neonatal-perinatal medicine. Diseases of the fetus and infant. Vol. 2. 9th ed. Missouri: Elsevier Mosby; 2011. p. 1303-1360. 11. Benitz WE. Adjunct laboratory tests in the diagnosis of early-onset neonatal sepsis. Clin Perinatol 2010; 37(2): 421-438. 12. Basu S, Guruprasad, Narang A, Garewal G. Diagnosis of sepsis in the high risk neonate using a hematologic scoring system. Ind J of Hemat & Blood Transf 1999; 17(2): 32-34. 7 9. Signature of Candidate 10. Remarks of the Guide 11. Name and Designation of the Guide (in block letters). 11.1 Guide Neonatal anemia is a complex problem and interpretation of laboratory findings is crucial. This study will be useful for institution of appropriate therapy. DR. S. S. HIREMATH, MD. PROFESSOR & HOD, DEPARTMENT OF PATHOLOGY, JJM MEDICAL COLLEGE. DAVANGERE-577004 11.2 Signature _ 11.3 Co-Guide (if any) 11.4 Signature 11.5 Head Of the Department DR. S.S.HIREMATH, MD. PROFESSOR AND HOD, DEPARTMENT OF PATHOLOGY, JJM MEDICAL COLLEGE. DAVANGERE-577004. 11.6 Signature 12. 12.1 Remarks of the Chairman & Principal 12.2 Signature 8