SBA

Case 1
Michelle Yuen, a 26 year old woman, presented to the antenatal clinic at 28
weeks pregnancy. She had not previously sought antenatal care. She
reported that she smokes 5 cigarettes daily and drinks 10-20 g alcohol
daily. You noticed that she was pale and proceeded to do a full blood count
and blood film. The results are given in the table below.
Indices

Ms Yuens Results

Normal Range

Hb

*78 g/L

115 - 165 g/L

MCV

*102 fL

76 - 96 fL

MCH

30 pg

27 - 32 pg

WCC

*1.8 x 109/L

4.0 - 11.0 x 109/L

Platelets

*120 x 109/L

150 - 500 x 109/L

Investigation confirms folate deficiency with a normal B12 level.

Question 1.1
Which one of the following disorders is never associated with pancytopenia?
A) Folate deficiency
B) Iron deficiency
C) Vitamin B12 deficiency
D) Aplastic anaemia

Question 1.2
Which one of the following statements best describes the biochemical abnormality
underlying megaloblastic anaemia?
A) Reduction in levels of folic acid or vitamin B12 impairs the ability of purine
analogues to be converted to pyrimidines
B) Absence of folic acid impairs the conversion of homocysteine to pyrimidines
C) Folic acid and vitaminB12 deficiency combine to inhibit the enzyme dihydrofolate
reductase and pyrimidine synthesis
D) Low levels of folic acid or vitamin B12 impair one-carbon transfer important in the
production of folate polyglutamates and generation of pyrimidines

Question 1.3
Red cell breakdown (haemolysis) is associated with which one of the following?
A) Reduced level of lactate dehydrogenase
B) Elevated serum haptoglobin levels

C) Erythroid hyperplasia in the spleen

D) Erythroid hyperplasia in the bone marrow

Question 1.4
A haematocrit of 14% means that, in the sample of blood analyzed:
A) 14% of the haemoglobin is in the plasma
B) 14% of the total blood volume is blood plasma
C) 14% of the total blood volume is the red cells
D) 14% of the haemoglobin is in red cells

Question 1.5
Which one of the following changes in the blood is rarely seen during pregnancy?
A) Anaemia
B) Neutrophilia
C) Thrombocytopenia
D) Reduced factor VIII level

Case 2
During her first pregnancy 3 months ago, Melissa Simms, a 25 year old
woman, suffered an intrauterine death at a gestation of 28 weeks. Her
periods have not yet restarted. She is seen by her general practitioner 3
weeks after discharge from hospital, complaining of fatigue and exertional
breathlessness. Blood tests were performed, and were consistent with a
diagnosis of iron deficiency anaemia.
Question 2.1
Which one of the following is characteristic of pregnancy?
A) The placenta produces inhibitors of maternal red cell production
B) There is reduction in the circulating fibrinogen level
C) There is decreased folate absorption
D) There is a substantial increase in iron requirements

Ms Simms' menstrual cycles began at age 13 years, with regular cycles of

28 days, but up to 7 days bleeding, with heavy flows for the first 3 days,
and with some dysmenorrhoea. Oral contraceptives have been used in the
past to control these problems. She is otherwise well, has no other
significant medical or surgical history, and has no gastrointestinal
symptoms. There is no family history of anaemia or other blood disorders.

Question 2.2
Which one of the following statements summarizes the most likely cause of this
patients anaemia?
A) Iron deficiency due to heavy periods
B) Poor dietary intake of iron, especially since the induced labour
C) Recent post-partum bleeding, together with pre-existing iron deficiency and
increased demand for iron during pregnancy
D) Failure to take folate supplements during the pregnancy.

Question 2.3
Which one of the following series of results is consistent with iron deficiency?
A) Elevated serum ferritin, reduced serum iron, and normal serum transferrin
B) Normal serum ferritin, reduced serum iron, and reduced total iron binding
capacity
C) Reduced serum ferritin, elevated serum transferrin, and absent stainable marrow
iron
D) Elevated serum ferritin, normal iron saturation, and stainable marrow iron

Question 2.4
Which one of the following statements is correct?
A) Re-utilization of iron from phagocytosed red cells prevents iron deficiency
B) The majority of absorbed iron is utilized by myoglobin
C) Iron balance is primarily controlled by the rate of iron excretion in men
D) Vitamin C reduces iron absorption when iron is in the ferrous form

Question 2.5
Which one of the following proteins is the major carrier of iron in blood?
A) Albumin
B) Ferritin
C) Transcobalamin
D) Transferrin

Case 3
Mrs Peta Jones, a 24 year old woman who is currently 34 weeks pregnant
presents complaining of fatigue, headache, palpitations, brittle nails and
sore tongue. Her husband comments that Peta is always eating ice.
This is her first pregnancy with a past history of early menarche, moderate
menstrual losses and low meat content to her diet.
On examination she is pale with angular stomatitis, glossitis and
koilonychia. There is no detectable hepatosplenomegaly and an enlarged
uterus at the appropriate size for her stage of pregnancy. She is slightly
tachycardic.
Her full blood count results reveal:
Haemoglobin

83 gm/L

(Normal Range 115-165 gm/L)

White Cells

9.6 x 10 /L (Normal Range 4.0-11.0 x 109/L)

Platelets

425 x 109/L (Normal Range 150-400 x 109/L)

Mean Cell Volume (MCV)

69fl

(Normal Range 80-100fl)

Mean cell Haemoglobin (MCH)

19pg

(Normal Range 27-32pg)

Mean cell Haemoglobin concentration (MCHC)

28g/L
(Normal Range 27-

32g/L)
Question 3.1
Which one of the following statements regarding iron deficiency in pregnancy is
correct?
A) Commencement of adequate iron therapy will result in a brisk reticulocytosis and
rise in her haemoglobin in 7-8 weeks.
B) Moderate-severe maternal iron deficiency during pregnancy can result in iron
deficiency anaemia and lower birth weight in the neonate.
C) Pregnancy results in the loss the equivalent of 450-500 mls blood (labour
excluded)
D) Failure of haemoglobin returning to the normal range with iron tablet therapy
indicates the anaemia is due to thalassaemia trait.

Question 3.2
Which one of the following is your interpretation of the full blood count results? It is
consistent with:
A) the stage of this patients pregnancy
B) acute GIT blood loss
C) hereditary sideroblastic anaemia
D) prolonged inadequate dietary iron intake.

Question 3.3
Which one of the following is correct about iron?
A) Iron is more readily absorbed in the ferric (Fe3+) form
B) Iron absorption is enhanced in the presence of ascorbate
C) Transferrin is the main reservoir of iron in the liver
D) Ferritin represents the major circulating form of iron

Question 3.4
Which one of the following surveys is likely to give the most valid estimate of the
prevalence of iron deficiency anaemia amongst women in Sydney?
A) A survey of a sample of women presenting to haematology clinics in Sydney;
1000 respondents; 90% response rate
B) A survey of a sample of women presenting to haematology clinics in Sydney;
2,000 participants; 80% response rate
C) A random sample survey of women identified through random number dialing;
2,000 respondents; 40% response rate
D) A random sample survey of women identified through random number dialing;
1,000 respondents; 80% response rate

Question 3.5
If we wanted to know what the incidence of iron deficiency anaemia in women in
Sydney was, what would be the most appropriate study design to answer this
question?
A) Cohort study
B) Randomised controlled trial
C) Meta-analysis of randomised controlled trials
D) Cross-sectional

Case 4
During her first pregnancy 3 months ago, Jane McDonald, a 25 year-old
woman, suffered an intrauterine death at a gestation of 28 weeks, with
subsequent induction of labour and delivery of a macerated fetus. Postpartum bleeding required a dilatation and curettage to remove retained
products of conception. Her periods have not yet restarted. She is seen by
her general practitioner 3 weeks after discharge from hospital, complaining
of fatigue and exertional breathlessness. The following blood tests are
performed.
Indices

Results

Reference Range

Haemoglobin

*100 g/L

115160 g/L

MCV

*70 fl

8096 fl

Haematocrit

*33%

3547%

MCH

*20.9 pg

2732 pg

MCHC

*300 g/L

320360 g/L

Reticulocyte count

53.9 x 109/L

20110 x 109/L

WCC

8.6 x 109/L

4.011.0 x 109/L

Platelets

415 x 109/L

150500 x 109/L

Serum Ferritin

* < 2 g/L

10120 g/L

White cell differential and morphology are normal. Red cells show moderate
microcytosis, anisocytosis and hypochromasia, with some elliptocytes noted.
Question 4.1
Which one of the following is characteristic of pregnancy?
A) The placenta produces inhibitors of maternal red cell production resulting in
anaemia
B) There is reduction in the circulating fibrinogen level resulting in a haemorrhagic
tendency
C) There is decreased folate requirements due to enhanced folate absorption in the
gut
D) There is a substantial increase in iron requirements predisposing to iron deficiency
anaemia

Question 4.2
Which one of the following statements is correct?
A) Re-utilization of iron from phagocytosed red cells is required to prevent iron
deficiency
B) The majority of absorbed iron is utilized by myoglobin
C) Iron balance is primarily controlled by the rate of iron excretion

D) Iron absorption is reduced in the presence of vitamin C and when iron is in the
ferrous form

Ms McDonald's menstrual cycles began at age 13 years, with regular cycles

of 28 days, but up to 7 days bleeding, with heavy flows for the first 3 days,
and with some dysmenorrhoea. Oral contraceptives have been used in the
past to control these problems. She is otherwise well, has no other
significant medical or surgical history, and has no gastrointestinal
symptoms. There is no family history of anaemia or other blood disorders.
Question 4.3
Which one of the following statements summarizes the most likely cause of this
patients anaemia?
A) Iron deficiency due to heavy periods
B) Poor dietary intake of iron, especially since the induced labour
C) Recent post-partum bleeding, together with pre-existing iron deficiency and
increased demand for iron during pregnancy
D) Failure to take folate supplements during the pregnancy.

Question 4.4
Which one of the following series of results is consistent with iron deficiency?
A) Increased iron saturation, elevated serum ferritin, and normal serum transferrin
B) Normal serum ferritin, reduced serum iron, and reduced total iron binding
capacity
C) Reduced serum ferritin, absent stainable marrow iron, and elevated serum
transferrin receptor
D) Elevated serum ferritin, normal iron saturation, and stainable iron present in the
marrow