Extensive myeloid response during folic acid therapy in megaloblastic anaemia of pregnancy.

The patient, aged 29 years, para 3, unmarried, and of subnormal intelligence, was first seen in the thirtyfourth week of pregnancy at the hospital antenatal clinic. Previous pregnancies were uneventful and there was no record of serious illnesses. The family history was irrelevant. The present pregnancy progressed uneventfully until early in the sixth month when she had a severe haemorrhage from a varicose ulcer of the leg. On her first visit to the antenatal clinic on January 15, 1951, she complained of breathlessness, frequency of micturition, and suprapubic pain. On examination she was seen to be of fair nutrition but the skin and mucous membranes were very pale. There was no evidence of icteric pigmentation, koilonychia, glossitis, or of splenic or lymphatic glandular enlargement. No toxaemic manifestations and no abnormalities of heart or lungs were noted. The Wassermann reaction was negative and her blood group was A, Rh negative (no antibodies with anti-D serum). Blood levels were: Hb 7.6 g.%, red blood cells 3.95 x 106/c.mm., colour index 0.69. Examination of a catheter specimen of urine showed oxalate crystals, a few clumps of pus cells, and coliform organisms on culture. She was given a course of sulphamerazine and alkalis pending admission to the obstetrical ward. After admission on February 2 repeated examination revealed a persistent pyuria; 30 g. of sulphamerazine, 10.5 g. of chloromycetin, and a subsequent course of sulphatriad were given before the urine became sterile. During the administration of these antibiotics a course of 'ferrivenin " was given, in all containing 1,500 mg. of elemental iron. Despite this, the blood values continued to fall. Two weeks after admission she developed symptoms of an upper respiratory infection, with herpes of the lips, and two episodes of epistaxis. To improve her condition before delivery, she was given two pints of whole blood which raised the Hb to 10.0 g.% and red blood cells to 3.75 x 106/c.mm. Surgical induction was now performed and she was delivered of a healthy girl on February 28 after a labour of seven hours five minutes. Blood loss was minimal. A low-grade intermittent pyrexia persisted until the seventeenth day of the puerperium despite continuous penicillin therapy. On March 3, after transfer to a medical ward, the Hb had fallen to 4.6 g.0% and the red blood cells to 1.9x 106/c.mm. A white-cell count on March 6 gave 5,400 c.mm. (Table I); platelets. 75,000/c.mm. Peripheral blood films showed moderate polychromasia, marked hypochromia and anisocytosis, a small proportion of macrocytes, extremely scanty platelets, and a few immature white cells. The coagulation time was normal but the bleeding time was prolonged (12 minutes by Duke's method). Sternal marrow examination revealed the presence of megaloblastic erythropoiesis. The serum bilirubin level was 0.4 mg.%. The urinary urobilinogen was excessive. Free hydrochloric acid was present in the gastric contents. Tests for faecal occult blood were negative, and a barium meal and radiograph of the chest were also negative.