Pancytopenia related to malnutrition during pregnancy

Abstract

Pancytopenia during pregnancy secondary to folate deficiency is rare, but is a potentially life-threatening disease with poor fetomaternal prognosis in the absence of accurate diagnosis and optimal treatment [1,2]. In August 2012, a low-risk primigravida aged 26 years presented to Rene Dubos Hospital, Pontoise, France, for a routine consultation at 27 weeks of pregnancy. Persistent fetal bradycardia (100 beats per minute) was recorded. The patient also reported fatigue, dizziness, and recent decreased visual acuity. All previous pregnancy investigations had been normal. Clinical maternal examination revealed severe paleness, oral aphthae, tachycardia (140 beats per minute), and retinal hemorrhage. Ultrasonography indicated intrauterine growth restriction (b5th percentile), oligoamnios, and absent end-diastolic umbilicalflow. Laboratory results showed severe pancytopenia (hemoglobin 1.9 mmol/L; leukocytes 1.49 × 10 per L; platelets 6 × 10 per L). Elevated lactate dehydrogenase (1839 U/L), ferritin (1568.4 pmol/L) and iron values (60 μmol/L) pointed to megaloblastosis with peripheral hemolysis. Serologic investigations excluded recent infections and other diseases. A bone marrow biopsy sample showed severe megaloblastosis, moderate blastosis of the erythroblast line, and absence of a megakaryoblast line with no leukemic population (Table 1, Fig. 1). Diminished levels of vitamin B12 (135 pmol/L), vitamin C (b3.0 μmol/L) and folate (8.73 nmol/L) were subsequently recorded. The patient was diagnosed with pancytopenia secondary to folate and vitamin B12 deficiency. Meticulous anamnesis revealed a particular nutrition pattern characterized by little food intake, no consumption of fruits or vegetables from childhood, and no psychiatric anorexia. The patient was not taking vitamin supplements. Pregnancy was thought to have reduced the patient’s minimal deposits of folate and vitamin B12. The patient received transfusions of seven units of erythrocytes and three units of platelets on the first day, and high daily doses of oral vitamins from the second day (100 IU vitamin B12, 1 g vitamin C, and 45 mg folic acid). The blood counts returned to normal after