Repeated Blood Transfusions Research Articles

Hematological profile of children with sickle cell Disease in special reference to body iron stores

Introduction: Sickle cell anemia is a genetic disorder commonly seen in rural population of western and central India. Being an important cause of hemolytic anemia, repeated blood transfusions are frequently required for the sickle cell anemia cases. Few studies have exclusively addressed hematological profile of sickle cell disease patients. This study was planned to study the hematological profile of children with special reference to body iron stores. Methods: This was a prospective observational study carried out in department of pediatrics S.B.K.S MIRC. All the confirmed cases of children diagnosed with sickle cell disease or sickle β thalassemia were subjected to complete hematological analysis in special reference to body iron store by evaluation of serum iron, TIBC, % transferrin saturation and serum ferritin to find out total body iron store. Results: About 110 patients were included in the study. In our study low MCV values were seen in 60.4% of patients, low MCH values in 84.9% of patients while MCHC was normal in 94.3% of patients. Serum iron levels showed normal values in majority of patients (94.3%) while transferrin saturation was low in 62.3% patients thus showing the discrepancy on correlating both values for diagnosis of iron deficiency. Conclusion: Out of various parameters for diagnosis of iron status in SCD-SS patients, low MCV, MCH, Serum iron level and transferrin saturation more consistently associated with iron deficient state.

Frequency of red blood cell alloimmunization in sickle cell patients and healthy donors: the influence of racial and antigenic pattern differences

Background: Red blood cell (RBC) transfusions are frequently used in patients with sickle cell disease (SCD) to treat and prevent of their disease complications. However repeated blood transfusions are often complicated by RBC alloimmunization. Race and antigenic pattern differences are the common risk factor to develop alloimmunization. This study was performed to determine the frequency of RBC alloimmunzation in sickle cell patients and healthy blood donors.Methods: This is a cross sectional study that has been done on 140 patients with SCD and 140 healthy blood donors from April 2015 to April 2016. The RBC phenotype of all patients and donors investigated by Tub method and all panel test phases were done at immunohematology laboratory of Iranian Blood Transfusion Organization of Ahwaz.Results: Of all SCD patients 61 (43.6%) were male and 79 (56.4%) were female. 68 (48.5%) were HbSS and 72 (51.4%) were S/B thalassemia. The mean age of patients was 19.69 (range: 2-60) years. Of all patients, 114 (81.25%) had received transfusion. The RBC alloimmunization rate among SCD patients was 7.1% and 50% of the RBC alloimmunization had anti-Kell and 30% had anti-Rh. The comparison of the RBC phenotypes between the group of patients with SCD and the group of blood donors (non-Arab) revealed a statistically significant difference in the frequency of S (54% vs. 67%, p=0.024), M (82.7% vs. 90.7%, p=0.049), and FYb (73.4% vs. 55.7%, p=0.002).Conclusions: Althoguh alloimmunization rate in SCD patients in this study was lower than reported by other studies but cross matchining at least for the Rh and Kell systems from the time of initial transfusion may decrease the incidence of alloimmunization.

Iron overload directly affecting the ovaries in a patient with Diamond–Blackfan anaemia: a case report

Iron is a ‘one-way’ element and the primary point of regulation of body iron stores is at the level of intestinal iron absorption. Repeated blood transfusions for congenital anaemias bypass this regulatory checkpoint and inevitably lead to iron overload in the long-term. Iron overload causes multi-organ dysfunction of the heart, liver, pancreas and joints. It also causes reproductive toxicity primarily through its damaging effect on the anterior pituitary leading to hypogonadotrophic hypogonadism. Another less understood mechanism of reproductive toxicity is direct gonadal damage of excess free iron. In this article, we present the case of a 24-year-old woman with Diamond–Blackfan anaemia who presented to our unit seeking fertility assistance. The evaluation revealed a combination of hypogonadotrophic hypogonadism and reduced ovarian reserve along with evidence of severe iron overload. A literature search along with input from clinical experts has allowed us to counsel the patient to help her make an informed choice. A multi-disciplinary approach which would include initial optimization of pre-conceptional health with aggressive iron chelation therapy and subsequent ovulation induction with gonadotrophins has been planned, failing which, egg donation may be the only viable alternative.

Serum ferritin, serum nitric oxide, and cognitive function in pediatric thalassemia major

Background Hemolysis and repeated blood transfusions in children with thalassemia major cause iron overload in various organs, including the brain, and may lead to neurodegeneration. Hemolysis also causes decreased levels of nitric oxide, which serves as a volume transmitter and slow dynamic modulation, leading to cognitive impairment.Objective To assess for correlations between serum ferritin as well as nitric oxide levels and cognitive function in children with thalassemia major. Methods This analytical study with cross-sectional design on 40 hemosiderotic thalassemia major patients aged 6−14 years, was done at the Thalassemia Clinic in Dr. Hasan Sadikin Hospital, Bandung, West Java, from May to June 2015. Serum ferritin measurements were performed by an electrochemiluminescence immunoassay; serum nitric oxide was assayed by a colorimetric procedure based on Griess reaction; and cognitive function was assessed by the Wechsler Intelligence Scale for Children test. Statistical analysis was done using Spearman’s Rank correlation, with a significance value of 0.05.Results Abnormal values in verbal, performance, and full scale IQ were found in 35%, 57.5% and 57.5%, respectively. Serum nitric oxide level was significantly correlated with performance IQ (P=0.022), but not with verbal IQ (P=0.359) or full scale IQ (P=0.164). There were also no significant correlations between serum ferritin level and full scale, verbal, or performance IQ (P=0.377, 0.460, and 0.822, respectively).Conclusion Lower serum nitric oxide level is significantly correlated to lower cognitive function, specifically in the performance IQ category. However, serum ferritin level has no clear correlation with cognitive function.

Hemolytic Anemia after Mitral Valve Repair: Case Report

Mechanical hemolytic anemia, although there is a well-known complication of mechanical valve replacement is reported to be rare after mitral valve repair. In this article, hemolytic anemia after mitral ring annuloplasty, undetectable improvement after repeated blood transfusions and tried to offer patients who underwent mechanical valve replacement.

Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus Infection in Multi-Transfused Thalassemic Patients, Kermanshah, Iran, 2015

Background: Repeated blood transfusions in Thalassemic patients predispose them to blood-borne infections including Hepatitis B, Hepatitis C, and human immunodeficiency virus. These infections cause cirrhosis, portal hypertension, and acquired immunodeficiency syndrome. Objectives: The current study aimed at determining the prevalence of these infections in Thalassemic patients of Kermanshah province, Iran. Methods: Thalassemic patients registered at Mohammad Kermanshahi university hospital were included. Demographic data, history of blood transfusions, Hepatitis B surface antigen (HBsAg), Hepatitis B core antibody (HBC Ab), Hepatitis B surface antibody (HBs Ab), Hepatitis C antibody, and Human immunodeficiency virus (HIV) antibody were extracted. Serologic tests were done using the third-generation enzyme linked immunosorbent assay (ELISA) and positive Hepatitis C virus (HCV) Ab and HIV Ab results was confirmed by Western Blotting. Results: A total number of 232 patients were enrolled (111 females and 121 males), among whom HBsAg and HIV Ab were both negative. Positive HBS Ab was reported in 222 subjects (95.7%) and 19 cases (8.2%) had positive HBC Ab. Immunity to hepatitis B was the result of vaccination in 87.5% of cases. Hepatitis C antibody was positive in 14 cases (6%). Finally, a significant relationship was found between HCV infection and blood transfusion done before 1996. Conclusions: High rate of hepatitis C was found to be due to the lack of screening for HCV Ab among blood donors before 1996. The negative HBS Ag can be justified by regular hepatitis B vaccination program in patients with thalassemia. The lack of HIV infection was concluded to be attributed to the low prevalence of this virus in the general population and blood donors as well as proper screening methods.

Ocular involvement in beta thalassemia major: a prospective study in an Indian cohort

Background: Thalassemia is the commonest haemoglobinopathies worldwide. Repeated blood transfusions lead to hemosiderosis which affects all the organs in the body including eyes. This study aims to study Ocular manifestations in these children and its correlation with age and serum Ferritin level.Methods: 75 children diagnosed with B-Thalassemia major (BTM) and on regular transfusions underwent detailed Ocular examination between 2013 and 2015, including visual acuity, slit lamp bio microscopy, direct & indirect Opthalmoscopy).Results: Mean age for children was 9.73 years, with 77 % males and 23% females. Average S. Ferritin being 2701.96 ng/dl. The most common eye changes seen were in the Retina (32%, n=24), Iris (34.7%, n=26) and lens (32%, n=24). Retinal changes were temporal Retinal thinning (29.3%, n=22), retinal venous engorgement (21.3%, n=16), vessel tortuosity (17.3%, n=13), atrophy of disc (17.3%, n=13). Lens opacities were seen in 32 %, posterior sub capsular haze, streaks in posterior capsule, and heterochromia in 34.7%. Retinal changes correlated with duration of disease in children above 10 years and with increasing Serum Ferritin levels.Conclusions: Corneal dryness, lenticular opacities, disc atrophy and thinning were observed in children with B- Thalassemia and on blood transfusions. These changes increased with duration of disease. Hence there is need to screen BTM adolescents and follow up.

Thalassemia Minor and Major:Current Management.

Thalassemia is a common genetic disorder. It has been estimated that in India nearly 5 crore people are thalassemia carriers. They are asymptomatic and are detected on blood tests. These people are at same risk of developing iron deficiency anemia as general population and need iron therapy in the presence of iron deficiency anemia. Nearly 12,000 children with thalassemia major (Homozygous state) are born every year. These children often present with significant anemia along with hepatosplenomegaly during infancy and require early diagnosis and institution of therapy with repeated blood transfusions and chelation therapy. Adequate dose of chelation therapy is essential to maintain serum ferritin around 1000ng/ml. With present protocol of management, thalassemic children have near normal life. Bone marrow transplantation offers cure for these children; results of bone marrow transplantation are best when performed below 7y of age.

EFFECT OF REPEATED BLOOD TRANSFUSION ON SOME BLOOD PARAMETERS

Background: Repeated blood transfusion causes a lot of complications in the body specially iron deposition in different organs in the body. Objective: Investigating the changes which occurred in the human body blood parameters on repeated blood transfusion. Subjects and methods: This study was performed at outpatient clinic, Faculty of Medicine, Al-Azhar University Hospital (Assiut). The patients were forty patients already diagnosed as thalassemic major and exposed to repeated blood transfusion and the following parameters were measured (oral glucose tolerance, plasma glucose level, plasma insulin level, C- peptide level, lipase level, serum iron, total iron binding capacity and serum Ferritin). Results: The study showed that hemosidtherosis affected the level of serum lipase which decreased in thalassemic patients as a model of hyperplastic anemia. Also, C-peptide level decreased in those patients more than control. This indicated that the pancreatic functions were affected by iron deposition. Also, serum iron and serum ferritin increased which led to decrease in the level of total iron binding capacity which caused by decrease in Hb level. Conclusion: Blood glucose level increased significantly in thalassemic patients while insulin level decreased in them. Serum Ferritin level was increased in thalassemic patients where the hemoglobin decreased. Serum lipase and C-lipase decreased in thalassemic patient

Study of Serum Calcium and Serum Phosphorus Levels in Patients of Thalassemia Receiving Repeated Blood Transfusion

Study of Serum Calcium and Serum Phosphorus Levels in Patients of Thalassemia Receiving Repeated Blood Transfusion

Immune Status 'in Children with Beta Thalassemia' in Correlation 'with Iron Overload': Single Center Egyptian Study.

'Beta thalassemia is inherited hemoglobin disorder resulting in chronic hemolytic anemia that requires lifelong transfusion therapy'. 'Repeated blood transfusions and RBCs hemolysis are the main causes of iron overload', which in addition to immune abnormalities, are common predisposing factors to infections in patients with thalassemia. The Aim of this Work: The aim of this work was to study immune status including T lymphocyte subsets and serum immunoglobulin levels 'in children with beta- thalassemia in correlation with iron overload'. The present 'study was conducted on 40 children with beta thalassemia major under follow up at Hematology Unit, Pediatric Department, Tanta University' 'including 24 males and 16 females with mean' age value of 9. 22 ± 3.9 years and 20 'healthy children of matched age and sex as a control group'. All children included in the study were subjected to; 'complete blood count, Hb electrophoresis, serum iron status', T cell subsets including CD3, CD4 and CD8 and serum immunoglobulin levels including IgM, IgA and IgG. 'Pallor and jaundice were the most common presenting' clinical manifestations. Infective episodes 'were significantly higher in patients' compared with controls. There were significantly lower Hb, MCV and MCH levels and significantly higher WBCs and platelets counts, reticulocytes and lymphocytes percentage in patients than controls and no significant differences in MCHC between patients and controls. Serum ferritin and iron were 'significantly higher but TIBC was significantly lower in' patients than controls. CD3, CD4 and IgM were significantly lower but CD8, IgG, and IgA 'were significantly higher in patients than controls' with negative correlation between CD3, CD4, IgM and ferritin and positive correlation between CD8, IgG, IgA and ferritin. Iron overload can affect humeral and cell mediated immunity in patients with beta thalassemia with reduction of IgM, CD3 and CD4 and elevation of CD8, IgG, and IgA. Regular follow up of patients with beta thalassemia for detection of iron overload as it affects humeral and cell mediated immunity.

Red cell alloimmunization in repeatedly transfused patients.

INTRODUCTION:Repeated blood transfusions can result in the production of alloantibodies against one or more red cell antigens, which complicates subsequent transfusions. Aims: The study was done to find incidence of various red cell alloantibodies; to determine the type of alloantibody; to identify the factors such as frequency of transfusion, splenectomy status, donor ethnicity and gender and their association with the development of antibody in repeatedly transfused patients.MATERIALS AND METHODS:This study was carried out in Dept. of IHBT, Shree M. P. Shah Medical College, Jamnagar, Gujarat. Blood was taken from the patients of thalassemia major, sickle cell disease, chronic renal failure, post partum haemorrhage, aplastic anemia, Myelodysplastic syndrome with more than 10 red cell transfusions. The plasma/serum was used for antibody screening and antibody identification test. Three cell antibody screening was performed using antihuman globulin gel cards (ID-Card LISS/Coombs) and three cell panel (ID-DiaCell I, II, III-Asia). Those with positive antibody screening were analyzed further for antibody identification test using eleven cell panel (Set ID-Dia Panel).RESULTS:Antibody screening and identification was done in 2 consecutive set of samples (n = 300) which showed, nine (9) patients (3%) were alloimmunized. All repeatedly transfused patients had developed alloantibody before the starting of study period, no patient developed new alloantibody during study period.CONCLUSIONS:Alloantibodies should be identified in repeatedly transfused patients and should be given corresponding antigen negative blood unit which will minimize the antibody mediated destruction of transfused red cells.

Correlation between Serum Malondialdehyde and sVCAM-1 in Pediatric Thalassemic Patients with Hypercoagulation

Introduction: Repeated blood transfusions with increased intestinal iron absorption in thalassemia causes iron overload, catalyzed production of various reactive oxygen species subsequently trigger oxidative stress. Endothelial as the first organ exposed to reactive oxygen species would suffer a marked increase in adhesion molecule due to endothelial dysfunction that will trigger a hypercoagulation. Objective: To investigate the correlation between oxidative stress status (malondialdehyde, MDA) and endothelial dysfunction (serum Vascular Cell Adhesion Molecule-1, sVCAM) in iron overload pediatric thalassemic patients with hypercoagulation. Methods: A cross-sectional study was conducted on thalassemic subjects with inclusion criteria: aged 5 - 14 years with iron overload who had hypercoagulation based on TEG (Throm-boelastography) examination. The determination of thalassemia degree was based on a Novel scoring system. The correlation between serum MDA and sVCAM-1 was analyzed using Rank Spearman, with a significance value of 5% and 95% confidence intervals. Results: Nineteen male and twelve female children were included in the study. All subjects had pretransfusion Hb p = 0.02, r = 0.416). The results also showed that there was a significant difference between serum MDA and thalassemia degree (p = 0.029, p = 0.026). Conclusions: Serum MDA level as stress oxidative status marker has moderately positive correlation with sVCAM-1 as endothelial dysfunction marker in iron overloaded pediatric thalassemic patients with hypercoagulation.

Neoadjuvant Chemotherapy for Duodenal GIST: A Case Report

The principal treatment for gastrointestinal stromal tumors (GISTs) is surgical; and complete excision is important, but cannot always be achieved. For such cases, neoadjuvant chemotherapy (NAC) with imatinib mesylate (IM) has been recommended. A case of a GIST of the second portion of the duodenum for which pancreatoduodenectomy was indicated, and for which partial resection was made possible as a result of cytoreduction by IM NAC, is reported. A 64-year-old man with pancytopenia due to hepatic cirrhosis caused by hepatitis C infection received repeated blood transfusions because of anemia of unknown origin starting 2 years earlier. Most recently, the patient had melena with hemoglobin of 5.1 mg/dL. Diagnostic imaging showed a solid tumor, 55 × 48 × 65 mm3, in the second portion of the duodenum showing mainly extramural development. Endoscopic aspiration biopsy showed proliferation of KIT-positive spindle-shaped heterotypic cells. GIST was diagnosed, and an exon 11 KIT mutation was found. Because of the exon 11 mutation, neoadjuvant IM was started at 400 mg/day and then eventually maintained at 300 mg/day for 10 months. Regular CT examinations showed gradual tumor shrinkage. At surgery, a tumor with strong extramural growth was found on the outer side of the duodenum that invaded the retroperitoneum. The tumor was excised as a mass, and the duodenum was resected partially. There has been no recurrence at 9 years postoperatively. Evaluating KIT exon mutations and predicting the effectiveness of NAC appear useful for determining the treatment policy for advanced GISTs.

Selenoproteins are involved in antioxidant defense systems in thalassemia.

Thalassemia major (TM) is a hereditary blood disease that affects the production of hemoglobin, resulting in severe anemia. Iron overload because of repeated blood transfusion and increased intestinal iron absorption and hemolysis are the major causes of increased oxidative stress in these patients. Growth and maturational delay, cardiomyopathy, endocrinopathies, and osteoporosis are the complications of thalassemia, secondary to anemia and iron overload. The human body has endogenous defense mechanisms to help protect against free radical-induced cell damage. Selenoproteins are important enzymes involved in these antioxidant defense mechanisms. In thalassemia patients, selenoproteins are essential because of their potential defense against oxidative damage due to iron overload and hemolysis. The aim of this review is to provide an overview of data regarding selenoproteins including glutathione peroxidase, thioredoxin reductase and iodothyronine deiodinases in TM patients. We also underline some complications of thalassemia that may be associated with selenoproteins.

Oxidative stress in pediatric patients with β thalassemia major

Background β-thalassemia major (β-TM) is a common inherited hemolytic type of anemia. Repeated blood transfusions predispose β-TM patients toward peroxidative tissue injury because of secondary iron overload. Objectives This study aimed to evaluate the effects of iron overload on antioxidant enzymes and liver cell damage in β-TM patients undergoing regular blood transfusions. Patients and methods This prospective case–control cohort study included 30 pediatric patients with a confirmed diagnosis of β-TM on regular blood transfusions and 20 age-matched and sex-matched healthy children attending the Qena University Hospital, Pediatric Clinic. Blood samples were withdrawn from each patient to measure serum levels of ferritin, glutathione peroxidase (GPX), and superoxide dismutase (SOD). Results Total bilirubin, aspartate transaminase (AST), alanine transaminase (ALT), and ferritin levels were significantly higher in the β-TM group (P Conclusion Impaired levels of antioxidant enzymes SOD and GPX in patients with β-TM on repeated transfusion, in addition to excessive free iron concentration, iron overload may attribute to oxidative damage in these patients. Antioxidant systems that compensate for reduced lipid peroxidation to lower tissue damage are needed.

Chronic anemia and thyroid function.

Anaemia is a global public health problem affecting both developing and developed countries with major consequences for human health as well as social and economic development. It occurs at all stages of the life cycle, but is more prevalent in pregnant women and young children. Iron deficiency anaemia (IDA) impairs thyroid metabolism in animals and human and may negatively affect growth and develpment of children. On the other hand both overt and subclinical hypothyroidism are associated with anemia and adding iron to thyroxine therapy improves both conditions compared to thyroxine therapy alone. In addition patients with chronic hemolytic anemia requiring repeated blood transfusion have high prevalence of hypothalamic-pituitary thyroid axis. Both primary hypothyroidism and central hypothyroidism occur in these patients with increasing prevalence with age, severity of the anemia and higher ferritin concentration denoting poor chelation. Proper blood transfusion and intensive chelation appears to prevent deterioration of thyroid function and in many cases can reverse thyroid pathology. Physicians treating these forms of anemia should be aware of thyroid disorders in these patients for early screening, prevention and proper management of any thyroid dysfunction. (www.actabiomedica.it)

ANEMIA

Iron, folate and B12 deficiencies are the common throughout in the world.National survey 2011 conducted in Pakistan revealed; nutrition anemia is 50.5% in womenof child bearing age and 51% in pregnant women. Iron, folate, and B12 can be correctedby oral/, injectable and dietary supplementation however it takes 3-6 months treatment. Thepatients are symptomatic in moderate to severe anemia. Erythropoietin injection stimulateerythropoiesis in bone marrow and addition of iron ,folate B12 , improve heamoglobin up to10g/dl after 04 weeks therapy .There is immediate symptomatic improvement and it avoidsmultiple blood transfusion. Objectives: To determine the efficacy of erythropoietin in correctionof heamoglobin along with supplementation of iron, folate, and B12 for a period of 04 weeks.Period: January 2015-December 2015. Study Design: A prospective descriptive study. Placeof Study: Mohi-Ud-Din Teaching Hospital Mirpur AJK. Results: Among 110 selected male andfemale patients, (age ranging 20-50 years), after erythropoietin injection plus iron,folateB12supplementation, the reticulocytes and heamoglobin increased from 1.2 to11% and 4.5 to 10.5g/dl respectively after 04 weeks therapy. Conclusion: Erythropoietin injection plus iron, folate,B12 supplementation is an effective way of erythropoiesis for correction of anemia after 04weeks therapy. This immediately improved symptoms &sign of anemia thus avoiding the needof repeated blood transfusion.

English

Iron, folate and B12 deficiencies are the common throughout in the world.National survey 2011 conducted in Pakistan revealed; nutrition anemia is 50.5% in womenof child bearing age and 51% in pregnant women. Iron, folate, and B12 can be correctedby oral/, injectable and dietary supplementation however it takes 3-6 months treatment. Thepatients are symptomatic in moderate to severe anemia. Erythropoietin injection stimulateerythropoiesis in bone marrow and addition of iron ,folate B12 , improve heamoglobin up to10g/dl after 04 weeks therapy .There is immediate symptomatic improvement and it avoidsmultiple blood transfusion. Objectives: To determine the efficacy of erythropoietin in correctionof heamoglobin along with supplementation of iron, folate, and B12 for a period of 04 weeks.Period: January 2015-December 2015. Study Design: A prospective descriptive study. Placeof Study: Mohi-Ud-Din Teaching Hospital Mirpur AJK. Results: Among 110 selected male andfemale patients, (age ranging 20-50 years), after erythropoietin injection plus iron,folateB12supplementation, the reticulocytes and heamoglobin increased from 1.2 to11% and 4.5 to 10.5g/dl respectively after 04 weeks therapy. Conclusion: Erythropoietin injection plus iron, folate,B12 supplementation is an effective way of erythropoiesis for correction of anemia after 04weeks therapy. This immediately improved symptoms &sign of anemia thus avoiding the needof repeated blood transfusion.

Pregnancy with Paroxysmal Nocturnal Hemoglobinuria (PNH) : A Case Report

Paroxysmal nocturnal hemoglobinuria (PNH) resulting from failure of expression of anchoring protein glycosylphosphatidylinositol (GPI), is an uncommon acquired hemolytic anemia manifested by hemoglobinuria, abdominal pain, smooth muscle dystonia, fatigue and thrombosis. Pregnancy with PNH is rare, and studies showed an increased risk of foetomaternal complications even death due to worsening cytopenias and consequent thrombosis. Here we reported a case of PNH in pregnancy. Mrs. Nasima, aged 25 years, para: 0+0, was diagnosed as a case of PNH by flowcytometry analysis on granulocytes about 1 year 3months back. Her pregnancy was no planned and she was not on antenatal care but took consultation from haematologist time to time. Her Hb level was 7-8gm/dl throughout pregnancy and needed repeated blood transfusion for anaemia. She was referred from a nearby clinic at 37 weeks of pregnancy with PROM and labour pain to the Foetomaternal medicine wing of Obs & Gynae department of BSMMU. On admission she was mildly icteric. She was treated with steroid as per consultation of haematologist. Due to failure of progress of labour emergency caesarean section was done under spinal anesthesia and a low birth weight female baby of 1.6 kg was delivered. One unit of blood transfusion was given post operatively.Bangladesh J Obstet Gynaecol, 2014; Vol. 29(2) : 111-115