How should I manage a 30‑year‑old woman with severe anemia, marked thrombocytosis, menorrhagia, and asthma?

Management of Severe Anemia with Thrombocytosis in a Young Woman with Menorrhagia

This patient requires immediate packed red blood cell transfusion followed by intravenous iron replacement, with concurrent gynecologic evaluation to control menorrhagia—the hemoglobin of 5.9 g/dL is life-threatening and demands urgent correction regardless of hemodynamic stability. 1

Immediate Transfusion Protocol

• Transfuse 2-3 units of packed red blood cells immediately to achieve a target hemoglobin of 7-9 g/dL, as each unit raises hemoglobin by approximately 1 g/dL 1
• Monitor vital signs continuously during transfusion to detect transfusion reactions, and assess for signs of volume overload including dyspnea, pulmonary crackles, and elevated jugular venous pressure 1
• Recheck hemoglobin 1 hour post-transfusion to confirm adequate response, then monitor daily until stable 1
• Given the patient's young age (30 years) and severe anemia, consider a higher transfusion target (>8 g/dL) to ensure adequate oxygen delivery 1

Concurrent Diagnostic Workup

While transfusion proceeds, obtain the following without delay 1:

• Complete blood count with differential and reticulocyte count to assess bone marrow response 1
• Peripheral blood smear to evaluate red cell morphology and confirm the marked thrombocytosis 1
• Iron studies (serum ferritin, transferrin saturation, total iron-binding capacity) to confirm iron deficiency as the cause 2, 1
• Vitamin B12 and folate levels to exclude nutritional deficiencies 1
• Serum creatinine and estimated glomerular filtration rate 1

Understanding the Thrombocytosis

• Extreme thrombocytosis (platelets 1200 × 10⁹/L) is reactive and secondary to severe iron deficiency, not a primary hematologic disorder 3, 4
• The peripheral smear will show marked microcytic hypochromic cells with increased platelets 3
• This thrombocytosis will resolve with iron replacement—do not treat the elevated platelet count itself 3, 4

Critical caveat: While thrombocytosis is typical, rare cases of iron deficiency present with thrombocytopenia instead 3, 5, 4. The platelet count of 1200 confirms reactive thrombocytosis in this case.

Iron Replacement Strategy

Initiate intravenous iron immediately after initial transfusion, as oral iron will be inadequate for this degree of deficiency 2:

• Ferric carboxymaltose (Injectafer) 750 mg IV on day 1, repeat in 7 days for a total cumulative dose of 1,500 mg per course 6
• Alternatively, for patients ≥50 kg, a single dose of 1,000 mg IV may be administered 6
• IV iron is first-line for severe anemia (hemoglobin <7 g/dL) rather than oral supplementation 2
• Expect the need for regularly-scheduled iron infusions until menorrhagia is controlled 2

Monitoring Iron Replacement

• Assess adequacy of response at 1 month: hemoglobin should rise ≥1.0 g/dL with normalization of ferritin and transferrin saturation 2
• Check serum phosphate levels before any repeat course within 3 months, as IV iron can cause hypophosphatemia 6
• Continue monitoring hemoglobin every 3 months for 1 year, then annually 2

Addressing the Menorrhagia

Urgent gynecologic consultation is essential to control the source of bleeding 2:

• Menorrhagia is the primary driver of this patient's iron deficiency and will cause recurrent anemia unless addressed 2, 7
• Without controlling menstrual blood loss, iron replacement alone will not maintain adequate hemoglobin 2
• Consider hormonal therapies, endometrial ablation, or surgical intervention depending on gynecologic evaluation 2

Asthma Considerations

• Asthma is not a contraindication to blood transfusion or IV iron, but monitor for allergic reactions during IV iron administration 6
• Ferric carboxymaltose has a low risk of anaphylaxis, but emergency equipment should be available 6

Expected Clinical Course

• The thrombocytosis will normalize with iron replacement—expect platelet counts to decrease to normal range within 2 months of adequate iron therapy 3, 4
• Symptoms of fatigue and dizziness should resolve as hemoglobin improves 7
• Failure to achieve hemoglobin rise ≥1.0 g/dL at 1 month warrants hematology consultation to evaluate for additional causes of anemia 2, 1

Common Pitfalls to Avoid

• Do not delay transfusion while awaiting complete diagnostic workup—treatment and diagnosis proceed simultaneously 1
• Do not use oral iron as initial therapy for hemoglobin 5.9 g/dL—it is too slow and inadequately absorbed in severe deficiency 2
• Do not treat the thrombocytosis with antiplatelet agents or aspirin—it is reactive and will resolve with iron replacement 3, 4
• Do not use erythropoiesis-stimulating agents (ESAs) for acute management—their onset is too slow for severe anemia 1
• Do not assume hemodynamic stability means transfusion can be deferred—hemoglobin 5.9 g/dL requires immediate correction even in stable patients 1, 7