One of the most frequent public health challenges in the world is anaemia; women of the reproductive age are especially susceptible to the disease because of their unique physiological needs, such as menstruation, pregnancy, and lactation.1,2 Being determined by the World Health Organization (WHO) as the level of haemoglobin that is less than 12 g/dL in non-pregnant women and less than 11 g/dL in pregnant women, anaemia has health effects that are far- reaching, including the limitation of working capacity, impaired cognitive functions, maternal morbidity, preterm childbirth, and low birth weight in babies. The current World statistics indicate that about 30-34 percent of women aged 15-49 years are anaemic and this translates to about half a billion women and higher in pregnant women.3

The latest studies and pooled analyses of the Global Burden of Disease indicate that though some improvement has been made over the last two decades, this is slow and inadequate to accomplish the aim of the World Health Assembly to reduce anaemia among women of reproductive age by half in the forthcoming 2025. The disproportion is experienced in South Asia with India taking the greatest share. According to the National Family Health Survey (NFHS-5, 2019-21) 57 percent of Indian women of reproductive age are anaemic, which is higher than 53 percent in NFHS-4 (2015-16).4 There are states and even districts where the prevalence rates are above 60, which is a sign not only of the continuation but also aggravation of the issue, even though national iron-folic acid supplementation and nutrition programs are still in place. These statistics help to understand that anaemia among this population is not only a health concern but also one of the challenges of the health systems in the population.

Determination of the cause of anaemia cannot be done based on haemoglobin concentration alone. Morphological classification, which is a peripheral blood smear examination, gives important information on the nature as well as the etiology of anaemia. The most frequently identified forms of iron deficiency or thalassaemia traits are microcytic hypochromic anaemia, which is marked by a decrease in the mean corpuscular volume (MCV) and mean corpuscular Haemoglobin (MCH), and most cases of anaemia in reproductive-aged women.5,6 Normocytic anaemia tends to be associated with either acute blood loss or anaemia of chronic disease and macrocytic anaemia indicates folate or vitamin B12 deficiency, alcoholism, or liver disease. Dimorphic anaemia with characteristics of microcytic and macrocytic cells is usually a manifestation of simultaneous nutritional deficiencies or combined haemoglobinopathy and iron deficiency. These morphological results should be confirmed by automated red cell indices (MCV, MCH, mean corpuscular haemoglobin concentration (MCHC), red cell distribution width (RDW) to reduce the differential diagnosis. Red cell indices provide an inexpensive and reliable method of screening and classifying and providing information about a further diagnostic study in resource limited settings where the use of detailed biochemical and genetic diagnostics is not readily available.

AIM: Evaluation of Morphological Patterns of Anaemia and correlations with Red Cell Indices in females of reproductive age group.

OBJECTIVES:

1. To categorize the anaemia morphologically in females of reproductive age group.
2. To analyze the variation in the hematological indices and severity of anaemia in the study population.

Complete blood count (CBC) was performed in 400 anaemic females using EDTA- anticoagulated blood samples on a Fully Automated 5-Part Differential Hematology Analyzer (Sysmex). Peripheral blood smears were prepared from the same EDTA samples. The smears were stained with Leishman stain using standard procedures. Morphological evaluation of red blood cells was carried out under light microscope. Serum ferritin was assessed in 100 pregnant women by using Bio Merieux Mini VIDAS system. A detailed clinical history was obtained from all participants, including dietary habits, menstrual history, obstetric history, history of chronic illness, medication intake, and prior treatment for anaemia. A thorough general and systemic examination was performed. Under aseptic precautions, 3 mL of venous blood was collected from each participant into EDTA vacutainers. Samples were processed promptly to avoid pre-analytical errors. i. Inclusion Criteria • Females aged 15–49 years with anaemia as per WHO criteria (Hb < 12 g/dl).58 ii. Exclusion Criteria • Smears showing pathological diagnoses other than anaemia. • Females with a history of blood transfusion within the last three months. • Females with a history of iron therapy or vitamin B12/folic acid supplementation in the past one month.

Table 1: Age-wise Distribution of Study Participants

The age-wise distribution of study participants shows that the majority of cases were in the 30–39 years age group, comprising 35.5% (142 cases) of the total sample, followed closely by the 20–29 years group with 33% (132 cases). Participants aged 40–49 years accounted for 19.5% (78 cases), while the smallest proportion was observed in the 15–19 years group, contributing only 12% (48 cases). Overall, the data indicates that the highest representation came from individuals in their second and third decades of life, highlighting a predominance of participants in the younger to middle age categories.

Table 2: Parity wise distribution of Participants

The parity history of the 400 participants shows that the majority had a history of 1–2 pregnancies (45.5%), followed by those with 3–4 pregnancies (25.5%). Nulligravida women constituted 20% of the study population, while a smaller proportion, 9%, had a higher parity of five or more pregnancies. This distribution indicates that most participants were multiparous, with comparatively fewer nulligravida and grand multiparous women.

Table 3: Clinical Symptoms Reported (Multiple Response)

The analysis of clinical symptoms reported in the study reveals that pallor was universally present in all cases (100%). Fatigue was the second most common symptom, observed in 72% of cases, followed by dyspnea on exertion in nearly half of the participants (49%), indicating significant compromise in physical activity tolerance. Palpitations were reported by 37% of individuals, reflecting cardiovascular strain associated with the underlying condition, while giddiness was comparatively less frequent, affecting 21% of cases. These findings suggest that while pallor and fatigue are predominant

indicators. Palpitations, and giddiness vary in prevalence and may reflect differing severity or stages of disease progression.

Table 4: Morphological Types of Anaemia (Peripheral Smear)

The distribution of morphological types of anaemia among 400 cases based on peripheral smear examination. Microcytic hypochromic anaemia was the most prevalent type, observed in 206 cases, accounting for 51.5% of the total, indicating a predominant occurrence of iron-deficiency or chronic disease-related anaemia in the studied population. Normocytic normochromic anaemia was the second most common type, seen in 128 cases (32.0%), which typically reflects anaemia of acute blood loss or chronic disease where red blood cell size and hemoglobin concentration remain normal. Macrocytic anaemia was the least frequent, affecting 66 cases (16.5%), suggesting the presence of vitamin B12 or folate deficiency in a smaller segment of the population. Overall, these findings indicate that more than half of the females in the study population exhibit microcytic hypochromic anaemia, highlighting the significant burden of iron-deficiency- related anaemia in the reproductive age group. No dimorphic red cells were detected.

Table 5: Association of MCHC with Morphology

X² = 104.78, d. f = 4, P < 0.05

The association between mean corpuscular hemoglobin concentration (MCHC) and red blood cell morphology among the study participants. Microcytic hypochromic cells predominantly exhibit low MCHC, with 160 cases falling in this category, while only 42 and 4 cases show normal and high MCHC, respectively, indicating a strong association between microcytosis with hypochromia and reduced hemoglobin concentration. Normocytic normochromic cells are mostly associated with normal MCHC, as evidenced by 106 cases, though 18 cases still present with low MCHC and 4 with high MCHC, reflecting minor deviations in hemoglobin content. Macrocytic cells demonstrate a distinct pattern, with the majority showing either normal (46 cases) or high MCHC (20 cases) and none with low MCHC, highlighting that macrocytosis is more likely linked to normal or elevated hemoglobin concentration per cell.

In the present study, the majority of participants were in the 20–39 years age group, representing the most active reproductive period. This is comparable to the demographic distribution reported by Patel et al. (2024)7 and Nida Mehreen et al. (2024)8, who also observed a higher representation of women in the second and third decades of life in their anaemic cohorts. This age predominance reflects increased healthcare-seeking behavior during pregnancy and childbirth, as well as the cumulative impact of menstruation, nutritional inadequacy, and repeated pregnancies on iron stores.

Clinical symptomatically in the present study correlated well with severity. Pallor was universal, while fatigue, dyspnea on exertion, and palpitations were common, particularly in moderate and severe cases. Similar symptom patterns were reported by Hafiz et al. (2019),9 where pallor and easy fatigability were the predominant complaints. These manifestations reflect reduced oxygen- carrying capacity and compensatory cardiovascular strain. The high prevalence of symptomatic anaemia reinforces that the condition in this population is not merely laboratory-defined but clinically significant, affecting daily functioning and quality of life. 

The predominance of microcytic hypochromic morphology in the present study underscores iron deficiency as the most common underlying pathology. Females of reproductive age are uniquely vulnerable due to physiological iron loss during menstruation, increased requirements during pregnancy and lactation, and often inadequate dietary intake of bioavailable iron. This is compounded by socioeconomic constraints and dietary practices that limit consumption of heme iron. Saba et al.10 in their comparative evaluation of iron deficiency anaemia, demonstrated that the majority of anaemic females had depleted iron stores, corroborating the nutritional basis of microcytic hypochromic patterns. These findings collectively suggest that, despite ongoing public health interventions, iron deficiency continues to dominate the anaemia landscape in this population.

Normocytic normochromic anaemia constituted nearly one-third of cases (32.0%) in the present study. This morphological pattern is typically associated with anaemia of chronic disease, acute blood loss, hemolysis, and early stages of nutritional deficiency. Comparable proportions have been reported by Ashok et al.11 and Rajurkar et al.12 who observed that a substantial subset of anaemic patients exhibited normocytic morphology. In reproductive-age females, this pattern may reflect early iron deficiency before overt microcytosis develops postpartum blood loss, or underlying inflammatory conditions. The substantial proportion of normocytic anaemia in the present study highlights that not all anaemia in this age group is overtly microcytic and that reliance on hemoglobin alone may obscure evolving nutritional deficiency or systemic disease.

The presence of mixed morphological patterns in a subset of cases reinforces the need for an integrated diagnostic approach combining clinical assessment, red cell indices, smear examination, and selective biochemical testing. In conclusion, this hospital-based observational study demonstrates that microcytic hypochromic anaemia, predominantly due to iron deficiency, is the most common morphological type among women of reproductive age.

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