A woman born 1961. She is a technician with international travels. She eats a vaired
Swedish diet. Normal body weight. As part of a routine gynecological examination in 1989
blood tests show Hb 136 g/L and MCV 99 fl. The gynecologist reacts upon the unsuspected
MCV and serum cobalamins are analyzed. It is 70 pmol/L in one test, confirmed again to 80
( local reference range 110 - 650 ). She is prescribed oral B 12 substitution, which she
takes in a sporadic way.
After a year she is referred to a hospital specialist in internal medicine. Serum
cobalamins are again confirmed to be 88 pmol/L. She is investigated with negative outcomes
for the Shilling test, parietal cell antibodies, contrast X-ray of the small bowel,
biopsies from stomach and duodenum.
The patient is then suspected to have intestinal parasites due to multiple travels to the
African continent. Microscopy of fecal specimens are reported to be positive for eggs of
Schistosoma . Such findings are rara in Sweden. The microsopist was excited. After a week
of brooding, the initial diagnosis was rejected in favour of the more common differential
diagnosis “birch pollen”.
Thereafter the patient is substituted with intramuscular B12 with good compliance and MCV
returns to 87 fl. Three years later she has an early spontaneous abortion. As her wish to
have a child is strong, it is decided to continue her substitution. A cease of
supplementation would otherwise at that time have been tempting, to see if she again
develops low B12-associated laboratory values.
A year later she gives birth to a child with biliary atresia and cardiac vitium, who dies.
A year later she has a new pregnancy, and that child is born healthy. Thereafter she has a
fourth pregnancy that is terminated due to chromosome abnormality found in the amnion
fluid.
At that stage she plans no more children and the B12 substitution is terminated in
1996. She is then followed with tests for cobalamins, methyl malonate and homocysteine.
All remain normal until today.
Two years later she is, however, again pregnant. A difficult decision is taken not to
start the B12 substitution. She is followed during the pregnancy with short interval blood
tests and all parameters remain normal. A healthy child is born.
To conclude, this woman has given birth to two healthy children after five pregnancies.
One child was born during ongoing B12 substitution, the other without. Initially the woman
has had B12 deficiency in repeated tests for at least one year without any detectable
reason.
Updated september 23, 1999