It has been appreciated for nearly 30 years that a severe macrocytic type of anaemia occurs rather frequently in -pregnant women in India. A recent article by Mudaliar and Menon' gives a good account of the disease. Anaemia of all forms is unduly common in pregnant women in Madras; over 70 % of them are anaemic by Western European standards. Macrocytic anaemia of pregnancy is actually more frequent there than pre-eclamptic toxaemia, and 103 cases were found in 1,200 admissions to the ante-natal wards. It manifests itself in the second or third trimester, and the presenting symptoms are oedema, dyspnoea, diarrhoea, heartburn, nausea, and vomiting. Labour is often premature and precipitate, and the gross maternal mortality is approximately 25 %. The anaemia may be profound, and haemoglobin values ranged from 50% to less than 10%. By definition the anaemia in Mudaliar and Menon's cases was macrocytic-i.e., the mean volume of the red cells in all the women was above 85 cu. microns. Nevertheless, in nearly one-third the colouLr index was below unity, even as low as 0.5, which means that, though the red cells were always larger than normal, they were often incompletely filled with haemoglobin. In the shorthand of haematology the anaemia in this subgroup was macrocytic hypochromnic, and by inference due to shortage of both P.A. factor and iron. Megaloblasts were always present in plenty in the blood films. Complete achlorhydria was unusual, and the diet differed in no way from that of the normal Madras woman admitted for confinement. Malaria and kala-azar were not aetiological factors, but hookworm infestation was a dangerous and not uncommon comnplication. Recovery is complete, but relapse may occur in subsequent confinements. The risk is not great, and is an admonition to supervision and not suspension of further pregnancies. In treatment marmite was disappointing, but good results were obtained with liver given parenterally. In exceptional cases the anaemia may not respond to liver therapy before delivery, and transfusion should then be employed in addition.So long as search was confined to cases with a peripheral blood picture identical with that of Addison's anaemia, pernicious anaemia of pregnancy remained a haematological curiosity in Western Europe and the U.S.A. But macrocytosis is only one feature of the haematology of the anaemias due to deficiency of the P.A. factor. More pathognomonic characters are the presence of megaloblasts in the peripheral blood smear along with megaloblastic degeneration of the bone marrow, and the therapeutic response to treatment by liver. The rather sharp controversy in our correspondence columns2 over the definition of the megaloblast may have shaken the faith of our readers in the second of these criteria, but this would be to misunderstand the point at issue. Classical teaching is that the megaloblast is a cell which is found only in foetal life and in anaemias due to lack of P.A. factor, and which is incapable of developing into a normoblast and normal red
