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Evaluate the patient’s admitting history and physical. Are there any signs or symptoms that
support the diagnosis of anemia?
The patient has several signs and symptoms that support anemia. This patient has presented with pale
skin and reports fatigue and SOB, all of which support the diagnosis of anemia.
1.
2.
What laboratory values or other tests support this diagnosis? List all abnormal values and
explain the likely cause for each abnormal value.
● Hemoglobin (Hgb) levels are below reference range of 12-15 g/dL1.
○ Likely causes for this abnormal value for Hgb include: pregnancy, anemia,
malnutrition, deficiencies of iron, copper, folic acid, B6 and B12, as well as
pharmacological agents such as chemotherapy drugs2.
● Total iron binding capacity (TIBC) is above reference range for a normal individual 240450 mcg/dL1.
○ Likely causes for higher than normal TIBC include iron-deficiency anemia and
pregnancy3.
● Ferritin levels are below reference range of 20-120 mcg/dL1.
○ Likely causes for lower than recommended levels for ferritin include irondeficiency anemia, poor iron absorption secondary to intestinal condition, or
heavy menstrual bleeding4.
● Hematocrit (Hct) levels are below reference range of 37-47%1.
○ Likely causes for lower than recommended values for Hct include anemia,
bleeding, malnutrition, and nutritional deficiencies of iron, folate, B12 and B65.
● Folate levels are below reference range of 5-25 ng/dL1.
○ Likely causes for lower than recommended values for folate include low fruit and
vegetable intake and certain medications6.
● Mean cell volume (MCV) value is below the reference range of 80-96 mcm3, indicating
microcytic anemia1,7.
○ Likely causes for lower than recommended values for MCV include: iron
deficiency, blood disorders, or inflammation7.
Mean cell Hgb, mean cell volume, and RBC count are all below reference range. These values alone can
be used to diagnose anemia2,7. Overall, these values support the patient’s diagnosis of anemia. The values
aforementioned are outside the reference values, which can be attributed to her increased needs during
pregnancy, anemia diagnosis, not consuming a nutrient-rich diet, and/or lack of adherence to prenatal
vitamin therapy.
Mrs. Morris’s physician ordered additional lab work when her admitting CBC revealed a
low hemoglobin. Why is this a concern? Are there normal changes in hemoglobin associated
with pregnancy? If so, what are they? What other hematological values, if any, normally
change in pregnancy.
Low hemoglobin levels can be concerning due to their strong indication of iron-deficiency anemia, which
in the case of a pregnant female can cause damage to the fetus through several mechanisms1. However, it
is very common for blood volume to expand during pregnancy lending to the tendency of hemoglobin to
decrease naturally during pregnancy1. Because of the generalized effects pregnancy has on the body, it is
required to conduct other tests that identify mean cell volume, hemoglobin, hematocrit, among other
3.
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things to truly determine if an anemia diagnosis is warranted. Additionally, it is common to see reduced
serum albumin and water-soluble vitamins and an increased cardiac output and accumulation of fatsoluble vitamins during pregnancy1.
4.
There are several classifications of anemia. Define each of the following: megaloblastic
anemia, pernicious anemia, normocytic anemia, microcytic anemia, sickle cell anemia, and
hemolytic anemia.
● Megaloblastic Anemia: Characterized by very large, underdeveloped, and abnormal red
blood progenitors in the bone marrow. This causes the bone marrow to produce less
RBCs with lower life spans. These cells are usually oval and caused by folate/B12
deficiency1.
● Pernicious Anemia: Categorized as a megaloblastic, macrocytic anemia. A decrease in
RBC that occurs when the intestines can not properly absorb B12, commonly due to lack
of IF. Usually caused by weakened stomach lining and an autoimmune condition. The
average age of diagnosis is 60 yrs1.
● Normocytic Anemia: Low levels of normal sized RBC. The most common cause of
acquired normocytic anemia is due to chronic disease8.
● Microcytic Anemia: Small, usually hypochromic, RBC most commonly caused by low
Iron. Characterized by low MCV (less than 83 micron 3)9.
● Sickle Cell Anemia: Most common form of sickle cell disease, a chronic hemolytic
anemia, in which the body makes sickle shaped red blood cells. These abnormally shaped
cells get caught in capillaries and don’t carry oxygen well. In sickle cell anemia, cells
that should live for ~120 days, die after 10-20 days1.
● Hemolytic Anemia: A condition due to defects in RBC that lead to oxidative damage,
lysis, removal from blood stream before lifespan is over1.
5.
What is the role of iron in the body? Are there additional functions of iron during fetal
development?
Pregnant women require 27mg/d of iron as compared to the iron recommendation of 8.1 mg/d for
menstruating females1. This increase is due to expanding volemia and fetal demands during pregnancy1.
Given its ability to participate in redox reactions throughout the body, iron’s primary function is
transportation of oxygen through the blood as a Hgb-oxygen complex, or in muscle with myoglobinoxygen complex1. Supporting roles of iron can be found in the electron transport chain in the form of
cytochrome system, critical structure in several enzymes, and may be involved in immune reactions1.
Iron, also, interacts with other vitamin and minerals such as Vit. C, Copper, and Calcium1.
6.
Several stages of iron deficiency actually precede iron-deficiency anemia. Discuss these
stages - including the symptoms - and identifying the laboratory values that would be
affected during the stage.
There are 4 sequential stages associated with altered iron status. The first two stages are categorized by
depletion of iron stores with Stage I being moderate depletion and Stage II severe depletion1. During
these stages there is decreased iron stores without decreased serum iron, increased iron absorption,
decreased ferritin, and decreased bone marrow iron1. Hgb, MCV & transferrin saturation are all WNL
during Stages I and II1. Stage III is categorized by iron deficiency; in this stage, iron stores are exhausted
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while Hgb/MCV remains WNL1. There is a decrease in ferritin and transferrin saturation, increase in
TIBC, increase in transferrin receptors and bone marrow iron is absent1. Stage IV, the last stage, is
categorized by iron deficiency accompanied by anemia. During this stage, Hgb and MCV are decreased,
erythrocytes are microcytic, there is a decrease in ferritin and transferrin saturation, increase in TIBC and
transferrin receptors and bone marrow Fe is absent1.
7.
What potential risk factors for the development of iron-deficiency anemia can you identify
from Mrs. Morris’s history?
Mrs. Morris’s pregnancy is a risk factor for the development of iron-deficiency anemia. During
pregnancy, there is a significant increase in the maternal blood supply, which greatly increases the need
for iron1. A pregnant mother should consume an additional 700-800 mg of iron across her pregnancy to
support hematopoiesis and fetal and placental tissues1. Mrs. Morris’s inadequate iron intake is a definite
risk factor for the development of iron-deficiency anemia. Additionally, pregnant women should increase
their calorie intake by 340-360 kcal/d within the second trimester1. Since Mrs. Morris’s calorie intake is
approximately 1560 kcal/d, it would be considered well below her calculated energy requirements of
2201 - 2354 kcal/d given that she is in her second trimester. Additionally, our patient does not consume
many fruits and vegetables and neglects to take her prenatal vitamins, which may pose an additional risk
for developing iron-deficiency anemia1.
8.
What is the relationship between the health of the fetus and maternal iron status? Is there a
risk for the infant if anemia continues?
The health of the fetus is directly affected by maternal iron status due to the effects iron plays on
hemoglobin production1. This results in reduced oxygen delivery to a fetus1. If the underlying causes of
anemia is not treated appropriately, this places an increased demand on the heart in addition to the normal
increased cardiac output during pregnancy1. This can result in preterm delivery, fetal growth retardation,
or LBW all of which can negatively influence neonatal development and future disease risk1.
9.
Discuss the specific nutritional requirements during pregnancy. Be sure to address all
macro- and micronutrients that are altered during pregnancy.
Food Group
RDA during Pregnancy1:
Demands?
Calories
No change during first trimester
Increase 340-360 kcal/d during 2nd
trimester
Additional increase of 112 kcal/d during
3rd trimester
Metabolism increases by 15% for singleton
pregnancy.
Carbs
175 g/d (increase 35 g)
Maintain appropriate blood glucose during
pregnancy and prevent ketosis.
Protein
1.1 g/kg of pre-pregnant weight or 71 g in
2nd half of pregnancy
Increased in order to support synthesis of
maternal and fetal tissues
Fat
20-35% total calories
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Vitamin A
770 mcg (increase 70 mcg)
Pregnancy in Anemia
Low Vit A: reduced kidney size, premature
birth, poor lung function
High Vit A: teratogenic, increases risk for
neural crest defect
Vitamin C
85 mg (increase 10 mg)
Needed for collagen synthesis
Vitamin D
15 mcg
Enhances immune function and brain
development; may prevent autism
Vitamin E
15 mg
Vitamin B1
1.4 mg
Vitamin B2
1.4 mg
Vitamin B3
18 mg
Vitamin B6
1.9 mg
Vitamin B12
2.6 mcg (0.2 mcg increase)
Increased due to its potential role in fetal
brain development that may affect cognitive
and motor development.
Folic Acid
600 mcg (200 mcg increase)
Prevent neural tube defects by supporting
neural tube development in first 28 days; cell
differentiation later in pregnancy
Choline
450 mg (25 mg increase)
Needed to maintain cell structure; plays a
role in cell signaling and nerve impulse
transmission.
Calcium
1,000 mg
Fiber
28 g
Iron
27 mg (increase by 19 mg) → especially
vital during 2nd and 3rd trimester
Needed to support an increased erythocyte
volume, hematopoiesis, and fetal tissues.
Zinc
11-12 mg (3 mg increase)
Increased to prevent congenital
malformations, abnormal fetal brain
development; can alter Vitamin A status.
10.
What are best dietary sources of iron? Describe the difference between heme and nonheme
iron.
The following foods provide a great source of Iron:
● Iron fortified cereals (1.8-21.1 mg per serving)11
● Organ meats (5.2-9.9 mg per serving)11
● Cooked soybeans (4.4 mg per serving)11
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● Pumpkin seeds (4.2 mg per serving)11
● White beans (3.9 mg per serving)11
● Lentils (4.3 mg per serving)11
● Spinach (4.2 mg per serving)11
● Beef (3.1-2.8 mg per 3 oz serving)1
● Kidney beans (2.6 mg per serving)11
● Chickpeas (2.4 mg per serving)11
The difference between heme and non-heme iron is that heme iron comes primarily from meat whereas
non-heme iron comes primarily from plants sources. Non-heme iron is more difficult for the body to
absorb, but this can be combated if you consume non-heme (leafy greens or beans) and heme (lean red
meat) iron sources together11. This, along with other tactics such as including Vitamin C containing foods
at meals with iron present, can increase the body’s non-heme iron absorption1.
11.
Explain the digestion and absorption of dietary iron
Iron absorption efficiency depends on the needs of the host. Iron uses at least one transport protein and
has the ability to increase absorption when needed1. Heme iron (animal sources) is easier for the body to
digest due to the absence of phytates and oxalates from plants sources1.
● Non Heme Iron Absorption: Fe 3 is converted to Fe2 by duodenal cytochrome B and then can be
absorbed using the di-metal transporter-DMT1. The Iron pool then has two fates: Incorporation
into ferriton as storage or export to the bloodstream by Ferroportin. When needed, Fe2 is
converted back to Fe3 by either hephaestin or ceruloplasmin. Fe3 is then transported to the tissues
in a complex with Transferrin1.
● Heme Iron Absorption: Iron binds to the heme carrier transport on the brush border membrane.
Heme is hydrolyzed to Fe2 by heme oxygenase. Iron interacts with other nutrients (Vit. C, Cu,
Zn, Ca)1.
12.
Asses Mrs. Morris’s prepregnancy height and weight. Calculate her BMI and % usual body
weight.
Ht. 65in (165cm)
Wt. 142lbs (65kg); 135lbs prepregnancy (61kg)
BMI:23.6 (normal)
Calculation used:[Wt(lb)x703/Ht^2(in^2)]
IBW: 125#
Calculation used: 100 + 5(inches over 5 ft)
%IBW (@UBW): 105%
Calculation used: (CBW/UBW)x100
Check Mrs. Morris’s prepregnancy weight. Plot her weight gain on the maternal weight
gain curve. Is her weight gain adequate? How does her weight gain compare to the current
recommendations? Was the weight gain from her previous pregnancies WNL?
At 23 weeks of pregnancy, Mrs. Morris has gained 7 lbs since the beginning of the pregnancy. At a BMI
of 23, which is considered a normal BMI, a healthy weight gain is considered 25-35 lbs1,14. At 23 weeks
of pregnancy, it is recommended that weight gain be around 12 lbs1,14. Mrs. Morris’s weight gain of 7 lbs
13.
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is, at this point, inadequate. In her previous two pregnancies, Mrs. Morris gained 15 lbs and ~20 lbs,
respectively. Both of these weight gains were below what is recommended, and not WNL1,14.
Determine Mrs. Morris’s energy and protein requirements. Explain the rationale for the
method you used to calculate their requirements.
Energy needs: REE: Mifflin-St. Jeor Female:10W+6.25H-5A-161
Mifflin-St. Jeor was used because Mrs. Morris is 31, which falls between the 19-78 yo range for the
equation. Her UBW, pre-pregnancy, was used in the equation. An activity factor of 1.3 was used for
normal maintenance. An additional 340-360 calories/day was also added to account for pregnancy during
the second trimester1.
● Energy needs: 2,195-2,528 kcal/day
Protein needs: 0.8-1g/kg for normal maintenance, plus and extra 10g/day to account for pregnancy.
● Protein needs: 59-71g/day
14.
15.
Using her 24-hour recall, compare her dietary intake to the energy and protein
requirements that you calculated in Question 14.
For Mrs. Morris’s 24 hour recall, her dietary intake of energy was 1,568 kcalories/day. This falls short of
the calculated recommended range of 2,195-2,528 kcal/day. Her dietary intake of protein was 55.2
grams/day. This falls short of the recommended range of 62-75g/day. (Nutritionist Pro)
Using her 24 hour recall, assess the patient’s daily iron intake. How does it compare to the
recommendations for this patient (which you provided in question #9)?
In Mrs. Morris’s 24-hour recall, her iron intake was listed at 21 mg. This falls short of the recommended
intake of 27 mg.
16.
17.
Identify the pertinent nutrition problems and the corresponding nutrition diagnoses.
Mrs. Morris’s pertinent nutrition problems include:
● Inadequate caloric intake
● Inadequate protein intake
● Imbalance of nutrients
● Inadequate iron intake
● Suboptimal gestational weight gain
18.
Write a PES statement for each nutrition problem.
NI-2.1 - Inadequate oral intake r/t self-reported “picky eating” AEB intake of 68% recommended TEE
(2,278 kcal/d).
NI-5.7.1 - Inadequate protein intake r/t self-reported “picky eating” AEB protein intake of 83% calculated
recommended protein intake (71 g/d).
NI-5.5 - Imbalance of nutrients r/t self-reported “picky eating” AEB low fruit and vegetable intake and
low intakes of vitamins A (49%), C (41%), E (3%), biotin (2%) and minerals zinc (57%), iron (78%), and
calcium (78%).
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NI-5.10.1.3 - Inadequate iron intake r/t increased demand due to pregnancy AEB general fatigue, pale
sclera, pale skin and lab values: RBC 3.8 x106/mm, Hgb 9.1 g/dL, Hct 33, MCV 72 μg3, and ferritin 10
μg/dL.
NC-3.6 – Suboptimal gestational weight gain r/t self-reported “picky eating” AEB inadequate pregnancy
weight gain 7# at 23 wks.
19.
Mrs. Morris was discharged on 40mg of ferrous sulfate three times daily. Are there
potential side effects from this medication? Are there any drug-nutrient interactions? What
instructions might you give her to maximize the benefit of her iron supplementation.
Ferrous sulfate is the recommended treatment for hypochromic microcytic anemia due to the ease
of absorption when iron is in its reduced ferrous state1. However, long-term oral iron supplementation
has been associated with several side effects, namely gastrointestinal (GI) upset15. These side effects
include, but are not limited to, nausea, vomiting, dyspepsia, bloating, constipation, diarrhea, and dark
stools16.
Iron is best absorbed on an empty stomach when taken with water, but this can cause gastric
inflammation; therefore, while consuming food reduces iron absorption by 50% it also mitigates GI side
effects16,17. In order to increase absorption and reduce GI distress, it is possible to take ferrous sulfate
with vitamin C rich foods, such as citrus fruits, or meat, fish, or poultry16. There are also foods that can
decrease iron absorption. For instance, high doses of Vitamin E decreases hematologic response in
children with iron-deficiency anemia and Vitamin A decrease iron mobilization from stores16.
In conclusion, the ferrous sulfate supplement should be taken by Mrs. Morris because oral
supplementation of iron (that leads to 10 to 20 mg iron absorbed) has been shown to increase red blood
cell count by three times the normal rate and hemoglobin levels by 0.2 g/dl daily15,17. To ensure that GI
upset is minimized while iron absorption is maximized, the patient could take the supplement with food
as long as Vitamin C or meats are incorporated into her meal. Mrs. Morris should work with a dietitian to
identify reliable sources of these nutrients.
20.
Mrs.Morris says she does not take her prenatal vitamins regularly. What nutrients does this
vitamin provide? What recommendations would you make to her regarding her difficulty
taking the vitamin supplement?
Prenatal supplements can be critical during high-risk pregnancies1. For Mrs. Morris, she is
considered a high-risk pregnant female because of her clinical diagnosis of hypochromic microcytic
anemia, her inadequate pregnancy weight gain, and inappropriate nutrient intake during her first
trimester1. The importance of prenatal supplements increase as nutrition status decreases, indicating that
women with impaired nutrition status require these supplements most.
As mentioned earlier, Mrs. Morris’ diet analysis indicates that she is low in total calories, vitamin
A, vitamin C, calcium, iron, Vitamin D, biotin, phosphorous, magnesium, zinc, copper. While prenatal
supplements might not completely compensate for these low intakes, it could help protect the mother and
fetus from developing further malnutrition. This is because prenatal vitamins are typically composed of
vitamins and minerals critical for fetal development; these may include: vitamins A, C, D, E, K, B1, B2,
B3, B6, and B12, pantothenic acid, and folic acid, as well as, choline, biotin, calcium, copper, iron,
chromium, iodine, magnesium, zinc, selenium, manganese, phosphorous, and sodium1. However,
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different formulas may contain different amounts of each of these nutrients, so Mrs. Morris should be
counseled on an ideal prenatal supplement to suit her increased caloric demands and vitamin needs1.
However, Mrs. Morris has explained that she is unable to consistently take her prenatal
supplement because of GI symptoms that arise. I would stress the importance of taking these supplements
during the rest of her pregnancy and try to generate possibilities to improve her consistency. First, I
would ask her about the days that she was able to tolerate her vitamins, specifically I would want to know
if and what she ate before or after taking her vitamin, what time of day, and any other pertinent
information. Therefore, my suggestion would be to take prenatal supplements with food to better tolerate
and absorb the provided nutrients and reduce GI symptoms16. Additionally, I would clarify that many
people experience signs and symptoms of GI distress when initiating a supplement therapy; however, the
GI symptoms will dissipate as therapy continues.
21.
List factors that you would monitor to assess her pregnancy, nutritional, and iron status?
Mrs. Morris presents a complicated case in which several factors must be taken into
consideration. In order to assess her pregnancy, her pregnancy weight gain should be assessed frequently.
Currently, she has only gained 7 lbs when she should be at approximately 12 lbs above pre-pregnancy
weight1. Inadequate weight gain places additional stress on the fetus and increases the likelihood for a
preterm delivery1. She should continue to see an obstetrician for regular check-ups to assess fetal
development.
Since her usual intake and 24-hour diet recall (24-HDR) prior to admission revealed nutrient
inadequacies, it is recommended to complete additional 24-HDRs to ensure adequate calorie,
macronutrient, and micronutrient intakes are consumed. To make sure she reaches a total pregnancy
weight gain of 25 to 35 lbs, she should consume enough calories (REE at UBW + 360 kcal/d) to lead to a
weight gain rate of approximately 0.4 - 0.8 kg/wk. When evaluating her diet, it will also be important to
identify consumption of foods that contain a higher amount of absorbable dietary iron and consider
supplements prescribed to her17. Therefore, adherence to supplement therapy should be assessed either by
pill counts or a “drug history.” In the “drug history,” it would be suggested to ask questions about
tolerance of supplements, particularly with regard to signs and symptoms of GI distress, such as nausea,
vomiting, diarrhea, and constipation.
Finally, to examine improvements in her hematology biochemical labs should be reassessed. It is
expected that Mrs. Morris’ values for red blood cell count, hemoglobin, hematocrit, mean corpuscular
volume, total iron binding capacity, ferritin, and folate would be significantly improved if following her
ferrous sulfate supplement regimen. Additionally, it would be beneficial to ask the client if she is still
experiencing general fatigue as well as complete an additional nutrition-focused physical assessment to
monitor changes in pallor, sclera color and overall health status.
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REFERENCES
1. Mahan LK, Escott-Stump, S, Raymond JL. Krause’s Food and the Nutrition Care Process. St.
Louis, MO: Elsevier Saunders; 2012.
2. National Institute of Health. RBC Count. Medline
Plus.http://www.nlm.nih.gov/medlineplus/ency/article/003644.htm. February 24, 2014. Accessed
October 13, 2014.
3. National Institutes of Health. Total Iron Binding capacity. Medline
Plus.http://www.nlm.nih.gov/medlineplus/ency/article/003489.htmhttp://www.nlm.nih.gov/m
edlineplus/ency/article/003489.htm. February 24, 2014. Accessed October 3, 2014.
4. National Institutes of Health. Ferritin blood test. Medline Plus.
http://www.nlm.nih.gov/medlineplus/ency/article/003490.htm. February 24, 2014. Accessed
October 13, 2014.
5. National Institutes of Health. Hematocrit. Medline Plus.
http://www.nlm.nih.gov/medlineplus/ency/article/003646.htm. February 24, 2014. Accessed
October 13, 2014.
6. National Institutes of Health. Folate Deficienciy. Medline Plus.
http://www.nlm.nih.gov/medlineplus/ency/article/000354.htmhttp://www.nlm.nih.gov/medlin
eplus/ency/article/000354.htm. September 20, 2013. Accessed October 3, 2014.
7. National Institutes of Health. RBC indices. Medline
Plus.http://www.nlm.nih.gov/medlineplus/ency/article/003648.htmhttp://www.nlm.nih.gov/m
edlineplus/ency/article/003648.htm. February 24, 2014. Accessed October 3, 2014
8. Brill JR, Baumgarnder DJ. Normocytic Anemia. Am Fam Physician. 2000 15; 62(10):2255-2263.
9. Massey AC. Microcytic anemia. Differential diagnosis and management of iron deficiency
anemia. 1996; 76(3):549-66
10. Nutrients and Vitamins for Pregnancy.http://americanpregnancy.org/pregnancyhealth/nutrients-vitamins-pregnancy/http://americanpregnancy.org/pregnancy-health/nutrientsvitamins-pregnancy/. Updated January 2014. Access October 3, 2014
11. Center for Disease control. Iron and Iron Deficiency.
CDC.http://www.cdc.gov/nutrition/everyone/basics/vitamins/iron.htmlhttp://www.cdc.gov/n
utrition/everyone/basics/vitamins/iron.html. February 23, 2011. Accessed October 3, 2014.
12. National Institutes of Health. Iron in Diet. Medline
Plus.http://www.nlm.nih.gov/medlineplus/ency/article/002422.htmhttp://www.nlm.nih.gov/m
edlineplus/ency/article/002422.htm. February 18, 2013. Accessed October 3, 2014
13. Nutritionist Pro Diet Analysis. Computer software. Axxya Systems, n.d. Web. 07 Oct. 2014.
14. Thomas-Dobersen D. Nutritional management ofgestational diabetes and nutritional management
of women with a history of gestational diabetes: two different therapies or the same? Clin
Diabetes. 1999; 17(4).
15. Bayoumeu F, Subiran-Buisset C, Baka NE, Legagneur H, Monnier-Barbarino P, Laxenaire, MC.
Iron therapy in iron deficiency anemia in pregnancy: Intravenous route versus oral route. Am J
Obstet Gynecol. 2002; 186(3):518-522.
16. Pronsky ZM, Crowe JP. Food Medication Interactions. Birchrunville, PA: Food Medication
Interactions; 2012.
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17. Association of Nutrition and Dietetics. Iron-deficiency anemia. Nutrition Care Manual.
http://www.nutritioncaremanual.org/http://www.nutritioncaremanual.org. Accessed October
13, 2014.