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Mallory Ditchfield
10/28/14
MNT1 81395
Case Study 2: Anemia in Pregnancy
1. Evaluate the patient’s admitting history and physical. Are there any signs or symptoms that
support the diagnosis of anemia?
Upon evaluation of the patient’s history, it is clear that there are multiple signs/symptoms
that occur from anemia. She reported suffering from shortness of breath and exhaustion.
These are two very common symptoms that follow anemia.1 She also stated that she had
vomiting in the first trimester due to morning sickness. This excessive vomiting may increase
her risk of developing anemia later on in the pregnancy since the proper nutrients do not have
time to be absorbed. Another issue that can be recognized is the fact that she has become
pregnant less than two years after giving birth. Her physical signs of pale skin and pale sclera
also point in the direction of anemia during pregnancy.2
2. What laboratory values or other tests support this diagnosis? List all abnormal values and
explain the likely cause for each abnormal value.
The laboratory tests show low values for red blood cell count, hemoglobin, hematocrit,
and MCV-supporting the diagnosis of iron-deficiency anemia. The low red blood cell count and
proportion in the body are hindering the transfer of oxygen throughout the body. Accordingly,
the hemoglobin value is decreased as well; this is caused by being deficient in iron. A low MCV
value shows that the blood cell size is too small since they do not have efficient amounts of iron
to bind to. Ferritin levels are also low in the patient, which is an indicator of iron storage. Her
total iron binding capacity, which reflects the body’s cells capability to bind to iron, is elevated.
Since her levels are high, this means her cells have a very low amount of iron.2
3. Mrs. Morris’s physician ordered additional lab work when her admitting CBC revealed low
hemoglobin. Why is this 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?
During pregnancy, iron requirements increase significantly. The amount of blood in the
body will increase and iron is needed to produce more hemoglobin for the added blood.
Hemoglobin is an iron-rich protein in red blood cells that carries oxygen from the lungs to
tissues in the body (in the case, also the baby). Extra iron is also needed for the placenta to
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nourish the baby.3 If a lack of iron arises, hemoglobin will not be created and anemia will be
developed. Maternal iron status cannot be gauged simply from hemoglobin concentration
because pregnancy produces a rise in plasma volume and the hemoglobin concentration
decreases consequently due to dilution.4
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.
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Megaloblastic anemia (a macrocytic anemia) is any anemia characterized by
megaloblasts in bone marrow. Vitamin B12 and folic acid deficiencies along with certain
medications are the most common causes of megaloblastic anemia. 1,2
Pernicious anemia is a megaloblastic anemia that most commonly affects older adults,
and is due to failure of the gastric mucosa to secrete adequate and potent intrinsic
factor, resulting in malabsorption of B12. 1
Microcytic anemia is the most common anemia and is the presence of small, often
hypochromic, red blood cells in peripheral red blood smear and is usually characterized
by a low MCV. Iron deficiency is the most common cause of microcytic anemia.1,2
Hemolytic anemia is a disorder in which the red blood cells are destroyed prematurely. 2
Normocytic anemia is caused by chronic disease or blood loss, cells retain normal size. 1
Sickle Cell anemia is a hereditary disease that causes production of crescent-shaped red
blood cells which can get stuck in capillaries and cause pain, liver, and kidney problems.2
5. What is the role of iron in the body? Are there additional functions of iron during fetal
development?
Iron is considered an essential mineral because it is needed to make certain parts of
blood cells. Iron plays a very important role in the body by creating hemoglobin and
myoglobin- oxygen-carrying proteins. Iron is also part of many other cells and proteins in the
body. Iron is used throughout the body in energy production, brain function, immune function,
and even enzyme function.3
During pregnancy, the body creates more blood to support the development of the
fetus. If there is not enough iron intake or absorption, the body might not be able to produce
the amount of red blood cells it needs to make this additional blood. Iron serves a great
purpose during fetal development. Enhanced blood flow from adequate stores can help
improve fetal growth and the development of organs. Also, increasing iron stores for the fetus
during pregnancy will ensure that once born, iron stores are efficient.4
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6. Several stages of iron deficiency actually precede iron-deficiency anemia. Discuss these
stages—including the symptoms—and identify the laboratory values that would be affected
during each stage.
Stage I: Early signs of low iron; shown by slightly low amount of ferritin; iron reduction is
most likely not going to cause issues or symptoms at this point1
Stage II: Iron depletion; serum transferrin receptors are high, ferritin is low; symptoms
of fatigue may arise1
Stage III: Iron deficiency; iron deficient erythropoiesis; ferritin and serum iron are both
low; fatigue increases, lack of ability to concentrate1
Stage IV: Iron deficiency anemia; microcytic hypochromic RBC, very high serum
transferrin receptors, very low ferritin, serum iron, hematocrit, hemoglobin, and MCV;
extreme fatigue, weakness, shortness of breath, poor muscle function, pica, and pallor
are all symptoms at this stage1
7. What potential risk factor(s) for the development of iron-deficiency anemia can you
identify from Mrs. Morris’s history?
A risk factor that might increase her development of iron-deficiency anemia would not
only be her current pregnancy, but her previous pregnancy as well. She had cesarean section
18 months previous to this pregnancy. It is recommended that at least a minimum of two years
passes before becoming pregnant again.3 This time is necessary for the body to recover and go
back to the way it was prior to becoming pregnant. It is also needed to replace and replenish all
the blood stores that were lost from the previous pregnancy/birth.4 Along with this short
recovery time, her intake shown in her diet recall provide us with the information that her
dietary intake of iron is low, further increasing her risk for iron-deficiency anemia.
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?
Fetal needs take precedence over maternal needs for iron delivery, thus depleting
maternal stores at a fast rate. Fetal iron deficiency can be caused by maternal iron deficiency
anemia along with maternal cigarette smoking which was reported by the patient.4 If there is
any type of deficiency or issue with iron being passed to the fetus, this may cause problems
with brain iron concentrations, further hindering brain development and function. Also, failure
of the plasma volume to expand sufficiently can lead to limited growth of the fetus, resulting in
the infant being small for gestational age at birth.5 Another issue or harm for the infant would
be the cause of a premature labor.4
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9. Discuss the specific nutritional requirements during pregnancy. Be sure to address all
macro- and micronutrients that are altered during pregnancy.
Certain nutritional requirements will change drastically when becoming pregnant.
Specific nutrients, macro- and micronutrients, can assist in the growth and development of the
fetus, as well as the overall health for the mother.6 One noticeable change in the diet of the
mother will be the amount of calories she consumes in a day. Depending on which trimester
she is in, her total caloric needs will increase.7,8 Generally speaking, pregnant women require
anywhere between 2,200 calories and 2,900 calories each day.9 During the first trimester the
caloric needs remain the same. The change occurs during the second trimester where 340
extra calories are needed, and 450 in the third trimester. When focusing on macronutrients,
protein requirements will need to increase to support proper tissue growth. The amount
needed per day will escalate to approximately 1.1g per (pre-pregnancy) body weight in
kilograms, equating to around 70g each day. When assessing the micronutrients, iron, zinc,
folic acid/folate, and calcium will all need to be implemented in the diet. Iron intake will need
to be at least 27mg each day in order to provide oxygen to the fetus, support the mother’s red
blood cell count during and after birth, and also to prevent the onset of iron-deficiency
anemia.10 Zinc needs will increase to 11mg per day due to high fetal needs. This mineral is
useful during pregnancy to assist the immune system and cell growth. Lactation after birth can
also drain the mother’s zinc stores.11 Folate during pregnancy is vital throughout each
trimester to prevent neural tube defects in the fetus, so the requirements will increase to
600mcg each day. The recommended intake for calcium will not increase, but it is necessary to
maintain the 1000mg every day to prevent the fetus from depleting the mother’s calcium in her
bones.10
10. What are best dietary sources of iron? Describe the differences between heme and
nonheme iron.
Adequate dietary sources of iron are derived from clams, steak, poultry, fortified
cereals, spinach, kidney beans, and potatoes (with skin). These are all suitable sources of iron,
but the meats are more bio-available than the vegetables and cereals.2
Heme iron, approximately 15% of which is absorbable, is from meat, fish, and poultry.
Heme iron is absorbed at a higher rate than nonheme iron. Nonheme iron comes from eggs,
grains, vegetables, and fruits. This absorption rate varies between 3%-8%.2
11. Explain the digestion and absorption of dietary iron.
Dietary iron exists as heme and nonheme iron. The absorption of iron occurs primarily
in the duodenum and the upper part of the jejunum. Heme iron is absorbed via brush boarder
of intestinal absorbing cells. Nonheme iron is brought into the cell through an active transport
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process by the protein DMT-1, which occurs on the apical surface of enterocytes in the
duodenum. Enterocytes also absorb heme iron. Iron, in the reduced ferrous state is preferred
for the entry step of absorption. Once iron enters the enterocytes it may leave and enter the
body by ways of ferroportin, or it may bind with ferritin and linger there. Once iron exits the
enterocyte via ferroportin it will bind to transferrin. It will then be delivered to red blood cell
precursors. Generally speaking, the volume of transferrin to bind iron in the plasma exceeds
the amount of circulating iron. In relation to nonheme iron, vitamin C consumed during the
same time of iron intake will enhance the absorption rate.1
12. Assess Mrs. Morris’s height and weight. Calculate her BMI and % usual body weight.
Height: 5’ 5”/65 in/1.651 m
Current weight: 142 lbs/64.4 kg
Pre-pregnancy weight: 135 lbs/61.2 kg
BMI calculation1: kg/m2 [61.2/(1.651)2]=22.45
%UBW1= actual weight/usual weight X 100 [142/135X100]=105.185
Her pre-pregnancy BMI was 22.45 and percent usual body weight is 105.2%.
13. 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?
Mrs. Morris’ pre-pregnancy weight was 135 lbs. and she now currently weighs 142 lbs.
That is a total weight gain of only 7 lbs. throughout her 23 weeks of pregnancy. Based on the
maternal weight gain curve, her weight gain is subpar. For a woman who is of normal weight
prior to pregnancy, approximately 11-16 lbs. should be gained by the 23rd week. When
comparing her weight gain to the current recommendations, it is clear that she is meeting only
half of the suggested weight gain. This can directly hinder fetal development. Her weight gains
during her two previous pregnancies were not within normal limits either- 15 lbs. for the first
and 20 lbs. for the second. For a woman of normal weight prior to pregnancy, the suggested
total weight gain should range from 25-35 lbs.1,9
14. Determine Mrs. Morris’s energy and protein requirements. Explain the rationale for the
method you used to calculate these requirements.
Energy requirements can be calculated by using the Mifflin- St. Jeor equation (for
females in this case). An additional 340 calories need to be added after the equation due to the
increase in caloric needs during her second trimester of pregnancy. From this calculation, she
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needs approximately 1,668 calories each day to maintain a healthy pregnancy weight. These
caloric needs will increase again in her third trimester (1,777.875 calories).
REE= 10(weight in kg) + 6.25(height in cm) -5(age) -161
REE =10(61.2) + 6.25(165.1) -5(31) -161 = 1,327.875
1,327.875 + 340 = 1,667.875
Using pre-pregnancy weight as a reference, protein requirements will equate to 1.1 g
per kg of body weight each day. Since Mrs. Morris’ pre-pregnancy weight in kg was 61.2, she
will need 67.32g of protein/day.1,2
15. Using her 24-hour recall, compare her dietary intake to the energy and protein
requirements that you calculated in Question 14.
To further assess her 24-hour diet recall, I entered each meal into the
choosemyplate.gov Food Tracker. This shows that she is only eating approximately 1,325
calories per day. Based on my previous calculations, she should be consuming 1,668 calories
during this point of gestation. The Food Tracker also calculated that she consumed only 44 g of
protein throughout the entire day. These two assessments show that her caloric and protein
intake need to be increased in order to fulfill her daily nutritional requirements. 12
16. Again 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)?
As previously stated, I used the choosemyplate.gov Food Tracker to assess Mrs. Morris’
24-hour diet recall. Based on the calculations of the Food Tracker, she is receiving
approximately 25 mg of iron from her diet. This is mainly due to the fortified cereal she ate for
breakfast.12 Based on the recommendations for pregnant women, 27 mg/day is needed to
maintain the health of the mother and fetus.10 She is currently not quite meeting the specified
requirements, though she is very close. One issue that I noticed in her diet recall is the fact that
she is drinking a cup of coffee with breakfast, and iced tea during lunch and dinner. This could
be contributing to her anemia since tea and coffee are absorption inhibitors of iron. A
suggestion should be made to drink these beverages before or in between meals, not during. 13
17. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses.
Based on the information provided from her history, physical, nursing assessment, and
24-hour diet recall, the pertinent nutrition problem is a deficiency in iron. The corresponding
nutrition diagnosis is an inadequate mineral intake of iron.
A second pertinent nutrition problem based on the information provided is low daily
calorie consumption. The corresponding nutrition diagnosis is inadequate daily caloric intake.
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18. Write a PES statement for each nutrition problem.
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Inadequate mineral intake of iron, related to hypochromic microcytic anemia, as evidenced
by abnormal lab values of red blood cell count, hemoglobin, hematocrit, and MCV along
with 24-hour diet recall.
Inadequate daily caloric intake, related to insufficient weight gain in the second trimester,
as evidenced by anthropometric measurements and 24-hour diet recall.
19. Mrs. Morris was discharged on 40 mg 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?
Iron supplements are (usually) given regularly to pregnant women to prevent reduction
of body iron stores and reverse the anemia. The first dose of ferrous sulfate should be taken
midmorning to be most effective. A higher or more frequent dose can increase gastrointestinal
adverse effects (constipation) and one dose blocks absorption of the next dose, in turn reducing
percentage intake. To avoid this, each dose should be spaced out evenly throughout the day,
also with meals if a negative reaction to the stomach or gastrointestinal tract occurs. It is
important, though, to not take the dose with any dairy products or calcium supplements to
prevent interference with the iron absorption. About 20% of pregnant women do not absorb
enough supplemental oral iron. To increase the absorption rate, vitamin C intake should be
increased with each meal and each dose, especially with the intake of nonheme ironcontaining foods. Also, it is necessary to take an iron supplement at a different time than other
mineral supplements or multivitamins. In doing so, competition for absorption will not be an
issue.5
20. Mrs. Morris says she does not take her prenatal vitamin regularly. What nutrients does this
vitamin provide? What recommendations would you make to her regarding her difficulty taking
the vitamin supplement?
Vitamins and minerals are best when received through a healthy diet, but prenatal
vitamins are necessary if the mother is falling short of her requirements. Prenatal vitamins
provide more folic acid and iron that other multivitamins. There usually is enough iron in a
prenatal vitamin to prevent anemia, but a physician may prescribe an extra iron pill if anemia is
an issue. They also contain calcium, vitamin C, zinc, copper, vitamin B-6, and vitamin D.14 Since
the prenatal vitamins are causing her to have an upset stomach after taking them, I would
suggest her to take them with a meal or snack to prevent any gastrointestinal upset. 5 If she has
an issue with remembering to take them, it could be helpful to set them out on the kitchen
counter or dinner table so that while she is eating, she will notice the bottle and take on with
the meal.
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21. List factors that you would monitor to assess her pregnancy, nutritional, and iron status.
When monitoring Mrs. Morris, lab work would need to be assessed within one week to
see how her anemia is reacting to supplementation. A reticulocyte count should be looked at
to see the effects of the ferrous sulfate tablet. This illustrates that red blood cells are
adequately being created in the bone marrow. Hematocrit or hemoglobin should be measured
weekly, also, to determine the response of the ferrous sulfate supplementation. 8 Monitoring is
necessary to ensure that she is absorbing the supplementation accurately. It will also be
necessary to monitor her weight throughout the remainder of her pregnancy since she is
underweight for the second trimester. We can assess this factor by her weight measurements
taken at each of her OBGYN appointments. Also, more 24-hour diet recalls can be taken if any
other issues or concerns arise.
22. You note in Mrs. Morris’s history that she received nutrition counseling from the WIC
program. What is WIC? Should you refer her back to that program? What are the qualifications
for enrollment? Are there any you can confirm for her referral?
WIC is a women, infant, and children nutrition supplementation program that provides
supplemental foods, referrals to health care physicians, and nutrition education for low-income
pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and
children up to five years old who seen as having a nutritional risk to some degree. Applicants
must fit in the specific categories listed above, as well as live in the identified state, meet
poverty guidelines issued by that state, and meet a nutrition risk requirement. I would refer
Mrs. Morris back to this program because she meets the pregnancy requirement, as well as the
nutrition risk requirement. She is suffering from a medical and dietary-based condition (iron
deficiency anemia and poor caloric intake).15
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References
1. Krause’s Food and Nutrition Therapy, 13th Edition. Mahan K, Escott-Stump S.
Elsevier/Saunders, 2012.
2. Nutrition Therapy and Pathophysiology Nelms M, Sucher K, Long S. Thomson/Wadsworth,
Australia, Third Edition, 2010- 2011.
3. Baby Center. Iron Deficiency Anemia in Pregnancy. Available at:
http://www.babycenter.com/0_iron-deficiency-anemia-in-pregnancy_3073.bc?page=2.
Accessed on: October 25, 2014.
4. PubMed Central NLM/NIH. The Role of Iron in Neurodevelopment: Fetal Iron Deficiency and
the Developing Hippocampus. Available at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711433/. Accessed on: October 25, 2014.
5. The Merk Manual. Anemia in Pregnancy. Available at:
http://www.merckmanuals.com/professional/gynecology_and_obstetrics/pregnancy_comp
licated_by_disease/anemia_in_pregnancy.html. Accessed on: October 25, 2014.
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http://www.ucsfhealth.org/education/anemia_and_pregnancy/. Accessed on October 25,
2014.
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at: http://www.medicinenet.com/anemia_in_pregnancy/views.htm. Accessed on: October
25, 2014.
8. Web MD. Anemia in Pregnancy. Available at: http://www.webmd.com/baby/guide/anemiain-pregnancy. Accessed on: October 25, 2014.
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http://www.eatright.org/Public/content.aspx?id=10933. Accessed on: October 26, 2014.
10. Nutrition MD. Nutritional Requirements Throughout the Life Cycle: Pregnancy and
Lactation. Available at:
http://www.nutritionmd.org/health_care_providers/general_nutrition/lifetime_pregnancy.
html. Accessed on: October 26, 2014.
11. National Institute of Health. Zinc. Available at: http://ods.od.nih.gov/factsheets/ZincHealthProfessional/. Accessed on: October 26, 2014.
12. Choose My Plate. Super Tracker Food Tracker. Available at:
https://www.supertracker.usda.gov/foodtracker.aspx. Accessed on October 27, 2014.
13. Pub Med. Effect of tea and other dietary factors on iron absorption. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/11029010. Accessed on: October 27, 2014.
14. Mayo Clinic. Prenatal Vitamins: Why they matter, how to choose. Available at:
http://www.mayoclinic.org/healthy-living/pregnancy-week-by-week/in-depth/prenatalvitamins/art-20046945. Accessed on: October 27, 2014.
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15. USDA Food and Nutrition Service. Women, Infants and Children (WIC). Available at:
http://www.fns.usda.gov/wic/wic-eligibility-requirements. Accessed on: October 27, 2014.
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