UNIVERSITY OF NORTH FLORIDA
Case Study #2
Anemia in Pregnancy
Clara Foran
10/28/2014
Questions:
1. Evaluate the patient’s admitting history and physical. Are there any signs or
symptoms that support the diagnosis of anemia?
The only symptom that could be associated with anemia would be her fatigue, paleness
and shortness of breath. When microcytic anemia or iron-deficiency anemia becomes
more severe, issues arise in the structure and function of the epithelial tissues. This can
cause paleness in the skin. Amber’s general appearance was stated as pale. She also
mentioned being much more tired with this pregnancy. With anemia another symptom is
malfunction of a variety of body systems. The neurologic symptoms manifest in
behavioral change, one being fatigue. Progressive, untreated anemia can result in
respiratory changes, possibly causing shortness of breath which she also complained.
2. What laboratory values or other tests support this diagnosis? List all abnormal
values and explain the likely cause for each abnormal value.
RBC is 3.8 should be 4.2-5.4 in females. Hemoglobin is 9.1g/dL should be 12-15g/dL in
females. Hematocrit is 33% should be 37-47% in females. Mean cell volume is 72um3
should be 80-96um3. Total iron binding capacity is elevated to 465 ug/dL should be 240450ug/dL. Ferritin is 10 ug/dL should be 20-120 ug/dL in females. The likely cause for
these values has to do with the fact that she is pregnant, not taking her prenatal vitamins
and not consuming a sufficient diet.
3. 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?
With a low level of hemoglobin the concern is that the body is not getting enough iron or
certain other nutrients, in order for the body to be able to produce the amount of red
blood cells it needs to make the additional blood needed during pregnancy to supply the
fetus. The normal hemoglobin level for a non pregnant female is 12-15 g/dL. When
pregnant the hemoglobin level actually drops due to the increase in plasma volume. The
normal level for a pregnant female then becomes 11.5 g/dL. The issue is Amber’s
hemoglobin level dropped lower than 11.5 g/dL. Amber’s level was down to 9.1 g/dL.
When pregnant the blood volume increase by approximately 50% by the end of the
pregnancy. This causes not only a decrease in hemoglobin but also a decrease in serum
albumin, other serum proteins and water soluble vitamins. On the other hand serum
concentrations of fat-soluble vitamins and other lipid factions such as triglycerides,
cholesterol and free fatty acids increase.
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- any anemia characterized by megaloblast in the bone marrow.
Pernicious anemia- is a disease in which the red blood cells are abnormally formed, due to an
inability to absorb vitamin B12
Normocytic anemia- is an anemia with a mean corpuscular volume (MCV) of 80-100 which
is the normal range. However, the hematocrit and hemoglobin is decreased.
Microcytic anemia- anemia marked by decrease in size of the red cells.
Sickle cell anemia- a chronic hemolytic anemia. Results in defective hemoglobin synthesis,
which produces sickle shaped RBCs that get caught in the capillaries and do not carry
oxygen well.
Hemolytic anemia- is a disorder in which the red blood cells are destroyed prematurely. The
cells are broken down at a faster rate than the bone marrow can produce new cells.
5.
What is the role of iron in the body? Are there additional functions of iron during fetal
development?
Iron is needed in order to make the oxygen-carrying proteins hemoglobin and myoglobin.
Hemoglobin is found in red blood cells and myoglobin is found in muscles. Iron is also in the
makeup of many other proteins that are in the body. During pregnancy there is an increase
demand on blood supply, which in turn increases the demand for iron. Not only is iron need
in order to make the blood that carries oxygen to the fetus but it is also need in the
development of the fetus. Iron plays an important role in the cellular function of all organ
systems. The need for iron is greater in rapidly growing and differentiating cells. Iron
deficiency during the fetal and neonatal period can result in dysfunction of multiple organ
systems, some of which might not recover despite iron rehabilitation.
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 One: Early Negative Iron Balance
A negative iron balance reduces iron absorption produces a moderate depletion of iron
stores. There is no dysfunction at this stage.
Laboratory values affected are Iron stores, RE marrow Fe, Transferrin IBC, Plasma
ferritin, Iron absorption and Plasma Iron. All values are affected but not in any significant
amount.
Stage Two: Iron Depletion
A negative iron balance is characterized by severely depleted iron stores, sometimes
absent iron stores. There is still not dysfunction at this stage. This level of iron deficiency is
often characterized by low serum ferritin levels.
Laboratory values affected are Iron stores, Circulating iron, RE marrow Fe, Transferrin
IBC, Plasma ferritin, and Iron absorption.
Stage Three: Damaged Metabolism: Iron-deficient Eruthropoiesis
This stage is considered iron deficiency. Iron deficiency is characterized by inadequate
body iron, dysfunction and disease. Dysfunction is not yet accompanied by anemia. Iron
deficient erythropoiesis may be difficult to detect using traditional laboratory parameters. In
iron deficient erythropoiesis, storage iron may be normal or even increased due to impaired
release of iron into the circulation.
Laboratory values affected are all the same as stage stage two plus Erythron iron, Plasma
iron, Tranferrin saturation, Sideroblasts, RBC protoporphyrin, Serum transferring receptors
and Ferittin-iron.
Stage Four: Clinical Damage: Iron Deficiency Anemia
Iron stores are insufficient to maintain red blood cell synthesis, leading to anemia. Iron
deficiency anemia is characterized by a significant reduction in hemoglobin levels and a
decrease in mean corpuscular volume. Dysfunction and anemia are present.
Laboratory values affected are all the same as stage three plus Erythrocytes. These values
are affected on a much larger range then all the other stages.
7.
What potential risk factor(s) for the development of iron-deficiency anemia can you
identify from Mrs. Morris’s history?
In Amber’s history she mentioned that she smokes 1-2 cigarettes per day but is trying to cut
back. Smoking is not healthy for the developing fetus or the mother. Smoking lowers the
amount of oxygen available to the mother and the growing baby. It can also cause a lot of
other complication such as premature birth and/or low birth weight. Smoking has also been
linked to anemia due to its effects on the blood.
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 maternal iron status is directly connected to the fetuses iron status. If the mother is not
consuming enough iron the fetus will not have the adequate amount of iron needed for
development. There is a large risk for the infant if anemia continues. Not enough iron in the
body can lead to poor hemoglobin production, followed by not enough oxygen delivered to
the uterus, placenta and developing fetus. The added workload of the heart from the mother
having anemia and increased cardiac output can lead to premature delivery, fetal growth
retardation, low birth weight or inferior neonatal health issues.
9.
Discuss the specific nutritional requirements during pregnancy. Be sure to address all
macro- and micronutrients that are altered during pregnancy.
Protein: During the first half of the pregnancy the RDA is 0.8 g/kg/day. The need for protein
increases in the second half of the pregnancy, the RDA is 71 g/day, based on 1.1 gm/kg/day
of pre-pregnant weight. For each additional fetus 25 g/day of additional protein is
recommended.
Carbohydrates: DRI for carbohydrates while pregnant is an estimated average requirement of
135 g/day. The RDA is 175 g/day. 135-175 is the recommended amount.
Fiber: DRI for fiber during pregnancy is 28 g/day
Lipids: There is no DRI for lipids while pregnant. There is however an AI of 13 g/day for
omega 6 polyunsaturated fatty acids and an AI of 1.4 g/day for omega 3 polyunsaturated fatty
acids.
Water: 8-10 glasses
Folic Acid: RDA is 600 mcg/day
Vitamin B6: RDA is 1.9 mg/day
Vitamin B12: RDA is 2.6 mcg/day
Choline: RDA is 450 mg/day
Vitamin C: RDA is 80 mg/day ages 14-18 and 85 mg/day ages 19-50
Vitamin A: RDA is 750 mcg (2500 IU)/day ages 14-18 and 770 mcg (2567 IU)/day ages 1950 should not exceed 3000 IU
Vitamin D: RDA is 15 mcg/day
Vitamin E: RDA is15 mg/day
Vitamin K: RDA is 75 mcg/day ages 14-18 and 90mcg/day ages 19-50
Calcium: RDA is 1300 mg/day ages 14-18 and 1000 mg/day ages 19-50
Copper: RDA is 1 mg/day
Fluoride: RDA is 3mg/day
Iodine: RDA is 220mcg/day
Iron: RDA is 27 mg/day
Magnesium: RDA is 400 mg/day ages 14-18, 350 mg/day ages 19-30, and 360mg/day ages
31-50
Phosphorus: RDA is 1250 mg/day ages 14-18 and 700 mg/day ages 19-50
Sodium: RDA is 1500 mg/day
Zinc: RDA is 12 mg/day ages 14-18 and 11 mg/day ages 19-50
10. What are best dietary sources of iron? Describe the differences between heme and
nonheme iron.
The best dietary source of iron is liver, followed by seafood, kidney, heart, lean meat and
poultry. Dried beans and vegetables are the best plant sources. Heme is the iron binding
protein found in animals and nonheme is the iron binding protein found in plants. Heme iron
is absorbed better then nonheme iron.
11. Explain the digestion and absorption of dietary iron.
Both heme and nonheme iron ions undergo two important changes of oxidation state during
digestion and absorption. The first change occurs in the stomach due to the low pH and
reducing agents, such as ascorbic acid. The reducing agents in the stomach reduce iron (III)
into iron (II). This change occurs because iron (II) dissociates from ligands more easily then
iron (III). The second change occurs in the duodenum of the small intestine. The duodenum
is bicarbonate-rich, and alkaline. In this alkaline environment heme iron will be absorbed
directly across the brush board and into the cytosol where the ferrous iron is enzymatically
removed from the ferroporphyrin complex. Free iron ions combine immediately with
apoferritin to form ferritin. Ferritin is the carrier that then carries the bound iron from the
brush board to the basolateral membrane of the absorbing cell.
12. Assess Mrs. Morris’s height and weight. Calculate her BMI and % usual body weight.
Height: 62 in  (1.65m) × (1.65m) = 2.72 m2
Weight: 135lbs  61kg
BMI = 61 kg ÷ 2.72 m2 = 22.5
% UBW = actual weigh/ UBW × 100
142/135 × 100 = 105%
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?
Amber is in her 23rd week of gestation. She currently weighs 142 lbs and her prepregnancy
weight was 135 lbs. It is recommended by the IOM, a weight gain of 25-35 lbs for women of
normal weight (pregravida BMI 18.5-24.9). Amber falls into this category with a BMI of
22.5. According to the maternal weight gain curve Amber should have gained on average 1115 lbs by her 23rd week. Amber is now in her 23rd week and has only gained 7 lbs. She is
well below the current recommendations. Both of her previous pregnancies were under the
recommended weight gain. She gained 15lbs with her first pregnancy and 20 with her second
pregnancy.
14. Determine Mrs. Morris’s energy and protein requirements. Explain the rationale for
the method you used to calculate these requirements.
I choose to use choosemyplate.gov to calculate Amber’s calorie requirements also referred to
as energy requirement and her protein requirements. According to Choose My Plate Amber
should be eating 6 ½ oz of protein a day and she should also be consuming 2600 calories a
day to meet her energy requirement.
15. Using her 24-hour recall, compare her dietary intake to the energy and protein
requirements that you calculated in Question 14.
Using Choose My Plate I entered in Ambers 24 hour recall and found out that she is not
eating near enough calories. She had only consumed 1371 calories based off her 24 hr recall.
She needs to consume 1229 more calories to reach her recommended amount of 2600
calories a day. As for her protein she only consumed 3 oz of protein in her 24 hr recall. She
needs to consume another 3 ½ oz of protein to meet her recommended amount of 6 ½ oz.
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)?
Based off of the Choose My Plate calculations, in Amber’s 24 hr recall she consumed exactly
27 mg of iron. The recommended amount of iron is 27mg. In this 24 hr recall she managed to
meet her recommended iron requirement, that is not to say that she is getting this amount
every day but based off this 24 hr recall she is. I would say based on her test results though
that her iron intake should be monitored and increased to insure that she is consuming the
correct amount daily and not just lucking up on one 24 hr. recall.
17. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses.
Amber’s pertinent nutrition problems are that she is not consuming enough vitamins and
mineral. She is not getting enough protein, calories and other nutrients. Her laboratory values
that have to do with her nutrition are not good and the increased nutrition required for her
pregnancy is not being met. The corresponding nutrition diagnoses would be inadequate
mineral intake, imbalance of nutrients, altered nutrition laboratory related values and
increased nutrition needs.
18. Write a PE S statement for each nutrition problem.
Inadequate protein and energy intake related to protein and calorie intake less then bodily
needs as evidence by a weight gain below the IOM recommended amount for pregnant
women in their 23rd week.
Inadequate nutrient intake related to increased needs as evidence by low HgB, low Hct, low
RBC, low albumin levels and anemia
Inadequate weight gain related to lack of nutrients as evident by a weight gain below the
IOM recommended amount for pregnant women in their 23rd week.
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?
Ferrous sulfate is used to treat iron-deficiency anemia. It supplies the body with a sufficient
amount of iron so that the body can produce red blood cells. Ferrous sulfate may cause stool
to turn dark; this effect is harmless. It may also cause teeth to stain from the liquid. It is
recommended to mix each dose with water or fruit juice to help prevent staining. It is also
recommended to brush teeth with baking soda once a week to help with the prevention of
stains. Upset stomach and constipation are common. If either of these symptoms is severe or
does not go away a doctor should be notified. Ferrous sulfate is known to interact with a
number of different antibiotics, bisphosphonates, levodopa, methyldopa, and thyroid
replacement. Do not take antacids at the same time as ferrous sulfate; take them as far apart
as possible. Ferrous sulfate can also interact with some anti-seizure medications. For best
results this medication should be taken exactly as instructed. It should be taken between
meals on an empty stomach, at least 1 hour before or 2 hours after eating. It is also suggested
that you continue to eat a balance diet including those foods rich in iron.
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?
A prenatal vitamin provides many vitamins and minerals to help cover any nutritional gaps in
the mother's diet. They generally provide energy, protein, vitamins and mineral that exceeds
the routine daily intake of the mother. The greater that nutritional status of the mother is, the
greater the benefit is for the pregnancy. Amber complains that the vitamin supplement hurts
her stomach. This is a side effect to some prenatal vitamins. I would suggest that she try a
different type of supplement, such as the chewable or liquid vitamins rather than those you
swallow whole.
21. List factors that you would monitor to assess her pregnancy, nutritional, and iron
status.
I would have periodic follow up visits where I would monitor her laboratory values such as
serum ferritin, hemoglobin, total iron binding capacity, and hematocrit or transferring
saturation. I would do repeated evaluations of food and supplement documentation using
such things as a patient food log, 24 hr recall, or direct observation. Additional monitoring
could include a subjective patient report of symptoms such as nausea, constipation, and
fatigue.
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 special supplemental nutrition program for women, infants, and children. It was
created under the auspices of the U.S. Department of Agriculture for pregnant women at
nutritional risk. For the U.S. citizens, the WIC program serves eligible pregnant women,
postpartum women until 6 months’ postpartum, breastfeeding women until 1 year postpartum
and infants and children under the age of 5 years. In order to be eligible a women or child has
to be in “Nutritional Risk.” The criteria for the nutritionally at risk may include anemia, poor
gestational weight gain, inadequate diet or FTT in the infant or child. Amber not only has
anemia but she also has a low gestational weight gain and an inadequate diet. I would most
definitely refer her back to the program, so that she could gain the additional help she needs.
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