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Jared McArdle

Case Study #2
DIE 3213 Nutrition Therapy 1
Alireza Jahan-Mihan
10/28/2014

Title: Case 21 Anemia in Pregnancy


1. Evaluate the patients admitting history and physical. Are there any signs or symptoms that support
the diagnosis of anemia?
There are signs and symptoms that support the diagnosis of anemia. The patient did not gain
enough weight, and did not take her prenatal vitamins. The patient appeared pale, tired, and had a
shortness of breath. The patients intake of iron during the 24-hour recall was 19mg which is 8mg short
of the daily recommendation.
2. What laboratory values or other tests support this diagnosis? List all abnormal values and explain
the likely cause for each abnormal value.
Low RBC count, possible inadequate intake of iron.
MCV result of 72, when MCV is less than 80 it is indicative that a patients RBC volume is less
than the average and termed microcytic.
Folate result of 2. Range should be 5-25. Serum folate can be an indicator of body stores, and a
decreased value may indicate a folate deficiency.

3. Mrs. Morriss 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?
This is a concern because low levels of hemoglobin may result in the diagnosis of anemia. Yes,
pregnancy requires additional maternal absorption of iron. Maternal iron status cannot be assessed
simply from hemoglobin concentration because pregnancy produces increases in plasma volume and
the hemoglobin concentration decreases accordingly. Some hematological values that normally change
in pregnancy are serum albumin and water-soluble vitamins.1,2
4.

There are several classifications of anemia. Define each of the following:

Megaloblastic anemia- a blood disorder marked by the appearance of very large red blood cells.2
Pernicious anemia- a decrease in red blood cells that occurs when your intestines cannot properly
absorb vitamin B12.3
Normocytic anemia- that marked by a proportionate decrease in the hemoglobin content, the packed
red cell volume, and the number of erythrocytes per cubic millimeter of blood.
Microcytic anemia- the presence of small, often hypochromic, red blood cells in a peripheral blood
smear and is usually characterized by a low MCV (less than 83 micron 3).3

Sickle cell anemia- the most common form of sickle cell disease (SCD). SCD is a serious disorder in which
the body makes sickle-shaped red blood cells. Sickle-shaped means that the red blood cells are shaped
like a crescent.4

5. What is the role of iron in the body? Are there additional functions of iron during fetal
development?
The human body needs iron to make the oxygen-carrying proteins hemoglobin and myoglobin.
Hemoglobin is found in red blood cells and myoglobin is found in muscles. Iron also makes up part of
many proteins in the body. Iron and iron-containing compounds play vital roles in cellular function in all
organ systems. The requirement for iron is greater in rapidly growing and differentiating cells. Iron
deficiency during the fetal and neonatal (perinatal) period can result in dysfunction of multiple organ
systems, some of which might not recover despite iron rehabilitation.3
6. Several stages of iron deficiency actually precede iron-deficiency anemia. Discuss these stages
including the symptomsand identify the laboratory values that would be affected during each stage.
Stage 1 (Iron Depletion): This is caused by a decrease in iron stores, which results in reduced levels of
circulating ferritin in the blood. Typically, there are no general physical symptoms because hemoglobin
levels are not yet affected. When iron stores are low, the amount of iron available to mitochondrial
proteins and enzymes appear to be depleted, which reduces the individuals ability to produce energy
during periods of high demand.
Stage 2 (Iron-deficiency erythropoiesis): The stage is manifested by a reduction in the saturation of
transferrin with iron. Transferrin, the transport protein for iron, has the ability to bind two iron
molecules and transport them to the cells of the body. During this stage, the iron binding sites on
transferrin are left empty, because there is no iron available for binding this results in the transferrin
having an increased ability to bind iron, which is called total iron binding capacity (TIBC). In addition
transferrin receptors on the cells increase to promote uptake of iron by the cell. Overall, then,
individuals with iron-deficiency erythropoiesis have low serum ferritin and iron concentrations, a low
level of iron saturation, and a high TIBC and transferrin receptors. Production of heme stats to decline
during this stage, leading to symptoms of reduced work capacity, because fewer RBS are being made.
Stage 3 (Iron-deficiency anemia): In iron-deficiency anemia, production of healthy red blood cells has
decreased, the cell size decreases by as much as a third, and hemoglobin levels are inadequate resulting
in less RBC being made and those that are not made cannot transport oxygen adequately. Those with
stage 3 will still have abnormal values for all the assessment parameters measured in stages one and
two.1
7. What potential risk factor(s) for the development of iron-deficiency anemia can you identify from
Mrs. Morriss history?

From her history, she had an increase of blood flow to sustain her fetus. Also she had below
normal weight loss in previous pregnancies.

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 relationship between the health of the fetus and maternal iron status is the demand for RBC
increases to accommodate needs such as maternal blood volume, growing uterus, placenta, and fetus.
Due to this, an increase in iron is needed. As time goes by, the fetus stores more iron in the liver
preparing for the first few months of life. Severely inadequate iron intake has potential to harm the
fetus which can result in low birth weight, preterm birth, still birth, and death of the newborn. Most
cases the iron-deprived fetus will rob the maternal iron resulting in iron-deficiency anemia in the mother
during pregnancy. Maternal iron deficiency causes extreme paleness and exhaustion and at birth
endangers the mothers life.1

9. Discuss the specific nutritional requirements during pregnancy. Be sure to address all macro- and
micronutrients that are altered during pregnancy.
A woman should consume close to the same number of calories daily as during her no pregnant
days during the first trimester. However, she should attempt to maximize nutrient density of what she
eats. For example, drink low-fat milk instead of soft drinks. Because the milk provides valuable protein,
vitamins, and minerals to feed the fetuss rapidly dividing cells whereas soft drinks are nutritionally
empty calories. During the last two trimesters energy needs to increase to about 350 to 450 kcal/day.
During pregnancy, protein needs increase approximately 1.1 grams per day per kilogram body weight
over the entire 9 month period. This comes out to an increase of 25 grams of protein per day. Pregnant
women are advised to intake at least 175 grams of carbohydrates per day. All pregnant women need to
be counseled on the potential hazards of very low-carbohydrate diets. Glucose is the primary metabolic
fuel of the developing fetus. The recommended intake will also prevent ketosis and help maintain
normal blood glucose levels. Additional carbohydrates may be needed to support physical activity for th
mother. Fat calories do not change during pregnancy. However adequate consumption of dietary fat is
crucial because cells and tissues are being built. During the third trimester, the fetus stores most of its
own body fat. Consumptions of the right fats are important. Limit intakes of saturated and Trans fats.
Poly- and monounsaturated fats should be chosen whenever possible. DHA has been found to be
uniquely critical for both neurological and eye development. Because the fetal brain grows dramatically
during the third trimester, DHA is crucial in the maternal diet. Pregnant women who eat fish should be
aware of the potential for mercury contamination.1

Micronutrient needs increase during pregnancy do to the expansion of the mothers blood supply and
growth of the uterus, placenta, breasts, body fat, and the fetus. Changes in nutrient recommendations
with pregnancy for adult women:
Folate: pre-pregnancy- 400ug/day pregnancy- 600ug/day
Vit B12: Pre- 2.4ug/day Pregnancy- 2.6ug/day
Vit C: Pre-75mg/day Pregnancy- 85mg/day
Vit A: Pre- 700ug/day Pregnancy- 770ug/day
Vit D: Pre- 5ug/day Pregnancy- 5ug/day
Calcium: Pre- 1,000mg/day Pregnancy- 1,000mg/day
Iron: Pre- 18mg/day Pregnancy- 27mg/day
Zinc: Pre- 8mg/day Pregnancy- 11mg/day
Sodium: Pre- 1,500mg/day Pregnancy- 1,500mg/day
Iodine: Pre- 150ug/day Pregnancy 220ug/day

10. What are best dietary sources of iron? Describe the differences between heme and nonheme iron.
The best sources of iron include:
Dried beans
Dried fruits
Eggs (especially egg yolks)
Iron-fortified cereals
Liver
Lean red meat (especially beef)
Oysters
Poultry, dark red meat
Salmon
Tuna

Whole grains3
Heme iron- iron that is part of hemoglobin and myoglobin, only found in animal based foods.
Non-heme iron- The form of iron that is not a part of hemoglobin or myoglobin, is found in both animal
based and plant based foods1.
11. Explain the digestion and absorption of dietary iron.
Iron is released from bound food components. Some HCI in the stomach may reduce Fe3+ to
Fe2+. Free heme is absorbed intact by heme carrier protein HCP 1, located primarily in the proximal
small intestine. Within the enterocyte, heme is catabolized by heme oxygenase to protoporphyrin and
Fe2+. Nonheme iron in the small intestine may react with one or more inhibitors, which promote the
fecal excretion of iron. Any of three reductases may reduce Fe3+ to Fe2+. Divalent metal transporter
DMT 1 carriers Fe2+ across the brush border membrane into the cytosol of the enterocyte, endocytosis
of DMT1 as part of transcytosis may also enable the absorption if iron. Fe2+ may bind to poly rC binding
protein or a et unidentified protein for transport in the cytosol; iron may als be used within the cell or
stored as ferritin. Ferroportin transports iron across the basolateral membrane. Iron transport is coupled
with its oxidation to Fe3+ by hephaestin. Fe3+ attaches to transferrin for transport via blood.1
12. Assess Mrs. Morriss height and weight. Calculate her BMI and % usual body weight.
Height: 55 (65) Weight: 142lbs
% UBW= (142/135)X 100= 105%
BMI= (135/4225) X 703= 22.53,6

13. Check Mrs. Morriss 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?
Her weight gain is inadequate. Her weight gain is below current recommendations by 4-9lbs. She did not
meet the recommended weight gain from her previous pregnancies as well3.

14. Determine Mrs. Morriss energy and protein requirements. Explain the rationale for the method you
used to calculate these requirements.
EER= (354-6.91) X 31 years old + 1.27 PA X (9.36 X 64.41kg) + (726 X 65in/39.370m) =
1,994.52 kcal/day
Patient is 23 wks pregnant and requires increased energy needs of about 364 kcal/day

1994.52 + 364 = 2,359 kcal/day4


15. Using her 24-hour recall, compare her dietary intake to the energy and protein requirements that
you calculated in Question 14.
Patient meets 65% of recommended energy intake and 80% recommended protein intake.

16. Again using her 24-hour recall, assess the patients daily iron intake. How does it compare to the
recommendations for this patient (which you provided in question #9)?
The recommendations for this patient are 27 mg/day and she is only at about 19.6mg/day.

17. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses.
Patient needs increases in iron, energy, and protein intakes.

18. Write a PE S statement for each nutrition problem.


Inadequate iron intake, patient needs to exceed daily intake to reach 27mg/day.
Inadequate energy intake, 24-hour recall states patient is only at 65% of recommended energy
intake.
Inadequate protein intake, 24-hour recall states patient is only at 80% of recommended protein
intake.

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 drugnutrient interactions? What instructions might you
give her to maximize the benefit of her iron supplementation?
Ferrous may prevent IDA. Constipation, diarrhea, stomach cramps, or upset stomach may occur as well
as dark stools. I would recommend for her to take on an empty stomach.7

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?
400 micrograms (mcg) of folic acid.
400 IU of vitamin D.
200 to 300 milligrams (mg) of calcium.
70 mg of vitamin C.
3 mg of thiamine.
2 mg of riboflavin.
20 mg of niacin.
6 mcg of vitamin B12.
10 mg of vitamin E.
15 mg of zinc.
17 mg of iron.
150 micrograms of iodine
I would make recommendation such as, making sure she knows why it is important to make sure she is
consuming her vitamins. As well as, carrying around a pill container around with her via purse or
whatever it may be so she will have them accessible when she forgets. Last, taking the vitamin in the
morning is the best but if she forgets as long as she takes one it is better than not taking one at all.7
21. List factors that you would monitor to assess her pregnancy, nutritional, and iron status.
In order to assess the patients pregnancy, nutritional, and iron status, an outpatient RD referral
should be made in order to monitor a variety of factors such as weight gain throughout the rest of the
pregnancy. Energy intake, serum folate levels, iron status, protein consumption and vitamin and
mineral (calcium, zinc, vitamin B12, and vitamin C) intake should be monitored especially. Tracking of
prenatal vitamin and ferrous iron supplement should be conducted, with continued education of
recommendations to be met. If patient is re-admitted to the hospital, laboratory values should be
reassessed. RBC (X 106/mm3) count, MCV values, and ferritin levels should be evaluated and compared
to previous laboratory values to assess iron stores. Hgb and Hct levels should be taken into account but
with caution because they can be affected by the increase in blood volume during pregnancy. TIBC levels
should be evaluated, but with caution as TIBC levels can be increased due to pregnancy.

22. You note in Mrs. Morriss 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 for Women, Infants, and Children that provides Federal grants to States for supplemental
foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and nonbreastfeeding postpartum women, and to infants and children up to age five who are found to be at
nutritional risk. Yes, I would refer her back. Qualifications include: Categorical, Residential, Income, and
Nutrition Risks. She meets the categorical qualification by being pregnant. She will meet the residential
requirements if her state is not an ITO or it if is an ITO depending where she resides.8

References
1.) The Science of Nutrition 3rd edition; Thompson, Manore, Vaughan.
2.) The American Journal of Clinical Nutrition Website http://ajcn.nutrition.org/content/71/5/1285s.full
Accessed 10/20/2014
3.) Healthline Website http://www.healthline.com/health/megaloblastic-anemia#Overview1 Accessed
10/20/2014
4.) National Heart, Lung, and Blood Institute http://www.nhlbi.nih.gov/health/healthtopics/topics/prnanmia/ Accessed 10/21/2014
5.) Medical Dictionary Website http://medical-dictionary.thefreedictionary.com Accessed 10/21/2014
6.) UBW indicator Website http://www.tpnteam.com/secure/calc%25UBW.htm Accessed 10/21/2014
7.) WebMD Website http://www.webmd.com Accessed 10/22/2014
8.) Food and Nutrition Service Website http://www.fns.usda.gov/wic/women-infants-and-children-wic
Accessed 10/22/2014