GOVT.

COLLEGE OF
NURSING
C.R.P. LINE INDORE(M.P.)

SUBJECT: OBSTETRICS & GYNAECOLOGICAL

NURSING
CASE PRESENTATION ON : ANEMIA IN
PREGNANCY

SUBMITTED TO: SUBMITTED BY:

Mrs. A. ram Miss. Pragati Bhole

Mrs. M. Auchat MSc. Nursing 1st Year

Mrs. K. Vincent Govt.College of Nursing

Govt. College of Nursing C.R.P Line Indore (M.P)

C.R.P Line Indore (M.P)

DATE OF SUBMISSION:
IDENTIFICATION DATA

Name : Mrs. Ashma khan

Age : 22 year

Sex : female

Education : 10th Pass

Occupation : House wife

Religion : Hindu

Address : Rishi nagar, Indore

Obstetrical score : G1P0L0A0

LMP : 15/05/21

EDD : 22/02/22

Gestational age : 35 +3 weeks gestation

Consultant Name : DR Seema Vijayvergiya

Hospital : M.Y.H Indore

Diagnosis : Gravida 1 para 0 anemia with 35+3weeks of

Pregnancy

Date of admission : 20/01/2022

HISTORY OF MOTHER

Present chief concern-

My mother Mrs Ashma khan 22year female came to MY. Hospital, Indore under Dr :Seema
Vijayvergiya with the chief complain of having mild back pain, weakness and leg cramps .
Pt is diagnosed with G1P0L0A0 anemia with 35+3 weeks in of pregnancy . Her last LMP is
15/05/21 and EDD is 22/02/22.

Present medical history-

My mother Mrs Ashma khan 22year female got admitted in MY. Hospital indore on
20/01/2022 , under Dr. : Seema Vijayvergiya with present medical condition of having mild
pain in back , weakness and leg cramps and diagnosed as a moderate anemia 8.0gm/dl

Present surgical history-

Patient do not underwent any surgery at present .

Past medical history-

Chronic illness: Patient doesn’t have any history of DM, hypertension, asthma or any major
medical health problems.

Allergy: No specific allergy present.

Communicable disease: No significant history of any communicable disease.

Past surgical history-

Patient does not have any significant past surgical history.

Antenatal history-

EVENTS OF TRIMESTER

1ST Trimester:

1st USG scan –

Radiation exposure- none

Drug taken - Folic Acid

She was having vomiting, weakness , leg pain was present in my mother.
2nd Trimester

2nd USG scan-

Mother took folic acid & iron tablet , she taken does of T.Tduring 4 th and 6th moth, HIV&
HbsAg test was done, it was non- reactive , she had poor nutritional diet .

3rd Trimester

During 3rd trimester mother took folic acid and iron tablet and calcium tablet. Blood
examination and urine examination was done, her Hb was 8.0 gm/dl. She had poor
nutritional diet.

Intranatal history : NIL

Postnatal history : NIL

FAMILY HISTORY

Family tree
Type of family: Nuclear family

No of members: 4

Support person: Mr. Hasheb khan

S.NO NAME OF AGE SEX RELATION MARITA EDUCATI OCCUPA HEALT

FAMILY WITH L ON TION H
MEMBER PATIENT STATUS STATUS
S
1. Mr. azmad 50yrs M Father in Married Illiterate Service Healthy
khan law

2. Mrs. 47yrs. F Mother in Married Illiterate Housewif Healthy

Rukaiya law e & well
Khan
3. Mr. Hasheb 26yrs M Husband Married 10th Service Healthy
Khan
4. Mrs Ashma 22yrs F patient Married 12th Housewif Patient
khan e
FAMILY TREE

Mr. Azmad khan Mrs Rukayia khan

Father-in-law Mother-in-law

Mr Hasheb Mrs Ashma khan

Husband Psatient

= MALE

= FEMALE

= PATIENT
Socio economic background
 Religion : Muslim
 Family Income : Rs. 20,000/ Month.
 Education : Husband-10th, Wife-12th.
 Occupation : Husband-Service, Wife- Housewife.

Menstrual history
 Menarche : 13years
 Duration : 3-5days
 Interval : 30 days
 Flow : Regular

Marital history
Age of marriage : 21 year

Year of marriage : 2021

Dietary pattern
Vegetarian : yes

Non vegetarian : yes

Like : Paneer,rice, chapatti , chicken Dislike: milk , palk

Habits : smoking/drinking/chewing pan/tobacco: Not have any habit of

substance abuse.

Marital history
 Age of marriage : 20years
 Years married : 02years
 Use of contraception : They used condom
 Relation with Husband ; Satisfactory relationship.
 PAST OBSTETRICAL HISTORY

S.No Year Full Preterm Aborti Types of Baby Remark

term on birth
Sex Aliv Still Weight
e born

PR IMI GRA VIDA

ADMISSION NOTES:

Admission on : 20/01/2022

Height of fundus :32cm

Presentation :Cephalic

Position : L.O.A

Engaged / not engaged : Not engaged

F.H.R : 128b/m

Bladder : Normal

Bowels :Normal

S.N HT WT Urine BP FHR Gestation Ht. of Abdominal Presentatio Position Rx &

fundus girth n remark
01 152cm 45 clear 128/80 136 28 38cmm 40cm Cephalic ROA Mv/fe/cal
weeks

PRENATAL VISIT

PHYSICAL EXAMINATION
GENERAL APPEARANCE

 Body Built : Ectomorphic

 Nourishment : Nourished
 Height : 152cm
 Weight : 45 Kg

VITAL SIGN

 Temperature : 97.60F
 Pulse : 78bts/min
 Respiration : 20bths/min
 Blood Pressure : 110/70mmhg

SKIN

 Colour : pale yellow

 Temperature : Normal
 Texture & Turgor : Good, hydrated
 Ulcer : Not present
 Oedema : Absent
 Capillary refill : Normal
 Pigmentation : Absent

HEAD

 Symmetry : Symmetrical
 Hair : Normal growth & development, no dandruff or lice.

EYES

 Symmetry : Symmetrical
 Vision : Normal
 Pupils : Reactive to light
 Eye brows & eye lids : Symmetrical, no haemorrhage or inflammation seen
EARS

 Hearing : Normal
 Nose : Symmetrical. No discharge, lesion or bleeding noted.
 Sinuses : Normal.

MOUTH

No dental carries or plaque present

 Symmetry : Normal
 Tongue : No crust formation, normal
 Gums : No bleeding or gingivitis present

NECK

No enlargement of thyroid or lymph nodes

 Range of motion : Normal

CHEST

 Symmetry : Symmetrical, Normal chest expansion

S1 S2 heard, no murmur or abnormal heart sound
heard.
 Breathing pattern : Normal, R.R- 20/min

BREAST

ON INSPECTION:

 Erectile nipple
 Presence of secondary areola
 Pronounced pigmentation of the primary areola & nipple
 Development of Montgomery tubercles

ON PALPATION:

 No lump palpated
 No breast engorgement
 No auxiliary lymph node palpated.

ABDOMEN

ON INSPECTION:

 Shape : Globular
 Contour : Normal
 Lie : Longitudinal
  Skin condition :Linea nigra present
 Fundal height : 35+3 weeks

ON AUSCULTATION:

 FHR : 130beats/min

GENETALIA

 No inflammation, swelling or bulging seen

 Rectum: Anal opening normal, no inflammation, haemorrhoids, rashes or ulcers seen

EXTREMITIES

 Symmetry : Symmetrical
 R.O.M : Normal
 No varicosity or Homan’s sign present
 Sensory or motor power is normal.

INVESTIGATIONS

S.NO NAME OF PATIENT’S NORMAL REMARKS

INVESTIGATION VALUE VALUE

BLOOD INVESTIGATIONS
1. 8.0 gm% 13-17gm% Moderate
Hb
anemia
RBC 3.8mill pre 11.5-16 mill -
cumm per cumm
PCV 34 mill pre 36-46mill per -
cumm cumm
MCV 81fl 81-101 fl -
M.C.H 30.9pg 25-35pg -
Platelets 4.1 lac 1.5-4.5 lac -
TLC 9,300 per 4000- Normal
cumm 10000per
cumm
2. Partial prothrombin time 32 sec 28-36 sec -
BT 3min 02-07min -
 CT 3.40 min 03-09min -
PTT 32min 28-36min -
3. BIOCHEMICAL -
Blood sugar 83mg% 70-110mg% -
BUN 12mg% 05-20mg% -
Creatinine 0.86mg% 0.6-1.4mg% -
Na 137mEq/L 136- -
149mEq/L
K 3.6mEq/L 3.5- 5.0mEq/l -
Cl 104mEq/L 98-105mEq/L -
4. BLOOD GROUP O+ve -
5. URINE ANALYSIS
Colour Pale yellow Yellow -
Appearance Turbid - -
Specific gravity 1.020 1.010-1.020 -
Reaction Acidic - -
CHEMICAL REACTION
Albumin Present+++ Absent Present
Glucose Nil Nil -
Acetone Nil Nil -
Bile pigment Nil Nil -
Bile salts Nil Nil -
MICROSCOPIC EXAMINATION

WBC 10-12/hpf 6-8/hpf -

RBC erythrocytes 0-1/hpf Absent -
Crystals Nil Nil -
Casts Nil Nil -
Epithelial cells 35-40/hpf Nil -
Others Nil Nil -
6. VDRL NR - -
7. HIV NR - -

INTRODUCTION

Commonest medical disorder in pregnancy.

• 18-20 pregnant women are anaemic in developed countries as compared to 40-75 % in
developing countries.
• It is responsible for significant high maternal and fetal mortality rate worldwide.

DEFINITION

 Anemia is a condition in which the number of red blood cells or their oxygen carrying
capacity is insufficient to meet the physiological needs of the individual, which
consequently will vary by age, sex, attitude, smoking, and pregnancy status (WHO
2013).

• Anemia in pregnancy is defined as hemoglobin (Hb) concentration is less than 11 g/dl.

CLASSIFICATION

• Mild: 9- 10.9 gm/dl

• Moderate: 7.8- 9 gm/dl
• Severe:< 7 gm/dl
• Very severe :<4 gm/dl

CLASSIFICATION OF ANEMIA
1. Physiological Anemia

2. Pathological Anemia
 Iron deficiency
 Folic acid deficiency
 Vitamin B12 deficiency

3. Haemorrhagic Anemia
 Acute—following bleeding in early months of pregnancy or APH
 Chronic—hookworm infestation, bleeding piles, etc.

4. Haemolyticanaemia
 Familial—congenital jaundice, sickle cell anaemia, etc.
 Acquired—malaria, severe infection, etc

5. Bone marrow insufficiency

 hypoplasia or aplasia due to radiation, drugs or severe infection.

6. Hemoglobinopathies
 Abnormal structure of one of the globin chains of the haemoglobin molecule of globin
chains of the haemoglobin molecule ex- sickle cell disease
PHYSIOLOGICAL ANEMIA OF PREGNANCY

• During pregnancy, maternal plasma volume gradually expands by 50%, an increase of

approximately 1,200 ml by term.
• Most of the rise takes place before 32nd to 34th week’s gestation and thereafter there is
relatively little change (Letsky, 1987).
• The total increase in red blood cells is 25%, approximately 300 ml that occurs later in
pregnancy. This relative hemo-dilution produces a fall in haemoglobin concentration, thus
presenting a picture of iron deficiency anaemia.
• However, it has been found that these changes are a physiological alteration of pregnancy
necessary for the development of foetus.

ERYTHROPOISIS

• In adults, erythropoiesis is confined to the bone marrow.

• Red cells are formed through stages of
PR normoblasts- normoblasts- reticulocytes-nature nonnucleated erythrocytes
••The average life- span of red cells is about 120 days after which the RBC’s degenerate and
the haemoglobin are broken into hemosiderin and bile pigment.

IRON REQUIREMENTS IN PREGNANCY

 During pregnancy approximately 1,500 mg iron is needed for: -

 Increase in maternal haemoglobin (400-500mg)
 The fetus and placenta (300-400 mg)
 Replacemet of daily loss through urine, stool and skin (250mg)
 Replacement of blood lost at delivery (200mg)
 Lactation (1mg/day)
IRON AND FOLIC ACID REQUIREMENT IN PREGNANCY

 Elemental iron- 30 mg to 60 mg
 Folic acid- 400 µg (0.4 mg)
 It is recommended for pregnant women to prevent maternal anaemia, puerperal sepsis,
low birth weight, and preterm birth of babies.

IRON DEFICIENCY ANEMIA

• About 95% of pregnant women with anemia have iron deficiency type.
• A pregnant woman is said to be anemic if her hemoglobin is less than 10 gm/dl.

CAUSES

• Reduced intake or absorption of iron

• Excess demand such as multiple pregnancy
• Blood loss

EFFECTS OF ANEMIA ON THE MOTHER

• Reduced resistance to infection caused by impaired cell-mediated immunity

• Reduced ability to withstand postpartum haemorrhage
• Strain of even an uncomplicated labour may cause cardiac failure
• Predisposition to PIH and preterm labour due to associated malnutrition
• Reduced enjoyment of pregnancy and motherhood owing to fatigue
• Potential threat to life.

EFFECTS TO FETUS/ BABY

• Intrauterine hypoxia and growth retardation

• Prematurity
• LBW
• Anemia a few months after birth due to poor stores
• Increased risk of perinatal morbidity and mortality
PREVENTION OF IRON DEFICIENCY ANEMIA
• The midwife can help to identify women at risk of anemia by
• Accurate history of medical, obstetric and social life

MANAGEMENT

• Avoidance of frequent childbirths

• Supplementary iron therapy
• Dietary advice
• Adequate treatments to eradicate illnesses likely to cause anemia
• Early detection of falling haemoglobin level

CURATIVE MANAGEMENT

1. Women having haemoglobin level of 7.5 mg% and those associated with obstetrical
medical complications must be hospitalized.
2. Following therapeutic measures are to be instituted:

• Diet
• Antibiotic therapy
• Blood transfusion
• Iron therapy which may be oral/ parental
• Oral iron: daily dose 120- 180 gm is given.

MANAGEMENT DURING LABOR

 1st stage
 Special precautions
 Comfortable position on bed
 Light analgesia
 Oxygenation to increase oxygenation of maternal blood and prevent fetal hypoxia
 Strict asepsis
 2nd stage
 Usually no problem.
 IV Methergin 0.2mg or 20 units oxytocin in 500ml RL IV and 10units of IM given.
 3rd stage
 Intensive observation.
 blood loss must be replaced by fresh pack cell and amount must not exceed loss
amount to avoid overloading
 Puerperium
 Bed rest
 Sign of infection detected and treated
 Pre delivery iron therapy must be continued until patient restores.
 Diet
 Patient and family members must be counselled for help at home regarding baby care
and household chores
FOLIC ACID DEFICIENCY ANEMIA (MEGALOBLASTIC ANEMIA): -

• Folic acid deficiency anemia happens when body does not have enough folic acid.
• Folic acid is one of the B vitamins, and it helps your body make new cells, including new
red blood cells
• Deficiency of folic acid can cause placental abruption, neural tube defect and congenital
cardiac septal defects

VITAMIN B 12 DEFICIENCY

o Vitamin B12 deficiency, also known as hypocobalamine anaemia, refers to low blood
levels of vitamin B 12.
o Deficiency of vitamin B 12 can also produce megaloblastic anaemia.
o Deficiency is most likely in vegetarians who eat no animal product.
 SICKLE CELL ANEMIA

o Sickle cell anaemia is a disease in which body produces abnormally shaped red blood
cells. The cells are shaped like a crescent or sickle.
o They don't last as long as normal, round red blood cells.
o This leads to anaemia.
o The sickle cells also get stuck in blood vessels, blocking blood flow.
o This can cause pain and organ damage

THALESEMIA SYNDROMES:

o The Thalassemia syndrome are commonly found genetic disorders of the blood.
o The basic defect is reduced rate of haemoglobin chain synthesis.
o This leads to ineffective erythropoiesis and increased haemolysis with resultant
inadequate haemoglobin content.

The syndrome is of two types:

 The alpha and beta thalassemia depending on the globin chain synthesis affected.

LIST OF NURSING DIAGNOSIS:

 Fatigueness related to decreased oxygen carring capacity of the blood as evidenced by

inability to maintain usual level of physical activity.
 Ineffective tissue perfusion related to decrease in haemoglobin concentration in the
blood as evidence by blood reports.
 Altered nutrition status less than body requirement related to less intake and loss of
appetite as evidenced by I/O chart and mother verbalization .
 Ineffective pattern of breathing related to decrease O2 carrying capacity as evidence
by fatigue and mother verbalization .
 Impared gas exchange related to decreased O2 carrying capacity of blood and
decrease hb level as evidenced by investigation and SPO2 monitoring SPO2 80%
ASSESSMENT NURSING EXPECTED INTERVENTION IMPLEMENTATION EVALUATIO
DIAGNOSIS OUTCOMES N

Subjective Fatigueness To reduce the Assess the general General condition Fatigueness
Data- related to fatigueness. condition of the assessed mother reduced to
Mother said decreased mother having weakness some extend
that I am oxygen after the
having carrying further
weakness and capacity of implementati
fatigueness. the blood as To provide Adequate rest and on .
evidenced by adequate rest and sleep ( 8-9hrs)
inability to sleep to the provided to the
maintain mother. mother
Objective usual level of
Data- physical
I observed that activity. To provide oral Oral fluids and juiced
mother is . fluid and juices to provided to the
having the mother . mother.
weakness as
evidenced by
verbalization Encourage mother Encouraged mother to
and to take deep take deep breath nose
observation. breath from nose and exhale from
and exhale from mouth.
mouth.

To provide Semi- fowler position

comfortable provided to the
position to the mother
mother
ASSESSMENT NURSING EXPECTED INTERVENTION IMPLEMENTATION EVALUATIO
DIAGNOSIS OUTCOMES N

Subjective Ineffective To maintain Assess the general General condition Tissue

Data – tissue adequate condition of the assessed mother perfusion
Mother said perfusion tissue mother. having tiredness and improved to
that I am feel related to perfusion . weakness . some extend
weakness and decrease in after futher
tiredness. haemoglobin implementati
concentratio Advise mother to Advised mother to on.
Objective n in the drink adequate drink at least 2-3 liter
Data- blood as fluid . water per day.
I observed that evidence by
mother look blood
tired and reports. Encourage mother Encouraged mother to
weak . . to do antenatal do antenatal
exercise . exercises.

Encourage mother Encouraged mother to

to take iron rich take iron rich diet
diet. ( spinach,
pomegranate ,beetroot
etc)
ASSESSMENT NURSING EXPECTED INTERVENTION IMPLEMENTATION EVALUATI
DIAGNOSIS OUTCOMES ON

Subjective Altered To improve Asses the general General condition Nutritional

data- nutrition the condition of the assessed mother status
Mother said status less nutritional mother having loss of improved to
that I am than body status of the appetite . some extend
having loss of requirement mother. after further
appetite. related to implementat
less intake To provide small Small and frequent ion .
Objective and loss of and frequent diet diet provided to the
data- appetite as to the mother mother
I observed that evidenced by
mother was I/O chart and
looking dull mother To provide iron Iron rich diet like
and drowsy. verbalization rich diet to the green leafy
mother . vegetable , chicky etc

To provide juice Citric juiced and

and fruits to the fruits provided to the
mother. mother .

Provide Psychological support

psychological provided to the
support to the mother.
mother.
ASSESSMENT NURSING EXPECTED INTERVENTION IMPLEMENTATION EVALUATIO
DIAGNOSIS OUTCOMES N

Subjective Ineffective To improve Assess the general General condition Breathing

Data- pattern of breathing condition of the assessed mother pattern
Mother said breathing pattern. mother having breathing improved to
that I am related to difficulty. some extend
having decrease O2 after further
breathing carrying implementati
difficulty and capacity as To provide rest Adequate rest and on.
weakness evidence by and sleep to the sleep provided to the
fatigue and mother. mother .
Objective mother
Data- verbalization
I observe that . Encourage mother Encouraged mother to
mother having . to take deep take deep inhale from
breathing breath . nose and exhale from
difficulty as mouth.
evidenced by
facial
expression. To provide Semi-fowler position
comfortable provided to the
position to the mother.
mother

Provide Psychological support

psychological provided to the
support to the mother.
mother.
ASSESSMEN NURSING EXPECTED INTERVENTION IMPLEMENTATIO EVALUATI
T DIAGNOSIS OUTCOMES N ON

Subjective Impared gas To improve Assess the general General condition Gas exchange
Data- exchange gas exchange condition of the assessed mother is process
Mother said related to process. mother having breathing improved to
that I am decreased difficulty and some extend
having O2 carrying weakness. adter further
breathing capacity of investigation.
difficulty blood and To provide Adequate ventilation
decrease hb adequate provided to the
Objective level as ventilation to the mother .
data- evidenced by mother.
I observe that investigation
mother is and SPO2
having monitoring Advise mother to Advised mother to
difficulty in SPO2 80% take deep breath take deep breath from
breathing . nose and exhale from
the mouth

To provide Adequate fluid 3-4

adequate fluid to liter provided to the
the mother mother in a day.

Provide Semi – fowler

comfortable position provided to
position to the the mother
mother.

Provide Psychological support

psychological provided to the
support to the mother .
Mother
HEALTH EDUCATION

Dietary Therapy

 To aid in supplemental doses of iron and for secondary prevention of iron deficiency,
increase in dietary iron intake is recommended
 Diet rich in iron are red meat, chicken, fish, legumes, and green leafy vegetables
 Limit cow’s milk consumption to 500 mL/day
 Inhibitors of iron absorption, eg calcium, tannins in coffee and tea, phytates in cereals,
should be decreased or removed from meals rich in iron 

INTERVENTION IMPLEMENTATION

 Educate mother on anaemia Explain about the effects of that and how to
manage that.

 Explain about dietary management
Explain the importance of diet , rich in iron
are red meat, chicken, fish, legumes, and
green leafy vegetables and explained the
lactational diet for the benefit of breast
feeding .

 Explain about the importance of Explained to manage stress and anxiety , do

taking rest and physical activity and daily exrcise and yoga and morning walk .
exercise Sleep and rest are most important for mother
appropriate sleep should be taken.
Explained about life style to be managed .

 Explain about personal hygiene Explain about the importance of personal

hygiene before and after cleaning of hands
and breast .

Explained about the hazardious effect caused

 Explain the patient about the
by drug substance and smoking to avoid
importance of avoiding alcohol and
further complication of anemia .
drug substance .

Explained about importance of medication

 Explain about medication and also explained about route, dose, action
and side effects.

Explained about the importance of follow up

 Explain about the follow up
and also explained the condition that she
have to come and visit doctors.
DISCHARGE CARE PLAN
CONTENT
 Explain about medication
 Explain about dietary management
and types of nutritional intake .
 Explain about the rest and sleep
 Explain about precaution taken.
 Explain about family planning .
 Explain about immunization and
follow up visit .
ACTION TAKEN
Encourage the mother to take medicine at
correct time and correct dose.
Explained the mother , attenders about the
action , side effects of medication prescribed
The mother was tought to take proper and
adequate amount of food to avoid the adverse
effect of medicine on the body .
The family member and mother was told to
avoid intake of any medication without
prescription from doctor.
Explained the mother and her family
members about the importance of dietary
management and to take food rich in iron,
vitamin, and minerals, green leafy vegetable
and also avoid fatty food .
Explained the mother to avoid drug
substance.
Mother was explained about the importance
of rest and sleep
She was explained to take daily weight and to
increase physical activity , in order to detect
any further complication . mother and
relatives were on courage to come for regular
follow up to prescribed by physician.
Explained about precaution taken after
delivery.
Explained about the importance of family
planning and various methods and its
advantages
Explained about the importance of
immunization and importance and
advantages of follow up visits
 PROGNOSIS

Mother Mrs. Ashma khan 22year old female was came in MY.H hospital indore on
20/01/2022
She is primi gravid mother no other hereditary or secondary disease. The condition of mother
and fetus is stable. Mother started doing her normal activity and also she planned for
discharge after 4days observation.
 CONCLUSION

• Anemia in pregnancy is the most commonly occurring disorder during pregnancy, so every
mother who are pregnant must screen for anemia and must take treatment as soon as possible
along with foods rich in iron and also must have family support and care throughout
pregnancy.
 BIBLIOGRAPHY

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3) Datta D.C. (2004),’’Text book of obstetrics’’,6th ed .New central book agency (P) LTD
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4) Jacob Annamma,(2019) ‘’Acomprehensive textbook of midwifery & gynecological

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