KENYA METHODIST UNIVERSITY

SCHOOL OF MEDICINE AND HEALTH

SCIENCES

DEPARTMENT OF NURSING

NAME: DORCAS JEPKEMOI KIPROP

REG. NUMBER: BSN-1-8179-3/2019

COURSE CODE: NRSG 242

COURE TITLE: REPRODUCTIVE HEALTH 1-

CASE STUDY

LECTURER: MADAM ROSELYNE ODHIAMBO

TASK: CASE STUDY ON ANEMIA IN

PREGNANCY.
 INTRODUCTION
Background of Embu County and Referral Hospital.

Embu County and Referral Hospital is government hospital. It started as a dispensary in 1924,
then elevated to a health center in 1935, then sub district hospital in 1941, it had a one 30 bed
ward and the first medical officer of health was posted to the institution. Became district hospital
in 1960 and by 1984 it had a capacity of 166beds. A major expansion program was started by the
government in 1984 to upgrade the hospital to a provincial general hospital. In 1985 the nyayo
wards were completed (144 bed capacity). In 1987 the kitchen and laundry were completed. In
1991 an eye unit which comprises an outpatient, theatre and a 22-bed ward was completed. In
1993 a psychiatric unit with 20 beds was completed. At the end of 1995 a maternity unit of 148
beds and 40 cots with an operation theatre was completed. It was occupied on 22nd February
1996. This project was funded by plan international Embu at an approximate cost of 42 million.
The hospital is located in Embu county, municipality ward in manyatta constituency. It serves as
a Referral hospital for the various counties and sub county hospitals such as manyatta, runyenjes,
mbeere and other counties in Eastern part of Kenya.There hospital is a Teaching Hospital for six
learning institutions. These institutions are Kenya Methodist University, Kenya Medical training
college [KMTC] Embu, KMTC Nakuru, Chuka University and Embu University.

Type: County hospital

County: Embu County

Owner: Ministry of health

Status: Operational institution

Constituency: Manyatta, Eastern Region

Location: Municipality

Sub location: Township

HOSPITAL VISION; an efficient and high-quality health care system that is accessible,
equitable and affordable for every Kenyan.

MISSION: to promote and participate in provision of integrated and high quality promotive,
preventive, curative and rehabilitative health care services to all Kenyans. Mandate, to formulate
policies, set standards, provide health services, create an enabling environment and regulate the
provision of health service delivery.

SERVICES OFFERED MCH DEPARTMENT AT EMBU LEVEL 5 HOSPITAL

i. Curative and diagnostic services.

ii. Child Health services.

iii. Family planning

iv. ANC

v. PMTCT

vi. Postnatal

vii. HTS/Comprehensive care services.

viii. TB clinic

ix. Cervical Screening

x. Laboratory Services

Activities that nurses and students are involved in

7.30am- duty staffs and students report on duty with duty. Preparation for the daily routine is
done and nurses together with students get ready to start offering services to the clients.
After that Students and staff are allocated to take care of various clients.

8:00am- Reporting to the stationed area and begin of daily routine

13:00pm- 14:00- lunch break for student and staffs.

16:30- Students and staff leave for various places Review is done and report is taken to the
management.
ABBREVIATIONS

ANC: Antenatal Clinic

APH: Antepartum Haemorrhage

BD: Twice per day

BP: Blood Pressure

CCF: Congestive Cardiac Failure

CSSD: Central Sterile Services Department

ENT: Ear, Nose and Throat

EDD: Expected Delivery Date

FHR: Foetal Heart Rate

HB: Haemoglobin

IM: Intramuscular

IV: Intravenous

IUFD: Intrauterine Foetal Death

IUGR: Intrauterine Growth Retardation

LBW: Low Birth Weight

LMP: Last Menstrual Period

PO: Per Oral

PPH: Postpartum haemorrhage

QID: Four times a day

TDS: Three times a day

VDRL: venereal disease research laboratory test

OD: Once a day

Justification of the case

I choose the client because on the first antenatal visit she had a hemoglobin level of 10.2gm/dl
and on the next visit it had dropped to 8.3gm/dl which is classified as moderate anemia.

BIO DATA

NAME: Pamela Murugi Ngare

GENDER: Female

AGE: 25years

D.O.B: 07/05/1997

COUNTY: Embu

SUB-COUNTY: Nthagayia

ADDRESS: Kangaari S.W

NATIONALITY: Kenyan

RELIGION: Christian

MARITAL STATUS: Married

PHONE NUMBER: 0708521223

HUSBAND: Daniel Murimi

PHONE NUMBER: 0704519440

INTERVIEWER: Dorcas Memo

DIAGNOSIS: Moderate Anemia

Chief complain
The above named patient came into the antenatal clinic on 19th January 2023 with complains of
general body weakness and fatigue for the past 4 days. Also, she complained of headache with
dizziness for the past 2 days. On examination, there was no signs of blurred vision, fainting,
breathlessness nor lower abdominal pains.

History of Present Illness

Pamela Murugi reported that her problem started on 15th January, 2023. She started feeling tired
after doing any small activity and felt as if she had been on a very strenuous exercise. She
reported feeling fatigue and general body weakness for the past 4 days especially when she
walks or climbing stairs. She also reported that her symptoms was accompanied by dizziness,
headaches and feeling light headiness. She also stated her fatigue and dizziness is relieved when
she rests while lying on her side. At 22nd week of her pregnancy, she started her antenatal clinic,
a full antenatal profile was done then, results showered a HB of 10.2g/dl. Which is a sign of mild
anemia. She was given nutritional education and advised to take large amounts of green leafy
vegetables. A prescription of IFAS tabs, was given to be taken one tablet, twice a day. She
reported to have trouble taking the medication as they made her feel nauseous.

Medical surgical history.

Pamela Murugi never knew she was anemic until she was pregnant. She reported that she has
never been admitted .She has no history of hypertension, diabetes, T.B nor sickle cell disease.
Her HIV status is negative. She has never contracted coronavirus. She has never undergone any
kind of surgery. She has no history of blood transfusions or injuries. She has no history of any
drug or food allergies.

Past Obstetric history

Pamela Murugi is a primigravida and has no history of abortions or miscarriages.

Present Obstetric history/History of present Pregnancy

Pamela Murugi is para 0+0, gravida 1 .Her L.MP 20/07/2022 is and her E.D.D 27/04/2023.
Gestation is 26weeks.FH-?/40 FHR-regular 144b/min LIE-longitudinal, Presentation-
cephalic ,Position-LOA, Engagement 0/5

Gynecological history

Pamela Murugi started her menstrual flow at the age of 14 years. Her menses were regular and
lasted for 3 days, in a cycle of 23 days each month. She reported no history of pain during her
menstrual period other than mild lower abdominal pain one day prior to start of the menstrual
flow. She had no history of abortions or miscarriage. She also has no history of STIs. She
reported to have been using an IUCD as her means of family planning for 3 years before it was
removed in November 2021 because of her desire to conceive.

Family History

Pamela Murugi is married to Daniel Murimi. There is no family history of anemia or any genetic
disorders or medical conditions: Hypertension, T.B or Diabetes Mellitus. Also, no history of
twins in the family .Her parents are both alive and her 3 siblings are also both alive.

Socio-economic History
She has no history of chronic illness .She has no history of substance abuse, neither does she
smoke nor take alcohol. She is a business woman and reached College level of Education.She is
a Christian and attends church every Sunday.

Physical Examination
The following is head to toe examination.

General Examination
General appearance:
BP: 92/63 mmHg
PR: 94b/min
Respirations: 20b/min
Temperature: 37.20c Height: Weight:

Head

On inspection the hair was equally distributed. It was clean and with a fine texture. She had no
rashes and no scars. On palpation there is no sign of head lumps or masses. No evidence of
tenderness on touch. Sinus show no signs of infection, no evidence of tenderness, redness, nor
swelling. The mastoid, post auricular, cervical, and sub mandibular lymph nodes are not
palpable, and there is no sign of tenderness on touch. Dry mucous membrane is a sign of fluid
volume deficit.

Eyes
On inspection the eyes were equal in symmetry, there was no discharge from the lachrymal
apparatus, and all the eyes could see both long and short distance. No cataracts, no squint. The
conjunctiva was slightly pale.

Ears

There was no discharge on inspection, no pain on palpation and had no hearing problems. Both
air and bone conduction are normal with normal hearing abilities at whispers and also loud
sounds.

Nose

On inspection the nostrils were well separated by the septum, no swelling, no discharge, no
polyps. They were symmetrical and thus had good smelling sense. Ethmoidal sinus is normal, no
swelling, and no redness. On palpation, there is no sign of tenderness, lumps or masses. There is
slightly palority in the mucous membrane of the nose..

Mouth

The mucous membrane was on the lips is slight dry. No lesions, tongue not pale, no decayed
teeth and all teeth were present. No inflammation of the gums on inspection. She had no
dentures. She had no sign of tonsillitis.

Neck

No lymph node swelling, no thyroid enlargement, palpable jugular vein and regular rhythm. No
bruise on jugular vein. No palpable lymph nodes nor sign of tenderness..

Chest

On inspection no swelling on right and left side, the respiratory rate was 18 breaths per minute
which is under a normal range that varies between 16-20 beats per minute. Chest movements are
equal on both sides. No use of extra muscle to breath. Skin color distribution is equal with no
pigmentation. No lesion not scars seen. Breasts are symmetrically equal in size and shape, no
lesion, no scaring nor striae seen. There is no abnormal discharge seen. On palpation, there is no
lumps, no masses. There is slight tenderness at the nipples on pressing them. On dividing the
breasts into four quadrants and palpating there are no lumps felt. No signs of burrell chest. I also
taught the mother on how to perform a self-breast exam which she will be doing twice weekly.

Arms

The arms were bilaterally equal, no deformities, and no clubbed nails. On palpation of a wiped
axilla, no swollen lymph nodes. She had a temperature of 37.2⁰c that was equally distributed in
both axilla and a blood pressure of 92/63 mmHg. No lesions on the arms, short and clean nails.
She had a capillary refill of 2seconds, normal capillary refill is at a range of less than 2 seconds.
Abdomen

On inspection it was gravid or distended and had no lesions, no scaring, linear nigra was present.
Colour distribution was equal with slight brown pigmentation which is normal in pregnancy. On
palpation the liver and spleen are normal, nontender and no sign of swelling. No tenderness
noted. The fundal height was ?/40 weeks which was consistent with the her gestation of 26
weeks of pregnancy. The fetus is in right occipitoanterrior position, in longitudinal lie, in
cephalic presentation. On auscultation using the fetoscope I listened the fetal heart rates that
were regular at rate of 144 beats per minute which was normal with the known range of 120 -
160 beats per minutes.

Back

There were no curves, no abnormal growths on palpation. There was also continuity of the spine
and no tenderness noted. There are no sign of sacral edema, no sign of accessory muscle use
during breathing. Tactile fremitus are present and normal.

Lower limbs

The limbs were bilaterally equal, no edema, no varicose veins, and knee-jerk reflex present.
Intact skin, no deformities, varicosities, the capillary refill was within 2-3seconds,Slight edema
in the ankles, posterior tibial pulse and dorsalis pedis pulse felt, no fungal infections on the toes.

LITERATURE REVIEW

ANEMIA IN PREGNANCY

Introduction

Anemia is one of the most frequently observed nutritional deficiency diseases in the world today.
It is especially prevalent in women of reproductive age, particularly during pregnancy where it is
often a contributory cause of maternal death. In areas where malaria is prevalent, the number of
women affected increases. The prevalence of anemia in rural Kenya was found to be 7.4%. It is a
major obstetric complication in Kenya and one of the commonest medical condition encountered
during pregnancy.
Anaemia is a global burden particularly during pregnancy, affecting up to 56% of pregnant
women in non-industrialized countries and around 20% in industrialized countries. Anaemia
during pregnancy is most frequently caused by iron deficiency with other causes including
uncorrected anaemia due to heavy menstrual bleeding (i.e., low iron stores preconception) and
maternal haemorrhage

Mild anaemia is normal during pregnancy due to an increase in blood volume which is treated by
giving the mother IFAS tabs (combined Ferrous sulphate and Folic acid). But you may have
more severe anaemia from low iron or vitamin levels or from other reasons. Anaemia can leave
you feeling tired and weak. If it is severe but goes untreated, it can increase your risk of serious
complications like preterm delivery. Being anaemic also burdens the mother by increasing the
risk of blood loss during labour and making it more difficult to fight infections.

During pregnancy, delay in treatment is common with large numbers of those affected being
seen for the first time with severe degrees of anemia. Consequently, pressure on the health
services rises and treatment costs increase, while maternal and fetal lives are lost on a large scale.
After the puerperium, the debilitating effect of anemia undermines women’s health, lowers their
economic productivity, and reduces their ability to care for their homes and look after their
children.

Definition of Anemia

Anemia is a disorder characterized by blood hemoglobin concentration lower than the defined
normal level and it is usually associated with decrease in circulating mass of red blood cells. This
may result from decreased generation of red blood cells, or from their premature destruction, or
from loss through chronic blood loss or hemorrhage.

A low red blood cell count makes it harder to send oxygen throughout your body, which can
result in symptoms like excessive fatigue. Severe, untreated anaemia during pregnancy can
increase the risk for complications including preterm birth and Post-Partum Haemorrhage.

Classification of anaemia in pregnancy WHO

Normal Hb 11gm/dl or hematocrit <32%

Mild- 9-10.9gm/dl

Moderate -7-8.9gm/dl

Severe-7gm/dl
Very severe- <4

Types of Anaemia in pregnancy

Anaemia can be categorized in terms of degrees or it's causes.

According to the most frequent cause of anemia in pregnancy, pregnancy related anaemia can be
categorized as:

Physiological Anaemia

In pregnancy, usually blood capacity raises by 15 percent within the 10th week of pregnancy and
50 percent by the 32nd - 35th week of pregnancy. The normal red blood cells mass also increases
by 30 percent. The above named changes results in increased cardiac output from 5-7 litres per
minute thus resulting to what we call non pathological Anaemia, physiological Anaemia.

Pathological Anaemia

Iron Deficiency Anaemia

During fetal development, approximately 1.4kg of iron is required for fetal development and to
curb the increased demand for the mother's readiness for delivery and infant hostage. This is
approximated to 200g of iron requirement daily. This is important because the iron has to carter
for increased demand of red blood cells, development of the fetus and the placenta, replacement
of blood lost during pregnancy and most important component of milk during lactation. Thus
lack of iron supplement during pregnancy leads to insufficient supply as per the body
requirements, reducing blood formation hence leading to Anaemia.

Folic Acid Deficiency Anaemia

In pregnancy and normal fetal development, folic Acid play a very important role in cell growth
and development to meet the increased demand for the developing fetus and reduce overstraining
of the mother to sustain the fetus. Deficiency of folic acid can be as a result of low dietary intake,
reduced folic acid absorption, interference with utilization more so in substance abuse and
sulphonamide intake which antagonizes folate actions and excessive demand as in pregnancy
without supplement and loss of folate in cases of hemolytic Anaemia.

Diagnosis of Anaemia

A comprehensive history and physical examination is of much importance to rule out the
underlying causes of anaemia, and to detect any complications that may have occurred.
Basic laboratory work up should include the following:

1. Haemoglobin and haematocrit Estimation - this is determine the degree of the anaemiaa
(mild, moderate or severe).

2. Full blood count and peripheral blood film- this is know the type of anaemia
3. Stool examination for ova and cysts, Blood Slide or RDTs for malaria diagnosis,
urinalysis / microscopy- this is done to determine the cause of the anaemia.
4. . Blood group and Rhesus factor determination
5. Other tests will be determined by the findings on history and physical examination.

Causes of Anaemia

During pregnancy, the growth of the foetus and the placenta and the larger amount of blood
circulating blood in the expectant mother lead to an increase in the demand for nutrients,
especially iron and folic acid. The fact that most women start pregnancy with depleted body
stores of these nutrients mean that their extra requirements are even higher than usual.

The daily requirement of iron as well folic acid is six times greater for a woman in the last
trimester of pregnancy than for a non-pregnant woman. This need cannot be met by diet alone,
but it is derived at least partly from maternal reserves.

Common causes are as follows;

a. A low intake of dietary meals that are rich in iron, folic acid and proteins. Also the faulty
absorption of nutrients such iron and nutrients due gastrointestinal conditions (nutritional
causes).
b. Physiological anaemia- this is a disproportionate increase in plasma volume in relation to
the red blood cells mass during Pregnancy.
c. Anaemia in pregnancy can be caused pregnancy related blood loss such as abortions,
ectopic pregnancy, antepartum haemorrhage and postpartum haemorrhage.
d. Anaemia can result also due to frequent pregnancies or multiple pregnancies, this may
lead to increased demand for iron and vitamins in blood to process more red blood cells.
e. It can also be caused by other chronic illnesses such as bleeding disorders, pulmonary
tuberculosis and pre-existing medical conditions such as HIV/AIDS, sickle cell disease.
f. Frequent attacks of malaria, dysentery, bookworm infestations and urinary tract
infections including bilharzia.
g. Vomiting frequently due to morning sickness.
h. Having history of anaemia or heavy menstrual flow.
Women at risk of anaemia

 Pregnant women in malaria endemic areas.

 Young primigravida.
 Previous history of postpartum haemorrhage.
 Low socio-economic status.
 History of antepartum haemorrhage.
 Frequent or too many pregnancies.
 Multiple pregnancies, and also as per the current information all pregnant women are at
risk of Anaemia. So at each ANC visit thorough investigation has to be done and
appropriate intervention done.

Signs and symptoms

Pallor of palms, soles of feet, and mucous membranes. Pallor of mucous membranes due to lack
of enough supply of oxygen and blood in the site.

Breathlessness that is caused by poor circulation of blood in the lungs and poor gas exchange in
the lungs as a result of reduced oxygen carrying capacity.

Dizziness most common, due to lethargy and low oxygen supply to the brain. Dizziness can be a
sign of many medical condition, thus other signs and symptoms should be thoroughly assessment
before relating this sign to Anaemia

Fatigue and lethargy, this is caused by reduced energy production due to poor oxygen supply to
the tissue that manufacture energy. Low supply of oxygen makes the body switch to anaerobic
means of survival which requires a lot of energy hence lethargy and fatigue.

Fainting attacks due to poor oxygen supply to the brain may lead to temporary loss of
consciousness. This is usually observed in moderate and servers Anaemia. Thus care should be
urgently initiated incase this occurs to help reduce injury to the brain.

Headaches due to lack of sufficient oxygen to brain cells.

Chest pains due to difficulty in breathing as there is low oxygen supply.

Rapid and irregular heartbeat due to insufficient oxygen supply to the heart.

Fever in cases of infection like malaria and hookworm infestation.

Effects of Anaemia in pregnancy

The effect of anaemia on pregnancy results from the diminished oxygen carrying capacity of the
blood. When this occurs, even minor blood loss at delivery may be fatal.

Anaemia during pregnancy is associated with increased maternal morbidity and mortality.
Anaemia in pregnancy is associated with negative consequences for both the woman and
neonate. Foetal anaemia, low birth weight, intrauterine hypoxia preterm birth, and stillbirth have
been associated with anaemia.

Anaemia was observed as a predictor for poor perinatal outcomes such as foetal anaemia and
low birth weight deliveries. Analysis showed that anaemia during early pregnancy, but not late
pregnancy, is associated with slightly increased risk of preterm delivery and low birth weight.

Maternal effects

Diminished resistance to infections

Preterm labour-Foetal hypoxia

Congestive heart failure (during 30-32 weeks gestation, labour and after delivery).

Maternal death

Postpartum haemorrhage

Puerperal sepsis

Foetal/neonate effects

Intrauterine growth retardation

Prematurity

Foetal malformations especially in folate deficiency

Low birth weight

Intrauterine foetal death

Still births (fresh or macerated)

Management of anaemia in Pregnancy

There is clear evidence to support prompt treatment in all patients with anaemia because it is
known that treatment improves quality of life and physical condition as well as alleviates fatigue
and cognitive deficits. Anaemia management in pregnancy varies depending on the level of
hemoglobin in blood and the cause of the presenting symptoms. According to degree of
Anaemia, pregnancy related anaemia can be managed in the following manners:

Mild Anemia

At a gestation of 20 to 29 weeks, the woman is given hematinic and a diet rich in protein and
iron. This helps replace the iron store, increase blood formation and help improve the
hemoglobin concentration Standard nutritional education should be highly recommended to
ensure that the woman gets full information regarding her current status and the recommended
nutritional requirements thus helps a lot improve the health status of the mother and the infant at
large.

At 30 to 36 weeks, the hemoglobin levels are checked, diet is emphasized and hematinic
continued. Blood iron levels and sign of iron toxicity should also be taken into consideration to
help detect any risk that might be presented due to treatment regimen.

The mother should be watched closed to detect improvement, side effects of medication, proper
intervention to curb any abnormalities should be instituted promptly.

Investigations are carried out to establish the cause of the anemia, for example, malarial
parasites, hookworms, sickle cell disease.

The mother is given health messages on nutrition, rest and taking drugs as prescribed

Together with the above interventions, regular antenatal clinic visits are reinforced to help detect
any risk on the current pregnancy.

Moderate Anemia

At gestation of 29 to 30 weeks investigations are carried out to establish the cause and institute
treatment. Thorough blood workings and other tests are done to help rule out the possible cause
of the condition while symptoms are dealt with appropriately.

Hematinic are given and a total dose of parenteral inferno 50 mgs/milliliter is given in a slow
intravenous infusion of normal saline after a test dose to rule out sensitivity.

Intramuscular iron in the form of sorbitol 50mg/ml is also administered. The dose is 1.5mg/kg
body weight weekly. Hemoglobin levels are monitored regularly starting on the third day after
commencement of treatment and then monthly. The injection should not be given in conjunction
with oral iron as this enhances toxic effects.
At 30 to 36 weeks of gestation the woman is given total dose inferon and transfused with no
more than 500ml whole blood. At 37 weeks blood transfusion is given again as above if the Hb
is still low. After transfusion the mother will be given a folic acid prescription to help improve
cell development in the fetus. The above interventions are aimed to help maintain blood levels of
hemoglobin and red blood cells. Regular vital sign measurements should be done during blood
transfusion to help detect any reaction to the blood or changes that might befall during blood
transfusion.

In cases of pathological cause of Anaemia, the agents are eliminated, health education given to
avoid future occurrence and also reoccurrence of the same conditions. Fetal heart rates are
monitored four hourly to detect any deviation and total bed rest with minimal exercise should be
advised

In consultation with the available literature, I would suggest that the mother be summoned
thorough investigation done to find out the cause of her condition. The mother should be
admitted for parenteral inferon infusion, blood transfusion when possible and proper
management including total bed rest until the Anaemia level stabilized

Severe Anemia

Hemoglobin below 7gm per deciliter.

This is an emergency where the mother is admitted and put on complete bed rest to reduce
cardiac workload as she could go into cardiac failure. She is nursed in left lateral position.

Investigations are carried out to establish the cause. Minimal activities are encouraged to help
put the body into active state, Vital observations are taken quarter hourly and the fetal heart rate
is monitored. With stable vitals, investigation are done to help rule out the cause of anaemia

The mother is nursed in the left lateral position to help prevent compression of the vena cava by
the gravid uterus.

Transfuse three units of packed cells slowly as vital signs are taken half hourly not forgetting the
fetal heart rate to help figure out the state of the mother. In cases of malaria parasite, hookworms
infestation or sickle cell Anaemia disease, the root cause is treated and health message given
with emphasis on the diet and general preventive measures to help improve the state of the
mother and the infant.
Dietary advice- As physiological iron requirements are several times higher in pregnancy than
they are in the non-pregnant women, the recommended daily intake of iron for the second half of
pregnancy is 30 mg with iron absorption increasing threefold. The amount of iron absorbed
depends upon the following factors: amount of iron in the diet, its bioavailability, and
physiological requirements. Dietary heme iron is found mainly in red meats, fish, and poultry
they are easily absorbed.

Nutritional health education is the main objective of antenatal care to assist in the prevention of
anaemia. In addition, family planning and control of birth spacing is another preventive measure
that should be considered by health-care providers.

The WHO jointly with the International Nutritional Anaemia Consultative Group and the United
Nations Children’s Fund recommend routine supplements of 60 mg iron per day and 400 μg
folate per day to all pregnant women for at least 6 months. This guideline also recommends
continuation until 3 months postpartum in areas of high prevalence of anaemia. The standard oral
preparation, Fefol, comprising 100 mg iron and 350 μg folate, is suitable for both prevention and
treatment. Parenteral iron does not provide rapid correction of haemoglobin levels compared
with oral form but is an option for those with poor compliance and who cannot tolerate the oral
formulation. It is also suitable in cases of malabsorption.

Blood transfusion is indicated in cases of severe anaemia (Hb< 7 g/dl) and anaemia in late
pregnancy when delivery is due.

Follow up care and Referral:

Referral to secondary care level should be considered if any of the following situations exist:

Significant symptoms and/or severe anaemia (Hb < 7g/dl), or

Advanced gestation (>34 weeks), or

If there is no rise in Hb at 2 weeks.

In non-anaemic women who are at increased risk of iron depletion such as those with: Previous
anaemia, Multiple pregnancy, Consecutive pregnancies with <1 year’s interval, Women at high
risk of bleeding and Pregnant teenagers.

Nursing care plan for 24hours

NAME: Pamela Murugi Ngare AGE: 25YRS HOSPITAL NO.:00290/23 SEX: Female

MEDICAL DIAGNOSIS: Moderate anaemia

Assessment Nursing Expected Interventions Rationale Implementatio Ev
Diagnoses outcome n

Client asking questions Deficient Client will Explain the To provide Cli
knowledge participate in condition, clear eno
Client looks frustrated. related to the learning likely causes information kn
Restless condition and process on and and to avoid abo
its causes as the condition prescribed assumptions hea
evidenced by treatment
client asking protocols
questions.

Patient looks irritable Anxiety Client will Clearly To enable in Cli

related to be able to explain availing of to
Dry mouth perceived discuss fears situation to complete fea
Fear of unspecified threat to freely in the client and information sel
consequences( difficulty mother and regards to all the efforts on fet
concentrating) fetus as self and in place to concerning
evidenced by fetus improve issues
client condition outcome
verbalizing

Sleeplessness Fatigue Patient will Educate the Organization Cli

related to be able to patient and and to
Dry mouth decreased explain family about management act
Difficulty concentrating performance energy task of time can tha
as evidenced conservation organization assist the her
by reports of plan to offset methods and patient save ene
lack of fatigue time energy and
energy by the organization avoid fatigue
client methods
Complications of Anaemia:
Post-partum haemorrhage
Still birth due to foetal hypoxia
Preterm birth

PREVENTION AND HEALTH EDUCATION

Efforts aimed at preventing iron deficiency and iron deficiency anaemia among pregnant women
include iron supplementation, fortification of staple foods with iron, increasing health and
nutritional awareness, combating parasitic infections, and improvement in sanitation.

1. PRENATAL COUNSELLING- Pre-conception counselling should be a key component of

reproductive health in the hospital. This is particularly for women's who are living with chronic
illnesses such as diabetes mellitus, hypertension, cardiac disease and women who had previously
experienced pregnancy complications in their previous pregnancies. This will greatly help in
maternal and foetal complications in pregnancy as care given on basis of increased cases.Pre-
pregnancy care for early diagnosis and management of anaemia and any underlying causes
should be encouraged.

2. FANC-The patient is encouraged to attend all antenatal clinics for prompt diagnosis of
anaemia and to plan for immediate interventions to prevent the patient from developing
complications. In addition, important investigation in antenatal profile such as haemoglobin level
and screening for malaria parasites, should not be only conducted in first visit. They ideally be
conducted at every visit to detect any fall in haemoglobin level. Evidence show that malaria is
likely to cause anaemia in pregnancy which may lead to other complications such as postpartum
haemorrhage. Blood grouping and rhesus also should be conducted as it will help in severe cases
where blood transfusion is part of the management.

3. IRON AND FOLIC SUPPLEMENTATION- During pregnancy, women need iron

supplementation to ensure they have sufficient iron stores to prevent iron deficiency. Hence, in
most developing countries, iron supplements are used extensively during pregnancy to prevent
and correct iron deficiency and anaemia during gestation.

Following publication of a number of studies supporting the periconceptional use of folic acid in
the prevention of neural tube defects, the supplemental dose is 400 μg (0.4 mg) of folic acid
daily. This dose was considered to provide more folic acid than needed to produce an optimal
haemoglobin response in pregnant women. If supplementation is delayed till after the first
trimester of pregnancy, it will not contribute to preventing birth defects.
Giving out of routine supplementation of iron and folic acid and encouraging drug compliance is
key to prevention. Also, deworming mothers with Mebendazole to prevent risk of worm
infestations like hookworms.

4. MALARIA PREVENTION-Giving out intermittent preventive of malaria prophylaxis drugs

(sulphadoxine/pyrimethamine), especially in malaria endemic areas, clearing bushes and
draining still water. Also, malaria treated nets should be issued at all first antenatal care visits.

5. NUTRITION-Nutritional health education is the main objective of antenatal care to assist in

the prevention of anaemia. Giving dietary advice which is appropriate for each woman
depending on health status, religious and cultural preferences. Highlighting the sources of iron
available in the index community.

Iron rich foods include; green vegetables (spinach, sukuma wiki) red meat and proteins. Also
encouraged to drink water frequently.Also, vitamin c rich foods such as citrus fruit, orange juice,
strawberries and potatoes to increase absorption of iron. Also advise client to avoid taking coffee
with iron rich foods because it will interfere with absorption of iron in the body. Folate-rich
foods such as beans, dark green leafy vegetables: spinach, citrus fruits, mangoes and avocados.In
addition, the client is advised not to overcook vegetables so as not to destroy the folic acid.

6. CHILD SPACING- family planning and control of birth spacing is another preventive
measure that should be considered by health-care providers. This is to ensure there is sufficient
replenishment of iron stores of the mother for her next child.

7. PROPER HYGIENE AND SANITATION-Maintain proper disposal of human wastes to

reduce risk of hookworm infestations. Also, Treat any concurrent infections and manage medical
conditions as appropriate.

PROGNOSIS:

Anticipatory care is a key component in antenatal care of anaemia as it forms a key component
in prevention of development of pregnancy complications or to prevent severe disease outcome.
Thus at every level of care delivery, the patient health is prioritised by health care provider.

Important investigation in antenatal profile such as haemoglobin level and screening for malaria
parasites, should not be only conducted in first visit. They ideally be conducted at every visit to
detect any fall in haemoglobin level. Evidence show that malaria is likely to cause anaemia in
pregnancy which may lead to other complications such as postpartum haemorrhage. Blood
grouping and rhesus also should be conducted as it will help in severe cases where blood
transfusion is part of the management.
I would advocate for massive campaign and health education by the ministry of health on
Anaemia in Pregnancy and its management, this will enlighten the population and the same time
educate them and significantly lower risks of anaemia in pregnancy.

CONCLUSION:
Anaemia during pregnancy is a considerable health problem, with around two-fifths of pregnant
women worldwide being anaemic. Many gynaecological and infectious diseases are predisposing
factors for anaemia during pregnancy. Anaemia during pregnancy—especially the severe form—
can lead to various maternal and perinatal adverse effects such as preterm labour, low birth
weight, and intrauterine foetal death. It is one of the leading causes of maternal mortality.
Therefore, preventive measures are needed if anaemia and its adverse effects are to be prevented.
Iron and folic acid supplements are the cornerstone for the prevention of anaemia during
pregnancy and one of the earliest preventive measures adopted in antenatal care. Other measures
to prevent anaemia during pregnancy include the fortification of principle foods with iron,
increasing health and nutritional awareness, combating parasitic infections, and improvement in
sanitation.

REFERENCES
1. Stevens GA, Finucane MM, De-Regil LM, (2013), Global, regional, and national trends in
haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant
and non-pregnant women. Lancet Glob Health.

2. Jayne E.M, Maureen (D.R, 2014), Myles Textbook for Midwifes, 16th Edition. Elsevier

3. Butler E., Walden J., (2006), The definition of Anaemia in Pregnancy

4. World Health Organization (2011) Logic model for micronutrient interventions in public
health: vitamin and mineral nutrition information system. Geneva, World Health Organization,
Switzerland.

5. Murray-Kolb L (2012) maternal mortality, child mortality, perinatal mortality, child

cognition, and estimates of prevalence of anaemia due to iron deficiency.