Anemia in Pregnancy Case Study

Alice Argueta, Karissa Castro, Nancy Macias, Sasha Millice

PI:
AM is a 31 YOW gravida 3, para 2 admitted to University Hospital ER in her 23rd week of gestation on January 17, 2016.

CC:
Pt states that she went out out get the mail and slipped on the ice. After I got back in I noticed a small amount of bleeding when
I went to the bathroom. Over the next hour, I had some abdominal pain. I called my doctor and the office said I should come
here to be checked out.

HPI:
Patient presents with shortness of breath which patient states is attributed to pregnancy; feeling tired which patient states is
attributed to two young children; patient slipped on ice and fell prior to hospital admission; admitted for vaginal spotting and
abdominal pain following fall.

PMH:
Medications: Prenatal Vitamin
Surgical History: Appendectomy (removal of vermiform appendix) treatment for acute appendicitis - age 12; cesarean
section (surgical procedure with incisions through abdomen and uterus to deliver a baby) procedure for childbirth- 18
months previously.

FH:
Mother: Type 2 Diabetes Mellitus (adult onset diabetes)
Father: Hypertension (high blood pressure); Coronary Artery Disease (hardening and narrowing of arteries)

SH:
Alcohol use: None
Tobacco use: Yes, 1-2 cigarettes/day. Patient states she is attempting to cut back.
Marital Status: Married
Family members: Husband- age 31; sons- age 3 years and 12 months.

 Occupation: Stay at home mom

Religious Affiliation: Methodist

PE:
General: 23 week gestation - no contractions; no futher vaginal spotting
Hydration status: Normal
HEENT:
Head: WNL (within normal limits)
Eyes: Sclera pale, PERRLA (Pupils Equal Round Reactive to light and Accomodation), fundi without lesions
Ears: Clear
Nose: Clear
Throat: Pharnyx clear without postnasal drainage
Genitalia: Normal
Neurologic: Alert and oriented
Extermities: No edema, DTR (deep tendon reflex) 2+ and symmetrical throughout
Skin: Pale, warm and dry
Chest/lungs: Clear to ausculation and percussion
Peripheral vascular: Diminished pulses bilaterally
Abdomen: Bowel sounds X4
Blood Pressure: 120/82
Respiration: 20
Temperature: 98.6

Nursing Assessment

1/17

Abdominal appearance (Concave, flat, rounded, obese, distended)

Rounded with
pregnancy

Palpation of abdomen (soft, rigid, firm , masses, tense)

soft

Bowel sounds (P=present, AB=absent, hypo, hyper)

RUQ

LUQ

RQL

LLQ

Stool color

none

Stool consistency
Tubes/ostomies

N/A

Genitourinary
Urinary continence

yes

Urine source

Clean catch

Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria,

orange, blue, tea)

Clear yellow

Integumentary
Skin color

pale

Skin temperature (DI= diaphoretic, W=warm, dry, CL=cool,

CLM=clammy, CD+= cold, M=moist, H= hot)

Skin tugor (good, fair, poor, TENT= tenting)

good

Sking condition (intact, EC=ecchymosis, A= abrasions, P= petechiae,

R= Rash, W=weeping, S= sloughing, D= dryness, EX=excoriated, T=
tears, SE= subcutaneous emphysema, B=blisters, V=vesicles, N=
necrosis)

Intact

Mucous membranes (intact, EC=ecchymosis, A=abraisons, P=

petechiae, R= Rash, W=weeping, S= sloughing, D= dryness,
EX=excoriated, T= tears, SE= subcutaneous emphysema, B=blisters,
V=vesicles, N=necrosis)

Intact

Other components of Braden score: special bed, sensory pressure,

moisture, activity, friction/shear(>18 no risk, 15-16=low risk, 13-14=
moderate risk, <12= high risk)

21

ASSESSMENT:
Hypochromic Microcytic Anemia (decreased number of red blood cells [RBC]; small sized RBC and decreased
concentration of hemoglobin within each RBC); 23 weeks gestation (pregnancy) with normal ultrasound.

HOSPITAL COURSE or Patient Treatment Course:

Date: 1/17
Diagnosis: Gravida 3, para 2 - 23 week gestation
Medication: Prenatal vitamins (oral supplement)(x1 tablet per day for gestation)
Labs:
Laboratory Results

Ref. Range

1/17

Sodium

136-145

142

WNL

Potassium

3.5-5.5

3.8

WNL

Chloride

95-105

104

WNL

Carbon dioxide

23-30

26

WNL

BUN

8-18

WNL

Creatinine serum

0.6-1.2

0.7

WNL

BUN/ Crea ratio

10.0-20.0

11.4

WNL

Uric acid

2.8-8.8 F
4.0-9.0 M

3.2

WNL

Glucose

70-110

105

WNL

Phosphate inorganic

2.3-4.7

3.1

WNL

Magnesium

1.8-3

2.2

WNL

Calcium

9-11

10.2

WNL

Osmolality

285-295

292

WNL

Bilirubin total <1.5

<1.5

0.4

WNL

Bilirubin direct

<0.3

0.1

WNL

Protein total

6-8

6.2

WNL

Albumin (g/dl)

3.5-5

3.9

WNL

Prealbumin (mg/dl)

16-35

33

WNL

Ammonia

9-33

WNL

Alkaline phosphatase (U/L)

30-120

45

WNL

ALT (U/L)

4-36

WNL

AST (U/L)

0-35

WNL

Chemistry

CPK (U/L)

30-135 F
55-170 M

31

WNL

Lactase dehydrogenase (U/L)

208-378

210

WNL

Lipase (U/L)

0-110

WNL

Amylase (U/L)

25-125

26

WNL

CRP (mg/dL)

<1

0.004

WNL

Cholesterol (mg/dL)

120-199

145

WNL

HDL-C (mg/dL)

>55 F, >45 M

62

WNL

VLDL (mg/dL)

7-32

13

WNL

Laboratory Results

Ref. Range

1/17 1540

LDL

<100

70

WNL

LDL/ HDL ratio

<3.22 F
<3.55 M

1.12

WNL

Triglycerides (mg/dl)

35-135 F
40-160 M

75

WNL

PT (sec)

12.4-14.4

13.2

WNL

PTT (Sec)

24-34

27

WNL

WBC

4.8-11.8

7.2

WNL

RBC

4.2-5.4 F
4.5-6.2 M

3.8

low

Hemoglobin (hgb,gl/ dl)

12-15 F
14-17 M
CDC <10.5

9.1

low

Hematocrit (Hct, %)

37-47 F
40-54 M

33

low

Mean cell volume

80-96

72

low

Retic (%)

0.8-2.8

0.2

low

Mean cell Hgb (pg)

26-32

23

low

Mean cell Hgb content (g/dl)

31.5-36

28

low

RBC distribution (%)

11.6-16.5

22

WNL

Platelet count

140-440

282

WNL

Total iron binding capacity

240-450

465

high

Ferritin

20-120 F
20-300 M

10

low

Coagulation (Coag)

Hematology

ZPP

30-80

84

high

Vitamin B12

24.4-100

95

WNL

Folate

5-25

low

Diet or Nutrition order: NPO (nothing by mouth)

Medical treatment plan: Fluids: 2000-2400 ml/day (Lactated Ringers Intravenous Fluid [130 mEq Na1, 4 mEq K1, 2 mEq
Ca21, 109 mEq Cl2, 29 g lactate] @ 100 mL//hr ); Hematological assessment (Initial: Complete blood count [CBC], Rapid
Plasma Reagin [RPR], Chemistry 16 (Comprehensive Metabolic Panel); In 12 hours: Repeat CBC, Amylase, Lipase; Every 6
hours: Repeat CBC, Chem 7 (Basic Chemistry Panel); Vitals every 4 hrs; Patient and fetal heart monitoring; Intake/output every
8 hrs; Activity: bed rest.

Brief nutrition assessment: Patient states a good appetite and some morning sickness experienced during first trimester. Patient
describes herself as a picky eater, states there are a lot of foods she does not like. Patient states she takes prenatal vitamins
inconsistently due to stomach discomfort. Patient gained 15 lbs for first pregnancy and almost 20 lbs for her second pregnancy.
Pre-pregnancy within normal weight range, inadequate weight gain in pregnancy of 7 lbs. The inadequecy puts the patient at
2.8%-6.0% below optimal pregnancy weight gain. Patient 24 hr recall suggests total calorie intake of 1440 calories. Based on
estimated energy requirements of 2500 calories, energy intake is inadequate.

Medical Nutrition Therapy: Not applicable. Patient should follow treatment plan as indicated by MD.
Date: 1/18
Diagnosis: Hypochromic Microcytic Anemia; 23 weeks gestation with normal ultrasound; Fetal heart sounds WNL.
Medications: Ferrous Sulfate 40 mg (oral supplement x3 per day for Hypochromic Microcytic Anemia); Prenatal vitamins (oral
supplement x1 per day for gestation)
Laboratory values as of 1/17 1540:
Low:
RBC 3.8 (ref range 4.2-5.4 F)

High:
RBC distribution: 22 %(11.6-16.5%)

Hemoglobin: 9.1 gl/ dl (12-15 gl/ dl F) Total Iron binding capacity

Hematocrit: 33 % (37-47%)

(TIBC):465 (240-450)

Mean cell Volume: 72 (80-96)

ZPP: 84 (30-80)

Retic: 0.2 % (0.8-2.8%)

Mean cell Hgb: 23 pg (26-32 pg)
Mean cell Hgb content: 28 (g/dl)(31.5-36(g/dl))
Ferritin 10 (20-120 F)
Folate 2 (5-25)

Diet or Nutrition Order: Mineral-Modified Diet; Estimated energy needs of 2500 calories per day; Estimated protein needs of
71 g per day; Fluid recommendations of 2500 ml per day.

Medical treatment: Discontinue intravenous fluids; Nutrition consult before discharge to home; Begin 40 mg Ferrous Sulfate x
3 per day.

Brief Nutrition Assessment: No changes from last nutrition assessment.

Medical Nutrition Therapy: Increase energy intake to 2500 calories per day. Prevent iron-deficiency anemia complications by
increasing iron intake (x3 svgs per day). Reduce medication side effects, such as constipation, by increasing fiber intake 25-35
grams per day and drinking adequate fluids (10-11 cups per day).

THEORETICAL DISCUSSION OF DISEASE PROCESSES :

Anemia, in general, is a condition resulting from a reduction in red blood cell (RBC) or hemoglobin (Hgb) in the blood,
which consequently impairs oxygen transportation via blood to tissues. There are many types of anemia distinguished as acute
or chronic, and categorized into different classes based on data obtained from a complete blood count (CBC) analysis. Mean cell
volume (MCV) and mean corpuscular hemoglobin concentration (MCHC) are used to evaluate the cell size and hemoglobin
content of the blood. MCV, or cell size, can be large (macrocytic), normal (normocytic) or small (microcytic). The MCHC is a
measure of the concentration of hemoglobin in a given volume of packed red blood cells and is used to determine if anemia is
hypo-, normo-, or hyperchromic. Hypochromic Microcytic Anemia arises a result of insufficient hemoglobin synthesis. It is

characterized by small erythrocytes which contain insufficient hemoglobin resulting in a reduction in oxygen carrying
capabilities (Nelms et al, 2015).
Pregnant women, like AM, are at increased risk of iron deficiency, which is the most common cause of Hypochromic
Microcytic Anemia. Iron deficiency anemia accounts for 75% of all anemias in pregnancy (Brown, Isaacs, 2011). Iron is used
by the body to make hemoglobin, an oxygen carrying protein found in red blood cells. By six weeks gestation hemodynamic
changes cause maternal blood volume to begin to increase by up to 50% by 32-34 weeks gestation. The increase in blood
volume is a result of plasma volume and RBC mass expansion. However, there is a lag between the expansion of blood volume
and the creation of new red blood cells. This causes the existing red blood cells to expand. During pregnancy iron needs double,
due to the increased blood volume, to accomodate growth and help create the babys blood supply. Low iron stores and low iron
intake both contribute to anemia during pregnancy. Iron-deficiency anemia increases the risk of preterm and low-birth weight
infants and is related to lower intelligence and poor motor skills in affected children (Brown, Isaacs, 2011).
Although red blood cell (RBC) mass increases during pregnancy, plasma volume increases more, resulting in a relative
anemia. This is refered to as hemodilution (Lynch, 2011). This results in a physiologically lowered hemoglobin level, hematocrit
(Hct) value, and RBC count, but it has no effect on the mean corpuscular volume (MCV). If iron status is normal, the mean
corpuscular volume and mean corpuscular hemoglobin should be within normal limits. Laboratory evaluation reveal a
microcytic, hypochromic anemia with low plasma iron, high total iron-binding capacity, and low ferritin. One of the most
accurate measurement of iron status includes plasma hematocrit, Hgb levels and ferritin concentration. Hgb and Hct are used
together to evaluate the iron status of an individual, Hgb is a more direct parameter because it measures the amount of Hgb in
RBCs (Lynch, 2011). Most Iron deficiency anemia (IDA) patients have low Hct and Hgb levels. According to The Centers for
Disease Control and Prevention, levels of hemoglobin and hematocrit to less than the fifth percentile of a healthy reference
population indicate anemia in pregnancy. These are 11% and 33% in the first trimester, 10.5% and 32% in the second trimester,
and 11% and 33% in the third trimester. Therefore, hemoglobin is evaluated and values of Hgb <110 g/L in the first and last
trimester and <105 g/L in the second trimester of pregnancy are indicative of anemia. A serum ferritin level value of <15 g/L
provides clear evidence for iron-deficiency anemia. High levels of ferritin can be an early diagnosis of IDA. Ferritin, a protein
that stores iron in the liver, spleen and bone marrow, is an indicator of the bodys iron status along with the saturation of
transferrin (Brown, Isaacs, 2011). Further diagnostic parameters for iron deficiency anemia are serum iron, total circulating
transferrin, percentage of saturated transferrin, and soluble serum transferrin receptors (SFTR). Serum iron levels and those
bound to transferrin are not accurate measurements of iron status because of large fluctuations in iron levels from day-to-day.

Other parameters such as total iron-binding capacity (TIBC) and transferrin saturation which may be used to measure iron
status. However, they are not an accurate measurement due to lack of specific correlation with serum iron (Lynch, 2011).
It is recommended to screen for and treat iron deficiency anemia in pregnancy, as was done with AM by completing
complete blood count analysis. Treatment to maintain maternal iron stores may be beneficial to neonatal iron stores. In
pregnancy, an intake of 27mg/day of iron is recommended, 9 mg more iron than required daily for non-pregnant women, with an
upper limit of 45 mg/day. Supplementation during pregnancy is necessary for prevention as most women do not have adequate
iron stores. Even with a well balanced diet an iron supplement is recomended. Iron-deficiency anemia therapy should consist of
60120 mg/day of ferrous iron in divided doses throughout the day. AM was prescribed 40 mg Ferrous Sulfate x 3 per day
which aligns with the recommendations. When Hgb returns to normal levels, 30 mg/day of iron supplements in divided doses
should be continued (Brown, Isaacs, 2011)
FINAL NUTRITIONAL CARE PLAN:
Sex: Female; gravida 3, para 2; 23rd week of gestation
Age: 31
Height: 5 ft. 5 in; 65 in
Pre-pregnancy weight: 135 lbs
ABW: 142 lbs UBW(pregnancy):146-151 lbs %UBW(pregnancy): 94-97%
IBW: 125#

%IBW: 97.2 %

Calculations of patients BMI:

BMI: [weight (lb) / height (in2)] x 703
BMI: [135 lb / (35 in2)] x 703 21-10
BMI = 22.53 % = normal healthy weight between 18.5 and 24.9%
Calculations of patients UBW:
ABW as actual pregnancy weight at 23rd week = 142 lbs
Usual body weight gain for pregnancy in 23rd week for a healthy pregravid BMI = 11 to 16 lbs
Therefore UBW = pre-pregnancy weight + 11 to 16 lbs
UBW(pregnancy) = 135 lbs + 11 lbs = 146 lbs
UBW( pregnancy)= 135 lbs + 16 lbs = 151 lbs
UBW range (pregnancy) = 146 to 151 lbs

% UBW = (ABW/UBW) x 100

% UBW = (142 lb / 146 lb) x 100
% UBW (pregnancy) = 97.2 % = 2.8 % below optimal pregnancy weight gain
% UBW = (ABW/UBW) x 100
% UBW = (142 lb / 151 lb) x 100
% UBW (pregnancy) = 94.0 % = 6.0 % below optimal pregnancy weight gain
AM has gained 7lb during her pregnancy thus far. The optimal range of weight gain for someone of her stature would 11
lbs to 16 lbs.

Nutritional diagnoses:
i.

Inadequate mineral intake (iron) R/T Hypochromic Microcytic Anemia AEB Low Hemoglobin of 9.1 g/dl (reference
value: 12-15 g/dl Female), low MCH of 23 pg (reference value:26-32 pg),low Ferritin of 10 ug/dl (reference value:
20-120 ug/dl Female).

ii.

Inadequate energy intake R/T increased nutrient needs required in pregnancy AEB patients 24-hr recall report with a
caloric intake total of 1441 kcal (reference value: 2500 kcal /day).

iii. Altered nutrition-related laboratory values RT suboptimal mineral stores attributed to proximal pregnancies AEB
decreased serum ferritin 10 ug/dl (reference value=20-120 ug/dl Female), elevated TIBC 465 ug/dl (reference values=
240-450 ug/dl Female).

DIET HISTORY:
Patient states a good appetite. Some morning sickness experienced during first trimester. Patient describes herself as a
picky eater, states there are a lot of foods she dislikes. Patient states she takes prenatal vitamins inconsitently due to stomach
discomfort. Patient only cooks full meals some nights as husband works night shifts.
According to the patients 24-hour recall, the total protein intake was estimated to be 46g and the total energy intake was
approximatly 1500 kcal. Usual dietary intake indicates: drinks coffee, cold cereal and occasionally toast at breakfast; consumes

sandwich or soup for lunch; prepares Hamburger Helper casserole, hot dogs, soup and occasionally a full meal with meat and
vegetables for dinner.

EVALUATION OF LABORATORY FINDINGS:

Iron deficiency anemia can be characterized by (1) the number of normal circulating RBCs per cubic
millimeter of blood, (2) the level of hemoglobin, or (3) the volume of packed RBCs per deciliter of blood as a result
of greater demand on stored iron than can be supplied. (Nelms et al, 2015). Thus, the laboratory findings most
crucial in determining the type of anemia are hemotological values that entail 1) the amount and size of red blood
cells 2) the amount, size and concentration of hemoglobin 3) circulation, storage, precursors, and receptors of iron.
Lab findings with clinical significance were as follows:
Low end
i.

Hemoglobin (9.1 g/dL): Iron is found within the heme units of hemoglobin which is an important protein that
transports oxygen to cells. When iron depletion occurs, there is not enough iron to support normal heme
synthesis, decreasing Hgb levels. Low Hgb levels particularly represents an iron deficiency diagnosis. Poor
oxygenation to cells can present symptoms of fatigue and shortness of breath as AM has reported.

ii.

MCH (23 pg ): This is an estimation of the amount of hemoglobin in each cell. The MCH value will be low as
the circulating iron is not adequate to maintain hemoglobin.

iii. MCHC (mean corpuscular hemoglobin concentration, 28 g/dl): Similar to MCH, MCHC is an estimation of the
amount of Hgb levels in each red blood cell but expressed as a percentage.
iv. Hematocrit (33%): Hematocrit expresses the portion of red blood cells in a total blood volume or determined by
the amount of hemoglobin with the average volume of RBCs. As previously mentioned, RBCs are dependent on
iron for maintenance so inadequate iron effects hematocrit. As with the current condition of AM, blood volume
expands during pregnancy causing hematocrit to decrease.
v.

MCV (Mean cell volume, 72 um3): Mean cell volume is a measure of the size of red blood cells. MCV is low in
iron and copper deficiencies, but elevated in folic acid and vitamin B12 deficiencies. The patients value indicates

a microcytic anemia, with a low MCV. This change in RBC size is reduced with iron depletion, in this case
smaller than normal is indicative of Microcytic.
vi.

Ferritin (10 ug/dL, low): Ferritin is the storage form of iron and is usually the first value that is indicative of
iron deficiency. When iron is needed and inadequate amounts are available, iron stores are immediately released
for the bodys use, thus depleting iron from ferritin.

vii. Folate (2 ng/dl): is a water soluble B-vitamin that functions as a co-enzyme synthesis of DNA or amino acid
metabolism. During pregnancy there is an increased demand for folate because of its role in nucelic acid
synthesis. AM has inconsistent use of prenatal vitamins may be a cause of insufficient folate intake.

High end
i.

Total Iron Binding Capacity (465 ug/dl): This value is high because it represents the ability of iron to bind to
transferrin. There is increased need for the body to bind iron when iron is inadequate.

ii.

Zinc Protoporphyrin (84 umol/mol): Protoporphyrin is a protein transporter for zinc which is utilized in the body
as a precursor to hemoglobin synthesis. When iron is unavailable, zinc is transported instead, thus elevating the
levels of ZPP.

REVIEW OF MEDICATIONS AND FOOD/NUTRIENT INTERACTIONS:

Patient has experienced abdominal pains after ingesting prenatal vitamins. This could be the cause of taking them on an
empty stomach. Recommendations to prevent stomach discomfort would be to consume a vitamin with a meal. In
addition to prenatal vitamins, MD prescribed 40 mg of ferrous sulfate to be taken 3x/day. The side effects of taking
ferrous sulfates are GI symptoms, nausea, vomitting, and constipation. Possibly a lower dosage or more frequent doses/
gradually increasing the doses will help with the symptoms shes experiencing. Other possible suggestions that can help
are:
Take iron supplements and prenatals separately. Timing medication avoids competitive absorption between
supplements.
Vitamin C, berries, citrus fruits, melons, and tomatoes enhances iron absorption
Due to extra iron intake, constipation can occur. Adequate fluid intake and consuming prune juice can help.
Consumption of foods with high iron bioavailability

 Using cast iron skillets when cooking

Although, there are food-drug interactions that hinder iron absorption in taking these supplements.
Milk and Antacids are to be avoided
Calcium, zinc, and magnesium
Coffee and tea

EVALUATION OF PHYSICAL OR CLINICAL FINDINGS:

Patient self-reported tobacco use, although attempting to cut back, her use can effect proper growth and development of
the fetus. Smoking can effect appetite and decrease the oxygen transported throughout the body. Reported symptoms of fatigue
and shortness of breath could sustain.
AM, currently at 23 weeks gestation, requires higher energy and protein needs. Food intake assessment proves AM is
not meeting her recommended nutrient demands. In addition, AM self reported being a picky eater which can further delay her
correction of Hypochromic Microcytic Anemia.

ENERGY REQUIREMENTS:
Energy Requirements calculations:
Age= 31 yo

Physical Activity (low active)= 1.12

Pre-pregnancy Weight (kg)= 135 lbs/ 2.2= 61.36 kg

Height (meters)= 5 ft. 5 in. = 65 in. x 0.0254 = 1.651 meters
EER=354 -(6.9xA)+PAx(9.36xW+726xH)
EER= 354-(6.9x 31)+ 1.12 x(9.36 x 61.36 + 726 x 1.651 m)
EER= 354- 213.9+1.12 x (574.33+1198.63) = 140.1 + 1.12 x 1772.96
EER=140.1 + 1985.71= 2125.81
EER= 2126 kcal

Institute of Medicine (IOM) guidelines for 2nd trimester:

2nd trimester = Adult EER + 160 kcal + 180 kcal

= 2126+ 340 kcal = 2466 kcal

Using AM pre-pregnancy weight, low active activity of 1.12, weight in kilograms and height in meters, the calculated
estimated energy requirements for adult non-pregnant women would be approximately 2126 kcal/day. According to Institute of
Medicines guidelines (2006),second trimester warrants an extra 340 kcal per day. Mrs. Morris recommended EER equates to an
approximate 2500 kcal/day.

PROTEIN REQUIREMENTS:
The requirements of protein within the second half of pregnancy, as the patient is currently, increases from the 0.8 g/kg/
day RDA of protein to 1.1 g/kg/day of pre-pregnancy weight, or an approximate 71 g/day.
At the actual current pregnancy weight of 142 pounds in the 23rd week of term:
Actual weight = 142 lbs = 64.5 kg
Estimated protein requirements = (1.1 g/day) x (64.5 kg) = 70.95 g/day for the patient

DIET ORDER:
i.

Increase energy intake to 2500 calories per day (based on IOM adult female EER and 2nd trimester needs).

ii.

Increase protein (high-bioavailable iron) intake 71 grams per day (based on 1.1 g/kg)

iii. Prevent iron-deficiency anemia complications by including high iron rich foods (x3 svgs per day).
iv. Reduce medication side effects, such as constipation, by increasing fiber intake 25-35 grams per day and drinking
adequate fluids (10-11 cups per day).
DIET THERAPY:
Diet should be followed upon discharge. Continued use of prenatal vitamins with a meal, to prevent stomach
discomfort, and implementation of iron supplements in between meals with a high vitamin c source should be consumed.
Medications should be taken seperately. Fiber rich snacks and adequate fluids should be taken to prevent associated side-effects,
such as constipation.

The energy demands and protein demands are set to address individual nutrition needs focusing on high bioavailable
iron sources (heme- and non-heme) and caloric intake for maternal energy demands and healthy fetal development. The current
low iron status of the patient requires a protein need greater than what is expected of a non-pregnant adult woman.

NUTRITIONAL GOALS:
Short-term goals:
i. Attain normal hematological laboratory values that reflect a correction of Hypochromic Microcytic Anemia.
i. Increase consumption of iron rich foods (3 servings a day) paired with vitamin c foods. Encourage prenatal and
iron supplemenation use throughout pregnancy.
ii. To address individual nutrition needs focusing on high bioavailable iron sources and caloric intake for maternal energy
demands and fetal development
i. Encourage nutrient dense meals. Follow-up with food intake assessments. Refer patient to community based
programs that aid in nutritionally at risk individuals, such as WIC.
iii. To educate on the risks associated with complications from iron deficiency anemia and tobacco use throughout
pregnancy.
i. Provide patient with pamphlets that include information on healthy lifestyle tips related to nutrition and IDA
complications background info.
Long-term goals:
i.

Achieve and maintain body weight goals based on IOM guidelines for normal adult weight gestational weight goals of
25-35 pounds.
i.

ii.

Monitor weight gain via pregnancy weight charts.

Delay or prevent complications of iron-deficiency anemia.

i.

Evaluate iron status with continued CBC labs. Recommend continued iron supplementation post-partum, refer
patient to follw-up with MD for proper medication prescription.

iii. Provide nutrition education for increasing macro- and micronutrients at 3rd trimester.

i.

Collaborate with medical team for laboratory findings of clinical significance. Continue food intake assessments
and patient interviews.

ADIME NOTE:
Date/Time
Assessment

Pertinent
information
provided by
patient

PT noticed bleeding when going to the bathroom after slipping on ice. Pt felt
abdominal pain with in an hour of noticing the blood and immediately called the
doctor to get checked out.
Patient reported stomach discomfort with consumption of prenatal vitamin
supplement. Currently patient has good appetite but describes self as a picky
eater. Patient states she has had nutritional counseling and access to food provided
by WIC.
Usual dietary intake indicates: drinks coffee, cold cereal and occasionally toast at
breakfast; consumes sandwich or soup for lunch; prepares Hamburger Helper
casserole, hot dogs, soup and occasionally a full meal with meat and vegetables for
dinner.

Age; Gender;
Dx; PMH

Age: 31 , Sex: Female

Dx: Hypochromic Microcytic Anemia; 23rd week of gestation
PMH: Gravida 3, para 2; Cesarean section 18 months previously;Appendectomy age
12

Ht; Wt; UBW/

%UBW; IBW;
%IBW; BMI

Height: 5 ft., 5 in; Pregravid wt: 135#; Wt: 142# UBW:146-151 ;

% UBW= 94.0-97.2%; IBW: 125 ; %IBW: 97.2 %; BMI:22.5

Labs

RBCs; dec RBC count: 3.8 x 106/mm3, dec Hct: 33%, dec Retic: 0.2%, inc RBC
distribution: 22%, dec Folate: 2 ng/dL,
dec MCV: 72 m3,
Hgb; dec Hgb: 9.1 g/dL, dec MCH: 23 pg, dec MCHC: 28 g/dL
Iron: inc TIBC: 465 g/dL, dec Ferritin: 10 g/dL, inc ZPP: 84 mol/mol, dec
transferrin saturation: 2.1%

Meds

prenatal vitamins; inconsistent use

Skin

Diagnosis

5/13/16; 1.40 pm

pale

EER; EPR;
Fluid
requirements

EER: 2500 kcal (based on IOM adult women and 2nd trimester needs); EPR: 71 g/
day (based on 1.1 g/kg)
Fluid: 2500 mL/day (based on 1 ml/kcal)

Current Diet

NPO

PES #1

Inadequate
mineral intake
(iron)

R/T

Hypochromic
Microcytic Anemia

AEB

Low Hemoglobin of 9.1g/dl

(reference value:12-15 g/
dl Female),Low MCH of 23
pg(reference value:
26-32pg) and Low Ferritin
of 10 ug/dL (reference
value: 20-120 ug/
dlFemale).

Intervention

PES #2

Inadequate
energy intake

R/T

Increased
nutrtient needs
required in
pregnancy

AEB

patients 24-hr recall report

with a caloric intake total of
1441 kcal (reference value:
2500 kcal/day).

PES #3

Altered
nutrition-related
laboratory
values

R/T

Decreased iron
stores attributed
to proximal
pregnancies

AEB

decreased serum ferritin 10

ug (reference
value=20-120 ug/dl
Female), elevated TIBC 465
ug/dl (reference values=
240-450 ug/dl Female).

Nutrition
Prescription

i.
Increase energy intake to 2500 kcal/ day and protein to 71 g/day.
2. Increase dietary sources of iron (3 svg per day).
3. Increase fiber 25-35 g per day (4 g of fiber per svg).
4. Adequate fluid intake 2500 ml (10-11 cups) per day.

Treatment plan:
nutrition
therapy,
education,
acquisition of
additional
information

i.

ii.
iii.
iv.
v.
vi.

Recommend patient consume a varied diet containing 2500 kcal/ day and
protein to 71 g/day to achieve gestational weight gain 0.8-1 lb/wk to reach
a goal of 25-35 lbs
Recommend patient take folic acid containing prenatal vitamins consistently
in additions to iron supplementation (40 mg 3x/day)
Recommend patient increase consumption of iron rich foods (3 servings per
day) paired with vitamin C rich foods
Educate patient on timing of medications; iron supplements should be taken
between meals and prenatal vitamins with a meal to prevent discomfort
Recommend patient to discontinue smoking during pregnancy.
Educate patient on anemia and smoking risks/consequences during
pregnancy.

vii. Educate patient on foods sources of heme and non-heme iron foods and
reading nutrition labels.
viii. Educate patient on techniques to increase iron bioavailability such as
cooking with cast iron cookware and consumption vitamin C rich foods
ix. Recommend that patient consume fiber rich snacks, frequent meals and
adequate water to avoid nausea and constipation
x. Provide patient with handouts and pamphlets regarding examples of iron
and fiber rich foods
xi. Refer patient for continued participation in WIC.
Monitoring/
Evaluation

Plan(s) for
evaluating
outcomes of
interventions
listed above;
plan for followup

i.
ii.
iii.
iv.

Patient will gain 0.8-1 lb/wk to reach a goal of 25-35 lbs

Monitor weight throughout pregnancy via pregnancy weight gain chart
Patients lab values will normalize
Patient will complete food logs indicating compliance with prenatal vitamins
and iron supplementation
v. Food logs will indicate increased consumption of iron rich foods
vi. Patient will state understanding of anemia and pregnancy outcomes
vii. Patient will state understanding of heme and nonheme iron sources and
bioavalibility
viii. Food logs will indicated increased fiber consumption
ix. Patient will reenroll in WIC program

Signature (&
name)

Karissa Alice Millice-Macias

Karissa A. Millice-Macias

REFERENCES & IN-TEXT CITATIONS:

See References section at the end of the paper.
CASE STUDY QUESTIONS:
1. Evaluate the patients admitting history and physical. Are there any signs or symptoms that support the diagnosis of
anemia?
The signs and symptoms present in the patients diagnosis of anemia is vaginal spotting, fatigue, pale skin color and
sclera of the eyes,close proximity between pregnancies, increased respiratory rate and effort, abdominal cramping, irregular use
of prenatal vitamins,and poor dietary intake.
2. What laboratory values or other tests support this diagnosis? List all abnormal values and explain the likely cause for
each abnormal value.
The abnormal values which support the diagnosis of hypochromic microcytic anemia are low Hemoglobin of 9.1 g/dl
indicates that there is not enough iron to support hemoglobin synthesis. High ZPP of 84 umol/mol is high due the accumulation
of Protoporphyrin which is the precursor to heme synthesis. Low MCH of 23 is an estimation of the amount of hemoglobin in
each cell. The MCH value will be low in anemia. Low Hematocrit reading of 33%, is low due to the dilutional effect of
pregnancy. As blood volume expands during pregnancy, the percentage of red blood cells (hematocrit) decreases. Low Mean cell
volume of red blood cells indicting iron and copper deficiencies.Low Ferritin of 10 ug/dL which is the storage form of iron and
therefore indicates an iron deficiency. Low Mean Corpuscular Hemoglobin Concentration indicates that iron and hemoglobin are
low.High TIBC of 465 ug/dL, reveals how low levels of iron increases its ability to bind to transferrin (Escott-Stump, 2012, Pg.
726-730).
Also, the normal range for RBC in females is 4.2 x 106/mm3 to 5.4 x 106/mm3. Therefore, we can conclude that the
patient has anemia because she has a decreased size/number of red blood cells that is approximantely 3.8 x 106/mm3,which is
below normal. Having a decreased red blood count value may be the reason why the patient has abnormal readings that are
likely to cause poor dietary intake,blood loss as hemorrhage due to vaginal spotting and previous birth.

3. Mrs. Morriss 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?
The physician ordered additional lab work because low hemoglobin has been linked to anemia which may be caused by
deficient iron stores or inadequate dietary intake of iron. This is a concern because low hemoglobin can diminish oxygen supply
to the fetus thereby compromising its respiration and energy status. In pregnancy, red cell mass increases by about 30% in
women. Plasma volume expands more than by 50%. This makes levels of hemoglobin, ferritin, and red blood cell lab values
lower. The levels appear to have decreased because the blood is diluted by the greater increase in plasma volume. During
pregnancy, hemoglobin levels show plasma volume expansion rather than low iron status. Therefore, these levels will change in
pregnancy and can still be considered normal. However, there are different cut-off points for anemia during these times which is
why the physician ordered additional lab work. During the second trimester of pregnancy, the levels for Hgb change because of
dilution of blood volume. The cut-off for Hgb to be considered anemic is <10.5 g/dL. This is different than the first and third
trimester cut-off point, which is <11 g/dL. Levels that represent iron-deficiency anemia in pregnant women despite plasma
volume expansion are <11.0 g/dL during the first and third trimesters and <10.5 g/dL in the second trimester (Brown, J.

E.,Isaacs, J. S. 2011). Thus, an increased intake of iron is required to compensate for a larger volume of maternal blood. If
hemoglobin production is unable to fulfill large requirements to compensate for greater blood volume, the hemoglobin levels
will decline (Brown, J. E.,Isaacs, J. S. 2011).

"

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.
Anemia is a deficiency that manifests when your blood is deficit in healthy red blood cells or hemoglobin. The root of
most anemias is nutrient deficiency of folate (folic acid), iron and cobalamin. Megaloblastic anemia is characterized by red
blood cells that are not produced properly and are too enlarged to deliver oxygen. Megaloblastic anemia is a result of vitamin
B-12 or folate deficiency, which are needed to produce healthy red blood cells. Pernicious anemia is an autoimmune disease in
which vitamin B12 is unable to be absorbed due to the lack of intrinsic factor secretion and achlorhydria ("Your Guide to
Anemia", 2011). Normocytic anemia is a normal sized red blood cell but could reveal chronic disorders. Microcytic anemia is a
smaller than normal sized blood cell, as a result of iron-deficiency. Sickle cell anemia is an inherited red blood cell disorder
which has abnormal hemoglobin caused by a recessive chromosome trait. The mutated hemoglobin causes a sickle shaped red
blood cell which leads to increased hemolysis (destruction). In hemolytic anemia, red blood cell size is normal but the anemia
manifests due to hemolysis of red blood cell caused by toxins and deficiencies or excesses of vitamin E (Nelms, 2015,Pg.

569).

5. What is the role of iron in the body? Are there additional functions of iron during fetal development?
Iron is a component of hemoglobin, an oxygen carrying protein found in red blood cells. Hemoglobin also helps transfer
carbon dioxide from the tissues to the lungs to be expired. It is also a component of myoglobin, collagen, and many enzymes.
Additionally iron helps you maintain a healthy immune system. During pregnancy, blood volume doubles. This means that the
need for hemoglobin increases and therefore so does the need for iron. During pregnancy the fetal and placenta blood supplies
are created which also take additional iron, especially during the last two trimesters. Iron is also important for fetal collagen
synthesis and brain development. Iron status is also important for the babys developing organ systems. Inadequate iron during
pregnancy is linked to learning disabilities and cognitive impairments in children due to irons role in brain development. Its
also important for the baby to develop adequate iron stores in utero so that the iron stores are adequate until they are weaned
(Luke, 1991).
6. Several stages of iron deficiency actually precede iron-deficiency anemia. Discuss these stagesincluding the
symptomsand identify the laboratory values that would be affected during each stage.

The first stage of iron deficiency is described as a state of early negative iron blance. Ferritin is one of the first lab value
to indicate depletion of iron storage and may be slightly lowered in this stage. However, often lab values may appear to be
normal. The next stage, iron depletion, may be indicated by low ferritin levels and an increae in transferrin iron-binding
capacity. Hemoglobin and iron serum levels will remain normal. The iron depletion is probably not great enough to cause any
symptoms. Iron deficient erythropoiesis is the next stage and is indicated by low plasma iron and transferrin saturation in
addition the the prior alterations. During this stage fatigue increases and there may be a decrease in ones ability to concentrate.
Symptoms can range from mild to moderate. Complete iron deficiency anemia is characterized by microcytic, hypochromic red
blood cells, very high serum transferrin receptors, very low ferritin, low serum iron, high TIBC, low hemoglobin and
hematocrit, as well as low MCV. This last stage of iron deficiency can have many symptoms including: poor muscle function,
fatigue, difficulty concentrating, irratability, leg pain, defects in epithelial tissue, pallor, glossitis, gastritis, and if left untreated
for a long period of time iron deficiency anemia can lead to cardiac failure.
7. What potential risk factor(s) for the development of iron-deficiency anemia can you identify from Mrs. Morriss
history?
The greatest risk factor for anemia that Mrs. Morris has is her pregnancy. She is in her second trimester which is when
blood volume begins to expand and the recommendation for iron needs change. In addition, she has not been taking her prenatal
supplement containing iron and her diet is not sufficient to meet her needs during pregnancy. Another risk factor is the patients
smoking, which is associated with higher hemoglobin levels. This alteration of lab values may hide a more severe level of
anemia. Finally, the blood loss from her vaginal bleeding would be a risk factor. Any time blood is lost from the body iron is as
well.

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?
During pregnancy, plasma volume and red cells expand due to increases in maternal red blood cell production. As a
result of this, the amount of iron that women need increases during pregnancy in order to meet the needs of the fetus and
placenta. If the mothers hemoglobin levels decrease then transfering oxygen to the baby will be a difficult task. Iron deficiency
during pregnancy increases the risk of maternal and infant mortality, premature birth, and low birthweight. Iron is important for

collagen synthesis, brain, organ system development in fetuses as well. Maternally, the effects of iron deficiency may lead to
postpartum depression and gallstones.
9. Discuss the specific nutritional requirements during pregnancy. Be sure to adress all macro and micronutrients that
are altered during pregnancy.
It is vital for fetal growth that expecting mothers need to increase their intake of macro and mirconutrients. For this
reason, expected mothers are recommended to take prenatal vitamins and mineral supplements. During pregnancy, around the
2nd and 3rd trimester, energy requirements are increased around 350-450 kcal/day due to the development of the baby and
physical changes the mother will go through. Energy intake will vary according to the maternal weight.

Body Mass Index and Pregnancy

BMI

Weight
Category

Recommended Weight
Gain

Below 18.5

Underweight

2840 lbs.

18.524.9

Normal

2535 lbs.

25.029.9

Overweight

1525 lbs.

Above 30.0

Obese (all
classes)

1120 lbs.

Source: Institute of Medicine. Weight Gain during Pregnancy: Reexamining the Guidelines. May 2009. http://www.iom.edu/~/media/Files/
Report%20Files/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines/Resource%20Page%20-%20Weight%20Gain
%20During%20Pregnancy.pdf.
Macronutrients

Carbohydrates-RDA: 175-265 g/day. Carbohydrates provide calories and help maintain blood glucose levels.
Consuming carbohydrates such as whole grain breads, fruits, and legumes help build up the placenta, brain
development and provide every needs for the fetus.
Protein- RDA: 71 g/day. Protein needs are to be met for building muscle, enzymes, hormones, blood supply and
creating tissue for both the mother and fetus.
Fat-RDA: No specific recommendations, but should make up 25-35% of daily kcals from healthy fats. Consuming
essential fatty acids such as Omega 6/Omega 3 found in salmon among other oils help develop structure, growth,
brain and eye development.
Micronutrients
Vitamin A- Kidney formation and lung function.
Vitamin B6/12- Red blood cell formation, DNA, amino acid metabolism and nervous system function. Also, may
help with morning sickness, feeling nauseous and vomitting.
Vitamin C/E- Prevention in preclampsia, antioxidant, and helps in the bioavailability of iron.
Vitamin D- Sunlight exposure is the main source and helps with disease prevention and health.
Calcium- Regulates bodys use of fluids, help develop babys bones/skeletal, help reduce gestational hypertension.

Folic Acid (Folate)- Vital for embroyonic and fetal growth. Prevention of neural tube defects and helps produce extra
blood.
Iron-Prevention of iron deficiencies. Most women have low iron stores before getting pregnant; therefore, iron
supplements are given and an increase of an iron diet is necessary. Serves as an aid in most biological functions such
as transporting oxygen to the fetus, red blood cell expansion, growth and development to the fetus and placenta.
Magnesium- Needed for embryonic and fetal development.
Zinc-Deficiencies effects low birth weight, premature delivery, labor and delivery complications. needed for cell
growth, immunity and protein synthesis for mother and child.
Recommended Nutrient Intakes during Pregnancy
Nutrient

Nonpregnant
Women

Pregnant
Women

Vitamin A (mcg)

700.0

770.0

Vitamin B6 (mg)

1.5

1.9

Vitamin B12 (mcg)

2.4

2.6

Vitamin C (mg)

75.0

85.0

Vitamin D (mcg)

5.0

5.0

Vitamin E (mg)

15.0

15.0

Calcium (mg)

1,000.0

1,000.0

Folate (mcg)

400.0

600.0

Iron (mg)

18.0

27.0

Magnesium (mg)

320.0

360.0

Niacin (B3) (mg)

14.0

18.0

Phosphorus

700.0

700.0

Riboflavin (B2)
(mg)

1.1

1.4

Thiamine (B1)
(mg)

1.1

1.4

Zinc (mg)

8.0

11.0

Source: Institute of Medicine. Nutrition during Pregnancy: Part I: Weight Gain, Part II: Nutrient Supplements. January 1, 1990. http://
iom.edu/Reports/1990/Nutrition-During-Pregnancy-Part-I-Weight-Gain-Part-II-Nutrient-Supplements.aspx.

10. What are best dietary sources of iron? Describe the differences between heme and nonheme iron.

The best dietary sources of iron would be red meat, poultry, clams, soybeans, lentil, spinach and some whole
grains. Heme iron is readily absorbed and can be found in beef, chicken, eggs, fish and certain organ meats. Heme is

found in blood cells. Non-heme iron is absorbed through non-animal sources which would be plant based sources.
Non-heme iron is opposite to heme iron and is less readily absorbed. Oddly enough, eating heme iron sources
increases the absorption of non-heme iron. Vitamin C has been shown to increase the absorption on non-heme iron.
While coffee, tea , and milk can interfere with absorption.

11. Explain the digestion and absorption of dietary iron

The first step of digestion and absorption of dietary iron is in the stomach. Iron is absorbed mostly in the
duodenum and the jejunum. Heme iron is readily absorbed compared to non heme iron. For heme iron, Fe2+ (ferrous
iron) binds to apoferritin to form ferritin in whch it has two fates, either being stored in the cell or transported to the
basolateral membrane for absorption into the blood using an active transport mechanism. Iron is then transported in
the blood by transferrin.
For nonheme iron it is reduced from Fe3+ (ferric iron) to Fe2+ in order to be absorbed into the enterocyte.
This is possible because of the low pH and acidity that help with iron absorption. Once reduced, the iron can be
transported into the cell by divalent metal transporter 1 (DMT1). After the Fe2+ enters the cell, it can then bind to
apoferritin. Then after being absorbed by the intestinal mucosal cells, leaving he enterocyte by binding to transferrin which
then transport iron into te blood stream.
12. Assess Mrs. Morriss height and weight. Calculate her BMI and % usual body weight.
Calculations of patients BMI:
Pre-pregnancy weight = 135 lbs
Height = 5 ft., 5 in. = 65 in.
BMI = [weight (lb) / height (in2)] x 703
BMI = [135 lb / (35 in2)] x 703 21-10
10
BMI = 22.53 % = normal healthy weight between 18.5 and 24.9%
Calculations of patients UBW:
ABW as actual pregnancy weight at 23rd week = 142 lbs
Usual body weight gain for pregnancy in 23rd week for a healthy pregravid BMI = 11 to 16 lbs

Therefore UBW = pre-pregnancy weight + 11 to 16 lbs

UBW = 135 lbs + 11 lbs = 146 lbs
UBW = 135 lbs + 16 lbs = 151 lbs
UBW range = 146 to 151 lbs
% UBW = (ABW/UBW) x 100
% UBW = (142 lb / 146 lb) x 100
% UBW = 97.2 % = 2.8 % below optimal pregnancy weight gain
% UBW = (ABW/UBW) x 100
% UBW = (142 lb / 151 lb) x 100
% UBW = 94.0 % = 6.0 % below optimal pregnancy weight gain
Therefore, the patients actual pregnancy weight of 142 lbs at the 23rd week of pregnancy is 2.8% to 6.0% below the UBW of
weight gain she should achieve for optimal maternal and fetal health.
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?
At 23 weeks into her pregnancy, Mrs. Morris has gain 7lb. According to the maternal weight gain curve, a gain of
15-16lbs is recommended. Therefore, she has only gained about half the weight that is recommended in this pregnancy. In her
previous pregnancies she gained 15 lbs and 20 lbs in total. If these pregnancies were carried to term, the recommended weight
gain would have been closer to 23 lbs to 33 lbs throughout the pregnancy.
14. Determine Mrs. Morriss energy and protein requirements. Explain the rationale for the method you used to
calculate these requirements.
Age= 31 yo

Physical Activity (low active)= 1.12

Pre-pregnancy Weight (kg)= 135 lbs/ 2.2= 61.36 kg

Height (meters)= 5 ft. 5 in. = 65 in. x 0.0254 = 1.651 meters
EER=354 -(6.9xA)+PAx(9.36xW+726xH)
EER= 354-(6.9x 31)+ 1.12 x(9.36 x 64.5 + 726 x 1.651 m)
EER= 354- 213.9+1.12 x (603.72+1198.63) = 140.1 + 1.12 x 1772.96
EER=140.1 + 1985.71= 2157.9
EER= 2157.9 kcal
Institute of Medicine (IOM) guidelines for 2nd trimester:

2nd trimester = Adult EER + 160 kcal + 180 kcal

= 2157.9+ 340 kcal = 2497.9 kcal

Using Mrs. Morris pre-pregnancy weight, low active activity of 1.12, weight in kilograms and height in meters, the
calculated estimated energy requirements for adult non-pregnant women would be approximately 2500 kcal. According to
Institute of Medicines guidelines (2006),second trimester warrants an extra 340 kcal per day. Mrs. Morris recommended EER
equates to an approximate 2500 kcal per day.

Step 4: Estimating Protein Requirements

The requirements of protein within the second half of pregnancy, as the patient is currently, increases from the 0.8 g/kg/day
RDA of protein to 1.1 g/kg/day of pre-pregnancy weight, or an approximate 71 g/day.
At the actual current pregnancy weight of 142 pounds in the 23rd week of term:
Actual weight = 142 lbs = 64.5 kg
Estimated protein requirements = (1.1 g/day) x (64.5 kg) = 70.95 g/day for the patient
15. Using her 24-hour recall, compare her dietary intake to the energy and protein requirements that you calculated in
Question 14.

Meal
AM

Lunch

Dinner

Food/ Beverage

Quantity

Calories

Protein

frosted flakes

2 cups

301

whole milk

cup

74

Black Coffee

1 cup

Hot Dog on Bun

1 Each

250

Macaroni and
Cheese

cup

168

Iced Tea
(sweetened)

1 cup

47

Salbury stake

3 oz

214

19

Green beans

1 cup

38

Mashed potatoes
Wg

1 cup

193

Roll with Butter

1 each

100

Ice Tea
(sweetened)

1 cup

47

Total Energy:

1441 kcal

Total Protein:

46g

According to the patients 24-hour recall, the total protein intake was 46g and the total energy intake was 1441 kcal. The
patients recommended energy intake is 2500 kcal/day and protein intake is 71 g/day. Therefore, by the 24-hour recall patient
failed to meet recommended intakes. The insuficient energy intake in macronutrient content will decrease the absorption of
vitamins and minerals, which could harm the fetus.
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)?
Meal
AM

Lunch

Dinner

Food/ Beverage

Quantity

Iron (mg)

Iron Form

frosted flakes

2 cups

19

Non-heme

whole milk

cup

------

Black Coffee

1 cup

polyphenol
decrease
obsorbtion

Hot Dog on Bun

1 Each

Heme

Macaroni and
Cheese

cup

Non-heme

Iced Tea
(sweetened)

1 cup

polyphenol
decrease
obsorbtion

Salbury stake

3 oz

Heme

Green beans

1 cup

Non-heme

Mashed potatoes
Wg

1 cup

Non-heme

Roll with Butter

1 each

Non-heme

Ice Tea
(sweetened)

1 cup

polyphenol
decrease
obsorbtion

Total Iron:

27 mg

The average 2000 kcal/day diet consumed by adult females is averaged to provide 12 mg/day of iron. The estimated
average requirement for an adult pregnant female of 31 years of age is 22 mg/day of iron which the patient has achieved.
Nonetheless, throughout a full term pregnancy, maternal iron intake must include an additional 700 to 800 mg of iron (Rolfes,
Pinna, Whitney, 2014). Therefore, although the patient achieved/ surpassed recommended daily iron intake for the 24-hour
recall, she may not be upholding proper iron intake throughout full term. Also, due to the patients recent labor could have
resulted in the depletion of iron stores via compensation of blood loss. She may not of had enough time to recuperate her total
iron and iron stores status prior to conception (Rolfes, Pinna, Whitney, 2014).

17. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses.

i. Picky eater; Nutrition Dx: Undesirable food choices

ii. Skipping meals; Nutrition Dx: Disordered eating patterns
iii. Decreased availability of iron; Nutrition Dx: Inadequate mineral intake (iron)
iv. Dietary iron deficiency; Nutrition Dx: Less than optimal intake of types of proteins or amino acids (heme-, non-heme
protein)
v. Insufficient caloric intake; Nutrition Dx: Inadequate energy intake
vi. Inconsistent Prenatal vitamin use
vii. Below normal hematological values; Nutrition Dx: Altered nutrition-related lab values (serum ferritin, Hgb, MCV,
MCHC)
18. Write a PES statement for each nutrition problem.
i.

Inadequate mineral intake (iron) R/T Hypochromic Microcytic Anemia AEB Low Hemoglobin of 9.1 g/dl (reference
value:12-15 g/ dl Female), Low MCH of 23 pg(reference value:26-32 pg) and Low Ferritin of 10 ug/dL (reference

value:20-120 Female).
ii.

Inadequate energy intake R/T increased nutrient needs required in pregnancy AEB patients 24-hr recall reports with a
caloric intake total of 1441 kcal (reference value: 2500 calories).

iii. Altered nutrition-related laboratory values RT suboptimal mineral stores attributed to proximal pregnancies AEB
decreased serum ferritin 10 ug (reference value=20-120 ug/dl Female), elevated TIBC 465 ug/dl (reference values=
240-450 ug/dl Female).

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?
Side-effects associated with ferrous sulfate supplements would include constipation, nausea, vomiting, cramping and
gastrointestinal distress. Recommendations to alleviate distress would include increasing consumption of fiber rich sources,
increasing water consumption as well as regular physical activity. With symptoms associated with nausea or vomiting, bland and
cold food consumption would be recommended.
Instructions on the use for ferrous sulfate would include the following:
i. Drug-drug interaction (Prenatal vitamin and Ferrous Sulfate): the minerals found in multi-vitamin decreases iron
absorption and bioavailability of iron if taken at the same time. Ferrous sulfate competes with calcium, copper and zinc
absorption because these minerals use the same transport system. Patient should take medications separately.

ii. Iron supplementation and Vitamin C source: Ferrous sulfate absorption increases with consumption of vitamin c sources
when paired, best to be taken on a empty stomach. Patient should consume ferrous sulfate supplement 1 hr before or 2
hours after consuming foods high in dietary iron (Nelms et al., 2015).
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 the adequate amount of vitamins (A,D,E,K,C) and minerals (Ca, Zn, Fe, B-vitamins)
needed for fetal development. Common vitamins and minerals that are found in higher amounts include zinc, folic acid, calcium
and iron. Recommendations to increase tolerance towards prenatal vitamins would include:
i. Taking medication with a meal or snack should alleviate gastrointestinal discomforts associated with the prenatal
vitamin.

21. List factors that you would monitor to assess her pregnancy, nutritional, and iron status.
Factors to assess:
i. Pregnancy:
Weight gain via pregnancy weight chart.
Patient interviews to discuss whether reported symptoms have improved
i. Nutritional:
Food intake assessment via 24-hr recall and food logs
i. Iron status:
Evaluation of hematological values during prenatal care follow-up visits
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 the program? What are the qualifications for enrollment? Are there any you can confirm
for her referral?
Womans Infants and Children (WIC) is a federally funded nutrition assistance program. The latest Food and Nutrition
Service (2016) WIC eligibility requirements note participants eligible for this program have to be pregnant, post-partum or
breastfeeding women, infants to children up to 5 years of age or individuals who have been identified as nutritionally at risk.
Participants also need to meet residential requirement and meet a family income level limit or automatically enrolled via other
community benefit programs like SNAP, Medicaid, TANF. In regards to the patient, we would highly recommend her continued
participation in WIC services and to disclose nutritional risk for added supplemental nutrition assistance in iron rich food
sources.

Nutrients Report 04/27/16 - 04/27/16

Your plan is based on a default 2000 Calorie allowance.
Nutrients
TargetAverage Eaten
Status
Total Calories
2000 Calories
1441 Calories
Under
Protein (g)***
46 g 50 g OK
Protein (% Calories)*** 10 - 35% Calories 14% Calories
OK
Carbohydrate (g)***
130 g 225 g OK
Carbohydrate (% Calories)*** 45 - 65% Calories 63% Calories
OK
Dietary Fiber
25 g 13 g Under
Total SugarsNo Daily Target or Limit 75 g No Daily Target or
Limit
Added Sugars
< 50 g 56 g Over
Total Fat
20 - 35% Calories 25% Calories
OK
Saturated Fat
< 10% Calories
9% Calories OK
Polyunsaturated Fat
No Daily Target or Limit 4% Calories No
Daily Target or Limit
Monounsaturated Fat
No Daily Target or Limit 11% Calories
No Daily Target or Limit
Linoleic Acid (g)*** 12 g 5 g
Under
Linoleic Acid (% Calories)***
5 - 10% Calories 3% Calories
Under
-Linolenic Acid (% Calories)*** 0.6 - 1.2% Calories 0.5% Calories
Under
-Linolenic Acid (g)***
1.1 g 0.8 g Under
Omega 3 - EPA
No Daily Target or Limit 1 mg No Daily Target
or Limit
Omega 3 - DHA
No Daily Target or Limit 1 mg No Daily Target
or Limit
Cholesterol < 300 mg
103 mg
OK
Minerals
TargetAverage Eaten
Status
Calcium
1000 mg
410 mg
Under
Potassium 4700 mg
1956 mg
Under
Sodium**
< 2300 mg 3237 mg
Over
Copper
900 g
1146 g
OK
Iron 18 mg 27 mg OK

References
Anemia Causes, Types, Symptoms, Diet, and Treatment. (n.d.). Retrieved May 07, 2016,
from http://www.webmd.com/a-to-z-guides/understanding-anemia-basics
Anemia Drugs for its Treatment. (n.d.). Retrieved May 02, 2016, from
http://www.medindia.net/drugs/medical-condition/anemia-in-pregnancy.htm
Brown, J. E., & Isaacs, J. S. (2011). Nutrition through the life cycle. Belmont, CA:
Wadsworth, CENGAGE Learning.
Drake PhD, V. J. (2011, July). Micronutrient Information Center. Retrieved May 10, 2016,
from http://lpi.oregonstate.edu/mic/life-stages/pregnancy-lactation
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krauses Food and the Nutrition
Care Process (13th Ed) (pp 195-200, 357, 726-730). St. Louis, MO: Elsevier.
Institute of Medicine. Weight Gain during Pregnancy: Reexamining the Guidelines.
May,2009.http://www.iom.edu/~/media/Files/Report%20Files/2009/Weight-Gain-During-PregnancyReexamining-the-Guidelines/Resource%20Page%20-%20Weight%20Gain%20During%20Pregnancy.pdf.
Institute of Medicine. Nutrition during Pregnancy: Part I: Weight Gain, Part II: Nutrient
Supplements.January1,1990.http://iom.edu/Reports/1990/Nutrition-During-Pregnancy-Part-I-Weight-GainPart-II-Nutrient-Supplements.aspx.
Lynch, S. (2011). Case studies: Iron. American Journal of Clinical Nutrition, 94(2).
doi:10.3945/ajcn.110.005959
Luke, B. (1991). Nutrition During Pregnancy: Part I, Weight Gain; Part II, Nutrient
Supplements. JAMA JAMA: The Journal of the American Medical Association, 265(2), 281. doi:10.1001/
jama.1991.03460020139044

Maakaron, J. E., MD, Taher, A. T., MD, PhD, FRCP, Conrad, M. E., MD, & Besa, E. C., MD.
(2015, May 20). Anemia Medication. Retrieved May 02, 2016 from
http://emedicine.medscape.com/article/198475-medication#3
Nelms, Marcia., Sucher, Kathryn P., & Lacey, Karen. (2015). Nutrition Therapy and
Pathophysiology (ed 3rd.); (pp. 569-589). Boston, MA: Cengage Learning.
Nutritional Needs During Pregnancy. (2016, March 30). Retrieved May 09, 2016, from
http://www.healthline.com/health/pregnancy/nutrition#1
Pregnancy and Nutrition. (n.d.). Retrieved May 09, 2016, from
http://2012books.lardbucket.org/books/an-introduction-to-nutrition/s16-02-pregnancy-and-nutrition.html
Rolfes, S. R., Pinna, K., & Whitney, E. N. (2014). Understanding Normal and Clinical
Nutrition(10 edition ( ed.). Brooks Cole
United States Department of Agriculture-Food and Nutrition Service. (2016, April).
Womens Infant Children (WIC) Eligibility Requirements. Retrieved May 7, 2016 from
http://www.fns.usda.gov/wic/wic-eligibility-requirements
United States, National Heart Lung and Blood Institute. (2011, September). Your Guide to
Anemia. Retrieved May 7, 2016 from
https://www.nhlbi.nih.gov/files/docs/public/blood/anemia-inbrief_yg.pdf
What to expect. (2015, March 25). Retrieved May 03, 2016, from
http://www.whattoexpect.com/pregnancy/anemia/