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Katlyn Carter

Practice Guideline Last updated: 10/27/18

Evaluation and Management of Anemia


1. Definition or Key Clinical Information: Iron-deficiency anemia is the most common

anemia in the United States (roughly 20% of pregnant women experience anemia). It is usually

mild and easily remedied. The increase in blood volume during pregnancy also includes blood

plasma levels, but a much smaller increase in red blood cells. Anemia affects the oxygenation of

both mother and fetus and can result in reduced fetal growth, increased susceptibility to

infection, maternal exhaustion, and other complications.

2. Assessment

i. Risk Factors

 Current hematocrit and hemoglobin


 Potential causes of anemia:
o Tobacco use
o History of close pregnancies
o Blood loss, heavy menses
o Chronic illness
o Malabsorption factors (hookworms, bariatric surgery, etc.)
o Living in higher altitudes
o Higher risk of thalassemia or sickle cell (African, Mediterranean, or Asian
descent)

ii. Subjective Symptoms

 Fatigue, drowsiness
 Dizziness
 Headache
 Sore tongue
 Pica (consuming non-food items: example clay, starch, chewing ice, etc.)
 Poor appetite, malaise,
 Difficult/labored breathing
 Changes in sleep habits
 Changes in mood
 Restless leg syndrome
 Irritability

iii. Objective Signs

 Palpitations or tachycardia
 Pallor
 Pale mucous membranes and nail beds
 Smooth, sore tongue
 Low energy, fatigued/apathetic expression, mental dullness, and difficulty
concentrating
 Peripheral Edema
 Bruising

iv. Clinical Test Considerations

o Routine CBC in office and sent to lab at intake and repeat each trimester, or as
needed (client presents with s/sx)
o CBC with indices in simple iron-deficiency anemia
 Lab values indicating anemia
- At risk of developing anemia: Hgb <12.0 g/dL, Hct <33.5%
- First and third trimesters: Hgb <11.0 g/dL, Hct <33%
- Second trimester: Hgb <10.5 g/dL, Hct <32%
- Severe: Hgb <7.0 g/dL, Hct <30%
 Microcytic
 Hypochromic
o Serum ferritin decreased
o Total iron binding capacity increased
o B12 levels
o Stool for occult blood, ova, parasites
o Differential diagnosis to consider
 Physiologic anemia of pregnancy
 Pernicious anemia
 Hemolytic anemia
 Thalassemia
 Sickle cell anemia
3. Management plan

i. Therapeutic measures to consider

o Hemoglobin less than 12 g/dL or low serum ferritin: Iron replacement therapy
 Dietary assessment and counseling
 Increase consumption of high Iron foods sources, along with vitamin C
intake
 Quality prenatal vitamin containing at least 60 mg/day of iron
o Hemoglobin less than 11.0 g/dL or low serum ferritin: Iron replacement therapy
 Floradix liquid iron, 2 Tbs. daily by mouth between meals with foods high
in vitamin C
 (or) quality iron supplement supplying 60-65 mg/day of elemental iron
 Dietary assessment and counseling
 Increase consumption of high iron food sources, along with vitamin C
intake
 First and second trimester: repeat in-office H&H in 2 to 4 weeks
 Third trimester: repeat in-office H&H in 1-2 weeks
o Hemoglobin less than 10.5 g/dL or low serum ferritin: Iron replacement therapy
 Begin iron replacement therapy with Floradix liquid iron or other
supplements
 Dietary assessment and counseling, and increase iron-rich foods
 Consider consultation or referral
 Repeat CBC in 2-4 weeks
o Hemoglobin 7.0 g/dL or less: immediate iron replacement therapy
 Consult and/or referral to hematologist and possible blood transfusion
ii. Complementary measures to consider

o Chlorophyll: liquid or capsule, standard dose


o Blackstrap molasses: 1 Tbs. daily
o B vitamins supplementation and/or dietary increase
o Increase folate in the diet, consider folate supplementation
o Spirulina: 1 Tbs. daily
o Dried nettle leaf infusion, daily
o Yellow dock or dandelion root syrup
o Mega Foods “Blood Builder” supplement, 1 capsule daily
o Alfalfa in capsule or liquid form
o Use of cast-iron cookware
o For optimal iron absorption:
 consume iron with vitamin C and water
 Avoid caffeine and black teas
 Consume iron before going to bed
 Avoid simultaneous calcium supplementation
iii. Considerations for pregnancy, delivery, and breastfeeding

o Repeat CBC to ensure Hgb and Hct levels are improving and stabilizing
o Stress the importance of quality diet for optimal health during pregnancy and
lactation
o Discuss comfort measures to deal with discomforts of anemia
o Consider collaboration/referral options
 WIC, social services, food stamps, local food pantry
 Nutritional counseling
 Smoking cessation services
iv. Client and family education

 Physiologic nature of anemia in pregnancy


 Pica decreases iron absorption
 Discuss supplemental dosages
 Discuss food sources
 Discuss possible side-effects (and management of those side-effects)

v. Follow-up

 Document
 Record in client charts
- History, signs, symptoms
- Lab results (initial and subsequent values)
- Client education and resources provided
- Consultations and referrals
- Transfer of care
 Repeat lab values 4 weeks after initiating dietary changes,
supplementation, and other therapeutic measures

4. Indications for Consult, Collaboration or Referral

 For diagnosis or treatment outside the midwife’s scope of practice


 Abnormal indices or elevated serum ferritin
 Anemia resistant to conventional therapy (after 4 weeks)
 Concern regarding the cause of anemia
 Consult with hematologist if Hgb is <7.0 g/Dl
 Postpartum Anemia
o Transfusion recommended for Hgb less than 8g/dL
5.References

Jordan, R.G., Engstrom, J.L., Marfell, J.A., & Farley, C.L. (2014). Prenatal and postnatal care: A
woman-centered approach. Ames, IA: Wiley-Blackwell.

King, T. L., Brucker, M. C., Kriebs, J. M., & Fahey, J. O., Gegor, C. L., Varney, H. (2015). Varney's
midwifery. Jones & Bartlett Learning.

Tharpe, N. L., Farley, C. L., & Jordan, R. G. (2016). Clinical practice guidelines for midwifery
& women's health. Jones & Bartlett Publishers.

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