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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
2. Assessment
i. Risk Factors
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
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
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
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 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
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
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.