Jared McArdleCase Study #2 DIE 3213 Nutrition Therapy 1 Alireza Jahan-Mihan 10/28/2014 Title: Case 21 – Anemia in Pregnancy 1. Evaluate the patient’s admitting history and physical. Are there any signs or symptoms that support the diagnosis of anemia? There are signs and symptoms that support the diagnosis of anemia. The patient did not gain enough weight, and did not take her prenatal vitamins. The patient appeared pale, tired, and had a shortness of breath. The patient’s intake of iron during the 24-hour recall was 19mg which is 8mg short of the daily recommendation. 2. What laboratory values or other tests support this diagnosis? List all abnormal values and explain the likely cause for each abnormal value. Low RBC count, possible inadequate intake of iron. MCV result of 72, when MCV is less than 80 it is indicative that a patients RBC volume is less than the average and termed microcytic. Folate result of 2. Range should be 5-25. Serum folate can be an indicator of body stores, and a decreased value may indicate a folate deficiency. 3. Mrs. Morris’s physician ordered additional lab work when her admitting CBC revealed low hemoglobin. Why is this 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? This is a concern because low levels of hemoglobin may result in the diagnosis of anemia. Yes, pregnancy requires additional maternal absorption of iron. Maternal iron status cannot be assessed simply from hemoglobin concentration because pregnancy produces increases in plasma volume and the hemoglobin concentration decreases accordingly. Some hematological values that normally change in pregnancy are serum albumin and water-soluble vitamins.1,2 4. There are several classifications of anemia. Define each of the following: Megaloblastic anemia- a blood disorder marked by the appearance of very large red blood cells.2 Pernicious anemia- a decrease in red blood cells that occurs when your intestines cannot properly absorb vitamin B12.3 Normocytic anemia- that marked by a proportionate decrease in the hemoglobin content, the packed red cell volume, and the number of erythrocytes per cubic millimeter of blood. Microcytic anemia- the presence of small, often hypochromic, red blood cells in a peripheral blood smear and is usually characterized by a low MCV (less than 83 micron 3).3 Sickle cell anemia- the most common form of sickle cell disease (SCD). SCD is a serious disorder in which the body makes sickle-shaped red blood cells. “Sickle-shaped” means that the red blood cells are shaped like a crescent.4 5. What is the role of iron in the body? Are there additional functions of iron during fetal development? The human body needs iron to make the oxygen-carrying proteins hemoglobin and myoglobin. Hemoglobin is found in red blood cells and myoglobin is found in muscles. Iron also makes up part of many proteins in the body. Iron and iron-containing compounds play vital roles in cellular function in all organ systems. The requirement for iron is greater in rapidly growing and differentiating cells. Iron deficiency during the fetal and neonatal (perinatal) period can result in dysfunction of multiple organ systems, some of which might not recover despite iron rehabilitation.3 6. Several stages of iron deficiency actually precede iron-deficiency anemia. Discuss these stages— including the symptoms—and identify the laboratory values that would be affected during each stage. Stage 1 (Iron Depletion): This is caused by a decrease in iron stores, which results in reduced levels of circulating ferritin in the blood. Typically, there are no general physical symptoms because hemoglobin levels are not yet affected. When iron stores are low, the amount of iron available to mitochondrial proteins and enzymes appear to be depleted, which reduces the individual’s ability to produce energy during periods of high demand. Stage 2 (Iron-deficiency erythropoiesis): The stage is manifested by a reduction in the saturation of transferrin with iron. Transferrin, the transport protein for iron, has the ability to bind two iron molecules and transport them to the cells of the body. During this stage, the iron binding sites on transferrin are left empty, because there is no iron available for binding this results in the transferrin having an increased ability to bind iron, which is called “total iron binding capacity” (TIBC). In addition transferrin receptors on the cells increase to promote uptake of iron by the cell. Overall, then, individuals with iron-deficiency erythropoiesis have low serum ferritin and iron concentrations, a low level of iron saturation, and a high TIBC and transferrin receptors. Production of heme stats to decline during this stage, leading to symptoms of reduced work capacity, because fewer RBS are being made. Stage 3 (Iron-deficiency anemia): In iron-deficiency anemia, production of healthy red blood cells has decreased, the cell size decreases by as much as a third, and hemoglobin levels are inadequate resulting in less RBC being made and those that are not made cannot transport oxygen adequately. Those with stage 3 will still have abnormal values for all the assessment parameters measured in stages one and two.1 7. What potential risk factor(s) for the development of iron-deficiency anemia can you identify from Mrs. Morris’s history? From her history, she had an increase of blood flow to sustain her fetus. Also she had below normal weight loss in previous pregnancies. 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? The relationship between the health of the fetus and maternal iron status is the demand for RBC increases to accommodate needs such as maternal blood volume, growing uterus, placenta, and fetus. Due to this, an increase in iron is needed. As time goes by, the fetus stores more iron in the liver preparing for the first few months of life. Severely inadequate iron intake has potential to harm the fetus which can result in low birth weight, preterm birth, still birth, and death of the newborn. Most cases the iron-deprived fetus will rob the maternal iron resulting in iron-deficiency anemia in the mother during pregnancy. Maternal iron deficiency causes extreme paleness and exhaustion and at birth endangers the mother’s life.1 9. Discuss the specific nutritional requirements during pregnancy. Be sure to address all macro- and micronutrients that are altered during pregnancy. A woman should consume close to the same number of calories daily as during her no pregnant days during the first trimester. However, she should attempt to maximize nutrient density of what she eats. For example, drink low-fat milk instead of soft drinks. Because the milk provides valuable protein, vitamins, and minerals to feed the fetus’s rapidly dividing cells whereas soft drinks are nutritionally empty calories. During the last two trimesters energy needs to increase to about 350 to 450 kcal/day. During pregnancy, protein needs increase approximately 1.1 grams per day per kilogram body weight over the entire 9 month period. This comes out to an increase of 25 grams of protein per day. Pregnant women are advised to intake at least 175 grams of carbohydrates per day. All pregnant women need to be counseled on the potential hazards of very low-carbohydrate diets. Glucose is the primary metabolic fuel of the developing fetus. The recommended intake will also prevent ketosis and help maintain normal blood glucose levels. Additional carbohydrates may be needed to support physical activity for th mother. Fat calories do not change during pregnancy. However adequate consumption of dietary fat is crucial because cells and tissues are being built. During the third trimester, the fetus stores most of its own body fat. Consumptions of the right fats are important. Limit intakes of saturated and Trans fats. Poly- and monounsaturated fats should be chosen whenever possible. DHA has been found to be uniquely critical for both neurological and eye development. Because the fetal brain grows dramatically during the third trimester, DHA is crucial in the maternal diet. Pregnant women who eat fish should be aware of the potential for mercury contamination.1 Micronutrient needs increase during pregnancy do to the expansion of the mother’s blood supply and growth of the uterus, placenta, breasts, body fat, and the fetus. Changes in nutrient recommendations with pregnancy for adult women: Folate: pre-pregnancy- 400ug/day pregnancy- 600ug/day Vit B12: Pre- 2.4ug/day Pregnancy- 2.6ug/day Vit C: Pre-75mg/day Pregnancy- 85mg/day Vit A: Pre- 700ug/day Pregnancy- 770ug/day Vit D: Pre- 5ug/day Pregnancy- 5ug/day Calcium: Pre- 1,000mg/day Pregnancy- 1,000mg/day Iron: Pre- 18mg/day Pregnancy- 27mg/day Zinc: Pre- 8mg/day Pregnancy- 11mg/day Sodium: Pre- 1,500mg/day Pregnancy- 1,500mg/day Iodine: Pre- 150ug/day Pregnancy 220ug/day 10. What are best dietary sources of iron? Describe the differences between heme and nonheme iron. The best sources of iron include: Dried beans Dried fruits Eggs (especially egg yolks) Iron-fortified cereals Liver Lean red meat (especially beef) Oysters Poultry, dark red meat Salmon Tuna Whole grains3 Heme iron- iron that is part of hemoglobin and myoglobin, only found in animal based foods. Non-heme iron- The form of iron that is not a part of hemoglobin or myoglobin, is found in both animal based and plant based foods1. 11. Explain the digestion and absorption of dietary iron. Iron is released from bound food components. Some HCI in the stomach may reduce Fe3+ to Fe2+. Free heme is absorbed intact by heme carrier protein HCP 1, located primarily in the proximal small intestine. Within the enterocyte, heme is catabolized by heme oxygenase to protoporphyrin and Fe2+. Nonheme iron in the small intestine may react with one or more inhibitors, which promote the fecal excretion of iron. Any of three reductases may reduce Fe3+ to Fe2+. Divalent metal transporter DMT 1 carriers Fe2+ across the brush border membrane into the cytosol of the enterocyte, endocytosis of DMT1 as part of transcytosis may also enable the absorption if iron. Fe2+ may bind to poly rC binding protein or a et unidentified protein for transport in the cytosol; iron may als be used within the cell or stored as ferritin. Ferroportin transports iron across the basolateral membrane. Iron transport is coupled with its oxidation to Fe3+ by hephaestin. Fe3+ attaches to transferrin for transport via blood.1 12. Assess Mrs. Morris’s height and weight. Calculate her BMI and % usual body weight. Height: 5’5” (65”) Weight: 142lbs % UBW= (142/135)X 100= 105% BMI= (135/4225) X 703= 22.53,6 13. Check Mrs. Morris’s 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? Her weight gain is inadequate. Her weight gain is below current recommendations by 4-9lbs. She did not meet the recommended weight gain from her previous pregnancies as well3. 14. Determine Mrs. Morris’s energy and protein requirements. Explain the rationale for the method you used to calculate these requirements. EER= (354-6.91) X 31 years old + 1.27 PA X (9.36 X 64.41kg) + (726 X 65in/39.370m) = 1,994.52 kcal/day Patient is 23 wks pregnant and requires increased energy needs of about 364 kcal/day 1994.52 + 364 = 2,359 kcal/day4 15. Using her 24-hour recall, compare her dietary intake to the energy and protein requirements that you calculated in Question 14. Patient meets 65% of recommended energy intake and 80% recommended protein intake. 16. Again using her 24-hour recall, assess the patient’s daily iron intake. How does it compare to the recommendations for this patient (which you provided in question #9)? The recommendations for this patient are 27 mg/day and she is only at about 19.6mg/day. 17. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses. Patient needs increases in iron, energy, and protein intakes. 18. Write a PE S statement for each nutrition problem. Inadequate iron intake, patient needs to exceed daily intake to reach 27mg/day. Inadequate energy intake, 24-hour recall states patient is only at 65% of recommended energy intake. Inadequate protein intake, 24-hour recall states patient is only at 80% of recommended protein intake. 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 drug–nutrient interactions? What instructions might you give her to maximize the benefit of her iron supplementation? Ferrous may prevent IDA. Constipation, diarrhea, stomach cramps, or upset stomach may occur as well as dark stools. I would recommend for her to take on an empty stomach.7 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? 400 micrograms (mcg) of folic acid. 400 IU of vitamin D. 200 to 300 milligrams (mg) of calcium. 70 mg of vitamin C. 3 mg of thiamine. 2 mg of riboflavin. 20 mg of niacin. 6 mcg of vitamin B12. 10 mg of vitamin E. 15 mg of zinc. 17 mg of iron. 150 micrograms of iodine I would make recommendation such as, making sure she knows why it is important to make sure she is consuming her vitamins. As well as, carrying around a pill container around with her via purse or whatever it may be so she will have them accessible when she forgets. Last, taking the vitamin in the morning is the best but if she forgets as long as she takes one it is better than not taking one at all.7 21. List factors that you would monitor to assess her pregnancy, nutritional, and iron status. In order to assess the patient’s pregnancy, nutritional, and iron status, an outpatient RD referral should be made in order to monitor a variety of factors such as weight gain throughout the rest of the pregnancy. Energy intake, serum folate levels, iron status, protein consumption and vitamin and mineral (calcium, zinc, vitamin B12, and vitamin C) intake should be monitored especially. Tracking of prenatal vitamin and ferrous iron supplement should be conducted, with continued education of recommendations to be met. If patient is re-admitted to the hospital, laboratory values should be reassessed. RBC (X 106/mm3) count, MCV values, and ferritin levels should be evaluated and compared to previous laboratory values to assess iron stores. Hgb and Hct levels should be taken into account but with caution because they can be affected by the increase in blood volume during pregnancy. TIBC levels should be evaluated, but with caution as TIBC levels can be increased due to pregnancy. 22. You note in Mrs. Morris’s history that she received nutrition counseling from the WIC program. What is WIC ? Should you refer her back to that program? What are the qualifications for enrollment? Are there any you can confirm for her referral? WIC is for Women, Infants, and Children that provides Federal grants to States for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and nonbreastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk. Yes, I would refer her back. Qualifications include: Categorical, Residential, Income, and Nutrition Risks. She meets the categorical qualification by being pregnant. She will meet the residential requirements if her state is not an ITO or it if is an ITO depending where she resides.8 References 1.) The Science of Nutrition 3rd edition; Thompson, Manore, Vaughan. 2.) The American Journal of Clinical Nutrition Website http://ajcn.nutrition.org/content/71/5/1285s.full Accessed 10/20/2014 3.) Healthline Website http://www.healthline.com/health/megaloblastic-anemia#Overview1 Accessed 10/20/2014 4.) National Heart, Lung, and Blood Institute http://www.nhlbi.nih.gov/health/healthtopics/topics/prnanmia/ Accessed 10/21/2014 5.) Medical Dictionary Website http://medical-dictionary.thefreedictionary.com Accessed 10/21/2014 6.) UBW indicator Website http://www.tpnteam.com/secure/calc%25UBW.htm Accessed 10/21/2014 7.) WebMD Website http://www.webmd.com Accessed 10/22/2014 8.) Food and Nutrition Service Website http://www.fns.usda.gov/wic/women-infants-and-children-wic Accessed 10/22/2014