A 26-year-old woman, gravida 1 para 0, with a history of systemic lupus erythematosus (SLE) comes to the office for a follow-up visit. The patient is at 22 weeks gestation and feels well. She had mild nausea during the first trimester but reports no fatigue, joint or chest pain, or shortness of breath. Her SLE has been quiescent for several years and she takes hydroxychloroquine. The patient also takes a prenatal vitamin containing folic acid and iron daily. She has never smoked and does not use alcohol or illicit drugs.
Temperature is 37 C (98.6 F), blood pressure is 116/68 mm Hg, pulse is 74/min, and respirations are 14/min. Physical examination shows no skin rash or oral ulcerations. The lungs are clear to auscultation and heart sounds are normal. Abdominal examination shows an appropriately sized gravid uterus with no tenderness. The joints are nontender and there is no edema of the extremities.
Laboratory results are as follows:
Prepregnancy hemoglobin was 13.2 g/dL and at 8 weeks gestation was 12 g/dL.
Which of the following is the most appropriate next step in management of this patient?

Question

A 26-year-old woman, gravida 1 para 0, with a history of systemic lupus erythematosus (SLE) comes to the office for a follow-up visit.  The patient is at 22 weeks gestation and feels well.  She had mild nausea during the first trimester but reports no fatigue, joint or chest pain, or shortness of breath.  Her SLE has been quiescent for several years and she takes hydroxychloroquine.  The patient also takes a prenatal vitamin containing folic acid and iron daily.  She has never smoked and does not use alcohol or illicit drugs.
Temperature is 37 C (98.6 F), blood pressure is 116/68 mm Hg, pulse is 74/min, and respirations are 14/min.  Physical examination shows no skin rash or oral ulcerations.  The lungs are clear to auscultation and heart sounds are normal.  Abdominal examination shows an appropriately sized gravid uterus with no tenderness.  The joints are nontender and there is no edema of the extremities.
Laboratory results are as follows:
 Prepregnancy hemoglobin was 13.2 g/dL and at 8 weeks gestation was 12 g/dL.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98a5_24ec_853d_c974f1cbe97b_MD0002_00 During pregnancy, maternal organ systems physiologically adapt to increased metabolic demands of the growing fetus, leading to a disproportionate increase in maternal plasma volume compared to the increase in red blood cell volume. These dilutional changes are dynamic in pregnancy, with the greatest disproportion of the plasma volume to red blood cell mass ratio occurring during the second and early third trimesters. The expected physiologic levels of hemoglobin during pregnancy are: ≥11 g/dL in the first trimester≥10.5 g/dL in the second trimester≥11 g/dL in the third trimester ≥11 g/dL in the first trimester ≥10.5 g/dL in the second trimester ≥11 g/dL in the third trimester Therefore, this patient with an expected physiologic change in hemoglobin levels during pregnancy can be managed with observation, and no further evaluation is indicated. All patients should be screened for anemia during pregnancy. Patients with treatable causes of anemia (eg, iron deficiency) benefit from supplementation, due to an increased risk of maternal (eg, blood transfusion) and fetal (eg, low birth weight) morbidity with severe disease (ie, hemoglobin 6-7 g/dL). At term (37-40 weeks gestation), a trend toward higher hemoglobin levels evolves and baseline hemoglobin levels return within 6-8 weeks postpartum. (Choices B and D) Autoimmune hemolytic anemia is a complication in approximately 10% of patients with systemic lupus erythematosus and can be evaluated by direct antiglobulin (Coombs test), lactate dehydrogenase, and haptoglobin levels. Mean corpuscular volume (MCV) is often increased due to increased reticulocytosis. This patient has a normal bilirubin, suggesting no hemolysis, and a normal MCV. (Choice C) Iron deficiency anemia is the most common anemia in pregnancy, often requiring iron supplementation. This patient has normal MCV and hemoglobin levels. (Choice E) Vitamin B₁₂ and folate deficiency can present with anemia in patients with nausea; this patient's nausea was mild and resolved during pregnancy. ₁₂ Educational objective: All pregnant patients should be screened for anemia, and physiologic changes in hemoglobin can be observed without further evaluation or treatment; baseline levels return 6-8 weeks postpartum. __________ References: Practice bulletin no 95: anemia in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/18591330)

A 26-Year-Old Woman, Gravida 1 Para 0, with a History