A 29-year-old Asian woman, gravida 1 para 0, comes to the office at 26 weeks gestation for prenatal care. The patient has no abdominal pain, vaginal bleeding, or leakage of fluid. Fetal movement is normal. For the last few weeks, she has become increasingly fatigued and is sleeping at least 8 hours a night in addition to taking an afternoon nap. Her pregnancy has been uncomplicated and initial prenatal laboratory results were as follows: The patient has no chronic medical conditions and has had no previous surgeries. She takes a daily prenatal vitamin; however, she was unable to begin taking it until 18 weeks gestation due to daily nausea and vomiting. Blood pressure is 110/60 mm Hg and pulse is 64/min. Weight is 60 kg (132.3 lb), a 5-kg (11-lb) increase from her prepregnancy weight. Fetal heart rate is 145/min by Doppler ultrasound. Fundal height is 26 cm. Urine dipstick is negative for protein and glucose. Routine third-trimester laboratory results include the following:
The results of a peripheral blood smear are shown below:
The patient asks about the cause of her fatigue and whether she needs treatment. Which of the following is the most appropriate response to this patient?

Question

A 29-year-old Asian woman, gravida 1 para 0, comes to the office at 26 weeks gestation for prenatal care.  The patient has no abdominal pain, vaginal bleeding, or leakage of fluid.  Fetal movement is normal.  For the last few weeks, she has become increasingly fatigued and is sleeping at least 8 hours a night in addition to taking an afternoon nap.  Her pregnancy has been uncomplicated and initial prenatal laboratory results were as follows:  The patient has no chronic medical conditions and has had no previous surgeries.  She takes a daily prenatal vitamin; however, she was unable to begin taking it until 18 weeks gestation due to daily nausea and vomiting.  Blood pressure is 110/60 mm Hg and pulse is 64/min.  Weight is 60 kg (132.3 lb), a 5-kg (11-lb) increase from her prepregnancy weight.  Fetal heart rate is 145/min by Doppler ultrasound.  Fundal height is 26 cm.  Urine dipstick is negative for protein and glucose.  Routine third-trimester laboratory results include the following:
The results of a peripheral blood smear are shown below:
 The patient asks about the cause of her fatigue and whether she needs treatment.  Which of the following is the most appropriate response to this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c02c_e27b_8f63_751a06a5a9d7_MD0005_00 Pregnant patients are routinely screened for anemia at the initial prenatal visit and in the third trimester. Further evaluation for the cause of anemia is indicated in pregnant patients with a hemoglobin level of: <11 g/dL in the first trimester <10.5 g/dL in the second trimester <11 g/dL in the third trimester This patient has microcytic hypochromic anemia consistent with iron deficiency anemia. Iron deficiency impairs hemoglobin synthesis, resulting in small, pale erythrocytes. Fetal hematopoiesis, placental development, and the expansion of the maternal red blood cell mass during pregnancy result in an increased iron requirement. This increased requirement can precipitate maternal iron deficiency in patients who have inadequate prepregnancy iron stores or have inadequate iron intake (eg, hyperemesis gravidarum) during pregnancy. Iron deficiency anemia is associated with an increased risk of preterm delivery, cesarean delivery, and blood transfusion after delivery. It is treated with oral ferrous sulfate. Intravenous iron repletion may be required for patients who do not respond to or cannot tolerate oral iron. (Choice A) Thalassemia (eg, hemoglobinopathy) can present with anemia and is common in Asian patients. However, the peripheral blood smears of patients with thalassemia typically show target cells. target cells (Choices C and E) Inadequate folate and vitamin B₁₂ intake can occur in pregnancy secondary to inadequate maternal intake due to persistent nausea and vomiting or a lack of prenatal vitamins. However, folate and vitamin B₁₂ deficiency are rare and cause macrocytic anemia with associated hypersegmented neutrophils. ₁₂ ₁₂ macrocytic anemia (Choice D) A physiologic anemia occurs due to a larger increase in maternal plasma volume relative to the red blood cell mass. Patients are typically asymptomatic and have mild, incidental anemia (eg, hemoglobin >11 g/dL during the third trimester) on routine testing and a normal peripheral blood smear. Educational objective: Iron deficiency anemia presents with hypochromic microcytic red blood cells on peripheral blood smear and is common during pregnancy due to a combination of increased iron demand and poor maternal intake. References: How I treat anemia in pregnancy: iron, cobalamin, and folate. (http://www.ncbi.nlm.nih.gov/pubmed/28034892) Anaemia in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/22138002)

A 29-Year-Old Asian Woman, Gravida 1 Para 0, Comes to the Office