How do you adjust Hgb/Hct for smoking?

<2 packs/day

>2 packs/day

<2 packs Hgb +.3, Hct +1.0

>2 packs hgb +.7, hct +2.0

1st trimester decrease in iron absorption with decreased iron requirements from nonpregnant state

2nd trimester iron absorption increased by ~50 percent

3rd trimester iron absroptino increaed by 4x

The exponential growth of the fetus implies that iron needs are almost negligible in the first trimester and that more than 80 percent relates to the last trimester. The total daily iron requirements, including the basal iron losses (0.8 mg), increase during pregnancy from 0.8 mg to about 10 mg during the last 6 weeks of pregnancy.

Iron deficiency

Thalessemia trait

Anemia of chronic disease

Lead poisoning

Sideroblastic anemia

Hx of anemia

Family history of anemia or hemoglobinopathies

Dietary intake of iron

Medical/OB/Menstrual history

Symtoms (many are subclinical):

weakness

fatigue

syncope

vertigo

dizziness

SOB

chest pain

irritability

brittle nails

food cravings

cold intolerance

pallor

irregular heartbeat

headache

VS: Increased HR, dec BP, decreased O2 sat

Assess general appearance, color/pallor of gums, mucus membranes, extremities

Assess for lymphadenopathies, hepatosplenomegaly, bone tenderness

Acute blood loss

hemolysis (intravascular blood loss)

Anemia of chronic disease

early iron deficiency anemia

mixed anemias

Endocrine dysfunction

CBC with normal MCV - Reticulocyte count used to classify normocytic anemias

• increased retics with RBC loss or destruction (hemolysis)
• decreased retics with anemia of chronic disease

• usually consult
• if Hct in 30-34% range, give a trial of iron; order retics; follow-up with Hct/Hgb & indices in not earlier than 14 days
• if retics are >3% on iron Tx, there was some component of iron deficiency
• if anemia persists, work it up according to the new MCV

.5-2.5

Slightly high could be bump due to increased RBC production in response to iron treatment.

1. B12 deficiency

2. Folic acid deficiency

3. Hypothyroidism

4. Alcoholism

5. Chronic liver or renal disease

Pregnancy-induced folic acid deficiency: 1mg folic acid PO daily.
Pt.Ed: Increase nutritional intake of folate rich foods-legumes, green leafy veggies or animal proteins.

“Macrocytic anemia in pregnancy caused by vitamin B12 (cyanocobalamin) deficiency may be encountered in women who have had a partial or total gastric resection or in women with Crohn disease. Women who have had a total gastrectomy require 1,000 micrograms of vitamin B12, intramuscularly, at monthly intervals

Good sources of dietary iron?

What percent of heme and non-heme iron is absorbed? 

lean red meat, poultry, beans, dried fruit, dark leafy greens, broccoli, asparagus, or infusion of dried nettle.

- Heme iron e.g., meat: 20-30% absorbed

- Non-heme iron from grains and vegetables: 2-10% absorbed

meat, fish, poultry, tofu, fermented sauces and 

vegetables e.g. soy sauce, sauerkraut, vitamin A (if vit. A deficient), vitamin C - although 

relatively minor

It is an X-linked recessive disorder, so males are more likely to be affected than females.  

10-15% of African-Americans and western and central Africans have a G6PD A- variant.
The Mediterranean variant is the most common in caucasians from the Mediterranean region and the Mid-East.  

In infants with persistent billirubinemia (jaundice) you might suspect a G6PD deficiency.

• Exclude iron deficiency with ferritin. If ferritin <20 ng/mL, give iron and repeat CBC in six weeks

After six weeks:

If MCV normal – iron deficiency

If ferritin > 20 ng/mL and still low MCV – alpha thalassemia

If ferritin > 20 ng/mL, alpha thalassemia by diagnosis of exclusion – FOB testing, if (+) to genetics

• Beta thalassemia is diagnosed – FOB testing, if (+) to  genetics

• On hgb electrophoresis presence of Hb S (30-50%) indicates trait. If low level of Hb S, may have alpha thalassemia or iron deficiency