Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 28-year-old woman presents with the new-onset of worsening fatigue, present for approximately the last month. She's 28 weeks pregnant with her second child and has a 1.5-year-old healthy child at home. She also states that she remembers being tired towards the end of her first pregnancy, but states, “Well, this is worse than my last pregnancy.” 

She denies vaginal bleeding or discharge, denies abdominal pain or other concerning issue, is sleeping about 7 hours a night, and has adequate access to nutritious food. She is not taking a prenatal vitamin reporting, “I kept throwing up every time I took one.” During her early pregnancy, her PHQ-9 screening tool results are without concern and her laboratory results are as follows: 

Hemoglobin 9.2 (Normal is 12 to 14) 
Hematocrit 27 (Normal 36 to 42) 
Total RBC 2.9 million (Normal 3.9 million to 5.2 million) 
MCV 75 (Normal 80 to 98) 
MCH 22 (Normal 27 to 33) 
RDW 18% (Normal 11.5 to 15%) 

These results are most consistent with:
A: Pregnancy-related hemodilution. 
B: Folic acid deficiency anemia. 

C: Iron-deficiency anemia. 

D: Beta-thalassemia minor. 

And the correct answer is C: Iron-deficiency anemia. 

Where should we start with this question? First, determine what type of question it is. And given that we're provided with a clinical scenario and select laboratory results, this is an assessment question. How about some background information? As I've said more times than I can possibly count in these podcasts, common diseases occur commonly. The most common type of anemia worldwide is iron-deficiency anemia. 

And this is, of course, the most common type of anemia encountered during pregnancy. Maternal iron requirements increase in the second and third trimester of pregnancy, in part because the fetuses need to build iron stores during this time period. That said, most IDA, abbreviation for iron-deficiency anemia, cases occur because the person enters pregnancy iron-deficient, rather than developing this problem due to the increased iron requirements. 

Look at the information we're being given about this patient. She's 28 weeks pregnant into her second pregnancy and has a 1.5-year-old at home. She has a rather short inter-conception period, defined as the time between considering she likely entered the pregnancy rather iron-poor somewhat depleted from the first pregnancy. And now of course, she's in her third trimester, entering their third trimester, and the fetal demands of iron have gone up and she has developed this anemia. Pregnancy-related iron requirements given in terms of elemental iron are as follows:  
 

In the absence of iron-deficiency 30 milligrams a day, which generally can be met by a balanced diet  

With iron-deficiency or multiple gestation pregnancy, i.e. carrying more than one baby at a time, the iron requirements are 60 to 100 milligrams a day.  

To give you a little bit of background here, a 325 milligrams ferrous sulfate tablet contains about 65 milligrams of elemental iron, where most prescription prenatal vitamins contain around 30 milligrams of iron. 

Some might be as high as 65 milligrams of elemental iron. There is, I will say, ongoing debate about the helpfulness of prenatal vitamin use, particularly with the iron supplementation or individuals who eat a really well-balanced diet. But at the same time, what we have here is that she has a short inter-conception period. You know, that's a risk factor for iron-deficiency. 

She also says she has access to a nutritious diet, but of course, prudent practice would be to review her diet with her, too. She might be able to have access to lean meats, leafy greens, all of the good things that we think of as having iron in them for her to take in during her pregnancy. But maybe she's actually not eating those things. 

She is telling you she's not taking a prenatal vitamin because of GI upset during her early pregnancy. But there's no mention that her stomach's bothering her now. This is actually incredibly common that women will tell you they don't want to take their prenatal vitamin because they threw it up in time during early pregnancy. There is a little work around. 

There are now some prescription prenatal vitamins that are available in a chewable form. What's magic about chewable? It's just that they go into the stomach, all mashed up, and the stomach finds them easier to digest. The other work around that I've often done is to take one chewable children's multivitamin with iron twice a day and do that particularly with a meal and a lot of times that can replace a prenatal vitamins. 

But also, I want you to know and this she is complaining that she feels tired. You know, she's entering her last trimester. She has a toddler at home. She's a little anemic, not profoundly anemic. However, worsening fatigue during pregnancy should always make you think, ‘Could you be seeing a new showing of a mental health issue?’ So, the screening for depression is absolutely appropriate. And untreated mental health problems, of course, are common reasons for worsening fatigue. 

With that in mind, let's take a look at the question and the possible responses. A 28-year-old woman presents with new-onset of worsening the fatigue for about the last month. She's 28 weeks pregnant with her second child and has a 1.5-year-old healthy child at home. She states she remembers being tired towards the end of her prior pregnancy, but states, “This is worse than with my last pregnancy.” 

She denies vaginal bleeding or discharge, denies abdominal pain or other concerning issues, is sleeping about 7 hours a night, and has adequate access to nutritious food. She's not taking a prenatal vitamin reporting, “I kept throwing up every time I took this” during early pregnancy. PHQ-9 screening tool results are without concern. Her lab results include the following: 

Hemoglobin is 9.2. 
Hematocrit is 27. 
Total RBC is reduced. 
MCV is 75. 
 
So by Winthrop's classification, she is microcytic; MCH, hypochromic; RDW elevated at 18%, telling us new cells are even smaller and paler than the old cells. These results are inconsistent with A: Pregnancy-related hemodilution. This is incorrect. Now hemodilution naturally occurs in the third trimester of pregnancy, as the body adjusts to the demands of the fetus. 

And what actually happens is the hematocrit can go down a little bit. The hemoglobin is unchanged. And so, what we would see is a situation where the H&H wouldn't quite match. But if it's hemodilution, what would we be saying? First of all, somebody is not going to hemodilute down to a hemoglobin of 9.2. Plus, with hemodilution, the MCV would be normal, the MCH would be normal, RDW would be normal as well. 

And we wouldn't be seeing the microcytic hypochromic anemia with the elevated RDW that we have in this case scenario. No, option A is an example of a question response that I think looks good but is incorrect and what sometimes people will do is they'll gravitate towards 'look good but isn't right’ answer when they're unclear or about a situation like caring for a woman during pregnancy. 

So just be aware of that. Option B: Folic acid deficiency anemia. Of course, this is also incorrect. In folate deficiency or folic acid deficiency anemia, the hemogram would reveal a slight macrocytic normochromic anemia with an elevated RDW. Folic acid deficiency during pregnancy is relatively uncommon in individuals who have access to a healthy diet. 

On rare occasion, folic acid deficiency will be seen in very late pregnancy or during lactation due to high folic acid demands. And to be honest, that's one of the reasons why we would want during pregnancy and lactation for the person to be on at bare minimum, that multivitamin that I had mentioned before to avoid folic acid deficiency. The iron-deficiency anemia, of course, is just the correct answer. 

And the laboratory presentation of anemia will be the same in individuals, pregnant or not pregnant. So just to review a few of the basics of evaluating a person with iron-deficiency anemia, red blood cells will be small and pale because of low hemoglobin content. Hemoglobin makes up 90% of the RBC volume, and it's what gives the red blood cell its characteristic color. 

Small cells will always, always, always, always be pale red blood cells, and the new cells will be smaller and paler than the old red blood cells because they're even more iron deficient until the anemia is treated. And that's what causes the elevated RDW. Plus, I just have to say it one more time, common diseases occur commonly. And what's the most common anemia during pregnancy? Iron deficiency.  

D: Beta-thalassemia minor. With a diagnosis like beta-thalassemia minor, it's really important to take a look at the information. You're going to consider this as correct and then say, ‘What do I have that would point me to considering this diagnosis?’ Her ethnicity is not mentioned, and what do we know about the thalassemia minors? They're more common in people of select ethnicity. 

That includes people of African ancestry, Middle Eastern ancestry, and a few other places in the world. And it doesn't mention that. And I would expect if they were asking if they were going to give you a case of thalassemia minor, that ethnicity would be mentioned. On top of that, the hemogram is wrong for beta-thalassemia minor. On hemogram, beta-thalassemia minor presents as a microcytic hypochromic anemia just like we have here. 

But here's what happened here, here lies the difference. The RDW would be normal because beta-thalassemia minor genetically based cells are normally made. It's just the way the person makes them. They're small and pale. They'll all be around the same size. So that's going to give us a normal limit RDW. But what's the compensation with beta-thalassemia minor? The person makes small pale cells all the same size but makes lots of them. 

So, you would expect the RBC to be elevated. Key takeaway: In recognizing physiologic changes during pregnancy, it's important to providing prenatal care. But also recognizing when certain assessments, including lab data and anemia, do not change during pregnancy, are equally as important. If a person during pregnancy presents with a microcytic, hypochromic anemia with an elevated RDW that is going to be iron-deficiency as if it was with or without the pregnancy. 

Voiceover: Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast and for more NP resources, visit FHEA.com.