our appointment

What a delightful couple.
Di and Dave are so excited about the pregnancy, and I feel very special in sharing in this occasion with them.
We did talk about Di continuing to breastfeed Peter, however, I am not too overly concerned at the moment. We still have a bit of time left, after all, Peter may well wean himself.

My main concern for this appointment is her first antennal blood results.
(haemaglobin 110g/L and Ferritin 9ug/L)
To start with, it appears to me Di has iron deficiency. Our appointment went for at least an hour, as I was explaining to Di and Dave what these terms mean in regard for a healthy pregnancy. I am concerned that she is a vegatarian, however, she has been doing a lot of research herself on the internet, looking at ministry of health sites etc, to gain a better understanding. I think we can become great partners in care together. Communication seems to be going well. I have sourced some literature to help with my treatment plan.

According to Pairman et al (2006), a ferritin level less than 12-15ug/L “indicates empty stores of iron and iron deficiency.” (Harram et al 2001, cited in Pairman et al 2006).
Di’s Haemaglobin is also lowish being 110g/L, however it can be difficult to determine whether this is associated with the relatively normal process in pregnancy of haemodilution, or, anaemia. According to Pairman et al (2006), this result would most likely be anaemia. Pairmain et al (2006) continues by stating that serum ferritin is the blood test of choice in determining iron stores in the body, particularly in the first trimester. As Di is right on the cusp of moving in to the second trimester, I could expect her serum ferritin to drop even more, as according to Pairman et al (2006), haemodilution occurs independent of changes in iron stores. A ferritin level of 15-30ug/L shows that iron stores are too small to cope with the requirements of pregnancy. (Pairman et al 2006).

We began our appointment quite casually. Di and Dave knew what we were to discuss, and appeared relaxed and comfortable. I actually had a few hours to spare, so I could relax too.
We talked about how important the mineral “iron” is to the body, particularly during pregnancy. I explained that iron is an important mineral that is available to the body from food, in two forms. Haem, being a structure of haemaglobin, and, non-haem iron.
Haem iron is present in meat, poultry and fish. Non –haem is also present in meat, fish and poultry, but is also the only form found in plant foods.
Since she is a vegetarian, I would like to recommend her including foods in each meal of non-haem and haem foods. Ideally, I would like to suggest including fish twice a week together with a selection of non-haem foods. She also does not consume dairy products, however according to the NZ dietetic Association, soy is a good form of calcium as well as cooked legumes, nuts and seeds, almond butter spread for her morning toast, green leafy veggies, dried figs and even calcium fortified orange juice. I have given her lists of recipe ideas for each main meal of the week, and encouraged her to include foods rich in vitamin C to assist in iron absorption in the gut.
Fortunately, Di does not drink too much tea and coffee. I have advised her to consume a cuppa at least 3 hours apart from her meals as the tannins in tea particularly, reduces iron absorption up to 40%.

ABOUT ANAEMIA
During our appointment, I also explained that significant anaemia can pose a real threat to the overall well being of the mother and baby. The physiological changes that commonly occur in pregnancy may either expose an underlying anaemia, or it may continue to develop during the pregnancy. (coggins 2001, cited in Pairman et al 2006). “Haemoglobin levels are used as a primary measure of anaemia, as approximately 70% of iron in the body is haemoglobin”. (Jordan 2002, pg 268, cited in Pairman et al 2006, pg 353).
Another thing is, when diagnosing anaemia, it’s important to differentiate between other types of anaemia, such as folate, b12, sickle cell, thalassaemia and autoimmune anaemia. Pairman et al (2006) recommends correct diagnosis to avoid unnecessary treatment regimes that may actually cause more harm than good. Iron overload can occur in women with haemochromatosis, or inneffectice erythropoiesis, such as sickle cell disease and thalassaemias.
However, from her latest antennal screen, I feel we need to treat iron deficiency anaemia. She does take 800mcgs of folate per day, and has done for the past 3 months. There are no indications of family history with any above mentioned conditions.
My recommendations include diet variation as described, and also an iron supplementation of approximately 105mg of iron daily throughout pregnancy. Mainly as her ferritin is only 9ug/L. Best to be taken before food, to help reduce side effects of tummy upsets. I would recommend Ferrogradumet, which contains 105mg of elemental iron. I have also written out blood slips for a repeat screen in another 4 weeks.
By the end of our appointment, I could tell Di and Dave were a little overwhelmed with our topic, however I think I have inspired them to be creative in their meal preparations, making them interesting, healthy and cost effective for their lifestyle. Hopefully Peter will enjoy it too.

I am a fairly new midwife, so I tend to source my books and current literature to support my practice. I think we’re on track so far. Di and Dave both know to call me at any time if any more questions arise.
I shall catch up with them both within 4 weeks.

These references were great.
Pairman S, Pincombe J, Thorogood C, Tracy S, (2006), Midwifery preparation for practice, Elsevier, Australia

Vegetarian Diets – American Dietetic Association, Journal of the NZ Dietetic Association, Vol 54, No 2.