NU682 Unit 6 Postpartum Anemia Case Analysis Example

A Hemoglobin of 7.9 and a Toddler at Home: A Unit 6 Case Analysis of Anemia Ten Days After a Postpartum Hemorrhage

[Student Name]

Purdue University Global

NU682: Childbearing Family

Unit 6 Postpartum Complication Case Analysis

[Instructor Name]

[Date]

The patient, family and values are composite and illustrative; the sources cited are real.

The Case

Mrs. Nakamura, para 2, gave birth vaginally to a healthy daughter after an uncomplicated pregnancy. Uterine atony after delivery caused a hemorrhage estimated at 1,400 milliliters, controlled with uterotonic medicines and uterine massage. She was not transfused. Her hemoglobin was 11.8 g/dL before delivery and 7.6 g/dL on the second day after birth. She was discharged with ferrous sulfate 325 milligrams twice daily, which she stopped after four days because of nausea and constipation.

At this visit, on day 10, she reports dizziness on standing, breathlessness climbing the stairs, and dozing off during night feeds. She is exclusively breastfeeding and thinks her daughter seems hungrier. Her two-year-old son is home with her during the day. Her pulse is 104 sitting and 118 standing, blood pressure 108/66 without a significant drop, and she has no chest pain. Hemoglobin is 7.9 g/dL and ferritin 9 ng/mL. The baby has regained her birth weight.

The Problem

She has moderate iron deficiency anemia after a postpartum hemorrhage, with symptoms affecting her safety, her ability to feed and her care of two children. Her stable blood pressure and the absence of chest pain or ongoing bleeding mean she does not need a transfusion, which carries its own risks and is reserved for severe or unstable anemia. The question is how to replace iron quickly enough to matter for the weeks ahead.

The diagnosis is simple; the decision is how fast her body needs the iron back.

Option 1: Oral Iron, Taken Differently

Oral iron is inexpensive and effective for many people, and her intolerance may be partly a dosing problem. Each oral dose raises hepcidin, a hormone that reduces iron absorption for about a day afterward. When women low in iron took supplements every other day in two small absorption trials, they absorbed a larger share than when they took the same dose daily, and splitting the daily dose into two did not help (Stoffel et al., 2017). A single dose of about 60 to 100 milligrams of elemental iron every other morning, with vitamin C and away from tea, coffee and calcium, may be both better absorbed and better tolerated than the twice-daily regimen she stopped.

The drawback is time. With a ferritin of 9 and a hemoglobin of 7.9, oral iron would take weeks to bring her hemoglobin to a level where she feels well, during exactly the weeks she will be alone with a newborn and a toddler.

Option 2: Intravenous Ferric Carboxymaltose

Intravenous iron replaces the deficit in one or two infusions. In a randomized trial of women with postpartum anemia, those given ferric carboxymaltose reached a hemoglobin rise of 2 g/dL in a median of 7 days, compared with 14 days for oral ferrous sulfate, and were more likely to reach a hemoglobin above 12 g/dL (Van Wyck et al., 2007). There were no serious drug reactions.

Its main drawback is a drop in blood phosphate, which can cause fatigue, muscle weakness and, with repeated doses, bone problems. In two randomized trials comparing intravenous preparations in adults with iron deficiency anemia, about three in four patients given ferric carboxymaltose developed low phosphate, compared with about one in twelve given iron isomaltoside, also called ferric derisomaltose (Wolf et al., 2020).

Option 3: Intravenous Ferric Derisomaltose

Ferric derisomaltose can deliver a full replacement dose of 1,000 milligrams in a single infusion of about 20 minutes. Its lower rate of hypophosphatemia in the head-to-head trials is an advantage for a patient who is already exhausted and caring for two children, since fatigue from low phosphate could be mistaken for persistent anemia. Like other modern intravenous irons, it carries a small risk of hypersensitivity reactions, so it is given where staff can monitor her for 30 minutes afterward.

Breastfeeding

Very little of an intravenous iron complex reaches breast milk, because the molecules are large, and neither intravenous nor oral iron is a reason to interrupt breastfeeding. Her concern about supply is taken seriously. Severe anemia and exhaustion can reduce milk production, and her daughter's weight gain will be checked at the pediatric visit later this week. Treating the anemia is likely to help feeding more than any supplement would.

The Decision

The options were explained to Mrs. Nakamura and her husband together. She chose a single infusion of ferric derisomaltose, scheduled for the next day at the outpatient infusion center, because one visit fit her week and because she did not want to risk the nausea again. Her insurer covered it after a short prior authorization. She was told that she would likely feel better within one to two weeks, before the full hemoglobin rise.

The Family Plan

Her husband arranged to work from home for the first three days after the infusion. Her sister will visit on two afternoons to take the toddler to the park so she can rest. Until her dizziness resolves, she will feed the baby in a chair rather than in bed, and her husband will handle the first night feed with expressed milk so she can sleep a five-hour block. She was told to sit before standing and to call if the dizziness worsens or she feels faint.

Mood

Anemia and postpartum depression share symptoms, and severe fatigue makes both worse. Her Edinburgh Postnatal Depression Scale score today is 8, below the screening threshold, and she denies thoughts of self-harm. The scale will be repeated at her six-week visit.

Follow-Up

Hemoglobin is rechecked in two weeks, when a rise of at least 2 g/dL is expected, and hemoglobin and ferritin at her six-week visit. If hemoglobin has not risen, other causes such as ongoing bleeding or a coexisting deficiency will be investigated. She was told to call immediately for heavy bleeding, chest pain, fainting or shortness of breath at rest.

Conclusion

Mrs. Nakamura's anemia is common after a hemorrhage, but its timing makes it more than a laboratory problem. Oral iron taken on alternate days is a reasonable choice for many patients; for her, the speed of intravenous iron and the lower phosphate effect of ferric derisomaltose fit a week in which she will soon be alone with two young children. The plan pairs a single infusion with practical help at home and clear follow-up.

References

Stoffel, N. U., Cercamondi, C. I., Brittenham, G., Zeder, C., Geurts-Moespot, A. J., Swinkels, D. W., Moretti, D., & Zimmermann, M. B. (2017). Iron absorption from oral iron supplements given on consecutive versus alternate days and as single morning doses versus twice-daily split dosing in iron-depleted women: Two open-label, randomised controlled trials. The Lancet Haematology, 4(11), e524-e533. https://doi.org/10.1016/S2352-3026(17)30182-5

Van Wyck, D. B., Martens, M. G., Seid, M. H., Baker, J. B., & Mangione, A. (2007). Intravenous ferric carboxymaltose compared with oral iron in the treatment of postpartum anemia: A randomized controlled trial. Obstetrics & Gynecology, 110(2), 267-278. https://doi.org/10.1097/01.AOG.0000275286.03283.18

Wolf, M., Rubin, J., Achebe, M., Econs, M. J., Peacock, M., Imel, E. A., Thomsen, L. L., Carpenter, T. O., Weber, T., Brandenburg, V., & Zoller, H. (2020). Effects of iron isomaltoside vs ferric carboxymaltose on hypophosphatemia in iron-deficiency anemia: Two randomized clinical trials. JAMA, 323(5), 432-443. https://doi.org/10.1001/jama.2019.22450