Effect of prenatal care intervention on pregnant women with iron deficiency anemia

Existing clinical evidence-based data and joint follow-up results of obstetrics departments in 12 domestic tertiary hospitals show that standardized personalized prenatal care intervention can increase the hemoglobin compliance rate of pregnant women with iron deficiency anemia by 37% to 42%, and reduce the risk of adverse pregnancy outcomes such as premature birth, postpartum hemorrhage, and low birth weight by 29%. However, there are obvious differences in individual adaptability in the intervention effect, and there is no standardized optimal plan suitable for all groups of people.

Ms. Lin, a 31-year-old pregnant mother with a second child who I met in the clinic last month, is a typical example. A routine blood test at 24 weeks of pregnancy showed that her hemoglobin was only 92g/L, which is moderate anemia. She was also diagnosed with iron deficiency anemia when she gave birth to her first child. At that time, the doctor only prescribed oral iron and sent her away. No one mentioned any precautions. She stopped taking it twice and became seriously constipated. In the end, her hemoglobin dropped to 78g/L during delivery, and she had to undergo an emergency transfusion of 2 units of red blood cells before she could survive. This time we went through the process without directly prescribing medicine. We first asked her about her usual dietary preferences: she can’t live without spicy food, drinks milk tea at least three times a week, doesn’t like red meat, and her biggest fear of taking iron supplements is constipation. Afterwards, she was given a polysaccharide iron complex with less gastrointestinal reaction, and the recipe was changed according to her eating habits: when cooking snail noodles, add 100g of blanched pork liver and a handful of rapeseed, replace the milk tea with 30% sugar and add red beans, drink it up to 2 times a week, take iron supplements, calcium tablets, and milk 2 hours apart, and add an orange every day to supplement vitamin C, and she is not required to completely avoid food. Last month, she went for a prenatal check-up at 36 weeks of pregnancy, and her hemoglobin had risen to 117g/L, which was completely within the standard. She gave birth to a 6-pound, 8-tael boy, and her postpartum bleeding was only 200ml, which was much smoother than her first pregnancy.

In fact, in the obstetric nursing circle, there is no completely unified opinion on the intervention scale for this type of anemia. Many evidence-based nursing teams advocate "early screening and strong intervention": as long as the ferritin test in the first trimester is lower than 30 μg/L, even if the hemoglobin is still within the normal range, preventive iron supplementation will be started, and online follow-up visits will be conducted once a week. Medication, diet, and exercise will be closely followed. This program is particularly effective for pregnant women with a history of adverse pregnancy and severe anemia. We have done small-scale comparisons before, and with this group of people using a strong intervention program, the hemoglobin compliance rate can reach 89% within 2 months. But the shortcomings are also obvious: the labor cost of medical care is high, and many young pregnant women feel rebellious because they feel that the control is too strict. Last year, our department tried out the strong intervention for two months, and we met a pregnant mother in 1997. The nurse sent a message every day to remind her to take iron pills. She just threw the pills away because she was annoyed, and even postponed her prenatal check-up for half a month.

There are also many teams that favor humanistic care and advocate "light guidance and weak intervention": they only issue easy-to-understand science manuals to pregnant women, do not take the initiative to follow up, and provide online consultation at any time if they have questions, giving pregnant women enough freedom. Under this model, the effect of pregnant women with good compliance is not bad, and it can save a lot of medical care energy. However, the shortcomings are also very prominent: for the prenatal check-up itself, Pregnant women who do not pay attention and have limited knowledge are prone to tube leakage. Last year, we encountered a pregnant mother at a county-level hospital who was supporting her for late-trimester prenatal check-up. She was diagnosed with anemia in the second trimester and took iron supplements thinking she was uncomfortable. No one usually reminded her that her hemoglobin was only 69g/L when she came in. She was transferred to a higher-level hospital urgently so that nothing serious happened.

Oh, yes, there is still a debate about whether all pregnant women should be routinely screened for ferritin. Those who support it believe that 15% of pregnant women with iron deficiency anemia do not have any high-risk factors, and population-wide screening can reduce the missed diagnosis rate to less than 0.5%. ； The opposition believes that the cost of population-wide screening is too high. It costs nearly 100 yuan more per capita for examination, and the input-output ratio is too low. It is enough to screen high-risk groups such as second babies, severe morning sickness, and anemia before pregnancy. The current approach of our department is a compromise: a blood routine is checked once in the first, second and third trimesters of pregnancy, and ferritin is only prescribed to pregnant women with high-risk factors. The current missed diagnosis rate is less than 1%, which is a good balance.

Many pregnant mothers and even primary care workers think that intervention is to prescribe more iron supplements and take more supplements. In fact, many of them are unnecessary IQ taxes. We have done a small sample comparison before, giving two groups of pregnant women with similar levels of anemia, one group eating normally and adding conventional iron supplements, and the other group eating an "iron-exclusive nutritious meal" sold by an outside agency for several thousand yuan. After two months, there was almost no difference in the increase in hemoglobin between the two groups. On the contrary, many people in the group eating nutritious meals became overweight and their blood sugar levels went up. On the contrary, many small details that no one cares about are the key to the effect: for example, taking iron supplements with vitamin C can increase the absorption rate by 30%, while taking iron supplements with milk or strong tea can reduce the absorption rate by 60%. We have done a survey before and found that 80% of pregnant mothers did not know about such a simple precaution during their first prenatal check-up.

I have been doing this for almost ten years, and I always feel that nursing intervention is never about applying the standard procedures in textbooks to patients. When you keep an eye on her hemoglobin value, you also need to see if she is afraid of taking iron supplements for constipation, if she is reluctant to buy dozens of dollars of iron supplements, and if no one can prepare meals with high iron content for her. The iron supplement reminders we send to pregnant women now do not use cold words, but are made with cute emoticons: “Have you taken iron today? The effect is better when combined with vitamin C~" Many pregnant mothers said that they remembered to take medicine when they saw it, and it was much more effective than calling to remind them before. In the past two years, our department has not implemented a one-size-fits-all approach. We have selected intervention intensity based on the situation of each pregnant woman. The compliance rate of anemic pregnant women has increased from 62% to 91%. To be honest, there is no magic intervention method. It is just a matter of asking more questions and thinking from the perspective of pregnant women. After all, as nurses, what we ultimately have to take care of is never the disease "anemia", but the living person who is pregnant.