A 26-Year-Old Woman, Gravida 1 Para 0, with a History

question 371

Multiple Choice

A 26-year-old woman, gravida 1 para 0, with a history of systemic lupus erythematosus (SLE) comes to the office for a follow-up visit.  The patient is at 22 weeks gestation and feels well.  She had mild nausea during the first trimester but reports no fatigue, joint or chest pain, or shortness of breath.  Her SLE has been quiescent for several years and she takes hydroxychloroquine.  The patient also takes a prenatal vitamin containing folic acid and iron daily.  She has never smoked and does not use alcohol or illicit drugs.
Temperature is 37 C (98.6 F) , blood pressure is 116/68 mm Hg, pulse is 74/min, and respirations are 14/min.  Physical examination shows no skin rash or oral ulcerations.  The lungs are clear to auscultation and heart sounds are normal.  Abdominal examination shows an appropriately sized gravid uterus with no tenderness.  The joints are nontender and there is no edema of the extremities.
Laboratory results are as follows:
Prepregnancy hemoglobin was 13.2 g/dL and at 8 weeks gestation was 12 g/dL.
Which of the following is the most appropriate next step in management of this patient?

• A)Close observation only
• B)Direct antiglobulin (Coombs) test
• C)Increase iron supplementation
• D)Lactate dehydrogenase and haptoglobin levels
• E)Serum vitamin B₁₂ and folate levels

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