What are the treatment options for anemia in pregnancy?

From the Guidelines

Treatment of anemia in pregnancy primarily involves iron supplementation, with oral iron being the first-line therapy, as recommended by the USPSTF 1. For mild to moderate anemia, ferrous sulfate 325 mg (containing 65 mg elemental iron) taken orally 1-3 times daily between meals is recommended. Alternative oral preparations include ferrous gluconate or ferrous fumarate. These supplements should be continued for 3 months after hemoglobin normalization to replenish iron stores. Side effects like constipation, nausea, and dark stools are common but can be managed by taking iron with food or reducing dosage. For severe anemia (hemoglobin <7 g/dL) or when oral therapy fails, intravenous iron formulations such as iron sucrose (300 mg per dose) or ferric carboxymaltose (up to 1000 mg per dose) may be necessary. In critical cases with hemoglobin below 6 g/dL or maternal compromise, blood transfusion might be required. Concurrent folic acid supplementation (400-1000 mcg daily) is important, especially in the first trimester. For non-iron deficiency anemias, treatment targets the underlying cause, such as vitamin B12 injections for B12 deficiency. Dietary counseling to increase iron-rich foods (lean meats, beans, fortified cereals) and vitamin C to enhance iron absorption is also essential. Some key points to consider in the treatment of anemia in pregnancy include:

• The usual dose of elemental iron per day is 60 to 120 mg 1.
• Prenatal vitamins often include a low dose of iron, with the usual dose prescribed in early pregnancy being 30 mg of elemental iron per day 1.
• Higher doses of iron (60 to 100 mg of elemental iron per day) may be prescribed in populations at increased risk for iron deficiency anemia 1.
• The Recommended Dietary Allowance for iron in pregnant women is 27 mg per day, according to the Institute of Medicine 1. Treatment is crucial as anemia in pregnancy increases risks of preterm birth, low birth weight, and maternal complications.

From the FDA Drug Label

Folic acid is effective in the treatment of megaloblastic anemias due to a deficiency of folic acid (as may be seen in tropical or nontropical sprue) and in anemias of nutritional origin, pregnancy, infancy, or childhood. Folic acid requirements are markedly increased during pregnancy, and deficiency will result in fetal damage

The treatment options for anemia in pregnancy include folic acid supplementation. Folic acid is usually indicated in the treatment of megaloblastic anemias of pregnancy, and its requirements are markedly increased during pregnancy.

• Key points:
  • Folic acid is effective in treating megaloblastic anemias due to folic acid deficiency, including those occurring during pregnancy.
  • Folic acid requirements are increased during pregnancy, and deficiency can result in fetal damage.
  • Folic acid should be used during pregnancy only if clearly needed, as studies cannot rule out the possibility of harm 2, 2.
• Additional considerations:
  • Vitamin B12 deficiency can also occur during pregnancy, and its requirements are increased during this period 3.
  • Patients with pernicious anemia should be informed that they will require monthly injections of vitamin B12 for the remainder of their lives 3.

From the Research

Treatment Options for Anemia in Pregnancy

• Oral iron therapy is the first-line treatment for iron deficiency anemia in pregnancy, as stated in the study 4.
• Intravenous iron therapy should be administered in cases of severe iron-deficiency anemia, intolerance of oral iron, lack of response to oral iron, or when there is a clinical need for rapid and efficient treatment of anemia 4.
• The American College of Obstetricians and Gynecologists recommends screening for anemia with a complete blood count in the first trimester and again at 24 0/7 to 28 6/7 weeks of gestation, and a trial of oral iron can be both diagnostic and therapeutic for mild anemia 5.
• For patients with iron deficiency anemia who cannot tolerate, cannot absorb, or do not respond to oral iron, intravenous iron is preferred, with contemporary formulations having rare allergic reactions 5.

Iron Supplementation Regimens

• Daily iron supplementation resulted in a 73% reduction in the incidence of anemia at term and a 67% reduction in iron deficiency anemia at term compared to no intervention/placebo 6.
• A study found that treatment with ferrous sulfate administered twice a week is an alternative for patients who are unable to adhere to daily treatment, with a cure rate of 34% compared to 47% for daily treatment 7.
• A pilot randomized trial investigated the impact of different doses of oral iron supplementation started early in pregnancy and found that a daily iron dosing schedule might give the best opportunity for delivering an adequate iron load during pregnancy in women without anemia 8.

Key Considerations

• Iron deficiency is the most common cause of anemia in pregnancy, and maternal anemia is associated with adverse fetal, neonatal, and childhood outcomes 5.
• Close surveillance during administration is recommended for all intravenous iron products due to the risk of anaphylactic reactions, although they are extremely rare with non-dextran products 4.
• The choice of iron supplementation regimen should be based on individual patient needs and circumstances, taking into account factors such as adherence, side effects, and the severity of anemia 7, 8.