What is the first line treatment for Hemoglobin (Hgb) anemia in pregnancy?

From the Guidelines

The first line treatment for hemoglobin anemia in pregnancy is oral iron supplementation, typically with ferrous sulfate 325 mg taken once or twice daily (providing 65 mg elemental iron per tablet). This treatment approach is based on the most recent and highest quality evidence available, which emphasizes the importance of iron supplementation in pregnant women to improve maternal health and birth outcomes 1.

Key Considerations for Treatment

• Treatment should continue throughout pregnancy and for at least 3 months postpartum to replenish iron stores.
• Iron should be taken on an empty stomach with vitamin C (such as orange juice) to enhance absorption.
• It is recommended to take iron at least 2 hours apart from calcium supplements, antacids, or caffeine, which can reduce absorption.
• Common side effects like constipation, nausea, and dark stools can be managed by taking iron with food if necessary, though this reduces absorption.

Alternative Treatment Options

For women who cannot tolerate oral iron or have severe anemia (hemoglobin <7 g/dL), intravenous iron formulations may be considered 1. This approach is supported by evidence that highlights the effectiveness of intravenous iron in treating iron deficiency anemia in pregnant women.

Importance of Iron Supplementation

Adequate iron is crucial during pregnancy as blood volume expands by approximately 50%, increasing iron requirements substantially. Iron supplementation works by providing the essential building blocks for hemoglobin synthesis, allowing the body to produce more red blood cells to carry oxygen to maternal and fetal tissues. The current evidence, although insufficient to recommend specific screening tests, supports the use of measurement of serum hemoglobin or hematocrit as the first step in diagnosing iron deficiency anemia in pregnant women 1.

From the FDA Drug Label

The usual therapeutic dosage in adults and children (regardless of age) is up to 1 mg daily. In the presence of alcoholism, hemolytic anemia, anticonvulsant therapy, or chronic infection, the maintenance level may need to be increased. 0.8 mg for pregnant and lactating women, but never less than 0. 1 mg/day.

The first line treatment for Hemoglobin (Hgb) anemia in pregnancy is folic acid at a dose of 0.8 mg daily 2.

• Key considerations:
  • Doses greater than 0.1 mg should not be used unless anemia due to vitamin B12 deficiency has been ruled out or is being adequately treated with a cobalamin.
  • Patients should be kept under close supervision and adjustment of the maintenance level made if relapse appears imminent.
• Special populations:
  • Pregnant women have a higher requirement for folic acid, and deficiency can result in fetal damage 2.

From the Research

Hgb Anemia in Pregnancy

• Hgb anemia in pregnancy is a common condition that can have significant effects on both the mother and the fetus 3, 4, 5.
• The first line treatment for Hemoglobin (Hgb) anemia in pregnancy is oral iron supplementation, which is recommended for mild anemia 3, 5.
• According to the American College of Obstetricians and Gynecologists, screening for anemia with a complete blood count is recommended in the first trimester and again at 24 0/7 to 28 6/7 weeks of gestation 3.
• New evidence suggests that intermittent dosing of oral iron is as effective as daily or twice-daily dosing with fewer side effects 3.
• For patients with iron deficiency anemia who cannot tolerate, cannot absorb, or do not respond to oral iron, intravenous iron is preferred 3.

Diagnosis and Treatment

• A hemoglobin concentration of less than 11.0 g/dL in the first trimester and less than 10.5 or 11.0 g/dL in the second or third trimester is considered anemia 3, 4.
• Mild anemia, with a hemoglobin of 10.0 g/dL or higher and a mildly low or normal mean corpuscular volume (MCV) is likely iron deficiency anemia 3.
• A trial of oral iron can be both diagnostic and therapeutic for mild anemia 3.
• Severe anemia may have adverse effects on the mother and the fetus, including prematurity, spontaneous abortions, low birth weight, and fetal deaths 4, 6.

Prevalence and Impact

• The global prevalence of anemia in pregnancy is estimated to be approximately 41.8% 5.
• Undiagnosed and untreated iron deficiency anemia can have a great impact on maternal and fetal health, including fatigue, reduced working capacity, and increased risk of adverse outcomes 5.
• Early recognition and treatment of iron deficiency anemia is fundamental to preventing adverse maternal-fetal outcomes 5.