What is the management approach for a pregnant female with normocytic normochromic anemia and mild polychromasia, with normal leukocyte (white blood cell) and platelet counts?

Management of Normocytic Normochromic Anemia with Mild Polychromasia in Pregnancy

In a pregnant female with normocytic normochromic anemia and mild polychromasia, oral iron supplementation at 60-120 mg/day should be initiated as first-line treatment, with follow-up hemoglobin assessment after 4 weeks to evaluate response. 1

Diagnostic Interpretation

The peripheral blood smear findings of normocytic normochromic anemia with mild polychromasia in a pregnant female suggest:

• Iron deficiency anemia (most common cause of anemia in pregnancy)
• The presence of polychromasia indicates active bone marrow response with reticulocyte production
• Normal leukocyte and platelet counts rule out bone marrow suppression disorders

Management Algorithm

Initial Treatment

1. Start oral iron supplementation at 60-120 mg/day 1
   • Iron-rich foods should be encouraged in the diet
   • Foods that enhance iron absorption (vitamin C-containing foods) should be recommended

Monitoring Response

1. Repeat hemoglobin/hematocrit after 4 weeks of treatment 1

   • Adequate response: Hemoglobin increase of ≥1 g/dL or hematocrit increase of ≥3%
   • Continue treatment until hemoglobin normalizes for pregnancy stage

2. If inadequate response after 4 weeks despite compliance:

   • Further evaluate with additional tests: MCV, RDW, serum ferritin 1
   • Consider alternative or coexisting causes:
     • Thalassemia minor or sickle cell trait (especially in women of African, Mediterranean, or Southeast Asian ancestry) 1
     • Anemia of chronic disease or infection 2
     • Malaria or parasitic infections in endemic areas 2

Dosage Adjustment

• Once hemoglobin normalizes for gestational age, decrease iron dose to 30 mg/day for maintenance 1
• Continue supplementation throughout pregnancy

Special Considerations

Severe Anemia

• If hemoglobin <9.0 g/dL or hematocrit <27.0%, refer to a physician specialized in anemia during pregnancy 1
• Intravenous iron may be considered for:
  • Severe iron deficiency anemia
  • Intolerance to oral iron
  • Lack of response to oral iron
  • Need for rapid correction of anemia in advanced pregnancy 3

Postpartum Management

• Continue iron supplementation if risk factors for postpartum anemia exist:
  • Anemia continued through third trimester
  • Excessive blood loss during delivery
  • Multiple birth 1
• Screen for anemia at 4-6 weeks postpartum in high-risk cases 1

Pitfalls to Avoid

1. Misdiagnosis: Normocytic anemia in pregnancy is often automatically attributed to iron deficiency, but could be due to chronic disease, infection, or hemoglobinopathies 2, 4

2. Inadequate dosing: Insufficient iron supplementation may not correct the anemia

3. Overlooking compliance issues: Gastrointestinal side effects often lead to poor compliance with oral iron therapy 5

4. Failure to follow up: Not reassessing hemoglobin levels after initiating treatment may miss non-responders who need further evaluation

5. Excessive iron: Continuing high-dose iron after hemoglobin normalization is unnecessary and may cause side effects

The presence of polychromasia in this case is a positive prognostic sign indicating active erythropoiesis and likely good response to iron therapy, provided iron deficiency is the underlying cause of the anemia.