How to manage severe anemia in pregnancy?

Management of Severe Anemia in Pregnancy

Severe anemia in pregnancy should be treated with oral iron supplementation at a dose of 60-120 mg of elemental iron per day, with intravenous iron therapy reserved for cases that fail to respond to oral treatment after 4 weeks despite compliance. 1

Diagnosis and Assessment

• Screen for anemia at the first prenatal visit and again at 24-28 weeks of gestation using hemoglobin concentration or hematocrit test 2
• Severe anemia in pregnancy is defined as hemoglobin <7.0 g/dL, requiring further investigation beyond routine iron supplementation 2
• Confirm iron deficiency anemia with serum ferritin measurement when possible (threshold value <30 μg/L) 3
• If the pregnant woman is not acutely ill, a presumptive diagnosis of iron deficiency anemia can be made and treatment begun immediately 1

Treatment Algorithm for Severe Anemia

First-Line Treatment: Oral Iron Therapy

• Prescribe 60-120 mg of elemental iron daily for severe anemia 1
• Consider intermittent dosing (every other day) to improve tolerability and adherence while maintaining effectiveness 2
• Counsel pregnant women about iron-rich foods and dietary factors that enhance iron absorption 1
• Monitor response with repeat hemoglobin/hematocrit testing after 4 weeks of treatment 1

When to Escalate Treatment

• If hemoglobin is less than 9.0 g/dL or hematocrit is less than 27.0%, refer to a physician familiar with anemia during pregnancy for further medical evaluation 1
• Consider intravenous iron therapy if any of the following occur 4, 3:
  • No response to oral iron after 4 weeks despite compliance
  • Intolerance to oral iron (severe gastrointestinal side effects)
  • Advanced pregnancy requiring rapid correction of anemia
  • Severe anemia (Hb <7.0 g/dL) requiring rapid correction

Intravenous Iron Options

• Ferric carboxymaltose is preferred due to better tolerability and rapid effectiveness 4, 3
• Iron sucrose is an alternative if ferric carboxymaltose is unavailable 4
• Administer IV iron in settings with resuscitation facilities available 4

Special Considerations

• Before switching to IV iron, confirm compliance with oral iron and rule out other causes of anemia unresponsive to iron therapy, such as thalassemia minor or sickle cell trait in women of African, Mediterranean, or Southeast Asian ancestry 1, 4
• For vegetarian women, iron requirements may be almost twice as high due to lower absorption of non-heme iron; consider higher supplementation doses 1
• In women with severe anemia who do not respond to iron therapy, evaluate for other causes including hemoglobinopathies, folate or B12 deficiency, or occult bleeding 5, 6

Postpartum Management

• For mild postpartum anemia, continue oral iron therapy 3
• For moderate to severe postpartum anemia (Hb <9.5 g/dL), consider intravenous iron therapy 4, 3
• Monitor hemoglobin levels at 4-6 weeks postpartum in women at risk for persistent anemia 1

Potential Complications and Prevention

• Severe anemia in pregnancy increases risk of maternal mortality, postpartum hemorrhage, preterm birth, and low birth weight 2, 5
• Delayed cord clamping at delivery can help prevent infant iron deficiency 5
• Continue iron supplementation throughout pregnancy and the postpartum period to prevent recurrence of anemia 1