What is the management for a pregnant woman at 35 weeks gestation with severe anemia (hemoglobin level of 7.8 g/dL)?

Management of Severe Anemia at 35 Weeks Gestation

A pregnant woman at 35 weeks with hemoglobin 7.8 g/dL requires urgent blood transfusion followed by high-dose oral iron supplementation and close monitoring, as this represents severe anemia with significant risk for maternal and fetal complications. 1

Immediate Management

Urgent blood transfusion is the first-line treatment for this patient, as hemoglobin below 7.0 g/dL (and your patient at 7.8 g/dL is very close) requires immediate intervention to prevent hemodynamic compromise. 1 While guidelines specifically cite <7.0 g/dL as the threshold, a hemoglobin of 7.8 g/dL at 35 weeks still represents severe anemia requiring aggressive management. 1, 2

• Transfuse 2-3 units of packed red blood cells, with each unit expected to raise hemoglobin by approximately 1.5 g/dL. 1
• Establish IV access immediately and prepare for potential emergency delivery if fetal distress develops, given the viable gestational age. 1
• Perform transfusion in a location with immediate access to operating room capabilities, as this is a viable pregnancy and complications may necessitate urgent delivery. 1
• Continuous maternal vital signs and fetal heart rate monitoring must be maintained throughout the transfusion. 1

Post-Transfusion Iron Therapy

After stabilization with blood transfusion, initiate therapeutic-dose oral iron at 60-120 mg elemental iron daily. 3, 1, 2 This is critical because transfusion alone does not address the underlying iron deficiency that will persist throughout the remainder of pregnancy and postpartum period.

• Continue this therapeutic dose throughout the remainder of pregnancy. 1
• Monitor hemoglobin response within 1-2 weeks, expecting an increase of at least 1 g/dL after 4 weeks of treatment. 3, 1
• Once hemoglobin normalizes for gestational age (≥10.5 g/dL in third trimester), decrease to maintenance dose of 30 mg/day. 3, 1

Diagnostic Workup

Investigate the underlying cause of severe anemia through additional laboratory testing:

• Perform hemoglobin electrophoresis if the patient is of African, Mediterranean, or Southeast Asian ancestry to rule out thalassemia or hemoglobinopathy. 1
• Obtain mean corpuscular volume (MCV), red cell distribution width (RDW), and serum ferritin to characterize the anemia. 3, 2
• Peripheral blood smear should be conducted to investigate morphologic abnormalities. 1

If anemia does not respond to iron treatment after 4 weeks (hemoglobin does not increase by 1 g/dL or hematocrit by 3%), further evaluation is needed, particularly for thalassemia minor or sickle cell trait in at-risk populations. 3

Obstetric Management Considerations

Administer corticosteroids for fetal lung maturity given the viable gestational age (35 weeks) and potential need for preterm delivery if maternal or fetal status deteriorates. 1

• Plan delivery timing carefully, balancing the severity of maternal anemia against fetal maturity. 1
• Severe anemia (hemoglobin <6 g/dL) is associated with poor pregnancy outcomes including prematurity, spontaneous abortions, low birth weight, and fetal deaths. 4
• At 35 weeks, if maternal condition stabilizes after transfusion, aim for delivery at 37-39 weeks to optimize outcomes. 1

Nutritional Counseling

Counsel the patient on iron-rich foods (red meat, poultry, fish, legumes, fortified cereals) and absorption enhancers (vitamin C-rich foods like citrus fruits, tomatoes, bell peppers). 3, 1

• Advise avoidance of iron absorption inhibitors such as tea, coffee, and calcium supplements taken simultaneously with iron. 1
• Emphasize compliance with iron supplementation, as dietary changes alone cannot correct severe iron deficiency anemia. 3

Common Pitfalls to Avoid

• Do not rely on oral iron alone without transfusion in severe anemia at this gestational age—the risk of maternal decompensation during labor and delivery is too high. 1
• Do not delay transfusion while waiting for laboratory workup; transfuse first, then investigate the cause. 1
• Do not stop iron supplementation once hemoglobin normalizes; continue at maintenance dose (30 mg/day) through delivery and postpartum period. 3
• Do not assume all severe anemia is iron deficiency—hemoglobinopathies, folate deficiency, and other causes must be ruled out, especially if there is no response to iron therapy. 3, 2