What is the most appropriate choice for a prima gravida (first-time pregnant woman) at 28 weeks gestation with normal antenatal appointments to contribute to her health and wellness?

Oral Iron Supplementation is the Most Appropriate Choice

For a prima gravida at 28 weeks with normal antenatal findings, oral iron supplementation (30 mg/day elemental iron) is the most appropriate intervention, as the CDC recommends universal iron supplementation starting at the first prenatal visit for all pregnant women regardless of anemia status to prevent iron deficiency anemia and optimize maternal-fetal outcomes. 1

Rationale for Prioritizing Iron Supplementation

Universal Recommendation for All Pregnant Women

• The CDC recommends that all pregnant women receive low-dose oral iron supplementation (30 mg/day elemental iron) starting at the first prenatal visit, regardless of whether anemia is present 1
• For women without documented anemia, 30-40 mg elemental iron daily is adequate 1
• Iron supplementation should continue through delivery and be reassessed postpartum at 4-6 weeks 1

Critical Importance for Fetal Development

• Iron is mandatory for normal fetal brain development, and iron deficiency may have deleterious effects on intelligence and behavioral development 2
• Iron deficiency anemia during pregnancy increases risk of preterm delivery and low birth weight 2
• Prophylactic iron supplementation results in a large reduction in maternal anemia during pregnancy (NNT = 10) 3

Why Not the Other Options?

Tdap Vaccine (Option B)

• While the ACOG recommends Tdap vaccine between 27-36 weeks gestation 1, this patient is at 28 weeks and could receive it
• However, iron supplementation takes priority because it should have been initiated at 10 weeks (first prenatal visit) and represents an ongoing daily intervention throughout pregnancy 1
• Tdap is a one-time intervention that can be administered at any visit between 27-36 weeks 1

Calcium Supplements (Option D)

• Calcium supplementation (1.0-1.5 g daily) reduces preeclampsia risk by approximately 50%, particularly in low dietary calcium populations 1, 4
• The WHO recommends initiating calcium at the first antenatal visit and continuing until delivery 4
• However, calcium is not the primary concern for this patient with normal antenatal findings 1
• Calcium supplementation is most beneficial in populations with low dietary calcium intake 1, 4

Influenza Vaccine (Option A)

• While influenza vaccination is recommended during pregnancy, it is seasonal and not universally applicable year-round
• Iron supplementation represents a more fundamental nutritional requirement that affects all pregnant women 1

Clinical Implementation Considerations

Dosing Strategy

• Start with 30-40 mg elemental iron daily for women without documented anemia 1
• If anemia develops, increase the dose to 60-120 mg/day 1
• If hemoglobin normalizes, decrease back to 30 mg/day 1

Common Pitfall to Avoid

• Do not delay iron supplementation waiting for anemia to develop - the goal is prevention, not treatment 1
• Iron supplementation consistently increases serum ferritin and hemoglobin while reducing the prevalence of iron deficiency anemia 2
• Women receiving intermittent iron supplementation have fewer side effects than daily supplementation, but daily dosing provides better opportunity for delivering adequate iron load 5, 6