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 Maternal-Fetal Benefits

• Iron deficiency anemia during pregnancy increases the risk of preterm birth and low birth weight 2
• Iron is essential for fetal brain development and cognitive abilities of the newborn 2
• Children born to iron-deficient mothers will start their lives suffering from iron deficiency or even IDA 2
• Prophylactic iron supplementation likely results in a large reduction in maternal anemia during pregnancy (NNT = 10) 3

Why Other Options Are Less Appropriate at This Visit

Tdap Vaccine (Option B)

• While the ACOG recommends Tdap vaccine between 27-36 weeks gestation, this patient is at 28 weeks and just entering the recommended window 1
• Tdap can be administered at this visit or any subsequent visit through 36 weeks, making it less time-sensitive than ensuring ongoing iron supplementation 1

Calcium Supplementation (Option D)

• Calcium supplementation (1.0-1.5 g daily) reduces preeclampsia risk by approximately 50%, particularly in populations with low dietary calcium intake 1, 4
• However, calcium should ideally be initiated at the first antenatal care visit or at 20 weeks' gestation 4
• At 28 weeks, this patient has already missed the optimal initiation window, though late supplementation still provides benefit 4
• Calcium is not universally recommended for all pregnant women like iron, but rather targeted to specific populations 1

Influenza Vaccine (Option A)

• While influenza vaccination is recommended during pregnancy, it is seasonal and not universally applicable at every antenatal visit 1
• The question states "everything is normal," suggesting routine preventive care rather than seasonal interventions

Clinical Implementation Considerations

Iron Dosing Strategy

• If anemia develops during pregnancy, the dose should be increased to 60-120 mg/day 1
• If hemoglobin normalizes after treatment, the iron dose should be decreased back to 30 mg/day 1
• The ACOG recommends screening for anemia at the first prenatal visit and using stage-specific criteria throughout pregnancy 1

Common Pitfall to Avoid

• Do not delay or withhold iron supplementation in non-anemic pregnant women—the goal is prevention of iron deficiency anemia, not just treatment of existing anemia 1, 3
• Prophylactic supplementation may improve pregnancy outcomes when the mother is iron deficient, and universal supplementation ensures no woman is missed 5