In a 14‑week pregnant woman with isolated hemoglobin of 9.4 g/dL and otherwise normal findings, what is the appropriate management?

Management of Anemia at 14 Weeks Gestation with Hemoglobin 9.4 g/dL

Start oral ferrous sulfate 60-120 mg of elemental iron daily immediately as first-line treatment for this mild anemia in pregnancy. 1, 2

Rationale for Oral Iron as First-Line Treatment

This patient has mild anemia (Hb 9.4 g/dL falls in the 7-10.9 g/dL range) at 14 weeks gestation with otherwise normal findings. 3 The Centers for Disease Control and Prevention and American College of Obstetricians and Gynecologists both recommend making a presumptive diagnosis of iron deficiency anemia in non-acutely ill pregnant women and beginning oral iron treatment immediately without waiting for additional testing. 1, 2

Specific Dosing Regimen

• Prescribe 60-120 mg of elemental iron daily (typically as ferrous sulfate 325 mg tablets, which contain 65 mg elemental iron, taken 1-2 times daily). 1, 2, 4
• One 325 mg ferrous sulfate tablet twice daily provides 130 mg elemental iron and is within guideline recommendations. 4, 5
• Alternatively, a single daily dose of 65 mg elemental iron is nearly as effective with fewer gastrointestinal side effects and better compliance. 5

Why Not the Other Options

Blood transfusion (Option B) is not indicated because the hemoglobin of 9.4 g/dL does not meet criteria for severe anemia requiring transfusion. 1 The CDC recommends physician referral only when Hb is <9.0 g/dL or Hct <27.0%, and even then, transfusion is reserved for hemodynamically unstable patients or those with severe symptoms. 1

IV iron (Option C) is premature at this stage because the American College of Obstetricians and Gynecologists recommends considering intravenous iron only after oral iron fails to produce adequate response after 4 weeks of compliant treatment, or when oral iron is not tolerated. 2, 3 While IV ferumoxytol shows superior hemoglobin increases compared to oral iron in research studies, 6, 7 guidelines prioritize oral iron as first-line due to safety, cost-effectiveness, and accessibility. 2

Observation alone (Option D) is inappropriate because this patient has documented anemia requiring treatment, not just routine prophylaxis. 1, 2

Monitoring and Follow-Up Protocol

• Reassess hemoglobin or hematocrit after 4 weeks of treatment. 1, 2
• Expected response is an increase of ≥1 g/dL in hemoglobin or ≥3% in hematocrit. 1, 8
• If no response after 4 weeks despite confirmed compliance and absence of acute illness, perform additional testing including mean corpuscular volume, red cell distribution width, and serum ferritin. 1, 2
• Once hemoglobin normalizes for gestational age (≥11 g/dL), reduce iron dose to 30 mg/day for maintenance throughout pregnancy. 1, 2

Dietary Counseling

Provide guidance on iron-rich foods including meat, poultry, and fortified cereals, as well as factors that enhance iron absorption (vitamin C) and inhibit it (calcium, tea, coffee). 1, 2

Common Pitfalls to Avoid

• Do not wait for ferritin or other iron studies before starting treatment in an otherwise healthy pregnant woman with isolated anemia. 2
• Warn the patient about expected gastrointestinal side effects including dark stools, constipation, and epigastric discomfort, which are generally self-limited but can affect compliance. 8, 5
• Consider once-daily dosing instead of twice-daily if the patient experiences significant side effects, as once-daily 65 mg elemental iron is nearly as effective with better tolerability. 5
• Do not discontinue iron at delivery if anemia persists; continue supplementation postpartum. 8

When to Escalate Treatment

Switch to intravenous iron (ferric carboxymaltose preferred) if: 2, 3

• No hemoglobin response after 4 weeks of compliant oral iron therapy
• Intolerable gastrointestinal side effects preventing oral iron use
• Rapid iron repletion is needed for clinical reasons