What should the primary‑care clinician do for a pregnant patient with a hemoglobin of 10 g/dL and an imminent abortion?

Management of Anemia in Early Pregnancy with Imminent Abortion

Primary care should immediately initiate oral iron supplementation (60-120 mg elemental iron daily) to address the hemoglobin of 10 g/dL, and if the patient is Rh-negative, administer 50 μg of anti-D immunoglobulin after the abortion is complete. 1, 2

Immediate Assessment and Iron Supplementation

• A hemoglobin of 10 g/dL in early pregnancy meets the diagnostic threshold for anemia (defined as <11.0 g/dL in the first trimester) and requires treatment. 1, 3

• Begin oral iron therapy immediately with 60-120 mg of elemental iron daily, using iron sulfate, ferrous fumarate, or iron polymaltose complex. 1, 4 The evidence now supports that intermittent dosing (every other day) is as effective as daily dosing with fewer gastrointestinal side effects, though daily dosing remains standard. 1

• This hemoglobin level (10 g/dL) represents mild anemia and does not require transfusion or intravenous iron at this stage, as transfusion is reserved for hemoglobin <7 g/dL or cardiorespiratory compromise. 2, 5

Rh Immunoglobulin Administration

• If the patient is Rh-negative, administer 50 μg of anti-D immunoglobulin after the abortion is complete (whether spontaneous or induced). 2 This is critical because:

  • Complete spontaneous abortion carries a well-established risk of Rh alloimmunization 2
  • The 50 μg dose is appropriate for first-trimester pregnancy loss, as the volume of fetal cells is small 2
  • Failure to provide prophylaxis can result in hemolytic disease in future pregnancies 2

• The timing should be as soon as possible after the abortion is complete, ideally within 72 hours, though protection may extend beyond this window. 2

Monitoring and Follow-Up

• Recheck complete blood count 2-4 weeks after initiating iron therapy to confirm hemoglobin response (expected rise of approximately 1 g/dL per week with adequate treatment). 1, 4

• If hemoglobin fails to rise appropriately or the patient cannot tolerate oral iron, consider intravenous iron formulations such as iron sucrose, which have low rates of allergic reactions with contemporary preparations. 1, 6

• Continue iron supplementation until hemoglobin normalizes (>11 g/dL) and for at least 3 months thereafter to replenish iron stores, targeting ferritin levels of 30-50 ng/mL. 4

Clinical Context and Pitfalls

The hemoglobin of 10 g/dL, while meeting criteria for mild anemia, is associated with increased risks during pregnancy including preterm delivery and low birth weight if pregnancy were to continue. 3, 7 However, with imminent abortion, the immediate priorities shift to:

1. Preventing further anemia progression through iron supplementation 1
2. Preventing Rh alloimmunization if applicable 2
3. Monitoring for complications of the abortion itself

A common pitfall is failing to administer Rh immunoglobulin in threatened abortion with a viable fetus before 12 weeks. While some guidelines suggest this may be unnecessary, the consensus is that it is prudent to administer anti-D when there is heavy bleeding, abdominal pain, or gestational age near 12 weeks. 2 Since this patient has an imminent (not just threatened) abortion, prophylaxis is clearly indicated once the abortion completes. 2

Another pitfall is assuming that mild anemia does not require treatment. Even mild iron deficiency anemia in pregnancy should be corrected, as it increases maternal transfusion risk at delivery and is associated with adverse outcomes. 1, 3

Post-Abortion Care

• After the abortion is complete, continue iron supplementation for at least 3 months to replenish depleted iron stores, as pregnancy and blood loss both deplete maternal iron reserves. 4

• Counsel the patient that iron supplementation should ideally continue until any future pregnancy, as entering pregnancy with adequate iron stores reduces anemia risk. 4