In a 14‑week pregnant woman with otherwise normal findings and a hemoglobin of 9.4 g/dL, what is the most 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 without waiting for additional testing. 1

Rationale for Oral Iron as First-Line Treatment

At 14 weeks gestation with hemoglobin 9.4 g/dL, this patient has mild anemia (defined as Hb 10-10.9 g/dL, though she falls just below this threshold at 9.4 g/dL). 2 The American College of Obstetricians and Gynecologists recommends making a presumptive diagnosis of iron-deficiency anemia and beginning treatment immediately in non-acutely ill pregnant women without waiting for confirmatory laboratory tests, as delaying therapy can lead to worsening anemia and adverse pregnancy outcomes. 1

Why Not the Other Options?

Blood Transfusion (Option B) - Not Indicated

• Blood transfusion is not indicated in stable pregnant patients with hemoglobin around 9 g/dL who have no active bleeding or hemodynamic instability, as this level does not meet established transfusion criteria. 1
• Referral to a physician for further evaluation is only recommended when hemoglobin falls below 9.0 g/dL or hematocrit below 27.0%. 3

IV Iron (Option C) - Reserved for Specific Situations

• Intravenous iron should be considered only after oral iron failure, intolerance to oral preparations, or when rapid correction is needed. 1
• Before switching to IV iron, you must confirm compliance with the oral regimen and rule out other causes of iron-refractory anemia. 1
• Ferric carboxymaltose is the preferred IV option when indicated due to rapid effectiveness and better tolerability. 1, 2

Observation (Option D) - Inappropriate

• Observation alone is inappropriate because all pregnant women should receive at least 30 mg/day of elemental iron starting at the first prenatal visit regardless of anemia status. 2
• With documented anemia, higher therapeutic doses of 60-120 mg/day are required, not observation. 1

Specific Treatment Protocol

Prescribe oral ferrous sulfate providing 60-120 mg of elemental iron daily. 1, 2 This is the standard therapeutic dose for mild to moderate anemia in pregnancy, which is higher than the 30 mg/day prophylactic dose given to all pregnant women. 3, 1

Concurrent Dietary Counseling

• Provide counseling on iron-rich foods (meat, poultry, fortified cereals) and factors that enhance iron absorption. 1
• Vegetarian women may require nearly double the iron supplementation due to lower absorption of non-heme iron from plant sources. 1

Expected Side Effects

• Warn the patient about gastrointestinal side effects including darkening of stool, constipation, nausea, and gastrointestinal discomfort, which are generally self-limited. 4
• Advise not to take iron within 2 hours of tetracycline antibiotics if prescribed, as iron interferes with tetracycline absorption. 4

Monitoring Response to Treatment

Reassess hemoglobin or hematocrit after 4 weeks of treatment. 1

Expected Response

• The expected response is an increase of ≥1 g/dL in hemoglobin or ≥3% in hematocrit. 1
• Once hemoglobin normalizes for gestational age, reduce the iron dose to 30 mg/day for maintenance throughout pregnancy. 1

If Treatment Fails

• If there is 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
• In women of African, Mediterranean, or Southeast Asian ancestry, mild anemia unresponsive to iron therapy may be due to thalassemia minor or sickle cell trait. 3
• At that point, consider switching to intravenous iron therapy. 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for ferritin levels or other confirmatory tests in a non-acutely ill pregnant woman—start presumptive treatment immediately. 1
• Do not prescribe excessive doses thinking more is better; doses above 120 mg/day increase side effects without improving absorption due to the hepcidin-ferroportin regulatory pathway that limits gastrointestinal iron uptake. 5
• Do not stop iron supplementation once hemoglobin normalizes; continue at maintenance dose (30 mg/day) throughout pregnancy and postpartum to prevent recurrence. 1, 2