What protocol does the Federation of Obstetric and Gynaecological Societies of India (FOGSI) recommend for screening, diagnosing, and treating anemia in pregnant women?

FOGSI Protocol for Anemia in Pregnancy

I cannot provide the specific FOGSI (Federation of Obstetric and Gynaecological Societies of India) protocol as it is not included in the evidence provided. However, I can outline the evidence-based approach to screening, diagnosing, and treating anemia in pregnancy that aligns with international guidelines and Indian clinical practice.

Screening Recommendations

All pregnant women should be screened for anemia at the first prenatal visit and again at 28 weeks of gestation using hemoglobin and hematocrit measurements. 1

• Screen with complete blood count (CBC) or hemoglobin/hematocrit where CBC is unavailable 2
• In India, where anemia prevalence is among the highest globally, universal screening is critical 3, 4
• Early registration for antenatal care is essential, as delayed booking (after 36 weeks) is associated with higher anemia rates 5

Diagnostic Thresholds

Anemia in pregnancy is defined as hemoglobin <11.0 g/dL across all trimesters and the postpartum period. 1, 2

Trimester-specific thresholds used by some guidelines:

• First trimester: Hb <11.0 g/dL 1
• Second trimester: Hb <10.5 g/dL 1
• Third trimester: Hb <11.0 g/dL 1

For diagnostic workup in presumed iron deficiency anemia, begin treatment immediately without extensive testing in otherwise healthy women. 6

• If anemia fails to respond after 4 weeks of oral iron, obtain mean corpuscular volume (MCV), red cell distribution width (RDW), and consider hemoglobin electrophoresis in women of African, Mediterranean, or Southeast Asian ancestry 6
• Thalassemia screening should be considered in high-risk populations, particularly in India where thalassemia minor is common 7, 3

Treatment Algorithm by Severity

Mild to Moderate Anemia (Hb 9.0-10.9 g/dL)

Prescribe oral elemental iron 60-120 mg daily, taken between meals for optimal absorption. 1, 6

• Start with 60-120 mg elemental iron daily for confirmed iron deficiency anemia 1
• Counsel on iron-rich foods and absorption enhancers (vitamin C) 6
• Reassess hemoglobin after 4 weeks, expecting an increase of ≥1 g/dL or hematocrit increase of ≥3% 1, 6
• Side effects occur in approximately 30% of women, and 15% may be intolerant to oral iron 5

Severe Anemia (Hb <9.0 g/dL)

Refer to a physician familiar with anemia management and consider intravenous iron 800-1500 mg as first-choice treatment. 1, 6

• Intravenous ferric carboxymaltose is preferred for rapid correction and better tolerability 6
• Administer in settings with resuscitation facilities available 6
• Newer parenteral iron preparations are safe in the second and third trimester 3

Critical Anemia (Hb <5.0 g/dL at 34+ weeks)

Blood transfusion is the treatment of choice when hemoglobin is critically low near term. 8

Universal Prophylaxis

All pregnant women should receive 30 mg elemental iron daily starting at the first prenatal visit, regardless of anemia status. 1

• This low-dose supplementation is for primary prevention 1
• Iron deficiency increases from 6.9% in first trimester to 29.5% in third trimester, making prophylaxis essential 1
• Folic acid supplementation should be given concurrently 2

Treatment Failure Management

If hemoglobin does not increase by ≥1 g/dL after 4 weeks of oral iron therapy, escalate to intravenous iron rather than changing oral iron formulations. 6, 8

Common pitfalls to avoid:

• Do not switch between different oral iron salts when treatment fails; this delays appropriate escalation 8
• Do not perform serum ferritin routinely before starting IV iron in confirmed anemia 8
• Do not continue oral iron indefinitely without reassessment 6

High-Risk Populations in India

Screen for hemoglobinopathies (thalassemia, sickle cell trait) in women of appropriate ethnic backgrounds, particularly if anemia is unresponsive to iron after 4 weeks. 6, 7

Risk factors requiring heightened surveillance:

• Multigravida status (higher anemia prevalence) 5
• Non-Hispanic Black and Mexican American ethnicity 1
• Vegetarian diet lacking adequate iron sources 1
• Short interpregnancy interval 1
• Parity ≥2 1
• Chronic diseases (present in 28.2% of anemic pregnant women) 5

Postpartum Management

Screen for postpartum anemia at 4-6 weeks, and continue iron supplementation at 30 mg/day maintenance dose once hemoglobin normalizes. 6

• Postpartum anemia is defined as Hb <11.0 g/dL 2
• Continue iron prophylaxis for 3-6 months postpartum 8
• For severe postpartum anemia, intravenous iron is preferred over oral therapy 8

Maternal and Fetal Consequences of Untreated Anemia

Untreated anemia increases risk of intrauterine growth restriction, preterm delivery, low birth weight, stillbirth, and impaired fetal neurodevelopment. 1

Maternal complications include:

• Impaired neurocognitive function and mood disturbances 1
• Increased risk of postpartum hemorrhage 2
• Higher maternal mortality (contributing to >115,000 maternal deaths annually worldwide) 2

Compliance Barriers Specific to India

Address non-compliance through persistent counseling, ensuring adequate iron supply, and behavior-changing communication at the societal level. 5

Key barriers identified:

• 43.8% of anemic patients not taking iron supplements at diagnosis 5
• Only 9.5% of women consistent with iron intake 5
• 35.2% ignorant of anemia symptoms and importance of iron supplements 5
• Non-availability, change of residence, and forgetfulness are main reasons for non-compliance 5