In a 19-year-old primigravida at 8 weeks gestation with hemoglobin 8 g/dL, what is the next step in management?

Management of 19-Year-Old Primigravida at 8 Weeks with Hemoglobin 8 g/dL

Immediately initiate therapeutic oral iron supplementation at 60-120 mg elemental iron daily, as this represents moderate anemia requiring treatment beyond routine prophylaxis. 1, 2

Immediate Therapeutic Intervention

• Start oral iron at 60-120 mg elemental iron daily (not the routine 30 mg prophylactic dose) since hemoglobin of 8 g/dL constitutes moderate anemia in the first trimester 1, 2
• This hemoglobin level falls below the mild anemia threshold (10.0-10.9 g/dL in first trimester) and requires therapeutic rather than prophylactic dosing 2
• Counsel the patient on consuming iron-rich foods and absorption enhancers (vitamin C-containing foods) while avoiding tea, coffee, and calcium supplements near iron intake 1

Critical Diagnostic Workup

Obtain baseline laboratory studies to identify the underlying cause and guide management:

• Complete blood count with indices (MCV, MCH) to differentiate iron deficiency from other causes 1
• Serum ferritin to confirm iron deficiency (target <30 µg/L in reproductive-age women) 1, 3
• Red cell distribution width (RDW) to assess heterogeneity of red cell size 1
• Peripheral blood smear if indices suggest microcytic anemia 2
• Consider hemoglobin electrophoresis if patient is of African, Mediterranean, or Southeast Asian ancestry to rule out thalassemia or hemoglobinopathy, particularly if anemia fails to respond to iron therapy 1, 4

Follow-Up Assessment Timeline

• Recheck hemoglobin in 4 weeks to assess response to therapy 1
• Expect hemoglobin to increase by at least 1 g/dL after 4 weeks of compliant iron supplementation 1, 2
• If hemoglobin fails to increase by 1 g/dL despite documented compliance and absence of acute illness, proceed with additional testing (MCV, RDW, serum ferritin) to investigate non-iron causes 1

When to Escalate Care

Refer to a physician specialist if: 1

• Hemoglobin remains below 9.0 g/dL or drops further despite treatment
• No response to 4 weeks of therapeutic oral iron with documented compliance
• Evidence of thalassemia minor or hemoglobinopathy on testing
• Patient develops symptoms of severe anemia (dyspnea, tachycardia, chest pain)

Maintenance Strategy

• Once hemoglobin normalizes for gestational age (typically >11 g/dL in first trimester), reduce iron dose to 30 mg/day for maintenance throughout pregnancy 1, 2
• Continue monitoring hemoglobin at routine prenatal intervals (24-28 weeks) 2
• Maintain iron supplementation through delivery and postpartum period if anemia persisted into third trimester 1

Common Pitfalls to Avoid

• Do not use only prophylactic 30 mg/day dosing for hemoglobin of 8 g/dL—this requires therapeutic 60-120 mg/day 1, 2
• Do not delay treatment while awaiting laboratory results; begin therapeutic iron immediately based on hemoglobin alone 1
• Do not assume simple iron deficiency without baseline testing, as thalassemia trait can present identically and will not respond to iron 1, 4
• Do not continue high-dose iron indefinitely once hemoglobin normalizes, as excessive iron supplementation with normal stores is potentially harmful 3
• At 8 weeks gestation with hemoglobin 8 g/dL, transfusion is not indicated unless the patient is symptomatic or hemodynamically unstable 4, 5