In a 38‑week‑gestation pregnant woman with hemoglobin 10.1 g/dL and transferrin saturation 24%, what is the recommended treatment?

Treatment of Anemia at 38 Weeks Gestation with Hemoglobin 10.1 g/dL and Transferrin Saturation 24%

Start therapeutic oral iron supplementation immediately at 60–120 mg elemental iron daily without waiting for additional confirmatory tests, and recheck hemoglobin in 4 weeks to assess response. 1

Immediate Management

• Begin oral ferrous sulfate 325 mg (65 mg elemental iron) once or twice daily to achieve the therapeutic range of 60–120 mg elemental iron per day, which is required for confirmed anemia rather than the prophylactic 30 mg dose. 1

• The hemoglobin of 10.1 g/dL meets diagnostic criteria for anemia in the third trimester (threshold <10.5 g/dL), and the transferrin saturation of 24% (normal >20%) suggests iron deficiency as the underlying cause. 1, 2

• Do not delay treatment while awaiting serum ferritin or additional iron studies in this stable patient at 38 weeks gestation, as postponing therapy can worsen anemia and increase peripartum transfusion risk. 1

Dietary Counseling

• Counsel the patient to consume iron-rich foods including red meat, poultry, fish, legumes, and fortified cereals, along with vitamin C-rich foods (citrus fruits, tomatoes, peppers) to enhance iron absorption. 1

• This dietary approach complements but does not replace therapeutic iron supplementation at this hemoglobin level. 1

Monitoring Strategy

• Recheck hemoglobin or hematocrit 4 weeks after initiating therapy to confirm adequate response, defined as an increase of ≥1 g/dL in hemoglobin or ≥3% in hematocrit. 1

• Given that delivery is imminent at 38 weeks, obtain a complete blood count within 1–2 weeks to ensure hemoglobin is trending upward before labor, as maternal anemia increases transfusion risk at delivery. 2

Peripartum Considerations

• This hemoglobin level (10.1 g/dL) does not require blood transfusion, as transfusion thresholds in stable obstetric patients are reserved for hemoglobin <7 g/dL or hemodynamic instability with active bleeding. 1

• Ensure that the obstetric anesthesia team is aware of the anemia, as most anesthetists require a platelet count ≥75 × 10⁹/L (not hemoglobin-dependent) for neuraxial anesthesia, though hematologists consider ≥50 × 10⁹/L adequate for cesarean section. 3

• Prepare for potential postpartum hemorrhage by having the patient's blood type and screen current, and consider cell salvage availability if cesarean delivery is planned, as anemia increases the clinical impact of any blood loss. 3

Management of Iron-Refractory Anemia

• If hemoglobin fails to rise by ≥1 g/dL after 4 weeks of confirmed adherence to oral iron, obtain mean corpuscular volume (MCV), red cell distribution width (RDW), and serum ferritin to evaluate for alternative causes. 1

• Consider hemoglobinopathies (thalassemia minor, sickle cell trait) if anemia persists despite adequate oral iron, particularly in women of African, Mediterranean, or Southeast Asian ancestry. 1

• Verify medication adherence before labeling therapy as failed, as gastrointestinal side effects (nausea, constipation) frequently lead to discontinuation of oral iron. 2

Intravenous Iron Indications

• Intravenous iron is not indicated at this time unless the patient cannot tolerate oral iron, has documented malabsorption, or fails to respond after 4 weeks of confirmed adherence. 1

• If IV iron becomes necessary, ferric carboxymaltose is preferred due to rapid effectiveness and better tolerability compared to older formulations. 1

Dose Adjustment After Delivery

• Once hemoglobin normalizes to ≥10.5 g/dL postpartum, reduce oral iron to the prophylactic dose of 30 mg elemental iron daily but continue supplementation throughout the postpartum period to replenish iron stores. 1

• Screen for anemia at 4–6 weeks postpartum using hemoglobin or hematocrit, as this patient has multiple risk factors: third-trimester anemia and potential peripartum blood loss. 1

Common Pitfalls to Avoid

• Do not use the prophylactic 30 mg/day dose to treat confirmed anemia; the therapeutic dose of 60–120 mg/day is required for adequate hemoglobin repletion. 1

• Do not postpone iron therapy while awaiting ferritin results in a stable pregnant woman with hemoglobin 10.1 g/dL at 38 weeks, as time to delivery is limited. 1

• Do not discontinue iron supplementation once hemoglobin normalizes postpartum; instead reduce to prophylactic dosing and continue for several months to restore iron reserves. 1

• Do not overlook evaluation for hemoglobinopathies if anemia remains refractory after 4 weeks in ethnically at-risk populations. 1