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WOMEN’S HEALTH GUIDLINE ANEMIA IN …-acog anemia in pregnancy treatment

4/23/16njm
WOMEN'S HEALTH GUIDLINE
ANEMIA IN PREGNANCY
MANAGEMENT GUIDELINE
Discussion: PAGE:
Background 2
Diagnosis 2
Management Protocol:
Therapy
o Oral 2
o Parenteral 3
o Screening 4
References 5
Original by George Gilson MD
ANEMIA IN PREGNANCY
MANAGEMENT GUIDELINES
Background
Anemia is very common in pregnant women, and 99% of such women in the United States are
iron deficient. Iron deficiency is seen frequently because of prior menstrual losses, prior
pregnancy related losses, and nutritional factors. As a result of a dilutional effect, the normal
hemoglobin (Hgb) and hematocrit Hct) for third trimester pregnant women at sea level is 11 g/dL
or 33+3 %, but anemia varies by trimester:
1st trimester below Hgb 11 g/dL Hct 33%
2nd trimester below Hgb 10.5 g/dL Hct 32%
3rd trimester below Hgb 11 g/dL Hct 33%
To standardize care we have chosen an oral treatment cut-off of Hgb < 10.5 and a parenteral
cut-off of Hgb < 6 (see therapy below)
Diagnosis
Sophisticated studies are usually not needed in the work up of a woman with pregnancy
associated anemia. The CBC that revealed the low hemoglobin/hematocrit will usually also
reveal a low MCV (microcytosis), a low MCH (hypochromia), and an increased RDW
(anisocytosis), characteristic of iron deficiency. Women with mild (or acute) anemia may not yet
have these typical red cell morphologic changes however.
The most sensitive and specific test for iron deficiency during pregnancy is a low serum ferritin,
which reflects total body iron stores. Normal values are 40-200 ng/mL. Serum iron, TIBC
(transferrin), and the per cent transferrin saturation, are all less accurate indices during
pregnancy. Hemoglobin electrophoresis should be reserved for women who, on the basis of
their ethnicity or family history, are suspected of having a hereditary hemoglobinopathy (e.g.,
thalassemia, sickle cell disease, etc.).
Management Guidelines
A. Oral Iron Therapy
Most women with iron deficiency can be treated with oral iron. Ferrous sulfate 325 mg contains
57 mg of elemental iron, and is the most efficient form; it is given once or twice daily. The
evidence is unclear as to the value of adding ascorbic acid. Oral iron commonly causes
gastrointestinal symptoms. These are usually dose dependent, but may be severe enough that
women will not, or cannot, adhere to their regimen, even with stool softeners and/or acid
reducing agents. Slow-release iron formulations may prevent gastric irritation, but not
constipation, and are significantly more expensive.
Ferrous gluconate causes fewer GI symptoms, but it only has 34 mg of elemental iron. Liquid
formulations of ferrous sulfate (2 mL = 50 mg of elemental iron) are available, and may be more
acceptable to women who can't take pills. Stools will become black after taking iron, and asking
about stool color is a good way to check adherence to therapy.
To see if the patient is responding to (or taking) therapy, a reticulocyte count may be obtained 7
days after starting treatment. The normal value is 1.0-2.4%, and it should rise to at least 4-5%.
A rise in the hemoglobin or hematocrit will usually not occur until 3-4 weeks. It may also be
prudent to prescribe supplemental folic acid, at least 1 mg daily, as this nutrient will also
commonly be deficient in women who are iron deficient.
To recap:
When to treat orally?
Hgb < 10.5 g/mL
This guiBde.liPneairsednesteigrnaeldIfroor ngenTehraelruaspe yfor most patients but may need to be adapted
to meet the special needs of a specific patient as determined by the patient's provider. 1
Anemia may become severe enough to cause symptoms (fatigue, tachycardia, etc.). Since
acute post partum hemorrhage is such a common event (approximately 5 per cent of births),
this has the potential to becoming a life-threatening condition.
Fetal growth and oxygenation will usually not be affected until the maternal hemoglobin is less
than 6 g/mL however.
On the other hand, maternal morbidity and mortality is noted at a maternal hemoglobin less than
7 g/mL. In symptomatic or worrisome cases, where adherence is a limiting factor, parenteral
iron therapy may be considered sooner.
There are 3 parenteral iron therapy options available in the United States at the present time:
iron dextran, ferric gluconate, and iron sucrose. Iron dextran is no longer widely used because
of its significant risk of anaphylaxis (0.6%), or other hypersensitivity reactions (0.2-3%). It is also
usually given intramuscularly, and is painful, can cause skin discoloration, and is unpredictably
absorbed. Ferric gluconate and iron sucrose are both given intravenously, and are safe and
effective alternatives, although they are somewhat more expensive. Iron sucrose has the lowest
rate of serious adverse reactions (anaphylaxis 0.002%, hypersensitivity 0.005%), and so is our
drug of choice.
Who to treat:
-Initiate Oral Fe++ at Hgb treat once a day
Hgb < 8 ->treat twice a day
-Initiate IV Fe++ sucrose at Hgb

How to prevent anaemia in pregnancy?Encourage breast feeding of infants.Encourage exclusive breast feeding of infants (without supplementary liquid, formula, or food) for 4-6 months after birth.When exclusive breast feeding is stopped, encourage use of an additional source of iron (approximately 1 mg/kg per day of iron), preferably from supplementary foods.More items...