The document provides guidelines for managing iron deficiency in pregnancy. It defines iron deficiency anemia thresholds during different trimesters and postpartum. Iron deficiency anemia prevalence is 30-40% in pregnant women. Effects include increased risk of infections, poor work performance, and disturbances in cognition for mothers as well as preterm birth, low birth weight, and increased risk of iron deficiency in infants. Diagnosis involves clinical exams and laboratory tests like complete blood count and serum ferritin. Prevention focuses on universal iron supplementation. Management includes dietary advice, oral iron supplementation, parenteral iron for non-responders or intolerant women, and blood transfusion in rare severe cases.

1. Guidelines on management of
iron deficiency in pregnancy
British Committee for Standards in Haematology
2012.
Aboubakr Elnashar, Egypt
Aboubakr Elnashar

2. 1. DEFINITION
2. PREVALENCE
3. EFFECTS
4. DIAGNOSIS
5. PREVENTION
6. MANAGEMENT
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3. 1. DEFINITION
 1st T:
<11g/dL
(WHO, 2001)
2nd and 3rd T:
<10.5 gm
Postpartum:
<10 gm
{relative plasma expansion being particularly marked
in the second trimester}
MildModerateSevereAdam , 2005
9-117-9<7Hgb g/dl
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4. 2. PREVALENCE
IDA:
Most common cause
30- 40% pregnant women
(WHO, 2008).
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5. 3. EFFECTS
Maternal
{immune function}
1. Increased susceptibility or severity of infections
(Eliz et al, 2005)
2. Poor work capacity and performance
(Haas et al, 2001)
3. Disturbances of postpartum cognition and
emotions
(Beard et al, 2005).
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6. Pregnancy outcome
1. PTD
(Scholl et al, 1994)
2. Low birth wt
(Cogswell et al, 2003)
3. Placental abruption
4. Increased peripartum blood loss
(Arnold et al, 2009).
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7. Fetus:
protected from the effects of iron deficiency by
upregulation of placental iron transport proteins
(Gambling et al, 2001)
Infant:
increases the risk of iron deficiency in the first 3
months of life
(Puolakka et al, 1980, Colomer et al, 1990).
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8. 4. DIAGNOSIS
Clinical
usually nonspecific, unless the anaemia is severe.
1. Fatigue: most common symptom.
2. Pallor, weakness, headache, palpitations,
dizziness, dyspnoea and irritability.
3. Feel colder than normal {Impair temperature
regulation}
4. Rarely pica develops, where there is a craving for non-
food items such as ice and dirt.
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9.  Laboratory tests
1. CBC:
At booking
At 28 w
(NICE, 2008).
low Hb, MCV, MCH, and MCHC
Blood film:
microcytic hypochromic red cells
characteristic ‘pencil cells’.
N.B: microcytic, hypochromic indices may
also occur in haemoglobinopathies.
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10. H=hypochromic RBC; p=pencil RBC;T=target RBC; M=microcytic RBC
The Lancet 2000;355:1260
Iron Deficiency Anemia
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11. 2. Serum ferritin
Accurately reflects iron stores in the absence of
inflammatory change.
≤ 15 μg/l: iron depletion
≤ 30 μg/l: early iron depletion which will worsen
unless treated: Treatment should be considered
(van den Broek et al, 1998).
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12. Indications for assessment of serum ferritin
I. Anaemic women where estimation of iron stores is
necessary
1. Known Haemoglobinopathy
2. Prior to parenteral iron replacement
II. Non-anaemic women with high risk of iron depletion
1. Previous anaemia
2. Multiparity >P3
3. Consecutive pregnancy <1year following delivery
4. Vegetarians
5. Teenage pregnancies
6. Recent history of bleeding
III. Non-anaemic women where estimation of iron
stores is necessary
1. High risk of bleeding
2. Jehovah’s witnesses
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13. 3.Trial of Iron therapy
Diagnostic and therapeutic for normocytic or
microcytic anaemia
Ferritin should be checked first In the presence of
known haemoglobinopathy,
If no improvement in Hb by 2 ws:
referral to consider other causes of anaemia, such
as folate deficiency.
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14. 5. PREVENTION
Universal supplementation
From booking
(WHO) or
From 2nd T
(INACG)
(Stolzfus et al, 1998; WHO, 2001).
Cochrane review (2009):
Iron supplementation improved
birth length
Apgar scores
infant ferritin at 3 months
reduces the need for postpartum maternal transfusion
 iron–folic acid supplementation
improved birth weight.
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15. 6. MANAGEMENT
1. Dietary Advice
 Diet rich in iron
 Avoid inhibitors of iron absorption
PoorMediumRich
milk and its
products, root
vegetables
meat, chicken,
fish, spinach,
banana, apple
liver, egg yolk, dry
beans, dry fruits,
wheat germ, yeast
EnhanceInhibit
HemePhytates: cereals
Ascorbic acidTannins: tea –coffee
Ferrous iron(Fe2+)Calcium
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16. 2. Oral Iron
Patil et al, 2012: I J Med Pharmaceutical Sci
I. Conventional iron preparations
Fe sulfate, Fe fumarate.
Cheap.
No scientific evidence that any particular brand is
better .
Should not be given with food
{salts bind the iron: impair absorption}
Side effects
40%
Nausea, vomiting, heart burn, metallic taste,
constipation, abdominal cramps, diarrhea.
10%: Discontinue
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17. Extended (slow) release capsules or enteric
coated capsules
Less side effect
{slow/decreased iron absorption, absorbed lower
parts of the GI}
{Iron absorption occurs at the duodenum and
proximal jejunum}
Not very effective
Should be avoided
{majority of the iron is carried past the duodenum:
limiting absorption}
(Tapiero, 2001).
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18. II. New iron preparations
Multi Amino Acid Chelated iron, Carbonyl iron,
Iron polymaltose, others……….
Multi Amino Acid Chelated iron Vs iron salt
(Pineda et al, 1994; Sofia et al, 2001)
Low GIT intolerance
Increase Hbg level faster with significant low
doses
High bioavailability and regulation
Better improve iron stores
Higher cost.
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19. {Higher stability of amino acid chelate:
prevents the molecule from being destroyed in the
gut}: less GI irritation
{Atomic structure and chemistry}:
protects the ferrous iron from undesirable chemical
reactions in the stomach and intestine that limit iron
absorption.
Absorption
not reduced in presence of phytates.
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20. Oral iron should be taken
On an empty stomach, 1 h before meals
With a source of vitamin C:
orange juice {maximise absorption}.
Other medications or antacids should not be
taken at the same time (1A).
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21.  Response to oral iron
Hgb should rise by 2.0 g/l over 3-4w
(British National Formulary, 2010).
Oral therapy should be continued for 3 months
after anemia has been corrected
{replenish iron stores},
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22. Failure to respond to oral iron
 Incorrect diagnosis:
thalassemia
 Presence of a coexisting disease interfering with
response:
anemia of chronic disease, renal failure
 Patient is not taking the medication
 Medication is not being absorbed:
enteric coated tablets, concomitant use of antacids, malabsorption
 Iron (blood) loss or need is in excess of the amount
ingested:
severe continuous GI bleeding, dialysis patient
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23. 3. Parenteral Iron Therapy
Indication
From the 2nd T onwards and postpartum period
1. Failure to respond
2. Intolerant of oral iron (1A).
3. Proven malabsorption
Dose calculated based on
Pre-pregnancy wt,
Target Hb of 11.0 g/l (1B).
Potential side effects
written information.
Skin discoloration
Local abscess
Allergic reaction
Iron over load.
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24. Parenteral Vs oral iron:
Faster increases in Hbg
Better replenishment of iron stores, particularly
iron sucrose
(Al et al, 2005; Bhandal et al, 2006) and iron (III) carboxymaltose (Van
Wyk et al, 2007; Breymann et al, 2007, Shafi et al, 2012)
Equivalent increases in Hbg
(Bayouneu and colleagues, 2002; Sharma and co-workers, 2004).
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25. 4. Blood transfusion:
 Red cells (preferred) or whole blood
 Indications: rare
1. Severe anemia near term
{ maximum rise in hgb achievable with either oral or parenteral iron is
0.8 g/ dL/wk}.
2. Other complication: placenta previa
3. Hypovolemia from blood loss
4. Emergency operation on a severely anemic
woman.
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26. Anaemia at the time of delivery
1) Delivery in an hospital setting
2) Available intravenous access
3) Blood group-and-save
4) Active management of 3rd stage of labour
5) Plans to deal with excessive bleeding.
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27. Postnatal anaemia
WHO: Hb <10g/dl.
CBC should be checked within 48 h of delivery in
1. Estimated blood loss≥ 500ml
2. Uncorrected anaemia in ANC
3. Symptoms suggestive of postpartum anaemia.
 Oral iron: for at least 3 months
Repeat CBC and ferritin
{ensure Hb and iron stores are replete}.
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28. Thank you
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