Practice Guideline Template

v. Summer 2016

Skaidre Brown
November 13, 2017

Evaluation and management of Iron Deficiency Anemia in Pregnancy

1. Definition or Key Clinical Information: Iron deficiency anemia in pregnancy is the most common type
of anemia in the United States. Pregnancy related demands increase daily iron requirements to 20-23 mg
of iron per day. In the first and third trimester anemia is diagnosed when Hgb is less than 11 g/dL; in the
second trimester, anemia is diagnosed when Hgb is less than 10.5 g/dL.
2. Assessment
i. Risk Factors Nutritional deficiency, restrictive vegetarian diet, pica, occult blood loss, closely
spaced pregnancies, and adolescent pregnancies.
ii. Subjective Symptoms fatigue, drowsiness, weakness, dizziness, short of breath, headaches,
malaise, racing heart, poor appetite, pica, change in food preferences, changes in mood,
changes in sleep habits, mental dullness, difficulty concentrating, smooth and sore tongue,
orthostatic hypotension, dyspnea on exertion.
iii. Objective Signs Pallor, orthostatic hypotension, pale mucous membranes and nail beds,
tachycardia, or flow murmur, tachypnea, dyspnea on exertion, smooth and sore tongue,
peripheral edema, jaundice, splenomegaly, hemoglobin <11 g/dL in 1st & 3rd trimester,
hemoglobin <10.5 g/dL in 2nd trimester.
iv. Clinical Test Considerations
Routine screening at first appointment: CBC with differential: normal hemoglobin is 12-12.5 +
g/dL.
Routine screening at 28 weeks: CBC with differential: expect a 1-2 g/dL drop in hemoglobin
Screening done anytime there are s/sx
Re-screening 1-2 weeks after treatment is initiated
Other screening to consider:
Serum iron
TIBC
Serum ferritin

3. Management plan
i. Therapeutic measures to consider
Iron supplementation with ferrous sulfate, ferrous fumarate, or ferrous gluconate. The standard
amount is 325 mg 3 times per day.
ii. Complementary measures to consider
Hemaplex
Floradix Iron plus Herbs
 Whole food prenatal supplement
Increase iron rich foods – dark leafy greens, wheat grass juice, blackstrap molasses, brewers
yeast, organ meats, meats, eggs, fish, and poultry (esp. dark meat), cherry juice, dried fruit,
quinoa
Cook with iron skillet
Increase efficacy – folate and vitamin C
Chlorophyll to increase RBC and regulate size
Avoid consuming antacids/calcium, aspirin, vitamin E, sugar, and caffeine at the same time as
iron supplement.
Homeopathic – ferrum metallicum or ferrum phosphoricum
Herbs – yellow dock root, nettle
iii. Considerations for pregnancy, delivery and breastfeeding Adequate iron and blood volume
at the time of delivery will help protect against adverse effects from postpartum blood loss,
reduce risk of preterm labor, and reduce risk of postpartum hemorrhage.
iv. Client and family education Careful diet history is to be taken, asking client about any
symptoms that she may have, physical exam. Client education about iron rich foods and s/sx of
low iron. Informed consent for screening tests.
v. Follow-up 1-2 weeks following initiation of treatment retest hemoglobin to see response to
treatment.
4. Indications for Consult, Collaboration or Referral
Referral is necessary when:
hemoglobin is less than 7 g/dL
folate deficiency is suspected
thalassemia is suspected
sickle cell anemia is suspected
or other chronic disease is expected
if there is no improvement following 7-14 days of treatment
ongoing s/sx not explained by lab values
anemia at term
Blood transfusion is necessary when hemoglobin is <6 g/dL
5.References
Delaney, S. (2017). Iron deficiency anemia. Prenatal Care I: Live session recording.

Frye, A. (2008). Holistic midwifery volume I: Care during pregnancy. Portland, OR: Labrys

Press

King, T., Brucker, M., Kriebs, J., Fahey, J., Gegor, C. & Varney, H. (2015). Varney’s Midwifery. Burlington,

MA: Jones & Bartlett Learning.