Iron Adequacy in Pregnancy
Denise Snow, JD, CNM, NP, RN
E
valuation of adequate iron
intake is an important aspect of
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prenatal care. Iron is an essen-
tial component of hemoglobin.
Maternal increases in red blood cell
production lead to increases in plasma
volume and red cell mass. As a result
(in addition to needs of the fetus and
placenta), the need for iron is increased
during pregnancy. Not meeting this
need can lead to iron deficiency ane-
mia (IDA), which can in turn increase
risk of complications, including pre-
mature and low birthweight infants,
low iron stores in the infant, impaired
cognitive and behavioral development
(National Institutes of Health [NIH],
n.d.). Knowledge gained by the
mother during pregnancy may confer
Pregnant women need adequate iron intake.
a lasting benefit on the family’s nutri-
tional needs. However, there is con-
fusing and conflicting information
about iron absorption and dietary
iron sources.
There are two sources of dietary
iron, heme and non-heme; each with
different bioavailability and are un-
equally influenced by iron absorp-
tion enhancers or inhibitors. Heme
iron has the greater bioavailability
and is less influenced by other foods.
Foods highest in heme iron include
lean meat and seafood. Non-heme
iron is the form of iron found in
plants and iron-fortified foods.
Meat, seafood, and poultry contain
both heme and non-heme iron. Good
sources of non-heme iron include
fortified cereals, dark chocolate,
tofu, cashews, white beans, chick
peas, lentils, and vegetables such as
spinach, potatoes, and canned toma-
toes. Ascorbic acid (Vitamin C) en-
hances absorption of non-heme iron,
as does meat, seafood, and poultry,
whereas some polyphenols found in
spinach, cereal and legumes and
phytates found in grains and beans
May/June 2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
inhibit bioavailability. Calcium may
reduce bioavailability of both heme
and non-heme iron. Milk and cheese
contain no iron.
Recommended Dietary Allowanc-
es of iron during pregnancy is 27 mg
(slightly higher for vegetarians) (NIH,
n.d.). A dietary review for adequate
iron intake may seem to be straight-
forward because iron is an aspect of
the Food and Drug Administration
(FDA) that requires “nutritional
facts” labeling. However, daily value
(DV) listed on labels is based on the
FDA’s recommendation of 18 mg,
thus making the percentage difficult
to calculate for daily adequacy. The
FDA has issued a new, more useful la-
beling rule that will state the actual
amount of iron in milligrams; howev-
er, it does not go into effect until 2020
or beyond. Some fast food restaurants
offer information on iron content, for
example, McDonalds lists iron in
both DV and in milligrams.
Insufficient iron intake during
pregnancy increases likelihood of
women developing IDA, so when
and should the clinician recommend
supplementation? Guidelines vary:
Some experts recommend treating
IDA (hematocrit less than 33% be-
fore 28 weeks; 32% thereafter) with
iron supplementation in addition to
prenatal vitamin. Others recom-
mend low-dose iron supplement for
all women and the United States
Preventive Services Task Force states
there is insufficient evidence for ei-
ther routine screening for IDA or
supplementation (NIH, n.d.).
If the clinician determines the
woman needs supplementation, the
next step is choosing the type and
amount of supplementation. Iron
supplements come in many forms.
Prescription prenatal multivitamins
can contain anywhere from 18 to
50 mg of iron. Most, but not all,
contain calcium, which can interfere
with absorption. Higher iron con-
tent multivitamins may also contain
a stool softener. Over-the-counter
prenatal vitamins generally contain
18 mg of iron; gummy prenatal vita-
mins contain no iron. The most
common iron supplements are in the
form of ferrous salts such as ferrous
sulfate, ferrous gluconate, and fer-
rous fumarate and each has a differ-
ent percentage of elemental iron (the
amount that will be absorbed). One
iron supplement that advertises as
being “gradually absorbed with less
side effects” contains carbonyl iron.
However, this preparation contains
lactose—an inappropriate choice for
vegan patients. Doses higher than 45
mg of elemental iron may cause nau-
sea or constipation (NIH, n.d.).
Some patients may tolerate one iron
preparation better than another.
Evaluating iron intake may be a
challenge but ensuring iron adequa-
cy is a critical aspect of quality pre-
natal care. Knowing about dietary
iron absorption and individualizing
iron supplementation is key. ✜
Denise Snow is a clinical associate pro-
fessor in the School of Nursing at the
State University of New York at Stony
Brook, Stony Brook, NY, and a health-
care law attorney in private practice.
She can be reached via e-mail at denise.
snow@stonybrook.edu
The author declares no conflicts of
interest.
Copyright © 2018 Wolters Kluwer
Health, Inc. All rights reserved.
DOI:10.1097/NMC.0000000000000425
Reference
National Institutes of Health. (n.d.). Office of
Dietary Supplements. Strengthening
knowledge and understanding of di-
etary supplements (Dietary Supplement
Fact Sheet: Iron). Retrieved from https://
ods.od.nih.gov/factsheets/Iron-Health
Professional/
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