King Edward Memorial Hospital

Obstetrics & Gynaecology

CLINICAL PRACTICE GUIDELINE

Anaemia and iron deficiency:

Management in pregnancy and
postpartum
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Contents

Quick Reference Guide: Anaemia management overview .................2

Anaemia treatment algorithm ..............................................................3

Anaemia in pregnancy and postpartum ..............................................4

Background information .......................................................................................... 4
Key points ............................................................................................................... 4
Prescribing iron supplements and follow-up............................................................ 5
Dietary information .................................................................................................. 6
Side-effects of oral medications and management ................................................. 6
Anaemia and haemoglobinopathies ........................................................................ 7
Anaemia and folate deficiency ................................................................................ 7
Other causes of anaemia ........................................................................................ 7

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 Anaemia and iron deficiency in pregnancy and postpartum

Quick Reference Guide: Anaemia management overview

Assess if Haemoglobin studies required?
Routine ANC and Obtain Hb studies* if Black African or MCV
Hb >110g/L and <=80 fL and MCH <=27 pg and not tested
ferritin >30ug/L monitoring
Iron rich diet before, unless documented to have been
normal previously. Assess if received IV Fe
elsewhere and responding?

Hb >110g/L and Commence at least

ferritin, ≤ 30ug/L 65mg elemental oral
iron daily. Iron rich diet
Hb >70g/L and ≤ Commence 100mg
110g/dL and ferritin elemental oral iron
≤ 30ug/L daily. Iron rich diet.
Consider IV Fe
imminent birth
Requires medical
review to assess cause
Hb >70g/L and ≤ of anaemia i.e.
110g/dL and ferritin > dilutional anaemia
30ug/L following blood loss,
thalassaemia, anaemia
chronic disease, or iron
deficiency with
coexisting inflammatory
disease or infection
(↑CRP).
Assess if Haemoglobin studies required?
Obtain Hb studies* if Black African or MCV
<=80 fL and MCH <=27 pg and not tested
before, unless documented to have been
normal previously
Exclude dilutional anaemia, establish
normovolaemia. Assess medical history to
exclude anaemia chronic disease, or iron
deficiency with coexisting inflammatory
disease or infection. Review red cell/iron
study historical trends alongside CRP.
Assess if received IV Fe elsewhere and is
responding?
Assess if Haemoglobin studies required?
Obtain Hb studies if Black African or MCV
<80 fL and MCH <27 pg and not tested
before, unless documented to have been
normal previously

Referral to Assess if Haemoglobin studies required?

Hb <70g/L Haematologist for Obtain Hb studies* if Black African or MCV
Irrespective ferritin urgent review if <=80 fL and MCH <=27 pg and not tested
level pregnant. before, unless documented to have been
normal previously.
Assess if actively bleeding, exclude
dilutional anaemia. Undertake additional
B12, Folate testing. Establish if haemolysis
is present.

* Hb studies can be requested as ‘add-on’ to FBP

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 Anaemia treatment algorithm
Hb and ferritin Immediate action Review blood tests Additional instructions
levels
#
Hb > 110 g/l & ferritin >30 mcg/l Continue iron rich diet Routine Routine ANC and follow up
#
follow up

At least 65mg elemental iron O.D. Hb ↑ continue Fe. Hb ↔ review diet, Fe (type/dose).
Trimester

Hb > 110 g/l & ferritin ≤ 30 mcg/l Routine

1st

Iron rich diet follow up

# Recheck FBP 4/52 following review

Hb > 70 and ≤ 110 g/l & 100mg elemental iron O.D. Iron rich Hb & ferritin Hb ↑ continue Fe. Hb ↔ review diet, Fe (type/dose),
ferritin ≤ 30 mcg/l diet 28/40 exclude/treat folate, B12 deficiency.
Recheck FBP & ferritin 4/52 following review

#
Hb > 105 g/l & ferritin >30 mcg/l Continue iron rich diet Routine Routine ANC and follow up
#
follow up
Hb ↑ continue Fe. Hb ↔ review diet, Fe (type/dose),
Trimester

Hb > 105 g/l & ferritin ≤ 30 mcg/l At least 65mg elemental iron O.D. Routine exclude /treat folate, B12 deficiency. Recheck FBP 2/52
2nd

#
Iron rich diet follow up following review

Hb > 70 and ≤ 105 g/l & 100mg elemental iron B.D. Iron rich Hb & ferritin Hb ↑ continue Fe. Hb ↔ review diet, Fe (type/ dose) and
ferritin 30 ≤ mcg/l diet after 4/52 exclude/treat folate, B12 deficiency. Recheck FBP &
ferritin 2/52following.
Refer CNC PBM for IV Fe if no improvement

Routine #
Hb > 110 g/l & ferritin > 30 mcg/l Continue iron rich diet #
Routine ANC and follow up
follow up

Hb ↑ continue Fe. Hb ↔ review diet, Fe (type/dose)

Hb > 110 g/l & ferritin ≤ 30 mcg/l* 65 -100mg elemental iron O.D.* Iron Routine
Trimester

# exclude/treat folate, B12 deficiency. Recheck FBP 2/52

rich diet follow up
3rd

following review.
* Refer high risk to CNC PBM

Hb > 70 and ≤ 110 g/l & 100mg elemental iron B.D. Iron rich Hb & ferritin Hb ↑ continue Fe. Hb ↔ review diet, Fe (type/dose),
ferritin ≤ 30 mcg/l diet after 2/52 exclude folate, B12 deficiency (treat as required).
Refer to CNC PBM for IV Fe if no improvement

# Routine follow up requires FBP repeated at 28 and 36 weeks in women (except women with known haemoglobin disease who require regular monitoring of ferritin levels)
*Denotes patients considered high risk of iron depletion or in whom tolerance levels for anaemia should be raised and includes: Twin pregnancy, refusal blood components,
teenage pregnancy, presence of co-morbidities, history of anaemia, bleeding disorders, planned home birth, poor compliance to ANC, malabsorption, thrombocytopenia
stage
Any

Hb ≤ 70 g/l 100mg elemental iron O.D. Urgent Ensure following blood tests undertaken prior to referral to Haematology
referral to Haematologist Full blood picture, iron studies, coagulation screen, biochemical profile, folate
and B12 levels. Haemoglobinopathy screen (high risk populations)

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Obstetrics & Gynaecology
 Anaemia in pregnancy and postpartum
Background information
Anaemia in pregnancy is defined as a haemoglobin (Hb) of less than 110 g/L in the
first and last trimester and less than 105 g/L in the second trimester. Women with
anaemia and/or iron deficiency may experience fatigue, reduced energy levels and
reduced mental performance. Severe anaemia is associated with preterm birth, low
birth weight, and a small for gestational age fetus. In the postpartum period both
anaemia and iron deficiency have been found to be linked to depression, emotional
instability, stress and lower cognitive performance tests.
The most common causes of anaemia in pregnancy are iron deficiency, folate
deficiency vitamin B12 deficiency. Haemolytic diseases, bone marrow suppression,
chronic blood loss and underlying malignancies are uncommon and require
haematology referral.
The gastrointestinal tract increases absorption when the body’s iron stores are low,
and it reduces the absorption when there are sufficient stores. Requirement for iron
ranges from 0.8mg/day in the first trimester to 7.5 mg/day in the third trimester,
averaging approximately 4.4 mg daily through pregnancy. In the second and third
trimester due to fetal growth, intestinal iron absorption in the gut is not sufficient to
meet this increased demand. Thus maintaining iron balance depends on adequacy
of maternal iron stores during this period.
Oral iron is the recommended initial treatment for all but the most severally anaemic
iron deficient patients. The haemoglobin should increase within 2 weeks, otherwise
further tests are required. A high iron diet should be recommended. Intravenous iron
should only be used in severe cases of iron deficiency anaemia, if the woman is
unresponsive to oral iron treatment, or when rapid repletion of iron is required. .

Key points
1. All women should be offered screening for anaemia:
 in first trimester (or at booking) (FBP and iron studies if not already done
by GP)
 with the next screening bloods (usually performed between 24-28 weeks)
see Treatment algorithm for tests required
 and at 36 weeks gestation- see Treatment algorithm
2. A FBP should be ordered within 2 - 8 weeks following initiation of treatment
(dependent upon gestation) to assess response and compliance with oral iron
treatments.
3. Iron deficiency in most circumstances is diagnosed by a full blood examination
and serum ferritin levels. Do not use serum iron, or serum ferritin alone to

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 Anaemia and iron deficiency in pregnancy and postpartum

diagnose iron deficiency. NB: Ferritin levels are elevated in active infection or
inflammation and in these cases measurement of C-reactive protein (CRP) will
support interpretation of ferritin levels.
4. Consider consulting a Haematologist in diagnosing and treating IDA in women
with known haemoglobinopathies. Serum ferritin should be checked prior to
starting iron with known haemoglobinopathy.
5. Oral iron if taken at the appropriate dose, and for a sufficient time, is an effective
first-line treatment for most women in pregnancy.
6. If a women fails to respond to iron therapy, investigate further to assess for
malabsorption problems. Consider non-compliance with medications or co-
existing disease.
7. Intravenous iron therapy is an effective alternative to oral treatment during the
second or third trimester only for treatment of IDA. Intravenous iron is restricted
to women failing to respond to oral iron treatment with known IDA or in those
whom a rapid repletion of ferritin is required.
8. The type, dosage, and frequency of iron supplements for treatment of IDA
should be documented in MR 220 ‘Pregnancy Health Record’.
9. At each antenatal visit all women taking iron supplements should be monitored
for medication compliance and side-effects.

Prescribing iron supplements and follow-up

All women with known haematinic deficiencies (includes B12 or iron deficiency)
should be advised:
 the type, frequency, and duration of the treatment or medication
 side-effects of the medication which can exacerbate the symptoms of
pregnancy including heartburn, nausea, vomiting and constipation
 management of side-effects
 how and when to take the medications
 of medications or food that may inhibit iron absorption
 dietary information to increase oral iron intake
Provide written instructions to the woman about iron supplementation - KEMH
brochure – Iron Supplements- supplied by pharmacy.
At each antenatal visit:
 assess and document the woman for compliance with taking the medication
 assess and document side-effects from the medication. Provide advice for
management of any side-effects
 assess compliance to dietary recommendations

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 Anaemia and iron deficiency in pregnancy and postpartum

Dietary information
Sources of dietary iron include meat, poultry and fish which are two to three times
more absorbable than plant-based iron foods and iron-fortified foods and ascorbic
acid enhances absorption. Vegetarians should be encouraged to eat foods high in
iron, such as, tofu, beans, lentils, spinach, whole wheat breads, peas, dried apricots,
prunes and raisins.
Medications inhibiting absorption or contraindicated include:
 anticonvulsants
 sulphonamides
 medications that raise gastric pH e.g. antacids (avoid where possible)
Foods that may interact or inhibit absorption:
 calcium in dairy products e.g.
 tea and coffee
 chocolate
 spinach and beetroot
 soy products
 phytates (salts found in plants capable of forming insoluble complexes with
iron) e.g. bran, cereal.
Non-haem iron requires an acidic pH to be reduced to ferrous for gut absorption. A
gap of 2 hours from dietary or medication inhibitors of iron absorption appears to be
sufficient to avoid the problem.

Side-effects of oral medications and management

When oral liquid iron is used it should be diluted with water and a straw used to
prevent discolouration of the teeth. However, liquid iron supplements should be
checked for the content of elemental iron.
Side-effects of oral iron supplements include nausea, epigastric pain,
constipationand black discolouration of the faeces.
Management for side effects include:
 nausea and epigastric discomfort – take iron tablets on an empty stomach 1
hour prior to or 2 hours after a meal, commence tablets on a low dosage and
then gradually increase the amount or iron, or take small doses more
frequently.
 constipation – see KEMH Clinical Guideline, O&G: Discomforts in Pregnancy:
Common

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 Anaemia and iron deficiency in pregnancy and postpartum

Anaemia and haemoglobinopathies

See KEMH Clinical Guideline, O&G: Haemoglobinopathy Screening in Pregnancy

For anaemia and B12 deficiency- see B12 Management in Pregnancy guideline

Anaemia and folate deficiency

Folate is required for DNA synthesis; demand increases in pregnancy. Deficiency
can develop rapidly as stores are minimal. The recommended dietary intake in
pregnancy is 600µg/day, and most commonly prescribed prenatal vitamins contain
800µg which is more than the recommended dose. Meat is not a good source for
folate, however folate can be found in green leafy vegetables, legumes and orange
juice.
Management
Women at risk of folate deficiency (e.g. multiple pregnancy, haemolytic anaemia)
should take 5 mg of folic acid throughout the pregnancy.

Other causes of anaemia

Haematologist referral is recommended for the investigation and treatment of other
causes of anaemia.

References
1. World Health Organisation. Daily iron and folic acid supplementation during pregnancy. World
Health Organisation 2017 http://www.who.int/elena/titles/daily_iron_pregnancy/en/
2. Munoz M, Pena Rosa J P, Robinson S et al. Patient blood management in obstetrics :
management of anaemia and haematinic deficiencies in pregnancy and the postpartum period:
NATA consensus statement. Transfusion Medicine. 2018; 28 (1): 22 - 39. 3. Breymann
C, Bian X, Blanco-Capito LR, et al. Expert recommendations for the diagnosis and treatment of
iron-deficiency anemia during pregnancy and the postpartum period in the Asia-Pacific region.
Journal of Perinatal Medicine. 2010;38:1-8.
3. Pavord S,Myers B, Robinson B, Allard S, Strong J, Oppenheimer C. UK guidelines on the
management of iron deficiency in pregnancy. Br J Haematol. 2012;156(5):588-600.
4. Pasricha SRS, Flecknoe-Brown SC, Allen KJ, et al. Diagnosis and management of iron
deficiency anaemia: a clinical update. MJA. 2010;193(9):525-32.

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 Anaemia and iron deficiency in pregnancy and postpartum

5. Simpson JL, Bailey LB, Pietrzik K, et al. Micronutrients and women of reproductive potential:
required dietary intake and consequences of dietary deficiency or excess. Part 1 - Folate,
Vitamin B12, Vitamin B6. The Journal of Maternal-Fetal and Neonatal Medicine.
2010;23(12):1323-43.
6. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Vitamin
and Mineral Supplementation in Pregnancy. College Statement C-Obs 25. 2008. Ammended
May 2015.
7. Australian Red Cross Blood Service. Toolkit for Maternity Blood Management. Australian Red
Cross Blood Service 2018.
http://resources.transfusion.com.au/cdm/singleitem/collection/p16691coll1/id/1000/rec/4
8. Peña-Rosas JP, De-Regil LM, Garcia-Casal MN, Dowswell T. Daily oral iron supplementation
during pregnancy. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No:
CD004736. DOI:10.1002 / 14651858.CD004736.pub5.
9. National Blood Authority. Patient Blood Management Guidelines: Module 5 - Obstetrics and
Maternity. Canberra: National Blood Authority 2015.
10. Haider BA, Olofin I, Wang M, et al. Anaemia, prenatal iron use, and risk of adverse pregnancy
outcomes: systematic review and meta-analysis. BMJ (Clinical Research Ed) 2013;346:pf3443.
11. Devalia, V. , Hamilton, M. S., Molloy, A. M. on behalf of the British Committee for standards in
Haematology, Guidelines for the diagnosis and treatment of cobalamin and folate disorders. Br
J Haematol, 2014 166: 496-513. doi:10.1111/bjh.12959.

Related WNHS policies, procedures and guidelines

KEMH Clinical Guidelines: Obstetrics & Gynaecology:
 B12 Management in Pregnancy guideline
 Discomforts in Pregnancy: Common - constipation
 Haemoglobinopathy Screening in Pregnancy
 Iron Therapy- Carboxymaltose; Polymaltose; Iron infusions

Keywords: Anaemia in pregnancy, anaemia, iron in pregnancy, iron deficiency anaemia,

iron deficiency, IDA, anaemic
Document owner: OGID
Author / Reviewer: Pod lead: CNC Haematology
Date first issued: March 2013 Version: 4.0
Reviewed dates: June 2015; Dec 2017 (amend) Next review date: Sept 2021
Supersedes: Version with amended date Dec 2017
Endorsed by: MSMSC Date: Sept 2018
NSQHS Standards 1 Governance, 4 Medication Safety
(v2) applicable:
Printed or personally saved electronic copies of this document are considered uncontrolled.
Access the current version from the WNHS website.

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