Iron Deficiency Anemia

in Pregnancy
Obstetrics and Gynecology October 2021 Issue
Clinical Expert Series

Karlene Vega Figueroa, PGY-1

April 29,2022
Anemia

• Low RBC count

• Low hematocrit
• Low hemoglobin (g/dl)

• Most common blood disorder in

pregnancy
• Affects 16% pregnant women in USA and
38% globally.
Physiologic Changes
in Blood Volume
During Pregnancy
• Plasma volume, red cell mass and Hb levels increase
• Plasma volume is disproportionately greater
(oligocythemic hypervolemia)
• Blood volume increases by 30-50% above baseline
• Hemodilutional changes serve to reduce viscosity of
maternal blood and improve uteroplacental perfusion
Causes of Anemia in
Pregnancy and
Post Partum Period
• Acute or chronic blood loss
• Increased destruction of RBCs
• Decreased production of RBCs

• Most common causes in pregnancy

1. Hemodilution
2. Iron deficiency anemia
Fetal, Neonatal,
and Childhood
Consequences of
Maternal Anemia
• Perinatal mortality
• Neonatal mortality
• Low-birth weight
• Preterm birth
• Small-for-gestational age newborns
• Behavioral and neurodevelopmental
abnormalities
• Lower cord-blood serum ferritin levels

Limited evidence that iron supplementation has any effect on fetal, neonatal or childhood outcomes
 • May manifest during pregnancy, at delivery or during
post partum period

Maternal • Signs or symptoms:

FATIGUE, PALLOR, LIGHT-HEADEDNESS, TACHYCARDIA,
Consequences of DYSPNEA, POOR EXCERSISE TOLERANCE, SUBOPTIMAL
WORK PERFORMANCE, DEPRESSED MOOD

Anemia • Recent studies show maternal anemia was associated

with significantly increased risk of cesarean delivery,
post partum anemia, and blood transfusion.
Screening for
Anemia in
Pregnancy
CBC
1. Registration for prenatal care
2. Third trimester
3. On admission for labor and delivery
4. Post partum

• ACOG recommends CBC in first

trimester and again at 24.0 – 28.6
WGA
 Approach depends on gestational age, severity of anemia and presence of other relevant conditions.

Patient with Anemia

Obstetric History
Initial Approach to • Anemia in previous pregnancy or risk factors such as hx of PPH

Gynecologic History

• Heavy menstrual bleeding

Surgical History

• Procedures that might impair nutrient absorption (bariatric surgery)

• Roux-en-Y gastric bypass (>20% develop iron deficiency anemia)
• Gastric Sleeve

Other History/Information

• Family hx
• Dietary hx
• Religious reasons for blood refusal
• Medications
• Clinical status
• Physical condition
Severity of the
Anemia
 Gold standard for diagnosis of iron
Confirmation of the deficiency anemia: low ferritin level
Ferritin Transferrin TIBC

• Hollow, globular • Glycoprotein • Measurement of

intracellular that can bind 2 amount of
protein that can ferric ions and transferrin’s
store up to 4500 transport to available binding
Diagnosis

ferric ions and various tissues sites

release them as
necessary.
• Indirect
measurement of
iron body stores
Iron requirements
During Pregnancy
Iron Requirements During Pregnancy
• Greatest demand on maternal iron:
Increase in fetal
Increase in RBC mass and placental Blood loss at
growth delivery
(500mg elemental
iron) (350mg elemental (250mg elemental
iron) iron)

Without supplementation, women have a loss of bone marrow iron stores, decrease in
serum ferritin and decrease in hemoglobin of approximately 0.5g/dl by the end of
pregnancy.
 Prevention of Iron Deficiency Anemia
Adequate dietary intake
of iron and low dose
iron supplementation
(30mg/d)

USPSTF found insufficient evidence that routine iron

supplementation in nonanemic pregnant women
improves clinical outcomes for women or their children,
but it may improve hematologic indices
First-Line Treatment of Oral Iron

Traditionally: Oral iron formulation (ferrous sulfate 325mg) BID + low

dose iron in prenatal vitamins + dietary iron, Vit C
Iron Deficiency
Absorption may be improved when taken between meals or at
bedtime (few data)

One study showed serum ferritin levels were slightly but higher in
patients who took oral iron supplements between meals or at bedtime
Anemia

Tolerability is a function of amount of elemental iron in a given dose

(less, better tolerated)

Side effects (GI): nausea, stomach pain, heartburn, vomiting,

constipation or diarrhea
 Hepcidin
• Peptide hormone produced by the liver
focused on regulating systemic iron
balance
• Controls delivery of iron to the plasma
from intestinal absorption, from red cell
recycling macrophages, and from iron
storing hepatocytes
• Production stimulated by plasma iron and
iron stored
• Increased hepcidin, decreased iron
absorption
• Oral iron 60-240mg BID increased
hepcidin and decreased fractional iron
absorption
• Conclusion: lower doses (40-80mg) given
on alternate days to maximize
absorption, increase efficacy, reduce GI
stress and improve compliance.
 IV Iron
• For patients who cannot tolerate,
cannot absorb, or do not respond
to oral iron
• Preferred in 3rd trimester and
sometimes as early as 2nd trimester
• Faster rise and greater increase
than oral iron
• Post partum
• Day 14: higher ferritin with IV
• Day 42: same in IV and PO
• IV side effects: metallic taste,
dizziness, hot flushes, arthralgias,
allergic reactions
 Hormone made in interstitial fibroblasts of the kidney
in response to hypoxia and anemia
EPO levels in pregnancy increase 2-4x

Used to tx anemia in pregnant patient with kidney

disease
In pregnancy + oral iron increased Hb or Hct, and more

Erythropoietin
quickly than those with oral iron alone
Postpartum> no difference

Does NOT cross placenta

OJO thromboembolism in those w/o kidney disease

Not approved to treat iron deficiency anemia in

pregnancy
 Gold standard: low ferritin

First line treatment: Iron PO

Conclusions New evidence: Intermittent

dosing is as effective
IV iron if cannot tolerate,
cannot absorb, or do not
respond