Anemia Screening and Management in Pregnancy

Screening and Diagnosis

The Centers for Disease Control and Prevention (CDC) recommends screening all pregnant women for anemia at the first prenatal care visit using hemoglobin/hematocrit levels appropriate for gestational age, and confirming positive screening results with repeat hemoglobin/hematocrit testing 1
Referral to a physician familiar with anemia during pregnancy is recommended if hemoglobin is <9.0 g/dL or hematocrit is <27.0% 1
The CDC identifies previous iron deficiency anemia, low iron intake, and extensive menstrual or other blood loss prior to pregnancy as risk factors that may require closer monitoring 1

The American Academy of Family Physicians and the American College of Obstetricians and Gynecologists (ACOG) recommend oral iron supplementation (60-120 mg elemental iron daily) as the first-line treatment for iron deficiency anemia in pregnancy 2, 1, 3
The CDC recommends starting oral, low-dose (30 mg/day) iron supplements at the first prenatal visit and continuing throughout pregnancy to optimize iron absorption and prevent iron deficiency anemia 1

The following iron supplementation dosages are recommended:

Condition	Dosage
Prophylaxis	30 mg elemental iron per day
Treatment of iron deficiency anemia	60-120 mg elemental iron per day
Non-anemic pregnant women	25 mg elemental iron daily (ferrous bisglycinate)
Iron deficiency anemia	50-100 mg elemental iron daily (ferrous bisglycinate) or 100 mg twice daily (iron(III) polymaltose complex)

Women with risk factors (extensive menstrual or blood loss, low iron intake, previous iron-deficiency anemia) may need higher doses, as recommended by the CDC 1
Women on vegetarian diets may require almost twice as much iron due to lower absorption of non-heme iron, and should be monitored closely for iron deficiency anemia, with hemoglobin and serum ferritin levels monitored to assess response to treatment, and supplementation continued until iron stores are replenished (ferritin >30 μg/L) 3, 2, 4

Women with African, Mediterranean, or Southeast Asian ancestry with mild anemia unresponsive to iron therapy may have thalassemia minor or sickle cell trait 1
During the second or third trimester, if hemoglobin >15.0 g/dL or hematocrit >45.0%, evaluate for pregnancy complications related to poor blood volume expansion 1
Common side effects of iron supplementation include gastrointestinal symptoms (nausea, constipation, diarrhea), as reported by the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) 3, 2
Other effects may include darkening of urine/stool and staining of teeth/gums, as reported by the ACP and the AAFP 3, 2

Continue monitoring postpartum, especially for women with risk factors (anemia through third trimester, excessive blood loss during delivery, multiple birth) 1
Screen women at risk for anemia at 4-6 weeks postpartum, particularly those with risk factors such as anemia continued through third trimester and excessive blood loss during delivery 1
If no risk factors for anemia are present, supplemental iron can be stopped at delivery 1
Iron deficiency anemia affects approximately 18.6% of pregnant women in the United States, with higher rates in later trimesters and minority populations 2, 3
The Recommended Dietary Allowance for iron during pregnancy is 27 mg/day, as stated by the ACP 3
Iron supplementation prevents maternal iron deficiency anemia, improves maternal iron status during pregnancy and postpartum, and cannot be met solely through diet during the second half of pregnancy, as stated by the CDC, ACP, and American Academy of Family Physicians (AAFP) 1, 3, 2, 5