This document provides guidelines on the prevention and management of iron deficiency anaemia during pregnancy. It defines anaemia levels and discusses the high prevalence of anaemia among pregnant women in India. The causes of iron deficiency anaemia include inadequate iron intake, poor absorption, and increased requirements during pregnancy. Left untreated, it can lead to maternal and infant complications. The guidelines recommend dietary changes, iron supplementation, investigation and treatment based on anaemia severity. It also covers vitamin B12 and folate deficiency anaemias, including symptoms, investigations and management.

1. National Nutrition Consensus,
ICOG Guidelines 2015-2016
Dr Meenakshi Sharma

2. Iron deficiency anaemia
 WHO defines anaemia in pregnancy as Hb <11gm/dl
WHO, 2001
 ICMR classification
 8-11 g% - mild,
 5-8 g % - moderate
 <5 g% - severe anaemia.
 Serum ferritin <12-15μg/l is considered as iron deficiency
 56 million women globally, two thirds in Asia
 Prevalence of anaemia in India – 58% (NFHS-3, 2007)
 78% lactating and 75% pregnant women are anaemic
 Anaemia – 20% direct maternal death and 50% indirect
maternal deaths

3. Aetiology of IDA
 Inadequate Iron intake-Poor iron content of diet -10-
20 mg/day
 Poor absorption- 1-2mg iron absorbed in SI
 Increased iron requirement -Total Pregnancy iron
requirement -1000mg
 Increased blood loss-Worm infestation, menorrhagia
 Poor iron stores – frequent childbirth, inadequate
spacing

4. Outcome of iron deficiency
• Reduced work capacity, intellectual capacity
• Increased maternal mortality
• Affect immune function and increases risk of
infections
Maternal morbidity and
mortality
• Decreased weight on delivery
• Greater risk of anaemia after birth
• Long term deficit in physical and mental
health
• Negatively contribute to infant and social
emotional behaviour
Effect on foetus and infant
• Preterm delivery, LBW and Possibly, placental
abruption and increased peripartum blood loss
• Further research necessary to establish a clear
causal relationship
Effects on pregnancy outcome

5. Investigations
• FBC
• Serum Ferritin
• Serum iron
• Total iron binding capacity
• Zinc protoporphyrin
• Soluble Transferrin Receptor
• Reticulocytes & Bone Marrow Iron (not applicable in routine
practice)
• Iron Therapy - diagnostic whilst being therapeutic at the same time
Signs and symptoms
• Fatigue, weakness, pallor, palpitations, dizziness and dyspnea
• May develop pica
• Temperature regulation may also be affected, leading to cold
intolerance.
Diagnosis & Investigations

6. Prevention of anaemia in pregnancy
 Pre-pregnancy counselling and dietary advice
 Rich sources of iron include haeme iron (in meat, poultry, fish and egg
yolk), dry fruits, dark green leafy vegetables (spinach, beans, legumes,
lentils) and iron fortified cereals.
 Using cast iron utensils for cooking and taking iron with vitamin C (orange
juice) can improve its intake and absorption.
 Avoid foods which may inhibit iron absorption - polyphenols (in certain
vegetables, coffee), tannins (in tea), phytates (in bran) and calcium (in
dairy products)
 CBC at the booking and at 28 weeks in pregnancy to screen
for anaemia.
 Repeat Hb near term in high risk mothers and multiple
pregnancies

7. Prevention of anaemia in pregnancy
 Iron supplementation weekly iron (60 mg) and
folic acid (2.8 mg) should be given.
 Deworming
 Delayed clamping of the umbilical cord at delivery
(by 1–2 min) is important step in prevention of
neonatal anemia.

8. Treatment of anaemia in pregnancy
• A course of iron therapy is simultaneously diagnostic
and therapeutic
• Ferritin levels should be checked if the patient has a
known haemoglobinopathy
• Microcytic or normocytic anaemia can be assumed to
be caused by iron deficiency anaemia until proven
otherwise
• Response to iron is both quick and cost effective; a rise
in Hb should occur within 2 weeks to confirm the
diagnosis.
• Furthermore, if there has been no improvement in Hb
by 2 weeks a referral should be made to secondary care.

9. Management of Iron deficiency
Dietary advice
 Physiological iron requirements are three times higher in pregnancy
compared to non-pregnant stage with increasing demand as pregnancy
advances.
 Iron absorption depends upon the amount of iron in diet, its
bioavailability and requirements of the body.
 The main source of dietary haem iron are haemoglobin and myoglobin
from red meat, fish and poultry.
 Haem iron is absorbed more readily than non-haem iron sources.
 Vitamin C significantly enhances iron absorption from non -haem
foods.
 Germination and fermentation of cereals and legumes improve the
bioavailability of non-haem iron by reducing the content of phytate, a
food substance that inhibits iron absorption.
 Tannins in tea inhibit iron absorption when consumed with a meal or
shortly after.

10. Oral iron supplementation
 Daily oral iron (60 mg) and folic acid (4 mg) should be started,
and continued up to 6 months' postpartum. The aim is to achieve a
hemoglobin of at least 10 g/dL at term.
 The recommended therapeutic dose of iron is 100- 200mg daily.
 It is recommended to take iron with orange juice to enhance its
absorption.
 Oral ferrous salts are the treatment of choice (ferric salts are less well
absorbed).

11. Oral iron supplementation
 Ferrous sulphate 200 mg 2– 3 times daily (each tablet
provides 60 mg elemental iron) is the most common
preparation used.
 First week of iron therapy – only reticulocytosis
 Second week –Hb starts rising 1g/dl/week
 Side effects - nausea, constipation and occasionally
diarrhoea which can be reduced by taking tablets after
meals.

12. Parenteral Iron
 Indications of parenteral iron
 Intolerance oral iron
 Severe anaemia in near term
 Failure of oral therapy
 Parenteral iron -intramuscular (IM) or intravenous (IV).
The main drawbacks of IM route are pain, staining of skin,
myalgia, arthralgia and injection abscess.
 Intravenous iron can be administered as total dose
infusion; however, utmost caution is needed as anaphylaxis
can occur.
 Iron dextran and iron polymaltose preparations can be
used by both IM and IV routes.

13. Parenteral Iron
 Newer IV preparations – iron sucrose and ferric gluconate are
associated with reduced side-effects.
 Iron sucrose- 50 mg elemental iron in one ampoule.
 It may be administered undiluted by slow I/V @ 1 mL/mt (20 mg
iron) not exceeding 100 mg iron per injection.
 I/V infusion – 2.5ml (50mg) iron sucrose in 100ml NaCl @100mg/15
minutes, 200mg alternate days
 Unused diluted solution must be discarded.
 Ferrinject (ferric hydroxide carbohydrate complex), IV as a single
dose of 1000mg over 15 minutes (max 15mg/kg by injection or
20mg/kg by infusion)

15. Blood Transfusion
Packed red cell transfusion may be indicated for
pregnant women with
 Severe anemia (Hb of 6 g/dL or less) close to due date
or less than 8 g/dL if they have increased risk of blood
loss at delivery

16. Intrapartum Management
 IV cannula and blood should be cross-matched in case
of significant hemorrhage at the time of delivery.
 Strict asepsis is very important.
 Active management of third stage
 In case of severe anemia with congestive cardiac
failure, active management of third stage (with
methyl ergometrine) is contraindicated.

17. Postpartum management
 Close monitoring should be done to look for signs
of decompensation, infection or thrombosis.
Appropriate thromboprophylaxis and
contraceptive advice should be provided and
haematinic supplementation should continue

18. Overview of treatment of IDA
Pre-pregnancy Antenatal Delivery
Dietary advice and iron
therapy
Iron therapy without
iron studies with 60mg
in second trimester.
Cross match blood in
case of severe anaemia
Folic Acid supplement
(which also prevent
NTDs)
Hb <10, Oral 100-200mg
elemental iron with Vit
C, deworming, treatment
for malaria
Active management of
third stage of labour
Blood transfusion if Hb
is <6g/dl
Intolerance to oral iron,
Malabsorption, non
compliance/poor, follow
up
Continue iron for three
months in post natal
period

19. Simplified flow chart for the iron deficiency anaemia

20. Recommendations
There is variation in definition of normal Hb levels in pregnancy. A
level of ≥ 11g/dl appears adequate in the first trimester and ≥ 10.5g/dl
in the second and third trimesters (1B).
Postpartum anaemia is defined as Hb <10g/dl (1B
Full blood count should be assessed at booking and at 28 weeks.
For anaemic women, a trial of oral iron should be considered as the
first line diagnostic test, increase demonstrated in two weeks is a
positive result.
All women should be counselled regarding diet in pregnancy including
details of iron rich food sources and factors that may inhibit or promote
iron absorption and why maintaining adequate iron stores in pregnancy is
important. This should be consolidated by the provision of an information
leaflet in the appropriate language (1A).

21. Recommendations
Women should be counselled as to how to take oral iron supplements
correctly. This should be on an empty stomach, 1 hour before meals, with a
source of vitamin C (ascorbic acid) such as orange juice to maximise
absorption. Other medications or antacids should not be taken at the same
time (1A).
Women with known haemoglobinopathy should have serum ferritin checked
and offered oral supplements if ferritin level is <30 ug/l.
Women with unknown haemoglobinopathy status with a normocytic or microcytic
anaemia, should start a trial of oral iron and screening should be commenced
without delay.
Women should undergo specialist assessment if there is a lack of response
(increase of less than 2 g/100 mL in the haemoglobin level) after 2–4 weeks.
Once haemoglobin concentration and red cell indices are normal, iron treatment
should be continued for 3 months to aid replenishment of iron stores, and then
stopped. The person's full blood count should be monitored every 3 months for 1
year.

22. Vitamin B12 deficiency anaemia
 SYMPTOMS
• Anaemia can result in many complications, including cardiovascular
symptoms, reduced physical and mental performances, reduced immune
function and fatigue.
• For the foetus consequences include growth retardation, prematurity, amnion
rupture, neural tube defects, low birth weight and even intrauterine death.
• The association between B12 deficiency and neural defects has been noted
multiple times.
• Very low B12 can cause anencephaly, due to its use in the metabolism of neural
tissue, resulting in demyelination, axonal degeneration and neuronal death.

23. Vitamin B12 deficiency anaemia
 INVESTIGATIONS
• B12 deficiency leads to megaloblastic anaemia, leading to vomiting,
diarrhoea and pyrexia, with oedema and albuminuria occurring at later
stages.
• Neurological involvements may be present, including mental slowness,
memory defects, hallucinations and numbness/tingling in the
extremities.
• The diagnosis of anaemia occurs fist by determining Hb levels, with a
threshold of 110 g/L.
• If the MCV is above 100fl, and the peripheral blood picture suggests B12
deficiency appropriate investigations should be carried out.

24. Treatment
 B12 deficiency can be prevented with a rich B12 diet, thus avoiding the need
for supplementation.
 However, if Vitamin B12 deficiency is suspected (caution in interpreting B12
levels as lower in pregnancy), therapy should be started if neurologic signs
are present.
 Cyanocobalamin or hydroxycobalamin 1mg is given three times a week for 2
weeks and then every 3 months.
Prenatal Labour and postpartum
2.6mcg of vitamin B12 is
the recommended daily
intake in pregnancy.
Continuation of
maintenance
therapy is needed
In strict vegetarians oral
supplementation might
be necessary.

25. Folate Deficiency
Investigations
 The clinical features of folate deficiency include symptoms of anaemia,
hyperpigmentation and low grade fever, falling after vitamin therapy.
 Neuropsychiatric symptoms may be present in conjunction with B12 deficiency.
Laboratory investigations include serum folate, red cell folate assay, serum B12, serum
homocyestein and methylmalonic acid.
 Bone marrow aspiration may be considered for megaloblastic changes suggestive of B12
or folate deficiency, and liver/thyroid function tests to find causes of macrocytosis.
 The criteria for folate deficiency is serum folate below 2.0 ug/L and red cell folate
concentration below 160 ug/L.
 Due to their close relation, it is important to rule out B12 deficiency as a cause of any
neuropsychiatric symptoms, as they will not improve with folic acid therapy.

26. Management of folate deficiency anaemia
Prenatal Labour Post natal
5mg of folic acid
daily
No specific management
apart from the previously
mentioned is needed.
WHO recommends
400mcg folic acid along
with 60mg iron for 6
months in pregnancy and
for 3
months postpartum in
areas with poor nutrition
Women with
haemolytic
anaemia require
high
doses (5-10mg)