Red Flags
- Severe anaemia (Hb <70 g/L) at any gestation — admit; investigate other causes; IV iron and possibly transfusion; obstetric and haematology review[1]
- Anaemia with cardiac decompensation (tachycardia, dyspnoea, oedema) — emergency obstetric and cardiology review; consider transfusion[1]
- Anaemia at term in labour — IV iron pre-delivery if Hb 70–100 g/L; cross-match and have transfusion ready; active third stage management[1]
- No response to oral iron after 4 weeks of adequate dose — investigate adherence, malabsorption, ongoing blood loss; consider IV iron and parasitology screen[1]
First-line treatment
Interventions
- Universal iron supplementation in pregnancy[1]Daily oral elemental iron 30–60 mg + folic acid 400 µg from booking through delivery (FOGSI/WHO); higher dose 60–120 mg in established deficiency or high-prevalence settings
- Dietary advice and counselling[1]Iron-rich foods (dark green leafy vegetables, pulses, jaggery, eggs, meat where consumed); vitamin C with iron meal; avoid tea/coffee within 1 hour of iron; treat helminthic infection in endemic areas
- Transfusion of packed red cells[1]Reserved for Hb <70 g/L, symptomatic anaemia, active haemorrhage, or imminent delivery without time for iron repletion; 1 unit at a time and reassess; avoid where IV iron sufficient
- Active third-stage management and postpartum iron continuation[1]Oxytocin 10 IU IM after delivery, controlled cord traction, uterine massage; continue oral or IV iron postpartum to repletion (ferritin >50 µg/L)
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Oral elemental iron (ferrous sulphate, fumarate, gluconate, or polymaltose)[1] | Iron salt | Established IDA: 100–200 mg elemental iron PO daily (or alternate-day for tolerance); empty stomach with vitamin C; reassess Hb in 2–4 weeks | Adolescent pregnancies: 60–120 mg elemental iron daily | First-line for mild–moderate IDA; nausea, constipation common — alternate-day dosing improves absorption per hepcidin physiology; iron polymaltose has fewer GI side effects |
| Intravenous iron — ferric carboxymaltose, iron sucrose, ferric derisomaltose[1] | Parenteral iron | Ferric carboxymaltose 1000 mg IV single dose (max 1000 mg/week, 2000 mg total); iron sucrose 200 mg IV per session × multiple sessions to total dose; ferric derisomaltose up to 20 mg/kg single infusion | — | Indications: oral iron intolerance or non-response, severe anaemia (Hb <90 g/L) at >34 weeks, malabsorption, or rapid repletion before delivery. Avoid first trimester unless severe; monitor for hypersensitivity, hypophosphataemia (FCM) |
Oral elemental iron (ferrous sulphate, fumarate, gluconate, or polymaltose)[1]
Iron salt
- Adult
- Established IDA: 100–200 mg elemental iron PO daily (or alternate-day for tolerance); empty stomach with vitamin C; reassess Hb in 2–4 weeks
- Paediatric
- Adolescent pregnancies: 60–120 mg elemental iron daily
First-line for mild–moderate IDA; nausea, constipation common — alternate-day dosing improves absorption per hepcidin physiology; iron polymaltose has fewer GI side effects
Intravenous iron — ferric carboxymaltose, iron sucrose, ferric derisomaltose[1]
Parenteral iron
- Adult
- Ferric carboxymaltose 1000 mg IV single dose (max 1000 mg/week, 2000 mg total); iron sucrose 200 mg IV per session × multiple sessions to total dose; ferric derisomaltose up to 20 mg/kg single infusion
- Paediatric
- —
Indications: oral iron intolerance or non-response, severe anaemia (Hb <90 g/L) at >34 weeks, malabsorption, or rapid repletion before delivery. Avoid first trimester unless severe; monitor for hypersensitivity, hypophosphataemia (FCM)
Safety-net
- Take iron tablets daily — missing doses delays recovery; alternate-day dosing improves absorption and reduces nausea, ask your clinician[1]
- Eat iron-rich foods with vitamin C (citrus, tomatoes); avoid tea or coffee within an hour of iron tablets[1]
- If tablets cause severe nausea, constipation, or you cannot tolerate them — return for review; intravenous iron is available and effective[1]
Referral criteria
- Severe anaemia (Hb <70 g/L) at any gestation, or Hb <80 g/L third trimesterJoint obstetric and haematology review; admission for IV iron ± transfusion[1]
- Non-response or partial response to oral iron at 4 weeksObstetric assessment for IV iron and aetiology workup[1]
- Suspected thalassaemia, sickle cell, or other haemoglobinopathy on smear or electrophoresisHaematology and antenatal genetics[1]
- Postpartum haemorrhage with subsequent anaemia (Hb <90 g/L)Obstetric review; IV iron with consideration of single-dose ferric carboxymaltose[1]
Clinical summary
Screening, oral and intravenous iron repletion, and transfusion thresholds for iron deficiency anaemia in pregnancy and the puerperium.