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 — investigate adherence, malabsorption, ongoing blood loss, helminthic infection; consider IV iron[1]
First-line treatment
Interventions
- Universal iron-folic acid supplementation[1]60 mg elemental iron + 500 µg folic acid PO daily for all pregnant women from booking through delivery, continued in postpartum (Anaemia Mukt Bharat); double dose for established anaemia
- Dietary counselling and culturally relevant iron-rich foods[1]Dark green leafy vegetables, pulses, jaggery, dates, eggs and meat where consumed; combine with vitamin C foods (citrus, tomatoes, amla); avoid tea/coffee within 1 hour of iron tablet
- Deworming in endemic areas[1]Single-dose albendazole 400 mg PO in second trimester per Anaemia Mukt Bharat in helminth-endemic regions
- Referral for severe anaemiaThe December 2025 ICMR antenatal STW directs referral to a higher centre when Hb is <7 g/dL. It does not specify a transfusion threshold or one-unit transfusion protocol. [2]
- Active third-stage management and postpartum repletion[1]Oxytocin 10 IU IM after delivery, controlled cord traction, uterine massage; continue iron supplementation postpartum to ferritin >50 µg/L
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Oral elemental iron (ferrous sulphate, fumarate, gluconate, 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 sucrose | Parenteral iron | December 2025 ICMR antenatal STW: iron sucrose no more than 200 mg per administration and no more than three administrations per week; it does not specify a fixed 5–10-dose or Ganzoni-total regimen. [2] | — | Indications: oral iron intolerance or non-response, severe anaemia (Hb <90 g/L), malabsorption; widely available in Indian programmes; multiple sessions required |
| Ferric carboxymaltose (alternative IV iron)[1] | Parenteral iron | 1000 mg IV single dose; can repeat once 7 days later if total dose >1000 mg required (max 2000 mg) | — | Single-dose convenience; faster repletion than iron sucrose; monitor for hypophosphataemia and hypersensitivity; avoid first trimester |
Oral elemental iron (ferrous sulphate, fumarate, gluconate, 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 sucrose
Parenteral iron
- Adult
- December 2025 ICMR antenatal STW: iron sucrose no more than 200 mg per administration and no more than three administrations per week; it does not specify a fixed 5–10-dose or Ganzoni-total regimen. [2]
- Paediatric
- —
Indications: oral iron intolerance or non-response, severe anaemia (Hb <90 g/L), malabsorption; widely available in Indian programmes; multiple sessions required
Ferric carboxymaltose (alternative IV iron)[1]
Parenteral iron
- Adult
- 1000 mg IV single dose; can repeat once 7 days later if total dose >1000 mg required (max 2000 mg)
- Paediatric
- —
Single-dose convenience; faster repletion than iron sucrose; monitor for hypophosphataemia and hypersensitivity; avoid first trimester
Safety-net
- Take iron-folic acid daily; missing doses delays recovery and increases delivery and postpartum risk[1]
- Eat iron-rich foods with vitamin C; avoid tea or coffee within an hour of iron tablets[1]
- Severe tiredness, breathlessness, or palpitations — same-day medical review (severe anaemia may need IV iron or transfusion)[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 haemoglobinopathyHaematology and antenatal genetics[1]
- Postpartum haemorrhage with anaemia (Hb <90 g/L)Obstetric review with consideration of IV iron[1]
Clinical summary
Universal supplementation, screening, and treatment of iron deficiency anaemia in pregnancy under the ICMR/MoHFW Anaemia Mukt Bharat framework.