Iron deficiency anaemia in pregnancy

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
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
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^[1]	Parenteral iron	200 mg IV per session × 5–10 doses to total dose calculated by Ganzoni formula (iron deficit + 500 mg replenishment)	—	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^[1]

Parenteral iron

Adult: 200 mg IV per session × 5–10 doses to total dose calculated by Ganzoni formula (iron deficit + 500 mg replenishment)
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.

References

1.ICMR Guidelines for Anaemia in Pregnancy (2022); MoHFW Anaemia Mukt Bharat Operational Guidelines; WHO Antenatal Care (2022)