OBSTETRICS AND GYNAECOLOGY

CLINICAL PRACTICE GUIDELINE

Anaemia and iron deficiency:

Management in pregnancy and
postpartum
Scope (Staff): WNHS Obstetrics and Gynaecology Directorate staff
Scope (Area): Obstetrics and Gynaecology Directorate clinical areas at KEMH, OPH
and home visiting (Community Midwifery Program)
This document should be read in conjunction with this Disclaimer

Contents

Quick reference guide: Anaemia management overview ..................2

Background information ......................................................................4

Key points .............................................................................................5

Prescribing iron supplements .............................................................6

Side-effects of oral iron medications and management .......................................... 7
Medications that interact with iron ........................................................................... 7

Dietary information ...............................................................................7

Anaemia and haemoglobinopathies or B12 deficiency......................8

Postpartum anaemia management ......................................................8

References and resources ...................................................................9

 Anaemia and iron deficiency in pregnancy and postpartum

Quick reference guide: Anaemia management overview

Routine antenatal care
Hb >110g/L and
and monitoring.
ferritin >30ug/L
Iron rich diet.

Hb >110g/L and Commence 100mg Assess if history of anaemia +/- iron treatment
ferritin, ≤ 30ug/L elemental oral iron on
Ask if patient has had previous iron infusions
is alternate days and an
iron deficiency iron rich diet Discuss oral iron options

Alternate oral iron doses in 1st and

Commence 100 -
sometimes 2nd trimester
Hb 70 - 110 g/L and 200mg elemental oral
ferritin ≤ 30ug/L iron daily and an iron Assess if haemoglobinopathy studies are
is rich diet required for thalassaemia as per guideline
iron deficiency
anaemia (IDA) Consider IV iron • MCV ≤80 fL and MCH ≤27 pg.
E-referral to CNC PBM • High risk ethnicity
• Family history
• Chronic anaemia
Contact and/or e-
referral to CNC PBM Contact and/or e-referral to CNC PBM for
discussion / patient management advice for:
Contact Haematologist • All the above
if severe symptoms • Blood refusal / Jehovah’s Witness
Hb 70-110 g/L and
ferritin > 30ug/L patients
Elevated ferritin levels • High risk patients e.g. placenta
is
can be caused by accreta
anaemia
inflammatory disease • Patients presenting with IDA and < 4
or infection. weeks until delivery
Check CRP.
• Some high-risk patients require
optimisation when not IDA
Check for Vit B12 /
folate deficiency Refer to Iron Infusion-Intravenous Guideline
for further information.

Referral to Haematologist
for urgent review

Hb <70g/L E-referral to CNC PBM

is
Possible:
severe anaemia
• RBC transfusion
• IV iron infusion
• 100-200mg elemental
oral iron daily

Obstetrics and Gynaecology

Page 2 of 11
 Hb and ferritin levels Immediate action Review blood tests Additional instructions

Hb > 110 g/l and ferritin >30 mcg/l Iron rich diet Routine Routine ANC and follow up#
follow up#

Routine Hb ↑ continue oral Fe. Hb ↔ review diet, Fe (type/dose).

Trimester

60 - 100mg elemental iron on

1st

Hb > 110 g/l and ferritin ≤ 30 mcg/l alternate days and an iron rich diet follow up# Recheck FBP 4/52 following review

Hb ↑ continue oral Fe. Hb ↔ review diet, Fe (type/dose),

Hb > 70 and ≤ 110 g/l and 60 - 100mg elemental iron on Hb and ferritin exclude/treat folate, B12 deficiency.
ferritin ≤ 30 mcg/l alternate days and an iron rich diet 28/40 Recheck FBP & ferritin 4/52 following review

Hb > 105 g/l and ferritin >30 mcg/l Continue iron rich diet Routine Routine ANC and follow up#
follow up#
Hb ↑ continue oral Fe. Hb ↔ review diet, Fe (type/dose),
Trimester

Hb > 105 g/l and ferritin ≤ 30 mcg/l At least 100mg elemental iron daily. Routine
2nd

exclude /treat folate, B12 deficiency. Recheck FBP 2-

Iron rich diet follow up# 4/52 following review

Hb ↑ continue Fe. Hb ↔ review diet, Fe (type/ dose) and

Hb > 70 and ≤ 105 g/l and 100-200mg elemental iron daily. Hb and ferritin exclude/treat folate, B12 deficiency.
ferritin ≤ 30 mcg/l Iron rich diet after 4/52 Recheck FBP & ferritin 2-4/52 following review
Refer to CNC PBM (e- referral) for IV Fe if no change

Hb > 110 g/l and ferritin > 30 mcg/l Continue iron rich diet Routine Routine ANC and follow up#
follow up#

Hb ↑ continue oral Fe. Hb ↔ review diet, Fe (type/dose)

Hb > 110 g/l and ferritin ≤ 30 mcg/l 100-200mg elemental iron daily. Routine
Trimester

exclude/treat folate, B12 deficiency.

Iron rich diet follow up#
3rd

Recheck FBP 2-4/52 following review.

Refer high risk to CNC PBM (e-referral)

Hb > 70 and ≤ 110 g/l and 100-200mg elemental iron daily. Hb and ferritin Hb ↑ continue oral Fe. Hb ↔ review diet, Fe
ferritin ≤ 30 mcg/l Iron rich diet after 2/52 (type/dose), exclude/treat folate, B12 deficiency
Refer to CNC PBM (e-referral) for IV Fe if no change

# Routine follow up requires FBP repeated at 28 and 36 weeks gestation.

Patients who may require more regular testing include: patients with known haemoglobin disease, adolescents, refusal of blood/components, history of anaemia,
presence of co-morbidities, bleeding disorders, planned home birth, malabsorption, thrombocytopaenia, multiple births, vegan/vegetarian, hyperemesis.

100mg elemental iron daily. Ensure following blood tests undertaken prior to referral to Haematology
stage
Any

Hb ≤ 70 g/l Urgent referral to Haematologist Full blood picture (FBP), iron studies, coagulation screen, biochemical profile,
folate and B12 levels. Haemoglobinopathy screen (high risk populations)

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Obstetrics and Gynaecology
 Background information
Table 1: Classification of iron deficiency anaemia in adult obstetric
patients
Hb (g/L) Time period
<110 1st and 3rd trimester
<105 2nd trimester
<100 Postpartum period
A serum ferritin of <30mcg/L for an adult is diagnostic of iron deficiency

Approximately 1.95-2.36 billion people worldwide have anaemia, with 30% of women
in high-resourced countries and 50% of women in low–resourced countries having
iron deficiency or iron deficiency anaemia (IDA).

Women with anaemia and/or iron deficiency may experience:

• fatigue
• dizziness/fainting
• headaches
• shortness of breath
• tachycardia
• heart palpitations
• a decreased physical working capacity
• reduced energy levels
• reduced cognitive ability
• emotional instability
• depression
• restless legs
• insomnia

Severe anaemia is associated with preterm birth, low birth weight, a small for
gestational age foetus, low Apgars, neonatal infection, possible cognitive
development and childhood anaemia.
In the postpartum period both anaemia and IDA have been found to be linked to
depression, emotional instability, stress and lower cognitive ability.

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 Anaemia and iron deficiency in pregnancy and postpartum
The most common causes of anaemia in pregnancy
• inadequate iron intake (dietary +/- oral supplementation)
• iron deficiency
• folate deficiency +/- vitamin B12 deficiency
• haemoglobinopathies
• gastrointestinal absorption reasons e.g. gastric/bariatric surgery, Crohn’s
disease or diverticulitis
• hyperemesis
• blood loss, chronic or acute
• haemolytic diseases
• bleeding disorders e.g. Von Willebrand’s disease
• underlying malignancies

Pregnancy requirements
• 27mg of iron is required daily in pregnancy which is 1.5 x greater than when
not pregnant.
• An iron rich diet should be encouraged.
• Oral iron is the recommended initial treatment for all but the most severally
anaemic iron deficient patients.
• The haemoglobin should increase within 2 weeks if oral iron supplements are
taken correctly and consistently, otherwise further tests are required.
• Intravenous iron should only be used in severe cases of IDA, if the patient is
unresponsive to oral iron treatment, or when rapid repletion of iron is required.
For treatment guideline refer to: Iron Therapy: Intravenous

Key points
1. All patients should be offered screening for anaemia:
• in first trimester (or at booking): FBP and iron studies
• with the next screening bloods: FBP and ferritin (usually performed between
24-28 weeks). See Anaemia Treatment algorithm.
• and at 36 weeks gestation: FBP and ferritin. See Anaemia Treatment algorithm
2. A FBP / ferritin should be ordered within 2 - 4 weeks (dependent on gestation)
following initiation of treatment, and at any time when there is a change of
dosage or treatment type in order to assess response and compliance with oral
iron treatments.
3. Iron deficiency +/- anaemia in most circumstances is diagnosed by a FBP and
serum ferritin levels. Do not use serum iron, or serum ferritin alone to diagnose
iron deficiency. NB: Ferritin levels are elevated in active infection or inflammation

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 Anaemia and iron deficiency in pregnancy and postpartum
and in these cases measurement of C-reactive protein (CRP) will support
interpretation of ferritin levels.
4. Identify and document risk factors for anaemia which include: multiple pregnancy,
refusal of blood components, teenage pregnancy, presence of co-morbidities, history
of anaemia, bleeding disorders, poor /non-compliance to oral iron supplementation,
malabsorption, coeliac disease, inflammatory bowel disease, bariatric surgery,
diabetes, grand multiparity, thrombocytopenia, vegan/vegetarian,
haemoglobinopathies.
5. Consult with CNC PBM and/or the Haematologist in diagnosing and treating IDA
in patients with known haemoglobinopathies. Serum ferritin should be checked
prior to starting iron with known haemoglobinopathy, to avoid iron overload.
6. Oral iron if taken at the appropriate dose and correctly, and for a sufficient time, is
an effective first-line treatment for most patients in pregnancy. The type, dosage,
and frequency of iron supplements for treatment of IDA should be documented in
the patient notes, iron supplements increased if required, side effects noted,
discussed and advice given as required at each antenatal clinic visit.
7. If a patient fails to respond to oral iron therapy, investigate further to assess for
malabsorption problems. Consider non-compliance with medications or co-
existing disease.
8. Intravenous iron therapy is an effective alternative to oral treatment during the
second or third trimester only for treatment of IDA. Intravenous iron is restricted
to patients failing to respond to oral iron treatment with known IDA or in those
whom a rapid repletion of ferritin is required.
9. If not IDA or high risk, discuss with CNC PBM regarding anaemia management,
as treatment with IV iron may need to be accessed through the patient’s General
Practitioner (G) or other external provider.

Prescribing iron supplements

All patients with known haematinic deficiencies (includes B12 or iron deficiency)
should be advised:
• the type, frequency, and duration of the treatment or medication.
• alternate day oral iron dosing may increase absorption and have less side
effects, and may be adequate in 1st and 2nd trimester
• side-effects of the medication (see section below)
• management strategies for side effects e.g. pregnancy safe laxatives
• how and when to take the medications correctly
• of medications or food that may inhibit / decrease iron absorption
• dietary information to increase oral iron intake / refer to dieticians if required
Provide written instructions to the patient about iron supplementation - WNHS
brochure – Iron Supplements- supplied by pharmacy.

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 Anaemia and iron deficiency in pregnancy and postpartum
Side-effects of oral iron medications and management
When oral liquid iron is used, it should be diluted with water (or juice with Maltofer®)
and drink through a straw in order to prevent discolouration of the teeth. Follow each
dose with a drink of plain water. However, liquid iron supplements should be checked
for the content of elemental iron to ensure it is adequate.
Side-effects of oral iron supplements include heartburn, nausea, vomiting, constipation
and black discolouration of the faeces.
Management for side effects include:
• Nausea and epigastric discomfort
➢ take iron tablets on an empty stomach 1 hour prior to or 2 hours after a
meal. If it causes stomach upset, take with or shortly after food.
➢ take iron tablets at night
➢ take iron tablets on alternate days
➢ do not take iron tablets with other medications or supplements
➢ NB follow Pharmacy advice as some iron preparations can be taken with food
➢ See also WNHS Obstetrics and Gynaecology (OG): Antenatal Care: Discomforts
in Pregnancy: Common (guideline) and Iron Supplements (patient brochure)
• Constipation – see Clinical Guideline, OG: Bowel Care (constipation)

Medications that interact with iron

• medications used to treat gastric reflux (antacids and proton pump inhibitors
e.g. Mylanta®, Gaviscon®)
• Calcium supplements
• Vitamin D supplements
• Multi vitamin supplements containing calcium and magnesium
• Thyroid hormones
• Some antibiotics (quinolones and tetracyclines)
• Methyldopa

Dietary information
• Sources of dietary iron include haem iron from meat, poultry and fish, which are
more absorbable than non-haem iron plant-based foods and iron-fortified foods.
• Ascorbic acid (vitamin C) enhances absorption.
• Various factors including gut health and function affect iron absorption.
• Foods that may interact / inhibit / decrease iron supplement absorption include:
➢ calcium in dairy products
➢ tea, coffee/cola/caffeine products
➢ unprocessed bran
• See WNHS patient information brochure ‘Iron and Pregnancy’ and WNHS medical
library Nutrition Resources ‘Nutrients in Pregnancy’ tab e.g. ‘High Iron Foods’
Obstetrics and Gynaecology Page 7 of 11
 Anaemia and iron deficiency in pregnancy and postpartum

Anaemia and haemoglobinopathies or B12 deficiency

• Anaemia and haemoglobinopathies: See WNHS Clinical Guideline,
Obstetrics and Gynaecology: Haemoglobinopathy Screening in Pregnancy
• Anaemia and B12 deficiency: See WNHS Clinical Guideline, Obstetrics and
Gynaecology: Vitamin B12 Deficiency: Management During Pregnancy

Postpartum anaemia management

Post-partum haemorrhage has been defined as blood loss in the 24hrs after giving
birth vaginally (>500mls) or caesarean section (>1000mLs).

• If indicated check FBP post

• Assess if iron deficient or IDA
during pregnancy
• Check if patient had been
No PPH taking iron supplements
• Check if IV iron infusion
received during pregnancy
• Check for symptoms of
anaemia
• Assess blood loss
birth
• Do not order iron studies or
ferritin as these cannot be
interpreted accurately
immediately post birth
• If Hb >100g/L continue oral
supplements on discharge,
with GP follow up
• If Hb <100g/L and advice
required, liaise with medical
team or contact CNC PBM

• Repeat FBP 12-24 hrs post • Consider for IV iron as

birth unless required sooner
due to medical condition of
patient.
• Do not order iron studies or
ferritin as these cannot be
interpreted accurately
immediately post birth.
• If Hb >100g/L discharge on
PPH oral iron supplements with GP
follow up
If Hb <100g/L assess
• Blood loss
• Symptoms
• Liaise with medical team
as required
• E-referral to CNC PBM
for IV iron
inpatient or outpatient
Send e-referral to CNC PBM
• Consider for Blood
Transfusion should symptoms
of acute anaemia be present
• Single RBC unit transfusion
followed by haemoglobin
check
• Contact CNC PBM or
Haematologist for advice
• Follow guidelines for Blood/
Blood Products (Adults)

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 Anaemia and iron deficiency in pregnancy and postpartum

References and resources

Bibliography
Australian Medicines Handbook. Iron. Australian Medicines Handbook. 2023. Available from
https://amhonline.amh.net.au/
Australian Red Cross Lifeblood. Haemoglobin assessment and optimisation in maternity: A guide
for health professionals involved in antenatal care. Australian Red Cross Lifeblood. 2020.
Available from https://www.lifeblood.com.au/health-professionals/learn/resource-
library/featured-resources
Australian Red Cross Lifeblood. Toolkit for Maternity Blood Management: A guide to improving
identification and management of iron deficiency and anaemia. Australian Red Cross
LifeBlood. 2020. Available from https://www.lifeblood.com.au/health-
professionals/learn/resource-library/featured-resources
Froessler B, Gajic T, Dekker G, Hodyl NA. Treatment of iron deficiency and iron deficiency anemia
with intravenous ferric carboxymaltose in pregnancy. Archives of Gynecology and
Obstetrics, 298:75-82. 2018. https://doi.org/10.1007/s00404-018-4782-9
Froessler B, Schubert KO, Palm P, et al. Testing equivalence of two doses of intravenous iron to
treat iron deficiency in pregnancy: A randomised controlled trial. BJOG. 2022.
https://doi.org/10.1111/1471-0528.17288
Munoz M, Pena Rosa J P, Robinson S et al. Patient blood management in obstetrics:
Management of anaemia and haematinic deficiencies in pregnancy and the postpartum
period: NATA consensus statement. Transfusion Medicine. 2018; 28 (1): 22 – 39.
National Blood Authority. Patient Blood Management Guidelines: Module 5 - Obstetrics and
Maternity. Canberra: National Blood Authority. Available from
https://www.blood.gov.au/pbm-module-5
Richards T, Breymann C, Brookes MJ et al. Questions and answers on iron deficiency treatment
selection and the use of intravenous iron in routine clinical practice. Annals of Medicine,
53:1,274-285. 2021. https://doi.org/10.1080/07853890.2020.1867323
Stoffel NU, Cercamondi CI, Prof Brittenham G et al. Iron absorption from oral iron supplements
given on consecutive versus alternate days and as single morning dose versus twice-daily
split dosing in iron-depleted women: Two open-label, randomised controlled trials. The
Lancet Haematology; 4(11), E524-533. 2017. https://doi.org/10.1016/S2352-
3026(17)30182-5
Stoffel NU, Zeder C, Brittenham GM et al. Iron absorption from supplements is greater with
alternate day than with consecutive day dosing in iron-deficient anemic women.
Haematologica. 105(5). 2020. https://doi.org/10.3324/haematol.2019.220830
Therapeutic Guidelines. Oral iron supplementation. Therapeutic Guidelines. 2022. Available from
https://tgldcdp.tg.org.au
The Women’s. Management of iron deficiency in maternity and gynaecology patients guideline.
The Royal Women’s Hospital Victoria. 2020.
World Health Organisation [WHO]. Daily iron and folic acid supplementation during pregnancy.
WHO. 2017.

Related WNHS policies, procedures and guidelines

WNHS Clinical Guidelines: Obstetrics and Gynaecology:
• Antenatal Care: Discomforts in Pregnancy: Common - constipation
• Haemoglobinopathy Screening in Pregnancy
• Iron Therapy: Intravenous
• Vitamin B12 Management during Pregnancy

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 Anaemia and iron deficiency in pregnancy and postpartum

Useful resources and related forms

WNHS patient information:
• Pharmacy: Iron Supplements brochure
• Pharmacy: Obstetrics Medicine Information Service (6458 2723)
• Dietetics: Iron and Pregnancy brochure
• Medical Library Nutrition Resources: ‘Nutrients in Pregnancy’: ‘High Iron Foods’

Keywords: Anaemia in pregnancy, anaemia, iron in pregnancy, iron deficiency

anaemia, iron deficiency, IDA, anaemic ,iron infusion, haemoglobin,
FBP, ferritin
Document owner: Obstetrics and Gynaecology Directorate
Author / Reviewer: Pod lead: CNC PBM and Haematology
Date first issued: March 2013(v1) Version: 5
Reviewed dates: June 2015(v2); Dec 2017 (v3- amend); Sept Next review Jun 2026
2018(v4); Jun 2023(v5) date:
Approved by: Blood Management Committee [13/06/2023- Date: 26/06/2023
out of session approved post meeting]
Medicines and Therapeutics Committee Date: 22/06/2023
(MTC) and WNHS Health Service Permit
Holder under the Medicines and Poisons
Regulations 2016 [06/06/2023- out of
session approved post-meeting]
Endorsed by: Obstetrics and Gynaecology Directorate Date: 07/06/2023
Management Committee
NSQHS Standards 1: Clinical Governance 5: Comprehensive Care
(v2) applicable:
2: Partnering with Consumers 6: Communicating for Safety
3: Preventing and Controlling 7: Blood Management
Healthcare Associated 8: Recognising and Responding
Infection to Acute Deterioration
4: Medication Safety
Printed or personally saved electronic copies of this document are considered uncontrolled.
Access the current version from WNHS HealthPoint.

Version history
Version Date Summary
number
1 Mar 2013 First version. Archived- contact OGD Guideline Coordinator for
previous versions. Original titled ‘B2.23: Anaemia in Pregnancy’.
2 June 2015 Full routine review

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 Anaemia and iron deficiency in pregnancy and postpartum
3 Dec 2017 Amendment. QRG- Wording changed to “at least 65mg” iron (if
normal Hb and ferritin <30ug/L)
4 Sept 2018 • Streamlined and removed some repetitive elements
• Details added to flowcharts- see treatment algorithm for tests
required
• Vit B deficiency section removed & now refers directly to Vitamin
B deficiency guideline
• Other causes of anaemia: Haematologist referral is
recommended for investigation and treatment of other causes of
anaemia
5 Jun 2023 • Anaemia management overview QRG updated. Details added
for contacting CNC PBM, Haematology and e-referrals. Includes
option of increased oral iron supplement dose- read flowcharts
for relevant categories. Time frame for rechecking FBP
amended.
• Background details added; includes table for classification of
anaemia in adult obstetric patients
• Following initiation of treatment, order a FBP / ferritin within 2 - 4
weeks (dependent on gestation), and at any time when there is a
change of dosage or treatment type in order
• Identify and document risk factors for anaemia
• Document the type, dosage, and frequency of iron supplements
for treatment of IDA, iron supplements increased if required, side
effects noted, discussed and advice given as required at each
antenatal clinic visit.
• Added details for side effect management, medication
interactions and dietary information
• Postpartum anaemia management flowchart added

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with a disability.
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