Iron Deficiency Anemia in

Pregnancy
Wong Chui Yee
Case History
Patient Demographics

Name: Mdm A

Age: 29 years old

Ethnicity: Malay

Gravidity/Parity: G1P0, currently at 23 weeks 3 days

period of gestation

Occupation: Factory operator

Presenting Complaint and HOPC
Referred from KK for severe anemia (Hb 6.0 g/dL on 28th Feb 2016).
Asymptomatic no:
Per vaginal bleed
Palpitations
Dizziness / Syncopal episodes
Chest pain
Lethargy / Effort intolerance
Bleeding tendencies
Fever
No history of peptic ulcer disease and haemorrhoids.
No history of blood transfusion.
Associated with back soreness and ankle swelling for 3/52.
Systemic Review
Cardiovascular Gastrointestinal
x Exertional dyspnoea x Abdominal pain
x Paroxysmal norturnal dyspnoea x Weight loss/gain
x Orthopnea x Appetite change
x Intermittent claudication x Nausea/vomiting
Ankle swelling x Hematemasis
x Change in bowel habits
Endocrine x Malena
x Cold intolerance x Jaundice
x Hair thinning
x Hoarse voice
x Menorrhagia
Antenatal History
Singleton pregnancy.

Last menstrual period: Unsure of date

Estimated date of delivery: 19th June 2016

Claimed that pregnancy is uncomplicated except for anemia,

however never had any MGTT.

No PV bleed, no contraction pain and no liquor leak.

Late booker booking done on 28th Feb 2016.

Booking scan parameters correspond to dates, liquor adequate, placenta

anterior low-lying.

Blood group: A positive

Past Obstetrics and Gynaecological
History
Past obstetrics history: Primigravida

Past gynaecological history:

Menarche: 12 years old
Flow: 4 5 days, regular
Cycle length: 28 days
No dysmenorrhea
No menorrhagia, no clots, no flooding, no intermenstrual bleed
No history of contraceptive use
No history of pelvic inflammatory disease
No history of gynaecological surgery
Never had any pap smear
Background Details
Past Medical History: Drug History: Nil

No known medical illness Allergies : Nil

Unsure of thalassemia carrier Social History:

status
Patient is a non-smoker and does
Past Surgical History: Nil not consume alcohol.

Family History: Unbalanced diet does not

consume vegetables, minimal
Both parents healthy
dairy products.
No family history of blood
Husband is a store keeper, non-
disorders
smoker.
No family history of malignancies
Examination Findings
Vital signs:
Blood pressure: 120/66 mmHg
Pulse rate: 96 beats/min, regular, good volume
Respiratory rate: 18/min
Temperature: 37 C

General inspection:
Alert, resting in bed, no signs of distress

Hands:
Warm
Pallor of palmar creases
No nail changes
 Eyes: Abdomen:
Conjunctival pallor Soft, non tender, distended
No jaundice Linea nigra seen
No surgical scars
Neck: No distended veins, pulsations

Thyroid not palpable Symphysis fundal height: 22.5 cm

No cervical lymphadenopathy Lie, presentation, engagement

JVP not raised not appreciable

Fetal movement felt

Chest:
Fetal heart rate not audible
Breasts: No abnormality detected

Heart: S1S2, Diastolic murmur

Legs:
heard loudest at left sternal edge,
non radiating Slight peripheral edema up to mid
shin
Investigations
Investigations done: FBC, Serum Urea & Electrolytes, LFT, Serum Ferritin, PBF
FBC, Serum Ferritin:
Normal Range 28th Feb 1st Mac
Hb 11 16 g/dL 6.4 8.7
TWC 4 11 X 109/L 7.5 10.0
MCV 80 96 fL 68.0 75.0
MCH 28 32 Pg 20.0 22.0
MCHC 32 35 g/dL 28.8 30.0
Platelet 150 400 X 109/L 321 345
PCV 36 48% 22 29
Serum Ferritin 14 150 g/L 3.59 -

Serum Urea & Electrolytes, LFT: All values normal

PBF: Polychromasia, pencil shape cells Hypochromic microcytic anemia
suggestive of iron deficiency anemia
Management Plan
Fetal heart monitoring 4 hourly

Fetal kick count

Counsel patient for high iron diet

Haematinics ferrous fumarate, vit B12, vit C, folic acid

Venofer (IV iron sucrose) as patient is not keen for blood transfusion

Re-counsel patient for blood transfusion

KIV transfusion 2 PC

After recounselling patient agreed for blood transfusion.

Case Summary
Madam A, 29 year old primigravida, presently at 23 weeks 3 days, has been admitted

because of severe anemia. She is asymptomatic, and gives no history of chronic blood

loss and blood disorders. She is a late booker and her pregnancy is uneventful till date.

She has no significant past gynaecological, medical, surgical, family, drug and social

history.

Examination reveals pallor of palmar creases and conjunctiva, and diastolic heart

murmur on left sternal edge. Otherwise no abnormalities detected. Blood test and PBF

confirmed the diagnosis of iron deficiency anemia. She is prescribed with haematinics

and transfused with 2 pints of packed cells.

Case Discussion
Research Question

Is IV iron sucrose therapy as effective as oral iron therapy and

blood transfusion in the management of iron deficiency anemia

in pregnancy?

Does IV iron sucrose have a role in reducing the need of blood

transfusions?
 Aggarwal et. al., 2012
RCT on 50 pregnant patients with anemia Hb <8 g/dL and serum ferritin <16 g/L
IV iron sucrose vs 3 x 200 mg iron sulphate tablets/day for 4 weeks (total 180 mg
iron/day).
IV iron sucrose group
Reached target Hb level of 11 g/dL in 4 weeks.
Greater increase in ferritin level, transferrin saturation, MCHC, MCV and hypochromasia
on peripheral smear.
None needed additional antepartum or postpartum blood transfusion.

Neeru et.al., 2012

RCT on 100 pregnant women with Hb level 6.5 10.9 g/dL and ferritin <27 ng/dL
IV iron sucrose vs ferrous fumarate.
IV iron sucrose group
Better reticulocyte response.
Greater % increase in Hb, PCV, red cell indices, also greater rate of increase in serum
ferritin.
Shorter treatment duration (2 weeks vs 12 weeks).
 Litton et. al., 2013

Systematic review and meta-analysis of 72 studies to evaluate the safety and

efficacy of IV iron therapy in reducing requirement for allogeneic blood
transfusion.

Results:

Associated with an increase in Hb concentration (mean 6.5 g/L).

Reduced risk of requirement for red blood cell transfusion by 26%, especially when
used with erythroid stimulating agents and in patients with lower baseline plasma
ferritin concentration.

No significant difference in mortality or serious adverse events when compared to

oral iron.
Challenges faced in treatment of IDA
Oral iron therapy
Poor compliance due to gastrointestinal side effects.
Low and variable absorption rates (Khalafallah & Dennis, 2012).

Blood transfusion
Only temporary relief does not address fundamental issue ie. Iron deficiency
(Deepti et. al., 2012).
Risk of transfusion reaction.
Risk of transmission of blood borne infections.

Parentral iron therapy

Higher cost - $280 for 1000 mg iron sucrose vs approx. $57 for ferrous fumarate
tablets compensated by shorter duration of treatment (Khalafallah & Dennis,
2012).
Summary
IV iron therapy is more effective than oral iron therapy in the management of

iron deficiency anemia during pregnancy.

Insufficient data is available to compare effectiveness of IV iron therapy with

blood transfusion, however it reduces the need for transfusion.

IV iron therapy has the potential to replace blood transfusion as a safer and

more effective mode of treatment in managing pregnant women with iron

deficiency anemia, and blood transfusion should be reserved for acute

cases.
References
Aggarwal RS, Mishra VV, Panchal NA, Patel NH, Deshchougule VV, Jasani
AF. Evaluation Of Iron Surcrose And Oral Iron In Management Of Iron
Deficiency Anemia In Pregnancy. National Journal of Community Medicine
2012;3(1):55-60.
Deepti S, Sunetra I, Sindhu B, Amreen S. Effectiveness of Intravenous Iron
Sucrose in Management of Iron-Deficient Anemia of Pregnancy at Rural
Hospital Set Up. The Journal of Obstetrics and Gynecology of India
2012;62(2):154-157.
Khalafallah AA, Dennis AE. Iron Deficiency Anaemia in Pregnancy and
Postpartum: Pathophysiology and Effect of Oral versus Intravenous Iron
Therapy. Journal of Pregnancy 2012.
Litton E, Xiao J, Ho KM. Safety and efficacy of intravenous iron therapy in
reducing requirement for allogeneic blood transfusion: systematic review
and meta-analysis of randomised clinical trials. BMJ 2013; 347:f4822
Neeru S, Nair NS, Rai L. Iron Sucrose Versus Oral Iron Therapy In Pregnancy
Anemia. Indian Journal Community Med 2012;37(4):214-218.