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Prenatal Guideline
Consultation available 24 hours per day from OB on-call at 925-370-5608 or via page/see amion schedule for OBs on-call, via inbasket to OB dept member or by calling Perinatologist at 510-444-0790 during the day and 510-204-1572 after hours. Consultation appointments or transfer of care to more experienced prenatal clinician available at major clinics sites—see consultation guidelines for more information.

Anemia in Pregnancy
Screening
All prenatal patients screened for anemia and are given iron supplementation as part of the routine prenatal vitamin. Patients found to be anemic are screened as indicated for hemoglobinopathies and treated with additional oral iron for presumed iron deficiency.
Ferritin and/or iron levels are used to document iron deficiency when other causes are suspected, there is inadequate response to iron supplementation, or a hemoglobinopathy is present.
Additional iron is usually provided as ferrous sulfate 325mg 1-3 times per day with meals. Typically DSS is prescribed with the iron to prevent constipation common in pregnancy. If larger than usual blood loss is anticipated at delivery (previa, prior cesarean, h/o hemorrhage, etc), additional iron may be recommended to further enhance maternal iron stores.
In addition to the goal of decreasing need for blood transfusion and enhancing healing/recovery, there is some evidence that women with low hemoglobin after birth have more difficulty producing breast milk and are at more risk of postpartum depression.
Definition (ACOG PG #95)
  • First trimester Hb<11
  • Second trimester Hb<10.5
  • Third trimester Hb<11

Most providers are treating women with Hb < 11 with additional iron during pregnancy.

Screening for Hemoglobinopathies
Women with African ancestry should have a Hemoglobin electrophoresis ordered with initial labs, if no prior result is in the chart, to evaluate for sickle cell carrier state.

MCV <80. Check prior CBCs and if prior MCVs > 80 assume iron deficiency. All other women should have a ferritin and electrophoresis drawn (no need to redraw electrophoresis if prior result in chart).
If both ferritin and electrophoresis are normal and all MCVs are < 80, Southeast Asian women should get a alpha-thalessemia carrier test. If this test cannot be obtained, a paternal MCV greater than 80 will rule out risk of thalassemia disease in the fetus.
If Hemoglobinopathy found, consider consultation with genetic counselor at East Bay Perinatology or Diablo Valley Perinatology. To assess the risk to the fetus, the father of the baby will need an electrophoresis. This can be drawn from an order generated in the mother’s chart specifying that the blood is from the father of the baby.

When to use Iron Sucrose
  1. Persistent Hb < 9.5 despite several weeks of oral iron.
  2. Late third trimester Hb < 9, also start on oral iron.
  3. Hb < 8 and suspect inability to take, absorb or tolerate oral iron
To administer iron sucrose, call 925-370-5608 and schedule the first appointment on labor and delivery. If well tolerated follow up appointments may be scheduled in the Martinez Antepartum testing clinic at 925-370-5950. You may be asked to write orders in advance for outpatient administration if going to the antepartum testing center.

Fetal Monitoring
Start antepartum testing and order third trimester fetal growth ultrasound for Hb < 8

Postpartum
Patients are sent out from postpartum with advice to continue their prenatal vitamin.
Additional iron one daily is given for Hb 8-10 and twice daily if Hb < 8.

Further Consultation
Generally, consultation with OB by calling the OB on call or inbasket message is always indicated if you are uncertain or want further advice.
Consult Obstetrics and/or Perinatology for Hb < 7 especially if not corrected by second trimester.