Anaemia in pregnancy — structured SAQ (15 marks)

(a) Diagnosis, threshold and initial management (4 marks)

One mark per point, maximum four.

• Diagnosis: iron deficiency anaemia. FIGO diagnoses anaemia at a haemoglobin below 11.0 g/dL in all trimesters, and a serum ferritin below 30 μg/L is diagnostic of iron deficiency anaemia.^[7]
• Initial management: oral iron first-line at 60 to 120 mg of elemental iron daily, continued until haemoglobin reaches 11.0 g/dL or above.^[7]
• Dosing for absorption: in iron-depleted women, alternate-day dosing gave greater cumulative fractional absorption than consecutive-day dosing (21.8% vs 16.3%).^[8]
• How to take it: in the morning on an empty stomach, and 1 hour before or 2 hours after inhibitors such as calcium, proton pump inhibitors, antacids, tea, coffee and milk.^[7]

(b) Failure of oral iron despite adherence (4 marks)

One mark per point, maximum four.

• Indication met: FIGO gives parenteral iron after the first trimester for poor or no response to oral iron (a rise of less than 1 g/dL after 2 weeks or less than 2 g/dL after 4 weeks) and for iron deficiency anaemia within 4 to 6 weeks of anticipated childbirth.^[7]
• Intravenous ferric carboxymaltose (FCM) 1000 mg: in an Australian equivalence trial, 36 percent of the 500 mg group needed a repeat infusion at 4 weeks compared with 8 percent of the 1000 mg group; 1000 mg maintained iron stores and reduced repeat infusions.^[4]
• Trial evidence: in the Khalafallah RCT, a single FCM 1000 mg infusion over 15 minutes produced a 4.35 g/L haemoglobin advantage over oral iron at 4 weeks (P=0.0006) and a 166 micrograms per L ferritin advantage (P under 0.0001).^[3]
• Network meta-analysis: FRIDA found good evidence of benefit for intravenous iron sucrose and some evidence for intravenous FCM over oral ferrous sulfate.^[5]

(c) Severe anaemia and maternal mortality evidence (3 marks)

One mark per point, maximum three.

• Daru (WHO Multicountry Survey, n=312,281): severe anaemia (haemoglobin under 70 g/L) was associated with maternal death, adjusted odds ratio 2.36 (95 percent CI 1.60 to 3.48).^[2]
• Propensity score analysis: adjusted odds ratio for maternal death 1.86 (95 percent CI 1.39 to 2.49).^[2]
• Transfusion: FIGO indicates transfusion for severe anaemia close to childbirth, acute severe bleeding or a risk of further bleeding, and significant symptomatic anaemia with haemodynamic or cardiac compromise.^[7]

(d) Postpartum anaemia management (4 marks)

One mark per point, maximum four.

• Definition: FIGO applies the 11.0 g/dL cutoff postpartum; UK guidelines use 10.0 g/dL postpartum.^[7]
• Transfusion: FIGO indicates transfusion for severe anaemia, especially close to childbirth, for acute severe bleeding or a risk of further bleeding, and for significant symptomatic anaemia with haemodynamic or cardiac compromise.^[7]
• Continue iron: after haemoglobin normalises, prophylactic 30 to 60 mg elemental iron daily for at least 3 months or 6 weeks postpartum, whichever is longer.^[7]