Anaemia in pregnancy — structured oral station (12 minutes)

Opening prompt — "Tell me your diagnosis and the threshold on which it is based."

Model response — say it in this order:

• "This is iron deficiency anaemia. FIGO diagnoses anaemia at a haemoglobin below 11.0 g/dL in all trimesters, so her 89 g/L qualifies, and a serum ferritin below 30 micrograms per L is diagnostic of iron deficiency anaemia."^[7]
• "At 89 g/L she falls in FIGO's moderate band, 7.0 to 9.9 g/dL."^[7]
• "Oral iron is first-line at 60 to 120 mg of elemental iron daily, taken in the morning on an empty stomach and away from calcium, antacids, tea, coffee and milk."^[7]

Examiner is listening for: the named cutoff, the ferritin threshold, and the dose with route.

Probe 1 — "She has tried ferrous sulfate daily for two weeks and stopped. What now?"

• "Intolerance of oral iron, poor compliance and moderate to severe iron deficiency anaemia are each FIGO indications for parenteral iron after the first trimester."^[7]
• "If she prefers to retry oral iron, alternate-day dosing gave greater cumulative fractional absorption than consecutive-day dosing in iron-depleted women (21.8% vs 16.3%), with lower hepcidin."^[8]
• "The parenteral option I would offer is a single ferric carboxymaltose 1000 mg infusion over 15 minutes, as used in the Khalafallah trial."^[3]

Probe 2 — "What trial evidence supports IV ferric carboxymaltose in pregnancy?"

• "Khalafallah (n=246) randomised pregnant women to FCM 1000 mg vs iron polymaltose 1000 mg vs oral ferrous sulphate. At 4 weeks the haemoglobin difference was 4.35 g per L favouring FCM over oral (P=0.0006) and the ferritin difference 166 micrograms per L (P under 0.0001)."^[3]
• "Froessler (n=278) compared FCM 500 mg with 1000 mg: not equivalent, with 36 percent vs 8 percent needing a repeat infusion at 4 weeks, so 1000 mg maintains stores and reduces repeat infusions."^[4]
• "The FRIDA network meta-analysis found good evidence of benefit for intravenous iron sucrose and some evidence for intravenous FCM over oral ferrous sulfate."^[6]

Probe 3 — "Why not just transfuse her at 30 weeks?"

• "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. She has none of these."^[7]
• "Severe anaemia does matter: in Daru's WHO Multicountry Survey analysis, haemoglobin under 70 g/L was associated with maternal death, adjusted odds ratio 2.36 (95 percent CI 1.60 to 3.48)."^[2]

Probe 4 — "She is anxious about an iron infusion. How do you address this?"

This is a scored domain. Demonstrate it out loud:

• Move to her eye level, use her name, acknowledge the worry.
• "In the Khalafallah trial, the iron infusion was safe and better tolerated than oral iron, and there were no differences in the babies' outcomes."^[3]
• Explain the alternative (oral iron) and its trade-off, and let her choose.

Probe 5 — "She delivers vaginally at 38 weeks with a postpartum Hb of 72 g/L. What now?"

• "FIGO applies the 11.0 g/dL anaemia cutoff in the postpartum period, so at 72 g/L she is anaemic."^[7]
• "Once haemoglobin normalises, she continues prophylactic iron 30 to 60 mg elemental iron daily for at least 3 months or 6 weeks postpartum, whichever is longer."^[7]