Underdiagnosed: Iron Deficiency Anemia During Pregnancy

Jerome J. Federspiel, MD, often cares for patients who are about to deliver a baby but who have untreated iron deficiency anemia (IDA). Often, these patients require a blood transfusion after giving birth.

"I am sad to hear commonly from patients we treat that they have had iron-deficient anemia symptoms for many years. Correcting these conditions makes birth safer and, oftentimes, makes people feel much better — sometimes better than they have in years," Federspiel maternal fetal medicine physician and assistant professor of obstetrics and gynecology and population health sciences at Duke University, Durham, North Carolina, said.

Even for patients who he is able to diagnose earlier, they "will have difficulties catching up during pregnancy."

The condition is the most common type of anemia among people who are pregnant. IDA increases a patient's risk of delivering preterm and developing postpartum depression and puts their infants at a risk for perinatal mortality. Without proper treatment of IDA throughout pregnancy, the condition can also lead to low birth weights in infants or failing to meet weight goals later on.

But of all women with a new diagnosis of IDA from 2021 to 2022, 10% were pregnant, according to an analysis by Komodo Health, a healthcare analytics company.

While estimates of the prevalence of IDA vary, research from 2021 found 6.5% of nearly 1500 patients who were pregnant during the first trimester had the condition, a figure the researchers said might underrepresent the problem.

"In severe cases [fetal outcomes can include] abnormal fetal oxygenation, nonreassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilation, and fetal death," Alianne S. Tilley, NP, family nurse practitioner at Women's Care of Lake Cumberland, Somerset, Kentucky, said.

Research has shown that adequate levels of iron are an integral component in the development of the fetal brain. Some studies have reported that IDA during pregnancy increases an infant's risk for poor neurodevelopmental outcomes.

Lack of Screening Protocol

Discrepancies in guidance for testing patients who are pregnant for IDA may add to late diagnosis and low treatment, according to Katelin Zahn, MD, assistant professor of general obstetrics, gynecology, and midwifery at University of North Carolina at Chapel Hill.

"There's no consistency, which leads to a lot of variation in individual practice, which creates variation in outcomes, too," Zahn said. "You can only do so much as one independent physician and you need to be able to create change in a system that functions and provides standard of care even when you aren't there."

The American College of Obstetricians and Gynecologists (ACOG) recommends screening all patients who are pregnant with a complete blood count in the first trimester and again between 24 and 27 weeks of gestation.

Patients who meet criteria for IDA based on hematocrit levels less than 33% in the first and third trimesters, and less than 32% in the second trimester, should be evaluated to determine the cause. Those with IDA should be treated with supplemental iron, in addition to prenatal vitamins, ACOG says.

But the US Preventive Services Task Force in 2015 found insufficient evidence to recommend for or against screening patients without symptoms or signs of the condition. The organization is in the process of updating the recommendation.

Prevention as Best Practice

The most effective way to address IDA in patients who are pregnant is prevention, according to Federspiel.

"Having a systematic approach to screening and treatment is really important, and this starts before pregnancy," Federspiel said. "On average, a typical pregnancy requires an additional 1 g of iron."

Federspiel recommends clinicians discuss the causes and the effects of IDA with patients who are planning to or could become pregnant. Clinicians might recommend iron- and folate-rich foods and vitamins B12 and C and ask patients if they face any barriers to access.

"Prenatal vitamins with iron are the gold standard in preventing IDA in the pregnant population," Tilley said. "Education on the significant risk factors associated with IDA in early pregnancy is key."

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Cite this: Underdiagnosed: Iron Deficiency Anemia During Pregnancy - Medscape - Nov 30, 2023.