How I treat anemia in pregnancy: iron, cobalamin, and folate

Maureen M. Achebe and Anat Gafter-Gvili

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  • RE: Further considerations in the management of anemia in pregnancy
    • Maureen M Achebe, Hematologist Brigham and Women's Hospital, MA; Dana-Farber Cancer Institute, Boston, MA.
    • Other Contributors:
      • Anat Gafter-Gvili, Hematologist

    Thank you for taking the time to provide feedback to our ‘How I Treat Article’. We are delighted to provide a response.
    In addressing this ‘How I treat’ article our charge from the Editors of Blood was to present our application of current evidence to our clinical practice. There are a number of points in your letter that we wish to differ on, and for which you provide inadequate referencing. We will deal with these in sequence.
    Though anemia in pregnancy will rarely lead to mortality in the iron deficient woman or her offspring, we would like to debunk the impression of anemic pregnant women as ‘generally well people’, who therefore need not be treated. Anemia in pregnancy is potentially hazardous to the fetus and neonate. Several studies suggest possible neurological effects of iron deficiency in neonates of iron deficient women.1,2 Therefore we recommend aiming to correct iron deficiency well before the 34th week of gestation, that you suggest. Correction of iron deficiency in pregnancy should not be aimed solely at blood loss at parturition.
    The thought that 4-6 weeks is required for a change in hemoglobin upon oral iron supplementation is arbitrary and not backed by data. We previously showed that 2 weeks is adequate time to expect a change in hemoglobin from oral iron therapy.3 We know of no evidence of a deleterious effect of replacing iron in iron deficient patients with thalassemia trait. Certainly, it should not be assumed that all patients wi...

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    Conflict of Interest:
    None declared.
  • Further considerations in the management of anaemia in pregnancy
    • Giselle L Kidson-Gerber, Clinical and Laboratory Haematologist Prince of Wales Hospital, The Royal Hospital for Women, The University of New South Wales, Sydney, Australia
    • Other Contributors:
      • Susan J MacCallum, Clinical and Laboratory Haematologist

    We read with interest the article How I treat Anemia in Pregnancy by Achebe and Gafter-Gvili – this is a common problem worldwide with a growing body of evidence. This article does not describe standard practice and provides confusing messages, which may be deleterious in the management of such women.

    Of first concern is the early recourse to intravenous iron therapy or red cell transfusion, when oral iron therapy can be effective and we are moving into an era of reducing unnecessary red cell transfusions. Evidence suggests that lower or intermittent doses of oral iron may be as effective as higher doses [1,2]. A reticulocytosis is usually seen within 7-10 days with a subsequent rise in haemoglobin – hence sufficient time must lapse prior to re-assessment and a 4-6 week follow-up is preferable to the 2 weeks recommended in the review, unless the woman is beyond 34 weeks gestation. Unmentioned in the article was the possibility of thalassaemia trait, in which case iron replacement may be deleterious.

    If oral iron is not tolerated, ineffective or there is inadequate time for recovery of haemoglobin, such as mid 3rd trimester, then intravenous iron should be discussed. Intravenous iron is associated with increased adverse effects [3] although growing experience suggests that ferric carboxymaltose has a lower incidence. Table 1 does not provide guidance on choice of iron as beneficial and adverse outcomes are not included.

    Transfusion of red cells require...

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    Conflict of Interest:
    None declared.