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

Maureen M. Achebe and Anat Gafter-Gvili


Anemia of pregnancy is considered a global health problem, affecting almost 50% of pregnant women. Anemia is an important risk factor for both fetal and maternal morbidity. The purpose of this article is to discuss diagnosis and management of the most frequent causes of anemia in pregnancy: iron, cobalamin and folate deficiencies. This paper considers three clinical cases. Iron deficiency is the most common cause. The laboratory tests that define iron deficiency, the recognition of developmental delays and cognitive abnormalities in iron-deficient neonates and the literature addressing the efficacy and safety of intravenous iron in pregnancy are reviewed. An algorithm is proposed to help the clinician diagnose and treat iron deficiency, recommending oral iron in the first trimester and intravenous iron later in pregnancy. The association of folate deficiency with neural tube defects and the impact of fortification programs are discussed. With increased rates of obesity and bariatric surgery, the prevalence of cobalamin deficiency in pregnancy is rising. Low maternal cobalamin may be associated with fetal growth retardation, fetal insulin resistance and excess adiposity. The importance of treating cobalamin deficiency in pregnancy is considered and the heightened impact of combined etiologies on the severity of anemia is highlighted. A case of malarial anemia emphasizes the complex relationship between iron deficiency, iron treatment and malaria infection in endemic areas.

  • Submitted August 24, 2016.
  • Accepted December 21, 2016.