A 32-year-old multiparous woman (G3P2) attends the antenatal clinic at 20 weeks of gestation in Delhi. She has had two previous normal deliveries. On routine antenatal screening, her haemoglobin is 9.2 g/dL, MCV 68 fL, and serum ferritin 12 ng/mL. She denies any vaginal bleeding or systemic symptoms. According to RCH guidelines for anemia in pregnancy, what is the most appropriate management?

Explanation

## Clinical Diagnosis This patient has **iron-deficiency anemia in pregnancy** (Hb 9.2 g/dL, microcytic MCV 68 fL, low ferritin 12 ng/mL) at 20 weeks of gestation. **Key Point:** Moderate anemia in pregnancy (Hb 7–10 g/dL) without symptoms or hemodynamic compromise is managed with **oral iron supplementation** as first-line therapy, per RCH and WHO guidelines. ## RCH Protocol for Anemia in Pregnancy | Hemoglobin Level | Trimester | Management | |---|---|---| | ≥11 g/dL | Any | Prophylactic iron (30 mg elemental iron daily) | | 7–10.9 g/dL | Any | Therapeutic iron (100 mg elemental iron daily) | | <7 g/dL | 2nd/3rd trimester | Consider transfusion if symptomatic or Hb <5 g/dL | | <7 g/dL | 1st trimester | Oral iron; transfuse only if symptomatic | **High-Yield:** The RCH program recommends **oral iron supplementation** (ferrous sulphate 300 mg = 60 mg elemental iron, or ferrous fumarate 200 mg = 65 mg elemental iron) as the standard first-line approach. Dosing is adjusted based on Hb level and trimester. ## Why Oral Iron? 1. **Cost-effective** and widely available in primary health centres 2. **Safe** in pregnancy when used as directed 3. **Effective** — achieves Hb rise of 1–2 g/dL over 4 weeks 4. **Compliance** — once-daily dosing improves adherence 5. **No transfusion risk** — avoids bloodborne infection, alloimmunization, and volume overload ## Monitoring - Recheck hemoglobin in **4 weeks** - If Hb rises by ≥1 g/dL, continue the same dose - If no response, assess compliance and consider malabsorption or ongoing blood loss - Parenteral iron reserved for intolerance, malabsorption, or severe anemia requiring rapid correction **Clinical Pearl:** Gastrointestinal causes of iron loss (hookworm, bleeding ulcer) are common in India; however, in an asymptomatic multiparous woman at 20 weeks with typical iron-deficiency pattern, empiric oral iron is the standard first step. Endoscopy is not routine unless there are red flags (hematemesis, melena, or failure to respond to iron after 8 weeks). [cite:Park 26e Ch 10 (RCH), WHO Guideline on Anemia in Pregnancy 2021]