2.9.2.10. At 6 week recheck, if Hb is stable or increased compared to booking then continue oral iron therapy and recheck at 28/40. If significant side effects then consider alternative preparation and compliance with rules on when to take drug and what to take with.
2.9.3. 28-week appointment. Recheck FBC and ferritin for all women. The third trimester is the time when fetal iron uptake increases significantly. Therefore, the emphasis is very much on ferritin at this stage.
2.9.3.1. Hb < 100g/L – take full haematinics and refer to obstetricians.
2.9.3.2. If Hb > 100 and Ferritin is less than 30mcg/L then the woman is at risk of developing severe iron deficiency by term given then upcoming increase in fetal uptake of iron. Treatment depends on gestation.
2.9.3.3. Hb <100g/L, Ferritin <30mcg/L and 34 weeks or more. It is unlikely that there is sufficient time to increase ferritin to above 30mcg/L with oral alone, therefore please refer to obstetricians who may suggest IV iron.
2.9.3.4. HB<100g/L, ferritin <30mcg/L and less than 34 weeks. There may be sufficient time to improve ferritin with oral iron. If there has been good compliance with oral iron and they have tried different preparations including ferrous fumarate and ferritin is less than 10mcg/L then please refer as they may need IV iron to ensure they are not iron deplete by term. Otherwise, please continue oral iron, check compliance and side effects, consider alternative preparation and recheck in 6 weeks
2.9.3.5. Hb 100-120g/L and Ferritin >30 then continue or start oral iron. During this time monitor compliance and side effects and consider alternative preparations and recheck in 6 weeks.
2.9.3.6. Hb >120 and Ferritin >30: continue oral iron if already taking. No need for oral iron if not already on it.
2.10. Refractory anaemia: If anaemia is unresponsive to an appropriate trial of oral management (ferrous sulphate or ferrous gluconate):
2.10.1. Recheck booking bloods and haemoglobinopathy screening - for example thalassamia trait leads to borderline low haemoglobin which will be unresponsive to iron so long as the ferritin is adequate.
2.10.2. Check serum vitamin B12 and folate levels, together with a repeat ferritin if this has not been tested in the last month, and discuss the results with an obstetrician.