2.4.7. If there has been no improvement in haemoglobin and ferritin by 6 weeks, seek advice and guidance from obstetrics. Refractory anaemia may be due to poor compliance of oral iron therapy. The GP may be able to prescribe an alternative oral iron therapy e.g. ferrous fumarate 200mg. Alternatively, there may be other causes of anaemia than iron deficiency which need investigation and treatment. Take folate and B12 bloods prior to referral.
There is strong evidence that patients with a normal ferritin are at decreased risk of PPH and MOH. Therefore, given the religious beliefs surrounding receiving blood, it is prudent to ensure that maternal iron levels are as good as can be. To that end, we advise starting oral iron at booking before HB and Ferritin levels are back. If ferritin levels are normal and the woman no longer wants to take oral iron then they could stop but should be aware that they may be advised to restart at a later date. It is advisable to be vigilant with ferritin levels throughout pregnancy however extra ferritin tests are not required unless requested by the obstetric team.
2.6.1. If the woman is known to have haemoglobinopathy, ferritin should be checked and oral iron started only if ferritin is <30 mcg/L. If haemoglobinopathy status is unknown, it is reasonable to start oral iron whilst screening is being performed.
2.6.2. Sickle Cell Trait / Thalassaemia Trait - this should be referred to the womans area consultant to manage. They will likely need closer monitoring of their Ferritin.
2.6.3. Sickle Cell Disease / Thalassaemia - Please make an urgent referral to the haemobs clinic.
2.7.1. Patients with pernicious anaemia, coeliac disease or inflammatory bowel disease will be unlikely to respond to oral iron if their underlying disease is untreated.
2.7.2. Patients with macrocytosis may have B12 or folate deficiency as a cause of anaemia.
2.7.3. If patients are known to have one of these conditions, or if they have not responded to oral iron supplementation after 6 weeks, please check B12 and folate levels and refer to obstetrics for advice and guidance.
Please see appendix 5 for how midwives should supply the initial dose of ferrous sulphate or ferrous gluconate, from stocks kept in bases and ordered through POP. After re-check of haemoglobin and ferritin levels, this can be continued by the GP if needed (New 2025).