Iron optimisation in pregnancy: a Haematology in Obstetric and Women's Health Collaborative consensus statement

Anaemia is a well-recognised and widely accepted consequence of iron deficiency (ID); however, the two diagnoses are not synonymous with the effects of ID occurring long before the development of anaemia. In adults, ID can cause physical and neuropsychological symptoms, including lethargy, altered mood and poor concentration, reducing an individual's quality of life. Foetal and neonatal ID has been associated with impaired neurocognitive development with lasting effects despite iron replacement in early life. Obstetric ID is common, affecting up to 70% of Australian pregnancies. The impact, at both an individual and a population level, remains underappreciated and consensus on the identification and management of obstetric ID is lacking. This consensus statement was developed by the Haematology in Obstetrics and Women's Health (HOW) Collaborative and utilised the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate evidence and strength of recommendations. Recommendations are as follows: (i) Routine ferritin screening should be performed in all pregnant women (GRADE 1C) at booking and 24-28 weeks. Repeat testing should be performed at 36 weeks if clinically indicated or if the woman is previously unscreened. (ii) ID in pregnancy should be defined as a ferritin level <30 μg/L (GRADE 1D). (iii) An appropriate oral iron formulation should be offered as first-line therapy for obstetric ID (GRADE 1B). (iv) Alternate-day oral dosing can be considered to limit side effects in women with obstetric ID (GRADE 2B). (v) Intravenous iron should be offered to women with ID/ID anaemia who are intolerant of or refractory to oral iron or in the third trimester (GRADE 1B).