Iron Deficiency and Iron Deficiency Anemia in Obstetrics and Gynaecology

A complete blood count and serum ferritin should be ordered as the initial tests when evaluating for iron deficiency and iron deficiency anemia. A complete blood count alone is insufficient to accurately assess iron deficiency. ( S, M )

When patients do not respond appropriately to iron replacement therapy, additional diagnostic evaluations should be considered. If the cause of anemia cannot be determined, or if an underlying bleeding disorder is suspected, referral to Internal Medicine or Hematology is recommended. ( S, M )

Given the high prevalence of iron deficiency among individuals with heavy menstrual bleeding, periodic universal laboratory screening may be beneficial for women of reproductive age. ( C, M )

Laboratory screening for iron deficiency and iron deficiency anemia is recommended for all individuals with heavy menstrual bleeding, prior to planned pregnancy, during pregnancy, and pre-operatively for major gynaecologic surgery. ( S, H )

Oral iron salts are first line therapy for iron replacement due to their efficacy, availability, and low cost. Patients should be provided with strategies to improve tolerance, compliance and absorption of oral iron salts. ( S, H )

Intravenous iron is a safe and effective iron replacement therapy that can be administered in ambulatory settings and is recommended for patients with moderate to severe anemia, intolerance to oral iron, or when rapid correction of iron deficiency is required. Provincial healthcare systems should establish funding mechanisms to ensure that cost is not a barrier to accessing this treatment when clinically indicated. ( S, H )

Repeat laboratory testing is required to confirm appropriate treatment response following the initiation of iron replacement therapy. ( C, M )

Red blood cell transfusion should generally be reserved for patients with hemodynamic compromise, active bleeding, or cardiovascular symptoms (e.g. hypotension, chest pain, syncope). ( C, M )

In addition to iron replacement therapy, treatment of heavy menstrual bleeding is recommended as a key component of managing and correcting iron deficiency and iron deficiency anemia. ( S, H )

All patients undergoing major gynaecologic surgery should be screened for iron deficiency and iron deficiency anemia, ideally at the time of the decision to operate, to allow adequate time for correction. ( S, H )

Hemoglobin levels should be optimized prior to all major elective surgeries, with a target hemoglobin of ≥130 g/L. This practice should be supported by institutional policy. ( S, H )

For preoperative patients with iron deficiency and iron deficiency anemia with short “lead time” to gynaecologic surgery, there should be a low threshold for the initiation of intravenous iron to allow for rapid optimization. ( S, M )

Intravenous iron is recommended for patients who develop postoperative anemia due to intraoperative blood loss. ( S, M )

All individuals of reproductive age who are planning pregnancy should be screened for iron deficiency and iron deficiency anemia. Both hemoglobin levels and iron stores should be optimized prior to conception. ( S, H )

All pregnant women should be screened for iron deficiency and iron deficiency anemia in the first trimester, with repeat screening at 24–28 weeks’ gestation and again prior to delivery. ( S, H )

In addition to prenatal vitamins, oral iron should be routinely recommended in pregnancy to meet the increased iron demands of pregnancy. ( C, M )

Routine fetal monitoring during or after intravenous iron administration is not required. In the rare event of anaphylaxis, maternal stabilization should take priority, followed by appropriate fetal assessment. ( C, M )

Women with postpartum hemorrhage or antenatally identified iron deficiency anemia should have a postpartum complete blood count, with a low threshold for initiating intravenous iron therapy. ( S, M )