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  6. Prevention and Management of Iron Deficiency Anaemia in Pregnancy and the Puerperium (1195)
Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

Prevention and Management of Iron Deficiency Anaemia in Pregnancy and the Puerperium (1195)

Objectives

This guideline covers the prevention and management of iron deficiency anaemia during pregnancy and puerperium. It aims to ensure

  • Recognition of low iron states
  • Early intervention to prevent iron deficiency anaemia
  • The diagnosis of iron deficiency anaemia
  • Treatment of iron deficiency anaemia

Audience

This guideline is for use by midwives, obstetricians, and other members of the multidisciplinary team in Maternity. It is also of relevance to Primary Care – GPs, community pharmacists, and practice nurses who may be involved in the wider health care of pregnant women.

Iron deficiency is the most common cause of anaemia in pregnancy. Maternal anaemia can result in maternal fatigue, an increased risk of postpartum haemorrhage, and an increased risk of postpartum depression. It is associated with an increased risk of stillbirth, preterm birth and neonatal low ferritin levels.

Oral iron supplements can effectively treat iron deficiency anaemia. Supplements also have a role in treating low iron states and preventing the development of iron deficiency anaemia.

Maternal anaemia is defined as: 

  • Haemoglobin concentration (Hb) <110g/l 1st trimester
  • Hb <105g/l 2nd & 3rd trimesters
  • Hb <100g/l postpartum

All women should be offered screening for iron deficiency anaemia during pregnancy. At a minimum a full blood count (FBC) and serum ferritin should be obtained at

  • Booking appointment
  • 28 weeks
  • 34-38 weeks

It is the responsibility of the healthcare professional requesting and obtaining blood tests to ensure the results are reviewed and appropriate action taken.

  • Blood tests taken in the community should be followed up by the community midwife
  • Blood tests taken in the hospital should be followed up by the person requesting the test

Results of tests ordered through Trakcare will appear in the list of electronic results awaiting sign off. When results are signed off they should be actioned at the same time.

Blood tests taken, the results and actions should be documented in the electronic patient record (BadgerNet) using Blood Tests, Results and Actions.

Interpretation of results and treatments

The flow charts below detail the interpretation of blood test results and actions to either prevent or treat iron deficiency anaemia. Where further investigations are indicated refer to section 7.

Normal ranges in pregnancy are:

Ferritin  >30µg/l
Mean Cell Volume (MCV) 88-109fl
Transferrin   2-4g/l

 

Ferritin

<30

<30

>30

>30

MCV

Low

Normal

Normal/Low

Normal

Transferrin

High/ Normal/ Low

High /Normal/ Low

High

Normal/ Low

Cause

Iron deficiency anaemia

Iron deficiency anaemia

Iron deficiency anaemia is likely

Anaemia NOT likely to be due to iron deficiency. Look for other causes.

A raised ferritin result can be a transient inflammatory marker. If a serum ferritin result is >270 µg/l, repeat bloods and consultant review are indicated. If oral iron has previously been prescribed, treatment should be paused until further blood results are reviewed, and an individualised plan agreed.

Anaemias that present with a low haemoglobin but a normal or high ferritin (>30µg/l) need careful review. There are other causes of anaemia and iron therapy may not be the appropriate treatment.

Consider other causes of anaemia e.g. folate or Vitamin B12 deficiency and check levels. If there is a strong clinical suspicion of iron deficiency anaemia, consider checking transferrin (request “iron studies” on Trakcare).

These conditions

  • Thalassemia trait
  • Sickle cell disease (HbSS or HbSC)
  • Haemolytic anaemias (e.g. Hereditary spherocytosis)

can be associated with iron overload and therefore iron replacement is relatively contraindicated. Patients are likely to know they have these conditions.

Always consider the Hb result in conjunction with the serum ferritin result to confirm iron deficiency and exclude iron overload.

Discussion with a haematologist should take place before giving iron to women with these conditions.

A. First Line: Oral Iron

The first line iron therapy for both prevention and treatment of anaemia is one tablet of oral iron once daily. Recent evidence shows once daily dosing is as effective as twice or three times a day but has fewer side effects, so compliance is increased. Alternate day dosing is possible for women unable to tolerate daily dosing.

Ferrous fumarate or ferrous sulphate are suitable oral iron preparations. Sodium feredetate 5-10ml daily is a liquid alternative.

Women should be offered advice on how to take iron

  • In the morning
  • On an empty stomach
  • With orange juice (or other source of vitamin C)
  • Avoid tea or coffee and milk for two hours as they can reduce absorption of iron.
  • Some medications, including antacids, Thyroxine, calcium tablets and others interact with iron and should be taken at different times. If further advice is needed discuss with a pharmacist.

All women commenced on oral iron should continue on oral iron throughout the pregnancy, and for three months postpartum. For women commencing iron in the postnatal period oral iron should continue for at least three months.

Prescription requests to GPs should ideally be made through Clinical Portal. Local alternative arrangements may be in place in some areas. Women can be notified of results and prescription requests through the Badger App. Midwives can use the Midwifery Formulary to supply oral iron Midwifery Formulary for Mothers | Right Decisions (scot.nhs.uk).

 

B. Monitoring for a response to oral iron therapy

When oral iron is commenced as treatment for iron deficiency anaemia the effectiveness of the treatment should be monitored.

  • Check Hb and reticulocyte count 2-4 weeks after starting oral iron as treatment for iron deficiency anaemia.
  • Blood tests may be delayed until the patient’s next appointment if treatment started before 20 weeks gestation unless Hb≤80g/l (early monitoring required).
  • Reticulocyte count will increase prior to rise in Hb and will indicate that red blood cell production is responding to therapy
  • If no response in reticulocyte count at 2 weeks, review the diagnosis / compliance.
  • Response will depend on the initial degree of iron deficiency, patient requirements e.g. multiple pregnancy, and compliance.

Discussion with the obstetric team for individualised management is essential when

  • Hb <70g/l
  • Significant symptoms of anaemia
  • Advanced gestation >34/40
  • No response to treatment after 2-3 weeks of correctly taken oral iron

 

C. Second Line: Intravenous Iron

Intravenous iron is an alternative to oral iron for the treatment of anaemia. Careful consideration should be given to the use of intravenous iron as a range of common to rare side effects can be experienced.

It is intended for the treatment of significant iron deficiency anaemia – low haemoglobin and low ferritin in consultation with the obstetric team.

Indications for intravenous iron include

  • Known malabsorption condition;
  • Late pregnancy >34/40 gestation if Hb < 80g/l and iron deficient;
  • Postpartum in stable patient to avoid blood transfusion.
Benefits: Intravenous iron can improve iron stores and haemoglobin. Its use should be limited, as oral iron taken reliably is equally effective.
Risks: Rarely hypersensitivity and anaphylactoid reactions can occur -between 1 in 1000 and 1 in 10,000 people may be affected [BNF). Extravasation can occur and cause permanent brown discoloration to the skin.
Alternatives: Iron rich diet, oral iron, blood transfusion.
Nothing: If untreated iron deficiency anaemia will not resolve.

If a woman is not taking oral iron as recommended, or reports poor tolerance of oral iron, intravenous iron is not indicated. The second line in this circumstance should instead be to discuss and offer (see section 10a)

  • alternative iron preparations
  • alternate day dosing
  • optimising absorption of oral iron
  • dietary sources of iron.

It is essential that ferritin levels are checked prior to intravenous iron.

Contraindications for intravenous iron

  • History of anaphylaxis or allergy to intravenous iron
  • First trimester (possibly teratogenicity)
  • Acute/chronic infection
  • Chronic liver disease.

Refer to the GGC guideline for Iron Deficiency Anaemia (IDA) in Adults: Oral and Intravenous Iron Therapy Treatment available on Right Decisions platform - Iron Deficiency Anaemia (IDA) in Adults: Oral and Intravenous Iron Therapy Treatment (662) | Right Decisions

Ferinject (ferric carboxymaltose) should be used in obstetrics - prescribing-and-administration-information-for-ferinject.pdf

Please note it is recommended that oral iron is stopped 48h prior to administration of intravenous iron and should be withheld for five days after, if ongoing oral treatment is required.  

All women commenced on oral iron during pregnancy should continue on oral iron for three months postpartum.

The immediate postnatal management of anaemia will be determined by haemoglobin levels and a woman’s clinical condition. Refer to GGC Guideline Blood Transfusion in Stable Postpartum Patients

Postnatal

Intravenous iron can be used in a stable postpartum woman who is not actively bleeding or requiring immediate increase in Hb. An increase in haemoglobin of 30g/l can be expected in 14 days.

Booking appointment (pdf)

28 & 34/36 week (pdf)

Postnatal (pdf)

Patient Information Leaflet on anaemia (pdf)

Patient Information Leaflet on IV Iron (pdf)

Letter to GP (pdf)

Editorial Information

Last reviewed: 25/03/2025

Next review date: 31/03/2028

Author(s): Susan Kafka.

Version: 1

Approved By: Maternity Governance Group

Document Id: 1195

References
  1. Briley, A., Seed, P.T., Tydeman, G., et al. Reporting errors, incidence and risk factors for postpartum haemorrhage and progression to severe PPH: a prospective observational study. British Journal of Obstetrics and Gynaecology 2014;121: 876–888.
  2. Broche DE., Gay C., Armand-Branger S., et al. Severe anaemia in the immediate post-partum period. Clinical practice and value of intravenous iron. European Journal of Obstetrics & Gynecology and Reproductive Biology 2005; 123:S21-27 
  3. Daru J., Allotey J., Pena-Rosas JP.,et al. Serum ferritin thresholds for the diagnosis of iron deficiency in pregnancy: a systematic review. Transfusion Medicine, 2017, 27, 167–174.
  4. Haider, B.A., Olofin, I., Wang, M., et al. Anaemia, prenatal iron use, and risk of adverse pregnancy outcomes: systematic review and meta-analysis. British Medical Journal 2013;346, f3443.
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  8. Royal College of Obstetricians and Gynaecologists, Blood Transfusion in Obstetrics: Green-top Guideline No.47. 2015.
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