• American College of Obstetricians and Gynecologists (ACOG). Anemia in pregnancy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2008 Jul. 7 p. (ACOG practice bulletin; no. 95). [32 references]

This is the current release of the guideline.

• Anemia
• Pregnancy

Diagnosis
Evaluation
Management
Prevention
Screening
Treatment

Hematology
Obstetrics and Gynecology

Physicians

• To aid practitioners in making decisions about appropriate obstetric and gynecologic care
• To provide a brief overview of the causes of anemia in pregnancy and review iron requirements
• To provide recommendations for screening and clinical management of anemia during pregnancy

Pregnant women

1. Iron supplementation
2. Screening for anemia during pregnancy
3. Maternal transfusion in case of severe anemia
4. Parenteral iron for patients who cannot tolerate oral iron: iron dextran or ferrous sucrose
5. Autologous transfusion
6. Prenatal vitamin supplementation

• Effectiveness of screening for anemia during pregnancy
• Effectiveness of anemia prophylaxis during pregnancy

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' (ACOG's) own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and September 2007. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Systematic Review

Not stated

Expert Consensus

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

The following conclusion is based on good and consistent scientific evidence (Level A):

• Iron supplementation decreases the prevalence of maternal anemia at delivery.

The following recommendations and conclusions are based on limited or inconsistent evidence (Level B):

• Iron deficiency anemia during pregnancy has been associated with an increased risk of low birth weight, preterm delivery, and perinatal mortality.
• Severe anemia with maternal hemoglobin (Hgb) levels less than 6 g/dL has been associated with abnormal fetal oxygenation resulting in nonreassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilatation, and fetal death. Thus, maternal transfusion should be considered for fetal indications.

The following recommendations are based primarily on consensus and expert opinion (Level C):

• All pregnant women should be screened for anemia, and those with iron deficiency anemia should be treated with supplemental iron, in addition to prenatal vitamins.
• Patients with anemia other than iron deficiency anemia should be further evaluated.
• Failure to respond to iron therapy should prompt further investigation and may suggest an incorrect diagnosis, coexisting disease, malabsorption (sometimes caused by the use of enteric-coated tablets or concomitant use of antacids), noncompliance, or blood loss.

Definitions:

Grades of Evidence

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Appropriate evaluation and treatment of anemia in pregnancy
• Iron supplementation decreases the prevalence of maternal anemia at delivery

• There is little evidence that iron supplementation results in morbidity beyond gastrointestinal symptoms, except in patients with hemochromatosis or certain other genetic disorders.
• Anaphylactic reactions have been reported in 1% of patients receiving parenteral iron dextran.

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

An implementation strategy was not provided.

Getting Better
Staying Healthy

Effectiveness

• American College of Obstetricians and Gynecologists (ACOG). Anemia in pregnancy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2008 Jul. 7 p. (ACOG practice bulletin; no. 95). [32 references]

Not applicable: The guideline was not adapted from another source.

2008 Jul

American College of Obstetricians and Gynecologists - Medical Specialty Society

American College of Obstetricians and Gynecologists (ACOG)

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins - Obstetrics

Not stated

Not stated

This is the current release of the guideline.

Proposed performance measures are included in the original guideline document.

None available

This NGC summary was completed by ECRI Institute on January 5, 2008. The information was verified by the guideline developer on January 23, 2009.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.