Who this is for: GPs, medical officers and clinic teams running antenatal care who must find, treat and follow anaemia before it becomes a peripartum emergency.

Epidemiology in Pakistan

Anaemia affects roughly 40 to 45 percent of pregnant women in Pakistan (National Nutrition Survey 2018 reported maternal anaemia at 41.7 percent), driven by iron-deficient diets, short birth intervals, adolescent pregnancy, hookworm in some districts, and a substantial background of beta-thalassaemia trait (5 to 7 percent carrier rate). Anaemia multiplies the risk of low birth weight, preterm birth, peripartum transfusion and maternal death from haemorrhage; postpartum haemorrhage on top of a Hb of 7 is a different disease than on a Hb of 11. ANC is where this is won.

Definitions and screening

WHO cutoffs in pregnancy: anaemia is Hb below 11.0 g/dL in the first and third trimesters, and below 10.5 g/dL in the second trimester (physiological haemodilution nadirs mid-pregnancy); severe anaemia is Hb below 7.0 g/dL, and very severe below 4.0. Classify severity: mild 10.0 to 10.9 (first or third trimester), moderate 7.0 to 9.9, severe below 7.0.

Screen with a CBC at the booking visit and again at 28 weeks (align with your provincial ANC schedule; WHO recommends Hb testing as part of routine ANC, ideally with a full blood count rather than haemoglobin colour scale where labs exist). A third check around 36 weeks is prudent where earlier anaemia was treated, so delivery is not entered blind.

Workup: find the cause, cheaply

Most antenatal anaemia in Pakistan is iron deficiency, but do not reflexively label it:

  1. CBC with indices. Low MCV and MCH suggest iron deficiency or thalassaemia trait; high MCV suggests folate or B12 deficiency.
  2. Serum ferritin where affordable is the best single iron test (below 30 ng/mL indicates deficiency; interpret cautiously with infection since ferritin is an acute-phase reactant).
  3. Thalassaemia trap: microcytosis with a normal ferritin, a normal-ish red cell count, or anaemia unresponsive to 4 weeks of iron should trigger Hb electrophoresis, and partner testing if the mother is a carrier: this is also the entry point to prenatal counselling in a country with a large thalassaemia major burden.
  4. Stool for ova and parasites in rural or barefoot-exposure settings; malaria testing in endemic districts with fever.
  5. Where no lab exists, conjunctival and palmar pallor plus symptoms justify presumptive iron-folate treatment and referral for testing at the next opportunity, per IMCI-style pragmatism; but severe pallor is a referral, not a prescription.

Prevention and treatment

Prevention for all pregnant women (WHO ANC recommendations, 2016): daily oral supplementation with 30 to 60 mg elemental iron plus 400 mcg (0.4 mg) folic acid throughout pregnancy. In populations where anaemia prevalence exceeds 40 percent, which describes Pakistan, WHO advises the 60 mg elemental iron dose. Iron-folate tablets are free at government ANC clinics and cheap as DRAP-registered generics; counsel on taking them away from tea (tannins block absorption), ideally with vitamin C-containing food or a glass of water with lemon.

Treatment of established iron-deficiency anaemia: 100 to 200 mg elemental iron daily in divided doses (for reference, ferrous sulfate 200 mg tablets contain roughly 65 mg elemental iron; ferrous fumarate 200 mg roughly 66 mg), continuing folic acid, until Hb normalises and then for a further 3 months to rebuild stores. Expect Hb to rise about 1 g/dL every 2 to 3 weeks on adherent therapy; recheck at 3 to 4 weeks. Gastrointestinal side effects are the main adherence killer: take with food, use alternate-day dosing if needed (emerging evidence supports absorption efficiency), or switch salt.

Parenteral iron: IV iron (iron sucrose or ferric carboxymaltose, both available in Pakistani hospitals) is indicated for intolerance or non-response to oral iron, malabsorption, or moderate-to-severe anaemia presenting after 34 weeks when oral therapy cannot correct Hb before delivery. Administer where anaphylaxis can be managed, generally at referral level; IM iron injections in clinics are discouraged.

Deworming: in hookworm-endemic areas WHO supports a single dose of albendazole 400 mg after the first trimester.

Transfusion is reserved for severe anaemia with decompensation (breathlessness at rest, tachycardia, heart failure signs) or severe anaemia near term or before caesarean delivery, decided at hospital level.

Folate or B12 pattern (macrocytosis): folic acid 5 mg daily, and check or empirically treat B12 where testing is unavailable, especially in strict vegetarians.

Red flags: refer

Hb below 7.0 at any gestation; any anaemia with breathlessness at rest, chest pain, tachycardia or oedema; anaemia unresponsive to 4 weeks of adherent oral iron; anaemia first detected after 34 to 36 weeks (delivery planning and possible IV iron); suspected thalassaemia or other haemoglobinopathy; bleeding per vaginam; pancytopenia or other cell-line abnormalities on CBC.

Plan the birthplace explicitly: a woman entering labour with moderate or severe anaemia should be booked at a facility with blood bank access, and her family counselled about donor arrangement in advance, which is the operational reality of Pakistani transfusion services.

Follow-up schedule

  • Recheck Hb 3 to 4 weeks after starting treatment, then at 28 weeks and around 36 weeks.
  • Verify tablet supply and adherence at every ANC contact; count remaining tablets rather than asking yes-no questions.
  • Postpartum: continue iron-folate for at least 3 months after Hb normalises, and screen again at the 6-week postnatal visit, especially after haemorrhage.

The MyPatient EHR problem list carries the anaemia severity grade and the next scheduled Hb check into every ANC contact, so a booking-visit Hb of 8.9 cannot quietly disappear until delivery. Share the patient guide to share covering iron-rich Pakistani foods and tablet-taking tips.

Key points

  • Cutoffs: Hb below 11.0 (first and third trimester), below 10.5 (second); severe is below 7.0.
  • Screen CBC at booking and 28 weeks; add a 36-week check after treated anaemia.
  • Prevent with daily 60 mg elemental iron plus 400 mcg folic acid for all; treat deficiency with 100 to 200 mg elemental iron.
  • Microcytosis with normal ferritin or iron non-response means Hb electrophoresis, and partner testing for carriers.
  • Refer Hb below 7, symptomatic anaemia, non-responders at 4 weeks, and late-pregnancy anaemia for IV iron and delivery planning.
  • Continue iron 3 months beyond normalisation and recheck postpartum.

References

  • WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. World Health Organization, 2016.
  • Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity. World Health Organization, 2011 (updated guideline 2024).
  • Daily Iron and Folic Acid Supplementation During Pregnancy: WHO Guideline. World Health Organization, 2012.
  • Antenatal Care Routine Care Recommendations, NG201. National Institute for Health and Care Excellence, 2021.
  • National Nutrition Survey Pakistan: Key Findings Report. Ministry of National Health Services and UNICEF, 2018.

Clinical judgement and local protocols take precedence.