Fe struggles....

I honestly believe we overtreat women for assumed "anemia" in pregnancy.

Again, it's a case of applying non-pregnant lab values to pregnant women - with a total disregard of what happens physiologically to a woman's body while carrying and growing a baby.

A Guide to Effective Care in Pregnancy & Childbirth by Enkin, Keirse, Renfrew and Neilson reports that a hemoglobin count of 9.5 is optimal for fetal growth and maternal well-being:

The normal haematological adaptations to pregnancy are frequently misinterpreted as evidence of iron deficiency that needs correcting. Iron supplements have been given with two objectives in view: to try to return the haematological values towards the normal non-pregnant state, a strange objective when millions of years of evolution have determined otherwise, and to improve the clinical outcome of the pregnancy and the future health of the mother. The first objective can certainly be accomplished; the key question is whether or not achieving the "normalized" blood picture benefits the woman and her baby. Routine iron supplementation raises and maintains serum ferritin above 10 microgram/litre and results in a substantially lower proportion of women with a haemoglobin level below 10 or 10.5 grams per cent (below 6-6.5 mmol/litre) in late pregnancy. Routine folate supplementation as a haematinic after the first few weeks of pregnancy substantially reduces the prevalence of low serum and red cell folate levels, and of megaloblastic haematopoiesis. As yet, neither iron nor folate supplementation after the first trimester have shown any detected effect on the following substantive measures of maternal or fetal outcome: proteinuric hypertension, antepartum haemorrhage, postpartum haemorrhage, maternal infection, preterm birth, low birthweight, stillbirth, or neonatal morbidity. Women do not feel any subjective benefit from having their haemoglobin concentration raised.

A possible advantage claimed for a high level of haemoglobin in pregnancy is that the woman would be in a stronger position to withstand haemorrhage. There is no evidence to support this claim. indeed, as a low haemoglobin in healthy pregnant women generally implies a large circulating blood volume, it is at least possible that women with a low haemoglobin might better withstand a give loss of blood.

There are few data derived from communities in which nutritional anaemia from either iron or folate deficiency is prevalent. Trials are needed in these populations to establish the most appropriate strategies for combatting the deficiencies.

Whether routine iron supplementation causes any harm in well-nourished communities is still unclear, but it is clearly wasteful. The evidence suggests that, except for genuine anaemia, the best reproductive performance is associated with levels of haemoglobin that are traditionally regarded as pathologically low. There is cause for concern in the findings of two well-conducted trials that iron supplementation resulted in an increase in the prevalence of preterm birth and low birthweight. Perhaps there is an adverse effect on fetal growth due to the increased viscosity of maternal blood that follows the iron-induced marcrocytosis and increased haemoglobin concentration, which may impeded uteroplacental blood flow.

An individuals' haemoglobin concentration depends much more on the complex relation between red-cell mas and plasma volume than on deficiencies of iron or folates. The advent of electronic blood counters has given an opportunity for more appropriate criteria to be applied to the diagnosis of anaemia. Mean cell volume may be the most useful; it is not closely related to haemoglobin concentration and declines quite rapidly in the presence of iron deficiency. A low haemoglobin without other evidence of iron deficiency requires no treatment.

If there is evidence of genuine iron deficiency, iron treatment is needed, and the usual approach is to give iron salts by mouth. There is no convincing evidence that the addition of copper, manganese, molybdenum, or ascorbic acid improves the efficiency with which the iron is used.

The cause of megaloblastic anaemia in pregnancy is almost always folate deficiency, and treatment with folic acid supplementation is rapidly effective.

For example, you see a woman at 10 weeks for her initial prenatal visit. Drawing blood, the results show her hemoglobin at 12.3. At 28-30 weeks (when the blood volume expansion peaks), another draw shows the hgb at 10.9. Many providers will immediately label this woman as being anemic and suggest an iron supplement. What is given is usually a synthetic form of iron that is not absorbed well at all. Some researchers have pointed that routine iron supplementation leads to a higher rate of pre-eclampsia. (As Anne Frye says, if the blood volume is adequately expanded you won't see pre-eclampsia, so the drop in hgb is a positive sign!)

A woman with true anemia will feel it, regardless if her hgb is 10.1 or 12.3. She will be overly tired, her conjunctiva will be pale, she may have dark circles around her eyes. THIS is when I look at offering supplementation nutritionally or with sound iron.

From Michel Odent:

In many countries, the amount of red blood cells pigment (hemoglobin concentration) is routinely measured in pregnancy. There is a widespread belief that this test can effectively detect anemia and iron deficiency. In fact, this test cannot diagnose iron deficiency, because the blood volume of pregnant women is supposed to increase dramatically, so the hemoglobin concentration indicates first the degree of blood dilution, an effect of placental activity. A large British study, involving 153,602 pregnancies (17), found that the highest average birth weight was in the group of women who had a hemoglobin concentration between 8.5 and 9.5. Furthermore, when the hemoglobin concentration fails to fall below 10.5 there is an increased risk of low birth weight, preterm birth and pre-eclampsia. The regrettable consequence of routine evaluation of hemoglobin concentration is that, all over the world, millions of pregnant women are wrongly told that they are anemic and are given iron supplements. There is a tendency both to overlook the side effects of iron (constipation, diarrhea, heartburn, etc.) and to forget that iron inhibits the absorption of such an important growth factor as zinc (18). Furthermore iron is an oxidative substance that can exacerbate lipid peroxidation (free radicals) and might even increase the risk of pre-eclampsia (19).