The commonest failure in antenatal anaemia care is not the choice of iron. It is that nobody checks whether it worked. A woman is prescribed oral iron at booking, told to take it, and next has a haemoglobin measured in labour — by which time the window in which treatment could have changed anything has closed.
The fix is administrative rather than clinical. At the visit where iron is started, book the repeat test. Write the date, and write the action: if haemoglobin remains below 10.5 g/dL at 20 to 24 weeks, escalate.
What escalation means depends on why the first treatment failed, and the two causes need separating. If she has not been taking the tablets — because of nausea, constipation, or because they ran out — the answer is a different oral preparation, a different schedule, or a supply that lasts. If she has been taking them and has not responded, the answer is intravenous iron, and a look for the reasons oral iron fails: ongoing blood loss, malabsorption, infection, haemoglobinopathy.
Ask which it is rather than assuming. 'How many days in the last week did you take it?' produces a more honest answer than 'are you taking your iron?'
And check the haemoglobinopathy status where it is relevant. A woman with thalassaemia trait will not respond to iron, and giving her more of it is both useless and potentially harmful.
- Book the 20 to 24 week repeat haemoglobin at the visit where you start iron, with the date written down
- Write the escalation trigger in the notes: haemoglobin below 10.5 g/dL means treatment failure
- Separate non-adherence from non-response before escalating — they need different answers
- Ask how many days in the last week she took it, not whether she is taking it
- Check haemoglobinopathy status; thalassaemia trait will not respond to iron and more iron may harm
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