Assessing and Addressing ID/IDA: The Need for Guidance

Transcript

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Dr. Munro: 
Hello. This is CME on ReachMD, and I’m Dr. Malcolm Munro here with Dr. Arjeme Cavens from Northwestern University, and we’re here to talk about screening and diagnosis of women with iron deficiency and iron deficiency anemia. 

So, Arjeme, tell us, what are the guidelines that are provided by the American College for women who are pregnant?  

Dr. Cavens:
We know that maybe up to 30% or even 50% of women in their first trimester of pregnancy will be iron deficient even if they aren’t anemic. So that gives us some information about these conditions outside of pregnancy. Our guidance really is limited to pregnancy-specific times, and that’s guidance from ACOG who recommends that we screen all pregnant women for anemia, which will consist of a CBC [complete blood count] in the first trimester, and then again repeating that between 24 and 28 weeks. ACOG also recommends that we supplement all pregnant women with low-dose iron. Usually that’s accomplished by just taking a prenatal vitamin, and I think it’s also important to recognize that the definitions of anemia in pregnancy are different than they are outside of pregnancy. So in the first and third trimester, anemia is defined as a hemoglobin of less than 11, and in the second trimester, it’s defined as a hemoglobin of less than 10.5. Really, any patient with anemia in pregnancy should be undergoing further testing for iron deficiency, at least with the ferritin but potentially with other iron studies, and I think it’s important to do that, even if it’s not a patient with a microcytic anemia specifically, because there can be a multitude of micronutrient-deficiencies. 

Now, that’s all about pregnancy, and I think what is deficient here is we really don’t have guidelines for screening for iron deficiency or iron deficiency anemia outside of pregnancy, even though we know there can be some adverse outcomes. So we know there can be increased neurodevelopmental disorders, we know that within pregnancy itself there can be an increased risk of low birth rate, preterm delivery, abnormal weight gain, blood transfusions, but we really don’t have good guidance outside of pregnancy of how to screen women pre-conceptually. 

Dr. Munro: 
So doesn’t that beg the question of routine screening for iron deficiency as a preferential approach than starting with anemia alone?

Dr. Cavens:
I think the guidelines aren’t there yet, so certainly an area for further development. This is something that the Women’s Physician Section of the AMA has recognized as concern and is putting forward proposals, but the guidelines aren’t there yet. I think this also highlights what as providers we often focus on for iron deficiency anemia in pregnancy, which is getting a hemoglobin up by the time of delivery, when really we need to minimize the time that that iron deficiency is there throughout the gestation in general. 

Dr. Munro:
Well, of course, that brings up the question about the non-pregnant individual prior to pregnancy. And so what does the College do for preconceptual iron deficiency screening or anemia screening even in women who have heavy menstrual bleeding. Is there any guidance there?

Dr. Cavens:
So at least at this juncture, there isn’t any screening guidance. I think we are encouraged to be diligent about taking histories and examining our patients to identify patients who might be at risk based on their symptoms or other lifestyle factors or other medical conditions that might put them at risk for iron deficiency, but there really isn’t recommendations for screening, and I think that is an area for future exploration.

Dr. Munro: 
Yeah, certainly when you have a disorder that may be present in 50% of women, it would seem that it’s shortsighted not to be evaluating the nonpregnant individual, especially the one whom you know has abnormal uterine bleeding.

Tell us about the issue of disparity and how that influences this entire problem of iron deficiency.

Dr. Cavens:
We know that iron deficiency and iron deficiency anemia are more likely to affect women of color, specifically Black and Hispanic women, but also those of lower socioeconomic status, teenage individuals. I do think it’s important to note that in the past, ACOG actually had differential race-based definitions for anemia, and those have since been eliminated. So we need to reiterate that while the thresholds for anemia in pregnancy may be different than those outside of pregnancy, all individuals, regardless of race, age, ethnicity, we all need to be evaluated by the same laboratory standards and therapy recommended for the same treatment goals as well. 

Dr. Munro:
Great points. So that’s all the time we have today. Thanks for listening.

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