These result in a total requirement of <1000mg Fe requiring an average daily intake of 3.5-4.0mg/d. Average Western diet provides <4.0mg Fe/d so that balance is marginal during pregnancy. Diets with Fe mainly in non-haem form (e.g. vegetables) provide less Fe available for absorption. Thus a high risk of developing Fe deficiency anaemia which is exacerbated if preconception Fe stores are reduced.

Folate requirements are increased during pregnancy because of increased cellular demands; folate levels tend to drop during pregnancy.

Prophylaxis recommendation to give 40-60mg elemental Fe/d which will increase availability of dietary absorbable Fe and protect against chronic Fe deficiency; debated whether supplements required by all pregnant women or only for those in at-risk socio-economic and nutritionally deficient groups. Folate supplementation is recommended for all and also appears to reduce incidence of neural tube defects.

• Dilutional anaemia—Hb seldom <10.0g/dL (requires no therapy).

• Fe deficiency—may occur with normal MCV because of 4 MCV associated with pregnancy; check serum ferritin and give Fe replacement; assess and treat the underlying cause.

• Blood loss—sudden 5 in Hb may signify fetomaternal bleeding or other forms of concealed obstetric bleeding.

• Folate deficiency—macrocytic anaemia in pregnancy almost invariably will be due to folate deficiency (B12 deficiency is extremely rare during pregnancy).

• Microangiopathic haemolysis/DIC may be seen in eclampsia or following placental abruption or intrauterine death. HELLP syndrome (p34) is rare but serious cause of anaemia.

• Anaemia may also arise during pregnancy from other unrelated causes and should be investigated.

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