A 32-year-old woman with severe iron deficiency anemia (hemoglobin 6.8 g/dL) at 34 weeks gestation is hemodynamically stable with no active bleeding. She has not responded to oral iron after 4 weeks. Which is the most appropriate next step?

• A Packed red cell transfusion of 2 units over 4 hours with furosemide prophylaxis
• B Erythropoietin injection subcutaneously three times weekly combined with oral iron
• C Intramuscular iron dextran daily for 10 days until total iron deficit is repleted
• D Intravenous ferric carboxymaltose infusion as a single dose, with repeat hemoglobin check in 2-3 weeks ✓

Explanation

IV ferric carboxymaltose is the preferred parenteral iron preparation in the second and third trimesters when oral iron is ineffective or not tolerated, as it allows rapid repletion in a single or few doses with good safety data. Distractor A is wrong because transfusion is reserved for hemodynamic instability or symptoms, not a stable patient with time for iron repletion. Distractor C is wrong because IM iron dextran is painful, stains skin, and is no longer preferred. Distractor B is wrong because erythropoietin is reserved for specific scenarios like renal failure, not routine iron deficiency.

Reference: Williams Obstetrics, 26th ed.

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