Treatment of iron deficiency and iron deficiency anemia with intravenous ferric carboxymaltose in pregnancy

A new effect of intravenous iron treatment in pregnancy: contraction in nonstress test and timing of labor

OBJECTIVE

The aim of this study was to elucidate the cause and results of contractions occurring in term pregnant women receiving intravenous iron therapy.

METHODS

During 2019-2020, 136 pregnant women beyond 35 weeks of gestation, who received intravenous iron treatment due to iron deficiency anemia, were included through retrospective screening. Iron deficiency anemia was defined as having hemoglobin levels <10 g/dL and ferritin levels <15 ng/mL, and the pregnant women underwent nonstress test before and after treatment.

RESULTS

The average treatment week for the pregnant women was 36.82±0.74, and the presence of regular contractions in post-treatment follow-up nonstress tests was 72.1% (n=98). The average week of birth was 38.48±1.60. Pregnant women with contractions who had previous cesarean were found to have a mean delivery week of 36.82±0.67, which was statistically significant earlier than for nulliparous and multiparous women (p<0.001).

CONCLUSION

In pregnant women with iron deficiency anemia who were beyond 35 weeks, temporary regular contractions may be observed in the nonstress test following intravenous iron replacement. We think that this effect may lead to early term birth in pregnant women with a history of cesarean section. It needs to be confirmed by further prospective studies and animal studies.

Ferric carboxymaltose: A game changer in the management of iron deficiency anaemia in pregnancy

Anaemia is a well-known global health concern in the South Asian countries, and it is estimated that India has the utmost prevalence of anaemia and maternal deaths due to iron deficiency anaemia. This study aims to assess the efficacy and safety of intravenous ferric carboxymaltose (FCM) in antenatal women with anaemia in the second and third trimesters of pregnancy.

Methods

A single-arm prospective cohort (before-after) study among 60 antenatal women with moderate to severe anaemia in the second and third trimesters was conducted from December 2020 to December 2022, and the eligible women were given 1000 mg of intravenous FCM injection. Efficacy was assessed by rate of improvement in haemoglobin and ferritin at 2 weeks post infusion. Safety analysis was done by assessing adverse drug reactions and foetal heart monitoring during the infusion.

Results

A total 60 antenatal women with a median gestational age of 32.5 weeks at presentation received 1000 mg of intravenous FCM. There was a rise in mean haemoglobin from 8.05 gm% pre-infusion to 10.93 gm% 2 weeks post infusion, showing a mean rise of 2.88 gm%. Similar improvement was noted in mean serum ferritin levels from 25.92 pre-infusion to 253.96 post FCM infusion. There were no reports of drug-related major adverse effects in the mother or the foetus.

Conclusions

FCM is found to be safe and effective treatment with rapid replenishment of haemoglobin and ferritin levels in a single dose, which makes it suitable and compels consideration as the first choice for treatment of iron-deficiency anaemia.

Intravenous iron versus blood transfusion for postpartum anemia: a systematic review and meta-analysis

BACKGROUND

Intravenous iron (IV-iron) is used as an alternative to, or alongside, red blood cell transfusion (RBC-T) to treat more severe postpartum anemia (PPA), although optimal treatment options remain unclear. No previous systematic reviews have examined IV-iron and RBC-T, including patient-reported outcomes and hematological responses.

METHODS

A systematic review and meta-analysis of randomized trials comparing IV-iron and RBC-T with each other, oral iron, no treatment, and placebo for the treatment of PPA. Key inclusion criteria were PPA (hemoglobin < 12 g/dL) and IV-iron or RBC-T as interventions. Key exclusion criteria were antenatal IV-iron or RBC-T. Fatigue was the primary outcome. Secondary outcomes included hemoglobin and ferritin concentrations, and adverse events. From 27th August 2020 to 26th September 2022, databases, registries, and hand searches identified studies. A fixed-effect meta-analysis was undertaken using RevMan (5.4) software. The quality of the studies and the evidence was assessed using the Cochrane Risk of Bias table, and Grading of Recommendations, Assessment, Development, and Evaluation. This review is registered with the Prospective Register of Systematic Reviews (CRD42020201115).

RESULTS

Twenty studies and 4196 participants were included: 1834 assigned IV-iron, 1771 assigned oral iron, 330 assigned RBC-T, and 261 assigned non-intervention. Six studies reported the primary outcome of fatigue (1251 participants). Only studies of IV-iron vs. oral iron (15 studies) were available for meta-analysis. Of these, three reported on fatigue using different scales; two were available for meta-analysis. There was a significant reduction in fatigue with IV-iron compared to oral iron (standardized mean difference - 0.40, 95% confidence interval (CI) - 0.62, - 0.18, I2 = 0%). The direction of effect also favored IV-iron for hemoglobin (mean difference (MD) 0.54 g/dL, 95% confidence interval (CI) 0.47, 0.61, I2 = 91%), ferritin, (MD 58.07 mcg/L, 95% CI 55.74, 60.41, I2 = 99%), and total adverse events (risk-ratio 0.63, 95% CI 0.52, 0.77, I2 = 84%). The overall quality of the evidence was low-moderate.

DISCUSSION

For all outcomes, the evidence for RBC-T, compared to IV-iron, non-intervention, or dose effects of RBC-T is very limited. Further research is needed to determine whether RBC-T or IV-iron for the treatment of PPA is superior for fatigue and hematological outcomes.

Clinical effectiveness of ferric carboxymaltose (iv) versus iron sucrose (iv) in treatment of iron deficiency anaemia in pregnancy: A systematic review and meta-analysis

BACKGROUND OBJECTIVES

Iron deficiency anaemia (IDA) during pregnancy is treated with oral and parenteral iron. The objective of this review was to compare the clinical effectiveness, safety, pregnancy and neonatal outcomes of intravenous (iv) ferric carboxymaltose (FCM) and iv iron sucrose (IS) in treating IDA in pregnancy.

METHODS

The Department of Health Research funded this study. PubMed, Cochrane Library, EMBASE and Scopus were searched to include studies published till November 2022. The protocol was registered in PROSPERO (CRD42022306092). Pregnant women (15-49 yr) in second and third trimesters, diagnosed with moderate-to-severe iron deficiency anaemia, treated with either of the drugs were included. The included studies were critically assessed using appropriate tools. We conducted a qualitative synthesis of the studies and meta-analysis for improvement in haematological parameters and incidence of adverse events.

RESULTS

A total of 18 studies were included. The risk of bias was low to moderate. A rise in haemoglobin up to four weeks was higher with FCM than IS by 0.57 (0.24, 0.9) g/dl. Intravenous FCM is associated with fewer adverse events than IS [pooled odds ratio: 0.5 (0.32, 0.79)]. The included studies had limited evidence on pregnancy and neonatal outcomes after iv iron treatment.

INTERPRETATION CONCLUSIONS

Intravenous FCM is effective and safer than intravenous IS in terms of haematological parameters, in treating IDA in pregnancy. Further research is required on the effects of iv FCM and iv IS on the pregnancy and neonatal outcomes when used for treating IDA in pregnancy.

Approaches to Address the Anemia Challenge

Anemia is a multifactorial condition; approaches to address it must recognize that the causal factors represent an ecology consisting of internal (biology, genetics, and health) and external (social/behavioral/demographic and physical) environments. In this paper, we present an approach for selecting interventions, followed by a description of key issues related to the multiple available interventions for prevention and reduction of anemia. We address interventions for anemia using the following 2 main categories: 1) those that address nutrients alone, and, 2) those that address nonnutritional causes of anemia. The emphasis will be on interventions of public health relevance, but we also consider the clinical context. We also focus on interventions at different stages of the life course, with a particular focus on women of reproductive age and preschool-age children, and present evidence on various factors to consider when selecting an intervention-inflammation, genetic mutations, nutrient delivery, bioavailability, and safety. Each section on an intervention domain concludes with a brief discussion of key research areas.

Patient blood management to minimize transfusions during the postpartum period

Patient blood management is an evidence-based concept that seeks to minimize blood loss by maintaining adequate hemoglobin levels and optimizing hemostasis during surgery. Since the coronavirus disease 2019 pandemic, patient blood management has gained significance due to fewer blood donations and reduced amounts of blood stored for transfusion. Recently, the prevalence of postpartum hemorrhage (PPH), as well as the frequency of PPH-associated transfusions, has steadily increased. Therefore, proper blood transfusion is required to minimize PPH-associated complications while saving the patient's life. Several guidelines have attempted to apply this concept to minimize anemia during pregnancy and bleeding during delivery, prevent bleeding after delivery, and optimize recovery methods from anemia. This study systematically reviewed various guidelines to determine blood loss management in pregnant women.

Incidence of iron deficiency Anaemia during pregnancy in Far North Queensland

INTRODUCTION

The WHO estimates the incidence of iron deficiency anaemia in Australia is 25%. However there is considerable variation during pregnancy and in regional areas.

OBJECTIVE

The aim of this investigation is to quantify the incidence of iron deficiency anaemia during pregnancy within Far North Queensland.

DESIGN

This is a single-centre retrospective cohort study. Cairns Hospital is the main referral centre for complex maternity care in Far North Queensland with an estimated population of 280-000, which includes many people from rural and remote communities and a high proportion who identify as Aboriginal or Torres Strait Islander. This study included all births at the Cairns Hospital in 2018, a total of 2190 deliveries.

FINDINGS

The study randomly sampled 551 mothers from the cohort, and the incidence of iron deficiency anaemia was 34.9%. 48.7% of women who identified as Aboriginal or Torres Strait Islander within the region were anaemic. This was significantly higher than an incidence of 28.9% for the rest of the population. Other risk factors include booking appointment after 28-weeks, Asian ethnicity and age less than 25-years. A BMI greater than 35 was protective DISCUSSION: This study will inform antenatal care providers within the region and improve obstetric outcomes by increasing awareness. Identifying risk factors will also facilitate prompt treatment and improve maternity care for vulnerable patient groups. On a broader level, the study provides new data to inform population health estimates both nationally and internationally.

CONCLUSION

The incidence of iron deficiency anaemia during pregnancy in Far North Queensland is significantly higher than previous estimates.

The incidence, complications, and treatment of iron deficiency in pregnancy

Iron deficiency and/or iron deficiency anemia (IDA) complicate nearly 50% of pregnancies globally, negatively impacting both maternal and fetal outcomes. Iron deficiency can cause a range of symptoms that range from aggravating to debilitating including fatigue, poor quality of life, pagophagia, and restless leg syndrome. Iron deficiency and IDA are also associated with maternal complications including preterm labor, increased rates of cesarean delivery, postpartum hemorrhage, and maternal death. Fetal complications include increased rates of low birth weight and small for gestational age newborns. Prenatal maternal anemia has also been associated with autism spectrum disorders in the neonate, although causation is not established. Deficiency in the newborn is associated with compromised memory, processing, and bonding, with some of these deficits persisting into adulthood. Despite the prevalence and consequences associated with iron deficiency in pregnancy, data show that it is routinely undertreated. Due to the physiologic changes of pregnancy, all pregnant individuals should receive oral iron supplementation. However, the bioavailability of oral iron is poor and it is often ineffective at preventing and treating iron deficiency. Likewise, it frequently causes gastrointestinal symptoms that can worsen the quality of life in pregnancy. Intravenous iron formulations administered in a single or multiple dose series are now available. There is increasing data suggesting that newer intravenous formulations are safe and effective in the second and third trimesters and should be strongly considered in pregnant individuals without optimal response to oral iron repletion.

A Randomised Controlled Trial to Compare Injection Ferric Carboxymaltose and Oral Iron in Treating Iron Deficiency Anemia During Pregnancy

Introduction

Iron deficiency anemia (IDA) in pregnancy has a prevalence as high as 40-60% in different countries of the world. Oral iron is used to treat his commonest medical disorder in pregnancy. Ferrous sulphate is associated with considerable side effects. Ferric carboxymaltose (FCM) is a newer iron preparation which allows for single and higher dose (up to 1000 mg) of IV iron infusion. This study was conducted to compare the efficacy of FCM and FS in treating IDA during pregnancy.

Methods

A randomised control trial was done at a tertiary care centres involving 362 women (181 women each in FS and FCM group). The pregnant anemic women with IDA were enrolled between 18 and 34 weeks of pregnancy. They were given 1000 mg of FCM iv as single dose or were given FS tablets twice daily (120 mg iron daily). The data were collected for rise in the Hb and serum ferritin over a period of 6 weeks.

Results

Nine and 18 patients were lost to follow-up in the FCM and FS group, respectively. The data were analysed as per protocol analysis. FCM group women showed 2.6 gm% rise in Hb compared to 1.7 gm% of FS group. One hundred and sixty-six out of 172 women in FS group achieved anemia correction at 6 weeks. No difference was observed in the neonatal outcome. No major side effects were observed in the either group.

Conclusion

In our study, FCM was more effective than oral FS in increasing Hb in women with IDA during pregnancy. This clinical benefit with FCM was achieved without the concerns for safety and tolerability of the drug.

Ferric carboxymaltose for treatment of iron deficiency and iron deficiency anemia caused by abnormal uterine bleeding

Introduction

Heavy menstrual bleeding leads to depletion of iron stores, with subsequent iron deficiency (ID) and iron deficiency anemia (IDA). To evaluate the efficacy and safety of ferric carboxymaltose (FCM) in treatment of ID/IDA caused by abnormal uterine bleeding (AUB).

Material and methods

One hundred and twenty women ≥ 40 years old with chronic AUB and ID/IDA were included in this study for correction of ID/IDA. Participants received FCM infusion for correction of ID/IDA. The pre-treatment ferritin, hemoglobin (Hb), red blood cell (RBC) mean corpuscular volume (MCV), and RBC mean corpuscular hemoglobin (MCH) values were compared with the 6- and 12-week post-treatment values.

Results

The pre-treatment ferritin and Hb levels significantly increased from 13.2 ±7.4 µg/l and 8.8 ±0.8 g/dl, respectively, to 111.5 ±5.6 µg/l and 13.9 ±0.6 g/dl, respectively, 6 weeks after FCM (p = 0.001 and 0.0009; respectively), and to 98.7 ±6.1 µg/l and 12.9 ±0.65 g/dl, respectively, 12 weeks after FCM (p = 0.01 and 0.01; respectively). In addition, the pre-treatment RBC MCV and RBC MCH values significantly increased from 74.3 ±2.3 fl and 26.6 ±5.3 pg, respectively, to 88.7 ±1.9 fl and 29.6 ±4.5 pg, respectively, 6 weeks after FCM (p = 0.01 and 0.03, respectively), and to 93.3 ±1.75 fl and 30.3 ±3.8 pg, respectively, 12 weeks after FCM (p = 0.001 and 0.0001, respectively).

Conclusions

FCM was safe and effective for correction of ID/IDA caused by chronic AUB within 6 weeks. The serum ferritin, Hb, and RBC indices remained significantly high compared to the pre-treatment values 12 weeks after FCM infusion.

Ferric Carboxymaltose in the Management of Iron Deficiency Anemia in Pregnancy: A Subgroup Analysis of a Multicenter Real-World Study Involving 1191 Pregnant Women

Background. Real-world evidence of the efficacy and safety of ferric carboxymaltose (FCM) infusion in Indian pregnant women with iron deficiency anemia (IDA) is lacking. Objective. To assess the efficacy and safety of intravenous (IV) FCM in Indian pregnant women with IDA in 4 weeks in a real-life scenario. Methods. This is a subgroup analysis of our previously conducted retrospective, multicenter, observational, real-world PROMISE study. Data on demographic and hematological parameters, patient-reported adverse events, and physicians’ clinical impressions of efficacy and safety were analysed at 4 ± 1 week. Results. This subgroup analysis included 1191 pregnant women in whom IV FCM resulted in a significant increase in hemoglobin (Hb) by 2.8 g/dL and serum ferritin by 30.03 μg/L at 4 weeks ( $P<0.001$ for both). In 103 pregnant women with severe IDA, there was a significant increase in Hb by 3.6 g/dL ( $P<0.001$ ), and serum ferritin by 16.96 μg/L ( $P=0.12$ ). In 978 pregnant women with moderate IDA, significant improvement in Hb by 2.74 g/dL and serum ferritin by 33 μg/L ( $P<0.001$ for both) was noted. Similarly, there was a significant increase in red blood cell count, hematocrit, mean corpuscular volume, and mean corpuscular hemoglobin ( $P<0.001$ for all). In pregnant women with mild IDA (n = 26), Hb increased significantly by 1.99 g/dL ( $P<0.001$ ). Adverse effects were reported in 8.6% of pregnant women. No new safety signals or serious adverse effects were observed. Based on physicians’ global assessment, good to very good efficacy and safety of IV FCM was noted in 99.2% and 98.6% of pregnant women, respectively. Conclusions. IV FCM rapidly corrected anemia in a short period of 4 weeks with favorable safety in the second and third trimester of pregnancy with all severities of IDA (severe, moderate, and mild). The physicians’ favorable global assessment of FCM’s efficacy and safety in pregnant women with IDA supports its use in daily clinical practice. This trial is registered with CTRI/2021/12/039065.

High-Dose Intravenous Iron with Either Ferric Carboxymaltose or Ferric Derisomaltose: A Benefit-Risk Assessment

The intravenous iron formulations ferric carboxymaltose (FCM) and ferric derisomaltose (FDI) offer the possibility of administering a large amount of iron in one infusion. This results in faster correction of anemia and the formulations being better tolerated than oral iron formulations. This triad of logistic advantages, improved patient convenience, and fast correction of anemia explains the fact that intravenous iron formulations nowadays are frequently prescribed worldwide in the treatment of iron deficiency anemia. However, these formulations may result in hypophosphatemia by inducing a strong increase in active fibroblast growth factor-23 (FGF-23), a hormone that stimulates renal phosphate excretion. This effect is much more pronounced with FCM than with FDI, and therefore the risk of developing hypophosphatemia is remarkably higher with FCM than with FDI. Repeated use of FCM may result in severe osteomalacia, which is characterized by bone pain, Looser zones (pseudofractures), and low-trauma fractures. Intravenous iron preparations are also associated with other adverse effects, of which hypersensitivity reactions are the most important and are usually the result of a non-allergic complement activation on nanoparticles of free labile iron-Complement Activation-Related Pseudo-Allergy (CARPA). The risk on these hypersensitivity reactions can be reduced by choosing a slow infusion rate. Severe hypersensitivity reactions were reported in < 1% of prospective trials and the incidence seems comparable between the two formulations. A practical guideline has been developed based on baseline serum phosphate concentrations and predisposing risk factors, derived from published cases and risk factor analyses from trials, in order to establish the safe use of these formulations.

Testing equivalence of two doses of intravenous iron to treat iron deficiency in pregnancy: A randomised controlled trial

OBJECTIVE

To test equivalence of two doses of intravenous iron (ferric carboxymaltose) in pregnancy.

DESIGN

Parallel, two-arm equivalence randomised controlled trial with an equivalence margin of 5%.

SETTING

Single centre in Australia.

POPULATION

278 pregnant women with iron deficiency.

METHODS

Participants received either 500 mg (n=152) or 1000mg (n=126) of intravenous ferric carboxymaltose in the second or third trimester.

MAIN OUTCOME MEASURES

The proportion of participants requiring additional intravenous iron (500mg) to achieve and maintain ferritin >30ug/L (diagnostic threshold for iron deficiency) at 4 weeks post-infusion, and at 6 weeks, and 3-, 6- and 12-months postpartum. Secondary endpoints included repeat infusion rate, iron status, birth, and safety outcomes.

RESULTS

The two doses were not equivalent within a 5% margin at any timepoint. At 4 weeks post infusion, 26/73 (36%) participants required a repeat infusion in the 500 mg group compared with 5/67 (8%) in the 1000 mg group (difference in proportions, 0.283 95% confidence interval (0.177, 0.389)). Overall, participants in the 500 mg arm received twice the repeat infusion rate (0.81 (SD= 0.824 vs 0.40 (SD= 0.69), rate ratio 2.05, 95% CI (1.45, 2.91)).

CONCLUSIONS

Administration of 1000 mg ferric carboxymaltose in pregnancy maintains iron stores and reduces the need for repeat infusions. A 500 mg dose requires ongoing monitoring to ensure adequate iron stores are reached and sustained.

Essentiality of Trace Elements in Pregnancy, Fertility, and Gynecologic Cancers-A State-of-the-Art Review

Gynecological neoplasms pose a serious threat to women's health. It is estimated that in 2020, there were nearly 1.3 million new cases worldwide, from which almost 50% ended in death. The most commonly diagnosed are cervical and endometrial cancers; when it comes to infertility, it affects ~48.5 million couples worldwide and the number is continually rising. Ageing of the population, environmental factors such as dietary habits, environmental pollutants and increasing prevalence of risk factors may affect the reproductive potential in women. Therefore, in order to identify potential risk factors for these issues, attention has been drawn to trace elements. Trace mineral imbalances can be caused by a variety of causes, starting with hereditary diseases, finishing with an incorrect diet or exposure to polluted air or water. In this review, we aimed to summarize the current knowledge regarding trace elements imbalances in the case of gynecologic cancers as well as female fertility and during pregnancy.

Clinical effects and safety of ferric carboxymaltose in pregnancy: An Indian real-life experience

BACKGROUND

There is limited clinical evidence of ferric carboxymaltose injection (FCM) usage in Indian pregnant women. We assessed the efficacy and safety of FCM in Indian pregnant women with moderate-to-severe anemia.

METHODS

Single-center, retrospective, observational data collection was conducted at a tertiary care research institute. Data of pregnant women with anemia who received FCM in their second and third trimester was retrieved and analyzed for hematological parameters at baseline and at 4 ± 2 weeks. Neonatal outcomes were also assessed. Adverse events and other safety parameters were noted.

RESULTS

Data of 271 patients was retrieved and analyzed for safety and data for 168 patients analyzed for efficacy. A significant increase in hemoglobin was noted with FCM in 4 weeks (1.25 g/dL; p < 0.001). Patients with severe anemia reported an increase in hemoglobin of 4.23 g/dL (p = 0.01). Patients receiving FCM in the second trimester noted a significant increase in hemoglobin of 1.74 g/dL (p < 0.001). A significant increase in hemoglobin was noted as early as 20 days (p < 0.001) and also in patients receiving FCM after 34 weeks (p = 0.002). No adverse fetal or neonatal outcomes were observed. Adverse events noted in 4% of patients with itching and rash being most common. Continuous monitoring of blood pressure, heart rate, and oxygen saturation for 40 min during and after FCM administration reported no deterioration or negative safety signal.

CONCLUSION

FCM corrects anemia in all subsets of Indian pregnant women and supports evidence of efficacy and safety. Continuous monitoring of vital parameters during FCM infusions supports its excellent safety.

Anaemia in chronic kidney disease pregnancy

AIM

To review the incidence and management of anaemia and outcomes in pregnancies in a cohort of Australian women with chronic kidney disease.

METHODS

A retrospective audit of 63 pregnancies in 52 women with chronic kidney disease.

RESULTS

Sixty-eight percent of chronic kidney disease pregnancies were complicated by haemoglobin less than 100 g/L. Iron stores were measured in only 62% of all pregnancies. Serum ferritin was less than 100 ng/ml in 95% of those tested. Erythropoietin-stimulating agents were used in 24 pregnancies (38%). Intravenous iron was used in only nine non-dialysis pregnancies.

CONCLUSION

Greater awareness of the importance of regular measurement of iron stores and appropriate levels for repletion in chronic kidney disease pregnancies amongst health professionals involved in obstetric care may result in earlier detection and treatment of iron deficiency, and potentially improve maternal and fetal outcomes.

Comparative efficacy and safety of intravenous ferric carboxymaltose and iron sucrose for iron deficiency anemia in obstetric and gynecologic patients: A systematic review and meta-analysis

INTRODUCTION

Iron deficiency anemia (IDA) is common among obstetric and gynecologic patients. This systematic review aimed to assess the comparative efficacy and safety of commonly used intravenous (IV) iron formulations, ferric carboxymaltose (FCM), and iron sucrose (IS) in the treatment of IDA in obstetric and gynecologic patients.

METHODS

We systematically searched PubMed, EMBASE, Cochrane CENTRAL, and Google Scholar for eligible randomized controlled trials (RCTs) comparing IV iron replacement using FCM and IS up to October 2019. The primary outcome was to compare the efficacy of FCM and IS, assessed by measuring serum hemoglobin (Hb) and ferritin levels before and after iron replacement. The secondary outcome was to compare the safety of FCM and IS, assessed by the incidence of adverse events during iron replacement. The meta-analysis was performed using RevMan 5.3.

RESULTS

We identified 9 RCTs with 910 patients (FCM group, n = 456; IS group, n = 454). Before iron replacement, FCM and IS group patients had similar baseline Hb (mean difference [MD], 0.04 g/dL; 95% confidence interval [CI], -0.07 to 015; I2 = 0%; P = 0.48) and ferritin levels (MD, -0.42 ng/mL; 95% CI, -1.61 to 0.78; I2 = 45%; P = 0.49). Following iron replacement, patients who received FCM had higher Hb (MD, 0.67; 95% CI, 0.25-1.08; I2 = 92%; P = 0.002) and ferritin levels (MD, 24.41; 95% CI, 12.06-36.76; I2 = 75%; P = 0.0001) than patients who received IS. FCM group showed a lower incidence of adverse events following iron replacement than IS group (risk ratio, 0.53; 95% CI, 0.35-0.80; I2 = 0%; P = 0.003). Serious adverse events were not reported in any group.

CONCLUSION

FCM group showed better efficacy in increasing Hb and ferritin levels and a favorable safety profile with fewer adverse events compared with IS group for IDA treatment among obstetric and gynecologic patients. However, this meta-analysis was limited by the small number of RCTs and high heterogeneity.

TRIAL REGISTRATION

The review was prospectively registered with the International Prospective Registry of Systematic Reviews (https://www.crd.york.ac.uk/prospero/, registration number CRD42019148905).

Are Pregnant Women Who Are Living with Overweight or Obesity at Greater Risk of Developing Iron Deficiency/Anaemia?

Low-grade inflammation is often present in people living with obesity. Inflammation can impact iron uptake and metabolism through elevation of hepcidin levels. Obesity is a major public health issue globally, with pregnant women often affected by the condition. Maternal obesity is associated with increased pregnancy risks including iron deficiency (ID) and iron-deficiency anaemia (IDA)-conditions already highly prevalent in pregnant women and their newborns. This comprehensive review assesses whether the inflammatory state induced by obesity could contribute to an increased incidence of ID/IDA in pregnant women and their children. We discuss the challenges in accurate measurement of iron status in the presence of inflammation, and available iron repletion strategies and their effectiveness in pregnant women living with obesity. We suggest that pre-pregnancy obesity and overweight/obese pregnancies carry a greater risk of ID/IDA for the mother during pregnancy and postpartum period, as well as for the baby. We propose iron status and weight gain during pregnancy should be monitored more closely in women who are living with overweight or obesity.

Comparison of the maternal and neonatal outcomes of pregnant women whose anemia was not corrected before delivery and pregnant women who were treated with intravenous iron in the third trimester

AIM

Anemia is one of the most common problems of pregnancy. In this study, we aimed to compare the maternal and fetal outcomes in labor and delivery in women whose anemia was treated with intravenous iron and women who delivered with uncorrected anemia.

MATERIALS

METHODS: This retrospective case-control study was carried out in a tertiary obstetric care center. Term (> 37 weeks), singleton, low-risk pregnant women who were admitted for delivery were evaluated. Seventy-two pregnant women who had intravenous ferric carboxymaltose treatment in the third trimester were compared with 72 women who were anemic (Hb < 10 g/dL) at the time Queryof admission for delivery.

RESULTS

The groups were similar in terms of age, parity, and gestational age. The mean gestational age of the study group was 38.6 weeks. Their mean Hb of 8.2 ± 0.8 g/dL improved to 11.1 ± 1.3 g/dL prior birth. The mean Hb of the anemic group was 9.1 ± 0.5 g/dL upon admission for birth. The mean APGAR scores, admission to neonatal intensive care unit, and the rates of preterm delivery, small for gestational age, and low-birth weight infant were similar between groups. The primary cesarean section rate was significantly higher in anemic women (4.2% vs. 19.4%; p < 0.001) and the need for postpartum blood transfusion also decreased with iv iron treatment (8.3% vs. 29.2%; p = 0.02).

CONCLUSION

Correction of anemia with intravenous ferric carboxymaltose in the third trimester does not significantly change neonatal outcomes but it is effective in reducing maternal morbidity.

Essential Role of Patient Blood Management in a Pandemic: A Call for Action

The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVID-19 worldwide. Across the world, medical care is hampered by a critical shortage of not only hand sanitizers, personal protective equipment, ventilators, and hospital beds, but also impediments to the blood supply. Blood donation centers in many areas around the globe have mostly closed. Donors, practicing social distancing, some either with illness or undergoing self-quarantine, are quickly diminishing. Drastic public health initiatives have focused on containment and "flattening the curve" while invaluable resources are being depleted. In some countries, the point has been reached at which the demand for such resources, including donor blood, outstrips the supply. Questions as to the safety of blood persist. Although it does not appear very likely that the virus can be transmitted through allogeneic blood transfusion, this still remains to be fully determined. As options dwindle, we must enact regional and national shortage plans worldwide and more vitally disseminate the knowledge of and immediately implement patient blood management (PBM). PBM is an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This multinational and diverse group of authors issue this "Call to Action" underscoring "The Essential Role of Patient Blood Management in the Management of Pandemics" and urging all stakeholders and providers to implement the practical and commonsense principles of PBM and its multiprofessional and multimodality approaches.

Patient blood management (PBM) in pregnancy and childbirth: literature review and expert opinion

PURPOSE

Patient blood management [PBM] has been acknowledged and successfully introduced in a wide range of medical specialities, where blood transfusions are an important issue, including anaesthesiology, orthopaedic surgery, cardiac surgery, or traumatology. Although pregnancy and obstetrics have been recognized as a major field of potential haemorrhage and necessity of blood transfusions, there is still little awareness among obstetricians regarding the importance of PBM in this area. This review, therefore, summarizes the importance of PBM in obstetrics and the current evidence on this topic.

METHOD

We review the current literature and summarize the current evidence of PBM in pregnant women and postpartum with a focus on postpartum haemorrhage (PPH) using PubMed as literature source. The literature was reviewed and analysed and conclusions were made by the Swiss PBM in obstetrics working group of experts in a consensus meeting.

RESULTS

PBM comprises a series of measures to maintain an adequate haemoglobin level, improve haemostasis and reduce bleeding, aiming to improve patient outcomes. Despite the fact that the WHO has recommended PBM early 2010, the majority of hospitals are in need of guidelines to apply PBM in daily practice. PBM demonstrated a reduction in morbidity, mortality, and costs for patients undergoing surgery or medical interventions with a high bleeding potential. All pregnant women have a significant risk for PPH. Risk factors do exist; however, 60% of women who experience PPH do not have a pre-existing risk factor. Patient blood management in obstetrics must, therefore, not only be focused on women with identified risk factor for PPH, but on all pregnant women. Due to the risk of PPH, which is inherent to every pregnancy, PBM is of particular importance in obstetrics. Although so far, there is no clear guideline how to implement PBM in obstetrics, there are some simple, effective measures to reduce anaemia and the necessity of transfusions in women giving birth and thereby improving clinical outcome and avoiding complications.

CONCLUSION

PBM in obstetrics is based on three main pillars: diagnostic and/or therapeutic interventions during pregnancy, during delivery and in the postpartum phase. These three main pillars should be kept in mind by all professionals taking care of pregnant women, including obstetricians, general practitioners, midwifes, and anaesthesiologists, to improve pregnancy outcome and optimize resources.

Comparison of ferric Carboxymaltose and iron sucrose complex for treatment of iron deficiency anemia in pregnancy- randomised controlled trial

BACKGROUND

To evaluate the efficacy and safety of intravenous Ferric Carboxymaltose. (FCM) in comparison with intravenous Iron sucrose complex (ISC) for treatment of iron deficiency anemia in pregnancy.

METHODS

A randomized clinical trial was conducted from (January 2016-August 2017). at a tertiary hospital. Pregnant women diagnosed with moderate to severe iron deficiency anaemia were screened for the study. One hundred patients were randomized to receive either intravenous FCM or ISC. Primary outcome was rise in hemoglobin (Hb) from baseline after 12 weeks. Secondary outcomes were change in RBC indices, serum iron studies, improvement in fatigue scores, number of visits and perinatal outcome.

RESULTS

Mean rise in Hb at 12 weeks was significantly higher in FCM group (29 g/L vs 22 g/L; p value < 0.01). FCM was associated with greater improvement in fatigue scores. Number of visits were significantly less in FCM group. No serious adverse events were noted in either group.

CONCLUSION

Treatment with FCM resulted in rapid replenishment of iron stores in pregnant women with significantly higher Hb rise over a 12 week period. The convenient dosing with lesser number of total doses to complete the treatment will lead to better compliance in community setting. CLINICAL TRIAL REGISTRATION ( WWW.CTRI.NIC.IN ): CTRI/2015/09/006224. Registered on 21/07/2017 (Trial registered retrospectively).

Heme-bound iron in treatment of pregnancy-associated iron deficiency anemia

Background

The iron requirements increase during the second and third trimesters of pregnancy. Maternal anemia is a leading cause of adverse perinatal outcome.

Objectives

This study was designed to evaluate the efficacy of the heme-bound iron in treatment of pregnancy-associated iron deficiency anemia (IDA).

Materials and Methods

In all, 122 women with IDA during pregnancy and hemoglobin ≤10 g/dL were studied. The studied women were treated with heme-bound iron tablets for ≥3 months. Pretreatment hemoglobin, ferritin, mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH) were compared with the posttreatment values to detect the efficacy of heme-bound iron (Optifer^®) in treatment of IDA during pregnancy.

Results

The mean pretreatment hemoglobin significantly increased from 8.4 ± 2.7 to 11.2 ± 2.1 g/dL and the mean pretreatment ferritin level significantly increased from 22.6 ± 5.6 to 112.8 ± 4.8 μg/L (P < 0.003 and 0.04; respectively) 3 months after heme-bound iron treatment. In addition, the mean pretreatment red blood cells' MCV and MCH significantly increased from 74.2 ± 4.8 fL and 24.2 ± 7.8 pg, respectively, to 92.0 ± 4.1 fL and 32.6 ± 6.2 pg) (P = 0.04 and 0.007, respectively) 3 months after heme-bound iron treatment.

Conclusion

Heme-bound iron (Optifer^®) is an effective oral iron preparation to treat IDA during pregnancy and to replace the depleted iron store.

Effect of microalgae as iron supplements on iron-deficiency anemia in rats

Microalgae are functional iron nutritive fortifiers that can supply more intestinal nanosized iron.

Treatment of iron deficiency and iron deficiency anemia with intravenous ferric carboxymaltose in pregnancy

BACKGROUND

Iron deficiency (ID) and iron deficiency anemia (IDA) in pregnancy are global health issues, affecting around 30% of women in high-resourced countries, and increasing to over 50% of women in low-resourced countries.

OBJECTIVES

Froessler et al. study published in Archives of Gynecology and Obstetrics (2018) 298: 75. https://doi.org/10.1007/s00404-018-4782-9 , raised many queries and we would like to know the answers of those queries from the authors if possible.

RESULTS

Diagnosis of IDA should be based on hemoglobin concentration (gm/dl), serum ferritin (ug/l), mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH), and the efficacy of the treatment of IDA evaluated by comparing pre-treatment values of hemoglobin, serum ferritin, mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH) by the post-treatment values. Parenteral iron dose for correction of IDA calculated according to the formula; total iron needed in mg = 2.4 × pre-pregnancy weight in kg × (target hemoglobin concentration - actual hemoglobin concentration) gm/dl + 500 mg.

CONCLUSION

The efficacy of the treatment of IDA evaluated by comparing pre-treatment values of hemoglobin, serum ferritin, MCV, and MCH by the post-treatment values. Parenteral iron dose for correction of IDA calculated according to the formula; total iron needed in mg = 2.4 + pre-pregnancy weight in kg + (target hemoglobin concentration - actual hemoglobin concentration) gm/dl + 500 mg.