Expert recommendations for the diagnosis and treatment of iron-deficiency anemia during pregnancy and the postpartum period in the Asia-Pacific region

Screening and treatment of iron deficiency anemia in pregnancy: A review and appraisal of current international guidelines

Iron deficiency anemia (IDA) in pregnancy is a common diagnosis that is associated with adverse obstetric and neonatal outcomes. There remains uncertainty regarding how best to screen for, prevent, and treat established IDA in pregnancy. There is no consensus on the benefits of routine iron supplementation in pregnancy, with concerns regarding potential harmful effects of routine iron supplementation in women who are iron replete. Fourteen international guidelines were selected and appraised and compared by a multidisciplinary team. The AGREE II GRS tool was used. Each reviewer independently made their own assessment, and the scores from 1 to 7 were also collated and averaged for an overall score incorporating seven domains: process of development, clarity of presentation, completeness of reporting, clinical validity, and overall quality. The reviewers' scores were also individually compared according to discipline. The mean score across all the guidelines was 4.4 (range 3.5-6.5). Only half of the guidelines recommend routine iron in pregnancy. In terms of screening recommendations, five guidelines recommend screening with ferritin in addition to a full blood count in pregnancy, two recommend selective screening with ferritin for at risk groups only, and one guideline suggests using ferritin where feasible. Although many of the guidelines recommend similar doses of oral elemental iron of 100-200 mg daily for the treatment of established IDA in pregnancy, two recommend twice or three times daily dosing. Only five guidelines give hemoglobin rises to expect within specific timeframes. There remains a need to clarify the optimal screening method, dosing regimen, timing, and route of iron supplementation in pregnancy. Robust randomized controlled data are needed to guide appropriate prevention and management.

Identification and treatment of iron-deficiency anemia in pregnancy and postpartum: A systematic review and quality appraisal of guidelines using AGREE II

BACKGROUND

Several international guidelines provide recommendations for the optimal management of iron-deficiency anemia (IDA) in the pregnant and postpartum populations.

OBJECTIVES

To review the quality of guidelines containing recommendations for the identification and treatment of IDA in pregnancy and postpartum using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument and to summarize their recommendations.

SEARCH STRATEGY

PubMed, Medline, and Embase databases were searched from inception to August 2, 2021. A web engine search was also performed.

SELECTION CRITERIA

Clinical practice guidelines that focused on the management of IDA in pregnancy and/or postpartum populations were included.

DATA COLLECTION AND ANALYSIS

Included guidelines were appraised using AGREE II independently by two reviewers. Domain scores greater than 70% were considered high-quality. Overall scores of six or seven (out of a possible seven) were considered high-quality guidelines. Recommendations on IDA management were extracted and summarized.

MAIN RESULTS

Of 2887 citations, 16 guidelines were included. Only six (37.5%) guidelines were deemed high-quality and were recommended by the reviewers. All 16 (100%) guidelines discussed the management of IDA in pregnancy, and 10 (62.5%) also included information on the management of IDA in the postpartum period.

CONCLUSIONS

The complex interplay of racial, ethnic, and socioeconomic disparities was rarely addressed, which limits the generalizability of the recommendations. In addition, many guidelines failed to identify barriers to implementation, strategies to improve uptake or iron treatment, and resource and cost implications of clinical recommendations. These findings highlight important areas to target future work.

Expert consensus on improving iron deficiency anemia management in obstetrics and gynecology in Asia

Iron deficiency anemia (IDA) is a major health burden among women in Asia. Key issues in IDA management in Asia are under-diagnosis and under-treatment. The lack of Asia-specific guidelines, and suboptimal utilization of treatment compounds the management of IDA. To address these gaps, a panel of 12 experts in obstetrics, gynecology, and hematology from six regions in Asia convened to review current practices and clinical evidence and provide practical guidance on IDA diagnosis and management in Asian women. The Delphi approach was used to obtain objective opinions and attain consensus on statements pertaining to awareness, diagnosis, and management of IDA. In total, 79 statements attained consensus and are summarized to provide guidance on raising awareness of IDA and approaches for improved diagnosis and treatment of IDA among women in various settings: pregnancy, postpartum, heavy menstrual bleeding, gynecologic cancers, and perioperative care. This clinician-led consensus integrates appropriate recommendations based on clinical evidence and best practices and is intended to guide decision making in the management of iron deficiency/IDA in women. The expert panel raises a call for timely diagnosis and utilization of appropriate treatment, including use of high-dose intravenous iron, stringent blood management, and interdisciplinary collaboration, for optimization of IDA management among women in Asia.

Maternal and Neonatal Outcomes of Twin Pregnant Women With Anemia

The aim of this study was to investigate the prevalence of anemia in twin pregnancies and the influence of anemia on maternal and neonatal outcomes. This retrospective study included twin pregnant women who delivered in a tertiary hospital in China from January 2018 to December 2018. Patients were divided by WHO criteria (hemoglobin <11.0 g/dL): the anemic and nonanemic groups. Patients with anemia were further classified as recovered or unrecovered subgroup after oral iron therapy. Maternal and neonatal outcomes in women carrying twins were compared using Student's t test and the chi-squared test or the Fisher exact test. Univariable and multivariable logistic regression models were used to determine the association of maternal and neonatal characteristics with anemia. Linear regression analysis was used to estimate mean birth weight and gestational week. The prevalence of anemia was 42.6% (182/427) in twin pregnancies. The anemic group had higher rates of low 1-minute Apgar score (4.4% vs. 1.8%, p = .028), perinatal death (1.9% vs. 0.2%, p = .012) and neonatal intensive care unit (NICU) admission (27.2% vs. 20.2%, p = .017; adjusted OR, 1.478; 95% CI [1.07, 2.044]). The recovered subgroup had lower NICU admission rate (13.5% vs. 30.3%, p = .006; OR, 0.388; 95% CI [0.186, 0.809]), higher gestational week and birth weight (β, 0.954 week; 95% CI [0.114, 1.794] and β, 171.01 g; 95% CI [9.894, 332.126] respectively). The prevalence of anemia in twin gestation is high. Anemia is associated with adverse neonatal outcomes, and correction of anemia significantly improved the pregnancy outcomes.

Prevention and Management of Iron Deficiency/Iron-Deficiency Anemia in Women: An Asian Expert Consensus

The lack of standardized clinical practice impeding the optimal management of iron deficiency (ID) and iron deficiency anemia (IDA) in women is a global concern, particularly in the Asia-Pacific region. The aim of this study was to determine best practices through a Delphi consensus process. In Round 1, panelists were asked to rate their level of agreement with 99 statements across four domains: identification, diagnosis and assessment, prevention, and treatment of ID/IDA in women. In Round 2, panelists reappraised their ratings in view of the collective feedback and responses to Round 1. After two rounds, consensus (≥85% agreement) was reached for 84% of the Delphi statements. Experts agreed on the role of presenting symptoms and risk factors in prompting assessments of anemia and iron status in women. Experts repeatedly called for prevention, recommending preventive iron supplementation for pregnant women irrespective of anemia prevalence levels, and for non-pregnant adult women, adolescent girls, and perimenopausal women living in areas with a high prevalence of anemia. Experts unanimously agreed to prescribing oral ferrous iron as first-line therapy for uncomplicated ID/IDA. The recommendations and clinical pathway algorithms generated should be used to inform clinical practice and standardize the care of women at risk or presenting with ID/IDA in the Asia-Pacific region.

Prevalence and predictors of postpartum anemia after caesarean delivery in Ethiopia: A retrospective analysis of risk factors

BACKGROUND

Despite the burden of anemia during pregnancy has been extensively studied, the magnitude of postpartum anemia (PPA) and its predictors, especially after caesarean delivery remains unexplored. Therefore, we investigated the prevalence of postpartum anemia, and its predictors among women who underwent cesarean delivery.

METHODS

A retrospective study was conducted among women who underwent caesarean delivery in Southern Ethiopia. Data were retrospectively retrieved from the medical records of the participants. Multivariate logistic regression analysis identified independent predictors associated with postpartum anemia. An adjusted odd ratio (AOR), and a 95% confidence interval (CI), were used to identify associations. A p-value < 0.05 is considered statistically significant.

RESULTS

A total of 368 women who underwent caesarean delivery were included in this study. The overall incidence of PPA using a cut-off value of hemoglobin level < 11 g/dl after cesarean delivery was 103(28%). Multiple logistic regression analysis showed that the predictors of PPA were more likely among women with Prepartum Anemia (AOR=5.46: 95% CI=2.09-14.31), Grand parity (AOR=3.98: 95% CI=1.45-10.90), Placenta previa (AOR=7.73: 95% CI=1.91-31.38), ANC follow-up < 3 times (AOR=2.33: 95% CI=1.07-3.47), and those who developed Postpartum Hemorrhage (AOR=2.73: 95% CI=1.51-4.93).

CONCLUSION

More than one-fourth of women who underwent caesarean delivery in Southern Ethiopia had PPA. Poor ANC- follow-up, grand parity, placenta previa, Prepartum anemia, and PPH were the best predictors of PPA. Therefore, implementing strategies that consider the identified predictors could help to reduce the prevalence of PPA and its complications.

A Predictive Role of Autoantibodies Against the Epitope aa168–183 of ENO1 in the Occurrence of Miscarriage Related to Thyroid Autoimmunity

Objective

The aim of the research is to study the association between the serum levels of autoantibodies against one important epitope (¹⁶⁸FMILPVGAANFREAMR¹⁸³, designated as P6) of α-enolase (ENO1-P6Abs) and miscarriage among euthyroid females with thyroid autoimmunity (TAI).

Methods

Anti-ENO1-P6 total IgG was investigated in 432 euthyroid women, and its four subclasses were analyzed in 184 euthyroid women. The serum FT4, TSH, TgAb, and TPOAb levels were determined using an electrochemiluminescence immunoassay. The serum ENO1-P6Ab and anti-protein disulfide isomerase A3 autoantibody (PDIA3Ab) levels were determined using an enzyme-linked immunosorbent assay.

Results

The serum levels of anti-ENO1-P6 total IgG, IgG2, IgG3, and IgG4 were significantly higher in euthyroid TAI females than in non-TAI controls. Additionally, anti-ENO1-P6 total IgG and its 4 subtypes were all markedly higher in euthyroid TAI females with pregnancy loss than those without miscarriage. Moreover, logistic regression analysis showed that highly expressed anti-ENO1-P6 total IgG, IgG1, IgG2, and IgG3 subtypes in the serum were all independent risk factors for euthyroid TAI-related miscarriage, and its IgG1 was also for non-TAI-related abortion. According to the trend test, the prevalence of miscarriage was increased in a titer-dependent manner with the raised levels of serum anti-ENO1-P6 total IgG and IgG1, IgG2, and IgG3 subtypes among euthyroid TAI females. The receiver operating characteristic curve analysis of anti-ENO1-P6 total IgG and IgG1, IgG2, and IgG3 subclass expressions in the serum for miscarriage prediction in euthyroid TAI females exhibited that the total areas under the curves were 0.773 ± 0.041, 0.761 ± 0.053, 0.827 ± 0.043, and 0.760 ± 0.050, respectively (all P <0.0001). Their corresponding optimal cut-off OD450 values were 0.68 (total IgG), 0.26 (IgG1), 0.97 (IgG2), and 0.48 (IgG3), with sensitivities of 70.8, 87.5, 83.3, and 85.4%, and specificities of 70.8, 59.1, 77.3, and 56.8%, respectively. There was an additive interaction between serum anti-ENO1-P6 and anti-PDIA3 total IgGs on the development of miscarriage (RERI = 23.6, AP = 0.79, SI = 5.37).

Conclusion

The highly expressed ENO1-P6Abs may be important risk factors for euthyroid TAI-related miscarriage. The serum levels of ENO1-P6Abs may become good predictive markers for pregnancy loss in euthyroid TAI females, especially its IgG2 subclass expression.

The expression of anti-protein disulfide isomerase A3 autoantibody is associated with the increased risk of miscarriage in euthyroid women with thyroid autoimmunity

Miscarriage frequently occurs in euthyroid women with thyroid autoimmunity (TAI), but its mechanisms remain unclear. Our previous study has found that the serum level of anti-protein disulfide isomerase A3 autoantibody (PDIA3Ab) was significantly increased in mice with TAI. This study was aimed to explore whether there could be an association between the expression of PDIA3Ab and the occurrence of miscarriage in euthyroid TAI women. It was found that the serum level of PDIA3Ab was significantly increased in euthyroid TAI women as compared with that of non-TAI controls. Especially, serum PDIA3Ab level was markedly higher in euthyroid TAI women with miscarriage than the ones without miscarriage. Furthermore, binary logistic regression analysis showed that the serum PDIA3Ab level was an independent risk factor for spontaneous abortion in euthyroid TAI women with an odds ratio of 13.457 (95% CI, 2.965-61.078). The receiver operating characteristic (ROC) analysis of serum PDIA3Ab expression for predicting the miscarriage in euthyroid TAI women showed that the area under the curve was 0.707 ± 0.05 (P < 0.001). The optimal cut-off OD450 value of serum PDIA3Ab was 0.7129 with a sensitivity of 52.5% and specificity of 86.3% in euthyroid TAI women. Trend test showed that the prevalence of spontaneous abortion was markedly increased with the rise of serum PDIA3Ab level among TAI women in a titer-dependent manner. In conclusion, serum PDIA3Ab expression may imply an increased risk of spontaneous abortion in euthyroid TAI women, and it can be used as a new predictive bio-marker.

Addition of oral iron bisglycinate to intravenous iron sucrose for the treatment of postpartum anemia-randomized controlled trial

BACKGROUND

Studies that have compared the effectiveness of oral with intravenous iron supplements to treat postpartum anemia have shown mixed results. The superiority of one mode of treatment vs the other has yet to be demonstrated. Therefore, despite guidelines and standards of care, treatment approaches vary across practices. A single 500 mg dose of iron sucrose, which is higher than what is usually administered, has not been evaluated to treat postpartum moderate to severe anemia.

OBJECTIVE

This study aimed to compare the efficacy of intravenous iron sucrose alone with intravenous iron sucrose in combination with oral iron bisglycinate supplementation in treating moderate to severe postpartum anemia.

STUDY DESIGN

A randomized controlled trial was conducted between February 2015 and June 2020. Women with postpartum hemoglobin level of ≤9.5 g/dL were treated with 500 mg intravenous iron sucrose after an anemia workup, which ruled out other causes for anemia. In addition to receiving intravenous iron, women were randomly allocated to receive either 60 mg of oral iron bisglycinate for 45 days or no further iron supplementation. The primary outcome was hemoglobin level at 6 weeks after delivery. Secondary outcomes were iron storage parameters and quality of life.

RESULTS

Of 158 patients who participated, 63 women receiving intravenous and oral iron, and 44 women receiving intravenous iron-only, completed the study and were included in the analysis. Baseline and obstetrical characteristics were similar between the study cohorts. Although statistically significant, postpartum hemoglobin levels were only 0.4 g/dL higher in the intravenous and oral iron than intravenous iron-only cohort (12.4 g/dL vs 12.0 g/dL, respectively; P=.03), with a respective increase from baseline of 4.2 g/dL vs 3.7 g/dL (P=.03). There was no difference in the rate of women with hemoglobin level of <12.0 or 11.0 g/dL. Iron storage and health quality were not different between the cohorts. Oral iron treatment was associated with 29% rate of adverse effects. Compliance and satisfaction from treatment protocol were high in both cohorts.

CONCLUSION

Intravenous 500 mg iron sucrose treatment alone is sufficient to treat postpartum anemia without the necessity of adding oral iron treatment.

Development of standard definitions and grading for Maternal and Fetal Adverse Event Terminology

OBJECTIVE

Adverse event (AE) monitoring is central to assessing therapeutic safety. The lack of a comprehensive framework to define and grade maternal and fetal AEs in pregnancy trials severely limits understanding risks in pregnant women. We created AE terminology to improve safety monitoring for developing pregnancy drugs, devices and interventions.

METHOD

Existing severity grading for pregnant AEs and definitions/indicators of 'severe' and 'life-threatening' conditions relevant to maternal and fetal clinical trials were identified through a literature search. An international multidisciplinary group identified and filled gaps in definitions and severity grading using Medical Dictionary for Regulatory Activities (MedDRA) terms and severity grading criteria based on Common Terminology Criteria for Adverse Event (CTCAE) generic structure. The draft criteria underwent two rounds of a modified Delphi process with international fetal therapy, obstetric, neonatal, industry experts, patients and patient representatives.

RESULTS

Fetal AEs were defined as being diagnosable in utero with potential to harm the fetus, and were integrated into MedDRA. AE severity was graded independently for the pregnant woman and her fetus. Maternal (n = 12) and fetal (n = 19) AE definitions and severity grading criteria were developed and ratified by consensus.

CONCLUSIONS

This Maternal and Fetal AE Terminology version 1.0 allows systematic consistent AE assessment in pregnancy trials to improve safety.

Is IV iron sucrose a cost-effective option for treatment of severe anaemia in pregnancy as compared with oral iron?

Anaemia in pregnancy is a public health concern because it is strongly associated with maternal and perinatal morbidity and mortality. An open label randomized controlled trial (RCT) was conducted in India across four government medical colleges, comparing intravenous (IV) iron sucrose and oral iron for the treatment of anaemia in pregnancy. This RCT failed to demonstrate superiority of IV iron sucrose compared with oral iron therapy in reducing adverse clinical (maternal and foetal/neonatal) outcomes in moderate-to-severe anaemia in pregnancy. However, IV iron sucrose seemed to reduce the need for blood transfusion among women with severe anaemia. The study objective was to conduct a cost-effectiveness analysis of IV iron sucrose over oral therapy for treatment of severe anaemia in pregnancy, alongside the RCT, to inform policy. The outcome of interest in our study was a 'safe delivery' defined by the absence of composite maternal and foetal/neonatal adverse clinical outcomes. Incremental cost-effectiveness ratio (ICER) was calculated from a limited societal perspective. IV iron sucrose was found to be more costly but more effective than the oral therapy for treatment of severe anaemia. The ICER was calculated at INR 31 951 (USD 445.2) per safe delivery. We considered a threshold of half the gross national income for decision-making. Considering this threshold of India (INR 57 230, USD 797.4), IV iron-sucrose remained cost-effective in 67% of the iterations in the model. At the current ICER, for every 32 severely anaemic pregnant woman treated with IV iron sucrose one additional pregnant woman will have a safe delivery. Such analyses can complement the national strategy to support evidence-based action.

Iron deficiency anaemia in pregnancy: A contemporary review

Iron deficiency anaemia is a global health problem, which particularly affects pregnant women. Iron deficiency anaemia during pregnancy is associated with increased maternal and perinatal morbidity and mortality. Maternal iron deficiency may also be associated with neurocognitive deficits in infants. Iron requirements increase during pregnancy and are influenced by hepcidin, the master regulator of iron homeostasis. The enduring global burden of maternal anaemia suggests that currently employed iron supplementation strategies are suboptimal. Recent developments in our understanding of systemic and placental iron homeostasis may improve therapeutic effectiveness by altering the dose and frequency of oral iron. Intravenous iron appears to be a safe treatment to correct maternal anaemia rapidly but research on patient-centred outcomes and cost-effectiveness is needed. Future trials should be adequately powered to assess outcomes relevant to pregnant women.

The effects of Helicobacter pylori infection on pregnancy-related diseases and fetal development in diabetes in pregnancy

Background

This study aimed to determine the association of Helicobacter pylori (H. pylori) infection with pregnancy-related diseases and fetal development in women with diabetes in pregnancy (DIP).

Methods

All the participants were recruited before 16 weeks of gestation. According to their medical history and the results of a 75-g oral glucose tolerance test at the 24^th week of pregnancy, the participants were divided into a normal control group (NC group), a gestational diabetes mellitus group (GDM group), and a pre-pregnancy diabetes mellitus group (PGDM group). According to the results of an H. pylori serum antibody detection test, each group was further divided into two subgroups: an H. pylori positive subgroup (HP+ subgroup) and an H. pylori negative group (HP- subgroup). The incidences of pregnancy-related diseases, the fetal developmental status, and the newborn status were compared among the groups.

Results

This study recruited 356 pregnant women. The infection rates of type I H. pylori were significantly higher in the GDM group and the PGDM group than in the NC group (χ²=6.949, P=0.031). With the exception of the NC-HP+ subgroup, there were higher incidences of pregnancy-related diseases in the HP+ subgroups than in the HP− subgroups (P<0.05). Furthermore, the incidences of pregnancy-induced hypertension (PIH), preeclampsia, and premature delivery were significantly higher in the GDM-HP+ subgroup and the PGDM-HP+ subgroup than in the NC-HP+ subgroup (P<0.05). At the end of pregnancy, all 3 HP− subgroups showed better fetal development than the HP+ subgroups (P<0.05), and the NC-HP+ subgroup showed better fetal development than the GDM-HP+ and PGDM-HP+ subgroups (P<0.05). Meanwhile, the PGDM-HP+ subgroup showed poor fetal development, even in the 2^nd trimester of pregnancy.

Conclusions

H. pylori infection is extremely common in DIP. For women with DIP, infection with H. pylori can increase the risks of pregnancy-related diseases and poor fetal development. H. pylori screening and eradication therapy before pregnancy may aid in preventing pregnancy-related diseases and improve fetal development.

Antepartum and postpartum anemia: a narrative review

Antepartum anemia impacts over a third of pregnant women globally and is associated with major maternal and perinatal morbidity, including peripartum transfusion, maternal death, maternal infection, preterm birth, and neurodevelopmental disorders among offspring. Postpartum anemia impacts up to 80% of women in low-income and rural populations and up to 50% of women in Europe and the United States, and is associated with postpartum depression, fatigue, impaired cognition, and altered maternal-infant bonding. Iron deficiency is the most common cause of maternal anemia because of insufficient maternal iron stores at the start of pregnancy, increased pregnancy-related iron requirements, and iron losses due to blood loss during parturition. Anemic women should undergo testing for iron deficiency; a serum ferritin cutoff level of 30 μg/L is commonly used to diagnose iron deficiency during pregnancy. The first-line treatment of iron deficiency is oral iron. Intravenous iron is a consideration in the following scenarios: a poor or absent response to oral iron, severe anemia (a hemoglobin concentration <80 g/L), rapid treatment for anemia in the third trimester, women at high risk for major bleeding (such as those with placenta accreta), and women for whom red blood cell transfusion is not an option. Given the high prevalence of antepartum and postpartum anemia, anesthesiologists are advised to partner with other maternal health professionals to develop anemia screening and treatment pathways.

Prediction of anemia at delivery

We aimed to assess risk factors for anemia at delivery by conducting a secondary analysis of a prospective cohort study database including 1527 women who delivered vaginally ≥ 36 gestational weeks. Anemia (Hemoglobin (Hb) < 10.5 g/dL) was assessed at delivery. A complete blood count results during pregnancy as well as maternal and obstetrical characteristics were collected. The primary endpoint was to determine the Hb cutoff between 24 and 30 gestational weeks that is predictive of anemia at delivery by using the area under the curve (AUC) of the receiver operating characteristic curve. Independent risk factors for anemia at delivery were assessed using stepwise multivariable logistic regression. Hb and infrequent iron supplement treatment were independent risk factors for anemia at delivery (OR 0.3 95%CI [0.2–0.4] and OR 2.4 95%CI [1.2–4.8], respectively; C statistics 83%). Hb 10.6 g/dL was an accurate cutoff to predict anemia at delivery (AUC 80% 95%CI 75–84%; sensitivity 75% and specificity 74%). Iron supplement was beneficial to prevent anemia regardless of Hb value. Altogether, Hb should be routinely tested between 24 and 30 gestational weeks to screen for anemia. A flow chart for anemia screening and treatment during pregnancy is proposed in the manuscript.

Trial registration: ClinicalTrials.gov Identifier: NCT02434653.

Hemoglobin drop following postpartum hemorrhage

Postpartum hemorrhage (PPH) is defined as blood loss of ≥ 500–1000 ml within 24 h after delivery. Yet, assessment of blood loss is imprecise. The present study aimed to profile the hemoglobin (Hb) drop after vaginal delivery with versus without PPH. This was a secondary analysis of a prospective cohort study of women who delivered vaginally. Women were included if complete blood counts (CBC) before and after delivery were taken until stabilization (N = 419). Women were categorized into the PPH group and controls, for whom post-delivery CBCs were performed due to indications unrelated to bleeding. The PPH patients were then classified as either overt or occult PPH (symptoms related to hypovolemia without overt bleeding) subgroups. The primary endpoint was mean Hb drop after delivery. One hundred and ten (26%) and 158 (38%) women presented with overt PPH or occult PPH, respectively; 151 (36%) women were included in the control group. Mean Hb decrease from baseline was 3.0 ± 1.6, 2.0 ± 1.4 and 0.9 ± 1.0 g/dl, respectively (p < 0.0001). In all groups, maximal rate of Hb decline was in the first 6–12 h postpartum and plateaued after 24–48 h. At 48 h post-delivery, 95% and 86% of women who had dropped to Hb ≤ 9.5 and < 7 g/dl, respectively, reached those thresholds. Taken together, an Hb decrease ≥ 2 g/dl was consistent with PPH diagnosis and should be followed for at least 48 h after delivery.

FOR A FEW STEPS TO..., OR HOW TO AVOID FOR IRON DEFICIENCY AT PREGNANCY. LITERATURE REVIEW

The article presents modern data on the etiology, pathogenesis, diagnosis, prevention and treatment of iron deficiency anemia (IDA) and anemia of chronic disease, as well as their combination on the eve of and during pregnancy. The emphasis is made on the role of iron deficiency of any etiology in the development of obstetric and perinatal complications, especially its impact on the central nervous system formation and further psychophysical child development. Need for prevention of iron deficiency states in risk groups which includes all women of reproductive age who have menstruation is shown based on evidence-based medicine data. Effectiveness and safety of modern drugs containing iron in oral and parenteral forms has analyzed. The paper presents data on the safety and effectiveness of an innovative form of ferric iron in the form of liposomal iron, which differs in the mechanism of action, digestibility and the absence of side effects typical for this group of drugs. According to various authors the frequency of IDA in pregnant women ranges up to 80%, in puerperas up to 40%. It is unimpossible to stop IDA without iron supplementation only with an iron-rich diet. Two main groups of iron preparations are used to correct iron deficiency differing in the valence of iron atoms – bivalent iron salts and trivalent complexes. These drugs differ in the tolerability and bioavailability of atomic iron. Liposomal iron is a new drug for treatment of iron deficiency and IDA today; it has an innovative way of iron delivery to the body. Liposomal iron has advantages for the prevention of anemia in patients with anemia of chronic disease or its combination with IDA (inflammatory bowel diseases, obesity, after resection of the stomach and intestines, etc.). An innovative form of liposomal iron in Ukraine is represented by a dietary supplement Ferroview containing 30 mg of elemental iron, that is corresponds to the average prophylactic dose recommended in WHO documents.

Safety and effectiveness of intravenous iron sucrose versus standard oral iron therapy in pregnant women with moderate-to-severe anaemia in India: a multicentre, open-label, phase 3, randomised, controlled trial

BACKGROUND

Intravenous iron sucrose is a promising therapy for increasing haemoglobin concentration; however, its effect on clinical outcomes in pregnancy is not yet established. We aimed to assess the safety and clinical effectiveness of intravenous iron sucrose (intervention) versus standard oral iron (control) therapy in the treatment of women with moderate-to-severe iron deficiency anaemia in pregnancy.

METHODS

We did a multicentre, open-label, phase 3, randomised, controlled trial at four government medical colleges in India. Pregnant women, aged 18 years or older, at 20-28 weeks of gestation with a haemoglobin concentration of 5-8 g/dL, or at 29-32 weeks of gestation with a haemoglobin concentration of 5-9 g/dL, were randomly assigned (1:1) to receive intravenous iron sucrose (dose was calculated using a formula based on bodyweight and haemoglobin deficit) or standard oral iron therapy (100 mg elemental iron twice daily). Logistic regression was used to compare the primary maternal composite outcome consisting of potentially life-threatening conditions during peripartum and postpartum periods (postpartum haemorrhage, the need for blood transfusion during and after delivery, puerperal sepsis, shock, prolonged hospital stay [>3 days following vaginal delivery and >7 days after lower segment caesarean section], and intensive care unit admission or referral to higher centres) adjusted for site and severity of anaemia. The primary outcome was analysed in a modified intention-to-treat population, which excluded participants who refused to participate after randomisation, those who were lost to follow-up, and those whose outcome data were missing. Safety was assessed in both modified intention-to-treat and as-treated populations. The data safety monitoring board recommended stopping the trial after the first interim analysis because of futility (conditional power 1·14% under the null effects, 3·0% under the continued effects, and 44·83% under hypothesised effects). This trial is registered with the Clinical Trial Registry of India, CTRI/2012/05/002626.

FINDINGS

Between Jan 31, 2014, and July 31, 2017, 2018 women were enrolled, and 999 were randomly assigned to the intravenous iron sucrose group and 1019 to the standard therapy group. The primary maternal composite outcome was reported in 89 (9%) of 958 patients in the intravenous iron sucrose group and in 95 (10%) of 976 patients in the standard therapy group (adjusted odds ratio 0·95, 95% CI 0·70-1·29). 16 (2%) of 958 women in the intravenous iron sucrose group and 13 (1%) of 976 women in the standard therapy group had serious maternal adverse events. Serious fetal and neonatal adverse events were reported by 39 (4%) of 961 women in the intravenous iron sucrose group and 45 (5%) of 982 women in the standard therapy group. At 6 weeks post-randomisation, minor side-effects were reported by 117 (16%) of 737 women in the intravenous iron sucrose group versus 155 (21%) of 721 women in the standard therapy group. None of the serious adverse events was found to be related to the trial procedures or the interventions as per the causality assessment made by the trial investigators, ethics committees, and regulatory body.

INTERPRETATION

The study was stopped due to futility. There is insufficient evidence to show the effectiveness of intravenous iron sucrose in reducing clinical outcomes compared with standard oral iron therapy in pregnant women with moderate-to-severe anaemia.

FUNDING

WHO, India.

Prevalence, Morphological Classification, And Factors Associated With Anemia Among Pregnant Women Accessing Antenatal Clinic At Itojo Hospital, South Western Uganda

PURPOSE

The study aimed to determine the prevalence, morphological classification, and risk factors of anemia among pregnant mothers attending antenatal clinic at Itojo hospital, Ntungamo district, southwestern Uganda.

PATIENTS AND METHODS

After obtaining an informed consent, 5mL of blood was collected from the vein of each participant for complete blood count (CBC) and peripheral film report. The CBC was performed using HumaCount 80 hematology analyzer (HUMAN Gesellschaft für Biochemica und Diagnostica mbH Max-Planck-Ring 21 65,205 Wiesbaden Germany). Peripheral blood smears were made and stained using Wright's Romanowsky stain and examined under ×1000 magnification for morphological classification of anemia. Structured questionnaires were administered to each participant to collect information on patients' demography and risk factors of anaemia in pregnancy. The data generated were prepared in EXCEL and later transferred to SPSS version 20 for analysis. Univariate logistic regression and multivariate logistic regression were used to evaluate the association of socio-demographic characteristics of the participants with anemia. A 95% confidence level was used and statistical significance was reached at p<0.05.

RESULTS

One hundred and sixty-three participants (n=163) were recruited for the study with the median age of 25 years and range of (17 to 40 years). The overall prevalence of anemia was 12 (7.4%), the morphological classification was 1 (8.3%) normocytic normochromic anemia, 6 (50%) microcytic hypochromic anemia, and 5 (41.7%) macrocytic anemia. Spouse occupation (p=0.03), household income (p=0.04), use of insecticide-treated mosquito nets (p=0.001), history of urinary tract infection (p=0.002), use of haematinics (p≤0.001), and history of postpartum hemorrhage (p=0.03) were significantly associated with anemia in pregnancy.

CONCLUSION

Despite the reported high prevalence of anemia in pregnancy in other areas within the country, anemia prevalence was low in this study. Routine screening for anemia at all antenatal care clinics countrywide is recommended.

Impairment of the Developing Human Brain in Iron Deficiency: Correlations to Findings in Experimental Animals and Prospects for Early Intervention Therapy

Due to the necessity of iron for a variety of cellular functions, the developing mammalian organism is vulnerable to iron deficiency, hence causing structural abnormalities and physiological malfunctioning in organs, which are particularly dependent on adequate iron stores, such as the brain. In early embryonic life, iron is already needed for proper development of the brain with the proliferation, migration, and differentiation of neuro-progenitor cells. This is underpinned by the widespread expression of transferrin receptors in the developing brain, which, in later life, is restricted to cells of the blood–brain and blood–cerebrospinal fluid barriers and neuronal cells, hence ensuring a sustained iron supply to the brain, even in the fully developed brain. In embryonic human life, iron deficiency is thought to result in a lower brain weight, with the impaired formation of myelin. Studies of fully developed infants that have experienced iron deficiency during development reveal the chronic and irreversible impairment of cognitive, memory, and motor skills, indicating widespread effects on the human brain. This review highlights the major findings of recent decades on the effects of gestational and lactational iron deficiency on the developing human brain. The findings are correlated to findings of experimental animals ranging from rodents to domestic pigs and non-human primates. The results point towards significant effects of iron deficiency on the developing brain. Evidence would be stronger with more studies addressing the human brain in real-time and the development of blood biomarkers of cerebral disturbance in iron deficiency. Cerebral iron deficiency is expected to be curable with iron substitution therapy, as the brain, privileged by the cerebral vascular transferrin receptor expression, is expected to facilitate iron extraction from the circulation and enable transport further into the brain.

Evaluation of postpartum anaemia screening to improve anaemia diagnosis and patient care: A prospective non-randomized before-and-after anaemia screening protocol implementation study

We assessed the efficacy of a screening protocol for postpartum anaemia diagnosis and treatment in the maternity ward. A prospective non-randomized before-and-after anaemia screening protocol implementation study during two consecutive periods was conducted. Women who were scheduled for vaginal birth were tested for haemoglobin (Hb) before delivery. During the first period (June 29-October 10, 2015; N = 803) Hb was measured postpartum for women with anaemia-related symptoms, postpartum haemorrhage, or pre-delivery severe anaemia (Hb < 8 g/dL; "symptoms" group). During the second period (October 11, 2015-January 27, 2016; N = 755) Hb was also measured in all women with pre-delivery anaemia [i.e., Hb < 10.5 g/dL] ("screening" group). The primary outcomes were the rates of women with (1) postpartum anaemia diagnosis (Hb < 10 g/dL) and (2) administration of parenteral iron sucrose (indicated for postpartum Hb ≤ 9.5 g/dL). The detection rate of postpartum anaemia was higher in the screening group compared with the symptoms group (140 (19%) versus 100 (12%), OR_adjusted 2.2 95%CI [1.6-3.0], respectively). The iron sucrose treatment rate was also higher (110 (15%) versus 88 (11%), OR_adjusted 2.0 95%CI [1.4-2.7], respectively). A total of 122 women were diagnosed with moderate-severe anaemia in the screening group, 27 of whom (22%) were diagnosed solely due to the screening protocol. The results demonstrated that a routine screening of women with predelivery anaemia for postpartum anaemia led to increased anaemia diagnosis and consequently better medical care.

Intravenous Iron Versus Placebo in the Management of Postoperative Functional Iron Deficiency Anemia in Patients Undergoing Cardiac Valvular Surgery: A Prospective, Single-Blinded, Randomized Controlled Trial

OBJECTIVE

To compare the efficacy of intravenous iron versus placebo to correct postoperative functional iron deficiency anemia in patients undergoing cardiac valvular surgery.

DESIGN

A prospective, single-blinded, randomized controlled study.

SETTING

National Center for Cardiovascular Diseases and a university hospital.

PARTICIPANTS

The study comprised 150 patients with postoperative functional iron deficiency anemia after cardiac valvular surgery.

INTERVENTIONS

The patients were randomly assigned (1:1) to either the treatment (intravenous iron) group or the control (placebo) group.

MEASUREMENTS AND MAIN RESULTS

The hemoglobin and ferritin concentrations and postoperative adverse events were collected and compared between the 2 groups. The hemoglobin concentration and the proportion of patients who had their anemia corrected or achieved hemoglobin increments of >20 g/L in the intravenous iron group were significantly higher than that in the placebo group at postoperative day 14 (p = 0.023, p = 0.037, and p = 0.001), whereas there was no statistical difference at postoperative day 7. The ferritin concentration was substantially higher at postoperative day 7 and postoperative day 14 in the intravenous iron group compared with the placebo group (both p < 0.001). There were no significant differences in rates of death, blood tranfusion, antibiotic upgrade, ventilator time >24 hours, postoperative hospital stay >10 days, poor wound healing, and perivalvular leakage between the 2 groups.

CONCLUSIONS

Intravenous iron could significantly increase the hemoglobin level in patients with postoperative functional iron deficiency anemia at postoperative day 14. However, there is no difference in blood transfusion requirements or postoperative adverse outcomes between the 2 groups.

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.

Prevalence of Anemia and Iron Deficiency among Palestinian Pregnant Women and Its Association with Pregnancy Outcome

BACKGROUND

Anemia is a public health problem especially among pregnant women. This study aimed to investigate the prevalence of anemia and iron deficiency among pregnant women and its association with pregnancy outcome in Hebron Governorate in southern Palestine.

METHODS

This is a cross-sectional study that included 300 pregnant women in their first trimester and 163 babies. Maternal anthropometric and socioeconomic and newborns' data were collected. Complete blood count for study subjects and maternal serum ferritin were measured.

RESULTS

The prevalence of iron deficiency anemia among pregnant women was 25.7% and 52% of them had depleted iron stores. When pregnant women were grouped into three hemoglobin (Hb) tertile groups, a significant difference was observed between maternal Hb and newborns' birth weight (P= 0.009), height (P= 0.022), head circumference (P= 0.017), and gestational age (P= 0.012). There was a significant association between maternal serum ferritin and frequency of low birth weight (P= 0.001) and frequency of preterm delivery (P= 0.003). No significant association was observed between maternal anthropometric measures or the socioeconomic status and pregnancy outcomes.

CONCLUSION

Iron deficiency is a moderate public health problem among the study subjects. Maternal Hb and serum ferritin significantly affect pregnancy outcomes.

Impact and management of iron deficiency and iron deficiency anemia in women's health

INTRODUCTION

Iron deficiency and iron deficiency anemia are highly prevalent among women throughout their lives. Some females are particularly vulnerable to iron deficiency/iron deficiency anemia, including those with heavy menstrual bleeding (HMB) and pregnant/postpartum women. Despite the high prevalence of iron deficiency/iron deficiency anemia in women, the condition is still underdiagnosed and therefore undertreated, with serious clinical consequences. Areas covered: The following review examines the impact of iron deficiency and iron deficiency anemia on clinical outcomes and quality of life in women from adolescence to post-menopause, paying particular attention to guidelines and current recommendations for diagnostic tests and management. Expert commentary: There are numerous adverse health consequences of an iron-deficient state, affecting all aspects of the physical and emotional health and well-being of women. Guidelines must be developed to help clinicians better identify and treat women at risk of iron deficiency or iron deficiency anemia, particularly those with HMB, or who are pregnant or postpartum. Replacement therapy with oral or intravenous iron preparations is the mainstay of treatment for iron deficiency/iron deficiency anemia, with red blood cell transfusion reserved for emergency situations. Each iron therapy type is associated with benefits and limitations which impact their use.

Iron deficiency in gynecology and obstetrics: clinical implications and management

Iron deficiency is the commonest cause of anemia during pregnancy; however, its prevalence is highly determined by nutritional and socioeconomic status. Oral iron is the frontline therapy, but is often poorly tolerated. Awareness of the available intravenous formulations is essential for management. Before delivery, risk factors such as multiparity and heavy uterine bleeding increase the prevalence of iron deficiency and should be motivation for early diagnosis and treatment. Neonates born with iron deficiency have a statistically significant increment in both cognitive and behavioral abnormalities that persist after repletion, highlighting the need for heightened awareness of the diagnosis. A smartphone application providing information on nutrition and treatment is provided. New formulations of intravenous iron with carbohydrate cores, which bind elemental iron more tightly, minimize the release of labile free iron to allow complete replacement doses of intravenous iron in 15 to 60 minutes, facilitating and simplifying care.

The relationship between iron level and thyroid function during the first trimester of pregnancy: A cross-sectional study in Wuxi, China

Our objective was to evaluate the relationship between iron level and thyroid function during the first trimester of pregnancy in Eastern China. This was a hospital-based, cross-sectional observational study. A total of 1764 pregnant women were enrolled during their first trimester of gestation in Wuxi city. Serum ferritin (SF), hemoglobin (Hb), urinary iodine concentrations (UIC), thyroid-stimulating hormone (TSH), free thyroxine (FT4) and free triiodothyronine (FT3) were measured and evaluated in pregnant women. The median of TSH,FT4 and FT3 were 1.53mIU/L,10.43pmol/L and 4.50pmol/L respectively. The median UIC was 200μg/L and the median Hb was 126g/L. Of all the women, 1.76% of the subjects had iron deficiency anaemia (IDA) (SF<20μg/L and Hb<105g/L), and 39.06% of the population had iron deficiency (ID) (SF<15μg/L). Compared with SF>100μg/L group, the FT4 level was significantly lower in SF<20μg/L group (P=0.031) and in SF 20-100μg/L group (P=0.048). The TSH value of SF>20μg/L group was significantly higher than that in SF 20-100μg/L group (P=0.038) and SF>100μg/L group(P=0.034). There was an inverse linear relationship between TSH and FT4 after log transformation (r=0.245,P=0.000). Moreover, spearman's correlation analysis showed that UIC were correlated with SF and FT3 (all P<0.001) and iodine status more than adequate was associated with reduced serum ferritin concentration and FT3 levels. Thus, it is recommended that iron deficiency and iron deficiency anaemia shoud be evaluated and treated to combat thyroid dysfunction during the first trimester of pregnancy, Meanwhile, an increased attention should be paid on iodine nutritional status among this pregnant women simultaneous iron deficiency and thyroid dysfunction.

Retrospective Case Reports of Anemic Pregnant Women Receiving Intravenous Ferric Carboxymaltose: Experience from a Tertiary Hospital in Spain

Iron deficiency and iron deficiency anemia during pregnancy call for safe treatment options that raise maternal hemoglobin levels and counterbalance iron demand and blood volume expansion while minimizing risks for the growing fetus. This retrospective study describes experience with intravenous ferric carboxymaltose given to pregnant women in a tertiary hospital in Spain. In a 5-year period, 95 pregnant women who had pretreatment hemoglobin <10 g/dL and at least one time of ferric carboxymaltose administration during pregnancy were included. Main outcome measures were week of pregnancy at iron administration, Hb levels before and after treatment, neonatal 5-minute Apgar scores, and birth weight. The majority received one dose of ferric carboxymaltose (1000 mg iron) during advanced pregnancy (median 31 weeks; interquartile range [IQR]: 27; 37 weeks) with minor to no adverse outcomes. Overall, median Hb increased from 8.5 g/dL (8.1; 8.9 g/dL) before treatment to 11.0 g/dL (9.9; 11.7 g/dL) after treatment. Normal Apgar scores were observed in all 97 infants (median birth weights 3560 g, 3270, and 3798 g). Four women received ferric carboxymaltose in the first trimester and twenty-eight during the second trimester without adverse outcomes for mother or child. These cases add to the evidence that ferric carboxymaltose administration during pregnancy is effective and safe.

Iron deficiency anaemia in pregnancy: The role of parenteral iron

Maternal and perinatal morbidity and mortality remain major challenges in the delivery of safe maternity care worldwide. Anaemia in pregnancy is an important contributor to this dismal picture, especially where blood transfusion services are poorly developed. An early diagnosis and treatment of iron deficiency anaemia in pregnancy using the new generation dextran-free parenteral iron preparations can save lives and reduce morbidity in selected pregnancies. It is time to cast aside the fears associated with the use of the old parenteral iron preparations which were associated a high incidence of anaphylaxis, and embrace the use of new parenteral iron products which have better side effect profiles and can deliver total dose infusions without the need for test dosing. In selected women, the benefits of this treatment far outweigh any disadvantages.

Diagnosis and treatment of iron deficiency anemia during pregnancy and the postpartum period: Iron deficiency anemia working group consensus report

According to the World Health Organization (WHO), anemia is the most common disease, affecting >1.5 billion people worldwide. Furthermore, iron deficiency anemia (IDA) accounts for 50% of cases of anemia. IDA is common during pregnancy and the postpartum period, and can lead to serious maternal and fetal complications. The aim of this report was to present the experiences of a multidisciplinary expert group, and to establish reference guidelines for the optimal diagnosis and treatment of IDA during pregnancy and the postpartum period. Studies and guidelines on the diagnosis and treatment of IDA published in Turkish and international journals were reviewed. Conclusive recommendations were made by an expert panel aiming for a scientific consensus. Measurement of serum ferritin has the highest sensitivity and specificity for diagnosis of IDA unless there is a concurrent inflammatory condition. The lower threshold value for hemoglobin (Hb) in pregnant women is <11 g/dL during the 1^st and 3^rd trimesters, and <10.5 g/dL during the 2^nd trimester. In postpartum period a Hb concentration <10 g/dL indicates clinically significant anemia. Oral iron therapy is given as the first-line treatment for IDA. Although current data are limited, intravenous (IV) iron therapy is an alternative therapeutic option in patients who do not respond to oral iron therapy, have adverse reactions, do not comply with oral iron treatment, have a very low Hb concentration, and require rapid iron repletion. IV iron preparations can be safely used for the treatment of IDA during pregnancy and the postpartum period, and are more beneficial than oral iron preparations in specific indications.

Intravenous iron isomaltoside 1000 administered by high single-dose infusions or standard medical care for the treatment of fatigue in women after postpartum haemorrhage: study protocol for a randomised controlled trial

Background

Postpartum haemorrhage can lead to iron deficiency with and without anaemia, the clinical consequences of which include physical fatigue. Although oral iron is the standard treatment, it is often associated with gastrointestinal side effects and poor compliance. To date, no published randomised controlled studies have compared the clinical efficacy and safety of standard medical care with intravenous administration of iron supplementation after postpartum haemorrhage.

The primary objective of this study is to compare the efficacy of an intravenous high single-dose of iron isomaltoside 1000 with standard medical care on physical fatigue in women with postpartum haemorrhage.

Methods/Design

In a single centre, open-labelled, randomised trial, women with postpartum haemorrhage exceeding 700 mL will be allocated to either a single dose of 1,200 mg of iron isomaltoside 1000 or standard medical care. Healthy parturients with a singleton pregnancy will be included within 48 hours after delivery.

Participants will complete structured questionnaires that focus on several dimensions of fatigue and mental health (Multidimensional Fatigue Inventory, Edinburgh Postnatal Depression Scale and the Postpartum Questionnaire), at inclusion and at follow-up visits after three days, one week, three weeks, eight weeks, and 12 weeks postpartum. The primary endpoint is the aggregated change in physical fatigue score within 12 weeks postpartum, as measured by a subscale of the Multidimensional Fatigue Inventory. The primary objective will be considered to have been met if an intravenous high single dose of iron isomaltoside 1000 is shown to be superior to standard medical care in women after postpartum haemorrhage regarding physical fatigue.

For claiming superiority, we set the minimal clinically relevant difference between the mean scores at 1.8, and the assumed standard deviation at 4.2. Hence, 87 participants per treatment group are needed in order to demonstrate superiority; to provide an extra margin for missing data and dropouts, 200 women will be included.

Discussion

The study will provide evidence on relevant clinical outcomes beyond biochemical parameters for intravenous iron isomaltoside 1000 compared to standard medical care in women after postpartum haemorrhage.

Trial registration

This trial is registered with Clinicaltrials.gov (identifier: NCT01895218) on 26 June 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/1745-6215-16-5) contains supplementary material, which is available to authorized users.

Survey of women's perceptions of information provided in the prevention or treatment of iron deficiency anaemia in an Australian tertiary obstetric hospital

BACKGROUND

There is limited literature to understand the perceptions of Australian women regarding the information provided by healthcare professionals relating to the prevention and treatment of iron deficiency anaemia in pregnancy.

AIM

To establish an insight into the key themes and trends within a tertiary obstetric hospital related to the provision of dietary advice and use of iron supplements in pregnancy.

METHODS

A prospective patient survey of pregnant women and women up to 4 weeks postnatal attending hospital.

FINDINGS

Of the 110 women who participated, 73.6% were provided with information on iron rich foods and 67% made dietary changes. Eighty percent of women were advised to take oral iron and 65.5% of women were taking it at the time of the survey. In women who had independently ceased oral iron, 41.7% failed to inform their healthcare professional. In the women who did inform their healthcare professional 89.5% received advice to help overcome the reason that led to cessation. The main causes included forgetfulness and side effects. Women were less likely to require intravenous iron if oral iron was commenced early.

CONCLUSIONS

Compliance with recommended oral iron is variable within a population of pregnant women. Women are provided with information on a range of issues relating to the prevention and treatment of iron deficiency anaemia; yet there is a disparity between the information provided and the resulting action. Further research should focus on targeted measures to improve understanding and compliance with treatment from the both women's and health professionals perspective.

Iron sucrose - characteristics, efficacy and regulatory aspects of an established treatment of iron deficiency and iron-deficiency anemia in a broad range of therapeutic areas

INTRODUCTION

Iron is a key element in the transport and utilization of oxygen and a variety of metabolic pathways. Iron deficiency is a major cause of anemia and can be associated with fatigue, impaired physical function and reduced quality of life. Administration of oral or intravenous (i.v.) iron is the recommended treatment for iron-deficiency anemia (IDA) in different therapeutic areas.

AREAS COVERED

This article provides an overview of studies that evaluated i.v. iron sucrose for anemia and iron status management, either alone or in combination with erythropoiesis-stimulating agents, across various diseases and conditions.

EXPERT OPINION

Iron sucrose is an established, effective and well-tolerated treatment of IDA in patients with acute or chronic conditions such as chronic kidney disease, inflammatory bowel disease, pregnancy (second and third trimester), postpartum period, heavy menstrual bleeding and cancer who need rapid iron supply and in whom oral iron preparations are ineffective or not tolerated. Available data on patient blood management warrant further studies on preoperative iron treatment. First experience with iron sucrose follow-on products raises questions about their therapeutic equivalence without comparative clinical data in newly diagnosed patients or patients on existing chronic treatment.

Stereological analysis of terminal villi of the placentas of pregnant woman with sideropenic anemia

Iron deficiency, causing maternal sideropenic anemia, is one of the most frequent nutritive disorder that develops during the pregnancy. We collected 30 placentas from anemic mothers and 30 placentas from mothers belonging to the control group. Terminal villi (magnification 10x) and terminal villi capillaries (magnification 40x) were stereologically analyzed and numerically determined.In the placentas from anemic mothers we noted the values a) terminal villi: volume density 0,43 mm0, surface density 24.13 mm-1, total volume 185.57 cm3 and total surface 10.27 m2; b) capillaries of terminal villi: volume density 0.53 mm0 and total volume 224.18 cm3. In the placentas from mothers belonging to the control group we observed the following values a) terminal villi: volume density 0.44 mm0, surface density 22.27 mm-1, total volume 200.17 cm3 and total surface 10.15 m2; b) capillaries of terminal villi: volume density 0.42 mm0 and total volume 197.00 cm3. Compared with the control group anemic mothers' placentas have a significant higher values of surface density of terminal villi (p&lt;0.05), volume density (p &lt;0.01) and absolute volume (p&lt;0.0001) of terminal villi capillaries, and significant lower values of absolute volume of terminal villi (p&lt;0.05).In anemic mothers' placentas, the total volume of terminal villi changes disproportionately to the total surface of terminal villi with statistically significant increase of terminal villi capillaries compared with control group. 

Comparison of adverse event profile of intravenous iron sucrose and iron sucrose similar in postpartum and gynecologic operative patients

OBJECTIVE

Severe iron deficiency resulting in anemia is a common problem during pregnancy and in menstruating women. Several choices for IV iron replacement therapies exist and increased pressures on budgets may require cheaper 'iron sucrose similar' (ISS) to be used. In our practice, an iron sucrose similar (Ferex; ISS(FRX)) was introduced to reduce costs in the treatment of pregnant women or those planned for surgery. Post several months of use we observed increased rates of adverse events from patients and hence performed this analysis to confirm these findings.

METHODS

Data on adverse events was retrospectively collected from 658 patients treated between September 2004 and December 2011. Patients were analyzed in three cohorts, iron sucrose originator (IS(ORIG)), ISS(FRX) diluted in 100 mL saline and ISS(FRX) diluted in 200 mL saline.

RESULTS

The mean age was 38.5 years and included patients having normal delivery, Cesarean section, myomectomy, hysterectomy, cystectomy and adnexectomy. There were 169 patients in the IS(ORG) group and 210 and 279 in the ISS(FRX)-100 and ISS(FRX)-200 groups respectively. Adverse drug reactions were more frequent in the ISS(FRX) groups vs. IS(ORIG) (11.0 vs. 14.3 vs. 1.8%; p < 0.02). Events were mild-to-moderate in nature and were predominately injection site reactions and phlebitis.

RESULTS

may be impacted by imbalance in baseline characteristics and cumulative iron dose received, however events were mostly acute and all patients received 200 mg iron as single administration.

CONCLUSION

This is the first large analysis suggesting increased adverse events due to an ISS. For our practice, the use of ISS(FRX) was discontinued owing to safety concerns outweighing the theoretical cost benefit. This study raises the question on the appropriate approval process for complex drugs and if these can be substituted without appropriate clinical testing, both for efficacy and most importantly safety, in routine clinical practice.