Abstract
Iron deficiency anemia of pregnancy is common, especially in South Asia, and is associated with adverse maternal and fetal outcomes including increased incidences of maternal mortality, preterm labor and low birth weight. Screening for anemia alone is not sufficient to diagnose iron deficiency. Iron deficiency in neonates is associated with a statistically significant increment in cognitive and behavioral abnormalities which persist after iron repletion. Oral iron is the frontline standard but is associated with an unacceptably high incidence of gastrointestinal adverse events leading to poor adherence. Prospective evidence reports an incidence of neonatal iron deficiency up to 45% even with oral iron supplementation. New evidence reports oral iron ingestion increases serum hepcidin leading to decreased absorption suggesting further decreasing efficacy. Published evidence reports that intravenous iron is safe and effective in the second and third trimesters of pregnancy. Intravenous iron is the preferred route when there is oral iron intolerance or in those situations where oral iron is ineffective or harmful. Intravenous iron is also preferred if the anemia is severe (< 8 g/dL) in the second trimester or at any time in the third trimester when there is little expectation that adequate quantities of iron will be delivered to the fetus as iron requirements increase in each trimester. Guidelines for maternal and neonatal screening and treatment lack consistency and differ between the United States and Europe. New formulations of intravenous iron with complex carbohydrate cores that bind elemental iron more tightly mitigating the release of large quantities of labile free iron allow the administration of complete replacement doses in 15–60 min. The preponderance of published evidence suggests that intravenous iron is underutilized in pregnancy and guidelines suggesting there is insufficient evidence to recommend the routine screening and treatment of iron deficiency in gravidas should be revisited. The major recommendation from this commentary is that in low-income countries, a trial or demonstration project to test the efficacy, safety, cost and feasibility of the administration of intravenous iron to anemic and/or iron-deficient women be undertaken.
Highlights
The estimated incidence of anemia of pregnancy varies between eight and 20 %, largely dependent on the economic status of the measured populations [1,2,3,4] with some areas of India and Pakistan reporting up to 90%
These recommendations were supported by a recent United States Preventive Service Task Force (USPSTF) publication which reported that “there is insufficient evidence that routine prenatal screening and supplementation for iron deficiency anemia improves maternal or infant clinical health outcomes, but supplementation may improve maternal hematologic indices” [12]. While these recommendations are syntactically accurate due to the lack of published outcome data, a plethora of published evidence suggests the recommendations be revisited. This position is supported by The Cochrane Collaboration, reporting that despite the high incidence and burden of disease associated with iron deficiency anemia of pregnancy, there “is a paucity of quality trials assessing clinical maternal and neonatal effects of iron administration in pregnant women with anemia [4]
Lending further support to the inadequacy of oral iron in many gravid women is published evidence reporting that a ferritin level less than 15 ng/ml in the mother compromises iron status of the growing fetus whose iron requirements for normal brain development are maximal from week 34 on [6]
Summary
The estimated incidence of anemia of pregnancy varies between eight and 20 %, largely dependent on the economic status of the measured populations [1,2,3,4] with some areas of India and Pakistan reporting up to 90%. This position is supported by The Cochrane Collaboration, reporting that despite the high incidence and burden of disease associated with iron deficiency anemia of pregnancy, there “is a paucity of quality trials assessing clinical maternal and neonatal effects of iron administration in pregnant women with anemia [4].
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