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Evidence summaries

Treatment for Women with Postpartum Iron Deficiency Anaemia

Intravenous iron is more effective than oral iron for women with postpartum iron deficiency anaemia. Level of evidence: "C"

A Cochrane review [Abstract] 1 included 22 studies on the treatments for postpartum anaemia, with a total of 2858 subjects. Intravenous iron was compared to oral iron in 10 studies (1553 women). Fatigue was reported in 2 studies and improved significantly favouring the intravenously treated group in one of the studies. Other anaemia symptoms were not reported. One woman died from cardiomyopathy (RR 2.95; 95% CI 0.12 to 71.96; 2 studies; one event; n=374; low quality evidence). One woman developed arrhythmia. Both cardiac complications occurred in the intravenously treated group. Allergic reactions occurred in 3 women treated with intravenous iron, not statistically significant (average RR 2.78; 95% CI 0.31 to 24.92; 8 studies; n=1454; I² = 0%; low quality evidence). Gastrointestinal events were less frequent in the intravenously treated group (average RR 0.31; 95% CI 0.20 to 0.47; 8 studies; 169 events; n=1307; I² = 0%; very low quality evidence).One study evaluated red blood cell transfusion versus non-intervention. General fatigue improved significantly more in the transfusion group at three days (MD -0.80; 95% CI -1.53 to -0.07; n=388; low quality evidence), but no difference between groups was seen at 6 weeks. Maternal mortality was not reported.The remaining comparisons evaluated oral iron (with or without other food substances) versus placebo (3 studies), intravenous iron with oral iron versus oral iron (2 studies) and erythropoietin (alone or combined with iron) versus placebo or iron (7 studies). These studies did not investigate fatigue. Maternal mortality was rarely reported.

A meta-analysis 2 included 15 RCTs (n = 1001 and 1 181 women receiving oral iron and IV iron, respectively). Higher postpartum week 6 hemoglobin concentrations in the IV iron group were observed compared to the oral iron group (mean difference, 0.9 g/dL; 95% CI, 0.4 to 1.3; P = .0003). Compared to oral iron, women receiving IV iron had higher ferritin concentrations at postpartum week 6; an increased likelihood of skin flushing (odds ratio [OR], 6.95; 95% CI, 1.56 to 31.03; P = .01); and a decreased likelihood of constipation (OR, 0.08; 95% CI, 0.03 to 0.21; P < .00001) and dyspepsia (OR, 0.07; 95% CI 0.01 to 0.42; P = .004). The reported event rate for anaphylaxis among women receiving IV iron was 0.6%.

Comment: The quality of evidence is downgraded by study limitations (unclear allocation concealment in half of the studies, no blinding, incomplete outcome data, and selective reporting), by imprecise results (limited study size for each comparison), and by indirectness (clinical outcomes were rarely reported).

    References

    • Markova V, Norgaard A, Jørgensen KJ et al. Treatment for women with postpartum iron deficiency anaemia. Cochrane Database Syst Rev 2015;(8):CD010861. [PubMed]
    • Sultan P, Bampoe S, Shah R et al. Oral vs intravenous iron therapy for postpartum anemia: a systematic review and meta-analysis. Am J Obstet Gynecol 2019;221(1):19-29.e3.[PubMed]

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