Diagnosis and treatment of iron-deficiency anaemia in pregnancy and postpartum

Postpartum care: Clinical considerations for improving genital and sexual health

The postpartum period encompasses the biological and psychoaffective transition to motherhood. However, it remains a most neglected phase in a woman's life. Furthermore, the transition to parenthood is a critical and potentially disrupting factor in a couple's relationship, which can be complicated by undiagnosed biological and psychosexual difficulties. Lack of recognition of the many biological and medical factors that can affect women's health and sexuality in the postpartum period is a common and persistent clinical omission worldwide. Communication difficulties exist between healthcare professionals and women and there are wording biases in describing female genitalia. This can further contribute to the diagnostic lack of attention and timely diagnosis and treatment of even very bothersome symptoms. Early diagnosis and treatment of common postpartum conditions is vital and quality care for new mothers should include psychological and emotional support, lactation assistance, early diagnosis and treatment of genital and sexual pain symptoms, pelvic floor rehabilitation and sexual health guidance. The inclusion of correct genital hygiene practices is a critical element of postpartum gynaecological counselling and can help improve overall genital and sexual health. In this review, we summarise the variability in global professional guidelines for postpartum care, identify common health problems faced by postpartum women and discuss appropriate postpartum care. We pay specific attention to prominent biological or medical factors that can impact the emotional and psychosexual wellbeing of women and couples. The aetiology, diagnosis and treatment of sexual dysfunction, in particular sexual pain disorders, is therefore discussed with a pragmatic approach. Finally, the role of intimate hygiene care is discussed with special attention given to cleanser ingredients with solid scientific evidence to help clinicians adopt a more tailored approach with their clinical recommendations.

Anemia in Pregnancy With CKD

Chronic kidney disease (CKD), anemia, and iron deficiency are global health issues affecting individuals in both high-income and low-income countries. In pregnancy, both CKD and iron deficiency anemia increase the risk of adverse maternal and neonatal outcomes, including increased maternal morbidity and mortality, stillbirth, perinatal death, preterm birth, and low birthweight. However, it is unknown to which extent iron deficiency anemia contributes to adverse outcomes in CKD pregnancy. Furthermore, little is known regarding the prevalence, pathophysiology, and treatment of iron deficiency and anemia in pregnant women with CKD. Therefore, there are many unanswered questions regarding optimal management with oral or i.v. iron and recombinant human erythropoietin (rhEPO) in these women. In this review, we present a short overview of the (patho)physiology of anemia in healthy pregnancy and in people living with CKD. We present an evaluation of the literature on iron deficiency, anemia, and nutritional deficits in pregnant women with CKD; and we evaluate current knowledge gaps. Finally, we propose research priorities regarding anemia in pregnant women with CKD.

The fatigue after infusion or transfusion pilot trial and feasibility study: A three-armed randomized pilot trial of intravenous iron and blood transfusion for the treatment of postpartum anemia

BACKGROUND

Evidence for the management of moderate-to-severe postpartum anemia is limited. A randomized trial is needed; recruitment may be challenging.

STUDY DESIGN AND METHODS

Randomized pilot trial with feasibility surveys.

INCLUSION

hemoglobin 65-79 g/L, ≤7 days of birth, hemodynamically stable.

EXCLUSION

ongoing heavy bleeding; already received, or contraindication to intravenous (IV)-iron or red blood cell transfusion (RBC-T). Intervention/control: IV-iron; RBC-T; or IV-iron and RBC-T.

PRIMARY OUTCOME

number of recruits; proportion of those approached; proportion considered potentially eligible.

SECONDARY OUTCOMES

fatigue, depression, baby-feeding, and hemoglobin at 1, 6 and 12 weeks; ferritin at 6 and 12 weeks. Surveys explored attitudes to trial participation.

RESULTS

Over 16 weeks and three sites, 26/34 (76%) women approached consented to trial participation, including eight (31%) Māori women. Of those potentially eligible, 26/167 (15.6%) consented to participate. Key participation enablers were altruism and study relevance. For clinicians and stakeholders the availability of research assistance was the key barrier/enabler. Between-group rates of fatigue and depression were similar. Although underpowered to address secondary outcomes, IV-iron and RBC-T compared with RBC-T were associated with higher hemoglobin concentrations at 6 (mean difference [MD] 11.7 g/L, 95% confidence interval [CI] 2.7-20.7) and 12 (MD 12.8 g/L, 95% CI 1.5-24.2) weeks, and higher ferritin concentrations at 6 weeks (MD 136.8 mcg/L, 95% CI 76.6-196.9).

DISCUSSION

Willingness to participate supports feasibility for a future trial assessing the effectiveness of IV-iron and RBC-T for postpartum anemia. Dedicated research assistance will be critical to the success of an appropriately powered trial including women-centered outcomes.

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.

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.

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.

Antenatal Optimization of Maternal Anemia Leads to Decreased Risks of Maternal Morbidity

Purpose of Review

Our review focuses on the appropriate use of intravenous iron to increase the likelihood of achieving target hemoglobin levels prior to delivery to reduce maternal morbidity.

Recent Findings

Iron deficiency anemia (IDA) is a leading contributor to severe maternal morbidity and mortality. Prenatal treatment of IDA has been demonstrated to reduce the likelihood of adverse maternal outcomes. Recent investigations of intravenous iron supplementation have demonstrated superior efficacy and high tolerability for the treatment of IDA in the third trimester, compared against oral regimens. However, it is unknown whether this treatment is cost-effective, available to clinicians, or acceptable to patients.

Summary

Intravenous iron is superior to the oral treatment of IDA; however, its use is limited by the lack of implementation data.

Current concepts in preoperative anemia management in obstetrics

PURPOSE OF REVIEW

The purpose of this article is to provide an overview of currently recommended treatment approaches for anemia during pregnancy, with a special focus on iron deficiency and iron deficiency anemia (IDA).

RECENT FINDINGS

As consistent patient blood management (PBM) guidelines in obstetrics are still lacking, recommendations regarding the timing of anemia screening and the treatment recommendations for iron deficiency and IDA during pregnancy are still controversial. Based on increasing evidence, early screening for anemia and iron deficiency should be recommended at the beginning of each pregnancy. To reduce maternal and fetal burden, any iron deficiency, even without anemia, should be treated as early as possible during pregnancy. While oral iron supplements administered every other day are the standard treatment in the first trimester, the use of intravenous iron supplements is increasingly suggested from the second trimester onwards.

SUMMARY

The treatment of anemia, and more specifically iron deficiency anemia during pregnancy, holds many possibilities for improvement. The fact that the period of risk is known well in advance and thus there is a long optimization phase is per se an ideal prerequisite for the best possible therapy of treatable causes of anemia. Standardization of recommendations and guidelines for screening and treatment of IDA in obstetrics is required for the future. In any case, a multidisciplinary consent is the precondition for a successfully implementation of anemia management in obstetrics to establish an approved algorithm easily enabling detection and treatment of IDA during pregnancy.

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.

Recognizing who is at risk for postpartum hemorrhage: targeting anemic women and scoring systems for clinical use

Iron deficiency anemia during pregnancy is a common concern, affecting 38% of women worldwide and up to 50% in developing countries. It is defined differently throughout all 3 trimesters. It has several detrimental effects on pregnancy outcomes for both the mother and the fetus, such as increasing the risk for postpartum depression, preterm delivery, cesarean delivery, preeclampsia, and low birthweight. Management of iron deficiency anemia is done classically via oral iron supplementation. However, recent evidence has shown that intravenous iron is a good alternative to oral iron if patients are unable to tolerate it, not responding, or present with a new diagnosis very late in pregnancy. Management of iron deficiency anemia was demonstrated to be protective against postpartum hemorrhage. Other ways to prevent postpartum hemorrhage include improving prediction tools that can identify those at risk. Several risk assessment kits have been developed to estimate the risk for postpartum hemorrhage among patients and have been proven useful in the prediction of patients at high risk for postpartum hemorrhage despite limitations among low-risk groups. More comprehensive tools are also being explored by determining clinically relevant factors through nomograms, with some proving their efficacy after implementation. Machine learning is also being used to develop more complete tools by including risk factors previously not accounted for. These newer tools, however, still require external validation before being adopted despite promising results under testing conditions.

Patient Blood Management programs for post-partum hemorrhage

Patient blood management (PBM) strategies aim to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss to improve patient outcomes. Because postpartum hemorrhage (PPH) is a leading cause of maternal mortality and blood product utilization, PBM principles can be applied in its therapeutic approach. First, pre-operative identification of risk factors for PPH and identification of peri-delivery anemia should be conducted. Iron supplementation should be used to optimize hemoglobin concentration before delivery; it can also be used to treat anemia in the postpartum period after severe PPH. Both acute normovolemic hemodilution and intraoperative cell salvage can be effective techniques to reduce allogeneic blood transfusion during or after surgical procedures. Furthermore, these strategies appear to be safe when used in the pregnant population.

Placenta Accreta Spectrum Part II: hemostatic considerations based on an extended review of the literature

"Placenta accreta spectrum" (PAS) is a rare but serious pregnancy condition where the placenta abnormally adheres to the uterine wall and fails to spontaneously release after delivery. When it occurs, PAS is associated with high maternal morbidity and mortality-as PAS management can be particularly challenging. This two-part review summarizes current evidence in PAS management, identifies its most challenging aspects, and offers evidence-based recommendations to improve management strategies and PAS outcomes. The first part of this two-part review highlighted the general anesthetic approach, surgical and interventional management strategies, specialized "centers of excellence," and multidisciplinary PAS treatment teams. The high rates of PAS morbidity and mortality are often provoked by PAS-associated coagulopathies and peripartal hemorrhage (PPH). Anesthesiologists need to be prepared for massive blood loss, transfusion, and to manage potential coagulopathies. In this second part of this two-part review, we specifically reviewed the current literature pertaining to hemostatic changes, blood loss, transfusion management, and postpartum venous thromboembolism prophylaxis in PAS patients. Taken together, the two parts of this review provide a comprehensive survey of challenging aspects in PAS management for anesthesiologists.

Iron Deficiency in the United States: Limitations in Guidelines, Data, and Monitoring of Disparities

Iron deficiency and the more severe sequela, iron deficiency anemia, are public health problems associated with morbidity and mortality, particularly among pregnant women and younger children. The 1998 Centers for Disease Control and Prevention recommendations for prevention and control of iron deficiency in the United States is old and does not reflect recent evidence but is a foundational reference for many federal, clinical, and program guidelines. Surveillance data for iron deficiency are sparse at all levels, with critical gaps for pregnant women and younger children. Anemia, iron deficiency, and iron deficiency anemia are often conflated but should not be. Clinical guidelines for anemia, iron deficiency, and iron deficiency anemia give inconsistent recommendations, causing nonsystematic assessment of iron deficiency. Screening for iron deficiency typically relies on identifying anemia, despite anemia's low sensitivity for iron deficiency. In the National Health and Nutrition Examination Survey, more than 70% of iron deficiency is missed among pregnant women and children by relying on hemoglobin for iron deficiency screening. To improve assessment and diagnosis and strengthen surveillance, better and more complete data and updated foundational guidance on iron deficiency and anemia are needed that consider new evidence for measuring and interpreting laboratory results. (Am J Public Health. 2022;112(S8):S826-S835. https://doi.org/10.2105/AJPH.2022.306998).

Beneficios del uso del hierro parenteral como alternativa eficaz en el manejo de la anemia gestacional en Colombia

Introducción. La Organización Mundial de la Salud (OMS) estima que más del 40% de las mujeres embarazadas a nivel mundial tienen anemia, y la mitad de estas padecen deficiencia de hierro. La prevalencia en América Latina es del 40% y en Colombia del 44.7%. Fisiológicamente en el embarazo se produce una mal llamada “anemia dilucional”, existen condiciones en la embarazada que la predisponen a tener una anemia patológica. Esta última es causada principalmente por un déficit de hierro, de allí la importancia de diagnosticar a tiempo esta entidad e iniciar el manejo. La administración de hierro es la base del tratamiento de la anemia por deficiencia de hierro. Puede ser administrado por vía oral, la cual es la preferida en la mayoría de las pacientes; sin embargo, cuando este no es posible administrarlo, es esencial recurrir al hierro parenteral. No obstante, el hierro parenteral es poco usado como primera línea en el manejo de la anemia gestacional. El presente artículo tiene como objetivo realizar una revisión que permita identificar la terapia con hierro parenteral como una alternativa eficaz de manejo para la anemia gestacional, teniendo en cuenta las características farmacológicas, la administración y el uso entre las diferentes moléculas disponibles en Colombia. Metodología. Corresponde a un estudio de revisión de literatura en bases de datos y bibliotecas electrónicas, los criterios que se tuvieron en cuenta fueron textos publicados entre 1996 y 2020, en español e inglés. Se obtuvo un resultado de 95 artículos, de los cuales se seleccionaron 49. Las palabras clave para su búsqueda fueron fisiología, hierro parenteral, anemia gestacional, déficit de hierro, complicaciones del embarazo, compuestos de hierro, farmacocinética, diagnóstico y tratamiento. División de temas tratados. Fisiología; ayudas diagnósticas; características farmacológicas del hierro parenteral; ventajas, indicaciones y contraindicaciones del hierro parenteral; efectos secundarios y forma de aplicación. Conclusiones. El hierro parenteral es un tratamiento seguro y eficaz para manejar la anemia en el embarazo, se debe tener en cuenta las indicaciones y la farmacología de las moléculas para elegir la más adecuada. Además, repone más rápidamente las reservas de hierro y los niveles de hemoglobina.

Postpartum anaemia in three New Zealand district health board regions: An observational study of incidence and management

BACKGROUND

The incidence of postpartum anaemia (PPA) in New Zealand, and the extent of intravenous iron (IV-iron) use in its treatment, are unknown.

AIMS

To report the incidence of PPA in three district health board (DHB) regions and describe current management of moderate to severe PPA, including by ethnicity.

MATERIALS AND METHODS

Retrospective observational study of PPA (haemoglobin (Hb) <100 g/L) in three DHBs from July-December 2019. Cases with moderate to severe PPA (Hb <90 g/L) were reviewed and management compared to local and national guidance. Logistic regression examined demographic associations of PPA.

RESULTS

There were 8849 women who gave birth during the study period: 4076 (46%) had postpartum Hb testing and 1544 (38%) had PPA. Of those tested, and after adjusting for deprivation and region, European women had lower adjusted odds ratios compared to Māori for being identified as having PPA (0.46, 95% CI 0.37-0.57, P < 0.01). Of 681 women with Hb <90 g/L, 278 (41%) received IV-iron only, 66 (10%) red blood cell transfusion (RBC-T) only and 155 (23%) both. Of those receiving RBC-T, 40/221 (18%) were actively bleeding. Māori (92/138, 67%) and Pacific (127/188, 68%) women with Hb <90 g/L had the highest incidence of IV-iron use. No guidelines provided recommendations for haemodynamically stable women without active bleeding.

CONCLUSION

The incidence and management of PPA differs by ethnicity but fewer than half of the women had Hb testing, making precise determination of incidence impossible. The majority of women with Hb <90 g/L received IV-iron, with or without RBC-T.

[Patient blood management in the preparation for birth, obstetrics and postpartum period]

The implementation of patient blood management (PBM) is increasingly becoming standard in operative medicine. Recently, interest has also been shown for the vulnerable collective of pregnant women and neonates. As the information regarding anesthesiological procedures for pregnant women and the peripartum period including an informed consent process should be carried out long before childbirth, this provides a good possibility in this connection to incorporate PBM. An anesthesiological risk estimation as well as the diagnostic workup and treatment of potential anemia should be carried out during the pregnancy. Furthermore, loss of blood in anticipation of bleeding complications should be reduced by interdisciplinary preventive measures and an individually coordinated postpartum care should be organized. This results in an early diagnosis of anemia or iron deficiency with subsequent treatment also postpartum, analogous to the prepartum period.

Applying reflective multicriteria decision analysis to understand the value of therapeutic alternatives in the management of gestational and peripartum anaemia in Spain

BACKGROUND

The objective of the FeminFER project was to assess the value of ferric carboxymaltose following a multicriteria decision analysis in obstetrics and gynaecology in Spain.

METHODS

Ferric carboxymaltose (FCM) and ferrous sulphate were evaluated using the EVIDEM framework. Ten stakeholders participated to collect different perspectives. The framework was adapted considering evidence retrieved with a PICO-S search strategy and grey literature. Criteria/subcriteria were weighted by level of relevance and an evidence-based decision-making exercise was developed in each criterion; weights and scores were combined to obtain the value of intervention relative to each criterion/subcriterion, that were further combined into the Modulated Relative Benefit-Risk Balance (MRBRB).

RESULTS

The most important criterion favouring FCM was Compared Efficacy/Effectiveness (0.183 ± 0.07), followed by Patient Preferences (0.059 ± 0.10). Only Direct medical costs criterion favoured FS (-0.003 ± 0.03). MRBRB favoured FCM; 0.45 ± 0.19; in a scale from -1 to + 1.

CONCLUSIONS

In conclusion, considering the several criteria involved in the decision-making process, participants agreed with the use of FCM according to its MRBRB.

Maternal first trimester iron status and its association with obstetric and perinatal outcomes

PURPOSE

To assess the following in singleton pregnant women: (1) associations between first trimester iron deficiency and obstetric and perinatal outcomes, (2) overall first trimester iron status and (3) post-treatment iron status after intensified iron supplementation.

METHODS

A prospective cohort study was conducted with linkage of first trimester hemoglobin and plasma ferritin with obstetric and perinatal data from a hospital database. Blood sample data were obtained from a Danish University Hospital. The cohort was divided into groups according to ferritin and hemoglobin: (1) iron-deficient anemic (ferritin < 30 ng/mL and Hb < 110 g/L), (2) iron-deficient non-anemic (ferritin < 30 ng/mL and Hb ≥ 110 g/L), and (3) iron-replete non-anemic (ferritin 30-200 ng/mL and Hb ≥ 110 g/L). Obstetric and perinatal outcomes in each iron-deficient group were compared to the iron-replete non-anemic group using multivariable logistic regression. The effect of 4 weeks intensified iron supplementation on hemoglobin and ferritin was assessed by groupwise comparisons.

RESULTS

The cohort comprised 5763 singleton pregnant women, of which 14.2% had non-anemic iron deficiency, and 1.2% had iron-deficiency anemia. Compared to iron-replete non-anemic women, iron-deficient anemic women had a higher risk of gestational diabetes (aOR 3.8, 95% CI 1.4-9.0), and iron-deficient non-anemic women had a higher risk of stillbirth (aOR 4.0, 95% CI 1.0-14.3). In group 1 and 2, 81.5% and 67.7% remained iron-deficient after intensified iron supplementation.

CONCLUSION

Iron-deficiency anemia was associated with gestational diabetes, and non-anemic iron deficiency with stillbirth, although risk estimates were imprecise due to few events. Iron deficiency was present in 15.4% and often persisted despite 4 weeks intensified iron supplementation.

Questions and answers on iron deficiency treatment selection and the use of intravenous iron in routine clinical practice

Iron deficiency is a common cause of morbidity and can arise as a consequence or complication from many diseases. The use of intravenous iron has increased significantly in the last decade, but concerns remain about indications and administration. Modern intravenous iron preparations can facilitate rapid iron repletion in one or two doses, both for absolute iron deficiency and, in the presence of inflammation, functional iron deficiency, where oral iron therapy is ineffective or has not worked. A multidisciplinary team of experts experienced in iron deficiency undertook a consensus review to support healthcare professionals with practical advice on managing iron deficiency in gastrointestinal, renal and cardiac disease, as well as; pregnancy, heavy menstrual bleeding, and surgery. We explain how intravenous iron may work where oral iron has not. We provide context on how and when intravenous iron should be administered, and informed opinion on potential benefits balanced with potential side-effects. We propose how intravenous iron side-effects can be anticipated in terms of what they may be and when they may occur. The aim of this consensus is to provide a practical basis for educating and preparing staff and patients on when and how iron infusions can be administered safely and efficiently. Key messages Iron deficiency treatment selection is driven by several factors, including the presence of inflammation, the time available for iron replenishment, and the anticipated risk of side-effects or intolerance. Intravenous iron preparations are indicated for the treatment of iron deficiency when oral preparations are ineffective or cannot be used, and therefore have applicability in a wide range of clinical contexts, including chronic inflammatory conditions, perioperative settings, and disorders associated with chronic blood loss. Adverse events occurring with intravenous iron can be anticipated according to when they typically occur, which provides a basis for educating and preparing staff and patients on how iron infusions can be administered safely and efficiently.

Variability in Oral Iron Prescription and the Effect on Spanish Mothers' Health: A Prospective Longitudinal Study

Background: No consensus exists regarding the hemoglobin (Hb) values that define postpartum anemia. Knowledge is currently lacking regarding prescription and consumption practices, which prevents evaluating the rational use of iron supplementation postpartum. Aim: In this study, our objective was to describe this practice and analyze its association with maternal health outcomes. Methods: A prospective observational study was conducted with 1010 women aged between 18 and 50. The hemoglobin value on the first postpartum day; the prescription schedule at hospital discharge; iron consumption; and data on hemoglobin, serum ferritin, maternal fatigue, type of breastfeeding, and perceived health six weeks after delivery were collected. Findings: Oral iron was prescribed to 98.1% of mothers with anemia and 75.8% without anemia. At the same Hb value, the maximum amount of total iron prescribed was between 8 and 10 times greater than the minimum amount. Iron intake was significantly lower than prescribed (p < 0.01). At six weeks, anemic mothers who took iron presented a 3.6-, 3-, and 2.4-times lower probability of iron deficiency, anemia, and abandoning breastfeeding, respectively. Discussion: Postpartum iron intake shows a protective effect on iron deficiency and anemia at six weeks, but not on fatigue or self-perceived health level. Conclusion: We conclude that there is wide variability in the prescription regimen. Oral iron supplementation can benefit mothers with anemia and harm those without. Subsequent studies should further explore the Hb figure that better discriminates the need for postpartum iron.

STUDIES OF MAGNESIUM AND PHOSPHORUS COMBINED MEDICATION BASED ON CASEIN

Aim. The Department of Biochemistry and Physiology of Animals, named after Academician Guly NUBIP of Ukraine, developed magnesium and phosphorus combined medication based on casein. Our aim was to test its bioavailability based on the ability to be hydrolyzed by a mixture of pancreatic digestive enzymes trypsin and chymotrypsin, also check the absence of cytotoxic effects on cell cultures. Methods. To assess bioavailability, we used hydrolysis of the medication with a mixture of trypsin and chymotrypsin, followed by detection of hydrolysis products by polyacrylamide gel electrophoresis. A standard MTT-test performed on both MT-4 and Namalva cell lines was used to assess cytotoxic effects. Results. Based on electrophoresis data, it was found that despite chemical modifications of the natural casein, the medication based on it is characterized by a high ability to hydrolyze by digestive enzymes under the same conditions as casein. Also, an MTT-test demonstrates that the medication has no cytotoxic properties against cell lines MT-4 and Namalva. Conclusions. Since the negative effects of the drug associated with its digestibility and toxicity have not been observed, it is recommended to continue the study of its effects on living organisms.

Risk factors of anaemia and iron deficiency in Somali children and women: Findings from the 2019 Somalia Micronutrient Survey

There are limited data on the prevalence of anaemia and iron deficiency (ID) in Somalia. To address this data gap, Somalia's 2019 micronutrient survey assessed the prevalence of anaemia and ID in children (6–59 months) and non‐pregnant women of reproductive age (15–49 years). The survey also collected data on vitamin A deficiency, inflammation, malaria and other potential risk factors for anaemia and ID. Multivariable Poisson regressions models were used to identify the risk factors for anaemia and ID in children and women. Among children, the prevalence of anaemia and ID were 43.4% and 47.2%, respectively. Approximately 36% and 6% of anaemia were attributable to iron and vitamin A deficiencies, respectively, whereas household possession of soap was associated with approximately 11% fewer cases of anaemia. ID in children was associated with vitamin A deficiency and stunting, whereas inflammation was associated with iron sufficiency. Among women, 40.3% were anaemic, and 49.7% were iron deficient. In women, ID and number of births were significantly associated with anaemia in multivariate models, and approximately 42% of anaemia in women was attributable to ID. Increased parity was associated with ID, and incubation and early convalescent inflammation was associated with ID, whereas late convalescent inflammation was associated with iron sufficiency. ID is the main risk factor of anaemia in both women and children and contributed to a substantial portion of the anaemia cases. To tackle both anaemia and ID in Somalia, food assistance and micronutrient‐specific programmes (e.g. micronutrient powders and iron supplements) should be enhanced.

Management of Restless Legs Syndrome in Pregnancy and Lactation

Restless legs syndrome (RLS) affects about 20% of all pregnant women. RLS symptoms are usually moderate to severe in intensity during pregnancy and can result in insomnia, depression, and other adverse outcomes. Although iron deficiency has been implicated as a potential etiological factor, other mechanisms can also play a role. Nonpharmacologic methods are the primary recommended form of treatment for RLS in pregnancy and lactation. Iron supplementation may be considered when the serum ferritin is low; however, several patients are unable to tolerate iron or have severe symptoms despite oral iron replacement. Here, we describe a case of severe RLS in pregnancy and illustrate the dilemmas in diagnosis and management. We review the literature on the prevalence, diagnosis, course, possible underlying pathophysiologic mechanisms and complications of RLS in pregnancy. We describe current best evidence on the efficacy, and safety of nonpharmacologic therapies, oral and intravenous iron supplementation, as well as other medication treatments for RLS in pregnancy and lactation. We highlight gaps in the literature and provide a practical guide for the clinical management of RLS in pregnancy and during breastfeeding.

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.

The definition, screening, and treatment of postpartum anemia: A systematic review of guidelines

BACKGROUND

Postpartum anemia can negatively affect maternal health and interfere with early parenting. Thus, it is important to have clear, evidence-informed recommendations on its diagnosis and treatment.

OBJECTIVE

To compare global recommendations regarding the appropriate management of postpartum anemia and to highlight similarities and differences.

METHODS

Systematic searches were conducted in the databases PubMed, CINAHL, LILACS, TRIP database, and Scopus, and in the websites of health institutions and scientific societies. Search terms were related to anemia and the postpartum period. Two hundred and eighty papers were identified; the full texts of 30 sets of guidelines were reviewed, with seven being included in the final analysis. Recommendations were extracted through an evaluation of the evidence on the definition, screening, and diagnosis of anemia. The quality of the guidelines was assessed using the AGREE II instrument.

RESULTS

Two sets of guidelines have been elaborated by international organizations, and the rest were produced by professional associations within high-resource countries. The discrepancies found in the guidelines are important and affect the definition of anemia, the criteria for screening asymptomatic women, or the criteria guiding treatment. The quality of the guidelines commonly scored between 4 and 6 on a scale of 0 to 7. Recommendations with poor-quality evidence predominated over recommendations with high-quality evidence.

CONCLUSIONS

This review highlights the need to reach a consensus on the definition of postpartum anemia, to agree on what constitutes a problem for maternal health, and to provide recommendations that reach greater consensus on its diagnosis and treatment.

[Treatment of iron deficiency anemia during pregnancy with oral iron: State of practice among midwives]

OBJECTIVES

Iron deficiency anemia represents a public health issue which is usually managed by midwives. Because it is associated with maternal and fetal risks, a treatment is warranted. Oral iron represents the main option for treating this condition. Despite the existence of national and international guidelines no consensus about its modality of use has emerged so far. The primary objective of this study was to analyze midwives'practice with regards to iron deficiency anemia treatment using oral iron formulations.

METHODS

We conducted an observational and descriptive cross-sectional in a sample of midwives from the Gironde administrative region using a questionnaire.

RESULTS

We obtained 85 questionnaires from midwives working in private or public health facilities. Doses of iron and duration of treatment seem insufficient for a majority of responders. Folic acid and vitamin C are often associated with oral iron. Most midwives assess the efficacy of oral iron at one month with hemoglobin and ferritin levels. A significant fraction of these midwives shares similar practices which are in good accordance with the literature such as patient counselling with regards to drug intake, management of gastrointestinal side effects and inefficacity of oral iron. Noticeably, some of these midwives don't follow any guidelines.

CONCLUSION

The majority of participants demonstrated practices in accordance with various national guidelines although no precise therapeutic algorithm is available as reference. Larger studies on the management of iron deficiency anemia in pregnancy by health professionals and harmonization of practices are necessary.

Prevalence of anemia and iron deficiency anemia in Chinese pregnant women (IRON WOMEN): a national cross-sectional survey

Background

The current evidence about anemia and iron deficiency anemia (IDA) during pregnancy remains elusive in China. The purpose of this study is to investigate the prevalence of anemia and IDA and their risk factors in Chinese pregnant women.

Methods

A nationwide cross-sectional survey of pregnant women was conducted during their antenatal visits. Using a multi-stage sampling method, 24 hospitals from 16 provinces across China were selected. Structured questionnaires were administered to collect information from participants and to extract clinical data from electronic medical records. Mixed-effects logistic regression models were performed to determine the risk factors associated with anemia and IDA.

Results

In total, 12,403 pregnant women were enrolled, including 1018 (8.2%) at the first trimester, 3487 (28.1%) at the second, and 7898 (63.7%) at the third. Overall, 19.8% of women were diagnosed with anemia and 13.9% were diagnosed with IDA. The prevalence of anemia and IDA varied among regions and increased by gestational month, peaking at the eighth gestational month (24.0% for anemia and 17.8% for IDA). Pregnant women at advanced stage of gestation, non-local residents, multiple gestations, multiparity, pre-pregnancy underweight, and those experiencing severe nausea or vomiting during pregnancy, were associated with higher risks of anemia and IDA.

Conclusions

The prevalence of anemia and IDA during pregnancy are similar to those from developed countries and vary across regions in China.

Iron Deficiency Anemia in Pregnancy: Novel Approaches for an Old Problem

Iron needs increase exponentially during pregnancy to meet the increased demands of the fetoplacental unit, to expand maternal erythrocyte mass, and to compensate for iron loss at delivery. In more than 80% of countries in the world, the prevalence of anemia in pregnancy is > 20% and could be considered a major public health problem. The global prevalence of anemia in pregnancy is estimated to be approximately 41.8%. Undiagnosed and untreated iron deficiency anemia (IDA) can have a great impact on maternal and fetal health. Indeed, chronic iron deficiency can affect the general wellbeing of the mother and leads to fatigue and reduced working capacity. Given the significant adverse impact on maternal-fetal outcomes, early recognition and treatment of this clinical condition is fundamental. Therefore, the laboratory assays are recommended from the first trimester to evaluate the iron status. Oral iron supplementation is the first line of treatment in cases of mild anemia. However, considering the numerous gastrointestinal side effects that often lead to poor compliance, other therapeutic strategies should be evaluated. This review aims to provide an overview of the current evidence about the management of IDA in pregnancy and available treatment options.

Red blood cell transfusion in obstetrics and its implication for patient blood management: a retrospective analysis in Switzerland from 1998 to 2016

PURPOSE

Peripartum hemorrhage (PPH) remains one of the main causes of maternal mortality worldwide. Treatment includes administration of packed red blood cells (RBC) in severe cases and patient blood management (PBM) may reduce it significantly. In our study, we wanted to retrospectively assess red blood cell administration in PPH to evaluate the impact of PBM in Switzerland.

METHODS

Using data from the Swiss obstetric hospital registry (Arbeitsgemeinschaft Schweizer Frauenkliniken, ASF), we included patients with deliveries from 1998 to 2016. We examined available obstetric data as well as blood loss and RBC administration in the acute and subacute peripartal phase. We categorized data into two time intervals: 1998-2011 and 2012-2016, as new PPH guidelines in Switzerland were established in 2012.

RESULTS

PPH incidence increased between 1998 and 2016 significantly. The number of vaginal instrumental deliveries and cesarean sections increased as well. Administration of three or more RBC units, as defined in the ASF registry, in the acute and subacute phase in Switzerland has decreased after 2012. Conversely, we saw an increase in the administration of one to two RBC units in the acute and subacute phase. Nevertheless, overall RBC administration has been decreasing from 1998 to 2016.

CONCLUSION

The increase of patients obtaining one or two units of RBC for PPH suggests that there may be a potential for effective implication of PBM in obstetrics. Reduction of RBC transfusion in the context of PPH may not only decrease maternal morbidity, but decrease economic costs as well.

Cohort profile: targeted antenatal screening for haemoglobinopathies in Basel

PURPOSE

The pregnancy cohort was established to examine the prevalence and variety of haemoglobinopathies in a high-risk group of pregnant women.

PARTICIPANTS

The pregnancy cohort is located in the Department of Obstetrics and Antenatal Care, University Hospital of Basel. The pregnant women were recruited in the first trimester between June 2015 and May 2019. Family origin questionnaires were used to screen pregnant women for the risk of a haemoglobin variant. Based on the questionnaire, pregnant women were divided into two groups: women with a high risk and women with a low risk of a haemoglobin variant. In women with a high risk, red blood cell indices, iron status and chromatography were conducted.

FINDINGS TO DATE

1785 pregnant women were recruited. Out of the 1785 women, 929 were identified as a part of the high-risk group. Due to the missing data of 74 pregnant women with a high risk, the final analysis was conducted in the remaining 855 women. The prevalence of haemoglobinopathies in the high-risk group was 14.5% (124/855).

FUTURE PLANS

This cohort will be used to: (1) implement the screening in prenatal care in Basel; (2) recommend the screening among pregnant women with a high risk of a haemoglobin variant in Switzerland; (3) improve prenatal and neonatal care in patients with a haemoglobin variant; (4) examine adverse pregnancy outcomes in women with a haemoglobin variant and (5) reduce maternal and neonatal morbidity and mortality in the future.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04029142).

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.

Iron deficiency anaemia revisited

Iron deficiency anaemia is a global health concern affecting children, women and the elderly, whilst also being a common comorbidity in multiple medical conditions. The aetiology is variable and attributed to several risk factors decreasing iron intake and absorption or increasing demand and loss, with multiple aetiologies often coexisting in an individual patient. Although presenting symptoms may be nonspecific, there is emerging evidence on the detrimental effects of iron deficiency anaemia on clinical outcomes across several medical conditions. Increased awareness about the consequences and prevalence of iron deficiency anaemia can aid early detection and management. Diagnosis can be easily made by measurement of haemoglobin and serum ferritin levels, whilst in chronic inflammatory conditions, diagnosis may be more challenging and necessitates consideration of higher serum ferritin thresholds and evaluation of transferrin saturation. Oral and intravenous formulations of iron supplementation are available, and several patient and disease-related factors need to be considered before management decisions are made. This review provides recent updates and guidance on the diagnosis and management of iron deficiency anaemia in multiple clinical settings.

Validation of Point of Care Hemoglobin Estimation Among Pregnant Women Using Digital Hemoglobinometers (HemoCue 301 and HemoCue 201+) as Compared with Auto-Analyzer

Accurate and reliable point of care tests (POCTs) for hemoglobin estimation is essential for early diagnosis and management of anemia. This study was aimed to assess the reliability and validity of two versions of digital hemoglobinometer (HemoCue 201+ and HemoCue 301) compared to the gold standard Sysmex autoanalyzer for hemoglobin estimation. Pregnant women attending antenatal clinics of Primary Health Centre and a Sub Divisional Hospital in Haryana, India, were recruited. After obtaining consent, capillary blood samples were collected and tested for hemoglobin levels with digital hemoglobinometers (HemoCue 201+ and HemoCue 301). Among same pregnant women venous blood was collected and hemoglobin levels were estimated using autoanalyzer. Validity and reliability of POCTs compared to Sysmex autoanalyzer were reported. Of the 102 pregnant women included in the study, 44 (43%) were primigravida, with mean (SD) age of 23.3 (3.4) years. The mean (SD) of difference in hemoglobin levels using HemoCue 201+ was - 0.53 (1.01) and using HemoCue 301 was - 0.25 (0.85) g/dL as compared to auto-analyzer. Lin's concordance coefficient was 0.80 for HemoCue 201+ and 0.85 for HemoCue 301. Weighted Cohen's Kappa indicated moderate degree of agreement with the gold standard. Sensitivity (HemoCue 201+: 93%; HemoCue 301: 90%) and specificity (HemoCue 201: 76% HemoCue 301: 80%) for detecting anemia was similar for both the POCT devices. The digital hemoglobinometers used in the study had moderate degree of agreement and concordance with the autoanalyzer for hemoglobin estimation. HemoCue 301 had higher validity as compared to HemoCue 201+.

Patient blood management in obstetrics - Review

Patient blood management (PBM) aims to reduce red blood cell transfusion, minimize preoperative anemia, reduce intraoperative blood loss as well as optimize hemostasis, and individually manage postoperative anemia. Benefits include improved clinical outcome with a reduction in patient morbidity and mortality, but also lower hospital costs and shorter hospital length of stay. To date, it has been successfully implemented in several medical specialties, such as cardiac, trauma and orthopedic surgery. In obstetrics, postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality. PBM has the potential to improve outcome of mother and child. However, pregnancy and childbirth pose a special challenge to PBM, and several adaptations compared to PBM in elective surgery are necessary. To date, awareness of the clinical advantages of PBM among obstetricians and midwifes regarding PBM and its concept in PPH is limited. In the following review, we therefore aim to present the current status quo in PBM in obstetrics and its challenges in the clinical routine.

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.

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

Purpose

To evaluate the efficacy and safety of intravenous ferric carboxymaltose administration to pregnant women with varying severities of iron deficiency anemia and iron deficiency without anemia.

Methods

In this prospective observational study of local obstetric practice, we analyzed data from 863 pregnant women with iron deficiency according to anemia status and severity. All women were treated with intravenous ferric carboxymaltose in pregnancy. Treatment efficacy was assessed by repeat hemoglobin measurements at 3 and 6 week post-infusion and ferritin levels, where available. Safety was assessed by analysis of adverse events, fetal heart rate monitoring, and newborn health outcome data.

Results

Ferric carboxymaltose significantly increased hemoglobin in women with mild, moderate, and severe iron deficiency anemia and women with iron deficiency alone at 3 and 6 week post-infusion (p < 0.01 for all). No hemoconcentration occurred in iron-deficient women without anemia. No serious adverse events were recorded, with minor temporary side effects (including local skin irritation, nausea, and headache) occurring in 96 (11%) women. No adverse fetal or neonatal outcomes were observed.

Conclusions

Ferric carboxymaltose infusion corrects iron deficiency or various degrees of iron deficiency anemia efficaciously and safely pregnant women, and does not cause hemoconcentration.