The total requirement of iron during pregnancy is approximately 1000 mg (500 mg for developing foetus and placenta and similar amount for red cell increment)11
. Usually, this iron is mobilized from iron stores. However, women with poor iron stores become iron deficient during pregnancy. Studies have shown that Hb levels <8 g% (moderate to severe anaemia) in pregnancy are associated with higher maternal morbidity3,11,12
. Hb less than 5 g% is associated with cardiac decompensation and pulmonary oedema. Blood loss of even 200 ml in third stage of labour can cause sudden shock and death in these women.
As compared to western women whose iron stores are sufficient and they need 30-40 mg elemental iron per day for anaemia prophylaxis in pregnancy13,14
, the stores in Indian women are deficient and they need 100 mg elemental iron per day for prophylaxis. For treatment of anaemia, dose recommended is 200 mg elemental iron per day14
. In the present study, 5-9 g% Hb was taken as cut-off. Intravenous iron is superior to oral iron with respect to faster increase in Hb and faster replenishment of body iron stores15
. Also, it reduces the need of blood transfusions16
, and it can be given at outpatient basis.
In a study to compare the clinical efficacy and safety of intravenous iron sucrose with intramuscular iron sorbitol citrate, it was found that rise of Hb was more in intravenous group17
. This study emphasized the superiority of iv iron therapy to intramuscular therapy in terms of rise of Hb and also safety profile.
Perewunsnyk et al18
studied 400 women who received a total of 2000 ampoules of iron sucrose. Minor general adverse effects including a metallic taste, flushing of the face and burning at the injection site occurred in 0.5 per cent cases. The high tolerance of the drug has been partly attributed to slow release of iron from the complex and also due to the low allergenicity of sucrose. Till date, one death has been reported with intravenous iron sucrose injection19
. The explanation given for this was because of very slow infusion (1-2 h). The cause of death may be free radicals released from the iron sucrose. The injection should be given within 15-20 min or up to 200 mg can be given as slow iv push over 2-3 min. This case has not been mentioned in the literature but is available on clinical trial registry site19
. In the present study, no major side effect was reported.
treated more than 500 antenatal women diagnosed with iron deficiency anaemia. Intravenous iron sucrose was given according to the calculated dose as either iv push over 5-10 min or iv infusion over 20-30 min. All injections were given on outpatient basis without any test dose. This study also emphasizes on the safety of iron sucrose injection. In the present study, the first dose was given in ward where facilities for emergency care were available. All subsequent doses were given on OPD basis. None of the patients required any emergency care. In other studies17,21
, target Hb for calculation of required dose has been taken 11 g/dl and for replenishment of stores 500 mg has been added. Keeping in mind very low iron stores in Indian women, we took 14 as index Hb and added 1000 mg for replenishment of stores. Even with this, maximum mean serum ferritin after 8 wk of starting therapy was 69 μg/l which is well within normal range. As compared to previous studies17,20
, ferritin levels in our study women showed a lesser increase. The reason can be due to severely depleted iron stores in Indian women.
Hookworm is one of the well established causes of anaemia in developing countries. Routine antihelminthic therapy in pregnancy is not recommended. But due to high prevalence in developing countries including India, it is advisable to give antihelminthic therapy to pregnant women presenting with anaemia21
A study conducted to evaluate the safety and efficacy of iron sucrose in dialysis patients who were sensitive to iron dextran, demonstrated the safety of iv iron sucrose injections22
In a study to assess and compare the efficacy of two and three doses of intravenous iron sucrose with oral iron therapy, there was higher frequency of responders (Hb>11g%) in intravenous group (75 vs. 80%). There was a significant difference of repleted iron stores before delivery (ferritin >50 mg/l) in the group with three intravenous iron doses in comparison to the oral iron group (49 vs. 14%; P
<0.001). No differences were observed in maternal and perinatal outcomes. The study did not conclude any significant benefit of parentral iron therapy over oral iron therapy23
. However, in practice, noncomplaince is very common with oral iron therapy.
Drawbacks of our study was lack of control group (intramuscular iron therapy) and non-randomised trial. Large randomized controlled trials are required to compare the efficacy and safety of intravenous iron sucrose complex over intramuscular iron therapy.
In conclusion, our results showed that intravenous iron sucrose therapy was effective to treat moderate anaemia in pregnant women. Intramuscular preparations are known to be associated with local side-effects. Iron sucrose complex iv therapy was with negligible side effects. It caused rapid rise in haemoglobin level and the replacement of stores was faster. Long term comparative studies are required to assess if it can be used at peripheral level.