Oral iron
Iron absorption is regulated according to body iron reserves and the intensity of erythropoiesis. It is well documented that exhausted body iron reserves in otherwise healthy women will increase the intestinal iron absorption [
52]. Furthermore, the increased erythropoietin-induced erythropoiesis during the second and third trimester [
57] stimulates iron absorption. This combined stimulation of iron absorption has been confirmed in studies showing that iron absorption increases with increasing length of gestation, being most pronounced after 20 weeks gestation [
33,
58,
59]. However, the marked increase in iron absorption is caused by iron deficiency, i.e. pregnant women with replete iron stores have an absorption, which is almost similar to the absorption in non-pregnant iron-replete women [
33,
60].
This high iron absorption capacity is quite favourable for treatment of IDA with oral iron in pregnant women. During treatment of IDA, absorption is highest in the first 2 weeks and subsequently declines [
61]. There is consensus that oral iron therapy should be the first therapeutic option in the first and second trimester [
55,
56]. Women having slight to moderate IDA with haemoglobin of 90–105 g/L should initially be treated with ferrous iron. The recommended doses are traditionally quite high, i.e. 100–200 mg elemental iron per day, being based on old studies performed in anaemic men [
61]. High-dose iron therapy should preferably be administered as sustained release iron preparations in order to optimise absorption and reduce gastrointestinal side effects [
62]. However, a recent study of anaemic pregnant women has questioned the use of high-dose oral iron therapy and presented evidence for the efficiency of ferrous iron in doses of 20–80 mg/day, taken between meals [
63]. The effect on iron status increased with iron dose (20 → 40 → 80 mg/day) and was highest with the 80-mg dose [
63]. As a consequence of this study, the recommended standard dose for treatment of IDA should hardly exceed 100 mg ferrous iron per day taken between meals. Following oral iron treatment for 2 weeks, the therapeutic response should be checked by assessment of haemoglobin. If haemoglobin has increased ≥10 g/L, oral iron therapy should continue during the remaining period of gestation with subsequent check of haemoglobin and plasma ferritin. When haemoglobin has reached a level of >105 g/L, the iron dose may be reduced to 60–80 mg/day as maintenance therapy.
A failing haemoglobin response to treatment could be the consequence of non-compliance due to psychological mechanisms, non-compliance due to gastrointestinal side effects, impaired gastrointestinal iron absorption due to achlorhydria or inflammatory bowel disease or non-recognised ongoing bleeding with iron losses.
Intravenous iron
Treatment with intravenous iron is clearly superior to oral iron with respect to a faster increase in haemoglobin and faster replenishment of body iron stores [
64‐
66]. Intravenous iron reduces the need for blood transfusions and constitutes an alternative to transfusion in profound IDA [
67]. Intravenous iron preparations comprise among others iron sucrose (Venofer®, Vifor, St. Gallen, Switzerland) [
68], low molecular weight iron dextran (Cosmofer®, Pharmacosmos, Holbæk, Denmark) [
69] and the recently introduced iron carboxymaltose (Ferinject®, Vifor, St. Gallen, Switzerland) [
70]. Provided the Summary of Product Characteristics (SPC) are observed, the frequency of adverse events is below 0.5% [
64,
65,
68‐
70]. Infusion of iron should be given on an outpatient basis in a setting where equipment for cardiopulmonary resuscitation is available. Infusion should be given in peripheral veins and care should be taken to avoid chemical phlebitis at the infusion site. In severe IDA being resistant to oral iron, intravenous iron treatment can be combined with the administration of recombinant human erythropoietin of ∼20,000 U subcutaneously in order to further stimulate the erythropoiesis [
71].
Intravenous iron is considered safe in the second and third trimester [
55,
56]. There is limited experience in the fist trimester concerning the potential teratogenic and/or toxic effects on the foetus. Consequently, if parenteral iron treatment is mandatory in the first trimester, the choice stands between intravenous iron and blood transfusions, the latter method carrying the well-known risks.
Treatment with intravenous iron should be considered at: (1) as second option if oral iron fails to increase haemoglobin within 2 weeks; (2) as first option at profound IDA, i.e. haemoglobin of <90 g/L in any trimester beyond 14 weeks gestation; (3) as first option at IDA in the third trimester.
Profound IDA has serious consequences for both the pregnant women and the foetus [
4‐
8] and requires prompt intervention. In the first trimester, a combination of high-dose oral and low-dose intravenous iron could be the choice, otherwise blood transfusion should be considered. In the second and third trimester, intravenous iron should be the preferred treatment [
56]. In the third trimester, there is too short time for oral iron therapy to be effective and it is imperative to alleviate IDA and replenish iron reserves prior to delivery in order to prevent peripartum anaemia and avoid blood transfusions. This is especially important in women who for religious or other reasons oppose blood transfusions.
The dose of intravenous iron should be adequate to obtain a haemoglobin level of >105 g/L. In the majority of women, a total dose of 600–1,200 mg intravenous iron is adequate.
When a haemoglobin of >105 g/L has been reached, the women can subsequently switch to maintenance treatment with oral ferrous iron of 80–100 mg/day taken between meals, provided they have normal gastrointestinal iron absorption.
Iron sucrose should be given in repetitive doses of maximum of 200 mg iron pro dosis dissolved in minimum 100 ml isotonic saline and infused over at least 30 min [
55,
68]. Separate doses should be administered with ∼3-day interval. Low molecular weight iron dextran is less prone to produce hypotension (<0.1%) [
69] than iron sucrose (<1%) [
68], while the frequency of serious adverse events appears to be the same.
In non-pregnant patients, iron dextran can be administered as “total dose infusion” where up to 20 mg iron per kilogram body weight is given in a single infusion [
69,
72]. However, there is limited experience concerning its use in pregnancy. According to the SPC [
69], prior to the first administration, a test dose of 25 mg iron dissolved in 100 mL isotonic saline should be infused over 15 min. If no adverse reaction has occurred 60 min after the test, 500–1,000 mg iron should be dissolved in 500 mL isotonic saline and infused over 4 h. At subsequent infusions, 25 mg iron should be infused over 15 min and, if no adverse reactions are seen, the remainder of the infusion can be administered.
Iron carboxymaltose has recently been introduced on the European market and has proved effective in the treatment of postpartum anaemia [
73]. According to the SPC [
70], up to 1,000 mg iron dissolved in 250 mL isotonic saline can be given as a single infusion over 15 min. However, due to the limited experience with this novel iron compound, its use in pregnant women should await further controlled clinical trials.
The total dose infusion concept, which is convenient for the patient and save resources in the health care system, can probably also be applied to pregnant women beyond the first trimester, but the experience is until now scarce and further controlled studies are needed. Intravenous iron treatment appears effective in correcting both the anaemia and quality-of-life deficits and shows promising aspects in the future management of prepartum IDA.