Role of parenteral iron sucrose in the treatment of iron-deficiency anemia in pregnant women of gestational age 20–34 weeks

T Deepthisri; N Chaitanya; Rohin

doi:10.4103/mjhs.mjhs_68_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 11 | Issue : 3 | Page : 196-200

Role of parenteral iron sucrose in the treatment of iron-deficiency anemia in pregnant women of gestational age 20–34 weeks

T Deepthisri, N Chaitanya, Rohin
Department of Obstetrics and Gynaecology, Deccan College of Medical Sciences, Hyderabad, Telangana, India

Date of Submission	31-Jul-2022
Date of Decision	25-Aug-2022
Date of Acceptance	01-Oct-2022
Date of Web Publication	27-Oct-2022

Correspondence Address:
T Deepthisri
Department of Obstetrics and Gynaecology, Deccan College of Medical Sciences, Hyderabad, Telangana
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjhs.mjhs_68_22

Abstract

Background: Anemia is responsible directly or indirectly for 40%–60% of maternal deaths from cardiac failure, hemorrhage, infection, and preeclampsia. It also increases perinatal mortality and morbidity rates consequent to preterm deliveries, intrauterine growth restriction, low iron stores, iron-deficiency anemia, and cognitive and affective dysfunction in the infant.
Objective: The objective of this study is to study the efficacy of intravenous iron sucrose in terms of hemoglobin rise and side effects.
Materials and Methods: Single-center, hospital-based comparative prospective study was conducted among 60 patients admitted with anemia in pregnancy with a hemoglobin concentration of 7.5–9 g/dl. Blood samples were sent for evaluation of hemoglobin, packed cell volume (PCV), and serum ferritin levels at baseline, at 4, and 8 weeks.
Results: Mean age was 29.08 ± 5.74 years. About 51.7% belonged to the middle social class. Most were gravida III (36.7%). About 46.7% had 20–24 weeks of gestations. Seventy-five percent had microcytic hypochromic anemia. Hemoglobin improved significantly (P < 0.05) from 8.76 ± 0.54 g% at baseline to 11.47 ± 0.85 g% at 4 weeks, and to 12.68 ± 1.04 g% at 8 weeks; PCV also improved significantly (P < 0.05) from 26.78 ± 3.11% to 34.64 ± 3.73% at 4 weeks and again improved to 42.50 ± 4.67% at 8 weeks; serum ferritin also improved significantly (P < 0.05) from 23.06 ± 7.96 μg/l to 28.86 ± 9.79 μg/l at 4 weeks and again improved to 36.31 ± 12.53 at 8 weeks after parenteral iron sucrose therapy. Only one pregnant woman complained of vomiting and only four women complained of pain at the site of injection after giving parenteral iron sucrose therapy. About 91.6% of the women had no complaints.
Conclusion: Parenteral iron sucrose therapy in pregnant women with a gestational age of 20–34 weeks with iron-deficiency anemia was found effective in improving the hemoglobin, PCV, and serum ferritin with negligible side effects.

Keywords: Anemia, iron, pregnancy, treatment

How to cite this article:
Deepthisri T, Chaitanya N, Rohin. Role of parenteral iron sucrose in the treatment of iron-deficiency anemia in pregnant women of gestational age 20–34 weeks. MRIMS J Health Sci 2023;11:196-200

How to cite this URL:
Deepthisri T, Chaitanya N, Rohin. Role of parenteral iron sucrose in the treatment of iron-deficiency anemia in pregnant women of gestational age 20–34 weeks. MRIMS J Health Sci [serial online] 2023 [cited 2023 Oct 3];11:196-200. Available from: http://www.mrimsjournal.com/text.asp?2023/11/3/196/380570

Introduction

Anemia in women during pregnancy is a serious threat, and severe anemia is associated with an increased risk of maternal mortality, which is unacceptably high in developing countries.^[1] The Centers for Disease Control and Prevention defines anemia when hemoglobin and hematocrit values are <11 g/dl and 33% in the first and third trimesters and 10.5 g/dl and 32% in the second trimester. As per the World Health Organization, anemia is defined as a hemoglobin concentration of <11 g%.^[2]

It is responsible directly or indirectly for 40%–60% of maternal deaths from cardiac failure, hemorrhage, infection, and preeclampsia. It also increases perinatal mortality and morbidity rates consequent to preterm deliveries, intrauterine growth restriction, low iron stores, iron-deficiency anemia, and cognitive and affective dysfunction in the infant. Anemia has a varied incidence, etiology, and degree of severity in different populations; being more prevalent in developing countries where it remains an important cause of maternal mortality. Common causes of anemia in pregnancy are iron deficiency, folic acid deficiency, Vitamin B12 deficiency, other nutrient deficiencies, and hemoglobinopathies of which iron-deficiency anemia is the most common cause. Anemia is implicated as the direct contributor to postpartum hemorrhage which is the leading cause of maternal mortality in 20% of cases. During the 10^th 5-Year Plan (2002–2007), a study conducted by the Indian Council of Medical Research showed that the prevalence of anemia was highest among pregnant women (50%–90%) and that of moderate (7–9 g%) and severe anemia (<7 g%) were persistently high. Prevalence was high in all states of the country with considerable variations in moderate-to-severe anemia. Other factors responsible for a high incidence of anemia in India include early marriage, teenage pregnancy, multiple pregnancies, less birth spacing, phytate-rich Indian diet, low iron and folic acid intake, and a high incidence of worm infections in the Indian population.^[3],[4],[5]

Iron-deficiency anemia is the most common form of anemia and also the most common nutritional disorder in the world. Iron-deficiency anemia affects approximately 15% of the world's population. In pregnancy, it affects 22% of pregnant women in industrialized countries and 52% in nonindustrialized countries. Iron-deficiency anemia manifests as hypochromic, microcytic anemia with low hemoglobin. Anemia indices (mean corpuscular volume (MCV), mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and serum ferritin. It is commonly seen in populations with inadequate iron intake, inadequate iron absorption, or increased iron requirements. These include infants, especially premature infants, children during rapid growth periods, pregnant and lactating women, and patients with chronic kidney disease who lose erythrocytes at a relatively high rate during hemodialysis.^[6]

Many iron preparations are available for the treatment of iron-deficiency anemia in pregnancy. Iron supplementation is mandatory in pregnancy in India unlike westerners who have better iron stores and supplementation is optional. The provision of iron supplements to pregnant women is one of the most widely practiced public health measures. The traditional treatment of iron-deficiency anemia includes oral/parenteral iron and blood transfusion. Oral iron preparations are used to treat mild-to-moderate iron-deficiency anemia; whereas parenteral preparations are used to treat severe iron-deficiency anemia, intolerance to oral iron preparations, and malabsorption.^[7],[8]

The present study aims to study the role of intravenous (IV) iron sucrose in terms of clinical efficacy as a rise in hemoglobin and side effects.

Materials and Methods

The present study was a single-center, hospital-based comparative prospective study conducted among patients admitted with anemia in pregnancy and in the Obstetrics and Gynecology Department of South Central Railway Hospital, Hyderabad from August 2019 to July 2021. Prior initiation of the study, ethical and research committee approval was obtained from South Central Railway Hospital, Hyderabad. During the present study, a total of 82 anemia-in-pregnancy patients were reviewed in the obstetrics and gynecology department. Among them, 60 patients were enrolled in the study according to the present study inclusion criteria and 22 patients were excluded according to the exclusion criteria.

Pregnant women with a hemoglobin concentration of 7.5–9 g/dl, gestational age of 20–34 weeks, and proven iron-deficiency anemia (MCV <50 fl and ferritin level <50 μg/l) were included in the present study. Any disorder complicating pregnancy such as tuberculosis, diabetes, pregnancy-induced hypertension, antepartum hemorrhage, multiple pregnancies, iron overload or disturbance in iron utilization, and known hypersensitivity to iron sucrose patients were excluded from the study.

The sample size was calculated using OpenEpi Software considering 80% power, 95% confidence level, with a mean expected difference of 0.75 in hemoglobin level after parenteral iron sucrose therapy, a sample size of 50 was required. We could include 60 patients in the present study.

The study was conducted among 60 individuals. All patients confirmed with anemia in pregnancy with decreased hemoglobin, packed cell volume (PCV), and serum ferritin levels who fulfilled the inclusion criteria were enrolled in the study. Written informed consent about the protocol of the study was obtained. A detailed history of the patient, general physical examination, and systemic examination were recorded in a study pro forma after admission. Blood samples were drawn from patients using all aseptic precautions and sent for the evaluation of hemoglobin, PCV, and serum ferritin levels. Investigations for hemoglobin, PCV, and serum ferritin levels were carried out as per the standard protocol using the standardized instruments in the certified laboratory of the study hospital.

Statistical analysis

The collected data were entered into Microsoft Excel Worksheet-2010. The data were described as mean and proportions. Analysis of variance test was applied to compare mean values in more than two groups. Two-sided P < 0.05 was taken as statistically significant.

Results

The mean age of study participants was 29.08 ± 5.74 years. The majority (51.7%) belonged to the middle social class. Most of the women were gravida III (36.7%). About 46.7% of the women had 20–24 weeks of gestation. Seventy-five percent of women had microcytic hypochromic anemia [Table 1].

Table 1: Patients demographics details

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The hemoglobin improved significantly (P < 0.05) from 8.76 ± 0.54 g% at baseline to 11.47 ± 0.85 g% at the end of 4 weeks and to 12.68 ± 1.04 g% after the parenteral iron sucrose therapy. PCV also improved significantly (P < 0.05) from 26.78% ± 3.11% to 34.64% ± 3.73% at the end of 4 weeks and again improved to 42.50% ± 4.67% at the end of 8 weeks after the parenteral iron sucrose therapy. Serum ferritin also improved significantly (P < 0.05) from 23.06 ± 7.96 μg/l to 28.86 ± 9.79 μg/l at the end of 4 weeks and again improved to 36.31 ± 12.53 at the end of 8 weeks after the parenteral iron sucrose therapy [Table 2].

Table 2: Effect of parental iron therapy on different parameters

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Only one pregnant woman complained of vomiting and only four women complained of pain at the site of injection after giving parenteral iron sucrose therapy. About 91.6% of the women had no complaints [Table 3].

Table 3: Distribution according to adverse events

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Discussion

In the current study, a total of 60 patients were enrolled in the study. In the present study, the mean gestational age was 29.08 ± 5.74 years. In a study conducted by Agarwal et al.,^[9] the mean age was 22.48 ± 4.21 years, and in a study conducted by Patil and Bhovi,^[10] the mean age was 25.4 ± 3.6 years.

The patients were distributed based on socioeconomic status and there were more patients in the middle and upper economy group with 51.67% and 28.33%, respectively. In a study conducted by Perewusnyk et al.,^[11] the majority of patients (56%) were in the middle-income group, and in a study conducted by Yee and Besarab,^[12] the majority of patients, i.e., 40% were in low economic groups.

The patients were then distributed according to gravidity and among 60 patients receiving IV iron; 38.33% of the patients were gravida I followed by 36.67% in more than gravida III. In a study conducted by Ragip et al.,^[13] the majority of patients, i.e., 38% received IV iron were gravida I, and in a study conducted by Yee and Besarab,^[12] the majority of patients, i.e., 42% receiving IV iron were gravida I.

The patients were then distributed according to gestational age (weeks) and of the total 60 patients, 46.67% of patients had a gestational age between 20.1 and 24 weeks taking IV iron and 28.33% were between gestational age of 14–20 weeks receiving IV iron. In a study conducted by al-Momen et al.,^[14] 52% of patients had a gestational age between 23.2 and 25.8 weeks taking IV iron, and in a study by Ragip et al.,^[13] 63% had a gestational age between 21.7 and 23.9 weeks.

The patients were then distributed according to the type of anemia and 75% had microcytic hypochromic anemia. In a study by Rudra et al.,^[15] 75% had microcytic hypochromic anemia, and in a study by Ragip et al.,^[13] 63% had microcytic hypochromic anemia.

The patients were compared for the hemoglobin between at baseline, at the end of the 4^th week, and at the end of the 8^th week for hemoglobin, PCV, and serum ferritin level changes after parenteral iron sucrose therapy. The hemoglobin improved significantly (P < 0.05) from 8.76 ± 0.54 g% at baseline to 11.47 ± 0.85 g% at the end of 4 weeks and to 12.68 ± 1.04 g% after the parenteral iron sucrose therapy. PCV also improved significantly (P < 0.05) from 26.78% ± 3.11% to 34.64% ± 3.73% at the end of 4 weeks and again improved to 42.50% ± 4.67% at the end of 8 weeks after the parenteral iron sucrose therapy. Serum ferritin also improved significantly (P < 0.05) from 23.06 ± 7.96 μg/l to 28.86 ± 9.79 μg/l at the end of 4 weeks and again improved to 36.31 ± 12.53 at the end of 8 weeks after the parenteral iron sucrose therapy. In a study by Bayoumeu et al.,^[16] the hemoglobin was maximum in the 8^th week with a value of 13.01 ± 2.4 receiving oral iron compared to 13.08 ± 3.02 receiving IV iron. In the study by Rudra et al.,^[15] the mean improvement in the hemoglobin levels in the parenteral iron group was 13.02 ± 2.4 g/dl which was significantly more compared to the oral iron group of 12.56 ± 0.87 g/dl. The PCV was also significantly more in the parenteral group compared to the oral iron group in their study. However, in a study by Abhilasini et al.,^[17] the PCV was lower in the parenteral iron group compared to the oral iron group.

In a study by Bayoumeu et al.,^[16] the serum ferritin was lower in the parenteral iron group compared to the oral iron group. However, in a study by al-Momen et al.,^[14] serum ferritin level was significantly higher in the parenteral group compared to the oral iron group.

In the present study, only one pregnant woman complained of vomiting and only four women complained of pain at the site of injection after giving parenteral iron sucrose therapy. About 91.6% of the women had no complaints.

In a study by Govan and Scott,^[18] the majority of patients in the oral iron group had vomiting and nausea, whereas patients from the parenteral iron sucrose group did not have any symptoms, and some patients presented with skin rashes.

Conclusion

Parenteral iron sucrose therapy in pregnant women with a gestational age of 20–34 weeks with iron-deficiency anemia was found effective in improving the hemoglobin, PCV, and serum ferritin with negligible side effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Toteja GS, Singh P, Dhillon BS, Saxena BN, Ahmed FU, Singh RP, et al. Prevalence of anemia among pregnant women and adolescent girls in 16 districts of India. Food Nutr Bull 2006;27:311-5.
2.	World Health Organization. Report of a WHO Group of Experts on Nutritional Anemias, Technical Report Series 503. Geneva: World Health Organization; 1972.
3.	Adamson JW. Iron deficiency and other hypo proliferative anemias. In: Harrison's Principles of Internal Medicine. 18^th International Edition. New York: McGraw Hill; 2011. p. 586-93.
4.	Indian Council of Medical Research. Evaluation of the National Nutritional Anemia Prophylaxis Program. An ICMR Task Force Study. New Delhi: ICMR; 1989.
5.	WHO/UNICEF/UNU. Iron Deficiency Anemia: Assessment, Prevention, and Control. Geneva: World Health Organization; 2001. Archived: Iron Deficiency Anemia: Assessment, Prevention and Control. Available from: http://who.int. [Last accessed on 2019 Dec 30].
6.	Buza-Vidas N, Luc S, Jacobsen SE. Delineation of the earliest lineage commitment steps of haematopoietic stem cells: New developments, controversies and major challenges. Curr Opin Hematol 2007;14:315-21.
7.	Adolfsson J, Månsson R, Buza-Vidas N, Hultquist A, Liuba K, Jensen CT, et al. Identification of Flt3+ lympho-myeloid stem cells lacking erythro-megakaryocytic potential a revised road map for adult blood lineage commitment. Cell 2005;121:295-306.
8.	Wu H, Klingmüller U, Besmer P, Lodish HF. Interaction of the erythropoietin and stem-cell-factor receptors. Nature 1995;377:242-6.
9.	Agarwal KN, Agarwal DK, Sharma A, Sharma K, Prasad K, Kalita MC, et al. Prevalence of anaemia in pregnant & lactating women in India. Indian J Med Res 2006;124:173-84. [PUBMED] [Full text]
10.	Patil SD, Bhovi RA. Prevalence of anemia in pregnant & lactating women in rural Vijayapur. Int J Community Med Public Health 2020;7:224-7.
11.	Perewusnyk G, Huch R, Huch A, Breymann C. Parenteral iron therapy in obstetrics: 8 years experience with iron-sucrose complex. Br J Nutr 2002;88:3-10.
12.	Yee J, Besarab A. Iron sucrose: The oldest iron therapy becomes new. Am J Kidney Dis 2002;40:1111-21.
13.	Ragip AA, Unlubilgin E, Kandemir O, Yalvac S, Cakir L, Haberal A. Intravenous versus oral iron for treatment of anemia in pregnancy: A randomized trial. Obstet Gynecol 2005;106:1335-40.
14.	al-Momen AK, al-Meshari A, al-Nuaim L, Saddique A, Abotalib Z, Khashogji T, et al. Intravenous iron sucrose complex in the treatment of iron deficiency anemia during pregnancy. Eur J Obstet Gynecol Reprod Biol 1996;69:121-4.
15.	Rudra S, Chandna A, Nath J. Comparison of intravenous iron sucrose with oral iron in pregnant women with iron deficiency anemia. Int J Reprod Contracept Obstet Gynecol 2016;5:747-51.
16.	Bayoumeu F, Subiran-Buisset C, Baka NE, Legagneur H, Monnier-Barbarino P, Laxenaire MC. Iron therapy in iron deficiency anemia in pregnancy: Intravenous route versus oral route. Am J Obstet Gynecol 2002;186:518-22.
17.	Abhilasini GD, Sagili H, Reddi R. Intravenous iron sucrose and oral iron for the treatment of iron deficiency anemia in pregnancy. J Clin Diagn Res 2014;8:OC04-7.
18.	Govan AD, Scott JM. Intravenous iron in the treatment of anemia of pregnancy. 1949. Eur J Obstet Gynecol Reprod Biol 2005;123 Suppl 2:S33-5.