Prof. Dr.

Ashis Kumar Mukhopadhyay

Professor, G & O
Burdwan Medical College, Burdwan
Vice-President, The Bengal ObGyn Society
Vice-President, IMA New Garia Branch
 Anaemia
Anaemia is the state in which there is a decreased production
of RBCs or a decreased concentration of haemoglobin in the
RBCs. This results in decreased oxygen carrying capacity.

• WHO definition : Hb conc.  11 gm %1

• CDC definition : Hb conc. < 11gm % in 1st and 3rd
trimesters and < 10.5 gm% in 2nd trimester2
• For developing countries : cut off level suggested is 10 gm
%3
WHO technical report Series no. 405, Geneva 1968
Centre for disease control, MMWR 1989;38:400-4
Lao TT, Eur J Obstet Gynecol Rep Biol 1996;68:58

2
 Magnitude of problem

• Globally, incidence of anaemia is about 30 %

• In developing countries & India, incidence is
around 40 – 90%.
• Responsible for 40% of maternal deaths in
third world countries.
• Important cause of direct and indirect
maternal deaths
Vitere FE Adv Exp Med Biol 1994;352:127
Prevalence

WHO, 2001

4
 Indian Scenario
• Reported lowest prevalence: 33% in Andhra Pradesh 1
• Reported highest prevalence: 98% in Rajasthan 1
• Prevalence in pregnant women: 87% 1
• Contribution to maternal deaths: 16% 2
• Incidence of premature deliveries: 34.5% (three-fold greater
than non-anemics) 2
• Prevalence in children: 76% 3
• Prevalence in preschool children: 68% 4
1. Seshadri, S. Nutritional anaemia in south Asia. In: Malnutrition in South Asia. A Regional Profile. Ed.S.Gillespie, UNICEF
Regional Office for South Asia, Kathmandu, Publication No.5, p75, 1997.
2. Nutr Rep Int 1981;23: 637
3. Indian J Med Res. 1998;107: 269.
4. Indian J Med Res 1979;69: 448

5
 Reasons for increased incidence
of anaemia in tropics
• Low socioeconomic status and poor hygiene.
• Chronic malnutrition
• Poor availability of iron due to predominantly veg diet, diet
low in calories but rich in phytates. Food and religious
taboos
• GI infections and infestations (e.g. Kala azar, worm
infestations)
• Poor pre-pregnancy iron balance due to – untreated
systemic diseases & menstrual disorders
• Improper supplementation of iron in pregnancy (late
registration and poor follow up)
• Repeated childbearing
• Lack of awareness and illiteracy
 Iron Deficiency Anaemia

Decrease in the amount of red cells in the blood caused

by inadequate iron supply.

IDA is usually caused by a diet insufficient in iron or from

blood loss

7
 Etiological Factors
• Pregnancy and lactation
• Blood loss (Gastrointestinal, ulcer, worms)
• Excessive menstrual bleeding
• Chronic renal failure
• Trauma
• Pure cows milk diet in infancy

8
Causes of Iron Deficiency Anaemia
in Pregnancy
• Increased Physiological requirement

• Dietary insufficiency

• Multiple pregnancies

• Deficient absorption e.g. achlorhydria

• Bleeding in pregnancy

• Contributing factors: folic acid, vitamins A, B12, C

• Infectious diseases: malaria

• Parasites: hookworm

9
 Iron

• Iron is an important constituent of haemoglobin, myoglobin

(muscle protein) and some enzymes.
• It serves as a carrier of oxygen and electrons, and acts as a
catalyst for oxygenation and hydroxylation.
• It also has the ability to catch and release an electron (Fe (II)
/ Fe (III) cycling).

10
 Body Iron Distribution (%)

• Stores : 4-5 g
• 67 % functional iron: Hb (60%), myoglobin (5%), and various
enzymes
• Iron storage proteins: Ferritin (20%) + hemosiderin (10%)
• Transport iron: Transferrin (0.1%)
• If not required for the body, iron in the mucosal cells is stored
as ferritin and excreted in the faeces

11
 Iron Absorption

N Engl J Med. 2005 Dec 8;353(23):2508-9

12
 Ferrous vs Ferric Iron

 Ferrous iron is absorbed three times more than ferric iron.

 Ferric iron absorption is dependent on duodenal ferric

reductase

 Availability of duodenal ferric reductase is dependent on

ascorbic acid

 Supplementation of ascorbic acid may increase ferric iron

absorption

13
Factors That Modify Iron Absorption

14
Stages involved in Iron Deficiency
Anaemia

15
 Stages of IDA

Marrow Iron TSAT RBC Morphology

Normal Normal Normal normocytic,

normochromic

Latent IDA Reduced Normal normocytic,

normochromic

Early IDA Absent < 20% normocytic,

normochromic

Late IDA Absent < 10% microcytic,

hypochromic

16
 Effects of Anaemia on pregnancy

List is endless, but common problems are………

• Preterm labor
• Intrauterine growth restriction (IUGR)
• Preeclampsia
• Antepartum hemorrhage
• Intrapartum problems, e.g. dysfunctional labor, fetal
hypoxia, high risk for anaesthesia
• Postpartum problems, e.g. PPH., uterine
subinvolution, Puerperal sepsis, delayed wound
healing, lactational failure.
• Medical complications, e.g. cardiac failure
 Complications In Pregnancy
• Infections
• Maternal mortality
• Fetal mortality
• Preterm delivery
• anaemia associated pre-eclampsia
• Complications during labour
• Low birth weight baby
• Post partum hemorrhage- slight blood loss affects badly
• Implications for future physical and psychomotor growth of
infant

18
 Consequences of Maternal Iron
Deficiency in Children
• Impaired mental and psychomotor function

• Impaired sleep patterns and affective relationships

• Limited attention span

• Capacity of immune system decreased

• Increased morbidity from infectious diseases

• More severe and longer lasting diarrhoea

• Signs and symptoms of cardiac failure

Verster A. . WHO Guidlelines 1996

19
Diagnosis

20
 History
• Iron-poor diet
• Blood loss
• Personal or family history suggestive of malabsorption
syndrome, inflammatory bowel disease, or bleeding
disorder

21
 Symptoms*
• Breathlessness
• Palpitations
• Lightheadedness, Headache
• Fatigue
• Decreased work tolerance

*Symptoms may not be manifest until the haemoglobin level is less than 9 g/dL

22
Signs

23
 haemoglobin and Hematocrit
Haemoglobin and haematocrit levels below which anaemia is present in a
population (WHO, 2001)

24
 Investigations
• Hb conc. ( < 10 gm %)
• RBC count ( < 3.5 million/cu.mm)
• Peripheral smear
• MCV ( normal is 55- 74 fl )
• MCHC ( normal is 28 – 32 gm %)
• Transferrin saturation ( normal is 20 – 45 %)
• TIBC ( normal is 250 – 400 μg/dl)
• Serum Iron( normal is 80 – 180 mg %)
• Serum Ferritin ( normal is 150 – 2000 ng/dl)
• Stool R/M, Urine R/M
 Additional
Investigations
• Red Cell distribution width
• Free erythrocyte protoporphyrin.
• Transferrin receptor concentration for
cellular Iron status.
• Marrow iron
 Management

• Management may be curative or prophylactic

• National Nutritional anaemia prophylaxis programme
(1972) recommends Ferrous sulphate and Folic acid
to all pregnant women.
• Curative therapy depends on positive diagnosis of
anaemia during antenatal period.
• Prophylactic deworming recommended
Prevention and Treatment of Iron
Deficiency anaemia

28
Guidelines for prevention

Guidelines for the Use of

Iron Supplements to
Prevent and Treat
Iron Deficiency anaemia
International Nutritional
anaemia Consultative
Group

29
 Effects of Iron Supplementation
Population Group Effects of Iron Supplementation

Children - Improved behavioral and cognitive

development
- Improved survival
Adolescents - Improved cognitive development
- In girls, better iron stores for later pregnancies

Pregnant women and - Decreased low birth weight and perinatal

infants mortality
- Decreased maternal mortality and obstetrical
complications
All individuals - Improved fitness and work capacity
- Improved cognition

30
 Iron and Motherhood
Why iron supplementation is
important during pregnancy?
Physiologic iron requirements are 3 times higher in
pregnancy than in menstruating women

32
Total Iron Cost of Pregnancy

33
The daily elemental iron requirement increases
from 1.5 to 2 mg per day to 5 to 7 mg per day
by the late pregnancy

34
 According to WHO …

the haemoglobin concentration should not fall below 11.0 gm% at

any time during pregnancy , therefore need for iron therapy

35
Supplementation of Iron to Pregnant Women Is
Essential

Iron supplements to pregnant women have been shown to result

in a higher serum ferritin in the mother’s blood as well as in the
infant’s cord blood

Verster A. . WHO Guidlelines 1996

36
 Iron Preparations

Formulation Example

Elemental Iron Carbonyl iron

Iron Salts Ferrous ascorbate, Ferrous sulphate, Ferrous

fumarate, Ferrous citrate, Ferrous lactate, Ferrous
succinate

Iron Complexes Iron poly-sucrose complex, Iron dextran complex,

Iron polymaltose complex

Parenteral iron Iron dextran, Iron sucrose, Sodium ferric gluconate

complex

37
 Amount of Iron in
Some Oral Iron Preparations

Preparation % iron content

Ferrous sulfate 20
Ferrous fumarate 33
Ferrous gluconate 12
Ferric ammonium citrate 14.5 – 18.5
Ferrous succinate 35
Ferrous bisglycinate 20
Ferrous aminoate 10
Colloidal ferric hydroxide 50
Ferrous ascorbate 12-15

38
 Iron Bioavailability from Different Iron
Preparations
Compound Bioavailability Study reference

Ferrous ascorbate 40 % Scand J Haematol. 1981

Sep;27(3):201-8
Carbonyl iron 2.7 % Am J Clin Nutr. 1986
Jan;43(1):59-67
Ferrous sulphate 10.4 % Archivos Latinoamericanos de
Nutrición, Sept. 2001; 51(3):
Ferric ammonium citrate 2.4 % 217-224

Ferrous fumarate 8.25 % Am J Clin Nutr. 2004

Nov;80(5):1436-44
Sodium iron pyrophosphate 6.3 %

Ferric orthophosphate 8.3 % Br J Haematol. 1972

Mar;22(3):281-6
Ferric pyrophosphate 0%

39
 Advantages of Addition of Ascorbic Acid to
Iron
• Increased iron absorption
• Avoids interaction of iron with iron absorption inhibitors
• Scavanges free radicals generated during Fe++ → Fe+++
• Antioxidant properties
• AA acts as a precursor for ferric reductase required for
Fe+++ → Fe++
• Ferrous ascorbate has been used as a reference dose iron
in numerous absorption studies

40
 Iron Stores

1. SF is an acute-phase reactant protein and is therefore elevated in response to any infectious or inflammatory
process.
2. SF diminishes late in pregnancy, even when bone marrow iron is present.

41
 Treatment

• Oral iron supplementation

• Parenteral iron replacement

• Recombinant human

erythropoietin

• Blood transfusion

42
 According to WHO Report, 2000…

Severe anaemia is the main causal factor in up to

20% of maternal deaths in developing countries like
India

43
 Choice of curative therapy
The choice of curative therapy depends on:
1. Severity of anaemia
2. Gestational age of the patient
3. Compliance of the patient
4. Tolerance to the therapy chosen.
 Oral Iron therapy
• Ferrous sulphate 200 mg
• Ferrous fumarate 200 mg
• Ferrous gluconate 300 mg
• Iron polymaltose complex
• Preparations of carbonyl Iron
• Avoid intake of tea, coffee, calcium tablets simultaneously
• Watch for side effects
 Causes of Noncompliance
• Lack of motivation
• Metallic taste
• Staining of teeth
• Gastrointestinal side effects
• Co-administration with food
• Problems with frequency and number of tablets taken
 Problems with Conventional
Oral Iron Salts
• GI intolerance
• Constipation
• Diarrhoea

• Cellular damage (free radicals)

• LDL oxidation  Atherosclerosis
• Ageing process and tissue damage
• Poor bioavailability

47
 Problems with Conventional
Oral Iron Salts
Iron Absorption Inhibitors
• Phytates present in cereals
• Flour, legumes, nuts, and seeds
• Iron-binding phenolic compounds (tannins)
• Tea, coffee, cocoa, herbal infusions in general, certain
spices and some vegetables
• Calcium, particularly from milk and milk products.

49
 Effect of Calcium on Iron Bioavailability

Effect of supplementing meals with

calcium (1200 mg/d) on nonheme-iron
absorption in nonanemic adults.
Individual values (o----o). Mean value
(●----●). (+Calcium; 4.7 ± 1.4%) was
significantly less (P < 0.001) than from
the standard diet (−Calcium; 15.8 ±
2.1%)

Am J Clin Nutr 1998 68: 96-102

50
Haemoglobinopathies
• Thalassemia : genetic disorders
characterized by decreased or lack of
synthesis of globin chains
• Sickle cell anaemia : abnormal Hb due to a point mutation
in globin chain at position 6
• Cause considerable morbidity
• Prevalence relatively high in our population
Thalassemia
• Depending on globin chain affected, may
be  or -thalassemia.
• With advances in medicine, life expectancy of patients with
-thalassemia has increased.
• Few patients with -thalassemia major become pregnant.
• Those who become may require frequent blood transfusion
and have multiple organ involvement.
 Pregnancy in thalasemics
• sed risk of abortions
• sed risk of fetal wastage.
• sed risk of cong. Malformation
• sed risk of Preeclampsia
• Intrauterine growth retardation
• sed susceptibility to infections
• Risk of hydrops babies [esp. -thalassemia]
 Management pearls in thalassemia
• Iron supplementation in thalassemia pts inspite of
the risk of overload
• Monitoring of cardiac function closely
• Stop use of desferroxamine in pregnancy
• Stop use of Vitamin C in pregnancy as it will
increase iron absorption
• Patients who have had prior splenectomy may
have high platelet counts, so use of low dose
aspirin.
 Sickle cell anaemia
• Point mutation in -globin chain at position 6 [
valine is substituted for glutamic acid].
• Pts may be homozygous or heterozygous.
• Hypoxia causes sickling of RBC’s ; sickled RBC’s
are rigid and later hemolyse.
•  microvascular obstruction, thrombosis &
vasoocclusive crisis.
• Multiple organ damage; cause painful crisis,
aplastic crisis, hemolytic crisis.
 Management pearls in sickle cell
disease
• Iron supplementation
• Regular urinalysis ( ‘cause infections contribute to
vasoocclusive crisis )
• Polyvalent pnuemoccal vaccine for chest infections
• Frequent blood pressure recordings, b’cause proteinuric
hypertension common
• Prophylactic red cell transfusions.
Published Indian Study on Ferrous Ascorbate from
National Institute of Nutrition (ICMR).

57
 Summary of Efficacy
Sub-group Increase in haemoglobin (g/dl) in 45 days
Total 2.37

Non-pregnant with IDA 2.64

Pregnant and anemic 2.30
Pregnant without anaemia 1.74
Hb < 6 g/dl 3.60
Hb = 6-8 g/dl 2.91
Hb = 8.1-10 g/dl 2.23
Hb >10 g/dl 1.25

58
 Ferrous Ascorbate vs Carbonyl Iron

• An open-label, randomized, comparative study

• Sixty Indian patients with iron deficiency anaemia
• Treatment with either ferrous ascorbate or carbonyl
iron at dose of 100 mg of elemental iron daily.
• Duration 60 days

Int J Gynecol and Obstet- India, July-August, 2005; 8(4):23-30.

59
 Results
• Significantly higher (p<0.0001) increase in Hb (5.03 ± 1.81
g/dL) with Ferrous ascorbate as compared to Carbonyl Iron
(2.82 ± 1.43 g/dL)
• More patients rendered non-anemic by treatment with
Ferrous ascorbate (93.33%) compared to Carbonyl Iron
(46.66%) (Relative risk reduction 88%; Number needed to
treat 2.1)
• Significantly greater increase in serum ferritin with Ferrous
ascorbate than carbonyl iron (p=0.0002)
• More effective than carbonyl iron in improving PCV, MCV,
MCH, RBC, serum iron, TIBC and TSAT (p<0.05)
Int J Gynecol and Obstet- India, July-August, 2005; 8(4):23-30.

60
 Severe Anaemia

Considering the convenience and cost, oral iron salts are still the
first line therapy in the treatment and prevention of IDA during
pregnancy

Especially, in mild to moderate IDA

But, severe anaemia is an emergency which should

be corrected at the earliest

61
 Treatment Options for Severe Anaemia
• Blood transfusion
• Parenteral iron therapy
– Sodium Ferric Gluconate Complex (SFGC)
– Iron Dextran
– Iron Sucrose

62
 Intravenous Iron Preparations
• All preparations are effective, however differ
considerably in safety profiles
• Anaphylactic reactions are observed with iron
dextran administration; virtually absent with iron
sucrose
• Iron sucrose is being safely used in anaemia of
pregnancy

63
Clinical Studies on Iron Sucrose

64
 Ref #1

• 111 pregnant women with iron deficiency anaemia

• Group 1 (n= 52): Iron sucrose IV 200 mg/day
Total dose= Hb deficit (g/l) x body weight (kg) x 0.3
• Group 2 (n= 59): Oral ferrous sulphate 60 mg elemental
iron TID

Eur J Obstet Gynecol Reprod Biol. 1996 Nov;69(2):121-4

65
Ref #1 :Results

Eur J Obstet Gynecol Reprod Biol. 1996 Nov;69(2):121-4

66
 Ref #1 :Side-Effects

Serious Adverse Events (%)

10

6
% 4
4

2
0
0
Iron Sucrose Oral Iron

Eur J Obstet Gynecol Reprod Biol. 1996 Nov;69(2):121-4

67
 Ref #1 :Side-Effects

GI Adverse Events (%)

50

40
30
30
%
20

10
0
0
Iron Sucrose Oral Iron

Eur J Obstet Gynecol Reprod Biol. 1996 Nov;69(2):121-4

68
 Ref #1 :Conclusion
• Higher Hb values were achieved in a shorter period with
iron sucrose
• No major side-effects were observed in the iron sucrose
group
• Iron sucrose is safe and effective in the treatment of iron
deficiency anaemia during pregnancy.

Eur J Obstet Gynecol Reprod Biol. 1996 Nov;69(2):121-4

69
 Ref #2: Study Design
• A randomized, prospective, open study in 50 patients to
compare intravenous iron sucrose versus oral iron sulfate in
anaemia at 6 months of pregnancy
• Oral group (PO group):240 mg iron sulfate per day for 4
weeks
• Iron sucrose group: Dose= Weight before pregnancy (kg) x
(120 g/L – Actual haemoglobin [g/L]) x 0.24 + 500 mg

Eur J Obstet Gynecol Reprod Biol. 2005 Dec;123 Suppl 2:S15-9

70
 Ref #2: Results
• Hb increased similarly in both groups
• On day 30 (P < .0001) and at delivery (P = .01) ferritin was
higher in the IV group.
• A mean higher birth weight of 250 g was noted in the IV
group.

Eur J Obstet Gynecol Reprod Biol. 2005 Dec;123 Suppl 2:S15-9

71
 Ref #3: Study Design
• Randomized open-label study, 90 women to compare the
efficacy of intravenous iron to oral iron in the treatment of
anaemia in pregnancy.
• Oral iron polymaltose complex: 300 mg elemental iron per
day or
• Intravenous iron sucrose: Dose= weight before pregnancy
(kg) x (110 g/L – actual haemoglobin [g/L]) x 0.24 + 500 mg

Obstet Gynecol. 2005 Dec;106(6):1335-40

72
 Ref #3: Results
• The change in haemoglobin from baseline was significantly
higher in the intravenous group than the oral group
• Ferritin values were higher in patients receiving intravenous
iron throughout pregnancy.

Obstet Gynecol. 2005 Dec;106(6):1335-40

73
 Ref #3: Conclusion
Intravenous iron treated iron-deficiency anaemia of pregnancy
and restored iron stores faster and more effectively than oral
iron, with no serious adverse reactions.

Obstet Gynecol. 2005 Dec;106(6):1335-40

74
 Ref #4: Study Design
• A prospective comparative study in 60 pregnant women
with IDA with the gestational age of 12-34 weeks
• Group A (n = 15): Iron sucrose dose= weight before
pregnancy (kg) x (110 g/L – actual haemoglobin [g/L]) x
0.24 + 500 mg.
• Group B (n = 20): Iron sucrose dose = weight before
pregnancy (kg) x (110 g/L – actual haemoglobin [g/L]) x
0.24 + 200 mg.
• group C (n= 25): Intra muscular iron Sorbitol

J Pak Med Assoc. 2002 Sep;52(9):392-5

75
Ref #4: Rise in Hb Before Delivery

Rise in Hb Before Delivery

4 3.8

3
Hb (g/dL)

2.4
2
1.4
1

0
Group A Group B Group C

J Pak Med Assoc. 2002 Sep;52(9):392-5

76
Ref #4: Target Achievement By Delivery

Hb Target (11 g/dL) Achievement

100%
80%
80%
Achievement

70%
Hb Target

60%
40%
28%
20%
0%
Group A Group B Group C

J Pak Med Assoc. 2002 Sep;52(9):392-5

77
 Ref #4: Conclusion
• Intravenous iron therapy is safe, convenient and more
effective than intramuscular iron therapy in treatment of iron
deficiency anaemia during pregnancy.
• The intravenous iron therapy can replace blood transfusion
in antenatal period.

J Pak Med Assoc. 2002 Sep;52(9):392-5

78
 Ref #5: Study Design
• A single centre, prospective, randomized, controlled trial
conducted at Women’s Centre, John Radcliffe Hospital,
Oxford, UK.
• Forty-four women with Hb <9 g/dl and S. ferritin <15 mcg/l at
24–48 hours postpartum were enrolled.
• Oral ferrous sulphate 200 mg twice daily for 6 weeks (group
O) or
• Intravenous ferrous sucrose 200 mg, two doses given on
days 2 and 4 following recruitment (group I)

BJOG. 2006 Nov;113(11):1248-52

79
 Ref #5: Results

IV iron sucrose rapidly increases Hb levels and rapidly replenishes iron stores
BJOG. 2006 Nov;113(11):1248-52

80
 Ref #6: Study Design
• To compare the efficacy and safety of IV iron sucrose and
oral iron in the treatment of postpartum anaemia
• Total 75 women with Hb < 9 g/dl after delivery
• IV iron sucrose (calculated total dose), n= 50; oral iron (300
mg tid), n= 25
• Follow up for 28 days

Int J Gynaecol Obstet. 2005 Sep;90(3):238-9.

81
Ref #6: Results

82
 Ref #6: Conclusion
IV iron sucrose showed better efficacy and fewer side effects
compared with oral iron therapy in postpartum women with
iron deficiency anaemia

Int J Gynaecol Obstet. 2005 Sep;90(3):238-9.

83
Intravenous iron treated iron-deficiency anemia of
pregnancy and restored iron stores faster and more
effectively than oral iron, with no serious adverse
reactions.

(Obstet Gynecol 2005;106:1335–40)

84
 Ref #7: Study Design
• Experience with iron–sucrose complex in the department of
obstetrics, Zurich university hospital (1992–2000)
• A total of 500 pregnant/ postpartum IDA patients received a
total of 2500 ampoules, each containing the equivalent of
100 mg elemental Fe
• Retrospective analysis was done for 100 patients

British Journal of Nutrition (2002), 88, 3–10

85
 Ref #7: Results

*P<0·05, **P<0·01

British Journal of Nutrition (2002), 88, 3–10

86
 Ref #7: Conclusion
Iron sucrose therapy is a valid first-line option for the safe and
rapid reversal of Fe-deficiency anaemia

British Journal of Nutrition (2002), 88, 3–10

87
Ref #8
Data
collected over 8 years
and backed by
postmarketing experience
in 25 countries
indicate that iron sucrose
complex
therapy is a valid first-line
option
for the safe and rapid reversal
of iron-deficiency anaemia.
Blood Cells, Molecules, and
Diseases (2002) 29(3)
Nov/Dec: 506–516

88
 Ref #9

Am J Clin Nutr 2004;79:1–3.

89
 Monitoring Parameters
• Iron administration should be withheld in the presence of
evidence of tissue iron overload

• Patients receiving intravenous iron require periodic

monitoring

• Transferrin saturation values increase rapidly after IV iron

therapy

• To prevent iron overload, serum iron values may be reliably

obtained 48 hours after IV dosing

90
 IV Iron in Pregnancy

• Administration based on total iron deficit :

Pregnancy Anaemia :
– TID = BW X (Target Hb - Actual Hb) X 0.24 + 500
Stores need to be “refilled”

Post-partum Anaemia :
– TID = BW X (Target Hb - Actual Hb) X 0.24

91
 Dosing
• Slow Intravenous injection:

Iron sucrose may be administered undiluted by slow

intravenous injection at a rate of 1 mL (20 mg iron)
solution per minute not exceeding 100 mg iron per
injection. Discard any unused portion.

92
 Dosing
• Infusion:
Iron sucrose may also be administered by infusion.

Infusion must be administered as every 2.5 ml Iron

Sucrose diluted exclusively in a maximum of 100 ml of
0.9% NaCl, immediately prior to infusion. The solution
must be infused at a rate of 100 mg/15 minutes. Unused
diluted solution must be discarded.

93
 Blood Transfusion
• Given in emergency to correct severe anaemia
• Risk of transmission of serious infections: HIV, HBV
• Scarcity of blood donors
• Transfusion reactions, mismatch
• Unnecessary administration of WBCs, plasma, platelets
• Possibility of iron overload
• Prolonged IV administration
• Preferably packed cell transfusion or semi packed cells
given

94
 Treatment Options in a Nutshell

• Ferrous ascorbate for routine iron supplementation

during pregnancy
• Ferrous ascorbate for treatment of mild to
moderate iron deficiency anaemia
• Parenteral Iron sucrose for severe iron deficiency
anaemia
• Blood transfusion in emergencies like severe
anaemia close to term or cases of blood loss or
tissue hypoxia.

95
 Conclusion and take-home
• High prevalence of anaemia in our country.
• Major cause of maternal mortality
• Prevention is the key to avoid major morbidity and mortality
• Early diagnosis and early institution of treatment will decrease
complications related to anaemia
• Suspect Hemoglobinopathy if Hb is persistently less than 8
gm%
• Ferrous ascorbate is the oral iron of choice.
• IV Iron sucrose is the parenteral iron of choice.
• Attempt should be there to minimise Blood transfusion and it
should be reserved for emergencies only.
Without anaemia, the world will be a
safer place to live for women

Together, lets pledge to make

it a safer place.
THANK YOU