Treatments for iron-deficiency anaemia in pregnancy

RHL practical aspects by Walraven G

FIRST CONTACT (PRIMARY CARE) LEVEL

Routine iron supplementation is recommended in the model of routine antenatal care (1), (RCT). Haemoglobin measurement or estimation with the use of the WHO haemoglobin colour scale should be done to confirm severe anaemia (2), (RCT). Severe anaemia (Hb<7 g/dL) should be referred for investigation of the causes and treatment. Preferably, relatives who can donate blood should accompany the pregnant woman. In the trials included in the Cochrane Review on routine (preventive) iron supplementation 60-100 mg elementary iron have been used (3), (SR).The impact of supplementation can be improved by counselling on why, how, and when to take iron tablets and by supplying the tablets. Meta-analysis of intervention trials suggest that successful prevention of Plasmodium falciparum infections in endemic areas reduces the risk of severe maternal anaemia by 38% (4), (SR).

REFERRAL HOSPITAL (SECONDARY CARE) LEVEL

As it is difficult to rule out causes other than iron deficiency anaemia, and since anaemia causes are often combined, diagnosis and treatment for other causes of anaemia prevalent in the region should be considered for women with severe anaemia or other signs and symptoms.

The use of IV or IM iron should only be done in hospital. The pros and cons of different preparations and other alternatives such as oral iron and blood transfusion should be discussed with the patient taking into account the transport facilities, gestational age, cost and availability of these preparations.

Blood transfusion may become necessary for severe anaemia especially close to term. Unnecessary blood transfusions can be reduced by introducing guidelines, information materials for women and their families and the establishment of a hospital blood transfusion committee. A pregnant woman from a malarious area who has severe anaemia should be treated with effective antimalarials, irrespective of whether she has peripheral parasitaemia or other signs of clinical disease (5), (Personal opinion). The level of haemoglobin at which transfusion is required may be lower in women where the anaemia develops slowly than where acute rapid haemolysis has occurred. It is therefore difficult to give absolute recommended haemoglobin level at which to transfuse. However, transfusion should be considered in women at or above 34 weeks gestation who have a haemoglobin less than 7 g/dL, as it is important that severe anaemia is corrected prior to delivery. It is very important that women are transfused before developing very severe anaemia, as a haemoglobin of less than 5 g/dL is usually associated with imminent heart failure and carries a high risk of mortality.

AT HOME OR IN THE COMMUNITY

There is no role for treatment of severe iron-deficiency anaemia at the community level. If there are health workers at the community level, the advice should be immediate referral of clinically suspected cases of severe anaemia. Routine preventive iron supplementation has been successfully delivered through traditional birth attendants integrated into a primary health care programme in a trial in rural Gambia (6), (RCT).

References

  • Villar J, Ba’aqeel H, Piaggio G et al . WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. The Lancet 2001;357:1551-1564.
  • Van den Broek N, Ntonya C, Mhango E, White S. Diagnosing anaemia in rural clinics: assessing the potential of the Haemoglobin Colour Scale. Bulletin of the World Health Organization 1999;77:15-21.
  • Pena-Rosas JP, Viteri FE. Effects of routine oral iron supplementation with or without folic acid for women during pregnancy (Cochrane Review). In: The Cochrane Database Syst Rev, 2006;3:CD004736.
  • Desai M, ter Kuile FO, Nosten F et al. Epidemiology and burden of malaria in pregnancy. Lancet infectious diseases 2007;7:93-104.
  • Shulman C, Dorman E. Malaria in pregnancy. Africa Health. Malaria Supplement 2000;26-29.
  • Menendez C, Todd J, Alonso PL et al. The effects of iron supplementation during pregnancy, given by traditional birth attendants, on the prevalence of anaemia and malaria. Transactions of the royal society of tropical medicine and hygiene 1994;88:590-593.

This document should be cited as: Walraven G. Treatments for iron-deficiency anaemia in pregnancy: RHL practical aspects (last revised: 20 June 2007). The WHO Reproductive Health Library; Geneva: World Health Organization.