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DOI 10.1007/s13224-012-0222-0
ORIGINAL ARTICLE
Received: 1 February 2011 / Accepted: 4 June 2012 / Published online: 1 August 2012
Ó Federation of Obstetric & Gynecological Societies of India 2012
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Shafi et al. The Journal of Obstetrics and Gynecology of India (May–June 2012) 62(3):317–321
concern and maternal anemia is still a cause of considerable before the infusion. No test dose was given. Treatment was
perinatal morbidity and mortality [3]. completed after administration of the calculated dose.
According to the National Family Health Survey (2005– Additional iron was not administered during the study.
2006) incidence of anemia in pregnant women in India is Iron sucrose is a complex of poly nuclear iron(III)
54.6 % in urban and 59 % in rural areas [4]. hydroxide in sucrose for intravenous use. The poly nuclear
Anemia is responsible for adverse obstetric outcome in a iron(III) hydroxide cores are superficially surrounded by a
large number of women in developing countries. Almost large number of non covalently bound sucrose molecules
one thousand severely affected young women are reported resulting in a complex, with a molecular mass of approxi-
to die every week because of inability to cope with the mately 60,000 Da, prohibiting renal elimination. The iron
stress of childbirth. in the poly nuclear cores is bound in a similar structure to
Anemia leads to increased risk of blood transfusion that of physiologically occurring ferritin. The complex is
during the peripartum period. Iron therapy before delivery stable and does not release ionic iron under physiological
may reduce the transfusion rate for iron deficient women. conditions. Following intra venous administration, iron
The aim of this study was to compare the efficacy and sucrose is dissociated by the reticuloendothelial system into
safety of intravenous iron sucrose and oral ferrous ascorbate iron and sucrose. Iron sucrose can be administered as
in the treatment of iron deficiency anemia of pregnancy. intravenous injection or infusion. Iron sucrose does not
contain dextran hence chances of anaphylaxis are negligi-
ble. The rate of iron delivery to marrow is a major factor in
Methods regulation of marrow proliferation. Iron sucrose has an
intermediate stability and strength. It is quickly cleared
An experimental randomized study was conducted at K.J. from the serum with the terminal half life of approximately
Somaiya Medical College and Research Centre between 5–6 h. It is more rapidly available for erythropoiesis [5–7].
February 2008 and March 2010. Patients were recruited In the oral group, women were instructed to take two tablets
from the antenatal clinic of the hospital randomly by (ferrous ascorbate with 100 mg of elemental iron per day
computer generated randomization. The women were given with 1.1 mg of folic acid) twice daily throughout the
sequentially numbered sealed opaque envelopes. Eligible pregnancy. Women were instructed to take the tablets on an
participants were pregnant women between 28 and empty stomach either 2 h before or after their meals.
37 weeks of gestation with established iron deficiency Ferrous ascorbate iron salt was chosen because it pre-
anemia who had hemoglobin levels between 6 and 10 g% vents the formation of insoluble and unabsorbable iron
and serum ferritin less than 15 ng/ml. compounds and it causes reduction of ferric to ferrous iron
Exclusion Criteria were: Anemia from causes other than which seems to be a requirement for uptake of iron into
iron deficiency, multiple pregnancy, previous blood trans- duodenal and proximal mucosal cells of the small intestine.
fusion, h/o hematological disease, risk of preterm labor, The ascorbic acid forms a soluble complex with iron in the
intolerance to iron derivatives, recent administration of stomach and passes into the intestine. The effect of iron
iron, and current usage of iron supplements. absorption inhibitors which would normally bind to iron in
A total of 200 patients were studied. All were randomly the more alkaline pH of upper intestine is limited [8]. Oral
assigned to either intravenous or oral group. Hundred ferrous ascorbate has highest bio availability in the range of
patients were in intravenous and hundred patients in oral 26.4–50.4 % and it acts as an antioxidant.
group which was decided by sequentially numbered, sealed The primary outcome measure was hemoglobin con-
opaque envelopes. centration at 2, 4, and 6 weeks. The secondary outcome
In the intravenous group, the total iron dose in mg was was serum ferritin levels done at 2, 4, and 6 weeks. All
calculated from the following formula: women were followed up every 2 weeks. During each visit
2:4 weight ðtarget actual HbÞ in g=dl þ 500 mg: all adverse events immediate or delayed were evaluated.
Laboratory evaluation was performed at the time of
Rounded up to nearest multiple of 100. inclusion in the study and then at 2, 4, and 6 weeks. Initial
In the formula since the patient’s pre pregnancy weight was evaluation included CBC, PCV, MCV, MCH, MCHC,
not known, the weight at the time of the first visit was considered peripheral smear, and iron profile, whenever possible.
in kilograms. Target hemoglobin in g per dl was set at 12 g/dl.
In each infusion the maximum total dose administered
was 200 mg elemental iron in 100 ml of normal saline Results
infused over 20–30 min, given on alternate days. Each
ampoule was of 2.5 ml containing 50 mg of elemental iron. No participants were lost to follow up and there were no
The ampoules were diluted with normal saline immediately dropouts. The back count of tablets collected from women
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The Journal of Obstetrics and Gynecology of India (May–June 2012) 62(3):317–321 Iron Deficiency Anemia in Pregnancy
in the oral iron group showed that (88 women) 88 % took IV Oral
12
more than 90 % of their supplements. All women admin-
istered intravenous iron dose, which received the calculated 11
total iron dose.
HEMOGLOBIN-G/DL
Using SPSS software on computer, paired and inde- 10
pendent samples ‘‘t’’ test was applied.
9
Initial demographic and clinical characteristics were
generally similar in the two groups. The mean age of 8
women on inclusion in intravenous group was 24.30 ±
3.98 years with mean gestational age of 32 ± 2.46 weeks, 7
mean hemoglobin of 7.9 ± 0.87 and mean ferritin of 8.44 ±
1.35. In the oral group, mean age was 24.09 ± 3.84 years 6
123 319
Shafi et al. The Journal of Obstetrics and Gynecology of India (May–June 2012) 62(3):317–321
70
60 intravenous group compared to oral group [11].
50
Bencaivo et al. [12] assessed and compared the efficacy
and safety of intravenous iron sucrose to oral ferrous sul-
40
fate. There was a non significant increase in hemoglobin in
30 the intravenous group but the repleted iron stores were
20 significantly higher than in the oral group. This study
10 deviates from our study as only ferritin levels were sig-
0 nificantly raised, whereas difference in hemoglobin level
Base line Two Week Four Week Six Week was not significant [12].
TIME-WEEKS
ferrous sulfate. In the intravenous group an increase in Iron sucrose is an effective alternative to oral ferrous
hemoglobin was observed rising from 9.6 ± 0.79 to ascorbate in the treatment of iron deficiency anemia of
11.11 ± 1.3 g/dl on day 30 and from 9.7 ± 0.5 to pregnancy. Intravenous iron sucrose produces a more rapid
11 ± 1.25 g/dl on day 30 in the oral group which was not increase in hemoglobin concentration and serum ferritin
significant. Ferritin values were higher in intravenous levels than oral ferrous ascorbate.
group, on day 30 (P \ 0.0001) and at delivery P = 0.01 Intravenous iron therapy is a safe alternative for the
which was significant. This study slightly deviates from our treatment of anemia, being able to reduce the need for
study because sample size was small and iron sucrose was blood transfusion and its concomitant side effect such as
given over 21 days [10]. anaphylactic shock, febrile and hemolytic reactions,
In a study by Al RA et al. [11] compared intravenous infections (hepatitis B, C, HIV, protozoan and bacterial)
iron sucrose with oral iron polymaltose complex (300 mg alloimmunization and graft versus host disease. During
elemental iron per day). The change in hemoglobin from pregnancy and puerperium it helps to rebuild iron stores,
baseline was significantly higher in the intravenous group helping the symptoms of anemia to subside at a faster rate
than the oral group at each measurement; the changes with and reduces the risk of developing anemia in subsequent
respect to subsequent hemoglobin were significantly higher pregnancies. Major advantages are safety, efficacy, com-
on day 14th (P = 0.004) and 28th (P = 0.031). Serum pliance, simple mode of administration in an outpatient
ferritin levels were changed significantly across time with setting and cost effectiveness because admission is not
both the oral (P \ 0.05) and intravenous group (P \ 0.5). needed in all cases.
Serum ferritin levels were higher in the intravenous group, Normally blood transfusion is an option in the cases of
than in the oral group at each point of measurement. In the moderate and severe anemia in the third trimester of
oral group it was 11 ± 11 lg/l compared to 28 ± 26 lg/l pregnancy. The given Iron sucrose intravenously may
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The Journal of Obstetrics and Gynecology of India (May–June 2012) 62(3):317–321 Iron Deficiency Anemia in Pregnancy
reduce the need for blood transfusion because of its faster 6. Beshara S, Lundqvist H, Sundin J, et al. Pharmacokinetics and
action. Therefore, it can be considered as an alternative to red cell utilization of iron(III) hydroxide–sucrose complex in
anaemic patients: a study using positron emission tomography. Br
blood transfusion in the treatment of pregnant women with J Haematol. 1999;104:296–302.
moderate iron deficiency anemia during the third trimester. 7. Yee J, Besarab A. Iron sucrose: the oldest iron therapy becomes
new. Am J Kidney Dis. 2002;40:1111–21.
8. Teucher B, Olivares M, Cori H. Enhancers of iron absorption:
ascorbic acid and other organic acids. Int J Vitam Nutr Res. 2004;
74:403–19.
References 9. al-Momen AK, al-Meshari A, al-Nuaim L, et al. Intravenous iron
sucrose complex in the treatment of iron deficiency anemia
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5. Danielson BG, Salmonson T, Derendorf H, et al. Pharmacoki- 12. Bencaiova G, von Mandach U, Zimmermann R. Iron prophylaxis
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