Parenteral Versus Oral Iron for Treatment of Iron Deficiency Anaemia During Pregnancy and post-partum: A Systematic Review

  • A. G. RadhikaEmail author
  • Aparna Kandala Sharma
  • Vanamail Perumal
  • Anju Sinha
  • Vasumathi Sriganesh
  • Vidushi Kulshreshtha
  • Alka Kriplani
Systematic Reviews/Meta-analysis



The burden of iron deficiency anaemia during pregnancy and post-partum continues to remain high especially in India. Challenges to treatment include gastrointestinal side effects and non compliance to oral iron therapy. Newer parenteral formulations need to be explored as alternatives.


Meta-analysis of randomized controlled trials published between years 2011 and 2018 comparing anaemic pregnant and post-partum women treated with intravenous iron sucrose versus oral iron was performed. The primary outcomes were mean maternal haemoglobin, serum ferritin and haematocrit at the end of 1st, 2nd, 4th and 6th weeks and comparison of adverse effects.


Eighteen studies including 1633 antenatal women were randomly assigned to intravenous iron sucrose (n = 821) or oral iron [ferrous sulphate, ferrous ascorbate or fumarate] group (n = 812) in ten trials . Another eight studies compared iron sucrose infusion with oral iron in 713 post-partum women who were randomly assigned to intravenous iron sucrose group (n = 351) or oral iron group (n = 362). Cumulative analysis of all the time points indicates that the estimated mean values of Hb in the intravenous iron sucrose and oral iron groups were 10.11 g/dl and 9.33 g/dl, respectively, in antenatal group, while it was 10.57 g/dl and 9.74 g/dl in post-partum. The estimated mean ferritin level from first week to six weeks was 63.1 μg/l and 28.6 μg/l, respectively, in intravenous and oral iron groups. Cumulative estimate of haematocrit in the intravenous sucrose and oral iron over 6 weeks showed that the mean values in the respective groups were 30.5% and 29.5% in antenatal and 33.8% and 31.6%, respectively, in post-partum groups. Sensitivity analysis confirmed the reliability and consistency of the results. Oral iron was associated with significant gastrointestinal side effects. There was no significant difference in birthweight between the groups.


This meta-analysis demonstrates that intravenous iron sucrose is more effective than oral iron therapy for pregnant and post-partum women with iron deficiency anaemia. It is an effective and safe alternative to address the problem of iron deficiency especially in those who require rapid replacement of iron stores though medical personnel for intravenous administration of drug is required.

Trial registration CRD42015024343


Iron deficiency anaemia Intravenous iron Oral iron Pregnancy post-partum 



Iron deficiency anaemia


World Health Organization


National Family Health Survey-4


Odds ratio


Intravenous iron sucrose


Oral iron group


Packed cell volume


Mean difference


Confidence interval




Antenatal clinic


Quality of life


Low–middle-income countries



We wish to acknowledge the Covidence platform in the compilation of this systematic review.

Authors Contributions

AGR contributed to literature search, title and abstract screen, data extraction; AS contributed to data extraction and report writing; VP contributed to title and abstract screen, data extraction, statistical analysis; AS resolved discrepancies in study inclusion, data extraction, guidance on systematic review procedure; VS contributed to literature search; VK contributed to data extraction, report writing; AK contributed to formulation of protocol and finalizing the report. All authors have read and approved the final manuscript.

Compliance with Ethical Standards

Conflicts of interest

The authors declare no conflict of interest.

Ethical statement

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Supplementary material

13224_2018_1191_MOESM1_ESM.pdf (175 kb)
Supplementary material 1 (PDF 175 kb)
13224_2018_1191_MOESM2_ESM.pdf (71 kb)
Supplementary material 2 (PDF 71 kb)


  1. 1.
  2. 2.
    Candio F, Hofmeyr GJ. Treatments for iron deficiency anemia in pregnancy. RHL commentary. The WHO Reproductive Health Library. Geneva: World Health Organisation; 2007.Google Scholar
  3. 3.
    UNICEF/UNO/WHO. Iron deficiency anemia: assessment, prevention and control. Geneva: World Health Organisation; 2001.Google Scholar
  4. 4.
    Sharma JB. Nutritional anaemia during pregnancy in non-industrialised countries. In: Studd J, editor. Progress in obstetrics and gynaecology. Edinburgh; Churchill Livingstone; 2003. vol 15, p. 103–122.Google Scholar
  5. 5.
    Agarwal KN, Agarwal DK, Sharma A, et al. Prevalence of anaemia in pregnant & lactating women in India. Indian J Med Res. 2006;124(2):173.Google Scholar
  6. 6.
    National Family Health Survey (NFHS-4), India; 2015–2016.Google Scholar
  7. 7.
    Galloway R, Dusch E, Elder L, et al. Women’s perceptions of Iron deficiency and anaemia prevention and control in eight developing countries. Soc Sci Med. 1982;55(4):529–44.CrossRefGoogle Scholar
  8. 8.
    Drukker L, Hants Y, Farkash R, et al. Iron deficiency anemia at admission for labor and delivery is associated with an increased risk for Cesarean section and adverse maternal and neonatal outcomes. Transfusion. 2015;55(12):2799.CrossRefGoogle Scholar
  9. 9.
    Cook JD. Iron-deficiency anemia. Baillieres Clin Haematol. 1994;7(4):787–804.CrossRefGoogle Scholar
  10. 10.
    Bynum TE. Hepatic and gastrointestinal disorders in pregnancy. Med Clin N Am. 1977;61:129–38.CrossRefGoogle Scholar
  11. 11.
    Mithra P, Unnikrishnan B, Rekha T, et al. Compliance with iron-folic acid (IFA) therapy among pregnant women in an urban area of south India. Afr Health Sci. 2014;14(1):255–60.CrossRefGoogle Scholar
  12. 12.
    Hallberg L, Bjorn-Rassmussen E. Determination of iron absorption from whole diet: a new tool model using two radiation isotopes given as haem and nonhaem iron. Scand J Haematol. 1972;9:193–7.CrossRefGoogle Scholar
  13. 13.
    A strategic approach to reproductive, maternal, newborn, child and adolescent health (RMNCH + A) in India, January 2013. Accessed 24 Dec 2018.
  14. 14.
    Silverstein SB, Rodgers GM. Parenteral iron therapy options. Am J Hematol. 2004;76:74–8.CrossRefGoogle Scholar
  15. 15.
    Khalafallah AA, Dennis AE. Iron deficiency anaemia in pregnancy and postpartum: pathophysiology and effect of oral versus intravenous iron therapy. J Pregnancy. 2012;2012:630519.CrossRefGoogle Scholar
  16. 16.
    Peña-Rosas JP, De-Regil LM, Dowswell T, et al. Daily oral iron supplementation during pregnancy. Cochrane Database Syst Rev. 2012;12:CD004736.Google Scholar
  17. 17.
    Cancelo-Hidalgo MJ, Castelo-Branco C, Palacios S, et al. Tolerability of different oral iron supplements: a systematic review. Curr Med Res Opin. 2013;29(4):291–303.CrossRefGoogle Scholar
  18. 18.
    Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.Google Scholar
  19. 19.
    Abhilashini GD, Sagili H, Reddi R. IVS and oral iron for the treatment of iron deficiency anaemia in pregnancy. J Clin Diag Res. 2014;8(5):OC04–7.Google Scholar
  20. 20.
    Shafi D, Purandare SV, Sathe AV. Iron deficiency anemia in pregnancy: intravenous versus oral route. J Obstet Gynaecol India. 2012;62(3):317–21.CrossRefGoogle Scholar
  21. 21.
    Dubey S, Suri V, Aggarawal N, et al. Is it safe to use IVS during pregnancy? A randomized controlled trial. Int J Reprod Contracept Obstet Gynecol. 2013;2:544–9.CrossRefGoogle Scholar
  22. 22.
    Sunita VN, Kolekar R, Gundalli S, et al. Effectiveness of IVS versus oral iron in iron deficiency anemia in pregnancy (IOSR-JDMS). IOSR of Dental and Medical Sciences. 2015;1(14):52–60.Google Scholar
  23. 23.
    Gupta A, Manaktala U, Rathore AM. A randomised controlled trial to compare IVS and oral iron in treatment of iron deficiency anemia in pregnancy. Ind J Hematol Blood Trans. 2014;30(2):120–5.CrossRefGoogle Scholar
  24. 24.
    Kochhar PK, Kaundal A, Ghosh P. IVS versus oral iron in treatment of iron deficiency anemia in pregnancy: a randomized clinical trial. J Obstet Gynaecol Res. 2013;39(2):504–10.CrossRefGoogle Scholar
  25. 25.
    Meenal C, Hiremath PB, Bansal N, et al. Comparative study of IVS and oral iron in iron deficiency anaemia among pregnant women in rural. Evol Med Dental Sci. 2013;2(7):695–702.CrossRefGoogle Scholar
  26. 26.
    Mehta MN, Shah JM. Iron deficiency anemia in pregnancy: intravenous versus oral route. Natl J Commun Med. 2014;5(1):10–2.Google Scholar
  27. 27.
    Neeru S, Nair NS, Rai L. Iron sucrose versus oral iron therapy in pregnancy anemia. Indian J Commun Med. 2012;37(4):214.CrossRefGoogle Scholar
  28. 28.
    Froessler B, Cocchiaro C, Saadat-Gilani K, et al. IVS versus oral iron ferrous sulfate for antenatal and postpartum iron deficiency anemia: a randomized trial. Matern Fetal Neonatal Med. 2013;26(7):654–9.CrossRefGoogle Scholar
  29. 29.
    Vijayalakshmi S, Mahendra G, Pukale RS, et al. Intravenous Iron versus oral iron therapy in postpartum anaemia in rural India. Evol Med Dental Sci. 2015;4(10):1666–71.CrossRefGoogle Scholar
  30. 30.
    Verma S, Inamdar SA, Malhotra N. Intravenous iron therapy versus oral iron in postpartum patients in rural area. J South Asian Fed Obstet Gynaecol. 2011;3(2):67–70.Google Scholar
  31. 31.
    Aggarwal RS, Mishra VV, Panchal NA, et al. Comparison of oral iron and IV iron sucrose for treatment of anemia in postpartum Indian Women. Natl J Commun Med. 2012;3:48–54.Google Scholar
  32. 32.
    Perelló MF, Coloma JL, Masoller N, et al. Intravenous ferrous sucrose versus placebo in addition to oral iron therapy for the treatment of severe postpartum anaemia: a randomised controlled trial. BJOG. 2014;121(6):706–13.CrossRefGoogle Scholar
  33. 33.
    Pal SR, Mondal SC, Lahiri S, et al. A study to compare the efficacy and safety of treatment with intravenous ferrous sucrose versus oral ferrous sulphate therapy in postpartum anaemia. Int Curr Med Res. 2015;4(2):348–51.Google Scholar
  34. 34.
    Jain G, Palaria U, Jha SK. Intravenous iron in postpartum anemia. J Obstet Gynecol India. 2013;63(1):45–8.CrossRefGoogle Scholar
  35. 35.
    Kharde PS, Bangal VB, Panicker KK. Comparative study of IVS versus oral iron therapy in iron deficiency anemia during postpartum period. Int J Biomed Adv Res. 2012;3:238–43.CrossRefGoogle Scholar
  36. 36.
    Swati A, Mamta G, Madhu J, et al. Evaluation of iron sucrose for post partum anemia. Int Basic Appl Med Sci. 2013;3:208–11.Google Scholar
  37. 37.
    Mumtaz A, Farooq F. Comparison for effects of intravenous versus oral iron therapy for postpartum anemia. Pak J Med Health Sci. 2011;5(1):116–20.Google Scholar
  38. 38.
    Horowitz KM, Ingardia CJ, Borgida AF. Anemia in pregnancy. Clin Lab Med. 2013;33:281–91.CrossRefGoogle Scholar
  39. 39.
    Bothwell TH. Iron requirements in pregnancy and strategies to meet them. Am J ClinNutr. 2000;72(Suppl):S257–64.Google Scholar
  40. 40.
    Haider BA, Olofin I, Wang M, et al. Anaemia, prenatal iron use, and risk of adverse pregnancy outcomes: systematic review and meta-analysis. BMJ. 2013;346:f3443.CrossRefGoogle Scholar
  41. 41.
    Reveiz L, Gyte GM, Cuervo LG, et al. Treatments for irondeficiency anaemia in pregnancy. Cochrane Database Syst Rev. 2011;10:CD003094.Google Scholar
  42. 42.
    Kumar A, Jain S, Singh NP, et al. Oral versus high dose parenteral iron supplementation in pregnancy. Int J Gynaecol Obstet. 2005;89:7–13.CrossRefGoogle Scholar
  43. 43.
    Khalafallah AA, Dennis AE, Ogden K, et al. Three-year follow-up of a randomised clinical trial of intravenous versus oral iron for anaemia in pregnancy. BMJ Open. 2012;2(5):e000998.CrossRefGoogle Scholar
  44. 44.
    Al RA, Unlubilgin E, Kandemir O, et al. Intravenous versus oral iron for treatment of anemia in pregnancy: a randomized trial. Obstet Gynecol. 2005;106:1335–40.CrossRefGoogle Scholar
  45. 45.
    Habib F, Alabdin EH, Alenazy M, et al. Compliance to iron supplementation during pregnancy. J Obstet Gynaecol. 2009;29(6):487–92.CrossRefGoogle Scholar
  46. 46.
    Shi Q, Leng W, Wazir R, et al. IVS versus oral iron in the treatment of pregnancy with iron deficiency anaemia: a systematic review. Gynecol Obstet Invest. 2015;80(3):170–8.CrossRefGoogle Scholar
  47. 47.
    Ganz T. Hepcidin and iron regulation, 10 years later. Blood. 2011;117(17):4425–33.CrossRefGoogle Scholar
  48. 48.
    Theurl I, Mattle V, Seifert M, et al. Dysregulated monocyte iron homeostasis and erythropoietin formation in patients with anemia of chronic disease. Blood. 2006;107:4142–8.CrossRefGoogle Scholar

Copyright information

© Federation of Obstetric & Gynecological Societies of India 2019

Authors and Affiliations

  1. 1.University College of Medical Sciences & Guru Teg Bahadur HospitalDelhiIndia
  2. 2.All India Institute of Medical SciencesDelhiIndia
  3. 3.Indian Council of Medical ResearchDelhiIndia
  4. 4.QMed Knowledge FoundationMumbaiIndia
  5. 5.GhaziabadIndia

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