Annals of Hematology

, Volume 91, Issue 2, pp 143–154 | Cite as

Postpartum anemia II: prevention and treatment

Review Article

Abstract

This review focuses on the prevention and treatment of anemia in women who have just given childbirth (postpartum anemia). The problem of anemia both prepartum and postpartum is far more prevalent in developing countries than in the Western societies. The conditions for mother and child in the postpartum, nursing, and lactation period should be as favorable as possible. Many young mothers have a troublesome life due to iron deficiency and iron deficiency anemia (IDA) causing a plethora of symptoms including fatigue, physical disability, cognitive problems, and psychiatric disorders. Routine screening for postpartum anemia should be considered as part of the national maternal health programs. Major causes of postpartum anemia are prepartum iron deficiency and IDA in combination with excessive blood losses at delivery. Postpartum anemia should be defined as a hemoglobin level of <110 g/l at 1 week postpartum and <120 g/l at 8 weeks postpartum. Bleeding exceeding normal blood losses of approximately 300 ml may lead to rapid depletion of body iron reserves and may, unless treated, elicit long-standing iron deficiency and IDA in the postpartum period. The prophylaxis of postpartum anemia should begin already in early pregnancy in order to ensure a good iron status prior to delivery. The most reliable way to obtain this goal is to give prophylactic oral ferrous iron supplements 30–50 mg daily from early pregnancy and take obstetric precautions in pregnancies at risk for complications. In the treatment of slight-to-moderate postpartum IDA, the first choice should be oral ferrous iron 100 to 200 mg daily; it is essential to analyze hemoglobin after approximately 2 weeks in order to check whether treatment works. In severe IDA, intravenous ferric iron in doses ranging from 800 to 1,500 mg should be considered as first choice. In a few women with severe anemia and blunted erythropoiesis due to infection and/or inflammation, additional recombinant human erythropoietin may be considered. Blood transfusion should be restricted to women who develop circulatory instability due to postpartum hemorrhage. National health authorities should establish guidelines to combat iron deficiency in pregnancy and postpartum in order to facilitate a prosperous future for both mothers and children in a continuing globalized world.

Keywords

Anemia, Iron deficiency EPO protein, Human Hemoglobins Iron Iron i.v. Postpartum hemorrhage Postpartum period Pregnancy 

References

  1. 1.
    Milman N (2011) Postpartum anemia I: definition, prevalence, causes and consequences. Ann Hematol 90:1247–1253PubMedCrossRefGoogle Scholar
  2. 2.
    Milman N. Anemia—still a major health problem in many parts of the world! Ann Hematol 2011; 90:369–377. http://dx.doi.org/10.1007/s00277-010-1144-5
  3. 3.
    World Health Organization (1999) Reduction of maternal mortality. A joint WHO/UNFPA/UNICEF/World Bank statement. World Health Organization, GenevaGoogle Scholar
  4. 4.
    Potts M, Campbell M (2004) Three meetings and fewer funerals: misoprostol in postpartum hemorrhage. Lancet 364:1110–1111PubMedCrossRefGoogle Scholar
  5. 5.
    Tsu VD, Shane B (2004) New and underutilized technologies to reduce maternal mortality: call to action from a Bellagio workshop. Int J Gynecol Obstet 85(Suppl 1):S83–S93CrossRefGoogle Scholar
  6. 6.
    Bodnar LM, Siega-Riz AM, Miller WC, Cogswell ME, McDonald T (2002) Who should be screened for postpartum anemia? An evaluation of current recommendations. Am J Epidemiol 156:903–912PubMedCrossRefGoogle Scholar
  7. 7.
    Bergmann RL, Richter R, Bergmann KE, Dudenhausen JW (2010) Prevalence and risk factors for early postpartum anemia. Eur J Obstet Gynecol Reprod Biol 150:126–131PubMedCrossRefGoogle Scholar
  8. 8.
    Milman N, Kirchhoff M (1992) Iron stores in 1359, 30- to 60-year-old Danish women: evaluation by serum ferritin and hemoglobin. Ann Hematol 64:22–227PubMedCrossRefGoogle Scholar
  9. 9.
    Milman N (2008) Prepartum anaemia: prevention and treatment. Ann Hematol 87:949–959PubMedCrossRefGoogle Scholar
  10. 10.
    Oyelese Y, Ananth CV (2010) Postpartum hemorrhage: epidemiology, risk factors, and causes. Clin Obstet Gynecol 53:147–156PubMedCrossRefGoogle Scholar
  11. 11.
    Danish Society for Obstetrics and Gynaecology http://www.dsog.dk
  12. 12.
    Milman N, Agger OA, Nielsen OJ (1991) Iron supplementation during pregnancy. Effect on iron status markers, serum erythropoietin and human placental lactogen. A placebo controlled study in 207 Danish women. Dan Med Bull 38:471–476PubMedGoogle Scholar
  13. 13.
    Åkesson A, Bjellerup P, Berglund M, Bremme K, Vahter M (2002) Soluble transferrin receptor: longitudinal assessment from pregnancy to postlactation. Obstet Gynecol 99:260–266PubMedCrossRefGoogle Scholar
  14. 14.
    World Health Organization. Iron deficiency anemia. Assessment, prevention and control. 2001;WHO/NHD/01.3Google Scholar
  15. 15.
    Milman N, Bergholt T, Eriksen L, Byg K-E, Graudal N, Pedersen P, Hertz J (2005) iron prophylaxis during pregnancy—how much iron is needed? A randomised, controlled study of 20 to 80 mg ferrous iron daily to pregnant women. Acta Obstet Gynecol Scand 84:238–247PubMedGoogle Scholar
  16. 16.
    Milman N (2006) Iron and pregnancy—a delicate balance. Ann Hematol 85:559–565PubMedCrossRefGoogle Scholar
  17. 17.
    Bothwell TH (2000) Iron requirements in pregnancy and strategies to meet them. Am J Clin Nutr 72:257S–264SPubMedGoogle Scholar
  18. 18.
    Siimes MA, Vuori E, Kuitunen P (1979) Breast milk iron—a declining concentration during the course of lactation. Acta Paed Scand 68:29–31CrossRefGoogle Scholar
  19. 19.
    Pedersen AN, Fagt S, Groth MV, Christensen T, Biltoft-Jensen, Matthiessen J, et al. Dietary habits in Denmark 2003–2008. Main results: National Food Agency of Denmark. 2010Google Scholar
  20. 20.
    Commission of the European Communities. Nutrient and energy intakes for the European Community. Reports of the Scientific Committee for Food. Directorate General Industry 1993;31st series:180–181Google Scholar
  21. 21.
    National Collaborating Centre for Women's & Children's Health. NICE Clinical Guideline 62—Antenatal Care; March 2008Google Scholar
  22. 22.
    Social-og helsedirektoratet. Retningslinjer for svangerskapsomsorgen. www.shdir.no/publikasjoner Accessed December 2008
  23. 23.
    Recommendations CDC (1998) to prevent and control iron deficiency in the United States. Centers for Disease Control and Prevention. MMWR Recomm Rep 47:1–29Google Scholar
  24. 24.
    International Food information Council Foundation. Healthy eating during pregnancy. www.foodinsight.org Accessed January 2009
  25. 25.
    www.altomkost.dk Accessed January 2010
  26. 26.
    www.meraadet.dk Accessed March 2008
  27. 27.
    Swedish Society for Obstetrics and Gynecology. Maternal health, sexual and reproductive health (Mödrahälsovård, sexuell och reproduktiv hälsa) 2008;rapport no. 59:47–48Google Scholar
  28. 28.
    Trygg K, Lund-Larsen K, Sandstad B, Hoffman HJ, Jacobsen G, Bakketeig LS (1995) Do pregnant smokers eat differently from pregnant non-smokers? Paediatr Perinat Epidemiol 9:307–319PubMedCrossRefGoogle Scholar
  29. 29.
    Nordic Council of Ministers. Nordic Nutrition Recommendations 2004. Copenhagen 2004Google Scholar
  30. 30.
    Milman N, Byg K-E, Bergholt T, Eriksen L, Hvas A-M (2006) Body iron and individual iron prophylaxis in pregnancy—should the iron dose be adjusted according to serum ferritin? Ann Hematol 85:567–573PubMedCrossRefGoogle Scholar
  31. 31.
    Milman N (2006) Iron prophylaxis in pregnancy—general or individual and in which dose? Ann Hematol 85:821–828PubMedCrossRefGoogle Scholar
  32. 32.
    Breymann C, Honegger C, Holzgreve W, Surbek D. Diagnostik und Therapie der Anämie in der Schwangerschaft und postpartal. Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe. Expertenbrief 2007 no. 22Google Scholar
  33. 33.
    Beris P, Maniatis A, on behalf of the NATA working group on intravenous iron therapy. Guidelines on intravenous iron supplementation in surgery and obstetrics/gynecology. Transfusion Alternatives in Transfusion Medicine 2007;9 Suppl 1:29Google Scholar
  34. 34.
    ACOG Practice Bulletin (2006) clinical management guidelines for obstetrician/gynecologists number 76, 2006: postpartum hemorrhage. Obstet Gynecol 108:1039–1047CrossRefGoogle Scholar
  35. 35.
    L Royal College of Obstetricians and Gynaecologist, Green top Guidelines, November 2009 http://www.rcog.org.uk/files/rcog-corp/Green-top52PostpartumHaemorrhage.pdf
  36. 36.
    Rajan PV, Wing DA (2010) Postpartum hemorrhage: evidence-based medical interventions for prevention and treatment. Clin Obstet Gynecol 53:165–181PubMedCrossRefGoogle Scholar
  37. 37.
    Russell RT. WHO guidelines for the management of postpartum haemorrhage and retained placenta. World Health Organization WHO Press, Geneva, Switzerland, 2009, ISBN 978-92-4-159851-4Google Scholar
  38. 38.
    Dar S, Vardi IS, Holcberg G, Reuveni H, Yerushalmi R, Katz M, Sheiner E (2006) Do we need routine complete blood count following vaginal delivery? Int J Fertil Womens Med 51:270–273PubMedGoogle Scholar
  39. 39.
    Recommendation to prevent and control iron deficiency in the United States. MMWR Morb Mortal Wkly Rep 1998; 47(RR-3):13–25Google Scholar
  40. 40.
    Dodd JM, Dare MR, Middleton P. Treatment for women with postpartum iron deficiency anemia. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004222. DOI: 10.1002/14651858.CD004222.pub2
  41. 41.
    Skikne B, Baynes RD (1994) Iron absorption. In: Brock JH, Halliday JW, Pippard MJ, Powell LW (eds) iron metabolism in health and disease. Saunders, London, pp 151–187Google Scholar
  42. 42.
    Milman N, Graudal N, Nielsen OJ, Agger AO (1997) Serum erythropoietin during normal pregnancy: relationship to hemoglobin and iron status markers and impact of iron supplementation in a longitudinal, placebo-controlled study on 118 women. Int J Hematol 66:159–168PubMedCrossRefGoogle Scholar
  43. 43.
    Krafft A, Breymann C (2011) Iron sucrose with and without recombinant erythropoietin for the treatment of severe postpartum anemia: a prospective, randomized, open-label study. J Obstet Gynaecol Res 37:119–124PubMedCrossRefGoogle Scholar
  44. 44.
    Nielsen JB, Ikkala E, Sölvell L, Björn-Rasmussen E, Ekenved G (1976) Absorption of iron from slow-release and rapidly-disintegrating tablets—a comparative study in normal subjects, blood donors and subjects with iron deficiency anemia. Scand J Haematol Suppl 28:89–97PubMedGoogle Scholar
  45. 45.
    Venofer®. Summary of Product Characteristics www.medicines.org.uk Accessed February 6th 2011
  46. 46.
    CosmoFer®. Summary of Product Characteristics www.medicines.org.uk Accessed February 6th 2011
  47. 47.
    Ferinject®. Summary of Product Characteristics www.medicines.org.uk Accessed February 6th 2011
  48. 48.
    Lyseng-Williamson KA, Keating GM (2009) Ferric carboxymaltose: a review of its use in iron-deficiency anemia. Drugs 69:739–756PubMedCrossRefGoogle Scholar
  49. 49.
    Monofer®. Summary of Product Characteristics www.medicines.org.uk Accessed February 6th 2011
  50. 50.
    al-Momen AK, al-Meshari A, al-Nuaim L, Saddique A, Abotalib Z, Khashogji T et al (1996) Intravenous iron sucrose complex in the treatment of iron deficiency anemia during pregnancy. Eur J Obstet Gynecol Reprod Biol 69:121–124PubMedCrossRefGoogle Scholar
  51. 51.
    al-Ragip A, Unlubilgin E, Kandemir O, Yalvac S, Cakir L, Haberal A (2005) Intravenous versus oral iron for treatment of anemia in pregnancy: a randomized trial. Obstet Gynecol 106:1335–1340CrossRefGoogle Scholar
  52. 52.
    Hallak M, Sharon A, Duikman R, Auslender R, Abramovici H (1997) Supplementation iron intravenously in pregnancy. A way to avoid blood transfusions. J Reprod Med 42:99–103PubMedGoogle Scholar
  53. 53.
    Breymann C, Visca E, Huch R, Huch A (2001) Efficacy and safety of intravenously administered iron sucrose with and without adjuvant recombinant human erythropoietin for the treatment of resistant iron-deficiency anemia during pregnancy. Am J Obstet Gynecol 184:662–667PubMedCrossRefGoogle Scholar
  54. 54.
    Bashiri A, Burstein E, Sheiner E, Mazor M (2003) Anemia during pregnancy and treatment with intravenous iron: review of the literature. Eur J Obstet Gynecol Reprod Biol 110:2–7PubMedCrossRefGoogle Scholar
  55. 55.
    Van Wyck DB, Martens MG, Seid MH, Baker JB, Mangione A (2007) Intravenous ferric carboxymaltose compared with oral iron in the treatment of postpartum anemia. A randomised controlled trial. Obstet Gynecol 110:267–278PubMedCrossRefGoogle Scholar
  56. 56.
    Breymann C, Richter C, Hüttner C, Huch R, Huch A (2000) Effectiveness of recombinant erythropoietin and iron sucrose vs. iron therapy only, in patients with postpartum anemia and blunted erythropoiesis. Eur J Clin Invest 30:154–161PubMedCrossRefGoogle Scholar
  57. 57.
    Bhandal N, Russell R (2006) Intravenous versus oral iron therapy for postpartum anemia. BJOG 113:1248–1252PubMedCrossRefGoogle Scholar
  58. 58.
    Giannoulis C, Daniilidis A, Tantanasis T, Dinas K, Tzafettas J (2009) Intravenous administration of iron sucrose for treating anemia in postpartum women. Hippokratia 13:38–40PubMedGoogle Scholar
  59. 59.
    Seid MH, Derman RJ, Baker JB, Banach W, Goldberg C, Rogers R (2008) Ferric carboxymaltose injection in the treatment of postpartum iron deficiency anemia: a randomized controlled clinical trial. Am J Obst Gynecol 199:435e1–435e7CrossRefGoogle Scholar
  60. 60.
    Westad S, Backe B, Salvesen KÅ, Nakling J, Økland I, Borthen I et al (2008) A 12-week randomised study comparing intravenous iron sucrose versus oral ferrous sulphate for treatment of postpartum anemia. Acta Obstet Gynecol Scand 87:916–923PubMedCrossRefGoogle Scholar
  61. 61.
    Ganzoni AM (1972) Totalinfusion von Ferri-Kohlenhydrat-Komplexen (Total infusion of ferri-carbohydrate complexes). Blut 25:349–351PubMedCrossRefGoogle Scholar
  62. 62.
    Swedish Dental and Pharmaceutical Benefits Agency http://www.tlv.se/in-english Accessed February 6th 2011
  63. 63.
    Kotto-Kome AC, Calhoun DA, Montenegro R, Sosa R, Maldonado L, Christensen RD (2004) Effect of administering recombinant erythropoietin to women with postpartum anemia: a meta-analysis. J Perinatol 24:11–15PubMedCrossRefGoogle Scholar
  64. 64.
    Wågström E, Åkesson A, Van Rooijen M, Larson B, Bremme K (2007) Erythropoietin and intravenous iron therapy in postpartum anemia. Acta Obstet Gynecol Scand 86:957–962PubMedCrossRefGoogle Scholar
  65. 65.
    Lebrecth A, Häberlin f, Eberhard J (1995) Anämie im Wochenbett; parenterale Eisensubstitution macht Erythropoietin-Therapie entberlich (Postpartum anaemia; intravenous iron supplementation renders therapy with rhEPO redundant). Geburtshilfe Frauenheilkd 55:167–170CrossRefGoogle Scholar
  66. 66.
    Breymann c, Zimmermann R, Huch A (1996) Use of recombinant erythropoietin in combination with parenteral iron in the treatment of postpartum anemia. Eur J Clin Invest 26:123–130PubMedCrossRefGoogle Scholar
  67. 67.
    Macrydimas G, Lolis G, Lialios G, Tsiara S, Georgiou I, Bourantas KL (1998) Recombinant human erythropoietin treatment of postpartum anemia. Preliminary results. Eur J Obstet Gynecol Reprod Biol 81:27–31CrossRefGoogle Scholar
  68. 68.
    Gyamfi C, Berkowitz RL (2007) Management of pregnancy in a Jehova's Witness. Obs Gynecol Clin N Am 34:357–365CrossRefGoogle Scholar
  69. 69.
    Bunn HF (2009) End run about Epo. New Engl J Med 361:1901–1903PubMedCrossRefGoogle Scholar
  70. 70.
    Roberts CL, Ford JB, Thomson JF, Morris JM (2008) Population rates of hemorrhage and transfusions among obstetric patients in NSW: a short communication. Aust N Z J Obstet Gynaecol 48:481–484PubMedCrossRefGoogle Scholar
  71. 71.
    Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B (2008) Prevalence and risk factors of severe obstetric hemorrhage. BJOG 115:1265–1272PubMedCrossRefGoogle Scholar
  72. 72.
    Rouse DJ, MacPherson C, Landon M, Varner MW, Leveno KJ, Moawad AH et al (2006) Blood transfusion and cesarean delivery. Obstet Gynecol 108:891–897PubMedCrossRefGoogle Scholar
  73. 73.
    Fuller AJ, Bucklin BA (2010) Blood product replacement for postpartum hemorrhage. Clin Obstet Gynecol 53:196–208PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  1. 1.Departments of Clinical Biochemistry and ObstetricsNæstved HospitalNæstvedDenmark
  2. 2.VirumDenmark

Personalised recommendations