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Why I Don’t Recommend Iron Infusions in Pregnancy

First things first: some people choose to have an iron infusion in pregnancy and that is their choice. This information is intended to empower you with the knowledge to make an informed decision for your unique personal circumstances. There is no room for guilt here. 

Secondly, if you do currently have iron deficiency anaemia (IDA), please proceed with the medical advice you have been given. Iron infusions are most often required at this point in time, however this conversation is to help prevent the development of IDA in others and/or yourself for future pregnancies. As always, please make sure you have an informed discussion regarding the risks with your primary health care provider (discussed below).

Thirdly, optimising iron levels in preconception should be our primary goal. Blood tests should be conducted at least three months prior to your ideal conception date. More on this here.

Ok, let’s dive in.

Maintaining optimal iron stores can be challenging in pregnancy due to the changes in plasma volume and red cell mass. By trimester three, iron demands are three times greater than in non-pregnant women with regular menstruation, due to the normal increases in red cell mass to enable adequate foetal oxygenation. 

Recommendations for current practice in Australia (amongst other countries are to assess a woman’s haemoglobin level at the first antenatal visit and at 28 weeks gestation, and ensure that any anaemia is investigated and treated. Routine iron supplementation is not recommended for all pregnant women.

Oral iron is recommended as first line therapy for women with IDA. Intravenous (IV) iron is recommended when oral iron is poorly tolerated, absorption may be impaired, the response to oral iron is inadequate, or when rapid restoration of haemoglobin and iron stores is required.

There are three types of iron infusions available in Australia. 

  1. Iron carboxymaltose – may need to be given as multiple treatments.
  2. Iron polymaltose – given as a single treatment.
  3. Iron sucrose – may need to be given as multiple treatments. 

Let’s examine iron carboxymaltose, or Ferinject which is used more commonly following its listing on the Australian Pharmaceutical Benefits Scheme (PBS) in June 2014.

Iron carboxymaltose – Ferinject

There is no efficacy or safety data on the use of  Ferinject in pregnancy before 16 weeks’ gestation. Iron deficiency occurring in the first trimester of pregnancy can in many cases be treated with oral iron.

There is limited experience with the use of  Ferinject in women in pregnancy from 16 weeks’ gestation). If iron treatment is needed in pregnancy, oral iron should be used where possible and Ferinject only used where the benefit outweighs the risk.

So why are iron infusions handed out like candy then? Let’s look at the risks: 

The risks

Taken from ‘Intravenous iron use in pregnancy: Ironing out the issues and evidence’ (DOI: 10.1111/ajo.12794).

  • Perinatal death, low birthweight and preterm birth are increased with a high haemoglobin level. 
  • All IV iron preparations are associated with anaphylaxis/anaphylactoid reactions and while the risk is small, it is not negligible.
  • In addition to hypersensitivity reactions/anaphylaxis, other risks associated with IV iron include the potential for inducing iron overload, oxidative stress, infection, and severe hypophosphataemia.
  • The lack of demonstrated improvement in important clinical end points with IV iron use during pregnancy, together with the potential to cause harm, should discourage the widespread dissemination of this practice. 
  • Oral iron should remain the first line treatment of IDA. IV iron should only be used in appropriately selected cases of severe IDA, and not for iron deficiency in the absence of IDA.

In summary, I do not recommend iron infusions in pregnancy where possible. A big part of the solution is increased frequency of testing. Waiting until 28 weeks is absurd as it is well documented that stores often decrease by 20 weeks and mine and others experienced is a significant drop by as early as 13 weeks.

So what’s the solution: 

  1. Testing iron studies and haemoglobin every 8 weeks.
  2. Commencing supplementation relatively early, as prescribed by a skilled practitioner. Often more than the standard dose is required. 
  3. Consuming high quality iron supplements, which come with a very low risk of GI complications such as constipation.
  4. Avoiding caffeine for a least one hour either side of supplementation.
  5. Combining iron supplementation with additional vitamin C from whole food sources including berries, Kakudu plum and camu camu.
  6. Ideally, consume 3-4 serves of red meat/week. Slow cooked is ideal for optimal absorption and digestive ease. Check out my Pulled Beef Brisket with Sweet Potato Tacos for some delicious recipe inspiration.
  7. Consuming bone broth daily or if not tolerated, a collagen powder for increased nutrient absorption. 
  8. Adding incredible superfoods such as Mother’s Essentials by Foraged For You.

I hope that helps. Please learn more about personalised support via my program Preconception & Pregnancy Support.

References:

Seeho SKM & Morris JM. 2018. Intravenous iron use in pregnancy: Ironing out the issues and evidence. Aust N Z J Obstet Gynaecol, 58, 145–147.

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