Iron Infusions In Pregnancy
I get asked a lot over on Instagram, “what do you think of iron infusions, should I be getting one?” and it’s a lengthy topic with many things to consider - so here is an episode entirely dedicated to the topic!
The purpose of this episode is to help arm you with information so you can make your own informed decisions that feel right for you.
In this episode, I go over:
What the current guidelines and recommendations are in Australia for iron infusions in pregnancy, and what is the cut offs for diagnosing anaemia in pregnancy
What the risks of infusions outlining maternal and neonatal outcomes
What the difference is between iron deficiency and iron deficiency anaemia
When are iron infusions not recommended
What too little, and on the other end, too much iron could do in pregnancy
What is the solution to preventing iron deficient anaemia in the first place
As always, please make sure you have an informed discussion regarding the risks with your primary health care provider as this episode is not designed to replace medical advice.
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.
Khalafallah A, Dennis A, Bates J, et al. A prospective randomized, controlled trial of intravenous versus oral iron for moderate iron deficiency anaemia of pregnancy. J Intern Med 2010;268(3):286–95. doi: 10.1111/j.1365-2796.2010.02251.x
Breymann C. Iron deficiency anemia in pregnancy. Semin Hematol 2015;52(4):339–47. doi: 10.1053/j.seminhematol.2015.07.003.
Lee AI, Okam MM. Anemia in pregnancy. Hematol Oncol Clin North Am 2011;25(2):241–59. doi: 10.1016/j.hoc.2011.02.001.
Reveiz L, Gyte GM, Cuervo LG, Casasbuenas A. Treatments for iron-deficiency anaemia in pregnancy.
Cochrane Database Syst Rev 2011;(10):CD003094. doi: 10.1002/14651858.CD003094.pub3
Qassim A, Mol BW, Grivell RM, Grzeskowiak LE. Safety and efficacy of intravenous iron polymaltose, iron sucrose and ferric carboxymaltose in pregnancy: A systematic review. Aust N Z J Obstet Gynaecol 2018;58(1):22–39. doi: 10.1111/ajo.12695.
Hi, and welcome to another episode of the Nato Nature Path podcast. This is episode 14, and we're gonna be discussing iron infusions during pregnancy. And I'm Melanie Nolan. So this episode might be relevant for anyone considering an iron infusion. Although I do focus on pregnancy, it might be, there might just be some really good snippets and gems that you might wanna share
considering an infusion. So I decided to do this episode because I have been asked so many times on my Instagram, what do I think of infusions? Have you got a post about infusions? I've been recommended an infusion, but I'm finding it hard to just, you know, to sort of peek apart the research, the evidence, and I don't know what I should be doing. So I thought I'll just collate everything.
and what the research states in Australia at the moment. But I do want to start off by saying that whatever decision you make is yours. And as long as it's informed, that's what really matters. I really wouldn't want this episode to make anyone worried or concerned if you've had an infusion or if you think you might need one. I just really wanna inform you guys about what I found when looking through current research and help arm you with information so that you can make your own informed decisions that feel right for you.
And as always, please make sure that you have that informed discussion regarding the risks and benefits with your own primary health care provider. So iron, as we all know, but I might as well give a quick snippet, it's so essential during pregnancy. Obviously essential when we're not pregnant too, but especially so to support the expansion of red blood cell mass, the growth of maternal tissues, and then for fetal and percentile development.
Obviously has a huge job of carrying oxygen from the lungs to your tissues in the form of hemoglobin. So, iron deficiency in itself, that term represents a spectrum. So we start at one end with iron depletion, which is simply just a dropping or a low ferritin level, all the way to the other end where we've got iron deficiency anemia, which is the more serious version. And that's where we've got
iron as measured by serum ferritin concentration and then we've also got that low hemoglobin. So in iron deficiency alone, it's talking about your stored iron. You have a diminished amount of stored iron, but the amount of transporting and functional iron may not be affecting you, and your hemoglobin level might be totally fine. So that's not anemia.
women who have iron depletion, that iron deficiency, may not have any iron stores to mobilise, should the body require additional iron, like if it needs to make haemoglobin, or if you suffer a blood loss, or if you're not pregnant, you're getting a period every month and you are low in iron, it will end up eventuating anaemia if something's not done. And where we've got iron,
iron is low, you're ferritin. We've got a lack of that transport iron, which is measured by transferrin saturation, and your body may have increased transferrin, which is the carrier that it in that it carries iron around in the blood. And it might have done that because it's realized we need more iron, we need to increase the amount of carriers available so we can pick up as much as possible. And when this happens, we then don't get that red blood
cell production the way we need to. It's limited because we don't have enough iron to create the haemoglobin and therefore eventually you'll see your hemoglobin will go down. So we've got that impaired haemoglobin synthesis. Now iron deficiency anaemia is where we have anaemia being caused by iron deficiency. Anaemia by itself is simply just haemoglobin concentration
low. Now defining iron deficiency in pregnant women is very imprecise because of pregnancy associated changes in the plasma volume and red cell mass called haemodilution. And then we find that that creates a picture where it looks like your haemoglobin levels are lower because of this
of anemia and pregnancy is variable and there is actually no agreed normal range for haemoglobin concentration in pregnancy in Australia. Now the World Health Organisation defines anemia and pregnancy as a hemoglobin concentration less than 110 grams per litre at any stage in the pregnancy, whereas looking at the UK, they define anemia as 110 grams per litre in the first trimester,
per litre in the second and third trimester. Then we've got the US Centers for Disease Control and Prevention, CDC, they go by the cutoff of less than 110 grams per litre for the first and third trimester, and then they use less than 105 grams per litre for the second trimester to diagnose anemia. I know when I was pregnant at the Mercy Hospital in Melbourne, I was told were suggested when your hemoglobin level was less than 100. So, but then I hear of other women being told, it's a iron infusion, you're at 105 or 110. So it's super inconsistent in Australia. And when we, you know, bearing in mind, anemia can be with or without iron deficiency. So if it is without iron deficiency,
anemia. Sorry, you have low hemoglobin, but your ferritin is fine, then an IVU infusion will not be indicated for you because you have another form of anemia, potentially like pernicious anemia or anemia of inflammation, something like that. So despite this inconsistency in the definition of iron deficiency anemia, recommendations for current practice in Australia, New Zealand and UK are to assess a woman's hemoglobin level at the first antenatal visit
again at 28 weeks gestation to ensure that any anemia is investigated and treated. So we have a check at your first antenatal visit, which could be really at any point. It depends. Some people find out they're pregnant really early, some late. You might book your appointment soon or you might have a waiting time to see your obstetrician. Your GP might not run it, they might wait for your obstetrician to run the iron check. It's all over the show. So
So, you know, a great GP normally I've found will do your iron studies at first pregnancy confirmation, which is normally four or five weeks pregnant. That's when most people find out that they're pregnant. So that's when we've gotten it checked. Say it's at four and a half weeks pregnant, you got your iron checked. Then not again, this is what the clinical guideline is in Australia, until 28 weeks pregnant. Oh my gosh. You by then, if you are developing iron deficiency.
28 weeks, it's going to be dire. And at this point, it is difficult to treat with oral supplements if you are very anaemic. So herein lies the problem. And a part of the biggest solution, which I'll talk about at the end, is more regular blood tests. But anyway, now in Australia, oral iron supplements is the first line of treatment that is the guideline.
diagnosed with iron deficiency anaemia. Because remember, we've got iron deficiency anaemia and then just iron deficiency. So I'm talking about if you have low ferritin and low haemoglobin, you now have iron deficiency anaemia. Your practitioner should be outlining an oral treatment plan before resulting to an infusion. Because this is what the guidelines say, oral iron supplements are the first line of treatment.
infusions are recommended and this is sort of what the pharmaceutical benefit scheme and you know the guideline state is when oral therapy fails meaning don't try it before oral therapy and I'll go through when oral therapy might have failed but you know there are certain circumstances when I and IV infusions are recommended.
overall supplementation, but these are a little bit more rare. And it's where we really need that rapid restoration of haemoglobin. And I'll talk about that a little bit later on. Now, uncertainty does remain around the risk of too much iron as well. So it's quite clear in the clinical literature that we've got problems if we have not enough iron.
also have problems when we have too much iron. So iron has a U shaped nutrient health relationship where we've got at one end functional impairment at one end where we've got anaemia and iron deficiency that's detrimental to mum and baby. Then we've got toxicity at the other end and that can affect mum and baby too. If we have too much iron, now this can, this is
load in pregnancy is linked to very high haemoglobin levels, which is detrimental. We don't want too high haemoglobin, preeclampsia, and gestational diabetes, as well as a few other things which I'll go through later on. Now it's really well documented that humans must not have too much iron. It can contribute to oxidative stress within the body and it can cause a whole host of detrimental outcomes.
have an iron infusion, you're getting months and months of iron given to you in one single hit. I know one of them provides 2000 milligrams in one sitting. So that is a lot of iron, a lot. So to me, I do question that it seems so against the body's natural process of trying to inhibit too much iron in one hit via hepcidin. But in saying that, of course, iron deficiency anaemia is associated
with things like poor gestational weight gain, fetal growth restriction, preterm delivery, increased risk of birth complications, and then depression in mum. And then iron deficiency anemia in the mother can for the newborn also result in iron deficiency, behavioural cognitive disorders, and it's also been associated with retinopathy of prematurity. So we don't want any of this either. Now, the number of
being given has almost doubled in recent years. There is one article on the Australian Journal of General Practice and that article is called anemia in pregnancy and it states, although recent studies have shown the use of IV iron in pregnancy is well tolerated, there remains a lack of evidence on maternal and neonatal outcomes. Now there are really high rates of intravenous
iron used by obstetricians in Australia for both iron deficiency and iron deficiency anemia. And it's most commonly done in that later gestation. So in researching, I sort of found, I did find statistics that stated there was, sorry, so yeah, so when I was researching this podcast, I came across a survey, a recent survey done in Australia. Now it surveyed 457 obstetricians
when, how often. Now, 8% of these obstetricians stated they use IV infusions in the first trimester for either iron deficiency anemia or just iron deficiency, despite this actually being contraindicated. Contraindicated meaning in Australia, iron infusions are not recommended in the first trimester, yet we have a percentage of obstetricians out there in Australia that are doing this.
also contraindicated in women that are just low in ferritin. So if you just have iron deficiency without the anemia, this is not what iron infusions are indicated for. Yet again we have obstetricians in Australia doing this. I've heard of so many women getting infusions done when it was just their ferritin that was low and the haemoglobin was fine.
So, looking at some research, I found that IV-ion supplementation, sorry, so IV-ion infusions are actually effective in bringing up ferritin and haemoglobin. And in comparison to supplements though, there is not a great deal of difference. The difference is the rapidness of the restoration. So overall, if we look at what they actually do.
There was only a difference of a few points. So IV iron use improves maternal haemoglobin concentrations by about 21 grams per liter. So, you know, in really simple terms, if your haemoglobin started at 100 and you got an IV infusion, on average the research says it would shift about 21.8 points up. And then it stated by delivery. So if you've had an iron infusion in the pregnancy,
by delivery that goes up to about 30.1 grams per litre. So, we've got that. Now, if we compare it with oral iron alone, IV iron was associated with an additional increase of haemoglobin of an extra six grams per litre at four weeks following treatment and 6.8 grams per litre at delivery. So, this is talking about literally comparing an infusion
saying that it really in the research may only increase your haemoglobin by about 6 to 6.8 grams per litre. So that shows that obviously our oral iron supplements we know do increase haemoglobin, do increase ferritin. So it's sort of like comparing well how much better is an infusion. So interesting. Now that really, the outcome was that the benefit of IV oral,
benefit of IV, iron infusions over oral is modest. So it's not significant where we get a huge, huge shift in comparison, but of course that is also taking into account whether someone's oral supplementation actually is possible and that it works, you know, so there's that. We have to keep in mind too. So let's look at the risks of iron infusions. We've got some serious adverse effects
So the most serious really in the literature is major allergic reactions, so anaphylaxis. And this on average is occurring in 3.6 women out of 1,000. And we also have the risk of skin staining, which is permanent as well. A 2017 systematic review of the safety and efficiency of three commonly used IB preparations in pregnancy.
meltoase, iron polymoltoase and iron sucrose. This systematic review, the finding was, and I quote, there is a lack of evidence for improvement in important maternal and perinatal outcomes with IV iron use and the high incident of related adverse drug reactions. So that was quite interesting as well.
your iron and haemoglobin, so it's quite rapid this increase after an infusion, that can carry risks in itself because higher haemoglobin levels have been linked to perinatal death, low birth weight and preterm birth. And of course, if we circle back to the anaphylaxis, the risk is small, but it's not negligible as well. So it's just something to be aware of, that the risk is there. We also have other risks,
the potential for inducing iron overload, oxidative stress, too much iron can contribute to oxidative stress, infection, and then severe low phosphate levels. I just want to talk about this low phosphate levels for a second as well. So currently just to suggest that there is a high incident of low phosphate levels occurring when we use iron carboxymotos infusions compared to the other formulations. And the proposed mechanism was where we have
an inhibition of the degradation of fibroblast growth factor 23. This is a hormone that regulates phosphate metabolism in the body and then this in turn reduces phosphate reabsorption in the kidney tubules. This can also result in lower levels of vitamin D and then it reduces intestinal absorption of phosphate. So I wonder whether it should be also important to be checking someone's vitamin D levels post-infusion as well.
if you've had an iron carboxymol infusion.
Now, going, you know, if we look like at a broad overview, oral eye and should remain and is the first line of treatment for iron deficiency anemia. So IV iron infusions should only be used in appropriately selected cases of severe iron deficiency anemia and not for the iron deficiency where we have no anemia. Now, overall, what's my professional
opinion? So again, I'm going to reiterate, oral iron should be the first treatment for iron deficiency anemia. So, and IV infusion should absolutely not be within the first term of pregnancy because there is a lack of safety evidence for this especially. Now, anemia within pregnancy is obviously detrimental and we do need to weigh that up and then the risks also associated with infusion. So the risks to being anemic,
and then the risks to infusion. I myself, I'm not convinced there is enough safety data for me to ever get an infusion while I'm pregnant. Unless of course we're in a completely dire situation. Now these are where iron infusions are very, very much the, I guess the chosen treatment over oral supplements would be where we have dire situations like ongoing blood loss exceeding the ability to restore iron levels
oral iron or if we have unexpected major surgery and we're anaemic and we need to avoid the need for a blood transfusion because we do not have time to be you know using oral supplements or if the anaemia is picked up very late in the third trimester with birth being imminent and there isn't any time to be rectifying levels with oral supplements and also in cases of women with chronic kidney disease as well. Infusions are quite warranted. I also do wonder
whether the increase in infusion rates are due to inconvenience rather than an evidence of clinical benefit because they're a lot quicker and then we don't have to have that that person coming back constantly for blood tests and monitoring their oral supplementation and tweaking if it doesn't quite work. You know, it's just like, bang, you're done, you're out of here within a couple of hours, the infusion's been done. I personally feel for myself there is a lack of high quality research studies that evaluate meaningful clinical outcomes for mum and baby.
Now, there was another study done and I'll put all the references in. This was, it was a systematic review, the one I was speaking about earlier. They actually said that they found no effect of an IV infusion on clinically relevant outcomes, including no differences to be found really with low birth weight, preterm birth, infections, postpartum haemorrhaging and the need for blood transfusions. So that, you know, that's...
makes you do wonder. And that is why I mentioned I would love to see more high quality research studies done that evaluate meaningful clinical outcomes so it's quite clear, you know. So what could be a solution? I don't want to leave you with all this without a solution. So I believe optimising iron levels in preconception should be our primary goal where possible. And I harp on about preconception care so often. And this is because
This is one huge example because if we can do preconception care, this could lower the need for an infusion. Because sometimes infusions are necessary like I mentioned before.
it'd be great if we could get to a place where we could avoid the need for one.
Now, blood tests should be conducted at least three months prior to your ideal conception date and we want to check your iron studies in your haemoglobin. If there is an issue, we treat there and then with oral iron supplements and then we are allowing three months to sort that out because that's on average. You know, how long it takes. The issue is in pregnancy where we find out your anaemic or we find out you've got the low, the low ferritin. The time it takes to
this when we see women going to grab any old iron supplement. And I'll speak about that in a second, but if anyone that follows me know that I harp on constantly about high quality supplements and taking it on alternate days due to Hepcidin and all that sort of stuff. So, and you know, not taking your iron with things that don't absorb well with it. We need to be taking iron properly.
happens. You know, if someone has iron deficiency anemia, we may not get a complete fix of the situation. But absolutely, I've seen it within my clinic, we can get things moving in the positive direction with oral supplements. Absolutely. And especially so when we're doing it correctly. Now, testing iron studies in haemoglobin should be done every eight to
is increasing the frequency of testing. Because like I mentioned before, if we get a blood test at four weeks and then we wait until 28 weeks, honestly to me that's absurd. When it is really well documented that stores of iron often decrease by 20 weeks. And some do experience significant drops in the first trimester. So we need to check on that. I think it should be a blood test of four weeks, a blood test towards the end of the first trimester, a blood test, you know,
late in your late teens. So maybe if we had one at four weeks, then we have one at eight weeks. Sorry. And then we have one eight weeks later at 12 weeks, then 20 weeks, then, you know, 28 and so on. And also we want to be getting one when birth is nearing because we do want to check, right, we don't have long left. Where are we at?
It's my recommendation that women should be commencing supplementation as soon as there is a downhill trend in your blood tests or if ferritin is on that bottom end of the reference range. I personally do lack my clients, especially in preconception, to be seeing their ferritin maintained above 50, but we also need to look at the whole picture because ferritin can sometimes be falsely increased due to infection or inflammation or malignancy. So we also need to look at transferrin and transferrin saturation levels for the entire picture.
We also, a part of the solution is want to be taking high quality iron bisglycinate supplements. So this also in my recommendation should be on alternate days with the correct dose for your individual levels and needs. And this takes a skill practitioner to be guiding you on that one. Some people don't need as much as others, but I do personally believe and I see the results of this that every second day is amazing.
So, you know, part of the solution, like I said, is getting on top of it early. If you are anemic, going for the oral supplements first, giving that a chance to work, but also if possible, doing the iron by glass at eight every second day, not taking your iron supplement with caffeine or calcium supplements or zinc supplements for at least an hour either side of taking your iron supplement as well. Because what I tend to see in pregnancy,
me is women get their check done at 28 weeks pregnant and lo and behold, they're anemic. We then find that they're offered an infusion or they are offered oral supplements. It's either or. We then find you're taking the oral supplements and normally the recommendation is just go grab one from the chemist. Take it every day. We then get another blood test. Check on that.
few weeks later, whenever it is. And then they go, okay, my iron really hasn't, my, my, my parameters haven't shifted much, but I've been taking this iron every day that you told me to take. Now, there is a plethora of research to show that supplements like ferrous fumarate do not absorb anywhere near as well or as quickly as iron bisglycinate.
So sometimes the suggestion is, okay, just go take more iron. Or now we need an infusion. So can you see how, you know, if we treat this iron properly and early enough, we can avoid hopefully the need for an infusion at all, which would be amazing. And also ideally consuming 3-4 servings of red meat a week. And slow cooked red meat is just ideal.
It's great for absorption, so easy to digest, and also how good the slow cook up. Finished by 10am, like, love it. And then you also might like to combine some, you know, my product, Ironbiotic, has Iron bisglycinate. It also has cofactors in there to help absorption and aid in haemoglobin synthesis, like your activated B12. But you also might want to consider if your iron doesn't have additional vitamin C in it. You also might want to be having some...
rich vitamin C foods like berries, cacodoo plum, oranges, orange juice, things like that. I also want to reiterate, if someone is taking orange supplements and oral supplements and their levels aren't coming up, there is almost always a fixable reason for this. And I'll do another episode in a few weeks on this exact topic. So make sure you are subscribed to this podcast, so don't miss it. But, you know, it's mostly, except for the situations that I mentioned you know, imminent surgery happening and we're anemic or we are nearing birth and we're really very, very anemic or we've got ongoing blood loss that can't be sorted out. Most of the, oh, we've got that chronic kidney disease picture that I mentioned. Most of the time, these stuff's fixable with oral supplements. It's just being able to do it early enough. Now, as a part of my clinic, we do sell a blood test cheat sheet. It's only $29 and it really does go through what
I want to see your blood test levels are and what it means when you are out of range. So I use my own personal reference ranges that I have tweaked over the years in my clinic. They are functional optimal levels meaning where do you optimally sit? Where does the body optimally sit? This is not just going off lab reference ranges, which are often very skewed because they take a subsection of the average population and you've got your sickest if you sickest in there and your healthiest of the healthiest and that really does skew the reference ranges and to ensure that you're not sitting at that bottom end of a reference range because that's why you potentially could already have a symptom of the condition itself.
Ah, that was a science heavy episode. But as always, I would love to hear from you on Instagram at the natal naturopath. And I would so love it if you could share this episode with a pregnant mama, because it could really be the thing that helps her make her informed decision. And again, I'm not swinging either which way, but for my own professional opinion, I would rather see better studies done. And I of course, I'm always going to be suggesting oral supplementation as the first treatment line. All right, well, I will catch you next week have a lovely week everyone.