Iron Deficiency Anaemia in Pregnancy

Iron deficiency anaemia is a frequent complication in pregnancy worldwide and is associated with negative obstetric, fetal and long-term outcomes. Treatment is in theory straight-forward in the form of ferrous iron salts. However, compliance with treatment in pregnancy can be limited by tolerance as oral iron has been shown to significantly increase the risk of gastro-intestinal side-effects in pregnancy by a factor of 3. The first aim of this thesis was to compare current international guidelines with regards to the recommendations on management of iron deficiency anaemia in pregnancy. Diagnostic criteria, recommended screening, treatment and follow-up were all reviewed. There was significant variation in the recommendations regarding the use of prophylactic iron, screening, and dosing and dose frequency of elemental iron in pregnancy. Clear recommendations of appropriate follow-up, an appropriate haematological response and duration of therapy were not always specified and only two guidelines specified referral criteria for intravenous iron. There was a lack of robust evidence to guide management even in those guidelines that scored highly with systematically developed evidentiary base. The second aim of this thesis was to explore the problem of iron deficiency anaemia in pregnancy from both a clinician and a patient perspective. A survey was developed with multi-disciplinary input and distributed amongst staff in our tertiary academic centre. In summary the main findings were that 75% of staff surveyed recommend routine iron supplementation in pregnancy at varying gestations. There was wide variation in diagnostic haemoglobin thresholds, management options for anaemia not responding to treatment and variability in practice as regards frequency and dosing of oral iron. It demonstrated how management of this issue can be ad hoc among providers and highlights a need for a more stream-lined pathway of care. Qualitative interviews were performed with patients who had experience of iron deficiency anaemia in pregnancy. Thematic analysis showed recurring themes of awareness, compliance, the role of diet and pregnancy as a motivating factor. Significant unpleasant gastro-intestinal side-effects appeared to be experienced widely among interviewees and affected compliance. Knowledge and awareness of possible adverse consequences of iron deficiency anaemia in pregnancy were poor. Informing women on the important complications associated with iron deficiency has the potential to improve compliance with oral iron treatment. This topic was perceived as an important research area. The final part of this thesis describes the design, set-up and implementation of a randomised controlled trial of alternate day versus daily oral iron for the treatment of confirmed iron deficiency anaemia in pregnancy with ferrous fumarate. 184 participants are required to find a difference of -0.4g/dL in haemoglobin between the groups after 4 weeks of oral iron to determine that alternate day iron is non-inferior to daily iron for the treatment of anaemia in pregnancy. The baseline characteristics of the first 144 randomised patients were examined. In summary this thesis found that international guidance on this problem varies significantly and that high-quality robust evidentiary base to guide management is lacking. Variability in practice exists amongst providers. The effects of both anaemia and supplemental oral iron can have a negative effect on quality of life in pregnancy. Awareness surrounding short and long-term complications is lacking. IronMother is a randomised controlled trial of alternate day versus daily ferrous fumarate in pregnancy powered with a non-inferiority margin of 0.4g/dL. Analysis of the initial IronMother participants confirm that known risk factors are present in many women with confirmed iron deficiency anaemia in pregnancy and it is a condition that affects all socio-economic groups and ethnicities in pregnancy.