Comparing IV-Iron and RBC transfusion for postpartum anemia treatment


A systematic review highlights the need for more research on the efficacy of intravenous iron versus red blood cell transfusion for treating severe postpartum anemia.

Comparing IV-Iron and RBC transfusion for postpartum anemia treatment | Image Credit: © vchalup - © vchalup -

Comparing IV-Iron and RBC transfusion for postpartum anemia treatment | Image Credit: © vchalup - © vchalup -

Data about intravenous iron (IV-iron) vs red blood cell transfusion (RBC-T) for treating severe postpartum anemia (PPA) remains limited, according to a recent review published in Systematic Reviews.1


  1. The review highlights limited data on the effectiveness of intravenous iron (IV-iron) compared to red blood cell transfusion (RBC-T) for severe postpartum anemia (PPA), suggesting a need for further studies.
  2. PPA affects 22% to 50% of women in developed countries and is linked to increased maternal morbidity, with symptoms such as fatigue, altered cognition, and depressive symptoms.
  3. The primary outcome measured was fatigue, while secondary outcomes included hemoglobin (Hb) and ferritin levels, adverse effects, breastfeeding rates, and psychological well-being.
  4. IV-iron was associated with significantly higher Hb and ferritin levels compared to oral iron and had fewer adverse effects. It was also linked to higher depression outcomes compared to oral iron but not to RBC-T.
  5. The results indicated high variability in treatment outcomes, emphasizing the necessity for more research, particularly on the efficacy of RBC-T for treating PPA.

PPA, defined by low hemoglobin (Hb) after childbirth, has been linked to increased maternal morbidity and mortality. Approximately 22% to 50% of women in developed countries experience PPA, and adverse effects are often aggravated because of a longer recovery period from iron deficiency following pregnancy.2

Symptoms of PPA include fatigue, altered cognition, and depressive symptoms.1 Treatment is necessary to facilitate resumption of everyday activities after birth.

Oral iron, IV-iron, and RBC-T are the most common treatment methods for PPA. IV-iron is currently recommended over RBC-T for hemodynamically stable postpartum women, but recent trials evaluating RBC-T for PPA interventions have not been included in systematic reviews.

To compare IV-iron vs RBC-T for PPA treatment, investigators conducted a systematic review and meta-analysis. Completed randomized or cluster-randomized trials evaluating IV-iron or RBC-T in women with PPA were included in the analysis.1

Databases assessed for eligible studies included EMBASE, MEDLINE, Scopus, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and ClinicalTrials. gov. Searches occurred until September 26, 2022.

Eligibility assessment was performed by 2 independent reviewers, with disagreements resolved by consensus or a third reviewer. Data extraction was performed using a Microsoft Excel data extraction tool by one reviewer and independently by a second reviewer from the investigation team.1

Relevant data included location and year of study, duration of study, bias assessment, inclusion and exclusion criteria, methodology, number of participants and dropouts, demographic data, iron formulations, fatigue scored, Hb and ferritin concentrations, anemia symptoms, breastfeeding rates, adverse drug effects, depression scores, and other quality-of-life outcomes.

Fatigue was reported as the primary outcome of the analysis and was determined by any dichotomous patient reporting. Secondary outcomes included Hb, ferritin, adverse effects, breastfeeding, anemia symptoms, psychological well-being, and other quality-of-life measures.

There were 20 studies included in the final analysis, including 4196 women. Fifteen of the studies reported postpartum Hb concentration as the primary outcome. Baseline Hb ranged from 7 g/dL or less to 10.1 g/dL or more.1

Half of the studies with IV-iron intervention had IV ferric sucrose as the formation, vs IV ferric carboxymaltose in 7 and IV-iron isomaltoside in 2. Fixed IV-iron doses were reported in 5 studies, 400 mg IV-iron sucrose in 5, 600 mg IV-iron sucrose in 1, 1000 mg in 1, 1200 mg of IV-iron Isomaltoside in 1, and 1500 mg of IV-iron Isomaltoside in 1.

For oral iron, 13 studies assessed ferrous sulfate, 2 assessed ferrous ascorbate, and 1 assessed ferrous fumarate.RBC-T was assessed in 3 trials, with 1 determining RBC-T units by baseline Hb, the second randomizing women to receive a single or multiple units, and a third providing at least 1 unit to participants in the treatment arm.

When comparing fatigue between IV-iron and RBC-T, a significantly higher mean fatigue score based on the Multidimensional Fatigue Inventory was reported in women without intervention, with a mean difference (MD) of 1.06 at week 1. However, physical fatigue scores at week 12 did not significantly differ between IV-iron and RBC-T at week 12, with an MD of -0.63.1

There were also no differences in median general fatigue scores at weeks 4 through 9 between interventions in the trial comparing single and multiple units of RBC-T. Additionally, fatigue scores were similar between IV-iron and oral-iron at 14 and 42 days.

For secondary outcomes, IV-iron was associated with significantly higher Hb and overall higher ferritin concentration. When compared to oral iron, IV-iron had a significantly decreased prevalence of adverse effects. Breastfeeding outcomes did not differ between treatment modalities.1

While IV-iron led to significantly increased depression outcomes compared to oral iron, differences were not observed between IV-iron and RBC-T. Most other quality of life outcomes did not differ based on treatment, but physical function was significantly improved by RBC-T vs no intervention.

These results indicated high heterogeneity between treatment outcomes for PPA. However, evidence on RBC-T remains limited, indicating a need for future research based on the review.1


  1. Calije E, Groom KM, Dixon L, et al. Intravenous iron versus blood transfusion for postpartum anemia: a systematic review and meta-analysis. Systematic Reviews. 2024;13(9). doi:10.1186/s13643-023-02400-4
  2. Krewosn C. The impact of postpartum anemia and effective management strategies. Contemporary OB/GYN. June 3, 2024. Accessed July 8, 2024.
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