Bibliographic information
GuidelineConsolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage
Year of Publication2025
Issuing InstitutionWorld Health Organization
Recommendation
New
Intravenous iron therapy after postpartum haemorrhage. Intravenous iron therapy is recommended over oral iron therapy for women with iron-deficiency anaemia after birth when oral iron cannot be used or is not tolerated or there is a clinical need to treat women with severe iron-deficiency anaemia rapidly, provided staff are trained to evaluate and manage anaphylactic reactions.
Context specific recommendation
Only in specific contexts
Notes and Remarks
- Intravenous iron should only be used in women who are likely to be deficient in iron because of pre-existing iron deficiency or acute blood loss from PPH. Iron-deficiency anaemia is usually diagnosed by a low ferritin test. This test is sensitive to inflammation, which will be increased after birth. Therefore, it is not suitable to diagnose iron-deficiency anaemia in the postpartum period; clinicians will have to rely on the severity of PPH and, in case of women with pre-existing anaemia, on a peripheral blood smear demonstrating microcytic hypochromic anaemia typical of iron deficiency while other causes of anaemia are reasonably excluded. Alternatively, health workers may consider a treatment test where an improvement of anaemia is demonstrated after 2 weeks of oral iron treatment.
- Severe anaemia postpartum is defined as a haemoglobin of 80 g/L or less where women are likely to suffer severe or debilitating symptoms of acute anaemia. Intravenous iron in this context may reduce the need for blood transfusion for some women; however, blood transfusion should still be considered as a treatment option where clinically indicated.
- Intravenous iron preparations have been approved for treatment of iron-deficiency anaemia but not specifically in lactating women. Treatment should be confined to women for whom the benefit is judged to outweigh the potential risk for both mother and neonate. The decision to use intravenous iron therapy should be made with the woman’s informed consent, ensuring that she understands the benefits and potential risks. Health workers should clearly explain the rationale for choosing intravenous over oral iron, including how the woman’s symptoms, level of anaemia and ability to tolerate oral iron informed the decision to initiate intravenous iron therapy.
- Some intravenous preparations (e.g. iron dextran) appear to increase the risk of anaphylactic reactions more than others and should be avoided. The risk of anaphylaxis is estimated to be 9.8 per 10 000 for iron dextran, 1.2 per 10 000 for iron sucrose and 0.8 per 10 000 for ferric carboxymaltose. Monitoring for anaphylaxis should occur during the time it takes to infuse the medicine and 30 minutes after the infusion. The available studies mostly used intravenous iron sucrose or ferric carboxymaltose. Iron sucrose was usually given as several 200-mg infusions on alternating days until the calculated iron deficit was reached. Ferric carboxymaltose was usually given as a single infusion of 20 mg/kg body weight or up to a maximum of 1000 mg.
- To safely implement this recommendation, health facilities should ensure availability of resuscitation equipment and staff trained to recognize and manage hypersensitivity or anaphylactic reactions, including Fishbane reactions. A protocol for intravenous iron administration and monitoring should be in place.
- As intravenous iron use expands postpartum, national programmes should ensure that systems are in place to monitor for and report adverse events, especially rare outcomes like anaphylaxis, to support ongoing safety assessment.
- The GDG noted that the availability and cost of intravenous iron may vary across settings. Policy-makers should take steps to ensure equitable access where its use is clinically indicated, especially in facilities managing women with severe PPH or anaemia.