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VOLUME 16 , ISSUE S1 ( April, 2024 ) > List of Articles


Federation of Obstetric and Gynecological Societies of India Consensus Recommendations for the Management of Postpartum Anemia with Specific Reference to Usage of Ferric Carboxymaltose

S Shantha Kumari, Basab Mukherjee, Jai Bhagwan Sharma, Girija Wagh, Kavita Bapat, Reena Wani, Sneha Bhuyar, Vaishali Chavan, Aruna Suman, Chaitanya Ganpule, Deepa Mukundan

Keywords : Ferric carboxymaltose, Iron deficiency anemia, Postpartum anemia, Postpartum care

Citation Information :

DOI: 10.5005/jp-journals-10006-2373

License: CC BY-NC 4.0

Published Online: 06-03-2024

Copyright Statement:  Copyright © 2024; The Author(s).


Background: India has a substantially high burden of postpartum anemia (PPA). Several countries have guidelines regarding screening, diagnosis, and management of PPA. However, different modalities of treatment are followed in clinical practice, and consensus on management of PPA is lacking among the Indian practitioners. Aim: To review the current evidence and come to a consensus regarding definition, classification, appropriate time of screening and diagnosis, along with management of PPA, with specific reference to usage of ferric carboxymaltose (FCM). Methodology: The core committee comprised of 11 obstetricians. Using the modified Delphi method, eight statements were created, discussed, and ranked by the obstetricians and recommendations were recorded. Statements were ranked on a 9-point Likert's scale ranging from 1 (strongly disagree) to 9 (strongly agree). For each statement, the scores of all the obstetricians were summed and an average score of ≥7.00 was required to attain the consensus. Results: The cut-off hemoglobin (Hb) levels of above 11 gm/dL within 1-week postdelivery is termed as PPA. Postpartum anemia severity can be graded as mild, moderate, and severe with Hb levels of 10–10.9, 7–9.9, and below 7 gm/dL, respectively. All postpartum women (PPW) should be universally screened with Hb estimation and complete blood count (CBC) within 24–48 hours of delivery, prior to discharge, and repeat Hb estimation should be performed at 6 weeks postdelivery. Ferric carboxymaltose is superior to oral and other intravenous (IV) iron therapies and all PPW should be discharged with a single dose of FCM after an informed decision. Additionally, oral iron (OI) is not required during or following FCM administration, the decision to start oral therapy can be taken after 4 weeks of discharge, if required. Conclusion: Ferric carboxymaltose is a safe, effective, well-tolerated, and economical option for managing PPA and shall be practiced in all women with PPA before discharge.

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  1. Milman N. Postpartum anemia I: Definition, prevalence, causes, and consequences. Ann Hematol 2011;90(11):1247–1253. DOI: 10.1007/s00277-011-1279-z.
  2. Garrido CM, Leo'n J, Vidal AR. Maternal anaemia after delivery: Prevalence and risk factors. J Obstet Gynaecol 2018;38(1):55–59. DOI: 10.1080/01443615.2017.1328669.
  3. Ministry of Health and Family Welfare. National Iron+ Initiative: Guidelines for Control of Iron Deficiency Anaemia. Adolescent Division. Adolescent Division, Ministry of Health and Family Welfare, Government of India, New Delhi; 2013. Available at: Accessed on: 4 September 2022.
  4. Bhagwan D, Kumar A, Rao CR, et al. Prevalence of anaemia among postnatal mothers in coastal Karnataka. J Clin Diagnostic Res 2016;10(1):LC17–LC20. DOI: 10.7860/JCDR/2016/14534.7086.
  5. Iyengar K. Early postpartum maternal morbidity among rural women of Rajasthan, India: A community-based study. J Heal Popul Nutr 2012;30(2):213–225. DOI: 10.3329/jhpn.v30i2.11316.
  6. Selvaraj R, Ramakrishnan J, Sahu SK, et al. High prevalence of anemia among postnatal mothers in urban Puducherry: A community-based study. J Family Med Prim Care 2019;8(8):2703–2707. DOI: 10.4103/jfmpc.jfmpc_386_19.
  7. Siddiqui MZ, Goli S, Reja T, et al. Prevalence of anemia and its determinants among pregnant, lactating, and nonpregnant nonlactating women in India. SAGE Open 2017:7(3):1–10. DOI: 10.1177/21582440177255.
  8. Rubio–Alvarez A, Molina–Alarcon M, Hernandez–Martinez A. Incidence of postpartum anaemia and risk factors associated with vaginal birth. Women Birth 2018;31(3):158–165. DOI: 10.1016/j.wombi.2017.09.020.
  9. Petraro P, Duggan C, Urassa W, et al. Determinants of anemia in postpartum HIV-negative women in Dar es Salaam, Tanzania. Eur J Clin Nutr 2013;67(7):708–717. DOI: 10.1038/ejcn.2013.71.
  10. Wemakor A, Ziyaaba A, Yiripuo F. Risk factors of anaemia among postpartum women in Bolgatanga Municipality, Ghana. BMC Nutr 2022;8(1):58. DOI: 10.1186/s40795-022-00550-7.
  11. Kofie P, Tarkang EE, Manu E, et al. Prevalence and associated risk factors of anaemia among women attending antenatal and post-natal clinics at a public health facility in Ghana. BMC Nutr 2019;5:40. DOI: 10.1186/s40795-019-0303-x.
  12. Perez EM, Hendricks MK, Beard JL, et al. Mother-infant interactions and infant development are altered by maternal iron deficiency anemia. J Nutr 2005;135(4):850–855. DOI: 10.1093/jn/135.4.850.
  13. Bodnar LM, Scanlon KS, Freedman DS, et al. High prevalence of postpartum anemia among low-income women in the United States. Am J Obstet Gynecol 2001;185(2):438–443. DOI: 10.1067/mob.2001.115996.
  14. Milman N. Prepartum anaemia: Prevention and treatment. Ann Hematol 2008;87(12):949–959. DOI: 10.1007/s00277-008-0518-4.
  15. Chowdhury HA, Ahmed KR, Jebunessa F, et al. Factors associated with maternal anaemia among pregnant women in Dhaka city. BMC Womens Health 2015;17:77. DOI: 10.1186/s12905-015-0234-x.
  16. Galloway R, Dusch E, Elder L, et al. Women's perceptions of iron deficiency and anemia prevention and control in eight developing countries. Soc Sci Med 2002;55(4):529–544. DOI: 10.1016/s0277-9536(01)00185-x.
  17. Yip R, Parvanta I, Cogswell ME, et al. Recommendations to prevent and control iron deficiency in the United States. Morbidity and Mortality Weekly Report: Recommendations and Reports 1998;47(RR-3): i–29. Available at: Accessed on: 4 September 2022.
  18. Bodnar LM, Cogswell ME, McDonald T. Have we forgotten the significance of postpartum iron deficiency? Am J Obstet Gynecol 2005;193(1):36–44. DOI: 10.1016/j.ajog.2004.12.009.
  19. Ghadeer M, Alsahafi N, Shami B, et al. Incidence of postpartum anaemia among postpartum patients in East Jeddah Hospital. Int J Life Sci Pharma Res 2019;9(2):39–46. DOI: 10.22376/ijpbs/lpr.2019.9.2.P39-46.
  20. Barroso F, Allard S, Kahan BC, et al. Prevalence of maternal anaemia and its predictors: A multi-centre study. Eur J Obstet Gynecol Reprod Biol 2011;159(1):99–105. DOI: 10.1016/j.ejogrb.2011.07.041.
  21. Parker JA, Barroso F, Stanworth SJ, et al. Gaps in the evidence for prevention and treatment of maternal anaemia: A review of systematic reviews. BMC Pregnancy Childbirth 2012;12:56. DOI: 10.1186/1471-2393-12-56.
  22. Bodnar LM, Siega–Riz AM, Miller WC, et al. Who should be screened for postpartum anemia? An evaluation of current recommendations. Am J Epidemiol 2002;156(10):903–912. DOI: 10.1093/aje/kwf134.
  23. Yefet E, Suleiman A, Garmi G, et al. Evaluation of postpartum anaemia screening to improve anaemia diagnosis and patient care: A prospective non-randomized before-and-after anaemia screening protocol implementation study. Sci Rep 2019;9(1):7810. DOI: 10.1038/s41598-019-44334-9.
  24. Breymann C, Bian XM, Blanco–Capito LR, et al. Expert recommendations for the diagnosis and treatment of iron-deficiency anemia during pregnancy and the postpartum period in the Asia–Pacific region. J Perinat Med 2011;39(2):113–121. DOI: 10.1515/jpm.2010.132.
  25. Api O, Breyman C, Çetiner M, et al. Diagnosis and treatment of iron deficiency anemia during pregnancy and the postpartum period: Iron deficiency anemia working group consensus report. Turk J Obstet Gynecol 2015;12(3):173–181. DOI: 10.4274/tjod.01700.
  26. The Federation of Obstetric and Gynecological Societies of India. FOGSI general clinical practice recommendations management of iron deficiency anemia in pregnancy. 2017. Available at: Accessed on: 4 September 2022.
  27. Pavord S, Daru J, Prasannan N, et al. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol 2020;188(6):819–830. DOI: 10.1111/bjh.16221.
  28. World Health Organization. Guideline: Iron supplementation in postpartum women. 2016. Available at: Accessed on: 4 September 2022.
  29. Yoshida S. Approaches, tools and methods used for setting priorities in health research in the 21(st) century. J Glob Health 2016;6(1):010507. DOI: 10.7189/jogh.06.010507.
  30. Ruiz de Viñaspre–Hernández R, Gea–Caballero V, Juárez-Vela R, et al. The definition, screening, and treatment of postpartum anemia: A systematic review of guidelines. Birth 2021;48(1):14–25. DOI: 10.1111/birt.12519.
  31. Milman N. Postpartum anemia II: Prevention and treatment. Ann Hematol 2012;91(2):143–154. DOI: 10.1007/s00277-011-1381-2.
  32. Mremi A, Rwenyagila D, Mlay J. Prevalence of post-partum anemia and associated factors among women attending public primary health care facilities: An institutional based cross-sectional study. PLoS One 2022;17(2):e0263501. DOI: 10.1371/journal.pone.0263501.
  33. World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. 2011. Available at: Accessed on: 4 September 2022.
  34. Good clinical practice recommendations for iron deficiency anemia in pregnancy (IDA) in Pregnancy in India. J Obstet Gynaecol India 2011;61(5):569–571. DOI: 10.1007/s13224-011-0097-5.
  35. Muñoz M, Peña–Rosas JP, Robinson S, et al. Patient blood management in obstetrics: Management of anaemia and haematinic deficiencies in pregnancy and in the post-partum period: NATA consensus statement. Transfus Med 2018;28(1):22–39. DOI: 10.1111/tme.12443.
  36. Somdatta P, Reddaiah VP, Singh B. Prevalence of anaemia in the postpartum period: A study of a North Indian village. Trop Doct 2009;39(4):211–215. DOI: 10.1258/td.2009.080347.
  37. Danish Society of Obstetrics and Gynecology (DSOG). Anaemia and iron deficiency in pregnancy and postpartum. 2016. Available at: Accessed on: 5 September 2022.
  38. Khalafallah AA, Dennis AE. Iron deficiency anaemia in pregnancy and postpartum: Pathophysiology and effect of oral versus intravenous iron therapy. J Pregnancy 2012;2012:630519. DOI: 10.1155/2012/630519.
  39. Means RT. Iron deficiency and iron deficiency anemia: Implications and impact in pregnancy, fetal development, and early childhood parameters. Nutrients 2020;12(2):447. DOI: 10.3390/nu12020447.
  40. Pavord S, Myers B, Robinson S, et al. UK guidelines on the management of iron deficiency in pregnancy. British J Haematol 2012;156(5):588–600. DOI: 10.1111/j.1365-2141.2011.09012.x.
  41. Sultan P, Bampoe S, Shah R, et al. Oral vs intravenous iron therapy for postpartum anemia: A systematic review and meta-analysis. Am J Obstet Gynecol 2019;221(1):19.e3–29.e3. DOI: 10.1016/j.ajog.2018.12.016.
  42. Van Wyck DB, Martens MG, Seid MH, et al. Intravenous ferric carboxymaltose compared with oral iron in the treatment of postpartum anemia: A randomized controlled trial. Obstet Gynecol 2007;110(2):267–278. DOI: 10.1097/01.AOG.0000275286.03283.18.
  43. Seid MH, Derman RJ, Baker JB, et al. Ferric carboxymaltose injection in the treatment of postpartum iron deficiency anemia: A randomized controlled clinical trial. Am J Obstet Gynecol 2008;199(4):435.e1–435.e7. DOI: 10.1016/j.ajog.2008.07.046.
  44. Breymann C, Gliga F, Bejenariu C, et al. Comparative efficacy and safety of intravenous ferric carboxymaltose in the treatment of postpartum iron deficiency anemia. Int J Gynecol Obstet 2008;101(1):67–73. DOI: 10.1016/j.ijgo.2007.
  45. Pfenniger A, Schuller C, Christoph P, et al. Safety and efficacy of high-dose intravenous iron carboxymaltose vs. iron sucrose for treatment of postpartum anemia. J Perinat Med 2012;40(4):397–402. DOI: 10.1515/jpm-2011-0239.
  46. Becuzzi N, Zimmermann R, Krafft A. Long-term efficacy of postpartum intravenous iron therapy. Biomed Res Int 2014;2014:815437. DOI: 10.1155/2014/815437.
  47. Rathod S, Samal SK, Mahapatra PC, et al. Ferric carboxymaltose: A revolution in the treatment of postpartum anemia in Indian women. Int J App Basic Med Res 2015;5(1):25–30. DOI: 10.4103/2229-516X.149230.
  48. Damineni SC, Thunga S. IV ferric carboxymaltose vs oral iron in the treatment of post-partum iron deficiency anaemia. J Clin Diagn Res 2016;10(11):QC08–QC10. DOI: 10.7860/JCDR/2016/19375.8937.
  49. Mishra V, Roy P, Gandhi K, et al. Safety and efficacy of intravenous ferric carboxy maltose in iron deficiency anaemia during postpartum period. J Nepal Health Res Counc 2017;15(3):208–211. DOI: 10.3126/jnhrc.v15i3.18841.
  50. Sharma N, Thiek JL, Natung T. Comparative study of efficacy and safety of ferric carboxymaltose versus iron sucrose in post-partum anaemia. J Obstet Gynecol India 2017;67(4):253–257. DOI: 10.1007/s13224-017-0971-x.
  51. Anemia Mukt Bharat. Anemia management protocol for pregnant women. Available at: Accessed on: 7 September 2022.
  52. Toblli JE, Angerosa M. Optimizing iron delivery in the management of anemia: Patient considerations and the role of ferric carboxymaltose. Drug Des Devel Ther 2014;8:2475–2491. DOI: 10.2147/DDDT.S55499.
  53. Al-Shaghana M, Brooke E, Sinha A, et al. Efficacy and cost effectiveness of ferric carboxymaltose (Ferinject) in the treatment of pregnant women with iron deficiency anaemia. Eur J Obstet Gynecol Reprod Biol 2016;206:e6. DOI: 10.1016/j.ejogrb.2016.07.046.
  54. US Food and Drug Administration. Injectafer® prescribing information. Available at: Accessed on: 7 September 2022.
  55. UK Electronic Medicines Compendium. Ferinject SmPC. Available at: Accessed on: 7 September 2022.
  56. Di Renzo GC, Gratacos E, Kurtser M, et al. Good clinical practice advice: Iron deficiency anemia in pregnancy. Int J Gynecol Obstet 2019;144(3):322–324. DOI: 10.1002/ijgo.12740.
  57. Tsai PJ, Nakashima L, Yamamoto J, et al. Postpartum follow-up rates before and after the postpartum follow-up initiative at Queen Emma Clinic. Hawaii Med J 2011;70(3):56–59. PMID: 21365543.
  58. World Health Organization. Maternal, newborn, child and adolescent health. 2013. Available at: Accessed on: 7 September 2022.
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