From the Literature


Published: Nov 2019

Hepcidin-guided screen-and-treat interventions against iron-deficiency anaemia in pregnancy: a randomised controlled trial in The Gambia.
Bah A, Muhammad AK, Wegmuller R, et al.
Lancet Glob Health 2019;7:e1564-e1574.
Pub Med
NATA rating :


M. Muñoz


The World Health Organization recommends that pregnant women should take supplements containing 30-60 mg elemental iron (depending on anaemia prevalence in the area) and 400 μg folic acid daily to prevent maternal anaemia, puerperal sepsis, low birthweight and preterm birth. This supplementation regimen was also recommended in recent NATA guidelines for the management of anaemia and haematinic deficiencies in pregnancy and in the post-partum period (Muñoz M et al., Tranfus Med 2018;28:22-39).

In this double-blind randomised controlled trial, the authors tested two hepcidin-guided screen-and-treat approaches (hepcidin was tested every week and women received 30 mg/day or 60 mg/day if hepcidin <2.5 µg/L, or no iron if hepcidin >2.5 µg/L, until the next hepcidin measurement) against the standard-of-care 60 mg per day regimen. All women received folic acid 400 µg/day during the study period (12 weeks). Hepcidin-guided iron supplementation offered no advantages over the standard WHO recommendations in terms of efficacy (haemoglobin, ferritin) and safety (gastrointestinal side effects, infections) but carried a considerable increment in health-care costs.

Oral iron-related side effects are frequently reported by pregnant women, which may lead to poor adherence and undermine antenatal iron supplementation programmes. The unusually high adherence (86%) observed in this study may reflect the influence of sensitization and fieldworker encouragement and the fact that participants were aware that adherence was being monitored. As expected, the prevalence of illnesses and side effects was lowest in the 30 mg screen-and-treat group. This lower daily dose iron supplementation has been recommended for low anaemia settings (WHO 2019). Alternate day iron supplementation (60 mg dose) may increase adherence (Stoffel NU et al., Lancet Haematol 2017;4:e524-e533), and is also supported by NATA guidelines (Muñoz M et al., Tranfus Med 2018;28:22-39).

The use of parenteral iron formulations which can deliver ≥1000 mg elemental iron in a single seating could be an alternative for iron supplementation in pregnancy (starting in the second trimester), but it will need evidence of cost-effectiveness and safety in low-income settings, together with development of infrastructure, to overcome barriers to implementation. In addition, the European Medicines Agency (2013) considered that, during pregnancy, allergic reactions are of particular concern as they can put both the mother and unborn child at risk, and therefore intravenous iron should not be used during pregnancy unless clearly necessary.

The available evidence suggests that efforts should be directed towards developing newer oral iron supplements with better side-effect profiles. In this regard, the efficacy, tolerability and safety of sucrosomial iron administration for preventing iron deficiency and anaemia in pregnancy (14 mg/day or 28 mg/day, from gestation week 12-14 until postpartum week 6) has been reported recently (Parisi F et al., J Matern Fetal Neonatal Med 2017;30:1787-1792).

– Manuel Muñoz