Treatment of Anaemia After Caesarean With Intravenous Versus Oral Iron and Postpartum Depression

PPD is a frequent (10-20% of delivery) and serious condition that has a detrimental impact on both maternal and child health by altering the quality of their interactions. Moreover, it is a significant risk factor for suicide, which is the leading cause of maternal death.

The increased risk of PPD in women with postpartum anemia has been documented. Women who delivered by cesarean are particularly vulnerable to this risk as this mode of delivery is a risk factor for both postpartum anaemia and postpartum depression. Therefore, correcting anemia and preventing PPD in this population represent a major public health priority.

First line treatment recommended for iron deficiency moderate anaemia (8.0g/dL≤ Hb ≤10.0g/dL) is oral iron. However oral iron is associated with very frequent adverse effects, contributing to poor tolerance and compliance of this treatment. Actually, IV iron is indicated in women with non-severe postpartum anaemia with lack of response or intolerance to oral iron treatment. There is growing interest in the use of intravenous iron and several randomized controlled trials demonstrated that IV iron is significantly more efficient than oral iron supplementation to correct moderate postpartum anaemia and increase haemoglobin level. However, none of them compared the efficacy of IV iron versus oral iron on postpartum depression as a primary outcome.

The hypothesis of the IRON-DEP Study is that, among women with moderate postpartum iron deficiency anaemia after caesarean delivery, the prevalence of PPD symptoms at 8 weeks after delivery is lower in women treated with IV iron than in those treated with oral iron.

The IRON-DEP trial is a phase IV national multicenter comparative randomized controlled superiority open-label trial with 2 parallel groups.

Implementation of the study :

* 24 french maternity units will be participating * Women who delivered by cesarean admitted in the postpartum maternity ward, with postpartum anaemia will be screened to check the inclusion and exclusion criteria. * The investigator will inform the eligible patient about the protocol and obtain the written consent * The randomization will take place during the hospitalization for caesarean delivery and will be stratified on the centre and on the initial severity of post-partum anemia (according to the postpartum hemoglobin level). * IV iron will be administered during hospitalization and participants in the oral iron group will start their treatment during their hospitalization for 8 weeks treatment. * A follow up visit at 8 weeks postpartum will be planned at the maternity unit for all participants * All participants will fill in self-assessment questionnaires (online or paper form) at inclusion, 8 weeks and 6 months postpartum follow up.

• The mean Haemoglobin (Hb) level [Time frame: 8 weeks postpartum]
• Change in postpartum Haemoglobin (Hb) level [Time frame: At Inclusion and at 8 weeks postpartum]
• The proportion of women with Haemoglobin level < 12.0 g/dL [Time frame: 8 weeks postpartum]
• The mean ferritinemia level [Time frame: At Inclusion and at 8 weeks postpartum]
• The mean change in ferritinemia level [Time frame: At Inclusion and at 8 weeks postpartum]
• The proportion of women with ferritinemia < 20 ng/mL [Time frame: 8 weeks postpartum]
• Mean EPDS score [Time frame: 8 weeks postpartum, 6 months postpartum]
• The proportions of participants with moderate depressive symptoms level defined by an EPDS ≥ 11 and <13 [Time frame: 8 weeks postpartum, 6 months postpartum]
• The proportions of participants with high depressive symptoms level defined by an EPDS ≥13 [Time frame: 8 weeks postpartum, 6 months postpartum]
• The mean change in EPDS score [Time frame: 8 weeks postpartum, 6 months postpartum]
• The need for red blood cell transfusion [Time frame: From discharge to 8 weeks postpartum]
• The mean fatigue score measured by the Multidimensional Fatigue Inventory score-20 (MFI-20) [Time frame: 8 weeks postpartum, 6 months postpartum]