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| CASE REPORT |
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| Year : 2021 | Volume
: 19
| Issue : 4 | Page : 284-286 |
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Iron sucrose induced near fatal anaphylaxis in a postnatal mother
Vijayan Sharmila1, Thirunavukkarasu Arun Babu2
1 Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India
2 Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India
| Date of Submission | 20-May-2021 |
| Date of Decision | 11-Jul-2021 |
| Date of Acceptance | 15-Jul-2021 |
| Date of Web Publication | 07-Dec-2021 |
Correspondence Address:
Dr. Thirunavukkarasu Arun Babu
All India Institute of Medical Sciences (AIIMS), Mangalagiri - 522 503, Andhra Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_57_21
Iron deficiency anemia in pregnancy can lead to significant adverse effects on the mother and fetus. Patients with iron deficiency anemia are treated with parenteral iron therapy when oral iron therapy is ineffective or in case of non-compliance due to side effects. Parenteral iron preparations such as iron dextran and sodium ferric gluconate complex can cause side effects including life-threatening anaphylactic reactions. However, parenteral iron sucrose has a favorable safety profile and anaphylactic reactions are extremely rare. We report a rare case of near-fatal anaphylaxis following intravenous iron sucrose therapy in a postnatal mother with iron deficiency anemia.
Keywords: Anaphylaxis, iron sucrose, postnatal mother
How to cite this article:
Sharmila V, Babu TA. Iron sucrose induced near fatal anaphylaxis in a postnatal mother. Curr Med Issues 2021;19:284-6 |
| Introduction | |  |
Iron deficiency anemia is the most common nutritional pathology during pregnancy and can have deleterious effects on the mother and fetus. The prevalence of iron deficiency anemia in pregnancy is estimated to be 35%–75% in developing countries.[1] Parenteral iron therapy is recommended in patients in whom oral iron therapy is ineffective due to intolerance, malabsorption, and noncompliance.[2] Parenteral iron therapy is associated with side effects such as nausea, vomiting, diarrhea, abdominal pain, hypotension, allergic, and anaphylactic reactions.[2] Iron sucrose, an intravenous parenteral iron preparation, has a favorable safety profile in comparison to other parenteral iron preparations such as iron dextran and sodium ferric gluconate complex and is currently widely used for the treatment of iron deficiency anemia during pregnancy.[3] Rare anaphylactic reactions with iron sucrose have been reported in 0.002% of cases.[4] Here, we report a rare case of near-fatal anaphylaxis to intravenous iron sucrose therapy in a woman during the immediate postnatal period.
| Case Report | | |
A 22-year-old G2P1L1 woman with infrequent antenatal visits presented to our obstetrics outpatient department for a routine antenatal checkup at 36 weeks of gestation. On examination, she had severe pallor, and her vitals were stable. Her fundal height corresponded to 36 weeks with a singleton live fetus in cephalic presentation. History revealed that the patient had not taken iron supplementation regularly during her antenatal period. She had no history of allergies or significant past medical illness. She had not received a blood transfusion or parenteral iron therapy in the past. Her hemoglobin was 7.5 g/dl, and peripheral smear report was suggestive of iron deficiency anemia. The patient was admitted, and parenteral iron therapy was initiated. She received the first infusion of intravenous iron sucrose injection 200 mg diluted in 100 ml normal saline on the day of admission. Her vitals were stable, and no adverse reactions were noted. She had spontaneous onset of labor on the same day and delivered a male baby weighing 3 kg with good Apgar score. Active management of the third stage of labor was done to prevent postpartum hemorrhage. She received the second dose of iron sucrose infusion on the first postnatal day. The patient complained of giddiness, difficulty in breathing, and rashes within few minutes of starting iron sucrose infusion. On examination, she was conscious (Glasgow coma scale 15/15), oriented but agitated. She was afebrile, pulse rate 130/min, respiratory rate 35/min, blood pressure 80/50 mmHg, and oxygen saturation was 90% at room air. On physical examination, she had rashes all over the body and marked pallor of mucous membranes. Chest examination revealed bilateral normal vesicular breath sounds. Other system examination was normal. This clinical scenario fulfilled the diagnostic criteria for anaphylaxis (NIAID/FAAN, 2005).[5] Iron sucrose infusion was immediately stopped, and she was treated with intravenous adrenaline, hydrocortisone, antihistaminic, and H2 receptor blockers. The patient was transferred to the intensive care unit (ICU) for monitoring. Her hemoglobin was 6.5 g/dL and her blood–gas analysis report was normal. Her urine analysis, serum electrolytes, renal, and liver function tests were normal. Following resuscitative measures, her condition improved. She received one packed cell transfusion under ICU monitoring. She was monitored for the next 48 h in ICU and later transferred to the ward. She was discharged on oral iron and is currently on follow-up.
| Discussion | | |
Iron deficiency anemia is common in pregnancy. The bioavailability of iron in the systemic circulation is ensured with intravenous iron therapy and hence results in more rapid resolution of iron deficiency anemia when compared to oral iron therapy.[1] Iron dextran, sodium ferric gluconate complex, and iron sucrose are the commonly used formulations for intravenous iron therapy. Iron dextran and sodium ferric gluconate are associated with a higher risk of anaphylaxis than iron sucrose.[2] Numerous reports show the efficacy and safety of the iron sucrose complex.[3],[4] The adverse events with iron dextran, sodium ferric gluconate, and iron sucrose are 29.2, 10.5, and 4.2 reports per million 100 mg dose equivalents, respectively, while documented fatality is 1.4, 0.6, and 0.0 reports per million 100 mg dose equivalents, respectively.[4] Good tolerance to iron sucrose is due to the low allergenic effect of the sucrose complex and slow release of elementary iron from the complex. Accumulation of iron sucrose in parenchyma of organs is low compared to other formulations, whereas incorporation into the bone marrow for erythropoiesis is considerably faster.[4] It is currently used as an alternative to other forms of parenteral iron therapy in the correction of iron deficiency anemia because of its favorable safety profile. The use of Naranjo probability scale indicated a probable relationship between the hypersensitivity reaction and iron sucrose as the causal drug.
Anaphylaxis is an acute severe Type I hypersensitivity reaction developing over minutes to hours with multisystem involvement due to the systemic effects of histamine release. Symptoms of anaphylaxis are generally sudden and severe in nature and include dyspnea, chest pain, angioedema, urticaria, and hypotension. The diagnosis is usually based on the clinical symptoms independent of pathomechanisms involved. The immunologic basis of allergic hypersensitivity to intravenous iron agents is not known. The systemic reaction observed in response to the first dose of intravenous iron preparations has not been found consistently to be IgE-mediated and is therefore described as anaphylactic or anaphylactoid reaction.[6] Iron dextran-induced toxicity is believed to be due to hypersensitivity related to the dextran moiety, since iron dextran is associated with a higher risk for anaphylaxis or anaphylactoid reactions than newer IV iron products.[7] Iron dextran had the highest reports of anaphylaxis, anaphylactoid reaction, urticaria, and upper airway angioedema, whereas iron sucrose carried the lowest risk for these hypersensitivity reactions. In our patient, an adverse drug reaction occurring few minutes after infusion of iron sucrose suggests a hypersensitivity reaction rather than immediate dose-related toxicity. Since serum IgE or tryptase levels were not obtained, we are not able to establish whether this reaction was an anaphylaxis or anaphylactoid reaction.
In conclusion, the clinicians should be aware of the possibility of potentially fatal anaphylaxis occurring with intravenous iron sucrose therapy. Hence, a rational use of this drug along with test dose before administration, close monitoring during infusion, and preparedness to manage this rare complication is recommended.
Consent
The authors have obtained signed informed consent from the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 4. | Perewesny G, Hugh R, Hugh A, Bremann C. Parenteral iron therapy in obstetrics: 8 years experience with iron-sucrose complex intravenous route versus oral route. Am J Obstet Gynecol 2002;186:518-22. |
| 5. | Sampson HA, Muñoz-Furlong A, Campbell RL, Adkinson NF Jr., Bock SA, Branum A, et al. Second symposium on the definition and management of anaphylaxis: Summary report – Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. Ann Emerg Med 2006;47:373-80. |
| 6. | Bailie GR, Clark JA, Lane CE, Lane PL. Hypersensitivity reactions and deaths associated with intravenous iron preparations. Nephrol Dial Transplant 2005;20:1443-9. |
| 7. | Mishra A, Dave N, Viradiya K. Fatal anaphylactic reaction to iron sucrose in pregnancy. Indian J Pharmacol 2013;45:93-4. [ PUBMED] [Full text] |
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