Iron supplements and erythropoiesis-stimulating agents in intensive care of postpartum hemorrhage: a Bayesian network meta-analysis

Introduction. The incidence of postpartum anemia ranges from 20 to 40%. Data on the use of erythropoietin for the treatment of postpartum anemia are limited. Objective. To quantify and rank the relative efficacy of different combinations of iron preparations and erythropoiesis-stimulating drugs in intensive care of postpartum hemorrhage. Material and methods. Biomedical databases were searched for studies investigating the efficacy of intravenous and/or oral iron preparations in combination with or without erythropoietin for the treatment of postpartum anemia. The comparison strategy is ferrotherapy with ferrous sulfate (SulfatFe). Primary endpoints: hemoglobin increment between baseline and after 5 and 14 days of treatment. Secondary endpoints: hematocrit, reticulocyte, blood ferritin, and transferrin saturation values at the same time points. Design: systematic review, Bayesian random-effects network meta-analysis, augmented by a frequentist approach and network meta-regression. Results. The network meta-analysis included 6 studies, 279 patients. Compared with SulfatFe, the EPO_SulfatFe combination provided a significant increase in hemoglobin concentration at day 5: MD=9.01 g/L, 95% CrI (0.25; 18.90); evidence was insufficient for the other interventions. According to the values of area under the SUCRA cumulative ranking curve: best method EPO_SulfatFe (84.6%), followed by EPO_SucrosFe_SulfatFe (58.8%), SucrosFe_SulfatFe (54.3%), worst: Placebo_SucrosFe_SulfatFe (28.5%), SulfatFe (23.7%). On the 14th day, the EPO_SulfatFe combination showed the maximum increase in hemoglobin concentration: MD=10.00 g/L, 95% CrI (0.56; 19.70), ranked in the same order. The results of network meta-regression in this endpoint for total SulfatFe dose by day 14 of therapy are consistent with the estimates of the main meta-analysis. Conclusions. The network meta-analysis demonstrated the feasibility of including erythropoiesis-stimulating drugs in the intensive care setting for postpartum hemorrhage. Further studies with sufficient sample sizes are needed, including high-dose iron preparations in combination with EPO.