Extragenital diseases �in pregnancy

Medvediev M.V., MD, PhD

Department of Obstetrics and gynecology

Dnepropetrovsk medical academy

Cardiac Diseases in Pregnancy

Circulatory System

Cardiovascular Changes

• Blood volume
• Cardiac (heart) output
• Stroke volume
• End diastolic volume
• Resting pulse
• % of blood plasma
• Blood supply to uterus

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• Hematocrit
• Blood pressure
• Cardiac reserve
• Vascular resistance

DECREASE ↓

INCREASE ↑

Cardiovascular Physiology of Pregnancy

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• Normal pregnancy is associated with an increase of 30 to 50 percent in blood volume
• Blood volume increases, starting at the sixth week and rising rapidly until mid pregnancy; the levels peak by 20 to 24 weeks of pregnancy and then are either sustained until term or decrease An estrogen-mediated stimulation of the renin-angiotensin system results in sodium and water retention appears to be the mechanism underlying the blood volume increase.

Cardiovascular Physiology of Pregnancy

• Increase in cardiac output is most significant change during pregnancy.
• It begins to rise in first trimester and steadily rises to peak at 32 weeks by 30 to 50%.
• Cardiac output is normally 4.2 L/min., is 6.5 L/min. at 8-10 weeks of pregnancy and remains so till near term.
• Increase in cardiac output is achieved by rise in stroke volume (in early pregnancy) and Heart Rate (in latter part of pregnancy) adjusting together

• Due to rise in endogenous circulating catecholamine, there is positive inotropic and chronotropic myocardial response.

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• Later in pregnancy, the rise is related to an acceleration of heart rate (25%), since stroke volume decreases as a result of vena caval compression.

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Cardiovascular Physiology of Pregnancy

• Blood Pressure remains almost to prepregnant levels except tendency to fall during pregnancy (particularly during midtrimester) as the systemic vascular/peripheral resistance falls

(due to large arteriovenous shunts at placental bed and physiologic vasodilation secondary to endothelial prostacyclin and circulating progesterone)

• Colloid oncotic pressure is another important variable
• Both plasma and interstitial colloid oncotic pressure decrease throughout pregnancy
• There is accompanying increase in capillary hydrostatic pressure
• An increase in hydrostatic pressure or decrease in colloid oncotic pressure may overcome the delicate balance that favors oedema formation

Colloid oncotic pressure

• After delivery, decrease in plasma colloid oncotic pressure takes place reaching a peak between 6 to 16 hours and returns towards intrapartum level after 24 hours.
• These changes can lead to dependant oedema complicating diagnosis of cardiac decompensation.

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�The incidence and changing pattern of heart disease

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• It ranges from 0.1% to 4%.
• Hospital statistics - industrialized countries have shown a decrease in the incidence from 0.9% to 0.3%

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Incidence of heart disease………

Sharp decline in the incidence of chronic rheumatic heart disorders.

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Advances in the medical and surgical treatment of patients with congenital heart defects has resulted in an increased survival to reproductive age.

Maternal mortality from heart disease

• Statistics have demonstrated a decline in maternal mortality from cardiac disease since 1950 from 5.6 to 0.3 per 100 000 births.
• B’s of improved medical care of the pregnant cardiac patient and a sharp decrease in the incidence of rheumatic heart disease.

Maternal mortality from heart disease

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Cardiac diseases is also the leading cause of indirect maternal death. Of the cardiac deaths reported to the Confidential enquiry between 2000-2002, 40% were noted to have substandard care.

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Deans CL, Uebing A, Steer PJ. Cardiac disease in pregnancy. In Progress in Obstetrics and Gynaecology, Vol 17, Edi Studd J, Tan S L, Chervenak FA.Churchill Livingstone 2007, 164-182.

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Simulating cardiac disease

Owing to these normal changes, many healthy pregnant women have symptoms mimicking those of cardiac disease, Including:

fatigue, dyspnea, and light-headedness, & number of “abnormal” findings on physical examination, electrocardiography, and echocardiography

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Management areas

Areas be considered in the clinical approach to the woman with heart disease who is pregnant or considering pregnancy:

1. Risk stratification, Pre-conceptional
2. Antepartum management,
3. Peripartum management,
4. Recurrence of congenital lesion in the neonate,
5. Site of antepartum and peripartum care.

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Pre-conceptional counselling

• This is an important aspect of management or the cardiac patient planning a pregnancy.
• Ideally, the obstetrician and cardiologist should work together to help the patient make an informed decision.
• Prevent an unwanted pregnancy and avoid the risks associated with pregnancy continuation or termination.

Risk assessment

• Poor functional status
• Left ventricular systolic dysfunction (ejection

fraction < 0.40)

• Left heart obstruction (mitral valve area

<2.0 cm², aortic valve area < 1.5 cm², or

peak left ventricular outflow tract gradient

> 30 mm Hg)

• Pulmonary hypertension

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Risk assessment

A cardiac event (arrhythmia, stroke, transient ischemic attack, or pulmonary edema) before pregnancy but since a prior cardiac surgical procedure.

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Risk assessment

Siu developed a risk index incorporating these factors.

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In a woman with heart disease and no other risk factors, the likelihood of a cardiac event during pregnancy is about 5%, increasing to 25% with one risk factor & 75% with more than one risk factor.

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Siu SC, Sermer M, Colman JM, et al. Prospective multicenter

study of pregnancy outcomes in women with heart disease.

Circulation 2001; 104:515–521.

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Maternal mortality risk and cardiac disease

Group Cardiac disease Associated mortality risk

I Atrial septal defect* <1%

Ventricular septal defect*

Patent ductus arteriosus*

Pulmonary/tricuspid valve disease

Corrected tetralogy of Fallot

Bioprosthetic valve

Mitral stenosis, NYHA Class I, II

II Coarctation of aorta without valvular involvement 5% - 15%

Uncorrected tetralogy of Fallot

Marfan’s syndrome with normal aorta

Mechanical prosthetic valve

Mitral stenosis with atrial fibrillation or NYHA Class III, IV

Aortic stenosis

Previous myocardial infarction

III Pulmonary hypertension—primary or secondary 25% - 50%

Coarctation of aorta with valvular involvement

Marfan’s syndrome with aortic involvement

Peripartum cardiomyopathy

*Uncomplicated

• A careful history is obtained to identify previous cardiac complications.
• The patients functional status as per The New York Heart Association(NYHA) is defined

Table 3.NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION OF CARDIAC DISEASE

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CLASS I No functional limitation of activity.

No symptoms of cardiac decompensation with activity.

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CLASS II Mild amount of functional limitation.

Patients are asymptomatic at rest. Ordinary physical activity results in symptoms.

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CLASS III Limitation of most physical activity.

Asymptomatic at rest

Minimal physical activity results in symptoms.

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CLASS IV Severe limitation of physical activity results in symptoms.

Patients may be symptomatic at rest/heart failure

at any point of pregnancy.

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CLASS V If patient is on ionotropic support, ventilator, Assisted circulation or having comprised renal or pulmonary function necessitating dialysis/EMCO to

maintain vital signs.

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The criteria committee of the New York Heart Association, Nomenclature and criteria for diagnosis of diseases of heart and great vessels, Edi 8, New York Association,1979.

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Antepartum Care

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• The chief aim of management of the patient in pregnancy is to keep patient within her cardiac reserve.
• It is preferable to have detailed baseline information prior pregnancy.

Antepartum care

• Limiting activity is helpful in severely

affected women with ventricular dysfunction,

• left heart obstruction, or class III or IV symptoms.
• Hospital admission by mid-second

trimester may be advisable for some.

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Antepartum care

• Problems should be identified early and treated aggressively, especially pregnancy induced hypertension, hyperthyroidism, infection, and anemia.

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Antepartum care

Beta-blockers rather than digoxin should be used to control heart rate for patients with functionally significant mitral stenosis.

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Empiric therapy with beta-blockers is offered

to patients with coarctation, Marfan syndrome,

and ascending aortopathy for other reasons (eg, a bicuspid aortic valve).

Arrhythmias should be treated if warranted

Premature atrial or ventricular beats are common in normal pregnancy, and in patients with preexisting arrhythmias,

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Pregnancy may exacerbate their frequency and hemodynamic severity.

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These usually are not treated.

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Antepartum care

Sustained tachyarrhythmias, such as

atrial flutter or atrial fibrillation, should be

treated promptly.

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If possible, all antiarrhythmic drugs should

be avoided during the first trimester, and those

known to be teratogenic should be avoided

throughout pregnancy.

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Because of their safety profiles, preferred drugs include digoxin, beta-blockers and adenosine.

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Cardiovascular diseases in pregnant females. Atrial septal defect

Cardiovascular diseases in pregnant females. Ventricular septal defect

Cardiovascular diseases in pregnant females. �Mitral stenosis

Cardiovascular diseases in pregnant females. �Mitral regurgitation

Aortic stenosis

Antepartum care

• Anticoagulation therapy. No current

strategy is equally safe for both mother and fetus.

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Anticoagulation therapy

Oral therapy with warfarin is effective and

logistically easy.

However, it can affect embryonic organ development, although some evidence shows that a dosage of 5 mg per day may not be teratogenic.

Fetal intracranial bleeding is a risk throughout pregnancy, particularly during vaginal delivery, unless warfarin is stopped before labor.

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Anticoagulation therapy

* Heparin in adjusted subcutaneous doses

does not cross the placenta and so has no teratogenic effects.

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However, it may cause maternal thrombocytopenia and osteoporosis and is less effective in preventing thrombosis in patients with prosthetic valves.

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Anticoagulation therapy

More recent guidelines recommend either

(1) adjusted-dose heparin during the entire pregnancy or

(2) adjusted-dose heparin until the 13th week of gestation,

warfarin from the 14th week to the middle of the third

trimester, and then restart adjusted-dose heparin.

* Low-molecular-weight heparin in adjusted

doses is easier to administer and has been

suggested as an alternative to adjusted-dose

unfractionated heparin.

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Bates SM, Greer IA, Hirsh J, Ginsberg JS. Use of antithrombotic agents during pregnancy. Chest 2004; 126:627S–644S.

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Anticoagulation therapy

At week 36 #

*Discontinue warfarin

*Change to UFH titrated to a therapeutic aPTT or anti-factor Xa level.

At Delivery:

*Restart heparin therapy 4 to 6 hr after delivery if no contraindications

*Resume warfarin therapy the night after delivery if no bleeding complications

#if labor begins while the woman is receiving warfarin, anticoagulation should be reversed and caesarean delivery performed

Ginsberg JS, Greer I, Hirsh J. Use of antithrombotic agents during pregnancy. Chest 2001;119:Suppl:122S-131S

Anticoagulation therapy

Monitoring

• With LMWH administered sc. twice daily maintain anti-Xa level between 0.7 and

1.2 U/ml 4 hours after admn.

• With dose adjusted UFH, the aPTT should be at least twice control.
• those on warfarin, the INR goal should be 3.0(range 2.5 to 3.5)

Chan WS, Anand S, Ginsberg JS. Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature. Arch Intern Med 2000;160:191-196

Peripartum management

• Cesarean section is indicated only for the

following conditions:

• Aortic dissection
• Marfan syndrome with dilated aortic root
• Taking warfarin within 2 weeks of labor.

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Peripartum care

Preterm induction is uncommon.

However, once fetal lung maturity is assured, a planned induction and delivery may be warranted for high-risk patients to ensure that appropriate staff and equipment are available.

Peripartum care

Antibiotic prophylaxis for endocarditis is

not routine. AHA guidelines do not recommend routine endocarditis prophylaxis for cesarean section delivery or for uncomplicated vaginal delivery without infection.37

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However, some centers do administer

endocarditis prophylaxis for vaginal delivery

in women with structural heart disease, as an

uncomplicated delivery cannot always be

anticipated.

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Peripartum care

Positioning the patient on her left side

lessens the hemodynamic fluctuations associated with contractions when the patient is supine.

Peripartum care

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• Forceps or vacuum extraction should be

considered at the end of the second stage of labor to shorten and ease delivery.

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Peripartum care

• Postpartum monitoring

�Because hemodynamics do not return to baseline for many days after delivery, patients at intermediate or high risk may require monitoring for at least 72 hours postpartum.

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Peripartum care

• Lactation should be encouraged unless patient is in failure.
• Cardiac output is not compromised during lactation.
• Lactation is a pathway for fluid excretion and diuretic requirement may actually fall.

Contraception

• Barrier methods – unreliable.
• COC contraindicated.
• Progesterone only pill have better side effect profile & long acting slow releasing as Mirena intrauterine system have improved efficacy.
• Sterilization where family completed. (Laparoscopic clip sterilization carries risk).

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Deans CL, Uebing A, Steer PJ. Cardiac disease in pregnancy. In Progress in Obstetrics and Gynaecology, Vol 17, Edi Studd J, Tan S L, Chervenak FA.Churchill Livingstone 2007, 164-182.

Conclusion

Pregnancy causes significant haemodynamic changes and imposes an additional burden on the cardiac patient, especially around the time of labour and in the immediate puerperium.

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To achieve a successful pregnancy outcome, a clear understanding of these haemodynamic adaptations as well as meticulous maternal and foetal surveillance for risk factors and complications throughout the pregnancy is essential.

Conclusion

Appropriate contraceptive and family planning advice as well as pre-conceptional counselling are also important.

The concerted efforts of a team consisting of the

obstetrician, cardiologist, anaesthetist, cardiothoracic surgeon, neonatologist, and paediatric cardiologist are mandatory to ensure optimal results.

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DIABETES MELLITUS IN PREGNANCY

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Effects of pregnancy on diabetes and of diabetes on pregnancy are complex and profound. The severity of diabetes will greatly influence perinatal outcome. The incidence of diabetes in pregnancy is about 10%. Diabetes in pregnant women is generally categorized as either gestational or pregestational diabetes. Gestational diabetes firstly appears after 28 weeks of pregnancy and means transient impairment of glucose utilization during pregnancy.

Varieties of diabetic trait during pregnancy:

1. Potential. Potential diabetic is one with normal glucose tolerance test but who has got: positive family history diabetes or previous birth of an overweight baby.

2. Latent. The individual has got normal glucose tolerance in non-pregnant condition. But in conditions of stress there is impairment of glucose tolerance which becomes normal when the stress is removed.

3. Subclinical. There is a persistent abnormal glucose tolerance test even without stress. Symptoms of diabetes have not appeared yet.

4. Prediabetic condition. The features of the state are history of previous delivery of overweight baby (more than 4 kg), unexplained perinatal death with hypertrophy of the pancreas on autopsy and diabetes in the family.

5. Overt or clinical diabetes. A patient with abnormal glucose tolerance test with or without symptoms and a raised fasting blood - glucose level is called overt diabetes. The condition may be pre-existing or detected for the first time during present pregnancy.

CLASSIFICATION OF DIABETES

�A. Clinical forms of diabetes.

• Insulin-dependent diabetes (diabetes of the 1st type).
• Insulin-independent diabetes (diabetes of the 2nd type).
• Other forms of diabetes (secondary diabetes due to other endocrine diseases, etc.).
• Gestational diabetes.

B. The degrees of diabetes.

• Mild degree (1st degree).
• Moderate degree (2nd degree)
• Severe degree (3d degree).

C. Dependence on compensation.

• Compensated diabetes.
• Subcompensated diabetes.
• Decompensated diabetes.

Diabetes mellitus. Risk factors of the development gestational diabetes mellitus

• Obesity (more than 90 kg or more than 15% mass of body before pregnancy)
• Burdened family anamnesis, age is more than 30 years
• Antenatal loss of the newborn
• Preeclampsia, chronic hypertension
• Developmental defects
• Preterm birth
• Delivery of large fetus (more than 4 kg)
• Polyhydramnion
• Glucosuria, symptoms of diabetes with the previous pregnancy
• Traumatic delivers with neurologic disorders in child
• Recurrent candidosis, repeated infection of the urinary tracts.

Diabetes mellitus.

Pregnant females with the factors of risk must thoroughly be inspected within the early periods, with the normal test of tolerance to the glucose it must be repeated in 30 weeks. Diabetic type of sugar curved for the pregnant females according to the data WHO (World Health Organization) on an empty stomach - 7 mmole/l, in the hour (100 g of glucose) - 11,1 mmole/l, after 2 hours - 7,8 mmole/l and glucosuria.

With conducting of pregnancy and childbirths should be considered the following moments: diabetes compensation, the maximum compensation for metabolic disturbances, timely diagnostics and the therapy of microcirculatory disturbances, fetal monitoring, the preventive maintenance of septic diseases, the selection of optimum period and method of delivery, postpartum rehabilitation.

Diabetes mellitus. Contraindications to the pregnancy

• presence of the progressive vascular complications
• presence of severe forms of diabetes mellitus
• presence of diabetes in husband
• combination of diabetes and rhesus- conflict
• combination of diabetes and active pulmonary tuberculosis

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Diabetes mellitus

Hospitalization is achieved with the first rotation or within the periods of the establishment of the gestational diabetes (correction of the dose of insulin, the study of the state of kidneys, sight, heart, resolution of a question about the prolongation of pregnancy); 20-24 weeks (refinement of state FPS, the exception of the anomalies of the development of fetus, diagnostics of preeclampsia); 32-34 weeks (preparation for the labor, the selection of their technology)

The need for insulin is reduced to 30% in first half of pregnancy, from 16-20 weeks grows by 50-100% (making more active of the function of the placenta, the adrenal glands and hypophysis), tendency toward ketoacidosis and hyperglycemic states, 38-40 weeks - again are reduced the need for insulin, after delivery - sharply it is lowered, reaching original values to 5-7 days.

Diabetes mellitus

The period of labor is determined taking into account gravity of the course of basic disease, the degree of its compensation, by the state of fetus, by the presence of obstetrical complications. Optimum natural lobour with the monitoring of the content of glucose every 2-3 hours and by adequate insulin therapy by the preparations of quick action. Planned cesarean section is produced taking into account additional obstetrical indications.

Gestational Diabetes Mellitus

Gestational diabetes mellitus is diagnosed on the basis of 2 or more abnormal values on a 3-hour glucose tolerance test. Gestational diabetes is common, occurring in up to 5% of pregnancies. The main risk factor of gestational diabetes in pregnancy is fetal macrosomia with potential injury to fetus and mother at the time of delivery. Women with gestational diabetes have a high risk (up to 50%) of developing overt diabetes later in life.

Gestational Diabetes Mellitus

Management of gestational diabetes is usually achieved with diet alone, but some women require insulin therapy. Professional nutritional guidance is recommended to maintain normoglycemia. Women whose blood glucose levels are consistently high despite diet therapy require insulin treatment. Unfortunately, many of these women are obese and insulin resistant, and normoglycemia may he difficult to achieve. Diagnosis and initiation of therapy before 30 weeks gestation is necessary to avoid the hard of macrosomia.

Insulin-Dependent Diabetes Mellitus

Obstetric complications seen in diabetic women are multiple. A high rate of spontaneous abortion and fetal anomalies (cardiac, neurological, and renal abnormalities and caudal regression syndrome) occur in diabetics with poor glucose control .

The risk of hydramnios in the diabetic patient is double that of the nondiabetic patient, as is the risk of preterm labor. Women with diabetes are twice as likely to develop pregnancy-induced hypertension.

As in gestalional diabetes, the woman with insulin-dependent diabetes mellitus and no vascular disease carries a fetus at risk to develop macrosomia.

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Insulin-Dependent Diabetes Mellitus

• Management of the pregnant diabetic requires the efforts of obstetrician, nutritionist, diabetic educators, and at times, consultation with endocrinologists, ophthalmologists, and other medical subspecialists.
• Regular consultation with a nutritionist will help achieve normoglycemia and optimal weight gain during the pregnancy.
• Renal function should be monitored in each trimester in patients with nephropathy with measurement of creatinine clearance and 24-hour urinary protein levels.
• Retinal examination should also be performed early in pregnancy, and follow-up examinations performed as necessary.
• Fetal surveillance should include alpha-fetoprotein measurements at 16-20 weeks and a fetal ultrasound survey with a fetal echocardiogram at 22 weeks, as indicated, to identify congenital anomalies.

Pyelonephritis in pregnancy

• The incidence of pyelinephritis during pregnancy is 6-10%
• It is an infectious disease
• Most frequent causative agents are E. coli, enterococci, staphilococci, streptococci, and mixed
• Pregnancy may facilitate the development of
• 20-24 weeks of pregnancy is the term of high risk of appearing or aggravation of pyelonephritis. Acute pyelonephritis usually appears beyond the 16 week of pregnancy

Pyelonephritis in pregnancy. Symptoms

• Acute aching pain over the loins, often radiating to the groin
• Fever with chill and rigor
• Anorexia, nausea and vomiting may occur due to general intoxication
• Disuria is a typical symptom.
• Urine tests usually show bacteriuria, leukocituria, proteinuria.
• Chronic pyelonephritis may be a chronic process from the beginning or may develop as a sequela of an incomplete treatment
• Asymptomatic bacteriuria treatment is important option for decreasing rate of pyilonephritis in pregnancy.

EFFECTS OF PYELONEPHRITIS ON PREGNANCY

• Preeclampsia, eclampsia
• Prematurity
• Intrauterine contamination of the fetus
• Increased rate of newborn’s asphyxia, IUGR

EFFECTS OF GESTATION ON PYELONEPHRITIS

• The pyelonephritis’ course becomes worse during pregnancy
• Chronic pyelonephritis becomes acute during pregnancy, and may occur twice or thrice during gestation without antibacterial treatment

MANAGEMENT OF PYELONEPHRITIS IN PREGNANCY

Special groups of high risk are distinguished for pregnant with pyelonephritis:

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1. Women with acute pyelonephritis which appears during pregnancy for the first time
2. Pregnant with chronic pyelonephritis which appeared prior to pregnancy
3. Women with pyelonephritis complicated with nitrosemia or hypertension, or women with pyelonephritis of single kidney are patients of the highest risk in pregnancy

Pyelonefritis in pregnancy

There are three dates of prophilactic hospitalizations during pregnancy for the patients with chronic pyelonephritis.

The 1st is - prior to the 10 week of pregnancy — to examine the general condition, the condition of the renal system and be sure that pregnancy can be allowed. The treatment is: antibiotic therapy (penicillin 10,000,000 units daily intramuscularly, or ampicillin 500 mg four times a day,

The second prophilactic hospitalization should be done in term from 20-22 weeks of gestation to treat a patient for prevention of pyelonephritis.

The treatment is: antibiotic therapy Nevigramon, negram should be administered in doses 2 capsules 4 times a day during 10 days. Furagin may be admmistered by O.lg 4 times a day during 4 days, and then by 0|.2g 3 times a day during 10 days. Diet with less salt and water should be administered. Bed rest is administered in cases of elevated temperature.

The third hospitalization should be done in the third trimester of pregnancy, in term from 34-36 weeks of pregnancy, for general examination, decision of the way of delivering and preparation for delivering. Antibiotics may be used under the indications, treatment of fetal hypoxia.

The natural ways of labor is the best for the patients with pyelonephritis. During postpartum period any infections may appear, so antibiotic therapy is indicated.

ANEMIA IN PREGNANCY

• Anemia is the commonest hematological disorder that may occur in pregnancy
• The incidence of anemia in pregnancy varies widely. In the developed countries the incidence ranges from 10-20%. In the developing countries it ranges from 40-80%.

ANEMIA IN PREGNANCY CLASSIFICATION

1. Deficiency anemia (isolated or combined):
1. Iron deficiency
2. Folic acid deficiency
3. Vitamin B12 deficiency
2. Hernorrhagic anemia:
1. Acute - following bleeding in early terms
2. Chronic
3. Hemolytic forms - congenital and secondary.
4. Bone marrow insufficiency - hypoplasia or aplasia due to radiation, drugs or severe infections, etc.
5. Hemoglobinopathies.

ANEMIA IN PREGNANCY

• Disproportionate increase in plasma volume, erythrocyte number and hemoglobin mass. Whereas the plasma volume increases by about 40%, the number of erythrocytes and hemoglobin mass increase by about 20%.
• There is marked extra demand of iron during pregnancy specially in the second half. The fall in the hemoglobin concentration during pregnancy is due to the combined effect of hemodilution and negative iron balance. The woman who has got sufficient iron reserve and is on balanced diet is unlikely to develop anemia during pregnancy in spite of increased demand of iron. But if the iron reserve is inadequate or absent, the factors which lead to the development of anemia during pregnancy are:
• increased demands of iron, deminished intake of iron (faulty dietetic habits, loss of appetite and vomiting in pregnancy are responsible factors; disturbed metabolism; pre-pregnant health status; abnormal demand: multiple pregnancy increases the iron demand twofold. Women with rapidly recurrent pregnancy, within 2 years following the last delivery, need more iron to replenish deficient iron reserve. '

ANEMIA IN PREGNANCY

ANEMIA IN PREGNANCY

Iron deficiency anemia is also classified depending on degree of deficiency.

• The 1st degree - the level of hemoglobin from 110 to 90 g/1;
• The 2nd degree - the level of hemoglobin from 90 to 80 g/1;
• The 3rd degree - the level of hemoglobin is less than 80 g/1.

CLINICAL FEATURES OF IRON DEFICIENCY ANEMIA

The clinical features depend on degree of iron deficiency. The symptoms are: general fatigue and lassitude, breathlessness on exertion, dizziness, giddiness, headache, insomnia. Pallor of skin and mucous membrane corresponds to the degree of anemia. Patients with significant degrees may have tachycardia. Anorexia and dyspepsia may be too. In severe cases there may be edema of the skin of the ankles and crepitation, at the bases of the lungs. There may be glossitis, stomatitis and dysphagia.

ANEMIA IN PREGNANCY. MANAGEMENT

Routine antenatal check up with blood examination at the 10th week is carried out. Finding of the 3 degree of anemia in early stages of pregnancy may be an indication for medical abortion. In other cases the examination of blood must be done regularly, and the treatment must be prescribed to prevent progressive worsening.

Complications during pregnancy in patients with anemia are: fetal hypoxia and hypotrophya , prematurity, preeclampsia, abruptio placenta intercurrent infection.

Complications during the labor are: anomalies of labor pains (more often weak labor pains), hemorrhages in the 2nd and 3rd stages of labor.

After delivering puerperal septic diseases are common for these patients. The treatment is: supplementary iron therapy

Dietary prescription: balanced diet rich in iron should be prescribed. The foods rich in iron are liver, meat, egg, green vegetables, green peas, beans.

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