ANEMIA
In normal pregnancy :
Hemoglobin levels is falled ® not associated with iron or
folate deficiency
Caused by : expansion in plasma volume is greater than
the increase in red cell mass
haemodilution
Mean corpuscular volume (MCV) or
mean corpuscular haemoglobin concentration (MCHC)
no change
Pregnancy causes 2 – 3 fold increase in the requirment for iron
& 10 -20 fold increase in folate requirement
This is to meet the demands of the expanding red cell mass
and the fetus and placenta
¡ Iron-deficiency anemia
¡ Anemia caused by acute blood loss
¡ Anemia of inflammation or malignancy (chronic disease)
¡ Megaloblastic anemia
¡ Acquired hemolityc anemia
¡ Aplastic or hypoplastic anemia
Hereditary
¡ Thalassemias
¡ Sickle-cell hemoglobinopathies
¡ Other hemoglobinopathies
¡ Hereditary hemolityc anemias
IRON-DEFICIENCY ANEMIA
Two most common causes anemia during pregnancy :
iron deficiency & acute blood loss
excessive blood loss with its concomitant loss of hemoglobin iron
&
exhaustion of iron stores
in pregnancy
can be cause of iron-deficiency anemia
in the next pregnancy
Anemia in pregnancy may present with :
§ Tiredness
§ Lethargy
§ Dyspnoe
§ Dizziness
§ Fainting
Iron stores depleted ® metabolic effects
influence muscle & neurotransmitter activity,
gastrointestinal absorption and epithelial changes
§ Menstrual loss
§ Inadequate diet
§ Previous pregnancy (particularly with
an interval of less than a year between
delivery and conception)
Iron deficiency anemia is associated with
§ preterm birth
§ low birthweight
§ increased blood loss at delivery
Diagnosis
¡ Routine haematological investigation ® first visit, 28 & 36 weeks
§ Hb
§ Hematocrit
§ Red blood cell
¡ Peripheral blood smear
¡ Serum iron concentration
¡ Ferritin
Treatment
¡ Ferrous sulfate, Ferrous fumarat or Ferrous gluconate :
200 mg (for 3 month)
response therapy : elevated reticulocyte count
¡ Transfussions or red blood cells or
whole blood if severely anemic woman
(hematocrit <>
ANEMIA FROM ACUTE BLOOD LOSS
¡ Massive acute hemorrhage :
immediate treatment to restore & maintain perfusion of
vital organ, such as the kidney
¡ Blood replaced does not completely repair the hemoglobin deficit
created by hemorrhage ® should be treated with iron
MEGALOBLASTIC ANEMIA
¡ Almost caused by folic acid deficiency
¡ Usually is found in women who do not consume
fresh green leafe vegetables, legumes, or animal protein
¡ Treatment :
§ folic acid 1 mg/daily
§ A nutritious diet
§ iron
¡ Folate dificiency is associated with neural tube defects
® CDC & ACOG recommended pregnant women consume
at least 0,4 mg folic acid daily
¡ Hb > 7 gr%, condition is stable, can ambulate without
adverse symptoms
iron therapy at least 3 mont is the best treatment
rather than blood transfussion
¡ Additional folic acid is given to :
§ Multifetal pregnancy
§ Hemolytic anemia
§ Crohn disease
§ Alcoholism
§ Inflamatory skin disorder
¡ Women who previously have had infants with neural tube defects :
folic acid 4 mg/daily, is given prior to and through early pregnancy :
¡ Megaloblastic anemia caused by vitamin B12 deficiency during pregnancy is rare
§ Total or partial gastric resection
§ Chron disease
§ Ileal resection
§ Bacterial overgrowth in the small bowel
GESTATIONAL DIABETES
¡ Is defined as carbohydrate intolerance of variable severity
with onset of first recognition during pregnancy
¡ Develops as a consequence of the increased insulin resistance
of pregnancy and resolves postpartum
¡ Associated with excessive fetal growth (macrosomia) ® birth trauma
¡ Gestational diabetes with elevated fasting glucosa
has been associated with unexplained stillbirth
¡ Adverse maternal effect :
§ Hypertension
§ Cesarean delivery
¡ Macrosomia
¡ Birthweigh > 4000 g
¡ Birth trauma ® shoulder dystocia
¡ Macrosomia infants of diabetic mother are
anthropometrically different from other
large for age infants, specifically there is
excessive fat deposition on the shoulder and the trunk
¡ Maternal hyperglycemia : fetal hyperinsulinemia & stimulates
excessive somatic growth
¡ Neonatal hyperinsulinemia may provoke hypoglycemia
Screening
¡ ACOG (2001) :
Performed screening between 24 and 28 weeks in those
women not known to have glucose intolerance earlier in pregnancy
Using a 50-g oral glucose challenge test
> 140 mg/dL are then tested with a diagnostic
100 g oral glucose tolerance test
Management
¡ Diet
§ The goal :
▪ To provide the necessary nutrients for mother and fetus
▪ To control glucose level
▪ To prevent starvation ketosis
§ The American Diabetes Association (2000) :
30 kcal/kg/day. (
¡ Exercise
§ Appropriate exercise : use the upper-body muscle or
place little mechanical stress on the trunk region
§ Upper body cardiovascular training may result in
lower glucose level and reduce the insulin therapy
¡ Insulin : if fasting hyperglycemia > 105 mg/dL persists
despite diet therapy
¡ Oral Hypoglycemic Agent : not recommended
HEART DISEASE IN PREGNANCY
¡ Hemodynamic changes during pregnancy ® harmful for heart disease
¡ During pregnancy :
§ Oxygen consumption increased
§ Increased cardiac output
§ Increased circulating blood volume
§ Increased heart rate
§ Increase stroke volume
Diagnosis
¡ Clinical indicator of Heart Disease during pregnancy
§ Symptoms
▪ Progressive dispnea or othopnea
▪ Nocturnal cough
▪ Hemoptysis
▪ Syncope
▪ Chest pain
§ Clinical findings
▪ Cyanosis
▪ Clubbing of fingers
▪ Persistent neck vein distention
▪ Systolic murmur grade 3/6 or grater
▪ Diastolic murmur
▪ Cardiomegaly
▪ Persistent arrhytmia
▪ Persistent split second sound
▪ Criteria for pulmonary hypertension
¡ Diagnostic studies
§ Most studies are noninvasive & can be conducted safely in pregnancy
▪ Electocardiography
▪ Echocardiography
▪ Chest-X Ray
Clinical classification
¡ New York Heart Association Classification (NYHA)
§ Class I : Uncompromised – no limited of physical activity.
No symptoms or cardiac insufficiency, nor or
they experience anginal pain
§ Class II : Slight limitation of physical activity.
These women are comfortable at rest, but
if ordinary physical activity is undertaken, discomfort resulta
in form of excessive fatique, palpitation, dyspnea or anginal pain
§ Class III : Marked limitation of physical activity. These women are comfortable at rest, but less than ordianary activity causes discomfort by excessive fatique. Palpitation, dyspnea or anginal pain
§ Class IV : Severely compromised-inability to perform
any physical activity without discomfort.
Symptoms of cardiac insuficiency or angina may develop
even at rest, and if any physical activity is undertaken,
discomfort increased
Management
¡ Classes I and II
§ Special attention should be directed toward both prevention
and early recognition of heart failure
▪ First warning : nocturnal cough
▪ Increasing dyspnea, hemoptysis, progressive edema and tachycardia
▪ Infection has proved to be an important factor in
precipitating cardiac failur. Avoid contact with person
who have respiratory infections, including common cold
▪ Cigarette smoking is prohibited
§ Labor and delivery
▪ Vaginal delivery unless there are obstetrical indication for
cesarean delivery
▪ Cardiovascular decompensation during labor manifest as
pulmonary odema, hypoxia, hypotension
▪ During labor :
▪ mother kept in a semirecumbent position with lateral tilt.
▪ Vital sign should be taken frequently between contraction.
▪ Increased pulse rate above 100 perminute or respiratory
above 24 associated with dyspnea ®
impending ventricular failure
▪ Delivery itself not improve maternal condition
¡ Classes III and IV
§ Early pregnancy : termination
§ If pregnancy continued : prolonged hospitalization or bed rest
§ Most cases : Vaginal delivery is preferred , cesarean delivery
is limited to obstetrical indication
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