Management of pregnancy with anemia. Thesis: The role of a paramedic in the prevention of anemia in children of primary and secondary school age. Diagnosis and treatment

O.D. SHAPOSHNIK, L.F. RYBALOVA

ANEMIA IN PREGNANT WOMEN

(ETIOLOGY, PATHOGENESIS, CLINIC, DIAGNOSIS, TREATMENT)

Educational and methodological manual for medical cadets

Chelyabinsk, 2002

In the practice of an obstetrician-gynecologist, anemia in pregnant women occurs as the most common pathology that determines the development of many complications of the gestational period.

The manual is compiled on the basis of generalization of literature data.

Modern data on etiology, pathogenesis, clinical picture, diagnosis and treatment are presented in a brief form. various kinds anemia in pregnant women. Particular attention is paid to tactical approaches (therapeutic and obstetric tactics) to the management of patients with anemia at various stages of pregnancy, during childbirth and the postpartum period.

Questions for self-control are included. The manual is designed for cadets, interns, clinical residents, obstetrician-gynecologists and therapists.

The teaching aid was developed and prepared for printing at the Department of Therapy, Functional Diagnostics and Preventive Medicine and the Department of Obstetrics and Gynecology of the Ural State Academy additional education(Rector of the Academy - Doctor of Medical Sciences, Professor A.A. Fokin) with the assistance of the pharmaceutical company EGIS (Hungary).

Compiled by:

Olga Dmitrievna Shaposhnik, Candidate of Medical Sciences, Associate Professor of the Department of Therapy, PD and PM

Larisa Fedorovna Rybalova, Candidate of Medical Sciences, Associate Professor of the Department of Obstetrics and Gynecology

Reviewers:

Valentina Fedorovna Dolgushina, Doctor of Medical Sciences, Professor, Head. cafe obstetrics and gynecology of the pediatric faculty of ChelGMA

Alexander Vladimirovich Korobkin, Candidate of Medical Sciences, Chief Hematologist of the Chelyabinsk region

Review

on the tutorial for attending physicians, clinical residents, interns, obstetrician-gynecologists and therapists O.D. Shaposhnik and L.F. Rybalova "Anemia in pregnancy"

The problem of anemia and pregnancy is very important at the present stage for obstetrician-gynecologists due to the wide spread of anemia in women. It is especially important to take into account the presence of anemia during pregnancy, since increasing hypoxemia and hypoxia adversely affect both the state of the mother and the fetus. In the presented manual, the authors detail not only the features of the diagnosis and treatment of various types of anemia, but also, which is very important, outline the issues of management tactics during the period labor activity. Of particular interest are questions for self-control, each of which can be easily answered in the material presented.

The manual "Anemia in Pregnancy" is written at a sufficient methodological level. The latest data from the field of obstetrics and gynecology are presented. Undoubtedly, they will help improve the diagnosis and management of pregnant women in the presence of anemia.

Head department

obstetrics and gynecology

Faculty of Pediatrics

Professor

V.F. Dolgushin

Review

for a textbook for clinical residents, interns, obstetrician-gynecologists and therapists O.D. Shaposhnik and L.F. Rybalova "Anemia in pregnancy".

The problem of anemia and pregnancy is very relevant for both general practitioners and obstetricians and gynecologists. Anemia is one of the most common diseases among women, especially of reproductive age. It is known that the combination of pregnancy and anemia adversely affects the condition of both mother and fetus.

In the manual under review, the authors describe in detail the features of the course of anemia in pregnant women. Of particular interest are data on the features of the tactics of managing pregnant women against the background of various types of anemia. It is very important to take into account the indications and contraindications for prescribing drugs necessary for the relief of anemia. Of great practical importance are methods for calculating the doses of iron-containing drugs in the presence of absolute indications for their use.

The manual "Anemia in Pregnancy" is written at a high methodological level using modern ideas in hematology, aimed at improving the provision of medical care to patients with anemia during pregnancy.

Chief hematologist

GUZO of the Chelyabinsk region,

A.V. Korobkin

FOREWORD

Anemia in pregnancy is the most common type of anemia. They occur in 50-90% of pregnant women, regardless of their social and financial status. Despite this, the hematological problems of the gestational process are given very little space both in the manuals on obstetrics and in the works on hematology.

Anemia of pregnancy occupies a special, ("middle") place between two such different disciplines - obstetrics and hematology. In this respect, they represent a typical example of the boundary problem, which is of great theoretical and practical importance, but without a definite affiliation, since they fall into "no man's" land. This "no one's" problem often becomes a "bone of contention", and the disputes concern everything: the term, content, nosological independence, and even the existence of this type of anemia in general.

Anemia is a clinical and hematological syndrome caused by a decrease in the concentration of hemoglobin and, in most cases, erythrocytes per unit volume of blood.

Anemia is a common syndrome and therefore is of practical interest to physicians of all specialties.

According to WHO, 1,987,300,000 inhabitants of the planet have anemia, i.e. this is one of the most frequent, if not the most frequent, group of diseases (Vorobiev P.A., 2001).

Table 1. Primary incidence of anemia in Russia according to the data of appealability.

Table 2. The general incidence of anemia in Russia according to the data of appeals

Table 3. Incidence of anemia in pregnant women in Russia

Anemias that develop during pregnancy are not uniform either in pathogenesis or in the clinical and hematological picture. Physiological "pseudo-anemia" should be distinguished from anemia of pregnant women, or rather, hemodilution, or hydremia of pregnant women due to hyperplasmia(I.A. Kassirsky, G.A. Alekseev, 1970).

Physiological hyperplasmia is observed in 40-70% of pregnant women. It has been shown that, starting from the 7th month of pregnancy, an increase in plasma mass occurs, reaching its apogee on the 9th lunar month (up to 150% compared to the plasma mass in a non-pregnant woman), slightly decreasing during the 10th month (by 15%) and returning to normal condition 1-2 weeks after birth.

Along with an increase in plasma mass during pregnancy, there is an increase, but to a lesser extent (by a maximum of 20%), the total mass of red blood cells and total hemoglobin. These processes that take place during pregnancy lead to physiological hypervolemia: an increase in blood mass by 23-24%, which occurs both due to an increase in the mass of red blood cells (reaching 2000 ml by the end of pregnancy) and due to an increase in plasma mass (reaching 4000 ml). The predominant increase in plasma mass in the last months of pregnancy causes, as a natural phenomenon, a decrease in hematocrit and red blood indicators, erroneously referred to by some authors as "physiological anemia of pregnant women."

Unlike true anemia, hyperplasma of pregnant women is characterized by the absence of morphological changes in erythrocytes. The latter are normochromic and have normal sizes. The acceptable limits of physiological hemodilution during pregnancy are considered to be a decrease in hematocrit to 30/70, hemoglobin to 100 g / l and erythrocytes to 3.6x10 12. A further decrease in red blood counts should be regarded as true anemia! The compensatory value of hemodilution in pregnant women is that it facilitates the exchange of nutrients and gases through the placenta, and with birth blood loss, the true loss of red blood cells decreases by about 20%. Clinically, hyperplasia of pregnant women is asymptomatic and does not require treatment!

With the end of pregnancy, a normal blood picture is restored quickly, within 1-2 weeks.

The development of true anemia during pregnancy is associated with many factors: the initial state of the pregnant woman, nutritional conditions, intercurrent diseases. All this leaves an imprint on the features of diagnosis and tactics of managing patients with anemia during pregnancy.

All anemic conditions in pregnant women are reduced to two forms (A. Alder, 1927):

1. Anaemia ex graviditate - when the condition is caused by pregnancy and does not exist outside of it;

2. Anaemia cum et in graviditate - when anemia precedes pregnancy or only manifests itself during pregnancy.

Entitled "anemia of pregnancy" or "hemogestosis" refers to a range of anemic conditions that occur during pregnancy. They complicate its course and usually disappear soon after childbirth or after its interruption (Dimitr Ya., Dimitrov, 1974).

Table 4. Average values ​​of hemodynamic parameters during normal pregnancy and outside of it.

The causes, mechanisms of development of anemia are very numerous and varied. The basis of their development can be both a primary lesion of the bone marrow (aplasia, leukemia), and various "non-hematological" diseases.

The development of anemia is based on three main mechanisms:

I. Insufficient production of red blood cells due to deficiency of the most important hematopoietic factors (iron, vitamin B 12, folic acid, protein, etc.), ineffective erythropoiesis (myelodysplastic syndrome - MDS) or depression of bone marrow function (hypoplasia, cancer);

II. Increased breakdown of red blood cells(hemolysis);

III. RBC loss(bleeding).

Among all anemias, the following can be conditionally distinguished: pathogenetic variants :

1. Iron deficiency anemia;

2. Anemia associated with the redistribution of iron (iron-redistributive anemia);

3. Anemia associated with impaired heme synthesis (sideroahrestic anemia);

4. B 12 - and folic acid deficiency anemia;

5. Hemolytic anemia;

6. Anemia associated with bone marrow failure (hypo- and aplastic).

For an approximate determination of the pathogenetic variant of anemia, it is necessary to conduct mandatory laboratory tests, which include:

2. Counting the number of erythrocytes, reticulocytes;

4. Counting the number of platelets;

5. Counting the number of leukocytes and blood counts;

6. Determination of serum iron content;

7. Determination of the total iron-binding capacity of serum;

8. Examination of the bone marrow, sternal punctate and trepanobiopsy of the ilium (according to indications).

These research methods are practically publicly available and should be carried out in every patient with anemia.

IRON DEFICIENCY ANEMIA (IDA)

In the general structure of anemia, 80-90% is accounted for by iron deficiency anemia (IDA). According to WHO, the number of people in the world with iron deficiency reaches 200 million. The frequency of iron deficiency anemia in women averages 8-15%, and in men it ranges from 3-8%. In addition, women have a very high percentage (20-25) of latent iron deficiency. Thus, iron deficiency in the III trimester of pregnancy is found in almost 90% of women and persists after childbirth and lactation in 55% of them.

Iron deficiency anemia is the most common form of anemia in pregnant women.

In relatively developed countries, where there is enough meat in the diet, and women give birth to 1-2 children, iron deficiency anemia accounts for only 15-20% of all cases of anemia among women of childbearing age, but this level increases during pregnancy (Table 4.5) .

Table 5. The frequency of iron deficiency anemia in various countries and different age groups (% of patients among the corresponding population group)

The main reason for the development is a decrease in the iron content in the blood serum, bone marrow and depot.

The relationship between IDA and gestation is mutually aggravating. Pregnancy itself suggests an iron deficiency condition., since it is one of the most important reasons for the increased consumption of iron, which is necessary for the development of the placenta and fetus.

The biological significance of iron

· A universal component of any living cell;

An irreplaceable participant in phosphorylated oxidation in cells;

Participates in the synthesis of collagen;

Participates in the metabolism of porphyrin;

Participates in the growth of the body, nerves;

· Participates in the work of the immune system.

Physiological losses and iron requirements

Table 6. Distribution of iron in healthy people

Physiological iron loss in urine, sweat, feces, hair and nails, independent of gender, is 1 mg/day.

For a day, no more than 1.8-2 mg can be absorbed from food.

During pregnancy, childbirth, lactation, the daily requirement increases to 3.5 mg.

During pregnancy, iron is intensively consumed due to the intensification of metabolism (Petrov V.N., 1982):

In the first trimester of pregnancy, the need for iron does not exceed that before pregnancy, and is 0.6-0.8 mg / day;

In the II trimester, the daily need for iron increases to 2-4 mg;

In the III trimester - up to 10-12 mg / day. For the entire gestational period, 500 mg of iron is consumed for hematopoiesis;

For the needs of the fetus - 280-290 mg;

Placenta - 25-100 mg,

The total need for iron is 1020-1060 mg.

In childbirth, 150-200 mg of iron is lost, for 6 months. lactation loss of iron with milk is 189-250 mg. going on depletion of iron depot by 50%.

Strengthening the process of iron absorption during pregnancy, amounting to 0.6-0.8 mg / day in the I trimester and reaching 2.8-3 mg / day in the II trimester, and 3.5 - 4 mg / day in the III. , does not compensate for the increased consumption of this element, especially during the period when the bone marrow hematopoiesis of the fetus begins (16-20 weeks of pregnancy) and the mass of blood in the mother's body increases. It leads to a decrease in the level of deposited iron in 100% of pregnant women by the end of the gestational period (Rozyeva E., Khaidarova T.M., 1991). It takes at least 2-3 years to restore iron stores spent during pregnancy, childbirth and lactation.

Iron deficiency in this period is also facilitated by the often observed vomiting of pregnant women. In its turn, IDA, first of all, pregestational, negatively affects pregnancy, contributing to the threat of miscarriage, miscarriage, weakness of labor, postpartum hemorrhage, infectious complications. Anemia adversely affects intrauterine development fetus, causing hypoxia and sometimes death.

It is important to emphasize that endogenous iron deficiency contributes to this form of anemia, which is associated not only with frequent childbirth and lactation, but also with other pathologies (for example, gastric ulcer, hiatal hernia, impaired iron absorption due to enteritis, helminthic invasions, hypothyroidism etc.). This leads to the important conclusion that the management of pregnant women with IDA should also include the treatment of extragenital diseases that contribute to anemia (together with a general practitioner, gastoenterologist, endocrinologist, hematologist, etc.).

A detailed study of the causes of IDA has led to the idea of ​​the polyetiology of the disease, the main pathogenetic link of which is a lack of iron in the body.

Causes of iron deficiency anemia

Currently, conditionally allocated two forms of iron deficiency states:

A. Latent iron deficiency;

B. Chronic iron deficiency anemia.

Table 7. Severity of anemia.

ZhDA clinic.

The clinical picture of IDA consists of general symptoms of anemia caused by hemic hypoxia and signs of tissue iron deficiency (sideropenic syndrome).

General anemic syndrome - weakness, fatigue, dizziness, headaches (more often in evening time), shortness of breath physical activity, palpitations, syncope, flickering of "flies" before the eyes with a low level of blood pressure, drowsiness during the day and poor falling asleep at night, irritability, nervousness, tearfulness, memory and attention loss, loss of appetite. Expression of complaints of envy from adaptation to anemia. A slow rate of anemia contributes to better adaptation, therefore, there is not always a corresponding correlation between the results of laboratory testing and the objective state of patients, especially with a slow rate of anemia development.

sideropenic syndrome

1. Changes in the skin and its appendages (dryness, peeling, easy cracking, pallor). Hair is dull, brittle, split, turns gray early, falls out intensively. In 20-25% of patients, nail changes are noted: thinning, brittleness, transverse striation, sometimes spoon-shaped concavity (koilonychia);

2. Changes in the mucous membranes (glossitis with atrophy of the papillae, cracks in the corners of the mouth, angular stomatitis);

3. Damage to the gastrointestinal tract (atrophic gastritis, atrophy of the esophageal mucosa, dysphagia). Thus, atrophic gastritis is not a cause, but a consequence of a long-term iron deficiency;

4. The muscular system (due to the weakening of the sphincters, imperative urges to urinate appear, the inability to retain urine during the scheme, coughing, sneezing, sometimes bedwetting in girls);

5. Addiction to unusual smells (gasoline, kerosene, acetone);

6. Perversion of taste (most often in children, adolescents). It is expressed in the desire to eat something inedible (chalk, clay, lime, raw dough, minced meat);

7. Sideropenic myocardial dystrophy, tendency to tachycardia, hypotension, shortness of breath;

8. Disturbances in the immune system (the level of lysozyme, B-lysins, complement, some immunoglobulins decreases, the level of T- and B-lymphocytes decreases, which contributes to a high infectious morbidity in IDA);

9. Functional insufficiency of the liver (with prolonged and severe anemia). Against the background of hypoxia, hypoalbuminemia, hypoprothrombinemia, and hypoglycemia occur;

10. Changes in the reproductive system (disturbance of the menstrual cycle, and there are both menorrhagia and oligomenorrhea);

11. During pregnancy, oxygen consumption increases by 15-33%. With a decrease in iron reserves in the body, this affects not only the amount of hemoglobin, but also the processes of tissue respiration. In this regard, even a clinically mild iron deficiency in pregnant women in conditions of developed fetoplacental insufficiency aggravates hypoxia and the pathology caused by it.

The main laboratory criteria for iron deficiency anemia are:

1. Low color index ( < 0,85);

2. Hypochromia of erythrocytes;

3. Decrease in the average concentration of hemoglobin in the erythrocyte;

4. Microcytosis, poikilocytosis of erythrocytes (in a smear of peripheral blood);

5. Reducing the number of sideroblasts in the bone marrow punctate;

6. Decreased iron content in blood serum (< 12,5 мкмоль/л);

7. Increasing the total iron-binding capacity of serum TIBC > 85 µmol/l (indicator of "starvation");

8. Decreased serum ferritin levels (<15 мкг/л).

The level of ferritin is judged on the stock of iron in the body. It is a reliable test for diagnosing iron deficiency.

Latent iron deficiency

Widespread in women of childbearing age;

Accompanied by the same clinical symptoms as iron deficiency anemia;

He needs to be diagnosed and treated!

Table 8. Criteria for diagnosing iron deficiency in terms of transport and reserve iron funds

The incidence of iron deficiency.

Iron deficiency varies by gender as well as by age.

Practically empty iron depots are to be expected (Berlin, 1987):

»13% of 20-50 year old women;

»5% of 20-50 year old men;

»16% of girls aged between 12 and 15;

»11% of boys aged between 12 and 15;

In »60% of pregnant women at the end of pregnancy.

For vegetarians, the situation is even worse. Research 1985-1986 in Berlin on vegetarians found iron deficiency anemia in approximately 11% of women between 20 and 39 years of age and in 17% of women between 40 and 49 years of age.

Risk groups for IDA during pregnancy:

Past illnesses (frequent infections: acute pyelonephritis, dysentery, viral hepatitis);

Extragenital background pathology (chronic tonsillitis, chronic pyelonephritis, DBST);

· Menorrhagia;

Frequent pregnancies;

The onset of pregnancy during lactation;

Pregnancy in adolescence;

Anemia in previous pregnancies;

· Vegetarian diet;

· Level Hb in the first trimester of pregnancy less than 120 g/l;

Complications of pregnancy (early toxicosis);

· Multiple pregnancy;

· Polyhydramnios.

Gestational complications in IDA :

Termination and miscarriage of pregnancy;

· Chronic feto placental insufficiency;

Syndrome of intrauterine growth retardation;

· Chronic fetal hypoxia;

Decreased motor function of the uterus (weak labor activity);

Bleeding in the III trimester of pregnancy and early postpartum period;

· Hypogalactia;

Purulent-septic infections in the postpartum period (decreased immunity).

Treatment of chronic iron deficiency anemia

In general, the treatment of iron deficiency anemia

– the task is easy and rewarding”

L.I. Idelson.

Principles of therapy

1. Correction of the causes (diseases) underlying iron deficiency;

2. Compensation for iron deficiency in the blood and tissues;

3. Diet therapy is not enough;

4. Do not resort to blood transfusions without vital indications (Nv < 40-50 g/l, anemic, hypoxemic precoma);

5. Use only iron preparations (vitamins B 12, B 6, B 2, B 1 are not shown);

7. Limit parenteral administration to absolute indications;

8. Prescribe sufficient doses of iron supplements for a long time and eliminate not only anemia, but also iron deficiency;

9. When choosing a drug and daily dose, proceed from knowledge of the content of elemental iron in the drug and the degree of iron deficiency in the patient;

10. Carry out preventive treatment with iron preparations if necessary.

Diet for IDA

One diet, even if the food is saturated with iron, anemia cannot be cured: the absorption of iron is limited. A typical diet contains about 18 mg of iron. Absorbed the same as mentioned above, only 1-1.5 mg. With iron deficiency in the body, absorption increases to 2.3-3 mg, but no more.

Dietary iron is divided into heme (as part of heme) and non-heme iron. There are differences between these forms (Table 8).

Table 9

The main source of iron is These are meat products.

From beef, lamb, pork and rabbit meat, from 15 to 30% of heme iron is absorbed. Less (10-20%) - from chicken meat and liver. Most heme iron in veal, black pudding and brawn.

Treatment with iron preparations

It is known from history that iron began to be prescribed to patients with anemia around 1660 - with the aim of "strengthening strength", still not knowing anything about its role in the pathogenesis of anemia.

Currently, a three-stage iron therapy regimen is generally accepted (Table 9).

Table 10 Treatment steps

Most patients with IDA need to be treated with oral iron supplements.(short-acting or prolonged). The daily dose is determined by the stage of therapy. Number of tablets, capsules, drops selected taking into account the content of elemental iron in one tablet or capsule. Short-acting drugs are usually taken 3 times a day, prolonged - 1, less often 2 times a day.

A brief description of some iron preparations is presented in table 10.

Table 11. Main oral iron preparations

Attention!!!

The selection of the dose of iron preparations is carried out on the basis of the following data:

With the same indicator below 8 µmol/l average appointment required up to 70-100 mg elemental iron per day at an optimal course dose of 6500-7000 mg for 3 months. Treatment according to this scheme ensures the restoration of the reserve fund of iron;

· In cases of insufficient effectiveness of ferrotherapy in eliminating the source of blood loss, antioxidants are currently used that significantly improve the effect of ferrotherapy (vitamins C, E);

· With a tendency to reduce the indicators of the transport fund, and even more so with a relapse of anemia, a second course of treatment is indicated for 1-2 months.

Criteria for a normal response to iron therapy in chronic iron deficiency anemia.

1. Subjective improvement 48 hours after the start of treatment;

2. Maximum reticulocytosis after 9-12 days;

3. Normalization of hemoglobin after 6-8 weeks;

4. Normalization of iron levels in blood serum after 3-6 months;

5. The refractoriness of iron deficiency anemia is due to the inadequacy of the prescribed therapy.

Criteria for the effectiveness of treatment at stage 1

1. Clinical Improvement(reduction of muscle weakness as a result of activation of respiratory enzymes) may occur by 5-6 days;

2. Level Up reticulocytes bowl observed on 8-12 day;

3. Level up hemoglobin many patients begin after 3-3.5 weeks therapy;

4. The effectiveness of treatment is considered sufficiently high if the concentration of hemoglobin weekly increases by an average of 5 g / l;

5. Normalization level hemoglobin going on about after 1.5 months ;

6. Control content hemoglobin must be carried out during treatment every 10 days;

7. The study of iron in the blood serum monthly (after a 7-10 day break in taking iron preparations).

In the case of a delayed onset of a positive effect:

1. Add to therapy antioxidants, for example, vitamin E at a dose of 100 to 300 mg per day;

2. To improve protein metabolism, connect the so-called protein-synthetic therapy(potassium orotate, vitamin B 6);

3. For better absorption, iron preparations should not be combined with food intake: they best taken one hour before meals or 2 hours after eating. If dyspeptic symptoms occur, then you can reduce the dose or change the drug;

4. It is advisable to combine the intake of iron supplements with ascorbic acid which improves its absorption. Ascorbic acid is included in some iron preparations; in other cases, it can be taken separately in tablets (0.1 three times a day), better combined with iron supplementation).

Table 12. Factors affecting iron absorption.

IDA in pregnant women is the most common pathogenetic variant of anemia that occurs during pregnancy. Most often, IDA is diagnosed in the II-III trimester and requires correction. It is advisable to prescribe drugs containing ascorbic acid (ferroplex, sorbifer durules, etc.). The content of ascorbic acid should exceed 2-5 times the amount of iron in the preparation. With this in mind, ferroplex and sorbifer durules can be optimal drugs. Daily doses of ferrous iron in pregnant women with non-severe forms of IDA may not exceed 50 mg, since at higher doses, various dyspeptic disorders are likely to occur, to which pregnant women are already prone . Combinations of iron preparations (PI) with vitamin B 12 and folic acid, as well as pancreas containing folic acid (fefol, irrovit, maltoferfol), are not justified, since folic acid deficiency anemia in pregnant women rarely occurs and has specific clinical and laboratory signs.

The parenteral route of administration of the pancreas in most pregnant women without special indications should be considered inappropriate. Treatment of the pancreas in the verification of IDA in pregnant women should be carried out until the end of pregnancy. This is of fundamental importance not only for the correction of anemia in a pregnant woman, but mainly for the prevention of iron deficiency in the fetus.

Treatment of mild IDA is carried out in a antenatal clinic, moderate and severe IDA - in a hospital (together with a therapist, if necessary - with a hematologist!). In this case, there is a need for a thorough examination, in-depth analysis of the data obtained, complex therapy with dynamic monitoring of indicators by the mother and fetus, and preparation of the pregnant woman for delivery.

Principles of approach to the preparation and management of childbirth.

Drawing up a plan for conducting childbirth, taking into account:

complete clinical diagnosis;

· Prenatal risk factors;

· Indicators of hemodynamics of a pregnant woman (BCC, IOC, SI, OPSS);

· Prediction of obstetric complications for mother and fetus;

Permissible blood loss during childbirth (calculation should be carried out with a comparison of the BCC value - up to 5% of the BCC).

I period:

· Carrying out clinical and laboratory control;

Assessment of fetal hemodynamics;

Treatment of FPI (according to general principles).

II period:

Administering with a drip;

Prevention of bleeding at the end of the straining period (in / in the introduction of an uterotonic - oxytocin 5 units).

III period:

Careful monitoring of the signs of separation of the placenta and its release;

In case of IDA of moderate and severe degree, management in the presence of an anesthesiologist;

Accurate recording of blood loss.

Early postpartum period:

· Monitoring the state of the puerperal in the conditions of the birth block for 4 hours (the state of the uterus, hemodynamics in the mother).

Postpartum period:

Prevention of GSI (antibiotic therapy);

Treatment of hypogalactia when it is established;

Continuation of treatment for IDA;

· Examination by a therapist;

·Agreed discharge from the maternity hospital (therapist, neonatologist) with appropriate recommendations for rehabilitation and contraception.

Particularly noteworthy are puerperas with IDA who were delivered surgically - by caesarean section. A decrease in immunological competence and suppression of immunity create a high risk of purulent-septic complications in the postpartum and postoperative periods in this group of women. In order to reduce postoperative complications, according to Akhmatova (1996), it is advisable to administer T-activin 100 μg IM immediately after surgery and then continue its administration for 5 days.

Rehabilitation of women with IDA after childbirth

Observation after childbirth with a therapist for ½ year (1 time per month);

· Control of the general analysis of blood (1 time per week in a hospital, 1 time per month on an outpatient basis with persistent anemia), serum iron (monthly with a decrease in indicators);

· Consultation of a hematologist - according to indications (insufficient effectiveness of treatment);

· After ½ year – follow-up according to the health group;

Reception of iron-containing preparations during the entire period of lactation (maintenance doses for anemia, prophylactic doses - in its absence - Hb 120 g / l and above).

HYPERCHROMIC

MACROCYTIC ANEMIA IN PREGNANT WOMEN

The cause of hyperchromic anemia in pregnant women is a combined deficiency of the most important hematopoietic factors - folic acid and vitamin B12

It is known that during pregnancy and lactation, a woman's need for vitamin B 12 and folic acid increases several times, reaching 5-10 g per day (instead of 2-3 g per day under normal conditions) for vitamin B 12 and 5 mg (instead of 2 mg) for folic acid. Studies by numerous authors have shown that during pregnancy, the content of vitamin B 12 progressively decreases, remaining, however, within normal fluctuations. The high permeability of vitamin B 12 and folic acid through the placental barrier provides the fetus with a sufficient amount of hematopoietic vitamins.

According to research Rachmilevitz And Izak, the content of vitamin B 12, folic and folinic acids in the blood of the umbilical vein of a newborn, respectively, is 2-4-8 times higher than in maternal blood. Similar ratios found in women in labor without anemia, of course, create a favorable prerequisite for the development of anemia in pregnant women with appropriate exogenous (alimentary) insufficiency. This once again confirms the position that pregnancy is a physiological process, sometimes proceeding on the verge of acceptable physiological norms.

Deficiency of vitamin B 12 or folic acid, which develops during pregnancy, alcoholism, and other conditions (Table 13), leads to impaired DNA synthesis in bone marrow cells and the formation of large erythroid cells in the bone marrow with a delicate nuclear structure and asynchronous differentiation of the nucleus and cytoplasm , i.e. to megaloblastic hematopoiesis, which occurs only in the embryonic period.

Table 14. Main diseases and syndromes leading to the development of B12-deficiency or folic acid deficiency anemia

Vitamin B 12 is found in food of animal origin: liver, kidneys, meat, milk and is practically not destroyed during the heat treatment of products, unlike folic acid. Its reserves in the depot of the body are large, they last for 3-5 years, therefore, in pregnant women, megaloblastic anemia associated with cyanocobalamin deficiency is rare, only with helminthic invasion, in patients with chronic enteritis who underwent resection of the small intestine or total removal of the stomach (with resection of 2/3 of its internal factor is preserved).

Much more often in pregnant women, megaloblastic anemia is a consequence of folate deficiency. Folic acid is found mainly in plant foods and is absorbed by eating only raw vegetables and fruits, as it is destroyed by boiling. There is a significant amount of folic acid also in the liver and milk. The daily requirement for folic acid in non-pregnant women is limited to 50-100 mcg. In pregnant women, it is increased to 400 mg, in lactating women - 300 mg (WHO, 1971). The reserves of folic acid in the body are small (5-12 mg), they are enough at this expense for 3 months (in the absence of intake).

The most serious factor leading to the development of folic acid deficiency anemia in pregnant women is insufficient dietary intake of folic acid, despite the fact that biosynthesis in the intestine can fill 50% of the total need for it. The synthesis of folic acid in the intestine increases with the intake of plant foods.

Folic acid deficiency can develop when eating only boiled vegetables, chronic enteritis (Crohn's disease), alcoholism (impaired absorption), the use of anticonvulsants, hypnotics, with hereditary hemolytic anemia, thalassemia (erythropoiesis is sharply activated), with frequent pregnancies, multiple pregnancy, long-term use hormonal contraceptives. Hidden deficiency of folic acid is present in 4-33% pregnant women, however, megaloblastic folate deficiency anemia accounts for only 1% of all anemias in pregnancy.

Megaloblastic folate deficiency anemia most often develops in the third trimester of pregnancy, often before childbirth and in the first week of the postpartum period. Anemia is rarely severe (hemoglobin in the range of 80-100 g / l) and is not treatable with iron preparations.

Folic acid deficiency in a pregnant woman not only leads to the development of megaloblastic anemia, but is also accompanied by pregnancy complications.

Complications of pregnancy in folate deficiency anemia :

Spontaneous miscarriages;

Anomalies in the development of the fetus;

· Gestosis;

Premature birth;

Pathology of the placenta (PONRP).

As a rule, anemia disappears after childbirth, but it is possible to recur with a new pregnancy if the deficiency that occurred during pregnancy and lactation has not been replenished. No anemia in newborns but folic acid deficiency leads to the development of malformations of the nervous system in the fetus.

General clinical signs of B 12 - and folate deficiency anemia are nonspecific: weakness, fatigue, palpitations, shortness of breath on movement, pallor of the skin and mucous membranes, subicteric sclera, some patients may have subfebrile condition. With a deficiency of vitamin B 12, some patients develop signs of glossitis, crimson (lacquer) tongue, symptoms of damage to the nervous system - funicular myelosis (paresthesia, polyneuritis, sensitivity disorders, etc.). With a deficiency of folic acid, there is no glossitis and funicular myelosis, but there may be a burning sensation of the tongue, hemorrhagic diathesis on the skin and mucous membranes, and in 1/3 of patients the spleen is enlarged.

Funicular myelosis develops only with repeated relapses of anemia, if pregnancy persists, the patient's condition progressively worsens, anemia and concomitant hemolytic jaundice increase sharply. During this period, the picture of bone marrow hematopoiesis and peripheral blood is fully consistent with severe megaloblastic anemia. Untreated anemia in such cases leads the pregnant woman to a state of hypoxemic coma and death. With a successful delivery, the further development of the disease proceeds in different ways: either a complete recovery occurs (even without special antianemic therapy) and relapses can be observed only with repeated pregnancies (especially if the latter are often repeated), or a typical megaloblastic anemia develops with a cyclic course and exacerbations not associated with repeated pregnancies.

The criteria for megaloblastic anemia are :

1. High color index (>1.1);

2. Macrocytosis, megalocytosis, Jolly bodies, Cabot rings;

3. Normoblasts in a blood smear;

4. Reticulocytopenia (in the absence of treatment with vitamin B 12)!!!;

5. Leukopenia, thrombocytopenia;

6. Hypersegmentation of neutrophils;

7. Increasing the content of serum iron, bilirubin (indirect fraction);

8. Decreased concentration of vitamin B 12;

9. Atrophic gastritis (Genter's glossitis - "varnished" tongue);

10. Signs of damage to the nervous system (funicular myelosis in severe cases);

11. In the bone marrow - megaloblastic hematopoiesis (diagnosis without sternal punctate is impossible, often there are masks B 12 deficiency anemia). Bone marrow examination is absolutely indicated before treatment!

Previously, it was believed that the appearance of megaloblasts is a return to embryonic hematopoiesis. Relatively recently, it was shown and confirmed in a number of laboratories using modern radioisotope methods that megaloblasts in B 12-deficient anemia are not a special, shunt population of cells, but cells capable of differentiating into ordinary erythrokaryocytes in the presence of the coenzyme form of vitamin B 12 within a few hours. It means that one injection of vitamin B 12 can completely change the morphological picture of the bone marrow. In this case, sternal puncture does not make it possible to establish the correct diagnosis; reticulocytes appear in the peripheral blood. On the other hand, a patient with B 12 deficiency anemia must be treated for life, therefore, the diagnosis cannot be approximate, it must be accurate.

The largest number errors in the diagnosis of B 12 deficiency anemia due to the fact that the patient, before being referred to a hematologist or therapist who knows this pathology, received one or more injections of vitamin B 12.

Treatment of megaloblastic anemia.

I. Diet with enough folic acid (or vitamin B 12):

Table 15. Foods high in folic acid (mg/100g)

Table 16. Foods High in Vitamin B12 (mg/100g)

II. Replacement of vitamin B 12 deficiency (with B 12 - deficiency anemia)

1. Saturation stage(4-6 weeks):

Diet in (table. 15) in combination with 200-400 mcg of vitamin B 12 / m or s / c daily;

2. Fixing therapy(4-6 months):

500 micrograms of vitamin B 12 weekly;

3. Maintenance therapy (for life):

500 micrograms of vitamin B 12 monthly;

500 mcg of vitamin B 12 2 times a month with a 2-month break (20 injections in total);

500 mcg of vitamin B 12 daily for 2 weeks, 2 times a year.

“It is difficult to overestimate the clinical significance of the reticulocyte crisis, which usually occurs 4-6 days after the start of vitamin B 12 administration. In order not to miss a crisis, reticulocytes in the first period of treatment should be counted daily!(A.A. Krylov, 1991).

III. Replacement of folic acid deficiency (with folic acid deficiency anemia).

Treatment and prevention of folate deficiency megaloblastic anemia consists in good nutrition, primarily including fresh herbs, raw vegetables and fruits (Table 14). Folic acid is prescribed at a dose of 5-15 mg / day. until normalization of blood counts. In the future, the dose is reduced to 1 mg / day, and this dose is taken until the end of lactation. At the same time, ascorbic acid is prescribed at a dose of 100 mg / day.

Patients with a constantly increased need for folic acid (with hemolytic anemia, treatment with folate inhibitors) and with a decrease in the absorption capacity of the intestine should take folic acid almost constantly (for life!).

The use of folic acid is contraindicated in megaloblastic anemia due to vitamin B 12 deficiency without simultaneous treatment with vitamin B 12(aggravation of funicular myelosis).

It should be remembered that the appointment of folates in B 12 deficiency anemia can cause a reticulocyte crisis, sharply worsen the patient's condition (up to his death), but will never lead to anemia correction and, moreover, to the elimination of neurological disorders.

Therefore, the evaluation of the effectiveness of therapy for unclear megaloblastic anemia and the lack of sufficient information should begin with the appointment of vitamin B12.

Attention! The effectiveness of therapy for megaloblastic anemia is assessed by an increase in the number of reticulocytes in the peripheral blood from 4-6 days of treatment and relief of all symptoms of anemia within 1-2 months of treatment.(it is important to know the initial number of reticulocytes!).

IV. Erythrocyte mass (no more than one or two doses) can be used only for health reasons, in particular with the development of a precomatous state. Main criteria of the latter with megaloblastic anemia are the white conjunctiva of the lower eyelid and orthostatic collapses.

Treatment of anemia should not be stopped until complete clinical and hematological remission. Especially it is necessary to be afraid of interruption of treatment before delivery.

Preventive treatment megaloblastic anemia should be carried out until the end of pregnancy and in the postpartum period, using maintenance doses of vitamin B 12 in tablets of 50 mcg twice a day or folic acid in tablets of 10 mcg twice a day.

HEMOLYTIC ANEMIA

The main symptom of this group of anemias is the shortening of the life span of erythrocytes, which is normally about 120 days. Hemolysis can occur in a variety of pathological processes, proceed permanently or occasionally in the form of hemolytic crises.

Two groups (Table 17) of hemolytic anemia should be distinguished - hereditary and acquired, differing among themselves in the main disorders underlying hemolysis, the course of diseases, methods of diagnosis and treatment.

Table No. 17 Options for hemolysis

In clinical practice, hemolytic anemias of immune origin are more common (see classification).

Classification of immune hemolytic anemias

Autoimmune anemia

Autoimmune hemolytic anemia should be understood as such forms of anemia in which blood or bone marrow cells are destroyed by antibodies or sensitized lymphocytes directed against their own unchanged antigens.

Not all immune hemolytic anemia is autoimmune. Immune hemolytic anemia can be divided into 4 groups:

- isoimmune,

- transimmune,

- heteroimmune,

- Autoimmune.

About Isoimmune Hemolytic Anemia can be said in cases where incompatible erythrocytes are transfused. The donor's blood cells are destroyed by antibodies present in the recipient and directed against the donor's antigen, as well as in cases of antigenic incompatibility between the mother's and child's cells. The mother produces antibodies against the antigens of the child's cells that are absent from the mother, and if the antibodies are directed against the antigens of the child's red blood cells, hemolytic anemia develops in the mother.

Under transimmune hemolytic anemias we understand those in which antibodies produced in the body of a mother suffering from autoimmune hemolytic anemia enter the blood of the fetus through the placenta. These antibodies are directed against the mother's antigen in common with the child's antigen. . In a child, red blood cells are destroyed due to accidental ingestion of maternal antibodies.

Under heteroimmune hemolytic anemias should be understood as those in which antibodies are directed against a foreign antigen fixed on cells that are destroyed under the influence of antibodies. Yes, antibodies can react with drugs. , fixed on the surface of erythrocytes (for example, against penicillin, analgin). This can lead to the destruction of red blood cells. Hemolysis continues as long as the body receives this drug. Destruction of red blood cells can also occur when antibodies are directed against a virus fixed on the surface of red blood cells during an acute infection (eg, viral hepatitis). Under the influence of a virus or some other factors, the structure of the antigen changes and the immune system does what it is supposed to do: it produces antibodies to an actually "foreign" antigen. After stopping the medication or after recovery from the infection, heteroimmune hemolytic anemias completely disappear.

Only in cases where antibodies are directed against their own unchanged antigen, we can speak of autoimmune hemolytic anemia (AIHA). In the autoimmune process, there is a loss of immunological tolerance to one's own antigen, i.e., the own antigen is perceived by the immune system as foreign, and the immune system must produce antibodies against all foreign antigens.

All autoimmune hemolytic anemias, regardless of the cellular orientation of antibodies, can be divided into idiopathic and symptomatic. Under symptomatic forms we understand those in which antibodies are produced in response to some other diseases (hemoblastoses: chronic lymphocytic leukemia, Waldenström's disease, multiple myeloma; lymphosarcoma; systemic lupus erythematosus, rheumatoid arthritis, chronic active hepatitis). Autoimmune hemolytic anemia that occurs after influenza, tonsillitis and other acute infections, during pregnancy or after childbirth, should not be classified as symptomatic forms, since these factors are not causative, but provoking clinical manifestations of a latent disease. When autoimmune hemolytic anemias occur without apparent cause, they should be classified as idiopathic forms of the disease.

Acquired immune hemolytic anemias are associated with the appearance of antibodies to erythrocytes, less often to erythropoiesis cells. Autoimmunization develops in connection with the "breakdown" of immunological tolerance, against the background of a decrease in the glucocorticoid activity of the adrenal cortex. In this group of anemias, autoimmune hemolytic anemia with incomplete thermal agglutinins occurs predominantly (in 70-80% of cases), which is characterized by all the signs of hemolytic anemia with intracellular hemolysis. Decisive in the diagnosis are a positive direct Coombs test, an increase in the level of gamma globulins in the blood , a clear positive effect of glucocorticoid therapy (effective dose of prednisolone 1 mg/kg/day).

The clinical picture does not depend on whether the patient has an idiopathic or symptomatic form. The onset of the disease may be different. In some cases, there is an acute onset of the disease against the background of complete well-being: suddenly there is a sharp weakness, sometimes discomfort in the lower back, pain in the heart, shortness of breath, palpitations, fever often occurs, jaundice develops rapidly.

In other cases, a more gradual onset is noted. There are precursors of the disease: arthralgia, abdominal pain, subfebrile temperature. Often the disease develops gradually, the state of health remains satisfactory.

Among the main signs of the disease, one can single out those characteristic of anemia in general (pallor, dizziness, shortness of breath, enlargement of the heart, systolic murmur at the apex and fifth point, tachycardia), and for hemolysis (jaundice, enlargement of the liver and spleen). Splenomegaly can be detected in 2/3 of patients with autoimmune hemolytic anemia. The size of the spleen is different: a significant increase in size is noted in the chronic course of the disease. Half of the patients have an increase in the size of the liver.

In acute hemolytic crises, there is a drop in hemoglobin to extremely low numbers, however, in most cases, the hemoglobin content does not decrease so sharply (up to 60-70 g / l). A number of patients with a chronic course of autoimmune hemolytic anemia have a slight decrease in hemoglobin (up to 90 g/l). Anemia is most often normochromic or moderately hyperchromic. The content of reticulocytes is increased in most of the patients.

Hematological criteria for hemolytic anemia:

1. Anemia is normochromic;

2. A sharp decrease in hemoglobin during hemolytic crises;

3. Polychromatophilia of erythrocytes

4. Increased content of reticulocytes (more than 30-50‰);

5. The appearance in the blood of nuclear erythrocytes - normocytes;

6. Significant neutrophilic leukocytosis with a shift to promyelocytes during crises;

7. Moderate thrombocytopenia;

8. Decreased osmotic resistance of erythrocytes;

9. Positive hemagglutination test for the presence of antibodies to erythrocytes (direct Coombs test, AGP);

10. Increase in the content of indirect bilirubin;

11. Increasing the content of iron in blood serum;

12. Free hemoglobin in serum and urine (dark urine);

13. Hyperplasia of the erythroid germ of hematopoiesis;

14. Splenomegaly;

15. Jaundice of the skin and icterus of the sclera.

The combination of pregnancy and autoimmune hemolytic anemia is rare. The disease during pregnancy in many women occurs with severe hemolytic crises and progressive anemia. Often there is a threat of termination of pregnancy. The prognosis for the mother is favorable. Conservative management of labor is preferred. Artificial termination of pregnancy is not indicated for most women, however, there are observations of recurring autoimmune hemolytic anemia with each new pregnancy. In such cases, termination of pregnancy and sterilization are recommended.

Treatment of autoimmune hemolytic anemias should begin with the use of prednisolone in doses sufficient to stop acute hemolysis (from 30 to 100 mg per day). The first indicator of the effectiveness of glucocorticoid therapy is a decrease in temperature. The increase in hemoglobin is gradual. In a serious condition of the patient, a transfusion of erythrocytes is indicated, preferably washed, necessarily individually selected according to the indirect Coombs test. Transfusions of erythrocytes are carried out only as long as the patient is threatened with coma. After normalization of the hemoglobin level, the dose of prednisolone is reduced gradually: from large doses it is reduced relatively quickly, and from small doses it is much slower (1/4 tablet every 2-3 days). In the absence of a lasting effect of treatment with prednisolone and in case of recurrence of the disease (after 4-6 months), splenectomy is indicated.

A feature of the postoperative management of patients with hemolysin form of autoimmune hemolytic anemia is the need to prevent thrombotic complications inherent in these patients (heparin 5000 units 3-4 times a day under the skin of the abdomen, on day 4-5 heparin can be replaced by chimes 75 mg 3- 4 times a day).

APLASTIC ANEMIA (AA)

A disease of the hematopoietic system, characterized by depletion of hematopoiesis and fatty degeneration of the bone marrow. The question of the causes of aplastic anemia currently remains open ...

Etiology(the most common factors associated with AA).

A. Idiopathic forms;

B. Constitutional (Fanconi anemia);

B. Acquired, caused by the following physical and chemical agents:

but. Benzene;

b. Ionizing radiation;

in. Alkylating agents;

d. Antimetabolites (antagonists of folic acid, purine and pyrimidine);

G. Aplasia, developing according to the mechanism of idiosyncrasy (taking a number of drugs in highly sensitive individuals);

Drugs and substances that cause hematopoietic aplasia by this mechanism:

but. Chloramphenicol (levomycetin);

b. Phenylbutazone;

in. non-steroidal anti-inflammatory drugs;

d. Preparations of gold;

e. Insecticides;

D. Hepatitis. The likelihood of developing hematopoietic aplasia does not correlate with the severity of chronic hepatitis. It can also develop after recovery from hepatitis;

E. Pregnancy!

Aplastic anemia that develops during pregnancy may develop after the birth of the fetus.

G. Paroxysmal nocturnal hemoglobinuria (PNH);

Z. Miscellaneous: miliary tuberculosis, cytomegalovirus sepsis, Hashimoto's goiter, thymoma, etc.

Pathophysiology

Lack of stem cells or pathology of the microenvironment (as a result of oppression, exhaustion). In more than 50% of patients, an autoimmune mechanism of bone marrow damage is assumed.

Clinical course

Distinguish with the flow soft And heavy forms. Spontaneous recovery is possible. In severe cases, the outcome is fatal.

The disease can begin acutely and progress rapidly, but gradual development is also possible. The clinical picture is dominated by three main syndromes: anemic, hemorrhagic and septic-necrotic.

Patients are pale, sometimes somewhat icteric. On the skin, hemorrhagic elements are visible from a small rash to large extravasations: petechiae, petechial hemorrhages, bruises. Patients complain of palpitations, shortness of breath, bleeding gums, more often nose and uterine bleeding. A systolic murmur is heard at the apex of the heart. Due to leukopenia (neutropenia) infectious processes occur (in the urinary tract, respiratory organs). The spleen and liver are not enlarged.

Laboratory indicators:

Anemia is normochromic (the average concentration of hemoglobin in the erythrocyte is 33-36%) and macrocytic (the average erythrocyte volume is more than 95 microns 3);

Hemoglobin, as a rule, is reduced to 30-50 g/l;

The number of reticulocytes is reduced;

Leukopenia - the number of leukocytes drops to 0.2x10 9 / l, (neutropenia with relative lymphocytosis);

Thrombocytopenia, sometimes with complete disappearance of platelets. The bleeding time is lengthened, hemorrhagic syndrome develops;

ESR is sharply increased;

Serum iron normal or elevated;

Characteristic picture of the bone marrow (myeloid tissue is almost completely replaced by fat, there are only small foci of hematopoiesis).

In many cases, the disease progresses rapidly despite treatment and quickly ends in death. Perhaps a more calm course of the disease with a change in periods of exacerbations and remissions. The combination of aplastic anemia and pregnancy is observed infrequently, but the prognosis for the mother in this case is poor, mortality reaches 45%.

More often, aplastic anemia is detected in the second half of pregnancy. Hematological indicators deteriorate rapidly, hemorrhagic diathesis develops, infectious complications join. Termination of pregnancy does not stop the progression of the disease. Treatment is ineffective. The duration of illness from onset to death averages 3-11 months.

Pregnancy that occurs against the background of hypoplastic anemia, as a rule, causes an exacerbation of the disease. Therefore, the tactics are essentially the same in both cases. An urgent diagnosis is required, and, if aplastic or hypoplastic anemia is detected, early termination of pregnancy is indicated, followed by splenectomy, since the disease is associated with a risk to the life of the mother and fetus. In the case of a categorical refusal of a woman to terminate a pregnancy, careful hematological control is necessary at least 2 times a month.

Unfavorable signs are:

Decreased hemoglobin level below 60 g/l;

· The number of leukocytes is less than 1.5x10 9 /l;

Neutrophils - less than 20%;

Persistent relative lymphocytosis (more than 60%);

Hemorrhagic syndrome;

Severe infectious complications.

In these cases, termination of pregnancy is indicated.

When detecting hypoplastic anemia in late pregnancy, there should be an individual approach to the issue of delivery by caesarean section combined with splenectomy. In the presence of adaptation of the body of a pregnant woman to the state of hematopoiesis, it is possible to maintain pregnancy until spontaneous delivery.

Single observations of pregnancy in women suffering from hypoplastic anemia with a favorable immediate outcome are described. The offspring in the first months of life is diagnosed with iron deficiency anemia.

criteria for the severity of the disease.

1. Soft flow:

but. Hematocrit >32%;

b. Segmented< 2000/мкл;

in. Platelets > 20x10 9 /l;

Bone marrow: moderate decrease in cellularity.

2. Severe flow:

but. Number of reticulocytes< 1 0 / 00 ;

b. Segmented<500/мкл;

in. platelets<20х10 9 /л;

Bone marrow: severe hypoplasia or aplasia.

Therapy of aplastic anemia is carried out under the supervision of a hematologist.

Therapeutic tactics in each individual case

is a test for the clinician"

G.A. Alekseev, 1970

In the treatment of patients with aplastic anemia, an important role belongs to substitution therapy: transfusion of blood fractions - erythrocyte, platelet and leukocyte. A single dose of erythrocyte mass is 100-125 ml. The washed erythrocytes are transfused. Platelet concentrate, granulocyte concentrate require selection according to the HLA system. Transfusion of blood components is performed against the background of prednisolone and heparin. In infectious complications, broad-spectrum antibiotics are prescribed.

Glucocorticoid hormones have a stimulating effect on hematopoiesis and inhibit immunological reactions. Prednisolone is prescribed in doses of 60-80 mg / day, in the absence of effect - in smaller doses for hemostatic purposes - 20-40 mg per day for 4-6 weeks.

If this therapy does not have an effect, splenectomy is performed. It is indicated for less severe forms of the disease: the absence of large bleeding and signs of sepsis. The effect occurs 2-5 months after the operation, but the bleeding stops immediately.

Antilymphocyte globulin is also used, usually after splenectomy, 120-160 mg into a vein up to 10-25 times.

The best effect in the treatment of aplastic anemia is given by allogeneic bone marrow transplantation (Kozlovskaya L.V., 1993), especially in severe forms of the disease:

· The platelet level is below 2x10 9 /l;

Neutrophils less than 0.5x10 8 /l;

The number of reticulocytes after correction is less than 1%;

· The number of bone marrow cells is less than 25% of the total volume.

CONCLUSION

Anemia is the most common hematological syndrome. In 80% of cases, anemia is a mask (symptom) of another pathological process. It is conditionally possible to distinguish:

1. "Anemia of chronic diseases":

Infectious - inflammatory genesis;

Non-infectious - inflammatory genesis (SLE, rheumatoid arthritis, etc.);

Malignant neoplasms (primary and metastatic tumors);

2. Hemoblastosis (chronic lymphocytic leukemia, paraproteinemic leukemia);

3. Chronic intoxication (CKD, alcoholism, drug addiction, liver failure, etc.).

Anemia usually takes a long time to develop. The body adapts to a gradual decrease in hemoglobin (the number of red blood cells), so the disease acquires an erased clinic and is usually detected by chance.

"A blood test can be thunder

in the clear sky"

L.I. Butler, 1998 .

REQUIRED LABORATORY STUDIES FOR ANEMIA

1. Determination of hemoglobin content;

2. Counting the number of red blood cells;

3. Determination of the color index;

4. Counting the number of reticulocytes;

5. Counting the number of leukocytes and formulas;

6. Counting the number of platelets;

7. Determination of iron content in serum (OZHSS, ferritin);

8. Study of bone marrow punctate.

REMEMBER!

1. Perform all laboratory studies before prescribing drugs (vitamins B 6, B 12, C, rutin, multivitamin complexes, iron-containing preparations, folic acid, glucocorticosteroids, oral contraceptives, etc.) and blood transfusions;

2. Blood sampling should be done in the morning on an empty stomach;

3. Test tubes must be treated with distilled water twice;

4. Blood clotting (dehydration, vomiting, diarrhea, diuretics, hypertonic solutions, glucocorticosteroids), hemodilution (rehydration, edematous syndrome) distort peripheral blood counts;

5. One injection of vitamin B 12 (5-10 g is enough !!!, in an ampoule not< 2 раз) может изменить картину костного мозга в течение нескольких часов;

6. After the appointment of drugs containing iron, the true indicators of iron in the blood serum can be established only after they are canceled for 7-10 days;

7. Blood transfusions cause a distortion of hemoglobin and erythrocytes within » 2-3 days.

The effect of the treatment may not be at :

2. Unsystematic therapy;

3. Incorrectly established diagnosis.

Anemia of unknown (unexplained origin) - these are cases of anemia, in which it is not possible to speak about the causes at first (unidentified source of bleeding, combined anemia, hematopoietic depression against the background of a severe concomitant disease).

Carrying out diagnostic, therapeutic and preventive measures for anemia in pregnant women, women in childbirth and puerperas helps to improve the outcomes of pregnancy and childbirth for mother and child.

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Respiratory muscle training, improved perfusion through alveoli and membranes. The cycle of physical exercises for pregnant women with anemia also aims to increase the level of physical performance.

The main form of the therapeutic-motor regimen was therapeutic gymnastics. For its implementation, we formed homogeneous groups of 5–7 women.

When performing physical exercises, pregnant women must adhere to the following conditions:

Choose exercises taking into account the period of pregnancy, the possibilities of their implementation, the condition of the pregnant woman and the fetus;

Follow the gradual transition from easy exercises to more complex ones;

Increase physical activity gradually;

Evenly include the muscles of the trunk, upper and lower extremities;

Limit the performance of a large number of exercises for the muscles of the abdominal wall;

Exclude exercises that were associated with shaking the body, jumping, sharp turns.

Focusing on the peculiarities of thematic patients and the fact that most of the pregnant women were not physically prepared, when building physiotherapy exercises, we used simple exercises that did not require significant efforts from the muscular and nervous systems. The advantage was given to floor exercises, the implementation of which did not require a volitional load.

Breathing exercises were used to relieve a significant psycho-emotional load during classes. In addition, separate elements of vestibular training were included in the complex of exercises, since pregnant women have some coordination disorders.

Various starting positions were used, with the exception of lying on the stomach
(due to the peculiarities of pregnant women). Late (after
28 weeks) of pregnancy limited the use of the initial standing position, since at this time there is the greatest increase in body weight and a significant possibility of developing leg edema.

During the classes, the pregnant women performed exercises for the main muscle groups, with special attention being paid to exercises to strengthen the muscles that take part in the birth act (pelvic floor and abdominals).

Complexes of therapeutic gymnastics also included a limited number of exercises in isometric mode for the upper limbs and shoulder girdle. Their use is associated with a hypotensive effect. Since pregnant women with anemia have hypotension and weakness, excessive use of these exercises can cause deterioration and dizziness. To prevent the occurrence of this condition, the exercises were performed from the initial sitting or standing position and were necessarily combined with voluntary muscle relaxation and breathing exercises.

The duration of physiotherapy exercises varied in different periods of pregnancy from twenty to forty minutes.

The proposed load was predominantly aerobic in nature. At the same time, it was observed that the heart rate of pregnant women did not exceed 110–120 beats min-1.

The most intense loads, relative to those recommended, were prescribed to women whose gestational age was 17–31 weeks. The lower load was used up to 16 weeks of pregnancy and the lowest - from 32–36 weeks.

Classes were held with musical accompaniment. Classic melodies were selected. They gave the lesson a richer and more harmonious character.

In case of fetal hypoxia, the method of normobaric hypoxic therapy was included in the program of sanatorium treatment. The use of the method of normobaric hypoxic therapy for pregnant women with anemia, in our opinion, has a significant healing effect. It helps to increase the nonspecific resistance of the body of pregnant women, normalize the autonomic balance, stabilize the psycho-emotional state, improve microcirculation; performs hemostimulating, immunomodulating effects and a number of other positive actions.

The basic mode of hypoxic therapy was prescribed: three cycles of breathing according to
15 min with a break of 7 min (5). The course contains 12-14 daily sessions. The oxygen concentration is reduced according to the scheme. The total duration of one session is 59 minutes.

All the presented means and methods of physical rehabilitation were used in a complex way, taking into account their mutual influence and the action of other factors that were used in the process of sanatorium treatment.

In the fifth section "Evaluation of the effectiveness of the developed program of physical rehabilitation in pregnant women with anemia" a comparative analysis of the evaluation of the effectiveness of the proposed differentiated program of physical rehabilitation (main group) and the program that was used in the clinical sanatorium "Zhovten" ZAT "Ukrprofzdravnitsa" (control group) is presented.

After the course of physical rehabilitation of pregnant women with anemia, a higher level of physical performance was determined in pregnant women who practiced according to the proposed method than according to the traditional program (Fig. 3). Thus, the level of physical performance in the first half of pregnancy increased by 16.4% (= 76.9; S = 4.9 W) against 12.2% (https://pandia.ru/text/79/561/images/ image002_103.gif" width="13" height="23"> = 75.4; S = 4.2 W), while in the control - by 6% ( = 69.4; S = 4.6 W ) is more efficient than the initial data (р<0,05).

As a result, after undergoing a course of physical rehabilitation according to the proposed method, pregnant women had better success in performing a given load and, accordingly, had a higher level of physical performance, which indicates a more effective approach to the rehabilitation of pregnant women with this pathology.

Rice. 3. Data on the physical performance of pregnant women with anemia after undergoing a course of physical rehabilitation based on bicycle ergometric testing:

– basic before rehabilitation;

– control before rehabilitation;

– main after rehabilitation;

– control after rehabilitation;

* - significant difference relative to the indicators before the introduction of the physical rehabilitation program (р<0,05);

** - significant difference relative to the indicators of the main group after the course of physical rehabilitation (р<0,05).

Studies of indicators of the erythrocyte link of hematopoiesis after undergoing a course of physical rehabilitation of pregnant women with anemia showed that the indicators approached the norm in women of the main group, while in the control group there was a slight improvement. Significantly better data were also found in pregnant women of the main group (p<0,05). Так, у беременных, которые занимались по предложенной методике, эритроциты составили
= 3.93; S = 0.21 g l-1 against https://pandia.ru/text/79/561/images/image002_103.gif" width="13" height="23">.gif" width="13" height="23 src=">=49.8; S = 6.6 µg lֿ¹ vs 684

Anemia of pregnancy occupies a special place in obstetrics and hematology and is a related problem of great theoretical and practical importance.

Anemia of pregnancy is a widespread type of anemia that adversely affects the course of the gestational process, childbirth, the condition of the fetus and newborn. According to WHO, 1,987,300,000 inhabitants of the planet have anemia, i.e. this is one of the frequent (if not the most frequent) group of diseases. In Russia, over the past 10 years, there has been a significant increase in the frequency of iron deficiency and, as a result, iron deficiency anemia (IDA) in pregnant women. Thus, according to the Ministry of Health and Social Development of the Russian Federation (2005), IDA accounts for 41.7% of total number pregnant.

Anemia is a clinical and hematological syndrome caused by a decrease in the concentration of hemoglobin and (in most cases) erythrocytes per unit volume of blood.

Iron deficiency during pregnancy is associated with an increase in the need of the body of a pregnant woman for this element. So, in the II-III trimesters, it reaches 5.6-6 mg / day, which is associated with the costs of the development of the placenta and fetus (up to 350-380 mg), the formation of an additional globular volume, accompanied by increased erythropoiesis (450-550 mg), expenses for a growing uterus and other needs (150-200 mg). For unknown reasons, the absorption of iron in the small intestine in the first trimester of pregnancy decreases, and in the II and III it increases. However, this increase in absorption does not allow you to get the required daily 5.6-6 mg of iron, so its natural deficiency is created.

In most cases (up to 98-99%), anemia in pregnant women is a consequence of iron deficiency conditions.

At the end of pregnancy, latent iron deficiency (pre-latent and latent anemia) is present in almost all women, 1/3 of them develop IDA. With IDA, the iron content in the blood serum, bone marrow and depot decreases, which leads to impaired hemoglobin synthesis, the development of hypochromic anemia, and trophic disorders in tissues.

However, ID is not the only reason for the decrease in hemoglobin concentration during pregnancy. So, from the 16-18th week of pregnancy, the volume of circulating plasma increases by 40%, and the volume of circulating red blood cells - only by 20-25%. Thus, the so-called physiological hemodilution develops, which reaches its maximum values ​​by the 32nd week of pregnancy.

In iron deficiency, the main factor that has a pronounced damaging effect on the body of the mother and fetus is tissue hypoxia, followed by the development of secondary metabolic disorders. In addition, oxygen consumption during pregnancy increases by 15-33%, which exacerbates the development of hypoxia. Under conditions of insufficient oxygen supply to tissues and ATP deficiency, lipid peroxidation processes are activated, which can cause heme iron oxidation and the formation of methemoglobin, which is not able to transport oxygen. The activation of free radical fractions may result in increased lipid peroxidation of cell and subcellular membranes, plasma lipoproteins, proteins, amino acids, leading to the formation of toxic degradation products.

Pregnant women with severe anemia develop tissue, hemic and circulatory hypoxia, which leads to dystrophic changes in the myocardium, impaired contractility and the development of a hypokinetic type of blood circulation. The state of hemic hypoxia, an increase in the concentration of lactate in tissues and organs lead to an increase in the production of erythropoietin by the kidneys and, accordingly, stimulation of erythropoiesis in mild forms of IDA. In moderate and severe IDA, this compensation mechanism replaces the development of a maladjustment reaction due to the severity of hypoxia and a decrease in the production of erythropoietin by the kidneys. In this case, anemia acquires a hyporeactive character.

It is known that disturbances in iron metabolism affect the metabolism of important essential microelements, which include iodine, copper, manganese, zinc, cobalt, molybdenum, selenium, chromium and fluorine, which are part of enzymes, vitamins, hormones and other biologically active substances.

Equally, along with iron, copper and manganese are necessary for participation in the synthesis of hemoglobin and erythrocytes, as well as for providing antioxidant protection of the body.

Copper is part of erythrocytes and nucleic acids, which play an important role in the synthesis of hemoglobin, as well as in the provision of erythropoiesis and granulocytopoiesis. It contributes to the stability of the cell membrane and the mobilization of iron, its transport from the tissue to the bone marrow. In addition, copper is involved in biochemical processes as an integral part of electron-carrying proteins, i.e. in more than 90% of proteins circulating in the blood that carry out the reactions of oxidation of organic substrates with molecular oxygen. Copper deficiency can block the activity of the copper-containing enzyme superoxide dismutase, which is responsible for the inhibition of lipid peroxidation of cell membranes. Copper is essential for the entry of iron into the mitochondria. Its deficiency leads to a reduction in the life span of erythrocytes, although its direct role in the processes of hematopoiesis remains unclear. It is assumed that the effect of copper on iron metabolism is realized through ferrochelatase, which includes iron in the heme composition. At healthy people The concentration of copper in the blood is constant and increases during pregnancy and during stress.

The interaction between iron and copper becomes apparent both in the case of an excessive intake of one of the elements, and in the case of a deficiency. Copper deficiency causes iron overload due to lack of mobilization, and iron deficiency causes an increase in hepatic copper.

However, the isolated introduction of only iron reduces the content of manganese in the blood serum. Manganese serves as a cofactor in many multienzyme systems, which in turn determine the most important biochemical and physiological processes in the body: the synthesis of nucleic acids and the metabolism of various hormones. Manganese is an essential part of superoxide dismutase, which plays a key role in the regulation of free radical processes of cellular metabolism, in particular, the implementation of platelet function, ensuring normal secretion of insulin, cholesterol synthesis, regulation of chondrogenesis, etc. There are also data on the participation of manganese in the synthesis of functionally capable hemoglobin molecules.

In the study of the concentration of iron, copper and manganese in the blood of the mother, fetus and placental tissue, it was found that with IDA there is a decrease in iron in the blood of the mother and fetus and an increase in the placental tissue. This is regarded as a compensatory reaction of the mother-placenta-fetus system - cumulation of iron coming from outside.

In the human body, all three trace elements are in a competitive dynamic balance. An increased intake of one of them disrupts the balance of others due to the consumption of carrier proteins by this microelement. At the same time, when three microelements are introduced into the body at once, synergism is observed. Therefore, the iron-copper-manganese combination better satisfies the needs of the body of a pregnant woman, which does not happen when only one of them is received.

The main criteria for IDA are a decrease in the level of hemoglobin and a color indicator that reflects the content of hemoglobin in the erythrocyte. Morphologically, erythrocyte hypochromia, microcytosis, anisocytosis and poikilocytosis are determined. The content of reticulocytes in the blood, as a rule, remains within the normal range. An important diagnostic value is a decrease in the level of serum iron and ferritin and an increase above the normative values ​​of transferrin and total iron-binding capacity of serum. Recently, it has been important to determine the level of transferrin receptors in blood plasma, which are a sensitive indicator of the degree of tissue iron deficiency.

There are several classifications of anemia based on etiological, pathogenetic and hematological features.

In practice, the severity of the clinical course of anemia is usually determined by the level of hemoglobin in the peripheral blood. According to WHO recommendations (2001), the lower limit of the normal concentration of hemoglobin for a pregnant woman is reduced to 110 g / l (outside pregnancy - 120 g / l), hematocrit - up to 33% (outside pregnancy - 36%).

Iron deficiency leads to increased susceptibility of pregnant women to infectious diseases, since this mineral is involved in the growth of the body and nerves, collagen synthesis, porphyrin metabolism, terminal oxidation and oxidative phosphorylation in cells, and in the work of the immune system.

Anemia of pregnant women is accompanied by changes in the utero-placental complex. Dystrophic processes develop in the myometrium. In the placenta, hypoplasia is noted, the level of progesterone, estradiol, and placental lactogen decreases.

IDA is characterized not only by heme changes, but also by protein metabolism disorders. If hypoproteinemia occurs only with severe anemia, then hypoalbuminemia is also observed with moderate and mild disease. Hypoalbuminemia is accompanied by severe dysproteinemia. Severe hypoproteinemia and hypoalbuminemia are the cause of edema in pregnant women with severe anemia.

With anemia, depending on its severity, immunosuppression is noted. Immunological changes are manifested in the form of a decrease in the phagocytic activity of leukocytes and complementary activity of blood serum, a deficiency of circulating T-lymphocytes, and in cases of severe anemia, a decrease in the level of B-lymphocytes.

The clinical picture of IDA depends on the severity of iron deficiency. With a mild degree of IDA, clinical symptoms are usually absent, and only laboratory parameters are objective signs. Clinical symptoms appear, as a rule, with anemia of moderate severity. As iron deficiency increases, weakness, dizziness, headache, palpitations, shortness of breath, fainting, decreased performance, and insomnia appear. These symptoms are not specific to IDA and may be seen in anemia of other etiologies. Pathognomonic for IDA can be considered a perversion of taste, changes in the skin, nails, hair, muscle weakness, corresponding to the degree of anemia.

Anemia of pregnancy can adversely affect the course of pregnancy, birth outcomes and fetal development. So, according to different authors, in pregnant women with IDA, preeclampsia occurs 1.5 times more often, premature termination of pregnancy is 15-42%, including premature birth, polyhydramnios, untimely discharge amniotic fluid observed in every 3rd pregnant woman, weakness of labor forces - in 15%, increased blood loss during childbirth - in 10%, postpartum septic complications - in 12%, hypogalactia - in 39% of women.

Anemia of pregnant women has an adverse effect on the intrauterine state of the fetus, contributing to the development of the syndrome of fetal growth retardation and complications during the early neonatal period. In children during the neonatal period, there is a large loss of body weight and its slower recovery, belated falling off of the umbilical cord residue and delayed epithelialization of the umbilical wound, a long course physiological jaundice.

According to the etiological and pathogenetic factors of iron deficiency anemia, treatment should be comprehensive, aimed at eliminating the cause of the disease, and include adequate intake of microelements, vitamins, proteins and correction of iron deficiency.

The diet during pregnancy should be rational and contain, in addition to iron, essential trace elements. However, since it is iron deficiency that plays a leading role in the pathogenesis of anemia during pregnancy, the main attention is paid to this problem.

When choosing a diet, one should focus not on the amount of iron in the product, but on the form in which it is presented. It is the form that determines the percentage of absorption and assimilation of iron, therefore, the effectiveness of diet therapy. Iron is absorbed most effectively from foods that contain it in the form of heme, when it is actively captured and absorbed by the cells of the intestinal mucosa in unchanged form (beef tongue, rabbit meat, turkey meat, chicken meat, beef). The processes of heme absorption in the intestine do not depend on the acidity of the environment and inhibitory nutrients. In cereals, fruits and vegetables, iron is in non-heme form and absorption from them is much worse. The presence of oxalates, phytates, phosphates, tannin and other inhibitors of ferroabsorption also contributes to a decrease in absorption. It should be noted that meat, liver, fish, ascorbic acid, as well as substances that lower the pH of food (for example, lactic acid), increase the absorption of iron from vegetables and fruits while consuming them. A diet that is complete and balanced in terms of its main ingredients can only "cover" the body's physiological need for iron, but not eliminate its deficiency, and should be considered as one of the auxiliary components of therapy.

Risk factors for developing anemia in pregnancy:

State Autonomous Professional educational institution Republic of Bashkortostan

"Birsk Medical and Pharmaceutical College"

COURSE WORK

Features of the course of pregnancy and childbirth with anemia

Artist: Mukhametova Gulnaz

4th year student,

m/s com B group

Introduction

Chapter 1. Anemia during pregnancy and childbirth

1 Etiology and pathogenesis

2 Severity of anemia and manifestations of anemia

3 Why is anemia dangerous during pregnancy?

4 Diagnosis and treatment

5 Principles of therapy

6 Course and management of pregnancy and childbirth

1.7 Iron deficiency anemia and pregnancy

Conclusion on the theoretical part

Chapter 2

1 Materials and research methods

2 Research results and discussion

Conclusion

Bibliography

Introduction

The relevance of research:

Anemia complicates the course of pregnancy and childbirth, affects the development of the fetus. Even with hidden iron deficiency, 59% of women have an unfavorable course of pregnancy and childbirth.

Features of the course of pregnancy with anemia.

Threat of termination of pregnancy (20-42%).

Early toxicosis (29%).

Preeclampsia (40%).

Arterial hypotension (40%).

Premature placental abruption (25-35%).

Fetoplacental insufficiency, fetal growth retardation syndrome (25%).

Premature birth (11-42%).

Features of the course of childbirth and the postpartum period with anemia.

Premature discharge of amniotic fluid.

Weak labor activity (10-37%).

Premature detachment of the placenta.

Atonic and hypotonic bleeding in the afterbirth and early postpartum period (10-51.8%).

DIC and coagulopathy bleeding (chronic and subacute form of DIC, platelet hypofunction, shortened APTT, increased prothrombin index).

Purulent-septic diseases in childbirth and the postpartum period (12%).

Hypogalactia (39%).

Antenatal and intranatal fetal hypoxia.

Perinatal mortality in anemia ranges from 4.5 to 20.7%. congenital anomalies fetal development occurs in 17.8% of cases.

Anemia complicating the course of pregnancy is a common pathology. They are detected in 15-20% of pregnant women. There are 2 groups of anemia: those diagnosed during pregnancy and those that existed before the onset of it. Anemia most often occurs during pregnancy.

Most women develop anemia by the 28-30th week of a physiological pregnancy. Such changes in the picture of red blood, as a rule, do not affect the condition and well-being of the pregnant woman.

True anemia of pregnant women is accompanied by a typical clinical picture and affects the course of pregnancy and childbirth.

Causes of occurrence. Anemia in pregnant women is the result of many reasons, including those caused by pregnancy: high levels of estrogen, early gestosis, which prevent the absorption of iron, magnesium, and phosphorus elements in the gastrointestinal tract, which are necessary for hematopoiesis.

Purpose: To consider anemia during pregnancy and childbirth.

To study the etiology and pathogenesis of anemia

Discuss the severity of anemia and manifestations of anemia

To study the course and management of pregnancy and childbirth

4. Consider iron deficiency anemia and pregnancy

Consider materials and research methods

Object of study: Features of the course of pregnancy and childbirth.

Subject of study: Features of the course of pregnancy and childbirth with anemia.

Chapter 1. Anemia during pregnancy and childbirth

1 Etiology and pathogenesis

Anemia in pregnant women is the result of many reasons, including those caused by pregnancy: high levels of estrogen, early gestosis, which prevent the absorption of iron, magnesium, and phosphorus elements in the gastrointestinal tract, which are necessary for hematopoiesis. One of the main reasons for the development of anemia in pregnant women is considered to be a progressive iron deficiency, which is associated with the utilization of iron for the needs of the fetoplacental complex, to increase the mass of circulating red blood cells. However, most women of childbearing age do not have an adequate supply of iron; decreases with each subsequent birth, especially complicated by bleeding and the development of posthemorrhagic (iron deficiency) anemia. The lack of iron stores in the body of women may be due to its insufficient content in the usual diet, the way food is processed and the loss of vitamins necessary for absorption (folic acid, vitamins B12, B6, C); with the lack in the diet of a sufficient amount of raw vegetables and fruits, animal proteins (milk, meat, fish).

All of the above factors can be combined with each other and lead to the development of true iron deficiency anemia in pregnant women, against which 40% of women develop OPG - preeclampsia. Anemia of pregnant women is associated with a violation of the mechanism of lipid peroxidation. Acute infectious diseases, influenza, gastrointestinal diseases, tonsillitis, sinusitis, hypotension, in some cases, late onset of menstruation, spontaneous abortions, and premature births predispose to the development of anemia. Anemia often occurs in multi-pregnant women in the second half of pregnancy.

1.2 Severity of anemia and manifestations of anemia

The severity of anemia is determined by the level of hemoglobin in the peripheral blood. There are 3 degrees of severity:

I. Hemoglobin 100-91 g / l, erythrocytes 3.6-3.2 * 1012 / l.

II. Hemoglobin 90-71 g / l, erythrocytes 3.2-3.0 * 1012 / l.

III. Hemoglobin is less than 70 g/l, erythrocytes are less than 3.0×10 12/l

It is characterized by pallor of the skin and mucous membranes, dry skin, brittle nails, increased heart rate. Symptoms associated with impaired tissue trophism: cracks in the palms, heels, brittle hair and hair loss, smoothness of the papillae of the tongue, cracks in the lips, stomatitis - they indicate the duration of anemia that prevents the development of pregnancy. Anemic myocardial dystrophy may occur, which can lead to acute cardiovascular failure.

In pregnant women suffering from even mild anemia, the level of total protein in the blood decreases. This leads to the development of fetoplacental insufficiency, which is clinically manifested in 20% of cases by intrauterine fetal malnutrition, and in 10% by miscarriage. Children of the 1st year of life in women with anemia of pregnancy fall ill with ARVI 10 times more often than in healthy women, enterocolitis, pneumonia, and allergic alertness in the form of exudative diathesis often occur. Features of the course of pregnancy and childbirth. Often, a severe degree of anemia develops in multi- and frequent-bearing women. The frequency of late gestosis with anemia in pregnant women is 29%. Hypoproteinemia - reduced protein levels. Increasing percentage premature birth. Stillbirth - 11.5% due to antenatal death of the fetus. In childbirth with anemia in pregnant women, obstetric bleeding occurs 3-4 times more often than in healthy children.

1.3 Why is anemia dangerous during pregnancy?

For the child: In children whose mothers suffered from anemia during pregnancy, iron deficiency is also often found by the age of one. Children of the first year of life born to women with anemia of pregnancy are much more likely to get ARVI, they are much more likely to develop enterocolitis, pneumonia, and various forms of allergies (including diathesis).

How to prevent anemia in pregnancy? In some women, it is possible to foresee the development of anemia during pregnancy: in those who previously suffered from it, suffer from chronic diseases of internal organs, in women who have given birth many times, and also if at the beginning of pregnancy the hemoglobin content in the blood did not exceed 120 g / l. In all these cases, preventive treatment is necessary. Doctors usually prescribe an iron supplement, which is recommended for 4-6 months starting from the 15th week of pregnancy.

1.4 Diagnosis and treatment

The assessment of the severity of the disease is based on indicators of hemoglobin content, hematocrit level, iron concentration in blood plasma (normally 13 - 32 μmol / l), iron-binding ability of transferrin and transferrin saturation with iron. As the disease develops, the concentration of iron in the blood plasma decreases, the iron-binding ability increases, as a result, the percentage of transferrin saturation with iron decreases to 15% or less (normally 35-50%). The hematocrit is reduced to 0.3 or less. Stocks are judged by the level of ferritin in the blood serum - a protein containing iron atoms. Serum ferritin is determined by radioimmunoassay. At the same time, a study of other biochemical parameters of blood, a study of the function of the liver, kidneys, and gastrointestinal tract are carried out. Exclude the presence of specific infectious diseases, tumors of various localizations. It is advisable to conduct a study of a blood smear obtained by sternal puncture. A characteristic feature of the blood in iron deficiency anemia is hypochromia and microcytosis of erythrocytes.

It is possible to prevent the development of serious disorders in the mother and fetus by timely prevention of anemia: starting from the second half of pregnancy, milk nutritional mixtures such as Enpit, Vigor and others containing microelements necessary for erythropoiesis are prescribed. With a decrease in the level of hemoglobin less than 110 g / l, iron preparations are prescribed: ferroplex, iron sulfate, ferramid, maltofer, hemostimulin and others. The introduction of iron preparations is combined with the appointment of a complex of vitamin tablets "Gendevit", "Undevit", "Aevit" or vitamins B1, B12 in injections. A significant excess of free radicals led to the widespread use of antioxidants in the treatment of anemia in pregnant women: vitamin E, unithiol. Treatment is supplemented with the appointment of vitamins of group A, folic acid. The etiological treatment of anemia is the basis in the treatment of placental insufficiency. Periodically (at least 3 times) a comprehensive examination of the intrauterine fetus is carried out, the growth of its mass, the state of hemodynamics are monitored. Treatment of anemia should be comprehensive and long-term, as the symptoms of anemia continue to increase with the progression of pregnancy. Treatment can be done in outpatient settings, but in severe forms of the disease, it is necessary to send the pregnant woman to the hospital, especially on the eve of childbirth.

Treatment I st. - is carried out on an outpatient basis, and II and III Art. - in the hospital.

5 Principles of therapy

protein diet

Correction of deficiency of iron, protein, trace elements, vitamins Elimination of hypoxia of the body

Treatment of placental insufficiency

Normalization of hemodynamics, systemic, metabolic and organ disorders

Prevention of complications of pregnancy and childbirth

Early rehabilitation in the postpartum period

Family planning

Proteins occupy a special place in the nutrition of a pregnant woman. The daily diet should contain 2-3 g of protein per 1 kg of body weight of a woman, 180-240 g - in the form of boiled meat or poultry (60-100 g), fish (40-60 g), cottage cheese (100-120 g) , egg 1 pc., cheese 15 g. Fats 75 g per day in the form of butter and vegetable oil. The main source of iron is meat products: beef, liver, offal contain 5-15 mg of iron per 100 g of the product. Rich in iron: eggs, fish, oatmeal and buckwheat, beans, bread (1-5 mg / 100 g). Iron contained in fruits is well absorbed: peaches, spinach, parsley - vitamin C is also present there. Iron is also found in pomegranates, apricots, melons, beets, tomatoes.

Carbohydrates (350-400 g per day) come in the form of vegetables, fruits (tomatoes, eggplants, potatoes, green onions, parsley, spinach, green peas, beans, cabbage, melon, apricots, apples, apricots, cherry plums, figs, pomegranates, pumpkin), dried fruits (dried apricots, raisins, wild rose), cereals (rice, oatmeal, buckwheat, rye bread). When fruits are not enough, juices are consumed (apple, plum, tomato, carrot, pomegranate). The total calorie content of the diet in the first half of pregnancy should be 2500-2700 kcal, in the second half - 2900-3200 kcal. Food should contain vitamins of groups B, C, folic acid, taking into account the increased need for them during pregnancy: vitamin C up to 70-100 mg, folic acid up to 40-60 mg. Vitamin C is found in: tomatoes, dried rose hips, red peppers, lemons, apples, grapes, walnuts, red and black currants. Folic acid in: liver, kidney, poultry, potatoes, green onions, cucumbers, beets, beans, cauliflower, spinach, yeast, melon. The requirement for vitamin B12 is 4 micrograms per day. It is found in the liver, kidneys, cod and cod liver. Vitamin preparations are also recommended for women threatened with the development of anemia: gendevit, undevit, oligovit, vitamin C - 1 g: 10-15 days.

Medical treatment: Art. under the control of red blood, with a color index less than 0.8 - iron preparations: ferrogradment, ferroplex, ferrocal and others. Vitamin C 0.5 g per day, methionine 0.25 g 4 times a day, glutamic acid 0.5 g 3-4 times a day. II and III Art. (carried out in a hospital) the same as I st. + intramuscular preparations, folic acid 5 mg 3 times a day. Treatment of placental insufficiency: glucose, intravenous aminofillin, trental, etc.

6 Course and management of pregnancy and childbirth

Pregnancy is contraindicated in aplastic anemia and hemoglobinopathies due to high maternal and perinatal mortality; in other types of anemia, pregnancy is allowed. Iron deficiency anemia is accompanied by numerous complications during pregnancy and childbirth, both in the mother and the fetus. These complications include miscarriage. In the presence of severe violations of erythropoiesis, the development of obstetric pathology is possible in the form of premature detachment of the placenta, bleeding during childbirth and the postpartum period. A constant oxygen deficiency can lead to the development of dystrophic changes in the myocardium in pregnant women. Clinical signs of myocardial dystrophy may include heart pain and ECG changes.

Iron deficiency anemia has an adverse effect on the development of contractile activity of the uterus, either prolonged prolonged labor or fast and rapid labor is possible. True anemia of pregnant women can be accompanied by a violation of the properties of the blood, which is the cause of massive blood loss. A characteristic sign of anemia in pregnant women is the birth of immature children with low body weight. Often there is hypoxia, malnutrition and anemia of the fetus. Hypoxia of the intrauterine fetus may result in its death during childbirth or in the postpartum period. Birth outcomes for children whose mothers suffered anemia during pregnancy are closely related to the etiological factors of anemia. Iron deficiency in the mother during pregnancy affects the growth and development of the brain in the child, causes serious deviations in the development of the immune system, anemia and infection may develop during the life of the newborn. Childbirth is usually conducted conservatively.

1.7 Iron deficiency anemia and pregnancy

Hematological diseases in pregnant women are primarily anemia, which account for 90% of blood diseases. Moreover, 9 out of 10 patients with anemia suffer from iron deficiency anemia (IDA). Other forms of anemia are much less common, with essentially the same frequency as in the population among non-pregnant women or slightly more often. IDA is a disease in which the iron content in the blood serum, bone marrow and depot is reduced. As a result, the formation of hemoglobin is disrupted, hypochromic anemia and trophic disorders in tissues occur. IDA remains a serious problem of extragenital pathology in obstetrics, since the frequency of the disease does not decrease.

IDA is widespread throughout the world. They affect people of both sexes at any age, but especially children, young girls and pregnant women. At the end of pregnancy, almost all women have a hidden iron deficiency, and 1/3 of them develop IDA (M.S. Rustamova, 1991; S.N. Vakhrameeva et al., 1996; I. Puolakka et al., 1980) . Like hypovitaminosis, this is one of the most common nutritionally dependent conditions in pregnant women (M.K. Kalenga et al., 1989). According to WHO, the frequency of IDA in pregnant women in different countries ranges from 21 to 80%, judging by the level of hemoglobin, and from 49 to 99% - according to the level of serum iron. In underdeveloped countries, the frequency of IDA in pregnant women reaches 80%. In countries with a high standard of living and a lower birth rate, IDA is diagnosed in 8-20% of pregnant women. Over the past decade, due to the decline in the standard of living of the population of Russia, the frequency of IDA has increased significantly, despite the low birth rate. In 1987, in Moscow, this disease occurred in 38.9% of pregnant women (M.M. Shekhtman, O.A. Timofeeva). The frequency of anemia, according to the Ministry of Health of the Russian Federation, has increased by 6.3 times over the past 10 years.

Table 1. Main oral iron preparations.

The main reason for the development of IDA is blood loss of various nature. They violate the balance existing in the body between the intake and excretion of iron. The natural source of iron is food. A woman consumes daily with food an average of 2000-2500 kcal, which contain 10-20 mg of iron, of which no more than 2 mg can be absorbed - this is the absorption limit of this mineral. At the same time, a woman loses about 1 mg of iron daily with urine, feces, sweat, listening to the skin epithelium, and falling hair. In this, women are no different from men. However, women also lose a significant amount of blood during menstruation, pregnancy, childbirth and lactation. Therefore, often the need for iron exceeds the ability to absorb iron from food. This is what causes IDA. Up to 75% of healthy women lose 20-30 mg of iron during menstruation. In the days remaining until the next menstruation, the body compensates for this loss and anemia does not develop. With heavy or prolonged menstruation, 50-250 mg of iron is released from the blood. The need for iron in these women increases by 2.5-3 times. Such an amount of iron cannot be absorbed even with a high content of it in food. There is an imbalance leading to the development of anemia (LI Idelson, 1981).

This view dominates the literature. However, there are also objections. They relate to menstrual blood loss, which is not so great and does not correlate with the amount of hemoglobin (C. Hershko, D. Brawerman, 1984) and the possibility of iron absorption more than 2 mg / day. A number of authors claim that with iron deficiency in the body, its absorption from bread increases by 1.51 times, and with anemia - by 3.48 times. IA Shamov (1990) proceeds from the fact that the human body is a complex self-regulating (homeostatic) system. Homeostasis has been worked out and fixed in the course of a long evolution. Pathology occurs only in those cases when the action of the "disturbing" factor is excessive or several factors act simultaneously. A significant increase in the body of factors counteracting anemization is evidenced by the fact that with IDA, the number of receptors that bind transferrin increases by 100 times or more. This increase has great importance and in the absorption of iron and the implementation of increased intestinal absorption (K. Shumak, R. Rachkewich., 1984). I.A. Shamov (1990) examined 1061 girls aged 16-22 and found that neither prolonged nor heavy menstruation lead to a decrease in hemoglobin levels.

Iron loss during each pregnancy, childbirth and during lactation is 700-900 mg (up to 1 g) of iron. The body is able to restore iron stores within 4-5 years. If a woman gives birth before this period, she inevitably develops anemia. Iron deficiency inevitably occurs in a woman with more than 4 children (LI Idelson, 1981). Many factors predispose to the development of anemia both outside and during pregnancy. This may be a decrease in the intake of iron from food (with a predominantly vegetarian diet); however, I.A. Shamov (1990) did not find this relationship. Possible violation of the absorption of iron in the digestive tract, which is rare. Violation of iron absorption in the intestine is observed in chronic enteritis, after extensive resection of the small intestine and in chronic pancreatitis with impaired exocrine function. T.A. Izmukhambetov (1990) draws attention to environmental pollution with chemicals, pesticides, high salinity of drinking water as circumstances that prevent the absorption of iron from food products.

Chronic overt or hidden loss of iron by the body due to gastrointestinal bleeding in gastric and duodenal ulcers, hemorrhoids, hiatal hernia, cardia insufficiency, reflux esophagitis, erosions of the gastric mucosa, diverticulum of the small (Mikkel's diverticulum) and colon, nonspecific ulcerative colitis, helminthic invasion (ankylostomoidosis), etc. lead to anemia in patients outside and especially during pregnancy. Endometriosis, the frequency of which is increasing, uterine fibroids and other gynecological diseases, accompanied by external or internal bleeding, can be the cause of IDA prior to pregnancy.

Diseases manifested by chronic nasal bleeding are also anemized: idiopathic thrombocytopenic purpura, thrombocytopathies, Rendu-Osler disease (hereditary hemorrhagic telangiectasia) and renal bleeding: glomerulonephritis, urolithiasis, hemorrhagic diathesis.

The cause of anemia can be a pathology of the liver in pregnant women with chronic hepatitis, hepatosis, with severe toxicosis of pregnant women, when there is a violation of the deposition of ferritin and hemosiderin in the liver, as well as a lack of synthesis of iron-transporting proteins.

Achilia due to atrophic gastritis - possible reason IDA. Indeed, hydrochloric acid promotes the absorption of dietary iron. However, L.I. Idelson (1981) believes that in itself a violation of gastric secretion does not lead to the development of IDA. We (M.M. Shekhtman, L.A. Polozhenkova) studied the indicators of red blood, serum iron and basal gastric secretion in 76 non-pregnant, healthy pregnant women and women with anemia that occurred during pregnancy. The debit-hour of hydrochloric acid was significantly reduced in uncomplicated pregnancy (1.67±0.31 meq compared with 3.6±0.67 meq in non-pregnant women) and even more in anemia of pregnant women (0.4±0.2 meq) . The debit-hour of free hydrochloric acid also decreases during pregnancy, but with anemia it is almost the same as in healthy pregnant women. Our data suggest that both factors - iron deficiency and the state of gastric secretion - are important in the pathogenesis of anemia in pregnant women. As the work of many researchers shows, it is not hydrochloric acid that plays a role in the absorption of iron, but other components of gastric juice. VN Tugolukov (1978) believes that a significant decrease in the secretion of macromolecular substances (gastromucoproteins), which are directly related to iron metabolism in its early phases, is reflected in its absorption in erythropoiesis. Iron forms strong high-molecular compounds with the biocomponents of gastric juice. The acidity of gastric juice is of limited importance and only creates optimal conditions for ionization and complex formation in the stomach. The transformation of ferric iron oxide obtained from food into a divalent form easily absorbed in the intestine in patients with IDA is difficult, and in some cases is absent. Probably, complex formation is of primary importance for the absorption of various forms of dietary iron and plays a lesser role in the treatment of anemia with ferrous iron preparations. The hypochromic IDA observed by us in pregnant women with a resected stomach also testifies to the role of gastric juice in erythropoiesis.

Predispose to the development of anemia in a pregnant woman and factors such as frequently recurring bleeding with placenta previa; anemia that existed in the mother during pregnancy; prematurity of the patient (since up to 1.5 years the mechanism of iron absorption is "not turned on" and the child's hematopoiesis occurs due to the accumulated iron stores); chronic internal diseases accompanied by anemia (pyelonephritis, hepatitis, etc.); seasonality and related changes in the composition of food (vitamin deficiency in the winter-spring period).

O.V. Smirnova, N.P. Chesnokova, A.V. Mikhailov (1994) identifies the following main etiological factors of IDA:

) blood loss;

) nutritional factor;

) gastrogenic factor;

) enterogenic factor.

Conclusion on the theoretical part

Based on everything, we can say that iron deficiency anemia is a pathological condition characterized by impaired hemoglobin synthesis as a result of iron deficiency, which develops against the background of various pathological or physiological (pregnancy) processes. It occurs in 20-30% of all women, in 40-50% of women of childbearing age, in 45-99% of pregnant women. IDA accounts for about 90% of all anemias. According to WHO, the incidence of IDA in pregnant women ranges from 14% in Europe to 70% in Southeast Asia. In countries with a high standard of living, IDA is diagnosed in 18-25% of pregnant women, in developing countries this figure can reach 80%. The frequency of this pregnancy complication in Russia is 30-40% and is growing steadily. Over the past decade, according to the Ministry of Health and Social Development of Russia, the frequency of IDA has increased by 6.8 times.

According to modern data, iron deficiency at the end of the gestational process develops in all pregnant women, without exception, either in a latent or explicit form. This is due to the fact that pregnancy is accompanied by an additional loss of iron: 320-500 mg of iron is spent on an increase in hemoglobin and increased cellular metabolism, 100 mg - on the construction of the placenta, 50 mg - on an increase in the size of the uterus, 400-500 mg - on the needs of the fetus. As a result, taking into account the reserve fund, the fetus is provided with iron in sufficient quantities, but at the same time, iron deficiency conditions of varying severity often develop in pregnant women.

anemia hemoglobin pregnancy

Chapter 2

The negative impact of IDA on the course of pregnancy is explained by the fact that developing hypoxia can cause stress in the body of the mother and fetus, stimulating the synthesis of corticotropin-releasing hormone (CRH). Elevated concentrations of CRH are the main risk factor for preterm birth, preeclampsia, and premature rupture of amniotic fluid. CRH enhances fetal cortisol release, which can inhibit fetal growth. The result of these complications of IDA may be oxidative stress of erythrocytes and the fetoplacental complex.

With a long course of anemia, the function of the placenta is disturbed, its trophic, metabolic, hormone-producing and gas exchange functions change, and placental insufficiency develops. Often (in 40-50%) preeclampsia joins; preterm birth occurs in 11-42%; weakness of labor activity is noted in 10-15% of women in labor; hypotonic bleeding during childbirth - in 10%; the postpartum period is complicated by purulent-septic diseases in 12% and hypogalactia in 38% of puerperas.

Fetoplacental insufficiency (FPI) in IDA is caused by a sharp decrease in the level of iron in the placenta, a change in the activity of respiratory enzymes and metalloproteinases.

A.P. Milovanov believes that one of the essential mechanisms in the development of hypoxic, circulatory, tissue and hemic hypoxia in the placenta is the pathology of the spiral arteries of the uterus. According to G.M. Savelieva et al., FPI of any etiology is based on disorders of placental circulation, including microcirculation, and metabolic processes, which are closely related and often interdependent. They are accompanied by changes in blood flow not only in the placenta, but also in the body of the mother and fetus. This fully applies to FPI that develops during pregnancy aggravated by IDA.

The main criteria for IDA are a low color index, hypochromia of erythrocytes, a decrease in serum iron, an increase in the total iron-binding capacity of blood serum, and clinical signs of hyposiderosis. The most important indicator of anemia is the level of hemoglobin, at which anemia should be diagnosed. This value has repeatedly changed in the direction of increasing the minimum indicator: 100, 110 g/l (WHO, 1971). Mild (I) degree of anemia is characterized by a decrease in hemoglobin levels to 110-90 g/l; medium (II) degree - from 89 to 70 g/l; heavy (III) - 70 and less g/l.

Treatment of IDA involves, in addition to eliminating the main cause of this pathological condition, the use of iron preparations. The ideal antianemic drug should contain the optimal amount of iron, have minimal side effects, have a simple circuit applications, the best efficiency/price ratio. However, many iron-containing preparations have a number of disadvantages that create problems in their use: unpleasant organoleptic properties, low bioavailability, the ability to irritate the mucous membrane of the gastrointestinal tract, which often causes dyspepsia. From this point of view, interest in the problem of finding new methods of treating IDA that can affect not only the condition of a pregnant woman, but also prevent adverse complications in the fetus associated with impaired functioning of the FPC is justified.

Treatment of IDA in pregnant women should be comprehensive. First of all, you need to pay attention to the diet. However, the main type of therapy for IDA in pregnant women is iron preparations. Of great clinical interest is Sorbifer Durules with a high content of Fe2+ (100 mg) and ascorbic acid (60 mg), which creates more favorable conditions for iron absorption in the intestine and ensures its higher bioavailability.

1 Materials and research methods

Observation of 115 pregnant women with IDA in the II and III trimesters of gestation. Pregnant women are divided into two groups. In the 1st group in 75 pregnant women in whom anemia was diagnosed in the second trimester of pregnancy; 2nd group (comparison group) 40 patients who were admitted to the group " Future mom» in the Birsk Central District Hospital before delivery at 35-40 weeks of gestation.

All pregnant women received IDA therapy with the iron-containing drug Sorbifer Durules in continuous mode from the II trimester (1 tablet per day), and in pregnant women of the 2nd group, this drug was used at 36-38 weeks (1 tablet 2 times a day).

The age of the patients ranged from 22 to 37 years. In 37 (49.6%) patients of the 1st group and in 21 (52.5%) of the 2nd group, the first birth was expected, in 38 (50.4%) and 19 (47.5%) - repeated. Of the features of the obstetric and gynecological history in pregnant women of both groups, menstrual irregularities in 17 (22%) and 16 (40%), respectively, spontaneous miscarriages - in 18 (24%) and 10 (25%) should be noted. 5 (7%) patients of the 1st group and 6 (15%) patients of the 2nd group had a history of perinatal losses. 88.6% of pregnant women in both groups had various extragenital diseases: pathology of the cardiovascular system in 12 (16%) pregnant women in the 1st group, in 6 (15%) - in the 2nd; chronic tonsillitis - in 12 (16%) and 7 (17.5%) patients, respectively; chronic bronchopulmonary diseases - in 5 (6.6%) and 3 (7.5%); type 1 diabetes - in 8 (11%) and 9 (22.5%); thyroid pathology - in 5 (6.6%) and 4 (10.0%), respectively.

The listed somatic diseases and complications of obstetric and gynecological history created an unfavorable background for the development of pregnancy, causing deviations in the course of gestation.

Laboratory diagnosis of anemia was based on the determination of hemoglobin content, the number of red blood cells, serum iron and blood color index.

The study of uteroplacental-fetal blood flow was carried out on an ultrasound device Voluson-730, equipped with a specialized sensor (RAB 4-8p), using color Doppler mapping and pulsed Doppler umbilical artery, fetal thoracic aorta, fetal middle cerebral artery and placental vessels. Qualitative analysis of blood flow velocity curves included determination of the systolic-diastolic ratio (S/D) in the listed vessels (standard values ​​of S/D in the aorta up to 5.6, in the umbilical artery up to 2.8, in the spiral arteries 1.60 - 1.80 , middle cerebral artery 3.5-5.0). An increase in cerebral blood flow is a manifestation of compensatory centralization of fetal circulation in intrauterine hypoxia in conditions of reduced placental perfusion. According to D. Arduini et al. Doppler studies indicate that fetuses with intrauterine growth retardation (IUGR) and anemia have a significant decrease in the pulsation index in the middle cerebral artery. Researchers find that the pulsatile readings of the middle cerebral artery are best test in the detection of this pathology. With fetal hypoxia, the resistance to blood flow in the common carotid artery and middle cerebral artery decreases, and the resistance in the aorta and umbilical artery increases (method sensitivity 89%, specificity 94%).

When visually evaluating the results of a 3D study of the selected area of ​​the placenta, attention was paid to the nature of the distribution of the vascular component, the organization of the vessels in the study area. When computer processing of placentograms, the following parameters were calculated: VI - vascularization index, FI - blood flow index. Normative indicators of uteroplacental blood flow, developed in the department of perinatal diagnostics MONIAH: central zone - VI 4.0-8.1; FI 42.0-45.0; paracentral - VI 3.8-7.6; FI 40.5-43.7; peripheral - VI 2.8-5.9; FI 37.5-42.1.

To verify the ultrasound signs of FPI, the study of the morphological state of the placenta after childbirth was carried out.

2 Research results and discussion

Various clinical manifestations of anemia (pallor of the skin and visible mucous membranes, tachycardia, weakness, decreased performance, dizziness, paresthesia of the lower extremities) were present in 12 (16.0%) patients of the 1st group and in 20 (50%) - 2- th group.

The course of this pregnancy was aggravated by early toxicosis in 36 (48%) and 27 (67.5%) patients of the 1st and 2nd groups, respectively, the threat of abortion in the first trimester - in 18 (24.0%) and 26 ( 65.0%). The II trimester of pregnancy was complicated by the threat of abortion in 8 (10.6%) women of the 1st group and in 18 (45.0%) - of the 2nd group, dropsy of pregnant women - in 5 (6.6%) and 11 (27 .5%) respectively. In the third trimester, the main complications of gestation were preeclampsia of mild and moderate severity - in 6 (8.0%) and 9 (22.5%) pregnant women of the 1st and 2nd observation groups, the threat of preterm birth - in 5 (6. 6%) and 8 (20%), and in 3 pregnant women of the 1st group and in 7 - 2nd, despite the ongoing therapy, premature birth occurred at 35-36 weeks of pregnancy. Diffuse thickening of the placenta was diagnosed in 4 (5.3%) pregnant women of the 1st group and 5 (12.5%) - of the 2nd, FPI - in 16 (21.3%) and 23 (57.5%), IUGR - in 15 (20.6%) patients of the 1st group and in 26 (65.0%) of the comparison group, oligohydramnios - in 12 (16.0%) and 7 (17.5%), polyhydramnios - in 4 (5.3%) and 5 (12.5%) respectively. It is noteworthy that the most severe gestational complications - FPI and IUGR were observed in patients with anemia of II and III degrees (Table 1). These women also had the most serious extragenital diseases (diabetes mellitus, arterial hypertension, bronchopulmonary diseases).

Childbirth in patients of the comparison group was significantly more often complicated by untimely discharge of water, anomalies in labor activity; afterbirth and early postpartum periods - bleeding. The course of the postpartum period was much more often pathological.

The presented data indicate significantly more frequent complications during pregnancy, childbirth and the postpartum period in patients of the 2nd group (p<0,05). Значительно реже гестационные осложнения наблюдались у пациенток с анемией легкой степени. В частности, у них не отмечено признаков внутриутробного страдания плода. Это свидетельствует о том, что частота и тяжесть гестационных осложнений коррелируют со степенью тяжести анемии. Всем беременным проведена комплексная терапия гестационных осложнений, в том числе профилактика или лечение ФПН (антиагрегантная, антиоксидантная терапия, гепатопротекторы).

Indicators of red blood in pregnant women with IDA before and during the background. The increase in the average level of hemoglobin in the 1st group after treatment in relation to the baseline was 23.2 g/l, serum iron - 11.6 µmol/l, while in the 2nd group there was no significant positive dynamics in red blood values ​​and the increase in hemoglobin level was 5 g/l, and the level of serum iron remained almost at the initial level.

Indicators of volumetric uteroplacental blood flow in pregnant women of both groups are presented in Table 2.

Our studies indicated a decrease in placental vascularization (hypovascularization) in patients of the 2nd group, but in the 1st group, slightly reduced rates were recorded in peripheral areas, while in the 2nd group they were low in all areas, which was due to vascular spasm and beginning rheological disturbances in the intervillous space. In patients of both the 1st and 2nd groups, placental circulation disorders correlated with changes in maternal and fetal hemodynamics, which was expressed in a significant increase in resistance in the spiral arteries, in the vessels of the umbilical cord and aorta, and the C/D values ​​in the spiral arteries approached linear form (Table 3).

In the 2nd group, there was a tendency to a greater increase in C/D. At the same time, S/D in the middle cerebral artery of the fetus was increased only in pregnant women of the 2nd group. Only in one patient of the 2nd group with severe anemia (Hb 68 g/l) with increased resistance to blood flow in the umbilical artery and fetal aorta in the middle cerebral artery, its decrease was noted. The child was born with severe anemia (Hb 112 g/l). When drugs aimed at improving the function of FPC, as well as an iron-containing drug, were included in therapy, there was a positive trend in volumetric blood flow in patients of both groups compared with baseline data, however, in pregnant women of the 2nd group, they remained somewhat lower than in patients 1 -th group and normative (Table 4).

The C/D indices during dopplerometry of the maternal and fetal vessels during treatment in the 1st group approached the normative ones. In the 2nd group, S/D in the umbilical artery and fetal aorta tended to normalize, while increased resistance remained in the spiral arteries and the middle cerebral artery of the fetus, which, apparently, is associated with the inclusion in this group of pregnant women with anemia of the middle and severe severity and insufficient effect of short-term therapy.

In the study of the hormonal function of the placenta in pregnant women with anemia, it was found that only in 38% of women in the 1st group and 25% of the 2nd group it was normal. In 22.0% and 25.0% of pregnant women, respectively, it was intense, and in 12% and 20% of patients of the 1st and 2nd groups, depletion of the hormonal function of the placenta was noted (Table 5).

It is known that it is very difficult to achieve FPI compensation when the FPC function is depleted. As our studies have shown, the positive effect of the therapy in most patients with depletion of the FPC function is associated with the early start of treatment for anemia and FPI in patients of the 1st group.

In the 1st group, 63 (84%) pregnant women were delivered through the natural birth canal, 10 (13.3%) patients underwent a planned caesarean section. Indications for a planned caesarean section were placenta previa - in one case, severe diabetes mellitus - in 3 cases, absolute unpreparedness of the body for childbirth and advanced age - in 4 patients; in one case, there was a scar on the uterus after cesarean section and after myomectomy. An emergency caesarean section was performed in 2 (3.0%) pregnant women due to severe preeclampsia and progressive FPI at 31-32 weeks. FGR I degree was observed in 13.3% and II degree - in 6.7% of newborns. In this group, there were 2 children born in a state of asphyxia. In 12 (16%) newborns, the Apgar score at the 1st minute was 7 points, at the 5th minute in all children - 8 and 9 points. The average body weight in newborn mothers of the 1st group reached 3215.0 g (2650.0-3390.0 g). Cerebral blood flow indices were within the normative values ​​(S/D=3.3-3.4; IR=0.70-0.71). Thus, the birth of more than 75% of healthy newborns in pregnant women with IDA diagnosed in the second trimester of gestation is, of course, the result of adequately conducted and pathogenetically substantiated therapy. All newborns of the 1st group were discharged home in a satisfactory condition, but 18 (24.0%) of them were not on the 4-5th, but on the 6-8th day after birth.

15 (37%) pregnant women of the 2nd group were delivered through the natural birth canal, 18 (45%) - by the abdominal route in a planned manner. In this group, the indications for planned cesarean section were decompensation of FPI in 8 pregnant women, a scar on the uterus after cesarean section in one observation, acute fetal hypoxia - in 4, in one case - severe preeclampsia, in 4 cases - advanced age of the primipara in combination with pathology cardiovascular system and FPI. 7 (17.5%) patients were urgently delivered abdominally due to progressive FPI. FGR I degree was observed in 10 (25%) and II degree - in 9 (22.5%) newborns. In the state of asphyxia (with an Apgar score of 5-6 points at the 1st minute), 7 (17.5%) newborns were born. In 15 (37.5%) children, at the 1st minute, the Apgar score was 7 points; at the 5th minute, these newborns had an Apgar score of 8 points. The average body weight of newborns in mothers of the 1st group reached 2800.0 g (2600.0-3060.0 g). The parameters of cerebral blood flow were also within the normative values ​​(S/D=3.3-3.4; IR=0.70-0.71; PI=1.3-1.4). Only in one child born with severe anemia, cerebral blood flow was reduced.

In 27 (67.5%) newborns, the period of early neonatal adaptation proceeded satisfactorily; these children were discharged home in a timely manner. All newborns born to mothers with moderate and severe IDA had malnutrition, their weight and body length corresponded to the 3rd-10th percentile level; 6 (15%) newborns were transferred to the second stage of treatment and 7 (17.5%) were transferred to the intensive care unit. When analyzing the causes that complicated the period of early adaptation of children, it was revealed that a high percentage of complications was observed in the 2nd group (33%). In the 1st group, the number of newborns with complications was somewhat less, although this figure is also quite high (24%). Most often in both groups, there was a syndrome of respiratory disorders and infectious complications, convulsive syndrome. A characteristic feature of the group of newborn mothers with IDA was a delay in the healing of the umbilical wound, which indicates a decrease in regenerative processes due to the presence of moderate IDA in mothers.

There are isolated reports on the effect of IDA on the morphological features of the structure of the placenta. According to the author, there are characteristic morphological changes in the placenta depending on the time of detection, the degree of anemia and the therapy.

According to our observations, in the study of the placentas of women with IDA, the characteristic morphological and functional features are the dissociated type of maturation of cotyledons, the presence of pseudoinfarctions, afunctional zones, focal villus necrosis, sclerosis of the villus stroma and their thrombosis. The increase in sclerosed villi is directly dependent on the severity of anemia. With anemia of mild and moderate severity, the safety of syncytiotrophoblast is 80-70%, while with severe anemia, the safety does not exceed 60%. In patients of the 1st and 2nd groups, the morphological characteristics of the placentas significantly differ: in pregnant women who received antianemic therapy from the second trimester of pregnancy, a large mass and size of the placenta, plethora of villi, preservation of syncytiotrophoblast, compensatory changes in mitochondria were observed, which is aimed at improving metabolism in the placenta and maintaining its ability to synthesize. When examining placentas in women of the 2nd group, it was revealed that they are characterized by an increase in sclerosed and fibrinoid-altered villi and their pathological convergence, vascular obliteration, accumulation of erythrocytes in the intervillous space, and microinfarcts.

Timely and adequate treatment, prophylactic use of antianemic drugs from early gestation is the key to a successful pregnancy for both the mother and the newborn.

Conclusion

There is no doubt that IDA affects the morphological features of the structure of the placenta. According to the present study, the weight of the placenta in all groups with IDA decreases in proportion to the increase in the severity of anemia, which confirms the studies of Shakudina M.K. and contradicts the data of Averyanova S.A. (1980). At the same time, we did not find significant differences in the weight and size of placentas in groups with grade I IDA and in the comparison group. All placentas had predominantly paracentral attachment of the umbilical cord. In groups 1 and 2, peripheral attachment of the umbilical cord was noted, and in the group with anemia that developed before pregnancy, it was observed twice as often. The peripheral location of the umbilical cord was mainly in placentas with moderate and severe iron deficiency anemia.

In the placentas of women with anemia, it was found that in group 1, the area of ​​the placenta occupied by caverns and infarcts did not exceed 5%. Macroscopic parameters of the placentas of this group did not have significant differences from the placentas of the comparison group. In the placentas of women with anemia that developed before pregnancy, a slightly different picture was observed. In such placentas, the area occupied by infarctions and cavities was 7%-8%, in contrast to the placentas of women in whom IDA was diagnosed during pregnancy, and were more often observed in placentas with moderate and severe anemia.

Bibliography

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Grishchenko O.V., Lakhno I.V., Pak S.A. and other Modern approach to the treatment of fetoplacental insufficiency. Women's Reproductive Health 2003; 1:13:18-22.

Dvoretsky L.I. Algorithms for the diagnosis and treatment of iron deficiency anemia. RMJ 2002; 2:6:22-27.

Zhilyaeva O.D. Clinical and anatomical features of the mother-placenta-fetus system during pregnancy against the background of iron deficiency anemia: Abstract of the thesis. dis…. cand. honey. Sciences. M 2005; 24.

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Introduction

Chapter 1. Theoretical foundations of anemia in pregnant women

1.1 Anemia as a term, concept, content, diagnosis

1.2 Anemia in pregnancy

1.3 Iron deficiency anemia in pregnancy

1.4 Prevention and treatment of iron deficiency anemia in pregnant women

Chapter 2. Practical methods for the prevention of anemia in pregnant women

2.1 The role of the nurse in the prevention of anemia in pregnant women

List of used literature

Introduction

anemia pregnant iron deficiency treatment

Anemia is a decrease in the amount of hemoglobin per unit volume of blood, most often accompanied by a simultaneous decrease in the number of red blood cells.

Anemia can be associated with a large blood loss, a decrease in the function of the red bone marrow, insufficient intake of substances necessary for hematopoietic processes, in particular cyanocobalamin or iron, as well as an infectious-toxic effect on the bone marrow.

According to the color index of blood, hypochromic and hyperchromic anemia are distinguished. In the mechanism of development of a number of anemias, a common moment is a decrease in the regenerative capacity of the red bone marrow. The loss of the ability of the bone marrow to produce red blood cells leads to a rapid increase in anemia.

The relevance of this topic is due to the fact that anemia is detected in 10-20% of the world's population, and among women of childbearing age - in 40-50%.

By itself, any anemia is not a disease, but can occur as a syndrome in a number of diseases that are either associated with the primary lesion of the blood system, or do not depend on it. In this regard, there is no strict nosological classification of anemia.

According to WHO data, anemia is detected in 35-75% of pregnant women in the world every year. Anemia of pregnancy is the most common type of anemia.

According to various authors, they occur in 50-90% of pregnant women, regardless of social and financial status. Despite this, anyone who tries to begin to study this problem cannot but be surprised by two circumstances.

First, that anemia of pregnancy was described only 150 years ago, although they are quite common.

And, secondly, over the past century and a half, not enough has yet been done to clarify them.

The reason for this trouble lies mainly in the fact that anemia of pregnant women occupy a special, middle place between two such different disciplines - obstetrics and hematology.

In this paper, we will consider the role of a nurse in the prevention of anemia in pregnant women.

The purpose of the work is to study the role of a nurse in the prevention of anemia in pregnant women.

Work tasks:

Learn what anemia is, make out the classification and its types;

To analyze the role of a nurse in anemia in pregnant women;

Conduct a survey or questionnaire in the antenatal clinic for pregnant women who are registered on this topic.

The object of the study is the process of managing pregnant women in the gynecological department or in the antenatal clinic for the prevention of anemia in pregnant women.

The subject of the study is the volume of interaction of nurses and brothers with pregnant women for the prevention of anemia in pregnant women.

Research methods:

Theoretical analysis of literature and Internet sources;

Third-party observation of the activities of nurses in the department or in the antenatal clinic;

Survey of pregnant women in the gynecological department by the method of voluntary questioning using a self-developed questionnaire, which includes 5 questions;

Generalization of the results of the study;

1. Theoretical foundations of anemia in pregnant women

1.1 The concept, content and diagnosis of anemia

Anemia is a decrease in the amount of hemoglobin per unit volume of blood, most often accompanied by a simultaneous decrease in the number of red blood cells. Anemia or anemia has been known since ancient times. And only relatively recently, in the nineteenth and twentieth centuries, their causes were finally established and methods of treatment were developed.

Blood consists of a liquid part (plasma) and cells. Blood cells, in turn, are divided into white blood cells (leukocytes) and red blood cells or erythrocytes. Red blood cells contain a special protein-iron compound called hemoglobin. The task of hemoglobin is to carry oxygen to tissue cells. With a lack of hemoglobin, all human tissues and organs suffer from a lack of oxygen.

The term anemia has long been given the right of citizenship as a synonym for a pathological condition. However, we must also not forget that they designate only a symptom, but not a disease. As a symptom, anemia can be understood in a clinical and hematological sense.

From a clinical point of view, anemia is such a condition of the blood, which is externally manifested by a more or less pronounced pallor of the skin and visible mucous membranes. For an accurate clinical diagnosis, however, two more conditions are necessary. The first of them is that pallor should not only be general, that is, generalized, but be constant. The second condition is that the skin and mucous membranes must be in good condition, not swollen. It should immediately be added that the second condition is difficult to observe in pregnant women, since they are usually prone to swelling.

From a hematological point of view, anemia is a condition in which the total hemoglobin content in the body is below normal.

A huge number of cases of anemia is characterized by a simultaneous decrease in the content of hemoglobin and erythrocytes, and their digital values ​​are quite sufficient to recognize anemia.

Anemia can develop in a person who suffers from many other diseases. Quantitatively, it is expressed by the degree of decrease in the concentration of hemoglobin - the iron-containing pigment of erythrocytes, which gives the blood a red color.

There are many causes of anemia, but there are also the main ones:

Violation of the production of red blood cells by the bone marrow;

Hemolysis (destruction) or shortening of the life span of red blood cells, normally 4 months;

Acute or chronic bleeding.

Now let's take a closer look at the above points.

The first reason is a violation or decrease in the production of red blood cells. This fact, as a rule, underlies anemia, which is accompanied by kidney disease, endocrine insufficiency, protein depletion, cancer, chronic infections. The cause of anemia can be an insufficient amount of iron, vitamin B12 and folic acid in the body, and in rare cases, mainly in children, vitamin C and pyridoxine deficiency. These substances are necessary for the formation of red blood cells in the body.

Other pathogens include hemolysis. The main cause of this disease can be attributed to the malfunction of red blood cells, or their defect. With anemia, red blood cells begin to break down in the blood, this may occur due to a violation of hemoglobin or a change in internal hormones. It happens that the cause of hemolysis is a disease of the spleen.

Bleeding. This fact causes anemia only if the bleeding was prolonged. All the main parts of erythrocytes are restored, except for iron. Thus, chronic blood loss due to the depletion of iron stores in the body causes anemia, which can develop even with a sufficient amount of iron in the food consumed. As a rule, bleeding occurs in the uterus and gastrointestinal tract.

In clinical practice, the following classification for anemia is most often used:

Anemia due to acute blood loss;

Anemia due to impaired production of red blood cells (aplastic, iron deficiency, megaloblastic, sideroblastic, chronic diseases);

Anemia due to increased destruction of red blood cells.

Based on the above, anemia is a decrease in the number of red blood cells in the blood - erythrocytes (below 4.0 x / l), or a decrease in hemoglobin levels below 130 g / l in men and below 120 g / l in women, at a rate for women 120 - 140 g / l, for men - 130 - 160 g / l.

Depending on the severity of the decrease in hemoglobin levels, three degrees of severity of anemia are distinguished:

Light - hemoglobin level above 90 g / l;

Medium - hemoglobin level in the range of 90-70 g / l;

Severe - the level of hemoglobin is below 70 g / l.

Anemia can be of mixed pathogenesis. Most often there is a combination of iron deficiency and B12 deficiency, but other options are possible.

1.2 Anemia in pregnancy

Under the name "anemia of pregnancy" we mean a number of anemic conditions that have arisen during pregnancy. They complicate its course and usually disappear soon after childbirth or after its interruption.

From a pathogenetic point of view, according to A. Alder (1927), all anemic conditions in pregnant women are reduced to two forms:

From a terminological point of view, the name "anemia and pregnancy" is very broad and imprecise, since it includes all anemias, whether or not related to the gestational process. The name "anemia during or in pregnancy" does not clarify the causal relationship with it, and "anemia of pregnancy" is a misnomer, since a pregnant woman suffers from anemia, not pregnancy.

Based on the above reasons, we believe that the term "pregnancy anemia" is relatively the most correct and accurate.

Each pregnancy, with its increased requirements, disrupts the harmony and balance of the hemoimmune system.

According to M.A. Daniachia, bone marrow during normal pregnancy is characterized by the following changes: a) leukopoietic reaction - the formation of mainly metamyelocytes with neutrophilia in the blood; b) in women suffering from vomiting in the first months of pregnancy, toxic-degenerative changes are observed; c) in the second half of pregnancy, moderate anemia occurs as a result of an increased consumption of red blood cells to meet the needs of the fetus; d) changes in the bone marrow reach a maximum in the seventh and eighth months of pregnancy, after which they decrease and linger at this level until childbirth.

Table 1 - Some indicators of peripheral blood in different trimesters of pregnancy

In 90% of cases, anemia in pregnant women is iron deficiency. Such anemia is characterized by impaired hemoglobin synthesis due to iron deficiency developing due to various physiological and pathological processes. The presence of iron deficiency anemia leads to a violation of the quality of life, reduces performance, causes functional disorders of many organs and systems. With iron deficiency in pregnant women, the risk of developing complications during childbirth increases, and in the absence of timely and adequate therapy, iron deficiency in the fetus may occur.

Iron is one of the vital elements, it contains about 4 g in the human body, 75% of iron is in hemoglobin. Iron is most fully absorbed from animal products (meat), much worse from plant foods. Iron is excreted from the body of a woman in the amount of 2-3 mg / day through the intestines, bile, urine, through the epithelium of the skin, during lactation and menstruation.

Outside of pregnancy, the iron requirement is 1.5 mg/day. During pregnancy, this indicator steadily increases: In the first trimester by 1 mg / day, in the second trimester - by 2 mg / day, in the third trimester - by 3-5 mg / day.

Iron loss is most pronounced at 16-20 weeks of gestation, which coincides with the period of the onset of hematopoiesis in the fetus and an increase in blood volume in the pregnant woman.

During childbirth (with physiological loss), from 200 to 700 mg of iron is lost, later, during lactation, about 200 mg more. Thus, about 800-950 mg of iron is consumed from the maternal depot during pregnancy and in the postpartum period. The body is able to restore iron stores within 4-5 years. If a woman plans a pregnancy before this time, she will inevitably develop anemia.

The following processes lead to the development of anemia during pregnancy:

Metabolic changes occurring in the body of the patient during pregnancy;

Decrease in the concentration of a number of vitamins and microelements - cobalt, manganese, zinc, nickel;

Changes in hormonal balance during pregnancy, in particular, an increase in the amount of estradiol, which causes inhibition of erythropoiesis;

Deficiency in the body of a pregnant woman of vitamin B12, folic acid and protein;

Immunological changes in the body of a pregnant woman, occurring due to constant antigenic stimulation of the maternal organism from the tissues of the developing fetus;

The consumption of iron from the depot of the mother's body, which is necessary for the proper development of the fetus.

During pregnancy, the so-called physiological, or "false" anemia can also occur.

The emergence of this form is due to an uneven increase in the individual components of the blood. The fact is that during pregnancy, as a compensatory reaction, an increase of 30-50% of the mother's blood volume occurs, but mainly due to plasma. Accordingly, the ratio of the volume of blood cells and plasma is shifted towards the latter. This form of anemia does not require treatment.

Pathological forms of anemia during pregnancy are the following:

Megaloblastic anemia associated with folic acid deficiency accounts for 1% of all anemias in pregnant women, most often develops in the third trimester of pregnancy, before childbirth and in the early postpartum period.

Folic acid plays an important role in many physiological processes, participates in the synthesis of amino acids, plays a key role in the processes of cell division. Tissues with a high rate of cell division (bone marrow, intestinal mucosa) are characterized by an increased need for folic acid. Folic acid deficiency in the body occurs due to its insufficient content in the diet, increased need for it (pregnancy, prematurity, hemolysis, cancer); malabsorption and increased excretion of it from the body (some skin diseases, liver diseases). The daily requirement of the body of a pregnant woman in folic acid increases to 400 mcg, and by the time of delivery - up to 800 mcg, the need for folic acid during lactation is 300 mcg.

Folic acid deficiency is observed in pregnant women in approximately 30% and adversely affects the course of pregnancy and the development of the fetus. With such a deficiency, the formation of neural tube defects (anencephaly, encephalocele) is possible.

Another important fact is the close relationship between the level of folic acid in the mother's body and the weight of the child at birth. In the weeks before birth, the fetus uses up the mother's folic acid to increase its own weight and replenish its folate stores. As a result, in women with folic acid deficiency, the likelihood of having a child with malnutrition and a reduced supply of folic acid increases significantly.

The main sources of folic acid are raw green vegetables and fruits, beef liver, cheese, egg yolk.

Types of megaloblastic anemia:

1) Essential (cryptogenic) malignant anemia of Birmer-Erlich (pernicious anemia, megaloblastic anemia, Addison-Birmer anemia). This anemia is rare during pregnancy. This form of anemia is associated with a deficiency of vitamin B12 and folic acid. The development of this anemia is facilitated by past infections, insufficient intake of vitamins from food, diseases of the stomach and duodenum, the use of drugs (acyclovir, anticonvulsants, nitrofurans, oral contraceptives), Crohn's disease.

2) Hypo- and aplastic anemia, in which there is a sharp inhibition of bone marrow hematopoiesis. The causes of this anemia are most often ionizing radiation; taking medications (chloramphenicol, chlorpromazine, butadione, cytostatics); the entry into the body of chemicals (benzene, arsenic) that have a myelotoxic effect; chronic infectious diseases (viral hepatitis, polynephritis); autoimmune processes.

3) Hemolytic anemia - a large group of diseases, the main distinguishing feature is the shortening of the life of erythrocytes due to their hemolysis. Allocate hereditary and acquired hemolytic anemia. It is rare during pregnancy. The prognosis for the mother is favorable. Delivery is carried out through the natural birth canal.

4) True iron deficiency anemia occurs most often during pregnancy. A characteristic feature is either an absolute decrease in the number, or a functional insufficiency of erythrocytes. Clinical manifestations are due, on the one hand, to the presence of anemic syndrome, on the other hand, to iron deficiency.

Pregnancy is contraindicated in the following diseases of the blood and hematopoietic system:

Chronic iron deficiency anemia of 3-4 degrees;

hemolytic anemia;

Hypo- and aplasia of the bone marrow;

Leukemia;

Wergolf's disease with frequent exacerbations.

Based on the above, we can conclude that iron deficiency anemia is much more common than other types of anemia in pregnant women. So let's look at iron deficiency anemia in pregnant women in more detail.

1.3 Iron deficiency anemia in pregnancy

Clinical manifestations of iron deficiency anemia in pregnant women

Iron deficiency anemia in pregnant women is manifested by a complex of nonspecific symptoms and is caused by insufficient oxygen supply to tissues.

The main clinical manifestations of this pathology are general weakness, fatigue, anxiety, dizziness, tinnitus, flies before the eyes, tachycardia, shortness of breath during exercise, fainting, insomnia, morning headache, forgetfulness, decreased performance.

The consequence of iron deficiency is dry skin, the formation of cracks on it, a violation of the integrity of the epidermis, the appearance of expressions and cracks in the corners of the mouth with inflammation of the surrounding tissues, changes in the nails (brittleness, layering, take a concave spoon-shaped shape), hair damage (hair is split, the tips delaminate) .

In patients due to iron deficiency, a burning sensation of the tongue is noted, taste is distorted (the desire to eat chalk, toothpaste, clay, sand, raw cereals), an unhealthy addiction to certain odors (gasoline, kerosene, acetone) appears, a feeling of heaviness and pain in stomach, as in gastritis, urinary incontinence when coughing and laughing, nocturnal enuresis, muscle weakness, pallor of the skin, possible arterial hypotension, subfebrile temperature.

Due to the fact that during pregnancy oxygen consumption increases by 15-33%, pregnant women with iron deficiency anemia are characterized by severe tissue hypoxia with the subsequent development of secondary metabolic disorders.

And this means that it can be accompanied by the appearance of dystrophic changes in the myocardium, as well as in the uterus and in the placenta, which lead to the formation of placental insufficiency and delayed fetal development.

Iron deficiency anemia is characterized by protein metabolism disorders with the appearance of protein deficiency in the body, which leads to the development of edema in pregnant women.

The main complications of pregnancy with iron deficiency anemia are the following:

Preeclampsia (40%);

Premature birth (11-42%);

Diagnosis of iron deficiency anemia in pregnant women

Diagnosing anemia during pregnancy is quite simple. This requires only one complete blood count.

At the same time, the identification and elimination of the causes of its occurrence may be associated with certain difficulties, which will require additional laboratory studies.

For the timely detection of anemia (and other possible complications), it is recommended that all women during pregnancy undergo a preventive examination by a gynecologist at least three times.

Preventive visits to the gynecologist are carried out:

Up to 12 weeks of pregnancy. In this period, the general condition of the woman is assessed, and an ultrasound examination (ultrasound) is performed in order to detect abnormalities in the development of the fetus.

If, according to the results of the tests, anemia is found in a woman, it is definitely not related to the onset of pregnancy, that is, its causes must be sought in other organs and systems.

Up to 27 weeks of pregnancy. At this stage, the general condition of the woman and the developing fetus is also assessed. With a general blood test, initial signs of iron deficiency or other trace elements can be detected.

Severe clinical signs of anemia are rare, but this does not negate the need for preventive treatment.

From 28 to 42 weeks of pregnancy. Anemia at this stage of pregnancy can be observed only in the case of improper preventive treatment (or if the woman did not visit the gynecologist at all during the entire pregnancy and did not take any treatment).

During the examination, the general condition of the woman and the fetus is assessed and a decision is made on the method of delivery (through the natural birth canal or by caesarean section).

The fact is that with severe anemia, the female body (in particular, the cardiovascular and respiratory systems) may not withstand the increasing loads, which can cause weakness in labor and even lead to the death of the mother or fetus during childbirth.

In this case, if the duration of pregnancy allows, preventive treatment of anemia can be performed, after which (in case of a positive effect) it will be possible to give birth through the natural birth canal.

If severe anemia is diagnosed late in pregnancy (40 weeks or later), the doctor recommends a caesarean section (also after appropriate preoperative preparation).

To identify the cause of anemia during pregnancy, the doctor can conduct: a survey, a clinical examination, a complete blood count, a biochemical blood test, a bone marrow puncture.

Survey. The survey is an important step in the diagnosis, during which the doctor may suspect a particular cause of anemia.

During the interview, the gynecologist may ask:

How long ago was the pregnancy?

Have there been pregnancies before?

If there were, how did they proceed (in particular, the doctor is interested in whether the woman suffered from anemia and what treatment she took about this)?

How long ago was the last pregnancy?

How does a woman eat? Does the woman suffer from any chronic diseases (hepatitis, cirrhosis, etc.)?

Does the woman abuse (or did she abuse before) alcoholic beverages?

Has the woman ever suffered from anemia (even unrelated to pregnancy)?

How long ago did the woman have her last medical examination (including a complete blood count) and what were the results?

Have you noticed any taste deviations recently (desire to eat some inedible foods, feeling unusual tastes or smells in their absence, and so on)?

In addition to assessing standard indicators in a clinical blood test (hemoglobin, erythrocytes, hematocrit, ESR), the diagnosis of iron deficiency anemia is based on an assessment of such indicators as color, average hemoglobin content in an erythrocyte, morphological assessment of erythrocytes, serum iron, ferritin, transferrin, total iron-binding ability blood serum.

Analysis of the level of serum iron. This study allows you to identify iron deficiency in the patient's blood. However, it is worth noting that in the initial period of the development of anemia, false-negative results can be obtained, since iron will be released from the depot organs (liver and others), as a result of which its concentration in the blood will be normal.

The normal serum iron level in women is 14.3 - 17.9 micromoles/liter.

Ferritin is a protein complex that binds and stores iron in the body. With a lack of iron, it is primarily mobilized (released) from ferritin, and only after its depletion begins to be released from the depot organs.

That is why the determination of the level of ferritin allows you to identify iron deficiency at an earlier stage. The normal level of ferritin in the blood in women is 12 - 150 nanograms / milliliter.

Table 2 - Dynamics of ferritin levels during pregnancy (according to V.A. Demikhov)

It should be noted that after childbirth, the level of ferritin rises back.

With a decrease in the level of ferritin less than 30 ng / ml, it is necessary to carry out preventive courses of treatment with iron preparations for 2-3 months in combination with multivitamin complexes and probiotics.

Analysis of the total iron-binding capacity of blood serum. The free iron entering the blood immediately binds to the transport protein transferrin, which delivers it to the red bone marrow and other organs.

However, each transferrin molecule binds to iron by only 33%. With the development of iron deficiency in the body, the compensatory synthesis of transferrin in the liver is activated (in order to capture as many iron molecules as possible from the blood). The total amount of this protein in the blood increases, but the amount of iron associated with each molecule decreases.

By determining how much iron is bound to each transferrin molecule, the degree of iron deficiency in the body can be assessed. The normal level of total iron-binding capacity of blood serum in women is 45 - 77 micromoles / liter.

1.4 Prevention and treatment of iron deficiency anemia in pregnant women

Prevention of iron deficiency anemia in pregnant women

Prevention of anemia, first of all, should be carried out among pregnant women who are at high risk of developing it.

These pregnant women experience the following:

1) Decreased intake of iron in the body with food (vegetarianism, anorexia);

2) Chronic diseases of internal organs (rheumatism, heart defects, hepatitis, pyelonephritis);

3) The presence of diseases manifested by chronic nosebleeds (trobocytopathy, thrombocytopenic purpura);

4) Gynecological disease, accompanied by profuse uterine bleeding (endometriosis, uterine fibroids, hyperplastic processes in the endometrium);

5) Aggravated obstetric history (multiparous women, history of spontaneous miscarriages, bleeding during childbirth);

6) Complicated course of this pregnancy (multiple pregnancy, late toxicosis, young age in a pregnant woman (less than 16 years), primiparas over 30 years old, arterial hypotension, exacerbation of chronic, infectious diseases during pregnancy, premature detachment of the placenta);

Given the high incidence of anemia in pregnant women, it is necessary to carry out preventive measures.

Prevention of iron deficiency anemia in pregnant women at risk of this pathology consists in prescribing large doses of iron preparations and iron-containing multivitamin complexes for 6-7 months, starting from 14-16 weeks of pregnancy, in courses of 2-3 weeks, with interruptions for 14-21 days, only 3-5 courses per pregnancy.

At the same time, it is necessary to change the diet in favor of increasing the consumption of foods containing a large amount of easily digestible iron. However, with food, a pregnant woman cannot receive the necessary dose of iron necessary to improve the absorption of iron, which can be absorbed from food - 2.5 mg / day.

For the prevention of anemia and the treatment of mild anemia, it is recommended to prescribe drugs containing a physiological dosage of iron - 60 mg.

WHO experts recommend using oral preparations of ferrous iron, not ferric iron. These drugs include the drug Vitrum Prental Forte. It contains the recommended iron dosage of 60 mg, in the recommended form of ferrous iron.

Prevention of iron deficiency anemia in pregnant women should be carried out under the control of serum ferritin levels, which allows you to control the adequacy of therapy and prevent iron overload in the body. With a serum ferritin content of more than 40 μg / l, iron supplementation should be discontinued.

Treatment of iron deficiency anemia in pregnant women

Pregnant women with iron deficiency anemia, in addition to drug treatment, are prescribed a special diet.

The largest amount of iron is found in meat products. The iron contained in them is absorbed in the human body by 20-30%.

The absorption of iron from other products of animal origin (eggs, fish) is 10-15%, from vegetable products - only 3-5%.

The largest amount of iron (in mg per 100 g of product) is found in the liver (19.0 mg), cocoa (12.5 mg), egg yolk (7.2 mg), heart (6.2 mg), calf liver (5 .4 mg), stale bread (4.7 mg), turkey meat (3.8 mg), spinach (3.1 mg), and veal (2.9 mg).

It is important to remember that 2.5 mg of iron per day is absorbed from food, while 15-20 times more is absorbed from drugs. Therefore, drug therapy for anemia during pregnancy is necessary.

Treatment with iron preparations should be long-term. The content of hemoglobin increases only by the end of the third week of therapy for iron deficiency anemia. Normalization of blood counts occurs after 7-8 weeks of treatment, but this does not indicate the restoration of iron stores in the body.

For this purpose, WHO experts recommend that after 2-3 months in the treatment and elimination of anemia, do not stop therapy, but only halve the dose of the drug that was used for treatment. This course of treatment continues for 3 months.

Even with the full restoration of iron stores in the body, it is advisable to take small doses of iron-containing preparations for six months.

The most preferable is the intake of iron preparations inside, and not in the form of injections, since in the latter case, various side effects may occur more often.

In addition to iron, preparations for the treatment of iron deficiency anemia contain various components that enhance the absorption of iron (copper, manganese, vitamin B12, ascorbic acid, folic acid, etc.).

For better tolerability, iron supplements should be taken with food. It should be borne in mind that under the influence of certain substances contained in food (phosphoric acid, phytin, tannin, calcium salts), as well as with the simultaneous use of a number of drugs (tetracycline antibiotics, almagel), iron absorption in the body decreases.

For the treatment of iron deficiency anemia in pregnant women, a three-stage iron therapy regimen is currently adopted (Shaposhnik O.D., Rybolova L.F., 2002). In this case, the daily dose of iron is determined by the stage of therapy. The scheme can be seen in Table 3.

Table 3 - Three-stage regimen for the treatment of iron deficiency anemia in pregnant women

It is advisable to prescribe dosage forms with ascorbic acid, the content of which should be 2-5 times higher than the amount of iron in the preparation (ferroplex, sorbifer durules).

You can consider in detail the drug treatment of iron deficiency anemia in pregnant women in Table 4.

Table 4 - Drug treatment of iron deficiency anemia in pregnant women

Treatment of mild iron deficiency anemia in pregnant women is carried out in a antenatal clinic, moderate and severe - in a hospital.

The reasons for the ineffectiveness of the treatment of patients with anemia during pregnancy are the following:

Insufficient volume of therapy, discontinuation of medication when hemoglobin improves or because of the fear of taking medication;

The cause of anemia has not been eliminated;

Insufficient accounting of the balance of vitamins and microelements involved in iron metabolism;

The presence of dysbacteriosis, in which the synthesis of transport proteins (metal protectors, transferrin) is disrupted;

In an iron-deficient state, the body needs a sufficient amount of biologically active substances that made up the so-called biological chain: iron, calcium, copper, zinc, manganese, as well as vitamins - folic acid, vitamin B12, B1, B2, B6, biotin and others.

Thus, for the treatment of iron deficiency anemia in pregnant women, not only iron supplements are needed, but also a sufficient set of vitamins and minerals.

Iron-deficiency anemia of pregnancy is an important problem of both maternal and fetal health, so prevention of iron-deficiency anemia in pregnancy helps to create higher iron stores in newborns, preventing the development of iron deficiency and anemia in infants.

The use of drugs with a balanced content of iron and its synergists can achieve good results in the treatment of iron deficiency anemia.

2. The practical role of a nurse in the prevention of anemia in pregnant women

2.1 Nursing process for iron deficiency anemia in pregnant women

As we have listed above, the main complications of pregnancy with iron deficiency anemia are the following:

Threat of abortion (20-42%);

Preeclampsia (40%);

Arterial hypotension (40%);

Premature placental abruption (25-35%);

Fetal growth retardation (25%);

Premature birth (11-42%).

Based on this, we can conclude that the main task of a nurse with iron deficiency anemia in pregnant women is the correct management of pregnant women in order to avoid the above complications as much as possible.

Let's look at possible nursing care for anemia in pregnant women.

As we already know, the nursing process has five stages.

Stage 1 is a nursing examination. At this stage, the examination is subjective (complaints of the patient) and objective (control of blood pressure, body temperature, etc.).

Subjectively: the patient has general weakness, increased fatigue, anxiety, dizziness, tinnitus, flies before the eyes, morning headache, forgetfulness, burning tongue, taste perversion.

Objectively: the skin and visible mucous membranes (conjunctiva) are pale, dryness and peeling of the skin, seizures in the corners of the mouth, brittleness, dryness, and hair loss, tachycardia. On a blood test, a decrease in the level of hemoglobin and the number of erythrocytes, erythrocytes are hypochromic (poor in hemoglobin), a decrease in color index (less than 0.8), levels of serum iron and ferritin are reduced, an increase in the iron-binding ability of blood serum.

Step 2 is the nursing diagnosis. At this stage, the nurse identifies disturbed needs and identifies current, potential, and priority problems.

Impaired needs for iron deficiency anemia in pregnant women - eat, work, move, rest, communicate, be safe.

The real problems are a decrease in the level of hemoglobin and red blood cells, general weakness, increased fatigue, anxiety, dizziness, tinnitus, flies before the eyes, morning headache, forgetfulness, burning sensation of the tongue, taste perversion, tachycardia, pallor of the skin and mucous membranes, prolapse hair, dryness and peeling of the skin, seizures in the corners of the mouth.

The priority problem is a decrease in the level of hemoglobin and erythrocytes.

A potential problem is the risk of complications (threat of abortion, preeclampsia, arterial hypotension, premature detachment of the placenta, fetal growth retardation, premature birth).

Step 3 is nursing care planning. At this stage, the nurse sets a short-term, long-term goal and draws up a care plan.

The short-term goal is for the patient to have these blood test parameters, namely the content of hemoglobin and red blood cells in the blood, gradually increase over 2-3 weeks.

The long-term goal is for the patient to have these blood counts returned to normal by the time of discharge.

A sample nursing care plan can be found in Table 5.

Table 5 - An example of a nursing care plan for anemia

Stage 4 is the implementation of the nursing care plan. The purpose of the nurse at this stage is to provide appropriate patient care, training and counseling on the necessary issues. The nurse must remember that all nursing interventions are based on knowledge of the goal, on an individual approach and safety, respect for the individual, encouraging the patient to be independent.

Stage 5 - and the last stage of the nursing process is the evaluation of the effectiveness and correction of care. This stage includes an assessment of the effectiveness of care, the patient's response to the intervention, the patient's opinion, the achievement of goals, the quality of care provided in accordance with the standards. If the nurse believes that the goal has not been achieved, she adjusts the care plan and starts all over again.

Efficiency evaluation: in the patient, these blood parameters, namely the content of hemoglobin and erythrocytes in the blood, gradually increase. The goal has been reached.

I would like to note that the prevention of anemia should begin before pregnancy. Doctors currently recommend taking prophylactic doses of iron and folic acid supplements 2-3 months before conception.

Often, when planning a pregnancy, women do not even suspect that pregnancy can be complicated by anemia, and anemia is primarily complicated by the threat of abortion, preeclampsia, arterial hypotension, placental abruption, fetal growth retardation, and premature birth. Therefore, paramedical personnel should carry out sanitary and educational work with women of childbearing age on this topic (conducting a conversation, creating booklets, health schools, etc.).

The first thing you should pay attention to is the diet. It must contain meat. It is from it that the body absorbs more iron - about 6%.

For the sake of the health of the future baby, adherents of vegetarianism should reconsider their diet. The menu should have a large number of vegetables and fruits. Pomegranate juice is very useful for prevention.

The largest amount of iron (in mg per 100 g of product) is found in: pork liver (19.0 mg), cocoa (12.5 mg), egg yolk (7.2 mg), heart (6.2 mg), calf liver (5.4 mg), stale bread (4.7 mg), apricots (4.9 mg), almonds (4.4 mg), turkey meat (3.8 mg), spinach (3.1 mg), veal (2.9 mg).

Also, the diet should be 5-6 times a day, fractionally in small portions. Caloric intake is 2600-3000 kcal per day.

Sample menu for the day:

The second breakfast menu includes fried fish, carrots or beets, cheese, milk, stewed cabbage, tomatoes, as well as mixed vegetables, rosehip broth.

Soups are good for lunch. Also in the diet can be meat, fried liver, kidneys, mashed potatoes. The diet can be diluted with porridge, vegetables, cottage cheese. For dessert, you can drink compote, eat jelly, fruit.

A snack between lunch and dinner should contain berries and fresh fruits without fail.

Dinner should also consist of at least two courses. Again, fish dishes and meat, cottage cheese, cheese, puddings, vegetable stews will do.

According to WHO recommendations, all women during the II and III trimesters of pregnancy and for the first 6 months in lactation should take iron supplements. To prevent the development of anemia during pregnancy, the same drugs are used as for the treatment of this complication.

You should not stop treatment with iron preparations after the normalization of hemoglobin levels and the content of red blood cells in the body. Normalization of hemoglobin levels in the body does not mean the restoration of iron stores in it.

For this purpose, WHO experts recommend that after 2-3 months of treatment and the elimination of the hematological picture of anemia, do not stop therapy, but only halve the dose of the drug that was used to treat iron deficiency anemia. This course of treatment continues for 3 months.

Even having fully restored iron stores in the body, it is advisable to take small doses of iron-containing preparations for six months.

Also, for the prevention of anemia in pregnant women, periodic monitoring of blood parameters, namely the content of hemoglobin and erythrocytes in the blood, is recommended. Therefore, obstetrician-gynecologists always write out a referral for blood tests every month to their patients who are registered.

This method of observation makes it possible to detect anemia in pregnant women at an early stage and start treatment in a timely manner.

In order to find out the level of awareness of pregnant women about anemia and measures to prevent anemia, I conducted a survey.

8 pregnant patients of the gynecological department were interviewed. The survey was conducted on a voluntary basis.

The age of the respondents ranged from 20 to 37 years.

The results of the survey can be seen in Table 6.

Table 6 - Survey results

Based on the results of the survey, the following statistics can be made (Figure 1).

Figure 1 - Patient awareness of anemia.

Based on these statistics, we can conclude that most pregnant women are sufficiently informed about this disease.

However, there is still a need to inform women of childbearing age about the prevention of anemia during pregnancy.

List of used literature

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