1. By: Tamer Abdeldayem Lecturer of gynecology, Alexandria university

2.  One of the most significant changes is blood volume expansion with plasma volume increasing more than RBC volume, resulting in a normally decreased hematocrit: Physiological anemia of pregnancy.

3.  Increase in blood volume is about 45%.  It starts as early as 6 weeks of gestation.  It peaks at 28-32 weeks.  The increase in plasma volume is more than that in red bood cell volume; hence the name”dilutional’’

4.  The Centre for disease control and prevention [ CDC] defined anemia in women as: 1. Hemoglobin concentration less than 12 gm/dl in non- pregnant women. 2. Less than 11 gm/dl in first and third trimesters. 3. Less than 10.5 m/dl in second trimester.

5. 1. Iron deficiency anemia; the most common world-wide. 2. Acute blood loss : bleeding in early pregnancy, antepartum or postpartum hemorrhage. 3. Megaloblastic anemia: a) Folic acid deficiency. b) Vitamin B12 deficienc y.

6. 4. Anemia with chronic disease : e.g. chronic renal disease. 5. Acquired hemolytic anemias: eg.HELLP syndrome; in cases of severe pre-eclampsia.

7.  Symptoms: Effort intolerance and palpitations.  Signs: Pallor, tachycardia [pulse rate above 90/minute] ± lower limb oedema [non- specific as it may occur normally in pregnancy]

8. Increased incidence of: 1. Intrauterine growth restriction: in severe cases, due to lower oxygen supply to the placenta. It is usually compensated by the higher affinity of fetal hemoglobin to oxygen than adult [maternal] hemoglobin. 2. Preterm labour: due to improper function of myometrial cell receptor synthesis with inadequate oxygen supply.

9. 3. Atonic postpartum hemorrhage: due to diminished ability of the myometrium to contract with low oxygen supply. 4. Puerperal sepsis: due to diminished immunity with anemia.

10.  The most common type of anemia with pregnancy world-wide.  It accounts for two thirds of anemias with pregnancy.

11. During pregnancy, the mother needs 1000 mg of elemental iron; consumed in the following pattern: 1. 300 mg for the fetus and placenta. They are taken from maternal stores at any cost! 2. 200 mg excreted through shedded epithial cells over the months of pregnancy [unpreventable!!]. 3. 500 mg [if available] for red blood cell expansion.

12. 1. Complete blood picture: hypochromic microcytic anemia with low red blood cell indices; including :  Mean corpuscular volume[MCV]: normally 76-92 pg 2. Serum ferritin level: below 15 microgm/Litre

13. Iron supplements; either 1. Oral iron: Side effects include gastritis, constipation and poor compliance of some patients. Oral iron should be continued for 3 months following correction of hemoglobin levels, to replenish the iron stores. 2. Parenteral iron : Side effects include hypersensitivity reactions, skin staining and pain at the site of injection.

14. 3. Packed red blood cell transfusion: in cases of hemoglobin levels less than 7 gm/dl, and before surgical procedures including caesarian section.

15.  These anemias are characterized by blood and bone marrow abnormalities from impaired DNA synthesis.  Their incidence varies world wide but they are less common than iron deficiency anemia.

16.  Red blood cell indices are increased [megaloblasts] but with overall diminished hemoglobin levels.  They include: 1- Folic acid deficiency 2-Vitamin B12 deficiency

17.  Treated by supplements of folic acid.  Daily requirement is 800μgm/day.  Therapeutic dose is 5 mg/day.

18.  1000μg / week for 4 weeks then every month till the end of pregnancy.

20. 1. Rheumatic heart disease 2. Congenital heart disease: a) Non-cyanotic: usually represent no problem; e.g. VSD, ASD, mitral valve prolapse b) Cyanotic: an indication for termination of pregnancy [Therapeutic abortion] because maternal mortality reaches 50% of cases

21.  Grade 1: no limitation of activities  Grade 2: Dyspnea on usual daily effort  Grade 3: Dyspnea on effort less than usual daily one.  Grade 4: Dyspnea at rest/history of heart failure  Grades 3 and 4 carry a high risk for continuation of pregnancy  Prognosis is much guarded in cases with pulmonary hypertension

22.  Periods where heart failure is most likely to occur: 1. Around 28-32 weeks: when blood volume expansion is at the maximum. 2. Around 36 weeks gestation: maximum compression of diaphragm by gravid uterus. 3. Second stage of labour: due to bearing down effects of the mother; increasing cardiac output 15-20% with diminished venous return.

23. 4. During third stage of labour: with disappearnce of the arteriovenous shunt- effect of the placenta, return of 0.5-1 litre of blood to the circulation leading to overload 5. During the first week of puerperium: due to the high risk of infective endocarditis.

24.  During pregnancy: 1. Regular antenatal visits: avoid anemia and infection. 2. Consultation of cardiologist. 3. Termination of pregnancy in cases of: a) Active heart failure b) Congenital cyanotic heart disease c) Cases with pulmonary hypertension

25.  During first stage of labour: 1. Antibiotic prophylaxis 2. Oxygen inhalation. 3. Pain relief: epidural analegesia[best], nitrous oxide inhalation, opoids.

26.  Second stage of labour: 1. Continuous oxygen inhalation. 2. Bearing down is not allowed: assisted vaginal delivery by forceps or vacuum extraction 3. Caeserian delivery in cases with grade3 or 4 heart disease

27.  Third stage of labour: 1. Use of diuretics: to diminish the blood volume returning to the circulation after placental delivery 2. Ergometrine is contraindicated, oxytocin is used to prevent post partum hemorrhage 3. Suturing of episiotomy

28.  During puerperium: 1.Antibiotic prophylaxis for one week 2.Wound care.