Pregnancy EBook V1.01 [Pro]

Laboratory evaluation is fundamental for a definitive diagnosis of iron deficiency and IDA. As the etiology of anemia includes various causes, the diagnosis cannot be based only on Hb values. For diagnostic clarification, it is necessary to evaluate red blood count and serum ferritin (SF) levels. The most reliable parameter to revel iron deficiency is SF, and screening of SF concentration at the beginning of pregnancy is recommended.59 If SF is

Pregnancy eBook v1.01 [Pro]

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Another parameter that could be useful to detect iron deficiency during pregnancy, in the case of normal ferritin values and elevated CRP, is transferrin receptor (sTfR). It shows an increase in cases of iron deficiency or greater iron cellular demand. During pregnancy, the increase of sTfR values is related to increased stimulation of erythropoiesis and a major iron requirement due to iron-dependent cell proliferation. Low concentrations of sTfR in the first period of pregnancy seem to be associated with an inhibited erythropoiesis in the first trimester, as some studies have shown. Moreover, sTfR concentration is not influenced by infections or inflammatory reactions.53,62

Previous formulations of IV iron were responsible for undesirable and sometimes severe side effects such as anaphylaxis, shock, and death that led to their limited use. Conversely, the new type of iron complexes developed in the last years guarantees a higher efficacy, safety, and better compliance. The use of iron dextran has been limited in pregnancy due to the high rate of adverse reactions, even serious ones. No severe adverse effects have been shown with the use of iron gluconate; however, this approach is not very practical as it requires multiple infusions with high healthcare costs and reduced patient compliance.69 The maximum single dose is 125 mg. It has low molecular stability and is not indicated for use during the first trimester.60 As the IV iron bypasses intestinal iron absorption and the link to protein binding, it represents an optimal alternative to oral iron therapy. The new formulations bind iron more tightly to the carbohydrate core, so favoring a decrease of free iron released, which is toxic. Free iron leads to cell and tissue damage due to peroxidation, as it causes the production of reactive oxygen species such as hydroxide and oxygen radicals; therefore, the severe consequences related to free iron are limited. The most recent products of IV iron allow the use of high doses in a single administration.73

In pregnancy, a frequent alternative treatment to oral iron, when it is not indicated, is IV iron. The new formulations of IV iron therapy promote a higher, as well as faster, increase of Hb concentration and SF levels than oral iron supplementation, as was already shown in different studies.60,61 In comparison to oral iron, ICM guarantees a more rapid correction of anemia and also an evident improvement of quality life with a lower rate of symptoms such as fatigue and depression. It also presents higher tolerability and, consequently, greater compliance than oral iron. As the carbohydrate moiety binds the elemental iron more tightly, high doses of FCM (about 1000 mg in a single administration with a short infusion time) are allowed, thus guaranteeing an improvement in compliance and an abatement of costs due to repeated administrations. Compared to IS, FCM shows greater effectiveness and a comparable rate of safely profile, despite the dosage in a single administration is much higher. On the contrary, the maximum dose of IS in a single administration should not exceed 200 mg doses, because the sucrose portion binds elemental iron less tightly.53,60,61,78

Identifying the potential causes, as well as the appropriate assessments and any treatment required, is critical to intervening or consulting in a timely and meaningful way. This course provides a discussion of the differential diagnosis of a few of the many hemorrhagic conditions that may present during pregnancy, including the incidence and potential causes of early pregnancy loss and second and third trimester bleeding. Furthermore, nonobstetric causes of genital bleeding in pregnancy should be part of any differential diagnosis. Knowledge of appropriate history, physical, laboratory, and diagnostic data required to reach an accurate diagnosis and management plan is vital in providing optimal care to obstetric patients. The patient and her family's needs for education and support should also be addressed.

Bleeding during pregnancy is a frightening and potentially life-threatening event occurring in one out of every five pregnancies. The purpose of this course is to assist nurses, nurse practitioners, physicians, and physician assistants working in a variety of settings to understand, triage, and manage bleeding in pregnancy in order to facilitate more efficient diagnoses and treatment, resulting in better patient outcomes.

• Discuss the epidemiology of hemorrhagic conditions in pregnancy.

• Identify potential causes of bleeding in pregnancy and pregnancy loss.

• Compare the presentation and management of the different types of spontaneous abortion, including patient education and support needs.

• Describe the risk factors and signs and symptoms associated with ectopic pregnancy.

• Discuss the management and treatment of ectopic pregnancy, including the role of ultrasound.

• Describe gestational trophoblastic disease (GTD) and hydatidiform molar pregnancy.

• Review the differential diagnosis of and complications correlated with complete, partial, and marginal placenta previa.

• Define abruptio placenta and identify the associated risk factors.

• Review the appropriate management of abruptio placenta.

• Describe the evaluation of additional causes of bleeding in pregnancy.

• Outline the importance of an interpreter in caring for non-English-proficient patients.

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