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Questions and Answers
Which condition is a specific indication for parenteral iron therapy?
Which condition is a specific indication for parenteral iron therapy?
What is the maximum dose of iron sucrose that can be administered in one day?
What is the maximum dose of iron sucrose that can be administered in one day?
Which of the following is NOT a contraindication for blood transfusion?
Which of the following is NOT a contraindication for blood transfusion?
When should oral iron be withheld in relation to parenteral iron therapy?
When should oral iron be withheld in relation to parenteral iron therapy?
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What is the adverse effect that might occur due to parenteral iron therapy?
What is the adverse effect that might occur due to parenteral iron therapy?
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What is the recommended dosage of iron-folic acid (IFA) tablets for a pregnant patient?
What is the recommended dosage of iron-folic acid (IFA) tablets for a pregnant patient?
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When assessing the effectiveness of oral iron therapy, how soon is an increase in reticulocyte count expected?
When assessing the effectiveness of oral iron therapy, how soon is an increase in reticulocyte count expected?
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What indicates an adequate response to oral iron therapy after one month?
What indicates an adequate response to oral iron therapy after one month?
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What distinguishes mild-moderate anemia from severe anemia during pregnancy?
What distinguishes mild-moderate anemia from severe anemia during pregnancy?
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What should a compliant patient do with their IFA tablets beyond the pregnancy period?
What should a compliant patient do with their IFA tablets beyond the pregnancy period?
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Which of the following statements is least likely accurate regarding anemia management in pregnancy?
Which of the following statements is least likely accurate regarding anemia management in pregnancy?
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What is the maximum time frame in which an increase in reticulocyte count is expected?
What is the maximum time frame in which an increase in reticulocyte count is expected?
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In managing anemia during pregnancy, which approach is generally taken for mild-moderate cases?
In managing anemia during pregnancy, which approach is generally taken for mild-moderate cases?
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What is a common misconception about anemia during pregnancy?
What is a common misconception about anemia during pregnancy?
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What should be the first step in addressing symptoms of anemia in pregnant individuals?
What should be the first step in addressing symptoms of anemia in pregnant individuals?
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What is the recommended treatment for pregnant women on warfarin who are dosed at < 5mg/day?
What is the recommended treatment for pregnant women on warfarin who are dosed at < 5mg/day?
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What is a potential fetal anomaly associated with the use of warfarin during pregnancy?
What is a potential fetal anomaly associated with the use of warfarin during pregnancy?
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Which anti-epileptic medication is considered the least teratogenic?
Which anti-epileptic medication is considered the least teratogenic?
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What should be done if a woman with epilepsy conceives?
What should be done if a woman with epilepsy conceives?
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What is the appropriate management for a pregnant patient on warfarin at the time of delivery?
What is the appropriate management for a pregnant patient on warfarin at the time of delivery?
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What is the primary use of the Mentzer Index?
What is the primary use of the Mentzer Index?
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Which condition is associated with an MCV value less than 75 fL?
Which condition is associated with an MCV value less than 75 fL?
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What value indicates depletion of iron stores based on serum ferritin levels?
What value indicates depletion of iron stores based on serum ferritin levels?
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What is the normal range for transferrin saturation?
What is the normal range for transferrin saturation?
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How is Iron Deficiency Anemia differentiated from Anemia of Chronic Disease?
How is Iron Deficiency Anemia differentiated from Anemia of Chronic Disease?
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Which symptom is NOT commonly associated with heart disease?
Which symptom is NOT commonly associated with heart disease?
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Which heart condition has the highest risk of maternal mortality during pregnancy?
Which heart condition has the highest risk of maternal mortality during pregnancy?
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What characterizes WHO Class 4 heart disease in relation to pregnancy?
What characterizes WHO Class 4 heart disease in relation to pregnancy?
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Which statement regarding heart diseases with good prognosis in pregnancy is accurate?
Which statement regarding heart diseases with good prognosis in pregnancy is accurate?
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Which condition typically worsens a patient's status during pregnancy?
Which condition typically worsens a patient's status during pregnancy?
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What is the significance of measuring the JVP in pregnant patients?
What is the significance of measuring the JVP in pregnant patients?
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Which of the following physical examination findings is indicative of sickle cell anemia?
Which of the following physical examination findings is indicative of sickle cell anemia?
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Which laboratory test is NOT part of the screening recommended by Indian guidelines for anemia in pregnancy?
Which laboratory test is NOT part of the screening recommended by Indian guidelines for anemia in pregnancy?
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When should hemoglobin levels be checked according to international guidelines for anemia during pregnancy?
When should hemoglobin levels be checked according to international guidelines for anemia during pregnancy?
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What does a peripheral smear showing microcytic hypochromic anemia generally indicate?
What does a peripheral smear showing microcytic hypochromic anemia generally indicate?
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What is the recommended fluid restriction in patients during intrapartum management of heart disease?
What is the recommended fluid restriction in patients during intrapartum management of heart disease?
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Which of the following conditions is an indicator for a cesarean section in patients with heart disease?
Which of the following conditions is an indicator for a cesarean section in patients with heart disease?
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What is the primary medication used to manage postpartum hemorrhage (PPH) in patients with heart disease?
What is the primary medication used to manage postpartum hemorrhage (PPH) in patients with heart disease?
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Which anesthesia technique is preferred for cesarean delivery in patients with heart disease?
Which anesthesia technique is preferred for cesarean delivery in patients with heart disease?
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What should be monitored during intrapartum management for heart disease patients?
What should be monitored during intrapartum management for heart disease patients?
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Which antibiotics are considered safe during pregnancy?
Which antibiotics are considered safe during pregnancy?
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What is a significant risk associated with the use of Warfarin during pregnancy?
What is a significant risk associated with the use of Warfarin during pregnancy?
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Which statement is true regarding the use of Low Molecular Weight Heparin (LMWH) in pregnancy?
Which statement is true regarding the use of Low Molecular Weight Heparin (LMWH) in pregnancy?
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When is the teratogenic effect of Warfarin most significant during pregnancy?
When is the teratogenic effect of Warfarin most significant during pregnancy?
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Which of the following antibiotics should be avoided in individuals with G-6-PD deficiency?
Which of the following antibiotics should be avoided in individuals with G-6-PD deficiency?
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What physiological change occurs to cardiac output (CO) during pregnancy?
What physiological change occurs to cardiac output (CO) during pregnancy?
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What is the expected change in blood pressure during pregnancy?
What is the expected change in blood pressure during pregnancy?
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Which parameter remains unchanged in pregnancy?
Which parameter remains unchanged in pregnancy?
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What position is considered best for pregnant women to alleviate physiological stress on the heart?
What position is considered best for pregnant women to alleviate physiological stress on the heart?
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Which of the following statements about heart sounds in pregnancy is accurate?
Which of the following statements about heart sounds in pregnancy is accurate?
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Study Notes
Anemia in Pregnancy: Part 2
- Mild-Moderate Anemia: Treatment involves oral iron therapy with 2 IFA tablets/day. This should continue throughout pregnancy and for 180 days post delivery to replenish iron stores.
- Adequate Response to Oral Iron: Hb levels should increase by ≥ 19% after one month of treatment. For compliant patients, the dose of 2 tablets/day should be maintained. Inadequate responses require further assessment and may necessitate a switch to parenteral iron therapy.
- Reticulocyte Count: This is a preferred measure for assessing response to iron therapy as it indicates new red blood cell production.
- Therapeutic Decision Making: Iron supplementation is adjusted based on gestational age and the patient's response to treatment.
Therapeutic Decision Making for Anticoagulation During Pregnancy
- Warfarin: A dose of < 5mg/day can be continued with aspirin. For doses ≥ 5mg/day, switch to low molecular weight heparin (LMWH) plus aspirin.
- Delivery in Patients on Warfarin: Warfarin should be discontinued. Cesarean section is recommended to minimize the risk of fetal intracranial hemorrhage. Vitamin K should be administered to the mother and baby.
Disala Syndrome
- This syndrome is a rare but serious condition caused by warfarin use in pregnancy.
Fetal Anomalies Associated with Warfarin Use
- Chondrodysplasia: Features include a depressed nasal bridge and stippled epiphysis.
- Cataracts
Central Nervous System (CNS) Defects Associated with Warfarin Use
- Microcephaly: Reduced head size.
- Hydrocephalus: Abnormal accumulation of cerebrospinal fluid in the brain.
- Dandy-Walker malformation: This affects brain structure and can cause hydrocephalus.
Anti-epileptic Drugs in Pregnancy
- Teratogenicity: Valproic acid has the highest teratogenicity potential, followed by phenytoin, phenobarbital, carbamazepine, lamotrigine, and lastly levetiracetam.
- Valproic Acid Effects: Causes neural tube defects, CNS malformations, and urinary tract deformities.
- First Epileptic Attack in Pregnancy: Levetiracetam and lamotrigine are recommended.
- Epilepsy in Pregnancy: Continue the same medication at the lowest effective dose. Folic acid supplementation is essential.
- ≥ 1 month before conception: 0.4 mg/day
- After conception: 1 mg/day
RBC Indices and Anemia Diagnosis
- Mentzer Index: Used to differentiate between Iron Deficiency Anemia (IDA) and Thalassemia.
- < 13: Thalassemia
-
13: IDA
- Mean Corpuscular Volume (MCV): Used to classify anemias based on red blood cell size.
- Microcytic Anemia (< 75 fL): IDA, Thalassemia, Sideroblastic Anemia, Lead poisoning, Anemia of chronic disease
- Macrocytic Anemia (> 100 fL): Vit B12 deficiency, Folic acid deficiency, Anemia of liver disease, Thyrotoxicosis
- Serum Ferritin: The most sensitive and earliest indicator of iron stores.
- Normal: 34-37%
- IDA: < 30%
- Iron Study Parameters:
- Serum Ferritin:
-
100: Normal iron stores
- < 20: Depletion of iron stores
- < 40 mcg/dL: IDA
-
- Serum Iron: < 40 mcg/dL: IDA
- TIBC: 325-400 mcg/dL
-
410: IDA
-
- Transferrin Saturation:
- Normal: 25-50%
- < 10%: IDA
- Serum Ferritin:
- IDA vs Anemia of Chronic Disease: Serum hepcidin is useful for differentiation. Bone marrow biopsy is the gold standard method but invasive.
Parenteral Iron Therapy
- Indications: Non-compliance to oral therapy, intolerance to oral iron, and specific gestational age considerations.
- Parenteral Iron Preparations: Iron dextran (1st generation), iron sucrose (2nd generation), ferric carboxy maltose (3rd generation).
- Route: Intravenous
- Dose: Calculated using the Ganzoni formula.
- Infusion Rate: Start with a slow rate (15-20 drops/min) and gradually increase to 80-90 drops/min if no allergic reaction occurs.
Blood Transfusion
- Indications: Thalassemia major, heart failure, acute hemorrhage, Hb < 5, Hb 5-6.9 at >34 weeks, bone marrow failure.
- Contraindications: 1st trimester, hemochromatosis, thalassemia major.
- Blood Product: One packed cell transfusion/day can increase Hb by 1%.
- Exceptions: Hemorrhage > 1g%/day and congestive heart failure.
Anemia in Pregnancy: Part 1
- Previous Pregnancy: Relevant information includes previous use of parenteral iron and blood transfusions.
Physical Examination
- Pallor: Sites assessed for pallor include conjunctiva, oral mucosa, and nail beds.
- Nails: Koilonychia (distorted nails), platonychia (flat nails), and yellowish discoloration (hemolytic anemia, IDA).
- Glossitis/Cheilosis: Indicates folic acid deficiency.
- Jugular Venous Pressure (JVP): Normally elevated in pregnancy, but abnormal elevations suggest congestive heart failure.
-
8 cm of H₂O (3 cm above clavicle) indicates heart failure.
-
- Leg Ulcers: Suggestive of sickle cell anemia.
- Lymph Node Enlargement: To rule out chronic diseases such as tuberculosis and malignancy.
Laboratory Diagnosis
- Indian Guidelines: Hemoglobin levels should be checked four times during each antenatal visit. Screening threshold for anemia: Hb < 11 gm%.
-
- Complete Blood Count + Reticulocyte count
-
- Peripheral smear
-
- Hb electrophoresis (If sickle cell anemia or thalassemia is suspected)
-
- International Guidelines: Hemoglobin levels should be checked twice: at the first antenatal visit and again between 24-28 weeks of gestation.
Management of Heart Disease
Intrapartum Management (Vaginal Delivery)
- Spontaneous labor and induction of labor (as needed) are considered.
- For a ripe cervix, vaginal delivery is the preferred route.
- Prophylactic use of forceps/vacuum may be considered to shorten labor stages and reduce maternal effort.
- Monitor maternal and fetal heart rate, as well as fluid input and output.
- Semi-recumbent position with left lateral tilt is recommended.
- Restrict IV fluids to 75mL/hr.
- Epidural analgesia may be used.
- Limit pelvic exams to prevent infective endocarditis.
- Ampicillin + gentamicin is given when membranes rupture.
Postpartum Management
- Active Management of the Third Stage of Labor (AMSTL) is recommended.
Indicators for Cesarean Section
- Aortic Lesions: Increased risk of aortic dissection during vaginal delivery.
- Severe aortic stenosis (AS)
- Aortic aneurysm
- Marfan syndrome with aortic root dilatation
- Coarctation of aorta
- Patients on Warfarin: Within 2 weeks of delivery, there's an elevated risk of postpartum hemorrhage (PPH) and fetal intracranial hemorrhage.
- Refractory Heart Failure
Anesthesia
- Neuraxial anesthesia (epidural) is the preferred type for patients with heart disease.
- General Anesthesia (GA): Indicated for patients with:
- Intracardiac shunt
- Severe AS
- Heart Outcome/Complications (HOCT)
Postpartum Hemorrhage (PPH) in Heart Disease
- Oxytocin is the drug of choice for managing PPH.
- Methylergometrine can be considered as an alternative.
Preconceptional Counseling
- Ventricular Septal Defect (VSD): This has the highest risk of recurrence.
- Investigations: ECG and echocardiogram are essential.
- Surgery: If needed, should be performed before conception.
Indicators of Heart Disease
- Symptoms:
- Progressive dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Hemoptysis
- Chest pain
- Non-dependent edema/anasarca
Most Common Heart Disease (HD) in Pregnancy
- Rheumatic heart disease (especially mitral stenosis - ms) is the most common.
- Atrial septal defect (ASD) is the most common congenital HD.
- Tetralogy of Fallot (TOF) is the most common cyanotic HD.
- Mitral valve prolapse (MVP) is the most common congenital valvular HD.
- Eisenmenger syndrome: This carries the highest risk of maternal mortality.
Death due to Right Ventricular Failure
- Most common cause of death: Right ventricular failure.
- Time of death: During labor or within 1 week of delivery.
- Pregnancy is contraindicated in this condition.
- Mitral stenosis (mS) is the most frequent cause of maternal mortality.
WHO Class 4 Heart Disease
- Highest possibility of death due to pregnancy.
- Pregnancy is contraindicated.
- Medical termination of pregnancy (MTP) is advised.
Associated Conditions
- Pulmonary hypertension: Primary (1°) or secondary (2°)
- Severe mitral stenosis (mS)/aortic stenosis (AS)
- Left ventricular ejection fraction (LVEF) < 30%
- Chest X-ray: Marked cardiomegaly
- Arrhythmia
Heart Diseases with Good Prognosis in Pregnancy
- Congenital Heart Disease (CHD)
- Repaired VSD/ASD
- Corrected TOF, PDA, MVP
Heart Disease Prognosis in Pregnancy
- Worsens:
- Stenotic lesions: Increased heart rate reduces the time for atrial blood to enter ventricles.
- Symptom: Dyspnea on exertion
- Management: Limit physical activity, and prescribe beta-blockers
- Improves:
- Regurgitant lesions: Decreased diastolic blood pressure (DBP) reduces pressure gradient between chambers and decreases backflow of blood.
- Acyanotic HD
HEART DISEASES IN PREGNANCY
Physiological Changes:
- Increased Parameters:
- Cardiac Output (CO):
- CO = Stroke Volume (SV) x Heart Rate (HR)
- Increase begins at 5 weeks
- Maximum at 28-32 weeks
- Returns to normal: 10 days post-delivery
- Femoral Venous Pressure:
- Compression of inferior vena cava (IVC) by uterus
- Peripheral pooling of blood
- Increased risk: Varicose veins, vulval varicosities, hemorrhoids
- Cardiac Output (CO):
- Decreased Parameters:
- Peripheral Vascular Resistance (PVR):
- Progesterone and Relaxin act as smooth muscle relaxants.
- Blood Pressure:
- Systolic BP
- Diastolic BP: Maximum decrease
- Mean Arterial Pressure: Maximum decrease
- Peripheral Vascular Resistance (PVR):
- Unchanged Parameters:
- JVP
- Pulmonary Capillary Wedge Pressure (PCWP)
- Left Ventricular Ejection Fraction (LVEF)
- Best Position for Pregnant Women: Left Lateral > Right Lateral
Normal Pregnancy Symptoms:
- Easy fatiguability
- Decreased exercise tolerance
- Dyspnea on exertion
- Peripheral dependent edema
Clinical Indicators:
- Heart rate: Increased
- Pulse rate: Increased
- BP: Decreased
- JVP: Normal
- Heart Position Changes:
- Heart is displaced upwards and outwards towards the left.
- Apex beat: 4th intercostal space, 2.5 cm lateral to the mid-clavicular line.
- Heart Sounds:
- S1: Louder and more prominent split
- S2: Normal
- S3: Easily audible
- Murmurs: Continuous/mammary murmur, ejection systolic murmur grade 2-3 (involving the aortic and pulmonary valves).
Drugs in Pregnancy
Antibiotics
- Safe: Cephalosporins, ampicillin, metronidazole, penicillin
- In the 1st Trimester:
- Nitrofurantoin (DOC for asymptomatic bacteriuria)
- Fluconazole
- Trimethoprim
- Note:
- G6PD deficiency: Avoid nitrofurantoin and sulphamethoxazole
- Doxycycline: Tetracycline can be used only with a strong indication.
- Throughout Pregnancy: Avoid fluoroquinolones, aminoglycosides, and tetracyclines.
Anticoagulants
- Warfarin:
- Advantages: Crosses the placenta
- Disadvantages: Teratogenic, increases risk of postpartum hemorrhage and fetal intracranial hemorrhage when used at delivery time.
- Low Molecular Weight Heparin (LMWH):
- Advantages: Does not cross the placenta
- Disadvantages: Low potency anticoagulant
- Target Values:
- Warfarin: INR 2.5-3
- LMWH: Factor Xa 0.8-1.2
- Teratogenicity of Warfarin: Depends on:
- Dose: ≥ 5mg/day (Teratogenic dose)
- Gestational age: Maximum teratogenicity in the 1st trimester, particularly at 7-9 weeks.
- Note: LMWH can be replaced by unfractionated heparin (UFH) 1 week prior to delivery due to faster action and reversibility.
Valve Replacement
- Mechanical valve replacement: Anticoagulant + Aspirin (continue until 36 weeks)
- Bioprosthetic valve replacement: Aspirin only
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Description
Test your knowledge on anemia management during pregnancy with this quiz. It covers topics such as parenteral iron therapy, indications for blood transfusion, and recommended dosages of iron-folic acid tablets. Explore critical aspects including assessing therapy effectiveness and distinguishing between anemia severity.
