Iron metabolosm and anemia in pregnancy

Total iron content in the body is 38mg/kg and 70% of them are found in the hemoglobin and 30% in tissues.Iron loss from the body is not under regulation. Usual losses are in the form of menstrual loss and epithelial desquamation from the gut and skin. These losses amount to about 2mg/day. The iron balance is maintained by the iron absorption. Iron absorption is regulated by the amount of iron stores and the rate of erythropoiesis.

Iron absorption takes place at duodenum. Organic heme iron is well absorbed where as inorganic non-heme iron is poorly absorbed. Phytates, phosphates and tannin inhibit iron absorption. This factor has to be born in mind when dietary advice is given to the patient.

In pregnancy placental lactogen stimulates the erythropoietin secretion and produces bone marrow hyperplasia. This results in linear gradual increase in red cell mass, which reaches the peak of about 25% increase by 32-34 weeks of POA. This increase in red cell mass is enhanced by iron and folate supplementation.

Plasma volume too increases by about 40% and the net result is dilution of blood and dilutional (relative/physiological) anemia despite of increase in red cell mass. This factor has to be in mind when interpreting the Hb levels (normal is about 10-11g/dl) and hematocrit levels (normal is about 35%) in pregnancy.

Iron loss via menstrual blood (about 360mg) is saved during pregnancy. But the fetus totally depends on maternal circulation for its iron need (about 500mg). Also the need of iron is increased during pregnancy due to the increased red cell production (by about 500mg) and storage for future lactation (by about 180mg). Additional loss (of about 180mg) will occur at the time of partus. Hence, maternal intake has to be adequate to meet the net iron loss of 1000mg during pregnancy. Therefore in pregnancy iron requirement increase by about 3.6mg/day. Iron absorption is increased in pregnancy and iron supplementation in pregnancy will show good response.

Anemia in pregnancy

Anemia is a common medical disorder in pregnancy. The situation is worse in developing countries due to the poor nutritional status. Though anemia is associated with maternal mortality and morbidity, effective management can prevent most of them.

Inadequate erythropoiesis due to iron, folate and vitamin B12 deficiency and chronic blood loss are the commonest causes for anemia in pregnancy. Leukemia, sickle cell disease, thalassemia, myelodysplasias and hemolytic anemia are rare conditions but need to be born in mind while assessing the patients.

Effects of anemia in pregnancy

•     Increased risk of abortion
•     Increased risk of premature labour
•     Increased risk of intra uterine growth restriction (IUGR)
•     Lethargy
•     Ill health
•     Dyspepsia
•     Heart failure
•     Worsening of heart diseases
•     Bad prognosis following post partum hemorrhage (PPH)  and maternal death
•     Increased risk of puerperal sepsis

Intrauterine contraceptive device (IUCD)

Intrauterine contraceptive device is a device placed within the uterus in order to prevent pregnancy.Intrauterine contraceptive devices stimulate a non-inflammatory macrophage reaction and this effect is further enhance by the Copper content of it. In addition the progesterone releasing variety converts the endometrium unsuitable for implantation. As the end result sperm transportation in the upper female genital tract, ovum transport and fertilization are inhibited and implantation is impaired. These together make intrauterine contraceptive device as a very efficient method of contraception. But fertilization can occur in the fallopian tube. Efficacy of the intrauterine contraceptive device is increased when it is medicated with Copper and/or progesterone; the surface area is large and proper insertion high up in the uterus. The efficacy rate of the currently popular intrauterine contraceptive devices are about 99%. This is suitable for spacing and limitation of family. Since insertion of intrauterine contraceptive device is difficult in nullipara this is not suitable for delaying the first child.

Side effects

Abnormal menstrual bleeding, per vaginal discharge, lower abdominal cramps, back pain and infections leading to pelvic inflammatory disease are some side effects commonly seen with intrauterine contraceptive devices. Improper insertion may leads to perforation of the uterine wall usually at the time of insertion (use pull out method). Patient with uterine rupture may present with severe abdominal pain and per vaginal bleeding.Risk of perforation is during post partum when the uterus is soft. Removal of intrauterine contraceptive device is mandatory in this event. Ectopic pregnancy is a well established entry in intrauterine contraceptive device usage. When a patient complain about abnormal bleeding with abdominal pain while intrauterine contraceptive device is in situ, it is necessary to exclude ectopic pregnancy.

Contraindications for IUCD

• Known or suspected pregnancy
• Pelvic inflammatory disease
• Heart diseases - valvular or septal lesion
• Abnormal uterine bleeding
• Uterine abnormalities
• Confirmed or suspected malignancy of genital tract

As a routine intrauterine contraceptive device is perfect to be inserted at the time of menstruation since it rules out pregnancy, negotiation through cervix is easy and slight bleeding at the time of insertion goes unnoticed. Post partum intrauterine contraceptive device should be inserted after 6 weeks from delivery, but now newer devices are available, which can be inserted immediately after delivery. If the woman gets pregnant while in intrauterine contraceptive device she should be immediately referred to a specialist Obstetrician for the removal of intrauterine contraceptive device and further management.

Woman should be advised on the following:

• Bleeding per vagina for few days after insertion is normal
• First few menstrual cycles may be abnormal
• Lower abdominal pain and back pain may occur with menstruation. If disturbing can take analgesia.
• Always check for the presence of the thread especially after menstruation. Report to the clinic immediately if the thread is not felt.

The currently used intrauterine contraceptive devices can keep insitu for about 6-8 years. After insertion the woman should be reviewed frequently for two visits and later annually.

Post coital contraception with intrauterine contraceptive device

Intrauterine contraceptive device inserted within 72 hours of unprotected sexual intercourse can act as contraceptive method and prevents pregnancy.

Respiration, Blood, heart, and circulation

Respiration
The air we breathe in goes through the nose, or sometimes through the mouth, via the throat (pharynx) and the larynx (voice box) into the wind-pipe (trachea), and thence into the lungs. The trachea divides into two branches, called bronchi, which lead to the left and right lungs. These bronchi keep on dividing into smaller bronchi, like the branches of a tree. The terminal ends of these bronchi are called bronchioli. The brochioli end up in tiny cavities called alveoli (like the twigs of a tree, which end up in the leaves). The air is drawn into each alveolus during inspiration (breathing in). The oxygen in the air enters the capillaries (the smallest blood vessels) in the alveoli, and the excess of carbon dioxide is. discharged into the alveoli from the same capillaries. During expiration (breathing out) the carbon dioxide is expelled into the air.The chest cavity expands during inspiration by the outdrawing of the muscles of the chest and the downward movement of the diaphragm, which is the thick muscular wall that separates the chest cavity from the abdominal cavity.

Blood, heart, and circulation
Blood is essential for life. Blood is circulated to all parts of the body, by the action of the heart, through a network of blood vessels, which are referred to as arteries and veins. The heart is about the size of the fist (closed hand). It is enclosed within a sac called the pericardium, and is situated inside the chest on the left side. It pumps the blood to the periphery through the arteries, and the veins bring back the blood from the periphery to the heart. The terminal ends of arteries which are microscopic in size are referred to as capillaries. At this point the capillaries are referred to as the arterial capillaries.The arterial capillaries gradually become venous capillaries, which ends up as veins. At the arterial end of the capillary, Oxygen as well as the fluid comes out of the blood and bathes the cells, thus supplying them with Oxygen and nutrients. At the venous end of the capillary, fluid and carbon dioxide (which the body needs to get rid of) flow back into the capillary, and thence into veins. The veins take back this blood to the heart, which pumps the blood into the lungs. If we cut a finger. It would cut through some of the small blood vessels (capillaries) which cannot seen by the naked eye. That is why blood comes out through a wound.

The heart can be best described as an organ consisting of two pumps, which are joined together and exist side by side. The left side of the heart (left pump) consists of two chambers. The upper and smaller chamber, the left atrium – receives oxygenated blood from the lungs. This oxygenated blood flows (from the left atrium) through a valvular opening called the mitral valve, to a bigger and stronger chamber called the left ventricle. The left ventricle pumps this blood into a large artery called the aorta through a valve called the aortic valve. From the aorta the blood is transported through its many arterial branches which ends up in tiny vessels called capillaries, into all parts of the body into the space between cells. After delivering Oxygen and other substances the blood is brought back to the right side of the heart through a network of veins. The blood in the veins contain less oxygenated blood but large amount of Carbon dioxide when compared to the blood in the arteries. The right side of the heart also consist of two chambers. The smaller chamber, the right atrium which is situated above, receives the venous blood from all parts of the body. This venous blood flows from the right atrium through a valve called the tricuspid valve to the right ventricle. The right ventricle pumps the venous blood through a valve called the pulmonary valve into the lungs. In the lungs the blood gives up a large amount of carbon dioxide, and takes in oxygen. It is then returned to the left atrium.

The mind as a controlling agent

Most people think that their behavior is controlled by a rational mind, and that therefore behavior is within voluntary control through will power. This view promoted by religions and philosophers until the 19th century, received a setback in the 20th century. That was when Sigmund Freud pointed out that there are many activities of our minds that are not within our control and which influence our behavior a great deal. Just imagine the last time you took a bath. How many acts in that procedure did you perform with full consciousness? Usually not many. The example of the iceberg is a good one for the mind; a large part of our minds remains submerged and beyond consciousness - what Freud called the subconscious mind. Its influence on our behavior is great, as the unconscious part of the mind is large. Take the example of a parent who meets out harsh punishment to a child for a minor misdemeanor. The parent may be having an unconscious fear of loss of control of the child. This fear may be either due to his childhood experience or due to the experience of a brother who went out of control and ruined his life. We often notice that mothers overprotect their beautiful daughters. The mothers are guided either by their childhood experience when they received undue attention from males or even had a traumatic (painful) sexual experience. If they are asked why they are harsh to a child or why they are overprotecting a child, they cannot explain these unconscious fears. All you hear would be some common excuse usually a rational one.

Have you heard of the famous Freudian slip? We say something by mistake when we want to say something else. The thing said in mistake may well be true or expose something about you. Next time you catch yourself with a slip of the tongue, think about it. So most of our actions are not all that rational. There are many unconscious motives to our behavior. One such unconscious motive is to defend against injury to our self-esteem. We defend our self-esteem in many ways. These are called defense mechanisms. Take the example of an office worker who is taken to task for poor work by his boss in the office. He feels bad but does not say anything to his boss. That evening he beats up his wife over a minor conflict. He has transferred his aggression from boss to wife. Has somebody who accused you of harboring ill feelings towards him surprised you? You never felt that way towards him, but it was probably he who had ill feelings towards you. But since he cannot accept that fact, he unconsciously projects it onto you. People often project their own hostility towards rulers and accuse them of planning to cause harm to people. People project their own hostility towards neighbors, and claim the neighbors are indulging in “charms” against them. There are many such mechanisms of defense against injury to self-esteem. Some are harmless but in some cases we begin to believe ourselves.

Mood and behavior
Our moods refer to the state of our emotions. When we are depressed, our actions are guided by depression. We may lose confidence in our ability to work, have fears of making mistakes, and keep away from the company of friends, but perceive them as rejecting us. In the same way, when anxious, it shows in our behavior as in the stuttering and sweating public speaker who is a first timer. We often learn to avoid people who, and situations that, make us anxious. This in tum increases the problem of anxiety. Another state of mind recognized by psychologists is "learned helplessness". Those who fail repeatedly in life learn and adopt failure as a way of life. They soon give up trying. This is seen at a society level in many third world countries. The poor adopt fatalism as a determinant of their lives. This creates major obstacles to progress in their lives and in society, as a large segment of the population remains socially and economically crippled and resigned to their fate. At an individual level, it has been demonstrated that those patients who give up fighting against an illness, such as cancer, tend to die earlier than those who fight the illness do. Tied up with “learned helplessness“ is the influence of belief. We know now, that merely the belief that one can do well helps a person perform better and achieve. It can be said that believing in one's self is the first and essential step towards success.

The brain and nervous system

All our thinking processes physical activities and sensations, are initiated, controlled, and co-ordinated by the brain and nervous system. If you accidentally put your hand into some hot water, you will pull it away immediately. This response (called a reflex) is brought about by messages that are sent at high speed through the nervous system. The brain is like an extremely complicated computer, with thousands of electrical messages traveling from place to place. But it is much more than a computer because it makes us conscious persons with feelings and emotions.

The skull encloses the brain. The spinal cord comes down from it and goes down the spine (vertebral column). The human brain is of a soft consistency. It has a soft material on the outside called the grey matter which contains the basic cell units of the brain. These cells are called neurons; there are about 100 billion neurons in the brain. In the deeper parts of the brain there is a whitish firm material, called the while matter, which contains the connecting tracts, which carry the messages from the neurons. The brain is divided into the - cerebrum, cerebellum, and brain stem. Surrounding the soft brain tissue on the outside are two membranes (the meninges) with a thin layer of fluid (cerebro-spinal fluid, CSF) between them. The CSF nourishes the brain and also serves as a shock absorber, so that the brain is cushioned from damage when a person jumps around or bangs the head. There is a cavity in the inside of the brain, which is filled with CSF. This cavity continues as a canal inside me spinal cord. Doctors put in a needle at the back of the spine and get a small amount of CSF (Present between the two coverings of the meninges) for examination, to diagnose diseases such as meningitis and encephalitis.

The functions of the brain and nervous system may be broadly divided into; Higher functions such as thinking, speaking; remembering things (memory), emotions, appreciation of music; motor functions such as movements of the different parts of the body, sensory functions like appreciation of sensations such as pain, touch, seeing, hearing, taste, and smell, balance and coordination of movement in the different parts of the body and involuntary (unintentional) functions. Involuntary functions are two types, regular functions such as breathing and the beating of the heart and certain involuntary reactions with are referred to as reflexes which are usually take place at the level of the spinal cord.

The cerebrum controls the higher functions as well as motor and sensory functions. It is divided into 2 halves (left and right) which are called cerebral hemispheres. The left hemisphere controls the right side of the body, and the right hemisphere the left side of the body. The left hemisphere is said to be dominant in right handed people, and the right hemisphere in left handed people. The cerebellum is situated at the back of the brain. Its main function is to co-ordinate movements of the skeletal muscles and help maintain balance, a function which it shares with the inner ear. The cerebrum and cerebellum lead to the brain stem, which continues downwards as the spinal cord. The Spinal cord is a cylindrical structure that comes down through the vertebral column (spine) to the lower part of the back of the body. Nerves proceed from the brain stem and spinal cord to all parts of the body. In this way every part of the body is connected to the brain which ultimately controls all its activities.

Alimentary tract, food digestion

The food that we eat (or drink) enters the alimentary tract, which is the passage that starts at the mouth, passes through the food-pipe (esophagus), stomach, small and large intestine, rectum (lower end of bowel) and ends at the anus. The part of this passage from the stomach downward is also referred to as the gastrointestinal tract. Digestion of food starts in the mouth, firstly by the act of biting and chewing, and secondly through the action of the saliva. Saliva, which comes from small glands (salivary glands) situated below and on the side of the jaws, contains biochemical substances called enzymes. Enzymes that play a part in the digestion of food are referred to as digestive juices. These salivary enzymes start the presses of digestion. Further digestion takes place in the stomach (with the help of other enzymes and hydrochloric acid). Partially digested food passes from the stomach into the duodenum (the part of the tract immediately below the stomach). Pancreatic enzymes-enzymes produced in the pancreas, which is a small organ situated behind and below the stomach – are transported to the duodenum through a small tube (the pancreatic duct). These pancreatic enzymes, trypsin being one of the most important for digestion of proteins, play a most effective role in the main process of digestion of the fats, proteins and carbohydrates. From the duodenum the digested food passes to the small intestine, where intestinal juices (from the cells of the lining of the intestine) further help to complete the process of digestion.

In the small intestine, the digested foods are absorbed into the blood stream, which carries them into the liver. The undigested and unabsorbed food, along with most of the water and the intestinal juices, now passes on to the large intestine (colon). At the junction of the small and large intestine is a small outgrowth of the intestine, called the appendix. The terminal part of the large intestine is called the rectum. The opening of the rectum to the outside is called the anus. In the colon most of the water and minerals are absorbed. What is left behind is excreted as stools (feces).

The liver is situated in the upper part of the abdomen to the right of the stomach. In the liver, the nutrients are reassembled to suit the needs of the body, and distributed to the various parts of the body. Some nutrients, (e.g. vitamins A and D, folic acid, vitamin B 12, iron, etc.) are stored in the liver. In addition to nutrients, other substances are absorbed and transported to the liver. These may be drugs, alcohol, poisons etc. The liver has a limited capacity to safeguard the body against harmful substances, by neutralizing the harmful effects. For example alcohol is utilized to provide energy (calories) with the aid of Vitamin B 1. As a result of the various activities that go on in the liver; some waste products are formed within it. Most of these are expelled into the duodenum as a thick greenish-black liquid called bile. Bile contains substances such as bile pigments (resulting from the breakdown of red blood cells), bile salts, cholesterol, and some enzymes; Bile drains out of the liver through a small tube (bile duct) into the gall bladder, and from there into the duodenum.

Syphilis and Gonorrhea

Syphilis is caused by a germ called Treponema pallidum, This disease can be easily missed because a person can carry the germ of syphilis but may look healthy. Complications such as blindness, deafness and heart disease can occur many years after the initial infection and they do not respond to treatment at that stage. In its initial stage of infection, a sore appears in or around the genitalia (sex organs) usually about 2-3 weeks after sexual contact with an infected person. This sore usually heals on its own. The second stage of the disease is characterized by the appearance of some or all of the following features: a skin rash, loss of hair, enlargement of lymph nodes all over the body, sore throat, and a feeling of not being well. The skin rash may not be very obvious in dark skinned people and appears 3-6 months after genital sore appears. These symptoms also disappear gradually and the person goes into a latent or hidden stage, where the infected person feels well and healthy. The disease at this stage can be detected only by a blood test.

After many( usually 7-20 years) years of infection, complications such as blindness, paralysis and dementia occur in about 40% of patients. This stage is called tertiary syphilis. An infected mother may have several abortions and miscarriages. She could also infect the baby and cause congenital syphilis. (i.e. present at birth) The infection spreads through the placenta, from an infected mother to the unborn child. Most of the infected babies look normal at birth. involvement of the bones is common and the babies may develop swelling of the joints at around 6 weeks to 6 months of age; these are extremely painful, and as a result the baby may not move the limbs due to pain. Fever, anemia, failure to thrive, and irritability may be some of the features. Involvement of the nasal (nose) bone, teeth, enlargement of the liver and skin rashes are other later manifestations. The diagnosis is usually made by examining the scrapings from the lesions, and by doing the VDRL test. When a blood test is done a few days after the infection (soon. after the sore appears) the blood test may not be positive. Hence it is important to repeat the test again after 3 months. The VDRL may sometimes be positive in other conditions as well. In such instances other specific tests could be done to confirm the diagnosis. A blood test done during pregnancy helps to detect and treat congenital syphilis in the baby.

Treatment
Although syphilis can be completely cured when adequately treated in its early stages, treatment at the stage when complications set in is of little use. Self prescribed treatment with antibiotics such as tetracycline will suppress the disease but does not give a complete cure. Treatment is a prescribed course of Penicillin injections.

Gonorrhea
Gonorrhea is more prevalent than syphilis and is caused by bacteria Nisseria gonorrhoea (gonococci). The most noteworthy feature of this disease is that females frequently do not show any symptoms of the disease. Thus it is only the males (who get symptoms) that usually turn up for treatment. The larger infected pool of commercial sex workers usually does not seek treatment because they feel and look quite well. Symptoms in the male are burning sensation when passing urine, pus-like (thick and yellow) discharge from the tip of the urethra, and frequency of passing urine. If left untreated, complications can occur, but these are rare at present; these include swelling of joints, abscesses in the genital organs and infertility in women.Infection of the male urethra may lead to strictures (narrowing of the opening), and subsequent difficulty in passing urine. Infection of a pregnant mother may result in infection of baby's eyes, during birth. The eyes become reddened with a discharge. This may result in blindness, if untreated. Gonorrhea cannot be diagnosed by a blood test. The females in particular need to have a genital examination and special swabs taken for diagnosis. Penicillin used to be the drug of choice; however, many patients are now resistant to this drug.