hemoconcentration in pregnancy

Patients who develop DIC generally do so in the setting of well-developed HELLP syndrome. Ray Yip, Significance of an abnormally low or high hemoglobin concentration during pregnancy: special consideration of iron nutrition, The American Journal of Clinical Nutrition, Volume 72, Issue 1, July 2000, Pages 272S279S, https://doi.org/10.1093/ajcn/72.1.272S. The clinical significance of low or high hemoglobin concentrations that are less extreme has more to do with underlying conditions that cause abnormally high or low hemoglobin concentrations. Pain relief with intravenous narcotics and local anesthesia is acceptable but certainly not optimal for pain control. Mandani G, Branson HE. In such known clinical cases, iron supplementation can be avoided, but only if a sophisticated laboratory is available to diagnose the type of anemia. The process to prove such evidence often involves controlled trials with proper randomization. A woman who has a normal hemoglobin concentration when she is perfectly healthy but because of some condition (eg, pulmonary emphysema) has her hemoglobin shift from 120 to 140 g/L is at risk. Randomized placebo-controlled trial of iron supplementation and malaria chemoprophylaxis for prevention of severe anaemia and malaria in Tanzanian infants. The finding of a decreased serum haptoglobin level may confirm ongoing hemolysis when the hematocrit is normal.8 The serum transaminase levels may be elevated to as high as 4,000 U per L, but milder elevations are typical. High hemoglobin concentrations are often mistaken as adequate iron status; however, high hemoglobin is independent of iron status and is often associated with poor health outcomes. Another reason for supplementation is that anemia caused by iron deficiency alone or in combination with other factors, eg, folate deficiency, vitamin A deficiency, and malaria, has been implicated as having several negative effects on maternal and fetal health. Regarding the high-end hemoglobin issue, let us assume the population mean hemoglobin concentration is 140 g/L. Three elementary and clinical factorsergometrine, blood transfusion, and the rule for flying squadssuggest that iron deficiency anemia does not seem to come into the historical picture for hemorrhage-related maternal mortality on a crude basis. Patients who undergo cesarean section should be transfused if their platelet count is less than 50,000 per mm3 (50 109 per L). Additionally, the positive association observed in several epidemiologic studies does not establish a causal relation without the support of a plausible biological mechanism (5). Heilman L, Siekmann U, Schmid-Schonbein H, Ludwig H. Hallberg L, Hulthen L, Bengston C, Lapidus L, Lindstedt G. Presented at the meeting Iron and Maternal Mortality in the Developing World, held in Washington, DC, July 67, 1998. Experiences of women of childbearing age regarding Implanon provision in South Africa. A greater supply of the components for hemoglobin or red blood cells, including iron, will not result in a higher hemoglobin concentration without a tissue hypoxia drive. Acute iron poisoning is one of the most common fatal accidental childhood poisonings in some countries. (These studies were completed in 1958-1978 when such tests were not contraindicated in gravid women). Hemoglobin in the first half of pregnancy was 12.61 (1.06) g/dL and average hematocrit in the first half of pregnancy was 38.19 (3.07) grams percent. This lack of evidence does not negate the evidence for controlling maternal anemia. Although the association between high hemoglobin concentration and adverse pregnancy outcome is probably best explained by inadequate plasma volume expansion, this has not been directly demonstrated. Because of reported potentiation of effect, care should be taken when nifedipine and magnesium sulfate are given concurrently.22 Diuretics may compromise placental perfusion and therefore are not used to control blood pressure in patients with HELLP syndrome. If higher than normal hemoglobin concentrations lead to poor birth outcomes, then a related question is, Should we be concerned about iron supplementation during pregnancy, given that iron supplementation can increase the hemoglobin concentration of some women? Because of the variable nature of the clinical presentation, the diagnosis of HELLP syndrome is generally delayed for an average of eight days.7 Many woman with this syndrome are initially misdiagnosed with other disorders, such as cholecystitis, esophagitis, gastritis, hepatitis or idiopathic thrombocytopenia.3 In one retrospective chart review of patients with HELLP syndrome, only two of 14 patients entered the hospital with the correct diagnosis.7. The three chief abnormalities found in HELLP syndrome are hemolysis, elevated liver enzyme levels and a low platelet count. Common sense, for example, will keep surgeons from operating on patients with a hemoglobin concentration <80 or 90 g/L because they know the postoperative or intraoperative mortality will be higher. Pregnant women presenting with blood pressures higher than 160 mm Hg systolic or 110 mm Hg diastolic for 15 minutes should be given an antihypertensive medication as soon as possible, but at least within one hour. One piece of evidence comes from individuals with iron overload conditions who do not have higher hemoglobin concentrations than those of healthy individuals. In fact, sometimes it was higher in the upper classes. Lower serum insulin-like growth factor-1 levels are independently associated with anemia in patients undergoing maintenance hemodialysis. The findings of this multisystem disease are attributed to abnormal vascular tone, vasospasm and coagulation defects.2 To date, no common precipitating factor has been found. Anemia may not be a direct cause of poor pregnancy outcomes, except in the case of maternal mortality resulting directly from severe anemia due to hypoxia and heart failure. The risk factors for HELLP syndrome differ from those associated with preeclampsia (Table 1). Yes, Published source:Obstet Gynecol. In many developing countries, the principal reason that iron deficiency is common and can be severe is that diet quality is poor and the intake of bioavailable iron is low (51), not necessarily that dietary iron intake is poor. J Pediatr 1982; 101:99. Respiratory and cyanotic cardiac conditions, which compromise proper oxygenation of blood, are the principal pathologic reasons for elevated hemoglobin concentration (28). The differential diagnosis of HELLP syndrome includes acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. In an exercise state, however, any loss of hemoglobin or red blood cell mass can be detected as loss in work capacity, even within a hemoglobin range of 120130 g/L (20). A clearly defined pathophysiologic mechanism is required for classification of a nutritional disease or disorder, and an estimated nutrient requirement has been widely used for clinical and public health purposes. This difference in hematocrit is equivalent to a 20-g/L difference in hemoglobin and shows the extent of the severe failure of plasma expansion due to preeclampsia. This obstruction leads to periportal necrosis and, in severe cases, intrahepatic hemorrhage, subcapsular hematoma formation or hepatic rupture. Women with severe acute hypertension resistant to medical treatment or superimposed preeclampsia with severe features who are at 34 weeks' gestation or more should proceed to delivery. One such risk is accidental iron poisoning of young children through ingestion of iron tablets intended for maternal supplementation (45). In maternal anemia and iron deficiency, the anemia itself is often regarded as an adverse outcome. Normal coagulation findings, thrombocytopenia, and peripheral hemoconcentration in neonatal polycythemia. Could you comment on that possible interaction and, also, whether there is a larger literature outside women and pregnancy just relating anemia to the risk of blood loss from X, Y, and Z in men and women? The extensive experience from iron supplementation trials and programs does not support the possibility that abnormally high hemoglobin values can be the result of correcting iron deficiency. Patients should be observed for signs and symptoms of magnesium toxicity. Cigarette and tobacco products in pregnancy: Impact on pregnancy and the neonate; Clinical features and detection of congenital hypothyroidism . In doing this, the evidence will be categorized with respect to deficiency, risk, benefit, and feasibility to increase the effectiveness of public health programs. In fact, infants born to women who chewed tobacco also had low birth weights (41). Patients with HELLP syndrome may be eligible for conservative management if hypertension is controlled at less than 160/110 mm Hg, oliguria responds to fluid management and elevated liver function values are not associated with right upper quadrant or epigastric pain. Hemoconcentration: Big word, big problem - Center for Phlebotomy Education Although a very crude and indirect way of looking at it, if you plot the deaths from hemorrhage, the graph remains level throughout the second half of the 19th century up until ergometrine was introduced. Coffee consumption and future risk of type 2 diabetes among women with a history of gestational diabetes, Physical activity and individual plasma phospholipid SFAs in pregnancy: a longitudinal study in a multiracial/multiethnic cohort in the United States, Habitual coffee consumption and subsequent risk of type 2 diabetes in individuals with a history of gestational diabetes a prospective study, About The American Journal of Clinical Nutrition, RELATION BETWEEN MATERNAL ANEMIA AND IRON DEFICIENCY, HEMOGLOBIN CONCENTRATIONNORMATIVE DEFINITION COMPARED WITH PHYSIOLOGIC CONSEQUENCE, CAUSES OF ABNORMAL HEMOGLOBIN CONCENTRATION RELEVANT TO PREGNANCY, ASSOCIATION BETWEEN ELEVATED HEMOGLOBIN CONCENTRATION AND ADVERSE BIRTH OUTCOMES, RISK OF HIGH HEMOGLOBIN CONCENTRATION DUE TO IRON SUPPLEMENTATION DURING PREGNANCY, RISK OF IRON SUPPLEMENTATION DURING PREGNANCY, CONCERN ABOUT THE LACK OF EFFECTIVENESS OF CURRENT IRON SUPPLEMENTATION PROGRAMS DURING PREGNANCY, Supplement: Consultative Meeting on Iron and Maternal Mortality in the Developing World, Receive exclusive offers and updates from Oxford Academic. Methyldopa has a long history of use in pregnancy, but has limited effectiveness and significant adverse effects. Peeters, L., Verkeste, C., Saxena, P. et al. The D-dimer test may be a useful tool for the early identification of patients with preeclampsia who may develop severe HELLP syndrome. The American College of Obstetricians and Gynecologists (ACOG) has released an updated practice bulletin to outline diagnosis, effects on pregnancy outcomes, and approaches for management based on new evidence. We measured erythrocyte aggregation and hematocrit in 155 uncomplicated pregnancies and in 55 pregnant women with pre-eclampsia. It's a mouthful. This works at both ends of the distribution. Hookworm infection and anemia: an approach to prevention and control. The World Health Organization recommends that severe anemia be defined as a hemoglobin concentration <70 g/L (15). Pregnancy-induced hypertension, preeclampsia and HELLP syndrome are related and overlap in their presentations. Without other indications, pregnant women with chronic hypertension should not be induced for delivery before 37 weeks' gestation. Platelet count appears to be the most reliable indicator of the presence of HELLP syndrome. In most developed countries, iron deficiency is the main cause of significant anemia during pregnancy (23), as shown by the efficacy of iron supplementation in preventing maternal anemia (evidence of benefit). Disturbance of these mechanism leads to hemoconcentration and high Hb levels (13,14). The adverse effect of iron repletion on the course of certain infections. Supplementation is justified on the basis that moderate and severe anemia is undesirable (evidence of deficiency and risk). For individuals with this condition, any extra iron will contribute to their iron burden, including iron supplementation during pregnancy. The only condition of elevated hemoglobin that is due to the production of defective red blood cells, but not subject to the control of tissue oxygen drive, is polycythemia vera (31). Midwives' perceptions of and attitudes towards prevention of mother-to-child-transmission of HIV. Serum water analysis in normal pregnancy and preeclampsia Women with chronic hypertension should take 81 mg of aspirin daily from 12 to 28 weeks' gestation until delivery. Iron deficiency can be a major contributory factor to very severe anemia, but no evidence exists to show that a very high hemoglobin concentration is due to too much iron or to iron supplementation. See related patient information handout on HELLP syndrome, written by the author of this article. Managing Chronic Hypertension in Pregnant Women: ACOG Releases - AAFP A more recent study, however, did not show that the risk of malaria justifies the withholding of iron (50). Point-of-care ultrasound: The new district focus. In examining the evidence related to high and low hemoglobin concentrations, it is important to evaluate the meaning of hemoglobin concentration. Severe anemia has multiple causes much more often than does moderate or mild anemia. Such an evaluation has not been conducted because iron supplementation during pregnancy is a standard practice in most countries and, ethically, iron cannot be withheld from women assigned to a control group. This is often manifested as peripheral cyanosis and impaired mental function resulting from compromised cerebral blood circulation (21). This is related to each person having a set optimal hemoglobin concentration, and the only driving force that can increase this above the set point is the need to maintain the blood's oxygen carrying capacity (42). The hemoglobin concentration at which observed risk starts to increase is 120130 g/L. Control Clin Trials 1989;10:2908]; there were no placebos. In the study by Pritchard et al (34), the average hematocrit for women with preeclampsia was 0.405, compared with a mean of 0.374 for women with a normal pregnancy. In this supplement, Rush (2) questions the benefit of routine iron supplementation in relation to the evidence of the harm or burden of anemia on reproductive outcomes. One study20 found that pregnancy was prolonged by an average of 15 days when conservative management (i.e., bed rest, fluids and close observation) was used in patients who were at less than 32 weeks of gestation. Clinical manifestation of erythrocyte disorders. Another risk in many populations is that a small subset of women have conditions known as iron-loading diseases and can be harmed by the extra iron over the long term (1, 46). Iron and folate supplementation during pregnancy is commonly practiced to prevent maternal anemia, which is often caused by iron deficiency. PIH is still an important cause of . Moreover, if multiple deficiencies contribute to the severity of anemia, supplementation with iron alone may not achieve adequate hemoglobin response. Better efforts to ensure program functioning appear to be a prudent alternative to abandoning programs. That was a very powerful trial and it is almost surely a model for all future trials. Iron deficiency anemia and maternal mortality. The effect of first trimester hemoglobin levels on pregnancy outcomes In essence, the hemoglobin-based definition does not provide sufficient information on the meaning of, or reason for, either anemia or high hemoglobin concentrations. There is no evidence to support the proposition that iron supplementation during pregnancy can cause abnormally high hemoglobin concentrations, beyond the optimal level for an individual or population. I would not for a moment think that it had been anything but a good idea to introduce, in the late 1930s, the routine administration of iron for women. Hemoconcentration Definition & Meaning | Dictionary.com Epidemiologic studies that showed an association between maternal anemia and increased risk of poor birth outcomes did not establish a causal relation (evidence of risk only) (69). This may also increase the effectiveness of anemia control because other nutrient deficiencies can contribute to the burden of anemia. A bolus of 4 to 6 g of magnesium sulfate as a 20 percent solution is given initially. Electrocardiography or echocardiography may be helpful in patients with signs of decreased cardiac function. Consequently, large-scale iron supplementation programs during pregnancy are a common practice, although evidence of supplementation effectiveness has not been impressive (3, 4). The only evidence of risk associated with anemia is based on epidemiologic studies that showed an association between increased risk of poor birth outcomes and anemia or iron deficiency anemia. Third, during the Great Depression of the 1930s, when it was established that there was much anemia, it seemed to me that we should have seen a rise in deaths from hemorrhage but we did not. The purpose of this review is to look at normal and abnormal hemoglobin values in terms of their causes and consequences. This is because she has some primary disease condition that puts her in a different positionher increased value of 140 g/L is very different from that of someone who normally has a hemoglobin of 140 g/L. An appropriate trial has not yet been conducted to test the benefit of iron supplementation in reducing adverse reproductive outcomes. Mild anemia is routinely defined as a hemoglobin value within 10 g/L of the anemia cutoff value. Part of the rationale for this practice is the high iron requirement during pregnancy, almost 3 times that required for nonpregnant women of childbearing years, which is difficult to meet from dietary sources (1). Guideline source: American College of Obstetricians and Gynecologists, Systematic literature search described? Nevertheless, in many developing countries, limiting nutritional factors besides iron have to be considered if a meaningful reduction in anemia is to be achieved. Additionally, because many possible causes of anemia exist, such statistics-based anemia criteria provide only a guideline for establishing the probability of specific health and nutritional causes of anemia for a given population. Because iron supplementation can increase risk of malaria by 10%, primiparas are a high-risk group for iron supplementation. HELLP, a syndrome characterized by hemolysis, elevated liver enzyme levels and a low platelet count, is an obstetric complication that is frequently misdiagnosed at initial presentation. The pathogenesis of HELLP syndrome is not well understood. In the less severe range, however, the evidence that anemia is a direct cause of poor reproductive outcomes is not clear. Preeclampsia (PE) is a serious pregnancy complication and samples obtained from PE patients may be relatively hemoconcentrated when compared to those of normal pregnancy, where hemodilution is the norm.
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