Features of the Course of Pregnancy and Childbirth, Metabolic Indicators in Pregnancy Complicated by Iron-Deficiency Anemia, and Approaches to Correction

The dissertation research examines the course of pregnancy and childbirth and the condition of newborns in women with iron-deficiency anemia in pregnancy, including cases combined with gestosis, as well as metabolic disorders associated with this combined gestational pathology. The work covers the etiology and pathogenesis of iron-deficiency anemia, clinical and anamnestic assessment, biochemical indicators, statistical analysis, and prevention and correction.

The indicators examined include the binding capacity of serum albumin, transferrin, electrical conductivity, and blood osmolality, water-electrolyte balance, the condition of the fetus and newborn, and the course of pregnancy, childbirth, and the postpartum period. The objective of the work is to develop a targeted program for preventing and treating iron-deficiency anemia in pregnancy on the basis of identified metabolic disorders.

Relevance of the Study

One of the important problems of contemporary scientific and practical obstetrics is iron-deficiency anemia during pregnancy. The incidence of this gestational pathology varies widely, from 6.5% to 67% (Mordukhovich, A. S., et al., 1992); anemia of pregnancy consistently ranks first among extragenital disorders in pregnant women and adversely affects the course and outcome of the gestational process (Shekhtman, M. M., 1999; Murashko, L. E., 1999; Sarin, A., 1995).

Over the preceding 10 years, the incidence of anemia in pregnancy in the Samara Region increased 2.5-fold, reaching 38.5% in 1997, 39.2% in 1998, 42.2% in 1999, 45.14% in 2000, 48.0% in 2001, and 47.5% in 2002; iron-deficiency anemia accounted for 98% of all cases of anemia in pregnancy. Consequently, over the preceding seven years (1996–2002), the incidence of anemia in pregnancy increased by 7.1%, while the incidence of gestosis, a serious complication, increased by 2.4%.

Pregnancy and childbirth against the background of iron-deficient states and anemia are associated with a high frequency of complications that place the life of the mother and fetus at risk: pregnancy loss, abnormal labor, premature rupture of membranes, excessive blood loss in the early postpartum period, postpartum purulent-septic diseases, and hypogalactia (Nasolodin, V. V., et al., 1996; Shekhtman, M. M., et al., 1999; Omarov, N. S., 1999; Cheldiyeva, A. A., et al., 2000); several authors have noted the adverse effect of anemia on the formation of the fetoplacental complex and the development of fetal hypotrophy (Gaystruk, A. N., et al., 1991; Smirnova, O. V., 1994; Guzhvina, E. N., et al., 2000).

Iron deficiency and insufficient deposition of iron during the antenatal period contribute to the development of iron-deficiency anemia in newborns, leading to alterations in the metabolism of cellular structures, impaired hemoglobin formation, and impaired immune status in newborn children (Vakhrameeva, S. N., et al., 1996).

The high frequency of the combination of iron-deficiency anemia in pregnancy and gestosis is notable: up to 49.7% (according to Fedorova, Yu. V., 1999), up to 46.9% (according to Agafonova, O. V., 2002), and 24% to 50.7% (according to Dzhabbarova, Yu. K., et al., 1984; Abdullaeva, D. I., 1989). Such combinations arise against the background of environmental adversity, low social and material standards in families, and a high frequency of extragenital pathology. Thus, recent statistics show that the highest rates of anemia are recorded in cities with the greatest technogenic load on the environment, where anemia occurs in 57–71% of pregnant women. This fact is a manifestation of the problem of ecological–generative dissonance, that is, the mismatch between the rapid technogenic transformation of the environment and the adaptive reserves of a woman's body (Lineva, O. I., et al., 1995; Abramchenko, V. A., 1994; Sheshunov, I. V., 2001).

There are many commonalities in the epidemiology, etiology, and pathogenesis of gestosis and anemia in pregnancy; their combination mutually aggravates the gestational process and worsens the outcome of pregnancy for both mother and fetus. In their studies, several scientists have addressed the problem of combining the aforementioned gestational pathologies (Mordukhovich, A. S., 1991; Smirnova, O. V., 1994; Omarov, N. S., 1999; Fedorova, Yu. V., 1999). However, it remains debated whether anemia is a consequence of profound homeostatic disorders developing in gestosis or whether it is one of the pathogenetic links in the development of this pathology.

Therefore, studying the pathogenetic mechanisms underlying the development of iron-deficiency anemia in pregnancy and gestosis is an urgent issue in contemporary obstetrics and perinatology and is necessary for developing a targeted program for preventing and treating gestational pathology.

Research Objective

Development of a targeted program for the prevention and treatment of iron-deficiency anemia in pregnancy based on identified metabolic disorders.

Research Tasks

1. To study the role of destabilizing factors that contribute to the development of iron-deficiency anemia in pregnancy.

2. To conduct an in-depth clinical study of pregnant women with iron-deficiency anemia, assess the nature of complications during gestation and childbirth, and evaluate the condition of the fetus and newborn.

3. To carry out a comparative assessment of overall metabolic indicators by studying the binding capacity of serum albumin and transferrin, electrical conductivity, and blood osmolality in physiological pregnancy and iron-deficiency anemia in pregnancy.

4. To develop, on the basis of identified changes in overall metabolic indicators, a set of measures for preventing and treating iron-deficiency anemia in pregnancy.

Scientific Novelty

For the first time, a comprehensive study was conducted in pregnant women characterizing the key metabolic processes underlying the development of iron-deficiency anemia in pregnancy, including cases complicated by gestosis.

Distinct metabolic parallels in the development of iron-deficiency anemia in pregnancy and gestosis were established on the basis of studies of the binding capacity of serum proteins and blood osmolality in pregnant women.

It was demonstrated that the development of gestational complications in environmentally adverse regions results from the development of systemic endogenous toxemia syndrome.

In addition to the mandatory use of iron preparations, a rationale was provided for enteral detoxification using enterosorbents, hepatoprotectors, membrane stabilizers, and antioxidants to prevent and correct metabolic disorders in the “mother–placenta–fetus” system in iron-deficiency anemia in pregnancy, including its combination with gestosis.

Practical Significance

The common metabolic aspects of the formation of iron-deficiency anemia in pregnancy and gestosis have been elucidated; they consist of disturbances in the protein and detoxification components of metabolism.

Methods of preclinical diagnosis of iron-deficiency anemia in pregnancy and gestosis have been introduced into clinical practice. These methods are based on determining indicators of the reserve of functional activity of serum albumin and transferrin and on studying blood osmolality.

Clinical and laboratory criteria have been proposed for assessing the severity of endotoxemia during the course of the disease, as well as the appropriateness and potential of ongoing treatment for iron-deficiency anemia in pregnancy.

A targeted program for preventing and treating iron-deficiency anemia in pregnancy has been developed on the basis of identified metabolic disorders.

Theses Presented for Defense

1. Iron-deficiency anemia in pregnancy and gestosis share common metabolic aspects of development, formed through the combined action of destabilizing exogenous and endogenous factors, including the environmental characteristics of the urbanized Samara Region.

2. Characteristic patterns in the course of pregnancy, childbirth, and the newborn period against the background of iron-deficiency anemia in pregnancy and gestosis have been identified in the region.

3. The insufficient effectiveness of standard therapy in pregnant women with iron-deficiency anemia, especially when combined with gestosis, is associated with liver dysfunction and reduced transport and sorptive capacity of serum albumin in blood, as a consequence of the progression of systemic endotoxemia syndrome.

4. The scientifically grounded measures developed in this work, consisting in detoxification, bioantioxidant, and membrane-stabilizing therapy, increase the effectiveness of comprehensive treatment and prevention of iron-deficiency anemia in pregnancy.

Approval of the Work

The dissertation materials were presented and discussed at a joint meeting of the obstetrics and gynecology departments of the Postgraduate Education Institute and the Medical Faculty of the Samara State Medical University, as well as the obstetrics and gynecology department of the Samara Medical Institute “REAVIZ” (Samara, 2003).

Publications

Eleven scientific works were published on the topic of the dissertation. The dissertation materials were presented at the VI International Congress “Ecology and Human Health” (Samara, 1999), the VI Interregional Congress of Obstetrician-Gynecologists, Pediatricians, and Physicians (Samara, 1999), the “Postgraduate Readings—2000” conference (Samara, 2000), and the II Russian Forum “Mother and Child” (Moscow, 2000). Based on the dissertation materials, a manual for general practitioners, physicians, and obstetrician-gynecologists, “Treatment and Prevention of Iron-Deficiency Anemia in Pregnancy (IDA),” was published (Samara, 2001).

Implementation

The study results are used in the teaching process at the Department of Obstetrics and Gynecology of the Postgraduate Education Institute and have been implemented in the practice of the antenatal clinic of Municipal Medical Institution of Primary Care No. 15 of the Promyshlenny District of Samara.

Volume and Structure

The dissertation follows a traditional plan, comprises 182 pages of typewritten text, and is illustrated by 35 tables, 18 figures, and 6 diagrams. It consists of an introduction, four chapters containing the author's own research, discussion of the results obtained, conclusions, and practical recommendations. The bibliographic index includes 244 sources, of which 191 are domestic and 53 foreign.