A combination of oral and intravaginal application of enterosorbent “Enterosgel” in complex treatment of iron deficiency anemia in pregnant women with GIF increases the effectiveness of treatment by binding endotoxins, lipid peroxidation products and normalization of the vaginal and intestinal microflora.
Comprehensive treatment of iron-deficiency anemia in women with genital infection foci.
Obstetrics and gynecology, 2012
Hayatova Z.B., Pekarev O.G., Shpagin L.A., Kuzmin V.V. (Novosibirsk)
Anemic syndrome in pregnant women is among the urgent problems of extragenital pathology in obstetric theory and practice (V.N. Serov, 2001). According to the data of the World Health Organization frequency of laboratory confirmed forms of anemia in pregnant women are from 21% to 97%. Iron-deficiency anemia (IDA) in pregnancy occurs in 40-80% of cases (S. Loria, 2003).
High incidence of genital infection in pregnant women with anemia steadily growing in the recent years and increased perinatal morbidity of infectious genesis prove the relevance of study of development and course of anemia in genital infection.
It is known that with progression of pregnancy need of iron increases. However, we must not forget that these needs can grow in the presence of chronic foci of both genital and extragenital infections, leave alone anemias not associated with iron deficiency. As a result, there is often inefficient, inadequate treatment of anemia, with delayed diagnosis of other diseases.
We have examined 70 pregnant women with iron deficiency anemia and foci of genital infection (GIF). We have observed IDA on the background of foci of genital infection (GIF) mainly in pregnant women under the age of 25 years, of which almost half was at the age of 20 years. In pregnant women with IDA and the GIF, presence of severe clinical colpitis and endocervicitis was observed, mostly of purulent character and those of mixed etiology. Bacteriological examination of cervical secretions identified pathogens in 55% of pregnant patients. In most patients the culture showed opportunistic microflora: E.coli, St.epidermalis- in 69.7%, Candida albicans- in 28.9% and St.aureus – in 10%. Chlamydia was detected in 35% of pregnant women. Enzyme immunoassay with test systems allowed to detect viruses and their combination with agents of genital infection in 25% of patients.
IDA in pregnant women om the background of the GIF was normochromic, with significantly lower level of red blood cells – 3,26 ± 0,19 × 1012, with low serum iron (SI) – 9.02 ± 1.56mmol / l, serum ferritin (SF) – less than 10 ng / L, with percent transferrin saturation (PTS) at least 19%, increased total iron-binding capacity of the serum(TIBC) -86.4 ± 4.85mmol / l and latent iron-binding capacity of serum (LZHSS) – 77.4 ± 5.4mmol / l.
Red blood cells had microcytosis – a significant decrease of average diameter and area in comparison with data of healthy pregnant women (p <0.01). Significant microcytosis and poikilocytosis in pregnant women with typical IDA, on the background of intrauterine infection compared with morphometric data of erythrocytes in pregnant women with iron deficiency anemia, but without GIF, indicated the depths of erythropoietical disorders due factors – iron deficiency and endotoxemia due causative agents of genital infections in the case of a combination of IDA and OIG. Proof of this can be found in activation of lipid peroxidation (LPO), as evidenced by high rates of spontaneous (6148.6 ± 254.1 U) and, zymosanum-induced, biochemicoluminescence (BCL) (13012 ± 510.02 U) and shortening of the time of the peak of metabolic burst. Progression of iron deficiency is possible due to activation of lipid peroxidation and its redistribution in the inflammation foci.
Given the pronounced aniso- and poikilocytosis of erythrocytes in endotoxemia, as well as increased activation of LPO in pregnant women with IDA and the OIG, we have decided to include enterosorbent “Enterosgel” in the comprehensive treatment of pregnant women with IDA on the background of GIF.
At the stage I pregnant women with IDA and GIF received Enterosgel 15 g 3 times daily per os at the same time with intravaginal administration of Enterosgel for 7 days, while in intrauterine infection antibacterial therapy was performed as well before iron administration. At stage II antioxidants and iron preparations were administered. Administration of enterosorbent “Enterosgel” contributed to a more efficient rehabilitation of genital infection by binding lipid peroxidation products, endotoxins and increasing general immune status. The following ferrotherapy filled the serum iron deficiency, not redistributed in the inflammation foci.
In all 42 women with typical IDA and GIF treated with reasonable etiopathogenic therapy, the number of red blood cells (37 ± 0.24 × 1012) and hemoglobin (119 ± 3,08g / l) significantly increased by the time of delivery, while ferrokinetic data did not differ from those established in healthy pregnant women in 87.5% of cases (p <0.05). Along with this spontaneous and induced biochemicoluminescence decreased by 1.7 and 1.8 times, respectively, while biocidal activity of neutrophils increased (p <0.01). Recurrence of genital infection occurred in 10.3% of cases.
The effectiveness of integrated treatment, with the inclusion of Enterosgel has been confirmed by histological and histochemical examination of placentas of pregnant women with IDA and GIF. Histological examination of placentas in 20 women of the group identified compensated chronic placental failure, which manifested itself as moderately involutive and dystrophic changes and siginficant compensatory-adaptive reactions (vascularization of the villi, hyperplasia of the terminal villi with small syncytial knots) on the background of the expressed sclerosis of membranes and villous stroma, with their calcification as a result of earlier inflammatory process. Iron was detected in terminal villi in the form of individual pellets, or was not detected at all as an evidence of full absorption of iron.
For comparison, 28 pregnant women with typical IDA and GIF received iron and GIF sanitation without Enterosgel. After treatment Ferro kinetic IDA symptoms persisted in 68.9% of cases, genital infection foci – in 41.4%. In this group of pregnant women rate of late gestosis was 3 times higher compared with previous group, while postpartum iron deficiency anemia was observed 3.5 times more likely.
Low efficacy of treatment of IDA and GIF in pregnant in conventional manner, was also confirmed by data of histological and histochemical examination of placentas. As a result, chronic placental insufficiency was revealed as a pathological immaturity; histological picture of exacerbation of chronic placentitis, deciduitis, horioamnionitis with symptoms of trombovasculitis and trombofuniculitis, which explains the high incidence of signs of intrauterine infection in the newborns. In 19.5% of newborns intrauterine pneumonia was diagnosed, in 50% – signs of cerebral hemo-liquor-dynamic disturbance of infectious and hypoxic genesis. Deposition of iron pigments was noted in the sites of inflammation, as well as hemorrhages around them and presence of these pigments in the blood arteries and veins of the umbilical cord, and in macrophages, indicating the low efficiency of the therapy. Adequate iron absorption and decrease of both anemia and genital infection confirms the necessity of prescribing iron after sanitation of infection foci in pregnant women with iron-deficiency anemia and genital infection foci.