Effect of Thrombocytopenia on Pregnancy

The course of pregnancy and labor depends on form of disease and character of previous treatment (treatment before pregnancy).

At acute form of disease proceeding with appreciable bleedings from nose and gums, at hematencephalon, at chronic form with frequent relapses, pregnancy is contraindicated.

Pregnancy at idiopathic thrombocytopenia can be complicated by premature interruption of pregnancy at different terms (up to 30 %), bleedings at placental stage of labor and in early puerperal period (20 %); a characteristic and severe complication is premature separation of normally located placenta. The incidence of EPH-complex is also a little bit higher than in the other part of pregnant women. Besides labor is complicated by disturbance of uterine action (weakness of labor pains), asphyxia of intrauterine fetus, intracranial hemorrhages owing to disturbance of blood circulation in cerebrum.

In puerperal period the bleedings in places of slightest ruptures, cuts, and cracks are dangerous which assume a persistent character.

Approximately 2-8 % of maternal mortality at idiopathic thrombocytopenia are caused by bleedings during labor and in early puerperal period. The incidence of perinatal mortality makes up 50 %, the greater part of which is connected with intracranial hemorrhages.

Effect of Pregnancy on Thrombocytopenia. In 50-60 % of patients with Werlhof's disease exacerbations of the basic disease are observed at pregnancy. In some cases the signs of disease decrease.

Treatment. The modern therapy of disease is based on application of corticosteroids, immunosuppressive agents and performing splenectomy.

At presence of thrombocytopenia with a number of 40х10⁹/l without hemorrhagic manifestations the treatment at pregnancy is not required. Two weeks before the expected term the pregnant woman should be hospitalized at the in-patient department for examination and preparation for labor. 10 days prior to term of labor prednisolone in a dose of 30-40 mg/day is usually administered. After labor the dose is gradually reduced within 5-6 days, and then the preparation is cancelled.

On occurrence of the first signs of hemorrhagic diathesis during pregnancy, prednisolone in a dose of 30-40 mg/day should be prescribed; the dose can be enlarged up to 60 mg/day.

If it is ineffective and aggravation of hemorrhagic diathesis and anemia takes place, a dose of prednisolone is enlarged up to 80 mg/day, hemotransfusion of fresh blood in amount of 150-200 ml every 3-5 days is given. The prescription of prednisolone in doses of 80-100 mg/day during labor for such patients is obligatory, with a gradual decrease of dose in puerperal period. The question on necessity of splenectomy arises in case of inefficiency of all above-stated medical measures.

Making such operation in late terms of pregnancy (and also in puerperal period) is connected with a high rate of maternal (up to 10 %) and perinatal (25-30 %) mortality. Therefore splenectomy for pregnant women with an idiopathic Werlhof's disease is considered to be a forced measure and is carried out by life-saving indication, when hormonal and substitutive therapy is ineffective. At increased hemorrhages, anemia, and worsening of fetal general condition, cesarean section is indicated. In some cases simultaneously with cesarean section splenectomy may be made.

Labor Management. At number of thrombocytes equal to 40х10⁹/l without hemorrhagic manifestations the obstetric management remains expectant. Labor management, as a rule, is conservative with prevention of bleeding. At intensifying hemorrhagic diathesis in labor and ineffective medicamental therapy the extreme measures, i.e. cesarean section, are indicated.

In puerperal period antibacterial drugs for prophylaxis of puerperal septic diseases should be prescribed.

Diabetes Mellitus in Pregnancy. During each antenatal visit a routine examination of urine for sugar is practiced for each pregnant in many clinics of the world. This is due to the fact that asymptomatic forms of diabetes are responsible for significant fetus wastage.

The incidence of diabetes in pregnancy is about 10%.

Diabetes in pregnant women is generally categorized as either gestational or pregestational diabetes. Gestational diabetes firstly appears after 28 weeks of pregnancy and means a transient glucose malabsorption during pregnancy.

Classification of Diabetes Mellitus. Clinical forms of diabetes.
- Insulin-dependent diabetes (type I DM).
- Insulin-independent diabetes (type II DM).
- Other forms of diabetes (secondary diabetes associated with other endocrine diseases, etc.).
- Gestational diabetes.

Degrees of diabetes.
- Mild degree (1st degree).
- Moderate degree (2nd degree)
- Severe degree (3d degree).

Dependence on compensation.
- Compensated diabetes.
- Subcompensated diabetes.
- Decompensated diabetes.

Types of Diabetes during Pregnancy
- Potential diabetes. Potential diabetes is probable in patients with normal glucose tolerance test but who have a positive family history of diabetes or previous birth of an overweight baby.

Latent diabetes. The individual has normal glucose tolerance in non-pregnant condition. But in stress conditions, there is impairment of glucose tolerance which becomes normal when the stress is removed.

- Subclinical diabetes. There is a persistent abnormal glucose tolerance test irrespective of stress. Symptoms of diabetes have not appeared yet.
- Prediabetic condition. The features of the state are history of previous delivery of overweight baby (more than 4 kg), unexplained perinatal death with hypertrophy of the pancreas on autopsy and diabetes in the family.

- Overt or clinical diabetes. These are patients with abnormal glucose tolerance test, with or without symptoms and a raised fasting blood glucose level. The condition may be pre-existing or detected primarily during present pregnancy. The diagnosis can be presumptive if: 1) the fasting blood sugar exceeds 110 mg; 2) the peak level exceeds 180 mg%, and 3) a 2-hour value exceeds 140 mg% in glucose tolerance test.