Dear Colleagues!

Department of Family Medicine and Internal Diseases is one of the clinics at the Medical Center of Postgraduate Education (CMKP) which is providing education courses in internal medicine for specializing doctors whose goal is to practice family medicine. Four years ago, specialists working in this Department began to organize continuous education programs in the field of internal diseases for family physicians and other physicians who work in primary outpatient clinics.

Together with the continuous education programs, we prepare special issues of "Progress in Medicine” (a journal under the patronage of CMKP). Those issues are distributed among the participants of our courses as training materials and are also delivered to doctors of other specializations who are interested in internal medicine. The special issues have been very well received by family physicians and other readers of "Progress in Medicine”. They have become an important element of the training process of doctors in a variety of specializations. In the current volume of the journal, we have focused on internal diseases of pregnant women. The issues relating to pregnancy are an interdisciplinary problem that concerns not only gynecologists, midwives, internists, diet doctors, pediatricians, but also family doctors. While preparing this volume, we bore in mind that among primary health care doctors are professionals of different specializations and of varied expertise.

In the current issue, there are 12 articles focusing on different aspects of internal medicine and pregnancy. The article entitled "The influence of Vitamin D deficiency during pregnancy and lactation on the mother and the child” by E. Marcinowska-Suchowierska and Magdalena Walicka reports that women with serious Vitamin D deficiency during pregnancy have an increased risk for preeclampsia, and their children – right after birth – for seizures with hypocalcemia. The effect of Vitamin D deficiency during pregnancy is birth of a baby with Vitamin D deficiency which can result in the development of rickets, defects of tooth bone, decreased bone mass, increased risk for fractures, increased development of various diseases. Nowadays, it is known that pregnant women require Vitamin D supplementation from the second trimester of pregnancy. It is recommended that adults require a minimum of 800-1000 j.m./day when the exposition to the sun is inadequate (in Poland from October to April). This dosage should be given to all women who avoid being exposed to sunlight. From April to September, taking into consideration sun exposure to 18% of the skin for 15 minutes per day, additional supplementation of Vitamin D should be 400 IU per day.

The article entitled "Prophylaxis of Vitamin D Deficiency – Polish Recommendation 2009”, presents, based on current literature review and opinions of National Consultants and experts in the field, Polish recommendations for prophylactic vitamin D supplementation in infants, toddlers, children and adolescents as well as in adults, including pregnant and lactating women.

The article entitled "Diabetes and pregnancy” by M. Walicka, E. Czerwińska and E. Marcinowska - Suchowierska reports that diabetes mellitus can occur during pregnancy in 2 forms: pregestational and gestational diabetes. Both types of diabetes need special care during pregnancy. Pregestational diabetes represents very high-risk obstetrics. Gestational diabetes confers a much lower risk for both the mother and the fetus but is growing in prevalence. Recent studies show that diagnosis and management of this disorder have beneficial effects on maternal and neonatal outcomes. Diagnosis is made using a sequential model of universal screening with a 50-g one-hour glucose challenge test, followed by a diagnostic 75-g oral glucose tolerance test for women with a positive screening test. Treatment consists of glucose monitoring, dietary modification, exercise, and, when necessary, pharmacotherapy to maintain euglycemia. Insulin therapy is the mainstay of treatment, although glyburide and metformin may become more widely used. Women with gestational diabetes are at high risk of subsequent development of type 2 diabetes. Lifestyle modification should therefore be encouraged, along with regular screening for diabetes.

The article entitled "Hypertension in pregnant women” by M. Wąsowski and E. Marcinowska-Suchowierska reports that hypertension in pregnancy is, despite of progress in medical science, an important cause of maternal, fetal and neonatal morbidity and mortality. It occurs in approximately 3-15% of pregnancies and in 70% of women with first gestation. This article provides guidelines for diagnosis and treatment of high blood pressure in pregnancy based on ESH, PSH and ESC guidelines and current references.

The article entitled "Pulmonary emboliom” by A. Bogołowska-Stieblich and E. Marcinowska-Suchowierska reports that pulmonary embolism is the most common cause of death among pregnant women in well developed countries. Changes of hormones concentration, physiological changes in coagulation system and compression of large vessels by the enlarged uterine take place in pregnancy what leads to higher risk of thromboembolism development. Symptoms suggesting deep vein thrombosis (DVT) or pulmonary embolism (PE) can occur during pregnancy without thromboembolism. Furthermore, pulmonary embolism diagnostics has many limitations caused by unspecific VT symptoms, physiological elevated D-dimers concentration or potentially fatal influence of ionizing radiation on fetus. VT treatment in pregnant women can cause complications in both the mother and the fetus. A very careful medicine selection is most important to reduce potential complications. Prophylaxis is very significant among women with higher risk of thromboembolism development. Mechanical methods should be considered in every group of patients and in some of them pharmacological methods as well. In groups with higher risk of thromboembolism pharmacological prophylaxis during postpartum period should be applied. Anticoagulation treatment should be stopped before delivery and ought to be continued just after it. We have to remember that anticoagulation can be exert during breast-feeding including vitamin K antagonists.

The article entitled "Rheumatic diseases in pregnant women” by A. Jasik and E. Marcinowska-Suchowierska reports that rheumatic diseases often occur in young people, including women in the reproductive age. The main rheumatic diseases which we can find in pregnant women are: rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). The safety of pharmacotherapy in these diseases during pregnancy and lactation is very important. The most commonly used nonsteoridal anti inflammatory drugs should be used in the lowest therapeutically sufficient dose. Among the glicocorticoids, prednisone and prednisolon have the safest profile in pregnancy. Methotrexate, Cyclophosphamide and Leflunomide are contraindicated in pregnancy. The reports on the safety of the biological treatment during pregnancy are optimistic, however still not sufficient. Pregnancy in women with SLE can be complicated by preeclampsia, premature labour or miscarriage more often than in the healthy population, and it is considered a high- risk pregnancy. Symptoms of preeclampsia and SLE exacerbation are similar, so they need to be correctly differentiated. APS is associated with several pregnancy complications too. Treatment in this disease is still equivocal. Therapeutic schemes involve aspirin and heparins – preferable low molecular weight heparins. Steroids and immunoglobulins are not routinely used. Treatment in APS administrated in early pregnancy increases chances for life delivery to 80%.

The article entitled "Thyroid dysfunction in pregnancy and postpartum” by E. Czerwińska, M. Walicka and E. Marcinowska-Suchowierska reports the influence of thyroid disorders (hyperthyroidism and hypothyroidism) on fertility, pregnancy and fetus development as well as appropriate treatment of these disorders in pregnant women. Recommendations on screening for thyroid disorders in pregnant women or in women who are planning to become pregnant and iodine prophylaxis are presented.

The article entitled "Haematogical problems in pregnant women at a general practitioner's practice” by T. Sikorski and E. Marcinowska-Suchowierska presents information on quantitative changes in a peripheral blood picture related to an increase in blood volume and changes in coagulation and fibrinolysis system during pregnancy. A general practitioner must be familiar with these changes to diagnose correctly anemia and thrombocytopenia, the two most common haematological abnormalities occurring in pregnancy. Anemia in pregnant women is mainly due to iron deficiency, less frequently to folate deficiency. The most common cause of anemia in the puerperium is acute blood loss. Of thrombocytopenias, the most common is the benign one, but pregnancy may release or enhance autoimmune thrombocytopenia. Besides anemia and thrombocytopenia, we also consider thrombotic microangiopathies: thrombotic thrombocytopenic purpura and disseminated intravascular coagulation, and remind that myeloproliferative neoplasm may occur in pregnancy.

The article entitled "Pregnancy in women with valvular heart disease” by H. Puchalska-Krotki and E. Marcinowska-Suchowierska discusses significant hemodynamic changes in cardiovascular system following the hormonal changes in pregnancy and the impact of placental circulation. Coexisting valvular heart disease increases substantially and, although adaptive processes, can lead to a deterioration in cardiovascular function. A particular issue is the need for anticoagulation in patients with implanted artificial valve. The decision regarding choice of therapy should take into account the benefits and risks of alternative treatments and the principles to be taken by an experienced multidisciplinary team of specialists as well as informing the patient and her family about these solutions.

The article entitled "Bronchial asthma in pregnancy” by A. Sawicka and E. Marcinowska-Suchowierska reports the issue of bronchial asthma as the most chronic illness of the respiratory tract in pregnant patients. Diagnosis and monitoring of the disease are quite the same in pregnant and non-pregnant patients. The treatment procedures and drugs used in pregnant patients are the same as in the rest of the population. When we give "antiasthmatic” drugs to the pregnant women we have to remember about few rules. The medicines are to be used in the smallest possible doses controlling the symptoms. Inhaled drugs (eg. cromones, anticholinergic medicines, beta-agonists, methylxantines) are safe because they offer quite small exposition on the fetus. We have to be careful with oral and intravenous medicines (beta-agonists, steroids, methylxantines) because they can achieve dangerous concentration in the fetus' blood. Glucocorticosteroids are the drugs with the best effectiveness in disease controlling and exacerbations prevention. Budesonid is the safest for the patients in the beginning of the treatment. Short-acting beta-agonists are the drugs of choice in severe exacerbations, long-acting together with inhaled steroids offer very effective asthma control. Anticholinergic drugs can be used in aggravations of the disease. Methylxantines are not preferred for pregnant patients, but usage with steroids can be considered. Antileucotriens and cromones are not contraindicated as they were effective before pregnancy. Poor controlled bronchial asthma can cause severe risk for both the mother and the fetus.

The article entitled "Measles-mumps-rubella vaccine and autistic spectrum disorder: What do doctors need to tell the parents?” by M. Suchowierska and G. Novak discusses the problem of autism, which is a complex developmental disorder of multifaceted and not yet fully understood etiology. Autistic characteristics occur along a spectrum of three disorders, commonly referred to in clinical literature as autistic spectrum disorder (ASD). One of the purported causes of ASD that has received much public and political attention is measles-mumps-rubella vaccination (MMR). In 1998 Wakefield et al. study the authors proposed a hypothesis on the link between MMR and autism. Since then multiple experiments and meta-analyses have shown this hypothesis to be wrong. Despite the fact that the research evidence does not point to a causal link between MMR vaccination and ASD, and despite the serious medical problems associated with failure to vaccinate against these childhood diseases, there are many individuals, mainly parents of children with autism, who have arrived at conclusions based largely on personal experience pointing to MMR as the cause of their child's disorder. Pediatricians and family doctors are encouraged to educate parents about lack of connection between MMR and autism, so that parents do not refuse to vaccinate their children.

In my opinion, all of the topics covered in this volume are presented in an understandable fashion, especially when it comes to the practicalities of every day work. It is my hope that you will make use of this volume and that the information presented in the articles will aid you in your daily practice.

Prof. dr hab. med. Ewa Marcinowska-Suchowierska