RESEARCH ARTICLE

Change of Hemoglobin and Albumin Serum Levels

Before and After Caesarean Section
Siti Candra Windu Baktiyani
Social Obstetrics and Gynecology Division, Departement of Obstetrics and Gynecology Faculty of Medicine,
Brawijaya University, dr. Saiful Anwar Hospital, Malang, East Java - Indonesia

Received Feb. 20, 2020;
Revised March 5, 2020;
Accepted March 5, 2020.
The authors report no conflict
of interest.
Corresponding author:
obginfkub@gmail.com
Objectives The aim of this study is to examine the differences in hemoglobin and
albumin levels before and after cesarean surgery and the relationship between
hemoglobin and albumin levels before and after surgery with the amount of blood
loss during surgery.
Methods The sample of this study were pregnant women in the third trimester of
pregnancy that underwent Caesarean section (CS) due to maternal or fetal
indications. Blood samples from women who met the inclusion and exclusion
criteria were taken just before surgery and after surgery. Blood samples were
collected and analyzed at the central laboratory. During CS, blood loss was calculated
by estimating the amount of blood in the suction pump reservoir and the amount of
gauze used during surgery. Data analysis was performed using t-test and correlation
test with SPSS software version 18.
Results Mean of albumin levels before and after surgery are 0.324 ± 3:38 and 3:04 ±
0318, respectively. Mean of hemoglobin levels before and after surgery was 11 639 ±
1,295 and 10,949 ± 1,368, respectively. Differences in albumin and hemoglobin levels
before and after surgery was significant (p = 0.000). There was no association
between albumin levels before (r = 0.056, p = 0.587) and after (r = -0113, p = 0.271)
surgery with amount of blood loss during surgery. Moreover there is no relationship
between preoperative hemoglobin levels before (r = 0.034, p = 0742) and after
surgery (r = -0102, p = 0322) with amount of blood loss during surgery.
Conclusion There were no significant differences in albumin and hemoglobin levels
before and after CS. We found no significant association between albumin and
hemoglobin levels before and after CS with the amount of blood loss during surgery.
Keywords Albumin, Hemoglobin, Caesarean section

BACKGROUND the results of these studies, it was found that albumin is

a marker of risk of sepsis, post-surgical complications
Pregnant women in developing countries are
and in-hospital mortality.3 Albumin is the most plasma
experiencing some health problems, including anemia.
protein in human body. It’s levels ranged between 3.5-
The prevalence of anemia in the world, according to
5.5 g / dL and account for 60% of all plasma proteins.
WHO, was 81.8%. While in Indonesia, according to the
Several studies supported that preoperative albumin
Ministry of Health, the prevalence of anemia was 40%.1
levels can cause morbidity, because risk of infection
In general, anemia has long been known as a risk factor
after surgery, longer duration of treatment, need for
for morbidity and mortality of patients undergoing
blood transfusion and longer wound healing.4–6 In
surgery. Identification of patients at high risk for
addition to albumin, preoperative hemoglobin is an
surgery is considered important because it relates to the
important issue because it is a predictor of
determination of the decision to perform surgery.2
postoperative blood transfusion requirements and has
In late 1970s researchers tried to determine the
quite a lot of risk. Preoperative anemia is a very
nutritional status markers that can be used to determine
common condition, especially in pregnant women, and
the prognosis of a variety of clinical conditions. From
particularly in Indonesia. 7

The Journal of Obstetrics & Gynecology Science, Vol. 1, No.1, August 2020 1
 Caesarean section (CS) is an action to deliver the
baby through an incision in the wall of the intact uterus.
During surgery and postoperative process, there was a
changes in the local network which led to the emergence
of the adjustment process in response to trauma. The
process is known as post-traumatic acute reaction, it
characterized by changes in endocrine and metabolic
process.2 Among all the systemic response, a response
that appears most clearly was hepatocytes, a decrease in
albumin and ferritin synthesis. On the other hand, there
was also increase in serum concentrations of C-reactive
protein, ceruloplasmin and other proteins related to the
immune process. Albumin is a protein synthesized by
the liver in a long term (21 days), so the variability in a
short term can not be explained as changes of nutrient
or liver function. Several studies have found that
patients with serum albumin levels lower than 3g/dl
have a greater risk of postoperative complications.3
During surgical procedure, patient will lose blood,
blood loss will directly reduce levels of hemoglobin in
the blood. Spence et al, in their study showed that
preoperative Hb <6 g / dl increases the risk of mortality
in patients with major surgery and increase the risk of
transfusion because of low postoperative Hb.8 Although
hemoglobin levels was already was routinely measured,
only a few studies examined the effect of low
preoperative Hb to the results of surgical outcomes,
especially in terms of amount of blood loss during
surgery. A lot of studies had examined albumin levels
before and after major surgery, but only few studies that
examined the association of albumin concentration
with outcome of Caesarean surgery.
Therefore, we interested to see the differences in
hemoglobin and albumin levels before and after CS and
examined the association between hemoglobin and
albumin levels before and after surgery with the amount
of blood loss during surgery.
MATERIAL AND METHODS
This research was carried out in the delivery room of
Obstetrics Gynecology Department and Operating
Room in dr. Saiful Anwar Hospital, Malang.
Samples were taken using purposive sampling
technique, i.e women in third trimester of pregnancy
who went into Obstetrics and Gynecology Department
of dr.Saiful Anwar Hospital Malang during 1 - 31 June
2018 and underwent CS due to maternal or fetal
indications.
Before patients underwent CS, 5 cc of blood
samples were taken from the cubital vein, blood were
inserted into two tubes, one contained EDTA, and
labeled with subject's identity. After CS, blood samples
were taken after about 2 hours after CS in the treatment
2
room. Then, sample was sent to central laboratory of dr.
Saiful Anwar Hospital, Malang to be analyzed.
After CS, the amount of blood loss was determined
and recorded by the operator and the anesthetist by
seeing the amount of blood collected in the suction
pump reservoir and the amount of gauze that was used.
After data is collected, data were analyzed using
SPSS version 18 software. Analysis of normality
performed with Kolmogorov-Smirnov test. If data was
normally distributed, we used T-test to compare the
levels of albumin and hemoglobin before and after CS.
Correlation test was done to see the relationship
between albumin levels before and after SS with the
amount of blood loss during surgery. Differences and
correlations were considered significant if P <0.05.
RESULTS
Samples that meet the criteria and willing to be
participated in this study was 97 subjects. The average
age was 29.6 ± 7.09 years, ranged between 16 - 42 years.
Patient’s education mostly was high school (42.3%).
34% of patient’s husband worked as a laborer or
handyman.
Kolmogorov-Smirnov test showed that there was a
significant value of albumin, hemoglobin pre and
postoperative, and the amount of blood loss (0.886,
0.876, 0.925, 0.805 , and 0.077 (p> 0.05), respectively),
therefore it can be concluded that data was distributed
normally and can be tested with paired t test.
Table 1. Albumin Level Before and After CS (n = 97)
Albumin Mean ± SD* P Value
Before CS 3.38 ± 0.324
0,000
After CS 3.04 ± 0.318
*SD = Standard deviation
Table 1 showed that mean of preoperative albumin
level was 3.38 and after surgery was 3.04. Paired samples
t test showed that there was a significant differences of
albumin level before and after surgery (0.000, P <0.05,
Ho rejected). Preoperative albumin level was higher
than postoperative albumin level (Figure 1).
Figure 1. Mean of albumin level before and after surgery
4.00
3.50
3.38
3.00
Rerata Albumin
3.04
2.50
2.00
1.50
1.00
0.50
0.00
Albumin preoperasi Albumin pascaoperasi
 Based on data analysis, mean of preoperative Hb DISCUSSION
was 11.64 and post operative was 10.95. Paired samples
We found that there was a significant difference
t-test showed a significant differences between Hb
between albumin and hemoglobin levels before and
before and after surgery (P = 0,000, P<0.05, Ho
after CS. These results were consistent with the theory
rejected).
that major trauma, including surgery often followed by
Table 2. Hemoglobin Level Before and After Surgery tissue inflammation and systemic reactions that
Hemoglobin Mean ± SD P Value mobilize a lot of fluid into the interstitial and
Before CS 11.639 ± 1.295 intravascular areas. Trauma response is followed by a
0,000
After CS 10.949 ± 1.368
SD = Standard deviation; n = 97
decrease in albumin concentration.2
Our results support the research conducted by
Figure 2 shows that preoperative Hb tends to be higher Alberti and Petroianu in 2010. In their study on 100
than post operative Hb. adult patients who underwent major surgery, they
found no significant changes in albumin levels before
Figure 2. Hemoglobin level before and after CS and after surgery. Nevertheless, the difference they get
12.00 larger than the results of this study.2
11.80 Changes in albumin levels could also be explained
11.60 11.64 by the changes in vascular permeability and the dilution
effect caused by administration of saline or glucose
Rerata Hb

11.40

11.20 infusion during surgery. While the water reserves are

11.00 depleted, excess sodium will be excreted slowly and
10.80
10.95
consequently albumin dilution.9
10.60 During surgery, the same process also occurs in
10.40 hemoglobin level. Distribution of protein compounds
Hb preoperasi Hb pascaoperasi
has an important role in maintaining hemoglobin level.
Literature suggests that the extent of the damage will
After that, we conducted a correlation analysis of determine the catabolic enhancement of vascular
albumin and hemoglobin levels before and after CS. We permeability.2,9 In addition, dissection and bleeding
found that there was no significant correlation between during surgery can cause a decrease in hemoglobin and
preoperative (r = 0.056, p = 0.587) and postoperative (r hematocrit levels. This result is consistent with the
= -0113, p = 0.271) albumin level with blood loss during results of a research in Israel by Horowitz et al. Their
surgery. In other words, the amount of blood lost not study on 383 patients found a significant decrease in
related to level of albumin level either before or after hemoglobin levels before and after surgery.10,11
surgery (Table 3). Correlation test showed that there was no
significant association between albumin and
Table 3. Correlation between pre and post operative
hemoglobin levels before and after surgery with the
albumin level and blood loss during surgery
amount of blood loss during surgery. The result is in
Albumin Mean ± SD* r P value
Before CS 3.38 ± 0.324 0.056 0.587 contrast with the results of Horowitz et al, they found
After CS 3.04 ± 0.318 -0.113 0.271 significant association between hemoglobin levels and
SD = Standard deviation; n = 97 the amount of blood loss.11 However, the results of this
study support the results of Skjeldestad et al study in
We also found that there was no significant correlation Norway which found that hemoglobin levels are not
between pre (r = 0.034, p = 0742) and post operative (r directly determine the amount of blood loss during SS.12
= -0102, p = 0322) Hb level with blood loss during Changes in vascular permeability and the dilution effect
surgery. In other words, the amount of blood loss was caused by intravenous fluids during surgery is possible
not related to level of Hb in either before or after surgery to be one factors that influence the decreased levels of
(Table 4). albumin or hemoglobin in the absence of significant
Table 4. Correlation of Hemoglobin Level Before and blood loss.
After Surgery Special attention from clinicians to monitor
Hemoglobin Mean ± SD* R P value hemoglobin levels after SS for therapy and appropriate
Before CS 11.639 ± 1.295 0.034 0.742 nutrition to restore hemoglobin levels to normal value
After CS 10.949 ± 1.368 -0.102 0.322
is needed. Further research should assess the correlation
SD = Standard deviation; n = 97
between albumin and hemoglobin levels with the

The Journal of Obstetrics & Gynecology Science, Vol. 1, No.1, August 2020 3
amount of blood loss with a greater number of samples
and a better control of confounding factors.
CONCLUSION
There was a significant difference in albumin and
hemoglobin levels before and after SS. There was no
significant association between albumin and
hemoglobin levels before and after the SC with the
amount of blood loss during surgery.
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