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ANEMIA IN PREGNANCY AND

ITS ANAESTHETIC
IMPLICATIONS

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Anemia
Definition: Quantitative or qualitative reduction of Hb or
circulating RBCs or both.
As per WHO, Hb conc. Of <11 gm/dl or Hct < 0.33 in 1st
& 3rd trimester. In developing countries, limit brought
down to 10 gm/dl.
Incidence = 40 to 60 %

Normal Level Of Hb/Hct


Levels vary with age and gender

AGE
Newborn
1 month
3 month
12 months
Adult male
Adult female

Hb/Hct
16/55
12/38
10/30
12/38
14/45
12/36

WHO definition for Chronic Anemia

AGE
6/12 - 6 yrs
6 - 14 yrs
Adult male
Non pregnant female
Pregnant female
1st trimester
2nd trimester

Hb gm%
<10
<12
<13
<12
<11/ Hct <33
<11
<10.5

Severity of Anemia
ICMR CATEGORIES
Category
1
2
3
4

Severity
Mild
Moderate
Severe
Very severe

Hb levels gm %
10 10.9
7 10.0
<7.0
<4.0

Physiological anemia of pregnancy


Blood volume
Plasma vol
RBC vol
HCt
Hb

45%
55%
30%
30%
10.5-11

Physiological anemia of pregnancy


in RBC mass
demand for iron
in total body iron stores
in serum ferritin levels (28-32 weeks of
pregnancy)

Criteria for Physiological anemia


Hb = 10 gm%
RBC = 3.2 million/mm3
PCV = 30%
Peripheral smear showing normal morphology of RBC
with central pallor.

Regulation of Iron Transfer to fetus


Maternal circulation
Serum transferrin carries Fe
Transferrin receptors located on apical
surface of placental synctiotrophoblast

Holotransferrin is endocytosed

Fe is released & apotransferrin

Free Fe binds to ferritin in placental cells

Transferred to apotransferrin which enters from foetal side


of placenta & exits into fetal circulation.

Pathophysiology
Oxygen Hemoglobin
dissociation curve:
O2 released to the tissues is
affected by the shape & position
of ODC which can move either to
right or left. Shift is described in
terms of P50 O2 tension (Po2) at
which Hb is 50%
saturated with O2,
corresponds to 27
mm Hg.
.

Parameters

Arterial bloood

Venous Blood

Po2 (mm Hg)

100

45

O2 carried by
Hb/100ml blood(ml)

20

15

O2 in solution/100ml
of blood(ml)

0.3

0.15

Normal values of oxygen in arterial and Venous blood


Oxygen content: Volume of oxygen carried in 100ml of blood.
Arterial O2 content
CaO2 = (1.34 x Hb x SaO2) + (0.003 x PaO2)
Venous O2 content
CvO2 = (1.34 x Hb x SvO2) + (0.003 x PvO2)

Oxygen flux: Amount of oxygen leaving the left ventricle


per minute in the arterial blood.
CO x arterial O2 sat x Hb conc. X 1.31
Oxygen delivery: Amount of oxygen that reaches the
systemic capillaries each min.
Do2 = Q x CaO2 x 10

(Q = Cardiac output)

Oxygen uptake: Volume of oxygen that leaves the


capillary blood and moves into the tissues
each min.
Measure of oxygen consumption of
tissues.
Vo2 = Q X (CaO2 CvO2) X 10

Oxygen extraction ratio: Fraction of oxygen delivered


to the capillaries that is taken up into
the tissues.
Index of efficiency of oxygen.
O2ER = VO2 / DO2

Parameters

Absolute Range

Cardiac output
O2 delivery

5 6 L/min
900 1100ml/min

O2 uptake

200 270ml/min

O2 extraction ratio

0.20 0.30

Normal range for oxygen transport parameters

Acute Anemia
Blood loss > 20% of blood volume
Hypovolemia & hemodynamic instability.
Signs & symptoms of acute Blood loss
Blood loss %

Volume, ml

Symptoms

Signs

<20

<1000

Restlessness

Mild
Tachycardia

20-30

1000-1500

Anxiety

Tachycardia
on exertion &
pulse pressure

30-40

1500-2000

Syncope on
sitting or
standing

Tachycardia at
rest, RR,
Syst. Hypoten.

>40

>2000

Confusion,
shortness of
breath

Marked
tachycardia,
Shock

Compensatory mechanism:
Stimulation of adrenergic nervous system & release of
vasoactive hormones.
Sympathetic stimulation leading to CO & HR.
Systemic vasoconstriction, VR and SV.
Redistribution of blood volume to vital organs.
Anerobic metabolism, acidosis, hyperventilation.
Renal conservation of water & electrolytes.
Factors affecting Compensation:
Cardiopulmonary disease
Left ventricular dysfunction.
Magnitude of loss, oxygen consumption
Anaesthesia

Anaesthetic considerations:
Management of patient is judged by magnitude of
hemorrhage and adequacy of volume replacement.
Thiopentone - suitable induction agent for normovolemic
patients who sustained acute blood loss.
Ketamine or Etomidate - hypovolemic patients.
Decrease conc. of volatile anaesthetic or infusion rate of
agents administered i/v.
Regional anaesthesia not a good option.
Small doses of midazolam can be given.

Anaesthetic management:
Secure 2 large bore cannulas.
Monitor SpO2,ETCO2,NIBP,temp,UO,CVP,ECG.
GA with RSI.
Fluid resuscitation, oxygen by mask, aspiration
prophylaxis.
Send blood for CBC, cross matching, coagulation profile
Arrange adequate blood.
Ensure left uterine placement.
Transfuse blood if Hb < 7gm % with ongoing blood loss.
If coagulation disorder present, give FFP@ 15-20 ml/kg.
Prepare for intraop cell salvage if indicated.
Regional not indicated.

Guidelines for Blood Transfusion (By National Institutes


of Health Consensus Conference):
Hb > 10gm/dl transfusion rarely indicated.
Hb < 6gm/dl transfusion almost always indicated.
Hb 6 to10gm/dl decision to transfuse is determined by
patients risk for complications of decreased tissue
oxygenation ( pt. with IHD ).
Preoperative autologous donation in selected patients.
Intraoperative blood salvage when appropriate.
Acute normovolemic hemodilution when appropriate.

Chronic Anemia
Includes Iron Deficiency Anemia, Thalassemia, sickle cell
anemia.
Symptoms: No symptom (unless RBC count is very low).
Fatigue, dyspnoea on exertion, palpitation.
Nausea, loss of appetite, constipation, indigestion.
Postural hypotension, vertigo, light headedness.
Angina, heart failure, confusion.
H/O bleeding (DUB, malena, hematuria).
Signs:
Vitals - HR,RR
GPE - Pallor of skin & mucous membranes, JVP ,
pedal edema, generalised anasarca,
glossitis, stomatitis, Koilonychia, mouth soreness.
Resp. system - Tachypnoea
- Basal crepts, if LVF.

CVS - Tachycardia, strong peripheral pulses with wide


pulse pressure.
- Functional cardiac murmur (Ejection murmur).
- Evidence of cardiomegaly, CHF.
Abd. - Jaundice, hepatosplenomegaly.
CNS - altered sensorium.
- Mental disturbances (B12 def).
Edema (Renal failure).
Lower leg ulcers (Sickle cell Anemia).
Compensatory Mechanisms:
2,3 DPG shift of O2Hb dissociation curve to right.
Oxygen Extraction ratio.
Circulatory adjustments - CO by increasing SV.
- myocardial hypertrophy.
Release of erythropoietin which stimulates erythroid
precursors in bone marrow to produce RBCs.

Respiratory adjustments - physiological shunting in


lungs.
- respiratory reserve.
- tachypnoea,
hyperventilation.
GIT - reduced splanchnic blood flow.
Lab Investigations:
1. Complete blood count
a) RBC count Hb, Hct.
b) RBC indices MCV,MCH,MCHC, RDW.
c) WBC count
- Cell differential
- Nuclear segmentation of neutrophils.

d) Platelet count

2.
3.

4.

e) Cell morphology
- Cell size
- Hb content
- Anisocytosis, Poikilocytosis, Polychromasia
Reticulocyte count
Iron supply studies S.Iron, TIBC, S.Ferritin, Marrow
Marrow examination aspirate & biopsy

Iron Deficiency Anemia


Most common cause of anemia in pregnancy.
Stored as S.ferritin & Hemosiderin.
Adult male
Adult female
Stores
1000mg
300 500mg
Losses 1mg/day
2mg/day
3mg/day(Pregnancy)
Daily iron requirement
2.5mg early pregnancy.
5.5mg from 20 to 22 wks
6 to 8mg 32 wks onwards

Basal Iron
Transfer to fetus
For placenta
Blood loss at delievery
Expansion of red cell mass
Iron conserved by Amenorrhea
TOTAL REQUIREMENT
Causes:
Increased iron demand
Diminished intake of iron
Disturbed metabolism
Pre-pregnancy health status
Excess demand

280mg
200-350mg
50-150mg
100-250mg
570mg
240-480mg
800-900mg(4-6mg/d)

Haematological parameters:
Plasma iron
S.Ferritin
TIBC
Transferrin saturation
MCV
MCH
MCHC
RBC Protoporphyhrin

IDA

Normal values

<30
<12
>400
<15%
<75
<25
<30
>200

50-150ug/dl
14-150ug/l
300-350ug/dl
30-50%
75-93fl
25-36 pg
30-36g/dl
30-50ug/dl

Complications:
During Pregnancy - Pre eclampsia (due to malnutrition or
hypoproteinemia)
- Intercurrent infection (infection impairs
erythropoiesis by BM depression)
- heart failure (at 30-32wks or preg)
- Preterm labour
During labour
- Uterine inertia
- PPH
- Cardiac failure
- shock

Puerperium - Puerperal sepsis


- Subinvolution
- Failing lactation
- Puerperal venous thrombosis
- Pulmonary embolism
Effects on baby Amount of Fe transferred to fetus is
uneffected even if mother suffers from IDA.
- increased incidence of low birth.
- IUD due to severe maternal anoxemia.

Folic acid Deficiency


FA is cofactor in nucleic acid synthesis and has imp. role
in cell division.
Stores are limited (6-10mg).
Daily requirement is 300-500mg.
Def. causes Megaloblastic anemia.
High incidence in multigravida, twin pregnancy,
hyperemesis gravidarum, alcohol consumption, smoking,
malabsorption, antiepileptic drugs.
Effects on mother: Incidence of abortion high.
Effects on Fetus: Premature birth, Neural tube defects,
cleft palate.

Management
Prevention:
Avoidance of frequent child birth.
Supplementary Fe therapy (60mg elemental Iron three
times a day).
Dietary prescription.
Adequate treatment for any infection.
Early detection of falling Hb level, levels should be
estimated at 1st A/N visit, 30th & finally 36th week.

Pregnancy
<30wks
IDA
Oral iron

FA
def.

IDA

I/M iron
iron

Pregnancy
>36wks

FA def.

Parenteral

Oral FA

Intolerance or
Non-compliance
I/M iron
iron

Pregnancy
30-36wks

Oral
FA

Blood
transfusion

I/V

I/V

PROTOCOL OF SEVERE ANEMIA IN PREGNANCY

Curative:
1. ORAL THERAPY 200mg (60mg elemental iron) X 3 times a day.
WHO 60mg elemental iron + 250ug FA OD/BD.
Govt. of India Regimen
100mg Fe + 500ug FA during 2nd half of
pregnancy X 100 days.
Drawbacks:
- Intolerance
- Unpredictable absorption rate.
- Non Compliant patient.
- Long time for improvement @ 0.3-1gm/100ml/wk.

Response to therapy:
- Sense of well being.
- Increased appetite.
- Increase in Hb.
- Reticulocytosis with in 5-10 days.
PARENTERAL THERAPYIndications:
- Failure to iron therapy.
- Non compliant patient.
- Case seen for the 1st time during last 8-10 wks
with severe anemia.
2.

Advantages:
- Certainity of admission.
- Hb rises @1gm/100ml/wk.
I/V Route:
Iron Dextran (1ml contains 50mg elemental iron & one
ampoule contains 2ml).
Total dose infusion Deficit of iron calculated & total
amount required to correct deficit is
administered in single setting I/V
infusion.
Elemental Iron Needed (mg) =
(Normal Hb - Patients Hb) X Wt(kg) X 2.21 + 1000

Given @10 drops/min X 30 mins (diluted in normal


saline or 5% dextrose).
If no reaction, to 40 drops/min.
Side effects:
- Anaphylactoid reaction.
- Chest pain, rigors, chills, fall in BP, dyspnoea,
hemolysis.
Treatment: Stop infusion.
Give antihistaminics, corticosteroids &
epinephrine.
I/M Route:
Iron Sorbitol Citrate (Jactofer)
Iron Dextran (imferon)
Oral iron should be suspended at least 24 hrs prior to
therapy to avoid reaction.

Drawbacks:
- Painful injection (less with jactofer).
- Chances of abcess formation & discolouration of skin
over injection site.

BLOOD TRANSFUSION Transfusion triggers:

Task force 1996, 2006 No uniform transfusion


trigger
3.

Patient factors

Type of surgery

Preg
Preg
Elective
Emergency
<36wks
> 36wks
C/S
C/S
-Hb 5gm% - Hb 6gm%
- with H/O
-Always
Without CHF
without CHF
APH,PPH,
arrange
-Hb 5-7gm%,if -Hb 6-8gm%,if previous
blood.
CHF,hypoxia, CHF,hypoxia, LSCS.
Infections.
Infections.
Hb <8gm%,2 units blood should be arranged.

Guidelines for transfusion:


Prefer fresh Packed cells.
Do not repeat tranfusion within 24 hrs.
Effects of Transfusion:
O2 carrying capacity of blood.
Viscosity increases by 33%.
Hb increases by 1gm/unit.
Heart rate decreases by 7%.
Supplies natural constituents of blood.
Improvement with in 3 days.
Drawbacks:
Premature labour (blood reaction).
CHF
Transfusion rexn.
Infections: HIV, Hep B etc.

Anaesthetic Considerations:
Etiology & Chronicity of anemia
Pt. overall condition
Pt. ability to compensate for O2 delievery.
Operative procedure.
Anticipated blood loss.
Minimize factors interfering with O2 delivery
- low myocardial contractility, CO (careful with
volatile anesthetic agents
- left shift of ODC (hyperventilation,
hypothermia, alkalosis)
Prevent increase in O2 consumption (reduce postop pain,
fever, shivering).

Anaesthetic technique:
Regional anaesthesia
Spinal or epidural can be given
Preloading

fall in hct by 20% (2lt).


Exacerbate anemia
Heart failure.

General anaesthesia
Principle:
a) Avoid hypoxia.
b) Maintain cardiovascular stability.
c) Minimize factors which produce unwanted shift of O2
dissociation curve.

Secure 2 large bore cannulas.


Monitor SpO2,ETCO2,NIBP,temp,UO,CVP,ECG.
Induction:
a) Adequate preoxygenation.
b) I/V agents administered slowly.
Maintenance:
a) Ventilation should be maintained to provide
normocapnia.
b) Possibility of awareness is to be kept in mind as O 2
conc. is increased.
c) Mild tachycardia & wide pulse pressure may be
physiological
obtunded by anaesthetic agents.
d) Tissue perfusion judged by blanching ear lobes, nose.
e) Change posture cautiously
BP & CO.

Postoperative:
1. Extubate
relaxant effect worn off.
2. Monitor vitals, fluid intake/output & respiratory
parameters for 12 24 hrs.
3. Oxygen enriched air given by mask.
4. Prevent shivering.
5. Hb should be checked postoperatively & transfusion
accordingly.

Management during labour


Adequate oxygenation.
Avoid sympathetic stimulation and hyperventilation;
prevent rightward shift of ODC.
Decreased blood loss.
Avoid maternal stress, patient can go into CHF.
Improved uterine blood flow.
PPH should be emergently treated.

Sickle cell Anemia


Valine substituted for glutamic acid at 6th position on chain of Hb
molecule.
Common variants - SS ( sickle cell anemia).
- SA ( sickle cell trait).
- SC ( sickle cell disease).
Hb SS

Hb SA

Hb SC

Cell trait

Homozygous

Heterozygous

Double
heterozygous

HbS

70 90%, rest
HbF.

10 40%, 4060% HbA.

Very low

Hb (g/dl)

6-9

13 -15

9 - 12

Life expectancy 30 yrs

normal

Slightly

Propensity for
sickling

+ (O2 falls <


40%)

++

++++

Signs & symtoms of sickle cell disease:


1. Vaso-occlusive complications
a) Painful episodes
b) Acute chest syndrome
c) Strokes
d) Renal insufficieny
e) Splenic sequestration
f) Proliferative retinopathy
g) Priapism
h) Spontaneous abortion
i) Bone pains, leg ulcers, Osteonecrosis
2. Complications related to hemolysis
a) Anemia (Hct 15 30%)
b) Cholelithiasis
c) Acute aplastic episodes

Infectious complications
a) Streptococcus pneumonia sepsis
b) E.coli sepsis
c) Osteomyelitis
Factors favouring Sickling:
Hypoxia
Acidosis
Decrease in body temperature
Dehydration
Circulatory stasis
Investigations:
Hb, Hct, Reticulocyte count
Blood film
Hb electrophoresis
Sickle cell test (Na metabisulphite)
3.

Treatment
Acute pain:
a)Fluid replacement
b)Administer opoids & NSAIDS.
Chronic pain:
a)Acetaminophen with codiene
b)Fentanyl patches
c)NSAIDS

Anaesthetic Management:
Goals Avoidance of acidosis due to hypoventilation of lungs.
Maintenance of optimal oxygenation.
Prevention of circulatory stasis (improper body
positioning, use of tourniquets).
Maintenance of normal body temperature.
Preoperative period a) Admit to hospital 12 24 hrs before surgery to
permit optimal hydration with I/V fluids.
b) Correction of any coexisting infection.
c) Transfuse RBCs if needed ( keep Hb b/w 9-12
gm% & Hct of about 35%, with 60-70% HbA).
Intraoperative period a) Monitor SpO2,ETCO2,NIBP,temp,UO,CVP,ECG

b) Maintain arterial oxygenation


c) Hydration.
d) Body temperature.
e) Replace blood loss when necessary.
General anaesthesia:
Preoxygenate for 5 mins before induction to make HbS as
possible is in oxy form.
After airway is established, give 30 50% inspired oxygen.
Regional anaesthesia:
Maintain oxygenation, ventilation, hypotension.
Prevent stasis of blood flow.

Postoperative period
a) Maintain oxygenation, hydration
b) Avoid acidosis & hypothermia.
c) Adequate analgesia.
d) Incentive spirometry.

Thalassaemia
Quantitative abnormalities of polypeptide globin chain
synthesis.
Type

Hb

Hb
electrophoresis

Clinical
syndrome

1.Hydrops foetalis
(deletion of 4 genes)

3-10g/dl

Hb Barts(100%)

Fatal in utero
or in early
infancy

2.HbH disease
(deletion of 3 genes)

2-12g/dl

HbH (2%), rest


HbA,HbA2,HbF

Hemolytic
anemia

3.-thalassaemia
trait (deletion of 2
-genes)

10-14g/dl

normal

Microcytic
hypochromic
bloood picture
but no anemia

-thalassaemia

Type

Hb

Hbelectrophoresis

Clinical
syndrome

1. thallassaemias
Major (Cooleys
anemia)

<5g/dl

HbA(0-50%)
HbF(50-98)

Severe cong.
Hemolytic
anemia,requ BT

2. thallassaemias
Intermedia

5-10g/dl

Variable

Severe anemia
but no regular
BT

3. thallassaemias
minor

10-12g/dl

HbA2(4-9%)
HbF(1-5)

Usually
asymptomatic

thallassaemias

Anaesthetic management:
Management depends on severity of Anemia.
Preoperative evaluation of cardiac & hepatic function
in transfusion dependent patients as a risk of Fe toxicity
or haemochromatosis.
Extramedullary haematopoiesis
Hyperplasia of
facial bones
difficult intubation.
Spinal cord compression & massive haemothorax also
caused by extramedullary haematopoiesis.

Oxygen Cascade
Dry atmospheric air PO2 = 159 mmHg

PO2= PB x FiO2,
760 x .21 = 159

In Humidified air PiO2 = 149 mmHg

PiO2 = (PB 47) x FiO2

Alveolar air PAO2= 100 mmHg

PAO2 = PiO2 PACO2/RQ

Arterial blood PaO2 = 97 mmHg

PaO2 = 102 Age/3

Mixed venous blood PVO2 = 40 mmHg


Cell PO2= 5 to 40 mmHg
Mitochondria PO2 = 1 to 2 mmHg

Preoxygenation
Denitrogenation.
Replacement of the nitrogen volume of the lung
(upwards of 69% of the FRC) with oxygen to provide a
reservoir for diffusion into alveolar capillary blood after
the onset of apnoea.
Three Methods:
100% O2 via tight fitting mask for 5 mins in a
spontaneously breathing patient
10 mins of oxygen reserve
4 vital capacity breaths of 100% O2 over a 30 secs.
8 deep breaths in a 60 sec period.

Oxygen Stores
Normal Oxygen Stores in adults -1500 ml.
(O2 remaining in lungs + bound to Hb + dissolved in body fluids)

Hemoglobins high affinity and very limited quantity in


solution restricts the availibility of these stores.
The oxygen contained within the lungs at FRC becomes
the most important source of oxygen during the period of
apnea, of which 80% is used only.

Clinical Importance
Apnea in a patient breathing room air
Oxygen content= fiO2(.21) X FRC(2300 ml)=480 ml
Metabolic activity =V O2 =250ml/min

Severe hypoxemia in 90 sec.

Apnea in a patient breathing 100% O2


Oxygen content= fiO2(1) X FRC(2300 ml)=2300 ml
Metabolic activity =V O2 =250ml/min

Severe hypoxemia in 7-8 Min.

Pregnant patientsFRC (15-20%) +O2 Consumption(20-40%)


Rapid desaturation during period of apnea

Preoxygenation for 3 - 5 Min.

References
1.

2.
3.
4.
5.
6.
7.

Obstetric Anesthesia- Principles and practice David H


Chestnut 3rd edition
Anaesthesia & Co-existing diseases-Stoelting.
Millers Anesthesia- Ronald D. Miller 6th edition.
Short Practice of Anaesthesia Churchill Davidson.
Textbook of obstetrics- DC Dutta.
The ICU book Paul. L. Marino.
Text book of Pathology Robbins.

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