Anemia in PregnancyAnemia in Pregnancy

Presenter: Dr. Imran KhanPresenter: Dr. Imran Khan

Moderator: Prof. ChandralekhaModerator: Prof. Chandralekha

www.anaesthesia.co.in anaesthesia.co.in@gmail.com

Definition Definition

ClassificationClassification

Hematological changes in pregnancyHematological changes in pregnancy

Problems related to AnemiaProblems related to Anemia

Anaesthetic considerationsAnaesthetic considerations

DefinitionDefinition

Anemia - insufficient Hb to carry out O2

requirement by tissues.

WHO definition : Hb conc. 11 gm %

CDC definition : Hb conc. < 11gm % in 1st and 3rd trimesters and < 10.5 gm% in 2nd trimester

For developing countries : cut off level suggested is 10 gm %

- WHO technical report Series no. 405, Geneva 1968

Centre for disease control, MMWR 1989;38:400-4

Anemia - insufficient Hb to carry out O2

requirement by tissues.

WHO definition : Hb conc. 11 gm %

CDC definition : Hb conc. < 11gm % in 1st and 3rd trimesters and < 10.5 gm% in 2nd trimester

For developing countries : cut off level suggested is 10 gm %

- WHO technical report Series no. 405, Geneva 1968

Centre for disease control, MMWR 1989;38:400-4

Increased mortality figuresIncreased mortality figures

ConditionCondition Increased Increased mortality/morbidity mortality/morbidity below hemoglobinbelow hemoglobin

ReferenceReference

Old ageOld age <11 g/100 ml<11 g/100 ml Culleton 2006

Heart valve Heart valve operationoperation

<12 g/100 ml<12 g/100 ml Cladellas 2006

Heart failureHeart failure <11 g/100 ml<11 g/100 ml Ezekowitz 2003

PTCAPTCA <10 g/100 ml<10 g/100 ml Lee 2004

COPDCOPD <13 g/100 ml<13 g/100 ml Cote 2007

Figures are consequences of the reduced oxygen transport due to anemia

Degree Hb% Haematocrit (%)

Moderate 7-10.9 24-37%

Severe 4-6.9 13-23%

Very Severe <4 <13%

Degree Hb% Haematocrit (%)

Moderate 7-10.9 24-37%

Severe 4-6.9 13-23%

Very Severe <4 <13%

WHO Classification of Anaemia WHO Classification of Anaemia

Magnitude of ProblemMagnitude of ProblemMagnitude of ProblemMagnitude of Problem

Globally, is about 30 %Globally, is about 30 %

In developing countries & In developing countries & India, incidence is around India, incidence is around 40 – 90%. 40 – 90%.

Responsible for 40% of Responsible for 40% of maternal deaths in third maternal deaths in third world countries.world countries.

Important cause of direct Important cause of direct and and indirect maternal deathsindirect maternal deaths

- Vitere FE Adv Exp Med Biol 1994;352:127- Vitere FE Adv Exp Med Biol 1994;352:127

Globally, is about 30 %Globally, is about 30 %

In developing countries & In developing countries & India, incidence is around India, incidence is around 40 – 90%. 40 – 90%.

Responsible for 40% of Responsible for 40% of maternal deaths in third maternal deaths in third world countries.world countries.

Important cause of direct Important cause of direct and and indirect maternal deathsindirect maternal deaths

- Vitere FE Adv Exp Med Biol 1994;352:127- Vitere FE Adv Exp Med Biol 1994;352:127

Relation b/w symptoms of anemia to the Relation b/w symptoms of anemia to the hemoglobin level hemoglobin level

Hemoglobin (g/100 Hemoglobin (g/100 ml) ml)

SymptomsSymptoms

9-119-11 Slight pallor and tachycardiaSlight pallor and tachycardia

7-87-8 More pronounced pallor, plus dyspnea More pronounced pallor, plus dyspnea on exertionon exertion

66 All the above, plus many complain of All the above, plus many complain of weaknessweakness

33 All the above, plus people complain of All the above, plus people complain of dyspnea at restdyspnea at rest

2-2.52-2.5 All the above, plus congestive heart All the above, plus congestive heart failure may occurfailure may occur

Varat 1972 and Linman 1968

Brannon 1944, Duke 1969, Roy 1963

100

80

60

40

20

020 40 60 80 100

%S

atu

rati

on

PO2 (mmHg)

P50

Temp, CO2 , 2-3 DPG; pH(favors unloading)

OxygenTransport

P50

Temp, CO2 , 2-3 DPG; pH(favors loading) Bohr Effect

Physiological Changes

Blood volume increases +1500 ml

RBC 450 ml

Plasma 1000 ml

– Increase starts in the first trimester and gradually rises

Increased erythropoiesis but since more plasma is produced, a relative decrease in Hb and PCV

Iron stores +/- 500 mg

Iron requirements +/- 800 mg [500 mg for mother; 300 mg for fetus]. Hence need for supplementation

Hypercoagulable state increased risk of thrombosis

PROBLEMS RELATED TO PROBLEMS RELATED TO ANAEMIA..ANAEMIA..

OXYGEN AVAILABLE TO TISSUESOXYGEN AVAILABLE TO TISSUES

MANNER IN WHICH BODY COMPENSATESMANNER IN WHICH BODY COMPENSATES

COMPENSATORY COMPENSATORY MECHANISMSMECHANISMS

Increase in CORightward shift of ODCDecrease in blood viscosityIncrease in 2,3-DPG concentration

in RBCRelease of renal erythropoietin leading to stimulation of erythroid precursors in bone marrow

SymptomsSymptoms

Irritability

Fatigue

Weakness

Dizziness

Palpitation

Infection

Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features

Pallor of skin And m/m

Edema

PlatynychiaKoilonychia PlatynychiaKoilonychia

Glossitis

Stomatitis

Tachycardia

Soft ejectionsystolic murmur

SignsSigns

Physiological anaemia of pregnancy

Acquired

Causes of Anaemia Causes of Anaemia Causes of Anaemia Causes of Anaemia

Nutritional-• Iron deficiency Anaemia

Folic Acid deficiency anaemia

Vitamin B12 deficiency anaemia

Infections- Malaria, hookworm infestation, etc

Haemorrhagic- Acute or chronic blood loss

Bone marrow suppression- Aplastic anaemia, drugs,

Renal disease

Genetic - haemoglobinopathies – sickle cell disease, thalassaemia

Nutritional-• Iron deficiency Anaemia

Folic Acid deficiency anaemia

Vitamin B12 deficiency anaemia

Infections- Malaria, hookworm infestation, etc

Haemorrhagic- Acute or chronic blood loss

Bone marrow suppression- Aplastic anaemia, drugs,

Renal disease

Genetic - haemoglobinopathies – sickle cell disease, thalassaemia

Physiological Anaemia

Caused by pregnancy changes

Hb can vary from 10.0-14.5 g/dl

“Pathological” anaemia usually defined as Hb level <10.5 g/dl

Iron RequirementIron Requirement

Iron Absorption Iron Absorption

11

Amount of iron in the body

Amount of iron in the body

Iron Loss

Skin

Urine

Feces

Menstruation

1-2mg/d

1-2mg/d

20-30mg/c20-30mg/c

Early Pregnanc

y2.5 mg / day

32 to 40 weeks

6.8 mg / day

TOTAL800 – 1000

mg

20 to 32 weeks

5.5 mg / day

RBC =500mgFetus+Placenta =450mgThird stage blood loss=200mgTotal = 1150mg

Iron Requirement During PregnancyIron Requirement During Pregnancy

Laboratory Diagnosis of AnaemiaLaboratory Diagnosis of Anaemia

IDAIDA ThalassemiaThalassemia Chronic DiseasesChronic Diseases

Serum IronSerum Iron Decreased Decreased Normal / Normal / Increased Increased

DecreasedDecreased

TIBCTIBC IncreasedIncreased NormalNormal Decreased or NDecreased or N

TransferrinTransferrin

SaturationSaturation

DecreasedDecreased N or IncreasedN or Increased N or DecreasedN or Decreased

Serum FerritinSerum Ferritin DecreasedDecreased N or IncreasedN or Increased NN

Marrow IronMarrow Iron Decreased / Decreased / absentabsent

N or IncreasedN or Increased NN

Therapeutic test Therapeutic test with oral ironwith oral iron

Rise in HbRise in Hb No rise in HbNo rise in Hb No riseNo rise

Reason For Increased Reason For Increased Incidence Of AnemiaIncidence Of Anemia

Reason For Increased Reason For Increased Incidence Of AnemiaIncidence Of Anemia

Poor pre-pregnancy iron balance Poor pre-pregnancy iron balance

Improper supplementation Improper supplementation

Repeated childbearingRepeated childbearing

Lack of awareness and illiteracyLack of awareness and illiteracy

GI infections and infestationsGI infections and infestations

Poor pre-pregnancy iron balance Poor pre-pregnancy iron balance

Improper supplementation Improper supplementation

Repeated childbearingRepeated childbearing

Lack of awareness and illiteracyLack of awareness and illiteracy

GI infections and infestationsGI infections and infestations

ANAESTHETIC CONSIDERATIONSANAESTHETIC CONSIDERATIONS

Elective LSCS - Elective LSCS - Emergency LSCS - Blood TransfusionEmergency LSCS - Blood Transfusion

Not a Day before SurgeryNot a Day before Surgery

Fresh ( 2, 3 DPG Fresh ( 2, 3 DPG 24 HRS. ) 24 HRS. ) Chronic, Well compensated- Hb upto 8 gm% Chronic, Well compensated- Hb upto 8 gm% Safe Safe

Avoid Hypoxia ( ↑ Fi OAvoid Hypoxia ( ↑ Fi O22 ) , Maintain C V S Stability ) , Maintain C V S Stability Avoid Hypovolemia and Aortocaval CompressionAvoid Hypovolemia and Aortocaval Compression Minimize -Minimize -

• Lt. O D CLt. O D C

• HyperventilationHyperventilation

• AlkalosisAlkalosis

• HypothermiaHypothermia

• ↓ ↓ 2, 3 DPG2, 3 DPG Monitor- Complications like CCF & ShockMonitor- Complications like CCF & Shock

CHOICE OF ANAESTHETIC TECHNIQUECHOICE OF ANAESTHETIC TECHNIQUE

Regional Anaesthesia - Regional Anaesthesia -

Safe - Safe - Hb > 9 gm% OR 8 gm% Hb > 9 gm% OR 8 gm% No Cardiac Decomp. No Cardiac Decomp.

Avoid - Avoid -

•Hb < 8 gm % , Hb < 8 gm % ,

•Hemostatic Abnormalities, Hemostatic Abnormalities,

•Megaloblastic AnemiaMegaloblastic Anemia Precautions - Precautions - Fi OFi O2 2 , Low Dose L. A. + Opioid, Low Dose L. A. + Opioid

Disadvantages - Disadvantages - PreloadingPreloading

-- Sympath. Block Sympath. Block Ppt. Hypotension Ppt. Hypotension

ADVANTAGES OF REGIONAL ADVANTAGES OF REGIONAL ANAESTHESIAANAESTHESIA

Mother is aware of Child Birth Mother is aware of Child Birth

Less blood lossLess blood loss

Analgesia can be extended Analgesia can be extended post op period post op period

No risk of AspirationNo risk of Aspiration

No risk of Complications d/t intubation and drug induced S/ENo risk of Complications d/t intubation and drug induced S/E

EPIDURAL V/ S S.A.B.EPIDURAL V/ S S.A.B.

Adv. Of Epidural - Adv. Of Epidural - Less precipitous fall in B>PLess precipitous fall in B>P

- - Post Op AnalgesiaPost Op Analgesia

Disadv. Of Epidural - Disadv. Of Epidural - Time ConsumingTime Consuming

- - L.A Toxicity. L.A Toxicity.

-- Patchy, Inadeq. Blocks Patchy, Inadeq. Blocks

Adv of SAB. - Adv of SAB. - Easy Rapid onset with High Success Rate Easy Rapid onset with High Success Rate

-- Small Vol. of drug Small Vol. of drug Less Toxicity Less Toxicity

- - low dose L.A + Opioidlow dose L.A + Opioid

» Less Hypotension» Less Hypotension

» Intense surgical Anaesthesia.» Intense surgical Anaesthesia.

» Post op analgesia» Post op analgesia

-- Fine bore needle Fine bore needle No P.D.P.H. No P.D.P.H.

C. S. E.C. S. E.

S.A.B. - S.A.B. - Speed of Onset Speed of Onset

-- Reliability Reliability

-- Low Toxicity Low Toxicity

++

Epidural Catheter - Epidural Catheter - Control of Height of Block Control of Height of Block

- - Supplement Inadeq. BlockSupplement Inadeq. Block

-- Post Op Analgesia Post Op Analgesia

GENERAL ANAESTHESIAGENERAL ANAESTHESIA

choice - choice - If Hb = 8 gm % with cardiac decomp..If Hb = 8 gm % with cardiac decomp..

-- Hb < 8 gm % Hb < 8 gm %

Adv. - Adv. - Rapid InductionRapid Induction

-- less hypotension and better CVS. stability less hypotension and better CVS. stability

-- Control of Airway and Ventilation Control of Airway and Ventilation

-- Severe Anemia Severe Anemia Post op Ventilatory Support Post op Ventilatory Support

- - No Anxiety of being AwakeNo Anxiety of being Awake

Disadv. Disadv. --Failed IntubationFailed Intubation

-- Gastric Aspiration Gastric Aspiration

G. A. TECHNIQUEG. A. TECHNIQUE

Supine with wedge under right hipSupine with wedge under right hip

Pre oxygenationPre oxygenation

Thio+ Sux/Roc.Thio+ Sux/Roc.

Problems - Problems - Safe cricoid pressure Safe cricoid pressure

-- Failed Intubation Failed Intubation

-- Awareness Awareness

-- Neonatal Effects Neonatal Effects

» I. D. I. > 8 MIN.» I. D. I. > 8 MIN.

» U. D. I. > 3 MIN.» U. D. I. > 3 MIN.

Severity of anemia- Post Op VentilationSeverity of anemia- Post Op Ventilation

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