ANEMIA

IN
PREGNANCY

Under the guidance of : Presented by:

Dr. Tejash Sharma Sir Dr. Paras Anand
(Professor) (2nd year Resident)
Department of Anaesthesiology Department of Anaesthesiology
S.B.K.S.M.I.&R.C. S.B.K.S.M.I.&R.C.
DEFINITION
• Anaemia is a condition in which the number of the red
blood cells or their oxygen carrying capacity
( haemoglobin or haematocrit ) is insufficient to meet
physiological needs , which vary by age , sex , altitude ,
smoking and pregnancy status.

• According to WHO ( WORLD HEALTH ORGANISATION )

• Hb < 13 g/dL - in adult males
• <12 g /dL – in adult non pregnant
females
• <11 g/dL - in pregnant females
 ANEMIA IN PREGNANCY

• Hb concentration < 11 g/dL or HCT < 33 % in 1st and

3rd trimester.

• Hb concentration < 10.5 g/dL in 2nd trimester.

• Hb concentration < 10 g/dL or at any time in

pregnancy
CLASSIFICATION
SYMPTOMS - depends on rapidity with which anemia develops and pathological mechanism behind
it
• Chronic progressive anemia :
 Lassitude ; fatigue ; loss of stamina ; breathlessness ; tachycardia ; pallor of skin and
mucous membrane ; loss of appetite;Pica ;
 Signs of cardiac failure in severe anemia : cardiac dilatation ; systolic flow murmurs ;
Edema
• Blood loss anemia : Hypovolemia picture
 10- 15% loss: vascular instability
 >30% loss: postural hypotension and tachycardia
 >40 % loss: hypovolemic shock ; confusion; dyspnoea; diaphoresis; tachycardia;
hypotension
• Haemolytic Anemia: haemoglobinuria ; signs of renal failure
PHYSICAL EXAMINATION

• GENERAL
• Pallor in eyes , oral mucous membrane , nail bed , palmar
crease , vaginal mucosa
• Assess shape of nails –
• Koilonychia- distorted nails
• Platynychia- flat nails
 SIGNS OF B12
DEFICIENCY

CHELIOSI GLOSSITIS
S

DARKENING OF
RIDGES
Iron requirement in pregnancy
• Total iron requirement is 1000 mg /day
• One ml RBC – needs 1.1mg iron
• RBC volume increases by 450 ml during pregnancy
So, total iron needed for maternal RBC is 450*1.1 = 500mg
• Fetus requires 300mg (by active transport)
• Iron lost via urine, stool ,sweat : 250mg

• Average daily requirement of iron during pregnancy = 4-6 mg

• 1st trimester : 0.8 mg
• 3rd trimester : 7.5mg
Iron demands

• Fetus gets iron from mother by active transport (against

concentration gradient)
So, maternal anemia will NOT cause fetal anemia unless
it is severe / very severe.

• Dietary requirement of iron should be 40-60mg/day of

which only 10% is absorbed.
So, Iron Supplementation is MANDATORY !
LAB DIAGNOSIS

• Hb screening using digital hemoglobinometer

• International guidelines:
Check Hb twice at 1st antenatal visitand during 28 weeks of gestation

• As per Indian guidelines:

• Check Hb 4 times in an antenatal women ( minimum 4 antenatal visits )

• If Hb < 11gm% upon screening, evaluate further :

• Complete Blood count with reticulocyte count
• PBS
• Hb electrophoresis
• Use Mentzer Index to differentiate between IDA and Thalassemia
• MCV (normal 80-85fL) / RBC count ( normal 75-100
million/microlitre)
• <13 : thalassemia
• >13 : IDA

• Range of MCV in pregnancy = 75-100 fl

• Microcytic anemia : MCV < 75fl

• Macrocytic anemia: MCV >100fl
 Consequences of Anemia in pregnancy
Antepartum Intrapartum Postpartum
Fetal outcome
complications complications complications
Increased risk of Postpartum
Prolonged labor Low birth weight
preterm delivery hemorrhage
Increased rates of
Premature rupture of
operative delivery Purperal sepsis Prematurity
membranes
and induced labor
Preecclampsia Fetal distress Lactation failure Infections
Pulmonary Congenital
Intrauterine Death Abruption
thromboembolism malformation
Subinvolution of
Intercurrent infection Neonatal Anemia
uterus
Antepartum Postpartum Abnormal cognitive
hemorrhage depression development
Congestive Heart Increased risk of
Failure Schizophrenia
CARDIOVASCULAR CHANGES IN PREGNANCY
 COAGULATION CHANGES

• Pregnancy is a hypercoagulable state.

• There is increased risk of thromboembolic episode
Intravascular volumes and
haematology
•
Intravascular volume begins to rise secondary to renin
angiotensin aldosterone system promoting Na+
absorption and water retention
• Plasma protein conc. decreases & Colloid osmotic
pressure decreases
• O2 delivery is not reduced because of subsequent
increase in cardiac output
• Estimated blood loss in vaginal delivery 300-500 ml and
Cesarean section 800-1000 ml
• WBC count- more than 10000 and Neutrophilia at term.
PHYSIOLOGICAL ANEMIA OF PREGNANCY

• Plasma volume increase by 45-50% by 34 weeks

gestation
• Red cell mass ( RBC volume) increase by only 25-30 %.
• Fall in Hb concentration and haematocrit due to
haemodilution.

Plasma volume > RBC

volume
Hemodilution
PATHOLOGICAL ANEMIA IN PREGNANCY
• Nutritional: Iron, Vitamin B12, Folate, Proteins.

• Haemorrhagic:
– Acute: Antepartum hemorrhage
– Chronic: Hookworm, hemorrhoids

• Bone marrow insufficiency:

– Aplastic anemia
– Radiation
– Infection with parvovirus B12
– Drugs (aspirin, indomethacin).
• Anemia of chronic disease:
– Chronic renal failure
– Neoplasms

• Infections:
– Malaria
– Hookworm
– Tuberculosis

• Hereditary Anemia-
• Sickle-cell disease
• Thalassemia
• Other hemoglobinopathies
• Hereditary hemolytic anemia: Spherocytosis
Investigations
• Hb estimation
• Study of peripheral smear:

• IRON DEFICIENCY ANEMIA The peripheral smear looks pale; there is hypochromia (large
central vacuoles), and microcytosis (small red cells), and anisocytosis (varying size of
RBCs)

Megaloblastic anemia: There is macrocytosis (MCV is greater than > 95 femtoliters), and
fully hemoglobinized red blood cells. In addition to macrocytes, oval macrocytes and
hypersegmented neutrophils are seen in various types of macrocytic anemia. When the
anemia is more severe, there may be marked poikilocytosis, with teardrop poikilocytes and
red-cell fragments.
• Normochromic normocytic anemia is seen in patients with chronic diseases, such as long
standing infections (TB), malignancy and renal failure.
• Hemolytic Anemia there would be polychromatic cells, stippled cells and target cells.
• sickle cell disease, peripheral smear will reveal sickle cells and large number of
reticulocytes. Microspherocytes (cells that are both hyperchromic and significantly
reduced in size and therefore in diameter) may be present in low numbers in patients with
a spherocytic hemolytic anemia but are also characteristic of burns and of
microangiopathic hemolytic anemia.
• Total iron binding capacity (TIBC)
• serum ferritin concentration (SF)
• S folic acid levels
• S IRON concentration
• Bone marrow studies
• Sickle test
• HB electrophoresis
•
The serum iron, total iron-binding capacity, and serum ferritin are the
best indicators of iron available for
erythropoiesis.
TREATMENT OF IRON DEFIECIENCY ANEMIA
• Oral iron is safe, inexpensive and effective way to administer iron-
• IFA TABLETS
• Ferrous sulfate (60 mg elemental iron)+ folic acid (500mcg )
• 2 IFA TABLETS / day
• Hb increases 3 weeks later at rate of 0.7 gm/dL/week
• Reticulocyte count is a better marker than Hb( increases within 7
days, maximum 10 days)
• If Hb increases < 1 gm % after 1 month : Inadequate Response (m/c
cause is NON COMPLIANCE )

• Alternative options in noncompliant patients :

- Change salt to ferrous fumarate ( affordable pts )
- Parentral therapy ( unaffordable pts )
• Parenteral route of iron therapy:
• indications for parenteral iron therapy are:
pt unable to tolerate oral iron ( gastritis , nausea , vomiting )
Pt suffering from inflammatory bowel disease.
ƒNon-compliant patient.
Patient near term.
Failure of oral therapy

• Parentral Iron dose in mg :

• Using Ganzani Formula acc to MOHW :
• { 24 * weight in kg * Hb deficit } + 500 mg

• Weight = pre pregnancy weight

• Hb deficit = 11-patients’ Hb
•
• Iron-dextran ( 1st generation )
(Each mL contains 50 mg of elemental iron) can be used both by
intramuscular and intravenous route. ( test dose is required )
• Iron sucrose (2nd generation )is given as an infusion. ( most
commonly used)
It is available as 5 ml vials of 20 mg/mL strength ( no test dose is
required )
Max iron sucrose / day : 200mg . Hence , only 2 vials
Max iron sucrose / week : 600mg . Hence , 3 injections given on
alternate days

• Ferric Carboxy Maltose ( 3rd generation) – Best But Expensive

•
Iron-sorbitol-citric acid complex (75 mg) is used for intramuscular
route only.
• Contra-indications of parentral iron therapy :
• 1st trimester
• Hemochromatosis
• Thalassemia major
 Side effects of parentral iron therapy
• Intramuscular injections can cause pain and staining of
• the skin at injection site, myalgia, arthralgia and may cause
• injection abscess.
• ƒƒIntravenous administration can cause pain in the vein,
• flushing, and metallic taste in mouth.
• ƒƒAllergic reactions: With intravenous iron therapy reactions
• can range from rash to anaphylaxis and death. These are
• more common with iron dextran preparation.
• ƒƒAbdominal pain with nausea and vomiting.
• ƒƒHeadache, dizziness, disorientation, seizures.
• ƒƒWheezing, dyspnea, respiratory arrest.
• ƒƒChest pain, tachycardia, vascular collapse.
• ƒƒIron toxicity presents with nausea, dizziness, and a sudden
• drop in blood pressure.
Hb <5g% at any gestational age = BLOOD
TRANSFUSION

• Blood/Packed cell transfusions: Transfusion of packed RBC is reserved

for patients with either significant acute bleeding or patients in danger
of hypoxia and or coronary insufficiency or anemia discovered at term
• Thalassemia major
• Anemia leading to heart failure
• Bone marrow failure

• 1 packed cell transfusion/day is given except in pts with

heammorhage and congestive heart failure (>1/day)

• 1 packed cell transfusion will increase Hb by 1 g%

COMPENSATORY MECHANISMS

• Increased cardiac output

• Reduced blood viscosity
• Increased 2,3 DPG in RBC
• Rightward shift of Oxygen Dissociation Curve
(ODC)
• Increased production of erythropoietin.
COMPLICATION
S
MATERNAL COMPLICATIONS FETAL COMPLICATIONS
• Heart failure at 30–32 wks • Low birthweight
• Uterine atony, APH • Intrauterine death
• PPH • Fetal acidosis
• Preeclampsia
• Preterm labor
• Infection
• Puerperal sepsis
• Uterine subinvolution
• Pulmonary embolism
• Puerperal venous thrombosis.
 ANESTHETIC MANAGEMENT IN CASE
OF ANEMIC PREGNANT PATIENT
Preoperative Assessement
• History of tiredness, fatiguability, breathlessness,
palpitation, angina
• Tachycardia, wide pulse pressure, ejection systolic
murmur, pallor, crepts
• Investigations:
– Complete hemogram, reticulocyte count
– Stool and urine analysis, ESR, serum creatinine,
BUN, bilirubin
• Serum proteins, iron, B12 and folate levels, TIBC, Hb
electrophoresis
• ECG for evidence of MI
• MCHC, MCV, MCH.
 GOALS OF
ANESTHESIA
• Good IV access for maintenance of intravascular volume.
Careful positioning to reduce venous pressure
• Scrupulous surgical technique.
Maintain cardiac output, avoid myocardial depression and
hypotension
Adequate FiO2 to maintain SpO2.
Maintenance of adequate oxygen carrying capacity by
using blood transfusion if needed.

• Minimize factors affecting O2 delivery

• Prevent increase in O2 consumption
• Optimize PaO2 in arterial blood.
• Adequate pre-oxygenation is essential: FRC is decreased, which may
result in rapid and significant fall inPaO2 during period of apnea. This
may not be well tolerated by a severely anemic patient.
• Minimize the reduction in cardiac output: Titrated doses of induction
agents known to have little effect on myocardial contractility.
• Decreases in cardiac output due to the high levels of spinal
anesthesia required for cesarian section may be detrimental in
patients with severe anemia. General anesthesia with careful
titration of induction agent may be preferred
• Avoid hyperventilation, hypovolemia, hypothermia, acidosis and of
peripheral pooling of blood due to adverse posturing.
• Optimal blood replacement with goals of transfusion to achieve Hb >
7–8 g/dL (or HbA > 40% of the total Hb in
case of abnormal Hb).
• Avoid or vigorously treat the conditions, which increase oxygen
demand, such as shivering or fever.
• Nitrous oxide should be used with caution in patients with folate and
vitamin B12 deficiency.
 CHOICE OF ANESTHESIA
REGIONAL ANESTHESIA preferred (SAB/CSE) as:
– Good analgesia
– Ability to provide supplemental O2
– Reduce blood loss
– Reduce DVT.
• Disadvantages of regional anesthesia:
– Hypotension and hemodilution
– Chance of pulmonary edema due to overload
• Avoided in B 12 deficiency with CNS symptoms as it worsens
subacute degeneration of cord.
Monitoring
• ECG, SpO2, NIBP, ETCO2, temperature, urine output
• IBP, CVP in unstable patients
• PA catheter and mixed venous oxygen saturation helpful
• Serial Hb and HCT when major blood loss anticipated.
 ANESTHETIC CONSIDERATIONS
• Avoidance of hypoxia:
– Preoxygenate with 100% O2 for 3–5 mins or 4 vital capacity breaths
– High FiO2 (40–50%) intraoperatively
– Spontaneous ventilation used only for short surgeries
– Difficult airway anticipation
– Avoid conditions increasing O2 consumption:
- Shivering
- Fever
- Acute blood loss
- Pain
- Light planes.
• Minimize anesthesia induced oxygenation changes:
– N2O used cautiously in B12 and folate deficiency
– Avoid hypoventilation to minimize alkalosis
– Avoid hypoventilation to avoid acidosis
– Titrate induction agents to prevent hypotension
– Careful and slow positioning to avoid hypotension
– Left lateral tilt beyond 28 wks
– Avoid hypothermia
Hypotension Prophylaxis
• Administration of fluids before the administration ofregional anesthesia
• Left uterine displacement
• Administration of a prophylactic vasopressor

Vasopressors: Phenylephrine bolus 50–100 µg intravenously may be

associated with a lower incidence of intraoperative nausea and vomiting,
and higher umbilical artery pH and base excess; compared with
ephedrine. However, the difference
in pH is small and unlikely to be clinically relevant in low risk deliveries.
It may be more useful in patients undergoing emergency LSCS for fetal
distress.
Epidural Anesthesia: It is possible to extend the block by giving ‘top-up’
dose of local anesthetic agents to a patient having indwelling epidural
catheter inserted for labor analgesia. Additional (5-mL boluses of 2%
lidocaine + 1:400,000
epinephrine or 5-mL boluses of 0.5% bupivacaine or 0.5% ropivacaine
may be given to attain motor blockade and sensory level of T4, for
surgical procedures.
 Blood transfusion:
• – Hb >10 g%: Rarely indicated
• – Hb < 6 gm%: Always indicated
• – Hb 7–9 gm%: Decision based on:
• - Ongoing blood loss
• - Coexisting disease
• - Threat of bleeding.
 Indications of blood transfusion in pregnancy with IDA

Antepartum period Intrapartum period Post partum period

1. Pregnancy < 36 weeks
a. Hb < 4 g/dL with or without
signs of cardiac failure or
hypoxia
b. 5–7 g/dL with presence of
impending heart
a. Hb < 7 g/dL[in labor]
failure,hemodynamic instability a. Anemia with signs of
[Decision of blood transfusion
or acute hemorrhage shock/acute hemorrhage with
depends on medical history or
2. Pregnancy > 36 weeks signs of hemodynamic
symptoms]
a. Hb < 7 g/dL even without instability
b. Severe anemia with
signs of cardiac failure or b. Hb < 7gm %:Decision of
decompensation or acute
hypoxia transfusion depends on medical
hemorrhage with
b. Severe anemia with history or symptoms
decompensation
decompensation or acute
hemorrhage with
decompensation
c. Hemoglobinopathy/Bone
marrow failure syndromes or
General Anesthesia (GA)
•
Indications:
• Maternal refusal of regional anesthesia,
• fetaldistress in the absence of preexisting epidural
catheter
• failedregional anesthesia,
• significant coagulopathy,
• acute maternal hypovolemia
• Conduct of GA includes:
• ƒƒH2 receptor antagonist or proton pump inhibitor and/or
• metoclopramide intravenously.
• ƒƒClear antacid orally.
• ƒƒLeft uterine displacement.
• ƒƒApplication of monitors.
• ƒƒDenitrogenation (administration of 100% oxygen)
• ƒƒIntravenous induction: Thiobarbiturate, 5–7 mg/kg,
• propofol 2 mg/kg and succinylcholine 1–2 mg/kg OR
• rocuronium 0.6–1.2 mg/kg.
• ƒƒIntubation with a 6.0- to 7.0-mm cuffed endotracheal tube.
• ƒƒPreparedness for difficult intubation is always mandatory.
• ƒƒNondepolarizing neuromuscular blocking agent.
• ƒƒintermittent positive pressure ventilation using 30 to 50%
• nitrous oxide in oxygen and a low concentration (e.g.
• 0.5 minimum alveolar concentration [MAC]) of a volatile
• halogenated agent.
• ƒƒAfter delivery of the fetus, concentration of nitrous oxide
• can be increased, with or without a low concentration of a
• volatile halogenated agent; and opioids (Fentanyl 2 mcg/
• kg) can be administered.
• ƒƒPatient should be extubated once wide awake.
LIMITATIONS OF GENERAL
ANAESTHESIA
• Gravid Uterus = Full Stomach
• Increased Heartburn
• Increased Acid Reflux WORSEN GASTRIC
ACIDITY
• Increase In Intragastric Pressure
• Decrease In Gastroesophageal Angle
• Placental Gastrin secretion Is Increased

• Increased Basal Metabolic Rate And Oxygen

Consumption – ACCELERATED STARVATION
Failed Intubation More Common During
Pregnancy
• capillary engorgement and edema of the upper airway -
Upper airway obstruction and bleeding more likely and
may make tracheal intubation more difficult.

• The increase in chest diameter and enlarged breasts

can make laryngoscopy with a standard Macintosh
blade difficult –instead use POLIO BLADE / Magboul
Laryngoscope

POLIO BLADE
Magboul Laryngoscope
Sickle-cell Disease
Complications:
– Increased preterm labor
– Abruption, placenta previa
– Pregnancy-induced hypertension.
• GA/RA acceptable
• Avoid factors predisposing sickling
• – Hypoxemia
• – Hypovolemia
• – Hypotension
• – Acidosis
• – Hypoventilation
• – Hypothermia
• – Light planes.
• Thalassemia
• Chronic anemia causes tissue hypoxia
• Multiple transfusion: Hemosiderosis and heart
failure
• Concomitant difficult airway due to abnormal
facies.
References
• Williams textbook of Obstretics 26th edition
• Tandon R, Jain A, Malhotra P. Management of Iron Deficiency Anemia in
Pregnancy in India. Indian J Hematol Blood Transfus. 2018 Apr;34(2):204-215.
doi: 10.1007/s12288-018-0949-6. Epub 2018 Mar 14. PMID: 29622861; PMCID:
PMC5885006.
• Anaesthesia Review : Kaushik J 2nd edition
• Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL,
Quinn AC; Obstetric Anaesthetists' Association; Difficult Airway Society.
Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for
the management of difficult and failed tracheal intubation in obstetrics.
Anaesthesia. 2015 Nov;70(11):1286-306. doi: 10.1111/anae.13260. PMID:
26449292; PMCID: PMC4606761
• Objective Anaesthesia : Tata 5th edition
THANK YOU !