1. ANEMIA IN PREGNANCY AND ITS ANAESTHETIC IMPLICATIONS

2. Anemia
Definition: Quantitative or qualitative reduction of Hb or circulating RBC’s 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 %

4. Normal Level Of Hb/Hct AGE Newborn Hb/Hct 16/55 1 month 3 month
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
14/45
12/36

5. WHO definition for Chronic Anemia
AGE Hb gm%
6/ yrs <10
yrs <12
Adult male <13
Non pregnant female <12
Pregnant female <11/ Hct <33
1st trimester <11
2nd trimester <10.5

6. Severity of Anemia ICMR CATEGORIES Category Severity Hb levels gm %
Mild – 10.9
Moderate – 10.0
Severe <7.0
Very severe <4.0

7. Physiological anemia of pregnancy
Blood volume ↑45%
Plasma vol ↑55%
RBC vol ↑30%
HCt ↓30%
Hb ↓

8. Physiological anemia of pregnancy
↑ in RBC mass
↑ demand for iron
↓in total body iron stores
↓in serum ferritin levels (28-32 weeks of
pregnancy)

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

10. 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.

11. 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. .

12. 0.3 0.15 Oxygen content: Volume of oxygen carried in 100ml of blood.
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) .

13. 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 (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

14. Parameters Absolute Range
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
5 – 6 L/min
O2 delivery
900 – 1100ml/min
O2 uptake
200 – 270ml/min
O2 extraction ratio
0.20 – 0.30
Normal range for oxygen transport parameters

15. 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
Anxiety
Tachycardia on exertion & ↓ pulse pressure
30-40
Syncope on sitting or standing
Tachycardia at
rest, ↑RR,
Syst. Hypoten.
>40
>2000
Confusion, shortness of breath
Marked tachycardia, Shock

16. 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

17. 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.

18. 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 ml/kg.
Prepare for intraop cell salvage if indicated.
Regional not indicated.

19. 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 patient’s 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.

20. 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.

21. 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 RBC’s.

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

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

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

25. Basal Iron 280mg Transfer to fetus 200-350mg For placenta 50-150mg
Blood loss at delievery mg
Expansion of red cell mass mg
Iron conserved by Amenorrhea mg
TOTAL REQUIREMENT mg(4-6mg/d)
Causes:
Increased iron demand
Diminished intake of iron
Disturbed metabolism
Pre-pregnancy health status
Excess demand

26. Haematological parameters:
IDA Normal values
Plasma iron < ug/dl
S.Ferritin < ug/l
TIBC > ug/dl
Transferrin saturation <15% %
MCV < fl
MCH < pg
MCHC < g/dl
RBC Protoporphyhrin > ug/dl

27. 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

28. 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.

29. 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 mg.
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.

30. 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.

31. Pregnancy <30wks
Pregnancy
30-36wks
Pregnancy >36wks
IDA FA def.
Parenteral Oral FA
I/M iron I/V iron
IDA FA
def.
Oral iron Oral FA
Intolerance or
Non-compliance
I/M iron I/V iron
Blood transfusion
PROTOCOL OF SEVERE ANEMIA IN PREGNANCY

32. Curative:
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 0.3-1gm/100ml/wk.

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

34. Advantages:
- Certainity of admission.
- Hb
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

35. 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.

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

37. BLOOD TRANSFUSION -
Transfusion triggers:
Task force 1996, 2006 – No uniform transfusion
trigger
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.

38. 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.

39. 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).

40. Anaesthetic technique:
Regional anaesthesia –
Spinal or epidural can be given
Preloading fall in hct by 20% (2lt).
Exacerbate anemia
Heart failure.
General anaesthesia –
Principle:
Avoid hypoxia.
Maintain cardiovascular stability.
Minimize factors which produce unwanted shift of O2 dissociation curve.

41. Secure 2 large bore cannulas.
Monitor SpO2,ETCO2,NIBP,temp,UO,CVP,ECG.
Induction:
Adequate preoxygenation.
I/V agents administered slowly.
Maintenance:
Ventilation should be maintained to provide normocapnia.
Possibility of awareness is to be kept in mind as O2 conc. is increased.
Mild tachycardia & wide pulse pressure may be physiological obtunded by anaesthetic agents.
Tissue perfusion judged by blanching ear lobes, nose.
Change posture cautiously ↓ BP & CO.

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

43. 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.

44. Sickle cell Anemia
Valine substituted for glutamic acid at 6th position on ß 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%, 40-60% HbA.
Very low
Hb (g/dl)
6 - 9
13 -15
9 - 12
Life expectancy
30 yrs
normal
Slightly ↓
Propensity for sickling
++++
+ (O2 falls < 40%) ++

46. Signs & symtoms of sickle cell disease:
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
Complications related to hemolysis
a) Anemia (Hct 15 – 30%)
b) Cholelithiasis
c) Acute aplastic episodes

47. 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)

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

49. 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 RBC’s 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

50. 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.

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

52. Thalassaemia
Quantitative abnormalities of polypeptide globin chain synthesis.
Type Hb
Hb electrophoresis
Clinical syndrome
α-thalassaemia
1.Hydrops foetalis
(deletion of 4 α-genes)
3-10g/dl
Hb Barts(100%)
Fatal in utero or in early infancy
2.HbH disease (deletion of 3 α-genes)
2-12g/dl
HbH (2%), rest HbA,HbA2,HbF
Hemolytic anemia
3.α-thalassaemia trait (deletion of 2 α-genes)
10-14g/dl
normal
Microcytic hypochromic bloood picture but no anemia

53. Type Hb
Hb-electrophoresis
Clinical syndrome
ß-thallassaemias
1. ß-thallassaemias
Major (Cooley’s anemia)
<5g/dl
HbA(0-50%)
HbF(50-98)
Severe cong. Hemolytic anemia,requ BT
2. ß-thallassaemias
Intermedia
5-10g/dl
Variable
Severe anemia but no regular BT
3. ß-thallassaemias
minor
10-12g/dl
HbA2(4-9%)
HbF(1-5)
Usually asymptomatic

54. 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.

55. Oxygen Cascade Dry atmospheric air PO2 = 159 mmHg PO2= PB x FiO2,
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

56. 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.

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

58. 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
Severe hypoxemia in 7-8 Min.

59. ↓FRC (15-20%) +↑O2 Consumption(20-40%)
Pregnant patients-
↓FRC (15-20%) +↑O2 Consumption(20-40%)
Rapid desaturation during period of apnea
Preoxygenation for Min.

60. References Obstetric Anesthesia- Principles and practice David H
Chestnut 3rd edition
2. Anaesthesia & Co-existing diseases-Stoelting.
3. Miller’s Anesthesia- Ronald D. Miller 6th edition.
4. Short Practice of Anaesthesia – Churchill Davidson.
5. Textbook of obstetrics- DC Dutta.
6. The ICU book – Paul. L. Marino.
7. Text book of Pathology – Robbins.

61. Thank you