2. Anemia in Pregnancy Presenter: Dr. Imran Khan Moderator: Prof. Chandralekha www.anaesthesia.co.inwww.anaesthesia.co.in anaesthesia.co.in@gmail.comanaesthesia.co.in@gmail.com

3.  Definition  Classification  Hematological changes in pregnancy  Problems related to Anemia  Anaesthetic considerations

4. Definition   Anemia - insufficient Hb to carry out O 2 requirement by tissues.   WHO definition : Hb conc.  11 gm %   CDC definition : Hb conc. < 11gm % in 1 st and 3 rd trimesters and < 10.5 gm% in 2 nd 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 O 2 requirement by tissues.   WHO definition : Hb conc.  11 gm %   CDC definition : Hb conc. < 11gm % in 1 st and 3 rd trimesters and < 10.5 gm% in 2 nd 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

5. Increased mortality figures Condition Increased mortality/morbidity below hemoglobin Reference Old age <11 g/100 ml Culleton 2006 Culleton 2006 Heart valve operation <12 g/100 ml Cladellas 2006 Cladellas 2006 Heart failure <11 g/100 ml Ezekowitz 2003 Ezekowitz 2003 PTCA <10 g/100 ml Lee 2004 Lee 2004 COPD <13 g/100 ml Cote 2007 Cote 2007 Figures are consequences of the reduced oxygen transport due to anemia

6. 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

7. Magnitude of Problem  Globally, is about 30 %  In developing countries & India, incidence is around 40 – 90%.  Responsible for 40% of maternal deaths in third world countries.  Important cause of direct and indirect maternal deaths - Vitere FE Adv Exp Med Biol 1994;352:127 - Vitere FE Adv Exp Med Biol 1994;352:127  Globally, is about 30 %  In developing countries & India, incidence is around 40 – 90%.  Responsible for 40% of maternal deaths in third world countries.  Important cause of direct and indirect maternal deaths - Vitere FE Adv Exp Med Biol 1994;352:127 - Vitere FE Adv Exp Med Biol 1994;352:127

8. Relation b/w symptoms of anemia to the hemoglobin level Hemoglobin (g/100 ml) Symptoms 9-11 Slight pallor and tachycardia 7-8 More pronounced pallor, plus dyspnea on exertion 6 All the above, plus many complain of weakness 3 All the above, plus people complain of dyspnea at rest 2-2.5 All the above, plus congestive heart failure may occur Varat 1972Varat 1972 and Linman 1968Linman 1968

9. Brannon 1944Brannon 1944, Duke 1969, Roy 1963Duke 1969Roy 1963

10. 100 80 60 40 20 0 406080100 %Saturation PO 2 (mmHg) P 50  Temp, CO 2, 2-3 DPG;  pH (favors unloading) Oxygen Transport P 50  Temp, CO 2, 2-3 DPG;  pH (favors loading) Bohr Effect

11. 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

12. PROBLEMS RELATED TO ANAEMIA..  OXYGEN AVAILABLE TO TISSUES  MANNER IN WHICH BODY COMPENSATES

13. COMPENSATORY MECHANISMS  Increase in CO  Rightward shift of ODC  Decrease in blood viscosity  Increase in 2,3-DPG concentration in RBC  Release of renal erythropoietin leading to stimulation of erythroid precursors in bone marrow

14. Symptoms Irritability Fatigue Weakness Dizziness Palpitation Infection

15. Clinical Features Pallor of skin And m/m Edema Platynychia Koilonychia Platynychia Koilonychia Glossitis Stomatitis Tachycardia Soft ejection systolic murmur Signs

16. Physiological anaemia of pregnancy Acquired 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

17. 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

18. Iron Requirement Iron Absorption  1 1 Amount of iron in the body Iron Loss Skin Urine Feces Menstruation 1-2mg/d 20-30mg/c

19. Early Pregnancy 2.5 mg / day 32 to 40 weeks 6.8 mg / day TOTAL 800 – 1000 mg 20 to 32 weeks 5.5 mg / day RBC =500mg Fetus+Placenta=450mg Third stage blood loss=200mg Total = 1150mg Iron Requirement During Pregnancy

20. Laboratory Diagnosis of Anaemia IDAThalassemia Chronic Diseases Serum Iron Decreased Normal / Increased Decreased TIBCIncreasedNormal Decreased or N TransferrinSaturationDecreased N or Increased N or Decreased Serum Ferritin Decreased N or Increased N Marrow Iron Decreased / absent N or Increased N Therapeutic test with oral iron Rise in Hb No rise in Hb No rise

21. Reason For Increased Incidence Of Anemia  Poor pre-pregnancy iron balance  Improper supplementation  Repeated childbearing  Lack of awareness and illiteracy  GI infections and infestations  Poor pre-pregnancy iron balance  Improper supplementation  Repeated childbearing  Lack of awareness and illiteracy  GI infections and infestations

22. ANAESTHETIC CONSIDERATIONS  Elective LSCS -  Emergency LSCS - Blood Transfusion Not a Day before Surgery Not a Day before Surgery Fresh ( 2, 3 DPG  24 HRS. ) Fresh ( 2, 3 DPG  24 HRS. )  Chronic, Well compensated- Hb upto 8 gm%  Safe  Avoid Hypoxia ( ↑ Fi O 2 ), Maintain C V S Stability  Avoid Hypovolemia and Aortocaval Compression  Minimize - Lt. O D C Lt. O D C Hyperventilation Hyperventilation Alkalosis Alkalosis Hypothermia Hypothermia ↓ 2, 3 DPG ↓ 2, 3 DPG  Monitor- Complications like CCF & Shock

23. CHOICE OF ANAESTHETIC TECHNIQUE  Regional Anaesthesia -  Safe - Hb > 9 gm% OR 8 gm%  No Cardiac Decomp.  Avoid - Hb < 8 gm %, Hb < 8 gm %, Hemostatic Abnormalities, Hemostatic Abnormalities, Megaloblastic Anemia Megaloblastic Anemia  Precautions - Fi O 2, Low Dose L. A. + Opioid  Disadvantages - Preloading - Sympath. Block  Ppt. Hypotension - Sympath. Block  Ppt. Hypotension

24. ADVANTAGES OF REGIONAL ANAESTHESIA  Mother is aware of Child Birth  Less blood loss  Analgesia can be extended  post op period  No risk of Aspiration  No risk of Complications d/t intubation and drug induced S/E

25. EPIDURAL V/ S S.A.B.  Adv. Of Epidural - Less precipitous fall in B>P - Post Op Analgesia - Post Op Analgesia  Disadv. Of Epidural - Time Consuming - L.A Toxicity. - L.A Toxicity. - Patchy, Inadeq. Blocks - Patchy, Inadeq. Blocks  Adv of SAB. - Easy Rapid onset with High Success Rate - Small Vol. of drug  Less Toxicity - Small Vol. of drug  Less Toxicity - low dose L.A + Opioid - low dose L.A + Opioid » Less Hypotension » Less Hypotension » Intense surgical Anaesthesia. » Intense surgical Anaesthesia. » Post op analgesia » Post op analgesia - Fine bore needle  No P.D.P.H. - Fine bore needle  No P.D.P.H.

26. C. S. E.  S.A.B. - Speed of Onset - Reliability - Reliability - Low Toxicity - Low Toxicity +  Epidural Catheter - Control of Height of Block - Supplement Inadeq. Block - Supplement Inadeq. Block - Post Op Analgesia - Post Op Analgesia

27. GENERAL ANAESTHESIA  choice - If Hb = 8 gm % with cardiac decomp.. - Hb < 8 gm % - Hb < 8 gm %  Adv. - Rapid 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  Post op Ventilatory Support - Severe Anemia  Post op Ventilatory Support - No Anxiety of being Awake - No Anxiety of being Awake  Disadv. -Failed Intubation - Gastric Aspiration - Gastric Aspiration

28. G. A. TECHNIQUE  Supine with wedge under right hip  Pre oxygenation  Thio+ Sux/Roc.  Problems - 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 Ventilation

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