Severe Anemia in Critically Ill
Obstetric Patients
Kavita N. Singh and Jitendra Bhargava
Introduction
Severe anemia poses enough challenges to cure
for a clinician, and in the setting of pregnancy, it
assumes more significance as both maternal and
fetal aspects need equal considerations. It is esti-
mated that 0.070.08 % of all pregnant women
can find themselves into conditions that necessi-
tate admission in the ICU [1].
Pregnancy associated with any serious illness
including severe anemia can lead to acute organ
failures, and both situations in the critically ill
patients require special medical attention from
experts in a specialized setup to improve mater-
nal and fetal survival.
Denition of Anemia and Severity
The World Health Organization (WHO)
defines anemia in pregnancy as a hemoglobin
concentration of <11 g/dL [2]. However there
is variation in definition of normal hemoglo-
bin levels in pregnancy. Classification derived
K.N. Singh, MS, PhD (*)
Department of Obstetrics and Gynaecology,
NSCB Medical College, Jabalpur, MP, India
e-mail: drkavitasingh@rediffmail.com
J. Bhargava, MD, DTCD
Department of Pulmonary and Sleep Medicine,
NSCB Medical College, Jabalpur, MP, India
e-mail: jitendrabhargav@gmail.com
Springer India 2016
A. Gandhi et al. (eds.), Principles of Critical Care in Obstetrics: Volume II,
DOI 10.1007/978-81-322-2686-4_15
15
from an iron-supplemented population lists
the following levels as anemic: hemoglobin
(g/dL) and hematocrit (percentage) levels
below 11 g/dL and 33 %, respectively, in the
first trimester; 10.5 g/dL and 32 %, respec-
tively, in the second trimester; and 11 g/dL
and 33 %, respectively, in the third trimester
[3] (Table 15.1).
WHO defines anemia in postpartum period as
hemoglobin concentration of <10 g/dL [2]. The
Indian Council of Medical Research categorizes
severity of anemia on the basis of hemoglobin
levels as shown in Table 15.2 [4].
Prevalence of Anemia in Pregnancy
Anemia affects 1.62 billion people globally, cor-
responding to 24.8 % of the world population.
According to WHO survey, the global preva-
lence of anemia (19932005) among pregnant
women is at 42 %, that is, 56 million [5]. WHO
has estimated that the prevalence of anemia in
pregnant women is 14 % in developed countries
and 51 % in developing countries and 6575 %
in India. Anemia prevalence in rural and urban
India was found to be 32.4 and 27.3 % in the
third National Family Health Survey in 2005 and
2006 [6]. The relative prevalence of mild, mod-
erate, and severe anemia is 13 %, 57 %, and
12 % respectively in India [4].
139
15 Severe Anemia in Critically Ill Obstetric Patients 140
140
Table 15.1 Anemia classification based on hemoglobin study from India, of the 120 pregnant women,
and hematocrit
65 % had iron deficiency, 18.3 % had dimorphic
Trimester Hemoglobin g/dL Hematocrit % anemia, and 11.6 % had hemolytic anemia [7].
First <11 <33
Second <10.5 <32
Third <11 <33
Risk Factors for Development
of Anemia
Table 15.2 Anemia categories of severity [ICMR]
Iron deficiency is the major cause of anemia fol-
Anemia Hemoglobin concentration
Category severity in gram/dL lowed by folate and B12 deficiencies. In India,
1 Mild 1010.9 the prevalence of anemia is high because of (1)
2 Moderate 710 low dietary intake and poor iron (less than 20
3 Severe <7 mg/ day) and folic acid intake (less than 70
4 Very severe <4 mg/day), (2) poor bioavailability of iron (34 %
only) in phytate- and fiber-rich Indian diet, and
(3) chronic blood loss due to infection such as
Causes of Anemia in Pregnancy malaria and hookworm infestations [8]. In
addition, teenage pregnancy, short birth
Anemia is most commonly categorized by the intervals, and too many childbirths contribute to
underlying causative mechanisms: development of anemia in reproductive age
group females.
1. Decreased red blood cell production mainly
due to dietary deficiency or malabsorption
Iron deficiency Maternal Consequences of Anemia
B12 deficiency
Folate deficiency Women with chronic mild anemia may go
Bone marrow disorder or suppression through pregnancy and labor without any
Thyroid disorders adverse consequences, but those who had
Low erythropoietin levels moderate ane- mia have reduced working
2. Increased red blood cell destruction or blood capacity. Premature births are more common in
loss: acquired or inherited hemolytic anemia women with moder- ate anemia and have higher
Inherited: morbidity and mor- tality due to antepartum and
Sickle cell anemia postpartum hemorrhage, pregnancy-induced
Thalassemia major hypertension, and sepsis [ICMR 1989]. Severe
Hereditary spherocytosis anemia may be decompensated and associated
Acquired: with circulatory failure. Cardiac decompensation
Autoimmune hemolytic anemia usually occurs when Hb falls below 5.0 g/dl. The
Anemia associated with thrombocytopenic cardiac output is raised even at rest, and there is
purpura palpitations and breathlessness even at rest.
Anemia associated with hemolytic uremic Because of very low hemoglobin level, there is
syndrome tissue hypoxia and lac- tic acid accumulation,
Hemolytic anemia associated with malaria leading to circulatory fail- ure. If untreated, it
Hemorrhagic anemia may lead to pulmonary edema and death of the
patient. A blood loss of even
Iron deficiency is the most common cause, 200 ml in the third stage of labor produces shock
and even in the developed world an estimated and death. India data indicate that maternal mor-
3040 % of preschool children and pregnant bidity rates are higher in women with Hb below
women have iron depletion (WHO, 2001). In a 8.0 g/dl. Maternal mortality rates show a steep
increase when maternal hemoglobin levels fall
below 5.0 g/dl [8].
Fetal Consequences of Anemia Signs

Irrespective of maternal iron stores, the fetus
still obtains iron from maternal transferrin,
which is trapped in the placenta and which, in
turn, removes and actively transports iron to the
fetus. Gradually, however, such fetuses tend to
have decreased iron stores due to depletion of
maternal stores. Adverse perinatal outcome in
form of preterm and small-for-gestational-age
babies and increased perinatal mortality rates
have been observed in the neonates of anemic
mothers. Iron supplementation to the mother
during pregnancy improves perinatal outcome.
Mean weight, Apgar score, and hemoglobin
level 3 months after birth were significantly
greater in babies of the supplemented group
than the placebo group [9]. Most of the studies
suggest that a fall in maternal hemoglobin
below
11.0 g/dl is associated with a significant rise in
perinatal mortality rate. There is usually a two-
to threefold increase in perinatal mortality rate
when maternal hemoglobin levels fall below
8.0 g/dl and eight- to tenfold increase when
maternal hemoglobin levels fall below 5.0 g/dl.
A significant fall in birth weight due to increase
in prematurity rate and intrauterine growth
retardation has been reported when maternal
hemoglobin levels were below 8.0 g/dl [10].
There may be no signs especially in mild
anemia. Common signs that may be present are:
Pallor.
Glossitis.
Stomatitis.
Edema due to hypoproteinemia.
Soft systolic murmur can be heard in mitral
area due to hyperdynamic circulation.
Assessment of Fetal Well-Being
Maternal anemia could have a direct bearing on
childs growth and can lead to growth restric-
tions, premature rupture of membrane, increased
chances of preterm labor, and premature births,
so these aspects should be duly looked into.
Lab Diagnosis of Anemia
Lab diagnosis of anemia requires assessment of
serum iron levels, total iron-binding capacity,
serum ferritin levels, and iron and iron-binding
capacity ratio and is indicative of causative
factor (Table 15.3) [11].

Evaluation of Patients with Anemia

Clinical Features 1. Evaluation is done by assessment of hemato-
crit levels less than 33 % in the first and third
Symptoms trimesters and less than 32 % in the second
trimester.
Patients are largely asymptomatic in mild and 2. Apart from medical history, physical exami-
moderate anemia. nation; investigations like the complete blood
count, red blood cell indices, serum iron lev-
Weakness. els, and ferritin levels; and peripheral smear
Exhaustion and lassitude. exam are needed to rule out hemolytic or
Palpitation. para- sitic disease as the cause of anemia.
Dyspnea. Hemoglobin electrophoresis is useful in some
Giddiness. ethnic populations [12].
Edema and rarely. 3. To diagnose severe anemia in ICU settings,
Anasarca and even congestive cardiac failure one must look for active hemorrhage,
can occur in severe cases. persistent
Table 15.3 Lab diagnosis of anemia
Total iron-binding Iron/iron-binding
Type Serum iron level capacity (TIBC) Ferritin level capacity
Iron deficiency Decreased Increased Decreased <18 %
Thalassemia Normal Normal Normal Normal
Anemia of chronic Decreased Decreased Increased >18 %
disease

inflammatory condition like sepsis, the main

phlebotomy and increased use of blood
products, decreased or inadequate
erythropoietin level, and in some case a
combination of these, and assessment of
severe anemia should include detailed workup
of all the above conditions. In addition, coagu-
lopathy, nutritional deficiency due to critical
ill- ness, and drug-induced platelet dysfunction
due to use of aspirin or clopidogrel or a
combination of both must be kept in mind.
Mental status changes due to low oxygenation
as a result of reduced hemoglobin, radiological
assessment for search of active bleeding, and
pulmonary artery catheterization to assess
hemodynamic status and tissue oxygenation.
While testing hemoglobin level daily trends,
hydration status must be kept in mind as
volume-overloaded patients may show low
hemoglobin levels and dehydrated patients
may falsely show high levels.

Severe Anemia in Comorbid

Critical
Conditions

Anemia is a common problem in critically ill and

mostly it is due to anemia of chronic inflamma-
tion, phlebotomy, and reduced erythropoietin
lev- els. A hemoglobin level of 100 g/L (10
g/dL) is needed to be maintained in critically ill
patients. Patients who are not actively
hemorrhaging should be treated with
conservative transfusion strategy as a rule.
Anemia in patients with cardio- vascular
diseases can worsen quickly and lead to
decompensation and myocardial infarction. A
hematocrit level below 28 % and hemoglobin
level below 810 g/dL are associated with
increased mortality. Acute renal failure is
usually precipitated by hypoperfusion and/or
nephro- toxic agents; acute tubular necrosis is
pathologic event. Patients with antepartum active
hemorrhage should be considered for transfu-
sion. Aplastic anemia may occur during preg-
nancy and can disappear with delivery or
abortion.
Management: Strategy should be based on the
following principles:
1. Detection of anemia in critically ill obstetric
patients and assessment through lab markers
2. Assessment of various treatment plans and
risk-benefit analysis
3. Preparation of patient-specific plan
4. Maintenance of tissue oxygenation
5. Appropriate use of blood or blood components
6. Use of hemostatic drugs
7. Use of antifibrinolytic drugs for stopping
active bleeding
8. Use of recombinant factor VII
9. Maximum enhancement of hemoglobin level
10. Minimization of blood loss
11. Reversal of drug-induced coagulopathy
12. Prevention of anemia
Role of Iron Therapy in
Final
Outcome of Delivery
Prevalence of maternal anemia at the time of
delivery in patients who are on the weaker side
or malnourished is reduced by iron therapy, but it
is not clear whether well-nourished non-anemic
pregnant women get any benefit from iron
therapy and their perinatal outcome improves
[13]. Side effects of iron therapy usually are
gastrointestinal symptoms and do not cause any
significant mor- bidity; however patients with
hemochromatosis and with certain other genetic
disorders should be put on treatment with great
caution.
Role of Transfusion in Antepartum
or at the Time of Delivery
Indications for transfusions are few and include
severe blood loss leading to hypovolemia or sur-
gical intervention is needed for a secured deliv-
ery in patients with anemia. Only 24 % of
women who are predicted to require transfusion
actually need by the time delivery is completed
[14]. Trauma associated with surgery, placenta
previa, coagulation problems, and uterine atony
are the conditions where transfusion should be
consid- ered. Fetal conditions like abnormal
heart rate, low amniotic fluid volume, and
fetal cerebral vasodilatation in the setting of
severe maternal anemia should be treated with
maternal transfusion.
Role for erythropoietin: Oral iron prepara-
tions serve adequately in most clinical settings.
Patients who cannot tolerate oral iron and
patients with malabsorption syndrome and
severe iron deficiency anemia should receive
parenteral iron. Erythropoietin together with
parenteral iron has shown to improve hemoglo-
bin and hematocrit levels and increase reticulo-
cyte counts in 2 weeks or lesser time, but
erythropoietin alone has not shown any signifi-
cant benefit [15]. Hemorrhage remains the
leading cause of mortality during pregnancy. A
significant proportion of these women need
blood transfusion. Patients expected to have
blood loss more than 1000 ml should be admit-
ted where blood transfusion and ICU facility
are readily available [1619]. Due care about
infections related to transfusion, immunologi-
cal events like red cell alloimmunization, and
errors about incorrect blood transfusion must
be taken, and decision about choice of blood
component must be made with adequate cau-
tion. Minimizing blood loss is of paramount
importance [20].
Autologous transfusion: Hematocrit level
greater than 32 % at 32 weeks of gestation is
considered to be an indication for autologous
transfusion in high-risk case like placenta
previa but does not have the universal
consensus and also is not found to be cost-
effective as it
remains difficult to predict the future need for
transfusion [21].
Choice of Therapy
1. Oral iron should be given for hematinic
deficiencies.
2. When oral iron is not indicated, absorbed, or
tolerated, parenteral iron is indicated. Iron
dextran in single dose and iron sucrose can be
given in multiple doses.
3. Hemoglobinopathies and bone marrow fail-
ures should be treated with blood transfusion.
4. Recombinant human erythropoietin
(rHuEPO) can also be used during pregnancy
and in the postpartum period [18, 19].
5. Active management of third stage of labor is
integral to minimize blood loss [20].
6. Patients with concurrent illness and patients
on anticoagulation need optimization of their
regimens.
Prevention
1. Screening for iron deficiency anemia in all
pregnant women.
2. Universal iron supplementation to all preg-
nant women except with genetic condition
like hemochromatosis is helpful in maintain-
ing maternal iron stores and can also be help-
ful in building neonatal iron stores. It is also
useful in preventing maternal anemia at deliv-
ery and low birth weight, premature delivery,
and perinatal mortality.
3. Cooking and dietary advice: Cooking should
be encouraged in iron pots/vessels. Jaggery,
green leafy vegetables should be included in
meals. Parboiled rice and tea should be
avoided.
4. Treatment for malaria should be instituted
when required and deworming medicines
should be given if infestation is a possibility.
5. 100 mg of supplemental iron daily should be
given from second trimester onwards.
 Conclusion
Screening of all pregnant women for anemia
should be a routine part of assessment.
Women found to have iron deficiency anemia
should be treated with supplemental iron and
prenatal vitamins.
Patients with non-iron-deficiency anemia and
those with iron deficiency anemia who fail to
respond to therapy should be subjected to
deeper evaluation.
Approximately 75 % patients in the ICU suf-
fer from severe anemia.
The cause of severe anemia is multifactorial
in the ICU setting and includes active blood
loss, inflammation, nutritional deficiencies,
drug- induced coagulopathy, etc.
Tissue oxygenation, arrest of persistent
inflammation, and stopping of active bleed-
ing is key to management of severe anemia
in the ICU.
Acknowledgment Dr Rahul Rai, MD, DM, Associate
Professor of Medicine, NSCB Medical College, Jabalpur,
MP, INDIA.
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