Fluid Management in Obstetric Patients

15
Maria Grazia Frigo, Annalaura Di Pumpo
and Felice Eugenio Agrò

15.1 Physiopathology

In pregnancy, hemodynamic and cardiovascular changes occur that prevent

blood loss during delivery. In fact, there is an increase in blood volume, dur-
ing the first trimester [1]. The volume of blood continues to expand rapidly in
the second trimester before reaching a plateau in the last trimester. At the
same time, the increase in Red Blood Cell (RBC) mass occurs more slowly,
leading to a relative anemia and hemodilution [2], with the latter peaking by
30–32 weeks of gestation. Dilutional anemia is therefore common, especially
between 28 and 34 weeks gestation, when hemoglobin concentrations are low-
est. The accretion in RBC mass results in an 18–25% increase in the first
months of pregnancy, followed by a drop after childbirth due to hemorrhage
[3-5]. The increase in red cell volume provides for the extra oxygen demands
of the mother and fetus. The lower end of the normal range for hemoglobin in
pregnancy is 11–12 g/dL. These physiological responses have considerable
advantages during pregnancy: improved placental perfusion, decreased risk of
thrombosis and an adequate blood supply despite the bleeding that occurs with
childbirth [6-8].
The White Blood Cell (WBC) count increases in pregnancy beginning in
the first trimester, as a result of selective marrow erythropoiesis. This causes
a left shift, with granulocytosis and more immature white cells in the circula-
tion. The normal WBC count for pregnancy is 5000–12,000 WBC/mm3,
although values as high as 15,000 WBC/mm3 are not uncommon [9].

A. Di Pumpo ()
Postgraduate School of Anesthesia and Intensive Care, Anesthesia, Intensive Care and Pain
Management Department, University School of Medicine Campus Bio-Medico of Rome,
Rome, Italy
e-mail: annalaurad.p@live.it

F. E. Agrò (ed.), Body Fluid Management, 187

DOI: 10.1007/978-88-470-2661-2_15 © Springer-Verlag Italia 2013
188 M. G. Frigo et al.

In pregnancy, there is a decrease in the platelet count, perhaps due to

hemodilution and endothelial activation; the latter causes an increase in
platelet consumption. In response, there is an increase in immature platelets
[10-12].
Mild thrombocytopenia (100,000–150,000/mm3), which is not particularly
significant, is present in approximately 8% of pregnant women and has been
termed “gestational thrombocytopenia” [13].
Pregnancy causes alterations of coagulation and fibrinolysis. These
changes promote clotting, which acts as a defense mechanism against hemor-
rhage during childbirth [14]. Circulating levels of factors VII, VIII, IX, X, and
XII, fibrinogen and von Willibrand factor increase, factor XI decreases, and
prothrombin and factor V remain unchanged. The natural anticoagulants
antithrombin III and protein C levels are unchanged or increase, and protein S
levels fall [15]. There is a reduction in fibrinolytic activity that is mainly due
to the marked increase in the plasminogen activator inhibitors PAI-I and PAI-
2. Together, these changes increase the risk of thrombosis during pregnancy
and during the postpartum period.
A variety of physiological changes occurs during pregnancy. In the early
months, the retention of about 500 up to 900 mEq of sodium [16-18] generates
an increase in total body water from 6 to 8 L. Resistance to the pressor effects
of angiotensin II develops along with a rise in all components of the renin-
angiotensin system. This results in a large increase in the volume of extracel-
lular water (by 4–7 L) and in the retention of sodium and water, which acts to
maintain normal blood pressure [19-20]. Stroke volume and heart rate
increase. Cardiac output rises in the first trimester and then peaks by the end
of the second trimester, having reached approximately 30–50% of the non-
pregnant values (3.5–6.0L/min). The increase in cardiac output occurs rapidly
beginning at the fifth week of gestation (4.88 L/min) and continuing until the
32nd week. After birth, cardiac output decreases and is restored to normal lev-
els at 24 weeks postpartum. Between 8 and 16–20 weeks of gestation, stroke
volume increases [21-24].
Colloid osmotic pressure (COP) may also undergo changes that can affect
the well-being of the mother during pregnancy. For example, a decrease in the
plasma COP from 25 mmHg to 18–20 mmHg may cause edema.
All of these factors must be taken into account in the fluid management of
complicated obstetric patients.

15.2 Hemorrhage
Bleeding is a major cause of maternal mortality and of complications associ-
ated with childbirth [25]. In fact, a blood transfusion is required in 1–2% of
pregnancies [26-27]. In most women, however, the loss of blood is tolerated
due to the physiological changes that occur during pregnancy, as discussed
above.