Severe Anemia in Critically Ill Obstetric Patients

  • Kavita N. Singh
  • 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 estimated that 0.07–0.08 % of all pregnant women can find themselves into the conditions that necessitate admission in the ICU. More than 75 % of patients admitted in ICU encounter anemia.

Maternal consequences of anemia: Women with chronic mild anemia may go through pregnancy and labor without any adverse consequences. Preterm birth is more common in women. Severe anemia may be decompensated and associated with circulatory failure. Cardiac decompensation usually occurs when hemoglobin falls below 8.0 g/dl. A blood loss of even 200 ml in the third stage of labor produces shock and death.

Fetal consequences of anemia: Adverse perinatal outcome in the form of preterm and small-for-gestational-age babies and increased perinatal mortality rates have been observed in the neonates of anemic mothers. Most of the studies suggest that a fall in maternal hemoglobin below 11.0 g/d1 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.

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.

Evaluation of patients with severe anemia: To diagnose severe anemia in ICU settings, one must look for active hemorrhage, persistent inflammatory condition like sepsis, 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, coagulopathy, nutritional deficiency due to critical illness, and drug-induced platelet dysfunction due to use of aspirin or clopidogrel or a combination of both must be kept in mind.

Severe anemia in comorbid critical conditions: Anemia is a common problem in critically ill and mostly it is due to anemia of chronic inflammation, phlebotomy, and reduced erythropoietin levels. 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.

Management: Strategy should include due emphasis on prevention, conservative approach in non-active bleeding cases, and transfusion in actively bleeding cases. Choice of therapy from among the options of oral iron and parenteral, blood transfusion and recombinant human erythropoietin (rHuEPO) should be made after preparing a case-specific treatment plan.

Prevention: Screening for iron deficiency anemia in all pregnant women and universal iron supplementation to all pregnant women except with genetic condition like hemochromatosis should be adopted.

Conclusion: 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 maternal and fetal survival. Blood transfusion should be given to actively bleeding patients and others should be managed conservatively. Screening of all pregnant women for anemia should be a routine part of assessment. Prevention of anemia through iron and other nutritional supplementation can play a significant role in reducing mortality and morbidity due to severe anemia during pregnancy.


Iron Deficiency Anemia Severe Anemia Oral Iron Iron Therapy Hereditary Spherocytosis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Dr Rahul Rai, MD, DM, Associate Professor of Medicine, NSCB Medical College, Jabalpur, MP, INDIA.


  1. 1.
    Irene YV, Vaneet K, et al. Critical care in obstetrics-scenario in a developing country. J Obstet Gynecol India. 2008;58(3):217–20.Google Scholar
  2. 2.
    WHO. Iron deficiency anemia: assessment, prevention and control. WHO/NHD/01.3, Geneva. 2001.Google Scholar
  3. 3.
    47(RR-3):1–36. 3 Apr 1998. 47(RR-3);1–36.
  4. 4.
    Indian Council of Medical Research. Evaluation of the National Nutritional Anemia Prophylaxis Programme. Task Force Study. New Delhi: ICMR; 1989.Google Scholar
  5. 5.
    World Health Organization. Worldwide prevalence of anaemia 1993-2005: WHO global database on anaemia. Edited by Bruno de Benoist, Erin McLean, Ines Egli and Mary Cogswell. 2008.Google Scholar
  6. 6.
    Perumal V. Reproductive risk factors assessment for anaemia among pregnant women in India using a multinomial logistic regression model. Trop Med Int Health. 2014;19(7):841–51. doi: 10.1111/tmi.12312. Epub 2014 Apr 7.CrossRefPubMedGoogle Scholar
  7. 7.
    Sinha M, Panigrahi I, Shukla J, Khanna A, Saxena R. Spectrum of anemia in pregnant Indian women and importance of antenatal screening. Indian J Pathol Microbiol. 2006;49(3):373–5.PubMedGoogle Scholar
  8. 8.
    Kalaivani K. Prevalence & consequences of anaemia in pregnancy. Indian J Med Res. 2009;130(5):627–33.PubMedGoogle Scholar
  9. 9.
    Prema K, Neela Kumari S, Ramalakshmi BA. Anaemia and adverse obstetric outcome. Nutr Rep Int. 1981;23:637–43.Google Scholar
  10. 10.
    Adebisi OY, Strayhorn G. Anemia in pregnancy and race in the United States: blacks at risk. Fam Med. 2005;37:655–62 (Level III).PubMedGoogle Scholar
  11. 11.
    Angastiniotis M, Modell B. Global epidemiology of hemoglobin disorders. Ann N Y Acad Sci. 1998;850:251–69 (Level II-3).CrossRefPubMedGoogle Scholar
  12. 12.
    Pena-Rosas JP, Viteri FE. Effects of routine oral iron supplementation with or without folic acid for women during pregnancy. Cochrane Database Syst Rev. 2006;(3);CD004736. doi: 10.1002/14651858.CD004736.pub2. (Level III).
  13. 13.
    Sherman SJ, Greenspoon JS, Nelson JM, Paul RH. Obstetric hemorrhage and blood utilization. J Reprod Med. 1993;38:929–34 (Level II-2).PubMedGoogle Scholar
  14. 14.
    Wagstrom E, Akesson A, Van Rooijen M, Larson B, Bremme K. Erythropoietin and intravenous iron therapy in postpartum anaemia. Acta Obstet Gynecol Scand. 2007;86:957–62 (Level I).CrossRefPubMedGoogle Scholar
  15. 15.
    Perez EM, Hendricks MK, Beard JL, Murray-Kolb LE, Berg A, Tomlinson M, et al. Mother-infant interactions and infant development are altered by maternal iron deficiency anemia. J Nutr. 2005;135:850–5 (Level I).PubMedGoogle Scholar
  16. 16.
    Snow CF. Laboratory diagnosis of vitamin B12 and folate deficiency: a guide for the primary care physician. Arch Intern Med. 1999;159:1289–98 (Level III).CrossRefPubMedGoogle Scholar
  17. 17.
    Bothwell TH, Charlton RW. Iron deficiency in women. Washington DC: The Nutrition Foundation; 1981 (Level III).Google Scholar
  18. 18.
    Baynes RD. Iron deficiency. In: Brock JH, Halliday JW, Pippard MJ, Powell LW, editors. Iron metabolism in health and disease. Philadelphia: W.B. Saunders; 1994. p. 189–225 (Level III).Google Scholar
  19. 19.
    Agency for Healthcare Research and Quality. Screening for iron deficiency anemia in childhood and pregnancy: update of the 1996 U.S. Preventive Task Force review. AHRQ Publication No. 06-0590-EF-1. Rockville (MD): AHRQ; 2006. (Level III).Google Scholar
  20. 20.
    Johnson-Spear MA, Yip R. Hemoglobin difference between black and white women with comparable iron status: justification for race-specific anemia criteria. Am J Clin Nutr. 1994;60:117–21 (Level III).PubMedGoogle Scholar
  21. 21.
    Etchason J, Petz L, Keeler E, Calhoun L, Kleinman S, Snider C, et al. The cost effectiveness of preoperative autologous blood donations. N Engl J Med. 1995;332:719–24 (Level III).CrossRefPubMedGoogle Scholar

Copyright information

© Springer India 2016

Authors and Affiliations

  1. 1.Department of Obstetrics and GynaecologyNSCB Medical CollegeJabalpurIndia
  2. 2.Department of Pulmonary and Sleep MedicineNSCB Medical CollegeJabalpurIndia

Personalised recommendations