Severe Anemia in Critically Ill Obstetric Patients

Abstract

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.