|Year : 2013 | Volume
| Issue : 4 | Page : 255-260
Emergency cesarean section and blood transfusions in patients with severe anemia-Our experience
Kalavala Lakshminarayana Subramanyam1, M Sree Ramachandra Murthy2
1 Department of Anaesthesiology, Government Medical College and Government General Hospital, Anantapur, India
2 Department of Anaesthesiology, Osmania Medical College and Government Maternity Hospital, Hyderabad, Andhra Pradesh, India
|Date of Web Publication||26-Nov-2013|
Kalavala Lakshminarayana Subramanyam
# 202, Rajahamsa Rainbow Apartments Aravindnagar 1st Cross, Anantapur - 515 001,Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Anemia in pregnancy is a ubiquitous problem, more so in the developing countries. Many of the changes that accompany blood loss appear later, rather than sooner, because obstetric patients are usually young fit adults with an expanded blood volume. In such cases, the needs for blood transfusions mainly depend on the clinical condition rather than the preoperative value of the hemoglobin (Hb) and blood loss. This is usually due to the tolerance of these chronic anemia patients to the accompanying blood loss.
Aim: This study was aimed to see how frequently the patients actually received blood perioperatively.
Material and Methods: This was a retrospective analysis of patients who underwent emergency cesarean sections. A total of 303 patients underwent emergency cesareans with Hb <8.5 g% over a period of 18 months in our hospital. These patients divided into three groups based on Hb status, Group I <7 g%, Group II 7-8 g%, and Group III >8 g%. Patients in each group were studied regarding the perioperative blood transfusion, any multiple units received, and complications encountered
Results: In Group I, blood transfusion done in 88% cases fell drastically to 30% in Group II and 20% in Group III. No significant complications were noted and all patients were discharged without any morbidity.
Conclusions: The lower cutoff value of Hb level for an emergency surgery remains a big enigma, which needs further evaluation. Clinical judgment in conjunction with the monitoring of tissue oxygen delivery determines the individual patient's transfusion trigger, and not the use of categorical magic number. Parturient women tend to have lower hematocrit values due to physiological changes and dilutional effect, but they still can tolerate this chronic anemia without any ill effects. This may be one of the reasons for the reduced need for blood transfusion in our study and also for the successful outcome in spite of severe anemia.
Keywords: Anemia, blood transfusion, cesarean section
|How to cite this article:|
Subramanyam KL, Murthy M S. Emergency cesarean section and blood transfusions in patients with severe anemia-Our experience. J NTR Univ Health Sci 2013;2:255-60
|How to cite this URL:|
Subramanyam KL, Murthy M S. Emergency cesarean section and blood transfusions in patients with severe anemia-Our experience. J NTR Univ Health Sci [serial online] 2013 [cited 2019 May 20];2:255-60. Available from: http://www.jdrntruhs.org/text.asp?2013/2/4/255/122161
| Introduction|| |
Anemia is perhaps the most common problem in pregnancy in developing countries. Anemia contributes to 10-15% of direct maternal deaths in India. 
Anemia is defined as a qualitative or quantitative deficiency of hemoglobin or red blood cells in circulation, resulting in a decrease in oxygen carrying capacity of blood to organs and tissues.
According to WHO, Hb level of 11 g% is considered anemic during pregnancy.
Classification: Mild: 10-10.9 g/dl
Moderate: 7-9.9 g/dl
Severe: <7 g/dl
WHO estimates indicate a 65-75% prevalence of anemia in pregnant women in India.  Nearly half of the global maternal deaths due to anemia occur in South Asian countries, 80% of which is contributed by India.  In India, Hb level of 10 g% is considered anemic by FOGSI. 
The heart delivers 2-4 times the amount of oxygen to be consumed at the tissue level. Normal oxygen delivery is approximately 1000 ml/min, and whole-body oxygen consumption is 200-300 ml/min. Oxygen consumption remains constant and is independent of delivery. The critical level of oxygen consumption is approached when Hb concentration decreases to 5 g/dl. Below this value, oxygen consumption becomes dependent on delivery. ,
The changes during pregnancy include the following: 
- Increase in cardiac output, heart rate, and stroke volume
- Decrease in systemic and pulmonary vascular resistance
- Dilutional anemia: Disproportionate increase between plasma volume and red cell mass leading to physiological anemia of pregnancy. Plasma volume increases by 40-45%. Red cell mass increases by 15-20%
- Increase in factors I, VII, VIII, and X (hypercoagulable state)
To summarize, in an anemic pregnant patient, various compensatory mechanisms get activated, as follows: ,,,
- Increase in cardiac output
- 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
Thus, although tissue oxygenation is not impaired during physiological or chronic anemia as a result of compensatory mechanisms, these may be compromised in severe or acute onset anemia, leading to serious consequences like right heart failure, angina, and tissue hypoxemia. , Clinical experience suggests that Hb levels <7 g/dl is often well-tolerated even in elderly patient. A Hb level of 6 g/dl may be appropriate for normovolemic healthy patient who sustain blood loss and for well compensated chronic patients.
Hb transfusion threshold
Transfusion threshold is the Hb value, and the Hb value should not fall below it during the perioperative period, particularly in the context of ongoing or anticipated blood loss.
ASA task force on blood component therapy (1994) states that "Transfusion is rarely indicated when the Hb conc. is >10 g/dl and almost always indicated when it is <6 g/dl. When Hb conc. is between 6 and 10 g/dl, transfusion based on patient risk for complications of inadequate oxygenation." 
There is scarcity of data regarding the need of blood transfusions in severely anemic patients posted for emergency LSCS, more so in patients coming from rural background and low socioeconomic status, where prevalence of nutritional anemia is high. We undertook this retrospective analysis to assess the course and outcome of such patients admitted into emergency obstetric ward.
The aim of our study was to evaluate the requirement of blood transfusions (if any), complications, and outcome in anemic patients with Hb level <8.5 g/dl posted for emergency cesarean sections in our hospital, where blood bank facilities are restricted.
| Materials and Methods|| |
This retrospective study was done in a government hospital that caters primarily to the rural and low socioeconomic population of the district. Most of the patients come to the hospital without proper antenatal work-up and referred to the hospital at odd hours and in emergency situations.
This study of 303 patients over a period of 18 months (July 2010 to Dec 2011) with a Hb of <8.5 g/dl were posted for emergency cesarean section.
All the patients underwent emergency cesarean section under spinal anesthesia, with oxygen supplementation of 5-6 L/min with a polymask throughout the procedure. Patients pulserate,oxygensaturation, blood pressure, ECG, and urine output were monitored.
These patients were divided into three groups: Group I (Hb <7 g%), Group II (Hb 7-8 g%), and Group III (Hb >8 g%).
Of the total 303 patients who underwent emergency LSCS, 26 patients belong to Group I, 171 patients belong to Group II and 106 patients belong to Group III [Figure 1].
We evaluated the following:
- Need for transfusions in each group
- Multiple blood unit requirement
- Any intra-operative complications encountered
- Post-op complications
- Influence of other factors viz.
- Maternal age
- Primary/repeat section
- Use of methergin
Finally, the data was compiled systematically and subjected to statistical analysis using Chi-square test. After obtaining the Chi-square values and comparing with the tabular values at 5% LOS (P = 0.05) the null hypothesis and variables were studied and interpreted for the dependency of stages and groups. P values less than 0.05 was considered significant for all comparisons.
| Results|| |
- Blood transfusion was given in 88% of Group I, 30% of Group II, and 20% of Group III patients [Figure 2].
- In Group I, the blood transfusion was done in 23 patients (88%), of which 11 patients (42%) received post-op transfusions only, 6 patients received both pre-op and post-op transfusions, and 2 patients received both intra-op and post-op transfusions [Figure 3].
- In Group II patients, the number of transfusions came down significantly to 30% (51 out of 171).
- Of the 51 patients who received transfusions, 44 patients (86%) received in the postoperative period. Multiple transfusions were given in one patient [Figure 4].
- In Group III, which consisted of 106 patients, only 20 patients (19%) received post-op transfusion and 1 patient pre-op. No one received multiple transfusions [Figure 5].
|Figure 3: Bar diagram showing frequency of blood transfusions perioperatively in Group I (Hb <7 g%)|
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|Figure 4: Bar diagram showing frequency of blood transfusions perioperatively in Group II (Hb 7-8 g)|
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|Figure 5: Bar diagram showing frequency of blood transfusions perioperatively in Group III (Hb >8 g%)|
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- In Group I, 1 patient had burst abdomen and required secondary suturing and 1 patient complained of breathlessness.
- In Group II, 4 patients complained of breathlessness and 1 patient had pedal edema.
- In Group III, 2 patients complained of breathlessness and 1 patient complained of abdominal distension
- Other minor problems include vomiting (2 patients) and cough (3 patients).
- Three patients of PIH had convulsions post-operatively, treated conservatively.
All these patients were managed conservatively
- There were no maternal deaths in any group.
- All the patients were discharged without any morbidity.
- Only 1 patient in Group II who had a Hb% of 7.6 g/dl had a fall of Hb% to 4.8 and, in spite of two transfusions, the Hb% did not improve (4 g/dl). The patient absconded in spite of the advice of hospital stay and need for further blood transfusions.
No statistical significance (Chi-Square values obtained less than the tabular values) found between maternal age (5.4375 < 9.49), primary/repeat LSCS (0.3815 < 9.49), and blood transfusions. Also, no influence of usage of injection methergin (2.7473 < 9.49) and need for blood transfusions was noted [Table 1].
|Table 1: Table Depicting Influence of Blood Transfusions on Maternal Age, Primary/Repeat Section, Use of Methergin)|
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| Discussion|| |
The anesthetic implications of anemia in pregnancy are based on the understanding of the normal and compensatory mechanisms that optimize tissue oxygenation. The main aim was to maintain a fine balance between the compensatory mechanisms and adequate tissue oxygenation in these parturient. Monitoring should aim at assessing the adequacy of perfusion and oxygenation and the magnitude of ongoing losses. Deleterious effects of chronic tissue hypoxemia along with threat of major blood losses in the perioperative period need to be anticipated and treated adequately.
Chronic anemia is better tolerated than acute anemia. In chronic anemia, cardiac output usually does not change until Hb concentration falls below 7 g/dl  Obstetric patients usually tolerate chronic anemia without significant maternal or fetal effects.
For years, anesthesiologists have believed a minimum Hb of 10 g/dl for a safe conduct of anesthesia. A better understanding of and better means of monitoring the relationship between oxygen delivery and oxygen consumption will eventually lead to a more precise delineation of the appropriate transfusion trigger. No single index can be the basis of perioperative transfusion.
Clinical judgment in conjunction with the monitoring of tissue oxygen delivery will determine the individual patient's transfusion trigger and not use categorical magic number. FDA drug bulletin 1989 states that "adequate oxygen carrying capacity can be met by a Hb of 7 g/dl or even less, when intravascular volume is adequate for perfusion.'' 
The concept of an acceptable Hb level varies with the underlying medical condition, extent of physiological compensation, the threat of bleeding, and ongoing blood losses. The main anesthetic considerations are to minimize factors interfering with oxygen delivery, prevent any increase in oxygen consumption, and optimize the partial pressure of oxygen in the arterial blood. Monitoring should focus mainly on the adequacy of perfusion and oxygenation of vital organs.  Hypoxia, hyperventilation, hypothermia, acidosis, and other conditions that shift the ODC to left should be avoided. Any decrease in cardiac output should be averted and aggressively treated.
Most of the rural Indian women has moderate to severe anemia without any clinical signs and symptoms. These women after becoming pregnant tend to still have lower hematocrit values due to physiological changes and dilutional effect, but then, they can tolerate this chronic anemia without any ill effects. This may be one of the reasons for the reduced need for blood transfusion in our study and also for the successful outcome despite severe anemia.
The decision to transfuse blood should be taken on clinical and hematological grounds. Transfusion is rarely indicated in a stable patient when Hb level is >10 g and is almost always indicated when Hb is <6 g. , In our study, we found that there was a significant increase in the blood transfusions in Group I.
If the Hb is 7-8 g in labor or in the post-partum period, the decision to transfuse should be made on an informed basis according to symptoms, coexisting medical condition, continuing blood loss, and threat of bleeding. There is little evidence of benefit of blood transfusion in asymptomatic parturient. ,, Our study showed the same as there was significant reduction in blood transfusions in Group II and Group III.
The general policy of our hospital was to wait and watch in parturients with Hb of 8 g/dl. Benefits from replenishing oxygen carrying capacity by transfusion must always be balanced against transfusion-associated risks like pulmonary oedema and immune suppression. , In a large randomized controlled trial (RCT), Hebert established that there was no difference in mortality rates between restrictive and liberal transfusion strategies in non-cardiac and critically ill patients who were able to tolerate lower levels of Hb. , Reiles and Linden  indicated in a study that the maintenance of a higher Hb concentration with RBC transfusion in an attempt to increase tissue oxygen delivery is not associated with clinical benefit, as transfusion-related increased blood viscosity can result in a reduction in blood flow and incipient cardiac failure. Also, the storage process affects the ability of RBCs to transport and deliver oxygen to the tissues, due to decreases in erythrocyte concentrations of 2, 3-DPG to 1 mol/g of Hb or less at 21 days of storage.  This point, however, remains controversial. 
After considering the various clinical data, we may conclude that low Hb level alone is not a trigger to initiate transfusion. Various physiological aspects like cardiovascular fitness, age, operative blood loss, and disease status of the parturient are important than mere relying on a single value of hemoglobin. Decision should be taken only after considering the potential clinical benefits, adverse effects, and cost of blood component therapy.
Spencer studied patients undergoing elective joint replacement surgery and found that enforcement of local transfusion algorithms reduced overall transfusion rates by half, with no adverse outcomes, and with sustained effect.  Similarly, Mallett found a 43% decrease in transfusions following the implementation of transfusion guidelines after an initial audit. 
It was appropriately pointed by Weiskopf (1998)  as we merely awaited an advance in technology that will enable us to measure directly the value of concern and thereby free us from arguments over which surrogates (e.g., Hb) to measure and what value indicates the need for augmented oxygen delivery.
A "minimum acceptable hemoglobin level" does not exist.  A healthy myocardium compensates for the low Hb or Hct levels (7-8 g/dL of Hb or 21-24% Hct) in order to optimize oxygen delivery. In patients with overt or silent episodes of myocardial ischemia (diabetic parturient), a level of <10 g/dL carries risk of decompensation. ,
Our study had some limitations. We estimated Hb% alone and not other blood indices or complete hemogram (hemoglobin value alone may not truly reflect the correct status of the patient). Also, intraoperative bedside estimation of Hb was not performed. Moreover, we used whole blood transfusion rather than packed cells/blood component therapy.
Anesthesiologist faces 1) a worried mother, 2) her critically ill fetus, and 3) an anxious obstetrician. It is not ethical to defer an emergency cesarean section, just for anemia. Perioperative management of patients with low Hb values, posted for emergency cesarean sections can be safe and effective, provided proper clinical judgment of the patient, clinical lab facility, intraoperative management, post-operative care, and back-up blood bank facilities are good.
In India, cesarean section is the most common emergency surgery that is required to be done at the district and taluq hospitals, both government and private, and severe anemia is the most common problem encountered with little assistance of blood bank facilities. The anaesthesiologist should be able to assess the condition of the patient and should not hesitate to undertake cesarean section rather than referring the patient, thereby delaying the operation and risking the lives of both the mother and child.
Despite a plethora of manuscripts in the current literature of anemia in pregnancy, comprehensive evidence is still lacking regarding the cut-off Hb value for emergency cesarean sections, probably due to heterogeneity of clinical studies, various study designs, and sample sizes.
Hence, further clinical studies in this regard are mandatory in higher centers.
Be more optimistic, as you are dealing with TWO LIVES!
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]