In a pregnant woman with severe hypoalbuminemia (<2 g/dL) or massive hemorrhage, when is intravenous albumin indicated and what is the appropriate dosing regimen?

Albumin Use in Pregnancy: Evidence-Based Recommendations

Intravenous albumin should NOT be used routinely in pregnant women for hypoalbuminemia correction alone, but has specific time-limited indications in massive obstetric hemorrhage requiring volume resuscitation and in ovarian hyperstimulation syndrome. 1, 2

Primary Recommendation for Pregnant Women

Crystalloid solutions (lactated Ringer's or normal saline) are the first-line resuscitation fluid for pregnant women with hypotension or hypovolemia. 1, 2 The 2024 International Collaboration for Transfusion Medicine Guidelines explicitly recommend against using albumin as first-line volume replacement in critically ill patients, and this applies to pregnant women as well. 1

Specific Clinical Scenarios Where Albumin May Be Considered

Massive Obstetric Hemorrhage

• After initial crystalloid resuscitation (30 mL/kg) fails to restore adequate blood pressure, albumin may be considered as a second-line adjunct while awaiting blood products. 2, 3
• Administer 5% albumin at 0.5-1.0 g/kg over 3 hours if crystalloids alone are insufficient and blood products are not immediately available. 2
• Stop albumin immediately if signs of fluid overload develop (pulmonary rales, hepatomegaly, rising jugular venous pressure) and transition to vasopressor support. 2, 4

Ovarian Hyperstimulation Syndrome

• In severe ovarian hyperstimulation syndrome with symptomatic hypovolemia, albumin 5% at 500 mL may be administered after oocyte retrieval to reduce syndrome incidence. 5, 6
• This represents one of the few pregnancy-specific indications supported by randomized trial data. 5

Regional Anesthesia for Cesarean Section

• Historical data suggested 5% albumin at 15 mL/kg before spinal anesthesia reduced maternal hypotension and improved neonatal Apgar scores compared to crystalloid. 5
• However, modern practice favors crystalloid co-loading or pre-loading (15-20 mL/kg of lactated Ringer's) as first-line, reserving albumin only for refractory hypotension. 2, 5

When Albumin is Contraindicated in Pregnancy

Hypoalbuminemia Without Specific Complications

• Do NOT administer albumin to correct low serum albumin levels alone in pregnant women with preeclampsia, malnutrition, or nephrotic syndrome. 1, 7, 4
• Even in severe preeclampsia with albumin <20 g/L, albumin infusion neither decreases blood pressure nor increases uterine blood flow. 5, 8
• Low albumin in preeclampsia is a marker of disease severity but not an independent treatment target. 8

Preeclampsia Management

• Albumin should NOT be used for volume loading before initiating antihypertensive therapy in preeclampsia, as it provides no clinical benefit. 5
• Focus on treating the underlying condition (delivery, antihypertensives, magnesium sulfate) rather than correcting albumin levels. 7, 8

Critical Safety Considerations in Pregnancy

Fluid Overload Risk

• Pregnant women with preeclampsia have increased capillary permeability, making them particularly susceptible to pulmonary edema with albumin administration. 2, 4
• Doses exceeding 87.5 g may be associated with worse outcomes due to fluid overload complications. 4

Fetal Considerations

• Albumin is not teratogenic and does not cross the placenta in significant amounts, making it relatively safe from a fetal standpoint when maternal indication exists. 5
• However, maternal hypotension or fluid overload from inappropriate albumin use can compromise uteroplacental perfusion. 5, 8

Cost and Resource Allocation

• Albumin costs approximately $130 per 25g vial, making it substantially more expensive than crystalloids without demonstrated superiority in most obstetric scenarios. 7, 4

Practical Algorithm for Pregnant Women with Hypotension

1. Identify the cause: Hemorrhage, sepsis, anaphylaxis, regional anesthesia, or preeclampsia-related. 2

2. First-line resuscitation: Administer 20-30 mL/kg of lactated Ringer's or normal saline over 5-10 minutes. 2

3. Reassess hemodynamics: Check blood pressure, heart rate, capillary refill, and urine output. 2

4. If hemorrhage continues: Activate massive transfusion protocol with packed red blood cells, fresh frozen plasma, and platelets in 1:1:1 ratio rather than albumin. 2

5. If hypotension persists after adequate crystalloid: Consider vasopressor support (phenylephrine or norepinephrine) before albumin. 2

6. Reserve albumin only for: Refractory hypotension after crystalloid failure and while awaiting blood products, or documented ovarian hyperstimulation syndrome. 2, 3, 5

Common Pitfalls to Avoid

• Do not use albumin to "support" a pregnant woman with low serum albumin from preeclampsia or malnutrition – this is ineffective and expensive. 1, 7, 8
• Do not assume albumin is superior to crystalloids for preventing hypotension during cesarean section – modern evidence supports crystalloid as first-line. 2, 5
• Do not continue albumin beyond the acute resuscitation period – its effect is transient (hours to days) and does not address underlying pathology. 4
• Do not give albumin to mobilize edema in preeclampsia – this is explicitly contraindicated and may worsen fluid overload. 1, 4