Agus AbadiAgus AbadiDivisi Kedokteran FetomaternalDivisi Kedokteran FetomaternalBagian Obstetri dan GinekologiBagian Obstetri dan Ginekologi

RSU. Dr. Soetomo SurabayaRSU. Dr. Soetomo Surabaya

DAMPAK ANEMIA DAMPAK ANEMIA TERHADAP KEHAMILAN, TERHADAP KEHAMILAN,

PERSALINAN DAN PERSALINAN DAN OUTCOME PERINATALOUTCOME PERINATAL

DEFINISI ANEMIADEFINISI ANEMIA

REKOMENDASI WHOREKOMENDASI WHO

1.1. Non Pregnant - Hb. < 12.0 Non Pregnant - Hb. < 12.0 g/dl.g/dl.

2.2. Pregnant - Hb. < 11.0 g/dlPregnant - Hb. < 11.0 g/dl

3.3. Post partum – Hb. < 10 g/dlPost partum – Hb. < 10 g/dl

Pregnancy related changes in maternal blood volume (L)Total Blood, Plasma and Erythrocyte Value

( From Longo LD et al. 1999 )

Gest. Age in weeks

Vol. (L)

8.0

6.0

4.0

2.0

0 10 20 30 40

Total Blood Volume

Plasma Volume

Erythrocyte Volume

Haemoglobin ( gr/dl ) during pregnancy

( From CDC – 1989 )Hb

GESTATIONAL AGE (Weeks)

14

13

12

11

10

10 12 16 20 24 28 32 36 40 42

CHANGE IN HEMATOLOGICAL PARAMETERS DURING PREGNANCY

PARAMETERS NONPREGNANT PREGNANT

TOTAL BLOOD VOLUME 4000 ml 5200 ml

PLASMA VOLUME 2600 ml 3500 ml

ERYTHROCYTE VOLUME 1400 ml 1700 ml

HAEMOGLOBIN 12-16g/dl 11,5-13g/dl

HEMATOCRYT 37-44 % 34-41 %

( From Ramsay, 1999 )

COURSE OF HB VALUES IN HEALTHY PUERPERIUM DURING 14 DAYS ( From Richters, 1995 )

13.5

13.0

12.5

12.0

11.5

11.0

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Hb

Days PP

THE PREVALENCE ANEMIA DURING PREGNANCY

≥ 80% Hb. ≥ 8 gr/dl

20% Hb. < 8 gr/dl

2-7% Hb. < 7 gr/dl

1. RISK OF ABNORMAL COURSE OF PREGNANCY AND DELIVERY2. RISK OF MATERNAL INFECTION AND BLEEDING TENDENCIES3. INCREASE MATERNAL AND INFANT MORBIDITY AND MORTALITY

GENERAL CONSEQUENCES OF ANEMIA DURING PREGNANCY

95 % OF ANEMIA DURING PREGNANCY

IRON DEFICIENCY

IRON DEFICIENCY IRON DEFICIENCY

ETIOLOGI :ETIOLOGI :

- INTAKE KURANG- INTAKE KURANG

- INFEKSI PARASIT- INFEKSI PARASIT

- INTERVAL KEHAMILAN PENDEK- INTERVAL KEHAMILAN PENDEK

SERING TERJADI PADASERING TERJADI PADATRIMESTER II & IIITRIMESTER II & III

IRON DEFICIENCY IRON DEFICIENCY

DI NEGARA SEDANG BERKEMBANG

KEKURANGANPROTEIN HEWANIDAN VITAMIN C

JAGUNGGANDUM

FE (HIGH BIOAVAILABILITY )

MENURUN

ABSORBSI FE MENURUN

PHYTAT & POLYPHENOL

SISTIM APOFERRITIN DAN FERRITINDIDALAM HEPAR

PENYANGGA KADAR FE DAN SEBAGAI MEDIA

PENYIMPANAN CADANGAN FE

STADIUM DEFISIENSI BESISTADIUM DEFISIENSI BESI

DEFINISI DAN KLASIFIKASI

IRON DEFICIENCY

ABSOLUTE IRON DEFICIENCY

LATENT IRON DEFICIENSI

IRON DEFICIENSI ANEMIA

FERRITIN < 15 µg/L

FERRITIN < 15 µg/LHb > 11 g/dL (WHO)

FERRITIN < 15 µg/LHb < 11 g/dL (WHO)

1st TRIMESTER : Hb > 11 g/dL2nd TRIMESTER : Hb > 10,5 g/dL3rd TRIMESTER : Hb > 11 g/dL

1st TRIMESTER : Hb < 11 g/dL2nd TRIMESTER : Hb < 10,5 g/dL3rd TRIMESTER : Hb < 11 g/dL

(HUCH & BREYMANN 2005)

RISK OF IRON DEFICIENCY ANEMIA

DURING PREGNANCY

FATIGUEDECREASE OF PHYSICAL FITNESS

CARDIOVACULAR SYMPTOMPREDISPOSING TO INFECTION RISK OF PERIPARTUM BLOOD

LOSSRISK OF IMPAIRED WOUND

HEALING

MATERNAL RISK

PRETERM BIRTHIUGRIUFD

RISK OF IRON DEFICIENCY

ANEMIADURING PREGNANCY

FETAL RISKIF MATERNAL Hb < 9 g/dl

EFFECT ON THE PLACENTA

CHRONIC HYPOXIA INDUCE COMPENSATORY PLACENTAL MECHANISM ESPECIALLY ON ANGIOGENESIS.

FINALLY THE RELATIONSHIP BETWEEN PLACENTA AND FETAL GROWTH INFLUENCES THE RISK OF DEVELOPING

VARIOUS DISORDERS IN ADULTHOOD SUCH AS CARDIOVASCULAR DESEASES AND DIABETES MELLITUS

( BAKER HYPOTHESIS)

1. INCIDENCE OF IUGR 2X AT Hb. < 9 gr/dl

2. IUFD 3X AT Hb. < 8 gr/dl

3. RISK OF PRETERM BIRTH 60% AT Hb. < 9 gr/dl

4. ANEMIA ASSOCIATED WITH RR FOR PRETRM BIRTH OF 2,7 AND SMALL FOR GESTATIONAL AGE OF 3,5

5. ANEMIA ASSOCIATED WITH AN ODDS-RATIO OF 1,8 FOR PRETERM BIRTH BETWEEN 28-32 WEEKS.

6. IUGR AT Hb. < 8,5 gr/dl OR FERRITIN < 10 µg/l

ASSOCIATION BETWEEN HAEMOGLOBIN LEVELS AND

FETAL RISK ACCORDING TO VAROUS AUTHORS

Diagnosa laboratoriumDiagnosa laboratorium

HemoglobinHemoglobinHematokrit Hematokrit MCVMCVSerum FeritinSerum Feritin Serum Iron/TIBC: Tranferrin SaturationSerum Iron/TIBC: Tranferrin SaturationC-Reactive Protein (CRP)C-Reactive Protein (CRP)

SIMPLE FLOW-CHART USED TO RULE OUT OR DIAGNOSIS IRON DEFICIENCY ANEMIA

ANEMIA IN PREGNANCY

FERRITIN< 15 µg/L FERRITIN & CRP NORMAL

FERRITIN N OR ELEVATED

CRP ELEVATED

IRON DEF. ANEMIA

ORAL IRON 80-120 mg/day

RETICULOCYTOSISHB INCREASE ?

YES NO

TX. CONTINUEFOLLOW UP

FERRITIN

FURTHERINVESTGATION

MACROCYTOSIS MICROCYTOSIS

BI2/FOLIC A. DEFICIENCY

THALLASEMIA

Tx. BI2/FOLIC A.

HB ELECTROPH.

ß THALLASEMIA

FERRITIN< 15 µg/L

ORAL FE 80 mgTwice daily

ANEMIA ASSOCIATED WITH INFECTION

(FEVER LEUKOCYTOSIS)

FURTHERINVESTGATION

( BREYMANN, 2003 )

POLA TERAPIPOLA TERAPI

Oral therapyOral therapy Parenteral administration by IM routeParenteral administration by IM route Intravenous routeIntravenous route Blood TransfusionBlood Transfusion Recombinant Human ErythropoietinRecombinant Human Erythropoietin

KOREKSI CADANGAN BESI DAN KOREKSI CADANGAN BESI DAN MASSA HEMOGLOBINMASSA HEMOGLOBIN

TUJUAN

Fe-Oral Fe-Oral TherapyTherapy

Respons optimal : 200 mg elemental iron per hariRespons optimal : 200 mg elemental iron per hari Absorbsi > baik bila perut kosong, tetapi iritasi Absorbsi > baik bila perut kosong, tetapi iritasi

meningkatmeningkat Bila sesudah makan absorbsi berkurang 40 – 50 %Bila sesudah makan absorbsi berkurang 40 – 50 %

ADVERSE EFFECTS ADVERSE EFFECTS - Diarrhea - Diarrhea - ConstipationConstipation- Heart burn - Nausea - Heart burn - Nausea - Stomach pain - Dark - Stomach pain - Dark StoolsStools

Fe- IM Fe- IM RoutesRoutes

Iron DextranIron Gluconate Iron Hydroxide Sorbitol

Irregular AbsorbtionIM injection----- painful

ADVERSE EFFECTS

StainingTissue ToxicityFeverUrticariaAnaphylaxis

Iron Deficiency Anemia Iron Deficiency Anemia during pregnancyduring pregnancy Anemia caused by PPHAnemia caused by PPH Post Operatives Anemia Post Operatives Anemia Peri-operatives AnemiaPeri-operatives Anemia

Fe- Intravenouse Fe- Intravenouse RoutesRoutes

Fe- Intravenouse Fe- Intravenouse RoutesRoutes

POLYNUCLEAR FERRIC HYDROXIDE SACCHARATE

COMPLEX

ADVANTAGES

EffectiveHb Synthesis in 16 HrsTherapeutic Dose 3-4 mg/ KgBW

MAX : 600 mg. / Day

IRON STORAGE ASFERRITIN & TRANSFERIN

KESIMPULANKESIMPULAN

Anemia defisiensi besi pada kehamilan dan Anemia defisiensi besi pada kehamilan dan postpartum akan meningkatkan resiko tinggi postpartum akan meningkatkan resiko tinggi mortalitas & morbiditas baik pada ibu dan fetus.mortalitas & morbiditas baik pada ibu dan fetus.

Oral – Fe memerlukan waktu yang lebih lama Oral – Fe memerlukan waktu yang lebih lama untuk meningkatkan Hb dan efek samping pada untuk meningkatkan Hb dan efek samping pada GI sering terjadi.GI sering terjadi.

IV –Fe meningkatkan cadangan besi (Ferritin) IV –Fe meningkatkan cadangan besi (Ferritin) dan meningkatkan Hb lebih cepat.dan meningkatkan Hb lebih cepat.