Download - Anemia Dalam Kehamilan
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.