DAMPAK ANEMIA TERHADAP KEHAMILAN, PERSALINAN DAN OUTCOME PERINATAL
Agus Abadi Divisi Kedokteran Fetomaternal Bagian Obstetri dan Ginekologi RSU. Dr. Soetomo Surabaya
DEFINISI ANEMIA l
REKOMENDASI WHO
Non Pregnant - Hb. < 12.0 g/dl. 2. Pregnant - Hb. < 11.0 g/dl 3. Post partum – Hb. < 10 g/dl 1.
AKIBAT ANEMIA l Penurunan
kapasitas transport O2 l Risiko terjadinya hipoksia jaringan l Gangguan dari fungsi organ dan metabolisme (O2 dependent metab.)
ADAPTASI l Peningkatan
Cardiac Output (Heart Rate) l Hypoxia Induce Vasodilatation l Peningkatan perfusi jaringan l Redistribusi darah pada organ vital l Peningkatan Resp. Minute Volume l Peningkatan A-V O2 Gradient l Erythropoetin Release
Total Blood Volume 8.0
Plasma Volume Erythrocyte Volume
Vol. (L) 6.0 4.0 2.0 0
10
20
30 40 Gest. Age in weeks
Pregnancy related chages in maternal blood volume (L) Total Blood, Plasma and Erythrocyte Value ( From Longo LD et al. 1999 )
14 Haemoglobin ( gr/dl ) during pregnancy ( From CDC – 1989 )
13
Hb
12 11 10 10
12
16
20
24
28
32
36
40
GESTATIONAL AGE (Weeks)
42
Low Limit of Normal ( 5th Percentile ) For Hb and Hct during Pregnancy From CDC - 1989 Gestational Age ( Weeks )
12
16
5th Percentile of Hb
11.0 10.6
5th Percentile of Hct
33
32
20
24
28
32
10.5
10.5
10.7 11.0
32
32
32
33
36
40
11.4
11.9
34
36
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 )
13.5 Hb
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 Days PP
COURSE OF HB VALUES IN HEALTHY PUERPERIUM DURING 14 DAYS ( From Richters, 1995 )
CHANGES IN ERYTHROCYTE COUNT, HB AND HCT IN NORMAL FETUSES ( From Forestier et al. 1991 )
GEST.AGE ( Weeks )
ERY COUNT ( 1000.000/dl)
HEMOGLOBIN (g/dl)
HEMATOCRYT (%)
18-21
2,85
11,69
37,3
22-25
3,09
12,2
38,59
26-29
3,46
12,91
40,88
=30
3,82
13,64
43,55
95 % OF ANEMIA DURING PREGNANCY
IRON DEFICIENCY ANEMIA
THE PREVALENCE ANEMIA DURING PREGNANCY
= 80%
Hb. = 8 gr/dl
20%
Hb. < 8 gr/dl
2-7%
Hb. < 7 gr/dl
GENERAL CONSEQUENCES OF ANEMIA DURING PREGNANCY
1. RISK OF ABNORMAL COURSE OF PREGNANCY 2. RISK OF MATERNAL INFECTION AND BLEEDING TENDENCIES 3. INCREASE MATERNAL AND INFANT MORBIDITY AND MORTALITY
CLINICAL CONSEQUENCES
1. FATIGUE, EXHAUSTION, WEAKNESS, LESS OF ENERGY 2. CARDIOVASCULAR SYMPTOM - TACHYCARDIA - HYPOTENSION - CARDIAC HYPERTROPHY IN CHRONIC CASES 3. PALLOR ( PALE OF MUCOUS MEMBRANE OF CONJUNCTIVAE )
IRON DEFICIENCY ANEMIA l l l
TRIMESTER II & III KEBUTUHAN FE SELAMA KEHAMILAN 1000 MG ETIOLOGI : - INTAKE KURANG - INFEKSI PARASIT - INTERVAL KEHAMILAN PENDEK
NEGARA SEDANG BERKEMBANG
KEKURANGAN PROTEIN HEWANI DAN VITAMIN C JAGUNG GANDUM
BIOAVAILABILITY FE MENURUN
ABSORBSI FE MENURUN
RISK OF IRON DEFICIENCY ANEMIA DURING PREGNANCY
MATERNAL RISK FATIGUE, DECREASE OF PHYSICAL FITNESS CARDIOVACULAR SYMPTOM, PREDISPOSING TO INFECTION, RISK OF PERIPARTUM BLOOD LOSS, RISK OF IMPAIRED WOUND HEALING
FOETAL RISK ( IF MATERNAL Hb < 9 gr/dl ) PRETERM BIRTH IUGR IUFD
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
ASSOCIATION BETWEEN HAEMOGLOBIN LEVELS AND FETAL RISK ACCORDING TO VAROUS AUTHORS
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 ON FERRITIN < 10 µg/l
FOLIC ACID DEFICIENCY ANEMIA MEGALOBLASTIC ANEMIA RARE OCCUR IN WOMEN WITH - UNBALANCED DIET - MALABSORBTION - ALCOHOL ABUSE NO SPECIFIK EFFECT ON THE FOETUS FETAL RISK DEPEND ON THE SEVERITY OF THE ANEMIA ITSELF
VITAMINE B12 DEFICIENCY ANEMIA RARE CAUSED BY : - DEFICIENCY OF INTRINSIC FACTORS - FOLLOWING GASTRIC SURGERY - SECONDARY TO MALABSORBTION SYMPTOM : - MACROCYTIC ANEMIA - NEUROLOGICAL SYMPTOM - NO FETAL RISK
ANEMIA ASSOCIATED WITH INFLAMATORY DISORDERS ANEMIA ASSOCIATED WITH INFECTION
- Parasitic
- HIV
- Bacterial
- Crohn’s Desease
- Acute Pyelonephritis
- Ulcerative Colitis
PATOPHYSIOLOGI
1. Cytokine Mediated inhibition of hematopoesis 2. Reduce of iron to the erythrocyte from RES 3. Increase breakdown of erythrocytes ( some microorganism use iron for their enzymatic reaction )
