ABNORMAL UTERINE BLEEDING-L + ANEMIA

MAGISTER FARMASI KLINIKFAULTAS FARMASI UNIVERSITAS AIRLANGGA

2016

ANA NURLAILI HIDAYAH051515153004

Ruang rawat Merak

Nama Ny. A.W

No. RM 12.39.xx.xx

Umur 48 tahun

Alamat Surabaya

Alasan MRS Pasien datang sendiri dengan keluhan perdarahanpervaginam ± 3 minggu banyak bergumpal – gumpal, lemah, pusing, sesak

Riwayat pasien • Menarche : 12 tahun siklus 28 hari lama : 7-14 hari• HpHT : 5/3/2016 (premenopause)• P3002

Diagnosa AUB-L + Anemia

Tanggal MRS 29/3/2016 jam 11.00 WIB

PROFIL PASIEN

PERJALANAN PENYAKITTanggal Uraian

Thn 2010 Nyeri haid diagnosa myoma

2010 – Feb 2016

Menstruasi normal, nyeri bisa ditahan dg lama 7 – 14 hari

Maret 2016

Nyeri, perdarahan terus – menerus

29 Maret 2016 Lemas datang ke IRD RSDS

Pemeriksaan awal :TD : 100/70 RR : 20Nadi : 80Cervical spine stabilThorax dbnKonjunctiva pucatPemeriksaan Laborat :

No Data Lab Nilai Normal 29/3

1. Hb 10,8-14,2 g/dL 3.8

2. WBC 3,7-10,1 x10^3/µl 5630

3. PLT 155-366 x10^3/µl 290000

4. HCT 37,7-53,7 % 13.8

5. RBC 3,6-4,69 x10^6/µl

6. MCV 81,1-96,0 fL 60.5

7. MCH 27,0-31,2 pg 16.7

8. MCHC 31,8-35,4 g/dL 27.5

9. PPT 9-12 detik 10.4

10. APTT 23-33 detik 20.6

11. GDA 40-121 mg/dL 106

Didapat massa ukuran 3.72x44 cmKesan : myoma uteri

Hasil USG Abdomen

Kesan :Anemia Hipokromik Anisopoikilositosis dd Anemia Defisiensi Fe+

HASIL KONSULTASI PATOLOGI KLINIK

Kesan :Anemia Hipokromik Mikrositik akibat perdarahan pervaginamSaran : diet TKTP 2100 KcalPZ 14 tpmTranfusi PRC 2 kolf/hari sampai Hb≥ 10g/dLPost tranfusi cek : BUN, SCr, GDA, SE, LPT

HASIL KONSULTASI IPD

29/3/2016

Data Klinik

No. Data KlinikTanggal

29/3 30/3 31/3 1/4 2/4

1. Suhu (oC) 36,8 36,5 37,5 36 36

2. Nadi (x/menit) 80 84 85 80 84

3. RR (x/menit) 20 20 18 18 20

4. TD (mmHg) 100/70 110/70 110/70 110/70 110/70

5. Nyeri 1 - - -

6. Perdarahan (ml) +(p.v)

±(p.v) - -

7. k/u lemah lemah lemah baik baik

8. Cair masuk (ml) 2400 2100 2500

9. Cair keluar (ml)

10. Sesak +

11. Mual/muntah - - - - -

Data LaboratNo Data Lab Nilai Normal 29/3 30/3 31/3 1/4 2/4

1. Hb 10,8-14,2 g/dL 4.2 10.5

2. WBC 3,7-10,1 x10^3/µl 6300 14000

3. PLT 155-366 x10^3/µl 327000 244000

4. HCT 37,7-53,7 % 15.4 34.5

5. RBC 3,6-4,69 x10^6/µl

6. MCV 81,1-96,0 fL 58.1 74.6

7. MCH 27,0-31,2 pg 15.8 22.6

8. MCHC 31,8-35,4 g/dL 27.2 30.4

9. PPT 9-12 detik

10. Ctrl PPT

11. APTT 23-33 detik

12. Ctrl APTT

13. GDA 40-121 mg/dL

14. GDP < 100 mg/dL

15. GD2JPP < 140 mg/dL

Data LaboratNo Data Lab Nilai Normal 29/3 31/3 1/4 2/4

16. Natrium 136-144 mmol/L

17. Kalium 3,8-5,0 mmol/L 5.1

18. Chlorida 97-103 mmol/L

19. BUN 10-20 mg/dL 11

20. S. Kreatinin 0,5-1,2 mg/dL 1.08

21. SGOT 0-35 U/L

22. SGPT 0-35 U/L

23. Asam urat 2,6 - 7,2 mg/dL

24. Trigliserid 30 - 150 mg/dL

25. CholesterolTotal ≤ 200 mg/dL

26. LDL ≤ 99 mg/dL

27. HDL 40 - 60 mg/dL

28. HbA1C 4,3 - 6,0

29. HBsAg Negatif

30. Albumin 3,4-4,8 g/dL 4.0

Data Terapi

No Obat RegimenTanggal [maret – april

2015]29 30 31 1 2

1. O2 3 Lpm NC √

2. RL 800 cc √

3. PZ 14 tpm √ √ √

4. PRC 1 kolf 2 kolf 2 kolf

5. Asam tranexamat 3x500mg (iv) √ √ √ √

6. SF 2x300mg (po) √ √ √ √

7. Parracetamol Ekstra prn √

8. OC kombinasi 4x1 tab (4 hari)

3x1 tab (3hari)

2x1 tab (2 hari)

1x1 tab (3 minggu)

OC Kombinasi yang digunakan MycroginonKandungan : EE 30 mcg & Levonorgestrel 0.15 mg

ABNORMAL UTERINE BLEEDING L

DEFINISI

AUB abnormalitas perdarahan menstrual yang meliputi jumlah, lama, dan jadwal menstruasi.

Symptom AUB : heavy menstrual bleeding (HMB), intermenstrual bleeding, atau kombinasi antara heavy and prolonged menstrual bleeding.

Spencer CP, Whitehead MI. Endometrial assessment re-visited. Br J Obstet Gynaecol 1999; 106:623.Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine

bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011 Apr;113(1):3-13

KLASIFIKASI FIGO (PALM – COEIN)

PALM (STRUCTURAL CAUSES) COEIN (NON STRUCTURAL CAUSES)

Polyp Coagulopathy

Adenomyosis Ovulatory Dysfunction

Leiomyoma Endometriosis

Malignancy & Hyperplasia Iatrogenik

Not yet classified

FISIOLOGI MENSTRUASI

Sumber : Hadi, Syamsul. Presentasi Sp II Farmasi Obat Fertilitas. Maret 2015

Unopposed Estrogen

Inhibit Vassopresin Release

Reducing vascular toneAnd vasodilatation

Increased uterine blood flow

Stimulate stromal VEGF

Distrubed angiogenesis

Excessive endometrialproliferation and hyperplasia

Dilated draining veins

Suppression spiral arterioles

Increase endometrium fragility

Falling progesterone level

Excessive blood-loss

Endometrial lysosomesrelease

Hydrolytic enzymerelease

Rupture endometrium

Activation of proinflamatory cytokineand release endometrial MMP

Prostaglandin releaseInhibit clot formation

NSAID

Livingstone dan fraser, 2002. Mechanisms of Abnormal Uterine Bleeding

Inhibit COX

(PGF2α , PGI2 dan PGE2)

PATOFISIOLOGI AUB L

Bradley, Linda D, et al. 2015. Medical Management of Abnormal Uterine Bleeding In Reproduktive Aged Women. American Journal of Obstetric and Gynecologic . Doi : 10.106/j.ajog.2015.07.044

Harold CE, Lenker DP, Sussman TP. 2005. Diseases. Philadelphia : Lipincott Williams & Wilkins.

KLASIFIKASI LEIOMYOMA

Advancing Minimally Invasive Gynecology Worldwide. AAGL Practice Report: Practice Guidelines for the Diagnosis and Management of Submucous Leiomyomas. Journal of Minimally Invasive Gynecology, Vol 19, No 2, March/April 2012.

Lasmar et al. Presurgical classification of SM myomas. J Minim Invasive Gynecol. 2005;12:308–311.

PENATALAKSANAAN AUB

DASAR PEMILIHAN TERAPI • gejala klinis• etiologi yg mendasari• harapan thd fertilitas• problem medis yang menyertai

TUJUAN TERAPI • menurunkan menstrual blood loss• mengontrol episode heavy bleeding• menurunkan urgensi intervensi pembedahan mayor

MEDICAL THERAPY• terapi hormonal• antifibrinolitik• NSAID

SURGICAL THERAPY• histeroscopy D&C• myomectomy• Histerectomy

Bradley, Linda D, et al. 2015. Medical Management of Abnormal Uterine Bleeding In Reproduktive Aged Women. American Journal of Obstetric and Gynecologic . Doi : 10.106/j.ajog.2015.07.044

Committee on Gynecologic Practice. Management of Abnomal Uterine Bleeding In Nonpregnant Reproductive-Aged Women.2013. American Journal of Obstetric and Gynecologic (4) : 557

Bradley, Linda D, et al. 2015. Medical M

anagement of Abnorm

al Uterine Bleeding In

Reproduktive Aged Wom

en. American Journal of O

bstetric and Gynecologic . Doi : 10.106/j.ajog.2015.07.044

REKOMENDASI TERAPI

PILIHAN TERAPIHORMONAL

Bradley, Linda D, et al. 2015. Medical M

anagement of Abnorm

al Uterine Bleeding In

Reproduktive Aged Wom

en. American Journal of O

bstetric and Gynecologic . Doi : 10.106/j.ajog.2015.07.044

PILIHAN TERAPIHORMONAL

Bradley, Linda D, et al. 2015. Medical Management of Abnormal Uterine Bleeding In Reproduktive Aged Women. American Journal of Obstetric and Gynecologic . Doi : 10.106/j.ajog.2015.07.044

HORMONALmedication regimen Effic

acyContraindication Side Effect Contra

ceptive

TERAPI NON HORMONAL

Bradley, Linda D, et al. 2015. Medical Management of Abnormal Uterine Bleeding In Reproduktive Aged Women. American Journal of Obstetric and Gynecologic . Doi : 10.106/j.ajog.2015.07.044

HORMONAL

medication regimen Efficacy

Contraindication Side Effect Contraceptive

EBM OC KOMBINASI sbg TERAPI AUBJudul (Author/Jurnal) Tujuan Hasil & KesimpulanOral MedroxyProgesterone Acetate and Combination Oral Contraceptive for Acute Uterine Bleeding : Randomized Control Trial(Munro et al, 2006)Obstet Gynecol. 2006;108(4):924–929.

Membandingkan efektivitas multidosis medroxyprogesteron asetat dan To compare the efficacy monophasic oral contraceptive (OC) kombinasi untuk stabilisasi hemodinamik pada wanita nongestasional dengan acute uterine bleeding.

Perdarahan berhenti dalam 3 hari selama pemberian 88% (Medroxyprogesterone acetate) dan 76% (OC kombinasi) ketika diberikan terapi AUB akut untuk stabilitas Kedua regimen efektif dan ditoeransi dengan baik.

Efective treatment of Heavy Menstrual Bleeding with Estradiol Valerate and Dienogest : randomized controlled trial(Jensen et al, 2011)Obstet Gynecol. 117(4) : 777-787

Menilai efektivitas dari estradiol (E2) valerate dan dienogest pada wanita dengan heavy menstrual bleeding, prolonged menstrual bleeding, atau heavy and prolonged menstrual bleeding tanpa kondisi patologis

Pemberian E2 valerate dan dienogest sangat efektif jika dibandingkan dengan plasebo pada terapi wanita dengan heavy menstrual bleeding, prolonged menstrual bleeding, atau heavy and prolonged menstrual bleeding tanpa kondisi patologis

Efficacy, Safety, and Tolerability of a Monophasic Oral Contraceptive Containing Nomegestrol Acetate and 17-Estradiol A Randomized Controlled Trial(Westhoff et al, 2011)AJOG.Vol 119 No 25.May 2012

Menilai efektivitas, kontrol siklus, toleransi & keamanan dari monofasic OC kombinasi yg mengandung nomegestrol acetate dan 17- estradiol (E2) dibanding drospirenone & ethinyl E2.

Nomogestrel acetat and 17-E2 ditoleransi dengan baik & memberikan efikasi & aseptabilitas yg tinggi tolerated and provided pada kontrol siklus

EBM ASAM TRANEKSAMAT sbg TERAPI AUB

Judul (Author/Jurnal) Tujuan KonklusiEfficacy of tranexamic acid in the treatment of idiopathicand non-functional heavy menstrual bleeding: a systematicReview(Naoulou & Tsai, 2011)AOGS

Mengevaluasi efektivitas asam traneksamat untuk terapi HMB idiopatik & non fungsional

Indikasi evidensi terapi asam traneksamat efektif & aman serta potensial meningkatkan QoL pada HMB diopatik dan non fungsional

TERAPI AUB PADA PASIEN

Data KlinikTanggal

29/3 30/3 31/3 1/4 2/4

Perdarahan (ml) +(p.v)

±(p.v) - -

No Obat RegimenTanggal [maret – april

2015]29 30 31 1 2

4. Asam tranexamat 3x500mg (iv) √ √ √ √

7. OC kombinasi 4x1 tab (4 hari) √ √ √ √

3x1 tab (3 hari) √

2x1 tab (2 hari)

1x1 tab (3 minggu)

KESIMPULAN

• Pemberian Multidose Monofasic OC Kombinasi sbg Terapi Hormonal AUB L TEPAT

• Pemberian Asam Traneksamat sebagai agen Antifibrinolitik pada terapi AUB TEPAT

Hypochromic Anemia

DEFINISI Penurunan konsentrasi hemoglobin normal sehingga mengakibatkan kapasitas penghantaran oksigen darah menurun (Wells et al, 2009)

RCH. Clinical Practice Guidelines. Anaemia. The Royal Children's Hospital, Melbourne.

KLASIFIKASI ANEMIA

ETIOLOGI

( Am Fam Physician. 2013;87(2):98-104. Copyright © 2013 American Academy of Family Physicians.)

TRANFUSI PRC

Tranfusi PRC meningkatkan kapasitas penghantaran oksigen darah ketika tjd anemia akut/kronik.

Handbook of Tranfusion Medicines. United Kingdom Blood Services 4th edition

MANAJEMEN ANEMIA

Laju & Waktu Tranfusi pd Pasien Dewasa Berdasar : kondisi individualGunakan infusion pump yg sesuai

PRC• Tranfusi cepat (5-10 menit/kolf) major haemorrage• Pasien lansia beresiko overload sirkulasi infusi diperlambat• Pemberian PRC scr aman pd kondisi pasien stabil 90 menit/kolfTranfusi tiap kolf tdk boleh > 4 jam

Handbook of Tranfusion Medicines. United Kingdom Blood Services 4th edition

ELEMENTAL IRON

( Am Fam Physician. 2013;87(2):98-104. Copyright © 2013 American Academy of Family Physicians.)

REGIMEN ELEMENETAL IRON

No Data Lab Nilai Normal 29 29 30 31 1 2

1. Hb 10,8-14,2 g/dL 3.8 4.2 10.5

4. HCT 37,7-53,7 % 13.8 15.4 34.5

5. RBC 3,6-4,69 x10^6/µl

6. MCV 81,1-96,0 fL 60.5 58.1 74.6

7. MCH 27,0-31,2 pg 16.7 15.8 22.6

8. MCHC 31,8-35,4 g/dL 27.5 27.2 30.4

TERAPI ANEMIA PADA PASIEN

No Obat RegimenTanggal [maret – april

2015]29 30 31 1 2

3. PRC 1 kolf 2 kolf 2 kolf

5. SF 2x1 tablet (po) √ √ √ √

KESIMPULAN

• Pilihan & regimentasi terapi PRC dan SF anemia TEPAT

Wells, Barbara. 2014. Pharmacotherapy principles and practice. New York : Mc Graw Hill

PROBLEM

Regimentasi OC kombinasi multidose evaluasi pemahaman aturan minum & monitoring kepatuhan pengaruh efektivitas & outcome

Terapi Hormonal monitoring kebehasilan terapi & ESO

Penggantian terapi

Surgical terapi

TERIMAKASIH

FISIOLOGI MENSTRUASI

MEKANISME KERJA OC KOMBINASI

Sumber : Hadi, Syamsul. Presentasi Sp II Farmasi Obat Fertilitas. Maret 2015

Katzung. Basic and Clinical Pharmacology 11th edition. New York : Mac Graw Hill Companies

Sifat Agen Progestasional

MEKANISME KERJA ASAM TRANEKSAMAT

Agen antifibrinolitik meningkatkan efek trombogenik (efek Anti-inhibitor koagulan)

Dana et al. 2014. Drug Informatorium Handbook 22nd edition. Maryland : Lexi Comp

PROSES ERITROPOIESIS

Wells, Barbara. 2009. Pharmacotherapy principles and practice. New York : Mc Graw Hill

Wells, Barbara. 2014. Pharmacotherapy principles and practice. New York : Mc Graw Hill

Wells, Barbara. 2014. Pharmacotherapy principles and practice. New York : Mc Graw Hill