Anemia in Obs-gyn

8/13/2019 Anemia in Obs-gyn

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ANEMIA IN OBSTETRI

Sulchan Sofoewan

Departement of Obstetrics and

Gynecology Faculty of MedicineGadjah Mada University


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Pendahuluan

Eropa Amerika Afrika As-teng Total

1019

4657

35.6

Prevalensi Anemia Dunia ( )

WHO, 2000


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ANEMIA IN PREGNANCY

Definition:

Non pregnant : Hb < 12g/dl

Pregnant : Hb < 10g/dl

Hb concentr lower in midpregnancy

In early and near term : 11g/dl

CDC criteria: anemia as less than 11g/dl inthe 1stand 3rdtrim, and less than 10,5g/dl

in the 2ndtrim


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PHYSIOLOGICAL ANEMIA

Fall in Hb level during pregnancy causedby a relatively greater expansion ofplasma volume compared with theincrease in Hb mass and red cell volume,called hydremia / hemodlution

The disproportion between the rates atwhich plasma and erythrocyte are added

to the maternal circulation during the 2ndtrim

The long-used term: physiological anemia


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HYDREMIA/HEMODILUTION

During 10 weeks of pregnancy to 7 day

after delivery:

Plasma : 30%

Red cells : 18%

Hb : 19%

Cause: physiological anemia


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THE ADVANTAGES OF

HYDREMIA

The need of circulation is fulfilled

To decrease the function of heart

To decrease the peripheral resistency To minimized the iron loss during

hemorrhage


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THE PREVALENCE OF ANEMIA

Pregnant women : 50.9%

Young persons : 57.1%

Child schools : 47.2% Under 5 yrs child : 40.5%


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Prevelansi

Di US: 5-10% wanita 20 to 44 th menderita defisiensibesi

Lebih tinggi, pada kelompok berisiko: Wanita hamil, apalagi berulang dengan interval pendek

Paritas tinggi Soial ekonom dan edukasi rendah

Wanita dengan riwayat menoragi

Kehamilan ganda

Diet rendah daging dan vitamin C

Donor darah lebih dari 3 kali per tahun

Adolesent

Pengguna aspirin


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Prevalensi anemia di Indonesia, 1995 (%)

Semua Wan hamil Pra sekolah

35.9

63.555.5


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THE INFLUENCES OF ANEMIA

TO THE PREGNANCY, DELIVERY

AND PUERPURIUM

To increase the morbidity and mortality ofmaternal and perinatal


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CLASSIFICATION OF ANEMIA

Iron deficiency anemia

Megaloblastic anemia

Hypoplastic anemia Hemolytic anemia


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IRON DEFICIENCY ANEMIA

Iron deficiency anemia:

The most common anemia in pregnant

women, especially in the 3rdtrim

Iron metabolisme depend on dynamic

equilibrium


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DYNAMIC EQUILIBRIUM

Influenced by:

Hb destruction

Up take of bone marrow for Hb synthesis Utilization / deposition in the tissue

Absorption in the intestine


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Fisiologi perubahan kadar

hemoglobin selama kehamilan Perubahan fisiologis volume intravaskular

Volume plasma meningkat 50-70 %

Mulai minggu ke 6, puncak ke 32, plato sampaipersalinan

Sel darah merah meningkat 20-35 %

Mulai minggu ke 12

Kenaikan vol plasma melebihi sel darah merahhemodilusi

Ameneorea dan kenaikan absorpsi besi dan folat

menaikan cadangan besi

Penurunan fisiologis kadar hemoglobin dan hematokrit

Anemia: penurunan lebih dari 2 SD


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Sumber besi

Jenis besi diet Penghambat

absorpsi

Penguat absorpsi

Heme iron Highbioavailability): daging danjeroan

Kalsium dan

mangane yang ada

dalam diet sehari-

hari

Protein sehari-hari

Nonheme iron Lowbioavailability): daun-

daunan, produk makanan

dan garam yang

difortifikasi besi,kacang-

kacangan, buncis, bayam,lobak, kentang, labu,

pisang, strawberi, cherries,

melon dll

Tanin (teh, kopi

dan coklat)

Asam fitat (biji-

bijian, kacang-

kacangan, beras)

Serat, proteinkedelai

Protein, asam amino

Asam yang mereduksi

feri ke fero: asam

askorbat (tomat dan

jeruk), asam sitrat,

malat , laktat dantartarat

Hasil fermentasi:

yoghurt


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Elemen Besi

Iron Salt Elemental Iron

Content

Required to Provide

30 mg of Iron

Ferrous sulfate 20% 150 mg

Ferrous sulfate, dry 30% 100 mg

Ferrous gluconate 12% 250 mg


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Diagnosis

Klinis: tanda dan gejala klinis

Laboratori

Hemoglobin dan hematokrit turun

Mikrositosis dan hipokromia

Feritin serum turun (


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Terapi

Tujuan: 1. koreksi hemoglobin dan cadangan besi

2. memperbaikipregnancy outcome

Sifat: preventif atau kuratif Preventive: optimasi intakebesi & suplementasi rutin besi

Kuratif: hanya diberikan pada wanita hamil dengan anemiaatau cadangan besi rendah

Women with prepregnancy ferritin levels >20 mg/L didnot have a marked decline in serum ferritin throughoutthe course of pregnancy in contrast to


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PROT BOUND IRON & TOTAL

IRON BINDING CAPACITY

Prot bound iron (BI):

90120 ug / 100ml

Total iron binding capacity (TIBC): 300360 ug / 100 ml

Iron deficiency anemia:

BI : decrease TIBC : increase


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IRON LOSS DURING DELIVERY

Newborn : 400 mg Placenta : 150 mg

Hemorrhage : 200 mg

Lactation / day : 1,5 mg Total : 750 mg

Hb: 0.245 Fe= 34 mg Fe, Iron loss during

delivery 220 g Hb or 39% from Hb levelbefore


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CAUSE OF IRON DEF ANEMIA

Decrease iron intake

Intestinal absorption disturbence

Ancylostomiasis Hemorrhage


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TX OF IRON DEF ANEMIA

60 mg Fe + 400 ug folic acid / day is better

than:

1. Folic acid only

2. Folic acid + Fe + Zn 30 ug

3. Folic acid + Fe + Zn + 11 micronutrients


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THE INFLUENCE OF

SUPLEMENTATION

To decrease the prevalence of anemia in

3rdtrim

To decrease the prevalence of anemia in 3

months after delivery

To increase ferritin in newborn

The length and Apgar score of the

newborn more higher than the placebo


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SOLVE THE ANEMIA PROBLEM

IN INDONESIA

1950 the focus efforts to the pregnant

women

1970 through the UPGK in the primary

health care

Suplementation of : Fe; Fe + folic acid and

promoting of health and nutrition,

especially to the women workers


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THE RESULTS OF EFFORTS

1996 the prevalence of iron deficiencyanemia 63,5%

Cause of fail:

Incontinuity of intake iron tabletsconsumption

Low animal protein consumption

Iron deficiency The low of role of micronutrients


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Program Penanggulangan

Anemia Ibu Hamil

Program suplementasi zat besi belum

berhasil menurunkan anemia

Rendahnya kepatuhan minum tablet besi

merupakan kendala utama

Alasan tidak patuh:

Kebanyakan lupa

Efek samping yang tidak disukai


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CAUSES OF ANEMIA DURING

PREGNANCY

Acquired

Iron-def anemia

Acute blood loss Inflammation or malignancy

Folic acid def/megaloblastic anemia

Hemolytic anemia Aplastic/hypoplastic anemia


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CAUSES OF ANEMIA DURING

PREGNANCY

Hereditary

Thalassemias

Sickle-cell hemoglobinopathies

Other hemoglobinopathies

Hereditary hemolytic anemias


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EFFECT OF ANEMIA ON

PREGNANCY

Increased risk of :

Abortion

Preterm IUGR

Stillbirth

Obstetrical hemorrhage Maternal deaths


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Efek anemia terhadap ibu

Mudah lelah

Kinerja menurun (10% vs 5%)

Stres kardiovaskular (hb dan saturasi oksgen rendah)palpitasi, sesak nafasdekompensasi jantung

Tidak tolerans thd kehilangan darahshockhemoragikMMR meningkat

Kesulitan persalinan: partus lama, partus dengantindakan

Infeksi postpartum meningkat Transfusi meningkatrisiko tertular penyakit

Muncul setelah kadar Hb turun di bawah 7-8 g/dL


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Efek terhadap janin dan neonatus

Dasar: berkurangnya pasokan oksigen ke

rahim, plasenta dan janin

Efek: Persalinan preterm, BBLR &JMDR

(Evidence: II-b)

Ibu hamil dengan defisiensi besi tidak

menaikkan risiko kelahiran janin dengan

defisiensi besi

Plasenta menyediakan cukup cadangan besi untuk

janin

Delayed cord cramping (3 menit) menaikkan


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IRON-DEFICIENCY ANEMIA The two most common causes of anemia during

pregnancy and the puerperium: iron deficiencyand acute blood loss

Associated with poor nutritional status

Maternal need for iron induced by pregnancy

average: 800 mg, about 300 mg for the fetusand placenta and about 500 mg for maternal Hbmass expansion and about 200 mg are shedthrough the gut, urine and skin

This total amount 1.000 mg exceeds the ironstores


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Continue

With the rather rapid expansion of blood

volume duing second trimester, iron

deficiency is often manifested

In the third trimester, additional iron is

needed to augment maternal Hb and for

transport to the fetus.


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DIAGNOSIS

Classical morphological evidence of irondeficiency anemia: erythrocyte hypochromia andmicrocytosis is less prominent in the pregnantwoman compared with that in the pregnant

woman

Initial evaluation of a pregnant woman withmoderate anemia should include measuremantof Hb, Hmt and red cell indices, serum iron,ferritin.

Serum ferritin


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TREATMENT OF IRON-DEF The objective of treatment:

1. correction of the deficit in Hb mass

2. restitution of iron stores

Tx: orally of ferrous sulfate , fumarate, or

gluconat, daily dose about 200 mg element iron

If can not take oral iron, parenteral Tx is given.

Transfusion only for hypovolemia from blood

loss, or an emergency operative procedure mustbe performed on a severely anemic


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Studi tentang Pemberian Besi

Ziaei S, Norrozi M, Faghihzadeh S, Jafarbegloo E: A

randomised placebo-controlled trial to determine the effect of

iron supplementation on pregnancy outcome in pregnant

women with hemoglobin 13.2 g/dl.BJOG vol 114 (6):684-8,

2007

small-for-gestational-age birth rate and the number

of women with hypertension disorder increased

significantly in the treated group in 15.7% vs

10.3%, P = 0.035, and 2.7% vs 0,8%, P = 0.05

CONCLUSIONS: Our finding proves that routine

iron supplementation in nonanemic women is not

rational and may be harmful (Evidence Ia)


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Wu Y, Weng L, Wu L (1998):

To study the efficacy of iron supplementation during

pregnancy and its influences on the outcome ofpregnancy. Preventive (Hb >11 g/dL) and treatment

(Hb


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Wu Y, Weng L, Wu L (1998):

To study the efficacy of iron supplementation during

pregnancy and its influences on the outcome ofpregnancy. Preventive (Hb >11 g/dL) and treatment

(Hb


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K Mahomed. Folate supplementation in pregnancy. The

Cochrane Database of Systematic Reviews1997, Issue 3.

Art. No.: CD000183. 83 Evidence based of routine folatesupplementation

21 studies, comparing placebo or no supplementation

increased or maintained serum folate levels & red cell folate reduction in the proportion of women with low haemoglobin level in late

pregnancy & megaloblastic erythropoiesis (odds ratio 0.65, 95%confidence interval 0.45 to 0.95).

a possible reduction in the incidence of low birthweight

have no measurable effect on any other substantive measures of

pregnancy outcome. Where there is evidence that megaloblastic anaemia in pregnancy is a

common problem, particularly in areas where malarial infection iscommon for example, routine supplementation may well be justified.

Evidence: Ia


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LG Cuervo, K Mahomed. Treatments for iron deficiency

anaemia in pregnancy. The Cochrane Database of

Systematic Reviews2001, Issue 2. Art. No.: CD003094.

Five trials, involving 1234 women

One trial (n=125) ,

Oral iron treatmenta reduction in the number of women with

hemoglobins under 11g/dl , mean hemoglobin level 11.3g/dl

compared to 10.5 g/dl (cmp to plasebo)

There were no data on clinically relevant outcomes

1 trial (n=74), the intravenous (IV) route of administration was

associated with an increased risk of venous thrombosis

Authors' conclusions

This review provides inconclusive evidence on the effects of treatingiron deficiency anaemia in pregnancy due to the shortage of good

quality trials

Evidence: Ia


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Pena-Rosas JP, Viteri FE. Effects of routine oral ironsupplementation with or without folic acid for women duringpregnancy. Cochrane Database of Systematic Reviews2006, Issue 3. Art. No.: CD004736 Evidence Ia)

Forty trials, involving 12706 women, were included in thereview

The data suggest that daily antenatal iron supplementationincreases hemoglobin levels in maternal blood bothantenatally and postnatally

Women who receive daily antenatal iron supplementation areless likely to have iron deficiency and iron-deficiency anemiaat term as defined by current cutoff values.

Side-effects and hemoconcentration are more common in

women who receive daily iron supplementation vs weekly. Very limited information related to clinical maternal and infant

outcomes was available in the included trials.

R i L G t GML C LG T t t f i


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Reveiz L, Gyte GML, Cuervo LG. Treatments for iron-

deficiency anaemia in pregnancy. Cochrane Database of

Systematic Reviews 2007, Issue 2. Art. No.: CD003094.

Randomized controlled trials comparing treatments for iron-deficiency anemia in pregnancy.

17 trials, involving 2578 women.

Oral iron in pregnancy showed a reduction in the incidence ofanaemia (one trial, 125 women; relative risk 0.38

No scientific basis to suggest that in otherwise healthy women,the benefits of treatments for mild anemia in pregnancy willoutweigh the adverse effects associated with them.

No evidence that in women with iron-deficiency anemia inpregnancy, improvement in womens hematological indicestranslate into clinical improvements for them or their children

Treatments are associated with frequent adverse effects suchas gastrointestinal disturbances and poor compliance.

Evidence: Ia


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FOLIC ACID DEFICIENCY Megaloblastic anemia/pernicious anemia

Megaloblastic anemia may havedeveloped nausea, vomiting and anorexia

Folic acid deficiency during prepregnancy

and 1sttrim is a cause of NTD Daily folic acid requirement is about 400

ug is recommended

Tx: 1 mg folic acid and a nutritious andiron


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VIT B12 DEFICIENCY

Megaloblastic anemia caused by lack of vit B12

Addisonian pernicious anemia: failure yo absorb

vit B12 because of lack of intrinsic factor

Following partial or total gastric resection Crohn disease, ileal resection and bacterial

overgrowth in the small bowel

Decrease of transcobalamin, serum B12-carrier

protein

ANEMIA CAUSED BY ACUTE


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ANEMIA CAUSED BY ACUTE

BLOOD LOSS

Early in pregnancy anemia caused byabortion, ectopic pregnancy andhydatiform mole

Trim-III of pregnancy and puerperiumanemia resulting from hemorrhage,antepartum bleeding: abruptio placentaeand placenta previa

Early post partum bleeding and late postpartum bleeding

ANEMIA ASSOCIATED WITH


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ANEMIA ASSOCIATED WITH

CHRONIC DISEASE

Chronic disease recognized as characteri:weakness, weight loss and pallor

Wide variety of disorders: chronic infection

and malignant neoplasms, hypochromicand microcytic erythrocytes

Tbc, endocarditis, osteomyelitis, SLE

Chronic renal failure, cancer andchemotherapy, HIV are most common


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CHRONIC RENAL DISEASE Chronic renal insufficiency can be accomp by

anemia, due to erythrpoietin deficiency

During pregnancy , red cell mass is augmented,

but less so than normal pregnancy

The degree of red cell expansion correspd to thedegree of renal impairment

Tx: recombinant erythropoietin used for anemia

caused by chronic renal insufficien, chronic

inflammation and malignancy


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ACQUIRED HEMOLYTIC ANEMIA 1. Autoimmune hemolytic anemia:

Due to warm-active, cold-active antibody or a

combination, classified as primary/idiopathic,

Secondary to underlying diseases, or

other factors: lymphomas, leukemia, connective-tissue diseases, infections, chronic

inflammatory diseases, or drug induced

factors

Tx: prednison, 1 mg/kg per day


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Continue 2. Drug-induced hemolytic anemia:

Must be differentiated from other forms

of autoimmune hemolytic anemia

Hemolysis typically is mild, it resolves

upon withdrawing the drug

The severity depand on the degree of

hemolysis

Tx: corticosteroid quesenable efficacy,

transfusion for severe anemia

Related to a congenital erythrocyte enzimatic defect

glucose-6-phosphate dehydrogenase (G6PD) defic


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Continue 3. Pregnancy-induced hemolytic anemia:

Unexplained hemolytic anemia during

pregnancy is a rare, severe hemolysis

develop early in pregnancy and resolves

within months after delivery

Fetus-infant also demonstrated transient

hemolysis, immunological cause is suspected

Tx: corticosteroid is effective


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OTHER ACQUIRED ANEMIAS

Microangiopathic hemolysis:

Complicated PE-E: HELLP syndrome

Exotoxin of clostridium perfringes or group

A-beta-hemolytic streptococcus

Gram neg bacterial endotoxin , or

liposaccharide especially with severe

acute pyelonephritis

INHERITED ERYTHROCYTE


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INHERITED ERYTHROCYTE

DEFECT

Inherited red cell membrane defect or enzymedeficiencies result in destabilizatn of the

membrane lipid bilayer

Loss of lipid from the erythrocyte membrane,surface area deficiency poorly deformable cells

that undergo hemolysis

Inherited membrane defect will cause accelerat

destruction: hereditary spherocytosis,pyropoikilocytosis, ovalocytosis


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RED CELL ENZYME DEFICIENCY Erythrocyte enzyme are necessary for its

anaerobic utilization of glucose

Hereditary nonspherocytic anemia

G6PD deficiency

Pyruvat kinase deficiency, most commonenzyme deficiency it is inherited as anautosomal recessive trait

Enzyme deficiency are reduced by drugsor infections


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APLAST & HYPOPLAST ANEMIA Dx: anemia with thrombocytipenia, leucopenia,

hypocelluler bone marrow

Anemia is induced by drugs and other

chemicals, infection, irradiation, leukemia and

immunological disorders Fanconi anemia and Diamond Blackfan

syndrome inherited autosomal recessive

Tx: glucocorticoid most are transfusion, severe:

bone marrow or stem cell transplantation


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HEMOGLOBINOPATHIES Sickle-cell hemoglobinopathies:

1) Sickle-cell anemia (SS disease),2) Sickle-cell hemoglobin C disease (SC

disease), 3)Sickle-cell beta-thalassemia

disease (S-beta-thalassema disease)

are the most common of sickle-cellhemoglobinopathies, increased matern/perinatalmorbidity and mortality, infection, abortion,stillbirth, neonatal death

Tx: folic acid and prophylactic transfusion


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THALASSEMIA Alfa-thalassemia:

Genetically determined hemoglobinopathiy

characterized by impaired production of one or

more of the normal globin peptide chain

Abnormal synthesis rates may results inineffective erythropoeisis, hemolysis and anemia

2 major forms alfa-thalassemia and beta-

thalassemia


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Continue Fetus with alfa-thalassemia at 25, 26 and

32 weeks: ascites, hydrops fetalis

Alfa-thalassemia minor characteristic byminimal-moderate hypochromic microcytic

anemia, tolerate pregnancy quite well Beta-thalassemia:

Decrease beta-chain production and

excess alfa-chains precipitate to cause cellmembrane damage


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Continue Thalassemia major neonate is healthy at

birth, but as the hemoglobin F level falls,

become severely anemia

Beta-thalassemia minor during pregnancy:

mother and fetus are satisfactory

Prophylactic iron 60 mg, folic acid 1 mg

Prenatal Dx: CVS can be carried out at 9

to 13 weeks.


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TERIMA KASIH

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Anemia in Obs-gyn