Agus Abadi

Divisi Kedokteran Fetomaternal

Bagian Obstetri dan Ginekologi
RSU. Dr. Soetomo Surabaya
DAMPAK ANEMIA TERHADAP
KEHAMILAN, PERSALINAN
DAN OUTCOME PERINATAL
DEFINISI ANEMIA
REKOMENDASI WHO

1. Non Pregnant - Hb. < 12.0 g/dl.
2. Pregnant - Hb. < 11.0 g/dl
3. Post partum Hb. < 10 g/dl
AKIBAT ANEMIA
Penurunan kapasitas transport O2
Risiko terjadinya hipoksia jaringan
Gangguan daro fungsi organ dan
metabolisme (O2 dependent metab.)
ADAPTASI
Peningkatan Cardiac Output (Heart Rate)
Hypoxia Induce Vasodilatation
Peningkatan perfusi jaringan
Redistribusi darah pada organ vital
Peningkatan Resp. Minute Volume
Peningkatan A-V O2 Gradient
Erythropoetin Release
Pregnancy related chages 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
Low Limit of Normal ( 5
th
Percentile )
For Hb and Hct during Pregnancy
From CDC - 1989
Gestational Age ( Weeks ) 12 16 20 24 28 32 36 40

5
th
Percentile of Hb 11.0 10.6 10.5 10.5 10.7 11.0 11.4 11.9

5
th
Percentile of Hct 33 32 32 32 32 33 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 )
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
CHANGES IN ERYTHROCYTE COUNT, HB AND HCT IN NORMAL FETUSES
( From Forestier et al. 1991 )
GEST.AGE ERY COUNT HEMOGLOBIN HEMATOCRYT
( Weeks ) ( 1000.000/dl) (g/dl) ( % )

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
THE DEFINITION OF ANEMIA DURING PREGNANCY
Hb. < 11.0 gr/dl ( During Pregnancy )

Hb. < 10.0 gr/dl ( During The PP periode )
REGARDLESS OF ITS CAUSE
( WHO 1972 )
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. INCREASE MATERNAL AND INFANT MORBIDITY AND MORTALITY
CLINICAL CONSEQUENCES REGARDLESS
OF THE CAUSE OF THE ANEMIA

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 )
ADDITIONAL RISK

1. INFECTION
2. BLEEDING TENDENCIES
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
RISK OF IRON DEFICIENCY ANEMIA
DURING PREGNANCY
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

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 g/l
ASSOCIATION BETWEEN HAEMOGLOBIN LEVELS AND
FETAL RISK ACCORDING TO VAROUS AUTHORS

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
FOLIC ACID DEFICIENCY ANEMIA

RARE

CAUSED BY : - DEFICIENCY OF INTRINSIC FACTORS
- FOLLOWING GASTRIC SURGERY
- SECONDARY TO MALABSORBTION

SYMPTOM : - MACROCYTIC ANEMIA
- NEUROLOGICAL SYMPTOM
- NO FETAL RISK
VITAMINE B12 DEFICIENCY ANEMIA
ANEMIA ASSOCIATED WITH INFLAMATORY DISORDERS
ANEMIA ASSOCIATED WITH INFECTION
- Parasitic - HIV
- Bacterial - Crohns 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 )
RENAL ANEMIA
Perinatal Risk


Prematurity
Typical :

Erythropoetin deficient
Normocytic Hpoproliferative