POKOK BAHASAN
• Analisis situasi
• Program triple eliminasi
• Diagnosis infeksi HIV, sifilis, hepatitis B
• Penatalaksanaan ibu hamil terinfeksi HIV, sifilis, hepatitis B
INDONESIA
SDG 3 = Promosi hidup sehat dan kesejahteraan bagi semua orang dari segala usia dengan
memperhatikan prioritas kesehatan sebagai wawasan pembangunan, termasuk kesehatan
reproduksi, kesehatan ibu dan anak dan penanggulangan penyakit menular.
2,50%
1,70% Resiko penularan dari ibu ke anak untuk HIV 20 – 45 %
Resiko penularan dari ibu ke anak untuk sifilis 69 – 80 %
Resiko penularan dari ibu ke anak untuk hepatitis B > 90 %
0,30%
2018 -
• Akses Terbuka
2019
2020-
• Pra Eliminasi
2021
2022 • Eliminasi
2023-
• Pemeliharaan
2025
Infeksi baru HIV, sifilis dan hepatitis < = 50 / 100.000 kelahiran hidup pada tahun 2022
Indikator dan Target Ibu hamil
dalam ‘triple’ Eliminasi Penularan
Indikator HIV Sifilis Hepatitis B
Ibu hamil diperiksa, Cakupan 2018 : 60% dari ibu hamil K1
dites, dideteksi dini Cakupan 2019 : 70% dari ibu hamil K1
ANC 10T lengkap Cakupan 2020 : 80% dari ibu hamil K1
Cakupan 2021 : 90% dari ibu hamil K1
berkualitas
Cakupan 2022 : 100% dari ibu hamil K1
Penanganan bagi 100% ibu hamil diobati 100% ibu hamil diobati 100% kasus
ibu hamil dengan ARV, berupa Kombinasi dengan Benzatin hepatitis B pada ibu
hasil positif Dosis Tetap (KDT) setiap Penicilin G 2,4 juta IU hamil dalam
hari sekali (tiap 24jam) IM sebagai program pengawasan,
seumur hidup dosis tunggal pada fase dirujuk ke rumah
dini, diulang 2 kali dgn sakit yang mampu
selang waktu 1 minggu tatalaksana
atau dirujuk hepatitis B
Ibu bersalin di 100% bersalin di 100% bersalin di 100% bersalin di
fasyankes fasyankes oleh nakes fasyankes oleh nakes fasyankes oleh
nakes
Indikator dan Target Bayi
dari Ibu terinfeksi dalam Eliminasi Penularan
Indikator HIV Sifilis Hepatitis B
Penanganan anak 100% mendapat 100% mendapat 100% mendapat
dari ibu positif pelayanan standar pelayanan standar pelayanan standar
profilaksis ARV dalam 6 - pengobatan Benzatin imunisasi HB0 <24
12 jam sampai usia 6 Penicilin G 50.000 jam dan
minggu, selanjutnya IU/kgBB IM dosis HBIg <24 jam,
ditambahkan tunggal, pemeriksaan dilanjutkan dengan
kotrimoksazol profilaksis, titer RPR usia 3 bulan imunisasi HB1,2,3,4
pemeriksaan EID (PCR dibandingkan titer (vaksin DPT-HB-
kualitatif dgn DBS) dan ibunya, atau Hib),
atau RNA/viral load mulai pemeriksaan lain atau pemeriksaan
6 minggu atau pemantauan klinis serologis HBsAg
pemeriksaan serologis sampai 2 tahun saat bayi usia 9-12
pada usia 18 bulan bulan.
Anak negatif 95 - 100% anak dari ibu 95 - 100% anak dari ibu 95 - 100%
(keberhasilan HIV hasil pemeriksaannya sifilis hasil pemeriksaan
program 3E) negatif. pemeriksaannya negatif serologis HBsAg
,atau sama dengan titer negatif.
ibu anak sehat, tanpa
cacat atau kematian
Pencegahan &
Pengendalian
HIV AIDS & PIMS Permenkes 97 thn 2014
pada Bag Kedua : pelayanan
KEHAMILAN masa kehamilan
Pasal 12 ayat 3
ANC Terpadu
(10 T) PMK 51/2013 tentang
Pedoman PPIA
5 Juta Ibu 1. Timbang Badan dan Ukur Tinggi RUMAH SAKIT
Hamil Badan
2. Ukur Tekanan Darah
+ + +
R1 (+), R2 (+), R3 (+) TP Rapid Rapid Hep B
Hasil
Any child with symptomatic congenital syphilis should undergo a lumbar puncture, complete
blood count, and long-bone radiography before treatment. If these results are normal, a
single intramuscular dose of benzathine penicillin G (50,000 units/kg) should be given. With
abnormal results or if compliance is not ensured, the infant should be given a 10-day course
of either aqueous crystalline penicillin G (50,000 units/kg IV every 12 hours for the first 7
days of life, and then every 8 hours for the next 3 days) or procaine penicillin (50,000
units/kg/d IM).
Duff. P. Maternal and Fetal Infections. In: Resnik R, editor. Creasy and resnik's maternal-fetal medicine : principles and
practice. 8th edition. ed. Philadelphia, MO: Elsevier; 2018. p. 862-919.e8,.
The natural history of untreated syphilis
in pregnancy
Blencowe H, Cousens S, Kamb M, Berman S, Lawn JE. Lives Saved Tool supplement detection and treatment of syphilis
in pregnancy to reduce syphilis related stillbirths and neonatal mortality. BMC Public Health. 2011;11 Suppl 3:S9.
The course of untreated syphilis.
Dobson SR. Syphilis. In: Cherry JD, Harrison GJ, Kaplan SL, Hotez PJ, Steinbach WJ, editors. Feigin and Cherry's Textbook
of Pediatric Infectious Diseases 8th edition. ed. Philadelphia, PA: Elsevier/Saunders; 2019. p. 1268-84.e3.
Algorithm for evaluation and treatment of infants born to
mothers with reactive serologic tests for syphilis
TREATMENT:
(1) Aqueous penicillin G 50,000 U/kg IV q 12
hr ( 1 wk of age), q 8 hr (>1 wk), or procaine
penicillin G 50,000 U/kg IM single daily
dose, x 10 days
(2) Benzathine penicillin G 50,000 U/kg IM x 1
dose
Dobson SR. Syphilis. In: Cherry JD, Harrison GJ, Kaplan SL, Hotez PJ, Steinbach WJ, editors. Feigin and Cherry's Textbook
of Pediatric Infectious Diseases 8th edition. ed. Philadelphia, PA: Elsevier/Saunders; 2019. p. 1268-84.e3.
Treatment Guidelines for Congenital Syphilis
Scenario Maternal Stage/Treatment Evaluation Antimicrobial Regimen
Infant age ≤28 d with proven or highly Any or none CSF analysis: VDRL, cell count, and Aqueous penicillin G 50,000 U/kg IV q12h
probable disease: protein; CBC and platelet count; other (≤1 wk old), q8h (>1 wk old, ≤4 wk old),
(a) Abnormal physical examination tests as clinically indicated (e.g., long q6h (>4 wk old) × 10 d, or
a
(b) Abnormal evaluation bone radiographs, liver function tests, Procaine penicillin G 50,000 U/kg IM × 10
(c) Serum nontreponemal titer ≥4 times ophthalmologic examination, hearing d (≤4 wk old)
maternal titer evaluation, neuroimaging)
(d) Visualization of spirochetes in clinical
specimen
Infant age ≤28 d with possible congenital Any stage of infection and: mother CSF analysis for VDRL, cell count, and If complete evaluation normal:
syphilis: normal physical examination and (a) was not treated, inadequately protein; CBC and platelet count; long (a) benzathine penicillin G 50,000 U/kg
b
serum quantitative nontreponemal titer treated, or has no documented bone radiographs IM
c
the same or less than fourfold the treatment; (b) was treated with × 1 or
b
maternal titer erythromycin or other nonpenicillin (b) aqueous penicillin G 50,000 U/kg IV
regimen; or (c) received appropriate q12h (≤1 wk old), q8h (>1 wk old, ≤4 wk
treatment but ≤4 wk before delivery old), q6h (>4 wk old) × 10 days, or
(c) procaine penicillin G 50,000 U/kg IM ×
10 d (≤4 wk old)
Infant age ≤28 d with congenital syphilis Mother with: No evaluation Benzathine penicillin G 50,000 U/kg IM ×
less likely: normal physical examination (a) adequate therapy >4 wk before 1 (preferred), or
and serum quantitative nontreponemal delivery, and appropriate for stage of Clinical, serologic follow-up
titer the same or less than fourfold the infection; or
maternal titer (b) nontreponemal titers remained stable
and low for late syphilis and no evidence
of reinfection or relapse
Infant age ≤28 d old with congenital Mother with adequate therapy before None None
syphilis unlikely: normal physical pregnancy and nontreponemal serologic titer
examination and serum quantitative remained low and stable during pregnancy
and at delivery
nontreponemal titer the same or less
than fourfold the maternal titer
Congenital syphilis in infant age >28 d Any or none CSF analysis: VDRL, cell count, protein; Aqueous penicillin G, 50,000 units/kg q4–
d
CBC and differential; platelet count. 6h × 10 d
As clinically indicated: radiographs of
long bones, liver function tests,
neuroimaging (cranial ultrasonography),
eye examination, hearing evaluation
Dobson SR. Syphilis. In: Cherry JD, Harrison GJ, Kaplan SL, Hotez PJ, Steinbach WJ, editors. Feigin and Cherry's Textbook
of Pediatric Infectious Diseases 8th edition. ed. Philadelphia, PA: Elsevier/Saunders; 2019. p. 1268-84.e3.
Natural course of untreated syphilis
Radolf JD. Syphilis (Treponema pallidum). Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases.
8th Ed, Updated Edition ed2015. p. 2684-709.e5.
Stage of syphilis
Cohen SE, Engelman J, Klausner JD. Syphilis (Treponema pallidum). Netter’s Infectious Diseases2012. p.
351-61.
Study-specific and summary estimates of the proportion (%) of all
adverse pregnancy outcomes (APOs) among women with untreated
syphilis and women without syphilis
Gomez GB, Kamb ML, Newman LM, Mark J, Broutet N, Hawkes SJ. Untreated maternal syphilis and adverse outcomes of
pregnancy: a systematic review and meta-analysis. Bull World Health Organ. 2013;91(3):217-26.
Study-specific and summary estimates Study-specific and summary estimates of
of the proportion (%) of selected the proportion (%) of selected adverse
adverse outcomes among women outcomes among women with
WITHOUT syphilis UNTREATED SYPHILIS
Gomez GB, Kamb ML, Newman LM, Mark J, Broutet N, Hawkes SJ. Untreated maternal syphilis and adverse outcomes of
pregnancy: a systematic review and meta-analysis. Bull World Health Organ. 2013;91(3):217-26.
Neonatal Premature birth/
Stillbirth
death low birth weight
n n % 95% CI n % 95% CI n % 95% CI
2013 233 5 2.15 [0.70– 4.94] 3 1.29 [0.27– 3.72] 22 9.82 [6.01– 13.95]
2014 350 4 1.14 [0.31– 2.90] 1 0.29 [0.72– 1.58] 25 7.25 [4.68– 10.36]
2015 2330 5 2.15 [0.70– 4.94] 0 0 [0–1.57] 26 11.40 [7.42– 15.92]
Total 8160 14 1.72 [0.94– 2.86] 4 0.49 [0.13– 1.25] 73 9.16 [7.08– 11.12]
APO (excluding
Neonatal Congenital
premature or low
asphyxia syphilis
birth weight)
n n % 95% CI n % 95% CI n % 95% CI
2013 233 2 0.89 [0.10– 3.07] 3 1.34 [0.27– 3.72] 13 5.63 [3.00– 9.35]
2014 350 3 0.87 [0.18– 2.48] 3 0.87 [0.18– 2.48] 11 3.17 [1.58– 5.55]
2015 2330 0 0 [0–1.57] 1 0.44 [0.01– 2.37] 6 2.62 [0.95– 5.52]
Total 8160 5 0.63 [0.20– 1.42] 7 0.88 [0.35– 1.76] 30 3.72 [2.49– 5.21]
Quality assessment of evidence for treatment with at least 2.4MU
penicillin for women with active syphilis in pregnancy to prevent
adverse pregnancy and neonatal outcomes
Blencowe H, Cousens S, Kamb M, Berman S, Lawn JE. Lives Saved Tool supplement detection and treatment of syphilis in
pregnancy to reduce syphilis related stillbirths and neonatal mortality. BMC Public Health. 2011;11 Suppl 3:S9.
Sensitivity and Specificity of Serologic Tests for Syphilis
Sensitivity during stage of infection, % (range) Specificity, %
Primary Secondary Latent Late (range)
Nontreponemal tests
VDRL 78 (74–87) 100 96 (88–100) 71 (37–94) 98 (96–99)
TRUST 85 (77–86) 100 98 (95–100) NA 99 (98–99)
RPR 86 (77–99) 100 98 (95–100) 73 98 (93–99)
Early treponemal tests
MHA-TP 76 (69–90) 100 97 (97–100) 94 99 (98–100)
TPPA 88 (86–100) 100 100 NA 96 (95–100)
TPHA 86 100 100 99 96
FTA-ABS 84 (70–100) 100 100 96 97 (94–100)
Enzyme immunoassays
IgG-ELISA 100 100 100 NA 100
IgM-EIA 93 85 64 NA NA
ICE 77 100 100 100 99
Immunochemiluminescence
assays
CLIA 98 100 100 100 100
Sena AC, White BL, Sparling PF. Novel Treponema pallidum serologic tests: a paradigm shift in syphilis screening for the
21st century. Clin Infect Dis. 2010;51(6):700-8.
Screening Syphilis Infections in Pregnancy
When to screen All women should be screened at their
first prenatal visit.
Repeat screening should be performed in
all pregnancies early in the third trimester.
Patients should be screened at delivery if
not screened previously or if at high risk.
How to screen* Treponemal and nontreponemal test
Diagnostic criteria Positive treponemal and nontreponemal
test
Nyholm JL. Maternal and Perinatal Infection: Chlamydia, Gonorrhea, and Syphilis in Pregnancy. In:
Gabbe SG, Niebyl JR, Simpson JL, Landon MB, Galan HL, Jauniaux ERM, et al., editors. Obstetrics :
normal and problem pregnancies. Seventh edition. ed. Philadelphia, PA: Elsevier; 2017. p. 1089-98.
Composite results of syphilis
testing algorithms using
treponemal tests for initial
screening and recommendations
from the Centers for Disease
Control and Prevention, 2008
Sena AC, White BL, Sparling PF. Novel Treponema pallidum serologic tests: a paradigm shift in syphilis screening for the
21st century. Clin Infect Dis. 2010;51(6):700-8.
DIAGNOSA IBU HAMIL DENGAN SIFILIS
Kollmann TR. Syphilis. Remington and Klein's Infectious Diseases of the Fetus and Newborn
Infant. 8th Ed ed2016. p. 512-43.
SKRINING
• Semua ibu hamil → skrining sebelum usia
kehamilan 16 minggu dan diulang pada awal
kehamilan trimester 3 (3 bulan kemudian).
• Skrining dengan VDRL / RPR atau TP rapid jika
fasilitas ini ada pada kunjungan pertama
pelayanan antenatal di semua Fasyankes.
• Jika selama kehamilan belum dikerjakan
skrining, maka dilakukan pada masa nifas.
W_Indriatmi 44
TERIMA KASIH
Management Options Evidence Quality and Recommendation
Labor and Delivery
Some states in the United States require testing —/GPP
of all women at delivery.
Evaluate all cases of stillbirth > 20 wk for the IV/C
presence of syphilis.
Inform pediatricians of prenatal syphilis. IV/C
Postnatal
Alert pediatricians to the presence of syphilis IV/C
during pregnancy so that they can properly
evaluate the neonate for early (snuffles, rash,
hepatosplenomegaly, jaundice) and late
(deafness, hydrocephalus, optic nerve atrophy,
mental retardation) manifestations of congenital
syphilis.
Follow-up tests should occur up to 2 yr after III/B
treatment, with concomitant fall in titers during
that period.