KONSEP PENCEGAHAN ABORTUS

SEJAK AWAL KEHAMILAN

NUSWIL BERNOLIAN

Divisi Fetomaternal Departemen Obstetri dan Ginekologi

RSUP Dr. Mohammad Hoesin Palembang
Fakultas Kedokteran Universitas Sriwijaya

Pertemuan Ilmiah Tahunan XX Fetomaternal

Bandung, 15 – 22 Maret 2019
ABORTUS
Per definisi: terminasi kehamilan pada UK <20 minggu dan BB <500 gram

• Istilah: abortion, miscarriage, wastage, early

pregnancy loss
• Angka kejadian: 15% dari seluruh kehamilan
• 1 dari 5 kehamilan <24 minggu : abortus

Cunningham F. Gary, Kenneth JL, Steven LB, Jodi SD, Barbara LH, Brian MC, et al. Williams obstetrics. 25th edition. New York: McGraw-
Hill Education, 2018.
Garcı ́a-Enguı ́danos A, Calle M, Valero J, Luna S, Domı ́nguez-Rojas V. Risk factors in miscarriage: a review. Eur J Obstet Gynecol Reprod
Biol.. 2002;102(2):111-9.

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 3

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 Perlu diketahui berbagai faktor risiko
dan pencegahannya

Studi  ↓ risiko berulangnya atau

terjadinya abortus & ↓ morbiditas
dan mortalitas

Identifikasi FAKTOR RISIKO

Faktor risiko yang

Faktor risiko dapat
tidak dapat
dimodifikasi
dimodifikasi
Cunningham F. Gary, Kenneth JL, Steven LB, Jodi SD, Barbara LH, Brian MC, et al. Williams obstetrics. 25th edition. New York: McGraw-
Hill Education, 2018.
Garcı ́a-Enguı ́danos A, Calle M, Valero J, Luna S, Domı ́nguez-Rojas V. Risk factors in miscarriage: a review. Eur J Obstet Gynecol Reprod
Biol.. 2002;102(2):111-9.

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1. NUTRISI
Nutrisi merupakan salah satu faktor terpenting

• Rekomendasi ANC WHO: keseimbangan asupan kalori dan protein, pemberian

suplementasi besi elemental 30-60 mg dan asam folat 0,4 mg

• Maconochie dkk.  nutrisi dan perilaku makan sebagai salah satu faktor risiko.
62% perempuan mengkonsumsi vitamin sejak 12 minggu pertama kehamilan

• Konsumsi multivitamin  ↓ abortus sekitar 50% terutama asam folat, besi

• Konsumsi buah, sayur, produk susu, konsumsi daging putih, dan ikan 2 kali
seminggu  ↓ abortus

World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva; 2016.

Maconochie N, Doyle P, Prior S, Simmons R. Risk factors for first trimester miscarriage-results from a UK-population-based
case-control study. BJOG. 2007;114(2):170-186

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 1. NUTRISI

Lashen et al : 1.644 perempuan hamil yang obesitas  ↑ risiko

sebesar 1.2x untuk abortus TM I dan 3.5x untuk kejadian abortus
berulang

Pencegahan abortus : ASUPAN NUTRISI + AKTIVITAS FISIK

Lashen H. Obesity is associated with increased risk of first trimester and recurrent miscarriage: Matched case-control study. Human Reprod. 2004;19(7):1644-6.

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2. KAFEIN
Waktu paruh kafein : 2,5-4,5 jam (manusia
normal)
Terjadi pemanjangan waktu paruh kafein pada
perempuan hamil (10,5 jam)
Kafein juga terdapat di produk
lain seperti coklat, teh, obat-
107 mg obatan!

• Dominguez et al: terdapat dose

relationship pada hubungan abortus dan
kafein
• Rasch et al: konsumsi kafein >375 mg/hari
dapat meningkatkan risiko abortus secara
signifikan
Garcıá -Enguıd́ anos A, Calle M, Valero J, Luna S, Domıń guez-Rojas V. Risk factors in miscarriage: a review. Eur J Obstet Gynecol Reprod Biol..
2002;102(2):111-9.

Rasch V. Cigarette, alcohol, and caffeine consumption: Risk factors for spontaneous abortion. Acta Obstet Gynecol Scand. 2003;82(2):182-8.

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 2. KAFEIN
• Sriruphan et al:
• Kafein pada kopi lebih berisiko untuk abortus dibanding
kafein dari sumber lain
• Kafein juga terdapat kemiripan struktur dengan adenin dan
guanin  bekerja pada asam nukleat dan menghasilkan
aberasi kromosom

Kadar kafein 200 mg sudah dapat menyebabkan ↓ sirkulasi uteroplasenta

Kadar kafein > 375 mg/hari  ↑ abortus secara signifikan

Garcıá -Enguıd́ anos A, Calle M, Valero J, Luna S, Domıń guez-Rojas V. Risk factors in miscarriage: a review. Eur J Obstet Gynecol Reprod Biol..
2002;102(2):111-9.

Rasch V. Cigarette, alcohol, and caffeine consumption: Risk factors for spontaneous abortion. Acta Obstet Gynecol Scand. 2003;82(2):182-8.

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 KAFEIN

↑ cyclic AMP ↑ katekolamin

Menghambat perkembangan Menyebabkan vasokonstriksi

janin dan insufisiensi uteroplasenter

EFEK
Mengganggu profil hormonal
Hipoksia janin
ibu dan janin
Garcıá -Enguıd́ anos A, Calle M, Valero J, Luna S, Domıń guez-Rojas V. Risk factors in miscarriage: a review. Eur J Obstet Gynecol Reprod Biol..
2002;102(2):111-9.

Rasch V. Cigarette, alcohol, and caffeine consumption: Risk factors for spontaneous abortion. Acta Obstet Gynecol Scand. 2003;82(2):182-8.

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 KAFEIN
Kafein  obat yang paling banyak dikonsumsi
dan terdapat pada kopi

Estimasi konsumsi kafein harian di US (1987) 

200 mg kafein dikonsumsi oleh populasi berusia
> 18 tahun (kopi: > 75% dari total kafein yang
dikonsumsi)

Rerata 1 cangkir kopi mengandung 85-107 mg

kafein  rerata konsumsi 2 cangkir kopi per
hari

McCusker RR, Goldberger BA, Cone EJ. Caffeine Content of Specialty Coffees. J Anal Toxicol. 2003; 27:1-3.

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 Coffee and Origin Amount Caffeine Dose (mg)
Espresso coffees
Big Bean Espresso, 1-shot 1 shot 75.8
Big Bean Espresso, 2 short shots 2 short shots 140.4
Big Bean Espresso, 2 tall shots 2 tall shots 165.3
Starbucks Espresso, regular, small 1 shot 58.1
Hampden Cafe Espresso 2 shots 133.5
Einstein Bros Espresso, double 2 shots 185.0
Brewed specialty coffees
Big Bean, regular 16 oz 164.7
Big Bean, Boat Builders Blend, regular 16 oz 147.6
Big Bean Organic Peru Andes Gold, regular, Peru 16 oz 186.0
Big Bean French Roast, regular 16 oz 179.8
Big Bean Ethiopian Harrar, regular,, Ethiopia 16 oz 157.1
Big Bean Italian Roast, regular, Brazil 16 oz 171.8
Big Bean Costa Rican French Roast, regular, Costa 16 oz 245.1
Rica
Big Bean Kenya AA, regular, Kenya 16 oz 204.9
McCusker RR, Goldberger
Big Bean Sumatra Mandheling, Indonesia 16 oz 168.5 BA, Cone EJ. Caffeine
Content of Specialty
Hampden Cafe Guatemala Antigau 16 oz 172.7 Coffees. J Anal Toxicol.
Starbucks regular 16 oz 259.3 2003; 27:1-3.
Royal Farms regular 16 oz 225.7
Dunkin’ Donuts regular 16 oz 143.4
5/13/2019
Einstein Bros regular Pertemuan Ilmiah Tahunan
16 ozXX Fetomaternal 2019
206.3 12
 3. ALKOHOL
• Jones et al: Tidak tedapat dosis aman alkohol pada kehamilan 
alkohol dapat menyebabkan fetal alcohol syndrome

• Abel et al: kadar alkohol dalam darah >200 mg/dL dapat

menimbulkan suatu abortus spontan

• Harlap dan Shiono et al: Terdapat ↑ risiko pada wanita yang

mengkonsumsi alkohol dalam jumlah sedang (≥ 1 minuman per
hari)
Tidak terdapat dosis yang aman untuk alkohol dalam kehamilan

Garcıá -Enguı́danos A, Calle M, Valero J, Luna S, Domı́nguez-Rojas V. Risk factors in miscarriage: a review. Eur J Obstet Gynecol Reprod Biol..
2002;102(2):111-9.

Abel EL. Maternal alcohol consumption and spontaneous abortion. Alcohol. 1997;32:211–9.

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 3. ALKOHOL

Mampu melewati plasenta

Melewati sawar darah otak janin

Mencapai kadar dalam plasma = kadar dalam

darah ibu

Efek teratogenik hasil metabolit yang

terakumulasi dalam janin (Asetaldehid)

Garcıá -Enguı́danos A, Calle M, Valero J, Luna S, Domı́nguez-Rojas V. Risk factors in miscarriage: a review. Eur J Obstet Gynecol Reprod Biol..
2002;102(2):111-9.

Abel EL. Maternal alcohol consumption and spontaneous abortion. Alcohol. 1997;32:211–9.

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 4. MEROKOK
14% dari seluruh ibu hamil + 23% seluruh wanita usia
reproduktif memiliki kebiasaan merokok
Merokok dalam
kehamilan • Pineles dkk.: hubungan antara paparan asap rokok
tembakau ibu dan kejadian abortus
• Wanita hamil perokok aktif  RR 1,23 kali
• Paparan asap rokok saat hamil  RR 1,32 kali

BBLR, solusio
plasenta, SIDS, • Wang dkk.: Perempuan hamil yang terpapar asap rokok
abortus dari suami 1,17 kali kemungkinan mengalami abortus
• Penghentian kebiasaan merokok suami pada periode
perikonsepsi  ↓ risiko abortus sebanyak 18%.

Risiko abortus ↑ 1% untuk setiap batang asap rokok yang dihisap setiap harinya
Pineles B, Park E, Samet J. Systematic review and meta-analysis of miscarriage and maternal exposure to tobacco smoke during pregnancy. Am J Epidemiol.
2014;179(7):807-823.
Wang L, Yang Y, Liu F, Yang A, Xu Q, Wang Q, et al. Paternal smoking and spontaneous abortion: A population-based retrospective cohort study among non-
smoking women aged 20–49 years in rural China. J Epidemiol Community Health. 2018;72(9):783-9.

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 MEROKOK  Kelainan Kualitas Sperma

Untaian yang
Aneuploidi DNA adducts
putus

Kerusakan Disfungsi
Janin yang
oksidatif pada perkembangan
abortif
spermatozoa janin

Pineles B, Park E, Samet J. Systematic review and meta-analysis of miscarriage and maternal exposure to tobacco smoke during pregnancy. Am J Epidemiol.
2014;179(7):807-823.
Wang L, Yang Y, Liu F, Yang A, Xu Q, Wang Q, et al. Paternal smoking and spontaneous abortion: A population-based retrospective cohort study among non-
smoking women aged 20–49 years in rural China. J Epidemiol Community Health. 2018;72(9):783-9.

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5. PROGESTOGEN
Progesteron

Memperkuat implantasi
Efek Samping:
Menjaga keseimbangan kadar sitokin
Moduasi aktivitas sel Natural Killer Virilisasi genitalia eksterna janin
Mengatur pelepasan asam arakidonat perempuan  pembesaran
Mengatur kontraktilitas myometrium
klitoris atau penyatuan labia
Meningkatkan sirkulasi uteroplasenta

ABORTUS

Carp H. Progestogens in the prevention of miscarriage. Horm Mol Biol Clin Investig. 2016;27(2).

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 Pemberian Progesteron
Manfaat Progesteron:
1. Esensial persiapan dan kelangsungan kehamilan
2. Meningkatkan reseptivitas endometrium (fasilitasi
implantasi)
3. Imunomodulasi sistem imun maternal (terhadap antigen
paternal embrio)
4. Menghambat aktivitas Natural Killer Cell
5. Mempengaruhi keseimbangan sitokin Th-1 dan Th-2
6. Mensintesis Progesteron Induce Blocking Factor (PIBF)
7. Uterus quiscent (mencegah kontraksi miometrium)
8. Mencegah dilatasi serviks

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BUKTI ILMIAH PROGESTERON
UNTUK KEGUGURAN

Efektivitas & Keamanan Dydrogesterone

untuk terapi defisiensi progesterone
mencakup lebih dari 500 publikasi
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Cochrane Systematic Review dari
Progestogens pada Pencegahan Keguguran
Progesterone dan Dydrogesterone
Haas & Ramsey 2013

Data set :
14 studi (n=2158 wanita) terlepas dari kondisi hamil atau yang pernah mengalami keguguran
sebelumnya

Hasil Utama :
• Tidak ada perbedaan signifikan resiko keguguran pada penggunaan progestogen
• Tidak ada perbedaan signifikan rute pemberian progestogen baik diberikan secara oral, vaginal dan
intramuscular
• Terdapat bukti pada wanita yang mengalami keguguran berulang (3+) secara signifikan
progestogen dapat menurunkan keguguran dibandingkan dengan plasebo.

Subgroup analysis dari 4 studi (225) pada keguguran berulang (3+) dibandingkan dengan plasebo atau
tidak diterapi, terapi progestogen menunjukan penurunan signifikan secara statistic pada angka
keguguran (Peto OR 0.39; 95% CI 0.21 to 0.72) tetapi kualitas metodologi rendah.

(Studies: dydrogesterone; hydroxyprogesterone caproate IM; medroxyprogesterone acetate; dan

progesterone pellets yang dimasukkan kedalam gluteal muscle)
CI: confidence interval; OR: odds ratio.

Haas DM, Ramsey PS. Cochrane Database Syst Rev 2013 Oct 31; 10:
CD003511.
 2013 Australian dan New
Zealand Guidelines

Rekomendasi Tingkat dan Referensi

Untuk wanita yang menunjukan diagnosis klinis Consensus-based

keguguran mengancam, terdapat bukti recommendation
penurunan angka keguguran spontan pada
penggunaan progestin. Referensi: Wahabi 2011

Untuk wanita yang menunjukan diagnosis klinis keguguran mengancam, terdapat

bukti penurunan angka keguguran spontan pada penggunaan progestin. Kesimpulan
ini berdasarkan data dari RCTs yang meliputi 411 wanita. Keguguran secara
signifikan lebih rendah terjadi pada pengunaan progestin dibandingkan dengan
plasebo atau tanpa terapi (risk ratio 0.53; 95% CI 0.35 to 0.79), tanpa bukti
peningkatan angka pendarahan antepartum, hipertensi, atau abnormalitas
kongenital. Terdapat heterogenitas pada penelitian ini, dengan 2 laporan
penggunaan oral dydrogesterone dan 2 laporan penggunaan vaginal progesteron.

Bukti menyarankan manfaat progestin pada wanita dengan keguguran berulang

dan keguguran mengancam, masih ada preliminary dan studi tambahan yang
didesign dengan baik untuk mengkonfirmasi penemuan ini.

Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 2013.
http://www.ranzcog.edu.au/doc/progesterone-support-of-the-luteal-phase-and-early-pregnancy.html
(Last accessed March 2014).

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 6. PAPARAN RADIASI
Radiasi yang paling sering ditemukan  magnetic field non-ionizing radiation

• Radiasi jenis ini dilepaskan oleh perangkat elektrolik,

menara pemancar, wi-fi, telefon genggam dll
• Li et al. : paparan radiasi meningkatkan risiko aborsi
sebesar 2,72 kali (1,42-5,19).

Radiasi  gangguan pertumbuhan jaringan embrio dan apoptosis

Li D, Chen H, Ferber J, Odouli R, Quesenberry C. exposure to magnetic field non-ionizing radiation and the risk of miscarriage: A prospective cohort
study. Sci Rep. 2017;7(1).

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 7. INFEKSI
Infeksi

KPD IUGR Lahir mati Abortus

• Listeria monocytogenes, Parvovirus, Cytomegalovirus dan virus Herpes

simplex  tidak berperan signifikan terhadap abortus
• Infeksi periodontal  ↑ 2-4 kali lipat mengalami abortus
• 15% abortus dini keguguran dini dan 66% abortus lanjut dapat dicegah
• Infeksi terjadi pada unit fetoplasenta lewat airan darah (bloodborne) atau lokal
lewat kolonisasi traktus genitourinarius
Cunningham F. Gary, Kenneth JL, Steven LB, Jodi SD, Barbara LH, Brian MC, et al. Williams obstetrics. 25th edition. New York: McGraw-Hill
Education, 2018.

Giakoumelou S, Wheelhouse N, Cuschieri K, Entrican G, Howie S, Horne A. The role of infection in miscarriage. Hum Reprod Update. 2015;22(1):116-33.

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 7. INFEKSI
Giakoumelou et. al.:

• BV, malaria, CMV, demam dengue, bruselosis dan HIV mampu

meningkatkan risiko aborsi

• C. Burnetti, adeno-associated virus, Bocavirus, Hepatitis C, dan

M. genitalium  tidak terdapat hubungan dengan abortus

• Infeksi  disregulasi sistem imun maternal  abortus

Cunningham F. Gary, Kenneth JL, Steven LB, Jodi SD, Barbara LH, Brian MC, et al. Williams obstetrics. 25th edition. New York: McGraw-Hill
Education, 2018.

Giakoumelou S, Wheelhouse N, Cuschieri K, Entrican G, Howie S, Horne A. The role of infection in miscarriage. Hum Reprod Update. 2015;22(1):116-33.

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8. BEBAN KERJA
Aktivitas Risiko mengalami
abortus
Stres psikologis 1,42 -2
Wanita yang bekerja 1,51
hanya pada shift malam
Wanita yang bekerja 3 1,12
shift berlainan
Lama kerja > 40 1,36
jam/minggu
Kebiasaan mengangkat 1,32
Terdapat hubungan antara stres berat saat bekerja
psikologis dan abortus Bekerja berdiri selama > 1,02
6-8 jam/hari
Qu F, Wu Y, Zhu Y, Barry J, Ding T, Baio G, et al. The association between psychological stress and miscarriage: A systematic review and meta-
analysis. Sci Rep. 2017;7(1).
Bonde JP, Jørgensen KT, Bonzini M, Palmer KT. Miscarriage and occupational activity: A systematic review and meta-analysis regarding shift work,
working hours, lifting, standing, and physical workload. Scand J Work Environ Health. 2012;39(4):325-34.

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Apakah Harus Bedrest Total???

• Hipotesis: Kelelahan fisik dan pekerjaan meningkatkan

angka keguguran (Lapple 1990)
• Fakta :
- Kebanyakan keguguran TIDAK BERHUBUNGAN dengan
aktifitas fisik.
- Meningkatkan DVT (Kovacevich – 2000)
- Atrofi otot, gangguan muskuloskeletal ( Maloni 2002)
- Meningkatkan stress dan biaya tinggi (Gupton 1997)
 Bedrest untuk menenangkan ibu, support mental.

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 9. OBAT-OBATAN
Berhubungan dengan Abortus Tidak Berhubungan dengan Abortus

AKDR  abortus septik Kontrasepsi oral dan agen spermisidal

OAINS
• 1,59x lipat (daripada tidak
menggunakan obat-obatan)
• 1,45x lipat (daripada kelompok yang
menggunakan asetaminofen)

Ondansentron
OAINS  menghambat Prostaglandin
Prostaglandin penting untuk proses implantasi embrio
Cunningham F. Gary, Kenneth JL, Steven LB, Jodi SD, Barbara LH, Brian MC, et al. Williams obstetrics. 25th edition. New York: McGraw-Hill
Education, 2018.

Li D, Ferber J, Odouli R, Quesenberry C. Use of nonsteroidal antiinflammatory drugs during pregnancy and the risk of miscarriage. Am J Obs
Gynecol. 2018;219(3):275.e1-275.e8.

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10. GENETIK
Aneuploidi janin merupakan kelainan genetik
yang paling sering ditemukan (30-90%)

Kelainan Sitogenetik 50-70% produk konsepsi yang mengalami

keguguran spontan mengalami kelainan
Trisomi: sitogenetik
60% Poliploidi:
20% • Aneuploidi sering terjadi akibat non-
Monosomi: disjunction
20% • Aneuploidi yang sering terjadi pada akhir
kehamian  lahir hidup  trisomi 13, 18, dan
21
• Kejadiannya cenderung acak dan sukar
diprediksi
• Meningkat seiring dengan usia ibu

Hyde KJ, Schust DJ. Genetic considerations in recurrent pregnancy loss. Cold Spring Harb Perspect Med. 2015;5(3):a023119.
Grimstad F, Krieg S. Immunogenetic contributions to recurrent pregnancy loss. J Assist Reprod Genet. 2016;33(7):833-47.
Bashiri A, Halper KI, Orvieto R. Recurrent implantation failure-update overview on etiology, diagnosis, treatment and future directions. Reprod Biol Endocrinol.
2018;16(1):121

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10. GENETIK
• Pada kasus-kasus recurrent pregnancy loss analisis
sitogenetik dianjurkan untuk dilakukan  lebih cost-
effective

• Aneuploidi fetal, kelainan numerik kromosom parental,

translokasi

• Skrining genetik pre-implantasi dianjurkan untuk kasus-

kasus keguguran berulang

Hyde KJ, Schust DJ. Genetic considerations in recurrent pregnancy loss. Cold Spring Harb Perspect Med. 2015;5(3):a023119

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11. IMUNOGENETIK
Respons imunologis yang Beberapa komponen penting:
berimbang dibutuhkan untuk • Sel NK (sel imun terbanyak di
implantasi dan uterus  70%)
mempertahankan kehamilan • Sitokin  TNF-α, IL-1, IL-6, IL-
8, IL-10 dan IFN-γ
• Human Leukocyte Antigen 
kemiripan HLA ↑ risiko
keguguran

Kosovo et al: terdapat variasi alel terkait ekspresi sel-sel imun :

leukosit, limfosit dan aktivasi sel T pada pasien dengan abortus
berulang

Grimstad F, Krieg S. Immunogenetic contributions to recurrent pregnancy loss. J Assist Reprod Genet. 2016;33(7):833-47.
Bashiri A, Halper KI, Orvieto R. Recurrent implantation failure-update overview on etiology, diagnosis, treatment and future directions. Reprod Biol
Endocrinol. 2018;16(1):121

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12. PELAYANAN ANTENATAL
Rekomendasi WHO terbaru menyarankan ANC minimal 8
kali

Masfiah et al : perempuan hamil yang melengkapi

kunjungan ANC berisiko 7x lebih rendah untuk mengalami
abortus dan lahir mati

World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva; 2016.

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The 2016 ANC guideline
• Essential core package of ANC Overarching questions
that all pregnant women and
adolescent girls should receive • What are the evidence-
based practices during ANC
• With the flexibility to employ that improved outcomes
different options based on the
context of different countries and lead to positive
• What is the content of the
model/package? pregnancy experience?
• Who provides care?
• Where is the care provided?
• How is the care provided to meet
the needs of the users? • How should these
practices be delivered?
• Complement existing WHO
guidance on complications during
pregnancy

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 Recommendations on ANC
49 recommendations were grouped into five
topic areas:
A. Nutritional interventions (14)
B. Maternal and fetal assessment (13)
C. Preventive measures (7)
D. Interventions for common physiological
symptoms (6)
E. Health systems interventions to improve
the utilization and quality of ANC (9)
Including 10 recommendations relevant to routine ANC
from other WHO guidelines

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 RECOMMENDATIONS
(WHO, 2016)

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 A. Nutritional interventions - 1
A.1.1: Counselling about healthy eating and keeping physically active Recommended
during pregnancy is recommended for pregnant women to stay
healthy and to prevent excessive weight gain during pregnancy.

A.1.2: In undernourished populations, nutrition education on Context-specific

increasing daily energy and protein intake is recommended for recommendation
pregnant women to reduce the risk of low-birth-weight neonates.
A.1.3: In undernourished populations, balanced energy and protein Context-specific
dietary supplementation is recommended for pregnant women to recommendation
reduce the risk of stillbirths and small-for-gestational-age neonates.

A.1.4: In undernourished populations, high-protein supplementation Not recommended

is not recommended for pregnant women to improve maternal and
perinatal outcomes.

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 A. Nutritional interventions -2
A.2.1: Daily oral iron and folic acid supplementation with 30 mg to Recommended
60 mg of elemental iron and 400 µg (0.4 mg) of folic acid is
recommended for pregnant women to prevent maternal anaemia,
puerperal sepsis, low birth weight, and preterm birth.
A.2.2: Intermittent oral iron and folic acid supplementation with 120 Context-specific
mg of elemental iron and 2800 µg (2.8 mg) of folic acid once weekly is recommendation
recommended for pregnant women to improve maternal and neonatal
outcomes if daily iron is not acceptable due to side-effects, and in
populations with an anaemia prevalence among pregnant women of
less than 20%.
A.3: In populations with low dietary calcium intake, daily calcium Context-specific
supplementation (1.5–2.0 g oral elemental calcium) is recommended recommendation
for pregnant women to reduce the risk of pre-eclampsia.

A.4: Vitamin A supplementation is only recommended for pregnant Context-specific

women in areas where vitamin A deficiency is a severe public health recommendation
problem, to prevent night blindness.

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 Nutritional interventions - 3
A.5: Zinc supplementation for pregnant women is only recommended Context-specific
in the context of rigorous research. recommendation
(research)
A.6: Multiple micronutrient supplementation is not recommended for Not recommended
pregnant women to improve maternal and perinatal outcomes.

A.7: Vitamin B6 (pyridoxine) supplementation is not recommended Not recommended

for pregnant women to improve maternal and perinatal outcomes.

A.8: Vitamin E and C supplementation is not recommended for Not recommended

pregnant women to improve maternal and perinatal outcomes.

A.9: Vitamin D supplementation is not recommended for pregnant Not recommended

women to improve maternal and perinatal outcomes.

A.10: For pregnant women with high daily caffeine intake (more than Context-specific
300 mg per day), lowering daily caffeine intake during pregnancy is recommendation
recommended to reduce the risk of pregnancy loss and low-birth-
weight neonates.

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 B.1. Maternal assessment - 1
B.1.1: Full blood count testing is the recommended method for Context-specific
diagnosing anaemia in pregnancy. In settings where full blood count recommendation
testing is not available, on-site haemoglobin testing with a
haemoglobinometer is recommended over the use of the haemoglobin
colour scale as the method for diagnosing anaemia in pregnancy.
B.1.2: Midstream urine culture is the recommended method for Context-specific
diagnosing asymptomatic bacteriuria (ASB) in pregnancy. In settings recommendation
where urine culture is not available, on-site midstream urine Gram-
staining is recommended over the use of dipstick tests as the method
for diagnosing ASB in pregnancy.

B.1.3: Clinical enquiry about the possibility of intimate partner Context-specific

violence (IPV) should be strongly considered at antenatal care visits recommendation
when assessing conditions that may be caused or complicated by IPV
in order to improve clinical diagnosis and subsequent care, where
there is the capacity to provide a supportive response (including
referral where appropriate) and where the WHO minimum
requirements are met.

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B.1. Maternal assessment - 2

B.1.7: In high-prevalence settings, provider-initiated testing and Recommended

counselling (PITC) for HIV should be considered a routine component of
the package of care for pregnant women in all antenatal care settings. In
low-prevalence settings, PITC can be considered for pregnant women in
antenatal care settings as a key component of the effort to eliminate
mother-to-child transmission of HIV, and to integrate HIV testing with
syphilis, viral or other key tests, as relevant to the setting, and to
strengthen the underlying maternal and child health systems.
B.1.8: In settings where the tuberculosis (TB) prevalence in the general Context-
population is 100/100 000 population or higher, systematic screening for specific
active TB should be considered for pregnant women as part of antenatal recommendati
care. on

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 B.1. Maternal assessment - 3
B.1.4: Hyperglycaemia first detected at any time during pregnancy Recommended
should be classified as either gestational diabetes mellitus (GDM)
or diabetes mellitus in pregnancy, according to WHO criteria.
B.1.5: Health-care providers should ask all pregnant women about Recommended
their tobacco use (past and present) and exposure to second-hand
smoke as early as possible in the pregnancy and at every antenatal
care visit.
B.1.6: Health-care providers should ask all pregnant women about Recommended
their use of alcohol and other substances (past and present) as
early as possible in the pregnancy and at every antenatal care visit.

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 B.2.Fetal assessment - 1
B.2.1: Daily fetal movement counting, such as with “count-to- Context-specific
ten” kick charts, is only recommended in the context of recommendation
rigorous research. (research)
B.2.2: Replacing abdominal palpation with symphysis-fundal Context-specific
height (SFH) measurement for the assessment of fetal growth recommendation
is not recommended to improve perinatal outcomes. A change
from what is usually practiced (abdominal palpation or SFH
measurement) in a particular setting is not recommended.
B.2.3: Routine antenatal cardiotocography is not Not recommended
recommended for pregnant women to improve maternal and
perinatal outcomes.

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B.2.Fetal assessment

B.2.4: One ultrasound scan before 24 weeks of gestation Recommended

(early ultrasound) is recommended for pregnant women
to estimate gestational age, improve detection of fetal
anomalies and multiple pregnancies, reduce induction of
labour for post-term pregnancy, and improve a woman’s
pregnancy experience.
B.2.5: Routine Doppler ultrasound examination is not Not
recommended for pregnant women to improve maternal recommended
and perinatal outcomes.

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C. Preventive measures - 1
C.1: A seven-day antibiotic regimen is recommended for all Recommended
pregnant women with asymptomatic bacteriuria (ASB) to
prevent persistent bacteriuria, preterm birth and low birth
weight.
C.2: Antibiotic prophylaxis is only recommended to prevent Context-specific
recurrent urinary tract infections in pregnant women in the recommendation
context of rigorous research. (research)
C.3: Antenatal prophylaxis with anti-D immunoglobulin in non- Context-specific
sensitized Rh-negative pregnant women at 28 and 34 weeks of recommendation
gestation to prevent RhD alloimmunization is only recommended (research)
in the context of rigorous research.
C.4: In endemic areas, preventive anthelminthic treatment is Context-specific
recommended for pregnant women after the first trimester as recommendation
part of worm infection reduction programmes.

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C. Preventive measures - 2
C.5: Tetanus toxoid vaccination is recommended for all pregnant Recommended
women, depending on previous tetanus vaccination exposure, to
prevent neonatal mortality from tetanus.

C.6: In malaria-endemic areas in Africa, intermittent preventive Context-specific

treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommendation
recommended for all pregnant women. Dosing should start in
the second trimester, and doses should be given at least one
month apart, with the objective of ensuring that at least three
doses are received.
C.7: Oral pre-exposure prophylaxis (PrEP) containing tenofovir Context-specific
disoproxil fumarate (TDF) should be offered as an additional recommendation
prevention choice for pregnant women at substantial risk of HIV
infection as part of combination prevention approaches.

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D. Common physiological symptoms
D.1: Ginger, chamomile, vitamin B6 and/or acupuncture are recommended for Recommend
the relief of nausea in early pregnancy, based on a woman’s preferences and ed
available options.
D.2: Advice on diet and lifestyle is recommended to prevent and relieve Recommend
heartburn in pregnancy. Antacid preparations can be offered to women with ed
troublesome symptoms that are not relieved by lifestyle modification.
D.3: Magnesium, calcium or non-pharmacological treatment options can be Recommend
used for the relief of leg cramps in pregnancy, based on a woman’s preferences ed
and available options.
D.4: Regular exercise throughout pregnancy is recommended to prevent low Recommend
back and pelvic pain. There are a number of different treatment options that ed
can be used, such as physiotherapy, support belts and acupuncture, based on a
woman’s preferences and available options.

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 D. Common physiological symptoms

D.5: Wheat bran or other fibre supplements can be used to relieve Recommen
constipation in pregnancy if the condition fails to respond to dietary ded
modification, based on a woman’s preferences and available options.
D.6: Non-pharmacological options, such as compression stockings, leg Recommen
elevation and water immersion, can be used for the management of ded
varicose veins and oedema in pregnancy, based on a woman’s
preferences and available options.

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E. Health systems interventions to improve the
utilization and quality of ANC – 1

E.1: It is recommended that each pregnant woman carries her own Recommended
case notes during pregnancy to improve continuity, quality of care and
her pregnancy experience.
E.2: Midwife-led continuity-of-care models, in which a known midwife Context-specific
or small group of known midwives supports a woman throughout the recommendation
antenatal, intrapartum and postnatal continuum, are recommended
for pregnant women in settings with well functioning midwifery
programmes.
E.3: Group antenatal care provided by qualified health-care Context-specific
professionals may be offered as an alternative to individual antenatal recommendation
care for pregnant women in the context of rigorous research, (research)
depending on a woman’s preferences and provided that the
infrastructure and resources for delivery of group antenatal care are
available.

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E. Health systems interventions to improve the
utilization and quality of ANC – 2
E.4.1: The implementation of community mobilization through Context-
facilitated participatory learning and action (PLA) cycles with specific
women’s groups is recommended to improve maternal and newborn recommendati
health, particularly in rural settings with low access to health services. on
Participatory women’s groups represent an opportunity for women to
discuss their needs during pregnancy, including barriers to reaching
care, and to increase support to pregnant women.

E.4.2: Packages of interventions that include household and Context-

community mobilization and antenatal home visits are specific
recommended to improve antenatal care utilization and perinatal recommendati
health outcomes, particularly in rural settings with low access to on
health services.

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E. Health systems interventions to improve the
utilization and quality of ANC – 3

E.5.1: Task shifting the promotion of health-related behaviours for Recommended

maternal and newborn health to a broad range of cadres, including lay
health workers, auxiliary nurses, nurses, midwives and doctors is
recommended.

E.5.2: Task shifting the distribution of recommended nutritional Recommended

supplements and intermittent preventative treatment in pregnancy
(IPTp) for malaria prevention to a broad range of cadres, including
auxiliary nurses, nurses, midwives and doctors is recommended.

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E. Health systems interventions to improve the
utilization and quality of ANC – 4

E.6: Policy-makers should consider educational, Context-specific

regulatory, financial, and personal and professional recommendation
support interventions to recruit and retain qualified
health workers in rural and remote areas.
E.7: Antenatal care models with a minimum of eight Recommended
contacts are recommended to reduce perinatal mortality
and improve women’s experience of care.

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 In the early months of pregnancy spontaneous expulsion of the
ovum is neary always preceded by the death of the foetus. For
this reason the consideration of the aetiology of abortion
practically resolves itself into determining the cause of foetal
death. In the later months, on the other hand, the foetus is
frequently born alive, and other actors must be looked or to
explain its expulsion

-J . Whitridge Williams ( 1903)

Thank You

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Take Home Messages

• Sejak sebelum hamil dan awal kehamilan,

perhatikan nutrisi, kurangi atau hindari kafein,
alkohol, merokok, radiasi, beban kerja
• Tambahan progesteron
• Antenatal Care yang berkualitas
• Eliminasi infeksi
• Kurangi konsumsi obat-obatan
• Risiko genetik : Skrining, penyakit-penyakit
autoimun dikontrol sebelum hamil

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 TERIMA KASIH

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5/13/2019 Pertemuan Ilmiah Tahunan XX Fetomaternal 2019 54
11. VAKSINASI
• Vaksinasi salah satu cara terbaik untuk
memberikan kekebalan

• Pemberian vaksin selama kehamilan harus

mempertimbangkan risiko dari vaksinasi dengan
keuntungan

Pregnant women are at risk for vaccine preventable disease–

related morbidity and mortality and adverse pregnancy
outcomes, including congenital anomalies, spontaneous
abortion, preterm birth, and low birth weight.
Swamy GK and Heine RP. Vaccinations for Pregnant Women. Obstet Gynecol. 2015; 125(1): 212–26.

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56

VAKSINASI DALAM KEHAMILAN

• DIREKOMENDASIKAN
1 AMAN

• TIDAK
2 DIREKOMENDASIKAN

3 • REKOMENDASI KHUSUS

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57

Swamy GK and Heine RP. Vaccinations for Pregnant Women. Obstet Gynecol. 2015; 125(1): 212–26.

5/13/2019 Pertemuan Ilmiah Tahunan XX Fetomaternal 2019 57

58

Swamy GK and Heine RP. Vaccinations for Pregnant Women. Obstet Gynecol. 2015; 125(1): 212–26.

5/13/2019 Pertemuan Ilmiah Tahunan XX Fetomaternal 2019 58

Measles-Mumps-Rubella (MMR)
• Measles ok paramyxovirus  rash, diarrhea, and otitis media.

• Infeksi saat hamil  spontaneous abortion, preterm birth, & BBLR

• Rubella ok togavirus  lymphadenopathy, arthralgias, dan demam

• Congenital rubella syndrome : deafness, cataracts, cardiac defects, neurologic

damage, and death.

• Vaksin MMR : kontraindikasi saat hamil

• Skrining pre konsepsi dan vaksin  menghindari congenital rubella syndrome.

• Semua wanita hamil curiga rubela  vaksin postpartus

• Menyusui tidak merupakan kontraindikasi vaksin MMR

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60

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Varicella
• Varicella-zoster virus (VZV), a member of the herpes virus family,
causes chicken pox.

• Illness usually presents as a pruritic rash for 4–7 days, during

which time the infected individual is highly contagious.

• Infection during pregnancy is associated with neonatal varicella or

herpes zoster and congenital varicella syndrome, which is
characterized by skin scarring, limb hypoplasia, low birth weight,
and numerous other anomalies.

• Varicella vaccine is contraindicated in pregnancy due to its live

attenuated formulation.

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• Congenital varicella syndrome occurs in 1–2% of
cases of maternal varicella infection, with the
greatest risk of occurrence associated with
maternal infection from 13–20 weeks of
gestation.

• Preconception varicella vaccine administration is

ideal to avoid congenital varicella syndrome.

• Antivirals such as acyclovir should be used for

actual chicken pox

• Mothers who are or suspected to be VZV

susceptible should receive two doses of vaccine
postpartum – the first immediately postpartum
and the second 4–8 weeks later.

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63

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64

• The CDC recommends several vaccines for

individuals traveling to areas with endemic vaccine-
preventable diseases.

• Therefore, pregnant women planning international

travel should be advised to search the CDC travel
website, which provides up-to-date country-specific
immunization recommendations and aids in risk
factor determination.

• Three travel-related vaccine preventable diseases

that are frequently encountered are yellow fever,
Japanese encephalitis/meningitis, and typhoid fever.

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65

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66

SUMMARY OF VACCINE IN PREGNANCY

Swamy GK and Heine RP. Vaccinations for Pregnant Women. Obstet Gynecol. 2015; 125(1): 212–26.

5/13/2019 Pertemuan Ilmiah Tahunan XX Fetomaternal 2019 66

World Health Organization. Safety of Immunization during Pregnancy Safety of Immunization during Pregnancy A review of the evidence. WHO
Press. 2014;1-30.

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 "To achieve the Every Woman Every Child vision and the Global Strategy for
Women's Children's and Adolescents' Health, we need innovative, evidence-
based approaches to antenatal care. I welcome these guidelines, which aim to
put women at the centre of care, enhancing their experience of pregnancy and
ensuring that babies have the best possible start in life."

Ban Ki-moon, UN Secretary-General

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