CASE BASED DISCUSSION

“Iron Deficiency Anemia In Pregnancy”

14 January 2020

DEPARTEMEN OBSTETRI DAN GINEKOLOGI

UNIVERSITAS NAHDLATUL ULAMA SURABAYA
RSI JEMURSARI SURABAYA
1/29/2020 1
Periode 02 Desember 2019 - 21 Februari 2020
 Pembimbing :
dr. Amir Fahad, Sp.OG

Dokter Muda :
Athiyatul Ulya
Bahtiar Nawabigh Hidayatullah
Nurma Islamiyah
Maimunah Faizin
Niken Ayu Kusumawardani

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 Preliminary
Conditions
where the
number & size
of cells / Hb is
less than
normal

Anemia

8% anemia in
trimester I, 12%
anemia in 50% Iron
trimester II, and Deficiency
29% anemia in Anemia
trimester III 3
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 Case
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 Case
• Mrs. N / 23 yo
• MRS 11 January 2020 at 17.00

• Patient Data
– Name : Mrs. N
– Age : 23 tahun
– Adress : Surabaya
– Profession : Housewife
– Status : Married
– Religion : Moslem
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 Case
HPHT : 13/04/2019 • Married : 1x Selama 2 tahun
EDD : 20/01/2020 • Antenatal Care:
Age of Pregnancy: 39/40 mgg - RS Gresik 5X  KRR
- RKZ 4X KRR
Childbirth History : - RSI 2X  KRT
1. ♀/Spt B/Bidan/2900 g /11 • History of contraception : (-)
bulan.
2. Hamil ini.

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 Case

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 Case
• RIWAYAT PENYAKIT SEKARANG (RPS)
– Pasien datang ke IGD RSI Jemursari dengan keluhan lemas dan sedikit pusing
sejak 2 hari ini. Pasien 1 hari sebelum MRS sudah periksa darah dan hasilnya
Hb 7. Saat pagi SMRS pasien kontrol ke RSI dan disarankan untuk transfusi
darah.
– Pasien merasakan kenceng-kenceng sejak 2 hari ini yang jarang. Adanya
keluar darah, lendir, cairan bening disangkal.
– Pasien juga mengatakan kaki dan tangan nya bengkak sejak kurang lebih 1
bulan SMRS. Adanya mata kabur, pusing, mual, muntah disangkal. Pasien
mengatakan saat hamil anak pertama badan pasien juga bengkak seperti ini.
– Pasien mengatakan tensi nya tinggi saat 2 kali kontrol terakhir.
– BAB dan BAK dalam bataa normal.

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 Case
RPD
• DM (-)
• HT (-)
• Asma (-)

RPK
• DM (+) ibu
• HT (+) Ibu
• Alergi (-)

RPO
• DHA
• Calcium
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 Case
Physical Examination (11/01/2020 at 17.00) : BB sebelum hamil : 63 kg
BB saat ini : 83 kg
TB : 160 cm
General Status BMI : 32,4
• GCS : 456 Indeks kenaikan BB :4
• TD : 130/85 mmHg, MAP : 100, ROT : 15
• Nadi : 104 x/menit
• RR : 20 x/menit
• Temp : 36,5 oC

• K/L : A(+/+) I(-) C(-) D(-)

• Thorax : Cor
: S1/S2 tunggal, reguler, murmur (-), gallop (-)
Pulmo: ves +/+ , rh -/-, wh -/-
• Abdomen : soepel
• Ekstremitas : Edema : +/+, AHKM, CRT < 2 dtk
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 Case
Physical Examination (11/01/2020 at 17.00) :
Status Obstetri
TFU : 32 cm
DJJ : 150 x/mnt
His : 1-2x @ 15-30” dalam 10’

• Leopold 1: teraba bagian lunak (bokong)

• Leopold 2: kiri teraba bagian datar, kanan teraba bagian kecil janin
• Leopold 3: teraba kepala
• Leopold 4: sudah masuk PAP

• VT : seujung jari / eff 25%

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 Case
Hasil NST (11/01/2020 at 18.20)
Baseline 130-150 dpm, variabilitas normal, reaktif  kategori I

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 Case
Hasil Laboratorium (11/01/2020)
Darah Lengkap Kimia Klinik Urin Lengkap
Hb 6.43 GDA 80 Protein 1+

WBC 10.50 BUN/SK - Blood Negatif

Plt 351 Alb - Leuko 1+
Hct 23.1 SGOT/SGPT - Epitel 5-7 plp
MCV 59.2 Na/K/Cl - Leukosit 5-7 plp
MCH 16.5 PPT - Eritrosit 0-1 plp
MCHC 27.9 APTT - Kristal Amorf urat (+)
HBsAg NR LDH - Keton Negatif

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 Case
Hasil Laboratorium Darah Lengkap
11/01/2020 12/01/2020
Hb 6.43 Hb 7,95

WBC 10.50 WBC 10.28

Plt 351 ribu Plt 311 ribu
Hct 23.1 Hct 27,6
MCV 59.2 MCV 63,8
MCH 16.5 MCH 18,4
MCHC 27.9 MCHC 28,8

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 Case
Diagnosis :
GII P1A0H1 39/40 mgg + Tak Inpartu + Anemia + Preeklampsia + ATK < 1th +
Obesitas gr I + JTHIU + Presentasi kepala + TBJ 2800 - 3000 gram

Planning Terapi :
Profenid supp 2
Dopamed tab 3 x 250 mg PO
Nifedipin 3 x 10 mg PO
Transfusi PRC 2 kolf / hari tanpa premed
Terminasi bila Hb > 9

Planning Monitoring :
Keluhan pasien, TTV, CHPB
Planning Edukasi :
Bedrest, miring ke kiri.
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 Case
Tanggal 13/01/2020 pukul 19.10 :
Lahir bayi Spt B
♀ / 3400 g / 50 cm / AS 8 - 9
BS : 39 mgg LS : p 50

Kondisi ibu dan bayi saat ini

Bayi nafas spontan
Ibu : di R. Nifas
Status umum
GCS : 456 A(-) I(-) C(-) D(-)
TD : 130/90 N : 90 RR : 20 Trec : 36,5 C
Cor : S1 S2 tunggal, M (-)
Pulmo : ves +/+, rh -/-, wh -/-
Abdomen : Supel
Status Obstetri
TFU : ~ 2 jbpst
Kont. Uterus : (+) baik
v/v : fluksus (-)

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 Literature review
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 pregnancy is a
In the 2nd trimester
condition ofDefinition
the need for blood-
pregnant women
forming substances,
with Hb levels <11
especially iron,
gr% in the 1st & 3rd
increased sharply to
trimester This
or Hbsituation is due
two times
levels <10.5 gr%toinincreased
compared to when
the 2nd trimester
maternal blood
not pregnant.
volume due to the
(Wiknjosastro,
2010). fetus's need for
oxygen and
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nutrients carried by 18
 CDC:

Pregnancy Status Hb (g/dl) Hct (%)

Not Pregnant 12,0 36%

Pregnant

1st Trimester <11,0 33

2nd Trimester <10,5 32

3rd Trimester <11,0 33

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 Epidemiology
• The prevalence of anemia
worldwide ranges from 10 - 20% →
35 - 75% in developing countries &
15% in developed countries.
• WHO: 40% of maternal deaths in
developing countries are related to
anemia.
• In Indonesia: the incidence of
anemia is 63.5%.
• 75 - 95% of the cause is iron
deficiency.

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 tional Micro
/ Iron nutri
Pre-pregnancy
poor nutrition

defici ent
ency (folat
Chronic blood loss CauseRecur
anem
due to parasitic
infections – e acid Aplastic anemia
is rare
Hookworm & Malaria
s of rent
ia &
Anem infect
VIta
Multiparity ia inions Hemoglobinopathies
like Thalassemia,

min sickle cell anemia

Pregn (UTI)
B12)
Multiple
ancy - Hemolytic
pregnancy anemia in PIH
anem
ia
Acute blood loss
in APH, PPH
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due
 WHO Anemia Severity Classification Hb Values

Severe
Moderate < 7 g/dL
7 - 9 g/dL
Mild
9 - 11
g/dL
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 Maternal Physiology

Hematologic Change :
• Blood Volume
• Hemoglobin and Hematocrit
Concentration

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 in Too
Pathophysiology of Nutritional
plasma Anemia in Pregnancy
soon &
is more too
Iron
Blood as many
Augment stores
volume compare pregnan
ed are
increase d to red cies
erythrop depleted
s 40-45% cell mass result in
oiesis in with
in leading higher
pregnan each
pregnan to prevalen
cy pregnan
cy hemodil ce of
cy
ution & iron
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1/29/2020 25
 CLassification Of Anemia
• Iron Deficiency Anemia
Iron deficiency anemia is the most nutritional deficiency
problem and is the biggest cause of anemia in pregnancy.
As many as 20% of the world's population is known to suffer
from iron deficiency and 50% of individuals suffering from
iron deficiency continue to become iron deficiency anemia.

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 Iron deficiency can be divided into 3 levels, namely:
• The degree of prelaten iron deficiency
Iron reserves in the endothelium ↓ due to plasma ferritin levels ↓ and have
an impact on increasing iron absorption. Hb and serum iron ↓ levels but
biochemical changes have not occurred and have not shown clinical
symptoms.
• The level of latent iron deficiency
Iron reserves in reticuloendothelial ↓ and serum ferritin are also experienced
↓. Biochemical changes occur in the body namely, serum iron and an increase
in Free Erythrochyte Protophorphyrin (FEP). But Hb levels are still normal.
• The level of iron deficiency anemia.
Iron reserves are greatly decrease or even non-existent
Serum iron greatly decreases, Hb levels decrease and an increase in FEP,
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Clear clinical symptoms. At this level it is already called anemia. 30
 • Anemia Due to Acute Blood Loss
In early pregnancy, anemia due to acute blood loss is common in cases
of abortion, ectopic pregnancy, and hydatidiform mole. Postpartum
anemia is much more often caused by obstetric bleeding.

• Anemia Associated with Chronic Disease

Feeling lethargic, losing weight, and pale has long been known as a
characteristic of chronic disease. Various diseases such as chronic kidney
failure, cancer and chemotherapy, HIV infection, and chronic
inflammation, cause moderate and sometimes severe anemia, usually
with erythrocytes that are slightly hypochromic and microcytic
(Cunningham, 2012).

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 Megaloblastic Anemia
This anemia is characterized by abnormalities of blood and bone marrow due to
impaired DNA synthesis.
• Folic Acid Deficiency
In the past, this disease was called pregnancy pernicious anemia. This disease is
usually found in women who do not eat green leafy vegetables, legumes or
animal protein.
• Vitamin B12 deficiency
– Megaloblastic anemia during pregnancy due to vitamin B12 deficiency is
cyanocobalamin
– Autoimmune disease (Addison's pernicious anemia), fails to absorb vitamin B12
which is very rare in women of childbearing age and usually has onset after the
age of 40 years.
– Vitamin B12 deficiency in pregnant women is more likely to be found after
partial or total gastric resection.
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 Aplastic anemia
• Rarely found during pregnancy
• This disease is characterized by pancytopenia and extremely hypocellular
bone marrow. There may be more than one form, and there is evidence
that one of them is related to autoimmune disease.

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 Clinical Presentation
• Depends on severity of anemia
• High risk women – adolescent, multiparous, multiple
pregnancy, lower socio economic status
• Mild anemic - asymptomatic

Mild Moderate Severe

• Pale
Anemia • Palpitatio
Anemia • Fever
Anemia
• Tired, ns • Stomatiti
weak, • Dyspneu s
lethargic • Signs of • Koilonych
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• Anorexia malnutrit ia 34
 Supporting Examination
Enforcement of diagnosis → supporting investigations:
• Hemoglobin levels
• Hematocrit levels
• Erythrocyte index
• Serum iron levels
• Ferritin levels
• TIBC
• Blood smear
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 Most Critical Period
• 28-30 weeks of pregnancy
• In labor
• Immediately after delivery
• Early Puerperium

• CHF
(Failure to cope up with pregnancy induced cardiac load)

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 Red Cell Indices
MCHC –
RBC count –
Decreases,
Decreases in MCV – Low
PCV – one of the
anemia (N in Fe def MCH –
< 32%, most
3.2 anemia, Decreases
(N37 – 47%) sensitive
million/cu microcytic
indices
mm)
(N26-30%)

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 Protoporphy
Special Investigations rin –
Serum Iron
Serum Percentage 30ug/dl, it
Serum Iron binding
Ferritin – saturation ofdoubles or
– capacity –
abnormal if transferrin –triples in Fe
N 65 – 165 300 – 360
< 20 ng/ml 35 – 50%, def anemia (
ug/dl, ug/dl,
(N 40 – 160 decreases tosubstrate to
decreases in increases
ng/dl), less than bind with
Fe def with
assess iron 20% in fe Fe, can not
anemia severity of
stores def anemia be
anemia
converted
into Hb in Fe
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 Other Investigations

Bone
Urine Stool BUN/Serum
marrow X–Ray chest
examination examination Creatinine –
examination – Pulmonary
– RBC & – occult Renal
– refractory TB
Casts blood, ova disease
anemia

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 Effect of Anemia on Pregnancy & Mother
Higher incidence of
pregnancy complications
Predisposed to infections Increased risk to PPH (Post
(Pre Ecamptic Toxaemia,
like – UTI, puerperal sepsis Partum Haemorrhage)
abruptio placentae,
preterm labor)

Maternal mortality – due

to CHF, Cerebral anoxia,
Lactation failure Subinvolution of uterus
Sepsis, Thrombo-
embolism

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 Effect of Anemia on Fetus & Neonate
Anemic
Higher
Low Neonate infant
incidence Higher
IUD APGAR at more with
of Perinatal
(Intrauter birth susceptib cognitive
abortions morbidity
ine le for &
, preterm Low birth &
Death) anemia & affective
birth, weight infectionsmortalitydysfuncti
IUGR
on
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1/29/2020 46
 Treatment For Iron Deficiency Anemia
• Improving diet rich in iron , fruits, and • Heme Iron (found in liver, meat, fish)
leafy vegetables will donate a small amount of iron
• Treat worm infections, maintain (only about 10-15%). However, heme
general hygiene iron is well absorbed, where 10-35%
• Iron & folic acid supplementation of which is eaten will enter the blood
during pregnancy circulation
• Heme iron better, present in animal • Non - Heme Iron (found in grains,
food & is better absorbed beans, dried peas, green fruits and
vegetables such as spinach, sweet
• Iron absorption enhanced by citrous potatoes and kale) is absorbed by
fruits, Vit C only about 2-8%.
• Avoid tea, coffee, Ca, phytates,
phosphates, oxalates, egg, cereals
with iron
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 s-chana
sag,
sarson ka
Cereals - sag, Animal
wheat, chauli. flesh food
ragi, Sowa,
Iron Rich - meat,
jowar, salgam Vit C -liver
bajra Foods
lemon,
orange,
guava,
Jaggery
amla,
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green
 Iron Supplementation in Pregnancy
Iron
Route of administration supplementation
60 mg elemental iron & Oral iron can have side
400 ug of folic acid daily
depends on, severity of not
effects like nausea,
anemia, Gest age,
during pregnancy and 3
compliance & tolerability
recommended
vomiting, gastritis, in
months there after diarrhoea, constipation
of iron first trimester
Higher incidence
In anemia
Various preparations – of miscarriage
fumarate, gluconate,
Therapeutic doses are
succinate, sulfate, Birth defects
180 - 200 mg /d
ascorbate Bacterial
infection
1/29/2020 (bacteria grow 49
 Oral Iron
Contraindication to
Hb Failure to
Oral Iron Therapy
Respond
Indicato
• Hb 8-11 • Intolerance to • Inaccurate rs of
• Feeling
g/dL, early oral iron diagnosis
pregnancy • Severe anemia • Faulty respons
of well
in advanced absorption
pregnancy • Continuous ebeing
to
• Non compliant blood loss
• Co-existant therapy
infection • Improv
• Concomitant
folate deficiency ed look
of
patient
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• Better
 Parenteral Iron TransfusionDose Iron
sucrose
calculated -
for
Weight (Kg) x
parenter
Iron Deficit x
al use
2.2 + 1000
Response - by
mg forin
increase iron
Hb
Increase
stores
level 1g/week in
Reticulocyte
countClinical
with in
5-10 days
symptom
s improve
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 Indications for Blood Transfusion
Severe anemia first
seen after 36 weeks
of pregnancy
Anemia due to
acute blood Loss
– APH & PPH

Anemic & symptomatic pregnant

women (dyspneic, with heart failure
etc) irrespective of gestational age

Patient not
responding to oral or
parenteral therapy

Associated
Infection

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 Management
Blood of Labor
Proper Women
Labor (whole
counseli nursed Intermitt
should &
ng &
Strict in ent O2
be
Precauti packed)
consent
aseptic Prophyla propped
Patent iv toInbe
supervis
on to kept decomp
to be
precauti ctic up
line but given
ed
prevent cross ensated
taken
ons & antibioti position
fluids
infection matched patient
minimal c can be are
& blood diuretic
P/V given avoided
loss given
exams
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 Second & Third Stage of Labor
Oxytocics, P/R
Second stage cut Active management
misoprostol can be
short by forceps or of 3rd stage of labour
given after delivery of
ventouse to be done
fetus

Even normal blood

IV Furosemide given
Injection methergin iv loss may be tolerated
after delivery to
contraindicated poorly in anemic
decrease cardiac load
patient

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 Post Natal Care & Contraception
Watch for subinvolution
Hematinics are
Early ambulation is , puerperal sepsis, CHF,
continued for 3-6
encouraged thrombo-embolism &
months
lactation failure

LAM, barrier
Avoid pregnancy at least contraception, POP after
for 2 years 3 weeks, IUCD or
permanent sterilization

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 Thank You
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