CME Anaemia

ANEMIA SEMASA MENGANDUNG

Anemia di kalangan ibu mengandungOleh Dr Nini Shuhaida Mat Harun Pegawai Perubatan & Kesihatan Klinik Kesihatan Seberang Takir1

Tahap pengetahuan staf semasa pra intervensi mengikut pecahan bahagian soalanSoalan Definisi anemia Klasifikasi anemia Bagaimana anemia berlaku Tanda dan simptom anemia Faktor risiko anemia Nasihat pemakanan yang lengkap Mengenalpasti pengambilan vitamin yang betul Nasihat Komplikasi pada ibu dan janin

Peratus staf yang menjawab dengan betul70% 49% 55% 71% 85% 90% 86% 90%

Mencapai standard baik (80%)X X X X 2

Standard: 85% staf mencapai tahap baik

ANEMIA SEMASA MENGANDUNGAPAKAH ANEMIA? Anaemia bermaksud kekurangan sel darah merah (SDM) Dapat dilihat daripada keputusan hemoglobin (hb) Mengikut WHO: wanita mengandung < 11g%

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ANEMIA SEMASA MENGANDUNGGambar 1 - Sel darah merah yang kecil dan pucat

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ANEMIA SEMASA MENGANDUNG Physiological changes in pregnancy In plasma volume (50%) In red cell mass (18-25% - depends on iron status) These changes cause a dilutional decrease in Hb concentration : physiological anaemia in preg Maximal at 32 w gestation WHO recommend Hb should not fall below 11.0g/dL at any time during pregnancy Appropriate prophylaxis will prevent anaemia of pregnancy5

ANEMIA SEMASA MENGANDUNGSEBAB-SEBAB ANEMIA

Kurang pengambilan zat makanan yang mempunyai protin, zat besi, asid folik, vitamin menyebabkan kurang penghasilan Banyak dikeluarkan- pendarahan Mengandung yang kerap Keguguran berulangan Darah haid yang banyak berak berdarah/buasir Jangkitan cacing

Hemolysis Anemia Hemolitik thalassaemia, malaria, ubatan Aplastic anemia - ubatan6

ANEMIA SEMASA MENGANDUNG Pathological anaemia of pregnancy - mainly iron deficiency (IDA) > 90% of anaemia due to red cell iron deficiency assoc with depleted iron stores & deficient intake Infection will inhibit iron binding from the stores into Hb.

Folate defiency : Minor component & assoc with poor diet

Vit B12 deficiency : Rarely causes anaemia in pregnancy Addisonian pernicious anaemia : does not usually occur in the reproductive years & usually assoc with infertility7

ANEMIA SEMASA MENGANDUNGFACTORS AFFECTING IRON STATUS IN PREGNANT WOMEN Iron absorption : Dietary iron (haem & non-haem) Haem iron contained food : animal blood, flesh & viscera Absorption in normal women : 15-30% but in IDA up to 50% Non-haem iron contained food : cereal, seeds, vege, milk8

ANEMIA SEMASA MENGANDUNG Enhancers of absorption Haem iron, proteins, meat, ascorbic acid, fermentation, ferrous iron, gastric acidity, alcohol, low iron stores, increased erythropoietic activity Inhibitors of iron absorption Phytates, calcium, tannins, tea & coffee, herbal drinks, fortified iron supplements

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ANEMIA SEMASA MENGANDUNGPENGKELASAN ANEMIA

Anemia teruk

Hb < 8gm%

Anemia sederhana Hb 8 - 9gm% Anemia ringan Hb > 9 -11gm%

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ANEMIA SEMASA MENGANDUNGKESAN-KESAN ANEMIA? Bila kurang SDM kekurangan hemoglobin oksigen tidak sampai keseluruh bahagian badan, maka fungsi badan terjejas Cepat penat, letih dan tidak bermaya Tidak dapat melakukan aktiviti seharian Meninggikan risiko ibu yang mengalami pendarahan selepas bersalin Perkembangan janin yang terbantut Keguguran/kematian janin11

ANEMIA SEMASA MENGANDUNG Symptoms : No symptoms ~ mild & moderate C/o feeling of weakness, exhaustion & lassitude, indigestion & loss of appetite In severe cases : palpitation, dyspnoea, giddiness, oedema & rarely generalised anasarca & CCF + symptoms of original conditions.e.g PR bleed

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ANEMIA SEMASA MENGANDUNG Signs : Mild anaemia : no signs Findings : pallor, glossitis & stomatitis Oedema ~ due to hypoproteinaemia Soft systolic murmur at mitral area ~ due to hyperdynamic circulation Fine basal crepitation of lungs ~ due to congestion

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ANEMIA SEMASA MENGANDUNG KOMPLIKASI KEPADA BAYI/JANIN - Premature delivery - IUD - Poor Apgar Score - Low Birth Weight - Perinatal Death

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ANEMIA SEMASA MENGANDUNGKAJIAN ANEMIA/PUNCA ANEMIA

Paras Hemoglobin (Hb) or FBC Paras Ferritin Full blood picture Najis ova/ cyst Blood film parasit malaria Paras Folate dan B12 Hb electrophoresis

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ANEMIA SEMASA MENGANDUNGKEPERLUAN SEHARIAN Kehilangan Zat Besi- haid ~ 30mg/ bulan Keperluan seharian ~ 1mg Ibu hamil- perlu zat besi tambahan janin , uri dan peningkatan keperluan ibu untuk menempuh kehilangan darah semasa bersalin Keperluan harian ~ 2.5mg + 1mg asas = 3.5 mg

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ANEMIA SEMASA MENGANDUNGKEPERLUAN SEHARIAN B12 dan Folic asid ~ sintesis DNA B12 (cobalamin) ~ 6000ug Folic asid ~ 300ug Vitamin C ~ 100 mg

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ANEMIA SEMASA MENGANDUNGRAWATAN ANEMIA Pemakanan- Tinggi kandungan protin, zat besi, asid folik Sumber haiwan- daging merah, daging putih Sumber sayuran- kekacang, sayuran hijau Rawatan jika terdapat pendarahan Merancang keluarga dengan menjarakkan kehamilan Ubatan

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ANEMIA SEMASA MENGANDUNGUBATAN Ferrous fumarate 200mg setiap hari Folic acid 5mg setiap hari Vitamin BCo sebiji setiap hari Vitamin C sebiji setiap hari

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ANEMIA SEMASA MENGANDUNGRAWATAN ANEMIA LAIN: Suntikan Iron dextran Pemindahan darah

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ANEMIA SEMASA MENGANDUNGPENGENDALIAN KES Prophylaxis Ferrous Fumarate 1 biji 200mg elemental iron 60mg Penyerapan 10% - 6 gm Theraputik Ferrous Fumarate 2 biji 400mg elemental iron 120mg Max: 400mg BD (11/11 BD) Penyerapan 10% - 12 gm

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Ferrous ANEMIA SEMASA MENGANDUNG Iberet Folic 500 Obimin Pramilet fumerate

Elemental Iron Vitamin C Niacinamide Calcium Pantothenate Vitamin B1 Vitamin B2 Vitamin B6 Vitamin B12 Folic Acid Vitamin A Vitamin D Calcium Lactate Copper Iodine Dimethyl polysiloxane Ca Mg Zinc

105mg 500mg 30mg 10mg 6mg 6mg 5mg 25mcg 800mcg

30mg 100mg 20mg 7.5mg 10mg 2.5mg 15mg 4mg 250mcg 6000USP 400USP 250mg 0.1mg 0.1mg 20mg

5mg 60mg 10mg 1mg 3mg 2mg 3mg 3mg 500mcg 4000IU 400IU0.15mg 0.1mg 250mg 10mg 0.85mg

60mg

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ANEMIA SEMASA MENGANDUNG Side effect of oral iron administration Related to the quantity given Rare side effect with daily dose to 100 mg & delay introduction till 16 wks gestation Most common complaint : constipation Others nausea Vomiting Diarrhoea abd cramping25

ANEMIA SEMASA MENGANDUNGPENGENDALIAN KES 8g% Menjalani ujian darah untuk mengenal pasti anemia Kaunseling pemakanan dan rawatan Ubatan Hematinik theraputik di beri Pemeriksaan ulangan Hb selepas 3-4 minggu

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ANEMIA SEMASA MENGANDUNGPENGENDALIAN KES 36 minggu Kaunseling pemakanan dan rawatan Ubatan Hematinik theraputik atau suntikan iron dextran Mesti bersalin di hospital Merancang keluarga dengan menjarak kelahiran penting untuk meningkatkan iron store

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ANEMIA SEMASA MENGANDUNG PENGENDALIAN KES

Pastikan ibu-ibu mendapat vitamin tambahan Beri di klinik Pastikan ibu makan ubat vitamin tambahan Tanya Berulangkali Pastikan ubat tambahan berkesan Periksa Hb

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ANEMIA SEMASA MENGANDUNGRawatan Iron Dextran Untuk mengganti Iron store Rawatan secara IM selepas dos percubaan Bagi ibu yg tidak compliance atau ada kesan sampingan pada oral Tidak boleh diberi pd -ibu Thalassemia ,alergi kpd iron dextran Kesan sampingan-sakit di tempat suntikan, gatal, lelah,anaphylaxis30

ANEMIA SEMASA MENGANDUNG Iron deficit is calculated as :

Elemental Iron need (mg) = (Normal Hb-Pts Hb) x weight (kg) x 2.21 + 1000e.g, 65 kg lady with Hb 7.0 g/dL, the iron requirement will be 2005 mg (normal Hb taken as 14) 80 kg lady with Hb 9.0 g/dL, the iron requirement will be 1884 mg31

ANEMIA SEMASA MENGANDUNG With adequate treatment,

An increase of Hb of 0.8g/ dL/ week (1.0 g/ dL/wk in non-pregnant women) in absence of other abnormalities. The response is similar with iron given orally or parenterally. If there is no enough time to achieve reasonable Hb for delivery or symptomatic, transfusion with all its hazards should be considered.

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ANEMIA SEMASA MENGANDUNG Blood transfusion Rarely indicated except severe anaemia regardless of gestation & to replenish blood loss due to APH / PPH Disadv : transfusion reaction, infectious disease

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Gambar 2 Pemindahan darah

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ANEMIA SEMASA MENGANDUNG Normal RBC

1- lymphocyte 2- platlet

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1- ring-shaped RBC 2- microcytic cells 3- faintly visible target cell 4- lymphocyte 5- normal RBC

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Thalassemia trait

1- anisopoikilocytosis2- basophil 3- target cell

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Thalassemia major 1- erythroblasts 2- target cell 3- polychromatic RBC 4- Howell-Jolly body

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ANEMIA SEMASA MENGANDUNGHypochromic microcytic anemia: How to differentiate between Iron Deficiency anemia and Thalassaemia trait

Thal trait Hb RBC N/ N

IDA

MCV,MCHRDW N39


SEKIANTERIMA KASIH

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CME Anaemia