FISIOLOGI KEHAMILAN

Pregnancy causes physiologic changes in all maternal organ systems; most return to normal after
delivery. In general, the changes are more dramatic in multifetal than in single pregnancies.
Cardiovascular: Cardiac output (CO) increases 30 to 50%, beginning by 6 wk gestation and
peaking between 16 and 28 wk (usually at about 24 wk). It remains near peak levels until after
30 wk. Then, CO becomes sensitive to body position. Positions that cause the enlarging uterus to
obstruct the vena cava the most (eg, the recumbent position) cause CO to decrease the most. On
average, CO usually decreases slightly from 30 wk until labor begins. During labor, CO
increases another 30%. After delivery, the uterus contracts, and CO drops rapidly to about 15 to
25% above normal, then gradually decreases (mostly over the next 3 to 4 wk) until it reaches the
prepregnancy level at about 6 wk postpartum.
The increase in CO during pregnancy is due mainly to demands of the uteroplacental circulation;
volume of the uteroplacental circulation increases markedly, and circulation within the
intervillous space acts partly as an arteriovenous shunt. As the placenta and fetus develop, blood
flow to the uterus must increase to about 1 L/min (20% of normal CO) at term. Increased needs
of the skin (to regulate temperature) and kidneys (to excrete fetal wastes) account for some of the
increased CO.
To increase CO, heart rate increases from the normal 70 to as high as 90 beats/min, and stroke
volume increases. During the 2nd trimester, BP usually drops (and pulse pressure widens), even
though CO and renin and angiotensin levels increase, because uteroplacental circulation expands
(the placental intervillous space develops) and systemic vascular resistance decreases. Resistance
decreases because blood viscosity and sensitivity to angiotensin decrease. During the 3rd
trimester, BP may return to normal. With twins, CO increases more and diastolic BP is lower at
20 wk than with a single fetus.
Exercise increases CO, heart rate, O
2
consumption, and respiratory volume/min more during
pregnancy than at other times. The hyperdynamic circulation of pregnancy increases frequency
of functional murmurs and accentuates heart sounds. X-ray or ECG may show the heart
displaced into a horizontal position, rotating to the left, with increased transverse diameter.
Premature atrial and ventricular beats are common during pregnancy. All these changes are
normal and should not be erroneously diagnosed as a heart disorder; they can usually be
managed with reassurance alone. However, paroxysms of atrial tachycardia occur more
frequently in pregnant women and may require prophylactic digitalization or other
antiarrhythmic drugs. Pregnancy does not affect the indications for or safety of cardioversion.
Hematologic: Total blood volume increases proportionally with CO, but the increase in plasma
volume is greater (close to 50%, usually by about 1600 mL for a total of 5200 mL) than that in
RBC mass (about 25%); thus, Hb is lowered by dilution, from about 13.3 to 12.1 g/dL. This
dilutional anemia decreases blood viscosity. With twins, total maternal blood volume increases
more (closer to 60%).
WBC count increases slightly to 9,000 to 12,000/L. Marked leukocytosis ( 20,000/L) occurs
during labor and the first few days postpartum.
Iron requirements increase by a total of about 1 g during the entire pregnancy and are higher
during the 2nd half of pregnancy6 to 7 mg/day. The fetus and placenta use about 300 mg of
iron, and the increased maternal RBC mass requires an additional 500 mg. Excretion accounts
for 200 mg. Iron supplements are needed to prevent a further decrease in Hb levels because the
amount absorbed from the diet and recruited from iron stores (average total of 300 to 500 mg) is
usually insufficient to meet the demands of pregnancy.
Urinary: Changes in renal function roughly parallel those in cardiac function. GFR increases 30
to 50%, peaks between 16 and 24 wk gestation, and remains at that level until nearly term, when
it may decrease slightly because uterine pressure on the vena cava often causes venous stasis in
the lower extremities. Renal plasma flow increases in proportion to GFR. As a result, BUN
decreases, usually to < 10 mg/dL (< 3.6 mmol urea/L), and creatinine levels decrease
proportionally to 0.5 to 0.7 mg/dL (44 to 62 mol/L). Marked dilation of the ureters
(hydroureter) is caused by hormonal influences (predominantly progesterone) and by backup due
to pressure from the enlarged uterus on the ureters, which can also cause hydronephrosis.
Postpartum, the urinary collecting system may take as long as 12 wk to return to normal.
Postural changes affect renal function more during pregnancy than at other times; ie, the supine
position increases renal function more, and upright positions decrease renal function more. Renal
function also markedly increases in the lateral position; this position relieves the pressure that the
enlarged uterus puts on the great vessels when pregnant women are supine. This positional
increase in renal function is one reason pregnant women need to urinate frequently when trying
to sleep.
Respiratory: Lung function changes partly because progesterone increases and partly because the
enlarging uterus interferes with lung expansion. Progesterone signals the brain to lower CO
2

levels. To lower CO
2
levels, tidal and minute volume and respiratory rate increase, thus
increasing plasma pH. O
2
consumption increases by about 20% to meet the increased metabolic
needs of the fetus, placenta, and several maternal organs. Inspiratory and expiratory reserve,
residual volume and capacity, and plasma Pco
2
decrease. Vital capacity and plasma Po
2
do not
change. Thoracic circumference increases by about 10 cm. Considerable hyperemia and edema
of the respiratory tract occur. Occasionally, symptomatic nasopharyngeal obstruction and nasal
stuffiness occur, eustachian tubes are transiently blocked, and tone and quality of voice change.
Mild dyspnea during exertion is common, and deep respirations are more frequent.
GI and hepatobiliary: As pregnancy progresses, pressure from the enlarging uterus on the rectum
and lower portion of the colon may cause constipation. GI motility decreases because elevated
progesterone levels relax smooth muscle. Heartburn and belching are common, possibly
resulting from delayed gastric emptying and gastroesophageal reflux due to relaxation of the
lower esophageal sphincter and diaphragmatic hiatus. HCl production decreases; thus, peptic
ulcer disease is uncommon during pregnancy, and preexisting ulcers often become less severe.
Incidence of gallbladder disorders increases somewhat. Pregnancy subtly affects hepatic
function, especially bile transport. Routine liver function test values are normal, except for
alkaline phosphatase levels, which increase progressively during the 3rd trimester and may be 2
to 3 times normal at term; the increase is due to placental production of this enzyme rather than
hepatic dysfunction.
Endocrine: Pregnancy alters the function of most endocrine glands, partly because the placenta
produces hormones and partly because most hormones circulate in protein-bound forms and
protein binding increases during pregnancy.
The placenta produces a hormone (similar to thyroid-stimulating hormone) that stimulates the
thyroid, causing hyperplasia, increased vascularity, and moderate enlargement. Estrogen
stimulates hepatocytes, causing increased thyroid-binding globulin levels; thus, although total
thyroxine levels may increase, levels of free thyroid hormones remain normal. Effects of thyroid
hormone tend to increase and may resemble hyperthyroidism, with tachycardia, palpitations,
excessive perspiration, and emotional instability. However, true hyperthyroidism occurs in only
0.08% of pregnancies.
The placenta produces corticotropin-releasing hormone (CRH), which stimulates maternal
ACTH production. Increased ACTH levels increase levels of adrenal hormones, especially
aldosterone and cortisol, and thus contribute to edema. Increased production of corticosteroids
and increased placental production of progesterone lead to insulin resistance and an increased
need for insulin, as does the stress of pregnancy and possibly the increased level of human
placental lactogen. Insulinase, produced by the placenta, may also increase insulin requirements,
so that many women with gestational diabetes develop more overt forms of diabetes (see
Diabetes Mellitus and Disorders of Carbohydrate Metabolism: Diabetes Mellitus (DM) and
Pregnancy Complicated by Disease: Diabetes Mellitus in Pregnancy (Gestational Diabetes)).
The placenta produces melanocyte-stimulating hormone (MSH), which increases skin
pigmentation late in pregnancy. The placenta also produces the subunit of human chorionic
gonadotropin (-hCG), a trophic hormone that, like follicle-stimulating and luteinizing
hormones, maintains the corpus luteum and thereby prevents ovulation.
The pituitary gland enlarges by about 135% during pregnancy. The maternal plasma prolactin
level increases by 10-fold. Increased prolactin is related to an increase in thyrotropin-releasing
hormone production, stimulated by estrogen. The primary function of increased prolactin is to
ensure lactation. The level returns to normal postpartum, even in women who breastfeed.
Dermatologic: Increased levels of estrogens, progesterone, and MSH contribute to pigmentary
changes, although exact pathogenesis is unknown. These changes include melasma (mask of
pregnancy), which is a blotchy, brownish pigment over the forehead and malar eminences;
darkening of the mammary areolae, axilla, and genitals; and linea nigra, a dark line that appears
down the midabdomen. Melasma due to pregnancy usually regresses within a year.
Incidence of spider angiomas, usually only above the waist, and thin-walled, dilated capillaries,
especially in the lower legs, increases.
MAYO CLINIC CAUSES IDA
Iron deficiency anemia occurs when your body doesn't have enough iron to produce hemoglobin.
Hemoglobin is the part of red blood cells that gives blood its red color and enables the red blood
cells to carry oxygenated blood throughout your body. If you aren't consuming enough iron, or if
you're losing too much iron, your body can't produce enough hemoglobin, and iron deficiency
anemia will eventually develop.
Causes of iron deficiency anemia include:
Blood loss. Blood contains iron within red blood cells. So if you lose blood, you lose
some iron. Women with heavy periods are at risk of iron deficiency anemia because they
lose blood during menstruation. Slow, chronic blood loss within the body such as from
a peptic ulcer, a hiatal hernia, a colon polyp or colorectal cancer can cause iron
deficiency anemia. Gastrointestinal bleeding can result from regular use of some over-
the-counter pain relievers, especially aspirin.
A lack of iron in your diet. Your body regularly gets iron from the foods you eat. If you
consume too little iron, over time your body can become iron deficient. Examples of iron-
rich foods include meat, eggs, leafy green vegetables and iron-fortified foods. For proper
growth and development, infants and children need iron from their diet, too.
An inability to absorb iron. Iron from food is absorbed into your bloodstream in your
small intestine. An intestinal disorder, such as celiac disease, which affects your
intestine's ability to absorb nutrients from digested food, can lead to iron deficiency
anemia. If part of your small intestine has been bypassed or removed surgically, that may
affect your ability to absorb iron and other nutrients.
Pregnancy. Without iron supplementation, iron deficiency anemia occurs in many
pregnant women because their iron stores need to serve their own increased blood
volume as well as be a source of hemoglobin for the growing fetus.
EFFECTS IDA AND PREGNANCY
Negative Effects on the Mother During Pregnancy and the Perinatal Period.
a) Reproduction-related mortality.
It has been clearly demonstrated that the anemic pregnant woman is at greater risk of death
during the perinatal period. Close to 500,000 maternal deaths ascribed to childbirth or early post-
partum occur every year, the vast majority taking place in the developing world. Anemia is the
major contributory or sole cause in 20-40% of such deaths (6). In many regions anemia is a
factor in almost all maternal deaths, and it poses a 5 fold increase in the overall risk of maternal
death related to pregnancy and delivery. The risk of death increases dramatically in severe
anemia. In Zaria, Nigeria, Harrison (7) reported that mortality for women during delivery or
shortly after was 20% if their haemoglobin (Hb) concentration was <50g/L. Mortality decreased
as Hb concentration rose: 4.5% for Hb levels between 60 and 50 g/L, Average figures of 12.8%
applied for Hb concentrations <60g/L in contrast to 2.9% among women whose Hb level was
between 80 and 60 g/L. Overall maternal mortality was 1 %, not very different from that in many
parts of Africa, Asia and among certain Latin American populations. These rates of maternal
deaths, mostly associated with pregnancy and delivery, contrast with those in the industrial world
where maternal mortality is near 100 times less and severe anaemia is very rare. It is important to
realize that severe anaemia is associated with very poor overall socioeconomic and health
conditions in certain countries and regions of the developing world. As a rule malaria, other
infections, and multiple nutritional deficiencies, including folate and vitamin A are also endemic
in these populations. Iron deficiency, however, is responsible for, or contributes significantly to,
the majority of anaemia cases during pregnancy.
The risk of complications during birth, including fetal mortality, is higher among stunted
populations who also exhibit poor pelvic development. General undernutrition and specifically
iron and folate deficiencies during childhood and adolescence impair physical growth. Both iron
and folate supplementation can result in improved growth in children and in pregnant teenage
girls.
b) Performance during pregnancy and delivery.
Iron deficient anemic women have shorter pregnancies than non-anemic, or even anemic but not
iron deficient pregnant women. An elegant prospective study showed that all anemic pregnant
women had a higher risk of pre-term delivery in relation to non-anemic women (8). The iron-
deficient, anemic group had twice the risk of those with anemia in general. However, iron-
deficient, non-anemics did not differ from other non-anemics. These results were obtained after
controlling for maternal age, parity, ethnicity, prior low birth-weight or pre-term delivery,
bleeding at entry to health care, gestational age at initial blood draw, number of cigarettes
smoked per day, and pre-pregnancy body mass index (Wt/Ht-squared). Inadequate gestational
weight gain (for gestational age) was significantly higher for all anemic cases, particularly
among those that were iron-deficient. Inadequate weight gain has also been associated with pre-
term delivery.
In some tropical populations, folate supplementation also resulted in improved hematological
status, birth weight and reduced incidence of premature deliveries, suggesting a deficiency of
this nutrient.
These results confirm and clarify other retrospective studies or provide indirect evidence that
better nutrition, including lesser prevalence of anemia, was associated with better newborn
weights and lower rates of pre-term deliveries, and that anemia was associated with increased
risk of pre-term delivery. The more severe the anemia the greater the risk of low-birth weight. It
must be mentioned here that elevated hemoglobin levels because of poor plasma expansion due
to other pathological conditions are also associated with poor pregnancy outcomes.
Delivery demands endurance and severe physical effort and physically fit women (almost an
impossibility in the face of severe anemia) perform better and have less complications during
delivery when contrasted with less fit women. In severe anemia, cardiac failure during labour is a
major cause of death.
c) Lactation performance.
There is no evidence that iron deficient or anemic mothers are less competent than their normal
counterparts in the process of lactation, and milk composition, both in terms of macro and micro-
nutrients is essentially unaltered.
However even under the best of circumstances, breast milk iron has been proven insufficient to
maintain an adequate iron nutrition in infants beyond 4 to 6 months of age.
d) Working capacity and general well-being.
Even though there are no direct data on the effect of anemia and iron deficiency on the capacity
of pregnant women to perform physical work in relation to non-anemic-iron-sufficient pregnant
women, the negative relationship between anemia and working capacity is well established in
both men and women. The impact of pregnancy anemia and its residual anemia and iron
deficiency surely affects the woman as a mother, as a worker and as a person in general.
e) Immunity status.
Two studies in India demonstrate that severely anemic as well as iron deficient pregnant women
have impaired cell mediated immunity that is reversible with iron treatment. An important
control variable lacking in these studies is documentation of folate nutrition.
Negative Effects on the Infant.
a) Health and development.
Two large studies in the industrial world involving over 100,000 pregnancies clearly indicate that
favourable pregnancy outcomes are less frequent among anemic mothers (9,10). Both studies
found higher rates of fetal deaths and abnormalities, premature deaths, and low birth weight
newborns among anemic mothers. These risks were evident even among mothers who had
anemia only in the first half of pregnancy. Significant correlations between the severity of
anemia, premature birth, and low birth weight were very evident.
The causality of anemia in these undesirable pregnancy outcomes has been established further by
studies that show the positive results obtained in birth weights and perinatal deaths by the
successful treatment of anemia with iron and folic acid. For example, low birth weight (<2,000g)
was reduced from 50% to 7% and perinatal mortality dropped from 38% to 4% in a study in
Nigeria (11).
In terms of infant health and development, the low birth weight child is at a disadvantage
particularly in the developing world where the risk of malnutrition, infection and death are
markedly increased. An additional risk to the infant may come from the fact that iron deficiency
and anemia in children, as well as in adults, produce alterations in brain function that may result
in poor mother-child interactions and impaired schooling later. There is mounting evidence that
in infants iron deficiency anaemia may produce long-lasting defects in mental development and
performance that my further impair the childs learning capacity..
b) Hematological status and iron nutrition.
Mild maternal iron deficiency and anemia have little significant repercussions on the
hematological status of newborns. It has been suggested that placental transferring receptors
protect the fetus. However, it appears that the capacity of iron to transfer from placenta to fetus is
limited by a threshold mechanism so that fetal iron deficiency exists in severe maternal iron
deficiency and anemia. Also, the fetus of iron deficient mothers accumulates less iron reserves,
and has smaller hemoglobin mass than their normal counterparts. This has been termed hidden
iron deficit and is further magnified by low birth weight, mainly due to preterm delivery.
Further evidence of hidden iron deficiency at birth comes from studies that showed that
maternal and cord serum ferritin levels were lower in the presence of maternal iron deficiency
and that this difference with children from non-anemic mothers was magnified when the children
were again studied at 2 months of age. This may account for the well documented higher
prevalence of iron deficiency and anemia in late infancy among populations where anemia of
pregnancy is highly prevalent. This situation increases the risk of long term and even permanent
impairments in mental and physical development among such children.

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