Pendekatan Kasus

rima.irwinda@gulardicentre.com

Kasus
Ny. 26 tahun, G2P1 hamil 8 minggu, datang untuk melakukan
asuhan antenatal
Riwayat depresi post partum pada kehamilan pertama
Anak pertama: berat lahir 2580 g pada usia kehamilan 39
minggu
Laboratorium:

Hb 10 g/d
Ht 29%
MCV 80
MCH 28
MCHC 30

Diagnosis?
Anemia mikrositik hipokrom
The Centers for Disease Control and Prevention:
1st and 3rd trimester Hb concentration < 11 g/dL

Hb concentration <10.5 g/dL in the second trimester

World Health Organization (WHO): hemoglobin levels of 11 g/dl
or hematocrit of < 33%

JIMSA October - December 2010 Vol. 23 No. 4

 Hemoglobin
Hematocrit (Hct)
RBC count
Serum iron
Serum ferritin
Total iron binding capacity

NO change in the mean corpuscular volume (MCV)

or in the mean corpuscular Hb concentration (MCHC)
Diagnostic Pathology 2012, 7:168

Hemoglobin

THALASSEMIA

Iron, vitamin B12 and

folic acid deficiency

 The ratio of the volume of red cells to the volume of whole

blood.
Both hemoglobin and hematocrit are dependent on plasma
volume.
Significant inverse relationship of hematocrit in the second
half with height (p = 0.024 and r = -0.093) and weight (p =
0.03 and r = -0.095) at birth.

Iranian Journal of Nursing and Midwifery Research | February 2012 | Vol. 17 | Issue 2

MCV, MCH, MCHC

The mean of the red blood cell distribution histogram (microcytic,
normocytic or macrocytic)
Are not sensitive indicators for diagnosing anemia/IDA because
they are reduced only when anemia is well established

Diagnostic Pathology 2012, 7:168

J Med Assoc Thai. 2009 Jun;92(6):739-43.

 MCH < 26.5 pg: sensitivity 95.2%, specificity 82.3%,

PPV 40.4% and NPV 99.3%.
MCV 80 fl: sensitivity of 92.9%, specificity 83.9%,
PPV 37.9% and NPV 99.1%

J Med Assoc Thai. 2009 Jun;92(6):739-43

Diagnostic Pathology 2012, 7:168

Pemeriksaan tambahan apa yang diperlukan?

Red Blood Cells

Anucleated and contain hemoglobin
Most abundant blood cells (4.5-5.5 x 106
cells/mm3)
Biconcave disc
Provides a large surface area for O2 entry/exit
Enables them to bend and flex when entering
small capillaries

2-3 million red blood cells (RBCs) are produced every second and
require 3040mg of iron delivered to the erythron to make 30 pg
of hemoglobin per cell, a total of 6 g of hemoglobin daily.
Advances in Hematology Volume 2010, Article ID 605435, doi:10.1155/2010/605435

Red Distribution Width (RDW)

A quantitative measure of variability in the size of circulating
erythrocytes (normal range: 11.5 - 14.5%)
Can reflect early changes in RBCs

Diagnostic Pathology 2012, 7:168

Red Distribution Width (RDW)

Performance of RDW in the diagnosis of IDA among pregnant women at Khartoum Hospital

Diagnostic Pathology 2012, 7:168

Peripheral Blood Film

Changes are less prominent
during pregnancy than during
the non-pregnant condition,
even in moderate iron
deficiency

Peripheral blood film with changes attributed

to iron deficiency anemia

Diagnostic Pathology 2012, 7:168

Reticulocyte
Used as a marker of erythropoiesis in the bone marrow

Reticulocyte

An increase is seen in acute blood loss or hemolysis

A decrease is seen in iron, B12, folate deficiency, inadequate
erythropoietin response, intrinsic problem in the bone marrow

Reticulocyte Hemoglobin Content (CHr)/

Reticulocyte Hemoglobin Equivalent (RET-He/RET-Hb)
Measures of the hemoglobin content in reticulocytes
Affected to a lesser degree by inflammation (vs iron, ferritin,iron
binding capacity and transferin saturation)

haematologica 2005; 90:11331134

Rather than examining the Hb content of the entire RBC

population that may be anywhere between 1 and 120 d old, the
CHr provides a snapshot of how much iron was available for RBC
production in a clinically relevant timeframe.
haematologica 2005; 90:11331134

Ferritin
High molecular weight protein that consists of approximately 20%
iron; provide a store of iron that is available for protein and haem
synthesis
Found in all cells, but especially in hepatocytes and
reticuloendothelial cells

Assessing the iron status of populations

Incubation
Early convalescence
Late convalescence

30%
90%
36%

Serum ferritin was related to APP concentrations, but poor PPV (<72%)

Inflammation increased ferritin by 30% and was associated with a 14%

(CI: 7%, 21%) underestimation of ID
Am J Clin Nutr 2010;92:54655
Am J Clin Nutr 2006;84:1498505

Serum Iron
A measure of the amount of iron bound to transferrin
Normal 50-150 ug/dL
When the SI < 50 Ug/dL, the erythroid marrow cannot increase
production above basal levels and new red blood cells will be
poorly hemoglobinized

Total Iron Binding Capacity

Equivalent to measuring the level of transferrin protein

Normal 300 360 Ug/dL
TIBC changes independently of the SI in situations of iron deficiency
Used to calculate a percent saturation of transferrin

Kasus
Nama
Pemeriksaan

Hasil

Nilai Rujukan

Satuan

Hemoglobin

10

11.7-15.5

g/dL

Hematokrit

29

35-47

Eritrosit

3.5

3.8-5.2

106/L

MCV

79.1

80-100

fL

MCH

26.9

26-34

pg

MCHC

31

32-26

g/dL

RDW-CV

16

11.5-14.5

% Retikulosit

0.7

0.50-1.70

Ret-He

32.8

24.1-35.8

pg

Ferritin

8.9

11-148

ng/mL

Serum Iron

45

50-150

ug/dL

TIBC

385

300-360

ug/dL

Diagnosis?

Brain does not function normally while it is iron deficient

A strong relation between iron status and depression, stress,
and cognitive functioning

J. Nutr. 135: 267272, 2005

J HEALTH POPUL NUTR 2013 Sep;31(3):398-402

Birth Weight Is Influenced by the Mothers Iron

Status

BMJ 2013;346:f3443 doi: 10.1136/bmj.f3443

Stages

Okonko et al. J Am Coll Cardiol 2011;58:124151

World Health Organization (WHO)
U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md.: Williams & Wilkins,
1996:231-46.
Guyatt GH et al. J Gen Intern Med 1992;7:145-53

Dietary Iron Intake Is Inadequate in the Majority of

Pregnant Women
The demand for absorbed iron increase steadily during pregnancy
from 0.8mg/day in the initial 10 weeks of gestation to 7.5mg/day in
the last 10 weeks of gestation (during the entire gestation period, the
average demand is 4.4mg/day)

The majority of the women (>90%) have

an iron intake below the recommended
intake of 1518 mg/day in women of
fertile age

Iron intake from the diet

Heme-iron
containing food
Iron from meat, poultry
and fish (heme iron)
is 2-3 times
more absorbable
than non-heme iron

Non heme-iron
containing food

Vitamin C
enhances non-heme
iron absorption

Plant-based food
Absorption influenced by the
presence of enhancing and
inhibiting factors

Iron
absorption

Inhibitors of non-heme
iron absorption:
Phytates (bran, brown rice)
Calcium (dairy products)
Polyphenols (certain vegetables and tannins in tea)

Centers for Disease Control and Prevention.MMWR Recomm Rep 1998;47(RR-3):129

Iron Supplements in Pregnancy

Many studies have shown that pregnant women taking iron
supplements have higher iron status and higher hemoglobin
compared to women not taking supplements, and still
recognizable many months after the women have given
childbirth

When to start?

How Little is Enough?

Time
Low-dose iron prophylaxis should probably start when
pregnancy is planned or as early in pregnancy as possible
Supplementation starting in the first trimester was more effective
than that staring in the second trimester and adjusted odds ratios for
low birth weights were even more favorable (0.14; 95% confidence
limits: 0.050.40)

Could a daily multivitamin-multimineral

supplement especially designed for pregnant
women?

72% of pregnant women taking a multivitamin-multimineral supplement

containing 18 mg ferrous iron develop iron deficiency.
Absorptive interaction of iron with the other divalent metal ions
contained in the tablets (zinc, copper, manganese, selenium, chromium,
molybdenum, and sometimes calcium).

WHO dosage schedules for iron supplementation

to prevent iron deficiency
Population

Indication for
supplementation

Dosage
schedule

Duration

Pregnant women

All women

60 mg iron/day

6 months in pregnancy

Postpartum women

Areas where anemia

prevalence is 40%

60 mg iron/day

3 months postpartum

Children 6-24
months of age

All children

12.5 mg iron/day 6-12 months of age*

Areas where anemia

prevalence is 40%

12.5 mg iron/day 6-24 months of age*

* 2-24 months if low birth weight (<2500 g)

World Health Organization (2001). WHO Guidelines for the Use of Iron Supplements to Prevent
and Treat Iron Deficiency Anemia WHO/NHD/01.3.
http://www.who.int/nutrition/publications/micronutrients/guidelines_for_Iron_supplementation.pd

Oral Iron Supplement

Iron Size

Dose of salt in mg

Elemental Iron

Ferrous fumarate

200

65

Ferrous sulphate

300

60

Ferrous sulphate dried

200

65

Ferrous succinate

100

35

Ferrous gluconate

300

35

JIMSA October - December 2010 Vol. 23 No. 4

Oral Iron Supplement

Hemoglobin increases within 2-3 weeks after iron supplementation.
Therapeutic doses of iron should increase hemoglobin levels by 0.31.0 g/dL per week.
Reticulocyte response occurs within 5-10 days after initiation of iron
therapy.
Adequate iron replacement has typically occurred when the serum
ferritin level reaches 50 g/L .

JIMSA October - December 2010 Vol. 23 No. 4

Responsiveness to oral iron therapy

Baseline hepcidin levels are a
better predictor of
responsiveness to oral iron
therapy than ferritin measures
A hepcidin >20 ng/mL: PPV 81.6%
for non-responsiveness to oral iron
therapy
Ferritin >30 ng/mL and TSAT >15%:
PPV 59.2% and 55%

Parenteral Forms
Iron dextran
Sodium ferric gluconate
Iron sucrose
Iron sucrose and sodium ferric gluconate preparations
appear to have fewer adverse events, including
anaphylaxis, in part because of lower molecular weights.

Erythropoiesis

proteins (erythropoietin)
iron
zinc
cobalt
copper,
folic acid
vitamin B 12 [cyanocobalamin]
vitamin C
Pyridoxine
riboflavin

JIMSA October - December 2010 Vol. 23 No. 4

Thank you