Minggu, 15 Juli 2012

TROMBOSITOPENIA dalam KEHAMILAN

LATAR BELAKANG
Trombositopenia sering terjadi pada seorang ibu dan neonatus yang selalu disebabkan oleh destruksi trombosit (platelet destruction). Kadar trombosit ibu tidak hamil dan neonatus adalah 150.000 – 400.000 / µL ; dan pada wanita hamil umumnya lebih rendah.
Trombositopenia dalam Kehamilan , dapat disebabkan oleh berbagai penyebab:
  • Trombositopenia Gestasional
  • Infeksi virus dan bakteri
  • Preeklampsia dengan komplikasi sindroma HELLP (hemolisis-Elevated Liver Enzyme dan Low Platelet.
Berikut akan dibahas tentang imune trombositopenia , imune trombositopenik purpura (ITP) dan NAIT – neonatal alloimmune thrombocytopenia.

PATOFISIOLOGI
Trombositopenia pada ITP terjadi oleh karena destruksi trombosit yang di mediasi oleh autoantibodi trombosit langsung terhadap antigen permukaan sel. Sistem retikuendotelial merusak antibodi-trombotis komplek. Autoantibodi ini dapat menembus plasenta sehingga dapat mengganggu ibu dan anak.
NAIT disebabkan oleh imunisasi maternal terhadap antigen “fetal paternally plateler-specific antigen ( mirip dengan penyakit Rhesus ). Ibu memiliki jumlah trombosit normal, namun janinnya mengalami trombositopenia berat.
EPIDEMIOLOGI
Angka Kejadian :
Amerika
Angka kejadian ITP : 1 – 2 kasus per 1000 persalinan[2]
Diagnosa ITP ditegakkan saat pemeriksaan antenatal pada pasien dengan riwayat kelainan darah.
Angka kejadian NAIT : 1 – 2 kasus per 1000 persalinan
Internasional
Angka kejadian ITP : 1.8 kasus per 1000 persalinan di Helsinki, Finlandia. [3]
Angka kejdian NAIT : 0.5 kasus per 1000 persalinan dan 1.5 kasus per 1000 neonatus hidup di Inggris dan Perancis. [4]
Di Jepang angka kejadian NAIT 0.3 kasus per 1000 lahir hidup dan adanya inkompatibilitas HPA (human Platelet Antigen) – 4 merupakan etiologi dari 80% kasus. [6] Rekurensi NAIT sangat tinggi (mendekati 100%) [7]
image
Immune thrombocytopenia. An infant born with neonatal lupus syndrome and severe thrombocytopenia. Note extensive bruising and petechiae.
image
Immune thrombocytopenia. An infant born with a cephalohematoma.

MORTALITAS dan MORBIDITAS
  • Resiko ibu bersalin dengan ITP adalah perdarahan, terutama bila jumlah trombosit < 20.000. Trombositopenia neonatus akibat transportasi aktif antibodi trombosit transplasenta menimbulkan masalah klinik yang bermakna dan terjadi 9 dari 66 kehamilan dengan ITP (13.6%). Dari kehamilan tersebut, 5 neonatus dari 66 kehamilan menderita trombositopenia dengan jumlah trombosit < 50.000/µL
  • Trombositopenia neonatus yang hebat menempatkan neonatus dalam resiko perdarahan intrakranial atau viseral.
  • Morbiditas neonatus lebih sering terjadi pada NAIT dengan 10% kematian pada neonatus yang menderita dan 10% menderita kelainan neurologis akibat perdarahan intrakranial. Neonatus yang terkena menunjukkan petechiae generalisata, perdarahan inraabominal dan perdarahan lainnya.
Hemaotoma
Immune thrombocytopenia. Neonatal brain at autopsy showing extensive subdural hemorrhage.

RAS
  • ITP dapat terjadi pada semua ras
  • Lebih dari 50% kasus NAIT terjadi pada ras kulit putih
SEX
  • ITP lebih sering terjadi pada wanita (rasio 3:1).[12]
  • NAIT pada neonatus dapat terjadi pada kedua jenis kelamin
USIA
  • Diagnosa ITP seringkali ditegakkan pada dekade II dan III kehidupan
  • NAIT terjadi dalam kehidupann janin dengan 25 – 50% perdaeahan intrakranial terdeteksi pada pemeriksaan USG prenatal sebelum onset persalinan[13]

 ANAMNESA

  • Ibu hamil dengan ITP dapat tanpa gejala atau dengan gejala ringan (epistaksis atau perdarahan gusi, atau petekiae))
  • Dapat terjadi riwayat menorrhagia atau menometrorrhagia sebelum kehamilan. ·
  • Seorang wanita dengan riwayat persalinan neonatus dengan trombositopenia, perdarahan viseral atau intrkranial patut diduga menderita NAIT. Namun, 50% neonatus dengan NAIT adalah anak pertama .
DIAGNOSA BANDING
Rujukan Kepustakaan
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