Triple

Eliminasi

dr.Anwar Fauzi, M.Ked.Klin, Sp.OG

 Triple Eliminasi

• Tujuan negara  meningkatkan derajat kesehatan  ibu

dan anak dalam kandungan
• Hak anak  UU No.17 Tahun 2016 tentang Perlindungan
Anak

Target
2020  90% ibu hamil dapat diperiksa, dideteksi dan diobati
Program Triple Eliminasi
Permasalahan

Mother to child transmision

 Pola penularan

• Hubungan seksual tidak aman

• Kontaminasi darah dan produk
darah
• Vertical transmision
2016
3E – MTCT / PPIA

ANC HIV Sifilis Hep B

Deteksi
dini Tes HIV Tes Sifilis Tes Hep B

R1 (+), R2 (+), R3 (+) TP Rapid Rapid Hep B

Hasil
+
ARV
+
Benzatin Penisilin G
+
ANC KDT 1 tab/24jam
seumur hidup
2,4 juta IU
boka-boki
Pengawasan
ketat

6/30/2019 3jk
Human Immunodeficiency Virus

Retrovirus RNA

Decrease of immune system  oppurtunistic

infection
Transmision - Vertical transmision 
mother to child transmision
(MTCT)
- Transexual transmision
- Horizontal transmision
(blood transfusion, drug
abuse with injection, tatto,
hemodialisa, etc)
World  2015 : 36,7 milions (34,0- 39,8)
New cases 2013  2,1 milions
 adult : 1,9milions
 child 240.000
 Diagnosis HIV
1. Epidemiological risk factors
- life style  high risk sexual activities
- Sexual transmited dissease
- drug abuse with injection, tatto
2. WHO criteria
3. Laboratoris

Pregnant women ≈ adult

 Diagnosis HIV
Clinical criteria WHO
Clinical stage 1
- Asimptomatic
- Normal activities, asimptomatic
Clinical stage 2
- Body lose (<10%), mucocutaneus manifestation, recurrent respiratorius
infection
- Normal activities, simptomatic
Clinical stage 3
- Body lose (>10%), chronical diarhe, fever, candidiasis oris, TBC pulmoner,
severe bacterial infection
- Weak body, <50% activities at bed
Clinical stage 4
- Oportunistic infection : PCP, encefalitis toxoplasmosis, chronic diarhe, CMV
infection, sarcoma kaposi, TB extrapulmoner, encefalopati HIV
- very weak, >50%activities at bed
Diagnosis HIV

1) Serologic test
- Rapid test
- Enzyme
Immunoassay (EIA)
test
- Wastern Blot test
2) Virologi test
- HIV DNA
kualitative (EID)
- HIV RNA
kuantitative
 Vertical transmission  important to child infection
• Ascending infection from plasenta
• Maternal vaginal/cervical
Without prevention  20-50% infected
5-10%  during pregnancy
10-20%  delivery
5-20%  breastfeeding

• Primary prevention so that women are not infected with HIV

• Prevention of unwanted pregnancies at women with HIV
• Prevention from mother to child transmision
• Psychological and social support , mother and child care

With appropriate effort, the risk of transmission can be reduced to less

than 2%. Even less than 1% if ARV already given long time before
pregnancy
ARV recommendation according to the health ministry
World Health Organisation, 2013
 Vertical transmission  important to child infection
• Diagnosis
• ARV and prophylaxis ARV at baby
• Sectio caesarean delivery
• Non breastfeeding

WHO (2013)
- Viral load < 1000 copies/ml and Vaginal delivery can be considered
- ARV > 6 month

After delivery
1) Baby  profilaksis Zidovudine until 6 weeks  evaluation VL 4-6
weeks
2) Non breastfeeding

World Health Organisation, 2013

 Delivery
• To Reduce transmission from mother to child  elective SC
• WHO (2013) : vaginal delivery can be consideration if patient
consumption ARV > 6 month and viral load value < 1000
World Health
copies/ml
Organization

Criteria Theory
ARV (+)
< 14 weeks
Viral load (+)
< 1000 copies/ml

Delivery SC (+) or
Vaginal (+)
 Neonatal Governance
Criteria Theory
ARV prophylaxis (+)
< 12 hours after
delivery
Evaluation Viral load 4-6 weeks
4-6 month

Feeding Breastfeeding (+) or

Formula (+)
Immunization Can be given if the
baby does not show
clinical symptoms

With appropriate effort, the risk of transmission can be reduced to less than 2%.
Even less than 1% if ARV already given long time before pregnancy
Hepatitis B
• Hepadnaviridae
• DNA virus
• Tidak sitopatik
• Lebih dari 240 juta pengidap hepatitis B kronik, dengan kematian
mencapai 800.000/tahun

• 78% kanker hati dan 57% sirosis hati disebabkan infeksi kronik
virus hepatitis
 Hep B
Faktor Resiko

- Multiple sexual partners

- Pekerja yg sering terpapar
- Intravenous drug abuse
- Riwayat transfusi
- Chronic hospitalization

Semua ibu hamil dilakukan pemeriksaan tanpa

memperhatikan faktor resiko
 Hep B
Risk of the fetus of acquiring HBV infection
1. Usia Kehamilan
 10% jika terinfeksi ditrimester pertama & 90% jika
terinfeksi di trimester ketiga
2. Maternal infectivity status
 10-20% HbsAg (+)
 90% HbsAg (+) + HbeAg (+)
 Serological screening Hep B
• HBsAg (serface antigen  viral surface and free ini maternal
serum)
• HBcAg (core antigen  in hepatocytes)
• HBeAg (envelope antigen  expressed of a high viral load and
marker of high infectivity)

Liver function test

Hemostatic status
Bilirubin
Dampak hepatitis B terhadap
Kehamilan
• Kontroversi
1. Tidak berpengaruh
2. Berpengaruh
- premature
- KPD
- mortalitas perinatal
- BBLR

• Teoritis  flare
• Secara klinis tidak signifikan
 Transmisi vertikal
intrauterine perinatal postnatal

Small size HbeAg HbsAg and HbeAg

pass throuh transmision during
placenta delivery

Failure of
immuno-
prophylaxis

HbsAg (+) & HbeAg (-) ~ 3,7-9,9 %

HbsAg (+) & HbeAg (+) ~ 9,8-17,39 %
HbsAg (+) & HbeAg (-) ~ 10-30 %
HbsAg (+) & HbeAg (+) ~ 70-90 %
Insiden meningkat  viral load
 Tatalaksana Hepatitis B dan
Pencegahan transmisi vertikal

Vaksin Hep B dan HBIg

ARV pada ibu hamil

Telbivudine &Tenovofir

C sectition vs normal delivery

Syphilis
• Treponema palidum
• Sexual acquired
(except in case
vertical
transmission)
• High risk of fetal
infection
 Pemeriksaan rutin pada ibu hamil pada
kunjungan pertama
• Identifikasi faktor resiko

• Kenali perjalanan penyakit dan gejala

• Serelogical screening
 Clinical manifestations
• Primary syphilis
- papule, ulcerated, indurated margin and regional lymphadenopathy
- 3-6 weeks

• Secondary syphilis
- generalized maculopopular rash, genital lesion, general lympohadenopathy,
fever, pharyngitis
- 6 weeks – 6 month

• Latent syphilis
- usually subclinical

• Tertiary syphilis
- gumma formation, CV disease, neurosyphilis
- 5-20 years
Serelogical screening
 Treponema pallidum
• Menembus barier plasenta  stadium
berapapun dan usia hamil kapanpun
• Infeksi natal  IUGR, preterm, stillbirth, hydrops
fetalis, BBLR, neonatal death, congenital
anomalies

70-100% untreated
vs
1-2 % adequately treated in pregnancy
 Strategi
Nasional

• Meningkatkan akses dan kualitas layanan bagi

ibu hamil
• Ibu menyusui sesuai standar
• Meningkatkan peran fasilitas pelayanan
kesehatan
• Peningkatan sumberdaya di bidang kesehatan
• Kemitraan lintas program dan lintas sektor
• Peran serta masyarakat