Annual Meeting

indonesian
indonesian society
societyOF
OF
maternal
maternalfetal
fetalmedicine
medicine

Evaluasi dan Perawatan Postpartum –

Interval pada Pasien Pasca Kelahian
Preterm dan Pertumbuhan Janin
Terhambat
Nugrahanti Prasetyorini

Fakultas Kedokteran Universitas Brawijaya

Himpunan Kedokteran Feto-Maternal Malang
 Background
• Pregnancy presents a unique opportunity in a woman's life course to consider her health
over the long term.

• It is known that adverse pregnancy outcomes (APO) are associated with later life risks for
type 2 diabetes mellitus and cardiovascular disease (hypertension, ischæmic heart disease,
and stroke.)

• The number of women dying because of CVD has increased recently.

• The post pregnancy period presents a unique opportunity to improve maternal long-term
health.

• Pregnancy complications can be reviewed and management plans devised to arrange follow-
up to ensure that women can avail of early identification of chronic diseases.

2
Wu et al., 2021. https://doi.org/10.15420/ecr.2021.18 3
(Parikh et al., 2021. DOI:
10.1161/CIR.0000000000000961) 4
 302,686 women and girls.
Median follow-up time for each patient was
4.9 years.

The unadjusted rate of subsequent cardiovascular disease among women with

any placental syndrome (11.8 per 1000 women) was 39% higher than the rate
among women without a placental syndrome (8.5 per 1000 women).

After adjusting for sociodemographic factors, preexisting conditions, and clinical

and behavioral conditions associated with the current pregnancy, women with
any placental syndrome experienced a 19% increased risk of cardiovascular
disease (hazard ratio, 1.19; 95% CI).

Women with >1 placental syndrome had the highest cardiovascular disease risk
(hazard ratio, 1.43; 95% CI)
Maternal placental
syndrome : PE, placental
infarction, placental
When placental syndrome was combined with preterm birth and/or small for
abruption. gestational age, the adjusted risk of cardiovascular disease increased 45% (95%
Fetal PS : preterm, CI).
SGA/IUGR
5
Cain et al, 2016. DOI: 10.1097/01.aoa.0000521255.96405.ed
Adverse pregnancy outcomes and future maternal cardiovascular disease

Associations between prepregnancy risk factors, adverse pregnancy outcomes,

and postpregnancy cardiometabolic risk factors and outcomes Hauspurg et al,.
6
DOI: 10.1002/clc.22887
Wu P, Park K, Gulati M
Impact of Adverse Pregnancy Outcomes on the Cardiovascular System
Citation: European Cardiology Review 2021;16:e31.
https://doi.org/10.15420/ecr.2021.18

Low-resistance
Anti-inflammatory state
blood flow

sFlt-1 ↑
 PRETERM BIRTH History of preterm birth and
interval pregnancy < 6 months
2020, 15 million babies
born preterm every year
Global preterm birth rate 11%
Increase risk 3 folds for preterm
birth in the subsequent
pregnancy

In US, The preterm birth

rate rise 4% from 10.1% in
2020 to 10.5% in 2021
In Indonesia,
2020,
779.000
Mother had serious
babies are
born too complication
soon each
year

8
WHO, CDC, 2021
 Cardiovascular disease ↑ 1,43x
Cardiovascular disease death ↑
1,78x
Coronary heart disease ↑ 1,49x
Coronary heart disease death ↑
2,1x
Stroke ↑ 1,65x

women with preterm births about their

increased cardiovascular risk and
advocating and supporting lifestyle and
behavioral changes to control their
modifiable risk factors.

assessment of preterm delivery in

cardiovascular risk assessment in
women, with the 6-week postpartum visit
the ideal place for this to occur.

(Wu et al., 2018. doi:10.1161/jaha.117.007809 ) 9

 Women with a history of preterm
A potential mechanism may be the
delivery have a two-fold increased
inflammatory pathway
risk for IHD, stroke and overall
CVD over time

Inflammatory phenomena are

especially observed in women with
preterm delivery, even in the absence
of infection→ have a ‘proinflammatory’
phenotype

Inflammation is one of the key factors

in the development of atherosclerosis
→ from the initial lesion to the
progression resulting in thrombotic
complications

(Heida et al., 2016. doi: 10.1177/2047487314566758) 10

 In the 10 years after delivery, the relative rates of ischemic
heart disease were increased twofold in women with other
hypertensive disorders of pregnancy, 1.7-fold in those with
preterm delivery

Most relative rates decreased with longer follow-up but

remained significantly increased (1.1-fold to 1.5-fold), even 30-
46 years after delivery

Women with adverse pregnancy outcomes should be

considered for early preventive evaluation and long term risk
reduction to help prevent the development of ischemic heart
disease.

(Crump et al., 2023. doi:10.1136/bmj-2022-072112) 11

 Fetal Growth Restriction
Intrauterine growth restriction (IUGR) affects 10 to 15% of all pregnancies worldwide.

Neonatal and adult complication

Future maternal diseases

Cardio Vascular Diseases

Data Riset Kesehatan Dasar (Riskesdas)

2013 dan 2018 menunjukan tren
peningkatan penyakit jantung yakni 0,5%
pada 2013 menjadi 1,5% pada 2018.

Berdasarkan Global Burden of Desease dan

Institute for Health Metrics and Evaluation
(IHME) 2014-2019 penyakit jantung menjadi
penyebab kematian tertinggi di Indonesia.
Data Riset K 12
(Sharma et al., 2016. https://doi.org/10.4172/2167-0897.1000232
 Birth Characteristics and Subsequent Risks of Maternal Cardiovascular
Disease Effects of Gestational Age and Fetal Growth

Women in Sweden giving first singleton births from 1983 to 2005 (N923 686) were included. Follow-up started at
delivery and ended at first event of CVD, death, emigration, or December 31, 2005.

(Bonamy et al., DOI: 10.1161/CIRCULATIONAHA.111.034884)

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 Adverse Pregnancy Outcomes: The Missing Link in Discovering
the Role of Lactation in Cardiovascular Disease Prevention

Abbi Lane. Journal of the American Heart Association. Adverse

Pregnancy Outcomes: The Missing Link in Discovering the Role of
Lactation in Cardiovascular Disease Prevention, Volume: 11, Issue: Copyright © 2022 The Authors. Published on behalf of the
20, DOI: (10.1161/JAHA.122.027707) American Heart Association, Inc., by Wiley Blackwell
 15
ACOG, 2018. doi: 10.1097/AOG.0000000000002633
 FOURTH
TRIMESTER

16
ACOG, 2018. doi: 10.1097/AOG.0000000000002633
Suggested brief pregnancy history questionnaire

Hauspurg et al,.
DOI: 10.1002/clc.22887 17
Hauspurg et al,.
DOI: 10.1002/clc.22887 18
 FOURTH
TRIMESTER

Interval post
partum care

19
(Arabin & Baschat, 2017. doi: 10.3389/fped.2017.00069)
Nisha I. Parikh. Circulation. Adverse Pregnancy Outcomes and
Cardiovascular Disease Risk: Unique Opportunities for
Cardiovascular Disease Prevention in Women: A Scientific Statement
From the American Heart Association, Volume: 143, Issue: 18, Pages:
e902-e916, DOI: (10.1161/CIR.0000000000000961) © 2021 American Heart Association, Inc.
RINGKASAN

• Luaran kehamilan yang buruk (APO) berhubungan dengan risiko maternal lanjut untuk
mengalami non communicable diseases (diabetes mellitus tipe 2 dan penyakit
kardiovaskular seperti hipertensi, penyakit jantung iskemik, dan stroke).

• Periode post partum merupakan kesempatan unik untuk melakukan eksplorasi dan
prevensi terhadap penyakit kardiovaskular untuk meningkatkan kesehatan jangka panjang
ibu.

• Data mengenai non communicable diseases pada wanita yang pernah hamil di Indonesia
belum ada.

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SARAN :

1. Dilakukan studi multisenter dan multidisipliner untuk mengetahui

data penyakit jantung dan kardiovaskular pada wanita pasca
persalinan baik jangka menengah atau jangka Panjang di Indonesia.

2. Diterbitkannya rekomendasi dari Pemerintah dan Organisasi Profesi

terkait untuk mengoptimalkan perawatan post partum dan interval
dari tingkat dasar hingga tingkat lanjutan untuk mengidentifikasi
risiko terjadinya PJK sehingga dapat dilakukan upaya preventif yang
optimal.

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 LITERATURES

1. Abbi Lane. Journal of the American Heart Association. Adverse Pregnancy Outcomes: The Missing Link in Discovering the Role of Lactation in Cardiovascular Disease
Prevention, Volume: 11, Issue: 20, DOI: (10.1161/JAHA.122.027707)
2. ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstet Gynecol. 2018 May;131(5):e140-e150. doi: 10.1097/AOG.0000000000002633. PMID: 29683911.
3. Arabin, B., & Baschat, A. A. (2017). Pregnancy: An Underutilized Window of Opportunity to Improve Long-term Maternal and Infant Health—An Appeal for Continuous
Family Care and Interdisciplinary Communication. Frontiers in Pediatrics, 5. doi:10.3389/fped.2017.00069
4. Bonamy, A.-K. E., Parikh, N. I., Cnattingius, S., Ludvigsson, J. F., & Ingelsson, E. (2011). Birth Characteristics and Subsequent Risks of Maternal Cardiovascular Disease: Effects
of Gestational Age and Fetal Growth. Circulation, 124(25), 2839–2846. doi:10.1161/circulationaha.111.034884 .
5. Cain, M.A.; Salemi, J.L.; Tanner, J.P.; Kirby, R.S.; Salihu, H.M.; Louis, J.M.. Pregnancy as a Window to Future Health: Maternal Placental Syndromes and Short-term
Cardiovascular Outcomes. Obstetric Anesthesia Digest 37(3):p 156, September 2017. | DOI: 10.1097/01.aoa.0000521255.96405.ed
6. Crump C, Sundquist J, McLaughlin M A, Dolan S M, Govindarajulu U, Sieh W et al. Adverse pregnancy outcomes and long term risk of ischemic heart disease in mothers:
national cohort and co-sibling study BMJ 2023; 380 :e072112 doi:10.1136/bmj-2022-072112 Hauspurg, A., Ying, W., Hubel, C. A., Michos, E. D., & Ouyang, P.
(2018). Adverse pregnancy outcomes and future maternal cardiovascular disease. Clinical Cardiology, 41(2), 239–246. doi:10.1002/clc.22887
7. Heida KY, Velthuis BK, Oudijk MA, Reitsma JB, Bots ML, Franx A, van Dunné FM; Dutch Guideline Development Group on Cardiovascular Risk Management after
Reproductive Disorders. Cardiovascular disease risk in women with a history of spontaneous preterm delivery: A systematic review and meta-analysis. Eur J Prev Cardiol.
2016 Feb;23(3):253-63. doi: 10.1177/2047487314566758. Epub 2015 Feb 9. PMID: 25665808.
8. Nisha I. Parikh. Circulation. Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A
Scientific Statement From the American Heart Association, Volume: 143, Issue: 18, Pages: e902-e916, DOI: (10.1161/CIR.0000000000000961) .
9. Sharma, D., Sharma, P., & Shastri, S. (2016). Postnatal Complications of Intrauterine Growth Restriction. Journal of Neonatal Biology, 05(04). doi:10.4172/2167-
0897.1000232
10. Wu, P., Gulati, M., Kwok, C. S., Wong, C. W., Narain, A., O’Brien, S., … Mamas, M. A. (2018). Preterm Delivery and Future Risk of Maternal Cardiovascular Disease: A
Systematic Review and Meta‐Analysis. Journal of the American Heart Association, 7(2), e007809. doi:10.1161/jaha.117.007809
11. Wu, Pensée & Park, Ki & Gulati, Martha. (2021). The Fourth Trimester: Pregnancy as a Predictor of Cardiovascular Disease. European Cardiology Review. 16.
10.15420/ecr.2021.18.
12. Wu P, Park K, Gulati M. Impact of Adverse Pregnancy Outcomes on the Cardiovascular System. European Cardiology Review 2021;16:e31.
https://doi.org/10.15420/ecr.2021.18

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