Accuracy of Hemoglobin Measurement Using Noninvasive Oxyhemoglobinometer in Pregnant Women at Health Center of Bantul District

Iron defi ciency anemia is a major health problem in pregnant women and has a detrimental effect on mothers and newborns. Given the consequences of anemia during pregnancy, an easy and accurate diagnosis is important. During this measurement of hemoglobin levels by involves taking the blood invasively, causing discomfort and trauma for the patient. Therefore, a hemoglobin level gauge is required using a non-invasive oxymeter system, in which the patient will be free of pain with minimal risk of infection and allow for the monitoring of the patient in critical condition. The purpose of this study was to compare the results of hemoglobin concentration using an oxyhemoglobinometer with automated hematology analyzer as gold standard to know the difference of result of accuracy. This ISSN 2354-7642 (Print), ISSN 2503-1856 (Online) Jurnal Ners dan Kebidanan Indonesia Tersedia online pada: http://ejournal.almaata.ac.id/index.php/JNKI INDONESIAN JOURNAL OF NURSING AND MIDWIFERY


INTRODUCTION
Pregnancy influences a variety of physiological changes.One of the most significant changes is improvement volume so that hematocrit normally declines.This often results in the state of pregnant women experiences iron deficiency anemia.(1)Iron defi ciency anemia is a major health problem in pregnant women and it has adversed effects on mothers and newborns.This affects about 1.62 billion people from the global population (2).The prevalence of anemia in India is 82% (3), Ethiopia is 56.8% (4).In Indonesia, the prevalence of anemia in pregnant women is 37.1% according to the data of Basic Health Research in 2013 (5).
In Yogyakarta the prevalence of maternal anemia increases in 2012 to 2013, which is 17.35% to 17.60%.The prevalence of pregnant woman's anemia in Bantul Regency is 27, 76% (6).Iron defi ciency anemia in pregnancy can result in harmful effects for the mother and fetus (7).
Given the consequences of anemia during accuracy is one of the parameters to measure the effectiveness of oxyhemoglobinometer compared to the automated hematology analyzer as the gold standard (20).

MATERIALS AND METHOD
This research is a diagnostic test with cross sectional design, which is the data retrieval for each subject is done in one unit of time (10).This research is to compare the result of hemoglobin content using new tool with gold standard so that the difference of the result is obtained the accuracy.
The subjects of this study are pregnant women at Health Center of Bantul District who fulfi lled inclusion criteria, pregnant women who came to check their pregnancy at Health Center of Bantul Regency and pregnant mother who was willing to take blood for hemoglobin examination, and pregnant mother who do not use nail polish.
The exclusion criteria of pregnant women who experience an emergency.

Result
The characteristics of research subjects presented to determine the frequency distribution of respondent characteristics, can be seen in the

Discussion
The principle of observation of hemoglobin and noninvasive blood oxygen content in the oxymeter system is the change in the color of the oxidized hemoglobin measured by the difference in absorption, when light is of a certain wavelength and penetrates tissue and blood.
Blood containing oxygen-bound hemoglobin (HbO2 / Oxyhemoglobin) with no (Hb) will show different absorption spectra of light emission.
In this study, hemoglobin levels were examined in a non-invasive way or not by injury, ie light with a certain wavelength was transmitted across the probe and reached the detector / photodiode, then processed with a preprogrammed microcontroller so that the resulting hemoglobin levels were displayed on the LCD.
On developing tools using red and infrared  Microcontroller".The realization of the design result of the tool can measure by 0-0.250 mg / dl for sugar content, 0-20 gr / dl for hemoglobin, and 0-100% for oxygen content in blood (17).
In the selection of red LED color is also in From the analysis of several factors causing inaccurate readings of the above pulse oxymeter, and only a few that can be controlled by the researchers, it is possible to be the cause of the low validity of the oxyhemoglobinometer tool in this study.

CONCLUSION AND RECOMMENDATION
There is difference result between tool of oxyhemoglobinometer and automated hematology analyzer (Sysmex KN-21) in checking hemoglobin level in pregnant woman at Health Center area of Bantul district of Yogyakarta with value p = 0,001.The oxyhemoglobinometer device cannot be used as a measure of hemoglobin levels accurately because of the low validity of the tool, it is accuracy 69.2%.

T h e p r i m a r y d a t a w e r e c o l l e c t e d f r o
m h e m o g l o b i n c o n c e n t r a t i o n f r o m oxyhemoglobinometer and automated hematology analyzer.The data collection instrument in this study used a hemoglobin diagnostic tool consisting of an oxyhemoglobinometer and an automated hematology analyzer.
LEDs.The wavelength on the red LED is 620nm and the infrared LED is 940nm.Both LEDs act as transmitters and photodiodes as receivers.The LED transmits light through the blood vessels and the photodiode receives the output from both LEDs which can be used to calculate the percentage of oxygen concentration.Appropriate wavelengths are selected for the relative analysis of changes in hemoglobin levels.Both wavelengths are chosen because the oxygencontaining hemoglobin absorbs the wavelength of 910 nm light and the hemoglobin-induced hemoglobin that absorbs oxygen absorbs the 650 nm wavelength.This research is in line with the research design entitled "Design of Measuring Tools of line with research conducted by Guruh and fi rends entitled " The Design of Building Microcontroller-Based Microcontroller ATMega16", the results of his research that red LEDs are better to break through the organ network of fi ngers.48On examination of the tool researchers using the index fi nger, this is in line with the results of the research entitled "Design of Measure Measures Hemoglobin and Oxygen in Blood with the Sensor of Oxymeter Non-invasive", which concluded that the most accurate fi nger for measurement is the index fi nger because the index fi nger has the fi nger size corresponding to the oxymeter sensor.23The results of the oxyhemoglobinometer showed that the accuracy were still low, its 69,2%.This could be due to several factors below: 1) Bright light (such as indoor lights or sunlight) directly on the probe can affect the reading.This is in line with the results of a study entitled 'Potential errors in pulse oxymetry', it is the external light source influences the reading, with the result decreasing from 97% to 93%.The researchers recommend the use of fabric or rubber-wrapped fabrics wrapped around the probe to reduce external light to reach the light detector.55,59In this study the factor has been controlled by means of a probe protected by an opaque material; 2) Movement can make diffi culty for probe in taking signal.In this study the factors were controlled by asking respondents not to talk and move during the test.59;3) Pulse oxymeter works well when all light passes through arterial blood.However, if the probe is wrong or not properly applied, some light does not pass through the arteries or travel on the side of the artery (shunting).It will reduce the pulsed signal strength making the pulse oxymeter vulnerable to errors.Therefore it is important to select the probe of the correct size so that the finger placement is right for best results.In this study researchers used a probe that conforms to the standard for oxygen saturation checks.57;4) Pulse oxymeter only detects pulsed fl ow.When blood pressure is low due to hypovolemic shock or low cardiac output or the patient has arrhythmias, the pulse may be very weak and the oxymeter may not be able to detect the signal.59;5) Vasoconstriction can reduce blood fl ow to peripheral, this causes the oxymeter may fail to detect the signal if the patient is very cold (chills) .59;6) Poisoning can give high false saturation readings.Carbon monoxide binds hemoglobin and displaces oxygen to form a bright red compound called carboxyhaemoglobin.This can occur in patients who breathe smoke from fire.57,59; 7) Pulse oxymeter cannot distinguish between different forms of hemoglobin.Carboxyhaemoglobin (hemoglobin combined with carbon monoxide) is listed as 90% oxyhemoglobin and 10% deoxyhemoglobin.The presence of methaemoglobin will prevent the oxymeter from working accurately and the reading will tend toward 85% .58;8) Nail polish can cause inaccurate readings.It based on the results of a study entitled "Effects of nail polish on oxygen saturation determined by pulse oxymetry in critically ill patients", suggesting researchers to remove nail polish to help reduce measurement errors.56This factor is controlled by researchers by inserting into the criteria inclusion of respondents.
test with cross sectional design.78 normal pregnant women who checked their pregnancy at the center of health in Bantul district, each of them are examined their hemoglobin level by using the oxyhemoglobinometer and automated hematology analyzer as a comparison.For the different results were used pairwise t test, and with diagnostic test formula obtained accuracy values.There is a difference between the oxyhemoglobinometer tool with the average of 12.2 ± 1.7 and in the automated hematology analyzer obtained an average of 11.6 ± 1.2.With a value of p 0.001 which means there is a signifi cant difference between the two tools.The results of the diagnostic test analysis obtained an accuracy of 69.2%.The oxyhemoglobinometer device cannot be used as an accurate measurement of hemoglobin levels, because the tool its low of accuracy.
pregnancy, an easy and accurate diagnosis is important.Several methods are available for HB estimation in fi eld settings, such as heavy copper sulphate type method, Lovibond comparator, HemoCue, Rapid test, Hemoglobin Color study is a diagnostic

table 1 .
The result of difference of result from oxyhemoglobinometer and Sysmex KN-21 can be seen in table below: