Antenatal Care
Dr. dr. I Nyoman Bayu Mahendra, SpOG(K)
Department Obstetric and Gynaecology
of Medical Faculty Udayana University
Definition of ANC
An examination and a management of pregnant
woman with aims to prepare the pregnant
woman and the baby in healthy state as
physically and mentally and safe both of them
during pregnancy, labor and puerperium
Prenatal Care Effectiveness
• analysis of data from 1998 to 2005 from the
Pregnancy Mortality Surveillance System
(PRAMS), Berg and associates (2010)
identified a fivefold increased risk for maternal
death in women who received no prenatal
care
• Herbst and colleagues (2003) found that lack
of prenatal care was associated with more
than a twofold increased risk of preterm birth.
• National Center for Health Statistics data
showed that women with prenatal care had an
overall stillbirth rate of 2.7 per 1000 compared
with 14.1 per 1000 for women without
prenatal care (Vintzileos, 2002a)
Aims of ANC
• Pregnant woman in healthy state
• Treat her if there is any diseases during
pregnancy
• Deliver without any complications
• Baby and mother in healthy state until post
partum
Examination of ANC
• The better frequent of ANC is at least 4 times during
pregnancy which arrange as one time in 1st trimester,
one time in 2nd trimester and two times in 3rd
trimester.
• Suggestion:
– Till 7 months gestational age might be controlled every
monthly
– Beyond 7 month gestational age might be controlled twice
in a month
– And from 36 week until delivery might be controlled every
week.
Examination of ANC
• in the United States. In 2001, there were
approximately 50 million prenatal visits. The
median was 12.3 visits per pregnancy, and
many women had 17 or more total visits.
INITIAL PRENATAL EVALUATION
• Prenatal care should be initiated as soon as
there is a reasonable likelihood of pregnancy.
Major goals are to: (1) define the health status
of the mother and fetus, (2) estimate the
gestational age, and (3) initiate a plan for
continuing obstetrical care.
What is evaluated in ANC?
Anamnesis
Physical examinations
generally
Obstetrics examinations
Supported investigations
Anamnesis
• A. Last menstrual period (LMP) that’s can predict
due date or estimation date of delivery (EDD)
– The role to count EDD is date added with 7 days, month
extracted with 3 months and year added with 1 year.
• Example: If the LMP is 23-06-2016 EDD is 30-03-2017
• amenorrhea is not a reliable pregnancy indicator
until 10 days or more after expected menses.
(willams obs)
Naegele rule
• It is customary to estimate the expected delivery
date by adding 7 days to the date of the first day of
the last normal menstrual period and counting back
3 months.
• For example, if the last menstrual period began
September 10, the expected date of delivery is June
17. However, a gestational age or menstrual age
calculated in this way assumes pregnancy to have
begun approximately 2 weeks before ovulation,
which is not always the case
Normal Pregnancy Duration
• The mean duration of pregnancy calculated
from the first day of the last normal menstrual
period is very close to 280 days or 40 weeks.
• In a study of 427,581 singleton pregnancies
from the Swedish Birth Registry, BergsjØ and
coworkers (1990) found that the mean
pregnancy duration was 281 days with a
standard deviation of 13 days.
Anamnesis
• B. Previous pregnancies history
– Mode of deliveries: normal vaginal delivery or
instrumental (ventouse, forceps), CS.
– Are there any history of post-partum
hemorrhage ?
– How about out come of babies? How many
vigorous babies? How old the baby/babies
currently? Is there any stillbirth history? Sex of
baby/babies. And birth weight.
Physical Examination Generally
• Vital signs: BP, pulse, respirations rate, temperature
• Mother weight. Total gain until term over 10 to 12
kg since 16 weeks pregnancy
• Eyes: pale anemia
• Thyroid gland
• Mammae: nipple inverted?
• Heart: murmur or abnormal heart sounds?
• Lung: wheezing?, ronchi?
• Liver and spleen: hepato-splenomegaly?
• Extremities: edema?, varicose?
Obstetrics Examinations
• If the gestational age is less than 12 week might be
confirmed by vaginal examination. Exceptionally if the
patient does not allow it.
• If pregnancy is 12 to 20 week fetal heart beat
should be detected by doppler.
• The ballottement sign should be positive and fetal
heart beat should be detected in 20 to 28 week
pregnant.
• If more than 28 week the baby head is establish in
lower abdomen of mother.
• The baby head already engaged in 36 week or after.
The Supported Investigations
• Laboratory investigations:
– Routine of HGB, leukocyte, urinalysis, serologist
screening: HBsAg.
– In Caucasian woman, blood group for rhesus must
be examined because approximately 15 % with Rh
negative. In African or black women the incidence
is 3 % to 8 %. In Indonesian is over 0.5 %).
• If any indication might be examined blood
sugar level, serologist of TORCH, etc.
HCG
• Syncytiotrophoblast produce hCG in amounts that increase
exponentially during the first trimester following
implantation.
• With a sensitive test, the hormone can be detected in
maternal serum or urine by 8 to 9 days after ovulation.
• The doubling time of serum hCG concentration is 1.4 to 2.0
days.
• serum hCG levels increase from the day of implantation
and reach peak levels at 60 to 70 days. Thereafter, the
concentration declines slowly until a plateau is reached at
approximately 16 weeks
HCG
• Elevated hCG levels may also reflect molar
pregnancy and its associated cancers
• Other rare causes of positive assays without
pregnancy are: (1) exogenous hCG injection used
for weight loss, (2) renal failure with impaired
hCG clearance, (3) physiological pituitary hCG,
and (4) hCG-producing tumors that most
commonly originate from gastrointestinal sites,
ovary, bladder, or lung (Montagnana, 2011).
The Supported Investigations
• Ultrasound imaging (USG)
– Performed with indication such as threatened
miscarriage, antepartum bleeding, to confirm
viability in less than 10 week pregnant, suspected
IUGR, morphologic scan for congenital anomaly in
18 – 20 week, etc.
• X-Ray:
– Abdomen in suspected anencephaly
– Chest in mother with suspected lung tuberculosis
USG
• A gestational sac—a
small anechoic fluid
collection within the
endometrial cavity—is
the first sonographic
evidence of pregnancy.
It may be seen with
transvaginal sonography
by 4 to 5 weeks’
gestation
after 6 weeks, an embryo is seen as a linear
structure immediately adjacent to the yolk sac, and
cardiac motion is typically noted at this point.
USG
• a first-trimester crown-rump length is the
most accurate tool for gestational age
assignment and is performed as clinically
indicated
Trimesters
• Historically, the first trimester extends through
completion of 14 weeks, the second through
28 weeks, and the third includes the 29th
through 42nd weeks of pregnancy. Thus, there
are three periods of 14 weeks each.
Trimesters
• Because precise knowledge of fetal age is
imperative for ideal obstetrical management,
the clinically appropriate unit is weeks of
gestation completed.
• And more recently, clinicians designate
gestational age using completed weeks and
days, for example, 334/7 weeks or 33 + 4, for
33 completed weeks and 4 days.
Communication, Information and Education
• Hygienist of cloths, body and environment
• Nutrition: Enough of protein, carbohydrate, fat, avoid
smoking, minimize drink coffee
• Medicine: vitamins, mineral: Fe,calcium, vitamin B12,
folic acid, etc
• Beware to consume medicines in 1st trimester such
as tetracycline, prednisone, tranquilizer, etc
Psychosocial Screening
• Women should be screened regardless of social status,
education level, race, or ethnicity. Such screening
should seek barriers to care, communication
obstacles, nutritional status, unstable housing, desire
for pregnancy, safety concerns that include intimate
partner violence, depression, stress, and use of
substances such as tobacco, alcohol, and illicit drugs.
• This screening should be performed on a regular basis,
at least once per trimester, to identify important
issues and reduce adverse pregnancy outcomes
smoking
• There is a twofold risk of placenta previa, placental abruption,
and premature membrane rupture Prenatal Care compared with
nonsmokers.
• More likely to be preterm, have lower birthweights, and are
more likely to die of sudden infant death syndrome (SIDS) than
infants born to nonsmokers (Tong, 2009).
• In 2005, LBW in American women who smoked during
pregnancy was 11.9 percent compared with 7.5 percent born to
nonsmokers (Martin, 2007). Risks for spontaneous abortion,
fetal death, and fetal digital anomalies are also increased (Man,
2006).
• Finally, children who were exposed to smoking in utero are at
increased risk for asthma, infantile colic, and childhood obesity
(American College of Obstetricians and Gynecologists, 2013i)
alcohol
• Ethyl alcohol or ethanol is a potent teratogen
that causes a fetal syndrome characterized by
growth restriction, facial abnormalities, and
central nervous system dysfunction
• Women who are pregnant or considering
pregnancy should abstain from using any
alcoholic beverages
Diet and weight gain
Exercise in pregnancy
• To maintain pregnant woman health
• To introduce and teach pregnant woman
about physiologic position and simulation
during in labor
• Not allowed pregnant woman with:
– Preterm contractions, bleeding, history of
recurrent miscarriage, PPROM
Exercise in pregnancy
Exercise in pregnancy
Automobile and Air Travel
• In general, air travel in a properly pressurized
aircraft has no harmful effect on pregnancy
(Aerospace Medical Association, 2003). Thus,
in the absence of obstetrical or medical
complications, the American Academy of
Pediatrics and the American College of
Obstetricians and Gynecologists (2009a, 2012)
have concluded that pregnant women can
safely fly up to 36 weeks’ gestation.
Coitus
• In healthy pregnant women, sexual
intercourse usually is not harmful. Whenever
abortion, placenta previa, or preterm labor
threatens, however, coitus should be avoided.
caffein
• Whether adverse pregnancy outcomes are
related to caffeine consumption is somewhat
controversial. A heavy intake of coffee each
day—about five cups or 500 mg of caffeine—
slightly increases the abortion risk.
• Studies of “moderate” intake—less than 200
mg daily— did not report increased risk.
Cord Blood Banking
• Since the first successful cord blood
transplantation in 1988, more than 25,000
umbilical cord blood transplantations have
been performed to treat hemopoietic cancers
and various genetic conditions (Butler, 2011)
Addition
• Immunization: TT
• Needed an establish state of physically and
mentally
Thank you
