ANTENATAL CARE

Ova Emilia

Goal : Longitudinal care to achieve

healthy mother and baby
Term:
G3 P2 A0

Gravida : number of pregnancy

Paritas : viable baby
Abortus : non viable baby
Nuligravida / Nulipara
Primigravida / Primipara
Multigravida / Multipara

Case
N is a 22 year-old female, gravida 0 who has
recently married and is interested in
beginning a family. She is a healthy woman
except for her blood sugars. She was
diagnosed DM 4 years ago (?), but at present
her blood sugars are maintained normal. Her
husband has no medical problems. Their
families do not have any dominant diseases.
The couple visit the doctor to understand
what potential risks N may have in becoming
pregnant.

Reproduc
tive
history

Social
assessmnt

Family
history

Preconception
care

Nutrition
assessmnt

Risk
assessmnt

Reproductive history

Diagnosis and treatment

Uterine malformation
Maternal autoimmune disease
Genital infection

Family history

Carrier screening
Tay-Sachs, Canavans disease, thalassemia,
Sickle cell anemia, Cystic fibrosis

Genetic disease
Muscular dystrophy, fragile X syndrome, Down
syndrome

Other diseases: DM, Hypertension, CV

disease, etc

Case
N is briefed on the potential impact of
diabetes on pregnancy. Tight control
during the preconception period and early
in conception is important to reduce the
incidence of diabetes-related birth defects.
Good control over pregnancy will reduce
macrosomia. N is told to have plan for
controlling her blood sugar with
endocrinologist if she desires to conceive.

Risk assessment

Infectious disease screening

Rubella, HBV, tuberculosis, CMV, Toxoplasm,
Parvovirus B19IgG, varicella, HIV, gonorhoe,
chlamydia, syphilis

Exposure to medication
Isotretinoin, Warfarin sodium, anticonvulsant

Nutritional assessment

BMI (weight/height2), anorexia, bulimia

Eating habits
Fasting, pica, eating disorder, megavitamine

Folic acid intake

Social assessment
Alcohol
Tobacco
Mood altering substances
Domestic violence
Financial difficulties

Case
N return to her physicians office in six
months, reporting that seven weeks
have passed since her last menstrual
period. She took a home pregnancy test
two weeks ago that gave a positive
result. She has noted some breast
tenderness but only minimal nausea.
She denies any abdominal pain or
cramping.

Gestational age
Calculated from LMP
Gestational age: 280 days or 40 weeks
Naegel formula : LMP = 10-6-1999
EDD = 17-3-2000
Trimester : represent period of 3 months

Gestational age

Doppler ultrasound: FHR 11-12 weeks

Fetoscope: 19-20 weeks

Quickening: 17-19 weeks

TFU up to umbilicus: 20 weeks

Gestational Age Assessment

When to expect onset of labor

Critical in assessment and management of preterm
labor, IUGR, postdates, and PROM
Important for scheduling amniocentesis, Csection, or induction of labor
Important in assessment of abnormal AFP
Important in management of maternal diseases
(i.e.. DM, HTN, PIH, renal disease)

Common Causes of Gestational

Dating Inaccuracies -- Early
Pregnancy
Incorrect recall of
LMP

Irregular menses

Late registration
Inaccurate home
for prenatal care
pregnancy test
Conception during Uterine fibroids or
amenorrhea
pelvic masses
Implantation
bleeding

Obesity

Conception during Incorrect

or after BCPs or
estimation of
Depo
uterine size

Incorrect
measurement of
ultrasound images
Molar gestation
Multiple gestation

Clinical Indicators of Gestational Age

Indicator

Appropriate Time

LNMP

Entire pregnancy
Conception/ovulation Entire pregnancy
Serum preg test
Before 4 weeks
Urine preg test
Detection of FHT
Between 9-12
week
Uterus at umbilicus 20 weeks
Between 18-35
Fundal height

Accuracy
+/- 14.6 days
+/- 1 day
7-10 days after
conception
+/- 3 weeks
+/- 15 days
+/- 13-19 days

week

Quickening primi 18-19 weeks

Quickening multi 16-17 weeks

+/- 18 days
+/- 18 days

Recommendations for Dating

Pinpoint LMP and/or time of likely conception

Perform pelvic exam as early as possible
Listen with Doppler as early as possible
Schedule u/s for approximately 17 wks
gestation (best time for dating and anatomic
survey)
Based on all clinical and ultrasound
information, determine an EDD by 20 weeks
and stick to it -- dont change it based on
later ultrasounds!

First visit
As soon as the period is late:
Anamnesis
Physical examination
Obstetrics examination
Supporting examination (USG)
Lab. test
Objective: obtain base line data.

Advices
See the doctor in following conditions:

Vaginal bleeding, edema, headache,

blurred vision, abdominal pain,
excessive vomits, fever, dysuria, and
vaginal discharge.

Sebsequent visits
Every 4 weeks until 28 weeks of GA
Every 2 weeks until 36 weeks of GA
Every week until delivery

At least 4 ANC visits at various trimester

Monitor
Mother: weight gain, blood pressure,
anemia, fundal height, subjective
complains
Fetus: EFW (estimated fetal weight),
lie, presentation, single/ twin,
movement, FHR (fetal heart rate)
Lab: Hb, urine, TORCH etc
At week 36th (primigravida): bimanual
examination

LEOPOLD MANEUVER

Measure fundal height

Ultrasound

Weight gain during pregnancy

Range between 7-13 kg, i.e:
Fetus
3,5 kg
Plasenta
0,5 kg
Amniotic fluid 1,0 kg
Uterus
1,0 kg
Blood
2,0 kg
Breast
1,0 kg

Nutrition during pregnancy

1. Calori :

2. Protein :
3. Mineral :
4. Vitamin:

Non pregnant 2000 cal

Pregnant
2300 cal
Lactation
2800 cal
Non pregnant 0,9 g/kg bw/day
Pregnant
1,5 g/kg bw/day
Iron
17 mg/day
Calsium
1 gram/day
food or supplement

Exercise
Non-weight bearing exercise
Regular exercise, 3x/wks
No supine position
Ensure adequate diet
Ensure hydration
Contraindication: PiH, preterm rupture of
membranes, preterm labor, incompetent
cervix, bleeding, IUGR

Cigarette (nicotine)
Increase

the incidence of abortus,

premature labor, low birth weight,
abruptio placentae, placenta previa,
sudden infant death syndrome.
Congenital anomaly: congenital heart
disease such as tetralogi Fallot and
patent ductus arteriosus.
Smoking cessation

Alcohol (chronic)

Microsephal, palatoschisis
Cardiovascular disorder
Intra uterine growth retardation
Mental retardation

Substance use
Marijuana: not clear effect
Cocaine: hypertension, cardiac
ischemia, cerebral infarction
Opiates: increased rates of stillbirth,
fetal growth retardation, premature,
mortality
Amphetamines: microcephal, IUGR,
fetal death
Hallucinogens/LSD: not clear effect

Sexual activity
As needed
Abstinence when:
1. History of habitual abortion
2. Vaginal bleeding
3. Partus prematurus imminens
4. Rupture of the membrane
5. Dilatation of cervix

Working and travel

No special requirement
Avoid prolonged sitting
Drive max 6 hours/day, stop every 2 hours
and walk for 10 minutes
Support stockings, belly belt

Genetic counseling
Older maternal age
Fetal anomalies
Abnormal triple screen or alpha fetoprotein
Exposure to teratogens (drugs, radiation,
infection)
Family history
Reproductive failure

Drugs during pregnancy

Basic principles: drugs are toxin, should be used
with caution (teratogenic).
Only prescribed by appropriate indication, and
consider contraindication or side effect.
Teratogenic features depend on:
1. Type and dosage
2. Developmental period
3. Plasental barrier
4. Type of the organism

Highly Teratogenic
Talidomide
Anti

tumor drugs
Hormones (corticosteroid, androgen,
progestogen)
Valproat (anticonvulsan)
Isotretionin

Anti tumor drugs

Alkilating

agent (chlorambucyl,
cyclophosphamyde, busulfan etc)
Anti metabolit (e.g. aminopterin,
metotreksat)
Alkaloid (vincristin, vinblastin)
Antibiotika (actinomysin D)

Hormone
Cortison

: palatoschisis
Androgen and progestin: virilisation
of female fetus
Estrogen: clear cell adenocarcinoma

Anticonvulsant
Phenytoin, trimetadion, and
carbamazepin
Anomaly: labioschisis, palatoschisis,
mental retardation, gingiva
hypertrophy, and sceletal anomaly.

Antimalaria
Quinine:

cause abortus (oxitosic effect ) &

eight nerve disorder
Chloroquine may interfere histogenesis of
central nervous system (retina and 8th nerve)
eye disorder or congenital deafness
Primaquine and pentaquine relatively safe.
Pirimetamine: anti folic acid that is used as
antimalaria and antitoksoplasmosis.

Tetracyclin

Trimester I, bone growth disorder,

micromelia and syndactili.
Trimester II, yellow teeth and enamel
hipoplasia. (but no disturbance of the
strength or resistance of caries)

Aminoglicoside

streptomycin, kanamycin,
gentamycin and vancomycin.
Eight nerve and labyrinth (congenital
deafness) disorder

Vaccine
Vaccination

in trimester I, increase
the abortus risk
Tetanus vaccine