Practical Points : Antenatal Care : What You Need To Know?

(Part I : 1st ANC)

Maternal and Fetal well-being

Health promotion Health education, Health screening and Health

prevention


...
extern, intern ANC

part 1st ANC
Trimester
1st trimester
GA 0 - 14 week
2nd trimester
GA 15-28 week
3rd trimester
GA 29 - until birth
Term
Term newborn GA 37 week
Preterm newborn GA37 week
Late preterm newborn GA 34-36 6/7 week
expectant GA 34 week
lung maturation ( RDS)
prolong
Preterm 555+

first ANC ANC trimester
1st ANC
> History taking


Primigravida

2
Risk assessment ?



review/ ANC check list

Gestational Ages (GA)
UPT 2
UPT
document LMP (Last menstrual period)
? ? regular ? ?

GA : LMP
-> ? regular hormone ?
GA LMP
uncertain date
U/S
Dating U/S 1st ANC confirm GA
Naegales rule EDC
EDC = LMP + 7 - 3
App PregWheel OBwheel

GA LMP

 GA 18-20 week

GA 16-18 week
medicine
Past medical history : Underlying, current medication, food and drug allergy
Past surgical history
Gynaecologic history :
STD
Systematic review
Vaccination history : Tetanus toxoid 10
booster 1 dose
> Physical examination
Vital signs

Blood pressure Hypertension GA < 20 week Chronic
Hypertension GA > 20 week PIH, Gestational HT BP >
140/90 mmHg rest BP
HT
Record Initial body weight, height BMI

Total weight gain

1st ANC
bimanual palpation

normal size
top normal size 7 week size ( )
GA > 12 week (Fundal height above PS)
PS umbilicus 3 FH
1/3 > PS GA 12-14 week
2/3 > PS GA 14-16 week
At Umbilicus GA 20 week (average 20-22 week)
 umbilicus
upper border of PS Fundus

GA 20-34 week : 25 cm PS GA 25 week

GA by LMP
Size and Date Size > Date
Size < Date ? investigation Size and Date discrepancy
Ultrasound size and date 2 week

Size and Date discrepancy
GA GA
most common cause of Size and Date discrepancy Wrong GA !!!
check
PAP smear check up cervix gross lesion

note manage spatula

cervix
hypervascularity
bleeding check stop bleed
PV + pap smear

Thyroid, Heart diseases

(

)
? Heart
and lung?
> Baseline Lab (Lab I)
investigation



Lab 1

CBC c platelet , Blood group ABO, Rh ? MCV
VDRL, Anti-HIV, HBsAg STD
UA WBC, Sugar, Albumin

Thalassemia screening
3

Beta thalassemia major (Bo/Bo)
Barts hydrops fetalis (/)
Beta thalassemia E disease (Be/Bo)
MCV 80 fL
MCV < 80 fL DDx IDA, Thalassemia, ACD
MCV < 80 fL Beta thal-trait, E-trait, Alpha-thal trait
MCV > 80 fL E-trait
MCV screen Beta, Alpha
DCIP screen HbE ( HbE screening)
2 MCV/DCIP
neg/neg (no risk)
positive risk
high risk
worst case screnario


> any neg/neg no risk
> any pos/pos at risk
> any pos/neg at risk
> neg/pos at risk neg/pos no risk
at risk HbTyping, PCR for alpha thal
DM screening :
risk for GDM Low/Intermediate High risk
High risk Glucose challenge test (GCT) 1st ANC
intermediate risk GA 24-28 week
 high risk for GDM
> Maternal obesity BMI > 30 kg/m2
> History of previous GDM
> History of 1st degree relative with DM
> Persistent glycosuria (UA dipstick 2+ x 1 , 1+ x 2 )
GCT stat
Option Down screening
Down screening

Downs syndrome marker U/S Nuchal translucency
GA11-14 week risk Prenatal diagnosis ?
Nutrition and Supplements

2,500 kcal





3
Iron
1,000 mg
anemia in pregnancy
trimester Hb cut off
1st trimester : Hb < 11 anemia
2nd trimester : Hb < 10.5 anemia
3rd trimester : Hb < 11 anemia
Hb anemia

6-7 mg/day
18-20 mg/day
 10-20% 3 mg/day

3 mg/day elemental iron 30 mg
Ferrous fumarate 1x1 po pc
Ferrous fumarate 200 mg elemental iron 65 mg 10-20%
6-13 mg
30 mg/day : Ferrous fumarate 1x1 po pc
60-100 mg/day Ferrous fumarate 1x1 to 1x2 po pc
anemia iron deficiency cause
treatment elemental iron 200 mg/day
20-25 mg/day
treat IDA Ferrous fumarate 1x3 po pc

5-10 days : reticulocyte count
2-3 weeks : Hb 0.3-1.0 g/dl / week
Summary
Iron supplement : consider Hb/Hct
Hct < 30 mg% : Ferrous Fumarate 1x3
Hct 30-33 mg% : Ferrous Fumarate 1x2
Hct > 33 mg% : Ferrous Fumarate 1x1
Folic Supplement

Neural tube defect
Folic 0.4 mg/day

embryogenesis and early organogenesis Folic acid

Neural tube defect 4 mg/day 3


Folic acid 0.5-1 mg
4 mg/day Folic acid (5 mg) 1x1 po pc
Iodine

iodine
concern endemic area of hypothyroidism congenital hypothyroidism
cretinism
Recommended supplementation regimen

choice
Folic acid (5) 1x1 po pc
Ferrous fumarate morning sickness
S/E GI upset
morning sickness Vit B6 (Pyridoxine) (10) 1x3 po pc
morning sickness
Triferdine, Obimin AZ, Ferli-6 1x1 po pc

anemia add ferrous fumarate

Summary of 1st ANC

> History taking (Risk assessment + Confirm GA)
> General physical examination
> PV + Pap smear
> Baseline Lab (Lab 1)
> Dating U/S (if uncertain date or Size and date discrepancy)
> Thalassemia screening
> Down screening
> Hypertension screening
> GDM screening
> Vaccination
> Nutrition and Supplements
> Plan for F/U