Preconcep(on

counseling and
Antenatal care

Triono Adisuroso
MD, SpOG, MMed, MPhil
 Components
Preconcep(on counseling
Prenatal care
Screening and inves(ga(ons
Complica(ons
 Preconcep(on counseling
Objec&ves
Describe preconcep(on care components
Iden(fy complica(ons of maternal age >35

Preconcep(on care ensures maternal and fetal
health outcomes:
Risk assessment
pa(ent counseling
Risk assessment
Past obstetrical & gynecological history
Past medical history: chronic illnesses and
infec(ous diseases
Family history of gene(c disease
Psychological history

Pa&ent counseling
Focuses: nutri(on and lifestyle
Risk related to maternal age > 35:
Chromosomal abnormali(es
Spontaneous abor(on
Hypertension
Preeclampsia
Diabetes
Placenta previa
Preterm birth
Prolong labour
Infer(lity
Low birth weight newborn
 Prenatal care
Objec&ves
Understand prenatal care goals
Describe 3 components and rou(ne
inves(ga(ons of rst antenatal visit
Know prenatal care visit schedule
Outline prenatal visit components
Prenatal care goals:
Primary goal to provide a healthy maternal
and fetal outcome
Involving pregnancy planning, educa(on, risk
assessment, clinical monitoring each trimester

 Pregnancy
Trimester 1

Trimester 2

Trimester 3
 First antenatal visit
3 goals:
Diagnosis of
pregnancy
Maternal and fetal
health assessment Ways:
Development of a Thorough history
plan for con(nued Physical and
obstetrical care
rou(ne
inves(ga(ons
Conrma&on of pregnancy
Naegeles rule:
LMP + 1 week 3 month + 1 year = EDD
LMP= 20-4-2015 EDD= 27-1-2016
LMP= 27-1-2015 EDD= 04-11-2015
-HCG (qualita(ve/quan(ta(ve)
USG: GS at 5 weeks, fetal heart tone at 6
weeks or 10-12 weeks by Doppler stethoscope


 Sign and symptoms: amenorrhea, nausea,
vomi(ng, fa(gue, breast sensi(vity/
tenderness, more frequent urina(on,
cons(pa(on, abdominal disten(on, increased
vaginal discharge.
Assessment of common complaints: vaginal
bleeding, and visual changes.
Histories: past medical, obgyn, family.
Psychosocial assessment
Rou&ne inves&ga&ons
CBC, Blood test and type, Rh status
Urinalysis: microscopic and culture
HBsAg
VDRL
HIV
Screening for infec(ons
Pap test
Immuniza(on status
Nutri(onal assessment
 Subsequent antenatal care
Visits throughout pregnancy: 14 visits
First visit: within 12 weeks
Typical visit schedule:
1 visit every 4 weeks during 28 weeks
1 visit every 2 weeks un(l 36 weeks
Weekly thereacer
Each visit:
Reconrma(on of gesta(onal age
Blood pressure check
Symphysis-fundal height (SFH)
FHR measurement
Leopold maneuvers (1-4) acer 24 weeks
Kirkham, C. Am Fam Physician 71(7):2005
Kirkham, C. Am Fam Physician 71(7):2005
Kirkham, C. Am Fam Physician 71(7):2005
 Nutri(on during pregnancy
Well-balanced diet
2300-2400 kcal/day

Weight gain
10 lbs (~5 kg) by 20 weeks
15-35 lbs (~12.5 17.5 kg) in pregnancy
eat for two is not recommended
300 kcal extra for each woman

ACOG No. 548 January 2013
Folic acid
0.4 1 mg daily star(ng 3 months prior to
preconcep(on
Combined 4 mg folic acid + vit B12 for previous
NTD un(l 10-12 weeks

Iron supplementa&on
Controversial
Incidence of anemia: >30%
Required screening and treatment

Prenatal/maternal vitamin is recommended

Vegetarians
Protein 40-60 grams/day
Adequate vit B12 and iron
Maternal vitamin is required
>3 serving/day for calcium intake
Referred to die((an

Alcohol should be avoided

Recommended dietary changes

Nausea: small amount and frequent
Cons(pa(on: liquid intake and add bulk-containing foods
Heartburn: elimina(ng uid with meals, restric(ng uid 2
hour before and acer meals, take low-sodium non
aluminum antacid
Avoid lying down acer ea(ng
Kirkham, C. Am Fam Physician 71(7):2005
 Screening and inves(ga(ons

Objec&ves
Discuss prenatal screening op(ons
Understand inves(ga(ons at each trimester
 Prenatal screening
Early prenatal screening op&ons
First trimester screening (FTS)
Integrated prenatal screening (IPS)
Serum integrated prenatal screening (SIPS)

Later prenatal screening op&ons
Maternal serum screening/Triple screening/
Quadruple screening
 Pyramid of prenatal care
Past (lec) and Current (right)

Nicolaides, K. Prenat Diagn 2011.

Past method
High concentra(on in late 3rd trimester
Most adverse outcomes cannot be detected in
rst trimester

Current method
Integrated rst trimester (11-13 weeks) maternal
biophysical and biochemical tests can dene
specic risks of pregnancy complica(ons:
miscarriage, fetal death, preterm delivery,
preeclampsia, gesta(onal diabetes, IUGR, and
macrosomia
 Ultrasound roles
First trimester
Gesta(onal age, number of fetuses
Ectopic pregnancy
Evalua(on of fetal abnormali(es e.g. Nuchal translucency
(NT) for Downs
Molar pregnancy
Missed abor(on

Second and third trimesters

Gesta(onal age
Fetal growth
Evalua(on of fetal abnormali(es
Placenta(on
 Nuchal translucency (NT)

Normal <3 mm Abormal 3 mm

ACOG No. 101 February 2009
ACOG No. 101 February 2009
 Maternal serum screening
Fetal aneuploidies: Trisomy 13, 18, 21
Other anomalies
triple screen: hcg, AFP, Estriol
quadruple screen: triple screen + inhibin A.
15-20 weeks
High-risk women
Trisomy 21 (Down syndrome)
Integrated prenatal screening (IPS)

Combined rst trimester screening (cFTS):

HCG + PAPP-A + NT
87% detec(on for T21 (Downs)

 Diagnos&c tests for chromosomal
disorders

Invasive
Amniocentesis
CVS
Cordocentesis

Non-invasive prenatal test (NIPT)

cell-free fetal DNA (c-DNA)
ACOG No. 88, December2007
Kirkham, C. Am Fam Physician 71(7):2005
 Complica(ons

Objec&ves
Know complaints and management during
pregnancy
Iden(fy serious complica(ons
Benign complica&ons
Vaginal discharge
Urinary complaints

Serious complica&ons
1st trimester: implanta(on bleeding, spontaneous
abor(on, ectopic pregnancy, molar pregnancy,
cervici(s, hyperemesis gravidarum
2nd-3rd trimesters: IUGR, T3 bleeding,
hypertension in pregnancy, preeclampsia,
eclampsia, GDM, GBS infec(on, thyroid
disorders.
Thank you