Antenatal Care

High risk and low risk

 Antenatal Care
A comprehensive antepartum program involving
● a coordinated approach to medical care
● continuous risk assessment
● psychological support
optimally begins before conception and extends throughout
the postpartum period and interconceptional period
Contents
1. History taking
2. Physical examination
3. Laboratory investigations
4. High risk pregnancy
5. Advices for pregnancy
6. Symptoms in pregnancy
7. Vaccination
1. History taking

● Family history : husband, relatives

↪ TB, hematoligic dz, HT, twin pregnancy, DM, STD
● Past medical history : Sx, U/D, drug allergy
● Pregnancy history
↪ Previous : complications (preterm, Postpartum
hemorrhage, abortion), contraception
↪ Present : LMP, fetal movement (normally in first
18-20 wk and last 16-18 wk), symptoms
● Personal history : age, education, religion, alcohol
drinking, smoking, narcotics
1. History taking
Gestational age
Last menstrual period (LMP) ⟶ Expected date of confinement (EDC)
normally 40 weeks / 280 days since the first day of LMP
Naegele’s rule: + 7 days - 3 months
Example;

if irregular periods or uncertained LMP ⟶ USG

2. Physical examination

weight, height, BP, gait

nipples

Waller’s test

Hoffman
maneuver
2. Physical examination

Fundal height
2. Physical examination
Leopold’s maneuver

Fundal Grip Umbilical Grip

↪ fundal height ↪ large part or small part
↪ head or buttock

Pawlik’s Grip Bilateral Inguinal Grip

↪ Presentation : ↪ engagement
head or buttock ↪ attitude : flexion or
extension

head : round, smooth, solid, ballottement ⊕

2. Physical examination

Lie
fetal axis ⟷ maternal axis
2. Physical examination
Attitude/Habitus

Occiput Sinciput Brow Face

/ Vertex / Bregma
2. Physical examination
Cephalic presentation

Left Occipito Left Occipito

Anterior (LOA) Posterior (LOP)
2. Physical examination
Cephalic presentation

Right Occipito Right Occipito Right Occipito

Anterior (ROA) Posterior (ROP) Lateral (ROL)
2. Physical examination
Cephalic presentation

Left Right Right

mento-anterior mento-anterior mento-posterior
2. Physical examination

Breech presentation Shoulder presentation

Left Sacrum Right Acromio
Posterior (LSP) Dorso Posterior
(RADP)
2. Physical examination
Breech presentation
2. Physical examination
Per vaginal Examination (PV)

Indications
eg. leukorrhoea
Vaginal bleeding in 20 wk
Pelvic assessment near EDC
3. Laboratory Investigation

CBC : Hb, Hct, Platelet count

⭐ anemia (Hb<11 g/dL in 1st/3rd trimester or Hb
< 10.5 g/dL in 2nd trimester)
eg. Thalassemia (➝ Hb electrophoresis)

UA : WBC, bacteria, protein, glucose

⭐UTI, preeclampsia, GDM

Blood group : ABO, Rh

3. Laboratory Investigation

Serological tests:
VDRL for Syphilis
(if reactive ⟶ confirm with FTA-ABS or TPHA)
HBsAg (if ⊕ ⟶ newborn immunization)
anti HIV (if ⊕ ⟶ give antivirus)

Screening tests:
Thalassemia : MCV, OF, DCIP
DM : 50 gm GCT ; if > 140 mg/dL ⟶ 100 gm OGTT
USG at 18-20 wk
4. High risk pregnancy

A high risk pregnancy is one that threatens

the health or life of the mother or her fetus. It
often requires specialized care from specially
trained providers.
Risk Factors
1. Biological factors
2. Socioeconomic factors
3. Medical factors
4. High risk pregnancy

Biological factors
1. Maternal age

2. Maternal education

3. Maternal height

4. Maternal weight
4. High risk pregnancy

Socioeconomic factors
1. Occupation

2. Social environment

3. Marital status
4. High risk pregnancy

Medical factors
1. OB-GYN History

2. Mothers with underlying disease

3. Current obstetric status

4. Habits
5. Advices for pregnancy

1. Nutrition
2. Sanitation
3. Behavior
5. Advices for pregnancy

1. Nutrition

“Weight before pregnancy” and “Total weight gain” is indicator

- Underweight (<18.5 kg/m2) : 12-18 kg

- Normal weight (18.5-22.9 kg/m2) : 11-16 kg
- Overweight (23-24.9 kg/m2) : 7-12 kg
- Obese (>25 kg/m2) : 5-9 kg

Recommend : 2nd and 3rd trimester weight gain rate

- 0.4-0.5 kg/wk
5. Advices for pregnancy

1. Nutrition

Total calories 80,000 kcal

Take more 100-300 kcal/day (approximately 2500 kcal/day)

- Protein : 1.3 g/kg/day → 75 g/day
- Teen-age pregnancy : 1.5-1.7 g/kg/day
- Ex meat, milk, egg, fish and dairy product

Inadequate calories intake → poor growth and low-birth weight

5. Advices for pregnancy

1. Nutrition
Iron
- For hemoglobin synthesis
- Dose
- 7 mg/day : absorb 10% in GI
- Ferrous fumarate : 33 %
- Ferrous sulfate : 20 %
- Ferrous gluconate : 10 %

- Ferrous fumarate 200 mg → Iron 66 mg → absorb 6.6 mg

- No recommend to give during first 4 months

- S/E : N&V → on an empthy stomach or before bed

5. Advices for pregnancy

1. Nutrition

Folic acid
- prevent NTD and megaloblastic anemia
- Dose
- 400 microgram/day
- 4 g/day for 3 mo before pregnancy in risk for NTD
5. Advices for pregnancy

2.Sanitation
2.1) Excercise
- Low risk : mild exercise 30 min/day ex aerobic excercise

2.2) Working :
- ทําไดตามปกติ งดงานที่ออกแรงมาก เดินหรือยืนนานๆ

2.3) Traveling :
- Three point restraint
- นอยกวา 36 wk เดินทางบนเครื่องบินได ระวังการนั่งเครื่องบินนานๆ
ใหลุกเดินไปมาทุกชั่วโมงเพื่อปองกันลิ่มเลือดอุดตัน

2.4) Sexual intercourse :

- ไมมี complication สามารถรวมไดตามปกติ
- เลือกทาที่ไมเกิด supine hypotension
5. Advices for pregnancy

3. Behavior

3.1) Smoking
3.2) Alcohol
6. Symptoms in pregnancy

1) Nausea and vomiting

- Dimenhydrinate or pyridoxine
2) Amenorrhea

3) Back pain
- Resting, lie on one’s sides or massage
4) GERD and abdominal pain
- Change behavior, PPH
6. Symptoms in pregnancy

5) Cramp
- Calcium intake
6) Constipation
- High fiber diet, water intake or laxative drug
7) Hemorrhoids
- Prevent constipation, self-limited after deliver
8) Leucorrhoea
- Normal or complication
9) Frequent urination
6. Symptoms in pregnancy

Urgency symptom
- Bleeding per vagina
- PROM
- Abdominal pain with non-relieved
- Decrease or no fetal movement
- Fever, blurry, severe headache
7. Vaccination

Do not give “Live attenuated vaccine”

Contraindication vaccine

- Influenza (LAIV)
- MMR
- Varicella-zoster
- BCG.
7. Vaccination

Considered safe if otherwise indicated

- Hepatitis A : Base decision on risk vs. benefit.

- Hepatitis B : Recommended in some
circumstances.
- Influenza (Inactivated) : Recommended.
- Td : Should be used if otherwise indicated (Tdap
preferred).
- Tdap : Recommended.
Thank you