Antenatal Care (ANC)
Systematic supervision (examination and advice)
of a woman during pregnancy is called antenatal
(prenatal) care.
Actually prenatal care is the care in continuum
that starts before pregnancy and ends at Delivery
and the postpartum period.
# AIMS AND OBJECTIVE –
∆ AIMS –
To screen the “high risk” cases.
For ex. –
Eclampcia, pre-eclampcia, thyroid disorders,
HIV, DM, Cardiac Disorders, Hep. B etc.
To prevent or to detect and treat at The earliest
any complication.
To ensure continued risk assessment and to
provide ongoing primary Preventive health care.
to educate the mother about the physiology of
pregnancy and labor by demonstrations, charts
and diagrams (mothercraft classes), so that fear is
removed and psychology is improved.
To discuss couple about the date, mode, place of
delivery.
∆ Objectives –
To ensure a normal pregnancy with delivery of a
healthy baby from a healthy mother.
# The criteria of a normal pregnancy –
delivery of a single baby in good condition at term
(between 38 and 42), with fetal weight of 2.5 kg or
more and with no maternal complication.
ANC Visits –
•Total visit – 12 to 15
• 0 to 28th wks – every 4th wk
• 29th to 36th – every alternative week
•After 36 wk – every week.
WHO Recommends atleast 4 Visit :
Ist Visit : 16 Weeks
2nd Visit : 24-28 Weeks
3rd Visit : 32 Weeks.
4th Visit : 36 Weeks.
Note – 1st visit is K/A Booking Visit.
Gravida and Parity –
# GTPAL score –
G – Gravida (pregnant state both present and past).
Nulligravida – Never become pregnant.
Primigravida – 1st time pregnant.
Multigravida – 2nd or more time Pregnant.
Grandmultigravida – 5th or more time pregnant.
Greatgrandmultigravida – more than 7 time pregnant.
T – Term (37 to 42 wks)
P – Preterm (between 28th to 36th wks)
A – Abortion (Death Before 20 wks)
L – Live (No.of live children).
# Parity –
State of previous pregnancy beyond the period
of viability.
Primipara – Who has given one birth.
Multipara – given 2 or more.
Grandmultipara – Given 5 or more
Greatgrandmultipara – Given 7 or more.
Nullipara – Never given Birth.
Question 1:
A 26 year old female is currently 26 weeks
pregnant. She had a miscarriage at 10 weeks gestation
five years ago. She has a three year old who was born
at 39 weeks. What is her GTPAL?
Answer: G=3, T=1, P=0, A=1, L=1
Question 2:
A 35 year old female is currently pregnant
with twins. She has 10 year old triplets who were born
at 32 weeks gestation, and 16 years old who was born
at 41 week gestation. Twelve years ago she had a
miscarriage at 8 weeks gestation. What is her GTPAL?
Answer: G=4, T=1, P=1, A=1, L=4
Question 3
A 30 year old female is 25 weeks pregnant
with twins. She has 5 living children. Four of the 5
children were born at 39 weeks gestation and one child
was born at 27 weeks gestation. Two years ago she had
a miscarriage at 10 weeks gestation. What is her
GTPAL?
A. G=7, T=4, P=0, A=1, L=5
B. G=7, T=4, P=1, A=1, L=5
C. G=6, T=4, P=0, A=1, L=5
D. G=6, T=2, P=2, A=1, L=5
Ans. B
Question 4
A 27 year old female is currently 16
weeks pregnant. She has 2 year-old twins that
were born at 39 weeks gestation and a 5 year-old
who was born at 40 weeks gestation. She had no
history of miscarriage or abortion. What is her
GTPAL?*
A. G=3, T=1, P=0, A=1, L=3
B. G=3, T=1, P=1, A=0, L=3
C. G=3, T=2, P=0, A=1, L=1
D. G=3, T=2, P=0, A=0, L=3
Ans. D
Expected Date Of Delivery
The estimated due date (EDD ) is the date that
spontaneous onset of labor is expected to occur.
Accuracy Rate –
Only 5 % Give Birth on the EDD.
1 wk before And After EDD – 50%
2 wks Before and After EDD – 80%
@ 42nd wk of pregnancy – 10%
After 42nd wks of Pregnancy – 4%
#How to Calculate –
1. Naegele’s formula
2. By Quickening (If women Forgot
LNMP) .
1.Naegele's Formula –
1st Day of LMP + 9 month + 7 days
Note – If leap year then Feb. 29 days
( LMP + 9 Month + 6 days)
2. Quickening –
First fetal movement.
In Primigravida – 18 wks of pregnancy.
Then EDD – 18 + 22 = 40 wks (Term).
In multipara – 16th wk + 24 wks = 40 wks.
1. During a prenatal visit a patient tells you her last
menstrual period was May 21, 2016. Based on the
Naegele's Rule, when is the estimated due date of her
baby?*
A. February 27, 2016
B. March 19. 2017
C. February 28, 2017
D. April 16, 2016
Ans. C
2. During a prenatal visit a patient tells you
her last menstrual period was March 14,
2016. Based on the Naegele’s Rule, when is
the estimated due date of her baby?*
A. January 27, 2017
B. December 21, 2016
C. December 28, 2016
D. January 1, 2016
Ans. B
#Nutrition during Pregnancy –
Energy requires –
Mild worker – 1800 – 1900 kcal/ Day
Moderate* – 2200 kcal / Day.
Hard worker – 2400 – 2500 kcal / Day.
Nutrient Non-pregnant Pregnant Lactating
Energy 2200 kcal/day +350 +600
Protein 50gm/day +15 +25
Fat 20gm/day +10 +25
Calcium 500mg/day 1000mg/day 1000 –
1500 (1250
mg / Day
Iron 30mg /day 40md/ day 30mg/ day
Folic acid 200mcg/day 400 mcg/day Same as
pregnancy
#Weight Gain during Pregnancy –
Total wt gain – 11 to 12 kg
A/c to BMI –
< 18 = up to 19 kg
18– 24 = 11 to 12 kg.
>24 = 7 to 8 kg.
A/c to Trimesters –
In 1st trimester = 1kg
In 2nd trimester = 5 kg
In 3rd trimester = 5 kg.
Mother weight gain maximum in 2nd
trimester, fetus weight gain maximum in
3rd Trimester .
० Weight Gain –
Reproductive weight Non Reproductive
( 5 to 6 kg) ( 5 to 6 kg)
Fetus – 3kg Fat & Protein – 3 to
3.5kg
Amniotic fluid – 0.8 kg Blood volume – 1.5 lit.
Breast – 0.4 kg Extra cellular fluid –
1.5lit
Uterus – 0.9 kg
Placenta – 0.5 kg
If Rapid wt gain –
It indicates – twin pregnancy
Polyhydramnios
Pre-eclampcia
If slow wt gain –
It indicates – Abortion
IUGR
IUD
# Fluid Gain During pregnancy –
Total fluid gain – 6 to 6.5 lit.
From fetus ( 3 – 3.5 lit) In mother ( 3 – 3.5 lit)
Fetus – 2 lit. Blood volume – 1.5 lit
Amniotic fluid – 0.8 lit. ECf – 1.5 lit
Placenta – 0.5 lit.
Iron supplementation –
Iron
supplementation should be start from
2nd trimester, bcz it cause N/ V.
1.Ferous sulphate – 300 mg (M/C)
2.Ferous fumarate – 180 mg
3.Ferous Gluconate – 600 mg
Before Iron supplement Hb should be
check if –
Hb >11gm % - Tab. Ferous sulphate
OD×30days.
Hb 9 – 11 gm% - tab. Ferous sulphate BD
×30days.
Hb 6 – 9 gm% - Inj. Iron + sucrose in 100
ml NS.
Administer 5 Inj. On alternative day till
Hb 9 – 11 gm% level and then start Tab.
Ferous sulphate.
Skin allergy test should be done before
Iron supplement.
If Hb <6gm% - BT
Hb measured at every ANC visit but
@28th and 36th wks of pregnancy HB
must be checked.
#Folic Acid Supplementation –
Folic acid start one month before LMp to
end of embryonic period or till 3rd month
of pregnancy this is called Prophylactic
dose of Folic acid.
Dose of folic acid –
Therapeutic – 4000mcg /4 mg
Prophylactic – 400 mcg / 0.4mg
Folic acid prevent from –
1st trimester – from NTD
2nd and 3rd trimester – Erythropoisis
from kidney.
Indian govt. Supply Iron and folic acid
free of cost in which elementry Iron is
100mg and folic acid is 500mcg.
#Immunization In pregnancy –
Live vaccine are contraindicated –
rubella, measles, mumps, varicella,
yellow fever
Safe vaccines – Hep. A & B,
Influenza,Tetanus,Rabies.
Tetanus –
0.5ml IM in upper arm.
First dose – As early as pregnancy
detected. Or @ 16 – 20 wks.
2nd dose – 6 wks after first dose.
If a women pregnant again within 3year
then only Booster dose is administer in 3rd
trimester.
# Detection of Diabetes mellitus –
Check RBS at every visit.
@24 – 28 wks RBS and GTT must be done.
GTT –
Glucose tolerance Test. 75 gm (A/c To
WHO) oral intake of glucose / 100gm A/c to
India.
Take 4 samples –
1st – just before Glucose intake.
2nd – 1hr after glucose intake.
3rd - 2 hrs after Glucose intake.
4th – 3hrs after glucose intake.
#Criteria for Diagnosis of Gestational DM –
Time Carpenter & NDDG (National
coustan Daibetes Data
Group)
Fasting 95mg /dl 105 mg /dl
After 1hr 180 mg /dl >190 mg /dl
After 2 hr 155 mg /dl >165mg /dl
After 3 hr 140 mg /dl >145 mg /dl
GDM diagnosed when any 2 values are
elevated.
# Time for Routine Ultrasound Scan
At the Booking Visit (Ist Trimester)
18-22 Weeks.
In 3rd Trimes
Best Time for USG 18-20 Weeks.
∆ First Annomalies which seen in USG –
Anencephaly, detect on
10th week of pregnancy.
# Sign of Anencephaly on USG :
Fetal Head has an Irregular contour
and No Bone.
No calcified Cranium.
Face Shows Mickey Mouse Sign.
Eye of Fetus are big- Frog eye sign.
# Anencephaly is a NTD – absence of
Forebrain and mid brain.
# Diagnosis :
Screening Method :
(i) Increased level of Maternal
serum alpha fetoprotein.
(ii) Most Specefic Marker of
Anencephaly —
Acetylcholinesterase.
(iii)Investigation of Choice — Ultrasound.
# Prenatal Diagnostic Techniques :
1.Biochemical test
2.Amniocentesis.
3.Chorionic villi sampling.
4.Umbilical cord sempling.
5.USG
1.Biochemical test –
A. Triple marker test –
Done @ 15 – 18wk /16 – 18 wks
Earliest - @14 to 16 wks.
#Markers –
Estriol / E3 ( Unconjugated estriol)
Alfafeto protein.
Beta HCG.
# Note –
Alfafetoprotein – originated from Yolk sac
(mainly) and fetal liver.
HCG –
Origin – From Syncytiotrophoblast.
Half life – 36 hrs.
Earliest detected – 8 -9 days after
fertilization by RIA.
Max. Level in blood. - @60 – 70 days. ( 8
to 10 wk) 100 – 200 IU / ml.
@16 to 18 wks – 10 to 20 IU / ml.
Second Rise - @32 wks.
It disappear from blood – within 2 wks of
delivery. And in Abortion after 4 to 6 wks.
Disappear from urine – after 48 hrs. Of
delivery.
# Results –
∆ Estriol E3 –
If level Decrease – it indicates
Down Syndrome.
NTD
Hydatidyform mole
IUD.
If increase –
Twin pregnancy.
# Beta HCG –
Decrease – Spontaneous Abortion.
Ectopic pregnancy.
IUD.
Increase – twin Pregnancy
Molar pregnancy.
Down Syndrome.
# Alfa Fetoprotein –
Decrease – down syndrome
Increase – NTD
B. Quadruple marker test –
@ 15 to 18 wk
# Markers –
HCG
Alfafetoprotein
Estriol
Inhibin A
This is more effective than triple marker test.
# Inhibin A –
1. In down syndrome it is Increase.
2.Amniocentesis –
Removal of amniotic fluid from
amniotic cavity by needle and
syringe.
Diagnostic Therapeutic
Diagnostic
To detect congenital annomalies
- Trisomy 21
- NTD
At 12-16wks (14-16wks)
Earliest – (12-14wks)
Therapeutic
- To treat hydroamnios
Indications
- When triple marker result are
suggestive of chromosomal
annomaly in current pregnancy.
- Previous history of congenital
annomaly of fetus
- Family history suggestive of
chromosomal annomaly
3. Chorionic villi sampling
Done at 10-12 wks (9-11wks)
But less confirmative than that of
amniocentesis
18-20G needle
15-25gm villi sample
10-12wks Transcervical
10wks transabdominal
Side effect
Limb deformities
Oromandibular deformities
(most common if CVS done
before 8-9 wks).
Pervaginal bleeding (Late m/c)
Intrauterine sepsis
4. Umblical cord sampling
Collection of blood sample from
umblical blood vessels
pervaginally
At 18-20wks
It is as much confirmative as
amnioCentesis.
A/k/a Cordocentesis.
It can perform per abdominally.
# Side effect –
It is perform late than any other test
thus difficulty in performing MTP.
There are high chances of infection to
fetus.
More invasive and required skill.
USG guided.
5. USG –
Less invasive, more confirmative.
Finding –
- Nuchal Translucency.
- Gap at the junction of Nasal
septum and Nasal Bone.
# Fetal kick count –
1. Cardif count 10 formula.
2. Daily fetal movement count (DFMC).
1. Cardif count 10 formula –
12 hrs count. When 10 count
complete then stop counting.
Ex. Start from 9 AM to 9PM.
# She is instructed to report the Physician if –
< 10 movement occur during 12 on
succesive days.
If there is no movement perceived even
after 12 hrs in a single day.
2. DFMC –
Three counts each of 1 hr duration
(Morning, noon, evening) and then
multiply with 4 that gives daily (12hr)
fetal movement.
Conclusion –
If there is <10 count in day that means
fetal compromise.
# Edema during pregnancy –
1. Physiological edema –
Ex. – Hemodilution
- Physiological anemia
- IVC compression syndrome.
- Malnutrition.
2. Pathological –
- CHF
- Renal failure
- Pathological anaemia
- Gestational HTN, preeclampcia
# Edema – Directaly proportional to
Hydrostatic pressure.
And disproportional to colloidal oncotic
pressure.
#NSg. Role –
Health education.
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