Optimalisasi ANC

di FKTP

dr. Fifi Noviana Sp.OG

 ANC
DEFINISI

Pemeriksaan kehamilan yang bertujuan untuk meningkatkan

kesehatan fisik dan mental pada ibu hamil secara optimal,
hingga mampu menghadapi masa persalinan, nifas,
mengahadapi persiapan pemberian ASI secara ekslusif, serta
kembalinya kesehatan alat reporduksi dengan wajar.
 TUJUAN ANC
•Memantau kemajuan proses kehamilan demi memastikan kesehatan pada
ibu serta tumbuh kembang janin yang ada di dalamnya.
•Mengetahui adanya komplikasi kehamilan yang mungkin saja terjadi
saat kehamilan sejak dini, termasuk adanya riwayat penyakit dan tindak
pembedahan.
•Meningkatkan serta mempertahankan kesehatan ibu dan bayi.
•Mempersiapkan proses persalinan sehingga dapat melahirkan bayi dengan
selamat serta meminimalkan trauma yang dimungkinkan terjadi pada masa
persalinan.
•Menurunkan jumlah kematian dan angka kesakitan pada ibu.
•Mempersiapkan peran sang ibu dan keluarga untuk menerima kelahiran
anak agar mengalami tumbuh kembang dengan normal.
•Mempersiapkan ibu untuk melewati masa nifas dengan baik serta dapat
memberikan ASI eksklusif pada bayinya.
 1000 hari kehidupan 1000 hari kehidupan 1000 hari kehidupan
1000 hari kehidupan 1000 hari kehidupan 1000 hari kehidu

1000 hari kehidupan

1000 hari kehidupan

1000 hari kehidupan 1000 hari kehidupan

1000 hari kehidupan 1000 hari kehidupan
1000 hari kehidupan
1000 hari kehidupan
Mencegah stunting
Mencegah stunting Mencegah stuntingMencegah stunting Mencegah stunting
Mencegah stun

Mencegah stunting
Mencegah stunting Mencegah stunting

Mencegah stunting Mencegah stunting Mencegah stunting

Mencegah stunting Mencegah stunting Mencegah
Mencegah stunting Mencegah stunting Mencegah stunting Mencegah stunting

Kualitas Generasi Kualitas Generasi

Kualitas Generasi Kualitas Generasi Kualitas Generasi Kualitas Generasi Kualitas Generasi
Kualitas Generasi

Kualitas Generasi Kualitas

Generasi
Kualitas Generasi Kualitas Generasi
Kualitas Generasi Kualitas Generasi
Kualitas Generasi Kualitas Generasi
Kualitas Genera
Kualitas Generasi
 ANC yang efektif

•ANC dilakukan oleh petugas yang terampil ( dokter Umum,

bidan ) dan bekerjasama dengan dokter spesialis
•Mengetahui tujuan ANC
• persiapan persalinan serta potensi komplikasi
•Mempromosikan kesehatan dan pencegahan penyakit ( TT,
suplemen, Gizi, dll)
• Deteksi dan penatalaksanaa komplikasi secara dini
•Skrining ibu hamil dengan risiko tinggi
• Deteksi penyakit kronis seperti hipertensi, dM) dan
penyakit seperti HIV, sipilis, TB
ANC minimal 4 (empat) kali selama masa kehamilan, yaitu 1 kali
pemeriksaan pada trimester pertama, 1 kali pemeriksaan pada
trimester kedua, dan 2 kali pemeriksaan pada trimester ketiga
(Kemenkes)

2016 WHO ANC model

E.7: Antenatal care models with a minimum of eight contacts are
1
recommended to reduce perinatal mortality and improve
women’s experience of care.

This GDG recommendation was informed by:

• Evidence suggesting increased perinatal deaths in 4-visit ANC model
• Evidence supporting improved safety during pregnancy through increased
frequency of maternal and fetal assessment to detect complications
• Evidence supporting improved health system communication and support
around pregnancy for women and families
• Evidence indicating that more contact between pregnant women and
respectful, knowledgeable health care workers is more likely to lead to a
positive pregnancy experience
• Evidence from HIC studies indicating no important differences in maternal
and perinatal health outcomes between ANC models that included at
least eight contacts and ANC models that included 11 to 15 contacts.
ANC TRIMESTER 1
• 1 Kali kunjungan uk <12 mgg
• Riwayat penyakit dan riwayat keluarga
•Penentuan risiko , penilaian kemungkinan komplikasi
•Perencanaan ANC selanjutnya

ANC TRIMESTER 2
• 2 kali kunjungan (uk 20 mgg, 26 mgg)
• penilaian pertumbuhan janin dan kesejahteran ibu ( pemeriksaan obstetri
TFU dan USG)
• seleksi malformasi kongenital < 24 minggu
•Untk usia ibu > 35 th usg usia 12-14 mgg untuk skring SD
•Seleksi diabetes gestational 24-28mgg

ANC TRIMESTER 3
• 5 Kali kunjungan (UK 30 mgg, 34 mgg, 36 mgg, 38 mgg, 40 mgg)
• Penilaian pertumbuhan jianin , kesejahteraan ibu, deteksi preeklampsia
•Menilai persiapan persalinan, rumah sakit atau di rumah
•Penilaian kesejahteraan janin pada 35-37 mgg
 A. Nutritional interventions - 1
A.1.1: Counselling about healthy eating and keeping physically active Recommended
during pregnancy is recommended for pregnant women to stay
healthy and to prevent excessive weight gain during pregnancy.

A.1.2: In undernourished populations, nutrition education on Context-specific

increasing daily energy and protein intake is recommended for recommendation
pregnant women to reduce the risk of low-birth-weight neonates.

A.1.3: In undernourished populations, balanced energy and protein Context-specific

dietary supplementation is recommended for pregnant women to recommendation
reduce the risk of stillbirths and small-for-gestational-age neonates.

A.1.4: In undernourished populations, high-protein supplementation Not recommended

is not recommended for pregnant women to improve maternal and
perinatal outcomes.
 A. Nutritional interventions -2
A.2.1: Daily oral iron and folic acid supplementation with 30 mg to Recommended
60 mg of elemental iron and 400 µg (0.4 mg) of folic acid is
recommended for pregnant women to prevent maternal anaemia,
puerperal sepsis, low birth weight, and preterm birth.

A.2.2: Intermittent oral iron and folic acid supplementation with 120 Context-specific
mg of elemental iron and 2800 µg (2.8 mg) of folic acid once weekly is recommendation
recommended for pregnant women to improve maternal and neonatal
outcomes if daily iron is not acceptable due to side-effects, and in
populations with an anaemia prevalence among pregnant women of
less than 20%.
A.3: In populations with low dietary calcium intake, daily calcium Context-specific
supplementation (1.5–2.0 g oral elemental calcium) is recommended recommendation
for pregnant women to reduce the risk of pre-eclampsia.

A.4: Vitamin A supplementation is only recommended for pregnant Context-specific

women in areas where vitamin A deficiency is a severe public health recommendation
problem, to prevent night blindness.
 Nutritional interventions - 3
A.5: Zinc supplementation for pregnant women is only recommended Context-specific
in the context of rigorous research. recommendation
(research)
A.6: Multiple micronutrient supplementation is not recommended for Not recommended
pregnant women to improve maternal and perinatal outcomes.

A.7: Vitamin B6 (pyridoxine) supplementation is not recommended Not recommended

for pregnant women to improve maternal and perinatal outcomes.

A.8: Vitamin E and C supplementation is not recommended for Not recommended

pregnant women to improve maternal and perinatal outcomes.

A.9: Vitamin D supplementation is not recommended for pregnant Not recommended

women to improve maternal and perinatal outcomes.

A.10: For pregnant women with high daily caffeine intake (more than Context-specific
300 mg per day), lowering daily caffeine intake during pregnancy is recommendation
recommended to reduce the risk of pregnancy loss and low-birth-
weight neonates.
 USG
USG PERTRIMESTER

USG MINIMAL 2x ( < 24 MGG DAN 30-32 MGG) dan jika sudah HPL
belum partus

Pasien yg lupa HPHT usg 10-12 minggu, lbh akurat menentukan usia
kehamilan, untuk mencegah posterm

Usia ibu > 35 th usg saat usia kehamialn 12-14 mgg untk deteksi dini DS

Ibu dengan risiko preklampsia usg < 20 mgg dan lbh sering saat trimester 3
awal , deteksi dini IUGR, kesejahteraan janin ( doppler) dan menentukan
terminasi kehamilan
 MORTALITY IN PREGNANCY

Penyebab kematian ibu terbanyak di

Indonesia :
1. Hipertensi/pre eklampsia/ eklampsia
2. Perdarahan
3. Infeksi
HIPERTENSI DALAM KEHAMILAN
Hipertensi dalam kehamilan menempati urutan pertama penyebab
kematian di Indonesia sebesar 33% (SRS Litbangkes, 2016)
 Hipertensi/pre eklampsia/ eklampsia

Risk factor
high risk of preeclampsia
history of hypertensive disease during a previous pregnancy or a
maternal disease including chronic kidney disease, autoimmune
diseases, diabetes, or chronic hypertension. (National Guideline Alliance (UK)
Hypertension in Pregnancy: Diagnosis and Management (NG133) [(accessed on 3 October 2019)

moderate risk
nulliparous, ≥40 years of age, have a body mass index (BMI) ≥ 35 kg/m
(Brown M.A., Magee L.A., Kenny L.C., Karumanchi S.A., McCarthy F.P., Saito S., Hall D.R., Warren C.E., Adoyi G., Ishaku S.
Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for
International Practice. Hypertension. 2018)

a family history of preeclampsia, a multifoetal pregnancy, or a

pregnancy interval of more than 10 years (National Guideline Alliance (UK) Hypertension in
Pregnancy: Diagnosis and Management (NG133) [(accessed on 3 October 2019 )
 additional clinical factors that significantly increase preeclampsia risk

raised mean arterial blood pressure before 15 weeks’ gestation. (North R.A.,
McCowan L.M.E., Dekker G.A., Poston L., Chan E.H.Y., Stewart A.W., Black M.A., Taylor R.S., Walker J.J., Baker P.N., et al. Clinical Risk
Prediction for Pre-Eclampsia in Nulliparous Women: Development of Model in International Prospective Cohort. BM

polycystic ovarian syndrome (Bahri Khomami M., Joham A.E., Boyle J.A., Piltonen T., Silagy M., Arora C., Misso M.L.,
Teede H.J., Moran L.J. Increased Maternal Pregnancy Complications in Polycystic Ovary Syndrome Appear to Be Independent of Obesity-A
Systematic Review, Meta-Analysis, and Meta-Regression. Obes. Rev. 2019;20:659–674

sleep disordered breathing(Pamidi S., Pinto L.M., Marc I., Benedetti A., Schwartzman K., Kimoff R.J. Maternal Sleep-Disordered
Breathing and Adverse Pregnancy Outcomes: A Systematic Review and Metaanalysis. Am. J. Obstet. Gynecol. 2014

various infections such as periodontal disease, urinary tract infections (Rustveld L.O.,
Kelsey S.F., Sharma R. Association between Maternal Infections and Preeclampsia: A Systematic Review of Epidemiologic
Studies. Matern. Child Health J. 2008)

In terms of obstetric history, vaginal bleeding for at least five days during
pregnancy increases preeclampsia risk (North R.A., McCowan L.M.E., Dekker G.A., Poston L., Chan E.H.Y.,
Stewart A.W., Black M.A., Taylor R.S., Walker J.J., Baker P.N., et al. Clinical Risk Prediction for Pre-Eclampsia in Nulliparous Women:
Development of Model in International Prospective Cohort. BMJ. 2011;)
 PENCEGAHAN PREEKLAMPSIA

Uterine artery Doppler analysis has mixed results in predicting

preeclampsia and USG for predicting IUGR, umbilical artery Doppler
Velocymetry predicting Fetal wellbeing to terminated (Chien P.F., Arnott N., Gordon A.,
Owen P., Khan K.S. How Useful Is Uterine Artery Doppler Flow Velocimetry in the Prediction of Pre-Eclampsia, Intrauterine Growth
Retardation and Perinatal Death? An Overview. BJOG. 2000;107:196–208.)

advise low dose (75–150 mg) aspirin as prophylaxis from 12 weeks’

gestation until delivery (National Guideline Alliance (UK) Hypertension in Pregnancy: Diagnosis and
Management (NG133) [(accessed on 3 October 2019)

The presence of one high risk factor, or two or more moderate risk factors,
is used to help guide aspirin prophylaxis, which is effective in reducing the
risk of preeclampsia if administered before 16 weeks of pregnancy.
taken before 16 weeks’ gestation, low dose aspirin has a modest,
but consistent effect, estimated to reduce the risk of preeclampsia
by approximately 10%
(Askie L.M., Duley L., Henderson-Smart D.J., Stewart L.A. Antiplatelet Agents for Prevention of Pre-Eclampsia: A Meta-Analysis of
Individual Patient Data. Lancet. 2007)
vitamin D supplementation may offer some benefit in reducing preeclampsia
risk (Arain N., Mirza W.A., Aslam M. Review-Vitamin D and the Prevention of Preeclampsia: A Systematic Review. Pak. J. Pharm.
Sci. 2015)

A 2018 Cochrane review of high dose (>1 g/day) calcium supplementation from
20 weeks’ gestation did see a reduction in preeclampsia, although this finding
relied on small studies and is likely an over-estimate (Hofmeyr G.J., Lawrie T.A., Atallah Á.N., Torloni
M.R. Calcium Supplementation during Pregnancy for Preventing Hypertensive Disorders and Related Problems. Cochrane Database
Syst. Rev. 2018)

5-methyl-tetrahydrofolate supplementation, a more bioavailable form of folic acid, may be

effective in preventing recurrent preeclampsia (accone G., Sarno L., Roman A., Donadono V., Maruotti G.M.,
Martinelli P. 5-Methyl-Tetrahydrofolate in Prevention of Recurrent Preeclampsia. J. Matern. Neonatal Med. 2016)

Drug treatment of hypertension in pregnancy

methyldopa, labetalol, beta blockers (other than atenolol), slow release
nifedipine, and a diuretic in pre-existing hypertension are considered as
appropriate treatment. women with chronic hypertension, methyldopa
is recommended as first line therapy.
Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in
Pregnancy. American journal of obstetrics and gynecology. 2000;
 postpartum hemorrhage
Worldwide, postpartum hemorrhage accounts for 8% of maternal deaths in developed
regions of the world and 20% of maternal deaths in developing regions (Say L, Chou D, Gemmill
A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014)

The traditional definition of postpartum hemorrhage is blood loss of more than 500 ml
after a vaginal delivery or more than 1000 ml after a cesarean delivery. postpartum
hemorrhage has been redefined as a cumulative blood loss of 1000 ml or more or blood
loss associated with signs or symptoms of hypovolemia, irrespective of the route of
delivery .
(Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 183: postpartum hemorrhage. Obstet Gynecol 2017)

Postpartum hemorrhage is considered to be primary when it occurs within the first

24 hours after delivery and secondary when it occurs between 24 hours and up to
12 weeks after delivery. (Prevention and management of postpartum haemorrhage: Green-top Guideline no.
52. BJOG 2017)
The causes of postpartum hemorrhage:
1. tone (uterine atony) 70% of cases
2. trauma (lacerations or uterine rupture) 20%
3. tissue (retained placenta or clots) 10%
4. Thrombin (clotting-factor deficiency)

Postpartum hemorrhage can lead to severe anemia requiring

blood transfusion, disseminated intravascular coagulopathy,
hysterectomy, multisystem organ failure, and death.
Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 183: postpartum hemorrhage. Obstet
Gynecol 2017)
Faktor resiko :
• paritas
• peregangan uterus yang berlebih
• partus lama
• umur
• jarak hamil kurang dari 2 tahun
• persalinan yang dilakukan dengan tindakan
• anemia
• riwayat persalinan buruk sebelumnya
• status Gizi Ibu.
Manuaba (2007)
 Kapan harus dirujuk?
• Memerlukan pemeriksaan USG
Tdk ada USG :
- Minimal 2x usg ( UK 10-14mgg dan 28-30mgg)
- UK 10-14 mgg jika usia ibu > 35 th
- kapan saja segera jika HPHT tidak diketahui
- Adanya perdarahan antepartum
Sdh ada USG :
- jika menemukan kecurigaan dan atau keraguan terhadap hasil
pemeriksaan.(janin, air ketuban, plasenta)
- Riwayat operasi mioma atau sc sebelumnya
- Didapatkan hasil patologis lainnya
- Jika fullterm
 Kapan harus dirujuk?
• Pasien dengan Risiko Tinggi
• Pasien dengan penyakit kronis (HT, DM )
• Pasien ditemukan lab patologis
• Pasien dengan Perdarahan antepartum