Prenatal Care - Beyond Evidence Based Obstetrics

PRENATAL CARE - BEYOND EVIDENCE

BASED OBSTETRICS

Hermanto TJ

Evidence Based Medicine vs Personalized Medicine –

Value Based Medicine?

Penulis Quotes

William

Ossler

Clinical Medicine as the science of uncertainty and the art

of probability

Bernard

Lown 1996

Health care in USA: Physician = provider, patients =

consumers, Medicine convert to business, Depersonalizing

Patient and deprofessionalizing doctors

Berghella

2012

These are guidelines, not rules. Even the best scientific

studies are not always perfectly related to any given

individual, and clinical judgment must still be applied to

allow the best ‘‘particularization’’ of the best knowledge

for the individual, unique patient.

Greenhalgh

et al 2016

Six ‘biases’ against patients and carers in evidence-based

medicine

Buku-buku mengenai PNC

Batasan dan Tujuan PNC

Penulis Quotes

A A P & A C

O C 2012

A comprehensive antepartum program involves a coordinated approach to medical care,

continuous risk assessment, and psychological support that optimally begins before

conception and extends throughout the postpartum period and interconceptional period

Berghella

2012

the care provided to pregnant women to prevent complications and decrease the incidence

of perinatal and maternal morbidity/mortality

Cunningha

m et al 2014

Prenatal care identifies pregnancies with maternal or fetal conditions associated with

maternal or perinatal morbidity/ mortality, and provides interventions to prevent such

complications. Care should be systematic, evidence based, and provide both medical and

psychological support as well as ongoing risk assessment. It should result in informed shared

decision making between the patient and provider.

Lockwood

UTD April

2016

The major goal of prenatal care is to ensure the birth of a healthy baby with minimal

risk for the mother

Tumbuh Kembang Otak

Penulis Temuan

Volpe Proliferasi, migrasi, diferensiasi, mielinisasi, apoptosis

Shonkoff Pengaruh urutan stimulasi – nutrisi terhadap tumbuh

kembang otak

Gilbert Proliferasi berhenti usia kehamilan 20-25 minggu

Bures Stimulation Induced Morphological Changes

Rozenstein Otak membutuhkan stimulasi untuk tumbuh dan

berkembang

Brent Logan Apoptosis neuron meningkat di 4 minggu terakhir

kehamilan

Skeletal muscle fibres

Neurons

Seminiferous tubules

Renal nephrons

Heart muscle fibres

Pulmonary alveoli

Intestinal villi

Ovarian follicles

Thyroid follicles

Hepatic chord

Exocrine acini

Endocrine cells

Blood cells

Birth Maturity

1 9 1 10 90Prenatal months Postnatal years

Duration of hyperplasia

hogsi jogya april 2012 hos hermanto

Determinate tissues(number fixed near

birth)

Indeterminate tissues(number not fixed near birth

The Duration of multiplicative growth for various human tissues (After Gilbert SF. Developmental Biology,Sinauer Associates, MA,1992


Oogenesis


FOAD - OGPenulis Temuan

Barker

et al

1995

IUGR dan penyakit metabolik masa dewasa

Abbott

et al

2006

animal models of fetal programming through androgen excess

show remarkable resilience and reliability in replicating PCOS,

including metabolic defects in males, and therefore strongly

implicate a fetal etiology in the developmental origins of PCOS

Gur et

al 2015

Experimental animal studies suggest that maternal

hyperandrogenism at a critical stage of fetal development may

cause permanent changes in fetal physiology that can trigger

PCOS development later in adult life

Signoril

e et al

2012

…the presence of ectopic endometrium in human female fetuses

at different gestational ages. … four new cases of fetal

endometriosis found among a series of 52 female fetuses

analyzed at autopsy


Barker: Fetal Origin of Adult

Diseases


0

5

10

15

20

25

30

< 5.5 -6.5 -7.5 -8.5 -9.5 >9.5

Minggu-minggu terakhir

kehamilan

• “Any very actively

developing event is

highly vulnerable to

insults,” (Volpe).

• Apoptosis

meningkat di

minggu 36 – lahir

(Logan)


Endometriosis satu penyakit yang

diprogram sejak dalam rahim


2009

The Journal of Clinical Endocrinology & Metabolism

91(5):1660–1666, 2006 by The Endocrine Society


MISTRA: Kepribadian dibentuk

sejak dalam rahim


Nutrisi Makro dan Mikro

Penulis Temuan

Roseboom

2006 Dutch

famine.

2414 people: Exposure to famine during any stage of

gestation was associated with glucose intolerance., more

coronary heart disease, a more atherogenic lipid profile,

disturbed blood coagulation, increased stress

responsiveness, breast cancer and more obesity among

those exposed to famine in early gestation.

Berberapa

penelitian

Thalidomite, Alkohol, Rokok, NAPZA terhadap Luaran

Perinatal

Fallin et al

2016

Asam Folat yang berlebihan dihubungkan dengan Autisme

Scaling Up

Nutrition

Pentingnya 1000 hari pertama kehidupan

Stress selama kehamilan

Lilliecreutz 2016 Maternal stress during pregnancy was more common among women who gave birth preterm compared to women who gave birth at term

Lutgendorf 2016 In a military population, PTSD is a common problem. There is a significant relationship between PTSD and depression, and obstetric providers should be mindful of PTSD and traumatic events that may contribute to or worsen depression in pregnant women.

Surabaya 2014 - 2015

Peneliti Hasil

Eka N,

Hermanto

TJ

Pengaruh Kombinasi Stimulasi Auditorik(Mozart) dan Nutrisi

Selama Kebuntingan kadar pada malam dan siang hari

Tony W,

Hermanto

TJ

Kombinasi Stimulasi Auditorik(Mozart) dan Nutrisi Selama

Hamil meningkatkan kadar BDNF tali pusat bayi baru lahir

Rozy A,

Hermanto

TJ

Stimulasi Auditorik(Mozart) saat kebuntingan menghasilkan

BDNF dan Jumlah Sel Glia yang lebih tinggi

Cininta M,

Hermanto

TJ

Stimulasi Auditorik(Mozart) saat kebuntingan menghasilkan

BDNF dan Jumlah Dendrit yang lebih tinggi

EBO u PNC 1Cunningham 2014 : Empat

Hambatan

1. Studi observational yang

membandingkan luaran persalinan antara

yang menerima PNC dan tidak menerima

selalu terpengaruh faktor sosioekonomi

terhadap akses u PNC/ faskes

2. PNC bukan intervensi tunggal tetapi

merupakan serangkaian asesmen dan

intervensi sehingga mungkin diaplikasikan

secara berbeda

3. Pengukuran dampak kuantitas lebih mudah

dibanding dampak kualitas disamping kesulitan

mendefinisikan beberapa luaran yang

berbeda(maternal, fetal dan neonatal

4. Sebagian besar kajian, kurang memenuhi syarat

jumlah kasus yang dibutuhkan

E B O u PNC 2 – kajian yang sudah

dilakukan

1. Antara Bidan dan Sp OG: keefektivan sama, lebihmemuaskan dan lebih murah bila dilakukan olehbidan

2. Keunggulan PNC oleh bidan: lebih sedikitmenggunakan anesthesia regional, lebih sedikitekstraksi forceps/vacuum meskipun laju mortalitasperinatal and persalinan sesar sama

3. Meskipun diterima sebagai bagian dari PNC, tidakada bukti yang cukup kuat yang menunjukkan klinikPNC khusus memperbaiki luaran.

EBO u PNC 3: Berghella 2012

Masih kontroversial – tidak ada bukti definitive PNC memperbaiki luaran persalinan

Belum ada RCT yang membandingkan PNC vs tanpa PNC – yang ada studi observasional dengan hasil yang sebagian menguntungkan dan sebagian tidak

PNC mungkin sangat menguntungkan kelompok Risti – sedangkan u KRR: belum cukup bukti

EBO PNC 4: Lockwood 2016

1995: there was no conclusive evidence that routine prenatal care improved birth outcomes

RCT antara routine vs enhanced PNC: enhanced care did not significantly improve outcome

RCT antara routine vs reduced PNC visits u KRR: a reduction in care did not adversely affect outcome

Peran pemeriksaan ultrasonografi: Pam

West


Pretorius et al 2005

• CONCLUSION: 3DUS appears to more positively

influence the perceptions of mothers to their babies

postbirth compared to 2DUS. Specifically, mothers

who had 3DUS showed their ultrasound images to a

greater number of people compared to mothers who

had 2DUS alone and this may represent mother's

social support system. 3DUS may have a greater

impact on the maternal-fetal bonding process.


Pretorius, et al. 2006.

• Objective. The purpose of this study was to

determine whether there is a change in parental

bonding and couples’ attitudes toward their fetus

after undergoing 3-/4-dimensional ultrasonography

(3D/4DUS).

• Results … The positive feelings questionnaire showed

a statistically significant change for women in all

sections but for men in only 2.

• Conclusions. Parents have a change in attitude

regarding their fetus after undergoing 3D/4DUS.

Mothers showed an increase in bonding to their

fetus after 3D/4DUS in more categories than fathers


Asemen neurobehaviour

• Dulu: janin dianggap sebagai entitas

biofisik, saat ini bukti-bukti mendukung

janin sebagai individu tersendiri – fetus

as person

• Acceptance

• Bonding

• KANET

Hak Janin Sebagai Individu/ Pasien

bukan hanya entitas biofisik:


Working Mothers

Terminasi Kehamilan

• Mandujano

• Rosenstein

Kasus Preeklamsia

• Skrining Ax, BMI, ROT, MAP, DVAU

• Terminasi 37 minggu

• 4 hal baru dari Prof Dekker: sindroma,

hipoksia?, misfolding protein dan

misteri

• Bentuk lain?

Temuan-temuan di atas

seharusnya membuat kita1. mendefinisikan kembali obstetris - tidak hanya ranah yang

membahas kehamilan, persalinan dan nifas serta kesehatan

wanita namun ditambah sebagai ranah yang membahas

bagaimana menyiapkan satu generasi yang lebih baik dan

memandang janin sebagai pemilik masa depan

2. memperkuat kegiatan prakonsepsi dan mendorong

perencanaan jumlah, jarak dan saat kehamilan

3. memberikan stimulasi auditorik dan nutrisi saat hamil

4. mendorong skrining kelainan medis termasuk stres dalam

kehamilan dan kelainan obstetris

5. meningkatkan kualitas dan kuantitas hubungan ibu dan janin-

bayi-anak dengan mengurangi jam kerja dan cuti melahirkan 6

bulan

Date post:	19-Feb-2017
Category:	Health & Medicine
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Prenatal Care - Beyond Evidence Based Obstetrics

Health & Medicine