prenatal care - beyond evidence based obstetrics
TRANSCRIPT
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
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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
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Oogenesis
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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
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Barker: Fetal Origin of Adult
Diseases
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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)
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Endometriosis satu penyakit yang
diprogram sejak dalam rahim
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2009
The Journal of Clinical Endocrinology & Metabolism
91(5):1660–1666, 2006 by The Endocrine Society
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MISTRA: Kepribadian dibentuk
sejak dalam rahim
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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
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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.
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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
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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:
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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