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Summary Table

Domain	Detail
Definition	Integrated antenatal care (ANC Terpadu) encompassing all activities from conception until the onset of labor, aimed at ensuring a healthy pregnancy and a positive birth experience
Target Population	All pregnant women, with heightened surveillance for those with risk factors (age ≤16 or ≥35, grand multiparity ≥4, prior cesarean section, prior obstetric complications, multiple gestation, chronic disease)
Visit Schedule	Minimum 6 contacts (K6): 1x in trimester 1 (0-12 weeks), 2x in trimester 2 (>12-24 weeks), 3x in trimester 3 (>24 weeks to delivery). At least 2 visits must be with a physician (1x in T1 and 1x in T3)
Standard of Care	10T (10 standardized service components performed at each antenatal visit)
Key Screening	Triple elimination screening (HIV, Syphilis, Hepatitis B) via rapid tests at the first trimester 1 visit; hemoglobin, blood type and Rh; malaria (endemic areas); urinalysis and blood glucose as indicated
Supplementation	Iron-folate tablets (Tablet Tambah Darah/TTD), minimum 90 tablets throughout pregnancy
Immunization	Tetanus-Diphtheria (Td) vaccine, targeting T5 status for lifelong protection
Counseling	Results of examination, age-appropriate care, nutrition, birth preparedness, recognition of danger signs, postpartum contraception planning, exclusive breastfeeding, early initiation of breastfeeding (IMD), and mental health assessment
Keywords for Exam Vignettes	"K1," "K4," "K6," "10T," "ANC terpadu," "triple eliminasi," "Tablet Tambah Darah 90 tablet," "LILA <23.5 cm = KEK," "Td immunization status T1-T5," "USG trimester 1 and trimester 3"

1. Overview and Rationale

Antenatal care exists to detect, prevent, and manage conditions that threaten the mother and fetus before labor begins. The Kemenkes 2021 regulation shifted the minimum visit standard from 4 contacts (K4) to 6 contacts (K6), aligning with the 2016 WHO recommendation that emphasizes more frequent contact to improve detection of complications and to provide a positive pregnancy experience.

The concept of ANC Terpadu (integrated ANC) is central. This is not simply an obstetric check-up; it is a platform that integrates screening and management for nutritional deficiencies, communicable diseases (HIV, syphilis, hepatitis B, malaria, tuberculosis), non-communicable diseases (hypertension, diabetes, heart disease), and mental health disorders (depression, anxiety, psychosis). Test-writers frequently assess whether students understand that ANC is a comprehensive screening opportunity, not just a fundal height measurement.

A critical exam concept is the distinction between K1 (access indicator, first contact ideally before week 8), K4 (quality indicator under the old standard, 4 visits minimum), and K6 (current quality indicator, 6 visits minimum). The visit distribution for K6 is: 1x trimester 1, 2x trimester 2, 3x trimester 3. The requirement for 2 physician visits (trimester 1 and trimester 3), each including ultrasonography (USG), is a high-yield testable point.

2. Visit Schedule and Distribution

Indicator	Minimum Visits	Trimester 1 (0-12 wk)	Trimester 2 (>12-24 wk)	Trimester 3 (>24 wk to delivery)
K4 (old standard)	4	1x	1x	2x
K6 (current standard, Permenkes 21/2021)	6	1x	2x	3x
Physician contact	2 (mandatory)	1x (screening + USG)	--	1x (birth planning + USG)

First visit (K1) should occur as early as possible in trimester 1, ideally before 8 weeks of gestation. At this visit, the physician performs a comprehensive risk factor screening and the first USG. The trimester 3 physician visit focuses on delivery planning, fetal presentation assessment, repeat USG, and arranging a planned referral if needed.

Additional visits beyond 6 are warranted whenever there are complaints, detected disease, or pregnancy complications.

3. The 10T Standard (Standar Pelayanan Antenatal)

This is the backbone of every ANC visit and the most commonly tested framework.

No.	Component (Indonesian shorthand)	What Is Done	Key Exam Detail
T1	Timbang berat badan dan ukur tinggi badan	Weigh the patient, measure height (first visit only for height)	Height is measured once; weight is tracked at every visit to monitor appropriate gestational weight gain
T2	Ukur tekanan darah	Blood pressure measurement	Screening for hypertensive disorders; systolic ≥140 or diastolic ≥90 mmHg triggers workup for preeclampsia
T3	Nilai status gizi (ukur LILA)	Mid-upper arm circumference (MUAC/LILA) measurement	LILA <23.5 cm = Chronic Energy Deficiency (KEK); risk of low birth weight (BBLR)
T4	Ukur tinggi puncak rahim (fundus uteri)	Symphysis-fundal height measurement	Screens for fetal growth restriction or macrosomia; discrepancy with gestational age requires USG
T5	Tentukan presentasi janin dan DJJ	Determine fetal presentation and fetal heart rate (DJJ)	Fetal heart rate normal 120-160 bpm; presentation assessment relevant from third trimester onward
T6	Skrining status imunisasi tetanus, berikan Td bila diperlukan	Tetanus-Diphtheria immunization screening and administration	Target is T5 status (lifelong protection >25 years); if unknown status, restart from T1
T7	Pemberian Tablet Tambah Darah (TTD)	Iron-folate supplementation	Minimum 90 tablets over the entire pregnancy, given as 1 tablet daily starting as early as possible, continued through the postpartum period
T8	Tes laboratorium	Laboratory investigations	Routine: pregnancy test, Hb, blood type + Rh, triple elimination (HIV, syphilis, HBsAg). Endemic areas: malaria rapid test. As indicated: urine glucose-protein, random blood glucose, sputum AFB, complete blood count for thalassemia screening
T9	Tata laksana / penanganan kasus	Case management per competency	Management or referral of any detected complication
T10	Temu wicara (konseling) dan penilaian kesehatan jiwa	Counseling and mental health assessment	Covers exam results, nutrition, birth preparedness, danger sign recognition, postpartum contraception, breastfeeding, and mental health screening (minimum at T1 and T3)

4. Laboratory Workup at ANC

Test	Timing	Purpose	Exam Pearl
Hemoglobin	First visit + repeat as indicated	Detect anemia; Hb <11 g/dL in pregnancy = anemia	Low Hb in trimester 2 can be physiological (hemodilution); confirm with repeat and iron supplementation response
Blood type + Rh	First visit	Identify Rh-negative mothers at risk for hemolytic disease of the newborn	If Rh-negative, anti-D immunoglobulin is the management principle
Triple elimination (HIV, Syphilis, HBsAg)	First visit, trimester 1 (rapid tests)	Prevent mother-to-child transmission (PPIA program)	All three are done simultaneously as a package at K1; this is a national program mandate
Malaria RDT / microscopy	First visit (K1) in high-endemic areas; selective in low-endemic areas	Detect malaria in pregnancy	In high-endemic areas: all pregnant women screened + given insecticide-treated bed nets
Urine glucose-protein	As indicated	Screen for gestational diabetes and preeclampsia	Proteinuria in the setting of hypertension supports preeclampsia
Random blood glucose	As indicated	Classify hyperglycemia as pre-existing DM type 2 or gestational DM	The regulation distinguishes between DM with pregnancy and gestational DM
Complete blood count (MCV, MCH, MCHC, RDW)	As indicated	Thalassemia carrier screening	If mother is carrier, screen the father; if both are carriers, offer genetic counseling and consider prenatal diagnosis
Sputum AFB	If symptomatic	TBC screening	All pregnant women are screened by history; if suspected, proceed with sputum and HIV test

The test-writer logic here is: triple elimination at K1 is mandatory, not optional. The most commonly tested concept is the timing (trimester 1, first contact) and the fact that all three (HIV, syphilis, hepatitis B) are done as a single package using rapid tests that do not require specialized laboratory personnel.

5. Supplementation, Immunization, and Nutrition

Iron-Folate Supplementation (TTD)

The standard is 1 tablet daily, minimum 90 tablets throughout pregnancy, started as early as possible and continued through the postpartum period. TTD addresses the physiological decline in hemoglobin that occurs due to plasma volume expansion during pregnancy, with the nadir in trimester 2 and partial recovery in trimester 3.

Contraindication: TTD is not given to women who already have an Hb ≥13 g/dL (per the regulation's guidance for non-pregnant females; during pregnancy, the threshold is adjusted clinically).

Tetanus-Diphtheria (Td) Immunization

The goal is T5 status for lifelong protection (>25 years). The immunization history is traced back from infancy:

Status	Interval	Duration of Protection
T1	--	None
T2	4 weeks after T1	3 years
T3	6 months after T2	5 years
T4	1 year after T3	10 years
T5	1 year after T4	>25 years (effectively lifelong)

A key exam trap: a child who completed the full infant immunization series (DPT-HB-Hib 1, 2, 3) is at T2 status, not T3. Completion of the 18-month booster brings them to T3. Completion of the school-age BIAS program (DT and Td) brings them to T5. If immunization status is unknown, restart from T1.

Nutritional Assessment

LILA <23.5 cm is the threshold for Chronic Energy Deficiency (KEK). This is a critical exam value. A woman with KEK who becomes pregnant has increased risk for anemia, hemorrhage at delivery, low birth weight, infection, miscarriage, stillbirth, and congenital malformations.

BMI classification used:

Category	BMI
Severely underweight	<17.0
Underweight	17.0 to <18.5
Normal	18.5 to 25.0
Overweight	>25.0 to 27.0
Obese	>27.0

Women with KEK should ideally delay pregnancy until nutritional status is corrected.

6. Integrated Programs Within ANC

The concept of ANC Terpadu means that multiple vertical programs are delivered through the ANC platform. This is high-yield because exam questions may present a pregnant woman at her first visit and ask which screenings must be performed.

Integrated Program	Key Action at ANC
Nutrition	LILA measurement, TTD supplementation, KEK management
Malaria Control	RDT/microscopy at K1 (endemic areas), insecticide-treated bed nets for all pregnant women in high-endemic areas, treatment of positive cases
Tuberculosis	History-based screening for all; if suspected, sputum examination + HIV testing; treatment with OAT (Amikacin, Streptomycin, Ethionamide/Prothionamide are contraindicated in pregnancy)
Triple Elimination (PPIA)	Rapid tests for HIV, syphilis, HBsAg at K1; positive results mandate treatment, facility-based delivery, breastfeeding counseling, and contraception counseling
NCD (Hypertension, DM, Thalassemia)	Risk stratification for hypertension; classification of hyperglycemia (pre-existing vs. gestational DM); thalassemia carrier screening with CBC indices (MCV, MCH)
Mental Health	Screening at minimum trimester 1 and trimester 3 using clinical interview; identifies stress, anxiety, depression, OCD, bipolar disorder, PTSD, psychosis, substance abuse

7. Risk Factors and Complications Encountered in ANC

Category	Examples
Nutritional	Anemia, KEK (LILA <23.5 cm), obesity, inappropriate weight gain
Obstetric Risk Factors	Age ≤16 or ≥35 years, youngest child ≤2 years old, first pregnancy after ≥4 years, interpregnancy interval >10 years, grand multiparity (≥4 deliveries), multiple gestation, malpresentation, macrosomia, poor obstetric history, prior cesarean section, post-term (>40 weeks)
Obstetric Complications	Premature rupture of membranes, antepartum hemorrhage, preeclampsia/eclampsia, threatened preterm labor, dystocia, placenta previa
Non-Communicable Disease	Hypertension, DM, cardiac disease, renal disease, asthma, cancer, epilepsy, autoimmune disease
Communicable Disease	HIV, syphilis, hepatitis B, malaria, TB, dengue, typhoid
Psychiatric	Depression, anxiety, psychosis, schizophrenia

8. Exam Context

Since ANC is a care protocol rather than a single diagnosis, the exam tests ANC through clinical scenario questions. Below are the most testable confusion points.

Exam Trap	Why Students Get Confused	Key Discriminator
K4 vs. K6	Students recall the old 4-visit minimum	Current standard per Permenkes 21/2021 is K6 (minimum 6 visits). K4 is the legacy indicator.
TTD "90 tablets" vs. "1 tablet/week for adolescents"	Both involve iron-folate tablets	Adolescent (non-pregnant) girls receive 1 tablet per week year-round; pregnant women receive 1 tablet per day, minimum 90 tablets total
LILA 23.5 cm threshold for KEK	Confused with BMI cutoffs	LILA is used as a rapid field screening for chronic energy deficiency; BMI is used for overall nutritional status. LILA <23.5 cm = KEK is the high-yield number.
"Who must perform the ANC visit?"	Students assume all visits are by midwives (bidan)	Minimum 2 visits must be with a physician (trimester 1 and trimester 3), including USG at both
Triple elimination at K1	Students may only recall HIV testing and forget syphilis or hepatitis B	All three (HIV + syphilis + HBsAg) are tested simultaneously as a single package at the first contact
Td status "unknown"	Students assume partial protection	If immunization status cannot be verified (no KIA book, no records), the patient is treated as T1 and immunization restarts from the beginning
OAT in pregnancy	Students may not know which anti-TB drugs are contraindicated	Amikacin, Streptomycin, and Ethionamide/Prothionamide are not recommended during pregnancy
Mental health screening	Students overlook this as part of ANC	T10 explicitly includes mental health assessment, performed at minimum in trimester 1 and trimester 3

9. High-Yield Pearls

The most common way students lose points on ANC questions is by applying outdated standards. The shift from K4 to K6 is a regulation-level change that exam writers use to separate current from outdated knowledge. If a vignette asks for the minimum number of antenatal visits per current national guidelines, the answer is 6, not 4.

Another frequent trap involves the physician visit requirement. Many students assume ANC is exclusively a midwife's domain. Under Permenkes 21/2021, at least 2 of the 6 visits must involve a doctor, with USG performed at both the trimester 1 and trimester 3 physician visits. The trimester 1 physician visit focuses on risk factor screening, while the trimester 3 physician visit focuses on birth planning and referral arrangement.

Students also commonly forget that T8 (laboratory testing) at the first visit is not optional. The triple elimination panel (HIV, syphilis, hepatitis B) is a mandatory national program integrated into ANC. A question that presents a pregnant woman at her first visit and asks "what laboratory tests should be ordered?" expects the student to list hemoglobin, blood type with Rh, and the triple elimination rapid tests as the baseline panel.

The LILA threshold of 23.5 cm for KEK is one of the most testable numbers in the entire ANC module. It frequently appears as a clinical detail in vignettes where the student must identify that the pregnant woman is at nutritional risk and counsel her accordingly.

Finally, the TTD dosing distinction between pregnant women (1 tablet/day, minimum 90 tablets) and non-pregnant adolescent girls (1 tablet/week, year-round) is a classic distractor pair. The exam expects you to match the correct dosing schedule to the correct population.

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