RUSSIAN ACADEMY OF MEDICAL SCIENCES

SCIENTIFIC RESEARCH INSTITUTE OF Obstetrics and Gynecology them. D.O. OTTA

V. V. Abramchekko, A. G. Kiselev, O. O. Orlova, D. N. Abdullaev

MANAGEMENT OF PREGNANCY AND HIGH-RISK LABOR

ST. PETERSBURG

INTRODUCTION

Abramchenko V.V., Kiselev A.G., Orlova O. O., Abdullaev D. N. "Management of high-risk pregnancy and childbirth.- SPb,1995 year

Based on the literature data and our own experience, the issues of identifying and managing high-risk pregnant women and women in labor are covered. Particular attention is paid to the treatment of women with complications of pregnancy and childbirth. In particular, the issues of management of pregnant women with breech presentation of the fetus, a narrow pelvis, diabetes mellitus are highlighted. The second part of the monograph is devoted to a number of complications of pregnancy and childbirth: regulation of labor activity, prevention and treatment of mecoium aspiration syndrome, modern methods of treatment of fetal hypoxia

The book is intended for obstetricians-gynecologists, neonatologists and anesthesiologists working in obstetric institutions.

V. V. Abramchenko, A. G. Kiselev, O. O. Orlova, D. N. Abdullaev.

In Russia, the main goal in the field of maternal and child health "is to develop conditions for" preserving the health and working capacity of women, addressing issues of rational tactics - management of pregnancy 1, childbirth, postpartum and neo-natal period, determining ways to reduce maternal, perinatal and child morbidity and mortality ... At the same time, the creation of optimal conditions for the health of women and the development of pregnancy is the basis of "Prevention of perinatal pathology. OG Frolova et al. (1994) consider one of the main directions in the protection of mothers and children to reduce reproductive losses. The authors propose to consider reproductive losses. as the final result of the influence of social, medical and biological factors "on the health of pregnant women and newborns. The authors attribute the loss of embryos and fetuses to reproductive losses throughout the entire gestational period. On average, 32.3% of all pregnancies in the Russian Federation end in childbirth.

According to statistics, high-risk pregnancies in the general population are approximately 10%, and in specialized hospitals or perinatal centers, they can reach 90% (Barashnev Yu. I., 1991, etc.). WHO materials (1988) show that in Europe we are still far from defining what should be a rational delivery technique.

In the work of the World Health Organization (WHO, Geneva, 1988, 1992) "-programs of family protection, in particular, protection of mothers and children, are also given a priority task. It is emphasized that deaths in the perinatal period are responsible for most of the persistent and catastrophic It is shown that * perinatal mortality is closely related to poor health and nutritional status of the mother, complications of pregnancy and childbirth.

V. V. Chernaya, R. M. Muratova, V. N. Prilepskaya et al. (1991) recommend, depending on the complaints, about the general medical and reproductive history, the data of an objective examination, among those examined, 3 health groups should be distinguished:

- Is healthy- in the anamnesis there are no violations in the formation and subsequent, course of menstrual function, there are no pinecolotic diseases, complaints; during an objective examination (laboratory and clinical), there are no changes in the structure and function of the organs of the reproductive system.

- Practically healthy- history contains indications of gynecological diseases, functional abnormalities

or abortion; there are no complaints at the time of the examination, or an objective examination may be anatomical changes that do not cause dysfunctions of the reproductive system and do not reduce the working capacity of women.

__ Sick- there may be (or not) indications of

a history of gynecological diseases. Complaints at the time of the examination may or may not be present. An objective examination revealed the presence of a gynecological disease. On. for the purpose of monitoring the state of health and effectiveness of each patient, * medical and health-improving measures, a “control card of a dispensary patient (study f. No. 30)” is started.

Assessment of the health of pregnant women should be carried out as follows:

The health of a pregnant woman can be regarded as a state of optimal physiological, mental and social functioning, in which the race of the system! of the mother's body ensure the full health and development of the fetus.

The healthy group includes pregnant women who do not have somatic and gynecological diseases, who carry their pregnancies up to the term of physiological childbirth. These pregnant women have no risk factors for perinatal pathology.

To the group practically healthy pregnant womeninclude women who do not have somatic and gynecological diseases, who carry their pregnancies up to the term of normal childbirth. The overall assessment of the identified risk factors for perinatal pathology corresponds to a low degree of risk throughout pregnancy.

The rest of the pregnant women belong to the group sick,Assessment of the health status of the contingent of women who gave birth

should be carried out depending on ■ the state of health at the time of pregnancy, childbirth and the postpartum period, with particular attention to the restoration of reproductive function.

The postpartum observation group is established at her first visit to the antenatal clinic.

Group I includes healthy individuals with the physiological course of pregnancy, childbirth and the postpartum period, with sufficient lactation.

Group II includes practically healthy persons with a physiological or complicated course of pregnancy, childbirth and the postpartum period, having risk factors for the onset or deterioration of extragenital and gynecological diseases; complaints "at the time of the examination are absent, during an objective examination there may be anatomical changes

tions that cause reproductive and general health problems.

Group III includes patients with a physiological or complicated course of pregnancy, childbirth and the postpartum period, with an objective examination of which the presence of obstetric pathology, gynecological diseases, deterioration of the course of extragenital diseases was revealed.

The allocation of these groups is determined by the different nature of medical measures.

Dispensary observation of the contingent of women giving birth is carried out within a year after childbirth. In the future, regardless of the health group, “ablation is carried out three times by actively calling the mothers to the antenatal clinic (by the 3rd, 6th and 12th months after childbirth). Three months after childbirth, a bimanual examination and examination of the cervix with the help of mirrors must be performed using the screening test "Schiller's test" (colposcop-p "s, if possible), bacterio- and pythological studies. At this stage, recreational activities and an individual selection of contraceptive methods are required.

At the 6th month after delivery, in the absence of contraindications, intrauterine contraception should be recommended. An active call of women to a consultation is carried out with the aim of controlling lactation by menstrual function and preventing unwanted pregnancy, social legal assistance. The third visit is advisable for the formation of an epicrisis for the final rehabilitation of women by the year after childbirth, for issuing recommendations on contraception, planning a subsequent pregnancy and women's behavior in order to prevent existing complications.

At the same time, it is essential to emphasize that an analysis of domestic and foreign literature shows that the level of perinatal morbidity and mortality is especially high in a certain group of pregnant women, united in the so-called. i chew a high-risk group.The selection of such a group of pregnant women and women in labor makes it possible to organize a differentiated system of providing obstetric and pediatric care to this contingent of women and<их новорожденным детям. В этой связи особое значение приобретает совершенствование организации акушерско-гинекологической помощи в сельской местности.

To date, the urgency of the problem of maternal mortality has not diminished. The level of maternal mortality in the Russian Federation is still high, 6-10 times higher than the corresponding indicator of developed economic countries, and does not tend to decrease (Sharapova E.I., 1992; Perfilieva G.N., 1994). Analysis shows that the high rate of maternal mortality is mainly due to abortion and such

obstetric complications such as bleeding, gestosis and purulent-septic complications.

Great importance is attached to the relationship and interaction of an obstetrician-gynecologist and a paramedical worker in the prevention of a number of complications of pregnancy, childbirth and perinatal morbidity and mortality.

Every year, 95 people die from various diseases unrelated to pregnancy in the Russian Federation. 110 women, accounting for 14 - 16% of all maternal deaths 1. It was also established that acstratenital pathology significantly influences the formation of the most dangerous obstetric complications. So, in women who died from obstetric bleeding, extragenital pathology was determined in 58% of cases, from gestosis - in 62%, from sepsis - in 68%. While in the population of pregnant women, extragital diseases are found in 25 - 30% (Serov V.N., 1990).

The proposed monograph will acquaint the reader with modern tactics of pregnancy and childbirth management in high-risk groups.

Chapter I. High-risk pregnant women

"Researchers from many countries are engaged in determining the factors and high-risk groups of pregnant women. At the same time, most of the authors, based on the data of the clinic, identified risk factors, and then developed a system for their assessment. The authors, based on the study of the literature data, as well as the multifaceted development of the birth histories in the study of the causes of perinatal mortality, identified individual risk factors. by this indicator in the entire group of examined pregnant women.L.S. Persianinov et al. (1976) divided all the identified risk factors into prenatal (A)

and intranatal (B).

Prenatal factors were divided into 5 subgroups: 1) socio-biological factors; 2) data of obstetric-hynecological history; 3) the presence of extragenital pathology; 4) complications of this pregnancy; 5) assessment of the condition of the fetus. The total number of prenatal factors was 52.

Intranatal factors were divided into 3 subgroups: 1) maternal risk factors, 2) placenta, and 3) fetus. This group contains 20 factors. Thus, a total of 72 risk factors were identified (see Table 1). A number of authors have identified ^

from 40 to 126 factors. Further, the authors point out that the analysis of the literature data, the assessment of the work of antenatal clinics and maternity hospitals convinced that for obstetric-gynecological practice in the present time the most acceptable should be considered a point system for assessing risk factors. It makes it possible to assess not only the probability of an unfavorable outcome of childbirth in the presence of each specific factor, but also to obtain a total expression of the probability of the influence of a particular factor. An assessment scale of risk factors (in points) was developed by the authors based on an analysis of 2511 births that ended in fetal death in the perineum.

Table 1RISK FACTORS DURING PREGNANCY AND LABOR

Continuation

8. Height and weight indicators of the mother:

height 150 cm and less 1

weight 25% above normal 2 II. Obstetric and gynecological history

I. Parity:

2. Abortions before the first birth:

3 4 3. Abortion before re-birth:

4. Premature birth:

5. Stillbirth:

6. Death in the neonatal period:

7. Developmental anomalies in children 3

8. Neurological disorders 2

9. Weight of children less than 3500 2 and more than 4000 g. 1

10. Complicated course

previous rounds 1

I1. Infertility more than 2 - 5

12. Scar on the uterus after operations 4

13. Tumors of maggoi and ovaries 1 - 4

14. Isshiko-vdrvikalnya failure 2

15. Malformations of Maggki 3

3 4

8. Chronic specific infections (tuberculosis, brucellosis, syphilis, current noplasmosis, etc. ______ 2-6

9. Acute infections during pregnancy 2- 7

IV Complications of pregnancy

1. Severe early toxicosis 2

2. Bleeding in the first and second half of pregnancy 3-5

3. Late toxicosis .:

dropsy 2 vephropathy I-II-III

degrees 3-5-1 (

preeclamisia 11

eclampsia 12

4. Concatenated Tokoikoya 9

5. Ph-negative blood 1

6.Ph and ABO-isooensibile-

7. Myogovodve, 3

9. Pelvic presenting zyosh

10. Plurality m £ Ns

11. Postterm pregnancy! - SCH

12. Repeated use of medicines 1

V. Assessment of fetal health

1. Fetal hypotrophy 10-20

2. Fetal hypoxia 3-8

less than 4.9 mg / day. at 30 over. 34

less than 12.0 mg / day. at 40 weeks 15

4. The presence of meconium in amniotic fluid 3

Continuation

B. INTRANATAL PERIOD

tal period, and 8538 deliveries with a favorable outcome. In addition, the results of the study of the state of the fetus (ECG, F | KG, ultrasound examination) were used.

The total perinatal mortality in the aggregate of deliveries in the group as a whole was conventionally taken as I point. Based on this provision, the assessment of points for each risk factor was made on the basis of calculating the level of perinatal mortality for the entire set of births and its indicators in women with the presence of one of these factors.

The principle of risk assessment was as follows. The likelihood of risk of adverse pregnancy and childbirth outcomes for the fetus and newborn was divided into three degrees: high, medium and low. Each degree of risk was assessed based on the indicators of the Angar scale and the level of perinatal mortality. The degree of risk of perinatal pathology was considered high for children born with an Apgar score of 0 - 4 points, medium - 5 - 7 points and low - 8 - 10 points.

To determine the degree of influence of risk factors of the mother on the course of pregnancy and childbirth for the fetus L. S. Persianinov

et al. calculated in points all antenatal and intranatal risk factors present in the mother of these children. At the same time, women with a total assessment of prenatal factors of 10 points or more were assigned to the high-risk group of pregnant women, 5–9 points to the medium-risk group, and up to 4 points to the low-risk group.

According to LS Persianinov et al. (1976) at the first examination of women (up to 12 weeks of pregnancy), the high-risk group is 18%, and by the end of pregnancy (32 - 38 weeks) it increases to 26.4%. According to the literature, the high-risk group of pregnant women is 16.9-30% (Hicks, 1992,

Zacutti et al., 1992 and others).

During childbirth, women were distributed according to the degree of risk as follows: with low risk - 42.8%, medium - 30%, high - 27.2%. Perinatal mortality was 1, 4, 20, 0 and 65.2%, respectively. Thus, the share of the group of women with low risk during childbirth decreases, while the groups of medium and high risk, respectively, increase. The data obtained by the authors show that risk factors during childbirth have a stronger effect on the level of perinatal mortality compared to those during pregnancy. The combination of high risk factors during pregnancy and childbirth is accompanied by a high perinatal mortality rate (93.2%). Since the same level of perinatal mortality occurred in pregnant women and women in labor with risk factors estimated at 4 points, this group was attributed to high risk factors. The presence of one of these factors in a pregnant woman or a woman in labor requires special attention of an obstetrician-gynecologist and other specialists who monitor her during pregnancy and childbirth. In conclusion, LS Persianinov et al. emphasize that the organization of specialized clinics, intensivemonitoring high-risk pregnant women can significantly reduce perinatal mortality. Thus, intensive dynamic monitoring of one of the high-risk groups allowed to reduce the level of perinatal mortality by 30% in comparison with this indicator in a similar group of pregnant women who were under routine observation.

OG Frolova, EI Nikolaeva (1976 - 1990) based on the study of the literature, as well as the development of more than 8000 birth histories, individual risk factors were identified. Assessment of the outcomes of childbirth based on the materials of 2 basic antenatal clinics showed that the group of low-risk pregnant women lagged behind 45%, medium-risk - 28.6%, high-risk -26.4%. At the same time, perinatal mortality in the high-risk group of pregnant women was 20 times higher than in the low-risk group and 3.5 times higher than in the medium-risk group. During childbirth

the group of women with low risk was 42.8%, medium - 30%, high - 27.2%.

VA Sadauskas et al (1977) also emphasize the importance and appropriateness of identifying risk factors for the fetus during pregnancy and childbirth.

In each group, from 4 to 11 subgroups were identified, the severity of each factor was assessed using a five-point system. The classification used, according to the authors, quite accurately reflects the risk to the fetus in case of mild pathology in pregnant women and allows organizing timely and specialized intensive monitoring of the fetus. Other Russian authors also point out the expediency of identifying high-risk groups. So, A.S. Bergman et al. (1977) emphasize the role of functional diagnostic imaging in high-risk pregnant women, the role of radioimmunological determination of placental lactogen in high-risk pregnancies is indicated in the study by G. Radzuweit et al. (1977). L. S. Persiaminov et al. (1977) point to the role and importance of the use of hyperbaric oxygenation in pregnant women with high risk factors for the fetus, as a way to reduce perinatal mortality. It is also reported about the role of some extragenital diseases as a factor of increased risk (Butkevichyus S. et al., 1977; Shui-kina E. P., 1976, etc.).

Some researchers (Radonov D., 1983) offer the organization of observation of high-risk pregnant women. Firstly, in order to improve the quality of observation of pregnant women with an increased risk of perinatal pathology, the author developed a special classification, consistent on the etiological principle, according to which 8 groups were identified:

Pregnant women with impaired uteroplacental circulation (late toxicosis, hypertension, xipocytic nephritis, placenta previa, abortion);

Causes that adversely affect the fetus (ionization, iso immunization, infections, chromosomal and gene abnormalities);

Adverse factors from the side of the pelvis, uterus and appendages (narrow pelvis, uterine hypoplasia, tumors);

Wrong position and presentation of the fetus, multiple pregnancies, polyhydramnios, delayed fetal development;

Adverse factors on the part of the mother before and during pregnancy (extragenital diseases, too young or old primiparas, giving birth to 3 or more children, smoking);

Complicated obstetric history (infertility, dead

birth, caesarean section, bleeding, late toxicosis);

Factors related to the social environment (difficult living conditions, inadequate training, etc.);

Psycho-emotional state (unwanted or illegitimate pregnancy, bad psychoclimate iB family and at work). D. Radonov determines the degree of risk by a point system. All medium- and high-risk pregnant women are

hospital.

Secondly, after 20 weeks of pregnancy, all data are entered on a special gravidogram, which can be used to diagnose early signs of a developing pathology (toxicosis, delayed fetal development, multiple pregnancy, etc.). Thirdly, due to the rapid development in the third trimester, especially in the last month of pregnancy, various complications of the usual weekly monitoring of high-risk pregnant women are insufficient. Most of them must be hospitalized, which requires an increase in the number of beds in the "intensive observation unit" - from 1/4 to 1/3 of all beds in the maternity hospital. In this department, a thorough examination of the fetus is carried out (non-stress and oxytocin tests, daily counting of the pregnant woman herself 3 times a day for 1 hour of fetal movements, ultrasound scanning, amnioscopy) with the recording of the data obtained on a special chart. Thanks to the implementation of these measures, it was possible to reduce perinatal mortality to 8.9% o in undispensed pregnant women - 13.76% o) ■

Domestic scientists have made a great contribution to the development of the problem of high-risk pregnant women. A number of scientists have established a number of risk factors that must be taken into account by a practicing obstetrician-gynecologist during pregnancy, and this group of pregnant women often requires a comprehensive examination of the state of the fetus using modern apparatus and biochemical methods 1 of observation. V.G. Kono-nikhina (1978), when studying the risk of obstetric pathology in primiparous of various age groups, showed that the young (16-19 years old) and older (30 years and older) age of primiparous women is a high risk factor for the development of obstetric pathology ... In pregnant women of a young age, compared with the optimal age (20 - 25 years), early and late toxicosis (almost two raves), especially severe forms of toxicosis, more often occur, in two raves there is a threat of termination of pregnancy, prolonged pregnancy occurs in 3.2 times more often. In older primiparas, compared with the optimal age, early and late toxicosis are noted 3 times more often, the threat of termination of pregnancy is also 2 times more likely, and prolonged pregnancy 6 times, premature and early rupture of amniotic fluid 1.5 times, weakness of labor forces 6.2 times, twice as often

childbirth takes place with a large fetus and in breech presentation, "pathological blood loss increases by 2.3 times."

In older primiparas, compared with the optimal age, delivery operations are more often used: obstetric forceps - 3.1 times, vacuum - fetal extractions - 2.9 times, caesarean section almost 5 times High frequency of complications during pregnancy and childbirth, especially in primiparas over 30 years of age, it is accompanied by a higher incidence of abnormalities in the fetus and newborn: hypoxia is 6.5 times more common, and the incidence of newborns is 4.5 times higher.

The author believes that the use of the method of intensive observation of primiparas of young and old age contributes to a more favorable course of pregnancy and childbirth, and the rates of perinatal morbidity and mortality also decrease. According to T.V. Chervyakova et al. (1981) one of the most pressing problems of modern obstetrics is the determination of the tactics of pregnancy and childbirth in women at high risk of perinatal pathology. Addressing these issues will be one of the main ways to improve maternal, perinatal and child morbidity and mortality rates. According to the authors, as a result of the studies conducted, significant progress has been achieved in the development of criteria for identifying groups and the degree of risk perinatal pathology.

All studies were carried out in the following 6 main directions: 1) clarification of risk groups for extragenital diseases of the mother; 2) with complicated pregnancy; 3) with anomalies of the birth forces; 4) with the threat of intrauterine and postnatal infection; 5) with the threat of bleeding during childbirth and the early postpartum period. T.V. Cheriakova et al. indicate that as a result of these works, new interesting data were obtained on the pathogenesis and clinical picture of complications of pregnancy and childbirth in women with various types of extragenital pathology, contraindications to the preservation of pregnancy were determined, indications and contraindications for the use of obstetric operations and anesthesia in childbirth were clarified, issues were resolved the use of various types of correlating therapy aimed at maintaining homeostasis in the body of the mother and fetus.

A number of authors propose a set of modern methods for diagnosing risk factors for the fetus during pregnancy. So, in (Research by G.M.Savelyeva et al. (1981) in order to identify the degree of risk to the fetus in the complicated course of pregnancy (nephrosis), overmaturity, miscarriage, Rh-sensitization), a set of modern methods was used to judge about fetal-llacental circulatory

fetal status and condition: cardiac monitoring, ultrasound scanning, study of volumetric blood flow in the intervillous space of the placenta (TC), concentration of placental lactogen and estriol in blood and amniotic fluid: biochemical parameters (ipH, O 2 voltage, concentration of basic electrolytes, glucose, urea , activity of histidase and urocania) of amniotic fluid. The authors examined more than 300 pregnant women.

The studies carried out made it possible to reveal a correlative relationship between OK and the appearance of changes in the pathological nature of the parameters under study; initial and pronounced signs of fetal hypoxia according to cardiac monitoring data; the possibility of predicting the development of fetal hypoxia during labor according to some of the studied physiological and biochemical parameters. So, according to the value of OK, starting from 32 weeks, it is possible to predict the mass of newborns at the time of delivery. A decrease in TC by 30% or more indicates "intrauterine hypoxia of the fetus. An increase in TC with Rh sensitization above 200 ml / min per 100 g of placental tissue (normally, about 100 ml / min, with a placenta weight equal to 500 g) indicates the giant size of the placenta and edematous form of hemolytic disease. ... j

The analysis of the results of cardiac monitoring allowed us to determine the value of basal changes, which were expressed in the form of rhythm monotony, basalva bradacardic, with iso- or arrhythmia. The authors cite a number of the most informative indicators that indicate fetal suffering. Therefore, according to the authors, the use of these methods in practice in combination or in isolation makes it possible to more accurately identify the degree of risk to the fetus in a complicated course of pregnancy and to determine the optimal medical tactics. Similar opinions are expressed by other authors. So, NG Kosheleva (1981) believes that complications of pregnancy should be considered a risk factor for perinatal pathology. The author points out that the read-out forms of late toxicosis are especially unfavorable, while the loss of children with late toxicosis, which developed against the background of hypertension and kidney disease, is especially high.

Particular attention should be paid to the peculiarities of the course of pregnancy in diabetes mellitus. In the presence of genital infection, endocercicytes, colpitis or their combination, late toxicosis develops in every second to fourth pregnant woman, the threat of termination of pregnancy occurs in every sixth, with cavid colpitis four times more often with genital mixed plasma in the genital tract. Thus, in order to reduce perinatal mortality, it is important not only to diagnose the complicated course of pregnancy, but also to clarify the “background”, “in which these complications arose. Along with

with this, it is necessary to constantly monitor the state of the intrauterine fetus using modern methods of examination and treatment of the intrauterine fetus.

Of particular importance is the study of risk factors in order to reduce perinatal mortality in a antenatal clinic (Orlean M. Ya. Et al., 1981). The authors identified four risk groups in the antenatal clinic: 1) socio-economic; 2) obstetric history; 3) obstetric pathology; 4) concomitant pathology. In this case, Rhck was determined using a point system from 5 to 45 points. 30 points in one group or 60 points in total are indicators of high risk. These measures made it possible to timely diagnose the early stages of toxicosis (shretoxicosis, watery) of pregnant women, and their timely hospitalization in hospitals made it possible to reduce the incidence of I-II degree nephropathy. S. Ye. Rub "ivchik, N. I. Turovich (1981), using a point estimate. Of risk factors in obstetrics, developed by prof. F. Lyzikov, revealed that the first risk group for the socio-alsh-biological factor was 4% , the second group of claims - burdened obstetric history - 17%, the third scolded the risk - complications of pregnancy - 45%, the fourth risk group - estragevital pathology - 41% - At the same time, temporary ones with a combination of two or more factors amounted to 4% - In each risk group preventive measures are taken to prevent the weakness of labor, miscarriage, treatment of subclinical forms of late toxicosis, treatment of rhesus - “conflict and pregnancy, and in the presence of astratenital pathology, the presence of pregnant women in dispensary registration with a therapist and obstetrician-gynecologist.

Thus, the identification of pregnant women with a risk of pregnancy pathology, timely preventive measures help to reduce complications in childbirth and perinatal mortality. Some authors (Mikhailenko E.T., Chernena M.Ya., 1982) have developed an original method of prenatal preparation of pregnant high-risk groups for the development of weakness in labor by increasing endogenous synthesis of prostaglandins, which allowed the authors to reduce the incidence of weakness by 3.5 times labor activity and halve the frequency of newborn asphyxia. L. G. Si-chinav; a et al. (1981) propose to use the data of ultrasound scanning to determine the degree of risk to the fetus in rhesusconflict pregnancy.

At the same time, the optimal scanning time in pregnant women with isoserological incompatibility of the blood of the mother and the fetus should be considered 20 - 22 weeks, 30 - 32 weeks and immediately before delivery, which makes it possible to diagnose the initial form of hemolytic disease of the fetus, to determine

the degree of risk For the latter, which is important for the development of individual tactics for the management of pregnancy and childbirth. Other researchers also propose to use more widely the office of prenatal diagnostics to assess the condition of the fetus (Shmorgun FB, 1981; Tsupping E.E. et al., 1981).

At the same time, it is recommended, in addition to cardiac monitoring, "to use biochemical methods - to determine the activity of thermojutabilic alkaline phosphatase in the blood serum at a risk of pregnancy (Liivrand V.E. et al., 1981;), the coefficient of estrogen creaginine - as one of the indicators of the state of the fetus ( Oinimäe H. V. et al., 1981), the content of steroidal hormones and cortisone. (Ttamer-mane L. P. et al., 1981); Daupaviete D.O. et al., 1981), determine the dynamics of the placental lactogen in the blood plasma of pregnant pears at risk (Reischer N.A. et al., 1981), as well as those consisting of the simindo-adrenal system (Paiu A. Yu. et al., 1981), sex determination as a risk factor based on analysis of X and Y-chromatin in cells of tissue of fetal membranes (Novikov Yu. I. et al., 1981).

N. V. Strizhova et al. (1981) to determine risk groups for late toxicosis of pregnant women, a complex immunodiffusion test is used using standard monospecific test systems for trophoblastic beta globulin, placental lactogen, placentarial alpha in the amniotic fluid! - microglobulin, alphag - globulin of the "pregnancy zone", C-reactive protein, fibrinogen, alpha and beta-lipoproteins, as well as kidney tissue antigens. EP Zaitseva, GA Gvozdeva (1981) for the purpose of timely diagnosis of the true severity of toxicosis suggest using the immunological reaction of suppression of adhesion of leukocytes according to Holliday (Halliday., 1972). Postpartum complications in women with an increased risk of developing infections are also being studied (Zak I.R., 1981).

There are isolated reports on the peculiarities of the mental development of children born to mothers of high-risk groups. So, M.G. Vyaskova et al. (1981) on the basis of a deep and qualified examination of 40 children of sick mothers (with the involvement of a specialist in psychology and defectology) found that children of sick mothers differ in the specifics of the development of mental activity, especially speech. The number of children with speech and intellectual pathology in the risk group turned out to be significant (28 out of 40), that is, 70%. All children with speech and intellectual pathology need special assistance of a different nature - from counseling to education in special schools.

A few works are devoted to modern methods of diagnosis and especially treatment of pregnant women with a high risk of perinatal pathology. So, I. P. Ivanov, T. A. Aksenova

i (1981) note that with a complicated course of pregnancy (toxicosis, anemia, the threat of termination), the presence of extragenic - ["thal pathology) heart defects, vegetative-vascular dystonil, hypertension, diseases of the kidneys, endocrine system, etc. (often observed its npl and central insufficiency, accompanied by hypoxia or fetal malnutrition.

The degree of fetal suffering depends both on the severity and duration of the underlying disease, and on the severity of pathological changes in the placenta - a violation of its respiratory, transport, hormonal functions. The success of antenatal disease prevention and treatment of intrauterine fetal suffering is largely determined by the informativeness of methods for diagnosing the state of the fetus and the timeliness of targeted, highly effective therapy. I.P. Ivanov et al. in terms of dynamic monitoring of the state of the fetus, it is proposed to use phonoelectrocardiography in combination with functional tests and ultrasound scanning, as well as indicators of estriol, placental lactogen, activity of a thermostable isoenzyme, alkaline phosphatase, which reflect the functional activity of the placenta and indirectly allow to judge the state of the fetus, as well as the rate of uterine-placental blood flow by the radioisotope method, indicators of the acid-base state and activity about the visitor are all new and innovative processes.

The complex of the obtained data makes it possible to carry out pathogenetically substantiated therapy of fetal hypoxia and prevention of fetal malnutrition in a timely and adequate volume.

From modern methods of treatment of hypoxia I.P. Ivanov et al. indicate the widespread use of hyperbaric oxygenation in combination with medications (cocarbocoylase, ATP, sygetin, compliamin, vitamins, etc.) against the background of treatment of the underlying disease, taking into account the maternal-fetal relationship. As a result of such therapy, the disturbed indices of the acid-base state and blood gases, hemodynamics, uterine-placental blood flow, indicators of the function of the placenta and the state of the fetus are normalized.

Foreign researchers also widely use monitoring methods for determining the state of the fetus in high-risk pregnant women (Bampson., 1980, Harris et al, 1981, etc.). Studies by Teramo (1984) show that 2/3 of women whose children die in the perinatal period or suffer from asphyxia at birth or diseases in the neonatal period ™ can be identified in advance during pregnancy. Such women at high risk., Make up 1/3 of the total number of pregnant women. Careful monitoring of a pregnant woman in a antenatal clinic is essential to identify pregnant women at high risk.

The basis for identifying a high-risk pregnant woman is a detailed medical history, including social, medical and obstetric information, as well as clinical signs and symptoms. The author emphasizes that, along with clinical methods, an instrumental examination of the fetus in perinatal centers is necessary.

Tegato (1984) out of a total number of 1695 pregnant women, identified 1 high-risk pregnant women in 480: a history of caesarean section 1 (60), a history of premature birth (birth of a child weighing less than 2500 g) (46), a child with congenital | disease (malformations - 20, neurological * defects - 3, miscellaneous - 12) in history (35), stillbirth (17), chronic diseases (63), chronic urinary tract infections (34), diabetes mellitus ( 10), the presence of diabetes mellitus in the family (185), pathological changes in glucose tolerance (21), hypertension (66), uterine bleeding in early pregnancy (IU), the first birth at the age of over 35 years (9).

The author proposes to use cardiotocigraphy with a decrease in motor activity. It has been shown that the number of movements less than 10 in 12 hours is associated with an increased frequency of fetal asphyxia (Pearson, Weaver, 1976). Next, you need to monitor the growth of the fetus, determine estriol in blood plasma, urine, while it is important to take into account what medications a woman is taking during this period, since, for example, taking glucocorticoids reduces the production of estriol, it is advisable to analyze estriol every 2 to 3 days, and also determine placental lactosgen, functional tests (oxytocin test).

It is important to note that when using a stress-free test, the author recommends performing cardiotocography (CTG) every 1 to 3 days in case of preeclampsia, 1–3 times a week in chronic hypertension, every 1 to 3 days in case of intrauterine growth retardation, and - amniotic fluid 1-2 times a day, three hepatosis of pregnant women - daily, with diabetes mellitus, class A according to White's classification weekly at a gestational age of 34 to 36 weeks, and at a gestational age of 37 weeks - 2 to 3 times a week, diabetes mellitus, classes A. B, C, D and gestational age 32 - 34 weeks. - every 2nd day., at 35 weeks. - daily, diabetes mellitus, classes F, R at a gestational age of 28 - 34 weeks. - every 2nd day, at 35 weeks. - daily. With changes in the fetal heart rate curve and 26 weeks of gestation 1 - 3 times a day.

In a comprehensive monograph by Babson et al. (1979) on the management of pregnant women with an increased risk and intensive care of the newborn, when determining the degree of risk in the perinatal period, the authors define that such a risk in the perinatal period is the risk of death or

disability changes during the growth and development of a person from the moment of birth to 28 days after birth. At the same time, the authors distinguish between the risk associated with intrauterine fetal development and the risk associated with the development of the child after birth. This division makes it possible to better represent the factors associated with risk in the perinatal period.

Risk Factors Related to Fetal Development

It is necessary to identify women who are likely to die or damage the fetus during pregnancy. Completely unexpected complications rarely occur in women who underwent a comprehensive examination and long-term observation, during which significant deviations from the norm were detected in a timely manner, appropriate therapy was carried out during pregnancy and the prognosis of the "course of labor."

Here is a list of increased risk factors that contribute to perinatal mortality or morbidity in children. Approximately 10 - 20% of women belong to these groups, and in more than half of the cases, the death of fetuses and newborns is explained by the influence of these factors.

1. A history of serious hereditary or familial abnormalities, such as defective osteogenesis, Down's disease.

2. The birth of the mother herself is premature or very small for the period of pregnancy at which the birth occurred or the cases when the previous birth of the mother ended in the birth of a child with the same deviations.

3. Serious congenital anomalies affecting the central nervous system, heart, skeletal system, lung abnormalities, as well as general blood diseases, including anemia (hematocrit is below 32%).

4. Serious social problems such as teenage pregnancy, drug addiction, or fatherlessness.

5. Absence or late start of medical supervision in the perinatal period.

6. Age under 18 or over 35.

7. Height less than 152.4 cm and pre-pregnancy weight 20% lower or higher than the standard weight for the given height.

8. Fifth or subsequent pregnancy, especially if the pregnant woman is over 35 years old.

" 9. Another pregnancy that occurred within 3 months. after the previous I Shchey.

| 10. A history of prolonged infertility or serious drug or hormonal treatment.

11. Teratogenic viral disease in the first 3 months of pregnancy.

12. Stressful conditions, for example, severe emotional stress, indomitable vomiting of pregnant women, anesthesia, shock, critical situations or a high dose of radiation.

13. Smoking abuse.

14. Complications of pregnancy or childbirth in the past or present, such as pregnancy toxicosis, premature placental abruption, isoimmunization, polyhydramnios or amniotic fluid discharge.

15. Multiple pregnancy.

16. Retardation of normal growth of the fetus or fetus sharply different in size from normal.

17. No weight gain or minimal gain.

18. Wrong position of the fetus, for example, breech presentation, transverse position, unidentified presentation of the fetus at the time of delivery.

19. The gestation period is more than 42 weeks.

Further, the author cites demographic studies on specific complications and the percentage of perinatal mortality in each of the complications, while in more than 60% of cases of fetal death and in 50% of cases, the death of a newborn is associated with complications such as breech presentation, premature detachment, placenta, pregnancy toxicosis , giving birth to twins, and a urinary tract infection.

Factors contributing to the increased risk to the newborn

Postpartum, additional environmental factors can increase or decrease the infant's viability. Babson et al. (1979) point to the following pre- or post-delivery factors that place the infant at increased risk and therefore require special treatment and monitoring:

1. The mother has a history of the above risk factors during pregnancy, especially:

a) belated rupture of the fetal bladder;

b) incorrect presentation of the fetus and childbirth;

c) prolonged, difficult labor or very rapid labor;

d) prolapse of the umbilical cord;

2. Asphyxia of the newborn, suspected on the basis of:

a) fluctuations in the number of fetal heart beats;

b) staining of amniotic fluid with meconium, especially its withdrawal;

c) fetal acidosis (pH below 7.2);

d) the number of points according to the Apgar system is less than 7, especially if the assessment is given 5 minutes after birth.

3. Premature birth (up to 38 weeks).

4. Delayed labor (after 42 weeks) with signs of fetal malnutrition.

5. Babies are too small for the given pregnancy rate (below 5% of the curve).

6. Babies are too big for the given gestational age (below 95% of the curve) especially large babies born prematurely.

7. Any breathing disorders or stopping.

8. Obvious congenital defects.

9. Convulsions, lameness, or difficulty sucking or swallowing.

10. Bloating and / or vomiting.

11. Anemia (hemoglobin content less than 45%) or hemorrhagic diathesis.

12. Jaundice in the first 24 hours after birth or bilirubin levels above 15 mg / 100 ml of blood.

1. Initial selection.

2. Selection during a visit to a pregnant antenatal clinic.

3. Selection at the time of childbirth: upon admission to the obstetric facility and upon admission to the maternity ward.

4. Assessment during labor:

a) a newborn,

b) mother.

5. Postpartum assessment:

a) newborn

b) mother.

Pregnant women with identified risk factors are classified as follows: according to the criteria below at each stage:

I. Initial selectionBiological and marital factors.

a) high risk:

1. The mother is 15 years old or younger.

2. The mother is 35 years old or older.

3. Excessive obesity.

b) Moderate risk:

1. The mother's age is from 15 to 19 years.

2. The mother's age is from 30 to 34 years.

3. Unmarried.

4. Obesity (weight 20% above the standard weight for a given height).

5. Exhaustion (weight less than 45.4 kg.).

6. Small in stature (152.4 cm or less).

Obstetric history

A. High risk:

1. Pre-diagnosed anomalies of the birth canal:

a) inferiority of the cervix; "

b) abnormal development of the cervix;

c) abnormal development of the uterus.

2. Two or more previous abortions.

3. Intrauterine fetal death or death of a newborn during a previous pregnancy.

4. Two previous premature births or the birth of babies at term, but underweight (less than 2500 g).

5. Two previous children are oversized (weighing more than 4000 g).

6. Malignant tumor in the mother.

7. Myoma of the uterus (5 cm or more or submucosal localization).

8. Cystic ovaries.

9. Eight or more children.

10. Presence of isoimmunization in a previous child.

11. A history of enlampsia.

12. Presence of the previous child:

a) known or suspected genetic or family abnormalities;

b) congenital malformations.

13. A history of complications requiring special therapy in the neonatal period, or the birth of a child with an injury sustained during childbirth.

14. Medical indications for termination of a previous pregnancy. B. Moderate risk:

1. Previous premature birth or delivery of a child at term, but with a low weight (less than 2500 g), or abortion.

2. One oversized child (over 4000 g). m\u003e "p ^ and

3. Previous births ended with surgery: SC

a. caesarean section, b. the imposition of forceps, c. extraction at the pelvic end.

4. Previous prolonged labor or significantly obstructed labor.

5. Narrowed pelvis.

6. Serious emotional problems associated with a previous pregnancy or childbirth.

7. Previous operations on the uterus or cervix.

8. First pregnancy.

9. The number of children from 5 to 8.

10. Primary infertility. , |

P. Incompatibility in the ABO system in history.

12. Incorrect presentation of the fetus in previous births.

13. A history of endometriosis.

14. Pregnancy after 3 months. or sooner after the last birth.

Medical and surgical history

A. High risk:

1. Average degree of hypertension.

2. Kidney disease of moderate severity.

3. Severe heart disease (II - IV degree of heart failure) or congestion caused by heart failure.

4. Diabetes.

5. Removal of endocrine glands in history.

6. Cytological changes in the cervix.

7. Cardiac anemia.

8. Drug addiction or alcoholism.

9.Presence of a history of tuberculosis or PPD test (diameter more than 1 cm)

10. Pulmonary disease. ;

11. Malignant tumor.

12. Gastrointestinal disease or liver disease.

13. Previous surgery on the heart or blood vessels.

B. Moderate risk.

1. The initial stage of hypertension.

2. Mild kidney disease.

3. Mild heart disease (I degree).

4. Presence of mild hypertensive in the anamnesis during! ■ pregnancy.

5. Postponed pyelonephritis.

6. Diabetes (mild).

7. Familial diabetes.

8. Disease of the thyroid gland.

9. Positive results of a serological test.

10. Excessive drug use.

11. Emotional problems.

12. The presence of sickle-shaped erythrocytes in the blood.

13. Epilepsy.

II. Selection during a visit to a pregnant antenatal clinic "in the prenatal period. ,

Early pregnancy I

A. High risk: : ";" ■; : I

1. No enlargement of the uterus or a disproportionate increase. I

2, Action of teratogenic factors :: I

a. radiation; !■:■, ■. ..... - ..... \|

b. infections;

in. chemical agents.

3. Pregnancy complicated by immunization.

4. The need for genetic diagnosis in the antenatal period. 5. Severe anemia (hemoglobin content 9 g% or less).

B. Moderate risk:

1. A refractory urinary tract infection.

2. Suspected ectopic pregnancy.

3. Suspicion of a failed abortion.

4. Severe, indomitable vomiting of a pregnant woman.

5. Positive serological reaction for gonorrhea.

6. Anemia, not amenable to treatment with iron preparations.

7. Viral disease.

8. Vaginal bleeding.

9. Mild anemia (hemoglobin content from 9 to 10; 9 g%).

Late pregnancy

A. High risk:

1. No enlargement of the uterus or a disproportionate increase.

2. Severe anemia (hemoglobin content less than 9 g%).

3. The gestation period is more than 42 1/2 units.

4. Severe preeclampsia.

5. Eclampsia.

6. Breech presentation if normal labor is planned.

7. Isoimmuyaization of moderate severity (required intrauterine blood flow or complete exchange transfusion of blood to the fetus).

8. Placenta previa.

9. Polyhydramnios or multiple pregnancy.

10. Intrauterine fetal death.

11. Thromboembolic disease.

12. Premature birth (less than 37 weeks gestation).

13. Premature rupture of the amniotic fluid (less than 38 weeks of gestation).

14. Obstruction of the birth canal caused by a tumor or other reasons.

15. Premature placental abruption.

16. Chronic or acute pyelonephritis.

17. Multiple pregnancy.

18. Abnormal reaction to oxytocin test.

19. Falling estriol level in the urine of a pregnant woman. B. Moderate risk:

1. Hypertensive conditions during pregnancy (mild).

2. Breech presentation if a cesarean section is planned.

3. Unidentified presentation of the fetus.

4. The need to determine the degree of maturity of the fetus.

5. Post-term pregnancy (41-42.5 weeks).

6. Premature rupture of membranes (childbirth does not occur more than 12 hours if the gestation period is more than 38 weeks).

7. Excitement of labor.

8. Estimated imbalance between the size of the fetus and the pelvis at the time of delivery.

9. Non-fixed presentation for 2 weeks. or less before the estimated due date.

In the United States, the maternal mortality rate is 6/100,000; the frequency is 3-4 times higher among women of color. The most common causes are bleeding, preeclampsia.

Risk assessment is part of routine prenatal care. Risks are also assessed during or shortly after childbirth, as well as whenever an event may change the risk. Risk factors should be assessed systematically because each individual risk contributes to an increase in the overall risk. High-risk pregnancies require close monitoring and sometimes referral to a perinatal center. In such a situation, referral before childbirth contributes to lower morbidity and mortality than referral after childbirth. The most common reasons for referral before childbirth are:

• premature birth,
• preeclampsia
• bleeding.

Risk factors for complications during pregnancy

Risk factors include current maternal disabilities or illnesses, physical and social characteristics, age, problems with previous pregnancies (eg, miscarriages) and during actual pregnancy or in labor and delivery.

Hypertension. Chronic hypertension should be distinguished from gestational hypertension, which develops after 20 weeks. Hypertension increases the risk of impaired intrauterine development of the fetus by reducing uteroplacental blood flow.

In women with hypertension, the risks of pregnancy must be assessed before pregnancy occurs. When pregnancy occurs, prenatal management should be started as early as possible and include an assessment of renal function (creatinine and serum nitrogen), fundus examination, cardiac arrest (cardiac auscultation, sometimes ECG, echocardiography, or both). In each trimester, daily urine protein, uric acid and hematocrit are measured. Fetal growth is monitored by ultrasound from 28 weeks of gestation, and then every 4 weeks. With growth retardation, multichannel Doppler examination is used and a specialist in fetal medicine is involved.

Diabetes... Diabetes mellitus is observed in 3-5% of pregnancies, but its frequency increases with overweight.

If a pregnant woman is initially ill with insulin-dependent diabetes, this increases the risk of pyelonephritis, ketoacidosis, preeclampsia, fetal death, severe malformations, macrosomia and, with the development of vasculopathy.

Women with gestational diabetes are at increased risk of hypertensive disorders and fetal macrosomia. Screening for gestational diabetes is undertaken in the period of 24-28 weeks, and in the presence of risk factors - in the 1st trimester. Risk factors include previous gestational diabetes, fetal macrosomia in previous pregnancy, family history of non-insulin dependent diabetes, unexplained pregnancy loss.

Some clinicians believe that the diagnosis can be made on the basis of a fasting plasma glucose level\u003e 126 mg / dL or a randomly measured glucose level\u003e 200 mg / dL. If\u003e two tests show abnormal results, the woman should remain on the diet and receive insulin or hypoglycemic drugs as needed until the end of the pregnancy.

Close control of blood glucose during pregnancy almost eliminates the risk of complications associated with diabetes.

Infectious STDs... Intrauterine syphilis in the fetus can cause fetal death, malformations and severe disability. Prenatal care includes screening for the listed infections at the first prenatal visit. Syphilis testing is done during pregnancy, if the risk persists, and at delivery to all women. Pregnant women with known infections should receive appropriate antibiotic therapy.

Treatment of HIV with zidovudine or nevirapine reduces the risk of transmission by two-thirds; the risk is less (<2%) при комбинации 2 или 3 противовирусных препаратов. Эти лекарства рекомендованы, несмотря на потенциальные токсические воздействия на мать и плод.

Pyelonephritis... Pyelonephritis increases the risk of PRPO, preterm labor, and respiratory distress in the newborn. Pregnant women with pyelonephritis are hospitalized for examination and treatment (3 generation IV cephalosporins with or without aminoglycosides, antipyretic, hydration). Oral antibiotic treatment is started 24-48 hours after the fever stops and continues until the full course is completed (7-10 days). Prophylactic antibiotics (eg, nitrofurantonin, trimethoprim / sulfamethoxazole) under the control of periodic urine cultures are continued until the end of pregnancy.

Acute surgical pathology... General surgical interventions on the abdominal organs increase the risk of premature birth and fetal death. However, both the pregnant woman and the fetus tolerate surgery well with proper management and anesthesia (maintaining blood pressure and oxygenation at normal levels); therefore, doctors should not refrain from necessary operations; delaying treatment for emergencies is fraught with more serious consequences.

After the operation, tocolytics and antibiotics are prescribed for 12-24 hours.

Genital pathology... Structural abnormalities of the uterus and cervix (eg, intrauterine septum, bicornuate uterus) contribute to abnormal presentation of the fetus, anomalies in labor, and increase the need for a cesarean section. Although unlikely, uterine fibroids can cause abnormalities in the placenta (eg, presentation), premature birth, and recurrent miscarriage. Fibroids can grow rapidly and degenerate during pregnancy; the latter is manifested by severe pain and peritoneal symptoms. Inconsistency of the cervix (ischemic-cervical insufficiency) increases the likelihood of premature birth. Uterine abnormalities resulting in poor obstetric outcomes often require surgical correction after delivery.

Mother's age... Adolescence accounts for 13% of all pregnancies and an increased incidence of preeclampsia. One of the reasons is that adolescents neglect prenatal care, often smoke and often have STDs.

Women\u003e 35 years of age have a higher incidence of preeclampsia, gestational diabetes, abnormalities of labor, placental abruption and previa, and stillbirth. These women are also more likely to have chronic illnesses before pregnancy (hypertension, diabetes). Because the risk of fetal chromosomal abnormalities increases with the mother's age, genetic testing should be done.

Mother's body weight... It is believed that pregnant women whose BMI before pregnancy was<19,8 кг/м2, имеют недостаточную массу тела, что предрасполагает к низкой массе тела у новорожденного. Таким женщинам рекомендуют прибавить в весе не менее 12,5 кг во время беременности.

Pregnant women with a BMI\u003e 29.0 kg / m2 before pregnancy are considered to be overweight, which increases the likelihood of hypertension, diabetes, overmaturity, fetal macrosomia, and caesarean section.

Mother's height... In women of short stature (<152 см) может иметь место узкий таз, что может привести к несоответствию размеров плода размерам таза или дистонии плечиков.

Exposure to teratogens... Teratogens include infections, drugs, and physical agents. Malformations are most likely if exposure occurs between 2 and 8 weeks after conception, when fetal organogenesis occurs. Other adverse pregnancy outcomes are also possible. Pregnant women exposed to teratogens should be counseled about the risks and referred to a thorough ultrasound scan to detect defects.

Common substances such as alcohol, tobacco, cocaine and some medications are potentially teratogenic.

Alcohol is the most commonly used teratogen. Regular alcohol consumption reduces the weight of the fetus by 1-1.3 kg. Drinking a daily dose, even as low as 45 ml of pure alcohol, can lead to the development of fetal alcohol syndrome. This is the leading cause of mental deficiency and possible death of the newborn.

Cocaine use carries indirect risks to the newborn. It also directly causes vasoconstriction and hypoxia in the fetus. Repeated use raises the risk of spontaneous miscarriage, stillbirth and congenital defects (central nervous system, urinary system, skeleton).

Prior stillbirth... The causes of stillbirth can be related to the mother, placenta, or fetus. Assessment of fetal health is recommended.

History of preterm labor increase the risk of subsequent preterm birth; if the weight of the newborn in previous births was<1,5 кг, риск последующих преждевременных родов составляет 50%. Женщины с предшествующими преждевременными родами должны быть под пристальным наблюдением, с контрольными визитами каждые 2 недели начиная с 20-недельного срока беременности.

Monitoring includes:

• Ultrasound with an assessment of the shape and size of the cervix at 16-18 weeks;
• study of the contractile activity of the uterus;
• tests for bacterial vaginosis;
• measurement of fetal fibronectin levels.

Women with a history of premature birth or cervical shortening (<25 мм) следует назначить 17 а-оксипрогестерон по 250 мг в/м один раз в неделю.

Preceding childbirth of a child with a genetic or congenital disorder... Most of the congenital malformations are of multifactorial origin; the risk of giving birth to a fetus with defects is<1%. После рождения такого ребенка паре рекомендуют пройти генетическое консультирование, экспертное УЗИ и обследование специалистом по фетальной медицине.

Polyhydramnios and low water... Polyhydramnios can lead to respiratory failure in the mother.

Low water usually accompanies congenital malformations of the urinary system and severe fetal growth retardation (<3 перцентили). Также во 2 триместре может развиться синдром Поттера с гипоплазией легких или компрессионными аномалиями и фатальным исходом.

Polyhydramnios and oligohydramnios are suggested if the size of the uterus does not correspond to gestational age, and can also be accidentally detected by ultrasound.

Preceding birth trauma... Most cases of cerebral palsy and developmental delays are caused by factors other than birth trauma.

Injuries, such as damage to the brachial plexus, can be caused by procedures such as forceps or vacuum extraction, or misplaced fetuses. Previous shoulder dystonia may be a risk factor for subsequent dystonia. The history of previous labor should be examined for potentially preventable risks (eg, macrosomia, operative labor).

A high-risk pregnancy is a pregnancy in which the risk of illness or death of the mother or newborn before or after childbirth is greater than usual.

To identify a high-risk pregnancy, a doctor examines a pregnant woman to determine if she has any medical conditions or symptoms that make her or the fetus more likely to get sick or die during pregnancy ( risk factors). Risk factors can be assigned scores corresponding to the degree of risk. Identification of high-risk pregnancy is necessary only so that a woman who needs intensive medical care receives it in a timely manner and in full.

A woman with a high-risk pregnancy may be referred to an antenatal (perinatal) care unit (the term "perinatal" is used to refer to events that occur before, during, or after delivery). These units are usually associated with obstetric and neonatal intensive care units to provide the highest level of care for the pregnant woman and infant. The doctor often refers a woman to a perinatal observation center before childbirth, since early medical supervision greatly reduces the likelihood of pathology or death of the child. The woman is also sent to such a center during childbirth if unexpected complications arise. Generally, the most common reason for referral is a high likelihood of premature birth (before 37 weeks), which often occurs if the fluid-filled membranes containing the fetus rupture before it is ready for birth (i.e., a condition called premature rupture of the membranes occurs ). Treatment at a perinatal care center reduces the likelihood of preterm birth.

In Russia, maternal mortality occurs in 1 out of 2000 births. Its main causes are several diseases and disorders associated with pregnancy and childbirth: the ingress of blood clots into the vessels of the lungs, complications of anesthesia, bleeding, infections and complications arising from increased blood pressure.

In Russia, the perinatal mortality rate is 17%. Slightly more than half of these cases are stillbirths; in other cases, babies die within the first 28 days after birth. The main causes of these deaths are congenital malformations and prematurity.

Several risk factors are present even before a woman becomes pregnant. Others occur during pregnancy.

Pre-pregnancy risk factors

Before a woman becomes pregnant, she may already have some medical conditions and disorders that increase her risk during pregnancy. In addition, a woman who has had complications in a previous pregnancy is more likely to develop the same complications in subsequent pregnancies.

Maternal risk factors

The risk of pregnancy is influenced by the woman's age. Girls aged 15 and under are more likely to develop preeclampsia (a condition during pregnancy in which blood pressure rises, protein appears in the urine and fluid accumulates in tissues) and eclampsia (seizures resulting from preeclampsia). They are also more likely to the birth of a child with low body weight or premature... Women age 35 and older are more likely to increased blood pressure, diabetes, the presence of fibroids (benign neoplasms) in the uterus and the development of pathology during childbirth... The risk of having a baby with a chromosomal abnormality, such as Down's syndrome, increases significantly after age 35. If an older pregnant woman is concerned about the possibility of fetal abnormalities, chorionic villus sampling or amniocentesisto determine the composition of the fetal chromosomes.

A woman who had a pre-pregnancy body weight of less than 40 kg is more likely to have a baby that is lighter than expected according to gestational age (low body weight for gestational age). If a woman gains less than 6.5 kg in weight during pregnancy, then the risk of death of a newborn increases to almost 30%. Conversely, an obese woman is more likely to have a very large baby; obesity also increases the risk of diabetes mellitus and high blood pressure during pregnancy.

A woman less than 152 cm tall often has a reduced pelvis. She is also more likely to have a premature birth and a low birth weight.

Complications during a previous pregnancy

If a woman had three consecutive miscarriages (spontaneous abortions) in the first three months of previous pregnancies, then another miscarriage is possible with a 35% probability. Spontaneous abortion is also more likely in women who have previously delivered stillborn babies between the 4th and 8th months of pregnancy, or have had a preterm birth in previous pregnancies. Before attempting a new conception, a woman who has had a spontaneous abortion is recommended to undergo an examination to identify possible chromosomal or hormonal diseases, structural defects of the uterus or cervix, connective tissue diseases, such as systemic lupus erythematosus, or an immune response to the fetus - most often Rh incompatibility -factor. If the cause of the spontaneous abortion is established, it can be eliminated.

A stillbirth or death of a newborn may be due to chromosomal abnormalities in the fetus, diabetes, chronic kidney or blood vessel disease, high blood pressure, or a connective tissue disorder such as systemic lupus erythematosus in the mother or her drug use.

The more preterm the previous births were, the greater the risk of preterm births in subsequent pregnancies. If a woman has a baby weighing less than 1.3 kg, then the probability of a premature birth in the next pregnancy is 50%. If intrauterine fetal growth retardation has been noted, this complication may recur during the next pregnancy. The woman is examined to look for abnormalities that can lead to a delay in fetal development (for example, high blood pressure, kidney disease, overweight, infections); smoking and alcohol abuse can also lead to fetal malformation.

If a woman has a baby weighing more than 4.2 kg at birth, she may have diabetes. The likelihood of a spontaneous abortion or death of a woman or baby is increased if a woman suffers from such diabetes during pregnancy. Pregnant women are tested for its presence by measuring blood sugar (glucose) between the 20th and 28th weeks of pregnancy.

A woman who has had six or more pregnancies is more likely to have weakness in labor (contractions) during labor and bleeding after delivery due to weakening of the muscles in the uterus. Rapid labor is also possible, which increases the risk of severe uterine bleeding. In addition, such a pregnant woman is more likely to have placenta previa (the location of the placenta in the lower part of the uterus). This condition can cause bleeding and may be an indication for a caesarean section because the placenta often obstructs the cervix.

If a woman has a child with a hemolytic disease, then the next newborn has an increased likelihood of the same disease, and the severity of the disease in the previous child determines its severity in the next one. This disease develops when a pregnant woman with Rh negative blood develops a fetus whose blood is Rh positive (that is, there is an incompatibility with the Rh factor), and the mother develops antibodies against the blood of the fetus (sensitization to the Rh factor occurs); these antibodies destroy the fetal red blood cells. In such cases, the blood of both parents is tested. If a father has two genes for Rh-positive blood, then all his children will have Rh-positive blood; if he has only one such gene, then the probability of Rh-positive blood in the child is approximately 50%. This information helps doctors to properly provide medical assistance mother and child in subsequent pregnancies. Usually, no complications develop during the first pregnancy with a fetus with Rh-positive blood, but contact between the mother's blood and the baby during labor causes the mother to develop antibodies against the Rh factor. As a result, there is a danger to subsequent newborns. If, however, Rh0- (D) -immunoglobulin is administered after the birth of a child with Rh-positive blood of a mother whose blood is Rh-negative, then the antibodies against Rh factor will be destroyed. Due to this, hemolytic diseases of newborns are rare.

A woman who has had preeclampsia or eclampsia is more likely to recur, especially if the woman has chronically increased blood pressure.

If a woman has a child with a genetic disease or congenital defect, then a genetic examination of the child is usually carried out before a new pregnancy, and in case of stillbirth, both parents. When a new pregnancy occurs, ultrasound (ultrasound), chorionic villus sampling and amniocentesis are done to check for abnormalities that are likely to recur.

Developmental defects

Defects in the development of a woman's genital organs (for example, doubling of the uterus, weakness or insufficiency of the cervix that cannot support the developing fetus) increase the risk of miscarriage. To detect these defects, diagnostic operations, ultrasound or X-ray examination are necessary; if a woman has had repeated spontaneous abortions, these studies are carried out even before the onset of a new pregnancy.

Fibroids (benign neoplasms) of the uterus, which are more common at an older age, can increase the likelihood of premature birth, complications during childbirth, pathological presentation of the fetus or placenta and repeated miscarriages.

Diseases of a pregnant woman

Some diseases of a pregnant woman can be dangerous for both her and the fetus. The most important of these are chronic high blood pressure, kidney disease, diabetes mellitus, severe heart disease, sickle cell disease, thyroid disease, systemic lupus erythematosus, and blood clotting disorders.

Diseases in family members

The presence of relatives with mental retardation or other hereditary diseases in the mother's or father's family increases the likelihood of such diseases in the newborn. The tendency to have twins is also common among members of the same family.

Risk factors during pregnancy

Even a healthy pregnant woman can be exposed to adverse factors that increase the likelihood of impairment to the fetus or her own health. For example, she may come into contact with such teratogenic factors (influences that cause congenital malformations), such as radiation, certain chemicals, drugs, and infections, or she may develop a pregnancy-related illness or complication.

Exposure to drugs and infection

To substances that can cause congenital malformations fetus when taken by a woman during pregnancy, include alcohol, phenytoin, drugs that counteract the effect of folic acid (lithium preparations, streptomycin, tetracycline, thalidomide). Infections that can lead to birth defects include simple herpes , viral hepatitis , flu , paratitis (mumps), rubella , chickenpox , syphilis , listeriosis , toxoplasmosis , diseases caused by the Coxsackie virus and cytomegalovirus. At the beginning of pregnancy, a woman is asked if she has taken any of these medications or has suffered any of these infectious inflammations after conception. Of particular concern is smoking, alcohol and drug use during pregnancy.

SmokingIs one of the most common bad habits among pregnant women in Russia. Despite awareness of the health risks of smoking, the number of adult women who smoke themselves or live with smokers has declined slightly over the past 20 years, while the number of women who smoke has increased. Smoking among adolescent girls has become significantly more common and exceeds this figure among adolescent boys.

Although smoking harms both mother and fetus, only about 20% of women who smoke stop smoking during pregnancy. The most common consequence of maternal smoking during pregnancy for the fetus is its low birth weight: the more a woman smokes during pregnancy, the less the baby's weight will be. This effect is more pronounced among older women who smoke, who are more likely to have babies with less weight and height. Women who smoke are also more likely to have placental complications, premature rupture of membranes, premature birth, and postpartum infections. A pregnant woman who does not smoke should avoid exposure to tobacco smoke while smoking in others, as it can similarly harm the fetus.

Congenital malformations of the heart, brain and face are more common in newborns born to pregnant smokers than to nonsmokers. Maternal smoking may increase the risk of sudden infant death syndrome. In addition, children of mothers who smoke have a small but noticeable delay in growth, intellectual development and behavior formation. These effects, according to experts, are caused by the effects of carbon monoxide, which reduces the delivery of oxygen to the tissues of the body, and nicotine, which stimulates the release of hormones that constrict the blood vessels of the placenta and uterus.

Alcohol consumption during pregnancy - the leading known cause of congenital malformations. Fetal alcohol syndrome, one of the main consequences of drinking during pregnancy, affects an average of 22 out of 1,000 live births. This condition includes stunted growth before or after birth, facial defects, a small head size (microcephaly), possibly associated with underdeveloped brain, and impaired mental development. Mental retardation is more often a consequence of fetal alcohol syndrome than any other known cause. In addition, alcohol can cause other complications, from miscarriage to severe behavioral disorders in a newborn or developing child, such as antisocial behavior and inability to concentrate. These abnormalities can occur even when the newborn has no obvious physical birth defects.

The chances of spontaneous abortion almost double when a woman drinks any form of alcohol during pregnancy, especially if she drinks a lot. Often, birth weight is below normal in those newborns who were born to women who drank alcohol during pregnancy. Newborns whose mothers drank alcohol have an average birth weight of about 1.7 kg, compared with 3 kg for other newborns.

Drug use and an increasing number of pregnant women are dependent on them. For example, in the United States, more than five million people, many of whom are women of childbearing age, regularly use marijuana or cocaine.

An inexpensive laboratory test called chromatography can be used to test a woman's urine for heroin, morphine, amphetamines, barbiturates, codeine, cocaine, marijuana, methadone, and phenothiazine. Injecting drug addicts, that is, drug addicts who use syringes for drug use, have a higher risk of developing anemia, infection of the blood (bacteremia) and heart valves (endocarditis), skin abscess, hepatitis, phlebitis, pneumonia, tetanus and sexually transmitted diseases (in including AIDS). Approximately 75% of newborns with AIDS have their mothers who are injecting drug users or prostitutes. Other sexually transmitted diseases, hepatitis and other infections are more common in these newborns. They are also more likely to be born prematurely or have intrauterine growth retardation.

Main component marijuana, tetrahydrocannabinol, can cross the placenta and affect the fetus. Although there is no definitive evidence that marijuana causes birth defects or slows the growth of the fetus in the uterus, some studies show that using marijuana leads to abnormalities in baby behavior.

Use cocaine during pregnancy, it causes dangerous complications in both the mother and the fetus; many women who use cocaine also use other drugs, which aggravates the problem. Cocaine stimulates the central nervous system, acts as a local anesthetic (pain reliever), and constricts blood vessels. The narrowing of the blood vessels reduces blood flow and the fetus does not receive enough oxygen. Decreased delivery of blood and oxygen to the fetus can affect the development of various organs and usually leads to skeletal deformities and narrowing of some parts of the intestine. Diseases of the nervous system and behavioral disorders in children of those women who use cocaine include uncontrollable hyperactivity tremor and significant learning disabilities; these violations can last for 5 years or more.

If a pregnant woman has a sudden high blood pressure, bleeding from premature placental abruption, or a stillborn baby for no apparent reason, her urine is usually tested for cocaine. Approximately 31% of women who use cocaine throughout their pregnancy have preterm labor, 19% have fetal growth retardation, and 15% have premature placenta exfoliation. If a woman stops taking cocaine after the first 3 months of pregnancy, the risk of premature birth and premature placental abruption remains high, but fetal development is usually not impaired.

Diseases

If raising blood pressure First diagnosed when a woman is already pregnant, it is often difficult for a doctor to determine if the condition is due to pregnancy or has another cause. Treatment of such a disorder during pregnancy is difficult, as therapy, while beneficial to the mother, carries a potential hazard to the fetus. At the end of pregnancy, an increase blood pressure may indicate a serious threat to the mother and fetus and should be addressed quickly.

If a pregnant woman has had a bladder infection in the past, a urine test is done at the beginning of pregnancy. If bacteria are found, your doctor will prescribe antibiotics to prevent infections from entering the kidneys, which can cause premature birth and premature rupture of membranes. Bacterial infections of the vagina during pregnancy can have the same consequences. Suppressing the infection with antibiotics reduces the likelihood of these complications.

The disease, accompanied by an increase in body temperature above 39.4 ° C in the first 3 months of pregnancy, increases the likelihood of spontaneous abortion and the occurrence of defects in the nervous system in a child. A rise in temperature at the end of pregnancy increases the likelihood of premature birth.

Emergency surgery during pregnancy increases the risk of premature birth. Many diseases, such as acute appendicitis, acute liver disease (biliary colic), and intestinal obstruction, are more difficult to diagnose during pregnancy because of the natural changes occurring at this time. By the time such a disease is nevertheless diagnosed, it may already be accompanied by the development of severe complications, sometimes leading to the death of a woman.

Complications of pregnancy

Rh incompatibility... The mother and fetus may have incompatible blood types. The most common Rh incompatibility, which can lead to hemolytic disease in the newborn. This disorder often develops when the mother's blood is Rh negative and the baby's blood is Rh positive because of the father's Rh positive blood; in this case, the mother develops antibodies against the fetal blood. If the pregnant woman's blood is Rh negative, the presence of antibodies to the fetal blood is checked every 2 months. These antibodies are more likely to form after any bleeding in which maternal and fetal blood may mix, particularly after amniocentesis or chorionic villus sampling, and within the first 72 hours after delivery. In these cases, and at the 28th week of pregnancy, the woman is injected with Rh0- (D) -immunoglobulin, which combines with the antibodies that appear and destroys them.

Bleeding... The most common causes of bleeding in the last 3 months of pregnancy are abnormal placenta previa, premature placental abruption, vaginal or cervical disease, such as infection. All women who bleed during this period are at increased risk of miscarriage, heavy bleeding, or death during childbirth. Ultrasonography (ultrasound), a check of the cervix, and a Pap test can help determine the cause of the bleeding.

Conditions associated with amniotic fluid... Excess amniotic fluid (polyhydramnios) in the membranes surrounding the fetus stretches the uterus and puts pressure on the woman's diaphragm. This complication sometimes leads to breathing problems in a woman and premature birth. An excess of fluid may occur if a woman has uncontrolled diabetes mellitus, if several fetuses develop (multiple pregnancy), if the mother and fetus have incompatible blood groups, and if there are congenital malformations in the fetus, especially esophageal atresia or defects in the nervous system. In about half of the cases, the cause of this complication remains unknown. A lack of amniotic fluid (oligohydramnios) can occur if the fetus has congenital malformations of the urinary tract, intrauterine growth retardation, or intrauterine fetal death.

Premature birth... Premature birth is more likely if the pregnant woman has defects in the structure of the uterus or cervix, bleeding, mental or physical stress or multiple pregnancies, or if she has had previous uterine surgery. Premature birth often occurs when the fetus is in an abnormal position (such as breech presentation), when the placenta separates prematurely from the uterus, when the mother has high blood pressure, or when too much amniotic fluid surrounds the fetus. Pneumonia, kidney infections, and acute appendicitis can also trigger preterm labor.

Approximately 30% of women who have preterm labor have an infection of the uterus, even if the membranes do not rupture. There is currently no reliable data on the effectiveness of antibiotics in this situation.

Multiple pregnancy... Having multiple fetuses in the uterus also increases the likelihood of fetal malformations and birth complications.

Delayed pregnancy... In a pregnancy that lasts more than 42 weeks, fetal death is 3 times more likely than a normal pregnancy. To control the condition of the fetus, electronic monitoring of cardiac activity and ultrasound examination (ultrasound) are used.

Underweight newborns

• A premature infant is a newborn born less than 37 weeks pregnant.
• An underweight infant is a newborn who weighs less than 2.3 kg at birth.
• A small infant for its gestational age is a baby that is underweight for gestational age. This definition refers to body weight but not height.
• Developmental retardation infant - a newborn whose development in the uterus has been insufficient. This concept refers to both body weight and height. A newborn may have developmental delays, may be small for its gestational age, or both may be present.