What sexually transmitted infections are dangerous during pregnancy? Infectious diseases in pregnant women

Unfortunately, the life and health of a woman and her child are threatened by dangerous infections during pregnancy. To prevent troubles, doctors suggest taking tests at the stage of planning conception or in the early stages of fetal development. This post discusses a list of hidden infections that affect pregnancy negatively.

The most dangerous bacterial infections during pregnancy

Gonorrhea

During pregnancy, a bacterial infection called Neisseria gonorrhoeae causes disastrous consequences; the pathogen is often transmitted through sexual contact. Symptoms of acute or chronic illness may take 3-7 days to appear or may never occur. Pathogenic bacteria of the Gonococcus series progress on the mucous membranes of the urogenital system. Female carriers have purulent or mucous discharge from the genitals, they are bothered by pain and burning in the urethra, urination is frequent and painful. The child becomes infected in utero or during childbirth. It is known that the effect of infections on the fetus is expressed in such diagnoses as ophthalmia of the newborn (causing blindness), vulvovaginitis, otitis and chorioamnionitis. The appearance of gonococcal sepsis is possible, and sometimes arthritis and meningitis develop.

Koch stick

The dangerous pathology is designated as Mycobacterium tuberculosis and is transmitted by airborne dust. At risk are pregnant women who have previously had tuberculosis or women who are carriers of Mycobacterium tuberculosis. The pathogen is dangerous because it causes destructive processes in the tissues of the lungs.

Chlamydia

It is believed that the pathogen Chlamydia trachomatis is present in the body of 40% of all female representatives. The most common diagnosis is urethritis (inflammation in the urethra); there are also diseases such as pelvioperitonitis, bartholinitis and salpingitis. Endometritis and endocervicitis can be diagnosed. In advanced cases, when adhesions and tubal obstruction have already developed, the pathogen causes ectopic pregnancy and early miscarriages. If a woman is not treated correctly, the fetus' development is delayed or it dies. Complications also include conjunctivitis, pneumonia and pharyngitis. After illness, bronchitis, proctitis, urethritis and vulvovaginitis can be diagnosed.

B-streptococci

Bacteria belonging to group B Streptococci can exist as a representative of the vaginal microflora without causing illness. It has been observed that Streptococus agalactiae has a negative effect on pregnancy. There are no vaccines against this infection, sometimes it does not cause pathologies, and in some cases it provokes complex conditions in women, for example, fasciitis, sepsis and urinary tract infection, endometritis. There are also consequences: endocarditis, meningitis and abscess. The streptococcal pathogen affects children, causing stillbirth, meningitis, respiratory problems, and sepsis.

Pallid spirochete

Treponema pallidum, a sexually transmitted infection that poses a danger to children, is widespread today. If pregnancy proceeds without medical supervision, then the probability of the appearance of a pale spirochete (the second name is treponema pallidum) in children is 89%. Intrauterine infection of the child through the placenta or during childbirth is possible, which is fraught with congenital syphilis, which always leads to complications.

Trichomoniasis

Amazingly, 180 million patients are diagnosed with Trichomonas vaginalis per year. The pathogen belongs to the group of STDs, as it passes to a person through sexual contact. The pathology often progresses in conjunction with fungi, gonococci, chlamydia and ureaplasma. Affected women suffer from endocervicitis, vaginitis, urethritis and vulvitis. If a child receives bacteria during childbirth, he may be diagnosed with urethritis and vulvovaginitis.

Listeria

Doctors say that the gram-positive rod bacteria Listeria can have a negative effect on children, as they are able to penetrate the placenta. If the pathogen Listeria monocytogenes is detected, then most often pathologies occur in the child’s body.

Ureaplasma and mycoplasma

The common pathogens Ureaplasma urealyticum and Mycoplasma hominis lack a cell wall, so they cannot be destroyed by taking antibiotics. Many authoritative sources suggest considering them separately from protozoa, bacteria and viruses. Women with mycoplasma may be diagnosed with endocervicitis, vaginitis and urethritis. Acute infection often causes developmental delays, reactive ureaplasmosis, miscarriage and various fetal pathologies. A woman in whose body a ureaplasma infection is progressing notices clear discharge, pain in the abdominal area, inflammation of the uterus and tubes.

Fungi and microorganisms as sources of infections in pregnant women

Toxoplasmosis

A huge number of women are faced with Toxoplasma gondii infection; it is dangerous because it easily passes through the placenta to the child. The sad consequences of such infection is the death of the fetus in utero or after birth. If the child survives, the congenital pathology develops into complex lesions of the nervous system, abnormalities in the retina and choroid of the eyes. Be careful, this infection can be transmitted from cats to humans.

Candida albicans

Immunodeficiency due to HIV, treatment with broadly effective antibiotics, and diabetes mellitus can be a breeding ground for the development of the pathogenic fungal environment Candida albicans. Of all pregnant women, about 36% of women have this fungus; it is believed that it cannot cause defects in the child, although it becomes infected during childbirth.

Malaria

Plasmodium Falciparum can cause significant harm if the body is not yet familiar with the infection and the woman becomes pregnant for the first time. The condition of the patients is serious, often leading to death.

Viral infections during pregnancy

Chickenpox

Anyone who has suffered the disease in childhood receives natural immunity. In pregnant women, the infection can cause death. We also note that the virus penetrates the placenta. It provokes pathologies or causes a frozen pregnancy.

Rubella

As we know, the analysis for torch infections includes rubella, which is dangerous because 65% of women giving birth for the first time face complex developmental disorders or death of children. The likelihood of negative consequences for the fetus decreases as the timing increases: when infected in the first trimester, the risk of fetal disease is 80%, infection at 13-14 weeks implies a risk of 70%, 26 weeks - 25%. It is believed that infection in women after 16 weeks often does not affect children; in rare cases, hearing is lost. Congenital rubella in the first weeks can manifest as low body weight, enlarged spleen and liver, bone pathologies, meningoencephalitis and lymphadenopathy. As they grow, they are diagnosed with deafness, heart defects, microcephaly and mental retardation, glaucoma and cataracts, and diabetes mellitus.

Hepatitis

With hepatitis, the liver and other parts of the body suffer greatly. The most common are hepatitis B, D, C viruses. It is known that the D virus variety progresses along with the others, aggravating their picture. You can be a carrier of hepatitis B without having symptoms; the chronic form is fraught with exacerbations, carcinoma, and cirrhosis. Scientists know little about hepatitis C in children, but it is believed that liver enlargement, failure, or tumors may occur with this pathology.

Cytomegalovirus

As a rule, the fetus suffers from cytomegalovirus infection, as deviations appear in its development. Often the diagnosis of congenital CMV is associated with hearing loss. The probability of diagnosing cerebral palsy as a consequence of the progression of cytomegalovirus is about 7%. In addition, we will name other consequences: microcephaly, enlarged spleen, enlarged liver, chorioretinitis, thrombocytopenia. About 10% of all children are born with CMV, but half of them experience a particularly severe course of the disease.

HIV

Children with HIV infection are special; they experience characteristic symptoms from an early age. In a quarter of patients, infection develops into AIDS. Sadly, HIV progresses faster in children than in adults. Thanks to modern medicine, it is often possible to minimize or completely avoid infection of the child from the mother.

Herpes simplex

The provocateurs of the disease are herpes simplex viruses of the first and second types. The disease can develop latently. The likelihood of transmitting genital and other types of herpes to the child during childbirth is high. Occasionally, the virus penetrates the placental barrier, usually occurring in the 3rd trimester. The first herpes virus is different in that it occurs without symptoms or in a mild form without consequences. Herpetic infection of the second type is the cause of complex neurological pathologies in a child, for example, encephalitis.

ARVI

Respiratory infections are hidden under the familiar term ARVI. Viruses can significantly complicate bearing a child or cause developmental abnormalities. Influenza is especially dangerous. When the virus enters the body in the first trimester, severe defects develop. It is interesting that when infected before the 12-week period, there are 2 options for events - a spectrum of disorders will occur that cause death, or all pregnancy parameters will remain normal and the child will not suffer at all. When the infection takes hold in the body after 12 weeks, the risk of problems is minimal, but it still cannot be ruled out that the likelihood of early birth, oxygen starvation, and fetoplacental insufficiency increases. Many women experience ARVI, most of them do not encounter any difficulties and give birth to healthy children.

Pregnancy and infections

If you are planning a pregnancy, first find out what tests are done for infections. Most mothers are prescribed a blood test to identify infectious pathogens from the TORCH group (this includes herpes, toxoplasmosis, rubella, cytomegalovirus, other examinations can be added at the discretion of the attending physician).

It is also mandatory to diagnose sexually transmitted infections (this category includes the considered chlamydia, mycoplasmosis, gonorrhea, papilloma virus and trichomoniasis).

The blood is tested for hepatitis B, hepatitis C, syphilis and HIV. Each pregnant woman gives urine and a series of smears, which carries a lot of important information about her health. It is important that in order to have children without pathologies and maintain their own health, both partners must lead a healthy lifestyle, receive timely treatment and be examined.

In addition to the disorders discussed above, pregnant women often encounter a number of other problems that can affect the child. For example, intestinal, kidney, rotavirus, staphylococcal pathogens or the bacterial infection Gardnerella enter the body.

Self-medication and the use of folk remedies are unacceptable. The interpretation of tests and the choice of medications is the responsibility of the attending physician. It is advisable to tell him about all the ailments so that he can adequately assess the condition of the body.

If you are an expectant mother and you are scheduled to undergo tests, then take this matter as seriously and responsibly as possible. Doctors know very well what the threat of a particular disease is, so they strive to detect the infection in a woman’s body as early as possible and select effective and safe treatment (suppositories, tablets, IVs, injections) so as not to provoke complications in the mother and fetus. If you need to go to the clinic and buy expensive drugs, you can’t skimp on your health.

Divorced from my husband five years ago. From the marriage there are two children aged 9 and 11 years. I’m tired of solving and carrying all the family problems on myself, and besides, my husband started going out. I left him, as they say, “with one knot”... All this time I was organizing a house from scratch, paying off three loans, raising children, it wasn’t easy. Thank God I was lucky and I changed my job and started earning more. Life began to get better, more or less. A year ago I met a man... And Oh God... This is the man I dreamed of. The complete opposite of my ex-husband. And care and attention. One thing... He is a single father... His wife left him and their child and went to his best friend. In principle, this situation did not frighten me and I thought, well, where are there two children and the third will not be a hindrance... But it turned out that everything was not so simple... I, like a wise woman, immediately began to look for an approach to the child, bought her toys, completely replaced them her wardrobe, the poor child didn’t even have decent things, everything was so washed out.... I bought her a bunch of beautiful rubber bands for the garden. I tried my best to please. The girl is 5 years old... The child is problematic, does not understand anything, in the kindergarten they complain about her that she does not obey, does not want to study... At home she does whatever she wants, does not respond to comments. She says that she understands and immediately does it again!!!
The mother does not participate in any way in raising the child, does not pay child support, citing the fact that she is paying off a joint loan... Oh well, God be with her...
We all lived together for a year... I thought that she would change and we would live happily... But nothing changed...
I was infuriated by her behavior and because of this I was constantly in a bad mood, so Alexei and I started arguing. I couldn’t tell him that his daughter infuriates me... I understand that he loves her more than life itself... I thought about breaking up, but I love him and he loves me very much... and he communicates well with my children, with my son goes to chess.... I don’t know what to do.. It seems to me that his daughter will never change and I will never be able to love her....

Olga Morozova

Hello. I’ve already created a topic here about neighbors’ dogs, how to keep them away. In the fall, in September, a neighbor’s dog killed our kitten, in the middle of the day, one might say, in front of the neighbor (the dog’s owner) and ours (my son and I saw it). We simply didn’t have time to do anything, how much does a 3 month old kitten need? At that time, I expressed a lot of things to my neighbors because of their dogs. They apologized, promised to look after them, but at the same time the phrase was said: hunting dogs (ordinary mongrels at the same time) will still attack cats, they called it happy (((
To be honest, I didn’t want to have any more cats, but in October, for my daughter’s birthday, they brought her a kitten as a gift.. There is a litter box at home and the cat goes there, but only for small ones, but for the most part she is used to going outside. They let her out and looked after her all the time. And then that week, the neighbor’s dog jumped over the snowdrifts into our yard and grabbed the cat right on the porch. At that time I was hanging out laundry to dry under the canopy, he didn’t see me, but I didn’t see/hear him right away either - he attacked without a sound. I jumped out at the cat’s squeal. I fought it off, while he slashed his teeth along the sleeve of my jacket and tore my sleeve. When I calmed and treated the cat a little and calmed down myself, I went to the neighbors and said I would complain. The weekend passed, they did not take any measures (the dog was running along the street and continues to run). Today I wrote a complaint to the local police officer, but I was struck by his words, saying that we cannot take any measures against the dog’s owner, there is no punishment or fine for this. Only if you go further and sue them for material and moral damage. But I don’t want to go to court over a cat and a torn sleeve. Are there really no laws so that the local police officer, relying on them, can somehow influence the owners of dogs who strangle cats while walking on their own and in other people’s yards? In general, I wrote a lot, just if you’re going to start a war with your neighbors, then rely on the laws... Maybe someone can tell me something...

Elena Nefedova

I’ll say right away that I saw doctors when I was 2 years old, and no one saw any problems. Is this character?
The youngest daughter is 2.1. He doesn’t speak very much, there are no phrases, probably 20-30 words. The rest is incomprehensible. She is efficient, understands everything, responds to names, fulfills requests. She goes to the potty and eats herself.
But for the last 4 months the behavior is just out of whack... She freaks out if something doesn’t suit her. And when he freaks out, he starts throwing everything. That is, he specifically takes everything that is at hand and throws it. Or brushes it off the table. A toy, remote control, cup - whatever. Very touchy. If she throws something, I can slap her on the hand. That is, in terms of strength - as soon as I put my hand on her arm, there is no talk of even the slightest pain - she begins to roar and yell, and turns all red. And until either I give up or someone comes up to take pity on her, she won’t calm down.
Another joke: if he doesn’t want to go somewhere on the street, he sits on the ground. And that's all. Either wait for half an hour and persuade him, or grab him by force and run. If I leave, he won’t run after me. Well, it also happens at home that he can lie down on the floor in protest.

Is this even normal? Nothing like this had ever happened to the eldest. So I’m in a slight shock, although everyone around me just says how lucky I am that my youngest daughter is so calm and obedient. Whereeeee? By the way, they adore her in the garden, she just behaves perfectly there. How is that?
And this behavior happens to me, and to my husband, and to my grandparents!!

Katerina

Topic to chat. Do you think about your children’s skills? Will explain. A friend’s son is a couple of months younger than mine, and so she proudly sends me a video of her baby crawling across the floor like a worm. She happily writes that he is starting to crawl. But for me, it’s just fussing on the carpet))) Or he kicks his butt back, and she thinks that he gets on all fours. I'm just either too critical of my son or a realist. But until he specifically crawled at least 30 centimeters, I somehow didn’t say that he was starting to crawl. And if he sits with support on one arm, he is not sitting yet. Which camp will you join and why?

Anonymous

I got a job six months ago. The child is 3.5. He goes to the garden. I walked normally in the fall. I went out for the full day. And now I’ve been sitting at home for almost the entire month of February and half of March. I got a job based on an acquaintance, no one said anything to me about absences, but last time they already hinted that something needed to be resolved with sick leave. I found a nanny through an agency, but my mother panicked that there was no need for a nanny (my mother is also a commander), she herself meets him from the garden, but sick leave says we will sit in turns, 2 days she, three me. But often she either flies away somewhere, then she’s at the theater, or she doesn’t want to at all and everything is unreliable. And nothing good came of it. The nanny eventually found some other shift work and now cannot come on call, only on her weekends. Mom also teases me that I will give half of my salary to the nanny. I can't work normally. I don’t want to leave, because my husband now doesn’t earn enough for everything, I buy clothes for myself, for women’s necessities, plus I pay for vacation, I can save for a mortgage, we are saving. Mom realized that we just couldn’t save up for an apartment, she stopped reproaching us for buying an apartment, before this she constantly asked her husband what he was thinking about when he started a family. Although my husband considers himself a breadwinner, he doesn’t have enough for everything. And I don’t want to lose my job, experience, qualifications. It’s also very difficult mentally to sit with a child for 2 weeks. I feel better at work, but I can’t get there. Only goes to the garden for 5 days and again at home for 2 weeks. I'm constantly nervous. How can you work and watch your child at the same time? How do women do this?

LTA LTA

Good afternoon, dear forum members. We need a collective mind, my brain is no longer working. Given: there is a small studio for preparing for the Unified State Exam and the Unified State Exam: Russian, English, Society and Mathematics. I am planning to expand - open a second one in another area, and change the name of both studios. The so-called rebranding. Now the name is AbvEGE. I want something interesting and to the point. My husband suggests “studio for preparing for the Unified State Exam last name first name.” I don't like it, it's too pretentious. The room is small, three classrooms and an admin desk, behind which I stand if there is no lesson. You can't call them courses. I would be grateful for advice on how to call it more interesting.

Expectant mothers have to face many troubles, complications and even illnesses during pregnancy. Infectious diseases are among the most dangerous. Therefore, it is worth arming yourself with useful information about them.

What are the types of infections during pregnancy in mother and fetus?

There are many infectious diseases. But during pregnancy, cytomegalovirus, rubella, herpes, and toxoplasmosis are considered dangerous. Their danger is that in the case of a primary disease during pregnancy, they can cause serious damage to the body of the woman and the unborn child, leading to early miscarriages and premature birth.

That is why gynecologists emphasize that a man and a woman plan a pregnancy, and at the stage of preparation for it, undergo the appropriate tests to make sure that there are no infections in their bodies.

Many infectious diseases (for example, thrush) are not dangerous for the fetus and do not lead to disastrous consequences. The influence of others depends on the stage of pregnancy. If the expectant mother is only a carrier of the infection, then the pathogen will not be able to penetrate the fetus.

Tests for infections during pregnancy

If a woman has not undergone the appropriate tests before conceiving a baby, then when registering at the antenatal clinic she will be prescribed:

1. Blood test for TORCH infections (rubella, toxoplasmosis, herpes, cytomegalovirus); for syphilis, hepatitis C and B; HIV.
2. Screening for STIs (chlamydia, gonorrhea, mycoplasmosis, trichomoniasis, human papillomavirus).

A woman is tested for TORCH infection only once. The main task of such a survey is to identify women who do not have protective antibodies to the above infectious diseases. For this purpose, the enzyme immunoassay method is used. Two types of antibodies are used: immunoglobulins G and M. A woman’s preparation for such an examination consists of sexual abstinence for 24 hours. The analysis is taken on an empty stomach.

Sexual infections during pregnancy

This is a group of sexually transmitted diseases. They lead to self-abortion in the early stages of gestation, premature birth, and a high risk of infection of the fetus during delivery with the development of otitis media, pharyngitis, and pneumonia in the baby.

Sexual infections are diagnosed using microscopy (smear) and biochemical blood test. The most effective research method is enzyme-linked immunosorbent assay (ELISA).

It is worth noting that in most cases, the causative agents of such infectious diseases as ureaplasmosis and mycoplasmosis do not manifest themselves in anything in the body of a pregnant woman. This is called latent bacterial carriage. If a woman becomes infected with these infections in the first trimester of pregnancy, then, like chlamydia, they can cause infection of the fetus. By the way, taking hormonal contraceptives before pregnancy reduces the risk of infection with chlamydia, because these drugs increase the protective properties of cervical mucus.

Urogenital infections during pregnancy

Their name suggests that they have a negative effect on the genitourinary system of the expectant mother. The most common among them are the following:

They are most common in the summer. In addition to rotavirus infection, expectant mothers should be wary of food poisoning. They occur due to the consumption of spoiled foods or contaminated with E. coli. If food is stored for a long time, then active reproduction of microorganisms, bacteria, and fungi begins in it. This causes poisoning with intoxication of the female body. The pregnant woman’s body becomes dehydrated, and, accordingly, dangerous substances also reach the fetus through the placenta, and there are not enough nutrients.

Despite the “harmlessness” of summer poisoning, pregnant women should still consult a doctor in such cases. It is worth considering that intoxication of the body can cause an exacerbation of chronic diseases of a non-infectious nature.

In addition, domestic animals are often carriers of pathogens of intestinal infections. Even a regular cat litter box can become a source of infection.

Viral infections during pregnancy

There are a huge variety of viruses that can infect the human body. Therefore, we will focus only on the most dangerous and common ailments:

1. Rubella. If a woman becomes infected for the first time during pregnancy, the infection is transmitted to the fetus. He develops dangerous developmental defects, often incompatible with life. But this risk depends on the period of infection of the pregnant woman. If this happens in the first trimester, then the frequency of damage to the unborn baby is 80%, in the second trimester - up to 70%, in the third - 25%. Maternal rubella can cause the birth of a deaf child, with congenital heart defects or glaucoma, or a mentally retarded child.
2. Cytomegalovirus. It is dangerous for the fetus. Hearing loss is the most common consequence of congenital CMV infection. About 7% of cerebral palsy are also the result of it.
3. Hepatitis. During pregnancy, the most dangerous viruses are types B and C. Children born from an infected mother are susceptible to liver cirrhosis and hepatocellular carcinoma.
4. HIV infection. Babies infected with the virus may develop AIDS at an early age. HIV progresses at a faster rate in children than in adults.
5. Chicken pox. If a woman first becomes infected while pregnant, the risk of death is quite high. Malformations of the fetus are also possible, because the virus easily penetrates the placental barrier.
6. ARVI. Of these, the most dangerous for expectant mothers is influenza. If they suffer from the disease in the first trimester, then a group of fetal malformations incompatible with life occurs, or nothing happens - and the pregnancy proceeds normally. After 12 weeks, there remains a risk of fetal hypoxia and the development of fetoplacental insufficiency.

Intrauterine infections during pregnancy

All of the above infections are intrauterine. They are characterized by the presence in the body of a pregnant woman of pathogens that provoke inflammatory processes with subsequent infection of the child during intrauterine development. Its infection occurs due to the joint blood flow of the woman and the baby. Infection of the fetus occurs through ingestion of contaminated amniotic fluid or during its passage through the birth canal.

The causes of intrauterine infections are bacteria, viruses, fungi, and protozoa. They are also commonly called TORCH infections (TORCH). The abbreviation stands for this:

T - toxoplasmosis;

O - group combining chlamydia, gonorrhea, ureaplasmosis, enterovirus and gonococcal infections, hepatitis, measles, chickenpox;

R - rubella;

H - herpes;

C - cytomegalovirus infection.

Chronic infections during pregnancy

Experts call them persistent. They are no less dangerous when carrying a baby. Almost lifelong persistence in the body is characteristic of viruses of the herpes family, Epstein-Barr, herpes zoster, and cytomegalovirus.

The danger of chronic diseases is that they can recur and go into an acute stage, which is very dangerous in the first trimester of pregnancy. It is worth emphasizing that all expectant mothers with chronic diseases are recommended for planned hospitalization during critical periods. This is 8-12 weeks of the period when the placenta is formed; 18-22 weeks (active growth of the uterus occurs); 28-32 weeks (second period of active growth of the fetus and uterus). Preventive therapy in a gentle manner, limiting stress allows women to overcome critical periods of pregnancy favorably and without consequences, and bring the baby to the optimal time. Pregnant women with chronic infectious diseases are advised to visit antenatal clinics more often. Such patients are prescribed additional diagnostic tests. Their pregnancy is managed jointly with a specialized specialist.

How to treat infections during pregnancy

They are detected in 5-7% of all expectant mothers. Therapy of infectious diseases is the task of the obstetrician-gynecologist observing the woman. Each of them has its own treatment specifics. For example, gardnerellosis is treated after the 20th week of pregnancy, when the effect of antibacterial drugs on the fetus is minimal. Vaginal candidiasis at different stages of pregnancy is treated with different drugs.

In any case, self-medicating this type of disease is extremely dangerous! You must trust an experienced doctor and follow all his instructions, including hospitalization if necessary.

Especially for - Diana Rudenko

Some of them can seriously affect the health of the fetus.

Urinary infections (cystitis), kidney (pyelonephritis) and genital (especially fungal) infections can be triggered by hormonal changes during pregnancy. Some of them are completely harmless, but others carry the risk of premature birth or infection of the newborn during natural birth. Therefore, it is important to constantly monitor them.

Other infections, such as rubella, listeriosis, cytomegalovirus, and toxoplasmosis, should be avoided through preventive measures. They can cause serious consequences for the baby (depending on the case - risk of malformation, serious infection, fetal death, miscarriage or premature birth).

And finally, hepatitis B, a viral infection that requires mandatory treatment. If the mother is infected, the baby can be vaccinated immediately after birth. However, there is no technology yet that makes it possible to 100% avoid infection of a child if the mother has AIDS.

Most infectious diseases in the mother, as a rule, do not complicate the course of pregnancy, although some infections of the genital tract affect the choice of method of delivery. The main challenge is the use and safety of antibacterial drugs. However, some infectious diseases of the mother can harm the fetus (such as congenital cytomegalovirus infection, herpes, rubella, toxoplasmosis, hepatitis, syphilis - see HIV).

Listeriosis most often occurs during pregnancy. Transmission to a newborn is also possible.

Bacterial vaginosis and chlamydia. Tests for these infections are performed during routine prenatal testing or when symptoms develop.

Genital herpes can be transmitted to a newborn during childbirth. The risk is high enough to justify caesarean section in the following situations:

• In the presence of visible herpetic rashes;
• if a woman with a history of herpes experiences symptoms of prodrome before childbirth;
• if herpes first appeared in the late stages of the 3rd trimester (and the virus is likely to be excreted from the cervix during childbirth).

In the absence of visible rashes and prodrome, even in the presence of a relapsing course of the disease, the risk is low. In asymptomatic cases, even serial virological studies of cultures do not help determine the risk of transmission. If a woman has recurrent herpes during pregnancy, but there are no other risk factors for transmission, induction of labor is possible so that delivery takes place between relapses

Pregnancy in combination with various infectious diseases is an important problem in obstetrics. There is a huge variety of such diseases, and bearing a child depends on many factors.

Classification of infectious diseases:

1. intestinal infections;
2. helminthiases;
3. respiratory tract infections;
4. vector-borne infections;
5. infections of the outer integument.

Among this variety of diseases, there are special diseases that always cause the development of various abnormalities in the child during pregnancy. They are combined into a separate group of diseases, which include pathogens of STDs, rubella and a number of others. In the presence of these diseases, the same disorders occur in the child’s body as with rubella.

TO intestinal infections include: typhoid and paratyphoid fever, dysentery, salmonellosis, cholera, food poisoning, botulism, polio, hepatitis, leptospirosis, brucellosis, listeriosis, toxoplasmosis, amoebiasis. With these diseases, there is a similar pattern of their course and complaints from patients. In most cases, infection occurs through food, water, and dirty hands. During the course there is a short latent period (with the exception of hepatitis) - the manifestations always include digestive and stool disorders (diarrhea), nausea, vomiting, leading to large loss of water, body temperature above 37.5 ° C, abdominal pain.

Food toxic infections, salmonellosis occur predominantly in mild forms, so they do not affect pregnancy. In general, the prognosis for pregnant women regarding infectious diseases depends on the severity of the disease. Infections such as typhoid fever and paratyphoid fever, cholera, dysentery, and amoebiasis most often occur in severe forms, so pregnancy is called into question. Often pregnancy in these cases ends in miscarriage, intrauterine fetal death, or artificial termination of pregnancy (dictated by circumstances). If the expectant mother managed to recover and maintain the pregnancy, then the birth of a healthy child cannot be guaranteed.

Botulism and polio refer to very serious infections in which pregnancy must be terminated. Listeriosis and toxoplasmosis are considered dangerous to a child’s health.

Listeriosis classified as zoonotic (animal disease) infections, humans are a temporary host for listeria bacteria. All pregnant women have very reduced immunity to listeria. In them, the disease can be atypical, asymptomatic, remaining unrecognized; spontaneous abortions and premature births are often recorded. In newborns born from a sick mother, respiratory disorders, interruptions in heart function, vomiting, mucous stool, and meningitis are detected (ending in the death of the child). In children, the liver and spleen may become enlarged and a rash may appear. Even with recovery, dysfunction* of the central and peripheral nervous systems persists for life.

Toxoplasmosis children become infected in utero. The acute form of this disease is severe: with fever, jaundice, many children develop damage to the eyes and brain, and there may be epilepsy. The prognosis for the life of such a child is unfavorable; since the disease most often leads to either death (both fetus and newborn) or severe disability.

Besides the fact that you all love cats (not that there's anything wrong with that), you can get it if you eat raw meat. Even if undercooked, it can be dangerous. You can also become infected by cleaning up after your cat if you don't wash your hands, allowing for fecal-oral transmission by biting your nails, for example. But when it comes to cats, the very thing that puts you in danger is also what protects you. I'm one of those who believe in the once-you'll-love-them-ever theory, which means that if you have a cat, you've probably had one your whole life. This proximity may have exposed you to some extent to toxoplasmosis, providing good immunity. However, all cat owners should have an antibody blood test to check for immunity.

If you are not protected, should you force your husband to let Barsik out for a walk? No. You just need to be more responsible about your hand hygiene. And stay away from garden parties where the hosts don't know how to barbecue.

Affected babies have low birth weight, eye inflammation, anemia, enlarged liver/spleen, and/or jaundice. There are severe neurological lesions - convulsions and mental retardation. The really strange thing about toxoplasmosis is that the earlier you catch it, the less likely it is that your baby will be affected (60% in the third trimester), but when it does happen, it is less severe.

If you have xoplasmosis, you may not even know it, so you should ask your doctor if you are at risk. The good news is that complications from toxoplasmosis occur in one pregnancy in a thousand, so it must be one bad-ass cat. (Perhaps "Ugly Ralph" is a famous cat story that you will read to your child at some point.)

Classification of helminthiases:

1. ascariasis (pathogen - roundworm);
2. trichinosis (causative agent - Trichinella);
3. enterobiasis (pathogen pinworm);
4. teniarinhoz (causative agent - bovine tapeworm);
5. taeniasis (caused by pork tapeworm);
6. diphyllobothriasis (caused by tapeworm or tapeworm), opisthorchiasis (caused by opisthorchiasis, or cat fluke);
7. echinococcosis (causative agent - Echinococcus).

Helminths do not have a direct damaging effect on the fetus; the influence of toxic products of their vital activity and the allergic reaction of the mother’s body are dangerous. With timely detection and treatment, helminthiasis does not pose a danger to pregnant women, except in cases of severe depletion of the mother's body due to insufficient supply of nutrients (since everything is absorbed by the worm).

Among respiratory tract infections Diseases caused by viruses predominate. Viruses are much smaller in size than bacteria, so they freely penetrate the membranes and infect the fetus; Viruses also have a mutagenic effect on the cells of the body, since, without their own vital systems, they are integrated into the host’s DNA. Viral infections include: acute respiratory infections (influenza, parainfluenza, adenoviral infection, PC infection, rhinovirus infection), herpes, chicken pox, infectious mononucleosis, cytomegalovirus infection, measles, rubella. All these diseases are distinguished by an approximately similar pattern of manifestations and transmission features: they are transmitted by airborne droplets (coughing, sneezing), manifested by fever, nasal congestion and nasal discharge, sore throat when swallowing, sometimes lacrimation and conjunctivitis (redness of the eyes), coughing, sneezing, . bronchitis, tracheitis. Some viruses cause stool disorders (diarrhea). Among all these diseases, the most dangerous for pregnant women are rubella, herpes, cytomegalovirus infection and influenza; the severe course of these diseases affects the development of the child.

When a fetus is infected with herpes viruses, a special form develops - congenital herpes. First, numerous inflammatory and destructive processes develop in the membranes. All this leads to the birth of a premature baby with blistering skin lesions, disease of the central nervous system, and severe damage to internal organs. A child born alive shows signs of pneumonia and respiratory failure. The surviving infants are far behind their peers in development and remain disabled for life.

This infection can be passed on to the baby through direct contact of the baby with the vagina during vaginal birth, so it is a common reason for cesarean sections. The generally accepted recommendation is that if there is a fresh lesion (within two weeks before birth), a cesarean section is indicated. If no lesions have been observed for more than two weeks, vaginal birth is acceptable. Previously, half of the children born vaginally with herpes lesions became infected, and half of these children died! But with caesarean section and Zovirax (which is a good medicine), the death of a newborn is very rare today.

When a pregnant woman is infected in the first trimester cytomegalovirus either the death of the embryo or a spontaneous miscarriage occurs. At a later stage, hemorrhage syndrome develops in the skin and all internal organs, hepatitis and hemolytic anemia develop. With a chronic form of infection, some children manage to survive, but they remain disabled because they develop blindness and a steady decline in intelligence.

Flu in severe form, it threatens the life of both mother and child, because the pregnant woman’s body is weakened. Sick women must be immediately hospitalized in a hospital.

Bacterial respiratory tract infections include scarlet fever, diphtheria, whooping cough, meningococcal infection, legionellosis and mycoplasmosis. The likelihood of getting sick with the first three listed diseases is very small, since these infections are considered “childhood” infections and they are included in the vaccination calendar, i.e., the entire population of the country is vaccinated against diphtheria, scarlet fever and whooping cough from childhood. If, nevertheless, a pregnant woman was not vaccinated and fell ill, then the course of the disease is unpredictable: “childhood” infections are more severe in adults, and the effect of bacteria on the fetus is nonspecific. The prognosis for a child's life depends on the severity.

Flow meningococcal generalized infection(meningitis and meningococcemia) extremely severe: in these situations there will be a struggle for the life of the mother, the condition of the child, of course, will be taken into account, but not put in first place in importance.

Vector-borne infections transmitted through the bite of various blood-sucking insects (mosquitoes, ticks, lice). These include various hemorrhagic fevers, encephalitis, rickettsiosis, typhus and relapsing fever, malaria, leishmaniasis, etc. All these infections are characterized by severe course and difficulty of treatment. However, most of them are endemic (distributed in certain areas), so pregnant women are not recommended to travel far beyond their region. Severe forms of these diseases can lead to intrauterine fetal death and spontaneous abortion or miscarriage.

Sexually transmitted diseases (STDs)

We used to call them venereal diseases - a word derived from the name of the goddess of love, Venus. (Interestingly, the word “awe” has the same origin.) Today they are called sexually transmitted diseases, or STDs. A routine part of initial pregnancy testing includes screening for STDs, and this issue has been discussed previously. Pregnancy itself does not provide any special protection against STDs. In fact, during pregnancy such a diagnosis is even more important, since infections can affect the baby.

Hepatitis

It is easily diagnosed by a blood test, but difficult to treat and can be passed on to the child.

AIDS

It is also easily diagnosed through blood tests. It is still a fatal disease, but great strides have been made to prevent it from being passed on to the baby by taking prenatal antiretroviral drugs such as zitovudine and by caesarean section birth to avoid direct inoculation (called vertical transmission).

Gonorrhea

Congenital gonorrhea can cause damage to a newborn's eyes. Most states have laws mandating the administration of antibiotic eye drops because the disease is not always accurately recognized. (Cultures are not reliable, there may be no symptoms, and the history cannot always be relied upon. Of course, we are talking about all sorts of other people.) Easily treated.

Chlamydia

This infection can accompany premature birth. Even more insidious than gonorrhea, it often produces no symptoms. Easy to treat.

Human papillomavirus or HPV

It is a sexually acquired virus that is detected by Pap smear and confirmed by colposcopy. It can lead to genital growths and/or cervical cancer, especially in women who smoke. It can pass to the newborn through contact with your birth canal, but this is extremely rare, so it is not a strict indication for a caesarean section.

Trichomoniasis

This infection is caused by tiny microscopic spiral-shaped organisms. If you were to look at a vaginal smear under a microscope (this is how trichomoniasis is diagnosed), it would look like there was a party going on. Trichomonas would be adorable if it weren't a sexually transmitted disease. Trichomoniasis is safe, although it is suspected of causing premature labor (unconfirmed) and burning, foul-smelling vaginitis. It is easily treated with pills, but your partner should be treated too.

Syphilis

This disease is a snide response to those who are too fixated on AIDS. It is easily diagnosed and easily treated, but if left untreated, it can affect the child, causing neurological problems. It reacts easily to antibiotics, but don't catch it on a deserted island where it will go unrecognized because in its final stage, after 20 years, it is terrible.

Molluscum contagiosum

It causes small, painless bumps on the skin in the genital area. A dermatologist can remove them - it's not difficult. They do not pose a danger to the child.

Infections acquired through non-sexual contact

Rubella, or Measles rubella

This is a mild infection for you, but it can seriously harm your baby. It is easy to become infected; this means that you may have had it and are immune to it; but it also means that if you didn't have one, you are at serious risk during pregnancy. If so, you should get vaccinated when the baby is born.

There is an accepted congenital rubella syndrome that includes deafness, heart defects, VMR, visual impairment and chromosomal abnormalities. Its severity, however, is related to how early you get it. If in the 11th week or earlier, this is alarming; after the 16th week, manifestations of this syndrome are rare.

Listeria

Bacterial infection. Up to one in twenty adults have this bacteria in their stool, so the infection is transmitted by the fecal-oral route, similar to feline toxoplasmosis, and is likely to be present everywhere. Foods contaminated with Listeria, such as soft cheese and unpasteurized and frozen foods, can cause an outbreak of the disease, but during pregnancy it may be completely asymptomatic or cause an illness that can be mistaken for a urinary tract infection or simply the flu, which is treated with fluids and acetaminophen.

If infected early, listeria can cause miscarriage. If infection occurs later, it can cause intrauterine growth restriction (IGR). In the third trimester, Listeria can lead to preterm labor, premature birth and ultimately neonatal sepsis, meningitis and death - this infection can be a baby killer. A child can develop meningitis even after the first few weeks of life. It is a fairly weakly infecting bacterium, usually seeking out immunocompromised people such as those with AIDS or pregnant women. Exposure to it is not thought to cause infection because it is such a common microbe.
The actual prevalence of infection and contamination affecting pregnancy remains unknown for several reasons. Few obstetricians perform bacterial cultures in cases of miscarriage, correctly assuming that miscarriage is usually the result of genetic failure, especially if there are no maternal symptoms. Since the presence of the infection is not thoroughly tested and it appears to be present everywhere in contaminated products, epidemiological statistics are still in a state of complete confusion. In real life, obstetricians do not do blood cultures and other tests for listeriosis in every case of mild fever, headache or muscle pain.

Listeria during pregnancy usually manifests itself as flu and similar illnesses, which can be scary when almost every pregnant woman complains of flu-like symptoms at some point during pregnancy. Low-grade fever, headache and muscle pain are common, but there are also cases where there are no symptoms at all1. Diarrhea and cramping are less common. Birth is indicated at the end of the third trimester so that treatment can be attempted for the newborn. In cases of severe prematurity, the question remains open.

Group B beta-hemolytic streptococcus

Although it is rare, it can cause serious infection, as discussed earlier, if associated with PPM or preterm labor.

Group A streptococcus

Very rare. This is a villain that can cause toxic shock. Don't worry about him, and don't make me take back what I said.

Piggy

A common childhood disease that affects the salivary glands and sometimes other structures such as the gonads, pancreas, etc. Treatment is symptomatic only. It rarely occurs during pregnancy because most adults are already immune. Although there is no hard evidence that it causes miscarriage, one case of this condition during pregnancy that I encountered ended up doing just that. Mumps is not a reason to terminate a pregnancy, as it does not appear to cause abnormalities in children.

Cytomegalovirus (CMV)

He's everywhere. It turns out that almost all people have it, since they have not yet figured out a way to protect themselves from it. By the age of three, most children have this virus, and are happy to pass it on to you, too, if you have avoided it. You can get it from a very harmful, but rarely culprit, toilet. In fact, if you're reading this, you may have already received it. If you don't have one, you can get it from this book if the last sales manager sneezed on it.

Because of its constant presence, true cytomegalovirus syndrome is rare, and of those born with it, only one in ten suffers from mental retardation. Other effects include hearing loss and anemia.

Chicken pox and herpes zoster

It's actually the same thing. Both are the result of the varicella zoster virus (VZV), a type of herpes virus. Chickenpox is the primary infection. After the skin heals from the smallpox marks, the virus retreats into the nerve roots of the spine and can return years later to form an inflamed rash called shingles. The fact that sores can spread to different parts of the body over time, fed by special nerve roots (nerves that harbor the virus), helps make a diagnosis. Both forms of VZV are contagious, and unless you are immune, you are likely to get it (possibly in the form of chickenpox) if you are exposed to it in your family, so you should stay away from anyone who has chickenpox or shingles.

Chickenpox during pregnancy can cause congenital smallpox lesions or, if the infection occurs shortly before birth, can affect your baby before you have a chance to develop any antibodies to pass on to him. This unprotected newborn may have a life-threatening infection, so all babies born to recently infected mothers are given an injection with VZV antibodies.

During pregnancy, chickenpox is also extremely dangerous for you, both because it is generally dangerous for adults and because pregnancy changes your immune resistance. You may develop chickenpox pneumonia, which is a complication that can leave you in critical condition.

I recently had a pregnant patient who was not immune to VZV. I told her to avoid Christmas shopping, crowds, theaters, etc., because in any crowd there must be a VZV. If you know you have been exposed, you should report it immediately, and if you are less than 20 weeks pregnant, you may be vaccinated against VZV. This vaccination should definitely be given to women of childbearing age before or after pregnancy.

In antenatal emergencies with VZV, large doses of the antiviral drug acyclovir, which is also given for genital herpes, can be used. There is still no evidence that acyclovir is harmful to children, and since it has been used successfully for some time, it greatly improves safety.

You don't need to avoid people with shingles or chickenpox if you are immune. Your doctor will do a simple blood test to tell you whether you have it or not. If there is, everything is fine. If not, ask your doctor to get vaccinated after pregnancy.

Vaginitis

Typically fungal or bacterial vaginosis, both likely originate in your rectum. Since your rectum is located close to your vagina, the greenhouse effect from underwear can cause colonization even with the most sophisticated hygiene, so don't wrinkle your nose. The use of creams in the second half of pregnancy is safe, and most doctors treat it in the first part as well without any second thought. I think it's safe because I'm one of them.

Infectious diseases of the urinary system

Urinary tract infections (UIDs) are common during pregnancy, mainly due to urinary stasis caused by dilation of the ureters, weakened by their peristalsis under the influence of hormones and (pressure from the gravid uterus. Asymptomatic bacteriuria occurs in approximately 15% of pregnancies and sometimes develops into symptomatic cystitis or pyelonephritis .

Diagnostics

The diagnosis of symptomatic IDSM does not change due to pregnancy.

Treatment

• Antibiotics such as cephalexin, nitrofurantoin, or trimethoprim/sulfamethoxazole.
• Control culture and sometimes suppressive therapy.

Treatment of symptomatic IDSM does not change due to pregnancy, other than avoiding medications that may harm the fetus. Because asymptomatic bacteriuria can lead to pyelonephritis and should be treated with antibiotics as acute IDCM.

The choice of antibiotics is based on individual and local susceptibility and resistance, but the following empirical treatment gives good results:

• cephalexin,
• nitrofurantoin,
• trimethoprim/sulfamethoxazole.

After treatment, cultures are performed to confirm effectiveness. Women with pyelonephritis or who have had >1 SMI may require suppressive therapy, usually trimethoprim/sulfamethoxazole (up to 34 weeks) or nitrofurantoin until the end of pregnancy. In women with bacteriuria with or without IDSM or pyelonephritis, urine cultures should be performed monthly.

Treatment of infectious diseases during pregnancy

Antibacterial therapy. Not using antibiotics in pregnant women without strong evidence of bacterial infection is extremely important. In general, penicillins, cephalosporins and macrolides are considered safe. The use of any antibiotic during pregnancy should be based on a comparison of benefits and risks, the balance of which varies at different stages of pregnancy. The severity of the infection and other possible treatment options must be taken into account.

Aminoglycosides can be used during pregnancy to treat pyelonephritis and chorioamnionitis, but treatment must be well monitored to avoid harm to the mother or fetus.

Chloramphenicol, even in large doses, is harmless to the fetus; however, neonates cannot adequately metabolize chloramphenicol, and high blood levels can cause circulatory collapse (gray baby syndrome). Chloramphenicol is rarely used in the United States.

The use of metronidazole in the 1st trimester is controversial, but this drug is usually used to treat bacterial vaginosis or trichomoniasis during the 2nd or 3rd trimester.

Fluoroquinolones are not used during pregnancy; they have high affinity for bone and cartilage tissue and therefore may cause musculoskeletal side effects.

Sulfonamides are generally safe during pregnancy. These drugs are often not prescribed after 34 weeks of pregnancy due to the risk of developing kernicterus in newborns.

Expectant mothers carefully monitor their health - they try to eat right, breathe fresh air, play sports, and protect themselves from stress and illness. Therefore, infections discovered during pregnancy sometimes become a real blow for them. Let's find out what the expectant mother needs to be afraid of, and under what diagnosis there is no need to panic. After all, experiences are also stress. Let's try to save our nerves. But knowledge will not hurt, because if you don’t take enough care of your health, intrauterine infections may develop during pregnancy (that is, the infection will be transmitted from the mother to the baby), which can affect its development and health. They are called:

• fungi (for example, the well-known thrush);
• bacteria();
• protozoa (toxoplasmosis).

The most commonly transmitted diseases are the TORCH group (cytomegalovirus, herpes, and others: enterovirus, hepatitis A, B, listeriosis, gonococcus, chlamydia). These are truly dangerous infections during pregnancy, but fortunately they can be prevented by getting tested before conception and getting the necessary vaccinations.

It would seem that you went through exhaustive examinations before pregnancy and tested everything for infections. But it's not time to relax yet. After all, you will have to take an infection test during pregnancy, which involves the following studies:

• for HIV (2 times: at the first visit to the gynecologist and at the thirtieth week of pregnancy);
• for hepatitis B, C (at the first visit and in the third trimester);
• at the first visit);
• for syphilis (3 times: at the first visit, at the thirtieth week of pregnancy, a few weeks before birth).

What to do if you have already suffered from a disease and are now planning to give birth to a baby? Is pregnancy possible after infections? Yes, sure. But since there are a huge number of infections, and each has its own characteristics, it is necessary to consult a doctor after treatment. He will tell you what to do to ensure conception takes place (and how long after the illness it is best to carry it out), and what precautions to take to ensure that the baby is born healthy (or at least reduce the risks as much as possible).

Sexual infections during pregnancy

Many diseases pose a threat to a child growing peacefully in his mother’s tummy. However, sexually transmitted infections are especially dangerous: under their influence, a woman runs the risk of not being able to carry the baby to term. Therefore, it is recommended to take all the necessary tests at the stage of thinking about pregnancy. Optimally, several months before active planning. However, pregnancy can also be unexpected. What to do if you are diagnosed with an STD?

If syphilis can be successfully cured in the early stages of an “interesting situation” (the baby cannot become infected with it until the 16th week), and women with AIDS are able to give birth to healthy children, then how can other sexually transmitted infections during pregnancy affect the mother and fetus? Let's look at the most common ones.

With chlamydia, it is quite possible to give birth to a completely healthy baby. However, if this infection is discovered during pregnancy, it must be treated urgently, because it can lead to:

• dangerous premature birth;
• placental insufficiency;
• premature rupture of water.

This also applies to sexually transmitted infections that are dangerous for a child. If the mother becomes infected with it before pregnancy, then, as a rule, decidual endometritis develops, which leads to involuntary abortion. If a woman becomes infected after four months of the “interesting situation,” then she carries the baby: the pathogens of the disease will no longer reach him. But after childbirth, serious problems may arise for the mother herself - the infection can penetrate the appendages and uterus.

Genital ureaplasmosis, which, as a rule, behaves extremely “quietly”, asymptomatically, can cause:

• miscarriage;
• intrauterine infection;
• postpartum diseases;
• premature birth.

Some mothers are afraid that treating an infection during pregnancy may harm the baby, so they think about whether to postpone it until later. But, as we see above, “later” may not come for the child. Therefore, sexually transmitted infections must be treated immediately after detection, and the sooner the better. If they are discovered during pregnancy, then you need to start fighting them now.

Rotavirus infection during pregnancy

It is very easy to become infected with rotavirus infection. Of course, by taking certain precautions, you can significantly reduce the risk of infection. And yet it is hardly possible to say with certainty that anyone is completely immune from this. Therefore, let us immediately reassure expectant mothers: rotavirus infection during pregnancy in itself is not dangerous for the baby. True, it can cause dehydration in a woman, which can lead to oxygen starvation of the fetus, which can cause spontaneous abortion or premature birth. However, we will hasten to reassure you again: timely treatment will allow you to protect yourself and your baby from negative consequences. After all, an intestinal infection during pregnancy has quite noticeable symptoms, so don’t worry - you won’t miss the disease.

Signs of rotavirus (or intestinal) infection include:

• stomach ache;
• diarrhea;
• nausea, vomiting.

Your temperature may rise. But if you immediately undergo appropriate therapy, then all these signs will become weaker every day, and within a few days you will feel a significant improvement. In most cases, it is possible to do without specific medications. However, if the disease manifests itself in a particularly complex form, the doctor may prescribe antibiotics. In general, treatment comes down to

• rest (or better yet, bed rest);
• drinking large amounts of liquid (mineral water, juices, fruit drinks).

Your doctor may advise you to take absorbents (such as activated charcoal), rehydration medications, and other medications. If the temperature has risen significantly, then it must be brought down. But it is better to do this not with the help of pills, but by resorting to traditional recipes, which it would also be a good idea to discuss with your doctor.