A complete plan of examinations during pregnancy. Pregnancy management: examinations and tests at different times
Physical examination
See the chapter "Clinical methods of examination of pregnant women".
Laboratory research
· When a pregnant woman is registered, a general analysis of blood and urine, determination of the group and Rh-belonging of blood, determination of the level of glucose in the blood must be performed.
If you have a history of stillbirth, miscarriage, extragenital diseases, you should:
Determine the content of hemolysins in the blood of a pregnant woman;
- to establish the blood group and Rh blood belonging to the husband, especially when determining the negative Rh; factor or blood group 0 (I) in a pregnant woman;
- to conduct research for the presence of causative agents of urogenital infection by the method of quantitative PCR diagnostics;
Determine the excretion of hormones, indicators of immunoresistance, as well as all the necessary studies to judge the presence and nature of the course of extragenital diseases;
- for pregnant women with a burdened obstetric, family and gynecological history, conduct medical genetic counseling.
In the future, laboratory tests are carried out in the following terms:
Complete blood count - 1 time per month, and from 30 weeks of pregnancy - 1 time per
2 weeks;
- general urine analysis - at each visit;
- blood test for AFP, hCG - at 16–20 weeks;
- the level of glucose in the blood - at 22-24 and 36-37 weeks;
- coagulogram - at 36–37 weeks;
- bacteriological (desirable) and bacterioscopic (required) examination of vaginal discharge - at 30 weeks
· Screening for infections (see chapter "Infection screening"). Most infections diagnosed during pregnancy do not deserve much concern, since in most cases they do not affect the course pregnancy, the risk of intrauterine or intrapartum infection. Therefore, those who lead a pregnant woman it is important not to apply unnecessary restrictions to pregnancy and not to waste existing resources.
When a pregnant woman is registered, they are tested for syphilis (Wasserman reaction), hepatitis B and C, HIV infection. In addition, microscopic, microbiological and cytological examination is necessary. smears and scrapings from the vagina and cervix to detect STIs (gonorrhea, trichomoniasis, chlamydia).
- Testing for syphilis and HIV is repeated at 30 weeks and 2–3 weeks before delivery.
Additional research methods
· An ECG is performed for all pregnant women at the first visit and at 36–37 weeks, if there are special indications - if necessary.
Ultrasound during pregnancy is performed three times: first, to exclude the pathology of the development of the ovum - on up to 12 weeks; second, for the purpose of diagnosing congenital malformations of the fetus - for a period of 18–20 weeks; the third - for a period of 32–34 weeks.
The study of the clinical significance of additional ultrasound methods in late pregnancy revealed an increase in the number of antenatal hospitalizations and induced labor without any improvement outcomes.
The expediency of ultrasound in special clinical situations has been proven:
- when determining the exact signs of vital activity or fetal death;
- when assessing the development of a fetus with suspected FGR;
- when determining the localization of the placenta;
- confirmation of multiple pregnancy;
- assessment of the volume of AF in case of suspicion of a lot or lack of water;
- clarification of the position of the fetus;
- with some invasive interventions.
· KTG. There is no evidence of the appropriateness of the routine use of CTG in the antenatal period as additional verification of the well-being of the fetus during pregnancy. The application of this method is shown only when a sudden decrease in fetal movements or prenatal bleeding.
Assessment of fetal movement is a simple diagnostic method that can be used in a comprehensive assessment fetal conditions in high-risk pregnant women.
Subjective assessment of fetal movement. Pregnant women should be offered informal follow-up movements of the fetus for self-control. Deterioration of fetal movement during the day is an alarming symptom. during pregnancy, which must be reported to the expectant mother at one of the first appointments (no later than the 20th weeks) so that she can navigate in time and seek medical help.
Counting the number of fetal movements. Two different techniques have been proposed, but there is no data on the advantages of one over the other.
- Cardiff method: starting at 9 am, the woman, lying or sitting, should concentrate on the movements of the fetus and record how long it takes for the fetus to make 10 movements. If the fetus has not made 10 movements before 9 evenings, a woman should see a specialist to assess the condition of the fetus.
- Sadowski technique: within one hour after a meal, a woman should, if possible, lie down, concentrate on the movements of the fetus. If the patient does not feel 4 movements within an hour, she should fix them for the second hour. If after two hours the patient has not felt 4 movements, she should consult a specialist.
Routine counting of fetal movements leads to more frequent detection of decreased fetal activity, more frequent use of additional methods for assessing the condition of the fetus, to more frequent hospitalizations pregnant women and an increase in the number of induced labor. However, there is no data on the efficiency of counting fetal movements to prevent late antenatal fetal death.
It is best to contact an antenatal clinic for registration at a gestational age of 6–8 weeks. For registration, you need to present a passport and a compulsory health insurance policy (MHI). By the way, with early registration (up to 12 weeks), a one-time cash benefit is entitled. In the normal course of pregnancy, it is recommended to visit a gynecologist at least seven times during the entire period of gestation. In the first trimester - once a month, in the second trimester - once every 2-3 weeks, from week 36 to childbirth - once a week. Also, during pregnancy, it will be necessary to undergo three screening ultrasound examinations: at 11-14 weeks, 18-21 weeks and 30-34 weeks.
At the first appointment, the obstetrician-gynecologist examines the woman, confirms the fact of pregnancy, assesses the condition of the walls of the vagina and cervix. The doctor also measures the weight, height, blood pressure and pelvic size of the expectant mother - in the future, these parameters will be recorded at each examination. In addition, the doctor fills out the necessary documents, gives recommendations on nutrition and taking vitamins, and prescribes referrals for tests and other specialists.
A smear on flora during pregnancy. The doctor must take a smear for flora and cytology for microscopic examination. Repeated smear on flora during pregnancy is taken at the 30th and 36th week. The analysis allows you to determine the development of the inflammatory process, to identify infections. For any deviations from the norm, additional studies are prescribed, for example, a test for sexually transmitted diseases (STDs). If they are found, the doctor decides on the appropriateness of treatment. Some infections pose a danger to the normal development of the fetus, can lead to the appearance of chromosomal abnormalities, damage to the placenta and various organs of the child - it makes sense to treat them. Of the medications, topical agents that do not contain antibiotics (suppositories, creams) are most often used; starting in the second trimester of pregnancy, your doctor may prescribe antibacterial drugs.
General analysis of urine during pregnancy. Allows you to quickly assess the general health of a pregnant woman and the work of her kidneys. In the future, it is carried out at each visit to the doctor during the entire period of bearing the child. You need to collect urine in a special plastic container (you can buy them at the pharmacy) in the morning, immediately after waking up. At night, the kidneys work more actively, as a result, the urine becomes more concentrated - this allows for more accurate diagnosis.
Normal urine should be light yellow and almost clear. Dark, cloudy urine is a sure sign of abnormalities in the body. This can be, for example, diseases of the kidneys, organs of the genitourinary system, the development of infections or diabetes, and much more. More precisely, the doctor will be able to determine what is wrong after studying the results of the urine test. According to changes in some indicators, one can suspect the development of gestational pyelonephritis (an infectious inflammation of the kidneys, often occurring in pregnant women due to obstructed outflow of urine) or gestosis (a complication of pregnancy, which is manifested by increased pressure, edema and the appearance of protein in the urine). Thus, a regular urine test allows you to timely track the occurrence of many serious diseases and begin their treatment.
General (clinical) blood test during pregnancy. One of the most informative analyzes, along with urine analysis, allows you to assess the state of a woman's health as a whole, indicates the presence of problems in the work of certain body systems. A blood test during pregnancy is taken three times: when registering and then in each trimester (at 18 and 30 weeks), and more often if necessary. This allows the doctor leading the pregnancy to monitor the dynamics of the patient's condition and monitor important indicators. According to the results of a clinical blood test during pregnancy, the number of leukocytes, platelets, hemoglobin is determined, ESR and other indicators are assessed. For example, a high level of white blood cells and neutrophils indicates that an inflammatory process is taking place in the body. A low level of hemoglobin indicates an iron deficiency in the body and the likelihood of developing anemia. This disease is dangerous because the fetus does not receive enough oxygen, this negatively affects its development, and the risk of miscarriage and premature birth also increases. High rates of ESR (erythrocyte sedimentation rate) indicate the possible development of several serious diseases at once, up to oncological ones, in this case additional studies are carried out to clarify the diagnosis. Platelets are responsible for blood clotting, so a high level of platelets suggests that there is a risk of blood clots.
Coagulogram. How the blood coagulation system works is also judged by the coagulogram, this analysis is done once every trimester, if there are no abnormalities. The indicators here are normally higher than before pregnancy, since during pregnancy the activity of the coagulation system increases.
Biochemical blood test during pregnancy. It is usually done at the same time as other blood tests. It helps to identify malfunctions in the work of various organs. For example, high levels of creatinine and urea indicate impaired renal function. High bilirubin indicates possible liver problems, including the development of jaundice in pregnant women. A very important indicator is glucose level (blood sugar test). Allows you to evaluate the work of the pancreas and not miss the onset of the development of a rather frequent complication of pregnancy - gestational diabetes. This is because the pancreas has a lot of stress during pregnancy. An elevated blood glucose level indicates that the gland is not doing its job.
Analysis for blood group and Rh factor. Doctors are required to do this test, even if you have done it before. It is very important to accurately determine the blood group of the expectant mother, since in the event of a large blood loss or an unscheduled operation, doctors may urgently need this information, and there will be no time to do an analysis. If a woman has a negative Rh factor, and the child's father is positive, a Rh conflict may occur, when the mother's body perceives the child as a foreign body and produces antibodies to eliminate it. This can have serious consequences: cause the development of anemia, miscarriage or intrauterine fetal death. Therefore, if it turns out that a woman has a negative Rh factor, the child's father donates blood. If he has a positive Rh factor, the expectant mother regularly takes an analysis to track the appearance of antibodies: once a month until the 32nd week of pregnancy, and after this period until the end of pregnancy - twice a month. If this is the first pregnancy and antibodies have not appeared before the 28th week, doctors suggest introducing a special drug that blocks the production of antibodies in the future.
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. The incubation period of these diseases is long, they may not manifest themselves immediately or not at all during pregnancy, the test results may also be negative for some time. Therefore, blood is checked for HIV and hepatitis twice - at the beginning of pregnancy and at the 30-35th week. To diagnose syphilis, a Wasserman test (RW) is used - it is done when registering, for a period of 30-35 weeks and 2-3 weeks before the expected date of birth. If any of the listed serious diseases are detected at an early stage, the option of terminating the pregnancy is possible, if at a later stage, the doctor prescribes treatment, if possible.
Blood test for. These include: toxoplasma, rubella, cytomegalovirus, herpes, and some other infections. They are dangerous not so much for the health of the mother as for the development of the child. If a woman has suffered diseases that cause the listed infections before pregnancy, then she should develop immunity to potentially harmful TORCH infections for the fetus, and special antibodies will be present in the blood - their presence allows this analysis to be detected. If there are no antibodies, the doctor will tell the expectant mother about the preventive measures that she must follow.
Also, in the first two weeks after contacting the antenatal clinic, a woman will need to visit a therapist, endocrinologist, ophthalmologist and otolaryngologist, and do an electrocardiogram. If the expectant mother has health problems, any chronic diseases, consultations of other specialists and additional examinations during pregnancy may be needed.
If the pregnancy is late or there are other indications, between the 10th and 12th weeks, the doctor may prescribe a chorionic villus test (PVC) - a study of the tissues of the placenta to determine chromosomal abnormalities in the fetus.
"Double test"
At 11-14 weeks of pregnancy, the first screening, or "double test", is done during pregnancy. It is also used to find out if the fetus is at risk of developing chromosomal abnormalities, such as Down's syndrome. Screening includes ultrasound, blood tests to determine the level of human chorionic gonadotropin (hCG) and a protein that is produced by plasma (PAPP-A).
Pregnancy check-ups: second trimester (14th to 27th weeks)
In the second trimester, it is recommended to visit a gynecologist once every 2-3 weeks, from the 16th week, during the examination, the doctor begins to measure the height of the fundus of the uterus and the volume of the abdomen to determine whether the child is developing correctly. These parameters will be recorded at each visit. A second screening or “triple test” is performed at 18-21 weeks. With its help, the presence of hCG, alpha-fetoprotein (AFP) and free estriol (a steroid hormone) is again determined. Together, these indicators allow doctors to make a fairly accurate prognosis. However, even if it turns out that the risk of developing pathology in a child is high, this is not yet a sentence. In this case, additional clarifying studies are carried out, for example, analysis of amniotic fluid (between the 14th and 20th weeks).
Also, in the period from the 18th to the 21st week, a second scheduled ultrasound is performed, during which the state of the placenta and amniotic fluid is assessed, the child's development conforms to the norms, and it is also already possible to determine the sex of the baby.
Pregnancy check-ups: third trimester (28 to 40 weeks)
As a rule, on the 30th week, the antenatal clinic doctor takes out maternity leave and issues an exchange card to the pregnant woman. From the 30th to the 34th week, an ultrasound is done for the third time - to determine the growth and approximate weight of the fetus, its position in the uterus, the state of the placenta, the quantity and quality of amniotic fluid, the presence of an umbilical cord entanglement. Based on these data, the doctor makes recommendations regarding the method of delivery.
At a period of 32–35 weeks, cardiotocography (CTG) is performed - a study of the work of the cardiovascular system of the embryo and its motor activity. This method can be used to determine how well the child is doing.
From the 36th week until delivery, the doctor conducts a routine examination every week. During the entire period of bearing the baby, the gynecologist can prescribe additional tests or send the expectant mother for consultations to other doctors - it all depends on the characteristics of the course of pregnancy.
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An exchange card is the most important document of a future mother
The exchange card is issued at the antenatal clinic for a period of 22-23 weeks, and it is better to always have it with you. This is an important medical document for a pregnant woman, which will be needed when applying for a maternity hospital.
The exchange card consists of three parts (coupons):
- Information of the antenatal clinic about the pregnant woman. Here an obstetrician-gynecologist, observing a woman throughout the entire period of pregnancy, enters basic information: personal data of the expectant mother, blood group and, past and chronic diseases, information about previous pregnancies and childbirth, the results of examinations, analyzes, screenings, ultrasound, CTG, conclusions other specialists. After reviewing these data, the doctor in the maternity hospital will be able to find out all the necessary information about the features of this pregnancy and assess the woman's health.
- Information of the maternity hospital about the woman in childbirth. It is completed by the doctor before the woman is discharged from the hospital - he enters information about how the childbirth went and the period after it, about the presence of any complications, makes notes about the need for further treatment. This part of the card will need to be given to the antenatal clinic doctor.
- Information of the maternity hospital about the newborn. All the parameters of the baby are recorded here: height, weight, Apgar score (summary analysis of five important criteria for the baby's condition) and others. This part of the card will need to be handed over to the pediatrician, who will observe the child, he will keep a medical record and transfer all the necessary data there.
Approximate examination schedule during pregnancy:
|
When registering (8-12 weeks) |
|
| Within 2 weeks after registration |
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| 11-14 weeks |
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| 16 week |
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| 18-21 weeks |
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| 20 week |
|
| 22 week |
|
| 24 week |
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| 26 week |
|
| 28 week |
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| 30 weeks |
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| 30-34 weeks |
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| 32-35 weeks |
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| 36 weeks (and then - once a week before delivery) |
|
Carrying out a certain set of studies in a pregnant woman makes it possible to predict the course of pregnancy and childbirth, possible complications and, therefore, timely correction aimed at reducing the risk of developing diseases in her and the fetus. This complex will include: a survey, an objective study of the functions of all organs, external and internal obstetric research, clinical and laboratory research.
Interviewing a pregnant woman
Anamnesis is collected according to the following plan.
1. Passport data.
2. Diseases transferred in childhood, adulthood, their course and treatment.
3. Heredity.
4. Working and living conditions.
5. Epidemiological history.
6. Allergic history.
7. Obstetric and gynecological history:
Menstrual function (menarche and the establishment of the menstrual cycle, duration, soreness and regularity of menstruation, the amount of blood lost during menstruation, the date of the last menstruation);
sex life (at what age, married or not);
Gynecological diseases (what, when, duration and nature of their course, therapy, treatment results);
Generative function - the number of previous pregnancies with a detailed clarification of their course and outcome (artificial and spontaneous abortions, childbirth);
The course of a real pregnancy (the first and second half of pregnancy, past illnesses and for how long, outpatient, inpatient treatment).
Objective research
Examination of a pregnant woman includes: examination of a pregnant woman, special obstetric examination (external and internal), clinical and laboratory studies.
Inspectionpregnant includes:
Anthropometric studies (assessment of physique, gait, abdominal shape, measurement of height and body weight);
Research of organ functions.
Special obstetric examination aims to assess in a timely manner obstetric factors and resolve the issue of the possibility of giving birth through the vaginal birth canal.
External obstetric examination includes the following.
1. Measurement of the abdominal circumference and the height of the uterine fundus, It is carried out starting from 16 weeks of pregnancy at each visit to the antenatal clinic, which allows you to clarify the correspondence of the height of the uterine fundus to the gestational age and timely diagnose polyhydramnios, multiple pregnancies, large fetuses, fetal malnutrition. In the horizontal position of the pregnant woman, the abdominal circumference is measured at the level of the navel and the height of the uterine fundus from the upper edge of the pubic articulation.
2. Measurement of the external dimensions of the large pelvis (allows you to approximately judge the size and shape of the small pelvis) is carried out with a pelvis meter in the following sequence:
Distantia spinarum - the distance between the anterosuperior spines of the iliac bones (normally 25-26 cm);
Distantia cristarum - the distance between the most distant points of the crests of the iliac bones (on average 28-29 cm);
Distantia trochanterica - the distance between the large trochanters of the femur (usually 31-32 cm);
Conjugata externa - the distance between the upper edge of the pubic articulation and the spinous process of the V lumbar vertebra, measured in the position of the pregnant woman on her side (normally equal to 20-21 cm);
The straight size of the exit of the pelvis (normally 9.5 cm) is the distance between the middle of the lower edge of the pubic articulation and the apex of the coccyx, measured in the position of the pregnant woman on her back with the legs bent and bent in the hip and knee joints;
The transverse size of the pelvic outlet (normally 11 cm) is the distance between the inner surfaces of the ischial tubercles (the position of the pregnant woman is the same as when measuring the direct size of the pelvic outlet);
Rhombus Michaelis - assessment of the shape of the rhombus, measurement of the vertical (normal 11 cm) and horizontal (normal 10 cm) of its diagonals (the woman stands with her back to the doctor);
Solovyov's index (gives information about the thickness of the pelvic bones) - the circumference of the wrist joint, which is measured with a centimeter tape (normally it is 14 cm);
The height of the symphysis (gives an idea of the thickness of the pelvic bones, the measurement is carried out with a vaginal examination).
3. Techniques of Leopold - Levitsky. First reception allows you to determine the height of the standing of the uterine fundus in relation to the xiphoid process (correspondence of the height of the standing of the uterine fundus to the gestational age) and the part of the fetus, which is located in the bottom of the uterus. The pelvic end is defined as a large, soft and non-ballot part of the fetus, the head is defined as a large, well-contoured, dense ballot part. To do this, it is necessary to place the palms of both hands at the bottom of the uterus and determine the distance between the bottom of the uterus and the xiphoid process or navel, to clarify the part of the fetus in the bottom of the uterus.
Second reception external obstetric examination aims to determine the position, position and type of the fetus.
Fetal position is the ratio of the longitudinal axis of the fetus to the longitudinal axis of the uterus. There are the following positions: a) longitudinal - the longitudinal axis of the fetus and the longitudinal axis of the uterus coincide; b) transverse - the longitudinal axis of the fetus crosses the longitudinal axis of the uterus at a right angle; c) oblique - the longitudinal axis of the fetus forms an acute angle with the longitudinal axis of the uterus.
Fetal position - the ratio of the fetal back to the right and left side of the uterus. In the first position, the back of the fetus (dense and wide surface) faces the left side of the uterus, in the second position, to the right.
Fetal type - the ratio of the back of the fetus to the front (front view) or back (back view) of the uterine wall.
To perform the second Leopold-Levitsky technique, the palms of both hands of the obstetrician palpate the lateral parts of the uterus, determining the position of the fetus and the location of its back.
Third reception external obstetric examination serves to determine the presenting part of the fetus (head, pelvic end) - To perform it, the obstetrician needs to move the thumb of the right hand as far as possible from the other four, grasp the presenting part of the fetus and determine its mobility in relation to the plane of the entrance to the small pelvis.
Fourth reception allows you to determine the level of standing of the presenting part. During pregnancy, the fetal head can be mobile or pressed against the entrance to the small pelvis. This technique is especially important for assessing the progress of the fetal head through the birth canal during childbirth.
4. Auscultation. Heart sounds of the fetus are heard from the gestational age of 20 weeks in primiparous and from 18 weeks in multiparous. Auscultation is performed at each visit of the pregnant woman to the antenatal clinic, the frequency, rhythm and sonority of the fetal heart sounds are assessed (normal heartbeat is 120-160 beats / min, clear, rhythmic).
Internal obstetric examination carried out when taking to dispensary registration for pregnancy and during hospitalization in the antenatal department with a complicated course of pregnancy or to prepare for childbirth. It is performed in order to assess the state of the soft birth canal, structural features of the bony pelvis, the nature of the presenting part, as well as to resolve the issue of the method and timing of delivery. Research includes:
Examination and assessment of the external genital organs (type of pubic hair growth - male or female, the correct development of the labia majora and small labia, the presence of pathological changes, scars in the vulva and perineum);
Examination using mirrors (folding and spoon-shaped) with an assessment of the shape of the external os of the cervix, the color of the mucous membrane of the vagina and cervix, pathological changes and the nature of the discharge;
Vaginal examination (digital) (according to indications at any time of pregnancy).
Vaginal examination in the early stages of pregnancy allows you to establish the duration of pregnancy and identify the pathology of the internal genital organs. At the same time, the condition is consistently assessed:
The vagina is narrow (in a nulliparous woman) or capacious (in a woman who has given birth);
Cervix - length, consistency, shape (conical in primiparous and cylindrical in multiparous), the state of the external os (the external pharynx is closed in primiparas and passes the fingertip in multiparous);
Uterus - position, gestational age in weeks, consistency (soft), its mobility and tenderness on palpation; in the early stages of pregnancy, it is possible to identify a crest-like protrusion on the anterior surface of the uterus along the midline (Genter's sign), asymmetry of the uterus due to protrusion of one of its corners (Piskachek's sign), contraction and compaction of the uterus on palpation (Snegirev's sign);
Appendages of the uterus (size, consistency, soreness);
Vaginal vaults (high, free);
bone pelvis (cape reachability, pelvic deformity, exostosis).
Vaginal examination during full-term pregnancy makes it possible to establish the degree of readiness of the soft birth canal for childbirth. When performing the study, the condition is assessed sequentially:
Vagina (narrow or capacious, the presence of pathological changes);
The cervix with the definition of the degree of its "maturity" (table. 1);
Fetal bladder (its presence or absence); the presenting part and its relation to the planes of the pelvis;
the oblique pelvis - the height of the symphysis, the presence of bony protrusions and deformities, the shape and depth of the sacral cavity, the reachability of the cape and the measurement of the diagonal conjugate (normally, the cape is not reached).
Comprehensive examinations of expectant mothers, which are carried out during pregnancy, make it possible to detect fetal anomalies. Timely and comprehensive examination in the long term is a guarantee of the birth of a healthy baby.
What examinations do you need to undergo during pregnancy?
Prenatal screenings are examinations of all pregnant women or expectant mothers. The goal of prenatal screening is to create risk groups. They include women who have a particularly high risk of having a child with one or another genetically determined pathology. The patient's data are sent for a number of additional studies (analyzes).
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Prenatal screening involves two basic research methods - and.
Note:ultrasound scanning makes it possible to determine pronounced anatomical abnormalities in an unborn child.
The purpose of laboratory (biochemical) prenatal diagnostics is to determine a particular chromosomal pathology in a child.
If the result is positive, the pregnant woman is assigned to a certain risk group. Subsequently, such patients are subject to extensive examination using invasive methods.
Ultrasound during pregnancy
Ultrasound scans should be performed at least three times while carrying a baby.
Important:contrary to popular belief, ultrasound does not harm the unborn child.
- The first study is at 10-14 weeks;
- The second study is at 20-24 weeks;
- The third (last) scan - at a period of 30-32 weeks.
At 10-14 weeks, ultrasound scanning already makes it possible to identify the most pronounced pathologies of intrauterine development of the embryo. In particular, an umbilical hernia, cervical hygroma (cystic formation), as well as such an incompatible pathology with life as the absence of a brain are determined. In this period, the thickness of the collar space is determined.
Note:this indicator is normally no more than 3 mm. Excess can be a marker of anomalies in the development of the embryo (chromosomal or other genesis).
For a period of 20 to 24 weeks, ultrasound makes it possible to detect the vast majority of pronounced developmental anomalies.
Significant anatomical abnormalities that are detected during this period of pregnancy:
- abnormalities in the development of the kidneys;
- underdevelopment of the limbs;
- pronounced disturbances in the formation of the gastrointestinal tract;
- serious heart defects.
Fetal malformations discovered in early pregnancy are usually not subject to correction. The identified anomalies are the basis for raising the question of carrying out an artificial termination of pregnancy. 
At these times, it already becomes possible to detect the so-called. markers of chromosomal pathology.
Among them:
At a period of 30-32 weeks, ultrasound screening makes it possible to detect defects that are characterized by late manifestation and relatively low severity from the point of view of anatomy.
At a later date, you can identify:
- majority ;
- significant narrowing or complete obstruction of the organs of the urinary system.
This type of intrauterine developmental defects can be surgically corrected immediately after the birth of the baby. In many cases, timely surgical intervention makes it possible to completely eliminate these defects.
Biochemical screening is carried out in a laboratory setting; The blood of a pregnant woman serves as the material for research.
Important:the presence of certain serum markers is the basis for placing the patient in the risk group for a certain chromosomal pathology of the fetus.
A fetoplacental complex is formed in the body of a pregnant woman, which includes the fetus itself and its membranes (chorion + amnion). The membranes synthesize special proteins that enter the blood of the expectant mother. Almost any changes in their condition lead to the fact that special markers appear in the blood serum of the expectant mother.
The modern biochemical test is carried out in two stages. The first screening for serum markers is done at 10-14 weeks, and the second at 16-20 weeks. Thus, the study is carried out in the first and second trimesters.
Analysis of PAPP-A and hCG in the 1st trimester
During the biochemical analysis performed in the first trimester, the levels of specific placental proteins - hCG (chorionic gonadotropin) and PAPP-A (plasma protein type A) - are detected.
Note:for biochemical analysis, it is necessary to carry out the so-called. "Double" test. Differences in plasma protein levels suggest some abnormalities in the unborn child. In particular, a decrease in the level of PAPP-A in combination with an increased level of free ß-hCG is the basis for suspicion of the presence of Down's disease.
The test for two specific proteins can diagnose up to 85% of the presence of Down syndrome.
Most often in this period of pregnancy, the so-called. "Triple" screening. In the course of this study, the level of α-protein (AFP), hCG and unbound estriol is determined.
The most important for mass screening is the level of AFP and hCG. If there is a significant increase in the plasma alpha-protein content, there is a possibility of serious disturbances in the intrauterine development of the central nervous system of the unborn child. Other serious pathologies, which may be indicated by a high level of AFP, include teratomas, duodenal atresia, etc.
Important:a high level of α-protein may indicate the presence of a Rh conflict, the likelihood of spontaneous abortion, as well as the death of an unborn child.
If a woman is diagnosed with multiple pregnancies, then a high level of AFP is considered normal.
Low α-protein levels suggest Down's disease. A decrease in this indicator may indicate a low location of the placenta, obesity of a pregnant woman, or the presence of a disease such as diabetes mellitus in the expectant mother.
Important:in general, a decrease in the AFP level is considered an unfavorable symptom, but it can also be recorded with a normal pregnancy.
According to some experts, the level of α-protein depends on the race of the woman.
Chorionic gonadotropin and unconjugated estriol are placental proteins. An increase or decrease in the level of these proteins indicates a change in the state of the placenta. In some cases, this may indicate chromosomal abnormalities. A change in the level of these proteins in the blood plasma often indicates the threat of spontaneous abortion, as well as the presence of immunological incompatibility or infection.
Important:a change in the level of placental proteins can also be observed with a normal pregnancy.
A decreased level of unbound estradiol in combination with an increase in human chorionic gonadotropin is one of the characteristic signs of Down's syndrome. A triple test makes it possible to identify this pathology in 60% of cases.
Note:different laboratories may have their own serum marker standards, depending on the type of reagents used. As a rule, international relative units are used for the assessment, which are denoted as MoM.
Norm
For each of the markers, regardless of the gestational age, the reference values are 0.5-2.0 MoM.
An increase or decrease in the serum content of one of the biochemical markers has no clinical significance; indicators are assessed only in combination.
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I the trimester of pregnancy is decisive in predicting its outcome for the mother and the fetus, therefore, an in-depth examination of the woman's health status and identification of prenatal risk factors is necessary.
The first examination is performed at 8-14 weeks of pregnancy. Further, the schedule of mandatory examinations includes gestational periods: 20-24 weeks, 36-38 weeks, 40-41 weeks.
The main tasks of the survey in I trimester are as follows:
Establishing the presence of pregnancy, determining its duration, the date of the expected birth. If necessary, the question of the gestational age is decided taking into account the ultrasound data.
Examination of the health status of a pregnant woman to identify risk factors for the development of complications of the mother and fetus. After the first examination by an obstetrician-gynecologist, the pregnant woman is sent for examination to a therapist, who examines her twice during pregnancy (in the early stages and at 30 weeks of pregnancy). The pregnant woman is also consulted by other specialists (dentist, ophthalmologist, otorhinolaryngologist and, if indicated, other specialists).
Deciding on the possibility of maintaining or recommending termination of pregnancy if it threatens life or poses a danger of giving birth to a sick, disabled child.
Drawing up an individual examination plan and conducting an algorithm for prenatal monitoring.
Prevention and treatment of complications during pregnancy.
When the doctor first communicates with a pregnant woman, the following is necessary:
1. Reveal:
Features of anamnesis (family, gynecological, obstetric). When familiarizing with the family history, it is necessary to highlight the presence of diabetes mellitus, hypertension, tuberculosis, mental, oncological diseases, multiple pregnancy, the presence of children with congenital and hereditary diseases in the family. The obstetric and gynecological history includes information about the features of the menstrual cycle, the number of pregnancies, the intervals between them, the outcomes of childbirth, the weight of newborns, the development and health of children. There is also a need for data on abortions and their complications, undergone surgeries, gynecological diseases, and infertility. It is important to identify whether there have been laparoscopic operations, including the removal of myomatous nodes.
Past and concomitant diseases, medications taken, allergies. It is necessary to obtain information about past diseases such as rubella, toxoplasmosis, genital herpes, cytomegalovirus infection, chronic tonsillitis, diseases of the kidneys, lungs, liver, cardiovascular, endocrine systems, oncological pathology, increased bleeding, operations, blood transfusions, allergic reactions.
The nature of work, lifestyle, bad habits, occupational hazards.
2. Conduct a general clinical and special (gynecological and obstetric) examination.
At the first examination of a pregnant woman, the height, constitution, body weight, and pelvic dimensions are assessed. They measure blood pressure on both hands, examine the state of the heart, respiratory organs, thyroid and mammary glands, liver, and abdominal organs. A vaginal examination is mandatory (examination of the cervix and vagina using mirrors, the size of the uterus, its consistency, tone, the area of the appendages).
At 10 weeks of pregnancy, it is necessary to record blood pressure. With the normal development of pregnancy, it should be within 120 / 80-115 / 70 mm Hg. Art. The presence of hypertension during this period is the basis for an in-depth examination for renal pathology or the presence of hypertension, as well as the possibility of reduced production of PGE 2 (primary placental insufficiency). It is important at this time to identify the peak of hCG secretion, which confirms the function of the trophoblast.
3. Research: blood tests with the determination of the group, Rh-affiliation, coagulogram, hematocrit number, acetone level, ketone bodies (according to indications); as well as blood tests for HIV, RW, Hbs, HCV ... The general analysis of urine allows you to roughly judge the condition of the kidneys.
4. Conduct research on the most common infections, which are leading in the formation of complications of pregnancy and the occurrence of congenital malformations. This group TORCH -infections (toxoplasmosis, rubella, cytomegalovirus, herpes, etc.). If antibodies to rubella virus, CMV, toxoplasma are not detected, the patient is classified as a risk group for primary infection during pregnancy, which is especially dangerous for the fetus.
Based on the data obtained, there may be grounds for testing for diabetes, tuberculosis, syphilis, etc.
It is necessary to conduct bacteriological and virological studies of vaginal contents. It is necessary to investigate not the luminal, but the parietal flora (scraping of the mucous membrane).
A screening ultrasound scan should be carried out to clarify the gestational age, assess the size of the ovum, embryo, fetus, determine the number of embryos, as well as the length of the cervix and the size of the internal pharynx if a miscarriage is suspected.
Primary laboratory tests:
1. Clinical blood test.
2. General analysis of urine.
3. Coagulogram, antibodies to hCG, antibodies to lupus antigen.
4. Determination of blood glucose.
5. Blood group, Rh -factor, determination of anti-rhesus antibodies.
6. Serodiagnostics of syphilis, HIV infection, hepatitis.
7. Determination of the titer of antibodies to rubella virus, toxoplasmosis.
8. Determination of the level of 17-KS (according to indications).
9. Examination for urogenital infection.
Determination of hemoglobin and hematocrit number. According to the WHO definition, anemia of pregnant women is considered to be a decrease in hemoglobin levels below 100 g / l, hematocrit is below 30%. In such cases, an examination of the pregnant woman is necessary to establish the cause of the disease.
Study of the average portion of urine for the presence of protein, glucose, bacteria, leukocytes. If a pregnant woman has kidney disease, it is necessary to determine the prognosis of pregnancy for the mother and fetus, prevent the occurrence of possible complications during the development of pregnancy, prescribe appropriate therapy and, if necessary, be hospitalized in a specialized hospital.
Coagulogram and determination of antibodies. The risk group for the presence of autoantibodies to phospholipids is the following category of women with a history of:
Habitual miscarriage of unknown origin;
Intrauterine fetal death during II and III trimesters of pregnancy;
Arterial and venous thrombosis, cerebrovascular diseases;
Thrombocytopenia of unknown origin;
False positive reactions to syphilis;
Early toxicosis, preeclampsia;
Delayed intrauterine development of the fetus;
Autoimmune diseases.
In the presence of antiphospholipid antibodies in I trimester of pregnancy is determined by platelet hyperfunction. The degree of hypercoagulation of the plasma hemostasis link increases. As a result of platelet hyperfunction and hypercoagulation of the plasma hemostasis link, thrombosis and infarction occur in the placenta, markers of intravascular coagulation activation - PDP and soluble complexes of fibrin monomers - are determined. All these disorders can lead to thrombosis of the blood vessels of the placenta and fetal death.
It is necessary to emphasize the particular importance of early initiation of therapy in patients with APS due to the damaging effect of lupus antigens on the vessels of the placental site. The detected disorders of the hemostatic system are an indication for the use of antiplatelet agents and anticoagulants against the background of glucocorticosteroid therapy. For relief of hemostasiological disorders, it is prescribed from 9-10 weeks of pregnancy and later:
Prednisolone or metipred 2.5-5 mg / day;
Curantil 75.0 mg / day one hour before meals;
Trental 300.0 mg / day;
Fraxiparine 0.3 ml 2 times subcutaneously or small doses of heparin from 10,000 to 30,000 U / day (the duration of heparin therapy is determined by the severity of hemostasiological disorders).
This treatment regimen is optimal for gestational age up to 20 weeks and can be used repeatedly before delivery.
Control of the hemostasis system is carried out once every 2 weeks.
With autosensitization to hCG or pregnancy proteins associated with hCG, impaired hemostasis in I trimester is also expressed, which is an indication for heparin therapy.
Determination of blood glucose. All pregnant women undergo a scanning study to detect diabetes by determining the glucose concentration on an empty stomach and 1 hour after taking 50 g of glucose. If the fasting blood glucose level is above 5.00 mmol / L, an hour after taking 50 g of glucose - more than 7.77 mmol / L, as well as in the presence of risk factors (glucosuria, a family history of diabetes), a test is required for glucose tolerance.
Determination of the blood group, Rh -factor and anti-rhesus antibodies. All pregnant women should undergo a blood test in order to timely identify Rh - isoimmunization, which is especially often the cause of the most severe forms of hemolytic disease of the fetus. Other isoantibodies can also cause serious complications.
Serodiagnostics of syphilis, HIV infection, hepatitis. Abortion may be recommended for seropositive women. The risk of vertical transmission is at least 24%. The fetus becomes infected with syphilis during II trimester.
Screening results for hepatitis B may indicate that the newborn should receive immunoglobulin and the hepatitis B vaccine immediately after birth. The risk of transmission early in pregnancy is low.
Determination of antibodies to rubella virus and toxoplasmosis. Rubella serological positive results due to primary infection during I trimester of pregnancy indicate a high risk of congenital anomalies, therefore it is advisable to recommend termination of pregnancy.
Screening for rubella appears to be advisable because negative tests can warn the patient that contact with an infected person is dangerous for her baby and offer active immunization after childbirth.
If a pregnant woman is diagnosed with acute toxoplasmosis, the question of terminating the pregnancy for medical reasons may arise. It should be noted that most of these women give birth to an infected child.
Determination of the level of 17-KS in daily urine, the level of GDEA to determine the source of hyperandrogenism. 17-KS is determined every 2-3 weeks to adjust the dose of dexamethasone. Monitoring the course of pregnancy in women with hyperandrogenism should be carried out taking into account the critical periods of pregnancy characteristic of this pathology: 13 weeks (release of testosterone by the ovaries of the male fetus), 20-24 weeks (the beginning of hormonal production of the adrenal cortex), 28 weeks (release of ACTH by the pituitary gland fetus).
In addition to dexamethasone, with the threat of termination of pregnancy in I trimester, it is advisable to use CG 1500 IU intramuscularly 1 time per week. With combined and ovarian hyperandrogenism, pronounced hyperestrogenism, it is advisable to prescribe drugs of natural (but not synthetic) progestogen. With adrenal hyperandrogenism, the appointment of gestagens is not justified, since in most cases there is an increased content of progesterone.
Examination for urogenital infection. Given the widespread prevalence of urogenital infection among the population in terms of pregravid preparation and during pregnancy, it is necessary to conduct a laboratory examination for the presence of a sexually transmitted infection:
Examination of scrapings from the cervical canal and urethra by the method PCR for the presence of bacteria of the genusChlamydia, Mycoplasma, Ureaplasma, viruses of the familyHerpesviridae - BUT and CMV;
Determination of class M antibodies in blood serum by ELISA and G to C. Trachomatis, M. Hominis, VPG-1, VPG-2, CMV;
Microscopic examination of vaginal, cervical and urethral discharge.
Pregnant women with urogenital infection should be classified as a high-risk group, if possible, to have a child with intrauterine infection, morphological and functional immaturity and malnutrition.
Echographic scanning. Echography is the most important tool for examining a pregnant woman and can be used for clinical indications at any time of pregnancy.
In the early stages of pregnancy, ultrasound is performed for:
Confirmation of pregnancy;
Clarification of the gestational age;
Clarification of the location of the ovum;
Detection of multiple pregnancies;
Exceptions of cystic drift;
Exclusion of formations in the small pelvis or hormonally active ovarian tumors;
Diagnosis of uterine fibroids or ovarian masses that could interfere with the normal course of labor.
With the help of ultrasound, you can identify:
Fetal hypoplasia;
Non-immune dropsy;
Cystic hygroma of the neck;
Anencephaly;
spina bifida;
Cephalocele;
Cysts of the choroid plexus of the lateral ventricles of the brain;
Splitting of the hard palate;
Polydactyly;
Diaphragmatic hernia;
Sacrococcygeal teratomas;
Renal agenesis;
Polycystic kidney disease;
Fused twins.
Ultrasound diagnostics available:
Most of the limb defects;
Hydronephrosis;
Polycystic kidney disease;
Gastroschisis (splitting of the anterior abdominal wall of the fetus);
Cleft face;
Defects of the nervous system.
Generally accepted indications for medical genetic counseling and in-depth prenatal examination:
1. Late age of parents (mothers 35 years and more).
2. A history of a child with intrauterine malformations.
3. Hereditary diseases in the family.
4. Consanguineous marriage.
5. Occupational hazards (chemical production, radiation exposure and UFO).
6. Bad habits (alcohol, drugs).
7. Taking teratogenic drugs (antidepressants, tetracycline, codeine, antithyroid drugs, etc.).
8. Acute viral diseases during pregnancy.
9. Threat of early termination of pregnancy.
10. History of spontaneous miscarriages.
Invasive diagnostics. Indications for invasive methods of prenatal diagnosis in Itrimester (chorionic biopsy, amniocentesis, cordocentesis, placentocentesis):
The age of the pregnant woman is over 35;
Chromosomal aberration in one of the spouses;
A history of a child with intrauterine malformations or chromosomal abnormalities;
The presence of congenital malformations or echo markers of fetal development disorders;
Changes in the level of AFP and hCG;
X-linked diseases in the family.
Invasive interventions are carried out with the consent of the pregnant woman under ultrasound control by a trained specialist in order to obtain fetal cells and establish the genetic state of the fetus from them.
When a pregnancy is terminated within 12 weeks, direct methods of genetic diagnosis are used, which are used during the prenatal examination of a pregnant woman.
A sample of fetal tissue taken after termination of pregnancy should be identified on the basis of cytomorphological examination.
Additional research methods (according to indications):
Hormonal;
Biochemical;
Immunological;
Hematological:
Lupus anticoagulant,
APS;
Invasive methods of prenatal diagnosis (amniocentesis, chorionic biopsy).
The scope of examination of pregnant women is presented in table. 1 .
table 1 . The standard of clinical and laboratory examination of pregnant women in I trimester Primary treatment (up to 12 weeks)
Physical examination: measurement of body weight, height, blood pressure (on both arms), palpation of the thyroid gland, mammary glands, auscultation of the heart and lungs, examination of the abdomen and limbs, examination by a dentist Gynecological examination: bimanual vaginal examination, cytological analysis of vaginal discharge and smears from cervical canal (diagnosis of chlamydia), determination of the configuration and size of the uterus and the condition of the appendages, external pelviometry, examination of the cervix in the mirrors