High-risk pregnant women. High-risk pregnancy
Risk stratification in obstetrics provides for the identification of groups of women in whom pregnancy and childbirth can be complicated by a violation of the vital functions of the fetus, obstetric or extragenital pathology. Based history, physical examination data and laboratory tests reveal the following adverse prognostic factors.
I. Socio-biological:
- mother's age (up to 18 years old; over 35 years old);
- the father's age is over 40;
- professional harm from parents;
- smoking, alcoholism, drug addiction, substance abuse;
- weight growth indicators of the mother (height 150 cm or less, weight 25% higher or lower than normal).
II. Obstetric and gynecological history:
- the number of births is 4 or more;
- repeated or complicated abortions;
- surgical interventions on the uterus and appendages;
- malformations of the uterus;
- infertility;
- miscarriage;
- undeveloped pregnancy (NB);
- premature birth;
- stillbirth;
- death in the neonatal period;
- the birth of children with genetic diseases and developmental anomalies;
- the birth of children with low or large body weight;
- complicated course of a previous pregnancy;
- bacterial gynecological diseases (genital herpes, chlamydia, cytomegaly, syphilis,
gonorrhea, etc.).
III. Extragenital diseases:
- cardiovascular: heart defects, hyper and hypotensive disorders;
- diseases of the urinary tract;
- endocrinopathy;
- blood diseases;
- liver disease;
- lung disease;
- connective tissue diseases;
- acute and chronic infections;
- violation of hemostasis;
- alcoholism, drug addiction.
IV. Complications of pregnancy:
- vomiting of pregnant women;
- the threat of termination of pregnancy;
- bleeding in the first and second half of pregnancy;
- gestosis;
- polyhydramnios;
- lack of water;
- placental insufficiency;
- multiple pregnancy;
- anemia;
- Rh and AB0 isosensitization;
- exacerbation of a viral infection (genital herpes, cytomegaly, etc.).
- anatomically narrow pelvis;
- wrong position of the fetus;
- post-term pregnancy;
- induced pregnancy.
For a quantitative assessment of factors, a scoring system is used, making it possible not only to assess the probability of an unfavorable outcome of childbirth under the action of each factor, but also to obtain a total expression of the probability of all factors.
Based on the calculations of the assessment of each factor in points, the authors distinguish the following degrees of risk: low - up to 15 points; average - 15-25 points; high - more than 25 points. The most common mistake in calculating points is that the doctor does not summarize the indicators that seem insignificant to him.
The first point screening is carried out at the first visit of the pregnant woman to the antenatal clinic. The second - at 28–32 weeks, the third - before childbirth. After each screening, the pregnancy management plan is specified. The identification of a group of pregnant women with a high degree of risk makes it possible to organize intensive monitoring of the development of the fetus from the beginning of pregnancy.
From 36 weeks of pregnancy, women from the group of medium and high risk are re-examined by the head of the antenatal clinic and the head of the obstetric department, where the pregnant woman will be hospitalized before delivery.
This examination is an important point in the management of at-risk pregnant women. In areas where there are no maternity wards, pregnant women are hospitalized for preventive treatment in certain obstetric hospitals.
Since antenatal hospitalization for examination and comprehensive preparation for childbirth is mandatory for women at risk, the length of hospitalization, the estimated plan for the management of the last weeks of pregnancy and childbirth should be developed in conjunction with the head of the obstetric department. Antenatal hospitalization at the time determined jointly by the doctors of the consultation and the hospital is the last, but very important task of the antenatal clinic. Having timely hospitalized a pregnant woman from the middle or high risk groups, the antenatal clinic doctor can consider his function fulfilled.
A group of pregnant women at risk of perinatal pathology. It was found that 2/3 of all cases of PS occurs in women from the high-risk group, accounting for no more than 1/3 of the total number of pregnant women.
On the basis of literature data, own clinical experience, as well as the multifaceted development of birth histories in the study of PS, O. G. Frolova and E. N. Nikolaeva (1979) identified individual risk factors. These include only those factors that led to a higher level of PS in relation to this indicator in the entire group of surveyed pregnant women. The authors divide all risk factors into two large groups: prenatal (A) and intranatal (B).
Prenatal factors, in turn, are divided into 5 subgroups:
Socio-biological;
- obstetric gynecological history;
- extragenital pathology;
- complications of this pregnancy;
- assessment of the state of the intrauterine fetus.
Intranatal factors were also divided into 3 subgroups. These are factors from the outside:
Mothers;
- placenta and umbilical cord;
- the fetus.
Among the prenatal factors, 52 factors are distinguished, among the intranatal ones - 20. Thus, a total of 72 factors have been identified.
risk.
DAY STATIONARY
Day hospitals are organized at outpatient polyclinic institutions (women's consultation), maternity homes, gynecological departments of multidisciplinary hospitals in order to improve the quality of medical care pregnant and gynecological patients who do not require round-the-clock observation and treatment.
The hospital carries out continuity in the examination, treatment and rehabilitation of patients with others health care institutions: when the condition of sick women worsens, they are transferred to the appropriate departments hospitals.
· The recommended capacity of a day hospital is at least 5-10 beds. To ensure a full-fledged medical of the diagnostic process, the duration of the patient's stay in the day hospital should be at least 6-8 hours day.
The day hospital is managed by the chief physician (head) of the institution, on the basis of which this structural unit was organized.
The staff of the medical staff and the working hours of the day hospital of the antenatal clinic depend on the volume assistance provided. For each patient of the day hospital, a "Card of the patient of the day hospital polyclinics, home inpatient care, day care in the hospital ”.
Indications for the selection of pregnant women for hospitalization in a day hospital:
Vegetovascular dystonia and hypertension in the first and second trimesters of pregnancy;
- exacerbation of chronic gastritis;
- anemia (Hb not lower than 90 g / l);
- early toxicosis in the absence or presence of transient ketonuria;
- the threat of termination of pregnancy in the first and second trimesters in the absence of a history of habitual miscarriages and preserved cervix;
- critical periods of pregnancy with a history of miscarriage without clinical signs of threat of termination;
- medical genetic examination, including invasive methods (amniocentesis, chorionic biopsy, etc.) in pregnant women in the high perinatal risk group in the absence of signs of threatened abortion;
- non-drug therapy (acupuncture, psycho and hypnotherapy, etc.);
- Resuscitation in the I and II trimesters of pregnancy (for examination, conducting nonspecific desensitizing therapy);
- suspicion of PN;
- suspicion of heart disease, pathology of the urinary system, etc.;
- carrying out special therapy for alcoholism and drug addiction;
- upon discharge from the hospital after suturing the cervix for ICI;
- continuation of observation and treatment after a long stay in the hospital.
A high-risk pregnancy is one in which the risk of illness or death of the mother or newborn before or after childbirth is greater than usual. There are a number of risk factors for pregnancy.
To identify a high-risk pregnancy, a doctor examines a pregnant woman to determine if she has any medical conditions or symptoms that make her or the fetus more likely to get sick or die during pregnancy (risk factors). Risk factors can be assigned scores corresponding to the degree of risk. Identification of high-risk pregnancy is necessary only so that a woman who needs intensive medical care would receive it in a timely manner and in full.
A woman with a high-risk pregnancy may be referred to an antenatal (perinatal) care unit (the term “perinatal” refers to events that occur before, during, or after delivery). These units are usually associated with obstetric and neonatal intensive care units to provide the highest level of care for the pregnant woman and infant. The doctor often refers a woman to a perinatal observation center before childbirth, since early medical supervision very significantly reduces the likelihood of pathology or the death of the child. The woman is also sent to such a center during childbirth if unexpected complications arise. Generally, the most common reason for referral is a high likelihood of premature birth (before 37 weeks), which often occurs if the fluid-filled membranes containing the fetus rupture before it is ready for birth (i.e. a condition called premature rupture of the membranes occurs ). Treatment at a perinatal care center reduces the likelihood of preterm birth.
In Russia, maternal mortality occurs in 1 out of 2000 births. Its main causes are several diseases and disorders associated with pregnancy and childbirth: the ingress of blood clots into the vessels of the lungs, complications of anesthesia, bleeding, infections and complications arising from increased blood pressure.
In Russia, the perinatal mortality rate is 17%. Slightly more than half of these cases are stillbirths; in other cases, babies die in the first 28 days after birth. The main causes of these deaths are congenital malformations and prematurity.
Several risk factors are present even before a woman becomes pregnant. Others occur during pregnancy.
I. Risk factors before pregnancy
Before a woman becomes pregnant, she may already have some medical conditions and disorders that increase her risk during pregnancy. In addition, a woman who has had complications in a previous pregnancy is more likely to develop the same complications in subsequent pregnancies.
II. Maternal risk factors
The risk of pregnancy is influenced by the woman's age. Girls aged 15 and younger are more likely to develop preeclampsia (a condition during pregnancy in which blood pressure rises, protein appears in the urine, and fluid builds up in the tissues) and eclampsia (seizures that result from preeclampsia). They are also more likely to have a baby that is underweight or premature. Women aged 35 and older are more likely to have increased blood pressure, diabetes mellitus, fibroids (benign neoplasms) in the uterus, and the development of pathology during childbirth. The risk of having a baby with a chromosomal abnormality, such as Down's syndrome, increases significantly after age 35. If an older pregnant woman is concerned about the possibility of fetal abnormalities, chorionic villus sampling or amniocentesis may be done to determine the composition of the fetal chromosomes.
A woman who had a pre-pregnancy weight of less than 40 kg is more likely to have a baby that is lighter than expected according to gestational age (low body weight for gestational age). If a woman gains less than 6.5 kg in weight during pregnancy, then the risk of death of a newborn increases to almost 30%. Conversely, an obese woman is more likely to have a very large baby; obesity also increases the risk of diabetes and high blood pressure during pregnancy.
A woman less than 152 cm tall often has a smaller pelvis. She also has an increased likelihood of premature birth and low birth weight.
Complications during a previous pregnancy
If a woman has had three consecutive miscarriages (spontaneous abortion) in the first three months of previous pregnancies, then another miscarriage is possible with a 35% probability. Spontaneous abortion is also more likely in women who have previously delivered stillborn babies between the 4th and 8th months of pregnancy, or have had a preterm birth in previous pregnancies. Before attempting a new conception, a woman who has had a spontaneous abortion is recommended to undergo an examination to identify possible chromosomal or hormonal diseases, structural defects of the uterus or cervix, connective tissue diseases, such as systemic lupus erythematosus, or an immune response to the fetus - most often Rh incompatibility -factor. If the cause of the spontaneous abortion is established, it can be eliminated.
A stillbirth or death of a newborn may be due to chromosomal abnormalities in the fetus, diabetes, chronic kidney or blood vessel disease, high blood pressure, or a connective tissue disorder such as systemic lupus erythematosus in the mother or her drug use.
The more preterm the previous birth was, the greater the risk of preterm birth in subsequent pregnancies. If a woman has a baby weighing less than 1.3 kg, then the probability of a premature birth in the next pregnancy is 50%. If intrauterine fetal growth retardation has been noted, this complication may recur during the next pregnancy. The woman is examined to identify abnormalities that can lead to fetal growth retardation (for example, high blood pressure, kidney disease, overweight, infections); smoking and alcohol abuse can also lead to fetal malnutrition.
If a woman has a baby weighing more than 4.2 kg at birth, she may have diabetes. The likelihood of a spontaneous abortion or death of a woman or baby is increased if a woman suffers from such diabetes during pregnancy. Pregnant women are tested for its presence by measuring blood sugar (glucose) between the 20th and 28th weeks of pregnancy.
A woman who has had six or more pregnancies is more likely to have weakness in labor (contractions) during labor and bleeding after delivery due to weakening of the muscles in the uterus. Rapid labor is also possible, which increases the risk of severe uterine bleeding. In addition, such a pregnant woman is more likely to have placenta previa (the location of the placenta in the lower part of the uterus). This condition can cause bleeding and may be an indication for a caesarean section because the placenta often obstructs the cervix.
If a woman has a child with a hemolytic disease, then the next newborn has an increased likelihood of the same disease, and the severity of the disease in the previous child determines its severity in the next one. This disease develops when a pregnant woman with Rh-negative blood develops a fetus whose blood is Rh-positive (that is, there is an incompatibility with the Rh factor), and the mother develops antibodies against the blood of the fetus (sensitization to the Rh factor occurs); these antibodies destroy the fetal red blood cells. In such cases, the blood of both parents is tested. If a father has two genes for Rh-positive blood, then all his children will have Rh-positive blood; if he has only one such gene, then the probability of Rh-positive blood in the child is approximately 50%. This information helps doctors to properly care for the mother and baby in subsequent pregnancies. Usually, during the first pregnancy with a fetus with Rh-positive blood, no complications develop, but contact between the blood of the mother and the baby during childbirth causes the mother to develop antibodies against the Rh factor. As a result, there is a danger to subsequent newborns. If, however, Rh0- (D) -immunoglobulin is administered after the birth of a child with Rh-positive blood of a mother whose blood is Rh-negative, then the antibodies against Rh factor will be destroyed. Due to this, hemolytic diseases of newborns are rare.
A woman who has had preeclampsia or eclampsia is more likely to recur, especially if the woman has chronically high blood pressure.
If a woman has a child with a genetic disease or congenital defect, then a genetic examination of the child is usually carried out before the new pregnancy, and in the case of stillbirth, both parents. When a new pregnancy occurs, ultrasound (ultrasound), chorionic villus sampling and amniocentesis are done to look for abnormalities that are likely to recur.
Developmental defects
Defects in the development of a woman's genitals (for example, doubling of the uterus, weakness or insufficiency of the cervix that cannot hold the developing fetus) increases the risk of miscarriage. To detect these defects, diagnostic operations, ultrasound or X-ray examination are necessary; if a woman has had repeated spontaneous abortions, these studies are carried out even before the onset of a new pregnancy.
Fibroids (benign neoplasms) of the uterus, which are more common in older age, can increase the likelihood of premature birth, complications during childbirth, abnormal presentation of the fetus or placenta, and repeated miscarriages.
Diseases of a pregnant woman
Some diseases of a pregnant woman can be dangerous for both her and the fetus. The most important of these are chronic high blood pressure, kidney disease, diabetes mellitus, severe heart disease, sickle cell disease, thyroid disease, systemic lupus erythematosus, and blood coagulation disorders.
Diseases in family members
The presence of relatives with mental retardation or other hereditary diseases in the family of the mother or father increases the likelihood of such diseases in the newborn. The tendency to have twins is also common among members of the same family.
III. Risk factors during pregnancy
Even a healthy pregnant woman can be exposed to adverse factors that increase the likelihood of impairment to the fetus or her own health. For example, she may come into contact with teratogenic factors (exposures that cause birth defects) such as radiation, certain chemicals, drugs, and infections, or she may develop a disease or complication associated with pregnancy.
Exposure to drugs and infection
Substances that can cause congenital malformations of the fetus when taken by a woman during pregnancy include alcohol, phenytoin, drugs that counteract the effect of folic acid (lithium preparations, streptomycin, tetracycline, thalidomide). Infections that can lead to birth defects include herpes simplex, viral hepatitis, influenza, paratitis (mumps), rubella, chickenpox, syphilis, listeriosis, toxoplasmosis, Coxsackie and cytomegalovirus diseases. At the beginning of pregnancy, a woman is asked if she has taken any of these medications or if she has suffered any of these infectious inflammations after conception. Of particular concern is smoking, alcohol and drug use during pregnancy.
Smoking is one of the most common bad habits among pregnant women in Russia. Despite awareness of the health risks of smoking, the number of adult women who smoke themselves or live with smokers has declined slightly over the past 20 years, and the number of women who smoke has increased. Smoking among adolescent girls has become significantly more common and exceeds this figure among adolescent boys.
Although smoking harms both mother and fetus, only about 20% of women who smoke quit smoking during pregnancy. The most common consequence of maternal smoking during pregnancy for the fetus is its low birth weight: the more a woman smokes during pregnancy, the less the baby's weight will be. This effect is more pronounced among older women who smoke, who are more likely to have children with lower weight and height. Women who smoke are also more likely to have placental complications, premature rupture of membranes, premature birth and postpartum infections. A pregnant woman who does not smoke should avoid exposure to tobacco smoke when smoking in others, as it can similarly harm the fetus.
Congenital malformations of the heart, brain and face are more common in newborns born to pregnant smokers than to nonsmokers. Maternal smoking may increase the risk of sudden infant death syndrome. In addition, children of mothers who smoke have a small but noticeable lag in growth, intellectual development and the formation of behavior. These effects, according to experts, are caused by exposure to carbon monoxide, which reduces the delivery of oxygen to the tissues of the body, and nicotine, which stimulates the release of hormones that constrict the blood vessels of the placenta and uterus.
Alcohol consumption during pregnancy is the leading known cause of congenital malformations. Fetal alcohol syndrome, one of the main consequences of drinking during pregnancy, affects an average of 22 out of 1,000 live births. This condition includes stunted growth before or after birth, facial defects, a small head (microcephaly), probably associated with insufficient brain development, and impaired mental development. Mental retardation is a consequence of fetal alcohol syndrome more often than any other known cause. In addition, alcohol can cause other complications, from miscarriage to severe behavioral disorders in a newborn or developing child, such as antisocial behavior and inability to concentrate. These abnormalities can occur even when the newborn does not have any obvious physical birth defects.
The likelihood of a miscarriage almost doubles when a woman drinks any form of alcohol during pregnancy, especially if she drinks a lot. Often, birth weight is below normal in those newborns who were born to women who drank alcohol during pregnancy. Newborns whose mothers drank alcohol have an average birth weight of about 1.7 kg, compared with 3 kg for other newborns.
An increasing number of pregnant women are experiencing drug use and dependence. For example, in the United States, more than five million people, many of whom are women of childbearing age, regularly use marijuana or cocaine.
An inexpensive laboratory test called chromatography can be used to test a woman's urine for heroin, morphine, amphetamines, barbiturates, codeine, cocaine, marijuana, methadone, and phenothiazine. Injecting drug users, that is, drug addicts who use syringes for drug use, have a higher risk of developing anemia, infection of the blood (bacteremia) and heart valves (endocarditis), skin abscess, hepatitis, phlebitis, pneumonia, tetanus and sexually transmitted diseases (in including AIDS). Approximately 75% of newborns with AIDS had mothers who were injecting drug users or in prostitution. Other sexually transmitted diseases, hepatitis and other infections are more common in these newborns. They are also more likely to be born prematurely or have intrauterine growth retardation.
The main component of marijuana, tetrahydrocannabinol, can cross the placenta and affect the fetus. Although there is no definite evidence that marijuana causes birth defects or slows the growth of the fetus in the uterus, some studies show that using marijuana leads to abnormalities in the baby's behavior.
Cocaine use during pregnancy causes dangerous complications in both the mother and the fetus; many women who use cocaine also use other drugs, which aggravates the problem. Cocaine stimulates the central nervous system, acts as a local anesthetic (pain reliever), and constricts blood vessels. The narrowing of the blood vessels leads to a decrease in blood flow and the fetus does not receive enough oxygen.
Reduced delivery of blood and oxygen to the fetus can affect the development of various organs and usually leads to skeletal deformities and narrowing of some parts of the intestine. Diseases of the nervous system and behavioral disorders in children of those women who use cocaine include hyperactivity, uncontrollable tremors and significant learning difficulties; these violations can last for 5 years or even more.
If a pregnant woman suddenly has a large increase in
Some expectant mothers are at risk of pregnancy. This term scares many women, becomes the cause of their excitement, which is very contraindicated during the period of expectation of a child. Identification of high-risk pregnancy is necessary in order for a woman to receive the necessary medical care on time and in full. Let's consider what are the risk factors during pregnancy, and how doctors act in the case of such pathologies.
Who is at risk for pregnancy
High-risk pregnancies are characterized by an increased likelihood of fetal death, miscarriage, premature birth, intrauterine growth retardation, intrauterine or neonatal illness and other disorders.
Determining the risks during pregnancy is extremely important, as it allows you to start the necessary therapy in a timely manner or carefully monitor the course of pregnancy.
Who is at risk for pregnancy? Experts conditionally divide all risk factors into those that are present in a woman even before the moment of conception and those that arise already during pregnancy.
Risk factors that a woman has before pregnancy and can affect its course:
- Age under 15 and over 40... The expectant mother under 15 years of age has a high probability of preeclampsia and eclampsia - severe pathologies of pregnancy. They also often have premature or underweight babies. Women over 40 have a high risk of having a baby with a genetic disorder, most often Down syndrome. In addition, they often suffer from high blood pressure during gestation.
- Body weight less than 40 kg... Such expectant mothers have a chance of having a baby with a low weight.
- Obesity... Obese women are also at high risk of pregnancies. In addition to the fact that they are more likely than others to have high blood pressure and the development of diabetes mellitus, there is a high probability of having a baby with a large weight.
- Height less than 152 cm... These pregnant women often have a smaller pelvis, a high risk of premature birth and low birth weight.
- The risk during pregnancy exists in those women who have had multiple consecutive miscarriages, premature birth or stillbirth.
- A large number of pregnancies... Experts note that already the 6-7th pregnancies often have many complications, including placenta previa, weakness of labor, postpartum hemorrhage.
- Developmental defects of the genital organs(insufficiency or weakness of the cervix, doubling of the uterus) increase the risk of miscarriage.
- Diseases women often pose a danger to both her and the unborn child. Such diseases include: kidney disease, chronic hypertension, diabetes mellitus, thyroid disease, severe heart disease, systemic lupus erythematosus, sickle cell anemia, disorders of the blood coagulation system.
- Family member diseases... If there are people with mental retardation or other hereditary diseases in the family or among close relatives, the risk of having a baby with the same pathologies significantly increases.
Risk factors that arise already during pregnancy include the following conditions and diseases:
- Multiple pregnancy... About 40% of multiple pregnancies end in miscarriage or premature birth. In addition, expectant mothers carrying two or more babies are more prone to high blood pressure than others.
- Infectious diseases that have arisen during pregnancy. Rubella, viral hepatitis, infections of the genitourinary system, herpes are especially dangerous during this period.
- Alcohol abuse and nicotine. Probably, everyone already knows that these addictions can cause miscarriages, premature birth, intrauterine pathologies of the child, the birth of an infant prematurely or with low weight.
- Pregnancy pathologies... The most common are oligohydramnios and polyhydramnios, which can lead to premature termination of pregnancy and many of its complications.
Management of high risk pregnancies
If a woman has risks during pregnancy, there is a need for strict medical supervision. Usually, such expectant mothers are advised to visit the doctor at least once a week.
In addition, additional examinations are prescribed for pregnant women from this group, depending on the indications. The most commonly used are ultrasound, umbilical cord puncture, amnioscopy, determination of the level of GT21, determination of the content of alpha-fetoprotein, fetal endoscopy, Doppler apparatus, embryoscopy, trophoblast biopsy, pelvic x-ray.
Risk factors include maternal health disorders, physical and social characteristics, age, complications of previous pregnancies (eg, spontaneous abortion), complications of the current pregnancy, labor and delivery.
Arterial hypertension. Pregnant women suffer from chronic arterial hypertension (CAH) if they had arterial hypertension before pregnancy or developed before the 20th week of pregnancy. CAH should be differentiated from pregnancy-induced arterial hypertension occurring after the 20th week of gestation. Arterial hypertension is defined as systolic hypertension when blood pressure is more than 140 mm Hg. and diastolic with blood pressure more than 90 mm Hg. more than 24 hours. Arterial hypertension increases the risk of intrauterine growth retardation and decreases uteroplacental blood flow. CAH increases the risk of developing preeclampsia by up to 50%. Poorly managed hypertension increases the risk of placental abruption by 2 to 10%.
When planning a pregnancy, women with hypertension should be counseled based on all risk factors. If such women are pregnant, it is recommended to start prenatal training as early as possible. A study of renal function (measurement of serum creatinine and urea), ophthalmoscopic examination, as well as examination of the cardiovascular system (auscultation, ECG, echocardiography) are necessary. In each trimester of pregnancy, protein in daily urine, uric acid, serum creatinine and hematocrit are determined. To monitor fetal growth, ultrasonography is used at 28 weeks and then every few weeks. Fetal growth retardation is diagnosed using Doppler imaging by a prenatal diagnostician (to manage hypertension during pregnancy).
Assessment of risk factors in pregnancy
Pre-existing
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Cardiovascular and renal disorders |
Moderate to severe preeclampsia |
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Chronic arterial hypertension |
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Moderate, severe renal impairment |
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Severe heart failure (class II-IV, NYHA classification) |
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History of eclampsia |
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History of pyelitis |
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Moderate heart failure (class I, NYHA classification) |
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Moderate preeclampsia |
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Acute pyelonephritis |
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History of cystitis |
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Acute cystitis |
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History of preeclampsia |
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Metabolic disorders |
Insulin-dependent diabetes |
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Previous endocrine ablation |
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Thyroid disorders |
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Prediabetes (diet-controlled gestational diabetes) |
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Family history of diabetes |
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Obstetric history |
Exchange transfusion to the fetus in case of Rh incompatibility |
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Stillbirth |
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Post-term pregnancy (over 42 weeks) |
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Premature newborn |
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Newborn, small by gestational age |
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Pathological position of the fetus |
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Polyhydramnios |
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Multiple pregnancy |
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Stillborn |
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Cesarean section |
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Habitual abortion |
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Newborn> 4.5 kg |
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Birth parity> 5 |
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Epileptic seizure or cerebral palsy |
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Fetal malformations |
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Other violations |
Pathological results of cytological examination of the cervix |
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Sickle cell disease |
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Serum positive for STIs |
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Severe anemia (hemoglobin |
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History of tuberculosis or induration of the injection site with the introduction of a purified protein derivative> 10 mm |
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Moderate anemia (hemoglobin 9.0-10.9 g / dL) |
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Anatomical abnormalities |
Malformations of the uterus |
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Isthmic-cervical insufficiency |
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Narrow pelvis |
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Maternal characteristics |
Age 35 or |
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Body weight 91 kg |
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Emotional problems |
Prenatal factors
During childbirth
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Maternal factors |
Moderate to severe preeclampsia |
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Polyhydramnios (polyhydramnios) or oligohydramnios (oligohydramnios) |
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Amnionitis |
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Ruptured uterus |
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Pregnancy> 42 weeks |
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Moderate preeclampsia |
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Premature rupture of membranes> 12 h |
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Premature birth |
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Primary weakness of labor |
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Secondary weakness of labor |
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Meperidine> 300 mg |
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Magnesium sulfate> 25 g |
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Second stage of labor> 2.5 h |
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Clinically narrow pelvis |
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Medical induction of labor |
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Rapid childbirth ( |
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Primary caesarean section |
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Repeated caesarean section |
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Selective induction of labor |
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Prolonged latent phase |
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Thetanus of the uterus |
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Oxytocin overdose |
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| Placental factors | Central placenta previa | |
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Placental abruption |
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Regional presentation of the placenta |
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Fetal factors |
Abnormal presentation (pelvic, frontal, facial) or transverse position |
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Multiple pregnancy |
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Fetal bradycardia> 30 min |
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Breech delivery, pelvic end extraction |
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Prolapsed umbilical cord |
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Fruit weight |
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Fetal acidosis |
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Fetal tachycardia> 30 min |
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Amniotic fluid stained with meconium (dark) |
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Amniotic fluid stained with meconium (light) |
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Operative delivery using forceps or vacuum extractor |
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Breech delivery, spontaneous or aided delivery |
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General anesthesia |
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Weekend Obstetric Forceps |
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Hanger dystocia |
1 10 or more points indicate a high risk.
NYHA - New York Heart Association; STIs are sexually transmitted infections.
Diabetes. Diabetes mellitus occurs in 3-5% of pregnancies, its influence on the course of pregnancy increases with increasing weight of patients. In pregnant women with preexisting insulin-dependent diabetes, the risk of pyelonephritis, ketoacidosis, pregnancy-related hypertension, intrauterine death, malformations, fetal macrosomia (weight> 4.5 kg) increases, and, if vasculopathy is present, fetal growth retardation is noted. Insulin requirements usually increase during pregnancy.
Women with gestational diabetes are at risk for hypertensive disorders and fetal macrosomia. Screening for gestational diabetes is usually done between the 24th and 28th weeks of pregnancy or, in women with risk factors, during the 1st trimester of pregnancy. Risk factors include prior gestational diabetes, neonatal macrosomia in a previous pregnancy, family history of non-insulin dependent diabetes, unexplained fetal loss, and a body mass index (BMI) greater than 30 kg / m 2. A glucose tolerance test is applied using 50 g of sugar. If the result is 140-200 mg / dl, then the glucose determination is performed after 2 hours; if the glucose level is more than 200 mg / dl or the results are abnormal, then women are treated with diet and, if necessary, with insulin.
Good blood glucose control during pregnancy minimizes the risk of adverse outcomes associated with diabetes (diabetes management during pregnancy).
Sexually transmitted infections... Intrauterine syphilis infection can cause intrauterine fetal death, congenital malformations, and disability. The risk of transmission of HIV infection from mother to fetus in utero or perinatally is 30-50% within 6 months. Bacterial vaginosis, gonorrhea, urogenital chlamydia during pregnancy increase the risk of premature birth and premature rupture of the membranes. Routine prenatal diagnosis includes screening tests to detect latent forms of these diseases at the first prenatal visit.
Testing for syphilis is repeated during pregnancy if there is a risk of infection during delivery. All pregnant women with these infections are treated with antimicrobial drugs.
Treating bacterial vaginosis, gonorrhea, and chlamydia can prevent premature rupture of the membranes during labor and reduce the risk of intrauterine infection in the fetus. Treatment of HIV infection with zidovudine or nevirapine reduces the risk of transmission by 2/3; the risk is much lower (
Pyelonephritis... Pyelonephritis increases the risk of premature rupture of membranes, premature birth, and fetal respiratory distress syndrome. Pregnant women with pyelonephritis are hospitalized for diagnosis and treatment. First of all, a bacteriological study of urine with culture for antibiotic sensitivity is carried out.
Intravenous antibiotics are used (for example, cephalosporins of the third generation in combination with or without aminoglycosides), antipyretics and drugs to correct hydration. Pyelonephritis is the most common non-obstetric cause of hospitalization during pregnancy.
Prescribe specific antibiotics for oral administration, taking into account the pathogenic agent within 24-48 hours after the cessation of the fever, and also carry out a full course of antibiotic therapy for 7-10 days. Prophylactic antibiotics (eg, nitrofurantoin, trimethoprim-sulfamethoxazole) are given during the remainder of pregnancy with periodic urine culture.
Acute surgical diseases... Major surgical interventions, especially intra-abdominal ones, increase the risk of premature birth and intrauterine fetal death. During pregnancy, physiological changes occur that make it difficult to diagnose acute surgical diseases requiring urgent surgical intervention (for example, appendicitis, cholecystitis, intestinal obstruction), and thus worsen the results of treatment. After the operation, antibiotics and tocolytics are prescribed for 12-24 hours. If planned surgical treatment is necessary during pregnancy, it is better to perform it in the 2nd trimester.
Reproductive system pathology... Malformations of the uterus and cervix (for example, a septum in the uterine cavity, a bicornuate uterus) lead to abnormalities in the development of the fetus, pathological childbirth and increase the frequency of caesarean section. Fibroid tumors of the uterus can be the cause of pathology of the placenta, growth may increase or degeneration of nodes may occur during pregnancy; degeneration of the nodes leads to severe pain and peritoneal symptoms. Isthmic-cervical insufficiency often leads to premature birth. In women who have had myomectomy, spontaneous uterine rupture may occur during vaginal delivery. Uterine defects requiring surgical correction, which cannot be performed during pregnancy, worsen the prognosis of the course of pregnancy and childbirth.
Mother's age... Adolescents, in whom pregnancy occurs in 13% of cases, neglect prenatal preparation. As a result, the incidence of preeclampsia, premature birth and anemia increases, which often lead to intrauterine growth retardation.
In women over 35 years of age, the incidence of preeclampsia increases, especially against the background of gestational diabetes mellitus, the incidence of abnormalities in uterine contractile activity during childbirth, placental abruption, stillbirth and placenta previa increases. These women also have the most common pre-existing disorders (eg, chronic hypertension, diabetes). Genetic testing is necessary, since the risk of chromosomal abnormalities in the fetus increases with increasing maternal age.
Mother's body weight... Pregnant women with a BMI of less than 19.8 (kg / m2) before pregnancy are considered underweight women, which predispose to the birth of a low birth weight baby (
Pregnant women with a BMI of more than 29.0 (kg / m) before pregnancy are considered overweight patients, which leads to arterial hypertension, diabetes, post-term pregnancy, fetal macrosomia and increases the risk of caesarean section. These women are advised to limit their weight gain to 7 kg during pregnancy.
Influence of teratogenic factors... Teratogenic factors (agents that lead to fetal malformations) include infections, drugs, and physical agents. Malformations most often form between the 2nd and 8th weeks after conception (4-10 weeks after the last menstruation), when the organs are laid. Other unfavorable factors are also possible. Pregnant women who have been exposed to teratogenic factors, as well as those with increased risk factors, should be carefully examined using ultrasound in order to identify malformations.
Teratogenic infections include: herpes simplex, viral hepatitis, rubella, chickenpox, syphilis, toxoplasmosis, cytomegalovirus and Coxsackie virus. Teratogenic substances include alcohol, tobacco, some anticonvulsants, antibiotics, and antihypertensive drugs.
Smoking is the most common addiction among pregnant women. The percentage of women who smoke moderately and significantly is increasing. Only 20% of women who smoke quit smoking during pregnancy. Carbon monoxide and nicotine present in cigarettes lead to hypoxia and vasoconstriction, increasing the risk of spontaneous abortion (miscarriage or delivery in less than 20 weeks), lead to intrauterine growth retardation (birth weight is on average 170 g less than that of neonates whose mothers do not smoke), placental abruption, placenta previa, premature rupture of membranes, premature birth, chorioamnionitis and stillbirth. Newborns whose mothers smoke are more likely to have anencephaly, congenital heart defects, cleft maxilla, physical and intellectual retardation, and behavioral disorders. Sudden death of an infant during sleep is also noted. Limiting or stopping smoking reduces the risk of teratogenic effects.
Alcohol is the most common teratogenic factor. Drinking alcohol during pregnancy increases the risk of spontaneous abortion. The risk depends on the amount of alcohol consumed; any amount is dangerous. Regular alcohol intake reduces the birth weight of the baby by about 1-1.3 kg. Even drinking as much alcohol as 45 ml of alcohol per day (equivalent to about 3 servings) can cause fetal alcohol syndrome. This syndrome occurs in 2.2 per 1000 live births and includes intrauterine growth retardation, facial and cardiovascular defects, and neurological dysfunction. Fetal alcohol syndrome is the main cause of mental retardation and can cause death in a newborn.
Cocaine use also carries indirect risks (for example, maternal stroke or death in pregnancy). Cocaine use can also lead to vasoconstriction and fetal hypoxia. Cocaine use increases the risk of spontaneous abortion, intrauterine growth retardation, placental abruption, premature birth, stillbirth, and congenital malformations (eg, CNS, urinary tract, skeletal malformations, and isolated atresia).
Although the main metabolite of marijuana crosses the placenta, occasional use of marijuana does not increase the risk of birth defects, intrauterine growth retardation, or postnatal neurological disorders.
Prior stillbirth... Stillbirth (intrauterine fetal death> 20 weeks) can be maternal, placental, or fetal factors. A history of stillbirth increases the risk of intrauterine fetal death in subsequent pregnancies. It is recommended to monitor the development of the fetus and assess its viability (non-stress tests and the biophysical profile of the fetus are used). Treatment of maternal disorders (eg, chronic hypertension, diabetes, infection) can reduce the risk of stillbirth in the current pregnancy.
Prior premature birth... A history of preterm birth increases the risk of preterm birth in subsequent pregnancies; if in previous preterm birth the body weight of the newborn was less than 1.5 kg, then the risk of preterm birth in subsequent pregnancy is 50%. Causes of premature birth include multiple pregnancies, preeclampsia or eclampsia, abnormalities in the placenta, premature rupture of membranes (the result of an ascending uterine infection), pyelonephritis, certain vector-borne sexual diseases, and spontaneous uterine activity. Women with a previous preterm birth need ultrasound examination with measurement of the length of the cervix, monitoring should be carried out at 16-18 weeks to diagnose pregnancy-induced hypertension. If the symptoms of threatening premature birth progress, it is necessary to monitor the contractility of the uterus, tests for bacterial vaginosis; the definition of fetal fibronectin can identify women who need closer medical supervision.
Previous birth of a newborn with genetic or birth defects. The risk of having a fetus with a chromosomal abnormality is increased for most couples who have had a fetus or newborn with a chromosomal abnormality (diagnosed or undiagnosed) in previous pregnancies. The risk of recurrence for most genetic disorders is unknown.
Most congenital malformations are multifactorial; the risk of developing a subsequent fetus with a genetic disorder is 1 % or less. If couples in previous pregnancies had a newborn with genetic or chromosomal disorders, then genetic screening is indicated for such couples. If couples have had a newborn with a congenital malformation, then high-resolution ultrasonography and examination by a prenatal specialist are necessary.
Polyhydramnios (polyhydramnios) and oligohydramnios... Polyhydramnios (excess amniotic fluid) can lead to severe shortness of breath in the mother and premature birth. Risk factors include uncontrolled maternal diabetes, multiple pregnancies, isoimmunization, and fetal malformations (eg, esophageal atresia, anencephaly, spina bifida). Low water (amniotic fluid deficiency) often accompanies congenital malformations of the urinary tract in the fetus and severe intrauterine growth retardation.
Pregnancy in patients with Potter's syndrome in a fetus with pulmonary hypoplasia or superficial compression disorders can be interrupted (more often in the 2nd trimester of pregnancy) or end in intrauterine fetal death.
Polyhydramnios or oligohydramnios may be suspected in cases where the size of the uterus does not correspond to the gestational date or is discovered by chance on diagnostic ultrasonography.
Multiple pregnancy... Multiple pregnancies increase the risk of intrauterine growth retardation, premature birth, placental abruption, congenital malformations of the fetus, perinatal morbidity and mortality, uterine atony, and postpartum hemorrhage. Multiple pregnancies are detected by routine ultrasonography at 18-20 weeks of gestation.
Prior birth injury... Injury to the newborn during childbirth (eg, cerebral palsy, developmental delay or trauma from forceps or vacuum extractors, shoulder dystocia with Erbe-Duchenne palsy) does not increase the risk in subsequent pregnancies. However, these factors must be assessed and avoided in the subsequent delivery.
The risk strategy in obstetrics provides for the identification of groups of women in whom pregnancy and childbirth may be complicated by fetal disruption, obstetric or extragenital pathology. Pregnant women who are registered with antenatal clinics can be attributed to the following risk groups:
With perinatal pathology
With obstetric pathology
With extragenital pathology.
At 32 and 38 weeks of pregnancy, point screening is performed, since new risk factors appear during these periods. Recent research data indicate that by the end of pregnancy there is an increase in the number of pregnant women with a high degree of perinatal risk (from 20 to 70%). After re-determining the degree of risk, the pregnancy management plan is specified.
From 36 weeks of pregnancy, women from the group of medium and high risk are re-examined by the head of the antenatal clinic and the head of the obstetric department, where the pregnant woman will be hospitalized before delivery. This examination is an important point in the management of at-risk pregnant women. In those areas where there are no maternity wards, pregnant women are hospitalized according to the schedules of regional and city health departments for preventive treatment in certain obstetric hospitals. Since antenatal hospitalization for examination and comprehensive preparation for childbirth is mandatory for women at risk, the length of hospitalization, the estimated plan for the management of the last weeks of pregnancy and childbirth should be worked out in conjunction with the head of the obstetric department.
Antenatal hospitalization at the time determined jointly by the doctors of the consultation and the hospital is the last, but very important task of the antenatal clinic. Having timely hospitalized a pregnant woman from medium and high risk groups, the antenatal clinic doctor can consider his function fulfilled.
A group of pregnant women at risk of perinatal pathology. It was found that 2/3 of all cases of perinatal mortality occurs in women from the high-risk group, accounting for no more than 1/3 of the total number of pregnant women. Based on the literature data, his own clinical experience, as well as the multifaceted development of birth histories in the study of perinatal mortality, O.G. Frolova and E.N. Nikolaeva (1979) identified individual risk factors. These include only those factors that led to a higher level of perinatal mortality in relation to this indicator in the entire group of surveyed pregnant women. The authors divide all risk factors into two large groups: prenatal (A) and intranatal (B).
9.2. Prenatal factors:
Socio-biological:
Mother's age (under 18, over 35)
Father's age (over 40)
Occupational hazards for parents
Tobacco smoking, alcoholism, drug addiction
Mass growth indicators (growth less than 153 cm, weight 25% higher or lower than normal).
Obstetric and gynecological history:
Number of births 4 or more
Repeated or complicated abortions
Surgical interventions on the uterus or appendages
Malformations of the uterus
Infertility
Miscarriage
Non-developing pregnancy
Premature birth
Stillbirth
Death in the neonatal period
The birth of children with genetic diseases, developmental abnormalities
Low or high birth weight babies
Complicated course of a previous pregnancy
Bacterial and viral gynecological diseases (genital herpes, chlamydia, cytomegalovirus, syphilis, gonorrhea, etc.)
Extragenital pathology:
Diseases of the urinary system
Endocrinopathy
Diseases of the blood
Liver disease
Diseases of the lungs
Connective tissue diseases
Acute and chronic infections
Violation of hemostasis
Alcoholism, drug addiction.
Complications of a real pregnancy:
Vomiting of a pregnant woman
The threat of termination of pregnancy
Bleeding in the I and II half of pregnancy
Polyhydramnios
Malnutrition
Plurality
Placental insufficiency
Rh and ABO isosensitization
Exacerbation of viral infection
Anatomically narrow pelvis
Wrong fetal position
Postterm pregnancy
Induced pregnancy
Assessment of the state of the intrauterine fetus.
The total number of prenatal factors was 52.