WHO recommendations for the management of pregnancy. Algorithm for diagnosing pregnancy on an outpatient basis. Identification of a risk group. Benefits of contacting EMC
The antenatal surveillance system in Europe was formed at the beginning of the 20th century. Its main goal was to reduce the high level of maternal mortality. And this was very logical, because a pregnant woman is under the supervision of a specialist for a much longer time than during childbirth, which means that there are more opportunities for the prevention of various complications of pregnancy. But these expectations were not fully justified. Antenatal care affects maternal mortality from only one cause - eclampsia. Ineffective turned out to be: the distribution of women by risk groups (based on formal scoring for each trimester), strict control of the weight of the pregnant woman (weighing at each appointment), routine pelviometry, etc. Some activities turned out to be very expensive and did not bring the expected results, for example, routine prescription iron preparations to reduce the amount of anemia during pregnancy and after childbirth + routine examination for STIs. Effective turned out to be: the development of clinical protocols for the management of obstetric complications, counseling of pregnant women and their families about urgent situations, distribution of flows to provide assistance to the most trained personnel in the most acceptable conditions (regionalization of care).
Despite this, in our country, more and more often, the process of bearing a child turns into an endless series of visits to antenatal clinics, repeated visits to narrow specialists during pregnancy, multiple tests and repeated passage of certain types of research. At the same time, even such an enhanced version of antenatal care does not have an effect on the result, that is, the preservation of the health of the mother and child, or has a very small degree. Studies initiated by WHO in 4 countries with different systems of care for pregnant women (including Cuba, whose medicine is very similar to Russian) and which included more than 50 thousand participants, have shown that in order to reduce the number of complications from the mother and 4 antenatal visits are sufficient for the fetus. In addition, the advisability of observing women with uncomplicated pregnancies with an obstetrician-gynecologist is also questioned after the results of several RCTs. With a constant lack of time, the specialist is faced with a difficult choice: to devote less time to patients with normal pregnancies in order to concentrate on helping women with complications, or to spend most of his time observing the physiological process, but quickly losing his qualifications. At the same time, midwives and general practitioners are initially focused on providing care for normal pregnancies, which is likely to better meet the needs of women and their families. In most developed countries, where midwives provide most of the birth care, rates of maternal, perinatal and early childhood morbidity and mortality are the lowest.
Of course, 4 visits during pregnancy are unlikely to suit most women. Four visits is the minimum that ensures quality, that is, good results at a minimum cost. But 7-10 visits to antenatal clinics should change, first of all, qualitatively. The main tasks of the personnel providing assistance during the antenatal period should be the maximum possible psychological support for the family and high-quality counseling on all issues of interest, above all, to the woman herself. In addition, preparation for childbirth, feeding and caring for a child is important. This protocol is a modern perspective on antenatal care, an attempt to redefine the attitude of medical professionals to many routine procedures that have no evidence of their effectiveness, and planning observation and education, taking into account the interests of the consumer, that is, the pregnant woman and her family.
Developed within the framework of the "Mother and Child" project. Here you can get up-to-date information on the management of pregnancy (many standard procedures turned out to be, in fact, ineffective), as well as a new view of medical science on the "pregnant" way of life.
High-risk pregnancy is a pregnancy that is likely to require further intervention or has already required the intervention of specialists. Therefore, all other pregnancies are proposed to be classified as low risk pregnancies, normal or uncomplicated pregnancies.
All pregnant women should have access to antenatal care and the right to choose an institution and a healthcare professional providing care.
All pregnant women should receive full information in a language understandable to them about the goals and possible results of any screening tests, any types of treatment and drugs prescribed during pregnancy, including for prophylactic purposes.
All pregnant women have the right to refuse any research at all or postpone it for a while. The indications for their appointment must be absolutely clear to patients.
Pregnancy can be managed by an obstetrician-gynecologist or a trained midwife(1b)in a municipal women's clinic or a medical institution of any other form of ownership, which has an appropriate license for this.
The number and frequency of visits is determined by the needs of the woman herself or the course of a real pregnancy.(2a), but not less than 4 (1b)... The length of each visit is also determined by the wishes of the patient; at the same time, the duration of the first visit, as well as the attendance devoted to the discussion of the survey results, must obviously be longer than the usual, regular ones.
Risk assessment
The distribution of pregnant women into low and high risk groups is necessary to provide timely and adequate care, especially to women who are included in the high risk group. It cannot be said about any pregnancy that there is no likelihood of certain complications. There is always the possibility of a process changing for the worse. However, pregnancy should not be viewed pessimistically. Pregnancy should always be treated as normal (physiological) from the outset, but healthcare providers should be vigilant for signs of existing or impending danger. Thus, at present, the main principles of perinatal care should be:
attentive attitude to all women;
individual care protocols;
reassessment of the condition of the mother and fetus at each visit.
A formalized assessment of the degree of perinatal risk based on scoring (especially the summation of these points by trimester) for certain risk factors should no longer be used, since it too often leads to unnecessary interventions without altering perinatal outcomes.
Instead, it is suggested to gofrom risk-oriented to problem-oriented help.
Lifestyle
Work during pregnancy
there is no reason to recommend stopping work in case of uncomplicated pregnancy(3b), but it is necessary to exclude heavy physical activity, for example, carrying heavy loads, and contact with aggressive liquids and gases;
at the first visit, it is necessary to provide all available legal information about benefits, rights, benefits for all pregnant women, both with a permanent job and housewives, and their families(4) ;
it is necessary to explain the meaning and components of the generic certificate, the timing of its issuance;
when confirming pregnancy, issue a certificate to be provided at the place of work or study to change the work schedule or its nature - excluding night or long shifts, transferring to light work;
during the observation, discuss in advance the issues of issuing sick leave, terms, conditions.
Physical education and sports
there is no reason to restrict physical education and sports during an uncomplicated pregnancy(1b);
it is necessary to warn a pregnant woman about the potential dangers of certain sports, for example, all types of martial arts, skiing, parachuting, motor sports, diving, etc., as they pose a high risk of abdominal injury and can cause
damage to the fetus.
Sex life
there is no reason to restrict sexual life in the physiological course of pregnancy(3a).
Smoking
information should be provided on the relationship between smoking during pregnancy and the risk of having a small baby and premature birth(1a);
organize work to stop, or at least reduce the amount of cigarettes consumed, which may include individual counseling or group sessions, distribution of special literature or films.
A government policy is needed to promote the harm of smoking. The greatest success is brought by special programs to reduce the prevalence of smoking. Pregnant physicians and midwives should be the most active participants in this policy.
Alcohol
the negative effect of alcohol on the fetus in an amount exceeding 1 standard dose has been proven (15 ml of pure alcohol per day, or up to 30 ml of spirits, or a small glass of unfortified wine, or about 300 ml of light beer);
the patient must be convinced to stop drinking alcohol completely during pregnancy or to take no more than 1 standard dose of alcohol once or twice a week.
Drugs
the negative effect of any drug on the fetus has been proven;
it is necessary to convince the patient to completely stop taking drugs;
offer specialized medical care.
Pregnant women who smoke, use drugs or alcohol should be the most closely watched by antenatal care professionals. It is necessary to use all available resources to help this category of patients.
Airtrips
it is necessary to advise that long flights are dangerous for the development of venous thrombosis, for the prevention of which it is recommended to use compression stockings or bandages during the flight(3a);
no other effects on pregnancy were noted;
most air carrier companies have restrictions depending on the gestational age (most often they are not allowed to fly after 34-36 weeks).
Travel by car
it is necessary to remind of the mandatory use of seat belts, and the belt itself should be located below or above the abdomen (ideally, special devices with two belts should be used)(3a).
Tourist travel
it is necessary to remind pregnant women of the importance of purchasing appropriate insurance when traveling abroad and having a compulsory medical insurance policy for all trips in Russia;
offer advice before planning your trip with your specialist, midwife, or pregnancy care provider.
Nutrition of a pregnant woman
Pregnancy does not require dietary changes
Healthy eating principles
it is necessary to eat a variety of foods, most of which should be of plant, not animal origin;
bread, flour products, cereals, potatoes should be eaten several times a day;
eat vegetables and fruits several times a day, preferably fresh and grown in the area of residence;
control the intake of fat from food (no more than 30% of the daily calorie content);
replace animal fat with vegetable;
replace fatty meats and meat products with legumes, grains, fish, poultry and lean meats;
consume milk and dairy products (kefir, yogurt, yogurt, cheese) with a low fat content;
Choose foods that are low in sugar and consume sugar in moderation, limiting the amount of sugar and sugary drinks;
avoid excessive salt intake, but you do not need to limit the amount of salt. On the one hand, the total amount of salt in food should not exceed one teaspoon (6 g per day), on the other hand, the level of salt intake should be considered as a matter of individual preference. It is advisable, especially in iodine-deficient regions, to use iodized salt;
food preparation must be safe. Steaming, microwave, baking, or boiling will help reduce the amount of fat, oil, salt and sugar used in the cooking process.
Vitamins and minerals
The addition of artificial vitamins to the diet during pregnancy is extremely rare. Only with extremely inappropriate nutrition, as well as in regions where the population is starving, has the use of vitamins turned out to be effective.
the routine use of folic acid at a dose of 400 mcg daily before conception and in the first 12 weeks of pregnancy significantly reduces the risk of developing neural tube defects in the fetus (anencephaly, spina bifida); folic acid intake should be recommended to all women(1a);
there is no rationale for routine use of folate to prevent anemia;
iron supplementation is not indicated routinely due to lack of effect on perinatal outcomes. Iron supplements reduce the incidence of anemia with Hb levels< 100 г/л к моменту родов, но часто вызывают побочные эффекты: раздражение желудка, запор или диарею (1a);
a daily dose of more than 700 mcg of vitamin A may have teratogenic effects, so routine vitamin A supplementation should be avoided(4) ... In addition, the pregnant woman should have information about products containing an increased concentration of vitamin A, for example, liver or products from it;
additional administration of iodine is indicated in regions with a high incidence of endemic cretinism.
Herbs, herbal tinctures and infusions are also medications and should not be taken without a doctor's prescription. The safety of such drugs both for the unborn child and for the health of the pregnant woman herself is unknown.
Medications
It is advisable to exclude the use of any drugs during pregnancy, except in cases dangerous to the life and health of the patient.
any doctor, prescribing treatment for a woman of reproductive age, should think about a possible pregnancy;
practically none of the drugs can be classified as teratogenic or non-teratogenic without analyzing dosage, duration of use, gestational age;
very few drugs have been tested for the safety of their use during pregnancy, that is, they can be considered completely safe;
the most dangerous periods for the effect of drugs on the fetus are 15-56 days after conception, with the exception of antihypertensive drugs from the group of angiotensin-converting enzyme inhibitors (for example, kapoten, hopten, renitek) and AT II receptor antagonists
(for example, losartan, eprosartan), the use of which in the II and III trimesters can lead to oligohydramnios due to impaired development and functioning of the fetal kidneys;
it is advisable to prescribe already proven drugs during pregnancy, try to exclude the use of new ones that have just appeared on the pharmaceutical market;
it is desirable to use the minimum effective doses in the shortest possible time;
in the presence of chronic extragenital diseases in a pregnant woman, treatment (choice of drug, dose, frequency of administration, duration of the course) should be prescribed in conjunction with the relevant narrow specialist.
Medical professionals must clearly understand the physical and psychological changes in the body of the future parents and the stages of development of the fetus in order to provide the correct information and advice when necessary (see appendices).
Discomfort during pregnancy
Pregnancy is not a disease. Of course, while agreeing with this statement, nevertheless, it must be admitted that there are quite a few symptoms that in another situation, in a non-pregnant woman, could be mistaken for a manifestation of the disease. By themselves, these conditions are not dangerous for the normal development of the fetus and do not lead to any complications, but the discomfort that a pregnant woman experiences affects, sometimes significantly, her performance, mood, and general perception of pregnancy. Reducing the impact of these symptoms is
an important part of antenatal care. The medical professional should not be limited to phrases: "This is all the norm, do not worry!" or “It poses no danger to your child,” etc. Only well-conducted counseling, possibly repeated, can truly help the patient.
Nausea and vomiting, except in cases of excessive vomiting of pregnant women (ICD-X-O21)
the reason is unknown;
most often manifests itself in multiple pregnancies;
nausea occurs in 80-85% of all pregnancies, vomiting - up to 52%;
severe cases - excessive vomiting, leading to dehydration and electrolyte disturbances - occur no more than 3-4 cases per 1000 pregnancies and require hospital treatment;
34% of women note the appearance of unpleasant symptoms within the first 4 weeks after the last menstruation, 85% - within 8 weeks;
about 90% of pregnant women notice a decrease in symptoms by 16-20 weeks of pregnancy;
the rest report nausea later in the morning;
has no effect on pregnancy outcomes, fetal development(1b), but can significantly affect the patient's quality of life.
Tips for women:
Eat a few dry crackers or a slice of bread early in the morning.
eat more often and in small portions.
Treatment:
non-pharmacological:
- ginger in the form of powders or syrup, 250 mg 4 times a day - reducing the severity of nausea and vomiting after 4 days of administration;
- acupressure of the Neiguan point (about 3 transverse fingers above the wrist);
pharmacological:
– antihistamines - promethazine (diprazine, pipolfen). It is necessary to warn the patient about possible drowsiness as a side effect;
– metoclopramide (cerucal), due to unknown safety, cannot be recommended as a first-line drug and can be prescribed in especially severe cases;
– there is evidence of the effectiveness of vitamin B, but its toxicity is not clear, so at the moment it cannot be recommended for use;
– there is evidence of the effectiveness of vitamin B 12 , but the safety of its use has not been proven.
Heartburn
the pathogenesis is not clear, possibly associated with a hormonal status that alters the activity of the stomach, causing gastroesophageal reflux;
the frequency depends on the gestational period: in the first trimester it occurs up to 22%, in the second - 39%, in the third - up to 72%;
does not have any effect on pregnancy outcomes, fetal development, but may affect the patient's quality of life.
Tips for women:
eat more often and in small portions;
avoid spicy and fatty foods;
avoid drinking coffee and soda containing caffeine;
do not lie down or bend over after eating;
while sleeping, your head should be on a high pillow;
for heartburn, drink milk or kefir, or eat yogurt.
Treatment:
antacids can be used in cases where heartburn continues to bother you despite lifestyle and dietary changes(2a).
Constipation
may be associated with a decrease in the consumption of food rich in fiber, as well as with the effect of progesterone on the activity of the stomach and, as a consequence, an increase in the duration of evacuation of food from it;
the frequency decreases with an increase in the gestational period: at 14 weeks - 39%, at 28 weeks - 30%, at 36 weeks - 20%.
Tips for women:
drink at least 8 glasses of water and other liquids per day;
eat foods rich in dietary fiber, such as green vegetables and bran cereals (wheat and bran reduce constipation by 5 times).
Treatment:
in cases where the use of physiological methods does not help, the appointment of laxatives is justified, which increase the volume of fluid in the intestine (seaweed, flaxseed, agar-agar) and stimulate peristalsis (lactulose), as well as soften the consistency of the stool (sodium docusate). Their safety has been proven with prolonged use during pregnancy and lactation;
if these groups of laxatives do not lead to an improvement in the condition in short periods of time, the appointment of irritating laxatives (bisacodyl, senna preparations) is indicated;
saline laxatives and lubricants (mineral oils) should not be used during pregnancy.
Haemorrhoids
8-10% of pregnant women present characteristic complaints in the third trimester;
the occurrence is facilitated by both pregnancy itself and a decrease in the diet of rough food.
Tips for women:
changes in diet - an increase in the proportion of rough, fibrous foods;
while maintaining clinical symptoms, it is possible to use conventional antihemorrhoidal creams;
surgical treatment during pregnancy is rarely used.
Phlebeurysm
Tips for women:
Tell women that this is a common symptom that is harmless, apart from aesthetic problems, general discomfort, and sometimes itching.
compression elastic stockings can reduce leg swelling, but are not prevention of varicose veins(2a).
Back pain
the prevalence is high - from 35 to 61% of pregnant women complain of pain in the lower back;
47-60% of patients reported the first symptoms in the period from the 5th to the 7th month of pregnancy;
for most, the intensity of pain increases in the evening;
pain associated with changes in the posture of pregnant women, the weight of the pregnant uterus and
relaxation of the supporting muscles as a result of the action of relaxin;
are not a sign of a painful condition, for example, a symptom of the threat of termination of pregnancy, but significantly affect the activity of a pregnant woman in the daytime and the impossibility of a full night's rest.
Tips for women:
wear shoes without heels;
avoid lifting heavy weights; if you have to lift weights, bend your knees, not your back;
water exercises, massage, individual or group sessions in special groups may be helpful.
Leg cramps
the reasons are not clear;
disturb almost 50% of pregnant women, more often at night in the last weeks of pregnancy;
are not signs of any disease, but cause significant concern in women;
there is no reason to prescribe Mg, Na, Ca preparations, since there is no evidence of their effectiveness;
massage and stretching exercises are advisable during seizures.
Vaginal discharge
the quantity and quality of vaginal discharge during pregnancy changes, more often women pay attention to an increase in the amount of discharge, which in most cases is not a sign of the disease;
complaints of an unpleasant odor, itching, soreness may be symptoms of bacterial vaginosis, Trichomonas vaginitis or thrush (candidal colpitis);
sometimes these same signs are associated with physiological or pathological conditions, such as dermatosis of the vulva and allergic reactions;
vaginal candidiasis does not affect pregnancy, there is no connection with fetal diseases, therefore, screening and active identification of sick women does not make any sense;
however, when complaints appear, the best treatment is to prescribe imidazoles: miconazole (Ginesol 7, Gino-dactarin, Klion-D 100) or clotrimazole (Antifungol, Yenamazole 100, Kanesten, Kanizon, Clotrimazole) for a week course;
the safety and efficacy of oral therapy for vaginal candidiasis is not known, so this group of drugs should not be prescribed.
Tips for women:
some increase and change in vaginal discharge is usually characteristic of a normal pregnancy;
in cases of the appearance of an unpleasant odor, itching, soreness, it is necessary to contact a medical specialist for additional examination.
Clinical examination of pregnant women
Weight, height, BMI
the concept of the rate of weight gain both during pregnancy in general and by week, month and trimester is very individual;
the so-called pathological weight gain over a certain period of pregnancy should not be used as a criterion for assessing the course of pregnancy and diagnosing any complications (for example, preeclampsia) or predicting the birth of low birth weight children due to the extremely low predictive value of this indicator, on the one hand, and significant concern of a pregnant woman about this - on the other;
the woman's weight and height should be determined at the first visit to calculate the BMI(2a);
BMI = weight (kg) / height (m) squared:
o low BMI -< 19,8;
o normal - 19.9-26.0;
o excessive - 26.1-29.0;
o obesity -> 29.0;
more attention is deserved by patients with BMI other than normal, especially those with low and obesity.
Breast examination
routine examination of the mammary glands is carried out to identify oncopathology;
there is no special preparation for breastfeeding during pregnancy(1b).
Gynecological examination
(may be postponed until a second visit if the patient is not ready)
Inspection in mirrors:
o assessment of the cervix (shape, length);
o analysis for oncocytology (smear);
o in the presence of pathological changes in the cervix, the patient should be offered colposcopy.
Bimanual explorationIt may not be routinely carried out, since the accuracy of confirming the presence of pregnancy or clarifying the gestational age is low, the diagnosis of an ectopic pregnancy requires the mandatory use of additional studies, the prevalence of masses in the small pelvis (cysts) is small, especially since a pregnant woman will be offered to undergo an ultrasound scan in the first trimester, which will be a better and more accurate method for determining and confirming all the diagnoses described above.
Hematological screening
Anemia
– low and high Hb levels increase the risk of low birth weight and premature birth;
– the most common cause of anemia around the world is a lack of iron in the body of a pregnant woman;
– on the one hand, this is a consequence of increased iron consumption due to fetal growth, on the other, a relatively large increase in blood plasma volume (up to 50%) and a smaller increase in the volume of erythrocytes (up to 20%);
- other causes of anemia - thalassemia or sickle cell anemia - are quite rare in Russia;
– It is recommended to consider the Hb level> 110 g / l as the norm for pregnancy in the first and third trimesters; in the second trimester due to physiological anemia (maximum relative increase in plasma volume to the volume of erythrocytes) -> 105 g / l(1a);
– Hb level< 70 г/л относится к тяжелой степени анемии, требующей обязательного лечения;
– with a screening study for anemia in a general blood test, it is sufficient to determine only the level of Hb;
– determination of the level of Hb should be carried out 2 times during pregnancy(2a) - upon registration and at 28-30 weeks;
– at the same time, the routine use of iron preparations at normal or moderately low (100 g / l) Hb levels did not lead to an improvement in perinatal indicators, morbidity and mortality both among pregnant women and among children, while reducing the number of patients with Hb levels< 100 г/л к моменту родов. Отмечена бóльшая толерантность
pregnant women with a moderate decrease in Hb levels to postpartum blood loss;
– if indicated, iron preparations (sulfate) should be prescribed per os for a long course of at least 3 months with an individually selected dose.
Determination of blood group and Rh factor
– determination of these indicators is important for the prevention of hemolytic disease of the fetus and newborn and possible transfusion problems;
– blood group and Rh-factor are determined at the first visit of a woman(2a) , information about the results must be entered into an exchange card or other document that is constantly in the hands of a pregnant woman;
– with Rh-negative blood of the patient - offer to go through a similar
testing for the child's future father;
o it is necessary to determine the presence of antibodies to the Rh factor in the blood at the first visit and at 26-27 weeks again (with a negative result of the first test) for the timely prevention of anti-DMaintaining a normal pregnancyimmunoglobulin(2a) , except in cases of Rh-negative affiliation of the future father;
– when detecting antibodies in the blood of a pregnant woman, it is necessary to monitor their titer. The number of tests and the frequency of testing depends on the specific clinical situation, women with high titer of antibodies should be consulted in a higher level institution, preferably the 3rd one.
Screening for fetal pathology
Down Syndrome Screening
– prevalence in the population - 6.2 per 10,000 pregnancies (1: 1613);
– 80% of children with Down syndrome have severe intellectual disabilities, the remaining 20% may have moderate or no such disorders;
– the prevalence of the syndrome depends on the age of the mother:
At 20 years old - 1 in 1,440 pregnancies;
At 35 years old - 1 in 338;
At 45 years old - 1 in 32;
– screening for Down syndrome is quite effective, but you should not insist if a woman refuses to take the test;
- should only be offered if there is a pre- and post-treatment counseling facility in the health care facility, in which the woman is educated about the benefits and risks of testing , as well as the consequences of obtaining positive results;
– It is also necessary to have high quality standard equipment for ultrasound scanning, experienced staff, and the ability to monitor the effectiveness of testing;
– if these conditions are met, it is recommended to conduct complex (integrated) testing, which includes ultrasound at 10-14 weeks of pregnancy to measure the thickness of the collar space, as well as serological tests at 11-14 and 14-20 weeks;
– positive results of comprehensive testing are an indication for amniocentesis (the risk of abortion is up to 1%). In addition, it should be borne in mind that the probability of detecting pathology (sensitivity) during complex testing is 90%, and the probability of a false-positive result is 2.8%. That is, for every nine detected fetuses with Down syndrome, there is one healthy
a fetus mistakenly listed as a sick person;
– upon confirmation of the presence of pathology by invasive tests and karyotyping, the woman is offered to terminate the pregnancy, preferably in a hospital of the 3rd level.
Screening for structural abnormalities
– offered to all pregnant women for a period of 18-20 weeks, while some of the gross structural abnormalities, for example, anencephaly, can be detected during the first ultrasound;
– the quality of screening (percentage of detected abnormalities) depends on:
Gestational period;
The anatomical system of the fetus, in which the abnormalities are determined;
Researcher experience and skills;
Equipment quality;
Duration of the study (on average, 30 minutes should be spent on the ultrasound protocol);
o if there is a suspicion of structural abnormalities of the pregnant woman, it is proposed to undergo a more detailed examination at the regional consultation center.
Screening for infections
Characteristics of a Successful Screening Program
– the disease must be a public health problem;
– the history of the disease is well known;
– screening tests are accurate and reliable;
– the effectiveness of the treatment has been proven;
– screening programs are worth the investment.
Most infections diagnosed during pregnancy do not deserve special concern, since most often they do not affect the course of pregnancy, the risk of intrauterine or intrapartum infection. Therefore, it is important for those who lead a pregnant woman not to apply unnecessary restrictions to pregnancy and not to waste the available resources thoughtlessly.
Of course, some infections can be dangerous for the mother and / or child, but such infections are in the overwhelming minority. Screening for infections should not be performed if the result of such screening is not practical - that is, if the treatment of a woman with a positive test result cannot be carried out due to limited local resources or the lack of treatment with proven effectiveness. You should not treat a pregnant woman with methods, the usefulness of which has not been proven during pregnancy.
A pregnant woman should not be isolated from her baby, from other family members, or from other patients unless there is a serious risk to her or others from such contact.
A woman should not be hospitalized for treatment, unless outpatient treatment is not possible. A hospital stay itself can pose a risk to both the mother and the baby (primarily due to nosocomial infections).
You should not give up breastfeeding if the mother has an infection. She should be encouraged to stop breastfeeding only if there is a specific, identifiable risk to the baby from such contact.
Due to the high prevalence of STIs, HIV, hepatitis B, C among the population, health workers need to follow general precautions when treating all women. That is, observe the rule:treat all patients, without exception, as knowingly infected.
Asymptomatic bacteriuria
– prevalence - 2-5% of pregnancies;
– increases the risk of premature birth, low birth weight, acute pyelonephritis in pregnant women (on average, it develops in 28-30% of those who have not received treatment for asymptomatic bacteriuria);
– definition - presence of bacterial colonies> 10 5 in 1 ml of the average portion of urine, determined by the culture method ("gold standard") without clinical symptoms of acute cystitis or pyelonephritis;
– diagnostic test - culture of the middle portion of urine - should be offered to all pregnant women at least once upon registration(1a);
– for treatment, nitrofurans, ampicillin, sulfonamides, 1st generation cephalosporins, which have shown the same effectiveness in studies, can be used;
– treatment should be prescribed after 14 weeks of pregnancy to exclude a possible negative effect on the development of the fetus;
– the criterion for successful treatment is the absence of bacteria in the urine;
– a single dose of antibacterial agents is as effective as 4- and 7-day courses, but because of the fewer side effects, single-use should be used;
– it is logical to use drugs for which sensitivity has been established;
– treatment of severe forms of AIM infection (pyelonephritis) should be carried out in a specialized hospital (urological).
Routine antenatal screening
HELLshould be measured at each visit for signs of hypertension. Hypertension is only a symptom and may or may not indicate the presence of preeclampsia.
Rules for measuring blood pressure
The most accurate readings are given by a mercury sphygmomanometer (all devices used must be calibrated against it)(1b).
The patient should be relaxed after rest (at least 10 minutes).
Position - half-sitting or sitting, the cuff should be at the level of the patient's heart.
The cuff of the pressure monitor should match the patient's upper arm circumference (more is better than less).
A measurement on one hand is sufficient.
The level of systolic pressure is assessed by I Korotkov tone (appearance), and diastolic - by V (termination).
Indicators should be recorded with an accuracy of 2 mm Hg. Art.
Urinalysis for protein (OAM) .
Any urinalysis can be used for screening, although an analysis of the total protein excretion in the daily urine volume should be done to obtain the most complete and accurate data.
Measurement of the height of the standing of the fundus of the uterus (WDM) to predict low birth weight. Also, this test can be useful for screening in order to further investigate the possible delay in fetal development. The quality of this research is enhanced by the use of a gravidogram, which should be included in every exchange card.
Palpation of the abdomen. Determining the exact position of the presenting part of the fetus is not always accurate up to 36 weeks and can cause discomfort to a woman(3a), but at 36 weeks it is necessary to determine the presentation.
Examination of the condition of the legs for the presence of varicose veins at each visit. In this case, the presence of edema (with the exception of severe or rapidly emerging edema of the face or lower back) should not be considered as signs of a pathological condition, since edema of the lower extremities occurs normally in 50-80% of pregnant women.
Routine examinations , which are not recommended , since their effectiveness is absent or not proven
Woman weight. Measuring weight gain at every visit is unreasonable, and there is no need to advise women to make dietary restrictions to limit weight gain.
Pelviometry. It has been proven that neither clinical nor X-ray pelviometry data have sufficient predictive value to determine the discrepancy between the sizes of the fetal head and the mother's pelvis, which is best detected with careful monitoring of the course of labor.(2a).
Routine fetal heart rate auscultation has no predictive value, since it can only answer the question: is the child alive? But in some cases, she can give the patient confidence that everything is fine with the child.
Counting fetal movements . Routine counting leads to more frequent detection of decreased fetal activity, more frequent use of additional methods for assessing the condition of the fetus, more frequent hospitalizations of pregnant women and an increase in the number of induced labor. Of greater importance is not the quantitative, but the qualitative characteristic of fetal movements(1b).
Routine ultrasound in the second half of pregnancy . A study of the clinical relevance of routine ultrasound in late pregnancy has shown an increase in antenatal hospitalizations and induced labor without any improvement in perinatal outcomes.(1b)... However, the expediency of ultrasound has been proven in special clinical situations:
When determining the exact signs of vital activity or fetal death;
When assessing the development of a fetus with suspected IUGR;
When determining the localization of the placenta;
Upon confirmation of the alleged multiple pregnancy;
When assessing the volume of amniotic fluid in case of suspicion of high or low water;
When clarifying the position of the fetus;
For procedures such as placing a circular suture on the cervix or
external rotation of the fetus to the head.
Stress and non-stress CTG . There is no evidence of the advisability of using CTG during the antenatal period as an additional check of fetal well-being in pregnancies of even high risk(1a)... In 4 studies evaluating the effect of routine CTG, identical results were obtained - an increase in perinatal mortality in the CTG group (3 times!) With no effect on the frequency of CS, the birth of children with a low Apgar score, neurological disorders in newborns and hospitalization in neonatal PETE. The use of this method is indicated only with a sudden decrease in fetal movements, with prenatal bleeding and any other conditions associated with the risk of the fetus (preeclampsia, diabetes decompensation, etc.).
Possible minimum visits to the obstetrician – a gynecologist or midwife during pregnancy
Ideally, it should be before conception before 12 weeks
Taking anamnesis:
o Obstetric and gynecological history:
Information about the menstrual cycle and methods of contraception. Knowing the characteristics of the menstrual cycle helps to more accurately determine the expected date of birth. It is important to take into account that in those taking oral contraceptives, amenorrhea that develops after their cancellation can lead to erroneous calculations. Be sure to clarify whether intrauterine contraceptives have been used (if so, note the date of removal);
Information about the transferred gynecological diseases, pregnancies and childbirth. The total number of pregnancies and their outcome are noted: urgent or premature birth, spontaneous or induced abortion, the state of health of children. For each birth, the features of the course, duration, method of delivery, complications, condition and weight of the newborn are noted. Repeated spontaneous abortions in the first or second trimester of pregnancy may indicate hereditary pathology, isthmic-cervical insufficiency or infection;
If there was a history of cesarean section, discuss with the woman the possibility of giving birth through a natural birth canal.
It is necessary to collect documents about the previous operation.
o Past diseases and surgical interventions.
o Occupational hazards and early medication
terms of pregnancy.
o Side effects of drugs, allergic history.
o Family history. Find out if the family had hereditary diseases and cases of multiple pregnancies.
o Social factors. They ask about the woman's family and socio-economic status, mental trauma and abuse in the past, bad habits. It is important to remember that not every woman will easily admit that she smokes, uses alcohol or drugs.
o Concomitant manifestations, including those associated with pregnancy: nausea, vomiting, abdominal pain, constipation, headache, fainting, discharge from the genital tract, painful or frequent urination, edema, varicose veins, hemorrhoids.
Clinical examination.
Filling in an exchange card and a surveillance card (preferably an electronic version).
Measuring the weight and height of a woman, calculating BMI.
Measurement of blood pressure.
Gynecological examination (may be postponed until the second visit): examination in the mirrors, taking a smear for oncocytology, bimanual examination.
Laboratory tests:
o blood test (Hb);
o urine culture;
o blood for hepatitis B, C, HIV, RW;
o determination of blood group and Rh-factor.
Referral for ultrasound at 10-14 weeks.
Consulting on lifestyle, proper nutrition.
Providing the following information (including in writing): phone numbers, addresses of medical institutions providing emergency assistance. Emergency Behavior Communication.
Issuance of booklets, reference books, books on pregnancy, childbirth, the postpartum period (organization of a special library for pregnant women is desirable).
14-16 weeks
Measurement of blood pressure.
OAM.
Referral for an ultrasound scan at 18-20 weeks (to an advisory center).
18-20 weeks
Ultrasound.
22 weeks
Discussion of the ultrasound results.
Measurement of blood pressure.
OAM (total protein).
26 weeks
Measurement of blood pressure.
WDM measurement (gravidogram).
OAM (total protein).
30 weeks
Issuance of a sick leave (if necessary) and a birth certificate.
Measurement of blood pressure.
WDM measurement (gravidogram).
Providing information on preparation courses for childbirth.
Laboratory tests:
oblood test (Hb);
oOAM;
oblood for hepatitis B, C, HIV, RW.
33 weeks
Discussion of the survey results.
Measurement of blood pressure.
WDM measurement (gravidogram).
OAM (total protein).
36 weeks
Measurement of blood pressure.
WDM measurement (gravidogram).
OAM (total protein).
Determination of the presenting part, with a breech presentation - a proposal for an external turn at 37-38 weeks.
Discussion of the place of birth, organization of a visit to the selected institution.
38 weeks
Measurement of blood pressure.
WDM measurement (gravidogram).
OAM (total protein).
40 weeks
Measurement of blood pressure.
WDM measurement (gravidogram).
OAM (total protein).
41 a week
Measurement of blood pressure.
OAM (total protein).
Offer of labor induction or bimanual examination to assess the cervix and detachment of the lower pole of the fetal bladder - in this case, the offer of additional examination in the volume of the abbreviated form of the biophysical profile of the fetus.
Special conditions during pregnancy
C rock pregnancy > 41 weeks
childbirth at 37-42 weeks of gestation is considered normal, while the risk of antenatal losses increases depending on the period: for example, at 37 weeks the risk of stillbirth is 1/3000 births, at 42 weeks - 1/1000 births, at 43 weeks - 1 / 500 births;
routine ultrasound in the first half of pregnancy allows you to more accurately determine the duration of pregnancy than the beginning of the last menstruation, and reduces the likelihood of stimulating labor in the case of an expected post-term pregnancy;
there is no evidence of the advisability of routine induction of labor before the 41st week of gestation. On the one hand, routine induction of labor at 41+ weeks allows to reduce perinatal mortality, on the other hand, it is necessary to carry out about 500 labor inductions, not forgetting about the possible complications of this procedure, to exclude one case of perinatal mortality;
it is necessary to provide the patient with the opportunity to make informed choices: induction of labor in the presence of conditions or careful monitoring of the fetus;
in the presence of conditions for relatively safe labor induction [obstetric facilities of the 2nd or 3rd level, availability of means for effective preparation of the cervix (prostaglandins, only gel forms for local, vaginal or intracervical use)] it is necessary to offer labor induction at 41 weeks(1a) ;
it is necessary to provide the patient with complete information about the various methods of stimulating labor, about the benefits and complications associated with each of them, in order for her to accept informed consent;
in case of refusal of labor induction, it is possible to continue outpatient monitoring of the pregnant woman in the conditions of the GI or maternity ward with attendance at least 2 times a week and additional examination of the condition of the fetus in the amount of: ultrasound (amniotic index) + CTG (non-stress test), if possible - dopplerometry of the vessels umbilical cord;
in case of pathological or suspicious changes according to the test results, urgent hospitalization in a hospital of at least level 2 is required for further examination and possible delivery;
before formal induction of labor, women should be offered a vaginal examination in order to exfoliate the lower pole of the fetal bladder(1b) ;
to prevent one antenatal death, 500 births are required.
Vi. The procedure for providing medical care to women with HIV infection during pregnancy, childbirth and the postpartum period
51. The provision of medical care to women with HIV infection during pregnancy, childbirth and the postpartum period is carried out in accordance with Sections I and III of this Procedure.
52. Laboratory examination of pregnant women for the presence of antibodies to the human immunodeficiency virus (hereinafter - HIV) in their blood is carried out when registering for pregnancy.
53. If the first test for HIV antibodies is negative, women planning to maintain a pregnancy are re-tested at 28-30 weeks. Women who have used parenteral psychoactive substances during pregnancy and (or) have had sexual intercourse with an HIV-infected partner are recommended to be examined additionally at 36 weeks of gestation.
54. Molecular biological examination of pregnant women for HIV DNA or RNA is carried out:
a) upon receipt of questionable test results for antibodies to HIV obtained by standard methods (enzyme-linked immunosorbent assay (hereinafter - ELISA) and immune blotting);
b) upon receipt of negative test results for HIV antibodies obtained by standard methods if a pregnant woman belongs to a high-risk group for HIV infection (intravenous drug use, unprotected sex with an HIV-infected partner within the last 6 months).
55. Blood sampling during testing for antibodies to HIV is carried out in the treatment room of the antenatal clinic using vacuum systems for blood sampling, followed by blood transfer to the laboratory of a medical organization with a referral.
56. Testing for antibodies to HIV is accompanied by mandatory pre-test and post-test counseling.
Post-test counseling is provided to pregnant women regardless of the test result for HIV antibodies and includes a discussion of the following issues: the value of the result, taking into account the risk of HIV infection; recommendations for further testing tactics; ways of transmission and methods of protection against HIV infection; the risk of HIV transmission during pregnancy, childbirth and breastfeeding; methods of preventing mother-to-child transmission of HIV that are available to pregnant women with HIV; the possibility of chemoprophylaxis of HIV transmission to a child; possible pregnancy outcomes; the need for follow-up of mother and child; the possibility of informing the sexual partner and relatives about the test results.
57. Pregnant women with a positive laboratory test for HIV antibodies are sent by an obstetrician-gynecologist, and in his absence, a general practitioner (family doctor), a medical worker of a feldsher-obstetric center, to the Center for the Prevention and Control of AIDS of the subject Russian Federation for additional examination, dispensary registration and prescribing chemoprophylaxis for perinatal HIV transmission (antiretroviral therapy).
Information received by medical workers about a positive HIV test result of a pregnant woman, a woman in labor, a postpartum woman, antiretroviral prophylaxis of mother-to-child transmission of HIV infection, joint observation of a woman with specialists from the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation, perinatal HIV contact infection in a newborn is not subject to disclosure, except as otherwise provided by applicable law.
58. Further observation of a pregnant woman with an established diagnosis of HIV infection is carried out jointly by an infectious disease doctor at the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation and an obstetrician-gynecologist at the antenatal clinic at the place of residence.
If it is impossible to send (follow up) a pregnant woman to the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation, the observation is carried out by the obstetrician-gynecologist at the place of residence with the methodological and advisory support of the infectious disease doctor of the Center for the Prevention and Control of AIDS.
The obstetrician-gynecologist of the antenatal clinic during the period of observation of a pregnant woman with HIV infection sends information about the course of pregnancy, concomitant diseases, complications of pregnancy, mother to the child and (or) antiretroviral therapy and requests information from the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation about the characteristics of the course of HIV infection in a pregnant woman, the regimen of taking antiretroviral drugs, agrees the necessary diagnostic and treatment methods, taking into account the woman's health status and the course of pregnancy ...
59. During the entire observation period of a pregnant woman with HIV infection, the obstetrician-gynecologist of the antenatal clinic in strict confidentiality (using a code) notes in the woman's medical documentation her HIV status, presence (absence) and admission (refusal to admit) antiretroviral drugs necessary for the prevention of mother-to-child transmission of HIV, prescribed by specialists of the Center for the Prevention and Control of AIDS.
The obstetrician-gynecologist of the antenatal clinic immediately informs the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation about the absence of antiretroviral drugs in a pregnant woman, refusal to take them, so that appropriate measures can be taken.
60. During the period of dispensary observation of a pregnant woman with HIV infection, it is recommended to avoid procedures that increase the risk of fetal infection (amniocentesis, chorionic biopsy). The use of non-invasive methods for assessing the condition of the fetus is recommended.
61. Upon admission to childbirth in an obstetric hospital of women who are not examined for HIV infection, women without medical documentation or with a single test for HIV infection, as well as who have used intravenous psychoactive substances during pregnancy, or who have had unprotected sex with an HIV-infected partner, it is recommended that a laboratory examination by the express method for HIV antibodies is obtained after obtaining informed voluntary consent.
62. Testing a woman in childbirth for HIV antibodies in an obstetric hospital is accompanied by pre-test and post-test counseling, including information on the importance of testing, methods of preventing HIV transmission from mother to child (use of antiretroviral drugs, mode of delivery, breastfeeding characteristics of a newborn (after birth, the child does not attach to the breast and not fed with breast milk, but transferred to artificial feeding).
63. Testing for antibodies to HIV using diagnostic express test systems approved for use on the territory of the Russian Federation is carried out in the laboratory or the admission department of an obstetric hospital by specially trained medical workers.
The study is carried out in accordance with the instructions attached to the specific rapid test.
A part of the blood sample taken for the express test is sent for testing for HIV antibodies according to the standard method (ELISA, if necessary, an immune blot) in a screening laboratory. The results of this study are immediately transmitted to a medical organization.
64. Each study for HIV using express tests must be accompanied by a mandatory parallel study of the same portion of blood by classical methods (ELISA, immune blot).
If a positive result is obtained, the rest of the serum or blood plasma is sent to the laboratory of the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation for a verification study, the results of which are immediately transferred to the obstetric hospital.
65. If a positive HIV test result is obtained in the laboratory of the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation, a woman with a newborn, after being discharged from the obstetric hospital, is sent to the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation for counseling and further examination.
66. In emergency situations, if it is impossible to wait for the results of standard HIV testing from the Center for the Prevention and Control of AIDS of the Subject of the Russian Federation, the decision to conduct a preventive course of antiretroviral therapy for mother-to-child transmission of HIV is made upon detection of antibodies to HIV using a rapid test -systems. A positive rapid test result is the basis only for the appointment of antiretroviral prophylaxis of HIV transmission from mother to child, but not for the diagnosis of HIV infection.
67. To ensure the prevention of mother-to-child transmission of HIV infection, the obstetric hospital should have the necessary supply of antiretroviral drugs at all times.
68. Antiretroviral prophylaxis for women during childbirth is carried out by an obstetrician-gynecologist leading the labor in accordance with the recommendations and standards for the prevention of mother-to-child transmission of HIV.
69. A prophylactic course of antiretroviral therapy during childbirth in an obstetric hospital is carried out:
a) a woman in labor with HIV infection;
b) with a positive result of express testing of a woman in childbirth;
c) in the presence of epidemiological indications:
the inability to conduct express testing or timely obtain the results of a standard test for antibodies to HIV in a woman in labor;
the history of a woman in labor during this pregnancy of parenteral use of psychoactive substances or sexual contact with a partner with HIV infection;
with a negative test result for HIV infection, if less than 12 weeks have passed since the last parenteral use of psychoactive substances or sexual contact with an HIV-infected partner.
70. The obstetrician-gynecologist takes measures to prevent the duration of the anhydrous interval for more than 4 hours.
71. During vaginal delivery, the vagina is treated with a 0.25% aqueous solution of chlorhexidine upon admission to childbirth (at the first vaginal examination), and in the presence of colpitis, at each subsequent vaginal examination. With an anhydrous interval of more than 4 hours, the vagina is treated with chlorhexidine every 2 hours.
72. During the management of childbirth in a woman with HIV infection with a living fetus, it is recommended to limit the procedures that increase the risk of fetal infection: delivery stimulation; childbirth; perineo (episio) tomia; amniotomy; the imposition of obstetric forceps; vacuum extraction of the fetus. These manipulations are performed only for health reasons.
73. A planned cesarean section for the prevention of intrapartum HIV infection of a child is carried out (in the absence of contraindications) before the onset of labor and amniotic fluid rupture in the presence of at least one of the following conditions:
a) the concentration of HIV in the mother's blood (viral load) before childbirth (not earlier than 32 weeks of gestation) is more than or equal to 1,000 kopecks / ml;
b) maternal viral load before childbirth is unknown;
c) antiretroviral chemoprophylaxis was not carried out during pregnancy (or was carried out as monotherapy or its duration was less than 4 weeks) or it is impossible to use antiretroviral drugs during labor.
74. If it is impossible to carry out chemoprophylaxis during childbirth, caesarean section can be an independent preventive procedure that reduces the risk of HIV infection in a child during childbirth, and it is not recommended to carry out it with an anhydrous interval of more than 4 hours.
75. The final decision on the method of delivery of a woman with HIV infection is made by the obstetrician-gynecologist leading the delivery individually, taking into account the condition of the mother and the fetus, comparing in a particular situation the benefits of reducing the risk of infection of a child during a caesarean section with the probability the occurrence of postoperative complications and the characteristics of the course of HIV infection.
76. Immediately after birth, blood is drawn from a newborn from an HIV-infected mother for testing for HIV antibodies using vacuum blood collection systems. The blood is sent to the laboratory of the Center for the Prevention and Control of AIDS in the constituent entity of the Russian Federation.
77. Antiretroviral prophylaxis for a newborn is prescribed and carried out by a neonatologist or pediatrician regardless of the mother's intake (refusal) of antiretroviral drugs during pregnancy and childbirth.
78. Indications for the appointment of antiretroviral prophylaxis to a newborn born to a mother with HIV infection, a positive result of rapid testing for HIV antibodies in childbirth, unknown HIV status in an obstetric hospital are:
a) the age of the newborn is not more than 72 hours (3 days) of life in the absence of breastfeeding;
b) in the presence of breastfeeding (regardless of its duration) - a period of no more than 72 hours (3 days) from the moment of the last breastfeeding (subject to its subsequent cancellation);
c) epidemiological indications:
unknown HIV status of a mother who uses parenteral psychoactive substances or has sexual contact with an HIV-infected partner;
a negative result of the examination of a mother for HIV infection, who has been using parenteral substances within the last 12 weeks or who has sexual contact with a partner with HIV infection.
79. The newborn is given a hygienic bath with chlorhexidine solution (50 ml of 0.25% chlorhexidine solution per 10 liters of water). If it is not possible to use chlorhexidine, a soap solution is used.
80. Upon discharge from the obstetric hospital, the neonatologist or pediatrician explains in detail in an accessible form the mother or persons who will take care of the newborn, the further scheme of taking chemotherapy for the child, issue antiretroviral drugs to continue antiretroviral prophylaxis in accordance with the recommendations and standards.
When carrying out a preventive course of antiretroviral drugs by methods of emergency prevention, discharge from the maternity hospital of the mother and child is carried out after the end of the preventive course, that is, not earlier than 7 days after childbirth.
In the obstetric hospital, women with HIV are consulted on the issue of refusing to breastfeed; with the woman's consent, measures are taken to stop lactation.
81. Data on a child born to a mother with HIV infection, antiretroviral prophylaxis for a woman in childbirth and a newborn, methods of delivery and feeding of a newborn are indicated (with a contingent code) in the medical documentation of the mother and child and are transmitted to the Center for the Prevention and Control of AIDS of the subject of the Russian Federation. Federation, as well as to the children's clinic where the child will be monitored.
List of basic and additional diagnostic measures
| I visit - (recommended up to 12 weeks) | |
| Consulting | - taking anamnesis, identifying risk - identifying previous infectious diseases (rubella, hepatitis) (see Appendix A) - Recommend a school for preparing for childbirth - Recommend a visit to a specialist with a family representative - Provide information with the ability to discuss problems and ask questions; offer verbal information supported by childbirth classes and printed information. (see example Appendix G) |
| Inspection: | - height and weight indicators (calculate body mass index (BMI) (2a); BMI = weight (kg) / height (m) squared: - low BMI -<19,8 - нормальный – 19,9-26,0 - избыточный – 26,1-29,0 - ожирение – >29.0 - patients with a BMI other than normal are referred for a consultation with an obstetrician-gynecologist - blood pressure measurement; - examination of the legs (varicose veins) - examination in mirrors - assessment of the state of the cervix and vagina (shape, length, cicatricial deformities, varicose veins); - internal obstetric examination; - routine examination of the mammary glands is carried out to identify oncopathology; - Ultrasound at 10-14 weeks of pregnancy: for prenatal diagnosis, clarification of the duration of pregnancy, detection of multiple pregnancies. |
| Laboratory tests: Mandatory: | - general analysis of blood and urine - blood sugar with a BMI above 25.0 - blood group and Rh factor - bacterial urine culture - screening (up to 16 weeks of pregnancy) - study for genital infections only with clinical symptoms (see Appendix A) - smear for oncocytology (appendix) - HIV (100% pre-test counseling, upon obtaining consent - testing), (see Appendix B) - RW - biochemical genetic markers - HBsAg (conduct a test for HBsAg when immunization with immunoglobulin of a newborn born from a carrier of HBsAg in the guaranteed volume of medical care, appendix C) |
| Consultation of specialists | - Therapist / GP - Geneticist over 35 years of age, history of congenital malformations in the fetus, 2 miscarriages in history, consanguineous marriage |
| - folic acid 0.4 mg daily during the first trimester | |
| II visit - within 16-20 weeks | |
| Conversation | - Review, discussion and recording of the results of all passed screening tests; - clarification of the symptoms of complications of this pregnancy (bleeding, leakage of ophthalmic waters, fetal movement) - Provide information with the possibility of discussing problems, questions, "Alarming signs during pregnancy" (see example Appendix G) - Recommend classes to prepare for childbirth |
| Inspection: | - measurement of blood pressure - examination of the legs (varicose veins) - measurement of the height of the fundus of the uterus from 20 weeks (put on the gravidogram) (see Appendix E) |
| Laboratory examination: | - urine analysis for protein - biochemical genetic markers (if not performed at the first visit) |
| Instrumental research: | - screening ultrasound (18-20 weeks) |
| Treatment and prophylactic measures: | - calcium intake 1 g per day with risk factors for preeclampsia, as well as in pregnant women with low calcium intake up to 40 weeks - taking acetylsalicylic acid at a dose of 75-125 mg once a day with risk factors for preeclampsia up to 36 weeks |
| III visit - within 24-25 weeks | |
| Consulting | - identification of complications of this pregnancy (preeclampsia, bleeding, leakage of ophthalmic waters, fetal movement) - if necessary, revise the pregnancy management plan and refer and consult an obstetrician-gynecologist - Provide information with the possibility of discussing problems, questions, "Alarming signs during pregnancy" (see example Appendix G) |
| Inspection: | - measurement of blood pressure. - examination of the legs (varicose veins) - measurement of the height of the fundus of the uterus (put on the gravidogram) (see Appendix E) - fetal heartbeat |
| Laboratory examinations: | - Urinalysis for protein - Antibodies with Rh negative blood factor |
| Treatment and prophylactic measures: | - Introduction of anti-D human immunoglobulin from 28 weeks. pregnant women with Rh negative blood factor without an antibody titer. Subsequently, the determination of the antibody titer is not carried out. If the biological father of the child has Rh-negative blood, this study and the introduction of immunoglobulin are not carried out. |
| IV visit - within 30-32 weeks | |
| Conversation | - identification of complications of this pregnancy (preeclampsia, bleeding, leakage of ophthalmic waters, fetal movement), alarming signs - if necessary, revise the pregnancy management plan and consult an obstetrician-gynecologist, in the presence of complications - hospitalization - Provide information with the possibility of discussing problems, questions; "Birth plan" (see Appendix E) |
| Inspection: | - Repeated measurement of BMI in women with an initially low indicator (below 18.0) - measurement of blood pressure; - examination of the legs (varicose veins) - measurement of the height of the fundus of the uterus (put on the gravidogram) - fetal heartbeat - registration of prenatal leave |
| Laboratory research: | - RW, HIV - urine analysis for protein - complete blood count |
| V visit - within 36 weeks | |
| Conversation | - identifying the symptoms of complications of this pregnancy (preeclampsia, bleeding, leakage of ophthalmic waters, fetal movement) - Provide information with the possibility of discussing problems, questions; "Breast-feeding. Postpartum contraception " |
| Inspection: | - external obstetric examination (fetal position); - examination of the legs (varicose veins) - measurement of blood pressure; - measurement of the height of the fundus of the uterus (put on the gravidogram) - external obstetric examination - fetal heartbeat - urine analysis for protein |
| VI visit - within 38-40 weeks | |
| Conversation | - identifying the symptoms of complications of this pregnancy (preeclampsia, bleeding, leakage of ophthalmic waters, fetal movement) - if necessary, revising the pregnancy management plan and referring and consulting an obstetrician-gynecologist - Provide information with the possibility of discussing problems, questions; - "Breast-feeding. Postpartum contraception " |
| Inspection: | |
| VII visit - within 41 weeks | |
| Conversation | - identification of symptoms of complications of this pregnancy (preeclampsia, bleeding, leakage of ophthalmic waters, fetal movement), alarming signs - if necessary, revise the pregnancy management plan and refer and consult an obstetrician-gynecologist - Provide information with the possibility of discussing problems, questions; - Discussion of questions about hospitalization for delivery. |
| Inspection: | - measurement of blood pressure; - Examination of the legs (varicose veins) - External obstetric examination (fetal position); - measurement of the height of the fundus of the uterus (put on the gravidogram) - external obstetric examination - fetal heartbeat - urine analysis for protein |
Based on the history, physical examination data, and laboratory tests, the following adverse prognostic factors are identified.
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-viral 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, which makes 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.
Similar information.
An interdisciplinary expert council, held in St. Petersburg on June 17, 2017, was devoted to the development of recommendations for the management of pregnant women at risk of thrombosis and pregnancy complications against the background of activation of the hemostasis system.
In the structure of pregnancy complications, a significant role belongs to complications associated with disorders in the hemostasis system, which can be divided into two groups: venous thromboembolic complications (VTEC) and obstetric complications proper (preeclampsia, fetal loss syndrome, fetal growth retardation, placental abruption, etc.) ... The pathogenesis of the latter is based on impaired fetoplacental blood circulation with thrombosis in the microcirculation zone of the placenta.
Pharmacological prevention of thromboembolic complications during pregnancy
Currently, low molecular weight heparins (LMWH) are the only safe group of anticoagulants for the prevention and treatment of thrombosis in pregnant women. In the absence of large randomized or comparative studies, which are very difficult to carry out in pregnant women, drugs in this group, in accordance with the manufacturer's instructions, can be used in cases where the expected benefit outweighs the risk of the expected complications. The decision on the prescription of drugs (in the absence of the need for a collegial opinion of a multidisciplinary team) is made by the obstetrician-gynecologist.
International and Russian recommendations clearly define the risk factors for VTEC and the indications for the prophylactic administration of LMWH (hereinafter referred to as thromboprophylaxis), as well as the tactics of treating the complications that have developed. In accordance with these recommendations, the decision to prescribe thromboprophylaxis with the use of LMWH during pregnancy or after childbirth is made individually according to the patient's stratification by risk factors presented in Table. 1, fig.
Women with a history of VTEC (except for women with a single VTEC associated with major surgery, in the absence of other risk factors) should undergo thromboprophylaxis with LMWH throughout the antenatal period.
All women with four or more active risk factors (except for previous VTEC and / or the presence of thrombophilia) should be prescribed LMWH in prophylactic doses throughout pregnancy before delivery and 6 weeks postpartum.
All women with three active risk factors (except for previously transferred VTEC and / or the presence of hereditary thrombophilia and APS) are recommended prophylactic use of LMWH from the 28th week of pregnancy before childbirth and for 6 weeks after childbirth (with mandatory postpartum VTEC risk assessment) ...
All women with two active risk factors (except for previously transferred VTEC and / or the presence of hereditary thrombophilia and APS) are recommended prophylactic use of LMWH for at least 10 days of the postpartum period.
Women hospitalized during pregnancy in gynecological departments with indomitable vomiting of pregnant women, ovarian hyperstimulation syndrome (OHSS) or forced immobilization are recommended to carry out thromboprophylaxis of LMWH in the absence of absolute contraindications (active bleeding).
Women with a history of VTEC associated with APS are advised to undergo thromboprophylaxis with higher doses of LMWH (50%, 75%, or the full therapeutic dose) during pregnancy and for 6 weeks after delivery or before switching to oral anticoagulant therapy, if required. Pregnant women with APS should be treated with a hematologist and / or rheumatologist experienced in this area.
Heterozygous gene mutations FV (Leiden), FII (G20210A), or antiphospholipid antibodies are considered weak risk factors for thrombosis in women without any clinical manifestations of VTEC (Table 1). If there are three additional risk factors in these patients, antenatal LMWH thromboprophylaxis should be considered for at least 10 days after delivery; in the presence of two additional risk factors, thromboprophylaxis should be considered from the 28th week of LMWH and continued for at least 10 days after delivery; in the presence of one additional risk factor or asymptomatic thrombophilia, thromboprophylaxis of LMWH is recommended within 10 days of the postpartum period.
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Women with asymptomatic antithrombin, protein C or protein S deficiencies or with more than one thrombophilic defect (including a homozygous mutation of factor V Leiden, the prothrombin gene, or a combination of heterozygous carriage of these mutations) should be referred to an expert (hematologist, obstetrician with experience in managing pregnant women with hemostasis ) to address the issue of antenatal thromboprophylaxis. For this category of patients, thromboprophylaxis is also recommended within 6 weeks after delivery, even in the absence of additional risk factors.
Antenatal thromboprophylaxis in patients with previous VTEC, if indicated, should be started as early as possible during pregnancy.
The timing of thromboprophylaxis in the presence of transient risk factors is determined by the clinical condition:
- with indomitable vomiting of pregnant women, it is recommended to prescribe thromboprophylaxis with LMWH until the condition resolves;
- with mild OHSS, prophylaxis of LMWH should be carried out in the first trimester of pregnancy;
- with moderate and severe OHSS, it is necessary to carry out prophylaxis with LMWH within 3 months after the syndrome is resolved;
- during pregnancy with in vitro fertilization (IVF) and the presence of three other risk factors, thromboprophylaxis with LMWH should be performed starting in the first trimester of pregnancy.
Pharmacological prevention of thromboembolic complications after childbirth
In women with two or more persistent risk factors listed in table. 1, consideration should be given to the use of LMWH within 10 days after delivery in prophylactic doses appropriate to their body weight.
All women after an emergency caesarean section should receive thromboprophylaxis with LMWH within 10 days after delivery. In women with elective caesarean section, consideration should be given to thromboprophylaxis with LMWH within 10 days postpartum if additional risk factors are present (Table 1).
In all women with grade III obesity (BMI 40 kg / m 2 or more), prophylactic use of LMWH should be considered within 10 days after delivery in doses appropriate to their body weight.
The first thromboprophylactic dose of LMWH, if indicated, should be administered after childbirth during the first day, but not earlier than 6 hours after spontaneous delivery and not earlier than 8-12 hours after cesarean section, provided that hemostasis is reliable.
In women with a history of thrombosis, thrombophilia and / or a family history of VTEC, thromboprophylaxis should be continued for 6 weeks; in women after a cesarean section, with obesity or with concomitant somatic pathology, as well as with an increase in hospital stay for more than 3 days, thromboprophylaxis should be continued for 10 days.
In women with additional persistent (lasting more than 10 days after delivery) risk factors, such as prolonged hospitalization, wound infection or surgery in the postpartum period, thromboprophylaxis should be extended to 6 weeks or until additional risk factors disappear.
Regional methods of anesthesia should not be used, if possible, for at least 12 hours after the administration of the prophylactic dose of LMWH and within 24 hours after the administration of the therapeutic dose of LMWH.
LMWH should not be given within 4 hours after spinal anesthesia or after removal of the epidural catheter. The epidural catheter should not be removed within 12 hours of the last LMWH injection.
Indications for testing for thrombophilia from the point of view of VTEC prevention
Currently, the indications for testing for thrombophilia are significantly limited; it should only be done if the results influence the management of the patient. The examination should be carried out before the onset of pregnancy, as pregnancy can affect the result of the research.
A woman whose several relatives have had thrombosis should be considered as a carrier of antithrombin deficiency, and its detection may influence the decision about prevention.
Women with unprovoked VTEC should be tested for antiphospholipid antibodies (lupus anticoagulant, antibodies to IgG / IgM cardiolipin and IgG / IgM β2-glycoprotein) to exclude APS.
A history of unprovoked thrombosis or thrombosis associated with estrogen intake or pregnancy is an indication for prophylaxis. In this case, there will be no additional benefit from testing for thrombophilia.
The tactics of VTEC prevention can be influenced by the detection of certain types of thrombophilia during pregnancy: when an antithrombin or APS deficiency is detected, the dose of drugs used for thromboprophylaxis changes, which determines the feasibility of this examination.
Prevention of obstetric complications associated with pathology of the hemostatic system (thrombophilic risk)
Considering that physiological hypercoagulation of pregnancy contributes to pathological thrombosis (clinical manifestations of a tendency to thrombosis), including those with microcirculation disorders in the fetoplacental complex, an assessment of the risk of not only thrombotic, but also obstetric complications is necessary for every woman at the planning stage and during pregnancy.
The criteria for assessing the risks and tactics of preventing obstetric complications associated with the activation of the hemostasis system have not yet been finally determined. In the professional communities of obstetricians-gynecologists, hematologists-hemostasiologists, anesthesiologists-resuscitators, specialists in assisted reproductive technologies, discussions continue and opinions are expressed, ranging from complete rejection of the prophylactic prescription of LMWH to their indiscriminate use in almost all pregnant women.
Based on the vast experience of various schools in St. active discussion and consideration of various points of view came to the following conclusions.
Anamnestic data, including obstetric, somatic and family history of a woman, are leading in assessing the risk of obstetric complications associated with pathologies of hemostasis, and should be stratified repeatedly in each woman simultaneously and even in advance compared to screening coagulogram tests, including the determination of the concentration of D-dimers ...
A burdened personal obstetric history includes:
1) fetal loss syndrome:
- one or more cases of spontaneous termination of pregnancy after a period of more than 10 weeks (with the exclusion of anatomical, genetic and hormonal causes of miscarriage);
- stillbirth of a morphologically normal fetus;
- neonatal death as a complication of premature birth, preeclampsia (severe preeclampsia) and / or placental insufficiency, confirmed by histological examination;
- three or more cases of spontaneous abortion up to 10 weeks of gestation with the exclusion of anatomical, genetic and hormonal causes of miscarriage;
2) preeclampsia (severe preeclampsia) / HELLP-syndrome, premature placental abruption;
3) delayed fetal development;
4) three or more failures of ART (excluding artificial insemination due to male factor of infertility).
When assessing the risk of obstetric complications, it is also advisable to take into account:
1) burdened family obstetric history: recurrent miscarriage, stillbirth or severe preeclampsia in relatives);
2) burdened personal thrombotic history: thrombosis of various localization, strokes, transient ischemic attacks, heart attacks;
3) burdened family thrombotic history: thrombosis of various localization, strokes, heart attacks in first-line relatives under the age of 50;
4) burdened personal somatic history: lung and heart diseases, systemic autoimmune diseases (for example, systemic lupus erythematosus), cancer, arterial hypertension, varicose veins (segmental varicose veins), obesity (BMI> 30 kg / m 2), inflammatory bowel diseases , nephrotic syndrome, type 1 diabetes mellitus, sickle cell anemia, smoking, intravenous drug use;
5) the age of the pregnant woman is over 35 years old.
The risk stratification of pregnancy complications associated with hemostasis pathology should be carried out, if possible, before pregnancy, at the time of establishing the fact of uterine pregnancy or registration, and then repeatedly, depending on the course of pregnancy.
The obstetric risk factors for gestational complications that have arisen against the background of this pregnancy include:
1) multiple pregnancy;
2) the use of ART (ovulation induction, IVF);
3) OHSS;
4) severe toxicosis of the first half of pregnancy.
Genetic analysis for thrombophilia, determination of the level of homocysteine and antiphospholipid antibodies are the main laboratory tests in assessing the risk of pregnancy loss and the formation of obstetric complications.
Hereditary thrombophilia, including a deficiency of antithrombin, protein C, protein S, a mutation in the coagulation factor V gene (Leiden mutation) and a mutation in the prothrombin gene G20210A, are undoubted risk factors for placental-associated obstetric complications due to microthrombus formation and circulatory disorders of placental fetuses. Polymorphisms of other components of the hemostasis system are widespread in the population; their clinical significance in the formation of thrombosis and obstetric complications has not been proven.
Carriage of antiphospholipid antibodies can be significant for the development of pregnancy complications. The main criterion antibodies for the diagnosis of APS in accordance with international recommendations are lupus anticoagulant, anticardiolipin antibodies and antibodies to β2-glycoprotein I (IgG and IgM class). Nevertheless, additional testing of other antibodies (to annexin V, prothrombin, phosphatidylserine, phosphatidylinositol, phosphatidyl acid, double-stranded DNA, antinuclear factor, etc.) may be useful in women with a history of obstetric complications, but without clear clinical or laboratory criteria for classical AFS. However, the assessment of their presence and clinical conclusions, including for the appointment of anticoagulant protection, can only be discussed in conjunction with anamnestic data and data on the course of this pregnancy with the participation of a multidisciplinary team.
The result of a comprehensive assessment of anamnestic, clinical and laboratory data may be the basis for the use of drugs in pregnant women that reduce the thrombotic potential in the vascular-platelet and plasma link.
LMWH are the drugs of choice for the prevention of placental-mediated complications in pregnant women.
Patients with known hereditary thrombophilia and obstetric risk factors that have arisen during this pregnancy should consider prescribing LMWH in prophylactic doses in the antenatal period.
With a combination of a burdened obstetric history, somatic history and / or age over 35 years, consider prescribing antiplatelet agents (low doses of acetylsalicylic acid - 50-100 mg per day) and / or prophylactic doses of LMWH. The decision is made as part of a multidisciplinary team.
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In the case of a confirmed APS (Table 2), without a history of thrombosis, low doses of aspirin (50-100 mg / day) are recommended at the planning stage with the addition of LMWH in a prophylactic dose from the moment of confirmation of uterine pregnancy.
In the case of incomplete clinical and laboratory criteria for APS and a complicated obstetric history, regardless of the presence of additional risk factors, low doses of acetylsalicylic acid (50-100 mg / day) are recommended at the planning stage or prophylactic doses of LMWH from the moment of confirmation of uterine pregnancy. The decision is made as part of a multidisciplinary team.
Additional laboratory tests assessing the degree of hypercoagulable disorders, such as thrombin generation test, thrombodynamics, thromboelastography / metry, should be evaluated with caution in pregnant women. Currently, there is insufficient data for the introduction of these tests into wide clinical practice or for making clinical decisions based on their results in a particular patient.
Timely correction of violations in the hemostasis system, carried out taking into account all clinical and laboratory data, can significantly reduce the risk of complications for the mother and fetus.
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Literature
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- Giannakopoulos B., Passam F., Ioannou Y., Krilis S. A. How we diagnose the antiphospholipid syndrome // Blood. 2009; 113: 985.
- Bertolaccini M. L., Gomez S., Pareja J. F. et al. Antiphospholipid antibody tests: spreading the net // Ann Rheum Dis. 2005; 64: 1639.
- Royal College of Obstetricians and Gynaecologists. Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. Green-top Guideline No. 37 a. London: RCOG; 2015 https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37 a.pdf. Last accessed 10.11.2016.
- Kjellberg U., van Rooijen M., Bremme K., Hellgren M. Factor V Leiden mutation and pregnancy-related complications // Am J Obstet Gynecol. 2010; 203: 469.e1.
- Said J. M., Higgins J. R., Moses E. K. et al. Inherited thrombophilia polymorphisms and pregnancy outcomes in nulliparous women // Obstet Gynecol. 2010; 115: 5.
- Rodger M. A., Betancourt M. T., Clark P. et al. The association of factor V leiden and prothrombin gene mutation and placenta-mediated pregnancy complications: a systematic review and meta-analysis of prospective cohort studies // PLoS Med. 2010; 7: e1000292 7.
- Silver R. M., Zhao Y., Spong C. Y. et al. Prothrombin gene G20210 A mutation and obstetric complications // Obstet Gynecol. 2010; 115: 14.
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- Girardi G., Redecha P., Salmon J. E. Heparin prevents antiphospholipid antibody-induced fetal loss by inhibiting complement activation // Nature medicine. 2004; Vol 10, 11; 1222-1226.
- Nelson S. M., Greer I. A. The potential role of heparin in assisted conception // Human Reproduction Update, 2008; Vol. 14, no. 6, p. 623-645.
- Rovere-Querinia P., D'Angeloc A., Maugeri N. Low molecular weight heparins prevent the induction of autophagy of activated neutrophils and the formation of neutrophil extracellular traps // Pharmacol Res. 2017; 1043-6618. 2016 Elsevier Ltd.
- Shamer E. et al. Microvesicles of pregnant women receiving low molecular weight heparin improve trophoblast function // Thromb Res. 2016; 137.141-147.
- Tormene D., Grandone E., de Stefano V. et al. Obstetric complications and pregnancy-related venous thromboembolism: The effect of low-molecular-weight heparin on their prevention in carriers of factor V Leiden or prothrombin G20210 A mutation // Thromb Haemost. 2012: 107/3 (Mar), p. 397-599.
- Bouvier S., Cochery-Nouvellon E., Lavigne-Lissalde G. et al. Comparative incidence of pregnancy outcomes in thrombophilia-positive women from the NOH-APS observational study // Blood. 2014; 123: 414-421.
- Dobbenga-Rhodes Y. et al. Shedding Light on Inherited Thrombophilias, The Impact on Pregnancy, J Perinat Neonat Nurs. 2016, March, vol. 30, no. 1, 36-44.
- Bates S. M., Greer I. A., Middeldorp S. et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines // Chest. 2012; 141: e691S.
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- Empson M., Lassere M., Craig J. C., Scott J. R. Recurrent pregnancy loss with antiphospholipid antibody: a systematic review of therapeutic trials // Obstet Gynecol. 2002; 99: 135.
- Tincani A., Branch W., Levy R. A. et al. Treatment of pregnant patients with antiphospholipid syndrome // Lupus. 2003; 12: 524.
- Derksen R. H., Khamashta M. A., Branch D. W. Management of the obstetric antiphospholipid syndrome // Arthritis Rheum. 2004; 50: 1028.
- Kutteh W. H., Rote N. S., Silver R. Antiphospholipid antibodies and reproduction: the antiphospholipid antibody syndrome // Am J Reprod Immunol. 1999; 41: 133.
- Fishman P., Falach-Vaknin E., Sredni B. et al. Aspirin modulates interleukin-3 production: additional explanation for the preventive effects of aspirin in antiphospholipid antibody syndrome // J Rheumatol. 1995; 22: 1086.
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- Stevens S. M., Woller S. C., Bauer K. A., Kasthuri R., Cushman M., Streiff M., Lim W., Douketis J. D. Guidance for the evaluation and treatment of hereditary and acquired thrombophilia // J Thromb Thrombolysis. 2016; 41: 154-164.
- Russian clinical guidelines (protocol). Prevention of venous thromboembolic complications in obstetrics and gynecology. 2014, 10.
Venous thromboembolic complications- deep vein thrombosis (DVT), superficial vein thrombosis (TPV) and pulmonary embolism (PE).
Thrombophilia- a condition characterized by a tendency to pathological thrombus formation in blood vessels of different localization (mainly veins) due to violations of the composition and properties of blood.
Hereditary thrombophilia- deficiency of natural anticoagulants - antithrombin, protein C, protein S, mutation of the blood coagulation factor V gene (Leiden mutation) and mutation of the prothrombin gene G20210A. Assessment of the state of the anticoagulant system is carried out according to their functional activity as part of the study of the coagulogram; the result is presented in%. Mutations in the genes of coagulation factors V and II are detected using polymerase chain reaction (PCR diagnostics). Homozygous carriage of a pathological allele is extremely rare and belongs to severe risk factors for thrombosis (increased risk from 7 to 80 times). Heterozygous carriage refers to weak risk factors (3.5-6 times). None of the hereditary thrombophilia affects the occurrence of relapses, with the exception of antithrombin deficiency, and then only to a weak extent (increased risk by 2.6 times) (2016).
Antiphospholipid Syndrome (APS)- an acquired form of thrombophilia, which is an autoimmune multisystem disorder with occlusive vascular lesions (arteries and veins) as a result of the formation of antibodies to protein-phospholipid complexes of cytoplasmic membranes. APS is diagnosed in accordance with the international criteria adopted in Sydney in 2005: the presence of clinical signs (venous or arterial thrombosis and fetal loss, classified according to gestational age) and laboratory signs (persistent lupus anticoagulant and / or persistent antibodies to cardiolipin IgG / IgM and / or β2? IgG / IgM glycoprotein in moderate / high titer) (Table 2). Other forms of antiphospholipid antibodies (antibodies to annexin V, prothrombin, phosphotidylserine, etc.) are not the basis for the diagnosis of antiphospholipid syndrome, but are considered as a risk factor for pregnancy complications.
Hyperhomocysteinemia- mixed (hereditary and acquired) form of thrombophilia, characterized by an increase in the level of homocysteine in the blood exceeding 15 μmol / L, and weakly associated with venous and arterial thrombosis. Intermediate and high homocysteine concentrations (31-100 µmol / L and> 100 µmol / L) are more severe risk factors, especially when combined with smoking.
M. A. Repina *,
L. P. Papayan **, Doctor of Medical Sciences, Professor
T.V. Vavilova ***,Doctor of Medical Sciences, Professor
I. E. Zazerskaya ***, Doctor of Medical Sciences
M. S. Zainulina ****, Doctor of Medical Sciences, Professor
T. M. Korzo *,Candidate of Medical Sciences
S. A. Bobrov *, 1Candidate of Medical Sciences
E. A. Kornyushina *****,Candidate of Medical Sciences
* FGBUVO North-Western State Medical University named after I. I. Mechnikov, Ministry of Health of the Russian Federation, St. Petersburg
** FSBI RosNIIGT FMBA of Russia, St. Petersburg
*** FGBU SZFMITS them. V. A. Almazov, Ministry of Health of the Russian Federation, St. Petersburg
**** SPb GBUZ Maternity hospital № 6 named. prof. V. F. Snegireva, St. Petersburg
***** FGBNU NII AGiR them. D.O. Ott, St. Petersburg
Interdisciplinary expert council for the development of recommendations (protocol) "Management of pregnant women at risk of thrombosis and complications of pregnancy against the background of activation of the hemostasis system" / M. A. Repina, L. P. Papayan, T. V. Vavilova, I. E. Zazerskaya, M. S. Zainulina, T. M. Korzo, S. A. Bobrov, E. A. Kornyushina.
For citation: Attending physician no. 11/2017; Page numbers in the issue: 57-64
Tags: pregnant women, thrombophilia, antiphospholipid syndrome, hyperhomocysteinemia
The plan for the examination and management of physiological pregnancy is based on the order of the Ministry of Health of the Russian Federation 572N. The EMC clinic uses a physiological pregnancy management program developed on the basis of this order.
Pregnancy management is a complex of medical and diagnostic measures aimed at the safe bearing and birth of a healthy baby. A woman expecting a baby is provided not only with the necessary medical, but also informational and psychological support.
Primary reception
The first visit to the doctor may occur when menstruation is delayed by 2-3 weeks. A diagnostic ultrasound scan is performed, the purpose of which is to visualize the uterine pregnancy. If pregnancy is diagnosed very early, a second diagnostic ultrasound may be needed to confirm that the pregnancy is progressing. As a rule, from the 6th week, the heartbeat of the embryo is already recorded.
When do you need to register?
For effective management of pregnancy and the timely identification of individual characteristics and probable complications, it is recommended to undergo all the necessary clinical tests before 12 weeks.
Medical supervision of pregnancy is necessary, even if it proceeds without complications.
Features of pregnancy management in each trimester
Pregnancy management has its own characteristics in each trimester.
With a normal pregnancy, the frequency of calls for pregnancy should be at least 7 times (according to order No. 572).
- up to 32 weeks - once a month;
- from the 32nd week - once every 2 weeks;
- from the 36th week - once a week.
If, during the examination, any violations were found on the part of the health of the pregnant woman or the fetus, the frequency of visits increases. An individual schedule of visits to the gynecologist can be set.
Pregnancy management in the first trimester
After the initial visit to the doctor within the next 10-14 days, it is recommended to undergo all clinical studies prescribed by the gynecologist. Early diagnosis (up to 12 weeks) allows you to identify the main risk factors that threaten the normal course of pregnancy and take the necessary measures in a timely manner.
A standard general clinical examination includes:
blood chemistry;
coagulogram;
blood for syphilis, HIV, hepatitis B, C;
blood group and Rh factor;
analysis for TORCH-infections (T-toxoplasmosis, O-other infections, R-rubella, C-cytomegalovirus, H-herpes);
analysis for TSH (thyroid stimulating hormone);
smear for microflora;
smears for genital infections (PCR diagnostics);
smear for cytology.
You will also need consultations of narrow specialists - a therapist, ophthalmologist, otorhinolaryngologist, dentist and others (according to indications). Electrocardiography (ECG) is also done.
According to the order of the Ministry of Health of the Russian Federation 572N, the analysis for TORCH infection requires the mandatory determination of antibodies to toxoplasmosis and rubella.
The standard analysis for a coagulogram does not include D-dimer and contains the minimum indicators required to determine the parameters of hemostasis. An extended analysis is carried out when indicated.
If the pregnant woman is Rh negative, it is necessary to obtain information about the spouse's Rh and blood group. In the presence of Rh-negative blood type, every 4 weeks the expectant mother needs to donate blood for titers of antibodies to Rh. Further, for a period of 28-30 weeks, the prevention of Rh-conflict is carried out: the introduction of anti-D immunoglobulin 1500 IU intramuscularly once.
The standard STD swab is aimed at ruling out chlamydia.
A cytological smear is taken from the cervix by scraping. It is performed once, and it should be done as early as possible.
Prenatal ultrasound screening with morphological examination
In the first trimester, in the interval of 11-13 weeks, prenatal screening is carried out, aimed at identifying risks for the chromosomal pathology of the fetus.
Additionally, according to indications, the doctor may recommend to undergo other tests: NIPT (non-invasive prenatal test) or, if necessary, invasive diagnostics.
Second trimester pregnancy management
According to the order, in the second trimester, in addition to standard clinical studies of blood and urine, a bacteriological culture of urine is prescribed.
Also in the second trimester, a morphological ultrasound of the fetus is performed. The survey is carried out from 18 to 20 weeks. It is aimed at a complete study of the anatomical structures of the fetus. This EMC study is carried out by an expert physician.
In the EMC clinic, after morphological ultrasound, ultrasound fetometry can additionally be carried out - the measurement of the biometric parameters of the fetus, aimed at monitoring the growth rate of the fetus.
In the second trimester, the expectant mother needs to undergo another important examination - a glucose tolerance test, aimed at identifying or excluding gestational diabetes mellitus. According to the standards, it runs from 24 to 28 weeks.
Pregnancy management in the third trimester
In the third trimester at 30 weeks, the main general clinical tests are repeated:
clinical analysis of blood and urine;
blood chemistry;
coagulogram;
analysis for syphilis, HIV, hepatitis B, C;
smear for microflora;
sowing for group B streptococcus;
morphological ultrasound of the fetus with dopplerometry;
cardiotocography.
Also, at 30 weeks, a second consultation of narrow specialists is required.
Physiological childbirth can occur within 38-41 weeks. This is individual and depends on the initial parameters of the course of pregnancy, the presence of concomitant pathology, etc.
Advantages of contacting EMC:
Management of pregnancy and childbirth of any complexity: in patients with concomitant diseases, with a scar on the uterus or with multiple pregnancies.
A team of doctors with experience in clinics in Europe, the USA and Israel.
Comfort and pleasure of your stay: deluxe and deluxe studios, family suites.