The degree of risk of 15 points on the exchange card. A method for assessing the risk of risk of pregnancy and upcoming genera with the help of the scale of monitoring of pregnant women risk groups. The main critical moments of the perinatal prediction system
To determine the degree of risk of perinatal pathology, an indicative scale of estimating prenatal risk factors is proposed, in points; The scale is used taking into account the individual characteristics of the anamnesis, the flow of pregnancy and childbirth.
Evaluation of prenatal risk factors (O.G. Frolova, E.I. Nikolaev, 1980)
Risk factors \u003d score in points
Socio-biological factors
Mother's age:
younger than 20 years \u003d 2
30-34 years \u003d 2
35-39 years \u003d 3
40 years old older \u003d 4
Father's age:
40 years and more \u003d 2
Professional Harm:
Mother \u003d 3
Father \u003d 3
Bad habits
mother:
Smoking (one pack of cigarettes per day) \u003d 1
Alcohol abuse \u003d 2
father:
Alcohol abuse \u003d 2
Mother's emotional loads \u003d 2
Growth and mass of the mother's body:
Height 150 cm and less \u003d 2
Body weight 25% higher than normal \u003d 2
Obstetric and gynecological history
Parity (number of preceding childbirth):
4-7=1
8 or more \u003d 2
Abortions before childbirth at primordin:
1=2
2=3
3 or more \u003d 4
Abortions in the intervals between childbirth:
3 or more \u003d 2
Premature childbirth:
1=2
2 or more \u003d 3
Straw:
1=3
2 or more \u003d 8
Death of children in the neonatal period:
one child \u003d 2
two or more children \u003d 7
Anomalies of development in children \u003d 3
Neurological disorders in children \u003d 2
The mass of the bodies of day-old children is less than 2500 g or 4000 g and more \u003d 2
Infertility:
2-4 years \u003d 2
5 years and more \u003d 4
Scar on the uterus after surgery \u003d 3
Tumors of uterus and ovarian \u003d 3
Eastic and cervical insufficiency \u003d 2
Vices for the development of the uterus \u003d 3
Extgazenital diseases of pregnant
Cardiovascular:
Heart defects without circulatory disorders \u003d 3
Vices of the heart with blood circulation impairment \u003d 10
Hypertensive disease I-II-III stages \u003d 2-8-12
Vegeta dystonia \u003d 2
Diseases of the kidneys:
Before pregnancy \u003d 3
Exacerbation of the disease during pregnancy \u003d 4
Adrenal diseases \u003d 7
Diabetes \u003d 10
Sugar diabetes in relatives \u003d 1
Thyroid disease \u003d 7
Anemia (hemoglobin content of 90-100-110 g / l) \u003d 4-2-1
Blood coagulation violation \u003d 2
Myopia and other eye diseases \u003d 2
Chronic infections (tuberculosis, brucellosis, syphilis, toxoplasmosis, etc.) \u003d 3
Acute infections \u003d 2
Complications of pregnancy
Pronounced early toxicosis of pregnant women \u003d 2
Late toxicosis of pregnant women:
Wasyanka \u003d 2.
Nephropathy of pregnant women I-II-III degrees \u003d 3-5-10
Preeclampsia \u003d 11.
Eclampsia \u003d 12.
Bleeding in the first and second half of pregnancy \u003d 3-5
Rhow and AV0-Isossentialization \u003d 5-10
Multi-way \u003d 4.
Major \u003d 3.
Pelvic presence of the fetus \u003d 3
Multiple \u003d 3.
Transferred pregnancy \u003d 3
Incorrect position of the fetus (transverse, oblique) \u003d 3
Pathological states of the fetus and some indicators of violation of its livelihoods
Fetal hypotrophy \u003d 10
Hypoxia fetal \u003d 4
Estor content in daily urine
less than 4.9 mg in 30 weeks. Pregnancy \u003d 34.
less than 12 mg in 40 weeks. Pregnancy \u003d 15.
Changes in amnicopopia \u003d 8
With the amount of points 10 and more - the risk of perinatal pathology is high, with the amount of 5-9 points - the average, with the amount of 4 points and less - low. Depending on the degree of risk, an obstetrician-gynecologist of the female consultation is an individual plan of dispensary observation, taking into account the specifics of the available or possible pathology, including special research in order to determine the state of the fetus: electrocardiography, ultrasound research, amnioscopy, etc. With a high risk of perinatal pathology, it is necessary to resolve On the feasibility of pregnancy preservation. Risk assessment is carried out at the beginning of pregnancy and in 35-36 weeks. To address the issue of hospitalization terms. Pregnant women with a high risk of perinatal pathology should be hospitalized for childbirth in a specialized hospital.
KTG (cardiotokography) is a method for studying the heartset of the fetus and uterine contractions in pregnant women, in which all record data is fixed on a special tape. Church indicators in the child will depend on some factors, such as: time of day, and on the presence of risk factors.
-
In which cases is assigned to ktg?
How are the end indicators of the CTG decryp?
Deciphering the final, is carried out by a specialist, taking into account such data as: CSS variability of the Fetal, basal rhythm, activation, deceration and motor activity of the fetus. Such indicators at the end of the survey are displayed on the tape, and have the form of graphs, different in shape. So, consider Read more above the listed indicators:
- The variability (or amplitude) is called the impairment of the frequency and the regularity of the contractile rhythm movements and the amplitude of the hearts, which are based on the obtained results of the basal rhythm. If there is no pathology for the development of the fetus, the EFS indicators should not be monotonous, it is clearly visible by visualizing the constant change of numerical indicators on the monitor during the CTG survey. Changes within the normal range can vary in the range of 5-30 beats per minute.
- Basal rhythm is indicated by the average figure of the Church. The rate indicators are the heartbeat from 110 and to 160 shots in one minute during the peace of fetus and women. If the child is actively moving, the heart rate will stay from 130 to 180 shots in the continuation of one minute. Basal rhythm indicators within the norm mean the absence of a hypoxic state of the fetus. In cases where the indicators are lower than the norm or higher, it is considered that there is a hypoxic state that adversely affects the nervous system of the kid, which is in underdeveloped state.
- Under the activation implies a rapid amount of heartbeat, relatively level of basal rhythm. The activation indicators are reproduced on the cardiotocogram in the form of teeth, the norm is from two to three times in 10-20 minutes. Perhaps not a large increase in rapidity up to four times in 30-40 minutes. The pathology is considered if the activation is not at all over a period of 30-40 minutes.
- Decomleration is a decrease in the frequency of heart blows relatively with the degree of basal rates of cardiac rhythm. Indicators of deceleration have the form of failures or in a different negative teeth. Within the normal functioning of the fetus, these indicators must be completely absent or completely shown in depth and duration, and very rarely meet. After 20-30 minutes of the CTG study during the manifestation of deceleration, suspicions arise in the deterioration of the state of the future kid. Big concern in the development of the fetus causes the re-and diverse manifestation of deceration during the entire survey. This can be a signal about the presence of decompensated stress in the fetus.
The importance of fetal state indicators (PSP)
After the graphic results of the CTG studies are ready, the specialist determines the value of the fetal status indicators. For the normal development of the child, these values \u200b\u200bwill be less than 1. When the PSP indicators are from one to two, this suggests that the state of the fetus begins to deteriorate and some not favorable changes appear.
When the PSS indicators are over three, it means that the fruit is in critical condition. But with only such data, the specialist cannot accept any decisions, first will be considered a fully history of pregnancy.
It should be understood that not only the pathological processes in the development of the baby may cause the rejection of the indicators from the norm, these may also be some states of pregnant and kid who do not depend on violations (for example, elevated temperature indicators in a pregnant woman or if the baby is in a state sleep).
What CTG points are considered the norm when conducting a CTG, considered pathology?
The results of cardiotockography are estimated at the Fisher's special point - assignment of 0-2 points to each of the above indicators. Then the points are summed up and the general conclusion is made on the presence or absence of pathological changes. The result of the CTG from 1 to 5 points declares an unfavorable forecast - the development of hypoxia in the fetus, 6 is a ball value can talk about beginner oxygen deficiency.
What does the assessment of KTG 7 points in the conclusion?
KTG 7 points - such an assessment is considered an indicator of the beginning of the oxygen deficiency of the fetus. In this state, the specialist appoints appropriate treatment to avoid the emergence of hypoxia, as well as to improve the condition of the baby if it is presented. When evaluating in 7 points on the 32 week, therapeutic measures begin to carry out without slowing. A doctor who is observing the course of pregnancy may urgently send a woman to inpatient treatment or limit himself to droppers at day hospital.
During the facilitated stage of starvation with oxygen, they cost more frequent and long stay in the fresh air, if the weather allows. Or the method of medication to prevent this state.
Even if after decrypting the CTG survey, the specialist determines the result of 7 points, which are an alarming mark, do not panic, because modern medicine will be able to help the future kid get rid of this state.
With the identified pathological processes in the baby, which are a reaction to the contraction of the uterus, it is necessary to urgently with the results of the study, refer to the gynecologist. After evaluating the results, the specialist will be able to assign competent treatment, as well as send to a repeated passage of KTG.
The value of the assessment of KTG 8 points
Very many future mothers are interested in the question of 8 ball values \u200b\u200bof the CTG, are these indicators cause for concern? KTG 8 points shows the lower limit of the norm, and such a state of the fetus usually does not require the conduct of medical measures or hospitalization.
What value are estimates in 9 and 10 points?
Normal values \u200b\u200bare estimated 9 and 10 points. These indicators may mean one thing that the development of the fetus passes well, without the development of pathologies. Evaluation of 10 points suggests that the state of the future kid within the normal range.
What pathological processes can be revealed in the study of KTG?
How to perceive the results of the CTG? Relying only on the obtained data of the CTG, it is impossible to finally determine the diagnosis, since pathological deviations from 10 points norms may be a temporary state in response to any external stimulus. This technique is easy to execute and will help without any special cost to identify deviations from the norm in the development of the fetus.
The KTG method will help identify the following pathologies:
When deviations from the norm were revealed when deciphering KTG, the doctor prescribes an ultrasound as well. If required, pregnant pain and re-CTG.
Hello, hope! I am not a gynecologist and I can not say for sure what it is meant in these two lines. Still, it is better to ask the doctor himself about it. But, as I can guess, the doctor identified prenatal risk factors.
The course of pregnancy can be complicated by the development of the toxicosis of pregnant women, premature interruption or unimpressing, premature detachment of a normally located placenta. There is a violation of the development of the fetus, his death. A certain danger for the mother and fetus is an improper position of the fetus (oblique, cross position), the pelvic presence of the fetus, the anomalies of the placenta, many and low, multipleness. Heavy complications (uterine bleeding, premature interruption B., fetal death) may be a consequence of bubble drift. In the immunological incompatibility of the mother and the fetus, spontaneous miscarriages, toxicosis of pregnant women, hypoxia and fetal death are possible; As a result of sensitization of pregnant erythrocytic antigens of the fetus, hemolytic disease of the fetus and a newborn is developing. The pathological course of pregnancy and disruption of the development of the fetus may be observed in the presence of certain extragenital and gynecological diseases.
With the amount of points 10 and more - the risk of perinatal pathology is high, with the amount of 5-9 points - the average, with the amount of 4 points and less - low. Depending on the degree of risk, an obstetrician-gynecologist of the female consultation is an individual plan of dispensary observation, taking into account the specifics of the available or possible pathology, including special research in order to determine the state of the fetus: electrocardiography, ultrasound research, amnioscopy, etc. With a high risk of perinatal pathology, it is necessary to resolve On the feasibility of pregnancy preservation. Risk assessment is carried out at the beginning of pregnancy and in 35-36 weeks. To address the issue of hospitalization terms. Pregnant women with a high risk of perinatal pathology should be hospitalized for childbirth in a specialized hospital.
You can also read additional information on the links: http://bonoxese.ru/blizzard/aku/factor_r.html, http://cureplant.ru/index.php/medicinskaya-enciklopedia/1035-perinatalnaja-patologija
But it is better to talk to the doctor, suddenly I am mistaken ...
Additionally
Health Department of Primorsky Territory
ORDER
On the introduction of a new perinatal risk assessment scale
In order to improve the quality of medical care for the abuse of "Obstetrics and Gynecology" in accordance with the decision of the XVI All-Russian Scientific Forum "Mother to Child" 2015 Ordering:
1. Include in the Medical Organizations of the Primorsky Territory, the scale of the degree of perinatal risk (hereinafter - the scale) in accordance with the recommendations of the XVI All-Russian Scientific Forum "Mother and Child" 2015
2. In the accounting forms "Individual map of the pregnant and herds" and "History of childbirth" to replace the sheet "Divider an estimation scale of perinatal risk" according to Appendix 1.
3. To determine the level of medical care and obstetric tactics according to the new scale.
4. Responsibility for the execution of the order to impose on the chief specialist of the department of medical care to women and children E.V. Joke.
Director Department
A.V.Kuzmin
Attachment 1
Perinatal risk
N outpatient card: ____
FULL NAME. Patients: _____________________________________________________
___________________________________________________________________________
Date of Birth: ____________________________________________________________
Address: ____________________________________________________________________
First day of the last menstruation: ________________________________________
First ultrasound ____________________ / _____________________
(date) (term)
Estimated delivery time: ________________________________________________
Date of registration: ________________, pregnancy weeks ____________
Pregnancy in account ______________, childbirth _______________________
___________________________________________________________________________
Screening results: _________________
First screening: ______________________ points
Second screening: ______________________ points
Third screening: ______________________ points
The amount of points to childbirth: ________________ points
Intranatal increase: _______________ points _______%
Total scores: ___________________
___________________________________________________________________________
Anamnestic factors, first screening - at the first turn of pregnant
Date: ______________________________________
Gestation period: _____________________________
Doctor, Fm.o. _______________________________
Signature: ___________________________________
Risk factors (emphasize available) | |
Socio-biological |
|
Mother's age: | |
Less than 18 years old | |
40 years and more | |
Father's age: 40 years and more | |
Professional Harm: | |
In the mother | |
Harmful habits from the mother: | |
Smoking one pack of cigarettes per day | |
Alcohol abuse | |
Father's bad habits: | |
Alcohol abuse | |
Marital status: Lonely | |
Emotional loads | |
Growth and weight indicators of the mother: | |
Height 158 \u200b\u200bcm and less | |
Body weight by 25% above the norm | |
Sum of points (a) | (Enter the amount) |
Obstetric and gynecological history |
|
8 or more | |
Abortions in front of the first upcoming births: | |
Three or more | |
Abortion before repeat. childbirth or after the last birth: | |
Three or more | |
Intrauterine interventions | |
Premature childbirth: | |
Two or more | |
Strawing, unbearable, undevelopable pregnancy: | |
One case | |
Two cases and more | |
Death in the neonatal period: | |
One case | |
Two cases and more | |
Development Anomalies in children born earlier | |
Neurological violations in children born earlier | |
Mass of duplicate children up to 2500 g, 4000 g and more | |
Infertility: | |
24 years | |
5 years and more | |
Scar in the uterus after surgery | |
Tumors of uterus and / or ovaries | |
Eastic-cervical insufficiency, benign diseases, deformation, transferred destruction of the cervix | |
Vices for the development of uterus | |
Chronic inflammatory processes of appendages, complications after abortion and childbirth, intramatic contraceptive | |
Ectopic pregnancy | |
Auxiliary reproductive technologies: | |
Intracitoplasmic spermatozoa injection | |
The amount of points (b) | (Enter the amount) |
Extgazenital diseases of the mother |
|
Cardiovascular: | |
Heart defects without circulatory disorders | |
Circulatory violations | |
Chronic arterial hypertension 1 - 3rd stage | |
Varicose disease | |
Hypotensive syndrome | |
Kidney disease | |
Endocrinopathy: | |
Adrenal diseases, neuro-exchange endocrine syndrome | |
Diabetes | |
Diseases of thyroid gland | |
Obesity | |
Coagulopathy | |
Myopia and other eye diseases | |
Chronic specific infections (tuberculosis, brucellosis, toxoplasmosis, etc.) | |
Positive reaction to the lupus anticoagulant | |
Antibodies to phospholipids: | |
IgG from 9.99 and above | |
Igm from 9.99 and above | |
The amount of points (B) | (Enter the amount) |
The amount of points for anamnestic factors (g) | (Enter the amount) |
Pregnancy factors. The second screening - at 28 - 32 weeks; Third screening - at the end of pregnancy<*>
________________
<*> - Filled as information accumulates.
Second screening
Third screening
Date: ____________________________________________
Gestation period: ___________________________________
Doctor, Full name: ____________________________________
Signature: _____________________________________
Complications of pregnancy (emphasize available) | Score in points (circle available) |
|
Expressed early toxicosis | ||
Recurrent threat to interrupts | ||
Maternity swelling | ||
Easy degree | ||
Middle degree | ||
Heavy degree | ||
Preeclampsia | ||
Eclampsia | ||
Aggravation of kidney disease during pregnancy | ||
Acute infections during pregnancy, incl. Acute respiratory viral | ||
Negative Rhow Factor or AV0-Sensitization | ||
Multi-way | ||
Malovodie | ||
Pelvic presence of the fetus, large fruit, narrow pelvis | ||
Multi-flow | ||
Running pregnancy | ||
Wrong fetal position (transverse, oblique) | ||
Biological immaturity of generic pathways in 40 weeks. Pregnancy | ||
Screening |
||
betta Hgch: | ||
Increased content | ||
Reduced content | ||
Increased content | ||
Reduced content | ||
Increased content | ||
Reduced content | ||
The amount of points (e) | ||
(Enter the amount) |
||
Estimation of the state of the Future |
||
Fetal hypotrophy: | ||
1st degree | ||
2nd degree | ||
3rd degree | ||
Chronic placental insufficiency | ||
Assessment of the CTG on the Fisher W.M. (points): | ||
Points (E) | ||
(Enter the amount) |
||
The amount of points by pregnancy factors (g) | ||
(Enter the amount) |
||
Total amount of points of prenatal factors (anamnestic factors and pregnancy factors) (s) | ||
(Enter the amount) |
||
Note. Copies with. 1 - 6 must be transferred along with the exchange card to the institution of objects.
Intranatal risk factors. The fourth screening is carried out in childbirth
N childbirth history: ____________________________
FULL NAME. Patients: ___________________________
Age: ____________________________________
Gestation period: ______________________________
The total amount of Prenatal Risk Points (I, II, III Screenings):
_____________________________________________
Intranatal complications (emphasize available) | date and time |
|||
Scores (circle available) |
||||
Mesconial coloring of amniotic waters | ||||
Prenatal power (in the absence of generic activities for 6 hours) | ||||
Pathological preliminary period | ||||
Anomalies of generic activity | ||||
Horioamnionit | ||||
The sum of the points of intranatal factors (and) | ||||
(Enter the amount) |
||||
The total amount of poles of perinatal risk (the sum of the points of the anamnestic factors, pregnancy factors and intranal recalculation) (K) | ||||
(Enter the amount) |
||||
Intranatal increase (the ratio of the amount of points of intranatal risk factors to the sum of the points of prenatal factors, in%) (L) | ||||
(Enter%) |
||||
Plan of completion of childbirth
_________________________________________________
_________________________________________________
_________________________________________________
Doctor, Full name: ___________________________________
Signature: ________________________________________
Determination of the degree of perinatal risk:
Low risk - up to 15 points;
Average risk - 15 - 24 points;
High risk - 25 points and more.
Screening scheme is presented in the table. Deciphering alphabetics is given later.
Screening algorithm for perinatal risk factors
Stage Screening | Doctor's Time and Action |
At the first turnout (anamnestic factors: |
|
At 28 - 32 weeks. (Pregnancy factors: (g) \u003d (e) + (e)) |
|
At the end of pregnancy (pregnancy factors: (g) \u003d (e) + (e)) |
|
Note | When conducting the II and III screening, the "total amount of prenatal factors" ((s) \u003d (g) + (g)) is calculated. |
During the I and II periods of childbirth (intranatal factors - (s)) |
|
Note | During labor when changing the clinical situation (the appearance of intranal risk factors specified in the scale) recalculate "the total amount of perinatal risk points" ((k) \u003d (h) + (and)), and also calculate the "intranatal increase" ((L) \u003d (And) / (h) x 100%) |
NB! The obstetric tactics in childbirth should be changed (staged joint inspection, therapeutic activities, operational delivery) in the following cases: |
|
In our country, the first perinatal risk scales were developed by L. S. Persianinov and O. G. Frolova (Table 7). Based on the study of these literature, its own clinical experience and multifaceted studies of childbirth stories when studying the causes of perinatal mortality, O. G. Frolova and E. I. Nikolaeva identified separate risk factors. These were attributed only to the factors leading to a higher level of perinatal mortality in relation to this indicator existing in the entire group of examined pregnant women. For a quantitative assessment of the significance of factors, a baller system was applied. The principle of assessing the degree of risk in points was as follows: each perinatal risk factor was estimated retrospectively on the basis of indicators of the evaluation of the newborn on the scale of apgar and the level of perinatal mortality. The degree of risk of perinatal pathology was considered high for children who received an estimate of 0-4 points on the apgar scale, the average - 5-7 points and low - 8-10 points. To determine the degree of influence of mother's risk factors for pregnancy and childbirth for the fetus, it was recommended to produce the total counting of all available antenatal and intranatal risk factors.
In principle, the scale of O. G. Frolova and L. S. Persianinova, with the exception of single differences, identical: each contains 72 perinatal risk factor, divided into 2 large groups: prenatal (a) and intranatal (B). Prenatal factors for the convenience of working with a scale are combined in 5 subgroups: 1) socio-biological; 2) obstetric-gynecological history; 3) Extragenate pathology; 4) complications of real pregnancy; 5) Estimation of the state of the fetus. The total number of prenatal factors was 52. Intranatal factors were also divided into 3 subgroups. Factors from: 1) Mother; 2) placenta and umbilical cord; 3) Fetal. This subgroup contains 20 factors. Thus, 72 risk factor was allocated.
Table 7.
Perinatal risk scale O. G. Frolova and E. I. Nikolaeva
The probability of the risk of adverse outcome of pregnancy and childbirth for the fetus and a newborn based on the created scale was divided into 3 degrees - high, middle and low. The group of pregnant women should investigate all pregnant women with a total estimate of the prenatal factors 10 points and more, to the middle risk group - 5-9 points low - up to 4 points. In addition, the presence of one factor estimated at 4 points was interpreted as a high degree of perinatal risk.
Dynamic changes over time
Along with the change in the frequency of the factor occurrence, the degree of influence of the unfavorable factor on the perinatal outcome can change. This continuous process is due to the development of diagnosis, improving therapeutic and preventive measures aimed at improving the health of the population.
Z. Tosovska and L. Hemalova when analyzing perinatal mortality over 20 years in the Prague clinic found that the value of such risk factors as the age of 30 years old and the mother's growth is less than 155 cm decreases over the past 10 years in the structure of perinatal mortality, and with the course Time to the fore The plan was made by new factors, such as bleeding during pregnancy, artificial abortion and pelvic presence, changed the overall picture of the somatic morbidity of pregnant women.
Over the past 20 years, a significant increase in the growth of extragationalital pathology has a significant increase in pregnant women (Fig. 4).
The boundaries of high perinatal risk defined using a scoring system for assessing risk factors over time are subject to even stronger changes. The value of a factor expressed in the number of points may decrease due to the development of therapeutic technologies or intensify due to the worsening of the population's health. Due to the development of diagnostics, new factors will appear, and accordingly their score assessment. As a result, it is impossible to create a single perinatal risk scale "for centuries", the system must continue to be complemented and overestimated, during modern information flow it should occur once every 15-20 years. However, this circumstance does not diminish the advantages of the scaling scale of risk, and on the contrary, its ability to modernization is one of its main advantages.
Modern condition of the problem in the Russian Federation
The practical use of a perinatal risk prediction system in the Russian Federation began with the 80s. The last century, when in 1981, an order of the Ministry of Health of the USSR No. 430 "On the approval of guidance and methodological instructions for organizing the work of women's consultation", containing the following instructions: "... After clinical and laboratory surveys (up to 12 weeks of pregnancy), the belonging of pregnant one or another risk group. In the "Individual map of pregnant and the Rigor", an individual monitoring plan for pregnant women using modern methods for examining the state of the mother and fetus is drawn up. Pregnant high-risk groups need to be directed to childbirth in a specialized maternity hospital.
For a quantitative assessment of risk factors, use the score system. The group of pregnant high risk includes women with a total assessment of harmful prenatal factors in 10 points and higher. To the middle risk group - 5-9 points. To the low risk group - up to 4 points. Depending on the degree of risk, the labeling of individual maps of pregnant women is ensured.
If pregnant women have 10 points and the question is resolved about the feasibility of pregnancy conservation ... ". The application to the orders contained the scale of the prenatal risk of O. G. Frolova and E. I. Nikolaeva.
The allocation of risk groups made it possible to differentiate the system of medical monitoring of pregnant and allocate a group of children under the observation of the pediatrician. Already at the first visit, a pregnant woman has become a comprehensive examination and compulsory determination of the degree of prenatal risk. After an outpatient examination of pregnant women, attributed to the high risk group, amounted to an individual observation plan for a woman with a guarantee of preventive hospitalization. According to the testimony, an outpatient expanded examination and treatment was carried out. The separation of pregnant women on risk groups, differentiated their maintenance during pregnancy and childbirth made it possible to reduce the level of perinatal mortality by 30% compared with this indicator in a similar group of pregnant women who were under normal observation. Over time, this scale of prenatal risk has not lost the relevance. In subsequent years, on the basis of determining the degree of perinatal risk, the criteria for a comprehensive assessment of pregnant women were proposed, including in addition to accessories to their risk groups of perinatal pathology, an assessment of the physical development and the functional state of the main systems of the mother and fetus. In accordance with the proposed criteria, it is advisable to distinguish between the three dispensary groups in the population of pregnant women: healthy, practically healthy, patients with risk factors. The only omission of this system was the bad continuity of the outpatient and stationary link: the risk count was made in an outpatient map, in the exchange card, issued to the hands of a pregnant woman, the graph with the number of risk points was absent at all. It did not allow to obtain the maximum effect of the activities carried out to identify the high risk contingent and the organization of the relevant, the contingent of pregnant women, subsequent medical and diagnostic events at the hospital level. However, for its time, this system was truly a breakthrough in the perinatal protection of the fetus, which made it possible to significantly reduce perinatal mortality in the territory of the former USSR.
In subsequent years, the most optimal method for determining high perinatal risk continued.
V. N. Serov offered to distinguish three degrees of risk of upcoming birth.
I The degree of risk - childbirth in repeated women who have an anamnesis of up to three clans inclusive with the uncomplicated course of previous pregnancies. This group includes primarmerable without obstetric complications and extragnenital diseases with normal data of obstetric anthropometry and primary data, having no more than one abortion in an anamnesis that has not accompanied complications.
II Risk degree - childbirth in pregnant women with extragenital diseases (diseases of the cardiovascular system in a state of compensation, grieving form of diabetes, kidney disease, hepatitis, blood disease, anemia, etc.), with an anatomically narrow pelvic of I degree, large fruit, incorrect The position of the fetus, the prelationship of the placenta and pregnant older than 30 years. The same group includes women with gestosis, signs of infection, dead fruit, underdeveloped pregnancy, repeated abortions and pregnant women who had operations in the uterus, childbirth complicated by bleeding. The Risk II is pregnant with elevated danger of perinatal injury and mortality. First of all, this refers to pregnant women with a former perinatal mortality or injury; To the same group should include women with the usual and threatening non-penny of pregnancy.
III Risk degree - childbirth in pregnant women with severe extragenital diseases (heart failure, rheumatic and septic endocarditis, pulmonary hypertension, hypertensive disease II-III stage, exacerbation of systemic diseases of connective tissue, blood, severe flow of gestosis, pairing placenta, shock or collapse during childbirth, complications for anesthesia, embolism by oily water, bacterial and pain).
However, the options that are not formalized in the battle system are the options for the distribution of pregnant women in the degrees of risk of upcoming births are conditional, since unpredictable changes may occur during pregnancy and childbirth. According to E. A. Chernukhi, obtained by retrospective assessment, in hospitalization in hospitals for pregnant women with I, the degree of risk needs approximately 30%, with the second degree - 55-60%, with the III degree - 10-15% of pregnant women.
In childbirth there is a redistribution of risk groups. Careful examination of pregnant women, timely conducting medical and preventive measures, monitor control in childbirth, etc. allows to reduce the degree of risk in childbirth with high risk factors during pregnancy. Studies show that risk factors in childbirth have a stronger impact on the level of perinatal mortality compared to those during pregnancy. The combination of high-risk factors during pregnancy with high perinatal risk factors in childbirth is accompanied by high perinatal mortality rates.
Currently, to determine the degree of perinatal risk, the Order of the Ministry of Health of the Russian Federation No. 50 of 2003 is guided by the order of the dispensary monitoring of pregnant women, and the formation of groups of "high obstetric and perinatal risk" is carried out by the teacher of the gynecologist of the female consultation.
Based on these surveys and laboratory tests, the following risk factors are determined by the risk of adverse pregnancy.
I. Socio-biological:
mother age (up to 18 years old; over 35 years);
Father's age over 40 years;
Professional harm to parents;
tobacco and alcoholism, drug addiction, toxicism;
Mass-raising motors of the mother (height 150 cm and less, weight is 25% higher or lower than the norm).
II. Obstetric and gynecological history:
the number of clans 4 or more;
repeated or complicated abortions;
Operational interventions in the uterus and appendages;
malformations of the uterus;
infertility;
non-pregnancy;
undeveloping pregnancy;
premature childbirth;
Strawing;
death in the neonatal period;
The birth of children with genetic diseases and developmental anomalies;
Birth of children with low or large body weight;
complicated course of previous pregnancy;
Bacterial-viral gynecological diseases (genital herpes, chlamydia, cytomegaly, syphilis, gonorrhea, etc.).
III. Extgazenitial diseases:
Cardiovascular: heart defects, hyper- and hypotensive disorders;
Diseases of urinary tract;
Endocrinopathy;
blood disease;
liver disease;
lung diseases;
Connective tissue diseases;
acute and chronic infections;
violation of hemostasis;
Alcoholism, drug addiction.
IV. Complications of pregnancy:
vomiting of pregnant women;
threat of abortion;
Bleeding in I and II half of pregnancy;
Gestosis;
Multi-way;
Malovodie;
placental insufficiency;
multipleness;
anemia;
RH- and AV0-Isossentialization;
aggravation of viral infection (genital herpes, cytomegaly, etc.);
anatomically narrow pelvis;
malposition;
transferred pregnancy;
Induced pregnancy.
All pregnant risk groups inspect the chief physician (head) female consultation and the testimony sends to a consultation to the relevant specialists to address the issue of pregnancy prolongation. In cases where it is necessary to conduct a survey in a hospital, pregnant women are sent to a profile medical institution. In the presence of such risk factors, like a scar in the uterus, the prelationship of the placenta, multiple pregnancy, it is recommended to be hospitalized in 36-37 weeks for the date and method of the delivery. The prenatal hospitalization in 37-38 weeks is recommended for narrow tase, arterial hypertension, urinary tract infection, varicose veins of the lower extremities, if pregnant older than 35 years old, with a mass of more than 4000 grams.
In pregnant women belonging to the group of high perinatal risk, when choosing a method of roostering, it is advisable to expand the readings to the cesarean operation.
In pregnant women who do not have listed risk factors, the prenatal observation should be carried out under the protocol of the Order of the Ministry of Health of the Russian Federation No. 50 "Physiological Pregnancy".
A similar system for determining high perinatal risk, at first glance, has a number of advantages compared to the previous scale O. G. Frolova and E. I. Nikolaeva. It takes into account new risk factors: induced pregnancy, hemostasis disorders, etc., but in fact, the refusal of the score system is "step back", to determine the summary influence of factors is not possible, and some factors such as multi-way In its isolated state, do not pose a risk for mother and fetus. The most optimal way to determine the risk is the addition of the risk scale by new factors.
Controversial issues of using perinatal prediction systems
The main critical moments of the perinatal prediction system
Since the occurrence of perinatal risk scales, discussions are underway on the benefits and harm of the perinatal prediction systems. Possible use of risk accounting is widely discussed in the literature, but the possible negative effect of these techniques is rarely mentioned on the print pages. Such harm may result from invalid invasions into the personal life of women, excessive medical interventions and therapeutic impacts, creating excessive stress and anxiety and waste of resources where it is not necessary.Theoretically, the process of rationally reasonable risk accounting should differ greater accuracy compared to the vague process of clinical impression on the basis of everyday medical practice. As in other tests, the value and practical value of the risk metering system need to determine borders and capabilities. When using the risk accounting system, many practical difficulties arise. For example, the need for further separation and clarification of options that differ from each other, such as arterial pressure options (how long is heated?) Or smoking (as a lot of cigarettes?) Is associated with significant obstacles, often sharply distorting meaning of the indicator, right up to the opposite . Formalized risk accountability makes it possible to attribute a woman to a high-risk group on the basis of formally fixed and calculated signs, while a talented clinician can estimate the situation more subtle.
The most convincing way to determine the effectiveness of the formalized prediction system is to carry out randomized controlled studies in which a formalized forecast is based on the antenatal screening and factors arising in the objective process, while in the control group, with other things being equal, the definition of risk factors is not carried out.
In a large number of studies based on the principle of simple observation, conclusions are made to reduce the number of adverse perinatal outcomes due to the risk accounting system. The improvement is associated with the fact that the possibility of a more rational selection of women truly needing therapy, and the "systematization of the necessary interventions" is created. At the same time, in many institutions there is an increase in the frequency of medical interventions, whose value, however, is of doubt.
For the clinician, it is possible that it is useful to know which of the pregnant women who observed them is more likely to threaten the danger of an unfavorable outcome. For a particular woman, the introduction of it in the risk group is useful only if certain activities will be taken to reduce the risk or reduction of its consequences.
Often, many elements called risk factors and administered when calculating the formula of the forecast are only risk markers. Indicating a statistically reliable connection with the forecast, they determine the number of scored points to determine the forecast and do not affect the outcome of pregnancy. The most important is the number of birth, the body weight before the occurrence of pregnancy, the growth and state of reproductive health in the past, can no longer be changed.
The performance of the risk counting system also has weaknesses. With the exception of a small number of antenatal clinics, where all data on each pregnancy is made to the computer, usually calculations produce manually and without that very busy doctors. Therefore, to improve the performance of formal metering the degree of risk, too many questions should not be introduced into the system - the values \u200b\u200bof the indicators must be expressed by any numbers, and the addition in the process of calculations should be preferable to multiply.
In some risk accounting systems, it is assumed that the state of a woman should be appreciated only once. In contrast to some systems, revaluation is carried out at each visit to the doctor during pregnancy. This makes it possible to include complications arising during pregnancy, and review the degree of risk towards increasing or decreasing depending on the course of pregnancy.
Risk accounting is more reliable in second or subsequent pregnancies compared to primordin. The smaller prognostic value of formalized risk accounting systems for the first pregnancy is partly due to the fact that many of the indicators used in the system are associated with the characteristics of the events of previous pregnancies.
The ideal system for determining the degree of risk should identify the risk group at a time when the necessary measures can be carried out to prevent danger, threatening mother or child. The system will naturally work more reliably if it is used in a later date or is the possibility of its revaluation in the process of pregnancy. This leads to a paradoxical situation when the most accurate predictions are made at a time when they are already practically needed, while potentially more useful risk definitions are relatively inaccurate.
It must be recognized that both positive and negative assessment of the prognostic system still remains controversial. Depending on the point of reference and the indicators used, only 10-30% of women attributed to the risk group actually observed those dysfunctional outcomes of pregnancy, which were predicted on the basis of the use of a formal risk accounting system.
Obstetric aggression
Most often, the prediction system of perinatal risk is reproached to provoke excessive obstetric aggression. This is especially true of the universal perinatal risk scales. O. J. KNOX, created in 1993 its own perinatal risk scale, concluded that universal counting systems are potentially harmful because they can create unreasonable concern for the patient and lead to obstetric activity. In the "Guidelines for Effective Assistance during pregnancy and childbirth", published by E. Enkin in 1995, the perinatal prediction systems are attributed to "Assistance methods that have both favorable and negative impact." According to the authors, the perinatal risk determination system has dubious benefits for a particular woman and a newborn. It provides a minimum level of care, help and attention in institutions, where such assistance was insufficient, and leads to the potential risk of disadvantaged outcome of dubious treatment and unreasonable interventions with a powerful diagnostic and medical base.The authors did not take into account two factors: first, the main goal of determining the degree of perinatal risk - as early as possible detection of women's high-risk groups to ensure their respective observation, and secondly, obstetric aggression is a consequence of a set of a number of reasons, none of which Not related to the definition of risk in pregnant.
Obstetric Aggression - Yatrogenic, unfulfilled actions, directed allegedly benefits, and as a result, only harm caused. According to WHO, 50 thousand cases of maternal mortality (every tenth death) were a consequence of medical errors. It can be safely assumed that half of them are the result of obstetric aggression.
However, this "excessive obstetric activity" has recently been observed regardless of which the risk group includes a given pregnant woman. In terms of information boom, when a large number of disordered theories, ideas and suggestions on tactics of pregnancy and childbirth, practical doctors are difficult, and sometimes it is impossible to understand the feasibility and benefits, or, on the contrary, the harmfulness of those or other provisions for mother and fetus.
Unobtrusive "aggression" often begins on the first appearance of a pregnant woman in female consultation. Adjust extra, sometimes expensive research and tests, treatment. Standard complex of drugs (vitamin and mineral complexes, dietary supplements, etc.) often replaces pathogenetically substantiated therapy. For example, with threatening interruption of the pregnancy of early terms, progesterone, hynipral and others are prescribed without the appropriate examination, which not only costs expensive, but also unreasonably.
High-quality PCR gives a lot of incorrect information that makes the doctor take those or other "aggressive" solutions. Therefore, in the US, this study is carried out 6 times less frequently than in the Russian Federation, for the reason that it is "too expensive and super informative." In order to get rid of the desire to "treat analyzes" since 2007, even the bacterioscopic study of the vaginal secretions of pregnant women without complaints was prohibited in the United States.
The study of the evolution of the composition of the genital biotop over the past decades has shown that each second healthy female reproductive age in the contents of the vagina can be allocated for Gardnerells and Candids, each fourth is an intestinal wand, each fifth - mycoplasma. If some of these pathogens do not exceed 10 5, and some lactobacilli is more than 10 7 and there are no clinical manifestations of inflammation, then a woman is considered healthy. This important information does not give high-quality PCR. It is informative only when microorganisms are found, which are practically absent in the vagina (pale treponema, gonococci, chlamydia, trichomonas, etc.).