As for the topic...
She herself went through this 3 times, and if it was still required, she still went through it.
The first time, too, there were deviations on the triple test. After amniocentesis, it was necessary to do cordocentesis (the same puncture, only blood from the umbilical cord is taken for analysis). They found that the placenta is slightly mutated, hence the discrepancies in the analyzes. But after the analysis, there is complete confidence that everything is in order. "The child has a genetic passport that there are no gene deviations 99.9%" (c)
Third time in my second pregnancy. The analyzes are also slightly outside the norm. And I went through it again.
Regarding the procedure itself, it is almost painless, they ask me to lie down for 2 hours after that, they do a control ultrasound and, if everything is in order, they send me home. On this day, they give sick leave, and the next. day to work is possible. The first 2 times the procedure took 20 minutes (in 2002), the third time - 5 minutes (probably already filled with a hand).
IMHO I wouldn't be able to do otherwise. It is my choice.

Received today analysis. "high risk of down syndrome" ......... 1 to 197 ......... The doctor said: "redo the screening, suddenly the error of the laboratory" . I did the screening in Art-med, I have a doctor in another clinic, and I will redo it in it. I'll go on Monday. Keep your fists..........

Discussion

With my second son, I had almost the same screening result of 1:175. But I found out about it by the time the second screening came up. I didn’t do the second one, I went for an ultrasound to Malmberg (I think it’s spelled that way) - she is an excellent specialist in developmental anomalies - the ultrasound showed that everything is fine. I also went to a geneticist - he asked everything about hereditary diseases, bad habits and said that this was most likely a false positive. result. Also, in the initial stages, I took duphaston, the doctor said that he could have an effect. She explained that they take the mother's blood and try to determine what is happening with the child. This is a VERY unreliable analysis, which can be influenced by a bunch of factors. In short, I didn’t worry anymore, everything is fine with the child.

My risk was much higher. She refused amnio, but when the second screening was done, the result was even worse. Did for fidelity in two different places. I had a cordocentesis at 22 weeks. 3 minutes, not painful and not scary. They did it in RD 17, head of the department of genetics. I got there in the direction from the LCD. In the end, everything is fine. But my nerves to wait until the birth of a child would not be enough. And for sure, it would be worse for the child.

The relevance of this issue has become more and more obvious lately :) Girls, do not be lazy, connect! Pregnancy FAQ Managers, please include the collected statistics in the FAQ. So. Please look into your documents and see all 1st trimester screening figures. I explain: this is an ultrasound scan at 10-13 obstetric weeks (from menstruation) and blood for PAPP-A and free betta hCG. 1) Pregnancy period 2) TVP (collar space) by ultrasound 3) The result of PAPP-A in units (and norms in brackets) 4) ...

Discussion

Hello. Help dispel my worries about the results of 1 screening.
I am 37 years old, we are on the 5th, there was no birth. Previously, there were 2 deputy pregnancies, ectopic and after an accident (2009) long treatment and rehabilitation (this is all that is indicated in the anamnesis). According to genetics, a predisposition to thrombophilia, but none of the relatives was noticed. I give Enoxaparin 4000 injections 1 injection per day. Dufaston 1 tab. 3 times a day.
The results of 1 screening came yesterday. Although the doctor warned on the ultrasound that the blood would definitely not be ice with age and taking Duphaston, but the main thing is that according to the ultrasound, everything is fine with us.
1) The term was set at 12 weeks 3 days (everything is the same day to day) both according to ultrasound and DPM.
2) TVP -2.1 mm, CTE -61 mm, BPR - 19 mm, OG - 73 mm, coolant -58 mm, Chorion - low on the back wall, Nasal bone - is determined, no fetal pathologies were detected by ultrasound, the length of the church canal was at 10-11 weeks 35-36mm, at the time of ultrasound 39mm.
3) PAPP-A 3.340 IU/l
4) PAPP-A 1.494 MoM
5) betta hCG 22.00 IU/l
6) betta hCG 0.584 MoM
Uterine arteries PI: 1.490 or 0.937 MoM
7) Trisomy 21 Baseline risk 1:145, Individual adjusted risk 1:2906
Trisomy 18 Baseline risk 1:350, Individual adjusted risk 1:7000
Trisomy 13 Baseline risk 1:1099, Individually adjusted risk Pre-eclampsia before 34 weeks 1:1288
Preeclampsia up to 37 weeks 1:244
Growth retardation up to 37 weeks. 1:720
Spontaneous delivery up to 34 weeks. 1:1461
8) At the time of the research on 08/08/18 (12 weeks and 3 days):
- Defects and anomalies of the fetus - NOT DETECTED
-Risk of fetal chromosomal abnormalities - INCREASED
- Risk of preeclapsia and fetal growth retardation -LOW

Pregnancy 2a, 29 years old, first with a healthy boy. Real 13 weeks 3 days, TVP 1.8. According to ultrasound, the nasal bone is 1.6. But the ultrasound was redone the next day and the nasal bone was 2.2 mm, KTP 64MM. And the blood data and risks were calculated for the 1st ultrasound: B-hCG 44.01 IU / l / 1.336 MoM (norms not indicated), PAPP-a PAPP-2.719 IU/l/0.597 MoM...equipment BRAHMS kryptor. Trisomy 21 baseline risk 1:724, individual 1:42, others do not exceed

Health experts have long been saying that women should take at least a two-year break between births, but a new study suggests that this is not enough. Several recent studies show that babies born three to five years after previous births are less likely to be born prematurely or underweight than those born after a shorter interval. The increase in the break between children is also beneficial for mothers ...

At present, the optimal mode of delivery for infected women has not been fully determined. To make a decision, the doctor needs to know the results of a comprehensive virological study. Natural childbirth includes a whole range of measures aimed at adequate pain relief, prevention of fetal hypoxia and early rupture of amniotic fluid, and reduction of trauma to the birth canal in the mother and skin of the baby. Only when all preventive measures are observed ...

Discussion

Absolutely agree. Unfortunately, at the moment there is no consensus on the safest management of childbirth with hepatitis C. According to statistics, the likelihood of a child being infected with hepatitis is slightly lower with a planned caesarean section than with natural childbirth. However, none of these methods can guarantee the safety of the child in terms of infection with hepatitis. Therefore, the choice of method of delivery is based more on the obstetric history than on knowledge of the presence of this infection.

Any person who is preparing to become a parent wants his child to be healthy, so that the pregnancy goes as smoothly and easily as possible. And possible threats come not only from external negative factors, but also from internal ones, and one of them is genetics. All biological characteristics that are inherited are contained in the 46 chromosomes that make up the genetic set of each person. These chromosomes contain encrypted information about many, many generations of the genus...

The most common complications associated with twin/twin/triple pregnancy are: Premature birth. Low birth weight. Retardation of intrauterine development of the fetus. Preeclampsia. Gestational diabetes. Placental abruption. C-section. premature birth. Births that occur before the 37th week of pregnancy are considered premature. The duration of a multiple pregnancy decreases with each additional child. On average, a pregnancy with one baby lasts 39 weeks ...

Recently, the number of women who decide to give birth to their first child after 35 and even after 40 years is growing. And if earlier women who gave birth after 28 years were already considered “old-timers”, today this does not surprise anyone. In the modern world, many women postpone the birth of children indefinitely because they first want to achieve career success, improve their financial situation, stabilize their personal lives, because now the age of marriage has also increased. Due to the fact that under...

Discussion

Hello Olga!
I really liked your article about late children. So detailed and very well built logically. And most importantly - so well conveying my own thoughts. I also gave birth to a child at almost 40 and do not regret it at all. I think if I had given birth earlier, there would have been more problems and much less satisfaction. I hope you raise this topic in your blog more than once, and we will read and comment :-) Therefore, I subscribe to your RSS feed. Thanks again!

RUSSIAN ACADEMY OF MEDICAL SCIENCES

RESEARCH INSTITUTE OF OBSTETRICS AND GYNECOLOGY them. D. O. OTTA

V. V. Abramchekko, A. G. Kiselev, O. O. Orlova, D. N. Abdullaev

MANAGEMENT OF HIGH RISK PREGNANCY AND BIRTH

SAINT PETERSBURG

INTRODUCTION

Abramchenko V. V., Kiselev A. G., Orlova O. O., Abdullaev D. N. Management of high-risk pregnancy and childbirth.- St. Petersburg, 1995

Based on literature data and our own experience, the issues of identifying and managing high-risk pregnant women and women in childbirth are highlighted. Particular attention is paid to the treatment of women with complications of pregnancy and childbirth. In particular, the issues of managing pregnant women with breech presentation of the fetus, narrow pelvis, diabetes, and diabetes are highlighted. The second part of the monograph is devoted to a number of complications of pregnancy and childbirth: the regulation of labor activity, the prevention and treatment of mecoia aspiration syndrome, modern methods of treating fetal hypoxia

The book is intended for obstetrician-gynecologists, neonatologists and anesthesiologists working in obstetric institutions.

V. V. Abramchenko, A. G. Kiselev, O. O. Orlova, D. N. Abdullaev.

In Russia, the main goal in the field of maternal and child health" is to develop conditions for "preserving the health and working capacity of women, addressing issues of rational tactics - pregnancy management 1 , childbirth, the postpartum and neonatal period, identifying ways to reduce maternal, perinatal and child morbidity and mortality . At the same time, the creation of optimal conditions for women's health and the development of pregnancy is the basis of "Prevention of perinatal pathology. O. G. Frolova et al. (1994) consider the reduction of reproductive losses to be one of the main directions in the protection of motherhood and childhood. The authors propose to consider reproductive losses as the end result of the influence of social, medical and biological factors "and the health of pregnant women and newborns. The authors refer to reproductive losses as the loss of embryos and fetuses throughout the entire gestation period. On average, 32.3% of all pregnancies in the Russian Federation end in childbirth.

According to statistics, high-risk pregnancies in the general population are approximately 10%, and in specialized hospitals or perinatal centers they can reach 90% (Yu. I. Barashnev, 1991 and others). Materials from WHO (1988) show that in Europe we are still far from defining what a rational birth technique should be.

In the work of the World Health Organization (WHO, Geneva, 1988, 1992), "family protection programs, in particular, maternal and child health, are also assigned a priority task. It is emphasized that deaths in the perinatal period are responsible for most of the stable and catastrophic high rates equal to infant mortality It has been shown that * perinatal mortality is closely associated with poor health and nutrition of the mother, complications of pregnancy and childbirth.

V. V. Chernaya, R. M. Muratova, V. N. Prilepskaya et al. (1991) recommend, depending on complaints, general somatic and reproductive history, objective examination data, 3 health groups should be distinguished among those examined:

- Healthy- in the anamnesis there are no violations in the formation and subsequent course of menstrual function, there are no pinecolic diseases, complaints; with an objective examination (laboratory and clinical), there are no changes in the structure and function of the organs of the reproductive system.

- Practically healthy- in the anamnesis there are indications of gynecological diseases, functional abnormalities

or abortions; there are no complaints at the time of the examination, or an objective examination may be anatomical changes that do not cause dysfunction of the reproductive system and do not reduce the working capacity of women.

__ sick- there may be (or be absent) indications of

gynecological diseases in history. Complaints at the time of the examination may or may not be present. An objective examination revealed the presence of a gynecological disease. On the. for the purpose of monitoring the state of health and the effectiveness of the medical and recreational activities carried out *, a “Control card of a dispensary patient (account file No. 30)” is entered for each patient.

Assessment of the health status of pregnant women should be carried out as follows:

The health of a pregnant woman can be considered as a state of optimal physiological, mental and social functioning, in which the race system! maternal organism ensure the usefulness of the health and development of the fetus.

The healthy group includes pregnant women who do not have somatic and gynecological diseases, who carry the pregnancy to the term of physiological childbirth. These pregnant women do not have risk factors for perinatal pathology.

To the group practically healthy pregnant women include women who do not have somatic and gynecological diseases, who carry their pregnancy to the term of normal delivery. The total assessment of the identified risk factors for perinatal pathology corresponds to a low degree of risk throughout pregnancy.

The rest of the pregnant women belong to the group sick, Assessment of the health status of the contingent of women who gave birth

should be carried out depending on the state of health at the time of pregnancy, childbirth and the postpartum period, with particular attention to the restoration of reproductive function.

The group of observation for puerperas is established at her first visit to the antenatal clinic.

Group I - includes healthy individuals with a physiological course of pregnancy, childbirth and the postpartum period, with sufficient lactation.

Group II includes practically healthy individuals with a physiological or complicated course of pregnancy, childbirth and the postpartum period, who have risk factors for the occurrence or worsening of extra genital and gynecological diseases; complaints" at the time of the examination are absent, with an objective examination there may be anatomical changes

niya, ve causing violations of reproductive function and the general state of health.

Group III includes sick persons with a physiological or complicated course of pregnancy, childbirth and the postpartum period, whose objective examination revealed the presence of obstetric pathology, gynecological diseases, worsening of the course of extragenital diseases.

The allocation of these groups is determined by the different nature of medical events.

Dispensary observation of the contingent of women who gave birth is carried out within a year after childbirth. In the future, regardless of the health group, “observation is carried out three times by actively calling those who have given birth to the antenatal clinic (by the 3rd, 6th and 12th months after birth). Three months after childbirth, a bimanual examination and examination of the cervix with the help of mirrors are performed using the Schiller test screening test (if possible, colposco-p "ii), bacteriological and pytological studies. At this stage, health measures and individual selection of contraceptive methods are necessary.

At the 6th month after delivery, in the absence of contraindications, intrauterine contraception should be recommended. An active call for women to a consultation is carried out in order to control lactation, menstrual function and prevent unwanted pregnancy, social legal assistance. The third visit is advisable for the formation of an epicrisis on the final rehabilitation of women by the year after childbirth, the issuance of recommendations on contraception, planning subsequent pregnancy and women's behavior in order to prevent existing complications.

At the same time, it is essential to emphasize that the analysis of domestic and foreign literature shows that the level of perinatal morbidity and mortality is especially high in a certain group of pregnant women, united in the so-called. chew high-risk group. The allocation of such a group of pregnant women and women in labor allows organizing a differentiated system for providing obstetric and pediatric care to this contingent of women and<их новорожденным детям. В этой связи особое значение приобретает совершенствование организации акушерско-гинекологической помощи в сельской местности.

So far, the urgency of the problem of maternal mortality has not decreased. The level of maternal mortality in the Russian Federation is high, exceeding the corresponding indicator of developed economic countries by 6-10 times, and does not tend to decrease (Sharapova E.I., 1992; Perfilieva G.N., 1994). The analysis shows that the high level of maternal mortality is mainly due to abortion and such

obstetric complications, such as bleeding, preeclampsia and purulent-septic complications.

Great importance is attached to the relationship and interaction between the obstetrician-gynecologist and the paramedical worker in the prevention of a number of complications of pregnancy, childbirth and perinatal morbidity and mortality.

From rare diseases not related to pregnancy in the Russian Federation, 95- 110 women, accounting for 14-16% of all maternal deaths 1 . A significant influence of extratenital pathology on the formation of the most dangerous obstetric complications was also established. Thus, in women who died from obstetric bleeding, extragenital pathology was determined in 58% of cases, from gestosis - in 62%, from sepsis - in 68%. While in the population of pregnant women, extrahegoital diseases occur in 25-30% (Serov V.N., 1990).

The proposed monograph will acquaint the reader with the modern tactics of managing pregnancy and childbirth in high-risk groups.

Chapter I. High risk pregnant women

The definition of factors and high-risk groups of pregnant women is carried out by "researchers from many countries. At the same time, most authors, based on clinical data, identified risk factors, and then developed a system for their assessment. In the Russian Federation, the most thorough studies on the identification of risk factors belong to L. S. Persianinov and et al. (1976) The authors, based on a study of literature data, as well as a multifaceted development of birth histories in the study of the causes of perinatal mortality, identified individual risk factors.They included only those factors whose presence led to a higher level of perinatal mortality compared to L. S. Persianinov et al (1976) divided all identified risk factors into prenatal (A)

and intranatal (B).

Prenatal factors were divided into 5 subgroups: 1) socio-biological factors; 2) obstetric and gynecological history data; 3) the presence of extragenital pathology; 4) complications of this pregnancy; 5) assessment of the condition of the fetus. The total number of prenatal factors was 52.

Intranatal factors were divided into 3 subgroups: 1) maternal risk factors, 2) placenta, and 3) fetus. This group contains 20 factors. Thus, a total of 72 risk factors were identified (see Table No. 1). A number of authors

lie from 40 to 126 factors. Further, the authors point out that the analysis of literature data, the evaluation of the work of antenatal clinics and maternity hospitals convinced that for obstetrics and gynecology practice at present, the scoring system for assessing risk factors should be considered the most acceptable. It makes it possible to evaluate not only the probability of an unfavorable outcome of childbirth in the presence of each specific factor, but also to obtain a total expression for the probability of the influence of a particular factor. The assessment scale of risk factors (in points) was developed by the authors based on the analysis of 2511 births that ended in fetal death in the perineum.

Table 1RISK FACTORS DURING PREGNANCY AND DELIVERY

Continuation

8. Height-weight indicators of the mother:

height 150 cm or less 1

weight is 25% higher than normal 2 II. Obstetric-gynecological history

I. Parity:

2. Abortions before the first birth:

3 4 3. Abortions before repeated childbirth:

4. Premature birth:

5. Stillbirth:

6. Death in the neonatal period:

7. Developmental anomalies in children 3

8. Neurological disorders 2

9. Weight of children less than 3500 2 and more than 4000 g. 1

10. Complicated course

previous rads 1

I1. Infertility more than 2 - 5

12. Scar on the uterus after operations 4

13. Maggoi and ovarian tumors 1 - 4

14. Isshiko-vdrvikalnaya insufficiency 2

15. Maggie Malformations 3

3 4

8. Chronic specific infections (tuberculosis, brucellosis, syphilis, current soplasmosis, etc. ______ 2-6

9. Acute infections during pregnancy 2- 7

IV Complications of pregnancy

1. Severe early toxicosis 2

2. Bleeding in the first and second half of pregnancy 3-5

3. Late toxicosis.:

dropsy 2 nephropathy I-II-III

degree 3-5-1(

preeclampsia 11

eclampsia 12

4. Combined tokoikoya 9

5. Ph-negative blood 1

6. Ph and ABO-isooensibilia-

7. Miogovodve, 3

9. Breech presentation zЁSH

10. Multiple pregnancy m£Nz

11. Post-term pregnant! - SC

12. Repeated use of medications 1

V. Assessment of the condition of the fetus

1. Fetal hypotrophy 10-20

2. Fetal hypoxia 3-8

less than 4.9 mg / day. at 30 over. 34

less than 12.0 mg / day. at 40 weeks 15

4. Presence of meconium in amniotic fluid 3

Continuation

B. INTRANATAL PERIOD

tal period, and 8538 deliveries with a favorable outcome. In addition, the results of a study of the state of the fetus (ECG, F | KG, ultrasound examination) were used.

The total perinatal mortality in the totality of births in the group as a whole was conditionally taken as I point. Based on this provision, the assessment of scores for each risk factor was made on the basis of the calculation of the level of perinatal mortality for the entire set of births and its indicators in women with the presence of one of these factors.

The risk assessment principle was as follows. The probability of the risk of an adverse outcome of pregnancy and childbirth for the fetus and newborn was divided into three degrees: high, medium and low. Each degree of risk was assessed on the basis of the Angar scale and the level of perinatal mortality. The degree of risk of perinatal pathology was considered high for children born with an Apgar score of 0-4 points, medium - 5-7 points and low -8-10 points.

To determine the degree of influence of maternal risk factors on the course of pregnancy and childbirth for the fetus L. S. Persianinov

et al. scoring of all antenatal and intranatal risk factors present in the mother of these children was performed. At the same time, women with a total assessment of prenatal factors of 10 points or more were assigned to the group of high-risk pregnant women, to the group of medium risk - 5 - 9 points, low - up to 4 points.

According to L. S. Persianinov et al. (1976) at the first examination of women (up to 12 weeks of pregnancy), the high-risk group is 18%, and by the end of pregnancy (32 - 38 weeks) increases to 26.4%. According to the literature, the high-risk group of pregnant women is 16.9 - 30% (Hicks, 1992,

Zacutti et al., 1992 and others).

During childbirth, women were distributed according to the degree of risk as follows: with low risk - 42.8%, medium - 30%, high - 27.2%. Perinatal mortality was 1, 4, 20, 0 and .65.2%, respectively. Thus, the proportion of the group of women with low risk during childbirth is decreasing, while the groups of medium and high risk are increasing, respectively. The data obtained by the authors show that risk factors in childbirth have a stronger effect on the level of perinatal mortality compared to those during pregnancy. The combination of high risk factors during pregnancy and childbirth is accompanied by a high rate of perinatal mortality (93.2%). Since the same level of perinatal mortality occurred in pregnant women and women in labor with the presence of risk factors, estimated at 4 points, this group was classified as high risk factors. The presence of one of these factors in a pregnant woman or a woman in labor requires special attention from an obstetrician-gynecologist and other specialists who monitor her during pregnancy and childbirth. In conclusion, L. S. Persianinov et al. emphasize that the organization of specialized clinics, intense monitoring high-risk pregnant women can significantly reduce perinatal mortality. Thus, intensive dynamic monitoring of one of the high-risk groups 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 supervision.

O. G. Frolova, E. I. Nikolaeva (1976 - 1990) on the basis of a study of the literature, as well as the development of more than 8000 birth histories, individual risk factors were identified. Evaluation of the outcomes of childbirth based on the materials of 2 basic antenatal clinics showed that the group of pregnant women of low risk left 45%, medium risk - 28.6%, high risk - 26.4%. At the same time, perinatal mortality in the high-risk group of pregnant women was 20 times higher than in the low-risk group and 3.5 times higher than in the medium-risk group. During childbirth

the group of women with low risk was 42.8%, medium - 30%, high - 27.2%.

VA Sadauskas et al (1977) also emphasize the importance and expediency of identifying risk factors for the fetus during pregnancy and childbirth.

In each group, from 4 to 11 subgroups were identified, the severity of each factor was assessed according to a five-point system. The applied classification, according to the authors, quite accurately reflects the risk to the fetus in case of diffuse pathology in pregnant women and allows organizing timely and specialized intensive monitoring of the fetal condition. The expediency of identifying high-risk groups is also indicated by other domestic authors. So, A. S. Bergman et al. (1977) emphasize the role of functional and thyroid diagnostics in high-risk pregnant women, the role of radioimmunological determination of placental lactogen in high-risk pregnancy is indicated in the study by G. Radzuveit et al. (1977). L. S. Persiaminov et al. (1977) point to the role and importance of the use of piperbaric oxygen in pregnant women with high risk factors for the fetus, as a way to reduce perinatal mortality. It is also reported about the role of some extragenital diseases as an increased risk factor (Butkyavichyus S. et al., 1977; Shui-kina E.P., 1976 and others).

Some researchers (Radonov D., 1983) proposes the organization of monitoring of high-risk pregnant women. Firstly, in order to improve the quality of monitoring pregnant women with an increased risk of perinatal pathology, the author developed a special classification based on the etiological principle, according to which 8 groups were distinguished:

Pregnant women with impaired uteroplacental circulation (late toxicosis, hypertension, xipo-nichesmiy nephritis, placenta previa, prostrate interruption);

Causes that adversely affect the fetus (ionization, isoimmunization, infections, chromosomal and gene abnormalities);

Adverse factors from the pelvis, uterus and appendages (narrow pelvis, uterine hypoplasia, tumors);

Incorrect position and presentation of the fetus, multiple pregnancy, multiple pregnancy, fetal growth retardation;

Adverse factors on the part of the mother before and during pregnancy (extragenital diseases, too young or old primiparous, who gave birth to 3 or more children, smoking);

Aggravated obstetric history (infertility, death

birth, caesarean section, bleeding, late toxicosis);

Factors related to the social environment (difficult living conditions, insufficient training, etc.);

Psycho-emotional state (unwanted or out-of-wedlock pregnancy, bad psychoclimate iB family and at work). D. Radonov determines the degree of risk by a point system. All intermediate and high risk pregnant women are

hospital.

Secondly, after 20 weeks of pregnancy, all data are recorded on a special gravidogram, which can be used to diagnose early signs of a developing pathology (toxicosis, retardation in fetal development, multiple pregnancy, etc.). Thirdly, due to the rapid development in the third trimester, especially in the last month of pregnancy, various complications of the usual weekly monitoring of high-risk pregnant women are not enough. Most of them must be hospitalized, which requires an increase in the number of beds in the "intensified observation unit" - from 1/4 to 1/3 of all beds in the maternity hospital. In this department, a thorough examination of the fetus is carried out (non-stress and oxytocin tests, daily counting of the most pregnant woman 3 times a day for 1 hour of fetal movements, ultrasound scanning, amnioscopy) with fixing the data obtained on a special graph. Thanks to "The implementation of these measures, it was possible to reduce perinatal mortality to 8.9%o in non-dispensary pregnant women - 13.76%o) ■

Domestic scientists have made a great contribution to the development of the problem of high-risk pregnant women. A number of scientists have established a number of risk factors that must be taken into account by a practical obstetrician-gynecologist during pregnancy, and this group of pregnant women often requires a comprehensive examination of the fetal condition using modern hardware and biochemical methods of observation. V. G. Kono-Nikhina (1978), when studying the risk of obstetric pathology in primiparas of various age groups, showed that the young (16-19 years) and older (30 years and older) age of primiparous women is a high risk factor for the development of obstetric pathology . Pregnant women of a young age compared with the optimal (20-25 years old) more often have early and late toxicosis (almost twice), especially severe forms of toxicosis, there is a threat of abortion twice more often, overpregnancy occurs in 3.2 times more often. In older primiparas, compared with the optimal age, 3 times more often - early and late toxicosis are noted, also 2 times more often the threat of termination of pregnancy, and overpregnancy 6 times, premature and early rupture of amniotic fluid 1.5 times, weakness of labor forces 6.2 times, twice as often noted

There are births with a large fetus and in breech presentation, "pathological blood loss" increases by 2.3 times.

In older primiparas, compared to the optimal age, delivery operations are more often used: obstetric forceps - 3.1 times, vacuum - extraction of the fetus - 2.9 times, caesarean section almost 5 times High incidence of complications during pregnancy and childbirth, especially in primiparous older than 30 years, it is accompanied by a higher frequency of impaired functioning in the fetus and newborn: hypoxia is 6.5 times more common, and the incidence of newborns is 4.5 times higher.

The author believes that the use of the method of intensive monitoring of primiparas of young and older age contributes to a more favorable course of pregnancy and childbirth, and perinatal morbidity and mortality also decrease. According to T.V. Chervyakova et al. (1981) one of the most urgent problems of modern obstetrics is the determination of the tactics of pregnancy and childbirth in women at high risk of perinatal pathology. Addressing these issues will be one of the main ways to improve maternal, perinatal and child morbidity and mortality rates. According to the authors, as a result of the studies carried out, significant progress has been made in the development of criteria for identifying groups and the degree of risk. perinatal pathology.

All studies were carried out in the following 6 main areas: 1) clarification of risk groups for extragenital diseases of the mother; 2) with a complicated course of pregnancy; 3) with anomalies of tribal forces; 4) with the threat of intrauterine and postnatal infection; 5) with the threat of bleeding during childbirth and the early postpartum period. T. V. Cheriakova et al. indicate that as a result of these works, new interesting data have been obtained regarding the pathogenesis and clinic of complications of pregnancy and childbirth in women with various types of extragenital pathology, contraindications for maintaining pregnancy have been identified, indications and contraindications for the use of obstetric operations and anesthesia in childbirth have been clarified, issues have been resolved the use of various types of correlating therapy aimed at maintaining homeostasis in the body of the mother and fetus.

A number of authors offer a set of modern methods for diagnosing risk factors for the fetus during pregnancy. So, in (Study by G. M. Savelyeva et al. (1981) in order to identify the degree of risk for the fetus in complicated pregnancy (nephropathy), overmaturity, miscarriage, Rh-sensitization), a complex of modern methods was used to judge the feto-llacental blood circulation

and the state of the fetus: cardiac monitoring, ultrasound scanning, study of volumetric blood flow in the intervillous space of the placenta (OK), the concentration of placental lactogen and estriol in the blood and amniotic fluid: biochemical parameters (ipH, O 2 voltage, concentration of basic electrolytes, glucose, urea , activity of histidase and urokanyaase) amniotic fluid. The authors examined more than 300 pregnant women.

The conducted studies made it possible to identify a correlative relationship between OK and the appearance of changes in the pathological nature of the studied parameters; initial and pronounced signs of fetal hypoxia according to cardiomonitoring; the possibility of predicting the development of fetal hypoxia in childbirth according to some of the studied physiological and biochemical parameters. So, according to the value of OK, starting from 32 weeks, it is possible to predict the weight of newborns at the time of delivery. A decrease in OC by 30% or more indicates "intrauterine fetal hypoxia. An increase in OC with Rh sensitization above 200 ml / min per 100 g of placental tissue (normally about 100 ml / min, with a placental weight of 500 g) indicates the gigantic size of the placenta and the edematous form of hemolytic disease. . j

Analysis of the results of cardiomonitoring observation made it possible to determine the significance of basal changes, which were expressed as rhythm monotony, basal bradacardia, with iso- or arrhythmia. The authors give a number of the most informative indicators indicating the suffering of the fetus. Therefore, according to the authors, the use of these methods in practice in combination or in isolation makes it possible to more accurately identify the degree of risk to the fetus in a complicated pregnancy and determine the optimal medical tactics. Similar opinions are expressed by other authors. So, N. G. Kosheleva (1981) believes that pregnancy complications should be considered as a risk factor for perinatal pathology. The author points out that the acute forms of late toxicosis are especially unfavorable, while the loss of children in late toxicosis, which developed against the background of hypertension and kidney disease, is especially high.

Particular attention should be paid to the peculiarities of the course of pregnancy in diabetes mellitus. In the presence of a genital infection - endocerkitis, colpitis, or a combination of them, late toxicosis develops in every second or fourth pregnant woman, the threat of termination of pregnancy occurs in every sixth, with cervical colpitis four times more often with genital mikshlazma in the genital tract. Thus, in order to reduce perinatal mortality, it is important not only to diagnose a complicated course of pregnancy, but also to clarify the “background” in which these complications arose. Along

with this, it is necessary to constantly monitor the condition of the intrauterine fetus using modern methods of examination and treatment of the intrauterine fetus.

Of particular importance is the study of risk factors in order to reduce perinatal mortality in a antenatal clinic (Orlean M. Ya. et al., 1981). The authors have identified four risk groups in the conditions of the antenatal clinic: 1) socio-economic; 2) obstetric history; 3) obstetric pathology; 4) concomitant pathology. Rhck was determined by a scoring system from 5 to 45 points. 30 points in one group or 60 points in total is a high risk indicator. These activities made it possible to timely diagnose the early stages of toxicosis (shretoksikoz, vodka) of pregnant women, and their timely hospitalization in hospitals made it possible to reduce the frequency of I-II degree hephropathy. S. E. Rub "ivchik, N. I. Turovich (1981), using a scoring assessment of risk factors in obstetrics, developed by Prof. F. Lyzikov, revealed that the first risk group for the socio-alsh-biological factor was 4% , the second group of the claim - burdened obstetric anamnesis - 17%, the third risk scold - pregnancy complications - 45%, the fourth risk rumpa - eustragevital pathology - 41% - At the same time, temporary ones with a combination of two or more factors amounted to 4% - In each risk group preventive measures are taken to prevent weakness of labor activity, miscarriage, treatment of subclinical forms of late toxicosis, treatment of Rhesus-conflict and pregnancy, and in the presence of znstratenital pathology, the presence of pregnant women in dispensary registration with a therapist and an obstetrician-gynecologist.

Thus, the identification of pregnant women at risk of pregnancy pathology, timely preventive measures contribute to the reduction of complications in childbirth and perinatal mortality. Some authors (Mikhailenko E. T., Chernena M. Ya., 1982) developed an original method of prenatal preparation of pregnant high-risk groups w> the development of weakness of labor by increasing the endogenous synthesis of prostaglandins, which allowed the authors to reduce the incidence of weakness by 3.5 times labor activity and 2 times reduce the frequency of asphyxia in newborns. L. G. Si-chinav; and et al. (1981) propose to use ultrasound scanning data to determine the degree of risk to the fetus in Rhesus-conflict pregnancy.

At the same time, the optimal timing of scanning in pregnant women with isoserological incompatibility of the blood of the mother and fetus should be considered 20–22 weeks, 30–32 weeks and immediately before delivery, which allows diagnosing the initial form of fetal hemolytic disease, determining

degree of risk For the last, which is important for the development of individual tactics for the management of pregnancy and childbirth. Other researchers also propose to use a prenatal diagnostic room more widely to assess the condition of the fetus (Shmorgun F. B., 1981; Zupping E. E. et al., 1981).

At the same time, it is recommended, in addition to cardiomonitoring, "to use biochemical methods - to determine the activity of thermoutabile alkaline phosphatase in the blood serum at the risk of pregnancy (Liivrand V. E. et al., 1981;), the coefficient of estrogen creaginine - as one of the indicators of the state of the intrauterine fetus ( Oinimäe X. V. et al., 1981), the content of steroid hormones and cortisone (Ttamer-mane L. P. et al., 1981); Daupaviete D. O. et al., 1981), to determine the dynamics of the content of placental lactogen in the blood plasma of pregnant pears at risk (Reisher N. A. et al., 1981), as well as the components of the symndao-adrenal system (Payu A. Yu. et al., 1981), sex determination is a risk factor based on analysis of X and Y-chromatin in the cells of the tissue of the membranes (Novikov Yu. I. et al., 1981).

N. V. Strizhova et al. (1981) to determine risk groups for late toxicosis of pregnant women, a complex immunodiffusion test is used using standard monospecific test systems for trophoblastic beta-globulin, placental lactogen, placental alpha in the amniotic fluid! - microglobulin, alphag - globulin of the "pregnancy zone", C-reactive protein, fibrinogen, alphag and beta-lipoproteins, as well as tissue antigens of the kidney. E. P. Zaitseva, G. A. Gvozdeva (1981), in order to timely diagnose the true severity of toxicosis, suggest using the immunological reaction to suppress leukocyte adhesion according to Holliday (Halliday., 1972). Postpartum complications are also being studied in women with an increased risk of developing infections (Zak IR, 1981).

There are isolated reports on the features of the mental development of children born from mothers of high-risk groups. So, M. G. Vyaskova et al. (1981), based on a deep and qualified examination of 40 children of sick mothers (with the involvement of a specialist in psychology and defectology), found that the children of sick mothers differ in the specifics of the development of mental activity, especially speech. The number of children with speech and intellectual pathology in the risk group turned out to be significant (28 out of 40), i.e. 70%. All children with speech and intellectual pathology need special assistance of a different nature - from counseling to education in special schools.

Single works are devoted to modern methods of diagnostics and especially treatment of pregnant women with a high risk of perinatal pathology. So, I. P. Ivanov, T. A. Aksenova

i (1981) note that with a complicated course of pregnancy (toxicoses, anemia, the threat of interruption), the presence of extragenital pathology) heart defects, vegetative-vascular dystonil, hypertension, diseases of the kidneys, endocrine system, etc. (often observed f its npl is central insufficiency, accompanied by hypoxia or fetal hypotrophy.

The degree of fetal suffering depends both on the severity and duration of the underlying disease, and on the severity of pathological changes in the placenta - a violation of its respiratory, transport, and hormonal functions. The success of antenatal disease prevention and treatment of intrauterine fetal suffering is largely determined by the informativeness of methods for diagnosing the condition of the fetus and the timeliness of targeted, highly effective therapy. I. P. Ivanov et al. in terms of dynamic monitoring of the state of the fetus, it is proposed to use phonoelectrocardiotraphy in combination with functional tests and ultrasound scanning, as well as indicators of estriol, placental lactogen, activity of a thermostable isoenzyme, alkaline phosphatase, which reflect the functional activity of the placenta and indirectly allow one to judge the state of the fetus, as well as determining the rate of uteroplacental blood flow by the radioisotope method, indicators of the acid-base state and activity of the dependent and innovatory processes.

The complex of data obtained allows timely and in due volume to carry out pathogenetically substantiated therapy of fetal hypoxia and prevention of fetal hypotrophy.

Of the modern methods of treating hypoxia, I. P. Ivanov et al. point to the widespread hyperbaric oxygenation in combination with medications (cocarbocoilase, ATP, sigetin, complamin, vitamins, etc.) against the background of the treatment of the underlying disease, taking into account the mother-fetal relationship. As a result of such therapy, disturbed indicators of the acid-base state and blood gases, hemodynamics, utero-mammary blood flow, indicators of placental function and fetal condition are normalized.

Foreign researchers also widely use monitoring methods for determining the state of the fetus in high-risk pregnant groups (Bampson., 1980, Harris et al, 1981, etc.). Teramo (1984) studies show that 2/3 of women whose children die in the perinatal period or suffer from birth asphyxia or diseases in the neonatal period ™ can be detected in advance during pregnancy. Such high-risk women make up 1/3 of the total number of pregnant women. Careful monitoring of a pregnant woman in a antenatal clinic is essential to identify high-risk pregnant women.

The basis for identifying a high-risk pregnant woman is a detailed medical history, including social, medical and obstetrical data, as well as clinical signs and symptoms. The author emphasizes that, along with clinical methods, instrumental examination of the fetus in perinatal centers is necessary.

Tegato (1984) out of a total number of 1695 pregnant women, identified 1 high-risk pregnant woman in 480: caesarean section in history 1 (60), premature birth (birth of a child weighing less than 2500 g) in history (46), childbirth with congenital | medical history (malformations - 20, neurological defects - 3, miscellaneous - 12) (35), stillbirth (17), chronic diseases (63), chronic urinary tract infections (34), diabetes 10), presence of diabetes mellitus in the family (185), pathological changes in glucose tolerance (21), hypertension (66), uterine bleeding in early pregnancy (IW), first birth over the age of 35 (9).

The author proposes to use cardiotocrgraphy with a decrease in motor activity. It has been shown that the number of movements less than 10 per 12 hours is associated with an increased frequency of fetal asphyxia (Pearson, Weaver, 1976). Next, it is necessary to monitor the growth of the fetus, determine estriol in blood plasma, urine, while it is important to consider what medications a woman takes during this period, since, for example, taking glucocorticoids reduces the production of estriol, it is advisable to analyze estriol every 2 to 3 days, and also determine placental lactsgene, functional tests (oxytocin test).

It is important to note that when using a stress-free test, the author recommends that cardiotocography (CTG) be performed every 1–3 days in preeclampeia, 1–3 times a week in chronic hypertension, every 1–3 days in intrauterine fetal growth retardation, and prenatal effusion. amniotic fluid 1-2 times a day, three hepatosis of pregnant women - daily, with diabetes mellitus, class A according to White's classification weekly at a gestational age of 34-36 weeks, and at a gestational age of 37 weeks - 2-3 times a week, diabetes mellitus, classes A. B, C, D and gestational age 32 - 34 weeks. - every 2nd day., at 35 weeks. - daily, diabetes mellitus, classes F, R at a gestational age of 28 - 34 weeks. - every 2nd day, at 35 weeks. - daily. With changes in the curve of the fetal heart rate and the period of 26 weeks of pregnancy, 1 to 3 times a day.

In a comprehensive monograph by Babson et al. (1979) on the management of high-risk pregnant women and intensive care of the newborn, when determining the degree of risk in the perinatal period, the authors define that such a risk in the perinatal period is the risk of death or

the occurrence of disability during the period of growth and development of a person from the moment of the birth of life to 28 days after birth. At the same time, the authors distinguish between the risk associated with intrauterine development of the fetus and the risk associated with the development of the child after birth. This division allows a better understanding of the factors associated with risk in the perinatal period.

Risk factors related to fetal development

Women who are at high risk of fetal death or injury during pregnancy should be identified. Completely unexpected complications rarely occur in women who have undergone a comprehensive examination and long-term follow-up, during which significant deviations from the norm were detected in a timely manner, appropriate therapy was carried out during pregnancy, and the course of childbirth was predicted.

Here is a list of increased risk factors that contribute to perinatal mortality or morbidity in children. Approximately 10 - 20% of women belong to these groups, and in more than half of the cases, the death of fetuses and newborns is due to the influence of these factors.

1. A history of serious hereditary or family anomalies, such as defective osteogenesis, Down's disease.

2. The birth of the mother herself prematurely or very small for the gestational age at which the birth occurred or cases where the mother's previous birth ended in the birth of a child with the same deviations.

3. Serious congenital anomalies affecting the central nervous system, heart, skeletal system, lung anomalies, as well as general blood diseases, including anemia (hematocrit below 32%).

4. Serious social problems, such as teenage pregnancy, drug addiction, or absence of a father.

5. Absence or late start of medical supervision in the perinatal period.

6. Age under 18 or over 35 years old.

7. Height less than 152.4 cm and weight before pregnancy 20% below or above the weight considered standard for this height.

8. Fifth or subsequent pregnancy, especially if the pregnant woman is over 35 years old.

" 9. Another pregnancy that occurred within 3 months. after the previous I Chey.

| 10. History of long-term infertility or serious drug or hormonal treatment.

11. Teratogenic viral disease in the first 3 months of pregnancy.

12. Stressful conditions, such as severe emotional stress, uncontrollable vomiting of pregnant women, anesthesia, shock, critical situations or a high dose of radiation.

13. Smoking abuse.

14. Complications of pregnancy or childbirth in the past or present, such as toxicosis of pregnancy, premature placental abruption, isoimmunization, polyhydramnios or discharge of amniotic fluid.

15. Multiple pregnancy.

16. Delay in the normal growth of the fetus or a fetus that differs sharply from normal in size.

17. No weight gain or minimal gain.

18. Incorrect position of the fetus, for example, breech presentation, transverse position, unidentified presentation of the fetus at the time of delivery.

19. The gestation period is more than 42 weeks.

Further, the author cites demographic studies on specific complications and the percentage of perinatal mortality for each of the complications, while in more than 60% of cases, fetal death and 50% of newborn death are associated with complications such as breech presentation, premature detachment, placenta, pregnancy toxicosis , twins and urinary tract infection.

Factors causing an increased risk to the newborn

After birth, additional environmental factors may increase or decrease the viability of the infant. Babson et al. (1979) point out that the following pre- or post-natal factors place the infant at increased risk and therefore require special treatment and supervision:

1. The presence in the anamnesis of the mother of the above risk factors during pregnancy, especially:

a) belated rupture of the fetal bladder;

b) incorrect presentation of the fetus and childbirth;

c) prolonged, difficult labor or very rapid labor;

d) prolapse of the umbilical cord;

2. Asphyxia of the newborn, assumed on the basis of:

a) fluctuations in the number of fetal heart beats;

b) staining of amniotic fluid with meconium, especially its discharge;

c) fetal acidosis (pH below 7.2);

d) an Apgar score of less than 7, especially if the score is given 5 minutes after birth.

3. Preterm delivery (up to 38 weeks).

4. Late delivery (after 42 weeks) with signs of fetal malnutrition.

5. Babies are too young for this stage of pregnancy (below 5% of the curve).

6. Babies too big for a given gestational age (below 95% of the curve) especially large babies born prematurely.

7. Any breathing disorders or stoppage.

8. Obvious birth defects.

9. Seizures, lameness, or difficulty sucking or swallowing.

10. Bloating and/or vomiting.

11. Anemia (hemoglobin content less than 45%) or hemorrhagic diathesis.

12. Jaundice in the first 24 hours after birth or bilirubin level above 15 mg/100 ml of blood.

1. Initial selection.

2. Selection during a visit to a pregnant antenatal clinic.

3. Selection during childbirth: upon admission to a maternity facility and upon admission to the maternity ward.

4. Evaluation at birth:

a) a newborn

b) mother.

5. Postpartum assessment:

a) a newborn

b) mother.

Pregnant women with identified risk factors are classified as follows: according to the criteria below at each stage:

I. Initial selection Biological and marital factors.

A) high risk:

1. Mother's age is 15 or younger.

2. Mother's age is 35 or older.

3. Excessive obesity.

b) Moderate risk:

1. The age of the mother is from 15 to 19 years.

2. The age of the mother is from 30 to 34 years.

3. Unmarried.

4. Obesity (weight 20% above the standard weight for a given height).

5. Exhaustion (weight less than 45.4 kg.).

6. Small stature (152.4 cm or less).

Obstetric history

A. High risk:

1. Previously diagnosed anomalies of the birth canal:

a) inferiority of the cervix; "

b) abnormal development of the cervix;

c) abnormal development of the uterus.

2. Two or more previous abortions.

3. Intrauterine fetal death or death of a newborn during a previous pregnancy.

4. Two previous premature births or the birth of babies at term, but with insufficient weight (less than 2500 g).

5. Two previous children are excessively large (weighing more than 4000 g).

6. Malignant tumor in the mother.

7. Uterine fibroids (5 cm or more or submucosal localization).

8. Cystic ovaries.

9. Eight or more children.

10. The presence of isoimmunization in a previous child.

11. History of enlampsia.

12. Previous child had:

a) known or suspected genetic or familial anomalies;

b) congenital malformations.

13. A history of complications that required special therapy in the neonatal period, or the birth of a child with a birth injury.

14. Medical indications for termination of a previous pregnancy. B. Moderate risk:

1. Previous preterm birth or the birth of a child at term, but with a small birth weight (less than 2500 g), or abortion.

2. One excessively large child (weight over 4000 g). t>"p^u

3. Previous childbirth ended with surgery: SC

A. caesarean section b. forceps, c. extraction for the pelvic end.

4. Previous prolonged labor or significantly obstructed labor.

5. Narrowed pelvis.

6. Serious emotional problems associated with a previous pregnancy or childbirth.

7. Previous operations on the uterus or cervix.

8. First pregnancy.

9. Number of children from 5 to 8.

10. Primary infertility. ,|

P. Incompatibility according to the ABO system in history.

12. Incorrect presentation of the fetus during previous births.

13. Presence of a history of endometriosis.

14. Pregnancy that occurred after 3 months. or earlier after the last birth.

Medical and surgical history

A. High risk:

1. The average degree of hypertension.

2. Moderate kidney disease.

3. Severe heart disease (II-IV degree of heart failure) or congestion caused by heart failure.

4. Diabetes.

5. Removal of endocrine glands in history.

6. Cytological changes in the cervix.

7. Cardiocellular anemia.

8. Drug addiction or alcoholism.

9. History of tuberculosis or PPD test (diameter greater than 1 cm)

10. Pulmonary disease. ;

11. Malignant tumor.

12. Gastrointestinal disease or liver disease.

13. Previous heart or vascular surgery.

B. Moderate risk.

1. The initial stage of hypertension.

2. Mild kidney disease.

3. Mild heart disease (I degree).

4. The presence of a history of hypertensive consisting of a mild degree at the time! ■ pregnancy.

5. Transferred pyelonephritis.

6. Diabetes (mild).

7. Familial diabetes.

8. Disease of the thyroid gland.

9. Positive results of a serological study.

10. Overuse of drugs.

11. Emotional problems.

12. The presence of sickle-shaped erythrocytes in the blood.

13. Epilepsy.

II. Selection during a visit to a pregnant antenatal clinic” in the prenatal period. ,

Early Pregnancy I

A. High risk: :";"■; : I

1. Absence of an increase in the uterus or its disproportionate increase. I

2, Effect of teratogenic factors:: I

A. radiation; !■:■, ■. ..... - ..... \|

b. infections;

V. chemical agents.

3. Pregnancy complicated by immunization.

4. The need for genetic diagnosis in the antenatal period. 5. Severe anemia (hemoglobin content of 9 g% or less).

B. Moderate risk:

1. Untreated urinary tract infection.

2. Suspicion of an ectopic pregnancy.

3. Suspicion of a failed abortion.

4. Severe indomitable vomiting of a pregnant woman.

5. Positive serological test for gonorrhea.

6. Anemia, not amenable to treatment with iron preparations.

7. Viral disease.

8. Vaginal bleeding.

9. Mild anemia (hemoglobin content from 9 to 10; 9 g%).

Late pregnancy

A. High risk:

1. Absence of an increase in the uterus or its disproportionate increase.

2. Severe anemia (hemoglobin content less than 9 g%).

3. The gestation period is more than 42 1/2 units.

4. Severe preeclampsia.

5. Eclampsia.

6. Breech presentation if normal delivery is planned.

7. Isoimmunization of moderate severity (necessary intrauterine transfusion of blood or complete exchange transfusion of blood to the fetus).

8. Placenta previa.

9. Polyhydramnios or multiple pregnancy.

10. Intrauterine fetal death.

11. Thromboembolic disease.

12. Premature birth (less than 37 weeks of pregnancy).

13. Premature rupture of the amniotic sac (less than 38 weeks of pregnancy).

14. Obstruction of the birth canal caused by a tumor or other causes.

15. Premature detachment of the placenta.

16. Chronic or acute pyelonephritis.

17. Multiple pregnancy.

18. Abnormal reaction to an oxytocin test.

19. Drop in the level of estriol in the urine of a pregnant woman. B. Moderate risk:

1. Hypertension during pregnancy (mild degree).

2. Breech presentation if a caesarean section is planned.

3. Unidentified presentation of the fetus.

4. The need to determine the degree of maturity of the fetus.

5. Post-term pregnancy (41-42.5 weeks).

6. Premature rupture of the membranes (delivery does not occur for more than 12 hours if the gestational age is more than 38 weeks).

7. Induction of labor.

8. Estimated disproportion between the size of the fetus and pelvis by the time of delivery.

9. Unfixed presentation for 2 weeks. or less before the estimated due date.

Over the past decades, life has made significant changes in the relationship between the doctor and the patient. Currently phrases like; “The doctor forbade me to give birth!” - cause a smile and seem to be borrowed from a women's magazine of the middle of the last century. Now doctors do not “prohibit” anything, and even if they did, the patients, it seems, would not be in a hurry to follow such directives. A woman has the right to independently decide the issue of motherhood - this is evidenced by the current legislation and common sense. Meanwhile, it should be noted that over these decades, the health indicators of the female population of Russia have not improved significantly. In addition, the proportion of older women in childbirth is increasing year by year - a modern woman often seeks to first strengthen her position in society and only then have children. It is no secret that over the years we do not get younger, and accumulate a number of chronic diseases that can affect the course of pregnancy and childbirth.

Igor Bykov
Obstetrician-gynecologist

Modern science knows several thousand diseases. Here we will talk about the diseases that are most typical for women of childbearing age, and their impact on the course of pregnancy.

Hypertension 1 is one of the most common chronic diseases among young women. Manifested by vascular spasm and a persistent increase in blood pressure above 140/90 mm Hg. In the I trimester, under the influence of the natural factors of pregnancy, the pressure usually decreases somewhat, which creates the appearance of relative well-being. In the second half of pregnancy, the pressure increases significantly, pregnancy, as a rule, is complicated by preeclampsia (this complication is manifested by an increase in blood pressure, the appearance of edema, protein in the urine) and insufficient supply of oxygen and nutrients to the fetus. In pregnant women and women in labor with hypertension, complications such as premature detachment of a normally located placenta, postpartum hemorrhage, and cerebrovascular accidents are not uncommon. That is why patients with severe hypertension (a significant increase in blood pressure) are sometimes recommended to terminate the pregnancy at any time.

If the risk is low, the district gynecologist observes the pregnancy together with the therapist. Treatment of hypertension during pregnancy is mandatory and differs little from the treatment of hypertension outside of pregnancy. Delivery, in the absence of other indications for surgery, is performed through the natural birth canal.

Arterial hypotension 2 quite common in young women and is manifested by a persistent decrease in blood pressure to 100/60 mm Hg. and below. It is easy to guess that problems with hypotension begin in the first trimester, when blood pressure already tends to decrease.

Complications of arterial hypotension are the same as in hypertension. In addition, during pregnancy there is often a tendency to overbearing, and childbirth is almost always complicated by the weakness of the birth forces.

Treatment of hypotension during pregnancy consists in normalizing the regime of work and rest, taking fortifying agents and vitamins. Hyperbaric oxygen therapy is also used (a method of saturating the body with oxygen under elevated barometric pressure). Delivery is carried out through the natural birth canal. Sometimes prenatal hospitalization is required before childbirth in order to prepare the cervix for childbirth and prevent overgestation.

Varicose disease 3(violation of the outflow of venous blood as a result of a deterioration in the functioning of the valvular apparatus of the veins, expansion of the veins) affects mainly the lower extremities and the vulva. Most often, varicose veins are first detected or first appear during pregnancy. The essence of the disease consists in changes in the wall and valvular apparatus of peripheral veins.

Uncomplicated varicose veins are manifested by dilatation of the veins (which is perceived by pregnant women as a cosmetic defect) and pain in the lower extremities. Complicated varicose disease suggests the presence of other diseases, the cause of which is a violation of the venous outflow from the lower extremities. These are thrombophlebitis, acute thrombosis, eczema, erysipelas (an infectious disease of the skin caused by pathogenic microbes - streptococci). Fortunately, complicated varicose veins are rare in young women.

Childbirth in patients with varicose veins is often complicated by premature detachment of the placenta, postpartum hemorrhage. Childbirth is carried out through the natural birth canal, if pronounced varicose veins of the external genital organs do not prevent this. During pregnancy and in the postpartum period, physiotherapy exercises and elastic compression of the lower extremities are necessary - the use of special tights, stockings or bandages that have a compressive (compressive) effect on the venous wall, which reduces the lumen of the veins, helps the venous valves work.

Heart defects are diverse, so the course of pregnancy and its prognosis in such cases are very individual. A number of severe defects, in which the heart cannot cope with its functions, is an absolute contraindication to carrying a pregnancy.

The gynecologist observes the rest of the pregnant women with heart defects in close contact with the therapist. Even if the pregnant woman feels good, she is sent for planned hospitalization at least three times during pregnancy: at terms of 8-12, 28-32 weeks and 2-3 weeks before delivery. In the absence of heart failure, delivery is through the natural birth canal. To exclude attempts, the imposition of obstetric forceps is sometimes used. Particular attention is paid to anesthesia in order to prevent an increase in the load on the heart under stress. A caesarean section is not advantageous in women with heart defects, since the operation itself is no less stressful on the cardiovascular system than natural childbirth.

Bronchial asthma- an allergic disease. Pregnancy sometimes alleviates the course of asthma, sometimes it aggravates it significantly.

Bronchial asthma during pregnancy requires the usual treatment for this disease with bronchodilator drugs, used mainly in the form of inhalations. Asthma attacks are not as dangerous for the fetus as it is commonly believed, since the fetus is much more resistant to hypoxia (oxygen starvation) than the mother's body. Conducting childbirth on the background of bronchial asthma does not require any significant adjustments.

Pyelonephritis 4 fairly common among women of childbearing age. This is an inflammatory disease of a microbial nature that affects the tissue of the kidney and the walls of the pelvicalyceal apparatus - the system through which urine flows from the kidneys. During pregnancy, pyelonephritis is often first detected, and long-term chronic pyelonephritis is often exacerbated due to the fact that pregnancy represents an increased functional load for the kidneys. In addition, the physiological bends of the ureters are aggravated, which creates favorable conditions for the habitation of pathogens in them. The right kidney is affected somewhat more often than the left or both.

A contraindication to pregnancy is a combination of pyelonephritis with hypertension, renal failure, and pyelonephritis of a single kidney.

Pyelonephritis is manifested by lower back pain, fever, detection of bacteria and leukocytes in the urine. The concept of "asymptomatic bacteruria" is distinguished - a condition in which there are no signs of an inflammatory process in the kidneys, but pathogenic bacteria are found in the urine, which suggests that they inhabit the renal pelvis and urinary tract in abundance. Like any inflammatory process, pyelonephritis is a risk factor for intrauterine infection of the fetus and other elements of the fetal egg (chorioamnionitis, placentitis - inflammation of the membranes, placenta). In addition, pregnancy in patients with pyelonephritis is much more often complicated by preeclampsia with all its attendant troubles.

Pyelonephritis and asymptomatic bacteruria are subject to mandatory treatment with antibiotics and agents that improve urine excretion. Childbirth in this case, as a rule, proceeds without features. Children born to mothers with pyelonephritis are more likely to be prone to purulent-septic diseases.

diabetes mellitus 5 during pregnancy poses a serious threat to the health of the mother and fetus. The obstetric classification of diabetes distinguishes pregestational (existing before pregnancy) diabetes and gestational diabetes, or "diabetes in pregnancy" (impaired glucose tolerance, manifested in connection with pregnancy).

Diabetes mellitus has a number of categorical contraindications to pregnancy. This is diabetes complicated by retinopathy (damage to the vessels of the eyes) and diabetic nephropathy (damage to the vessels of the kidneys); diabetes resistant to insulin treatment; a combination of diabetes and Rhesus conflict; the birth of children with congenital defects in the past; as well as diabetes mellitus in both spouses (since in this case there is a high probability of having children with diabetes).

The first half of pregnancy in diabetic patients often proceeds without complications. In the second half, pregnancy is often complicated by polyhydramnios, preeclampsia, pyelonephritis.

1 You can read about folk remedies used for hypertension during pregnancy in the magazine "9 months" No. 7/2005.

2 You can read about folk remedies used for hypotension during pregnancy in the magazine "9 months" No. 6/2005.

3 Read more about varicose veins of the lower extremities in the magazine "9 months" No. 7/2005.

4 You can read more about pyelonephritis during pregnancy in the Pregnancy magazine No. 6/2005.

The risk strategy in obstetrics provides for the selection of groups of women in whom pregnancy and childbirth can be complicated by a violation of the fetus, obstetric or extragenital pathology. Pregnant women who are registered in the antenatal clinic can be assigned to the following risk groups:

With perinatal pathology

With obstetric pathology

With extragenital pathology.

At 32 and 38 weeks of pregnancy, a scoring screening is performed, since new risk factors appear at these times. Recent studies indicate that by the end of pregnancy there is an increase in the number of pregnant women with a high degree of perinatal risk (from 20 to 70%). After re-determining the degree of risk, the pregnancy management plan is clarified.

From 36 weeks of pregnancy, women from the medium and high risk groups are re-examined by the head of the antenatal clinic and the head of the obstetric department, in which the pregnant woman will be hospitalized until delivery. This examination is an important point in the management of pregnant women at risk. In those areas where there are no maternity wards, pregnant women are hospitalized according to the schedules of the regional and city health departments for preventive treatment in certain obstetric hospitals. Since antenatal hospitalization for examination and comprehensive preparation for childbirth for women at risk is mandatory, the duration of hospitalization, the estimated plan for managing the last weeks of pregnancy and childbirth should be developed jointly with the head of the obstetric department.

Antenatal hospitalization at the time determined jointly by the doctors of the consultation and the hospital is the last, but very important task of the antenatal clinic. Having timely hospitalized a pregnant woman from the medium and high risk groups, the doctor of the antenatal clinic can consider his function fulfilled.

A group of pregnant women at risk of perinatal pathology. It has been established that 2/3 of all cases of perinatal mortality occurs in women from the high-risk group, constituting no more than 1/3 of the total number of pregnant women. On the basis of literature data, own clinical experience, as well as multifaceted development of birth histories in the study of perinatal mortality, O.G. Frolova and E.N. Nikolaeva (1979) identified individual risk factors. These include only those factors that led to a higher level of perinatal mortality in relation to this indicator in the entire group of examined pregnant women. The authors divide all risk factors into two large groups: prenatal (A) and intranatal (B).

9.2. Prenatal factors:

Socio-biological:

Mother's age (under 18, over 35)

Father's age (over 40)

Occupational hazards in parents

Tobacco smoking, alcoholism, drug addiction

Mass-height indicators (height less than 153 cm, weight 25% above or below the norm).

Obstetric and gynecological history:

• Number of births 4 or more

  Repeated or complicated abortions

  Surgical interventions on the uterus or appendages

  Malformations of the uterus

  Infertility

  Miscarriage

  Non-developing pregnancy

  premature birth

  Stillbirth

  Death in the neonatal period

  Birth of children with genetic diseases, developmental anomalies

  Birth of children with low or large body weight

  Complicated previous pregnancy

  Bacterial-viral gynecological diseases (genital herpes, chlamydia, cytomegalovirus, syphilis, gonorrhea, etc.)

Extragenital pathology:

• Diseases of the urinary system

  endocrinopathy

  Blood diseases

  Liver disease

  lung disease

  Connective tissue diseases

  Acute and chronic infections

  Violation of hemostasis

  Alcoholism, drug addiction.

Complications of this pregnancy:

• Vomiting pregnant

  Threat of abortion

  Bleeding in the 1st and 2nd half of pregnancy

• Polyhydramnios

  oligohydramnios

  multiple pregnancy

  placental insufficiency

• Rh and ABO isosensitization

  Exacerbation of a viral infection

  Anatomically narrow pelvis

  Malposition of the fetus

  Postterm pregnancy

  induced pregnancy

Evaluation of the state of the intrauterine fetus.

The total number of prenatal factors was 52.