High-risk pregnancy is characterized by an increased likelihood of spontaneous, fetal death, premature birth, intrauterine growth retardation, disease in the prenatal or neonatal period, developmental defects and other disorders.

Among the risk factors are both those that cause violations of intrauterine development, for example, the use of teratogenic drugs in the first trimester of pregnancy, and those that are their consequence, and therefore require clarification of the cause and prevention of complications, for example, polyhydramnios. Based on the history, 10-20% of pregnant women can be classified as high-risk. High-risk pregnancies are associated with nearly 50% of perinatal morbidity and mortality. Adequate risk assessment before delivery reduces them. Some of the risk factors arise in the first and second stages of labor, so monitoring the condition of the fetus during childbirth is critical.

Identifying high-risk pregnancies is important because it is the first step in preventing their consequences. If aware of the potential hazard, therapeutic measures can significantly reduce the risk to the fetus and newborns.

Hereditary factors... High-risk pregnancy factors are chromosomal abnormalities, developmental defects, hereditary metabolic disorders, mental retardation and other hereditary diseases in blood relatives. It should be borne in mind that parents usually report such diseases only if their manifestations are obvious, and in the process of collecting anamnesis, ask leading questions.

Maternal-specific risk factors... The lowest neonatal mortality and morbidity during the neonatal period are observed in children from mothers aged 20-30 years who were under full medical supervision during pregnancy. High-risk pregnancies are observed in adolescents and women over 40 years of age, especially the first, often accompanied by intrauterine growth retardation, fetal hypoxia and intrauterine death. A young mother's age also increases the risk of chromosomal abnormalities and unrelated malformations.

The risk to the fetus increases with diseases of the mother, multiple pregnancies, especially monochorionic, infections, taking certain medications. Pregnancy resulting from the successful use of modern reproductive technologies (in vitro fertilization, injection of sperm into the cytoplasm of the egg) is associated with the risk of low or very low birth weight, multiple malformations, multiple pregnancies. Prematurity, low birth weight, and multiple pregnancy, in turn, increase the risk of cerebral palsy.

High-risk pregnancies often end in preterm labor. Predictive factors for preterm labor include cervical flattening, genital infections, the presence of fetal fibronectin in the secretions of the cervical canal and vagina, and prenatal amniotic fluid.

Factors that allow pregnancy to be classified as a high-risk group

Diseases of the mother affecting the fetus and newborn

High and low water also indicates that pregnancy is at risk. Although the exchange of amniotic fluid occurs quickly, normally it gradually (by less than 10 ml / day) increases up to 34 weeks. pregnancy and then gradually decreases. The volume of amniotic fluid during normal pregnancy varies widely (500-2000 ml by the 40th week). A volume of more than 2000 ml in the III trimester is regarded as polyhydramnios, less than 500 ml - as oligohydramnios.

Polyhydramnios is observed in 1-3% of pregnancies, lack of water - in 1-5%. When the volume of amniotic fluid is assessed by the index of amniotic fluid, which is measured by the vertical diameter of its part, filled with fluid, in 4 quadrants. An index of more than 24 cm indicates polyhydramnios, less than 5 cm indicates low water.

Acute polyhydramnios is rare and is usually accompanied by late spontaneous abortion up to 28 weeks. Chronic polyhydramnios in the third trimester is manifested by a discrepancy between the size of the uterus and the gestational age. Sometimes it is only diagnosed during childbirth. Polyhydramnios is often accompanied by premature birth, placental abruption, malformations, including obstruction of the gastrointestinal tract, which prevents the fetus from swallowing amniotic fluid, their subsequent absorption, congenital neuromuscular diseases. Polyuria of the fetus and its dropsy also lead to polyhydramnios. Ultrasound reveals an increase in the volume of amniotic fluid, concomitant malformations, dropsy of the fetus, ascites or hydrothorax in him. In 60% of cases, the cause of polyhydramnios cannot be established. To eliminate polyhydramnios, multiple amniocentesis is used. If it is caused by fetal polyuria, a short course of indomethacin is prescribed to the pregnant woman. Treatment of polyhydramnios is indicated if it causes acute respiratory failure in the mother, and with the threat of premature birth. In the latter case, it gives additional time, allowing for a course of corticosteroid therapy, which accelerates the maturation of the fetal lungs.

Low water accompanies intrauterine growth retardation, malformations, in particular of the kidneys, bladder, the use of certain drugs that reduce fetal urine output, so it becomes obvious after 20 weeks. pregnancy, when urine becomes the main component of amniotic fluid. If ultrasound reveals a normal-sized bladder in the fetus, amniotic fluid leakage should be excluded. Low water causes minor developmental anomalies caused by compression of the fetus - clubfoot, spatulate hands, deformity of the nose. The most severe complication of chronic oligohydramnios is lung hypoplasia. The risk of compression of the umbilical cord during childbirth due to lack of water is partially eliminated by intra-amnial administration of saline. Ultrasound in low water reveals a decrease in the amniotic fluid index up to 1-2 cm, intrauterine growth retardation or malformations. Often, oligohydramnios is accompanied by an increase in the level of a-fetoprotein, intrauterine growth retardation, uterine bleeding and is associated with the risk of intrauterine fetal death.

Antenatal diagnostics: examination of the mother's blood, ultrasound, examination of amniotic fluid and cells obtained by amniocentesis, biopsy of chorionic villi or fetal tissues, fetal blood examination.

Timely diagnosis of complications of childbirth and high-risk pregnancies is extremely important, since they are the leading cause of death and morbidity in the first day of life. The size of the uterus inappropriate for the gestational age should be alarming. Its increase is observed with multiple pregnancies, polyhydramnios, the size of the fetus, much more corresponding to the gestational age, a decrease - with oligohydramnios and intrauterine growth retardation. Rupture of the membranes earlier than 24 hours before the end of labor increases the likelihood of intrauterine infection. More often it occurs with premature birth. In full-term pregnancy, rupture of the fetal bladder, as a rule, entails the onset of labor in the next 48 hours, but increases the likelihood of chorioamnionitis and compression of the umbilical cord. With gestational age up to 37 weeks. the period between rupture of the fetal bladder and the onset of labor can be much longer, which increases the risk of umbilical cord prolapse, oligohydramnios, placental abruption, and abnormal fetal position. With a duration of more than 7 days, the development of hypoplasia of the lungs, fetal deformities and contractures of the extremities associated with compression of the uterus is possible. With prolonged and difficult labor, there is a high probability of fetal hypoxia and mechanical injury. At the same time, the risk of hypoxia and intracranial hemorrhage is also high with rapid labor. The danger of hypoxic damage to the fetal brain is especially great with premature detachment of the placenta, anomalies of its attachment, compression of the umbilical cord. A brown or green color of amniotic fluid indicates an intrauterine discharge of meconium due to an episode of hypoxia several hours ago. The successful outcome of childbirth in high-risk pregnancies depends to a large extent on the qualifications of the obstetrician, but the methods of delivery and the circumstances dictating their use create additional risks. Thus, the risk of intracranial hemorrhage with vacuum extraction, use of obstetric forceps and caesarean section is much higher than with spontaneous birth through natural routes. Traumatic intracranial hemorrhage is often the cause of death of a newborn removed by the application of high or abdominal forceps by the pelvic end or by turning the fetus from a transverse position.

When it is necessary?

Day hospital - this is a short-term stay department, where the pregnant woman spends several hours a day while performing the necessary procedures (for example, droppers), and after their completion goes home
.

In many conditions, already from the beginning of pregnancy, the doctor may warn that at certain times it will be necessary to go to the hospital. it planned hospitalization... First of all, this applies to women who have various diseases of internal organs, such as arterial hypertension (high blood pressure), diabetes mellitus, heart and kidney disease. They also plan hospitalization for women with miscarriage (previously there were 2 or more miscarriages) and other unfavorable outcomes of previous pregnancies, or if the current pregnancy did not occur naturally, but with the help of hormone therapy or IVF (in vitro fertilization). Such hospitalization will occur during critical periods (dangerous in terms of miscarriage and premature birth) and for the period in which the previous pregnancy was lost.
In the case of a planned hospitalization in a hospital, first of all, an additional examination is carried out, which is not possible on an outpatient basis, and the prevention of possible complications of pregnancy. The timing of such hospitalizations can be discussed in advance with the doctor, they can be shifted by 2-3 weeks if necessary.

Emergency hospitalization recommended for conditions that threaten the health of the expectant mother, the health of the baby and the termination of pregnancy. In this case, refusing hospitalization, the woman may lose the only chance of a successful pregnancy.
The need for hospitalization can arise at any stage of pregnancy, from the first days to those cases when childbirth does not occur at the expected time (prolongation of pregnancy). Women before 12 weeks of pregnancy are hospitalized in the department of gynecology of the hospital, and after 12 weeks in the department of pathology of pregnant women in the maternity hospital.

High-risk pregnant women

1. Severe toxicosis in the 11th half of pregnancy.

2. Pregnancy in women with Rh and ABO - incompatibility.

3. Polyhydramnios.

4. Estimated discrepancy between the size of the fetal head and the mother's pelvis (anatomical narrow pelvis, large fetus, hydrocephalus).

5. Incorrect fetal position (transverse, oblique).

6. Postterm pregnancy.

7. Antenatal fetal death.

8. Threatening premature birth.

11 . Pregnancy and extragenital pathology.

(gestational age 22 weeks and above).

1. Cardiovascular diseases (heart defects, arterial hypertension).

2. Anemia.

3. Diabetes mellitus.

4. Pyelonephritis.

5. Thyrotoxicosis.

6. High myopia.

7. Chronic lung diseases (chronic bronchitis, bronchial asthma, history of light surgery).

8. Pregnant women with gestational age up to 35 weeks and extragenital pathology are hospitalized in somatic departments of the appropriate profile.

111. Pregnancy and certain risk factors.

1. Pregnancy in primiparous 30 years and older.

2. Pregnancy and uterine fibroids.

3. Breech presentation.

4. Scar on the uterus from previous surgery.

5. Multiple pregnancy.

6. Pregnancy in women who have given birth to children with developmental defects.

7. Pregnant women with intrauterine growth retardation.

8. Threat of termination of pregnancy.

9. Habitual miscarriage at critical stages of pregnancy from 22 weeks

10. Anomalies of fetal development.

11. Chronic placental insufficiency.

12. Delayed intrauterine development of the fetus.

13. Pregnancy and uterine fibroids.

14. Termination of pregnancy for medical reasons.

15. Placenta previa.

16. Hepatosis of pregnant women.

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 if they had undertaken to prohibit - the patients, it seems, would not be very quick 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 increases from year to 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 most typical for women of childbearing age and their impact on the course of pregnancy.

Hypertension 1is one of the most common chronic diseases among young women. It manifests itself as vascular spasm and a persistent increase in blood pressure above 140/90 mm - Hg. In the I trimester, under the influence of natural factors of pregnancy, the pressure usually decreases slightly, 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 gestosis (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 essential 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 advised to terminate a pregnancy at any time.

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

Arterial hypotension 2 It is 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 overmaturity, and childbirth is almost always complicated by the weakness of the labor forces.

Treatment of hypotension during pregnancy consists in the normalization of work and rest, the intake of fortifying agents and vitamins. Hyperbaric oxygenation (a method of saturating the body with oxygen under high barometric pressure) is also used. Delivery is carried out through the vaginal birth canal. Sometimes prenatal hospitalization is required before childbirth in order to prepare the cervix for childbirth and prevent overmaturity.

Varicose veins 3 (violation of the outflow of venous blood as a result of deterioration of the valve apparatus of the veins, varicose veins) affects mainly the lower extremities and the area of \u200b\u200bthe external genital organs. Most often, varicose veins are first detected or first appear during pregnancy. The essence of the disease consists in changes in the wall and valve apparatus of peripheral veins.

Uncomplicated varicose veins are manifested by varicose veins (which is perceived by pregnant women as a cosmetic defect) and pain in the lower extremities. Complicated varicose veins suggest the presence of other diseases, the cause of which is a violation of 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 placental abruption, postpartum hemorrhage. Childbirth is carried out through the natural birth canal, if severe varicose veins of the external genital organs does 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 diverse, therefore, 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 monitors the rest of the pregnant women with heart defects in close contact with the therapist. Even if the pregnant woman feels good, she is referred for planned hospitalization at least three times during pregnancy: at 8-12, 28-32 weeks and 2-3 weeks before delivery. In the absence of heart failure, delivery is through the vaginal birth canal. To exclude attempts, the imposition of obstetric forceps is sometimes used. Particular attention is paid to pain relief in order to prevent an increase in the load on the heart under stress. Caesarean section is not advantageous for women with heart defects, since the operation itself is as stressful for the cardiovascular system as natural childbirth.

Bronchial asthma- a disease of an allergic nature. Pregnancy sometimes eases the course of asthma, sometimes it makes it much worse.

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

Pyelonephritis 4quite widespread 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 calyx-pelvic 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 presents an increased functional load for the kidneys. In addition, the physiological bends of the ureters are aggravated, which creates favorable conditions for pathogens to inhabit them. The right kidney is affected more often than the left or both.

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

Pyelonephritis is manifested by back pain, fever, and the 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 have been identified 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 ovum (chorioamnionitis, placentitis - inflammation of the membranes, placenta). In addition, pregnancy in patients with pyelonephritis is much more often complicated by gestosis with all the accompanying troubles.

Pyelonephritis and asymptomatic bacteria are subject to mandatory treatment with antibiotics and drugs that improve urinary excretion. Childbirth in this case, as a rule, proceeds without features. Children born to mothers with pyelonephritis are more likely to be susceptible 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 between pre-gestational (pre-pregnancy) diabetes and gestational diabetes, or "pregnancy diabetes" (impaired glucose tolerance associated with pregnancy).

Diabetes mellitus has a number of categorical contraindications for carrying a pregnancy. This is diabetes complicated by retinopathy (damage to the vessels of the eyes) and diabetic nephropathy (damage to the vessels of the kidneys); insulin resistant diabetes; a combination of diabetes and Rh-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 is more likely to proceed without complications. In the second half, pregnancy is often complicated by polyhydramnios, gestosis, pyelonephritis.

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

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

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

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

RUSSIAN ACADEMY OF MEDICAL SCIENCES

SCIENTIFIC RESEARCH INSTITUTE OF Obstetrics and Gynecology them. D.O. OTTA

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

MANAGEMENT OF PREGNANCY AND HIGH-RISK LABOR

ST. PETERSBURG

INTRODUCTION

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

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

The book is intended for obstetricians-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 - management of pregnancy 1, childbirth, the postpartum and neoatal period, determining ways to reduce maternal, perinatal and child morbidity and mortality ... At the same time, the creation of optimal conditions for the health of women and the development of pregnancy is the basis of "Prevention of perinatal pathology. O. G. Frolova et al. (1994) consider one of the main directions in the protection of mothers and children to reduce reproductive losses. The authors propose to consider reproductive losses. as the end result of the influence of social, medical and biological factors on the health of pregnant women and newborns. The authors attribute the loss of embryos and fetuses to reproductive losses throughout the entire gestational 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% (Barashnev Yu. I., 1991, etc.). WHO materials (1988) show that in Europe we are still far from defining what should be a rational delivery technique.

In the work of the World Health Organization (WHO, Geneva, 1988, 1992) "-programs of family protection, in particular, protection of mothers and children, are also given a priority task. It is emphasized that deaths in the perinatal period are responsible for most of the persistent and catastrophic It is shown that * perinatal mortality is closely related to poor health and nutritional status of the mother, complications of pregnancy and childbirth.

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

- Is healthy- in the anamnesis there are no violations in the formation and subsequent, the course of menstrual function, there are no pinecolotic diseases, complaints; during 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 abortion; there are no complaints at the time of the examination, or an objective examination may be anatomical changes that do not cause dysfunctions of the reproductive system and do not reduce the working capacity of women.

__ Sick- there may be (or not) indications of

history of gynecological diseases. Complaints at the time of the examination may or may not be present. An objective examination revealed the presence of a gynecological disease. On. for the purpose of monitoring the state of health and effectiveness of each patient, * medical and health-improving measures, a “control card of a dispensary patient (study f. No. 30)” is set up.

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

The health of a pregnant woman can be regarded as a state of optimal physiological, mental and social functioning, in which the race of the system! of the mother's body ensure the full health and development of the fetus.

The healthy group includes pregnant women who do not have somatic and gynecological diseases, who carry their pregnancies up to the term of physiological childbirth. These pregnant women have no risk factors for perinatal pathology.

To the group practically healthy pregnant womeninclude women who do not have somatic and gynecological diseases, who carry their pregnancies up to the term of normal childbirth. 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 postpartum observation group is established at her first visit to the antenatal clinic.

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

Group II - includes practically healthy persons with a physiological or complicated course of pregnancy, childbirth and the postpartum period, having risk factors for the onset or deterioration of extragenital and gynecological diseases; complaints "at the time of the examination are absent, during an objective examination there may be anatomical changes

tions that cause reproductive and general health problems.

Group III includes patients with a physiological or complicated course of pregnancy, childbirth and the postpartum period, with an objective examination of which the presence of obstetric pathology, gynecological diseases, deterioration of the course of extragenital diseases was revealed.

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

Dispensary observation of the contingent of women who have given birth is carried out within a year after childbirth. In the future, regardless of the health group, “abduction is carried out three times by actively calling the mothers to the antenatal clinic (by the 3rd, 6th and 12th months after childbirth). Three months after childbirth, a bimanual examination and examination of the cervix using mirrors must be performed using the screening test "Schiller's test" (if possible, colposcop-p "si), bacterio- and pythological studies. At this stage, recreational activities and individual selection of contraceptive methods are required.

At the 6th month after childbirth, in the absence of contraindications, intrauterine contraception should be recommended. An active call of women to a consultation is carried out with the aim of controlling lactation by menstrual function and preventing unwanted pregnancy, social legal assistance. The third visit is advisable for the formation of an epicrisis for the final rehabilitation of women by the year after childbirth, for issuing recommendations on contraception, planning for subsequent pregnancy and the behavior of women 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. i chew a high-risk group.The selection of such a group of pregnant women and women in labor makes it possible to organize a differentiated system of 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.

To date, the urgency of the problem of maternal mortality has not diminished. The level of maternal mortality in the Russian Federation is still high, 6-10 times higher than the corresponding indicator of developed economic countries, and does not tend to decrease (Sharapova E.I., 1992; Perfilieva G.N., 1994). The analysis shows that the high rate 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 of an obstetrician-gynecologist and a paramedical worker in the prevention of a number of complications of pregnancy, childbirth and perinatal morbidity and mortality.

Every year 95- 110 women, accounting for 14-16% of all maternal deaths 1. It was also established that acstratenital pathology has a significant effect on the formation of the most dangerous obstetric complications. So, 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, extragital diseases are found in 25 - 30% (Serov V.N., 1990).

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

Chapter I. High-risk pregnant women

"Researchers from many countries are engaged in determining the factors and high-risk groups of pregnant women. At the same time, most of the authors, on the basis of the clinic's data, identified risk factors, and then developed a system for their assessment. In the Russian Federation, the most detailed studies on the isolation of risk factors belong to L. S. Persianinov and The authors, based on the study of literature data, as well as the multifaceted development of childbirth histories in the study of the causes of perinatal mortality, identified individual risk factors. by this indicator in the entire group of examined pregnant women.L.S. Persianinov et al. (1976) divided all the identified risk factors into prenatal (A)

and intranatal (B).

Prenatal factors were divided into 5 subgroups: 1) socio-biological factors; 2) data of obstetric-hynecological history; 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 1). A number of authors have identified ^

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

Table 1RISK FACTORS DURING PREGNANCY AND LABOR

	anka\u003e allah		evka Zallah
A. ANTENATAL PERIOD
1. Socio-biological		III. Extragenic diseases
1. Mother's age (years);		levania of the mother
		1. History of infections
		2. Cardiovascular diseases
		heart defects
		without breaking
2. Father's age (years):		circulation
		heart defects
		in violation
3. Occupational harm		circulation
		hypertonic disease
		I-II-III stages
		arterial hypotension
4. Bad habits: the mother:		3. Kidney disease: before pregnancy
smoking 1 pack of cigarettes		exacerbation of the disease
		during pregnancy
alcohol abuse		4. Eidocrinopathies:
		lrediabet
alcohol abuse		diabetes in relatives
		thyroid disease
5. Marital status:
lonely		adrenal diseases
6. Education:		5. Anemia:
initial		Not less than 9-10-11 g%
		6. Coagulapathy
7. Emotional loads		7. Myopia and other eye diseases

Continuation

8. Height and weight indicators of the mother:

height 150 cm and less 1

weight 25% above normal 2 II. Obstetric and gynecological history

I. Parity:

2. Abortions before the first birth:

3 4 3. Abortions before re-birth:

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 over 4000 g. 1

10. Complicated course

previous rounds 1

I1. Infertility more than 2 - 5

12. Scar on the uterus after operations 4

13. Tumors of the maggoi and ovaries 1 - 4

14. Isshiko-vdrvikalny failure 2

15. Malformations of Maggki 3

3 4

8. Chronic specific infections (tuberculosis, brucellosis, syphilis, current noplasmosis, 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 vephropathy I-II-III

degrees 3-5-1 (

preeclamisia 11

eclampsia 12

4. Concatenated Tokoikoya 9

5. Ph-negative blood 1

6. Ph and ABO-isooensibile-

7. Myogovodve, 3

9. Pelvic presenting zyosh

10. Multiple pregnancies m £ Ns

11. Postterm pregnancy! - SCH

12. Repeated use of medicines 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. The presence of meconium in amniotic fluid 3

Continuation

B. INTRANATAL PERIOD

From the side of Mia ter and			From the fetus
1. Nephropathy 2. Presclampmia _ ,.			Premature birth (week of pregnancy): 28 - 30
3. Eclampsia
4. Untimely change
amniotic fluid (12 hours or more)			Heart rhythm disorder (within 30 minutes and
5. Weakness of labor
■ gelatinousness			Umbilical cord pathology:
6. Rapid labor			dropping out
7. Gender stimulation, sti-
imitation of the generic act			Pelvic extension:
tities
8. Clinically narrow pelvis			extraction of the fetus.
9. Threatening rupture			Operative intervention
11. From the placenta 1. "Presence of placentas:			caesarean section obstetric forceps: abdominal
partial			weekend
			vacuum extraction
2. Premature withdrawal			difficult excretion
puff normally spread			shoulders
placed placenta			General anesthesia during labor

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

The total perinatal mortality in the aggregate of births in the group as a whole was conventionally taken as I point. Based on this provision, the assessment of points for each risk factor was made on the basis of calculating 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 principle of the risk assessment was as follows. The likelihood of the risk of an unfavorable 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 based on the indicators 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 risk factors of the mother on the course of pregnancy and childbirth for the fetus L. S. Persianinov

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

According to LS 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) it 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 decreases, while the groups of medium and high risk, respectively, increase. The data obtained by the authors show that risk factors during 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 perinatal mortality rate (93.2%). Since the same level of perinatal mortality occurred in pregnant women and women in labor with risk factors estimated at 4 points, this group was classified as a high-risk factor. The presence of one of these factors in a pregnant woman or woman in labor requires special attention of an obstetrician-gynecologist and other specialists who monitor her during pregnancy and childbirth. In conclusion, LS Persianinov et al. emphasize that the organization of specialized clinics, intensivemonitoring high-risk pregnant women can significantly reduce perinatal mortality. Thus, intensive dynamic follow-up of one of the high-risk groups allowed to reduce the level of perinatal mortality by 30% in comparison with this indicator in a similar group of pregnant women who were under routine supervision.

OG Frolova, EI Nikolaeva (1976 - 1990) based on the study of the literature, as well as the development of more than 8000 birth histories, individual risk factors were identified. An assessment of the outcomes of childbirth based on the materials of 2 basic antenatal clinics showed that the group of low-risk pregnant women lagged behind 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 appropriateness 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 using a five-point system. The classification used, according to the authors, quite accurately reflects the risk to the fetus in case of malignant pathology in pregnant women and makes it possible to organize timely and specialized intensive monitoring of the condition of the fetus. Other Russian authors also point to the expediency of identifying high-risk groups. So, A.S. Bergman et al. (1977) emphasize the role of functional diagnostic imaging in high-risk pregnant women, the role of radioimmunological determination of placental lactogen in high-risk pregnancies is indicated in the study by G. Radzuweit et al. (1977). L. S. Persiaminov et al. (1977) indicate the role and importance of the use of hyperbaric oxygenation 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 a factor of increased risk (Butkevichyus S. et al., 1977; Shui-kina EP, 1976, etc.).

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

Pregnant women with impaired uteroplacental circulation (late toxicosis, essential hypertension, xipocytic nephritis, placenta previa, abortion);

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

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

Wrong position and presentation of the fetus, multiple pregnancies, polyhydramnios, fetal growth retardation;

Adverse factors on the part of the mother before and during pregnancy (extragenital diseases, too young or elderly primiparas, giving birth to 3 or more children, smoking);

Complicated obstetric history (infertility, dead

birth, caesarean section, bleeding, late toxicosis);

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

Psychoemotional state (unwanted or illegitimate pregnancy, poor psychoclimate iB family and at work). D. Radonov determines the degree of risk by a point system. All medium- and high-risk pregnant women are

hospital.

Secondly, after 20 weeks of pregnancy, all data are entered on a special gravidogram, which can be used to diagnose early signs of developing pathology (toxicosis, delayed 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 insufficient. Most of them must be hospitalized, for which it is necessary to increase the number of beds in the "intensive 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 pregnant woman herself 3 times a day for 1 hour of fetal movements, ultrasound scanning, amnioscopy) with the recording of the data obtained on a special chart. Thanks to the "Carrying out of these measures, it was possible to reduce perinatal mortality to 8.9% o in undispanserized pregnant women - 13.76% o) ■

Domestic scientists have made a great contribution to the development of the problem of high-risk groups of pregnant women. A number of scientists have established a number of risk factors that must be taken into account by a practicing obstetrician-gynecologist during pregnancy, and this group of pregnant women often requires a comprehensive examination of the state of the fetus using modern apparatus and biochemical methods 1 of observation. V.G. Kono-nikhina (1978), when studying the risk of obstetric pathology in primiparous of various age groups, showed that the young (16-19 years old) and older (30 years and older) age of primiparous women is a high risk factor for the development of obstetric pathology ... In pregnant women of a young age, compared with the optimal age (20 - 25 years), early and late toxicosis (almost two times), especially severe forms of toxicosis, more often occur, in two times there is a threat of termination of pregnancy, pregnancy is overdue in 3.2 times more often. In older primiparas, compared with the optimal age, early and late toxicosis are noted 3 times more often, the threat of termination of pregnancy is also 2 times more likely, and prolonged pregnancy is 6 times, premature and early rupture of amniotic fluid is 1.5 times, weakness of labor forces 6.2 times, twice as often

childbirth is taking place with a large fetus and in breech presentation, "pathological blood loss increases by 2.3 times."

In older primiparas, compared with the optimal age, delivery operations are more often used: obstetric forceps - 3.1 times, vacuum - fetal extractions - 2.9 times, caesarean section almost 5 times High frequency of complications during pregnancy and childbirth, especially in primiparas over 30 years of age, it is accompanied by a higher incidence of abnormalities 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 observation of primiparas of young and old age contributes to a more favorable course of pregnancy and childbirth, and the rates of perinatal morbidity and mortality also decrease. According to T.V. Chervyakova et al. (1981) one of the most pressing 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 indicators of maternal, perinatal and child morbidity and mortality. According to the authors, as a result of the studies carried out, significant progress has been achieved 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 directions: 1) clarification of risk groups for extragenital diseases of the mother; 2) with a complicated course of pregnancy; 3) with anomalies of the birth 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 were obtained regarding the pathogenesis and clinical picture of complications of pregnancy and childbirth in women with various types of extragenital pathology, contraindications to the preservation of pregnancy were determined, indications and contraindications for the use of obstetric operations and anesthesia in childbirth were clarified, issues were 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 propose a set of modern methods for diagnosing risk factors for the fetus during pregnancy. So, in (Research by G.M.Savelyeva et al. (1981) in order to identify the degree of risk to the fetus in the complicated course of pregnancy (nephrosis), prolonged gestation, miscarriage, Rh-sensitization), a set of modern methods was used to judge about fetal-llacental circulatory

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

The studies carried out 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 cardiac monitoring data; the possibility of predicting the development of fetal hypoxia during labor 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 mass of newborns at the time of delivery. A decrease in TC by 30% or more indicates "intrauterine hypoxia of the fetus. An increase in TC with Rh sensitization above 200 ml / min per 100 g of placental tissue (normally about 100 ml / min, with a placenta weight equal to 500 g) indicates the gigantic size of the placenta and the edematous form of hemolytic disease. ... j

An analysis of the results of cardiac monitoring allowed us to determine the value of basal changes, which were expressed in the form of rhythm monotony, basalva bradacardic, with iso- or arrhythmia. The authors cite a number of the most informative indicators that indicate fetal suffering. 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 course of pregnancy and to determine the optimal medical tactics. Similar judgments are expressed by other authors. So, N.G. Kosheleva (1981) believes that complications of pregnancy should be considered as a risk factor for perinatal pathology. The author points out that the read-out forms of late toxicosis are especially unfavorable, while the loss of children with 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 genital infection, endocercicytes, colpitis or their combination, late toxicosis develops in every second to fourth pregnant woman, the threat of termination of pregnancy occurs in every sixth, with cavid colpitis four times more often with genital mixplasm in the genital tract. Thus, in order to reduce perinatal mortality, it is important not only to diagnose the complicated course of pregnancy, but also to clarify the “background”, “in which these complications arose. Along with

with this, it is necessary to constantly monitor the state 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 identified four risk groups in the antenatal clinic: 1) socio-economic; 2) obstetric history; 3) obstetric pathology; 4) concomitant pathology. In this case, Rhck was determined using a point system from 5 to 45 points. 30 points in one group or 60 points in total are indicators of high risk. These measures made it possible to timely diagnose the early stages of toxicosis (shretoxicosis, vodyavka) of pregnant women, and their timely hospitalization in hospitals made it possible to reduce the incidence of I-II degree nephropathy. S. Ye. Rub "ivchik, N. I. Turovich (1981), using the point estimate. Of risk factors in obstetrics, developed by Prof. F. Lyzikov, revealed that the first risk group for the social-al-biological factor was 4% , the second group of the claim - burdened obstetric history - 17%, the third scolded the risk - complications of pregnancy - 45%, the fourth risk group - estragevital 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 the weakness of labor, miscarriage, treatment of subclinical forms of late toxicosis, treatment of rhesus - “conflict and pregnancy and, in the presence of astratenital pathology, the presence of pregnant women in the dispensary with a therapist and obstetrician-gynecologist.

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

At the same time, the optimal scanning time in pregnant women with isoserological incompatibility of the blood of the mother and the fetus should be considered 20 - 22 weeks, 30 - 32 weeks and immediately before delivery, which makes it possible to diagnose the initial form of hemolytic disease of the fetus, to determine

the degree of risk For the latter, which is important for the development of individual tactics for the management of pregnancy and childbirth. Other researchers also propose to use more widely the office of prenatal diagnostics to assess the condition of the fetus (Shmorgun FB, 1981; Tsupping E.E. et al., 1981).

At the same time, it is recommended, in addition to cardiac monitoring, "to use biochemical methods - to determine the activity of thermojutabilic alkaline phosphatase in the blood serum at a 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 H. V. et al., 1981), the content of steroidal hormones and cortisone. (Ttamer-mane L.P. et al., 1981); Daupaviete D.O. et al., 1981), determine the dynamics of the placental lactogen in the blood plasma of pregnant pears at risk (Reischer N.A. et al., 1981), as well as those consisting of the simindo-adrenal system (Paiu A. Yu. et al., 1981), sex determination as a risk factor based on analysis of X and Y-chromatin in cells of tissue of fetal 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, placentarial alpha in the amniotic fluid! - microglobulin, alfag - globulin of the "pregnancy zone", C-reactive protein, fibrinogen, alpha and beta-lipoproteins, as well as tissue antigens of the kidney. EP Zaitseva, GA Gvozdeva (1981) for the purpose of timely diagnosis of the true severity of toxicosis suggest using the immunological reaction of suppression of adhesion of leukocytes according to Holliday (Halliday., 1972). Postpartum complications in women with an increased risk of developing infections are also being studied (Zak I.R., 1981).

There are sporadic reports on the mental developmental features of children born to mothers in high-risk groups. So, M.G. Vyaskova et al. (1981) on the basis of a deep and qualified examination of 40 children of sick mothers (with the involvement of a specialist in psychology and defectology) found that children of sick mothers differ in the specificity 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), that is, 70%. All children with speech and intellectual pathology need special assistance of a different nature - from counseling to education in special schools.

A few works are devoted to modern methods of diagnosis 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 (toxicosis, anemia, the threat of termination), the presence of extragenic - ["thal pathology) heart defects, vegetative-vascular dystonil, hypertension, diseases of the kidneys, endocrine system, etc. (often observed its npl and central insufficiency, accompanied by hypoxia or fetal malnutrition.

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, 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 state 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 phonoelectrocardiography 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 judging 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 about the visitor are all new and innovative processes.

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

From modern methods of treatment of hypoxia I.P. Ivanov et al. indicate the widespread use of hyperbaric oxygenation in combination with medications (cocarbocoylase, ATP, sygetin, compliamin, vitamins, etc.) against the background of treatment of the underlying disease, taking into account the maternal-fetal relationship. As a result of such therapy, the disturbed indices of the acid-base state and blood gases, hemodynamics, uterine-placental blood flow, indices of the function of the placenta and the state of the fetus are normalized.

Foreign researchers also widely use monitoring methods for determining the state of the fetus in pregnant high-risk groups (Bampson., 1980, Harris et al, 1981, etc.). Studies by Teramo (1984) showed that 2/3 of women whose children die in the perinatal period or suffer from asphyxia at birth or diseases in the neonatal period ™ can be identified in advance during pregnancy. Such women at high risk., 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 pregnant women at high risk.

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

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

The author proposes to use cardiotocigraphy with a decrease in motor activity. It has been shown that the number of movements less than 10 in 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 take into account what medications a woman is taking 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 lactosgen, functional tests (oxytocin test).

It is important to note here that when using a stress-free test, the author recommends performing cardiotocography (CTG) every 1 to 3 days for preeclampsia, 1-3 times a week for chronic hypertension, every 1 to 3 days with intrauterine fetal growth retardation, - 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 to 36 weeks, and at a gestational age of 37 weeks - 2 to 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 gestational age 28 - 34 weeks. - every 2nd day, at 35 weeks. - daily. With changes in the fetal heart rate curve and 26 weeks of gestation 1 - 3 times a day.

In a comprehensive monograph by Babson et al. (1979) on the management of pregnant women with an increased risk 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 a danger of death or

changes in disability during the period of growth and development of a person from the moment of origin 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 makes it possible to better represent the factors associated with risk in the perinatal period.

Risk factors related to intrauterine fetal development

It is necessary to identify women who have a high probability of death or damage to the fetus during pregnancy. Completely unexpected complications rarely occur in women who have undergone a comprehensive examination and long-term observation, during which significant deviations from the norm were detected in a timely manner, appropriate therapy was carried out during pregnancy and the prognosis of the "course of labor" was carried out.

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 explained by the influence of these factors.

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

2. The birth of the mother herself is premature or very small for the period of pregnancy at which the birth occurred or the cases when the previous birth of the mother ended in the birth of a child with the same deviations.

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

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

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

6. Age under 18 or over 35.

7. Height less than 152.4 cm and pre-pregnancy weight 20% lower or higher than the standard weight 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 Shchey.

| 10. A history of prolonged infertility or serious drug or hormonal treatment.

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

12. Stressful conditions, for example, severe emotional stress, indomitable 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 pregnancy toxicosis, premature placental abruption, isoimmunization, polyhydramnios or amniotic fluid discharge.

15. Multiple pregnancy.

16. Retardation of normal growth of the fetus or fetus sharply different in size from normal.

17. No weight gain or minimal gain.

18. Wrong 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 in each of the complications, while in more than 60% of cases of fetal death and in 50% of cases, the death of a newborn is associated with complications such as breech presentation, premature detachment, placenta, pregnancy toxicosis , giving birth to twins and a urinary tract infection.

Factors contributing to the increased risk to the newborn

Postpartum, additional environmental factors can increase or decrease the infant's viability. Babson et al. (1979) point to the following pre- or postnatal factors that place the infant at increased risk and therefore require special treatment and monitoring:

1. The mother has a history 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, presumptive on the basis of:

a) fluctuations in the number of fetal heart beats;

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

c) fetal acidosis (pH below 7.2);

d) the number of points according to the Apgar system is less than 7, especially if the assessment is given 5 minutes after birth.

3. Premature birth (up to 38 weeks).

4. Delayed labor (after 42 weeks) with signs of fetal malnutrition.

5. Babies are too small for the given pregnancy rate (below 5% of the curve).

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

7. Any breathing disorder or stoppage.

8. Obvious birth defects.

9. Cramping, 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 levels 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 the obstetric facility and upon admission to the maternity ward.

4. Assessment during labor:

a) a newborn,

b) mother.

5. Postpartum assessment:

a) newborn

b) mother.

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

I. Initial selectionBiological and marital factors.

and) high risk:

1. The mother is 15 years old or younger.

2. The mother is 35 years of age or older.

3. Excessive obesity.

b) Moderate risk:

1. The mother's age is from 15 to 19 years old.

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 in stature (152.4 cm or less).

Obstetric history

A. High risk:

1. Pre-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 underweight (less than 2500 g).

5. Two previous children are oversized (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. Presence of isoimmunization in a previous child.

11. A history of enlampsia.

12. Presence of the previous child:

a) known or suspected genetic or family abnormalities;

b) congenital malformations.

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

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

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

2. One oversized child (over 4000 g). m\u003e "p ^ and

3. Previous childbirth ended with surgery: SC

and. caesarean section, b. the imposition of forceps, c. extraction at 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. The number of children from 5 to 8.

10. Primary infertility. , |

P. Incompatibility in the ABO system in history.

12. Incorrect presentation of the fetus in previous births.

13. A history of endometriosis.

14. Pregnancy after 3 months. or sooner after the last birth.

Medical and surgical history

A. High risk:

1. The average degree of hypertension.

2. Kidney disease of moderate severity.

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. Cardiac anemia.

8. Drug addiction or alcoholism.

9.Presence of a history of tuberculosis or PPD test (diameter more than 1 cm)

10. Pulmonary disease. ;

11. Malignant tumor.

12. Gastrointestinal disease or liver disease.

13. Previous surgery on the heart or blood vessels.

B. Moderate risk.

1. The initial stage of hypertension.

2. Mild kidney disease.

3. Mild heart disease (I degree).

4. Presence of mild hypertensive in the anamnesis during! ■ pregnancy.

5. Postponed pyelonephritis.

6. Diabetes (mild).

7. Family diabetes.

8. Disease of the thyroid gland.

9. Positive results of a serological test.

10. Excessive drug use.

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. Lack of uterine enlargement or disproportionate enlargement. I

2, Action of teratogenic factors :: I

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

b. infections;

in. chemical agents.

3. Pregnancy complicated by immunization.

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

B. Moderate risk:

1. A refractory urinary tract infection.

2. Suspected ectopic pregnancy.

3. Suspicion of a failed abortion.

4. Severe indomitable vomiting of a pregnant woman.

5. Positive serological reaction 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 enlargement of 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 labor is planned.

7. Isoimmuyaization of moderate severity (necessary intrauterine blood flow 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 gestation).

13. Premature rupture of the amniotic fluid (less than 38 weeks of gestation).

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

15. Premature placental abruption.

16. Chronic or acute pyelonephritis.

17. Multiple pregnancy.

18. Abnormal reaction to oxytocin test.

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

1. Hypertensive conditions during pregnancy (mild).

2. Breech presentation if a cesarean section is planned.

3. Unidentified presentation of the fetus.

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

5. Postterm pregnancy (41-42.5 weeks).

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

7. Excitement of labor.

8. Estimated imbalance between the size of the fetus and the pelvis at the time of delivery.

9. Non-fixed presentation for 2 weeks. or less before the estimated due date.

The risk strategy in obstetrics provides for the identification of groups of women in whom pregnancy and childbirth may be complicated by fetal disruption, obstetric or extragenital pathology. Pregnant women who are registered with antenatal clinics can be attributed to the following risk groups:

With perinatal pathology

With obstetric pathology

With extragenital pathology.

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

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

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

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

9.2. Prenatal factors:

Socio-biological:

Mother's age (under 18, over 35)

Father's age (over 40)

Occupational hazards for parents

Tobacco smoking, alcoholism, drug addiction

Mass growth indicators (growth less than 153 cm, weight 25% higher or lower than normal).

Obstetric and gynecological history:

• Number of births 4 or more

  Repeated or complicated abortions

  Surgical interventions on the uterus or appendages

  Malformations of the uterus

  Infertility

  Miscarriage

  Non-developing pregnancy

  Premature birth

  Stillbirth

  Death in the neonatal period

  The birth of children with genetic diseases, developmental abnormalities

  Low or high birth weight babies

  Complicated course of a previous pregnancy

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

Extragenital pathology:

• Diseases of the urinary system

  Endocrinopathy

  Diseases of the blood

  Liver disease

  Diseases of the lungs

  Connective tissue diseases

  Acute and chronic infections

  Violation of hemostasis

  Alcoholism, drug addiction.

Complications of a real pregnancy:

• Vomiting of a pregnant woman

  The threat of termination of pregnancy

  Bleeding in the I and II half of pregnancy

• Polyhydramnios

  Malnutrition

  Plurality

  Placental insufficiency

• Rh and ABO isosensitization

  Exacerbation of viral infection

  Anatomically narrow pelvis

  Wrong fetal position

  Postterm pregnancy

  Induced pregnancy

Assessment of the state of the intrauterine fetus.

The total number of prenatal factors was 52.