Recommendations of pulmonologists for the management of pregnant women with various lung diseases. Clinical protocol for the management of physiological pregnancy Algorithm for diagnosing pregnancy on an outpatient basis

Physiological pregnancy- the course of pregnancy without complications according to the gestational age.
A high-risk pregnancy is a pregnancy that is likely to require further or has already required specialist intervention. Therefore, all other pregnancies are proposed to be classified as pregnancies low risk, normal or uncomplicated pregnancies (WHO definition).

I. INTRODUCTION

Protocol name:"Management of physiological pregnancy"
Protocol code:
ICD-10 code(s):
Z34 - current monitoring normal pregnancy:
Z34.8
Z34.9

Abbreviations used in the protocol:
BP - blood pressure
IUI - intrauterine infection
BMI - body mass index
STIs - sexually transmitted infections
PHC - primary health care
WHO - World Health Organization
Ultrasound - ultrasonography
HIV - Human Immunodeficiency Virus

Protocol development date: April 2013

Protocol Users: outpatient midwives, GPs, obstetricians and gynecologists

Indication of no conflict of interest: developers do not cooperate with pharmaceutical companies and have no conflict of interest

Diagnostics

METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

Diagnostic criteria: the presence of doubtful and reliable signs of pregnancy.

List of basic and additional diagnostic measures

Treatment

Treatment Goals: The physiological course of pregnancy and the birth of a live full-term newborn.

Treatment tactics

Non-drug treatment: no

Medical treatment: folic acid, acetylsalicylic acid, calcium preparations

Other treatments: no
Surgical intervention: no

Preventive actions: taking folic acid

Further management: childbirth

The first patronage is carried out by a midwife / nurse / GP during the first 3 days after childbirth (By order No. 593 of 08/27/12 "Regulations on the activities of healthcare organizations providing obstetric and gynecological care"). Examination 6 weeks after childbirth to determine the medical examination group, according to order No. 452 of 03.07.12. "On measures to improve medical care pregnant women, women in childbirth, puerperas and women of childbearing age.

Goals of postpartum checkup:
- Identification of existing problems with breastfeeding, the need to use contraceptives and the choice of contraceptive method.
- Measurement of blood pressure.
- If it is necessary to determine the level of hemoglobin in the blood, send the ESR to the clinic;
- If there are signs of infection, refer to an obstetrician-gynecologist.
- If you suspect that the child has any pathology of a hereditary nature, it is necessary to refer the woman for a consultation with a doctor.

Treatment activity and safety of diagnostic and treatment methods:
- no complications during pregnancy;
- timely detection, counseling, if necessary, hospitalization in case of complications;
- no perinatal mortality.

List of basic and additional diagnostic measures

Based on the history, physical examination, and laboratory tests, the following adverse prognostic factors are identified.

I. Sociobiological:
- mother's age (up to 18 years old; over 35 years old);
- the age of the father is over 40;
- occupational hazards of parents;
- smoking, alcoholism, drug addiction, substance abuse;
- weight and height indicators of the mother (height 150 cm or less, weight 25% above or below the norm).

II. Obstetric and gynecological history:
- number of births 4 or more;
- repeated or complicated abortions;
- surgical interventions on the uterus and appendages;
- malformations of the uterus;
- infertility;
- miscarriage;
- non-developing pregnancy (NB);
- premature birth;
- stillbirth;
- death in the neonatal period;
- the birth of children with genetic diseases and developmental anomalies;
- the birth of children with low or large body weight;
- complicated course of a previous pregnancy;
- bacterial-viral gynecological diseases (genital herpes, chlamydia, cytomegaly, syphilis,
gonorrhea, etc.).

III. Extragenital diseases:
- cardiovascular: heart defects, hyper and hypotensive disorders;
- diseases of the urinary tract;
- endocrinopathy;
- blood diseases;
- liver disease;
- lung diseases;
- connective tissue diseases;
- acute and chronic infections;
- violation of hemostasis;
- alcoholism, drug addiction.

IV. Complications of pregnancy:
- vomiting of pregnant women;
- the threat of abortion;
- bleeding in the I and II half of pregnancy;
- preeclampsia;
- polyhydramnios;
- oligohydramnios;
- placental insufficiency;
- multiple pregnancy;
- anemia;
- Rh and AB0 isosensitization;
- exacerbation of a viral infection (genital herpes, cytomegaly, etc.).
- anatomically narrow pelvis;
- incorrect position of the fetus;
- delayed pregnancy;
- induced pregnancy.

For quantitative assessment of factors, a scoring system is used, which makes it possible not only to assess the probability of an unfavorable outcome of childbirth under the action of each factor, but also to obtain a total expression of the probability of all factors.

Based on the calculation of the assessment of each factor in points, the authors distinguish the following degrees of risk: low - up to 15 points; medium - 15–25 points; high - more than 25 points. The most common mistake when calculating points, the doctor does not summarize the indicators that seem insignificant to him.

Similar information.

VI. The procedure for providing medical care to women with HIV infection during pregnancy, childbirth and the postpartum period

51. The provision of medical care to women with HIV infection during pregnancy, childbirth and the postpartum period is carried out in accordance with sections I and III of this Procedure.

52. Laboratory examination of pregnant women for the presence of antibodies to the human immunodeficiency virus (hereinafter - HIV) in the blood is carried out when registering for pregnancy.

53. If the first test for HIV antibodies is negative, women who plan to continue their pregnancy are retested at 28-30 weeks. Women who used parenteral psychoactive substances during pregnancy and (or) had sexual contact with an HIV-infected partner are recommended to be examined additionally at 36 weeks of gestation.

54. Molecular biological examination of pregnant women for HIV DNA or RNA is carried out:

a) upon receipt of doubtful results of testing for antibodies to HIV obtained by standard methods (enzymatic immunoassay (hereinafter referred to as ELISA) and immune blotting);

b) upon receipt of negative test results for antibodies to HIV, obtained by standard methods, if the pregnant woman belongs to a high-risk group for HIV infection (intravenous drug use, unprotected sexual contact with an HIV-infected partner within the last 6 months).

55. Blood sampling during testing for antibodies to HIV is carried out in the treatment room of the antenatal clinic using vacuum systems for blood sampling, followed by blood transfer to the laboratory of a medical organization with a referral.

56. Testing for antibodies to HIV is accompanied by mandatory pre-test and post-test counseling.

Post-test counseling is provided to pregnant women regardless of the result of testing for antibodies to HIV and includes a discussion of the following issues: the significance of the result obtained, taking into account the risk of contracting HIV infection; recommendations for further testing tactics; ways of transmission and ways of protection from infection with HIV infection; the risk of HIV transmission during pregnancy, childbirth and breastfeeding; methods for preventing mother-to-child transmission of HIV infection available to a pregnant woman with HIV infection; the possibility of chemoprophylaxis of HIV transmission to the child; possible outcomes of pregnancy; the need for follow-up of mother and child; the possibility of informing the sexual partner and relatives about the results of the test.

57. Pregnant women with a positive result laboratory examination for antibodies to HIV, an obstetrician-gynecologist, and in his absence - a general practitioner (family doctor), a medical worker of the feldsher-obstetric station, sends the subject to the Center for the Prevention and Control of AIDS Russian Federation for additional examination, dispensary registration and prescription of chemoprevention of perinatal transmission of HIV (antiretroviral therapy).

Information received by medical workers about a positive result of testing for HIV infection of a pregnant woman, a woman in labor, a puerperal woman, antiretroviral prevention of HIV transmission from mother to child, joint observation of a woman with specialists from the Center for Prevention and Control of AIDS of a constituent entity of the Russian Federation, perinatal contact with HIV infection in a newborn is not subject to disclosure, except as required by applicable law.

58. Further monitoring of a pregnant woman with an established diagnosis of HIV infection is carried out jointly by an infectious disease doctor of the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation and an obstetrician-gynecologist of a antenatal clinic at the place of residence.

If it is impossible to send (observe) a pregnant woman to the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation, the observation is carried out by an obstetrician-gynecologist at the place of residence with methodological and advisory support from the infectious disease specialist of the Center for the Prevention and Control of AIDS.

The obstetrician-gynecologist of the antenatal clinic during the period of observation of a pregnant woman with HIV infection sends to the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation information on the course of pregnancy, concomitant diseases, complications of pregnancy, the results of laboratory tests to adjust the schemes of antiretroviral prevention of HIV transmission from mother to a child and (or) antiretroviral therapy and requests information from the Center for Prevention and Control of AIDS of a constituent entity of the Russian Federation about the characteristics of the course of HIV infection in a pregnant woman, the regimen for taking antiretroviral drugs, agrees on the necessary diagnostic and treatment methods, taking into account the woman’s health status and the course of pregnancy .

59. During the entire period of observation of a pregnant woman with HIV infection, the obstetrician-gynecologist of the antenatal clinic, in conditions of strict confidentiality (using a code), notes in the woman’s medical records her HIV status, presence (absence) and admission (refusal to accept) antiretroviral drugs needed to prevent the transmission of HIV infection from mother to child, prescribed by specialists from the Center for the Prevention and Control of AIDS.

The obstetrician-gynecologist of the antenatal clinic immediately informs the Center for the Prevention and Control of AIDS of the subject of the Russian Federation about the absence of antiretroviral drugs in a pregnant woman, the refusal to take them, to take appropriate measures.

60. During the period of dispensary observation of a pregnant woman with HIV infection, it is recommended to avoid procedures that increase the risk of infection of the fetus (amniocentesis, chorion biopsy). The use of non-invasive methods for assessing the condition of the fetus is recommended.

61. When women who have not been tested for HIV infection, women without medical documentation or with a single examination for HIV infection, as well as those who used psychoactive substances intravenously during pregnancy, or who had unprotected sexual contacts with an HIV-infected partner, are admitted to an obstetric hospital for delivery, it is recommended to conduct an express laboratory test for antibodies to HIV after obtaining informed voluntary consent.

62. Testing a woman in labor for antibodies to HIV in an obstetric hospital is accompanied by pre-test and post-test counseling, including information on the significance of testing, methods for preventing mother-to-child transmission of HIV (antiretroviral drugs, mode of delivery, feeding habits of the newborn (after birth, the baby is not attached to the breast and is not fed with mother's milk, but is transferred to artificial feeding).

63. An examination for antibodies to HIV using diagnostic express test systems approved for use in the territory of the Russian Federation is carried out in a laboratory or in the emergency department of an obstetric hospital by medical workers who have undergone special training.

The study is carried out in accordance with the instructions attached to a specific rapid test.

Part of the blood sample taken for the rapid test is sent for testing for antibodies to HIV according to the standard method (ELISA, if necessary, immune blot) in the screening laboratory. The results of this study are immediately transferred to the medical organization.

64. Each HIV test using rapid tests must be accompanied by a mandatory parallel test of the same portion of blood classical methods(ELISA, immune blot).

Upon receipt of a positive result, the remaining part of the serum or blood plasma is sent to the laboratory of the Center for the Prevention and Control of AIDS of the subject of the Russian Federation for a verification study, the results of which are immediately transferred to the obstetric hospital.

65. If a positive HIV test result is obtained in the laboratory of the Center for Prevention and Control of AIDS of a constituent entity of the Russian Federation, a woman with a newborn after discharge from an obstetric hospital is sent to the Center for Prevention and Control of AIDS of a constituent entity of the Russian Federation for counseling and further examination.

66. In emergency situations, if it is impossible to wait for the results of standard HIV testing from the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation, the decision to conduct a prophylactic course of antiretroviral therapy for mother-to-child transmission of HIV is made when antibodies to HIV are detected using a rapid test -systems. A positive rapid test result is only grounds for prescribing antiretroviral prophylaxis for mother-to-child transmission of HIV infection, but not for making a diagnosis of HIV infection.

67. To ensure the prevention of mother-to-child transmission of HIV infection, the obstetric hospital should always have the necessary stock of antiretroviral drugs.

68. Antiretroviral prophylaxis in a woman during childbirth is carried out by an obstetrician-gynecologist who conducts childbirth, in accordance with the recommendations and standards for the prevention of mother-to-child transmission of HIV.

69. A prophylactic course of antiretroviral therapy during childbirth in an obstetric hospital is carried out:

a) in a woman in labor with HIV infection;

b) with a positive result of rapid testing of a woman in childbirth;

c) if there are epidemiological indications:

the impossibility of conducting express testing or timely obtaining the results of a standard test for antibodies to HIV in a woman in labor;

the presence in the anamnesis of a woman in labor during the present pregnancy of parenteral use of psychoactive substances or sexual contact with a partner with HIV infection;

with a negative test result for HIV infection, if less than 12 weeks have passed since the last parenteral use of psychoactive substances or sexual contact with an HIV-infected partner.

70. The obstetrician-gynecologist takes measures to prevent the duration of the anhydrous interval for more than 4 hours.

71. When conducting labor through the natural birth canal, the vagina is treated with a 0.25% aqueous solution of chlorhexidine upon admission to childbirth (at the first vaginal examination), and in the presence of colpitis - at each subsequent vaginal examination. With an anhydrous interval of more than 4 hours, the treatment of the vagina with chlorhexidine is carried out every 2 hours.

72. During labor in a woman with HIV infection with a live fetus, it is recommended to limit procedures that increase the risk of infection of the fetus: labor stimulation; childbirth; perineo(episio)tomy; amniotomy; the imposition of obstetric forceps; vacuum extraction of the fetus. These manipulations are performed only for health reasons.

73. Planned C-section to prevent intranatal infection of a child with HIV infection, it is carried out (in the absence of contraindications) before the onset of labor and outflow amniotic fluid if at least one of the following conditions is present:

a) the concentration of HIV in the mother's blood (viral load) before childbirth (for a period not earlier than 32 weeks of pregnancy) is more than or equal to 1,000 kop/ml;

b) maternal viral load before delivery is unknown;

c) antiretroviral chemoprophylaxis was not carried out during pregnancy (or was carried out in monotherapy or its duration was less than 4 weeks) or it is impossible to use antiretroviral drugs during childbirth.

74. If it is impossible to carry out chemoprophylaxis during childbirth, caesarean section can be an independent prophylactic procedure that reduces the risk of a child becoming infected with HIV during childbirth, while it is not recommended for an anhydrous interval of more than 4 hours.

75. The final decision on the method of delivery of a woman with HIV infection is made by the obstetrician-gynecologist in charge of childbirth, on an individual basis, taking into account the condition of the mother and fetus, comparing in a particular situation the benefit of reducing the risk of infection of the child during a caesarean section with the probability occurrence of postoperative complications and features of the course of HIV infection.

76. Immediately after birth, a newborn from an HIV-infected mother is bled for testing for antibodies to HIV using vacuum blood sampling systems. The blood is sent to the laboratory of the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation.

77. Antiretroviral prophylaxis for a newborn is prescribed and carried out by a neonatologist or pediatrician, regardless of whether the mother takes (refuses) antiretroviral drugs during pregnancy and childbirth.

78. Indications for prescribing antiretroviral prophylaxis for a newborn born to a mother with HIV infection, a positive rapid test for antibodies to HIV at birth, an unknown HIV status in an obstetric hospital are:

a) the age of the newborn is not more than 72 hours (3 days) of life in the absence of breastfeeding;

b) in the presence of breastfeeding (regardless of its duration) - a period of not more than 72 hours (3 days) from the moment of the last breastfeeding (subject to its subsequent cancellation);

c) epidemiological indications:

unknown HIV status of a mother who uses parenteral psychoactive substances or has sexual contact with an HIV-infected partner;

a negative HIV test result for a mother who has used psychoactive substances parenterally in the last 12 weeks or has had sexual contact with a partner with HIV infection.

79. A newborn is given a hygienic bath with chlorhexidine solution (50 ml of 0.25% chlorhexidine solution per 10 liters of water). If it is impossible to use chlorhexidine, a soapy solution is used.

80. When discharged from an obstetric hospital, a neonatologist or pediatrician explains in detail to the mother or persons who will care for the newborn the further regimen for taking chemotherapy drugs by the child, hands out antiretroviral drugs to continue antiretroviral prophylaxis in accordance with the recommendations and standards.

When conducting a prophylactic course of antiretroviral drugs using emergency prophylaxis methods, discharge from the maternity hospital of the mother and child is carried out after the end of the prophylactic course, that is, not earlier than 7 days after childbirth.

In the obstetric hospital, women with HIV are counseled on the issue of refusing breastfeeding, with the consent of the woman, measures are taken to stop lactation.

81. Data on a child born to a mother with HIV infection, antiretroviral prophylaxis for a woman in childbirth and a newborn, methods of delivery and feeding of a newborn are indicated (with a contingent code) in the medical documentation of the mother and child and transferred to the Center for the Prevention and Control of AIDS of the subject of the Russian Federation, as well as to the children's clinic where the child will be observed.

The system of antenatal surveillance in Europe was established at the beginning of the 20th century. Its main goal was to reduce the high level of maternal mortality. And it was very logical, because a pregnant woman is under the supervision of a specialist for a much longer time than during childbirth, which means that there are more opportunities for preventing various complications of pregnancy. But these expectations were far from fully justified. Antenatal care affects maternal mortality from only one cause, eclampsia. ineffective turned out to be: the distribution of women by risk groups (based on formal scoring every trimester), strict control of the weight of the pregnant woman (weighing at each appointment), routine pelvimetry, etc. Some activities turned out to be very expensive and also did not bring the expected results, for example, routine prescription iron supplements to reduce anemia during pregnancy and postpartum + routine testing for STIs. Effective turned out to be: the development of clinical protocols for the management of obstetric complications, counseling pregnant women and their families about emergency situations, the distribution of streams to ensure the most trained personnel in the most appropriate conditions (regionalization of care).

Despite this, in our country, more and more often, the process of bearing a child turns into an endless series of visits to antenatal clinics, repeated visits to narrow specialists during the pregnancy period, passing numerous tests and repeatedly undergoing certain types of research. At the same time, even such an enhanced version of antenatal care does not have any effect on the result, that is, the preservation of the health of the mother and child, at all or to a very small extent. Studies initiated by WHO in 4 countries with different systems of care for pregnant women (including Cuba, whose medicine is very similar to Russian) and which included more than 50 thousand participants, proved that in order to reduce the number of complications from the mother and 4 antenatal visits are sufficient. In addition, the feasibility of seeing women with uncomplicated pregnancies by an obstetrician-gynecologist is also questioned after the results of several RCTs. With a constant lack of time, the specialist faces a difficult choice: to devote less time to patients with normal pregnancies in order to concentrate on helping women with complications, or to spend most of their time observing the physiological process, but quickly losing their qualifications. At the same time, midwives and general practitioners are initially focused on providing care for normal pregnancies, which is likely to be more in line with the needs of women and their families. In most developed countries, where midwives provide the main care during childbirth, maternal, perinatal and early childhood morbidity and mortality rates are the lowest.

Of course, it is unlikely that 4 visits during pregnancy will suit most women. Four visits is the minimum that ensures quality, i.e. good results at a minimum cost. But even 7-10 visits to the antenatal clinic should change, first of all, qualitatively. The main tasks of the personnel providing assistance in the antenatal period should be the maximum possible psychological support for the family and high-quality counseling on all issues of interest, first of all, to the woman herself. In addition, preparation for childbirth, feeding and caring for a child is important. This protocol is modern look on antenatal care, an attempt to reconsider the attitude of medical professionals to many routine procedures that have no evidence of their effectiveness, and the planning of observation and education, taking into account the interests of the consumer, that is, the pregnant woman and her family.

Developed as part of the "Mother and Child" project. Here you can get up-to-date information on the management of pregnancy (many standard procedures turned out to be ineffective in fact), as well as a new view of medical science on the "pregnant" lifestyle.

A high-risk pregnancy is a pregnancy that is likely to require further or has already required specialist intervention. Therefore, all other pregnancies are proposed to be classified as low-risk pregnancies, normal or uncomplicated pregnancies.

All pregnant women should have access to antenatal care, the right to choose an institution and a medical professional who provides care.

All pregnant women should receive full information in a language they can understand about the purpose and possible results of any screening tests, any treatment and drugs prescribed during pregnancy, including prophylactic purposes.

All pregnant women have the right to refuse any research at all or to postpone it for a while. Indications for their appointment should be absolutely clear to patients.

Pregnancy management can be performed by an obstetrician-gynecologist or a trained midwife(1b)in a municipal antenatal clinic or a medical institution of any other form of ownership that has an appropriate license for this.

The number and frequency of visits is determined by the needs of the woman herself or the course of the present pregnancy.(2a), but not less than 4 (1b). The duration of each visit is also determined by the wishes of the patient; at the same time, the duration of the first visit, as well as the attendances devoted to discussing the results of the survey, must obviously be longer than the usual, regular ones.

Risk assessment

The distribution of pregnant women into low and high risk groups is necessary to provide timely and adequate assistance, especially to women who are included in the high risk group. It cannot be said about any pregnancy that there is no likelihood of certain complications. There is always the possibility that the process will change for the worse. Nevertheless, pregnancy should not be viewed pessimistically. Pregnancy should always be treated as normal (physiological) initially, but health care providers should be alert for signs of present or imminent danger. Thus, at present, the main principles of perinatal care should be:

respect for all women;

individual care protocols;

reassessment of the condition of the mother and fetus during each visit.

Formalized perinatal risk assessment based on scoring (especially summing up these scores across trimesters) for certain risk factors should no longer be used, as it too often leads to unnecessary interventions without changing perinatal outcomes.

Instead, it is suggested to gofrom risk-focused care to problem-focused care.

Lifestyle

Work during pregnancy

there is no basis for a recommendation to stop working in an uncomplicated pregnancy(3b), but it is necessary to exclude severe physical exercise such as carrying heavy loads and contact with corrosive liquids and gases;

at the first visit, it is necessary to provide all available legal information about the benefits, rights, benefits for all pregnant women, both those with a permanent job and housewives, and their families(4) ;

it is necessary to explain the meaning and components of the birth certificate, the timing of its issuance;

upon confirmation of pregnancy, issue a certificate for submission at the place of work or study to change the work schedule or its nature - exclusion of night or long shifts, transfer to light work;

during the observation, discuss in advance the issues of issuing a sick leave, terms, conditions.

Lessons physical education and sports

there is no reason to limit exercise and sports during an uncomplicated pregnancy(1b);

it is necessary to warn a pregnant woman about the potential dangers of certain sports, for example, all types of martial arts, skiing, parachuting, motor sports, diving, etc., as they pose a high risk of abdominal injury and can cause

fetal damage.

sex life

there is no reason to limit sexual life during the physiological course of pregnancy(3a).

Smoking

provide information on the association between smoking during pregnancy and the risk of low birth weight and preterm birth(1a);

organize work to stop, or at least reduce the number of cigarettes consumed, which may include individual counseling or group sessions, distribution of special literature or films.

A government policy is needed to promote the harms of smoking. The greatest success is brought by special programs to reduce the prevalence of smoking. Physicians and midwives who care for pregnant women should be the most active participants in this policy.

Alcohol

the negative effect of alcohol on the fetus in excess of 1 standard dose (15 ml of pure alcohol per day, or up to 30 ml of spirits, or a small glass of unfortified wine, or about 300 ml of light beer) has been proven;

it is necessary to convince the patient to completely stop drinking alcohol during pregnancy or to take no more than 1 standard dose of alcohol once or twice a week.

drugs

the negative effect of any drugs on the fetus has been proven;

it is necessary to convince the patient to completely stop taking drugs;

offer specialized medical care.

Pregnant women who smoke, take drugs or alcohol should be the most targeted by antenatal care professionals. It is necessary to use all available resources to help this category of patients.

Airtravels

it must be reported that long-term flights are dangerous for the development of venous thrombosis, for the prevention of which it is recommended to use compression stockings or bandages during the flight(3a);

no other effects on pregnancy were noted;

most airline companies have restrictions depending on the gestational age (most often they are not allowed to fly after 34-36 weeks).

Travel by car

it is necessary to recall the mandatory use of seat belts, and the belt itself should be located below or above the abdomen (ideally, special devices with two belts should be used)(3a).

tourist travel

it is necessary to remind pregnant women of the importance of acquiring appropriate insurance when traveling abroad and of having a compulsory medical insurance policy for all trips within Russia;

offer advice before planning your trip with your specialist, midwife or pregnancy doctor.

Nutrition of a pregnant woman

Pregnancy does not require dietary changes

Principles of healthy eating

it is necessary to consume a variety of foods, most of which should be products of plant and not animal origin;

bread, flour products, cereals, potatoes should be consumed several times a day;

eat vegetables and fruits several times a day, preferably fresh and grown in the area of ​​\u200b\u200bresidence;

control the intake of fat with food (no more than 30% of daily calories);

replace animal fat with vegetable fat;

replace fatty meats and meat products with legumes, grains, fish, poultry and lean meats;

consume milk and dairy products (kefir, curdled milk, yogurt, cheese) with a low fat content;

choose low-sugar foods and consume sugar in moderation, limiting sugar and sugary drinks;

avoid excessive salt intake, but you do not need to limit the amount of salt. On the one hand, the total amount of salt in food should not exceed one teaspoon (6 g per day), on the other hand, the level of salt intake should be considered as a matter of individual preference. It is advisable, especially in iodine-deficient regions, to use iodized salt;

cooking should be safe. Steaming, microwaving, baking or boiling will help reduce the amount of fat, oil, salt and sugar used in the cooking process.

Vitamins and trace elements

The addition of artificial vitamins to the diet during pregnancy is extremely rare. Only with extremely irrational nutrition, as well as in regions where the population is starving, the use of vitamins has been effective.

routine use of folic acid at a dose of 400 mcg daily before conception and in the first 12 weeks of pregnancy significantly reduces the risk of developing neural tube defects in the fetus (anencephaly, spina bifida); all women should be advised to take folic acid(1a);

there is no evidence for the routine use of folate to prevent anemia;

routine use of iron supplements is not indicated due to lack of effect on perinatal outcomes. Iron supplements reduce the incidence of anemia with Hb levels< 100 г/л к моменту родов, но часто вызывают побочные эффекты: раздражение желудка, запор или диарею (1a);

a daily dose of more than 700 micrograms of vitamin A may be teratogenic, so routine vitamin A supplementation should be avoided(4) . In addition, a pregnant woman should have information about products containing a high concentration of vitamin A, such as liver or products from it;

additional administration of iodine is indicated in regions with a high incidence of endemic cretinism.

Herbs, herbal tinctures and infusions are also medicines and should not be taken without a doctor's prescription. The safety of such drugs for both the unborn child and the health of the pregnant woman herself is unknown.

Medications

It is advisable to exclude the use of any drugs during pregnancy, except in cases that are dangerous to the life and health of the patient.

any doctor, prescribing treatment to a woman of reproductive age, should think about a possible pregnancy;

virtually none of the drugs can be classified as teratogenic or non-teratogenic without analysis of dosing, duration of use, gestational age;

very few drugs have been tested for the safety of their use during pregnancy, that is, they can be recognized as completely safe;

the most dangerous periods for the effect of drugs on the fetus are 15-56 days after conception, with the exception of antihypertensive drugs from the group of angiotensin-converting enzyme inhibitors (for example, capoten, hopten, renitec) and AT II receptor antagonists

(for example, losartan, eprosartan), the use of which in the II and III trimesters can lead to oligohydramnios due to impaired development and functioning of the fetal kidneys;

it is advisable to prescribe already proven drugs during pregnancy, try to exclude the use of new ones that have just appeared on the pharmaceutical market;

it is desirable to use the minimum effective doses in the shortest possible time;

in the presence of chronic extragenital diseases in a pregnant woman, treatment (choice of drug, dose, frequency of administration, course duration) should be prescribed together with the relevant narrow specialist.

Medical professionals must clearly understand the physical and psychological changes in the body of future parents and the stages of fetal development in order to provide correct information and advisory assistance if necessary (see attachments).

Discomfort during pregnancy

Pregnancy is not a disease. Of course, agreeing with this statement, nevertheless, it must be recognized that there are quite a few symptoms that in another situation, in a non-pregnant woman, could be taken as a manifestation of the disease. By themselves, these conditions are not dangerous for the normal development of the fetus and do not lead to any complications, but the discomfort that a pregnant woman experiences affects, sometimes significantly, her performance, mood, and general perception of pregnancy. Reducing the impact of these symptoms is

an important part of antenatal care. The health worker should not be limited to the phrases: “This is all normal, don’t worry!” or “This does not pose a danger to your child”, etc. Only a well-conducted counseling, possibly repeated, can really help the patient.

Nausea and vomiting, except in cases of excessive vomiting of pregnancy (ICD-X - O21)

cause unknown;

most often manifested in multiple pregnancies;

nausea occurs in 80-85% of all pregnancies, vomiting - up to 52%;

severe cases - excessive vomiting leading to dehydration and electrolyte disorders - occur no more than 3-4 cases per 1000 pregnancies and require inpatient treatment;

34% of women note the appearance of unpleasant symptoms within the first 4 weeks after the last menstruation, 85% - within 8 weeks;

about 90% of pregnant women report a decrease in symptoms by the 16-20th week of pregnancy;

the rest note nausea in the morning in the future;

no effect on pregnancy outcomes, fetal development(1b)but can significantly affect the patient's quality of life.

Tips for women:

eat a few dry crackers or a slice of bread early in the morning;

eat more often and in small portions.

Treatment:

non-pharmacological:

- ginger in the form of powders or syrup, 250 mg 4 times a day - reduction in the severity of nausea and vomiting after 4 days of use;

– acupressure of the Neiguan point (about 3 transverse fingers above the wrist);

pharmacological:

– antihistamines - promethazine (diprazine, pipolfen). It is necessary to warn the patient about possible drowsiness as a side effect;

– metoclopramide (cerucal), due to unknown safety, cannot be recommended as a first-line drug and may be prescribed in especially severe cases;

– there is evidence of the effectiveness of vitamin B, but its toxicity is not clear, so at the moment it cannot be recommended for use;

– there is data on the effectiveness of vitamin B 12 but its safety has not been proven.

Heartburn

pathogenesis is not clear, possibly related to hormonal status, changing the activity of the stomach, causing gastroesophageal reflux;

the frequency depends on the gestational age: in the first trimester it occurs up to 22%, in the second - 39%, in the third - up to 72%;

does not have any effect on pregnancy outcomes, fetal development, but may affect the quality of life of the patient.

Tips for women:

eat more often and in small portions;

avoid spicy and fatty foods;

avoid drinking coffee and carbonated drinks containing caffeine;

do not lie down or bend over after eating;

during sleep, your head should be on a high pillow;

for heartburn, drink milk or kefir, or eat yogurt.

Treatment:

antacids may be used in cases where heartburn persists despite lifestyle and dietary changes(2a).

constipation

may be associated with a decrease in the intake of food rich in fiber, as well as with the effect of progesterone on the activity of the stomach and, as a result, an increase in the duration of the evacuation of food from it;

the frequency decreases with increasing gestational age: at 14 weeks - 39%, at 28 weeks - 30%, at 36 weeks - 20%.

Tips for women:

drink at least 8 glasses of water and other liquids per day;

eat foods rich in dietary fiber, such as green vegetables and cereals with bran (wheat and bran reduce constipation by 5 times).

Treatment:

in cases where the use of physiological methods does not help, it is reasonable to prescribe laxatives that increase the volume of fluid in the intestines (seaweed, flaxseed, agar-agar) and stimulate peristalsis (lactulose), as well as soften the consistency of the stool (sodium docusate). Their safety has been proven for long-term use during pregnancy and lactation;

if these groups of laxatives do not lead to an improvement in the condition in short periods of time, the appointment of irritating laxatives (bisacodyl, senna preparations) is indicated;

saline laxatives and lubricants (mineral oils) should not be used during pregnancy.

Haemorrhoids

8-10% of pregnant women present characteristic complaints in the third trimester;

both pregnancy itself and a decrease in the diet of roughage contribute to the occurrence.

Tips for women:

changes in diet - an increase in the proportion of rough, fibrous foods;

while saving clinical symptoms it is possible to use conventional antihemorrhoidal creams;

surgical treatment during pregnancy is extremely rare.

Phlebeurysm

Tips for women:

inform women that this is a common symptom and is not harmful, except aesthetic problems feelings of general discomfort, sometimes itching;

compression elastic stockings may reduce swelling of the legs, but are not a prevention of varicose veins(2a).

Back pain

the prevalence is high - from 35 to 61% of pregnant women complain of pain in the lower back;

47-60% of patients reported the first symptoms during the period from the 5th to the 7th month of pregnancy;

in most, the intensity of pain increases in the evening;

pain is associated with a change in the posture of pregnant women, the mass of the pregnant uterus and

relaxation of supporting muscles as a result of the action of relaxin;

are not a sign of a disease state, for example, a symptom of a threatened abortion, but significantly affect the activity of a pregnant woman during the day and the impossibility of a good night's rest.

Tips for women:

wear shoes without heels;

avoid heavy lifting; if you have to lift weights, bend your knees, not your back;

water exercises, massage, individual or group sessions in special groups can be useful.

Leg cramps

the reasons are not clear;

disturb almost 50% of pregnant women, more often at night in recent weeks pregnancy;

are not signs of any disease, but cause significant concern in women;

there is no reason to prescribe drugs Mg, Na, Ca, since there is no evidence of their effectiveness;

during attacks, massage and muscle stretching exercises are advisable.

Vaginal discharge

the quantity and quality of vaginal discharge during pregnancy changes, more often women pay attention to an increase in the amount of discharge, which in most cases is not a sign of a disease;

complaints of an unpleasant odor, itching, soreness can be symptoms of bacterial vaginosis, trichomonas vaginitis or thrush (candidiasis colpitis);

sometimes these same signs are associated with physiological or pathological conditions, such as dermatosis of the vulva and allergic reactions;

vaginal candidiasis does not affect pregnancy, there is no connection with fetal diseases, so screening and active identification of sick women does not make any sense;

however, when complaints appear, the best treatment is to prescribe imidazoles: miconazole (Ginezol 7, Gino-dactarin, Klion-D 100) or clotrimazole (Antifungol, Yenamazol 100, Kanesten, Canizon, Clotrimazole) for a weekly course;

The safety and efficacy of oral treatment for vaginal candidiasis is not known, so this group of drugs should not be used.

Tips for women:

some increase and change in vaginal discharge is usually characteristic of a normal pregnancy;

in cases of unpleasant odor, itching, soreness, you should contact a medical specialist for additional examination.

Clinical examination of pregnant women

Weight, height, BMI

the concept of the rate of weight gain both during pregnancy in general and by weeks, months and trimesters is very individual;

the so-called pathological weight gain for a certain period of pregnancy should not be used as a criterion for assessing the course of pregnancy and diagnosing any complications (for example, preeclampsia) or predicting the birth of small children due to the extremely low predictive value of this indicator, on the one hand, and significant anxiety of a pregnant woman about this - on the other;

the woman's weight and height must be determined at the first visit for BMI calculation(2a);

BMI = weight (kg) / height (m) squared:

o low BMI -< 19,8;

o normal - 19.9-26.0;

o excess - 26.1-29.0;

o obesity -> 29.0;

patients with a BMI other than normal, especially those with low and obese, deserve more attention.

Breast examination

routine examination of the mammary glands is carried out to detect oncopathology;

there is no special preparation for breastfeeding during pregnancy(1b) .

Gynecological examination

(may be delayed until the second visit if the patient is not ready)

View in mirrors:

o assessment of the cervix (shape, length);

o analysis for oncocytology (smear);

o in the presence of pathological changes on the cervix, the patient should be offered a colposcopy.

Bimanual studyroutinely may not be carried out, since the accuracy of confirming the presence of pregnancy or clarifying the gestational age is low, diagnosis ectopic pregnancy requires the mandatory use of additional studies, the prevalence of volumetric formations in the pelvis (cysts) is low, especially since a pregnant woman will be asked to undergo an ultrasound scan in the first trimester, which will be a better and more accurate method for determining and confirming all the diagnoses described above.

Hematological screening

Anemia

– low and high Hb levels increase the risk of low birth weight and preterm birth;

– the most common cause of anemia worldwide is a lack of iron in the body of a pregnant woman;

– on the one hand, this is a consequence of increased iron consumption due to fetal growth, on the other hand, a relatively large increase in blood plasma volume (up to 50%) and a smaller increase in erythrocyte volume (up to 20%);

- other causes of anemia - thalassemia or sickle cell anemia - are quite rare in Russia;

– the norm for pregnancy in the I and III trimesters is recommended to consider the level of Hb\u003e 110 g / l; in the II trimester due to physiological anemia (the maximum relative increase in plasma volume to the volume of erythrocytes) -\u003e 105 g / l(1a);

– Hb level< 70 г/л относится к тяжелой степени анемии, требующей обязательного лечения;

– screening for anemia in general analysis blood, it is enough to determine only the level of Hb;

– Hb levels should be measured twice during pregnancy(2a) - at registration and at 28-30 weeks;

– at the same time, the routine use of iron preparations at normal or moderately reduced (100 g/l) Hb levels did not lead to an improvement in perinatal parameters, morbidity and mortality among both pregnant women and children, while reducing the number of patients with Hb levels< 100 г/л к моменту родов. Отмечена бóльшая толерантность

pregnant women with a moderate decrease in Hb levels to postpartum blood loss;

– if indicated, iron preparations (sulfate) should be administered per os for a long course of at least 3 months with an individually adjusted dose.

Determination of blood group and Rh factor

– determination of these indicators is important for the prevention hemolytic disease fetus and newborn and possible transfusion problems;

– blood type and Rh factor are determined at the first visit of a woman(2a) , information about the results is mandatory entered into the exchange card or other document that is constantly in the hands of the pregnant woman;

– with Rh-negative blood of the patient - offer to undergo a similar

testing the future father of the child;

o it is necessary to determine the presence of antibodies to the Rh factor in the blood at the first visit and at 26-27 weeks again (with a negative result of the first analysis) for timely anti-D prophylaxisMaintaining a normal pregnancyimmunoglobulin(2a) , except for cases of Rh-negative affiliation of the future father;

– when detecting antibodies in the blood of a pregnant woman, it is necessary to control their titer. The number of tests and the frequency of testing depends on the specific clinical situation, women with a high antibody titer should be consulted at a higher level institution, preferably a 3rd one.

Screening for fetal pathology

Screening for Down Syndrome

– population prevalence - 6.2 per 10,000 pregnancies (1:1613);

– 80% of children with Down syndrome have severe intellectual disabilities, the remaining 20% ​​may have moderate impairments or no such disorders at all;

– the prevalence of the syndrome depends on the age of the mother:

At 20 years old - 1 in 1,440 pregnancies;

At 35 years old - 1 in 338;

At 45 years old - 1 in 32;

– screening for Down syndrome is quite effective, but you should not insist if a woman refuses to have a test;

– should only be offered if the facility has pre- and post-counseling facilities that explain the benefits and risks associated with testing , as well as the consequences of obtaining positive results;

– it is also necessary to have high-quality standard equipment for ultrasound scanning, experienced staff, as well as the ability to monitor the effectiveness of testing;

– if these conditions are met, complex (integrated) testing is recommended, which includes ultrasound at 10-14 weeks of gestation to measure the thickness of the collar space, as well as serological tests at 11-14 and 14-20 weeks;

– positive results of comprehensive testing are an indication for amniocentesis (risk of miscarriage up to 1%). In addition, it should be taken into account that the probability of detecting pathology (sensitivity) in complex testing is 90%, and the probability of a false positive result is 2.8%. That is, for every nine identified fetuses with Down syndrome, there is one healthy

a fetus erroneously listed as sick;

– when the presence of pathology is confirmed by invasive tests and karyotyping, the woman is offered to terminate the pregnancy, preferably in a hospital of the 3rd level.

Screening for structural abnormalities

– it is offered to all pregnant women for a period of 18-20 weeks, while some of the gross structural anomalies, such as anencephaly, can be detected during the first ultrasound;

– The quality of screening (percentage of anomalies detected) depends on:

gestational age;

The anatomical system of the fetus, in which anomalies are determined;

Experience and skills of the researcher;

The quality of the equipment;

The duration of the study (on average, the implementation of the ultrasound protocol should take 30 minutes);

o if structural abnormalities are suspected, the pregnant woman is invited to undergo a more detailed examination at the regional consultation center.

Infection screening

Characteristics of a successful screening program

– the disease must be a public health problem;

– the history of the disease is well known;

– screening tests are accurate and reliable;

– the effectiveness of treatment has been proven;

– screening programs are worth the money spent.

Most infections diagnosed during pregnancy do not deserve much concern, since most often they do not affect the course of pregnancy, the risk of intrauterine or intranatal infection. Therefore, it is important for those who manage a pregnant woman not to impose unnecessary restrictions on pregnancy and not to waste available resources thoughtlessly.

Of course, some infections can be dangerous for the mother and / or child, but such infections are in the vast minority. Screening for infections should not be performed if the result of such screening is not practical - that is, if the treatment of a woman with a positive test result cannot be carried out due to limited local resources or the absence of proven effective treatments. A pregnant woman should not be treated with methods that have not been proven useful during pregnancy.

A pregnant woman should not be isolated from her baby, from other family members, or from other patients unless there is a serious risk to her or others as a result of such contact.

A woman should not be hospitalized for treatment unless outpatient treatment is not possible. In itself, hospital stay can pose a risk to both mother and child (primarily due to nosocomial infections).

Breastfeeding should not be discontinued if the mother has an infection. She should be advised to stop breast-feeding only if there is a specific, identifiable risk to the child as a result of such contact.

Due to the high prevalence of STIs, HIV, Hepatitis B, C among the population, healthcare professionals need to follow general precautions when treating all women. That is, follow the rule:treat all patients, without exception, as if they were known to be infected.

Asymptomatic bacteriuria

– prevalence - 2-5% of pregnancies;

– increases the risk of premature birth, the birth of small children, acute pyelonephritis in pregnant women (on average, it develops in 28-30% of those who have not received treatment for asymptomatic bacteriuria);

– definition - the presence of bacterial colonies > 10 5 in 1 ml of an average portion of urine, determined by the cultural method ("gold standard") without clinical symptoms of acute cystitis or pyelonephritis;

– diagnostic study - culture of the middle portion of urine - should be offered to all pregnant women at least once at registration(1a);

– for treatment, nitrofurans, ampicillin, sulfonamides, 1st generation cephalosporins, which in studies have shown the same effectiveness, can be used;

– treatment should be prescribed after the 14th week of pregnancy to exclude a possible negative effect on the development of the fetus;

– the criterion for successful treatment is the absence of bacteria in the urine;

– a single dose of antibacterial agents is as effective as 4- and 7-day courses, but due to fewer side effects, single doses should be used;

– it is logical to use drugs for which sensitivity has been established;

– treatment of severe forms of MVS infection (pyelonephritis) should be carried out in a specialized hospital (urological).

Routine antenatal screening

HELLshould be measured at each visit to detect signs of hypertension. Hypertension is only a sign and may or may not indicate the presence of preeclampsia.

Rules for measuring blood pressure

The most accurate readings are given by a mercury sphygmomanometer (all devices used must be calibrated against it)(1b).

The patient should be relaxed after rest (at least 10 minutes).

Position - half-sitting or sitting, the cuff should be located at the level of the patient's heart.

The cuff of the pressure measuring device should correspond to the circumference of the patient's upper arm (more is better than less).

It is enough to measure on one hand.

The level of systolic pressure is estimated by Korotkov's I tone (appearance), and diastolic - by V (cessation).

Indicators should be recorded with an accuracy of 2 mm Hg. Art.

Urinalysis for the presence of protein (PAM) .

Any urinalysis can be used for screening, although total protein excretion in daily urine volume should be analyzed to obtain the most complete and accurate data.

Measurement of the standing height of the fundus of the uterus (VDM) to predict low birth weight. Also, this test may be useful for screening to further investigate possible fetal growth retardation. The quality of this study is enhanced by the use of a gravidogram, which should be in every exchange card.

Palpation of the abdomen. Determination of the exact position of the presenting part of the fetus is not always accurate before 36 weeks and may cause discomfort to the woman.(3a), but at 36 weeks it is necessary to determine the presentation.

Examination of the condition of the legs for the presence of varicose veins at each visit. At the same time, the presence of edema (with the exception of severe or rapidly occurring edema of the face or lower back) should not be considered as signs pathological condition, since edema of the lower extremities occurs normally in 50-80% of pregnant women.

Routine examinations , which are not recommended , because their effectiveness is not available or proven

Woman's weight. Measuring weight gain at each visit is unreasonable, and it is not necessary to advise women to make dietary restrictions to limit weight gain.

Pelvimetry. It has been proven that the data of neither clinical nor radiological pelvimetry have sufficient prognostic value to determine the discrepancy between the size of the fetal head and the mother's pelvis, which is best detected by careful monitoring of the course of childbirth.(2a).

Routine auscultation of the fetal heart has no predictive value, since it can only answer the question: is the child alive? But in some cases, it can give confidence to the patient that everything is fine with the child.

Counting fetal movements . Routine scoring results in more frequent detection of decreased fetal activity, more frequent use of additional methods for assessing the condition of the fetus, more frequent hospitalizations of pregnant women and an increase in the number of induced births. Of greater importance is not the quantitative, but the qualitative characteristics of fetal movements(1b).

Routine ultrasound in the second half of pregnancy . Studying the clinical significance of routine ultrasound in later dates pregnancy revealed an increase in antenatal hospitalization and induced labor without any improvement in perinatal outcomes(1b). However, the feasibility of ultrasound in special clinical situations has been proven:

When determining exact signs life or death of the fetus;

When assessing the development of a fetus with suspected IUGR;

When determining the localization of the placenta;

When confirming a suspected multiple pregnancy;

When assessing the volume of amniotic fluid in case of suspected poly- or oligohydramnios;

When specifying the position of the fetus;

For procedures such as circumferential suture to the cervix or

external rotation of the fetus on the head.

Stress and non-stress CTG . There is no evidence for the use of antenatal CTG as an additional check for fetal well-being in even high-risk pregnancies.(1a). In 4 studies evaluating the impact of routine CTG, identical results were obtained - an increase in perinatal mortality in the CTG group (3 times!) With no effect on the incidence of CS, the birth of children with a low Apgar score, neurological disorders in newborns and hospitalization in the neonatal PETE. The use of this method is indicated only with a sudden decrease in fetal movements, with prenatal bleeding and any other conditions associated with the risk of the fetus (preeclampsia, decompensation of diabetes, etc.).

Possible minimum visits to the obstetrician – gynecologist or midwife during pregnancy

Ideally, it should be before conception before 12 weeks

Collection of anamnesis:

o Obstetric and gynecological history:

Information about the menstrual cycle and methods of contraception. Knowing the features of the menstrual cycle helps to more accurately determine the expected date of birth. It is important to bear in mind that in those taking oral contraceptives, amenorrhea that developed after their cancellation can lead to erroneous calculations. Be sure to clarify whether intrauterine contraceptives were used (if so, then note the date of removal);

Information about past gynecological diseases, pregnancy and childbirth. Celebrate total number pregnancies and their outcome: urgent or premature birth, spontaneous or induced abortion, the state of health of children. For each birth, the characteristics of the course, duration, method of delivery, complications, condition and weight of the newborn are noted. Repeated spontaneous abortions in the 1st or 2nd trimester of pregnancy may indicate a hereditary pathology, isthmic-cervical insufficiency, or infection;

If there was a caesarean section in the anamnesis, discuss with the woman the question of the possibility of childbirth through the natural birth canal.

It is necessary to collect documents about the previous operation.

o Past diseases and surgical interventions.

o Occupational hazards and taking medicines in the early

terms of pregnancy.

o Side effects of drugs, allergic history.

o Family history. Find out if there were any hereditary diseases and cases of multiple pregnancy in the family.

o social factors. Ask about the woman's family and socio-economic status, mental trauma and abuse in the past, bad habits. It is important to remember that not every woman easily admits that she smokes, uses alcohol or drugs.

o Concomitant manifestations, including those associated with pregnancy: nausea, vomiting, abdominal pain, constipation, headache, fainting, discharge from the genital tract, painful or frequent urination, edema, varicose veins, hemorrhoids.

Clinical examination.

Filling out an exchange card and an observation card (preferably an electronic version).

Measuring the weight and height of a woman, calculating BMI.

Measurement of blood pressure.

Gynecological examination (may be delayed until the second visit): examination in the mirrors, taking a smear for oncocytology, bimanual examination.

Lab Tests:

o blood test (Hb);

o urine culture;

o blood for hepatitis B, C, HIV, RW;

o determination of blood group and Rh factor.

Referral for ultrasound at 10-14 weeks.

Counseling about lifestyle and nutrition.

Provision of the following information (including in writing): telephone numbers, addresses of medical institutions providing emergency assistance. Information about behavior in emergency situations.

Issuance of booklets, reference literature, books about pregnancy, childbirth, the postpartum period (it is desirable to organize a special library for pregnant women).

14-16 weeks

Measurement of blood pressure.

OAM.

Referral for ultrasound at 18-20 weeks (to the advisory center).

18-20 weeks

ultrasound.

22 weeks

Discussion of the results of ultrasound.

Measurement of blood pressure.

OAM (total protein).

26 weeks

Measurement of blood pressure.

WDM measurement (gravidogram).

OAM (total protein).

30 weeks

Issuance of a sick leave (if necessary) and a birth certificate.

Measurement of blood pressure.

WDM measurement (gravidogram).

Providing information on childbirth preparation courses.

Lab Tests:

oblood test (Hb);

oOAM;

oblood for hepatitis B, C, HIV, RW.

33 weeks

Discussion of survey results.

Measurement of blood pressure.

WDM measurement (gravidogram).

OAM (total protein).

36 weeks

Measurement of blood pressure.

WDM measurement (gravidogram).

OAM (total protein).

Definition of the presenting part, with breech presentation- suggestion of external rotation at 37-38 weeks.

Discussion of the place of birth, organization of a visit to the selected institution.

38 weeks

Measurement of blood pressure.

WDM measurement (gravidogram).

OAM (total protein).

40 weeks

Measurement of blood pressure.

WDM measurement (gravidogram).

OAM (total protein).

41 a week

Measurement of blood pressure.

OAM (total protein).

Proposal of labor induction or bimanual examination to assess the cervix and detachment of the lower pole of the fetal bladder - in this case, the proposal of an additional examination in the amount of an abbreviated form of the biophysical profile of the fetus.

Special conditions during pregnancy

C pregnancy rock > 41 weeks

births are considered normal at 37-42 weeks of gestation, while the risk of antenatal losses increases depending on the period: for example, at 37 weeks the risk of stillbirth is 1/3000 births, at 42 weeks - 1/1000 births, at 43 weeks - 1/ 500 births;

routine ultrasound in the first half of pregnancy allows you to more accurately determine the duration of pregnancy than the beginning of the last menstruation, and reduces the likelihood of inducing labor in case of an alleged post-term pregnancy;

there is no evidence to support routine induction of labor before 41 weeks' gestation. On the one hand, routine induction of labor at 41+ weeks can reduce perinatal mortality, on the other hand, it is necessary to perform about 500 labor inductions, not forgetting the possible complications of this procedure, in order to exclude one case of perinatal mortality;

it is necessary to provide the patient with an opportunity for an informed choice: labor induction under conditions or careful monitoring of the fetus;

if there are conditions for relatively safe labor induction [level 2 or 3 obstetric facilities, availability of facilities for effective cervical preparation (prostaglandins, only gel forms for topical, vaginal or intracervical use)], labor induction should be offered at 41 weeks(1a) ;

it is necessary to provide the patient with full information about the various methods of inducing labor, the benefits and complications associated with each of them, so that she can take informed consent;

in case of refusal to induce labor, it is possible to continue outpatient monitoring of the pregnant woman in the conditions of the LC or the maternity ward with attendance at least 2 times a week and an additional examination of the fetal condition in the amount of: ultrasound (amniotic index) + CTG (non-stress test), if possible - vascular Doppler umbilical cord;

in case of pathological or suspicious changes based on the test results, urgent hospitalization in a hospital of at least level 2 is necessary for additional examination and possible delivery;

before formal induction of labor, women should be offered a vaginal examination to peel off the lower pole of the amniotic sac(1b) ;

to prevent one antenatal death, 500 labor inductions are necessary.