Medical management of pregnancy monitors the health of the woman and the unborn child. The purpose of such monitoring is to minimize the risk of complications. Therefore, the first visit to the doctor is recommended no later than the 8-10th week of pregnancy, and it is better to register at 6-7 weeks. This measure is important to ensure the normal course of pregnancy, the calculation of the expected date of birth (PDD) and, if necessary, the appointment of certain studies.

Schedule of doctor visits during pregnancy:

• up to 20 weeks - once every 4 weeks;
• from 20 to 30 weeks - once every 2 weeks;
• after 30 weeks - once every 10 days.

In high-risk pregnancies for various complications, the follow-up program is drawn up individually.

First appointment with the doctor

Before the consultation and examination, the nurse finds out the height of the pregnant woman, determines her body weight, pulse and blood pressure, and measures the size of the pelvis.
Then the doctor writes down the age of the pregnant woman, the date and characteristics of the last menstrual period in the medical record, sets the expected date of delivery. He asks questions about the habits of a pregnant woman, her profession, possible hereditary pathology, current and past diseases, injuries and surgical interventions, previously used methods of contraception, previous pregnancies, possible abortions, miscarriages and the presence of children.

Examination and examination at the beginning of pregnancy

Medical examination
A gynecological examination during the first visit to the doctor is intended to give an overall picture of the condition of the pregnant woman. It includes:

• assessment of the condition of the vagina and muscle tone of the perineum;
• examination of the state of the mucous membrane of the cervix and vagina;
• identification of a possible infection in the presence of white or bloody discharge or visible damage to the cervix and vagina;
• finger vaginal examination to determine the state of the ovaries and uterus;
• assessment of changes in the uterus to suggest the age of the embryo or fetus.

Research
At the onset of pregnancy, such studies as determining the blood group, Rh factor, immunity to rubella and toxoplasmosis are required. An ultrasound scan at the first visit is performed in cases where a woman does not accurately remember the date of the last menstrual period, when the menstrual cycle is irregular or pregnancy occurred less than 3 months after hormonal contraception was canceled.

Routine examinations of a pregnant woman

Follow-up visits to the doctor are necessary to monitor the well-being of the expectant mother and child. During each appointment, the pregnant woman will:

• weighing (body weight can increase by about 1 kg per month for the first six months and by 1.5-2 kg per month in the third trimester);
• blood pressure measurement;
• examination of the legs and feet (to identify possible edema).

From the 10th to the 14th week of pregnancy, a double test is performed,
and from the 16th to the 20th week - a triple test to identify the risk of chromosomal
fetal diseases and malformations of the nervous system. Their frequency is
from 0.2% to 5% and increases in parents over 35 years old. When identifying
at increased risk, consultation with a geneticist is required.

Obstetric examination of a pregnant woman and a fetus

An obstetric examination includes examinations such as:

• probing the abdomen of a pregnant woman to establish the position of the fetus;
• measuring the height of the bottom of the uterus and the circumference of the abdomen using a measuring tape to determine the estimated weight of the unborn child;
• listening to the fetal heart rate with a stethoscope (normally 120-160 beats per minute);
• establishing the length of the cervix for the factor of its closure;
• control of the final position of the fetus and clarification of the size of the mother's pelvis (during the last consultation before childbirth).

Tradition for 9 months

Visiting a doctor during pregnancy should be a rule of thumb. After all, the guarantee of its successful course, and then childbirth, depends on careful monitoring of the health status of the expectant mother.

Necessary examinations and deadlines for their delivery by week of pregnancy

Specialist consultations:

1. Obstetrician-gynecologist: up to 20 weeks 1 time per month, from 20 to 30 weeks 2 times a month, after 30 weeks 1 time per 10 days
2. Therapist: first consultation at first visit (preferably before 12 weeks), second at 30 weeks
3. Oculist: one consultation in the first trimester of pregnancy
4. Dentist: one consultation in the first trimester
5. Otolaryngologist: one consultation in the first trimester

Examinations and analyzes:

1. Blood test for group and Rh factor: once in the first trimester of pregnancy
2. General analysis blood: at the first visit, at 18 weeks, at 30 weeks and at 37-38 weeks
3. Blood sugar test: at the first visit
4. Blood test for HIV, syphilis: at the first visit, at 30 weeks and at 37-38 weeks
5. Blood test for hepatitis B and C: at the first visit and in the third trimester
6. Blood test for biochemical markers of congenital fetal pathology: double test at 10-14 weeks, triple test at 16-20 weeks
7. General urine analysis: before each visit to the obstetrician-gynecologist
8. Flora swab: at first visit, at 30 weeks and at 37-38 weeks
9. Coagulogram: at the first visit
10. Biochemical blood test: at the first visit and at 30 weeks
11. TORCH blood test: at the first visit
12. Ultrasound: for a period of 10-14 weeks, 20-24 weeks, 32-34 weeks
13. Cardiotocogram (CTG): at 32 weeks of gestation, repeated if necessary

Expert: Irina Isaeva, obstetrician-gynecologist
Elena Nersesyan-Brytkova

The portal contains prices for pregnancy management in St. Petersburg, as well as detailed information on the benefits of this service. Waiting for the desired replenishment in the family is both a joyful and an alarming event for parents. It is accompanied by a special condition of a woman, which is manifested by fear of pain during childbirth, anxiety about the correct development of the baby, anxiety and happiness of future motherhood.

At this time, it is important to pay close attention to your physical, emotional health, and it is advisable to do this under the strict supervision of an experienced private clinic specialist. Therefore, in the early stages, it is recommended to choose a clinic, get to know the doctor you like better and meet with an obstetrician. It would be wise to conclude a contract for paid pregnancy management in order to eliminate worry for yourself and the unborn child.

Paid pregnancy management in medical centers

Pregnancy management for a fee implies close personal contact with your doctor, the ability to receive medical and psychological advice at any time in all trimesters of the term. This strengthens the woman's confidence that everything will turn out well. Highly qualified control of the correct development of the baby, monitoring the health of the mother, the necessary set of examinations and medical diagnostics during pregnancy are prescribed in the contract.

Paid pregnancy management is characterized by an individual approach to each patient, a thorough examination and timely detection of any deviations from the normal formation of the fetus, therefore such programs are especially recommended for women who have difficulties with the heart and blood vessels. The program includes both routine examinations of doctors and necessary examinations. This includes:

• Tests for blood clotting, for the threat of interruption, thyroid hormones.
• Research for markers of hereditary diseases and latent infections.
• General tests and mandatory smears.
• Determination of the Rh factor, blood group.
• Detection of antibodies to viral diseases: measles and rubella.

The cost of pregnancy management is calculated in an affordable amount and allows you to economically plan financial costs.

Benefits of paid pregnancy management

Paid pregnancy care is organized with maximum attention to the pregnant woman, which includes:

• No crowds in front of the office and no queues.
• Individual attention to a pregnant woman, normal development unborn child.
• Skilled training in newborn care.
• Affordable price.

The clinic's specialist will select a personal program, in which, based on the results of examinations and analyzes, visits to the clinic, clinical standard examinations and communication with a personal doctor, who is ready to consult at any moment, will be planned and clearly spelled out.

The long-awaited two strips on the dough or a pleasant surprise - remember this moment, because after it your life will change dramatically. From sleepless nights, expectant parents are separated by a long nine months, and it's time to think about who to entrust the management of pregnancy. Especially this question worries those who are expecting their first child.

Vitamins, the necessary tests, individual recommendations and the well-being of the pregnant woman - the baby must grow and develop under the supervision of a competent specialist.

Women's consultation

Pregnancy management in Moscow is primarily carried out by antenatal clinics. Reception and almost all manipulations are free of charge. Expectant mothers, according to the law, can also apply for a dairy recipe and get free vitamins.

Over the past few years, the healthcare system has undergone dramatic changes: electronic queues, visit alerts and more. However, the only thing that legislators cannot change is their attitude towards people. Some doctors are indifferent to their duties, allow them to make unacceptable comments to patients and completely ignore their questions and requests.

A happy woman who finds out about an interesting situation is faced with indifference from the doctor, waits for coupons for a free ultrasound scan and re-tests due to the fact that the previous ones simply cannot be found. We are not saying that such a mess is happening in all district consultations, but the reviews of disgruntled patients cannot be hidden anywhere.

The expectant mother should trust her doctor and be able to contact him at any time. For this reason, many people prefer paid pregnancy management.

Advantages of private clinics

The obvious advantage of a contract involving medical management of pregnancy is an individual approach. There are no queues in private clinics, and the appointment takes place at exactly the appointed time.

In addition, all necessary examinations and analyzes are carried out in short term, and the results will definitely not be lost. The attending physician is ready to answer all questions, no matter how silly they seem to you.

As in the antenatal clinic, closer to childbirth, an exchange card is issued here, which must be presented at the maternity hospital.

Cons of private clinics

The contract for the management of pregnancy, depending on the duration and cost, includes an appointment with a doctor and a set of tests. Private clinics try to make money on every client, so you may be strongly encouraged to do more examinations for an additional fee. In this case, it is better to consult with another specialist so as not to fall for the bait.

Another disadvantage concerns sick leave. Severe toxicosis, feeling unwell, tone or a cold - very often pregnant women need a little rest. Write out sick leave must be a doctor conducting pregnancy. Reviews of young mothers note that in government agency getting this document is much easier. We advise you to sometimes look into antenatal clinic and be in good relationship with a local gynecologist.

We will consider private clinics that offer pregnancy management at the cost of contracts and read patient reviews in our review.

1. Center for Reproduction and Genetics Nova Clinic

The most expensive observation will be at the Lapino Clinical Hospital:

Program from the 1st trimester - 243,100 rubles,

Program from the 2nd trimester - 221,000 rubles,

Program from the 3rd trimester - 180,200 rubles.

A contract signed in the first trimester at the Novogireevo clinic, for example, costs half the price - 95,685 rubles.

Most of the young mothers who were observed in “Lapino” were satisfied with their choice. A superbly equipped hospital, highly qualified doctors from all over the capital, an incredibly sensitive attitude and the best management of pregnancy - it is very difficult to find negative reviews. The remarks concern only the location of the medical institution: the road, taking into account traffic jams, takes at least 1.5 hours.

3. Scientific Center for Obstetrics. Kulakova

Where can I find reasonable prices for pregnancy management in Moscow? The rating is continued by the Scientific Center for Obstetrics, Gynecology and Perinatology at 4 Academician Oparina Street.

According to the information on the official website, the simplest pregnancy management contract (without complications) from the early stages “Optima” will cost 100,000 rubles. Execution of the contract implies the issuance of an exchange card, as well as outpatient and maternity sick leave certificates.

Reviews indicate that qualified doctors work in the center on Oparina Street. Pregnancy management is limited to the prescribed procedures, and no one has a goal of extracting money from you. Some gynecologists even advise not to conclude a contract, but to pay separately for each appointment. Tests can be taken in the clinic itself, in private laboratories, or even in the antenatal clinic. In this case, the exchange card and sick leave are also issued at the place of residence.

4. Center for Traditional Obstetrics

The best shots, modern equipment and qualified pregnancy management - the rating of Moscow clinics cannot be imagined without the Center for Traditional Obstetrics. Specialists try to build partnerships with future parents.

The basic program provides for a minimum set of examinations and appointments with doctors, which are necessary to obtain an exchange card. The minimum contribution is 25,000 rubles.

The "Exclusive" program includes an unlimited number of appointments with an obstetrician-gynecologist, all kinds of laboratory and instrumental studies, attending group sessions, as well as a consultation with an osteopathic doctor (once a month) and a perinatal psychologist. The cost of the program is 120,000 rubles.

One-time consultations of ultrasound specialists and obstetricians-gynecologists.

Much time is devoted to preparing for childbirth. For this, specialists conduct thematic lectures, trainings and practical exercises. School of moms and dads helps prepare for childbirth and learn about the physiology of the baby, useful information about hardening and explore the main stages in a child's life.

"Sensitive and responsive people" - this is how grateful patients characterize the CTA team. According to reviews, pregnancy management takes place in a friendly environment. Expectant mothers do not spend hours in huge queues waiting for an appointment. You can have tea while sitting on a cozy sofa. There is a play area for children.

5. Center for Immunology and Reproduction

The Center for Immunology and Reproduction, founded in 1996, is proud of the introduction of advanced Western technologies. For expectant mothers, pregnancy management programs have been developed here, courses and master classes are held, as well as classes in the fitness room.

The center differs from many other private clinics by having its own laboratory, which allows you to quickly receive research data and make the necessary appointments. Branches are located in the Central, Southern and Northern districts of the capital.

Depending on the term, a pregnancy management contract will cost from 78,000 to 86,000 rubles. Full and partial payment is provided. When concluding a contract, the future patient receives a 25% discount, as well as a discount card (10%) for additional services.

Patients have different impressions of observation at the CIR. Among the pluses, they note the absence of queues and an attentive attitude. The comments relate to the work of individual specialists - we hope that the clinic's management at least occasionally reads reviews on the Web.

6. Family Planning Center

At the time of opening in 2006, it was an advanced hospital, where many expectant mothers dreamed of being monitored. Today, everyone has the opportunity to come to an appointment with an obstetrician-gynecologist, but it is even easier to do this together with the purchase of a contract.

On a paid basis, you can become a member of a unique pregnancy management program, which provides not only examinations and analyzes, but also an unlimited number of consultations with all specialists of the center. In addition, when concluding a contract, there are discounts on payment for childbirth and further supervision of the baby.

However, the once-cutting-edge Family Planning Center is ranked fifth in our modest ranking for its past merits. Almost ten years ago, celebrity mothers and businessmen's wives gave birth here. Much has changed since then. According to patients' reviews, the building needs cosmetic repairs for a long time. The best doctors were lured away by the Lapino hospital, and the pregnancy management program on a paid basis (the cost must be specified by calling the center) implies hours of waiting in queues and an indifferent attitude on the part of the staff.

By the way, on the basis of the center there is a branch of the clinic "Mother and Child" - Perinatal Medical Prospect. The minimum contract value for the weekend program is 124,524 rubles.

7. "Healthy generation"

Maternity hospital No. 25 is one of the best in Moscow, so the Healthy Generation Medical Association, which actively cooperates with it, inspires a lot of confidence in young families.

The main task of antenatal clinics is systematic monitoring of a pregnant woman, starting from the early stages of pregnancy, timely detection of pregnancy pathologies and the provision of qualified medical care... All pregnant women are under dispensary supervision; on average, a woman must visit antenatal clinics 13-14 times during pregnancy.

You need to visit the antenatal clinic before the 12th week of pregnancy - during these periods it is decided whether pregnancy is permissible.

Until the 28th week, you will be asked to come once a month (in the absence of pathology).

Later, visits will become more frequent: twice a month - until the 37th week, before childbirth - every 7-10 days.

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Tasks of the antenatal clinic

The main purpose of monitoring pregnant women in the antenatal clinic is to preserve the physiological course of pregnancy and to carry out preventive measures to prevent complications and, first of all, placental insufficiency and gestosis.

In this regard, the following tasks have been set for the antenatal clinic.

1. Determine the presence of pregnancy and its duration.

2. Assess the history, general and gynecological health of the pregnant woman.

3. To carry out a full-fledged clinical, laboratory and instrumental examination of the mother and fetus, to reveal the presence and nature of somatic, neuroendocrine and gynecological diseases.

4. To identify the risk factors for the development of FPN and preeclampsia.

5. Decide on the possibility of maintaining pregnancy.

6. To carry out preventive measures to prevent the complicated course of pregnancy.

7. If clinical and / or laboratory signs of pregnancy pathology appear, timely admit the patient to the hospital.

8. Provide the necessary highly qualified assistance.

9. Assess the condition of the fetus and its growth in accordance with the gestational period.

10. Continue the treatment of FPN and preeclampsia after the patient is discharged from the hospital.

11. Maintain constant continuity between antenatal clinics and hospitals in the observation and treatment of pregnant women and women in childbirth (exchange of information).

At the first visit of a woman about pregnancy, it is necessary:

^ To collect a general and special anamnesis, paying attention to heredity, past diseases (general and gynecological), operations, blood transfusions, especially menstrual and reproductive functions.

^ To note the course and outcome of previous pregnancies (preeclampsia, premature birth, stillbirth, operations in childbirth, weight of children born, complications in childbirth, after childbirth and abortion, etc.).

In the presence of extragenital diseases, determine their nature (acute, chronic, exacerbation), taken drug treatment, supervision by specialists. Clarify the husband's health status, the nature of the production (the presence of occupational hazards, bad habits).

During the first visit to the antenatal clinic, the woman must be provided with written information about the screening tests available during pregnancy that the city health authorities can offer.

Printed brochures for the various screening programs (preferably with a description of each individual situation) should be available.

Sometimes it is necessary to have an interview with a psychologist, which will help the expectant mother to understand the real values ​​of life, to warn her and her husband against rash actions regarding the possible termination of pregnancy.

9.9.2. Risk factors for the development of preeclampsia

The risk of developing preeclampsia occurs in almost every pregnant woman. However, the risk of gestosis is most likely in the following diseases and conditions.

1. Cardiovascular diseases (arterial hypertension and hypotension).

2. Diseases of the kidneys, liver, gastrointestinal tract.

3. Endocrinopathies: obesity, diabetes mellitus, thyroid gland diseases.

4. Multiple pregnancy.

5. Pregnancy in young people under 18 years of age and primiparous late age over 35 years.

6. Hereditary burden (maternal preeclampsia).

7. Autoimmune diseases ( antiphospholipid syndrome, systemic lupus erythematosus).

8. Chronic infections.

9. Social disadvantage (poverty, unregistered marriage, poor living conditions).

9.9.3. Evidence-based medicine for preeclampsia

From the point of view of evidence-based medicine, the main provisions in the diagnosis of preeclampsia are as follows.

^ Simultaneous increase in blood pressure and the appearance of proteinuria after the 20th week of pregnancy.

^ Blood pressure is considered high during pregnancy if, when measured every 6 hours, the following results are obtained:

Systolic blood pressure is equal to or higher than 140 mm Hg. Art .;

Diastolic blood pressure is equal to or higher than 90 mm Hg. Art .;

Systolic blood pressure increased by 30 mm Hg. Art. or more;

Diastolic blood pressure increased by 15 mm Hg. Art. or more.

^ Significant daily proteinuria (0.3 g / L or more).

^ Early diagnosis increasing blood pressure is the task of the antenatal clinic.

^ Usually diastolic blood pressure decreases in the middle of pregnancy, so the risk of preeclampsia is lowest during this period.

¦ Pathological changes in urine

^ During pregnancy, especially for the detection of preeclampsia, the amount of protein in daily urine is determined. The risk of developing preeclampsia appears from the 20th week of pregnancy:

If proteinuria occurs early in pregnancy, kidney disease should be ruled out;

If protein is found in the urine, urine culture is required;

If proteinuria is not detected in the control study after 3 days, then it is sufficient during the woman's visits to the doctor (in the antenatal clinic) to carry out control studies of urine;

If a pregnant woman has proteinuria, but no symptoms of disease or edema, and her blood pressure is normal, it is necessary to conduct a study of urine sediment, serum creatinine and protein in daily urine. If the patient has hematuria or the creatinine level reaches 90 μmol / L, the woman should always be consulted with a nephrologist and hospitalized.

^ At the beginning of pregnancy, a test should be performed once for the presence of bacteria in the urine in pregnant women who are at high risk (for example, with a recurrent urinary tract infection, the threat of premature birth). This test is done regularly, as is the urine culture. In asymptomatic bacteriuria, drug therapy should be prescribed.

¦ Others laboratory research

^ Hematocrit blood count.

^ Blood hemoglobin.

^ AsAT serum.

^ The number of platelets in the blood.

^ The hematocrit number may increase due to thickening of the blood during preeclampsia.

^ An increase in the activity of aminotransferases in the blood serum, a decrease in the number of platelets and an increase in the content of urea nitrogen in the blood reflect the development of a pathological process in the body.

¦ Treating high blood pressure during pregnancy

^ Limiting the consumption of table salt and adherence to a regimen with adequate rest.

^ Drug therapy is prescribed when diastolic blood pressure rises to 100 mm Hg. Art. and higher.

^ For diabetes mellitus or kidney disease, drugs are often prescribed at lower blood pressure levels.

^ Treatment is prescribed after consultation with a specialist.

None of the treatments increase blood flow to the fetus.

A significant drop in blood pressure can interfere with blood circulation in the uterus. The prescribed drug must be safe for the fetus.

^ Labetalol (? -,? -Adrenergic blocker) is usually used at 100-400 mg 3 times a day.

^ You can prescribe? -Adrenergic blockers with internal adrenomimetic activity - nifedipine, clonidine, verapamil or prazosin.

^ Avoid the appointment of ACE inhibitors, diuretics, reserpine and diazoxide.

^ Pregnant women at high risk of developing gestational hypertension may benefit from additional calcium supplementation.

¦ Prevention of preeclampsia

^ Prescribing to pregnant women at risk of small doses of acetylsalicylic acid (50-75 mg / day), starting from the end of the first trimester of pregnancy (12 weeks and later), can improve the prognosis for the fetus.

¦ The main provisions of evidence-based medicine from the section "Pregnancy and blood pressure"

The most important goal of monitoring a woman during pregnancy is the earliest possible detection of preeclampsia (gestosis).

^ It is necessary to closely monitor the course of hypertension caused by pregnancy.

^ Arterial hypertension during pregnancy is the main cause of maternal morbidity, perinatal morbidity and mortality.

^ Should carefully monitor the course of pregnancy in women with a history of previous hypertension.

^ In women with a history of arterial hypertension and the development of a combined form of preeclampsia (preeclampsia) during the second and subsequent pregnancies, the risk of perinatal death is significantly higher than in primary pregnant women with preeclampsia that occurred without prior arterial hypertension.

^ Blood pressure exceeding 140/90 mm Hg. Art., or an increase in systolic blood pressure by 30 mm Hg. Art. or diastolic blood pressure by 15 mm Hg. Art. called high blood pressure during pregnancy.

^ When high blood pressure is diagnosed before pregnancy or before the 20th week of pregnancy, arterial hypertension is considered chronic.

^ Gestational arterial hypertension occurs only after the 20th week of pregnancy.

^ The concept of preeclampsia includes both an increase in blood pressure and the appearance of proteinuria after the 20th week of pregnancy.

^ Proteinuria 0.3 g / day may occur during the normal course of pregnancy; to confirm the diagnosis of preeclampsia, proteinuria should be 0.5 g / day.

^ At the initial stage of development of preeclampsia (synonym - preeclampsia), changes in the kidneys may still be absent and arterial hypertension may not be accompanied by proteinuria.

^ The combined form of preeclampsia occurs when proteinuria joins chronic arterial hypertension after the 20th week of pregnancy.

¦ Other sections of evidence-based medicine

^ In the normal course of pregnancy, systolic blood pressure for almost the entire pregnancy is at a level slightly lower than the initial one, which was available before pregnancy.

^ Diastolic blood pressure until the third trimester of pregnancy is at a level lower than the initial, which is available before pregnancy, and then rises to the initial level.

^ In almost half of pregnant women, blood pressure in the second trimester decreases moderately.

^ These physiological changes may be misinterpreted by the antenatal clinic physician.

^ It is important to monitor the level of blood pressure and its changes from the very beginning of pregnancy.

^ Blood pressure must be measured at every visit to the doctor, as it can rise rapidly in a very short period of time.

^ Blood pressure should be measured on the right arm (not through clothing) after at least 15 minutes rest, and for obese patients, a cuff of sufficient length and width should be fitted.

^ Pregnant women are advised to have a blood pressure monitor at home: it allows more active monitoring of the blood pressure level when it exceeds 140/90 mm Hg. Art., as well as in women at risk.

^ In the II trimester of pregnancy, an increase in diastolic pressure of more than 85 mm Hg. Art. regarded as a risk factor.

^ An increase in blood pressure at night increases the degree of risk.

^ At the beginning of pregnancy, the likelihood of high blood pressure and preeclampsia should be established.

^ If there is an increased risk after the 20th week of pregnancy, intensive monitoring of the condition of such pregnant women should be carried out (the interval of 4 weeks is too long!).

9.9.4. Identification of early signs of preeclampsia

But back to the tasks of antenatal clinics in monitoring pregnant women in the prevention of preeclampsia.

All pregnant women, starting from the earliest stages of pregnancy (up to 12 weeks), and women in childbirth are subject to medical examination. The identification of pregnant women is carried out when women contact the antenatal clinic and during preventive examinations.

During the normal course of pregnancy healthy woman it is recommended to visit a consultation with all analyzes and conclusions of doctors 7-10 days after the first visit, and then visit a doctor in the first half of pregnancy once a month, after 20 weeks of pregnancy - 2 times a month, after 32 weeks - 3-4 times a month. During pregnancy, a woman should visit a consultation about 14-15 times. In case of a woman's illness or a pathological course of pregnancy that does not require hospitalization, the frequency of examinations is determined by the doctor on an individual basis. It is especially important that the pregnant woman carefully attend the consultation during the prenatal leave.

Each pregnant woman should be examined by a therapist, dentist, otolaryngologist and, if indicated, by other specialists (ophthalmologist, endocrinologist, etc.) and, if necessary, sanitized.

When a woman first contacts a pregnancy consultation, it is necessary to conduct a general examination of the woman, measure her height, body weight, abdominal circumference and pelvic size; perform a two-handed study, measure the diagonal conjugate of the pelvis, measure blood pressure (on both hands) and determine the state of the lungs, heart, liver, kidneys and other organs. Conduct an ultrasound scan.

At each repeated examination of a pregnant woman, in addition to an obstetric examination (the height of the bottom of the uterus, abdominal circumference, fetal heartbeat, its position, etc.), it is necessary to measure body weight and blood pressure, to reveal the presence of latent and obvious edema.

After the first inspection and taking all required analyzes the second examination is carried out in 7-10 days. It is desirable that the woman come with her husband. It is necessary to find out the spouses' attitude to pregnancy (desired, unplanned), explain the presence of risk factors (diseases, infection, developmental anomalies), warn about the possibility of preventive hospitalization, talk about nutritional habits during pregnancy, provide the spouses with the necessary brochures with the necessary information.

The therapist examines a pregnant woman at least 2 times during pregnancy: at the first visit and at 32 weeks. Other specialists - according to indications. When the first signs of incipient gestosis are detected, the patient should be examined 2 times a week. If the symptoms of gestosis do not disappear, hospitalization is necessary. Special attention should be given to pregnant women with risk factors (extragenital diseases, aggravated obstetric and gynecological history, etc.).

When determining the gestational age for the first time, it is necessary to coordinate it with the period expected by the woman herself. At each repeated examination of a pregnant woman, in addition to a survey and an obstetric examination, it is necessary to identify the presence of obvious and latent edema, pay attention to the correct observance by the woman of the regime of work, rest, nutrition and the implementation of the appropriate complex physical exercise... Particular attention should be paid to the functional state of the fetus (movement, palpitations, estimated weight).

It is necessary to pay attention to the most early signs a novice gesto.

1. Complaints about an increased need for fluid (drinks a lot) and a decrease in the amount of urine excreted, as well as nocturia. If 25-30% of the daily urine output is released at night, with gestosis the night urine output is 35-40%.

2. Pathological weight gain (latent edema). A pregnant woman from 20 weeks of gestation adds in body weight not 50 g / day - 350 g / week, but 500-600 g / week or more in combination with a decrease in urine output.

After adhering to the diet, "fasting" days (which many patients tolerate with difficulty), the diuresis normalizes for some time, then decreases again, which indicates hidden edema.

3. Although many authors emphasize that edema is not always pathognomonic signs of the onset of preeclampsia, nevertheless, one should pay attention to morning edema around the eyes, in the region of the lower extremities, which cannot be classified as hydrostatic.

4. It is necessary to assess the change (increase) in blood pressure for minor psychoemotional irritations ("white coat hypertension") and / or for small physical activities (test with turning the body to the right side in a horizontal position for 5 minutes, test with changing position: sit down , stand up for 20 times). In a healthy pregnant woman, blood pressure practically does not change, in a pregnant woman with the onset of gestosis, the pressure rises by 15-20%.

5. Of particular importance is the increase in diastolic blood pressure (120/90 mm Hg), which indicates an increase in peripheral vascular resistance.

6. Violation of microcirculation is evidenced by a test with raising the arms above the head. For 20-30 seconds, the woman is asked to raise her hands up and clench her hands into a fist, after which her hands are lowered. Blanching of the extremities, the appearance of paresthesia indicate certain disorders of the peripheral circulation.

7. Particular attention should be paid to identifying arterial hypertension in relation to the initial blood pressure (before pregnancy, in early dates gestation, at 10 weeks of gestation, when blood pressure should be the lowest in the entire pregnancy).

8. Such well-known symptoms as proteinuria, daily loss of protein in the urine of more than 300 mg / day, hypoproteinemia (protein content in the blood plasma less than 65 g / l), are later symptoms of already developed gestosis, requiring hospitalization of the pregnant woman in the hospital.

9. Gestosis begins with an increase in the permeability of the placenta for neurospecific proteins of the fetus, which occurs at 22 weeks of gestation and later, therefore, in a woman with risk factors for the development of preeclampsia, it is necessary to conduct a complete examination of the fetus at 19-20 weeks of pregnancy, and in the mother - a repeated hemostasiological examination ...

In the future, the assessment of fetal growth and changes in the coagulogram is compared with the first assessment study performed in the first trimester.

In gestosis, the primary lesion is the vascular-platelet, therefore it is important to study the adhesive-aggregation function of platelets with ADP, collagen and ristomycin. Thrombocytopenia, hyperfibrinogenemia, hyperprothrombinemia are signs of progressive hypercoagulability.

Unlike a normal pregnancy, when hypercoagulation is observed, with gestosis, the activity of anticoagulants is inhibited (a decrease in the activity of antithrombin III), and the number of platelets decreases, which are not only consumed in the formation of loose blood clots in the microcirculation system, but also are destroyed when on their membranes recorded by the CEC.

10. The increase in blood viscosity reflects the hematocrit number. If its normal value during pregnancy is 30-32%, then an increase from 33 to 42% is considered pathological (the higher, the worse).

11. Periodically, after 20 weeks of gestation, it is necessary to measure daily urine output. This can be done by the pregnant woman herself and the results of the drunk and secreted fluid can be provided to the doctor.

9.9.5. Prevention of preeclampsia in antenatal clinics

1. The mode is medical-protective, calm, night sleep should be at least 8-10 hours and daytime rest 1-2 hours. Staying in a warm bed improves uteroplacental blood flow. It is advisable to listen to calm classical music during pregnancy.

2. In the absence of contraindications and the presence of conditions, swimming in the pool under the guidance of a coach 1-2 times a week, as well as general strengthening breathing exercises. Hydrotherapy to a certain extent dilates the vessels of the kidneys, lowers blood pressure, stimulates diuresis, and reduces peripheral vascular resistance.

3. Walking in the fresh air for an hour at least 2 times a day, more often in spring and summer.

4. You should avoid heavy physical exertion, stressful situations, stay in crowded places. This is especially important in case of an unfavorable epidemiological situation (risk of infection with ARVI).

5. Smoking, alcohol consumption is contraindicated during pregnancy.

¦ Nutrition

Proper nutrition affects the preservation of metabolism, endocrine-humoral regulatory mechanisms. Meals during pregnancy should be fractional (5-6 times food intake in small portions). Undoubtedly, the consumption of table salt should be limited to 3-5 g per day.

The chemical composition of the daily diet is: proteins 120-140 g, fats 80-90 g, carbohydrates 400-450 g. Up to 50% of proteins should be of animal origin (meat, fish, eggs, dairy products), the rest - vegetable. Especially useful is cottage cheese (up to 100-150 g), which has lipotropic properties. Pregnant women should limit their intake of high-saturated fats. fatty acids and replace with fats with a predominant content of polyunsaturated fatty acids (vegetable oil). The effect of lipid peroxide, which is dangerous for blood vessels, should be emphasized; therefore, fried foods should be excluded. It is necessary to recommend up to 40 ml per day vegetable oil, which is rich in essential fatty acids (precursors of the formation of arachidonic acid in the body) necessary for the synthesis of prostaglandins.

The diet should be dominated by vegetables, fruits, berries, raw juices.

Carbohydrates significantly replenish energy costs: for example, 500 g of carbohydrates when burned give 2 thousand kcal, that is, 2/3 of the total daily energy. With a lack of carbohydrates, proteins and glycogen from the liver are consumed for the formation of energy, the content of which is significantly reduced during gestosis. Excessive consumption of carbohydrates reduces the body's resistance.

The number of calories for pregnant women is up to 2.5-3 thousand per day (no more).

Nutrition for pregnant women should be varied and complete. Every day a pregnant woman should receive: meat or fish -120-150 g; milk or kefir - 200 g; cottage cheese - 50 g; eggs-1 pc .; bread -200 g; cereals and pasta - 50-60 g; potatoes and other vegetables - 500 g; fruits and berries - 200-500 g.

With a lack of fresh fruits and berries in the daily diet, it is necessary to take multivitamin complexes for pregnant women every day.

It is advisable to cook daily for breakfast cereals (oatmeal, buckwheat, millet, pumpkin, pearl barley, semolina) with 1-2 tablespoons of sunflower oil. It is advisable to add fresh berries and fruits to cereals.

With IUGR of the fetus, a course of honey with lemon is prescribed: 1 tablespoon of honey is dissolved in 1/3 cup of hot water, lemon juice is added. Take at night for 2 weeks. In combination with Actovegin (0.2 g 2 times a day), it is possible to quickly achieve the alignment of fetal growth in accordance with the proper gestational period.

From 14-16 weeks of pregnancy, antiplatelet drugs are prescribed.

9.9.6. Possibilities of drug prevention of gestosis. Prevention of severe forms

Data on the pathogenesis of preeclampsia testify to the most complex disorders in vital organs and regulatory systems and do not allow pinning great hopes on the effectiveness of treatment. Clinical observations confirm that at the present stage of development of medicine, it is almost impossible to cure severe preeclampsia. Modern methods treatment with the inclusion of intensive infusion-transfusion therapy, at best, can prevent the transition of gestosis to more severe form... And only timely delivery (removal of the fetus and placenta as the main reason for the development of preeclampsia), often performed with premature pregnancy, allows you to save the life of a woman and her child.

Treatment of gestosis is not always effective, but prevention gives good results.

After analyzing more than 6 thousand birth histories over 6 years, we came to the conclusion that at present the true frequency of preeclampsia in Moscow is from 17.4 to 24.9%. The most common and likely risk factors are: hypertension, chronic glomerulonephritis, pyelonephritis, arterial hypotension, impaired fat metabolism.

One of the main preventive measures is the early detection and registration of pregnant women with risk factors for the development of preeclampsia.

Preventive measures using medications in pregnant women of the risk group, it is advisable to carry out from the 14-16th week until the term of delivery. The course of antiplatelet agents and hepatoprotectors lasts at least 4 weeks, other drugs - 2-3 weeks. After one course, the treatment can be repeated after 10-14 days. During pregnancy - 3 courses.

Carrying out preventive drug therapy with the beginning of the second trimester is due to the fact that during these periods of pregnancy the most intensive growth of the fetus and placenta takes place, requiring adequate blood supply and optimal energy supply.

In pregnant women of the risk group, from this period, chronic placental insufficiency begins to form, and signs of maladjustment to the developing pregnancy are especially acute.

Drug prophylaxis enhances the compensatory-adaptive reactions of the mother and the fetus, prevents discirculatory disorders of BMD and FPK, as well as morphological disorders in the placenta.

The lack of correction of the preexisting pathology during these periods leads to a violation of the synthesis and balance of prostaglandins of pressor, aggregate, vasoconstrictor action and prostaglandins of depressor, antiplatelet and vasodilator effects.

¦ Antiplatelet agents

To improve uteroplacental hemodynamics, rheological and coagulation properties of blood, intensify tissue perfusion and supply them with oxygen, trental and / or curantil are used in the complex of preventive therapy.

These drugs are pathogenetically substantiated, since they have an active rheological effect, improve microcirculation, peripheral and cerebral circulation, and reduce platelet aggregation.

Thus, antiplatelet agents, by the essence of their action, are most pathogenetically justified for the treatment and prevention of vascular-platelet, microcirculatory and hemostatic disorders inherent in gestosis.

Trental increases the elastic properties of erythrocyte membranes, improves their deformability, reduces blood viscosity, increases capillary blood flow, reduces vascular resistance, reduces the force of spastic contraction of precapillary sphincters, releases prostacyclin from the vascular endothelium. Trental (agapurin) is prescribed 10 mg 3 times or 200 mg 2 times.

Curantil (dipyridamole) refers to myotropic drugs:

Reduces vascular resistance;

Increases the volumetric blood flow rate, especially in small arteries;

Has an inhibitory effect on platelet aggregation;

Improves microcirculation. Revealed its antiviral activity (promotes the synthesis of interferon).

With latent coronary insufficiency, the drug is poorly tolerated (!).

The drug inhibits phosphatidyl esterase and increases cAMP. Courantil is taken at 25 mg 2-3 times. Curantil is combined with small doses of acetylsalicylic acid (aspirin).

Acetylsalicylic acid (aspirin). Assign in a dose of 50-75 mg / day.

The drug is known as a cyclooxygenase inhibitor. In small doses, it inhibits the synthesis of thromboxane, therefore it has an antiplatelet effect.

So, antiplatelet drugs used during pregnancy to prevent preeclampsia include:

Trental (agapurin);

Curantil;

Acetylsalicylic acid (aspirin) in small doses.

¦ Antioxidants

Tocopherol acetate (vitamin E). Assign 100-200 mg 1 time per day for 2-3 weeks.

Glutamic acid. Apply 0.25 g 3 times a day.

Vitamin B6 (pyridoxine). Inject 1.0 ml intramuscularly or appoint 1 tablet orally 1 time within 2 weeks. Vitamin is found in large quantities in cereals, legumes, bananas, meat, fish, kidneys. Vitamin B6 regulates protein and lipid metabolism by affecting the metabolism of polyunsaturated fatty acids. In this case, the transition of linoleic acid to arachidonic acid, which is a precursor of prostaglandin synthesis, is possible only with the participation of vitamin B6.

Antioxidants, as well as antiplatelet agents, are prescribed when appropriate complaints appear or at the first signs of onset preeclampsia (hemoconcentration, hypercoagulation).

Close to heparin, but milder effect of tocopherol acetate is combined with its pronounced antioxidant effect. Tocopherol acetate, entering the structure of platelets, stabilizes their biological membranes, participates in the synthesis of prostaglandins. With the use of tocopherol acetate, the normalization of platelet function, an increase in the activity of antithrombin III, and antioxidant protection are noted.

The beneficial effect of tocopherol acetate in vascular-platelet disorders is confirmed by the data that platelet hyperactivity is associated with the action of free radicals against the background of increased lipid peroxidation. When this drug is prescribed, the uteroplacental blood flow is normalized.

The drug is combined with antiplatelet agents (trental, courantil).

To normalize the state of the vascular-platelet link, it is advisable to conduct a course of ATP: 2.0 ml of 1% solution intramuscularly No. 10. The drug has a positive effect on platelets, vascular wall, improves cerebral blood flow.

Pathogenetic rationale for the use of antioxidants in gestosis:

Normalize antioxidant enzymes;

They have a membrane stabilizing effect;

Activates respiratory enzymes;

Improves the rheological properties of blood and microcirculation;

Restore glomerular filtration in the kidneys;

Increase the detoxification function of the liver, reduce cholestasis, restore protein-synthetic function;

Reduces toxic-metabolic disturbances in the mother-placenta-fetus system.

¦ Hepatoprotectors

The action of antioxidants largely overlaps with membrane-stabilizing drugs and hepatoprotectors. The best is Essentiale Forte, which is prescribed 2 capsules 3 times a day with meals for 3 weeks.

Considering the main role of the liver in the production of proteins and procoagulants, its detoxification function, hepatoprotectors, antioxidants and vitamins are of great importance in complex and pathogenetically justified therapy. A sparing regimen, balanced nutrition and metabolic therapy do not always lead to the restoration of the impaired functional state of the liver. Therefore, in the treatment of preeclampsia, it is necessary to use medicines with a targeted effect on hepatocytes.

Hepatoprotectors (Essentiale forte, lipoic acid) protect the liver parenchyma from toxic products, correct redox processes. Essentiale forte contains essential phospholipids and a group of vitamins. The drug stabilizes cell membranes, improves the metabolism of hepatocytes and their regeneration.

One capsule of Essentiale forte contains: essential phospholipids 300 mg, thiamine mononitrate 6 mg, riboflavin 6 mg, nicotinamide 30 mg, α-tocopherol acetate 6 mg, cyanocobalamin 6 μg, pyridoxine chloride 6 mg.

One ampoule of Essentiale (5 ml) contains: essential phospholipids 250 mg, pyridoxine hydrochloride 2.5 mg, cyanocobalamin 10 μg, sodium -? - pantothenate 10 μg, nicotinamide 2.5 mg.

Lipoic acid (lipamide) improves redox processes, plays important role in the bioenergetics of hepatocytes, participates in the regulation of carbohydrate, protein, lipid metabolism, has a lipotropic effect.

Legal - a herbal preparation that has a hepatoprotective effect. Its main value lies in stimulating the synthesis of ribosomal RNA - the main source of protein biosynthesis, which is necessary for reparative reactions. There are indications that legalon reduces the risk of fatty liver, as it is a strong antioxidant.

To protect hepatocytes from increased free radical peroxidation, to enhance antioxidant protection, significant (5% - 5.0-10.0 ml) doses of ascorbic acid are used.

Antioxidants are powerful inhibitors of enzymes that promote prostacyclin synthesis, so they also improve microcirculation and perfusion of vital organs.

9.9.7. Prevention of preeclampsia in patients with essential hypertension

Prevention of gestosis in women with arterial hypertension consists primarily in the treatment of the disease itself, since the development of pregnancy (placenta) in conditions of high blood pressure will invariably be accompanied by a failure of the first and second waves of cytotrophoblast invasion into the walls of the spiral arteries of the uterus. An increase in pressure in the general hemodynamic system causes a decrease in BMD, placental insufficiency and "breakthrough" placental barrier for fetal antigens, more precisely, for fetal neurospecific proteins. Gestosis will develop with a high degree of probability.

Ca2 + plays a central role in different stages of platelet activation. Regulation of Ca2 + metabolism in platelets using drugs allows you to normalize the hyperactivity and excitability of platelets. Calcium ion blockers reduce the Ca2 + content in platelets, suppress their aggregation, cause vasodilation, and increase blood flow.

Calcium ion antagonists (verapamil, finoptin, nifedipine) not only have a hypotensive effect, since they primarily reduce peripheral vascular resistance and diastolic blood pressure, but also have a blocking effect on platelet and erythrocyte aggregation.

The main effect of calcium ion blockers is to inhibit the incoming slow calcium current, hindering the entry of extracellular calcium ions into the cell. The latter open when the cell membrane is depolarized. Calcium ion antagonists improve the perfusion of vital organs, increase urine output. Pathogenetically, they are the most appropriate.

Unlike other antihypertensive drugs, calcium ion antagonists do not cause significant metabolic changes, increase blood levels of aldosterone, and also neutralize damage to the vascular wall.

Increased production of thromboxane induces the release of calcium ions from the cell, while prostacyclin and PGE2 decrease their concentration. Therefore, the imbalance of prostaglandins is invariably accompanied by the leakage of calcium ions from the cell, their transmembrane transition into the interstitial space. Instead of Ca2 +, Na + and water ions enter the cell, which causes edema.

The advantages of calcium ion antagonists also lie in the fact that the decrease in blood pressure occurs in proportion to the dose of the drug, without causing too sharp a decrease in blood pressure and orthostatic hypotension. The therapeutic and maintenance doses are easily selected, the cardiac output and minute volume do not decrease, the circadian rhythm of blood pressure changes during the day is not disturbed.

Monotherapy with calcium ion antagonists has undoubted advantages over combined antihypertensive therapy, since it gives fewer side effects associated with the interaction of two or three drugs, has less adverse effect on the body.

If the pregnant woman has severe arterial hypertension, the following combination of drugs is recommended:

Atenolol 25 mg in the morning;

Arifon 2.5 mg 2 times a week in the morning;

Adalat 5-10 mg once a day.

Pressure control should be carried out not only by medical personnel, but also by the patient herself at least 2-3 times a day. The woman provides the doctor with the records with the dynamics of the blood pressure figures at each examination.

An individual approach to antihypertensive therapy depends on the type of central hemodynamics of each particular patient.

In the hyperkinetic type, it is recommended to prescribe predominantly? -Adrenergic blockers (obzidan 2 mg / kg per day with the appointment of equal doses in 4 doses), stimulants of central and peripheral? 2-adrenergic receptors (clonidine, dopegit), calcium ion antagonists.

In patients with eu- and hypokinetic type of blood circulation, the main task of hemodynamic correction is to ensure an adequate cardiac output while reducing the systemic vascular resistance. For this purpose, it is advisable to use calcium ion antagonists, peripheral vasodilators (prazosin, apressin), stimulants of peripheral a2-adrenergic receptors (clonidine up to 1.5 mg per day), periodic administration of aminophylline in combination with cardiac glycosides and drugs that improve heart function, - cocarboxylase, ATP.

In the course of therapy and with its effectiveness in patients with a hypokinetic type of blood circulation, there is a decrease in the systemic vascular resistance, an increase in the minute volume of the heart by an average of 14-14.8%. In patients with the hyperkinetic type, the transition of hemodynamics to the eukinetic type, a decrease in the systemic vascular resistance (if it was initially increased), and an improvement in cerebral hemodynamics are noted.

With the eukinetic type of blood circulation, mainly there is a decrease in mean arterial pressure, OPSS (with initially increased) without a decrease in cardiac output and cardiac output. The lack of effect of the therapy is accompanied by an increase in angiospasm, worsening cerebral circulation, which occurs 1-10 days (depending on the severity of the disease) earlier than the onset of clinical symptoms.

Naturally, all drugs prescribed for pregnant women must be coordinated with a therapist, cardiologist and other specialists, and also checked with reference books.

In pregnant patients with arterial hypertension, antihypertensive drugs should be combined with one of the antiplatelet agents (preferably trental) and one of the antioxidants.

Pregnant women should not be prescribed more than 3-4 drugs.

It should be especially emphasized the advisability of using magnesium ions during pregnancy (Magne B6 drug), 2 tablets 2 times a day, the course is 2-3 weeks). Magnesium is a universal regulator of biochemical and physiological processes.

The development of pregnancy against the background of the initial arterial hypertension also requires the prophylaxis of gestosis with the help of phytin (a mixture of calcium and magnesium salts), 1 tablet 2-3 times a day until the normalization of blood pressure.

In conclusion, it should be emphasized once again that gestosis in most cases can be prevented, and if it occurs, against the background of preventive measures, its course is easier.

Thus, the main emphasis in drug prevention should be shifted to improving blood flow in the area of ​​capillary circulation and microcirculation. It is the microcirculatory link that is the main one in the life support of organs and tissues, since the action of the entire cardiovascular system is aimed at capillary microcirculation and optimal tissue metabolism.

All of these drugs, used in the II and III trimesters of pregnancy, have an effect on the vascular-platelet link of the placenta, which is affected first during gestosis. Some drugs of this complex act on the vessel wall, enhancing the synthesis of prostacyclin, which preserves the antithrombotic activity of the endothelium. Others reduce thromboxane synthesis and restore disturbed prostaglandin metabolism. Still others increase the antifibrinolytic activity of the blood.

Prevention of microcirculation disorders in the placenta, the development of placental insufficiency and intravascular blood coagulation with gestosis are today the main factors in the prevention of this common severe, often unpredictable complication of pregnancy.