Diagnosis of the intrauterine state of the fetus. Assessment of the condition of the fetus: development, size, movement
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Ultrasound scanning is highly informative harmless
method of research and allows for dynamic monitoring of the state
Observation of the development of pregnancy is possible from the earliest dates. Already at 3 weeks
pregnancy in the uterine cavity, a fetal egg with a diameter of 5-6 mm is visualized. At 4-5
weeks, it is possible to identify an embryo in the form of an echopositive strip 6-7 mm in size.
The head of the embryo is identified from 8-9 weeks as a separate anatomical
formations of a rounded shape with a diameter of 10-11 mm. Embryo growth takes place
unevenly. The highest growth rates are observed at the end of the first trimester. Most
an accurate indicator of the duration of pregnancy in the first trimester is the value of the coccygeal
parietal size.
Assessment of the vital activity of the embryo in the early stages is based on the registration of its
cardiac activity and motor activity. Use of an intrauterine
operating mode allows you to register cardiac activity from 4-5
weeks of pregnancy. Heart rate increases from 150-160 per minute
5-6 weeks to 175-185 in 1 minute in 7-8 weeks, followed by a decrease to 150 in 1
minute by 12 weeks.
Motor activity is detected from 7-8 weeks of pregnancy. Absence of saddle
activity and motor activity indicates the death of the embryo.
The most important place is occupied by ultrasound examination in complicated course.
pregnancy, since other additional research methods are laborious and not
always provide sufficient information about the development of the embryo.
Diagnosis of non-developing pregnancy is possible by detecting an empty fetal hypoxia of the fetus and umbilical cord pathology.
3. Fetal cardiotocography.
Cardiotocographic examination of the fetus is one of the leading methods for assessing
fetal condition. Modern cardiac monitors are based on the Doppler principle, their
use allows you to register the change in the intervals between individual
cycles of fetal cardiac activity, which are converted into frequency changes
heart contractions and are reflected in the light, sound, digital and
graphic image. The devices are also equipped with sensors that allow
record simultaneously the contractile activity of the uterus and the movement of the fetus.
The cardiac activity of the fetus is evaluated in points. The score indicates the presence
or no signs of fetal cardiac dysfunction: 8-10 points
is regarded as a norm, 5-7 points, as a prepathological condition indicating
the need for further careful monitoring of the fetus; 4 points or less - like
pathological.
4. Biophysical profile of the fetus (BFP).
Biophysical profile assessment includes 6 parameters:
a) non-stress test (NST)
b) fetal respiratory movements (FDP)
c) physical activity (YES)
d) fetal tone (T)
e) the volume of amniotic fluid (OVV)
f) the degree of maturity of the placenta (FFP)
The maximum score is 10-12 points. The non-stress test is scored at
cardiomonitoring study. Its essence lies in the study of the reaction
fetal cardiovascular system in response to movement. Normal fetal movement
accompanied by an increase in heart rate. In the absence of a reaction
fetal cardiac activity in response to movement test is considered negative, which
testifies to tension and exhaustion of fetal compensatory reactions.
The remaining BFP parameters are determined by ultrasonic scanning.
The respiratory movements of the fetus become regular from 32-33 weeks of pregnancy and
occurs at a frequency of 40-70 in 1 minute. With complicated pregnancy
there is an increase in the number of respiratory movements up to 100-150 per minute, or
there is a decrease to 10-15 in 1 minute, with the appearance of individual convulsive
movements, which is a sign of chronic intrauterine hypoxia.
An indicator of the state of the fetus is its motor activity and tone. In healthy
in pregnant women, fetal movements reach a maximum by the 32nd week of pregnancy,
after which their number decreases by the 40th week. Tonks of the fetus is characterized
extensor-flexion movements of the limbs and the spinal column with
return to the original flexion position. If the limbs are extended or movements
the fetus does not end with a return to the flexion position, this indicates
progressive hypoxia. An indicator of good fetal condition is at least 3
active fetal movements in 30 minutes.
The volume of amniotic fluid, unlike other parameters, does not reflect the functional
the state of the central nervous system of the intrauterine fetus, however, this indicator is directly related to
outcome of pregnancy. A decrease in the amount of amniotic fluid indicates
pathological outcome of pregnancy.
Ultrasound placentography allows you to determine the degree of maturity
placenta gestational age. In uncomplicated pregnancy, 0 degree of placental maturity is observed at a gestational age of 27-30 weeks, 1 degree - at 30-32
weeks, II degree - at 34-36 weeks, III degree - at 38 weeks. With complications
pregnancy or extragenital pathology of the mother, premature
maturation and aging of the placenta.
5. Amnioscopy.
To study the state of amniotic fluid and the fetus during pregnancy, apply
amnioscopy - transcervical examination of the lower pole of the fetal bladder. At
uncomplicated pregnancy, a sufficient amount of light,
transparent, opalescent amniotic fluid with the presence of a white cheese-like lubricant.
Insufficient amount of water, detection of meconium and their greenish color
indicate fetal hypoxia and prolonged pregnancy.
6. Amniocentesis.
In order to obtain amniotic fluid for research, a puncture is performed
amniotic cavity - amniocentesis. To do this, several methods of sampling are used.
amniotic fluid: transabdominal, transvaginal, transcervical.
Amniocentesis is performed from the 16th week of pregnancy. It is used to evaluate
maturity of the lungs of the fetus, latent intrauterine infection with suspected
congenital malformations of the fetus, hemolytic disease, postmaturity
pregnancy, chronic fetal hypoxia.
With the help of amniocentesis, they study the biochemical and bacteriological composition,
acid-base state of amniotic fluid, as well as diagnostics
genetic diseases.
In diseases associated with the X chromosome, the sex of the fetus is determined. For this
produce a cytological study of native cells (determination of X- and Y-
chromatin) or put a cell culture of amniotic fluid and determine the karyotype.
When establishing the male sex of the fetus, termination of pregnancy is indicated due to
high risk of having a sick boy (50%).
Prenatal diagnosis of open malformations of the central nervous system is carried out using
determining the content of alpha-fetoprotein in the blood serum of the mother and amniotic
liquids by radioimmunoassay. An increase in alpha-fetoprotein over 200
ng/ml in serum and 10,000 ng/ml in amniotic fluid indicates
malformation in the fetus.
For the diagnosis of hereditary pathology in the first trimester of pregnancy,
method of transcervical chorion biopsy. Chorion can be used for
prenatal diagnosis of fetal sex, determination of karyotin and detection of chromosomal
pathology.
7. Fetoscopy - direct examination of the fetus with a special fiberoptic
endoscope inserted into the amniotic cavity through the abdominal wall and uterus. Method
allows you to examine individual parts of the fetus, placenta, umbilical cord, detect some
fetal malformations, biopsy the fetal skin or obtain a blood sample from
umbilical cord vessels for the diagnosis of hemophilia or hemoglobinopathies.
8. The acid-base state of the fetal blood reflects the severity of metabolic changes during hypoxia. Normal pH is 7.24 and above. pH shift from 7.24
up to 7.2 is regarded as subcompensated acidosis. pH below 7.2 indicates the presence
decompensated acidosis. The ultimate criterion for fetal viability is
blood pH = 6.7.
9. Hormonal research methods.
In assessing the hormonal status of a woman, it should be taken into account that in the early stages
Pregnancy increases the function of all endocrine glands. Already in
pre-implantation period at the blastocyst stage germ cells secrete
progesterone, extradiol and human chorionic gonadotropin, which are of great importance for
implantation of the ovum. During fetal organogenesis, hormonal function
placenta increases and during the whole pregnancy it secretes a large amount
hormones.
Depending on the content of placental hormones (placental lactogen and
progesterone) can be judged on the function of the placenta, while the change in fetal
hormones (estradiol, estriol) to a greater extent reflect the condition of the fetus.
In the last week before childbirth, estrogen excretion in the urine is 23-24 mg / day.
In the presence of fetal hypoxia, the level of estrogen in daily urine decreases to 10
mg/day, and a decrease to 5 mg/day indicates the need for urgent
delivery.
A sharp decrease in estrogens (less than 2 mg / day) is observed with anencephaly, pathology
fetal adrenal glands, Down syndrome, intrauterine infection.
The state of the fetus can be judged by the content in the blood of pregnant women of some
enzymes produced by placental tissue. Among them, particular attention is given to
thermostable alkaline phosphatase, which increases with fetal hypoxia
Methods for assessing the condition of the fetus 1. Assessment of the features of the anatomical development of the fetus. 2. The study of its functional state. To assess the condition of the fetus during pregnancy and childbirth, clinical, biochemical and biophysical research methods are used.
Clinical methods auscultation determination of the frequency of fetal movements determination of the growth rate of the uterus determination of the nature of the staining of the amniotic fluid (with amnioscopy, amniocentesis, rupture of amniotic fluid)
Amnioscopy n Inspection of the lower pole of the fetal egg (fetal membranes, amniotic fluid and the presenting part of the fetus) using an amnioscope.
n n Normal color of amniotic fluid - transparent or straw-yellow Pathological color: Green - stained with meconium, a sign of fetal hypoxia Bright yellow (golden) - Rh conflict Red - premature detachment of the placenta Brown (dark brown) - intrauterine fetal death
Amniocentesis Puncture of the amniotic membrane to obtain amniotic fluid for subsequent laboratory testing, or the introduction of drugs into the amniotic cavity.
Biochemical methods for studying the hormonal profile: chorionic gonadotropin, placental lactogen, estrogens (estriol), progesterone, prolactin, thyroid hormones, corticosteroids; determination of the degree of maturity of the fetus on the basis of a cytological examination of amniotic fluid and the concentration of phospholipids (lycetin and sphingomyelin) in amniotic fluid obtained by amniocentesis; examination of fetal blood obtained by intrauterine puncture - cordocentesis; chorionic villus biopsy for fetal karyotyping and determination of chromosomal and gene abnormalities.
Electrocardiography determines the heart rate, the nature of the rhythm, the size, shape and duration of the ventricular complex. Phonocardiography is represented by oscillations reflecting I and II heart sounds.
Echography (ultrasound) n n n Dynamic fetometry Evaluation of general and respiratory movements of the fetus Evaluation of fetal cardiac activity Measurement of the thickness and area of the placenta Determination of the volume of amniotic fluid Measurement of the rate of fetal-uterine circulation (Doppler)
Cardiotocography (CTG) - continuous synchronous registration of the heart rate (HR) of the fetus and uterine tone with a graphical representation of the signals on the calibration tape.
Registration of heart rate is performed by an ultrasonic sensor based on the Doppler effect. Registration of the tone of the uterus is carried out by strain gauges.
CTG parameters n n n basal heart rate basal rhythm variability: frequency and amplitude of oscillations amplitude and duration of accelerations and decelerations fetal heart rate in response to contractions fetal movements functional tests
The basal rhythm is a long-term change in heart rate of 160 beats. 10 min. 120 beats Physiological basal rhythm - 120 -160 beats. /min During pregnancy - 140 -150 beats. /min The first stage of childbirth - 140 -145 beats. /min The second stage of childbirth - 134 -137 beats. /min
Amplitude 145 max min 135 1 min. The amplitude, or width of the record, is calculated between the maximum and minimum heart rate deviations within 1 minute.
The amplitude distinguishes the following types of oscillations n n "mute" or monotonous type - deviations from the basal level are 5 or less beats per minute "slightly undulating" - 5-9 beats / min "undulating" (uneven, intermittent) type - deviations from the basal level 10 -25 beats / min "saltatory" (jumping) type - deviations from the basal level by more than 25 beats / min).
Classification of oscillations 140 0 -5 beats /min 100 140 "Mute" type 5 -9 beats. /min Slightly undulating type
140 10 -25 beats /min Undulating type 180 140 100 25 and ud. /min Saltatory type
The frequency of oscillations is determined by the number of intersections of the line drawn through the midpoints of the oscillations in 1 min 160 139 1 min. Low - less than 3 oscillations per minute Moderate - from 3 to 6 oscillations per minute High - more than 6 oscillations per minute
ACCELERATION 160 DECELERATION 120 Acceleration - an increase in heart rate by 15 beats / min for at least 15 seconds. Deceleration - deceleration of heart rate by 15 beats / min for 10 seconds. and more
criteria for normal. GKT n n Basal rhythm within 120-160 beats/min Amplitude of basal rhythm variability – 5-25 beats/min Frequency of oscillations 6 or more per minute Decelerations are absent or sporadic, shallow and very short are observed 2 or more accelerations are recorded during 10 minutes of recording
n n n 8 - 10 points - the norm. 6-7 points - prepathological type, re-examination is necessary. Less than 6 points - pathological type, signs of intrauterine fetal hypoxia, requires immediate hospitalization or urgent delivery.
Ultrasound screening
The main method of monitoring the condition of the baby is ultrasound. Thanks to its use, it is possible to detect the embryo itself, starting from the earliest dates - from 2-3 weeks. Already during this period, with the help of ultrasound, the fetal heartbeat is determined, which confirms its correct development.
Ultrasound is performed several times during pregnancy. At 10-14 weeks, the first screening is performed, aimed at identifying chromosomal abnormalities in the fetus. It evaluates:
1. thickness of the collar space (TVP); this is the area between the inner surface of the skin of the fetus and the outer surface of its soft tissues covering the cervical spine, in which fluid can accumulate; normally in terms of 11-14 weeks is 2-2.8 mm; TVP is a marker of fetal chromosomal disorders, primarily Down syndrome;
2. the presence and length of the nasal bone (NK); normal for a period of 12-13 weeks is 3 mm; its absence is suspicious of Down syndrome.
Together with the first ultrasound screening, maternal serum markers (“double test”) are determined: free human chorionic gonadotropin (b-hCG) and pregnancy-associated plasma protein A (PAPP-A), the level of which changes with fetal chromosomal abnormalities: Down syndrome ( trisomy 21 chromosomes), Edwards syndrome (18) and Patau syndrome (13).
The second ultrasound screening is carried out at 20-22 weeks, so that if a genetic pathology is detected, the woman has the opportunity to terminate the pregnancy until 24 weeks, that is, until the time when the fetus is considered viable. Second trimester biochemical screening (the "triple test") has now been canceled due to the large number of false positives.
When prolonging pregnancy, the next ultrasound is recommended to be performed at 32-34 weeks and before delivery. If necessary, the number of studies is increased.
Feto- and placentometry
During ultrasound, fetometry is performed - measuring the size of the fetus. At the same time, such fetal parameters are determined and compared with the norm for the corresponding period, such as:
Biparietal size (BDP),
-head circumference (OH),
- circumference of the abdomen (OC),
- thigh length (DB),
- the size of the liver and spleen,
- estimated mass (PMP).
With ultrasound, it is possible to assess the size of the placenta, its condition, the degree of maturity and the amount of amniotic fluid, the parameters of which can change with some fetal pathology.
Ultrasound also allows you to determine the muscle tone of the fetus in real time, to identify increased (“boxer posture”) or decreased tone (“open handle” symptom - unclenched hand and outstretched fingers), to study the fetal respiratory movements (RDP), which are contractions of the respiratory muscles and diaphragm .
Normally, at 35-40 weeks of gestation, the frequency of respiratory movements in the fetus can reach up to 50 per minute, combined with periods of apnea (lack of breathing). A change in fetal respiratory movements at the end of pregnancy, especially in the type of shortness of breath, is considered an unfavorable prognostic sign and requires the appointment of special treatment.
Doppler
Today, ultrasound data allow not only to estimate the size of body parts, organs and the fetus itself. With the help of a modern modification of ultrasound - Doppler, which studies the blood flow in various vessels, it is possible to assess the composition of the blood of the fetus non-invasively, that is, without using surgical methods for taking the baby's umbilical cord blood.
So, by the speed of blood flow in the middle cerebral artery of the fetus, one can judge the level of its hemoglobin (oxygen carrier), as well as the presence and severity of anemia (decrease in red blood cells and hemoglobin) and hypoxia (lack of oxygen).
Evaluation of blood flow parameters in the middle cerebral artery makes it possible to determine the management tactics for multiple pregnancies and hemolytic disease of the fetus. If signs of anemia are detected, an intervention is performed - intrauterine blood transfusion (IPK) to the fetus to replenish the volume of circulating blood (up to 32-33 weeks of gestation) or delivery (after 32-33 weeks).
Cardiotocography
To assess the condition of the baby, all pregnant women undergo cardiotocography - registration of the fetal heart rate depending on its activity (movements), uterine contractions and various external factors.
CTG is performed from 32 weeks of pregnancy. The study is performed in the position of the pregnant woman on her back, on her left side or sitting in a comfortable position. In this case, the sensor is placed in the area of stable registration of the fetal heart rate. The study is carried out for 50-60 minutes.
Fetal cardiograms are interpreted taking into account 5 indicators of cardiac activity: heart rate (HR), amplitude and frequency of oscillations (oscillations), the presence of accelerations (heart rate slowdown) and decelerations (heart rate acceleration).
Each of these parameters is evaluated in points (from 0 to 2), the condition of the fetus - by the total score. With 8-10 points, the fetal condition is considered good, with 6-7 points - it requires intensive care, less than 5 - emergency delivery.
CTG has no contraindications and is absolutely safe. Using the method allows you to monitor the condition of the fetus for a long time, if necessary - daily. However, it should be understood that the conclusion of CTG is not a diagnosis, but only represents some information along with the results of other research methods.
Amniocentesis
Often, fetal examination requires invasive (with introduction into the body) procedures, which include amniocentesis - obtaining amniotic fluid through a puncture in the fetal membranes.
The procedure is performed on an outpatient basis in the II and III trimesters under ultrasound guidance. For puncture, choose the most convenient place, depending on the location of the placenta and small parts of the fetus. For intervention, a special puncture needle is used, which, after puncturing the anterior abdominal wall, uterus and fetal membranes, enters the amniotic bladder. 10-15 ml of amniotic fluid is taken from it.
In the future, a laboratory study of the obtained waters is carried out. In this case, the following indicators can be determined:
Signs of intrauterine infection;
- fetal blood type;
- optical density of bilirubin (OPD) - a sign of hemolytic disease of the fetus;
-fetal karyotype (genetic testing of the sample); used to diagnose chromosomal abnormalities (Down syndrome, etc.) and hereditary diseases (cystic fibrosis, etc.);
- the degree of maturity of the lungs according to a special foam test.
Also, through amniocentesis, a number of therapeutic manipulations are performed during pregnancy: the introduction of drugs into the amniotic cavity, the treatment of complications of multiple pregnancy.
You should know that amniocentesis is performed only if there are certain indications, since complications are possible in the postoperative period. Here are the main ones:
Water leakage;
-infection;
- premature birth.
Cordocentesis
In some critical situations, a more in-depth examination of the fetus is required - the study of cord blood. This is possible through the use of cordocentesis - a puncture (puncture) of the umbilical cord vein.
Cordocentesis is performed if fetal chromosomal abnormalities are suspected, severe forms of fetal hemolytic disease, fetal anemia in multiple pregnancies, etc. Contraindications to cordocentesis are: the threat of abortion and severe disorders of the blood coagulation system in the mother.
The study is carried out under ultrasound control. The first step is amniocentesis. Then, through the lumen of the first needle, a second needle is inserted into the amniotic cavity, brought to the umbilical cord vein and punctured. Next, a syringe is connected and 2 ml of fetal blood is removed, after which the needles are slowly removed from the uterine cavity.
At the same time, the surgeon's work can be compared with jewelry, because the size of the umbilical cord vein is extremely small, which leads to the risk of complications (thrombosis of the umbilical vein, attachment of a bacterial infection, fetal death). In the obtained blood sample from the vein of the umbilical cord, the following indicators are evaluated:
Blood type, Rh-affiliation,
- values of hematocrit, hemoglobin, leukocytes, platelets;
-levels of liver enzymes, bilirubin;
-indicators of iron metabolism;
-blood gas composition;
-acid-alkaline state.
Cordocentesis is performed not only for diagnostic, but also for therapeutic purposes. If, according to the examination, anemia (decrease in hemoglobin) is detected in the fetus, then an intervention is carried out - intrauterine blood transfusion (IPT) to the fetus to replenish the volume of circulating blood, which fully justifies the risk of intervention. After all, without the military-industrial complex, the fetus could die.
Modern diagnostic technologies make it possible to detect any deviation in the development of the fetus from the very early stages of pregnancy. The main thing is to pass all the necessary examinations in a timely manner and follow the recommendations of specialists.
Always with you,
Methods for assessing the condition of the fetus1. Feature evaluation
anatomical development of the fetus.
2. Studying its functional
states.
To assess the condition of the fetus during
pregnancy and childbirth are used
clinical,
biochemical and biophysical
research methods
Clinical Methods
auscultationdefinition
movement frequency
fetus
determination of the growth rate of the uterus
definition
character
staining
amniotic
liquids
(at
amnioscopy,
amniocentesis,
outpouring
amniotic fluid)
Amnioscopy
Inspection of the lower polefertilized egg (fetal
shells,
amniotic
water and presenting part
fetus)
at
help
amnioscope. Normal amniotic fluid color
clear or straw yellow
Pathological coloration:
Green - stained with meconium, sign
fetal hypoxia
Bright yellow (golden) - Rh
conflict
Red - premature detachment
placenta
Brown (dark brown) -
intrauterine fetal death
Amniocentesis
Puncture of the amniotic membranefor the purpose of obtaining amniotic
waters
For
subsequent
laboratory research, or
introductions
V
amniotic
drug cavity.
Biochemical methods
studyhormonal
profile:
chorionic gonadotropin, placental
lactogen, estrogens (estriol), progesterone,
prolactin,
thyroid
hormones,
corticosteroids;
determining the degree of maturity of the fetus
basis
cytological
research
amniotic
waters
And
concentration
phospholipids (lycetin and sphingomyelin)
amniotic
waters,
received
through
amniocentesis;
examination of fetal blood obtained by
intrauterine puncture - cordocentesis;
chorionic villus biopsy for karyotyping
fetus and determination of chromosomal and gene
anomalies.
Biophysical methods
electrocardiographyphonocardiography
echography
cardiotocography Electrocardiography
determine the heart rate, the nature of the rhythm,
size, shape and
duration
ventricular complex.
Phonocardiography
represented by oscillations,
reflecting I and II cardiac
tones.
Echography (ultrasound)
Conducting dynamic fetometryAssessment of general and respiratory movements
fetus
Assessment of fetal cardiac activity
Thickness and area measurement
placenta
Determining the volume of the amniotic
liquids
Measuring fruit-uterine speed
blood circulation (doppler)
Cardiotocography (CTG)
continuoussynchronous
registration of heart rate
contractions (HR) of the fetus and
uterine tone with graphic
image
signals
on
calibration tape. Registration
heart rate
produced by ultrasonic
effect-based sensor
Doppler.
Registration of uterine tone
carried out
tensometric
sensors.
Cardiotocogram
CTG parameters
basal heart ratebasal rate variability:
oscillation frequency and amplitude
amplitude and duration
accelerations and decelerations
fetal heart rate in response
for contractions
fetal movements
functional tests Basal Rhythm
is a long-term change in heart rate
160
beats
10 min.
120
beats
Physiological basal rhythm - 120-160 bpm.
During pregnancy - 140-150 beats / min.
The first stage of labor - 140-145 beats / min.
The second stage of labor - 134-137 beats / min. Amplitude
145
max
min
135
1 min.
Amplitude, or record width,
calculated between the maximum and
minimal heart rate fluctuations within 1 min.
According to the amplitude, the following types of oscillations are distinguished
"silent" or monotonic type −are 5 or less beats per minute
"slightly undulating" - 5-9 beats / min
"undulating" (uneven,
intermittent) type - deviations
from the basal level 10-25 bpm
"saltatory" (jumping) type -
deviations from the basal level
more than 25 beats/min). Classification of oscillations
140
0-5 bpm
100
140
"Dumb"
type
5-9
bpm
Slightly
undulate
type 140
10-25 bpm
I undulate
common type
180
140
100
25 and bpm
Saltator
type Oscillation frequency
determined by the number of line crossings,
through the midpoints of the oscillations in 1 min
160
139
1 min.
Low - less than 3 oscillations per minute
Moderate - 3 to 6 oscillations per minute
High - over 6 oscillations per minute ACCELERATION
160
DECELERATION
120
Acceleration - an increase in heart rate by 15 beats / min in
for at least 15 sec.
Deceleration - deceleration of heart rate by 15 beats / min in
within 10 sec. and more
Criteria for normal CTG
Basal rhythm within 120-160bpm
Amplitude of variability
basal rhythm - 5-25 beats / min
Oscillation frequency 6 or more per minute
Decelerations are absent or
are sporadic,
shallow and very short
2 accelerations are registered and
more than 10 minutes of recording
Fisher scale
8 - 10 points - the norm.6-7 points - prepathological
type,
necessary
repeated
survey.
Less than 6 points - pathological
type, signs of intrauterine
hypoxia
fetus,
requires
immediate hospitalization or
urgent delivery.
non-invasive methods.
Depending on the anamnestic data, the nature of the course of pregnancy and its duration, the results of the examination of the pregnant woman, after determining the appropriateness, it is planned to use various methods for studying the condition of the fetus. Preference is given to non-invasive methods.
Determination of the level of alpha-fetoprotein is carried out as part of screening programs to identify pregnant women at increased risk of congenital and hereditary diseases of the fetus and complicated pregnancy. The study is carried out from 15 to 18 weeks of pregnancy. The level of alpha-fetoprotein in the mother's blood increases with some fetal malformations (neural tube defects, pathology of the urinary system, gastrointestinal tract and anterior abdominal wall). A decrease in the level of this protein can be observed with Down's disease in the fetus.
Ultrasound diagnostics during pregnancy is the most accessible, informative and at the same time safe method for studying the condition of the fetus.
When performing ultrasound in obstetric practice, both transabdominal and transvaginal scanning can be used.
During pregnancy, it is advisable to conduct a 3-fold screening ultrasound: 1. at the first visit of a woman (up to 12 weeks of pregnancy) about the delay of menstruation in order to diagnose pregnancy, localize the ovum, identify possible deviations in its development, as well as the anatomical structure of the uterus,
2. at a period of 16-18 weeks in order to determine the rate of fetal development, their compliance with the gestational age, as well as identify possible anomalies in the development of the fetus for the timely use of additional methods of prenatal diagnosis or raising the question of termination of pregnancy,
3. at a period of 32-35 weeks in order to determine the condition, localization of the placenta and the rate of fetal development, their compliance with the gestational age, estimated fetal weight, quantity and quality of amniotic fluid.
Ultrasound devices can be equipped with special attachments that allow Doppler study of blood flow in the heart and vessels of the fetus.
Cardiotocography (CTG) continuous simultaneous recording of fetal heart rate and uterine tone with a graphical representation of physiological signals on a calibration tape. Currently, CTG is the leading method for monitoring the nature of fetal cardiac activity. CTG can be used to monitor the condition of the fetus both during pregnancy and childbirth. There is an indirect (external) CTG technique, which is used during pregnancy and childbirth in the presence of a whole fetal bladder. In this case, the sensors are attached to the anterior wall of the abdomen and the bottom of the uterus.
Direct (internal) CTG is used only when the integrity of the fetal bladder is broken, when a special electrode is inserted into the presenting part of the fetus, which allows you to record not only the heart rate, but also record its ECG. If signs of a violation of the fetal condition appear during pregnancy, functional tests should be performed: non-stress test, step test, sound test, etc., which allows assessing the degree of violation of the functional state of the fetus.
invasive methods.
Invasive intrauterine interventions during pregnancy have been widely used with the advent of ultrasound diagnostic technology, which has a high resolution, ensuring the relative safety of their implementation. All invasive procedures are carried out in compliance with the rules of asepsis, in an operating room.
Chorionic biopsy carried out by different methods. Currently, aspiration transcervical or transabdominal puncture chorion biopsy is used in the first trimester of pregnancy and transabdominal puncture biopsy of the chorion (placenta) in the second trimester. Aspiration of the chorionic villi is carried out under ultrasound control using a special catheter or a puncture needle inserted into the thickness of the placenta. The main indication for chorionbiopsy is prenatal diagnosis of congenital and hereditary diseases of the fetus.
Amnioscopy. With the help of an endoscope inserted into the cervical canal, it is possible to assess the quantity and quality of amniotic fluid. A decrease in the amount of water and the detection of meconium in them is considered as an unfavorable diagnostic sign. The method is simple, but it is only feasible. when we pass the cervical canal. This situation develops at the very end of pregnancy.
Amniocentesis puncture of the amniotic cavity in order to aspirate the amniotic fluid is performed using transabdominal access under ultrasound guidance. It is punctured in the place of the largest "pocket" of amniotic fluid, free from parts of the fetus and umbilical cord loops, avoiding injury to the placenta. 10-20 ml of amniotic fluid is aspirated, depending on the goals of diagnosis. Amniocentesis is used to detect congenital and hereditary diseases of the fetus, to diagnose the maturity of the lungs of the fetus, hemolytic disease of the fetus, intrauterine infection of the fetus, and postmaturity of the fetus.
Cordocentesis- puncture of the vessels of the umbilical cord of the fetus in order to obtain his blood. Currently, the main method of obtaining fetal blood is transabdominal puncture cordocentesis under ultrasound control. Manipulation will be carried out in the II-III trimesters of pregnancy. Cordocentesis is used not only for the purpose of diagnosing fetal pathology (chromosomal pathology of the fetus, determining the blood type and Rh factor of the fetus during immunoconflict pregnancy, and also to do all the necessary laboratory blood tests of the fetus to determine its intrauterine state), but also for its treatment (intrauterine transfusions blood to the fetus in case of hemolytic disease).
Fetal skin biopsy- obtaining fetal skin samples by aspiration or forceps under ultrasound or fetoscopic control for the purpose of prenatal diagnosis of hyperkeratosis, ichthyosis, albinism, etc.
Liver biopsy- obtaining samples of fetal liver tissue by aspiration for the purpose of diagnosing diseases associated with a deficiency of specific liver enzymes.
Bipsy of tissue of tumor-like formations- is carried out by aspiration method to obtain tissue samples of a solid structure or the contents of cystic formations, for the diagnosis and choice of pregnancy management tactics.
Urine aspiration in obstructive conditions of the urinary system - puncture of the urinary cavity or renal pelvis of the fetus under ultrasound control in order to obtain urine and its biochemical study to assess the functional state of the renal parenchyma and clarify the need for antenatal surgical correction.
DETERMINATION OF DATE OF DELIVERY
It is almost impossible to determine the exact date of birth in each specific case of pregnancy. It is presumably determined.
However, using anamnestic and objective data, with a sufficient degree of probability, the term of delivery in each pregnant woman is determined.
The expected due date is set as follows:
1. by the date of the last menstruation: 280 days are added to the first day of the last menstruation and the date of the expected due date is obtained, in order to quickly and easily establish this period, at the suggestion of Negele, 3 months are counted back from the first day of the last menstruation and 7 days are added;
2. by ovulation: from the first day of the last menstruation, count back 3 months and add 14 days;
3. according to the date of the first fetal movement: 20 weeks are added to the date of the first fetal movement in the primipara, and 22 weeks in the multiparous;
4. according to the gestational age diagnosed at the first appearance of the pregnant woman in the antenatal clinic, the error will be minimal if the woman went to the doctor in the first 12 weeks of pregnancy;
5. according to the ultrasound examination, the gestational age is determined according to the biometric indicators of the fetus;
Thus, the term of the expected birth will be determined quite accurately if all the data received are not contradictory, but complement and reinforce each other.
LITERATURE:
1. V.I.
2. E.V. Ailamazyan "Obstetrics", St. Petersburg, 1997, pp. 85-113.
3. I.V. Duda, V.I. Duda "Clinical obstetrics", Minsk, 1997, pp. 62-72.
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