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UDC 618.2/.5-07-082
OBSTETRIC RISK. CRITICAL MOMENTS OF THE PERINATAL PROGNOSIS SYSTEM
1 Altai State Medical University, Barnaul
2 Perinatal Center (Clinical) of Altai Krai, Barnaul E.G. Ershova2, O.V. Remneva1
In this literature review based on the study of factors influencing the level of perinatal morbidity and mortality, the concept of perinatal risk is presented, approaches to the allocation of obstetric risk groups and forecasting of perinatal outcomes are introduced, the scales of perinatal risk scoring are analyzed. There are described medical and organizational measures, including the regionalization of the obstetrics service, various options for rational choice of the term and method of delivery for the prevention of adverse perinatal outcomes. Key words: perinatal prognosis; risk factors; the scale of perinatal risk; rational delivery; obstetrics service.
The current demographic situation in the Russian Federation is characterized by high mortality, unfavorable indicators of the somatic and reproductive health of the population, which contributes to the complicated course of pregnancy and childbirth, and low quality of newborn health [1, 2]. The problem of protecting the health of women, mothers and children in Russia in recent years has evolved from a medical problem into a state problem, from the solution of which the future of the nation depends. It is one of the priority components of the national project "Health", because not only the quantity of the population, but also the quality of its life has always characterized the power and prosperity of the country [3, 4].
The high morbidity of newborns is conditioned by a whole range of causes. An important role is played by an increase in the number of elderly primiparous women, the proportion of first-borns among children, especially those born as a result of infertility treatment and habitual miscarriage, the growth of extramarital births [1, 5, 6]. Paradoxical as it may seem, it is also connected with the success of medicine, providing an increase in survival of premature, low-weight newborns and children with severe perinatal pathology, mainly of hypoxic and infectious genesis. The paradox is that perinatal technologies themselves become the source of the birth of disabled children [2].
The strategy of risk in obstetrics provides for the allocation of groups of women in whom pregnancy and childbirth may be complicated by impaired fetal functioning, obstetric or extragenital pathology [1, 7, 8, 9, 10]. The level of maternal, perinatal morbidity and mortality is especially high in pregnant women, united in the so-called high risk group (no more than 1/3 of the total number of pregnant women). Allocation of such a group allows creating a differentiated system of obstetric care for this contingent of women and their new-borns [1, 9].
Among the measures aimed at improving the health services for pregnant women, proposals that improve the selection of at-risk groups, reducing the timing of the choice of preventive measures, as well as proposals that increase the effectiveness of monitoring the quality of care, are essential [11, 12]. The goal of regionalization is to improve the quality and accessibility of perinatal care through the rational use of the capabilities of the existing obstetrics system. World experience shows that the regionalization of the service of obstetrics provides progress in reducing reproductive and maternal losses [13, 21, 22]. To date, in all economically developed countries, the perinatal care system is based on the principle of regionalization. The European Bureau of the World Health Organization (WHO), under the term "regionalization of medical care", implies the rational territorial distribution of individual types of assistance, technologies and institutions in three levels (primary, secondary and tertiary), thereby ensuring universal access to quality medical care for the population and its clinical and economic efficiency [13, 14, 15, 16, 21].
To differentiate the service of obstetrics in many countries, medical service was divided into three levels, differing in the volume and quality of care provided. This made it possible to reduce reproductive losses, morbidity and mortality (both in the mother and the child) [13, 14].
The main goal of risk assessment is to identify women at high risk as soon as possible to ensure their appropriate supervision [1, 9]. The high risk of perinatal pathology is the increased risk of death or illness of the fetus and newborn due to the presence of adverse factors on the part of the mother, diseases of the fetus itself or anomalies of its development. Pregnant women with a high degree of perinatal risk have a multifactorial combination, and there is often a certain synergy between risk factors that increase their adverse effects on the mother and fetus [10, 11, 17, 19].
The first attempts to predict perinatal outcomes were made in the early 50's of the XXth century, when doctors began to note that perinatal mortality is higher in a group of children whose mothers had complications of pregnancy, somatic pathology, bad habits [7, 8, 11, 15, 17]. More than half of all cases of perinatal mortality were observed in a group of women of "high risk". Different risk factors have a different impact on the level of perinatal morbidity and mortality. In their totality, it is difficult to determine the degree of influence of one factor on another, their joint influence, the possibility of synergistic or antagonistic factors. The use of mathematical calculations makes it possible to assess not only the probability of an unfavorable outcome of labor for a fetus for each risk factor, but also to obtain a summary expression of the effect of these factors. This influence is inte-grative, i.e. Their impact is not the result of simple summation [1].
The practical use of the system of perinatal risk prognosis in the Russian Federation began in 1981, when an order was issued by the Ministry of Health of the USSR No. 430 "On the approval of instructive and methodological guidelines for organizing the work of a women's consultation", containing the following indications: "... after clinical and laboratory examination (before 12 weeks of pregnancy) there is determined the belonging of the pregnant woman to a particular risk group." For practical purposes, numerous scales were developed for predicting the risk of an adverse outcome. At present, the scale proposed by prof. V.E. Radzinsky, I. Kostin [1, 9] is most widely spread.
Since 2012, the main regulatory document for the provision of medical care to women during pregnancy is the order of the Ministry of Health of the Russian Federation No. 572n, which determines the Order on the basis of routing sheets taking into account the occurrence of complications during pregnancy, including extragenital diseases. According to this order, the main task of dispensary observation of women during pregnancy is prevention and early diagnosis of possible complications of pregnancy, childbirth, the postpartum period and the pathology of newborns; dispensary observation of pregnant women, including the allocation of women "at risk" aimed at prevention and early detection of complications of pregnancy, childbirth and the postpartum period; doctors of women's consultations carry out planned referral of pregnant women to the hospital for delivery, taking into account the risk of complications in childbirth; at the gestational age of 35-36 weeks, taking into account the course of pregnancy for trimesters, assessing the risk of complications of the further course of pregnancy and childbirth on the basis of the results of all carried studies, including consultations of medical specialists, the obstetrician-gynecologist doctor formulates
a full clinical diagnosis and determines the place of planned of the delivery [20].
Timely detection of risk factors in pregnant women and appropriate treatment significantly reduce the risk of perinatal pathology. Medical and organizational measures in the field of perinatal complications should first of all provide for the proper level of organization and provision of preventive measures, an assessment of the state of women's health, possible prognosis of the state of health of the child at the stage of pregnancy planning or its early stages [21, 22, 23]. Every woman who has an unfavorable obstetrical anamnesis must undergo a whole complex of examinations, which includes the diagnosis of congenital and hereditary pathology of the fetus; detection of a latent current bacterial and viral infection; evaluation of hormonal status; prediction and diagnosis of placen-tal insufficiency, evaluation of the functional state of the fetus [1, 3, 12].
A comprehensive examination of the pregnant woman makes it possible to determine the prognosis with an assessment of the degree of risk to the fetus, the possible risk of unfavorable course of pregnancy and the outcome of labor, the direction of the therapeutic and preventive measures, the advisability of aborting in the case of a child with "uncontrollable" pathology, to determine the optimal place, time and method of delivery [1, 3, 20].
Since the introduction of the scales of perinatal risk, discussions have been held about the benefits and harms of perinatal prognosis systems. Harm can result from unacceptable intrusions into the woman's private life, excessive medical interventions and therapeutic effects, creating unnecessary stress and anxiety, and wasting resources where it is not necessary at all. It is important for the clinician to know which of the pregnant women he watches is more likely to be at risk of an unfavorable outcome. For a specific woman, introducing it into a risk group is only useful if certain measures are taken to reduce the risk or reduce its consequences. The system will work more reliably if it is used at a later date or there is a possibility of its reassessment in the course of pregnancy. This leads to a paradoxical situation, when the most accurate predictions are made at a time when they are practically not needed, while potentially more useful early definitions of the degree of risk are relatively inaccurate. Admittedly, both positive and negative evaluation of the prognostic system is still controversial. Only in 10-30% of women at risk, in fact, there are those unsuccessful pregnancy outcomes that were predicted based on the use of a formal risk management system [1, 9, 20].
The rational term of delivery is chosen in the interests of the mother and/or fetus, determined by the obstetrician-gynecologist (for ob-
stetric/perinatal pathology) or by a specialist (in the presence of extragenital diseases) [1, 3, 20, 24].
The method of delivery can also be determined by an obstetrician-gynecologist or an adjacent specialist (in the presence of somatic pathology). In pregnant high-risk groups, the indication for a planned caesarean section should be expanded. It is necessary to consider a variant of the "planned" cesar-ean section, when labor leads through the natural birth canal, but by complications, immediately, without correction, carry out abdominal delivery. The advantage of the "planned" cesarean section is the ability to conduct flexible delivery tactics that do not exclude the possibility of deliveries through the natural birth canal with an initially high risk of complications in labor (cicatricial eruption, multiple pregnancy, pelvic delivery, pregnancy due to ART, subcompensated forms of placental insufficiency, extremely burdened by obstetrician-gynecological anamnesis). This approach allows to differentiate approach to the method of delivery and, giving a chance to a woman, reduce the frequency of unreasonable surgical interventions [1, 6, 7, 8].
Induced births, or "scheduled births," the third option of a rational method of delivery for pregnant high-risk groups, are considered a reserve for reducing the rate of cesarean delivery. They are carried out with the prepared birth canal, under the monitor control of the contractile activity of the uterus, and controlled administration of uterotonic drugs. Since they are conducted in the daytime, it is possible to take a more balanced, collegial decision when changing the obstetric situation. When conducting induced labor for a clinician, it is quite difficult to maintain a balance between active tactics and functional capabilities of the maternity and fetus organisms. Nevertheless, in women with high perinatal risk, they have better results than by spontaneous labor. The effectiveness of amniotomy as an independent method of induction is quite high - contractions in the first 2-4 hours appear in 50-75% of patients [1, 8, 26].
The fourth method of delivery is spontaneous delivery through natural birth canals. In patients with high perinatal risk in labor, maximum anesthesia should be performed (in the absence of contraindications - epidural anesthesia) and CTG monitoring [1, 20]. An integral part of conducting conservative labor in women at high risk is the constant counting of the amount of intranatal risk scores and the calculation of intranatal growth, which allows for timely review of obstetric tactics. The maximum number of points is gained by meco-nium in the waters and anomalies of labor. Intranatal increase of 30% in the high-risk group, despite the absence of a direct threat to the life of the mother and the fetus, is an indication to the caesarean section [1, 9].
Thus, the concept of perinatal risk is based on the study of factors that affect the level of perinatal morbidity and mortality; studies the features of the course of pregnancy, the nature of its complications, requires planning activities to improve medical and social care for pregnant and children; is aimed at preserving the life and health of the fetus and the newborn.
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Contacts:
Corresponding author: втор, ответственный за переписку: Remneva Olga Vasilyevna, Doctor of Medical Sciences, Associate Professor, Head of the Department of Obstetrics and Gynecology with the course of FVE of the Altai State Medical University, Barnaul. 656038, Barnaul, Lenina Prospekt, 40. Tel.: (3852) 566946. E-mail: [email protected]
Ershova Elena Germanovna, chief doctor of the"Perinatal Center (Clinical) of Altai Krai", Barnaul.
656038, Barnaul, Lenina Prospekt, 40.
Tel.: (3852) 566946.
E-mail: guzkpc2010@ mail.ru
