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Modern methods of studying the state of the fetus. Contraindications

During the physiological course of pregnancy, the condition of the fetus is assessed on the basis of:

The results of comparing the size of the uterus and fetus with the gestational age;

Auscultation of fetal heart sounds at each visit to a pregnant women's clinic:

Motor activity of the fetus;

The results of ultrasound, which is performed at 18-22 weeks of gestation, 32-33 weeks of pregnancy and before childbirth (to identify compliance biophysical profile fetus and degree of maturity of the placenta, gestational age).

In a complicated course of pregnancy, the assessment of the condition of the fetus is included in the complex of a stationary examination of a pregnant woman, aimed at diagnosing her pathology, fetal hypoxia and determining its severity.

To diagnose fetal hypoxia, you need:

Assessment of fetal cardiac activity:

Assessment of fetal motor activity;

Amnioscopy;

Ultrasound of the fetus and placenta.

Fetal cardiac activity is assessed based on the results of auscultation of fetal heart sounds and cardiotocography (CTG). Auscultation of the fetal heart sounds is carried out at each examination of the pregnant woman, in the first stage of labor - every 15-30 minutes and outside the contraction, in the second stage of labor - after each contraction. Assess the frequency, rhythm and sonority of the fetal heart sounds. Tachycardia or bradycardia, arrhythmia, dull or muffled fetal heartbeat are clinical signs hypoxia.

Ante- and intranatal cardiotocography makes it possible to assess the fetal heart rate against the background of uterine contractility and fetal motor activity. Changes in basal rate, heart rate variability, acceleration and deceleration reflect the state of the fetus and may be signs of hypoxia.

The motor activity of the fetus is assessed by the results of counting the number of fetal movements in 30 minutes in the morning and evening. Normally, 5 or more fetal movements are recorded in 30 minutes. By evening, in healthy pregnant women, the motor activity of the fetus increases. With the beginning of fetal hypoxia, there is an increase and increase in perturbations, with progressive hypoxia - weakening and slowing down, followed by cessation of fetal movements. At chronic hypoxia fetus there is an excessive increase or a sharp decrease in the difference between the number of movements in the morning and the number of movements in the evening.

fetal heart rate response to motor activity can be objectively recorded with CTG (myocardial reflex).

Amnioscopy (transcervical examination of the lower pole amniotic sac) is carried out using an amnioscope in the absence of contraindications (placenta previa, colpitis, endocervicitis) but during pregnancy (after 37 weeks) and in the first stage of labor. Normally, there is a sufficient amount of light, transparent amniotic fluid, with fetal hypoxia - a small amount of greenish water and lumps of meconium.

Ultrasound procedure allows to identify the syndrome of fetal growth retardation, fetoplacental insufficiency, on the basis of which it is possible to establish chronic intrauterine hypoxia fetus.

To clarify the severity of fetal hypoxia, you must use:

CTG with functional (stress) tests;

Doppler ultrasound;

Determination of the biophysical profile of the fetus, ultrasound placentography;

Amniocentesis;

Biochemical studies of placental enzymes and indicators acid-base balance fetus;

Hormone studies.

CTG with functional (stress) tests is performed in order to timely identify the compensatory capabilities of the fetus. It is possible to conduct tests with holding the breath on inhalation and exhalation, with physical activity(step test), thermal test and detection of fetal reaction to ultrasound. A change in the CTG curve against the background of functional (non-stress) tests makes it possible to diagnose fetal hypoxia and its severity. The oxytocin stress test is rarely used due to possible complications for mother and fetus.

Doppler ultrasound makes it possible to examine the blood flow in the aorta and umbilical cord of the fetus and in uterine arteries with obtaining curves of blood flow velocities on the monitor screen. Normally, in the third trimester of pregnancy, there is a gradual increase in volumetric blood flow due to a decrease in peripheral vascular resistance. If the fetoplacental circulation is disturbed, the diastolic blood flow in the umbilical artery and fetal aorta decreases. Decompensated placental insufficiency has zero and negative indicators of diastolic blood flow.

The fetal biophysical profile is a cumulative score of five parameters: the results of a non-stress test according to CTG and four indicators of fetal ultrasound. Assess the respiratory movements of the fetus, motor activity and tone of the fetus, the volume of amniotic fluid, taking into account the degree of "maturity" of the placenta. The score indicates the severity of fetal hypoxia.

Ultrasound placentografiya involves determining the localization, size and structure of the placenta. At normal flow During pregnancy, the placenta matures and its thickness and area progressively increase by the time of delivery. At placental insufficiency there is a thinning or thickening of the placenta, an increase or decrease in its area, as well as premature ripening and pathological changes its structures (cysts, calcification, heart attacks and hemorrhages).

Amniocentesis - study amniotic fluid, obtained by transabdominal (less often - transcervical) puncture of the amniotic cavity under ultrasound control, allows for a cytological and biochemical study of fetal cells, to determine its sex, chromosomal pathology, metabolic diseases, malformations (during pregnancy 16-18 weeks).

In terms of pregnancy more than 34 weeks determine:

PH, pCO2, pO2, content of electrolytes, urea, protein in the amniotic fluid (for diagnosing the severity of fetal hypoxia;

The level of hormones (placental lactogen, estriol), enzymes (alkaline phosphatase, ?-glucuronidase, hyaluronidase, etc.) (to exclude placental insufficiency and fetal hypotrophy);

The optical density of bilirubin, the blood type of the fetus, the titer of Rh or group antibodies (to diagnose the severity hemolytic disease fetus);

Cytological and biochemical (creatinine, phospholipids) indicators (to assess the degree of fetal maturity).

Biochemical studies of the level of specific enzymes (oxytocinase and thermostable alkaline phosphatase) of the placenta in the dynamics of the II and III trimesters of pregnancy make it possible to identify the functional state of the placenta.

The study of indicators of the acid-base state (COS) of the fetus (pH, pCO2 and pO2) is carried out by cordocentesis (puncture of the fetal umbilical cord during amniocentesis) during pregnancy or puncture of the presenting part of the fetus during childbirth (Saling test). Amniotic fluid can also be used for research. The CBS indicators in comparison with the results of clinical and instrumental studies (CTG, ultrasound) make it possible to objectively determine the severity of hypoxia.

Determination of the level of hormones (progesterone, placental lactogen, estrogens) formed in the placenta and fetal organs is carried out in the II and III trimester of pregnancy. Normally, the content of all hormones constantly increases towards the end of pregnancy. With placental insufficiency, there is a decrease in the level of progesterone and placental lactogen. An indicator of fetal suffering is a decrease in the amount of estriol (produced mainly in the body of the fetus). In chronic placental insufficiency with impaired fetal trophism, a decrease in the concentration of all hormones is detected.

Clinical Methods

auscultation
definition
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 pole
gestational sac(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 membrane
for the purpose of obtaining amniotic
waters
for
subsequent
laboratory research, or
introductions
in
amniotic
cavity medicines.

Biochemical methods

study
hormonal
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

electrocardiography
phonocardiography
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 fetometry
Assessment 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)

continuous
synchronous
registration of heart rate
contractions (HR) of the fetus and
uterine tone with graphic
image
signals
on the
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 rate
basal 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
this is long term change 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 minute.
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 of
5-9
bpm
Slightly
undulate
type of

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 minute.
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 120-160
bpm
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 of,
necessary
repeated
survey.
Less than 6 points - pathological
type, signs of intrauterine
hypoxia
fetus,
requires
immediate hospitalization or
urgent delivery.

Methods for determining the condition of the fetus.

NON-INVASIVE METHODS

The development of modern medical technologies makes it possible to assess the condition of the fetus throughout pregnancy, from the first days from the fertilization of the egg until the birth of the fetus.

Determination of the level of alpha-fetoprotein is carried out as part of screening programs to identify pregnant women of the group increased risk congenital and inherited diseases of the fetus and complicated pregnancy. The study is carried out in the period from the 15th to the 18th week of pregnancy. The average figures for the level of alpha-fetoprotein in the blood serum of pregnant women are at a period of 15 weeks. - 26 ng / ml, 16 weeks. - 31 ng / ml, 17 weeks. - 40 ng / ml, 18 weeks. - 44 ng / ml. The level of alpha-fetoprotein in the mother's blood increases with some malformations in the fetus (defects neural tube, pathology of the urinary system, gastrointestinal tract and anterior abdominal wall) and the pathological course of pregnancy (threat of termination, immunoconflict pregnancy, etc.). The level of alpha-fetoprotein is increased and with multiple pregnancy. A decrease in the level of this protein can be observed in Down's disease in the fetus. If the level of alpha-fetoprotein deviates from normal values, further examination of the pregnant woman in a specialized perinatal medical center is indicated.

ultrasound currently during pregnancy is the most accessible, the most informative and at the same time the safest method for examining the condition of the fetus. Thanks to high quality provided information, the most widely used ultrasonic devices operating in real time, equipped with a gray scale. They allow you to get a two-dimensional image with high resolution. Ultrasonic devices can be equipped with special attachments that allow Doppler study of blood flow velocity in the heart and vessels of the fetus. The most advanced of them make it possible to obtain a color image of blood flows against the background of a two-dimensional image. When performing ultrasound in obstetric practice, both transabdominal and transvaginal scanning can be used. The choice of sensor type depends on the gestational age and the objectives of the study. In pregnancy, it is advisable to conduct a 3-fold screening ultrasound:

at the first visit of a woman about a delay in menstruation in order to diagnose pregnancy, localize the fetal egg, identify possible deviations in its development, as well as the abilities of the anatomical structure of the uterus;

with a gestational age of 16-18 weeks. in order to identify possible anomalies in the development of the fetus for timely use additional methods prenatal diagnosis or raising the question of termination of pregnancy;

at a period of 32-35 weeks. in order to determine the condition, localization of the placenta and the rate of development of the fetus, their compliance with the gestational age, the position of the fetus before childbirth, its estimated weight.

With ultrasound, the diagnosis of uterine pregnancy is possible already from 2-3 weeks, while in the thickness of the endometrium a fetal egg is visualized in the form of a rounded formation of reduced echogenicity with an internal diameter of 0.3-0.5 cm. is approximately 0.7 cm, and by 10 weeks. it fills the entire uterine cavity. By 7 weeks During pregnancy, in most pregnant women, when examining the cavity of the fetal egg, it is possible to identify the embryo as a separate formation of increased echogenicity 1 cm long. At these times, the embryo can already visualize the heart - a site with rhythmic fluctuations of small amplitude and mild motor activity. When performing biometrics in the first trimester, the determination of the average internal diameter of the fetal egg and the coccyx-parietal size of the embryo is of primary importance for determining the gestational age, the values of which are strongly correlated with the gestational age. The most informative method of ultrasound examination during pregnancy early dates is a transvaginal scan; transabdominal is used only when the bladder is full in order to create an "acoustic window".

Ultrasound examination in the II and III trimesters allows obtaining important information about the structure of almost all organs and systems of the fetus, the amount of amniotic fluid, the development and localization of the placenta and diagnosing violations of their anatomical structure. The greatest practical significance in conducting a screening study from the second trimester, in addition to a visual assessment of the anatomical structure of the fetal organs, is the determination of the main fetometric indicators:

in the cross section of the fetal head in the area of the best visualization of the midline structures of the brain (M-echo) is determined biparietal size(BPR), fronto-occipital size (LZR), on the basis of which it is possible to calculate the head circumference (CG) of the fetus;

with a transverse section of the abdomen perpendicular to the fetal spine at the level of the intrahepatic segment of the umbilical vein, on which the section of the abdomen has a regular rounded shape, the anteroposterior and transverse diameters of the abdomen are determined, on the basis of which the average abdominal diameter (AID) and its circumference (OC) can be calculated;

with free scanning in the area of the pelvic end of the fetus, a distinct longitudinal section is achieved femur fetus with subsequent determination of its length (DB).

Based on the obtained fetometric indicators, it is possible to calculate the estimated fetal weight, while the error when changing the generally accepted calculation formulas usually does not exceed 200-300 g.

For a qualitative assessment of the amount of amniotic fluid, the measurement of “pockets” free from parts of the fetus and loops of the umbilical cord is used. If the largest of them has a size of less than 1 cm in two mutually perpendicular planes, we can talk about oligohydramnios, and when it vertical size more than 8 cm - about polyhydramnios.

Currently, tables of organometric parameters of the fetus have been developed, depending on the gestational age, for almost all organs and bone formations, which should be used if there is the slightest suspicion of a deviation in its development.

Cardiotocography (KTG)- continuous simultaneous registration 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 cardiac activity, which, due to its ease of use, information content and stability of the information received, has almost completely replaced phono- and electrocardiography of the fetus from clinical practice. CTG can be used to monitor the condition of the fetus both during pregnancy and during labor.

Indirect (external)) CTG is used during pregnancy and in childbirth in the presence of a whole amniotic sac. Registration of heart rate is performed by an ultrasonic sensor operating on the Doppler effect. Registration of the tone of the uterus is carried out by strain gauges. The sensors are attached to the front wall of the woman with special straps: ultrasonic - in the area of stable registration of heart contractions, strain gauge - in the area of the fundus of the uterus.

direct (inner) CTG is used only when the integrity of the fetal bladder is broken. The heart rate is recorded using a needle spiral electrode inserted into the presenting part of the fetus, which allows you to register not only the heart rate of the fetus, but also to record its ECG, which can be decoded using special computer programs. Direct recording of intrauterine pressure is carried out using a special catheter inserted into the uterine cavity, connected to a pressure measurement system, which makes it possible to determine intrauterine pressure.

The most widespread use of CTG in the III trimester of pregnancy and in childbirth in women of the group high risk. CTG recording should be carried out within 30-60 minutes, taking into account the activity-rest cycle of the fetus, taking into account that the average duration of the fetal rest phase is 20-30 minutes. Analysis of CTG recording curves is performed only in the phase of fetal activity.

The CTG analysis includes an assessment of the following indicators:

average (basal) rate heart rate(normal - 120-160 beats / min);

fetal heart rate variability; allocate instantaneous variability - the difference in the actual heart rate from "beat to beat", slow intraminute fluctuations in heart rate - oscillations that are of the greatest clinical significance. The magnitude of the oscillation is estimated by the amplitude of the deviation of the fetal heart rate from its average frequency (normally 10-30 beats / min);

myocardial reflex - an increase in the fetal heart rate by more than 15 beats / min (compared to the average frequency) and lasting more than 30 s; increased heart rate associated with fetal movements; the presence of heart rate accelerations on the cardiotocogram is a favorable prognostic sign. He is one of the leaders in the evaluation of cardiotocogram;

decrease in fetal heart rate; in relation to the time of uterine contraction, early, late and variable contraction are distinguished (normally this sign is not observed);

slow oscillations in the form of a sinusoid in the absence of instantaneous variability, lasting more than 4 minutes; this is a rare and one of the most unfavorable types of fetal heart contractions detected by CTG - a sinusoidal rhythm.

An objective assessment of a cardiotocogram is possible only taking into account all of the listed components; at the same time, the disparity in their clinical significance should be taken into account.

If there are signs of a disturbance in the condition of the fetus during pregnancy, functional tests should be performed: non-stress test, step test, sound test, etc.

Comprehensive cardiotocographic and ultrasound diagnostics of the state of respiratory movements, motor activity and fetal tone, as well as a qualitative assessment of the amount of amniotic fluid, allows us to assess the biophysical profile 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. Depending on the gestational age and indications, chorion biopsy, amniocentesis, cordocentesis, biopsy of the fetal skin, liver, tissues of tumor-like formations, aspiration of fetal urine from the bladder or kidney pelvis are used for diagnosis in order to obtain fetal material. All invasive procedures are carried out in compliance with the rules of asepsis, in an operating room.

Amnioscopy also applies to invasive research methods. 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 not feasible for all pregnant women, but only in cases where the cervical canal can “miss” the instrument. This situation develops at the very end of pregnancy, and even then not for all women.

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 degree of maturity of the lungs of the fetus.

Chorionic biopsy (chorion biopsy) is performed different methods. Currently, aspiration transcervical or transabdominal puncture chorionbiopsy is used in the first trimester of pregnancy. 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 chorion. The main indication for chorionbiopsy is prenatal diagnosis congenital and hereditary diseases fetus.

Fetal skin biopsy - obtaining fetal skin samples by aspiration or forceps method 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.

Biopsy of tumor tissue - 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 bladder 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.

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 research on 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 research on 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. At present CTG time 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.

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 fetal lung maturity, fetal hemolytic disease, intrauterine infection fetus, fetal prematurity.

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 research fetal blood to determine its prenatal 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

Define the exact date childbirth in each specific case pregnancy is almost impossible. 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 date last menstrual period: 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.

Similar information.

At the present stage of development of medicine, prevention and timely diagnosis are quite important. possible violations from the life of the fetus. The main task of modern obstetrics is to reduce perinatal morbidity and mortality. For this, an assessment of the intrauterine state of the fetus throughout pregnancy is used.

Features of assessing the intrauterine state of the fetus in pregnant women

At the moment, there are opportunities to diagnose not only disorders that occur during pregnancy in the fetus, but also the presence of chromosomal hereditary diseases, delayed development of the fetus or individual organs and systems, and much more.

The condition of the fetus can be judged by the presence or absence of certain substances in the waters. For example, a decrease in the level of estriol in them indicates violations important functions fetus, the presence of creatinine, glucose, protein, etc. in the waters also plays an important role.

Sometimes, with the pathological course of the birth act, it becomes necessary to examine the blood of the fetus for oxygen starvation, acidosis and other disorders. To do this, blood is taken very carefully with a special instrument from the presenting part of the fetus.

Often there is a need to investigate the function of the placenta. To do this, determine the content of hormones produced by it in the blood or their excretion in the urine. Chorionic gonadotropin, progesterone (in the blood), pregnadiol (in the urine), estradiol, etc. are determined.

It is also important in some cases to record and analyze the contractile activity of the uterus. For this, electrohysterography and mechanography are used. And if it is necessary to obtain information about intrauterine pressure, radio telemetry is used. In some institutions, thermography is used, which allows you to clarify the place of attachment of the placenta, establish an overdue pregnancy, the presence of twins, etc.

The program for assessing the intrauterine state of the fetus at different stages of pregnancy

There are certain programs for screening pregnant women for various terms pregnancies organized by Women's consultation where the woman is registered.

Assessment of the intrauterine state of the fetus in the 1st trimester of pregnancy

Starting from the first trimester of pregnancy, with a period of 10 weeks of pregnancy, it is possible to exercise following studies assessing the intrauterine state of the fetus. Assessment of the intrauterine state of the fetus:

Ultrasound examination at 10–14 weeks, which is necessary for the diagnosis of malformations, the presence of chromosomal abnormalities.

Maternal blood test for serum markers at 10–11 weeks, while risk groups are distinguished according to chromosomal pathology.

Aspiration biopsy of chorionic villi at 9–12 weeks also allows diagnosing chromosomal pathology.

Assessment of the condition of the fetus in the 2nd trimester of pregnancy

The second trimester of pregnancy allows you to expand the applied research methods.

Maternal blood test for serum markers at 16–20 weeks - AFP, hCG.

Ultrasound at 20–24 weeks diagnoses malformations.

Doppler study of uteroplacental-fetal blood flow at 16–20 weeks is performed to predict the development of preeclampsia in the second half of pregnancy and placental insufficiency (FPI).

Invasive prenatal diagnosis from 16 weeks is carried out strictly if indicated. You can perform amniocentesis, placentocentesis, cordocentesis - these methods diagnose chromosomal and gene anomalies.

Assessment of the intrauterine state of the fetus during the 3rd trimester of pregnancy

In the third trimester of pregnancy, all studies, as a rule, are aimed at diagnosing placental insufficiency. Assessment of the intrauterine state of the fetus:

Ultrasound examination at 32–34 weeks diagnoses malformations with late appearance, FGR (fetal growth retardation syndrome).

Doppler study of utero-placental-fetal blood flow assesses the functional state of the fetus.

Cardiotocographic study evaluates the functional state of the fetus.

When considering in more detail individual research methods, all methods used to assess the prenatal state of the fetus can be divided into non-invasive and invasive.

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