2 English reference high-risk pregnancy
The definition of high-risk pregnancy means that this pregnancy has a high risk to the pregnant woman and fetus, which may lead to dystocia and/or endanger the mother and baby. Pregnant women with high-risk pregnancy factors are called high-risk pregnant women. High-risk pregnancy includes primipara's advanced age, abnormal fetal position, maternal-infant blood group incompatibility, intrauterine growth retardation, pregnancy-induced hypertension syndrome, premature rupture of membranes, oligohydramnios and overdue pregnancy.
4. The category of high-risk pregnancy is high-risk pregnancy with one of the following circumstances:
Age < 18 or > 35;
(2) Those who have a history of abnormal pregnancy and delivery such as abortion, premature delivery, stillbirth, stillbirth, various dystocia and surgical delivery, neonatal death, neonatal hemolytic jaundice, birth defects or genetic diseases;
(3) Hemorrhage during pregnancy, such as placenta previa and placental abruption;
④ Pregnancy induced hypertension syndrome;
(5) Pregnancy complicated with medical diseases, such as heart disease, nephritis, viral hepatitis, severe anemia, virus infection (cytomegalovirus, herpes virus, rubella virus), etc. ;
(six) exposure to harmful substances during pregnancy, such as radiation, isotopes, pesticides, chemical poisons, carbon monoxide poisoning and taking drugs harmful to the fetus;
(7) Blood group incompatibility between mother and infant;
(eight) premature or overdue pregnancy;
(9) Abnormal placenta and umbilical cord;
(10) Abnormal fetal position;
(eleven) abnormal birth canal (including bone birth canal and soft birth canal);
(12) Multiple pregnancy;
(thirteen) too much amniotic fluid, too little;
(fourteen) infertility for many years after treatment;
(fifteen) suffering from or having suffered from reproductive organ tumors.
High-risk pregnancy can be managed quantitatively and scientifically through prenatal score. Attached is the China high-risk pregnancy prenatal score standard table.
5 Perinatal infants with one of the following conditions are defined as high-risk infants: (1) gestational age is less than 37 weeks or more than 42 weeks; (2) the birth weight is below 2500 grams; (3) Infants younger than gestational age or infants older than gestational age; (4) The brothers and sisters of the fetus have a serious neonatal history. Or those who died in the neonatal period. Or have a history of more than two fetal deaths; (5) If the situation is not good at birth or after birth, Apgar score is 0-4; (6) Intrapartum infection; (7) Newborns born to high-risk women; (8) Surgical delivery.
6 Focus on monitoring high-risk pregnancy Early screening, focusing on management and monitoring, and timely and correct handling of high-risk pregnant women are important measures to reduce maternal and perinatal mortality. It is also of great significance to prenatal and postnatal care. The key monitoring includes pregnant women and fetuses. Monitoring of pregnant women has been discussed in pathology and obstetrics. This section mainly expounds the important monitoring of the fetus.
6. 1 (1) Understand the growth and development of the fetus 1. Pregnancy chart: Make the weight, blood pressure, abdominal circumference, fundus height, fetal position, fetal heart rate, edema, proteinuria and biparietal diameter of pregnant women into a certain standard curve. During each prenatal examination, the findings and results of the examination are recorded on the map at any time. Through continuous observation and comparison, we can understand the growth and development of the fetus.
2. Measurement of fundus height: The data obtained by measuring fundus height is related to the birth weight of the fetus. Therefore, measuring the height of the fundus can predict the growth and development of the fetus.
From 20 to 34 weeks of pregnancy, the height of the fundus increased by about 65438±0cm per week on average, and the increase rate of the fundus slowed down at 34 weeks. The height of the fundus is more than 30cm, indicating that the fetus is mature. Japanese scholar Fifty Lan and others put forward a formula to calculate the fetal development index:
Fetal development index = fundus height (cm)- (month+1) × 3
The calculation result is 5. It may be twins, polyhydramnios or macrosomia.
Prenatal scoring standard for high-risk pregnancy
The abnormal situation score is the same as the abnormal situation score.
feel
situation
The age is ≥35 years old.
Pregnant
Pregnant
different
often
feel
situation
Teratogenic factor
Pelvic stenosis or deformation 10 ≥ 40 breech position, transverse position10 height < 1.5 > 1.4m threatened premature delivery < 34w15 ≤1.4m34 ~ 37w.
produce
history
History of spontaneous abortion ≥2 times overdue pregnancy 4 1 ~ 42w5 premature birth ≥2 times > 42w 10 neonatal death history 1 times polyhydramnios 10 stillbirth, stillbirth ≥2 times pregnancy-induced hypertension, medium-5 congenital abnormality 1 times weight/times.
inside
The branch of academic or vocational research.
close
and
disease
Anemia 5 ~ 7g fetal distress fetal heart rate < 100 beats/min > 160 beats/min.
Fetal movement < 1 times/hour
15 ≤ 5g fetal heart rate < 120 beats/min, > 160 beats/min fetal movement < 3 beats/min.
10 active pulmonary tuberculosis fetal movement < 5 times/hour 5 heart disease or cardiac function I-II multiple births (twins, triplets) 10 ⅲ premature rupture of membranes (delivery after premature rupture of membranes exceeds 12 hours) 10 history of heart failure or cardiac function IV to estimate fetal macrosomia (≥ 4000g
3.b-ultrasound examination: measure a certain part of the fetus, such as biparietal diameter (BPD), femoral length (FL), abdominal circumference (AC), etc. To judge the growth and development of the fetus, among which BPD is the most commonly used. Ultrasound examination with BPD > 8.5 cm showed that the fetal weight was > 2500 g, and the fetus was mature, > > 10cm, which might be a giant fetus.
6.2 (2) Determination of fetal maturity 1. Estimation of fetal maturity by gestational age and fetal size; Premature infants with gestational age < 37 weeks; 37 weeks to 42 weeks are full-term babies, and > 42 weeks are overdue babies. < 2500 g is premature or full-term infant, > 4000 g is macrosomia.
2. Amniotic fluid analysis
The ratio of lecithin to sphingomyelin (L/S) indicates lung maturity, and the ratio ≥2 indicates fetal lung maturity; < 1.5 indicates that fetal lung is immature, and neonatal respiratory distress syndrome (RDS) may occur after birth, which can be replaced by foam test in clinic. For example, there are complete foam rings on both liquid columns, indicating that L/S is ≥ 2. Fetal lung maturity; If no foam ring is found in both tubes, it means that the fetal lung is immature; One pipe with foam ring and the other pipe without foam ring is the critical value, and L/S may be less than 2.
Muscle gangue indicates renal maturity, > 2 mg/dl indicates renal maturity, < 1.5 >2mg/dl indicates renal immaturity.
Bilirubin measurement shows the maturity of fetal liver. Bilirubin value decreased with the prolongation of pregnancy time. If the optical density difference of 450um measured by spectrophotometer is above 0.04, it means that the fetal liver is immature. The critical value is 0.02 ~ 0.04, and the fetal liver is mature below 0.02.
Estriol content in amniotic fluid is related to birth weight. When the weight is less than 2500 g, the content is less than 0.6 mg/L; After 37 weeks of pregnancy, the fetal weight was > 2500 g, E3 >1mg/L; If the weight is more than 3000 g, the content is more than 2 mg/L.
Fetal adipocyte count indicates that the skin is mature. After 0. 1% Niloran sulfate staining, fetal fat cells were orange, and cells without fat particles were blue. More than 20% of orange cells are mature, < 10% are immature, and > 50% are overdue pregnancy.
6.3 (3) Determination of placental function 1. Determination of hCG in blood and urine: hCG can be detected in blood and urine about 7 days after the implantation of pregnant eggs, and gradually increases with the development of pregnant eggs, reaches a peak about 80 days, then gradually decreases, maintains a certain level, and gradually disappears after delivery. The determination of chorionic gonadotropin in early pregnancy reflects the function of placental villi, which is of great significance for monitoring threatened abortion and hydatidiform mole. It is of little value to the third trimester.
2. Determination of blood hPL; Placental prolactin (hPL) is a protein hormone secreted by placental trophoblast, which gradually increases with pregnancy, reaches its peak at 34 ~ 36 weeks, then tends to be flat, and gradually disappears after delivery. HPL can only be determined in the blood of pregnant women. The critical value of normal pregnancy in the third trimester is 4ug/ml, below which the placenta is dysfunctional and the fetus is in a critical period. HPL level can well reflect the secretory function of placenta, which is an internationally recognized method to measure placental function. Continuous dynamic monitoring is more meaningful. The combination of E3 and B-ultrasound has high accuracy in placental function grading.
3. Determination of estriol (E3) in urine: Collecting 24-hour urine of pregnant women and observing E3 by RIA is a common method to understand placental function. Urinary E3 < 10 mg in the third trimester of pregnancy, or the previous measurement value was in the normal range, and the current measurement value suddenly dropped by more than 50%, all of which suggested that the placental function was decreased.
4.b-ultrasound placental function classification: reflect the image structure of placenta from the sonogram. According to whether (1) fluff board is smooth or not; (2) Placenta parenchyma light spot; (3) Placenta is divided into 0-III grades.
6.4 (4) Fetal intrauterine monitoring 1. Fetal movement count Fetal movement is a sign of fetal health in uterus. Fetal movement values are different in different gestational weeks. At full term, 12 hour fetal movement times > 100. There are more fetal movements at night than during the day. Decreased fetal movement may indicate intrauterine hypoxia. High-risk pregnant women should do fetal movement count, three times a day, one hour each time, three times and ×4, which is 12 hours of fetal movement times. > 30 times/12h means normal, < 20 times/12h means intrauterine hypoxia. If the fetal movement gradually decreases, it means that hypoxia is aggravated. /kloc-There is no fetal movement within 0/2 hours. Even if you can still hear the fetal heart, you should be on high alert.
2. Fetal monitoring
(1) Fetal electronic monitoring According to the principle of ultrasonic Doppler and the change of fetal heart current, various fetal heart activity detectors have been widely used in clinic. It is characterized by not being affected by uterine contraction, and can continuously observe and record the dynamic changes of fetal heart rate. The relationship between uterine contraction instrument and fetal movement recorder can be reflected.
① There are two ways to monitor fetal heart rate: intrauterine monitoring and abdominal wall monitoring. The former must put the measuring catheter or electrode plate into the uterine cavity through the cervical canal, so it must be done when the cervical orifice has been opened and the membrane is broken, which may cause infection. So the latter is used more now.
There are two basic changes in fetal heart rate recorded by fetal electronic monitor, namely, baseline fetal heart rate (BF-HR) and periodic fetal heart rate (BF-HR).
BFHR is the fetal heart rate recorded between no contractions or contractions. BFHR can be estimated from two aspects: beats per minute (bpm) and FHR variation.
If the bpm of FHR lasts more than 160 times or less than 120 times for 10 minutes, it is called tachycardia or bradycardia. The change of FHR means that FHR has a small periodic fluctuation. The change of BFHR, the so-called baseline swing, shows that the fetus has a certain reserve capacity and is a manifestation of fetal health. The flattening of the baseline of fetal heart rate means that the variation disappears or stays still, suggesting that the fetal reserve capacity is lost. The following figure shows BFHR and baseline swing.
Figure 140 fetal heart rate and baseline swing
PFHR is the change of FHR related to uterine contraction.
After the acceleration of uterine contraction, FHR increased by about 15 ~ 20 BPM, which may be caused by temporary compression of fetal trunk or umbilical vein. Sporadic and short-term fetal heart rate acceleration is harmless. But if we continue to compress the umbilical vein, it will further develop into deceleration.
Deceleration can be divided into three types;
The early deceleration started almost at the same time as the uterine contraction, and immediately returned to normal after the uterine contraction, and the amplitude did not exceed 40bpm (Figure 14 1). Early deceleration is generally considered to be the performance of fetal head compression and temporary decrease of cerebral blood flow (generally harmless).
After the contraction begins, the fetal heart rate may not necessarily slow down. The relationship between deceleration and contraction is not constant. However, after it appeared, it declined rapidly, with a larger range (60-80 BPM), a longer duration and a faster recovery (Figure 142). It is generally believed that variation deceleration is caused by umbilical cord compression and vagus nerve excitation during uterine contraction.
Figure 14 1 PFHR early deceleration
Figure 142 PFHR change deceleration
After the onset of late deceleration contraction (mostly after the peak), the fetal heart sound slows down, but the decline is slow, the duration is long, and the recovery is slow (Figure 143). Late deceleration is the manifestation of fetal hypoxia, and its appearance should be paid great attention to fetal safety.
Figure143 Late Deceleration of PFHR
② The application of fetal electronic monitor in predicting fetal intrauterine reserve capacity.
Non-stimulation test (NST) This test is based on the short-term fetal heart rate acceleration during fetal movement, so it is also called fetal heart rate acceleration test (FHT). In this experiment, the changes of fetal heart rate during fetal movement were observed to understand the fetal reserve function. During the experiment, pregnant women take a semi-lying position, and the electronic monitoring probe is placed in the abdomen (fetal heart sound area). At the same time, when pregnant women consciously feel fetal movement, report or press the button and mark on the paper recording fetal heart rate for at least 20 minutes. It is generally believed that normal fetal movement is accompanied by fetal heart acceleration exceeding10 BPM at least 3 times; The abnormality is that the number of fetal movements and fetal heart rate acceleration are less than those mentioned above, and even there is no fetal heart rate acceleration during fetal movement. Find out the reason. This detection method is simple and safe, and can be carried out in outpatient department (if there is no electronic monitoring, fetal heart sounds and fetal movement times can be recorded and analyzed at the same time), which can be used as a screening test before oxytocin provocation test.
Oxytocin provocation test (OCT), also known as contraction provocation test (CST), is based on oxytocin-induced contractions, and the changes of fetal heart rate are recorded by fetal heart monitor. If late deceleration occurs repeatedly after multiple contractions, the variation of BFHR decreases, and FHR does not increase after fetal movement, which is positive. If BFHR has variation or fetal movement increases, FHR is accelerated, but FHR has no late deceleration, so it is negative.
This experiment can generally be carried out after 28 ~ 30 weeks of pregnancy. If it is negative, it means that the placenta function is still good, and there is no danger of stillbirth within one week. This test can be repeated after one week. If it is positive, it means that the placental function is decreased. However, because there are many false positives, the significance is not as great as negative. Therefore, urine E3 or other tests can be increased to further understand placental function.
(2) Fetal ECG fetal heart activity is a reflection of the situation of the fetus in the uterus, so fetal ECG examination is one of the better fetal monitoring. There are two kinds of fetal ECG detection: intrauterine detection and abdominal wall detection. The former must put the probe electrode into the uterine cavity through * * * and directly contact the fetal head or buttocks. Although the figures obtained are clear, they must be carried out when the cervix has dilated and the fetal membrane has ruptured, which may cause infection and make it impossible to measure it many times during pregnancy. The electrode of abdominal wall detection probe is placed in the abdomen of pregnant women, and the fetal heart current is transmitted to the abdominal wall of pregnant women through amniotic cavity. According to the multiple measurements of R wave, we can infer the intrauterine development, fetal survival, fetal position, multiple births, gestational age, placental function and high-risk infants, and the changes of PQRST also reflect high-risk infants. Although fetal electrocardiogram has certain diagnostic value, it is only one of many monitoring methods.
3. Amnioscopy was first used (1962), and now it has become an examination method in perinatal medicine. Under the condition of disinfection, it is of certain reference value to directly peep the amniotic fluid properties in the amniotic cavity through the amniotic cavity mirror. Contraindications: Prenatal bleeding, * * *, cervical and uterine cavity infection, threatened premature delivery, polyhydramnios, etc.
From the normal amniotic fluid, it is clear light blue or milky white, and fetal hair and floating fetal fat fragments can be seen through the fetal membrane. When meconium is polluted, amniotic fluid is yellow, yellow-green, or even grass green; Patients with Rh or ABO blood group incompatibility have yellow-green or golden amniotic fluid; The amniotic fluid of patients with placental abruption will be bloody.
4. The fetal monitoring method of measuring the PH value of fetal scalp peripheral blood during delivery can not fully reflect the real situation of the fetus in the uterus. To determine the PH value of fetal scalp blood, so as to know whether there is hypoxia and acidosis in uterus. PH7.25~7.35 is normal, and pH < 7.20 indicates that the fetus is seriously hypoxic and acidosis.
7 Maternal and neonatal monitoring The puerperal high-risk women will continue to receive treatment and observation in the high-risk ward, and the high-risk babies will be treated mainly by pediatricians in the high-risk neonatal intensive care unit (NICU) (see the relevant chapters on pathology obstetrics and neonatal diseases for details).
High risk factors before pregnancy 1. Age: 18 years old or over 35 years old. Pregnant women over the age of 35 are all elderly women, who are more likely to be pregnant with deformed fetuses and premature delivery, and are prone to pregnancy complications. Moreover, due to skeletal and physiological factors, the chances of normal delivery of elderly pregnant women may also be reduced, and the incidence of genetic defects in newborns is significantly higher.
2. Height: the height is below 145 cm, the weight is less than 40 kg or more than 85 kg, and the pelvis is narrow, which is prone to dystocia.
3. Physical quality:
Obese and obese women will have more complications during pregnancy, such as pregnancy-induced hypertension.
I suffer from diseases that affect bone development, such as rickets and tuberculosis.
Reproductive tract malformation is prone to pelvic stenosis and abnormal birth canal, which affects the normal progress of labor, leading to prolonged labor and fetal asphyxia.
Have a family history of genetic diseases.
The nutritional status is relatively poor.
4. Blood type: the woman's blood type is O, while the husband's blood type is non-O; Or if the woman's blood type is Rh negative and the husband's blood type is Rh positive, there will be blood type incompatibility between mother and baby, leading to hemolysis of newborn.
5. Suffering from medical diseases: such as essential hypertension, congenital heart disease, diabetes, hyperthyroidism, nephropathy, hepatitis, anemia, endocrine diseases, etc.
6. Have a history of abnormal pregnancy: if there are too many abortions; Had premature delivery, overdue pregnancy, stillbirth and various dystocia; Having given birth to macrosomia, low birth weight and congenital malformation; Those who have had surgical delivery (forceps, uterine delivery) and have symptoms of preeclampsia or a history of eclampsia, etc.
7 years of infertility, pregnant after treatment.
9 High risk factors after pregnancy 1. Pregnancy complicated with medical diseases: such as heart disease, hypertension, nephropathy, diabetes, viral hepatitis, etc.
2. Virus infection: such as cytomegalovirus, herpes virus and rubella virus.
3. Exposure to harmful substances in early pregnancy: such as radiation, pesticides, chemical poisons and taking drugs harmful to the fetus.
4. Abnormal conditions during pregnancy: pregnancy-induced hypertension syndrome, bleeding during pregnancy, abnormal placenta, overdue pregnancy, polyhydramnios, too large or too small fetus, fetal distress, intrauterine growth retardation, abnormal placenta position, and blood group incompatibility between mother and child.
5. It is difficult to estimate the delivery during pregnancy, such as pelvic stenosis, abnormal fetal position, abnormal umbilical cord, head-basin asymmetry, postpartum hemorrhage, postpartum infection or postpartum shock.
6. Other conditions: macrosomia, multiple pregnancy, etc.
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