Monitoring of pregnancy can be a source of discomfort for the general practitioner. However, this is usually a physiological phenomenon governed by a policy of monitoring and preventing well organized in France, both at the medical level at the legislative level. This has allowed since 1970, the decrease in perinatal mortality (from 35 to 6.5 deaths per 1,000 births) and maternal mortality (from 25 to 9 per 100 000 births). Prevention, initially based on the establishment of a regular medical follow-up including clinical examination and mandatory or oriented investigations, is changed from 1992 when the number of antenatal visits is set at seven mandatory examinations for a normal pregnancy progressing to completion (Decree No. 92-143 of 14 February 1992; Article L 154 of the Public Health Code).
The plan Perinatality 1994 aimed to reduce maternal mortality by 30%, perinatal mortality by 20% and sudden death by 35% of infants. These objectives were achieved for mortality indicators, but progress is still needed to improve the position of France in Europe, always “average” for perinatal and maternal mortality with more than a third of maternal deaths’ preventable. “This plan enabled the creation of perinatal networks and thus developed the concept of transfer in utero.
Perinatal The 2005 plan will modernize the 1994 level and reduce perinatal and maternal mortality. It establishes measures to improve the safety and quality of care, while developing a more human and closer to supply.
GPs are more involved in this broader perinatal network that involves all stakeholders in health and social protection.
This chapter focuses on the monitoring of normal pregnancies according to the new plan Perinatal, appropriate conduct of the treating physician, transfers of information to the obstetrics adapted and paperwork surrounding pregnancy (CPAM, Law work etc.)
CALENDAR OF PREGNANCY:
The different abbreviations are summarized in Box 1.
Box 1. Summary of Abbreviations
SA: week of amenorrhea
MG: months pregnant
DDR: last menstrual period or the date of the 1st day of the last period
DDG: start date of pregnancy or date of fertilization
DFG: date of end of pregnancy and expected delivery date (DPA) term or date
DFG = DDG + 9 months = DDR + 41 SA
Dating and terms:
What does “term”?
“A patient after 37 weeks and this is ultimately in the four weeks preceding his term. “The word” term “has many meanings in obstetrics:
– Either the current term of pregnancy, “you are now at 28 or 6 full months”;
– The date of the end of pregnancy, “even if you have not given birth to the date of the term, you will get to the end of maternity for consultation”;
– The period of the term where childbirth is neither premature nor post-mature, between 37 and 42 SA SA: “you are at term (37 weeks and 0 days or 8 MG + 4 days), which means your child is not mature premature. “
Be expressed in weeks or months?
Several methods of calculating the term of pregnancy are employed. For optimal communication, it would be good to use the same language.
The calculation in “weeks gestation” is more accurate and less ambiguous than “month of pregnancy” (Box 2). The number of SA is calculated by adding 2 SA to the number of weeks from the DDG. If the DDG is unknown (no dating ultrasound, nor notion of date of fertilization) count the number of SA announced since the DDR. The DFG or DPA is calculated by adding 9 months to the DDG.
Box 2. Conversion between months pregnant and weeks of gestation.
3 MG SA full = 15 + 1 day
4 MG = full 20 SA
5 = full 24 MG SA
MG 6 = full 28 SA
MG 7 = full 32 SA
8 MG SA full = 36 + 3 days
Dating of pregnancy:
To calculate the end of a pregnancy, it is best to know the date of fertilization or DDG.
We have three possibilities.
If the pregnancy is obtained by medically assisted procreation (in vitro fertilization, intracytoplasmic sperm injection, artificial insemination with sperm from the husband or a donor, etc.), the embryo in utero replacement date or date insemination gives the DDG (rare circumstances).
If the cycle is regular x days without pill, the date of fertilization is obtained by adding days (y = x – 14 days) after the DDR; this dating is less precise but more common in the absence of dating ultrasound.
Indeed, a regular cycle of x days includes a follicular phase of y days before ovulation and a constant 14-day luteal phase after ovulation. For a 24-day cycle (x = 24) ovulation (fertilization) will be held on the 10th day of the cycle (y =x – 14). For a 34-day cycle (x = 34) will be at ovulation 20th day of the cycle (20 = 34-14).
The pregnancy dating ultrasound widespread in France allows us to date the beginning of pregnancy with an accuracy of ± 3 or 4 days if done before 15 weeks. The ideal is to realize this ultrasound between 11 and 14 weeks for the couple to the measurement of nuchal translucency and early morphological analysis (see ultrasound dating).
In France fewer than 1% of pregnancies have an imprecise term (Box 3).
Box 3. Some definitions related to the term of pregnancy
Preterm birth before 37 = + 0 days
Exceeding delivery term = between 41 and 42 SA
Postterm = delivery beyond 42 SA
= Prematurity term delivery between 22 weeks and 32 weeks
Abortion before 22 weeks =
= Delivery from 22 SA
Early pregnancy = abortion before 15 weeks
= Late miscarriage abortion after 15 weeks (<22 weeks)
Gravidity débutées = number of pregnancies regardless of outcome
Parity = number of pregnancies passing 22 weeks regardless of the outcome
= Viability of the fetus from 24 weeks according to the neonatology teams
The calculation of maternity leave depends on the number of previous deliveries, the number of dependent children and the number of ongoing pregnancy (Table I).
In case of delivery before the presumed date:
When the woman could not benefit from the full antenatal leave, not taking share is postponed until after delivery. The total period of pre- and postnatal leave is not reduced.
The 2005 plan Perinatal plans to extend maternity leave for mothers of very premature infants (more than 6 weeks before term) and children with disabilities at birth requiring care. The leave is extended from the current number of days between the effective date of birth and date. The employee can thus participate, whenever possible, to care for her child and benefit from educational activities to health preparing the return home.
Extra rest (14 days) for pathological pregnancy:
If a medical condition certified by a medical certificate as a result of pregnancy or confinement makes it necessary, leave is increased by the duration of this condition a maximum of two weeks before the expected date of childbirth and four weeks after the date thereof.
The number of antenatal care (ANC) is set at seven mandatory examinations for a normal pregnancy progressing to completion.
Each prenatal examination includes a clinical examination and the search for glycosuria and albuminuria.
Additional tests surrounding prenatal monitoring is required or must be offered systematically with information (Boxes 4 and 5).
Box 4. Additional examinations during pregnancy (first trimester)
Rhesus and Kell phenotype full if not full group card (2 determinations)
Search of irregular antibodies (RAI)
Glycosuria and proteinuria by dipstick
Syphilis TPHA (Treponema pallidum Hemagglutinations Assay) and VDRL (Venereal Disease Research Laboratory)
Toxoplasmosis unless proven prior immunity (prenatal testing …)
Systematically to evaluate rubella immunity (vaccination after delivery if low or non-immunized)
To consistently offer
HIV (HIV) in Q1 HT21: evaluation of risk of trisomy 21 by maternal serum markers, to prescribe in the 1st quarter for the beginning of the second quarter between 14 and 17 + 6 SA J.
Complete blood count (CBC), platelets
Dating ultrasound: between 11 and 14 SA
If targeted risk factors
Hemoglobin electrophoresis if ethnicity at risk of thalassemia or sickle cell anemia
Hepatitis C (HCV) if risk factors (systematic for some)
Pap smear if no previous gynecological care
Box 5. Additional examinations during pregnancy (2nd and 3rd quarters)
Glycosuria and proteinuria dipstick every month
Toxoplasmosis every month if not immunized
RAI the 6th, 8th and 9th months if Rhesus negative
Blood count (hemoglobin) at 6 months
HBsAg (hepatitis B) at 6 months
Anesthesia consultation to the 7th or 8th month
Test O’Sullivan: 24-28 SA
Platelets at 6 months
RAI every month if Rhesus negative
RAI at 6 months in the 48 hours preceding the birth whatever the Rhesus
Q2 ultrasound (morphology biometrics): 21-24 SA
Ultrasound Q3 (biometrics morphology): 31-34 SA
Search B strep in the vagina 8th month
Coagulation profile in the 9th month
Do not do during pregnancy (unnecessary and costly)
Cholesterol, erythrocyte sedimentation rate, iron, cytomegalovirus (CMV)
Minimum clinical examination common to all EIC:
The interrogation kind for the presence of uterine contractions: contractions or cramps in the abdomen, painful or not, pain that can plan ahead next to the uterus, like back in the back and loins. They last 1 to 3 minutes followed by a relaxation period painless. They are considered “physiological” up to 10 contractions per day. The most pejorative uterine contractions are those that cause cervical changes, and / or are painful.
The ligament pain must be differentiated uterine contractions by their characteristics: continuous pain without painless interval, sitting in the folds of the groin, occurring when walking or in certain positions (mechanical type).Treatment involves the quiescence of the uterus by a supporting ligaments analgesic position (which depends on each woman) associated with magnesium and vitamin B6.
The perception of fetal active movements appears to SA 19 in multiparous and 21 to SA in primiparous. Its decline should alert.
Strong activity is a good prognosis even if it is sometimes poorly tolerated by the mother.
Functional signs of high blood pressure (hypertension) (phosphenes, tinnitus, headache, edema, vomiting), loss of blood and / or fluid must move towards obstetric emergencies without delay. Urinary signs and vaginal discharge will produce bacteriological samples and / or mycological.
Treatments ongoing and spontaneous complaints (reflux, cramps, constipation, asthenia, neuralgia, paresthesia, rash, pruritus, fever, flu syndrome etc.) complete the examination.
The systematic physical examination includes measuring blood pressure, uterine height (HU: the pubic symphysis to the uterine fundus, Table II), weight, weight gain since early pregnancy and since last CPN. Routine vaginal examination in France, only call signs in Anglo-Saxon countries, can appreciate the opening, length, consistency, position the neck, and the height, the type of presentation and exemplification of the lower segment. It is true that during the first two trimesters of pregnancy, vaginal examination was not a blatant interest. From 32 weeks the type of presentation is specified. The fetal heart sounds are heard with a stethoscope Pinard (almost deserted) or an ultrasonic sensor that is placed next to the fetal back (on the side opposite to the side that maternal abdomen perceived fetal movements). One can easily perceive from 10-12 SA then more easily during the 2nd and 3rd quarter.
The common prenatal diagnosis to all EIC includes:
– Dipstick: systematic search for glycosuria and albuminuria every month;
– Toxoplasmosis: every month if not immunized against toxoplasmosis;
– RAI: every month if Rh negative.
First EIC “declaration of pregnancy,” screening high-risk pregnancies, precise questioning
It must take place before 14 weeks preferably after dating ultrasound. This consultation helps to identify pregnancies at risk and prescribe mandatory reviews “declaration of pregnancy.” Screening of risk situations is based essentially on the examination which must be at the first ANC, targeted and comprehensive. It focuses on the obstetric history, family, transfusion, allergy, medical, surgical and addictions (smoking, alcohol or drug abuse). It is also an opportunity to deliver information on hygiene measures to be taken during pregnancy, to schedule for pregnancy and educate the DDG on pregnancy notification form.
It must specify:
– The social status of the mother: identity, ethnicity, place of birth, address, phone, profession, lifestyle (single, family, home), transport (duration, frequency);
– The child’s father (if the patient agrees to disclose): identity, profession, height, blood type, genetic diseases, inbreeding, lifestyle, ethnicity, place of birth, children and other beds become;
– Family history of diabetes, hypertension, thrombosis, cancer (breast) and all hereditary diseases eligible for prenatal diagnosis;
– Medical and non-obstetric surgical history: hypertension, diabetes, urinary tract infections, epilepsy, phlebitis, asthma, vasculitis, surgical procedures and method of anesthesia, transfusions, allergies;
– Gynecological history: endometriosis, prolapse, fibroids, desire for pregnancy, medically assisted procreation (in vitro fertilization, intracytoplasmic sperm injection, etc.), uterine malformations, OF syndrome and the date of the last cervical smear (more or less’ one year) ;
– Obstetric history, qui-have a high predictive value for this pregnancy.
For every birth is Collected Date and place of birth, race of pregnancy (hypertension, diabetes, preterm labor), the term, the duration of labor, method of delivery (episiotomy, forceps, vacuum extraction, indications Caesarean section, operative report). Specify the causes of acts (forceps, caesarean section), the kind of anesthesia. For Each child there is sex, birth weight, condition (Apgar) at birth, the hospital stay in neonatal resuscitation, the kind of feeding, the place of life (Placed or not?) And ‘Current state. Specify if there is change of progenitors, the number of Miscarriages with the term and the discharge mode, the number of abortions;
– Psycho-socio-economic conditions: it is essential to Identify vulnerable women in precarious situations and Perceive the social context of the patient (isolated woman violent husband, etc.). The precariousness Increases the risk of low birth weight and prematurity. It assesses the status of the mother or the couple with issues tactfully are: the profession of the patient and spouse, the father’s presence in the home, the number of children living in the household, the number of children from –other beds. We appreciate the difficulty of the profession, the travel time, the moyen de transport. We issue it in trust addictive behavior in the torque and / or in the patient, to QUANTIFY Each intoxication (smoking, alcohol, etc.), Taking Care not to blame the patient Unnecessarily , while Clearly Informing Risks to the fetus, pregnancy Itself. It will EMPHASIZE the benefits of stopping intoxication generate Avoiding stress and depression (guilt, depreciation) That moreover complicate pregnancy without stopping intoxication;
– The history of the current pregnancy (bleeding, pain, hospitalization …) and drugs taken During early pregnancy to tailor treatment to pregnancy.
Clinical examination of the 1st NPC added to the conventional clinical examination, auscultation heart and lung, examination of smears ± collar and a breast exam.
Required exams pregnancy declaration are: RAI group Rhesus phenotype, toxoplasmosis (unless there are positive results before pregnancy, prenuptial certificate, previous pregnancy …), rubella (ALTHOUGH Systematically notion of looking a positive rubella Reduced immunity will lead to postpartum vaccination) syphilis (TPHA and VDRL), glycosuria and albuminuria (dipstick).
Systematic reviews (not required): NFS, platelets, HIV, HCV risk if factoring (transfusion history, substance abuse, etc.), assessment of risk of trisomy 21 in this pregnancy (HT21, FRT21, maternal serum markers, triple test). Do not forget the smear of the cervix in women for cervical screening Followed not cancer. Ultrasound Q2 can already be programmed entre 22 and 24 weeks.
CPN 4th month: psychosocial dialogue:
The Perinatal Plan 2005-2007 sets up the conditions for a dialogue Permitting the Expression of the expectations and needs of prospective parent for a personal interview and / or couples Routinely offert During the 4th month. It shoulds evoke some issues Discussed During the CPN (body exchange, emotional, professional). This NPC can be Performed in maternity or in private sector, for a midwife or professional Reviews another from birth reconnu by the perinatal network.
The information shoulds be Relayed by social networks of proximity, maternal and child health, the permanence of access to health care, GPs, relatives’ networks, women relay so That All women benefit, Including The Most vulnerable or isolated.
CPN 5th month (20-24 SA): EIC standard prescription of the balance sheet of the 6th month:
The balance sheet of the 6th month prescribed in the 5th month of the CPN Consists of mandatory exams:
Search antigen of hepatitis B (HBsAg), RAI, hemoglobin. Often associated non-mandatory tests: Load test with 50 g glucose (O’Sullivan), NFS, platelets.
The dosage of the serum uric acid tend to disappear When the liver transaminases (GOT, GPT) are the MOST frequently requested.
EIC of the 6th month (24-28 SA): results from the balance sheet of the 6th month:
It Allows in addition to the standard EIC to collect the results of the balance sheet of the 6th month and Adapting therapeutic management based on results. This Ensures the proper use of ultrasound as Evidenced Q2 has postponed That meets the standards published by the French College of fetal ultrasound. If results are Insufficient or irrelevant it is the responsibility of the physician or midwife Note After pregnancy to the failure and apply for a new more full ultrasound examination.
EIC of the 7th month (28-32 SA) Provide childbirth:
This is a standard EIC qui are added to the recovery of results from the balance sheet of the 6th month and year of prescription anesthesia consultation on the place of birth. From this term must inform the patient about the signs to encourage to consult obstetric emergencies.
This is the period of preparation psychoprophylactic childbirth. This Ensures the prescription of ultrasound Q3 to 32 weeks.
EIC 8th month (from 32 to 36.5 SA) route of delivery, assessment of the limitation late pregnancy (9th month):
In addition to standard clinical examination we gladly carry out an assessment of the delivery prognosis with a clinical examination of the pelvis. We appreciate the fetal volume by uterine size and fetal ultrasound biometry 32 weeks. This Ensures the validity of the card and the blood group . results of the anesthesia consultation It is prescribed sheet of the 9th month Consists of systematic reviews: NFS, platelets, prothrombin time, partial thromboplastin time activated, fibrinogen, serum uric acid and RAI for Some Whose dosage is disappearing while liver transaminases (GOT, GPT) are the MOST frequently requested.
Most French obstetric teams advocate At That time exclusive research B streptococcus in the vagina from 34 weeks.It is preferable That this consultation When the patient Approaches practicing the maternity childbirth.
CPN 9th month (= 36.5 to 41 SA-term) Synthesis of prenatal record, prognosis of delivery, Provide for the term consultation to 41 weeks or 9 months full:
The lathing EIC must have imperatively place with the team of the maternity ward Where delivery is expected. It assesses the birthing prognosis, presentation, fetal volume and the situations Explains That Arise shoulds encourage motherhood. If a problem OCCURS the patient must carry Quickly to emergency obstetric care for maternity and / or monitoring adapté limit pregnancy. We verify que la obstetrical file is full with all the Necessary Elements for the delivery. If labor Does not start spontaneously the patient must go to the day of motherhood late pregnancy (DDG + 9 months) Even if it is a public holiday (Box 6).
CPN SA 39.5 “functional exploration,” a term of CPN:
This consultation is made by the team motherhood That delivery will selon His medical protocol. Most Often the NPC 39.5 SA is to monitor the end of pregnancy by Evaluating the cervix, the amount of liquid. Fetal biometry and fetal heart monitoring is made by Sometimes Some teams. This is Possibly the outcome of this consultation That Is Discussed as a trigger motherhood protocols.
6. Box . Tips for the third quarter is Repetitions Each CPN Q3. “You have an appointment on: dd / mm / yyyy in consultation with maternity. Until Then, if you happen anything you shoulds time immediately go to the emergency of motherhood, Especially Following in the boxes.
If you lose blood whatever the amount, Regardless of the hour, you must go to the emergency immediately All of motherhood. So if you wake up at night lost HAVING A Few drops of blood, go to the maternity night! Do not wait up to the next day or year appointment!
If you lose water Regardless of the amount Regardless of the time, go to maternity time immediately.
In case of doubt entre water or urine go to the maternity ward Where the tests will be made.
If your baby is less or not move at all or weird or if you are Concerned About His movements, go to the maternity ward at Any time of day or night.
If you feel painful, regular contractions every 5 or 10 or 15 minutes are going to motherhood .
Lastly, if you are vomiting or fever-have to go to maternity.
In general, if there is anything Either way, you’re going to motherhood, and if nothing happens, if it’s dead calm, you-have you just planned on dd / mm / aaaaa. “
The lathing mandatory consultation takes up 6 to 8 weeks postpartum. This consultation Allows for the synthesis of past pregnancy. The examination will inform on the terms of delivery, the requirement of the child since birth and breastfeeding mode.
We will tactfully inquire on genital problems, urinary and anal. The birth control is Discussed by Informing on misconceptions Such As “breastfeeding Protects Reviews another pregnancy.” For the duration of breastfeeding is prescribed progestin mini-pill with iron supplementation. Apart from nursing the contraceptives method is Chosen by the patient. The Pap smear screening for cervical cancer shoulds be scheduled After stopping breastfeeding Sooner or if the patient is “at risk”. This Ensures the prescription of physical therapy of perineal and abdominal postpartum. It is essential to perform thesis exercises before resuming sports activities Including Mobilizing the abdominal muscles. It provides for a minimum of 10 sessions, supported by social security. In case of urinary incontinence or anal Persisting insisted That thesis must be Held meetings and Direct the patient to a specialist.
The measurement of blood pressure, weight and examination of skin scars complement this consultation. It que la significant family doctor Evaluates the mother-child relationship and the psychological state of the couple.
In France, the three CPAM reimburse prenatal ultrasound (12, 22 and 32 weeks). These are available purpose are not “mandatory”. The objective and perception of ultrasound Differ Significantly entre sonographers and patients (and caregivers). For sonographers, it is That was challenging exam requires sustained concentration, in search of gold Rather pathologies elements “visible” normality. For patients the goal is to “see” the child Conceived Until Then to know the sex and finally to assurer That “everything is normal”. It is Necessary to inform patients about the limits of this review and the need to be in optimum sensory concentration requirements for the operator. It is better to come with more than one Accompanying and Avoid small children Who are Struggling to supporting the duration of the examination quietly . Fat, lipids are the enemies of ultrasound sonographers Because They block. All substances penetrating the skin lipid structures require Either the stretch mark creams, moisturizers, oils and others. The best is to put nothing at least 15 days before the exam, Especially as for stretch marks no product icts HAS Demonstrated effectiveness. All scans must meet quality criteria That must be controlled During Pregnancy monitoring, for critical reading of the minutes. If the ultrasound is rendered Clearly Insufficient account shoulds be prescribed a new addition to examination.
Some structures can REMAIN invisible or poorly Visualized Throughout pregnancy due to fetal position, or maternal parietal condition (obesity). The report is mandatory (legal) Given to the partner after the patient exam. There must be Recorded Regardless of the term of ultrasound: the Date of the examination, the name of the prescribing doctor or Attending Physician, the identifi cation of the patient, the DDG, the ultrasonographic age, abnormalities jour restera une the conditions for carrying out the examination (good, average, bad) and the conclusions of the ultrasound.
Ultrasound Q1 “dating ultrasound”:
It must be programmed to 12 DDR SA After fertilization or if known. If the dating ultrasound is made before 11 SA must be Reprogrammed entre 11 and 14 weeks to measure nuchal translucency. The minutes must indicate indication of ultrasound Q1 the number of fetuses, fetal vitality (cardiac activity and fetal movements), measurements of craniocaudal length (LCC) and biparietal diameter (BIP), qui allow future assessment ± 4 days. Other measures May be added to two major thesis Measures (femur length, foot, cephalic circumference, abdominal circumference). The measurement of nuchal translucency associated with the measurement of the CCA provides information on the risk of chromosomal abnormality to offer prenatal diagnosis. The measurement of nuchal translucency is Necessarily Proposed (Table III). If the conditions do not permit the measure, it shoulds be Mentioned on the transcript. Finally the morphological study (Table IV) Allows early detection of some defects (anencephaly, omphalocele, polycystic kidney disease, dwarfism, major heart disease, agenesis member, etc.).
In case of multiple pregnancy ultrasound Q1 is crucial for the diagnosis of chorionicity (number of placentas and amniotic pockets) qui aussi must be indicated otherwise redo ultrasound quickly.
The finding shoulds give DDG Determined by ultrasound.
Nuchal translucency is pathological When It is above-the 95th percentile.
Ultrasound Q2 ‘morphology fetal anatomy “:
This is the MOST difficulty ultrasound, The Most qui requires concentration. For patients, it is finally Determined que la ultrasound fetal sex. The sensitivity of detection of fetal malformation is around 65%. A ‘normal’ examination is in no way Synonymous with ” . normal “child This ultrasound is scheduled to SA 22 and the carry `shall contenir the results of biometrics: BIP, head circumference, abdominal circumference, femur length (femur) with percentiles or standard deviations. For non-morphology visualization or incomplete visualization of the Following must be reported about: skull, Interhemispheric structures, ventricular system, posterior fossa, face (upper lip and profile), spine, stomach, bladder, heart (rent, Cavities oven, departure of the great arteries), kidney members (four members and three segments per member). If all thesis Elements are Properly displayed, it is Sufficient que la postponement Indicates That Was Demonstrated no abnormality in the terms of realization of the exam. Fetal vitality Was Evaluated by heart rate and movements.
The position and appearance of the placenta, the number of vessels in the umbilical cord and amniotic fluid shoulds be reported. Items marked not viewed as the 2nd and 3rd quarter are subject to review Subsequent gold clear explanation.
Ultrasound Q3: “Biometrics presentation placentation”:
It is made to SA 32 and AIMS to accomplish achieve a biometrics (BIP, head circumference and abdominal femur) to make the diagnosis and presentation indicate indication the position of the placenta (low inserted or not). This is an important component in Assessing the prognosis of delivery.
It aussi Allows control of anatomical structures Such as face, brain, heart and kidneys and Evaluating the amount of amniotic fluid.
Ultrasound of multiple pregnancy:
In case of multiple pregnancy icts kind of accuracy is essential When ultrasound Q1. The report must imperatively indicate indication the number of embryos, placentas, amniotic pockets (dichorionic twins, monochorionic, bi monoamniotic gold, triple …).
Morphological study and biometric monitoring of These pregnancies require at least a monthly ultrasound up to delivery.
Study of Doppler velocimetry:
The measurement of the Doppler Allows velocity of blood flow to the uterine arteries, umbilical and fetal brain. The uterine artery to measure maternal placental resistance slope, umbilical artery explored the fetal placental side resistance and cerebral arteries can detect cerebral vasodilatation. The uterine arteries full Their adaptation to the pregnancy from 24 weeks (trophoblast invasion leads to lower resistance and elasticity of the wall of the uterine artery).
So uterine arteries Will Be Explored After 24 weeks. Increasing the resistance of the umbilical arteries, is a marker of fetal distress. Conversely, the Reduced resistance of the cerebral arteries (vasodilation) shows an adaptation of fetal hypoxia (redistribution of fetal blood flow to the brain). The exploration of Doppler in obstetrics is Indicated for diseases associated with placental insufficiency (hypertension, growth retardation, intrauterine death, retro placental hematoma, multiple pregnancies).
Information on the limits of ultrasound is to be Delivered to obtenir patients to informed consent.
LINES TO BE KEPT UNDER THE EXAMINATION RESULTS BIOLOGICAL PRENATAL:
Two determinations in the ABO system, Rhesus and Kell phenotype full, are required.
If the patient Does not-have full blood group card (two determinations), the 1st determination will take up at the first prenatal examination and 2nd in the last CPN (8th or 9th month of pregnancy). A transfusion in a pregnant woman shoulds Besides compliance ABO blood group, Rh, Kell phenotype and group.
Of irregular antibodies Search:
About 15% of women are Rh negative.
RAI is required When the first prenatal examination.
In Rhesus negative women gold Previously transfused, RAI are repeated the 6th, 8th and 9th months of pregnancy.We will soon Rhesus-have a single technical research group by fetal maternal blood sample. If the search is positive, identification and titration of antibodies are required . Prevention of Rh immunization is ensured by the injection of anti-D gamma globulin Among Rh negative women Delivering an Rh-positive child or during an abortion, a miscarriage, ectopic pregnancy, a prenatal screening (amniocentesis, cordocentesis, CVS), a strapping , an external cephalic version of gold in case of bleeding During Pregnancy.
In practice, a standard intravenous dose of 100 mg Was injected anti-D in the 72 hours Following The potential risk of immunization.
A control Within 48 hours Ensures que la anti-D dose Was Sufficient.
In case of appearance of antibodies During Pregnancy (RAI +), you must Refer the patient to a Specialized Center for support with the assessment of the seriousness of the infringement based on antibody levels (weight dosage of anti-D) and a history. The transition of maternal antibodies through the placenta in fetal hemolytic anemia resulting and with risk of death in utero. May be Amniocentesis Indicated for Assessment to fetal hemolysis assessment bilirubin in the amniotic fluid. Ultrasound provides information on the criteria of fetal Suffering: thickness of the placenta, enlarged liver, edema, ascites and fetal hydrops fetal. In severe forms, the fetal blood sampling SPECIFIED the degree of anemia and is asking the indication of exchange transfusion in utero . Birth is Often triggered Shortly before term and continued monitoring in the new-born with , if Necessary, exchange transfusions ex utero .
Globular blood count:
It was made compulsory in 1992 During consideration of the 6th month of pregnancy to detect and treat maternal anemia. Treating iron deficiency from a hemoglobin level below 11 g / dL. The serum iron assay is not essential to start treatment except in cases of Suspected hemolytic anemia hemoglobinopathies (sickle cell disease, thalassemia).
Thrombocytopenia end of pregnancy Occur in 6-7% of cases (platelets <150 000 109 / L. In MOST cases it is transient thrombocytopenia associated with pregnancy without fetal repercussion. The platelet count n ‘is not compulsory goal is systematic if vasculorénales of pregnancy pathologies (HTA). A level of platelets in early pregnancy is Useful in Assessing the gravity of thrombocytopenia Discovered later. Before Any thrombocytopenia liver function tests be Abebooks web sites (GOT, GPT) looking for abnormal liver function Evoking HELLP syndrome ( Hemolysis, Elevated Liver Enzyme , Low Platelet ).
Screening for hemoglobinopathies:
The hemoglobin electrophoresis Performed in early pregnancy is Indicated When there is a risk with homozygous haemoglobinopathy: beta-thalassemia and sickle cell disease.
Assessing the risk of trisomy 21:
These tests (HT21, FRT21, triple test, double test) for detection of two-Thirds of trisomies 21, performing amniocentesis to 5% of pregnancies. They are only applicable After A PARTICULARLY enlightened information if one wants That patients do not risk and confused diagnosis of trisomy 21.
We must “Understand what is being white done to explain to patients.”
The risk of trisomy 21 is maternal age varies DEPENDING During Pregnancy:
– 500-20 1/2 years;
– 1/700 at age 28;
– 1/250 at age 38;
– 1/100 to 40 years;
– 1/50 to 42 years.
. Only Karyotyping fetal cells Allows to make the diagnosis The sampling fetal cells is an invasive procedure Involving the risk of miscarriage: for amniocentesis 1/250, 1/100 for puncture of fetal blood and 1/100 for puncture of chorionic villi. 38 years before we see there is more risk of iatrogenic false layer as risk of trisomy 21. This is why Social Security supports amniocentesis from 38 years. There is since 1995 maternal blood test for Assessment to the risk of trisomy 21 To Each specific pregnancy.
This test assesses risk based on serum levels of two or three hormones entre 14 and 18 SA: HCG ( Human Chorionic Gonadotropin .), alpha-fetoprotein, estriol This is a risk assessment and not a diagnosis, selects qui qui amniocentesis for pregnancies be offert . If the Assessed Risk is Higher Than That of amniocentesis (> 1/250), amniocentesis is lawful, Because there is more Likely to detect trisomy 21 because qui a miscarriage. Conversely, if the Assessed risk is lower Than That of amniocentesis (< 1/250) No offer amniocentesis. This Does not mean the lack of trisomy 21, the goal is too low risk Compared To That of amniocentesis.
If amniocentesis is Proposed (risk> 1/250) and accepted and it Reveals has trisomy 21, it will Then a medical abortion offers. The torque shoulds be aware That it remains in control at all stages and That it is not a test Because Says “Positive” is Obliged to proceed to the next step. The blood is entre 14 and 18, preferably around 16 SA SA, in Any laboratory responsible for That Is sending it to the approved laboratory. This examination is not mandatory goal shoulds be obligatorily offert to all pregnant women in early pregnancy entre 12 and 16 SA SA (after the ultrasound dating). Doctors and midwives Who recevoir consultation of pregnant women in early pregnancy (declaration of pregnancy) has-have legal obligation to propose and test before prescribing SA to 17 em enable to benefit from screening.
Information concernant the benefits and drawbacks of this test is obligatory (Decree of 6 May 1995), Who patients choose to make or not this review. If They agree, They must sign an official information sheet. If the torque Appears hesitant, we can advise a genetic counseling. If the test shows a high risk leading to an amniocentesis, it is supported by Then Medicare. The test results are sent to the prescriber to Avoid the stress of a misinterpretation of the results Directly read by patients. Women 38 and older can benefit from this test to guide Their decision amniocentesis. Regardless of the test results, They May request an amniocentesis for “maternal age” which will be reimbursed by Medicare.
In France, 5,000 pregnant women a year contract toxoplasmosis. The risk of placental transfer is very low in early pregnancy to be maximum term (5% in Q1, 20% in Q2 and> 50% in Q3). Fetal Reached, When It OCCURS , is all the more severe it OCCURS early in pregnancy: intracranial calcification cations, hydrocephalus, intrauterine growth restriction (IUGR), severe chorioretinitis … Finally pregnancy, fetal damage is less severe, Especially eye.Serological screening is a legal requirement When Establishing the prenuptial certificate and at the time of declaration of pregnancy.
Seronegative pregnant woman:
During pregnancy: serology in Q1 (declaration of pregnancy tests) and serological monitoring every month up to the end.
At birth: serology in the cord blood and maternal serology (seroconversion recent weeks).
Prevention through dietary and lifestyle tips:
– Do not eat raw meat, cook meat;
– Wash all fruits and vegetables before eating em;
– Thoroughly wash hands before eating, After handling raw meat, After HAVING HAD touch with gold cats Their litter.
Seroconversion During Pregnancy:
Prescribe time immediately without waiting for confirmation of Spiramycin (Rovamycine®) 9 MU / d or 3 cp / d (compressed to 3 MU).
Confirming the placental transfer of toxoplasma in amniotic fluid by amniocentesis to make at least four weeks After seroconversion in an obstetric unit.
Seroconversion before 30 SA:
Negative prenatal diagnosis: lack of toxoplasma in amniotic fluid and lack of sonographic sign of fetal impairment.
“Preventive” treatment up to delivery by Rovamycine®: 9 MU / day.
Positive prenatal diagnosis: the presence of toxoplasma in amniotic fluid and no sonographic signs of fetal impairment.
Treatment “curative” until delivery by pyrimethamine (Malocid®) + sulfadiazine (Adiazine®) sulfadoxine-pyrimethamine gold (Fansidar) + folic acid + hydration + Rovamycine® continued in association.
Seroconversion After 30 weeks:
The risk of placental transfer is high, prescribe a “curative” treatment time immediately without waiting for confirmation of placental transfer.
Neonatal assessment is systematic whatever the results of the amniocentesis. The balance includes a neonatal ultrasound and serology transfontanellar a fundus newborn.
In the newborn:
If neonatal serology is negative: no treatment, the parents can be reassured.
If neonatal serology is positive. Curative treatment During the first year of life pyrimethamine (Malocid®) + sulfadiazine (Adiazine®) sulfadoxine pyrimethamine-gold (Fansidar).
Positive status as of 1 withdrawal During Pregnancy:
Search results toxoplasma serology made During the prenuptial certificate gold During a previous pregnancy. No risk if there is a positive toxoplasmosis serology before this pregnancy.
Make 2nd serology three weeks partner after the 1st positive serology:
– If the IgG Increased Significantly: recent toxoplasmosis; if IgG is steady: Contamination> 2 months before the first collection;
– If the 1st serology is made beyond 2 months of pregnancy can not be excluded seroconverted During early pregnancy.
The presence of IgM is no longer Synonymous with recent primary infection. With sensitive detection methods can persist IgM-have a year or more. This position shoulds no difficulty along exist if the pregnancy is Followed From The Beginning.
If ultrasound abnormalities associated with seroconversion:
If intracerebral calcification or dilation of the cerebral Ventricles, medical termination of pregnancy is offert to parents.In case of Refusal, treatment (+ Adiazine® Malocid®, or Fansidar) Will Be Established at high doses.
– Adiazine®: 50 to 80 mg / kg / day;
– Malocid®: 0.5 to 1 mg / kg / day;
– Rovamycine®: 9 MU / day.
Rubella, mild infection in early childhood, Was the first infectious disease reconnu as responsible for embryofetopathy (1941). The discovery of the vaccine (1969) and vaccination campaigns-have resulted in a considerable Decrease in the frequency of congenital rubella.
. Maternofetal transmission is through blood-placenta During maternal viremia The risk of fetal infection is maximum at the Beginning and at the end of pregnancy. Birth defects are more frequent and severe OCCURS When infection early in pregnancy: patent ductus arteriosus, pulmonary artery hypoplasia, deafness (impairment of the inner ear), cataract, retinopathy, microphthalmia, Central nervous system damage …
Infections or re-screening rubella infections in pregnancy:
With Each pregnancy, irrespective of the HIV status of the patient (Rubella – Rubella + Vaccinated), you-have to rubella serology in early pregnancy.
If “negative rubella” remake serology monthly up to 20 weeks. After 16 SA the risk of congenital rubella is Almost nil.After 20 weeks, make a serology Easily and Consistently When concept of contagion (rash and / or diagnosis of rubella in the entourage of the patient …), or before kindergarten Any rash. Systematic maternal immunization After delivery.
If “positive rubella before pregnancy” or “Vaccinated”. A systematic serology for Assessment in early pregnancy to the “level of immunity” of the patient If the IgG is positive or weakly negative Become The patient will be regarded as “negative rubella” and (re) vaccinate the patient After delivery.
If the IgG is positive Normally, not do UNLESS maternal serology in search of a rash can re-infection (rise of IgG, IgM ± reappearance). If the IgG is positive Strongly, Suggesting year Ongoing re-infection and repeat serology 15 days apart (in the same laboratory) for Assessment to the kinetics of IgG.
Prenatal diagnosis of congenital rubella infection is Indicated if maternal infection OCCURS in a period of risk for the fetus.
A peri-conceptional infection Does not sccm due to fetal consequences.
Beyond SA 18 the risk of fetal abnormalities are invasive prenatal Virtually zero and diagnosis is not profitable. Fetal infection before 12 SA is the Chat IMG year, Given the frequency and severity of fetal consequences to this term. The alternative is a Careful ultrasonographic monitoring. Infections entre 12 and 18 SA can hearing sequelae because of varying, degree, usually appareillables. When continuation of the pregnancy is planned, Will Be Sought in the new-born virus in nasopharyngeal secretions for several months. There is no active antiviral therapy against rubella.
The only treatment is a good prevention through vaccination. After delivery it is imperative to Routinely vaccinating all seronegative or weakly seropositive patients for rubella. For better adherence, vaccination Rudivax® this is done During hospitalization in maternity layer sequence. When used in combination with anti -D gamma globulin (prevention of anti-Rhesus immunization), make a rubella serology three months later for Assessment to the levels of IgG antibodies and if the spleen is insuffi health or negative Rudivax® must redo has vaccinia (theoretical risk of inefficiency in Rudivax® combination with anti-D). The vaccine in women of childbearing age is against-Indicated During Pregnancy (first trimester) and must be accompagné by a contraception for 3 months. HOWEVER in case of vaccination in early unrecognized pregnancy, placental transfer while possible, HAS never led to embryo-fetopathy (Center for Disease Control of 296 women Vaccinated During Pregnancy).
This is not an indication of systematic termination of pregnancy. Similarly, the postpartum vaccination is not against-Indicated During lactation Because Even Transmitted, the attenuated virus is not pathogenic for newborn.
Serological screening remains mandatory 1st trimester of pregnancy ALTHOUGH it is removed from the pre-marital counseling. The main risk is secondary to congenital syphilis transplacental fetal infection through blood After 16 SA (placental transfer from SA 16). The risk of maternal-fetal transmission Estimated to be entre is 30 to 60% in the lack of treatment. Treatment before the 4th month Avoids Any risk of fetal impairment. In the lack of treatment Or When treatment starts After 16 SA can Treponema causes a late abortion or premature labor. Perinatal mortality is 40% in pregnant women with early Untreated syphilis and 20% in the case of late syphilis (late pregnancy) Untreated.Congenital syphilis can be or latent Expressed by poly-organ damage, mucocutaneous lesions with palmoplantar pemphigus, syphilitic, hepatomegaly, meningeal involvement or bone lesions. For the mother, pregnancy Does not alter the symptoms of syphilis.
Two different serological tests shoulds be used for this screening: the nonspecific VDRL and l’autre with a specific treponemal kind TPHA antigen. These two tests can Distinguish in MOST cases serological scars of recent contamination Requiring immediate treatment:
– VDRL – and TPHA -: no syphilis, except in very recent contamination. Interest of abs-FTA with IgM if recent contagion doubt;
– VDRL and TPHA + +: in the lack of clinical signs or history of syphilis is the quantitative value of the two tests to estimate the course of infection;
– VDRL and TPHA + -: false positive (virus disease, non-syphilitic trépanomatoses, antiphospholipid syndrome);
– VDRL – and TPHA + Serological scar or incipient syphilis.
Congenital syphilis is Diagnosed in utero to the combination of a positive syphilis serology associated with ultrasound pictures of Hepato splenomegaly.
In practice it is Easily Treated (by excess) in Patients Suspected cases of syphilis.
MU Extencilline® 2.4 ounce daily (1.2 MU intramuscularly into Each buttock) to renew 8 days later. We will make two procedures During Pregnancy, the 1st and 2nd Rapidly at the end of the sixth month. In case of allergy to penicillin, erythromycin is used. 2 g / day in 4 doses of 500 mg 1 tab for 30 days It is feasible to use Equally Reviews another effective treatment protocol intended more tedious hospitalization for patients to follow difficulty: Biclinocilline®, 1 MU / day for 15 days.
At birth, neonatal Reached, it will be processed, is Sought with a pathological examination of the placenta and serology (FTA-abs, searchable IgM) in the cord blood.
The newborn infected with hepatitis B, Vertically Transmitted During childbirth, a high risk of progression to chronic hepatitis and Its complications (cirrhosis, hepatocellular carcinoma). If again, the mother caries the HBe antigen, the risk of transmission is 90% against 20% if the mother is not. It is Necessary to detect The Therefore chronic carriers is essential. About 1% of women are infected at birth. The immediate surroundings of a chronic carrier of HBsAg woman (previous child, husband) shoulds benefit from vaccination, After checking the sero-negativity.
The legislation requires establishments engaged in deliveries, to-have Constantly doses of vaccine against the virus of hepatitis B and hepatitis B immunoglobulin (Ig antiHB) for newborns. The decree of 14 February 1992 Provides for obligatory screening for HBs antigen (HBsAg) During the prenatal examination of the 6th month of pregnancy in France and recommends vaccination associated with Ig antiHB newborns of carrier mothers the HBsAg at birth.
If HBsAg + pregnant woman at the 6th month of pregnancy:
Treat newborns at birth with an intramuscular specific anti-HBs immunoglobulins before 12 hours After Birth and one injection of vaccinia Within 48 hours of life (at the site of injection to different Ig). A second injection one month apart vaccine and a booster (3rd injection ) in a full year the vaccination program newborn surrogate mother HBsAg.Current prophylaxis Reduces the risk of transmission of more than 90%.
HBsAg shoulds be absolutely detected before birth (mandatory in the 6th month of pregnancy in France). If testing of the 6th month Was omitted, it is imperative to seek HBsAg partner after the 6th month of pregnancy or childbirth During.
If no screening HBs the day of delivery:
The newborn Receives the first vaccination in doubt maternal HBsAg positivity. If the mother finally turns negative for HBsAg, vaccination of the baby goes through the normal program of children born to mothers negative. If the mother is positive for HBsAg, the administration of Ig antiHB Can Be Made Within 48 hours of birth, the full vaccination shoulds goal in all cases be completed (two vaccine injections one month and one year).
Cesarean section Does not Provide protection against vertical transmission.
In the postpartum period, breast milk HBsAg passes into goal breastfeeding is not cons-Indicated Provided the newborn at birth is Vaccinated, Respecting the rules of hygiene and in the lack of nipple lesions. Acute hepatitis B is one of 26 notifiable diseases.
The law requires the doctor to offer the HIV serostatus to all women in early pregnancy. The woman remains free After Informing refuse screening. It remains highly desirable Because It is a preventive treatment of risk of fetal contamination During Pregnancy. In case of pregnancy in HIV -positive women for HIV, has Multidisciplinary approach (obstetrician, infectious disease specialist, psychologist) Will Be Established in hospitals. Treatment is Discussed selon the immune deficiency. Monitoring of CD4, viral load of transaminases, NFS, in addition to classical monitoring of pregnancy. Infectious diseases are associated Systematically searched (hepatitis, herpes, genital warts, syphilis, CMV, tuberculosis, etc.). Invasive procedures are prohibited. The recommended route of delivery is cesarean section to Reduce the risk of transmission to the newborn.
The incidence of neonatal group B streptococcal infections is Estimated at 1.5% of pregnancies, They Are sepsis and / or lung infections.
Strep B screening of carry During Pregnancy: Given the frequency of asymptomatic carriage vaginal and severity of neonatal GBS infection, Many obstetric teams perform routine screening in late pregnancy entre 34 and 37 weeks. If the search is positive GBS antibiotic prophylaxis will be made During work gold at the opening of the egg (2 g intravenously Amoxicilline®, Then 1 g / 4 hours intravenously) for the duration of the work up to expulsion. In case of allergy to penicillin and erythromycin are used.
We do not treat vaginal colonization with group B streptococcus During Pregnancy.
Uncertainties diagnosis and prognosis of severe Difficulties fetal CMV infection led the CNGOF editing vis-à-vis the CMV During Pregnancy recommendations.
The recommended Preventive measures are information on preventive hygiene rules to all pregnant women (Box 7).
Box 7. Hygienic preparation for all pregnant women
Many bacteria or virus germs are harmless for adults goal Represent a risk to the fetus During Pregnancy. It is imperative During Pregnancy The Therefore to be more vigilant and to follow some hygiene rules qui are specified below.
These . rules apply to all pregnant women Regardless of Their serology results
Wash hands frequently Especially: before eating, to bring ’em to your mouth After handling Any Potentially infectious (land, food, animals, bedding, toilets etc.).
Be careful to PARTICULARLY Food . hygiene for all uncooked foods
Thoroughly Wash all fruits and vegetables before eating.
Avoid eating raw meat.
If you are in touch with a small child, Often asymptomatic carriers of germs in saliva and urine, Either yours or not: Do not use for yourself meals utensils. Refrain from “taste” bottles gold Spoonfuls of food, sucking His pacifier. Do not use Their toiletries (glove, towel, toothbrush) That must be it personal. Avoid kissing on the mouth. Wash your hands Thoroughly After Each change.
Precautions aussi apply if you are professionally in touch with one or more young children.
These precautions are valid until delivery.
We do not offer mass screening serology gold Targeted screening in pregnant women.
Similarly it is not Proposed preventive work stoppage in cases of “profession CMV at risk” (nursery nurses, crèches, etc.).
A patient making the request serological testing for CMV During Pregnancy, shoulds be Informed of the CNGOF recommendations (Box 8). If it Persists in icts desire, do it at May icts own expense CMV serology convenience, interpretation is not provided by obstetricians.
The CMV serology is Indicated only if there are signs of ultrasound calls as share of a workup (ventricular dilatation, IUGR, polyhydramnios, etc.) or maternal infections, fever, flu syndrome, etc. .
Box 8. CNGOF Press release (May 2002)
Should we screen for CMV During Pregnancy?
CMV is a common virus causes minor infections That in adults. HOWEVER, During Pregnancy, CMV infection can cause has child’s achievement and be responsible for serious sequelae Sometimes ( deafness, sensory disturbances …) A Few boxes in order. There is no vaccine against CMV Currently. The only feasible measure to Avoid being white infected with this virus are hygienic precautions, ALTHOUGH Certainly not prevent prevention contamination. Some women are more exposed than others to the risk of CMV infection: Those with young children, Especially Kept in Communities (nurseries) and Those Who Work From ’em. Recently, a group of experts with the CMV lancé holder of a pharmaceutical laboratory, an information campaign Suggesting the need to Systematically . CMV serology achieve achievement for all pregnant women The rationale for this screening serology Was That Would reassure Nearly half of em. Such an attitude of systematic screening Has No epidemiological studies HAS benefit Currently available. She About did, HOWEVER, Many perverse effects
– anxiety Many pregnant women with negative serology (about 50% of women);
– anxiety Even stronger Among Those Who are positive IgM antibodies (IgM General to testify recent goal infection May persist for several months or Even Years After infection)
– multiplication of additional tests (repeat bioassays, multiplication antenatal ultrasound, amniocentesis performing with a risk of miscarriage …)
-. That you can fear routine screening Would Inevitably lead to requests for abortions in single doubt situations
The CNGOF considers That in the current state of knowledge, a systematic screening policy CMV During Pregnancy n ‘is not Justified by proven benefits and probably Would Have harmful consequences. Decisions were systematic screening policy must be better Evaluated Implemented before being white. It is up to the competent autorités under the Ministry of Health, to decide the Merits Such a policy of.
CONDITIONS OF 1ST QUARTER:
Before all of Q1 or bleeding in the reproductive age woman Who May Become pregnant must be a β-HCG dosage and a pelvic ultrasound in emergency. The first diagnosis is Feared to Eliminate ectopic pregnancy. Other diagnoses include abortion or miscarriage threatened This (being white gold Expelled deported or arrested This gold blighted ovum), hydatidiform mole, the Ongoing pregnancy with detachment of the trophoblast or functional bleeding of early pregnancy. This is the β-HCG couple + That Allows ultrasound diagnosis, Sometimes After A Few days ambulatory monitoring (rarely more than 10) by the same obstetrics gynecology department.
The ectopic pregnancy is Treated in a specialized hospital is medically with methotrexate injections Either Surgically by laparoscopy MOST Often (salpingotomy or salpingectomy). The spontaneous Miscarriages are Treated Either by curettage or medically by Methergin® sidestream.
The molar pregnancy requires curettage high bleeding risk and monitoring the decay of beta-HCG up negativity Followed By a pulmonary monitoring (risk of metastasis) of at least one year qui During pregnancy is prohibited. The on-going pregnancy bleeding Can Be Treated with rest associated with natural progesterone vaginally or Orally.
These “little sympathetic pregnancy evils” can Become pathological with intractable vomiting of early pregnancy ultrasound and require That laboratory workup. Ultrasound can Eliminate a molar pregnancy or multiple pregnancy.
A chemistry panel assesses the severity of hypokalemia. Thyroid function tests is readily Applied. Frequently we note moderate elevation of liver transaminases without consequence. Symptomatic treatments are allowed (Primperan®).Hospitalization May be Necessary if significant weight loss or serious electrolyte disturbances.
CONDITIONS OF E 2 AND 3 ND QUARTER:
The threat of premature birth (MAP) is the diagnosis of the MOST common emergency During Pregnancy. We define the boundary entre childbirth and abortion from 22 weeks or 500 g birth weight. Neonatal viability is Acquired to 24 weeks and neonatal maturity (term) to . 37SA is Prematurity The Therefore entre 24 and 37 SA SA. We define three kinds of prematurity:
– Extreme prematurity before 29 SA;
– Extreme prematurity before 33 weeks;
– The mean prematurity entre 34 and 37 weeks.
The prevalence of preterm birth in France is about 5%.
The prematurity risk factors are premature rupture of membranes, multiple pregnancy, polyhydramnios, malformations of the uterus, incompetent cervix, DES syndrome (Distilbène®), history of premature delivery or abortion of the second quarter, maternal fever bacterial (urinary infection, listeriosis) or viral (flu), vaginal infections, placenta previa, placental abruption, vaginal bleeding, lower socio-economic level …
Often no risk factors is found.
The diagnosis of MAP is not always easy.
The classic clinical presentation of uterine contractions associated with a change in the cervix.
The interrogation can characterize uterine contractions as the uterus generalized hardening and intermittent lasting 30 to 60 seconds, separated by free intervals. It must specify the type (cramp, colic), frequency, regularity, and evolution.
Are in favor of MAP frequent and regular contractions (every 5 to 15 minutes), more or less painful (pain may radiate forward and backwards in the loins). A notion of premature rupture of membranes Wanted by the interrogation with a vulvar flow more or less honest, not always accompanied by uterine contractions and usually followed childbirth in fairly short time with the risk of maternal-fetal infection (neonatal prognosis ).
The interrogation eliminates differential diagnoses that are the ligament pain syndrome (Lacomme) and “physiological” contractions end of pregnancy.
The ligament pain are characterized by feelings of tugging and pulling down, centered on the pubis and femoral arcades. They are rude, stubborn, continuous (without free interval), unilateral or bilateral, mechanical, caused by walking, standing or sitting position and weight of the uterus. They are relieved by resting lying or sitting position analgesic. They can be associated to real or cause the uterine contractions. The physiological uterine contractions Q3 do not exceed 10 / day, especially prevalent at night and are favored by the effort and fatigue. They have no tendency to aggravation and without cervical change.
The vaginal examination can appreciate cervical characteristics (from normal to pathological):
– The length (2-3 cm, shortened by 30%, 50%, 80%, deleted);
– Consistency (toned, firm, soft);
– The position (posterior centrable, centered);
– The expansion of the external orifice (EO) and the internal os (IO) (OE closed, dehiscent = open OE and closed OI, OI open: pulp, one finger, two fingers wide = 3 cm from 2 fingers we talk cm dilation);
– The presentation of height (uncollected, Mobile High, applied, attached, bass);
– The amplification of the lower segment (SI) (no SI, SI amplié thick, IF amplié end).
The membranes are sometimes seen on the presentation if the cervix is open. Normally the cervix is long hind closed firm.
In primiparous collar begins by shortening before opening. In multiparous (birth vaginally) it opens early at the external os before losing the length in order to pregnancy. The most important characteristics are: the opening of the internal os, the shortening of the cervix and the height of the presentation.
Speculum examination should precede vaginal examination. It allows to visualize the cervix and possibly the intact membranes if cervical dilation is important. It is essential in a premature rupture of membranes to view and sample the amniotic fluid or washed note the appearance of the vaginal walls. It allows the realization of systematic vaginal samples in the balance sheet of a MAP.
The suspicion of premature rupture of membranes (vulva flow ± franc) must in an emergency in motherhood.Physical examination (speculum and vaginal) is cons-indicated (risk of infection), it will eventually be done in hospitals if the patient strongly contracts (diagnostic work).
What to do (Box 9):
The town doctor facing a severe MAP (open neck, frequent and painful uterine contractions or premature rupture of membranes) must promptly refer the patient in the maternity supporting childbirth or maternity to a suitable level. A corticosteroid treatment (or Célestene® Soludécadron®) deep intramuscular or subcutaneous emergencies can be started from 25 SA. Tocolytic therapy 1-2 Salbumol® suppositories can help soothe uterine contractions while waiting to emergencies.
Box 9. What to do before a suspicion of MAP in city
Go to obstetric emergencies without vaginal examination if suspicion of premature rupture of membranes
Corticosteroids to accelerate fetal lung maturation
Célestène Chronodose®: 12 mg (2 vials of 6 mg) in deep sub-cutaneous repeated once 24 hours later, 12 mg daily for 2 days between 24 and 34 weeks
Transfer in utero () to a level suitable for maternity gestational age:
– To level 3 (with neonatal resuscitation and mechanical ventilation) between 26 and 32 SA
– To Level 2 (with premature service without ventilatory support) between 32 and 36 SA
Tocolysis to begin in town awaiting transfer to motherhood: 1-2 Salbumol® rectal suppositories.
Antibiotics will be started after the samples taken in the emergency
After the initial hospitalization, it includes first the quiescence that can go from a reduction in activity (work) to hospitalization or home care (children in the household). The pursuit of a tocolytic treatment or antibiotic therapy is discussed during the initial hospitalization. Corticosteroid treatment is systematic between 24 and 34 weeks. It significantly improves neonatal prognosis for premature birth. We must insist on prevention through screening for risk factors at the first consultation, information for pregnant women on the signs of appeal which incite to consult and transfer the mother to a level of maternity adapted at the end of pregnancy.
HTA and pregnancy:
Hypertension in pregnancy, preeclampsia, eclampsia, preeclampsia, postpartum eclampsia, HELLP syndrome, nephropathy of pregnancy and vascular IUGR are all different manifestations of vasculorénaux syndromes of pregnancy. The definition of hypertensive disorders occurring during pregnancy leads to distinguish several types of attacks.
Hypertension in pregnancy associated hypertension (SBP ≥ 140 mmHg and / or DBP ≥ 90 mmHg) appeared isolated after 20 SA in a woman previously normotensive, without proteinuria (PU).
Preeclampsia and gestational hypertension associated with proteinuria (PU> 300 mg / L or PU> ++ or PU> 500 mg / 24 hours). The PU can initially be missed but it is permissible to suspect preeclampsia before a de novo hypertension associated with one or other of the following signs: edema of sudden onset or rapidly aggravated, thrombocytopenia <150,000 / mm3, serum uric acid> 360 mmol / L (60 mg / L), elevated liver enzymes (increased transaminases), IUGR. Severe preeclampsia is defined either by a significant hypertension (SBP ≥ 160 mmHg and / or DBP ≥ 110 mmHg) or gestational hypertension with one or more of the following: epigastric pain, nausea, vomiting, persistent headache, deep tendon hyperreflexia, unrest visual, proteinuria> 3.5 g / day, creatinine> 100 umol / L, oliguria <20 mL / H, hemolysis, elevated liver enzymes, thrombocytopenia <100,000 / mm3. Chronic hypertension is prior to pregnancy.
It is sometimes misunderstood and should be suspected when hypertension is discovered before 20 SA.
The diagnosis of hypertension during pregnancy based on DBP> 90 mmHg and / or SBP> 140 mmHg measured twice at rest. The moderate hypertension were confirmed by automatic recording of blood pressure or the realization of a Holter ambulatory blood pressure to eliminate stress hypertension or hypertension “labile” or “nervous”. A cuff adapted to the arm of obese patients is sometimes necessary.
Signs of severity:
The functional symptoms of hypertension are serious signs to look for: headache, tinnitus, phosphenes, vivid deep tendon reflexes, epigastric pain, vomiting, edema of the lower extremities and / or superiors, face edema. The presence of edema is common during a normal pregnancy but a quick and brutal weight gain generally occurs in women who will develop preeclampsia.
The biological signs of hypertension are serious signs that may lead to the termination of pregnancy:
– Early increase in serum uric acid (> 60 mg / L) or elevation of more than 30 mg uric acid;
– Significant proteinuria;
– Unusual renal failure, mainly in patients with severe disease with disseminated intravascular coagulation;
– T hrombopénie and elevated liver enzymes (HELLP).
The complications of preeclampsia in the absence of treatment are: prematurity, neonatal death, severe preeclampsia, eclampsia (defined as the occurrence of seizures) and maternal mortality.
Incidence and risk factors:
Preeclampsia is observed in 3-4% of pregnancies. The incidence of preeclampsia in a second pregnancy less than 1% in women who have a first normal pregnancy against 5-7% in women who have already developed preeclampsia.
There are various risk factors:
– Genetic: a history of pre-eclampsia in the mother or sister are increasing the incidence of a factor of 3 to 5;
– Immunological: primiparity, the brief period of prior exposure to the semen of the father, donor insemination;
– Physiological: mothers aged under 20 or over 35 years;
– Environmental: altitude in life, physical and psychological stress, the controversial ± tobacco;
– Related to maternal conditions: obesity, diabetes, insulin resistance, the thrombophilia, autoimmune diseases, hypertension and chronic kidney disease;
– Related to pregnancy: a long interval between pregnancies, multiple pregnancy, birth or chromosomal abnormalities of the fetus, fetal hydrops …
Several therapeutic classes can be used during pregnancy with hypertension.
Antihypertensive treatments have gained marketing authorization for the treatment of preeclampsia. This is clonidine (Dixarit®) centrally acting antihypertensive; nicardipine (Loxen®) calcium channel blocker; labetalol (Trandate®) alpha and beta blocker. Methyldopa (Aldomet ®) Central action and beta-blockers with sympathomimetic activity (pure beta blockers may increase fetal vascular resistance with a consequent risk of fetal growth retardation) is still used against chronic hypertension.
The Eupressyl®, arterial vasodilator, is used in second-line in combination with one of the four cited above.
Are cons-indicated during pregnancy diuretics, angiotensin converting enzyme and diet without salt. To the extent that preeclampsia is associated with hypovolemia, use of diuretics is against-indicated because of the risk of worsening uteroplacental ischemia.
Anticonvulsant treatment (benzodiazepines) are used in the curative treatment of seizure by slow intravenous.Magnesium sulfate is for the prevention of recurrence of the seizure and must be administered in intensive care.
Combination with calcium channel blockers is against-indicated (heart risk).
The antiplatelet therapy with aspirin is used in low doses (100 mg / d) as a preventive treatment for complications of hypertension during pregnancy.
Inhibition of breastfeeding by postpartum bromocriptine is cons-indicated in patients with severe hypertension during pregnancy. Breastfeeding is possible with Népressol® and Loxen®.
What to do:
The antihypertensive medical treatment has very limited influence on the evolution of pregnancy.
The only real treatment is the termination of pregnancy. The objective is to assess the severity of hypertension to distinguish: Mild or moderate forms which allow ambulatory monitoring until 9th month, followed by a discussion on labor induction at the beginning of the 9th month (at best collegial and multidisciplinary manner); Severe forms that require immediate hospitalization and fetal extraction in the short term, usually by cesarean section. The use of specialized environment monitoring should be systematic and early to initially assess the severity of hypertension and discuss preventive aspirin therapy that must be started around 14 weeks. Subsequently, in patients with moderate hypertension, surveillance could be organized between doctor and obstetricians.
Monitoring moderate hypertension (Box 10) during pregnancy requires at least a monthly consultation with clinical research and biological signs of severity. Clinical and laboratory tests monitoring will add a uterine artery Doppler to 24 SA (predictive of severity of hypertension during pregnancy).
Box 10. moderate hypertension monitoring Review
Clinic: research of functional signs of hypertension (phosphenes, tinnitus, headache, edema, vomiting), measurement of blood pressure, possibly Holter, weight (edema), height (IUGR), fetal vitality (active movements).
Biological, in addition to conventional examinations CPN: NFS, platelets, transaminases, serum uric acid, sample on proteinuria.
Ultrasound: fetal biometry (IUGR), uterine artery Doppler at 24 weeks, amniotic fluid (oligohydramnios), placental appearance.
Three complications to know: HELLP syndrome, placental abruption and eclampsia.
It is defined by the coexistence of Hemolysis ( Hemolysis ), hepatic cytolysis ( Elevated Liver Enzyme ) and thrombocytopenia ( low platelet ). It is a complication of preeclampsia That Threatens Both mother and fetus. The diagnosis is organic (hemolysis, cytolysis, thrombocytopenia) with digestive clinical signs Sometimes (hepatic pain, vomiting, epigastric pain). The management of a patient with HELLP syndrome can be envisaged as a structure for children’s resuscitation (risk of prematurity) and mother (risk of liver failure, subcapsular hematoma liver or liver failure). The treatment of HELLP syndrome is the termination of pregnancy, caesarean or vaginal delivery as considers. The evolution is usually full to healing in days after stopping pregnancy. Corticosteroids fetal maturation shoulds be started as soon as the diagnosis is Suspected.
It complicates 3-5% of severe preeclampsia.
It is placental abruption a (placental infarction) of sudden onset and usually unpredictable (thunderbolt from a clear sky), the clinical symptoms is misleading: isolated bleeding, painful uterine contraction, push of hypertension. The extremely urgent need cesarean Reduces perinatal mortality in bruises retroplacental with living child. The vaginal delivery is recommended in the dead child with bruises retroplacental After correcting of hemorrhagic shock, abnormalities of haemostasis and uterine atony.
It’s a seizure Occurring in a context of Hypertension During Pregnancy. It requires a cure for emergency crisis by injecting a slow intravenous benzodiazepines (Valium or 1 bulb of Rivotil®) to renew if recidivism associated transportation (UAS) extremely urgently to the hospital MOST close with a obstetrics and maternal resuscitation. In MOST cases the termination of pregnancy is made by emergency Caesarean section.
For Subsequent pregnancies:
An antecedent pregnancy-induced hypertension or preeclampsia may recur, usually was comparable fashion.Severe history (placental abruption, preeclampsia, death in utero …) fears a similar event. There shoulds be an early treatment by a specialist, with enhanced monitoring uterine Doppler as early as 5 months (May uterine Doppler alterations preceded the onset of several weeks of hypertension and IUGR), a preventive treatment with aspirin ® low dose (but limited proven effectiveness) 100 mg / day for 14 weeks (or Even Earlier) up to 34 weeks.
In this period of pregnancy, any breakthrough bleeding, HOWEVER May be it small, must lead to immediate hospitalization. Reviews The most serious causes include placenta previa and placental abruption.
Clinical examination is not contributory and shoulds not delay the transfer to the nearest ‘maternity. Obstetric care in emergency depends on the vitality fetal and maternal bleeding disorders. The emergency cesarean section for fetal backup is the treatment of placental abruption with living child. In case of fetal death cesarean section May be Indicated for maternal backup before the onset of bleeding disorders.
For placenta previa, vaginal examination is against-Indicated (risk of cataclysmic hemorrhage), the key consideration is the ultrasound. Transportation must be done with intravenous access. There is no specific treatment, rest and fetal extraction Otherwise in case of bleeding Endangering the health of the mother.
Gestational diabetes, the prevalence is 5%, May be associated with maternal and fetal complications: death in utero, pregnancy-induced hypertension, macrosomia, shoulder dystocia, cesarean; . respiratory distress and neonatal metabolic complications In the long term the Children are at Greater risk of obesity, cardiovascular disease and non-insulin dependent diabetes.
Diagnosing gestational diabetes early detection Allows a large part of future non-insulin dependent diabetes (Box 11).
Box 11. Tests screening for gestational diabetes
Load Test O’Sullivan (50 g)
Between 24 and 28 During prenatal assessment of the 6th month.
venous blood glucose one hour After ingestion of 50 g glucose.
Positive test: glycaemia> 1.30 g / L (7.2 mmol / L).
Hyperglycemia-induced oral (OGTT 100 g)
Fasting glucose H0, ingestion of 100 g of glucose and glucose levels H0 H1, H2, H3, at rest.
Standards: H0 <0.90 g / L; H1 <1.80 g / L; H2 <1.55 g / L; H3 <1.40 g / L
glucose: 8 hours fasting; 10:00 postprandial
H2; preprandial 12 hours; 14 hours postprandial
H2; 16 hours before snack.
Standards : fasting <0.90 g / L; preprandial <0.90 g / L; 2 hours postprandial <1.20 g / L
Testing by the O’Sullivan test entre 24 and 28 is for all pregnant women, Including Those without factoring risk.
In case of positive screening, it shoulds make the diagnostic test (oral glucose tolerance) 100 g OGTT as soon as possible. If O’Sullivan test is Greater Than 2 g / L (11.1 mmol), the diagnosis of gestational diabetes is made and Does not require a OGTT.
The diagnosis of gestational diabetes leads to the realization of a cycle That Allows glucose to tailor treatment based on blood glucose in normal living condition (without carbohydrate load). The glycemic cycle is MOST Often Performed During a day hospitalization in a Specialized Environment, Allowing to Educate patients in self monitoring and dietetics.
Whatever treatment (with or without single diet insulin) Monitoring is Introduced in a combination Specialized obstetricians, diabetologists and Dieticians at a frequency entre 1 / week 1 / month. The goal of treatment is to accomplish achieve normal blood sugar levels Throughout the day: fasting < 0.95 g / L (5.3 mmol), postprandial blood glucose 2 hours After Each meal <1.20 g / L (6.7 mmol). Treatment shoulds always include a dietary prescription tailored After dietary survey, based on the principles Following: at least 1,800 Kcal / day, 50% of carbohydrates in three meals and three snacks.
Insulin treatment in case of necessity must be
Established without delay if fasting glucose DURING THE OGTT is Greater Than 1.30 g / L (7.2 mmol) or After 1 to 2 weeks (DEPENDING on the term) of suitable dietary diet, if glucose levels are fasting Greater Than 0.95 g / L (5.3 mmol) and / or if the Measured glucose levels 2 hours After a meal are Greater Than 1.20 g / L (6.7 mmol).
It is desirable to Maintain the average of all blood glucose profiles below 1.05 g / L (5.8 mmol). Insulin is a rapid injection of insulin before Each meal postprandial blood glucose if the are high and intermediate-acting insulin injection at dinner or bedtime, wake up if blood glucose is high. The interest of a systematic insulin therapy, Regardless of the glycemic level is not Demonstrated.
Monitoring is Focused on glycemic control and the occurrence of complications.
Obstetrical ultrasound appreciate the growth, morphology and vitality of the fetus is poor goal for the diagnosis of macrosomia.
The preterm delivery is not indicated UNLESS complications (preeclampsia, IUGR, abnormal fetal vitality).Caesarean section immediately All to gestational diabetes is not Justified (no neonatal benefit, Increased maternal morbidity). The delivery route will depend on the foetopelvienne confrontation. When the bass track is accepted, the recommendations for the delivery of a macrosomic are similar to Those of the breech delivery: epidural analgesia;Good momentum of work; obstetrician and anesthesiologist on site (in need of difficulty obstetric procedures).
Fever and pregnancy:
Fever in a pregnant woman is never trivial, for ict risk of prematurity and maternal-fetal infection Involving the prognosis of pregnancy and newborn. Maternal temperature Above 38 ° C must consult the emergency of motherhood to make it an etiologic and evaluate-fetal repercussions.
What to do:
Antibiotics (penicillin A) is started without waiting for very Quickly the results of bacteriological samples: Urine culture, vaginal swab, and blood cultures Possibly if the temperature is Above 38 ° C or in the presence of signs of sepsis (chills, general alteration provided , shock, skin lesions). Serology is requested Systematically gold as the context: toxoplasmosis, rubella, syphilis, hepatitis A, B and C, cytomegalovirus, herpes, parvovirus B19. An NFS and the measurements of C-reactive protein complement the balance sheet . The sedimentation rate is Unnecessary.DEPENDING on the context in blood smear, thick drop or intradermal are requested.
The full gestational balance the etiological, uterine contractions and cervical looking exchanges. Fetal assessment includes a recording of fetal heart rate if the term Exceeds 26 SA (heart sounds before 26 SA) and Doppler ultrasound ± ± score Manning (fetal vitality).
Hospitalization is to ESTABLISH Often advocated intravenous antibiotics, antipyretics and tocolysis Possibly associated with corticosteroid therapy for fetal lung maturation.
Urinary tract infections, cystitis to pyelonephritis require rapid treatment When clinical suspicion positive urine test strips gold (nitrite, leukocyturia, ± albuminuria). Amoxicillins ± in association with clavulanic acid to help fight against Gram-negative bacilli MOST.
Listeriosis ( listeria monocytogenes bacillus gram +) shoulds be regarded In Some flu-franc table, fever, conjunctivitis, urinary tract infection with pelvic heaviness …
This infection HAS severe neonatal consequences That encourages Quickly process Any suspicion of listeriosis with amoxicillin or erythromycin intravenous infusion if allergy, without Awaiting the results of blood cultures are That Systematically Collected. Some laboratories are asking That it be specified on demand “research listeria . ”
The ovular infection is the second case of fever During Pregnancy, if there is rupture of membranes Obvious year or After an invasive amniocentesis procedure Such As. When in doubt, hospitalization in a Specialized environment is required. The risk of premature delivery and neonatal infection make gravity.
Malaria, WHETHER concept of travel in endemic areas, shoulds be Sought by a thick film.
Flu, “the great abortionist” presents a risk of preterm delivery.
Phlebitis shoulds not be forgotten. Finally toughest appendicitis diagnosis and aseptic necrobiosis of a fi bromine can be accompagné by fever, symptoms are the aims Often Dominated by bread.
The occurrence During Pregnancy varicella requires Careful management Because The maternal Risks Can Be (severe pneumonia), fetal (congenital varicella) or newborn (neonatal varicella). The maternal risk requires pulmonology Taking notice to the Chat is feasible for monitoring hospitalization or treatment in the presence of respiratory signs.
What to do:
If varicella infection in pregnant women: make a 1st serology quickly.
If it is negative, repeat the serology second 15 days later and the Chat the use of antiviral treatment Especially if the contagion takes up in the three weeks before the birth. If the 1st serology is positive: no risk, the patient is already immune (95 % of cases).
If varicella rash in pregnant women: treatment Will Be Discussed selon the term (to Avoid the first quarter) and the severity of maternal symptoms. There is no epidemiological Currently argument to suggest That thesis treatments Reduce the risk of maternal-fetal transmission or icts . severity Fetal and Neonatal Risks exchange DEPENDING on the term of the maternal varicella eruption:
– Before 8 SA: risk of miscarriage;
– Before 20 SA: maximum risk of embryofetopathy.
. The best screening is provided by fetal ultrasound . Brain abnormalities can be APPROBATION by MRI . Medical abortion is permissible in the presence of fetal ultrasound abnormalities The medical treatment with oral acyclovir is feasible After 15 weeks; After 20 SA: monitoring the risk of prematurity. No enhanced ultrasound monitoring.
Orally Acyclovir can be used to Decrease the intensity of the eruption and the risk of maternal pneumonia; in late pregnancy, avoid delivery During The Following 5 to 8 days to the start of kindergarten rash. In the presence of uterine contractions, with hospitalization for tocolysis Insulation will be offered. The rest home is possible, if the birth is not imminent. Treatment with acyclovir intravenously for 5 to 10 days and immunoglobulins are discussing;
– At birth, if the mother is infectious, it is Necessary to isolate the newborn. If the birth OCCURS Within seven days after the onset of rash, treat newborns with acyclovir (20 mg / kg / 8 hours) and insulation in the Chat immunoglobulins.
In case of diagnostic uncertainty about the etiology of maternal rash, it will confirm the diagnosis of chickenpox by VZV IgM serology with search and kinetics of IgG.
Serology results must not delay in Maternal-Fetal Taking load.
From 15 SA, with acyclovir Treated Orally started 7 days after the contagion for a period of seven days (no marketing authorization in France) to Decrease the intensity of the eruption and the maternal risk of varicella pneumonia:
– Zovirax 800 mg / 5x / day for 7 days;
– Zelitrex®: 1 g / 3x / day for 7 days.
In severe and / or late maternal forms: Respiratory hospitalization and intravenous acyclovir 10 mg / kg / 8 hours for 5 to 10 days.
It is Indicated as outside pregnancy: nails trimmed short and cleaned Regularly, twice daily cleaning of the skin with antiseptic baths (Septivon®, Solubacter®) Hextril® as a mouthwash and at intense pruritus: Polaramine®, Atarax®.
Aspirin is cons-Indicated During varicella, Given the occurrence of hemorrhagic lesions, goal aussi the potential risk of Reye’s syndrome occurrence. It is Necessary to wait for three months After vaccination To Become pregnant. Its distribution in HIV-negative women of childbearing age Would prevent prevention serious forms of maternal varicella and complexity of the management of pergravidiques chickenpox.
The Treating physician is an essential actor in monitoring pregnancy. One of main icts roles is to detect patients at risk and Refer em Quickly to motherhood (Boxes 12 and 13). That goal beyond taken Purely medical, it is in this non-pathological singular That position can forge strong links entre doctor and family. The proximity and knowledge of life de son _him_ enable patients to Get Involved in this project pregnancy and child. By participante in this episode of life of a family, the Attending Physician will boost up icts have a family doctor.
More humanity and humanism is one of the axes of the 2005 plan Perinatal and family physicians shoulds be major players in this living room. This is beneficial for patients and couples and Allows upgrading of the GP function. This est beneficial cooperation and Sought After by professional birth.
The monitoring of pregnant women shoulds not be stressful for the doctor in town, as it can take time at Any advice from motherhood if reading this chapter does not respond to His questions.
In practice, it is significant to address in obstetrics, early pregnancy, all pregnant women at risk to ESTABLISH the follow-up schedule of this pregnancy. Monitoring will Then organizes in cooperation entre les family doctor and motherhood.
Box 12. Pregnant Women to address From The Beginning of pregnancy to notice obstetrical
Women with a history of:
pathological pregnancy (hypertension, diabetes, MAP …)
On the difficulty delivery (caesarean section, neonatal resuscitation, neonatal infection with gold distress without sequelae)
fetal pathology: malformation, IUGR, macrosomia preexisting maternal pathology: epilepsy, multiple sclerosis, inflammatory bowel disease, hemoglobinopathies, vasculitis, diabetes, hypertension, thrombotic diseases etc.
Twin pregnancy or multiple
pregnancy before age 18 and After 35
Pregnancy and adverse psychosocial context or insecurity
Box 13. Pregnant women During Pregnancy to address emergency ±
the emergency room
Bleeding from the 2nd and 3rd quarter
loss of fluid (rupture of membranes)
Decrease in assets fetal movements
Vomiting of the 2nd and 3rd quarter
Infectious diseases Fever and
Concept of contagion rubella, varicella etc.
Seroconversion or Suspected toxoplasmosis
uncontrollable vomiting Q1
serology for interpretation Difficulties
Doubt record ultrasound
End of pregnancy without monitoring the maternity