Physiological pregnancy- the course of pregnancy without complications according to the gestational age.
High-risk pregnancy is a pregnancy that is likely to require further intervention or has already required the intervention of specialists. Therefore, all other pregnancies are proposed to be classified as low risk pregnancies, normal or uncomplicated pregnancies (WHO definition).

I. INTRODUCTORY PART

Protocol name:"Physiological pregnancy management"
Protocol code:
ICD-10 code (s):
Z34 - monitoring the course of a normal pregnancy:
Z34.8
Z34.9

Abbreviations used in the protocol:
BP - blood pressure
IUI - intrauterine infection
BMI - body mass index
STIs - Sexually Transmitted Infections
PHC - primary health care
WHO - World Health Organization
Ultrasound - ultrasound examination
HIV - Human Immunodeficiency Virus

Date of protocol development: April 2013

Protocol users: midwives of the outpatient clinic, GP, obstetricians, gynecologists

No Conflict of Interest Statement: developers do not cooperate with pharmaceutical companies and have no conflicts of interest

Diagnostics

METHODS, APPROACHES AND PROCEDURES OF DIAGNOSTICS AND TREATMENT

Diagnostic criteria: the presence of doubtful and reliable signs of pregnancy.

List of basic and additional diagnostic measures

Treatment

Treatment goals: Physiological course of pregnancy and live birth of a full-term newborn.

Treatment tactics

Drug-free treatment: no

Drug treatment: folic acid, acetylsalicylic acid, calcium preparations

Other treatments: no
Surgical intervention: no

Preventive actions: taking folic acid

Further management: childbirth

The first patronage is carried out by a midwife / nurse / GP within the first 3 days after childbirth (By order No. 593 of 08/27/12, "Regulations on the activities of health organizations providing obstetric and gynecological care"). Examination 6 weeks after childbirth to determine the group of medical examination, according to order No. 452 of 03.07.12. "On measures to improve medical care for pregnant women, women in labor, parturient women and women of fertile age."

Objectives of the Postpartum Checkup:
- Determination of existing problems with breastfeeding, the need to use contraception and the choice of contraceptive method.
- Measurement of blood pressure.
- If it is necessary to determine the level of hemoglobin in the blood, send ESR to the clinic;
- If there are signs of infection, refer to an obstetrician-gynecologist.
- If you suspect that the child has any pathology of a hereditary nature, it is necessary to send the woman for a consultation with a doctor.

Treatment activity and safety of diagnostic and treatment methods:
- no complications during pregnancy;
- timely detection, counseling, hospitalization, if necessary, in case of complications;
- absence of perinatal mortality.

The plan for the examination and management of physiological pregnancy is based on the order of the Ministry of Health of the Russian Federation 572N. The EMC clinic uses a physiological pregnancy management program developed on the basis of this order.

Pregnancy management is a complex of medical and diagnostic measures aimed at the safe bearing and birth of a healthy baby. A woman expecting a baby is provided not only with the necessary medical, but also informational and psychological support.

Primary reception

The first visit to the doctor may occur when menstruation is delayed by 2-3 weeks. A diagnostic ultrasound scan is performed, the purpose of which is to visualize the uterine pregnancy. If pregnancy is diagnosed very early, a second diagnostic ultrasound may be needed to confirm that the pregnancy is progressing. As a rule, from the 6th week, the heartbeat of the embryo is already recorded.

When do you need to register?

For effective management of pregnancy and the timely identification of individual characteristics and probable complications, it is recommended to undergo all the necessary clinical tests before 12 weeks.

Medical supervision of pregnancy is necessary, even if it proceeds without complications.

Features of pregnancy management in each trimester

Pregnancy management has its own characteristics in each trimester.

With a normal pregnancy, the frequency of calls for pregnancy should be at least 7 times (according to order No. 572).

• up to 32 weeks - once a month;
• from the 32nd week - once every 2 weeks;
• from the 36th week - once a week.

If, during the examination, any violations were found on the part of the health of the pregnant woman or the fetus, the frequency of visits increases. An individual schedule of visits to the gynecologist can be set.

Pregnancy management in the first trimester

After the initial visit to the doctor within the next 10-14 days, it is recommended to undergo all clinical studies prescribed by the gynecologist. Early diagnosis (up to 12 weeks) allows you to identify the main risk factors that threaten the normal course of pregnancy and take the necessary measures in a timely manner.

A standard general clinical examination includes:

blood chemistry;

coagulogram;

blood for syphilis, HIV, hepatitis B, C;

blood group and Rh factor;

analysis for TORCH-infection (T-toxoplasmosis, O-other infections, R-rubella, C-cytomegalovirus, H-herpes);

analysis for TSH (thyroid stimulating hormone);

smear for microflora;

smears for genital infections (PCR diagnostics);

smear for cytology.

You will also need consultations of narrow specialists - a therapist, ophthalmologist, otorhinolaryngologist, dentist and others (according to indications). Electrocardiography (ECG) is also done.

According to the order of the Ministry of Health of the Russian Federation 572N, the analysis for TORCH infection requires the mandatory determination of antibodies to toxoplasmosis and rubella.

The standard analysis for a coagulogram does not include D-dimer and contains the minimum indicators required to determine the parameters of hemostasis. An extended analysis is carried out when indicated.

If the pregnant woman is Rh negative, it is necessary to obtain information about the spouse's Rh and blood group. In the presence of Rh-negative blood type, every 4 weeks the expectant mother needs to donate blood for titers of antibodies to Rh. Further, for a period of 28-30 weeks, the prevention of Rh-conflict is carried out: the introduction of anti-D immunoglobulin 1500 IU intramuscularly once.

The standard STD swab is aimed at ruling out chlamydia.

A cytological smear is taken from the cervix by scraping. It is performed once, and it should be done as early as possible.

Prenatal ultrasound screening with morphological examination

In the first trimester, in the interval of 11-13 weeks, prenatal screening is carried out, aimed at identifying risks for the chromosomal pathology of the fetus.

Additionally, according to indications, the doctor may recommend to undergo other tests: NIPT (non-invasive prenatal test) or, if necessary, invasive diagnostics.

Second trimester pregnancy management

According to the order, in the second trimester, in addition to standard clinical studies of blood and urine, a bacteriological culture of urine is prescribed.

Also in the second trimester, a morphological ultrasound of the fetus is performed. The survey is carried out from 18 to 20 weeks. It is aimed at a complete study of the anatomical structures of the fetus. This EMC study is carried out by an expert physician.

In the EMC clinic, after morphological ultrasound, ultrasound fetometry can additionally be carried out - the measurement of the biometric parameters of the fetus, aimed at monitoring the growth rate of the fetus.

In the second trimester, the expectant mother needs to undergo another important examination - a glucose tolerance test, aimed at identifying or excluding gestational diabetes mellitus. According to the standards, it runs from 24 to 28 weeks.

Pregnancy management in the third trimester

In the third trimester at 30 weeks, the main general clinical tests are repeated:

clinical analysis of blood and urine;

blood chemistry;

coagulogram;

analysis for syphilis, HIV, hepatitis B, C;

smear for microflora;

sowing for group B streptococcus;

morphological ultrasound of the fetus with dopplerometry;

cardiotocography.

Also, at 30 weeks, a second consultation of narrow specialists is required.

Physiological childbirth can occur within 38-41 weeks. This is individual and depends on the initial parameters of the course of pregnancy, the presence of concomitant pathology, etc.

Advantages of contacting EMC:

Management of pregnancy and childbirth of any complexity: in patients with concomitant diseases, with a scar on the uterus or with multiple pregnancies.

A team of doctors with experience in clinics in Europe, USA and Israel.

Comfort and pleasure of your stay: deluxe and deluxe studios, family suites.

Vi. The procedure for providing medical care to women with HIV infection during pregnancy, childbirth and the postpartum period

51. The provision of medical care to women with HIV infection during pregnancy, childbirth and the postpartum period is carried out in accordance with Sections I and III of this Procedure.

52. Laboratory examination of pregnant women for the presence of antibodies to the human immunodeficiency virus (hereinafter - HIV) in their blood is carried out when registering for pregnancy.

53. If the first test for HIV antibodies is negative, women planning to maintain a pregnancy are re-tested at 28-30 weeks. Women who used parenteral psychoactive substances during pregnancy and (or) had sexual intercourse with an HIV-infected partner are recommended to be examined additionally at 36 weeks of gestation.

54. Molecular biological examination of pregnant women for HIV DNA or RNA is carried out:

a) upon receipt of questionable test results for antibodies to HIV obtained by standard methods (enzyme-linked immunosorbent assay (hereinafter - ELISA) and immune blotting);

b) upon receipt of negative HIV antibody test results obtained by standard methods if a pregnant woman belongs to a high risk group for HIV infection (intravenous drug use, unprotected sex with an HIV-infected partner within the last 6 months).

55. Blood sampling for testing for antibodies to HIV is carried out in the treatment room of the antenatal clinic using vacuum systems for blood sampling, followed by blood transfer to the laboratory of a medical organization with a referral.

56. Testing for antibodies to HIV is accompanied by mandatory pre-test and post-test counseling.

Post-test counseling is provided to pregnant women regardless of the test result for HIV antibodies and includes a discussion of the following issues: the value of the result, taking into account the risk of HIV infection; recommendations for further testing tactics; ways of transmission and methods of protection against HIV infection; the risk of HIV transmission during pregnancy, childbirth and breastfeeding; methods of preventing mother-to-child transmission of HIV that are available to pregnant women with HIV; the possibility of chemoprophylaxis of HIV transmission to a child; possible pregnancy outcomes; the need for follow-up of mother and child; the possibility of informing the sexual partner and relatives about the test results.

57. Pregnant women with a positive laboratory test for HIV antibodies are sent by an obstetrician-gynecologist, and in his absence, a general practitioner (family doctor), a medical worker of a feldsher-obstetric center, to the Center for the Prevention and Control of AIDS of the subject Russian Federation for additional examination, dispensary registration and prescribing chemoprophylaxis for perinatal HIV transmission (antiretroviral therapy).

Information received by medical workers about a positive HIV test result of a pregnant woman, a woman in labor, a postpartum woman, antiretroviral prophylaxis of mother-to-child transmission of HIV infection, joint observation of a woman with specialists from the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation, perinatal HIV contact infection in a newborn is not subject to disclosure, except as otherwise provided by applicable law.

58. Further observation of a pregnant woman with an established diagnosis of HIV infection is carried out jointly by an infectious disease doctor at the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation and an obstetrician-gynecologist at the antenatal clinic at the place of residence.

If it is impossible to send (follow up) a pregnant woman to the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation, the observation is carried out by the obstetrician-gynecologist at the place of residence with the methodological and advisory support of the infectious disease doctor of the Center for the Prevention and Control of AIDS.

The obstetrician-gynecologist of the antenatal clinic during the period of observation of a pregnant woman with HIV infection sends information about the course of pregnancy, concomitant diseases, complications of pregnancy, mother to the child and (or) antiretroviral therapy and requests information from the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation about the characteristics of the course of HIV infection in a pregnant woman, the regimen of taking antiretroviral drugs, agrees the necessary diagnostic and treatment methods, taking into account the woman's health status and the course of pregnancy ...

59. During the entire observation period of a pregnant woman with HIV infection, the obstetrician-gynecologist of the antenatal clinic in strict confidentiality (using a code) notes in the woman's medical documentation her HIV status, presence (absence) and admission (refusal to admit) antiretroviral drugs necessary for the prevention of mother-to-child transmission of HIV, prescribed by specialists of the Center for the Prevention and Control of AIDS.

The obstetrician-gynecologist of the antenatal clinic immediately informs the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation about the absence of antiretroviral drugs in a pregnant woman, refusal to take them, so that appropriate measures can be taken.

60. During the period of dispensary observation of a pregnant woman with HIV infection, it is recommended to avoid procedures that increase the risk of fetal infection (amniocentesis, chorionic biopsy). The use of non-invasive methods for assessing the condition of the fetus is recommended.

61. Upon admission to childbirth in an obstetric hospital of women who are not examined for HIV infection, women without medical documentation or with a single test for HIV infection, as well as who have used intravenous psychoactive substances during pregnancy, or who have had unprotected sex with an HIV-infected partner, it is recommended that a laboratory examination by the express method for HIV antibodies is obtained after obtaining informed voluntary consent.

62. Testing a woman in childbirth for HIV antibodies in an obstetric hospital is accompanied by pre-test and post-test counseling, including information on the importance of testing, methods of preventing HIV transmission from mother to child (use of antiretroviral drugs, method of delivery, feeding characteristics of a newborn (after birth, the child is not attached to the breast and not fed with breast milk, but transferred to artificial feeding).

63. Testing for antibodies to HIV using diagnostic express test systems approved for use on the territory of the Russian Federation is carried out in the laboratory or the admission department of an obstetric hospital by specially trained medical workers.

The study is carried out in accordance with the instructions attached to the specific rapid test.

A part of the blood sample taken for the express test is sent for testing for HIV antibodies according to the standard method (ELISA, if necessary, an immune blot) in a screening laboratory. The results of this study are immediately transmitted to a medical organization.

64. Each study for HIV using express tests must be accompanied by a mandatory parallel study of the same portion of blood by classical methods (ELISA, immune blot).

If a positive result is obtained, the rest of the serum or blood plasma is sent to the laboratory of the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation for a verification study, the results of which are immediately transferred to the obstetric hospital.

65. If a positive HIV test is obtained in the laboratory of the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation, a woman with a newborn after discharge from the obstetric hospital is sent to the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation for consultation and further examination.

66. In emergency situations, if it is impossible to wait for the results of standard HIV testing from the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation, the decision to conduct a preventive course of antiretroviral therapy for mother-to-child transmission of HIV is made upon detection of antibodies to HIV using a rapid test -systems. A positive rapid test result is the basis only for the appointment of antiretroviral prophylaxis of HIV transmission from mother to child, but not for the diagnosis of HIV infection.

67. To ensure the prevention of mother-to-child transmission of HIV infection, the obstetric hospital should have the necessary supply of antiretroviral drugs at all times.

68. Antiretroviral prophylaxis for women during childbirth is carried out by an obstetrician-gynecologist leading the labor in accordance with the recommendations and standards for the prevention of mother-to-child transmission of HIV.

69. A prophylactic course of antiretroviral therapy during childbirth in an obstetric hospital is carried out:

a) a woman in labor with HIV infection;

b) with a positive result of express testing of a woman in childbirth;

c) in the presence of epidemiological indications:

the inability to conduct express testing or timely obtain the results of a standard test for antibodies to HIV in a woman in labor;

the history of a woman in labor during this pregnancy of parenteral use of psychoactive substances or sexual contact with a partner with HIV infection;

with a negative test result for HIV infection, if less than 12 weeks have passed since the last parenteral use of psychoactive substances or sexual contact with an HIV-infected partner.

70. The obstetrician-gynecologist takes measures to prevent the duration of the anhydrous interval for more than 4 hours.

71. During vaginal delivery, the vagina is treated with a 0.25% aqueous solution of chlorhexidine upon admission to childbirth (at the first vaginal examination), and in the presence of colpitis, at each subsequent vaginal examination. With an anhydrous interval of more than 4 hours, the vagina is treated with chlorhexidine every 2 hours.

72. During the management of childbirth in a woman with HIV infection with a living fetus, it is recommended to limit the procedures that increase the risk of fetal infection: delivery stimulation; childbirth; perineo (episio) tomia; amniotomy; the imposition of obstetric forceps; vacuum extraction of the fetus. These manipulations are performed only for health reasons.

73. A planned caesarean section for the prevention of intrapartum HIV infection of a child is carried out (in the absence of contraindications) before the onset of labor and amniotic fluid rupture if at least one of the following conditions is present:

a) the concentration of HIV in the mother's blood (viral load) before childbirth (not earlier than 32 weeks of gestation) is more than or equal to 1,000 kopecks / ml;

b) maternal viral load before childbirth is unknown;

c) antiretroviral chemoprophylaxis was not carried out during pregnancy (or was carried out as monotherapy or its duration was less than 4 weeks) or it is impossible to use antiretroviral drugs during labor.

74. If it is impossible to carry out chemoprophylaxis during childbirth, caesarean section can be an independent preventive procedure that reduces the risk of HIV infection in a child during childbirth, and it is not recommended to carry out it with an anhydrous interval of more than 4 hours.

75. The final decision on the method of delivery of a woman with HIV infection is made by the obstetrician-gynecologist leading the delivery individually, taking into account the condition of the mother and the fetus, comparing in a particular situation the benefits of reducing the risk of infection of a child during a caesarean section with the probability occurrence of postoperative complications and features of the course of HIV infection.

76. Immediately after birth, blood is drawn from a newborn from an HIV-infected mother for testing for HIV antibodies using vacuum blood collection systems. The blood is sent to the laboratory of the Center for the Prevention and Control of AIDS in the constituent entity of the Russian Federation.

77. Antiretroviral prophylaxis for a newborn is prescribed and carried out by a neonatologist or pediatrician regardless of the mother's intake (refusal) of antiretroviral drugs during pregnancy and childbirth.

78. Indications for the appointment of antiretroviral prophylaxis to a newborn born to a mother with HIV infection, a positive result of rapid testing for HIV antibodies in childbirth, unknown HIV status in an obstetric hospital are:

a) the age of the newborn is not more than 72 hours (3 days) of life in the absence of breastfeeding;

b) in the presence of breastfeeding (regardless of its duration) - a period of no more than 72 hours (3 days) from the moment of the last breastfeeding (subject to its subsequent cancellation);

c) epidemiological indications:

unknown HIV status of a mother who uses parenteral psychoactive substances or has sexual contact with an HIV-infected partner;

a negative result of the examination of a mother for HIV infection, who has been using parenteral substances within the last 12 weeks or who has sexual contact with a partner with HIV infection.

79. The newborn is given a hygienic bath with chlorhexidine solution (50 ml of 0.25% chlorhexidine solution per 10 liters of water). If it is not possible to use chlorhexidine, a soap solution is used.

80. Upon discharge from the obstetric hospital, the neonatologist or pediatrician explains in detail in an accessible form the mother or persons who will take care of the newborn, the further scheme of taking chemotherapy for the child, issue antiretroviral drugs to continue antiretroviral prophylaxis in accordance with the recommendations and standards.

When carrying out a preventive course of antiretroviral drugs by methods of emergency prevention, discharge from the maternity hospital of the mother and child is carried out after the end of the preventive course, that is, not earlier than 7 days after childbirth.

In the obstetric hospital, women with HIV are consulted on the issue of refusing to breastfeed; with the woman's consent, measures are taken to stop lactation.

81. Data on a child born to a mother with HIV infection, antiretroviral prophylaxis for a woman in childbirth and a newborn, methods of delivery and feeding of a newborn are indicated (with a contingent code) in the medical documentation of the mother and child and are transmitted to the Center for the Prevention and Control of AIDS of the subject of the Russian Federation. Federation, as well as to the children's clinic where the child will be monitored.

For citation: Ignatova G.L., Blinova E.V., Antonov V.N. Recommendations of pulmonologists for the management of pregnant women with various lung diseases // BC. 2015. No. 18. S. 1067-1073

During pregnancy, significant functional and anatomical changes occur in various organs and systems of the woman's body, aimed at creating favorable conditions for the development of the fetus and associated with adaptation to the increasing size of the uterus. For effective prevention and treatment of lung diseases, as well as obstetric complications in the event of their development against the background of pulmonary pathology, it is necessary to have a clear understanding of these changes. In the first trimester of pregnancy, the swelling of the mucous membrane of the upper respiratory tract, especially the nose, due to the influence of estrogens, appears. Along with the symptoms of rhinitis, observed in 30% of pregnant women, this feature is the reason for a predisposition to nosebleeds and an increased risk of mucosal trauma.

Literature

1. Kilpatrick C.J., Hopper J.L. The effect of pregnancy on the epilepsies: a study of 37 pregnancies // Aust.N.Z.J. Med. 1993. No. 23. P. 370–373.
2. Fisher Yu.Ya., Oborotistova A.N., Brio G.B. Factors contributing to the onset of tuberculosis in pregnant women and women who have given birth, and the role of contact film thermal indication in their examination // Obstetrics and gynecology. 1995. No. 6. P. 40–43.
3. Petchenko A.I. Physiological changes in a woman's body during pregnancy: Ruk. in obstetrics and gynecology. M .: Medicine, 1996.T. II. Book. I S. 168-198.
4. Zaitsev A.A., Sinopalnikov A.I. Influenza: diagnosis and treatment // Russian medical journal. 2008. No. 16 (22). S. 1494-1496.
5. Siston A.M. Pandemic 2009 influenza A (H1N1) virus illness among pregnant women in the United States / A.M. Siston et all. // JAMA. 2010. Vol. 303 (15). P. 1517-1525.
6. Pierce M. Perinatal outcomes after maternal 2009 / H1N1 infection: national cohort study // BMJ. 2011. Vol. 342. P. 3214.
7. CDC. Guidelines for vaccinating pregnant women: from recommendation of the Advisory Committee on Immunization Practices (ACIP). Centers for Disease Control and Prevention 2007 May. Available from: http://www.cdc.gOv/vaccines/pubs/preg-guide.htm#5.
8. Recommendations for the organization and conduct of vaccination of pregnant women and women in childbirth against influenza A (H1N1): Information letter No. 15-4 / 3108-07 of 11.12.2009. http://www.rosminzdrav.ru/docs/mzsr/letters/161.
9. Chuchalin A.G., Sinopalnikov A.I., Kozlov R.S., Tyurin I.E., Rachina S.A. Community-acquired pneumonia in adults: practical guidelines for diagnosis, treatment and prevention: A guide for physicians. M., 2010.http: //pulmonology.ru/publications.
10. Order of the Ministry of Health of Russia dated 12.11.2012 No. 572n "On approval of the procedure for the provision of medical care in the profile of" obstetrics and gynecology (except for the use of assisted reproductive technologies) ".
11. Ramsey P.S., Ramin K.D. Pneumonia in pregnancy // Obstet. Gynecolol. Clin. 2001. Vol. 28. No. 3. P. 49.
12. Lim W.S., Macfarlane J.T., Colthorpe C.L. Treatment of community-acquired lower respiratory tract infections during pregnancy // Am. J. Respir. Med. 2003. Vol. 2. No. 3. P. 221–233.
13. Infections Diseases Society of America / American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults // Clin.Infect.Dis. 2007. Vol. 44. P. 27–72.
14. Goodnight W.H., Soper D.E. Pneumonia in pregnancy // Crit.Care Med. 2005. Vol. 33. No. 10. Suppl. P. 390–397.
15. Laibl V.R., Sheffield J.S. Influenza and pneumonia in pregnancy // Clin. Perinatol. 2005. Vol. 32. P. 727-738.
16. Antibiotic therapy: A practical guide / ed. L.S. Strachunsky. M., 2000.
17. Babylonian S.A. Optimization of bronchial asthma management in pregnant women: Author's abstract. diss. ... Cand. honey. sciences. M., 2005.
18. Ovcharenko S.I. Bronchial asthma: diagnosis and treatment // BC. 2002. T. 10.No. 17.
19. Pertseva T.A., Chursinova T.V. Pregnancy and bronchial asthma: the state of the problem // Health of Ukraine. 2008. No. 3/1. S. 24-25.
20. Federal clinical guidelines for the diagnosis and treatment of bronchial asthma. http://pulmonology.ru/publications/guide.php.
21. Global Initiative for Asthma3. 2014. (GINA). http://www.ginasthma.org.
22. Masoli M., Fabian D., Holt S., Beasley R. Global Burden of Asthma. 2003.20 p.

RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Observation of normal pregnancy, unspecified (Z34.9)

obstetrics and gynecology

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Healthcare Development
No. 18 MZ RK dated September 19, 2013

Physiological pregnancy- the course of pregnancy without complications according to the gestational age.
High-risk pregnancy is a pregnancy that is likely to require further intervention or has already required the intervention of specialists. Therefore, all other pregnancies are proposed to be classified as low risk pregnancies, normal or uncomplicated pregnancies (WHO definition).

I. INTRODUCTORY PART

Protocol name:"Physiological pregnancy management"
Protocol code:
ICD-10 code (s):
Z34 - monitoring the course of a normal pregnancy:
Z34.8
Z34.9

Abbreviations used in the protocol:
BP - blood pressure
IUI - intrauterine infection
BMI - body mass index
STIs - Sexually Transmitted Infections
PHC - primary health care
WHO - World Health Organization
Ultrasound - ultrasound examination
HIV - Human Immunodeficiency Virus

Date of protocol development: April 2013

Protocol users: midwives of the outpatient clinic, GP, obstetricians, gynecologists

No Conflict of Interest Statement: developers do not cooperate with pharmaceutical companies and have no conflicts of interest

Diagnostics

METHODS, APPROACHES AND PROCEDURES OF DIAGNOSTICS AND TREATMENT

Diagnostic criteria: the presence of doubtful and reliable signs of pregnancy.

List of basic and additional diagnostic measures

Treatment abroad

Undergo treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment goals

: Physiological course of pregnancy and live birth of a full-term newborn.

Treatment tactics

Drug-free treatment: no

Drug treatment: folic acid, acetylsalicylic acid, calcium preparations

Other treatments: no
Surgical intervention: no

Preventive actions: taking folic acid

Further management: childbirth

The first patronage is carried out by a midwife / nurse / GP within the first 3 days after childbirth (By order No. 593 of 08/27/12, "Regulations on the activities of health organizations providing obstetric and gynecological care"). Examination 6 weeks after childbirth to determine the group of medical examination, according to order No. 452 of 03.07.12. "On measures to improve medical care for pregnant women, women in labor, parturient women and women of fertile age."

Objectives of the Postpartum Checkup:
- Determination of existing problems with breastfeeding, the need to use contraception and the choice of contraceptive method.
- Measurement of blood pressure.
- If it is necessary to determine the level of hemoglobin in the blood, send ESR to the clinic;
- If there are signs of infection, refer to an obstetrician-gynecologist.
- If you suspect that the child has any pathology of a hereditary nature, it is necessary to send the woman for a consultation with a doctor.

Treatment activity and safety of diagnostic and treatment methods:
- no complications during pregnancy;
- timely detection, counseling, hospitalization, if necessary, in case of complications;
- absence of perinatal mortality.

Preparations (active ingredients) used in the treatment

Information

Sources and Literature

1. Minutes of meetings of the Expert Commission on Healthcare Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. Antenatal care: routine care for the healthy pregnant woman. National Collaborating 2. Center for Women’s and Children’s Health Commissioned by the National Institute for 3. Clinical Excellence. 2nd edition © 2008 National Collaborating Center for Women’s and Children’s Health. 1st edition published in 2003 4. Clinical protocol "Management of normal pregnancy (low risk pregnancy, uncomplicated pregnancy)", Project "Mother and Child", Russia, 2007 5. Routine Prenatal Care ICSI Management of Labor Guidelines for hospital-based care. August 2005, 80 p. 6. Guidelines for effective care during pregnancy and childbirth .. Enkin M, Keirs M, Neilson D et al. Translated from English under the editorship of AV Mikhailov, SP "Petropolis", 2007 7. WHO guidelines for effective perinatal care ... 2009. 8. Cochrane Guidelines. Pregnancy childbirth. 2010 9. Orders of the Ministry of Healthcare of the Republic of Kazakhstan No. 452 07/03/12 "on measures to improve medical care for pregnant women, women in labor, women in childbirth and women of fertile age" 10. Order No. 593 dated 27.08.12. "On approval of the regulation of the activities of health organizations providing obstetric and gynecological care"

Information

ORGANIZATIONAL ASPECTS OF THE PROTOCOL IMPLEMENTATION:

List of protocol developers with qualification data: Maishina M.Sh. - Obstetrician-gynecologist of the highest category, senior resident of the obstetrics department 2 of JSC "NSCMD".

Reviewers: Kudaibergenov T.K. - Chief freelance obstetrician-gynecologist of the Ministry of Health of the Republic of Kazakhstan, director of the RSE "National Center for Obstetrics, Gynecology and Perinatology."
Kobzar NN - candidate of medical sciences, doctor of the highest category in the specialty of obstetrics and gynecology, in social hygiene and organization of health care, head. Department of Obstetrics and Gynecology KRMU.

Indication of the conditions for revision of the protocol: The protocol is revised at least once every 5 years, or upon receipt of new data related to the application of this protocol.

ApplicationA

· The disease does not pose a danger to the mother;
There is a risk of developmental defects in the fetus if the mother develops symptoms of infection before the 16th week of pregnancy;
· For prevention, the most effective state program of universal universal vaccination of children of the first year of life and adolescent girls, as well as women in the postpartum period;
· Screening should be offered to all pregnant women at the first visit who do not have documented vaccination (2a);
· Accidental vaccination of women who subsequently find themselves pregnant is not an indication for termination of pregnancy because of the safety for the fetus of a live vaccine;
Women with suspected rubella infection should be isolated from other pregnant (or potentially pregnant) women, but after the disappearance of clinical signs of infection, they do not pose a danger to others
If the woman has not been vaccinated against rubella or, recommend vaccination after childbirth

ApplicationV

an infection that does not affect pregnancy.
Vaginal candidiasis is diagnosed by microscopy of vaginal discharge. Culture is used to confirm the diagnosis.
· Screening for vaginal candidiasis is not recommended.
· Treatment of infection is indicated only in the presence of clinical manifestations: butoconazole, clotrimazole, econazole, terconazole or nystatin. However, it is very important to remember that the effect of drugs taken by the mother orally on the child is unknown.
· There is no need to hospitalize or isolate women with vaginal candidiasis from other women.
· The newborn should be in a joint stay with his mother, and can also be breastfed.

Asymptomatic bacteriuria
· Prevalence - 2-5% of pregnancies;
· Increases the risk of premature birth, low birth weight, acute pyelonephritis in pregnant women (on average, it develops in 28-30% of those who have not received treatment for asymptomatic bacteriuria);
· Determination - the presence of bacterial colonies -> 10 5 in 1 ml of the average portion of urine, determined by the culture method (gold standard) without clinical symptoms of acute cystitis or pyelonephritis;
· Diagnostic examination - culture of the middle portion of urine - should be offered to all pregnant women at least once upon registration (1a);
· For treatment, ampicillin, 1st generation cephalosporins, which have shown the same effectiveness in studies, can be used;
· Treatment should be continuous during pregnancy when positive culture results are obtained, the criterion for successful treatment is the absence of bacteria in the urine;
· A single dose of antibacterial agents is also effective as 4- and 7-day courses, but because of the smaller number of side effects, one-time ones should be used;
· It is logical to use drugs for which sensitivity has been established;
Treatment of severe forms of AIM infection (pyelonephritis) should be carried out in a specialized hospital (urological)

Hepatitis B
· During pregnancy, the course and treatment of acute hepatitis does not differ from treatment outside of pregnancy;
· Infection of a child most often occurs intrapartumly (90%);
· A blood test for hepatitis B (2 times per pregnancy) should be offered to all pregnant women to identify women who are carriers of HBsAg, for children born to such mothers to carry out effective prophylaxis - anti-D human immunoglobulin + vaccination in the first day of life (1b);
· Patients - carriers of HBsAg do not pose a danger in everyday life for staff and other women, as well as for their children, therefore they should not be isolated in the antenatal and postpartum periods.

Hepatitis C
· Is one of the main causes of liver cirrhosis, hepatocellular carcinoma, liver failure;
There are no effective methods of prevention and treatment - therefore, it is logical to suggest not to conduct routine screening for hepatitis C (3a), it may be more expedient to investigate only the risk group (intravenous drug users with a history of blood and blood components transfusion, antisocial, etc.) etc.);
· But with a high prevalence of hepatitis C in the population and the financial capacity of the region, routine screening can be carried out at the discretion of the local authorities;
· Patients - carriers of the hepatitis C virus do not pose a danger in everyday life for staff and other women, as well as for their children, therefore they should not be isolated in the antenatal and postpartum periods.

Bacterial vaginosis
· Asymptomatic course is observed in 50% of pregnant women;
· RCT results show that screening and treating healthy (non-complaining) pregnant women for vaginal dysbiosis does not reduce the risk of preterm birth or other complications, such as premature rupture of membranes (1a);
In pregnant women with a history of premature birth
· Indications for the appointment of treatment are the presence of clinical symptoms, primarily the woman's complaints of itching, burning, redness in the vulva, abundant discharge with an unpleasant odor;
· Treatment - metronidazole for 7 days (per os or topically), however, safety for the fetus has not been proven before 13 weeks of gestation.

Human Immunodeficiency Virus (HIV)
· The risk of vertical transmission depends on the viral load of the pregnant woman and the state of immunity;
· The risk of vertical transmission without prophylaxis in developed countries is 15-25%;
3-stage prophylaxis:
· - chemoprophylaxis during pregnancy and childbirth;
- elective caesarean section before the onset of labor, with an anhydrous period<4 часов;
· - refusal from breastfeeding reduces the risk of vertical transmission of HIV infection to 1%;
· HIV testing should be offered to all pregnant women 2 times during pregnancy (upon registration and at 30-32 weeks of pregnancy) (1a);
· Obstetric care facilities should have rapid tests to screen pregnant women with unknown HIV status;
· Health care providers who look after a pregnant woman have a responsibility to actively promote adherence to treatment;
· Some patients with HIV (+) status belong to the group of socially maladjusted, therefore, they should be given increased attention in matters of possible domestic violence, smoking, alcoholism, drug addiction;
· Patient-carriers do not pose a danger in everyday life for staff and other women, as well as for their children, therefore they should not be isolated in the antenatal and postpartum periods.

Chlamydia
· The most common STI in the European region;
· Increases the risk of premature birth, IUGR, neonatal mortality;
· Transmission from mother to child leads to neonatal conjunctivitis and pneumonia in 30-40% of cases;
· It is necessary to provide information on methods of prevention of conjunctivitis during childbirth - the placement of tetracycline or erythromycin ointment in the conjunctiva of the newborn by the end of the first hour after childbirth;
· Screening for asymptomatic chlamydia should not be offered as there is no reliable evidence of their effectiveness and cost-effectiveness (3a);
· "Gold standard" diagnostics of chlamydia - PCR;
Treatment of uncomplicated genital chlamydia infection during pregnancy (outpatient):
- erythromycin 500 mg four times a day for 7 days, or
- amoxicillin 500 mg three times a day for 7 days, or
- azithromycin or clindamycin.

Cytomegalovirus infection (CMV)
· CMV remains the most important cause of congenital viral infections in the population;
· The risk of transmission of CMV infection is almost exclusively associated with primary infection (1-4% of all women);
Two possible variants of the course of CMV infection among newborns infected from mothers before birth:
- generalized infection (10-15% of infected fetuses) - from moderate enlargement of the liver and spleen (with jaundice) to death. With supportive care, most newborns with CMV disease survive. Despite this, 80% to 90% of these newborns have complications in the first years of life, which can include hearing loss, blurred vision, and varying degrees of mental retardation;
- asymptomatic form (90% of all infected fetuses) - in 5-10% of cases, hearing, mental or coordination problems of varying degrees may develop;
· The risk of complications in women who were infected at least 6 months before fertilization does not exceed 1%;
· Routine screening should not be offered to all pregnant women due to the impossibility, in practice, to prove the presence of a primary infection, the lack of an effective treatment for CMV infection, difficulties in diagnosing infection and damage to the fetus (2a);
Termination of pregnancy up to 22 weeks is possible in extremely rare cases with:
- confirmed primary infection of the mother;
- positive results of amniocentesis;
- nonspecific ultrasound data (fetal anomalies, developmental delay).

Toxoplasmosis
· Prevalence in Kazakhstan is generally low, therefore routine screening is not offered (2a);
· The route of transmission from mother to child - transplacental, can cause intrauterine death, IUGR, mental retardation, hearing defects and blindness;
· The risk of transmission is mainly associated with the primary infection;
The risk of fetal infection depends on the gestational age:
- the lowest (10-25%), when the mother becomes infected in the first trimester - severe lesions are observed up to 14% of cases;
- the highest (60-90%), when the mother becomes infected in the third trimester - severe lesions practically do not occur;
· Treatment - Spiramycin (not recommended until the 18th week of pregnancy), while there is no reliable evidence of the effectiveness of treatment in preventing congenital infections and fetal lesions;
At the first visit to a medical specialist, information on the prevention of toxoplasmosis infection (and other foodborne infections) should be provided:
- do not eat raw or uncooked meat;
- thoroughly clean and wash vegetables and fruits before eating;
- wash hands and kitchen surfaces, dishes, after contact with raw meat, vegetables and fruits, seafood, poultry;
- Wear gloves when gardening or contact with the ground, which can be contaminated with cat faeces. Wash your hands thoroughly after work;
- if possible, avoid touching the cat's bowl or toilet; if there is no assistant, always do it with gloves;
- do not let cats out of the house, do not take homeless cats into the house during pregnancy, it is not recommended to give cats raw or insufficiently processed meat;
· Patients who have undergone toxoplasmosis do not pose a danger to staff and other women, as well as to their children, therefore they should not be isolated in the antenatal and postpartum periods.

Genital herpes
· The prevalence of carriage in Kazakhstan in most regions is high;
· Screening is not recommended as the results do not change management (2a);
· Damage to the fetus varies widely - from asymptomatic to damage only to the skin, in severe cases - damage to the eyes, nervous system, generalized forms;
· The risk of infection of the newborn is high in the case of primary infection of the mother immediately before childbirth (up to 2 weeks) (risk up to 30-50%) - delivery by CS should be offered;
If the infection recurs, the risk is very low (<1-3%) - рекомендовано родоразрешение через естественные родовые пути;
· Herpes infection is not an indication for hospitalization of women. Women who are found to have an active form during childbirth should maintain personal hygiene when in contact with the baby, and should not pick up another baby. No insulation required.

Syphilis
· The prevalence in the population varies considerably in different regions, but remains relatively high;
· Screening is offered to all women twice during pregnancy (at registration and at 30 weeks) (2a);
• patients with syphilis have a high risk of having other STIs, so they should be offered additional testing;
· Treatment - penicillin, can be performed on an outpatient basis;
· A woman who has undergone an adequate course of syphilis treatment does not need isolation from other women and does not pose a risk to her child;
· Consultation, treatment and control - at the venereologist.

Tuberculosis
· In case of infection in the neonatal period - a high risk of mortality;
· Active form of tuberculosis - an indication for treatment (isoniazid, rifampicin, pyrazinamide and ethambutal). These drugs are safe for pregnant women and the fetus;
· Streptomycin, ethionamide and prothionamide should be excluded because of their danger;
It is necessary to inform the expectant mother about the management of the postpartum period:
- isolation from the child is not required;
- breastfeeding is possible, the use of all anti-tuberculosis drugs during breastfeeding is not dangerous;
- it is necessary to continue the full course of treatment for the mother;
- the child will need to receive preventive treatment;
· It is necessary to have information about the living conditions of the unborn child, the presence of people living in the same apartment or house with an active form of tuberculosis for timely measures when the newborn is discharged from the maternity ward.

Appendix C

Woman's weight. Measuring weight gain at every visit is unreasonable, and there is no need to advise women to make dietary restrictions to limit weight gain.

Pelvimetry. Routine pelvimetry is not recommended. It has been proven that neither clinical nor X-ray pelviometry data have sufficient predictive value to determine the discrepancy between the sizes of the fetal head and the mother's pelvis, which is best detected with careful monitoring of the course of labor (2a).

Routine fetal heart rate auscultation has no predictive value, since it can only answer the question: is the child alive? But in some cases, it can give the patient confidence that everything is fine with the child.

Counting fetal movements. Routine counting leads to more frequent detection of decreased fetal activity, more frequent use of additional methods for assessing the condition of the fetus, more frequent hospitalizations of pregnant women and an increase in the number of induced labor. Of greater importance is not the quantitative, but the qualitative characteristics of fetal movements (1b).

Preeclampsia.
- The risk of developing preeclampsia should be assessed at the first visit to determine an appropriate schedule for antenatal visits. Risk factors that necessitate more frequent visits after 20 weeks include: the first coming first birth, age over 40; a history of preeclampsia in close relatives (mother or sister), BMI> 35 at first visit, multiple births, or pre-existing vascular disease (hypertension or diabetes)
- Whenever blood pressure is measured during pregnancy, a urine sample should be taken to determine proteinuria
- Pregnant women should be informed about the symptoms of severe preeclampsia, as their presence may be associated with more adverse outcomes for the mother and child (headache, blurred vision or flickering in the eyes; moderate to severe pain under the ribs; vomiting; rapid onset of facial edema, arms and legs)

Routine ultrasound in the second half of pregnancy. A study of the clinical relevance of routine ultrasound imaging in late pregnancy revealed an increase in antenatal hospitalizations and induced labor without any improvement in perinatal outcomes (1b). However, the expediency of ultrasound has been proven in special clinical situations:
- when determining the exact signs of vital activity or fetal death;
- when assessing the development of a fetus with suspected IUGR;
- when determining the localization of the placenta;
- confirmation of the alleged multiple pregnancy;
- assessment of the volume of amniotic fluid in case of suspicion of high or low water;
- clarification of the position of the fetus;
- for procedures such as the imposition of a circular suture on the cervix or external rotation of the fetus on the head.

Doppler ultrasound of the umbilical and uterine arteries... Routine Doppler ultrasound of the umbilical artery should not be offered.

Stress and non-stress CTG. There is no evidence of the feasibility of using CTG during the antenatal period as an additional check of fetal well-being in pregnancies, even at high risk (1a). In 4 studies evaluating the effect of routine CTG, identical results were obtained - an increase in perinatal mortality in the CTG group (3 times!), With no effect on the frequency of cesarean sections, the birth of children with a low Apgar score, neurological disorders in newborns. and admission to a neonatal ICU. The use of this method is indicated only with a sudden decrease in fetal movements or with prenatal hemorrhage.

APPENDIX E
GRAVIDOGRAM

Maintaining a gravidogram is mandatory at every visit in the second and third trimester. The gravidogram shows the height of the uterine fundus (UDM) in cm (on the vertical axis) according to the gestational age (on the horizontal axis). A graph of changes in BMR during pregnancy is plotted. It is important not to find the measured height of the fundus between the lines, but to parallel them.

APPENDIX E

(To be completed together with a medical professional)
My name _______________________________________________
Expected due date ________________________________________
My doctor's name _______________________________
My child's doctor will be _________________________
The supportive person during labor will be ________________

These people will be present during labor ______________________

__ Antenatal education in PHC

Classes for dads
__ Maternity hospital

__ Antenatal courses other than PHC

Do you want to communicate something additional about yourself (important points, fear, concern) _______________________________________________________

My goal:
__ That only people close to me and the nurse support and comfort me
__ To provide pain relief medication in addition to support and comfort
__ Other, explain ___________________________________

__ First stage of labor (contractions)
Please indicate which anti-anxiety measures you would like your midwife to offer you during labor:
__ Put on your own clothes
__ Walk
__ Hot / cold compress
__ Lots of pillows
__ Using the generic ball
__ Listen to my favorite music
__ Focus on your favorite subject
__ Massage
__ Epidural anesthesia

Birth of a child

Your midwife will help you find various comfortable positions during the second stage of labor. Which of the following would you like to try:
__ Upright position during labor
__ On the side
__ I don’t want to use the obstetric chair

After the birth of my child, I would like to:
__ For _______________ to cut the umbilical cord
__ They put the baby on my stomach right after birth
__ Wrapped in a blanket before handing it over to me
__ For the child to put on their own hat and socks
__ To swaddle my baby for the first time
__ To take a video or photograph during labor

Unexpected incidents during childbirth

If you need more information on the following questions, ask your doctor or midwife:
Forceps use / vacuum extraction
__ Amniotomy
__ Episiotomy
__ Fetal monitoring
__ Labor arousal
__ Rodostimulation
__ Delivery by caesarean section

From birth to discharge

Our obstetric department considers it necessary for a mother and child to stay together for 24 hours. Health professionals will support you and assist you in caring for your child when he is in the same room with you.

I'm going to:
__ Breastfeed your baby
__ Give complementary food or supplements to my baby

While in the department, I would like to:
__ To be with the child all the time
__ Be present when my child is examined by a neonatologist
__ Be present during the procedures for my child
__ For the nurse to show you how to bathe my child
__ Bathe my child myself
__ To circumcise my child
__ For the child to be vaccinated with BCG and hepatitis B
__ Other _______________________________________________________________________

The following people will help me at home

________________________________________________________

Your suggestions and comments

I would like to be visited after discharge from the hospital:
__ Yes. Who?________________________________
__ No
__ Not decided

Signature ___________________________ date ___________________________________

Signature of the specialist who collected the information _________________________________

APPENDIX G

· Full-fledged self-care during pregnancy will help you to maintain not only your health, but also the health of your unborn child. As soon as it seemed to you that you are pregnant, immediately contact the antenatal clinic. If the pregnancy is confirmed and you are registered, visit your doctor regularly according to the established schedule.
· Eat healthy foods (see below for more information). You will gain approximately 8-16 kg in weight, depending on how much you weighed before pregnancy. Pregnancy is not the time to lose weight.
· Sleep or rest when you need it. Don't exhaust yourself, but don't relax completely either. The need for sleep is different for each person, but most people need eight hours a day.
· Do not smoke and avoid being near smokers. If you smoke, quit ASAP!
· Do not consume any alcoholic beverages (beer, wine, spirits, etc.). Of course, drugs are out of the question!
· Do not take any pills or medicines other than those prescribed by your doctor. Remember that herbs and herbal infusions / teas are also medications.
· During pregnancy, you should also avoid strong and pungent odors (such as paint or varnish). Precautions are also required when handling household cleaners and detergents: read and follow label instructions carefully, wear gloves and do not work in poorly ventilated areas.
· If you have a cat, ask someone from the family to clean her toilet, or be sure to use rubber gloves (there is a disease - toxoplasmosis, transmitted through cat feces and dangerous for pregnant women). In all other respects, your pets are not dangerous for you or your child.
· Exercise is good for both you and your child. If there are no problems (see below for a detailed list of problems), you can continue to do the same exercises as before pregnancy. Hiking and swimming are especially good and comfortable ways to stay active, stimulate circulation, and control weight gain.
· Sexual relationships during pregnancy are normal and safe for your health. They will not harm your child either. Do not worry if, due to hormonal changes, sexual desire increases or decreases - this is also normal for each woman individually. There are several precautions you must take. As your belly will gradually enlarge, you may have to try different positions to find the most comfortable one. It is not recommended to lie on your back. If you have previously had a miscarriage or premature birth, your doctor may advise you to refrain from sexual intercourse. And if you have vaginal bleeding, pain or amniotic fluid started to leak, exclude sexual intercourse and consult a doctor as soon as possible.
· Do not hesitate to ask your doctor or midwife for information and notify them if you feel unwell. Right now, timely receive information about the benefits of breastfeeding and family planning methods for lactating women.

Healthy food for you and your child
· Of course, good nutrition is important both for your health and for your child's growth and development. Eating healthy during pregnancy is just as important as eating healthy at any other time in a woman's life. There are no "magic" foods that are especially necessary for the normal course of pregnancy. There are very few "prohibited" products. Of course, you should avoid foods that you are allergic to; also try to eat as little sweets, fatty foods as possible.
· In structure, your food should resemble a pyramid: the widest part, the "base", consists of bread, cereals, cereals and pasta. You should eat more of these foods than any other. Fruits and vegetables form the second largest group of essential foods. The third, even smaller group is made up of dairy products, as well as meat, legumes, eggs and nuts. At the top of the pyramid are fats, oils and sweets, which are recommended to be eaten in minimal quantities. If you have any questions about healthy eating, see your doctor for help.
· Pregnant women need more iron and folic acid. Eat foods rich in iron (legumes, leafy greens, milk, eggs, meat, fish, poultry) and folate (legumes, eggs, liver, beets, cabbage, peas, tomatoes). Also take vitamins and iron tablets if your doctor recommends them.
· If your appetite is not very good, eat small meals 5-6 times a day instead of 3 large meals.
· Drink eight glasses of liquid, preferably water, daily. Do not drink more than three glasses a day of drinks containing caffeine (tea, coffee, cola) or drinks high in sugar. It is especially not recommended to consume tea and coffee with food (caffeine interferes with the absorption of iron).

Discomforts associated with pregnancy

Pregnancy is a time of physical and emotional change. During certain periods of pregnancy, many women experience some discomfort. Do not worry. These are common problems that will go away after the baby is born. The most common inconveniences are:
· Frequent urination, especially in the first three and last three months.
· Increased fatigue, especially in the first three months. Rest often, eat healthy foods, and do light exercise. This will help you feel less tired.
· Nausea in the morning or at other times of the day often goes away after the first three months. Try to eat dry biscuits or a slice of bread early in the morning. Avoid spicy and oily foods. Eat small meals often.
Heartburn may occur in the fifth month of pregnancy. To avoid it, do not drink coffee or caffeinated soda; do not lie down or bend over immediately after eating; sleep with a pillow under your head. If your heartburn persists, seek the advice of your doctor.
· During pregnancy, you may be concerned about constipation. Drink at least 8 glasses of water and other fluids a day and eat foods rich in fiber, such as green vegetables and bran cereals. The specified volume of water will also help you avoid urinary tract infections.
· Ankles or feet may swell. Raise your legs several times a day; sleep on your side to reduce swelling.
In the last 3-4 months of pregnancy, lower back pain may appear. Wear shoes without heels, try not to lift weights; if you do have to lift weights, bend your knees, not your back.

Alarms

Call your healthcare professional immediately if you develop any of the following symptoms:
Bloody discharge from the genital tract;
Profuse liquid discharge from the vagina;
· Persistent headache, blurred vision with the appearance of spots or flashes in the eyes;
• sudden swelling of the hands or face;
· Temperature rise up to 38º С and more;
Severe itching and burning in the vagina or increased vaginal discharge;
Burning and pain when urinating;
· Severe abdominal pain that does not subside even when you lie down and relax;
More than 4-5 contractions per hour;
· If you hurt your stomach during a fall, car accident, or if someone hit you;
· After six months of pregnancy - if your baby performs less than 10 movements in 12 hours.

Attached files

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