obstetric pathology. Risk factors for obstetric and perinatal pathology

Unfortunately, pregnancy does not always proceed smoothly and is accompanied by various pathologies. Some pathological conditions can be corrected, while others cannot be corrected. We will find out what pathologies a pregnant woman may encounter, who is at risk, how they are diagnosed and what should be done to minimize the risks of such abnormalities.

What is pathology

Pathology is a condition that is characterized by a painful deviation from the normal, which in the case of pregnancy means a violation of the norms of its course and the development of the fetus. The pathology of pregnancy is considered to be processes that lead to disruption of homeostasis, disease and dysfunction, which endangers the health of the mother and childbearing.

When is the greatest risk of pathology

Pathological processes during pregnancy are a threat to the health of the expectant mother and child, so factors that can cause various pathologies when carrying a child should be taken into account:

• existing chronic diseases- diseases of the cardiovascular system, liver and kidneys, problems with the functioning of the endocrine system;
• bad habits- alcoholism, smoking, drugs;
• bad heredity;
• multiple pregnancy;
• age over 35 years. In this case, the likelihood of genetic or chromosomal abnormalities in the fetus increases. In addition, by this age, people often acquire various chronic diseases;
• unfavorable anamnesis. If a woman has already had miscarriages and fetal death, there is already an unhealthy child;
• infectious diseases during pregnancy. The most dangerous are rubella, toxoplasmosis, herpes, hepatitis and infections of the urogenital area. The common flu that caused complications can also affect;
• unfavorable ecology, harmful working conditions;
• taking certain medications;
• severe stress and physical activity.

When the fetus is forming and growing, a woman should always be attentive to her health. During this period, time intervals are defined as critical:

• first 2 weeks. Unfavorable factors can cause the death of a nascent life already at the very beginning of pregnancy. In this case, the woman usually does not even know that there was a conception;
• - I am a week. The fetus is bookmarked internal organs, and pathogenic processes can lead to severe deviations. During this period, it is very dangerous for a woman to get sick, get very nervous and it is strictly forbidden to take many medicines;
• from 12 weeks to delivery. The formation of the brain, lungs, genital organs and teeth continues, therefore, at this time, with adverse factors, there is a risk of gross violations in them. In already formed systems, under the influence of inflammatory processes, secondary defects may appear.

Already at the earliest stages of development, chromosomal abnormalities (trisomy) can be detected in the embryo. These are congenital abnormalities in the set of chromosomes, the most famous of which is Down syndrome. The risk of their occurrence is high in the presence of such deviations in direct relatives, it increases in parents after 35 years.

Did you know? Often, how a child with chromosomal abnormalities will live fully depends on the parents and upbringing. Of course, this is primarily affected by aberration and the state of the organism as a whole, but usually such people can learn to serve themselves, get a job. For example, among people with Down syndrome there are famous actors, athletes and musicians.

Now the number of genetic anomalies has increased. The genetic risks of abnormalities in the fetus increase significantly in the following group of parents:

• age over 35 years;
• , the birth of a dead or non-viable child;
• the birth of a baby with pathologies;
• infertility of unknown origin and unsuccessful IVF;
• bad heredity. If there are genetic anomalies in the family, family ties, etc. Sometimes both parents are carriers of recessive genes for congenital diseases;
• taking heavy drugs for the body;
• exposure to radiation.

Pathologies of the course of pregnancy

Consider the most common obstetric pathologies of pregnancy and the causes of their occurrence.

Toxicosis and gestosis

The appearance of toxicosis is typical for the first half of pregnancy and occurs in half of pregnant women, but only a tenth needs treatment. The symptoms of this condition are vomiting (mainly in the morning), and if it occurs 1-2 times a day and disappears after the 13-16th week, then it does not cause concern. There is also weakness, drowsiness, salivation. If vomiting occurs not only in the morning, but also after eating, then it is referred to as early gestosis.

If there is repeated vomiting during the day, weight loss, palpitations, fever, a woman needs treatment. And if the number of vomiting has reached 20 and there is a significant loss in weight, then urgent hospitalization is required. The cause of early toxicosis is the restructuring of the body of a pregnant woman for bearing the fetus and the formation of the placenta. The causes of late toxicosis are already different, and it is referred to as preeclampsia, which also manifests itself as edema, high blood pressure, and the presence of protein in the urine.
The risk of preeclampsia increases in the presence of the following factors:

• age. It is more often diagnosed in mothers under 18 years of age or over 35 years of age;
• heredity. If preeclampsia was found in women in the family;
• chronic diseases. Usually found in diseases of the cardiovascular system or kidneys, high blood pressure;
• endocrine pathologies;
• lack of vitamin B9 (folic acid);
• nervous stress;
• thrombophilia and a tendency to thrombosis.

Did you know? In the presence of preeclampsia, the death of the fetus and newborn increases by 5-7 times. The causes of this condition often remain a mystery to doctors.

placenta previa

It is the attachment of the placenta above the cervical os or near it. In this case, the pharynx partially or completely overlaps. This condition manifests itself mainly by bleeding from the female organs. They occur most often in the second half of pregnancy, after the 30th week. They can be provoked by the slightest load, but can also occur at rest. Before childbirth, this bleeding intensifies.
Types of placenta previa

The factors that caused may be:

• endometrial diseases (, etc.);
• diseases and anomalies of the uterus (, etc.);
• surgical interventions (, and others);
• multiple pregnancy;
• diseases of the cervix;
• inflammatory processes affecting the endometrium.

Anemia

A decrease in hemoglobin manifests itself in the appearance of increased weakness, migraines, shortness of breath, low blood pressure and can cause fainting. Any physical activity begins to seem unbearable. This condition is easily detected by a blood test. Most often the reasons are as follows:

• defective . Lack of protein, iron, or vitamins B and C, necessary for the absorption of this trace element, can lead to a lack of hemoglobin. Often occurs in vegetarians;
• toxicosis and gestosis. Vomiting and weight loss in these conditions deprive the body of a pregnant woman of the necessary substances;
• chronic diseases of the digestive system. These diseases reduce the digestibility of food;
• multiple pregnancy;
• frequent uninterrupted labor.

Miscarriage

If the pregnancy was interrupted by itself before the 37th week from the day of the last menstruation, then this is referred to as a pathology. This condition is accompanied by the following symptoms:

• , spasms;
• bloody discharge from the birth canal;
• pain, weakness, dizziness;
• nausea and vomiting;
• elevated temperature.

The causes of fetal loss may be the following:

• pathology of the uterus (fibroids, cysts, bicornuate uterus, etc.);
• chromosomal diseases of the fetus;
• endocrine problems;
• infections affecting the genital area (venereal diseases, herpes, etc.);
• immunological factors (incompatible cells in parents, etc.);
• adverse environmental impact;
• chronic diseases of the heart and other organs, anemia;
• other pathologies of pregnancy.

Low water and polyhydramnios

Deviations amniotic fluid from a normal amount adversely affect the fetus. With their excess (), pressure on the internal organs increases. In this case, the following symptoms appear: shortness of breath, abdominal pain, swelling and other ailments. All these signs are characteristic of a normal pregnancy on later dates, but appear earlier. The most dangerous is the acute form, when the volume of water increases sharply within a few days.

In severe cases, the bladder is punctured (amniocentesis) and excess fluid is drained. Insufficient amount of amniotic fluid (oligohydramnios) negatively affects the development of the child and can lead to premature detachment of the placenta. Pronounced polyhydramnios reveals itself as an increase in the abdomen, which can sink due to its heaviness, pain in the lower back and perineum. Often, polyhydramnios and oligohydramnios do not manifest themselves in any way and are detected during examination using ultrasound.
The causes of polyhydramnios can be:

• infectious diseases (, and others);
• diabetes;
• Rhesus conflict;
• fetal pathology.

develops due to the influence of the following factors:

• infections;
• high pressure;
• obesity in a pregnant woman;
• prolongation of pregnancy;
• pathology of fetal development;
• abnormalities in the placenta;
• late gestosis.

Malposition

The situation when the axis of the fetus does not coincide with the axis of the uterus begins to interest obstetricians not earlier and can be corrected with the help of gymnastics (if there are no contraindications). The doctor can determine the incorrect position of the fetus by the shape of the uterus, but will give the most complete information.
Fetal position

The reason for this condition may be the following:

• multiple pregnancy;
• violations of the shape of the uterus;
• polyhydramnios;
• in women who give birth often due to poor uterine tone;
• heredity. If such a situation occurred with close relatives.

If the situation has not improved, then a few weeks before the planned birth, the woman is hospitalized in the department of the maternity hospital.

Uterine hypertonicity

The increased tone of the uterus in the early juices manifests itself as heaviness and pain in the lower abdomen, radiating to the lower back. For some, they are similar to ailments during menstruation. In the second half of pregnancy, with these symptoms, hardening of the abdomen can also be observed.

Important! With the appearance of such a threatening symptom as spotting, the pregnant woman must immediately seek medical help.

The reasons for the appearance may be:

• hormonal abnormalities ();
• severe toxicosis;
• uterine anomalies;
• inflammation of the genital organs;
• Rhesus conflict;
• multiple pregnancy or big sizes fetus;
• polyhydramnios;
• chronic diseases (hypertension, diabetes mellitus and others);
• increased gas formation;

These are the most common factors causing increased tone uterus, but there may be other reasons.

Extragenital pathology

Pregnancy against the background of extragenital diseases can occur with complications and affect the health of the fetus. The most common in pregnant women are the following pathologies:

• diseases of the cardiovascular system;
• hypertension or hypotension;
• kidney and liver diseases;
• blood diseases;
• lupus erythematosus and other connective tissue problems;
• diabetes;
• respiratory diseases;
• gastrointestinal ailments.

And it's not full list. Most often, pregnancy pathologies occur against the background of cardiovascular diseases (80%). All these diseases worsen during the period of bearing a child and require constant monitoring by the attending physician (therapist, cardiologist, endocrinologist, nephrologist, etc., depending on the disease).
With a planned pregnancy, you should seek advice from a specialist on an existing chronic disease before conception, undergo a comprehensive examination and treatment. Observation and proper timely treatment before and during pregnancy can significantly reduce the negative consequences.

Did you know? According to statistics kept in obstetric hospitals, only 30% of pregnant women are in good health, and 70% suffer from extragenital diseases.

Fetal pathologies

Pathological changes in the fetus occur under the influence of genetic and external factors. In this regard, congenital and acquired deviations from the norms appear. Genetic pathology occurs from the moment of pregnancy and is diagnosed in the early stages, but the acquired ones can appear at any time the baby is waiting. Chromosomal abnormalities are congenital. Consider the main such deviations:

Diseases arising from the wrong number of chromosomes:

• Shereshevsky-Turner syndrome. One X chromosome is missing in female children. Signs - small growth, violations of the sexual sphere, deformity of the joints, folds in the neck, deviations of a somatic nature;
• polysomy of the X chromosome. Signs - a slight lag in the development of intelligence, mental disorders, usually in the future high growth with a curvature of the spine. In the future, such a woman can give birth to a healthy child;
• polysomy of the Y chromosome. The signs are the same as on the X chromosome;
• Klinefelter syndrome. It is observed only in male children. Signs - poorly expressed hair growth throughout the body, anomalies of the genital area (both external and internal), high growth, often a lag in the development of intelligence.

Important! Genetic pathologies cannot be corrected, and they are not treatable.

Acquired pathologies arise under the influence of adverse external influences on the development of the embryo. These factors are:

• mother's illnesses while waiting for the baby - viral and bacterial infections (flu, rubella, hepatitis B and others), sexually transmitted diseases (syphilis, and others);
• poor ecology, increased radiation, the presence of many harmful industries near residence;
• chronic diseases of the mother;
• stress;
• unhealthy lifestyle of the expectant mother (alcohol, drug addiction, smoking, etc.).

With acquired pathology, the following deviations are most common:

• deformation processes in organs within the body or their absence (for example, there is no one kidney or pancreas), the absence of certain parts of the body (for example, legs, fingers or hands);
• facial defects;
• cardiac disorders;
• cerebral hypoexcitability. Observed after the birth of children. Signs - muscle weakness, constant drowsiness, lack of appetite, the baby does not cry. Such disorders can be cured;
• cerebral hyperexcitability. Signs - strong muscle tension, chin trembling, constant anxiety (the baby is constantly crying and screaming). This deviation can also be cured;
• hypertensive-hydrocephalic syndrome accompanied by increased intracranial pressure. It occurs due to excessive production of CSF (cerebrospinal fluid), which then lingers in the meninges and ventricles. It is very important to diagnose this disease in a timely manner. It is expressed by an increase in the size of the head, the fontanel protrudes somewhat, strabismus, convulsions, and mental retardation may appear.

Anomalies in the development of the fetus for uncertain reasons can be attributed to a separate group. This is, first of all:

• pathological deviations of the umbilical cord of the fetus. Such anomalies can contribute to the occurrence of a lack of oxygen and the death of the unborn baby;
• multiple pregnancy (Siamese twins);
• oligohydramnios or polyhydramnios;
• pathological processes in the placenta.

All of these deviations require special attention from doctors and future parents. Pregnant in such a situation, it is important to remain calm and feel the support of loved ones.

Diagnosis of pathologies

A woman should be registered in the antenatal clinic and regularly observe the pregnancy with a gynecologist, provide the doctor with all necessary information about their health and working conditions. Even if the pregnancy proceeds normally, a woman must take the following tests at a certain time to identify pathological processes:

• general blood analysis;
• blood chemistry. Allows you to determine the level of sugar and identify deviations;
• general urine analysis. Do at least 1 time per month and help control kidney function and other problems;
• vaginal swab. They take it first at registration and at the 30th week. Detects the presence of urinary tract infections;
• a blood test that determines its group and Rh. Hand over in the presence of a Rh-conflict with the father of the child at the beginning of pregnancy;
• blood test for venereal infections(syphilis and others);
• . It shows blood clotting. It is carried out every trimester, but in case of hemostasis disorders, it is given more often;
• "triple test"( , NE, ). They are done at the 16–20th week to establish abnormalities in pregnancy and in the fetus.

Alpha-feroprotein (AFP) is a protein produced at the onset of conception, as well as hCG (“pregnancy hormone”). Their deficiency or excess may indicate various complications of pregnancy and fetal anomalies. A lower result indicates chromosomal abnormalities, but such a result may be the result of other problems.

Let's get acquainted with the norms of AFP by weeks of pregnancy in the table:

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Consider the norms of hCG for weeks in the blood of pregnant women:

Term	Mean value, (mIU/ml)	Permissible limits, (mIU / ml)
2 n.	150	50–300
3–4 n.	2000	1500–5000
4–5 n.	20000	10000–30000
5–6 n.	50000	20000–100000
6–7 n.	100000	50000–200000
7–8 n.	80000	40000–200000
8–9 n.	70000	35000–145000
9–10 n.	65000	32500–130000
10–11 a.m.	60000	30000–120000
11–12 a.m.	55000	27500–110000
13–14 n.	50000	25000–100000
15–16 n.	40000	20000–80000
17–20 N.D.	30000	15000–60000

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When registering, a pregnant woman makes a round of doctors (therapist, ophthalmologist, dentist), makes an ECG. When determining the pathologies of pregnancy associated with the threat of its failure, future mother can put in an obstetric hospital and there to observe, diagnose and treat.

on the th week. The same studies are done as in the second ultrasound. The parameters of the placenta are also evaluated. Pathologies that were not noticed before may be detected. This study is usually accompanied by cardiotocography, which is necessary to assess the baby's heartbeat, and doplerometry, which studies the blood flow between the baby and his mother.

Ultrasonography can be carried out before childbirth to determine the position of the fetus and its entanglement with the umbilical cord, its general condition. Such studies largely depend on the competence of the doctor and the quality of the equipment. Cases when, according to the results of ultrasound, a boy is expected, and a girl is born, or abnormalities were diagnosed, but a healthy child was born (and vice versa), are not uncommon.

Therefore, the definition of pathology should be approached comprehensively in order to eliminate errors. If an ultrasound scan repeatedly (by another doctor and using more modern equipment) diagnoses abnormalities in the fetus and the markers show a greater likelihood of malformations, then the possibility of having a child with abnormalities is high, but not 100%, and it is better to be further examined .. Blood from the umbilical cord is examined . It is carried out after the 20th week.
All these studies are carried out in the first half of pregnancy, and only cordocentesis is done after the 20th week. The sampling of biological material is traumatic and is associated with risks of 1–5% (miscarriage, infection, etc.), and the woman herself decides whether to undergo it. If a woman, for ethical or religious reasons, wants to keep a child with disabilities, then it makes no sense for her to go through them. The decision to maintain or terminate a pregnancy is always made by the woman.

Therapeutic treatment of all types of pathology is carried out without fail at a hospital in the gynecology department. Outpatient treatment is allowed only for a mild form of early toxicosis and the initial stage of preeclampsia.

As a rule, in order to avoid problems, preventive measures against the occurrence of pathology during a planned pregnancy can be started already before it, eliminating bad habits, changing harmful work to an easier one, taking vitamin B9 and passing tests for infections that can interfere with the normal course of pregnancy.

Important! First of all, it is necessary to register in a medical institution in a timely manner and visit a gynecologist, pass all the necessary tests and undergo all the necessary studies. Follow all the doctor's recommendations for taking vitamins, nutrition, lifestyle.

It is also necessary to resolve the issue of chronic diseases that can affect the process of bearing a child. Future parents at risk should seek advice from a geneticist and undergo recommended examinations. It is important to follow all the prescriptions and recommendations of the doctor:

• control diseases of a chronic nature, which can worsen during the period of bearing a baby. Be sure to report them to your gynecologist;
• monitor your health and, if something bothers you, seek medical advice;
• only with a trusted partner;
• adhere to a healthy diet, take the necessary;
• special physical exercises and walks in the fresh air help to keep the future woman in good shape and strengthen the body;
• weight control, weight gain;
• refusal of bad habits (smoking, alcoholic beverages, coffee, etc.);
• prevention and timely treatment of colds and infectious diseases as prescribed by a doctor;
• avoid stress and physical overload;
• when working in hazardous production, change the type of activity;
• carry out timely prevention of preeclampsia, constantly weigh yourself, monitor pressure, take the necessary tests, undergo ultrasound.

Pathologies can overshadow any pregnancy, negatively affect the child, so it is important to monitor your health, take all tests and undergo all recommended studies. With a planned pregnancy, many of them should be taken before conception and get rid of bad habits. Women with extragenital diseases should also get advice from doctors who have registered them even before pregnancy. Couples at risk are advised to be examined by a geneticist.

In the field of obstetrical and gynecological conditions and pathology, mental factors are of particular importance in pregnancy, infertility, premenstrual syndrome and menopause. It is under these conditions and processes that there is a close interweaving of psychological and obstetric-gynecological factors. The mental state of women has specific features that differ from the typical reactions of men to diseases in other areas.

Features of the mental state of a woman during pregnancy for many years attract the attention of specialists. At the same time, both the emotionally negative role of pregnancy and the positive one are noted. Hippocrates wrote about the favorable effect of pregnancy on various mental disorders, pointing out that: “I prescribe marriage for hysterical girls so that they can be cured by pregnancy.”

All kinds of features in the psychological state of a woman during pregnancy can be considered as a manifestation of the adaptation of the body and personality of a woman to the onset of pregnancy and evaluate these manifestations from the standpoint of different levels of adaptation. The biological level of adaptation in the first half of pregnancy is significantly influenced by one of the ovaries, in the second - by the uterus. The tone of the vegetative nervous system as pregnancy develops, it increases abruptly, revealing the existence of peculiar critical periods for the mother's body. So, in terms of up to 12 weeks, the tone of the sympathetic-adrenal system prevails, in the second half - 28-30 weeks, the tone of both departments increases, but with a certain predominance of cholinergic reactions. From the standpoint of the analysis of neurodynamic processes, the emotional state of pregnant women is characterized by the fact that in the presence of a positive emotional background in the last months of pregnancy, there is an active state of cortical processes, leading to an increase in the threshold of pain sensitivity. As a result of negative emotions, overstrain of the central nervous system, the functional activity of the cortex weakens, and the threshold for pain sensations decreases. As a rule, these states depend on the expectation of a desired or unplanned child, a positive or negative attitude.

There is a typical dynamics of psychological manifestations during pregnancy. Usually in first months the pregnant woman feels insecure, remains ambivalent about the upcoming motherhood. Fear of the unknown can lead to depression. A pregnant woman likes (more or less consciously) her condition, she wants to be the subject of attention and care, at the same time, she feels that she is growing up, two tendencies are fighting in her - infantilism and growing up. This duality, often disturbing, can cause mood swings that are not always clear to others. In second trimester there is relative calm in the state of a pregnant woman, incidents are quite rare, complications - in healthy women - an exception. main feature third trimester -"immersion in the child", the child became the focus of the thoughts, interests and activities of the expectant mother. Directly before childbirth anxiety increases, the manifestation of which may be the hyperactivity of a pregnant woman who wants to speed up events. Psychological disorders in the last trimester are observed in 60-80% of cases.

An important psychosomatic problem is the problem of preeclampsia in pregnant women. It is known that in women with a pronounced unwillingness to have a child, a severe form of toxicosis is more often observed, in contrast to women with a desired and planned pregnancy. Representatives of foreign medicine, using the concept of the symbolic language of organs (A.Adler), interpret the vomiting of pregnant women as a symbolic expression of the unwillingness of pregnancy and the birth of a child. Other scientists, based on the principles of the teachings of Z. Freud, consider early gestosis of pregnant women as a result of "weakening of the will to motherhood in connection with the development of civilization" or as a manifestation of unconscious disgust for her husband.

In domestic medicine, most authors evaluate the phenomenology of gestosis depending on the functional state of the nervous system and psychological state (including characterological premorbid) of a pregnant woman. V.M.Volovik distinguishes two groups of patients. The first group includes women with minor affective disorders, manifested in the form of irritability, irascibility, tearfulness and resentment. These disorders occur at the height of gestosis and are quickly eliminated after the disappearance of vomiting and the normalization of the general condition. In all women of this group, the psychological characteristics practically do not differ from healthy pregnant women. Everyone has a positive attitude towards pregnancy, a favorable family situation. They are characterized by a harmonious personality, a realistic approach to emerging difficulties. Analyzing the causes of preeclampsia and the accompanying affective disorders in patients of this group, the author comes to the important conclusion that any pregnancy, including those proceeding completely normally, is in itself always a source of greater or lesser mental stress, which is why indifferent in the past, elements of the environment and situations acquire a different subjective meaning and become the cause of personal reactions. In the second group, the picture of the disease is characterized by significant polymorphism: in addition to vomiting and nausea, chills with hyperthermia, headaches, fainting, arterial pressure lability, hyperhidrosis are often noted here. Affective disorders are more common and more pronounced: some patients experience anxiety, a sense of pointless anxiety and tension that arises against their will. Many have neurotic disorders and autonomic disorders that have not been observed in them before. The conducted research allowed the author to substantiate psychosomatic nature of early gestosis of pregnant women, to show that psychogenic factors (along with pregnancy itself) are presented in a number of pathogenetic links with the greatest constancy, and often act as the main pathogenetic factor.

The prevalence of mental disorders in pregnant women ranges from 6% to 34%. They are presented as pre-nosological manifestations of impaired psychophysiological adaptation, as well as clinical psychopathological symptoms. Severe mood swings and other emotional changes have long been considered as characteristic physiological features of pregnant women, while these manifestations are mental disorders. G. Caplan shows that women in late pregnancy have introversion, passive dependence, depression, lack of self-confidence and fear of future motherhood.

Before giving birth, the health of the unborn child worries the vast majority of women. At the same time, in most pregnant women, concern about the condition of the child tends to increase as the birth approaches. Many pregnant women tend to worry about the possible effects of drugs, and some women about pain relief methods. Described phenomenon of prenatal anxiety and its impact on pregnancy outcome. In a pregnant woman, as a rule, several types of anxiety are detected: 1) generalized; 2) physical, when a woman has a hard time enduring the physical aspects of pregnancy; 3) fear for the fate of the fetus; 4) fear of the need to care for a newborn; 5) fear of childbirth; 6) fear of feeding a newborn; 7) psychopathological phenomena of anxiety. Anxiety about upcoming parenthood is more typical for older women.

The frequency of depressive phenomena of varying severity ranges from 10% to 14%, tending to worsen as pregnancy progresses. There is a pronounced dependence of depression on the presence of psycho-traumatic factors of a family nature and serious fears associated with the birth of a child, and a statistically significant dependence of depression on such psychogenic factors as: a high level of neuroticism, a psychiatrically burdened anamnesis, marital conflicts during pregnancy, fears regarding the fetus, thoughts about abortion during pregnancy, feeling of loss in the second and third trimesters, smoking during pregnancy.

One of the most well-known pathological behavioral phenomena during pregnancy is considered "fetal abuse syndrome" characteristic of patients with psychopathy of the excitable circle. This syndrome is noted in the period of relatively late pregnancy and is characterized by aggression directed at the fetus itself, in contrast to cases of deliberate provocation of abortion. This refers to the direct physical impact on the fetus (blows on the anterior abdominal wall) from the pregnant women themselves. Similar aggressive behavior can also be observed in women with a desired pregnancy.

Study relationships between changes in mental state and the menstrual cycle has a long history and goes back to the naive-materialistic idea of ​​psychosis in women as a consequence of uterine disease. Functional menstrual disorders in gynecological practice are extremely common and account for approximately one third of all menstrual disorders in women of childbearing age. With functional gynecological syndromes, various mental disorders occur. Of the most common syndromes, there are hypochondriacal, depressive,

overvalued formations, hysterical, hypomanic and obsessive-phobic syndromes are less often detected (V.N. Ilyin). There is a high frequency of affective syndromes: anxious, dysphoric, somatized depression. Similar mental states are found in patients with amenorrhea. It is believed that psychogenic dysmenorrhea occurs, as a rule, in emotionally unstable, anxious women with a distinct tendency to lower mood. The immediate cause of this syndrome is quite strong or too often repeated disappointments, disappointments and experiences. The development of psychogenic dysmenorrhea is also caused by “anxious expectations of the next menstruation” that occur after a mental shock or the first menstruation, with fear of pregnancy or abortion, or, conversely, with a passionate desire to become pregnant.

Menstrual disorders, and especially amenorrhea, which makes up about 2/3 of the nosological forms of endocrine and gynecological diseases, are of great social importance due to the fact that they often result in infertility. The negative impact of infertility on human behavior and consciousness is often associated with distress and the development of the so-called. "problem marriage" According to the WHO, a marriage is considered infertile if, despite regular sex life without the use of contraceptives, the wife does not become pregnant within a year, provided that the spouses are of childbearing age. The mental state of infertile patients can be decisive in the origin of some forms of infertility. It is indicated (T.Ya. Pshenichnikova) that infertility in marriage is a social, mental and often physical trouble. All three of these factors are closely interrelated and often influence each other. Thus, mental ill-being is manifested by an increase in the lability of nervous processes or lethargy, a decrease in interest in the environment and work, the emergence of inferiority complexes, psychosexual disorders, and the instability of family relationships. With male infertility, three-quarters of wives psychologically support their husbands, and with female infertility, only a fifth of the husbands are in favor of divorce, and the relationship becomes most aggravated after 3 years of fruitless marriage (EA Volkovich). interpersonal relationships spouses in an infertile marriage are much more often found in female infertility than in male infertility. Such violations are not only important for individuals in infertile marriages, but also have an impact on society as a whole, increasing the number of divorces and reducing the social activity of this part of the population.

McEwan identifies a number of situations in which one should expect the development of mental disorders in patients: 1) young women profess a religion that treats infertility as a sin; 2) women do not have a normal relationship with their spouse; 3) women have been exposed to various stresses during their lives; 4) women for whom the diagnosis of infertility is a surprise (for example, in the absence of somatic complaints).

Infertility includes a violation of the "sense of self-worth" and "body image". Feelings of personal inadequacy, loss of sex appeal, and "social incompleteness" often accompany this diagnosis. It is impossible not to take into account the fact that all large religious groups accept the birth of a child as a necessary completion of marriage, because. the biblical doctrine of fertility is the cardinal principle of marriage. In this regard, in the civil sphere, the vital function of the family is its replenishment, and childlessness, thus, indicates dysfunction and disorganization of the family. The belief that parenthood is seen by society as the most important function of marriage contributes to the feeling of "failure". Parenthood is equated with natural behavior, which indicates the belief in the presence of reproductive control or parental instinct that needs to be exercised. Reproduction can be perceived as the fulfillment of a sexual role: motherhood as the development and expression of the adulthood of a woman and fatherhood as the development and expression of the adulthood of a man. Childlessness, on the other hand, can testify to society about female genital qualities and male potency.

There are several stages of emotional response to infertility DX.Rosenfeld and E.Mitchell): surprise, grief, anger, isolation, denial and agreement. The initial reaction is one of surprise, followed by a period of shock and anguish, followed by recovery, as can be seen "after the death of a loved one." This "mourning process" is similar to the loss of desire to exist and is exacerbated by feelings of guilt, shame, and social inadequacy. Feelings of depression can "feed" inner anger, which is heightened by the frequently asked question "Why me?". The emerging desire to isolate and reduce contact makes such patients difficult to discuss and treat.

One of the important issues in diagnosing the condition of infertile patients is the assessment of their motives for having a child. At the devil

For fetal couples, there are motives that are somewhat different from the traditional motives of childbearing, Erikson proposed the term "generativity", which reflects not only the reproduction process, but also the person's need to care for the child and responsibility for his upbringing. There are other reasons to have a child - "keep the husband", "fill the void", maintain family traditions, etc. For many patients with infertility, the question of the motive for having a child remained unclear and unconscious. They make rational arguments that the child is needed, for example, for a “fuller life” or for a “good partnership”.

Many foreign researchers are inclined to explain the origin of infertility, especially psychosomatic, from the point of view of psychoanalysis. Some of them try to find the cause of infertility in early childhood. Restriction by a shy system of taboos or, on the contrary, unbridled sexual behavior of parents can have an inhibitory or deforming effect on the child. In the course of psychosexual development, various direct or indirect influences can build undesirable schemes in the structure of the personality, which can later become the cause of "inhibition of the female role."

R.J. Pepperel divides women suffering from psychogenic infertility into 3 main groups. The 1st group includes women whose infertility can stop spontaneously, and intensive examination can easily "break the barrier that prevents conception." The 2nd group includes women with a more stable "blockade" of conception, possibly occurring as a result of some external stressful situation. The 3rd group consists of women whose infertility arose "as a result of deep and prolonged psychosomatic stress associated with the presence of psychogenic fears." In this case, the peculiarities of the idea of ​​pregnancy and motherhood, formed in the process of education, are essential. They can deeply disrupt their mental balance, and any deviations and conflicts in this area lead to the fact that these women experience a strong fear of pregnancy, and infertility occurs in them as a psychological defense. These women may find a conflict between the conscious desire to become pregnant and the unconscious refusal of pregnancy and motherhood.

Deutsch describes certain types of women suffering from infertility: 1) immature, sensitive, picky women,

childishly capricious towards her husband and prone to functional disorders; 2) aggressively dominant women who do not agree to recognize their femininity; 3) mother-like women who, rightly or wrongly understanding their husband, feel that they are unable to copy him in children and therefore transfer their maternal instinct to caring for him; 4) women who have devoted themselves to ideological and other interests.

Many researchers emphasize the great importance of mental disorders and stressful influences in the origin of the so-called. "unexplained infertility". Unexplained infertility can be diagnosed if the partner is fertile, has a positive postcoital test, and fallopian tubes in women with regular ovulatory cycles and accounts for 4-40% of the total number of infertility (T.Ya. Pshenichnikova). Most of these patients have various psycho-emotional deviations, feelings of inferiority and loneliness, the presence of "hysterical states" on the days of ovulation or menstruation, which indicates "pregnancy waiting syndrome"(T.A. Fedorova).

One of the most famous in gynecological practice is premenstrual syndrome. Clinical symptoms of premenstrual syndrome appear, as a rule, 2-14 days before menstruation and disappear immediately after it occurs or in its first days. The combination of symptoms may be different, but most often the clinical picture presents borderline mental disorders, accompanied by abundant autonomic symptoms. Characteristic are irritability, low, sometimes angry mood, tearfulness and tearfulness, slight vulnerability, emotional lability, sleep disturbances, headaches and dizziness, inability to concentrate on the work performed, fatigue. In addition to these symptoms, itching of the whole body, tachycardia, various pains and discomforts in the region of the heart, fever, chills, engorgement of the mammary glands, and others are often found. Depending on the number of symptoms, the duration and intensity of their manifestations, premenstrual syndrome is divided into into light and heavy forms. The mild degree (form) includes asthenic and astheno-depressive symptom complexes in the presence of complete criticality of patients to the manifestations of the disease. In a severe degree (form), there is a slight decrease in criticality to the disease and one's behavior (within the non-psychotic level of mental disorders), a greater cohesion of the symptoms of the disease

with the personality of patients, the relative frequency of hysterical and hypochondriacal complaints. The severity of vegetative-vascular symptoms in premenstrual syndrome is not always directly dependent on the mental state. Diencephalic crises, which are considered the most severe manifestation of the autonomic dysfunction of the hypothalamic region, are more often combined with a severe form of premenstrual syndrome, although they can also occur with a mild form.

Borderline mental disorders detected in sick women with premenstrual syndrome are noticeable not only by the patients themselves, but also by their relatives. During the appearance of painful symptoms, a woman creates multiple conflict situations at home and at work, which leads to emotional experiences of both the patients themselves and those around them, their relatives and friends. If in the first half of the menstrual cycle, patients, as a rule, are good-natured, benevolent, self-possessed, calm, their behavior is ordered and corresponds to the prevailing stereotype, then with the approach of menstruation, the appearance of inadequate reactions and behavior can be increasingly noted. It should be noted that personal and characterological qualities in the first half of the menstrual cycle still sometimes tend to sharpen.

With a mild form of premenstrual syndrome, a woman independently consults a doctor, seeks help, understands the painful nature of the symptoms of the disease. In a severe form, as the disease progresses, symptoms appear that affect the personal level of response. At the same time, selfishness, captiousness, demonstrativeness, the desire to benefit from one's position, and a decrease in self-criticism begin to come to the fore. Patients demand increased attention from their relatives, forcing the latter to fulfill their every whim: during this period it was impossible to turn on the TV or tape recorder, turn on bright lights, and leave the house for a long time. The slightest “wrong step” caused a violent hysterical reaction from the wife, who believed that all the actions of her relatives were aimed at driving her “out of herself” or “driving her into the grave.”

Often with premenstrual syndrome, hypochondriacal symptoms occur, which can be presented in both mild and severe forms. They are manifested in increased suspiciousness of patients for their health, exaggeration of the severity of existing symptoms. At the same time, some women become intrusive, ready to complain about their well-being to “everyone they meet”. It should be noted that with a severe form of premenstrual syndrome, it is not the patients themselves who turn to doctors more often, but relatives who notice a change in the behavior of women bring them to treatment, which can be regarded by those as an insult.

Downstream, premenstrual syndrome is divided into three types: compensated, subcompensated and decompensated. The first type includes conditions in which the symptoms of the disease do not progress over the years, i.e. premenstrual syndrome flows cliche-like without the inclusion of new symptoms or the aggravation of old ones that have already taken place. Outside of the manifestations of the disease, the woman feels completely healthy. The subcompensated type of flow includes premenstrual syndrome, the manifestations of which increase in time over the years, but do not exceed, on the one hand, the middle of the menstrual cycle, on the other hand, the beginning of menstruation. The decompensated type of the course of premenstrual syndrome causes a simultaneous gradual aggravation of the clinical picture and an increase in the duration of the manifestation of the disease. With this type of flow, and after the end of menstruation, some symptoms of the disease do not completely disappear. The mild form of premenstrual syndrome is more often combined with compensated and subcompensated types of flow, the severe form is combined with decompensated.

The variety of manifestations of premenstrual syndrome fits into the following psychopathological symptom complexes: asthenic, anxiety-depressive, hystero-hypochondriac, dysphoric and mixed. Of particular interest is the dysphoric form of premenstrual syndrome. As early as the end of the last century, Kraft-Ebing wrote: “Very many women, being gentle spouses and mothers, lovely housewives and pleasant interlocutors in society, completely change in their character and treatment as soon as their regulars appear or approach. . It's like a storm - they become picky, irritable and grumpy, sometimes turn into real furies, which everyone fears and avoids. In court proceedings at the end of the last century, women who committed a crime during the menstrual or premenstrual period were recognized as insane, which may indicate that forensic doctors regarded the pathological condition of women associated with menstruation as a particularly serious illness, equated, apparently, with psychosis.

It is no coincidence that Kraft-Ebing compares the changes in the character of women / in the premenstrual period with the character of the furies (goddesses of vengeance) and the designation of such a state by M. Schlobies with the concept of "dysphoria". Diagnosis of the latter is based on the leading symptoms in the clinical picture - on psychologically unmotivated anger, irritability, anger. The clinical similarity of premenstrual syndrome with dysphoria is also confirmed by the critical attitude of women to the metamorphosis that occurs with them during the approach of menstruation. After this period, they are usually ashamed of "their antics", "do not imagine" that they could behave so "ugly". The relationship between the occurrence of a dysphoric variant of premenstrual syndrome and sexual conflicts of a woman and, in particular, with anorgasmia was revealed. Orgasm is physiologically a “discharge”, which is emotionally manifested by a paroxysmal feeling of satisfaction, and an electroencephalographic study at the time of orgasm describes the appearance of a “peak-slow wave” complex (W.H.Masters, V.E.Johnson, R.G.Heath). It is traditionally believed that the absence of an orgasm does not cause any pathological disorders and does not bring discomfort to a woman. However, it can be assumed that acquired anorgasmia clinically manifests itself in the form of psychopathological symptoms only in the premenstrual period (and not in other periods of the menstrual cycle), which is due to the fact that the orgastic ability (possibility) of a woman usually increases precisely when menstruation approaches. That is, the psychopathological symptomatology is vicarious in relation to the orgastic function. It is also important that in the character of women with premenstrual dysphoria one can see such properties as: rigidity, persistence of affects, some explosiveness, pedantry, ambition, inertia of attitudes. It is possible that the disappearance of the developed during sexual life and the necessary emotional and physiological "discharge" transformed the preorgasmic tension into a negatively colored premenstrual dysphoria.

The climacteric period in a woman's life is associated with age-related restructuring of the hypothalamic region, leading to a violation of the cyclical nature of menstruation and the cessation of reproductive ability. According to V.M. Dilman, menopause is both a norm and a disease: a norm because menopause in the female body is a natural phenomenon, and a disease because it is a persistent dysregulation that ultimately leads to a decrease in the body's viability. reproductive function is nothing but kvass increase in the hypothalamic threshold of sensitivity to the regulatory influence of sex hormones. The same compensation process, which is an integral part of the developmental mechanism, causes pathological changes or disease over time. Based on the mechanism of occurrence, such developmental diseases are called compensation diseases. Acting in the same team of unity, the opposites do not lose their essence: an increase in the duration of the childbearing period simultaneously creates conditions leading to an earlier termination of life due to aging diseases. The two faces of menopause, both norm and disease, characterize the absence of a line between age and disease, between norm and pathology, exposing once again the essence of the unity of opposites hidden in every natural phenomenon (V.M. Dilman).

The criteria for the physiological (normal) course of menopause should be recognized as adaptive processes both at the level of the soma and the psyche. The concept of pathological menopause, in turn, includes various pathological manifestations of the involutionary process that violate both somatic and mental health.

The frequency and severity of menopausal symptoms can be significantly influenced by biological, as well as cultural and socio-economic factors. The latter include: a) the social significance attached in certain ethnic groups to menstruation and the release from the stigma of menstruation after menopause, b) the social significance of childlessness; c) the social status of women in the postmenopausal period; d) the attitude of the husband to his wife in the postmenopausal period (for example, as a sexual partner); e) the degree of socio-economic deprivation experienced during this period; f) the degree of change in the role of women during this period and the possibility of her performing new or alternative functions; g) accessibility medical care due to perimenopausal symptoms. To date, very few comparative studies have been conducted to examine attitudes and responses to the state of menopause in different ethnic groups. The results obtained point to stark differences due to complex causes. Thus, women belonging to a certain (and relatively wealthy) Indian caste had fewer complaints during menopause than US women (M. Flint). It is believed that this is due to differences in the position of such women; Indian women are liberated from the yoke of many restrictions and gain a higher status, while American women foresee the loss of their position in a "youth-oriented" society. Differences have also been noted between middle-class Jewish and Cuban women in the US, with the latter experiencing great difficulty with menopause. Moreover, the social integration of such women is much lower, and the reasons for these apparent ethnic differences can be quite complex. Differences were also found in attitudes towards the state of menopause when examining 5 ethnic groups of women in Israel (4 Jewish, respectively, of Central European, Iranian, Turkish and North African origin and 1 Arab), and similar somatic complaints were recorded, including hot flashes and sweating. Arab women were the most positive about the "climacteric crisis", European women were the most worried about it, while Iranian women were the most negative and complained a lot. The most significant differences were in the area of ​​assessment of marital relations. At the same time, Arab women hoped that their husbands would show more interest in them after menopause, while Jewish women of Iranian origin were very pessimistic. The authors of this study concluded that their data clearly demonstrate the importance of ethnic characteristics in the formation of mental and psychosomatic symptoms and the perception of menopause. In the origin of the psychopathological symptoms of menopause, some social and cultural features (profession, level of well-being, education) may matter.

The question of clinical features is cardinal physiological and pathological menopause. Most authors consider menopause to be physiological, proceeding without pronounced pathological symptoms, with a gradual fading of menstrual function and manifested by various signs, which, however, do not cause symptoms of the disease. The concept of a disharmonious menopause includes the two most typical manifestations transition period- dysfunctional uterine bleeding and climacteric syndrome. Pathological manifestations of the menopause attract the attention of psychologists and psychiatrists in that often the clinical picture of the disease associated with menopause is exhausted by psychological phenomena or psychopathological symptoms and syndromes.

Painting climacteric syndrome consists of psychopathological, vegetative and endocrine symptom complexes. P. Malinovsky pointed out the connection between mental abnormalities and menopause in 1855: women's life there are many cases where the case is not without insanity. And further: “When a person moved for 40 years, when he saw how scattered bubble created by him when he drank enough from the cup of life and found out that only the edges were smeared with nectar, when he said in himself “vanity of vanities”, and especially if all this is joined by already rooted disturbances in the functions of the liver and portal vein or blockages in other abdominal viscera, it is quite natural that after this, insanity develops more often, no longer frenzied, but limited, gloomy.

Considering mental condition sick women from the standpoint of the teachings of V.N. at this age, suspicious, "anxious, easily vulnerable, insecure, indecisive, doubting everything. The system of personality relations changes especially significantly in the direction of underestimating one's own capabilities, the disappearance of life prospects, associated with an exaggeration of the severity of painful sensations. In menopausal age, a woman has many additional psychogenic factors that did not cause her concern before. These are the so-called opportunistic mental traumas associated precisely with a change in the system of personality attitudes. Such manifestations of menopause as a change in appearance (gray hair, decreased skin turgor, the appearance of wrinkles) become opportunistically pathogenic , a change in libido, the significance of which at this age increases dramatically. All this happens in violation of adaptation, with the appearance of features of rigidity, "stuck" on the slightest trouble, which in turn leads to a kind of "narrowing of the personality." Sometimes such a condition, which develops in connection with a pathologically current menopause, as a change in personality, ultimately leads to a kind of "defect", manifested by the pathology of emotions and motives. At the same time, progressive lethargy, passivity, indifference to those aspects of life that were of interest quite recently, caused emotional resonance, come to the fore.

Considering the causes of neurotic symptoms in menopausal women, V.N. Myasishchev and E.K. Yakovleva found that they primarily depend on the premorbid personality traits of patients. In addition, among patients suffering from climacteric syndrome, single women and widows are much more common than healthy ones.

Most of the psychologists in last years the leading role of the biological predisposition to the disharmonious course of menopause is questioned. Let us dwell in more detail on the argumentation of this point of view. In the well-known work "The menopause - socio-psychological aspects" U.Lehr asks the question: "Is the menopause a crisis situation today?". And she herself comments on it: “A hundred years ago, the climacteric period - if they lived to it at all, and did not die after the birth of the 6th, 7th or 8th child - meant the sudden end of the reproductive cycle that had lasted until that time and thoroughly used. The onset of menopause meant for most women a rapidly approaching death. Today, menopause begins an average of 23.6 years after the completion of the birth of the last child. Nowadays, a woman at the beginning of menopause has 25-30 years ahead of her, i.e. one third of your life. The statement “the dying beginning in this period” is somewhat exaggerated. Max Burger sees the beginning of aging (and thus the daily approach of death) at the moment of conception.

Three aspects of pathological menopause are currently found in groups of women who see their only task in the birth and upbringing of children and suddenly face a “loss of functions”: 1) the high significance of the menopause for the individual as a “turn in life”, 2) fixation of attention on physiological processes and 3) negative perception of these situations. Suddenly deprived of this goal, they feel that their future life has no meaning.

It is believed that in those cases in which a woman has unresolved problems by the age of involution (among which loneliness is in the first place), menopause is perceived as a catastrophe, as an event that destroys the remnants of hopes for a favorable resolution of the life situation. At the same time, various options for a woman's behavior associated with menopause (H. Prill) are possible: 1) indifferent (apersonal) behavior; 2) fixture; 3) development of neurotic behavior; 4) active overcoming.

The most characteristic signs of psychogeny in the involutionary period, according to V.N. Myasishchev and E.K. Yakovleva, are the experiences of the personality associated with the pathogenic contradiction of the inevitable loss of vital capabilities with still preserved vital needs. In the pathogenesis, the role of family trouble is traced (husband's infidelity, his intention to divorce, fear of family breakup due to the absence of children, reactions to a decrease in the husband's potency).

The climacteric syndrome is represented by four clinical variants: asthenic, senesto-hypochondriac, anxious-depressive and hysterical.

A person's ability to adapt to all kinds of stressful situations in life is associated with various factors, among which the structure of his personality and the prevailing stereotype of responding to frustrating events matter. From this point of view, the climacteric period in a woman's life can be compared with the extreme conditions in which a person finds himself. All this makes increased demands on the body and personality of a woman in the transitional age period, which for many of them are difficult to resolve due to violations of adaptive capabilities at an involutionary age. Women with a favorable microsocial environment (a prosperous family, caring children, grandchildren) experience the menopause relatively well, "neutralizing" the significance of the menopause by switching interests to family or other activities. Elastic in adolescence, there are many unresolved problems (loneliness, etc.), which determine their attitude to menopause as a catastrophe. In a number of cases, menopause is a particularly significant phenomenon, reflecting the core side of experiences that cause striking metamorphoses in women's behavior. Women who try to "protect" themselves from aging often develop hypercompensatory reactions arising from "protest" (for example, excessive concern for their own appearance, increased interest in cosmetics). Such reactions can be referred to as "mystification of reality" since patients consciously or unconsciously do not want to notice the objective signs of oncoming aging, denying it with all their deliberate behavior. The resulting change in the system of personality relations causes a significant reassessment of the significance of certain events. It was revealed that in this age period, with the pathological course of menopause, the most significant for most women is divorce, which sometimes even leads to psychotic disorders. Along with this, some psychotraumatic situations that provoke violations of psychological adaptation in women of a different age in menopause are not always pathogenic. Paradoxical, at first glance, seems to be the established fact that such an objectively significant mental trauma for any mother as the death of a child becomes less pathogenic for women with a pathologically current menopause than a divorce from her husband.

Summarizing the description psychological features and mental disorders in patients with obstetric and gynecological pathology, one can note the wide representation of changes in mental activity in patients, the severity and depth of psychological problems associated with the restructuring of the system of relations of the personality of a sick woman.

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Prevention of obstetric pathology

Prevention of complications of pregnancy, childbirth and perinatal pathology is carried out in consultation in two main areas related to primary and secondary prevention. Primary prevention is to prevent pregnancy complications in healthy women. The essence of secondary prevention is to prevent the transition of the initial manifestations of obstetric pathology into severe forms.

In the implementation of primary prevention, the joint work of an obstetrician-gynecologist and a pediatrician is of paramount importance. It is known that the reproductive system of a woman is laid in the early stages of ontogenesis. Its development depends on the conditions of intrauterine life, the characteristics of the neonatal period and childhood. The state of health of generations largely depends on the system for preventing diseases in parents, obstetric care for women, the totality of therapeutic and preventive measures inherent in children's health. Prevention consists in the appropriate recovery of girls of all ages, starting from the first years of life, and especially in adolescence and youth. Propaganda is important healthy lifestyle life of girls, the exclusion of bad habits, the formation of skills in the sanitary and hygienic regime, the timely detection and treatment of all intercurrent diseases.

Prevention should cover:

1. Pregnancy period (antenatal, prenatal prophylaxis).

2. The period of childbirth (intranatal prophylaxis).

3. The period after childbirth (postnatal, postpartum prophylaxis).

One of the basic principles of modern obstetrics, implemented in the health systems of most countries, is the planned onset of pregnancy. Reasonable medical and moral preparation for pregnancy allows you to prevent certain problems during pregnancy and determine the future plan for medical monitoring of its course.

Before pregnancy

Due to the fact that the state of health of the parents (especially their reproductive system) has a great influence on the formation of the embryo and its further development, it is necessary to examine the parents before conception. One visit to the doctor before conception is recommended - about three months before the planned pregnancy and always with a partner. During this visit: the past and present medical history of the future parents is clarified in detail; information is collected about the health status of the next of kin of future parents; according to the totality of the medical history data and the results of the examination, the necessary laboratory and other studies are prescribed; an exemplary program for conducting future pregnancy. First of all, you must stop smoking, drinking alcohol and drugs. In addition, you will need to change your diet and take care of protection against infections that are dangerous to the fetus.

During the embryonic development of the fetus, the pregnant woman must be provided with good nutrition, all rules must be observed to maintain her health. It is necessary to take measures to prevent a number of diseases of the pregnant woman, especially influenza, rubella, Coxsackie infections, viral hepatitis, etc., because it is during this period that the fetus is most vulnerable and these diseases can cause the development of various birth defects. The use of clean, fresh air, moderate exercise, personal hygiene, favorable housing and other conditions, etc. are also essential for the protection of the fetus.

Rubella. After suffering rubella, immunity to this disease persists for life. If the expectant mother did not suffer from rubella, even before the onset of pregnancy, it is imperative to do an analysis for the presence of antibodies in the blood. In their absence, get vaccinated against rubella. This is important - after all, rubella during pregnancy threatens with serious complications for the child. The risk is especially high in the first 3 months of fetal development.

Hepatitis B can be transmitted to the fetus in utero and during childbirth. If you have not been vaccinated in the past 5 years, get vaccinated against hepatitis B before pregnancy.

Genital herpes is sexually transmitted. The danger to the unborn child is only in those cases if the infection occurred with herpes during pregnancy, or if shortly before the birth there was an exacerbation of the disease. Having decided to become pregnant, you need to undergo treatment with antiviral drugs.

Diet changes before pregnancy. Include in the diet foods high in iron, calcium and folic acid (meat, dried fruits, bread, green vegetables, milk, cheese and dairy products, beans, rice, corn, cereals, oranges, bananas). If overweight, lose overweight even before pregnancy, overweight women are at higher risk of developing complications, especially in late pregnancy.

Married couples at risk of giving birth to genetically defective children, women with habitual miscarriages, as well as those who have previously given birth to children with congenital malformations and developmental anomalies must undergo a preliminary examination at the genetic center.

Women with severe extragenital pathology should consult with specialists about the advisability of pregnancy or about optimal preparation for it.

Dispensary observation during pregnancy

A woman must be registered at a gestational age of up to 12 weeks. This will make it possible to diagnose extragenital pathology in a timely manner and decide on the advisability of further preservation of pregnancy, rational employment, establish the degree of risk and, if necessary, ensure the recovery of the pregnant woman.

The anamnesis helps the doctor to find out the living conditions, the impact of general somatic and infectious diseases (rickets, rheumatism, scarlet fever, diphtheria, viral hepatitis, typhoid, tuberculosis, pneumonia, heart disease, kidney disease), diseases of the genital organs (inflammatory processes, infertility, menstrual dysfunction, operations on the uterus, tubes, ovaries), former pregnancies and childbirth to the development of a real pregnancy.

Family history gives an idea of ​​the health status of family members living with the pregnant woman (tuberculosis, alcoholism, sexually transmitted diseases, smoking abuse), and heredity ( multiple pregnancies, diabetes mellitus, cancer, tuberculosis, alcoholism).

It is necessary to obtain information about the diseases suffered by a woman, especially about rubella, chronic tonsillitis, diseases of the kidneys, lungs, liver, cardiovascular system, endocrine pathology, increased bleeding, operations, blood transfusions, allergic reactions, etc.

Obstetric and gynecological history should include information about the features of menstrual and generative functions, including the number of pregnancies, intervals between them, polyhydramnios, multiple pregnancies, duration, course and their outcome, complications in childbirth, after childbirth and abortion, newborn weight, development and health of those in the family children, use of contraceptives. It is necessary to clarify the age and state of health of the husband, his blood type and Rh affiliation, as well as the presence of occupational hazards and bad habits of the spouses.

Objective examination are carried out by an obstetrician, therapist, dentist, otolaryngologist, ophthalmologist, if necessary - endocrinologist, urologist.

If an extragenital pathology is detected in a pregnant woman, the therapist should decide on the possibility of carrying a pregnancy and, if necessary, perform additional studies or send the pregnant woman to a hospital.

Frequency of observation by an obstetrician-gynecologist:

* during pregnancy 14-15 times;

* after the first examination, the appearance after 7-10 days with tests, the conclusion of the therapist and other specialists, later in the first half of pregnancy - 1 time per month;

* after 20 weeks of pregnancy - 2 times a month;

* after 32 weeks of pregnancy - 3-4 times. Examinations by doctors of other specialties:

* therapist - 2 times (at the first appearance and at 32 week of pregnancy),

* Dentist, surgeon, neuropathologist, ophthalmologist - 1 time at the first appearance, later according to indications, other specialists - according to indications.

Name and frequency of laboratory and other diagnostic studies:

1. General analysis blood - after the first visit, as well as at 18 and 30 weeks.

2. General analysis of urine - at the first visit, up to 28 weeks - 1 time per month, after - 2 times per month.

3. Biochemical analysis blood - after the first visit and for a period of 30 weeks.

4. Analysis of urine and blood for sugar - after the first visit and at 30 weeks.

6. Analysis for infections:

for syphilis (RW) is given at the first visit, at 30 weeks and 2 weeks before delivery. HIV and hepatitis B and C - after the first visit and at 30 weeks.

sexually transmitted diseases (ureaplasmosis, chlamydia, herpes) and for the presence of antibodies to toxoplasmosis, rubella, cytomegalovirus, herpes infections - after the first visit. If everything is in order, then in the third trimester it will be necessary to pass an analysis only for hepatitis.

7. Blood test to determine the group and Rh factor.

It reveals the risk of Rhesus conflict, the mother's blood type is determined and the group of the future baby is predicted. If negative Rh or the first blood group, then the father of the child must pass the same analysis. If it turns out that the mother has a negative Rh factor, and the partner has a positive one, then every month at the beginning of pregnancy and twice at the end, you will need to donate blood for Rh antibodies (hemolysins).

8. Vaginal smear (bacteriological culture)

Taken at first visit and at 36-39 weeks.

9. Ultrasound examination (ultrasound)

During pregnancy, you need to do 3 studies:

9-12 weeks (confirmation of pregnancy and its nature - uterine or ectopic, exact date, number of fetuses, reveals serious defects and risk for chromosomal pathology);

17-22 weeks with sex determination (examination of fetal organs, heart function)

33-36 weeks Doppler study (a type of ultrasound), examining the blood flow of the placenta. Also, with the help of conventional ultrasound, the position of the fetus, its condition, growth rate, placenta condition, quantity and quality of amniotic fluid are assessed to determine the tactics in childbirth.

If the doctor has questions, then additional studies or ultrasound screening may be needed.

10. Fetal cardiotocography (CTG) - simultaneous registration of heart rate, motor activity of the child and uterine tone.

Held from the 30th week. According to indications, as constant monitoring of the fetus - every week.

At the first visit to a pregnant woman, after clinical and laboratory research it is necessary to determine which risk group it belongs to:

* the first group - healthy persons subject to periodic examinations;

* the second group - persons transferred from the third registration group in the stage of stable compensation of the disease;

* the third group - patients with a compensated course of the disease. This group also includes patients who have had acute diseases (infectious and non-infectious), for which they were under short-term observation, and persons at risk of developing chronic diseases as a result of frequently recurring acute pathological processes;

* the fourth group - patients in the stage of subcompensation. In most cases, such patients periodically experience exacerbations of the disease, and they often lose their ability to work;

* the fifth group is the most severe category of patients with decompensation of the disease (the adaptive ability of the body is sharply suppressed). In such patients, violations of physical and mental health are clearly manifested. They have been unable to work for a long time, they need hospital treatment and intensive implementation of a complex of recreational activities.

High-risk pregnant women should be carefully examined by specialist doctors. Their observation is carried out according to an individual plan, taking into account the specifics of the existing or possible pathology.

The probability of risk is determined three times: at registration, in the middle of pregnancy and during delivery. Individual plans for monitoring high-risk pregnant women provide for more frequent and targeted examinations, and, if necessary, hospitalization in appropriate medical facilities.

Methods for detecting antenatal pathology of the fetus- direct and indirect.

With the help of direct methods, the fetus is studied directly. These include ultrasound and radioisotope studies, radiography of the skeleton and soft tissues, phono- and electrocardiography, external rheohysterography. Amnioscopy, fetoscopy, biopsy of the placenta, amniocentesis allow cytoscopic, biological and other studies of the placenta.

Indirect methods include the study of blood, urine for the content of chorionic gonadotropic hormone.

There is also a functional diagnosis of communication disorders in the mother-fetus system due to dosed effects special means for a pregnant woman.

Preparation of medical documentation for a pregnant woman

All data from the interview and examination of the woman, advice and appointments should be recorded in the "Individual card of the pregnant woman and the puerperal woman"

(f. 111 / y), which are stored in the file of each obstetrician-gynecologist by the dates of the planned visit. Maps are also stored there: born; patronage women; hospitalized pregnant women. In order to inform the obstetric hospital about the state of health of the woman and the peculiarities of the course of pregnancy, the doctor of the antenatal clinic issues to the hands of each pregnant woman (with a gestational age of 28 weeks) an “Exchange card of the maternity hospital, maternity ward hospital "(f.113 / y) and at each visit to the pregnant antenatal clinic, all information about the results of examinations and studies is entered into it.

Systematic monitoring of the health of pregnant women (examination, identification of risk groups, treatment of somatic diseases)

* I half of pregnancy (up to 20 weeks) - once a month;

* II half (from 20 weeks to 32 weeks) - 2 times a month;

* after 32 weeks and before birth - 1 time in 7 days.

During pregnancy, a woman should visit a consultation about 15 times. In the presence of diseases, the frequency of examinations and the order of examination are determined individually. Each pregnant woman should be examined by a therapist (at the first appearance and at 32 weeks of pregnancy), a dentist, an otorhinolaryngologist.

During repeated examinations in a pregnant woman, body weight, blood pressure are determined, the position of the fetus is clarified, the height of the fundus of the uterus and the circumference of the abdomen are measured. Particular attention is paid to the functional state of the fetus (movement, palpitations). During dispensary observation of pregnant women, maximum attention is paid to their timely release from night and overtime work, business trips, work associated with lifting and carrying heavy loads, and transfer to lighter work.

prenatal care

In case of untimely appearance of a pregnant woman for a second appointment, the obstetrician performs prenatal patronage at home twice (after registration and at 32 weeks of pregnancy). It is also recommended to carry out prenatal care at the workplace at 18-20 weeks. Prenatal patronage is carried out at home in order to monitor the implementation of the prescribed recommendations, conduct appropriate research.

During the first prenatal visit, close contact is established between the expectant mother and medical worker. During its implementation, the marital status, psycho-emotional contact in the family, the level of sanitary and hygienic culture, and the living conditions of the pregnant woman are ascertained.

Second antenatal care: carried out at the 32nd week of pregnancy. The obstetrician again checks the implementation of the recommendations on the regimen, nutrition, alternation of sleep and wakefulness; taking medications and prophylactic agents for the prevention of complications and the normal development of the fetus. Particular attention is paid to the care of the mammary glands, targeted preparation of the mammary glands for breastfeeding, to prevent cracked nipples, and prevent mastitis. In accordance with the definition of the risk of perinatal factors, prevention of hypogalactia is carried out. The medical assistant-obstetrician gives recommendations on the preparation of a dowry for the unborn child, the necessary literature on raising an infant. Data on antenatal care are recorded on an insert, which is then pasted into the history of the child's development - registration form No. 112 / y.

Hospitalization of pregnant women requiring inpatient treatment

An important section of dispensary care is the hospitalization of a pregnant woman with extragenital pathology, starting from the first trimester and in subsequent periods for the appropriate rehabilitation of foci of acute and chronic diseases, preventing their exacerbations, and also in case of a threat of miscarriage.

Physical and psychoprophylactic preparation of pregnant women for childbirth

Physical training begins with the first visits to the antenatal clinic and is carried out group method. Women master a special set of exercises that are recommended to be performed at home for a certain time. It is advisable to start group classes on psychoprophylactic preparation for childbirth from 32-34 weeks of pregnancy. Preparation of pregnant women for childbirth is carried out by the site doctor, one of the consultation doctors or a specially trained midwife.

The complex of physical preparation of pregnant women for childbirth includes hygienic gymnastics, which is recommended to be practiced daily or every other day from early pregnancy under the guidance of an instructor physiotherapy exercises or a specially trained nurse. Pregnant women after the initial examination by an obstetrician-gynecologist and a therapist are sent to a physical education room indicating the duration of pregnancy and health status. Groups are formed from 8-10 people, taking into account the timing of pregnancy. Each set of exercises provides training in certain skills necessary to adapt the body to the appropriate period of pregnancy. If a pregnant woman cannot attend a physical education room, she is introduced to a set of gymnastic exercises, after which she continues gymnastics at home under the supervision of an instructor every 10-12 days.

Physical education is contraindicated in acute or often aggravated and decompensated somatic diseases, habitual miscarriages in history and the threat of termination of this pregnancy.

Psychoprophylactic training

In preparation for childbirth, pregnant women are not only introduced to the process of childbirth, but also taught exercises to auto-training and point self-massage as factors that develop and strengthen a person's volitional abilities for self-hypnosis.

Organization and conduct of classes in the "Schools of mothers"

Classes begin at 15-16 weeks of pregnancy. Topics of classes: "On the mode of a pregnant woman", "On nutrition during pregnancy", "On caring for an unborn child"

Pregnant women are taught the rules of personal hygiene and prepared for future motherhood in the "Schools of Motherhood" organized in antenatal clinics using demonstrative materials, visual aids, technical aids and items for child care. All women from the early stages of pregnancy should be involved in visiting the "School of Motherhood". Pregnant women should be taught the importance of attending these classes. The consultation should contain clear information about the program and the time of the classes. Midwives and nurses for child care are direct assistants to doctors when conducting classes at the "School of Motherhood".

When conducting classes on certain days of the week, it is advisable to form groups of 15-20 people, preferably with the same gestational age. The group may include pregnant women who are under the supervision of both one doctor and several. The head of the consultation organizes classes, taking into account the peculiarities of local conditions, supervises the work of the "School of Maternity" and communicates with the territorial health center to receive methodological assistance and printed materials.

The curriculum of the "School of Motherhood" provides for 3 classes of an obstetrician-gynecologist, 2 pediatricians and 1 legal adviser, if available. The curriculum and program of an obstetrician-gynecologist at the "School of Motherhood" are presented in the appendix. For the purpose of informing the obstetric hospital about the state of health of the woman and the peculiarities of the course of pregnancy, the doctor of the antenatal clinic gives the hands of a pregnant woman at a gestational age of 30 weeks "Exchange card of the maternity hospital, maternity ward of the hospital".

Rational nutrition of pregnant women

pregnancy childbirth preparation prophylactic

Properly organized rational nutrition is one of the main conditions for a favorable course of pregnancy and childbirth, the development of the fetus and newborn.

Nutrition in the first half of pregnancy is almost no different from the diet of a healthy person. The total energy value of food should fluctuate depending on height, weight and character. labor activity pregnant. In the first half of pregnancy, the weight gain should not exceed 2 kg, and with a weight deficit - 3-4 kg. With obesity, a pregnant woman up to 20 weeks should maintain her previous weight or lose weight by 4-6 kg (with obesity of II-III degree).

In the second half of pregnancy, meat concoctions, spicy and fried foods, spices, chocolate, pastries, cakes are excluded from the diet, and the amount of salt is reduced. After 20 weeks of pregnancy, a woman should consume 120 g of meat and 100 g of boiled fish daily. The daily diet of a pregnant woman must necessarily include sunflower oil (25-30 g), which contains essential unsaturated fatty acids (linoleic, linolenic and arachidonic). It is recommended to eat up to 500 g of vegetables daily. They are low-calorie, ensure the normal functioning of the intestines, contain a sufficient amount of vitamins and mineral salts.

by the most accessible method control of the diet is the regular weighing of the pregnant woman. In optimal cases, during pregnancy, a woman's weight increases by 8-10 kg (by 2 kg during the first half and by 6-8 kg during the second, therefore, by 350-400 g per week).

Study of working conditions of pregnant women. The working conditions of a woman largely determine the outcome of pregnancy. If they do not comply with the “Hygienic recommendations for the rational employment of pregnant women”, the obstetrician-gynecologist gives a “Medical opinion on the transfer of a pregnant woman to another job” (f. 084 / y). If necessary, issues a certificate of incapacity for work, which is drawn up in accordance with the current instructions and registered in the "Book of registration of certificates of incapacity for work" (f. 036 / y).

Therapeutic and preventive care for women in childbirth

The woman should make the first postpartum consultation visit no later than 10-12 days after discharge from the obstetric hospital. This should be explained to her before the birth. Under normal flow postpartum period a woman is examined by an obstetrician-gynecologist for the second time 5-6 weeks after childbirth.

Patronage is subject to puerperas:

1. who did not appear at the consultation 10-12 days after discharge from the maternity hospital;

2. at the direction of the obstetric hospital (telephone or written notification);

3. with a complicated course of the postpartum period;

4. those who did not appear again on time

Antelal prophylaxis

Prevention of rickets

Antenatal prevention of rickets is carried out before the birth of a child - during pregnancy and even during its planning. At about the 7th month of fetal development, the child's body begins to actively store up vitamins, including vitamin D. Therefore, during this period, a pregnant woman should pay special attention to her diet and lifestyle.

Prevention of rickets during pregnancy is based on the following principles: regular monitoring in the antenatal clinic; sufficient exposure to fresh air (walking); regular nutritious meals; starting from the 32nd week of pregnancy, the doctor may recommend taking prophylactic doses of vitamin D; women at risk (with diseases of the kidneys, liver, endocrine system) are recommended to take vitamin D in higher doses; the use of multivitamin and mineral complexes for pregnant women as directed by a doctor (most of them contain vitamin D); prevention of colds and other infectious diseases during pregnancy.

Important: It is unacceptable to use vitamin D during pregnancy without a doctor's prescription. Only a specialist can choose an adequate dose, taking into account the duration of pregnancy, the presence concomitant pathology and other factors. early start taking large doses of the drug can lead to the deposition of calcium in the placenta.

Breast care.

The mammary glands need to be prepared for this. After washing with water, vigorously rub the mammary glands and nipples with a hard towel. From this soft skin becomes rougher and more resistant to irritation. Air baths are also useful: after finishing the toilet, leave the mammary glands open for 10-15 minutes. Pull out flat or inverted nipples with clean fingers 2-3 times a day for 3-4 minutes, after lubricating them with a cosmetic cream.

Prevention of hypogalactia

Education for women, especially those who are nulliparous or who have negative experience breastfeeding older children during pregnancy on issues such as the benefits of breastfeeding, the dangers and difficulties of artificial feeding, breastfeeding technique and proper attachment of the baby to the breast so that the mother has a breastfeeding dominant by the time the baby is born.

Prevention of hemolytic disease in a newborn is carried out by prescribing anti-Ph-D-serum to the mother. Serum is obtained from Rh-negative donors whose blood contains antibodies. Sensitization is achieved by administration of small, repeated doses of the antigen. In some countries, this preventive measure is taken for all Rh-negative women.

Prevention of hypovitaminosis states is no less important for the proper development of the vascular, nervous, reproductive and other systems. IN summer season a pregnant woman can sunbathe in the sun, but systematic sunbathing, quartz irradiation, etc., can only be carried out as prescribed by a doctor.

Health education.

It is necessary to explain to a pregnant woman what harm alcohol, smoking, etc. brings, conversations and courses on various issues of pregnancy and childbirth should be held regularly. A pregnant woman should familiarize herself with the basic issues of caring for a newborn. The role of the patronage midwife in this respect is very great. She helps the pregnant woman prepare everything necessary for the newborn - diapers, clothes, bedding, etc., and, if possible, adapt the environment for the proper development of the newborn.

Intrapartum prophylaxis

The purpose of this prevention is to save the life and health of the mother and the newborn child. The fight against birth injuries, asphyxia, aspiration pneumonia, etc. is the basis of prevention during childbirth. The pediatrician should be a consultant in the delivery room and, together with the obstetrician, take an active part in saving the life of the child at this crucial moment for him.

The art of the obstetrician determines good or bad results, the pediatrician improves or does not improve what has been achieved. The use, if necessary, of diagnostic and therapeutic agents that are most suitable for the mother and non-traumatic to the newborn is the essence of intranatal prophylaxis.

Competent and active management of labor is the factor that can most contribute to reducing the percentage of birth traumatic injuries to the fetus. Qualification of personnel is a measure of great importance for reducing perinatal mortality.

The better organized and carried out ante- and intranatal prophylaxis, the more successful the neonatal period will be.

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In the field of obstetrical and gynecological conditions and pathology, mental factors are of particular importance in pregnancy, infertility, premenstrual syndrome and menopause. It is under these conditions and processes that there is a close interweaving of psychological and obstetric-gynecological factors. The mental state of women has specific features that differ from the typical reactions of men to diseases in other areas.

Features of the mental state of a woman during pregnancy for many years attract the attention of specialists. At the same time, both the emotionally negative role of pregnancy and the positive one are noted. Hippocrates wrote about the favorable effect of pregnancy on various mental disorders, pointing out that: “I prescribe marriage for hysterical girls so that they can be cured by pregnancy.”

All kinds of features in the psychological state of a woman during pregnancy can be considered as a manifestation of the adaptation of the body and personality of a woman to the onset of pregnancy and evaluate these manifestations from the standpoint of different levels of adaptation. The biological level of adaptation in the first half of pregnancy is significantly influenced by one of the ovaries, in the second - by the uterus. The tone of the autonomic nervous system as pregnancy develops increases abruptly, revealing the existence of peculiar critical periods for the mother's body. So, in terms of up to 12 weeks, the tone of the sympathetic-adrenal system prevails, in the second half - 28-30 weeks, the tone of both departments increases, but with a certain predominance of cholinergic reactions. From the standpoint of the analysis of neurodynamic processes, the emotional state of pregnant women is characterized by the fact that in the presence of a positive emotional background in the last months of pregnancy, an active state of cortical processes takes place, leading to an increase in the threshold of pain sensitivity. As a result of negative emotions, overstrain of the central nervous system, the functional activity of the cortex weakens, and the threshold for pain sensations decreases. As a rule, these states depend on the expectation of a desired or unplanned child, a positive or negative attitude.

There is a typical dynamics of psychological manifestations during pregnancy. Usually, in the first months, a pregnant woman feels insecure, remains ambivalent about the upcoming motherhood. Fear of the unknown can lead to depression. A pregnant woman likes (more or less consciously) her condition, she wants to be the subject of attention and care, at the same time, she feels that she is growing up, two tendencies are fighting in her - infantilism and growing up. This duality, often disturbing, can cause mood swings that are not always clear to others. In the second trimester, there is relative calm in the state of the pregnant woman, incidents are quite rare, complications - in healthy women - an exception. The main feature of the third trimester is “immersion in the child”, the child has become the focus of thoughts, interests and activities of the expectant mother. Immediately before childbirth, anxiety increases, the manifestation of which may be the hyperactivity of the pregnant woman, who wants to speed up events. Psychological disorders in the last trimester are observed in 60-80% of cases.

An important psychosomatic problem is the problem of preeclampsia in pregnant women. It is known that in women with a pronounced unwillingness to have a child, a severe form of toxicosis is more often observed, in contrast to women with a desired and planned pregnancy. Representatives of foreign medicine, using the concept of the symbolic language of organs (A.Adler), interpret the vomiting of pregnant women as a symbolic expression of the unwillingness of pregnancy and the birth of a child. Other scientists, based on the principles of the teachings of Z. Freud, consider early gestosis of pregnant women as a result of "weakening of the will to motherhood in connection with the development of civilization" or as a manifestation of unconscious disgust for her husband.

In domestic medicine, most authors evaluate the phenomenology of gestosis depending on the functional state of the nervous system and psychological state (including characterological premorbid) of a pregnant woman. V.M.Volovik distinguishes two groups of patients. The first group includes women with minor affective disorders, manifested in the form of irritability, irascibility, tearfulness and resentment. These disorders occur at the height of gestosis and are quickly eliminated after the disappearance of vomiting and the normalization of the general condition. In all women of this group, the psychological characteristics practically do not differ from healthy pregnant women. Everyone has a positive attitude towards pregnancy, a favorable family situation. They are characterized by a harmonious personality, a realistic approach to emerging difficulties. Analyzing the causes of preeclampsia and the accompanying affective disorders in patients of this group, the author comes to the important conclusion that any pregnancy, including those proceeding completely normally, is in itself always a source of greater or lesser mental stress, which is why indifferent in the past, elements of the environment and situations acquire a different subjective meaning and become the cause of personal reactions. In the second group, the picture of the disease is characterized by significant polymorphism: in addition to vomiting and nausea, chills with hyperthermia, headaches, fainting, arterial pressure lability, hyperhidrosis are often noted here. Affective disorders are more common and more pronounced: some patients experience anxiety, a sense of pointless anxiety and tension that arises against their will. Many have neurotic disorders and autonomic disorders that have not been observed in them before. The study allowed the author to substantiate the psychosomatic nature of early preeclampsia in pregnant women, to show that psychogenic factors (along with pregnancy itself) are represented in a number of pathogenetic links with the greatest constancy, and often act as the main pathogenetic factor.

The prevalence of mental disorders in pregnant women ranges from 6% to 34%. They are presented as pre-nosological manifestations of impaired psychophysiological adaptation, as well as clinical psychopathological symptoms. Severe mood swings and other emotional changes have long been seen as characteristic physiological features pregnant women, while these manifestations are mental disorders. G. Caplan shows that women in late pregnancy have introversion, passive dependence, depression, lack of self-confidence and fear of future motherhood.

Before giving birth, the health of the unborn child worries the vast majority of women. At the same time, in most pregnant women, concern about the condition of the child tends to increase as the birth approaches. Many pregnant women tend to worry about the possible effects of drugs, and some women about pain relief methods. The phenomenon of prenatal anxiety and its influence on the outcome of pregnancy are described. In a pregnant woman, as a rule, several types of anxiety are detected: 1) generalized; 2) physical, when a woman has a hard time enduring the physical aspects of pregnancy; 3) fear for the fate of the fetus; 4) fear of the need to care for a newborn; 5) fear of childbirth; 6) fear of feeding a newborn; 7) psychopathological phenomena of anxiety. Anxiety about upcoming parenthood is more typical for older women.

The frequency of depressive phenomena of varying severity ranges from 10% to 14%, tending to worsen as pregnancy progresses. There is a pronounced dependence of depression on the presence of psycho-traumatic factors of a family nature and serious fears associated with the birth of a child, and a statistically significant dependence of depression on such psychogenic factors as: a high level of neuroticism, a psychiatrically burdened anamnesis, marital conflicts during pregnancy, fears regarding the fetus, thoughts about abortion during pregnancy, feeling of loss in the second and third trimesters, smoking during pregnancy.

One of the most well-known pathological behavioral phenomena during pregnancy is the “fetal abuse syndrome”, which is characteristic of patients with psychopathy of the excitable circle. This syndrome is noted in the period of relatively late pregnancy and is characterized by aggression directed at the fetus itself, in contrast to cases of deliberate provocation of abortion. This refers to the direct physical impact on the fetus (blows on the anterior abdominal wall) from the pregnant women themselves. Similar aggressive behavior can also be observed in women with a desired pregnancy.

The study of the relationship between changes in mental state and the menstrual cycle has a long history and is rooted in the naive-materialistic idea of ​​psychosis in women as a consequence of uterine disease. Functional menstrual disorders in gynecological practice are extremely common and account for approximately one third of all menstrual disorders in women of childbearing age. With functional gynecological syndromes, various mental disorders occur. Of the most frequent syndromes, there are hypochondriacal, depressive, syndrome of overvalued formations, hysterical, hypomanic and obsessive-phobic syndromes are less common (V.N. Ilyin). There is a high frequency of affective syndromes: anxious, dysphoric, somatized depression. Similar mental states are found in patients with amenorrhea. It is believed that psychogenic dysmenorrhea occurs, as a rule, in emotionally unstable, anxious women with a distinct tendency to lower mood. The immediate cause of this syndrome is quite strong or too often repeated disappointments, disappointments and experiences. The development of psychogenic dysmenorrhea is also caused by “anxious expectations of the next menstruation” that occur after a mental shock or the first menstruation, with fear of pregnancy or abortion, or, conversely, with a passionate desire to become pregnant.

Menstrual disorders, and especially amenorrhea, which makes up about 2/3 of the nosological forms of endocrine and gynecological diseases, are of great social importance due to the fact that they often result in infertility. The negative impact of infertility on human behavior and consciousness is often associated with distress and the development of the so-called. "problem marriage" According to the WHO, a marriage is considered infertile if, despite regular sex life without the use of contraceptives, the wife does not become pregnant within a year, provided that the spouses are of childbearing age. The mental state of infertile patients can be decisive in the origin of some forms of infertility. It is indicated (T.Ya. Pshenichnikova) that infertility in marriage is a social, mental and often physical trouble. All three of these factors are closely interrelated and often influence each other. Thus, mental ill-being is manifested by an increase in the lability of nervous processes or lethargy, a decrease in interest in the environment and work, the emergence of inferiority complexes, psychosexual disorders, and the instability of family relationships. With male infertility, three-quarters of wives psychologically support their husbands, and with female infertility, only a fifth of the husbands are in favor of divorce, and the relationship becomes most aggravated after 3 years of fruitless marriage (EA Volkovich). Interpersonal relations of spouses in an infertile marriage are much more often found in female infertility than in male infertility. Such violations are not only important for individuals in infertile marriages, but also have an impact on society as a whole, increasing the number of divorces and reducing the social activity of this part of the population.

McEwan identifies a number of situations in which one should expect the development of mental disorders in patients: 1) young women profess a religion that treats infertility as a sin; 2) women do not have a normal relationship with their spouse; 3) women have been exposed to various stresses during their lives; 4) women for whom the diagnosis of infertility is a surprise (for example, in the absence of somatic complaints).

Infertility includes a violation of the "sense of self-worth" and "body image". Feelings of personal inadequacy, loss of sex appeal, and "social incompleteness" often accompany this diagnosis. It is impossible not to take into account the fact that all large religious groups accept the birth of a child as a necessary completion of marriage, because. the biblical doctrine of fertility is the cardinal principle of marriage. In this regard, in the civil sphere, the vital function of the family is its replenishment, and childlessness, thus, indicates dysfunction and disorganization of the family. The belief that parenthood is seen by society as the most important function of marriage contributes to the feeling of "failure". Parenthood is equated with natural behavior, which indicates the belief in the presence of reproductive control or parental instinct that needs to be exercised. Reproduction can be perceived as the fulfillment of a sexual role: motherhood as the development and expression of the adulthood of a woman and fatherhood as the development and expression of the adulthood of a man. Childlessness, on the other hand, can testify to society about female genital qualities and male potency.

There are several stages of emotional response to infertility DX.Rosenfeld and E.Mitchell: surprise, grief, anger, isolation, denial and agreement. The initial reaction is one of surprise, followed by a period of shock and anguish, followed by recovery, as can be seen "after the death of a loved one." This "mourning process" is similar to the loss of desire to exist and is exacerbated by feelings of guilt, shame, and social inadequacy. Feelings of depression can "feed" inner anger, which is heightened by the frequently asked question "Why me?". The emerging desire to isolate and reduce contact makes such patients difficult to discuss and treat.

One of the important issues in diagnosing the condition of infertile patients is the assessment of their motives for having a child. Infertile couples have motives that are somewhat different from the traditional motives of childbearing, Erikson proposed the term "generativity", which reflects not only the reproduction process, but also the person's need to care for the child and the responsibility for his upbringing. There are other reasons to have a child - "keep a husband", "fill the void", support family traditions etc. For many patients with infertility, the question of the motive for having a child remained unclear and unconscious. They make rational arguments that the child is needed, for example, for a “fuller life” or for a “good partnership”.

Many foreign researchers are inclined to explain the origin of infertility, especially psychosomatic, from the point of view of psychoanalysis. Some of them try to find the cause of infertility in early childhood. Restriction by a shy system of taboos or, on the contrary, unbridled sexual behavior of parents can have an inhibitory or deforming effect on the child. In the course of psychosexual development, various direct or indirect influences can build undesirable schemes in the structure of the personality, which can later become the cause of "inhibition of the female role."

R.J. Pepperel divides women suffering from psychogenic infertility into 3 main groups. The 1st group includes women whose infertility can stop spontaneously, and intensive examination can easily "break the barrier that prevents conception." The 2nd group includes women with a more stable "blockade" of conception, possibly occurring as a result of some external stressful situation. The 3rd group consists of women whose infertility arose "as a result of deep and prolonged psychosomatic stress associated with the presence of psychogenic fears." In this case, the peculiarities of the idea of ​​pregnancy and motherhood, formed in the process of education, are essential. They can deeply disrupt their mental balance, and any deviations and conflicts in this area lead to the fact that these women experience a strong fear of pregnancy, and infertility occurs in them as a psychological defense. These women may find a conflict between the conscious desire to become pregnant and the unconscious refusal of pregnancy and motherhood.

Deutsch describes certain types of women suffering from infertility: 1) immature, sensitive, choosy women, childishly capricious towards her husband and prone to functional disorders; 2) aggressively dominant women who do not agree to recognize their femininity; 3) mother-like women who, rightly or wrongly understanding their husband, feel that they are unable to copy him in children and therefore transfer their maternal instinct to caring for him; 4) women who have devoted themselves to ideological and other interests.

Many researchers emphasize the great importance of mental disorders and stressful influences in the origin of the so-called. "unexplained infertility". Unexplained infertility can be diagnosed if the partner is fertile, has a positive postcoital test, and the fallopian tubes are passable in women with regular ovulatory cycles and accounts for 4-40% of the total number of infertility (T.Ya. Pshenichnikova). Most of these patients have various psycho-emotional deviations, feelings of inferiority and loneliness, the presence of "hysterical states" on the days of ovulation or menstruation, which indicates a "pregnancy expectation syndrome" (T.A. Fedorova).

One of the most famous in gynecological practice is premenstrual syndrome. Clinical symptoms of premenstrual syndrome appear, as a rule, 2-14 days before menstruation and disappear immediately after it occurs or in its first days. The combination of symptoms may be different, but most often the clinical picture presents borderline mental disorders, accompanied by abundant autonomic symptoms. Characteristic are irritability, low, sometimes angry mood, tearfulness and tearfulness, slight vulnerability, emotional lability, sleep disturbances, headaches and dizziness, inability to concentrate on the work performed, fatigue. In addition to these symptoms, itching of the whole body, tachycardia, various pains and discomforts in the region of the heart, fever, chills, engorgement of the mammary glands, and others are often found. Depending on the number of symptoms, the duration and intensity of their manifestations, premenstrual syndrome is divided into mild and severe forms. The mild degree (form) includes asthenic and astheno-depressive symptom complexes in the presence of complete criticality of patients to the manifestations of the disease. In a severe degree (form), there is a slight decrease in criticality to the disease and one's behavior (within the non-psychotic level of mental disorders), a greater cohesion of the symptoms of the disease

with the personality of patients, the relative frequency of hysterical and hypochondriacal complaints. The severity of vegetative-vascular symptoms in premenstrual syndrome is not always directly dependent on the mental state. Diencephalic crises, which are considered the most severe manifestation of the autonomic dysfunction of the hypothalamic region, are more often combined with a severe form of premenstrual syndrome, although they can also occur with a mild form.

Borderline mental disorders detected in sick women with premenstrual syndrome are noticeable not only by the patients themselves, but also by their relatives. During the appearance of painful symptoms, a woman creates multiple conflict situations at home and at work, which leads to emotional experiences of both the patients themselves and those around them, their relatives and friends. If in the first half of the menstrual cycle, patients, as a rule, are good-natured, benevolent, self-possessed, calm, their behavior is ordered and corresponds to the prevailing stereotype, then with the approach of menstruation, the appearance of inadequate reactions and behavior can be increasingly noted. It should be noted that personal and characterological qualities in the first half of the menstrual cycle still sometimes tend to sharpen.

With a mild form of premenstrual syndrome, a woman independently consults a doctor, seeks help, understands the painful nature of the symptoms of the disease. In a severe form, as the disease progresses, symptoms appear that affect the personal level of response. At the same time, selfishness, captiousness, demonstrativeness, the desire to benefit from one's position, and a decrease in self-criticism begin to come to the fore. Patients demand increased attention from their relatives, forcing the latter to fulfill their every whim: during this period it was impossible to turn on the TV or tape recorder, turn on bright lights, and leave the house for a long time. The slightest “wrong step” caused a violent hysterical reaction from the wife, who believed that all the actions of her relatives were aimed at driving her “out of herself” or “driving her into the grave.”

Often with premenstrual syndrome, hypochondriacal symptoms occur, which can be presented in both mild and severe forms. They are manifested in increased suspiciousness of patients for their health, exaggeration of the severity of existing symptoms. At the same time, some women become intrusive, ready to complain about their well-being to “everyone they meet”. It should be noted that with a severe form of premenstrual syndrome, it is not the patients themselves who turn to doctors more often, but relatives who notice a change in the behavior of women bring them to treatment, which can be regarded by those as an insult.

Downstream, premenstrual syndrome is divided into three types: compensated, subcompensated and decompensated. The first type includes conditions in which the symptoms of the disease do not progress over the years, i.e. premenstrual syndrome flows cliche-like without the inclusion of new symptoms or the aggravation of old ones that have already taken place. Outside of the manifestations of the disease, the woman feels completely healthy. The subcompensated type of flow includes premenstrual syndrome, the manifestations of which increase in time over the years, but do not exceed, on the one hand, the middle of the menstrual cycle, on the other hand, the beginning of menstruation. The decompensated type of the course of premenstrual syndrome causes a simultaneous gradual aggravation of the clinical picture and an increase in the duration of the manifestation of the disease. With this type of flow, and after the end of menstruation, some symptoms of the disease do not completely disappear. The mild form of premenstrual syndrome is more often combined with compensated and subcompensated types of flow, the severe form is combined with decompensated.

The variety of manifestations of premenstrual syndrome fits into the following psychopathological symptom complexes: asthenic, anxiety-depressive, hystero-hypochondriac, dysphoric and mixed. Of particular interest is the dysphoric form of premenstrual syndrome. As early as the end of the last century, Kraft-Ebing wrote: “Very many women, being gentle spouses and mothers, lovely housewives and pleasant interlocutors in society, completely change in their character and treatment as soon as their regulars appear or approach. . It's like a storm - they become picky, irritable and grumpy, sometimes turn into real furies, which everyone fears and avoids. In court proceedings at the end of the last century, women who committed a crime during the menstrual or premenstrual period were recognized as insane, which may indicate that forensic doctors regarded the pathological condition of women associated with menstruation as a particularly serious illness, equated, apparently, with psychosis.

It is no coincidence that Kraft-Ebing compares the changes in the character of women / in the premenstrual period with the character of the furies (goddesses of vengeance) and the designation of such a state by M. Schlobies with the concept of "dysphoria". Diagnosis of the latter is based on the leading symptoms in the clinical picture - on psychologically unmotivated anger, irritability, anger. The clinical similarity of premenstrual syndrome with dysphoria is also confirmed by the critical attitude of women to the metamorphosis that occurs with them during the approach of menstruation. After this period, they are usually ashamed of "their antics", "do not imagine" that they could behave so "ugly". The relationship between the occurrence of a dysphoric variant of premenstrual syndrome and sexual conflicts of a woman and, in particular, with anorgasmia was revealed. Orgasm is physiologically a “discharge”, which is emotionally manifested by a paroxysmal feeling of satisfaction, and an electroencephalographic study at the time of orgasm describes the appearance of a “peak-slow wave” complex (W.H.Masters, V.E.Johnson, R.G.Heath). It is traditionally believed that the absence of an orgasm does not cause any pathological disorders and does not bring discomfort to a woman. However, it can be assumed that acquired anorgasmia clinically manifests itself in the form of psychopathological symptoms only in the premenstrual period (and not in other periods of the menstrual cycle), which is due to the fact that the orgastic ability (possibility) of a woman usually increases precisely when menstruation approaches. That is, the psychopathological symptomatology is vicarious in relation to the orgastic function. It is also important that in the character of women with premenstrual dysphoria one can see such properties as: rigidity, persistence of affects, some explosiveness, pedantry, ambition, inertia of attitudes. It is possible that the disappearance of the emotional and physiological “discharge” that developed during sexual life and became necessary transformed the preorgasmic tension into a negatively colored premenstrual dysphoria.

The climacteric period in a woman's life is associated with age-related restructuring of the hypothalamic region, leading to a violation of the cyclical nature of menstruation and the cessation of reproductive ability. According to V.M. Dilman, menopause is both a norm and a disease: a norm because menopause in the female body is a natural phenomenon, and a disease because it is a persistent dysregulation that ultimately leads to a decrease in the body's viability. reproductive function is nothing but kvass increase in the hypothalamic threshold of sensitivity to the regulatory influence of sex hormones. The same compensation process, which is an integral part of the developmental mechanism, causes pathological changes or disease over time. Based on the mechanism of occurrence, such developmental diseases are called compensation diseases. Acting in the same team of unity, the opposites do not lose their essence: an increase in the duration of the childbearing period simultaneously creates conditions leading to an earlier termination of life due to aging diseases. The two faces of menopause, both norm and disease, characterize the absence of a line between age and disease, between norm and pathology, exposing once again the essence of the unity of opposites hidden in every natural phenomenon (V.M. Dilman).

The criteria for the physiological (normal) course of menopause should be recognized as adaptive processes both at the level of the soma and the psyche. The concept of pathological menopause, in turn, includes various pathological manifestations of the involutionary process that violate both somatic and mental health.

The frequency and severity of menopausal symptoms can be significantly influenced by biological, as well as cultural and socio-economic factors. The latter include: a) the social significance attached in certain ethnic groups to menstruation and the release from the stigma of menstruation after menopause, b) the social significance of childlessness; c) the social status of women in the postmenopausal period; d) the attitude of the husband to his wife in the postmenopausal period (for example, as a sexual partner); e) the degree of socio-economic deprivation experienced during this period; f) the degree of change in the role of women during this period and the possibility of her performing new or alternative functions; g) availability of medical care in connection with the symptoms of perimenopause. To date, very few comparative studies have been conducted to examine attitudes and responses to the state of menopause in different ethnic groups. The results obtained point to stark differences due to complex causes. Thus, women belonging to a certain (and relatively wealthy) Indian caste had fewer complaints during menopause than US women (M. Flint). It is believed that this is due to differences in the position of such women; Indian women are liberated from the yoke of many restrictions and gain a higher status, while American women foresee the loss of their position in a "youth-oriented" society. Differences have also been noted between middle-class Jewish and Cuban women in the US, with the latter experiencing great difficulty with menopause. Moreover, the social integration of such women is much lower, and the reasons for these apparent ethnic differences can be quite complex. Differences were also found in attitudes towards the state of menopause when examining 5 ethnic groups of women in Israel (4 Jewish, respectively, of Central European, Iranian, Turkish and North African origin and 1 Arab), and similar somatic complaints were recorded, including hot flashes and sweating. Arab women were the most positive about the "climacteric crisis", European women were the most worried about it, while Iranian women were the most negative and complained a lot. The most significant differences were in the area of ​​assessment of marital relations. At the same time, Arab women hoped that their husbands would show more interest in them after menopause, while Jewish women of Iranian origin were very pessimistic. The authors of this study concluded that their data clearly demonstrate the importance of ethnic characteristics in the formation of mental and psychosomatic symptoms and the perception of menopause. In the origin of the psychopathological symptoms of menopause, some social and cultural features (profession, level of well-being, education) may matter.

The question of the clinical features of the physiological and pathological menopause is cardinal. Most authors consider menopause to be physiological, proceeding without pronounced pathological symptoms, with a gradual fading of menstrual function and manifested by various signs, which, however, do not cause symptoms of the disease. The concept of a disharmonious menopause includes the two most typical manifestations of the transition period - dysfunctional uterine bleeding and menopausal syndrome. Pathological manifestations of the menopause attract the attention of psychologists and psychiatrists in that often the clinical picture of the disease associated with menopause is exhausted by psychological phenomena or psychopathological symptoms and syndromes.

The picture of the climacteric syndrome consists of psychopathological, vegetative and endocrine symptom complexes. P. Malinovsky in 1855 pointed out the connection between mental abnormalities and menopause: “At a time when a woman becomes no longer able to be a mother, a coup takes place in her body - the cessation of monthly cleansing - and during this period of a woman’s life there are many cases where The matter is not without confusion." And further: “When a person moved for 40 years, when he saw how the soap bubbles he created scattered, when he drank enough from the cup of life and found out that only the edges were smeared with nectar, when he said in himself “vanity of vanities”, and especially if all this is joined by already rooted disturbances in the functions of the liver and portal vein, or obstructions in other abdominal viscera, then it is quite natural that after this insanity develops more often, no longer frenzied, but limited, gloomy.

Considering the mental state of sick women from the standpoint of the teachings of V.N. at this age they become suspicious, anxious, easily vulnerable, uncertain, indecisive, doubting everything. pain. In menopausal age, a woman has many additional psychogenic factors that have not caused her concern before. These are the so-called opportunistic psychic traumas associated precisely with a change in the system of personality attitudes. Conditionally pathogenic are such manifestations of menopause as a change in appearance ( White hair, decrease in skin turgor, the appearance of wrinkles), changes in libido, the importance of which at this age increases dramatically. All this happens in violation of adaptation, with the appearance of features of rigidity, "stuck" on the slightest trouble, which in turn leads to a kind of "narrowing of the personality." Sometimes such a condition, which develops in connection with a pathologically current menopause, as a change in personality, ultimately leads to a kind of "defect", manifested by the pathology of emotions and motives. At the same time, progressive lethargy, passivity, indifference to those aspects of life that were of interest quite recently, caused emotional resonance, come to the fore.

Considering the causes of neurotic symptoms in menopausal women, V.N. Myasishchev and E.K. Yakovleva found that they primarily depend on the premorbid personality traits of patients. In addition, among patients suffering from climacteric syndrome, single women and widows are much more common than healthy ones.

In recent years, most psychologists have questioned the leading role of biological predisposition to the disharmonious course of menopause. Let us dwell in more detail on the argumentation of this point of view. In the well-known work "The menopause - socio-psychological aspects" U.Lehr asks the question: "Is the menopause a crisis situation today?". And she herself comments on it: “A hundred years ago, the climacteric period - if they lived to it at all, and did not die after the birth of the 6th, 7th or 8th child - meant the sudden end of the reproductive cycle that had lasted until that time and thoroughly used. The onset of menopause meant for most women a rapidly approaching death. Today, menopause begins an average of 23.6 years after the completion of the birth of the last child. Nowadays, a woman at the beginning of menopause has 25-30 years ahead of her, i.e. one third of your life. The statement “the dying beginning in this period” is somewhat exaggerated. Max Burger sees the beginning of aging (and thus the daily approach of death) at the moment of conception.

Three aspects of pathological menopause are currently found in groups of women who see their only task in the birth and upbringing of children and suddenly face a “loss of functions”: 1) the high significance of the menopause for the individual as a “turn in life”, 2) fixation of attention on physiological processes and 3) negative perception of these situations. Suddenly deprived of this goal, they feel that their future life has no meaning.

It is believed that in those cases in which a woman has unresolved problems by the age of involution (among which loneliness is in the first place), menopause is perceived as a catastrophe, as an event that destroys the remnants of hopes for a favorable resolution of the life situation. At the same time, it is possible various options behavior of a woman associated with menopause (N.Prill): 1) indifferent (apersonal) behavior; 2) fixture; 3) development of neurotic behavior; 4) active overcoming.

The most characteristic signs of psychogeny in the involutionary period, according to V.N. Myasishchev and E.K. Yakovleva, are the experiences of the personality associated with the pathogenic contradiction of the inevitable loss of vital capabilities with still preserved vital needs. In the pathogenesis, the role of family trouble is traced (husband's infidelity, his intention to divorce, fear of family breakup due to the absence of children, reactions to a decrease in the husband's potency).

The climacteric syndrome is represented by four clinical variants: asthenic, senesto-hypochondriac, anxiety-depressive and hysterical.

A person's ability to adapt to all kinds of stressful situations in life is associated with various factors, among which the structure of his personality and the prevailing stereotype of responding to frustrating events matter. From this point of view, the menopause in a woman's life can be compared with extreme conditions into which the individual enters. All this makes increased demands on the body and personality of a woman in the transitional age period, which for many of them are difficult to resolve due to violations of adaptive capabilities at an involutionary age. Women with a favorable microsocial environment (a prosperous family, caring children, grandchildren) experience the menopause relatively well, "neutralizing" the significance of the menopause by switching interests to family or other activities. Elastic in adolescence, there are many unresolved problems (loneliness, etc.), which determine their attitude to menopause as a catastrophe. In a number of cases, menopause is a particularly significant phenomenon, reflecting the core side of experiences that cause striking metamorphoses in women's behavior. Women who try to "protect" themselves from aging often develop hypercompensatory reactions resulting from "protest" (eg, excessive concern for their own appearance, increased interest in cosmetics). Such reactions can be designated by the term "mystification of reality", since patients consciously or unconsciously do not want to notice the objective signs of oncoming aging, denying it with all their deliberate behavior. The resulting change in the system of personality relations causes a significant reassessment of the significance of certain events. It was revealed that in this age period, with the pathological course of menopause, the most significant for most women is divorce, which sometimes even leads to psychotic disorders. Along with this, some psychotraumatic situations that provoke violations of psychological adaptation in women of a different age in menopause are not always pathogenic. Paradoxical, at first glance, seems to be the established fact that such an objectively significant mental trauma for any mother as the death of a child becomes less pathogenic for women with a pathologically current menopause than a divorce from her husband.

Summarizing the description of psychological characteristics and mental disorders in patients with obstetric and gynecological pathology, one can note the wide representation of changes in mental activity in patients, the severity and depth psychological problems associated with the restructuring of the system of relations of the personality of a sick woman.

The risk group is determined after a clinical and laboratory examination of a pregnant woman at the first visit to the antenatal clinic in early dates gestation and throughout the follow-up period. The degree of risk is determined by the presence of various harmful factors that adversely affect the course of pregnancy and childbirth, the development of the fetus and the health of the newborn.

Perinatal risk factors:

1. Socio-biological:

a) age of the mother: up to 18 and over 35;

b) the age of the father is over 40;

c) occupational hazards: mother or father;

d) bad habits: mother - smoking, drinking alcohol; father - alcohol abuse;

e) weight and height indicators of the mother: height 150 cm and less; body weight is 25% higher than normal;

e) attendance at the antenatal clinic after 20 weeks of pregnancy;

g) ecological trouble of the area of ​​residence.

2. Obstetric and gynecological history: a) the number of births is 4 or more; b) repeated or complicated abortions; c) surgical interventions on the uterus and appendages; d) malformations of the uterus; e) infertility; f) miscarriage; g) non-developing pregnancy; h) premature birth; i) stillbirth; j) death in the neonatal period; k) the birth of children with genetic diseases and developmental anomalies; l) the birth of children with low or large body weight; m) complicated course of a previous pregnancy (threat of miscarriage, preeclampsia, etc.); o) bacterial-viral gynecological diseases (genital herpes, chlamydia, cytomegalovirus infection, syphilis, gonorrhea, etc.).

3. Extragenital diseases: a) cardiovascular: heart defects, hypertensive disorders; b) diseases of the urinary tract; c) endocrinopathy; d) blood diseases; e) liver disease; e) lung disease; g) connective tissue diseases; h) acute and chronic infections; i) violation of hemostasis.

4. Complications of pregnancy: a) vomiting of pregnant women; b) the threat of abortion; c) bleeding in the I and II half of pregnancy; d) OPG-preeclampsia; e) oligohydramnios; e) polyhydramnios; g) placental insufficiency; h) multiple pregnancy; i) anemia; j) Rh- and ABO-isosensitization; k) exacerbation of a viral infection (genital herpes, cytomegalovirus infection, etc.); m) anatomically narrow pelvis; m) incorrect position of the fetus; o) delayed pregnancy; n) induced pregnancy.

5. Fetal condition: a) intrauterine growth retardation; b) chronic hypoxia; c) developmental anomalies; d) hemolytic disease.

According to the presence of adverse factors (signs) of perinatal risk, groups of women with low, medium and high risk are distinguished. As the number of simultaneously acting adverse factors increases, the degree of perinatal risk increases, i.e. the course of pregnancy and childbirth, diseases of the fetus and newborn are aggravated. Perinatal mortality is also on the rise.

Perinatal risk groups:

1. Low risk group. The number of harmful factors is not more than 1-2. Pregnant women are practically healthy and there is no danger to the development of the fetus. Children are born full term. The Apgar score for most of them is 8-9 points. In the neonatal period, there are no special deviations in the state of health of children. Subsequent psychomotor development takes place according to age standards and is regarded as satisfactory by the end of the first year of life. Such women need dispensary observation according to the generally accepted system.

2. Medium risk group. The number of harmful perinatal factors ranges from 3 to 6 - this is predominantly extragenital and genital pathology leading to various complications of pregnancy. The perinatal risk for the fetus and newborn increases with the simultaneous action of several adverse factors. In children of this group of women, various somatic and neurological disorders are more often observed, which, however, are of a non-rough transient nature and disappear by the time of discharge. The development of newborns and children of the first year of life ultimately meets the age standards. The group of pregnant women with an average risk for the development of the fetus and newborn requires observation according to an individual plan using special medical methods and means in order for the pregnancy outcome to be favorable.

3. High risk group. The number of harmful perinatal factors is more than 6. Pregnancy is often complicated by the threat of miscarriage, severe forms of gestosis, the number of births of premature babies and children with various somatic pathologies increases sharply. When establishing a high perinatal risk, it is necessary to decide whether it is advisable to continue the pregnancy, since pregnancy in such patients poses a great danger not only to the fetus, but also to the mother. If pregnancy persists, an individual monitoring plan is drawn up using modern methods of examination of the mother and fetus and their treatment.

Hospital infection and its prevention in an obstetric hospital.

hospital infection- these are all purulent-inflammatory diseases that occur in pregnant women, women in childbirth or puerperas, newborns and medical personnel during their stay in the hospital. GI includes cases of the disease on an outpatient basis and during preventive measures among the population, since infection can occur during the treatment of patients, medical examinations, and vaccinations.

Etiological feature of GI currently: decrease in the proportion of obligate pathogens and increase in the proportion of opportunistic pathogens

Increasing resistance of opportunistic pathogens to antibiotics

Infection occurs most often exogenously during medical interventions, endogenous infection plays a secondary role.

The disease most often occurs due to infection in the uterus from the vulva and vagina

Gradually there is a change of causative agents of nosocomial infection:

30-40s – streptococcus

50-60s - staphylococcus aureus (now the main causative agent of postpartum mastitis)

since the beginning of the 60s - Gram-negative microorganisms (E.coli, Proteus, Pseudomonas, Klebsiella, Enterobacter) - the causative agents of postpartum endometritis, peritonitis, sepsis, inflammatory diseases of the urinary tract.

staph infection: source - patients and carriers; ways of transmission - airborne and airborne dust, contact through objects of medical importance.

Gr-negative infection: source - gastrointestinal tract; the main route of transmission is contact (pay special attention to the processing of personnel hands!).