Predictive tools and risk assessment
The use of scoring systems for pulmonary embolism (PE) risk stratification is actively discussed in obstetrics. Such predictive tools include the Wells score (Wells score) and the revised Geneva score (Geneva score).
- Initially, these scales were developed exclusively for non-pregnant patients.
- They rely on criteria that have low informative value during gestation (e.g., age over 65 years, recent fractures, or surgery within the last month).
- Out of seven leading foreign professional societies, five explicitly do not recommend their use in pregnant women, and one does not consider them at all. Only the European Society of Cardiology (ESC) permits the use of predictive tools, but without specifying the methodology.
For PE risk stratification, patients are divided into groups. Most societies (ASTH-SOMANZ, ATS-STR, ESC, GTH) distinguish between high (high risk) and non-high (non-high risk) risk. The Canadian Society (SOGC) uses low (low risk) and non-low (non-low risk) risk categories, while the Royal College (RCOG) uses high and low risk. However, there is no single clear system: for example, GTH provides only a list of factors without points, and the RCOG system does not account for diagnostic tests.
Instrumental diagnostics and care organization
Access to instrumental diagnostics depends on the level of the medical institution. In sparsely populated and hard-to-reach areas, care is organized stepwise:
- Primary pre-medical care: provided by a midwife or paramedic at feldsher-obstetric stations (FAP) and health posts.
- Primary medical care: provided by general practitioners (family physicians).
- Primary specialized care: provided by obstetrician-gynecologists in antenatal clinics or offices of Central District Hospitals (CDH) and District Hospitals (DH).
Comprehensive laboratory and instrumental diagnostics are performed precisely at the base of CDH and DH. For remote areas, the use of mobile medical units is critically vital. When complications are identified at the FAP level, consultation with a subspecialist is mandatory, including through the use of telemedicine technologies.
Routing depends on the situation: scheduled antenatal hospitalization is carried out in obstetric care departments, while emergency maternal or fetal conditions require admission to the emergency delivery room or the delivery department of the CDH/DH.
Instrumental support for cesarean section
Cesarean section is performed in 25–30% of all deliveries, optimally at 39–40 weeks of gestation. Preparation for elective surgery requires specific instrumentation and adherence to strict protocols:
- Invasive devices: placement of an intravenous catheter for infusions and a urinary catheter is mandatory, which is kept in place during the first hours of the postoperative period.
- Prophylactic measures: use of compression hosiery to prevent thromboembolic complications (put on before surgery and worn throughout the recovery period).
- Preparation: includes hair removal (pubis, perineum, lower abdomen), antibiotic prophylaxis to reduce the risk of purulent-inflammatory complications, and adherence to the fasting period. Refraining from solid food is required 8 hours prior, and from clear liquids (water, tea, coffee, pulp-free juice, carbonated drinks) 2 hours prior.
The choice of anesthesia method is made by an anesthesiologist-resuscitologist after a thorough history taking (allergies, bad habits, comorbid pathologies). The patient signs an informed consent form, warning her of the risks, possible extension of the surgery scope, and blood component transfusion. Postoperatively, early mobilization in the intensive care unit is indicated.
Instrumental methods in septic complications
When severe infectious processes develop, instrumental and laboratory diagnostics play a key role in locating the primary focus and assessing organ dysfunction.
- Transesophageal echocardiography (TEE): used to visualize vegetations on the valves when acute bacterial endocarditis is suspected. The disease is accompanied by rough aortic murmurs, dyspnea, Janeway lesions or Roth spots on the conjunctiva, Osler nodes on the feet, and subungual hemorrhages.
- Chest X-ray (CXR): necessary to detect pulmonary complications, such as left-sided hemorrhagic pleurisy in cutaneous staphylococcal sepsis (against the background of furunculosis, pathogen: Staphylococcus aureus) or respiratory distress syndrome in fulminant cryptogenic sepsis.
- ECG: used to assess cardiac activity against the background of severe infectious-toxic shock.
Laboratory tools in sepsis include blood bacteriological culture, procalcitonin test, determination of presepsin and C-reactive protein (CRP) levels. Treatment requires emergency transfer to a surgical or cardiology department and the administration of empirical antibiotic therapy (e.g., ceftriaxone + gentamicin or vancomycin + metronidazole).
To remember the rule for the preoperative fasting period, use the "8-2" formula: 8 hours without food, 2 hours without water.
Class and exam questions
At what gestational age is the pregnant woman's first doctor visit conducted?
It is optimal to have the first visit in the first trimester, up to 10 weeks of gestation. A total of 5–7 visits is recommended for a normal pregnancy course.
Where are pregnant women from remote areas hospitalized in the absence of pathologies?
For routine prenatal monitoring, they are referred to specialized obstetric care departments.
What antibiotics are used empirically in obstetric sepsis?
Combination therapy is prescribed, for example, a combination of ceftriaxone with gentamicin or vancomycin with metronidazole.
What is classified as clear liquids permitted 2 hours before surgery?
These include water, tea, coffee, carbonated drinks, and pulp-free fruit juices.
What else to study on this topic
- Clinical presentation and diagnosis of acute bacterial endocarditis
- Pathogenesis and intensive care of cryptogenic sepsis with the development of DIC syndrome
- Patient routing in emergency obstetric conditions
- Laboratory markers of sepsis: procalcitonin, presepsin, C-reactive protein
- Features of management of preterm birth with a dead fetus
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