Definition and Pathophysiology

It is the synthesis by the mother of antibodies against the fetal blood elements (erythrocytes fetal platelets, ...). The result is a hemolysis of fetal blood elements. Maternal antibody production can occur whenever there is introduction of red blood cells "foreign" transfusion, pregnancy, ...

Pregnant women with toxoplasmosis serology-negative are not immunized (ie unprotected) against toxoplasmosis. This affects about one in two women.

Pregnancy is a physiological process between fertilization and birth. It is an important part of the human reproductive system. Only 5% of pregnancies are not "low risk" in terms of fetal or maternal pathology.

Monitoring a pregnancy is regulated and a number of consultations and examinations are reimbursed 100% by Social Security.

Pregnancy is the cause of many changes that may be responsible for an imbalance in the psyche of a woman.

Also, during pregnancy, we must look for risk factors of onset of psychiatric disorders such as psychiatric history, personal and / or family history of obstetric accidents, a psycho-social context especially ..

Disorders encountered DURING pregnancy are::

-minor ailments: vomiting, anxiety attacks, phobias ...

-a depressive syndrome before birth and usually varied in intensity.

The troubles encountered DURING THE POSTPARTUM (after childbirth) are more frequent and of 3 types: :

-The baby blues or the 3rd day syndrome : the most frequent, it usually occurs between the 3rd and 6th day and can last from several hours to 4-5 days. It is totally benin and regresses completely

The patient has a feeling of guilt, failure, irritability with sleep disturbance, fear of not knowing how to care for the baby, not being a good mother ... It is important to reassure the mother about the common and temporary character of these symptoms and support the mother-child relationship. No psychiatric drug treatment is helpful.

-Depressions in the Postpartum: : less frequent, they are found in the weeks or months after delivery. We can see in the mother a delusional conviction of being unable to care for the child and a sense of guilt regarding her responsibility to death or misfortune

A stay at a psychiatric hospital is needed and a drug treatment with antidepressants. It is essential to preserve the mother-child relationship.

-Puerperal psychosis confuso-delusion: : It appears suddenly within 3 weeks after delivery. The patient has a delirium (with a hangover and disorientation in time and space) and lability of mood (alternating with agitation, sadness ...). We find an almost systematic denial of motherhood, a feeling of not belonging to the child or the belief that her child has been changed

A stay at a psychiatric hospital in mother-child unit is needed. An initial separation with the baby is necessary knowing that it will be essential to follow it up by a prudent reconciliation under supervision. Neuroleptic medication is put in place..

Definitions:

Prenatal diagnosis is the set of resources used for early detection of diseases or malformations of the fetus. .

It involves any diagnostic procedure performed in order to predict or determine the status of the child before its birth. It therefore aims to detect a fetal abnormality and to clarify the diagnosis and prognosis.

It is important to note at the outset the difference between prenatal diagnosis and screening, often confused notions: while prenatal screening detects mainly a risk factor for disability (trisomy 21, for example), prenatal diagnosis allows meanwhile to establish or exclude with certainty the presence of an anomaly. Usually the diagnosis is made following a positive screening.Thus, the serum markers is a method of detecting pregnancy as "high risk" and not a method of diagnosis of trisomy 21.

According to WHO (World Health Organization), a birth is premature if it occurs before 37 weeks gestation.

We musn't forget that premature births account for approximately 6% of births in France.

There are 3 types of prematurity according to the date of onset of delivery: :

-Average” prematurity(between 32 and 37 weeks gestation), the most common (approximately 30 000 children in France) for which the prognosis is good.

-The “great” prematurity(between 28 and 32 weeks gestation), it affects approximately 7000 children per year. In these cases transferal to a perinatal center are essential..

-The "very large" preterm (before 28 weeks gestation), whose numbers and prognosis are still poorly understood at present in France.

We can define two types of preterm birth::

-Induced”prematurity due to a voluntary fetal extraction indicated by obstetricians to save the mother and/or fetus.

-Spontaneous” preterm birth is not triggered by doctors.

Risk factors for preterm birth are:

-RELATED TO THE EGG:

-Multiple pregnancies with major risk 10 times higher than for singleton pregnancies

-Placental abnormalities: Placenta previa, placentae

-Bleeding during the second and third trimester (risk multiplied by 4)

-Polyhydramnios (insufficient amniotic fluid)

-

RELATED TO THE UTERUS:

-Congenital malformations of the cervix or uterus

-Incompetent cervix congenital or acquired

-Exposure to DES (Distilbène) in utero causing hypoplastic uterine, cervical and / or functional incompetence. This includes approximately 80 000 women born in France between 1950 and 1975

-Large fibroids distorting the uterine cavity or extensive synechia.

LINKED TO STATE OF THE MOTHER:

-History of premature birth or serious threat of premature delivery

-History of induced or spontaneous abortion

-Severe maternal fever, caused by bacteria (urinary tract infection, listeriosis) or viral

-Cervicovaginal infections and STDs at the origin of ascending infections

-Inadequate prenatal care

-Low socio-economic status

However, in a high proportion of cases, no risk factor is found. Vigilance is therefore required for any pregnancy.

The essential function of the mammary gland is to feed the newborn. Breast milk contains all the nutrients it needs. The composition of human milk differs from the industrial production, for example during the first days of lactation with the production of colostrum which is particularly rich in proteins and immune cells.

The delivery includes all the physiological phenomena leading to the separation of the fetus from the maternal organism

Its course is complicated by its physiology and mechanics:

-the fetus must initially pass three hurdles:

-the neck of the cervix

-the hipbone

-the perineum

-this complex transit can not occur without uterine contractions, the real "engine" of childbirth

-three main phases of work are to be noted :

-Phase 1: Modification of cervix

-Phase 2: Growth in fetal mobility divided into 3 stages:

-engagement

-the descent and rotation in the pelvis

-release, corresponding to the expulsion of the fetus

-Phase 3: the delivery

Vocabulary around childbirth: :

-Presentation :Part of the body of the fetus comes into contact with the brim of the maternal pelvis.

-Episiotomy :perineal incision made at the time of delivery, aiming to enlarge the vaginal opening, to prevent damage to the perineum.

-Labour: :involuntary uterine contractions , painful,which come quicker and more regular and changes of the cervix.

-Pelvic expulsion: :anatomical region in which the presentation makes its descent and rotation.

Some simple anatomical explanations: The die bone and soft tissue in question

Some simple anatomical explanations: The pelvic girdle and soft tissue in question

To exit the womb, during childbirth, the fetus will have to overcome two obstacles: :

-The The bony pelvis,, which is a narrow channel fixed and inextensible: Often compared to a bent cylinder open at the front the pelvis bone is limited at the front by the symphysis pubis, posteriorly by the sacrum and coccyx, and laterally by the iliac bone . The brim or orifice of the die is the engagement plan of the presentation

- A muscular portion,, corresponding to the pelvic floor muscles, firm the pelvic cavity. These elements are fibromuscular influenced by hormones, and distended, forming an open tube at the front

Uterine contractions, "key driver" »

The uterus although gradually distended with advancing pregnancy, maintains its functional structure in which the cervix is closed below

With the onset of labour, initially, the cervix will change by clearing the cervical canal.

Gradually the cervix dilates to allow passage to the presentation. This expansion is progressing at a rate of 1cm per hour of labour to reach a diameter of 10cm.

Uterine contractions of labor are characterized as being: :

-painful

-Involuntary

-close,together, regular

- and the frequency and duration increase gradually

Foetal mobility

The mechanical factor is important in the dynamics of the birth. In fact the fetal head,which is an incompressible element, in order to descend into the pelvis, will have to undergo at first a rotation and flexion. The portion of the inferior strait, the final step called "disengagement" corresponds to the combined effect of uterine contractions and expulsive efforts, with a movement of deflection of the head. To finish

Delivery

It is the third stage of labour, and is defined as all the events leading to the expulsion of the placenta and membranes. The 3 phases of the delivery are respectively:

-:detachment: after the expulsion of the fetus, the resumption of normal uterine contractions will help to detach the placenta.

-Under the action of the same uterine contractions and maternal expulsive efforts, the expulsion of the placenta will take place.

-Then the uterus will shrink to allow the closure of the uterine vessels, corresponding to the physiological hemostasis.

Close surveillance

The process of delivery is done under continuous fetal monitoring to monitor the "welfare" of the fetal heart rate . The work is performed by the analgesic anesthetic team, who increasingly suggest that epidural analgesia reduces or eliminates the sensation of pain.

The serving team will consist of the patient, nurses / nurse assistants, midwives and doctors that work in the best conditions for both mother and child.

presentation .

In most cases, in 57% of cases, the fetus presents head down, though bent, with the posterior fontanelle (fontanel posterior) oriented toward the front and left. (Next to the eminence iliopectineal left).

This presentation called LOA (left occiput anterior iliac) is the most common and the most favorable, since the bending will reduce by a huge amount the diameter of the moving fetus, and make it much less than the dimensions of the pelvis. The descent is easier then!

Special case of breech presentation

The breech presentation corresponds to a fetus whose buttocks are towards the brim while the head is located high in the uterus. There is a nuance with the breech where the legs are raised in front of the trunk.

When the breech is discovered before the 8th month, the obstetrician may try to turn the presentation by external manipulation.

Definition: This is the implementation and development of a pregnancy outside of the uterus, usually in the fallopian tube, rarely in the ovary or peritoneal cavity.

The consultation, which takes place in the first trimester is the most important because it assesses your state of health and to allows the doctor to plan the medical follow up of your pregnancy.

It is a termination of pregnancy for medical reasons at any time during pregnancy.

The medical reason in question may be:

-a serious endangerment of the health of the woman, in this case we talk about therapeutic abortion or ITG

-a high probability that the child may be born with an incurable disease at diagnosis (eg, trisomy 21, fetal heart defects or other ...) in this case we speak of Medical Termination of Pregnancy or IMG..

Applications of IMG should be reviewed by a multidisciplinary team composed among other gynecologists-obstetricians, geneticists, pediatricians, psychologists

The delivery:

A normal delivery must occur spontaneously within the 30 minutes after birth

The delivery or expulsion of the placenta and its membranes, will allow the uterus to retract, resulting in a physiological way which is called "globe uterine safety.

This retraction associated with the myometrial contraction compresses the uterine vessels remained gaping at the placental insertion zone. This is the process of local physiological hemostasis.

The delivery brings together four physiological conditions:

-Correct uterine retraction

-Complete uterine emptiness (uterine retraction required for proper hemostasis is possible only if the uterus is completely empty)

-Normal blood clotting

An anomaly of one or more of these four conditions can lead to postpartum hemorrhage.

Postpartum hemorrhage ( PPH:)

It is uterine bleeding that occurs within 24 hours after birth and whose volume exceeds 500 ml blood lost.

The main causes of postpartum hemorrhage are:

-uterine atony (failure of uterine contraction)

-retained placenta (incomplete delivery)

-bleeding disorders

Preventive actions:

Examination of Uterus: It is routine in cases of doubt on the integrity of the placenta and / or membranes during the examination of the latter.

Directed delivery: Injection of product tonic-utero at the time of birth, thus allowing for increased uterine contractions and to help the delivery