Уровень убедительности рекомендаций С (уровень достоверности доказательств

Комментарий: Данные основаны на значительном уменьшении распространённости, тяжести течения и последствий гриппа у беременных женщин с потенциальной пользой для рождённых ими младенцев.

Таблица 3

Вакцинация во время беременности (205)

Вакцина	Применение во время беременности	Комментарий
БЦЖ^а	Нет
Холера	Нет (206)	Безопасность не доказана
Гепатит А	Да в случае необходимости	Безопасность не доказана
Гепатит В	Да в случае необходимости
Грипп	Да в случае необходимости
Японский энцефалит	Нет	Безопасность не доказана
Корь^а	Нет^в
Менингококковая инфекция	Да в случае необходимости	Только в случае высокого риска инфицирования (206)
Эпидемический паротит^а	Нет^в
Оральная вакцина против полиомиелита	Да в случае необходимости
Инактивированная вакцина против полиомиелита	Да в случае необходимости	Обычно не назначается
Бешенство	Да в случае необходимости
Краснуха^а	Нет^в
Столбняк/дифтерия/коклюш	Да в случае необходимости
Тиф Ty21a^а	Нет	Безопасность не доказана
Оспа	Нет
Ветряная оспа^а	Нет
Желтая лихорадка^а	Только в случае высокого риска инфицирования
Грипп	В сезон гриппа

а – живая вакцина, противопоказана во время беременности

в – беременность должна планироваться не ранее, чем через 3 месяца после вакцинации

6. Организация оказания медицинской помощи

Показания для госпитализации в акушерско-гинекологический стационар:

1) Развитие родовой деятельности.

2) Излитие или подтекание околоплодных вод.

3) Кровянистые выделения из половых путей, свидетельствующие об угрозе выкидыша.

4) Признаки угрожающих ПР.

5) Признаки ПОНРП.

6) Признаки ИЦН.

7) Рвота беременных> 10 раз в сутки и потеря массы тела> 3 кг за 1-1,5 недели при отсутствии эффекта от проводимой терапии.

8) Однократное повышение диастолического АД ≥110 мм рт. ст. или двукратное повышение диастолического АД ≥90 мм рт. ст. с интервалом не менее 4 часов.

9) Повышение систолического АД ≥160 мм рт. ст.

10) Протеинурия (1+).

11) Симптомы полиорганной недостаточности (головная боль, нарушения зрения, боли в эпигастрии, рвота, симптомы поражения печени, олиго\анурия, нарушения сознания, судороги в анамнезе, гиперрефлексия).

12) Признаки хориоамнионита.

13) ЗРП 2-3 степени.

14) Нарушение функционального состояния плода по данным допплерометрии и КТГ.

15) Внутриутробная гибель плода.

16) Острый живот.

17) Острые инфекционные и воспалительные заболевания.

Показания к выписке пациента из медицинской организации:

1) После родов (см. клинические рекомендации «Послеродовая помощь и обследование»).

2) После купирования симптомов угрожающего выкидыша, угрожающих ПР, ИЦН с прогрессирующей беременностью (см. клинические рекомендации «Выкидыш в ранние сроки беременности», «Преждевременные роды и родоразрешение», «Истмико-цервикальная недостаточность»).

3) После купирования симптомов рвоты беременных с пролонгирующейся беременностью (см. клинические рекомендации «Рвота беременных»).

4) После купирования причины острого живота с пролонгирующейся беременностью.

5) После излечения острых инфекционных и воспалительных заболеваний с пролонгирующейся беременностью.

Показания для госпитализации в акушерско-гинекологический стационар 3-й группы:

Наличие рубца на матке после операции кесарева сечения и расположение плаценты по передней стенке матки согласно данным УЗИ (группа высокого риска по врастанию плаценты).

Кратность посещения врача акушера-гинеколога во время нормальной беременности:

Оптимальная кратность посещения врача акушера-гинеколога беременной женщиной с нормально протекающей беременностью составляет от 4 до 7 раз. Оптимальным временем первого визита к врачу является 1-й триместр беременности (до 10 недель).[56]

7. Дополнительная информация (в том числе факторы, влияющие на исход заболевания или состояния)

Не применимо

Критерии оценки качества медицинской помощи

№	Критерии качества	Уровень убедительности рекомендаций	Уровень достоверности доказательств
1.	Проведено определение срока беременности и родов при 1-м визите беременной пациентки	А
2.	Проведено измерение артериального давления при каждом визите беременной пациентки	С
3.	Проведено измерение высоты дна матки при каждом визите беременной пациентки и ведение гравидограммы после 20 недель беременности	В
4.	Проведено определение частоты сердцебиения плода при помощи акушерского стетоскопа после 20 недель беременности или при помощи фетального допплера после 12 недель беременности при каждом визите беременной пациентки	С
5.	Выполнено направление беременной пациентки на исследование уровня антител классов M, G (IgM, IgG) к вирусу иммунодефицита человека-1/2 (далее – ВИЧ) и антигена p24 (Human immunodeficiency virus HIV 1/2 + Agp24) в крови при 1-м визите и в 3-м триместре беременности	А
6.	Выполнено направление беременной пациентки на определение антител к поверхностному антигену (HBsAg) вируса гепатита В (Hepatitis В virus) в крови или определение антигена (HbsAg) вируса гепатита В (Hepatitis В virus) в крови при 1-м визите и в 3-м триместре беременности	В
7.	Выполнено направление беременной пациентки на определение антител к бледной трепонеме (Treponema pallidum) в крови при 1-м визите и в 3-м триместре беременности	В
8.	Выполнено направление беременной пациентки на определение антигена стрептококка группы В (S. agalactiae) в отделяемом цервикального каналав 35-37 недель беременности	В
9.	Выполнено направление беременной пациентки на микроскопическое исследование влагалищных мазков при 1-м визите и в 3-м триместре беременности	В
10.	Выполнено направление беременной пациентки на микробиологическое (культуральное) исследование средней порции мочи на бактериальные патогены однократно на выявление бессимптомной бактериурии при 1-м визите	А
11.	Выполнено направление беременной пациентки на определение основных групп по системе AB0 и антигена D системы Резус (резус-фактор) однократно при 1-м визите	В
12.	Выполнено направление беременной резус-отрицательной пациентки на определение антирезусных антител при 1-м визите и затем при отсутствии антител в 18-20 недель и в 28 недель беременности	В
13.	Выполнено направление беременной пациентки на проведение общего (клинического) анализа крови при 1-м визите, во 2-м и в 3-м триместре беременности	В
14.	Выполнено направление беременной пациентки на определение нарушения углеводного обмена при 1-м визите и в 24-26 недель беременности и на проведение перорального глюкозотолерантного теста (ПГТТ) с 75 г глюкозы в 24-28 недель беременности в случае, если у нее не было выявлено нарушение углеводного обмена	С
15.	Выполнено направление беременной пациентки исследование уровня тиреотропного гормона (ТТГ) в крови однократно при 1-м визите	А
16.	Выполнено направление беременной пациентки на проведение общего (клинического) анализа мочи при 1-м визите, во 2-м и в 3-м триместре беременности для выявления протеинурии	В
17.	Выполнено направление беременной пациентки на проведение скринингового ультразвукового исследования плода и биохимического скрининга при сроке беременности 11-13⁶ недель	А
18.	Выполнено направление беременной пациентки на проведение скринингового ультразвукового исследования плода и ультразвукового исследования шейки матки (УЗ-цервикометрию) при сроке беременности 18-20⁶ недель	А
19.	Проведено назначение перорального приема фолиевой кислоты** беременной пациентке на протяжении первых 12 недель беременности в дозе 400 мкг в день	А
20.	Проведено назначение введения иммуноглобулина человека антирезус Rho[D] в дозе, согласно инструкции к препарату, внутримышечно в 28-30 недель беременности беременной резус-отрицательной пациентке при отсутствии антирезусных антител	А

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Приложение А1. Состав рабочей группы по разработке и пересмотру клинических рекомендаций

Авторы

1) Долгушина Наталия Витальевна – д.м.н., профессор, заместитель директора – руководитель департамента организации научной деятельности ФГБУ «Национальный медицинский исследовательский центр акушерства, гинекологии и перинатологии им. акад. В.И. Кулакова» Минздрава России (г. Москва).