Elif Gül YAPAR EYİ, Özlem MORALOĞLU TEKİN

Covıd 19 Pandemisinde Yüksek Riskli Gebeliklerin Belirlenmesi ve Yönetimi: Antenatal Takip Piramidini Tersine Çevirme Zamanı mı ?

Dünya Sağlık Örgütü (DSÖ) Koronavirüs hastalığı 2019 (COVID-19) infeksiyonu doğrulanmış veya şüphelenilenler de dahil olmak üzere tümgebelerin kaliteli antenatal takip, doğum, ve lohusa takibi ve ruhsal sağlıkhizmeti alma hakkına sahip olduğunu yayınladı. COVID-19’ un DünyaSağlık Örgütü tarafından 11 Mart 2020 de pandemi olduğu ilanı 24 saatboyunca ve tatil günlerinden bağımsız kesintisiz doğum hizmeti veren,anne ve bebeği olarak iki ayrı hastanın sorumluluğunu taşıyan yeganebrans olan kadın doğumun iş yükünü ve sorumluluğunu daha da ağırlaştırmıştır. Acili en fazla olan uzmanlık alanı olması yanında hem doğumhem de düşük gibi üreme ile ilgili durumların ve komplikasyonların kadındoğum hekimi ile gebenin çok yakın temas halinde ve uzun süre biraradabulunarak yönetildiği bilinmektedir. Doğumların %50’ sinden fazlasınınsezaryen ile gerçekleştirilmesi ve cerrahinin getirdiği ek riskler, ultrasonografinin gebe muayenesinin bir parçası olarak kol boyundan dahakısa mesafeden uygulanması, 15-45 yaş aralığındaki gebe populayondasemptomatik dişında asemptomatik ya da presemptomatik COVID-19seyrinin sıklığı ve bulaş riski göz önüne alındığında kadın doğum hekimimesleğini yüksek riskle uygulamaktadır. Bu nedenle erken dönemdegebelerin risk değerlendirmelerinin rahim içi gebelik doğrulandıktan sonra ilk trimesterde anne öyküsü ve karakteristik özellikleri ve biyofizik vebiyokimyasal testlerle yapılarak düşük risk grubu gebelerde 12, 20,37.ve doğum gerçekleşmemiş ise 41. gebelik haftasında ek sorunlar olmadığı takdirde muayenelerin yapılması, riskli grupta ise 12-34. haftalardadeğerlendirmenin uzmanlarca gerçekleştirilmesi pandeminin yayılma hızına yetişme sıkıntısı çekebilecek olan sağlık sisteminin yükü ile birlikte,maternal ve perinatal komplikasyonları azaltabilecektir. Özellikle doğumve düşük gibi işlemlerin ve zorunlu cerrahinin ertelenmesi mümkün olamayacağından düşük risk grubunda antenatal muayene aralıklarınınaçılması gerekmektedir. Bu nedenle, “yüksek riskli gebelik” kavramınıöne çıkaran bir algoritmanın uygulanmasını hedeflemekteyiz. Bir taraftanda girişim gerektiren acil ve öncelikli hastalarda cerrahi ve sonrasında takip, infeksiyon koruma tedbirlerinin en üst düzeyde sağlandığı bir ortamda yapılmalıdır. Bu yazıda, obstetrik girişimlerin gebe ve sağlık çalışanıiçin güvenliliğin sağlandığı şartlarda gerçekleştirilebilmesi ve hem anneve hem de fetusun güvenliliğini sağlayacak ve kadın doğum/perinatolojiekibinin maksimum seviyede korunabilmesi için uygulanmasında yararlıolabilecek gebelikte “Yüksek risk algoritmasına” ilişkin bilgilendirme veyönetim sunulmaktadır

Detection and Management of High Risk Pregnancies in Covıd-19 Pandemic: Is it Time to Turning the Antenatal Care Pyramid Upside Down ?

World Health Organization (WHO) has declared that all pregnant women, including those with confirmed or suspected COVID-19 infections, have the right to high quality care before, during and after childbirth. This includes antenatal, newborn, postnatal, intrapartum and mental health care. Since the announcement of the Coronavirus disease 2019 COVID-19 outbreak as a pandemic by the WHO on March 11, 2020, the workload on obstetrics, the only specialty having both fetus and mother as two separate patients and responsibility of the obstetric service 24 hours a day, independent of holidays and weekends has aggravated. Due to the high frequency of emergency conditions in birth and abortion in obstetric practice obstetrician and pregnant woman are in intimate contact for a long duration. Considering the possibility and the frequency of transmission from not only symptomatic but also presymptomatic and asymptomatic (COVID-19) pregnant women between 15-45 years of age, obstetrician/ perinatologist. performs his profession at an advanced risk. Risk also increases during sonographic evaluation as a part of fetal examination as the distance between the ultrasonography operator and the pregnant women is 60 cm or less. Morever, more than one half of pregnant women are undergoing cesarean section adding the risks of surgery. There are two main issues caused by this pandemic regarding for the healthcare system. As it is not possible to reduce the number of deliveries and emergent complications, first it is a necessity to re organize the antenatal care protocols o reduce the burden of the healthcare system which may be confronted with strain by the increased speed of transmission. Therefore, we aim to use an algorithm called “Risk Assessment” data from maternal characteristics and history with findings of biophysical and biochemical test to reduce the number of antenatal visits for low risk pregnancies as a first step measure. For this reason, the risk assessment of pregnant women should be carried out in the first trimester after confirmation of the intrauterine pregnancy and the number of antenatal visits may be limited to 12th, 20th, and 41th weeks of gestation in the low-risk group whereas the number of antenatal visits may be determined by the specialists between 12th and 34th weeks in high risk group. Second: surgery and subsequent follow-up in emergency conditions and high risk women requiring intervention or follow up should be performed in an environment where infection protection measures are totally provided. In this review, we aim to give information about the Risk Assesment for pregnant women for the initial categorization to reduce the number of antenatal visits in low risk group and measures applied for obstetric interventions to be carried out under conditions that ensure safety not only for the pregnant women and her fetus but also the obstetric /perinatology team at the maximum level.

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