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Lecture notes, cheat sheets
Obstetrics and gynecology. Lecture notes: briefly, the most important
Directory / Lecture notes, cheat sheets Table of contents
Lecture number 1. Anatomy and physiology of the female genital organs 1. Anatomy of the female genital organs The genital organs of a woman are usually divided into external and internal. The external genitalia are the pubis, the labia majora and minora, the clitoris, the vestibule of the vagina, and the hymen. The internal organs include the vagina, uterus, fallopian tubes, and ovaries. external genitalia Pubis is an area rich in subcutaneous fat, covered with hair in adulthood, triangular in shape, with the base facing upwards. Large labia formed by two folds of skin containing fatty tissue, sebaceous and sweat glands. They are connected to each other by the anterior and posterior commissures, and separated by the genital gap. In the thickness of the lower third of the labia majora are large glands of the vestibule - the Bartholin glands, the alkaline secret of which moisturizes the entrance to the vagina and dilutes the seminal fluid. The excretory ducts of these glands open in the groove between the labia minora and the hymen. Small labia are a mucous membrane in the form of two folds. They are located medially from the labia majora. Normally, the inner surfaces of the large and small labia are in contact, the genital gap is closed. Clitoris is an organ similar to the male penis, located in the anterior corner of the genital fissure, consists of two cavernous bodies, richly supplied with blood vessels and nerve plexuses. Vaginal vestibule - the space bounded by the labia minora. It opens the external opening of the urethra, the excretory ducts of the large glands of the vestibule, the entrance to the vagina. Hymen is a thin connective tissue septum separating the external and internal genital organs. It has a hole, depending on its shape and location of the hymen, it can be semilunar, annular, serrated, lobed. The hymen is torn during the first sexual intercourse, the remains of it are called hymenal papillae, and after additional breaks in childbirth - myrtle papillae. internal sex organs Vagina It is a muscular-fibrous tube 8-10 cm long. It is located in the pelvic cavity, adjoining the urethra and bladder in front, and the rectum in the back. The walls of the vagina are in contact with each other and in the upper section, around the vaginal part of the cervix form dome-shaped recesses - the anterior, posterior, right and left lateral vaults of the vagina. The deepest of them is the posterior fornix. It accumulates the contents of the vagina. The walls of the vagina consist of a mucous membrane, a muscular layer and surrounding tissue. The mucous membrane of the vagina is covered with stratified squamous epithelium, has a pink color and numerous transverse folds, which ensure its extensibility during childbirth. There are no glands in the vaginal mucosa, but it is always in a hydrated state due to the perspiration of fluid from the blood, lymphatic vessels and the attachment of secretocervical, uterine glands, sloughing epithelial cells, microorganisms and leukocytes. In a healthy woman, these secretions are mucous in nature, milky in color, characteristic odor and acidic. In accordance with the nature of the microflora, it is customary to distinguish four degrees of purity of the vaginal contents. At the first degree of purity, only vaginal sticks and individual epithelial cells are found in the acidic vaginal contents. At the second degree of purity, the vaginal sticks become smaller, individual cocci appear, single leukocytes, the reaction remains acidic. Both degrees of purity are considered normal. The third degree of purity is characterized by an alkaline reaction, the predominance of leukocytes, cocci and other types of bacteria. At the fourth degree of purity, vaginal sticks are absent, a variety of microbial pathogenic flora (cocci, E. coli, Trichomonas, etc.), a large number of leukocytes are found in the contents. Uterus - hollow smooth muscle pear-shaped organ, flattened in the anteroposterior direction. In the uterus, the body, isthmus and neck are distinguished. The upper convex part of the body is called the fundus of the uterus. The uterine cavity has the shape of a triangle, in the upper corners of which the openings of the fallopian tubes open. At the bottom, the uterine cavity, narrowing, passes into the isthmus and ends with an internal pharynx. Cervix - This is a narrow cylindrical shape of the lower part of the uterus. It distinguishes between the vaginal part, protruding into the vagina below the arches, and the supravaginal upper part, located above the arches. Inside the cervix passes a narrow cervical (cervical) canal 1-1,5 cm long, the upper section of which ends with an internal pharynx, and the lower one ends with an external one. The cervical canal contains a mucous plug that prevents the penetration of microorganisms from the vagina into the uterus. The length of the uterus in an adult woman is on average 7-9 cm, the thickness of the walls is 1-2 cm. The weight of the non-pregnant uterus is 50-100 g. The walls of the uterus consist of three layers. The inner layer is a mucous membrane (endometrium) with many glands, covered with ciliated epithelium. In the mucous membrane, two layers are distinguished: the layer adjacent to the muscular membrane (basal), and the surface layer - the functional one, which undergoes cyclic changes. Most of the uterine wall is the middle layer - the muscular (myometrium). The muscular coat is formed by smooth muscle fibers that make up the outer and inner longitudinal and middle circular layers. The outer - serous (perimetry) layer is the peritoneum covering the uterus. The uterus is located in the cavity of the small pelvis between the bladder and the rectum at the same distance from the walls of the pelvis. The body of the uterus is tilted anteriorly, towards the symphysis (anteversion of the uterus), has an obtuse angle with respect to the neck (anteflexia of the uterus), open anteriorly. The cervix is facing backwards, the external os is adjacent to the posterior fornix of the vagina. The fallopian tubes start from the corners of the uterus, go to the sides to the side walls of the pelvis. They are 10-12 cm long and 0,5 cm thick. The walls of the tubes consist of three layers: the inner - mucous, covered with a single-layer ciliated epithelium, the cilia of which flicker towards the uterus, the middle - muscular and the outer - serous. In the tube, the interstitial part is distinguished, passing through the thickness of the uterine wall, the isthmic - the most narrowed middle part and the ampullar - the expanded part of the tube, ending with a funnel. The edges of the funnel look like fringes - fimbriae. Ovaries are paired almond-shaped glands, 3,5-4, 1-1,5 cm in size, weighing 6-8 g. They are located on both sides of the uterus, behind the wide ligaments, attaching to their back sheets. The ovary is covered with a layer of epithelium, under which the albuginea is located, the cortical substance is located deeper, in which there are numerous primary follicles in different stages of development, corpus luteum. Inside the ovary is a medulla consisting of connective tissue with numerous vessels and nerves. During puberty in the ovaries, the process of maturation and release into the abdominal cavity of mature eggs capable of fertilization monthly rhythmically occurs. This process is aimed at the implementation of the reproductive function. The endocrine function of the ovaries is manifested in the production of sex hormones, under the influence of which during puberty the development of secondary sexual characteristics and genital organs occurs. These hormones are involved in the cyclical processes that prepare a woman's body for pregnancy. Ligamentous apparatus of the genital organs and fiber of the small pelvis The suspensory apparatus of the uterus consists of ligaments, which include paired round, wide, funnel-pelvic and proper ligaments of the ovaries. Round ligaments extend from the corners of the uterus, anterior to the fallopian tubes, go through the inguinal canal, attach at the pubic symphysis, pulling the bottom of the uterus forward (anteversion). Broad ligaments depart in the form of double sheets of peritoneum from the ribs of the uterus to the side walls of the pelvis. In the upper sections of these ligaments, the fallopian tubes pass, and the ovaries are attached to the posterior sheets. Funnel-pelvic ligaments, being a continuation of the broad ligaments, go from the funnel of the tube to the pelvic wall. Own ligaments of the ovaries go from the bottom of the uterus backwards and below the discharge of the fallopian tubes are attached to the ovaries. The fixing apparatus includes sacro-uterine, main, utero-vesical and vesico-pubic ligaments. The sacro-uterine ligaments extend from the posterior surface of the uterus in the area of the transition of the body to the neck, cover the rectum on both sides and are attached to the anterior surface of the sacrum. These ligaments pull the cervix backwards. The main ligaments go from the lower part of the uterus to the side walls of the pelvis, the uterovesical - from the lower part of the uterus anteriorly, to the bladder and further to the symphysis, like the vesicopubic. The space from the lateral sections of the uterus to the walls of the pelvis is occupied by the periuterine parametric fiber (parametrium), in which the vessels and nerves pass. Milk glands They are modified sweat glands. During puberty, the mammary gland has a cluster-shaped structure and consists of many vesicles - alveoli, forming large lobules. The number of lobules is 15-20, each of which has its own excretory duct, which independently opens on the surface of the nipple. Each milk duct, before reaching the surface of the nipple, forms an expansion in the form of a sac - the milk sinus. Interlobular spaces are filled with layers of fibrous connective and adipose tissue. The lobules of the mammary glands contain cells that produce a secret - milk. On the surface of the gland is the nipple, covered with delicate, wrinkled skin and having a conical or cylindrical shape. The function of the mammary glands is the production of milk. 2. Physiology of the female reproductive system The female reproductive system has four specific functions: menstrual, reproductive, reproductive, and secretory. Menstrual cycle. menstrual cycle Rhythmically repeated complex changes in the reproductive system and throughout the body of a woman are called, preparing her for pregnancy. The duration of one menstrual cycle is counted from the first day of the last menstruation to the first day of the next menstruation. On average, it is 28 days, less often 21-22 or 30-35 days. The duration of menstruation is normally 3-5 days, blood loss is 50-150 ml. Menstrual blood is dark in color and does not clot. Changes during the menstrual cycle are most pronounced in the organs of the reproductive system, especially in the ovaries (ovarian cycle) and the lining of the uterus (uterine cycle). An important role in the regulation of the menstrual cycle belongs to the hypothalamic-pituitary system. Under the influence of releasing factors of the hypothalamus in the anterior pituitary gland, gonadotropic hormones are produced that stimulate the function of the gonads: follicle-stimulating (FSH), luteinizing (LH) and luteotropic (LTH). FSH promotes the maturation of follicles in the ovaries and the production of follicular (estrogen) hormone. LH stimulates the development of the corpus luteum, and LTH - the production of the corpus luteum hormone (progesterone) and the secretion of the mammary glands. In the first half of the menstrual cycle, the production of FSH predominates, in the second half - LH and LTH. Under the influence of these hormones, cyclic changes occur in the ovaries. Ovarian cycle. This cycle consists of 3 phases: 1) development of the follicle - follicular phase; 2) rupture of a mature follicle - the phase of ovulation; 3) development of the corpus luteum - luteal (progesterone) phase. In the follicular phase of the ovarian cycle, the growth and maturation of the follicle occurs, which corresponds to the first half of the menstrual cycle. There are changes in all components of the follicle: an increase, maturation and division of the egg, rounding and reproduction of the cells of the follicular epithelium, which turns into a granular membrane of the follicle, differentiation of the connective tissue membrane into the outer and inner. In the thickness of the granular membrane, follicular fluid accumulates, which pushes the cells of the follicular epithelium on one side to the egg, on the other - to the wall of the follicle. The follicular epithelium that surrounds the egg is called radiant crown. As the follicle matures, it produces estrogen hormones that have a complex effect on the genitals and the entire body of a woman. During puberty, they cause the growth and development of the genital organs, the appearance of secondary sexual characteristics, during puberty - an increase in the tone and excitability of the uterus, the proliferation of cells of the uterine mucosa. Promote the development and function of the mammary glands, awaken the sexual feeling. ovulation called the process of rupture of a mature follicle and the release of a mature egg from its cavity, covered on the outside with a shiny membrane and surrounded by cells of the radiant crown. The egg enters the abdominal cavity and further into the fallopian tube, in the ampullary section of which fertilization occurs. If fertilization does not occur, then after 12-24 hours the egg begins to break down. Ovulation occurs in the middle of the menstrual cycle. Therefore, this time is the most favorable for conception. The phase of development of the corpus luteum (luteal) occupies the second half of the menstrual cycle. In place of the ruptured follicle after ovulation, a corpus luteum is formed that produces progesterone. Under its influence, secretory transformations of the endometrium occur, which are necessary for implantation and development of the fetal egg. Progesterone reduces the excitability and contractility of the uterus, thereby contributing to the preservation of pregnancy, stimulates the development of the parenchyma of the mammary glands and prepares them for the secretion of milk. In the absence of fertilization, at the end of the luteal phase, the corpus luteum regresses, progesterone production stops, and a new follicle begins to mature in the ovary. If fertilization has occurred and pregnancy has occurred, then the corpus luteum continues to grow and function during the first months of pregnancy and is called corpus luteum of pregnancy. uterine cycle. This cycle is reduced to changes in the uterine mucosa and has the same duration as the ovarian one. It distinguishes two phases - proliferation and secretion, followed by rejection of the functional layer of the endometrium. The first phase of the uterine cycle begins after the rejection (desquamation) of the endometrium during menstruation ends. In the stage of proliferation, epithelialization of the wound surface of the uterine mucosa occurs due to the epithelium of the glands of the basal layer. The functional layer of the mucous membrane of the uterus thickens sharply, the endometrial glands acquire a sinuous shape, their lumen expands. The proliferation phase of the endometrium coincides with the follicular phase of the ovarian cycle. The secretion phase occupies the second half of the menstrual cycle, coinciding with the development phase of the corpus luteum. Under the influence of the corpus luteum hormone progesterone, the functional layer of the uterine mucosa is even more loosened, thickened and clearly divided into two zones: spongy (spongy), bordering on the basal layer, and more superficial, compact. Glycogen, phosphorus, calcium and other substances are deposited in the mucous membrane, favorable conditions are created for the development of the embryo if fertilization has occurred. In the absence of pregnancy at the end of the menstrual cycle, the corpus luteum in the ovary dies, the level of sex hormones decreases sharply, and the functional layer of the endometrium, which has reached the secretion phase, is rejected and menstruation occurs. 3. Anatomy of the female pelvis The structure of the pelvis women is very important in obstetrics, since the pelvis serves as the birth canal through which the fetus is born. The pelvis consists of four bones: two pelvic bones, the sacrum and the coccyx. Pelvic (innominate) bone It consists of three fused bones: the ilium, pubic and ischium. The bones of the pelvis are connected by means of a paired, almost immobile sacroiliac joint, an inactive semi-joint - the symphysis and a movable sacrococcygeal joint. The joints of the pelvis are reinforced with strong ligaments and have cartilaginous layers. The ilium consists of a body and a wing, expanded upwards and ending in a crest. In front, the crest has two protrusions - the anteroupper and anteroinferior awns, behind there are posterior superior and posterior inferior awns. The ischium consists of a body and two branches. The upper branch goes from the body down and ends with the ischial tuberosity. The lower branch is directed anteriorly and upward. On the back surface of it there is a protrusion - the ischial spine. The pubic bone has a body, upper and lower branches. On the upper edge of the upper branch of the pubic bone there is a sharp crest, which ends in front with a pubic tubercle. Sacrum consists of five fused vertebrae. On the anterior surface of the base of the sacrum, a protrusion is the sacral promontory (promontorium). The apex of the sacrum is movably connected to coccyxconsisting of four to five undeveloped fused vertebrae. There are two sections of the pelvis: the large and small pelvis, between them there is a boundary, or nameless line. The large pelvis is available for external examination and measurement, unlike the small pelvis. The size of the small pelvis is judged by the size of the large pelvis. In the small pelvis, an entrance, a cavity and an exit are distinguished. In the pelvic cavity there are narrow and wide parts. Accordingly, four planes of the small pelvis are conditionally distinguished. The plane of entry into the small pelvis is the boundary between the large and small pelvis. At the entrance to the pelvis, the largest size is the transverse. In the cavity of the small pelvis, the plane of the wide part of the cavity of the small pelvis is conditionally distinguished, in which the direct and transverse dimensions are equal, and the plane of the narrow part of the cavity of the small pelvis, where the direct dimensions are somewhat larger than the transverse ones. In the plane of the exit of the small pelvis and the plane of the narrow part of the small pelvis, the direct size prevails over the transverse. In obstetric terms, the following dimensions of the small pelvis are important: true conjugate, diagonal conjugate and direct size of the pelvic outlet. The true, or obstetric, conjugate is the direct size of the entrance to the small pelvis. This is the distance from the cape of the sacrum to the most prominent point on the inner surface of the pubic symphysis. Normally, it is 11 cm. The diagonal conjugate is determined during a vaginal examination. This is the distance between the sacral cape and the lower edge of the symphysis. Normally, it is 12,5-13 cm. The direct size of the exit of the small pelvis goes from the top of the coccyx to the lower edge of the symphysis and is 9,5 cm. During childbirth, when the fetus passes through the small pelvis, this size increases by 1,5-2 cm due to the deviation of the tip of the coccyx posteriorly. The soft tissues of the pelvis cover the bone pelvis from the outer and inner surfaces and are represented by ligaments that strengthen the joints of the pelvis, as well as muscles. Important in obstetrics are the muscles located in the outlet of the pelvis. They close the bottom of the bone canal of the small pelvis and form the pelvic floor. Obstetric (anterior) perineum called that part of the pelvic floor, which is located between the anus and the posterior commissure of the labia. The part of the pelvic floor between the anus and the coccyx is called back crotch. The pelvic floor muscles, together with the fascia, form three layers. These three layers can stretch and form a wide tube - a continuation of the bony birth canal, which plays a big role in the expulsion of the fetus during childbirth. The most powerful is the upper (inner) layer of the pelvic floor muscles, which consists of a paired muscle that lifts the anus, and is called the pelvic diaphragm. The middle layer of muscles is represented by the urogenital diaphragm, the lower (outer) - by several superficial muscles converging in the tendon center of the perineum: bulbous-spongy, ischiocavernosus, superficial transverse perineal muscle and external sphincter of the rectum. The pelvic floor performs the most important functions, being a support for the internal and other organs of the abdominal cavity. Failure of the pelvic floor muscles leads to prolapse and prolapse of the genitals, bladder, rectum. Lecture number 2. Physiological pregnancy 1. Fertilization and development of the ovum Fertilization is the process of joining male and female sex cells. It occurs in the ampulla of the fallopian tube. From this moment, pregnancy begins. Migration of a fertilized egg A fertilized crushing egg moves along the tube towards the uterus and on the 6-8th day reaches its cavity. Promotion of the egg is facilitated by peristaltic contractions of the fallopian tubes, as well as the flickering of the cilia of the epithelium. Implantation of a fertilized egg The mucous membrane of the uterus by the time the fertilized egg enters the uterine cavity is sharply thickened and loose. Glycogen accumulates in the endometrium due to the influence of the corpus luteum hormone. The lining of the uterus during pregnancy is called decidual, or falling away shell. A fertilized egg, the outer layer of which is a trophoblast, due to the presence of proteolytic enzymes, melts the decidua, sinks into its thickness and grafts. Placenta At the end of the 1st month of pregnancy, the fetal egg is surrounded on all sides by chorionic villi, which at first do not have vessels. Gradually, the vascularization of the chorion occurs: the vessels of the embryo grow into its villi. At the 2-3rd month of pregnancy, atrophy of the chorionic villi begins at one pole of the fetal egg facing the uterine cavity. On the opposite part of the chorion, immersed in the mucous membrane, the villi grow magnificently and at the beginning of the 4th month turn into a placenta. In addition to the chorionic villi, which make up the bulk of the placenta, the decidua of the uterus (the mother part of the placenta) takes part in its formation. The placenta secretes a complex complex of hormones and biologically active substances into the mother's body. Of particular importance is progesterone, which contributes to the development and maintenance of pregnancy. For the development of pregnancy, estrogenic hormones are also of great importance: estradiol, estriol and estrone. By the end of pregnancy, the placenta has a diameter of 15-18 cm, a thickness of 2-3 cm and a mass of 500-600 g. Two surfaces are distinguished in the placenta: internal (fetal) and external (maternal). On the fruit surface, covered with an aqueous membrane, there are vessels that diverge radially from the umbilical cord. The maternal surface consists of 15-20 lobules. The placenta performs the function of metabolism between the mother and fetus, a barrier function, and is also a powerful endocrine gland. Maternal blood is poured into the intervillous space and washes the chorionic villi. Maternal and fetal blood does not mix. Umbilical cord It is a cord-like formation in which two arteries and one vein pass. Venous blood flows from the fetus to the placenta through the arteries, and arterial blood flows through the vein to the fetus. Attachment of the umbilical cord may be central, eccentric, marginal, or sheath. The normal length of the umbilical cord is on average 50 cm. The afterbirth is formed from the placenta, umbilical cord, fetal membranes (amnion and chorion) and is expelled from the uterus after the birth of the fetus. Amniotic fluid They are formed as a result of the secretion of the amnion epithelium, extravasation from the mother's blood and the activity of the kidneys of the fetus. By the end of pregnancy, approximately 1-1,5 liters of water accumulate. The waters contain hormones, protein in the amount of 2-4 g/l, enzymes, macro- and microelements, carbohydrates and other substances. 2. Changes in a woman's body during pregnancy In connection with the development of the fetus in the body of a pregnant woman, a large restructuring of the activity of the most important systems and organs occurs. During pregnancy, physiological changes occur that prepare the woman's body for childbirth and feeding, and also contribute to the proper development of the fetus. A woman's body weight increases, especially in the second half of pregnancy. The weekly increase during this period is 300-350 g. On average, body weight increases by 12 kg by the end of pregnancy, of which 75% falls on the weight of the fetus, placenta, uterus, amniotic fluid and an increase in the amount of circulating blood. The cardiovascular system In the uterus, the number of vessels increases significantly, a new (utero-placental) blood circulation appears. This leads to increased work of the heart, as a result of which the wall of the heart muscle thickens a little, the strength of heart contractions increases. The pulse rate increases by 10-12 beats per minute. The volume of circulating blood begins to increase in the first trimester. In the second trimester of pregnancy, the increase in BCC is maximum. At the end of the III trimester, the BCC is 1,4-1,5 times higher than the initial one. The increase in the volume of circulating plasma and erythrocytes has unequal proportions. Thus, the volume of plasma increases on average by 1,5 times by the 40th week of pregnancy, and the volume of circulating red blood cells - only 1,2 times. As a result, the phenomenon of physiological hemodilution, or breeding anemia, occurs. Thanks to hemodynamic changes in the cardiovascular system, optimally comfortable conditions are provided for the life of the mother and fetus. There are also some changes in the blood coagulation system that need to be monitored. There is an increase in the concentration of plasma coagulation factors, i.e., the preparation of the woman's body for blood loss during childbirth. Respiratory During pregnancy, they perform intensive work, since the metabolic processes between the fetus and the mother require a large amount of oxygen. By the end of pregnancy, the minute volume of breathing of women in labor increases by an average of 1,5 times due to an increase in the volume of inhalation and respiratory rate. Physiological hyperventilation during childbirth is accompanied by hypocapnia, which is the most important condition for normal transplacental diffusion of carbon dioxide from the fetus to the mother. Digestive organs Changes are expressed in nausea, morning vomiting, increased salivation, reduction and even perversion of taste sensations. After 3 months of pregnancy, all these phenomena usually disappear. Bowel function is characterized by a tendency to constipation as the bowel moves upward and is pushed towards the pregnant uterus. The liver performs an increased function, which is due to the neutralization of toxic substances of interstitial metabolism and metabolic products of the fetus entering the mother's body. Urinary organs Experience the maximum load on the removal of metabolic products of the mother and fetus. The ureters during pregnancy are in a state of hypotension and hypokinesia, which leads to a slowdown in the outflow of urine, expansion of the ureters and renal pelvis. Renal blood flow increases during pregnancy. As a result, there is a slight increase in the size of the kidneys, expansion of the calyces and an increase in glomerular filtration by 1,5 times. Nervous system In the early stages of pregnancy, there is a decrease in the excitability of the cerebral cortex, an increase in the reflex activity of the subcortical centers and the spinal cord. This explains the increased irritability, fatigue, drowsiness, rapid mood swings, decreased attention. At the end of pregnancy, shortly before childbirth, the excitability of the cerebral cortex decreases again. As a result, the underlying parts of the nervous system are disinhibited, and this is one of the factors in the onset of labor. Endocrine system With the onset of pregnancy, changes appear in all endocrine glands. A new endocrine gland begins to function - corpus luteum. It exists in the ovary during the first 3-4 months of pregnancy. The corpus luteum of pregnancy secretes the hormone progesterone, which creates the necessary conditions in the uterus for the implantation of a fertilized egg, reduces its excitability and thereby favors the development of the embryo. The appearance in the body of a woman of a new powerful endocrine gland - placenta leads to the release of a complex of hormones into the maternal circulation: estrogens, progesterone, chorionic gonadotropin, placental lactogen and many others. The pituitary, thyroid, and adrenal glands also undergo great changes. The anterior pituitary gland secretes hormones that stimulate the function of the corpus luteum, and in the postpartum period - the function of the mammary glands. At the end of pregnancy, especially in childbirth, the production of pituitrin by the posterior pituitary gland increases significantly. Leather Pregnant women often develop skin pigmentation, which is associated with increased adrenal function. The deposition of melanin pigment is especially pronounced on the face, along the white line of the abdomen, on the nipples and areola. In the second half of pregnancy, bluish-purple arcuate stripes appear on the anterior abdominal wall, thighs, mammary glands, called scarring of pregnancy. After childbirth, these scars do not disappear, but gradually turn pale and remain in the form of white shiny (pearl) stripes. Genital organs During pregnancy, they undergo great changes. The external genitalia, vagina, cervix loosen, become juicy, easily stretchable, acquire a bluish color. The isthmus of the uterus softens and stretches especially strongly, which at the 4th month of pregnancy, together with a part of the lower part of the uterus, turns into the lower uterine segment. The mass of the uterus by the end of pregnancy increases from 50-100 g to 1000-2000 g. The volume of the uterine cavity increases, exceeding its volume outside pregnancy by 520-550 times. The length of the non-pregnant uterus is 7-9 cm, and by the end of pregnancy it reaches 37-38 cm. The increase in the mass of the uterus is mainly associated with hypertrophy and hyperplasia of its muscle fibers. The joints of the small pelvis soften, which creates favorable conditions for the birth of the fetus. The ligamentous apparatus undergoes significant thickening and elongation. Lecture number 3. Diagnosis of pregnancy Diagnosis of early pregnancy is made on the basis of the identification of presumptive (doubtful) and probable signs of pregnancy. 1. Alleged (doubtful) signs Associated with general changes in the body of a pregnant woman. There is a change in appetite and taste, smell, nausea, sometimes vomiting in the morning, weakness, malaise, irritability, tearfulness. The same signs include the appearance of skin pigmentation on the face, along the white line of the abdomen, in the nipples and external genitalia. 2. Possible signs of pregnancy These are objective changes that are found on the part of the female genital organs, mammary glands, or are detected during pregnancy tests. Probable signs can appear both during pregnancy and independently. These signs include the cessation of menstrual function in women of childbearing age, an increase in the mammary glands and the release of colostrum from them when pressed, a cyanotic color of the mucous membrane of the vagina and cervix, an increase in the uterus. Early pregnancy is characterized by certain signs. 1. An increase in the uterus becomes noticeable from the 5-6th week. At the end of the 2nd month, the size of the uterus reaches the size of a goose egg. By the end of the 3rd month, the bottom of the uterus is determined at the level of the upper edge of the symphysis. 2. Horvitz-Gegar sign - the appearance of softening in the isthmus. 3. Snegirev's sign - a change in the consistency of the uterus during its palpation (after the study, the uterus becomes denser). 4. Sign of Piskachek - bulging of one of the corners of the uterus associated with the development of the fetal egg. 5. Genter's sign - a ridge-like protrusion is felt on the anterior surface of the uterus along the midline. Diagnosis of late pregnancy is based on the registration of reliable signs, such as: fetal movement, listening to fetal heart sounds, probing parts of the fetus, X-ray and ultrasound examination data. Biological and immunological methods for diagnosing pregnancy Ashheim-Zondeka reaction With the onset of pregnancy, a large amount of chorionic gonadotropin appears in the urine of a woman, the excretion of which reaches a maximum at the 8-11th week of pregnancy. This hormone can be detected in the urine from the 2nd day after implantation. For research take the morning portion of urine. With an alkaline or neutral reaction, the urine is slightly acidified with acetic acid and filtered. Urine is administered to several (5) immature mice weighing 6-8 g: the first in the amount of 0,2 ml, the second - 0,25 ml, the third and fourth - 0,3 ml each, the fifth - 0,4 ml. On the 1st day, urine is administered 2 times - in the morning and in the evening, on the 2nd day - 3 times (morning, afternoon and evening) and on the 3rd day - 1 time. Thus, a total of 1,2-2,2 ml of urine is injected subcutaneously. After 96-100 hours from the moment of the first injection of urine, mice are slaughtered, the genitals are opened and examined. Depending on the data obtained, three reactions are distinguished. The first reaction: several maturing follicles are detected in the ovaries, the uterine horns are cyanotic. Such a response is doubtful. The second reaction: in the ovaries, multiple hemorrhages are found in the follicles - blood points; the reaction is specific to pregnancy. The third reaction: in the ovaries, atretic corpus luteum (luteinization of the follicles), uterine horns are found without any special changes; the reaction is specific to pregnancy. The reliability of the reaction reaches 98%. Sperm (spermatouric) Galli-Mainini reaction It is carried out on male lake frogs. It is based on the fact that frogs, outside the natural period of their reproduction, never have spermatozoa in the contents of the cloaca. Before injecting urine into a pregnant woman, the contents of the frog's cloaca should be obtained and examined to rule out the possibility of spontaneous spermatorrhea. 30-60-90 minutes after the introduction of 3-5 ml of the urine of a pregnant woman into the lymphatic sac located under the skin of the back, a large number of spermatozoa appear in the frog's cloacal fluid. They are obtained using a glass capillary pipette and examined under a microscope. The reaction accuracy ranges from 85 to 100%. Friedman reaction To diagnose pregnancy, a sexually mature rabbit at the age of 3-5 months weighing from 900 to 1500 g is used. Due to the fact that ovulation in rabbits does not occur spontaneously, but 10 hours after mating, the female and male should be kept in separate cages. In the ear vein of a sexually mature female rabbit, 6 ml of urine taken from the examined woman is injected 2 times within 4 days. 48-72 hours after the last injection under ether anesthesia, observing the rules of asepsis, the abdominal cavity is opened and the genitals are examined. With a positive reaction in the ovaries and uterus, changes similar to those found in mice are observed. The surgical wound of the abdominal wall of the rabbit is sutured in the usual way. After 6-8 weeks with a positive reaction and after 4 weeks with a negative reaction, the rabbit can be taken for re-examination. The reaction accuracy is 98-99%. Immunological research methods are based on the detection of human chorionic gonadotropin in the urine of the examined woman. They are used to diagnose early pregnancy along with biological reactions. The advantage of serological tests is their rather high specificity, speed and relative ease of implementation. The use of immunological tests virtually eliminates false positive results associated with the use of hormonal drugs. These tests are highly accurate (up to 98-99% positive), make it possible to detect small amounts of human chorionic gonadotropin, which is especially important in diagnosing early pregnancy. Lecture number 4. Signs of fetal maturity, the size of the head and body of a mature fetus The length (height) of a mature full-term newborn ranges from 46 to 52 cm or more, averaging 50 cm. Fluctuations in the body weight of a newborn can be very significant, but the lower limit for a full-term fetus is 2500-2600 g. The average body weight of a mature full-term newborn 3400-3500 g. In addition to body weight and length of the fetus, its maturity is also judged by other signs. A mature full-term newborn has a well-developed subcutaneous fat layer; skin pink, elastic; the vellus cover is not pronounced, the length of the hair on the head reaches 2 cm; ear and nasal cartilages are elastic; nails are dense, protruding beyond the edges of the fingers. The umbilical ring is located in the middle of the distance between the womb and the xiphoid process. In boys, the testicles are descended into the scrotum. In girls, the small labia are covered with large ones. The cry of a child is loud. Muscle tone and movements of sufficient strength. The sucking reflex is well expressed. The head of a mature fetus has a number of features. It is the largest and densest part of it, as a result of which it experiences the greatest difficulty in passing through the birth canal. After the birth of the head, the birth canal is usually well prepared for the advancement of the trunk and limbs of the fetus. The facial part of the skull is relatively small, and its bones are firmly connected. The main feature of the cranial part of the head is that its bones are connected by fibrous membranes - sutures. In the area of \uXNUMXb\uXNUMXbthe connection of the seams there are fontanelles - wide areas of connective tissue. The absence of a strong connection of the bones of the skull among themselves is of great importance in the process of childbirth. A large head can change its shape and volume, as the sutures and fontanelles allow the bones of the skull to overlap each other. Due to this plasticity, the head adapts to the mother's birth canal. The most important sutures connecting the bones of the fetal skull are the following: the sagittal suture, passing between the two parietal bones; frontal suture - between two frontal bones; coronal suture - between the frontal and parietal bone; lambdoid (occipital) suture - between the occipital and parietal bones. Among the fontanelles on the head of the fetus, large and small fontanelles are of practical importance. The large (anterior) fontanel is diamond-shaped and is located at the junction of the sagittal, frontal, and coronal sutures. The small (posterior) fontanel has a triangular shape and is a small depression in which the sagittal and lambdoid sutures meet. Head full-term mature fetus has the following dimensions: 1) direct size (from the bridge of the nose to the occiput) - 12 cm, head circumference in direct size - 34 cm; 2) large oblique size (from the chin to the occiput) - 13-13,5 cm; head circumference - 38-42 cm; 3) small oblique size (from the suboccipital fossa to the anterior angle of the large fontanel) - 9,5 cm, head circumference - 32 cm; 4) average oblique size (from the suboccipital fossa to the border of the scalp of the forehead) - 10 cm; head circumference - 33 cm; 5) sheer, or vertical, size (from the top of the crown to the sublingual region) - 9,5-10 cm, head circumference - 32 cm; 6) large transverse size (the largest distance between the parietal tubercles) - 9,5 cm; 7) small transverse dimension (distance between the most distant points of the coronal suture) - 8 cm. dimensions torso fruit are as follows: 1) the size of the shoulders (diameter of the shoulder girdle) - 12 cm, the circumference of the shoulder girdle - 35 cm; 2) the transverse size of the buttocks is 9 cm, the circumference is 28 cm. Lecture number 5. Examination of a woman in labor With the onset of labor activity, the pregnant woman enters the emergency department of the maternity hospital, where she is examined and a plan for the conduct of childbirth is drawn up. When examining a woman in labor, the anamnesis, physical examination, laboratory data and assessment of the fetus are taken into account. 1. Anamnesis History (real childbirth, current pregnancy, previous pregnancies, chronic diseases). real childbirth Contractions. It is important to find out the start time of contractions, frequency, strength and duration. If labor proceeds normally, the frequency of contractions is regular, they are strong, with a pronounced pain component, while the woman in labor cannot walk or talk, and there may often be bloody discharge from the vagina. Since the cervix smoothes and opens, labor contractions must be differentiated from preparatory contractions that may accompany the last weeks before childbirth. They are irregular in nature and weakly expressed. The cervix does not dilate. The discharge of amniotic fluid occurs during contractions or before them. It is necessary to know with accuracy the time of discharge of the waters, as well as the presence of meconium in them (while the amniotic fluid has a greenish color) or blood. If, during the collection of anamnesis, a simultaneous copious discharge of fluid from the vagina is reported, then we can conclude that this is amniotic fluid. If the discharge is scanty, a vaginal examination is performed and a smear microscopy is done to determine the nature of this discharge. This may be urine from the vagina or amniotic fluid. A long anhydrous period creates an opportunity for the development of chorioamnionitis. Bloody discharge from the vagina. Slight spotting is observed during the normal course of childbirth. With abundant bleeding, an urgent examination is necessary. Fetal movement. Usually pregnant women clearly feel the movement of the fetus. In cases of decreased movement, non-stress and stress tests are performed and the biophysical profile is examined. The course of a real pregnancy Evaluated based on the history and medical records of the woman in labor. Some data need to be clarified regardless of the results of antenatal care. Determination of gestational age. The expected date of birth is calculated by counting 40 weeks from the 1st day of the last menstruation. If the date of the last ovulation or the day of conception is known, 38 weeks are counted from this day. The date of the last ovulation is determined by the basal temperature measurement schedule. The following signs are also important: determination of the fetal heartbeat using the Doppler study (from the 10-12th week), and starting from the 18-20th week of pregnancy, the heartbeat can be determined using an obstetric stethoscope. A woman begins to feel the first movement of the fetus most often from the 17th week of pregnancy. The gestational age, determined by the size of the uterus in the first weeks of pregnancy, is also taken into account. In addition, the size of the fetus, detected by ultrasound before the 24th week of pregnancy, is important. It is possible to determine the exact gestational age and the estimated date of delivery based on the data collected during the examination of a woman in the first half of pregnancy. If the exact date of the last menstrual period is not established and there are no data from the antenatal examination, it is more difficult to accurately determine the timing of pregnancy. Since the observation of the course of full-term, premature and post-term pregnancies is different, ultrasound is necessary to establish or clarify the timing of pregnancy or, in some cases, amniocentesis to determine the degree of maturity of the fetal lungs. Diseases during the present pregnancy. The woman is asked about the course of pregnancy, all complaints are clarified in detail. It is necessary to pay attention to diseases in the woman’s history, such as cystitis, pyelonephritis, infections, impaired glucose tolerance, increased blood pressure, convulsions, as well as how often and at what stages of pregnancy these complications were noted, whether there was a need for hospitalization, what treatment was given. Complaints. Signs of preeclampsia include complaints of severe headache, spots before the eyes, swelling of the hands and face, and epigastric pain. Cholestasis of pregnancy or hepatitis may present with generalized itching. Complaints with cystitis of painful, frequent urination, lower back pain and fever are manifestations of pyelonephritis. Previous pregnancies It is necessary to identify the number of previous pregnancies, their duration, course, duration of each of them, complications (placenta previa, abnormal position and presentation of the fetus, preeclampsia and eclampsia, placental abruption). It is important to find out how each of these pregnancies ended, what is the outcome, the means and methods of delivery, the duration of labor, the presence or absence of complications (discoordination of labor, bleeding requiring transfusion of blood products). If there is a lack of information collected, it is necessary to contact the medical institution in which the treatment or delivery was performed. Chronic diseases During the period of delivery, relapses of chronic diseases may occur. These diseases can have a negative impact on the woman in labor and the fetus, and therefore it is important to know about the presence of chronic diseases in a woman, whether there were exacerbations during pregnancy. 2. Physical examination Physical examination is carried out taking into account the anamnesis and complaints of the pregnant woman. At the same time, attention is paid to those organs whose diseases were observed earlier. In the first stage of labor, the examination is carried out between contractions. General inspection Basic physiological indicators. The pulse rate is measured, blood pressure is measured in pauses between contractions. If necessary, the measurement is carried out several times. A sign of chorioamnionitis may be an increase in body temperature, especially after the rupture of amniotic fluid. Tachycardia and tachypnosis during labor in the absence of changes in other physiological parameters are normal. Ophthalmoscopy is necessary to exclude retinal hemorrhage, vasospasm, or retinal edema, which may be present in diabetes mellitus and arterial hypertension. Paleness of the conjunctiva or nail bed may be a sign of anemia. Swelling of the face, hands and feet are observed with preeclampsia. Palpation of the thyroid gland is mandatory. A rare but serious complication during childbirth - venous congestion is manifested by swelling of the cervical veins and requires mandatory treatment. If a woman has a history of bronchial asthma, auscultation of the lungs is performed to detect shortness of breath and wheezing and auscultation of the heart, paying attention to the presence of systolic murmur. It must be remembered that mesosystolic murmur is normal during pregnancy. The abdomen is palpated to exclude pain and the presence of volumetric formations. Soreness on palpation of the epigastric region may be a sign of preeclampsia. In full-term pregnancy, palpation of the abdomen is difficult. In full-term pregnancy, slight swelling of the legs occurs and is normal. A neurological examination is performed when pronounced swelling of the legs or hands (signs of preeclampsia) is detected. An increase in tendon reflexes and clonus indicate an increase in convulsive readiness. External obstetric examination Uterus dimensions. By the end of the 1st obstetric month (4th week), the uterus reaches the size of a chicken egg. It is usually not possible to determine pregnancy with a vaginal examination. By the end of the 2nd month (8th week), the uterus increases to the size of a goose egg. By the end of the 3rd month (12th week), asymmetry of the uterus (Piskachek’s sign) is noted; it increases to the size of a man’s fist, its bottom reaches the upper edge of the symphysis. By the end of the 4th month (16th week), the uterine fundus is determined at the middle of the distance between the symphysis and the navel or 6 cm above the navel. By the end of the 5th month (20th week), the fundus of the uterus is located 11-12 cm above the womb or 4 cm below the navel. By the end of the 6th month (24th week), the fundus of the uterus is at the level of the navel or 22-24 cm above the womb. By the end of the 7th month (28th week), the uterine fundus is determined two transverse fingers above the navel or 25-28 cm above the womb. By the end of the 8th month (32nd week), the fundus of the uterus is located in the middle of the distance between the navel and the xiphoid process, 30-32 cm above the pubis. By the end of the 9th month (36th week), the fundus of the uterus reaches the xiphoid process and costal arc. By the end of the 10th month (40th week), the fundus of the uterus drops to the level of a 32-week pregnancy. By palpation of the uterus, the approximate size of the fetus and the amount of amniotic fluid are determined. It is also important to determine the thickness of the anterior abdominal wall of the woman in labor and the degree of insertion of the presenting part of the fetus into the pelvic area. It is necessary to exclude malformations of the uterus or fetus or multiple pregnancies if the size of the uterus exceeds the expected gestational age. For this purpose, an ultrasound is performed. External obstetric research includes four Leopold's receptions. First trick allows you to determine the height of the standing of the bottom of the uterus and that part of the fetus that is located in the bottom of the uterus. The head is more rounded and denser than the buttocks. The head is balloting, and the pelvic part is displaced only together with the body of the fetus. Second trick serves to determine the position of the fetus and its type. It consists in palpation of the lateral surfaces of the uterus. It allows you to determine on which side the small parts of the fetus (handles, legs) are located, and on which side - the back, as well as its stirring, the tone of the uterus. Third reception used to determine the presenting part and its relation to the entrance to the small pelvis. The head must be able to distinguish from the pelvic end of the fetus. She is round and dense. With a moving head, a symptom of balloting is noted. In breech presentation above the entrance to the pelvis, a voluminous part of the fetus of a softish consistency without clear contours is determined, which does not give a symptom of balloting. By shifting the presenting part from side to side, its position is determined in relation to the entrance to the small pelvis. If the displacement is difficult, then it is fixed at the entrance to the small pelvis. Fourth reception allows you to specify the presentation of the fetus. To perform the reception, the obstetrician turns to face the legs of the woman in labor and palpates the presenting part with both hands. With occipital presentation, the occipital curvature is determined on the same side as the small parts of the fetus, while the head is bent, the occiput is presented. With facial presentation, the occipital curvature is determined on the opposite side of the small parts of the fetus, the head is unbent. Location of the fetus in the uterus. According to the basic research methods, it is possible to easily determine the position of the fetus in the uterus, its position, position and type of fetus. Fetal position is the ratio of the longitudinal axis of the fetal body to the longitudinal axis of the mother's body. The position of the fetus is longitudinal (with breech or head presentation), transverse and oblique, when the axes of the bodies of the fetus and mother intersect. The articulation of the fetus is the ratio of the limbs of the fetus and the head to its body. A favorable articulation is the flexion type, in which the fetus resembles an ovoid in appearance. Fetal presentation. This is the relationship of the large part of the fetus to the entrance to the pelvis. The presenting part is the part of the fetal body that is located above the entrance to the pelvis. The fetal head, pelvis or shoulder may be present. The most common and physiological is considered to be cephalic presentation. When the fetal head is flexed, the presentation will be considered occipital. When the head is in an extension position, a frontal or facial presentation is formed. If the pelvic part of the fetus is located above the entrance to the small pelvis, presentation is called pelvic. The breech presentation can be purely breech (the legs of the fetus are extended along the body, and the buttocks are facing the entrance to the pelvis), mixed breech (the buttocks and feet of the fetus are presented), foot full (both legs are presented) and incomplete (one leg is presented). With foot presentations, a complication often occurs in the form of prolapse of the umbilical cord. In a transverse position, the fetal shoulder is located above the entrance to the small pelvis. In a normal full-term pregnancy, there can very rarely be simultaneous presentation of several parts of the fetal body (head and small parts). Fetal position called the ratio of the back of the fetus to the left or right wall of the uterus. There are first (left) and second (right) positions of the fetus. Type of fetus - the ratio of its back to the anterior wall of the uterus. The first position is more often combined with the front view, the second - with the rear view. auscultation fetal hearts have recently been increasingly replaced by CTG. This method helps to more accurately record heart rate and heart rate variability (acceleration and deceleration). Conducting a vaginal examination It begins with examination and palpation of the perineum and pelvis. In the presence of bleeding from the vagina and premature discharge of amniotic fluid, a vaginal examination is performed only after ultrasound. Inspection of the perineum is to identify herpetic eruptions, varicose veins of the external genitalia, the presence of warts, scars. In cases of suspected herpes of the labia, a thorough examination of the cervix and vagina is necessary. Also, during examination, attention is paid to the integrity of the pelvic bones and the fetal bladder, the opening and smoothing of the cervix, as well as the position of the presenting part. Diagnosis of discharge of amniotic fluid almost never in doubt, but if necessary, examine the cervix and vaginal vault in the mirrors. When amniotic fluid breaks, the buttocks of the fetus, or the head, or loops of the umbilical cord can be detected during vaginal examination. In this case, amniotic fluid is present in the posterior fornix of the vagina. If the fluid present in the posterior fornix contains amniotic fluid, then microscopic examination of the dried smear shows the fern phenomenon. Amniotic fluid stains the test strip dark blue with a positive result, as it has an alkaline reaction. The test may be false positive if there is blood or urine in the posterior fornix. The possible admixture of meconium is also taken into account. Meconium is the primary fecal content of the fetal intestine, which increases in late pregnancy. The presence of meconium in the amniotic fluid is a sign of fetal hypoxia. The presence of blood in the amniotic fluid may be a sign of placental abruption. With the onset of preterm labor and suspicion of chorioamnionitis, a sowing of the vaginal discharge from the posterior fornix is done. With premature discharge of amniotic fluid, it is necessary to determine the degree of maturity of the pulmonary system of the fetus using a foam test. Cervix Opening degree The cervix is measured in centimeters: from 0 (cervix closed) to 10 cm (fully dilated). Smoothing the cervix is one of the indicators of her maturity and readiness for childbirth. The size of the immature cervix is 3 cm (smoothing degree 0%). Smoothing occurs gradually and becomes maximum by the beginning of labor (100% degree of smoothing). In primiparous women, smoothing first occurs, and after the opening of the cervix. With repeated births, smoothing and opening of the cervix occurs almost simultaneously. Palpation of the presenting part of the fetus Fetal presentation determined by palpation. With an occipital presentation, it is possible to palpate the sutures and fontanelles on the fetal head, with a pelvic presentation - to determine the buttocks and feet, with a facial presentation - the front part of the fetal head, but ultrasound gives more accurate data on the presentation. The degree of insertion of the presenting part into the pelvis. In order to determine the position of the presenting part, the line that connects the ischial spines of the woman is taken as a reference point. If, during occipital presentation, the fetal head reached this line, it means that it entered the small pelvis with a biparietal size (insertion degree "0"). If the presenting part is 1 cm above the ischial spines, the degree of its insertion is determined as "-1", if 2 cm below the spines - as "+2". If the degree of insertion of the presenting part is more than "-3", then this means its mobility above the entrance to the small pelvis. If the degree of insertion is "+3", then the presenting part is located on the bottom of the pelvis and during attempts is visible in the genital gap. Fetal position - this is the location of certain points of the presenting part of the fetus in relation to the anatomical structures of the small pelvis. In the anterior position, the presenting part faces the pubic joint, in the posterior position, towards the sacrum. Transverse (right or left) position - the presenting part is facing the right or left wall of the small pelvis. The position in occipital presentations can be determined by the point of intersection of the lambdoid and sagittal sutures. With a breech presentation - along the sacrum of the fetus, with a facial presentation - along the location of the chin. In the anterior position of the occiput presentation, the back of the head is turned towards the pubic symphysis. With the right transverse position of the occipital presentation - to the right vaginal wall. Pelvic bone examination. The size and shape of the small pelvis are determined by the size of the large pelvis. A narrow pelvis has such features that when a full-term fetus passes through it, mechanical obstacles are formed. External measurement of the pelvis does not always make it possible to identify the shape and degree of narrowing of the pelvis. In some cases, the discrepancy between the sizes of the pelvis and the fetal head can only be determined during childbirth. The size of the pelvis is one of the three main factors that determine the physiological course of childbirth. Other important factors are the size of the fetus and normal labor activity. Entrance to the pelvis anteriorly formed by the upper edge of the pubic articulation of the symphysis, posteriorly by the apex of the promontorium, lateral borders by the arcuate lines of the ilium. The direct size of the small pelvis is determined by the size of the diagonal conjugate - the distance between the promontory and the lower edge of the pubic symphysis, which is normally 12 cm or more. pelvic cavity anteriorly formed by the posterior surface of the pubic symphysis, posteriorly by the anterior surface of the sacral vertebrae, and the lateral walls by the ischial bones. The transverse size of the pelvic cavity is normally more than 9 cm. This distance between the ischial spines is determined during a vaginal examination. Exit from the pelvis in front is in the region of the lower edge of the pubic arch, in the back - in the region of the apex of the coccyx, on the sides - between the ischial tubercles. The transverse size of the small pelvis is the distance between the ischial tubercles of at least 8 cm at normal sizes. Indirectly, one can judge the size of the exit from the small pelvis by the size of the subpubic angle and by the protrusion of the top of the coccyx. An acute subpubic angle most often indicates a narrow pelvis. Usually there is a combined reduction of all sizes of the small pelvis. 3. Laboratory research Laboratories undergo laboratory tests: a general blood and urine test and a serological test for syphilis, if they belong to a high-risk group - and for HBsAg. If there are indications of changes in glucose levels in the anamnesis, then the level of glucose in the blood is determined. If preeclampsia is suspected, platelet counts, liver and kidney function, and serum uric acid levels are determined. If a placental abruption is suspected, a coagulogram is examined. If there is a possibility of a caesarean section, or a history of bleeding in the afterbirth period, or many births, the serum of the pregnant woman is stored for a quick test for individual compatibility. Additional laboratory tests are carried out in case of detection in history and examination of concomitant complications or diseases. If any concomitant diseases or complications are identified during the history taking or physical examination, additional laboratory tests are prescribed. 4. Assessment of the state of the fetus in childbirth It is carried out for the purpose of early diagnosis of intrauterine hypoxia and fetal death. To do this, a number of examinations are carried out: auscultation of the fetal heart at certain intervals, continuous CTG (direct or indirect), determination of the acid-base composition of the blood obtained from the skin of the head. Auscultation of the fetal heart in the phase of the first stage of labor is carried out every 15 minutes, and in the second stage of labor - every 5 minutes (or after each attempt). Formulation of the conclusion and labor management plan. Anamnesis collection, examination and laboratory data allow us to determine the prognosis and tactics of labor management. Lecture number 6. Physiological childbirth Childbirth is a staged physiological process during which the fetus is expelled, as well as the release of amniotic fluid, membranes and placenta through the natural birth canal. Urgent births are considered at 37-42 weeks of gestation, premature - childbirth before the 37th week of pregnancy. Childbirth after the 42nd week of pregnancy is called belated. 1. Periods of childbirth The opening period is the first period. It starts with the first fight. They are frequent, intense, long. During contractions, the cervix flattens and dilates. The first period is divided into two phases - the slow opening phase and the fast opening phrase. During the first phase, the cervix opens up to 4 cm, during the second - from 4 to 10 cm. The transition from contractions to attempts and the discharge of amniotic fluid completes the first period. The second period (exile) is characterized by the expulsion of the fetus. At this time, the opening of the cervix is full, the contractions turn into attempts. The second period ends with the birth of a child. Third period (sequential). The beginning is the moment of the birth of the child, the end is the separation of the placenta and the birth of the placenta. Delivery criteria are based on smoothing and dilation of the cervix and advancement of the presenting part of the fetus. At the same time, frequent vaginal examinations should not be carried out in order to avoid infection of the fetus and not to cause discomfort to the woman in labor. The first stage of labor Its duration in primiparous is about 12 hours, with repeated births - about 7 hours. Immediately after the onset of contractions, it is necessary to monitor the fetal heart rate. Fetal hypoxia (beginning or threatening) may be indicated by a sudden increase in heart rate (more than 140 per minute) or a decrease (less than 120 per minute). Amniotomy is performed according to the following indications: 1) polyhydramnios, flat fetal bladder, marginal placenta previa, premature detachment of the placenta; 2) the need for direct access to the fetus for invasive procedures; 3) labor induction and rhodostimulation. Only an amniotomy performed in the phase of rapid opening has a labor-stimulating effect. Amniotomy performed later or earlier, as a rule, does not affect the course of labor. Complications with amniotomy, they can be in the form of a rupture of vessels passing in the membranes. In this case, the fetus may die from blood loss. Also, with this manipulation, prolapse of the umbilical cord is possible, which requires immediate operative delivery. Amniotomy is performed only after inserting the fetal head into the small pelvis and forming a contact belt in order to prevent prolapse of the umbilical cord. Prolapse of the umbilical cord is possible with spontaneous rupture of the fetal bladder. The second period of childbirth The period of exile begins from the moment of full disclosure of the cervix and ends with the birth of a child. The duration of the second period in primiparas is about an hour, in multiparous it is 2 times shorter. In this period, attempts appear. In some cases, this period in primiparas for a number of reasons can be extended up to 2 hours or more. 2. Vaginal delivery Birth of the head. When pushing, the genital slit is stretched by the fetal head. First, the head is embedded - the head appears in the genital slit only during pushing, disappearing when they stop. Then the head appears more and more and does not disappear back in the intervals between attempts, the vulva does not close, the head erupts, and the vulvar ring stretches. Next comes the cutting of the forehead, face and chin. Birth of hangers. Most often, the shoulders appear immediately behind the external rotation of the head and are born independently. The anterior shoulder appears, is fixed under the symphysis, and the posterior shoulder appears above the perineum, and then the entire shoulder girdle is born. In cases where it is difficult to remove the shoulders, use your index finger to pull the shoulder up from the back, inserting the finger into the armpit of the front shoulder, and then release the other shoulder. Caution should be exercised, as excessive stretching with stretching of the fetal neck can injure the brachial plexus or the V and VI cervical vertebrae. This pathology is called Erb's spinal palsy. Delivery with cephalic presentation Regulating the advancement of the erupting head. To prevent extension of the head during labor during pushing, it is necessary to hold the head with three fingers of the right hand. With strong attempts, you need the help of a second hand: you need to very carefully bend the fetal head, preventing its rapid eruption. In between attempts, the left hand is left on the fetal head, and the right hand is used to borrow tissue - the fetal head is carefully freed from the tissue of the labia minora and the stretched tissue of the vulvar ring is shifted towards the perineum. Removing the head. After the birth of the fetal head, the woman in labor is advised to breathe deeply and rhythmically to control the efforts. At the same time, the parietal tubercles of the fetus are released from the tissue of the vulvar ring, the head is slowly unbent with the left hand, and the perineal tissue is removed from the face of the fetus with the right hand. A perineotomy or episiotomy is performed in some cases to avoid perineal rupture. If there is entanglement of the umbilical cord around the neck of the fetus, immediately after the birth of the head, an attempt should be made to remove the umbilical cord or cut it between two clamps. Release of the shoulder girdle. Turning the head to face the mother's thigh to the right or left occurs after her birth. At the same time, the shoulders rise in the straight size of the pelvis (internal rotation of the shoulders). The upper shoulder is born first. It is pressed against the pubic symphysis, and then the perineal tissue is removed from the lower shoulder. Birth of the torso. After releasing the shoulders, the palms of the hands on both sides are placed on the fetal chest and the body is directed upward. The birth of the lower torso occurs. Primary treatment of a newborn. Immediately after birth, mucus from the mouth and nose must be removed. After this, the newborn is placed on a tray covered with a sterile diaper. The baby should lie at the same level as the woman in labor; under no circumstances should the umbilical cord be allowed to stretch. Assessment of the condition of the newborn is carried out according to the Apgar scale and is aimed at determining the adequacy of the processes of oxygenation and respiration of the newborn, his adaptation during childbirth. The Apgar scale was created to assess the degree of asphyxia during childbirth according to certain uniform criteria. Apgar scores are performed 1-5 minutes after birth. It is determined in points from 0 to 10 according to five signs: heart rate, breathing depth, muscle tone, the state of reflexes and skin color. The sum of Apgar scores at the 5th minute of life shows the effectiveness of resuscitation and the depth of asphyxia during childbirth. Primary toilet of a newborn. The child's eyelids are treated with a sterile cotton swab (separate for each eye) and gonoblennorrhea is prevented using the Matveev-Crede method. A 30% solution of albucid is instilled into each eye (for girls also into the genital opening to prevent gonorrhea), repeating the instillations 2 hours after birth. Primary treatment of the umbilical cord. At a distance of 10-15 cm from the umbilical ring, after treating the umbilical cord with 96% ethyl alcohol, two sterile Kocher clamps are placed on it at a distance of 2 cm from each other. It is then cut between the clamps, and the baby end of the umbilical cord is wrapped together with the clamp in a sterile gauze pad. After preliminary blood sampling to determine the ABO and Rh affiliation of the child’s blood, a silk ligature or clamp is applied to the maternal end of the umbilical cord. Secondary umbilical cord treatment. The newborn, wrapped in a sterile diaper, is placed on a heated changing table. The umbilical cord residue is treated with 96% ethyl alcohol and tied with a thick silk ligature at a distance of 1,5-2 cm from the umbilical ring. The ligature is tied on one side of the umbilical cord and then on the opposite side. The umbilical cord is cut at a distance of 2-3 cm above the ligation site with sterile scissors. The cut surface is blotted with a sterile gauze swab and, after making sure that there is no bleeding, when the ligature is applied correctly, it is treated with a 5-10% alcohol solution of iodine or a 5% solution of potassium permanganate. Instead of a ligature, you can use a Rogovin bracket. Before applying the staple, the umbilical cord is examined under a light source, treated with 96% alcohol and the Wharton jelly is squeezed out with two fingers, after which the staple is applied. Afterwards, the umbilical cord residue is treated with a 5% solution of potassium permanganate. The umbilical cord is cut off 0,4 cm above the bracket, blotting it with a dry gauze swab. In the future, care for the umbilical cord is carried out in an open way. With Rh- and ABO-incompatibility between the blood of the mother and the child, the umbilical cord is treated in a different way. After the birth of a child, it is urgent to clamp the umbilical cord, without waiting for the cessation of vascular pulsation. Leave a section of the umbilical cord 8-10 cm long, having previously bandaged it, since the need for an exchange transfusion of blood is not excluded. When giving birth to twins, the maternal end of the umbilical cord must be tied up, since with monozygotic twins, the unborn fetus will have blood loss. Cheese grease is removed with sterile cotton wool soaked in sterile vaseline oil. After completion of the primary toilet of the newborn, its weight, body length, head and shoulder circumference are determined. Bracelets made of sterile oilcloth are put on the hands, where the surname, first name and patronymic of the puerperal, the number of the birth history, the sex of the child, the weight and length of the body, and the date of birth are recorded. The child is wrapped in warm sterile underwear and left on a heated changing table for 2 hours, after which they are transferred to the neonatal ward. Episiotomy - dissection of the vulvar ring during childbirth. This is the most commonly used surgical method in obstetric practice. After dissection, the perineum heals faster than after a rupture, since the edges after dissection are more even and the tissues are less injured. There are median (in domestic practice - perineotomy) and median-lateral episiotomy, i.e. dissection of the perineum along the midline or laterally. Episiotomy is performed when there is a threat of perineal rupture, the need for a gentle delivery for the fetus in breech presentation, large fetus, premature birth, to speed up labor in obstetric pathology, acute fetal hypoxia, and surgical vaginal delivery. The operation is performed under superficial, pudendal or spinal anesthesia at the moment when a section of the head with a diameter of 3-4 cm is shown from the genital slit. The perineal tissues are lifted above the fetal head and during the next attempt they are dissected towards the anus. With a low perineum, it is advisable to perform an episiotomy. Biomechanism of labor in anterior occiput presentation. Seven basic fetal movements during labor The biomechanism of childbirth consists in the process of adapting the position of the fetal head when passing through various planes of the pelvis. This process is necessary for the birth of a child and includes seven successive movements. The domestic school of obstetricians distinguishes four moments of the mechanism of childbirth in the anterior view of the occipital presentation. These moments correspond to the 3rd, 4th, 5th and 6th movements of the fetus during labor (according to the American classification). Head insertion - this is the location of the head at the intersection of the plane of entry into the small pelvis. The normal insertion of the head is called axial, or synclitic. It is carried out at a perpendicular position of the vertical axis with respect to the plane of entry into the small pelvis. The sagittal suture is at approximately the same distance from the promontory and the pubic symphysis. For any deviation from the distance, the insertion will be considered asynchronous. promotion. The first condition for the birth of a child is the passage of the fetus through the birth canal. If insertion of the fetal head has already occurred at the onset of labor (in primigravidas), progress can be observed before the start of the second stage of labor. In repeated births, advancement usually accompanies insertion. head flexion occurs normally when the descending fetal head encounters resistance from the cervix, pelvic wall, and pelvic floor. This is considered the first moment of the biomechanism of childbirth (according to the domestic classification). The chin approaches the chest. When bent, the fetal head presents its smallest size. It is equal to the small oblique size and is 9,5 cm. With the internal rotation of the head, the presenting part is lowered. The turn is completed when the head reaches the level of the ischial spines. The movement consists of a gradual rotation of the occiput anteriorly towards the symphysis. This is considered the second moment of the labor mechanism (according to the domestic classification). Extension of the head begins when the region of the suboccipital fossa (point of fixation) approaches the pubic arch. The back of the head is in direct contact with the lower edge of the pubic symphysis (support point), around which the head unbends. According to the domestic classification, this is the third moment of the biomechanism of childbirth. When unbending, the parietal region, forehead, face and chin are sequentially born from the genital tract. The unfolding of the crown in the direction of the genital slit is carried out by the expelling forces of contractions and the abdominal muscles, together with the resistance of the pelvic floor muscles. External rotation of the head and internal rotation of the body. The born head returns to its original position. The back of the head again occupies first an oblique position, then moving to a transverse position (left or right). With this movement, the fetal body rotates, and the shoulders are installed in the anteroposterior dimension of the pelvic outlet, which is the fourth stage of the labor mechanism (according to the domestic classification). Expulsion of the fetus. The birth of the anterior shoulder under the symphysis begins after the external rotation of the head, the perineum soon stretches the posterior shoulder. After the appearance of the shoulders, the baby is born quickly. Lecture No. 7 To avoid pain and stress during childbirth, as well as to prevent disruption of labor and create comfortable conditions for the woman, pain relief is used during childbirth. Pain relief during labor is a process that must be effective and necessarily safe for the fetus. Prior to childbirth, psychoprophylactic preparation for childbirth is carried out, during childbirth, narcotic analgesics are administered and regional anesthesia is performed. The choice of methods of anesthesia during childbirth is determined by the obstetrician-gynecologist together with the anesthesiologist, taking into account the individual characteristics of the psyche of the woman in labor, the condition of the fetus, the presence of obstetric and extragenital pathology, the period of the birth act, the nature of the contractile activity of the uterus. The main principles for choosing the method of anesthesia for childbirth are to ensure the rapid onset of analgesia and the absence of inhibition of labor, vasomotor and respiratory centers of the woman in labor and the fetus, the possibility of developing allergic reactions. 1. Psychoprophylactic preparation It is aimed at eliminating negative emotions, fear of childbirth and pain, and also reduces the number of analgesics used during childbirth. The main goal of psychoprophylactic training is to teach a woman not to be afraid of childbirth, to obey the doctor's instructions during childbirth and switch her attention from pain to something else, to teach different ways of breathing during labor and at the time of birth of the fetal head. This preparation makes it easier to transfer childbirth. This is the safest method of labor pain relief. 2. Medical pain relief To relieve agitation, reduce nausea and vomiting, tranquilizers and sedatives are used as components of drug anesthesia. When opening the cervix more than 4 cm in the active phase of labor and the occurrence of painful contractions, it is recommended to prescribe sedatives in combination with narcotic analgesics. Depending on the period of childbirth, various analgesics are prescribed. During the slow opening of the cervix, the use of short-acting barbiturates and tranquilizers (secobarbital, hydroxyzine, pentobarbital) is effective. They reduce pain during preparatory contractions without affecting the process of childbirth. But at present, barbiturates are used less frequently, since they have a depressant effect on the fetus. Despite the fact that hydroxidine quickly crosses the placenta, it does not have a depressing effect on the fetal central nervous system and on the Apgar score of the newborn. Narcotic analgesics in combination with antispasmodics are used only in the phase of rapid cervical dilatation (in primiparous after dilating the cervix by 3-4 cm, and in multiparous - by 5 cm). 2-3 hours before the expulsion of the fetus, it is necessary to stop the administration of narcotic analgesics in order to avoid its narcotic depression. Narcotic analgesicsare usually administered intravenously and subcutaneously. The most commonly used nalbuphine, pethidine, buttorphanol. When administered intravenously, these drugs have a faster and shorter duration of action than when administered intramuscularly or subcutaneously. The simultaneous use of sedatives makes it possible to greatly reduce the dose of narcotic analgesics. Nalbuphine is prescribed at a dose of 5-10 mg subcutaneously or intravenously every 2-3 hours. Pethidine is prescribed at a dose of 50-100 mg intramuscularly every 3-4 hours. Butorphanol is prescribed at a dose of 2 mg intramuscularly every 3-4 hours. In addition to the analgesic effect, this the drug has a pronounced sedative effect. But narcotic analgesics can cause fetal central nervous system depression (acceleration and heart rate variability) when administered parenterally. A side effect of analgesics is respiratory depression in both the fetus and the mother, therefore, when they are administered, naloxone, an opiate receptor blocker, should be at the ready (adults are administered 0,4 mg, newborns - 0,1 mg / kg intravenously or intramuscularly). Regional anesthesia. There are several methods of regional anesthesia: epidural (lumbar and sacral), spinal, paracervical and pudendal. Regional anesthesia is considered the best method of pain relief during childbirth. The sources of pain during childbirth are the body and cervix, as well as the perineum. Epidural anesthesia. Indications include painful contractions, lack of effect from other methods of pain relief, incoordination of labor, arterial hypertension during childbirth, childbirth with gestosis and fetoplacental insufficiency. Contraindications include dermatitis of the lumbar region, hemostasis disorders, neurological disorders, hypovolemia, sepsis, bleeding during pregnancy and shortly before delivery, volumetric intracranial processes accompanied by increased intracranial pressure, intolerance to local anesthetics. Complications can be arterial hypotension, respiratory arrest, allergic reactions, neurological disorders. The course of labor with epidural anesthesia is not disturbed. Immediately after the introduction of the catheter into the epidural space, the frequency and strength of contractions may decrease, but after the onset of anesthesia, the opening of the cervix usually accelerates. The use of epidural anesthesia in the absence of a decrease in pressure and a decrease in placental blood flow does not harm the fetus. Therefore, it is most preferable for operative delivery in pregnant women with preeclampsia and heart disease, with the exception of severe defects (aortic stenosis and stenosis of the pulmonary valve), when even a slight decrease in blood pressure is dangerous. Anesthesia is used only with full disclosure of the cervix and a sufficiently low position of the presenting part of the fetus (when childbirth through the natural birth canal can be completed without attempts). Manipulation technique. To prevent a decrease in blood pressure, 300-500 ml of liquid is administered through the installed catheter. A small diameter needle is inserted into the subarachnoid space between the vertebrae L4 - L5 or L5 - S1. The anesthetic is administered only after CSF begins to flow from the needle cannula. 1-1,5 minutes after administration of the drug, the woman in labor must be transferred to a vertical position, which allows the anesthetic to spread in the subarachnoid space. Then the woman in labor is placed in the gynecological position. Childbirth is usually completed by applying obstetric forceps. Paracervical anesthesia is safe for the woman in labor and is easy to perform and effective. However, paracervical anesthesia may be accompanied by fetal bradycardia, the latter may develop due to the toxic effect of a local anesthetic, as well as with narrowing of the uterine vessels or an increase in the contractile activity of the uterus. Almost all local anesthetics cause fetal bradycardia, the most common being bupivacaine. This type of anesthesia is used with great care. Manipulation technique. Paracervical anesthesia is indicated when other methods of labor anesthesia adversely affect the fetus or are contraindicated for other reasons. The method is based on blocking the uterovaginal plexus by injecting a local anesthetic on both sides of the cervix. Pudendal anesthesia. This type of anesthesia provides a blockade of the pudendal nerve and does not have a negative effect on the hemodynamics and respiratory system of the mother and fetus. It is used for pain relief in the second stage of labor when applying exit forceps and episiotomy. Manipulation technique. Using a lumbar puncture needle, a local anesthetic (mepivacaine, lidocaine, or chloroprocaine) is injected through both sacrospinous ligaments medial to and below their insertion into the ischial spines. Lecture number 8. Management of the second stage of labor Prepare to the adoption of childbirth begins from the moment of insertion of the fetal head in primiparas, and in multiparous - from the moment of full disclosure of the cervix. The woman in labor is transferred to the delivery room, where the equipment, instruments, sterile material and linen for the primary toilet of the newborn should be ready. Position of the woman in labor. To prevent compression of the aorta and inferior vena cava by the uterus, the pregnant woman is placed in the gynecological position with a slight tilt to the left side. This provides good access to the perineum. The most comfortable position during childbirth is the semi-sitting position (it does not affect the condition of the fetus and reduces the need to use obstetric forceps). To perform a half-sitting birth, leg holders are attached to the table. The perineum is treated with iodine. Choose a method of anesthesia. With the alleged episiotomy, anesthesia is performed by infiltration anesthesia of the perineum or pudendal anesthesia. Obstetric benefit for anterior occipital presentation Removing the head. The obstetric aid plays a big role in the passage of the head through the vulvar ring with its smallest diameter - small oblique size. The obstetric aid is aimed at preventing premature extension of the head and at carefully removing the fetal face and chin by pressing on the perineum and pushing it posteriorly and downward, which reduces tension in the perineum and reduces the risk of its rupture. After the birth of the head, mucus is removed from the fetal nasopharynx and oropharynx by suction using a catheter. If the umbilical cord is entwined around the neck, they try to move the umbilical cord to the back of the head or torso. If the manipulation is unsuccessful, two clamps are applied to the umbilical cord, and labor continues. Removing the hanger. To birth the anterior shoulder, the fetal head is slightly deflected down; when the anterior shoulder emerges from under the pubic arch, the head is lifted upward and the posterior shoulder is carefully brought out. When cutting through the shoulders, a significant stretch of the soft tissue occurs, and the perineum can rupture, so special attention should be paid to this process. The final stage. After birth, the baby’s shoulders are removed and turned onto his stomach to free the nasopharynx from mucus; after removing the mucus, two clamps are applied to the umbilical cord and it is crossed so that the remainder of the umbilical cord is 2-3 cm. The umbilical ring is examined to exclude an umbilical hernia and hernia of the umbilical cord. . To establish first contact, the baby is briefly placed on the mother's stomach and then placed in the incubator. Lecture number 9. Management of the third stage of labor The afterbirth period (the third period of childbirth) begins from the moment of the birth of the fetus and ends with the birth of the placenta. The afterbirth includes the placenta, amniotic membranes and umbilical cord. Usually the placenta separates on its own within 5-20 minutes after the birth of the fetus. You can not try to isolate the placenta before separation of the placenta. The succession period is characterized by the appearance of successive contractions, which lead to the gradual separation of the placenta from the walls of the uterus. Separation of the placenta from the walls of the uterus can occur in two ways - from the center (central separation of the placenta) and from the peripheral parts of the placenta (marginal separation of the placenta). With the central separation of the placenta, the blood that has poured out of the uteroplacental vessels accumulates between the placenta and the uterine wall, forming a retroplacental hematoma. The formation of a retroplacental hematoma, together with the subsequent contractions increasing in strength and frequency, contribute to the separation of the placenta and membranes from the walls of the uterus and the birth of the placenta. The marginal separation of the placenta begins with its peripheral areas, as a result of which the blood that has poured out of the uteroplacental vessels does not form a hematoma, but immediately flows out between the wall of the uterus and the amniotic membranes. By the time the placenta and membranes are completely separated from the walls of the uterus and the placenta descends into the lower uterine segment and the uterine vagina, the woman in labor has attempts, as a result of which the placenta is born within 2-3 minutes. When the placenta is separated from the center, the placenta is born with the fruit surface outward, when separated from the periphery, the maternal surface of the placenta will be located outside. In some cases, the placenta may separate from the wall of the uterus, but not be separated from the birth canal. The separated placenta continues to remain in the uterus, thereby preventing its contraction. The separated placenta should be removed using external techniques, but it must first be established whether the placenta has separated. Tactics for managing the afterbirth period. The basic principle: “hands off the uterus!” Signs of placenta separation. Before checking contact signs, you need to check non-contact signs: 1) the umbilical cord lengthens (positive sign of Alfeld); 2) the umbilical cord is retracted with a deep breath (Dovzhenko's sign); 3) the bottom of the uterus takes on a rounded shape, becomes denser to the touch and rises above and to the right of the navel (Schroeder's sign); 4) bloody discharge from the genital tract appears; 5) the outer segment of the umbilical cord is lengthened; 6) when pressing with the edge of the palm on the abdominal wall slightly above the pubis, the umbilical cord does not retract into the vagina, but, on the contrary, goes out even more. After separation of the placenta, a gentle massage of the fundus of the uterus is performed while pulling on the umbilical cord. It is recommended to use the Brandt-Andrews technique: after emptying the bladder through the catheter, pull the umbilical cord with one hand, and move the anterior wall of the uterus in the opposite direction with the other (to prevent uterine eversion). Bleeding in the afterbirth period, may occur as a result of a violation of the separation of the placenta and the discharge of the placenta. Violation of the process of separation of the placenta. It may be associated with weakness of labor activity, with dense attachment and true accreta of the placenta. Attachment of the placenta is considered dense if the chorionic villi do not extend beyond the compact layer of the decidua. It can be complete or incomplete, depending on the length. With a true increment, the villi penetrate the muscular membrane of the uterus up to the serous membrane and sometimes cause uterine rupture. There is 1 case per 10 births. It happens complete and incomplete, depending on the length. With complete true increment and complete tight attachment, bleeding is not observed, since the entire placental site adjoins or grows into the muscle wall. With a true partial increment of the placenta, part of it can be separated, and then bleeding occurs in the afterbirth period. When parts of the placenta are retained, bleeding can also develop in the postpartum period, when part of the placenta separates and is released, but a few lobules or a piece of the membrane remain, which interferes with uterine contraction. Violation of the discharge of the placenta occurs with spasm of the internal pharynx, hypotonicity of the uterus. Spasm may be the result of irrational use of contractile agents in the subsequent period. If bleeding occurs in the afterbirth period, then the first task of the obstetrician is to determine if there are signs of separation of the placenta. If there are signs of placental separation, it is necessary to immediately isolate the placenta by external methods, assess blood loss, introduce or continue the introduction of uterotonics, put ice and weight on the stomach, clarify the condition of the woman in labor and the amount of blood loss; examine the placenta and the integrity of its tissues. If blood loss remains within the normal range, it is necessary to monitor the condition of the woman in labor and administer uterotonics for another 30-40 minutes. If the blood loss is pathological, then it is necessary: 1) clarify the condition of the woman; 2) to compensate for blood loss: a) in case of blood loss of 400-500 ml, inject gelatinol, saline, oxytocin intravenously; b) with a blood loss of more than 500 ml, hemodynamic disorders occur, it is necessary to transfuse blood. If there are no signs of separation of the placenta, it is necessary: 1) assess the general condition of the woman in labor and the amount of blood loss; 2) give intravenous anesthesia and start or continue the introduction of uterotonics, having previously performed an external massage of the uterus; 3) proceed with the operation of manual separation of the placenta and removal of the placenta. Manual separation of the placenta and separation of the placenta performed in the absence of signs of separation of the placenta within 30 minutes after anesthesia. Complications of an infectious nature after this intervention are quite rare. Operation technique. Holding the body of the uterus with one hand, with the other gloved hand they penetrate the uterine cavity and carefully separate the placenta from its walls, then remove the placenta and massage the fundus of the uterus through the anterior abdominal wall to reduce bleeding. Inspection of the placenta. The placenta is examined for the presence of all its lobules and the membranes are examined. If broken vessels are present, there may be additional lobules that remain in the uterine cavity. The umbilical cord is examined in cases where one umbilical artery is missing; other anomalies are possible. In cases of pathological changes, the placenta is sent for histological examination. Further tactics depend on the result of the operation. When bleeding stops during surgery, it is necessary to assess the amount of blood loss and begin to replenish it, acting as in normal childbirth. In cases of continued bleeding due to accretion, attachment of the placenta and other things, this bleeding passes into the early postpartum period. Prior to manual separation of the placenta, for any reason, it is impossible to make a diagnosis - dense attachment or true accreta of the placenta. The final diagnosis can only be made with surgery. In cases of dense attachment of the placenta, it is possible to separate the decidua from the underlying muscle tissue by hand, with a true increment this is impossible. You must be very careful to avoid heavy bleeding. With a true increment, it becomes necessary to remove the uterus by amputation, extirpation, depending on the location of the placenta, obstetric history. Surgery is the only way to stop the bleeding. Prevention of hypotonic bleeding. The causes of bleeding in the postpartum period can be hypotension and uterine atony. To prevent hypotension and atony, gentle massage of the uterus and the administration of oxytocin are used, the latter is administered either at the birth of the anterior shoulder (10 units intramuscularly), or, better, after the birth of the placenta (20 units in 1000 ml of 5% glucose solution intravenously, with at a rate of 100 drops per minute). When administered intravenously, oxytocin can cause severe arterial hypotension. In cases of ineffectiveness of oxytocin, methylergometrine is administered - 0,2 mg intramuscularly. Methylergometrine is contraindicated in arterial hypertension, as well as in arterial hypotension (constriction of peripheral vessels during hypovolemic shock can be accompanied by severe complications). If bleeding continues, carboprost promethamine is prescribed - 0,25 mg intramuscularly. Restoration of the integrity of the soft tissues of the birth canal Soft tissue ruptures. To diagnose soft tissue ruptures, the lateral walls and vaults of the vagina, as well as the labia minora and the external opening of the urethra are examined. The palm of one hand is inserted into the vagina and the cervix and anterior lip are examined, which is then pulled up and the rest of the cervix is examined. Soft tissue ruptures are repaired by suturing with continuous or interrupted sutures. After perineo- or episiotomy, absorbable suture material 2/0 or 3/0 is applied to the perineum. Interrupted sutures are placed on the muscles of the perineum. The vaginal mucosa is sutured with a continuous suture, capturing the top of the gap, after which an intradermal cosmetic suture is applied. When the external sphincter of the anus is ruptured, which is the third degree of perineal rupture, nodal sutures are applied. On the rupture of the anterior wall of the rectum (the fourth degree of rupture of the perineum), it is necessary to impose a double-row intestinal suture, after which the perineum is sutured. Surgical delivery. Surgical delivery can be performed by caesarean section, forceps or vacuum extraction if spontaneous vaginal delivery is not possible. Lecture number 10. Childbirth with pelvic presentation of the fetus Breech presentation is more common in multiparous women, with preterm birth and accounts for 3,5% of all births. Distinguish: 1) pure breech presentation, when the buttocks are facing the entrance to the pelvis, and the legs are bent at the hip joints, unbent at the knee joints and extended along the body; 2) mixed breech presentation, when both (or one) legs are presented, bent at the hip and knee joints, crossed with each other and unbent at the ankle joints; 3) foot presentation, if the legs of the fetus are facing the entrance to the pelvis, and a full foot presentation is distinguished if both legs are presented, and incomplete if one leg is presented. Recognition of breech presentations is based on the ability to palpate the head from the buttocks. The buttocks are less dense, less rounded, have less volume and do not ballot. The diagnosis of breech presentation is easier to make if a dense, rounded, movable head can be found in the bottom of the uterus. Breech presentation is characterized by high (above the xiphoid process) standing of the fundus of the uterus, high (at the level of the navel or above) the location of the place of the most distinct listening to the heart sounds of the fetus. In childbirth, especially after the outflow of amniotic fluid, the vaginal examination specifies the presenting part by determining the sacrum, coccyx and legs of the fetus. By the location of the sacrum determine the position, its appearance. The buttocks of the fetus are located in a transverse dimension (linea intertrochanterika) in one of the oblique dimensions of the entrance to the pelvis. After the outflow of water and in the presence of labor, the fetus begins to move along the birth canal of the mother. In the biomechanism of childbirth with breech presentation, six points are distinguished. First moment. In this case, the buttocks make an internal rotation when moving from the wide part of the pelvic cavity to the narrow one. At the outlet of the pelvis, the diameter of the buttocks is set in a straight size, and the anterior buttock fits under the pubic arch. In accordance with the longitudinal axis of the pelvis, some lateral flexion of the fetal torso is observed. Second moment consists in lateral flexion of the lumbar region of the fetus. Under the influence of contractions, the fetus makes a forward movement. In this case, lateral flexion of the fetal spine occurs. From the genital gap, the posterior buttock is shown first, and then the anterior one. At this moment, the shoulders of the fetus enter the entrance to the pelvis in the same oblique size as the diameter of the buttocks. Third point. The internal rotation of the shoulders and the associated external rotation of the body ends at the exit from the pelvis and is characterized by the fact that the shoulders are installed in a straight size. The front shoulder fits under the pubic arch, and the back one is located at the tailbone. Fourth moment - this is the lateral flexion of the cervicothoracic spine of the fetus. It ends with the birth of the shoulder girdle and handles. Fifth moment - internal rotation of the head. The head enters one of the oblique dimensions of the entrance to the pelvis with its small oblique size (9,5 cm), depending on the position of the fetus and its type, but this oblique size is always opposite to that into which the shoulders of the fetus enter. With translational movement, the head performs translational movement and internal rotation at the entrance to the narrow part of the small pelvis from the wide one. The sagittal suture rises in the direct size of the exit of the pelvis. The region of the suboccipital fossa fits under the pubic arch. Sixth point. Bending of the head involves the gradual eruption of the head from the birth canal (the mouth is born first, then the nose, forehead and crown of the fetus). In a breech presentation, the head erupts in a small oblique size, as in the anterior view of an occipital presentation. Conducting childbirth in breech presentation Childbirth with a breech presentation stands on the verge between physiological and pathological. All pregnant women with breech presentation are hospitalized 2 weeks before the expected date of birth. In the first period, a woman is observed. During the period of exile from the moment of eruption of the buttocks, there is a danger of fetal hypoxia. After eruption of the buttocks, an obstetric (manual) allowance is provided according to Tsovyanov or in the classical way. Manual assistance according to Tsovyanov with a pure breech presentation begins to be provided after the eruption of the buttocks, which are grasped with hands in such a way that the thumbs are located on the hips of the fetus pressed to the stomach, and the remaining four fingers of both hands are located on the surface of the sacrum. During the birth of the torso, it is necessary that the legs of the fetus be pressed against its abdominal wall all the time (to prevent the arms from tipping over). The obstetrician advances his hands to the genital slit of the woman in labor, thereby preventing the legs from falling out and the fetal arms throwing back behind the head. Subsequent attempts contribute to the birth of the fetus to the umbilical ring, and then to the lower corners of the shoulder blades. The diameter of the fetus, having passed one of the oblique dimensions at the exit of the pelvis, is set in direct size. The doctor, holding the buttocks, directs them somewhat towards himself, so that the anterior handle can be born from under the pubic arch without complications. Raising the fetus upwards, the back handle is released from the sacral cavity. By further direction of the fetus towards itself and upwards, the head is released. The method of manual assistance in mixed breech presentation begins to be applied from the moment the fetus is born to the lower corners of the shoulder blades, after which the arms and head are released according to the rules of the classic manual assistance. The method of manual assistance with foot presentation is to prevent premature birth of the legs of the fetus until the uterine os is fully opened by holding the legs in a bent state for a long time. In this case, a mixed breech presentation is artificially formed. Due to the good preparedness of the birth canal by the buttocks, the fetus is usually born without difficulty. Lecture number 11. Childbirth with extensor presentation of the fetal head There are the following extensor presentations of the fetal head: anterior head, frontal and facial (the parietal region, forehead or face of the fetus, respectively, are facing the entrance to the small pelvis). These presentations are rare. The main causes of extensor presentations include reduced uterine tone, its uncoordinated contractions, underdeveloped abdominals, narrow pelvis, decreased muscle tone of the pelvic floor, too small or, conversely, large fetal sizes, and lateral displacement of the uterus. Childbirth with extensor presentation of the fetal head (anterocephalic, frontal and facial) are pathological. Anterior presentation of the fetus (first degree of extension). In this case, the large fontanel is a wire point, the head with a straight size passes the plane of the small pelvis. The direct size is the distance from the glabella to the outer protrusion of the back of the head (12 cm). frontal presentation characterized by the fact that the wire point is the forehead. The head passes all the planes of the pelvis with a large oblique size. This is the largest size (from the chin to the outer occipital protrusion), it is 13-13,5 cm. Facial presentation of the fetus is the third degree of extension. With this type of presentation, the wire point is the chin. The head passes the birth canal in a vertical size (from the hyoid bone to the middle of the large fontanel, which is 9,5-10 cm). extensor presentation include five main stages of the mechanisms of childbirth. The first moment is the extension of the head, the degree of which is determined by the presentation variant. The second point is the internal rotation of the head with the formation of a rear view (the back of the head is located in the sacral cavity). The third moment is the flexion of the fetal head after the formation of a fixation point at the lower edge of the pubic symphysis. With an anterior presentation, it is the forehead, with a frontal presentation it is the region of the upper jaw, with a facial presentation it is the hyoid bone. During the third moment of the mechanism of childbirth with facial presentation, the head is born. The fourth moment in frontal and frontal presentation is the extension of the head after fixing the back of the head at the top of the coccyx. The fourth moment (with facial presentation) and the fifth moment (with frontal and frontal presentations) include the internal rotation of the shoulders and the external rotation of the head. With an anterior presentation, the fetal head becomes brachycephalic as a result of the configuration, i.e., elongated towards the crown. In frontal presentation, the head is extended towards the forehead. With facial presentation, the lips and chin of the fetus are extended. With extensor cephalic presentations, other anomalies of insertion of the head are also possible: high straight standing of the head, low (deep) transverse standing of the head, asynclitism. The diagnosis of anterocephalic presentation of the fetus is carried out using data from a vaginal examination: the large and small fontanelles of the fetal head are at the same level or the large one is lower than the small one. Childbirth occurs through the natural birth canal, their management is expectant. If there are indications (fetal hypoxia, spasm and rigidity of the muscles of the birth canal) and appropriate conditions, it is possible to carry out surgical intervention in the form of obstetric forceps or the use of a vacuum extractor. Protection of the perineum of the woman in labor is carried out, as in the case of occipital presentation. A caesarean section is necessary if the size of the pelvis of the woman in labor and the head of the fetus do not match. frontal presentation the fetus is observed in most cases in the form of a transitional state to facial presentation. Diagnosis of frontal presentation is based on auscultation of fetal heart sounds, external obstetric and vaginal examinations. With frontal presentation, the fetal heartbeat is better heard from the side of the breast. During an external obstetric examination, on one side of the presenting part of the fetus, a sharp protrusion (chin) is probed, on the other, the angle between the back and the back of the head. The diagnosis is determined by vaginal examination. At the same time, the frontal suture, the anterior edge of the large fontanel, the superciliary arches with eye sockets, and the nose of the fetus are determined. Childbirth in a natural way is possible only with a small size of the fetus. In other cases, with a frontal presentation, a caesarean section is necessary if in the next 2 hours the frontal presentation does not turn into a facial or flexion presentation. Facial presentation of the fetus can be diagnosed by external obstetric examination. In this case, the dimensions of the head are larger than with the occipital presentation. In cases of severe swelling of the fetal face, vaginal examination is sometimes erroneously diagnosed as breech presentation. The differential diagnosis is based mainly on the determination of fetal bone formations. With facial presentation, the chin, superciliary arches, and the upper part of the orbit are palpated. With breech presentation, the coccyx, sacrum, ischial tubercles are determined. In cases of careless vaginal examination, damage to the eyeballs and mucous membrane of the oral cavity of the fetus is possible. If a vaginal examination reveals that the chin is turned backwards, then natural childbirth is not possible. In such cases, with a live fetus, a caesarean section is performed. If the fetus is not viable, then resort to perforation of the head. If, with the front presentation of the fetus, the chin is turned forward, childbirth takes place spontaneously. Lecture number 12. Transverse and oblique position of the fetus The transverse and oblique position of the fetus are observed in approximately 0,5-0,7% of cases in relation to the total number of births. They are classified as incorrect. The axis of the fetus forms a right or acute angle with the longitudinal axis of the uterus, and the fetus does not have a presenting part. At oblique position of the fetus the head or pelvic end is located below the line passing through the iliac crests. At transverse position all large parts of the fetus are above this line. The position of the fetus is determined by the head: when the head of the fetus is located on the left, the first position, on the right - the second position. The type of fetus is determined by the ratio of the position of the back to the anterior or posterior wall of the uterus (anterior or posterior view). Causes of the transverse and oblique position of the fetus varied. 1. Excessive fetal mobility - with polyhydramnios, flabbiness of the muscles of the anterior abdominal wall in multiparous. 2. Limited fetal mobility - with oligohydramnios, multiple pregnancy, large fetus, anomalies in the structure of the uterus, the presence of uterine fibroids, increased uterine tone, with the threat of termination of pregnancy. 3. The presence of obstacles to the insertion of the head - placenta previa, the presence of uterine fibroids in the lower segment, with a narrow pelvis. 4. Congenital malformations of the fetus: hydrocephalus, anencephaly. Diagnostics. The diagnosis is made on the basis of a visual examination: a transverse oval or oblique oval shape of the abdomen, a low position of the uterine fundus are determined. With an external obstetric examination, the presenting part of the fetus cannot be determined. Large parts (head, pelvic end) are determined by palpation in the lateral sections of the uterus. With the help of auscultatory examination, the fetal heartbeat is heard in the umbilical region. With vaginal examination, the presenting part of the fetus cannot be determined, while great importance is given to the ultrasound method. From the armpit, you can determine where the fetal head is located. Course of pregnancy and childbirth. During pregnancy, if the fetus is not positioned correctly, the most common complications may be premature rupture of amniotic fluid due to the lack of an internal seal, as well as premature birth. With placenta previa, which can cause abnormal positioning of the fetus, bleeding is possible. Among the common complications of the first stage of labor, early discharge of amniotic fluid is also noted. A long anhydrous interval, lasting 12 hours or more, contributes to the infection of the fetal egg, uterus and the spread of infection to the peritoneal area. Intensive discharge of amniotic fluid in the first stage of labor limits the mobility of the fetus, may be accompanied by prolapse of the umbilical cord or the handle of the fetus, and it is also possible to drive one of the shoulders into the small pelvis. This state is called neglected transverse position of the fetus. Very often, fetal hypoxia is observed, in some cases leading to its death. The contracted uterus reduces the blood supply to the placenta. If labor continues and the fetus does not move along the birth canal, the lower segment is first overstretched, and then the uterus ruptures. In exceptional cases, childbirth in the transverse position of the fetus may end spontaneously as a result of self-rotation of the fetus into a breech or head presentation, self-torsion. Even less often, childbirth with a double body can occur when passing the pubic arch of the shoulder with a handle. In this case, the buttocks, legs, and then the entire shoulder girdle and head are born sequentially. During childbirth with a double body, the fetus folds in the spine in half, and in this state it is born. Most often, such childbirth ends with the birth of a dead fetus. Management of pregnancy and childbirth. During pregnancy up to 34-35 weeks, the position of the fetus (transverse or oblique) is called unstable, because during this period the fetus is very mobile. The position of the fetus may change and become longitudinal. In this case, the pregnant woman must be thoroughly examined to determine the possible causes of abnormal fetal positions. They can cause complications in the further course of pregnancy and delivery. With a transverse position of the fetus, pregnant women are asked to lie on their side in the same position as much as possible, and with an oblique position - on the side of the underlying large part of the fetus. After 35 weeks of pregnancy, the fetus takes a more stable position. If the position remains incorrect, the pregnant woman is hospitalized to find out its cause and determine tactics for managing pregnancy and delivery. External prophylactic rotation of the fetus, which was often used in the past, is currently practically not used due to inefficiency and a large number of contraindications. In addition, in the process of external rotation, severe complications are possible: placental abruption, uterine rupture. The caesarean section is the optimal method of delivery in the transverse or oblique position of the fetus. The first stage of labor is most favorable for operative delivery. Sometimes, when the first contractions occur, the fetus changes its position to a longitudinal one. Before the onset of labor, indications for caesarean section are pregnancy, placenta previa, premature discharge of amniotic fluid, fetal hypoxia, scars on the uterus. If small parts of the fetus (umbilical cord, handles) fall out, an attempt to reduce them is unacceptable, as this leads to infection and lengthens the time of preoperative delivery. Conducting childbirth through the natural birth canal is possible only with a very premature fetus. Turning the fetus on the leg with its subsequent extraction is used upon admission of a woman in labor with full disclosure of the cervix, a live fetus and its preserved mobility. The prognosis in this case for the fetus is less favorable. Embryotomy under general anesthesia is performed with a running transverse position and a dead fetus. In the presence of an infectious process with a long anhydrous period, if the fetus is viable, a caesarean section, hysterectomy, and drainage of the abdominal cavity are performed to avoid the development of peritonitis. In some cases, with infection, a caesarean section is performed by extraperitoneal access. With a dead fetus, a fruit-destroying operation is indicated. obstetric turn - an operation that allows you to change the unfavorable (transverse, oblique, pelvic) position of the fetus for the course of childbirth to a favorable (longitudinal) one. There are the following types of obstetric rotations: external rotation on the head (less often on the pelvic end) and external-internal classical rotation on the leg with full opening of the uterine os. External rotation of the fetus is performed after the 35th week of pregnancy using external techniques. This effect is only through the abdominal wall without manipulation in the vagina. External rotation is indicated for transverse and oblique positions of the fetus, with breech presentations. Exposure can be carried out in the presence of good fetal mobility, normal size of the pelvis or its slight narrowing (true conjugate of at least 8 cm), in the absence of fetal hypoxia, premature detachment of the placenta, i.e., a quick end of labor is not indicated. External rotation for repeated pregnancies can be performed without general anesthesia. With oblique positions of the fetus, it may be sufficient to turn the pregnant woman to the side in which the presenting part is rejected. With a transverse and persistent oblique position of the fetus, special external techniques are used to rotate. It is first necessary to prepare a woman in labor: remove urine, inject a 1% solution of promedol (1,0 ml) subcutaneously, lay her on a hard couch on her back with legs slightly bent, drawn to her stomach. The obstetrician sits down on the side of the pregnant woman, puts both hands on her stomach, and one of his hands rests on the head, clasping it from above, and the other on the underlying buttock of the fetus. Then, clasping the fetus with one hand, put pressure on its head towards the entrance to the small pelvis. The other hand pushes the pelvic end up to the bottom of the uterus. These influences are carried out persistently, but very carefully. With pelvic presentation of the fetus at 29-34 weeks, a set of special physical exercises is carried out, the purpose of which is to correct the position of the fetus. If the effect of the ongoing exercises has not come, an attempt at 35-36 weeks in the hospital for an operation of external rotation of the fetus on the head is possible. It is called preventive turn. It is done according to the general rules: the buttocks of the fetus are shifted towards the back, the back towards the head, and the head is directed towards the entrance to the small pelvis. After the rotation, systematic monitoring of the condition of the pregnant woman is necessary. Recently, the implementation of a preventive rotation has been disputed. When carrying out an external rotation, complications of the following nature are possible: fetal hypoxia, premature detachment of the placenta. When the first signs of complications appear, the operation of external rotation is stopped, according to indications, operative delivery is performed. External-internal classic rotation is performed by a gynecologist, in emergency situations it can be performed by an obstetrician. When it is carried out, one hand is inserted into the uterus, the other is placed on the stomach. When carrying out the external-internal classical rotation, the fetus must be turned on the leg. The indications for the external-internal classical rotation of the fetus on the leg include the transverse position of the fetus and extensor head presentations that are dangerous for the mother (for example, frontal). As a rule, the operation is performed with a dead fetus, in the presence of a live fetus, a caesarean section is preferable. To carry out the external-internal classical rotation, the necessary condition is the complete opening of the uterine os and the full mobility of the fetus. This type of rotation is contraindicated in advanced transverse positions, when the fetus is immobile. Before the start of the rotation, it is necessary to completely empty the bladder and treat the external genital organs with disinfectants. Lecture No. 13 If the external-internal classical rotation fails, the delivery is completed by caesarean section. Presentation and prolapse of the fetal leg. A correct diagnosis is necessary, since this complication can be mistaken for incomplete breech position and improper fetal extraction can lead to its death. Complications are observed extremely rarely with cephalic presentation, for example with a premature and macerated fetus, as well as with twins, if there is a sharp flexion of the fetal trunk with an extended leg. If it is impossible to straighten the leg with a viable fetus, a cesarean section is indicated. Birth of a large and gigantic fetus. Childbirth with malformations and diseases of the fetus. A fruit weighing from 4000 to 5000 g is considered large, 5000 g or more is considered gigantic. Such fetal sizes are in most cases due to endocrine pathology of the pregnant woman, especially diabetes mellitus. Another cause may be an edematous form of hemolytic disease of the fetus. With a large and giant fetus, the circumference of the mother’s abdomen is more than 100 cm, the height of the uterine fundus is more than 38 cm, and the fetal head exceeds normal dimensions. Even with the normal course of labor, complications very often arise with a large and giant fetus: primary and secondary weakness of labor, premature and early rupture of amniotic fluid, increased duration of labor. Upon the onset of labor, it may be discovered that the sizes of the pelvis and the fetal head do not correspond to each other. The course of labor coincides with its management, as with a narrow pelvis. Often the birth of shoulders is difficult. Injuries to the mother and fetus during childbirth, in the afterbirth period, and hypotonic uterine bleeding in the early postpartum period are common. The larger the fetus, the more frequent the number of complications. The period of exile is especially difficult. In order to prevent weak labor during childbirth, the creation of an estrogen-glucose-vitamin background is indicated. If measures aimed at enhancing labor with the development of labor weakness are not effective, a cesarean section is performed. It is necessary to stop inducing labor and proceed to this operation if there is a discrepancy between the sizes of the pelvis and the fetal head. If there is a threat of rupture of the perineum during the period of expulsion, it is necessary to dissect it. From the beginning of cutting into the fetal head, to prevent uterine bleeding, the woman in labor must be administered oxytocin (5 units) with glucose intravenously or 1 ml of a 0,02% solution of ergometrine maleate. In case of breech presentation of a large and giant fetus, delivery is carried out by cesarean section. Childbirth with hydrocephalus. Often, fetal hydrocephalus is accompanied by weakness of labor and overextension of the lower uterine segment due to the disproportion between the pelvis and the fetal head. When examining a woman in labor, a large fetal head is palpated. Even with good labor activity, there is no insertion of the head into the small pelvis. Also, during a vaginal examination, thinning of the skull bones is detected (when pressing on the bones with a finger, a sound resembling the crunching of parchment is felt), their mobility, wide sutures and fontanelles. With breech presentations, signs of hydrocephalus are detected only after the birth of the body. Hydrocephalus is detected by ultrasound. With pronounced signs of fetal hydrocephalus, in cases of impossibility of delivery, fluid is released by puncturing the skull. Carrying out this manipulation is possible only with head presentations. Lecture number 14. Anomalies of labor activity Pathological preliminary period, primary and secondary weakness of labor activity, excessively strong labor activity, discoordination of labor activity, tetanus of the uterus are the main types of anomalies of labor activity. 1. Pathological preliminary period The pathological preliminary period is characterized by spastic, painful and erratic uterine contractions and the absence of structural changes in the cervix. The duration of the pathological preliminary period can be several days. Untimely discharge of amniotic fluid is the most common complication of the pathological preliminary period. The main causes of this complication are nervous stress, endocrine and metabolic disorders, inflammatory changes in the uterus, the age of the primipara older than 30 years and younger than 17 years. The main thing in the treatment of the pathological preliminary period is: accelerated preparation of the cervix for the onset of labor and the elimination of painful erratic contractions. With fatigue and increased irritability, the patient is prescribed sedatives (motherwort tincture, valerian root), antispasmodics, painkillers, b-mimetics (ginipral, partusisten). In case of urgent preparation of the cervix for the onset of labor, medicinal substances based on prostaglandin E are introduced into the cervical canal or into the posterior fornix of the vagina.2. The duration of treatment of the pathological preliminary period should not exceed 3-5 days. With a good readiness of the cervix (mature cervix), labor can proceed naturally. In this case, early opening of the fetal bladder is permissible. With the ineffectiveness of the therapeutic effect, operative delivery by caesarean section is performed. 2. Weak labor activity Weak labor activity is manifested by a slowdown in the opening of the cervix, an increase in the intervals between contractions, a violation of their rhythm, insufficient strength and duration of uterine contractions, and a delay in the advancement of the fetus. There are primary and secondary weakness of labor activity. With primary weakness from the very beginning, labor activity is ineffective, sluggish, contractions are weak. Secondary weakness occurs during the normal course of childbirth. The weakness of labor delays labor, contributes to the development of fetal hypoxia, fatigue of the woman in labor, lengthening of the anhydrous gap, infection of the birth canal, the development of inflammatory complications, bleeding during childbirth and the postpartum period. The reasons for the weakness of labor activity are very diverse. These can be changes in the function of the nervous system as a result of stress, endocrine dysfunction, menstrual disorders, metabolic diseases. In some cases, the weakness of the birth forces cause pathological changes in the uterus: malformations, inflammatory changes, overstretching. Insufficiency of contractile activity during childbirth is also possible in the presence of a large fetus, with polyhydramnios, multiple pregnancies, uterine myoma, post-term pregnancy. The reasons for the secondary weakness of labor can be fatigue of the woman in labor as a result of prolonged and painful contractions, an obstacle to the fetus being born due to a mismatch in the size of the head and pelvis, an incorrect position of the fetus, and the presence of a tumor in the small pelvis. Treatment of weak labor activity consists in rhodostimulation with an open fetal bladder. Rhodostimulation is carried out by intravenous drip of drugs that enhance the contractile activity of the uterus (oxytocin, prostaglandin F2a). A particularly good effect is observed with the combination of prostaglandin F2a with oxytocin. If the woman in labor is tired and there is weakness and insufficiency of contractions at night, as well as with a slight opening or unavailability of the cervix for labor, the woman should rest for several hours with the help of obstetric anesthesia. In no case should you continue to stimulate labor, so as not to complicate their course. Then a vaginal examination is performed to determine the obstetric situation and assess the condition of the fetus. After rest, labor activity may return to normal, and treatment is not required. In cases of insufficiency of labor activity after obstetric anesthesia, uterine stimulants are prescribed. Stimulation of labor activity has a number of contraindications. These include a discrepancy between the size of the pelvis of the mother and the size of the fetus, existing scars on the uterus of various origins (after gynecological operations to remove myomatous nodes or after previous births performed surgically using a caesarean section), the presence of symptoms of a threatening uterine rupture, a history of recent septic diseases severe genital organs. If, when using drugs that stimulate uterine contractions, the cervix does not open within 2 hours or the condition of the fetus worsens, then the administration of these drugs should be discontinued due to lack of effect. In such a situation, the issue should be resolved in favor of operative delivery. The choice of method of delivery is determined by the specific situation. With the weakness of labor activity in the first stage of labor, it is best to perform a caesarean section. During the period of exile, it is possible to use exit forceps or perform vacuum extraction. 3. Violent labor activity Strong and frequent contractions and attempts (after 1-2 minutes), which lead to rapid (1-3 hours) and rapid (up to 5 hours) childbirth, are characterized as excessively strong, violent labor activity. The expulsion of the fetus sometimes occurs in 1-2 attempts. Violent labor activity is dangerous for the mother and fetus, causing deep ruptures of the cervix, vagina, clitoris, and perineum in parturient women. Also, with violent labor activity, premature detachment of a normally located placenta or the development of bleeding is possible. The rapid and rapid course of labor, too frequent and intense contractions are often the cause of fetal hypoxia and birth trauma. To reduce violent labor activity, the woman in labor is given a position on her side, opposite to the position of the fetus, which she maintains until the end of childbirth. The mother is not allowed to get up. To normalize the process of childbirth and reduce too violent labor activity, magnesium sulfate is used intravenously and tocolytics (partusisten, ginipral). It is necessary to reduce the number of contractions to 3-5 within 10 minutes. 4. Tetanus of the uterus Uterine tetany is rare. It is characterized by constant tonic tension of the uterus, which does not relax at all. The reason is the simultaneous occurrence of several pacemakers in different parts of the uterus. At the same time, the contractions of various parts of the uterus do not coincide with each other. The total effect of the action from the contraction of the uterus is absent, which leads to a slowdown and arrest of labor. In view of a significant violation of the uteroplacental circulation, fetal hypoxia occurs and increases. This can be determined by the violation of his heartbeat. The dilatation of the cervix is reduced compared to the results of the previous vaginal examination. A woman in labor may experience chorioamniotitis, accompanied by elevated body temperature. This condition can worsen the prognosis for mother and child. Uterine tetany can be one of the symptoms of such formidable complications as threatening or incipient uterine rupture, premature detachment of a normally located placenta. The causes of this pathological condition can be significant obstacles to the passage of the fetus, a narrow pelvis, neoplasms, and inadequate use of labor-stimulating drugs. In the treatment of uterine tetany, anesthesia is used, after which labor activity is restored, and childbirth ends naturally. With tetany of the uterus, a caesarean section is performed in case of symptoms of uterine rupture, premature detachment of a normally located placenta, mechanical obstruction to the passage of the fetus. When the cervix is fully dilated, obstetric forceps are used to extract the fetus or the fetus is removed by the leg in breech presentation. 5. Discoordination of labor activity Discoordination of labor activity consists in chaotic contractions of various parts of the uterus due to the displacement of the pacemaker zone. Several such zones may occur simultaneously. The left and right halves of the uterus can contract in an uncoordinated way, but this mainly happens with its lower section. The nature of the contractions changes: they become more frequent (6-7 in 10 minutes), become irregular, prolonged. In the moment between contractions, the uterus cannot relax completely. The behavior of the mother in labor is restless. There is difficulty urinating. The opening of the uterine os, despite frequent, strong and painful contractions, occurs very slowly or does not occur at all, as a result of which the fetus almost does not move along the birth canal. Due to violations of the contractile activity of the uterus and its incomplete relaxation, the occurrence of complications is often observed: significant hypoxia of the fetus and its intracranial injury. Violation of the contractile activity of the uterus can lead to untimely discharge of amniotic fluid. The cervix thickens, the edges of the uterine os do not stretch, remain thick and tight. Therapy of discoordination of labor activity is aimed at eliminating excessive uterine tone. Use sedatives, antispasmodics, painkillers and tocolytic drugs. The most optimal method of pain relief is epidural anesthesia. Childbirth is carried out with constant monitoring of the fetal heart rate and uterine contractions. With ineffective treatment, as well as with the addition of other complications, it is advisable to perform a caesarean section without attempting corrective therapy. Lecture number 15. Placenta previa Placenta previa may be complete or incomplete, depending on the degree of occlusion of the internal os of the uterus by placental tissue. Placenta previa can be identified by the presence of placental tissue in the lumen of the pharynx throughout. This is complete placenta previa. When determining the placenta and membranes, presentation is considered partial. In addition, there may be a low location of the placenta, when it, located in the lower segment of the uterus, does not reach the edges of the internal os. With complete placenta previa, bleeding from the genital tract usually occurs at the end of pregnancy, with incomplete - at the beginning of labor. Bleeding occurs suddenly and is not accompanied by pain. Sometimes there may be prolonged, periodically renewed spotting. With placenta previa, the uterine vessels bleed, the fetus itself does not lose blood. But in this case, not all of the placenta is involved in the gas exchange of the fetus, and asphyxia may develop. Diagnosis is determined by anamnestic data and the results of an objective examination. Any bleeding in the last stages of pregnancy and at the beginning of labor may be due to placenta previa. An external obstetric examination reveals a relatively high location of the presenting part. Breech presentation and transverse position of the fetus are often diagnosed. Diagnosis of presentation is specified during vaginal examination, which, due to the risk of severe bleeding, should always be carried out with extreme caution and with a deployed operating room. Behind the internal uterine pharynx, spongy tissue (full presentation) or spongy tissue with nearby fetal membranes smooth on palpation (incomplete presentation) is palpated. If the cervix is not open, then the diagnosis is based on the characteristic pastosity of the vaginal vaults and pulsation of the vessels. At the end of the examination, the cervix and vaginal vaults are examined in mirrors to exclude bleeding. It can occur with erosions, malignant neoplasms of the cervix, varicose veins of the vagina. It is necessary to conduct a differential diagnosis with premature detachment of a normally located placenta and incipient uterine rupture. Pregnant women who are suspected of having placenta previa should be urgently taken to the clinic for examination and treatment. If the bleeding is not strong, then drugs that relax the uterus can be used during pregnancy. To relax the uterus in case of premature onset of labor, it is advisable to use beta-adrenergic agonists (partusisten) and drugs that enhance blood clotting (vitamin K 0,015 g 3 times a day), blood transfusion in small doses of 100 ml, the introduction of ascorbic acid (300 mg in 20 ml 40% glucose solution intravenously). A pregnant woman is prescribed strict bed rest to avoid severe bleeding. Due to the risk of pregnancy bleeding, it is not recommended to be discharged from the hospital. The tactics of conducting childbirth depends on the obstetric situation. Abdominal caesarean section is performed with unprepared birth canal and severe bleeding. Absolute indications for operative delivery by caesarean section: complete placenta previa, partial presentation in the event of heavy bleeding. If there is an incomplete placenta previa or slight bleeding, it is recommended to open the fetal bladder. With weak labor activity, the imposition of skin-head forceps is used. With a breech presentation and a movable presenting part, it is not always possible to perform a caesarean section. In such cases, an attempt is made as carefully as possible to try to bring the fetal leg down and hang a load of up to 200 g from it. An attempt to extract the fetus with incomplete opening of the cervix can lead to uterine rupture, so this is absolutely contraindicated. Hypotonic bleeding often occurs during the placenta and the early postpartum period. In view of this, in the third stage of labor, 1 ml of oxytocin (5 IU) is administered intravenously in 20 ml of a 40% glucose solution or 1 ml of methylergometrine together with a 40% glucose solution. After the end of the succession period, the cervix is always examined in the mirrors. Premature detachment of a normally located placenta Premature detachment of a normally located placenta is a pathological condition in which the placenta is not separated in time. Placental abruption does not occur after the birth of the fetus, as it should be normal, but during pregnancy or during the course of childbirth. In 1/3 of cases, premature placental abruption is accompanied by profuse bleeding with the development of appropriate complications in the form of hemorrhagic shock and DIC (disseminated intravascular coagulation). Causes of premature placental abruption. The reasons leading to premature abruption of a normally located placenta are divided into two groups. The first group of - these are the factors that directly lead to the development of this complication: prolonged gestosis, the therapy of which was insufficient, or untimely started, or was not carried out at all; diseases accompanied by changes in blood pressure, heart defects, diseases of the urinary system, thyroid gland, adrenal cortex, diabetes mellitus; incompatibility of mother and fetus according to the Rh factor or blood type; antiphospholipid syndrome; diseases of the blood and connective tissue (systemic lupus erythematosus); changes in the uterus of an inflammatory or cicatricial nature (surgery), inflammatory diseases of the uterus; operations, malformations of the uterus; the location of the placenta in the area of the myomatous node; delayed pregnancy. The second group of reasons - these are factors leading to premature detachment of the placenta against the background of existing disorders: overstretching of the walls of the uterus due to a large amount of amniotic fluid, multiple pregnancy, too large a fetus; untimely, rapid discharge of amniotic fluid with polyhydramnios; traumatic injury to the placenta (fall, blow to the stomach); violation of synchrony in the contractile activity of the uterus; inadequate use of uterotonic drugs in childbirth. All of the above factors lead to disruption of the links between the placenta and the uterine wall, rupture of blood vessels with the formation of hemorrhage (retroplacental hematoma). Symptoms of placental abruption, uterine bleeding. With detachment of a small area of the placenta, a retroplacental hematoma may form. In this case, the vessels of the uterus are thrombosed and the progression of placental abruption will stop. In some cases, blood permeates the uterine wall (with significant placental abruption, profuse bleeding, large retroplacental hematoma). In these cases, the contractile activity of the myometrium is disturbed. This pathological condition is called Couveler's uterus. If marginal placental abruption occurs, then blood passes between the fetal membranes and the uterine wall, then symptoms and a clinic of external bleeding are observed, as blood flows into the vagina. The color of blood from the genital tract immediately after placental abruption is scarlet. The dark color of the blood indicates the time elapsed from the moment of detachment to the onset of bleeding. Premature placental abruption can be mild or severe. With a mild form of premature placental abruption, there is a small bloody discharge from the vagina, the tone of the uterus is unchanged, but some tension is noted, the woman's condition is satisfactory, the fetal heartbeat is normal. In a severe form of premature detachment of the placenta, pain with severe bleeding is noted. In case of accumulation of blood between the wall of the placenta and the uterus, there may be no bleeding, a retroplacental hematoma forms in this place, a local painful swelling occurs with an increase in pain and spread to all parts of the uterus. Local pain may be unexpressed in cases where the placenta is located on the posterior wall of the uterus, as well as when blood flows out. In this case, the following signs are noted: frequent pulse and breathing, arterial hypotension, moisture and pallor of the skin, weakness, dizziness, bloating. Note the tension and soreness of the uterus. The uterus becomes asymmetrical. With the onset of placental abruption, signs of fetal hypoxia increase. Fetal death can occur as a result of an increase in retroplacental hematoma up to 500 ml, as well as an increase in the area of placental abruption by one third. There are symptoms of a violation of blood clotting up to the complete absence of blood clotting. Diagnosis of premature placental abruption. Diagnosis of premature abruption of a normally located placenta is based on clinical manifestations. These include the presence of bloody vaginal discharge against the background of increased uterine tone, changes in the shape of the uterus, and increasing signs of fetal hypoxia. When making a diagnosis, the pregnant woman’s complaints, medical history, clinical course of the complication, as well as the results of objective, instrumental and laboratory studies, in particular ultrasound, which makes it possible to determine the volume and boundaries of the retroplacental hematoma, are taken into account. Women with preeclampsia deserve special management tactics. Delivery with premature placental abruption. Emergency caesarean section is indicated in cases of progression of placental abruption, impossibility of delivery through the natural birth canal. Opening the fetal bladder is contraindicated in the absence of labor, as a result of a decrease in intrauterine pressure, premature detachment of the placenta may be aggravated. Expectant management of labor is possible in the conditions of an extended operating room of the maternity hospital in case of slight placental abruption, absence of anemia and signs of fetal hypoxia, with a satisfactory condition of the woman. At the same time, careful simultaneous monitoring of the fetus and placenta is carried out through regular dopplerometry, cardiotocography and ultrasound. The state of the blood coagulation system is regularly assessed. With the progression of placental abruption, accompanied by repeated bleeding, according to vital indications, both from the side of the mother and from the side of the fetus, an emergency caesarean section is performed. Delivery through the natural birth canal is possible with a mild form of placental abruption, in the case of head presentation of the fetus, with a mature cervix, the correspondence of the fetal head to the mother's pelvis, and under the condition of normal labor activity. During natural delivery, strict monitoring and control of the condition of the fetus and the contractile activity of the uterus is necessary. The opening of the fetal bladder is carried out with the development of regular labor activity. The opening of the fetal bladder leads to a decrease in the tone of the uterus, thereby reducing bleeding. Stimulation of labor activity in case of premature detachment of the placenta is unacceptable. Increased bleeding, progression of placental abruption, uterine hypertonicity, and increased fetal hypoxia are indications for caesarean section. After the birth of the fetus, it is necessary to immediately proceed to the manual separation of the placenta and the allocation of the placenta, after which they are examined with the help of mirrors of the cervix and vaginal walls for damage and their elimination. Preventive measures. All pregnant women must be examined to identify possible risk factors leading to premature separation of a normally located placenta. Pregnant women are treated if risk factors are identified. Particular attention should be paid to pregnant women with gestosis. If there is no effect from the therapy, the pregnant woman must be hospitalized in a maternity hospital. Pregnant women are subject to mandatory hospitalization at 38 weeks. The issue of timing and method of delivery is decided on an individual basis. Lecture No. 16 During childbirth, ruptures of the cervix, vagina, perineum, and vulva can occur. This happens with violent and rapid childbirth, with large fetal sizes, etc. Therefore, in the early postpartum period, it is imperative to examine the soft tissues of the birth canal and suture the gaps. With a rupture of the soft tissues of the birth canal, bleeding is usually not heavy. If the birth was carried out at home, the puerperal must be taken to the obstetric hospital, where the soft tissues of the birth canal will be examined and the tears will be sutured. The causes of ruptures are most often childbirth with a large fetus, the imposition of forceps, inept protection of the perineum, and rapid childbirth. There are III degrees of ruptures of the perineum. With a rupture of the XNUMXst degree, the integrity of the posterior commissure, the vaginal wall in the region of its lower third, and the skin of the perineum are violated. With a rupture of the II degree, the skin of the perineum, the walls of the vagina and the muscles of the perineum are disturbed (except for the external sphincter of the rectum). With a rupture of the III degree, the external sphincter of the rectum is additionally damaged. There are also three degrees of rupture of the cervix. I degree - a gap on one or both sides of not more than 2 cm, II degree - a gap of more than 2 cm, but not reaching the fornix of the vagina, III degree - a gap reaching the fornix or passing to it. Rupture of the uterus A complication of pregnancy is observed in 2-3 cases per 10 births. Distinguish between complete and incomplete rupture of the uterus. A complete rupture is characterized by a violation of the integrity of all layers of the uterus. Where parts of the peritoneum do not adhere tightly to the myometrium, incomplete ruptures of the uterus occur. An incomplete rupture is usually noted in the lower segment, lateral sections. In these cases, the integrity of the mucous membrane and the muscular layer of the uterus is violated, and the blood flowing under the visceral peritoneum forms an extensive subperitoneal hematoma. There are spontaneous and violent uterine ruptures. Violent ruptures of the uterus are observed with the wrong actions of the obstetrician during the performance of obstetric benefits and operations. Spontaneous uterine ruptures are more common, resulting from inflammatory and degenerative changes in the myometrium formed after abortion, childbirth, caesarean section, removal of myomatous nodes, removal of the fallopian tube, suturing of a perforation, etc. These histopathic uterine ruptures occur in the second half of pregnancy, especially after the 30th week, or during childbirth. A mechanical obstruction to the advancement of the fetus (mismatch between the size of the presenting part of the fetus and the mother's pelvis) is the most common cause of spontaneous uterine rupture, observed mainly at the end of the dilatation period. Before uterine rupture, symptoms of impending rupture are usually noted. With histopathic and mechanical genesis of uterine rupture, the symptoms of a threatening rupture are different. Symptoms threatening rupture of the uterus in histopathic genesis: scanty bloody discharge from the genitals, constant pain in the lower abdomen, lower back (pain may be local or not localized), weakness of labor activity, a long period of irregular precursors of contractions (2-3 days). Symptoms of a threatening rupture of the uterus of mechanical origin: a discrepancy between the size of the fetus and the mother's pelvis. It manifests itself in excessive labor activity, incomplete relaxation of the uterus between contractions. Contractions are sharply painful. The lower segment of the uterus is sharply painful on palpation, there is swelling of the tissue in the bladder area above the pubis, urination is difficult. Uterine rupture is accompanied by nausea, 1-2 times vomiting, pain in the abdomen without localization or localized in the epigastric region (with uterine rupture in the fundus, tubal angles), in the hypogastric or lateral sections (with a rupture in the lower segment or uterine edge) , symptoms of irritation of the peritoneum. On palpation, pain is noted with localization in the area of the gap. When a fetal egg enters the abdominal cavity, parts of the fetus can be palpated. They are located directly under the abdominal wall. The woman takes a forced position on her back, on her side. The pain increases, the general condition worsens. Violation of the vital activity of the fetus or even the absence of a fetal heartbeat are observed during auscultation. A woman in labor complains of dizziness, tachycardia, low blood pressure, pale skin, darkening of the eyes, weakness, dry mouth (signs of increasing anemia). In cases of damage to large vessels during rupture of the uterus and the exit of the fetus into the abdominal cavity, a picture of hemorrhagic shock develops. Fatal outcome in uterine rupture (with a combination of painful, traumatic and hemorrhagic components) is 2-3 times more likely than in patients with presentation and premature detachment of a normally located placenta, hypotonic bleeding. Diagnostics uterine rupture is based on the presence of characteristic symptoms of uterine rupture and history (such as uterine scar after caesarean section, uterine perforation, complications in previous births, weakness of labor forces, bleeding, birth of a large or still fetus, vaginal delivery operations, infection in childbirth and postpartum period). In some cases, women have a burdened gynecological history (myomectomy, tubectomy in the past, cervical surgery, inflammatory disease of the female genital organs, etc.). Help Tactics. If symptoms characteristic of uterine rupture occur, the woman must be transported to an obstetric hospital on a stretcher. The woman immediately begins transfusion of any blood replacement solutions in combination with ascorbic acid (3-4 ml of a 5% solution), cocarboxylase (100-150 mg); in case of arterial hypotension, prednisolone (60 mg) or hydrocortisone (150-200 mg) is administered. . The administration of analgesics should be avoided until an accurate diagnosis has been established. In cases of severe shock, the administration of analgesics is acceptable, especially during transport. During transportation, they most often resort to mask anesthesia with nitrous oxide and oxygen in a ratio of 1: 2. However, we should not forget that narcotic analgesics cause depression of the respiratory center and that pregnant women are especially sensitive to their effects. Treatment of uterine rupture. If the uterus ruptures, a transsection operation is performed and the scope of subsequent actions is determined, regardless of the condition in which the patient is, the presence of a concomitant infection, the nature of the damage, etc. The operation can be aimed at removing the fertilized egg, suturing the rupture, performing amputation or extirpation of the uterus. At the same time, antishock therapy is carried out. Lecture number 17. Toxicosis of pregnant women Toxicosis of pregnant women (gestosis) is a pathological condition during pregnancy associated with the development of the fetal egg, disappearing in the postpartum period. This is a complication of pregnancy, which is a consequence of the lack of adaptive capabilities of the mother, in which her body cannot adequately meet the needs of the growing fetus. Gestoses are manifested by various disorders of neurohumoral regulation. There are disorders of the functions of the central and autonomic nervous system, cardiovascular and endocrine systems, as well as a violation of a number of metabolic processes, the immune response, etc. Allocate early and late toxicosis. Early toxicosis of pregnant women It develops in the first 20 weeks of pregnancy and is called toxicosis of the first half of pregnancy. Of the existing many theories for the development of early toxicosis (such as neurogenic, corticovisceral, hormonal, allergic, immune), they currently adhere to the theory of violations of neuroendocrine regulation and metabolism, which develop as a result of previous diseases, pregnancy characteristics, and the impact on the body of adverse environmental factors. Early toxicosis of pregnancy is most often accompanied by vomiting and salivation (ptyalism). Vomiting It is typical for approximately 50-60% of pregnant women, however, only 8-10% of them need inpatient treatment. The appearance of vomiting is associated with a hormonal imbalance. The onset of vomiting temporarily corresponds to the peak production of human chorionic gonadotropin. With vomiting of pregnant women, the endocrine activity of the adrenal cortex may change in the direction of reducing the production of corticosteroids. Vomiting of pregnant women can also be regarded as an allergization of the body when particles of trophoblast enter the maternal bloodstream. Vomiting is most pronounced in multiple pregnancies and hydatidiform mole. There are III degrees of severity of vomiting of pregnant women. I. Mild degree is characterized by vomiting up to 5 times a day, while the condition of the pregnant woman is not disturbed, vomiting may be associated with food intake or odors or appear on an empty stomach. II. Moderate severity is accompanied by vomiting up to 10-12 times a day, symptoms of intoxication, weakness, weight loss and decreased diuresis. III. Severe (uncontrollable, or excessive, vomiting) is characterized by repeated vomiting (up to 20 times or more per day), leading to rapid weight loss, exhaustion, metabolic changes, and dysfunction of vital organs. Severe vomiting is characterized by severe weakness, agitation or apathy, low-grade fever, tachycardia, lowering blood pressure, the appearance of acetone, protein and cylinders in the urine. Often with severe vomiting, jaundice occurs, in rare cases, toxic liver dystrophy develops. Treatment of vomiting of pregnant women of the I degree of severity is carried out on an outpatient basis with the control of the dynamics of weight gain of the pregnant woman and regular urine tests for acetone. A diet with frequent, fractional meals, rinsing the mouth with astringents is prescribed, frequent walks in the fresh air are recommended, acupuncture is prescribed. Treatment of vomiting of pregnant women II and III severity is carried out in a hospital. A complex treatment is prescribed, the purpose of which is to normalize the functions of the central nervous system, restore the loss of nutrients and fluids, correct electrolyte balance and acid-base balance. Termination of pregnancy is performed in case of treatment failure, with persistent subfebrile body temperature, severe tachycardia, progressive weight loss, proteinuria, cylindruria, acetonuria, jaundice. hypersalivation often present with vomiting of pregnant women, but sometimes it can be in the form of an independent form of early toxicosis of pregnant women. With severe salivation, the loss of saliva per day can reach 1 liter or more. Abundant salivation has a depressing effect on the psyche of a pregnant woman, leads to dehydration, hypoproteinemia, sleep disturbance, loss of appetite and body weight. Sometimes there is maceration of the skin and mucous membranes of the lips. Treatment of hypersalivation is advisable to carry out in the clinic. In this case, atropine and local infusion of astringent and antiseptic herbs (oak bark, chamomile, sage) are used. Severe hypoproteinemia is an indication for plasma transfusion. Hypnosis and acupuncture are used as auxiliary methods. A special form of early preeclampsia is jaundice due to cholestasis (cholestatic hepatitis). This form of toxicosis occurs rarely, as a rule, occurs at the beginning of the second trimester of pregnancy and progresses as its duration increases. It is characterized by a predominant lesion of the liver, often accompanied by itching of the skin, an increase in cholesterol and alkaline phosphatase activity in the blood with normal alanine aminotransferase activity. This form of gestosis is often complicated by premature termination of pregnancy, bleeding during childbirth, and the formation of fetal malformations. When the pregnancy is terminated, jaundice disappears, but may recur in subsequent pregnancies. The differential diagnosis is carried out with jaundice that occurred during pregnancy due to viral hepatitis, cholelithiasis, intoxication of the body, hemolytic anemia. Treatment is carried out in accordance with the general principles of hepatitis treatment. A diet, vitamins, glucose, protein preparations, etc. are prescribed. Considering the extremely serious significance of liver damage during pregnancy, primarily for a woman, the question of its premature termination is often raised. Early toxicosis of pregnant women can also be expressed in some forms of dermatosis. The most common is pruritus. It can appear at the beginning and end of pregnancy, it can be local and limited to the vulva or spread throughout the body. Itching can be pronounced and constant, which worsens the well-being and mood of the pregnant woman. Perhaps the appearance of insomnia, irritability. With this form of toxicosis, it is necessary to exclude diseases accompanied by pruritus. It is necessary to exclude diabetes mellitus, fungal and parasitic skin lesions, trichomoniasis, helminthic invasion, an allergic reaction, etc. Treatment is reduced to the appointment of agents that regulate the functions of the nervous system, desensitizing agents, and UV radiation. Occasionally, dermatosis manifests itself in the form of eczema, herpes, impetigo herpetiformis. With impetigo herpetiformis, the likelihood of perinatal mortality is high. These dermatoses are treated in the same way as in the absence of pregnancy. Tetany is one of the rare forms of pregnancy toxicosis. Its cause is a violation of calcium metabolism in pregnant women. A manifestation of this form of toxicosis is the occurrence of muscle spasms of the upper and lower extremities, the face. It is also necessary to take into account the possibility of manifestations of hypoparathyroidism in connection with pregnancy. Calcium preparations are used to treat this form of toxicosis. An even rarer form of early toxicosis of pregnant women is bronchial asthma. It should be differentiated from exacerbation of previously existing bronchial asthma. Treatment includes the appointment of calcium preparations, sedatives, a complex of vitamins, general UVI. Pregnant women who have undergone early toxicosis need careful outpatient monitoring, since they often later develop late toxicosis. Late toxicosis of pregnant women Toxicosis that develops after 20 weeks of pregnancy is called late or toxicosis of the second half of pregnancy. In the 1990s this term has been replaced by the term "OPG-preeclampsia" (edema, proteinuria, hypertension). OPG-preeclampsia is a syndrome of multiple organ failure resulting from the development of pregnancy. The causes of this pathology have not yet been clarified enough. The immunological theory explains the occurrence of symptoms of OPG-preeclampsia by the reaction of the body of a pregnant woman to fetal antigens. In this case, the formation of autoimmune complexes that activate the kinin system occurs. Subsequently, arterial hypertension occurs. In addition, hemocoagulation increases, accompanied by the deposition of fibrin, impaired blood supply to the placenta and organs of the pregnant woman. The immune theory of the occurrence of OPG-preeclampsia is confirmed by the detection of subendothelial complement deposits, immunoglobulins G and M in the kidneys of a pregnant woman. Generalized vasospasm with subsequent or simultaneous development of hypovolemia is important in the development of OPG preeclampsia. According to most scientists, the primary is a violation of the uteroplacental circulation, after which a spasm of peripheral vessels occurs, as a result of which the volume of the vascular bed decreases, and hypovolemia occurs. V. N. Sterov and co-authors believe that there are two main reasons for the development of OPG-preeclampsia: diffusion-perfusion insufficiency of uteroplacental circulation and the presence of extragenital pathology in a pregnant woman, primarily circulatory disorders in the kidneys. In both cases, there is a syndrome of multiple organ failure with a different clinic and consequences. Mixed forms of OPG-gestosis are possible, in which several systems are affected simultaneously. For all the reasons for the development of OPG-gestosis, there is a violation of the functions of the placenta. Uteroplacental perfusion sharply decreases: with a full-term physiological pregnancy, it is 162 ml/min per 100 g of placental tissue, with OPG-gestosis - only 59 ml/min per 100 g of placental tissue. This is mainly due to a decrease in pulse blood pressure and deterioration of venous outflow. With a mild course of OPG-gestosis, perfusion disturbance is eliminated by increased cardiac activity of the pregnant woman and an increase in blood pressure. With an increase in the symptoms of OPG-preeclampsia, hypoxia and acidosis develop in the mother's body. They lead to a continued decrease in uteroplacental perfusion, which can have consequences such as hypoxia, malnutrition and fetal death. Obesity, multiple pregnancies, polyhydramnios, stress, physical stress are additional factors contributing to an increase in uteroplacental perfusion disorders. In the position of a woman lying on her back, the uterus presses the inferior vena cava, which impairs perfusion. Vascular disorders resulting from the development of OPG-gestosis disrupt the diffusion capacity of the placenta. The process is also enhanced by the activation of lipid peroxidation. The products of incomplete breakdown of fats cause damage to cell membranes, which leads to a sharp deterioration in gas exchange, disruption of the barrier, filtration and purification, endocrine, immune and metabolic functions of the placenta, in which areas of thrombosis, ischemia, hemorrhages and edema begin to form. As a result of these changes in the placenta, the needs of the fetus are not fully met, and its development is delayed. In the placenta, the synthesis of estrogens and progesterone, which contribute to the normal development of pregnancy, decreases. Basically, violations of perfusion and diffusion functions are associated with each other. Expressed perfusion-diffusion insufficiency of the placenta in severe form of OPG-preeclampsia V. N. Sterov and co-authors call shock placenta syndrome. There is a more frequent development of OPG-gestosis during repeated births, if signs of it were observed in previous pregnancies, as well as in women with urinary system disease, hypertension, and diabetes mellitus. Clinical picture and diagnosis. Clinical manifestations of OPG gestosis are as follows: significant increase in body weight, the appearance of edema, proteinuria, increased blood pressure, convulsions and coma. OPG-preeclampsia manifests itself in four clinical forms. These are dropsy, nephropathy, preeclampsia and eclampsia. Dropsy pregnant women is expressed in the appearance of pronounced persistent edema in the absence of proteinuria and normal blood pressure. Initially, edema may be hidden (positive symptom of the ring, McClure-Aldrich test), there is an excessive increase in body weight. Further, visible edema appears on the lower extremities, in the vulva, trunk, upper extremities and face. The general condition of a pregnant woman usually does not suffer. Pregnancy in most cases ends with delivery on time. Sometimes nephropathy of pregnant women develops. Nephropathy pregnant women are three main symptoms: proteinuria, edema, increased blood pressure. Allocate III severity of nephropathy. I. Edema of the lower extremities, blood pressure up to 150-90 mm Hg. Art., proteinuria up to 1 g / l - I degree. II. Edema of the lower extremities and anterior abdominal wall, blood pressure up to 170/100 mm Hg. Art., proteinuria up to 3 g / l - II degree. III. Severe edema of the lower extremities, anterior abdominal wall and face, blood pressure above 170/100 mm Hg. Art., proteinuria more than 3 g / l - III degree. The onset of preeclampsia and eclampsia can occur with II and even with I degree of severity of nephropathy. When prescribing treatment for nephropathy in pregnant women, it is also necessary to take into account the degree of impairment of the state of the cardiovascular, urinary systems, kidneys, and liver function. The severity of nephropathy is characterized by an increase in diastolic and a decrease in pulse pressure, as well as asymmetry in blood pressure. Further development of preeclampsia leads to an increase in hemodynamic disturbances: the volume of circulating blood decreases, central and peripheral venous pressure decreases, the value of cardiac output decreases, peripheral vascular resistance increases, and metabolic changes in the myocardium increase. To accurately determine the degree of proteinuria, the daily excretion of protein in the urine is determined. It increases with the progression of preeclampsia and in severe nephropathy exceeds 3 g. A violation of the concentration function of the kidneys can be assumed from stable hypoisosthenuria (urine specific gravity - 1010-1015) in the study according to Zimnitsky. With worsening preeclampsia, diuresis decreases, the nitrogen excretion function of the kidneys decreases (the urea content in the blood reaches 7,5 mmol / l or more). At the same time, there is a decrease in the amount of protein in the blood plasma (up to 60 g / l or less). The development of hypoproteinemia is associated with several reasons, one of them is a violation of the protein-forming and antitoxic functions of the liver and a decrease in the colloid-oncotic pressure of the blood plasma. An increase in the permeability of the vascular wall and, as a result, the appearance of protein in the extracellular space can also be the causes of hypoproteinemia. The more severe the gestosis, the lower the protein content in the blood plasma. The severity of preeclampsia is indicated by its early onset and prolonged course, as well as severe thrombocytopenia and fetal malnutrition. In severe nephropathy, there is a high probability of premature detachment of the placenta, premature birth, intrauterine death of the fetus. Nephropathy can result in preeclampsia and eclampsia. Preeclampsia. It is characterized by signs associated with dysfunction of the central nervous system. according to the type of hypertensive encephalopathy (cerebrovascular accident, increased intracranial pressure and cerebral edema). Excitement of patients is noted, less often drowsiness. Against the background of high blood pressure, a woman experiences headaches, dizziness, and blurred vision (flickering spots before her eyes). Phenomena of hypertensive angiopathy of the retina are noted. Some pregnant women experience pain in the epigastric region, nausea, and vomiting. At this time, hemorrhages in the brain and other vital organs are possible. Sometimes premature birth, premature placental abruption, and fetal death occur. As the clinical manifestations of gestosis increase, cerebral circulation is disrupted. As a result, convulsive readiness appears, eclampsia occurs - convulsions and loss of consciousness. Eclampsia occurs most often against the background of preeclampsia or nephropathy. It is characterized by convulsions and loss of consciousness. A seizure in eclampsia may have a sudden onset, but in most cases it is preceded by symptoms of preeclampsia. It develops in a certain sequence. The first stage lasts 20-30 s. At this time, small fibrillar contractions of the muscles of the face are noted, which then pass to the upper limbs. The second stage lasts 15-25 s. It is characterized by the appearance of tonic convulsions of all skeletal muscles, while there is a violation or complete cessation of breathing, cyanosis of the face, dilated pupils, loss of consciousness. At the onset of the third stage, lasting 1-1,5 minutes, tonic convulsions turn into clonic convulsions of the muscles of the trunk, then the upper and lower extremities. Breathing becomes irregular, hoarse, foaming at the mouth, stained with blood due to biting the tongue. The fourth stage is characterized by the fact that after the cessation of seizures, the patient falls into a coma (usually lasts no more than 1 hour, sometimes several hours or even days). Consciousness returns gradually, amnesia is noted, the patient is worried about headache, weakness. Sometimes the coma persists until a new seizure. A convulsive seizure may be single, or there is a series of seizures up to several dozen, recurring at short intervals (eclamptic status). The more seizures there were, the more often they were, the longer the period of the patient's coma, the more severe the eclampsia and the worse the prognosis. There may be a sudden loss of consciousness, not accompanied by convulsions. Complications of eclampsia include the development of heart failure, pulmonary edema, acute respiratory failure, aspiration pneumonia. There is also brain damage in the form of edema, ischemia, thrombosis, hemorrhage. Perhaps the development of retinal detachment, an acute form of disseminated intravascular coagulation, hepatic and renal failure. With eclampsia, premature detachment of the placenta, termination of pregnancy is not excluded. During respiratory arrest, fetal death may occur due to hypoxia. Therapy of preeclampsia depends on its severity. Treatment of dropsy of pregnancy is based on diet. Limit fluid intake to 700-800 ml and salt to 3-5 g per day. Diets are used in the form of unloading apple or cottage cheese days no more than once a week. In case of nephropathy in pregnant women, sedatives are additionally prescribed (motherwort tincture, Relanium (2,0 ml intramuscularly), phenobarbital (0,05 at night)), desensitizing agents (diphenhydramine 0,1 2 times a day). Antihypertensive drugs are used taking into account individual sensitivity and under regular control of A / D (2,4% eufillin - 10,0 ml intramuscularly, no-shpa - 2,0 ml intramuscularly, clonidine - 0,000075 each, 25% magnesium sulfate - 5,0-10,0 ml intramuscularly). In order to normalize the permeability of the vascular wall, askorutin is prescribed - 1 tablet 3 times a day, calcium gluconate - 0,5, 5% ascorbic acid - 2,0 ml intravenously. Reflexotherapy, electrotranquilization have a good effect. Hypovolemia is corrected using infusion therapy (10-20% albumin - 100,0 ml intravenously, hemodez - 400,0 ml intravenously). To restore water-salt metabolism, diuretics are used in the form of herbs (decoction of bearberry leaves), veroshpiron - 1 tablet 2-3 times a day, lasix - 40 mg intravenously. Methionine, folic acid, asparcam are used to normalize metabolism. For prophylactic and therapeutic purposes, in the event of intrauterine hypoxia and fetal hypotrophy, nootropic drugs are prescribed - piracetam - 5,0 ml intravenously, ambrobene, hormones, tocolytics. To improve the rheological and coagulation properties of blood, antiplatelet agents are prescribed: chimes 1 tablet 2-3 times a day, as well as reopoliglyukin - 400,0 ml intravenously, trental - 2,0 ml intravenously, antioxidants (vitamin E - 200 mg 1 time, Essentiale - 1 capsule 3 times a day). The immunomodulator Derinat is administered in the form of 10,0 ml of a 0,25% solution, 1 drop into the nose up to 8 times a day for 3-5 days, or 5,0 ml of a 1,5% solution intramuscularly from 3 to 5 -8 injections. Therapy of preeclampsia and eclampsia requires a special approach. The basic principles were developed by V. V. Stroganov. 1. Creation of a medical and protective regimen, including rest, sleep and rest. 2. Carrying out activities aimed at normalizing the functions of the most important organs. 3. The use of medications to eliminate the main manifestations of eclampsia. 4. Fast and gentle delivery. All activities are carried out in the intensive care unit by an obstetrician-gynecologist together with an anesthesiologist-resuscitator. All manipulations (injections, measurement of blood pressure, catheterization, vaginal examination) are carried out under anesthesia. Eclamptic status, eclampsia in combination with large blood loss, the development of symptoms of cardiopulmonary insufficiency, eclamptic coma are regarded as absolute indications for mechanical ventilation. In these cases, it is necessary to prescribe glucocorticoids: hydrocortisone hemisuccinate (500-800 mg per day) or prednisolonehemisuccinate (90-150 mg per day) with a gradual dose reduction. Artificial ventilation of the lungs is carried out in the hyperventilation mode until, without anticonvulsant therapy, there is no convulsive readiness for 2-3 days, the patient is in contact, blood pressure stabilizes, and there are no complications from the respiratory system. To prevent the onset and development of acute renal and renal-hepatic insufficiency, inflammatory-septic diseases, blood loss is mandatory during childbirth (with caesarean section - in the early postpartum period). In addition, it is advisable to conduct active antibiotic therapy. In renal and hepatic insufficiency, extracorporeal detoxification methods (hemodialysis, hemosorption, plasmapheresis), hemoultrafiltration are carried out. Delivery at term and the use of complex therapeutic effects can reduce mortality in eclampsia. Forecast depends on the severity of OPG-gestosis. The prognosis can be very doubtful in eclampsia, especially with the development of eclamptic coma against the background of cerebral edema, the appearance of ischemia and cerebral hemorrhages. Mortality in eclamptic coma can be 50%. Prevention consists in the early detection of diseases of various organs and systems, especially the cardiovascular, urinary and endocrine systems before pregnancy, timely treatment and careful monitoring of a pregnant woman with the above diseases throughout the entire period of pregnancy. Particularly noteworthy are women at risk for OPG-preeclampsia on an outpatient basis. An obstetrician-gynecologist should examine these patients at least once every 1 weeks in the first half of pregnancy and once a week in the second half. One of the important preventive measures is the timely detection and treatment of pretoxicosis. It is characterized by such features as asymmetry of blood pressure in the arms (difference of 10 mm Hg or more in the sitting position), pulse pressure of 30 mm Hg. Art. and less, a decrease in the oncotic density of urine, a decrease in daily diuresis to 900 ml, slight proteinuria and excessive weight gain. Lecture number 18. Uterine bleeding during pregnancy The most common cause of bleeding from the genital tract during pregnancy is its premature termination - spontaneous miscarriage (abortus spontaneus) or artificial miscarriage (abortus artificialis). Premature termination of pregnancy Abortion (abortus - "miscarriage") - termination of pregnancy during the first 28 weeks. Termination of pregnancy after 28 weeks (up to 38 weeks) is called preterm birth (partus praematurus). Spontaneous abortion. It is the most common obstetric pathology, occurring more often in the 3rd month in approximately 2-8% of pregnant women. The reasons for spontaneous abortion are quite complex and ambiguous. A miscarriage can be the result of not one, but several causes (endocrine disorders, underdevelopment of the uterus, the consequences of inflammatory diseases, infections, etc.), acting simultaneously or sequentially. Disturbances in the development of the reproductive system and various dysfunctions of the hypothalamus-pituitary-ovarian system are the most common causes of spontaneous abortion. Impaired ovarian function leading to miscarriage can occur due to induced abortions, inflammatory diseases of the female genital organs, and dysfunction of the endocrine glands. Complications arising in connection with induced abortions lead to miscarriage: trauma to the basal layer of the endometrium, isthmus and cervix. Infectious diseases in acute form (influenza, measles, rubella, scarlet fever, infectious hepatitis, etc.) often lead to termination of pregnancy. One of the reasons for miscarriage (spontaneous abortion and premature birth) is isthmic-cervical insufficiency of an organic nature (trauma during abortion, pathological birth). Functional isthmic-cervical insufficiency associated with endocrine disorders is observed less frequently. Often the causes of miscarriage are malformations of the uterus, neoplasms of the genital organs (uterine fibroids, ovarian cystomas) with the appropriate size and location, as well as concomitant neuroendocrine and other disorders. Chronic intoxication (nicotine, gasoline, lead, mercury, aniline compounds, etc.) often leads to fetal death and miscarriage. Clinic and course. During an abortion, the fertilized egg gradually peels off from the walls of the uterus, which is accompanied by damage to the vessels of the decidua. In this case, bleeding occurs, the severity of which depends on the degree of detachment of the ovum and the diameter of the damaged vessels. Under the influence of the contractile activity of the myometrium, the exfoliated fertilized egg is expelled from the uterine cavity, less often as a whole, more often in parts. Contractions of the uterus, promoting the expulsion of the fertilized egg, are felt as cramping pain. The following stages of abortion are distinguished: threatened abortion, started abortion, ongoing abortion, incomplete abortion, complete abortion, delayed (failed) abortion. Slight pulling pains, a feeling of heaviness in the lower abdomen in the absence of bleeding indicate a threat of abortion. The size of the uterus corresponds to the gestational age. The external os is closed. The abortion that has begun is characterized by the appearance of cramping pains and small bloody discharge due to the detachment of some part of the fetal egg from the uterine wall. The size of the uterus corresponds to the gestational age, the cervical canal is closed. With a threatening and incipient abortion, pregnancy can be maintained. Abortion in the course is characterized by the fact that contractions intensify and become painful, bleeding increases. The cervix shortens, the cervical canal opens, the fetal egg, exfoliated from the walls of the uterus, is pushed out of it. Bleeding becomes severe and often reaches an alarming degree. Preservation of pregnancy is impossible, the fetal egg is removed as a matter of urgency. Incomplete abortion is characterized by the fact that not all of the fetal egg is expelled from the uterus, but only the fetus and part of the membranes depart. The remaining parts of the ovum interfere with a good contraction of the uterus. The cervical canal is somewhat open, the size of the uterus is less than the gestational age. Bleeding continues and can be very heavy. Complete abortion in early pregnancy is much less common than in later periods. With a complete abortion, no elements of the fetal egg remain in the uterus, it contracts, the cervical canal closes and the bleeding stops. Modern methods of diagnosis and treatment allow in 80-90% of cases to detect the cause of premature termination of pregnancy and prescribe adequate therapy that will help maintain pregnancy. Currently, for the treatment of threatening abortion, a complex etiotropic, pathogenetic and symptomatic effect is used. For this purpose, sedative therapy is carried out, which helps to reduce emotional excitability, relieve anxiety and anxiety in a pregnant woman. The appointment of antispasmodic and tocolytic agents causes a decrease in the contractile activity of the uterus. Antiplatelet agents, angioprotectors, anticoagulants contribute to the normalization of microcirculation and rheological properties of blood. With insufficient function of the corpus luteum and the production of progesterone, replacement therapy with progesterone analogues is carried out. Glucocorticoid hormones are prescribed for autoimmune disorders and hyperandrogenism. Antimicrobial and immunostimulating drugs are indicated when infectious processes occur. The use of complex methods of therapy helps to reduce the contractile activity of the uterus and normalize impaired uteroplacental circulation. At the same time, these women make up a certain percentage of the risk group for the development of chronic fetoplacental insufficiency, possibly premature birth and premature detachment of a normally located placenta. Bleeding in the early postpartum period. Bleeding from the birth canal that occurs in the first 4 hours after delivery is called early postpartum bleeding. Bleeding after childbirth can be caused by various reasons: 1) retention of part of the placenta in the uterine cavity; 2) hypotension or atony of the uterus; 3) rupture of the soft tissues of the birth canal; 4) dysfunction of the blood coagulation system (hypo- and afibrinogenemia). Hypotension of the uterus - This is a pathological condition characterized by a sharp decrease in the tone and contractility of the uterus. As a result of ongoing activities and drug therapy that stimulate the contractile function of the uterus, the myometrium is reduced, but often the strength of the contractile reaction is inadequate to the strength of the effect. Uterine atony - this is a formidable complication that can accompany labor. At the same time, drugs and ongoing activities do not have any effect on the uterus. The state of the neuromuscular apparatus of the myometrium is regarded as paralysis. Atony of the uterus occurs very rarely, but causes profuse bleeding. Causes hypotonic and atonic bleeding are diverse: 1) violation of the neurohumoral regulation of the contractile function of the uterine muscles as a result of the exhaustion of the forces of the body of the puerperal and especially her nervous system during prolonged and complicated childbirth; 2) severe forms of preeclampsia (nephropathy, eclampsia), hypertension; 3) anatomical features of the uterus: infantilism and malformations of the uterus (double, bicornuate uterus), tumors (myoma) of the uterus, scars on the uterus after surgery, extensive inflammatory and degenerative changes after past inflammatory diseases or abortions; 4) functional inferiority of the uterus, prolonged overstretching of the uterus with polyhydramnios, multiple pregnancies, large fetuses; 5) rapid emptying of the uterus during operative delivery, especially after the application of obstetric forceps, is often accompanied by hypotonic bleeding due to the fact that the uterus does not have time to contract due to rapidly changing conditions; 6) presentation and low attachment of the placenta, especially in the presence of an extensive placental area; 7) adhesive processes in the abdominal cavity, especially adhesions of the uterus with adjacent organs, interfere with the normal contractile activity of the uterine muscles. The cause of hypo- and atonic bleeding may be a combination of several causes. Clinic. The leading symptom of hypotonic bleeding is massive bleeding from the uterus in the postpartum period. In addition, symptoms develop due to hemodynamic disturbances and acute anemia. A clinical picture of hemorrhagic shock appears. The condition of the woman in these cases is due to the massiveness and duration of bleeding. Physiological blood loss during childbirth does not exceed 0,5% of a woman's body weight (but not more than 450 ml). In women with anemia, preeclampsia, diseases of the cardiovascular system, even a slight excess of the physiological norm of blood loss can cause a severe clinical picture. The severity of clinical manifestations depends on the intensity of bleeding. With significant blood loss (1000 ml or more) that has occurred for a long time, the symptoms of acute anemia are less pronounced than with rapid blood loss, even in a smaller volume, when collapse can develop faster and death occurs. Diagnostics. The diagnosis of hypotension is made based on existing uterine bleeding and data from its objective examination. With uterine hypotension, pathological bleeding is inconsistent. Blood is released in portions, often in the form of clots. The uterus is flabby, rarely contracts, contractions are rare and short-lived. The uterus is enlarged in size due to blood clots accumulated in it; in some cases, it is poorly defined through the anterior abdominal wall. When performing an external massage, it contracts, and then it relaxes again, and bleeding continues. With atony, the uterus completely loses its tone and contractility, does not respond to mechanical and pharmacological stimuli. The uterus is flabby, poorly palpated through the abdominal wall. Blood flows out in a wide stream or is released in large clots. It is necessary to make a differential diagnosis between hypotonic bleeding and traumatic injuries of the birth canal. With an injury to the birth canal, the contractility of the uterus is not disturbed, the uterus is dense. Inspection of the cervix and vaginal walls in the mirrors, manual examination of the walls of the uterus indicate the presence or absence of ruptures of the soft tissues of the birth canal. With hypo- and afibrinenemia, the uterus is usually in good shape. The blood is liquid, without clots. To diagnose hypo- and afibrinogenemia during bleeding in the early postpartum period, a blood clot dissolution test can be performed. To conduct a test, 2 ml of blood is taken from a vein in a test tube from a healthy woman in labor. After 2-3 minutes, blood clotting occurs. The same amount of blood from the patient's vein is placed in the second tube. In this case, the blood does not clot. If you pour this blood into the first test tube, then the clot formed in it begins to dissolve. Treatment. If a placental defect is suspected and detected, a manual examination of the uterus is performed, and remnants of placental tissue are removed. At the same time, myotonics are administered. In case of hypotonic bleeding, a set of therapeutic measures aimed at stopping the bleeding and replenishing blood loss is immediately carried out. If conservative treatment is ineffective, surgical treatment must be started immediately. These may include transection and hysterectomy. All actions to stop bleeding are aimed at strengthening the contractility of the uterus and are carried out in a certain order: 1) emptying the bladder using catheterization; 2) the introduction of uterine contracting agents (1 ml of oxytocin intravenously slowly); 3) external massage of the uterus: with the palm of the right hand through the anterior abdominal wall, they cover the bottom of the uterus and make light circular massaging movements. In this case, the uterus becomes dense. With gentle pressure on the bottom of the uterus, blood clots that prevent contraction are removed from its cavity. Massage is continued until the uterus is completely contracted and bleeding stops. If, after the massage, uterine contraction does not occur or does not occur completely, and then the uterus relaxes again, then proceed to further measures; 4) an ice pack on the lower abdomen; 5) if the bleeding has not stopped, a manual examination of the uterus is performed, it is massaged on the fist. The external genital organs and hands of the doctor are treated with disinfectants and under general anesthesia the uterine cavity, its walls are examined by hand in order to exclude the presence of trauma and retained placental remnants. Remove existing blood clots that prevent uterine contraction. If after this the contraction of the uterus is insufficient, then it is massaged on the fist. The fist is located in the region of the bottom of the uterus, with the other hand through the anterior abdominal wall, a light massage of the uterus is performed, with an increase in tone, the uterus tightly covers the fist, the bleeding stops. The hand is carefully removed from the uterus. Rough manipulations with the use of force can lead to multiple hemorrhages in the myometrium. Simultaneously with the massage of the uterus on the fist, agents that reduce the uterus (oxytocin, prostaglandins) are injected; 6) to enhance the effect of stopping bleeding, a transverse catgut suture can be applied to the posterior lip of the cervix according to V. A. Lositskaya; 7) introduction of a tampon moistened with ether into the posterior fornix of the vagina. The lack of effect from all the measures taken indicates in favor of the presence of atonic bleeding, which requires emergency surgical intervention. In order to preserve the uterus, if circumstances permit, after opening the abdominal cavity, catgut ligatures are applied to the uterine and ovarian arteries on both sides, wait some time. In some cases, this leads to uterine contraction (hypoxia of the myometrium leads to reflex contraction), bleeding stops, and the uterus is preserved. If this does not happen, especially if there are signs of coagulopathy, then the bleeding cannot be stopped. In such a situation, the only method of saving the life of the puerperal is amputation or extirpation of the uterus. Lecture No. 19. Infusion-transfusion therapy of acute massive blood loss in obstetrics and gynecology Acute blood loss of 30% or more of the BCC within 1-2 hours is considered massive and requires intensive infusion-transfusion therapy, since the protective compensatory mechanisms of the body are untenable. The body responds to massive blood loss with compensatory reactions aimed at stopping bleeding and maintaining an adequate level of blood circulation, ensuring oxygen transport to vital organs and systems. First of all, the heart, lungs, brain, liver, kidneys are provided with oxygen. The activity of the secretory glands of the gastrointestinal tract is suppressed, hence a number of symptoms arise: dry mouth, a practical stop of intestinal motility, a decrease in urination, a collapse of the vessels of the skin and muscles (peripheral vasoconstriction). Along with the listed compensatory reactions, there is an increase in the supply of oxygen to the tissues and an increase in its use. Lymph, interstitial fluid, moves into the bloodstream, blood is diluted - hemodilution. This process does not occur rapidly, therefore, in the first hours of acute massive blood loss, it is impossible to assess its severity, focusing on the concentration of hemoglobin, which decreases during hemodilution. The level of hemoglobin for several hours may remain close to the original, despite heavy bleeding and severe pallor of the skin. Red blood cells enter the bloodstream. There is an autotransfusion of blood components and maximum centralization of blood circulation. Thus, the maximum possible conditions are created to preserve the transport of oxygen and its consumption by tissues. The syndrome of disseminated intravascular coagulation (DIC) accompanies many serious diseases and critical conditions, including massive blood loss. DIC is characterized by two phases: hypercoagulation and hypocoagulation. Pathogenetically, they are due to self-limitation of thrombus formation, since the fibrin precipitated in the thrombus undergoes enzymatic decomposition, and the decay products (degradation) of fibrin (PDF), in turn, themselves have fibrinolytic properties. In this regard, with massive thrombus formation in the hypercoagulable phase of the DIC syndrome, if measures are not taken to eliminate the cause of massive thrombus formation or the process is not stopped by the administration of heparin, a large amount of PDP will soon appear in the blood, which actively dissolve disseminated blood clots. In the opposition of coagulation factors and fibrinolysis, fibrinolysis often predominates due to the depletion of coagulation factors due to the fact that they are used at a high rate in the blood clots that have appeared. There is increased diffuse bleeding. The hypocoagulative phase of the DIC syndrome develops. In such cases, the balance in the coagulation system can be restored, pathological bleeding can be stopped only by emergency transfusion of coagulation factor concentrates or the use of donor fresh frozen plasma. Hypercoagulation syndrome Hypercoagulation syndrome is a state of increased readiness of the blood coagulation system for thrombosis resulting from platelet activation due to intoxication, infections, damage to the vascular wall, hyperthrombocytosis, and increased blood viscosity. The hypercoagulable syndrome, secretly occurring during pregnancy, in the event of acute massive bleeding, consists in increased thrombus formation and is detected, like the DIC syndrome, in the study of a coagulogram. The latent hypercoagulable syndrome does not manifest itself clinically, but there may be a rapid thrombosing of the catheter or needle located in the vein. The severity of manifestation of hypercoagulable syndrome does not always depend on the volume of acute blood loss. Sometimes even a small volume of acute blood loss (10-15% of BCC) in women with increased blood clotting can lead to the development of disseminated thrombosis with a rapid transition to the hypocoagulable phase of the DIC syndrome. In acute massive blood loss associated with vascular damage, there is a sharp activation of the primary platelet link of hemostasis, changes in plasma hemostasis and in the fibrinolysis system. Disbalance in these systems leads to the development of the DIC syndrome. Hypocoagulation phase of DIC syndrome Low shock blood pressure, as a rule, is successfully stopped by the introduction of relatively small doses of colloid solutions (up to 500 ml). If this is not done in a timely manner, then there will be a lot of tissue thromboplastin in the blood, loose platelet clots will turn into fibrin clots, which, undergoing enzymatic decay, will lead to the release of a large mass of PDPs with thrombolytic activity into the blood. With such a vicious circle, the hypocoagulable stage of the DIC syndrome unfolds. At the same time, characteristic accumulations of venous blood appear on pale skin, looking like cadaveric spots. The upper limit of blood pressure is steadily lowered, heart sounds become deaf, the ECG may decrease the height of the T wave. When auscultation of the lungs is determined in some parts of the bronchial tone of the breath. On the radiograph, cloud-like symmetrical shadows are visible - interstitial edema due to stasis of erythrocytes. Often there is a slight increase in the liver. Some time after the end of childbirth or operative delivery by caesarean section, non-clotting blood flows out of the genital tract. Usually in such a situation, an erroneous diagnosis of atonic uterine bleeding is made. The cause of bleeding in such a situation is not poor contractility of the uterus, but the loss of tone of all muscles, including the uterus, as a result of the fact that the blood in all small vessels has coagulated. This condition can be corrected by transfusing immediately and quickly (within 30 minutes) at least 1 L of fresh frozen plasma. The purpose of this transfusion is the rapid and high-quality replenishment of spent plasma coagulation factors, the restoration of blood fluidity. It is not the level of erythrocytes that determines at this time the possibility of avoiding microthrombosis of blood vessels. Understanding this determines the infusion-transfusion tactics for replenishing acute massive obstetric blood loss. Taking into account the possibility of negative consequences of transfusion of a large amount of fresh frozen plasma, at present, already in the early stages of blood loss, a complex of a colloidal solution (preferably a hydroethyl starch solution) and crystalloids in a ratio of 1 : 2 by volume, respectively, should be used instead. Their introduction in an adequate amount quickly and reliably restores hemodynamic parameters and, above all, mean arterial pressure. At the same time, the rheological properties of blood are improved, which ensures more active microcirculation in the affected tissues and organs and the restoration of increased permeability of the walls of blood vessels. If necessary, preparations containing blood coagulation factors, as well as fresh frozen plasma, can be used together with colloidal solutions. An erroneous diagnosis of atonic uterine bleeding often leads obstetricians and gynecologists to perform an abdominal operation (removal of the uterus), which is extremely dangerous in conditions of DIC hypocoagulation syndrome, as it is accompanied by high mortality. Often, an obstetrician-gynecologist is forced to go for a second operation, assuming that a vessel continues to bleed somewhere, since liquid blood is again found in the abdominal cavity shortly after the operation. It should be remembered that during the hypocoagulation phase of the DIC syndrome, bleeding is systemic in nature as a result of a deficiency in the hemostasis system of plasma factors and platelets. Bleeding continues from the uterine cavity due to the fact that it has a wound surface after removal of the placenta. After the extirpation of the uterus, the stitches applied both in the abdominal cavity and on the skin bleed. It is erroneous in such circumstances to transfuse whole blood and red blood cells. In DIC syndrome, the capillaries of the pulmonary alveoli are sharply expanded, filled with accumulations of red blood cells, which leads to impaired oxygen diffusion in the lungs. Blood oxygenation is sharply reduced, and the transfusion of erythrocyte mass leads to an even greater accumulation of erythrocytes in the pulmonary capillaries and not to an improvement in oxygenation, but to its further deterioration. The puerperal at this time has a sharp pallor, not because of the loss of red blood cells, but because of the centralization of blood circulation - spasm and desolation of the vessels of the skin, mucous membranes, muscles. Modern technologies for providing emergency infusion-transfusion care in acute massive blood loss Scheme of carrying out infusion-transfusion intensive therapy in acute massive blood loss. 1. Provide an adequate supply of oxygen. 2. Assess the most important vital signs (pulse, blood pressure, respiratory rate per minute, the patient's adequacy) and, based on the combination of these indicators, determine the severity and approximate volume of blood loss. Allocate IV severity of acute massive blood loss. I degree of severity: blood loss < 750 ml; blood loss < 15% BCC (< 15% BCC); pulse < 100; BP (mm Hg) - norm; pulse pressure (mm Hg) - normal; respiratory rate - 14-20; hourly urine output > 30 ml/h; state of the central nervous system - mild arousal. II degree of severity: volume of blood loss - 750-1500 ml; the volume of blood loss is 15-30% of the BCC; pulse > 100; BP (mm Hg) - norm; pulse pressure (mm Hg) is reduced; respiratory rate - 20-30; hourly diuresis - 20-30 ml / h; state of the central nervous system - excitation. III degree of severity: volume of blood loss - 2500-2000 ml; the volume of blood loss is 30-40% of the BCC; pulse > 120; BP (mm Hg. Art.) reduced; pulse pressure (mm Hg) is reduced; respiratory rate - 30-40; hourly diuresis - 5-15 ml / h; state of the central nervous system - lethargy. IV-th degree of severity: the volume of blood loss> 2000 ml; the volume of blood loss> 40% of the BCC; pulse > 140; BP (mm Hg. Art.) reduced; pulse pressure (mm Hg) is reduced; respiratory rate > 40; hourly diuresis (ml / h) is absent; state of the central nervous system - precoma. 3. Examine blood for group affiliation by erythrocyte antigens. Take blood for a general clinical analysis (Hb, Ht, erythrocytes, platelets), for a biochemical study (creatinine, electrolytes, total protein), for a coagulogram (clotting time, prothrombin, APTT, fibrinogen, clotting time). 4. Then carry out therapy in accordance with scheme 1 or, if the hospital has a solution of "Infucol HES" 6- or 10%, with scheme No. 2. Scheme No. 1. According to the indications, catheterize any available vein and start the infusion of a solution of crystalloids and colloids based on the amount of measured or estimated blood loss. The rate of transfusion of solutions is 100 ml/min until the blood pressure stabilizes at an average level. Calculate the sum of the upper and lower numbers and divide by 3. The result should not be lower than 60. Catheterize the bladder. In the absence of stabilization of hemodynamics, continue the same actions, but by puncturing and catheterizing another vein. With blood loss of 1500 ml (30% BCC) and more appropriate transfusion of up to 1500 ml of fresh frozen plasma without fail. With continued bleeding, a total blood loss of more than 2 liters, instability of hemodynamic parameters, increasing pallor of the conjunctiva and the appearance of congestion, proceed with the transfusion of erythrocytes. If there are no erythrocytes of one group, erythrocytes 0 (I) Rh neg. can be used. Scheme No. 2. With a loss of up to 30% of BCC (1500 ml), to maintain intravascular volume, only the administration of the Infucol HES solution (6- or 10%) is required simultaneously with the transfusion of crystalloid solutions in a ratio of 1: 2. Catheterize the bladder. In the absence of stabilization of hemodynamics with a loss of 50% of the BCC (2500 ml), puncture and catheterize another accessible vein and continue transfusing the Infucol HES solution (6- or 10%) simultaneously with the introduction of crystalloid solutions in a ratio of 1: 2 and 250 ml of erythrocyte masses. With a loss of 75% of the BCC (3750 ml), the Infucol HES solution (6 or 10%) should continue to be administered simultaneously with the administration of 1: 2 crystalloid solutions and coagulation factor preparations or fresh frozen plasma. An increase in blood and plasma viscosity and the appearance of signs of erythrocyte aggregation are an obvious indication for the introduction of a primary or additional dose of the Infucol HES solution. The drug reduces the tendency of erythrocytes to form aggregates, improves blood circulation in peripheral areas under conditions of hypovolemia, restores microcirculation and oxygen delivery to tissues and organs. Lecture number 20. Ectopic pregnancy An ectopic pregnancy is a situation in which a fertilized egg is implanted and develops outside the uterine cavity. This occurs in most cases in the fallopian tubes, sometimes in the ovaries or in the abdominal cavity. Causes of ectopic pregnancy: chronic inflammation of the uterine appendages, abnormalities in the development of the fallopian tubes, adhesions in the pelvic area due to endometriosis, appendicitis, infectious processes after childbirth or abortion, surgical interventions on the fallopian tubes, the use of IUDs, taking minipils and injections of medroxyprogesterone, endocrine violations. tubal pregnancy In tubal pregnancy, the fertilized egg is implanted in the lining of the fallopian tube. At the same time, changes occur in the uterus that are characteristic of a normal pregnancy in the early stages. The cervix, isthmus, body of the uterus increase, but to a small extent. The chorion grows and builds into the wall of the fallopian tube. This is the cause of the bleeding. Blood enters the cavity of the fallopian tube itself, or its wall delaminates. Decidual changes in the endometrium are less pronounced than in normal pregnancy. There are no favorable conditions for the development of the embryo in the fallopian tube, so the pregnancy is terminated. This happens at 6-12 weeks. Termination of pregnancy occurs as a rupture of the fallopian tube or expulsion of the fetal egg into the abdominal cavity (tubal abortion). Depending on the place of development of pregnancy in the fallopian tube, there are ampullar, isthmic, interstitial, fibrial tubal pregnancy. Ampullary tubal pregnancy accounts for 80% of tubal pregnancies. Since the ampullar section of the fallopian tube is its widest part, the fetal egg can reach a significant size. Pregnancy is most often terminated at the 12th week. There is a rupture of the fallopian tube or termination of pregnancy in the form of a tubal abortion, which can be one of the causes of another type of ectopic pregnancy - abdominal, ovarian or fimbria. Isthmic tubal pregnancy accounts for 10-12% of tubal pregnancies. As a rule, it ends with a rupture of the fallopian tube. Since the isthmic part of the fallopian tube is the narrowest part of it, the rupture occurs early enough. In this case, the egg is most often released into the abdominal cavity. If the rupture of the fallopian tube occurs along the line of attachment of the mesentery, the fetal egg is between the leaves of the wide uterine ligament and can develop further. Interstitial tubal pregnancy accounts for about 2% of tubal pregnancies. Due to the high extensibility of the myometrium, interstitial tubal pregnancy can develop up to 4 months. Termination of interstitial tubal pregnancy is accompanied by profuse bleeding, which can quickly lead to the death of a woman. Fimbrial tubal pregnancy accounts for approximately 5% of tubal pregnancies. Diagnosis of ectopic pregnancy Diagnosis of undisturbed ectopic pregnancy is quite difficult. If an ectopic pregnancy is suspected, a woman must be hospitalized for observation, where, if necessary, she will be provided with prompt assistance. If, during repeated examinations, the patient has a lag in the growth of the uterus, and the tumor of the uterine appendages increases in size in the absence of signs of inflammation, the suspicion of an ectopic pregnancy increases. It is possible to palpate an undisturbed ectopic pregnancy after 2-3 months. At the same time, an oblong tumor and a pulsation from the side of the lateral fornix of the vagina are determined on the side of a slightly enlarged and soft uterus. Since most often an ectopic pregnancy is interrupted at the 4-6th week, the diagnosis is practically established after the onset of symptoms associated with its interruption. Diagnosis of interrupted tubal pregnancy With an interrupted tubal pregnancy, a picture of hemorrhagic shock is often observed. Palpation noted soreness and tension in the muscles of the abdominal wall. Abdominal pain is not always severe even in the case of developed hemiperitoneum. Symptoms of peritoneal irritation are positive. During vaginal examination, the overhang of the posterior vaginal fornix is determined due to the presence of accumulating blood in the recto-uterine cavity. With a puncture of the posterior fornix (culdocentesis), blood is obtained. Research in ectopic pregnancy Laboratory studies in ectopic pregnancy are varied. One of the most common studies is the determination of the content of hCG in the blood and urine. A positive result of this test is determined at a very early date. With a normal pregnancy, already in the first 2-3 weeks, the content of the P-subunit of CG doubles every 1,2-1,5 days, and from 3 to 6 weeks - every 2 days. In ectopic pregnancy, the level of the P-subunit of hCG rises more slowly. Thus, if the date of conception is known, an ectopic pregnancy can be suspected by evaluating the result of a single determination of the level of hCG. The level of the P-subunit of hCG is determined repeatedly with an interval of 48 hours. In 85% of cases of ectopic pregnancy, the concentration of the p-subunit of hCG increases by less than 2 times. Of great importance is the determination of the content of progesterone. With a normal onset of pregnancy, the amount of progesterone in the serum is more than 25 mg / ml. US The detection of a fetal egg in the uterus excludes the presence of an ectopic pregnancy, since uterine pregnancy is very rarely combined with an ectopic one. With abdominal ultrasound, the fetal egg is determined in the uterine cavity at 6-7 weeks of pregnancy. When conducting a vaginal ultrasound, you can detect it at 4-4,5 weeks. Diagnostic puncture of the posterior fornix of the vagina (culdocentesis) The detection of dark liquid blood with small clots in the form of dark grains in the rectal-uterine cavity, the corresponding clinical manifestations and an increase in the level of the P-subunit of hCG in the urine and serum are fairly accurate signs indicating an ectopic pregnancy. The advantages of culdocentesis include the speed and relative safety of the manipulation. But it has several disadvantages, which are pain and often questionable results. If the doctor suspected an ectopic pregnancy in a woman, the patient should be hospitalized urgently. Every patient diagnosed with an ectopic pregnancy should be operated on. The patient is usually in critical condition. The severity of the patient's condition is explained not only, and sometimes not so much by blood loss, but by peritoneal shock. Shock and an acute abdomen are indications for surgery. The main tasks are to stop bleeding as soon as possible and fight shock. Clinical observations show that the removal of the ruptured fetus, the remnants of the fetal egg and, if possible, blood from the abdominal cavity is the best way to combat peritoneal shock. After stopping the bleeding, massive infusion-transfusion therapy is carried out. After stabilization of hemodynamics, the fallopian tube is removed. The ovary on the same side may be preserved if it remains intact. In interstitial tubal pregnancy, the tube is removed and the corner of the uterus is necessarily excised, sometimes hysterectomy may be required, which is almost the only indication for surgical intervention for ectopic pregnancy. Diagnostic laparoscopy The pelvic organs are examined. If there are adhesions, then they are separated. Fallopian tubes should be examined very carefully. When the fetal egg is localized in the fallopian tube, it is spindle-shaped thickened. On examination, the integrity of the wall of the fallopian tube is clarified. With a tubal abortion, a fetal egg can be determined in the abdominal opening of the tube or blood clots isolated from the abdominal cavity. When the fetal egg is localized in the isthmic or ampullar sections of the tube, the diameter of the fallopian tube is not more than 5 cm. Laparoscopic surgery is performed. Repeated ectopic pregnancy after salpingotomy occurs in about 20% of cases. After an ectopic pregnancy, the likelihood of subsequent pregnancies is about 60%, but only half of them end in a normal birth. Lecture number 21. Inflammatory diseases of the female genital organs Inflammatory diseases of the female genital organs (VZPO) occupy the first place in the structure of gynecological diseases. About 40% of gynecological patients in the hospital have VZPO. The cause of all inflammatory diseases of the genitals are microbes, which most often enter the body of a woman through sexual contact. The causative agents of infection can also spread by the lymphogenous, hematogenous route, along the intracanalicular route. Factors contributing to the spread of infection are intrauterine interventions: abortion, diagnostic curettage, hysterosalpingography, probing of the uterine cavity, placement and removal of an intrauterine contraceptive. 1. Bacterial vaginosis This disease is caused by a violation of the biocenosis of the normal microflora of the vagina. At the same time, the ratio of aerobic and anaerobic microorganisms changes towards an increase in anaerobes. The main complaint of a woman is an increase in the secretion of whites, sometimes there may be itching (or burning) in the genital area. There are no signs of inflammation in this case. When viewed in the mirrors of hyperemia, there is no swelling of the vagina. The presence of bacterial vaginosis proves a positive aminotest. When a certain component is added to the vaginal discharge, the smell of rotten fish appears. By themselves, the discharge does not smell of anything. Treatment. Since anaerobic flora predominates in the vaginal biocenosis, trichopolum is used. Since the vaginal pH is alkaline, 1-2 douches are performed with solutions of boric acid, citric acid, and potassium permanganate. Frequent douching is not recommended, as this leads to disruption of the biocenosis. Clindomycin has a good positive effect - it is used in the form of a cream and in tablets of 150 mg 3 times a day. A prerequisite for the treatment of all colpitis is the restoration of normal vaginal flora. This is achieved by introducing lactobacilli in the form of tampons with lactobacterin (6-8 tampons - 1 tampon for no more than 4-5 hours). In the presence of hypovitaminosis, vitamin therapy is carried out. 2. Chlamydia infection Chlamydia are gram-negative rods. Currently, it is infection No. 1, it has a lot in common with gonococcus: chlamydia are tropic to the cylindrical epithelium, they are located intracellularly. Chlamydial infection contributes to the massive formation of adhesions in the abdominal cavity and, most importantly, in the ampulla of the fallopian tubes. The main complaint in women will be infertility, often primary infertility. This infection does not have a bright clinical picture - it is erased, oligosymptomatically. For an infection of chlamydial etiology, a symptom of perihepatitis is characteristic, which consists in the formation of hepatic adhesions. This symptom was first noted in gonococcal pelvioperitonitis. Women with chlamydial infection complain of pain in the right hypochondrium, which must be differentiated from exacerbation of chronic cholecystitis, acute cholecystitis, various liver diseases, and in some cases with acute pneumonia. The real cause of these pains is perihepatitis, formed adhesions in the liver, where the pathogen enters the lymphogenous route. Identification of the chlamydia themselves is difficult. If the gonococcus can be seen in Gram smears, then the causative agent of chlamydial infection can only be determined with the help of special studies - by immunofluorescence using immunoclonal antibodies. Due to the fact that chlamydia affects tissues that have a cylindrical epithelium, it is necessary to take discharge from the cervical canal and from the urethra for analysis. Treatment. Chlamydia is sensitive to tetracyclines. Prescribe doxycycline - 0,1 g 2 times a day for 10 days, soluble doxycycline - unidoxolutab; macrolides: erythromycin (0,25 g 4 times a day for at least 7 days), summed (500 mg 1 time a day - 5 days), maropen (400 mg 4 times a day - 7 days), Rulide ( 150 mg 2 times a day - at least 7 days), Klacid (150 mg 3 times a day). To treat infections caused by mycoplasma and ureoplasma, the same medications are used as for chlamydial therapy. The danger of these infections is that they cause infertility, premature termination of pregnancy, postpartum complications - chorioamnionitis, endometritis, metroendometritis. They have a negative effect on the fetus and placenta, causing chlamydial, mycoplasma, and viral pneumonia. 3. Viral infections The herpes virus of the second serotype and the human papillomavirus cause inflammation of the cervix. Cytomegalovirus infection, as a rule, proceeds in the form of carriage, but has a damaging effect on the fetus, causing, in addition to miscarriages, fetal deformities. All viral infections are latent, difficult to treat, prone to relapses and exacerbations. In case of herpes infection during pregnancy, in order to prevent infection of the fetus, delivery is performed by abdominal caesarean section. Diagnose these infections using immunofluorescence microscopy or special sera. Treatment herpetic infection is carried out with antiviral drugs. The damaging effect of acyclovir (zovirax, virolex) affects the synthesis of viral DNA. The drugs are administered not only locally, but also orally or even intravenously. Acyclovir is prescribed in the form of tablets of 200 mg 5 times a day for 2 weeks. Locally applied viferon in the form of suppositories, it increases nonspecific antiviral activity. Neovir is used as an inducer of endogenous interferon. For the treatment of recurrent, difficult to treat genital herpes, famvir (Famciclovir) is used - 250-500 mg 3 times a day. 4. Candida colpitis Caused by fungi of the genus Candida. Mushrooms of the genus Candida are present in the normal microflora of the vagina. During the reproduction of fungi of the genus Candida, mycelium is found in the smear. For candidal colpitis, the presence of white curdled discharge is characteristic. Candidal colpitis is not sexually transmitted. Most often, the cause of the development of candidal colpitis is the uncontrolled conduct of antibiotic therapy, replacement therapy, the presence of hypovitaminosis, hypoestrogenism. Pregnancy can be a provoking factor, as it creates hypoestrogenism. With the development of candidal colpitis, only local treatment is carried out. Treatment. 1-2 douches with acidic solutions are necessary to normalize the vaginal pH. Clotrimazole is used in the form of cream or vaginal tablets. Representatives of econazole (ginotravalen, ginopivoril) are used in the form of vaginal tablets and suppositories. You can use pimafucin in the form of suppositories, which contain the antimycotic antibiotic katamycin. The course of treatment is 10-14 days. Terzhikan and Polygynax are prescribed in suppositories. They contain neomycin, a topical antibiotic. 5. Papillomavirus infection This infection is only transmitted sexually. The virus causes ectocervix, which is small flat warts - papillomas, which are sometimes not visible during colposcopic examination. Cytoscopies revealed poilocytes with air bubbles in the cytoplasm (Ballon cells). This disease is difficult to diagnose and very difficult to treat, since the papillomavirus is not sensitive to the antiviral drugs acyclovir, famvir. The disease is treated with laser and cryodestruction. 6. Specific infections Gonorrhea A specific infectious disease caused by Neisser's gonococcus. Infection occurs through sexual contact with the patient. The incubation period is from 3 to 20 days. Gonococcus infects mucous membranes covered with cylindrical epithelium, therefore, when infected, the primary foci of infection are the mucous membranes of the cervical canal, the urethra with paraurethral passages and the excretory ducts of the large vestibular glands. The pathological process in the area of primary lesions is usually called gonorrhea of the lower part of the female genital organs. The spread of infection in gonorrhea occurs ascending through the mucous membranes, or intracanalicularly. When the gonococcus penetrates beyond the internal os of the cervix, gonorrhea of the upper genital organs, or ascending gonorrhea, develops. This affects the endometrium, fallopian tubes, ovaries and pelvic peritoneum. Often formed abscesses fallopian tubes (pyosalpinx) and ovaries (pyovarium). Distinctive features of gonorrhea in women are quite often a sluggish course of the process, that is, the disease, regardless of the time of the course, is not felt sick (torpid gonorrhea), inflammation in the genitals is almost absent. The second feature of gonorrhea in women is that it often occurs as a mixed gonorrheal-Trichomonas infection caused by gonococci and Trichomonas vaginalis. The association of gonococcus with Trichomonas vaginalis is found in 96% of patients with acute ascending gonorrhea. With a mixed gonorrheal-Trichomonas infection, phagocytosis of gonococci with Trichomonas vaginalis occurs. Trichomonas and gonococci are in a state of endocytobiosis. Mixed infection changes the clinical course of gonorrhea, makes it difficult to diagnose, lengthens the incubation period, and requires multiple laboratory studies with provocations and cultural diagnostics during treatment. A characteristic feature of gonorrhea in women is the development of multifocal lesions. Recognition of gonorrhea is facilitated by the study of anamnestic data: the appearance of the disease 3-4 days after the onset of sexual activity, casual sexual intercourse, the appearance of discharge from the genitals, pain in the lower abdomen after menstruation, fever, the appearance of acyclic bleeding. A clinical study allows you to recognize gonorrhea with a sufficient degree of probability. Examination of the patient begins with examination and palpation of the abdominal wall, examination of the integument of the vulva and the mucous membrane of the vestibule. Determine the condition of the inguinal lymph nodes, their painlessness. When examining the urethra, its swelling, hyperemia of the sponges are noted. Infiltration of the urethra is determined by its palpation. After the massage, discharge appears. Smears are taken after rubbing the sponges of the urethra with sterile cotton wool with a blunt ear spoon or loop inserted to a depth of 0,5-1 cm. The discharge is applied with a thin smear in parallel on two glass slides in the form of the letter "U". The vestibular glands are palpated with the index finger. It is placed behind the hymen, and the thumb of the same hand is placed over the excretory duct. Selections are taken for analysis. The swab is done in the shape of a "B" next to the urethral swab. Pay attention also to the hyperemia of the mouths of the duct of the gland, its compaction, soreness. The vagina is examined in the mirrors. Note the hyperemia of the mucous membranes, the presence or absence of erosion, discharge. Discharge from the region of the posterior fornix is taken with a spoon, and to take material for fungi of the genus Candida, a light scraping is made from the walls of the vagina. Then they examine the cervix, determine the presence of erosion, their location, the nature of the discharge. The cervix is treated with a sterile cotton ball using long gynecological tweezers inserted into the cervical canal to a depth of 0,5-1 cm, parietal mucus is taken and applied to the same glasses in the form of the letter "C". Bimanual examination determines the state of the body of the uterus, its position, size, texture, pain. Next, the uterine appendages are palpated, their size, shape, consistency, soreness and the presence of adhesions are determined. Then, on palpation of the parametrium, the presence of infiltrates and their location are noted. When examining the rectum, attention is paid to the presence of swelling of the folds of the external sphincter, hyperemia, and the nature of the discharge. Wash water is taken with a double current catheter. Lumps of pus and mucus are taken from the resulting liquid with tweezers. They are rubbed between slides or applied to the slides in the form of the letter "R". In view of the difficulty of detecting gonococci during bacterioscopic examination of secretions, sowing is done, and then various types of provocations are carried out in order to detect infection in hidden foci. Several types of provocations are used. Chemical provocation - lubrication of the urethra and the lower segment of the rectum with a 1-2% solution of silver nitrate or Lugol's solution on glycerin, and the cervical canal with a 5% solution of silver nitrate. When carrying out a biological challenge, gonovaccine is administered intramuscularly in a dose of 500 million microbial bodies or pyrogenal (200 MTD) is administered simultaneously with gonovaccine. If before provocation the gonovaccine was used for therapeutic purposes, then a double therapeutic dose is administered, but not more than 2 billion microbial bodies. In a hospital setting, regional administration of gonovaccine is performed under the mucous membrane of the cervical canal and urethra (100 million microbial bodies in total). Thermal provocation involves performing inductothermy for 3 days. The duration of the procedure is 15-20 minutes, while the discharge is taken daily 1 hour after warming up. A physiological provocation is menstruation (smears are taken on the days of heaviest bleeding). The best indicators are observed after a combined provocation: a combination of chemical, biological and thermal. The discharge is collected 24, 48, 72 hours after provocation. The diagnosis of gonorrheal infection is made after the detection of gonococci. Treatment of gonorrhea of the lower genital organs is carried out on an outpatient basis; patients with ascending gonorrhea, as a rule, are treated in a gynecological hospital. The principles of treatment of patients with gonorrhea do not differ from the treatment of patients with inflammatory processes of septic etiology. General therapy (antibacterial, desensitizing, detoxification, etc.) in the subacute and chronic stages is combined with local treatment of lesions. Trichomoniasis (trichomoniasis) A specific infectious disease of the genitourinary organs caused by Trichomonas vaginalis, which are the simplest unicellular organisms from the flagellate class. They only parasitize humans. In the external environment, they are not stable, they quickly die at temperatures above 40 ° C, drying, exposure to disinfectants. The disease is transmitted sexually, very rarely - household. In women, the urethra, the glands of the vestibule of the vagina, and the cervical canal are affected. Often trichomoniasis is combined with gonococcal infection, chlamydia and bacterial urethritis of other etiologies. The duration of the incubation period is from 7 to 14 days or more. The clinic is due to the virulent properties of the microbe, the reactivity of the organism. The disease can have an acute, subacute and asymptomatic course. The diagnosis of chronic trichomoniasis is made after 2 months of illness. There is also asymptomatic trichomoniasis (trichomonas carriers). Trichomoniasis is acute. The vagina is most commonly affected (Trichomonas vaginitis). Usually patients complain of the appearance of yellow foamy liquid discharge, often with an unpleasant odor, itching and burning in the vulva, perineum, inner thighs. When the urethra is affected, patients experience pain and burning during urination. Sexual intercourse is often painful. Without treatment, the intensity of the inflammatory process gradually subsides, the process takes on a chronic course, and may be asymptomatic. With the transition of inflammation to the neck of the bladder, there are frequent urges to urinate and pain at the end of it. Chronic trichomonas urethritis is most often asymptomatic. When the glands of the vestibule of the vagina are affected, they swell, the lumen of the excretory duct closes, and a false abscess is formed. When the cervix is affected, the mucosa is hyperemic, edematous, muco-purulent discharge flows from the cervical canal, which often leads to the development of cervical erosion, especially on the back lip. Due to the ascending inflammatory process, the menstrual cycle may be disturbed, uterine bleeding is possible. Diagnosis of trichomoniasis is made by microscopic examination of discharge from the vagina, cervix and urethra. Treatment. Trichopolum - 5 g (total dose) per course of treatment. Trichopolum has a hepatotoxic effect, so it is recommended to use Flagyl (USA) or Atrican - 250 mg 2 times a day for 5 days. A prerequisite is treatment of the sexual partner, as reinfection is possible. For recurrent or difficult to treat trichomoniasis, the SolkoTrichovak and SolkoU-rovak vaccines are administered - 2 ml every 2 weeks, course - 3 injections. They normalize the vaginal microflora, damage Trichomonas and increase the body's resistance. Tuberculosis of the genital organs Genital tuberculosis is caused by Mycobacterium tuberculosis that enters the genitals from other sources. Most often, the infection comes from the lungs, less often from the intestines, mainly by the hematogenous route. Infection of the genital organs with Mycobacterium tuberculosis, as a rule, occurs in adolescence, but the clinical manifestations of the disease occur during puberty, with the onset of sexual activity or later. Most often, tuberculosis affects the fallopian tubes, uterus, less often the ovaries. Forms of tuberculosis of the genital organs: 1) exudative form, characterized by damage to the tubes and peritoneum with the formation of serous effusion, caseous-serous accumulations; 2) productive-proliferative form. Exudation is weakly expressed, the process of formation of tuberculous tubercles predominates; 3) fibrous-sclerotic form. The late stage of the process, which is characterized by sclerosis of the affected tissues, the formation of adhesions, scars, intrauterine synechia. Clinical manifestations of genital tuberculosis are extremely diverse. Tuberculosis of the appendages and uterus is characterized by a violation of menstrual and generative functions. Violation of the generative function is most often manifested by primary (rarely secondary) infertility. The resulting pregnancy is often ectopic or ends in spontaneous miscarriage. Hypofunction of the ovaries is often observed (insufficiency of both phases of the menstrual cycle, the predominance of violations of the second phase, anovulation), sometimes there is a violation of the function of the adrenal cortex with symptoms of hirsutism. The disease often begins imperceptibly, its symptoms are not very pronounced. Most patients go to the doctor with the only complaint of infertility or menstrual dysfunction. The diagnosis is established as a result of a careful study of the anamnesis, on the basis of clinical data and the use of special research methods. Treatment of genital tuberculosis is complex with the use of specific anti-tuberculosis drugs. Lecture 22 1. Endometritis Endometritis is an inflammation of the lining of the uterus (endometrium). Most often occurs after complicated childbirth, abortion, less often - after diagnostic curettage of the uterine cavity, probing and other intrauterine manipulations. An acute inflammatory process can be caused by a bacterial, viral, fungal, parasitic, mycoplasmal, protozoal and spirochetal infection. It is most often caused by a mixed aerobic-anaerobic association of several microorganisms. Rarely, an isolated lesion of the mucous membrane is observed, most often the muscular membrane of the uterus is also involved in the inflammatory process with the development of myoendometritis. Endometritis Clinic. Signs of the disease usually appear on the 3-4th day after infection. General symptoms of infection are observed: increased body temperature to 38-39 ° C, malaise, weakness, headache, neutrophilic leukocytosis with a shift to the left, increased ESR. Local symptoms appear: pain in the lower abdomen, profuse liquid serous-purulent or bloody-purulent discharge. On vaginal examination, a painful enlarged uterus of dense consistency is revealed. The acute stage of endometritis lasts 8-10 days, and with timely and adequate treatment, recovery is complete. If therapy was prescribed untimely and inadequately, then a transition to a chronic form is possible. Chronic endometritis is characterized by focal inflammatory infiltrates in the uterine mucosa, located around the glands and blood vessels, leading to structural changes in the endometrium - its atrophy, hypertrophy or the formation of small cysts. The ability of the endometrium to perceive hormonal stimulation is impaired, which leads to disruption of cyclic processes and menstrual function. The most pronounced clinical symptom is menstrual irregularity with the development of menorrhagia (hypermenorrhea, polymenorrhea) or metrorrhagia. Premenstrual and intermenstrual bleeding is less common. With chronic endometritis, infertility or recurrent miscarriage often develops, since implantation of the fertilized egg into the altered endometrium is extremely difficult. Clinical symptoms of chronic endometritis are mild. The temperature is usually normal, the patient notes scant mucopurulent discharge, aching pain in the lower abdomen and lower back. On vaginal examination, slight thickening and an increase in the size of the uterus are observed. Diagnosis of chronic endometritis is based on data from the anamnesis, clinic and histological examination of endometrial scraping. Diagnostic curettage is performed on the 8-10th day of the menstrual cycle. Treatment of endometritis. In the acute stage of endometritis, etiotropic therapy is carried out. Antibacterial drugs are prescribed taking into account the sensitivity of the pathogen to them; broad-spectrum antibiotics are most often prescribed. The dosage and duration of antibacterial therapy are determined individually, taking into account the severity of the patient’s condition. In order to suppress anaerobic flora, Trichopolum (Flagyl, Klion) is included in the treatment complex. Depending on the severity of the condition, infusion, desensitizing and restorative therapy is prescribed. Treatment of chronic endometritis is complex, including medications, physiotherapeutic methods of treatment and sanatorium-resort treatment. Postpartum endometritis - inflammation of the mucous membrane of the uterus that occurs after childbirth. With the spread of the inflammatory process to the muscular layer of the uterus, endomyometritis develops. Postpartum endometritis is a type of wound infection, since the inner surface of the uterus after separation of the placenta is an extensive wound surface. Epithelialization and regeneration of the endometrium ends 5-6 weeks after birth. Postpartum endometritis clinic. Clinical manifestations of a mild form of postpartum endometritis appear on the 5-10th day after birth. Body temperature rises to 38-39 °C, mild chills are observed, tachycardia is detected up to 80-100 beats/min. In the blood there is neutrophilic leukocytosis with a shift to the left, an increase in ESR. The general health of the postpartum mother is relatively satisfactory. On palpation, tenderness of the uterus is noted, which persists for several days. The uterus is slightly enlarged, and the discharge of bloody contents continues for a long time. Manifestations of a severe form of postpartum endometritis begin on the 2-4th day after birth. Very often, this complication develops against the background of chorioamnionitis, after a complicated birth or intrauterine intervention. Body temperature rises to 39 °C and above, accompanied by severe chills. The postpartum woman complains of headache, weakness, pain in the lower abdomen. There are sleep disturbances, loss of appetite, and tachycardia up to 90-120 beats/min. Upon examination, subinvolution of the uterus is revealed, and it is painful on palpation. From the 3-4th day, discharge from the uterus becomes cloudy, bloody-purulent, and sometimes becomes foul-smelling. There may be a delay in discharge (lochiometer) as a result of insufficient contraction of the uterus. Treatment of postpartum endometritis. A comprehensive anti-inflammatory treatment is carried out, aimed at localizing the inflammatory process, detoxification, activating the body's defenses and normalizing homeostasis. Before starting treatment, a culture of discharge from the uterine cavity and vagina is performed to determine pathogens and their sensitivity to antibiotics. Sometimes, in the process of treating postpartum endometritis, surgical treatment of the uterine cavity is performed, which includes hysteroscopy, vacuum aspiration of the contents of the uterus, and washing its cavity with chilled antiseptic solutions. The effectiveness of complex intensive therapy for postpartum endometritis is assessed 7 days after the start of treatment. If there is no effect from the therapy, even against the background of a satisfactory condition of the postpartum mother, but with persistent clinical and laboratory signs of inflammation, the issue of removing the uterus is decided. 2. Pelvioperitonitis Inflammation of the peritoneum limited to the pelvic cavity. It develops as a result of the spread of the inflammatory process in the pelvic organs (salpingoophoritis, pyovaritis, torsion of the leg of the ovarian tumor, necrosis of the myomatous node, perforation of the uterus). Pelvioperitonitis is most often a complication after an abortion, childbirth, surgery on the uterus or its appendages. Along the course, acute and chronic pelvioperitonitis are distinguished. In acute pelvioperitonitis, the process is localized in the small pelvis, however, the peritoneum of the upper abdominal cavity also reacts to the inflammatory process. The patient notes sharp pains in the lower abdomen, body temperature rises, dyspeptic symptoms occur: nausea, vomiting, bloating, stool and gas retention, painful urination. There are pronounced signs of intoxication: tachycardia 100-120 bpm, dry furred tongue, sharpened facial features. There are signs of irritation of the peritoneum, the abdominal wall is not involved in the act of breathing, its tension, pain and a positive Shchetkin-Blumberg symptom are noted. All these symptoms are more pronounced in the lower abdomen, weaker - in its upper sections. Dullness of percussion sound is determined in the sloping places of the lower abdomen, associated with the presence of effusion in the abdominal cavity. Intestinal peristalsis is sluggish, gases go badly. Vaginal examination determines the overhang of the posterior fornix, pain on palpation and displacement of the cervix. The uterus with appendages is palpated with difficulty due to severe pain and tension of the anterior abdominal wall. In the blood, neutrophilic leukocytosis with a shift to the left, toxic granularity of neutrophils, increased ESR are detected. With a favorable course of the inflammatory process, after 1-2 days, its delimitation is noted due to the formation of adhesions to the pelvic organs, the omentum and intestinal loops are soldered. If delimitation does not occur, diffuse peritonitis develops with more pronounced clinical symptoms, an increase in intoxication phenomena. When conducting active adequate anti-inflammatory therapy, the process gradually subsides, the exudate is absorbed, the general condition improves, the temperature normalizes, the pain weakens and disappears. However, sometimes the inflammatory process can be complicated by the formation of an encysted abscess in the recto-uterine cavity, which requires surgical treatment. The diagnosis is established on the basis of the clinical picture. It is important to clarify whether there is pelvioperitonitis or diffuse peritonitis. The general condition with pelvioperitonitis is more satisfactory, the symptoms of intoxication are less pronounced than with diffuse peritonitis. Symptoms of peritoneal irritation are more pronounced in the lower sections. During dynamic observation of the patient, a tendency to the spread or localization of the inflammatory process is revealed. In unclear cases, diagnostic laparoscopy is performed. In the process of diagnosis, a mandatory bacterioscopy of the vaginal discharge is carried out to determine the type of pathogen. Sometimes, in order to determine the presence and nature of the existing effusion in the abdominal cavity, they resort to puncturing the abdominal cavity through the posterior fornix. Therapy of pelvioperitonitis is carried out according to the general rules for the treatment of inflammatory diseases, taking into account the specifics of the process. Antibacterial, infusion, detoxification, desensitizing and restorative therapy is carried out. If the causes of pelvioperitonitis were rupture of the pyosalpinx, perforation of the uterus, necrosis of the tumor of the uterus or ovary, then urgent surgical intervention is indicated. 3. Parametric Inflammation of the peritoneal tissue. The reason for the development of parametritis is most often previous intrauterine interventions: childbirth, abortion, supravaginal amputation of the uterus, removal of appendages, diathermocoagulation. Postpartum parametritis most often occurs with ruptures of the cervix and the upper third of the vagina. Infection with parametritis spreads through the lymphogenous route. Diagnosis of parametritis is based on bimanual examination data. The mucous membrane of the vagina during palpation and examination of the vaults is motionless due to infiltration. Due to the existing anatomical features of the parametric fiber (on the one hand it is limited by the uterus, on the other hand by the pelvic wall, from below by the vault of the vagina), the cervix, the uterus itself and the vaginal vault are immobile with parametritis. These features relate to bilateral parametritis. With unilateral parametritis, the cervix is deviated in the opposite direction from the pathological process. The infiltration has a dense, painful, motionless texture, fanning out from the side wall of the uterus to the walls of the pelvis along the anterior or posterior surface. In a severe infection, inflammation can move to neighboring sections of the pelvic tissue. If the inflammation extends to the perivesical tissue, the infiltrate can be located on the posterior surface; when the inflammation passes to the abdominal wall, it takes the form of a triangle with the apex facing the navel. The most common is lateral parametritis. Differential diagnosis is carried out with pyovar, tubo-ovarian abscess, acute salpingo-oophoritis, ectopic pregnancy, torsion of the tumor stem. Therapy of parametritis is carried out according to the general rules for the treatment of inflammatory diseases, taking into account the specifics of the process. Includes antibacterial, desensitizing and restorative therapy. In case of suppuration of the infiltrate, drainage is performed. Lecture number 23. Menstrual disorders Menstrual disorders are a manifestation of various pathological conditions associated not only with disorders in the genital area, but also with general systemic and endocrine diseases. Menstrual disorders are characterized by a change in the cyclicity, duration and volume of menstrual blood loss. Types of menstrual irregularities: 1) menorrhagia, or hypermenorrhea, - regularly occurring uterine bleeding with a volume of more than 80 ml; 2) metrorrhagia - irregular uterine bleeding that occurs at various short intervals; 3) menometrorrhagia - irregularly occurring prolonged uterine bleeding; 4) polymenorrhea - bleeding from the uterine cavity, characterized by regular occurrence after a time interval of less than 21 days; 5) intermenstrual bleeding - this is a varying degree of bleeding intensity that occurs between menstruation; 6) postmenopausal bleeding - bleeding that appeared more than a year after the last menstruation in women with insufficient ovarian function; 7) postcoital bleeding - bleeding after coition; 8) premenstrual bleeding - scanty bleeding of a smearing nature that occurs a few days before the onset of menstruation; 9) postmenstrual bleeding. It has a smearing character, scanty, lasts for several days after the end of menstruation; 10) dysmenorrhea - painful menstruation; 11) primary amenorrhea - the absence of menstruation at the age of 16 years and older; 12) secondary amenorrhea - the absence of menstruation for six months or more after menstruation; 13) oligomenorrhea - rare menstruation that occurs once every 1-2 months; 14) spaniomenorrhea - periodic onset of menstruation once every 1-6 months; 15) hypomenorrhea - scanty menstruation; 16) cystomenorrhea - latent menstruation, clinically manifested by amenorrhea due to infection of the cervical canal, malformations of the genitals or a continuous hymen. Dysfunctional uterine bleeding Dysfunctional uterine bleeding (DUB) is a pathological uterine bleeding caused by a violation of the secretory function of the ovaries (the synthesis of sex hormones) in the absence of pregnancy, inflammatory processes and organic changes in the genital organs, as well as systemic diseases associated with impaired blood clotting. Most often, DMC is combined with chronic anovulation, but sometimes it also occurs against the background of ovulatory menstrual cycles. Violation of the menstrual cycle can be both in the presence of ovulation and anovulation. Menstrual irregularities in the presence of ovulation are most often detected during examination of patients who have consulted a gynecologist for infertility. During the examination, the following violations are most often observed: 1) shortening of the follicular phase of the cycle in the presence of a long luteal phase; 2) shortening or inferiority of the luteal phase of the cycle with a normal or somewhat prolonged follicular phase of the cycle; 3) lengthening of the luteal phase during the normal follicular phase of the cycle. The causes of ovulatory disorders of the menstrual cycle are pathological childbirth, abortion, inflammatory diseases in which the sensitivity of the receptor apparatus of the ovaries and uterus to normal gonadotropic stimulation is impaired. The reasons may also be the consequences of changes in the hypothalamic regulation of the gonadotropic function of the pituitary gland, in which the rhythm of FSH and LH excretion or their normal ratio necessary for ovulation is disturbed. Anovulatory cycles in women are clinically no different from the normal menstrual cycle, since the rhythm of menstruation is usually not changed. Sometimes there is a slight shortening or lengthening of the menstrual cycle, as well as a change in the intensity of blood loss. It is possible to alternate ovulatory and anovulatory cycles. In anovulatory cycles, the mechanism of their occurrence is more often associated with dysregulation of the "hypothalamus - pituitary gland - ovaries" system. With anovulatory cycles, there is no additional release of LH by the pituitary structures in the middle of the menstrual cycle. In view of this, the process of egg maturation is disrupted, ovulation does not occur. Due to the absence of ovulation, the formation of the corpus luteum in the ovaries and the secretion of progesterone in the second phase of the cycle, which is necessary for the secretory transformation of the proliferated endometrium and its normal rejection, do not occur. Anovulatory cycles may be associated with ovarian failure. DMC are anovulatory. This occurs with persistence and atresia of the follicle. With persistence, the follicle reaches the stage of maturity, but ovulation does not occur. The persistent follicle synthesizes a large amount of estrogen. This leads to hyperplasia of the endometrium, which subsequently undergoes rejection due to impaired blood supply and the occurrence of foci of necrosis. Follicular atresia is the process of reverse development of an immature follicle, accompanied by a decrease in estrogen secretion, which stimulates the release of gonadotropins, which cause the growth of a new follicle. When diagnosing pathological uterine bleeding, anamnesis data are taken into account, paying particular attention to the onset of bleeding, frequency, duration and severity, the cyclicity of these bleedings, the presence of pain, and obstetric and gynecological history. Take into account the data of objective and additional methods of examination. The task of differential diagnosis of DUB and organic causes of uterine bleeding is to exclude the presence of a complicated pregnancy (threatening abortion, abortion in progress, incomplete abortion), benign diseases of the pelvic organs (uterine fibroids, endometrial and cervical canal polyps, adenomyosis or endometriosis), malignant tumors of internal genitals. Differential diagnosis of DMC and disorders of the blood coagulation system, as well as somatic pathology, is carried out. Treatment of DMC consists of three stages. The first stage. Its task is to stop bleeding using surgical, hormonal and non-hormonal hemostasis. Surgical hemostasis is a separate diagnostic curettage of the uterus and cervical canal. After diagnostic curettage, the bleeding stops, and based on the results of histological examination (endometrial biopsy), differential diagnosis is carried out with organic pathology of the uterus or the presence of pregnancy. Hormonal hemostasis is the main method in the treatment of DUB in women of any age. This method uses oral contraceptives with different hormone contents: combined, monophasic, oral. Non-hormonal hemostasis is the use of medications to help stop bleeding. This: 1) uterotonic agents (oxytocin, ergotal); 2) drugs that increase the contractile ability of the myometrium (calcium chloride, calcium gluconate, ATP, cocarboxylase); 3) drugs that stimulate the coagulation ability of the blood (etamsylate, transamic acid, aminomethylbenzoic acid); 4) vitamins (ascorbic acid, rutin, vikasol, vitamin E, B vitamins). Non-hormonal hemostasis is usually used in combination with hormonal methods. The second stage - Prevention of relapses, correction of concomitant complications. Prevention of relapses of DMC and correction of associated complications is carried out by hormonal methods, including the appointment of estrogen-progestogen drugs or pure progestogens (dydrogesterone, levonorgestrel-containing IUD, medroxyprogesterone acetate, etc.). The third stage - preservation of fertility and the onset of ovulation in women who wish to become pregnant. Women who want to become pregnant are prescribed ovulation stimulation. Lecture number 24. Endometriosis Pathological process with benign growth in various organs of tissue, morphologically and functionally similar to the endometrium. Endometrial growths undergo the same monthly cyclical changes that occur in normal endometrium. Manifestations of endometriosis can be very diverse, depending on the affected organ, the degree of prevalence of the process, the presence of concomitant pathology and other conditions. Diagnosis and treatment of this disease is very difficult. Causes of endometriosis. Currently, there is no single theory that fully explains the cause of this disease. Genetic predisposition, disorders in the immune and neuroendocrine systems play a role in the occurrence and development of this disease. Types of endometriosis: genital and extragenital. Genital endometriosis is divided into internal and external. With endometriosis of any localization, endometrioid growths are glandular formations that look like small round, oval-shaped foci that are separate or merge with other tissues, the cavities of which contain a thick dark or clear liquid. Endometrioid formations may consist of one or many small cystic cavities. Internal endometriosis Occurs when the body of the uterus is affected, has a diffuse and nodular form. The uterine angles and the posterior wall of the uterus at the bottom are most often affected. It is accompanied by prolonged, painful and profuse menstruation, leading to anemia in patients. A characteristic sign is an increase in the uterus before menstruation and a decrease after it ends. Internal endometriosis is often combined with uterine fibroids and endometrial glandular hyperplasia. For diagnostic purposes, hysterography is performed on the 8-10th day of the cycle or on the 8-10th day after diagnostic curettage. At the same time, the penetration of the contrast mass into the dilated glands of the uterine wall is observed. External endometriosis It includes damage to the cervix, vagina, ovaries, fallopian tubes, pelvic peritoneum, etc. Endometriosis of the cervix The defeat of the cervix is the only localization of endometriosis, which is not accompanied by pain. When viewed in the mirrors, cyanotic areas in the form of eyes are found. Colposcopy and histological examination help clarify the diagnosis. Clinically, the disease is manifested by bloody spotting a few days before and after menstruation. Endometriosis of the ovary It manifests itself in the form of small-point cyanotic formations on the surface of the ovary. More often, cystic cavities are formed, filled with chocolate-colored contents. Hemorrhages in the walls of the cyst, microperforations cause perifocal inflammation, leading to extensive adhesions to surrounding tissues. Endometrioid ovarian cysts cause severe pain, which increases during menstruation. Tubal endometriosis It is less common than ovarian endometriosis. In the thickness of the pipes, dense nodules of various sizes are formed. Sometimes leads to tubal pregnancy. Often found during surgery. Vaginal endometriosis On palpation, a dense, sharply painful infiltrate without clear boundaries is determined. There are pains in the lower abdomen, in the perineum, in the lower back, spotting before and after menstruation. A biopsy helps clarify the diagnosis. Retrocervical endometriosis Occurs quite often. In the posterior fornix, a bumpy, sharply painful, mobility-limited formation is palpated. When viewed in the mirrors, cyanotic areas in the form of eyes are found. Retrocervical endometriosis is characterized by severe pain. Damage to the rectum is noted, the act of defecation is disturbed. Endometriosis of the peritoneum of the uterine rectal cavity is characterized by the presence of sharply painful dense nodules of various sizes. There are very severe pains, especially during menstruation. Extragenital endometriosis The most common localization of extragenital endometriosis is the navel and postoperative scar on the anterior abdominal wall and perineum. Endometriosis of the scar develops most often after gynecological operations on the uterus, therefore, during surgery on the uterus, care should be taken to avoid transplantation of endometrial cells. When examining the navel or scar, cyanotic formations of various sizes are found, from where blood can be released during menstruation. All localizations of endometriosis are characterized by a long progressive course of the disease, the presence of pain, especially pronounced in the premenstrual period or during menstruation. Pain is caused by the fact that in the endometrioid formations associated with the accumulation of blood in the endometrioid growths, there is a swelling of the glandular elements, the release and accumulation of blood. An increase in the size of endometrioid formations before menstruation is also characteristic. Infertility is the most frequent and formidable companion of this disease. About 50% of infertile women suffer from endometriosis. The reasons for the inability to become pregnant in this case are different: a violation of the ovulation process, the formation of adhesions in the pelvis, as well as the inferiority of the endometrium due to changes in the menstrual cycle. Diagnostics. The causes of endometriosis are not clear, but it is definitely established that if the mother and grandmother were ill, then the daughter will most likely have signs of endometriosis. When making a diagnosis, clinical data of the disease are taken into account, and special examination methods are used, such as ultrasound, hysteroscopy, hysterosalpingography, laparoscopy, as well as blood tests for hormonal levels and tumor markers. Endometriosis treatment. An integrated approach to the treatment of this pathology, based on a combination of medical and surgical methods, is considered optimal. For the purpose of drug treatment, hormonal drugs are used, leading to the shutdown of menstrual function for the duration of treatment. In this case, the foci of endometriosis undergo regression. Progestogens are widely used: norethisterone (norkolut, primolutnor), medroxyprogesterone acetate (provera, depo-provera), dydrogesterone (duphaston), linestrenol (orgametril) and others; estrogen progestogen drugs (single-phase oral contraceptives) in a continuous or cyclic mode, danazol (danoval, danol), gestrinone; gonadotropin-releasing hormone agonists (zoladex, decapeptyl-depot, etc.). The last group of drugs gives the best results in treating the disease. Symptomatic therapy consists of prescribing painkillers and hemostatic agents. Surgical treatment consists of removing foci of endometriosis. It is used for nodular forms of endometriosis of the uterine body, endometrioid ovarian cysts, with heavy blood loss and anemia of the patient, and with the failure of hormonal therapy. After surgery, hormonal medications are prescribed for up to 6 months. Recently, laparoscopy has been widely used in the presence of focal forms of endometriosis. Electrocoagulation of endometriosis foci is performed, followed by the administration of hormone therapy. In the postoperative period, restorative treatment is carried out aimed at preventing the development of adhesions and preventing possible complications of long-term hormone therapy. For this purpose, electrophoresis of iodine and zinc, drugs that improve the function of the gastrointestinal tract, liver and pancreas (festal, pancreatin, methyluracil) are prescribed. Complex therapy includes diet therapy, vitamins, sedatives, painkillers, and desensitizing drugs. Unfortunately, therapy for endometriosis, especially in combination with infertility, does not always bring positive results. In such cases, IVF is used to treat infertility. Lecture number 25. Uterine fibroids A benign tumor formed from the muscular and connective tissue of the uterus. The disease is quite common. 15-17% of women over 30 suffer from uterine fibroids. To date, there is no unified theory of the development of uterine fibroids. Most researchers associate its occurrence with hormonal disorders. Others adhere to the infectious theory of development. According to this theory, the formation of fibroids is associated with the IUD, abortion, inflammatory and infectious processes, and sexual transmission. A certain importance is attached to violations of immunological protection. Undoubtedly, the role of genetic predisposition to the occurrence of fibroids. Classification. Based on location, they distinguish between uterine fibroids (occurs in 95% of cases) and cervical fibroids (cervical fibroids - in 5% of cases). In relation to the myometrium, there are three variants of growth of fibroid nodes: intermuscular, or interstitial (the tumor is located in the thickness of the uterine wall), submucosal, or submucosal (fibroids grow towards the uterine cavity), subperitoneal, or subserous (fibroids grow towards abdominal cavity). If the submucosal tumor is located predominantly in the muscular layer, the term “intermuscular uterine fibroid with centripetal growth” is used. A special form of submucosal fibroids are tumors that produce tumors when they grow in the uterine cavity towards the internal os. Long-term growing myomatous nodes lead to smoothing and opening of the uterine pharynx, as a result of which the tumor extends beyond the external opening of the uterus. The clinical picture of uterine myoma depends on the age of the patient, the duration of the disease, localization, size of the tumor and the presence of concomitant extragenital pathology. Often, small uterine fibroids are asymptomatic, while there are no complaints and menstrual dysfunction. The main symptoms of the disease are pain of varying intensity, bleeding (meno- and metrorrhagia), dysfunction of neighboring organs. The most common pain is in the lower abdomen and lower back. Severe prolonged pain most often indicates the rapid growth of the tumor. Acute pain occurs mainly when blood supply to the tumor is disturbed, which can lead to the development of necrosis with a clinical picture of an acute abdomen. Cramping pains during menstruation, as a rule, indicate a submucosal location of the node. Bleeding with uterine myoma are in the nature of hyperpolymenorrhea. With multiple uterine myoma with interstitial arrangement of nodes, the uterine cavity is stretched and its surface is enlarged. This increases the amount of blood lost during menstruation. Particularly severe bleeding occurs with fibroids with centripetal growth and submucosal arrangement of nodes. Such localization is characterized not only by prolonged bleeding, but also by the presence of intermenstrual bleeding with the development of anemia. Fibroids tend to grow slowly. Rapid growth of fibroids refers to an increase in the size of the uterus, approaching the size of a 5-week pregnancy in a year or less. A rapid increase in neoplasm in some cases may indicate the malignancy of the process. Violation of the function of neighboring organs is observed with large tumor sizes, as well as with subperitoneal, cervical and interligamentous arrangement of nodes. The most common complication of uterine fibroids is necrosis of the myomatous node, torsion of the node located on the leg. Necrosis of the myomatous node is accompanied by acute pain, fever, the development of a picture of an acute abdomen. Subserous nodes are most often exposed to necrosis. Torsion of the legs of the myomatous node is a common complication of fibroids. In this case, the nutrition of the tumor is disturbed, dystrophic and degenerative changes, edema occur. It gives the impression of rapid tumor growth. There are acute pains accompanied by peritoneal phenomena. Anemia is another complication. Diagnosis of uterine fibroids. In the early stages of tumor formation, it is not always possible to make a clinical diagnosis of uterine fibroids. Typically, the diagnosis of uterine fibroids is made at an outpatient appointment, taking into account characteristic complaints and data from a bimanual examination, during which an enlarged, dense, tuberous uterus with an uneven, nodular surface is palpated. Reliable results can be obtained by ultrasound scanning of the uterus. This is the most informative method for diagnosing uterine fibroids, allowing you to dynamically monitor the development of the tumor. If the presence of submucosal uterine fibroids or deformation of the uterine cavity due to the centripental growth of the intermuscular node is suspected, hysteroscopy or metrosalpingography is performed. When diagnosing and assessing the effect of therapy, it is necessary to take into account the phase and day of the menstrual cycle, and conduct dynamic examinations and ultrasound scans on the same days of the cycle. Ultrasound scanning data allow you to accurately determine the location, size, condition of myomatous nodes, determine the tactics of managing patients and the extent of surgical intervention. Treatment of uterine fibroids. Indications for surgical treatment of uterine fibroids are: 1) rapid tumor growth; 2) profuse prolonged bleeding leading to anemia; 3) large sizes of fibroids (more than 15 weeks of pregnancy); 4) a tumor of 12-13 weeks of gestation and symptoms of compression of adjacent organs; 5) severe pain syndrome; 6) submucosal uterine fibroids; 7) cervical fibroids; 8) necrosis of the myomatous node; 9) torsion of the legs of the myomatous node; 10) intraligamentary tumor; 11) combination of uterine fibroids with ovarian tumor, endometriosis; 12) infertility due to atypical arrangement of nodes; 13) suspicion of malignant degeneration of fibroids; 14) centripental growth of the myomatous node; 15) a combination of uterine fibroids with a precancerous condition of the cervix. Surgery. Surgical treatment can be conservative or radical. Conservative methods of surgical treatment include laparoscopic myomectomy; hysteroscopic myomectomy, laparotomy with myomectomy. Conservative myomectomy is performed in young women, as a rule, regardless of the size, location and number of nodes. Laparoscopic myomectomy. Removal of nodes while preserving the uterus. Indications: subserous and intramural myomatous nodes with a diameter of more than 2 cm, pedunculated nodes, lack of effect from conservative therapy. Contraindications: all conditions in which an increase in pressure in the abdominal cavity is unacceptable, the presence of three or more myomatous nodes with a diameter of more than 5 cm, the size of the uterus is more than 16 weeks of pregnancy, a myomatous node with a diameter of more than 15 cm. Hysteroscopic myomectomy. Removal of nodes through the vaginal route. Indications: submucosal myomatous node. Contraindications: suspicion of endometrial hyperplasia or adenocarcinoma, infection of the upper and lower genital tract. Laparotomy with myomectomy. It is used when laparoscopic methods are not possible or there are contraindications for their implementation. After conservative surgery, recurrence of new myomatous nodes is possible. Hysterectomy (removal of the uterus). It is a radical surgical treatment method. This type of surgical intervention is indicated in cases where all of the above methods are contraindicated or have proven ineffective. Conservative treatment of uterine fibroids consists of prescribing drugs that inhibit tumor growth and symptomatic drugs to treat complications. To inhibit tumor growth, norcoltoid gestagens (norkolut) are used. It is prescribed in a cyclic regimen of 5 mg per day from the 16th to the 25th day of the cycle for 3-6 months annually. Potassium iodide electrophoresis is periodically prescribed to the suprapubic area. In the prevention of uterine fibroids, measures to prevent damage to the myometrium as a result of abortion and diagnostic curettage play an important role. Reliable methods of contraception can eliminate or reduce medical abortions and, consequently, damage to the myometrium. Good results in the prevention of infectious complications after uterine curettage are achieved by prescribing antibacterial drugs in the pre- and postoperative periods. The basis for the prevention and timely detection of uterine fibroids is regular visits to a gynecologist for examination. Lecture number 26. Multiple pregnancy Multiple pregnancy - the development of two or more fetuses in the uterus at the same time. It is generally accepted that it is an intermediate state between the norm and pathology. The frequency of multiple pregnancy is 0,4-1,6% of all pregnancies. The most common is twin pregnancy. The reasons for the development of multiple pregnancies have not been elucidated. The hereditary factor plays a certain role in the occurrence of multiple pregnancy. Such a pregnancy is more common when a woman or her husband or both spouses are twins. More often, multiple pregnancy occurs in women over 30 years old, which is associated with increased production of a hormone that stimulates the development and maturation of eggs at this age. Often, multiple pregnancy occurs after taking hormonal drugs that stimulate ovulation. A multiple pregnancy that has developed as a result of the fertilization of two or more simultaneously mature eggs leads to the birth of fraternal (dizygotic) or multi-ovarian twins. With the development of two or more fetuses from one fertilized egg, identical (monozygous) twins are born. The birth of identical twins is associated with the fertilization of a multinucleated (2 or more) egg, a nuclear-type division at the stage of crushing a single embryonic germ into parts, from which separate embryos subsequently develop. With the development of identical twins, the placenta, chorion and capsular decidua are common to both fetuses, less often the chorion is separate. The amniotic cavity can be shared (monoamniotic twins) or separate for each fetus (biamniotic twins). In rare cases, both amniotic sacs are enclosed in one chorion common to both twins (monochorial twins). Identical twins are always of the same sex and look very similar to each other, have the same blood type. With fraternal twins, each fertilized egg, after implantation in the decidua of the uterus, forms its own amnion and chorion, and then a separate placenta with an independent network of blood vessels is formed for each fetus. In the case of implantation of fertilized eggs at a considerable distance from each other, the capsular decidua is formed separately for each fetus. When implanting eggs at a close distance, the edges of both placentas are very closely adjacent to each other, the placentas seem to merge into a single whole, but the membranes of the fetus (chorion and amnion) remain separate, they have a common capsular decidua. The course of pregnancy with multiple pregnancy differs in a number of features. In the later stages, pregnant women often complain of fatigue, shortness of breath, heartburn, frequent urination, bloating (flatulence), and constipation. Sometimes there is pain in the back, lower back, pelvic bones. Anemia, gestosis often develop, and varicose veins of the lower extremities occur. One of the most common complications of such a pregnancy is premature birth. Sometimes there is an excessive accumulation of amniotic fluid in the amnion cavity of one or both fetuses, leading to a sharp increase and hyperextension of the uterus, which is accompanied by the appearance of shortness of breath, tachycardia and other disorders. Sometimes polyhydramnios of one fetus is combined with oligohydramnios of another. A large area of the placenta can be the cause of its presentation. Sometimes anastomoses are formed between the vessels of the placentas, uneven supply of nutrients from the common placenta can lead to impaired development (hypotrophy) of one of the fetuses up to its intrauterine death. Often there are fetal malformations (for example, fused fetuses with monoamniotic twins). Most often, incorrect positions of the fetuses are observed. One fetus may be in the head presentation, the other in the pelvic. In other cases, both fetuses are in a breech presentation, or one fetus is in a longitudinal position, the other is in a transverse position. Very rarely (0,5% of cases) both fetuses are in a transverse position. Diagnosis of multiple pregnancy in early pregnancy is difficult. During this period, attention should be paid to an unusually rapid increase in the size of the uterus. There is a discrepancy between the size of the uterus and the gestational age. It is possible to reliably detect the presence of multiple pregnancy already at very early stages (3-4 weeks) using ultrasound. An ultrasound examination of the uterus reveals two or more fetuses, the detection of one placenta indicates the presence of identical twins. In the late stages of pregnancy, especially towards its end, it is much easier to recognize the presence of multiple pregnancies. Signs suggesting the presence of a multiple pregnancy are a rapid increase in the height of the fundus of the uterus and the circumference of the abdomen at the level of the navel over 100 cm, the feeling of fetal movements simultaneously in different localizations. On palpation, small parts of the fetus are determined in different parts of the abdomen, the uterus has a saddle shape, grooves between the fetuses are felt. Of great diagnostic importance are the determination of three (or more) large parts of the fetus, listening to two (or more) distinct heart sounds in different places of the uterus with a difference in frequency of 10 beats per 1 minute or more, as well as the presence of a "zone of silence" between them. An accurate diagnosis of multiple pregnancy can be established by ultrasound examination of the uterus, electrocardiography, fetal phonocardiography, and radiography. Pregnant women with multiple pregnancies should be under the close dynamic supervision of a antenatal clinic doctor. In the II trimester of pregnancy, a woman should visit a doctor at least 2 times a month, in the III trimester at least 1 time per week. The diet should contain a sufficient amount of protein (at least 200 g per day), vitamins, iron. Particular attention should be paid to weight gain, it should not exceed the weight gain during normal pregnancy by more than 50%. In order to prevent premature termination of pregnancy, the appointment of antispasmodics in the I and II trimesters is indicated, and from the 24th week of pregnancy - tocolytic drugs. In the event of a threat of termination of pregnancy, a woman is hospitalized immediately, regardless of the gestational age. At a gestational age of 36-37 weeks, a woman is hospitalized to resolve the issue of the condition of the fetus, prevent possible complications, choose the timing and optimal method for the upcoming delivery. Childbirth with multiple pregnancies is taken by a doctor, since the conduct of such childbirth requires great attention, quick and clear orientation in the emerging obstetric situation, and high qualifications that allow you to perform any operational benefit. Often, childbirth is complicated by the development of primary and secondary weakness of labor due to overstretching of the uterus. Incorrect position and presentation of the fetus, the high location of the presenting part can be the causes of untimely rupture of the fetal bladder. The rapid outflow of amniotic fluid can be complicated by the prolapse of loops of the umbilical cord and small parts of the fetus, the formation of a neglected transverse position of the fetus, and premature detachment of the placenta. Often, the fetuses experience oxygen starvation due to the pathological course of childbirth. In the subsequent and early postpartum periods, hypotonic uterine bleeding is possible as a result of a violation of the contractile activity of the uterus and incomplete detachment of the placenta. Conducting childbirth requires great attention in order to identify the slightest deviations from the normal course. Carefully monitor the condition of the woman in labor and the fetus, the dynamics of childbirth, monitor the function of the bladder and intestines. In the first stage of labor, measures are taken to prevent the weakness of labor activity. For this purpose, estrogens, vitamins, glucose, calcium preparations, ATP and cocarboxylase are administered to the woman in labor. In case of weakness of labor activity, means are used that enhance the contractile activity of the uterus. In case of polyhydramnios or tense fetal bladder, it is recommended to open the fetal bladder of the first fetus, provided that the cervix is 3-4 cm open. The fetal bladder should be opened from the side, above the internal uterine os. Amniotic fluid must be released slowly, without removing the hand from the vagina, in order to prevent the umbilical cord or small parts of the fetus from falling out in loops. The period of exile is carried out expectantly. Carry out the prevention of fetal hypoxia. Active actions are resorted to only in case of complications that threaten the condition of the mother and fetus. Placental abruption before the birth of the second fetus can lead to its intrauterine death. There may be a transverse position of the second fetus, a collision of twins (adhesion of two large parts of the body with the simultaneous entry of the heads of both twins into the pelvis). After the birth of the first fetus, not only the fetal, but also the maternal end of the umbilical cord should be carefully tied up in order to avoid the death of the second fetus from blood loss, which can occur with identical twins. An external obstetric examination is performed, the position of the second fetus, the nature of its cardiac activity are ascertained. Contractions often begin immediately after the birth of the first fetus. In the absence of contractions within 5-10 minutes, it is recommended to open the fetal bladder of the second fetus and start intravenous drip administration of 5 units of oxytocin in a 5% glucose solution in order to accelerate the second stage of labor. In the event of bleeding from the birth canal, the development of hypoxia of the second fetus or its transverse position, for the purpose of rapid delivery, a classic external-internal obstetric rotation of the fetus on the leg is performed, followed by its extraction by the pelvic end. With fused twins, fruit-destroying operations or a caesarean section are performed, depending on the obstetric situation. In modern obstetrics, indications for abdominal delivery in the interests of fetuses have been expanded. Indications for caesarean section in case of multiple pregnancies are the presence of triplets, the transverse position of both or one of the fetuses, the breech presentation of both fetuses or the first of them. Other indications for operative delivery, not associated with multiple pregnancies, are: fetal hypoxia, labor anomalies, prolapse of the umbilical cord, the presence of extragenital pathology of the pregnant woman, severe forms of gestosis, placenta previa and abruption. Particular attention in the III stage of labor is paid to measures to prevent bleeding. Immediately after the birth of the second fetus, the woman in labor is injected with 1 ml of pituitrin intramuscularly or oxytocin (1 ml in 500 ml of 5% glucose solution intravenously at a rate of 40-50 drops per minute). If bleeding occurs, measures are taken to immediately release the placenta from the uterine cavity. For this purpose, external methods for isolating the placenta are used; if they are ineffective, manual separation and allocation of the placenta are performed. The born placenta (afterbirths) are carefully examined in order to determine the integrity of the lobules and membranes and the type of twins (one- or two-egg). The presence of two leaves in the partition separating the fruits indicates their identical origin. In the early postpartum period, drugs are prescribed that stimulate the contraction of the muscles of the uterus, since the involution of the uterus in the postpartum period is slower than after normal childbirth. Carefully monitor the condition of newborns, they are more likely to experience the effects of intrauterine hypoxia and intracranial injury. Lecture No. 27. Intrauterine fetal death. Fruit-destroying operations 1. Intrauterine fetal death Intrauterine fetal death is the death of a fetus during pregnancy or childbirth. Fetal death during pregnancy refers to antenatal mortality, death during childbirth - intrapartum death. The causes of antenatal fetal death can be infectious diseases of a pregnant woman (flu, typhoid fever, pneumonia, pyelonephritis, etc.), extragenital diseases (congenital heart defects, hypertension, diabetes mellitus, anemia, etc.), inflammatory processes in the genitals. The cause of fetal death can be severe OPG-preeclampsia, pathology of the placenta (malformations of its development, presentation, premature detachment) and the umbilical cord (true node), entanglement of the umbilical cord around the fetal neck, oligohydramnios, multiple pregnancy, Rh incompatibility of the blood of the mother and fetus. Fetal death in the intranatal period, in addition to the above reasons, may be associated with traumatic brain injury and damage to the fetal spine during childbirth. The immediate cause of fetal death is most often intrauterine infection, acute and chronic hypoxia, fetal malformations incompatible with life. Sometimes it is not possible to find out the cause of intrauterine death. A dead fetus can stay in the uterine cavity for a long time (from several days to several months) and undergo maceration, mummification or petrification in utero. Most often, maceration occurs (putrefactive wet necrosis of tissues), usually accompanied by autolysis of the internal organs of the fetus. In the first days after the death of the fetus, aseptic maceration occurs, then an infection joins, which can lead to the development of sepsis in a woman. The macerated fruit has a characteristic flabby appearance, soft texture, reddish skin, wrinkled with exfoliated epidermis in the form of bubbles. When infected, the skin turns green. The head of the fetus is soft, flattened, with severed skull bones. The chest and abdomen also have a flattened shape. Congenital atelectasis of the lungs is a reliable sign of intrauterine fetal death. Clinical manifestations of antenatal death of the fetus are the cessation of growth of the uterus, the disappearance of engorgement of the mammary glands. A woman complains of malaise, weakness, a feeling of heaviness in the abdomen, and the absence of fetal movements. During the examination, there is a decrease in the tone of the uterus and the absence of its contractions, palpitations and fetal movements. A sign of intranatal fetal death is the cessation of his heartbeat. If antenatal fetal death is suspected, the pregnant woman is urgently hospitalized for examination. Reliably the diagnosis of fetal death is confirmed by the results of FCG and ECG of the fetus, which register the absence of cardiac complexes, and ultrasound. Ultrasound in the early stages after the death of the fetus determines the absence of his respiratory activity and heartbeat, fuzzy contours of his body, in the later stages, the destruction of body structures is determined. In case of antenatal fetal death in the first trimester of pregnancy, the fetal egg is removed by scraping the uterine cavity. With the death of the fetus in the II trimester of pregnancy and with premature detachment of the placenta, urgent delivery is required. In this case, the method of delivery is determined by the degree of readiness of the birth canal. In the absence of indications for urgent delivery, a clinical examination of the pregnant woman is carried out with a mandatory study of the blood coagulation system, then labor induction is started, creating an estrogen-glucose-vitamin-calcium background for 3 days, after which the administration of oxytocin, prostaglandins is prescribed. In order to accelerate the first stage of labor, an amniotomy is performed. With antenatal death of the fetus in the third trimester of pregnancy, childbirth, as a rule, begins on its own. In case of intranatal fetal death, according to indications, fruit-destroying operations are performed. Fruit-destroying operations (embryotomies) are obstetric operations in which the fetus is dissected in order to facilitate its extraction through the natural birth canal. As a rule, such operations are carried out on a dead fetus. On a live fetus, they are permissible only as a last resort, if it is impossible to give birth through the natural birth canal, with fetal deformities (severe hydrocephalus), severe complications of childbirth that threaten the life of the woman in labor, and in the absence of conditions for delivery by surgery, allowing to save the life of the fetus. Fruit-destroying operations are possible only with full or almost complete opening of the uterine os, true conjugate of the pelvis is more than 6,5 cm. In these operations, the method of choice of anesthesia is short-term endotracheal anesthesia. Fruit-destroying operations include craniotomy, decapitation, evisceration (exenteration), spondylotomy, and cleidotomy. 2. Craniotomy Craniotomy is the operation of breaking the integrity of the fetal skull. Indications for craniotomy are a significant discrepancy between the size of the pelvis of the pregnant woman and the fetal head (hydrocephalus), unfavorable presentation of the fetus (frontal, anterior facial view), threatening uterine rupture, infringement of the soft tissues of the birth canal, the serious condition of the woman in labor, requiring immediate delivery or acceleration of labor, the inability to extract subsequent head during childbirth in breech presentation. Craniotomy consists of three stages: perforation (perforation) of the fetal head, destruction and removal of the brain (excerebration) with subsequent extraction of the fetus. Perforation is performed using a perforator (spear-shaped - Blo or trepan-shaped - Fenomenov). Using a large curette, the brain is destroyed and scooped out (excerbation). The destroyed brain can also be removed by washing out with a sterile solution introduced into the cranial cavity through a catheter, or by vacuum suction. For the operation of craniotomy, you can use a device designed by I. A. Sytnik et al. This device allows you to perform all stages of the operation. It is inserted into the vagina under the control of vision and fingers. A special screw is used to perforate and destroy the substance of the brain, which is sucked off using a vacuum apparatus, after which the reduced head is easily removed. The use of this device makes it possible to exclude the possibility of damage to the birth canal of a woman both with the instrument and the bones of the fetal head. 3. Decapitation Decapitation - separation of the head of the fetus from the body (decapitation). The indication is the running transverse position of the fetus. The operation is performed with a complete or almost complete opening of the uterine os, the absence of a fetal bladder, and the availability of the fetal neck for the obstetrician's hand. Decapitation is carried out with a Brown decapitation hook, consisting of a massive metal rod bent at one end in the form of a hook, ending in a button-like thickening. The other end is a handle that looks like a massive crossbar. A Brown hook applied to the neck of the fetus produces a fracture of the spine, and the head is separated from the body with scissors. Sipping on the handle of the fetus, the torso is removed from the uterus, and then the head is removed. I. A. Sytnik and co-authors designed an instrument (decapitator) that makes it possible to perform all stages of the operation less traumatically. 4. Cleidotomy Cleidotomy - dissection of the clavicle of the fetus. The operation is performed only on a dead fetus in cases where it is difficult to remove the shoulder girdle of the fetus due to the large size of the shoulders, a clinically narrow pelvis. The shoulders linger in the birth canal and thereby suspend the birth of the fetus. Most often, such a complication occurs with a breech presentation, but it can also occur with a headache. 5. Evisceration When the transverse position is running, if it is impossible to separate the fetal head from the body, evisceration is performed - the removal of the internal organs of the fetus. It is performed after a preliminary dissection of the abdominal wall or chest of the fetus. 6. Spondylotomy If, after evisceration, it is not possible to extract the fetus, then a spondylotomy is performed - dissection of the fetal spine in the thoracic or abdominal region. In the production of fruit-destroying operations, there is a high probability of complications associated with the slippage of sharp instruments that are used to produce them. As a result, injuries to the internal genital organs, as well as the rectum and bladder, can occur. To prevent possible injuries, one should strictly observe the caution and technique of performing the operation, and perform all manipulations, if possible, under visual control. Anesthesia should be deep enough to exclude the motor activity of the woman in labor. After carrying out fruit-destroying operations, after the birth of the placenta, a manual examination of the walls of the uterus is mandatory, the vagina and cervix are examined using vaginal mirrors in order to establish their integrity. Bladder catheterization eliminates the presence of damage to the urinary system. Author: Ilyin A.A.
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