Obstetrics and gynecology. Cheat sheet: briefly, the most important

Lecture notes, cheat sheets
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Obstetrics and gynecology. Cheat sheet: briefly, the most important

Lecture notes, cheat sheets

Table of contents

1. Anatomy of the female genital organs

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 hairline at puberty, 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.

The labia minora is a mucous membrane in the form of two folds. They are located inside from the labia majora.

Clitoris 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.

internal sex organs. The vagina is a muscular-fibrous tube 8-10 cm long. It is located in the pelvic cavity, adjacent to the urethra and bladder in front, and to the rectum at the back. The walls of the vagina consist of a mucous membrane, a muscle layer and surrounding tissue. The vaginal mucosa is covered with stratified squamous epithelium, has a pink color and numerous transverse folds, which ensure its extensibility during childbirth. In accordance with the nature of the microflora, it is customary to distinguish between four degrees of purity of vaginal contents. The first degree of purity of the contents is acidic in nature, only vaginal bacilli and individual epithelial cells are found. The second degree of purity of the rods becomes smaller, individual cocci and single leukocytes appear, the reaction remains acidic. The third degree of purity is characterized by an alkaline reaction, the predominance of leukocytes, cocci and other types of bacteria. With the fourth degree of purity, there are no vaginal bacilli; a variety of microbial pathogenic flora and 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.

2. Anatomy of the female genital organs (continued)

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. A narrow cervical canal passes inside the cervix, the upper section of which ends with an internal os, and the lower one with an external one. The cervical canal contains a mucous plug that prevents the penetration of microorganisms from the vagina into the uterus. The walls of the uterus are made up 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, and the surface layer - the functional one, which undergoes cyclic changes. Most of the uterine wall is the middle layer - the muscular (myometrium). 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 fallopian tubes start from the corners of the uterus, go to the sides to the side walls of the pelvis. 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.

Ovaries are paired glands almond-shaped, size. They are located on both sides of the uterus, behind the broad 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. During puberty in the ovaries, the process of maturation and release into the abdominal cavity of mature eggs capable of fertilization monthly rhythmically occurs. 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.

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, infundibulopelvic and proper ovarian ligaments.

Milk glands. During puberty, the mammary gland has a grape-shaped structure and consists of many vesicles - alveoli, forming large lobules. Each milk duct, before exiting to the surface of the nipple, forms an expansion in the form of a sac - a milk sinus. The interlobular spaces are filled with layers of fibrous connective and adipose tissue. The lobules of the mammary glands contain cells that produce secretion - milk. On the surface of the gland there is a nipple, covered with delicate, wrinkled skin and having a conical or cylindrical shape.

3. Physiology of the female reproductive system

The female reproductive system has four specific functions: menstrual, reproductive, reproductive, and secretory.

menstrual cycle Rhythmically repeated complex changes in the reproductive system and throughout the body of a woman are called, preparing her for pregnancy. Changes during the menstrual cycle are most pronounced in the organs of the reproductive system, especially in the ovaries and uterine mucosa. 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 three 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.

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 ampulla 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.

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. 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 the corpus luteum of pregnancy.

uterine cycle. This cycle comes down to changes in the uterine mucosa and has the same duration as the ovarian cycle. 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 endometrial shedding (desquamation) during menstruation ends. The endometrial proliferation phase 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.

4. Anatomy of the female pelvis

The structure of the bone pelvis of a woman is very important in obstetrics, since the pelvis serves as the birth canal through which the fetus is being 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 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 top of the sacrum is movably connected to the coccyx, which consists of four or 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. 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 11 cm.

The diagonal conjugate is determined during vaginal examination, it is equal to 12,5-13 cm. The direct size of the exit of the small pelvis 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 apex coccyx backwards. 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 the posterior perineum.

5. 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.

Migration of a fertilized egg. The fertilized, crushed egg moves along the tube towards the uterus and reaches its cavity on the 6-8th day.

Implantation of a fertilized egg. By the time the fertilized egg enters the uterine cavity, the mucous membrane of the uterus is sharply thickened and loose. Glycogen accumulates in the endometrium due to the influence of the corpus luteum hormone. The mucous membrane 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 fertilized egg is surrounded on all sides by chorionic villi. Gradually, 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 fertilized egg, facing the uterine cavity. On the opposite section of the chorion, immersed in the mucous membrane, the villi grow luxuriantly and at the beginning of the 4th month turn into the placenta. In addition to chorionic villi, the decidua of the uterus (the maternal part of the placenta) takes part in its formation. The placenta releases a complex complex of hormones and biologically active substances into the mother's body. By the end of pregnancy, the placenta has a diameter of 15-18 cm, a thickness of 2-3 cm and a weight of 500-600 g. There are two surfaces in the placenta: internal (fetal) and external (maternal). On the fruit surface, covered with a watery shell, there are vessels radiating from the umbilical cord. The maternal surface consists of 15-20 lobules. The placenta performs the metabolic function between mother and fetus, the barrier function, and is also a powerful endocrine gland. Maternal blood pours into the intervillous space and washes the chorionic villi. The blood of mother and fetus does not mix.

Umbilical cord. It is a cord-like formation in which two arteries and one vein pass. Venous blood flows through the arteries from the fetus to the placenta, and arterial blood flows through the vein to the fetus. The umbilical cord attachment may be central, eccentric, marginal, or tunicale. The normal length of the umbilical cord is on average 50 cm. The placenta 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 secretion by the amnion epithelium, extravasation from the mother’s blood and the activity of the fetal kidneys. By the end of pregnancy, approximately 1-1,5 liters of water accumulates. The waters contain hormones, protein in the amount of 2-4 g/l, enzymes, macro- and microelements, carbohydrates and other substances.

6. 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. 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.

The cardiovascular system. The number of vessels in the uterus increases significantly, and a new (uteroplacental) blood circulation appears. This leads to increased work of the heart. 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 third trimester, the bcc is 1,4-1,5 times higher than the initial one.

Respiratory. By the end of pregnancy, the minute volume of breathing of women in labor increases on average 1,5 times due to an increase in inhalation volume and respiratory rate. Physiological hyperventilation during labor 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, decreased and even distorted taste sensations. Bowel function is characterized by a tendency toward constipation as the bowel is pushed upward and displaced by the gravid uterus.

Urinary organs. They experience the maximum load of excreting metabolic products of the mother and fetus. During pregnancy, the ureters are in a state of hypotension and hypokinesia, which leads to a slower outflow of urine and dilation of the ureters and renal pelvis. Renal blood flow increases during pregnancy.

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 increased irritability, fatigue, drowsiness, rapid mood swings, and decreased attention.

Endocrine system. 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.

Genital organs. The external genitalia, vagina, and cervix loosen, become juicy, easily stretchable, and acquire a bluish color. The isthmus of the uterus softens and stretches especially strongly, which in the 4th month of pregnancy, together with part of the lower part of the uterus, turns into the lower uterine segment. The volume of the uterine cavity increases. The ligamentous apparatus undergoes significant thickening and elongation.

7. Diagnosis of pregnancy

Diagnosis of early pregnancy is made on the basis of the identification of presumptive (doubtful) and probable signs of pregnancy.

Presumable (doubtful) signs. Associated with general changes in the body of a pregnant woman. There is a change in appetite and taste, sense of smell, nausea, sometimes vomiting in the morning, malaise, and irritability.

Possible signs of pregnancy. These are objective changes in the female genital organs, mammary glands, enlargement of the mammary glands and the release of colostrum from them when pressed, bluish coloration of the mucous membrane of the vagina and cervix, enlargement of 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 palpated 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. Aschheim-Tsondek reaction. With the onset of pregnancy, a large amount of chorionic gonadotropin appears in a woman’s urine, the excretion of which reaches a maximum at the 8-11th week of pregnancy. This hormone can be detected in urine from the 2nd day after implantation. A morning sample of urine is taken for testing.

Friedman reaction. To diagnose pregnancy, a mature rabbit aged 3-5 months weighing from 900 to 1500 g is used. 6 ml of urine taken from the woman being examined is injected into the ear vein of a mature rabbit 2 times over 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, changes similar to those found in mice are observed in the ovaries and uterus. After 6-8 weeks if the reaction is positive and after 4 weeks if the reaction is negative, the rabbit can be taken for re-examination. The accuracy of the reaction is 98-99%.

Immunological research methods are based on the detection of human chorionic gonadotropin in the urine of the examined woman.

8. Signs of fetal maturity, dimensions 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. The average body weight of a mature full-term newborn is 3400-3500 g. 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 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. 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 converge.

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.

9. Examination of the 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.

History of current pregnancy, previous pregnancies, chronic diseases

The course of a real pregnancy. Assessed based on the history and medical record of the woman in labor. It is necessary to clarify some data 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.

If the exact date of the last menstruation is not established and there are no data from the antenatal examination, the exact timing of pregnancy becomes more difficult. 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, clarifying in detail all the complaints. It is necessary to pay attention to the diseases in the woman's history.

Examination during 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.

The discharge of amniotic fluid occurs during contractions or before them. 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.

10. Physical examination

General inspection

Basic physiological indicators. The pulse rate is measured, blood pressure is measured in pauses between contractions.

External obstetric examination

Uterus dimensions. By the end of the 1st obstetric month, 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 womb.

By the end of the 9th month (36th week), the fundus of the uterus reaches the xiphoid process and costal arches. By the end of the 10th month (40th week), the fundus of the uterus descends to the level of the 32-week pregnancy. The method of palpation of the uterus determines the approximate size of the fetus, the amount of amniotic fluid.

External obstetric research includes four Leopold's receptions.

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, transverse and oblique.

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. If the pelvic part of the fetus is located above the entrance to the pelvis, the presentation is called breech. Breech presentation can be purely breech, mixed breech, full or incomplete.

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 record heart rate and heart rate variability (acceleration and deceleration).

Conducting a vaginal examination begins with examination and palpation of the perineum and pelvis. When amniotic fluid breaks, the buttocks of the fetus, or the head, or loops of the umbilical cord can be detected during vaginal examination.

11. Physical examination (continued)

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. 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.

Fetal presentation determined by palpation. With an occipital presentation, you can palpate the sutures and fontanels on the fetal head, with a pelvic presentation - determine the buttocks and feet, with a facial presentation - the front of the fetal head.

Fetal position. In the anterior position, the presenting part faces the pubic symphysis, and in the posterior position, it faces the sacrum. Transverse (right or left) position - the presenting part faces the right or left wall of the pelvis. In case of pelvic presentation - along the sacrum of the fetus, in case of facial presentation - according to the location of the chin. In the anterior position of the occipital presentation, the back of the head is turned towards the pubic symphysis. In the right transverse position of the occipital presentation - to the right vaginal wall.

Examine the pelvic bones. The size and shape of the small pelvis are determined by the size of the large pelvis.

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, 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.

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 not less than 8 cm with normal sizes. An acute subpubic angle most often indicates a narrow pelvis. Usually there is a combined reduction of all sizes of the small pelvis.

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.

Assessment of the state of the fetus in childbirth is carried out for the purpose of early diagnosis of intrauterine hypoxia and fetal death. For 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.

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).

12. Physiological childbirth

Periods of childbirth

The opening period is the first period. It starts with the first fight. They are frequent, intense, long. 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.

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.

The first stage of labor. Its duration for first-time mothers is about 12 hours, for repeat births - about 7 hours.

Immediately after the onset of contractions, it is necessary to monitor the fetal heart rate.

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.

The second period of childbirth. The period of expulsion begins from the moment the cervix is fully dilated and ends with the birth of the child. The duration of the second period in primiparous women is about an hour; in multiparous women it is 2 times shorter. During this period, attempts appear. In some cases, this period in first-time mothers for a number of reasons can be extended to 2 hours or more.

Third stage of labor ends with the birth of the afterbirth. Its duration is 10-20 minutes.

Delivery through the natural birth canal

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.

Birth of hangers. Most often, the shoulders appear immediately behind the external rotation of the head and are born independently.

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.

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.

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)

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.

13. Biomechanism of labor in anterior occipital 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.

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.

When unbending, the parietal region, forehead, face and chin are sequentially born from the genital tract.

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 takes first an oblique position, then moving to a transverse position (left or right). With this movement, the fetal torso rotates and the shoulders are installed in the anteroposterior size of the pelvic outlet, which constitutes the fourth stage of the birth mechanism.

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.

14. Labor pain relief

Pain relief during labor is a process that must be effective and necessarily safe for the fetus.

Psychoprophylactic training

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 is the safest method of labor pain relief.

Drug 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. Despite the fact that hydroxidine quickly crosses the placenta, it does not have a depressing effect on the central nervous system of the fetus 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.

Regional anesthesia. There are several methods of regional anesthesia: epidural (lumbar and sacral), spinal, paracervical and pudendal.

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.

Pudendal anesthesia. This type of anesthesia provides a blockade of the pudendal nerve. It is used for pain relief in the second stage of labor when applying exit forceps and episiotomy.

15. 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.

Surveillance for spontaneous childbirth includes:

1) monitoring the condition of the woman in labor (pulse, blood pressure, temperature);

2) control over the nature of contractile activity and the condition of the fetus (external and internal CTG);

3) keeping a partogram;

4) determination of CBS from the presenting part of the fetus (according to indications);

5) the introduction of antispasmodic and painkillers;

6) epidno- and perinatomy (according to indications);

7) provision of manual assistance at the birth of a child;

8) prevention of bleeding during childbirth (according to indications);

9) assessment of the child's condition at birth according to the Angar scale and, if necessary, assistance to him.

Obstetric benefit for anterior occipital presentation

Removing the head. 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 back and down. 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.

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.

16. Management of the third stage of labor

The afterbirth period (the third period of childbirth) begins from the moment the fetus is born and ends with the birth of the placenta. 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).

Signs of placenta separation. Before checking contact signs, you need to check non-contact signs:

1) the umbilical cord lengthens (positive Alfeld sign);

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.

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.

Violation of the discharge of the placenta occurs with spasm of the internal pharynx, hypotonicity of the uterus.

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, enter gelatinol,

saline, intravenous oxytocin;

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 is performed in the absence of signs of separation of the placenta within 30 minutes after anesthesia.

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. In cases of pathological changes, the placenta is sent for histological examination.

17. Childbirth with breech presentation of the fetus

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. 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.

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).

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 delivery. 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.

18. 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). 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.

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.

frontal presentation characterized by the fact that the wire point is the forehead. The head passes through all the planes of the pelvis with a large oblique size, 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 with a vertical size, which is 9,5-10 cm).

extensor presentation include five main stages of the birth mechanism.

The first moment is the extension of the head.

The second point is the internal rotation of the head with the formation of a rear view.

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.

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 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. Childbirth occurs through the natural birth canal, their management is expectant.

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.

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.

19. Transverse and oblique position of the fetus

Causes of the transverse and oblique position fruits are varied.

1. Excessive fetal mobility - with polyhydramnios, sagging 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: the transverse oval or oblique shape of the abdomen and the low position of the uterine fundus are 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, bleeding is possible.

A long anhydrous interval lasting 12 hours or more contributes to the infection of the ovum, 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. If labor activity continues and the fetus does not move along the birth canal, the lower segment first overgrows, and then the uterus ruptures.

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.

The caesarean section is the optimal method of delivery in the transverse or oblique position of the fetus.

20. Obstetrical twist

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.

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 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. 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.

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.

21. Childbirth with prolapse of small parts of the fetus, large fetus, fetal hydrocephalus

Presentation and prolapse of the fetal leg. 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. 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. 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. 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, a vaginal examination reveals thinning of the skull bones, 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.

22. Anomalies of labor activity (pathological preliminary period, weakness 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.

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 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, antispasmodics, painkillers, b-mimetics (ginipral, partusisten). With the ineffectiveness of the therapeutic effect, operative delivery by caesarean section is performed.

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. Insufficiency of contractile activity during childbirth is possible in the presence of a large fetus, with polyhydramnios, multiple pregnancy, uterine myoma, post-term pregnancy. The reasons for the secondary weakness of labor can be the fatigue of the woman in labor as a result of prolonged and painful contractions, an obstacle to the fetus being born, the incorrect position of the fetus, 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 oxytocyne drugs, prostaglandin F2a. 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. Stimulation of labor activity has contraindications: discrepancy between the size of the mother's pelvis 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, which are present in the anamnesis recent septic diseases of the genital organs of severe course.

23. Anomalies of labor activity (violent labor activity, uterine tetanus)

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. With violent labor activity, premature detachment of a normally located placenta or the development of bleeding is possible. 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. 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.

Tetany uterus 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.

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.

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.

Therapy of discoordination of labor activity is aimed at eliminating excessive uterine tone. Use sedatives, antispasmodics, painkillers and tocolytic drugs.

24. 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. 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.

Diagnosis is determined by anamnestic data and the results of an objective examination. 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.

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-agonists (partusisten) and drugs that enhance blood clotting. A pregnant woman is prescribed strict bed rest to avoid severe bleeding.

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 down the fetal leg and hang a load of up to 200 g from it. During the period of placental release and the early postpartum period, hypotonic bleeding often occurs.

25. 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. Detachment of the patient occurs during pregnancy or during the course of childbirth. It is accompanied by profuse bleeding with the development of corresponding complications in the form of hemorrhagic shock and DIC.

The causes leading to the occurrence of premature detachment 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 preeclampsia; 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; diseases of the blood and connective tissue; changes in the uterus of an inflammatory or cicatricial nature.

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.

With detachment of a small area of the placenta, a retroplacental hematoma may form.

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 respiration, 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.

26. Diagnosis, delivery in case of premature detachment of the placenta

Diagnosis of premature detachment of a normally located placenta is based on clinical manifestations. These include the presence of bloody discharge from the vagina against the background of increased uterine tone, a change in the shape of the uterus, increasing signs of fetal hypoxia. When making a diagnosis, the complaints of the pregnant woman, the data of the anamnesis, the clinical course of the complication, as well as the results of an objective, instrumental and laboratory study, in particular ultrasound, which makes it possible to determine the volume and boundaries of the retroplacental hematoma, are taken into account.

Delivery with premature placental abruption. Emergency caesarean section is indicated in cases of progression of placental abruption and impossibility of vaginal delivery. Opening the amniotic sac is contraindicated in the absence of labor, since premature placental abruption may worsen as a result of decreased intrauterine pressure.

Expectant management of labor is possible in the conditions of an extended operating room of the maternity hospital in the case of minor placental abruption, the 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. 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.

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. An increase in bleeding volume, progression of placental abruption, uterine hypertonicity, and an increase in 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.

27. Birth injury

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 three degrees of perineal lacerations. 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.

uterine rupture called violation of its integrity.

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.

28. Clinic, diagnosis, treatment for birth trauma

Symptoms threatening rupture of the uterus in histopathic genesis: scanty bloody discharge from the genitals, constant pain in the lower abdomen, lower back, weakness of labor, 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, abdominal pain without localization or local in the epigastric region, in the hypogastric or lateral sections, symptoms of peritoneal irritation. On palpation, tenderness is noted with localization in the region of the rupture. When a fetal egg enters the abdominal cavity, parts of the fetus can be palpated. They are located directly under the abdominal wall. The pain increases, the general condition worsens. Violation of the fetus. A woman in labor complains of dizziness, tachycardia, low blood pressure, pale skin, darkening of the eyes, weakness, dry mouth (signs of increasing anemia).

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.

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.

29. Toxicosis of pregnant women

Toxicosis of pregnant women (gestosis) - 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.

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 of the development of early toxicosis, the theory of disruption of neuroendocrine regulation and metabolism, which develops as a result of previous diseases, characteristics of pregnancy, and the influence of unfavorable environmental factors on the body, is currently adhered to. Early toxicosis of pregnancy is most often accompanied by vomiting and drooling (ptyalism).

The appearance of vomiting is associated with a hormonal imbalance. 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 three degrees of severity of vomiting during pregnancy:

1) a mild degree is characterized by vomiting up to 5 times a day, while the condition of the pregnant woman is not disturbed;

2) moderate severity is accompanied by vomiting up to 10-12 times a day, symptoms of intoxication, weakness, weight loss and diuresis decrease;

3) severe degree (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 impaired function of vital organs. Severe vomiting is characterized by severe weakness, agitation or apathy, low-grade fever, tachycardia, a decrease in 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.

30. Toxicosis of pregnant women (continued)

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. 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). 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. 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. 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. 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.

31. Late toxicosis of pregnant women

Toxicosis that developed after 20 weeks of pregnancy is called late or toxicosis of the second half of pregnancy. 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. This theory of the occurrence of OPG-gestosis 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 is sharply reduced. 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.

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.

32. Clinical picture of OPG (dropsy, nephropathy)

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.

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, torso, upper extremities and face. 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.

There are three degrees of severity of nephropathy:

1) swelling of the lower extremities, blood pressure up to 150-90 mm Hg. Art., proteinuria up to 1 g / l - I degree;

2) swelling 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;

3) pronounced 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 increased hemodynamic disturbances. 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 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.

33. Clinical picture of OPG (preeclampsia, eclampsia)

Preeclampsia. It is characterized by signs associated with dysfunction of the central nervous system such as 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). 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, foam comes out of 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, fatigue. 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.

34. Treatment of preeclampsia

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, desensitizing agents. Antihypertensive drugs are used taking into account individual sensitivity and under regular blood pressure monitoring. In order to normalize the permeability of the vascular wall, askorutin is prescribed - ascorbic acid.

Reflexotherapy, electrotranquilization have a good effect.

Hypovolemia is corrected with infusion therapy. To restore water-salt metabolism, diuretics are used in the form of herbs (decoction of bearberry leaves), veroshpiron, lasix. Methionine, folic acid, asparcam are used to normalize metabolism. For preventive and therapeutic purposes, in the event of intrauterine hypoxia and fetal hypotrophy, nootropic drugs - piracetam - are prescribed. To improve the rheological and coagulation properties of blood, antiplatelet agents are prescribed: chimes, as well as reopoliglyukin.

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.

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 prednisolone-hemisuccinate (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 the incidence of mortality in eclampsia.

35. 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. 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. One of the reasons is isthmic-cervical insufficiency of an organic nature, malformations of the uterus, neoplasms of the genital organs with the appropriate size and localization, as well as concomitant neuroendocrine and other disorders.

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. This causes bleeding. 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.

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.

36. Bleeding in the early postpartum period

Bleeding from the birth canal that occurs within 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.

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, hypertension;

3) the anatomical features of the uterus: infantilism and malformations of the uterus, tumors of the uterus, scars on the uterus after surgery, extensive inflammatory and degenerative changes after past inflammatory diseases or abortions;

4) 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;

6) presentation and low attachment of the placenta, especially in the presence of an extensive placental area;

7) adhesive processes in the abdominal cavity.

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.

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. Blood flows out in a wide stream or is released in large clots.

37. Treatment for bleeding

If a placental defect is suspected and detected, a manual examination of the uterus is done, the remnants of the placental tissue are removed. At the same time, myotonics are administered. With hypotonic bleeding, a complex of therapeutic measures is carried out without delay, aimed at stopping bleeding and replenishing blood loss. With the ineffectiveness of conservative treatment, it is necessary to immediately begin surgical treatment. These can be operations of abdominal surgery and extirpation of the uterus. All actions to stop bleeding are aimed at enhancing 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 occurs incompletely, 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.

38. 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. 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. 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. 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.

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 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.

39. 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. 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. 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.

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 due to the loss of red blood cells, but due to the centralization of blood circulation - spasm and desolation of the vessels of the skin, mucous membranes, muscles.

40. Modern technologies for providing emergency infusion-transfusion care for acute massive blood loss

The scheme of infusion-transfusion intensive therapy for acute massive blood loss:

1) ensure an adequate supply of oxygen;

2) assess the most important vital signs (pulse, blood pressure, respiratory rate per minute, patient adequacy) and, based on the combination of these indicators, determine the severity and approximate volume of blood loss. There are four degrees of severity of acute massive blood loss:

a) I-I degree of severity: the volume of blood loss < 750 ml; the volume of blood loss < 15% of the BCC (< 15% of the BCC); pulse < < 100; BP (mm Hg) - norm; pulse pressure (mm Hg) - normal; respiratory rate - 14-20; hourly urine output > 30 ml/h; the state of the central nervous system - mild arousal;

b) II-nd degree of severity: the 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; the state of the central nervous system - excitation;

c) III-rd 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;

d) IV-th degree of severity: the volume of blood loss > > 2000 ml; volume of blood loss > 40% of 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) further carry out therapy in accordance with scheme 1 or, if the hospital has a solution of "Infucol HES" 6- or 10%, with scheme 2.

Sequencing. If indicated, catheterize any available vein and begin infusion of a solution of crystalloids and colloids based on the amount of measured or estimated blood loss. The rate of solution transfusion is 100 ml/min until blood pressure is stabilized 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. For blood loss of 1500 ml (30% of blood volume) or more, transfusion of up to 1500 ml of fresh frozen plasma is mandatory. If bleeding continues, the total volume of blood loss is more than 2 liters, instability of hemodynamic parameters, increasing pallor of the conjunctiva and the appearance of congestion, proceed with red blood cell transfusion. If there are no red blood cells of one group, you can use red blood cells 0 (I) Rh neg.

41. Ectopic pregnancy

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, abnormal development of the fallopian tubes, adhesions in the pelvic area caused by endometriosis, appendicitis, infectious processes after childbirth or termination of pregnancy, surgical interventions in the fallopian tubes, the use of IUDs, taking minipills and injections of medroxyprogesterone, endocrine disorders .

tubal pregnancy. In tubal pregnancy, the fertilized egg is implanted into the lining of the fallopian tube. At the same time, changes occur in the uterus that are characteristic of normal pregnancy in the early stages. The cervix, isthmus, and body of the uterus increase, but to an insignificant extent. The chorion grows and becomes embedded in the wall of the fallopian tube. This is the cause of bleeding. Blood enters the cavity of the fallopian tube itself, or its wall delaminates. Changes in the endometrium of a decidual nature are less pronounced than during 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.

42. 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. 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 reveals pain 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. A vaginal examination reveals an overhang of the posterior vaginal fornix due to the presence of accumulating blood in the rectouterine cavity. By puncture of the posterior fornix (culdocentesis), blood is obtained.

Research in ectopic pregnancy. Laboratory tests for ectopic pregnancy are varied. One of the most common studies is the determination of hCG levels in the blood and urine. A positive result of this test is determined very early. During an ectopic pregnancy, the level of the hCG P subunit increases more slowly. An ectopic pregnancy can be suspected when assessing the result of a single determination of hCG levels. The level of the hCG P-subunit is determined repeatedly at intervals of 48 hours. Determination of progesterone content is of great importance. With a normal onset of pregnancy, the amount of progesterone in the serum is more than 25 mg/ml.

US. Detection of a fertilized egg in the uterus excludes the presence of an ectopic pregnancy, since intrauterine pregnancy is very rarely combined with an ectopic pregnancy. With an abdominal ultrasound, the fertilized egg is detected in the uterine cavity at 6-7 weeks of pregnancy. When performing a vaginal ultrasound, it can be detected at 4-4,5 weeks.

Diagnostic laparoscopy. The pelvic organs are examined. If there are adhesions, they are separated. The fallopian tubes must be examined very carefully. When the fertilized egg is localized in the fallopian tube, it is fusiformly thickened. During examination, the integrity of the wall of the fallopian tube is clarified. With a tubal abortion, it is possible to detect a fertilized egg in the abdominal opening of the tube or blood clots isolated from the abdominal cavity. If the fertilized egg is localized in the isthmic or ampullary sections of the tube, the diameter of the fallopian tube is no more than 5 cm. Laparoscopic surgery is performed. After an ectopic pregnancy, the chance of subsequent pregnancies is about 60%.

43. Inflammatory diseases of the female genital organs (bacterial vaginosis, chlamydial infection)

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.

Bacterial vaginosis. This disease is caused by a disruption of the biocenosis of the normal vaginal microflora. The main complaint of a woman is an increase in leucorrhoea; sometimes there may be itching (or burning) in the genital area. When examined in the speculum, there is no hyperemia or swelling of the vagina. The presence of bacterial vaginosis is confirmed by a positive amino test. 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. Clindomycin has a good positive effect. A prerequisite for the treatment of all colpitis is the restoration of normal vaginal microflora.

Chlamydia infection. Chlamydia are gram-negative rods. Currently, it is infection No. 1. Chlamydial infection contributes to the massive formation of adhesions in the abdominal cavity and, most importantly, in the ampullary section of the fallopian tubes. The main complaint among women will be infertility, often primary infertility. This infection does not have a clear clinical picture - it is mild and asymptomatic. For infection of chlamydial etiology, a characteristic symptom of perihepatitis is 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, the formation of adhesions in the liver, where the pathogen enters through the lymphogenous route. Identification of chlamydia itself is difficult. If gonococcus can be seen in Gram smears, then the causative agent of chlamydial infection can only be determined using special studies - the method of immunofluorescence using immunoclonal antibodies. Due to the fact that chlamydia affects tissues that have columnar epithelium, it is necessary to take discharge from the cervical canal and urethra for analysis.

Treatment. Chlamydia is sensitive to tetracyclines. Doxycycline is prescribed. 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.

44. Inflammatory diseases of the female genital organs (viral infections, candidal colpitis)

Viral infections. The herpes virus of the second serotype and the human papillomavirus cause inflammation of the cervix. Cytomegalovirus infection 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. Locally applied viferon in the form of suppositories, it increases nonspecific antiviral activity. For the treatment of recurrent, difficult to treat genital herpes, famvir (Famciclovir) is used - 250-500 mg 3 times a day.

Candida colpitis. Caused by fungi of the genus Candida. Fungi of the genus Candida are present in the normal microflora of the vagina. When fungi of the genus Candida multiply, mycelium is found in the smear. Candida colpitis is characterized by the presence of white cheesy discharge. Candidiasis colpitis is not sexually transmitted. Most often, the cause of the development of candidal colpitis is uncontrolled antibacterial therapy, replacement therapy, the presence of hypovitaminosis, and hypoestrogenism. Pregnancy may 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.

Human papillomavirus infection. This infection is transmitted only through sexual contact. The virus causes ectocervix, which is small flat condylomas - papillomas, which are sometimes not visible during colposcopic examination. Cytoscopy reveals poilocytes with air bubbles in the cytoplasm (Ballon cells). This disease is difficult to diagnose and very difficult to treat, since the papilloma virus is not sensitive to the antiviral drugs acyclovir, famvir. The disease is treated with laser and cryodestruction.

45. Specific infections. Gonorrhea

Gonorrhea is 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. 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. This affects the endometrium, fallopian tubes, ovaries and pelvic peritoneum. Often formed abscesses fallopian tubes (pyosalpinx) and ovaries (pyovarium).

The association of gonococcus with Trichomonas vaginalis is found in 96% of patients with acute ascending gonorrhea. 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.

The 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. The condition of the inguinal lymph nodes and their painlessness are determined. When examining the urethra, its swelling and hyperemia of the sponges are noted. Smears are taken after wiping the urethral sponges with sterile cotton wool using a blunt ear spoon or loop inserted to a depth of 0,5-1 cm. The vestibular glands are palpated using the index finger. Pay attention also to hyperemia of the mouth of the gland duct, its compaction, and pain. The vagina is examined in the mirrors. Hyperemia of the mucous membranes, the presence or absence of erosions, and discharge are noted. The discharge from the area of the posterior fornix is taken with a spoon, and to collect material for fungi of the genus Candida, a light scraping is made from the walls of the vagina. Then the cervix is examined, the presence of erosions, their location, and the nature of the discharge are determined.

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. 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, detoxifying, etc.) in the subacute and chronic stages is combined with local treatment of lesions.

46. Trichomoniasis and genital tuberculosis

Trichomoniasis - This is 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. 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. 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. There is also asymptomatic trichomoniasis.

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. Without treatment, the intensity of the inflammatory process gradually subsides, the process takes on a chronic course, and may be asymptomatic.

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. The vaccines "SolkoTrichovak" and "SolkoUrovak" normalize the vaginal microflora, damage Trichomonas and increase the body's resistance.

Tuberculosis of the genital organs. Genital tuberculosis is caused by Mycobacterium tuberculosis, which enters the genitals from other sources. Most often, the infection comes from the lungs, less often from the intestines, mainly through the hematogenous route. Tuberculosis most often affects the fallopian tubes, uterus, and less commonly the ovaries. Forms of tuberculosis of the genital organs:

1) exudative form;

2) productive-proliferative form;

3) fibrous-sclerotic form.

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.

Treatment genital tuberculosis complex with the use of specific anti-tuberculosis drugs.

47. Endometritis

Endometritis - inflammation of the lining of the uterus (endometrium). 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. 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.

48. Postpartum endometritis

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 or higher, 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.

In severe forms of postpartum endometritis, a plasma cut is sometimes used, in addition, its positive effect on the hemostasis system, the rheological properties of blood is noted, and reparative processes in the uterus are accelerated.

Sometimes, in the process of treating postpartum endometritis, surgical treatment of the uterine cavity is performed, including hysteroscopy, vacuum aspiration of the contents of the uterus, washing its cavity with cooled solutions of antiseptics. The effectiveness of complex intensive care for postpartum endometritis is evaluated 7 days after the start of treatment. In the absence of the effect of the therapy, even against the background of a satisfactory condition of the puerperal, but with persistent clinical and laboratory signs of inflammation, the issue of removing the uterus is decided.

49. Pelvioperitonitis and parametritis

Pelvioperitonitis is an 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). 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. 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.

Treatment. Antibacterial, infusion, detoxification, desensitizing and restorative therapy is carried out. If the causes of pelvioperitonitis are rupture of the pyosalpinx, perforation of the uterus, necrosis of a tumor of the uterus or ovary, then urgent surgical intervention is indicated.

Parametritis is an 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.

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. 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.

50. Menstrual disorders

Menstrual irregularities - this is 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;

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. 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) cryptomenorrhea - hidden menstruation, clinically manifested by amenorrhea due to infection of the cervical canal, malformations of the genitals or a continuous hymen.

Dysfunctional uterine bleeding (DUB) - pathological uterine bleeding due to 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.

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.

51. Diagnosis and treatment of menstrual disorders

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.

52. Endometriosis

Causes of endometriosis. There is no single theory that fully explains the cause 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.

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.

External endometriosis

Endometriosis of the cervix. Damage to the cervix is the only localization of endometriosis that is not accompanied by pain. Upon examination, bluish areas in the form of eyes are found in the mirrors. Clinically, the disease manifests itself as bloody spotting a few days before and after menstruation.

Endometriosis of the ovary. It appears in the form of pinpoint bluish formations on the surface of the ovary. More often, cystic cavities are formed, filled with chocolate-colored contents. Hemorrhages into the cyst walls and microperforations cause perifocal inflammation, leading to extensive adhesions with surrounding tissues.

Tubal endometriosis. Dense nodules of various sizes form in the thickness of the pipes.

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, and spotting before and after menstruation.

Retrocervical endometriosis

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.

Extragenital endometriosis

Endometriosis of the scar develops most often after gynecological operations on the uterus

Diagnostics. When making a diagnosis, the clinical data of the disease are taken into account, and special examination methods are also used.

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. Symptomatic therapy consists of prescribing painkillers and hemostatic agents.

53. Uterine 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).

In the event that the submucosal tumor is located mainly in the muscle layer, the term "intermuscular uterine myoma with centripetal growth" is used. A special form of submucosal nodes of fibroids - giving birth to tumors, when their growth in the uterine cavity occurs towards the internal pharynx. Long-term growing emerging myomatous nodes lead to smoothing and opening of the uterine os, 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 fibroids with interstitial nodes, the uterine cavity is stretched and its surface is enlarged. This increases the amount of blood lost during menstruation. 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.

54. Diagnosis and treatment of uterine fibroids

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.

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.

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.

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.

55. Multiple pregnancy

Multiple pregnancy - development in the uterus at the same time of two or more fetuses. 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. A multiple pregnancy that has developed as a result of the fertilization of two or more simultaneously matured 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 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. A complication 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.

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. Diagnosis of multiple pregnancy in early pregnancy is difficult.

It is possible to reliably detect the presence of multiple pregnancy already at very early stages (3-4 weeks) using ultrasound. 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.

56. Intrauterine fetal death. Fruit-destroying operations

Fetal death during pregnancy refers to antenatal mortality, death during childbirth - intrapartum death. The causes of antenatal death of the fetus can be infectious diseases of the pregnant woman, extragenital diseases, inflammatory processes in the genitals. The cause of fetal death can be severe OPG-preeclampsia, pathology of the placenta and umbilical cord, entanglement of the umbilical cord around the neck of the fetus, 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 intrauterine infection, acute and chronic hypoxia, fetal malformations incompatible with life. 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.

Author: Ivanov A.I.

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