One of the terms that can be heard in the last trimester is the prolongation of pregnancy, which means its extension. That's just how relevant this is in this or that case, and what risks exist for both the mother and the child?

What is prolongation of pregnancy
Very often, prolongation is used in order to extend the gestation period by a couple of weeks in order to ensure the full development of the child. In this case, this is not a prolongation, but an opportunity to give the future baby a sufficient amount of time for the formation of all vital organs and systems.

Many expectant mothers have a question about what prolongation of pregnancy is, and how it differs from cases when labor does not occur on time. Unlike a post-term pregnancy, there is no risk to either the baby or the mother during its extension. Special examinations are carried out to determine the possible deterioration in the condition of the woman in labor and take appropriate measures. This includes a blood test to determine the hormonal level, and mandatory ultrasound examinations, checking the baby's heartbeat, as well as amniotic fluid.

As a rule, prolonged pregnancy does not carry any cause for concern. Nothing threatens the health of the mother or the child, and the fact that the “interesting situation” dragged on longer than the established term is practically the norm. Only a minimal percentage of women give birth on the date set by the gynecologist, as a rule, childbirth occurs a week either earlier or later.

Prolongation of pregnancy after the discharge of water
It is worth noting that very often it is important to prolong pregnancy after the discharge of water, if the child is not yet ready for birth. This will give the baby extra time so that all organs, systems and reflexes are fully formed, and the child is born in a timely manner.

By itself, prolonged pregnancy is not an indication for a caesarean section, and therefore you should not worry about possible complications during natural childbirth. If there are any contraindications or risks, it is important to discuss this issue with the observing gynecologist.

It is important to understand that the prolongation of pregnancy is very important for the preservation of the fetus, to provide more time for its normal development and formation. It is only necessary to distinguish between portability and prolongation. The first option can be dangerous, while the second is considered the norm. Only an experienced doctor after all the necessary examinations can determine how relevant special prolongation is.

Frozen pregnancy is a problem that a fairly large percentage of women face. And in this case, it is very important to diagnose ...

One of the problems faced by women in an "interesting position" is the appearance of stretch marks. After all, red, and then whitened scars...

Premature births are called when the pregnancy is 28-36 weeks. The frequency of preterm birth is 7%. The cause of premature birth can be hormonal deficiency, gestosis, extragenital diseases, polyhydramnios, multiple pregnancies, leg presentation, transverse position, excessive physical activity, stressful situations, active sex life, etc.

The pathogenesis of preterm birth can be different. Preterm labor can be spontaneous or induced. Spontaneous childbirth can begin with premature discharge of water or with an increase in uterine tone.

induced premature birth occur in case of early delivery with preeclampsia, antenatal fetal leucorrhoea or other complications during pregnancy. Signs of threatening premature birth are an increase in the tone of the uterus, aching pain in the lower abdomen, shortening of the cervix, and expansion of the diameter of the cervical canal.

Threat of preterm birth:

With a very pronounced threat, there may be irregular cramping pains in the lower abdomen and in the lumbar region, like precursors. The fact that during a full-term pregnancy is called signs of readiness for childbirth, or harbingers of childbirth, at a period of 28-36 weeks is called the threat of premature birth. Bloody discharge indicates not so much a threat as a pathology of the placenta (low location of the placenta, placenta previa, detachment of the low-lying placenta). Obstetric tactics in the pathology of the placenta is dealt with in the relevant sections.

If a threat of preterm birth is detected, it is necessary to hospitalize the pregnant woman in the antenatal department of the obstetric hospital. A therapeutic and protective regimen, tocolytic drugs, means for antenatal protection of the fetus are prescribed.
Sometimes with a low degree of threat, treatment is carried out in a day hospital, but such treatment gives worse results.

It is necessary to warn a woman that she needs to exclude sexual activity, physical activity. It is much more difficult to control the dynamics of changes, ensure strict bed rest and conduct intensive care at home. With a pronounced threat, observation and preserving therapy are carried out in the conditions of the maternity ward.

The beginning of preterm labor, as well as urgent labor, is considered to be the smoothing of the cervix and the development of regular labor activity. When labor has begun, with a cervical dilatation of less than 2 cm, they try to stop labor with the help of intensive tocolytic therapy (infusion therapy). At the same time, therapy is carried out aimed at the prevention of fetal respiratory distress syndrome (RDS).
Improving the development of the lungs contributes to dexamethasone, Essentiale, but the most effective use of a surfactant.

If maintenance therapy is not effective and labor continues, the woman in labor is monitored in the same way as in urgent labor, but the course of preterm labor may be complicated. Quite often, anomalies of labor activity are observed. With weak labor activity at the beginning of the first period, there are more chances to keep the pregnancy. Sometimes childbirth proceeds quite quickly. Then it is necessary to weaken labor activity in order to avoid complications. Discoordination of labor activity is often manifested, and in this case, the introduction of tocolytics and antispasmodics is indicated. Delivery should not be rushed if there is no threat to the woman's health.

In the second stage of labor, a perineal dissection is performed to prevent birth trauma and fetal asphyxia. Prevention of bleeding is carried out. Obstetric care is administered as carefully as possible.

Signs of prematurity in a newborn:

length less than 47 cm, weight less than 2600 g. (With a weight of less than 1000 g and a length of less than 35 cm, a newborn is called a fetus up to 8 days of life.);
the umbilical ring is below the middle of the distance between the xiphoid process and the pubis;
the skin is more pink and, with a greater degree of prematurity, red, a lot of cheese-like lubricant, vellus hair is more pronounced, hair and nails are shorter, ear and nasal cartilages are soft, as are the bones of the head, sutures and fontanelles are wide, the bones are easily configured;
in girls, the large labia do not cover the small ones, and in boys, the testicles may not be lowered into the scrotum;
movements, reflexes and muscle tone are less active, the cry is weaker;
signs of respiratory failure are often expressed, so a premature baby should be evaluated not only on the Apgar scale, but also on the Silverman scale.

It is necessary that even before the birth of the child, a neonatologist is called to the maternity ward.

Complications of preterm birth:

anomalies of tribal forces;
prolapse of the umbilical cord and limbs;
pathology of the subsequent period;
birth trauma of the mother and trauma and asphyxia of the newborn;
obstetric bleeding;
postpartum complications.

Due to the complications that have arisen, and also due to the fact that preterm birth is a consequence of pregnancy complications, the percentage of surgical interventions is high. Premature baby often cannot breastfeed or is not active enough, because of this there is lactostasis, and there is a threat of mastitis in the mother. There is a subinvolution of the uterus, and against this background, the risk of inflammation of the uterus increases.

Obstetric tactics in case of premature discharge of water during premature pregnancy:

In case of premature discharge of water, it is necessary to prepare the pregnant woman for delivery in order to avoid infectious complications, labor induction, antibiotic therapy are carried out.

If premature discharge of water occurs at 27-30 weeks of gestation, when the fetus is not yet viable enough, it is possible in some cases to use the method of prolonging pregnancy, preserving therapy in this case is not carried out, but labor induction is not carried out either.

Prolongation contraindications are:

unwillingness of the mother to prolong the pregnancy;
stillbirth;
the presence of infection (according to analyzes or clinical manifestations);
lack of examinations during pregnancy;
bleeding;
the serious condition of the mother, which requires urgent delivery;
risk of complications in case of prolongation of pregnancy;
breech presentation fetus;
low opening of the fetal bladder, abundant outpouring of water;
regular contractions;
twins;
presence of indications for surgery C-section.

In the case when there is a high opening of the fetal bladder with a small defect in the membranes, water leaks, but labor activity may not develop for a very long time. Even with the dilution of the membranes and the appointment of rhodostimulation, a miscarriage or premature birth does not always occur on the first day, and the anhydrous period can stretch for several days.

Experience shows that even with full-term pregnancy, until the fetal membranes are divorced, labor activity often does not develop. Since amniotic fluid is constantly produced, a small loss of it is not terrible.

Conditions for carrying out the prolongation of pregnancy:

the extreme interest of a woman in prolonging pregnancy;
absence of infection subject to a complete examination of the woman;
no contraindications for prolongation of pregnancy;
live fetus;
head presentation;
high opening of the fetal bladder and a slight defect in the membranes;
slight water leakage.

Observation and care of a pregnant woman during the prolongation of pregnancy when water breaks: a woman is placed in a separate ward in the antenatal department, sterile clothing, cleaning, as in the ward of the external observation department. To control infection, temperature is taken every 3 hours.

Daily or every two days: CBC, urinalysis, examination of the vaginal flora, cultures of urine and vaginal contents. To monitor the condition of the fetus - ultrasound and CTG. Doctor's examination in the morning and in the evening, including weekends, midwife supervision. Medicinal purposes: antibacterial therapy, means for the prevention of fetal hypoxia, closer to delivery - means for preparing the birth canal.

Usually prolongation is carried out within 2 weeks, but sometimes it is possible to extend the pregnancy by 5-6 weeks. If at 24-25 weeks of pregnancy there are practically no chances for the birth of a viable fetus, then at 30 weeks the chances increase, especially since therapy is carried out with agents that improve the adaptive capabilities of the fetus and the development of pulmonary surfactant. At near-term pregnancy, there is no reason for the risk of infection, and prolongation of pregnancy beyond 33-34 weeks is not recommended.

The midwife should be able to suspect miscarriage, identify risk factors, give recommendations for the prevention of miscarriage, follow doctor's orders, provide care during pregnancy, childbirth, provide first aid, conduct delivery and postpartum rehabilitation under the supervision of a doctor.

in general, girls, I reached an emotional peak after 7 days spent in the hospital ... I spent the whole day in tears - I was hysterical. the primary reason is the forced separation from the son of Kostya, her beloved and devoted husband ... she roared today from morning until evening

The impetus for an explosion of emotions was the infa that my G, who led my first birth and was directly present at them, and also led me now, is flying tomorrow on a business trip to Moscow until the end of April !!! instead of her, a young doctor will be on duty at the birth, who will be sent on Monday. it is precisely with the arrival of this lady that I will have wild fears:

1. Stimulates me without my consent or knowledge

2. will not let me into the EP, seeing my narrow pelvis

3. just doesn't want to talk to me...

I was offered the option of giving birth in another maternity hospital in the neighboring district or RD in the city of my choice ... I refused: I trust all midwives, 3 of them were at my last birth, the fourth was experienced without complaints (my friends gave birth to her), the fifth of our regions with unsullied reputation as a midwife. I have boundless trust in them, I managed to study each of them in my last days of waiting for my first child. fear only of the new doctor-G ....

my departing G tried to reassure me: she explained that I don’t walk around, but I have a PROLOGATED B. there’s nothing wrong with that, it’s common feature organism.

Here is some info I found about it:

Prolongation of pregnancy means untimely (late) occurrence of labor activity, with its development, violations of the contractile activity of the uterus are often observed, which leads to an increase in the number of surgical interventions, to intrauterine suffering of the fetus and an increase in perinatal mortality. With prolonged pregnancy, it is more correct to call childbirth timely, and with true overbearing - belated childbirth with an overripe fetus.

The frequency of overwearing is 1.4-14%, on average 8%.

Distinguish:

· true (biological) re-carrying of pregnancy

· imaginary (chronological), or prolonged pregnancy.

Prolonged pregnancy lasts more than 294 days and ends with the birth of a full-term, functionally mature child without signs of overmaturity and danger to his life.

True post-term pregnancy lasts more than 10-14 days after the expected date of delivery (290-294 days). The child is born with signs of overmaturity, and his life is in danger. Usually in these cases there are changes from the placenta (petrificates, fatty degeneration, etc.).

Post-term pregnancy diagnosis usually put on the basis of anamnesis and data obtained from clinical, laboratory and instrumental research methods. It is necessary to assess the general condition of the pregnant woman, the course of this pregnancy (toxicoses), to establish the timing of the onset of menarche, the characteristics of the menstrual cycle, the presence of infantilism, endocrine diseases, past inflammatory diseases of the genital organs, abortions, and a history of prolonged pregnancy.

Etiology and pathogenesis

It is more correct to consider a post-term pregnancy as a pathological phenomenon due to certain reasons, depending on the state of the body of both the mother and the fetus. A premorbid background for postponing a pregnancy can be previously transferred childhood infectious diseases (scarlet fever, parotitis, rubella, etc.), which play a significant role in the formation of a woman's reproductive system, as well as extragenital diseases.

Contribute to pregnancy delay infantilism, abortions, inflammatory diseases internal organs. which cause changes in the neuromuscular apparatus of the uterus and lead to endocrine disorders.

Endocrine diseases, disorders of fat metabolism, mental trauma, and toxicosis of the second half of pregnancy play a certain role in prolongation of pregnancy. In primiparous women (especially the elderly), overgestation is more common than in multiparous ones.

The hereditary factor also matters. The main pathogenetic factors leading to prolonged pregnancy are functional changes in the central nervous system, vegetative and endocrine disorders. A large role belongs to the disruption of the production of estrogens, progestogens. corticosteroids, oxytocin, certain tissue hormones (acetylcholine, catecholamines, serotonin, kinins, histamine, prostaglandins), enzymes, electrolytes and vitamins.

The condition of the placenta and fetus is also of some importance. Violations in the fetoplacental system are one of the reasons for the late onset of labor and its anomalies. The fetus overripes, its need for oxygen increases, the stability of the central nervous system to oxygen deficiency. At the same time, profound changes occur in the placenta (degeneration, calcification, dissociation of its maturation). When pregnancy is overdue, the oxygen demand of the fetus increases, and resistance to hypoxia decreases, changes occurring in the placenta make it difficult to deliver the required amount of oxygen and other necessary substances to the fetus. This is how it is created vicious circle pathological processes characteristic of post-term pregnancy.

Clinical picture of post-term pregnancy ill-defined and difficult to diagnose. With true pregnancy over 41 weeks, it is often observed; the absence of an increase in the body weight of a pregnant woman or its decrease by more than 1 kg; decrease in abdominal circumference by 5-10 cm, which is usually associated with a decrease in the amount amniotic fluid, decreased skin turgor; less often, a drop in body weight due to secondary malnutrition of a post-term fetus; oligohydramnios and green coloration of amniotic fluid, higher standing of the uterine fundus; secretion of milk, not colostrum, strengthening or weakening of fetal movements, which indicates fetal hypoxia due to impaired uteroplacental circulation; frequency change. rhythm and timbre of fetal heart tones; immaturity or insufficient maturity of the cervix; large fruit size. an increase in the density of the bones of the skull, narrowness of the sutures and fontanelles.

The course of childbirthin post-term pregnancy, it is characterized by numerous complications; premature or early discharge of amniotic fluid, anomaly of labor, prolonged labor, fetal hypoxia and birth trauma. As a rule, intrauterine fetal hypoxia during pregnancy occurs with the onset of labor or after premature rupture of amniotic fluid, which is associated with a deterioration in uteroplacental circulation due to functional and morphological changes in the placenta. Hypoxia is promoted by reduced function of the adrenal glands of the fetus, sensitivity to oxygen deficiency during childbirth due to increased maturity of the central nervous system, a decrease in the ability of the head to change, and a significant size of the fetus. frequent violations of the contractile activity of the uterus; excitation or stimulation of labor, frequent surgical interventions during childbirth.

Mommy is looking forward to that cherished fortieth week, but is the baby still not in a hurry to be born? In this case, doctors fix a post-term pregnancy for you. However, not everyone is aware that this deviation is no better than premature birth.

Note that forty weeks of pregnancy is recognized as normal (plus or minus two weeks is also considered the norm). Accordingly, delivery at 38 weeks cannot be called premature, just like delivery at 42 weeks post-term. Such a gap is usually due to the fact that it is extremely difficult to determine the exact day of pregnancy (the date is corrected with each subsequent ultrasound), usually the countdown is based on the last menstrual cycle. Doctors distinguish many aspects due to which labor activity may be late or absent completely, ranging from physiological and mental factors, ending with living conditions and ecology (we will talk about the reasons in detail below). Most often, overgestation is determined not by the gestational age, but by obvious signs of complications, which, without proper attention, can lead to serious consequences for the health of the mother and baby.

2. Prolonged pregnancy

We have already noted that the appearance of the crumbs into the world from 38-42 weeks of pregnancy is considered absolutely normal and safe for the life of mother and baby. But still, the generally accepted gestational age of 40 weeks is what doctors are guided by in their conclusions. So this is the period (usually 41 and 42 weeks), which proceeds without signs of deterioration in health future mother and her crumbs and is called prolonged pregnancy, in other words, prolonged without changes in condition. With prolonged pregnancy, the placenta also continues to perform its functions in full, and therefore the baby is not in danger. As practice shows, such prolonged gestation is usually hereditary.

Specialists identify a huge number of reasons why a true post-term pregnancy may occur, but even the most experienced doctor will not be able to name a hundred percent reason for a particular case. Here is a short list of reasons that are considered the most important:

heredity. We have already said that this is also a prerequisite for prolonged pregnancy. The same factor can be attributed to the fact that a woman has a menstrual cycle over the norm of 28 days;

various diseases of the internal organs (thyroid gland, endocrine system, diseases of the stomach and intestinal tract);

various kinds of inflammatory processes of the reproductive system of a woman can be caused by infections;

internal tumors;

problems with the work of the kidneys;

past illnesses during pregnancy. These include not only flu and colds, but also “childhood” diseases such as rubella and chickenpox, which are extremely dangerous for a pregnant woman and her unborn baby;

presentation of the fetus;

late first pregnancy;

numerous stressful situations;

overweight of the expectant mother, as well as a too large fetus.

This is not the whole list of reasons that can provoke a delayed pregnancy, but we tried to highlight the most common ones based on medical reports. Predicting the course of pregnancy without visible pathologies is very difficult, so no one will tell you in advance about a possible delayed pregnancy, so the maximum that you can do is to pass the necessary medical examinations and follow your doctor's instructions.

4. Signs and symptoms of post-term pregnancy

So, before you deal with the signs of a post-term pregnancy, it is worth remembering that it can be of two types:

imaginary (usually this is due to an incorrectly set date of birth);

true (in this case, there are noticeable biological changes that require urgent intervention of specialists).

Deviations begin in the placenta, and as we know, it is responsible for saturating the fetus with oxygen and feeding the baby. In order to diagnose a post-term pregnancy, an ultrasound is prescribed, the results of which reveal signs of a post-term pregnancy. The signs include:

green waters or very muddy;

despite the fact that the gestational age is already large, the cervix remained immature;

the placenta cannot function normally due to the fact that aging has occurred;

large cranial bones of the fetus.

If we talk about symptoms, then there are no clear signs of overwearing, so a woman has to rely on sensations and small concomitant factors that can indicate this. For example, when carrying over in a very short period, pregnant women experience weight loss, on the order of one or two kilograms per week. It is also worth paying attention to the volume of the abdomen, due to the decrease in amniotic fluid, it loses volume. But you will be able to make an accurate diagnosis only after undergoing an ultrasound examination.

5. Consequences of a post-term pregnancy

All the consequences of the transfer are associated with the aging of the placenta and the cessation of its proper functioning. For a pregnant woman, this is fraught with late toxicosis or even anemia. For the baby, the placenta is a way of supplying oxygen, and when it dies, oxygen starvation of the fetus begins, which in the future can lead to its death. The consequence of a post-term pregnancy for a woman may be multiple ruptures, which may well lead to infectious diseases, so most often in such cases, doctors resort to caesarean section. In such babies, the risk of birth injury is greatly increased due to the dense bones of the skull. There are also sad statistics in which about 20 percent of post-term babies die, this is due to the fact that it is difficult to establish true reason pathology. Most importantly, do not panic and do not bring yourself to a nervous breakdown, if by all the dates it is time for you to go to the hospital, and the baby is not going to be born, then collect all the necessary things and go to the hospital for an ultrasound scan.

Pregnant V., aged 26, was admitted to the maternity hospital at 13.00, at 43 weeks' gestation, due to the onset of labor.

Complaints of cramping body in the abdomen.

From history. Menstruation from the age of 14, regular, moderate, painless. sex life from 19 years old. Pregnancy second, desired. B female consultation is observed regularly, the course of pregnancy without features. The first pregnancy ended in childbirth at 42 weeks, without complications, three years ago.

status praesens. The condition is satisfactory. Body temperature 36.6°C, Ps 76 per minute, BP 110/70 - 120/70 mm Hg. Art.

status obstetricus. OB 108 cm. WDM 37 cm. Pelvic dimensions: 25-27-30-21 cm. The position of the fetus is longitudinal, the head is presented, pressed against the entrance to the small pelvis. The back is turned to the right. The fetal heartbeat is clear, rhythmic 136 beats/min.

Vaginal examination. On examination: the external genitalia are formed correctly. Hair on the female type.

Per vaginam: the cervix is ​​smoothed, the edges are soft, thin, easily extensible, along the wire axis of the pelvis, the opening is 3 cm. The head is placed, pressed against the entrance to the small pelvis. On examination, light amniotic fluid was poured out in the amount of 100 ml. The cape is not reachable.

Additional examination methods

Cardiotachogram: Fisher score 8 points.

At 23.00 hours

She gave birth to a live male child, weighing 3900 g, 50 cm long. Skin pink, clean, screamed immediately, loudly, reflexes are well expressed, movements are active, heartbeat is 134 beats / min. A large fontanel with a facet of 2 cm is determined on the head, a birth tumor is in the area of ​​the small fontanel. Umbilical hair on shoulders. The skin is not macerated. The nail plates extend to the edge of the nail bed. The afterbirth is examined - intact, without pathology.

Diagnosis? Apgar score?

Basic diagnosis: Belated delivery in cephalic presentation, longitudinal position, II position. Complications: Early rupture of amniotic fluid.

Newborn Apgar score: 8 points

In the present case, there was a prolonged pregnancy

More on the topic Problem 36. PROLONGED PREGNANCY:

1. The use of long-acting contraceptive regimens for therapeutic purposes
2. Pathology of pregnancy and the postpartum period. Spontaneous abortions. ectopic pregnancy. trophoblastic disease
3. Management of the 2nd group of pregnant women: a group of sensitized pregnant women threatened by Rh - conflict (there are antibodies, but there are no signs of GBP):

And belated births very often complicate the course of pregnancy. But there is also a prolonged pregnancy. How are they different.

Postterm pregnancy- this is a pregnancy that lasts 10-14 days more than a physiological pregnancy and its total duration is 290-294 days (42 weeks). The child is born with signs of overmaturity (Bellentine-Rooney syndrome).

Prolonged pregnancy, also lasts up to 290-294 days, but the child is born functionally mature, without signs of postmaturity.
The frequency of overwearing, according to various authors, is 1.4 - 42%.

Complications that may occur during a post-term pregnancy:

• placental insufficiency
• Fetal hypoxia
• Birth trauma (both in the child and in the mother)
• 
  Respiratory distress syndrome and pneumopathy
• 
  intrauterine infection
• 
  perinatal mortality
• 
  Perinatal morbidity
• 
  In the remote period, there may be a lag in the child's physical and neuropsychic development
• 
  Abnormalities in labor may occur during childbirth
• 
  Bleeding in the postpartum period
• 
  High percentage of caesarean section in post-term pregnancy

Causes of delayed pregnancy:

• Neuroendocrine diseases, obesity
• 
  Age over 30
• 
  Restructuring in the central nervous system with a predominance of the influence of the parasympathetic nervous system
• 
  Change in the ratio of gonadotropic hormones, progesterone, decrease in the level of estrogens, calcium, potassium, acetylcholine
• 
  Past abortions in anamnesis
• 
  Inflammatory diseases of the reproductive system in history
• 
  Delayed maturation of the placenta
• 
  Chronic placental insufficiency
• 
  Change in immune status
• 
  Malformations of the central nervous system in the fetus
• 
  Congenital malformations in the fetus

Changes in amniotic fluid during post-term pregnancy:

With a post-term pregnancy, there is a change in both quantity and quality. When overcarrying, the amount of amniotic fluid decreases and oligohydramnios occurs. Normally, by the full-term period, the amount of amniotic fluid is 800-900 ml, while with overbearing, the amount of amniotic fluid decreases by 100-200 ml per week.

There is a change in the transparency of amniotic fluid. With a mild degree of overdose, the water acquires an opalescent, whitish color due to the dissolution of the lubrication of the fruit in the waters. In severe forms of post-term pregnancy, the color of the amniotic fluid can become greenish and even yellowish, due to the release of meconium into the amniotic fluid.

With a post-term pregnancy, the composition of the amniotic fluid changes. The ratio of lecithin and sphingomyelin proteins changes. These proteins normally contribute to the formation of surfactant in the lungs of the fetus. With an imbalance of these proteins, the surfactant ceases to be formed and the child develops a syndrome of respiratory disorders and pneumopathy.

The bactericidal property of amniotic fluid changes. The longer the gestation period, the more bacteria accumulate in the waters.

There are changes in the umbilical cord, which lead to a decrease in the amount of Worton's jelly ("skinny umbilical cord"), due to which the umbilical cord blood flow is disturbed, which leads to the centralization of blood circulation in the fetus with insufficient nutrition of the peripheral sections.

Diagnosis of post-term pregnancy difficult not only in the absence of reliable signs of overgestation, but also in the inability to accurately determine the gestational age in each case. During the diagnosis of a post-term pregnancy, the following criteria are based:

Presence of post-term pregnancy in anamnesis.
- Systematic monitoring of a woman during pregnancy allows you to more accurately navigate the correct gestational age.
- Carrying out amnioscopy
- Carrying out amniocentesis
- Carrying out cardiotocography
- Carrying out dopplerometry
- Carrying out a colpocytological test

After the birth and examination of the child, it is possible to make an accurate conclusion whether the pregnancy was delayed or prolonged. They help in this signs of postmaturity- Bellentiney-Rooney syndrome:

Absence of vellus hair on the child's body
- Lack of original lubrication
- Increased bone density of the child's skull
- Narrowness of the sutures and fontanelles between the bones of the child's skull
- Lengthening the nails on the hands and feet of the baby
- Greenish skin tone
- "Parchment" dry skin
- Maceration of the feet and hands (arms, legs of the washerwoman)
- Reduced baby skin turgor
- Poorly developed subcutaneous fat

COMPLICATEDPREMATURE RUPTURE OF MEMBRANES

Although there is a lot of primordially medical, reinsurance, etc. in the work, it seemed to me useful, if only because the numbers are confirmed by real studies, and not taken from the ceiling. (my note)

Very many girls undergo CS for fear of infection with early discharge of amniotic fluid. The new work calls into question the existing practice of childbirth and, more broadly, the behavior of doctors in case of premature rupture of the amniotic membranes. The author's abstract of Nikolai Nikolaevich Lutsenko is called " OPTIMIZATION OF THE DURATION OF HCOMPLICATED PREGNANCYPremature rupture of membranes". As a result of the study, he concluded that the incidence of chorioamnionitis * during prolongation of pregnancy with premature rupture of membranes at gestational periods of 22-30.5 weeks does not depend on the duration of the anhydrous period, and With the development of premature rupture of membranes in terms of 28-30.5 weeks, prolongation of pregnancy for more than 48 hours, with the prevention of RDS **, contributes to a significant reduction in perinatal and postnatal mortality, and lengthening of the latent period for more than 168 hours, significantly reduces childhood morbidity. Below we present the text of the work in full. The defense took place on June 9, 2008. List of abbreviations at the end of the text.

NB: For reference, this path has long been followed inEngland, where after the rupture of the membranes, spontaneous labor is expected for another 96 hours.

* infection membranes and amniotic fluid

** respiratory distress syndrome

Despite the great progress of modern medicine, the problem of miscarriage remains one of the unsolved problems all over the world (Sidelnikova V. M., 2000, Villar J., 2004, Barros F., 2006). In the structure of the causes of perinatal and infant mortality, prematurity ranks first, with the highest mortality rates in newborns with extremely low and very low body weight (Avdeeva R.A., 1997, Marret H., 1998, Shabalov N.P., 2004 ). IN Lately, thanks to the successes achieved in the field of neonatology, the survival rate of newborns weighing less than 1500 grams has sharply increased (Ozhiganova I.N., 1997, Xiao ZH, 2000, EfferS.B., 2002), but the proportion of disabled people and patients with chronic pathology among of these children is very large (Avdeeva R.A., 1997, Marret H., 1998, Barros F., 2006).

Of particular importance in the structure of perinatal morbidity and mortality are premature births against the background of premature rupture of the membranes (PROM), which is one of the most common causes of initiation of labor in 34.9-56% of all preterm births (Marret H., 1998, Sidelnikova V. M., 2000, Villar J., 2004).

Studying the characteristics of the course of pregnancy in PROM and determining the optimal duration of the anhydrous period, methods for preventing infectious complications, terms and methods of delivery at various gestational periods will reduce the number of adverse outcomes in this serious pathology.

Purpose of the study: to determine the optimal duration of prolongation of preterm pregnancy complicated by premature rupture of the membranes in terms of 22-34 weeks, as well as to reduce perinatal morbidity and mortality, and the number of infectious complications in pregnant women, parturient women and puerperas.

Research objectives.

1) Conduct a complete clinical examination of pregnant women who have experienced premature rupture of the membranes at 22-33.5 weeks of gestation.

2) To study the microbiocinosis of the vaginal contents and the sensitivity of the identified microorganisms to antibiotics in pregnant women with premature rupture of the membranes at 22-34 weeks of gestation.

3) To analyze the frequency of occurrence of infectious complications in pregnant women, parturient women and puerperas with premature rupture of the membranes at 22-34 weeks of gestation, depending on the duration of the anhydrous period.

4) Analyze perinatal mortality at various gestational ages in the study group of pregnant women, depending on the duration of pregnancy prolongation complicated by premature rupture of the membranes.

5) Analyze the incidence of newborns, depending on the duration of prolongation of pregnancy, complicated by premature rupture of membranes at different gestational periods.

6) To substantiate the expediency of using the tactics of long-term prolongation of pregnancy, complicated by premature rupture of the membranes in terms of 22-34 weeks.

Scientific novelty.

For the first time in our country, based on a large clinical material, a method for long-term prolongation of preterm pregnancy complicated by PROM at 22-33.5 weeks of gestation has been developed, based on modern microbiological and clinical diagnostic research methods. This made it possible to significantly reduce perinatal and postnatal mortality and morbidity in newborns and minimize the risk of developing infectious diseases, including purulent-septic diseases of the mother.

Practical significance.

The optimal duration of prolongation of preterm pregnancy complicated by PROM at 22-33.5 weeks of gestation was developed, depending on the gestational age, the condition of the fetus and the data of the clinical and laboratory examination of the pregnant woman, without increasing the risk of developing infectious complications.

It has been proven that the prolongation of preterm pregnancy complicated by PROM in terms of 22-33.5 weeks is the only possible way significantly reduce perinatal and postnatal morbidity and mortality, as well as improve the quality of the future life of a premature newborn.

The study showed that prophylactic antibiotic therapy with semi-synthetic penicillins, macrolides of the first generation and nitrofurans during the prolongation of preterm pregnancy complicated by PROM is not desirable due to the low sensitivity of the detected microorganisms to these drugs. Therefore, we have proposed an effective scheme of preventive antibiotic therapy, taking into account the population sensitivity of the microbial flora.

Defense provisions.

1. The predominant microorganisms in pregnant women with premature rupture of the membranes are gram-negative rods of the Enterobacteriaceae family, the presence of which adversely affects perinatal and postnatal outcomes.

2. Conducted antibacterial prophylaxis in pregnant women with premature rupture of the membranes with semi-synthetic penicillins is not effective due to the low sensitivity of the detected microorganisms to this drug.

3. The frequency of occurrence of chorioamnionitis in pregnant women with PROM in gestational periods of 22-30.5 weeks depends on the fact of the presence of a long anhydrous interval, and not on its duration, but in terms of more than 31 weeks, the frequency of its development significantly increases with an increase in the duration of the anhydrous interval more than 168 hours (7 days).

4. In order to reduce perinatal and postnatal mortality, as well as the morbidity of newborns with PROM up to 28 weeks of pregnancy, the tactics of prolonging pregnancy for more than three weeks is justified; at 28-30.5 weeks, the management of pregnancy is aimed at prolonging it for more than 7 days, and at periods of more than 31 weeks of gestation, RDS prevention is indicated, followed by gentle delivery for 7 days.

Implementation of the results into practice.

The results obtained are implemented in the work of the maternity hospital of the City Hospital No. 8 of the Department of Health of Moscow, are used in the educational process of the State Educational Institution of Higher Professional Education of the Russian State Medical University ROSZDRAV.

Publications

Based on the dissertation materials, 3 articles were published in the central press and 9 theses in collections.

Approbation of the work took place at a meeting of the Department of Obstetrics and Gynecology of the Medical Faculty of the Russian State Medical University on November 22, 2005. The main provisions of the dissertation were reported at the V-th Congress of the Russian Association of Perinatal Medicine Specialists, Moscow (November 14-15, 2005), at the Congress of Perinatal Medicine Specialists "New Technologies in Perinatology", Moscow (November 21-22, 2006).

Structure and scope of work.

The dissertation is presented on 150 pages of typewritten text, consists of an introduction, literature review (Chapter 1), general characteristics of research materials and methods (Chapter 2), clinical characteristics of groups (Chapter 3), presentation of the results obtained (Chapter 4), conclusion, conclusions, practical advice and list of references.

The dissertation is illustrated - 14 tables, 29 histograms. The literature index includes 166 sources, of which 41 are in Russian and 125 are in foreign languages.

The content of the work

Materials and research methods.

A comprehensive study was carried out on the basis of the maternity hospital No. 8 of the Moscow Department of Health (Chief Physician Ph.D., Associate Professor N. N. Nikolaev). Microbiological studies were carried out in the laboratory of the FGUN MNIIEM. G.N. Gabrichevsky Rospotrebnadzor (Director - Professor, Doctor of Biological Sciences, Corresponding Member of the Russian Academy of Natural Sciences Aleshkin V.A.) and at the Department of Microbiology of the Russian State Medical University (Head of the Department Professor, Doctor of Medical Sciences Kafarskaya L.I.)

Comprehensive clinical and laboratory examination and treatment was performed in 252 pregnant women with PPROM in terms of 22-34 weeks of pregnancy. All examined pregnant women were divided into four groups depending on the gestational age at the time of the rupture of amniotic fluid, and the duration of the anhydrous period. The main group included 159 women with PROM who underwent prolongation of pregnancy under conditions of an anhydrous period, the duration of which was more than 48 hours. The main group was divided into two subgroups, depending on the duration of the anhydrous interval (BP): the main A - BP from 48 to 168 hours (108 pregnant women) and the main B - BP more than 169 hours (51 pregnant women). The control group consisted of 93 pregnant women who had preterm labor at different gestational ages, and the duration of the anhydrous period was less than 12 hours.

Given that the outcomes of pregnancies at different gestational periods were different, the main and control groups were divided into three subgroups, depending on the gestational age at the time of rupture of the membranes: I subgroup 22-27.5 weeks, II subgroup 28-30.5 weeks , III subgroup 31-33.5 weeks.

The obstetric tactics of managing pregnant women with PROM consisted in the maximum prolongation of pregnancy in the absence of contraindications with the appropriate sanitary and hygienic regimen, regulated by order of the Ministry of Health of the Russian Federation No. 318 of December 4, 1992. The complex of therapy included tocolysis, prevention of fetal respiratory distress syndrome (RDS) and antibiotic therapy.

Ultrasound was carried out according to the generally accepted method of Morgenstern (1986) Demidova V.N. (1991) on an ultrasonic device ALOKA - SSD 4000 (Japan), using a convex probe with a frequency of 3.5 MHz.

Dopplerometry was performed on an ALOKA - SSD 4000 device (Japan) according to the generally accepted method of Campbell (1991), Demidov V.N. (1993)

Cardiotocography was performed using OXFORD Team (England), Corometrics (USA) devices according to the generally accepted method. During childbirth, cardiotocographic examination was performed using Corometrics (USA) and Hewlett Packard (USA) devices, with simultaneous recording of the mother's hemodynamic parameters - pulse rate, blood pressure and oxygen saturation.

The amniotic fluid index (AFI) was determined according to the method developed by Phelan (1987) by summing the vertical diameters of the maximum "pockets" of water in each of the four quadrants of the uterus in a longitudinal section.

Fetal biophysical activity was assessed according to the scale proposed by Vintzileos (1992).

Differential diagnosis of neonatal pathology was performed on the basis of clinical and anamnestic data, laboratory methods research and X-ray diagnostics with the help of specialists from the Department of Neonatology of the Faculty of Education and Science of the Russian State Medical University (Head of the Department, Academician of the Russian Academy of Medical Sciences Prof. Volodin N.N.).

The research materials were processed using computer program STATISTICS 6.0. To assess the significance criterion in two independent groups represented by non-parametric rank values, the Mann-Whitney U-test was used, for groups represented by parametric values, the Student's t-test was used. The correlation dependence for non-parametric rank values ​​was estimated using the Spearman method (R), and for parametric ones, using the Pearson method (r). The significance criterion p > 95% was taken as the minimum threshold of significance.

Main results of the study and their discussion

Clinical and statistical analysis of the anamnesis, course of pregnancy and childbirth in the examined women revealed a statistical comparability of the group of pregnant women who had a premature birth at a period of 22-33.5 weeks, with an anhydrous interval of less than 12 hours (control group), and a group of pregnant women with PROM who underwent pregnancy prolongation at the same gestational time.

The results of the study showed that there was no age difference in pregnant women in all study groups, and the average gestational age at the time of amniotic fluid rupture differed by a maximum of two days.

When studying extragenital pathology in the analyzed groups, a high frequency of chronic somatic diseases was noted, despite the young average age. The most common pathology of the thyroid gland, and as a result, violations of fat metabolism. Chronic pyelonephritis and chronic arterial hypertension were detected somewhat less frequently, which was observed twice as often in pregnant women in the control group than in the main group.

In the study groups, more than 50 percent of pregnant women were nulliparous. In the vast majority of cases, women in both groups were multi-pregnant, and on average, each woman had three pregnancies, which equally often ended in childbirth and abortion. A higher number of abortions in pregnant women of the main group is directly related to a large number of pregnancies. In both study groups, almost every third pregnant woman had spontaneous miscarriages, and in pregnant women of the main group, previous pregnancies ended in premature birth three times more often.

Gynecological anamnesis was equally burdened in pregnant women of the main and control groups. Almost every patient was diagnosed with hyperandrogenism. Of the inflammatory diseases of the female genital organs, the high incidence of endometritis in pregnant women of the main group is directly related to a large number of pregnancies, spontaneous miscarriages and induced abortions.

Among sexually transmitted infections, ureaplasmosis and gardnerelosis were most often detected, mycoplasmosis and chlamydia were somewhat less common, and trichomoniasis was detected in seven cases. The incidence of viral infections (herpes simplex virus and cytomegalovirus) did not exceed 15%. Moreover, in pregnant women of the main group, three times more often, infection with cytomegalovirus was determined, compared with patients in the control group.

The course of a true pregnancy early dates was complicated by the threat of miscarriage in more than half of the women surveyed, and every fifth had an abortion that had begun. Pathology of the placenta among the complications of pregnancy was quite common and was represented by low placentation and premature detachment of the placenta in history.

Pregnant women in the control group were twice as likely to deliver by caesarean section, the indications for which were breech presentation or incorrect position of the fetus.

Analysis of seeded microflora and its sensitivity to antibiotics.

We conducted a bacteriological study in all pregnant women with PROM, starting from the first hours from the moment of amniotic fluid discharge.

Upon receipt of microbiological data, it turned out that the frequency of pathological growth was 38.8% (n=98) of total number surveyed women (n=252), and all cultured microorganisms are represented by three families.

1) Enterobacteriaceae - 47.9%, (n=47)

- Escherichia coli - 31.6%, (n=31)

- Enterobacter - 9.2%, (n=9)

- Klebsiella pneumoniae - 7.1%, (n=7)

2) Streptococcaceae - 28.6%, (n=28)

- Streptococcus haemolyticus - 8.2%, (n=8)

- Streptococcus agalactiae - 9.2%, (n=9)

Enterococcus - 11.2%, (n=11)

3) Micrococcaceae

- Staphylococcus epidermidis - 23,5%, (n=23)

Pathological growth of opportunistic microorganisms was often detected in both study groups. Moreover, in pregnant women who managed to prolong pregnancy for more than 48 hours, pathological growth was detected twice as rarely as compared with the control group. But there was no relationship between the duration of prolongation of pregnancy and the frequency of detection of pathological growth.

In the main group, all three families of microorganisms are equally common. In the control group, the family of enterobacteria predominated - 61.1%, the family of β-hemolytic streptococci was somewhat less common - 24.1%, epidermal staphylococcus was the least common - 14.8%. Moreover, the frequency of occurrence of Escherichia coli, Enterobacter, Klebsiella and β-hemolytic streptococcus of group B is significantly lower in the main group. Therefore, the presence of these microorganisms in pregnant women with PROM will adversely affect the possibility of using tactics for prolonging pregnancy.

In the main group, a positive correlation was found between the presence of pathological growth of conditionally pathogenic microflora and the incidence of chorioamnionitis, R = 0.76 (p<0,05). Так же определяется прямая зависимость между выявлением группы энтеробактерий и развитием хориоамнионита R = 0,54 (р<0,05).

In pregnant women who managed to prolong pregnancy for less than 169 hours, the development of chorioamnionitis directly depends on the detection of pathological growth of opportunistic microflora R = 0.7 (p<0,05) и частотой выявления группы энтеробактерий R = 0,54 (р<0,05). Причем, наличие кишечной палочки приводит к большей частоте развития хориоамнионита R = 0,63 (р<0,05), чем без нее.

When prolonging pregnancy for more than 7 days, a relationship was also revealed between the incidence of chorioamnionitis and the presence of pathological growth R = 0.89 (p<0,05). Как и в других группах, хориоамнионит обусловлен наличием энтеробактерий R = 0,56 (р<0,05).

With the prophylactic administration of ampicillin, in the presence of a group of eterobacteria, the antibacterial effect is possible only in 13.6% of cases, and if this group is represented only by E. coli, the effect of prescribing ampicillin will decrease to 11.7%. If we consider the overall sensitivity, then only 25.6% of all isolated microorganisms will be sensitive to ampicillin. A positive effect from antibacterial prophylaxis will not be observed with the appointment of erythromycin or nitrofurans. The appointment of drugs such as ampicillin, erythromycin, furagin does not have the desired effect due to the low sensitivity of microorganisms, most of which are enterobacteria, the presence of which leads to a significantly higher incidence of infectious complications.

infectious complications.

The incidence of clinically pronounced chorioamnionitis in pregnant women with PROM at 22-30.5 weeks' gestation depends on the very fact of the presence of a long anhydrous period, and not on its duration. A statistically significant increase in the incidence of CA in pregnant women with an anhydrous interval of more than 48 hours was established, compared with those in whom the anhydrous period did not exceed 12 hours (Fig. 1).

Rice. 1. The incidence of chorioamnionitis in the main and control groups.

<0,05).

<0,05).

However, no dependence of the incidence of chorioamnionitis on the duration of the anhydrous period was found, since there is no increase in cases of CA in pregnant women with a PD duration of more than 7 days, compared with pregnant women in whom PD did not exceed 7 days. But in terms of 31-33.5 weeks there is a statistically significant increase in the incidence of CA in the group where the duration of the anhydrous period exceeded 7 days.

We analyzed the data on the average body temperature, the average number of leukocytes and stab neutrophils in pregnant women with CA (clinically expressed and histologically confirmed) and without it. As the statistical processing of the results showed, all three indicators have a reliable prognostic value for the diagnosis of CA. The diagnosis of clinically pronounced chorioamnionitis can be made with an increase in body temperature above 37.50 C, with more than 13 thousand leukocytosis and more than 6% of stab neutrophils. The same situation develops with histologically confirmed CA. It should be noted that the average values ​​of these indicators in the absence of clinically pronounced and histologically confirmed CA are practically the same.

Postpartum infectious complications in puerperas with a long anhydrous period in history were significantly less common than in puerperas whose anhydrous period did not exceed 12 hours.

Indicators of perinatal and postnatal mortality.

The maximum perinatal mortality is observed with the development of preterm birth in gestational lines from 22 to 28 weeks. In our study, antenatal fetal death occurred only in two cases, moreover, the fetuses died before seven days of pregnancy prolongation. With the lengthening of the anhydrous interval by more than 168 hours, we did not reveal an increase in the frequency of antenatal fetal death, with PROM in terms of 22-27.5 weeks. The frequency of intrapartum fetal death in pregnant women who underwent prolongation of pregnancy was 5 times lower than in those who gave birth immediately. In the group where it was possible to prolong the pregnancy for more than a week, the most significant decrease in intrapartum mortality is observed - by 7 times. The highest percentage of early neonatal mortality was in the group where the anhydrous interval was less than 12 hours. Only those newborns who were in an anhydrous period for more than 7 days died least of all in the early neonatal period (Fig. 2).

With the prolongation of pregnancy complicated by PROM for more than 7 days, there is a significantly significant decrease in infant mortality - 5 times. But when prolonging pregnancy for less than 7 days, infant mortality is comparable to the group where prolongation of pregnancy was not carried out at all (Fig. 2).

If we bring to a common denominator all mortality rates of fetuses and newborns with premature rupture of the membranes, at a gestational age of 22-27.5 weeks, then it is necessary to prolong the pregnancy as much as possible, by at least 8 days, since only in this way can the overall mortality be reduced from 83 .3 to 19.2% (Fig. 2).

Rice. 2. The incidence of chorioamnionitis in the main and control groups.

* - the significance of differences was established in comparison with the control group (p<0,05).

**- reliability of differences was established in comparison of the main B with the main A group (p<0,05).

With the development of preterm birth in gestational lines from 28 to 30.5 weeks, perinatal mortality is significantly reduced compared to the previous group. Antenatal fetal death at this gestational age occurred only in one case, and when prolonging pregnancy for more than 7 days, there were no cases of antenatal fetal death. The frequency of intrapartum fetal death is also not significant, and does not depend on the applied tactics of pregnancy management. When prolonging pregnancy for more than 48 hours, regardless of the further duration of the anhydrous period, there are no cases of early neonatal mortality compared with the group where the pregnancy was not prolonged. Therefore, with the prolongation of preterm pregnancy complicated by PROM, there is a significant decrease in perinatal mortality from 15.6 to 6.0% (Fig. 3.).

Rice. 3. The incidence of chorioamnionitis in the main and control groups.

* - the significance of differences was established in comparison with the control group (p<0,05).

With prolongation of pregnancy for more than 7 days, infant mortality decreases from 23 to 2.1%, but with further prolongation of pregnancy, a significant decrease in this indicator does not occur, despite the fact that with the maximum prolongation of pregnancy, no cases of infant mortality were observed at all (Fig. 3 .).

In our study, antenatal fetal death at 31-33.5 weeks during pregnancy prolongation was recorded only in one case, and there were no cases of antenatal fetal death with a PD duration of more than 7 days. As for the intranatal death of the fetus, in pregnant women at 31-33.5 weeks of gestation, such a complication of the birth act did not occur at all. In addition, when prolonging pregnancy for more than 2 days, there is significantly no early neonatal mortality, compared with the group where the pregnancy was not prolonged. Therefore, the decrease in perinatal mortality in pregnant women with conservative tactics of management occurs due to a decrease in early neonatal mortality, and when prolonging pregnancy for more than 7 days, this indicator is equal to zero. In groups in which the pregnancy was prolonged for more than 48 hours, there were no cases of infant mortality (Fig. 4.).

Rice. 4. The incidence of chorioamnionitis in the main and control groups.

* - the significance of differences was established in comparison with the control group (p<0,05).

prolongation of pregnancy, causes of prolongation Pregnancy, which lasts 10-14 days longer, is called overdue.

It is possible both prolongation (lengthening) of physiological pregnancy, and true overbearing. Prolonged pregnancy lasts longer than normal by 10-14 days and ends with the birth of a functionally mature child without signs of overgestation and "aging" of the placenta.

True gestation occurs in 2% of cases and is characterized by the birth of a child with clearly expressed changes in the placenta and signs of gestation: lack of original lubrication, dryness and wrinkling of the skin. The amount of amniotic fluid also decreases.

Among the causes of overgestation, a special place is occupied by endocrine disorders - changes in the functioning of the thyroid gland, diabetes mellitus, disorders of the central nervous system, a change in the ratio of female sex hormones - estrogens and progesterone.

Women who have various diseases of the liver, stomach, and intestines often suffer from overbearing.

various kinds of ovarian dysfunction;

habitual miscarriage;

the threat of termination of a real pregnancy and hormone treatment;

the presence of concomitant pathology;

late preeclampsia;

breech presentation;

sedentary, sedentary lifestyle of a woman before and during pregnancy.

How to avoid the possible complications of overdose?

At the 41st week, a pregnant woman is hospitalized in the department of pathology of pregnant women. There they conduct an additional examination and decide on the further tactics of conducting pregnancy and childbirth. Sometimes doctors have to resort to stimulation (induction).

If the cervix is ​​not ready for childbirth, then for several days it is prepared with the help of special hormone-containing gels - the cervix softens, its canal expands. The implementation of all the recommendations of doctors, as well as regular visits to the antenatal clinic will help you give birth to a healthy and mature baby yourself and on time.

Dermatoses of pregnant women - rare forms of early gestosis. This group of various skin diseases that occur during pregnancy and disappear after it ends. The most common form of dermatoses is itching of pregnant women (pruritus gravidarum). It may be limited to the vulva, may spread throughout the body. For treatment, sedatives, antihistamines, vitamins Bx and B6, and general ultraviolet irradiation are used.

Impetigo herpetiformis (impetigo herpetiformis) is rare. This disease can be fatal. Its etiology is unknown. It appears as a pustular rash. In most cases, the disease is associated with endocrine disorders, especially with dysfunction of the parathyroid glands. Severe general phenomena are characteristic - prolonged or intermittent septic-type fever, chills, vomiting, diarrhea, delirium, convulsions. Itching is usually absent. The disease can be fatal in a few days or weeks, but can be long-term.

For treatment, calcium preparations, vitamin D2, dihydrotachysterol, glucocorticoids are used; locally - warm baths with a solution of potassium permanganate, opening pustules, disinfecting ointments. In the absence of success or insufficient effectiveness of treatment, the pregnancy should be terminated.

Tetany of pregnant women (tetania gravidarum) is manifested by muscle spasms of the upper extremities ("obstetrician's hand"), less often of the lower extremities ("ballerina's leg"), face ("fish mouth"). The basis of the disease is a decrease or loss of the function of the parathyroid glands and, as a result, a violation of calcium metabolism. In severe cases of the disease or exacerbation of latent tetany during pregnancy, the pregnancy should be terminated. For treatment, parathyroidin, calcium, dihydrotachysterol, vitamin D are used.

Osteomalacia of pregnant women (osteomalatia gravidarum) in a pronounced form is extremely rare. Pregnancy in these cases is absolutely contraindicated. The erased form of osteomalacia (symphysiopathy) is more often observed. The disease is associated with a violation of phosphorus-calcium metabolism, decalcification and softening of the bones of the skeleton. The main manifestations of symphysiopathy are pain in the legs, pelvic bones, muscles. There are general weakness, fatigue, paresthesia; the gait ("duck") changes, tendon reflexes increase. Palpation of the pubic joint is painful. X-ray and ultrasound examination of the pelvis sometimes reveals a divergence of the bones of the pubic joint, hence the treatment of the disease. A good effect is the use of vitamin D, fish oil, general ultraviolet radiation, progesterone.

Bronchial asthma of pregnant women (asthma bronchialis gravidarum) is observed very rarely. It is believed that its cause is hypofunction of the parathyroid glands with a violation of calcium metabolism.

Treatment includes calcium supplements, vitamins of group D, sedatives. Bronchial asthma of pregnant women should be differentiated from exacerbation of bronchial asthma that existed before pregnancy.

Prevention. Prevention of early gestosis consists in the timely treatment of chronic diseases, the fight against abortion, providing the pregnant woman with emotional peace, and eliminating the adverse effects of the external environment.

The impact of pregnancy on the course of HIV infection remains unclear. On the one hand, there are data on the acceleration of the progression of the disease during pregnancy: the interval from infection to the manifestations of AIDS is reduced from 6 years to 2-4 years.

Transmission of HIV from mother to newborn is carried out:

a) transplacental

b) in childbirth, by inoculation or ingestion of infected blood or amniotic fluid,

c) after childbirth through mother's milk.

If a newborn in the first days and weeks of life has signs of HIV infection (culture, PCR, serology), then most likely the infection occurred antenatal (about 50%). If HIV is detected on days 7-90 of life and there is no breastfeeding, it should be assumed that the transmission of the virus occurred during childbirth.

The third route of transmission of the virus to a newborn is breastfeeding, which doubles the risk of HIV infection.

Identification of HIV-infected newborns up to 18 months of age is possible only by determining the p24 antigen by PCR or by the cultural method, because IgG received by the fetus from the mother can be determined in his blood up to 15 months after birth.

HIV transmission factors are:

childbirth up to 34 weeks,

method of delivery (CS operation reduces the likelihood of transmission, but to prevent one case of perinatal infection, 16 women in labor must be operated on),

damage to the skin of the fetal head,

hyperthermia in the mother.

MANAGEMENT OF PREGNANT WOMEN WITH HIV.

All women planning a pregnancy should be screened for HIV. It is important to pay attention to risk factors: drug addict partners, a history of blood transfusions, STIs with ulcerative lesions on the genitals.

Necessary activities:

detection of tuberculosis (a papule equal to or more than 5 mm is considered a positive test).

cytological examination of the cervix for the presence of malignant changes (smear with Papanicolaou stain).

control over the immunological status: determination of the number of T-lymphocytes (DM 4 and DM 8).

ZIDOVUDINE (azidothymidine) was the first drug registered for the treatment of HIV infection. In pregnant women, Z. quickly penetrates the placenta,

Treatment of pregnant women with zidovudine.

Management in childbirth.

Delivery is conservative. K.S. to reduce the risk of perinatal transmission - not recommended. The use of forceps and vacuum extraction increases the risk of perinatal transmission of the virus.

After childbirth.

When caring for a newborn, use gloves, wash hands often, avoid surgical interventions, and do not vaccinate with a live vaccine until the fact of infection is clarified. Monitor the presence and level of HIV antibodies: until they disappear or up to 15 months of life.

Ticket 18

During pregnancy, a woman's body undergoes significant physiological changes that ensure the proper development of the fetus, prepare the body for the upcoming birth and feeding. During this difficult period, the load on all organs and systems of a woman's body increases significantly, which can lead to an exacerbation of chronic diseases and the development of complications. heart during pregnancy

The cardiovascular system during pregnancy performs more intense work, as an additional placental circle of blood circulation appears in the body. Here the blood flow is so great that every minute 500 ml of blood passes through the placenta. Instead of 4000 ml of blood, 5300-5500 ml circulates in the body now. Changes in blood pressure during pregnancy

in the last trimester of pregnancy, blood pressure can rise, reaching very high values. High blood pressure (140/90 mm Hg and above) is one of the signs of late toxicosis of pregnant women. Lungs during pregnancy

Due to the increase in the woman's body's need for oxygen during pregnancy, the activity of the lungs increases. The respiratory rate does not change, remains 16-18 times per minute, slightly increasing towards the end of pregnancy. Therefore, if shortness of breath or other respiratory disorders occur, a pregnant woman should definitely consult a doctor.

Kidneys during pregnancy

The kidneys during pregnancy function with great stress, as they remove the metabolic products of the pregnant woman herself and her growing fetus from the body. The amount of urine excreted varies depending on the amount of liquid drunk. A healthy pregnant woman excretes an average of 1200-1600 ml of urine per day, while 950-1200 ml of urine is excreted during the daytime, the rest at night.

Changes in the digestive organs

In the first 3 months of pregnancy, many women experience changes in the digestive organs: nausea and often vomiting in the morning (signs of early toxicosis), taste sensations change, and an attraction to unusual substances (clay, chalk) appears.

The liver during pregnancy works with a greater load, as it neutralizes the metabolic products of the woman herself and the fetus.

Breast changes during pregnancy

During pregnancy, the mammary glands are prepared for the upcoming feeding. They increase the number of lobules, adipose tissue, improves blood circulation. The mammary glands increase in size, the nipples become rough.

Changes in the genitals during pregnancy

The greatest changes during pregnancy occur in the genitals and concern mainly the uterus. The pregnant uterus is constantly increasing in size, by the end of pregnancy its height reaches 35 cm instead of 7-8 cm outside of pregnancy, the weight increases to 1000-1200 g (without a fetus) instead of 50-100 g. The volume of the uterine cavity by the end of pregnancy increases by about 500 once.

Weight gain during pregnancy

The growth of the fetus and physiological changes in the body of a pregnant woman affect her body weight. In a healthy woman, by the end of pregnancy, body weight increases by an average of 12 kg with fluctuations from 8 to 18 kg. Usually in the first half of pregnancy, it increases by 4 kg, in the second half - 2 times more.

2. Childbirth with a generally uniformly narrowed pelvis . A generally evenly narrowed pelvis is characterized by a decrease in all sizes of the pelvis by the same amount distantia spinarum - 23 cm distantia cristarum - 25 cm; distantia trochanterica - 27 cm; conjugate externa - 17 cm. Biomechanism of childbirth: with some delay, the head is inserted with a sagittal suture in one of the oblique dimensions of the entrance to the pelvis; then enhanced flexion is performed, a small (posterior) fontanel is established along the wire axis of the pelvis; further stages of the biomechanism of labor occur as with occipital insertion, but at a slower pace.

In the first stage of labor, the weakness of the tribal forces is more often observed. The head remains movable over the entrance to the pelvis for a long time, there is no contact zone, there is no separation of amniotic fluid into anterior and posterior, which leads to untimely discharge of amniotic fluid.

In the II period, the development of secondary weakness of labor activity is possible, since the advancement of the head is difficult and requires a strong contraction of the uterus. Slow movement of the head through the birth canal can lead to (soft tissue pressure, necrosis and further to the formation of fistulas. When the cervix is ​​fully dilated, a discrepancy (disproportion) in the size of the head and pelvis may be revealed; continued labor activity leads to overstretching of the lower segment and uterine rupture.

After evaluating the results of the examination of the pregnant woman, indications for a planned caesarean section are revealed: narrowing of the pelvis III-IV degree; the presence of exostoses, significant post-traumatic deformities, tumors; the presence of operated genitourinary and intestinal-genital fistulas; constriction of the pelvis of I and II degrees in combination with a large fetus, breech presentation, abnormal position of the fetus, pregnancy overdose, history of infertility and stillbirth, the birth of an injured child in the past, a scar on the uterus. In other cases, childbirth is provided by the natural course of Caesarean section. These signs include 1) the absence of advancement of the head with good labor activity; 2) urinary retention or the appearance of an admixture of blood in the urine; 3) the appearance of edema of the cervix, simulating incomplete disclosure; 4) the appearance of attempts with a high-standing head; 5) a positive sign of Vasten.

Lactational (postpartum) mastitis - an inflammatory disease of the mammary gland caused by bacteria that develops after childbirth and is associated with the lactation process, in which not only the mother, but also the newborn suffers. Infection of the mammary glands occurs either from the focus of chronic infection of the mother, or by hospitalization: from patients with purulent-inflammatory diseases or carriers of Staphylococcus aureus. Also, the source may be a newborn, which transmits the infection to the mother by applying it to the breast. The child becomes infected from medical personnel, items of care for him and linen.

Postpartum mastitis begins with milk stasis (lactostasis). Predisposing factors are anomalies in the development of the nipples (flat, inverted), nipple cracks, structural changes in the mammary glands (mastopathy, cicatricial changes). 3 forms, which are essentially successive stages of the inflammatory process: serous, infiltrative and purulent.

The disease begins acutely, with the appearance of pain and a feeling of heaviness in the mammary gland, chills and fever up to 38°C and above. In 90-95% of patients with mastitis, one mammary gland is affected. The general condition worsens (weakness, headache). The skin in the affected area is moderately hyperemic. The serous form of mastitis is characterized by the formation of inflammatory exudate in the tissues of the gland without focal changes. With a belated or ineffective treatment, the serous form quickly (within 1-3 days) becomes infiltrative. Under the changed area of ​​the skin in the thickness of the mammary gland, a painful dense infiltrate is determined, regional axillary lymph nodes increase. If the infiltrate does not resolve during therapy, it usually suppurates within 5-10 days. Often, the transition to a purulent process occurs after 3-4 days from the onset of the first clinical manifestations of mastitis. Purulent mastitis is characterized by a higher body temperature (39 ° C and above), chills, poor sleep, loss of appetite.

antibacterial agents use amoxicillin/clavulanate 625 mg orally or 1.2 g intravenously 3 times a day for 5-7 days. Staphylococcus cultures are also sensitive to cephalosporins (cephalexin 1 g 2 times a day orally, cefazolin 1 g 2 times a day intramuscularly, etc.). High efficiency (especially in severe cases) showed intramuscular or intravenous administration of cefoperazone 2 g 2 times a day for 5-7 days. With intolerance to drugs of the penicillin and cephalosporin series, which is often cross, aminoglycosides, lincosamides and, in very severe cases, vancomycin are used.

immunomodulating agents, infusion media, antihistamines, analgesics, sedatives and anti-inflammatory agents.

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ovaries The ovaries are paired formations, each the size of a plum. In them, egg cells mature in special egg-shaped vesicles. When the egg cell matures, the vesicle increases, its wall becomes thinner and, finally, breaks; a mature egg is released from the vesicles, which enters the abdominal region. This moment is called ovulation. Between the ovary and uterus is the oviduct, or tube. The end of the tube, which is adjacent to the ovary, consists of a large number of delicate petals that are in constant motion. When the egg comes out of the ovary, they pick it up and drag it into the tube. The tubes are located on both sides of the uterus. Each tube is a narrow channel lined with cells with ciliated hairs (cilia);

The uterus The uterus consists of the cervix and body. The cervix is ​​located deep in the vagina and has a channel leading from the vagina into the uterine cavity. In the body of the uterus there is a cavity, almost a gap, with one lower and two lateral openings. The lower opening is the opening of the cervical canal; side holes located on the right and left in the upper part of the cavity open into the right and left pipes. The cervical canal and uterine cavity are lined with a mucous membrane. By the time of maturation of the egg cell, the mucous membrane of the uterus swells strongly and becomes juicy. A fertilized egg easily settles in the mucosa and is introduced into it. If the fertilization of the egg released from the ovary does not occur, the mucous membrane of the uterus, under the influence of the blood vessels that have burst in it, is rejected and menstruation occurs (menstrual bleeding, menstruation). The Vagina The vagina is a flattened, easily expandable tube. The outer opening - the genital gap - is the entrance to the vagina; the inner end of the vagina ends blindly: in the depths of it is the cervix.

According to WHO, the first the critical period of development falls on the first 2 weeks of development - the period of blastogenesis. The response during this period is realized according to the “all or nothing” principle, that is, the embryo either dies, or, due to its increased stability and ability to recover, continues to develop normally. Morphological disorders that occur at this time are called "blastopathies". These include anembryony, which is formed as a result of early death and resorption of the embryoblast, aplasia of the yolk sac, etc. Some researchers refer ectopic pregnancy and violations of the depth of implantation of the developing embryo to blastopathies. Most of the embryos damaged during the period of blastogenesis, as well as those formed from defective germ cells carrying mutations, are eliminated during this period by spontaneous abortions. According to the scientific literature, the frequency of termination of pregnancy at this time is about 40% of all pregnancies that have taken place. Most often, a woman does not even have time to find out about her onset and regards the episode as a delay in the menstrual cycle. The second critical period of intrauterine development lasts from the 20th to the 70th for after fertilization - this is the time of maximum vulnerability of the embryo. The entire embryonic period - from the moment of implantation to 12 weeks - is a very important period in human development. This is the time when the laying and formation of all vital organs takes place, the placental circle of blood circulation is formed, the embryo acquires a “human appearance”.

Hypotonic bleeding in the early postpartum period. Clinic, diagnosis, treatment. Bleeding that occurs in the first 2 hours of the postpartum period is most often due to a violation of the contractility of the uterus - its hypo- or atonic state. Their frequency is 3-4% of the total number of births. Hypotension is characterized by a decrease in tone and insufficient ability of the uterus to contract.

The causes of the hypo- and atonic state of the uterus are the same, they can be divided into two main groups: 1) maternal conditions or diseases that cause hypotension or atony of the uterus (preeclampsia, diseases of the cardiovascular system, liver, kidneys, respiratory tract, central nervous system, neuroendocrine disorders, acute and chronic infections, etc.); all extreme conditions of the puerperal, accompanied by impaired perfusion of tissues and organs, including the uterus (trauma, bleeding, severe infections); 2) causes contributing to the anatomical and functional inferiority of the uterus: anomalies in the location of the placenta, retention of parts of the placenta in the uterine cavity, premature detachment of a normally located placenta, malformations of the uterus, accretion and dense attachment of the placenta, inflammatory diseases of the uterus (endomyometritis), uterine fibroids, multiple pregnancy, large fetus, destructive changes in the placenta. Such additional factors as anomalies of labor activity, leading to a prolonged or rapid and rapid course of labor, may also predispose to the development of hypotension and atony of the uterus; untimely discharge of amniotic fluid; rapid extraction of the fetus during obstetric operations; the appointment of large doses of drugs that reduce the uterus; excessively active management of the third stage of labor. clinical picture. The first option: it is atonic, does not respond to mechanical, temperature and drug stimuli; bleeding from the first minutes is profuse in nature, quickly leads the puerperal into a state of shock. The second option: the uterus periodically relaxes; under the influence of means stimulating the muscles, its tone and contractility are temporarily restored; then the uterus again becomes flabby; undulating bleeding; periods of amplification alternate with an almost complete stop; blood is lost in portions of 100-200 ml. Treatment. Methods of combating bleeding are divided into medical, mechanical and operational. After emptying the bladder, they begin to massage the uterus through the abdominal wall. At the same time intravenously and intramuscularly (or subcutaneously), drugs are administered that reduce the muscles of the uterus. As such funds, you can use 1 ml (5 IU) of oxytocin, 0.5-1 ml of a 0.02% solution of methylergometrine, ice on the stomach.

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external genitalia

The pubis is an area rich in subcutaneous fat, covered with hairline in adulthood, triangular in shape, with the base facing upwards.

The labia majora are formed by two folds of skin containing adipose 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 labia minora is a mucous membrane in the form of two folds. They are located medially from the labia majora

The clitoris, located in the anterior corner of the genital slit, consists of two cavernous bodies.

The vestibule of the vagina is 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.

The hymen is a thin connective tissue partition that separates the external and internal genital organs.

Usually pregnancy lasts 40 weeks. Every woman is looking forward to the date of birth determined by doctors. But sometimes this period passes, and the child does not seek to be born. Expectant mothers panic, it seems to them that they are overcarrying their baby, and this is fraught with some consequences. At this point, it is important to consult with doctors, determine the condition of the baby and not worry: in most cases, the diagnosis of "post-term pregnancy" is not confirmed.

Postterm or prolonged pregnancy

The duration of pregnancy is on average 40 weeks from the date of the last menstruation. The individual characteristics of each woman suggest that a child may be born earlier or later than this period (38 - 42 weeks) and this is not considered a deviation from the norm. But sometimes women do not give birth, although the gestational age is already 44 weeks. In this case, they speak of a delayed pregnancy.

It is important to determine whether the pregnancy is really delayed. Sometimes women forget the date of the last menstruation, which is why they set the due date incorrectly.

Modern doctors distinguish between true and imaginary overgrowth:

• true pregnancy overshoot is its continuation for more than 10-14 days after a certain period of childbirth, and the child appears with signs of overmaturity;
• with imaginary or chronological post-maturity, they speak of a prolonged pregnancy: it lasts more than 42 weeks, the child is born functionally mature, full-term without signs of overmaturity.

Signs of overexposure

A post-term pregnancy is determined by some signs that inhibit the onset of labor:

• one of the prerequisites for weak labor activity is a decrease in the volume of amniotic fluid,
• the absence of anterior waters (a flat bladder that fits the baby's head) inhibits labor and delays the opening of the cervix,
• definition for a period of 40 weeks of immature cervix,
• narrow seams, and dense bones of the baby's skull will complicate the straining period of childbirth,
• according to ultrasound, the first intestinal secretions of the baby are present in the amniotic fluid - which indicates oxygen starvation of the baby,
• according to ultrasound, signs of aging of the placenta are identified, which cannot cope with the needs of the child,
• also, according to ultrasound data, the absence of flakes of cheese-like lubricant in the amniotic fluid is visible, which indicates dry skin of the child due to its overmaturity
• during a post-term pregnancy, the amount of amniotic fluid physiologically decreases, thus a diagnosis of "" can be made.

Causes of delayed pregnancy

If a woman has a delayed pregnancy, causes This may be due to medical (biological) or psychological factors.

The most common biological causes of overweight are:

• endocrine disorders: CNS disorders, changes in the ratio of female sex hormones, etc.,
• inflammation of the pelvic organs, as well as diseases of the liver, intestines, stomach,
• abortion,
• irregular periods, cycle more than 32 days,
• ovarian dysfunction,
• and hormonal treatment
• a sedentary and sedentary lifestyle before and during pregnancy, as well as prolonged bed rest, lead to the fact that the fetal head does not fall into the entrance to the small pelvis and does not affect the receptors of the cervix,
• pelvic presentation.

The psychological causes of a post-term pregnancy are associated with various fears of the expectant mother:

• If at the beginning of pregnancy there was a risk of losing a child, then the woman is doing her best to reduce the likelihood of miscarriage or premature birth. This is good when carrying a child, but it interferes with childbirth itself.
• can also lead to overdue pregnancy. Doctors, psychologists, as well as family members will help to cope with it.
• The presence of fears associated with the appearance of a baby in a husband can also lead to a woman's lack of confidence in him and in herself, which can lead to a woman's psychological unpreparedness for childbirth.

Possible dangers of overwearing

Many babies born after 42 weeks of pregnancy do not experience health problems, but there are still risks associated with overbearing:

• . When a baby lacks oxygen, he can take his first breath while still in the womb. At the same time, he can inhale amniotic fluid along with his original feces - meconium. In this case, it may develop, the treatment of which requires prolonged artificial ventilation of the lungs and antibiotic therapy.
• An overweight child appears overweight, the bones of the skull become dense, because of which there is a risk of various complications during childbirth in the baby and mother.
• Due to a decrease in the amount of amniotic fluid, entanglement may occur, and there is also a risk of infection of the baby's skin.

What to do when overdone?

Usually, when the pregnancy is overdone, doctors give the woman a referral to the hospital, where they establish the causes of the overgrowth and determine the condition of the fetus. For this, special diagnostic methods are used: ultrasound, cardiotocography, amniocentesis, amnioscopy.

In the future, doctors determine the tactics of pregnancy and childbirth. If doctors have determined that the mother's cervix is ​​already ripe, they resort to to speed up the onset of the birth process. They also turn to stimulation if there are complications in the form of diabetes mellitus, hypertension, cloudy amniotic fluid, or other situations that threaten the health of the child.

If there are some alarming signals (for example, a decrease in the baby's motor activity, a deterioration in cardiac activity), then doctors turn to immediate surgery.