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on methodological meeting
of Department of Obstetrics and Gynecology
with course of Infant and Adolescent Gynecology
“___”______________________ 201_ year
protocol #
T.a.the Head of the department
Professor
________________ O.A. Andriyets
METHODOLOGICAL INSTRUCTION
for practical lesson
“Pregnancy and labor with extragenital diseases”
Chernivtsi – 2010
1. Actuality of theme
Pregnancy is often complicated by extragenital pathology. Some of extragenital diseases are
less clinically relevant but often they can be dangerous both for mother and fetus. Approximately
60% of pregnant women have different types of extragenital pathology. Student needs to be
familiar with the most frequent types of extragenital diseases in pregnant wome, approaches to
treatment and obstetrical tactics.
For the last decades intensity of researches of features of extragenital diseases increases for
pregnant. Considerable successes are now attained in development of obstetric cardiology,
nephrology, endocrinology. The tactic/pl of conduct of pregnancy and labor changed. More
frequent began to allow pregnancy at many forms and variants of diseases, which were before
considered contra-indicated for a genesial function.
Pathology of the cardiovascular system occupies 1st place among reasons of maternal death
rate from extragenital pathology. Very high percent of complications during pregnancy, in labor
and in a puerperium, the disease of kidneys, endocrine pathology (10 - 26% abortion, 14-35%
oligotrophy of fetus, removing layer by layer of placenta), give. At the same time experience
testifies that timely exposure these вадів pathologies for pregnant, assiduous treatment with the
repeated hospitalization during pregnancy, correct conduct of labor and puerperium enable acutely
to reduce lethality and amount of complications at pregnancy, encumbered with cardiovascular
diseases and diseases of kidneys.
2.Purpose of studying :
A student must know:
1. Diagnostics of diseases of the cardiovascular system
2. Diagnostics of disease of the respiratory system, blood of CNS, liver and gall-bladder.
3. Shows are for the pre-schedule breaking of pregnancy at this pathology
4. Features of flow and conduct of pregnancy are at the diseases of the cardiovascular
system, blood.
5. Prophylaxis of complications of the diseases of the cardiovascular system, respiratory
system related to the presence, to blood.
6. Features of corresponding pathology
7. Diagnostics of disease of kidneys, endocrine pathology
8. Features of flow and conduct of pregnancy are at the diseases of kidneys, endocrine
pathology
Student should be able:
1. To diagnose illnesses of the cardiovascular system during pregnancy.
2. To give a conclusion about possibility of maturing of pregnancy or necessity of her pre-
schedule breaking.
3. To develop the plan of conduct of pregnancy at the diseases of the cardiovascular
system.
4. To develop the plan of conduct of pregnancy at the diseases of blood, breathing organs,
CNS
5. To give recommendations in a puerperium at presence of diseases cardiac - vascular
system.
6. To diagnose pathology of kidneys, endocrine pathology during pregnancy.
7. To give a conclusion about possibility of maturing of pregnancy or necessity of her pre-
schedule breaking.
8. To lay down the plan of conduct of pregnancy at the diseases of endocrine pathology.
9. To lay down the plan of conduct of pregnancy at the diseases of kidneys
10. To appoint treatment at the diseases of kidneys during pregnancy
Practical skills:
o To lay down the plan of conduct of labor at the diseases of the cardiovascular
system, at a diabetes mellitus, diseases of the respiratory system, liver and gall-
bladder
o To lay down the plan of conduct of labor at the diseases of kidneys
o To appoint treatment at the diseases of kidneys during pregnancy
o To estimate clinical and laboratory indexes at extragenital diseases
3. Basic part
Disease of the cardiovascular system
Cardiac insufficiency is inability of heart to provide circulation of blood, corresponding
metabolic processes of organism in the period of pregnancy and labor. For pregnant insufficiency
of circulation of blood mostly develops at the purchased and congenital defects of heart, illness of
myocardium, chronic diseases of heart.
In the first months of pregnancy insufficiency of circulation of blood develops rarely. It
more frequently arises up at the end of to 2 trimesters of pregnancy, so as to 26-28 weeks of blood
circulation volume maximally increases during pregnancy, as well as intensity of work of heart. In
labor and early puerperium haemodynamic violations appear: repeated in-flow of blood 400-800 ml
at every uterine contraction, over-load by blood vessels of abdominal region after labor, rapid
decompression of bottom veins, pain syndrome which provokes development of insufficiency of
circulation of blood. These conditions are critical.
Chronic heart failure
Classification of heart failure of New York association of cardiologists (1995)
Functional class Sick with a disease hearts but No-symptom dysfunction of
I limitation of activity the left ventricle
FC ІІ Sick with a disease hearts are with Mild heart failure
small limitations of physical activity
FC ІІІ Sick with a disease hearts, Moderate heart failure
considerable limitation of physical
activity
FC IV Sick with a disease hearts in which Severe heart failure
even minimum physical exercise
causes discomfort
In our country the accepted classification of chronic heart failure by Н.Д.Стражеско-
В.Х.Василенко.
1st stage: symptoms of violation of circulation (of blood of dyspnoea, palpitation, fatigue
appearing only after physical effort).
2nd stage A: stuffiness and palpitation become almost permanent or appear at very easy
physical effort; the symptoms of heart dilatation and stagnant phenomena appear in the small circle
of circulation of blood at left-ventricle insufficiency, in liver at insufficiency of right part of heart.
2nd stage B: the blood sludge expressed as in small so in the large circle of circulation
(symptoms circulation disorders are present in liver, kidneys, edemas are acutely expressed at
insufficiency of right heart) of blood
3rd stage: the irreversible dysfunctions of all organs are expressed: the signs of dysfunction
of all organs develop in them; the signs of metabolic, feed, of dystrophic changes develop in them.
It is known that normal pregnancy can be complicated by appearance of symptoms of
insufficiency of blood circulation. A characteristic to healthy pregnant hyperpnoe gives the
impression of presence of stuffiness sometimes. For healthy pregnant there can be periodic
tachycardia (up to 100 beats in 1 min), extrasystols and other violations of rhythm, edema on feet,
dizziness, weakness, stethalgia.
Rheumatism is the system disease which includes inflammation of connecting tissue
with recurrent localization of process in the organs of circulation of blood.
A causative agent is β-hemolytic streptococcus of group А.
Classification of rheumatism by А.І. Нестеров:
1 - mild. It is characterized by weak expression of clinical symptoms of active rheumatism,
almost complete absence of signs of exsudate to the component inflammation in organs. Laboratory
indexes or not deviate from a norm, or changed minimum.
2 - moderate. It is characterized by the moderate clinical displays of rheumatic attack with a
not high fever or without her, without the expressed exsudate to the component inflammation in the
staggered organs. The laboratory signs of activity of process are mildly expressed. Leucocytosis
can be absent, RSE and other laboratory indexes is mildly increased.
3 - severe. Characteristic used for setting inflammation and local displays of disease with a
fever with advantage of exsudate to the component inflammation in the organs involved (acute
polyartritis, diffuse myocarditis, pancarditis, rheumatic pneumonia. In blood expose neutrophilic
leucocytosis, high RSE, С-reactive albumen, growth of level of Fibrinogenum etc.
During pregnancy it is very important clarification of activity of rheumatic process, so as
it determines not only the necessity of treatment, prophylaxis but also obstetric tactics, id est
activity is the criterion of possibility of maintenance or necessity of terminating pregnancy, also
choice of method of labor tactics.
Pregnant who suffers rheumatism has to be under strict clinical supervision of internist in
the female dispensary. At suspicion on activity of rheumatic process for diagnosis and treatment the
pregnant must be hospitalized in therapeutic department or a maternity hospital is specialized.
An active rheumatic process is contra-indication for pregnancy, especially at the acute
and subacute flow of disease. Pregnancy is contra-indicated in case when after the rheumatic attack
of passed less than 6 months.
At minimum activity of process (1st degree), if pregnant insists, pregnancy can be saved.
Thus it follows to take into account that medications of treatment of intensifying of rheumatism in
a 1 trimester are very limited (salicylates are contra-indicated). At FC 1 or 2 and at an active
rheumatic process conducted the stage of delivery through natural labor ways with the exception of
pushing efforts (imposition of obstetric forceps). In case of decompensation of blood circulation
caesarian section is indicated.
Treatment:
etiotropic therapy-penicillines;
Steroid and non-steroid medications give an anti-inflammatory effect and are symptomatic
but not nosotropic medications.
corticosteroids + prednisolon - 5 mg, dexametazone - 0,5 mg. They are
indicated in case of severe carditis, pericarditis, in case of unbearableness or inadequacy of
salicylates.
aspirin and other non-steroid drugs are indicated in case of weakly expressed
carditis. It should be remembered that under act of aspirin the chromosomal aberration
increase in lymphatic cages, that specifies on possibility of mutagene effect. Preparation
represses the biosynthesis of простагландинів of Е and F2 also, which stimulate reduction
to the myometrium which can become reason of the protracted labor or переношування of
вангітності.
at unbearableness of salicylates shown analgin, бутадіол.
Prophylactic treatment is conducted 3 times during pregnancy: 12 weeks, 28-32 weeks,
in post-natal period.
Diagnostics of hepatitis
Clinical data.
Presence one or more syndromes:
- it is an intoxication syndrome;
- it is an asthenovegetative syndrome;
- it is a cholestatic syndrome;
- it is the inflammatory syndrome;
- it is a cytolytic syndrome;
- - other.
Laboratory indexes.
1. A global analysis of blood is leucopenia (possibly leucocytosis), lymphopenia, decline of
RSE etc.
2. Biochemical indexes of blood are an increase of general bilirubin mainly due to direct,
increase of activity of АLАТ, and in less degree АSАТ, dysproteinemia, increase of thymol test,
decline of index of fibrinogenum, appearance of foods of disintegrations.
3. Specific inspection (an exposure is in blood) :
By the method of ІФА :
- it is hepatitis of А- of HAV IgM - even a single exposure is absolute proof of disease
(appear in blood 4-5 days prior to the exposure of symptoms of disease and disappear through 6-8
months);
- it is hepatitis In - HBsAg (basic marker of infecting of НВ - by a virus, it appears from
3-5 week of disease and determined 70-80 days), HBeAg (a marker of epidemiology risk, active
replication of virus and transmission is from a mother to the fetus; of the impression of fetus
here rises to 90%), HBcAg (it is not determined in blood, but there can be antibodies to him are
of HBcIgM and HBcIgG, that testifies to etiology of ГВГВ and about the prospect), HBcorAg,
HBxAg, of HBc IgМ;
- it is hepatitis of С - анти- of HСV IgM (a diagnostic value is at chronic hepatitis);
- it is hepatitis of D - HBsAg (a marker active of virus at acute hepatitis), - of HDV IgM
(appear on 10-15 day of disease and 2,5-3 months are kept);
- it is hepatitis of Е- of анти- of HЕV IgM.
By the method of PCR (on possibility) :
- it is hepatitis of А- of RNA of HAV;
- it is hepatitis In - DNA of HВV;
- it is hepatitis of С- of RNA of HСV;
- it is hepatitis of D - RNA of HDV;
- it is hepatitis of Е- of RNAof HЕV.
4. Urobilinuria.
About the unfavorable prognosis of hepatitis testify:
- it is appearance of hemorragic syndromes;
- it is an increase of level of general bilirubin anymore as 200 мкмл /л due to indirect;
- it is a decline of activity of АLАТ to the norm on a background growth of intoxication and
height of level of bilirubin;
- it is a considerable decline of level general protein, A/G coefficient <1,
- it is a decline of протромбінового index ≤ of 50% and Fibrinogenum.
Delivery conducts taking into account an obstetric situation at the worn pregnancy.
Puerperium:
- it is the protective mode
- it is the balanced feed (diet №5)
- - a patient can be written depending on involution of uterus on a 3-5 twenty-four hours. At
excerption estimate the state of patient. During the incomplete stabilizing of the state is shown
перевід in a therapeutic unit or in surgical permanent establishment.
After an extract from the maternity hospital of watching women with a chronic
cholecystitis:
- - for patients with a cholecystitis conduct a rehabilitation on a therapeutic area, in the
sanatoriums of gastroenteric type.
- - for women with a calculary cholecystitis decide a question about планове operative
treatment.
Vascular diseases of vessels of cerebrum and pregnancy.
Vascular violations of cerebrum can arise up at atherosclerosis, hypertensive illness,
kidney hypertension, endocrine pathology, traumas, aneurysm of vessels of cerebrum, dystonias,
cardiac pathology, infectious and allergic, at pulmonary insufficiency, diseases of blood. Each of
these diseases in the period of pregnancy and labor can show up in form different variants of acute
violation of cerebral circulation of blood. Character of violation of cerebral circulation of blood for
pregnant and during labor it can be in the form of transitional or proof violations with the
considerable defect of flows, up to a paralysis.
Classification. To transitional violations of cerebral circulation of blood ischemic attacks
(ТІА) behave at infectious and allergic , cerebral vascular crises(high- and low blood pressure).
Sometimes ТІА shows up in form vestibular violations (dizziness, vomiting, ataxia, nystagmus).
The feature of vascular cerebral кризів is absence of explorer sensible and mobile violations at
presence of brain symptoms (headache, vomiting, change of propulsion MODULE - гіпо- and high
blood pressure, vegetative violations).
A "stroke" or "cerebral blow" is included in the concept of proof violations of cerebral
circulation of blood. A stroke is acute violation of cerebral functions of vascular genesis with
general and symptomes by duration more than 24 hours and can be ischemic and hemorragic. At a
hemorragic stroke hemorrhages are determined or in cerebral fabric, or under pia maters. The flow
of vascular diseases of brain always becomes acute during pregnancy. Hemorrhages in a brain arise
up suddenly under act of acute tension at pregnancy or in labor.
Clinic: weight is sometimes preceded a stroke in a head, dizziness, headache, and
sometimes suddenly pregnant is unconsciousness, hyperemia of face, cyanosys of mucous
membranes, puffiness of face, pulsation of vessels, appears on necks, breathing hard, skin covers
moist, cold, temperature of low, pulse a liquid, tense, arteriotony is mionectic, pupils extended,
flows of eyeballs, defect to the mouth, paralyses or paresises appear, tendon reflexes on the side of
paralysis are mionectic, low blood pressure of muscles, abdominal reflexes absent, the symptom of
Бабінського can appear. Vomiting, violation of oesophageal reflexes develops sometimes. A blood
test is leucocytosis, hyperglycaemia, increase of remaining nitrogen. Blood is determined in a
neurolymph.
Barrel symptoms - violations of breathing and cardiac activity appear at widespread
encephalorrhagias.
Possible subacute flow is a headache, vomiting, with further development of symptomes.
Subarachnoidite hemorrhage. In a clinic the symptoms of irritation of pia maters prevail:
headache which carries acute character or terebrant pain with different localization, sudden
vomiting, dizziness, sonitus, excitation, epileptic attacks, sometimes acute getting up of propulsion
MODULE symptoms appear early, the genicular go out and ахілові reflexes. Face of patient of ,
temperature increased. An eyeground is hemorrhages in a retina, stagnant. For diagnostics it is
necessary to conduct of spinal cord, at which a liquid is evenly painted by blood.
The always favourable ran across. Proceeding in the broken functions comes in 3-4 weeks
after a hemorrhage. However for pregnant a clinic runs across more difficult and a prognosis
depends on localization and sizes of hemorrhage.
Ischemic stroke or cerebral heart attack. On the mechanism of development an
ischemic stroke can be caused by the spasm of cerebral vessels, thrombosis of vessels of brain,
atherosclerotic changes of vessels.
An ischemic stroke at late токсикозах of pregnancy is observed rarer from hemorragic.
They develop at in combination with rheumatic heart diseases, defects of heart, to blinking
arrhythmia, low blood pressure. Ischemic strokes develop gradually. In a clinic characteristic is
advantage of local symptoms above unlike a hemorragic stroke. At the heart attack of brain
consciousness is stored, insignificant headache, possible vomiting. A characteristic clinic of
cardiovascular insufficiency is with the changes of pulse and arteriotony. Symptoms show up as a
hemiparesis, hemianesthesias.
The clinic of thrombosis of vessels of cerebrum is characterized by the signs of high of
intracraneal pressure, which shows up a headache, dizziness, vomiting, seisure attacks. Violation of
sensitiveness, paresthesia, paresises and paralyses, show up. The clinic of thrombosis of vessels of
cerebrum depends on localization of blood clot.
Embolism of vessels of cerebrum is possible for pregnant at presence of endocarditis,
rheumatic mitral illness. A clinic develops acutely - appear cramps, dizziness, temporal loss of
consciousness. A face becomes pale, a pulse is frequent, rhythmic and corresponding cardiologic
status. It is arisen up mono- or hemiplegia.
Treatment of cerebral stroke :
1. Treatment of cardiovascular insufficiency – strofaitine, cordiaminum. In the case of
sudden stop of heart is an indirect massage of heart, adrenalin in myocardium.
2. At a pulmonary edema is breathing in oxygen with the pair of alcohol. Diazepamum
is used.
Conduct of pregnancy and labor at acute violations of cerebral circulation of blood :
1. In the early terms of pregnancy with appearance of clinic of hemorrhage or
thrombosis of vessels it is necessary to put a question about terminating pregnancy with the
previous stabilizing of process.
2. At the terms of pregnancy of 16 тиж. and it is anymore recommended to decide a
question individually taking into account character of cerebral stroke, reason, that caused him.
3. At a acute stroke in ІІІ trimester of pregnancy - labor (caesar section) after
stabilizing of process.
4. At presence of the remaining phenomena after acute violation of cerebral circulation
of blood labor can be conducted through natural maternity ways with the exception of ІІ of period
of labor or operation of caesar section.
Epilepsy is a chronic neurologic disease. Occurs often (in 5 persons on a 1000
population) enough. The real epilepsy is an only disease with the special clinical presentation, flow.
Epileptic attacks show up in form large convulsive attack, small attack and epileptic status. There
are other forms of attacks : attack, turn of chairman and eyes in parties, disorders of memory.
A large convulsive attack has a tonic and clonic phase. A tonic phase begins from the loss
of consciousness. All muscles are in tonic tension. On face a grimace, pupils extended, does not
react on light, a chairman and eyes is returned, jaws are compressed. Breathing is stopped, face
pale, and then . A tonic phase lasts a few seconds, and then a clonic phase comes. There are short,
unrhythmic, strong shoves in all muscles. This phase proceeds from 2-3 to 5 min. From saliva is
distinguished a mouth as suds, sometimes painted by blood. Often wilful urination. Later there is
the state an attack, a patient wakes up then, but does not keep remembrances about a past attack.
A small attack is a sudden, short (a few seconds) stop of ideas. At this time face of pale, a
patient does not fall, reductions of muscles of face or extremities are possible.
Epileptic status is possible both at epilepsy and at other of cerebrum. Going out it, patients
with epileptic status are divided into two groups: patients with epilepsy as with a basic disease and
epilepsy in combination with other diseases of cerebrum. At pregnancy epileptic status is observed
very rarely. In case of his occurring erroneous judgement is possible, that it is an eclampsia with the
loss of consciousness. Lethality is 16-20% cases.
The clinic of epileptic status is characterized by violation of consciousness, булькаючим
breathing, by frequent cramps with the expressed tonic tension of all muscles, cyanosys which
grows, expansion of pupils, threadlike pulse, unpleasant smell of patient.
A convulsive syndrome shows up the attacks of cramps, which arise up periodically from
2-3 to 20 and anymore during a hour and last from 30хв. to 20-30с. there are the phenomena of
cerebral edema at heavy flow of status. Epileptic status on character of convulsive displays is
divided on general, partial and one-sided.
Pregnancy and labor is at epilepsy. One opinion about influence of pregnancy on flow of
epilepsy it is not. Some authors consider that during pregnancy the displays of basic disease
diminish, and other - vice versa, pregnancy influences negatively on flow of epilepsy.
For patients violations of, aquatic-salt, carbohydrate proteometabolism and function of
liver appear with epilepsy; changes of saccharine curve, diminishing of amount of hepatin and
increase of suckling acid in muscles, decline of and concentration function of kidneys.
For patients with epilepsy more frequent there are early and late gestoses.
Tactic/pl of conduct of pregnancy and labor :
Necessary early exposure of pregnant with epilepsy and compatible supervision of these
patients by a psychiatrist, neurologist, accoucheur, internist and timely decision of question about
expedience of prolongation of pregnancy.
Some authors consider that pregnancy is at epileptic status, and at other forms of disease
possible maintenance of pregnancy subject to condition regular anticonvulsant therapy and periodic
hospitalization of these patients in permanent establishment.
An obstetric tactic/pl must be individual. It is considered in general that pregnancy can be
continued at the liquid attacks of cramps (1-2 times on a month), in default of heavy other diseases
and desire to have a child. Continuous anticonvulsant therapy is conducted in these cases.
Hospitalization in permanent establishment it is necessary to conduct 2 weeks prior to labor.
Plan of conduct of labor :
1. Pain relief of labor.
2. Bleeding prophylaxis in ІІІ period of labor.
3. At worsening of the state conduct the exception of ІІ of period of labor or at the
incomplete opening of ш/m and unefficiency of anticonvulsant therapy is craniotomia.
4. Labor by a caesar section it is shown: at epileptic status, frequent, heavy attacks
which do not yield to the combined medicinal therapy, and also at the increased sensitiveness to
medicinal medications.
Treatment of epileptic status
By basic principle of therapy of patients with epileptic status of stage, complexity of
treatment. Medical measures divide into next groups:
1. Medicinal therapy.
2. Unmedicinal therapy.
3. Surgical.
4. A care is of patient.
First help.
A release is from bodies, the vomitive masses of overhead respiratory tracts.
Introduction of air tube.
Injections of cardiac medications
Seduxenum of 10мг in/on 20 мл of 40% solution of glucose, to enter slowly.
An intubation is conducted if necessary.
At unefficiency of седуксену, conducted in anesthesia (to 1% solution of tiopental
sodium or hexenal - 50-ml).
Myasthenia is a heavy disease with the progressive flowing, shows up a weakness and
pathological fatigueability of muscles.
Frequency of is 0,15% among other nervous diseases.
Most difficult is a question about etiology and pathogeny of міастенії. Disfunction of
тимусу (лімфоїдна гіперплазія, tumours) matters at this pathology; endocrine-vegetative
violations; the carried encephalitis is with the defeat of hypothalamic area; аутоімунні violation;
diminishing of amount of АХ-рецепторів is in нервово-м'язових синапсах.
Clinic. The characteristic sign of міастенії is a muscular weakness, dysfunction of
muscles, which move an eye, dysfunction of masticatory and mimic muscles, syndrome of
бульбарного параліча, violation of functions of muscles of extremities, neck and trunk : atrophy of
muscles послаблення of м'язевого tone; decline of tendon, skin reflexes; phenomenon of
генералізації м'язевої of fatigue; changes of cardiovascular activity.
М'язева a weakness is noticeable even at watching a patient in a state of calmness.
Possible origin of paresises and paralyses which diminish after rest or use of прозериноподібних
medications.
Disorders of function of oculomotor muscles show up in form птоза different degrees of
expressed, with acute limitation of flows of eyeballs, doubling in eyes.
Syndrome of бульбарного параліча shows up paresis or paralysis of tongue with
disorders of language, хриплість, афонічність, hit of spoon-meat in a nose. At the weakness of
muscles of larynx and respiratory muscles there is closing of included надгортанником in a larynx
with the displays of stuffiness as a result of accumulation of mucus. In these cases there is a
necessity of urgent tracheotomy or intubation with sucking of mucus.
The dysfunction of muscles of extremities is observed relatively rarely and mainly in
proximal departments.
At the defeat of respiratory muscles there is a stuffiness, frequent shallow breathing, acute
stop of breathing.
Violation of sensitiveness shows up as paresthesias, feeling of crawl of ants, by periodic
pain in muscles.
In 32% of patients there is cardiovascular insufficiency, complaints about palpitation,
unpleasant aching and squeezing pain in the areas of heart, interruptions and feeling of "stopping"
beating of heart.
Distinguish the next types of clinical flow of :
the first type is the acute beginning, a clinic lasts from a few weeks to 2-3 months
with further progress;
the second type is the acute beginning, but a clinic fully shows up from 3 months to
1 year, a process makes progress in future;
third type - the gradual beginning over, a clinic fully shows up during a few years
with slow progress which brings to disability;
4th type - shows up a few symptoms with slow progress and disability.
Flow during pregnancy.
In the early terms of pregnancy - first three months there is worsening of the state of
patients and it is related to the increase of amount of pregesterone in an organism and decline of
естрогенів; from 4 months of pregnancy - improvement, and nearer to labor - again there is
worsening of general of pregnant.
For patients in a state of remission or with the local easy forms of disease pregnancy and
labor ran across well and there was diminishing of symptoms of disease in majority, but in 1/5
patients there was intensifying of process in a puerperium.
If a disease makes progress and symptoms are not corrected by application of and
potassium medications, pregnancy is contra-indicated. At plugging in a process vitally important
organs pregnancy termination is a necessity regardless of term of pregnancy.
With the heavy form of disease to and після of labor recommend a patient to appoint
prednizolone.
Labor it is better to conduct through natural maternity ways with the adequate
anaesthetizing.
Tactic/pl of conduct of pregnancy and labor
1. In 2nd trimester of pregnancy is hospitalization in a neurological unit.
2. At the easy form of міастенії or at the compensated processes and at the desire of
woman to have a child, pregnancy can be kept under surveillance of neurologist, internist and
endocrinology with continuation of reception of medications of type of prozerin in combination
with the vitamin of В1, В12 and chlorous potassium.
3. In the cases of abandonment from terminating pregnancy worsening of the state, it is
necessary to promote the doses of treatment.
4. Predelivery hospitalization is in permanent establishment. To shut out over-term of
pregnancy.
5. Labor it is better to conduct through natural maternity ways; at intensifying is a
caesar section under intratracheal anesthesia with the use of artificial ventilation of lungs.
6. In labor it is necessary to remember about possibility the weaknesses of childlabor is
timely stimulation by Oxytocinum and prosteglandines; in ІІ period of labor possible weakness of
tone of muscles of neck, extremities and that is why it is necessary to be ready to imposition of
ferceps. In ІІІ period of labor is a bleeding prophylaxis.
In puerperium period to continue treatment of basic illness. In addition at labor it is
necessary to remember the origin of respiratory insufficiency about possibility.
7. In a післяпологовму period it is necessary to continue treatment of basic disease for
woman, and sometimes to put a question about her translation in a neurological unit.
8. In new-born in the first 2 weeks there are signs of transitory myasthenia (low blood
pressure, hyporeflexia, weakness), which pass after treatment of prozerine.
The dissipated sclerosis (РС) is a widespread enough and heavy disease of CNS of
remittant character and occupies a leading place in the group of demyelinating defeats of
head and spinal brain with gross violation of circulation in these structures.
At РС a possible indrawing is in the process of lanocs of defence. In marrow the revival of
neutrophilic sprout is determined on the initial stages of disease, gradual decline of amount of cages
of marrow in the process of disease. In timus is hyperplasya, at the heavy forms of РС is his
involution, excrescence of ephithelial stroma, increase of little bodies of Gassal is structural
elements, what uninherent in a norm for this organ; diminishing of amount of T-cell and
suppressors, increase of В-cells. Lowering of protective properties of organism stimulates the
products of autoantibodies against myelin.
Clinic. РС runs across in such forms:
cerebral;
spinal;
cerebrospinal.
The last form is divided into a hyperkinetic and eye variant. Characterizes this form
combination of pyramid violations, possible defeats visual to the nerve with development of
diplopia.
The early symptom of РС is transitional agile, sensory or visual violations, loss of
abdominal reflexes, weakness of feet easy tremor in hands. Quite often there is a paropsis for to the
type of bulbar neuritis of visual nerve with the fall of central eyeshots. A loss of eyesight is partial
or bilateral.
Possible defeat of peripheral agile neurons: loss of tendon reflexes, atrophy of muscles.
The special symptom at РС are paresthesias which arise up at the acute bending of chairman
forward, to the breasts - feeling of electric current which runs across on a backbone downward with
an irradiation in feet, sometimes in hands. In the stage of height of disease the 90% cases have
paresis. Symptoms show up a cerebellum in a kind: ataxias, дизметрії, дизартрії, nystagmus;
rough тремор of extremities and chairman, which arises up at flows and tension. At a heavy form is
a dementia, euphoria and expressed forms of psychical disorders, violation of urination.
For early diagnostics of РС it is recommended to conduct research of eyeground, indexes
of spinal puncture (moderate increase of albumen with the increase of level γ-Gl), computer
tomography, research of immunological status, hormones.
Treatment of РС :
Etiologic treatment (treatment antiviral medications).
Immune therapy, including hormones and them synthetic analogues.
Symptomatic therapy is on the correction of violations of functions of the system of
homoeostasis, functions of the nervous system.
At the choice of method of treatment it is necessary to take into account the stage of
disease, type of flow, phase of disease.
Flow of pregnancy and labor. Pregnancy has a negative influence on flow of РС. During
pregnancy there is worsening of flow of РС or origin of the first displays of disease. At the acute
intensifying a disease in labor can arise up weakness of labor. To have of high quality flow of РС
and desire of woman a child is given by possibility of prolongation of pregnancy under surveillance
of neurologist.
Complication during labor:
premature outpouring of amniotic waters;
weakness of childlabor;
possibility of low blood pressure of uterus in the third and in an early puerperium;
hypoxia of fetus.
Tactic/pl of conduct of pregnancy.
1. At pregnancy at this group of patients it is necessary to cut pregnancy short, taking
into account the possible intensifying.
2. In the case of prolongation of pregnancy at will of woman, permanent control from
the side of accoucheur and neurologist, permanent treatment of РС.
3. Hospitalization of such patients in permanent establishment for 2 weeks before labor.
4. Plan of conduct of labor :
labor are conducted conservatively;
at the ill-timed outpouring of amniotic waters is stimulation of childlabor;
prophylaxis of infectious complications;
at the weakness of childlabor medicinal stimulation is conducted;
a bleeding prophylaxis is in ІІІ and early puerperium.
Complex therapy of basic disease is conducted in a puerperium.
Diseases of kidneys
Complication of pregnancy
1. Miscarriage is in 46% (some authors consider that the increased synthesis of
thyroxine unfavorably influences on implantation of oosperm which results in to abortion).
2. Early gestosiss, that coincides with intensifying of illness and it is bound to the
changes at CNS and exchange processes. A gestosis at Based illness runs across unfavorably,
badly responds to treatment, in connection with what pregnancy forced to interrupt.
In ІІ late gestosis develop the half of pregnancy and mostly they run across with a
hypertension syndrome. Labor in most роділь pass without complications, often take place
quickly, childlabor active. In ІІІ period quite often there are bleeding in connection with
violation of homoeostasis. In the first days after labor there is intensifying of базедової illness
the symptoms of which increase with a lactation. Sometimes a lactation is halted in connection
from intensifying by illnesses by treatment of patient, so as medications pass to milk and in the
organism of child.
Treatment: extract of valerian. Iodine-thyronin for 0,05х2 times on a day at the easy form.
At a middle degree - 0,15-0,2 gs/of доб. and 2-3 weeks prior to labor stop the reception of
дійодтироніну. At the conduct of heavy forms illnesses appoint mercazolil 0,005 to 40 мг in a day
and for 60 мг in a day - at heavy. At achievement of the good state a dose is diminished by to 5 мг
on a day.
Influence of thyroid hormones on a fetus: influence on a height and fetation, development of
pulmonary fabric, on the processes of myelinization of cerebrum.
Defects for children are observed in 19%, from them in 4% are defects of development of
brain, in 0,8% - cardiovascular system, in the 8,6% defects of development of genital organs, у4%
are кили, in 0,8% is a defect of soft palate and in 0,8% illness of Down.
The born children have a decline of hormones of thyroid, which bind to oppression to the
тіреоїдної function to the hypophysis of fetus maternal by thyroxines.
There is гіпотіреоз in 12%. For children dry filling out skin, пергаментність bones of
skull, increase of tongue, м'язева low blood pressure, hyporeflexia, slow peristalsis of кишківника.
These phenomena pass in the first 2 weeks of life of child, the half of children needs realization of
replace endocrinotherapy.
Conduct of pregnancy
The pregnant is under surveillance of accoucheur and endocrinology. At the heavy forms of
Based illness pregnancy is contra-indicated, for this purpose the pregnant must be hospitalized in
early terms to pregnancy, to inspect. At key forms operative treatment is shown in the end And to
the trimester. During pregnancy is control after the level of hormones and obligatory treatment. At
intensifying of illness is hospitalization. In labor to conduct a bleeding prophylaxis in ІІІ period of
labor. The new-born must be under a permanent supervision and to conduct adequate treatment
them .
At a thyroprivia pregnancy comes rarely, but comes even if, then children give labor
inferior. Pregnancy is interrupted even at the subclinical forms of hypothyreosis. Quite often iron-
deficient anaemia develops for pregnant. The weakness of maternity forces develops at labor.
For pregnant the state can become better due to the hormones of fetus. The new-born often
give labor with the signs of hypothyreosis, anomalies of development of brain, illness of Дауна.
The pregnant from hypothyreosis behave to the group of risk, they must conduct treatment:
thyroidine 0,1 № 50 for 1 pill 2-3 times on a day; triiodothyronine 0,00002 for 1 pill 1-2 times on a
day during all pregnancy under control research of hormones.
6.Methodical materials:
6.1Materials to control of base preparation of students: situational tasks.
6.2 Materials for the methodical providing of the basic stage of employment: tool of
maternity hospital, history of labor.
6.3Materials for the final stage of employment: clinical situational tasks.
6.4Materials for the methodical providing of self-study of students in the corresponding
methodical pointing for independent work.
Task № 1. Multipara 27 years at pregnancy 36 weeks entered a term maternity unit with
regular fights, that began 6 hours to the volume. It was ill a quinsy. From 16 years is on "Д"
of account in connection with the defect of heart. Obstetric anamnesis is without features.
Under surveillance of district accoucheur in woman consultation since from 8 weeks of
pregnancy. At the beginning and at the end of pregnancy was on prophylactic stationary
treatment. Objectively: In the lungs of the vesicular breathing. A liver is not megascopic.
Spleen is not palpated. The symptom of Pasternatskyi is negative on either side. In 20
minutes after amniotic waters released and beginning of pushing efforts a living boy was
born by mass of 2450г, long a 44 cm. After labor of child the state of породіллі became
worse acutely, a skin had gone by pale, sticky sweat appeared, a pulse became more
frequent, weak filling and tension, BP - 90/50 мм.рт.ст. Consciousness is stored.
1 .Diagnosis.
2. Reason of worsening of the state of woman is after labor of child.
З. How to prevent this complication.
Task. №2. Unit of pathology of pregnant the pregnant entered, pregnancy And, 27 weeks with
complaints about a fervescence to 380С, chill, pains in a lumbar area. Objectively: skin of
гіперемована, the symptom of Пастернацького is acutely positive on the right. An uterus is easily
excitative.
Your diagnosis?
Appoint treatment.
Task № 3.To the doctor of перинатолога the pregnant appealed concerning registering. Pregnancy
And, 7-8 weeks. Hypertensive illness of ІІа of century. In what terms of потібно to hospitalize
pregnant in what permanent establishment?
Tests.
For pregnant the volume of circulatory blood increases in a term:
А. of 28-32тиж.
В. of 39-40тиж.
С. of 22-23тиж.
D.37-38тиж.
Е. of 21-22тиж.
An congenital defect is hearts which are протипоказом for maturing of pregnancy :
А. Тетрада of Фалло
В. Defect of міжпередсердсерної membrane
С. Defect of міжшлуночкової membrane
D.The arterial is open channels
Е. Stenosis of mouth of aorta
Optimal term of пологорозрішення for pregnant with a diabetes mellitus:
А. of 36-37тиж.
В. of 39-40тиж.
С. of 34-35тиж.
D.37-38тиж.
Е. of 31-32тиж
7.Literature
Basic:
1. Э.К. Айламазян. СПб. "Специальная Литература", 1997. - С. 199-229
2.Бодяжина В.И., Жмакін К.Н., Кирющенков А.П. Акушерство. - М.: Медицина, 1998. - С.
251-252.
3.Шехтман М. М. Экстрагенитальные заболевания и беременность. - М.: Медицина, 1999.
4. Наказ МОЗ України № 676 Про затвердження клінічних протоколів з акушерства та
гінекології від 31.12.2004р.
Additional:
1. Гилязутдинова З.Ш. Беременность и роды at заболеваниях центральной и
периферической нервной системы. Из-во Казанской университета. 1988.- С. 10-33, 98-
110, 116-130.
2. Серов В.Н., Стрижаков А.Н., Маркин С.А. Практическое акушерство. - М.: Медицина,
1989.