“Approved”
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”
MODULE 4: Obstetrics and gynecology
CONTEXT MODULE 9: Pathology of pregnancy, labor and puerperium
Subject: Obstetrics and Gynecology
6th year of studying
2nd medical faculty
Number of academic hours – 6
Methodological instruction developed by:
ass.prof. Andriy Berbets
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 preschedule 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 preschedule 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 gallbladder
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.СтражескоВ.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.
Acquired defects of heart
Rheumatism strikes a mitral valve, less frequently aortic and tricuspidal valves.
Mitral stenosis is stenosis of the left atrioventricular aperture.
At mitral stenosis the violation circulation of blood begins not at once. The left venous
aperture must be narrowed on 60%, id est a to 2 cm (in a norm a 6-7 cm).
During pregnancy heart must anymore transport the blood, so as blood circulation
volume increases on 30-50% regardless of the state of heart. And it can result in a pulmonary
edema and cardiac asthma.
Mitral stenosis most severe type of defect of heart in connection with that he causes
over-load of small circle of circulation of blood, at the same time at pregnancy in itself there are
conditions for a bradyhemarrhea in lungs.
Labor for pregnant with mitral stenosis is quite serious clinical situation. For pregnant
with the expressed mitral stenosis during labor of oscillation arterial and venous pressure is arrived
at by large amplitude, pulse of 110 beats in 1 min, 24 breathings in 1 min
The method of labor is determined by the degree of insufficiency of circulation of blood
and activity of rheumatism.
Mitral stenosis is diagnosed for pregnant as well as not for pregnant. At palpation there is
the "cat-like purring" on an apex. On an apex a slamming 1 tone, pre-systolic or diastolic murmur,
accent of 2nd tone on a pulmonary artery. At an auscultation accent 2nd tone on the pulmonary
artery is present, prolongation of QT-interval on ECG. Heart ultrasound and Doppler investigation
will confirm the diagnosis.
At mitral stenosis pregnancy is contra-indicated, if from the beginning of pregnancy there
are signs of insufficiency of circulation of blood or rheumatic activity, blinking arrhythmia,
pulmonary hypertension and embolic complications.
The prognosis for pregnancy and labor gets better after surgical treatment of stenosis. A
mitral commissurotomy is technically accessible at the late term of pregnancy, but it’s better to
conduct it on 10-11 up to 18 weeks of pregnancy. It is not desirable to do an operation in days
which correspond menstruation, 2-3 months of pregnancy, which are accompanied by regress of
corpus luteum, term after 19-20 week, when uterus increases not due to the height of muscle
fibres, but due to by a stretching by growing fetus, in 26-28 weeks of pregnancy, when
haemodynamic load on a heart arrives at a maximum. Later 28 week of pregnancy not desirable
operation.
Insufficiency of mitral valve
At this defect blood during a systole enters not only aorta but also in back-flow direction
in the left ventricle. Because of the strong left ventricle of minute volume of blood supported at
normal level and decompensation develops lately. Most pregnant with "isolated" mitral
insufficiency carry pregnancy without no signs of insufficiency of circulation of blood
Insufficiency of valve is not contra-indication for pregnancy at the compensated defect.
Aortic stenosis
It is 16% of all heart organic defects. Diagnose is difficult. An area of the aortic opening
is a 2,6- 3,5 cm. Its narrowing twice is not reflected on the state of pregnant. The period of
complete indemnification of defect can proceed 20-30 years. At an area a 0,75-0,5 cm patients
grumble about a weakness, stuffiness, loss of consciousness. Develops dilatation of cavities of the
left ventricle, in him pressure rises and diminishes cardiac extrass. For stenosis of aorta systolic
murmur above an aorta is a diagnostic sign. 2nd tone on an aorta is weak. At "isolated" aortic
stenosis a pulse rarely is more frequent 60-65 beats per 1 min, systolic pressure is decreased to 90100 mm of mercury column, diastolic pressure is some increased.
Clinical flow during pregnancy
If aortic stenosis is compensated pregnancy is not contra-indicated. But even initial signs
of insufficiency of circulation of blood are contra-indication to pregnancy. More frequent patients
die not in a gestational period, in but a year after labor.
Insufficiency of valve of aorta
Second on frequency rheumatic defect of heart. A defect usually coincides with stenosis
of estuary of aorta.
At aortic insufficiency during a diastole part of blood from an aorta flows in
зворотньому direction in the left ventricle, as pressure in an aorta in this period does not exceed
pressure in a ventricle.
Patients complain at aortic insufficiency on the strong shoves of heart, pulsation of
vessels of neck, dizziness and loss of consciousness at the change of position of body, pain in area
of heart for as a stenocardia. Characteristic pallor of skin covers, pulsation of sleepy and other
peripheral arteries, a pulse is rapid. Systolic pressure is increased, diastolic is acutely decreased.
In default of relapses of rheumatism aortic insufficiency does not cause decompensation of
circulation of blood, runs across of high quality and is not contra-indication for pregnancy.
Insufficiency with the signs of insufficiency of circulation of blood results the valve of aorta in
death in 1-2 years. That is why pregnancy in this situation is contra-indicated.
Congenital defects of heart
To the congenital defects of heart there are 50 nosologic forms of anomalies of
development of cardiac system.
Classification of congenital defects (М. П. Чернова, 1977)

Defects with the extrass of blood from (defect of atrial membrane, open
arterial channels, defect of ventricular septa) left to right

Defects with the extrass of blood on the right on left and with arterial
hypoxemia (Fallo tetrade, transposition of main vessels, syndrome of hypoplasia of the left
heart)

Defects are with the barrier of blood stream (stenosis of pulmonary artery,
stenosis of aorta, co-arctation of aorta)
Most frequent expectant mothers have defects with the extrass of blood from left to right.
Good flow of pregnancy have patients with the defect of muscular part of v membrane, with the
small defect. If a disease is accompanied by insufficiency of circulation of blood, pulmonary
hypertension or extrass of blood from right to left, then pregnancy must be terminated.
Congenital malformations with the extrass of blood from right to left are most severe.
Fallo tetrade and transposition of large vessels is a testimony to terminating pregnancy.
Congenital defects with an obstacle to the blood stream in default of insufficiency of
circulation of blood are not contra-indication to pregnancy.
At coarctetion aortas pregnancy is possible only at the moderate narrowing, but even in
such case conducted caesarian section.
Pregnancy and hypertensive disease
There is not only classification on this time.
Classifications by WHO:
a 1 .- increase of propulsion MODULE is a from 160/95 to 179/104 mm of рт century
without the organic changes of the cardiovascular system; Propulsion MODULE and can
change during twenty-four hours.
a 2 ст.- increase of propulsion MODULE is a from 180/105 to 199/114 mm of рт
century with the hypertrophy of the left ventricle, but without the signs of damage of other
organs;
a 3 ст.- increase of propulsion MODULE is a 200/115 mm of рт century and higher
with the damage of heart and other organs (brain, retina of eye)
Hypertensive illness negatively influences on flow of pregnancy. The most common
complication is a late gestosis.
For determination of tactic/pl of conduct of pregnancy most essential is an estimation of
weight of disease and exposure of possible complications. Therefore the first hospitalization is
conducted to 12 weeks to pregnancy.
At 1 century pregnancy proceeds under surveillance of internist and accoucheur. At 2 and
century pregnancy can be stored in default of violations of ССС and pochard, 2б and 3 centurycontra-indications for pregnancy.
Second hospitalization in 28-32 weeks, третя-за 2-3 weeks to labor.
Labor conduct through natural maternity ways with the adequate anaesthetizing at
continuation of hypotension therapy and early amniotomy. 2 periods are shortened, conducting
перінеотомію or imposition of obstetric tongs. A bleeding prophylaxis is conducted in 3 periods.
Disease of breathing organs
Bronchitis for pregnant, as a rule primary, infectious or viral genesis, at cooling of body
often combines with laryngitis, tracheitis, acute respiratory disease, asthma state. Reason of
bronchitis can be productive harmfulness. Basic clinical signs are a rheum, cough, pain in a thorax,
sputum. What badly distinguished. Pregnancy does not assist a disease, but peculiar to pregnancy
of flowdown of mucous membrane of bronchial tubes bothers sputum. On flow of pregnancy an
acute bronchitis does not influence, but the intrauterine infecting of fetus is possible. Shown
frequent warm drink (tea with honey, milk with a soda, lime tea), which facilitates expectoration,
alkaline inhalations. For the output of bronchial spasm it can beta it is used euphylline. If necessary
there can be the used antibiotics. Simple and effective mustard plasters, banks.
A chronic bronchitis flows lasted with the periods of intensifying and remissions. Disease is
characterized by the protracted periods of cough with the two-bit/pl of sputum.
A неускладнений chronic bronchitis is not contra-indication for pregnancy and labor. At
the expressed respiratory insufficiency the exception of pushing is shown.
In transition the used for setting fire process there is a bronchopneumonia or catarrhal
pneumonia on pulmonary fabric. A patient has a fever, cough, general weakness which testifies to
the acute beginning of pneumonia; a pulmonary percussion sound is kept or dulling appears on the
limited area. Breathing is with wheezes. A disease lasts 2-3 weeks, possible abscess and
pneumosclerosis. Shown antibiotics, anti-fungal medications, coughing up facilities, banks, mustard
plasters, respiratory gymnastics, massage of chest.
Bronchial asthma
Frequency in 1% of pregnant, a disease can be to pregnancy and arise up during her. The
origin of asthma is related to the changes of sensitiveness to endogenous prastaglandines.
The pregnant have clinicopathologic forms:

atopic;

infectiously-dependent (infectiously-allergic);

auto-immune;

dyshormonal;

nervously-psychological;

cholinergic.
Pregnancy runs across under act of the cute nervous system, considerably the level of
pregnenetrioldione increases in blood. All these changes of good influence on flow of pregnancy.
At the same time in the organism of woman, changes which worsen the prognosis of disease pass:
activating of respiratory center, physiology overventilation, oppression of the system of immunity
passes for a mother. Foreseeing worsening of the state of pregnant is impossible.
Treatment is determined by the form of disease and includes the use of medications
recognition, by influence term of pregnancy on a fetus.
For cut short of attack use:

group of salbutamol;

mustard plasters, banks;

1 ml of 5% esadrin;

2,4% 10 ml of euphylline;

prednizolone is for 30 ml in 3 hours;
Conduct of pregnancy and labor
In the early terms of pregnancy the shown hospitalization is in therapeutic permanent
establishment for an inspection and decision of question about maintenance of pregnancy.
There is obligatory hospitalization 2-3 weeks prior to labor. Bronchial asthma which arose
up during pregnancy after labor can diminish. Labor are conducted through natural maternity ways.
Disease of blood
Anaemia of pregnant is a decline of amount of haemoglobin and red corpuscles.
Frequency of anaemia for pregnant of 30-35% and there is a tendency to the increase. At
anaemia a basic function - delivery to oxygen is violated to the different organs and tissues, a
hypoxia which influences on normal flow of pregnancy and fetus develops. Iron-deficient
anaemia appears in 90% of pregnant. Indexes of normal vibrations of Hb are 115-145 gs/of л
(11,5-14,5г%) and red corpuscles 3,7*1012 - 4,7*1012.
At iron-deficient to anaemia (ЗДА) there is a decline of amount of iron in the serum of
blood, marrow, high concentration of estrogen hormones, which assists the dyspoiesis of
haemoglobin What causes anamia: wrong feed, violation of suction of iron (disease of intestinal
highway), vomiting, bleeding, multifetation, lactation, too frequent pregnancies.
Classification on the degree of weight :

mild - Нb 91-110 gs/of л;

moderate - Нb a 81-91 g/of л;

severe degree - Hb not below 80 gs/л.
Clinical features. The pregnant compains about a weakness, stuffiness and dizziness at
insignificant physical effort, dizziness and headache. As a result of diminishing of enzymes iron is
included in composition of which, observed there are trophic violations (psilosis, change of taste,
fragility of nails). The some pregnant do not express at presence of anaemia of complaints. There is
a pallor of skin covers and scleras at a review. Sometimes there is subfebrile temperature. At
anaemia there are scray changes for the increase of oxygenation of tissues: increase of volume of
plasma, cardiac extrass and speed of blood stream. At an auscultation above the apex of heart
hearkened to systolic noise. There is the frequent breathing. Almost in half with anaemia arterial
low blood pressure is determined. A liver and spleen at ЗДА is not megascopic. The diagnosis of
ЗДА is based on the changes of next indexes is a decline of Hb below 115 gs/of л, diminishing of
content of iron in blood of to 10,7 mmol/l, decline of Ht less than 33%, colour index below 0,85.
There is less of red corpuscles, anisocytosis is norm or amount them increased. RSE is increased
always. For pregnant from ЗДА the gestosiss of the second half of pregnancy develop often, in 1542% is terminating pregnancy in different terms, often there is a high water-level, ФПН, hypoxia of
fetus, СЗРП. Labor at every third case at anaemia become complicated ill-timed outpouring of
amniotic fluid, weakness of labor (15%), by the increase of blood loss in labor - in 10%. In this
connection labor must be conducted actively with the prophylaxis of weakness of childlabor,
asphyxia of new-born, bleeding in an early puerperium. Even insignificant blood loss is badly
carried by women and can result in a collapse. A puerperium can become complicated by septic
diseases in 12%. Anemia can result in a hypoxia, oligotrophy and development of anaemia of fetus.
For children, born from mothers with anaemia, often there is oppression of erythrogenesis.
Treatment: rational feed (meat, liver, bread, is leguminous, soy-bean, dill, parsley). Day's
ration must contain albumens to 120г (50% of animal origin), limitation of fats to 70г on twentyfour hours and carbohydrates to 350-400г. apply medications of iron, vitamins, other medications.
Most effective are medications of iron supply. To apply medications of iron better in all with
ascorbic acid. Unrationally to apply at ЗДА medications which stimulate an erythrogenesis
(folicacid, vitamin of В12). It is necessary to remember that an effect from treatment comes not
early than as in 3 weeks. Blood transfusion is not conducted in connection with an of short duration
effect and immunization of pregnant. Prophylaxis: early exposure and timely hospitalization,
treatment.
Megaloblast anaemia - it anaemia at which is violated ripening of cages of red row,
conditioned by the deficit of vitamin of В12 or folic acid. Typical for such anaemias is a presence
in marrow of megaloblasts, reason of increase of which is a dyspoiesis of DNA. В12-anaemias are
hyperchromatic, characterized by the atrophy changes of tongue, gullet, stomach, changes of the
nervous system. The deficit of vitamin of В12 can be constrained from disorder of absorbtion
(atrophy changes of mucous membrane of stomach), by the invasion of helmints, inherited
violations of гемопоезу. A clinic consists of anaemic syndrome, violations, changes of the nervous
system (feeling of crawl of ants, numbness of extremities, violation of deep sensitiveness, spastic
парапарез). For a blood test characteristic presence of hyperchromatic anaemia, macro- and
anisocytosis of red corpuscles, diminishing of amount of leucocytes, moderate hyperbilirubinemia.
In marrow megascopic amount of megaloblasts.
Treatment: diet (meat, eggs, milk, liver, kidneys), vitamin of В12 (100-200 мг/twenty-four
hours, in/a m, folic acid 5-15 мг/twenty-four hours, vitamin of С to 100 мг/twenty-four hours).
Day's requirement of pregnant in фолієвій acid is 300-mcg (for unpregnant she is 100мкг). The
depot of folic acid in the organism of man is absent, and the exchange of her very unstable, that is
why the deficit of her at pregnancy arises up very quickly. A wrong feed, frequent pregnancies,
protracted reception of hormonal contraceptives, assists it. Hyperchromatic anaemia is 1% from all
cases of anaemias. For this form not the typical is expressed clinical flow (Hb within the limits of a
80-100 g/of л). Treatment to iron of effect medications is not given. A clinic is expressed in
absence of appetite, characteristic vomiting, diarrhea, burning of tongue. There can be signs of
hemorragic diathesis of skin, mucous membrane, scleras. There is an increase of spleen,
fervescence. There is a decline of amount of red corpuscles in blood, in the strokes of blood is a
presence of мегалоцитів, anisocytosis and grittiness and nuclear forms of red corpuscles. The
amount of RBC is diminished. The amount of leucocytes increases from to the left. An early sign is
a presence of the hypersegmented leucocytes. At pregnancy there can be next complications: wilful
abortions, anomalies of development of fetus, complication of labor. A prophylaxis and treatment
of anaemia consist in a valuable feed (green goods and fetus, meat foods, milk, nuts), setting of
medications of фолієвої acid (5-15мг/доб), vitamin of С to 100мг/day.
Hypoplasticanaemias - it a disease at which is observed acute oppression of hematogenesis.
The hypoplasia of hematogenesis arises up at the action of external factors: action of ionizing
radiation, use of some medicinal medications and chemicals. It is important have chronic infections
- hepatitis, pyelonephritis. On occasion reason is self-aggression against to the antigen of cages of
marrow. Consider that pregnancy is the possible etiologic factor of development of immune
conflict.
A clinic consists of three syndromes:
anaemic syndrome;
hemorragic syndrome;
septic syndrome.
The picture of blood is characterized by the expressed anaemia: Hb goes down a to 50 g/l
relative lymphocytosis.
In bone marrow almost complete absence of elements and substituting for them takes place
by fatty fabric. There is an increase of content of iron in the serum of blood which results in the
hemosiderosis of organs and tissues. The flow of disease is various. On occasion rapid progress of
disease. A death rate is 60,5%; in another cases a disease runs across with periodic remissions,
complete recovery is possible.
Treatment: blood tranfusion, prednizolone, splenectomy, transplantation of allogenic
marrow. Combination of anaemia with pregnancy is observed very rarely. Prognosis for the mother
is unfavorable, lethality is observed at 45% cases.
In case of occurring of disease during pregnancy (more frequent in the second half), clinical
displays appear quickly: Hb 80-38 gs/of л, low platelets 45*109/л. There are signs of hemorragic
diathesis. The flow of disease is very heavy, possible death of mother. At breaking to pregnancy
there can be hearths of necrosis in the place of operation. If pregnancy comes for a sick woman,
then there is intensifying of process. At the exposure of anaemia it is necessary to set her character
and hemophthisis, terminating pregnancy is conducted in early terms. As it is quicker all necessary
to conduct a splenectomy. If a woman renounces terminating pregnancy it is necessary to conduct
dynamic control after the indexes of blood. Worsening of the state of pregnant (Hb of 60г/л,
amount of leucocytes less than 1,5*109/л, less than 20%, proof relative lymphocytosis (anymore
60%), origin of hemoragias, infectious processes) forces to conduct terminating pregnancy.
Hemolytic anaemia
The inherited anaemias are constrained from the impairment structure of membranes of red
corpuscles, by violation of activity of enzymes and synthesis of hematohistone. Immune anaemias
are related to operating of autoantibodies on red corpuscles. Thus there is diminishing of amount of
red corpuscles. The level of bilirubin rises in blood, an icterus appears for patients. Most often at
pregnancy there is (due to defect of structure of membrane to the red corpuscles) hemolytic
anaemia. The defect of membrane assists penetration in the red corpuscles of water. The spherical
form of red corpuscles assists the increased destruction of red corpuscles in a spleen. A basic
syndrome is hemolytic (icterus, anaemia). A bilirubin at intensifying rises to 102-119 мкмоль/л.
There is an urobilinuria.. The picture of blood is characterized by the presence of
microspherocytosis, decline of osmotic of red corpuscles, clasmocytoma.
A disease has cyclic flow. Intensifying more frequent arise up at infectious at pregnancy.
Treatment. Blood transfusion is shown only at considerable анемізації. Most effective at
treatment of this anaemia is surgical treatment - splenectomy.
Auto-immune anaemia arise up at formation of antibodies to the own red corpuscles at
violations in the immunocompetency system. Distinguish symptomatic (at system red lupus,
heterospecific ulcerous colitis, chronic hepatitis) and due to unknown reason anaemias.
The clinic of anaemia is characterized by the presence of weakness, pain in area of heart,
stuffiness, palpitation, icteruses. There is unbearableness of cold at this form of anaemia.
At acute crises content of haemoglobin arrives at subzero numbers. The amount of immature
RBC rises mildly. A reliable laboratory test is a test of Kumbs.
The most effective treatment of anaemia is application of steroids. For liquidation of the
phenomena appoint the large doses of prednizolone (from 50-60 to 80 мг/day). At the heavy
intensifying blood transfusion is recommended after an individual Also indicated splenectomy.
At pregnancy in combination with anaemia. Often there is a threat of terminating pregnancy.
A prognosis is for the mother of good. The artificial breaking of pregnancy is not shown.
Treatment is conducted with the use of prednozolone in the dose of 80мг/доб., blood
transfusions until normalization of indexes of blood. A dose is reduced in future, a support dose
(10-15мг/доб) is recommended. Labor it is recommended to conduct conservatively. During labor
the dose of prednizolone it follows to increase.
Leucoses are malignant diseases of hematogenesis tissue
Classification:
1.
2.
3.
4.
5.
Lymphoblastic.
Myeloblastic.
Monoblastic.
Prometrin.
Erythroblastic
6.
Plasmoblastic.
7.
Megacaryoblastic.
Syndromes:
1.
Hyperblastic (increase of lymphatic knots, liver, spleen).
2.
Hemorragic (diffuse bleeding).
3.
Anaemic.
4.
Intoxication.
At the beginning of disease flows without symptoms. A diagnosis is proposed only
morphologically is an exposure of бластних cages of blood or marrow.
The separate forms of leucosis differentiate only tissue researches.
Pregnancy worsens the state of patient (not how many pregnancy, how many her
completions), often becomes complicated by abortions.
At a acute leucosis necessarily to terminate pregnancy in the first trimester. In the second
trimester of terminating pregnancy it is better to conduct conservatively. At development of acute
leucosis at the end of pregnancy and compensated state of patient is a temporizing tactic/pl and
conduct of labor conservatively.
Thrombocytopenia is a decline of amount of thrombocytes, related to the increased
destruction, necessity and their insufficient education.
There is destruction of thrombocytes most frequently. Distinguish to the inheritance and the
purchased forms. There is a change of functional properties of thrombocytes at the inherited form.
It is divided into immune and related to the action of factors.
In basis of pathogeny a disease lies insufficient amount of thrombocytes and diminishing of
components is related to it in the displacing system of blood. It is known that an important role is
taken in the system to гемостазу to the thrombocytes.
At platelets insufficiency arises up as a result of the increased fragility of vessels, so as a
result of exit of red corpuscles from a vascular river-bed through capillaries. The sanguifluousness
appears at the decline of amount of thrombocytes to 50*109/л (normal content is from 150*109/л
of to 400*109/л).
Clinically it shows up as rash on front of feet, trunk. Often there are hemorrhages in the
places of injections, at the insignificant damage of vessels (measuring of arteriotony, , grinding of
skin covers).
The amount of thrombocytes diminishes in peripheral blood, factors of hemopexis in a
norm, and their increase is possible. Bleeding time is prolonged. Broken retraction of faltung. In
marrow megascopic amount of megacaryocytes. A diagnosis is set on the basis of characteristic
clinical signs and indexes of blood.
A flow of disease can be acute and chronic recrudescent.
Nosotropic treatment consists of the use of steroids and splenectomy. If an effect from these
measures is not observed, then immunodepressants are used. Treatment immunodepressants during
pregnancy contra-indicated. Combination of this and pregnancy is often enough. Flow of pregnancy
and labor depends on the form of disease and character of treatment which was preceded to
pregnancy. During pregnancy, intensifying of anaemia is unoften. Sometimes intensity of
symptoms of disease diminishes during pregnancy. Some authors consider that intensive bleeding
during pregnancy and it is not arisen up up to labor. Pregnancy is contra-indicated at:
1.
2.
3.
4.
To the acute form.
Bleeding is from a nose and gums.
A hemorrhage is in a brain.
A chronic form is with frequent recidives.
Illnesses of liver and gall-bladder
Acute viral hepatitis is diffuse inflammation of liver, viral etiology, which is accompanied
by an icterus and reason of which is unconnected with pregnancy.
Classification.
After expressed of clinical displays :
1. Hidden forms:
- - subclinical.
2. Manifestal of forms:
- - anicteric;
- - icteric.
After the recurrence of flow :
1. Cyclic.
2. Acyclic.
After the degree of weight :
1. Easy.
2. Middle weight.
3. Heavy.
4. Extremely heavy.
Complication:
1. Acute and subacute dystrophy of liver (acute hepatic failure).
2. Functional
3. Extrahepatic
After consequences:
1. Recovery.
2. Less signs of pathology (hepatomegalia and hyperbilirubinemia).
3. Chronic hepatitis.
4. Cirrhosis of liver.
5. Primary cancer of liver.
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.
Stages of grant of medicare :
1. Woman consultation:
- it is an estimation of the state of pregnant;
- it is establishment of previous diagnosis jointly with an internist and infectiologist;
- it is a decision of question in relation to a necessity and place of hospitalization;
- - acute hepatitis is to terminating pregnancy in any term;
- - the risk of terminating pregnancy rises in two times, in ІІ-ІІІ trimester a risk is higher,
than in І-му (С).
2. Infectious unit (to 36 weeks pregnancies or to beginning of childlabor).
3. Unit of maternity hospital.
4. Treatment and rehabilitation of породіль is in ambulatory terms.
Principles of grant of obstetric help.
1. With beginning of childlabor a patient is hospitalized to the unit.
2. Labor conduct through natural maternity ways:
- - in the acute stage of disease labor do not threaten to complications which are related to
hepatitis (С);
- - labor conduct as premature (С).
- - caesar a section is conducted exceptionally after obstetric testimonies. Caesar a section
does not diminish the risk of transmission of hepatitis from a mother to the child (А).
- it is a bleeding prophylaxis in ІІІ period of labor (А).
- - with the purpose of prophylaxis of infectious complications medications are not used
with the mainly hepatic way of and with a hepatotoxic action. Medications of choice are
cephalosporines of ІІ - ІІІ of generation and semisynthetic penicillines.
3. In a puerperium:
- - medically is the protective mode;
- it is a dietary feed;
- it is an uranalysis - one time in three days;
- it is a global analysis of blood;
- it is biochemistry of blood and coagulogram - after testimonies;
- it is a supervision of infectiologist, internist.
4. For all new-born from infected HCV mothers in the serum of blood it is determined
maternal анти - HCV, which penetrate through a placenta. For germ-free children antibodies
disappear in the first year of life. The pectoral rearing does not influence on the risk of infecting of
child ( А). The new-born is not safe for other new-born.
A chronic cholecystitis is a chronic recrudescent disease, related to the used for setting fire
changes in the wall of gall-bladder.
A basic role in development of cholecystitis is played is an infection, stagnation of bile,
irritation of mucous membrane of gall-bladder.
Classification
1. Presence of stones :
-
chronic non-calculary cholecystitis;
chronic calculary cholecystitis;
2. Stage of process :
it is intensifying;
- incomplete remission;
are remissions;
3.Severity:
- - mild;
- middle;
- severe;
Diagnostics
1. Subjective data:
- it is a pain syndrome (dull, aching), pain in the area of right ribsarea, with an irradiation
in the right half of thorax, in a right collar-bone, sew on the right, right shoulder, shoulder-blade,
pain increases from rich and fried food;
- it is a dispeptic syndrome (weight in right area, swelling of stomach, nausea, bitter taste in
a company, violation of emptying, sometimes is a decline of appetite);
- are the phenomena of intoxication (weakness, headache, pain in joints, in area of
heart, high temperature, speed-up palpitation).
2. Objective data:
- are positive to the bladder symptoms ;
- it is a moderate jumboizing of liver,
3. Ultrasonic research:
- it is a bulge of walls of gall-bladder;
- it is content of bubble;
- it is a presence of symptom by Murphy (болючість at pressure of device a sensor on the
area of projection of gall-bladder);
- it is a presence of pls from the walls of gall-bladder;
- it is a presence of paravesical edema;
- are concrements;
- it is the assessed tongue, often with the prints of teeth.
4. Duodenal sounding:
- it is turbidity of bile in portion In;
- it is a presence of mucus, plenty of cages of cylindrical epithelium, leucocytes and their
accumulations;
- are crystals of cholesterol;
- it is a possible presence of vermin;
- it is a pathogenic flora from data of the bacteriological sowing.
5. Differential diagnostics is conducted with next diseases:
- are infections of urinary ways;
- it is an urolithiasis;
- it is a disease of stomach and duodenum;
- it is a disease of pancreas.
Medicare to pregnant
1 Decision of question about possibility of maturing of pregnancy :
1.1. Contra-indication to maturing of pregnancy (to 12 weeks) :
- it is a mechanical icterus
- are frequent attacks of hepatic colic
- it is festering inflammation of gall-bladder.
The state after operation does not hinder to maturing of pregnancy.
2.1. The supervisions of pregnant with a chronic cholecystitis in woman consultation
conduct jointly with an internist
2.2. Inspection (except for general for all pregnant) :
- of liver, gall-bladder, pancreas and spleen;
- it is determination of concentration in blood of bilirubin, АLАТ, АSАТ, alkaline
amylase, cholesterol;
- it is a clinical analysis of excrement;
- it is the duodenal sounding with clinical and bacteriological research of bile.
2.3 On condition of absence of intensifying of process carreer appoint:
- - medical physical education;
- it is a rational feed (table №5 in a warm kind, reception of food not less than 5 times on
twenty-four hours);
- are the medical duodenal soundings (only at a cholecystitis) - 1 one time per a week - 4-6
times in ІІ and ІІІ trimesters. In quality cholagogues apply 2 glasses of decoction of wild rose or
mineral water, 1-2 soupspoons of olive oil, 50-60 мл of 25-33 % solutions of sulfate of magnesium,
20 gs of Sorbitum or 20 gs of xilite, cut-in in 100 мл of water.
2.4 In the case of intensifying of process appoint:
- it is a release from work;
- - a diet is a table №5;
- - for liquidation of pain syndrome Platyphyllinum, myotropic spasmolysants No-Spa.
- antibacterial therapy (depending on a causative agent) during 1-2 weeks in middle
therapeutic doses (ampicillin, Nitroxolinum, erythromysin).
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
treatment.
Vascular diseases of vessels of cerebrum and pregnancy.
operative
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
Pyelonephritis is infectional disease with the repressing impression of interstitial
tissue, bowls and kidneys. A pyelonephritis can be during pregnancy (gestational pyelonephritis or
pyelonephritis of pregnant). Pyelonephritis which was to pregnancy can become acute or run across
in a chronic and latent form.
Factors which assist to development - violation of urination, alteration of hormonal and
immune status.
Cause: collibacillus, streptococci, funges, staphylococcuss. Ways of spread -hematogenic,
lymphogenic and ascending.
Clinic: it is more frequent arisen up on 22 weeks of pregnancy on 2-5 day after a
maternity period. High of temperature of body, chill, weakness, disuria, pains in a lumbar area.
Diagnostics:

global analysis of blood

global analysis of urine

an uranalysis is by Нечипоренку

an uranalysis is by Земницькому

sowing of urine is on a flora and sensitiveness to the antibiotics.
Treatment
 Hospitalization
 bed mode (position of pregnant on to the side, genicular-ulnar position)
 a diet is antibacterial therapy (пеніциліни and цефалоспорини);
 uroseptics (нітропросолін, левіграмін, 5-НОК)
 spasmolysants
 infision therapy
 in default of effect from conservative methods there is a treatment-cannulation of ureters.
Patients are divided a pyelonephritis by 3 degrees of risk :
1 ст.- women are with a mild pyelonephritis which arose up during pregnancy;
2ст.- patients by a chronic pyelonephritis which arose up to pregnancy;
3 ст.- pregnant with a pyelonephritis and hypertension with azotemia, and with the
pyelonephritis of one kidney;
To the patients from 3 centuries of risk pregnancy is contra-indicated.
Glomerulonephritis
Occurs rarely in 0,1-0,2% of pregnant, but is the most dangerous disease, so as
complications here meet very often. It’s an infectiously-allergic disease with the impression of
glomerulis and canals of kidneys, caused by the β-hemolytic streptococcus of the A-type. A
glomerulonephritis develops in 10-15 days after a quinsy, scarlatina, streptococcus pyoderma.
Rarely there is an uninfectious glomerulonephritis which develops after vaccinations.
Classification. Glomerulonephritis are acute and chronic, but more frequent there are
chronic forms.
The clinic of disease develops weakness, main pain, edema of soft tissues, increase of
arteriotony, hematuria appears.
Flow of glomerulonephritis during pregnancy: intensifying of chronic glomerulonephritis
comes, that it is possibly related to the increase of глюкокортикоїдів during pregnancy. A chronic
glomerulonephritis can run across in such forms:
1.
Hypertensive form, hematria, proteinuria, change of eyeground (in 7%).
2.
Nephrotic: proteinuria 10-30 gs/of л, edemata, hyperemia.
3.
Mixed: high blood pressure, proteinuria 1-3-6 gs/of л, increase of BP,
edemata, there can be an eclampsia;
4.
Latent: microproteinuria microhematuria, cylinders, normal BP, edemata are
not, sometimes there is hematuria at this form, then it will be to conduct a differential
diagnosis with the tumour of kidneys.
All forms sooner or later pass to chronic uremia.
Flow of pregnancy is at a glomerulonephritis. Pregnancy for such patients very dangerous, a
self disease becomes acute at first, secondly almost in 40% a late gestosis, which runs across
difficult, badly responds to treatment, develops at pregnancy, often there are attacks of eclampsia
and antenatal death of fetus. Premature removing layer by layer of the normally placed placenta
with the bleeding, that quite often results in death of patient. In 1/7 pregnant labor begin
prematurely. Oligotrophy of fetus.
Especially unfavorable for illness and mixed form of disease, most favorable is latent form.
3 groups of risk of pregnant of patients with are distinguished a glomerulonephritis.
To 1 degrees of risk take pregnant with the latent form of glomerulonephritis.
To 2 degrees of risk - pregnant with a nephrotic form.
To 3 degrees of risk pregnant with a hypertensive and mixed form, with a acute and
strained chronic glomerulonephritis, and also with an expensive form which runs across with
kidney insufficiency.
Conduct of pregnancy.
The pregnant with a glomerulonephritis must to 12 weeks to pregnancy to be hospitalized
in a nephrological unit, for the careful inspection of decision of question about possibilities to save
pregnancy. Pregnancy it can allow patients with a latent form 2/3 pregnant). Late gestosis for them
arise up in 20%, but responds to treatment.
There are strong edemata at a nephrotic form, they are treated by diuretic medications,
infusing into albuminous medications. They 3 times must be in permanent establishment in times
of pregnancy. If edemata, proteinuria and hematuria diminish, then pregnancy can be continued.
At 3 degrees of risk pregnancy is contra-indicated, so as quite often already kidney
insufficiency can develop during pregnancy, not speaking about such complications which arise up
as a heavy form of nephropathy, quite often прееклампсії and eclampsias, premature removing
layer by layer of placenta, death of fetus.
Treatment. Diet: albuminous, it is necessary to be increased to 2 gs/of kg, to decrease the
reception of NaCl a to 5 g, water of to 800 мг for a day.
Symptomatic treatment: hypotension medications, diuretics, albuminous medications.
Urolithiasis. Occurs in 0,15-0,3% and the attacks of colic become more frequent during
pregnancy. It is assisted by expansion and low blood pressure of kidney bowls, ureters and urinary
bladder, joining of infection, urinary stones begin migration and state of every third patient during
pregnancy gets worse.
Complication of flow of pregnancy :
- it is Terminating pregnancy.
- it is Origin of pyelonephritis due to the trauma of mucous membrane of urinoexcretory
ways joining of infection.
- it is the Late gestosis.
- - a mortinatality arrives at 50%.
- it is Гідронефроз, if there is the complete corking of сечовода by a large stone.
A monopathy does not influence on flow of pregnancy. Terminating pregnancy is shown
only at kidney insufficiency, or at combination with the heavy form of gestosis.
Labor in most cases runs across without complications.
Treatment: the boiled meat, fish 2-3 times per a week, apples, apricots, water-melons,
decoctions of blackberry. Spasmolysants: papaverin of 2% for 2 мл, Nospanum for 2 мл,
Platyphyllinum of 0,2% for 2 мл, Baralginum for 5 мл in/, atropine, misdelivering, morphine it is
not desirable. Atropin weakens the musculature of neck which can result in terminating pregnancy,
misdelivering - promotes retractive activity of musculature of uterus, Morphinum - represses a
respiratory center.
On occasion colic it is succeeded by medications which extend the musculature of ureter
(cystenal for 20 drops on the piece of sugar under a tongue, and at the repeated attacks for 20 drops
3 times per a day during a meal, or after-meal) preferentially; avisan 0,1 for 2 pill to the after meal,
or for 0,05-0,1, 3-4 times in the day of it is possible to give to 3 weeks.
Warm baths and hot-water bottles at pregnancy are contra-indicated. If the attacks of colic
are not bought by medicinal medications then conduct the cannulation of ureters, if a catheter it is
not possible to conduct in ureters - a question is put about operative treatment. Testimony for an
operation:
1. Anuria caused by block of ureter.
2. The septic state of patient is at a papular pyelonephritis.
3. At pyonefrosis.
Diabetes mellitus
Disease which is characterized by insufficiency of insulin in an organism : absolute, when
a pancreas produces a few of hormone, or relative, when tissues of illnesses of man are unfavorable
to insulin, although a secretory function is not broken. In a pre-insulin era women, patients, have
labor on a diabetes mellitus were very rarely, pregnancy came only for 5% women and threatened
to their life, a nepnatal death rate arrived at 60%.Treatment of insulinomas allowed sick diabetes
women to have children. But a mortinatality arrives at 20-30%.
Distinguish:

1th type (insulin-depending);

2th type (insulin-independent);

diabetes of pregnant (gestational diabetes);
1th type of disease which beta-cells of pancreas collapse βat. It develops in children and
teenagers, characterized by absolute insulin insufficiency, lability of flow, propensity to acidosis,
presence of autoantibodies to the own antigens β-cells of pancreas.
2th type – appears in people over 30 years, more frequent on a background obesity,
peculiar relative insulin insufficiency him, mionectic sensitiveness of tissues to endogenous
insulin.
Gestation diabetes is transitory violation of tolerance to glucose, first it appears during
pregnancy.
Insulin influences on all types of metabolism. Insulin is anabolic hormone, which assists
utilization of glucose and biosynthesis of hepatin, lipids, albumens. When insulin not enough is
violated utilization of glucose, a gluconeogenesis increases, by a result what a hyperglycaemia is.
During physiology pregnancy a carbohydrate exchange changes in accordance with the
large requirements of fetus in energy material, mainly in glucose. Physiology pregnancy is
characterized by the decline of tolerance to glucose, by the decline of sensitiveness to insulin, by
the increased disintegration of insulin by the increase of free fat acids. The changes of
carbohydrate exchange are related to influence of placenta hormones: placenta lactogen etc.
Due to placenta lactogen the amount of free fat acids which are used for the power expenses of
mother rises in the organism of pregnant, keeps glucose the same for a cyotrophy for which she is
a basic energy source. On the character the indicated changes of carbohydrate exchange are
considered as alike with changes at a diabetes mellitus, that is why pregnancy is examined as a
diabetic factor.
Distinguish:
- - diabetic (clinically expressed)
- - latent (violation of tolerance is to glucose)
About potential diabetes it is possible to think in next cases:
1.
when both the parents patients by diabetes, or there is heredity;
2.
when one of twins- diabetic;
3.
for women which were unparous living or dead children with mass of body
more than 4 500 g;
4.
for women which gave before a dead child with hypoplasia of pancreas;
5.
for women with obesity;
6.
for women with usual abortions;
7.
for pregnant with a high water-level;
8.
at a glucosuria;
Distinguish 3 degrees of weight of diabetes mellitus :
1 century (easy) - hyperglycaemia < of 7,7 ммоль/л, there are not signs of ketosis,
normalization of level of sugar in blood it is possible to attain by means of diet;
2 century (middle) - hyperglycaemia <of 12,7 ммоль/л, there are not signs of ketosis,
necessary treatment of insulinomas in doses, which do not exceed 60 odes/twenty-four hours;
3 century (heavy) - hyperglycaemia - >of 19,7 ммоль/л, кетоацидоз, microangiopathies,
for normalization of sugar in blood, dose of insulin more than 60 odes/twenty-four hours;
A 1st type diabetes mellitus is middle and heavy degree, and 2nd mild and moderate
degree.
Under pregnancies flow of diabetes mellitus changes considerably. It is possible to
distinguish 3 stages of changes :
1.
The improvement of flow of illness passes in the first trimester, the level of glucose
diminishes in blood, the sensitiveness of tissues rises to insulin and it can result in development of
hypoglycemia. Therefore the dose of insulin is diminished on 1/3. Diminishing of requirement in
insulin is related to the increased utilization of glucose by a fetus. In this period hard control is
needed after the state of carbohydrate exchange;
2.
From 13 week of pregnancy there is worsening of flow of illness. height of
hyperglycaemia which can result in acidosis and pre-coma. The dose of insulin must be increased,
as a requirement in insulin increases in connection with influence of placenta hormones. From 32
weeks and to labor the improvement of flow of diabetes is possible again. The improvement of flow
of diabetes in this period is related to influence of insulin of fetus on the organism of mother, and
also with the increase of the use of glucose which gets through a placenta from maternal blood a
fetus.
3.
In labor there is considerable fluctuation of level of sugar in blood, a
hyperglycaemia and acidosis under act of eflowal influences (pain, fear) or hypoglycemia can
develop as a result of physical work. After labor sugar of blood quickly diminishes and then rises
gradually. On 2-3 days the dose of insulin goes down, to 7-10 day a puerperium the dose of insulin
arrives at that which was to pregnancy.
Therefore the pregnant with a diabetes mellitus are hospitalized in such terms:
1.
in the first weeks of pregnancy, for the estimation of weight of illness;
2.
in 20-24 weeks, when the flow of illness gets worse;
3.
in 32 weeks for indemnification of diabetes mellitus and decision about a term and
method of labor;
Pregnancy is contra-indicated:
1.
at diabetic microangiopathies;
2.
at unstable and insulin-resistant forms of diabetes with propensity to acidosis;
3.
at a disease diabetes both the parents;
4.
at compatibility of diabetes and sensitization of rhesus;
5.
at compatibility of diabetes and tuberculosis;
6.
at presence of in anamnesis of repeated stillborn, or children which were born
flawy development;
Patients with a diabetes mellitus rarely wear pregnancy. They have 36-37 weeks an
optimal term.
Labor conduct through natural maternity ways.
Testimony to the operation: (except for obstetric)

vascular complications which make progress during pregnancy;

unstable diabetes is with propensity to acidosis;

heavy gestosis and diabetes; growth of the phenomena of acidosis;

acute kidney insufficiency.
Disease of thyroid
At pregnancy there is an increase of function of thyroid increase of secretion of
thyroid hormones in 2nd trimester. On the measure of development of pregnancy part of these
hormones contacts with the protein of blood and becomes nonactive biologically, and the
concentration of active factions remains such which was to pregnancy.
The thyroid of fetus begins to function early - from 12-16 weeks of development; to labor
the pituitery-thyroid system of fetus is in the functionally-active state. A thyrotropin hormone does
not pass through a placenta, and thyroxin and triiodo-thyronine - pass and from fetus to the mother,
and from a mother to fetus.
Mostly pregnancy combines with Based illness, which hyperplasia, hypertrophy and
hyperfunction of thyroid is at. This pathology occurs from 0,19 to 8%.
The pregnant complains about heartbeat, increased nervousness, fatigueability,
parahypnosis, feeling of heat, increased sweatness, tremor of hands, exophtalm, increase of neck. In
ІІ at the easy form of disease there is a remission of disease a half some patients have the state, due
to binding of hormones to the protein. At the middle and heavy forms of disease in ІІ a heart failure
(in connection with the change of hemodynamics) develops the half of pregnancy (from 28-30
weeks of pregnancy). Heartbeat arrives at 120-140 bpm, breathing, high pulse pressure becomes
more frequent, blinking arrhythmia develops sometimes.
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 irondeficient 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.
5.3. Control questions
1. Aquired defects of heart. Conduct of pregnancy and labor.
2. Congenital defects of heart. Conduct of labor.
3. Features of flow of diseases of breathing organs are at pregnancy
4. Features of flow of pregnancy are at the vascular diseases of CNS.
5. A conduct of pregnancy is at the vascular diseases of CNS.
6. Shows are to terminating pregnancy at the diseases of CNS.
7. A conduct of labor is at the vascular diseases of CNS.
8. Features of pregnancy and labor are at myasthenia.
9. Shows are to terminating pregnancy at myasthenia.
10. Methods of treatment in case of the diseases of CNS.
11. Features of flow of pregnancy and labor are at epilepsy.
12. A conduct of pregnancy and labor is at epilepsy.
13. What changes of blood are characteristic for women with physiology pregnancy?
14. Anaemias of pregnants.
15. Clinic, diagnostics of different forms of anaemias pregnant.
16. Treatment of anaemias of pregnant.
17. Who of pregnant belongs to the group of high risk?
18. A conduct of labor is at anaemias.
19. Leucosis. Classification.
20. Conduct of pregnancy, labor.
21. Symptomatology of leucosis.
22. Thrombocytopenia. Forms, clinic, diagnostics.
23. Conduct of pregnant, labor at thrombocytopenia.
24. To give determination: to the pyelonephritis, glomerulonephritis, urolithiasis.
25. Etiology: to the pyelonephritis, nephrite, glomerulonephritis.
26. The pregnant have classification of disease of kidneys.
27. Clinic: pyelonephritis (different forms), glomerulonephritis (different forms),
urolithiasis.
28. Determination of risk group: at a pyelonephritis, glomerulonephritis.
29. The pregnant have features of flow of disease of kidneys.
30. Features of flow of pregnancy are at the diseases of kidneys.
31. Features of flow of labor are at the disease of kidneys.
32. Features of conduct of pregnancy, labor, puerperium, period of new-bornness are at the
diseases of kidneys.
33. Treatment of disease of kidneys at pregnancy and in post-natal
34. A diabetes mellitus is pathology of carbohydrate exchange.
35. The pregnant have diagnostics, clinic and treatment of diabetes mellitus.
36. Contraindications to continuation of pregnancy for patients by a diabetes mellitus.
37. The pregnant have obstetric complications with a diabetes mellitus.
38. Methods of labor of pregnant are at a diabetes mellitus.
39. The pregnant have diagnostics, clinic and treatment of diabetes mellitus.
40. Contraindications to continuation of pregnancy for patients by a diabetes mellitus.
41. The pregnant have obstetric complications with a diabetes mellitus.
42. Methods of labor of pregnant are at a diabetes mellitus.
43. A conduct of pregnancy and labor is at the diseases of thyroid.
44. Features of conduct of pregnancy and labor are at the diseases of liver and gall-bladder.
5.4 FINAL STAGE
Control and correction of level of professional ability and practical skills is conducted by the
decision of situational and clinical tasks, tests.
A teacher sets a domestic task, recommends literature on the topic of next employment.
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, 98110, 116-130.
2. Серов В.Н., Стрижаков А.Н., Маркин С.А. Практическое акушерство. - М.: Медицина,
1989.