Ministry of Health of Uzbekistan
TASHKENT MEDICAL ACADEMY
Obstetrics and gynecology of GP training
Lecture on subject:
Management of pregnant women with EGP
(for students of medical and preventive health departments)
Tashkent – 2012
Ministry of Health of Uzbekistan
TASHKENT MEDICAL ACADEMY
Obstetrics and gynecology of GP training
"APPROVED"
Dean of the Faculty of Medicine
Professor Khalmatova B.T.
____________________
________________ 2012
Management of pregnant women with
EGP
Speaker: Professor, M.D. Magzumova N.M.
TECHNOLOGY OF TRAINING
Number of students 25-26
Time is 2 hours
Form of lesson
Lecture - presentation
1. A definition of the most common EGP during
Plan of lecture
pregnancy, the course and their classification
2. Discuss methods of diagnosis and management of
pregnant women with different EGP (anemia, BMI,
diabetes, CVD and liver syndrome, shortness of
breath)
3. Describe the tactics of control in pregnancy and
the complications EGP
4. The approaches to the prevention and treatment of
complications in various EGP
The purpose of the training session: To introduce students, future general practitioners with the
management of pregnant women with EGP, diagnostic criteria, management of pregnant women with
complications, modern principles of prevention and treatment of pregnant women with different EGP anemia, BMI, diabetes, CVD and liver syndrome "difficulty breathing. "
Tasks the teacher:
Learning outcomes:
1. Learn to identify women with risk factors for
the occurrence of complications of pregnancy
and childbirth in EGP
2. Learn to recognize and be able to use basic
methods of diagnosis and first aid treatment of
extragenital diseases in pregnant women
3. Develop students' skills of independent
informed decisions when interpreting the basic
functional studies of pregnancy with EGP
4. Familiarize students with the principles of
prevention activities in various EGP
Methods and techniques of teaching
Learning Tools
Forms of education
Conditions of education
The student should know:
1. complications during and various EGP during
pregnancy and childbirth, the classification of factors
that contribute to their development.
2. changes occurring in women with STIs
3. diagnostic features.
4. principles of outpatient and inpatient management
of pregnant women with extragenital diseases.
5. carrying out rehabilitation, and prevention.
Lecture - visualization, presentation, technique: a
quiz, focusing questions, the technique of "yes-no"
Laser projector, visual materials, information
technology
Collective
Audience, work with TSO
TECHNOLOGICAL CARD OF LECTURES
Stages, Time
stage 1
introduction
(5 min)
stage 2
update of
knowladge
(20 min)
stage 3
Information
(55 min)
stage 4
Final (10 min)
Activities
Teacher
1. Reports the topic name, purpose, deliverables
lectures and plan for its performance (lyrics №
№ 1-3 in English. Language)
2.1. Displays and offers available for the
purpose of the lecture. Comments on the
content of the slides. Slides № 2-3
2.2. With a view to mainstreaming gives
students a focusing problem: Slide number 4
Pregnant or have recently given birth to a
woman who:
- Has anemia, liver disease, kidney, heart, etc.
- Has a variety of complaints
- Has difficulty breathing
Conducts blitz poll.
2.3. Displays the slide number 5
3.1. Consistently presents the material lectures
on the plan, using visual materials and a system
of focusing questions:
Plan on 1st question:
Defines various extragenital diseases in
pregnancy
Plan on 2nd question: list methods of
diagnostics and management of pregnant
women with different EGP
Plan on the 3rd questions: describe the tactics
of control and management of pregnant women
with EGP
Plan on 4th question: approaches to prevention
and treatment of complications of pregnancy
and childbirth
Focuses on key topics, offers them down.
4.1. Asks the question:
1. What are the differential features between the
various diseases with difficulty breathing?
2. What is the initial first aid help for difficult
breathing?
4.2. Gives the task for independent work:
Contraception after birth in women with EGP
Students
1. Listen
2.1. Examine the content of a
slide № 2-3
2.2. Respond the questions
2.3. Examine the content of
the slide number 5
3.1. Discuss the content of the
proposed materials, clarifies
and asks questions.
Write down the main
4.1. Answer questions
4.2. Listen and writes
Conduction of pregnant women with EGD
Prof. Magzumova N.M.
 In the structure of maternal mortality in Uzbekistan EGD occupy 14.9%.
 Из 100% материнской смертности ЭГЗ имели место у 92,8% женщин: From 100% of
maternal deaths 92.8% female had EGD:
 IDA - 45.3%
 Kidney disease - 15.3%
 . Diseases of the heart and blood vessels - 9.1.
The frequency of diabetes
(WHO, 1998)
 The increase in patients with diabetes were reported in the world
 There are more than 100 mln. patients with diabetes
 Diabetes occurs 1 in 300 pregnant
 Vascular complications in diabetes mellitus varies from 68-91%
Risk factors for diabetes
 . Complicated obstetrical anamnesis - premature birth, premature birth with macrosomia
and death from hyaline membrane disease, perinatal death of children weight between
4500 gr. and higher.
 й. Unfavorable genetic history of diabetes - obesity, glycosuria, kidney disease,
disturbance of menstrual and childbearing function.
: Classification:
 1) Type I diabetes mellitus:
A) autoimmune;
B) idiopathic;
2) Type II diabetes;
3) gestational diabetes;
4) other types of diabetes: genetic defects in the cellular system.
Conduction Of pregnancy.
 indications for abortion
 1) the presence of diabetes mellitus in both parents,
2) insulin resistant diabetes disposed to ketoacidosis,
3) diabetes complicated by: microangiopathy, retinopathy,
nephrosclerosis, hypertension, azotemia.
4) The combination of diabetes with tuberculosis.
5) diabetes mellitus with Rh negative blood,
. 6) repeated fetal loss, the presence of malformations in the fetus.
Standard glucose tolerance test
 impaired glucose tolerance:
- on an empty stomach 5 mmol \ l
 An hour later, 9.4 mmol \ l
 And after 2 hours 7.7 mmol \ l
 In explicitly diabetes:
- on an empty stomach 7 mmol \ l
 After 2 hours, 11 mmol \ l
Groups at risk of developing diabetes:
 1) premature pregnancy;
2) large fetus birth in preterm labor
3) perinatal death of fetus;
4) fetopathy;
5) the birth of children with weight greater than 4000 grams.;
6) preeclampsia;
7) polyhydramnios in anamnesis;
8) genetic factor
9) obesity;
10), glycosuria
11) candidiasis coleitis
12) ovarian dysfunction;
13) infertility. In anamnesis
 Stages:
Stage I - up to 12 weeks in I trimester of pregnancy reducing the level of glucose
(hypoglycemia);
Stage II - from 12 to 32 weeks of pregnancy increasing the blood glucose level
(hyperglycemia);
III - 32 before delivery reduction in glucose (hypoglycemia);
Stage IV - during childbirth increases the level of glucose (hyperglycemia).
Every pregnant with diabetes should be hospitalized during certain stages of pregnancy:
 . I hospitalization up to 12 weeks of pregnancy - carried out a full clinical examination,
the selection of doses of insulin, the question of the possibility of abortion, professional
treatment. Pregnant lies into department of endocrinology.
 II hospitalization: 20 -24 weeks of pregnancy, carried out a full clinical examination,
regulation of insulin doses. Angioprotectors and vitamins. appointed
 . III hospitalization: 32 -34 weeks of pregnancy - carried out a full clinical examination,
lower doses of insulin.
From this moment women go to the department of Pathology pregnancy and prepares for
labor
Contraindications to maintain pregnancy in diabetes
 Insulin-dependent diabetes with rapid progressive vascular complications / retinopathy,
glomerulosclerosis, etc. / /
 The presence of labile / with a tendency to ketoacidosis / or insulin-resistant forms of
diabetes, beyond compensation.
 Prior decompensation with prolonged gepatodistrofy and purulent-inflammatory
processes.
 Diabetes in both parents, which dramatically increases the possibility of diseases of
children / inherited diabetes, congenital malformations /.
 The combination of diabetes and Rh immunization of the mother.
 The combination of diabetes and tuberculosis
 The combination of diabetes with cardiovascular disease with blood circulation and
active rheumatic fever.
 presence of children in diabetic patients with congenital malformations
Indications for Caesarean section:
 1) Vascular complications of diabetes, advanced in pregnancy;
2) labile diabetes with a tendency to ketoacidosis,
3) developed severe preeclampsia,
4) increasing events of neyroretinopathy,
5) events of intercapillar glomerulosclerosis,
6) acute renal failure.
Treatment.
 1) diet therapy
2) insulin
I trimester of pregnancy calculated daily dose of 0.5 U / kg body weight.
II, III trimester of pregnancy calculated daily dose of 0.7 U / kg
The dose is divided into prolonged and not prolonged drugs.
3) vitamin
Also depending on the complications of the pregnancy, the appropriate treatment.
Length of stay:
 1 st - to 12ti weeks - the goal is to settle the issue of prolongation of pregnancy, dose
adjustment of insulin and preventive treatment.
 2 nd - at 20-24 weeks - target: the choice of insulin dose and drainage sites of infection,
assessment of the fetus, providing treatment
 . 3 th - at term 32-38 weeks. Objective: To solve the problem of the time and method of
delivery, holding anti hypoxia therapy, and therapy to accelerate the maturation of a
child’s lung tissue.
Antenatal monitoring of the fetus in the clinic
 Determination of fetoprotein
 Ultrasound (diabetic fetopathy)
 Determination of estriol in intervals of 2 days
 CTG, Doppler examination of the fetus
Physiological changes in the CVS
 ISO increased
 Increased left ventricular work
 Circulating blood volume (CBV) increased by 30-50%
 The volume of extracellular fluid increses
 Heart rate increases to 88 in 1min.
 Growing influence of regional circulation by the minute volume of heart
 Dilatation of coronary and peripheral vessels
Contraindications to the prolongation of pregnancy
.I. Relative contraindications.
 Latent course of rheumatic heart disease
 Primary or relapse. rheumatic heart disease within 1-2 years.
 Mitral stenosis with deficiency of blood circulation 1 st.
 Pronounced "clean" and combinative complex of heart defects without or with deficiency
of blood circulation
 . Myocardial damage with attacks of paroxysmal tachycardia, with complete blockade of
the frequency and rhythm, at least - 40 min.
 Active course of rheumatic heart disease
 Primary or relapse. rheumatic heart disease in the past 12 months.

Mitral stenosis with the deficiency of blood circulation and the activation of rheumatism.
 Other 'clean', combined and complex heart defects with deficiency of blood circulation I
or with symptoms of pulmonary hypertension.
 The defeat of the myocardium with deficiency of blood circulation 1, atrial fibrillation
and the phenomena of heart-vascular system deficiency, arythmia, the blockade of I-II
stage.
 Ineffective commissurotomy or restenosis with deficiency of blood circulation
Contraindications
Aortic stenosis
Inborn defect
 Coarctation of the aorta 2-3 stage
 Cyanotic forms heart disease / tetrad of Fallot and peptada etc /
 Stenosis of the pulmonary trunk
 Mitral valve prolapse with severe regurgitation
 . Complex arrhythmias.
 All congenital malformations
Principles of treatment of the Heart Vascular diseases
 Bed rest






Salicylates
Cardiac glycosides
Peripheral vasodilators
Diuretics
Drugs enhancing metabolism
Hepatoprotectors
,Anemia develops at the 28-30-week of physiological pregnancy in most of women .
 32 Ht rate from 0.40 to 0.32
 л number of red blood cells is reduced from 4.0 x 1012 / L to 3.5 x 1012 / l
 Hb index from 140 to 110 g / l from I to III trimester.
 Such changes in pattern of red blood cells, usually do not affect the condition and state of
health of the pregnant woman.
. True anemia of pregnant women are accompanied by typical clinical features and influence
on pregnancy and childbirth.
The group of risk for anemia:
 pregnant women older than 35 years
 with a history of 4 or more births
 EGD
 miscarriage
 Premature peeling of normally located placenta
 bleeding in childbirth in history
 anemia in the previous birth
 with complications of the pregnancy
 chronic infectious diseases
 pregnant women with Hb less than 12 g / l
Treatment in the clinic
 Correction of diet: the exclusion of coffee or tea
 Screening for parasitic infestations;
 Iron and folic acid;
 Consultations of hematologist and therapeutics if the condition of patient is getting worse
THERAPY against IDA IN PREGNANCY
 Preferably, the prescribing of oral iron;
 Parenteral administration of iron supplements only if it is impossible oral
administration and only in a hospital;
 Treatment of IDA should not be withdrawn after the normalization of hemoglobin
levels
 Necessary to continue iron therapy for another 4 to 6 months after giving birth to
replenish iron stores
Contraindications to pregnancy
 IDA chronic grade 3
 Hemolytic anemia
 Hypo-and aplasiaof bone marrow
 Leukosis
 Verlgofs disease with frequent exacerbations
Urinary tract infections (UTI)
urothelial inflammatory response to the invasion of bacteria, which usually shows pyuria
and bacteriuria.
Localization of UTI
Possible sources of leukocyturia
Classification of pyelonephritis
Etiology.
: The etiologic spectrum of pathogens that cause uncomplicated infections of the upper and
lower urinary tract is similar:
E.coli (70-95% of cases)
Staphylococcus saprophyticus in 5% of cases.
Rarely the agent of infection are Bacteria of the family Enterobacteriaceae, such as Proteus
mirabilis and Klebsiella spp.
Ways of INFECTION
 Upward way
 Hematogenous way
 Lymphatic way
 E. Coli and Enterobacterioceae
 Staphilococcus aureus, Candida spp, Salmonella spp, Mycobacterium tuberculosis
 rarely, a severe infection of the intestine and retroperitoneal abscesses
There are 3 risk levels of pyelonephritis
1 uncomplicated gestational pyelonephritis
2 - st –chronic pyelonephritis before pregnancy
3 - st - Pyelonephritis and hypertension, and azotemia pyelonephritis of the only kidney
Contraindications to pregnancy in kidney diseases
 3 degree of risk of pyelonephritis
 Hypertensive a mixed form of chronic glomerulonephritis
 Urolithiasis with renal insufficiency
Conduction of pregnancy in policlinics
 . First hospitalization until 12 weeks.
беременности Objective: To examine and the issue of prolongation of pregnancy
 Second hospitalization in a 24-28 weeks.
Objective: Examination and preventive treatment
 3-. Third hospitalization at 38 weeks.
Objective: Antenatal preparation
Treatment in the clinic
 Nutritional therapy
 Antibacterial therapy
 Anti-inflammatory drugs
 Nitrofuran drugs
 Sulfonamide
 Diuretics
 Desensitizing therapy
 Treatment of placentofetal deficiency
 Tocolytics
Labored breathing
Labored breathing
 Severe anemia
 Heart failure (anemia, cardiac disease)
 Pneumonia
 Bronchial asthma
 Pulmonary edema associated with preeclampsia
Severe anemia
Clinic:
 Labored breathing
 Paleness of conjunctiva, tongue, nail phalanges and / or palms
 Haemoglobin 7 g / l or less
 Hematocrit 20% or less

+ Drowsiness, fatigue, flat or concave nails
Treatment:
 Red cell blood transfusion
 Furosemide 40mg after transfusion
Heart failure due to anemia
 Symptoms and signs of severe anemia
 . + Edema, cough, wheezing, swelling of the lower extremities, enlarged liver, swelling
of the neck veins.
Treatment:
 Red cell blood transfusion
 Furosemide 40mg after transfusion
Heart failure due to heart disease
Clinic:
 Labored breathing
 Diastolic sounds and / or rough systolic murmur with a palpable tremor
 + Heart rhythm disturbance, an enlarged heart, liver, cyanosis, cough, swelling of the
lower extremities, swelling of the neck veins
Treatment:
 Morphine 10 mg / m once
 Furosemide 40mg / O, again if needed
 Digoxin 0.5 mg / m once
 or 0.3 mg of nitroglycerin under the tongue to repeat c / o 15 minutes if necessary
During delivery:
 Lay the woman on the left side
 Limiting fluid transfusion
 Adequate analgesia
Pneumonia
Clinic:
 Labored breathing
 High Temperature
 Mucous Cough
 Chest pain
 + Seal of lung tissue, hoarseness, rapid breathing, wheezing / whistling
Bronchial asthma
Clinic:
 Labored breathing
 Noisy breathing

Cough with phlegm, wheezing / whistling
Pulmonary edema associated with preeclampsia
Clinic:
 Labored breathing
 Hypertension
 Proteinuria
 + Wheezing, coughing with frothy sputum
RESUME
"Conduct pregnant with exctraginatalis by diseases”
For the reason reductions maternal and prenatal to death-rate, necessary to
reveal the womans with exctraginatalis by diseases, know the tactician of conduct
pregnant.
The General practitioner must know how in good time to diagnose, direct for
study and decisions of prolonged pregnancy, define the periods planned and
emergency hospitalization pregnant with exctraginatalis diseases .
Work out the knowledges and skills on diagnostics, differential diagnostics,
principle to well-timed hospitalization, volume of the examination and
interpretation main laboratory and functional methods of the study applicable
beside pregnant with sugar diabetes, anemia and diseases liver.