At the present stage, premature pregnancy and premature birth are an urgent social issue, since it is directly related to the level of health of the population.

Miscarriage - spontaneous termination of pregnancy at various stages of pregnancy up to 38 weeks. Habitual miscarriage - termination of pregnancy twice or more. Undermaturity - termination of pregnancy in the period from 28 to 37 weeks (less than 259 days).

Despite modern advances in obstetrics and pharmacotherapy, the frequency of preterm birth is, according to the literature, from 6 to 15% and has not tended to decrease over the past 5 years. The frequency of preterm birth in the Russian Federation remains significant, reaching an average of 14%, and primarily determines the high rates of perinatal morbidity and mortality. According to the statistics of the Moscow Health Committee for 2000-2001, with a frequency of undermaturity of 6.9%, over 70% of children who died from perinatal causes are premature babies. The highest mortality rate is observed among very premature infants with a gestational age of less than 32 weeks and a body weight of less than 1500 g, the main cause of death of which is respiratory distress syndrome.

That is why the main obstetric task, along with prolongation of pregnancy, is to reduce the role of respiratory distress syndrome in the structure of mortality. This task has two directions: maximum prolongation of pregnancy and prevention of respiratory distress syndrome.

Premature birth - termination of pregnancy at 22-37 weeks. In connection with the peculiarities of obstetric tactics and nursing children, it is advisable to identify the following gestational intervals:

Premature birth at 22-27 weeks;

Premature birth at 28-33 weeks;

Premature birth at 34-37 weeks

Risk factors for premature birth

In the structure of the causes of premature birth, about 28% are cases of induced delivery due to severe forms of gestosis, fetal hypoxia, placental abruption and antenatal fetal death.

72% are spontaneous premature births, of which about 40% are induced by premature rupture of the membranes.

Predisposing factors of preterm birth

Social and behavioral: low socioeconomic status of the mother, malnutrition, smoking, primiparous mothers under 16 or over 30 years of age, psychosocial stress.

Pathology of pregnancy: abruption and placenta previa, antiphospholipid syndrome, isthmic-cervical insufficiency, infection of the amniotic fluid and chorioamnial infection, premature rupture of membranes, gestosis, anomalies in the development of the uterus, uterine myoma, multiple pregnancy, polyhydramnios.

Genetic factors: Preterm birth in family members and in history.

Extragenital diseases: arterial hypertension, bronchial asthma, hyperthyroidism, drug addiction, diabetes mellitus, Rh-isoimmunization.

Features of the course and complications of premature birth.

Premature rupture of amniotic fluid.

Incorrect position and presentation of the fetus.

Abnormalities of labor.

Placental abruption.

Bleeding in the successive and early postpartum periods.

Infectious complications during childbirth and in the postpartum period.

Fetal hypoxia.

Respiratory distress syndrome of the newborn.

A high level of ineffectiveness in the treatment of preterm labor is associated, on the one hand, with their polygenic nature and the frequent impossibility of timely identification of etiological factors and specific treatment; and on the other hand, with the ineffectiveness of tocolytic therapy, as a rule, due to inadequate selection of the administration regimen.

The clinical picture of threatening premature birth.

Pain in the lower back and lower abdomen.

Excitability and tone of the uterus are increased.

The cervix is ​​preserved, its external os is closed.

The clinical picture of the onset of premature birth.

Regular labor.

Dynamics of cervical dilatation (more than 2-4 cm).

Today, in our country, the main official guideline regulating the management of threatened premature birth is the Appendix? 1 to the Order of the Ministry of Health Russian Federation? 318 dated December 4, 1992

Morbidity structure of premature newborns.

Congenital infection.

Pneumopathy.

Birth injury.

Developmental defects.

Respiratory distress syndrome

This syndrome is the leading cause of death in premature babies in developed countries.

The fetal lungs are filled with fluid secreted by the epithelium of potential air spaces. In the first minutes after birth, absorption of this fluid occurs, probably stimulated by an increase in the concentration of catecholamines in the circulating blood of the fetus, and the lungs are usually quickly cleared of fluid. Lung surfactant forms an insoluble film at the air-liquid interface in the alveoli, replacing water molecules in the surface layer and reducing surface tension. The main component of the surfactant is phospholipid-dipalmitoyl-phosphatidylcholine.

The synthesis of phosphatidylcholine is enhanced by thyroid hormones, estrogens, prolactin, epidermal growth factor, and the secretion of surfactant phospholipids from type 2 alveolocytes is largely stimulated by corticosteroids. In general, adrenergic agonists increase surfactant secretion into potential airspaces and maternal treatment β -adrenergic drugs can reduce the severity of respiratory distress syndrome in newborns

leg. However, it is also possible that the administration of high doses or long-term courses of adrenergic agonists can lead to depletion of intracellular stores of surfactant if the rate of its synthesis is low.

The chemical composition of the surfactant

Phospholipids 80%

Phosphatidylcholine 65%

Phosphatidylglycerol 5%

Phosphatidylethanolamine 5%

Sphingomyelin 3%

Other components 2%

Neutral lipids 10%

Proteins 10%

Prenatal diagnosis

Assessment of fetal lung maturity by analysis of amniotic fluid

Ethanol "foam" Clements test.

Determination of the optical density of fetal waters with a spectrophotometer or photoelectrocalorimeter (wavelength 650 nm).

Lecithin / sphingomyelin concentration ratio (L / C> 2.0).

The presence of phosphatidylglycerol (> 2 μg / ml).

Determination of the number of lamellar bodies: the ratio of phospholipids of lamellar bodies to total phospholipids> 0.35.

It is known that it is advisable to determine fetal maturity by the sum of the following parameters: calendar dates of pregnancy, ultrasound data, biochemical parameters of amniotic fluid. The simplest tests for assessing fetal lung maturity are listed below.

1. Ethanol "foam" Clements test.

To 3-5 ml of fetal waters obtained by amniocentesis, add 1 ml of a 95% solution of ethyl alcohol. Shake the tube for 15 seconds twice with an interval of 5 minutes. The test is considered positive if there are bubbles covering the surface of the liquid, doubtful if there are bubbles around the circumference of the test tube, negative if there are no bubbles.

2. Determination of the optical density of waters with a spectrophotometer or photoelectrocalorimeter (at a wavelength of 650 nm after centrifugation for 10 min at a speed of 2000 rpm).

3. The most common and diagnostically valuable criteria for the synthesis and secretion of the surfactant system are obtained by determining the lipid component of amniotic fluid.

The level of total lipids of amniotic fluid is quite significant and averages 0.5 g / l. A special role is played by phospholipids, the identification of the content of which has the main diagnostic value for assessing the maturity of the fetal lungs.

By the end of the third trimester of pregnancy, phospholipids are most abundant in phosphatidylcholine (synonym: lecithin) and sphingomyelin; minor fractions are phosphatidylserine, phosphatidylinositol.

The increase in the amount of phospholipids during pregnancy occurs mainly due to an increase in the concentration of lecithin. Over the period from 24 to 40 weeks of pregnancy, there is a 6-fold increase in its level (from 0.62 ± 0.05 to 3.84 ± 0.17 mg%), and the share in the total fraction of phospholipids increases from 43.9 to 71, 2%.

At the same time, the content of sphingomyelin, which exceeds that of lecithin at 22-24 weeks, on the contrary, decreases during pregnancy and after 35 weeks becomes much lower than the level of lecithin.

These changes in the composition of phospholipids reflect the concentration ratio of lecithin / sphingomyelin (L / C), which is widely used to determine the degree of maturity of the fetal lungs, since it reflects the presence of pulmonary surfactant 1 in the amniotic fluid.

In the second trimester of pregnancy, this figure is approximately 1.5; at 35-36 weeks - 1.8-2.0; at 37-38 weeks - 2.5-2.7. As a rule, with an L / C equal to 2 or more, fetal lung maturity is noted, and the risk of SDD in newborns is minimized.

The second criterion for fetal lung maturity is the concentration of phosphatidylglycerol.

In the initial period of fetal development, the main phospholipid of the surfactant is phosphatidylinositol (sphingomyelin), and the level of phosphatidylglycerol remains low. High level sphingomyeli

1 The study of the relationship between the content of these phospholipids in amniotic fluid and fetal urine made it possible to conclude that urine cannot be a significant source of phospholipids in the amniotic fluid and, therefore, the role of pulmonary surfactant in the formation of amniotic phosphatidylcholine and sphingomyelin is prevalent.

on the blood of the fetus decreases in the period close to the end of pregnancy, and as its concentration decreases, the production of phosphatidylglycerol increases, which underlies the clinical use of its level in amniotic fluid as an indicator of fetal lung maturity. The presence of phosphatidylglycerol in the amniotic fluid is a reliable sign of the maturity of the surfactant system.

Phosphatidylglycerol in amniotic fluid is detected at 35-36 weeks of gestation. The criterion for lung maturity is considered to be its level equal to 2 μg / ml and higher.

4. The next diagnostic criterion for fetal lung maturity is determined by evaluating the lamellar bodies.

As already mentioned, surfactant is synthesized by type 2 alveolar epithelium. The lamellar bodies of this epithelium serve as a site of accumulation of the pulmonary surfactant, and the main components of the lamellar bodies are part of the surfactant system.

It should be emphasized that the phospholipid content of lamellar bodies correlates with the level of total phospholipids, and the ratio between the first and the second, equal to 0.35, is equivalent to the L / C ratio, equal to 2.

Treatment of the threat of premature birth.

Bed rest.

Non-drug means:

Psychotherapy;

Electro-relaxation of the uterus;

Acupuncture;

Electroanalgesia;

Magnesium electrophoresis.

Drug therapy:

Sedative (tinctures of motherwort, valerian);

Tocolytic therapy;

Prevention of fetal SDR;

Etiological: hormone therapy, antibiotic therapy.

Prevention of Respiratory Distress Syndrome

Glucocorticoids increase the secretion of surfactant by 2nd order alveolocytes.

Contraindications: bacterial, viral infection, tuberculosis, shingles.

Side effects: hyperglycemia, leukocytosis, immunosuppression, fluid retention - pulmonary edema, IVH, enterocolitis.

Fetal Respiratory Distress Syndrome Prevention Schemes

Dexamethasone - exchange rate 20 mg, 4 mg intramuscularly after 6 hours (? 5).

Betamethasone - exchange rate 24 mg, 12 mg intramuscularly after 12 hours (? 2).

Hydrocortisone 500 mg intramuscularly? 4 after 6 hours.Total dose = 2 g.

Usually the effect occurs within 24-48 hours.

Drug therapy

Analysis of the frequency of premature termination of pregnancy over the past 10 years shows that there has been no significant decrease. A large number of drugs and other interventions are used to suppress preterm labor, but, unfortunately, none of the methods are 100% effective (ACOG, 1995). Currently, in order to treat threatening labor and stop labor, tocolytic drugs with a different mechanism of action are used - β 2 -adrenomimetics, magnesium sulfate, nonsteroidal anti-inflammatory drugs, calcium channel blockers, two new groups of tocolytic agents - nitric oxide donors such as nitroglycerin and glyceryl trinitrate, and competitive oxytocin agonists - the drug atosiban.

1. β 2 -adrenomimetics

The mechanism of action of this group is to stimulate the receptors of smooth muscles of the uterus and increase the synthesis of cAMP, which plays important role in the suppression of uterine contractions.

When bound by catecholamines, adrenergic receptors can stimulate or inhibit adenylate cyclase, and the latter, in turn, affects the level of cAMP in the cell. In the normal course of pregnancy, from the 28th week, there is a gradual increase in the level of cAMP. Before giving birth, its concentration decreases. The level of cAMP during normal pregnancy is: 28-30 weeks - 15.79 nmol / l; at 31-36 weeks - 18.59 nmol / l; at 37-38 weeks - 17.16 nmol / l; at 40-41 weeks - 13.28 nmol / l. Increasing the contractile activity of the uterus

there is a decrease in cAMP in blood plasma by 1.5-2 times compared with the norm.

In our country, the most widespread are fenoterol (partusisten), terbutaline (bricanil), ginipral (hexoprenaline) and a new domestic β 2-adrenergic agonist - salgim. The drug is a derivative of salbutamol hemisuccinate and succinic acid, which takes part in the Krebs cycle and gives an antihypoxic effect.

Partusisten. Massive tocolysis: intravenous drip 1 mg / day (2 ampoules of 500 μg) per 400 ml of saline at a rate of 3-4 μg / min (25-30 drops per minute) Maintenance dose: enterally 2-3 mg (4-6 tablets ) per day.

Ginipral(hexoprenaline) - highly selective β 2 -adrenomimetic, selectively acting on the myometrium (selectivity index 5: 1). Massive tocolysis: intravenous drip of 100-150 mcg (4-5 ampoules of 25 mcg) per 400 ml of saline at a rate of 0.3 mcg / min (15-20 drops per minute). Maintenance tocolysis: intravenous drip at a rate of 0.075 μg / min (8-10 drops per minute), enterally 2-3 mg (4-6 tablets) per day.

Salgim. Massive tocolysis: intravenous drip of 10 mg (2 ampoules of 5 mg) per 400 ml of saline at a rate of 20-25 μg / min (15-20 drops per minute). Maintenance tocolysis: enterally 16-24 mg (4-6 tablets) per day. Contraindications for use β 2 -adrenomimetics: fever, infectious diseases in the mother and fetus, hypokalemia, cardiovascular diseases: cardiovascular

diomyopathy, conduction and heart rhythm disturbances; thyrotoxicosis, glaucoma, bleeding during pregnancy, diabetes mellitus.

Potential complications caused by β 2 -adrenomimetics: hyperglycemia; hypotension; hypokalemia; pulmonary edema; arrhythmia; myocardial ischemia.

2. Magnesium sulfate

The effect of magnesium sulfate is associated with the competitive interaction of magnesium ions and the blocking of calcium channels in the cell, which in turn reduces the intracellular intake of calcium and the activity of myosin light chain kinases.

Magnesium ions in high concentrations can inhibit the contractility of the myometrium as in vitro, and so in vivo by competing with free calcium ions. Magnesian tocolysis can be effective at a therapeutic serum concentration of at least 6 meq / l (5.5-7.5 mg%). Extensive foreign and own experience testifies: effective magnesian tocolysis is provided by the following administration regimen - 6 g of dry matter for 1 hour and 3 g per hour in a daily dose of 24 g.

The literature data regarding the tocolytic efficacy of magnesium sulfate are contradictory. Semchyshyn (1983) reported that unintentional (accidental) administration of 17.3 g of magnesium sulfate for 45 minutes did not stop uterine contractile activity. And yet, most authors note the lower efficiency of magnesium sulfate compared to that β 2 -adrenomimetics. According to our data, the effectiveness of tocolysis in threatening preterm labor was comparable with the use of ginipral and magnesium sulfate and amounted to 94.7 and 90%, respectively. In the latent phase of the first stage of labor, the effectiveness of ginipral was 83.3%, and magnesium sulfate - 30%.

Magnesium sulfate effects

Of course, hypermagnesemia has its negative consequences. Side effects in the form of hypotension, fever, facial hyperemia occur with massive magnesian tocolysis in almost half of the cases. Due to the curariform action of high doses of magnesium sulfate with a serum level exceeding 10 meq / l (120 g / l), inhibition of reflex activity, including knee reflexes, is observed. At a concentration of more than 10 meq / l, magnesium has a toxic effect, and more than 12 meq / l - causes paralysis of the respiratory muscles. Magnesium sulfate in toxic concentrations gives complications: pulmonary edema, respiratory depression, cardiac arrest, deep muscle paralysis, hypotension.

Therefore, magnesia tocolysis should be carried out taking into account potential complications under the strict control of diuresis (at least 30 ml / h), the activity of knee reflexes or the concentration of magnesium in the blood serum.

Influence of tocolytics on fetal heart rate according to CTG data

Magnesium sulfate

Decreased variability.

Lack of influence on the frequency of the basal rhythm.

Ginipral

Tachycardia.

Reducing the number of accelerations.

Decreased variability.

However, it was shown that the introduction of magnesium sulfate in the mode of 4.5 g per hour gives an effect equivalent to that of partusisten, terbutaline, isadrin. Moreover, magnesium sulfate with a combination of preterm labor and placental abruption is the only drug of choice for tocolysis, which distinguishes it favorably from the drugs of the group β 2 -adrenomimetics.

3. Non-steroidal anti-inflammatory drugs The most common drug in this group is indomethacin, a prostaglandin synthetase inhibitor. However, the data confirming the connection between the use of the drug (especially before 32 weeks of gestation) with premature closure of the ductus arteriosus, IVH and necrotizing enterocolitis cause concern. Potential complications with long-term use of indomethacin are

drug hepatitis, renal failure, bleeding of the gastrointestinal tract. Indomethacin infusion causes hemodynamic disturbances of cerebral circulation, namely: a significant decrease in the average blood flow velocity, peak systolic and end diastolic blood flow velocity in the anterior and middle cerebral arteries.

Indomethacin is prescribed at 50-100 mg every 8 hours for 2-3 days. Its purpose is justified for polyhydramnios, since it reduces the production of urine in the fetus.

Calcium antagonists reduce the contractile activity of the myometrium due to the violation of the penetration of calcium ions into the smooth muscle cell. Most of the studies carried out have shown low tocolytic efficacy of this group of drugs. Side effects are not expressed. Possible complications associated with the use of nifedipine are as follows: transient hypotension, tachycardia, arrhythmia.

Oxytocin receptor antagonists (atosiban)

The efficacy of oxytocin receptor antagonists has been shown with intravenous or long-term subcutaneous administration over 28 weeks of gestation with intact membranes.

The drug atosiban is a non-protein analogue of oxytocin, capable of suppressing oxytocin-induced contractions of the myometrium. The drug is approved for use in the United States for the cessation of labor. However, there is insufficient data on the clinical use of atosiban to accurately assess its efficacy and safety.

However, despite the large arsenal of modern tocolytic drugs, the frequency of preterm birth does not have a significant tendency to decrease. This is primarily due to the late start of treatment, inadequate choice of the drug, its dose and administration regimen.

The next aspect of tocolytic therapy that deserves special attention is its use in the management of pregnant women with prenatal effusion. Obstetric tactics for prenatal effusion (the cause of at least 40% of all preterm births) is the most difficult and not completely solved obstetric problem.

At present, when water is poured out before 34 weeks of pregnancy, a wait-and-see tactic has been officially adopted, and the duration of tocolysis is limited by the time of prevention of fetal respiratory distress syndrome - that is, 2 days. Is this approach regulated in the Order? 318 of the Ministry of Health of the Russian Federation.

However, the significant successes of neonatologists in the care of deeply premature newborns dictate the need to revise obstetric tactics in prenatal outpouring in the direction of maximum prolongation of pregnancy.

After 28 weeks of gestation, the survival rate of newborns progressively increases and the percentage of disability decreases. This means that the maximum prolongation of pregnancy during these periods should be a strategic task of perinatology.

Unfortunately, the high risk of purulent-septic complications of the mother makes it extremely cautious about prolonging pregnancy with prenatal outpouring of water. However, the precise implementation of preventive measures and the availability of a wide range of modern antimicrobial drugs can significantly reduce the percentage of purulent-septic complications and provide the possibility of long-term tocolysis during prenatal outpouring of water.

Antibiotic prophylactic regimens for prenatal effusion

1. The empirical appointment of antibiotic therapy immediately after taking the material for inoculation.

2. Carrying out antibacterial therapy after receiving the results of laboratory tests (microscopy / culture of amniotic fluid, culture from the cervical canal).

3. Conducting antibiotic therapy when clinical signs of chorioamnionitis appear.

The most common scheme for the empirical prescription of antibiotic therapy, and since group B streptococcus is of paramount importance among bacterial pathogens in the genesis of fetal infection, the antibiotics of choice are semi-synthetic penicillins (ampicillin).

In this regard, it is promising to carry out long-term tocolytic therapy up to 32-34 weeks of pregnancy in accordance with the level of equipment and qualifications of the neonatal service and against the background of the prevention of respiratory distress syndrome of the fetus, taking into account clearly limited contraindications.

Management of preterm pregnancy (up to 34 weeks) with prenatal rupture of amniotic fluid.

1. Prevention of infection: compliance with hygienic principles and norms;

Exclusion of vaginal examinations;

Dynamic laboratory analysis of microflora.

2. Monitoring the mother's condition:

Thermometry;

Clinical laboratory blood test;

Visual assessment of discharge (water) from the genital tract.

3. Monitoring fetal health:

Dynamic assessment of amniotic fluid volume (amniotic fluid index).

4. Prevention of fetal respiratory distress syndrome.

5. Tocolytic therapy.

6. Antibiotic therapy.

Contraindications to tocolytic therapy for premature rupture of the membranes

1. The gestational period is more than 34 weeks.

2. The appearance of signs of systemic inflammation (fever, leukocytosis with a shift in the leukocyte formula).

3. The appearance of clinical signs of chorioamnionitis and / or endometritis.

4. Intrauterine suffering and fetal death.

5. Complications of pregnancy and other pathologies in which abortion is indicated regardless of the presence of the fetal bladder.

Unfortunately, very, very many. These are referred to as various factors risk of a social, medical, physiological nature, and unforeseen life circumstances (for example, an emergency caesarean section). The most important thing - no matter what the reason for the child - is to do everything depending on doctors and parents to nurture him, so that in the future he does not differ in any way from his full-term peers. Premature (as defined by WHO) is a child who was born at the age of 22 to, weighing from 500 grams to 2500 grams.

Let's take a closer look at all sorts of prerequisites for the premature termination of pregnancy:

1.Socio-demographic reasons:

• low living (social) level of the family;
• too early or vice versa - late age for pregnancy (there is a tendency for an increase in the incidence of undermaturity depending on the age of the parents - the younger (less than 17-18 years) and the older (more than 35 years) the expectant mother, as well as the older the father of the child (more 50 years), the higher the likelihood of premature termination of pregnancy);
• problems in family life, frequent scandals, lack of understanding;
• unwanted pregnancy (as a factor in the psychological termination of pregnancy);
• poor nutrition and bad habits pregnant woman.

2.Medical reasons:

• pregnancy that occurred earlier than one to three years after the previous birth;
• the woman has chronic diseases (endocrine system, gynecological, genetic), as well as burdened heredity on the part of either parent;
• acute and infectious diseases suffered by a woman during pregnancy;
• strong early toxicosis, aggravated preeclampsia and other pathologies of pregnancy;
• undergone surgical interventions (operations) and physical injuries (especially the abdomen) while carrying a child;
• unstable mental and emotional state of a pregnant woman;
• hemolytic disease of the fetus, which developed against the background of incompatibility with the mother by blood group or Rh factor;
• previous surgical termination of pregnancy (induced abortion), especially if complications arose during or after the operation;
• multiple pregnancy;
• various defects in the structure and development of the uterus and cervical canal (for example, bicornuate uterus, underdeveloped cervix);
• presentation or premature placental abruption;
• polyhydramnios or premature discharge of amniotic fluid;
• defects in the development of the fetus or its intrauterine death.

3.Environmental and working conditions:

• the aggressive environment in which the expectant mother lives (for example, proximity to the Chernobyl zone or other hazardous radiation facilities, living near a chemical plant, etc.);
• harmful working conditions where any of the child's parents works;
• heavy physical labor in which a pregnant woman is involved (for example, prolonged standing during the working day, work on an assembly line, work involving the transfer of heavy loads).

Causes of premature pregnancy there are many more, and we simply do not have enough time or energy to list them all. In addition to the above reasons, there are also cases where the cause of the premature onset of labor remains unknown. Therefore, at the first suspicion of the threat of the onset of premature labor, immediately consult a doctor who will determine the cause of this phenomenon and take all the necessary measures to continue carrying the child.

Prevention of premature pregnancy

Prevention of this pregnancy pathology should be started even when planning the conception of a baby.

To do this, a woman (and a man also does not hurt) needs:

• it is imperative to treat all the chronic and acute diseases that she has (for which it is necessary to take responsibility for the passage of the necessary ones when planning pregnancy!);
• follow the rules intimate hygiene as well as lead a choosy sex life;
• protect yourself from unwanted pregnancy (according to statistics, more than half of the cases of undermaturity occur in women who had abortions shortly before pregnancy!);
• do not abuse alcoholic beverages, quit smoking;
• eat right, replenish the supply of vitamins in your body;
• avoid stress, anxiety, nervous strain.

If you find the first signs that you are pregnant, do not postpone a visit to the gynecologist and registration. This is the only way you can avoid medical errors in calculating the true gestational age, which is one of the most common causes of premature pregnancy, especially if you gave birth at the 36th - 37th week.

Pregnancy miscarriage

Premature pregnancy is a serious social problem... The frequency of this pathology ranges from 10 to 25%. A premature pregnancy is a pregnancy that ends in a premature birth or abortion.

The reasons for undermaturity are varied and many. They can be conditionally divided into two groups: diseases of a pregnant woman and anomalies of an obstetric nature. Among the diseases of a pregnant woman, in the first place are infectious diseases such as influenza, herpes, taxoplasmosis, rubella; as well as diseases of the kidneys, gastrointestinal tract, liver, blood, toxicosis of pregnancy. Anomalies of an obstetric nature include abnormal fetal position, multiple pregnancies, hemolytic disease, and premature discharge of water. A well-known role is also played by the deficiency of vitamins and microelements, the harmful influence of the external environment. Of great importance in this pathology is the state of the nervous system of the pregnant woman, negative emotions.

Among the reasons for miscarriage, the profession of a woman is also important. This pathology is more common in working women (34%), less often in housewives (24%).

Signs of threatening termination of pregnancy include pain in the lower abdomen and lower back, profuse mucous and mucous-bloody discharge from the vagina. In such cases, the pregnant woman should be urgently admitted to the hospital.

It is important for the unborn child to preserve every week of intrauterine development. The days corresponding to the period of menstruation are especially dangerous. Special care must be taken on such days. If a woman has had cases of miscarriage, hospitalization is necessary before the time when the interruption occurred the previous time.

Premature birth means that the child has a significant period of intrauterine development, in connection with which his further development changes sharply.

In premature babies, the body's resistance to various infections is reduced, and the immaturity of the lungs contributes to the rapid development of pneumonia. Even a normal delivery for a premature baby can be traumatic. The closer to the physiological end of pregnancy a premature birth takes place, the more viable the premature baby is. The weight of the premature baby is less than 2500 g, and the height is less than 45 cm, their skin is covered with small hairs, the nails do not completely cover the terminal phalanges of the fingers, the fontanelles are very large, in boys the testicles may not be lowered into the scrotum, the subcutaneous fat layer is poorly developed, therefore such children do not tolerate temperature changes. The movements of the premature baby are inactive, the cry is weak or absent altogether, the eyes are closed, he does not take the breast well, therefore such children require special care and attention to themselves.

Postponing pregnancy

A post-term pregnancy is a pregnancy, the duration of which exceeds the physiological period (280 days) by 10-15 days. The frequency of prolonged pregnancy ranges from 3 to 7%.

Postterm pregnancy ends in belated childbirth.

The causes of post-aging are complex and have not yet been sufficiently studied. A certain role is played by changes in the uterus, which reduce its contractile activity in connection with previous abortions, inflammatory and other diseases. Prolonged pregnancy is observed more often in primiparous over 30 years of age and can be inherited or observed in the same women several times. Oversight can also be caused by mental trauma. It is most often observed in the spring, mainly in women with menstrual dysfunction.

Distinguish between true prolonged pregnancy and imaginary (prolonged pregnancy). With prolonged prolonged gestation, the gestation period increases, but the child is born mature and without signs of prolonged gestation. This may be due to the reasons that slowed down the development of the fetus, and is considered as an adaptive phenomenon that contributes to the maturation of the fetus. With prolonged pregnancy, the fetus often becomes large with large head sizes and long nails... The bones of the head of a post-term baby are dense, and the fontanelles are small. Changes in the placenta also occur, making it difficult to deliver to the baby the required amount oxygen and other substances necessary for normal life. This placenta is called old.

The effect of prolonged pregnancy on the fetus is unfavorable, since the course of delayed labor is often complicated, an overripe fetus is poorly adapted to postpartum stress; exceptions are cases when prolongation of pregnancy is not accompanied by pronounced overripe, which is observed with a slight increase in the duration of pregnancy.

Usually, with this pathology, childbirth does not occur on its own, and it is necessary to carry out labor induction, that is, to prepare the pregnant woman for childbirth. For this, funds are used that increase the contractile activity of the uterus, and drugs that prepare the cervix for childbirth, vitamins, calcium preparations, sometimes resort to caesarean section.

Pregnant women who have previously given birth to a child weighing more than 4 kg, as well as whose previous pregnancies were post-term, who have suffered a psycho-emotional shock, must undergo a comprehensive examination and go to the hospital no later than 40 weeks of pregnancy. Oversight increases the risk of abnormal delivery and has an adverse effect on the unborn child.

Original article www.baby.com.ua The material was prepared by E. Tolstykh

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According to statistics, miscarriage is recorded in 10-25% of pregnant women.

The cause of miscarriage can be various diseases that are difficult to treat or become chronic. Moreover, these diseases do not belong to the genital area. An important feature of this kind of pathology is the unpredictability of the process, since for each particular pregnancy it is difficult to determine the true cause of the termination of pregnancy. Indeed, at the same time, many different factors affect the body of a pregnant woman, which can act covertly or explicitly. The outcome of pregnancy in the case of her habitual miscarriage is largely determined by the therapy. With three or more spontaneous miscarriages during pregnancy up to 20 weeks of pregnancy, the obstetrician-gynecologist diagnoses recurrent miscarriage. This pathology occurs in 1% of all pregnant women.

After the fertilized egg has “settled” in the uterine cavity, the complex process of its engraftment begins there - implantation. The future baby first develops from the ovum, then becomes an embryo, then it is called the fetus, which grows and develops during pregnancy. Unfortunately, at any stage of carrying a child, a woman may face such a pathology of pregnancy as miscarriage.

Miscarriage is the termination of pregnancy from the moment of conception to the 37th week.

Risk of primary miscarriage

Doctors note a certain kind of pattern: risk spontaneous interruption pregnancy after two failures increases by 24%, after three - is 30%, after four - is 40%.

With miscarriage, a complete or incomplete pregnancy occurs (the ovum detached from the wall of the uterus, but remained in its cavity and did not come out), a miscarriage in the period up to 22 weeks. At a later date, in the period 22-37 weeks, spontaneous termination of pregnancy is called premature birth, while an immature but viable baby is born. Its weight ranges from 500 to 2500 g. Premature, prematurely born children are immature. Their death is often noted. Developmental malformations are often recorded in surviving children. The concept of prematurity, in addition to the short term for the development of pregnancy, includes a low fetal body weight at birth, on average from 500 to 2500 g, as well as signs of physical immaturity in the fetus. Only by the combination of these three signs, a newborn can be considered premature.

With the development of miscarriage, certain risk factors are indicated.

Modern advances in medicine and new technologies, timeliness and quality of medical care make it possible to avoid serious complications and prevent premature termination of pregnancy.

A woman with a first trimester miscarriage should undergo a long examination even before the intended pregnancy and during pregnancy to identify the true cause of miscarriage. Highly difficult situation develops with spontaneous miscarriage against the background of the normal course of pregnancy. In such cases, the woman and her doctor can do nothing to prevent such a course of events.

The most common factor in the development of premature termination of pregnancy is chromosomal abnormalities of the fetus. Chromosomes are microscopic elongated structures located in the internal structure of cells. Chromosomes contain genetic material that sets all the properties characteristic of each person: eye color, hair, height, weight parameters, etc. In the structure of the human genetic code there are 23 pairs of chromosomes, in total 46, with one part inherited from organism, and the second - from the father. Two chromosomes in each set are called sex and determine the sex of a person (XX chromosomes determine female sex, XY chromosomes - male sex), while other chromosomes carry the rest of the genetic information about the whole organism and are called somatic.

It was found that about 70% of all miscarriages in early pregnancy are due to abnormalities of somatic chromosomes in the fetus, while most chromosomal abnormalities of the developing fetus occurred due to the participation of a defective egg or sperm in the fertilization process. This is due to the biological process of division, when the egg and sperm in the process of their pre-maturation divide in order to form mature germ cells, in which the set of chromosomes is 23. In other cases, eggs or spermatozoa with an insufficient (22) or with an excess (24) set are formed. chromosomes. In such cases, the formed embryo will develop with a chromosomal abnormality, which leads to a miscarriage.

The most common chromosomal defect can be considered trisomy, while the embryo is formed when the germ cell merges with chromosome set 24, as a result of which the set of fetal chromosomes is not 46 (23 + 23), as it should be normal, but 47 (24 + 23) chromosomes ... Most trisomies involving somatic chromosomes lead to the development of a fetus with defects that are incompatible with life, which is why spontaneous miscarriage occurs in the early stages of pregnancy. In rare cases, a fetus with a similar developmental anomaly survives to a long time.

Down's disease (represented by trisomy on chromosome 21) can be cited as an example of the most famous developmental abnormality caused by trisomy.

A large role in the occurrence of chromosomal abnormalities is played by the woman's age. And recent studies show that the age of the father plays an equally important role, the risk of genetic abnormalities increases when the father is over 40 years old.
As a solution to this problem, married couples where at least one partner has been diagnosed with congenital genetic diseases is offered mandatory counseling with a geneticist. In certain cases, IVF is proposed (in vitro fertilization - in vitro fertilization) with a donor egg or sperm, which directly depends on which of the partners has revealed such chromosomal abnormalities.

Causes of primary miscarriage

There can be many reasons for the occurrence of such violations. The process of conceiving and bearing a baby is complex and fragile, it involves a large number of interrelated factors, one of which is endocrine (hormonal). Female body maintains a certain hormonal background so that the baby can develop correctly at every stage of his intrauterine development. If, for some reason, the body of the expectant mother begins to produce hormones incorrectly, then hormonal imbalances cause the threat of termination of pregnancy.

Never take hormones on your own. Taking them can seriously disrupt the reproductive function.

The following congenital or acquired uterine lesions may threaten the course of pregnancy.

• Anatomical malformations of the uterus - doubling of the uterus, saddle uterus, two-horned uterus, one-horned uterus, partial or complete uterine septum in the cavity - are congenital. Most often, they prevent the ovum from successfully implanting (for example, the egg "sits" on the septum, which is unable to perform the functions of the inner layer of the uterus), which is why a miscarriage occurs.
• Chronic endometritis - inflammation of the mucous layer of the uterus - the endometrium. As you remember from the section that provides information on the anatomy and physiology of women, the endometrium has an important reproductive function, but only as long as it is "healthy". Prolonged inflammation changes the nature of the mucous layer and disrupts its functionality. It will not be easy for the ovum to attach and grow and develop normally on such an endometrium, which can lead to the loss of pregnancy.
• Polyps and endometrial hyperplasia - proliferation of the mucous membrane of the uterine cavity - the endometrium. This pathology can also interfere with embryo implantation.
• Intrauterine synechiae are adhesions between the walls in the uterine cavity, which prevent the fertilized egg from moving, implanting and developing. Synechiae most often occur as a result of mechanical trauma to the uterine cavity or inflammatory diseases.
• Uterine fibroids are benign tumor processes that occur in the muscular layer of the uterus - myometrium. Fibroids can cause miscarriage if the ovum is implanted next to the myoma node, which has violated the tissue of the inner uterus, "takes over" the blood flow and can grow towards the ovum.
• Isthmico-cervical insufficiency. It is considered the most common cause of perinatal losses in the second trimester of pregnancy (13-20%). The cervix is ​​shortened with subsequent dilatation, which leads to the loss of pregnancy. Usually, isthmic-cervical insufficiency occurs in women whose cervix was damaged earlier (abortion, rupture in childbirth, etc.), has a congenital malformation or cannot cope with increased stress during pregnancy ( large fruit, polyhydramnios, multiple pregnancies, etc.).

Some women have a congenital predisposition to thrombosis (blood clots, blood clots in the vessels), which makes it difficult to implant the ovum and interferes with normal blood flow between the placenta, baby and mother.

The expectant mother often does not even know about her pathology before pregnancy, since her hemostasis system coped well with its functions before pregnancy, that is, without the "double" load that appears with the task of carrying a baby.

There are other causes of miscarriage that need to be diagnosed for timely prevention and treatment. Correction methods will depend on the identified cause.

The reason for the habitual miscarriage can also be normal chromosomes that do not give development problems in both partners, but carry a latent carriage of chromosomal abnormalities, which affect fetal abnormalities. In such a situation, both parents must perform a karyotype test of their blood in order to detect such chromosomal abnormalities (carriage of non-manifest chromosomal abnormalities). With this examination, according to the results of karyotyping, a probable assessment of the course of subsequent pregnancy is determined, and the examination cannot give a 100% guarantee of possible anomalies.

Chromosomal abnormalities are manifold, they can also cause missed pregnancies. In this case, only the fetal membranes are formed, while the fetus itself may not be. It is noted that the ovum is either formed initially, or it stopped its further development in the early stages. For this, in the early stages, the cessation of the characteristic symptoms of pregnancy is characteristic, at the same time, dark brown discharge from the vagina often appears. An ultrasound scan allows you to reliably determine the absence of a fetal egg.

Miscarriage in the second trimester of pregnancy is mainly associated with abnormalities in the structure of the uterus (such as an irregular shape of the uterus, an extra uterine horn, its saddle shape, the presence of a septum, or a weakening of the retention capacity of the cervix, the disclosure of which leads to premature birth). In this case, the possible reasons for miscarriage in later dates may become infection of the mother ( inflammatory diseases appendages and uterus) or chromosomal abnormalities of the fetus. According to statistics, chromosomal abnormalities are the cause of miscarriage in the second trimester of pregnancy in 20% of cases.

Symptoms and signs of primary miscarriage

Bleeding is a characteristic symptom of miscarriage. Bloody vaginal discharge from spontaneous miscarriage usually begins suddenly. In some cases, a miscarriage is preceded by a pulling pain in the lower abdomen, which resembles pain before menstruation. Along with the release of blood from the genital tract, with the onset of spontaneous miscarriage, the following symptoms are often observed: general weakness, malaise, fever, decrease in nausea that was present before, emotional tension.

But not all cases of bleeding in early pregnancy end in spontaneous miscarriage. In case of discharge of blood from the vagina, a woman should consult a doctor. Only a doctor will be able to conduct a proper examination, determine the condition of the fetus, find out if the cervix is ​​dilated and choose the right treatment aimed at preserving the pregnancy.

If spotting from the genital tract is detected in the hospital, a vaginal examination is performed first. If the first miscarriage occurred in the first trimester of pregnancy, then the study is carried out shallowly. In the event of a miscarriage in the second trimester or two or more spontaneous abortions in the first trimester of pregnancy, a complete examination becomes necessary.

In this case, the course of a full examination includes a certain set of examinations:

1. blood tests for chromosomal abnormalities in both parents (clarification of the karyotype) and determination of hormonal and immunological changes in the mother's blood;
2. conducting a test for chromosomal abnormalities of aborted tissues (it is possible to determine when these tissues are available - either the woman herself saved them, or they were removed after curettage of the uterus in a hospital);
3. ultrasound procedure uterus and hysteroscopy (examination of the uterine cavity using a video camera, which is inserted through the cervix and displays a picture on the screen);
4. hysterosalpingography (x-ray examination of the uterus;
5. biopsy of the endometrium (inner layer) of the uterus. This manipulation involves taking a small piece of the uterine lining, after which a hormonal examination of the tissue is performed.

Treatment and prevention of primary miscarriage

If pregnancy is threatened by endocrine disorders in a woman, then after laboratory tests, the doctor prescribes hormonal therapy. In order to prevent unwanted surges in hormones, medications can be prescribed even before pregnancy, with subsequent dosage and drug adjustments already during pregnancy. In the case of hormone therapy, the condition of the expectant mother is always monitored and the corresponding laboratory tests (analyzes) are performed.

If miscarriage is due to uterine factors, then the appropriate treatment is carried out several months before the conception of the baby, since it requires surgical intervention. During the operation, synechiae are dissected, polyps of the uterine cavity are eliminated, fibroids that interfere with the course of pregnancy are removed. Medication before pregnancy is used to treat infections that contribute to the development of endometritis. Cervical insufficiency during pregnancy is corrected surgically. Most often, the doctor prescribes suturing of the cervix (for a period of 13-27 weeks) in the event of its failure - the cervix begins to shorten, become softer, the internal or external pharynx opens. Stitches are removed at 37 weeks of gestation. A woman with a sutured cervix is ​​shown a sparing physical mode, lack of psychological stress, since even on the sutured neck, amniotic fluid may leak.

In addition to suturing the cervix, a less traumatic intervention is used - putting on a Meyer's ring (obstetric pessary) on the cervix, which also protects the cervix from further disclosure.

The doctor will suggest the most appropriate method for each specific situation.

Do not forget that not only ultrasound data are important, but also information obtained during a vaginal examination, since the neck can be not only shortened, but also softened.

For the prevention and treatment of problems associated with the hemostasis system of the expectant mother, the doctor will prescribe laboratory blood tests (mutations of the hemostasis system, coagulogram, D-dimer, etc.). Based on the published survey results, it can be applied drug treatment(tablets, injections), which improves blood flow. Expectant mothers with impaired venous blood flow are recommended to wear medical compression hosiery.

There are many reasons for miscarriage. We did not mention severe extragenital pathologies (diseases not related to the genital area), in which it is difficult to bear a child. It is possible that for a particular woman, not one reason is "working" for her condition, but several factors at once, which, overlapping each other, give such a pathology.

It is very important that a woman with miscarriage (three or more losses in history) is examined and undergoes medical training BEFORE the forthcoming pregnancy in order to avoid this complication.

The treatment of such a pathology is extremely difficult and requires a strictly individual approach.

Most women immediately after spontaneous miscarriage in the early stages of treatment, as such, is not required. The uterus is gradually and completely self-cleaning, as it does during menstruation. However, in some cases of incomplete miscarriage (partially the remnants of the ovum remain in the uterine cavity) and when the cervix is ​​bent, it becomes necessary to scrap the uterine cavity. Such manipulation is also required with intense and non-stopping bleeding, as well as in cases of a threat of the development of an infectious process, or if, according to ultrasound data, remnants of the membranes are found in the uterus.

Abnormalities in the structure of the uterus are one of the main causes of habitual miscarriage (the cause is in 10-15% of cases of repeated miscarriage in both the first and second trimesters of pregnancy). Such structural anomalies include: irregular shape of the uterus, the presence of a septum in the uterine cavity, deforming the uterine cavity benign neoplasms(fibroids, fibromas, fibroids) or scars from previous surgical interventions(cesarean section, removal of fibromatous nodes). As a result of such violations, problems arise for the growth and development of the fetus. The solution in such cases is the elimination of possible structural abnormalities and very close monitoring during pregnancy.

An equally important role in the habitual miscarriage is played by a certain weakness of the muscular ring of the cervix, while the most characteristic term for termination of pregnancy for this reason is 16-18 weeks of pregnancy. Initially, the weakness of the muscle ring of the cervix can be congenital, and can also be the result of medical interventions - traumatic injuries of the muscle ring of the cervix (as a result of abortion, cleaning, rupture of the cervix during childbirth) or a certain kind of hormonal disorders (in particular, an increase in the level of male sex hormones). The problem can be solved by placing a special suture around the cervix at the beginning of the subsequent pregnancy. The procedure is called "cervical sequestration".

A significant cause of recurrent miscarriage is hormonal imbalance. Thus, the studies conducted have revealed that a low level of progesterone is extremely important in maintaining pregnancy in the early stages. It is the lack of this hormone that is the cause of early termination of pregnancy in 40% of cases. The modern pharmaceutical market has been significantly replenished with drugs similar to the hormone progesterone. These are called progestins. The molecules of such synthetic substances are very similar to progesterone, but they also have a number of differences due to modification. Such drugs are used in hormone replacement therapy in cases of insufficiency of the corpus luteum, although each of them has a certain range of disadvantages and side effects. Currently, one can name only one drug that is completely identical to natural progesterone - Utrozhestan. The drug is very easy to use - it can be taken orally and inserted into the vagina. Moreover, the vaginal route of administration has a large number of advantages, since, being absorbed into the vagina, progesterone immediately enters the uterine bloodstream, therefore, the secretion of progesterone by the corpus luteum is simulated. To maintain the luteal phase, micronized progesterone is prescribed in a dose of 2-3 capsules per day. If, against the background of the use of urozhestan, pregnancy develops safely, then its intake continues, and the dose is increased to 10 capsules (as determined by the gynecologist). With the course of pregnancy, the dosage of the drug is gradually reduced. The drug is reasonably used up to the 20th week of pregnancy.

Severe hormonal disturbance can be a consequence of polycystic ovaries, resulting in multiple cystic formations in the body of the ovaries. The reasons for repeated non-scaling in such cases are not well understood. Habitual miscarriage is often the result of immune disorders in the body of the mother and fetus. This is due to the specific nature of the body to produce antibodies to fight invading infections. However, the body can also synthesize antibodies against the body's own cells (autoantibodies), which can attack the body's own tissues, causing health problems and premature termination of pregnancy. These autoimmune disorders are the cause in 3-15% of cases of habitual pregnancy failure. In such a situation, first of all, it is necessary to measure the available level of antibodies with the help of special blood tests. Treatment involves the use of low doses of aspirin and blood thinners (heparin), which leads to the possibility of carrying a healthy baby.

Modern medicine draws attention to a new genetic abnormality - factor V Leiden mutation, which affects blood clotting. This genetic trait can also play an important role in recurrent miscarriage. Treatment of this kind of disorders is currently not fully developed.

Asymptomatic infectious processes in the genitals occupy a special place among the causes of habitual pregnancy failure. Preventing premature termination of pregnancy is possible by routinely screening partners for infections, including women, before a planned pregnancy. The main pathogens that cause recurrent miscarriage are mycoplasmas and ureaplasmas. For the treatment of such infections, antibiotics are used: ofloxin, vibromycin, doxycycline. Treatment must be performed by both partners. A control examination for the presence of these pathogens is performed one month after the end of antibiotic therapy. A combination of local and general treatment is essential in this case. Locally, it is better to use broad-spectrum drugs that act on several pathogens at the same time.

In the event that the reasons for repeated pregnancy failure even after a comprehensive examination cannot be found, the spouses should not lose hope. It was statistically established that in 65% of cases after pregnancy, the spouses have a successful subsequent pregnancy. For this, it is important to strictly follow the instructions of doctors, namely to take a proper break between pregnancies. For full physiological recovery after a spontaneous miscarriage, it takes from several weeks to a month, depending on the period at which the pregnancy was terminated. For example, certain pregnancy hormones remain in the blood for one or two months after a spontaneous miscarriage, and in most cases menstruation begins 4-6 weeks after the termination of the pregnancy. But psychoemotional recovery often takes much longer.

It should be remembered that the observation of a pregnant woman with habitual miscarriage should be carried out weekly, and if necessary, more often, for which hospitalization is carried out in a hospital. After establishing the fact of pregnancy, an ultrasound examination should be performed to confirm the uterine form, and then every two weeks until the period at which the previous pregnancy was terminated. If, according to the ultrasound, the fetal cardiac activity is not recorded, then it is recommended to take fetal tissues for karyotyping.

Once fetal cardiac activity is detected, additional blood tests are unnecessary. However, at later stages of pregnancy, in addition to ultrasound, an assessment of the level of α-fetoprotein is desirable. An increase in its level may indicate malformations of the neural tube, and low values ​​- chromosomal abnormalities. An increase in the concentration of α-fetoprotein for no obvious reason at 16-18 weeks of gestation may indicate the risk of spontaneous abortion in the second and third trimesters.

Assessment of the karyotype of the fetus is of great importance. This study should be conducted not only for all pregnant women over 35, but also for women with recurrent miscarriage, which is associated with an increased likelihood of fetal malformations during subsequent pregnancy.

When treating recurrent miscarriage of an unclear cause, IVF can be considered one of the alternatives. This method allows you to perform a study of germ cells for chromosomal abnormalities even before in vitro fertilization. The combination of the application of this technique with the use of a donor egg gives positive results in the onset of the desired full-fledged pregnancy. According to statistical data, full-fledged pregnancy in women with recurrent miscarriage after this procedure occurred in 86% of cases, and the frequency of miscarriages decreases to 11%.

In addition to the described various methods of treating recurrent miscarriage, it should be noted that non-specific, background therapy, the purpose of which is to remove the increased tone of the muscular wall of the uterus. It is the increased tone of the uterus of various natures that is the main cause of premature miscarriages. Treatment involves the use of no-shpa, suppositories with papaverine or belladonna (injected into the rectum), intravenous drip of magnesia.

Prolonged pregnancy- This is a pregnancy in which there is an increase in gestational age, but there are no violations from the fetus, placenta and amniotic fluid.

Premature pregnancy:

Etiology undermaturity and overmaturity is the same:

Infection (both genital and extragenital).

Complications of pregnancy (gestosis, abnormal fetal position, polyhydramnios).

Injuries (including abortion, mental trauma).

Anomalies of the female genital organs (infantilism, age-related fibromatosis, two-horned uterus, etc.).

Endocrinopathies and other extragenital diseases.

Chromosomal abnormalities.

Social and professional harm.

Classification of preterm labor:

Threatening (characterized by the appearance of pulling or cramping pains inside the abdomen or lower back, an increase in the amount of mucous discharge from the vagina, the tone of the uterus is increased).

Beginning (contractions can be both regular and irregular, but they are effective (lead to the opening of the cervix). If the opening is more than 2 cm - the onset of labor. An objective diagnosis is made on the basis of cardiac monitoring of the contractile activity of the uterus for 30 minutes.

Treatment... Conservation therapy in the Department of Pregnancy Pathology:

Bed rest.

Rest (we exclude even a vaginal examination).

Psychotherapy.

Sedatives, tranquilizers.

Tocolysis (tokos (Greek) - childbirth, lysis - dissolve, relax) - therapeutic measures aimed at relaxing the uterine muscles. There are 5 main tocolytic groups:

- adrenomimetics:

Partusisten;

Salbutamol;

Alupent;

Ritodrin;

Genipral;

Bricanil.

Partusisten is assigned according to the scheme:

First, intravenous 0.5 mg in 10 ml of the drug is dissolved in 400 ml of physical. solution or glucose and administered intravenously drip 5-20 drops / min for 8-12 hours. 30 minutes before the end of the dropper, 1 tab (0.5 mg) of partusisten is given inside, up to 6 tab per day. In the following days, the dose of the tablet preparation is reduced. Treatment should be long-term (up to 2 months). This drug can be administered up to 37 weeks of gestation. Side effects: tachycardia, hypotension, palpitations, headache, nausea, vomiting, with prolonged use - a tendency to constipation (in this case, Regulax is prescribed). These side effects are more common with overdose and intolerance. Contraindications for the appointment of -mimetics: cervical opening more than 2 cm, intrauterine infection, spotting, congenital malformations and fetal death, cardiovascular pathology, hypotension. To eliminate side effects, group 2 tocolytics (calcium antagonists) are prescribed.

Calcium antagonists:

Isoptin (phenoptin, veropamil);

Nifedipine (corinfar, cordipine).

Dose: 0.04 mg (tab) 2-3r / day for up to 5 days.

Prostaglandin synthetase inhibitors:

Indomethacin (suppositories or tablets). Dose: 200mg / day.

The course is 5 days.

Inhibitors of the release of oxytocin and its binding to receptors:

10% solution of ethanol (5-6 ml of 96% ethanol to dissolve in 500 ml of isotonic solution or glucose) is administered intravenously drip for 4-12 hours, you can repeat it for 2-3 days. Side effect: alcohol intoxication in the fetus - lethargy, weakness, depression of the respiratory center.

Other tocolytics:

Antispasmodics (no-shpa, papaverine, etc.).

Magnesia sulfate (i / m or i / v 25% solution from 10 to 30 ml).

The course of preterm labor:

Premature rupture of amniotic fluid (i.e. before the onset of labor; early rupture of amniotic fluid - with the onset of labor, but before the cervix opens). the doctor's tactics - prolongation or termination of pregnancy - depends on the presence or absence of infection or the risk of infection, on the presence or absence of congenital malformations of the fetus. If there are no deviations and the gestational age is less than 34 weeks, then the pregnancy can be prolonged.

Abnormalities of labor.

Fetal hypoxia (change in heart rate, green amniotic fluid).

Injuries to the mother and fetus (usually intrapartum).

Bleeding from the uterus, genital tract.

Management of preterm labor(in a special maternity home for undermaturity):

Treatment of hypoxia.

Cardiac monitoring (to identify abnormalities of labor and fetal pathology).

The peculiarity of anesthesia - promedol is not recommended to be used, it is better - long-term epidural anesthesia.

Glucose-vitamin-hormonal-calcium background (GVGKF).

Prophylaxis in the 1st period of SDR with glucocorticoids, and if they are contraindicated - with aminophylline.

In the 2nd period, the presence of a pediatrician is mandatory, careful, gentle management is necessary. The pediatrician must prepare everything for resuscitation n / a: warm linen, diapers, heated incubator, in which the initial treatment is performed n / a.

Reducing the resistance of the muscles of the perineum to the head of the child (for this, pudendal anesthesia is done, irrigation of the perineum with lidocaine).

If the weight of the fetus is up to 2 kg, childbirth is carried out without protection of the perineum. If the weight of the fetus is more than 2 kg - perineo- or episiotomy.

Obstetric forceps are not used for premature pregnancies.

Prevention of undermaturity:

Healthy lifestyle, peace.

Preclinical diagnostics (colpocytology, karyopycnotic index, etc.).

Sanatoriums for pregnant women.

Hospitalization at a critical time (individual, for example, the time of the previous miscarriage).

Timely hospitalization.

Postpartum leave.

Postterm pregnancy.

Signs:

Stopping the weight gain of the pregnant woman.

Reduction of abdominal circumference (due to lack of water).

High standing of the fundus of the uterus.

Restriction of fetal mobility.

Signs of fetal hypoxia (changes in fetal heart rate and green amniotic fluid).

Lack of maturity of the cervix, dense bones of the skull, narrow fontanelles (with vaginal examination).

With dopplerometry - a decrease in uteroplacental blood flow.

Ultrasound: a decrease in the thickness of the placenta, calcification, lack of water, a large fetus, rarely - hypotrophy, no increase in biparietal size, thickening of the skull bones.

The body is not ready for childbirth. In addition to the cervical test, the oxytocin and colpocytological test are negative, characterized by prolongation of types 3 and 4 of smears.

Hormone test:  the content of the level of estrogen in plasma (for a given period).

Tactics:

With prolonged pregnancy - expectant.

With a post-term pregnancy:

postterm pregnancy is a relative indication for a cesarean section.

after preparation of the body for childbirth (HVGKF, endocervical application of prostaglandins (prepedil-gel (PgE2), labor induction is performed (prostaglandins with oxytocin). Ineffectiveness of labor arousal is also a relative indication for KS surgery.

Prevention of overdue :

Healthy lifestyle.

Timely hospitalization of a woman in the department of pathology of pregnant women, especially those who have a reason for prolongation.