Department of Obstetrics and Gynecology

Childbirth history.

CLINICAL DIAGNOSIS:

Diagnosis:

Pregnancy 26/27 weeks.

Main disease:

Gestosis of moderate severity.

Moscow 2013

Name: Angelica

Age: 43

Gender: F

Profession: Sole proprietor

Date of admission: 27.03.13

Curation date: 01,04,13 16:35

Complaints: at the time of admission – no complaints.

At the time of curation – no complaints.

Anamnesis: Heredity is not burdened. The presence in the family and close relatives of hereditary pathology, congenital malformations, as well as cases of mental, venereal, infectious diseases denies. The presence of multiple pregnancy in parents and close relatives denies.

Born and raised in Moscow. In childhood, she grew and developed without pathological features, according to her age. Currently she is a housewife. Lives in good housing and sanitary and hygienic conditions. Meals are regular, varied and high-calorie. Bad habits are denied.

In childhood, she suffered: SARS, influenza, peptic ulcer 12p. to-ki. Hepatitis, tuberculosis, sexually transmitted diseases denies. Hemotransfusion was not carried out.

Allergological anamnesis is not burdened. Parents and close relatives do not suffer from chronic pathology.

Menstruation from the age of 13, after 30 days for 5-7 days, painless, moderate.

Sexual life since 20 years. Second marriage. My husband is 38 years old and healthy.

Gynecological diseases: Surgery for uterine fibroids.

Previous pregnancies:

The second in 1992 ended in timely delivery, without complications, a boy, 3735 gr., height – 52 cm.

1st in 1995 microabortion

-I in 1999 ended in timely delivery, without complications, boy, 3805 gr., height – 58 cm.

– I’m real in 2012

Current pregnancy: Last menstruation 09/26/2012, last day of menstruation December 2, 2012. The due date for menstruation is July 3, 2013.

First half: no complications

Date of the first stirring January 17, 2013

The second half: complicated by edema, weight gain 8 kg.

I went to the antenatal clinic for a period of 12 weeks.

Blood type I(0), Rh +, Wassermann negative, vaginal smears for flora: vaginal sticks – units. in sight.

Total weight gain during pregnancy 22 kg.

Received on 27.03.2013 at 14.40. on admission the patient was in a satisfactory condition. preeclampsia obstetric pregnant

Objective research

A. General examination: Satisfactory condition, body temperature 36.7, correct physique, normosthenic type. Weight 75.100 kg, height 158 cm, pale pink skin, no vein expansion, slight pastosity of the shins and hands, normal mammary glands, no pathology, pigmented nipples, thyroid gland is not enlarged, lymph nodes are not palpable.

Respiratory system: No complaints. Breathing through the nose is free, there are no pathological compartments from the upper respiratory tract. The chest is normosthenic in shape, both halves of the chest are symmetrically involved in the act of breathing. Respiration of moderate depth, rhythmic, frequency of respiratory movements in 1 minute 17. Palpation of the chest is painless, no pathological changes were detected. The borders of the lungs are within the normal range. Auscultatory breathing is vesicular, no wheezing.

Circulatory system: No complaints. There are no shortness of breath and edema. The condition of the veins and arteries without pathological features. There is no bulging of veins and arteries. The borders of the heart are within the normal range. Palpation and areas of the heart are painless. On auscultation, the heart sounds were clear, rhythmic, and no pathological murmurs were detected. Pulse on the radial arteries 80 beats. per minute, rhythmic, good filling. Blood pressure at the time of examination 11080 mm Hg. on both hands.

Digestive system: No complaints. Appetite is good. The chair is decorated, without pathological impurities. The tongue is bright pink, moist, without plaque. There are no raids, cracks, ulcers in the oral cavity. The oral cavity is sanitized. There is no visible peristalsis of the stomach and intestines. Venous collaterals are absent. Percussion was not performed due to pregnancy. Visually, the liver and spleen are not enlarged; palpation of this area was not performed due to pregnancy.

Urinary system: Complaints of pastosity of the shins and hands. There are no urinary disorders. The amount of urine is normal. Examination of the lumbar region showed no swelling or redness. There is no pain in the region of the kidneys and along the ureters.

Nervous system and sense organs: Consciousness is clear. There were no cerebral symptoms at the time of examination. No headache, clear vision. Motor sphere without disturbances. The patient is communicative, the conversation is free, the mood is even. There are no meningeal symptoms.

Sense organs without pathological changes.

B. Special obstetric examination:

Distacia spinarum – the distance between the anterior superior iliac spines. The buttons of the tazomer are pressed against the outer edges of the anterior superior spines. Normally 25-26 cm. This patient has 26 cm.

Distancia cristarum – the distance between the most distant points of the iliac crests. The norm is 28-29 cm. The patient has 29 cm.

Distancia trochanterica – the distance between the greater skewers of the femur. They look for the most prominent points of the large skewers and press the buttons of the tazomer to them. Normally 30-31 cm. The patient is 31 cm.

Conjugata externa – external conjugate, i.e. straight size of the pelvis. The woman is laid on her side, the underlying leg is bent at the hip and knee joints, the overlying leg is pulled out. The button of one branch of the tazomer is placed in the middle of the upper outer edge of the symphysis, the other end is pressed against the supracacral fossa. Normally 20-21 cm. The patient has 21 cm.

Sacral rhombus It is a platform on the back surface of the sacrum: the upper corner of the rhombus is a depression between the spinous process of the 5th lumbar vertebra and the beginning of the middle sacral crest; the lateral angles correspond to the posterior superior iliac spines: the lower one is the apex of the sacrum; above and outside the rhombus is limited by the protrusions of the large dorsal muscles, below and outside by the protrusions of the gluteal muscles

The shape is correct when the vertical size is 10 cm, the transverse size is 10 cm.

Solovyov’s index – measuring the circumference of the wrist with a measuring tape gives an idea of the thickness of the pelvic bones; normally, it is 14-16 cm. The patient has 15 cm.

The height of the uterus above the womb is determined by a centimeter tape. The patient is 30 cm.

Abdominal circumference 106 cm.

The estimated weight of the fetus is the circumference of the abdomen in cm at the level of the navel multiplied by the height of the uterus above the womb. In this case, the approximate weight of the fetus is 3200 gr.

The method of external obstetric examination: Palpation of the abdomen of a pregnant woman is carried out according to a certain plan, sequentially applying 4 doses. The pregnant woman lies on her back, her legs are bent at the hip and knee joints to relax the abdominal muscles. The doctor becomes to the right of the pregnant woman face to face.

The first technique: the palms of both hands are located on the bottom of the uterus, the fingers are brought together and with a careful downward movement determine the level of standing of the bottom of the uterus, by which the gestational age is judged. The first method is to determine the part of the fetus located in the bottom of the uterus, more often it is the pelvic end of the fetus. The pelvic end is a large, but less dense and rounded part than the head.

The second method: determine the back and small parts of the fetus: the position of the back is used to judge the position and appearance. Both hands from the bottom of the uterus are moved to the level of the navel and placed on the lateral surfaces of the uterus. Palpation of parts of the fetus is performed alternately with the right and left hands. The left hand lies in one place, the fingers of the right hand slide along the left lateral surface of the uterus and feel the part of the fetus facing there. Then the same manipulation is carried out with the left hand on the right half of the uterus. By the location of the back and small parts, the position and its appearance are judged. The second technique allows you to determine the tone of the uterus and its excitability. The location of the round ligaments is used to judge the place of attachment of the placenta. If the round ligaments diverge downward, the placenta is located on the front wall, if they converge, then on the back.

The third method: serves to determine the presenting part of the fetus. One hand (usually the right hand) is placed slightly above the pubic junction so that 1 finger is on one side and the other four fingers are on the other side of the lower uterine segment. Slowly, the fingers are immersed in depth and grasp the presenting part. The head is palpable in the form of a round dense part. With a breech presentation, a voluminous softish part is palpated, which does not have a clear rounded shape. In transverse and oblique positions, the presenting part is not determined. The third method can determine the mobility of the head. With short light pushes, they try to move it from right to left, and vice versa; at the same time, the investigating fingers feel the balloting of the head, which is especially well expressed in multiparous. The higher the head above the entrance to the small pelvis, the clearer the ballot. With a motionless head, they judge the pressing of the head to the entrance to the pelvis.

The fourth technique: is an addition to the third, allows you to determine not only the nature of the presenting part, but also the level of its standing. The researcher stands on the right, facing the legs of the pregnant woman. The palms of both hands are located on the lower segment of the uterus on the right and left, the fingertips reach the symphysis. With outstretched fingers, they carefully penetrate deep into the pelvic cavity and determine the presenting part and the height of its standing. This technique allows you to identify whether the head is located above the entrance to the small pelvis or passed through the plane of the entrance to the pelvis with a small or large segment; if the head has dropped significantly into the pelvic cavity, only its base is palpable. The standing height of the presenting pelvic end of the fetus is also successfully determined. Using the fourth technique, you can also determine the size of the head, the density of its bones and the gradual lowering of the head into the pelvis during childbirth.

In the study of this patient, the longitudinal location of the fetus, cephalic presentation was established. First position, front view. The head is located above the entrance to the small pelvis. The fetal heartbeat is clear, rhythmic, 136 beats per minute.

Vaginal examination: the vagina is free, the cervix is 2 cm, passable for 1 finger, the fetal bladder is intact, the head is present, pressed against the entrance to the small pelvis, the cape is not reachable, there are no exostases in the small pelvis.

Analytical data and expert opinion.

Clinical blood test from 1.02.2001.

hemoglobin 121 g/l

leukocytes 11.7 10 /liter

ESR 20 mm/h.

Urinalysis from 1.02.2001.

color light yellow

reaction is neutral

specific gravity 1010

protein, sugar-0

many epithelium

leukocytes 40 – 50 per field of view

erythrocytes 0 -1 in the field of view.

microflora coccal

Trichomonas not found

Clinical diagnosis: Pregnancy 26 – 27 weeks. Longitudinal position of the fetus, cephalic presentation, first position, anterior view, the position of the fetus may change due to the short gestation period. Gestosis of moderate severity.

Rationale for the diagnosis:

The presence of pregnancy can be proved by the presence of reliable signs of pregnancy in the patient, namely:

Parts of the fetus are felt – palpation determines the head, back, small parts of the fetus.

The fetal heart sounds are clearly audible, which are of a clear rhythmic nature, with a frequency of 136 beats per minute.

Fetal movements felt by the pregnant woman.

The position of the fetus in the uterus of a pregnant woman during palpation of the abdomen by methods of obstetric external examination is determined as longitudinal, the presenting part is the head, in the first position, anterior view. The head is located low above the entrance to the small pelvis.

With a vaginal examination of this pregnant woman, the presenting part is determined – the head, which is located above the entrance to the small pelvis.

The height of the fundus of the uterus in a pregnant woman is 25 cm.

The presence of preeclampsia in a patient is proved on the basis of examination data and complaints. Edema on legs and hands. There is a positive sign of the ring. As well as an increase in pressure above normal. Pathological weight gain during pregnancy – 22 kg.

Survey plan.

Clinical blood test

Clinical analysis of urine

Diuresis control

BP control

ECG

Etiology.

Gestosis is etiologically associated with pregnancy, therefore, after childbirth (or abortion), all their manifestations usually stop. However, with severe and long-term forms of gestosis, long-term consequences can be observed.

It is known that during pregnancy there are significant functional changes in all organs and systems, as well as changes in metabolism. These changes are adaptive in nature and contribute to the maintenance of homeostasis and the normal functioning of organs and systems, the proper development of the fetus, and ensure the preparation of the woman’s body for childbirth and for feeding the child. Thus, adaptive changes in the main physiological systems of the body of a pregnant woman compensate for the increased load on them during pregnancy.

In this regard, the occurrence of gestosis should be considered as a violation of the adaptive reactions of the physiological systems of a pregnant woman, and the key point in their etiology is a violation of the neurohumoral regulation of adaptive mechanisms.

Thus, congenital or acquired insufficiency of neuroendocrine regulation of adaptive reactions (risk factors: hypoxia, infections, intoxications, malnutrition in the antenatal period, various infectious and non-infectious diseases, hereditary factors) can predispose to the occurrence of preeclampsia. On the other hand, an increased load on certain adaptive mechanisms that has arisen in a pregnant woman due to the influence of any factors not related to pregnancy, for example, diseases of certain organs and systems, can lead to depletion of adaptation reserves and to a breakdown adaptive mechanisms in a pregnant woman, i.e. to the development of gestosis. The development of gestosis can also be facilitated by dysfunctions of the nervous system that existed before pregnancy, as well as past diseases of the genital organs, which can cause changes in the receptor apparatus of the uterus and the occurrence of inadequate impulses entering the central nervous system.

All of the above applies equally to both the occurrence of early and late gestosis.

Pathogenesis.

In relation to the pathogenesis of late gestosis, there have been and still exist many different theories (immunological, renal, hormonal, neurogenic), etc. Currently, preference is given to the neurogenic theory, according to which, due to violations of the functions of the central nervous system, the autonomic regulation of the vascular system is disturbed. Thus, the leading link in the pathogenesis of late gestosis is profound changes in the vascular system and the blood system (hemostasis disorders). Generalized angiospasm leads to the occurrence of circulatory tissue hypoxia, against which functional and then organic changes develop in parenchymal organs, myocardium, brain, and placenta. Joining metabolic disorders exacerbate hypoxia and microcirculation disorders, contribute to the formation of vicious circles. The severity of all changes depends on the severity of preeclampsia. Its final link is an attack of eclampsia as a manifestation of an increase in cerebral symptoms (headache – visual impairment – eclamptic convulsions) as a result of the development of intracranial hypertension and hypertensive encephalopathy.

Consider the pathogenetic and clinical features of dysfunction of individual organs and systems in late preeclampsia.

Leading in late gestosis are violations of the microcirculatory bed and the blood system. One of the most important symptoms of late gestosis – arterial hypertension – is determined by regional and generalized angiospasm. As a result of spasm of arterioles, OPSS increases, which, in turn, leads to an increase in blood pressure – both systolic and (most importantly) diastolic. As a result of high blood pressure, as well as with the participation of increased permeability of the vascular wall, the liquid part of the blood exits the vascular bed into the interstitial space. On the one hand, this contributes to the occurrence of edema, and on the other hand, it leads to an increase in hematocrit, blood viscosity, to aggregation, and then agglomeration, of formed elements. As a result of the destruction of erythrocytes against the background of the existing circulatory hypoxia, a decrease in the oxygen capacity of the blood joins it, i.e. hemic hypoxia. Hypoxia leads to the fact that the processes of anaerobic metabolism are enhanced in the tissues, which leads to the accumulation of acid metabolites, for example, lactate, ketone bodies. Along with this, the function of the antioxidant system is disrupted. Thus, metabolic acidosis develops, which, along with hypoxia, further increases the permeability of the vascular wall, which leads to aggravation of edema and hypoxia. Thus, a vicious circle is closed.

However, along with metabolic acidosis, respiratory alkalosis occurs in eclampsia and preeclampsia. In addition, pregnant women with late gestosis may show signs of liver failure with the accumulation of ammonia in the blood, which, having pronounced alkaline properties, also contributes to the development of alkalosis.

When formed elements are destroyed, a large amount of thromboplastin (for example, erythrocyte) is released into the blood, which starts the process of blood coagulation, leading to even greater aggregation of formed elements. Under conditions of constantly occurring release of coagulation factors (in particular, thromboplastin), against the background of aggravated hypoxia and acidosis, DIC may develop. Platelets are included in the coagulation process. Activation of the coagulation cascade leads to excessive formation of thrombin, microthrombi are formed in the microvasculature (hypercoagulation phase), which aggravates microcirculation disorders. In the hypercoagulable phase, coagulation factors are intensively consumed (the so-called consumption coagulopathy). At the same time, the fibrinolysis system is activated. Soon, the reserves of coagulation factors are depleted, fibrinolysis begins to prevail over coagulation, and the hemorrhagic phase of DIC develops, accompanied by a characteristic clinic. Hematomas may occur in parenchymal organs, and hemorrhagic and (or) ischemic strokes may occur in the brain.

On the one hand, an increase in the permeability of capillaries and other biomembranes caused by hypoxia and acidosis leads to the development of such kidney disorders as erythrocyturia, proteinuria, etc. At the same time, proteinuria can also be caused by impaired reabsorption of low molecular weight proteins in the renal tubules. as a result of hypoxia. Further, metabolic changes against the background of developing hemolysis and DIC can lead to the development of acute renal failure. Among other effects, renal ischemia leads to activation of the renin-angiotensin-aldosterone system, which aggravates arterial hypertension (secondary, renal arterial hypertension develops).

An increased load on the myocardium leads to its hypertrophy, and then ischemic myocardiopathy may develop up to asystole.

In the liver, under conditions of hypoxia, the synthesis of the albumin fraction of blood proteins is disrupted. At the same time, the synthesis of proteins of the globulin fraction, which occurs mainly in lymphocytes, does not suffer so much. Thus, hypoproteinemia and dysproteinemia develop with a shift in the albumin-globulin index towards an increase in globulins. Hypoproteinemia, in turn, exacerbates the edematous syndrome.

Hypoxia and metabolic disorders in late preeclampsia lead to dysfunction of the immune system (antibody synthesis is impaired, cellular immunity is suppressed). This increases the risk of infectious complications of pregnancy and childbirth, contributes to the activation of opportunistic flora.

Developing edema, hypoxia, as well as possible hemorrhages in the brain can lead to various dysfunctions of the central nervous system, even damage to vital centers. Angiospasm can be so strong that it can lead to rupture of connections between endothelial cells with the release of erythrocytes and plasma into the perivascular space. Pericapillary hemorrhages in the brain tissue, being foci of pathological discharges, can cause convulsions. Thus, arterial hypertension plays a leading role in the genesis of seizures.

Treatment of gestosis.

Intensive therapy of patients with preeclampsia depends on the clinical form of preeclampsia, on the severity and on when the treatment is carried out (before childbirth, during childbirth or in the postpartum period).

Since all forms of late gestosis are, in fact, stages of the same process, the principles of therapy are similar. Depending on the severity, the volume of intensive care varies, as well as the use of certain specific means.

The main criterion for the choice of therapeutic agents and methods is their effectiveness in this particular case and relative harmlessness to the mother and fetus. Do not abuse effective drugs that can adversely affect the condition of the fetus. With the ineffectiveness of therapy, urgent delivery is indicated.

Complex therapy of pregnant women with preeclampsia (nephropathy II, III degree, preeclampsia) is based on the following principles:

.Admission to the intensive care unit

.Creation of a medical and protective regimen

.Elimination of seizures. Magnesium sulphate 12g/day. Monitor magnesium levels.

.Diet high-calorie with an excess of protein 12.5 g per kg of body weight.

.Infusion therapy 600-700 ml crystalloids.

.Normalization of microcirculation: pentoxifylline, chimes, heparin.

.Hypotensive therapy: methyldopa 2g/day, nifedipine, nibivalol.

.Normalization of water-salt metabolism: Hypochloride diet. Lasix for pulmonary and cerebral edema.

. Membrane stabilizing therapy: ascorbic acid, actovigin.

Prognosis of childbirth, possible complications.

c) Forecast of upcoming births.

The degree of risk of complications in childbirth:

anemia – 2 points

dropsy – 2 points

Total: 4 points.

Childbirth lead through the natural birth canal. Possible complications are acute fetal hypoxia, bleeding, weakness of labor activity.

To prevent bleeding in the prenatal period, inject intravenously: glucose 40% – 20 ml., CaCl hypertonic solution 10% – 10 ml., Ascorbic acid 5% – 1 ml.

To stimulate labor activity, with hypotonic uterine bleeding, intravenous administration of 1 ml of synthetic oxytocin, diluted in 500 ml of 5% glucose solution, is poured in drip, starting with 5-8 drops / min, then their amount is gradually increased until vigorous labor activity is established.

Diary

04.2013: Satisfactory condition. There are no complaints. Physiological functions are normal. Temperature 36.6, pulse 76 beats per minute, rhythmic. BP 11070 mmHg The uterus is in normotonus. Movement is well defined. The fetal heartbeat is clear rhythmic 140 beats per minute.

Diuresis 1650 ml.

04.2013: Satisfactory condition. Complaints at the time of inspection no. Appetite is good. Skin and visible mucous membranes of normal color. There is no dyspepsia or dysuria. Temperature 36.5, pulse 80 beats per minute, rhythmic. BP 12070 mmHg The uterus is in normotonus. The fetal heartbeat is clear rhythmic 140 beats per minute.

04.2013: Satisfactory condition. There are no complaints. Temperature 36.7, pulse 82 beats per minute. BP 110/60 mmHg Fetal movement is determined. Heartbeat 138 beats per minute.

Epicrisis.

Patient A., 24 years old. Received on 03/27/2013 with a diagnosis of pregnancy 26 – 27 weeks. OPG-histosis, dropsy of pregnant women. Received in a satisfactory condition, with swelling on the legs and hands. The pregnant woman was hospitalized in the department of pathology of pregnancy for observation before the onset of labor. This is the fourth pregnancy in a row. The first half of this pregnancy was complicated by toxicosis. In the second half of this pregnancy, swelling of the legs and arms was noted. According to the survey found: pregnancy 26-27 weeks. Longitudinal position of the fetus, cephalic presentation, first position, anterior view. Pregnant women are being prepared for childbirth.

Timely delivery through the natural birth canal is planned, in case of complications from the side of the pregnant woman or from the side of the fetus, emergency obstetric care will be performed.

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