Medical methods of preparing pregnant women for childbirth

The literature discusses the feasibility of preparing the cervix with the help of estrogens, vitamins and ATP. A number of researchers claim that steroid hormones activate the processes of cervical ripening and sensitization of the myometrium, others - have not received evidence of the involvement of steroid hormones in these processes. In foreign clinics to prepare the cervix for delivery, estrogens are not used.

Method of preparation. Intramuscular injection of one of the estrogen preparations (most often folliculin or synestrol) in the amount of 20 thousand units is administered twice a day. Therapy continues at least 2-3 and not more than 10-12 days. Prolonged use of estrogens is contraindicated in the presence of signs of hepatic insufficiency in pregnant women (exacerbation of chronic liver disease of infectious and non-infectious origin, severe late toxicosis by type of hepatopathy, etc.).

Application of lidase. Introduction of estrogens, as a rule, should be combined with the use of lidase in the amount of 0.1 g of dry matter diluted in 5 ml of 0.5% solution of novocaine once a day. The action of lidase is potentiated by estrogens.

Use of antispasmodics:

• extract belladonna (belladonna) thick in the form of rectal suppositories 0.015 g 2 times a day;
• but-pill in tablets of 0.04 g 2 times a day orally, or as a 2% solution of 2 ml intramuscularly, also 2 times a day;
• dibasol in powders of 0.02 g 3 times a day inwards or as a 0.5% solution of 6 ml intramuscularly 2 times a day;
• spazmolitin in tablets on 0,005-0,1 2 times a day inside;
• halide in tablets by 0,05-0,1 2 times a day inwards or 2 ml intramuscularly 2 times a day.

The use of agents that stimulate the processes of tissue metabolism. In order to enhance the oxidation-reduction processes in the body, replenish its energy resources and improve the efficiency of the myometrium, it is advisable to administer 5-10% glucose solution intravenously, intravenously, drip in an amount of 500-1000 ml, solutions of Group C and Group B vitamins, and also cocarboxylase or ATP. Immediately before the planned delivery, calcium preparations (calcium gluconate intramuscularly or intravenously) are prescribed. The introduction of these drugs must be combined with oxygen therapy.

Infusion therapy with sygene

A technique for preparing pregnant women for genera sygetin in an optimally effective dose - 200 mg intravenously, drip. To this end, 20 ml of a 1% solution of sighetine are dissolved in 500 ml of isotonic sodium chloride solution or in 5% glucose solution and administered intravenously, drip at a frequency of 10-12 drops per minute for several hours.

The method of introducing sygetin is most indicated in the absence of readiness for childbirth in combination with symptoms of impairment of the fetus and fetoplacental insufficiency. Our data are consistent with the work of D. Dery (1974), who used sygetin 2 tablets 3 times a day (the total dose was 600 mg). The use of Sigetin proved effective in all cases and its effect is preparatory, with the subsequent duration of labor shorter than with the use of other estrogens and the assessment of the state of children on the scale Angar was above 8 points and in 85% - 10 points, which exceeds the state of newborns, born in physiological conditions.

The course of treatment is on average 3-4 days. Sigetin accelerates the maturation of the cervix, has a moderate normalizing effect on the contractile activity of the uterus and a favorable effect on the fetus.

Antioxidants and antihypoxants

We have developed a triad of using drugs that have antioxidant properties - unithiol, ascorbic acid and tocopherol (vitamin E).

Method of introduction: a solution of unithiol 5% - 5 ml in combination with 5 ml of a 5% solution of the sodium salt of ascorbic acid is intravenously dripped in a 5% glucose solution in an amount of 500 ml. Tocopherol - inside capsules 0.2 g 3 times a day. Course of preparation - 4-6 days. Indication: late toxicosis of pregnant women in the absence of biological readiness for childbirth, preparation for childbirth, especially in combination with symptoms of impairment of the fetus.

The most effective antihypoxants should be considered amtizole and trimin. These preparations for the purpose of preparation for childbirth are applied accordingly in doses of 50-100 mg / kg of body weight and 15 mg / kg. Amtizol and trimin lead to an improvement in the state of the cervix, slightly increase uterine activity, improve the fetus, probably due to improved oxygenation of the mother and fetus and improvement of energy processes in the myometrium. Hysterography shows that amtisol does not increase the basal tone of the uterus, but only slightly increases the frequency and amplitude of uterine contractions. Thus, antihypoxants, obviously, improve the broken regional hemodynamics and energy metabolism in the uterus.

Relaxin

Relaxin mainly affects the cervix, but at the same time, it relaxes the myometrium by inhibiting myosin regulation. The use of relaxin is not accompanied by any side effects. Relaxin in viscose gel at a dose of 2 mg, introduced into the cervical canal, significantly improves the maturation of the cervix. Relaxin is also effective in more than 80% of pregnant women, when it is administered as a pessary in a dose of 2-4 mg.

It is important to note that the local (vaginal) use of relaxin and prostaglandins produces the same clinical effect and causes the same type of histological changes in the cervix.

The rationale for the use of relaxin for the purpose of ripening the cervix is the following:

• in the cervix as a target organ for relaxin, there are receptors for polypeptides;
• relaxin causes maturation of the cervix not only in the experiment on animals, but also when using it in the clinic;
• Relaxin is secreted during ripening of the cervix in increased amounts.

Thus, the isolation of pure relaxin in humans, the introduction into practice of porcine relaxin, further study of its effect on cervical ripening, the contractile activity of the myometrium, the condition of the fetus and the newborn, may provide an effective and safe method for preparing pregnant high-risk groups for childbirth.

Prostaglandins

As the latest research shows, the generation of uterine contractions, the maturation of the cervix and the onset of labor are regulated by a number of factors, among which the central place belongs to prostaglandins.

In the clinical application of prostaglandins of the E and F group, it is necessary to remember the main clinical manifestations of the action of prostaglandins.

Effects of prostaglandin E2:

• reduces systemic arterial pressure;
• directly dilates small arteries in various organs;
• inhibits the action of pressor hormones;
• improves blood supply to the brain, kidneys, liver, limbs;
• increases glomerular filtration, creatinine clearance;
• reduces the reabsorption of sodium and water in the renal tubules and increases their excretion;
• reduces the initially increased ability of platelets to aggregate;
• improves microcirculation;
• increases blood oxygenation;
• leads to resorption of fresh ischemic foci on the fundus and reduces the number of fresh hemorrhages in the retina, which is important in pregnant women with diabetes mellitus.

Effects of prostaglandin F2a:

• increases systemic arterial pressure, increases arterial pressure in the pulmonary artery;
• reduces the saturation of blood with oxygen;
• reduces blood flow in the organs;
• directly increases the tone of the vessels of the brain, kidneys, heart, intestines;
• potenziruet vasoconstrictor action of pressor hormones;
• increases sodium naresis and diuresis.

In order to prepare pregnant women for childbirth, with various obstetric situations, we developed the following methods for the introduction of a prostaglandin gel with a prostenoid (prostaglandin E2):

• introduction of prostaglandins intravaginally together with carboxymethylcellulose;
• in pregnant women of high risk (symptoms of impairment of the fetus, placental insufficiency, etc.), a method has been developed for the joint use of beta-adrenomimetics (partus, alupent, bricanil, gynepral) together with prostaglandins to avoid cases of hyperstimulation of the uterus or worsening of the fetus;
• introduction of gel with prostaglandins in case of untimely discharge of water and immature cervix of the uterus;
• with the purpose of treating the weakness of labor activity against the background of insufficient readiness of the organism for childbirth (ripening or immature cervix of the uterus), especially in parturient women before giving a medicinal sleep-rest.

The following procedure for obtaining the gel was developed: 0.6 g of finely grated sodium salt of carboxymethyl cellulose is dissolved in 7 ml of distilled water in a sterile penicillin bottle. After sealing, the vial is placed in an autoclave, where it is held for 20-25 minutes at a temperature of 120 ° C and a pressure of 1.2 atm. The gel is stored at a temperature of + 4 C. Bacteriological studies have shown that with this treatment and storage it remains sterile for 2-3 months. Prostenone (PGEz) is added to the gel immediately before use.

Prostaglandin gel is installed in the posterior vaginal vault with a syringe along a polyethylene catheter. The catheter is inserted into the vagina under the control of the finger of the investigating arm. After the introduction of the gel, the pregnant woman is recommended to be in bed with a raised pelvis for approximately 2 hours. When the symptoms of hypertension of the uterus, it is necessary to insert an arm into the vagina and remove the gel.

At present, for the prevention of hyperstimulation of the uterus in pregnant women at high risk of perinatal pathology, beta-adrenomimetics are introduced before the introduction of the gel.

The technique of preparing pregnant women for childbirth with vaginal injections of prostaglandin together with nfuznjamin beta-adrenomimetikov. 10 ml of the preparation containing 0.5 mg of partuscene or 1 ml of alupent (0.5 mg) or 1 ml of bricanil (0.5 mg) are dissolved in 500 ml of a solution of glucose (5%) or isotonic sodium chloride solution and injected intravenously with at a rate of 10-12 drops per 1 minute, on average for 4-5 hours. No sooner than 10 minutes after the start of infusion of beta-adrenomimetic into the posterior vaginal forge, a gel with 3 mg of prostaglandin E2 or 15-20 is placed along a polyethylene catheter by a standard syringe mg of PGF. A prerequisite for the appointment of beta-adrenomimetics is the absence of contraindications to their use.

The method of preparation for childbirth by ET T. Mihalepko, M. Ya. Chernega (1988) for 7-10 days is as follows:

• linetol 20.0 2 times a day (morning and evening before meals);
• glutathione by 1O0 mg 2 times a day 30 minutes after taking linetol;
• oxygen - inhalation (preferably in hyperbaric conditions) for 5-6 liters per minute for 30 minutes 2 times a day;
• ultraviolet irradiation of the lumbar region (suberythmic dose 1 time per day);
• heparin 250 OD ED intramuscularly on the 3rd and 6th day of preparation of the pregnant woman to: birth;
• intramuscular folliculin 300 units once a day. Linetol can be replaced with arachidene or essential oil or intralipid.

Prof. NG Bogdashkin, NI Beretyuk (1982) developed the following set of therapeutic measures, applied 7-10 days before delivery:

• synestrel 300-500 IU per 1 kg of body weight intramuscularly once a day;
• Linetol 20 ml 2 times a day inside after eating;
• vitamin B1 1 ml S% solution intramuscularly 1 time day;
• vitamin B6 1 ml of 5% solution intramuscularly once a day;
• ATP 1 ml of a 1% solution intramuscularly once a day;
• galaskorbin 1.0 inward 3 times a day;
• calcium gluconate 10 ml 10% solution intravenously once a day;
• ascorbic acid 5 ml 5% solution intravenously once a day;
• oxygenation for 20 min 2 times a day;
• Albumin 100 ml of 10% solution intravenously every other day with hypoproteinemia.

Preparations containing polyunsaturated fatty acids are non-toxic. Sometimes, when they are taken, dyspeptic phenomena (nausea) are noted; in the early days a porous stool is possible. These phenomena usually pass independently and do not require discontinuation of treatment. However, with diarrhea from the use of drugs should abstain. In pregnant women suffering from cholecystitis, pains in the area of the gallbladder are sometimes exacerbated, in these cases, further use of the drugs should also be avoided.

Adrenergic agents

Beta-blockers.

IV Duda (1989) developed a scheme for prenatal preparation of pregnant women for childbirth.

Patterns of prenatal training with induction.

Five-day scheme.

1st day: estrogens (folliculin or synestrol) at 140-150 units per 1 kg of body weight 4 times intramuscularly; calcium chloride (1 tablespoon 10% solution 3-4 times) and galascorbine (1.0 g 3 times a day) inside;

2nd day: estrogens 160-180 units per 1 kg of weight 3 times intramuscularly; calcium chloride and galascorbin in the same doses;

Day 3: estrogens of 200 units per 1 kg of weight 2 times intramuscularly; calcium chloride and galascorbin in the same doses;

4 th day: estrogens 200-250 units are single intramuscularly; calcium chloride and galascorbin in the same doses;

Day 5: castor oil (50-60 ml orally); after 2 hours cleansing enema; 1 hour after the enema, obzidan (5 mg in 300-400 ml isotonic sodium chloride solution at 20-40 μg / min intravenously or 20 mg after 20 minutes 5-6 times inside (or anaprilin in tablets at the same dosage), calcium chloride (10 ml of a 10% solution intravenously) is administered with the onset of osidan administration and repeated with the development of labor activity, glucose (20 ml of a 40% solution) is administered after the onset of labor.

The three-day scheme.

Day 1: estrogens of 200 units per 1 kg of body weight 2 times intramuscularly, calcium chloride and galascorbin in the same way as in the 5-day regimen;

2nd day: estrogens 200-250 units per 1 kg of body once intramuscularly, calcium chloride and galascorbin as well as under the 5-day regimen;

3 rd day: all the same measures are carried out as on the 5th day with a 5-day schedule.

Two-day scheme.

1st day: estrogens 200-250 units per 1 kg of body weight once intramuscularly; calcium chloride and galascorbine inside, as in the 5-day regimen;

The second day is spent all the same measures as on the 5th day with a 5-day chart.

One-day circuit.

Provides for a set of activities proposed on the 5th day with a 5-day scheme.

When using anaprilina (obzidan, inderal, propranolol), it is necessary to take into account contraindications and adverse effects on the fetus and newborn baby. According to modern guidelines of domestic and foreign authors, it is contraindicated in pregnancy and lactation, because, passing the placental barrier, the drug is fetotoxic and leads to depression, polycythaemia, hypoglycemia and bradycardia in newborns for several days. During lactation propranolol passes into milk and can lead to bronchospasm, bradycardia, hypogenesis, congenital heart failure and hypoglycemia in newborns, but these effects do not always appear.

Anaprilin is contraindicated in pregnant women with sinus bradycardia, atrioventricular blockade, with severe heart failure, bronchial asthma and a tendency to bronchospasm, diabetes mellitus with ketoacidosis, and peripheral arterial blood flow disorders. It is undesirable to prescribe anaprilin for spastic colitis. Caution is needed and with the simultaneous use of hypoglycemic agents (the risk of hypoglycemia).

There are indications that anaprilin (and other beta-blockers) should not be used in combination with verapamil (isotype) in connection with the possibility of severe cardiovascular disorders (collapse, asystole).

Beta-adrenomimetics.

Beta-adrenomimetics are used according to the following indications:

• with the purpose of preparing pregnant women in the absence of biological readiness for childbirth;
• in pregnant women of high risk for perinatal pathology by combination with prostaglandin gels (E2 and F2a);
• with the induction and the immature cervix of the uterus.

The method of preparing pregnant partusistenom. 10 ml of the preparation containing 0.5 mg of partusystene were dissolved in 500 ml of 5% glucose solution or isotonic sodium chloride solution. Partusisten was injected intravenously at a rate of 15-30 drops per minute. Subsequently, immediately after discontinuation of intravenous infusion of the drug, the latter is prescribed in the form of tablets 5 mg 6 times a day. To reduce tachycardia and potentiation of the effect, pregnant women received finaptin (verapamil) 40 mg 2-3 times a day. Preparation of pregnant women is carried out within 5 days.

Of side effects, the doctor should pay special attention to the following:

• tachycardia;
• change in blood pressure;
• decreased serum potassium levels;
• possibility of water retention;
• possible changes in the myocardium of the heart;
• enhanced gluconeogenesis.

Contraindications.

Absolute.

• fever;
• infectious diseases in the mother and fetus;
• intrauterine infection;
• hypokalemia;
• cardiovascular diseases: myocarditis, myocardiopathy, conduction and heart rhythm disorders;
• thyrotoxicosis;
• glaucoma.

Relative.

• diabetes;
• disclosure of the uterine pharynx by 4 cm or more to the onset of tocolysis in preterm birth;
• premature discharge of amniotic fluid;
• gestational age is less than 14 weeks;
• hypertensive conditions in pregnancy with arterial pressure 150/90 mm Hg. Art. And higher;
• malformations of the fetus.

Glucocorticosteroids and precursors of noradrenaline synthesis - L-Dopa

Glucocorticoids increase the mitotic index in the cells of the epithelium of the vagina and cervix, inhibit the synthesis of prostacyclin, reduce the degree of postnatal hypoxia in premature newborns, increase the glomerular synthesis of prostaglandin and the level of arachidonic acid, accelerate the development of kidneys in the fetus, without affecting the duration of pregnancy. A number of modern authors recommend caution in the prenatal administration of corticosteroids, since rats and rhesus monkeys can cause damage to the brain in rats. At the same time, Brown et al. (1993) found that the new high-affinity 11beta-hydroxysteroid hydrogene in the placenta and kidney (?) Prevents the action of glucocorticoids on the fetus, and in the kidney - on the receptors of mineralocorticoids. It has a great affinity for glucocorticoids.

In a weakly contracting uterus, corticosteroid hormones are bound differently by corticosteroid receptors, which undoubtedly should attract attention and initiate an active search for the solution of the question of the role of corticosteroid hormones in regulating myometrium contraction and using them with the goal of preventing and treating the weakness of labor.

L-Dopa is not contraindicated in pregnancy.

A new method of preparing pregnant women for labor was developed: the norepinephrine precursor L-Dopa was used in a dose of 0.1 g three times daily for 3-5 days in combination with intramuscular injection of 50 mg hydrocortisone or dexamethasone in a dose of 0.5 mg 4 times in day also within 3-5 days.

Calcium antagonists

Pregnancy Pregnancy Technique for Childbirth Nursing. Nifedipine is used at a dose of 30 mg orally and then 10 mg every 4 hours for 3 days. Before and after the application, the condition of the mild toil tracts, the fetal and contractile activity of the uterus by cardiotocography and clinical data are carefully assessed. Necessary condition for the use of nifedipine are: term pregnancy, immature or maturing cervix. It is shown to pregnant women, who use other methods is contraindicated, especially for the most commonly used beta-adrenomimetics. It is most advisable to use this method in hypertensive forms of late toxicosis of pregnant women, in the presence of concomitant extragenital diseases, especially cardiovascular diseases: hypertension and its combination with late toxicosis of pregnant women, endocrine diseases (diabetes mellitus, thyroid disease, heart defects, vegetovascular dystonia in hypertensive type, etc.).

Nifedipine probably leads to maturation of the cervix due to its relaxing effect on the myometrium and the improvement of uterine-placental circulation, contributing to a change in the level of calcium in the myocytes, in particular, the transition from the intercellular environment into the cell, thereby bringing the content of Ca ^{2+ ions} in serum blood is reduced.

Thus, nifedipine is highly effective in preparing pregnant women for childbirth, in the absence of a negative effect on the mother's body, the condition of the fetus and newborn baby.

[1], [2], [3], [4]