Medical methods to prepare pregnant women for childbirth

The literature discusses the advisability of preparing the cervix with estrogens, vitamins and ATP. A number of researchers claim that steroid hormones activate the processes of cervical maturation and myometrium sensitization, while others have not received evidence of the participation of steroid hormones in these processes. In foreign clinics, estrogens are not used to prepare the cervix for childbirth.

Preparation method. One of the estrogen preparations (most often folliculin or sinestrol) is administered intramuscularly in the amount of 20 thousand units twice a day. The therapy is continued for at least 2-3 and no more than 10-12 days. Long-term use of estrogens is contraindicated if the pregnant woman has signs of liver failure (exacerbation of chronic liver disease of infectious and non-infectious origin, severe course of late toxicosis such as hepatopathy, etc.).

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

Use of antispasmodics:

• belladonna extract (thick belladonna) in the form of rectal suppositories, 0.015 g 2 times a day;
• no-shpa in tablets of 0.04 g 2 times a day orally, or in the form of a 2% solution of 2 ml intramuscularly, also 2 times a day;
• dibazol in powder form 0.02 g 3 times a day orally or in the form of a 0.5% solution 6 ml intramuscularly 2 times a day;
• spasmolitin in tablets 0.005-0.1 2 times a day orally;
• halidor in tablets 0.05-0.1 2 times a day orally or 2 ml intramuscularly 2 times a day.

Use of agents stimulating tissue metabolism processes. In order to enhance oxidation-reduction processes in the body, replenish its energy resources and increase the performance of the myometrium, it is advisable to administer 5-10% glucose solution parenterally, intravenously, drip in the amount of 500-1000 ml, solutions of vitamins of group C and group B, as well as cocarboxylase or ATP. Immediately before the planned induction of labor, calcium preparations are prescribed (calcium gluconate intramuscularly or intravenously). The administration of these drugs must be combined with oxygen therapy.

Sigetin infusion therapy

A method has been developed for preparing pregnant women for childbirth with sigetin in an optimally effective dose of 200 mg intravenously, by drip. For this purpose, 20 ml of a 1% solution of sigetin are dissolved in 500 ml of isotonic sodium chloride solution or in a 5% glucose solution and administered intravenously, by drip at a frequency of 10-12 drops per minute for several hours.

The method of introducing sigetin is most indicated in the absence of readiness for childbirth in combination with symptoms of impaired fetal vital activity and fetoplacental insufficiency. Our data are consistent with the work of D. Deri (1974), who used sigetin 2 tablets 3 times a day (the total dose was 600 mg). The use of sigetin was effective in all cases and its effect is preparatory, while the subsequent duration of labor is shorter than with the use of other estrogens and the assessment of the children's condition according to the Angar scale was higher than 8 points and in 85% - 10 points, which exceeds the indicators of the condition of newborns born in physiological conditions.

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

Antioxidants and antihypoxants

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

Method of administration: 5% unitiol solution - 5 ml in combination with 5 ml of 5% sodium ascorbic acid solution is administered intravenously by drip in 5% glucose solution in the amount of 500 ml. Tocopherol - orally in capsules of 0.2 g 3 times a day. The course of preparation is 4-6 days. Indications: late toxicosis of pregnancy in the absence of biological readiness for childbirth, preparation for childbirth, especially in combination with symptoms of impaired fetal vital activity.

The most effective antihypoxants are amtizol and trimin. These drugs are used in doses of 50-100 mg/kg of body weight and 15 mg/kg, respectively, for the purpose of preparing for childbirth. Amtizol and trimin improve the condition of the cervix, slightly increase uterine activity, improve the condition of the fetus, probably due to improved oxygenation of the mother and fetus and improved energy processes in the myometrium. Hysterography data show that amtizol 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 impaired regional hemodynamics and energy metabolism in the uterus.

Relaxin

Relaxin mainly affects the cervix, but at the same time it has a relaxing effect on 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 introduced as a pessary at a dose of 2-4 mg.

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

The rationale for using relaxin for the purpose of cervical ripening is the following:

• the cervix, as a target organ for relaxin, contains receptors for polypeptides;
• Relaxin causes cervical ripening not only in animal experiments but also when used clinically;
• Relaxin is secreted in increased quantities during the period of cervical ripening.

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

Prostaglandins

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

When using prostaglandins of groups E and F clinically, 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 the resorption of fresh ischemic foci in the fundus and reduces the amount of fresh hemorrhages in the retina, which is important for pregnant women with diabetes.

Effects of prostaglandin F2a:

• increases systemic arterial pressure, increases arterial pressure in the pulmonary artery;
• reduces blood oxygen saturation;
• reduces blood flow in organs;
• directly increases the tone of the blood vessels of the brain, kidneys, heart, and intestines;
• potentiates the vasoconstrictor effect of pressor hormones;
• increases natriuresis and diuresis.

In order to prepare pregnant women for childbirth, in various obstetric situations, we have developed the following methods for administering prostaglandin gel with prostenone (prostaglandin E2):

• intravaginal administration of prostaglandins together with carboxymethylcellulose;
• in high-risk pregnant women (symptoms of fetal dysfunction, placental insufficiency, etc.), a method has been developed for the combined use of beta-adrenergic agonists (partusisten, alupent, brikanil, ginepral) together with prostaglandins to exclude cases of uterine hyperstimulation or deterioration of the fetus's condition;
• introduction of a gel with prostaglandins in case of untimely discharge of waters and an immature cervix;
• for the purpose of treating weak labor activity due to the body's insufficient readiness for childbirth (ripening or immature cervix), especially in women in labor before providing drug-induced sleep-rest.

The following method for obtaining the gel has been developed: 0.6 g of finely grated sodium carboxymethylcellulose is dissolved in 7 ml of distilled water in a sterile penicillin bottle. After sealing, the bottle is placed in an autoclave, where it is kept for 20-25 minutes at a temperature of 120 C and a pressure of 1.2 atmospheres. The gel is stored at a temperature of + 4 C. Bacteriological studies have shown that with such processing and storage it remains sterile for 2-3 months. Prostenon (PGEz) is added to the gel immediately before use.

Prostaglandin gel is installed into the posterior vaginal fornix with a syringe through a polyethylene catheter. The catheter is inserted into the vagina under the control of a finger of the examining hand. After the gel is inserted, the pregnant woman is advised to stay in bed with her pelvis raised for approximately 2 hours. If there is evidence of uterine hypertonicity, it is necessary to insert a hand into the vagina and remove the gel.

Currently, to prevent uterine hyperstimulation in pregnant women at high risk of perinatal pathology, beta-adrenergic agonists are administered before the introduction of the gel.

Method of preparing pregnant women for childbirth with vaginally administered prostaglavdinamp together with infusions of beta-adrenergic agonists. 10 ml of the preparation containing 0.5 mg partusisten or 1 ml alupent (0.5 mg) or 1 ml brikanil (0.5 mg) are dissolved in 500 ml glucose solution (5%) or isotonic sodium chloride solution and administered intravenously by drip at a rate of 10-12 drops per 1 min, on average, for 4-5 hours. No earlier than 10 minutes after the start of the beta-adrenergic agonist infusion, a gel with 3 mg prostaglandin E2 or 15-20 mg PGF-2 is instilled into the posterior vaginal fornix using a standard syringe through a polyethylene catheter. A prerequisite for prescribing beta-adrenergic agonists is the absence of contraindications to their use.

The method of preparation for childbirth according to E. T. Mikhailepko, M. Ya. Chernega (1988) over 7-10 days is as follows:

• linetol 20.0 2 times a day (morning and evening before meals);
• glutathione 100 mg 2 times a day 30 minutes after taking linetol;
• oxygen - inhalation (preferably under hyperbaric conditions) 5-6 l per min for 30 min 2 times a day;
• ultraviolet irradiation of the lumbar region (suberythemal dose once a day);
• heparin 2500 U intramuscularly on the 3rd and 6th day of preparation of the pregnant woman for: childbirth;
• Folliculin 300 U intramuscularly once a day. Linetol can be replaced with Arachiden or Essentiale or Intralipid.

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

• sinestrol 300-500 ME per 1 kg of body weight intramuscularly once a day;
• linetol 20 ml 2 times a day orally after meals;
• vitamin B1 1 ml S% solution intramuscularly once a day;
• vitamin B6 1 ml of 5% solution intramuscularly once a day;
• ATP 1 ml of 1% solution intramuscularly once a day;
• galascorbin 1.0 orally 3 times a day;
• calcium gluconate 10 ml of 10% solution intravenously once a day;
• ascorbic acid 5 ml of 5% solution intravenously once a day;
• oxygenation for 20 minutes 2 times a day;
• albumin 100 ml of 10% solution intravenously every other day for hypoproteinemia.

Medicines containing polyunsaturated fatty acids are non-toxic. Sometimes dyspeptic symptoms (nausea) are observed when taking them; mushy stools are possible in the first days. These symptoms usually pass on their own and do not require stopping treatment. However, in case of diarrhea, the use of medicines should be avoided. Pregnant women suffering from cholecystitis sometimes experience increased pain in the gallbladder area; in these cases, further use of medicines should also be avoided.

Adrenergic agents

Beta-blockers.

I. V. Duda (1989) developed schemes for prenatal preparation of pregnant women for childbirth.

Schemes of prenatal preparation with labor induction.

Five-day scheme.

Day 1: estrogens (folliculin or sinestrol) 140-150 IU per 1 kg of body weight 4 times intramuscularly; calcium chloride (1 tablespoon of 10% solution 3-4 times) and galascorbin (1.0 g 3 times a day) orally;

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

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

Day 4: estrogens 200-250 IU once intramuscularly; calcium chloride and galascorbin in the same doses;

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

Three-day scheme.

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

Day 3: carry out all the same activities as on the 5th day of the 5-day scheme.

Two-day scheme.

Day 1: estrogens 200-250 IU per 1 kg of body weight once intramuscularly; calcium chloride and galascorbin orally, as in the 5-day regimen;

On the 2nd day, all the same activities are carried out as on the 5th day of the 5-day scheme.

One-day scheme.

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

When using anaprilin (obzidan, inderal, propranolol), it is necessary to take into account contraindications and adverse effects on the fetus and newborn. According to modern guidelines from domestic and foreign authors, it is contraindicated during pregnancy and lactation, since, crossing the placental barrier, the drug is fetotoxic and leads to depression, polycythemia, hypoglycemia and bradycardia in newborns for several days. During lactation, propranolol passes into milk and can lead to bronchospasm, bradycardia, hypogenia, congenital heart failure and hypoglycemia in newborns, but these effects do not always occur.

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

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

Beta adrenergic agonists.

Beta-adrenergic agonists are used for the following indications:

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

Method of preparation of pregnant women with partusisten. 10 ml of the preparation containing 0.5 mg of partusisten was dissolved in 500 ml of 5% glucose solution or isotonic sodium chloride solution. Partusisten was administered intravenously by drip at a rate of 15-30 drops per minute. Subsequently, immediately after the intravenous infusion of the preparation was stopped, the latter was prescribed in the form of tablets of 5 mg 6 times a day. To reduce tachycardia and potentiate the effect, pregnant women received finoptin (verapamil) 40 mg 2-3 times a day. Preparation of pregnant women is carried out for 5 days.

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

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

Contraindications.

Absolute.

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

Relative.

• diabetes mellitus;
• dilation of the cervical os by 4 cm or more at the onset of tocolysis in premature labor;
• premature rupture of membranes;
• pregnancy period less than 14 weeks;
• hypertensive conditions during pregnancy with blood pressure of 150/90 mm Hg and higher;
• fetal malformations.

Glucocorticosteroids and precursors of norepinephrine synthesis - L-Dopa

Glucocorticoids increase the mitotic index in the cells of the vagina and cervix epithelium, inhibit prostacyclin synthesis, reduce the degree of postnatal hypoxia in premature infants, increase glomerular prostaglandin synthesis and arachidonic acid levels, accelerate fetal kidney development without affecting the duration of pregnancy. A number of modern authors recommend caution in prenatal administration of corticosteroids, since they can cause brain damage in rat and rhesus macaque fetuses. At the same time, Brown et al. (1993) found that a new high-affinity 11beta-hydroxysteroidcehydrogenase in the placenta and kidney (?) prevents the effect of glucocorticoids on the fetus, and in the kidney - on mineralocorticoid receptors. It has a high affinity for glucocorticoids.

In a weakly contracting uterus, corticosteroid hormones bind differently to corticosteroid receptors, which should undoubtedly attract attention and stimulate an active search for an answer to the question of the role of corticosteroid hormones in regulating myometrium contraction and their use for the prevention and treatment of weak labor.

L-Dopa is not contraindicated during pregnancy.

A new method of preparing pregnant women for childbirth has been developed: a precursor of norepinephrine, L-Dopa, is used at a dose of 0.1 g 3 times a day for 3-5 days in combination with intramuscular administration of 50 mg hydrocortisone or dexamethasone at a dose of 0.5 mg 4 times a day, also for 3-5 days.

Calcium antagonists

Methodology for preparing pregnant women for childbirth with nifedipine. Nifedipine is used in a dose of 30 mg orally and then 10 mg every 4 hours for 3 days. Before and after use, the condition of the soft birth canal, the condition of the fetus and contractile activity of the uterus are carefully assessed by cardiotocography and clinical data. A necessary condition for the use of nifedipine is: full-term pregnancy, immature or ripening cervix. It is indicated for pregnant women for whom the use of other methods is contraindicated, especially for the most commonly used beta-adrenergic agonists. It is most appropriate to use this method in hypertensive forms of late toxicosis of pregnancy, in the presence of concomitant extragenital diseases, especially cardiovascular diseases: hypertension and its combination with late toxicosis of pregnancy, endocrine diseases (diabetes mellitus, thyroid disease, heart defects, vegetative-vascular dystonia of the hypertensive type, etc.).

Nifedipine probably leads to the maturation of the cervix due to its relaxing effect on the myometrium and improvement of uteroplacental blood flow, promoting a change in the calcium level in myocytes, in particular, the transition from the intercellular environment into the cell, due to which the content of Ca ²⁺ ions in the blood serum decreases.

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

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