Obstetrical tactics of preterm labor

The problem of maternal and child health is seen as an important part of health care, which is of paramount importance for the formation of a healthy generation of people from the earliest period of their life. Premature birth is one of the most important issues of this problem. The urgency of preterm labor is due to the fact that they determine the level of perinatal morbidity and mortality.

Preterm infants account for 60-70% of early neonatal mortality and 65-75% of infant mortality, stillbirth in preterm labor is 8-13 times more frequent than in case of timely birth.

Perinatal mortality of premature newborns is 33 times higher than full-term births.

The problem of premature birth also has a psycho-social aspect, since the birth of an inferior child, his illness or death is a serious mental trauma. Women who have lost children feel fear for the outcome of a subsequent pregnancy, a sense of their own guilt, which ultimately leads to a marked decrease in their life activity, conflicts in the family, and often to a renunciation of pregnancy. In this regard, the problem of premature birth is not only medical, but also of great social importance.

In our country it is considered to be premature birth - childbirth, which occurred at the gestation period from 28 to 37 weeks of pregnancy; the mass of the fetus is 1000 g. On the recommendation of WHO, perinatal mortality is accounted for from 22 weeks of pregnancy with a fetus weight of 500 g or more.

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

Risk factors for premature delivery

Based on the clinical and clinical laboratory analysis of the outcome of preterm delivery for the mother and fetus in 1000 pregnant women, we found that the risk factors for premature birth are, as socio-demographic: unsettled family life, low social level, young age; and medical: every third woman with preterm birth is first-pregnancy, risk factors include earlier abortions, premature births, spontaneous abortion, urinary tract infections, inflammatory diseases of the genitals. An important role in the occurrence of premature birth is played by the complicated course of this pregnancy, in the structure of complications, the threat of termination of pregnancy prevails. A special place belongs to the infection that was suffered during pregnancy (ARVI and other viral infections). However, these factors do not predict the outcome of premature births for the fetus.

Risk factors for perinatal morbidity and mortality in preterm delivery are the gestation period and the weight of the fetus, the features of the course of premature delivery itself. These factors include abnormal fetal position and presentation, including pelvic presentation, abruption of normal or low-lying placenta, rapid or rapid delivery, which increase the risk of perinatal mortality by 5 times in comparison with the uncomplicated course of preterm delivery in the headache. Premature outpouring of amniotic fluid contributes to the development of preterm labor in 25-38% of cases.

Medication support of preterm labor

At present, certain successes have been achieved in the fight against threatening premature birth due to the use of drugs in obstetrical practice that suppress the contractile activity of the uterus. The greatest use in modern conditions have been beta mimetics ortokolitiki, a group of substances specifically acting on beta-receptors and causing the relaxation of the uterus.

Tocolytic drugs can cause side effects and complications: heartbeat, lowering blood pressure (especially diastolic), sweating, tremor, anxiety (excitement), nausea, vomiting, chills, headache, flatulence. Side effects and complications are usually associated with an overdose of the drug and very rarely with its intolerance. Therefore, for therapeutic purposes, you should reduce the dose or stop the injection of tocolytics. In the treatment with beta mimetics, control of heart rate, blood pressure, and blood sugar level is necessary. To eliminate side effects of beta mimetics, they are combined with taking phenotin at 0.04 (1 table) 3-4 times a day. This drug, being a calcium antagonist, not only removes the side effects of beta mimetics, but also reduces the contractile activity of the uterus, strengthening their action. Reducing the dosage of medications can be achieved by combining drug therapy with physiotherapy - magnesium electrophoresis by a sinusoidal modulated current (CMT). Of modern beta mimetics attracts attention domestic drug Salgim. The peculiarity of this preparation is that the beta-particle is located on the molecule of succinic acid, an important component of the "breathing" of the cell. Therefore, side effects when taking Salgim is less than with other beta mimetics, and the effectiveness of the therapeutic effect is the same. The effectiveness of beta mimetics is 86%.

When the threat of interruption of pregnancy manifested by increased tone of the uterus, a scheme for the use of indomethacin, an inhibitor of prostaglandin synthesis, was developed. Indomethacin is administered at a dose of 200 mg per day in tablets or suppositories on the first day of 50 mg 4 times in tablets (in suppositories of 100 mg twice), 2 to 3 days of the day 10 m through 8 hours, 4 to 6 days on 50 mg at 12 hours, 7-8 days at 50 mg per night. The total dose should not exceed 1000 mg. Duration of treatment 5-9 days. Contraindications for the use of indomethacin are gastrointestinal diseases, bronchial asthma. The inhibition of the contractile activity of the uterus begins 2-3 hours after taking the drug and is expressed in a decrease in tone, a gradual decrease in the amplitude of contractions. Complete normalization of the condition of the uterus occurs 3-4 days after the start of therapy. The efficacy of indomethacin is 72%.

The drug does not have a negative effect on the fetal condition in these doses. The effectiveness of using indomethacin depends on the period of pregnancy and the severity of changes from the cervix. If the threat of interruption in the stage when the cervix is shortened or smoothed, indomethacin is less effective than beta mimetics. If the contractile activity of the uterus is characterized by a high tone of the uterus, and the cervix is preserved, then the effectiveness of indomethacin is not inferior to beta mimetics. Side effects of indomethacin are less pronounced than in beta mimetics and can be in the form of headache, allergic rash, pain in the area of the gastrointestinal tract.

To fix the effect, it is advisable to use a combination of indomethacin with magnesium electrophoresis (CMT).

Therapy of threatening miscarriages and premature births by intravenous drip administration of a 2% solution of magnesium sulphate in a dose of 200 ml is carried out for 1 hour with a course of treatment of 5-7 days. Tocolytic therapy with magnesium sulfate does not adversely affect the fetus, reduces the mother's blood pressure, increases diuresis, and a favorable sedative effect is noted. However, the efficacy is lower than with beta-mimetics and indomethacin, and is 67%.

To treat threatening premature births, it is necessary to use non-medicamentous and physiotherapeutic means of influence on the musculature of the uterus more widely. Electro-relaxation of the uterus is performed.

When the threat of premature birth is an integral part of therapy is the prevention of respiratory distress syndrome in newborns, by prescribing pregnant glucocorticoid drugs.

Under the influence of glucocorticoids, administered to the pregnant or directly to the fetus, there is a faster maturation of the lungs, since an accelerated synthesis of the surfactant occurs.

Pregnant women receive 8-12 mg of dexamethasone for treatment (4 mg twice a day intramuscularly 2-3 days or in tablets 2 mg 4 times the first day, 2 mg 3 times the second day, 2 mg 2 times a day the third day). The purpose of dexamethasone in order to accelerate the maturation of the fetal lungs makes sense when the therapy aimed at maintaining a pregnancy does not give a stable effect and premature birth occurs in 2-3 days. Since it is not always possible to foresee the success of therapy with preterm birth, corticosteroids should be prescribed to all pregnant women who are injected with tocolytic agents. Contraindications for glucocorticoid therapy are: gastric ulcer and duodenal ulcer (can use intramuscular route of administration), circulatory failure III, endocarditis, nephritis, active form of tuberculosis, severe forms of diabetes, osteoporosis, severe nephropathy.

When combined therapy with beta-mimetics and glucocorticoids with their intolerance or overdose, there are cases of development of pulmonary heart failure with pulmonary edema. To prevent these serious complications, strict control of the condition of the pregnant woman and all hemodynamic parameters is necessary.

Prevention of respiratory distress syndrome makes sense when the gestation period is 28-33 weeks. In earlier terms of gestation, antenatal maturation of the lungs requires a longer use of the drug. Although there is no great efficiency from repeated courses of glucocorticoids. In those cases when there is no possibility to prolong pregnancy, it is necessary to use surfactant for treatment of respiratory distress syndrome in a newborn. Antenatal prophylaxis of respiratory distress syndrome with the use of surfactant introduced into the amnion, as a rule, is not effective. After 34 weeks of gestation, fetal lungs already have enough surfactant and there is practically no need for the prevention of respiratory distress syndrome.

In order to reduce the birth traumatism in the period of exile, the allowance is without protection of the perineum. The midwife or doctor who takes the baby, inserts the fingers into the vagina and stretches the vulvar ring to promote the birth of the fetal head. In parturient women with a high rigid or cicatricial perineum, cutting of the perineum is necessary to facilitate the eruption of the fetal head. | |

A child is taken to a special pedestal, at the level of the mother's crotch. Do not raise the baby or lower the level of the uterus so as not to create hyper- or hypovolemia in the newborn, which can cause difficulty in his cardiac activity. Taking a baby is necessary in warm diapers. It is expedient to separate it from the mother within the first minute after birth and, if necessary, proceed to resuscitation (carefully, cautiously, better in the cuvette). The premature infant is contraindicated in the appointment of drugs - respiratory stimulants (lobedin hydrochloride, caffeine), since they can cause seizures.

Prevention of bleeding in the consecutive and early postpartum periods is carried out according to the usual method (intravenous injection of metargergometrin or oxytocin).

Clinical manifestations of rapid premature delivery are frequent, painful, prolonged contractions. The contracting activity of the uterus with rapid premature birth or complicated by excessively severe labor is characterized by a number of features: an increase in the rate of cervical dilatation exceeding 0.8-1 cm / h in the latent phase and 2.5-3 cm / h in the active phase of labor, frequency of fights 5 and more for 10 minutes, intensity of fights more than 5 kPa, uterine activity in Alexandrian units - 2100 AE in the latent phase and 2430 AE in the active phase of childbirth.

To predict rapid preterm delivery, patients enter a 10-20 minute scan for evaluation of the frequency of fights, their intensity, and repeat vaginal examination after 1 hour to assess the rate of cervical dilatation. If the parameters of evaluation of the contractile activity of the uterus and the dynamics of opening the cervix fit into the above criteria, you can expect rapid or rapid delivery.

Correction of disturbance of contractile activity in fast premature births is carried out by intravenous drip of partusisten (0.5 mg of partusistene in 250-300 ml of 0.9% saline solution).

For a preliminary assessment of the reaction of the uterus to administer the drug within the first 10 minutes, partusisten is administered at a dose of 0.8 μg / min (10 drops per minute).

In the case of non-coordinated labor, this dose is sufficient for its normalization. With excessively active labor, fast delivery, the dose of partusen is increased to 1.2-3.0 μg / min, i.е. Up to 40 drops per minute, to suppress excessively high activity of the uterus, while reducing the contractile activity of the uterus occurs on average after 10 minutes. Then gradually the rate of administration of the drug is reduced until the appearance on the monitor of regular contractions with a frequency of 3-4 contractions in 10 minutes. Tokolysis continues for at least 2-3 hours under the constant control of hysterography. Since, often after a quick discontinuation of the drug, discordant contractions or uterine hyperactivity again occur. During the introduction of the drug, you must constantly monitor the pulse and blood pressure level.

Tocolysis is stopped when the cervix is opened 8-9 cm, i.e. For 30-40 minutes before the expected delivery. In the postpartum and early postpartum periods, bleeding should be prevented by the administration of methylergometrine 1.0 or oxytocin 5 ED in 300 ml of saline.

In the process of giving birth, the condition of the fetus is evaluated on the basis of a dynamic study of the cardiogram. With the introduction of tocolytics at a rate of 40 drops per minute (1.2-3 μg / min), the fetal basal rhythm is increased in the fetus - up to 160-170 beats per minute with individual ac- celerations, which can be explained by the fetal response to the administration of large doses of tocolytics , a reduction in the dose of the drug administered resulted in a normalization of the fetal heart rate. Nevertheless, with threatening hypoxia, the introduction of small doses of partusisten led to normalization of heart rate. In the dosages used, partusisten does not adversely affect the condition of the intrauterine fetus and newborn.

The management of rapid premature birth under the guise of tocolytics, contributes to a decrease in the rate of cervical dilatation and a more gradual course of labor, normalization of contractile activity of the uterus, which is manifested in a decrease in the frequency of fights, increasing pauses between contractions, decreasing their intensity, along with a lack of a reliable reduction in the duration of labor.

Intravenous application of partuscysten or other tocolytics, under the control of external tocopheography, is an effective tool for preventing and correcting violations of labor during preterm labor, which creates a basis for preventing the trauma of the premature fetus and thereby reducing perinatal losses.

If weakness of labor occurs in the second stage of labor, endonasal administration of oxytocin can be used. To do this, from the ampoule oxytocin, containing 5 units of oxytocin, is taken by pipetting the drug and injected in a dose of 1-2 drops in each half of the nose after 20 minutes.

The use of the Cresteller method, a vacuum extractor with a premature fetus is contraindicated. The use of obstetric forceps is possible with gestational periods of 34-37 weeks.

In pelvic presentation of the fetus, manual care should be given very carefully, using the techniques of the classical manual. Tsovyanov's method, with a purely breech presentation at the deep-inferior children, is inexpedient, because of the mild vulnerability of the premature baby (danger of hemorrhage into the cervical spinal cord).

The issue of delivery by cesarean section in case of premature pregnancy is decided individually. At present, the cesarean section up to 34 weeks of gestation is performed according to the vital indications from the mother. In the interest of the fetus during these gestational periods, the question of surgery in case of complicated delivery in the pelvic presentation, with transverse, oblique fetal position in women with a burdened obstetric anamnesis (infertility, miscarriage) in the presence of resuscitative intensive neonatal service may be raised. In case of need of operative delivery with the nondegenerate lower segment of the uterus, it is better to use a longitudinal G incision on the uterus, since extraction of the fetus in the cross-section can be difficult. One of the most common complications of premature birth is premature rupture of the membranes (PRPO), which occurs in 38-51% of women with preterm labor. The possibility of infection with PEP has a decisive influence on the management of pregnancy. The risk of infection of the fetus with PEP is higher than that of the mother, which is understandable from the point of view of the mature mechanisms of protection in the fetus. At present, with preterm pregnancy, the PRPRs adhere to expectant management with control over the possible development of infection. Expectant tactics are more preferable, the shorter the gestation period, because with the prolongation of the time of the anhydrous interval, there is a more accelerated maturation of the fetal lung surfactant and a reduction in the frequency of hyaline membrane disease.

The following monitoring of the maternal and fetal health is necessary: to measure the abdominal circumference and the height of the uterine fundus, to monitor the quantity and quality of leaky waters, to measure the pulse rate, body temperature, and the fetal heart rate every 4 hours. Determine the leukocyte count every 12 hours, with increasing leukocytosis, look at the leukocyte blood formula. Sowing from the cervical canal, swabs - every five days. In the presence of an immunological laboratory, more sensitive tests can be used to detect a beginning infection: an evaluation of the T-cell link of immunity, the appearance of a C-reactive protein, a spontaneous test with nitro-blue tetrazolium (with NST).

Currently, the most informative test of infection in the fetus is to determine the levels of proinflammatory cytokines in the peripheral blood or il-6 in the mucus of the cervical canal, which rise 2-5 weeks before premature birth. The prognostic significance also has the definition of fibronectin. If the level of fibronectin is above 27% in premature discharge of water in the cervical canal, this indicates intrauterine infection.

At the PREV, it is necessary to decide on the use of tocolytic therapy, the prevention of distress syndrome by glucocorticoids and the use of antibiotics.

Tokoliticheskaya therapy can be prescribed to a pregnant woman with a PRE in the case of threatening and beginning premature births for the prevention of respiratory distress syndrome for 48-72 hours, then tocolytic therapy is canceled and surveillance continues. In the case of the onset of labor, it is no longer suppressed.

The use of glucocorticoids for the prevention of respiratory distress syndrome is one of the most complex issues in the PDS and premature pregnancies, since their use can increase the risk of infectious complications in the mother and fetus. Experience shows that the use of glucocorticoids for the prevention of respiratory distress syndrome should be used before the gestation period of 34 weeks, which is beneficial for perinatal mortality of premature newborns. However, the risk of infectious complications in the mother increases.

The use of antibiotics in patients with PREV is indicated in pregnant women at risk of infectious complications: long-term glucocorticoids, with ischemic-cervical insufficiency, pregnant women with anemia, pyelonephritis, etc., as well as patients who, due to the obstetric situation, vaginal examination even in the absence of signs of infection. All the rest, with the appearance of the slightest signs of infection, prescribe antibiotics, create a hormonal background with subsequent induction.

Causes of premature birth

Due to the peculiarities of obstetric tactics and the different outcome of labor for the fetus, we consider it expedient to divide premature births into three periods, taking into account the terms of gestation: premature delivery at 22-27 weeks; premature delivery at 28-33 weeks; premature birth in 34-37 weeks of gestation.

According to some reports, premature birth at 22-27 weeks (weight of the fetus from 500 to 1000 g) is most often due to ischemic-cervical insufficiency, infection of the lower pole of the bladder and premature rupture. Therefore, in this group of women, as a rule, few primitive women. The presence of infection in the genital tract precludes the possibility of prolonging pregnancy in most pregnant women. Fetal lungs are immature and to achieve acceleration of their maturation by prescription of medicamental remedies of the mother for a short period of time is not possible. In this regard, the outcome for the fetus in this group is most unfavorable. Extremely high perinatal mortality and morbidity.

Premature birth with a gestation period of 28-33 weeks (fetal mass of 1000-1800 g) is due to more varied causes than earlier premature births. Primary women in this category of births were more than 30%. More than half of the women had wait-and-see tactics and prolongation of pregnancy. Despite the fact that the lungs of the fetus are still immature, glucocorticoids can be administered to achieve their accelerated maturation after 2-3 days. Therefore, the outcome of labor for the fetus of this gestation period is more favorable than in the previous group.

Premature birth with a gestation period of 34-37 weeks (weight of the fetus 1900-2500 g and more) are due to even more diverse causes, the percentage of infected women is much lower than in the previous groups and the first-pregnancy groups more than 50%. Most women in this group have expectant management of labor. However, due to the fact that the fetal lungs are almost mature, there is no need to administer funds to stimulate the maturation of the surfactant and prolonging the pregnancy does not change the rates of perinatal mortality significantly.

The highest percentage of termination of pregnancy falls on the terms of 34-37 weeks of pregnancy (55.3%), while in pregnancy 22-27 weeks 10 times less (5.7%).

[5], [6], [7], [8], [9], [10],