Tactics of management of pregnant women at preliminaries

Until now, there is no single tactic for managing pregnant women with preliminaries. Many domestic obstetricians believe that during the preliminar period, the use of tranquilizers, analgesics, antispasmodics, estrogens is indicated. F. Arias (1989) showed that in a pregnant woman with regular contractions, but without structural changes in the cervix, labor activity ceases after the appointment of 0.015 g of morphine or 0.2 g of secobarbital, and in this case it is possible to speak of false labor. Probably, as modern experimental and clinical data show, there is opioid inhibition of the release of oxytocin during pregnancy and childbirth.

In recent years, methods of physical impact have been developed - acupuncture.

A method has been developed for the treatment of prolonged preliminaries with electroanalgesia. Electroanalgesia leads to the fact that in part of the pregnant contractions completely cease and after 3-7 days regular labor is established, resulting in spontaneous childbirth. The authors believe that this is due to the normalization of self-regulation processes in the central nervous system and vegetative equilibrium. Carrying out electroanalgesia in the presence of fights and the absence of structural changes in the cervix allows you to compare the diagnosis of the preliminaries and the primary weakness of labor, determine the interest of the central nervous system in the occurrence of abnormalities of labor. In these observations, the cessation of preliminar fights, the transition of the latent phase to the active phase, indicate the creation of optimal conditions for spontaneous delivery.

To select the most rational management of pregnant women, four groups of pregnant women with preliminaries were studied:

1. control group - no intervention;
2. creation of hormone-vitamin-glucose-calcium background;
3. excitatory oxytocin;
4. central regulation of motor activity of the uterus with diazepam (seduxen, sibazon).

A comparative analysis of the length of labor with regard to the duration of the preliminaries in the groups indicated above showed the following. The duration of childbirth increased in all groups except the last. In group 2, in 34% of pregnant women, induction was ineffective, i.e., did not lead to the initiation of regular labor. At the same time, the frequency of development of the weakness of labor was here the maximum - 38.5%. In the same group, as in the group of pregnant women, where drug-induced sleep-rest was applied, the highest frequency of premature water retreatment was noted.

The most favorable were groups of pregnant women who were treated with diazepam, beta-adrenomimetics, bradykinin inhibitor-parmidin, inhibitors of prostaglandin synthesis.

Mode of central regulation of diazepam. With the use of diazepam (seduxen) in doses of 10-40 mg intramuscularly or intravenously, there was no adverse effect on the pregnant woman's body, the state of the intrauterine fetus and newborn, and utero-placental hemodynamics. It is important that the drug has a pronounced relaxing effect on the myometrium.

Method of diazepam administration. Diazepam (seduksen) is recommended to use in a dose of 10-20 mg of a standard solution (1 ampoule contains 2 ml or 10 mg of diazepam). It is preferable to administer intravenously on an isotonic solution of sodium chloride in an amount of 20 ml, without the admixture of other drugs, slowly, at a rate of 1 ml (5 mg) for 1 min to avoid the possible appearance of diplopia or mild dizziness caused by the rapid administration of diazepam. The total dose of the drug during the day in pregnant women should not exceed 40 mg. In the absence of the effect, repeated administration is prescribed no earlier than 3 hours after the first injection.

With this technique, the shortest duration of labor compared with other groups was noted-12.8 hours for the first and 7.5 hours for the re-births, respectively, against 15.7 and 10.3 hours, respectively.

Weakness of labor was observed in pregnant women in 31% of cases in the control group against 3.4% in the group using diazepam.

It is important to note that in this group in 63% of cases the transition of preliminaries to regular labor took place within 6 hours after the administration of the drug. In 8% of pregnant women, preliminar contractions ceased, and subsequently occurred 1 to 2 days later with normal delivery. According to hysterography, an average of 8 hours after the introduction of the drug was established spontaneous labor, which ended in spontaneous labor with a total duration of the birth act of 10 hours.

All children were born with an Apgar score of 8-10 points, then, before discharge from the hospital, they developed without any special features.

According to the data of multichannel external hysterography, it was revealed that after the introduction of diazepam in 20-30 min, the uterine contractions over a period of 3 hours acquired a more rare character - 1-2 reduction in 10 min; more coordinated generic activities were noted; there were contractions in the area of the bottom and body of the uterus, and in the region of the lower segment of the uterus no abnormalities were recorded. The intensity of uterine contractions increased markedly, in spite of the fact that the duration of pauses between them increased. There was a decrease of 3-6 mm in the increased basal tone of the uterus.

A possible mechanism for the action of diazepam appears to be a decrease in mental stress and fear due to the normalization of the central structures located in the limbic region, which, as is known, is acted upon by diazepam, regulating the contractile activity of the uterus. In the course of the pathological course of the preliminaries, the diffuse nature of the disturbances in the bioelectrical activity of the cerebral cortex appears, ie, disturbances occur in the subcortical-stem reticular formations. The main indication for the use of diazepam in preliminaries is the violation of the neuropsychological status in a pregnant woman.

Changes in the excitability of the myometrium were detected before and every 30 min after diazepam administration (oxytocin test data). The excitability of the myometrium increased, becoming, according to the oxytocin test, distinctly positive at the 1-st minute, after the administration of the drug - from the 3-4th minute. In pregnant women with high excitability, myometrium diaepam did not alter the functional properties of the myometrium. These data suggested that there is another mechanism of diazepam action - due to the increased sensitivity of oxytocin zones that exist in the limbic region and in turn alter the reactivity of the myometrium.

Complex clinical and physiological studies in combination with the determination of the estrogenic body saturation by the method of luminescent microscopy made it possible to develop the following method of treatment of the pathological preliminar period with diazepam in pregnant women with psychosomatic status deviations.

When pregnant women with a pathological course of the preliminary period of absence of estrogenic readiness and immature or maturing cervix are diagnosed, pregnant women are injected with folliculin 10,000 units intramuscularly on the air 2 times a day at intervals of 12 hours; spasmolytics - gangleron solution 1.5% - 2 ml intramuscularly or intravenously on 40 ml of 40% glucose solution; diazepam in a dose of 10-20 mg of a standard solution according to the method described above, taking into account the body weight of the pregnant woman. In the absence of the effect, repeated administration of the drug in a dose of 10-20 mg is prescribed no earlier than 3 hours after the first injection of the drug.

It is important to note that such treatment is also important in terms of ante and intranatal protection of the fetus and the newborn child, because with the increase in the duration of the preliminaries (especially 13 hours and more), the number of fetal hypoxic conditions clearly increases as a result of abnormal contractile activity of the uterus leading to disruption utero-placental blood circulation. The incidence of asphyxia increases to 18%. A distinct increase in the number of children with a low Apgar score was observed with an increase in the duration of the preliminaries.

The use of the inhibitor bradykinin - parmidin in the treatment of the preliminaries.

Kallikrein-kinin system (CCS) is included in the regulation of the function of the reproductive system of the body. The greatest value among kinin is bradykinin. Bradykinin can be important in the process of childbirth. Some authors indicate a sharp drop in the level of kininogen with the onset of labor, reaching a maximum in the II period of labor. Some doctors believe that the influence of kinins on the uterus of animals and the muscles of the uterus during pregnancy is small and these data are contradictory. It is believed that the synthesis of kinins increases during pregnancy and especially increases vigorously during labor (with normal labor). Therefore, we can assume the active participation of kinins in the dynamics of physiological births. There was a decrease in the activity of the kinin system in case of weakness of labor activity (lack of sufficient muscular activity of the uterus).

The activity of CCS is one of the important factors in the onset of contractile activity of the uterus during childbirth. With some complications of pregnancy, a high activity of kininogenesis is observed. This circumstance led to the search for a pharmacological agent with antihypoxic and anti-Kinetic properties.

Parmidin belongs to the group of kinin antagonists and is now practically the only drug of anti-bradykinin action that reduces or completely eliminates the main effects of endogenous or exogenous kinins. Parmedin during hypoxia selectively acts on the mitochondria of the cell, stabilizing their membrane, protecting from the damaging effect of peroxide reactions and thereby strengthening the processes of energy formation. These data allow us to judge its protective role in the hypoxic hypoxia of cells.

The presence of anti-bradykinin and antihypoxic action ensures the ability of this drug to interfere with the metabolism of the brain by regulating the blood flow and permeability of microvessels of the brain, as well as increasing endurance to oxygen starvation. The listed properties of parmidin can provide recovery of cerebral hemodynamics and metabolic processes and the creation of stable anabolism of neurocytes, disturbed by hypoxia.

Being an active antioxidant, the drug reduces the body's need for oxygen, inhibits lipid peroxidation, reduces the amount of free radicals, and the ischemia of organs and tissues.

Acting as an angioprotector, parmidin reduces the permeability of the vascular wall, improves microcirculation in the vessels, including the brain, lungs, helps normalize the elasticity and tone of the cerebral vessels, reduces the processes of thrombosis, prevents the formation of hemorrhages. Influencing the processes of oxidative phosphorylation, parmidin stabilizes the alveolar wall, reduces the production of kinins.

The foregoing is the basis for including in the complex of therapeutic measures a pharmacological correction of the activity of this system using kininonegative means.

However, the questions of experimental substantiation of the use of drugs inhibiting the kallikrein-kinin system in obstetric practice have been extremely poorly developed.

The method of treatment with prostaglandin synthesis inhibitors.

Rationale for the use of inhibitors of prostaglandin synthesis. Prostaglandins play a role in the emergence and unleashing of labor, and inhibitors of prostaglandin synthesis can directly regulate the frequency and amplitude of uterine contractions due to oppression of prostaglandin synthesis.

Recommended to use one of the most effective and widely used in obstetrical practice indomethacin, which is most indicated with an increased concentration of endogenous prostaglandins, which is clinically most often manifested in high amplitude and frequency of uterine contractions. Indomethacin completely inhibits uterine contractions within 1-8 hours.

The procedure for the use of indomethacin. In the absence of biological readiness for labor, a siegetin solution is injected intravenously in a dose of 200 mg for 2-2.5 hours, after which the administration of indomethacin in a dose of 125 mg begins, with 1 capsule (25 mg) first taken, and the second dose is introduced rectally in the form of a suppository - 1 suppository (50-100 mg). In the absence of effect, after 2 hours again recommend the appointment of 100 mg of indomethacin. The total dose during the day should be 200-250 mg.

Indomethacin is an effective treatment for the pathological preliminaries, well tolerated by pregnant women. Negative effect of the drug on the subsequent course of labor, the condition of the fetus and the newborn was not noted. The course of treatment is 3-5 days.

The second effective drug is ibuprofen. The drug is well absorbed from the gastrointestinal tract. The most complete and rapid absorption is in the small intestine. After taking a single dose of 200 mg, the maximum concentration of the drug in human blood plasma is 15-30 μg / ml after 1% h. Ibuprofen binds intensively (up to 99%) to plasma proteins. Elimination of ibuprofen occurs rapidly: 24 hours after its administration, neither the drug nor its metabolites are detected in the blood. Ibuprofen is administered orally in the form of tablets of 0.2 g 3-4 times a day, depending on the hysterography. The course of treatment up to 3 days.

The most known adverse reactions from the gastrointestinal tract. The development of gastropathies can be accompanied by bleeding and the appearance of ulcers. Other side effects are also observed: changes in the function of the kidneys, liver, central nervous system, hematopoietic disorders, skin syndrome, the development of allergic reactions.

Method of treatment with beta-adrenomimetics. In the literature there are single reports on the use of beta-adrenomimetic partusisten in the form of rectal suppositories in the pathological preliminar period. It is believed that the inhibition of contractile activity of the uterus in pregnant women is carried out by the beta-adrenoreceptor inhibitory mechanism, i.e., through the interaction of endogenous beta-adrenomimetics with myometrium beta-adrenoceptors, so there is a need to diagnose its condition. A partusisten test was proposed that reflects the degree of inhibition of the contractile activity of the uterus by exogenous beta-adrenomimetic, and the ozidan test, which can probably be used to detect excess endogenous beta-adrenomimetic, and to diagnose the hyperreaction of the mother's body to endogenous beta-adrenomimetic.

We developed a technique for treating the pathological preliminaries with beta-adrenomimetics: partusisten, briikanil (terbutaline), and alupent (orciprenaline sulfate).

Method of applying partusisten. 10 ml of the preparation containing 0.5 mg of partusystene are dissolved in 500 ml of 5% glucose solution or isotonic sodium chloride solution. Partusisten is injected intravenously at a rate of 15-20-30 drops per minute. The duration of administration of the drug on average 4-5 hours. Later, immediately after stopping the intravenous infusion of the drug, the latter is prescribed in tablets 5 mg once a day. To reduce tachycardia, pregnant women received finctin 40 mg 2-3 times a day.

A similar method was prepared for 180 pregnant women with a preliminar period. Of these, 129 were primipara (71.7%) and 51 were moth-rats (28.3%).

Brikanil and alupent were used in 208 pregnant women aged 18-39 years with a gestational age of 39-41 weeks. Brikanil apply 5 mg orally, and alupent - at a dose of 0.5 mg intramuscularly. Brikanil causes a decrease in uterine contractions and a decrease in the amplitude of contractions after 30-40 minutes, and after 2-3 hours of contraction completely cease. Changes in the cardiovascular system are insignificant. The pulse increases by 15-20 beats per minute, but not more than 20 minutes. Systolic blood pressure does not change, and the diastolic blood pressure decreases by 10 mm Hg. Art.

Regular labor activity occurs 17.8 ± 1.58 hours, and the average duration of labor in primipara is 11.24 ± 0.8 h compared to 13.9 ± 0.8 h in the control group without medication. The difference is statistically reliable. In the case of miscarriages, the duration of labor is 6.1 ± 0.6 h compared to 9.08 ± 0.93 in the control group. Labor was complicated by the weakness of labor activity in 12.8 ± 4.9%, and in the control group - in 33.0 ± 4.7%.

When studying the condition of the fetus and the newborn, it was found that the use of briikanil reduced the number of children born in asphyxia (10.6%), while in the control group this number was significant (36%). The average assessment of newborns according to the Angar scale was 8.51 ± 0.095.

Alupent was used in a dose of 0.5 mg intramuscularly. After the administration of the drug, the contractions of the uterus ceased in 40-60 minutes, but after 2-3 hours most of the pregnant women again had weak, short, irregular contractions. Changes in the cardiovascular system were the same as with bricanil.

Spontaneous regular labor activity occurred 10.16 ± 1.12 hours after the administration of alupent. The duration of labor in primipara was 11.3 ± 0.77 h compared to 13.9 ± 0.8 h in the control group. Weakness of labor was noted in 18 ± 4.9%, in the control group - 33 ± 4.7%.

When beta-adrenomimetics were used to treat the preliminaries, a statistically significant decrease in the amount of late toxicosis in labor was noted. With the introduction of alupent, late toxicosis was noted in 16.4 ± 4.7%. Probably, this can be explained, on the one hand, by a change in hemodynamics, especially by a decrease in diastolic blood pressure, which is closely correlated with the blood flow in the intervillum space, by improvement of oxidation-reduction processes in myometrium and placenta. The relationship between placental insufficiency and anomalies of the ancestral forces has been revealed. On the other hand, there is a close relationship between the adrenergic system and endogenous prostaglandins, which, under the influence of beta-adrenomimetics, can improve the synthesis of prostaglandins in the placenta (especially prostacyclin type) and thus contribute to the prevention of late toxicosis in labor.

Contraindications to the use of beta-adrenomimetics: hypertension of pregnant women, hypertension with arterial pressure 150/90 mm Hg. Art. And above, heart defects, insulin-dependent diabetes mellitus, thyroid hyperfunction, fetal malformations, dead fetus, chorionamnionitis.

Medication sleep-rest during the preliminar period. At night, if after the introduction of the above medicines (ciazepam, beta-adrenomimetics, parmidin, etc.) contractions do not stop, you can re-enter 20 mg of diazepam in combination with 50 mg of pipolfene and 40 mg of promedol solution. If during the next hour the pregnant woman does not fall asleep, she is prescribed a steroid drug - Viadryl "G" in the form of a 2.5% solution intravenously, rapidly in an amount of 1000 mg per 20 ml of 40% glucose solution. To prevent possible irritation of the punctured vein, 5 ml of 0.5% novocaine solution is injected before the injection of the viadryl.

After applying this dose of Viadryl, a woman quickly, literally within the first 3-5 minutes and without the stage of excitation, comes a dream, which continues against the background of the preliminary introduction of diazepam, pipolfen and promedol.

Viadril (preion for injection) well relaxes the muscles, does not have a significant effect on respiration and the cardiovascular system, due to a slight effect on carbohydrate metabolism can be used in diabetes mellitus.

Instead of the viadril, sodium oxybutyrate can be used intravenously in a dose of 10-20 ml of a 20% solution. The drug is usually well tolerated; does not significantly affect the cardiovascular system, respiration, liver, kidneys. With rapid intravenous injection, motor excitation, convulsive twitching of limbs and tongue are possible.

Calcium antagonists. Recognition of the importance of the role played by calcium ions in the reduction of myometrium, allowed them to apply for the preparation of pregnant women and treatment of the pathological preliminaries.

We used nifedipine according to the following procedure: 3 tablets of nifedipine 10 mg each were prescribed alternately with an interval of 15 minutes (total dose of 30 mg). 160 pregnant women were examined. The duration of the preliminaries was more than 12 hours.

In the group of primiparas, the total percentage of somatic diseases was 27%, complicated during pregnancy in 65.5% of pregnant women. In the group of recurrent somatic diseases 34,2% were detected, complicated during pregnancy at 31,5%.

At 63,7% of women after application of nifedipine the strong tocolytic effect is received. The average duration of labor in primipara was 15.4 ± 0.8 h, in re-birth - 11.3 ± 0.77 h. Labor was complicated by the weakness of labor in 10.6% of cases. Fast and rapid births were observed at 4.3 ± 0.85%. There was no adverse effect of nifedipine on the mother, fetus, newborn baby.

The main clinical indications for the use of calcium antagonists in the treatment of pregnant women in the preliminaries are:

• presence of frequent uterine contractions with the phenomena of discomfort, sleep and rest disturbance;
• combination of uterine contractions with symptoms of impairment of the fetus, conditioned by a long preliminar period;
• presence of an increased tone of the uterus and symptoms of impairment of the fetus;
• contraindications to the use of other drugs (beta-adrenomimetics, inhibitors of prostaglandin synthesis, etc.);
• presence of cardiovascular pathology in pregnant women.

Combined treatment with calcium antagonists, beta-adrenomammetamine and glucocorticoids. Pregnant women have a high risk of developing a weakness of labor, with poor tolerability of beta-adrenomimetics, a scheme has been developed for the combined use of a calcium antagonist - nifedipine, beta-adrenomimetic - partusisten and glucocorticoids - dexamethasone in half doses.

Combined tocolysis with calcium antagonists and beta-adrenomimetics makes it possible to use significantly lower doses of these drugs; fewer ECG changes in the mother and heart rate in the fetus; the frequency of pronounced side effects is higher when using only partusisten.

Glucocorticoids (cexamethasone at a dose of 12 mg / day) for 2 days inhibits the synthesis of prostacyclin, reduce the degree of postnatal hypoxia by increasing the pulmonary surfactant that improves oxygen transfer through the alveolar membranes, increase the synthesis of renal PG and arachidonic acid, and in clinical conditions lead to a shortening duration of labor and unleashing of labor.

Thus, developing the tactics of managing pregnant women in the pathological course of the preliminaries, one must start from a number of considerations. First, in the pathogenesis of the development of this complication, various psychogenic factors acquire great importance, especially in women with signs of underdevelopment of the sexual apparatus and an insufficiently expressed readiness for childbirth. Secondly, it is obvious that a pregnant woman experiencing unusually painful contractions of the uterus, as well as constant pains in the lower abdomen and in the sacrum, needs a full rest and the cessation of debilitating pain. Therefore, in the complex therapy of the pathological preliminaries, spasmolytics, spasmoanalgesics and adrenergic agents (briikanil, ytopar, ritodrin, partusisten, ginepral, alupent, briikanil, etc.) should be used more widely. These substances make it possible to reduce unproductive uterine contractions with high efficiency, create complete rest, prevent fetal abnormalities, induce uterine relaxation and improve uteroplacental blood circulation, which leads to a decrease in the end result of perinatal morbidity and mortality.