Preventing and treating the threat of termination of pregnancy

The degree of threat of termination of pregnancy can be judged by:

• subjective complaints of women;
• colpocytological hormonal changes;
• changes in the contractile activity of the myometrium, recorded palpation and external hysterography;
• data of external and internal research;
• changes in the state of the cervix;
• bloody discharge;
• socio-economic factors;
• laboratory methods (determination of the level of collagenase in the serum of a pregnant woman: determination of granulocyte elastase in the cervico-vaginal secretion, as well as oncofetal fibronectin.

The threat of interruption should be diagnosed by the following features:

• pain in the lower abdomen and lower back of the pulling, aching or cramping character, provided that contractions occur less than 10-15 minutes and their duration is less than 20 seconds;
• increased excitability and tone of the uterus;
• bloody and sacred discharge from the genital tract;
• changes in the cervix (shortening and softening it, patency of the cervical canal for the investigating finger);
• low position of the fetal part in front of the entrance to the small pelvis.

Started generic activity is diagnosed by cramping pains in the lower abdomen, provided that contractions occur more often than after 10 minutes, and their duration is more than 30 seconds. The cervix is sharply truncated or smoothened, opening of the uterine pharynx is 1 cm or more. The present part is located low or pinned to the entrance to the small pelvis, often there are sutures from the genital tract.

To quantify the degree of threat of termination of pregnancy, it is recommended to use the modified Tsana-Troshchinsky index.

Pregnant women should be instructed by the doctor regarding the early signs of the threat of termination of pregnancy: the presence of uterine contractions during self-palpation in the morning and in the evening, slight pains in the lower abdomen, sometimes the uterus-like menstrual-like stresses, leading to discomfort, light chest pains and the appearance of minor secretions from the genital ways.

For the prevention and timely diagnosis of preterm labor in pregnant high-risk groups for miscarriages, ultrasound examination of the cervical and internal pharyngeal conditions and the presence of uterine contractions or strains of the myometrium of both the anterior and posterior walls of the uterus or an internal examination are also recommended once a week week in the gestation period between the 26th and 30th weeks of pregnancy and up to 34 weeks of gestation, that is, in the early stages of the third trimester of pregnancy.

In most pregnant women, premature births are most often observed when there are 3 symptoms:

• opening of the internal pharynx by 1 cm;
• the length of the cervical canal is less than 1 cm;
• presence of painful uterine contractions.

Luminescent colpocytological classification of preterm labor

The study of native vaginal swabs taken from the lateral vaginal fornix and air-dried, is recommended to be performed on a microscope at 100-fold magnification using a fluorochrome acridine orange.

Evaluation of the smear at terms up to 36 weeks of gestation is expedient for Schmitt classification, according to which reaction 1 indicates a sharp estrogen deficiency, reaction 2 - about moderate estrogen deficiency, reaction 3 - about moderate estrogenic effect, reaction 4 - about acute estrogenic effect. A study of vaginal smears performed in 300 healthy women with a gestation period of 28-36 weeks showed a response 2, which is recommended to be taken as the norm for this term of pregnancy. The criterion of well-being in this group is the absence of signs of threat of abortion.

In case of threatening premature birth, a luminescence colpositologic study was performed in 9500 women. In 85% of pregnant women, the third and fourth reactions of the vaginal smear were indicated, indicating an increased level of estrogen. In 15% of pregnant women, symptoms of degeneration of the flat epithelium, indicating a decrease in the level of estrogen, are found. For degeneration of the flat epithelium during luminescent colpocytological study, the following morphological changes are typical: vagueness of the cell contours, the yield of nuclei beyond the cytoplasm, the formation of homogeneous cell complexes, leukocyte infiltration within them, and the absence of inflammatory cell changes.

Taking into account the results of colpositology studies, depending on the severity of hormonal disorders, the following classification of the threat of termination of pregnancy is recommended according to colpositology.

With a hyperestrogenic form:

• a weak degree of threat (62%);
• moderate "» (27%);
• sharp "» (11%). When hypoestrogenic form:
• a low degree of threat (78%);
• moderate »» (16%);
• sharp "» (6%).

Thus, in 15% of pregnant women with the threat of abortion, degenerative signs and changes in flat epithelium are revealed as a sign of hypo-growth, reflecting fetoplacental insufficiency. The study of colpositograms by the luminescent method in preterm labor allows the use of an important diagnostic test - degeneration of the flat epithelium, which indicates a decrease in the incremental function of the placenta and the development of fetoplacental insufficiency.

Cardiotocography. It should be remembered that with early signs of premature birth threatening tachycardia in the fetus up to 180 beats / min should be regarded as a sign of immaturity of its organs and systems, and not as hypoxia (26-32 weeks of pregnancy). The symptoms of impaired fetal activity according to our data correlate with the data of the determination of oxytocinase.

Abroad, home-grown monitoring of contractile activity of myometrium in pregnant risk groups for miscarriages is becoming more common.

Oxytocinase activity in blood serum. The activity of oxytocinase in serum was determined by the method of Turrie et al. In the modification of the Baboon et al. In 120 pregnant women with a threat of interruption of pregnancy from the 16th to the 36th week of pregnancy, the activity level of oxytocinase is significantly lower in comparison with a physiologically occurring pregnancy at the same time (16-32 weeks gestation). At a later date, that is, at the 33-36th week of pregnancy, this difference was less pronounced and unreliable. When combined with the threat of abortion and fetal hypotrophy, oxytocinase activity was the lowest.

It must also be taken into account that, along with a decrease in the activity of oxytocinase, an increase in activity of oxytocinase can be observed in case of threatening births. In these cases, babies were born prematurely, at 35-36 weeks gestation with signs of pronounced hypoxia of the fetus.

Thus, the level of activity of oxytocinase in the serum is associated with the functional state of the placenta and therefore the determination of oxytocinase activity can be used as an additional functional test for the diagnosis and prognosis of disorders that may occur with functional inferiority of the placenta in preterm labor.

In addition, the level of oxytocinase in the serum can be used as an indicator of placental function and fetal condition in premature birth, because it is known that the placenta is the place of formation of a specific serum oxytocinase during pregnancy. It is proved that this enzyme is localized in syncytial cells of the placenta and secretes into the intracavitary space.

The linear increase in oxytocinase activity is characteristic of a physiologically occurring pregnancy. Deviation from the normal course of the curve, both in the direction of decrease and increase, characterizes the functional insufficiency of the placenta.

Thus, the detection of the dynamics of activity of this enzyme is recommended to be used as the most informative test for assessing the functional state of the placenta in case of threatening premature birth.

Ultrasound determination of the respiratory movements of the fetus. As you know, with full term pregnancy, before birth for 24-36 hours there is a decrease or even complete disappearance of respiratory movements.

For the prediction of preterm labor, it is recommended to take into account the respiratory movements of the fetus: if there are no respiratory movements , labor occurs within the next 48 hours. If there are respiratory movements of the fetus during preterm birth, even without treatment, the labor comes in a week or more.

The contracting activity of the uterus. Ambulatory in the context of antenatal clinic in pregnant women with the risk of miscarriage, it is advisable to record the contractile activity of the uterus. At home, especially in the evening, it is determined by self-palpation of the uterus, and in some cases using a special current meter, which is mainly carried out abroad. This is explained by the fact that, as with the self-palpation of the uterus, even with careful instruction of the pregnant woman, and using a tocopheometer, the latter early detects the initial stages of the threat of abortion earlier than the subjective sensations of the pregnant woman.

If there are 4 or more contractions of the uterus with a duration of 40-45 s or more for one hour, hospitalization in the hospital is necessary. This allows 85% to prevent premature births due to timely treatment.

There are four stages of threatening preterm birth according to multichannel external hysterography:

• / stage - presence of small uterine contractions - less than 8 in 15 min;
• // stage - the appearance of large uterine contractions with a duration of up to 150 s and a decrease in the frequency of small contractions of the uterus (by the type of uterine contractions of Alvarez and Brex-ton-Gyx);
• III stage - increase of contractile activity of the uterus from 150 to 250 seconds, intensity - from 10 to 25 mm;
• IV stage of threatening termination of pregnancy is characterized by an increase in contractile activity of the uterus over a duration of more than 250 s, in intensity - more than 25 mm, large reductions are coordinated, the phenomenon of the dominant of the bottom and the triple descending gradient is noted, and small reductions are rarely recorded (1-2 for 15 min).

Measurement of vaginal pH. As is known, with normal acidity of the vaginal environment, the vital activity of pathogenic pathogens is difficult. At pH in the vagina <4.2 the environment is too acidic. Therefore, a simple and effective method of preventive control of the threat of interruption is the measurement of pH, which is carried out either with the help of a pH electrode or an indicator paper. At pH 4.2, if an optional pathogenic agent is found, treatment with broad-spectrum antibiotics is necessary.

Serum serum relaxin is a potential marker of premature delivery. When determining the concentration of relaxin in the blood serum at a gestation period of 30 weeks, its high levels indicate a threat of birth -455 ± 169 pg / ml 75 ± 7 mmol / l. Normally, the level of relaxin is 327 ± 139 pg / ml or 54 ± 4 mmol / l.

Of great practical importance is the precise diagnosis of the rupture of the membranes, as this determines the tactics of management and the forecast of the outcome of preterm labor. When testing samples of amniotic fluid with nitrazine paper, an alkaline reaction is detected, and on the dried glasses - a picture of the fern. In doubtful cases, the volume of the amniotic fluid is estimated from the data of the echography.

Amniocentesis is widely used in the management of premature births, allowing to identify intrauterine infection, found in 10-20% of cases, while assessing the degree of maturity of the fetus.

The evaporation test is used to determine the rupture of membranes, first described by Iannetta in 1994. It is based on evaporation of a material taken from the cervical canal on a slide. In the presence of water after evaporation, a white precipitate remains , in the absence of water, a brown precipitate . Results of the test in 89,5% were positive, in 10,5% - false-negative. There were no false positive results, true negative data were confirmed in 100% of cases.

Luminescent-colpocytological studies for the diagnosis of the passage of amniotic fluid but a vaginal smear. A large number of studies on the issue of diagnostics of water discharge testify to the absence of an accurate and easily executable diagnostic test, which reliably indicates the passage of water.

To detect the elements of amniotic fluid in the vaginal content, use swabs from the posterior vaginal vault, applied a thin layer on the slide with a wooden spatula or a thick glass pipette with a pear on the end. In addition, a thick drop of vaginal contents is applied to the same slide to reveal crystallization patterns. The smears are dried in the air for 3-4 minutes, after which they are examined under a luminescent device with a microscope at a 100-fold magnification. To produce fluorescence, acridine orange is used in a dilution of 1: 30,000. The study on a fluorescent microscope for the detection of amniotic fluid crystallization figures was carried out without a cyanophilic filter (FS-1) with the condenser of the microscope lowered. To detect crystallization figures, it is not appropriate to use fluorochromes, since these crystallization figures Clearly visible on a yellow background, but not contrasted by fluorochrome.

In order to clarify the diagnostic value of the proposed methods for detecting amniotic fluid elements, we simultaneously conducted a Zeyvang test, a sample for crystallization with eosin staining and amnioscopy.

In the study of a vaginal smear against the background of the flat epithelium of the mother, leukocytes, mucus and vaginal flora, non-nuclear fetal scales are found, which are an indisputable sign of the presence of amniotic fluid in the vaginal contents. In the smear, the fetal scaly cells are located both singly and in groups among the maternal flat epithelium. Fetal scales in 1% - 2 times less than the size of the flat epithelium of the mother, glow gently-green or slightly pink. The intensity of luminescence is less than that of other elements of the vaginal smear. Their shape is oval or polygonal. In the presence of a small number of squamous cells in the vaginal content, they are mainly located around the periphery of the smear.

The test for the crystallization of amniotic fluid, largely dependent on the amount of water and the duration of the anhydrous gap, seems less reliable than the detection of fetal scales. With a long anhydrous interval (more than 6-8 hours), the diagnostic value of detection of crystallization figures drops sharply. Unlike the crystallization of cervical mucus, the crystallization of water forms figures of snowflakes and stars, which, being adjacent to each other, give the impression of fine openwork embroidery. Crystallization of the cervical mucus forms figures of fern sheets.

Thus, the most reliable test of water diversion is the method of luminescent colpocytology with the finding of fetal scales, in which in 98% of the cases the correct results are obtained. The reliability of this method does not depend on the amount of waste water and the duration of the anhydrous gap, it is applicable for a gestation period of more than 33-34 weeks, because at earlier stages of pregnancy rejection of the epidermis of the fetus is very slight.

Fruit fibronectin as a marker of premature birth. In recent years, a biochemical marker of premature births is widely discussed - fetal fibronectin, defined in cervico-vaginal contents.

To determine the concentration of fruit fibronectin in the secretion of the cervical canal and vagina, as well as in the amniotic fluid and in the blood plasma of the mother, the authors used a sensitive method to determine monoclonal antibodies. Immunohistochemical studies were also conducted to determine the distribution of fetal fibronectin in the placenta and in the amnion and chorion. The most detailed studies belong to Lockwood et al. It was established that in the course of the physiological course of pregnancy and urgent labor, the fruit fibronectin is very rarely detected in the cervico-vaginal secret in a concentration of no more than 0.05 μg / ml between 21-27 weeks of pregnancy from the cervical canal (4%) and 3% in the vaginal secretion . A high level of fruit fibronectin is determined in amniotic fluid, as well as in cervico-vaginal secretions in pregnant women with rupture of membranes (93.8%).

Cervico-vaginal fruit fibronectin was also found in 50.4% of pregnant women with threatening premature births amid increased uterine contractile activity and a whole fetal bladder. Fibronectin is determined in pregnant women, delivered before the term with a sensitivity of 81.7% and specificity - 82.5 %. In the placenta and the fruit membrane, fruit fibronectin is also found in places of contact with the wall of the uterus.

Thus, the presence of fruit fibronectin in the II and III trimester identifies a subgroup of pregnant women with a high risk of premature birth. This phenomenon can be explained by the reflex separation of the chorion from the deciduatum layer with the release of intact or decaying components of the extracellular matrix chorion into the cervical canal and the vagina.

It should be noted that neither 17-beta-estradiol, nor progesterone in blood plasma, nor C-reactive protein are markers of premature birth. Fibronectin is found in blood plasma, extracellular matrix, amniotic fluid, placenta, malignant cells, is designated in the literature as "oncofetal domain" and is detected using monoclonal antibodies FDS-6. There are suggestions that fruit fibronectin can be released into the cervix and vagina in the presence of inflammation in the area of the fruit membrane, which is damaged in this case.

In the dynamics of pregnancy, it was found that, in uncomplicated course of up to 22 weeks, fruit fibronectin is found in the cervical canal in 24% and in the secretion of the vagina in 17% of pregnant women. After 37 weeks of pregnancy, respectively, in 32% and 17% of cases.

Between 21-37 weeks of pregnancy, fruit fibronectin in the secretion of the cervical canal is defined only in 4%, and in the secretion of the vagina - only in 3%. The average concentration of fruit fibronectin in the secretion of the cervical canal was 0.26 ± 0.22 μg / ml and in the vagina 0.27 ± 0.23 μg / ml. Mean concentrations of fibronectin in the blood plasma in the mother, respectively, in the I, II and III trimester of pregnancy - 1.3 ± 0.7 μg / ml; 2.0 ± 2.3 μg / ml and 3.5 μg / ml ± 2.2 μg / ml. At the same time, the level of fibronectin in the mother's blood plasma correlates with the duration of pregnancy.

With prenatal outflow of amniotic fluid, fibronectin is determined in 93.8% in cervico-vaginal secretions and the average concentration is 5.5 ± 11.4 μg / ml and 6.9 ± 11.1 μg / ml, respectively; at full term pregnancy, the level of fibronectin in amniotic fluid is 27.1 ± 17.3 μg / ml. It is important to note that when the fruit fibronectin is found in the cervico-vaginal secretion and the prenatal outflow of water, the average time interval between the rupture of the bladder and premature birth was 2.1 days, and in its absence, 21 days. With increased uterine activity and a whole fetal bladder, 51.3% of pregnancies occurred before the 37th week of pregnancy in the presence of fibronectin, without it in 83.1% (p <0.01).

In premature births, the average concentration of fruit fibronectin in the cervico-vaginal secretion was 2.2 ± 5.7 and 2.3 ± 5.7 μg / ml, respectively, compared with the full term pregnancy - 1.5 ± 3.4 μg / ml and 0 , 4 ± 1.0 μg / ml. The threshold of fruit fibronectin is 0.025-0.075 μg / ml.

Since premature birth in the lower segment of the uterus is the separation of the chorion from the decidual layer or there is inflammation in this region, fibronectin is released from the extracellular matrix of the chorion upon activation of neutrophils. Therefore, the appearance of fruit fibronectin in full term pregnancy is a marker of the onset of labor, for in both urgent and premature births there are general changes - the separation of the chorion from the decidual layer. At the same time, the presence of fruit fibronectin in the cervico-vaginal secret in the II and III trimester of pregnancy is a marker of premature birth. Immunohistochemically it is shown that fruit fibronectin is determined in the extracellular matrix of basal decidua and intervorsin space.

At the same time, several researchers have shown that fibronectin increases with preeclampsia and damage to the vascular endothelium.

Until now, the source of "fruit" fibronectin has not been fully clarified. So, Feinberg, Kliman (1992) found that fruit fibronectin is actively synthesized, secreted and located in the extracellular matrix of the trophoblast. This suggests that the trophoblast of the chorion in the extracellular matrix is an important source of fibronectin in the cervico-vaginal secretion. In preterm births, proteolytic degradation of fibronectin in chorion can occur. By the way, isoenzymes of fibronectin are found in both non-pregnant and pregnant women. The authors believe that the determination of fibronectin is an early and more specific marker of preterm labor in the presence of an inflammatory process in the chorion of the fetal membrane.

Started generic activity is diagnosed by the following signs:

• cramping pains in the abdomen, provided that contractions occur more often than after 10 minutes, and their duration is more than 30 seconds;
• the cervix is sharply truncated or smoothened, opening of the uterine pharynx 1 cm or more;
• the presenting part is located low or pressed to the entrance to the small pelvis;
• often there are sutures from the genital tract.

It should be assumed that even in the presence of regular fights and a flattened cervix of the uterus, tocolytic therapy in the absence of effect is appropriate for maintaining a pregnancy, since it allows for regulation of labor and prevention of birth trauma in the mother and fetus. It is also known that for the development of adaptive mechanisms in a premature fetus, 15 hours are necessary. It should also be noted that the use of beta-adrenomimetics, in addition to the regulation of labor, contributes to the production of surfactant in the pulmonary tissue of an immature fetus.

The presence of uterine contractions at least every 10-15 min, progressive shortening and smoothing of the cervix and lowering the fetal part of the fetus with premature pregnancy is the basis for the diagnosis of premature birth.

Premature birth is characterized by frequent obstetric complications:

• premature discharge of amniotic fluid;
• abnormal position of the fetus;
• pelvic presentation of the fetus;
• presentation and low attachment of the placenta;
• premature detachment of the normally located placenta;
• multiplicity;
• postpartum and early postpartum hemorrhage.

In childbirth there is a discordant birth activity, fast or rapid flow of the birth act, which aggravates the severity of the fetal condition. Thus, fast and rapid births are observed in every third woman in labor, one in four notes the weakness of labor. This is probably due to the fact that premature birth occurs with a pronounced impairment of the hormonal function of the placenta: increased placental lactogen content, a sharp drop in levels of chorionic gonadotropin, estrogens, pregnanediol.

In the complex of measures for the treatment and prevention of the threat of interruption of pregnancy, the most important place is assigned to the use of drugs that inhibit the contractile activity of the myometrium: magnesium sulfate, metacin, prostaglandin inhibitors, progesterone, beta-adrenomimetics, especially for subcutaneous administration with a special perfusor / apparatus, GABA-positive substances , phenibut) and their combination with phenazepam, oxytocin antagonists and some others. Given the frequent development of weakness in labor, we recommend the following variant of rhythmostimulation in women with preterm labor. Give birth to 30 g of castor oil, cleansing enema. After cleansing the intestine, assign quinine to 0,05 g in 15 minutes 4 times, then oxytocin intramuscularly 0.2 ml after 30 minutes 5 times. At the same time, cardiomonitor monitoring of the dynamics of development of labor and fetus is carried out. In the case of a sharp increase in labor activity, rhythmostimulation at any stage can be canceled or the intervals between the use of drugs can be increased.

In case of premature birth, the threatening and started fetal hypoxia is observed in every fifth woman giving birth, therefore, in labor, it is necessary to give special attention to the intranatal protection of the fetus, because approximately 90% of women are allowed through the natural birth canal. The incidence of caesarean section in preterm pregnancy is about 10% on average. The main indication for abdominal delivery in this case is premature detachment of the normally located placenta, as well as placenta previa, prolapse of the umbilical cord loops, and incompetence of the scar on the uterus. To operative delivery should be used primarily for life indications from the mother, less often - according to the testimony from the fetus.

Analyzing the features of the course of preterm labor, one can come to the conclusion that in order to maintain pregnancy, it is first of all necessary to use more effective medications, especially beta-adrenomimetics. Eden, Sokol, Sorokin et al. Suggesting a test with the stimulation of mammary glands of pregnant women to predict the possibility of premature delivery, concurrently indicate that this test reduces the need for outpatient monitoring of the character of uterine contractile activity in pregnant women at high risk for miscarriage. Laros, Kitterman, Heilbron et al. When studying pregnancy and childbirth outcomes in pregnant women who received beta-adrenomimetics and were delivered with very low birth weight (<1500 g), showed different effects on the newborn with low birth weight of isoxuprine, ritodrine, terbutaline and their combinations. It was established that the lowest birth traumatism was noted when ritodrin was used in comparison with terbutaline.

Many domestic and foreign obstetricians cite data on the high efficacy of these drugs.

Currently, there are basically three groups of drugs used to maintain pregnancy: a solution of magnesium sulfate, inhibitors of prostaglandin synthetase synthesis and beta-adrenergic drugs.

The following medicines are recommended. magnesium sulfate in the form of a 25% solution of 10 ml intramuscularly 2-3 times a day; Metacin with a pronounced threat was first given intravenously - 2 ml of a 0.1% solution in 500 ml of a 5% solution of glucose or an isotonic sodium chloride solution at a rate of 20 drops / min. In the future metacin is prescribed intramuscularly for 1 ml of a 0.1% solution 2-3 times a day. With a less severe threat, methacin is immediately given intramuscularly or in the form of tablets of 0.002 g 2-3 times a day.

Partusisten used intravenously drip in a dose of 0.5 mg in 500 ml of a 5% solution of glucose or isotonic sodium chloride solution. The rate of administration is 10-20 drops / min. Intravenous administration of the drug continues for 6-8 hours. When the persistent tocolytic effect is achieved, tablets of partusisten are given 5 mg 6 times a day. If necessary, intravenous tocolysis is repeated. Partusisten should not be used in women in early pregnancy. If the drug is not well tolerated, we do not abolish it, but inject it intravaginally or subcutaneously, and a more pronounced tocolytic effect is observed, probably due to a delay in the onset of desensitization of beta-adrenergic receptors. In order to prevent preterm labor, it has been proposed to use a special device for subcutaneous injection of tocolytics. A tendency to return to the use of magnesium sulfate in small doses is noted. It is shown that magnesium sulfate does not adversely affect the condition and development of the fetus and is an effective tool in the treatment of fetoplacental insufficiency.

Alupent must first be administered intravenously drip - 1 ml of a 0.05% solution in 500 ml of a 5% solution of glucose or an isotonic solution of sodium chloride at a rate of 10-20 drops / min. After achieving a stable tocolytic effect (after 6-8 hours), alupent is prescribed intramuscularly 1 ml 4 times a day.

N-holinolitik Spasmolitin is prescribed in the form of a powder of 0.1 g 3-4 times a day; Isadrin - in tablets of 0.0025 - 0.005 g 3-6 times a day.

Considering the wide application in the treatment of menacing and beginning premature births, it is necessary to dwell especially on the indications and contraindications to the use of beta-adrenomimetics.

Indications for the appointment of beta-adrenomimetics are:

• the necessity of inhibition of the contractile activity of the myometrium for the prevention and treatment of late miscarriages and premature births;
• regulation of labor in the pathological process of delivery - excessive labor, threatening rupture of the uterus;
• prevention of complications after surgery for Isthmiko-cervical insufficiency, myomakemias and similar surgical interventions during pregnancy;
• treatment of placental insufficiency.

Some authors suggest including in the indications treatment of late toxicosis of pregnant women.

A necessary condition for the use of beta-adrenomimetics is the absence of contraindications (hypertension of pregnant women, hypertension with arterial pressure of 20/12 kPa, or 150/90 mm Hg, heart defects - congenital and rheumatic, insulin-dependent diabetes mellitus, hyperthyroidism, detachment placenta or uterine bleeding, uterine opening more than 4 cm, high fever, birth defects and dead fetus, chorioamnionitis). The integrity of the fetal bladder is important, the opening of the cervix is no more than 4 cm in primiparas and no more than 3 cm in the miscarriages. The duration of the bout is not more than 30 s. The frequency of contractions is no more than 10 minutes. The duration of regular contractions is not more than 2-3 hours.

When using beta-adrenomimetics, it is necessary to take into account possible minor side effects, which are typical for the pharmacodynamics of these drugs. The appearance of tachycardia to 120-130 beats per minute with the introduction of the drug and further exceeding the heart rate require discontinuation of the drug; for the prevention of this side effect, it is advisable to use isoptin (phinoptin, verapamil) 1 tablet 1-2 times inward simultaneously with beta-adrenomimetic.

Increase in blood pressure in the mother should not exceed more than 20 mm Hg. Art. From the initial, and the diastolic pressure should not decrease by less than 20 mm Hg. Art. Therefore, the administration of the drug, especially intravenously, in pregnant women should necessarily be carried out on the side, approximately 15 °.

Sometimes the mother has hyperglycemia. In addition, with intravenous administration of the drug should be measured every 10-20 minutes, blood pressure, heart rate and the nature of breathing. If the blood pressure, in particular, diastolic, falls by 20 mm Hg. Art. And less, and systolic - will decrease by 30 mm or more, a corresponding medical correction is required.

The study of various pharmacological agents showed that the absolute and relative efficacy of treatment with these agents when using magnesium sulfate and methacine was noted in 54.4%. It should be noted that treatment is considered absolutely effective if the pregnancy could be extended to 36 weeks, and relatively - if the pregnancy was not kept up to 36 weeks, but prolonged for 10 days or more. Partusisten was effective in 95.5%, alupent - in 83.5% with intravenous and 72% - with intramuscular injection; alupent in combination with spasmolitin - in 78%, metacin in 78 %, isadrin - in 86% and in combination with spazmolitin - in 91.3%.

The modified Baumgarten and Tsan-Troshchinsky indices are convenient criteria for assessing the threat of abortion, which allows us to compare the results of preserving therapy more objectively with different treatment methods.

It is important to note that the combination of beta-adrenomimetic alupent with spasmolytic in recommended dosages in the treatment of threatening and started premature births increases the effectiveness of tocolytic therapy by 20% compared to the use of one beta-adrenomimetic and by 30% compared to the use of magnesium sulfate and methacine.

These substances cause improvement in the fetus due to changes in the hormonal function of the placenta and fetus, ie, the entire fetoplacental complex; after their application, the excretion of estrogens-estrone, estradiol and estriol-increases, which simultaneously causes an increase in the tocolytic effect. It follows that beta-adrenomimetics are the most effective tocolytic agents that can be used in the second half of pregnancy without the risk of their harmful effects on the fetus. Preparations of this group have a beneficial effect on uteroplacental blood circulation, promoting the formation of pulmonary surfactant and faster maturation of the fetal lungs, which is an effective method of preventing hyaline membranes if the child is born prematurely, and, in addition, these substances contribute to the increase in fetal mass. Their use in the first half of pregnancy is contraindicated because of the possibility of embryotoxic effects.

Promising should be considered the use of thyroxine for the growth of the fetus, placenta and newborn in the early neonatal period. Now in experiments on rats it is shown that when the mother has a lower thyroxine level, the fetal brain cells are damaged and therefore thyroid hormones are necessary for the normal development of the brain of mammals. At the same time, the placenta is impassable for these substances. In humans, these processes have not been studied enough, but it is known that thyroid hormones are already determined in a 7-week embryo, and in 9-10 weeks of pregnancy in the fetal brain and these hormones are well synthesized by the fetus. Thyroxine is determined in the fetus and in later terms of pregnancy. Detailed studies in the experiment showed that the administration of thyroxine (T ₄ ) to pregnant rats at a dose of 10 μg as an injection resulted in a 10-fold increase in the thyroxine concentration in the mother's blood and which remained elevated for 12 hours and returned to the basal level after 24 hours. At the same time the fetus no marked increase of T ₄. The introduction of T ₄ at doses of 10, 20 and 50 μg / day resulted in an increase in the weight of the fruit by 20% and the weight of the placenta by 14.6%. In addition, in the postnatal period there was a faster growth in the newborn. The half-life of T ₄ in the mother's blood plasma is about 6 hours, that is, less than in non-pregnant animals. Hypothyroidism leads to fetal hypotrophy with a violation of the maturation of the nervous system and, accordingly, to the delay in the development of the brain. It has been established that thyroid hormones do not pass through the placenta from mother to fetus. However, modern research points to some passage of these hormones in hypothyroidism to the fetus. Most likely, secondary changes in metabolism in a mother with hypothyroidism (even without the passage of hormones through the placenta to the fetus) can affect fetal development. In the neonatal period, the phenomena of hyperthyroidism have not been revealed even in those cases where large doses of thyroxin were given. The increase in fetal and placenta mass may indirectly result from an increase in the number of nutrients that under these conditions go to the fetus or through the increase in the formation of placenta hormones, the introduction of estrogens. This increase in fetal mass is not associated with fluid retention or various forms of fetal hyperplasia in the uterus. T ₄ stimulates the postnatal growth of newborns, as shown in the treatment with anti-estrogens. Therefore, in pregnant women with a high risk of premature birth, the prophylactic use of thyroxin in small doses and other substances that increase the weight of the fetus and the placenta can be a promising direction for further reducing perinatal morbidity and mortality.

Treatment of threatening births with progesterone

According to the literature, progesterone is considered the most common and tried-and-tested means of treating a threatening abortion. The effect of progesterone on labor, the activation of hypothalamic large cell neurons, and the expression of oxytocin mRNA in the uterus of rats at the end of pregnancy were studied in the experiment. It was found that intramuscular injection of progesterone on the 20th day of pregnancy delayed the onset of labor for 28.2 hours compared to control animals, which, however, occur despite the low content of oxytocin mRNA in the uterus and the decrease in activation of large cell neurons in the hypothalamus during labor . Modern studies by several clinicians show that the use of progesterone at doses of 250 mg per week to 500 and even 1000 mg per week can prevent premature birth.

In clinical practice, with a threatening interruption of pregnancy, progesterone was prescribed and prescribed intramuscularly daily for 0.01 g (1 ml of 1% solution) for 10-15 days per treatment course. In this case, its effect is not immediately apparent, but after 7-15 days and therefore it is difficult to establish what caused the result: the use of progesterone, long-term treatment in a hospital or other medications. Treatment of threatening interruption of pregnancy with progesterone at 0.01 g once a day intramuscularly within 10-15 days leads to a decrease in increased contractile activity of the uterus, but only in a few cases it allows to normalize it. It is ineffective for normalization of the increased contractile function of the uterus. The low effectiveness of progesterone treatment in this dosage of a pronounced threat of termination of pregnancy shows that treatment of this pathology should be differentiated taking into account the stage of pregnancy pathology.

With the expressed threat of termination of pregnancy, especially in combination with functional istrmico-cervical insufficiency, progesterone was treated at doses much higher than usual. The basis for this was the study, which showed that the daily requirement of the body of a pregnant woman in progesterone is not less than 0.05 g, and if you consider that the progesterone injected from the outside is rapidly excreted from the body, this dose should be further increased. The drug, successfully used in the treatment of threatening preterm birth, was oxyprogesterone capronate, containing 0.1 ml of substance in 1 ml. Doses of the hormone of the yellow body in various of its preparations, prescribed for the course of treatment, range from 2 to 12 grams and higher, with the dosage of the drug per injection of 0.125 g to 0.25 g every 5-7 days. Treatment continues until the 36-week gestation period with different intervals between repeated injections of the drug. The effectiveness of treatment ranges from 80 to 93%. The data of the literature show that until recently there have not been determined solid guidelines for a number of issues related to progesterone treatment in large doses. This concerns the selection of a contingent of pregnant women for treatment, the choice of optimal doses of drugs,

In the face of the habitual miscarriage of pregnancy with the phenomena of functional ischemic-cervical insufficiency in the early stages of pregnancy, along with the use of progesterone in the above dosages simultaneously, chorionic gonadotropin of man (pregnil) is prescribed simultaneously in the early stages of pregnancy at an initial dose of 10,000 units and then 5000 ED twice a week until 12 weeks of pregnancy and then until 16 weeks of pregnancy 5000 units once a week.

According to the results of the study of long-term results, there was no adverse effect of this treatment on organogenesis in the fetus. As is known, there were indications in the literature of the virilizing effect of gestagens on the female fetus, but there are preparations like allylestrenol (gestantin) that do not exert such influence. Modern data of the literature did not reveal the negative effect of progesterone on fetal development.

Treatment should begin with intramuscular injection of 1 ml of a 12.5% solution of hydroxyprogesterone caprolate (0.125 g) 2 times a week, and with external hysterography of increased uterine activity, this dose is doubled (up to 500 mg per week). It is important to emphasize one of the essential signs of the effectiveness of treatment of oxyprogestheron capronate - after 3-4 injections of the drug, there is a more or less pronounced narrowing of the internal pharynx, which was sometimes freely passable for the investigating finger. Along with this, there was an increase in the turgor of the cervical tissues. Treatment in hospital should be carried out, especially in combination with functional istrmico-cervical insufficiency for up to 3 weeks, and later - outpatiently with the administration of the drug at a dose of 250 mg (2 ml of 12.5% solution) once a week to 36 weeks pregnancy.

It was not possible to establish a relationship between the effectiveness of treatment and the period of pregnancy at the beginning of treatment.

Childbirth proceeded without features, the birth of children and their subsequent development with the use of oxyprogesterone capronate - without deviations from the norm.

Treatment of threatening births with methacin

Clinical and experimental studies have shown that when pregnancy is 25-34 weeks, it is advisable to use metacin 0,002 grams 2 to 4 times a day. With the help of hysterography it was shown that complete normalization of increased contractile activity of the uterus was noted at the initial stages of the threat of abortion and a positive effect, unlike hormonal drugs, is observed already in the first 15 min after taking methacin powder. It should be noted that in pregnant women with severe signs of the threat of interruption of pregnancy, methacin in the indicated doses (0,002 grams) should be used more often - up to 6 times a day or supplemented by injections subcutaneously or intramuscularly with 1 ml of 0.1% solution in the morning and evening. The use of methacin reduces the duration of treatment of patients with the threat of abortion compared with the results of hormone treatment.

Treatment of threatening and onset births with inhibitors of prostaglandin synthesis

Inhibitors of prostaglandin synthesis can directly regulate the frequency of uterine contractions and their amplitude. It is advisable to use one of the most effective inhibitors of prostaglandin synthesis - indomethacin, most shown with an increased concentration of endogenous prostaglandins in the body, which is clinically most often manifested by high amplitude and frequency of uterine contractions. Indomethacin completely inhibits uterine contractions within 1-8 hours.

The procedure for the use of indomethacin in menacing and early premature births is as follows: the therapeutic dose of indomethacin should not exceed 0.125 g, while first one tablet (dragee or, better, 0.025 g capsule) of indomethacin is administered orally and the second dose is administered in the form of two rectal suppositories of 0.05 d. In the absence of effect in 1-2 hours, once again, the appointment of 0.1 g indomethacin in the form of two suppositories of 0.05 g, and after 2-4 hours - 0.1 g rectally and 0.025 g inside. At the beginning of treatment, the dose of indomethacin should be 0.2-0.25 g / day and not exceed 0.3 g. Indomethacin after ingestion is quickly and almost completely absorbed from the intestine, 90% of it binds to plasma proteins.

Indomethacin is available in the form of a prolonged dosage form of 75 mg (indomethacin retard, methindole retard).

The drug is effective in treating the threat of termination of pregnancy, is well tolerated by pregnant women, side effects are minimal, does not adversely affect the subsequent course of labor, the condition of the fetus and the newborn. The long-term developmental outcomes of children are good.

Indomethacin is not recommended for use in gastrointestinal, renal and CNS diseases, as well as in infections. Dyspeptic symptoms of the drug can be reduced if indomethacin is used during meals or in the form of suppositories containing 10 mg of the drug. It was found that phenybut in a dose of 50 mg / kg and phenazepam in a dose of 2.5 mg / kg intravenously exerts a depressing effect on the contractile activity of the uterus in non-pregnant and pregnant rabbits. In addition, it was shown that phenibut (150 mg / kg) and phenazepam (3 mg / kg) did not adversely affect fetal development in rats. Clinical study of phenibut and phenazepam as a gravidoprotector in case of a threat of miscarriage is recommended. With the introduction of Phenibutum in a dose of 100 mg / kg, there is a cessation of contractions. Phenibut is recommended to take 0.75 mg / kg in the first 2 days after 8 hours, on the third day for 0.5 mg / kg after 8 hours for 3-5 days. After the course of treatment, take a break for 5-7 days. A more effective effect of phenibut is manifested when combined with pheneepam as a result of mutual enhancement of the esterolytic and fetoprotective effect. Thus, with a pronounced threat and psychomotor agitation, use of phenibut 0.5 mg / kg with fenaeepam is recommended 0.001 (1 mg) 3 times a day for 5-7 days, followed by a break of 3-5 days. In emergency tocolysis, phenibut is used intramuscularly for 1-2 ml of 0.1% ampoule solution.

Phenibut and phenazepam have a physiological GABA-ergic mechanism of inhibition of uterine contractile activity. GABA-positive substances: phenibut - a preparation of nootropic and antihypoxic action and phenazepam - a tranquilizer of GABA-ergic mechanism of action are effective protectors of pregnancy.

Other recently introduced drugs (magnesium sulfate, calcium antagonists, oxytocin antagonists, diazoxide) have not yet been the subject of randomized controlled trials.

Surgical treatment of ischemic-cervical insufficiency in pregnant women suffering from miscarriage of pregnancy

The main method of treatment of ischemic-cervical insufficiency of traumatic nature is surgical. V. Shirodkar in 1954 for the first time proposed to strengthen the internal sphincter of the cervix by a circular suture with a nylon thread. In subsequent years, a number of modifications of this operation were proposed.

The most favorable time for the manufacture of this operation is the gestation period from 12 to 20 weeks, since the effectiveness of the operational benefit in the specified time will be higher, for the disclosure of the cervix is not yet reaching a significant degree. In addition, the expediency of surgical treatment during these pregnancy periods is confirmed by data on the increase in the sensitivity of the uterus to irritations of the cervix with an increase in the gestational age. In the smooth course of pregnancy, it is recommended to remove the stitch at the 36-38th week, and in case of fights and spotting - resort to this immediately. However, Shirodkar's operation and its modifications eliminate isthmico-cervical insufficiency only temporarily. In subsequent pregnancies, re-operative treatment is usually required.

Preparing for surgery. In the evening, on the eve of the operation, the pregnant woman is put in a cleansing enema. At night, appoint luminal (0.1 g) and gosholpene (0.025 g) inside. The operation is performed under viadril or thiopental anesthesia in a pregnant position with an elevated pelvis.

Operation technique. Both lips are naked with spoon-shaped mirrors of the cervix and grasp with Myso forceps and pull down. At the border of the transition of the mucous membrane of the anterior vaginal fornix to the cervix by a scalpel, a median longitudinal incision of the vaginal forte 0.5 cm long is made. Next, the cervix is withdrawn upward and anteriorly. At the border of the transition of the mucous membrane of the posterior vaginal vault into the cervix, a second longitudinal parallel incision of the vaginal fornix 0.5 cm in length is made. A needle with a blunt end under the wall of the vagina is made with a 0.5-cm-long leylanne tape through the anterior and posterior incisions

The free ends of the tape, which are pulled out through the front section, are tightened along the 0.5 cm diameter catheter inserted into the internal suture. The ends of the tape are tied with two knots. To facilitate the removal of the seam, the ends of the tape have a length of 3 cm. Such a procedure of surgery does not give complications during the last - rupture of amniotic membranes, bleeding, eruption of the tape. Pregnant in the postoperative period, the first 3 days must comply with strict bed rest, while in a position with an uplifted pelvis; for 2 days injected intramuscularly antibiotic and at the same time for 10 days to conduct therapy (progesterone, metacin, beta-adrenomimetics, magnesium sulfate), aimed at reducing the excitability of the uterus. In the postoperative period, pregnant women are allowed to get out of bed on the 4th day, an extract from the hospital - on the 10th day.

In all pregnant women, such a modification of the operation in the postoperative period does not give fever, bedsores, tissue tightening, as well as ischemia and edema of the cervix. Removing the tape occurs without any difficulties.

Thus, the treatment of miscarriages of pregnancy on the basis of ischemic-cervical insufficiency by modified Shirodkar surgery contributes to the birth of live children in 85% of women. An unfavorable outcome of the operation is more common in pregnant women with prolapse of the fetal bladder. In such cases, Scheeier, Lam, Bartolucci, Katz developed a new technique for reducing the failure rate in the prolapse of the fetal bladder. The maximal filling of the bladder was carried out, and 250 ml of isotonic sodium chloride solution was injected under fluorotaric anesthesia with Foley's catheter. After this, Shirodkar's operation was performed the subsequent appointment in the postoperative period of magnesium sulfate and ritodrine. Success was noted in all pregnant women.

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