Audio lectures on gynecology. Possible signs of pregnancy

1. Anomalies of contractile activity of the uterus. Narrow pelvis. Birth trauma of mother and fetus. Modern approaches to the diagnosis and treatment of birth injuries of mother and fetus - 2016
2. COMPLICATIONS OF THE POSTPARTUM PERIOD AND THEIR PREVENTION - 2016
3. GABARAEVA VICTORIA VLADISLAVOVNA. DIFFERENTIATED approach to choosing a protocol for CONTROLLED OVARIAL STIMULATION IN OOCYTE DONORS AND PATIENTS WITH ONCOLOGICAL DISEASES. Dissertation for the degree of Candidate of Medical Sciences. St. Petersburg - 2016 - 2016
4. KOSOVA ANNA SERGEEVNA. PRE-ECLAMPSIA: MODERN APPROACHES TO PREDICTION AND PREVENTION. Dissertation for the degree of candidate of medical sciences. Eagle 2015 - 2015
5. KUZNETSOV VADIM PETROVICH. TACTICS OF MANAGEMENT OF PREGNANT WOMEN WITH PRE-ECLAMPSIA COMPLICATED BY DISORDERS METABOLIC FUNCTION OF THE LIVER AND ENDOGENOUS INTOXICATION SYNDROME. Moscow 2015 - 2015
6. Mikhailova Kristina Pavlovna. INFLUENCE OF THE STATE OF THE AUTONOMIC NERVOUS SYSTEM ON THE COURSE OF PREGNANCY, CHILDREN AND THE CONDITION OF THE NEWBORN. Dissertation for the degree of Candidate of Medical Sciences. Moscow –2015 - 2015
7. KAZAKOVTSEVA SOFIA BORISOVNA. Evaluation of the effectiveness of conservative, puncture and surgical methods of treating pelvic tubo-ovarian formations. Dissertation for the degree of Candidate of Medical Sciences. MOSCOW –2015 - 2015
8. KUSHLINSKY Dmitry Nikolaevich. Clinical significance of angiogenesis factors and matrix metalloproteinases in patients with ovarian tumors. Dissertation for the degree of Candidate of Medical Sciences. Moscow –2015 - 2015
9. MAGOMEDOVA Lyudmila Attsikadievna. Early stage diagnosis of postoperative abdominal complications in gynecology. Dissertation for the degree of Candidate of Medical Sciences. Moscow-2015 - 2015
10. GERKULOV DMITRY ANDREEVICH. OPTIMIZATION OF PREPARATION FOR IVF PROTOCOL IN PATIENTS AFTER SURGICAL TREATMENT OF OVARIAN ENDOMETRIOMA. Dissertation for the degree of Candidate of Medical Sciences. St. Petersburg 2015 - 2015

Obstetrics and gynecology (lectures)

Tyumen 2000

General concepts in obstetrics

Obstetrics originated with the birth of man. The founder of domestic obstetrics is N.M. Maksimovich-Ambodik, who wrote the work “The Art of Appearance or the Science of Womanhood.”

Obstetrics- the science of physiological and pathological processes that occur in a woman’s body in connection with conception, pregnancy, childbirth and the postpartum period.

Gynecology is the science of diseases of the female reproductive system outside of pregnancy, childbirth and the postpartum period.

The founder of the national scientific school of gynecologists is Prof. Snegirev (Moscow).

Features of obstetric science:

Own terminology.

Providing assistance not only to the sick, but also to the healthy.

The massive population in need of obstetric care.

Responsibility for both the woman and the child.

This is a surgical specialty.

Types of maternity hospitals(by risk of maternal mortality):

I degree of risk. Contingent: healthy pregnant women with a physiological pregnancy, the maximum that can be in the anamnesis is one medical abortion. Risk level 1 maternity hospitals include:

A rural central district hospital with an obstetric department; The obstetrician-gynecologist of the Central District Hospital heads the district service, goes to the district, examines pregnant women there, provides stage-by-stage services for these women, and provides advisory assistance.

A local hospital with an obstetrician-gynecologist;

Collective farm family house;

A small urban clan house or a small urban association;

Paramedic and midwife stations with obstetric beds.

2. II degree of risk. Contingent: women with a complicated pregnancy (but pregnancy is not contraindicated for them). Risk level II maternity hospitals include:

Large urban family house;

Obstetrics department of a multidisciplinary hospital;

Maternity ward of the urban central district hospital.

It is mandatory that these institutions have consultants of various specialties and extensive anesthesiology services.

III degree of risk. Contingent: pregnant women for whom pregnancy is contraindicated. Maternity hospitals of the third degree of risk include:

Obstetric departments of multidisciplinary hospitals (all-Russian centers, etc.);

Large houses or departments on the basis of which departments are developed;

Specialized birth houses.

New forms of obstetric and gynecological institutions:

Day hospital.

Specialized consultations (for example, “family and marriage”).

Sanatoriums for pregnant women.

Structure of the house:

First, the woman enters the filter, where a midwife works and determines the indications for hospitalization. From the filter - to the I or II obstetric department (department of pathology of pregnant women). Each has an examination room, shower, and toilet. All this together is called a receiving-pass block. Then the woman enters the delivery unit (one in each department), postpartum and discharge wards (one in each department). The second obstetric department also has wards for pregnant women. Both departments have children's wards. In addition, there is an operating and anesthetic unit in the family home.

Principles of the sanitary-epidemic regime in the clan houses:

are determined by Order 691 “On the prevention of nosocomial infections in obstetric hospitals.” The main thing in prevention is the sanitary and epidemiological regime.

Indications for placing a woman in the II obstetric department:

Women with genital and extragenital acute and chronic inflammatory processes of specific and nonspecific etiology.

Increased temperature of unknown etiology.

Intrauterine fetal death.

Road births, home births, etc.

Women with skin diseases.

Women with malignant neoplasms.

Women not observed in antenatal clinic.

Women carrying a fetus with a congenital malformation (CDD).

Late termination of pregnancy.

Long water-free period (more than 12 hours)

The principle of flow - a woman should not move from a “dirtier” department (II obstetric department) to a “cleaner” one (I obstetric department), only the opposite is possible.

The principle of cyclicity: firstly, this concerns the work of the labor block (it is divided into 2 halves - one is processed, and the other is working), secondly, the work of the postpartum wards (women are placed in one ward only if the day of birth is close).

The principle of individuality - everything that comes into contact with a woman during and after childbirth must be sterile and individual for each woman.

In addition, the order defines the organization of epidemiological surveillance by the sanitary-epidemiological service:

constant monitoring of morbidity and mortality of postpartum women and newborns;

fence tank crops from the nose, throat, from various objects (scheduled once every 3 months and according to epidemiological indications (outbreak - simultaneous occurrence of 3 or more diseases)). If the results are poor, the maternity home can be closed due to an epidemic. indications.

control over preventive cleaning of the house (2 times a year, 1 time with cosmetic repairs), major repairs (1 time every 5 years).

Indicators of work at home:

Maternal mortality (MM):

MS = the number of dead pregnant women, women in childbirth and puerperas in

during the first 42 days after childbirth, regardless of the term

and localization of pregnancy

number of live births x 100,000 live births.

We have MS = 70-90 (this is a big number).

Perinatal mortality (PS).

PS = number of deaths in the perinatal period (28 weeks

pregnancy - 168 hours after birth) per 1000 births.

Our PS is 17-19% O.

Types of perinatal mortality:

antenatal (from 28 weeks of pregnancy until birth);

intrapartum (during childbirth);

postnatal (during the first 7 days).

Structure of maternal mortality:

Abortions (mostly criminal).

• Bleeding.

  Purulent-septic forms.

Structure of perinatal mortality:

asphyxia n/r;

birth injury;

developmental defects n/r, etc.

Exists scale for assessing postnatal risk factors for perinatal mortality(score based on 5 groups of characteristics):

Socio-biological characteristics (age of parents, their alcohol consumption, etc.).

Complicated obstetric history (stillbirth, abortion, etc.).

Extragenital diseases.

Complications of this pregnancy

Pathology of the fetus and placental system.

Up to 5 points - low risk;

5 - 10 points - average degree;

10 points and above - high degree(such women should be observed in maternity homes of the third degree of risk).

Early turnout- attendance at the antenatal clinic before 12 weeks of pregnancy.

The importance of early turnout:

Up to 12 weeks, you can accurately determine the gestational age, since the size of the uterus at this time corresponds to the gestational age; Subsequently, the size of the uterus depends on the size of the fetus and the number of fetuses.

If pregnancy is contraindicated for a woman, a medical abortion can be performed before 12 weeks of pregnancy.

Education of a pregnant woman in a “mother’s school” (in a antenatal clinic, conducted by an obstetrician-gynecologist, pediatrician, lawyer) from the earliest stages of pregnancy.

Until 12 weeks, there are no changes in the body’s hemostasis system characteristic of physiological pregnancy. Therefore, before this stage of pregnancy, it is possible to determine the initial indicators of hemostasis.

Order No. 430 - “Organization of the work of the antenatal clinic.”

Legislation on labor protection for pregnant women:

Leaves for pregnant women:

Prenatal - 70 days;

Postpartum - 70 days (if there were complications, then it

extended to 86 days, if 2 or more children were born - up to

Parental leave:

Partially paid leave up to 1.5 years;

Additional unpaid leave for up to 3 years.

Exemption (immediately after the diagnosis of pregnancy) from heavy physical, harmful, night, overtime, and travel work.

Lectures on obstetrics for the fourth year of the Faculty of Medicine

Here are all the lectures on obstetrics and gynecology IV for the medical course

abbreviations and abbreviations, most of which are explained when using them for the first time. For the entire course of lectures there was only 1 diagram - the Michaelis rhombus, due to the difficulty of conveying graphics, it is not given here. Some lectures were not presented or were presented in a truncated version, because they were not for recording, but only for listening. In places where there is a “?” sign in brackets, there are any inconsistencies, or I disagree with the lecturer in some way (this is just my opinion). Performed by Niyazov Ravil Rashidovich, Kazan, 2005

VII semester.

Lecture No. 2 (09/13/2004)

The first lecture was given by Professor Lev Aleksandrovich; it dealt with organizational issues, including the student scientific circle.

Obstetrics (ancient Greek) – standing nearby.

Obstetrics is a science that studies the changes that occur in a woman's body during pregnancy, childbirth and the postpartum period.

Vaginal epithelial cells, as they mature, accumulate glycogen for the vaginal microflora, for example, Doderlein vaginal bacillus (from the family of lactic acid bacteria) creates a pH of 3.5-4.5 in the vagina. Since 1949, in Russia, all women in the early postpartum period are examined

the cervix for a rupture, and if it is, then the gap is sutured. Chronic inflammation uterus can transform into cervical cancer.

Lecture No. 3 (09.20.2004)

Lecturer - Candidate of Medical Sciences, Associate Professor Zhuravleva Vera Ivanovna Menstrual-ovarian cycle (utero-ovarian cycle).

The reproductive system of a woman is a self-regulating system, it has 4 functions:

1. Menstrual;

2. Childbearing;

3. Secretory;

4. Sexy.

The reproductive function is a functional system similar to the cardiovascular system, etc., however, it provides reproduction, while all the rest are aimed at maintaining the homeostasis necessary for the existence of the individual.

functional activity reproductive system The hormonal function of the reproductive system increases by the age of 14, and subsides by the age of 45, and by the age of 55. The hormonal function of the reproductive system is built on a hierarchical principle: there are 5 links, each of which regulates the underlying one: cortex-hypothalamus-pituitary gland (higher links of regulation), ovaries, uterus, target organs: mammary glands, hair follicles, vagina, bones, blood vessels, brain neurons, etc.

Menstrual function is a constant, cyclically repeating preparation of a woman’s body for pregnancy. Menstruation is the result of the cyclical activity of the entire reproductive system. The menstrual cycle is a physiological process in the body of a woman (non-pregnant), starting from the first to the last menstruation and ending with the beginning next menstruation, during which in the ovaries

hypothalamus, stimulating the release of gonadotropin releasing factor. The hypothalamus secretes gonadotropin releasing factor (GTRF) in the circhoral mode. Normally, 1 act of secretion occurs every 60-90 minutes, in response to this the pituitary gland takes 2-5 minutes

releases gonadotropic hormones. GTRF is a liberin and a statin for follicle-stimulating and luteinizing hormones (FSH and LH), which ensure folliculogenesis and ovulation. By changing the frequency and amplitude of the releasing factor, it is possible to change the secretion of FSH and LH. So, if the pulsation frequency of GTRF is more often than 1 hour later, the LH concentration drops by 50%, and the FSH concentration by 65%. If every 15 minutes, then FSH and LH in the blood are not determined. Prolactin-releasing factor - thyrotropin-releasing hormone, also affects the thyroid gland through thyroid-stimulating hormone. A statin for prolactin is a prolactin inhibitory factor (PIF - dopamine). When the concentration of prolactin increases, menstrual function decreases up to amenorrhea; when its level decreases, the concentration of glucocorticoids decreases.

FSH to LH ratio every day menstrual cycle regulated by gonadal factors. An increase in the concentration of estrogen leads to a decrease in the concentration of FSH; and an increase in the concentration of progesterone leads to a decrease in the level of LH.

There are 3 types of gonadotropic hormone secretion rhythm:

1. In response to GTRF stimulation,

2. Cyclic type of secretion. FSH before ovulation, LH in the second half of the cycle.

3. Basic type of secretion.

The value of FSH is the growth and development of the follicle. Primordial follicle, second order oocyte, dominant follicle with a diameter of 20 mm - preovulatory follicle. 90% of follicles die before the age of 14 - 10% mature.

Mature granulosa synthesizes estrogens. Immature granulosa produces androgens. Estrogens (estriol, estrol, estradiol) are the strongest mitogens of the endometrium—the proliferation phase. Estriol is a hormone of a pregnant woman, estrone is a nongonadal secretion (adipocytes, etc.), estradiol affects the myometrium 14 days. Ovulation - peak estradiol concentration and LH production. Luteal granulosis under the influence of LH produces gestagens.

The second phase should not be shorter than 11 days; if shorter, then infertility occurs. Progesterone is the secretion phase. Uteroglobulins for blastocyst nutrition.

Ovulation. The pupil symptom is an expansion of the diameter of the uterine canal, there are many clear mucus, the more estrogen, the more viscous the mucus - a symptom of distension cervical mucus. Symptom of crystallization (arborization). A picture of a fern under a microscope - a lot of estrogens (?). study of the vaginal epithelium - colpocytology of the anterolateral vaginal vault - the more mature the cells, the more estrogens. Karyopyknotic index (max. 70-80%). Progesterone increases temperature by 0.6-0.8 ° C; Diuresis decreases, so edema and adynamia occur.

Lecture No. 4 (09/27/2004)

Lecturer – Candidate of Medical Sciences, Associate Professor Zhuravleva Vera Ivanovna Fertilization and pregnancy

After coitus, sperm is sucked into the cervical canal. There, capacitation (maturation) of sperm occurs within 24 hours.

The blastocyst feeds on endometrial glycogen, and the egg on pyruvate. fallopian tubes. Peristalsis of the fallopian tubes is ensured by estrogens. Blockade of peristalsis - progesterone (after 72 hours). On days 5-6, the blastocyst is in the uterus. Nidation occurs on days 8-9. Stimulation of protein production by blastocysts. Implantation is carried out when the endometrium is highly sensitive.

Contact at other times does not cause a decidual reaction in the endometrium. Typical place implantation - the posterior wall of the uterus. The trophoblast lyses the endometrium, and the blastocyst very quickly sinks into the thickness of the endometrium. By day 22, 2 layers of trophoblast are formed: cytotrophoblast and syncytiotrophoblast. Primary chorionic villi. Chorion (membrane, membrane). Secondary chorionic villi are ingrowths of mesenchyme. Tertiary chorionic villi - there are vessels formed at the 12th week, chorionic villi, which are located at

decidua capsularis degenerate – chorion laevae, the rest of the chorion with villi – villous chorion (chorion froddosum). By the tenth month, chorion froddosum and decidua basalis occupy 1/3 of the surface of the uterus. Highlight 3 structural elements placenta:

Chorionic membrane, basement membrane, intervillous space.

The cotyledon is the basic functional unit of the placenta. Villus + cotyledon complex

– uterine area where 1 spiral artery opens. Cotyledons unite into placentons. Hemochorionic type - close contact of the mother’s blood and chorion.

The morphogenesis of the placenta depends on the development of the uteroplacental circulation, and not on the fetal circulation. Leading importance is given to spiral arteries – terminal branches uterine artery. From the 12th week of gestation the period of placentation begins

– critical period of embryogenesis, because vascularization of the villi occurs. Anchor villi, which are found on the decidua basalis.

By the 140th day of gestation, the placenta is formed. 10-12 large, 40-50 small and 140-150 rudimentary cotyledons: size and thickness 1.5-2.0 cm, further increase occurs due to hypertrophy of the spiral arteries at the border of the myometrium and endometrium. They are equipped muscle layer, diameter 20-50 mm, SMCs are lost in the intervillous space, diameter 200 µm, in total there are 150-200 spiral arteries.

The outflow of blood occurs through 72-170 veins. Blood diffusion is carried out due to the pressure difference, because no SMC – no sensitivity to adrenergic regulation, no ability to vasoconstriction. The umbilical cord is formed from mesenchyme - a cord into which the allantois grows, bearing the umbilical vessels.

umbilical cord.

Before birth, the placenta is 15-18 cm in diameter, 2-3 cm thick, weighing 500-600 g. The placental barrier consists of 5 layers:

1. Syncytiotrophoblast (thin layer);

2. ... basement membrane;

3. Loose connective tissue with reticular fibers;

4. Capillary basement membrane;

5. Endothelium of the capillary of the fetus (embryo).

At 33-35 weeks of pregnancy, the permeability of the placenta increases,... syncytiotrophoblast disappears.

The function of the placenta is to nourish the fetus. 6 mg/min glucose per 1 kg of fetal weight. Sahara, molecular mass which does not exceed the weight of glucose, pass through diffusion. Complex molecules are broken down by enzymes. Protein synthesis in the placenta is intense in the third month of gestation. Amino acids are transported by active transport. The placenta synthesizes many proteins. Lipids penetrate in the form of triglycerides and higher fatty acids. The permeability to vitamins varies; the placenta is impermeable to vitamin A. At the beginning of gestation, the growth of the placenta exceeds the growth of the fetus; in the middle of gestation, the weight of the fetus increases by 800 times, and the weight of the placenta by 15-20 times. endocrine function placenta: producer – syncytiotrophoblast. Protective function: incomplete, depends on the properties of the damaging factor, gestational age, and the state of the mother’s body.

Pathology of the placenta. Extrachorionic placentation, in which the chorionic plateau is inferior in size to the basal plateau. Colon-marginal placenta, val-marginal placenta. Placental infarction (white plaques), with necrosis of more than 10%, fetal hypoxia occurs, up to antenatal death. A consequence of thrombosis of the uteroplacental vessels. Late necrosis, atherosis, calcification. Placental infection - in 98% of cases the genesis is unclear. Tumors of the placenta. Nontrophoblastic: placental metastases, hemangiomas, chorioangiomas (1% of all births). Clinical significance have hemangiomas with a diameter of 5 cm, which cause polyhydramnios and premature birth.

Lecture No. 5 (4.10.2004)

Lecturer – Head of the Department of Obstetrics and Gynecology No. 1 Doctor of Medical Sciences, Professor Khasanov Albir Almazovich

Female pelvis

I. Classification of pelvic planes fan-shaped from the symphysis. Entry plane. True conjugate (obstetric, conjugata vera) - normally 11 cm (now 11.5-12 cm) - promontory - the closest point of the pubic symphysis. The cape is parallel to the oblique size - Krassovsky size (8.8 cm). Wide part of II-III sacral vertebra

– the middle of the inner surface of the symphysis. Narrow part – horizontal part 9.5-10.5 cm; straight size – 11 cm.

The pelvis can expand – Deventer (French). Lying down increases the true conjugate. Squatting reveals the horizontal size of the narrow one. partsThe capacity of the sacral cavity increases by 30%. McRoberts pose: the hips are pressed to the stomach and the pelvis “dresses” the head.

Exit plane.

II. Parallel plane system:

1. The border plane is approximately equal to the plane of the entrance to the pelvis.

2. Through the lower edge of the symphysis pubis, parallel to the first plane (main plane).

3. Through the spines of the ischial bones (spinal plane).

4. Output plane.

All planes are parallel to each other.

III. In the UK and USA.

a transformation of the spiral arteries occurs: the diameter of their distal section increases by an order of magnitude. On the 18th day of gestation, chorion elements by type cancerous tumor invade the wall of spiral arteries (cytotrophoblast invasion, muscle is replaced by fibrinoid), so the spiral artery is constantly gaping. If transformation does not occur, in some cases the total peripheral vascular resistance (TPVR) increases, resulting in an increase in blood pressure.

Lecture No. 6 (10/11/2004)

Lecturer – Candidate of Medical Sciences, Associate Professor Nurullina Dilyara Vladimirovna Immunoconflict pregnancy. Hemolytic disease of newborns Immunoconflict pregnancy. Hemolytic disease of newborns - cause

perinatal morbidity and mortality in 8-11% of cases. There are 4 main types of human red blood cells:

The Rh factor was discovered in 1940 (Landsteiner and Wiener). Types of rhesus antigens. Rh0, rh’, rh’’. If the last 2 variants of antigens are located on the red blood cell, the blood is considered Rh negative. There are no natural antibodies to the Rh system in the blood; they can only appear during immunization. 2 main reasons for their appearance:

1. Transfusion of Rh incompatible blood.

2. Pregnancy with a Rh positive fetus (mother is Rh negative).

Risk groups for pregnant women with Rh-negative blood.

1. Rh negative pregnant woman with Rh-positive husband (father of the child), but without a complicated obstetric history (CAA), without the presence of antibodies (AT) - examination is carried out once a month until 32 weeks, after 32 weeks, 2 times a month.

2. Rh negative pregnant women with Rh-positive husband (father of the child), without the presence of AT, but with OAA.

3. Pregnant woman with the presence of specific anti-Rhesus antibodies. Observation 2 times a day

month in the first half of gestation and 3 times a month in the second half of gestation. OAA – intrauterine fetal death at 26-28 weeks with maceration; birth of children with jaundice; history of stillbirth - these women are observed at the Rhesus Center (RCH). Hidden ATs are examined here; if they are detected, observation is carried out across 3 risk groups; if hidden ATs are not detected, an examination is carried out 2 times a month + restorative therapy.

Hyposensitizing therapy:

1. Vitamin therapy (C, B 6, B12, E, P (rutin));

2. 2% solution of novocaine intramuscularly;

3. methionine tablets;

4. hormonal therapy after 12 weeks (glucocorticoids: prednisolone, dexamethasone);

5. infusion therapy in the second half of gestation (reopolyglucin, povidone - hemodez);

6. plasmapheresis for OAA;

7. transplantation of a skin flap and lymphocytes of the husband (father of the child) is a distracting factor, suppression is in progress cellular immunity humoral, Abs are fixed on the transplant antigen, block them and reduce the host's reactivity.

Pathogenesis of hemolytic disease of newborns

1. Maternal isoimmunization.

2. Penetration of the formed antibodies through the placenta into the fetus.

3. The effect of AT on the fetus.

blood transfusion. Most often, immunization occurs in the third stage of labor.

2. AT breakthrough occurs during childbirth, and neonatopathy occurs - a postpartum icteric form of hemolytic disease of the newborn (HDN).

3. Antibodies do not pass through the placenta, a healthy baby is born Rh-positive fetus (child).

Actually GBN. The severity of TTH is not the same and depends on many factors: the amount of AT, when and how long the exposure occurred, reactivity, compensatory capabilities of the fetus.

Rh antibodies can be fixed on erythrocytes, so hemolysis occurs, on rhesus antibodies in tissues, resulting in the formation of tissue damage.

There are 5 main forms of HDN:

1. Fetal death with maceration

2. Edema

3. Congenital jaundice

4. Anemic

5. Postpartum jaundice

1. The result of fetopathy. AT penetration into period 5-7 months. Massive AT passage. Tissues are mostly affected. Formation of Ag-AT immune complexes → dystrophic processes followed by necrotic changes. Organs that are rich in enzymes (liver, pancreas) are most susceptible; autolysis occurs in the first 2 days after fetal death.

2. Always fetopathy, but the number of antibodies is much less than in the first form.

Intravascular and tissue changes. Intravascular hemolysis, increased concentration of indirect bilirubin; lack of conjugation in the liver → indirect bilirubin enters the mother’s body and amniotic fluid. Tissue reactions – compensatory reactions → decompensation: permeability increases vascular wall, the protein-synthesizing function of the liver decreases, severe fetal hypoproteinemia → massive edematous syndrome. Severe anemia. Violation of fibrinogen synthesis → thrombohemorrhagic syndrome. Fetal death antenatally or intranatally. The fruit always dies.

3. Occurs as a fetopathy, but antibodies act on a fairly mature fetus(8-9 months of gestation). No decompensation, fetus is born with signs of jaundice or

4. One of the lightest forms. Low doses of AT for a short time(during childbirth). Due to the usefulness of liver enzymes, there is no jaundice, only hemolysis.

barrier), so kernicterus may occur.

Conflict on the AB0 system (II and III blood groups in the fetus and I blood group in the mother). AT breakthroughs only during childbirth → anemic or postpartum icteric form. Features of the course of pregnancy with Rh isosensitization.

There is an increased risk of miscarriage. Most often when intrauterine death fetus ... Frequent complication: anemia. This is due to the fact that the fetus's need for iron increases. TTH worsens in the presence of late toxicosis or gestosis; chronic fetoplacental insufficiency (CPI); diabetes mellitus(SD). Diagnosis of HDN before birth:

1. Obstetric history. The outcomes of previous pregnancies, blood transfusion analysis, blood tests for Rh-AT. According to the types of Rh-Ab titer, the following are distinguished:

· Stable titer

· Uniform decrease in titer,

· Uniform increase in titer,

· A sharp increase in titer,

· A sharp decrease in titer,

· Alternating titer increases and decreases.

The first three options can be for mild and normal forms of HDN. The last three forms are always severe forms of HDN.

2. Studies of bilirubin in the blood serum of a pregnant woman, determination of activity alkaline phosphatase in the mother, its thermostable fraction is produced by the placenta. During pathological processes, the concentration of alkaline phosphatase increases sharply.

3. Ultrasound examination:

· Thickening of the placenta:(40-42 mm is normal) thickening by 1-1.5 cm - severe forms of HDN.

· Increase in the area of ​​the placenta to 4/5 (normally 1/3 of the uterus).

· In the edematous form: double contour of the head, enlarged fetal abdomen, hepatomegaly, fetal ascites.

4. Changes in FCG and CTG indicate intrauterine fetal suffering.

Diagnosis of HDN after birth:

1. Examination data: pallor, icterus, lethargy, enlarged liver and spleen, general swelling and ascites.

2. Determination of the blood group and Rh factor.

3. Determination of bilirubin in umbilical blood.

4. Determination of hemoglobin in umbilical and capillary blood. Fine 170-180 g/l and 200-250 g/l, respectively.

5. Direct Coombs test (AT titers in the fetal body that came from the mother during childbirth).

6. Repeating the study of quantity and its hourly growth.

Treatment of tension-type headache

1. Replacement blood transfusion (RBT). 180-200 ml of blood per 1 kg of child.

2. Infusion therapy (plasma, albumin, hemodez, rheopolyglucin).

3. Intragastric fluid administration.

4. Phototherapy.

5. Phenobarbital is an inducer of microsomal oxidation in the liver.

6. At severe course– prednisolone.

7. Vitamin therapy (C, B 1, B6, glutamic acid).

8. Oxygen inhalation.

Until 5-7 days of life, feeding with donor milk (hydrochloric acid destroys RhAT) in case of AB0 conflict - feeding with donor milk or pasteurized milk.

Prevention of Rh isosensitization

1. Compliance with blood transfusion rules.

2. Prevention of abortion in women with Rh negative blood.

3. use of anti-Rhesus IgD within 72 hours after childbirth (abortion) with Rh-negative blood.

Lecture No. 7 (04/18/2004)

Lecturer – Candidate of Medical Sciences, Associate Professor Nurullina Dilyara Vladimirovna Normal physiological childbirth

The physiological essence of childbirth is the expulsion of the fetus and elements ovum beyond the borders

premature, more than 42 weeks - late. Abroad, normal term births begin at 37 weeks.

A woman's uterus has spontaneous contractility. This activity has been observed since the onset menstrual function up to menopause. At different stages of gestation, contractile activity is different. At the beginning of gestation, spontaneous contractility is sharply reduced. From the 30th week of gestation, more intense uterine contractions appear, the so-called. false contractions - Branston-Gicks contractions, with a frequency of 1 contraction per hour. The woman does not feel them. One of the main roles in preparing a woman for childbirth is played by the central nervous system. From the first weeks, a gestational dominant is formed - a focus of excitation, around which a focus of inhibition (progesterone block) is formed. At the end of gestation, a generic dominant is formed in the central nervous system.

A woman’s biological readiness for childbirth is the formation of a generic dominant + changes that occur in a woman’s body.

Childbirth is a physiological act for which a woman is evolutionarily prepared. Formation of perinatal matrices. The first matrix is ​​formed at the beginning of the first stage of labor, the second - with intensification of labor and the opening of the uterine pharynx by 4-5 cm, the third - in the second stage of labor when the fetus passes through the birth canal,

Chorionic gonadotropin (HCG) begins to be produced in the chorionic villi from the early stages of trophoblast formation. Produced in high concentrations

aging of the placenta. Placental lactogen is produced in high concentrations up to 36 weeks, a synergist with HCG.

The importance of estrogens

1. Activation of the synthesis of contractile proteins (actomyosin).

2. Increased synthesis of catecholamines.

3. Activation of the cholinergic system.

4. Inhibition of oxytocinase and monooxytocinase.

Estrogen concentrations increase in the last 2 weeks of gestation. With hypoestrogenism, post-term pregnancy is observed. Estrogens increase the synthesis of prostaglandins.

The meaning of prostaglandins. Produced in the decidua and amnion.

1. Depolarization of myometrial cell membranes.

2. Release of bound calcium.

Obstetrics and gynecology: lecture notes

“Ilyin and gynecology. Lecture notes": Eksmo; Moscow; 2007

annotation

The lecture notes presented to your attention are intended to prepare students of medical universities for passing tests and exams. The book includes full course lectures on obstetrics and gynecology, written by accessible language and will be an indispensable assistant for those who want to quickly prepare for the exam and pass it successfully.

Obstetrics and gynecology. Lecture notes

Lecture No. 1. Anatomy and physiology of female genital organs

1. Anatomy of the female genital organs

A woman’s genital organs are usually divided into external and internal. The external genitalia are the pubis, the labia majora and minora, the clitoris, the vestibule of the vagina, and the hymen. The internal ones include the vagina, uterus, fallopian tubes and ovaries.

External genitalia

Pubis It is an area rich in subcutaneous fat, covered with hair in adulthood, triangular in shape, with the base facing upward.

Labia majora formed by two folds of skin containing fatty tissue, sebaceous and sweat glands. They are connected to each other by the anterior and posterior commissures, and are separated by the genital slit. In the thickness of the lower third of the labia majora there are large glands of the vestibule - Bartholin's glands, the alkaline secretion of which moisturizes the entrance to the vagina and dilutes the seminal fluid. The excretory ducts of these glands open in the groove between the labia minora and the hymen.

Labia minora They are a mucous membrane in the form of two folds. They are located medially from the labia majora. Normally, the inner surfaces of the labia majora and minora touch, the genital slit is closed.

Clitoris is an organ similar to the male penis, located in the anterior corner of the genital fissure, consists of two cavernous bodies, richly supplied with blood vessels and nerve plexuses.

Vaginal vestibule- the space bounded by the labia minora. It opens the external opening of the urethra, the excretory ducts of the large glands of the vestibule, and the entrance to the vagina.

Hymen is a thin connective tissue septum separating the external and internal genital organs. There is a hole in it, depending on its shape and location of the hymen, it can be semi-lunar, ring-shaped, toothed, or lobed. The hymen is torn during the first sexual intercourse, its remnants are called hymenal papillae, and after additional ruptures during childbirth - myrtiform papillae.

Internal genital organs

Vagina It is a muscular-fibrous tube 8–10 cm long. It is located in the pelvic cavity, adjacent to the urethra and bladder in front, and to the rectum at the back. The walls of the vagina are in contact with each other and in the upper section, around the vaginal part of the cervix they form dome-shaped depressions - the anterior, posterior, right and left lateral vaults of the vagina. The deepest of them is the posterior arch. Vaginal contents accumulate in it. The walls of the vagina consist of a mucous membrane, a muscle layer and surrounding tissue. The vaginal mucosa is covered with stratified squamous epithelium, has a pink color and numerous transverse folds, which ensure its extensibility during childbirth. There are no glands in the vaginal mucosa, but it is always in a moist state due to the sweating of fluid from the blood vessels, lymphatic vessels and the attachment of secretory, uterine glands, rejected epithelial cells, microorganisms and leukocytes. At healthy woman these secretions are mucous in nature, milky in color, have a characteristic odor and are acidic. In accordance with the nature of the microflora, it is customary to distinguish between four degrees of purity of vaginal contents. At the first degree of purity, in the vaginal contents, which are acidic in nature, only vaginal rods and individual epithelial cells. With the second degree of purity, there are fewer vaginal bacilli, individual cocci and single leukocytes appear, the reaction remains acidic. Both degrees of purity are considered normal. The third degree of purity is characterized by an alkaline reaction, the predominance of leukocytes, cocci and other types of bacteria. At the fourth degree of purity, there are no vaginal bacilli; a variety of microbial bacteria are found in the contents pathogenic flora(cocci, coli, Trichomonas, etc.), a large number of leukocytes.

Uterus- a hollow, pear-shaped smooth muscle organ, flattened in the anteroposterior direction. The uterus is divided into the body, isthmus and cervix. The upper convex part of the body is called the fundus of the uterus. The uterine cavity has the shape of a triangle, in the upper corners of which the openings of the fallopian tubes open. Below, the uterine cavity, narrowing, passes into the isthmus and ends with the internal os.

Cervix- This is the narrow cylindrical lower part of the uterus. It distinguishes vaginal part, protruding into the vagina below the vaults, and the supravaginal upper part, located above the vaults. Inside the cervix there is a narrow cervical (cervical) canal 1–1.5 cm long, the upper section of which ends with the internal os, and the lower section ends with the external os. The cervical canal contains a mucus plug that prevents the penetration of microorganisms from the vagina into the uterus. Uterus length adult woman averages 7–9 cm, wall thickness 1–2 cm. The weight of the non-pregnant uterus is 50–100 g. The walls of the uterus consist of three layers. The inner layer is the mucous membrane (endometrium) with many glands, covered with ciliated epithelium. There are two layers in the mucous membrane: the layer adjacent to the muscular layer (basal), and the superficial layer - functional, which undergoes cyclic changes. Most The wall of the uterus is the middle layer - muscular (myometrium). The muscular layer is formed by smooth muscle fibers that make up the outer and inner longitudinal and middle circular layers. The outer serous (perimetric) layer is the peritoneum covering the uterus. The uterus is located in the pelvic cavity between the bladder and rectum at the same distance from the walls of the pelvis. The body of the uterus is inclined anteriorly, towards the symphysis (uterine anteversion), has an obtuse angle relative to the cervix (uterine anteversion), and is open anteriorly. The cervix is ​​facing backwards, the external os is adjacent to posterior arch vagina.

The fallopian tubes start from the corners of the uterus, go to the sides to the side walls of the pelvis. They are 10–12 cm long and 0.5 cm thick.

The walls of the tubes consist of three layers: the inner - mucous, covered with single-layer ciliated epithelium, the cilia of which flicker towards the uterus, the middle - muscular and the outer - serous. In the tube, an interstitial part is distinguished, passing through the thickness of the uterine wall, the isthmic part is the most narrowed middle part and ampullar - an expanded part of the pipe, ending with a funnel. The edges of the funnel look like fringes - fimbriae.

Ovaries are paired almond-shaped glands, measuring 3.5–4, 1–1.5 cm, weighing 6–8 g. They are located on both sides of the uterus, behind the broad ligaments, attached to their posterior leaves. The ovary is covered with a layer of epithelium, under which the tunica albuginea is located, deeper is the cortex, in which there are numerous primary follicles at different stages of development, corpus luteum. Inside the ovary is the medulla, which consists of connective tissue with numerous vessels and nerves. During puberty, the ovaries undergo a monthly rhythmic process of maturation and release into abdominal cavity mature eggs capable of fertilization. This process is aimed at reproductive function. The endocrine function of the ovaries is manifested in the production of sex hormones, under the influence of which during puberty the development of secondary sexual characteristics and genital organs occurs. These hormones are involved in cyclical processes that prepare a woman's body for pregnancy.

Ligament apparatus genital organs and pelvic tissue

The suspensory apparatus of the uterus consists of ligaments, which include paired round, wide, infundibulopelvic and proper ovarian ligaments. Round ligaments originate from the corners of the uterus, anterior to the fallopian tubes, pass through the inguinal canal, attach in the area of ​​the pubic symphysis, pulling the fundus of the uterus forward (anteversion). The broad ligaments extend in the form of double sheets of peritoneum from the ribs of the uterus to the lateral walls of the pelvis. IN upper divisions The fallopian tubes pass through these ligaments, and the ovaries are attached to the posterior layers. The infundibulopelvic ligaments, being a continuation of the broad ligaments, run from the funnel of the tube to the wall of the pelvis. Own ligaments The ovaries run from the fundus of the uterus posteriorly and below the origin of the fallopian tubes they are attached to the ovaries. The anchoring apparatus includes the uterosacral, main, uterovesical and vesico-pubic ligaments. The uterosacral ligaments extend from the posterior surface of the uterus in the area of ​​transition of the body to the cervix, cover the rectum on both sides and are attached to the anterior surface of the sacrum. These ligaments pull the cervix posteriorly. The main ligaments go from the lower part of the uterus to the lateral walls of the pelvis, the uterovesical ligaments - from the lower part of the uterus anteriorly, to the bladder and further to the symphysis, like the vesico-pubic. The space from the lateral sections of the uterus to the walls of the pelvis is occupied by periuterine parametric tissue (parametrium), in which vessels and nerves pass.

Mammary gland

They are modified sweat glands. During puberty, the mammary gland has a grape-shaped structure and consists of many vesicles - alveoli, forming large lobules. The number of slices is 15-20, each of which has its own excretory duct, self-opening on the surface of the nipple. Every milk duct Before emerging to the surface of the nipple, it forms an expansion in the form of a sac - the milk sinus. The interlobular spaces are filled with layers of fibrous connective and adipose tissue. The lobules of the mammary glands contain cells that produce a secret - milk. On the surface of the gland there is a nipple, covered with delicate, wrinkled skin and having a conical or cylindrical shape. The function of the mammary glands is to produce milk.

2. Physiology of the female reproductive system

The female reproductive system has four specific functions: menstrual, reproductive, reproductive and secretory.

Menstrual cycle.

menstrual cycle are rhythmically repeating complex changes in the reproductive system and throughout a woman’s body that prepare her for pregnancy. The duration of one menstrual cycle is counted from the first day of the last menstruation to the first day of the next menstruation. On average it is 28 days, less often 21–22 or 30–35 days. The normal duration of menstruation is 3–5 days, blood loss is 50–150 ml. Menstrual blood It has dark color and doesn't roll up. Changes during the menstrual cycle are most pronounced in the organs of the reproductive system, especially in the ovaries (ovarian cycle) and the lining of the uterus (uterine cycle). An important role in the regulation of the menstrual cycle belongs to the hypothalamic-pituitary system. Under the influence of releasing factors of the hypothalamus, the anterior lobe of the pituitary gland produces gonadotropic hormones that stimulate the function of the gonads: follicle-stimulating hormone (FSH), luteinizing hormone (LH) and luteotropic hormone (LTG). FSH promotes the maturation of follicles in the ovaries and the production of follicular (estrogenic) hormone. LH stimulates the development of the corpus luteum, and LTG stimulates the production of the corpus luteum hormone (progesterone) and the secretion of the mammary glands. In the first half of the menstrual cycle, the production of FSH predominates, in the second half - LH and LTG. Under the influence of these hormones, cyclic changes occur in the ovaries.

Ovarian cycle.

This cycle consists of 3 phases:

1) follicle development - follicular phase;

2) rupture of a mature follicle - the phase of ovulation;

3) development of the corpus luteum - luteal (progesterone) phase.

In the follicular phase of the ovarian cycle, the follicle grows and matures, which corresponds to the first half of the menstrual cycle. Everyone is changing components follicle: enlargement, maturation and division of the egg, rounding and proliferation of follicular epithelial cells, which turns into the granular shell of the follicle, differentiation of the connective tissue membrane into outer and inner. Follicular fluid accumulates in the thickness of the granular membrane, which pushes the follicular epithelial cells on one side towards the egg, and on the other towards the wall of the follicle. The follicular epithelium that surrounds the egg is called radiant crown. As the follicle matures, it produces estrogenic hormones that have a complex effect on the genitals and the entire woman’s body. During puberty, they cause the growth and development of the genital organs, the appearance of secondary sexual characteristics, and during puberty - an increase in the tone and excitability of the uterus, proliferation of cells of the uterine mucosa. Promote the development and function of the mammary glands, awaken the sexual feeling.

ovulation is the process of rupture of a mature follicle and the release from its cavity of a mature egg, covered on the outside with a shiny shell and surrounded by cells of the corona radiata. The egg enters the abdominal cavity and then into the fallopian tube, in the ampullary section of which fertilization occurs. If fertilization does not occur, then after 12–24 hours the egg begins to deteriorate. Ovulation occurs in the middle of the menstrual cycle. Therefore, this time is the most favorable for conception.

The developmental phase of the corpus luteum (luteal) occupies the second half of the menstrual cycle. In place of the ruptured follicle after ovulation, a corpus luteum is formed, producing progesterone. Under its influence, secretory transformations of the endometrium occur, necessary for implantation and development of the fertilized egg. Progesterone reduces the excitability and contractility of the uterus, thereby helping to maintain pregnancy, stimulates the development of mammary gland parenchyma and prepares them for milk secretion. In the absence of fertilization, at the end of the luteal phase, the corpus luteum reverses, the production of progesterone stops, and the maturation of a new follicle begins in the ovary. If fertilization has occurred and pregnancy has occurred, the corpus luteum continues to grow and function during the first months of pregnancy and is called corpus luteum of pregnancy .

Uterine cycle.

This cycle comes down to changes in the uterine mucosa and has the same duration as the ovarian cycle. It distinguishes two phases - proliferation and secretion, followed by rejection of the functional layer of the endometrium. First phase uterine cycle begins after the endometrial rejection (desquamation) ends during menstruation. In the proliferation stage, epithelization of the wound surface of the uterine mucosa occurs due to the epithelium of the glands of the basal layer. The functional layer of the uterine mucosa sharply thickens, the endometrial glands acquire a tortuous shape, and their lumen expands. The endometrial proliferation phase coincides with follicular phase ovarian cycle. The secretion phase occupies the second half of the menstrual cycle, coinciding with the development phase of the corpus luteum. Under the influence of the corpus luteum hormone progesterone, the functional layer of the uterine mucosa is even more loosened, thickened and clearly divided into two zones: spongy (spongy), bordering on the basal layer, and more superficial, compact. Glycogen, phosphorus, calcium and other substances are deposited in the mucous membrane, favorable conditions for the development of the embryo if fertilization has occurred. In the absence of pregnancy, at the end of the menstrual cycle, the corpus luteum in the ovary dies, the level of sex hormones decreases sharply, and the functional layer of the endometrium, which has reached the secretion phase, is rejected and menstruation occurs.

3. Anatomy of the female pelvis

Structure of the bony pelvis women is very important in obstetrics, since the pelvis serves as the birth canal through which the emerging fetus moves. The pelvis consists of four bones: two pelvic bones, the sacrum and the coccyx.

Pelvic (nameless) bone consists of three bones fused together: the ilium, pubis and ischium. The bones of the pelvis are connected through a paired, almost motionless sacroiliac joint, a sedentary semi-joint - the symphysis and a mobile sacrococcygeal joint. The joints of the pelvis are strengthened by strong ligaments and have cartilaginous layers. The ilium consists of a body and a wing, extended upward and ending in a crest. In front, the crest has two projections - the anterosuperior and anterioinferior spines; in the back there are posterosuperior and posteroinferior spines. The ischium consists of a body and two branches. The superior branch runs from the body downwards and ends at the ischial tuberosity. The lower branch is directed anteriorly and upward. On its posterior surface there is a protrusion - the ischial spine. The pubic bone has a body, upper and lower branches. On the upper edge of the superior ramus of the pubic bone there is a sharp ridge, which ends in front with the pubic tubercle.

Sacrum consists of five fused vertebrae. On the anterior surface of the base of the sacrum there is a protrusion - the sacral promontory (promontorium). The apex of the sacrum is movably connected to coccyx, consisting of four to five undeveloped fused vertebrae. There are two sections of the pelvis: the large and small pelvis, between them there is a boundary, or nameless line. The large pelvis is accessible for external examination and measurement, unlike the small pelvis. The size of the small pelvis is judged by the size of the large pelvis. In the small pelvis there are an entrance, a cavity and an exit. The pelvic cavity has a narrow and a wide part. Accordingly, four planes of the small pelvis are conventionally distinguished. The plane of entrance to the small pelvis is the boundary between the large and small pelvis. At the entrance to the pelvis, the largest dimension is the transverse one. In the pelvic cavity, the plane of the wide part of the pelvic cavity, in which the straight and transverse dimensions are equal, is conventionally distinguished, and the plane of the narrow part of the pelvic cavity, where the straight dimensions are slightly larger than the transverse ones. In the plane of the outlet of the small pelvis and the plane of the narrow part of the small pelvis, the direct dimension prevails over the transverse one. In obstetrics, the following dimensions of the small pelvis are important: true conjugate, diagonal conjugate and direct size of the pelvic outlet. The true, or obstetric, conjugate is the direct size of the entrance to the pelvis. This is the distance from the promontory of the sacrum to the most prominent point on the inner surface of the symphysis pubis. Normally it is 11 cm. The diagonal conjugate is determined by vaginal examination. This is the distance between the sacral promontory and the lower edge of the symphysis. Normally, it is 12.5–13 cm. The direct size of the pelvic outlet goes from the top of the coccyx to the lower edge of the symphysis and is equal to 9.5 cm. During childbirth, as the fetus passes through the pelvis, this size increases by 1.5–2 cm due to the posterior deviation of the tip of the coccyx. The soft tissues of the pelvis cover bony pelvis from the outer and inner surfaces and are represented by ligaments that strengthen the joints of the pelvis, as well as muscles. The muscles located at the pelvic outlet are important in obstetrics. They cover the bony canal of the small pelvis from below and form the pelvic floor.

Obstetric (anterior) perineum call that part pelvic floor, which is located between the anus and the posterior commissure of the labia. The part of the pelvic floor between the anus and the tailbone is called rear crotch. The pelvic floor muscles together with the fascia form three layers. These three layers can stretch and form a wide tube - a continuation of the bony birth canal, which plays a big role in the expulsion of the fetus during childbirth. The most powerful is the upper (inner) layer of the pelvic floor muscles, which consists of the paired levator muscle. anus, and is called the pelvic diaphragm. The middle layer of muscles is represented by the urogenital diaphragm, the lower (external) by several superficial muscles converging in the tendon center of the perineum: bulbospongiosus, ischiocavernosus, superficial transverse perineal muscle and external rectal sphincter. The pelvic floor performs the most important functions, being a support for the internal and other organs of the abdominal cavity. Incompetence of the pelvic floor muscles leads to prolapse and prolapse of the genital organs, Bladder, rectum.

Lecture No. 2. Physiological pregnancy

1. Fertilization and development of the fertilized egg

Fertilization is the process of union of male and female reproductive cells. It occurs in the ampullary part of the fallopian tube. From this moment pregnancy begins.

Migration of a fertilized egg

The fertilized, crushed egg moves along the tube towards the uterus and reaches its cavity on the 6th–8th day. The advancement of the egg is facilitated by peristaltic contractions of the fallopian tubes, as well as the flickering of the cilia of the epithelium.

Implantation of a fertilized egg

By the time the fertilized egg enters the uterine cavity, the mucous membrane of the uterus is sharply thickened and loose. Glycogen accumulates in the endometrium due to the influence of the corpus luteum hormone. The lining of the uterus during pregnancy is called decidual, or falling-off shell. A fertilized egg, the outer layer of which is a trophoblast, thanks to the presence of proteolytic enzymes, melts the decidua, sinks into its thickness and is grafted.

Placenta

At the end of the 1st month of pregnancy, the fertilized egg is surrounded on all sides by chorionic villi, which initially have no vessels. Gradually, vascularization of the chorion occurs: the vessels of the embryo grow into its villi. At the 2–3rd month of pregnancy, atrophy of the chorionic villi begins at one pole of the fertilized egg, facing the uterine cavity. On the opposite section of the chorion, immersed in the mucous membrane, the villi grow luxuriantly and at the beginning of the 4th month turn into the placenta. In addition to the chorionic villi, which make up the bulk of the placenta, the decidua of the uterus (the maternal part of the placenta) takes part in its formation. The placenta releases a complex complex of hormones into the maternal body and biologically active substances. Progesterone is of particular importance, promoting the development and maintenance of pregnancy. For the development of pregnancy great importance They also have estrogenic hormones: estradiol, estriol and estrone. By the end of pregnancy, the placenta has a diameter of 15–18 cm, a thickness of 2–3 cm and a weight of 500–600 g. There are two surfaces in the placenta: internal (fetal) and external (maternal). On the fruit surface, covered with a watery shell, there are vessels radiating from the umbilical cord. The maternal surface consists of 15–20 lobules. The placenta performs the metabolic function between mother and fetus, the barrier function, and is also a powerful gland internal secretion. Maternal blood pours into the intervillous space and washes the chorionic villi. Maternal and fetal blood does not mix.

Umbilical cord

It is a cord-like formation in which two arteries and one vein pass. Venous blood flows from the fetus to the placenta through the arteries, flows through the vein to the fetus arterial blood. The umbilical cord attachment may be central, eccentric, marginal, or tunicale. The normal length of the umbilical cord is on average 50 cm. The placenta is formed from the placenta, umbilical cord, fetal membranes (amnion and chorion) and is expelled from the uterus after the birth of the fetus.

Amniotic fluid

They are formed as a result of secretion by the amnion epithelium, extravasation from the mother’s blood and the activity of the fetal kidneys. By the end of pregnancy, approximately 1–1.5 liters of water accumulate. The waters contain hormones, protein in the amount of 2–4 g/l, enzymes, macro- and microelements, carbohydrates and other substances.

2. Changes in a woman's body during pregnancy

In connection with the development of the fetus, a major restructuring of the activities of the most important systems and organs occurs in the pregnant woman’s body. Occur during pregnancy physiological changes, preparing the body of a woman for childbirth and feeding, as well as contributing to proper development fetus A woman's body weight increases, especially in the second half of pregnancy. The weekly increase during this period is 300–350 g. On average, body weight by the end of pregnancy increases by 12 kg, of which 75% is due to the weight of the fetus, placenta, uterus, amniotic fluid and an increase in the amount of circulating blood.

The cardiovascular system

In the uterus, the number of vessels increases significantly, a new (utero-placental) blood circulation appears. This leads to increased work of the heart, as a result of which the wall of the heart muscle thickens a little, the strength of heart contractions increases. The pulse rate increases by 10–12 beats per minute. The volume of circulating blood begins to increase in the first trimester. In the second trimester of pregnancy, the increase in BCC is maximum. At the end III trimester The bcc is 1.4–1.5 times higher than the original. The increase in the volume of circulating plasma and erythrocytes has unequal proportions. Thus, the plasma volume on average increases by 1.5 times by the 40th week of pregnancy, and the volume of circulating red blood cells - only 1.2 times. As a result, the phenomenon of physiological hemodilution, or breeding anemia, occurs. Due to hemodynamic changes in cardiovascular system are provided optimally comfortable conditions for the life of mother and fetus. There are also some changes in the blood coagulation system that need to be monitored. There is an increase in the concentration of plasma coagulation factors, i.e., the preparation of the woman's body for blood loss during childbirth.

Respiratory system

During pregnancy, they perform intensive work, since the metabolic processes between the fetus and the mother require a large amount of oxygen. By the end of pregnancy, the minute volume of breathing of women in labor increases by an average of 1.5 times due to an increase in the volume of inhalation and respiratory rate. Physiological hyperventilation during childbirth is accompanied by hypocapnia, which is the most important condition for normal transplacental diffusion of carbon dioxide from the fetus to the mother.

Digestive organs

Changes are expressed in nausea, morning vomiting, increased salivation, reduction and even perversion of taste sensations. After 3 months of pregnancy, all these phenomena usually disappear. Bowel function is characterized by a tendency to constipation as the bowel moves upward and is pushed towards the pregnant uterus. The liver performs an increased function, which is due to the neutralization of toxic substances of interstitial metabolism and metabolic products of the fetus entering the mother's body.

Urinary organs

Are experiencing maximum load for the removal of metabolic products from mother and fetus. The ureters during pregnancy are in a state of hypotension and hypokinesia, which leads to a slowdown in the outflow of urine, expansion of the ureters and renal pelvis. Renal blood flow increases during pregnancy. As a result, there is a slight increase in the size of the kidneys, expansion of the cups and an increase in glomerular filtration by 1.5 times.

Nervous system

In the early stages of pregnancy, there is a decrease in the excitability of the cerebral cortex, an increase reflex activity subcortical centers and spinal cord. This explains the increased irritability, fatigue, drowsiness, rapid mood swings, decreased attention. At the end of pregnancy, shortly before childbirth, the excitability of the cerebral cortex decreases again. As a result, the underlying parts of the nervous system are disinhibited, and this is one of the factors in the onset of labor.

Endocrine system

With the onset of pregnancy, changes appear in all endocrine glands. The new endocrine gland begins to function - corpus luteum. It exists in the ovary during the first 3–4 months of pregnancy. The corpus luteum of pregnancy secretes the hormone progesterone, which creates the necessary conditions for implantation of a fertilized egg, reduces its excitability and thereby favors the development of the embryo. The appearance in a woman’s body of a new powerful endocrine gland - placenta leads to the release of a complex of hormones into the maternal bloodstream: estrogens, progesterone, chorionic gonadotropin, placental lactogen and many others. Great changes also occur in the pituitary gland, thyroid gland and adrenal glands. The anterior lobe of the pituitary gland secretes hormones that stimulate the function of the corpus luteum, and in the postpartum period, the function of the mammary glands. At the end of pregnancy, especially during childbirth, the production of pituitrin by the posterior lobe of the pituitary gland increases significantly.

Leather

Pregnant women often develop skin pigmentation, which is associated with increased function adrenal glands. The deposition of melanin pigment is especially pronounced on the face, along the white line of the abdomen, on the nipples and areola. In the second half of pregnancy, bluish-purple arcuate stripes appear on the anterior abdominal wall, hips, and mammary glands, called pregnancy scars. After childbirth, these scars do not disappear, but gradually turn pale and remain in the form of white shiny (pearl) stripes.

Genitals

During pregnancy, you undergo great changes. The external genitalia, vagina, cervix loosen, become juicy, easily stretchable, acquire a bluish color. The isthmus of the uterus softens and stretches especially strongly, which at the 4th month of pregnancy, together with a part of the lower part of the uterus, turns into the lower uterine segment. The mass of the uterus by the end of pregnancy increases from 50–100 g to 1000–2000 g. The volume of the uterine cavity increases, exceeding its volume outside pregnancy by 520–550 times. The length of the non-pregnant uterus is 7-9 cm, and by the end of pregnancy it reaches 37-38 cm. The increase in the mass of the uterus is mainly associated with hypertrophy and hyperplasia of its muscle fibers. The joints of the small pelvis soften, which creates favorable conditions for the birth of the fetus. The ligamentous apparatus undergoes significant thickening and elongation.

Lecture No. 3. Diagnosis of pregnancy

Diagnosis of early pregnancy is made on the basis of the identification of presumptive (doubtful) and probable signs of pregnancy.

1. Presumable (doubtful) signs

Connected with general changes in the body of a pregnant woman. There is a change in appetite and taste, smell, nausea, sometimes vomiting in the morning, weakness, malaise, irritability, tearfulness. The same signs include the appearance of skin pigmentation on the face, along the white line of the abdomen, in the nipples and external genitalia.

2. Possible signs of pregnancy

These are objective changes that are found on the part of the female genital organs, mammary glands, or are detected during pregnancy tests. Probable signs can appear both during pregnancy and independently. These signs include the cessation of menstrual function in women of childbearing age, an increase in the mammary glands and the release of colostrum from them when pressed, a cyanotic color of the mucous membrane of the vagina and cervix, an increase in the uterus. Early pregnancy is characterized by certain signs.

1. Enlargement of the uterus becomes noticeable from the 5th–6th week. At the end of the 2nd month, the size of the uterus reaches the size of a goose egg. By the end of the 3rd month, the uterine fundus is determined at the level of the upper edge of the symphysis.

2. Horwitz-Hegar sign – the appearance of softening in the isthmus area.

3. Snegirev’s sign – a change in the consistency of the uterus during palpation (after examination the uterus becomes denser).

4. Piskacek’s sign is a bulging of one of the corners of the uterus associated with the development of the fertilized egg.

5. Genter’s sign – a ridge-like protrusion is felt on the anterior surface of the uterus in the midline.

Diagnostics late dates pregnancy is based on recording reliable signs, such as: fetal movement, listening to fetal heart sounds, palpating parts of the fetus, X-ray and ultrasound examination data.

Biological and immunological methods for diagnosing pregnancy

Aschheim–Tzondek reaction

With the onset of pregnancy, a large amount of chorionic gonadotropin appears in a woman’s urine, the excretion of which reaches a maximum at 8–11 weeks of pregnancy. This hormone can be detected in urine from the 2nd day after implantation. A morning sample of urine is taken for testing. If the reaction is alkaline or neutral, the urine is slightly acidified with acetic acid and filtered. Urine is administered to several (5) immature mice weighing 6–8 g: the first in an amount of 0.2 ml, the second - 0.25 ml, the third and fourth - 0.3 ml, the fifth - 0.4 ml. On the 1st day, urine is administered 2 times - in the morning and in the evening, on the 2nd day - 3 times (morning, afternoon and evening) and on the 3rd day - 1 time. Thus, a total of 1.2–2.2 ml of urine is injected subcutaneously. After 96–100 hours from the moment of the first introduction of urine, the mice are killed, the genitals are opened and examined. Depending on the data obtained, three reactions are distinguished. First reaction: several maturing follicles are detected in the ovaries, the uterine horns are cyanotic. This reaction is doubtful. Second reaction: in the ovaries multiple hemorrhages are found in the follicles - blood spots; the reaction is specific to pregnancy. Third reaction: atretic corpus luteum (luteinization of follicles), uterine horns without any changes are found in the ovaries; the reaction is specific to pregnancy. The reliability of the reaction reaches 98%.

Spermatozoic (spermatouric) Galli–Mainini reaction

It is carried out on male lake frogs. It is based on the fact that frogs never have sperm in the contents of the cloaca outside their natural breeding season. Before injecting the urine of a pregnant woman, it is necessary to obtain and examine the contents of the frog's cloaca to exclude the possibility of spontaneous spermatorrhea. 30–60–90 minutes after the introduction of 3–5 ml of urine from a pregnant woman into the lymphatic sac located under the skin of the back, a large number of sperm appear in the cloacal fluid of the frog. They are obtained using a glass capillary pipette and examined under a microscope. The reaction accuracy ranges from 85 to 100%.

Friedman's reaction

To diagnose pregnancy, a sexually mature female rabbit aged 3–5 months weighing from 900 to 1500 g is used. Due to the fact that ovulation in female rabbits does not occur spontaneously, but 10 hours after mating, the female and male must be kept in separate cages. 4 ml of urine taken from the woman being examined is injected into the ear vein of a mature rabbit 6 times over 2 days. 48–72 hours after the last injection, under ether anesthesia, observing the rules of asepsis, the abdominal cavity is opened and the genitals are examined. At positive reaction changes similar to those found in mice are observed in the ovaries and uterus. Surgical wound abdominal wall rabbits are sewn up in the usual way. After 6-8 weeks for a positive reaction and after 4 weeks for a negative reaction, the female rabbit can be taken for re-examination. Reaction accuracy is 98–99%.