Abortion spontaneous. Ассистент Антонова Г. А. State medical

Abortion spontaneous. Ассистент Антонова Г. А. State medical University Semey town Assistant Antonova G.A.

. Situation task

It should be told , that risk of pregnancy interruption depending on the quantity of previous abortions

Patient of 29 years old, periodical on one week before menstruation has edema of face and legs, changing of mood, backache, abdominal pains, tendeness of breasts. Date of anamnesis.Menstruations from 12 years, during 3-4 days, not regular, with delays till 2 months, painful. She has hirsutism from this time. She had 2 pregnancies: 1- missed abortion at 7 weeks , the 2-nd - sponteneous abortion at 9 -10 weeks. During 3 years- infertility.

Height 175 sm. Mass- 58 kg. Female body buld. Breast are developed, There is growing of hair around areole of nipples, low part of abdomen , femur ‘s. Degree of hirsutism is 14 balls (on scale of Ferriman- Golvey) What are the date of objective examination: There are:

Dates are: External sexual organs are developed on the female type. There is growing of hair at the pubic region. Urethra, near urethra glands without changes In speculum :cervix is “ clean”, discharges are mucous P.V.: uterus is smaller in size, mobile, painless. Ovaries with both sides are increased, with soft surface , hard, painless, mobile. What are the date of special gynecologic examination?

? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? What is Your preliminary diagnosis?

Syndrome of polycystic ovaries. Habitual abortions. C.О.G.А. Diagnosis is

? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? What is the reason of pregnancy ‘s interruption?

Syndrome of polycystic ovaries. It is pathology of structure and ovaries function. The main criteria is an anovulation ,hyperandrogenia. Reasons are:

It is syndrome of Stein – Levental - poly endocrine syndrome with disturbance of ovary ‘s function ( absence or nor regular ovulation, increasing of androgen’s and estrogen’s secretion, hyper secretion of insulin , supra renal gland ( androgens), hypothalamus and hypophysis. Синдром поликистозных яичниковWould You, please, give the conception about PCOS.

It is the more often reason of habitual abortion невынашивания PCOS has frequency among woman of reproductive age - 15 % 73-75%- infertility among an ovulation 68-85% with hirsutism 12,1-22% among women with interrupted pregnancy . What is relationsheep of this syndrome to pre term interruption of pregnancy?

More important moment is of hypothalamus- hypophysis region disturbances with changes of gonad -thropins secretion, particular LH secretion, with increasing of its basal level, that led to atresia follicles with decreasing of estrogens and storing of its previous form – androgens. Can You explain a pathogenesis of this pathology?

Olygomenorrhea, amenorrhea Infertility Increasing of androgen’s level Central adipositas Androgenic alopecia Akantosis Stria’s Night ‘s apnoae What are the common symptoms of polycystic ovarian syndrome?

Depressionессия Irritability ), agresstion ь, apathy Many cysts in ovaries. On USI – many white vesicles or “ costs from frut’s on all tissue of ovaries;

There is increasing of ovaries size in 1.5 till 3 times due to small cysts ; Thick and hyperplastic endometrium due to chronic over loading by estrogens without progesterone influence;

Chronic pains in low part of abdomen due to pressure of enlarged ovaries , hypersecretion of prostaglandins. The exact reason of pains in low part of abdomen is unknown

CBA Coagulogram Smear on purity of vagina LH, FSH, free testosterone Progesterone, estradiolum 17-CS prolactine; ТТH, Т3, Т4 ; IFA, PCR on virus infections What are the methods of examinations in this case?

CBA – norm Coagulogram: в norm Smear on purity of vagina : the 2 degree. 17-CS - 9,99 mg/24 hours (norm 7,5-9 )0 higher of norm Testosterone- 0,72 ng/mg (norm 0,07-0,65) higher of norm Prolactinum 482,7mcМЕ/l (30,3-818,1), norm. What are the results of investigation?

Estradiolum-42,6 pgr/ml ( norm 57-227) – low norm LH 25,0 IU/L (0,7-24,5),high the norm . FSH 6,7 IU/L (2,2-15),norm. Progesterone 1,3 nmol\l ( norm 8-78) low the norm TTH 3,1 ngr/l (3,2), - norm. Three IT 1,42 ngr/l (1,46), norm. Thyroxin-170 (172±3,8 ngr/l-н norm What are the results of laboratory methods of investigation

Basal temperature during 3 months is mono phase USI: length of uterus is - 44,7 mm, wide - 37,5 mm, right ovary is - 41,2 mm, left is 39,7 mm, structure like a many peripheral situated small cysts Markers of urogenital infections - negative. Результаты дополнительных методов исследованийWhat are the results of additional methods of examination ?

What show this picture of USI?

Dexametason on ¼ table during 2- weeks Estroferm on 1 table from 5 till 15-й день day of menstrual cycle Clomifen fro stimulation of ovulation from 5-th till 9-th day. Didrogesteron from 16-th till 25-th day on 10 mg 2 times during 4-months What treatment should be performed in this case?

Decreasing of 17- CS in 2 weeks till- 9,86 mg/24 hours In one month : - testosterone is - 0,39 ngr/mg - 17CS - 5,57mg/ 24 hours . In 4 months – pregnancy Labor with alive boy with mass 3300,0 height 54 sm. :The results are :

Complex – didrogesteron+ receptors to progesterone Secretore transformation of endometrium Dominant of pregnancy formation Immunmodulate On uterus tocolytic effect Conclusion: Didrogesteronum protects pregnancy

How can YOU explain the action of didrogesteron? It is using in group of women with habitual abortions with aim of prophylaxis of pregnancy interruption . It is know a statistic truth decreasing of interruption of pregnancy frequency in group of women with habitual abortion as compare, as placebo or absence of treatment . (level of truth ‘s is А)

What are the advantages of this medicine : Possibility activity of drug during using per mouth Doesn’t make a block of ovulation Doesn’t have androgenic, estrogenic and cortic- steroid activity.

Pregnant woman of 28 years old was hospitalized with diagnosis: Pregnancy 12- 13 weeks. Syndrome of polycystic ovaries. Habitual abortions. Isthmus- cervical insufficiancy. There are 3 abortions spontaneous in anamnesis at term of pregnancy 17, 18, 20 weeks. She has used from 5 weeks of pregnancy didrogesteron on 10 mg. 2 times daily. Clinic case 2

Special gynecologic examination Examination of the external sexual organs: External organs developed on the right way, there is expressed developed of hair growing on the pubic region. In speculum: cervix without of pathology , discharges are white. P.V. Cervix is shortened till 1,5 sm, soft, cervical channel is dilated till 1, 5 sm over internal os. Uterus is enlarged till 10-11 weeks of pregnancy. Adnexa are not palpable..

Кокрайновское руководство. What is Your tactic? ?

Surgical correction of uterine cervix. Continue hormonal therapy by didrogesteronum till 20 weeks of pregnancy.

It is known that 1/3 of all patients with habitual abortion has hyperandrogenia , that can led to isthmus – cervical insufficiancy. Frequancy of isthmus – cervical insufficiancy in cases of hyperanndogenia is 13 – 14 % Isthmus – cervical insufficiancy

Специальное гинекологическое исследование What is a doctor’s tactic?

? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

The surgical correction of ICI was performed on method of Lubimova- Mamedalieva .

У As a rule surgical correction of ICI is performing at the term of pregnancy from 13-27 weeks of pregnancy , but should be individual relationship to person, depending on the time of starting of symptoms in every case. Risk of intrauterine infection is increasing after 13-17 weeks, due to mechanic going down of membranes.

What is a treatment after operation? Bacterioscopy after operation of vaginal contents; Spasmolytic drugs in cases of uterine hypertonus, Didrosteronum on 10 mg 2 times in day till 16-20 weeks of pregnancy. Every 2- 3 weeks to assess stitches on cervix. Control of fetus condition is performing according to date of USI, dopplerometry, cardiotocography of fetus . Врачебная тактика

Preterm interruption of pregnancy is a poly etiologic problem, it is not possible to decide a problem in all cases. Due to that the common examination of patient should be done in cases of 2 and more abortions in anamnesis before a pregnancy beginning. Conclusion

In cases of in time examination of patient and in time treatment performing before pregnancy, monitory of pregnancy, delivery of alive babies in time may be at 98%. Conclusion