State medical University town Semey Abortion spontaneous Ассистент

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

• Situation task .

It should be told , that risk of pregnancy interruption depending on the quantity of previous abortions after 3 abortions spontaneous after 2 - abortions spontaneous after the 1 -st abortion spontaneous

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.

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

What are the date of special gynecologic examination? 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 is Your preliminary diagnosis? ? ? ? ? ?

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

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

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

Синдром поликистозных яичников. Would You, please, give the conception about PCOS. • 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.

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

Can You explain a pathogenesis of this pathology? • 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.

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

• • • 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

What are the methods of examinations in this case? • • • CBA Coagulogram Smear on purity of vagina LH, FSH, free testosterone Progesterone, estradiolum 17 -CS prolactine; ТТH, Т 3, Т 4 ; IFA, PCR on virus infections

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

What are the results of laboratory methods of investigation o o o o 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 nmoll ( 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

Результаты дополнительных методов исследований. What are the results of additional methods of examination ? o Basal temperature during 3 months is mono phase o 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 o Markers of urogenital infections - negative.

What show this picture of USI?

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

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

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

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.

Clinic case 2 v 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. v She has used from 5 weeks of pregnancy didrogesteron on 10 mg. 2 times daily.

Special gynecologic examination v. Examination of the external sexual organs: External organs developed on the right way, there is expressed developed of hair growing on the pubic region. v In speculum: cervix without of pathology , discharges are white. v. 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 1011 weeks of pregnancy. Adnexa are not palpable. .

What is Your tactic? • ? Кокрайновское руководство.

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

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

• What is a doctor’s tactic?

? ? ? ? ?

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

• v У a rule surgical correction of ICI is As performing at the term of pregnancy from 1327 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 .

Conclusion • 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%.