Preterm birth is one of the most important aspects of maternal and child health. Premature babies account for 65-70% of early neonatal and infant mortality. Stillbirth in preterm births is observed many times more often than in timely ones. Perinatal mortality in premature newborns is 30-35 times higher than in full-term ones.
In Russia, it is customary to consider preterm birth that occurs between 28 and 37 weeks of gestation with a fetal weight of 900 g or more. However, in the coming years in Russia, statistics premature birth, as well as perinatal morbidity and mortality, will be carried out according to WHO recommendations, according to which perinatal mortality is recorded from the 22nd week of pregnancy with a fetus weighing more than 500 g. According to these criteria, in the United States, the rate of preterm birth in 2005 was 9.7%, in Great Britain - 7.7%, in France - 7.5%, in Germany - 7.4%. In connection with the terms of pregnancy adopted in our country, the frequency of premature births ranges from 5.4-7.7%.
The causes of preterm labor are multifactorial. Risk factors for preterm birth are both socio-demographic (disorder family life, low social level, young age), and clinical reasons. Every third woman who has a preterm birth is a primigravida, in which the risk factors include previous abortions or spontaneous miscarriages, urinary tract infection, inflammatory diseases of the genitals. An important role in the occurrence of preterm labor is also played by the complicated course of this pregnancy, the development mechanism of which allows us to identify the main causes.
Based on many years of experience in research and clinical work on the problems of habitual pregnancy loss and premature birth, V.M. Sidelnikova identifies the following main reasons for the latter.
. Infection - acute and/or chronic, bacterial and/or viral - is one of the main causes.
. Maternal and/or fetal stress due to the presence of extragenital pathology, pregnancy complications and placental insufficiency, which leads to an increase in the level of fetal and/or placental corticotropin-releasing hormone and, as a result, to the development of premature birth.
. Thrombophilic disorders that lead to placental abruption, thrombosis in the placenta. A high level of thrombin can provoke an increase in the production of prostaglandins, activation of proteases and placental abruption, which is the most common cause early delivery.
. Overdistension of the uterus in case of multiple pregnancy, polyhydramnios, malformations of the uterus, infantilism leads to the activation of oxytocin receptors, etc. - and to the development of premature birth.
Often there is a combination of these factors in the development of preterm birth. The appearance of symptoms of activation of the contractile activity of the uterus, that is, symptoms of threatening premature birth, is the final link in a complex chain of activation of the contractile activity of the uterus. Without knowledge of the causes of preterm labor, there can be no successful treatment. Currently, all treatment of the threat of interruption is reduced to symptomatic treatment - the use of funds to reduce the contractile activity of the uterus. This explains why, with a huge number of different tocolytic drugs in our arsenal, the frequency of preterm birth in the world does not decrease, and the decrease in perinatal mortality is mainly due to the success of neonatologists in nursing premature babies.
In connection with the above, tactics of management and treatment of threatened preterm birth should take into account possible reasons their development, and not consist only in the appointment of symptomatic agents aimed at reducing the contractile activity of the uterus.
Treatment tactics are determined by many factors, such as gestational age, the condition of the mother and fetus, the integrity of the fetal bladder, the nature of the contractile activity of the uterus, the degree of changes in the cervix, the presence of bleeding and its severity.
The duration of pregnancy is closely related to the causes of preterm birth. According to WHO recommendations, preterm birth is divided according to gestational age into very early preterm birth - 22-27 weeks of gestation, early preterm birth - 28-33 weeks and preterm birth - gestational age of 34-37 weeks. This division is due to different management tactics and different pregnancy outcomes for the fetus.
It depends on the state of health of the mother whether it is possible to prolong the pregnancy or whether it is advisable to deliver it ahead of schedule. The state of the fetus is assessed by special methods: ultrasound scanning, Doppler study of blood flow in the mother-placenta-fetus system, cardiotocography. If the condition of the fetus allows, it is necessary to prolong the pregnancy at least for the time necessary for the prevention of fetal respiratory distress syndrome.
The integrity of the amniotic sac is of great importance in the choice of management tactics. With a whole fetal bladder, expectant tactics and therapy aimed at prolonging pregnancy are possible. With premature discharge amniotic fluid or a high lateral rupture of the membranes, tactics are determined by the presence or absence of infection, the nature of the presentation of the fetus, etc.
Depending on the nature and activity of the contractile activity of the uterus and the degree of changes in the cervix, expectant management can be chosen, aimed at prolonging pregnancy. Conservative tactics are possible in the state of health of the mother and fetus, which allows prolongation of pregnancy, with a whole fetal bladder, with cervical dilatation no more than 2 cm, in the absence of signs of infection.
When choosing expectant management tactics in case of a threat of preterm birth, it is necessary to:
. decide in each specific case what type of tocolytic therapy should be used;
. accelerate the "maturation" of the lungs of the fetus by preventing fetal respiratory distress syndrome, as well as improve its condition;
. determine the alleged cause of the threat of preterm labor (infection, placental insufficiency, thrombophilic disorders, pregnancy complications, extragenital pathology, etc.) and treat pathological conditions in parallel with the treatment of threatened abortion.
Distinguish threatening, beginning and begun premature birth. Threatening preterm birth is characterized by intermittent pain in the lower back and lower abdomen against the background of increased tone uterus. In this case, the cervix remains closed. When starting premature birth, there are usually cramping pains in the lower abdomen, accompanied by a regular increase in the tone of the uterus (contractions). The cervix is shortened and opened. At the same time, it often happens premature effusion amniotic fluid.
Preterm birth is characterized by: untimely discharge of amniotic fluid; weakness of labor activity, discoordination or excessively strong labor activity; fast or rapid childbirth or, conversely, an increase in the duration of labor; bleeding due to placental abruption; bleeding in the afterbirth and early postpartum periods due to retention of parts of the placenta; inflammatory complications both during childbirth and in the postpartum period; fetal hypoxia.
If symptoms occur that indicate the possibility of preterm labor, treatment should be differentiated, since in the beginning of childbirth, treatment can be carried out aimed at maintaining the pregnancy. Bed rest, sedatives, antispasmodics, etc. are prescribed. To the main medicines To successfully resist untimely termination of pregnancy, belong tocolytic drugs, or tocolytics. These include all medications that relax the muscles of the uterus. There are many of these drugs now, and on the basis of studies of the contractile activity of the myometrium, more and more new drugs are being offered, some of which are at the stage of clinical trials. It should be noted that the search for new drugs is due to the fact that the frequency of preterm birth does not decrease, the effectiveness of many tocolytics is low, and there are many side effects on the mother and fetus.
Nevertheless, the use of tocolytic agents is extremely important and relevant, since, although they do not reduce the frequency of preterm labor, they inhibit the contractile activity of the uterus, help prolong pregnancy, prevent fetal respiratory distress syndrome, etc.
One of the most effective tocolytic drugs are?-mimetics - drugs used to treat threatened miscarriage after 24-25 weeks of pregnancy or preterm birth for more than 30 weeks. Preparations of this series (ritodrin, Ginipral, salbutamol, etc.) are derivatives of epinephrine and norepinephrine, released during stimulation of sympathetic nerve endings, and they are sometimes called sympathomimetics or adrenergists in the literature. The action of?-mimetics is carried out through?-receptors. Stimulation of?-receptors leads to contractions of smooth muscles, and?-receptors - to the opposite effect: to relax the muscles of the uterus, blood vessels, and intestines. The presence of ?-receptors in other tissues (in particular, in the muscles of the heart) determines the frequency of severity of side effects of ?-mimetics. α-receptors are divided into α1- and β2-receptors. The tocolytic effect is provided by acting through? 2 receptors on the uterus, bronchi, intestines, as well as on the formation of glycogen in the liver and insulin in the pancreas. Their influence on ?-receptors of the cardiovascular system is less pronounced.
The mechanism of action of ?-mimetics is manifested through adrenergic stimulation, which leads to an increase in the formation of cyclic adenosine monophosphate (cAMP) from ATP by activating the enzyme adenylate cyclase. Due to the action of cAMP, Ca2+ is released from the cells back into the depot and smooth muscles are relaxed. α-mimetics cause an increase in blood flow through tissues and organs, an increase in perfusion pressure, and a decrease in vascular resistance. The effect on the cardiovascular system is manifested by an increase in heart rate, a decrease in systolic and diastolic pressure. Such a cardiotropic effect of ?-mimetics must be taken into account during therapy with these drugs, especially when they interact with other drugs. medicines. Before the introduction of?-mimetics, it is necessary to control the level of blood pressure and pulse rate. To reduce side cardiovascular effects, calcium channel blockers are prescribed - finoptin, isoptin, verapamil. As a rule, compliance with the rules for the use of ?-mimetics, the dosing regimen, and strict control over the state of the cardiovascular system make it possible to avoid serious side effects.
Additional effects from the use of?-mimetics include: an increase in circulating blood volume and heart rate, as well as a decrease in peripheral vascular resistance, blood viscosity and plasma colloid-oncotic pressure.
AT last years data have been obtained that with long-term use of α-mimetics, a decrease in their effectiveness is observed. In addition, ?-adrenergic receptors are sensitive from 24-25 weeks of gestation; in more early dates pregnancy, the effect of their use is not so pronounced. If the threat of preterm labor is accompanied by an increase in the tone of the uterus, and not by contractions, then the effect of the use of?-mimetics is low, since they reduce the contractile activity of the uterus, and the tone decreases very slowly.
In Russia, the most common and frequently used drug from the group of?-mimetics is Ginipral - hexoprenaline. It is a selective?2-sympathomimetic that relaxes the muscles of the uterus. Under its influence, the frequency and intensity of uterine contractions decreases. The drug inhibits spontaneous, as well as labor pains caused by oxytocin; normalizes excessively strong or irregular contractions during childbirth. Under the influence of Ginipral, in most cases, premature contractions stop, which, as a rule, allows you to prolong the pregnancy to full term. Due to its? 2-selectivity, Ginipral has little effect on the cardiac activity and blood flow of the pregnant woman and fetus.
Ginipral consists of two catecholamine groups, which in the human body are methylated by catecholamine-O-methyl-transferase. While the action of isoprenaline is almost completely stopped by the introduction of one methyl group, hexoprenaline becomes biologically inactive only if both of its catecholamine groups are methylated. This property, as well as the high ability of the drug to adhere to the surface, are considered the reasons for its long-term effect.
Indications for the use of Ginipral are:
. Acute tocolysis - inhibition of labor pains during childbirth with acute intrauterine asphyxia, immobilization of the uterus before caesarean section, before turning the fetus from a transverse position, with umbilical cord prolapse, with complicated labor activity. As an emergency measure in preterm labor before taking the pregnant woman to the hospital.
. Massive tocolysis - inhibition of premature labor pains in the presence of a smoothed cervix and / or opening of the cervix of the uterus.
. Prolonged tocolysis - prevention of preterm labor with increased or frequent contractions without smoothing the cervix or opening the cervix. Immobilization of the uterus before, during and after surgical correction of isthmic-cervical insufficiency.
Contraindications to the appointment of this drug: hypersensitivity to one of the components of the drug (especially patients suffering from bronchial asthma and hypersensitivity to sulfites); thyrotoxicosis; cardiovascular diseases, especially cardiac arrhythmias occurring with tachycardia, myocarditis, mitral valve disease and aortic stenosis; cardiac ischemia; severe liver and kidney disease; arterial hypertension; intrauterine infections; lactation.
Dosage. In acute tocolysis, 10 μg of Ginipral, diluted in 10 ml of sodium chloride or glucose solution, is used (introduced slowly intravenously over 5-10 minutes). If necessary, continue administration by intravenous infusion at a rate of 0.3 µg/min. (as in massive tocolysis).
With massive tocolysis - at the beginning, 10 μg of Ginipral slowly intravenously, then - intravenous infusion of the drug at a rate of 0.3 μg / min. You can enter the drug at a rate of 0.3 mcg / min. and without prior intravenous injection. Introduce intravenously (20 drops = 1 ml).
As the first line of aid in case of threatened abortion after 24-25 weeks of pregnancy or the threat of preterm labor, Ginipral is prescribed at the rate of 0.5 mg (50 μg) in 250-400 ml of saline intravenously, gradually increasing the dose and rate of administration (maximum 40 drops / min.), combining infusion with the intake of calcium channel blockers (finoptin, isoptin, verapamil) under the control of pulse rate and blood pressure parameters. 20 minutes before the end of the intravenous infusion, 1 tablet of Ginipral (5 mg) per os every 4 hours.
Reducing the dose of Ginipral should be carried out after the complete elimination of the threat of interruption, but not less than 5-7 days later (reduce the dose, and not lengthen the time interval between taking the drug dose). Based on the long-term use of Ginipral, it has been established that the effectiveness of its use is about 90%.
Thus, the domestic and foreign experience accumulated over decades indicates that, despite the ever-increasing arsenal of tocolytic agents, today there are no more effective means to suppress the contractile activity of the uterus, i.e. threats of preterm birth than?-mimetics, and, in particular, Ginipral.
One of the terms that can be heard in last trimester- prolongation of pregnancy, which means its extension. That's just how relevant this is in this or that case, and what risks exist for both the mother and the child?
What is prolongation of pregnancy
Very often, prolongation is used in order to extend the gestation period by a couple of weeks in order to ensure the full development of the child. In this case, this is not a prolongation, but an opportunity to give the future baby a sufficient amount of time for the formation of all vital organs and systems.
Many expectant mothers have a question about what prolongation of pregnancy is, and how it differs from cases when labor does not occur in deadlines. Unlike a post-term pregnancy, there is no risk to either the baby or the mother during its extension. Special examinations are carried out to determine the possible deterioration in the condition of the woman in labor and take appropriate measures. This includes a blood test to determine the hormonal level, and mandatory ultrasound examinations, checking the baby's heartbeat, as well as amniotic fluid.
As a rule, prolonged pregnancy does not carry any cause for concern. Nothing threatens the health of the mother or the child, and the fact that the “interesting situation” dragged on longer than the established term is practically the norm. Only minimum percentage women give birth on the date set by the gynecologist, as a rule, childbirth occurs a week either earlier or later.
Prolongation of pregnancy after the discharge of water
It is worth noting that very often it is important to prolong pregnancy after the discharge of water, if the child is not yet ready for birth. This will give the baby extra time so that all organs, systems and reflexes are fully formed, and the child is born in a timely manner.
Prolonged pregnancy itself is not an indication for caesarean section so you don't have to worry about possible complications in the process natural childbirth. If there are any contraindications or risks, it is important to discuss this issue with the observing gynecologist.
It is important to understand that the prolongation of pregnancy is very important for the preservation of the fetus, to provide more time for its normal development and formation. It is only necessary to distinguish between portability and prolongation. The first option can be dangerous, while the second is considered the norm. To determine how relevant special prolongation can only be experienced doctor after carrying out all the necessary examinations.
Frozen pregnancy is a problem that a fairly large percentage of women face. And in this case, it is very important to diagnose ...
One of the problems women face in interesting position”, becomes the appearance of stretch marks. After all, red, and then whitened scars...
The pathogenesis of preterm birth can be different. Preterm labor can be spontaneous or induced. Spontaneous childbirth can begin with premature discharge of water or with an increase in uterine tone.
Induced preterm labor occurs in the case of early delivery with preeclampsia, antenatal fetal leucorrhoea, or other complications during pregnancy. Signs of threatening premature birth are an increase in the tone of the uterus, aching pain in the lower abdomen, shortening of the cervix, and expansion of the diameter of the cervical canal.
Threat of preterm birth:
With a very pronounced threat, there may be irregular cramping pains in the lower abdomen and in the lumbar region, like precursors. The fact that during a full-term pregnancy is called signs of readiness for childbirth, or harbingers of childbirth, at a period of 28-36 weeks is called the threat of premature birth. Bloody discharge indicates not so much a threat as a pathology of the placenta (low location of the placenta, placenta previa, detachment of the low-lying placenta). Obstetric tactics in the pathology of the placenta is dealt with in the relevant sections.If a threat of preterm birth is detected, it is necessary to hospitalize the pregnant woman in the antenatal department of the obstetric hospital. A therapeutic and protective regimen, tocolytic drugs, means for antenatal protection of the fetus are prescribed.
Sometimes with a low degree of threat, treatment is carried out in conditions day hospital, but such treatment gives worse results.
It is necessary to warn a woman that she needs to exclude sexual activity, physical activity. It is much more difficult to control the dynamics of changes, ensure strict bed rest and conduct intensive care at home. With a pronounced threat, observation and preserving therapy are carried out in the conditions of the maternity ward.
The beginning of preterm labor, as well as urgent labor, is considered to be the smoothing of the cervix and the development of regular labor activity. When labor has begun, with a cervical dilatation of less than 2 cm, they try to stop labor with the help of intensive tocolytic therapy (infusion therapy). At the same time, therapy is carried out aimed at the prevention of fetal respiratory distress syndrome (RDS).
Improving the development of the lungs contributes to dexamethasone, Essentiale, but the most effective use of a surfactant.
If maintenance therapy is not effective and labor continues, the woman is monitored in labor in the same way as in urgent labor, but the course of preterm labor can be complicated. Quite often, anomalies of labor activity are observed. With weak labor activity at the beginning of the first period, there are more chances to keep the pregnancy. Sometimes childbirth proceeds quite quickly. Then it is necessary to weaken labor activity in order to avoid complications. Discoordination of labor activity is often manifested, and in this case, the introduction of tocolytics and antispasmodics is indicated. Delivery should not be rushed if there is no threat to the woman's health.
In the second stage of labor, a perineal dissection is performed to prevent birth trauma and fetal asphyxia. Prevention of bleeding is carried out. Obstetric care is administered as carefully as possible.
Signs of prematurity in a newborn:
length less than 47 cm, weight less than 2600 g. (With a weight of less than 1000 g and a length of less than 35 cm, a newborn is called a fetus up to 8 days of life.);the umbilical ring is below the middle of the distance between the xiphoid process and the pubis;
the skin is more pink and, with a greater degree of prematurity, red, a lot of cheese-like lubricant, vellus hair is more pronounced, hair and nails are shorter, ear and nasal cartilages are soft, as are the bones of the head, sutures and fontanelles are wide, the bones are easily configured;
in girls, the large labia do not cover the small ones, and in boys, the testicles may not be lowered into the scrotum;
movements, reflexes and muscle tone are less active, the cry is weaker;
signs of respiratory failure are often expressed, so a premature baby should be evaluated not only on the Apgar scale, but also on the Silverman scale.
It is necessary that even before the birth of the child, a neonatologist is called to the maternity ward.
Complications of preterm birth:
anomalies of tribal forces;prolapse of the umbilical cord and limbs;
pathology of the subsequent period;
birth trauma of the mother and trauma and asphyxia of the newborn;
obstetric bleeding;
postpartum complications.
Due to the complications that have arisen, and also due to the fact that preterm birth is a consequence of pregnancy complications, the percentage of surgical interventions is high. A premature baby often cannot breastfeed or is not active enough, because of this, lactostasis occurs, and there is a threat of mastitis in the mother. There is a subinvolution of the uterus, and against this background, the risk of inflammation of the uterus increases.
Obstetric tactics in case of premature discharge of water during premature pregnancy:
In case of premature discharge of water, it is necessary to prepare the pregnant woman for delivery in order to avoid infectious complications, labor induction, antibiotic therapy are carried out.If premature discharge of water occurs at 27-30 weeks of gestation, when the fetus is not yet viable enough, it is possible in some cases to use the method of prolonging pregnancy, preserving therapy in this case is not carried out, but labor induction is not carried out either.
Prolongation contraindications are:
unwillingness of the mother to prolong the pregnancy;stillbirth;
the presence of infection (according to analyzes or clinical manifestations);
lack of examinations during pregnancy;
bleeding;
the serious condition of the mother, which requires urgent delivery;
risk of complications in case of prolongation of pregnancy;
pelvic presentation of the fetus;
low opening of the fetal bladder, abundant outpouring of water;
regular contractions;
twins;
indications for caesarean section.
In the case when there is a high opening of the fetal bladder with a small defect in the membranes, water leaks, but labor activity may not develop for a very long time. Even with the dilution of the membranes and the appointment of rhodostimulation, a miscarriage or premature birth does not always occur on the first day, and the anhydrous period can stretch for several days.
Experience shows that even with full-term pregnancy, until the fetal membranes are divorced, labor activity often does not develop. Since amniotic fluid is constantly produced, a small loss of it is not terrible.
Conditions for carrying out the prolongation of pregnancy:
the extreme interest of a woman in prolonging pregnancy;absence of infection subject to a complete examination of the woman;
no contraindications for prolongation of pregnancy;
live fetus;
head presentation;
high opening of the fetal bladder and a slight defect in the membranes;
slight water leakage.
Observation and care of a pregnant woman during prolongation of pregnancy when water breaks: a woman is placed in a separate ward in the antenatal department, sterile clothing, cleaning, as in the ward of the external observation department. To control infection, temperature is taken every 3 hours.
Daily or every two days: CBC, urinalysis, examination of the vaginal flora, cultures of urine and vaginal contents. To monitor the condition of the fetus - ultrasound and CTG. Doctor's examination in the morning and in the evening, including weekends, midwife supervision. Medicinal purposes: antibacterial therapy, means for the prevention of fetal hypoxia, closer to delivery - means for preparing the birth canal.
Usually prolongation is carried out within 2 weeks, but sometimes it is possible to extend the pregnancy by 5-6 weeks. If at 24-25 weeks of pregnancy there are practically no chances for the birth of a viable fetus, then at 30 weeks the chances increase, especially since therapy is carried out with agents that improve the adaptive capabilities of the fetus and the development of pulmonary surfactant. At near-term pregnancy, there is no reason for the risk of infection, and prolongation of pregnancy beyond 33-34 weeks is not recommended.
The midwife should be able to suspect miscarriage, identify risk factors, give recommendations for the prevention of miscarriage, follow doctor's orders, provide care during pregnancy, childbirth, provide first aid, conduct delivery and postpartum rehabilitation under the supervision of a doctor.
in general, girls, I reached an emotional peak after 7 days spent in the hospital ... I spent the whole day in tears - I was hysterical. the primary reason is the forced separation from the son of Kostya, her beloved and devoted husband ... she roared today from morning until evening
The impetus for an explosion of emotions was the infa that my G, who led my first birth and was directly present at them, and also led me now, is flying tomorrow on a business trip to Moscow until the end of April !!! instead of her, a young doctor will be on duty at the birth, who will be sent on Monday. it is precisely with the arrival of this lady that I will have wild fears:
1. Stimulates me without my consent or knowledge
2. will not let me into the EP, seeing my narrow pelvis
3. just doesn't want to talk to me...
I was offered the option of giving birth in another maternity hospital in the neighboring district or RD in the city of my choice ... I refused: I trust all midwives, 3 of them were at my last birth, the fourth was experienced without complaints (my friends gave birth to her), the fifth of our regions with unsullied reputation as a midwife. I have boundless trust in them, I managed to study each of them in my last days of waiting for my first child. fear only of the new doctor-G ....
my departing G tried to reassure me: she explained that I don’t walk around, but I have PROLOGUE B. There is nothing terrible about this, this is a normal feature of the body.
Here is some info I found about it:
Prolongation of pregnancy means untimely (late) occurrence of labor activity, with its development, violations of the contractile activity of the uterus are often observed, which leads to an increase in the number of surgical interventions, to intrauterine suffering of the fetus and an increase in perinatal mortality. With prolonged pregnancy, it is more correct to call childbirth timely, and with true overbearing - belated childbirth with an overripe fetus.
The frequency of overwearing is 1.4-14%, on average 8%.
Distinguish:
· true (biological) re-carrying of pregnancy
· imaginary (chronological), or prolonged pregnancy.
Prolonged pregnancy lasts more than 294 days and ends with the birth of a full-term, functionally mature child without signs of overmaturity and danger to his life.
True post-term pregnancy lasts more than 10-14 days after the expected date of delivery (290-294 days). The child is born with signs of overmaturity, and his life is in danger. Usually in these cases there are changes from the placenta (petrificates, fatty degeneration, etc.).
Post-term pregnancy diagnosis usually put on the basis of anamnesis and data obtained from clinical, laboratory and instrumental research methods. It is necessary to assess the general condition of the pregnant woman, the course of this pregnancy (toxicoses), to establish the timing of the onset of menarche, the characteristics of the menstrual cycle, the presence of infantilism, endocrine diseases, past inflammatory diseases of the genital organs, abortions, and a history of prolonged pregnancy.
Etiology and pathogenesis
It is more correct to consider a post-term pregnancy as a pathological phenomenon due to certain reasons, depending on the state of the body of both the mother and the fetus. A premorbid background for postponing a pregnancy can be previously transferred childhood infectious diseases (scarlet fever, mumps, rubella, etc.), which play a significant role in the formation of a woman's reproductive system, as well as extragenital diseases.
Contribute to pregnancy delay infantilism, abortions, inflammatory diseases internal organs. which cause changes in the neuromuscular apparatus of the uterus and lead to endocrine disorders.
Endocrine diseases, disorders of fat metabolism, mental trauma, and toxicosis of the second half of pregnancy play a certain role in prolongation of pregnancy. In primiparous women (especially the elderly), overgestation is more common than in multiparous ones.
The hereditary factor also matters. The main pathogenetic factors leading to prolonged pregnancy are functional changes in the central nervous system, vegetative and endocrine disorders. A large role belongs to the disruption of the production of estrogens, progestogens. corticosteroids, oxytocin, certain tissue hormones (acetylcholine, catecholamines, serotonin, kinins, histamine, prostaglandins), enzymes, electrolytes and vitamins.
The condition of the placenta and fetus is also of some importance. Violations in the fetoplacental system are one of the reasons for the late onset of labor and its anomalies. The fetus overripes, its need for oxygen increases, the stability of the central nervous system to oxygen deficiency. At the same time, profound changes occur in the placenta (degeneration, calcification, dissociation of its maturation). When the pregnancy is overdue, the need for oxygen in the fetus increases, and the resistance to hypoxia decreases, the changes that occur in the placenta make it difficult to deliver the required amount of oxygen and other necessary substances to the fetus. This creates a vicious circle of pathological processes characteristic of post-term pregnancy.
Clinical picture of post-term pregnancy ill-defined and difficult to diagnose. With true pregnancy over 41 weeks, it is often observed; the absence of an increase in the body weight of a pregnant woman or its decrease by more than 1 kg; a decrease in the circumference of the abdomen by 5-10 cm, which is usually associated with a decrease in the amount of amniotic fluid, a decrease in skin turgor; less often, a drop in body weight due to secondary malnutrition of a post-term fetus; oligohydramnios and green coloration of amniotic fluid, higher standing of the uterine fundus; secretion of milk, not colostrum, strengthening or weakening of fetal movements, which indicates fetal hypoxia due to impaired uteroplacental circulation; frequency change. rhythm and timbre of fetal heart tones; immaturity or insufficient maturity of the cervix; large fruit size. an increase in the density of the bones of the skull, narrowness of the sutures and fontanelles.
The course of childbirthin post-term pregnancy, it is characterized by numerous complications; premature or early discharge of amniotic fluid, anomaly of labor, prolonged labor, fetal hypoxia and birth trauma. As a rule, intrauterine fetal hypoxia during pregnancy manifests itself with the onset of labor or after premature rupture of amniotic fluid, which is associated with a deterioration in uteroplacental circulation due to functional and morphological changes in the placenta. Hypoxia is promoted by reduced function of the adrenal glands of the fetus, sensitivity to oxygen deficiency during childbirth due to increased maturity of the central nervous system, a decrease in the ability of the head to change, and a significant size of the fetus. frequent violations of the contractile activity of the uterus; excitation or stimulation of labor, frequent surgical interventions during childbirth.
Mommy is looking forward to that cherished fortieth week, but is the baby still in no hurry to be born? In this case, doctors fix a post-term pregnancy for you. However, not everyone is aware that this deviation is no better than premature birth.
Note that the normal pregnancy period is forty weeks (plus or minus two weeks is also considered the norm). Accordingly, delivery at 38 weeks cannot be called premature, just like delivery at 42 weeks post-term. Such a gap is usually due to the fact that it is extremely difficult to determine the exact day of pregnancy (the date is corrected with each subsequent ultrasound), usually the countdown is based on the last menstrual cycle. Doctors distinguish many aspects due to which labor activity may be late or absent completely, ranging from physiological and mental factors, ending with living conditions and ecology (we will talk about the reasons in detail below). Most often, overgestation is determined not by the gestational age, but by obvious signs of complications, which, without proper attention, can lead to serious consequences for the health of the mother and baby.
2. Prolonged pregnancy
We have already noted that the appearance of the crumbs into the world from 38-42 weeks of pregnancy is considered absolutely normal and safe for the life of mother and baby. But still, the generally accepted gestational age of 40 weeks is exactly what doctors are guided by in their conclusions. So this is the period (usually 41 and 42 weeks), which proceeds without signs of deterioration in health future mother and her crumbs and is called prolonged pregnancy, in other words, prolonged without changes in condition. With prolonged pregnancy, the placenta also continues to perform its functions in full, and therefore the baby is not in danger. As practice shows, such prolonged gestation is usually hereditary.
Specialists identify a huge number of reasons why a true post-term pregnancy may occur, but even the most experienced doctor will not be able to name a hundred percent reason for a particular case. Here is a short list of reasons that are considered the most important:
heredity. We have already said that this is also a prerequisite for prolonged pregnancy. The same factor can be attributed to the fact that a woman has a menstrual cycle over the norm of 28 days;
various diseases of internal organs (thyroid gland, endocrine system, diseases of the stomach and intestinal tract);
various kinds of inflammatory processes of the reproductive system of a woman can be caused by infections;
internal tumors;
problems with the work of the kidneys;
past illnesses during pregnancy. These include not only flu and colds, but also “childhood” diseases such as rubella and chickenpox, which are extremely dangerous for a pregnant woman and her unborn baby;
presentation of the fetus;
late first pregnancy;
numerous stressful situations;
overweight of the expectant mother, as well as a too large fetus.
This is not the whole list of reasons that can provoke a delayed pregnancy, but we tried to highlight the most common ones based on medical reports. It is very difficult to predict the course of pregnancy without visible pathologies, therefore no one will tell you in advance about a possible delayed pregnancy, so the maximum that you can do is to undergo the necessary medical examinations on time and follow the recommendations of your doctor.
4. Signs and symptoms of post-term pregnancy
So, before you deal with the signs of a post-term pregnancy, it is worth remembering that it can be of two types:
imaginary (usually this is due to an incorrectly set date of birth);
true (in this case, there are noticeable biological changes that require urgent intervention of specialists).
Deviations begin in the placenta, and as we know, it is responsible for saturating the fetus with oxygen and feeding the baby. In order to diagnose a post-term pregnancy, an ultrasound scan is prescribed, the results of which reveal signs of a post-term pregnancy. The signs include:
green waters or very muddy;
despite the fact that the gestational age is already large, the cervix remained immature;
the placenta cannot function normally due to the fact that aging has occurred;
large cranial bones of the fetus.
If we talk about symptoms, then there are no clear signs of overwearing, so a woman has to rely on sensations and small concomitant factors that can indicate this. For example, when carrying over in a very short period, pregnant women experience weight loss, on the order of one or two kilograms per week. It is also worth paying attention to the volume of the abdomen, due to the decrease in amniotic fluid, it loses volume. But you will be able to make an accurate diagnosis only after passing ultrasound.
5. Consequences of a post-term pregnancy
All the consequences of the transfer are associated with the aging of the placenta and the cessation of its proper functioning. For a pregnant woman, this is fraught with late toxicosis or even anemia. For the baby, the placenta is a way of supplying oxygen, and when it dies, it begins oxygen starvation fetus, which can lead to its death in the future. The consequence of a post-term pregnancy for a woman may be multiple ruptures, which may well lead to infectious diseases, so most often in such cases, doctors resort to a caesarean section. In such babies, the risk of birth injury is greatly increased due to the dense bones of the skull. There are also sad statistics in which about 20 percent of post-term babies die, this is due to the fact that it is difficult to establish the true cause of the pathology. Most importantly, do not panic and do not bring yourself to a nervous breakdown, if by all the dates it is time for you to go to the hospital, and the baby is not going to be born, then collect all the necessary things and go to the hospital for an ultrasound scan.
Pregnant V., aged 26, was admitted to the maternity hospital at 13.00, at 43 weeks' gestation, due to the onset of labor.
Complaints of cramping body in the abdomen.
From history. Menstruation from the age of 14, regular, moderate, painless. Sexual life since 19 years. Pregnancy second, desired. B female consultation is observed regularly, the course of pregnancy without features. The first pregnancy ended in childbirth at 42 weeks, without complications, three years ago.
status praesens. The condition is satisfactory. Body temperature 36.6°C, Ps 76 per minute, BP 110/70 - 120/70 mm Hg. Art.
status obstetricus. OB 108 cm. WDM 37 cm. Pelvic dimensions: 25-27-30-21 cm. The position of the fetus is longitudinal, the head is presented, pressed against the entrance to the small pelvis. The back is turned to the right. The fetal heartbeat is clear, rhythmic 136 beats/min.
Vaginal examination. On examination: the external genitalia are formed correctly. Hair on the female type.
Per vaginam: the cervix is smoothed, the edges are soft, thin, easily extensible, along the wire axis of the pelvis, the opening is 3 cm. The head is placed, pressed against the entrance to the small pelvis. On examination, light amniotic fluid was poured out in the amount of 100 ml. The cape is not reachable.
Additional examination methods
Cardiotachogram: Fisher score 8 points.
At 23.00 hours
She gave birth to a live male child, weighing 3900 g, 50 cm long. Skin pink, clean, screamed immediately, loudly, reflexes are well expressed, movements are active, heartbeat is 134 beats / min. A large fontanel with a facet of 2 cm is determined on the head, a birth tumor is in the area of the small fontanel. Umbilical hair on shoulders. The skin is not macerated. The nail plates extend to the edge of the nail bed. The afterbirth is examined - intact, without pathology.
Diagnosis? Apgar score?
Basic diagnosis: Belated delivery in cephalic presentation, longitudinal position, II position. Complications: Early rupture of amniotic fluid.
Newborn Apgar score: 8 points
In the present case, there was a prolonged pregnancy
More on the topic Problem 36. PROLONGED PREGNANCY:
- The use of long-acting contraceptive regimens with therapeutic purpose
- Pathology of pregnancy and the postpartum period. Spontaneous abortions. ectopic pregnancy. trophoblastic disease
- Management of the 2nd group of pregnant women: a group of sensitized pregnant women threatened by Rh - conflict (there are antibodies, but there are no signs of GBP):
1. Clinical picture (clinic) of overpregnancy. Clinical symptoms of post-pregnancy.
2. Degrees of fetal transfer. The degree of maturity of the child. Post-term pregnancy diagnosis.
3. Diagnosis of gestation of the fetus. Prolonged pregnancy. Amnioscopy in post-term pregnancy.
4. Ultrasound signs of post-term pregnancy. Ultrasound in post-term pregnancy. Ultrasound examination of the post-term fetus.
5. Fetal electrocardiography in post-term pregnancy. Hormones, hormonal tests during postmaturity.
6. Cytological signs of pregnancy overdose. Cytology during postmaturity. Amniotic fluid during gestation of the fetus.
7. The course of pregnancy and childbirth in the event of a prolonged pregnancy. Belated childbirth with an overripe fetus. Suffering of the fetus in childbirth during postmaturity.
8. Tactics of pregnancy and childbirth during prolonged pregnancy. Tactics of the doctor in case of re-carrying pregnancy.
9. Tactics of post-term pregnancy management. Doctor's tactics in post-term pregnancy. Cesarean section during pregnancy overdose.
10. Preparation of the cervix and induction of post-term pregnancy. Evaluation of the effectiveness of labor induction. The second stage of childbirth during postmaturity.
Diagnosis of gestation of the fetus. Prolonged pregnancy. Amnioscopy in post-term pregnancy.
Gestational age determined by the date of the last menstruation, according to the estimated ovulation, according to the first appearance in women's consultation, the first movement of the fetus, the results of objective research methods (the formulas of Skulsky, Zhordania, Figurnov, etc.). The smallest discrepancy in establishing the gestational age and date of birth is observed when determining but the date of the last menstruation (with the correct cycle).
At determining the duration of pregnancy and the date of the expected birth, you should pay attention to the general condition of the pregnant woman, the course of this pregnancy (preeclampsia), the duration of the menarche and the characteristics of the menstrual cycle, the presence of infantilism, endocrine diseases, inflammatory diseases of the genital organs, abortions, past pregnancy in history.
When diagnosing overdose take into account the data of objective research methods given above in the "Clinical picture" section.
With prolonged pregnancy of these signs, only the significant size of the fetus and the high standing of the uterine fundus are noted.
AT diagnosing a true miscarriage an important role is played by the results of amnioscopy, ultrasound, phono- and electrocardiography of the fetus, CTG, research amniotic fluid, Doppler assessment of blood flow, cytological examination of the vaginal smear, etc.
If, based on the data of the indicated research methods, it is impossible to put diagnosis of post-term pregnancy they should be repeated.
Dynamic monitoring with amnioscopy(every 2 days, starting from the 6th day after the expected date of delivery) allows you to timely detect changes typical of distortion: a decrease in the amount of amniotic fluid, their green coloration, a small amount (or absence) of flakes of caseous lubricant, their weak mobility. In the early stages of overdose, the waters are "muddy" opalescent, which is explained by the presence of the fetal epidermis in them. The exfoliation of the fetal bladder during post-term pregnancy is the smallest. The described amnioscopic picture is not typical for prolonged pregnancy (Lampe L., 1979; Persnaninov L.S. et al., 1973; Chernukha E.A., 1982; Savelyeva T.M., 2000).
And belated births very often complicate the course of pregnancy. But there is also a prolonged pregnancy. How are they different.
Postterm pregnancy- this is a pregnancy that lasts 10-14 days more than a physiological pregnancy and its total duration is 290-294 days (42 weeks). The child is born with signs of overmaturity (Bellentine-Rooney syndrome).
Prolonged pregnancy, also lasts up to 290-294 days, but the child is born functionally mature, without signs of postmaturity.
The frequency of overwearing, according to various authors, is 1.4 - 42%.
Complications that may occur during a post-term pregnancy:
- placental insufficiency
- Fetal hypoxia
- Birth trauma (both in the child and in the mother)
Respiratory distress syndrome and pneumopathy
intrauterine infection
perinatal mortality
Perinatal morbidity
In the remote period, there may be a lag in the child's physical and neuropsychic development
Abnormalities in labor may occur during childbirth
Bleeding in the postpartum period
High percentage of caesarean section in post-term pregnancy
Causes of delayed pregnancy:
- Neuroendocrine diseases, obesity
Age over 30
Restructuring in the central nervous system with a predominance of the influence of the parasympathetic nervous system
Change in the ratio of gonadotropic hormones, progesterone, decrease in the level of estrogens, calcium, potassium, acetylcholine
Past abortions in anamnesis
Inflammatory diseases of the reproductive system in history
Delayed maturation of the placenta
Chronic placental insufficiency
Change in immune status
Malformations of the central nervous system in the fetus
Congenital malformations in the fetus
Changes in amniotic fluid during post-term pregnancy:
With a post-term pregnancy, there is a change in both quantity and quality. When overcarrying, the amount of amniotic fluid decreases and oligohydramnios occurs. Normally, by the full-term period, the amount of amniotic fluid is 800-900 ml, while with overbearing, the amount of amniotic fluid decreases by 100-200 ml per week.
There is a change in the transparency of amniotic fluid. With a mild degree of overdose, the water acquires an opalescent, whitish color due to the dissolution of the lubrication of the fetus in the waters. In severe forms of post-term pregnancy, the color of the amniotic fluid can become greenish and even yellowish, due to the release of meconium into the amniotic fluid.
With a post-term pregnancy, the composition of the amniotic fluid changes. The ratio of lecithin and sphingomyelin proteins changes. These proteins normally contribute to the formation of surfactant in the lungs of the fetus. With an imbalance of these proteins, the surfactant ceases to be formed and the child develops a syndrome of respiratory disorders and pneumopathy.
The bactericidal property of amniotic fluid changes. How longer term gestation, the more bacteria accumulate in the waters.
There are changes in the umbilical cord, which lead to a decrease in the amount of Worton's jelly ("skinny umbilical cord"), due to which the umbilical cord blood flow is disturbed, which leads to the centralization of blood circulation in the fetus with insufficient nutrition of the peripheral sections.
Diagnosis of post-term pregnancy difficult not only in the absence of reliable signs of overgestation, but also in the inability to accurately determine the gestational age in each case. During the diagnosis of a post-term pregnancy, the following criteria are based:
Presence of post-term pregnancy in anamnesis.
- Systematic monitoring of a woman during pregnancy allows you to more accurately navigate the correct gestational age.
- Carrying out amnioscopy
- Carrying out amniocentesis
- Carrying out cardiotocography
- Carrying out dopplerometry
- Carrying out a colpocytological test
After the birth and examination of the child, it is possible to make an accurate conclusion whether the pregnancy was delayed or prolonged. They help in this signs of postmaturity- Bellentiney-Rooney syndrome:
Absence of vellus hair on the child's body
- Lack of original lubrication
- Increased bone density of the child's skull
- Narrowness of the sutures and fontanelles between the bones of the child's skull
- Lengthening the nails on the hands and feet of the baby
- Greenish skin tone
- "Parchment" dry skin
- Maceration of the feet and hands (arms, legs of the washerwoman)
- Reduced baby skin turgor
- Poorly developed subcutaneous fat
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