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22UDC: 618.5-08: 618.346-008.8
DIAGNOSTIC CRITERIA FOR PRENATAL RUPTURE OF AMNIOTIC
FLUID
KHATAMOVA MATLYUBA TILAVOVNA
Associate Professor of Obstetrics and Gynecology No. 2 of the Bukhara State Medical Institute named after Abu Ali ibn Sino, Uzbekistan, Bukhara. ORCID 0000-0002-0279-0240 ABSTRACT
Prenatal outflow of amniotic fluid combination with infectious diseases is a serious problem of modern obstetrics. The article presents modern views on the etiology and pathogenesis of premature and antenatal rupture of amniotic fluid. The pathological, genetic and microbiological aspects of this pathology are considered. Further solutions to the problems associated with premature and antenatal rupture of amniotic fluid are outlined. The causes of prenatal outflow of amniotic fluid, despite numerous studies, are not completely established, although the leading factor in this complication is considered to be infection.
Key words: full-term pregnancy, induction of labor, prenatal outflow of amniotic fluid
ДИАГНОСТИЧЕСКИЕ КРИТЕРИИ ПРЕНАТАЛЬНОГО ОТТОКА АМНИОТИЧЕСКОЙ ЖИДКОСТИ
ХАТАМОВА МАТЛЮБА ТИЛАВОВНА
Доцент кафедры акушерства и гинекологии №2 Бухарского Государственного медицинского института имени Абу Али ибн Сино, Узбекистан, г. Бухара. ORCID 0000-0002-0279-0240
АННОТАЦИЯ
Пренатальный отток амниотической жидкости в сочетании с инфекционными заболеваниями - серьезная проблема современного акушерства. В статье представлены современные взгляды
на этиологию и патогенез преждевременного и дородового разрыва амниотической жидкости. Рассмотрены патологические, генетические и микробиологические аспекты этой патологии. Описаны дальнейшие решения проблем, связанных с преждевременным и дородовым разрывом амниотической жидкости. Причины пренатального оттока амниотической жидкости, несмотря на многочисленные исследования, до конца не установлены, хотя ведущим фактором этого осложнения считается инфекция.
Ключевые слова: полноценная беременность, индукция родов, пренатальный отток амниотической жидкости
АМНИОН СУЮКЛИГИНИНГ ПРЕНАТАЛ ОКИМИНИНГ ТАШХИСЛАШ МЕЗОНЛАРИ
ХАТАМОВА МАТЛЮБА ТИЛАВОВНА
Акушерлик ва гинекология №2 кафедраси доценти, Бухоро давлат тиббиёт институти, Бухоро, Узбекистон.
ОИСЮ Ю 0000-0002-0279-0240 АННОТАЦИЯ
Амнион суюцлигининг пренатал оцимининг юцумли касал-ликлар билан биргаликда учраши замонавий акушерликнинг долзарб муаммоларидан саналади. Мацолада амнион парданинг тугруцдан олдинги даврда йиртилишининг этиологияси ва патогенези тугрисидаги царашлар келтирилган. Бу патологиянинг генетик, микробиологик ва патологик томонлари курилган. Тугруцдан олдинги даврда амнион суюцлигининг оцишини кейинги ечимлари тугрисида фикрлар берилган. Куп сонли текширувларга царамай, бу паталогиянинг сабаблари охиригача урганилмаган. Аммо инфекция асосий омил сифатида тилга олинади.
Калит сузлар: тулиц цомиладорлик, тугруц индукцияси, амнион суюцлигининг пренатал оциши
One of the most common complications of pregnancy is premature and prenatal rupture of amniotic fluid. There is no single point of view regarding the cause of premature rupture of the membranes. In literature
Until now, the role and nature of changes in the structure of the membranes during prenatal and premature rupture of amniotic fluid are being discussed. There is an assumption that the clinical variants of premature drainage of water, as well as the peculiarities of the histological structure of the membranes, can determine the differences in the degree of risk of infection between the mother and the child.
The study of the histological structure of the membranes showed that they are metabolically active tissue and consist of amniotic epithelium, basal membranes, connective tissue, chorion and decidua. Connective tissue is built from collagen types 1 and 3, which provide the strength of the membranes. The basement membrane is located under the epithelium in the form of a narrow eosinophilic acellular mass; the compact layer is represented by a homogeneous mass devoid of cells (indicating the strength of the amniotic membrane) - [12]. A layer of fibroblasts is located in a dense network of collagen and reticular fibers and intercellular substance. The spongy layer of the amnion is connected by means of connective tissue fibers and intercellular substance with a smooth chorion. There are four layers in the smooth chorion: cellular; reticular, containing fibroblasts, and a pseudobasal membrane formed by a layer of trophoblast. Rupture of membranes before labor is called premature rupture of amniotic fluid. (PIOT)... Childbirth complicated by premature rupture of amniotic fluid during full-term pregnancy is 15.1-19.6% and 535% with premature birth (up to 37 weeks of gestation) and does not tend to decrease - [7, 9]. Leading obstetricians-gynecologists note that this pathology contributes to the growth of complications during childbirth and in the postpartum period on the part of the mother, fetus and newborn - [4, 6, 1]. It should also be noted that PIOT tends to re-develop in subsequent
births with frequency up to 20-32% - [4, 3, 2] Factors leading to FTI remain under discussion to this day. Despite the constant attention of scientists to the problem of PIOT, the etiology of this obstetric pathology remains completely unexplored, there are no clear ideas about the possible mechanisms of rupture of the membranes. Ladfors L., Chernukha E.A, Savelyeva G.M., Arias F. consider that PIO is a polyetiologic pathology - [9, 7, 4].
Antenatal rupture of amniotic fluid (IOM) is a serious problem in modern obstetrics. Amniotic fluid, or amniotic fluid, being a biologically active environment surrounding the fetus throughout pregnancy, performs a variety of functions, ensuring the normal functioning of the mother-placenta-fetus system - [1, 11]. According to - [3] childbirth against the background of prenatal rupture of the membranes is often accompanied by abnormalities of labor, hypotonic and atonic bleeding, high rates of trauma to the soft tissues of the birth canal.
The causes of prenatal rupture of amniotic fluid, despite numerous studies, have not been definitively established, although infection is considered the leading factor of this complication - [4, 10]. Daneshmand et al., (2012) concludedthat morpho - functional, physiological and biochemical changes in the genital tract during pregnancy lead to the fact that the vaginal microflora becomes more homogeneous, with a pronounced dominance of lactobacilli, which reduces the likelihood of contamination of the fetus with opportunistic microorganisms during its passage through the birth canal. But childbirth leads to significant changes in the qualitative and quantitative composition of the vaginal microflora. The number of non-spore-forming gram-negative strict anaerobes (mainly bacteroids), Escherichia significantly increases, and the levels of lactobacilli and bifidobacteria decrease. Violations of the normal vaginal microflora contribute to the development of such an infectious complication as endometritis. One of the mechanisms for maintaining
normal vaginal microflora is associated with the formation of lactobacilli during their metabolism of lactic acid and other organic acids that maintain a low pH of the vaginal environment. Acidification of various media during the growth of lactobacilli inhibits the proliferation of opportunistic microorganisms such as candida, peptostreptococci, bacteroids, gardnerella and other bacteria secreted from the vagina of women with dysbiotic disorders. Gram-negative obligate - anaerobic bacteria, some of their types, have pathogenic properties: they contain lipopolysaccharide in the cell wall, which is an inducer of IL-8, the main cytokine that triggers the inflammatory process. They are capable of producing succinic acid, which inhibits the migration of polymorphonuclear neutrophils and their phagocytic ability - [8, 13].
Prenatal the outpouring of amniotic fluid and the tightening of the anhydrous gap often leads to complications of the labor act (fast and rapid labor, weakness and discoordination of the contractile activity of the uterus), which aggravates the condition of the fetus and in some cases requires prompt delivery - [5, 2, 14].
The frequency of prenatal rupture of membranes varies widely: from 5 to 19.8% of cases in full-term pregnancies - [4, 16]. Childbirth in this case does not always end favorably for the fetus and mother. Childbirth and the postpartum period may have: the risk of developing purulent-septic complications in the mother, abnormalities in labor and intrauterine infection of the fetus. In addition, labor induction may be ineffective, which leads to an increase in the frequency of surgical interventions - [1, 15, 17]
Purpose of the study:
Study of diagnostic criteria for prenatal rupture of amniotic fluid, at the same time studying the role of infection in DOV, forreduction of obstetric and perinatal complications and the development of rational tactics of labor management, with prenatal rupture of amniotic fluid.
Materials and methods of examination:
To solve the set tasks, a comprehensive examination was carried out of 72 pregnant women whose childbirth was complicated with DIOV at 37-40 weeks of gestation, who were admitted to the Bukhara Regional Perinatal Center for the period of 2017. Anamnestic, clinical, laboratory and instrumental data were used to study the course of pregnancy, childbirth, the postpartum period, the condition of the fetus and newborn, and the readiness of the birth canal was assessed according to the Bishop scale. According to the National Standard for the Management of Patients with DIOVafter 18 hours of anhydrous interval, antibacterial therapy was carried out to prevent purulent-septic complications in puerperas. ROde pathways in women in labor DIOV were examined after 24 hours in the absence of labor in order to resolve the issue of the expediency of induction of labor. The nature of labor was monitored on the basis of partograms. Completed: observation ofhemodynamic parameters, keeping a checklist, measuring to-body every 4 hours, laboratory monitoring of leukocytes once a day, general urine analysis, analysis of vaginal discharge. Ultrasound of the uterus and fetus, cervicometry, monitoring of the rhythm and heart rate of the fetus andthe general condition of the woman in labor. Given the high sensitivity of vaginal and cervical bacteria to ampicillin, this antibacterial drug was used according to the protocol. The state of the fetus was assessed by ultrasound and cardiotocography (CTG), and the state of the newborn at birth was assessed by the Apgar scale. Fetal monitoring during labor was performed using the Corometrics 170 apparatus.
Results and its discussion: The average age of the observed women was 26.5 years. In all women, pregnancy proceeded against the background of extragenital diseases, and in most cases a combination of several of them. Mild and moderate anemia (72.2%), thyroid disease (33.3%) and varicose veins
(25%) prevailed. Every third woman (32%) suffered infectious diseases during this pregnancy, mainly in the form of ARI, exacerbation of chronic sinusitis, cystitis, pyelonephritis. 16.7% of pregnant women had ARI episodes during pregnancy many times. Among the transferred gynecological diseases, colpitis of various etiologies was most often diagnosed, which amounted to 43%. 72.2% of women had a history of previous inflammatory diseases of the genital tract. This mainly manifested itself in the form of yeast, Trichomonas and banal colpitis, endometritis and adnexitis. 19.4% of women were treated for cervicitis and cervical erosion. According to previous analyzes of vaginal smears, 43% of women had 3 and 4 degrees of purity of vaginal smears.
All women with prenatal rupture of amniotic fluid underwent valaginal examination to assess the maturity of the cervix using the Bishop scale. The assessment was carried out according to 5 criteria....It was found that 61.1% of the examined pregnant women parameters of dilatation, length, consistency, position of the cervix and the state of the presenting part of the fetus had points up to 5, which was assessed as "immature cervix". And in 38.9% of women, the birth canal was assessed as "mature cervix".
Accordingly, the tactics of further management were chosen according to the OPC protocol. In pregnant women with "immature" cervix, induction of labor with Glandin E 2,3 mg, 1 tablet intravaginally, was proposed after the informed consent of the pregnant woman and relatives. Conducted a conversation about Possible complications of labor induction. During the induction, monitoring of fetal heartbeats and uterine activity. The birth canal was reevaluated after 8 hours to clarify the need for continued induction. In pregnant women with a "mature" cervix, labor was carried out with expectant tactics until regular labor was played out, or a consultation of doctors resolved the issue of oxytocin delivery. 58.3% of pregnant women delivered through the vaginal birth canal. Newborns born
to mothers with DIOV were assessed on the Apgar scale by an average of 6 points.
In this way, studies have shown that in the majority of women in labor with prenatal rupture of the membranes, cervical readiness was assessed up to 5 points, which meant "unpreparedness" of the birth canal for childbirth. Of this number, 58.3% of women in labor underwent labor induction after the informed consent of the woman in labor and her relatives. 22.2% of women in labor had relative or absolute contraindications to labor induction and birth stimulation. The remaining 19.4% of women in labor refused to undergo labor induction, for which cesarean section was chosen as a further tactic of delivery. The study of the postpartum period showed that 26.4% of women had complications such as lochiometer and hematometer, manifested in the form of subinvolution of the uterus, based on substantiated clinical data and ultrasound examinations. Secondary healing of soft birth canal wounds was observed in 18.1% of women. U 2,
Conclusions:
1. Long dry period increases the incidence of newborns and postpartum women in the postpartum period.
2. A prolonged anhydrous period is a factor in increasing infection, which leads to an increase in obstetric and perinatal pathology.
3. Long dry period increases the contamination of the birth canal of the general and conditionally pathogenic flora and leads to an increase in the imbalance of the vaginal ecosystem.
These data dictate the need for the use of antibacterial drugs in women in labor with DIOV. The appointment of antibiotic therapy after 18 hours of anhydrous interval prevents the development of purulent-inflammatory processes in the body of the woman in labor and the fetus, causes colonization resistance and is not a contraindication to surgical delivery by caesarean section.
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