Obs And Gyn Flashcards
Task 1
A 25-year-old puerpera(Time from the delivery of placenta through the first few weeks after delivery) was in the postpartum department of the city maternity hospital. The patient complained of chills, a rise in body temperature, and abdominal pain. The birth took place 2 days ago, with a complication in the third period of labor (a tight attachment of the placenta (placenta adhaerens)). The patient underwent manual separation and removal of the placenta (separatio et ex- tractio placentae manualis).Normally 3rd stage of labor is when the placenta is removed but in this patient it adhered to the uterus (endometrium
Clinician-observed, the patient was in the condition of moderate severity. Body temperature was 38.3 °С, pulse was rhythmic, 96 bpm. The tongue was moist and coated. The abdomen was soft, slightly tender in the lower parts, and the fundus of the uterus was at the level of the navel. The pa- tient had lochia rubra without odor(a normal bloody discharge after birth 1-4 days and it should not have a smell if it does then it’s bacteria infection.it should not smell like fish):The mammary glands were moderately swelled, not tender to palpation.
Task
1. Make a clinical diagnosis.
2. Explain the pathogenesis of the postpartum complication.
3. Decide on the treatment strategy and medication therapy according to the standards.
1.Diagnosis: Late postpartum period. Term labor complicated by an abnormally invasive placenta. Opera- tion: manual removal of placenta and afterbirth. Acute postpartum endometritis, the com- mon type.
2.Explain the pathogenesis of the postpartum complication
* Pathogenesis: the complications that have arisen are due to an invasive intrauterine procedure: the operation of manual separation of the placenta and the allocation of the placenta. Factors involved: activity of opportunistic microflora, invasive procedure, impaired contractile activity of the uterus (accumulation of blood in the uterus), manual separation of the placenta (damage and impaired epithelialization of the placental site).
Endometritis - transfer of other parts from the lower sections to the uterus + decreased immunity. Gave birth - ruptures - infection - endometritis.Thus this means during the manual operation bacteria would have being carried into the endometrium this leading to infection. And can also see symptoms such fever ,abdominal pain
3.Research plan
* Tactic: hourly thermometry
UAC (leukocytes, formula, ESR in dynamics h / z 4-6 h; at normal rate, elevated), LHC (CRP quantity)
* Ultrasound OMT (in order to exclude the presence of remnants of placental tissue - an enlarged uterine cavity, normally closed; hypoechoic contour of the uterine cavity, or fragments of placental tissue in the form of hyperechoic inclusions on the m-echo)
* Culture of blood , culture of lochia on nutrient media with the determination of sensitivity to antibiotics.
*Blood chemistry. Liver function test ,kidney function test
*ultrasound of abdomen Doppler
4. Treatment strategies
* Antibiotic therapy: protects penicillins (sultasin) or cephalosporins II-III, for example, ceftriaxone 1g 2 times / day intravenously administered up to 48 hours after the temperature has decreased, but not less than 5 days
* Uterotonics ( Oxytocin 5 U / m 2 r / d)
*pain and fever management acetaminophen 500-1000mg
* Infusion therapy with crystalloids ( Sterofundin isotonic) in a volume of up to 1 liter, taking into account the liquid administered with antibiotics
* Cancel GV, pumping every 3 hours (only on Cephson can you breastfeed)
* If the ultrasound OMT reveals tissue remnants - after the rate is normalized - hysteroscopy with gentle curettage of the cavity OR vacuum aspiration of the contents of the uterine cavity
Task 2
During a preventive examination, a 36-year-old woman was found to have a tumor of the left ovary. The tumor was mobile, with smooth contours and tight elastic consistency, measuring 8×8 cm(This is a cyst because normal size of a tumor is 1.5-2.0cm) The patient had one birth and two abortions. The patient had a regular menstrual cycle. Serum CA-125 level ( a test that measures amount protein cancer antigen(CA -125)was 20 UI / ml which normal (normal range is 0-35u/ml. Anything above 35 is indicative of cancer.HE4(Test for ovarian cancer) was 33.8 pmol / l. Normal range is up to 85pmol. Based on the pelvic ultrasound, the left ovary was an- echoic, measuring 75x80 mm, the capsule thickness was 2.5 mm; the inner and outer surface had well-defined and smooth contours, with single peripheral loci on CFM, no fluid in the posterior cul- de-sac was noted.
Task:
1.Make a clinical diagnosis.
2.Make a differential diagnosis between a functional ovarian cyst and a cystadenoma.
3.What would be the rational treatment if there were no signs of malignancy found?
Diagnosis: Volumetric formation of the left ovary or Massive formation of the left ovary(Functional cyst
2.make a differential diagnosis between a functional ovarian cyst and a cystadenoma.
* functional Ovarian Cysts
Ovarian cysts are fluid-filled sacs or pockets within or on the surface of one of the ovaries. Many women will develop them at some time during their lives and they are usually discovered during routine pelvic examinations. Most ovarian cysts are painless and cause no symptoms, usually disappearing on their own without the need for medical attention.
There are two main types of ovarian cyst: functional and pathological.
Most ovarian cysts develop as a result of the normal function of the menstrual cycle. These are known as functional cysts and are the most common type. Functional cysts are usually harmless, rarely cause pain and often disappear on their own within two or three menstrual cycles.
There are two types of functional cysts; follicle and corpus luteum.
Pathological Ovarian Cysts
These type of cysts are far more uncommon and have formed as a result of an abnormal cell growth, rather than the normal function of your menstrual cycle.
These cysts include; dermoid cysts, cystadenomas and endometrioma
Cystadenomas are basically benign tumors
These cysts develop from cells which cover the outer layer of the ovary and may be filled with a watery liquid or a mucous material. Instead of growing inside the ovary, cystadenomas are typically attached by a stalk to the ovary, and as such, they can grow to a very large size. Most are benign and, therefore not cancerous, though they should still be surgically removed.
- Research plan
- order to clarify the nature of the tumor, an additional examination is shown:
*CBC expanded (no changes in the form of a decrease in the level of Er, Hb, Ht, leukocytosis / leukopenia, an increase in ESR does not exclude the possibility of a malignant tumor)
* HD (no changes in the form of an increase in CRP, creatinine, urea, ALT, AST does not exclude the possibility of a malignant tumor)
* Coagulogram (the absence of changes in the form of hyper- / hypocoagulation does not exclude the possibility of the malignant nature of the tumor)
* OAM
Ultrasound OMT
* Calculation of the ROMA- test (assessment of the risk of developing cancer in women with ovarian opx) (based on CA-125, HE-4 + post- / premenopause), if <7.4, then the low risk of malignancy, if> 7.4 - high risk (these are numbers for the reproductive period / premenopause)
* RMI calculation
(AxBxC, where A - pre- (1 b) / postmenopausal (4 b), B - ultrasound signs:
bilateral / monolateral, solid, multi- / unicameral, metastases, ascites,
(more than 1 sign - 4 p, 1 sign - 1 b), C - level CA-125), if <200 - low risk of malignancy, if> 200 - high risk
* In the case of benign tumors, there will be no changes in the general examination, in case of malignant character of the opx, it is possible to identify - in the oak (anemia, increase / decrease in LC, increased erythrocyte sedimentation rate), tank (in case of metastasis of lesions org)
In order to exclude the germ cell nature of the tumor, taking into account the patient’s age (36 years) - study of serum for AFP , β -hCG , inhibin
* EGDS - exclusion of metastases in the ovary in gastric cancer According to indications (blood in the stool?) Colonoscopy; roentgen ogk
* Ultrasound of breast ,Ultrasound of OBP with assessment of pelvic lymph nodes + abdominal space
* MRI OMT with contrast (performed for all patients with suspected ovarian cancer)
4. Treatment and tactics
* Tactics:
Since this patient has no symptoms or problems we can just observe the patient,if patient comes with pain we can give oral contraceptives (estrogen 35mcg) to reduce the size of the cyst and after 1 month we can call for a follow up
*If there is a corpus luteal cyst rupture which causes the hemorrhage we can do a laparoscopic procedure to remove the blood from the abdomen and fluid
Task 3
A 52-year-old patient who had obesity, diabetes, and arterial hypertension had bloody discharge from the genital tract while she had been in postmenopause for 3 years. The patient underwent hys- teroscopy and fractional diagnostic curettage of the uterine cavity and cervical canal in the gyneco- logical hospital. Histology revealed highly differentiated adenocarcinoma.( This means the cancer grows slowly and and it’s spread is also slow but note poor differentiated cancer means the cancer grows rapidly fast and spreads really fast
Status genitalis: the uterus was of normal size, mobile, painless, pear-shaped. Uterine appendages were not enlarged. There was no parametrial infiltration. The cervix was normal. The patient had a small amount of bloody vaginal discharge.
Task:
1. Make a preliminary diagnosis and determine the pathogenetic type of endometrial cancer in this patient.
2. Specify a preliminary clinical stage.
3. List possible treatment options for this patient.
- Diagnosis : Endometrial cancer (adenocarcinoma), G1 phase, type I (estrogen-dependent endometrioid endometrial carcinoma).
Justification : histology revealed highly differentiated cancer which means cancer grows slowly and spreads slowly also women with endometrial cancer usually present with high levels of estrogen in post menopausal period than healthy post menopausal women. G1 phase because it’s well differentiated
pathogen variant 1 - since hormone-hormone dependent because there are usually high levels of estrogen in post menopause women
2.specify a preliminary clinical stage
* Based on the data of the stings, anamnesis, physicist, examination, gynecological examination and histological (when viewing the preparations obtained with rdv, no transition to CK was detected) stage 1.It’s well differentiated thus it’s stage 1 and according to FiGo classification of TMN cancer has no spread to lymph nodes or metastasized to other organs
3.Research plan
* General clinical analyzes
Ultrasound or MRI OMT (endom state m-echo cm thickness, 1ph not more than 8-10, 2 f 14-16mm; structure and c / t, length of the uterine cavity, contours of the uterus smooth / uneven, l / u), OBP, ZP , MF, RG OGK, mammography, FGDS, KFS, cystoscopy, CT um
- List possible treatment options for this patient
* If T1a is confirmed (invasion of less than half of the myometrium) stage, surgical treatment is indicated in the volume of extirpation of the type 1 uterus with appendages.
If she agrees to total hysterectomy we can go ahead
Task 4
A 24-year-old primigravida( a woman who is pregnant for the first time)was hospitalized in the surgical department of a multidisciplinary hos- pital with a diagnosis of 38-week pregnancy, acute appendicitis. The diagnosis was made on the basis of a thoroughly taken medical history, visual examination and palpation of the abdomen, and identification of the focus of severe pain in various positions. The number of leukocytes in periph- eral blood was 14.0 g / l, a leukocyte left shift was detected with an increase in the number of band neutrophils.
Task.
1. What would be the surgical tactics in this case?
2. What determines the tactics and scope of surgery for appendicitis in pregnant women?
3. Why was a pregnant woman with suspected acute appendicitis hospitalized in a surgical
department, and not in an obstetrics one
1.Diagnosis: Pregnancy 37-38 weeks. Acute appendicitis.
Surgical tactics: lower midline laparotomy, appendectomy, PD drainage. This is with catarrhal appendicitis. We are prolonging because the appendicitis needed to be treated before delivery on time through the ERP.Thus immediate surgery for acute appendicitis in pregnancy helps prevent infections of amniotic fluid and maternal infections
2.what determines the tactics and scope of surgery of appendicitis in pregnant women
* Signs of destructive (phlegmonous, gangrenous, perforated) appendicitis / the presence of peritonitis - an indication for a lower midline laparotomy, CS surgery, appendectomy, revision, hysterectomy, sanitation of the abdominal cavity, leaving drainages.
3. Why was a pregnant woman with suspected acute appendicitis hospitalized in a surgical
department, and not in an obstetrics one
* Hospitalized in a specialized institution - a surgical hospital, as there is a license to carry out surgical activities. Assessed by the most severe sign (that is, if there were appendicitis + eclampsia, they would be hospitalized in an obstetric hospital)because obstetric hospital will properly manage the eclampsia not that
In obstetrics we can do appendectomy - about ap-t during the CS (accidentally), a woman comes in with pain with s-m and on operations o.ap-t.
Task 5
A young nulliparous (a woman who has never given birth to a live baby)woman fell acutely ill on the second day after a surgical abortion. The patient complained of malaise, a rise in body temperature up to 39 °С, and a single chill. The patient took an aspirin tablet, called an ambulance, and was taken to the gynecological hospital on duty. During the examination, the patient had pale skin, tachycardia, an increased number of leukocytes to 13.6 x109, CRP ++, ESR 35 mm / hour. The abdomen was of the usual shape, soft, painful when palpat- ed above the womb. The patient had no signs of peritoneal irritation.
Status genitalis: the uterus is slightly enlarged, soft, mobile, tender; the cervical os is closed. Uter- ine appendages are painless and not enlarged. There is no parametrial infiltration. On visual exami- nation, the cervix is normal, the discharge is in small amounts, bloody and odorless.
Task:
1.Make a clinical diagnosis.
2.What would be a further examination for this patient?
3.Prescribe empiric therapy based on the presumptive and additional criteria of acute pelvic inflammatory disease.
4.What would be the algorithm of actions for suspected incomplete abortion?
- Diagnosis: Acute endometritis after abortion (N71.0 Acute inflammatory disease of uterus)
Justification of diagnosis: she fell ill after a surgical abortion with symptoms such as fever 39 degrees and during objective exam she had pale skin ; tachycardia, increased in leukocytes 13.6*109, cRp ++,ESR 35mm/hour. Abdomen was of usual shape,soft, painful when palpated above the womb and we can see her uterus was slightly enlarged
2: research plan for this patient
* Evidence-based: ultrasound, laparoscopy, hysteroscopy \
Thus, a set of examinations:
* General clinical all (OAC (leukocytosis, increased ESR), OAM, BAC (increased CRP), coagulogram (removed fibrinogen) …)
* Microscopy of discharge from the urethra, CC and posterior fornix of the vagina Buck sowing of discharge from the CC with determination of sensitivity to a / b
* Ultrasound OMT (dilated uterine cavity by m-echo - endometritis, if inclusions - incomplete abortion) - remnants of the ovum
*Ecg because she came with tachycardia
3: prescribe empirical therapy based on the presumptive and additional criteria of acute pelvis inflammatory disease
*empirical therapy: 1. Antibiotic therapy: Ceftriaxone 1 g 2 r / d i / v cap Gentamicin 40 mg 2 r / d 3 days i / m Metragil 500 mg 2 r / d 3 days i / v cap
* Chronic endometritis is typically treated with doxycycline 100 mg twice daily for 14 days. [4] For patients who fail doxycycline therapy, metronidazole 500mg daily for 14 days plus ciprofloxacin 400mg per day for 14 days can be used.
* Bed rest, diet easily digestible
* Until the temperature and symptoms disappear, then - taking into account the sensitivity to antibiotics
-NSAIDs in the absence of gastrointestinal pathology NSAIDs (Diclofenac 100mg + ppi omeprazole 20mg
-Uterotonics (Oxytocin 5 U)
-Infusion therapy: crystalloids (Sterofundin isotonic) up to 1 liter, taking into account fluid given with antibiotics
* If the temperature is also febrile, according to ultrasound, there are signs of the remains of the ovum, then, under
cover for antibiotic therapy, hysteroscopy + vacuum aspiration or gentle curettage is recommended
If the deterioration of the speakers does not wait for the temperature to drop, we go to the operation
In the postoperative period - COC for 6 months, physiotherapy is possible - UHF, magnetic laser
#criteria for acute pelvic inflammatory disease
PID Criteria:
Minimal: pain on palpation, with peritoneal irritation
Additional: temperature, leukocytosis, increased fibrinogen, CRP, ESR, patol leucorrhoea
- Algorithm Diagnosed with Acute post-abortion endometritis (incomplete abortion?)
* 2. Tactics for suspected incomplete abortion. - Based on: 1. Complaints: malaise, fever up to 39 ° C, single
chills 2. Anamnesis data: acutely ill on the second day after induced abortion at 6-7
weeks 3. Physical data: tachycardia, pallor of the skin, painful abdomen on palpation above the bosom. General examination - the uterus is slightly larger than normal size, softish consistency, moderately painful, scanty bloody discharge.
Diagnosed with Acute post-abortion endometritis (incomplete abortion?)
Task 6
A 38-year-old patient was referred to a gynecological hospital for hysteroscopy fractional curettage (a procedure where instruments are inserted through the vagina and cervix into the uterus to remove the uterine contents )due to symptoms of chronic abnormal uterine bleeding and secondary anemia (hemoglobin 80 g / l, serum iron 7 μmol / l). The menstrual cycle is regular.
The patient had one term birth and two spontaneous abortions. The patient used barrier methods of birth control.
Status genitalis: the uterus was enlarged corresponding to the 8-week gestation period, with tight consistency. Uterine appendages were not enlarged. On visual examination, the cervix was normal and of average size, the cervical os was closed. The patient did not want to undergo surgery to re- move the uterus because she was planning a pregnancy.
Task:
1.Make a clinical diagnosis.
2. Justify the diagnosis.
3. Make an examination plan.
4. What would be the treatment strategy after the diagnosis was accurate?
1.Diagnosis: Primary diagnosis: Uterine fibroids, 8 weeks. Suspected myomatous node type 0–3 accord- ing to the FIGO classification. Complication: chronic abnormal uterine bleeding, chronic posthemorrhagic anemia, class II.
-2. Justification:
* Hysteroscopy fractional curettage was performed to observe or to remove the uterine contents because this patient has chronic abnormal uterine bleeding which very typical classical symptoms of uterine fibroids
Palm coein is used by a doctor to determine the cause of abnormal uterine bleeding According to PALM-COEIN, the cause of Abnormal menstrual cycle or bleeding in the reproductive period can be:
P: polyps
A: adenomyosis
L: leiomyomas(uterine fibroids )benign growth in the muscles of the uterus
M:Malignancy :cancerous growth
C:coagulopathy:a problem with blood clotting
O: ovulatory dysfunction
E:Edometrial (conditions that affect the lining of the uterus (endometrium)
I:Iatrogenic-caused by medical procedures
*Thus we can see according to the palm coien FiGo classification number 3 (leiomyomas) thus it is myomatous node 3 and she had a complication post hemorrhagic anemia class II
3:examination plan
* Standard package of examinations: UAC, OAM, BAC, coagulogram, blood group, Rh,
at to HIV , at to Treponema pallidum, HBsAg, anti-HCV-total)
* Microscopy of the discharge from the CC and the posterior fornix of the vagina
* Smear for oncocytology
* hCG quality
* Ultrasound OMT Gold standard (to determine the localization, type, shape of the node) with Doppler Trans abdominal and transvaginal sensors are used
In the gynecological clinic: It is the Gold standard
*hysteroscopy, separate diagnostic curettage of the uterine cavity and cervical canal - we make a diagnosis - type, location, size
* Histological examination of scraping
Further tactics will depend on the results of the WFD study
4.Treatment strategy after diagnosis was accurate
Scope of surgical intervention:
* Myomectomy is possible if there is intact Organ preservation operation recommended by a woman of reproductive age to preserve reproductive function For excision laparoscopy or laparotomy For submucosal nodes - hysteroscopy
* Hysterectomy The only, leading to complete recovery (radical) method TOTAL HYSTERECTOMY. SUBTOTAL HYSTERECTOMY cervix.
* Medications can be prescribed such
- Progestogens oral capsules 400 mg once a day (per os, intrauterine device) Induce endometrial atrophy and decrease prostaglandin production in women with leiomyomas
-GnRH Receptor Agents (gonadotropin-releasing hormone agonists) Lead to suppression of pituitary ovarian function
-Antiprogestins (mifepristone 10 mg) Antiproliferative and proapoptotic effect
Task 7
A 32-year-old woman complained of bloody vaginal discharge, not associated with her period. Dur- ing the past four years, the patient had been undergoing periodic treatment for cervical erosion and had been receiving solkogil and using vaginal suppositories.
Status genitalis: the patient had an enlarged, dense, cervix with lumps. The body of the uterus was of normal size. Uterine appendages were painless and not enlarged. There was no parametrial infil- tration. On examination, there was a cauliflower formation on the cervix, measuring up to 3 cm in diameter; there was bleeding after examination.
Task.
1. Make a clinical diagnosis.
2. Make an examination plan according to the standards.
3. What would be the treatment strategy after the diagnosis was verified?
1.Diagnosis : stage I cervical cancer. Exophytic form(Exophytic cervical cancer IB1 Post coital )bleeding.
Rationale: Based on Complaints: indiscriminate bleeding from the genital tract ,cervical erosion is also pathogenic process of cervical cancer and because there was no parametrial infiltration it is stage 1 because parametrial infiltration is stage 2B
bimanual examination: an enlarged, dense, lumpy cervix is determined 3cm this is why it is stage 1B1 because the size is less than 4 cm or exactly 4 cm
Colposcopy: cauliflower-like growths are visible on the cervix. It’s exophytic because the tumor growth is above the surface epithelium of the cervix
2:Examination plan
* cytological examination of smears from the ecto- and endocervix,
* Extended colposcopy with biopsy, histological examination of the material
* Ultrasound OMT
-If the diagnosis of cervical cancer is confirmed, we refer the patient to an oncological dispensary to establish the st and choose a treatment method
* MRI OMT with contrast
* Ultrasound of OBP with assessment of pelvic lymph nodes + kidneys
* coagulogram
* examination of the cervix with speculum
* Complete blood count( anemia,platelets wbcs)
* HPVtesting,( human papilloma virus)
*blood biochemistry (liver function test;kidney function test)
* Excretory urography
* Scintigraphy of pelvic bones
3. Treatment strategies
* f IB2 st (cauliflower diameter 3 cm) is confirmed, the amount of treatment depends on reproductive plans.
If it is necessary to preserve the reproductive plans, it is shown - operation extended trachelectomy
In the absence of reproductive plans, a combined treatment is indicated -For stage Ib and selected IIa carcinomas of the cervix, either radical hysterectomy and lymph node dissection or radiation therapy with cisplatin-based chemotherapy should be considered.
Task 8
A 52-year-old patient went to the gynecologist with complaints of abdominal pain lasting for 2 years, dyspepsia, and abdominal enlargement. She was treated by a gastroenterologist for colitis. Her past medical history included 3 births and 4 abortions. The last visit to the gynecologist was 3 years ago. Postmenopause: 2 years. Objective findings: the abdomen is enlarged and tender in the lower parts, percussion reveals the presence of fluid in the abdominal cavity.
Status genitalis: palpation detected dense tumors in the area of uterine appendages; the tumors are stationary and moderately tender, the uterus is not palpable separately. The parametrium is not infil- trated(meaning it is not stage 2 cancer)The cervix has no visible changes, the discharge is light and mucoid.
Task
1. Formulate a clinical diagnosis.
2. Make an examination plan according to the standards.
3. Make a treatment plan.
1.Diagnosis: Bilateral ovarian tumors stage 1B. Ascites.
Rationale: based on the clinical evidence Status genitalis: palpation detected dense tumors in the area of uterine appendages; the tumors are stationary and moderately tender, the uterus is not palpable separately.Ascites(Objective findings: the abdomen is enlarged and tender in the lower parts, percussion reveals the presence of fluid in the abdominal cavity.)
2 research plan
* Pelvic exam. During a pelvic exam, your doctor inserts gloved fingers into your vagina and simultaneously presses a hand on your abdomen in order to feel (palpate) your pelvic organs. The doctor also visually examines your external genitalia, vagina and cervix.
* Imaging tests. Tests, such as ultrasound or CT scans of your abdomen and pelvis, may help determine the size, shape and structure of your ovaries.
*Blood test: test your blood for tumor markers that indicate ovarian cancer. For example, a cancer antigen (CA) 125 test can detect a protein that’s often found on the surface of ovarian cancer cells
*Liver function tests because of she has ascites (bilirubin, AST ALT)
*Kidney function test (GFr,creatinine BUN)
*complete blood count(CRP,ESR,Leukocytes,)
3.Make treatment plan
* Surgery is the primary treatment for ovarian cancer. It is used for staging and cytoreduction (debulking), but it is potentially curative in disease confined to the ovaries
* Fertility-sparing surgery involving unilateral salpingo-oophorectomy, preserving the uterus and contralateral ovary, is an option for women with early-stage invasive epithelial ovarian cancers, lesions with low potential for malignancy (e.g., lesions with histologically abnormal cells that are judged to have a low likelihood of developing into cancer), germ cell tumors, or sex cord–stromal tumors
* Postsurgical adjuvant chemotherapy is recommended for late-stage disease and stage II cases, but it is generally not indicated for disease confined to the ovaries.
* Postsurgical combination intraperitoneal and intravenous chemotherapy, in particular, increases the median survival rate by 12 months compared with intravenous chemotherapy alone, and is the current standard of care for late-stage tumors. Neoadjuvant (presurgical) chemotherapy has no advantage over postsurgical initiation of chemotherapy.
Task 9
A 31-year-old woman was admitted to the gynecological emergency department. The woman com- plained of abdominal pain, weakness, dizziness, and nausea. The patient got sick suddenly while she was at work. The patient noticed a 10-day delay in her menstrual cycle. The patient had three pregnancies: one term birth and two abortions. Clinician-observed, the condition was severe; the patient was extremely pale, and not alert (the patient had difficulty answering the questions and she also did it slowly). Blood pressure was 70 / 55, 65 / 50 mm Hg, heart rate was 120 bpm, the pulse was thready, the artery was easily squeezed. Respiration rate was 22 breaths per minute. The body temperature was 36.6 C. The tongue was moist. On palpation of the abdomen, the patient had a positive Kulenkampff sign(acute abdominal pain during palpating)
Status genitalis: the mucous membrane of the vagina and cervix was pale, vaginal discharge was dark, bloody, and in a small amount. It was difficult to palpate the uterus and uterine appendages due to sharp soreness, displacement of the uterus caused severe pain, uterine prolapse was detected. The posterior fornix overhung.
Task
1. Make a clinical diagnosis.
2. What would be therapeutic and diagnostic algorithm for this case?
3. What would be the treatment strategy and emergency measures in this case?
1.Diagnosis: Intra-abdominal bleeding. Hemorrhagic shock, class 3 Ectopic tubal pregnancy: rupture of the fallopian tube
Justification: we can see from objective examination patient was extremely pale and not alert (even difficult for her to answer questions and she did it slowly plus her blood pressure was very low 70/55,65/50 ,elevated Heart rate 120 ,threads pulse,elevated respiratory rate 22 this is indicative of (hemorrhagic shock class III. Ectopic pregnancy because her has risk factors such has multiple abortions and she has the above symptoms associated with severe bleeding and usually ectopic pregnancy is mostly occur in the fallopian tubes and in the case task we can see uterine prolapse a and it’s even difficult to palpate the uterus and uterine appendages due to sharp soreness and there is displacement of the uterus and posterior fornix overhung thus there is a ruptured ectopic pregnancy which lead to intrabdominal bleeding thus explains the bloody discharge and it explains the woman’s symptoms
2.what would be therapeutic and diagnostic algorithm
* Emergency hospitalization. Emergency operation.
* Calling an anesthesiologist-resuscitator, transfusiologist, nurse-anesthetist
* In parallel: catheterization of 2 peripheral veins with an 18G catheter
* In parallel: UAC (Hb, Ht, Er), BAC, CCK (INR, APTT, antithrombin III, fibrinogen, D-dimer), Lee White test, blood count, Rh, thromboelastogram
*HGc hormone pregnancy hormone is checked
*Ultrasound of pelvic
3.what would be the treatment strategies and emergency measures
* 1.In parallel: catheterization of the bladder and control of urine output (the test for hCG will put it ), the diagnosis will be WB interrupted by the type of rupture of MT
* 2.In parallel: infusion of crystalloid solutions up to 30-40 ml / kg
* 3.Transportation to the operating room
* 4.In parallel: monitoring blood pressure, SpO2, heart rate
*5. Surgical treatment - Lower midline laparotomy: intraoperative diagnosis, salpingoceliphoectomy
*6. in the presence of a cell-saver - autohemotransfusion or, according to indications, blood transfusion: HB less than 70, hematocrit less than 28% (or blood reinfusion)
*7. Indications for prolonged mechanical ventilation: unstable hemodynamics, continued bleeding, hemoglobin less than 70 g / l, saturation less than 70%, coagulopathy
*8. In the post-hemorrhagic period: control of blood pressure, heart rate, urine output, laboratory control (Hb, Ht, Er, fibrinogen, INR, APTT, TEG), low molecular weight heparins in the first 12 hours, elastic compression of the lower extremities
*9. Recommendations at discharge: Contraception for 6 months (if there is no RP), after 3 months check the patency of MT - chromohydrotubation / sonography (for RP)
Task 10
A 33-year-old woman in labor was admitted to the perinatal center. Intense contractions were every 2–3 minutes and lasted for 50 seconds. The patient was 40-week pregnant. The labor began four hours ago, and the water broke at the same time. This was the sixth pregnancy of the woman, the patient had one term birth and four artificial abortions.
Clinician-observed, the patient was 152 cm and 65 kg. Blood pressure was 130 / 80,125 / 80 mm Hg. Heart rate was 90 bpm. Pelvis dimensions were 27.5-28-30-18 cm Fundal height ( distance from mothers pubic bone to the top of the uterus) it basically assesses if the child suffers from macrosomia was 38 cm. Abdominal circumference was 105 cm. The Solovyov’s index was 1.6. The fetus was positioned with the head positioned longitudinally toward the pelvis. Fetal heartbeat was clear, rhythmic; 144 beats per minute. The Vasten’s sign was positive. During the contraction, the woman in labor was restless and screamed. On palpation, the lower segment was tender.
Per vaginum: the vagina of the parous, the cervix was smooth, the uterine pharynx was 9 cm open. The anterior cervix lip was swollen. The fetal head was down in the pelvis. The sagittal suture (su- tura sagittalis) was in the transverse diameter of the pelvis and deflected anteriorly. The diagonal conjugate (conjugata diagonalis) was 11 cm.
Task
1. Make an obstetric diagnosis.
2. Explain the etiopathogenesis of the complications that occurred in childbirth.
3. What would be the emergency measures?
1.Diagnosis: 40-week pregnancy. Remarkable obstetric and gynecological history. The first stage of term labor with cephalic presentation. Premature rupture of amniotic fluid. Flat rachitic pelvis, degree I. Posterior asynclitism. Large fetus (3990 g)( fundal height abdominal circumference 38105= 3990 ,Clinically contracted pelvis, degree 2. Rupture of uterus.
Rationale: Diagnosis is based on the features of the flat rachitic pelvis:
Patient got flat rachitic pelvis + large baby 3990 and the contracted pelvis,wrong position of fetal head posterior asynclitism which leading to overstretching the uterus leading to rupture
2.Explain the etiopathogenesis of the complications that occurred in childbirth
* Etiopathogenesis: a woman has a flat rachitic pelvis (a decrease in the direct size of the plane of entry into the small pelvis). 1 tbsp + fetal weight 3990 (up to 3600 usually) can give birth. Soloviev’s index = 1.6. (the thickness of the bones is greater)
The uterus contracted, but the head does not enter the plane of entry.
The head is configured prior to asynclical insertion, the true conjugate is insufficient to pass it. Overstretching of the uterus occurs => rupture
3:Emergency measures
1) Calling an anesthesiologist-resuscitator, transfusiologist, neonatologist-resuscitator
2) Call a nurse anesthetist; gravimetric blood loss control
3) Catheterization of 2 peripheral veins with an 18G catheter
4) Bladder catheterization, urine output control
5) Deep anesthesia (mechanical ventilation + fentanyl i.v.) in order to terminate labor
6) Operation of an emergency caesarean section, fetal extraction, separation of the placenta
7) After removing the fetus, we bring the uterus into the wound for revision and examination for a rupture, if there is, we suture the gap. If not, we finish the operation.
8) In the postoperative period - antibiotic therapy, prevention of VTEC
(compression hosiery, NMG - clexane(Enoxaparium 40mg ) anticoagulant/ fraxiparine(Nadroparin calcium) IV 0.3ml of solution
*** research plan= pelvimetry, ultrasound for shape and size of the head of the, blood fasting glucose for gestational diabetes
Task 11
In the Anesthesiology and Resuscitation Department of the Perinatal Center, there is a 36-year-old patient after caesarean section, performed two days ago due to the uterine scar. The patient has had increased body temperature of 37.9–38.6 °C from day 1 of the postoperative period. Antibacterial, IV and symptom-specific therapy is being carried out. During examination: the patient is coopera- tive and answers questions, body temperature is 38.1 °C, heart rate is 124 beats per minute, blood pressure is 110 / 70, 110 / 60 mm Hg, the tongue is dry and has white coating. Partial pressure of oxygen (PaO2) is 100 mmHg, FiO2 – 21% (oxygenation index 476). Platelets 150 x 10 9, bilirubin 20 μmol / l , blood creatinine 110 μmol / l. The abdomen is distended, soft, and tender in the lower parts, the Shchetkin – Blumberg’s sign (there is pain upon removal of pressure rather than application of pressure to the abdomen ) is weakly positive. Bowel sounds are not heard, gases do not pass, the conducted stimulation of the intestine is ineffective.
Task
1. Make a clinical diagnosis
2. Identify steps of diagnosis and treatment for this case.
3. What is your plan of actions in emergency care.
1.Diagnosis: Puerperal peritonitis after cesarean section, low-grade infection. Early stage.(postpartum period. Urgent operative delivery (2 days). A scar on the uterus. Obstetric peritonitis.
Justification- patient had a c.section after two days patient had increased body temperature 37.9-38.6 c from day 1 of the postoperative period , objective examination we can see patient had 38.1c heart rate is 124 beats ,blumberg’s sign which is associated with peritonitis)
2: identify steps of diagnosis and treatment
* lake formula in dynamics), LHC (CRP, quantitative procalcitonin test),
* hourly thermometry; sowing of blood, discharge from the uterus, ultrasound obp + kidneys and omt,
* ray of the lungs
* Blood for lactate
Evaluation of the patient’s condition according to the SOFA school (since in the OAID, if it were in the obstetric department, then according to qSOFA ) serves to assess organ failure, the risk of mortality and sepsis in patients in the intensive care and intensive care unit
3:Treatment strategies
* Treatment
Change ABT combination (cefson and metronidazole / cefson and gentamicin (1mg / kg in 1ml 40mg 2-3r / d) or meropenem 1g 3r / d i / v)
Stimulus gut (proserin 15mg daily dose)
Infuz ter
* Extracor methods of detoxification ( hemosorption, plasmapheresis, laser blood irradiation, ozone therapy ) elimination of toxic substances, antigens; there is a decrease in blood viscosity, improvement of microcirculation, normalization of altered tissue metabolism
* Hir treatment - relaparotamia, h / e with mat tubes (we leave the ovaries - do not enter inflammation, because the abdomen is not covered), sanitation and drainage of the BP (c / w the vaginal stump)
* The focus of infection is the uterus!
Causes of AP: chorioamnionitis, postpartum endometritis, incompetence or dehiscence of the sutures on the uterus after CS.
Task 12
A 20-year-old first-time pregnant woman with complaints of poor sleep, headache, vomiting, and eye floaters at 37 weeks of pregnancy was delivered to the perinatal center from the gynecologist by ambulance. The gynecologist gave her 250 mg of Methyldopa.
Objective findings: height 166 cm, weight 83 kg. The skin is somewhat pale; swollen face and legs and anterior abdominal wall edema are noted. Heart rate is 92 beats per minute, blood pressure is 175/115, 180/110 mm Hg. The uterus is enlarged according to the gestation period, uterine tone in- creases upon palpation. Longitudinal fetal lie, cephalic presentation, the head is pressed against the entrance to the lesser pelvis. Fetal heartbeat is clear, rhythmic, fetal heart rate is 132 beats per mi- nute.
An internal obstetric examination was conducted in the emergency room. Per vaginum: vagina of a nulliparous woman, uterus is retroverted, up to 2 cm long, dense, the cervical os is closed, the fetal head is pressed against the entrance to the lesser pelvis. Sacral promontory cannot be reached.
After the vaginal examination, the patient developed a convulsion and lost consciousness.
Task
1. Make an obstetric diagnosis.
2. Identify the algorithm of providing medical care in this situation.
3. Specify the choice of time and method of delivery for this obstetric pathology.
4. Evaluate the actions of medical workers at the pre-hospital stage.
1;Diagnosis:
Obstetric diagnosis: pregnancy of 37 weeks, incompetent cervix, eclampsia.(Pregnancy 36-37 weeks) convulsions and loss of consciousness and we can see other symptoms such as eye floaters and headaches
Justification of diagnosis: basically preclampsia is just sudden spike in blood pressure while eclampsia is more severe which can lead to seizures or coma and in this patient she already had high blood pressure which later developed to eclampsia that’s why she got convulsions and loss of consciousness
2: identify the algorithm of providing medical care in this situation
* During convulsions, provide help - keep from falling, head on one side, mouth dilator, carry oxygen place the patient on the left lateral lie and make sure we clear obstruction or foreign objects from the air ways
* Call the anesthesiologist and deploy the operating room, start the pre-trial therapy immediately magnesium sulfate - a 16 ml bolus of 25% MgSO4 (4 g) intravenously for 5 minutes, then maintenance therapy 4-8 ml (1-2 g) per hour through a perfuser!
* We continue up to 24 hours after delivery
Then nifedipine 10mg orally. If the patient is unconscious - nifedipine is liquid
-Methyl dopa 250-500mg
-Labetalol 100mg three times daily
-hydralazine 10-25mg 2 times daily
-Antibiotics for prevention of infections after c.section
Indications for intubation
*seizures is not controlled
*patient remains unconscious
*signs of aspiration
*post seizures hypoxia
3: specify the choice of time and method of delivery
*Method of delivery is c.section
*Transfer to the operating room after introducing nifedipine
* Peripheral catheterization, blood tests are taken. KLA, biochemical, coagulation system, blood group and Rh factor with phenotype, for compatibility.
* Prod-m infusion + monitoring (control of blood pressure, heart rate, saturation, NPV, rate, ECG and CTG)! + transfer to IVL and anesthesia , then the MP catheter (so as not to give an attack)
<~ As soon as the pressure is less than 150 and below, we begin the operative delivery by means of the CS (the baby is premature - we cause detrenimation)
Ivl prod-m to complete hemodynamic norms
24 hours after the end of the CS, we continue the anticonvulsant therapy we can give
*Benzodiazepine- Diazepam 5-25mg 3 times day
*Phenytoin oral 100mg 3 times a day
We translate into methyldopa. For refractory hypertension, ebrantil (urapidil) can be used after fetal retrieval
4:Evaluation of the actions of medical workers at the pre-hospital stage
* when the patient came in with preeclampsia methyl dopa should have been given together with magnesium sulphate to prevent eclampsia that is what lead to the convulsions
Task 13
A 19-year-old woman, 35 weeks pregnant, was delivered to the perinatal center by ambulance. It was her first pregnancy, she had not visited a gynecologist for a month. The patient became acutely ill 2 hours ago. She experienced severe abdominal pains and generalized weakness. Later, she de- veloped vaginal bleeding (approximately 100 ml).
Objective findings: the condition is of moderate severity. The patient is conscious, the skin is pale. Blood pressure is 100/50, 100/60 mm Hg. Heart rate is 100 beats per minute. The uterus corre- sponds to the gestation period, it is tense and does not relax. The fetal parts are difficult to recog- nize. Fetal heartbeat is dull, 100 beats per minute. CTG is 6 points on the Fisher scale( fisher score is just an indicator which shows normal activity of the fetus such as baby’s heart ,condition normal score 8-10 but here fisher score 6 which is not normal if the score is 0-4 it means fetus is in a severe state which needs immediate hospitalization
Per vaginum: vagina of a nulliparous woman, cervix is well-formed, the cervical os is closed. Ce- phalic presentation of the fetus, the head is located over the entrance to the lesser pelvis. Vaginal discharge: dark-colored blood, 100 ml.
Task
1. Make an obstetric diagnosis.
2. What is a modern algorithm for providing medical care for this disease?
3. Justify the choice of time and method of delivery for this obstetric pathology.
4. List possible complications that occur in delivery with this pathology.
1.Diagnosis: 35-week pregnancy. Placental abruption, moderate severity. Fetal distress. Hemorrhagic
shock, class 1
Justification:35 weeks pregnancy is premature and it’s not normal gestation, placental abruption is justified due to we can see fetal parts are difficult to recognize and fetal heart beat is dull and placental abruption is the most common cause of fetal distress because detachment of placenta from the wall of the uterus leads to decreased supply of oxygen and nutrients to the fetus and can cause heavy bleeding in the mother we can see patient lost some blood 100ml
Differential diagnosis include placental previa,uterine rupture ,chorioamnionitis. She is in shock 1 according to the classification of shock her symptoms are mild no loss of consciousness and her blood pressure is slightly reduced and no respiratory problems
2.what is algorithm for providing medical care for this disease
1.Calling an anesthesiologist-resuscitator, transfusiologist, neonatologist-resuscitator
2. Catheterization of 2 peripheral veins, Catheterization of the bladder, control of urine output
3. Parallel: transportation to the operating room
4. Administration of Tranexam 15 mg / kg followed by infusion of 5 mg / kg / hour until bleeding stops
5. Infusion therapy: crystalloid solutions (Sterofundin isotonic) up to 30-40 ml / kg. In case of ineffectiveness of crystalloids - infusion of synthetic colloids
6. In parallel with the therapy: monitoring of blood pressure, SaO2, heart rate
7. In parallel: KLA, BAC, SSC (APTT, INR, antithrombin III, fibrinogen, D-dimer), Lee White test, blood group, Rh factor
8. Performing thromboelastogram
9.Transfer of the patient to mechanical ventilation, provision of general anesthesia with fentanyl IV
10.Administration of FFP 15-20 ml / kg
11. At Hb <70 g / l - erythromass of at least 2 doses
12. Coagil 90-110 μg / kg
13. If the number of platelets is <50 thousand - thrombomass
14. Vasopressor support: Norepinephrine 0.1 μg / kg / min
15. Delivery by caesarean section. WITHDRAW THE UTERINE INTO THE RANGE in order to exclude the presence of Couveler’s uterus
We can also do fetal monitoring any signs of distress we can give corticosteroids
IF KUWELER’S UTERUS (uterus soaked in blood, hemorrhage in the muscle. St and under the serous membrane) - consultation (2 doctors or more) intraoperatively, the decision on the scope of the operation —– KS If the contractility of the uterus is not violated, there is no bleeding - compression sutures on the uterus, suture in, leave the drains
If all this is available - compression sutures, ligation of vascular bundles, hysterectomy, drainage through the vagina
16. In the postoperative period: clinical and laboratory control, thromboprophylaxis - LMWH, elastic compression of the lower extremities, antibiotic prophylaxis - cefabol
3.justify the choice of time and method of delivery
* Emergency c.section + after extraction of the fetus and placenta, remove the uterus into the wound (excluding the cuveler uterus) + compress prophylactic sutures,
Indications for hysterectomy - the uterus does not contract, uterine bleeding continues, blood loss of 2 liters or more
Less than 2 l, retained the sokrat rate M, no c / t - retained the uterus and compression sutures
4. List complications that occur in delivery with this pathology
* For the mother, placental abruption can lead to: Shock due to blood loss. Blood clotting problems. The need for a blood transfusion.
-For the baby, placental abruption can lead to:
* Restricted growth from not getting enough nutrients.
* Not getting enough oxygen
* Premature birth.
* Stillbirth
* increased rate of cerebral palsy and developmental disorders in the offspring later in life.
Task 14
A 32-year-old puerpera was in the individual delivery room of the perinatal center. It was patient’s fourth pregnancy and birth. Labor activity developed satisfactorily, and after 9 hours, a live full- term girl weighing 4,450 grams was born. In order to prevent bleeding, 10 units of oxytocin were administered intramuscularly to the puerpera.
Fifteen minutes after the birth, the placenta separated and the afterbirth came out intact. The blood loss was 250 ml. After 20 minutes, bleeding began from the genital tract. Catheterization of 2 pe- ripheral veins and catheterization of the bladder were performed, crystalloids were administered. The uterus was soft, after external massage, about 300 ml of liquid blood and clots were released. The uterus became somewhat denser, then relaxed again.
The condition was satisfactory, heart rate was 96 beats min, blood pressure was 110 / 60 mmHg, 110 / 70 mmHg, oxygen saturation was 98%.
Task
1. Make an obstetric diagnosis.
2. Make a differential diagnosis according to the protocol (the four T’s)
3. What would be the treatment strategy: sequence of measures to stop bleeding, prevention of shock?
1.Diagnosis : Early postpartum hypotonic bleeding. Pathological blood loss(blood loss 550 ml) Large fruit
Justification:patient loss blood 250ml +300 ml after birth which according to normal vaginal delivery blood loss should not be more than 500ml
Post Partum bleeding we can see bleeding from genital tract and blood pressure is reduced
Normal blood loss in delivery in delivery is 500ml
C:section 100ml
Hysterectomy is 1500ml
- Differential diagnosis
T- Search for the source of bleeding “4T”: tissue, tone (placental site is bleeding), thrombus, trauma
Fabric - whole afterbirth when examined!
* thrombin<1% : to check if patient has problems with coagulation Lee White test (normally 3-5 minutes) (excluded, since there is no history of pathological hemostasis, 32 years - three births without bleeding)
* tone: Atonic uterus doesn’t not contract enough to clamp the placenta shunt so that the bleeding can stop it will lead to bleeding
* trauma: uterine rupture ,uterine lacerations of cervix ,vagina : examination of the vagina, cervix for ruptures, if a rupture is found, it is necessary to suture
***This can be atonic uterus or trauma because of the size of the baby 4450. ( large fruits)
3. Treatment strategies and sequences of measures to stop bleeding,prevention of shock
* Given the blood loss of more than 500 ml - pathological
*Call an anesthesiologist
*for transfusion if Haemoglobin is less than 80 we should give blood transfusion
* ABP, intravenous anesthesia - surgery for revision of the uterine cavity followed by bimanual compression of the uterus
* Inspection of the birth canal for their integrity
* Continue uterotonics therapy within 24 hours in the postpartum period (early 2 hours, late 42 days, postpartum wounds 24 hours, later until 42 days)
* Shock profile k / t tranexam 1000mg, infusion therapy, main function monitor
During and after the operation, look at the level of hemoglobin and EC - to resolve the issue of transfusion
* Revision of the uterine cavity will add 200-300 ml = 800 ml
* If the first stage is not effective and blood loss is 1L, install an intrauterine balloon
If cr / loss of 1.5 L and the balloon is not effective - laparotomy and compression sutures on the uterus
If 2 l - extirpation of the uterus with MT
Treatment of posthemorrhagic anemia
* Calling an anesthesiologist-resuscitator
* Catheterization of 2 peripheral veins with an 18G catheter
* Bladder catheterization with assessment of urine output
* In parallel: KLA (hemoglobin level, hematocrit, erythrocytes, platelets), Lee-White test, CCK (fibrinogen, PTI, APTT, INR, antithrombin III), thromboelastogram
* In parallel: infusion therapy - intravenous Ringer’s solution 500 ml with 10 U of Oxytocin
* Search for the source of bleeding “4 T”
Task 15
In the maternal child unit of the Central City Hospital, there is a 29-year-old patient. Term birth took place 5 days ago and was complicated by premature discharge of amniotic fluid and failure to progress in labor. The baby had access to the breast 2 hours after the delivery and sucked actively. On day 3 after the delivery, the mother developed breast engorgement and had difficulty expressing milk.
On day 5 after the delivery, the mother had chills, headache, weakness, and pain in the right mam- mary gland, body temperature rose to 38.4 °C. The mammary glands were in a state of pronounced engorgement, there were cracks on the nipples. Palpation revealed a tender lump in the outer - quadrant of the right mammary gland with hot skin above it and skin hyperemia.
Task.
1. Make a clinical diagnosis.
2. List predisposing factors of the disease. Describe clinical classification of mastitis.
3. What are additional examinations and treatment according to the standards?
4. What are indications for lactation suppression and methods for it
1.Diagnosis: Postpartum lactation Urgent labor 5 days infiltrative mastitis of the right breast. stage of infiltration.
2:list predisposing factors of the disease
* Previous bout of mastitis while breast-feeding
* Sore or cracked nipples — although mastitis can develop without broken skin
* Wearing a tightfitting bra or putting pressure on your breast when using a seat belt or carrying a heavy bag, which may restrict milk flow
* Improper nursing technique
* Becoming overly tired or stressed
* Poor nutrition
* Smoking
Clinical classification of mastitis
-Mastitis is inflammation of the breast tissue and can be broken down into lactational and non-lactational mastitis.
Two types of non-lactational mastitis include periductal mastitis, and idiopathic granulomatous mastitis (IGM).
1. Lactational mastitis, also known as puerperal mastitis, is typically due to prolonged engorgement of milk ducts, with infectious components from the entry of bacteria through skin breaks. Patients can develop a focal area of erythema, pain, and swelling, and can have associated systemic symptoms, including fever. This occurs most commonly in the first six weeks of breastfeeding but can occur at any time during lactation, with most cases falling off after 3 months
2. Periductal mastitis is a benign inflammatory condition affecting the subareolar ducts and occurs most commonly in reproductive-aged women. Idiopathic granulomatous mastitis is a rare and benign inflammatory condition that can clinically mimic breast cancer.The condition occurs primarily in parous women, most commonly within 5 years of giving birth.
3.what is additional examinations
* 1. Additional examination: CBC every 6 hours (leukocytosis, increased ESR, neutrophilic shift to the left), BAC (CRP amount), milk culture with determination of sensitivity to a / b, blood culture, ultrasound of the mammary gland (infiltrative form - areas of a homogeneous structure with a zone of inflammation around, lactostasis, with purulent - dilated ducts, alveoli, cavities, “honeycomb” pattern, serous - lactostasis, shading of the pattern)
4: what are indications for lactation suppression and methods for it
* Stop feeding, continue lactation (expressing milk)
* Antibiotic therapy (Amoxicillin + Clavulanic acid 1000 + 125 mg 3 times a day i.v. then orally, min 7 days course or Ceftriaxone 1 g 2 r / d i / m 5 days)
* After the culture results - targeted therapy. Treatment of nipple cracks - actovegil, biponten. Semi-alcohol compresses or with Vishnevsky ointment for infiltrates or physio (Electrophoresis with 40% alcohol / with magnesium sulfate)
If there is no effect - repeated ultrasound in order to exclude signs of abscess formation.
* If an abscess is detected , surgical treatment, opening and drainage of the abscess + suppression of lactation
Indications for lactation
* . Indications for suppression of lactation: purulent or abscess mastitis; HIV infection and the use of drugs for k-x lactation is contraindicated (depakin chrono for epilepsy)
*. Methods for suppressing lactation: Dostinex (Cabergoline) ½ tablet 2 r / day for 2 days OR Parlodel (Bromocriptine) ½ tablet 3 r / day 5 days
*estrogens
