9. Practical skills on obstetrics and gynecology / of Metod.posobie//Tashkent 2008.
The case characteristic according to typological signs
The given case concerns a category room, subject. It volume, structured. It is a case-question.
On the didactic purposes a case trening, stimulating thinking in a real situation in the conditions of CRH.
The case can be used on disciplines: Obstetrics and gynecology. Urgent conditions.
«Methods of exzaminae of gynecologic patients»
The anamnesis, despite high technical equipment of modern medicine and introduction of numerous auxiliary methods of research, has not lost the urgency and now. Correctly and full collected data always is important, and is frequent and defining in a diagnosis establishment. The anamnesis provides gathering of following data: mediko-social given (factors of a family, a life and work); the transferred diseases and operations; hereditary factors; menstrual, sexual and generativ function; gynecologic diseases and operations with detailed elaboration of their current, treatment methods (the hormonal!) Both outcomes; complaints and history of the present disease; bad habits; allergic reactions and shipping of medical products; the data about health and diseases of the husband (partner); functions of adjacent bodies (urogenital ways, intestines). Many gynecologic diseases are specific to certain age. Function of genitals, and also their anatomic structure are exposed to age changes. Therefore some data representing the normal phenomenon for one age, can have pathological value for other period of life. Various diseases of genitals usually meet at certain age of the woman. Life conditions influence development of an organism of the woman and the sexual device with its numerous functions. Appreciably occurrence, a current and an outcome of the general diseases which can be a source of anatomic and functional anomalies of sexual sphere Acquaintance with a trade of the patient depend on living conditions helps to explain occurrence of additional complications (an allergy, nervous overloads, intoxications, etc.). A high-grade food defines correct development of an organism in is put-skom age and in puberty. A defective food in the childhood is at the bottom of a rickets with its consequences influencing the future genital function, cause later the puberty beginning, infantil genitals with adverse results (barreness, abortions). Defective (especially in a qualitative sense) a food can cause In adult women amenorey, gipo - oligo - opsomenorey, barreness.
Taking into account hereditary conditionality of many diseases it is necessary to receive data on mental diseases, endokrin frustration (a diabetes, a pathology of function of adrenal glands, gipotirioz, etc.) Presence of tumours (a myoma, a cancer of genitals and a mammary gland), pathologies of cardiovascular system at relatives of the first, the second and more remote generations. At women with infringement menstrual a cycle, barreness, superfluous girsutizm it is necessary to find out, whether close relatives (sisters, mother, the father) adiposity, oligomenorey suffer, whether there were cases abortion pregnancy. Great value for finding-out of character of gynecologic disease data on the transferred somatic diseases, their current, operative interventions concerning obstetric and gynecologic or eks-tragenitalnoj have pathologies. It is necessary to give special attention to the infectious diseases transferred at children's age and during the period on pubertate. They quite often make adverse impact on process of formation of the centres regulating function of reproductive system that causes frustration menstrual a cycle, reproductive function and development nejro-endokrinn diseases. It is necessary to receive data on diseases at which it was spent гормонотерапия because long, and quite often irrational use of hormones aggravates endokrin infringements, has negative influence on a metabolism.
Now very much the great value has the so-called "allergic" anamnesis (allergic reactions in the past, than they have been induced, shipping of medical products) Omission of this information to turn back catastrophic consequences in the course of treatment Finding-out of a state of health of the husband can is necessary for source specification infektion female genitals (a gonorrhoea, trichomoniaz) and the reasons of fruitless marriage. After acquaintance with the general data on the sick it is necessary to find out the complaints which have forced it to address to the doctor. Gynecologic diseases can be as the reason of infringements of reproductive function (barreness, self-any abortions), and their consequence (the inflammatory diseases which have arisen after abortions and sorts, neyroendokrin infringements after plentiful bleedings at lying-in women and women in childbirth other) . Most often patients have complaints to pains, bleach, a bleeding, infringement menstrual and genital function, infringement of function of the next bodies. At poll concerning the transferred diseases reveal the factors, capable to make adverse impact on a condition of genitals, and the diseases re-given by a hereditary way. Poll of the patient comes to an end with reception of data on development of the present disease. Time of occurrence of disease, its communication with that or other factor (childbirth, abortion, a trauma, менструация, cooling, the general diseases, etc.), a current, methods of research applied earlier and treatment, their results are specified. After poll the doctor usually receives the sufficient information for the presumable conclusion about character of disease. On the basis of the anamnesis data it is possible to put the correct diagnosis at 50-70 % of patients. For specification of the preliminary diagnosis after anamnesis gathering objective methods of research are conducted.
The general and gynecologic survey.
External survey of patients begins with an estimation of type of the constitution. The infantile type of a constitution is characterised by the small growth, the proportional addition in regular intervals narrowed by a basin. Mammary glands small, with flat and small dummies, insufficient development of hair on genitals is marked. The first mensis at such women quite often comes after usual term, and menstrual are characterised by an irregularity and morbidity. For women of hypersthenic type medium height is characteristic, the length of feet in comparison with length of a trunk is insignificant. The Hypodermically-fatty layer is usually developed Well specific functions of a female organism are not changed more often. Anatomic and functional weakness muscular and connecting tusis systems is inherent in asthenic type of women. Strengthening, lengthening and morbidity menstrual quite often take place. They after the delivery easily have a vagina and uterus omission in connection with weakness of the copular device and muscles pelvis a bottom. Uterus omission is sometimes observed at not giving birth women with the expressed asthenic constitution. Women intersexuale type usually have high enough growth, a massive skeleton, a wide humeral belt; the basin under the form comes nearer to the man's. Growth of hair on simfizis on man's type, gipertrichoz standing is marked. Are quite often observed infantile genitals, infringement menstrual functions, barreness. Between the specified basic types of the constitution there are various transitive variants. It is necessary to pay attention to character girsutizm, (especially superfluous), time of its occurrence. It is necessary to note presence of strips of a stretching on a skin, their colouring. Pay attention to skin colour. Pallor of integuments happens is caused by an anaemia more often. Hyperpigmentation or depigmentation skin is connected with function infringement endokrin glands. Mammary glands are a part of reproductive system, hormonal dependent body, a target for action of sexual hormones. Survey of mammary glands is spent in a standing position and lying, with the subsequent palpation external and internal kvadrant glands. It is necessary to consider a structure and the sizes of a mammary gland. At all patients it is necessary to pay attention to presence or absence separated of nipples, its colour, a consistence. Allocation of brown colour or with a blood impurity specify in possible malignant process. Milk or colostrum presence allows to establish the diagnosis galaktorey. Separated from a mammary gland it is necessary to subject to cytologic research. The palpation of mammary glands allows establish the diagnosis fibroz and kistoziz mastopatiy which can take place at 40 % of gynecologic patients. At its revealing it is necessary to make ultrasonic research of a mammary gland and mammagrafiy. Patients with this disease necessarily direct to the oncologist for performance of special methods of research. The condition of an internal is investigated on systems. Measurement of arterial pressure is made, character of pulse, frequency дыханий 1 minute are defined carried out перкуссия and аускультация heart and lungs. At survey of a stomach pay attention to its configuration, a swelling, symmetry, participation in the breath certificate, presence of a free liquid in a belly cavity. If necessary make measurement of a circle of a stomach by a centimetric tape. The stomach palpation is necessary for making in horizontal position of the patient after to empty a bladder and an intestines. By means of a palpation the condition of a belly wall (a tone, muscular protection, a divergence of direct muscles of a stomach), painful sites on it, presence in a belly cavity of tumours, infiltraty is defined. The palpation allows to define with known accuracy size, the form, borders, a consistence and morbidity of tumours and infiltraty, starting with genitals and settling down outside of a small basin. Perkussiya a stomach supplements a palpation and promotes specification of borders and contours of tumours, and also big infiltraty and exudate, the genitals formed at inflammatory diseases. Perkussiy at change of position of a body allows to reveal presence in a stomach cavity acitis the liquid which have streamed blood (the broken extra-uterine pregnancy, rupture ovari), contents custom at rupture of their walls. Perkussio can be used at carrying out of the differential diagnosis between parametrite and pelvioperitoniti. At parametriti borders infiltrate, defined by a way perkussiy and palpations, coincide, at pelvioperitoniti perkussion the border infiltrate seems less owing to pasting over its surface of loops of intestines. Ausculthion a stomach allows to define character peristaltic (parezis intestines, rough peristaltic). It helps at differential diagnostics between tumours of genitals and pregnancy. With the help auskulthion passableness uterinae pipes is defined at their blowing off. Gynecologic research includes survey of external genitals, research by means of gynecologic mirrors, vaginae research, two-manual (bimanual) research; rectum and vaginae-rectum researches. Research make in rubber sterile gloves in horizontal position of the patient on a gynecologic armchair after to empty a bladder and an intestines. At survey of external genitals consider degree and character of a scalp (on female or man's type); Development of small and big sexual lips, condition anus, presence of pathological processes an inflammation, tumours, ulcus kondilom, pathological allocation) Pay attention to, whether is not present omission or vagina and uterus loss, whether there is a pathological condition in area rectum apertures (varikoz knots, cracks, kondilome, allocation of blood, pus from a rectum). It is examined a vulva and an input in a vagina, taking into account their colouring, character of a secret, presence of pathological processes (an inflammation, cystom, ulcers), conditions of an external aperture urinae the channel and secretion channels bartolinae glands, virginae. Research by means of gynecologic mirrors make after survey of external genitals. Having entered mirrors into a vagina, survey mucous vaginas and uterus necks. Thus define mucous membrane colouring, character of a secret, size and the form of a neck of a uterus, a condition of an external pharynx, presence of pathological processes in the field of a uterus and vagina neck (an inflammation, traumas, ulcers, tumours, fistulas, etc.). At vaginal research the condition pelvic a bottom is defined, the arrangement area bartolinae glands is palpated. From a forward wall of a vagina the urethra is palpated the vagina condition, volume, fords mucous, an extensibility, presence of pathological process (infiltrate, hems, stenoses, tumours, developmental anomalies) Is defined. Reveal feature the vagina arches (depth, mobility, morbidity). Further investigate vaginal a part of a neck of a uterus size (a hypertrophy, gipoplazy), the form (conic, cylindrical, deformed by hems, tumours), presence of ruptures, a surface (smooth, hilly), a consistence (usual, softened, dense), position concerning a basin axis (it is directed before, back, to the left or to the right), a condition of an external pharynx (is closed or opened, the form a round, cross-section crack, gapes); mobility of a neck (it is excessively mobile, motionless or restriction is mobile). Two-manual vaginal-fbdominal wall research is the basic method of recognition of diseases of a uterus, appendages, pelvis abdomen and parametrium. In the beginning investigate a uterus At a palpation define its position, size, the form, a consistence, mobility, morbidity. Having finished uterus inspection, carry investigation of appendages. Fingers of an external and internal hand gradually move from uterus corners to lateral walls of a basin. Normal pipes usually are not defined, healthy ovari can be found at sufficient experience of the investigating. They are defined sideways from a uterus in the form of small oblong formations. Not changed sheaves of a uterus usually are not defined. At an inflammation, tumours it is possible palpation round, the basic, sakro uterinae sheaves. After a palpation of a uterus and appendages pathological processes in area pelvic (hems, solderings, etc.) come to light . Recto-abdominale and vaginal-rectale researches are made in following cases: at girls at аtreziy or a vagina stenosis, in addition to vaginal-abdominale research at tumours of genitals (especially a cancer of a neck of a uterus), at inflammatory diseases, presence allocation from a rectum. During research define, whether there are no tumours, polyps, narrowings and other processes in a rectum. The palpation of a neck of a uterus, pelvic, sakro-uterinae sheaves is made. At recto-abdominale a method investigate a body of a uterus and appendages. In the presence of pathological processes in a wall of a vagina, a gut and surrounding parametrium make recto-vaginalis research. With its help tumours, infiltratey and other changes in a wall of a vagina, a gut and surrounding are easily defined.
TOOL METHODS OF RESEARCH
Tool methods are applied to fuller inspection of gynecologic patients. Uterus sounding make with observance of all rules аseptic and antiseptics. It is carried out uterinae by a probe after previous definition of position of a uterus. Sounding allows to specify length of a cavity of a uterus, passableness of the cervical channel, precence stenoses and аtreziae, partitions in its cavity. It promotes revealing miomas knots (submucozis), polyps of a mucous uterus uterus Sounding apply not only with the diagnostic purpose, but also before manufacture of operations abrazio cavi uterus, abortion. Sounding with the diagnostic purpose is counter-indicative at sharp and chronic inflammatory diseases of a vagina, a neck, a uterus and appendages, and also at the established or prospective pregnancy. Separate (fractional) diagnostic abrazio a mucous membrane of the channel of a neck and a uterus body make for finding-out of a condition mucous at various good-quality and malignant processes (hyperplastic processes, precancer changes, a cancer). For performance of this operation bare a uterus neck in mirrors, fix for a forward lip and after uterus sounding expand cervicale the channel. Abrazio mucous cervcale the channel, and then a uterus body. Tuseus collect separately in vessels with formalin, mark and direct on histologic research. Biopsie make at pathological processes, at suspicion on the malignant formations localised in the field of a neck of a uterus, a vagina, external genitals and in a uterus cavity. For research it is necessary to receive a slice of a fabric from a suspected site. A material fence make by sektion a scalpel (less often konkhotomy) the changed site of a fabric. For correct histologic acknowledgement of pathological process the received material should contain the changed and not changed fabric (on border of the changed and healthy fabric). Аspiration biopsiy it is carried out by means of Brown's syringe without expansion cervicale the channel. A way аspiration receive endometrium from different departments of a cavity of a uterus (a bottom, corners). From received аspiration do dabs on subject glass with the subsequent research under a microscope. Аspiration biopsiy it is possible in out-patient conditions. Аspiration kuyretag it is carried out special hollow instrumental, connected to the vacuum pump. The aspiratsionnyj method of reception endometriy has advantages before abrazio a mucous uterus because of smaller travmatic fabrics and possibility of repeated application during menstrual a cycle. The puncture of a belly cavity through the back arch of a vagina is spent for the purpose of reception of contents of a belly cavity for differential diagnostics between extra-uterine pregnancy and an inflammation of appendages of a uterus, at rupture cistom formations or abscess break. At suspicion on a cancer яичника the puncture of a belly cavity for detection in асsitic liquids аtipical cages is carried out. A puncture make in the centre of the back arch of a vagina on depth to 2 sm a thick needle. Blowing off uterus pipes (pertubation) is used for passableness specification uterus pipes. The essence of a method consists that by means of the special device air which at passable pipes gets to a belly cavity is entered into a uterus cavity. Penetration of air into a belly cavity judge on a number of signs (painful sensation of the patient, noise of passage of air at auscultation of the bottom departments of a stomach by a stethoscope, air pressure decrease in system). Through not changed pipes air passes under the pressure of 75 mm hg, at stenozis pipes - at 100-125 mm hg; in case of impassability uterus pipes pressure increases in system. Кateterization a bladder in gynecologic practice it is made with the medical and diagnostic purposes. This method of research is applied at bladder-vaginalis fistulas to specification of their arrangement and size, for finding-out of capacity of a bubble, at suspicion on a stone or a foreign matter in a bladder, if necessary to deduce residual urine in the course of gynecologic research or at suspicion on a trauma of a wall of a bubble during gynecologic operation.
Cytologic and functional researches
Cytologic methods of research apply to diagnostics of hormonal function ovari, new growths of genitals and other pathological processes. A material for cytologic research receive in the various ways: aspirate from the back arch of a vagina, the channel of a neck and a cavity of a uterus, a belly cavity at a puncture through the back arch; reception of preparations-prints; a capture a stupid spoon superficial tuseys from suspicious sites of fabrics; washout from a surface of a neck of a uterus and mucous vaginas. From received for cytologic research a material do dabs with the subsequent microscopic research. Degree of cleanliness of a vagina is defined cytological by quantity of leukocytes, sticks of Doderlejna, various microorganisms. On impurity microflora distinguish four degrees of cleanliness of a vagina): I - in dab sticks of Doderlejna and a cage flat epitelium, reaction prevail
The sour; II - except vaginale sticks which it is less, in dab leukocytes (to 5 in sight), gramm + diploccocus, aerobic and аnаerobic coccus (but prevail lactobacteriy), reaction subacidic are found out;
III - влагалищных it is less than sticks, than other microorganisms, an abundance aerobic and аnаerobic кокков, leukocytes - till 15-20 in sight, reaction alkaline;
IV - it is few sticks of Doderlejna, set epiteliymic cages (including from deep layers), leukocytes and various microorganisms (strepto - and stafiloccocus, an intestinal stick, trichomonads, chlamidium, etc.) Reaction alkaline. In diagnostics of malignant new growths the cytologic method has auxiliary value. On a cancer in dab polymorphism of cages and kernels, a great number of mitoses is suspicious. In these cases after cytologic research it is made biopsiy. Dabs are investigated in native or the painted kind. Last years apply special methods of cytologic research - fazovo-contrast and luminescent microscopy. By means of fazovo-contrast microscopy investigate native dabs. At luminescent (fluorescent) microscopy dabs process fluroxromi dyes and investigate them by means of ljuminestsen microscopes. Recognition аtipic cages is based on morphological features and character of their luminescence. Cytologic research in a complex of tests functional diagnostik is widely used in gynecologic practice for definition of a condition of reproductive system. Research vaginale dabs (colpositigrammey) is based on definition in them of separate kinds of cages epitelium which changes depending on phases menstrual a cycle. For hormonal colpocitology it is necessary to take dabs each 3-5 days during 2-3 menstrual cycles. In out-patient practice it is possible to take throughout a cycle 3 dabs (for 8,14 and 22nd day of a cycle). At аmenore and оpsomenore it is necessary to take dabs once a week. For cjlpocitologi it is necessary to take vaginalis contents from the lateral arch as in the back arch of a vagina contents are mixed with a secret of cervical glands. Colpocitologocal research cannot be spent at a vagina inflammation, uteri a bleeding. The vagina mucous membrane is covered multilayered flat epithelium and consists of three layers: superficial, intermediate and bazale. In dabs from a vagina distinguish four kinds of cages: the superfisial intermediate, parabazale and bazale. On a parity specified epitelial cages judge a functional condition jvarian. It is accepted to distinguish following types vaginale dabs:
I type - dab consists from bazale cages and leukocytes that is characteristic for sharp estrogen insufficiency;
II type - dab consists from parabazale cages, meet separate intermediate and dazale leukocytes - insignificant estrogen insufficiency;
III type - in dab mainly intermediate cages, individual parabazale and superfisiale are found out. It testifies about easy estrogen insufficiency;
IV type - dab consists from superfasialis cages, the individual intermediate; bazale cages and leukocytes are absent. This type of dab is observed at sufficient estrogen saturations. For more exact estimation vaginale dabs the various are offered
The Kariopiknotichesky index (КPI) is a relation of number of superficial cages with picnotic a kernel to total number of the cages, expressed in percentage. During normal menstrual cycle КPI changes: during time folliculinae phases КPI - 25-30 %, ovulation - 60-80 %, in progesterone to a phase - of 25-30 %. Eozinifilae (аsidofil) an index - the relation superficial аsidofilae cages to superficial bazofile to cages. In folliculan menstruale a cycle it is equal to a phase of 20 %, during time ovuljatsii-to 70 %, in progesteron-to 25 %. The maturing index characterises a parity in dabs parabazale, intermediate and superficial cages. Formula shift to the left is characteristic for estrogen insufficiency, shift to the right - for high estrogen saturations. During menstrual a cycle under the influence of an estrogen and gestagene there is a change of cervical slime that is used from the diagnostic
The purpose. The quantity of a mucous secret in the channel of a neck of a uterus (a pupil phenomenon) depends from estrogen organism saturations. Its greatest quantity is observed during time ovulation, the least - before monthly. The test is estimated qualitatively and in points (1-3). The pupil phenomenon is based on expansion of an external aperture of the cervical channel and occurrence in it transparent glassed slime. It begins in I phase menstrual a cycle, is maximum - during time ovulation. The pupil phenomenon is defined at survey of a neck of a uterus in
Mirrors. The external pharynx of a neck of a uterus extends, reminding itself a pupil. The phenomenon of a pupil depending on degree of its expressiveness is estimated in points (1-3). The test is not characteristic at pathological changes of a neck of a uterus. The phenomenon of a fern (crystallisation) is based on ability of cervical slime at drying to be exposed to crystallisation, intensity to-toroj is maximum during time ovulation, in progesteronae a phase gradually decreases, and before the monthly is absent. Crystallisation of the slime which has been dried up on air, is estimated also on three-point system (+, ++, +++). Stretching cervical slime depends from estrogen a saturation influencing reduction of viscosity of slime and occurrence of fluidity. The tension is defined at careful cultivation tweezers after its extraction from the cervical channel. The maximum length of a thread time ovulation reaches 12 see Having combined a score at the account specified above tests cervical sli-zi, define cervical (cervicalis) number which makes in the beginning and the end menstrual a cycle 4-6, in a phase ovulation 10-12 points. The test bazal temperatures is based on hyperthermal influence of a progesterone on the thermoregulation centre. Measurement bazale body temperatures (morning rectal) allows to establish presence, expressiveness and duration progesteronae phases. At normal menstrual cycle bazal the temperature raises in progesteronae a phase on 0,4-0,8°С. The proof diphasic cycle (measurement bazale temperatures should pro-be found throughout 2-3 menstruale cycles) testifies about occurred ovulation and presence of functionally active yellow body. Absence of lifting of temperature in second half of cycle specifies on anovulation, and delay of lifting and its short duration (rise in temperature of 2-7 days) - in shortening lyuteinae the phases, insufficient lifting (on 0,2-0,3 °С) ++ - on insufficiency of function of a yellow body. The false result (increase bazal temperatures in the absence of a yellow body) can be at sharp and chronic infections, at some changes ЦНС. The skin-allergic test is based on occurrence of allergic reaction to intraskin introduction of hormonal preparations (an estrogen, a progesterone) during the periods of a saturation of an organism by one of these hormones. For test carrying out into a skin of an internal surface of a forearm enter 0,02 ml of 0,1 % of an oil solution estradiole benzoate or 0,02 ml of 2,5 % of an oil solution of a progesterone. At the maximum maintenance in an organism of this or that hormone occurs giperimiy and increase папулы to 10-12 mm. Biopsi endometrija - this histologic research tesus endometrial which change in reply to hormonal stimulation depending on a phase menstrual a cycle On biopsiy tnometrium define degree it is developed phases menstrual a cycle. The table of tests of functional diagnostics is called monociclogram, its link is the curve bazal temperatures, drawn on a calendar grid. Under research date mark the data colpocitogrammae, cervical phenomena, biopsiy endometrae.