Tashkent medical academy f. I. Shukurov case stady

Hormonal researches

Modern methods of research allow to define presence even insignificant quantity as polipepnidis, and steroid hormones. With that end in view methods radioimmunologic the analysis for definition in blood of the maintenance of hormones hipotalamus (Lg, FSG), a hypophysis (FSG, LG, prolactin, AKTG, ТТG, etc.) are widely used ovarian (estrogen connections Э1, Э2, Э3, a progesterone, anndrogenes). Adrenal glands (коrtizol, testosterone, aldosteronae), a thyroid gland (Т3, T4) and others endokrin glands and fabrics. The maintenance of hormones and them metabolic in daily urine is less often investigated. In urine are defined 17-KS-metabolity аndrogenis which women in an organism are formed in ovarian, adrenal glands and aut of ovarica. In a kind 17-KS are allocated degidroepiandesteronae, its sulphate, androstendion and аndrosteron. Indicators 17-KS at women of reproductive age fluctuate from 20 to 41 mkmol/l. For research glukokortikoids functions of adrenal glands define the 17-Construction Department maintenance in urine. Daily quantity of 17-Construction Department equally 11-28 mkmol/l. The maintenance of all hormones, especially sexual steroid and albuminous nature, has the expressed fluctuations both during menstrual a cycle, and by other cyclic variants. Activity endokrinae the systems, connected with reproductive function of the woman, in periovulatoriy the period is most expressed. Therefore it is expedient to spend research of the maintenance of hormones two or three times during menstrual a cycle (for 8, 13, 15 and 20th days). For topic and differential diagnostics endocrine diseases as across (ovarian-adrenal glands - a thyroid gland), and on a vertical (a uterus-ovarian-hypophysis-gipotalamus – neyrotransmetter mechanisms) carrying out of hormonal functional tests is quite often necessary. Hormonal tests, besides, allow to specify a functional condition of various departments gipotalamo-gipofizar-ovarica systems. Tests with hormones are specific, often are spent is out-patient. Following tests are most extended. Test with a progesterone is applied at аmenore any aetiology, but basically to an exception uterian forms. Test is considered positive if in 2-4 days after 6-8-daysо intramuscular introduction of a progesterone (10 mg/sut) or in 8 10 days after unitary introduction OPK (125-250мг) at sick there is menstrual a reaction. Positive test excludes uterus the form amenore and testifies to deficiency of a progesterone. Negative test can be at uterus to the form amenore or at estrogen insufficiency. Test with a progesterone can be applied to differential diagnostics giperandrogeniy ovarian and over a kidney genezis. Before test define 17-KS. Decrease 17-KS and more after test carrying out specifies in 50 % on ovarian genezis diseases. Test with an estrogen and a progesterone is spent for an exception (acknowledgement) uterus or ovarica forms amenorea. The patient within 10-14 days enter one of estrogen preparations intramuscularly (an estradiol benzoate on 1 ml of 0,1 % of a solution, folliculini1 ml of 0,1 % of a solution) or inside etinil-estradiol (microfollini) 0,1 mg (2 tablets on 0,05 mg in one stage), then a progesterone in the doses specified for test with a progesterone. Approach menstruale reactions testifies to the expressed deficiency endogen an estrogen; the negative result specifies on uterus the form amenore. Test with the preparations combined an estrogen-gestagen (novinet, regulon) is used for definition of a functional condition

gipotalamo-gipofizari systems. Preparations of this group appoint under the 21-day scheme within 3 months. Presence ovulation after carrying out of this test specifies in a good condition gipotalamo-gipofizar systems. Absence of response testifies to infringements in gipotalamo-gipofizar to system. Test with chorial gonadotropine (choriogonine) is applied to condition specification ovarica. After introduction chorial gonadotropine at functionally high-grade ovarica raise the maintenance of a progesterone and bazale temperature. For test carrying out chorial gonadotropine enter on 1500 ЕД intramuscularly within 5 days from 12th cycle till 14th day at regular menstrual a cycle, at amenore - irrespective of a cycle. If after test carrying out at amenore in some days there is mtnstruale a reaction, test is regarded as positive (insufficiency lutropinae a hypophysis and normal reaction ovarica). At primary defeat ovari test will be negative. Test with klomifeni is shown at the diseases accompanied anovulation, more often against oligomenore or amenore. Test spend after monthly or menstruale the reaction caused by carrying out an estrogen-progesteronae of test, appointing klomifensitratis with 5th till 9th day from the beginning menstrual reactions on 100 mg a day (2 tablets on 50 mg). Klomifenae-antiestrogen action is carried out through hipotalamus. Negative test with klomifen (absence of increase in concentration estradiolae, gonatropbyae in blood plasma, monophase bazalae temperature, from-sutstvie menstruale reactions) specifies on gipotalamo-gipofizarae infringements. Test with luledireni spend at negative test with klomifenae. Intravenously enter 100 mkg of synthetic analogue luliberine and define the maintenance лютеинизирующего a hormone in blood prior to the beginning of introduction and after introduction. At positive test by 60th minute the maintenance ljuteinizi-rujushchego a hormone increases to ovulator figures that specifies in function infringement hipotalamus and the kept function of a forward share of a hypophysis. Test with follitropin is used for definition of a functional condition ovarica. For test carrying out the preparation FSG actions is intramuscularly entered: pergonal (5000 ME6-10 days), folistiman (200 ME 3-5 days). Positive test with FSG a hormone (increase excresio an estrogen) testifies about hipofizare genesis patology but normal function ovarica. Negative test means primary defeat ovarica. Test with dexamethasone or prenadzolone is applied to character definition giperandrogeniy and based on oppression of secretion the CERTIFICATE. Test consists in dexamethasone appointment on 2 mg/sut (in 4 receptions) in those-chenie 2-3 days or prednizolonae on 20 mg (in 4 receptions) within 5 days. It is small dexamethazonae test. At the big test the patient accepts 8 mg of dexamethasone a day (in 4 receptions) within 3 days. Before test carrying out define the maintenance 17-KS. Maintenance decrease 17-KS after test carrying out specifies in 50-75 % on supra a kidney a source androgen (test positive); on 25 30 % - on ovarica an origin androgenae (test negative).

Endoskopichesky methods

Endoskopichesky methods of research have started to be developed with the beginning of last century. However their development and perfection went in parallel with scientific and technical progress. From diagnostic they in the majority have turned to the surgical. Now the great attention is given to perfection endoscopic methods for carrying out from them on-power surgical interventions, both in surgery, and in gynecology.

In gynecologic practice special distribution have received a laparoscopy, gisteroscopy and colposcopy. Colposcopy - a diagnostic method for definition of pathological conditions vaginal parts of a neck of a uterus, cervicalae the channel, a vagina and external genitals by their survey by means of special optical devices (colposcopy). Practical application has found simple (survey), expanded, colour and luminescent colposcopy. Simple colposcopy пия it is always shown in the beginning of research and is rough. With its help define the form and size of a neck of a uterus, an external pharynx, colour and a mucous membrane relief, a transitive zone flat cylindrical epiteley, vascular drawing. In the absence of pathological processes in studied bodies research can be finished at level idle time colposcopy, and if necessary pass to the expanded. Expanded colposcopy it is based on use farmakologic means for revealing of structural changes of fabrics at level of a cage and its components. So, at processing of a neck of a uterus of 3 % a solution of acetic acid or 0,5 % a solution of salicylic acid arise a hypostasis epitely, swelling of superficial cages, reduction of blood supply of fabrics at the expense of reduction subepitelialy vessels, and all it promotes more accurate detection of pathological changes. In the similar image the tumoral and pretumoral sites consisting from impoverished glicogeni of cages come to light. Processing vaginal a part of a neck of a uterus a solution of Ljugolja (Schiller's test), it is possible to notice that the cages containing enough glicgen, are painted in dark brown colour, and cages with its deficiency remain pale. This test allows to investigate purposefully certain sites at sufficient optical increase, and also to make aim biopsy. Version expanded colposcopy is colour (chromocolposcopy) when fabrics are painted 0,1 % by a solution gematoxilini or 1 % a solution toluidiny dark blue (nuclear dye). Thus cages pathological epitely are more intensively painted. Other dyes (metilen violet, etc.) are used also . More perfect technique of research is colpomikroskopy-lifetime histologic research vaginal parts of a neck of a uterus. It is spent without colouring and with colouring of cellular elements, with the help gematoxilini, toluidinovae dark blue, etc. is usually applied purposeful colpomikroskopy the separate sites revealed at expanded colposcopy with processing of a neck of a uterus by special substances. Gisteroscopy one of the best endoscopy methods, now was widely adopted and actually became the necessary attribute of activity of the qualified gynecologist. Development gisteroscopy has begun in the last century with use of devices of type cistoscopy. However anatomic distinctions of a uterus and a bladder have limited possibilities of application of such devices in gynecologic practice and the further perfection gisteroscopy has gone another, independent

Way. Began to use endoscopy and devices with electric illumination till the introduction moment in medical practice fibrofibres and rigid optics with system of air lenses that has demanded working out of environments, enter into a uterus for the purpose of a stretching of its walls as necessary condition gisteroscopy. By this time comprehensible environments for a stretching of a cavity of a uterus are an isotonic solution of chloride of sodium, 30-70 % solutions dextranae, 5-10 % a solution dextrozae and carbonic gas. Liquids with high viscosity (10 % a solution dextrozae, a solution dextranae) perfectly instal 32 % electrical equipment, well stretch a uterus cavity, do not mix up with blood and sekrety. But at their use in considerable quantities (it is more 100 ml) complications (allergic reactions, kogulopany, a distress-syndrome, etc.) are often marked. Liquids with low viscosity (a solution of Ringera, 5 % a solution dextrozae, isotonic solutions sorbitolae, mannitolae, etc.) Cause less complications and though they reduce fields of vision, in medical a praktic are used most often in comparison with gas environments. At use of the last there is no possibility of washing of a uterus, and in the presence of blood in it visualisation sharply is at a loss. Besides, at use of the gas environment there is a risk gas emboly, performance of operative interventions is complicated. At gisterosopy probably to spend a photo- and filming. It is most convenient in work television gisteroscopy. The information received at gisteroscopy, more authentic, than at rentgenogisterografia which at the specified conditions already practically is not used. Contra-indications are: sharp inflammatory processes of genitals, pregnancy, plentiful uterinae bleedings, a widespread cancer.

Necks and uterus bodies. Complications at gisteroscopy same, as well as at diagnostic abrazio a uterus: uterus punching, an aggravation of inflammatory processes, peritonealy symptoms, allergic reactions to applied environments. The technics gisteroscopy includes preparation and inspection of the patient, a choice of a method of anaesthesia and direct carrying out of procedure of research. Rectoscopy it is applied at suspicion on a rectum cancer, and also to specification of distribution of a malignant tumour on a rectum.

At a cancer of a neck of a uterus. This method of research use at break in a gut of the abscesses formed in genitals, recto-vaginalis fistulas. Cistoscopy allows to define a bladder inflammation, presence in it of stones, bladder involving in process in the presence of a malignant tumour of genitals, presence bladder-vaginalis a fistula and other damages of a bladder. Diagnostic methods with use of lighting devices began to be developed for survey of bodies of a belly cavity and a small basin in the XX-th century beginning. Before them called «peritoneoscopy», «pelvioscopy», «kuldoscopy». The laparoscopy survey of bodies of a belly cavity and a small basin by means of optical devices through a forward belly wall, and kuldoscopy - similar procedure, but survey is carried out through the back arch. A laparoscopy and kuldoscopy in gynecologic practice with the diagnostic purpose developed in parallel. However the laparoscopy allows to receive bo-lee the full review that is especially necessary at carrying out of differential diagnostics, for example, between extra-uterine pregnancy and an appendicitis. Further the laparoscopy has started to develop not only with diagnostic, but also with the operative purpose. In this connection it became more widespread method. The laparoscopy is spent against pnevmoperitoneum, and kuldoscopy is possible without it. For creation pnevmoperitoneum are used oxygen, zaxis nitrogen and carbonic gas. If in the course of a laparoscopy the current of high frequency for creation pnevmoperitoneum it is impossible to apply oxygen is used. Laparoskopichesky diagnostic research includes following stages: a puncture of a belly wall a needle and introduction through it of gas for creation pnevmoperitoneum; introduction троакара laparoscop; survey of bodies of a small basin and a belly cavity; removal endoscopy and gas deducing. The modern laparoscopy is carried out simultaneously with the diagnostic and surgical purposes. Therefore the device laparoscopy includes optical and shine-telnuju systems with a tooling for surgical interventions. The following will be indications for an emergency laparoscopy: suspicion on uterus punching, suspicion on capsule rupture cyst, piosalpinx, rupture ovarica, a trumpet abortion; differential diagnostics sharp аднексита, extra-uterine pregnancy and appendix. Possibility of a combination of a diagnostic and surgical laparoscopy allows to expand indications to it both in planned, and in an emergency order. In summary it is possible to notice that the laparoscopy is highly effective, To carry out and a popular method of research, and its value in gynecology continuously increases in a combination to surgical interventions. Laparotomy with the diagnostic purpose it is applied at impossibility of definition of character of disease by other methods of research, as at differential diagnostics of a gynecologic and surgical pathology, and at suspicion on malignant new growths. In certain cases trial laparotomy comes to an end with corresponding operation. If it is impossible to make operation, are limited to survey of bodies of a small basin and a belly cavity, a capture biopsy from the amazed body for histologic research.

Ultrasonic diagnostics. Ultrasonic diagnostics in gynecology, as well as in other directions of medicine, became now one of leading methods of research that is caused harmlessness of a technique, its high nformation with relative simplicity and availability. Ultrasonic research does not demand special preparation of the patient. Only sufficient filling of a bladder that is reached at abstention from мочеиспускания within several hours or the use of a liquid of 600-800 ml before procedure is necessary. Application diu-retikov or introduction in a liquid bladder through катетер is in case of emergency possible. Filled

The bladder plays a role of the original acoustic window providing access to internal genitals of the woman. Research is spent in position of the woman on a back through greased with gel or vaseline oil a skin of a surveyed site. At gauge application on a studied surface longitudinal, cross-section and slanting sections in various levels turn out. The modern ultrasonic equipment allows to visualise and estimate a condition almost all bodies of a small basin: a bladder, a uterus, ovarica, proximale vagina department, rectosigmpidal parts of thick intestines, muscles and vessels of a small basin. Ultrasonic diagnostics allows to reveal:

• uterus diseases (tumours good-quality and malignant, an endometriosis, hyperplastic processes endometriy, trofoblastaec processes);

• diseases ovarica (cyst and cystomy, an endometriosis, a cancer ovarica, kistozno-degenerate changes);

• anomalies of development of internal genitals (аplaziy bodies, uterus doubling, a two-horned uterus, partitions in it, a rudimentary uterus);

• diseases uteri pipes (a tumour, inflammatory processes, especially sackus formations, an endometriosis);

• tubovarial formations;

• extra-uterine pregnancy (trumpet, ovarica, belly, progressing and interrupted);

• intrauterinae contraceptive means and their complications (arrangement, a combination to pregnancy, uterus punching, a separation of parts etc.). In gynecologic practice by the basic method of ultrasonic diagnostics becomes transvaginal ultrasound thanks to high information, to absence of preparation to sick, relative simplicity and possibility of repeated researches. Last decade ultrasonic diagnostics has extended at the expense of the new method based on effect of Doppler. The method doplerometriy basically investigates a blood-groove in arteries and veins of an internal, especially at colour scantriy. Wider application doplerometriy has found in obstetric to practice. However and in gynecology more and more informative data turns out at method use doplerometriy in diagnostics of new growths, genez barrenesses and at many kinds endocrin pathologies.

RADIOLOGICAL METHODS

Radiological methods of research in gynecology till last years occupied one of leading places. With development ultrasonic and endoscopy methods radiodiagnosis began to be used much less often. Have kept the urgency radiological methods of research in onkоgynecologe, urology, and also in some cases differential diagnostics of gynecologic and surgical diseases. For radiological research two groups of indications allocate: pathology revealing in genitals and adjacent to them vascular and lymphatic systems (II group); diagnostics of a pathology of other bodies and the systems, accompanying diseases of genitals or them caused (I group). Under indications of the first group are spent rentgenoscopy or fluorografia thorax bodies; research of a digestive path: rentgenoscopy and rentgenigrafy a stomach, irrigoscopy; Research of uric ways (excretoty and infuzion urography). Indications of the second group in gynecology are the basis for carrying out gisterosalpingografy;. Gisterosalpingografy (GSG) is a radiological method of research utero-tubary cavities. From contrast substances now are used water-soluble (urografin, etc.) Each of them has the lacks and advantages because of which the individual approach is necessary at use. Suitable term for GSG is first half menstrual a cycle (8-12th day). At this time reception of a false picture in a uterus or incorrect obstruction of pipes owing to giperplazio and secretor stages utero-tubary a mucous membrane is excluded. For the purpose of diagnostics istmiko-servikaly insufficiency GSG it is carried out for 23-24th day of a cycle. Preparation for research includes: inspection according to the general condition and to an exception of inflammatory processes; clarification of intestines and bladder clearing; vagina sanitation; introduction (papaverin, no-shpa) for 30 mines before research; on occasion under indications appoint with the preventive purpose antibacterial means one days prior to procedure. Two pictures are traditionally carried out: 1st - after filling of a cavity of a uterus by contrast substance, 2nd - after new introduction of contrast. Performance of 3rd picture through a small time interval after removal of the device for introduction of contrast substance and 4-4-for check of permeability of pipes at level peritonealy cavities through 15-30 mines is possible at use of water-soluble or vater-viscose preparations and through 24 ч - at use preparations. There is a method of consecutive pictures for what special devices are required. For an accurate comparative estimation it is recommended to make a survey picture before introduction of contrast substance. As indications for GSG utero-trumpet variants of barreness serve; suspicion on a tuberculosis; anomalies of development of internal genitals, control over efficiency of plastic operations on a uterus and pipes; tumours and uterus polyps; hyperplastic processes and suspicions on malignant growth endometry. Quite often МСГ has medical influence owing to liquidation of separate variants of trumpet impassability. The main rule-to radiological researches should resort under strict clinical indications and in need of cases of impossibility of use of other harmless methods (ultrasonic, эндоскопических, hormonal, tests of functional diagnostics, etc.).

Cytogenetic researches

Cytogenetic researches in gynecologic practice allow to diagnose defects of sexual glands. It is considered that the kernel containing one Hromatin little body Barra, is called as hromatin-positive, and at its absence-hromatin-negative. Hromatin-positive kernels meet in the presence of not less than two H-chromosomes, as, for example, at the Hh-chromosomal complex at healthy women, and hromatin-negative - at normal man's XY-chromosomes th a complex. Hence, hromatin-positive kernels can meet and at a syndrome of Klajnfeltera with various (XXY, XXY/XY) the chromosomal complexes containing on 2Х and more of chromosomes. Conditions at which in kernels Barra (XXXY, XXXY/XY-sets) and even on three (a XXXY/XXXXY-set contains on 2 little bodies, etc.) are observed . Accordingly and hromatin-negative kernels meet at a syndrome Shereshevsky-ternera chromosomal complement Х0 and some chromosomal mosaics. Exists corrected that between number hromatiny little bodies and number of H-chromosomes exists exact sootnoshe-nie: the number of little bodies Barra in any kernel always on one is less than number of H-chromosomes. Definition H-hromatina is spent basically in epitelial cages of a mucous membrane of a mouth, in влагалищных эпителиальных cages and in kernels mature neytrofily leukocytes. The analysis chromosomal or the analysis kariotipy are based on calculation of quantity of chromosomes. Chromosomal anomalies by their quantity are characterised big (a syndrome of Klaynfeltera) or their smaller number. The second type of chromosomal anomalies is connected with infringements of structure of chromosomes. Research кариотипа is made on preparations of the metaphase chromosomes received from culture limosity of peripheral blood, a marrow, and also from a skin. In diagnostics cases mozasizm it is required full kariotype the analysis (numbers, size and the morphological characteristic of chromosomes) that it is possible to carry out at research of several fabrics of the given individual.

Features of gynecologic inspection of girls and teenagers

The purpose of gynecologic inspection of girls and teenagers is revealing at them a physiological and pathological condition of genitals, since the period newborn and till 16-18 years. Using traditional sheathe klinical receptions (the anamnesis, survey) and special methods of research, receive trustworthy information for diagnosis statement. Features of inspection of girls and teenagers are neobhodi-most overcomings of fear at children before survey, the account of distinction of structures genitaly in each age group and in this connection use of suitable tools and methods. After carefully collected anamnesis, an estimation of physical development and the somatic status special inspection genitaly spheres is carried out. The doctor should make the plan of such inspection, coordinate it with parents, convince them and the girl of necessity of its carrying out and for an exception of harmful consequences thus. Depending on prospective disease along with gynecologic inspection auxiliary methods of research (vaginoscopy, tests of functional diagnostics, ultrasonic, laparotomiya, a laparoscopy, radiological and genetic methods) can be used. Gynecologic inspection is spent depending on age in position of the girl on a back with led to a stomach and supported by someone from the personnel hips, in kolenno-elbow position or on a special gynecologic armchair. Before inspection the intestines and a bladder are emptied. Presence of mother, the staff nurse or the midwife necessarily. On occasion if necessary research it is carried out under anaesthetic. In many cases such methods of research can be replaced by the ultrasonic. At gynecologic inspection of girls it is necessary to be guided by a principle of reception of the maximum information in the simple and sparing ways. In children's gynecologic offices there should be a following toolkit: children's gynecologic mirrors and lifts, usual and probes, spoons of Folkmana and a loop for a capture of dabs, long pipetki with a rubber pear and Brown's syringe for vagina washing, tweezers, elastik and metal nurseries katetery, a frontal reflector and a set of otolaryngologic mirrors, vaginoscopy or their analogues, subject glasses, syringes, a sterile material. It is desirable to have the narcotic device or, as an extreme variant, sets for a narcosis.