#1
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Òàêòèêà ïðè ïîäîçðåíèè íà çàìåðøóþ áåðåìåííîñòü
Âûíåñåíî îòñþäà - Ïîìîãèòå ðàçîáðàòüñÿ ñ ÓÇÈ, çàìåðëà ëè áåðåìåííîñòü?
Öèòàòà:
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#2
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ß ðàáîòàþ íå â Ðîññèè, ïîýòîìó â ïðàêòèêå ïîëüçóþñü îáùåïðèíÿòûìè ìåæäóíàðîäíûìè ðåêîìåíäàöèÿìè. Åñëè ìîæíî, ïðèâåäèòå èñòî÷íèê "ïðèíÿòûõ ïðàâèë â Ðîññèè". Êñòàòè, ÊÒÐ 2.3 ìì - 6 íåäåëü, ýòî ñîãëàñíî êàêèõ áèîìåòðè÷åñêèõ òàáëèö, êàêîãî àâòîðà?
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#3
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ÒÀáëèöà âçÿòà èç ìåòîäè÷åñêîãî ïîñîáèÿ "Óëüòðàçâóêîâàÿ ôåòîìåòðèÿ: ñïðàâî÷íûå òàáëèöû è íîìîãðàììû" ïîä ðåäàêöèåé Ì.Â. Ìåäâåäåâà ðåêîìåíäîâàííàÿ Ðîññèéñêîé àññîöèàöèåé âðà÷åé ÓÇÄ â ïåðèíàòîëîãèè è ãèíåêîëîãèè. À ðåãèñòðàöèÿ â ñåðäöåáèåíèÿ â 6 íåäåëü - ýòî ñâåäåíèÿ òàê ñêàçàòü èç "áóêâàðÿ" âðà÷åé ÓÇÄ â Ðîññèè ïîä ðåäàêöèåé Â.Â. Ìèòüêîâà - ãëàâû âûøå íàçâàííîé àññîöèàöèè. ß ïîíèìàþ ÷òî ìíîãèå òàáëèöû ÊÒÐ ìîãóò ðàçíèòüñÿ â â äåñÿòûõ ìì, íî ïî êðàéíåé ìåðå çà ìîé 10 ëåòíèé îïûò ðàáîòû íà÷èíàÿ ñ 2,5 ìì ñåðäöåáèåíèå âèæó âñåãäà. Åñòåñòâåííî åñëè ó ýìáðèîíà òàêîãî ðàçìåðà íå çàðåãèñòðèðóþ ñåðäöåáèåíèå, òî êîíêòðîëèðóþ ÷åðåç íåäåëþ, íî óâû, ïîêà çà âðåìÿ ðàáîòû íè îäèí êîíòðîëü íå áûë ïîëîæèòåëüíûì äëÿ áåðåìåííûõ.
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#4
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10-ëåòíèé îïûò ðàáîòû, îòå÷åñòâåííûé "áóêâàðü" è ò.ï. - ýòî î÷åíü õîðîøî.
Íî ê Âàøåìó ñâåäåíèþ: "Recent advice concludes that a diagnosis of an empty sac (previously named ‘anembryonic pregnancy’, ‘early embryonic demise’ or ‘embryo loss’) should not be made if the visible crown–rump length is less than 6 mm, as only 65% of normal embryos will display cardiac activity." RCR/RCOG (Royal College of Radiologists/Royal College of Obstetricians and Gynaecologists) Working party. Guidance on Ultrasound Procedures in Early Pregnancy. London: RCOG Press, 1995. Farquharson RG, Jauniaux E, Exalto N, ESHRE (European Society of Human Reproduction and Embryology) Special Interest Group for Early Pregnancy (SIGEP). Updated and revised nomenclature for description of early pregnancy events. Hum Reprod 2005; 20:3008–3011. |
#5
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ÿ ê ñîæåëåíèþ íå ñèëåí â ÿçûêàõ, ýòî êàêîé äîñòóï â 6 ìì òîëüêî â 65% ñëó÷àåâ? â 3 íåäåëè çàêëàäêà ñåðäöà, à îíè â 6 íåäåëü ñ õâîñòîì íå ó âñåõ ñåðäöå âèäÿò?
Èíîñòðàííàÿ ëèòåðàòóðà ýòî êîíå÷íî õîðîøî, íî îíè òàêèå æå ëþäè êàê ìû è èõ ó÷åíûå âðÿäëè óìíåå âàøèõ èëè íàøèõ, ñêîðåå íàîáîðîò (ÈÌÕÎ) |
#6
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#7
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Íå çíàþ, êàê ìîæíî ñåðüåçíî çàíèìàòüñÿ ÓÇ-äèàãíîñòèêîé áåç çíàíèÿ àíãëèéñêãîãî ÿçûêà, áåç îãðîìíîãî îáúåìà ïðîôåññèîíàëüíîé èíôîðìàöèè, îñòàâàÿñü â ðàìêàõ îòå÷åñòâåííûõ "áóêâàðåé" è ñàìîäåÿòåëüíûõ ñî÷èíåíèé (õîòÿ ïåðåâîäíûå èçäàíèÿ óæå ïîÿâëÿþòñÿ). Íàäåþñü, Âû çíàåòå, ÷òî ÓÇ-äèàãíîñòèêà ñîçäàíà èíîñòðàííûìè ñïåöèàëèñòàìè çàäîëãî äî "íàøèõ è âàøèõ". Îäèí èç îáùåïðèçíàííûõ êðèòåðèåâ íåðàçâàþùåéñÿ áåðåìåííîñòè, î êîòîðîì èäåò ðå÷ü, îïèñàí íå òîëüêî â ïðîöèòèðîâàííûõ ðóêîâîäñòâàõ ïî ýõîãðàôèè áåðåìåííîñòè ðàííèõ ñðîêîâ, èçäàííûõ åâðîïåéñêèìè àññîöèàöèÿìè, ÷òî ïîçâîëÿåò èçáåæàòü ãðóáûõ äèàãíîñòè÷åñêèõ îøèáîê. È ýòî íåñìîòðÿ íà òî, ÷òî ñåðäöåáèåíèå ìîæíî îïðåäåëèòü óæå ïðè ÊÒÐ 2ìì. Õîòÿ ÿ íè ê ÷åìó íå ïðèçûâàþ è íå àãèòèðóþ.
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#8
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Öèòàòà:
Êñòàòè íîðìàòèâû ñåðäöåáèåíèÿ äëÿ ñðîêà 6 íåäåëü êàê ðàç èñïîëüçóþòñÿ ó íàñ ðàçðàáîòàííûå ñïåöèàëèñòàìè èç Âåëèêîáðèòàíèè. ß íå ïðèçûâàþ êàòåãîðè÷íî äåëàòü âûâîäû î çàìåðøåé áåðåìåííîñòè ïðè îòñóòñòâèè ñåðäöåáèåíèÿ ïðè ÊÒÐ 2,5 ìì, íóæíà äèíàìèêà, íî è íå ìîãó ñîãëàñèòüñÿ ñ óòâåðæäåíèåì ÷òî 35% ñëó÷àåâ ïðè ÊÒÐ 6 ìì ÿ íå óâèæó ñåðäöåáèåíèå. Êñòàòè ñëó÷àé òóò ïðîèçîøåäøèé ãîâîðèò ñêîðåå â ïîëüçó íàøèõ àâòîðîâ. Òàê èëè èíà÷å, â ëþáîé ñèòóàöèè òðåáóåòñÿ äèíàìè÷åñêîå íàáëþäåíèå, ÿ äóìàþ ñ ýòèì íèêòî ñïîðèòü íå ñòàíåò. ß íå ïðîòèâ ñòàíäàðòîâ èíîñòðàííûõ êîëëåã, ÿ ëèøü êðàéíå óäèâëåí òåì ïðîöåíòàì, ÷òî îíè äàëè. |
#9
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Åñëè áûòü òî÷íûì, ÿ ñ÷èòàþ ïðèåìëèìûìè ÷åòêèå îáùåïðèíÿòûå ìåæäóíàðîäíûå ðåêîìåíäàöèè (êîòîðûå, êàê ïðàâèëî, öèòèðóþòñÿ â ïóáëèêàöèÿõ, ïîñâÿùåííûõ ïàòîëîãèè áåðåìåííîñòè ìàëîãî ñðîêà), à íå ïàðó ñòðîê â îòå÷åñòâåííîì ðóêîâîäñòâå, êîòîðûå íèêàê íå ìîãó îòîæäåñòâëÿòü ñ "îïûòîì ñîîòå÷åñòâåííèêîâ". Òåì áîëåå íå ìîãó îòîæäåñòâëÿòü ñ "îïûòîì ñîîòå÷åñòâåííèêîâ" ïîïóëÿðíûå ñî÷èíåíèÿ îäíîãî àâòîðà. Êîíå÷íî, çàíèìàòüñÿ ÓÇÄ áåç çíàíèÿ àíãëèéñêîãî ìîæíî, íî ïåðåâîäíûå ñòàòüè è èçäàíèÿ - ýòî ïðîñòî êàïëÿ â ìîðå. À êîíôåðåíöèè ñ èíîñòðàííûìè ëåêòîðàìè -õîðîøî, õîòÿ ëó÷øå ïîñåùàòü (è ó÷èòüñÿ) çàãðàíè÷íûå êîíôåðåíöèè.
Ñîãëàøàòüñÿ èëè íå ñîãëàøàòüñÿ - äåëî Âàøå. |
#10
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Ó÷èòûâàÿ èçìåíåíèå íàçâàíèÿ òåìû, åñòü ñìûñë ðàçäåëèòü óëüòðàçâóêîâûå êðèòåðèè íåðàçâèâàþùåéñÿ áåðåìåííîñòè ìàëîãî ñðîêà (î ÷åì, ñîáñòâåííî, è øëà ðå÷ü) è ñðîê ãåñòàöèè (ñîîòâåòñòâåííî ÊÒÐ ýìáðèîíà), ïðè êîòîðîì ïðè ÓÇÈ îïðåäåëÿåòñÿ ñåðäå÷íàÿ àêòèâíîñòü ýìáðèîíà, è ïðèâåñòè ñëåäóþùèå äàííûå.
1. "The definition of a non-viable IUP (intrauterine pregnancy) was based upon the following: • the presence of an embryo with a CRL of ≥6 mm without demonstrable cardiac activity on the first scan; or • the presence of an embryo with a CRL of ≤5 mm with no demonstrable cardiac activity at the first scan and then at the second scan, 7 days later, still no fetal cardiac activity was demonstrated; or • the absence of an embryo in a gestational sac with a diameter of >20 mm or a gestational sac of <20 mm with no growth at ultrasound follow-up." (èñòî÷íèê â ïîñòå ¹4, è "The Management of Early Pregnancy Loss.(Clinical Green Top Guidelines 25). Royal College of Obstetricians and Gynaecologists Press: London, UK, 2000.) 2. "It is known that the fetal heart pulsation may be visible on TVS from 37 days of gestation in normal pregnancies." (Jurkovic D, Gruboeck K, Campbell S. Ultrasound features of normal early pregnancy development. Curr Opin Obstet Gynecol 1995; 7: 493–504). "Theoretically, cardiac activity should always be evident when the embryo is over 2 mm." (Levi CS, Lyons EA, Zheng XH, Lindsay DJ, Holt SC. Endovaginal US: demonstration of cardiac activity in embryos of less than 5.0 mm in crown–rump length. Radiology 1990; 176: 71–74). "Cardiac activity should be visualized when the embryonic length is greater than or equal to 4 mm, and not seeing a beating heart at this embryonic size is an ominous sign. However, in around 5–10% of embryos between 2 and 4 mm it cannot be demonstrated, although the corresponding pregnancies will have a normal outcome." (Goldstein SR. Significance of cardiac activity on endovaginal ultrasound in very early embryos. Obstet Gynecol 1992; 80:670–672). |
#11
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Îáñóæäàåìûé ñëó÷àé ñ "Àëåêñàíäðîé16" êàê ðàç ïîäïàäàåò ïîä ïóíêò 2 - îòñóòñòâèå ñåðäöåáèåíèé ÷åðåç 1 íåäåëþ. Òåì áîëåå ÷òî âòîðîå ÓÇÈ äåëàëîñü ÷åðåç 1 ìåñÿö ïîñëå ïåðâîãî â 5 íåäåëü áåðåìåííîñòè. Óæå íà âòîðîì ÓÇÈ ìîæíî áûëî ñ óâåðåííîñòüþ âûñòàâèòü "çàìåðøóþ áåðåìåííîñòü". Íà âòîðîì ÓÇÈ ýìáðèîí äîëæåí áûë ñîîòâåòñòâîâàòü 9-10 íåäåëü... Íà ýòîì ñðîêå òðóäíî îøèáèòüñÿ.
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#12
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Óâàæàåìûé Shtulman, ïî ïîâîäó ÿçûêîâ - åñòü ïåðåâîä÷èêè, åñëè íå ñèëüíû. À îòâåòû Volusona áîëåå ÷åì èñ÷åðïûâàþùèå. Ñïàñèáî Voluson!
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#13
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To evmal31
Êîëëåãà, ïðèâåòñòâóåòñÿ âàøå æåëàíèå ñäåëàòü ïåðåâîä. Íî êà÷åñòâî èìååò çíà÷åíèå. Ïîòîìó ñîîáùåíèå ñêðûòî. Íî îíî äîñòóïíî âðà÷àì ôîðóìà.
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Ñ óâàæåíèåì, Þñèô Àëõàçîâ. |
#14
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Äóìàþ, ÷òî àâòîð ïîñòà: [i][i][size="2"]Ñîãëàñíî ïðèíÿòûì ïðàâèëàì â Ðîññèè â 6 íåäåëü ñåðäöåáèåíèå ó ýìáðèîíà ðåãèñòðèðóåòñÿ ïðè òðàíñâàãèíàëüíîì èññëåäîâàíèè â 100% ñëó÷àåâ. 6 íåäåëÿì áåðåìåííîñòè ñîîòâåòñâóåò ÊÒÐ 2,3 ìì, à 5 ìì ýòî óæå 6 íåäåëü è 3-4 äíÿ, êîãäà ñåðäöåáèåíèå âïîëíå ÷åòêî ðåãèñòðèðóåòñÿ äàæå ïðè òðàíñàáäîìèíàëüíîì èññëåäîâàíèè.
ãîâîðèò âàì òàêòèêó íàâåðíîå âñåõ Óçèñòîâ è ãèíåêîëîãîâ. Ó íàñ â îêðóãå î÷åíü ÷àñòî ïî ÓÇÈ ñòàâèòñÿ îòñóòñòâèå ñåðäöåáèåíèÿ; èëè àíýìáðèîíèÿ â ñðîêå äî 6 íåäåëü. Ïðè íàëè÷èè äàííûõ ïðèçíàêîâ, ãèíåêîëîã ñòàâèò ñðàçó çàìåðøóþ áåðåìåííîñòü è îòïðàâëÿåò æåíùèíó íà àáîðò. Íèêàêèõ ðàçãîâîðîâ îá 1 íåäåëå. Ñïåöèàëèñòû Óçè-äèàãíîñòû íå ïåðâûé ãîä ðàáîòàþò, è íå õîòåëîñü âåðèòü â èõ íåêîìïåòåíòíîñòü. Íî ê ñîæàëåíèþ, ôàêòû ãîâîðÿò ñàìè çà ñåáÿ, åñòü æåíùèíû, êîòîðûå ÷åðåç 1-2 íåäåëè ñàìè ñäåëàëè êîíòðîëüíîå ÓÇÈ è áëàãîïîëó÷íî âûíîñèëè áåðåìåííîñòü. Ñïàñèáî åùå ðàç, ÷òî ïðîëèëè ñâåò íà íàøó òåìíîòó ñëàâíîãî ãîðîäà -ñòîëèöû îêðóãà! |
#15
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À ïåðåâîä ÷åðåç êîìï ñäåëàëà, äëÿ îáùåãî îçíàêîìëåíèÿ, êòî â òåìå, ðàçáåðåòñÿ, ÿ äóìàþ.
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