#1
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Áåçâîäíûé ïåðèîä
Óâàæàåìûå êîëëåãè, èìåþòüñÿ ðàçíûå ìíåíèÿ äëÿ íàçíà÷åíèÿ àíòèáèîòèêîâ ïðè áåçâîäíîì ïåðèîäå. Êåìåðîâñêèå òîâàðèùè íàçíà÷àþò èç ÷åðåç 6 ÷àñîâ, à Íîâîêóçíåöêèå ÷åðåç 12 ( â îñíîâíîì öåôàçîëèí).
À êàê ó Âàñ? à êàê äîêàçàòåëüíàÿ ìåäèöèíà ê ýòîìó îòíîñèòüñÿ? |
#2
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â Ðîññèè - 12 ÷.
â àìåðèêàíñêèõ ãàéäàõ - 18 ÷. |
#3
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Ïî ÂÎÇó - 18 ÷àñîâ ïðè áåðåìåííîñòè áîëüøå 37 íåäåëü è ñðàçó æå , åñëè ìåíüøå 37 íåäåëü.
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#4
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Òàêîé ïîðîã â 37 íåäåëü, èìåÿ â ãîëîâå ïðîëîíãèðîâàòü áåðåìåííîñòü? èëè êàêèå-òî îñîáî ÿäîâèòûå ñâîéñòâà èìåþò èíôåêöèîííûå àãåíòû â ýòîò ñðîê äëÿ ìàêðîîðãàíèçìà?
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#5
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Ïîñëå 37íåä óæå ñ÷èòàþòñÿ ñðî÷íûå ðîäû, çà÷åì ïðîëîíãèðîâàòü?
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#6
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À/á ïðîôèëàêòèêà âî âðåìÿ ðîäîâ ïîêàçàíà â ñëåäóþùèõ ñëó÷àÿõ:
•Ðîæäåíèå â ïðîøëîì ðåáåíêà ñ çàáîëåâàíèåì, âûçâàííûì ñòðåïòîêîêêàìè ãðóïïû  •Áàêòåðèóðèÿ, âûçâàííàÿ ñòðåïòîêîêêàìè ãðóïïû  âî âðåìÿ íàñòîÿùåé áåðåìåííîñòè •Ïîçèòèâíûé ðåçóëüòàò ïîñåâà íà ñòðåïòîêîêêè ãðóïïû  âî âðåìÿ íàñòîÿùåé áåðåìåííîñòè (êðîìå ñëó÷àåâ ïëàíîâîãî êåñàðåâà ñå÷åíèÿ, ïðîâîäÿùåãîñÿ ïðè îòñóòñòâèè ðîäîâîé äåÿ-òåëüíîñòè èëè ðàçðûâà ïðîäíûõ îáîëî÷åê) •Åñëè ñòàòóñ íîñèòåëüñòâà ñòðåïòîêîêêîâ ãðóïïû  íå èçâåñòåí (ïîñåâ íå ïðîâîäèëñÿ, ðå-çóëüòàò íå èçâåñòåí èëè íå ïîëíûé) è íàëè÷èè îäíîãî èç ñëåäóþùèõ ïðèçíàêîâ: -Ðîäû íà ñðîêå <37 íåäåëü áåðåìåííîñòè -Áåçâîäíûé ïåðèîä >18 ÷àñîâ -Òåìïåðàòóðà òåëà ó ìàòåðè âî âðåìÿ ðîäîâ >38.0°C |
#7
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Ïðè ñðîêå áåðåìåííîñòè ìåíåå 34 íåäåëü è ïðè îòñóòñòâèè ïðîòèâîïîêàçàíèé ê ïðîëîíãèðîâàíèþ áåðåìåííîñòè ðåêîìåíäîâàíî âûæèäàòåëüíîå âåäåíèå.
Ïàëüöåâîå âëàãàëèùíîå èññëåäîâàíèå íå äîëæíî ïðîâîäèòüñÿ æåíùèíàì, ó êîòîðûõ íå íà÷àëàñü ðîäîâàÿ äåÿòåëüíîñòü è íå ïëàíèðóåòñÿ íåìåäëåííàÿ èíäóêöèÿ ðîäîâîé äåÿòåëüíîñòè. Ïðåäïî÷òèòåëüíî ïðîâåñòè îñìîòð â çåðêàëàõ. Ïðèåì àíòèáèîòèêîâ, ñïîñîáñòâóåò ïðîäëåíèþ âðåìåíè äî íà÷àëà ðîäîâîé äåÿòåëüíîñòè è óëó÷øàåò ïåðèíàòàëüíûå èñõîäû. Äîðîäîâûé ïðèåì êîðòèêîñòåðîèäîâ äîëæåí íà÷àòüñÿ ïðè ñðîêå áåðåìåííîñòè îò 24 äî 34 íåäåëü. Êðàòêèé êóðñ ïðèåìà òîêîëèòèêîâ ðåêîìåíäîâàí ñ öåëüþ ïåðåâîäà ìàòåðè íà áîëåå âûñîêèé óðîâåíü îêàçàíãèÿ ìåä. ïîìîùè, à òàêæå ïðèåìà êîðòèêîñòåðîèäîâ è àíòèáèîòèêîâ. Ïðîëîíãèðîâàííûé êóðñ ïðèåìà òîêîëèòèêîâ íå ðåêîìåíäóåòñÿ. Ïðè äîíîøåííîé áåðåìåííîñòè ðîäû ìîãóò áûòü èíäóöèðîâàííû íåìåäëåííî èëè æåíùèíó ìîæíî íàáëþäàòü â òå÷åíèå 24-72 ÷àñîâ, ïîñêîëüêó âûñîêà âåðîÿòíîñòü ñàìîïðîèçâîëüíîãî íà÷àëà ðîäîâ. Àíòèìèêðîáíàÿ ïðîôèëàêòèêà èíôåêöèé, âûçâàííûõ ñòðåïòîêîêêàìè ãðóïïû Â, äîëæíà ïðîâîäèòüñÿ òîëüêî ïîñëå íà÷àëà ðîäîâ. Àíòèìèêðîáíàÿ ïðîôèëàêòèêà èíôåêöèé, âûçâàííûõ íå ñòðåïòîêîêêàìè ãðóïïû Â, ìîæåò áûòü îãðàíè÷åíà è ïðîâîäèòüñÿ òîëüêî òåì æåíùèíàì, ó êîòîðûõ åñòü êëèíè÷åñêèå ïîêàçàíèÿ ê ëå÷åíèþ àíòèáèîòèêàìè. Áëàãîäàðÿ íåìåäëåííîé èíäóêöèè ðîäîâîé äåÿòåëüíîñòè îêñèòîöèíîì äîñòèãàåòñÿ áîëåå çíà÷èòåëüíîå ñíèæåíèå ÷àñòîòû ðàçâèòèÿ õîðèîíàìíèîíèòà, ÷åì ïðè ïðèìåíåíèè âàãèíàëüíûõ ïðîñòàãëàíäèíîâ è âûæèäàòåëüíîé òàêòèêå âåäåíèÿ. Centers for Disease Control and Prevention. Prevention of Perinatal Group B Streptococcal Disease. Morbidity and Mortality Weekly Report (MMWR) Revised Guidelines from CDC 2002;51 Mazurekewich E., Wolf F. Premature rupture of membranes at term: A meta-analysis of three management strategies. Obstet Gynecol 1997;89:1035-43. Royal College of Obstetricians and Gynaecologists (RCOG). Preterm Prelabour Rupture of Membranes. Guideline No. 44, RCOG Press, November 2006. Crowley P. Prophylactic corticosteroids for preterm birth. The Cochrane Database of Systematic Reviews, Issue 3, 2005. Murray W. Enkin et al, A guide to effective care in pregnancy and childbirth, 3-rd edition, 2000. |
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#8
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ß ðàáîòàþ â ðîä äîìå, ãäå õîðîøàÿ äåò. ðåàíèìàöèÿ è 2-é ýòàï âûõàæèâàíèÿ. Ìû ñîõðàíÿì áåðåìåííîñòè äàæå ñ î÷. ðàííèì èçëèòèåì âîä (â ñìûñëå ñðîêà), íî äåêñîí ðàíüøå 28 íåä íå ïðèìåíÿåì, òàê êàê åùå íåò ñóáñòðàòà â ëåãêèõ, íà êîòîðûé îí äåéñòâóåò.
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#9
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Óâàæàåìûé Akusher, åñëè íå ñåêðåò, à ñêîëüêî âðåìåíè íà Âàøåé ïàìÿòè óäàâàëîñü ñîõðàíèòü áåðåìåííîñòü áåç âîä? À ãíîéíî-ñåïòè÷åñêèå îñëîæíåíèÿ áûëè?
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#10
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 øòàòàõ ïîñëå 37 íåäåëü àíòèáèîòèêè ïîñëå èçëèòèÿ âîä íàçíà÷àþòñÿ òåì, ó êîãî áåòà ñòðåïòîêîê >100 òûñÿ÷ âûðîñ íà âëàãàëèùíîé êóëüòóðå (35-36 íåäåëü), äëÿ òåõ, ó êîãî åãî íåò, àíòèáèîòèêè âîîáùå íå íàçíà÷àþòñÿ, åñëè òîëüêî òåìïåðàòóðà â ðîäàõ íå ïîäñêàêèâàåò.
Ïðàâèëî 18 ÷àñîâ íå èñïîëüçóåòñÿ ñ 2001 ãîäà. À ïðè èçëèòèè âîä íà ñðîêå 34-37 íåäåëü+ðîäû ïðîôèëàêòè÷åñêè âñåì ïàöèåíòêàì íàçíà÷àþò àìïèöèëëèí èëè ïåíèöèëëèí. Åñëè ðîäîâ íåò è ïûòàþòñÿ ïðîäëèòü áåðåìåííîñòü, íàçíà÷àåòñÿ ñåìèäíåâíûé êóðñ àìïèöèëëèíà+ýðèòðîìèöèíà (2 äíÿ âíóòðèâåííî, 5 äíåé â âèäå òàáëåòîê). Òîêîëèòèêè íå íàçíà÷àþòñÿ áîëüíûì ñ èçëèòèåì âîä ïîñëå 32 íåäåëü, à äî 32 íåäåëü - òîëüêî íà âðåìÿ ââåäåíèÿ ñòåðîèäîâ. Òóò ìíîãèå ïîëüçóþòñÿ ãèïîòåçîé, ÷òî åñëè ïðåæäåâðåìåííîå èçëèòèå âîä ïðîèçîøëî, ñêîðåå âñåãî íà ýòî åñòü èíôåêöèîííûå ïðè÷èíû è îñòàíàâëèâàòüòàêèå ðîäû íåðàçóìíî. |
#11
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Äà, ýòî òàê:
Table: Management of Premature Rupture of Membranes Chronologically Gestational Age Management Term (37 weeks or more) Proceed to delivery, usually by induction of labor Group B streptococcal prophylaxis recommended Near term (34 weeks to 36 completed) Same as for term Preterm (32 weeks to 33 completed weeks) Expectant management, unless fetal pulmonary maturity is documented Group B streptococcal prophylaxis recommended Corticosteroid—no consensus, but some experts recommend Antibiotics recommended to prolong latency if there are no contraindications Preterm (24 weeks to 31 completed weeks) Expectant management Group B streptococcal prophylaxis recommended Single-course corticosteroid use recommended Tocolytics—no consensus Antibiotics recommended to prolong latency if there are no contraindications Less than 24 weeks* Patient counseling Expectant management or induction of labor Group B streptococcal prophylaxis is not recommended Corticosteroids are not recommended Antibiotics—there are incomplete data on use in prolonging latency *The combination of birthweight, gestational age, and sex provide the best estimate of chances of survival and should be considered in individual cases. íî âñå æå åñòü ñìûñë íàçíà÷åíèÿ àíòèáèîòèêîâ ïðè ÏÐÏÎ [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Ïðè íåäîíîøåííîé áåðåìåííîñòè èìååò ñìûñë ñðàçó ïðè ïîñòóïëåíèè (ñ öåëüþ ïðîëîíãèðîâàíèÿ è ïðîôèëàêòèêè èíôåêöèé), à ïðè äîíîøåííîé - äëèòåëüíîñòü áåçâîäíîãî ïðîìåæóòêà íå îïðåäåëåíà.  Ðîññèè ïðèíÿòî 12 ÷àñîâ. Ãëþêîêðòèêîèäû ìû íàçíà÷àåì äî 34 íåäåëü. Òîëüêî íå ïîíÿòíî, ÷òî â ÑØÀ ïîñëå 34 íåäåëü ïûòàþòñÿ ïðîëîíãèðîâàòü áåðåìåííîñòü?  ðåêîìåíäàöèÿõ íàïèñàíî, ÷òî íåîáõîäèìà èíäóêöèÿ ðîäîâ (ñì.âûøå) |
#12
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Îáû÷íî, ýòî ñðîê â ðàéîíå 1-2 íåäåëü, áûâàëè ñëó÷àè ïðîëîíãèðîâàíèÿ áåðåìåííîñòè áîëåå ìåñÿöà, åñëè âûñîêèé áîêîâîé ðàçðûâ è íåò ïîäòåêàíèÿ âîä è â äàëüíåéøåì ìàçêè íà âîäû îòðèöàòåëüíûå - ðîäû â ñðîê. Íàø ðîä.äîì çàíèìàåòñÿ ýòèì óæå íå ïåðâûé ãîä - áûëè è õîðèîàìíèîíèòû, è ïàðà øîêîâ. Òàêèå ïàöèåíòêè ïîä ïîñòîÿííûì íàáëþäåíèåì, íà ñòðîãîì ïîñòåëüíîì ðåæèìå, ñ òðåõ÷àñîâîé òåðìîìåòðèåé, êîíòðîëåì ÈÀÆ, è ,êîíå÷íî, à\á è èíôóçèîííîé òåðàïèåé.
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#13
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Ïðî àíòèáèîòèêè. Ìû ïîëüçóåìñÿ öåôàçîëèíîì èëè öåôàòîêñèìîì ïî ãðàììó õ 4 ðàçà â äåíü (õîòÿ â ðåêîìåíäàöèÿõ 2 ãð â ñóòêè, ýòî òîëüêî "íàø" ëè÷íûé îïûò), à ó âàñ êàê?
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#14
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Ìû èñïîëüçóåì òîæå ñàìîå è â òàêèõ æå äîçèðîâêàõ. 2 ãð â ñóòêè - ýòî ñðåäíÿÿ ñóòî÷íàÿ äîçà, ìàêñèìàëüíàÿ 6 ãð. Ýòî ó íàñ, ïî ñïðàâî÷íèêàì äî 12 ãð.
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#15
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Óâàæàåìûå êîëëåãè, à çà÷åì îòðåçàòü ñåáå ïóòè è íà÷èíàòü àíòèáèîòèêîïðîôèëàêòèêó ñ öåôàëîñïîðèíîâ? Ìû íàçíà÷àåì ïîëóñèíòåòè÷åñêèå ïåíèöèëëèíû èëè ìàêðîëèäû - òàáëåòèðîâàííûå ôîðìû ïðè ÏÐÏÎ äî 37 íåäåëü
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