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#16
07.03.2006, 22:48
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проблема преждевременных родов очень горячая в современном акушерстве
и я бы не стал столь иронически подходить кэтому вопросу протоколы у нас пишутся после тщательного исследования литературы и обсуждения ведущими специалистами отделения из которых 6 профессоров прошедших по несколько усовершенствований в разных странах-все 6 поработали в США -часть из них члены ACOG и поверьте ориентируются в литературе помимо этого учитываются материальные возможности больницы, администрация лечебных учрежений в написании протоколов не участвует, между прочим никто не претендут получить истину в последней инстанции по такой серьезной проблеме 
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#17
07.03.2006, 22:51
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а Виллиамса предлагаю купить нового так как есть некоторые изменения по сравнению с 21 изданием
кстати зря вы так с пренебрежением упомянули имя Малиновского -я не нашел ни одной сравнимой с его оперативным акушерством западной монографии и эта книга мне очень помогла в развитии мануальных навыков так например приходилось не раз делать поворот на ножку извлечение за тазовый конец второго плода при родах двойни -это поинтереснее чем кесарево сечение а делают ли у вас это ?или всех оперируете? Это как вы выражаетесь- любой может
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#18
08.03.2006, 13:54
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Цитата:
Цитата:
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#19
08.03.2006, 14:01
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Цитата:
Цитата:
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Обязательно сделаю извлечение за тазовый конец, как только подвернется возможность. Обещаю Вам Кстати, Вы не ответили пока на мои вопросы относительно безопасности и эффективности индометацина с блокаторами кальциевых каналов в сравнении с бета2-адреномиметиками. Уходим от ответа....
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#20
08.03.2006, 16:03
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Я люблю ресурс firstconsult.com от знаменитого mdconsult. Вот, что там говориться:
Summary of evidence Evidence references Tocolytics Beta-agonists and indomethacin are associated with a significant prolongation of pregnancy for women in threatened premature labor, but there is no evidence of improved perinatal mortality or neonatal morbidity [1] Level A Evidence does not support the use of magnesium sulfate as a tocolytic, or as maintenance therapy to prolong pregnancy and prevent premature delivery. Its use is not associated with improved perinatal outcome [1-3] Level A In women who have had preterm labor arrested by tocolytics there is no evidence that maintenance terbutaline pump therapy is effective in reducing recurrent premature labor or the risk of preterm delivery [4] Level A, Compared with other agents, calcium antagonists reduce the rate of delivery at 7 days, the number of births prior to 34 weeks gestation, the incidence of drug withdrawal due to adverse drug effects and perinatal morbidity [5] Level A Блокаторы кальциевых каналов, таким образом, выглядят более привлекательно.
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#21
08.03.2006, 16:05
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Вот, что говорится о бета-миметиках:
Beta-adrenergic agonists are currently the most widely used group of tocolytic agents; agents include albuterol and terbutaline. They are epinephrine derivatives that have beta-2-adrenergic effects on the uterus, but also some beta-1 activity and relax uterine smooth muscle. This is an off-label indication for albuterol and terbutaline. Dose General considerations: This is an off-label indication for beta-adrenergic agonists, specialist advice must be followed May be administered as intravenous, intramuscular, subcutaneous, or oral doses Treatment can be initiated by intravenous infusion with a calibrated infusion pump and continuous external fetal monitoring of heart rate and uterine activity. Initial dose is lowest recommended by manufacturer for the particular drug and increased at 10-30min intervals as necessary according to uterine activity or until maternal side-effects are noted Once tocolysis is achieved some physicians continue infusion for another 6-24h and then switch to oral maintenance until 36 or 37 weeks Usual doses: Albuterol: initially, 10mcg/min intravenously, with rate of infusion increased gradually at 10-min intervals acccording to response (diminishment and then disappearance of contractions); maximum rate of infusion is 45mcg/min; maintain final effective rate of infusion for one hour after disappearance of contractions then gradually reduce dose by 50% every 6h; can be given orally at a dose of 4mg every 6-8h Terbutaline: usual subcutaneous dose of terbutaline is 0.25mg (0.25mL, one-quarter ampoule contents) injected into the lateral deltoid area. This may be repeated one hour after the initial injection; the usual terbutaline oral dose is 2.5-5mg every 4h or every 6h for 48h (dosing may be initiated at 2.5mg three or four times daily and titrated upward depending on clinical response); then 5mg every 6h as maintenance dose for subcutaneous dose. Some physicians suggest that a total dose of 15mg in a 24-h period should not be exceeded. If maternal heart rate >120 beats/min, change to another tocolytic agent Risks/benefits Risks Albuterol: Serious adverse reactions, including maternal pulmonary edema, have been reported during or following treatment of premature labor with albuterol Concomitant use with other sympathomimetics is not recommended; however, inhaled beta-2 agonists can be used cautiously with oral forms Use caution in cardiac disease, hypokalemia, and hyperglycemia Terbutaline: Use extreme caution during labor and delivery; transient hypokalemia, pulmonary edema (sometimes after delivery), and hypoglycemia in the mother and/or the neonatal child. Maternal death has been reported with terbutaline sulfate and other drugs of this class Risk of seizures, hypersensitivity reactions, and bronchospasm Use caution in patients with cardiovascular disorders (including arrhythmias, coronary insufficiency, and hypertension), hyperthyroidism, diabetes mellitus, history of seizures, and patients who are unusually responsive to sympathomimetic amines Use with caution in patients susceptible to hypokalemia May aggravate pre-existing diabetes and ketoacidosis Side-effects and adverse effects Albuterol: Cardiovascular system: palpitations, sinus tachycardia, hypertension Central nervous system: anxiety, tremor, headache, insomnia, dizziness, nightmares, hyperkinesia Eyes, ears, nose, and throat: cough, throat irritation, epistaxis, bronchospasm, hoarseness, congestion Gastrointestinal: nausea, vomiting, dyspepsia, abdominal pain Hypersensitivity: rash, urticaria, angioedema, anaphylaxis Metabolic: hyperglycemia, hypokalemia Musculoskeletal: muscle cramp Respiratory: bronchospasm Terbutaline: Cardiovascular system: tachycardia, palpitations, headache, drowsiness Central nervous system: tremor, nervousness Gastrointestinal: nausea, vomiting Metabolic: hypokalemia, elevated liver enzymes Musculoskeletal: muscle cramps Skin: sweating Interactions Albuterol: Beta-blockers Diuretics Monoamine oxidase inhibitors Sympathomimetics Thyroid hormones Tricyclic antidepressants Terbutaline: Beta-blockers Sympathomimetic bronchodilators Epinephrine Contraindications Albuterol: Hypersensitivity to sympathomimetics Diabetes mellitus Hyperthyroidism Cardiac arrythmias Ischemic heart disease Hypertension Seizures Terbutaline: Hypersensitivity to terbutaline Evidence Evidence references A systematic review of randomized controlled trials (RCTs) compared different tocolytic agents versus placebo or no tocolytic in women in preterm labor, with and without ruptured membranes. It found that beta-adrenergic agonists significantly delayed the time from onset of preterm labor until delivery by more than 24 hours, 48 hours and 7 days [1] Level A This review found no significant difference between beta-adrenergic agonists and placebo with respect to perinatal mortality, respiratory distress syndrome, incidence of low birth weight (<2500gm), patent ductus arteriosis, necrotizing enterocolitis, intraventricular hemorrhage, seizures, hypoglycemia or neonatal sepsis [1] Level A A systematic review of randomized controlled trials (RCTs) studied women who had had preterm labor arrested by tocolytics and the effect of maintenance terbutaline pump therapy in reducing the risk of recurrent preterm labor and preterm birth. This therapy was no more effective than a saline pump or oral terbutaline in prolonging pregnancy and reducing preterm birth [2] Level A Acceptability to patient Many women will find the potential risks of treatment with tocolytics acceptable; however, they need to be properly counseled so that an informed decision can be made. Follow-up plan Careful maternal and fetal monitoring are required during initial inpatient therapy After discharge, patients should be assessed weekly or as symptoms dictate Patient and caregiver information Tocolytic therapy is being used to try and delay delivery. It is likely that the pregnancy will not go to term but the extra time may allow corticosteroids to improve the function of the baby's lungs after birth.
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#22
08.03.2006, 16:06
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А вот, что об индометацине:
Indomethacin Further reading Anti-inflammatory; antipyretic; analgesic; inhibits prostaglandin synthesis by inhibition of cyclo-oxygenase (COX) enzyme Nonspecific NSAIDs inhibit both COX-I and COX-II isoforms Dose Adult rectal: 100mg suppository initially, followed by 25mg every 6h Maximum 200mg/day Most physicians treat for only 48h to avoid possible development of oligohydramnios Risks/benefits Warning: NSAIDs may cause an increased risk of serious cardiovascular thrombotic events including myocardial infarction and stroke. This risk may increase with duration of use or in patients with cardiovascular disease or risk factors for cardiovascular disease. Contraindicated in the treatment of perioperative pain in the setting of coronary artery bypass graft (CABG) surgery. Use caution in hypertension, fluid retention, and heart failure and monitor for adverse effects Warning: NSAIDs cause an increased risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which may be fatal. This risk increases with longer duration of use, concomitant use with corticosteroids or anticoagulants, smoking, use of alcohol, older age, and general health status. Use extreme caution in patients with a prior history of gastrointestinal bleeding or ulceration and monitor for adverse effects Warning: risk of serious and potentially fatal skin reactions including Stevens-Johnson syndrome and toxic epidermal necrosis. Advise patient to discontinue at first sign of rash Warning: reports of renal papillary necrosis and other renal injury with long-term administration of NSAIDs Warning: use minimum effective dose for shortest time possible to minimize risk of adverse effects Warning: stop therapy before surgery. Risk of renal impairment after surgery (especially if dehydration or renal hypoperfusion exists), and bleeding (with nonselective NSAIDs) owing to antiplatelet effect Warning: indomethacin may mask signs of infection Monitor: renal function, CBC and LFTs (long-term use), ophthalmic examinations (long-term use), and occult blood loss Use caution in patients with dehydration or hypovolemia (should be corrected before treatment begins), asthma or other allergic disorders, and coagulation disorders Use caution with indomethacin in patients with epilepsy, Parkinson's disease, psychiatric disorders Use caution in mild hepatic impairment; a dose reduction may be necessary. Avoid in severe hepatic impairment; NSAIDs increase risk of bleeding Use caution in mild renal impairment; may lead to deterioration of renal function and possibly renal failure; a dose adjustment may be necessary; monitor renal function. Avoid use in moderate-to-severe renal impairment; increased risk of NSAID-induced renal impairment Use caution in the elderly; increased risk of serious adverse effects. Elderly patients seem less able to tolerate ulceration and bleeding than other individuals and there have been many reports of fatal gastrointestinal events in this population. Elderly patients are more likely to have decreased renal function, and NSAIDs are excreted by the kidney, so care should be taken in selecting dose. Monitoring renal function may be useful Safety and efficacy of indomethacin have not been established in patients <14 years Pregnancy category B. Pregnancy category D (all NSAIDs in the final trimester). Avoid use in pregnancy where possible. Nonsteroidal use in the first trimester has been associated with higher risk of miscarriage, and in the third trimester may cause premature closure of the ductus arteriosus, fetal renal impairment, inhibition of platelet aggregation, and delay labor and birth Use caution in lactation. Short-acting, highly protein-bound NSAIDs such as ibuprofen and diclofenac are preferred Side-effects and adverse effects Adverse effects are more common with indomethacin than with other NSAIDs and may also rarely include convulsions, psychiatric disturbances, hyperglycemia, and ophthalmic disorders. Cardiovascular: congestive heart failure, myocardial infarction, stroke Eyes, ears, nose, and throat: tinnitus, blurred vision Gastrointestinal: nausea, diarrhea, dyspepsia, elevated LFTs, ulceration and bleeding, hepatotoxicity, pancreatitis, colitis, rectal irritation or bleeding (suppositories) Genitourinary: interstitial nephritis, renal failure, nephrotic syndrome, hematuria Hematologic: anemia, thrombocytopenia, neutropenia, eosinophilia, agranulocytosis Metabolic: salt and fluid retention, hyperkalemia Nervous: headache, dizziness, depression, insomnia Respiratory: alveolitis Skin: photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis Hypersensitivity reactions including fever, angioedema, bronchospasm, and rashes have been reported rarely Interactions ACE inhibitors (increased risk of renal impairment and hyperkalemia) Angiotensin-II receptor antagonists (increased risk of renal impairment and hyperkalemia) Anticoagulants (may enhance anticoagulant effects, especially nonselective NSAIDs) Antihypertensives (antagonize hypotensive effect) Antiplatelet agents (increased risk of bleeding) Baclofen (increased serum baclofen levels) Corticosteroids (increased risk of gastrointestinal bleeding/ulceration) Cyclosporine (increased risk of nephrotoxicity) Desmopressin (indomethacin increases effects of desmopressin) Diazoxide (antagonize hypotensive effect) Digoxin (possibly increase serum digoxin level) Diuretics (increased risk of nephrotoxicity and hyperkalemia; antagonize diuretic effect) Ketorolac (increased risk of adverse effects; risk of hemorrhage) Lithium (increased serum lithium level) Methotrexate (increased serum methotrexate level) Nonsteroidal anti-inflammatory drugs and aspirin (increased risk of adverse effects) Penicillamine (increased risk of nephrotoxicity) Phenytoin (increased serum phenytoin level) Potassium (increased risk of hyperkalemia) Probenecid (increases serum indomethacin level) Quinolones (possible increased risk of convulsions) Ritonavir (possibly increase serum NSAID level) Selective serotonin reuptake inhibitors (increased risk of bleeding) Sibutramine (increased risk of bleeding) Sulfonylureas (possibly enhances effects of sulfonylureas) Tacrolimus (increased risk of nephrotoxicity) Zidovudine (increased risk of hematological toxicity) Contraindications Hypersensitivity to NSAIDs, or any other component including patients with the 'aspirin triad' Treatment of perioperative pain in the setting of coronary artery bypass graft (CABG) surgery Evidence Evidence references A systematic review of randomized controlled trials compared different tocolytic agents versus placebo or no tocolytic, and pooled the results for all tocolytics including indomethacin. It found that indomethacin significantly decreased the risk of delivery within 7 days but had no significant effect in reducing perinatal mortality, respiratory distress syndrome, bronchopulmonary dysplasia, necrotizing enterocolitis, neonatal sepsis or low birth weight [1] Level A Follow-up plan Careful maternal and fetal monitoring are required during initial inpatient therapy After discharge, patients should be assessed weekly or as symptoms dictate Patient and caregiver information Use minimum effective dose for shortest time possible. Consult physician if pain persists, before dose increases, and before using OTC preparations for >10 days Avoid alcohol during therapy with this medication Therapy should be stopped before any type of surgery May cause photosensitivity. Avoid prolonged or excessive exposure to natural or artificial sunlight or take adequate precautions in the sun Advise patient of increased risk of serious cardiovascular, gastrointestinal, and dermatological adverse effects Report signs and symptoms of rashes, gastrointestinal bleeding or pain (including blood in stool), vision changes, blood cell disorders, hepatotoxicity, or cardiovascular events to physician immediately Regular blood and laboratory tests may be required with prolonged therapy This medication may interact with others. Consult physician or pharmacist before taking other prescription, complementary (including herbal), or over-the-counter medications
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#23
14.03.2006, 00:42
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Вы пишете что занимаетесь гинекологией -разделение у вас на гинекологов и акушеров является абсолютным?
возвращаясь к начатой теме я совсем не ухожу от от ответа -в Виллиамсе в той же о преждевременных родах все написано а есть ли возможности поспециализироваться за границей ?
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#24
14.03.2006, 19:50
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Нет, разделение не абсолютное. Просто есть очень много ньюансов которые заставляют так вот специализироваться. Вообще я очень люблю акушерство и с удовольствием бы занимался и тем, и тем.
По поводу ответов - я и сам их привел из firstconsult Вы хоть бы рассказали немного о себе. Интересно узнать где и сколько Вы работаете, если, конечно, это не большой секрет.
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Линейный вид
