Option № 1

First pregnant, 34 weeks pregnant, hospitalized with complaints of headache and

visual impairment. BP 170/120 mm Hg. Severe swelling of the limbs, anterior
abdominal wall, face. In urine - protein 5 g/l, cylinders hyaline and granular. During
the day of intensive treatment, the pregnant woman's condition improved. There is no
clan activity.

1 Arterial hypertension 3 stage. pronounced proteinuria

2 Pregnancy 34 weeks. Severe preclampsia.
3 General and clinical blood and urine tests
CBC- platelets (decreased)
liver test- liver enzymes
level of uric acid- increased
renal function test
Assessment of the condition of the fetus
biophysical profile.
ultrasound
4. Magnesium sulfate to prevent seizures
Anti hypertensive drugs- labetalol, methyldopa
It is necessary to carry out delivery. [Cesarean section]
Option № 2

A woman in labor S. 25 years old in the third stage of labor - 15 minutes have passed
since the birth of the fetus. From the birth canal minor spotting. After another 5
minutes, the placenta was born, a defect was found on the surface of the placenta.
Bleeding continues.

1. Objective data- defect on the surface of the placenta

2. Diagnosis: Bleeding in the third stage of labor

3 Additional method:
CBC
Estimate the amount of blood loss.
Ultrasound
Urıne output
BP measurement
Pulse rate

4. treatment-
Introduction of uterotonic agents -10-20 IU oxytocin iv in 400 ml of physiological
saline IV drip.
Urine catheter
Manual exploration of uterine cavity or diagnostic curretage
Option № 3
. On the fourth day after a
caesarean section, a 29-year-old woman in
labor had vomiting, severe pain in the lower abdomen, then throughout
the abdomen, stool and gas retention. The skin is pale, lips and tongue
are dry. Temperature 39 ° C. The abdomen is bloated, painful. Symptom
Shchetkina-Blumberg positive. Intestinal motility is absent, the uterus is
enlarged up to 20 weeks of pregnancy, painful on palpation.
1. Objective data: temperature is high, pale skin, lios and tongue are dry. Blumberg
sign (signs of peritonitis), uterus is enlarged.

2.Diagnosis: Peritonitis secondary to parametritis

3. Additional methods:

CBC

Ultrasound

Rectal examination

Culdocentesis

4. treatment

IV antibiotics (broad spectrum)

Laporotomy

IV fluids

.
Option № 4

In re-pregnant with blood group A (II) Rh- at the 34-th week of pregnancy, a titer of
Rhesus antibodies of 1:64 was detected. Ultrasound of the fetus was diagnosed with
hepatosplenomegaly, ascites, and an increase in the thickness of the placenta to 6
cm. According to the CTG of the fetus, a monotonous rhythm of heart activity is
observed. The optical density of the bilirubin indicator of amniotic fluid is 0.42.

1. Objective data: Signs of fetal dropsy, signs of chronic fetal hypoxia, hemolytic
anemia of fetus, bilirubin indicator of amniotic fluid.

2. Diagnosis: Erythroblastosis fetalis due to Rh conflict of the mother and the fetus)

3. Additional methods:
Transabdominal amniocentesis- Diluted amniotic fluid to assess the severity of
anemia in the fetus. In the case of fetal hypertension, an increase in the
concentration of bilirubin in the amniotic fluid and growth
amniotic fluid optical density index (GFV) reflects the severity of GC. Generally, GFV
0.1 and

below, then pregnancy can be prolonged to delivery on time. With OSNV 0.15 and
higher, preparation for
delivery.
Culdoocentesis - take the blood from the umbilical cord of the fetus. In the umbilical
cord of the fetus determine:
- hemoglobin and hematocrit;
- group blood and Rh factor;
- bilirubin;
- reticulocytosis;
Direct Coombs test
Doppler ultasound- middle cerebral artery blood flow measurement

4 It is not necessary to carry out delivery. [Cesarean section]

Indications for early delivery in case of Rh-conflict:
1. The titer of AT is equal to or exceeds 1:64 (critical level)
2. The increase in titer during re-analysis 4 times;
3. OSNVV 0.35-70 and above, the concentration of bilirubin in the amniotic fluid 4.7-
9.5 mg / l;
4. Ultrasound signs of GB in the fetus;
5. A history of stillbirth and birth of children with GB.
Immediately after the birth of the baby, the umbilical cord is squeezed and cut to
prevent Rh-Ab from entering the bloodstream
of the baby, the placental end of the umbilical cord is NOT squeezed (to reduce the
risk and volume of feto-maternal
transfusion). With caesarean section, the placenta is not separated by hand.
Option № 5

Re-pregnant at 8 weeks of pregnancy had cramping pains in the lower abdomen and
significant spotting from the genital tract. From the anamnesis - the third pregnancy,
there were two spontaneous miscarriages in the early stages of pregnancy. During a
gynecological examination: there are blood clots in the vagina, the cervical canal
passes one transverse finger, the lower pole of the fetal egg is palpated in the canal.
The size of the uterus corresponds to the gestational age.

1.Objective Data

Pain in the lower abdomen

Bleeding from abdominal tract

Fetal egg palpated in the canal

2. Diagnosis: Incipent abortion, habitual noncarrying of pregnancy

3. Additional methods

Ultrasound

Anti-cardin antibodies

Quantitative beta subunit of human chorionic gonadotropin (beta-hcg)

4. Treatment

Explusion of products of conception/ evacuation

Curretage (suction curretage)

Antibiotics

İV fluids (saline solutions)

.
.

Option № 6

A woman in labor K. has a first birth. History of metroendometritis after artificial

abortion. After the birth of the baby, there were no signs of placental separation
within 30 minutes. An attempt was made to manually separate the placenta - it was
not possible to exfoliate. After manipulation, bleeding from the genital tract (400 ml)
began and continues. Ps - 96 bрm satisfactory filling, blood pressure - 100/60 mm
Hg.

1. Objective data:
reduction of BP, pulse in increased, blood loss greater than 400ml as well as the
inability to separate the placenta).

2. Diagnosis: Post-partum Hemorrhage due to placenta accreta

3. Aditional method- ultrasound

MRI

4. Treatment
IV fluids,
urine catheter,
laparotomy
hysterectomy
Option № 7

A pregnant woman in the period of 8-9 weeks complains of vomiting up to 15-20

times a day, profuse salivation. Over 2 weeks, body weight decreased by 2 kg. BP
100/60 mm Hg, pulse - 110 bрm. The skin is dry, pale. Diuresis is reduced. In urine -
acetone +++. Drug therapy without effect.

1 Objective data: vomiting (severe), pale skin, dry skin, salivation, reduce BP,
Increase pulse, acetone in urine, signs of dehydration, oligouria,

2-diagnosis - pregnancy 8-9 weeks, complicated by early toxicosis of severe

severity.

3 – additional methods
check for hematocrit,
quantity of protein,
blood electrolyte,
bilirubin,
urea.
Urine analysis

4 - treatment :
parenteral preparations and intravenous rash of infusion.
Sedative and antihistamines: diphenhydramine, pipolfen, seduxen, droperidol.
Immunomodulating therapy: splenin.
Nausea: Atropine sulfate
Infusion therapy (volume and infusion up to 3 liters) reopoliglukin, physiological,
albumin, stabizol,
plasma.
Vitamin therapy: B vitamins,
Antiemetic drugs: cerucal.
Oxygen therapy, hyperbaric oxygenation
Rinses of the oral cavity
Option № 8

The 38-year-old first pregnant woman complained of weakening fetal movements at

weeks 41-42. Clinical and anamnestic data indicate a postponed pregnancy. The
estimated mass of the fetus is 4200 g. The fetal heartbeat is muffled, 160 bрm.
According to CTG, the assessment of the fetus is 4 points.

1. Objective data: muffled heart beat, fetus is big, prolonged pregnancy

2 - diagnosis - pregnancy 41-42 weeks, complicated by decompensated

cardiovascular disorders, fetal activity (4 points on the Fisher scale). Postponed
pregnancy. Fetal Macrosomia (Large fetus)

3 - ultrasound and biophysical profile of the fetus.

Dopplerographic studies,
index determination resistance of the uterine,
umblical and middle cerebral arteries.
Glucose tolerance test.

4 - delivery by cesarean section.

Option № 9

In women in labor for 30 years, the second birth is urgent, prolonged. Generic activity
is active. Contractions convulsive, sharp soreness of the lower segment. Contraction
ring at the navel. The size of the pelvis is 25-28-30-17 cm. The waters diverted even
at the beginning of labor. The fetal heartbeat is deaf, up to 100 bрm.

1. Objective data:
Spinarum (normal)
Crystarum (normal)
Trochanteric (normal )
Conjugate (decreased)

2 – Diagnosis- the risk/ threat of uterine rupture (contractions of a convulsive nature,

a sharp soreness of the lower segment)

3 - quick collection of anamnestic data, calculation of heartbeat, respiration rate,

measurement of blood
pressure palpation of the abdomen (special attention is paid to the postoperative scar
after cesarean),
assessment of the tonus of the fetus, the position of the fetus, ultrasound.

4 Treatment of the risk/ threat of uterine rupture

1) tocolytics,narcotics
2) transportation to the operating room, (CS)
Option № 10

A woman in labor with active labor. The first pregnancy. Coolant - 110 cm, standing
height of the uterine floor - 40 cm. The dimensions of the pelvis are 26-29-32-20 cm.
The position of the fetus is longitudinal, first position, front view. In the area of the
fundus of the uterus, a large, dense part of the fetus is determined. With internal
obstetric examination: the cervix is smoothed, opening 4 cm, the fetal bladder is
intact, the fetal leg is presented.

1. Objective data: coolant-110cm, fundic height -40 cm, pelvometry 26-29-32-20cm

,on palpation-tranverse lie of fetus ,vaginal examination-smoothened cervi, 4cm
opened, fetal bladder intact, fetal leg presented.

,2. Diagnosis: Pelvic (tender) presentation of the fetus.

3. additional methods:
an ultrasound scan that makes it possible to clearly diagnose
parts, its location relative to the entrance to the pelvis. Modern obstetric research:
● uterine hypertonicity;
● the uterus is enlarged, may be deformed, with local vipiachuvannyam;
● pain on palpation;
● accelerated abnormality of palpation and auscultation of the fetal heart
● fetal distress

4. only a caesarean section is indicated

Option № 11

In a primiparous 37 years of age, labor continues for 10 hours. Contractions for 20-25
seconds after 3-4 minutes. The position of the fetus is longitudinal, the head is
presented, pressed to the entrance to the small pelvis. With an internal obstetric
study: the cervix is smoothed, opening 4 cm. There is no fetal bladder.

1. objectively:
cervix is smooth, contractions 20-25 seconds after 3-4 minutes
,2. Diagnosis: Primary weakness of labor.

3. additional methods:
Ultrasound

4. If there is a violation of the progress of labor, an amniotomy should be

performed. At the same time, they note the color of amniotic fluid, fetal condition. If
within 1:00 after the amniotomy does not develop active labor, start stimulation with
oxytocin (1 ml oxytocin (5 units) is dissolved in 500ml of isotonic sodium chloride
solution. Mandatory catheterization of the ulnar vein for
ensure active behavior of women in childbirth. The introduction begins at a rate of 6 -
8 drops / min. (0.5-1.0 ml/ min.)
Option № 12

The multiparous 36 years old was admitted to the hospital in the first stage of labor
with moderate contractions. This pregnancy is the fifth, before that there was one
normal birth, two abortions, and the last pregnancy four years ago ended with a
caesarean section for a clinically narrow pelvis. At the height of one of the
contractions, the woman in labor complained of severe abdominal pain and
weakness. BP 70/40 mm Hg, fetal heartbeat is not heard. The contours of the uterus
are fuzzy.
1. Objective data: Uterine rupture in the scar after surgery

2. Diagnosis: Uterine rupture has begun.

3. Additional methods:
Uterine rupture, started on the scar in the first period of childbirth - pain in the scar
area, uterine hypertonicity, fetal distress, spotting from the birth canal may appear,
weakening or disappearance of heim.Hematuria.Maternal tachycardia, arterial
hypotension, chest pain, shortness of breath, feeling of lack of air

4. Treatment of uterine rupture, took place: - a woman in labor is immediately

transported to the operating room; if the woman’s condition is very serious, the
operating room takes place in the delivery room
– urgent carrying out antishock therapy with mobilization of the central veins, is
carried out laparotomy and interventions adequate to injury, revision of the pelvic
organs and abdominal cavity,abdominal drainage
- adequate size infusion-transfusion therapy blood loss and correction of
hemocoagulation disorders,
- transfusion of blood components,
blood substitutes should begin before, continue during surgery and in the postpartum
period.
5. Surgery is carried out in the following volume: suturing of the gap, supravaginal
amputation or hysterectomy with or without appendages. The amount of intervention
depends on the size
and localization of the gap, signs of infection, time elapsed after the gap, level
blood loss, woman's condition.
6. Indications for organ-preserving surgery: - incomplete rupture of the uterus - with a
complete rupture - linear
gap with clear edges - no signs of infection - with an anhydrous gap - saved
uterine contractility.
7. Indications for supravaginal amputation of the uterus - fresh uterine body tears with
uneven
crushed edges, with a vascular bundle, with moderate blood loss without signs
DIC syndrome and infection.
8. Indications for hysterectomy - a rupture of the body or lower segment of the uterus
that has passed to the cervix
with damaged edges - vascular bundle injury - inability to determine the lower angle
of the wound
- rupture of the cervix with the transition to the body.
9. Indications for hysterectomy with fallopian tubes: - preliminary indications for
prolonged
anhydrous interval (more than 10-12 hours) - manifestations of chorioamnionitis,
endometritis - the presence of chronic infection
Option № 13

A pregnant woman of 30 years old with edema of the lower extremities, with
complaints of bleeding from the vagina, which began 2 hours ago, was delivered to
the hospital. Pregnancy is 34 weeks. The last 2 weeks noted an increase in blood
pressure and swelling of the legs, was not treated. The condition of the woman is
serious. ВР 70/20 mm Hg, pulse 120 beats/min. Impaired consciousness. The uterus
is in hypertonicity, the fetus is not clearly defined, the fetal heartbeat is not heard.
With internal research, the cervical canal passes the finger along the entire length,
the amniotic fluid is tense. Isolation is dark blood with clots.

1. Objective data: decrease in BP, impaired consciousness, hypertony of the uterus,

heartbeat is not heard.

.2. Diagnosis: the detachment of a normally located placenta, pre-eclampsia.

3. Additional methods:
Ultrasound examinations, dopplerometry, MRI. However, using these techniques, we
state the fact
detachment of the placenta and determine the extent of the lesion. Diagnosis of the
fetus (auscultation, ultrasound scan, FCG).
Laboratory studies (red blood cells, platelets, Hb, Ht, coagulogram, coagulation time
according to Li-White).

4. Treatment
Caesarean operation is preceded by amniotomy (if there are conditions);
obligatory revision of the walls of the uterus (especially the external surface) in order
to exclude uterine-placental apoplexy;
when is there is Diagnosis of the uterus of Kuveler - hysterectomy without
appendages
Restoring the magnitude of blood loss, treatment of hemorrhagic shock and DIC
syndrome.
In the case of non-progressive placental abruption, dynamic observation is possible
Option № 14

Pregnant 27 years old, 3 hours have passed since the onset of labor, gestational
period 38-39 weeks, complains of acute abdominal pain. Mild preeclampsia is noted
from 38 weeks of gestation. Skin, mucous membranes are pale, pulse is frequent,
blood pressure decreases, fetal heart rate is 170 beats/min. Uterine hypertonicity is
noted. Opening the cervix 3 cm, the fetal bladder is intact, the discharge is dark,
bloody, moderate.

1. Objective data:
The first pregnancy, 38-39 weeks. Late fetal position, first position, front view tidy up
to date. Vegetovascular dystonia. Pathological preliminary period.

2.Diagnosis: The pathological preliminary period (is observed in women with

functional changes
regulation of the central nervous system, neurocirculatory dystonia, impaired function
endocrine system, autonomic disorder)

3. Additional methods:
disturbance of vegetative balance
reduction of erythrocytes
increas in the tone of the uterus
Reduction of Serotonin at blood.
İncrease in the blood of level of adrenaline and non-adrenaline
Low level of Glucose-6- phosphodehydrogenase

4. Treatment of a pathological preliminary period:

a) single use of tocolytic therapy, β2-adrenergic agonists;
b) sedative sedatives (diazepam up to 30 mg per day with intravenous the
introduction of 1 ml of a 2% solution of promedol)
c) with an immature cervix - preparation for the delivery of intravaginal
administration of prostaglandin E
Option № 15

Re-pregnant 24 years, pregnancy 30 weeks, was admitted with complaints of

spotting from the genital tract, which appeared after exercise. In the history of 2
artificial abortions, the latter was complicated by endometritis. Objectively: blood
pressure 110/60 mm Hg, pulse 82 beats/min The uterus is in normotone,
corresponds to the gestational age. The position of the fetus is longitudinal, the
heartbeat is 164 beats/min When viewed in the mirrors: the cervix is clean, a
moderate amount of blood flows from the external pharynx. Soft tissue is palpated
through the arches.

1. Objective data: BP is decreased, uterus is normal, heartbeat is normal

2. Diagnosis: incomplete placenta previa, Bleeding.

3. Additional methods - the appearance of bleeding, repeated, not accompanied by

pain and increased tone uterus.
Anamnesis - a detailed survey of a pregnant woman to identify risk factors that could
lead to abnormalities of the placenta.
Obstetric examination:
Careful external obstetric examination: high location of the underlying part; tone
the uterus is not elevated; auscultation in the region of the lower segment can be
determined by placental noise incorrect fetal position, or pelvic presentation may
occur.
Examination of the cervix and vagina in the mirrors exclusively in the conditions of a
deployed operating room:
eliminates other sources of bleeding (rupture of varicose nodes of the vagina,
pseudo-erosion and cervical cancer).
Vaginal examination exclusively in a comprehensive operating room
Ultrasound examination has a high informative value in determining localization.
placenta and presentation.

4.treatment
The term delivery by cesarean section.
Option № 16

The first-born 22 years old arrived 2 hours after the onset of labor. Complaints of pain
in the epigastric region, vomiting, blurred vision. ВР 180/120 and 170/110 mm Hg.
Severe swelling of the legs, feet, anterior abdominal wall. The fetal head is pressed
to the entrance to the small pelvis. The fetal heartbeat is clear, rhythmic, 136 beats
per minute. Proteinuria 3 g/day.

1. Interpretation of objective / laboratory data:

● term is more than 20 days of gestation.
● increase diast.tisk more than 110mm.rt.st. and syst. pressure over 170 mm
● generalized, significant edema, headache, visual impairment, epigastric pain and /
or right
hypochondrium, vomiting, hyperreflexia.
● proteinuria is greater than 3 g per day
● oliguria (<500 ml / day)

2. Diagnosis: Pregnancy 1, 39 weeks. Severe preeclampsia during childbirth.

3. additional methods:
● general blood test,
● hematocrit,
● platelet count,
● coagulogram, AlAT and AsAT;
● blood group and Rh factor (if absent)
● general urine analysis,
● determination of proteinuria, creatinine, urea, total protein, bilirubin and its
fractions, electrolytes.
Dynamic observation:
● blood pressure monitoring - hourly;
● auscultation of the fetal heartbeat - every 15 minutes
● urinalysis - every 4:00;
● control of hourly urine output (catheterization of the bladder with a Faley catheter)
● hemoglobin, hematocrit, platelet count, functional liver function tests, plasma
creatinine -
daily
● monitoring of the fetus: the number of movements in 1:00, heart rate - daily, by
possibilities - dopplerometric control of blood circulation in the vessels of the umbilical
cord, the vessels of the brain of the fetus,
placenta and fetoplacental complex;

4. treatment
Hospitalization:
● The patient is hospitalized in the department of anesthesiology and intensive care
to assess the degree of risk pregnancy for the mother and the fetus and the choice of
method of delivery within 24 hours.
● intensive follow-up.
● Urgent consultations of a physician, neurologist, optometrist.
● catheterize the peripheral vein, if necessary, control the Central Venous Pressure -
the central vein, and control bladder catheterization
Drug therapy:
Proof of blood pressure should be to a safe rest (150 / 90-160 / 100 mm Hg. Art., Not
lower!):
● methyldopa - 1.0-3.0 g per day (drug of choice),
● nifedipine - 10 mg under the tongue,
● labetalol - intravenously - 10 mg,
● clonidine - 0.5-1 ml of a 0.01% solution intravenously or intramuscularly 4-6 times a
day,
● hydralazine - 20 mg (1 ml) intravenously.

✔ Magnesium sulphate: It is used as an anticonvulsant with an instant

antihypertensive drug for prevention and treatment of seizures. This is a bolus is in
16 ml of a 25% solution by intermittent intravenous infusion. Therapy begins from the
moment of hospitalization, if diastolic blood pressure> 110 mm/hg
✔ Diazepam - 10 mg (2 ml of a 0.5% solution) intravenously for 2 minutes in 10 ml of
a 0.9% sodium chloride solution.
✔ infusion therapy . (Strict control of the volume of administration)
Drugs of choice for infusion therapy until delivery is isotonic saline solutions
BCC reduction - plasma substitutes (6% or 10% hydroxyethyl starch solutions), which
should be enter together with crystalloids in a ratio of 2: 1

Delivery tatics: obstetric forceps.

After childbirth: treatment is continued (blood pressure monitoring and
antihypertensive therapy, doses are gradually reduced, but
not earlier than 48 hours after birth. Magnesium sulphate lasts at least 24-48 hours
after birth)
Option № 17

First pregnant, hospitalized with complaints of headache, swelling on the legs, face,
hands. I did not attend women's consultation. The gestational age is 35-36 weeks.
ВР 160/100 mm Hg, 150/90 mm Hg. In the general blood test, the platelet level is
95x109/l, in the biochemical blood test - creatinine - 110 μmol/l, urea - 6.8 mmol/l,
uric acid - 0.4 mmol/l. In urine: protein - 2.8 g/l, hyaline and granular cylinders.

1. Interpretation of objective / laboratory data:

İncrease in BP
Proteinuria
Swelling on the face, hands and legs
2. Diagnosis: Pregnancy 1, 35-36 weeks, preeclampsia of moderate severity.

3. Additional methods
:
● general blood test,
● hematocrit,
● platelet count,
● coagulogram, AlAT and AsAT,
● general urine analysis,
● determination of daily proteinuria, creatinine, urea, plasma uric acid, electrolytes
(sodium and
potassium),
● assessment of the fetus: the number of movements in 1:00, heart rate, Doppler
blood circulation control in the vessels of the umbilical cord, vessels of the brain of
the fetus, placenta and fetoplacental
complex;
Dynamic Cautions :
● blood pressure monitoring - every 6:00 pershoid, in the future - twice a day
● auscultation of fetal sorbility every 8:00;
● analysis of sections - daily;
● proteinuria - daily;
● hemoglobin, hematocrit, coagulogram, platelet count, AlAT and AsAT, creatinine,
urea -
every three days;
● monitoring the condition of the fetus: kilk-shell for 1:00, heart rate - daily;
● galvanicabiophysical profile of the fetus (according to indications);
● cardiotocography (according to indications).
✔ When progressing to pre-eclampsia, the fetal condition should be reduced, prepare
before
delivery (preparation by a doctor in the case of an "immature" cervix - prostaglandins

4. treatment
Hospitalization .
✔ Hospitalization of the patient in hospital.
✔ Rational : food without salt and water .
Drug therapy:
✔ A complex of vitamins and minerals for a pregnant woman ("elevitpronatal", if
necessary
✔ With diastolic blood pressure of 100 mm Hg designated antihypertensive drugs:
● Methyldopa 0.25-0.5 g 3-4 times a day, the maximum dose - 3 g per day
● nifedipine 10 mg 2-3 times a day, the maximum daily dose is 100 mg)
✔ corticosteroids for the prevention of respiratory distress syndrome
- 6 mg dexamethasone after 12 hours 4 times within 2 days
Option № 18

A woman is hospitalized due to the threat of termination of pregnancy (13-14 weeks).

The previous 2 pregnancies ended in spontaneous miscarriage in the period of 14 -
16 weeks. During internal obstetric examination, the cervix is smoothed, shortened to
1 cm, the external pharynx of the uterus misses 1 finger, and the uterine tone is not
increased.

1.
Interpretation of objective / laboratory data:
anamnesis:
● Appearance of self-reliant disruption of front vacancies.
● manifestations of endocrinopathies, infantilism, post-adrenal adrenogenital
syndrome and
Internal obstetric research:
● First they show softening and contraction of the cervix (in the task - shortened to 1
cm),
● later - partial opening of the external pharynx of the cervix (misses 1 finger) and
prolapse of the fetal
the bubble.
● uterine tone is not increased.

2.Diagnosis: 3rd pregnancy ,13-14 weeks.Isthmico-cervical insufficiency.

3. Additional methods
✔ Transvaginal ultrasound:
● The diameter of the cervical canal is 1 cm or more of termination with viability up to
21 weeks.
● Even a uterus 2 cm or less is an absolute criterion for diagnosis
● Wedge-shaped transformation of the cervical canal by 40% or more.
✔ Cervical stress test
Methodology : with your hand, moderate pressure is applied to the anterior urethra on
the axis of the uterus in direct contact with a stretch of 15-30 seconds.
The test is considered positive - the uterus is reduced by 2 mm or more and
more than 5 mm wider than the inside.

4. Treatment
✔ Cerclage
✔ Surgical correction
Indications for surgical treatment:
● history of maternity days (in the II-III trimester of pregnancy)
● progressive dysfunction of the cervix: a change in its consistency (softening) and
reductions;
● a gradual increase in the partial opening of the external os and the expansion of
the entire channel of the cervix with opening of the internal os.
Scendi method: after removal of the mucous membrane around the external os of the
cervix, the front and rear lips the cervix is sutured together with separate catgut or
silk sutures.
During the first 2-3 days, antispasmodics and analgesics (suppositories with
papaverine, no-spa). In the uterine excitability
tocolytic - atosiban (traktotsil).
Complex antimicrobial drugs with vaginal route of administration.
Option № 19

In a 24-year-old woman in labor, on the 5th day, her body temperature suddenly
increased to 38.7° C. Complains of weakness, headache, pain in the lower abdomen,
irritability. Objectively: ВР 120/70 mm Hg, pulse - 92 beats/min, body temperature -
38.7° C. Bimanual: the uterus is enlarged up to 12 weeks of pregnancy, dense,
painful on palpation, the cervical canal passes 2 sm, the discharge is moderate,
cloudy, with an unpleasant odor. In the blood: leukocytosis with a shift to the left,
lymphopenia, ESR - 30 mm/hour.

1. Interpretation of objective / laboratory data:

violations
● weakness
● headache
● belly bill,
● irritability
● body temperature - 38,7 ° C .
anamnesis:
● after the birth period (characteristic late onset for the mild form - 5-12 days)
Diagnostic Lab:
The clinical picture of inflammation
● leukocytosis with a shift to the left,
● lymphopenia,
● erythrocyte sedimentation rate - 30 mm / hour.

bimanually:
● the uterus is enlarged to 12 weeks of pregnancy, dense, painful on palpation,
● the cervical canal passes 2cm
● the discharge is moderate, cloudy, with an unpleasant odor.

2. Diagnosis: postpartum period 5th day. Endometritis after childbirth, mild severity

3. Additional diagnosis
✔ clinical data: complaints, medical history
✔ laboratory data: in-depth analysis of blood (leukogram),
Biochemical test
Blood culture
urine culture
Imunogram, coagulogram
✔ instrumental data: ultrasound (ultrasound).

4. Treatment
✔ Antibiotic therapy - antibiotics (penicillins, macrolides) and broad spectrum
(chloramphenicol, tetracycline, ampicillin, cephalosporins
✔ infusion therapy: colloids-crystalloids 1 \ 1 (sodium chloride and others like
reopoliglyukin,glucose, albumin)
✔ Antihistamines.
✔ ascorbic acid.
✔ Vitamins of group B.
✔ Immunotherapy: staphylococcal toxoid and gammaglobulin, T-activin, thymalin).
Stimulation body forces (decaris, pengoxyl, methyluracil).
✔ Stimulation of leukopoiesis (methyluracil, pentoxyl).
✔ Uterotonic therapy (oxytocin, mamofizin, pituitrin).
✔ NSAIDs - ibuprofen, aspirin, paracetamol, indomethacin.
Surgical treatment - not shown in this situation
?

Option № 20

The second period of urgent birth is twins. After the birth of the first fetus, a vaginal
examination was performed, in which it was found that the second fetus was in a
transverse position. The fetal head is located on the right. The fetal heartbeat is clear,
rhythmic, 145 beats. in minutes.

1. Interpretation of objective / laboratory data:

● transverse
● fetal head

2. Diagnosis: Childbirth And urgency, 39-40 weeks, twins, the second period of
childbirth The position of the first fetus is longitudinal,
most importantly, the position of the second fetus is transverse, the second position.

3. Additional methods
✔ Great value of ultrasound (you can also read the position, type of fetus, location of
the back to the entrance to small pelvis. Especially effective method in the
development of agitation)
✔ Vaginal examination after amniotic fluid discharge and opening of the uterine os
(palpate the side of the fetus, scapula, acetabulum).

4. Treatment
CS
task21

A 25-year-old pregnant woman was admitted at 32 weeks with complaints of aching

pain in the lower abdomen,discharge of amniotic fluid. Objectively: the fetal position
is longitudinal, head presentation, fetal heart rate 140 beats / min, rhythmic. When
viewed in the mirrors, the cervix is clean, it is noted light watery discharge

1. Objective data: aching pain in the lower abdomen, discharge of amniotic fluid,
head presentation, fetal heart rate is normal

2. Diagnosis: Preterm premature rupture of the membrane

3. Additional methods:

Speculum Vaginal examination of the cervix and vaginal cavity

Nitrazine test- (brown to blue if PRM)

Fern test (observation under micoscope 1 drop of liquid on the slide)

Look for lecithin/ sphingomyelin, phosphatidyglycerol in liquid collected from the

pouch of douglas

4. treatment

Antibiotics

Corticosteriods

Aminocentesis
Option № 22

A woman in labor, 29 years old, complains of urine from the vagina. Leakage of urine
from the bladder is confirmed by the introduction of furatsilina with blue detected in
the vagina. General condition is satisfactory. Temperature - 36.9 ° C, blood pressure
120/80 mm Hg Pulse - 80 beats/min. The bottom of the uterus is 3 cm below the
navel.

1. Objective data
▪ involuntary discharge of urine from the vagina
▪ upon examination: a gap in the vaginal area from which urine is released

2. Postpartum period, 10 days. Vesico-vaginal fistula.

3.Additional methods:
▪ retrograde Cystouro-utherography
Combined Vaginoscopy-cystoscopy
Ultrasound
Magnetic resonance fistulography

4. treatment
surgery to close the fistula 2-3 months after birth.
Sanitary protection of the skin
Uretheral catheterization
Anti-cholinergic drugs
Option № 23

A woman in labor, 30 years old, was delivered to the hospital 4 hours after the onset
of labor, has a second full-term pregnancy. Complains of severe and painful
contractions, urinary retention. The waters receded 2 hours ago, bright. The
dimensions of the pelvis: 25-27-29-17 cm, IRR - 35 cm, coolant - 95 cm. The position
of the fetus is longitudinal, the head is pressed to the entrance to the small pelvis, the
back of the fetus is on the left, anteriorly. The fetal heartbeat is clear, rhythmic, 146
beats/min. Contractions after 2-3 minutes, for 40 s. Regular, excessively painful. A
sign of Vasten is the fetal head flush with the symphysis. Through a catheter, urine
cannot be removed. Michaelis rhombus changed - the upper triangle is very
low. During vaginal examination revealed swelling of the cervix, thickening of its
edges to 1.0 cm, opening of the cervix to 8 cm. There is no fetal bladder. The head of
the fetus is to be pressed, pressed to the entrance to the small pelvis, swept seam in
the transverse size of the pelvis.

1.Objective methods:
On complaints - painful, severe contractions, urinary retention, very rapid opening of
the cervix from 4:00, circulatory disturbance in the cervix (edema,
soreness), early discharge of amniotic fluid, Vasten's sign is doubtful, heavy
excretion of urine, changes in the Michaelis rhombus, achievement of the cape with
vaginal examination, the difference in growth and IRR is less than 120 cm.

2.Diagnosis: Clincally and anatomically contracted pelvis, occipital presentation and

position, early discharge of amniotic fluid

3.Additional methods:
Ultrasound
Clinical pelvimetry

4.Treatment
Survey by doctors (neonatologist and anesthesiologist).
Urgent delivery by caesarean section.
You can’t eat and drink. transfer to the operating room.
Option № 24

A 24-year-old pregnant woman was admitted to the hospital with a diagnosis of

pregnancy I, 38 weeks, twins. Complaints of cramping pains in the lower abdomen.
The abdomen is ovoid in shape, circumference 114 cm. VSD-41 cm, the position of
the fetus is longitudinal, the presentation of the first fetus is buttock, the second is the
head. Heart rate of the first fetus 134 in 1 min. on the left below the navel, the second
- on the right above the navel 145 beats. in 1 min When a vaginal examination was
found: the cervix is smoothed, the uterine pharynx is opened by 4 cm, the fetal
bladder is present, the buttocks are palpated, pressed to the entrance to the small
pelvis.

1.Objective data

Cramping pain in the lower abdomen, buttocks is palpated, pressed to the entrance
to the small pelvis

2.Diagnosis: twin birth, first fetus with incomplete breech presentation

3. Additional diagnosis

Ultrasound

Vaginal examination

Auscultation with a sthetosvope- fetal heatrbeat is felt above the umbilcus

CT scan

4. treatment

CS

.
Option № 25

The first pregnant woman, 25 years old, was urgently taken to the hospital with
complaints of severe headaches, flickering “flies” in front of her eyes, pain in the
epigastric region. Two weeks ago, swelling of the legs appeared, proteinuria 0.033-
0.09 g/l, refused to be hospitalized. ВР 180/100 – 190/110 mm Hg Generalized
edema. The fetal heartbeat is muffled, rhythmic up to 135 beats/ min, listens below
the navel on the left. The cervix is shortened to 2 cm, softened. Slated to be the
head, movable above the entrance to the pelvis.

1. Objective data: Proteinuria, increased blood pressure, generalized edema,

migraine flies, epigastric pain, headache.refused hospitalization,

2. diagnosis: Ist Pregnancy. Fetal position longitudinal, II position, front view, head
Presentation Complicated by Severe preeclampsia, Chronic intrauterine hypoxia of
the fetus of a mild degree.

3.Additional methods:
blood pressure control
auscultation of the fetal heartbeat - every 15 minutes
urinalysis every 4:00; control hourly urine output
fetal condition monitoring: number of movements in 1:00, heart rate
Dopplerometric control of blood circulation in the vessels of the umbilical cord,
vessels of the brain of the fetus, placenta and
fetoplacental complex;
estimation of amniotic fluid volume and fetal biophysical profile
fetal stress test

4. treatment
delivery in the next 24 hours from the moment of diagnosis.
Immediate hospitalization in the intensive care unit
Immediate delivery by caesarean section is indicated.
a) Therapeutic and protective regime. Neuroleptanalgesia (fentanyl, droperidol,
promedol)
b) Controlled hypervolemic hemodilution; hypertoncotable solutions with
simultaneous control hypotension. Reopoliglyukin, refortan, stabizol, plasma, glucose
40%. The volume of infusion therapy 800-1200
ml Pulse control, blood pressure, CVP, hourly urine output. The rate of infusion, the
rate of decrease in blood pressure.
c) antispasmodics: aminophylline, no-shpa, papaverine.
d) antiplatelet agents: chimes, trental.
d) antioxidants and membrane protector vitamins A, E, C, P.

e) treatment of fetal hypoxia, metabolic therapy

g) endocervical administration of prepidil gel to prepare the cervix for childbirth.
c) oxygen therapy. Hyperbaric oxygenation.
Strictly bed rest, to limit various auditory and sound stimuli.
After delivery, follow-up is recommended in a nephrologist, urologist, therapist,
optometrist
throughout the year. Preparing for a future pregnancy in 2-3 years
Option № 26

A woman in labor, 23 years old. Delivered to an obstetric hospital with complaints of

spotting from the genital tract that occurred with the onset of regular labor. The
gestational age is 38 weeks. Regular contractions for 30-35 sec., After 3-4 minutes.
Fetal heartbeat 172 beats/min. Internal obstetric examination: the cervix is softened,
smoothed, the cervical canal is 2.5 cm wide. The fetal bladder is intact. The edge of
the placenta is present. After amniotomy, bleeding intensified and is 350 ml.

1. Objective data- fetal heartbeat is 172 beats/min, cervix is soft, fetal bladder is
intact, Increased palpitations (norm 120-160), Placenta edge, bleeding.

2. Diagnosis- Pregnancy 38 weeks, 1st period of labor, latent phase, placenta

marginal previa.

3. additional method
Ultrasound
MRI

4. treatment-
IV fluid- colloids and crystalloids
Aminocaprionic acid or Tranexamic acid
CS
Option № 27

20 minutes after normal delivery, bleeding appeared from the vagina. After removal
of the placenta by the Crede-Lazarevich method, bleeding intensified. When
examining the maternal surface of the placenta, a 3.6 x 6 cm section was found
without placental tissue. ВР 115/70 mm Hg, pulse 70 beats/min. Blood loss was 600
ml. The uterus is dense, 2 cm below the navel.

1.OBJECTIVE data- blood loss

2. Diagnosis: Early postpartum hemorrhage due to Placental retention

3. Additional methods
• determination of the level of hemoglobin, hematocrit;
• coagulogram (platelet count, prothrombin index, fibrinogen level, time
blood coagulation)
• determination of blood type and Rh factor;
• biochemical examination according to indications.

4.treatment
The beginning or continued administration of uterotonics: 10-20 units of iv oxytocin
per 400 ml saline
Manual examination of the uterine cavity under intravenous anesthesia (integrity
assessment the walls of the uterus, especially the left wall, the removal of blood clots
or residues of the placenta or membranes).
Overview of the birth canal and restoration of their integrity.
External massage of the uterus.
In the case of continued bleeding, an additional 800mcg misoprostol rectally
administered
Recovery of blood loss.
treatment: hysterectomy without appendages; subject to continued bleeding - internal
ligation
In preparation for surgical treatment to reduce blood loss - temporary bimanual
external or internal compression of the uterus.
With continued bleeding after hysterectomy, a tight tamponade of the abdominal
cavity and vagina
(do not suture the abdominal cavity until bleeding stops)
With continued bleeding after hysterectomy, a tight tamponade of the abdominal
cavity and vagina
(do not suture the abdominal cavity until bleeding stops)
Option № 28

Multiparous complains of sharp abdominal pain, spotting that appeared during labor.
Pulse - 105 beats/min. BP 90/60 mm Hg. The uterus is hypertonic, painful. A tumor-
like formation measuring 5 x 5 cm is palpated along the front wall of the uterus. It is
sharply painful. Fetal heart rate 180 bpm. With vaginal examination: opening of the
cervix 5 cm, the fetal bladder is tense, the head lies. The allocation is dark, moderate

1. Objective data
The parturient woman has an increased pulse, low blood pressure, blood discharge,
the uterus in hypertonicity,
painful. On the front wall of the uterus, a puffy-like formation of 5 x 5 cm is palpated.
Fetal heartbeat accelerated, deaf,

2. Diagnosis: 1st period of labor, active phase. Premature detachment of a normally

located placenta.

3. additional diagnosis
Ultrasound studies

4. - immediate amniotomy,
- in the case of the head before the fetus - the insertion of obstetric forceps;
- short-term benefits - iv 10 units of oxytocin, in the absence of the effect of 800 μg of
misoprostol (rectally)
Option № 29

The first pregnant woman, 38 weeks old, was admitted with complaints of headache,
pain in the epigastric region, drowsiness, swelling in the legs. ВР 180/120 - 185/130
mm Hg. The position of the fetus is head, longitudinal. Fetal heartbeat 142 beats in
minutes In urine, protein is 4.8 g/l.

1. objective data: Increased blood pressure and protein.

2. Diagnosis: Pregnancy 38 weeks. Severe preeclampsia.

3. additional methods
general blood count, hematocrit, platelet count, coagulogram, AlAT and AsAT; Group
blood and Rh factor (in the absence) general urine analysis, determination of
proteinuria, creatinine,
urea, total protein, bilirubin and its fractions, electrolytes.
4. treatment
it is necessary to carry out delivery. Management tactics are active with delivery in
the coming 24 hours from the date of diagnosis.
Should strive to maintain blood pressure (150/90 - 160/100 mm Hg. Art., Not lower!),
A safe way to maintain adequate cerebral and placental blood flow
- Labetalol is first administered intravenously 10 mg, after 10 minutes, in the absence
of an adequate reaction
(diastolic blood pressure remained above 110 mm Hg.) - an additional 20 mg. AO
control every 10
minutes, and if the diastolic pressure remains above 110 mm/hg, administer40 mg,
and then 80 mg of labetalol
(up to a maximum of 300 mg)
-For the absence of labetalol, it is possible to use nifedipine 5-10 mg under the
tongue.
Option № 30

A primiparous with cramping pains in the lower abdomen arrived. The position of the
fetus is longitudinal, head presentation. The fetal heartbeat is clear, rhythmic, 140
beats/min. During vaginal examination, the cervix is smoothed, open 5-6 cm. There is
no fruit bubble. The root of the nose and orbit, as well as the front edge of the large
fontanel, are palpated

1.objective data: Palpated root of the nose and orbit, as well as the front edge of the
large fontanel.

2. Diagnosis: Pregnancy, 2nd stage of labor, active phase, facial presentation.

3. Additional methods
Diagnosis of facial presentation is based on external obstetric and vaginal data
research. The head of the fetus is maximally small, therefore, with an external
obstetric examination
possible division of the recess between the head and the back of the fetus, the
absence characteristic of others
presentation of the convexity of the back of the fetus.
-When vaginal examination, the facial parts of the fetus are determined: chin,
eyebrows, nose, mouth with hard gum.

4. treatment
Birth management with facial presentation with a normal pelvis and small fetuses
should be conservative, since in most cases childbirth ends favorably. Necessary
constantly monitor the nature of labor, fetal heartbeat.
In the first period of childbirth, careful monitoring of the safety of the rear view is
necessary, since in the event of the appearance of the anterior type, childbirth
through natural routes is impossible and it is necessary cesarean section. A
caesarean section is also indicated when signs of a clinically narrow pelvis appear,
fetal hypoxia, labor weakness.
Option № 31

The 29-year-old woman on the fourth day after cesarean section had vomiting,
severe pain in the lower abdomen, then all over the abdomen, delayed stool and gas.
The skin is pale, lips and tongue are dry. Temperature 39° C. Abdominal bloating,
painful. The Shchotkin-Blumberg symptom is positive. Intestinal motility is absent, the
uterus is enlarged to 20 weeks of pregnancy, painful on palpation.

1. Objective data
A swollen abdomen and gas and stool retention, S. Shchetkina-Blumberg- presence
of peritonitis. Painful uterus, enlarged up to 20 week
vaginality indicates postpartum endomyometritis; onset of symptoms on day 4
indicates on the classic form.

2. Diagnosis- Postpartum endomyometritis, classic form. Acute intestinal obstruction.

peritonitis after cesarean section.
3.Additional examination methods:
- CBC (red blood cell, leukocytosis, shift of the formula to the left, increased ESR)
- Urine (protein, leukocyturia, cylindruria)
- biochemical test (dysproteinemia, increased creatinine, decreased sodium and
potassium)
- Survey radiography of the abdominal organs (Kloiberg cups signs and a symptom of
intestinal arcades, )
- Irrigography (delay in barium passage)
- Microscopic and bacteriological analysis of transudate obtained during surgical
antibiotic susceptibility inoculation procedures

- Bacteriological and bacterioscopic examination of secretions from the cervix and

uterus
- Coagulogram
- ultrasound
- Diagnostic laparoscopy

4.treatment:
- hospitalization
Surgical treatment of peritonitis: laparotomy,
hysterectomy with fallopian
- Antibiotics for 7 days: cefatoxime 1.0 v / m 3r / d + metronidazole 100 ml i / v 2 r / d
(peritonitis)
detoxification therapy
- Within 3 days, ceftriaxone 1 g 2 r / d + oxytocin 2 ml 2-3r / s, NSAIDs 2R / D,
fluconazole, 0.9%
(immunostimulant) 150 mgn for 10 days (endometritis
Option № 32

A 24-year-old pregnant woman was admitted to the maternity hospital 2 weeks

before the expected due date with complaints of parenchymal pain in the lower
abdomen. An objective examination revealed that the general condition was
satisfactory, pulse 76 beats. for 1 min., blood pressure 120/80 mm Hg. The abdomen
is ovoid, circumference 114 sm. standing height of the uterine floor – 41 sm, the
position of the fetus is longitudinal, the presentation of the first fetus is sciatic, the
second – the main. The heartbeat of the first fetus 134 shocks in 1 minute. left below
the navel, the second - right above the navel 145 beats. for 1 minute Vaginal
examination revealed: the cervix is smoothed, the uterine eye is opened by 4 sm, the
amniotic sac is presented throughout, through which the buttocks are palpated, which
are pressed to the entrance to the small pelvis. Laboratory: Blood test wedge – НЬ -
89 g/l, er. - 2.68 x 10¹² /l, L - 6.2 x 109 /l, ESR - 20 mm/h. Analysis of allocations for
flora: U - 1-2 in the field of view; C- 4-6 in the field of view; V - 6-8 in the field of view
of the sticks. flora.

1. objective data
Complaints about parenchymal pain in the lower abdomen.
-position of the breech later, before the delivery of the first fruit of the buttock,
Heartbeat 134 tremors in 1 min another - the case above the navel 145 beats.
in 1 min, uterus smoothed out, through which the palms pressed to the entrance to
the pelvis. Blood test wedge. Moderate Anemia, Urine analysis wedge. – without
features.Microflora analysis - no features

2. Diagnosis- 38 weeks, twins, the first period of childbirth, buttock presentation of the
first fetus,anemia of the 2nd degree, caused by increased iron consumption during
pregnancy by twins.

3. additonal methods
Ultrasound

4. treatment
cesarean section.
Option № 33

Pregnant 25 years old, urgently taken by ambulance to the maternity hospital two
weeks before delivery with complaints of severe headaches, flickering "flies" in front
of the eyes. From the anamnesis: two weeks ago there was swelling of the legs,
proteinuria 0.033-0.09 g/l, refused hospitalization. Objectively: General satisfactory
condition, T - 37.0 C, Ps - 85 bpm. ВР – 180/100 - 190/110 mm Hg The edema is
generalized. The abdomen is enlarged by the pregnant uterus. The uterus is in
normal tone. Standing height of the uterine floor 40 sm, coolant - 98 sm. Fetal heart
rate 135 bpm, is heard below the navel on the left. The cervix is cylindrical, shortened
to 2 sm, soft, slightly deviated backwards from the leading axis of the pelvis. There is
a head that moves over the entrance to the small pelvis. Cape is not reachable.
Laboratory: Clinical analysis of urine: dark yellow urine, cloudy, drinking. weight
1010, acid reaction, protein 1.0 g/l, sugar - 0; L 1-2 in the field of view; epithelium
squamous 2-3 in sight.

1. Objective data
The pregnant woman was delivered by the emergency medical team in serious
condition with complaints of severe headache, flickering of "flies in front of the eyes",
generalized edema last 14 days. Previously, hospitalization refused. AO 180/100 -
190/110 mm Hg. Clinical analysis of urine- urine is dark yellow, turbid, pit. weight
1010, acidic reaction, protein 1.0 g/ l, L 1-2 in the field of view of the epithelium is flat
and transitional 2-3 in the field of view.

2. The diagnosis: I Pregnancy 38 weeks. Fetal position longitudinal, II position, front

view, head presentation complicated by Severe preeclampsia and Chronic
intrauterine hypoxia of the fetus

3. additional methods
Pregnant screening plan: RW, blood type Rh factor, clinical blood test
detailed, blood for sugar, coagulogram, biochemical analysis of blood, analysis of
urine for sugar,
clinical analysis of urine in dynamics, urine analysis according to Nechiporenko, urine
analysis according to Zimnitsky,
smear from the vagina on the microflora, ultrasound of the fetus with dopplerometry
of the uterine and umbilical arteries,
blood pressure monitoring - 4 times a day, specialist advice: therapist, urologist,
nephrologist, optometrist.
Conduct a biophysical profile of the fetus.

4. treatment.
Immediate hospitalization in intensive care unit and intensive care unit is indicated.
b) IV fluids( Reopoliglyukin, refortan, stabizol, plasma, glucose 40%. Volume
infusion therapy 800-1200 ml. Pulse control, blood pressure, CVP, hourly urine
output.
decrease in blood pressure.
c) antispasmodics: aminophylline, no-spa, papaverine.
d) antiplatelet agents
d) antioxidants and membrane protector vitamins A, E, C, P.
e) treatment of fetal hypoxia, metabolic therapy
g) endocervical administration of prepidil gel to prepare the cervix for childbirth.
c) oxygen therapy. Hyperbaric oxygenation.
6. Strictly bed rest, limit various auditory and sound stimuli.
7. After delivery, follow-up is recommended in a nephrologist, urologist, therapist,
Optometrist for a year. Preparation for future pregnancy in 2-3 years.
Option № 34

Pregnant, 27 years old. Childbirth second. The first ended with the birth of a boy
weighing 3500 g. The gestation period is 21 weeks. Notices pain in the lower
abdomen, slight bloody discharge from the birth canal. The heartbeat is listened to a
clear, rhythmic 140 per 1 min. On ultrasound: placental abruption 2 x 2 sm.
Segmental contractions of the posterior wall of the uterus. Vaginal examination: the
external genitalia are properly developed. The vagina of a woman giving birth. Cervix
2 sm long, tight-elastic consistency. The outer eye is closed

1. objective data
insignificant bloody discharge, and from the pathology of the mouth.
On ultrasound: placental abruption of 2 x 2 cm. Segmentation is shortened back of
the uterus

2. Diagnosis: Placenta abruption

3. additional methods
Ultrasound
4. give IV fluid
Hemostatic therapy
calcium antagonist nifedipine
Nsaids
corticosteroids
CS
Option № 35

The woman was hospitalized due to the threat of abortion (13-14 weeks). Previous 2
pregnancies ended in miscarriages at 14 to 16 weeks. At internal obstetric
examination the cervix is smoothed, shortened to 1 sm, the outer eye of the uterus
passes 1 finger, the tone of the uterus is not increased.

1. objective data
The previous 2 pregnanciesv have ended in a period of 14 to 16 weeks. At the
intrauterine obstetric uterine uterus is smoothed, shortened to 1 cm

2. diagnosis- Isthmic-cervical insufficiency. Habitual miscarriage, pathological

condition of the isthmus and cervix

3. Additional methods
Ultrasound

4. treatment
Cervical cerclage
Option № 36

Maternity, 18 years old. Is in labor for 14 hours. II period of childbirth. The size of the
pelvis is normal. Attempts are ineffective for 1.5 hours. Fetal heartbeat is deaf,
arrhythmic, 90 per 1 min. At vaginal research: opening of a neck of a uterus is full, a
fruit bubble is absent. Head in the pelvic cavity.

1. Objectively:
● The fetal heartbeat is deaf, arrhythmic, 90 in 1 min.
● Attempts are ineffective for 1.5 hours.

2. Diagnosis: II stage of labor. Fetal distress in the II period.

3. Additional method
● Listening to the fetal heartbeat. (Heart rate in 1 min).
● Cardiotocography (CTG) - synchronous electronic recording of the heart rate of the
fetus and uterine
contractions for 10-15 minutes.

4. treatment
The application of cavity obstetric forceps
vacuum extraction.
Option № 37

A woman was brought to the maternity hospital with complaints of bloody discharge
from the genital tract, which appeared with the onset of labor. The gestation period is
38 weeks. When examining the position of the fetus longitudinally, the head is
movable above the entrance to the pelvis, the fetal heartbeat is clear, rhythmic, 142
beats for 1 min. At internal obstetric research (at the expanded operating room): the
cervix is open on 5 sm, behind an internal eye spongy fabric on all extent.

1. Objectively:
● spotting from the genital tract.

2. Diagnosis: Antepartum hemorrgage, placenta previa

3. additional diagnosis
● It is determined by the volume of blood loss and the condition of the pregnant
woman.
● Ultrasound scanning is important to determine the location of the placenta and
establishing the correct diagnosis.

4. treatment
IV fluids
Blood transfusion
Urgent Caesarean section.
Option № 38

Maternity, 22 years old. Childbirth is the first. Childbirth is active, contractions turn
into attempts. The head of the fetus is pressed to the entrance to the small pelvis.
The fetal heartbeat is clear, rhythmic, 132 beats. for 1 minute Anhydrous period - 1
hour. Vasten's sign is positive. Body temperature - 36.8 C, pulse - 80 bpm. At
vaginal research: full disclosure of a uterine eye, on edges the thick, swollen neck of
a uterus is defined, on a head - a maternity tumor, allocations from a vagina - minor
bloody.

1. Objectively:
● anhydrous period - 1 h.
● Vasten’s sign is positive.
● The cervix is swollen, thick at the edges.
● Vaginal discharge –bloody

2. Diagnosis: Clinically narrow pelvis. Cephalohematoma in the fetus.

3. additional methods
CT scan
Ultrasound
XRAY
● Diagnosis of a clinically narrow pelvis is possible only with the onset of labor.
● Sign of Genkel-Vasten: positive - the surface of the head is higher than the surface
of the symphysis
(there is no correspondence between the pelvis and the head).
● Insufficient fit of the cervix to the fetal head (overhang of the cervix);
● High arrangement of a contraction ring;

4. treatment

Urgent Caesarean section

Option № 39

The mother is in the delivery room, in the first period of childbirth, behaves restlessly.
Contractions follow one another without a break. Contraction ring at the level of the
navel. Fetal heart rate 170 per 1 min. Internal obstetric examination: full opening of
the cervix, vaginal discharge from the vagina. The head is pressed to the entrance to
the small pelvis, on the head is a large birth tumor.

1. Objectively:
Contraction of ring at the level of the navel, vaginal discharge.

2. Diagnosis: The threat or risk of uterine rupture. Cephalohematoma in the fetus.

3.additional diagnosis
Ultrasound
MRI

4.treatment
Prolonged labor activity is stopped by the introduction of tocolytics and the
introduction of women in labor in anesthesia.
Immediate delivery by cesarean section
Option № 40

The mother delivered to the clinic behaves restlessly. Contractions follow one
another without a break. Contraction ring at the level of the navel. The fetal heartbeat
is not listened to. Internal obstetric examination: the opening of the cervix is
complete, the head is pressed against the entrance to the pelvis.

1. objectively:
the heartbeat is not heard, opening of the cervix is complete, the head is pressed
against the entrance to the pelvis

.2. Diagnosis: risk or threat of uterine rupture

3. additional methods
Ultrasound
MRI

4. treatment
prolonged labor activity is stopped by the introduction of tocolytics and the
introduction of women in labor in anesthesia.
Immediate delivery by cesarean section
Option № 41

Maternity, 23 years old, with a simple flat pelvis, narrowing of 1 degree, is in the first
period and first childbirth. The position of the fetus is transverse, the head of the fetus
on the left. At internal examination: the cervix is smoothed, the opening of the cervix
is 8 cm, the amniotic sac is absent, the anterior part is absent, behind the inner eye
nodes of the umbilical cord

1.OBJECTIVE: the fetus lies transversely, head of the fetus is on the left, cervix is
smooth

2. Diagnosis: First term birth. The transverse position of the fetus, prolapse of the
umbilical cord loops.

3. Additional methods
❖ Using the techniques of Leopold- manuevr, the following data are obtained: the
lateral parts of the uterus, large parts of the fetus are found.
❖ Ultrasound - allows you to determine not only the wrong position, but also the
expected mass of the fetus,position of the head, localization of the placenta.
❖ After discharge of amniotic fluid with sufficient opening of the cervix (4-5 cm),
determine the shoulder, shoulder blade, spinous processes of the vertebrae, inguinal
cavity.

4. treatment
The only way of delivery in the transverse position of the fetus, which ensures life
and maternal and child health, is a caesarean section in a period of 38-39 weeks
Option № 42

The woman in labor, 25 years old, on the 4-th day after cesarean section complains
of general weakness, fever up to 39° C, fever, bloating, gas and stool retention, a
symptom of a "falling drop". Pale, heart rate - 120 beats per minute The abdomen is
bloated, painful throughout, there is a positive symptom of Shchetkin-Blumberg. The
bottom of the uterus at the level of the navel, the uterus is painful, pasty consistency.
Vaginal discharge is purulent.
1. objectively:
fever, general weakness, bloating, gas and stool retention

2. Diagnosis: Obstetric peritonitis (purulent metroendometritis).

3. Additional methods:
Palpation of the abdomen. With inflammation of the peritoneum, diffuse sorene

❖ Auscultation of the intestine. When listening, there are no characteristic intestinal

murmurs.
❖ Microbiological research. The causative agent of the disease is determined in the
secretions of the uterus, blood, peritoneal exudate. Its sensitivity to antibiotics is
evaluated.
❖ Complete blood count- moderate or severe leukocytosis, stab shift
formulas, toxic granularity of neutrophils, high ESR.
❖ Urinalysis. The composition of urine determines leukocytes, hyaline cylinders,
protein.
❖ Abdominal ultrasound. Behind the uterus, in the intestine and between its loops is
fluid,
the intestinal wall is hyperechoic, the suture on the uterus has an uneven thickness
and structure.
❖ Abdominal radiography. The presence of peritonitis, Kloiber's bowls.

4. treatment
● Antibacterial drugs. Antibiotics are prescribed to determine the sensitivity of the
pathogen from the groups of semisynthetic penicillins, cephalosporins,
aminoglycosides. Further
treatment is adjusted based on the results of microbiological studies.
● infusion-transfusion therapy- detoxification solutions, protein preparations,
electrolytes.
If necessary, freshly frozen blood plasma is administered.
● With the ineffectiveness of drug treatment, an increase in signs of intestinal
obstruction and surgery is indicated.
● Surgery- laparotomy.
● In the postoperative period, infusion and antibiotic therapy continue;
hemostasis.

Option № 43

A 34-year-old pregnant woman was admitted to the maternity hospital. Pregnancy

3rd, full-term. Childbirth II, second period. The amniotic fluid receded 2 hours after
the onset of labor. At vaginal inspection it is established: position of a fruit cross, a
head at the left, a back in front, in a vagina the handle of a fruit is defined. The fetal
heartbeat is not heard.

1.Objectively:
Fetal heatbeat is not heard

2. Diagnosis: Pregnancy III, lateral position of the fetus. Antenatal fetal death.

3 Additional diagnosis
ultrasound

4 Embryotomy (obstetric surgery, fragmentation of the fetus, followed by extraction

through birth canal)
Option № 44

Maternity, 23 years old. She was taken to an obstetric hospital with complaints of
bloody discharge from the genital tract, which arose with the onset of regular labor.
The gestation period is 38 weeks. Contractions are regular for 30-35 seconds, after
3-4 minutes. Fetal heart rate 172 beats. per minute Internal obstetric examination: the
cervix is softened, smoothed, the cervical canal is open by 2.5 cm. The amniotic sac
is intact. The edge of the placenta is presented. After amniotomy, the bleeding
increased to 350 ml.1. Interpretation of objective / laboratory data.

1. Objectively:
Fetal heart rate is increased, cervix is soft, smooth, amniotic sac is intact, bleeding
increased to 350ml

2. Diagnosis: Pregnancy 38 weeks and the period of childbirth, incomplete placenta

previa, amnitomy.

3. additional methods
Ultrasound
CBC
MRI

4. treatment
Immediate delivery by caesarean section
Option № 45

Bleeding started 20 minutes after a normal birth. After removing the manure with
Krede-Lazarevich, the bleeding intensified. Examination of the maternal surface of
the placenta revealed an area of 3.6 x 6 sm without placental tissue. Blood pressure -
115/70 mm Hg, pulse 70 beats. per minute Blood loss was 600 ml. The uterus is
dense, 2 sm below the navel.

1. Objectively: pulse is normal, blood loss was 600ml, uterus is dense, 2cm below the
navel

2. Diagnosis: Postpartum hemorrhage due to placenta retention

3 . Additional methods
ultrasound
urine output

4. Treatment
● infusion therapy.
Uterine catheter
● If it is not possible to conduct a manual revision of the uterus, we do curettage of
the uterus
Option № 46

Repeated childbirth in women 32 years. Duration of childbirth 15 hours. The fetal

heartbeat is rhythmic, up to 100 beats. per minute Vaginal examination: the opening
of the cervix is complete, the head of the fetus in the plane of exit from the pelvis.
Sagittal suture in a straight size, a small temple near the womb

1. Objectively:
● pathological fetal heart rate <110 bpm, the cervix is complete, the head of the fetus
is in the plane of exit from the pelvis

2. Diagnosis: 2nd Pregnancy, The longitudinal position of the fetus, head

presentation, Ist position, front view, The second period of childbirth. Acute
intrapartum distress of the fetus.
3. Additional methods:
● Listening to the fetal heartbeat (heart rate in 1 min)
● Cardiotocography (synchronous electronic recording of the fetal heart rate and
uterine contractions for 10-15 min.):
● Determination of meconium in the amniotic fluid during rupture of the fetal bladder.
Partograph

4. Treatment
● Avoid the position of the woman in labor on her back
● Discontinue administration of oxytocin if previously prescribed;
● When determining fetal distress, urgent delivery is necessary:
● in the first stage of labor - cesarean section;
● in the second period: with head presentation, vacuum extraction orn obstetric
forceps
Option № 47

10 minutes after the birth of the child, the manure separated on its own. When
examining the placenta and the shell of the target. Examination of the birth canal
revealed no damage. The bleeding began. The uterus is soft, poorly contoured, its
bottom is 3 fingers above the navel. 10 U of oxytocin were administered
intravenously, external uterine massage was performed. The bleeding stopped
temporarily, but resumed after a while. The total blood loss was 700 ml. A manual
examination of the uterine cavity, massage of the uterus on the fist, clamps on the
parameters. The bleeding continues.

1. Objectively:
● bleeding in the absence of ruptures of the birth canal and with a whole litter
● responds to irritation with a reduction, but not a full one.

2. Diagnosis: The early postpartum period, Postpartum hypotonic bleeding.

3.Additional methods:
-quantify the value of blood loss
- assessment of the state of the woman in labor: complaints, AO, pulse rate, color of
the skin and mucous membranes, the amount of urine,
the presence and stage of hemorrhagic shock.
laboratory examination: - determination of the level of hemoglobin, hematocrit;
- coagulogram (platelet count, prothrombin index, fibrinogen level, clotting time
blood)
- blood type and Rh factor;
- biochemical examination according to indications.

4. Treatment
IV fluids
Blood tranfusion
types of surgical interventions:
● Bilateral uterine vessel ligation.
● Bilateral ovarian ligation.
● Applying compression sutures to the uterus.
● IV. Bilateral ligation of the internal iliac (hypogastric) arteries:

uterine devascularization is used to stop bleeding:

1. Laparotomy - lower median
2. A longitudinal section of the posterior sheet of the parietal peritoneum.
3. dissection of the internal iliac artery.
4. Bringing the ligature under the artery.
5. Ligature overlay on the hypogastric artery.
● V. Radical surgery (subtotal or total hysterectomy).
Option № 48

The first pregnant woman, 38 weeks old, came with complaints of headache,
epigastric pain, drowsiness, swelling in the legs. ВР 180 / 120-185 / 130. The position
of the fetus is the main, longitudinal. Fetal heart rate 142 beats per minute. In urine
protein of 4,8 g/l.

1. Objectively:
▪ Proteinuria 4.8g / day
▪ Headache
▪ Epigastric pain
▪ Swelling, drowsiness

2. –Diagnosis- 1st Pregnancy 38 weeks, The longitudinal position of the fetus, head
presentation. Preeclampsia severe degree.

3. Additional methods:
● blood pressure control
● auscultation of the fetal heartbeat - every 15 minutes
● urinalysis - every 4:00; control hourly urine output
● monitoring of the fetus: the number of movements in 1:00, heart rate
● Dopplerometric control of blood circulation in the vessels of the umbilical cord,
vessels of the fetal brain, placenta, and
fetoplacental complex;
● estimation of amniotic fluid volume and fetal biophysical profile
● fetal stress test

4. Treatment
delivery in the next 24 hours from the moment of diagnosis.
Immediate delivery by caesarean section is indicated
Option № 49

The mother, 29 years old, complains of urine from the vagina. Leakage of urine from
the bladder is confirmed by the introduction of furacillin with a bruise, which is found
in the vagina. The general condition is satisfactory. Temperature - 36.9 C, blood
pressure - 120/80 mm Hg. Pulse - 80 beats per minute. The bottom of the uterus is 3
sm below the navel.

1. Obejectively:
▪ involuntary discharge of urine from the vagina
▪ upon examination: a gap in the vaginal area from which urine is released

2.Diagnosis: Postpartum period, 10 days. vesico-vaginal fistula.

3.Additional methods:
retrograde Cystouro-utherography
Combined Vaginoscopy-cystoscopy
Ultrasound
Magnetic resonance fistulography

4. treatment
surgery to close the fistula 2-3 months after birth.
Sanitary protection of the skin
Uretheral catheterization
Anti-cholinergic drugs
Option № 50

A 26-year-old pregnant woman was taken to the maternity ward due to a pregnancy
of 40-41 weeks: anhydrous period of 6 hours. There is no labor. Body temperature is
normal. A history of infertility for 3 years, was examined and treated. During the
vaginal examination, the cervix is shortened to 1.5 sm, softened, the opening of the
cervix to 2 sm. There is no amniotic sac. The head of the fetus is high above the
entrance to the small pelvis. Fetal heart rate 140 beats per minute.

1. Objectively:
▪ lack of labor
▪ lack of progression of cervical dilatation
▪ absence of the fetal bladder

2. Diagnosis: the first birth, preganancy 40-41 weeks, Primary weakness of labor.
3. additional methods:
Determining the dynamics of cervical dilatation (maturity beyond Bishop) and head
advancement every 2:00 by external methods;
- internal obstetric research

4. Treatment
● intravenous drip of oxytocin or prostaglandin E
oxytocin dissolved in 500 ml of NaCL. at a speed of 6 to 8 drops / min. When the
effect is reached after 30 minutes, the rate of administration remains the same. In the
absence of effect, the rate of administration is increased every 30 minutes for 6
drops. The maximum rate of administration should not exceed 40 drops in a minute.
0.75 ml (1 ampoule) of prostaglandin E dissolved in 500 ml of NaCL. Initial infusion
rate which support at least 30 minutes., 5 to 8 drops / min. When the effect is
achieved, the rate of administration remains the same. If there is no effect, the rate of
administration is increased every hour until effect (no more than 25 - 30 drops / min.).
● Evaluation of effectiveness after 6 - 8:00 with a look at the indications of further
tactics childbirth:
- determination of the dynamics of cervical dilatation and head advancement every
2:00 by external methods;
- Internal obstetric examination after 4:00.
● In the absence of transition to the active phase of labor after 8:00, delivery by
oxytocin - delivery
cesarean section
Instrumental examination methods
I
1 CTG during pregnancy
norm:

● Basal heart rate (110-170)

● Variability (amplitude less than 5, or no variability) 5 mıld ,moderate 6-

25, severe greater 65

● acceleration (this is an increase in the frequency of the heartbeat of the

child by more than 15 beats / min and the preservation of such
tempo for 15 sec or more) for 30-40 min (absence or monotonous low
variable rhythm, 2 pcs /
10 minutes)

● Deceleration (this reduces the rhythm by 15 beats / min while

maintaining the pace for 15 or more seconds) - no or
shallow, variable, early

● Oscillations High oscillations (rhythm change by more than six beats

(there were 140, became 150).
distress:

● Basal heart rate (less than 100, more than 180)

● Variability (6-25)

● acceleration in 30-40 minutes (the same in duration and severity,

sinusoidal rhythm)

● Deletions (late, unfavorable, variable - more than 70 beats / min. And

lasting more than 60
sec)
● Calculated on the Fischer-Krebs or Figo scale
2. CTG 1 period of labor
Norm: (In the normal state of the fetus, CTG is characteristic of: BCHSS in
the range from 110 to 170 beats / min.
(Normocardia), variability (recording width) - 10-25 beats. / Min With an
oscillation frequency of 3-6 cycles. / min
(wave-like type), the presence of acceleration of heart rate and the absence
of deceleration.)
The frequency of labor in the active phase of the first stage of labor is 3-4
in 10 minutes, and the frequency of attempts in the second
period reaches 5 to 10 minutes.
At the beginning of the first stage of labor, the difference in the intervals
between contractions varies within 3 minutes or more.
Further, contractions become more rhythmic and the difference in intervals
does not exceed 1-2 minutes. Rhythm
contractions must be monitored during the recording process every 20
minutes.

● Basal heart rate beats / min (110-170sure, up to 180 permissible)

● Variability beats / min (wave-like 10-25 satisfactory, narrowed 5-9 for

example, monotonic 3-4
permissible)

● Deletions (amplitude, beats / min.) - (early - none - satisfactory, less than

50 - acceptable), (late
- none - satisfactory, less than 30 - acceptable), (variable - none -
satisfactory,
less than 50 - let's say)
Distress (With fetal distress during childbirth, CTG usually reveals one or
more pathological signs:
tachycardia or bradycardia, steady monotony of rhythm (recording width 5
beats / min. And less), early,
Variable and especially late deceletions with an amplitude of more than 30
bpm)

● Basal heart rate beats / min. (More than 180 - tachycardia, less than 100
- bradycardia)

● Variability bpm . (Monotonous 2 or less)

● Deletions (amplitude, beats / min.) (Early - more than 50, late - more
than 30 variable - more than 50)

3. Hysterosalpingography (normal, obstruction, lack of

fallopian tubes, hydrosalpinx, bicorn
uterus)
Hysterosalpingography is a method of X-ray diagnosis of the condition of
the fallopian tubes and internal cavity
the uterus, their patency and structure by introducing a contrast medium
into the uterine cavity and tubes.
the norm is
• The uterine cavity is a triangle with its top down. The base of the triangle
(also 4 cm) corresponds to the bottom
uterine cavity, at the apex there is an anatomical internal uterine pharynx.
In the lower part, the uterine cavity passes into the isthmus. The length of
the isthmus is 0.8-1.0 cm, behind it
the cervical canal begins. Its shape can be conical, cylindrical, spindle-
shaped and
depends on the phase of the cycle.
• Pipes - in the form of thin, sometimes rather winding, ribbon-like
shadows.
3 anatomical parts of the tube: interstitial, isthmic and ampullar. Interstitial
- in
in the form of a short cone, passes after a certain narrowing into the
isthmic section. Transition isthmic
department in the ampullar is not always clear.

Contrast fluid flows out of the tube ampoule in the form of a strip and then
spreads along the abdominal
cavity in the form of smoke of a burning cigarette. An indicator of a good
cross pipe - spreading contrast
substances along the peritoneum to places remote from the ampoule.
two-horned uterus
X-ray revealed a septum going from the bottom, wide in the upper part, at
the base. His
with the top, it almost reaches the isthmus, dividing the uterine cavity into
two halves. In this case, the angle
formed between the two parts of the uterine cavity - dull.
obstruction
With obstruction of the fallopian tubes, contrast is not detected in the
pelvic cavity.
Lack of fallopian tubes
In the x-ray, the fallopian tubes should be visible in the form of thin
smooth lines that
expand in the ampullar part. (Absence)
hydrosalpinx
With hydrosalpinx, fluid accumulates in the fallopian tube, forming a kind
of bubble, which,
increasing, stretches the fallopian tube. Contrast material, reaching the
point of expansion,
mixes with exudate and creates an expressive picture of the increase in the
fallopian tube (its ampullar
parts). In the picture, instead of the tape, which should be the normal pipe,
the image of the bulb is clearly “read”.

4. Hysteroscopy (endometrial polyp, submucous node,

Asherman syndrome)
Hysteroscopy is a highly informative diagnostic method that helps the
doctor examine the uterus (cervical canal
uterus, uterine cavity and uterine tubes eyes)
endometrial polyp
Endometrial polyp is a benign endometrial formation associated with
excessive growth
(proliferation) of cells of the basal layer of the uterine mucosa. The
endometrial polyp has a body and
leg (with which it is well supplied and tightly attached to the uterine
wall). It has
oblong or rounded shape, pale pink / yellow or purple. Hesitate in
washing liquid (unlike motionless myomatous nodes)
submucous node
Submucous nodes (fibroids) are benign lesions that are localized in the
submucosa
layer and partially protrude into the uterine cavity (grow into the uterine
cavity and deform it)
Asherman's syndrome
With hysteroscopy, synechia is defined as whitish avascular cords - fusion
between the walls
uterus of various density and length, often reduce the volume of the uterine
cavity, and sometimes
obliterate it completely. Synechia can also be located in the cervical canal,
causing it
fusion and obstructing access to the uterine cavity and the outflow of
contents from it. Gentle synechiae look
like cords of pale pink in the form of a web, sometimes the vessels that
pass through them are sometimes visible. More
dense synechiae are defined as dense whitish strands, usually located along
the lateral
walls, less often - in the center of the uterine cavity. Multiple transverse
synechiae cause partial
fusion of the uterine cavity with many cavities of various sizes.

5. Laparoscopy (hydrosalpinx, tubal pregnancy by type of

rupture of the tube, progressive,
ovarian apoplexy, ovarian cyst (endometrioid, serous,
dermoid, follicular), torsion
ovarian cysts, uterine leiomyoma, pelvic adhesions, peritoneal
endometriosis
Hydrosalpinx is a disease characterized by the accumulation of fluid in the
cavity of the tube, which leads to its
obstruction (the presence of smooth-walled one- or two-sided tumor-like
formation in the area of the appendages
uterus).
tube pregnancy by type of pipe rupture

● Visually established rupture of the fallopian tube;

● Bleeding from an ampullar opening or from a rupture of a fallopian tube;

● The presence in the abdominal cavity of blood and elements of the fetal
egg.
progressive tubal pregnancy

The uterus is softened, enlarged, but the sizes do not correspond to those
necessary for a given period of pregnancy. Form her
remains pear-shaped, asymmetric protrusion of one of the cohugs is not
noted, as is the case with uterine
pregnancy. Outside the uterus or a slightly thickened loose pregnant tube is
visible. Fetal egg
It appears in the area of the uterine appendages in the form of a round
formation and its dimensions correspond to
pregnancy.
ovarian apoplexy

violation of the integrity of the ovarian tissue and bleeding in the

abdominal cavity., fluid accumulation in
behind the datacle (douglas) space.
Ovarian cyst (endometrioid, serous, dermoid, follicular)

● Endometrioid (represent a whitish formation with blue or brownish

areas, have
dense capsule, uneven surface and often surrounded by a large number of
adhesions.). is a consequence
endometriotic tissue growth in the ovaries. The content is dark
(chocolate). Their content is shifted to
research process. They are distinguished by a thick wall, these cysts
enlarge before
monthly

● Serous (the formation of a round or oval gray or bluish color with a

transparent
content.)

● Dermoid ( this is a neoplasm whose content is fat, hair, embryos,

teeth., Have
heterogeneous structure and dense inclusions.)

● Follicular ( these are single-chamber thin-walled formations of elastic

consistency with transparent
contents that are formed as a result of fluid accumulation in the
follicle, diameter does not exceed 10 cm
..)

Torsion of ovarian cysts

In the pelvic cavity, a node of a crimson-cyanotic color and the presence of
serous-hemorrhagic fluid in the abdominal
cavities.
uterine leiomyoma
The myoma node is a ball of randomly interlocked smooth muscle fibers of
a rounded shape.
Most nodes have diameters from a few millimeters to a few centimeters,
but sometimes they
can reach large sizes and weight of several kilograms.
Adhesive process of the pelvis
According to the results of laparoscopy, three stages of the adhesive
process are distinguished:
Stage I - connections are located around the fallopian tube, ovary, or other
site, but do not interfere with capture
ovules;
AI stage - compounds are located between the fallopian tube and ovary, or
between these organs and other
structures and may interfere with egg capture;
III stage - there is a torsion of the fallopian tube, blockage of the
connection, or complete blockage of egg capture.
peritoneal endometriosis
Diagnostic laparoscopy is to identify typical signs of endometriosis, such
as
cicatricial black foci on the serous surface of the peritoneum, as well as
white-red foci;
irregular shape yellow-brown spots rounded defects of the
peritoneum; glandular bulging;
petechial rash, etc. Laparoscopic sign of adenomyosis is uterine marbling.
Endometrioid ovarian cysts are accompanied by retraction, pigmentation
and adhesions with a peritoneum, often
contain dark brown liquid ("chocolate cysts").

6 Colposcopy (normal, Schiller test, cervical polyp, cervical

erosion, cervical cancer)
the norm is

● Simple colposcopy consists in examining the mucosa, without finishing

the cervix with any substances.
(Pay attention to the shape and size of the cervix, its external pharynx,
color and relief of the mucous membrane,
border of squamous and cylindrical epithelium. Normal mucous pink with
smooth shiny
surface. subepithelial vessels not
are determined)

● Advanced colposcopy - examination in / uterus with special. tests:

a) 3% acetic acid - constricts blood vessels (under the influence of acid,
healthy vessels constrict and become
hardly noticeable. Pathological ones do not change their appearance, being
recently educated, because Dont Have
muscle layer for contraction. The epithelium in these areas acquires a white
color (acetobilia epithelium).
there is an epithelium norm - pales
b) Schiller test - a test with Lugol's solution (the surface of the vaginal part
of the oil is painted in dark brown.
The boundary between a multilayer flat and a single layer cylindrical - a
straight line
Polyp of the cervix (structure of small sizes from 2 to 40 mm in diameter.,
Oval or round, with
smooth surface, may have a thin or wide leg. Polyps are dark pink, soft
or dense consistency depending on the content of fibrous tissue. the surface
of the polyps can be covered
stratified (smooth with open ducts of the glands) or cylindrical epithelium
(papillary surface)
Lugol's solution is NOT stained

Polyps can be:

- single and multiple;

- glandular, glandular-fibrous, fibrous, adenomatous (atypical)
-Isolations (on the cervix) and compatible (except for the polyp on the
cervix, the polyp in the uterine cavity is diagnosed).
Cervical erosion (True erosion is a defect of the epithelium with a bare
under the epithelial stroma, with the bottom
below the level of the stratified squamous epithelium, the edges are
clear. (Red spot on a pale pink surface
mucous membrane (m) After treatment with acetic acid - the bottom of true
erosion pales, + Lugol's solution - bottom color
does not perceive, only the surrounding stratified squamous epithelium is
stained). (Pseudo-erosion or
ectopia - racemose clusters of bright red papillae. When applying acetic
acid to the surface of an ectopia
papillae turn pale - bunches of grapes. Flat (pale pink) epithelium is
replaced by a cylindrical
(red color) from the cervical canal, a defect in the epithelium is mute. The
mature flat epithelium is rich in glycogen
under the influence of a solution of Lugol painted in a dark brown
color. Cylindrical stain is weak.)
Cancer of the cervix (tuberous foci that rise above the surface of the
mucosa. A sign of malignancy is
polymorphism of vascular and epithelial formations - a diverse form, size,
length, color
epithelium. Atypovy vascular growths - lack of reaction to acetic
acid. Schiller's test
negative)

7. pelvic ultrasound (normal, polycystic ovary, uterine

pregnancy of various terms,
triple)
Transabdom - For the diagnosis of evil and good-natured
neoplasms. Transvaginal - to assess the condition
endometrium (inner lining of the uterus), myometrium (muscle walls of the
uterus) and ovaries
norm
organ
index
norm
uric
bubble
Wall thickness
2 to 4 mm
wall consistency
Homogeneous, without thickening and sophistication
residual urine
Up to 10% of the bladder volume
cavity
The absence of growths, calculi
uterus
Location
without features
Uterus body sizes
4-7.5 cm / 4.5-6 cm - length / width,
anteroposterior size 3-4.5 cm
Cervix
2-3 cm, front-back size 1.5-2 cm.
Endometrial Thickness (according to days)
menstrual cycle)
1 week - from 1 to 4 mm; 2-3 weeks -
from 4 to 8 mm; 4 weeks from 8 to 16 mm
endometrial structure
uniform
The condition of the walls and uterine cavity
The wall thickness is uniform, the formation in the thickness
walls and in the uterine cavity are absent
ovaries

The size
From 20 to 30 mm, front-back size from 15 to 25
mm; volume no more than 80 mm
3
structure
Homogeneous with small patches
contours
Lumpy, dominant determined
follicle.
uterine
pipes
NOT visualized
Ovulation - the disappearance of the follicle and the presence of a fluid
level in the back of the uterine space in the form
echo-negative strips. The cervix - the formation of a cylindrical or conical
shape, connects to the body
uterus. In the center is the uterine canal. (Length 2-2.5 cm).
The endometrium (the proliferation phase is a thin hyperechogenic strip.
The secretion phase is the strip thickens, and around it
zone of reduced echogenicity)
polycystic ovary

● An increase in the size of both ovaries (volume greater than 9 cm 3), the
shape changes from ovoid to spherical.
● The presence of 8-10 follicular cysts with a diameter of 3-8 mm

● Increased stromal density

Uterine pregnancy of various periods
● For 5-8 weeks of the alleged pregnancy, you should contact the antenatal
clinic at the place of residence and
to conduct ultrasound, which allows you to confirm the place
| implantation of the ovum to rule out
ectopic pregnancy; to traceheartbeat to rule outmissed abortion ,

● 10 - 11 weeks - fetal heart removal, early detection of fetal

abnormalities. (Uterine size, myometrium structure,
pathological exclusion, myometrial tone, visualization of the fetal egg -
diameter, number of embryos,
peeling sections. Fetal biometry - KTR, BDP, skull bones, abdominal
circumference, diameter of the abdomen, length
hips, collar space, the presence of the nasal bone, heart rate, physical
activity, localization
chorion, cervix, cervical canal, condition of the appendages

● 19-21 week-assessment of the development of organs and systems,

whether or not there are fetal pathologies that could not be determined
before. (Position, previa, fetal parameters, localization of the placenta,
reverse venous blood flow.
Presentation of the Single umbilical cord, the amount of amniotic fluid)

● 32 - 34 weeks - the third planned ultrasound, the last before

delivery. Assessment of possible developmental delays, pathologies.
The number of navkoloplids is determined. water, placenta previa, the
correct placement of the fetus.
Triplet (triplets can be trichorial (each child has a separate placenta and
chorion),
dichorionic (two out of three babies share the placenta and chorion, and the
third child separately) or
monochorionic (all three babies share the placenta and chorion)
.Dizygothes and monozygous (two and equal
egg)
● dichoric diamniotic triplet (hereinafter - DHDAT) - triplet in which one
fetus has a separate placenta and
amniotic cavity, and two fruits have one common placenta and a common
amniotic cavity;

● dichoric triamniotic triplet (hereinafter - DHTAT) - triplet in which one

fetus has a separate placenta, and
two fruits - one common placenta; each of the fruits has a separate
amniotic cavity;

● monochorionic diamniotic triplet (hereinafter referred to as MHDAT) -

triplet in which the fruits have one thing in common
the placenta (chorion), while one fetus has a separate amniotic cavity, and
the other two fruits have
one common amniotic cavity;

● monochorionic monoamniotic triplet (hereinafter - MKHMAT) - triplet

in which the fruits have one thing in common
the placenta (chorion) and one common amniotic cavity;

● monochorionic triamniotic triplet (hereinafter - MKHTAT) - triplet in

which the fruits have one in common
the placenta (chorion), but each fetus has its own separate amniotic cavity;

● trichorial triplets (hereinafter - TXT) - triplets in which each fetus has a

separate placenta (chorion) and
separate amniotic cavity.

All pregnant women should have an ultrasound scan during pregnancy 11

weeks + 1 day - 13 weeks + 6
days (CTE of a larger fetus - from 45 mm to 84 mm) in order to timely
diagnose BV and determine chorionic
(Appendix 2), as well as the exact gestational age and to calculate the
personal risks of a possible Down syndrome and
other chromosomal abnormalities (trisomy 13, 18). To search for possible
structural fetal abnormalities for everyone
pregnant women with BV should have an ultrasound scan for a period of
20 weeks + 0 days - 20 weeks + 6 days. In BV structural
fetal abnormalities (especially heart defects) occur more often than in a
single pregnancy (hereinafter - OB). For
an ultrasound scan to identify structural abnormalities in BV should be
allocated at least 45 minutes.
One of the tasks of ultrasound is to determine the type of choriality and
zygosity. In this aspect have
the importance of visualization of the septum between the fetuses and
localization of the placenta. Lack of septum
gives every reason to talk about monoamniotic pregnancy is a high risk
during childbirth
Monochorional (t sign)
Dichorionic (L-sign)

8. Edometry biopsy (glandular fibrous polyp, endometrial

hyperplasia)
* Glandular-fibrous polyp ( In addition to connective tissue contains a
small amount of glands , but
the stromal component prevails over the glandular, pale pink or pale gray)
* Endometrial hyperplasia ( Morphological signs of simple non-atypical
hyperplasia - an increase in the number of
both glandular and stromal elements, with a slight predominance of the
first: • Endometrium increased in
volume • Structurally different from normal endometrium (glands and
stroma are active, glands are located
unevenly, some cystically dilated) • blood vessels in the stroma are evenly
distributed •
Atypia of nuclei is absent
Morphological signs of complex non-atypical hyperplasia - the presence of
a close arrangement of glands
common or focal in nature:
• More pronounced proliferation of glands
• Glands structurally irregular in shape
• The balance between proliferation of glands and stroma is upset
• More pronounced multi-row epithelium
• Nuclear atypia
Morphological signs of simple atypical endometrial hyperplasia - the
presence of atypia of gland cells,
manifested by a loss of polarity and unusual configuration of the nuclei,
which often acquire
rounded shape. The nuclei of cells in this type of hyperplasia are
polymorphic, and large
nucleoli. The following signs of cell atypia are distinguished: • Cellular
dyspolarity • Improper
stratification of nuclei • Anisocytosis • Hyperchromatism of nuclei •
Enlargement of nuclei • Expansion of vacuoles • Eosinophilia
cytoplasm Complex atypical endometrial hyperplasia is characterized by
pronounced proliferation
epithelial component, as with complex non-type hyperplasia, which is
combined with tissue and cell
atypia without invasion of the basement membrane of glandular
structures. The glands lose their normal
endometrium regularity of location, they are very diverse in shape and
size. Epithelium lining
gland, consists of large cells with polymorphic, rounded or elongated
nuclei with impaired
polarity and multi-row arrangement.

9. Cervical tissue biopsy (signs of CIN I-III, cervical cancer)

Cin i
hyperplasia of the basal and a pair of basal layers (1/3 of the thickness of
the epithelial layer), cellular and nuclear
polymorphism, violations of mitotic activity.
CIN II
lesions 1 / 3-2 / 3 of the thickness of the squamous epithelium. The
affected part of the epithelium is represented by elongated cells,
oval, closely adjacent to each other. Mitoses, including pathological ones,
are visible. Characteristic insignificant
nuclear cytoplasmic shift - large nuclei, coarse chromatin structure.)
CIN III
hyperplastic cells of the basal and a pair of the basal layer occupy more
than 2/3 of the epithelial ball.
large, hyperchromic, is mitosis. Pronounced polymorphism of the nucleus,
nuclear cytoplasmic shift,
binuclear cells.

Laboratory examination methods

l 1. Clinical blood test of a pregnant or non-pregnant woman

(normal, signs of IDA, inflammation)
signs of IDA
Table. The severity of anemia depending on the level of hemoglobin, g / l
(WHO)
Patients
light
anemia
moderate
heavy
Children 6-59 months
100-
109
70-99
<70
Children 5-11 years old
110-
114
80-109
<80
Children 12-14 years old
110-
119
80-109
<80
Non-pregnant
women in
age> 15 years
110-
119
80-109
<80
pregnant
100-
109
70-99
<70
Men in
age> 15 years
110-
129
80-109
<80
erythrocyte microcytosis (usually in combination with aniso and
poikilocytosis)
erythrocyte hypochromia (color index <0.86)
- decrease in the average hemoglobin content in an erythrocyte (<27 pg)
- decrease in the average concentration of hemoglobin in the red blood cell
(<33%);
- decrease in the average volume of red blood cells (<80 microns
3
)
- a decrease in serum iron (<12.5 μmol / l);
- a decrease in the concentration of serum ferritin (<13 μg / l);
- increase the total ability of serum (> 85 μmol / l);
- reduction in transferrin saturation with iron (<15%);
- an increase in the content of protoporphyrins in erythrocytes (<90 μmol /
L).
Signs of inflammation (increased ESR, leukocytosis, CRP)

l2. Biochemical blood test (normal, pathology)

1) Total protein - 64 84 g / l
Increase: infectious disease, arthritis, rheumatism, or cancer
Decrease: liver, bowel, kidney, or cancer
2) Urea 2.5 - 8.3 mmol / L
Increase: poor kidney function, heart failure, tumors, bleeding, intestinal
obstruction
or urinary obstruction

3) Creatinine 53-97 μmol / L

Increase: indicates renal failure or hyperthyroidism.

4) cholesterol 3.5-6.5 mmol / l

Increase: risk of atherosclerosis, diseases of the cardiovascular system or
liver

5) bilirubin - 5-20 μmol / l

Increase With an indicator of more than 27 μmol / L, jaundice begins. Its
high content can be a signal
the presence of cancer or liver disease, hepatitis, poisoning or a symptom
of cirrhosis of the liver, gallstone
disease or vitamin B12 deficiency.

6) ALT - 31 units / l
Increase: High ALT in the blood signals a deterioration in heart or liver
function and associated
serious diseases: viral hepatitis, cirrhosis, liver cancer, heart attack, heart
failure or
myocarditis.

7) AST-31od / l
Increase: cause heart attack, hepatitis, pancreatitis, liver cancer, or heart
failure.
8) Lipase 0 - 190od / l
Increase: pancreatitis

9) Amylase -28 -100 u / l

Increase: peritonitis, pancreatitis, diabetes mellitus, pancreatic cyst, stone,
cholecystitis or
renal failure.

l3.Coagulogram of blood (normal, signs of blood

coagulation disorders).
1) APTT - 24-34 sec
Increase: von Willebrant factor deficiency, factor 8 and 9 deficiency,
vitamin K deficiency
Reduction: DIC, malignant tumors, acute bleeding.
2) Prothrombin time - 13 - 18 sec
3) Quincka prothrombin index - 70-130%
Increase: And heart attacks, polycetimia, vitamin K deficiency
Decrease: Hypoprothrombinemia
4) INR -0.85 - 1.15
Increase: Vitamin K deficiency, deficiency of factor 10 ICE - syndrome,
acute leukemia
Reduction: Polycetemia, deep vein thrombosis, pregnancy.
5) Thrombin time - 14-20 seconds
Increase - DIC, heart attack, stroke, placenta of the placenta in a pregnant
woman.
Reduction of myeloid leukemia, hepatitis, cirrhosis, vitamin deficiency.
6) Fibrinogen - 1.8 - 4.0 g / l
Increases Pregnancy, eclampsia, hepatitis, infections, autoimmune diseases
Reduction: DIC - syndrome, hemophilia, ekampsiya, anemia,
malabsorption, post-transfusion reactions.
7) Fibrinolytic activity - 5 12 min
8) Antithrombin III-80 120%
Increase: hyperglobulinemia, menstruation, vitamin K deficiency.
Reduction: DIC - syndrome, deep vein thrombosis, pulmonary embolism,
pregnancy - late
9) D - dimer - 0 - 0.55 μg FEU / ml. (In pregnant women up to 3.1)

l4. Blood glucose (PTTG) - normal, questionable positive test

Norm <7.8 mmol / L violates. glucose tolerance 7.8-11.0 mmol / l, C.
Diabetes> 11.1 mmol / l

PTTG is performed strictly on an empty stomach. First, blood is taken

from a vein and in a laboratory (not express
method) determine the glycemia (glucose content) in the blood plasma.
After this, the pregnant woman is given a drink of 300 ml
water in which 75 g of glucose is diluted. After 2 hours, another blood
sampling is done. During this time
pregnant is not obliged to eat: you can drink ordinary, not carbonated water

l5. Blood type and Rh factor of a pregnant woman and

man
AB0 conflict develops subject to the existence of an incompatible
combination of maternal blood groups and
the fetus and, if the mother has At, to the red blood cells of the fetal blood
group. Group At can form
the mother’s body before pregnancy in response to ongoing hemotherapy,
the introduction of vaccines and therapeutic sera,
upon contact of the mother with bacteria containing antigenic factors A and
B. Ag of the fetus A and B cause increased
production of α- or β-At. Most often, immune incompatibility is
manifested when the mother has 0 (1) group
blood, and in the fetus A (II), less often B (III) or AB (IV). In the event of
an immune conflict by the AB0 system in the mother’s blood
α- or β -AO appear: agglutinin and hemolysins. Isoimmunization on the
AB0 system can be the cause
subclinical to mild hemolytic disease (GB) of the infant, but it rarely
causes severe
erythroblastosis or fetal death and has a significantly lower risk compared
to Rh-
incompatibility. With incompatibility in the AB0 system, fetal red blood
cells, entering the body of a pregnant woman,
are rapidly destroyed, so At no time to synthesize.
Rh-isoimmunization - the humoral immune response to erythrocyte
antigens (Ag) of the fetus of the Rh group, including
CC, Dd and Her (encoded by Rh alleles). Antibodies (At), which are
formed by penetrating the placenta, cause
extravascular hemolysis (opsonization of the fetal red blood cells of a
woman and red blood cell phagocytosis) and anemia, which
leads to the development of erythroblastosis of the fetus.
l6. Blood on the tumor marker Sa-125 (normal)
Up to 35 U / ml (increases in cancer of the ovaries, uterus, endometrium,
breast, pancreas,
stomach, liver, lungs. Also with benign and inflammatory mines. Uterus
and appendages)

L7. Clinical analysis of the urine of a pregnant or non-

pregnant woman (normal, signs of pyelonephritis,
glomerulonephritis, gestosis)
norm
● Color - straw or bright yellow, depending on the products that the
pregnant woman took the day before.
● Degree of transparency: transparent, clean, no haze.
● Density - 1010 - 1030 g / l.
● The number of leukocytes - up to 5 units, otherwise the doctor will look
for inflammation of the urogenital
system.
● Acidity - up to 5-7 units.
● Red blood cells - up to 3 units.
● Bacteria, ketone bodies, cylinders and glucose should not be normal in
urine.
L8. Urinalysis according to Zimnitsky (normal,
hypostenuria)
Urinalysis according to Zimnitsky allows you to examine the concentration
ability of the kidneys. At 6:00 in the morning, the patient
emptying the bladder and this portion of urine is poured and urine
collection begins after 6:00 in the morning every 3:00 in
during the day. In total there should be 8 servings in 8 separate sterile
containers.
Urine counts are normal in the Zimnitsky study: daily diuresis is 0.8-2.0
liters, or 65-80%
drunk fluid per day, a significant fluctuation during the day, the amount of
urine in separate portions (40-300
ml) and its density (1.008-1.025 g / l); daytime diuresis prevails over
nighttime - 2: 1; density of at least one
portions of urine not lower than 1.015-1.025g / l. Concentration ability is
maintained if the lowest density is not
less than 1007, the density itself is not more than 1027, and the
discrepancy between the maximum and minimum values
a density of at least 7, or a density of at least one sample was at least 1017.
The amount of fluid released
should be at least 70 -80% of the drink.
A pathological decrease in density is called hypostenuria. It is formed in
the following conditions:
inflammation of the tubules of the kidneys; chronic renal failure; taking
medication
causing excessive excretion of urine (diuretic) violation of the
concentration ability of one or two
the kidneys.
L9. Urinalysis according to Nechiporenko (norm,
pathology)
1. Norms of analysis according to Nechiporenko
The results of urine analysis according to Nechiporenko are measured in
the ratio of the number of units per milliliter.
● Red blood cells: up to 1000 in 1 ml. (in the field of view from 1 to 3).
● White blood cells: up to 2000 in 1 ml. (in the field of view from 1 to 6).
● Cylinders: up to 20 in 1 ml.
Any deviation from the norm indicates the presence of inflammatory
processes or diseases of the kidneys and
urinary tract.
2. How to understand deviations from the norm
White blood cells, both in blood and urine, are a protective reaction to the
development of infections. Elevated level
white blood cells in the urine suggests that there is inflammation or an
infectious disease in the urinary
ways.

If hematuria - The presence of unchanged red blood cells can cause various
inflammations and diseases:
cystitis, urethritis, nephrolithiasis (movement of kidney stone along the
urinary tract).
Identification of altered red blood cells indicates kidney disease:
tuberculosis, glomerulonephritis, pyelonephritis.
An increased content of cylinders in the urine indicates the development of
viral hepatitis, epilepsy, toxicosis in
pregnant. This result can also be caused by intense physical exertion.

L10. Analysis of discharge on the microflora (normal,

signs of trichomoniasis, gonorrhea, candidiasis,
gardnerellosis,
dysbiosis)
Depending on the ratio of these elements, 4 degrees of vaginal purity are
distinguished:
1 degree - single leukocytes, a large number of lactobacilli (Dederlein
sticks), the flora is poor, consists in
mainly from sticks;
2 degree - white blood cells up to ten in the field of view, a large number
of lactobacilli, the flora is moderate in number;
Grade 3 - white blood cells from 10 to 30 in the field of view, there are few
lactobacilli, the flora is mixed, moderate;
Grade 4 - leukocytes completely cover the field of view, there are no
lactobacilli, the flora is mainly coccal,
significant in quantity.
- leukocytes - the norm of their content in the vagina and urethra is not
more than 10 units in the field of view, in the neck channel
uterus - no more than 30. Exceeding reference values indicates the
presence of inflammatory
process.
- squamous epithelium - the norm of these cells depends on the phase of
the menstrual cycle. Usually their number is not
exceeds 10. If the epithelium is not detected, this indicates atrophy of the
epithelial layer, but
an increase in the number is a sign of inflammation.
- Lactobacilli - normally these sticks are present in large numbers (up to
90% of the entire microflora). Decline
values observed with bacterial vaginosis.
- yeast - they are part of the normal flora in an amount of not more than 10
4 CFU / ml. Increase their norm
characteristic of candidiasis.
"Key" cells - the presence of a large number of them (more than 20% of
the total number of epithelial cells)
is one of the signs of BV.
- leptotrix, mobilunkus, trichomonas - bacteria that occur with candidiasis,
bacterial vaginosis,
trichomoniasis and chlamydia.
- gonococci (diplococci) - present in a smear for gonorrhea.
- cocci (streptococci, staphylococci, enterococci) - in a small amount are
part of the normal flora,
but their increase indicates the presence of infection and requires
bacteriological
sowing.

signs of trichomoniasis - a greenish-yellow frothy vaginal discharge with

an unpleasant odor.
Signs of gonorrhea are purulent profuse discharge.
Signs of candidiasis - Discharge becomes curdled, white, profuse, without
a strong odor.
Signs of gardnerellosis are pale, smell unpleasant, uniform, watery,
grayish-white discharge from
vaginas evenly covering its walls. In this case, the smell of vaginal
discharge resembles the smell of “rotten
fishes".
Signs of dysbiosis are profuse gray discharge with an unpleasant smell of
fish. Dysbacteriosis appears
then, when the number of lactobacilli is critical and their place is occupied
by other bacteria - conditionally
pathogenic.
L11. Spermogram (norm, pathology)
Normal Kruger sperm have one head and neck of the correct width, tail
normal shape and length. In general, the ratio of the tail, middle part and
head should be normal.
Pathological forms of sperm can have two heads, two tails, an irregularly
shaped neck, etc.
● Oligospermia - decrease in ejaculate volume, less than 2 ml.
● polyspermia - an increased amount of sperm fade or its large volume
(more than 8-10 ml).
● Oligozospermia - less than 20,000,000 sperm in the total volume
received.
● asthenospermia - reduced the number of sperm capable of movement
(normal - more than 20-30%)
● Teratospermia - more than 50% of pathologically altered forms of sperm
in the ejaculate.
● Teratozoospermia - the number of abnormal sperm more than 96%
● Azoospermia - lack of sperm in the ejaculate
● aspermia - lack of ejaculate (= "aneaculation)
● pyospermia - purulent inclusions in a sample of biomaterial.
● leukocytospermia, also leukospermia - the concentration of leukocytes is
higher than the standard value
Sometimes you can meet the following terms:
● akinospermia (akinozoospermia) - complete immobility of sperm,
● Necrospermia - more than 50% of sperm in the ejaculate are dead.
● cryptospermia (cryptozoospermia) - had a very large number of sperm
that can be detected
only after centrifugation of sperm.
● hemospermia - blood (red blood cells) in the ejaculate
Option № 1

A patient, 29 years was brought in an ambulance to the hospital

complaining of severe abdominal pain, vomiting; frequent
urination. On examination: abdomen uniformly distended,
Schotkin-Blumberg’s sign-positive, pulse – 88 bpm, temperature
- 37C. On bimanual examination: uterine body is mobile, not
increased, on the right and front, 6 x 6cm turgo-elastic mass is
palpated, which is painful on palpation; adnexa on the left are
not felt; mucous discharge.

Dıagnosıs : ruptured ovarıan cyst

Option № 2

A patient, 57 years old was hospitalized in the gynecology

department for surgical treatment of submucous uterine fibroids,
I degree anemia. Vaginal examination: cervix is eroded, the
body of the uterus was increased to 8-9 weeks of pregnancy,
mobile, not painful, Adnexa on both sides are unchanged,
mucous discharge.

Uterıne fıbroıd fırst degree of anemıa

Option № 3

Patient, 38 years was urgently brought in with complaints of

pelvic pain radiating to the rectum, bleeding from the genitals,
collapsed. Complaints appeared suddenly. Last menstruation
was 2 weeks ago. Skin is pale, pulse – 102 bpm, temperature -
36,6C, АP - 90/60mmHg. The abdomen is tense, slightly
painful in the lower abdomen, sign of irritation of the peritoneum
is weak(+).

Ovarıan apoplexy
Option № 4

A patient, 57 years old visited the O and G clinic with

complaints of nagging pain of the lower abdomen, general
weakness, poor appetite, significant weight loss over the past
four months. Menstrual function is not disturbed. On bimanual
examination: cervix and uterine body showed no pathological
changes. On both sides of the uterus, masses are found, limited
in mobility, without clear contours, with rough surface, about the
size of a fist. Discharge from the vagina – white.

Canser of endometrıum

Option № 5

A patient, 23 years was urgently brought in with complaints of

abdominal pain, more on the right, radiating to the rectum. It
came suddenly at night. LMP - 2 weeks ago. Objective
examination: skin pale; Pulse - 99 bpm, temperature - 36,6C,
BP – 100/60mmHg. Abdomen tense in the lower parts, sign of
irritation of the peritoneum is weakly expressed.

Ovarıan apoplexy

Option № 6

A woman in the gynecology ward, complains of delay of

menstruation for 2 weeks, spotting of the genitals, pain in the
lower abdomen, more on the left, vomiting, weakness. In history
- chronic adnexitis. On bimanual examination: the uterus is
slightly increased in size, softened, Adnexa on the left are
enlarged, painful on palpation. Posterior vaginal fornix
overhangs. The human chorionic gonadotropin test is positive.
Ultrasound: embryo was not detected in the uterus.
Ectopıc pregnancy as a complıcatıon of recurent pelvıc
ınflammatıonory dısease

Option № 7

A patient, 29 years old complained of severe abdominal pain,

vomiting. Objective examination: BP - 120/80mmHg, pulse –
108 bpm. Abdomen uniformly distended, sharply painful in the
lower part. Schotkin-Blumberg’s symptom is positive. Vaginal
examination: the body of the uterus is not enlarged, movable,
painless. On the right of the uterus, a mass, 7 x 7cm, elastic
consistency, sharply painful is palpated. Left adnexa are not
felt.

Ruptured ovarıan cyst

Option № 8

A patient, 28 years old was admitted with complaints of sharp

pain in the abdomen and momentary loss of consciousness.
Last menstrual period was 12 days ago. Vaginal examination:
the uterus is of normal shape, not painful, left adnexa slightly
increased, painful on palpation. Posterior fornix overhangs,
tense, sharply painful.

Torsıon of ovarıon cyst

Option № 9

Patient, 24 years old, complained of sharp pain in the abdomen,

which occurred abruptly after physical exertion. Notes nausea,
vomiting and dry mouth. In history: a cyst of the right ovary. On
bimanual examination: the uterus is dense, painless, not
increased. Left adnexa are set deep and not felt, the vault of the
right is shortened. A sharply painful 7 x 8cm mass, round
shape, elastic consistency and with limited mobility is found on
the right of the uterus. Blood analysis shows leukocytosis with a
shift to the left.

Infected ovarıan cyst

Option № 10

A girl, 14 year came to the doctor with complaints of pain in the

lower abdomen, amenorrhea, dysuria. On examination the
external genitalia is determined by the outward protrusion of the
conus, there is a dark bloody discharge through the intact
hymen. ……

Option № 11

A patient, 28 years old has had 3 months of nagging pain in the

right iliac region, menstruation became prolonged and heavy.
Bimanual examination in the dynamics (both before and after a
month) showed the formation of mass, size 7 x 9cm, painful
before menstruation and decreases slightly afterwards.

Ovarıan endometroma

Option № 12

A patient, 36 years old, was brought in an ambulance to the

gynecology department. Complaints: sharp abdominal pain,
chills, fever up to 38-39C, general weakness, malaise,
headache. She considers herself ill for the past 6 years, since
she had a miscarriage, after which she developed an acute
inflammation of the uterus. Adnexitis occured every year. On
bimanual examination, the body of the uterus was found to be
of normal size, slightly shifted to the right, limited mobility,
tender. The adnexa on the right is not palpated. On the left and
slightly posterior to the uterus a mass is palpated, limited in
mobility, sharply painful, thick consistency, with few soft areas.
Posterior cervix is prolapsed.

Ovarıan cyst from a pelvıc ınfectıon

Option № 13

A patient, 43 years, complains of post-contact bleeding for 6

months. Bimanual examination: cervix is increased in size,
limited in mobility. Speculum examination: the cervix as a
"cauliflower". Schiller’s test- is positive.

Cervıcal canser

Option № 14

A woman, 32 in the O & G clinic complains of heavy menses for

6 months, pulling pains in the abdomen, weakness.
Gynecological examination: the body of the uterus is enlarged
to 11-12 weeks of pregnancy, mobile, painless. In the blood: Hb
– 90 g/l.

uterıne leımyoma

Option № 15

Patient, 23 years was brought in urgently, complains of pain in

the abdomen, more on the right down into the rectum. The
symptoms suddenly emerged at night. LMP was 2 weeks ago.
Objective examination: skin pale. Pulse – 99 bpm., temperature
– 36.6 C, BP – 100/60 mmHg. Abdomen tense in the lower
parts, the symptoms of irritation of the peritoneum are slightly
positive.

Ruptured torsal pregnacy

Option № 16

The 52-years old woman suffering from obesity, complains of

bloody discharge from sexual paths during 4 days. Last normal
menses were 2 years ago. Histological investigation of biopsy of
the endometrium has revealed adenomatous hyperplasia.

Uterıne canser

Option № 17

The woman complains of slight dark bloody discharge and mild

pains in the bottom of abdomen for several days. Last menses
were 7 weeks ago. The test for pregnancy is positive. Bimanual
investigation: the body of the uterus is about 5-6 weeks of
pregnancy, has softish consistence, painless. On the left side in
range of appendages there is a retortlike formation, with
dimensions 7х5 cm, mobile, painless.

Ectopıc pregnacy

Option № 18

The 24-years old woman, earlier not pregnant, terminated to

accept oral contraceptives. After last reception of a drug she
had one menses, and then within 6 months the amenorrhea
was observed.

pregnacy

Option № 19

The 26 years old woman has addressed in female consultation

with complaints of mucopurulent excretions from sexual paths,
blunt periodic pains in the bottom of a gaste, frequent, painful
urination. At survey of the uterine neck in mirrors the hyperemia
around of outside fauces, puffiness mucosa, and also abundant
mucopurulent excretions are defined.

Pelvıc ınf dısease ,from sexually transmıted ınfectıon

Option № 20

In a gynecologic hospital the patient of 33 years old with

complaints of sharp pains in the inferior regions of a gaste, a
fervescence up to 38 C, excretions from a vagina of purulent
character has arrived. There were not labors and abortions in
an anamnesis. Sexual life is random. At bimanual research
neck of the uterus of the conic form, fauces it is closed. The
uterus is not enlarged, morbid at a palpation. Appendages are
enlarged, morbid from both sides. Vaults of the vagina are
painless.

Salpıngıtıs ,pelvıc ınf dısease

Option № 21

The 24-years woman after labors has addressed to the doctor

with complaints on absence of a menses within 6 months. The
first pregnancy was finished with a caesarian section under
indications: premature exfoliation of a normally posed placenta,
an intra-uterine asphyxia of a fetus. The hemorrhage has made
2000 ml.

Sheeans sendromu

Option № 22

Woman of 30 years old complains of the absence of menses

during 2 years after labors. Labors have become complicated
by a massive bleeding. After labors the patient has noted
abaissements of a hair, a lose of weight. At bimanual research
the body of the uterus diminished, vulvar lips are hypoplastic.

Sheehans sendrome

Option № 23

A patient complains of an irregular menstrual cycle, substantial

growth of mass of a body, a hirsutism, barrenness. At bimanual
research the uterus is a little bit less than normal, dense from
both sides, mobile ovaries in the dimensions 4х5х4 sm.

Polycystıc ovarıan syndrome

Option № 24

The patient of 40 years old shows complaints on excretions

from a vagina of yellow colour; in an anamnesis - 1 labors and 2
abortions. At survey in mirrors: mucosa is hyperhaemic, on a
back labium of neck of the uterus there are hazy fields with
legible contours. Bimanual research: a body of the uterus and
appendages are without pathological changes. The excretions
are white, foamy, in unguentum – vaginal trichomonades and
blended flora.

Vagınal trıchomones

Option № 25

The 23-years old woman has addressed with complaints of

serous-purulent discharges from a vagina, a pain in the bottom
of a stomach, a fervescence at the end of a menses.

Pelvıc ınflammatıon dısease

Option № 26
At the 18-years old woman never before was in labors 6 months
ago the gonorrhea was revealed. She received ampicillin per
os. Within last month she also received ampicillin concerning
inflammatory process of organs of a small pelvis. At a palpation
the expressed morbidity in the inferior departments of a
stomach is marked. Concentration of the Gonadotropinum is
normal.

Recurrent gonorrhea

Option № 27

At a gynecologic hospital the woman with complaints of sharp

pains in the inferior departments of a stomach, a fervescence
up to 38 C, the purulent excretions from a vagina is delivered.
Sexual life is random. At bimanual research the morbid
appendages of an uterus, and purulent excretions are defined.

Pelvıc ınf dısease

Option № 28

At the women of 28 years who did not become pregnant earlier,

in the period of a menses have appeared pains in the bottom of
a venter whining, arching character. At the bimanual
examination the uterus tumorous formation is determined in the
size 8x7x7 sm, the nonuniform consistence, morbid at shift,
mobile circumscribed.

Uterıne canser

Option № 29
The patient 28 years with complaints to pains in the bottom of a
venter, intensified on the eve and during a menses, barrenness
during 5 years. In an anamnesis a resection of a dextral ovary
concerning a breakage of a cyst. A uterus in anteflexio,
circumscribed mobile, the normal size, painless; on the right
and to the back from a uterus tumorous formation in the size
8x8 sm., elastic consistence, inactive, connected with posterior-
lateral face of a uterus, moderately morbid is palpated; the left-
hand appendages are not enlarged.

Canser

Option № 30

The patient 45 years shows complaints to an abundant morbid

menses, hemal discharges from sexual routes before and after
a menses. The uterus in a retroflexio, enlarged up to the size
conforming of 8-9 week pregnancies, the dense, circumscribed
mobile; appendages from both sidesare not determined,
parametrium is free, discharges mucous, light.

Uterıne fıbroıd

Option № 31

A 30-year-old woman complained to her doctor about the

absence of menstruation for 2 years after the second birth,
which was complicated by massive hypotonic bleeding. After
childbirth, the patient notes hair loss, weight loss. Objective:
asthenic. At gynecological examination: the external genitalia
are hypoplastic, the cervix is cylindrical, the body of the uterus
is small, painless, the appendages of the uterus are not
palpable.
1. Objective and laboratory data: Patient asthenic, weight loss,
external genitalia
hypoplastic, the cervix is cylindrical, the body of the uterus is small,
painless, applications
the uterus is not palpable. the patient notes hair loss.
2. Diagnosis: Pituitary amenorrhea. Sheehan's Syndrome.
3. Differential diagnosis. The differential diagnosis is carried out with
Addison's disease, myxedema, anorexia nervosa,
pituitary tumor.
4. Diagnosis of a is carried out thanks to anamnesis (childbirth /
abortion complicated by bleeding, absence
engorgement of the mammary glands after childbirth, lack of
lactation, long-term decrease in working capacity and
menstrual dysfunction.)
When hormonal studies reveal various degrees of decrease in blood
levels of gonadotropins,
ACTH, TSH, as well as E2, cortisol, T3 and T4.
5. Treatment: Prescribe HRT GCS and thyrotropic drugs with clinical
manifestations of hypofunction
corresponding glands.
With amenorrhea or oligomenorrhea, hormone replacement therapy is
recommended.
Nutrition should be complete, protein deficiency in food should be
avoided. Given constantly observed
Anemia patients are shown iron preparations under the control of
hemoglobin.
Patients with severe Shihan syndrome are only treated in an
endocrinological hospital.

Option № 32

The 29-year-old woman went to a gynecologist with complaints

of irritability, tearfulness, headache, nausea, sometimes
vomiting, heart pain, tachycardia, memory loss, and flatulence.
These complaints occur 6 days before menstruation and
disappear on the eve or in the first two days. At gynecologic
research of pathological changes from female genitals it is not
revealed.

1. Objective and laboratory data. During a gynecological examination

of pathological changes from
no female genitalia. irritability, tearfulness, headache, nausea,
sometimes vomiting, pain in
areas of the heart, attacks of tachycardia, decreased memory,
flatulence
2. Diagnosis: Premenstrual syndrome. Light form. Compensated
Stage.
3. Dif.diagnosis
Differential diagnosis of pathological symptoms of premenstrual
syndrome is necessary
carry out with chronic diseases characterized by a deterioration in the
luteal phase
menstrual cycle:
chronic kidney disease
migraine;
mental illness
brain tumors
arachnoiditis
-crisis form of hypertension;
prolactin-secreting pituitary adenoma
pheochromocytoma.
In these diseases, from the prescribed therapy against the symptoms of
PMS, there is no improvement in well-being.
will be.
4. Diagnosis: 1. The first stage of diagnosis includes identifying the
cyclical manifestation of the disease and its relationship with
luteal phase of the MC.
2. Hormonal studies:
• determination of serum hormone concentrations (FSH and LH,
prolactin estradiol, progesterone, total and / or
free testosterone, dehydroepiandrosterone sulfate during MC - in the
follicular, ovulatory and luteal
phase. If it is impossible to perform the full volume of the study, it is
advisable to conduct it in the II phase of the MC or
the moment of manifestation of the clinical symptoms of PMS.
• tests of functional diagnostics in the dynamics of the MC.
3. Ultrasound of the pelvic organs, which allows you to indirectly
study the hormone-producing function of the ovaries on the basis of
determination of their morphological characteristics (biometrics,
folliculogenesis state, quality and ratio
follicles and stroma) and uterus (thickness and quality of the
endometrium, myometrium structure).
5. PMS treatment
Treatment for PMS includes drug and non-drug therapy.
Non-drug therapy:
• normalization of work and rest;
• dosed physical activity;
• psychotherapy;
• physiotherapy, massage.
drug therapy
antipsychotics;
- drugs that provide an angioprotective effect (vitamins C, A, E
involved in the tissue reaction
metabolism and trace elements such as zinc, copper, selenium,
controlling oxidation reactions and
prevent the appearance of toxic products in the body);
-preparations with psychotropic and sedative properties (groups of
nootropics)

Option № 33

A 45-year-old woman complains of intermittent pain and

heaviness in the lower abdomen, low-grade fever, and has lost
5 kg in the last 6 months. Menses are regular, painless,
moderate. In the anamnesis of 2 physiological childbirth. At the
general inspection: the lowered food, a pale skin, pulse – 76 for
1 min, Blood pressure 120/70 mm.Hg At gynecological
examination: the cervix and body of the uterus without
pathological changes, on both sides of the uterus are palpated
appendages of the uterus measuring 7 x 8 cm are not mobile,
fill the entire pelvis. The posterior arch is bulged by these
tumors. In the general analysis of blood Hb – 85 g/l, er – 2,3 x
10¹²/l, leukocytes - 4,0 x 109/l, leukoformula: eosinophils - 7%,
rod-nuclear - 5%, segment-nuclear - 56%, lymphocytes - 15%,
monocytes - 6%. ESR – 60 mm/h.

Answer: Ovarian cancer 2 tbsp., Cl. column 2

Just in case !!
● I - only the ovaries are affected;
IA - affected one ovary, ascites does not exist;
IB - both ovaries are affected, ascites does not exist;
IC - the appearance of a tumor on the surface of the ovary (s), ascites;
● II - the disease spreads to the pelvis;
IIA - damage to the uterus or fallopian tubes;
IIB - damage to other tissues of the pelvis;
IIC - a tumor on the surface of the ovary (s), ascites.
● III - spreads to the peritoneum , metastases appear in the liver and
other organs within the abdominal cavity,
damage to the inguinal lymph nodes .
IIIA - distribution within the pelvis, with contamination of the
peritoneum.
IIIB - metastases with a diameter of up to 2 cm.
IIIC - metastases with a diameter of more than 2 cm involving
retroperitoneal and inguinal nodes.
● IV - distant metastases.
The diagnosis was established based on:
patient complaints: recurrent pain and a feeling of heaviness in the
lower abdomen, low-grade body temperature, over the past
6 months lost 5 kg.
Gynecological examination: cervix and uterine body without
pathological changes, on both sides of the uterus
palpable uterine appendages measuring 7 x 8 cm are not mobile, fill
the entire small pelvis.
In the general analysis of blood: a lower Hb of 85 g / l, er - 2.3 x 1012
/ l, an increase in eosinophilif - 7%
According to these data, we can suspect ovarian carcinoma.
Additional diagnostic methods:
- a puncture for receiving fluid from the abdominal cavity and
identifying tumor cells in it.
- ultrasound examination of the abdominal cavity and pelvis
- histological examination of ovarian biopsy
Based on this, we can put forward the final diagnosis
treatment:
The main methods of treating cancer are surgery and chemotherapy.
Chemotherapy is usually based on a combination of several drugs, for
example, Cisplatin (or Carboplatin),

Option № 34

A 43-year-old patient complains of bloody discharge from the

genitals after sexual intercourse, lifting heavy things. These
bloody discharges are not related to the menstrual cycle.
Somatically healthy. History of 1 medical abortion. The
menstrual cycle is regular. When examined in mirrors: the
cervix is cylindrical, the outer eye is closed, on the front lip is
determined by a large number of papillary growths that bleed
when touched. At bimanual research: a body of a uterus and
appendages from both parties without pathology. Parameters
are free.

Answer: Cervical Cancer

The diagnosis is based on:
patient complaints: blood discharge from the genitals after sexual
contact, blood discharge not associated with
menstrual cycle
When viewed in the mirrors: a large number of papillary growths that
bleed when
touch.
diagnostics:
- cytologic studies of a cervical smear.
Colposcopy
-Biopsy
Endocervical curettage
- Real-time HPV determination of polymerase chain reaction
treatment:
-Radied radiation therapy
Combined treatment (radiation therapy and surgical treatment or
radiation therapy and chemotherapy)
-Only surgical treatmen

Option № 35

A 47-year-old woman complains of vaginal bleeding within 2

weeks, which appeared after a delay of menstruation for 3
months. Menarche at 13 years old. Menstruation last year is
irregular. In the clinical analysis of blood: Hb - 90 g/l, er. -
2,0x10¹²/l, leukocytes - 5,6x109/l, ESR - 11 mm/h. Vaginal
examination: uterus of normal size, appendages are not
palpable, bloody discharge is abundant.

1. Laboratory - anemia of the 2nd degree. Нb - 90 g / l

2. Diagnosis: premenopausal DMK
3.. Differential diagnosis with diseases with coagulation disorders,
chronic
liver disease, excited uterine or ectopic pregnancy, polycystic ovary
syndrome,
organic pathology of the genitals, ovarian tumors producing estrogen,
body or neck cancer
uterus.
4. Diagnosis: UAC + platelets, coagulogram, carry out separate
curettage of the mucous membrane
cervical canal and uterine body. After that, hysteroscopy is performed
in a liquid medium. Ultrasound
examination of the uterus and ovaries.
5. The main therapeutic measure is separate curettage of the mucous
membrane of the cervical canal
uterus and uterine bodies
Option № 36

A 28-year-old woman applied to the women's clinic with

complaints of no pregnancy. Married, married for 4 years. Sex
is regular, does not use contraceptives. There were no
pregnancies. Menarche at 13 years old. Menses are regular,
moderate. At inspection of the woman it is established: a
condition of genitals without deviations from norm. Uterine
tubes are passable. Basal temperature during 3 menstrual
cycles 36.7-36.9. Spermogram is normal

1. Basal temperature is monophasic.

2. Diagnosis: anovulatory infertility.
3. Diagnosis of ultrasound of the pelvic organs at 11 - 13 DMC for the
diagnosis of dominant follicle, determination
blood levels of hormones of the anterior pituitary gland (FSH, LH,
prolactin, TSH, ACTH), ovarian hormones
(estradiol, progesterone), thyroid hormones (T3, T4), adrenal glands
(cortisol, testosterone,
the content of 17-KS), dehydroepiandrosterone sulfate, releasing
factors to determine
functional state of the hypothalamus.
4. Treatment is carried out by prescribing drugs that stimulate
ovulation (depending on the results
hormone test !!!) (estrogen-progestogen drugs, clomiphene,
exogenous gonadotropins, GnRH agonists).
Also use synthetic releasing hormones: the introduction of LH-
releasing hormone in a pulsating mode (5-
10 mcg pulse)
In case of insufficiency of estrogenic function of the ovaries
(insufficient follicular phase) is prescribed
estrogens (microfolin, span, estrofem, foliculin, etc.)
In case of insufficiency of the luteal phase, turinal, norkolut, pregnin,
dufaston, progesterone in the second are used
phase of the menstrual cycle.
Combined estrogen-progestogen drugs are prescribed in order to
obtain a rebound effect for 2-3
cycles

Option № 37

A 35-year-old patient was admitted to the gynecological

department of the oncology dispensary with complaints of
bloody discharge after sexual intercourse. Gynecological
examination: on the cervix near the outer eye revealed a defect
of the epithelium 1 x 0.5 cm Schiller test in this area is negative
Uterus, appendages and parameters without pathological
changes. The result of the PAP test type 4.

1. The result of the PAP test type 4 - individual cells with obvious
signs of malignancy.
Schiller's test in this area is negative, which indicates a pathological
process.
2. Diagnosis: Endophytic cervical cancer, stage 1.
Differential diagnosis: cervical intraepithelial neoplasia (CIN),
erosion, cancer of the uterus, cancer
ovaries. Benign tumors of the body and cervix.
3. Diagnosis: laboratory tests - in the patient's blood serum determine
the level
specific Ah - SCC.
Instrumental studies - cervical biopsy, curettage of the cervical canal.
Histological examination.
4. Treatment: high conical amputation of the cervix, Pap smears are
done after 4 months., After
10 months then annually, if both previous studies of cancer pathology
were not found.

Option № 38

A 62-year-old woman went to a gynecologist with complaints of

moderate genital bleeding within one day after working in the
backyard. Suffers from hypertension, diabetes. Menopause 4
years. There were no pregnancies. Gynecological diseases
denied. On gynecological examination, the cervix is conical, the
outer eye is closed, and there is little bloody discharge from the
cervical canal. The body of the uterus is normal in size, the
appendages of the uterus are not enlarged.

1. Interpretation of objective / laboratory data.

Gynecological examination - minor spotting from the cervical canal.
2. The diagnosis is established / Differential diagnosis of this
pathology.
Ds: Endometrial Cancer
Differential diagnosis: endometrial polyp, hyperplasia, submucous
myoma, atrophic vaginitis,
endometrial atrophy.
3. The appointment of additional examination methods to confirm the
diagnosis.
Cytological examination of aspirate from the uterine
cavity; hysteroscopy with targeted biopsy; separate
diagnostic curettage; Ultrasound CT, MRI; tumor marker SA-125.
4. Definition of treatment tactics - surgical (extirpation of the uterus
with appendages), radiation therapy, hormone-scratch
(megestrol 160-320 mg daily - progesterone)

Option № 39

A 26-year-old woman went to a women's clinic with complaints

of lower abdominal pain, which worsens during menstruation,
smearing brownish-red discharge before menstruation. These
symptoms began 2 years ago after "cauterization" of the cervix
due to erosion and gradually worsened. Examination in mirrors:
on the cervix 2 dark red inclusions measuring 3 x 5 mm.

1. Interpretation of objective / laboratory data.

Inspection in the mirrors: on the cervix 2 dark red inclusions
measuring 3 x 5 mm.
2. The diagnosis / differential diagnosis of this pathology.
Ds: Cervical Endometriosis
Differential diagnosis: erosion of m., Endocervicitis, erythroplakia,
cancer of Sh.M.
3. The appointment of additional examination methods to confirm the
diagnosis.
Colposcopy with targeted biopsy
4. Definition of treatment tactics - drug treatment (1) non-steroidal
anti-inflammatory drugs
(reduction of pain and reactive inflammatory reactions, alone or in
combination with hormonal
drugs); 2) oral contraceptives in a cyclic or continuous mode
(achievement of a state
“Pseudo-pregnancy”); 3) progestins (Provera Depo-Provera,
duphaston, orgametrile - in a cyclic or continuous
mode - "pseudo-gravity"). The mechanism of action of progestins is
associated with suppression of the effect of gonadotropins and
induction of atrophy of endometrial tissue 4) androgen derivatives -
danazole (danol, danoval, danocrin-17-alpha
etinyltestosterone), which inhibits the activity of numerous
steroidogenesis enzymes, as well as the activity
cytosolic estrogen receptors.)

Option № 40

A 25-year-old pregnant woman complains of aching pain in her

lower abdomen and lower back. This pregnancy is III at 18
weeks. History of 1 medical abortion, 1 miscarriage 24 weeks a
year ago. The general condition is not disturbed. Vaginal
examination: the cervix is shortened to 1.5 cm, the cervical
canal passes 1 transverse finger, the amniotic sac does not
prolapse.

1. Interpretation of objective / laboratory data.

Vaginal examination: the cervix is shortened to 1.5 cm, the cervical
canal passes 1 transverse
finger.
2. The diagnosis / differential diagnosis of this pathology.
Ds: Cervical insufficiency
Differential diagnosis: between organic and functional CPI, premature
birth.
3. The appointment of additional examination methods to confirm the
diagnosis.
Ultrasound scan
4. Determination of treatment tactics - prescribed strict bed rest,
corticosteroids (dexamethasone, betamethasone)
surgical correction (cerclage in the period of 12-14 weeks., remove the
seam in 36-38 weeks.); non-surgical correction
(use of obstetric unloading pessaries)

Option № 41

A 38-year-old patient complains of pulling pain in the lower

abdomen and lower back throughout the month, which worsens
on the eve of menstruation; premenstrual dark bloody
discharge, profuse menstrual bleeding. In the anamnesis of 4
artificial abortions, 1 childbirth. At gynecological examination:
the cervix and vagina without pathological changes, the body of
the uterus is spherical slightly enlarged before menstruation,
sensitive to palpation, the uterine appendages are not changed.
Ultrasound revealed individual foci of increased echogenicity in
the myometrium, an increase in anterior-posterior size of the
uterus, the presence of rounded hypoechoic inclusions with a
diameter of 2 mm.

1. Objectively Drawing pain in the lower abdomen and lower back

throughout the month, worse on the eve of menstruation -
cyclic pain premenstrual dark blood discharge, heavy menstrual
bleeding -
indicates hormonal disorders; the body of the uterus is spherical
slightly enlarged before
menstruation, sensitive to palpation - due to adenomyosis nodes.
Ultrasound examination revealed separate foci of increased
echogenicity in the myometrium, an increase in the anteroposterior
the size of the uterus, the presence of rounded hypoechoic inclusions
with a diameter of 2 mm - the presence of a tumor process.
2. Diagnosis: Adenomyosis, first stage.
Differential diagnosis .
For diffuse lesions, the following differential series:
● diffuse uterine leiomyomatosis
● malignant tumors
endometrial cancer
endometrial stromal sarcoma
For focal lesion ( adenomyoma ), the following differential series:
● uterine fibroids (leiomyoma)
Has clearer boundaries, lowering adenomyomas
may have a pseudocapsule represented by a crushed adjacent
myometrium
● malignant neoplasms
endometrial cancer
endometrial stromal sarcoma
leiomyosarcoma.
3.Add survey methods:
Hysterosalpingography: winding passages in the thickness of the
myometrium.
Histological examination for diagnostic curettage, or surgery.
4.Liquidity:
1) Surgical-removal of endometriotic foci. (Laparoscopy)
2) Drug NSAIDs, hormone therapy ( gonadotropin-releasing hormone
agonists (AGN-RG) or GN-antagonists
RG (antGn-RG), combined therapy with estrogens and progestogens

Option № 42

A 33-year-old woman has been complaining of no pregnancy

for 5 years. The menstrual cycle is regular. In the anamnesis -
before marriage treated chdamidium infection. The man is
healthy, the spermogram is fertile. A complete clinical
examination of the woman was performed: hormonal function is
not impaired, urogenital infections are absent, on
hysterosalpingography – the fallopian tubes on both sides are
partially filled with contrast to the ampullary department,
contrast is not visualized in the abdominal cavity.

1) Objectively Complaints about the absence of pregnancy for 5

years. History - treated for chlamydial treatment for marriage
infection. On hysterosalpingography - fallopian tubes on both sides
are partially filled with a contrast to
of the ampulla, in the abdominal cavity, contrasts are visualized -
adhesions may have occurred
process in the fallopian tubes / abdominal cavity.
2) Diagnosis:
Chlamydial infection, secondary tubal - peritoneal infertility.
Differential diagnosis: Differential diagnosis is carried out with other
types of infertility.
3) Diagnostics:
Bacterioscopic, bacteriological examination, PCR.
Instrumental diagnostic methods:
● laparoscopy;
● colposcopy;
● pelvic ultrasound (transvaginal examination in women);
● hysterosalpingography.
● CT and radiological research methods.
4.Liquidity:
Hysteroscopy, laparoscopy, laparotomy.
Anti-inflammatory therapy courses, immunotherapy, physiotherapy

Option № 43

The 55-year-old patient complains of sleep disturbances, up to

10 "hot flashes" per day, blood pressure fluctuations,
tachycardia attacks. Treatment by a neurologist and cardiologist
did not give the desired effect. Last menstruation 2 years ago.
At gynecologic inspection pathological changes of a uterus and
appendages are not revealed. At ultrasound examination:
uterus 54x47x34 mm, M-echo 3 mm, ovaries 29x20x15 mm
follicular apparatus is not expressed. High levels of FSH and LH
in the blood, low estrogen content

1) Objectively sleep disturbances, up to 10 “hot flashes” per day,

fluctuations in blood pressure, tachycardia attacks -

Last menstruation 2 years ago. Ultrasound examination: uterus

54x47x34 mm, M-echo 3 mm, ovaries 29x20x15 mm
the follicular apparatus is not expressed. In the blood, high levels of
FSH and LH, low estrogen levels.
2) Diagnosis:
Menopausal syndrome, menopausal period.
Dif.diagnosis:
Hormone-producing tumors (pheochromocytoma)
- it includes drugs (opiates, nicotinic acid, calcium channel blockers)
- tumors of islet cells of the pancreas;
renal carcinoma
chronic infections.
3) Diagnostics:
For all women over 40 who came to the reception, regardless of
complaints, the doctor must put 6 questions to
detection of menopausal syndrome:
Question 1 (on understanding the change in the nature of menstruation
with age, the presence / absence of menstruation): When do you have
the last time was menstruation (regularity, frequency, change in
duration and volume)?
Question 2 (on assessing changes in the patient’s emotional and
physical state): Do you have hot flashes or
night sweats (amount, duration)?
Question 3 Do you suffer from depression, mood swings, or
insomnia?
Question 4 Do you have any discomfort in the area of the heart or
behind the sternum, are these sensations related to physical
load; Are there episodes of high blood pressure (increased heart rate,
heart rhythm disturbance)?
Question 5 Do you have a sensation of dryness and burning of the
vaginal mucosa, problems with urination
(increased frequency of urination, urinary incontinence), problems
with sexual life (change in sexual desire,
sexual activity)?
Question 6 Do you have any unpleasant sensations in the joints and
muscles (joint pain, complaints like rheumatism)?
In addition, the doctor should find out the history of life (anamnesis
vitae) - ask if the patient’s mother had a heart attack or
stroke before the age of 60 years. To determine the assessment of the
severity of symptoms, use the international MRS scale for
assessment of symptoms of menopause (Menopause Rating
Scale). MRS has been officially standardized in accordance with
psychometric rules. During standardization of this tool, three
independent variables were allocated:
psychological, somatovegetative and genitourinary subscales. MRS
consists of 11 points (symptoms or complaints)
each of which can get from 0 (no complaint) to 4 points (severe
symptoms) depending on the severity
complaints.
4) Treatment: 1. Multilayer clothing, the use of a small fan, etc. can
help women handle
with vasomotor symptoms, but will not lead to their disappearance.
2. Weight loss can reduce vasomotor symptoms in overweight
patients.
3. Exercise does not always contribute to a decrease in vasomotor
symptoms, but an increase
physical activity can improve sleep and overall well-being.
4. The only pathogenetically substantiated and effective method for
the correction of menopausal disorders
is MGT. For MHT, natural estrogens (17β estradiol (micronized
estrogen), estradiol are used
valerate, estriol) in combination with gestagens or androgens. The
introduction of hormones parenterally (in
injection), transdermally, vaginally and orally.
5. To correct menopause, urogenital disorders using short-term
courses of MHT (in
within 1-5 years). In order to prevent and treat osteoporosis, MHT is
carried out for more than 3 years (if necessary,
combinations with bisphosphonates.)

Option № 44
A 32-year-old woman went to the doctor with complaints of
heavy and prolonged menstruation, which has been going on
for 6 months, general weakness, dizziness. The skin and visible
mucous membranes are pale. Vaginal examination revealed:
the uterus is enlarged to 9-10 weeks of pregnancy, the correct
shape, painless, mobile, the appendages on both sides are not
palpable, no infiltrates in the pelvis, the vaults are free

1. Interpretation - spotting from the genital tract, regular contractions

for 30-35 seconds after 3-4 minutes,
the cervix softened smooth, opening the cervical canal 2.5 cm (and the
period of childbirth); presentation
edges of the placenta, increased bleeding after amniotomy.
2. Diagnosis: Pregnancy 38 weeks. And the period of
childbirth. Regional presentation of the
placenta. Amniotomy. Bleeding
intensified.
Dif.diagnosis: rupture of the birth canal, complete presentation of the
placenta, premature detachment of the placenta.
3. Additional methods: clinical blood test (hemoglobin, red blood
cells, platelets), coagulogram.
4. Childbirth treatment to be completed by cesarean section

Option № 45

A 45-year-old woman complains of intermittent pain and

heaviness in the lower abdomen, low-grade fever. Menses are
normal. History of 2 births. Pulse -76 bpm. BP 120/70 mmHg
Vaginal: palpable bilateral tumors of the uterine appendages,
larger than the fist; tumors are not mobile, fill the entire pelvis.
The posterior arch is protruding. ESR- 60 mm/h blood test,
moderate lymphopenia, eosinophilia

1. Interpretation - a defect in the placenta, blood loss of 600 ml.

2. Diagnosis Early postpartum period. Bleeding is associated with the
remains of placental tissue in the uterus.
Dif.diagnosis: rupture of the birth canal, complete presentation of the
placenta, premature detachment of the placenta.
3. Additional methods: hysteroscopy, clinical blood test (hemoglobin,
red blood cells, platelets)
4. treatment. Manual separation of the placenta is indicated

Option № 46

A 26-year-old woman complains of delayed menstruation for 3

weeks, nausea, mostly in the morning. The pregnancy test is
positive. The menstrual cycle is regular. There were no
pregnancies. Examination revealed: cyanotic mucous
membranes of the cervix and vagina, soft body of the uterus,
slightly enlarged. On the left palpated tumor, painful on
palpation. Ultrasound of the embryo in the uterine cavity was
not detected.

1. Interpretation - duration of labor 15 hours, fetal heart rate 100 / min

2. Diagnosis: intrauterine hypoxia of the fetus during childbirth.
Dif.diagnosis: clinically / anatomically narrow pelvis, large fetus,
intracranial hemorrhage of the fetus, abnormalities
brain development.
3. Additional methods: general blood count, hematocrit, blood
glucose, plasma electrolytes,
coagulogram, partial pressure of blood gases.
4. treatment It is necessary to impose a weekend obstetric forceps

Option № 47
Patient B., 38 years old, 5 years old, is observed for uterine
fibroids (tumor size - up to 10 weeks of pregnancy), complains
of heavy prolonged menstruation, in which the amount of
hemoglobin is reduced to 80 g/l. 5th day of menstruation,
profuse discharge, the patient is pale.

1 .. Objective and laboratory data: posthemorrhagic iron deficiency

anemia of the II degree,
hyperpolymenorrhea, uterine fibroids up to 10 weeks of pregnancy.
Depending on the type of growth of fibroids in the muscular
membrane of the uterus, three forms of the tumor are distinguished:
- intramural (the tumor is located in the thickness of the uterine wall)
- submucous (myoma grows towards the uterine cavity)
- subserous (growth of fibroids in the direction of the abdominal
cavity).
2. Diagnosis: Uterine fibroids with submucous node
growth. Menstrual irregularities by type
hyperpolymenorrhea. Chronic posthemorrhagic iron deficiency
anemia II century.
Differential diagnosis:
- uterine sarcoma;
- tumors and tumor-like formations of the ovaries;
- pregnancy;
- internal endometriosis.
3. Additional examination methods: -
- - ultrasound examination of the pelvic organs - allows you to
visually read the size, quantity, localization,
exogenesis, structure of nodes, establish the presence of concomitant
endometrial hyperplasia, pathology of the uterus;
- hysteroscopy - used to detect submucosal fibromatous nodes,
determine the condition
endometrium, in some cases use hysterosalpingography. The
advantage of hysteroscopy is
the ability to perform simultaneous endometrial biopsy, removal of
polyps and submucous nodes, ablation and
endometrial resection
- histological examination of the endometrium and assessment of the
cervix
4. Treatment Treatment of uterine fibroids can be conservative and
prompt.
● Conservative methods include non-hormonal and hormonal therapy
● Hygienic regimen, rational diet, implementation of medication for
correction
metabolic disorders
● Hormone treatment consists of prescribing progestogens,
androgenic steroids and agonists
gonadoliberin.
● Hemostatic therapy involves intramuscular administration:
- drugs that reduce the uterus (oxytocin 1 ml, hyphotocin 1 ml)
- drugs that increase blood coagulability (10% calcium chloride
solution of 10 ml intravenously,
Vikasol 0.1 g 3 times a day);
- drugs that suppress the fibrinolytic activity of blood (5% of the
reasons for aminocaproic acid in
100 ml daily, dicinone 2 ml intramuscularly 2 times a day for 7 days).
● The method of embolization of the uterine arteries (EMA), the
essence of which is to conduct pelvic arteriography with
subsequent selective embolization of the small branches of the uterine
artery supplying myomatous blood
nodes. Particles of polyvinyl alcohol are used as embolizate in sizes
ranging from 350 to 700 microns. In myomatous nodes
focal infarction, sclerosis and hyalinization are detected
● Surgical treatment of hysteroresectoscopic myomectomy is
indicated, due to the submucous location
fibroids, accompanied by prolonged menstruation with heavy
discharge, anemia.

Option № 48

The patient is 34 years old. Uterine fibroids were discovered 2

years ago. There is no rapid growth. Complains of lower
abdominal pain. Leukocytosis 17x109/l. Symptoms of peritoneal
irritation are positive. At vaginal research the uterus is
increased to 10 weeks of pregnancy, hilly, one of knots is
mobile, painful

1.
Objective and laboratory data: leukocytosis 17x109 / l, the
phenomena of pelvioperitonitis, the size of the uterus
up to 10 weeks, tuberous, the presence of a painful, mobile node.
2.
. Diagnosis: Uterine fibromyoma . Necrosis of subserous fibromatous
node (torsion).
Pelvioperitonitis.
Differential diagnosis must be carried out with
- uterine sarcoma;
- tumors and tumor-like formations of the ovaries;
- pregnancy;
- internal endometriosis;
- appendicitis.
3. Additional examination methods:
- ultrasound
- laparoscopy
4. treatment:
- surgical treatment is performed - amputation or hysterectomy with
removal of the fallopian tubes (may be
source of infection); in women over 40, they also remove the ovaries
- It is necessary to drain the abdominal cavity through contra-holes
and through the posterior vaginal vault.
Postoperative intensive care includes antibiotics, desensitizing,
detoxification
Means, food preparations, vitamins, immunocorrectors

Option № 49

A 43-year-old patient complains of bloody discharge from the

genitals after sexual intercourse, lifting weights. Blood
secretions are not associated with the menstrual cycle. When
examined in mirrors: the neck is cylindrical, the eye is closed,
on the front lip is determined by a large number of papillary
growths that bleed when touched. The body of the uterus and
appendages on both sides without pathology. Parameters are
free

1. About
`
active and laboratory data: the neck is cylindrical, the eye is closed, on
the front lip is determined
a large number of papillary growths that bleed when touched. The
body of the uterus and appendages on both
parties without pathology. Parametries are free.
2. Diagnosis: Cervical cancer, exophytic form, stage I.
Dif.diagnosis of background and precancerous diseases of the cervix
and uterine body.
3. Diagnosis: - Cytological examination The main diagnostic
screening test for Papanicolaou,
Material for cytological examination is obtained from the transitional
epithelium zone in such a way that
turned out to be cells not only superficial, but also deep layers. Before
taking a smear, the cervix should be lightly
wipe with cotton, slides should be fat free. The resulting material is
transferred to glass, carefully
controlling the distribution of the material and making sure that the
thickness of the smear is moderate.
- direct visual examination using 3% acetic acid,
- colposcopy, targeted biopsy, cure and cervical canal.
- Histological examination is considered the final and decisive method
for the diagnosis of cervical cancer, which allows
determine the nature of morphological and structural changes.
- The stage of cervical cancer is determined using ultrasound,
radiography of the lungs, cystoscopy, irrigoscopy. According to
indications
perform CT and MRI.
4. Treatment Surgical treatment of cervical cancer
- chemoradiation treatment;
- extended uterine extirpation and postoperative radiation
(chemoradiotherapy) therapy,
- Neoadjuvant chemotherapy. Adjuvant radiation therapy.

Option № 50
The patient is 29 years old, complains of sharp pains in the
lower abdomen. The pain came on suddenly. The last period
was 10 days ago, on time. Childbirth - 2, abortion - 2. Half a
year ago, an ovarian tumor was found. Pulse - 100 beats per
minute, rhythmic, breaths 22 per minute. The tongue is dry, not
coated. The abdomen is bloated, tense, sharply painful,
especially on the left. The body of the uterus is not clearly
defined due to the tension of the anterior abdominal wall. Right
appendages are not defined. In the area of the left appendages,
the tumor is palpated with a tight elastic consistency, limited
mobility, painful. Parameters are free

1 From the anamnesis: ovarian tumor for six months. Complaints of

sharp pains in the lower abdomen. On physical examination:
tachycardia, stomach swollen, tense, sharply painful (intestinal
paresis), especially on the left. The body of the uterus is not clearly
determined by the tension of the anterior abdominal wall. In the area
of the left appendages, the tumor is palpated tight
elastic consistency, limited mobility, painful.
2 Diagnosis: torsion of the legs of an ovarian tumor.
Differential diagnosis should be carried out with acute appendicitis,
especially with pelvic placement
appendix, and renal colic. In this situation, additional research
methods can help -
survey x-ray of the abdominal organs, ultrasound of the abdominal
cavity and retroperitoneal
space.
Diagnosis 3 An important method for the diagnosis of torsion of the
legs of a tumor or cyst is ultrasound
a scan in which a volumetric formation with signs of a tumor is
determined in the area of the uterine appendages
ovarian cysts.
The most accurate information can be obtained
with laparoscopy . Endoscopic examination reveals in the pelvis
crimson-cyanotic formation - the ovary with a perversion of the legs,
with or without signs of necrosis, as well as serous
or serous hemorrhagic effusion.
4Likuvannya: Emergency surgical treatment. About "The volume of
surgical intervention is determined after visual
inspection of macrodrugs. In the absence of visual signs of necrosis,
the formation leg is untwisted and observed
for the restoration of blood circulation in the tissues. In case of
disappearance of ischemia and venous stasis instead of previously
accepted
removal of the uterine appendages can be limited to ovarian resection
 Statıon 4
1
. A woman was admitted to a gynecological hospital with complaints of
sudden sharp pain in the lower abdomen. Body temperature 38 C, pulse
100/min, BP - 120/80 mm. Hg. A 1year ago, upon examination, she was
diagnosed with a tumor of the right ovary. She refused the operation.
During the examination: the abdomen is moderately swollen, painful on
palpation in the lower sections, the symptoms of peritoneal irritation are
positive. In a bimanual examination, the uterus is of normal size,
painless, the mass of up to 8 cm was determined on the right side,
sharply painful, dense, with clear contours. In the clinical analysis of
blood - leukocytes 12 x 109 / l, stab neutrophils 15%, ESR 18 mm / hour.
1) Set emergency.
Torsion of the legs of an ovarian tumor
2) Necessary examination methods for this pathology.
- on the data of anamnesis, objective examination
and additional examination methods: laparoscopy, ultrasound (there is a tumor,
effusion into the abdominal cavity is sometimes determined).
3) What diseases should be used for differential diagnosis?
with acute peritonitis based on rupture of pyosalpinx, necrosis of the fibromatous node on the
leg, acute
appendicitis, acute intestinal obstruction, impaired tubal pregnancy, apoplexy
ovary, renal colic.
4) Determine the tactics of emergency care.
Laparoscopy - with confirmation of the diagnosis - adnexectomy.
An abdominal wall incision can be performed according to Pfanenstil or median
laparotomy. Removing adhesions
between adjacent organs and a tumor. The tumor is removed from the abdominal cavity and
non-screwed
leg, impose a ligature below the torsion, and then unwind it, apply clamps and
cut off. Then carry out peritonization, toilet of the abdominal cavity and layer-by-layer
suturing of the abdominal wound
the walls.
With tumor necrosis, drainage of the abdominal cavity is mandatory.
5) Indicate the dose and frequency of use of necessary medications.
-Premedication: Sibazon 0.5% 2 ml atropine sulfate 0.1% 0.5 ml
-Rn analgin 50% - 2.0+ rn diphenhydramine 1% - 1.0 V \ m 3 r / day
-Promedol 2% - 1 ml / m with analgin inefficiency
-Cefazolin 1.0 No. 12v \ m 2 g per day
Proserin 0.05% -1ml in \ m 1 ml 2p / day (intestinal atony)
-R n Ringer 10-15 ml / kg
- Novopassit 1 tab 2-3 g / day
- Timalin 5-20 mg in 1-2 ml of isotonic solution i / m 1-2 r / d
2. She went to the gynecologist a 24 years old woman complaining of
lower abdominal pain, which is bothering her for two months, gradually
growing, now also a weakness. Menstruation is regular, but the last two
months are very scarce. A pregnancy test is slightly positive. The
abdomen on palpation is soft, painful more in the right iliac region, where
the weakly positive Shchetkin-Blumberg symptom manifests itself.
During a gynecological examination, it was found that the uterus is soft,
slightly enlarged; a tumor-like formation of a test-like consistency is
palpated in the right area of the uterine appendages, painful during the
investigation. In the ultrasound: the thickness of the endometrium of 19
mm, a small amount of free liquid in Cul-de-sac, right side to the uterus
fetal sac visualized.

1) Set emergency.
An ectopic pregnancy is aroused.
2) Necessary examination methods for this pathology.
Gynecological examination data
when viewed in the mirrors, the cervix is cyanotic, the eye is closed;
• vaginal examination is sharply painful, especially cervical displacement;
• the uterus is slightly enlarged, soft, sharply painful on palpation, consists
the impression that the uterus “floats” in the fluid is a symptom of the “floating
uterus”;

• the size of the uterus is less than the expected gestational age;
• appendages without clear contours are detected through one of the lateral
arches.
• the posterior arch is protruded, palpation is sharply painful ("Douglas cry").
Hardware and instrumental methods of examination.
Transvaginal ultrasound:
• lack of a fetal egg in the uterine cavity;
• visualization of the embryo outside the uterine cavity;
• identification of the formation of a heterogeneous structure in the area of the
projection of the fallopian tubes;
• a significant amount of free fluid in the douglas space.
Laparoscopy - visual establishment of an ectopic pregnancy in the form of:
• retort-like thickening of the fallopian tube of a purplish-cyanotic color
• rupture of the fallopian tube;
• bleeding from the ampullar opening or from the rupture of the fallopian tube;
• the presence of blood in the abdominal cavity and in the douglas space in the
form of convolutions or in
liquid state;
• the presence in the abdominal cavity of the elements of the fetal egg.
3) What diseases should be used for differential diagnosis?
• Torsion or rupture of an ovarian cyst (history of ovarian cyst; no delay
• menstruation; no other signs of pregnancy).
• Acute appendicitis (no signs of pregnancy, no signs of bleeding -
• anemization, hemodynamic disturbances, the presence of signs characteristic
of appendicitis -
neutrophilic leukocytosis, symptoms of Sitkovsky, Rowzing and others ..)
• Termination of uterine pregnancy (based on ultrasound).
• Ovarian apoplexy (occurs in the middle of the menstrual cycle).
4) Determine the tactics of emergency care.
• Salpingostomy (tubotomy). A longitudinal salpingostomy is performed. after
removal
fetal egg salpingostomy is NOT sutured. In the case when the chorionic villi are
NOT
germinate into the muscle membrane of the fallopian tube limited to its
curettage.
• Segmental resection of the fallopian tube. The segment of the fallopian tube is
removed where
there is a fetal egg, after which anastomosis of the two ends of the tube is
performed. at
the inability to perform salpingo-salpingo anastomosis can be bandaged both
end and anastomosis later.
• salpingectomy. This operation is performed in case of impaired tubal
pregnancy.
accompanied by massive bleeding. Surgery and blood transfusion in this case
spend at the same time.
5) Indicate the dose and frequency of use of necessary medications.
the volume of emergency care is determined by the general condition of the
patient and the amount of blood loss.
Infusion therapy (volume, rate of administration of solutions) depends on the
stage of hemorrhagic shock.
-Premedication: Sibazon 0.5% 2 ml atropine sulfate 0.1% 0.5 ml
-Rn analgin 50% - 2.0+ rn diphenhydramine 1% - 1.0 V \ m 3 r / day
-Promedol 2% - 1 ml / m with analgin inefficiency
-Cefazolin 1.0 No. 12v \ m 2 g per day
Proserin 0.05% -1ml in \ m 1 ml 2p / day (intestinal atony)
-R n Ringer 10-15 ml / kg
- Novopassit 1 tab 2-3 g / day
- Timalin 5-20 mg in 1-2 ml of isotonic solution i / m 1-2 r / d
-methotrexate 75-100 mg \ m on the 1st and 2nd day after surgery (prof. in the
postoperative period of persistence
trophoblast
3. A pregnant woman of 30 years old with swelling of the lower
extremities, complaints of sharp abdominal pain, and bleeding from the
vagina, which began 2 hours ago during the morning toilet, was delivered
to the hospital. The pregnancy is 34 weeks. The last two weeks noted an
increase in blood pressure and swelling of the legs, was not treated. The
condition of the woman is dangerous. BP 70/20 mm Hg, pulse 120 / min.
Impaired consciousness. The uterus is in hypertonicity; the fetus is not
clearly defined due to uterine tension; the fetal heartbeat is not heard. In
the vaginal examination, the cervical canal passes the finger along the
entire length; the amniotic membrane is tense. Vaginal discharge is dark
blood with clots.

1) Set emergency.
Premature detachment of a normally located placenta. Hemorrhagic shock III
century.
2) Necessary examination methods for this pathology.
1) External obstetric research:
- uterine hypertonicity;
- the uterus is enlarged, may be deformed, with local
protrusion;
- pain on palpation;
- complications or impossibility of palpation and auscultation of the fetal
heartbeat
- fetal distress or death.
2) Internal obstetric research:
- tension of the fetal bladder;
- staining of amniotic fluid with blood with a broken fruitful bladder;
- bleeding of varying intensity from the uterus.
3) ultrasound - diagnostics with measurement of the area of detachment.
4) Diagnosis of the fetus (auscultation).
5) Laboratory studies (red blood cells, platelets, Hb, Ht, coagulogram,
coagulation time according to Li-
White's definition of “Algover's shock index” (heart rate / blood pressure
system)).
6) In the absence of external bleeding, the diagnosis of PVNRP is based on an
increased tone of the uterus,
local pain, deterioration of the fetus and mother.
3. For what diseases is it necessary to conduct differential diagnosis?
Placenta previa, umbilical cord rupture
4. Determine the tactics of emergency care.
Cesarean Roztin. Obovyazkova revision of the walls of the uterus (especially the
outer surface) to exclude
uteroplacental apoplexy.
• In case of diagnosis of the uterus of Kuveler - hysterectomy without
appendages; at
Necessity - ligation of the iliac arteries.
• If necessary, preserve the reproductive function (first birth, dead fetus) is
possible
uterine preservation (decided by consilium) with a small area of apoplexy (2-3
a focus of small diameter of 1-2 cm, or one in C cm) and the ability of the uterus
to contract,
the absence of bleeding and signs of DIC. Surgeons observe for some time (10-
20
min.) with an open abdominal cavity according to the state of the uterus and in
the absence of bleeding
drain the abdominal cavity to control hemostasis. Such tactics, in exceptional
cases allowed only in institutions in which there is a round-the-clock duty of
doctors
obstetrician-gynecologist, anesthetist.
• In the early postoperative period - careful monitoring of the state of the woman
in labor.
5. Assign the dose and frequency of use of necessary medications.
(Def BCC 30-40% = III Art.
Crystalloids (physical specs, Ringer's district) -7 ml / kg
Synthetic colloids (Reftan, Gelofusin) 10-15 ml / kg
Natural colloids (svizhozamor.plazma) 10-15 ml \ kg Albumin 10-20% -200 ml
Erythrocyte mass - 10-20 ml / kg
Ascorbic acid district 5 ml 5% cc
P-nriboxinum 10 ml iv slowly;
Rn dicinone 2-4 ml intravenously.
if necessary, cardiac glycosides: strophanthin 0.05% solution of 0.5-1 ml or
corglucon 0.06%
0.5-1 ml solution in saline under the control of a pulse

4. A 22-year-old woman in labor at a gestational age of 37 weeks was

received 2 hours after the onset of labor. Complaints of pain in the
epigastric region, vomiting, blurred vision. BP 180/130 and 170/120 mm
Hg. Severe swelling of the legs, feet, anterior abdominal wall, fibrillar
twitching of facial muscles of the face. Contraction of the uterus every
after 4 minutes for 30-35 seconds. The fetal head is pressed to the inlet
to the pelvis. The fetal heart rate is clear, rhythmic, 136 beats per minute.
Proteinuria 3 g / 24 hours. A vaginal examination: the cervix is smoothed,
the dilatation to 3 cm. The amniotic membrane is intact.
1.Restore emergency.
Pregnancy And 37 weeks. Severe preeclampsia - the threat of a seizure
2. Necessary examination methods for this pathology.
Complete blood count, hematocrit, platelet count, coagulogram, AlAT and
AsAT; blood type and rhesus
factor (in the absence) urinalysis, determination of proteinuria, creatinine, urea,
total protein,
bilirubin and its fractions, electrolytes.
Careful dynamic observation :
blood pressure monitoring - hourly;
auscultation of the fetal heartbeat - every 15 minutes
urinalysis every 4:00;
control of hourly urine output (catheterization of the bladder with a Faley
catheter)
hemoglobin, hematocrit, platelet count, functional liver function tests, plasma
creatinine -
daily
fetal condition monitoring: number of movements in 1:00, heart rate - daily,
every
possibilities - dopplerometric control of blood circulation in the vessels of the
umbilical cord, the vessels of the brain of the fetus,
placenta and fetoplacental complex;
assessment of amniotic fluid volume and fetal biophysical profile - according to
indications;
test for the absence of fetal stress - with a deterioration in the performance of
daily monitoring of the fetus and be sure
before delivery (assessment of the state of the cardiac activity of the fetus using
a fetal monitor).
3. For what diseases is it necessary to conduct differential diagnosis?
Chronic arterial hypertension, pregnant hypertension, pregnant acute fatty
hepatosis,
acute chronic renal disease (chronic glomerulonephritis), HELLP syndrome
4. Determine the tactics of emergency care.
The patient is hospitalized in the Department of Anesthesiology and Intensive
Care (OAIT) of a Level III hospital
to assess the risk of pregnancy for the mother and the fetus and the choice of
method of delivery within 24
hours. Active management tactics (cesarean section) with delivery in the next 24
hours from the moment
establishing a diagnosis.
5. Assign the dose and frequency of use of necessary medications.
Antihypertensive therapy.
Labetalol in 10 mg, after 10 minutes, in the absence of an adequate reaction
(diastolic blood pressure remained higher
110 mmHg) - an additional 20 mg. AOs are monitored every 10 minutes, and if
diastolic pressure
remains above 110 mm Hg, 40 mg are administered, and then 80 mg of labetalol
(up to a maximum of 300 mg).
nifedipine 5-10 mg under the tongue. If the effect is absent, then after 10
minutes it is necessary to give another 5 mg under the tongue.
hydralazine : 20 mg (1 ml) of the drug is dissolved in 20 ml of 0.9% sodium
chloride solution, administered
5 ml (5 mg hydralazine) slowly intravenously every 10 minutes until the
diastolic blood pressure drops to
safe level (90-100 mm Hg).
If necessary, repeat the administration of hydralazine 5-10 mg hourly or 12.5 mg
intramuscularly
every 2:00.
Magnesium sulfate bolus administration of 4 g of dry matter (16 ml of a 25%
solution
magnesium sulfate) is administered slowly over a 15 minute starting dose
dissolved in 0.9% sodium chloride solution or Ringer-Locke solution,
for this, 4 g of magnesium sulfate (16 ml of a 25% solution) is introduced into a
sterile vial with 34 ml of solution, with
subsequent maintenance infusion of 1 g of dry matter of magnesium sulfate per
hour for this 7.5 g
magnesium sulfate (30 ml of a 25% solution) is introduced into a vial containing
220 ml of 0.9% chloride solution
sodium infusion therapy.
In the absence of Magnesia, you can use - diazepam - 10 mg (2 ml) iv for 10
minutes in 10 ml of 0.9%
sodium chloride, if convulsions recur, repeat the starting dose.
Maintenance dose-40 mg in 500 ml of sodium chloride (6-7 drops per minute)
Infusion therapy The total volume of fluid introduced must correspond to the
daily physiological
women's needs (average 30-35 ml / kg) with the addition of non-physiological
losses
(blood loss, etc.). The rate of fluid injection should not exceed 85 ml / h or
hourly
diuresis + 30 ml / h. Preparations for the choice of infusion therapy until
delivery is
isotonic saline solutions (Ringer, 0.9% NaCl)
5. At the 36th week of pregnancy, the first pregnant woman was
delivered to the maternity ward in serious condition with complaints of
dizziness, weakness, severe abdominal pain, uterine tension, which
started 2 hours ago. BP 60/40 mm Hg, pulse 110 in 1 min. The uterus
corresponds to the period of pregnancy; according to hypertonicity, it is
sharply painful in the place where the protrusion is noticeable. Faint fetal
heartbeat 80 beats per 1 minute. Ultrasound revealed a retroplacental
hematoma with a volume of about 1 liter. A vaginal examination: cervix
2.5 cm long, closed.
1.Restore emergency.
Premature detachment of a normally located placenta. Hemorrhagic shock III III
station Distres
fetus
2. Necessary examination methods for this pathology.
● External obstetric research:
- uterine hypertonicity;
- the uterus is enlarged, may be deformed, with local
protrusion;
- pain on palpation;
- complications or impossibility of palpation and auscultation of the fetal
heartbeat
- fetal distress or death.
● Internal obstetric research:
- tension of the fetal bladder;
- staining of amniotic fluid with blood with a broken fruitful bladder;
- bleeding of varying intensity from the uterus.
● ultrasound - diagnostics with measurement of the area of detachment.
● Diagnosis of the fetus (auscultation).
● Laboratory studies (red blood cells, platelets, Hb, Ht, coagulogram,
coagulation time according to Li-
White's definition of “Algover's shock index” (heart rate / blood pressure
system)).

3. What diseases should be used for differential diagnosis?

Placenta previa, umbilical cord rupture

4. Determine the tactics of emergency care.

Cesarean Roztin. Obovyazkova revision of the walls of the uterus (especially the
outer surface) to exclude
uteroplacental apoplexy.
• In case of diagnosis of the uterus of Kuveler - hysterectomy without
appendages; at
Necessity - ligation of the iliac arteries.
• If necessary, preserve the reproductive function (first birth, dead fetus) is
possible
uterine preservation (decided by consilium) with a small area of apoplexy (2-3
a focus of small diameter of 1-2 cm, or one in C cm) and the ability of the uterus
to contract,
the absence of bleeding and signs of DIC.
• In the early postoperative period - careful monitoring of the state of the woman
in labor.
5.
Indicate the dose and frequency of use
necessary medications. (Def BCC 30-40% = IIist
Crystalloids (physical specs, Ringer's district) -7 ml / kg
Synthetic colloids (Reftan, Gelofusin) 10-15 ml / kg
Natural colloids (svizhozamor.plazma) 10-15 ml \ kg Albumin 10-20% -200 ml
Erythrocyte mass - 10-20 ml / kg
Ascorbic acid district 5 ml 5% cc
P-nriboxinum 10 ml iv slowly;
Rn dicinone 2-4 ml intravenously.
if necessary, cardiac glycosides: strophanthin 0.05% solution of 0.5-1 ml or
corglucon 0.06%
0.5-1 ml solution in saline under the control of a pulse

6. The first pregnant woman, 19 years old, was delivered by an

ambulance group to the unconscious perinatal center with a venous
catheter. It is known from the exchange card that the gestational age is
37 weeks, was observed irregularly in the antenatal clinic, blood
pressure and proteinuria periodically increased from 28 weeks to 1 g / l.
According to a friend during a walk, the pregnant woman suddenly fell
unconscious. An ambulance doctor recorded clonic seizures of limbs, a
bite of the tongue, blood pressure of 200/120 mm Hg. The uterus is soft,
not tense. The fetal heartbeat is dull, rhythmic 70 beats in 1 minute.
1. Set an emergency.
Eclampsia during pregnancy. Sudden seizure.
2. Necessary examination methods for this pathology.
Laboratory tests: blood test (thrombocytes, hematocrit, hemoglobin, clotting
time), total
protein, albumin, glucose, urea, creatinine, transaminases, electrolytes, level
calcium, magnesium, fibrinogen and its degradation products, prothrombin and
prothrombin time,
urinalysis, daily proteinuria.
Monitoring of blood pressure, determination of hourly urine output, assessment
of clinical symptoms is carried out with mandatory
registering in the birth history every hour
3. For what diseases is it necessary to conduct differential diagnosis?
epilepsy, ischemic / hemorrhagic stroke, cerebral vein thrombosis,
intracerebral hemorrhage / aneurysms, infections (encephalitis, meningitis),
brain tumors,
effect of drugs (amphetamine, cocaine, theophylline, chlozapine, hyperglycemia
4. Determine the tactics of emergency care.
immediate delivery (cesarean section), delivery is carried out immediately after
elimination
an attack of seizures against the background of continuous administration of
magnesium sulfate and blood pressure. Subject to continued
seizures urgent delivery is carried out after transferring the patient to mechanical
ventilation. sedative
therapy, anticonvulsant therapy, resolving the feasibility of mechanical
ventilation.
1.
Indicate the dose and frequency of use
necessary medications.
Antihypertensive therapy.
Labetalol is first administered intravenously 10 mg, after 10 minutes, in the
absence of an adequate reaction
(diastolic blood pressure remained above 110 mm Hg) - an additional 20
mg. AO control every 10
minutes, and if the diastolic pressure remains above 110 mm Hg, 40 mg and
then 80 mg of labetalol are administered
(up to a maximum of 300 mg) (B).
nifedipine 5-10 mg under the tongue. If the effect is absent, then after 10
minutes it is necessary to give another 5 mg under the tongue.
hydralazine : 20 mg (1 ml) of the drug is dissolved in 20 ml of 0.9% sodium
chloride solution, injected slowly
5 ml intravenously (5 mg hydralazine) every 10 minutes until the diastolic blood
pressure drops to a safe
level (90-100 mm Hg).
If necessary, repeat the administration of hydralazine 5-10 mg hourly or 12.5 mg
intramuscularly
every 2:00.
magnesium sulfate - bolus 4 g for 5 minutes intravenously, then maintenance
therapy 1-2 g / h) under
careful monitoring of blood pressure and heart rate.
If the attacks continue, another 2 g of magnesium sulfate (8 ml of a 25%
solution) is intravenously administered for 3-5
minutes. Instead of an additional bolus of magnesium sulfate, diazepam can be
used intravenously
(10 mg) or thiopental sodium (450-500 mg) for 3 minutes. If the seizure
continues
more than 30 minutes, this condition is considered as eclampic status.
Infusion therapy The total volume of fluid introduced must correspond to the
daily physiological
women's needs (average 30-35 ml / kg) with the addition of non-physiological
losses
(blood loss, etc.). The rate of fluid injection should not exceed 85 ml / h or
hourly
diuresis + 30 ml / h. Preparations for the choice of infusion therapy until
delivery is
isotonic saline solutions (Ringer, 0.9% NaCl).

7. Pregnant 21 years old at home suddenly fell unconscious, skin is

cyanotic, convulsions. A few minutes later she came up; she did not
remember the seizure. Before the ambulance arrived, there were two
more such attacks. Pregnancy is 30 weeks. The antenatal clinic was not
observed. BP 180/120 mm Hg, urine excreted by a catheter in an
amount of 40 ml of a dark yellow color. The uterus is in good shape. The
position of the fetus is longitudinal. Fetal heartbeat deaf rhythmic 100
beats in 1 minute.
1.
Set emergency:
Eclampsia during pregnancy. Sudden seizure.
2. Necessary examination methods for this pathology:
- blood pressure monitoring - hourly;
- auscultation of the fetal heartbeat - every 15 minutes
- urinalysis - every 4:00;
- control of hourly urine output (catheterization of the bladder with a Faley
catheter)
- hemoglobin, hematocrit, platelet count, functional liver function tests, plasma
creatinine -
daily
- monitoring of the fetus: the number of movements in 1:00, heart rate - daily,
possibilities - dopplerometric control of blood circulation in the vessels of the
umbilical cord, the vessels of the brain of the fetus,
placenta and fetoplacental complex;
- assessment of amniotic fluid volume and fetal biophysical profile - according
to indications;
- fetal stress test
- in case of deterioration of the indicators of daily monitoring of the fetus and
always before delivery
(assessment of the state of the heart activity of the fetus using a fetal monitor).
3. For which diseases it is necessary to conduct differential diagnosis:
Epilepsy, brain tumors, hyperglycemia, stroke, cerebral vein thrombosis,
intracerebral hemorrhage / aneurysm, infection (encephalitis, meningitis),
4. Determine the tactics of emergency care:
1. Treatment in case of an attack of seizures begins on the spot.
2. Open an intensive care unit or hospitalize a pregnant woman in the
anesthesiology department and
intensive care.
3. The pregnant woman is laid on a flat surface in a position on the left side,
quickly released
airways, opening the mouth and pushing the lower jaw forward, in parallel
evacuate the contents
the oral cavity. If possible, if spontaneous breathing is maintained, an air duct is
introduced and carried out
inhalation of oxygen.
4. Forced ventilation with a nasal-facial mask with a supply of 100% oxygen in
positive mode
pressure at the end of exhalation. If convulsions recur or the patient remains in a
coma, enter
muscle relaxants and transfer the patient to mechanical ventilation (mechanical
ventilation) in the mode of moderate
hyperventilation.
5. Catheterization of the peripheral vein, the introduction of anticonvulsants
(magnesium sulfate is administered in /
in a bolus for 5-100 min., 4 g of magnesium sulfate (16 ml of a 25% solution) is
introduced, then supporting
therapy 1-2 g / h, the maintenance dose is 2 g / hour (8 ml of a 25% solution),
the daily dose is 24-30 g / day)
under close monitoring of blood pressure and heart rate.
6. After liquidation by the court, infusion therapy - solutions of hydroxyethyl
starch (stabizol, reftan, 6%) in
a volume of 10-15 ml / kg, crystalloids.
7. Caesar's section: delivery is carried out immediately after the elimination of
an attack of seizures against a background of constant
the introduction of magnesium sulfate and blood pressure. Provided the seizure
continues, urgent delivery
carried out after transfer of the patient to mechanical ventilation
5. Assign doses and frequency of necessary medications.
Antihypertensive therapy.
Labetalol is first administered intravenously 10 mg, after 10 minutes, in the
absence of an adequate reaction
(diastolic blood pressure remained above 110 mm Hg) - an additional 20
mg. AO control every 10
minutes, and if the diastolic pressure remains above 110 mm Hg, 40 mg and
then 80 mg of labetalol are administered
(up to a maximum of 300 mg) (B).
Nifedipine 5-10 mg under the tongue. If the effect is absent, then after 10
minutes it is necessary to give another 5 mg under the tongue.
Hydralazine : 20 mg (1 ml) of the drug is dissolved in 20 ml of 0.9% sodium
chloride solution, injected slowly
5 ml intravenously (5 mg hydralazine) every 10 minutes until the diastolic blood
pressure drops to a safe
level (90-100 mm Hg).
If necessary, repeat the administration of hydralazine 5-10 mg hourly or 12.5 mg
intramuscularly
every 2:00.
Magnesium sulfate - 4 g bolus for 5 minutes intravenously, then maintenance
therapy 1-2 g / h) under
careful monitoring of blood pressure and heart rate.
If the attacks continue, another 2 g of magnesium sulfate (8 ml of a 25%
solution) is intravenously administered for 3-5
minutes. Instead of an additional bolus of magnesium sulfate, diazepam can be
used intravenously
(10 mg) or thiopental sodium (450-500 mg) for 3 minutes. If the seizure
continues
more than 30 minutes, this condition is considered as eclampic status.
Infusion therapy The total volume of injected fluid should correspond to the
daily physiological
women's needs (average 30-35 ml / kg) with the addition of non-physiological
losses
(blood loss, etc.). The rate of fluid injection should not exceed 85 ml / h or
hourly
diuresis + 30 ml / h. Preparations for the choice of infusion therapy until
delivery is
isotonic saline solutions (Ringer, 0.9% NaCl)
8. The delivery on time in a woman with preeclampsia. Ancestral labor
began. Suddenly, convulsions of the face and upper limbs appeared. BP
200/130 mm Hg The fetal heartbeat is muffled, rhythmic 100 beats in 1
minute. In vaginal examination: the cervix is fully delated, the amniotic
sac is absent. Presented is the fetal head in the narrow part of the small
pelvis. The sagittal suture in right oblique size, small fontanel on the left
at the symphysis

1) Set emergency.
Exampsia. Convulsive seizure
2) Necessary examination methods for this pathology.
Laboratory indicators for this pathology:
Uric acid, mmol / L> 0.45
Urea, mmol / L> 8
Creatinine, μmol / L> 120 or oliguria
Platelets 10
9
/ l <80
BP monitoring every hour
Hourly urine output control
Determination of protein in urine
3) What diseases should be used for differential diagnosis?
epilepsy
acute cerebrovascular accident
Encephalitis
-meningitis,
-surge of cerebral aneurysm,
-hysteria,
-reuremic coma
4) Determine the tactics of emergency care.
Initially relieve an attack:
1) Pregnant on the side
2) Oxygen inhalation
3) Staging of peripheral venous (2pcs) and urinary catheter
If the attack does not go away - Norkuron + ketamine + seduxen (muscle
relaxant + analgesic + tranquilizer
respectively) transfer to mechanical ventilation, and the operation is cesarean
section.
5. Indicate the dose and frequency of use of necessary medications.
B \ in magnesium sulfate 25% 16 ml (4 g) for 5 min, then 2 g / h
Infusion - Hydroxyethyl starch 10 ml / kg weight + sodium chloride (sodium
bicarbonate) 200 ml
Antihypertensive therapy.
Labetalol is first administered intravenously 10 mg, after 10 minutes, in the
absence of an adequate reaction
(diastolic blood pressure remained above 110 mm Hg) - an additional 20
mg. AO control every 10
minutes, and if the diastolic pressure remains above 110 mm Hg, 40 mg and
then 80 mg of labetalol are administered
(up to a maximum of 300 mg) (B).
nifedipine 5-10 mg under the tongue. If the effect is absent, then after 10
minutes it is necessary to give another 5 mg under the tongue.
hydralazine : 20 mg (1 ml) of the drug is dissolved in 20 ml of 0.9% sodium
chloride solution, injected slowly
5 ml intravenously (5 mg hydralazine) every 10 minutes until the diastolic blood
pressure drops to a safe
level (90-100 mm Hg).
If necessary, repeat the administration of hydralazine 5-10 mg hourly or 12.5 mg
intramuscularly
every 2:00.
Instead of an additional bolus of magnesium sulfate, you can use diazepam
intravenously (10 mg) or
thiopental sodium (450-500 mg) for 3 minutes. If a seizure lasts more than 30
minutes,
this condition is regarded as eclampic status.
Infusion therapy The total volume of fluid introduced must correspond to the
daily physiological
women's needs (average 30-35 ml / kg) with the addition of non-physiological
losses
(blood loss, etc.). The rate of fluid injection should not exceed 85 ml / h or
hourly
diuresis + 30 ml / h. Preparations for the choice of infusion therapy until
delivery is
isotonic saline solutions (Ringer, 0.9% NaCl)

9. In a woman in labor weighing 78 kg after the birth of the placenta,

uterine bleeding began. When examining the placenta, a defect of 3 x 4
cm found on the maternal surface. Blood loss was 800 ml.
1) Set emergency
Retention of parts of the placenta. Hemorrhagic shock of 1 degree
2) Necessary examination methods for this pathology
Laboratory indicators for this pathology:
Pulse, beats / min 100-110
Sis. AO. mm 90-100
Shock Index 0.8-1
TsVD, mm.vod.st 40-60
White Spot Test 2-3 s
Hematocrit, l / l 0.3-0.38
Respiratory rate 20-25
The rate of urine output (ml / h) 30-50
general blood analysis
platelet count
coagulogram
electrolytes
3) What diseases should be used for differential diagnosis?
Pinched placenta, placental increment, birth canal trauma, placenta attachment
pathology
4) Define emergency care tactics
1) peripheral vein catheterization + urinary catheter placement
2) urgent manual examination of the uterine cavity under anesthesia
5) Indicate the dose and frequency of use of necessary medications.
15 units of oxytocin per 400 ml of sodium chloride in \ in drops
BCC recovery - infusion volume up to 2.5 l, only crystalloids - sodium chloride
10 ml / kg

10. Delivery is urgent, quick. A newborn is weighing 3800.0 g with a

growth of 54 cm. After the birth of the placenta, the bleeding began. The
uterus is soft, the fundus of uterus is at the level of the navel. The use of
oxytocin did not give the desired effect. Bleeding continues. Blood loss
amounted to 1200 ml.
1) Set emergency
Atonic uterine bleeding. Hemorrhagic shock 2a degree
2) Necessary examination methods for this pathology
Laboratory indicators for this pathology:
Pulse, beats / min 110-120
Sis. AO. mm 70-90
Shock index 1-1.5
TsVD, mm.vod.st 30-40
White Spot Test> 3 s
Hematocrit, l / l 0.25-0.3
Respiratory rate 25-30
The rate of urine output (ml / h) 25-30
Blood group and rhesus
Complete blood count-lower hemoglobin and red blood cells
SaO2-less than 90
3) What diseases should be used for differential diagnosis?
uterine hypotension
placental tissue residues
uterine tears
birth trauma
inside of the uterus
pre-existing or acquired coagulation disorder.
4) Define emergency care tactics
1) Manual revision of the uterine cavity.
2) External economic internal massage of the uterus.
3) If the effect is not achieved (stopping bleeding), the operation is the
extirpation of the uterus without appendages,
ligation of the internal iliac arteries. If bleeding continues after extirpation, tight
tamponade of the abdominal cavity and vagina.
4) BCC recovery:
The total volume of infusion in 3l
5) Indicate the dose and frequency of use of necessary medications.
Kristaloidi-fiz .. rn 10ml \ kg, ringer Ringer
Colloid-reformed, stabizol 10 ml / kg, freshly frozen plasma 5 ml / kg
R-mass - 5 ml / kg
11. Postpartum woman 40 years old. History: two births, there were no
abortions. The woman's weight is 70 kg, height 174 cm. The third
physiological vaginal delivery stops on time at the birth of a healthy baby
weighing 3600.0 g, height 52 cm. 1 hour after birth, uterine bleeding
intensified, blood loss was 500 ml. The uterus is soft, during the
massage it contracts, it becomes dense, the fundus of the uterus is at
the level of the navel.

1) Set emergency
Hypotonic uterine bleeding.
2) Necessary examination methods for this pathology
Laboratory indicators for this pathology:
Pulse, beats / min <100
Sis. AO. mm N 90-100
Shock index 0.54-0.8
TsVD, mm.vod.st 60-80
White Spot Test N (2s)
Hematocrit, l / l 0.38-0.42
Respiratory rate 14-20
Diuresis rate (ml / h) 50
3) What diseases should be used for differential diagnosis?
uterine atony, placental tissue residues, uterine ruptures, trauma of the birth
canal, uterine inside,
pre-existing or acquired coagulation disorder.
4) Define emergency care tactics
1) Catheterization of peripheral veins
2) Insertion of a urinary catheter
5) Indicate the dose and frequency of use of necessary medications.
The introduction of uterotonic drugs: 20 units in \ in 1 liter of physical. district,
60 drops per minute (if further bleeding
continues)
-10 units in \ in for 1 liter of physical a solution of 30 drops per minute. The
maximum dose of 3 l in \ in a liquid with oxytocin (if
further bleeding continues)
-0.2 mg ergometrine in \ m (if further bleeding continues),
- Repeated administration of ergometrine 0.2 mg \ m every 15 minutes, the
maximum dose of 1.0 mg is not more than 5 doses,
(if further bleeding continues)
- The uterus does not respond to oxytocin / ergometrine 800 mcg rectally
misoprostol, repeated doses of 0.25 mg
every 15 minutes, no more than 2 mg (8 doses) (bleeding continues, more than
1.5% of body weight)
- urgent surgical treatment is indicated (hysterectomy without appendages)
-Restoration of bcc: physical .. rn 15 ml / kg, ringer Ringer

12. The second pregnancy at 42 weeks—unsuccessful attempt to induce

labor. During the cesarean section, after removing the child and the
placenta, uterine bleeding began. In a laboratory study: Lee-White
coagulation time-5 min., Spontaneous clot lysis - no, APTT - 28 sec.,
Platelets-210 * 10 9 \ l, prothrombin time - 8 sec, thrombin time - 22 sec,
fibrinogen - 4,5 g / l.

1) Set emergency
DIC, stage I - hypercoagulation
2) Necessary examination methods for this pathology
Laboratory indicators for this pathology:
Lee-White coagulation time, min. 5 minutes
Spontaneous clot lysis forum
APTT, with less than 30
The number of thrombocytosis 109 / l normal (150-320)
Prothrombin time, with less than 10
Thrombin time, with less than 24
Fibrinogen, g / l 5 or more
3) What diseases should be used for differential diagnosis?
uterine atony, uterine hypotension, placental tissue residues, uterine ruptures,
trauma of the birth canal, wrong side
uterus, local fibrinolysis, hyperheparinemia, hemodilution coagulopathy
4) Define emergency care tactics
1. Exclusion of diseases., What caused ICE (cesarean section)
2. Surgical stop bleeding
5) Indicate the dose and frequency of use of necessary medications.
.In / in the injection of 700-1000 ml svizhozam. plasma heated to 37 degrees
Antithrombin III - 100 U / kg
13. The third birth carried out with the stimulation of labor, ended with the
imposition of output obstetric forceps. A baby was born weighing 3600.0
g, height 51 cm, with an Apgar score of 7-9 points. After the birth of the
child, uterine bleeding began. Conservative methods of stopping
bleeding have been performed. In a laboratory study: blood coagulation
time according to Lee-White - 7 min., Spontaneous lysis of a clot - no,
APTT -27 sec., Platelets - 150 * 109 / l, prothrombin time - 12 sec.,
Thrombin time - 65 sec., Fibrinogen - 3 g / l.
1) Set emergency
DIC, stage II - hypocoagulation without generalized activation of fibrinolysis
2) Necessary examination methods for this pathology
Laboratory indicators for this pathology:
Lee White Time5-12hv
APTT <30 s
IF 12-15C,
PM> 60s
Fibrinogen 1.5-3.0 g / l
May -100-150◦109 / l
Spontan.Lysis bunch of forum
3) What diseases should be used for differential diagnosis?
uterine atony, uterine hypotension, placental tissue residues, uterine ruptures,
trauma of the birth canal, wrong side
uterus, local fibrinolysis, hyperheparinemia, hemodilution coagulopathy
4) Define emergency care tactics
1. The eradication of diseases., Which caused ICE
2. Surgical stop bleeding
3.Mistseva stop bleeding (tamponade, local hemo statics)
5) Indicate the dose and frequency of use of necessary medications.
In / in the injection of 700-1000 ml svizhozam. plasma heated to 37 degrees
Antithrombin III - 100 U / kg
Inhibitors of proteolysis (trazylol -50-100tis units, or kontrikal 20-60 thousand
units, or gordoks - 200-600 thousand units)
NovoSeven -60-90 mcg / kg (1-2 doses)
Cryoprecipitate of plasma - 200 PIECES
14. After the second stage delay in delivery, the woman began to bleed.
The placenta stood out whole. The uterus is dense, the bottom of the
uterus is two transverse fingers below the navel. The birth canal
examined - no damage was found. Blood loss is gradually increasing. In
laboratory studies: Lee-White coagulation time - 15 min, spontaneous
clot lysis - quickly, APTT - 70 s, platelets - 65x109 / l, prothrombin time -
16 s, thrombin time - 120 s, fibrinogen - 1.2 g / l.
1) Set emergency
DVZ_ syndrome, stage III -hypocoagulation with generalized activation of fibrinolysis
2) Necessary examination methods for this pathology
Laboratory indicators for this pathology:
Lee White Time> 12min
APTT 60-80 s
PCh15-18s,
PM> 100s
Fibrinogen 0.5-1.5 g / l
May -50-100◦109 / l
Spontaneous lysis of the clot is fast.
3) What diseases should be used for differential diagnosis?
uterine atony, uterine hypotension, placental tissue residues, thrombotic thrombocytopenic purpura.
von Willebrand disease, Glanzmann thrombasthenia, acquired thrombocytopathy. local fibrinolysis,
hyperheparinemia, hemodilution coagulopathy, von Willebrand disease
4) Define emergency care tactics
1. The eradication of diseases., Which caused ICE
2. Surgical stop bleeding
3. Local stop bleeding.
5) Indicate the dose and frequency of use of necessary medications.
In / in the injection of 700-1000 ml svizhozam. plasma heated to 37 ° C
Antithrombin III - 100 U / kg
Proteolysis inhibitors (trazylol -100300tis units, or contracal -60-100 thousand units, or gordox - 600-1000
thousand units)
NovoSeven -60-90 mcg / kg (1-2 doses)
Cryoprecipitate of plasma - 400 PIECES

15. A woman in labor in the early postpartum period developed hypotonic

uterine bleeding. Conservative measures did not give the desired effect,
bleeding continues. In a laboratory study: the coagulation time, according
to Lee-White, is 65 min, the clot does not form, APTT - 85 sec, platelets -
40 * 10 9 / l, prothrombin time - 22 sec, thrombin time - 200 sec,
fibrinogen is not determined.
1. Set emergency:
DIC, stage IV - complete blood coagulation.
2. Necessary examination methods for this pathology:
Lee White Coagulation Time
Activated coagulation time (ABC) .
Activated partial thrombin time (APTT) (normal 25-40 s)
Thrombin time (TB) (norm 16 - 20 s.) - characterizes the rate of transition of fibrinogen to fibrin.
Subjugation of PM may be due to hypofibrinogenemia, dysfibronegenemia,
elevated levels of prisoners in plasma PDF or the presence of direct anticoagulants
Prothrombin time (PTV) (norm 11 - 12 s.) Determines the activity or deficiency of factors
prothrombin complex (V, VII, X, II) of the external coagulation mechanism. Prothrombin Extension
time during normal thrombin time indicates suppression of the external coagulation mechanism
blood, that is, a deficiency of V and AI factors
The plasma fibrinogen content (norm 2.0 - 4.5 g / l). Fibrinogen reduction is observed when
the progression of DIC, treatment with fibrinolytic drugs, or congenital hypo- and
dysfibrinogenemia
3. With which diseases it is necessary to conduct differential diagnosis:
Uterine atony, uterine hypotension, placental tissue residues, thrombotic thrombocytopenic purpura.
von Willebrand disease, Glanzmann thrombasthenia, acquired thrombocytopathy. local fibrinolysis,
hyperheparinemia, hemodilution coagulopathy, von Willebrand disease.
4. Determine the tactics of emergency care.
1. Treatment of the underlying disease leading to the development of DIC-syndrome (surgical intervention,
drug and infusion therapy)
Local stop bleeding from the wound surface is carried out in all cases. Reached
various methods and methods: coagulation, and ligation of blood vessels, wound tamponade, application
local hemostatic agents.
5. Indicate the dose and frequency of use of necessary medications.
1. The introduction of proteolysis inhibitors is indicated from stage II. Contrical (or other drugs in
equivalent doses) injected prisoners depending on th e stage of DIC syndrome by drip
infusion for 1 - 2:00
Trazilol, OD 300000 - 500000
Kontrikal, OD - 100000 - 300000
Gordoks, OD - 1,000,000 - 4,000,000
2. Recovery of coagulation factors by the introduction of plasma cryoprecipitate (600 Units - IV stage)
If possible, it is recommended that the introduction of male recombinant factor VIIa (NovoSeven) - 60 - 90
mcg
/ kg (1 - 2 doses)
3. A thromboconcentrate is used in a low platelet count of less than 50 * 10 9 / l. Dose
thrombocyte concentrate depending on the clinical situation

16. The woman in labor on the third day after cesarean section, the
indications of which were premature rupture of the amniotic membranes
and ineffective induction of labor, developed the following menacing
symptoms: fever up to 39.5 °C, heart rate-100 beats in 1 minute., RR -25
in 1 minute. Laboratory: platelets - 80 * 10 9 / l, elevated C-reactive
protein, procalcitonin - 8 ng / ml, circulating microorganisms in the blood
culture, test for endotoxin-positive.
1. Show emergency
severe sepsis
2. Necessary examination methods for this pathology
• monitoring of hemodynamic parameters: blood pressure, heart rate, CVP;
• monitoring of respiratory system parameters (BH, blood gases, SpО2)
• hourly urine output control
• measurement of rectal temperature at least 4 times a day to compare with
body temperature in the armpits;
• cultures of urine, blood and secretions from the cervical canal;
• determination of acid-base balance of blood and tissue oxygen saturation;
• platelet count and determination of fibrinogen and monomer content
fibrin (soluble fibrin)
• ECG to detect the degree of metabolic disorders or myocardial ischemia;
• Ultrasound of the abdominal organs in order to identify possible abscesses;
• chest x-ray to confirm
acute respiratory distress syndrome or pneumonia
Laboratory indicators:
• leukocytosis> 12◦109 / l, a shift in the infusion formula. Leukopenia
• toxic granularity of neutrophils, the appearance of Dole bodies, vacuolization;
• lymphopenia;
• thrombocytopenia <100 · 109 / l, which cannot be explained by other reasons;
• decrease in fibrinogen level, lengthening of blood coagulation time and time
recalcification of plasma, an increase in prothrombin time, the appearance in the vascular
in line with increased concentrations of soluble complexes of fibrin monomers and
fibrin degradation products, the development of micro hemolysis;
• anemia
• characteristic biochemical changes (increased levels of lactate, creatinine, bilirubin).
• increased levels of procalcitonin over 6.0 ng / ml
• positive blood culture to detect circulating microorganisms;
• positive endotoxin test (LPS test)
3. What diseases should be used for differential diagnosis?
Mastitis, urinary tract infections, pneumonia, infections of the skin and soft tissues, gastroenteritis,
pharyngitis, bacterial meningitis, etc.
4.5. The basic principles of therapeutic measures:
1) Hospitalization in the intensive care unit.
2) Adequate venous access
3) Bladder catheterization, hourly urine output control
4) Correction of hemodynamic disturbances through isotropic therapy and adequate
infusion support.
Derivatives of HES are used for the infusion (reftan, Venofundin, voluven, stabizol) and
crystalloids (0.9% sodium chloride solution, Ringer's solution) in a ratio of 1: 2. In order to correct
hypoproteinemia is prescribed only 20-25% albumin solution. The use of 5-10% albumin for
critical conditions increases mortality in patients.
Freshly frozen plasma of 600-1000 ml should be included in the infusion, due to the presence of
antithrombin in it
Inotropic support is used if the CVP remains low.
Dopamine is administered at a dose of 5-10 μg / kg / min (maximum up to 20 μg / kg / min) or dobutamine
- 5-20 μg / kg / min.
In the absence of a persistent increase in blood pressure, norepinephrine hydrotartrate is administered 0.1-
0.5 mg / kg / min,
while reducing the dose of dopamine to 2-4 mcg / kg / min. Concurrent Appointment Justified
naloxone up to 2.0 mg, which contributes to an increase in blood pressure.
In case of ineffectiveness of complex hemodynamic therapy, the use of corticosteroids is possible
(hydrocortisone - 2000 mg / day) together with H 2 blockers (ranitidine, famotidine)
5) Support for adequate ventilation and gas exchange (IVL)
6) Normalization of bowel function and early enteral nutrition.
7) Timely correction of metabolism under constant laboratory control.
8) Antibiotic therapy
Empirical therapy (before determining the pathogen) - triple, double, monotherapy
• Piperacillin-tazobactam 4.5 g every 8 hours or ciprofloxacin 600 mg every 12 hours + gentamicin 3-5 mg
/ kg
per day in divided doses every 8 hours;
• Carbapenems, such as meropenem - from 500 mg to 1 g every 8 hours + gentamicin;
• metronidazole 500 mg every 8 hours may be considered to provide effects on anaerobic
pathogens;
• If there is a suspicion of streptococcal infection groups - clindamycin 600 mg to 1.2 g three or four
once a day;
• If there are risk factors for MRSA septicemia, add teicoplanin 10 mg / kg every 12 hours to
for three days, then 10 mg / kg every 24 hours or linezolid 600 mg every 12 hours
• The inclusion of anti-candida drugs (nystatin,
fluconazole, itraconazole, etc.).
9) Prevention of deep vein thrombosis (low dose unfractionated heparin, prophylactic
doses of low molecular weight heparin (LMWH):
• Calcium nadroparin - 0.3 ml subcutaneously 2:00 before surgery - then - 0.3 ml subcutaneously every 24
hours
• Enoxaparin sodium - 20 mg (0.2 ml) subcutaneously at 2:00 before surgery at high risk, the dose is
increased to
40 mg (0.4 ml) - then - 20 mg (0.2 ml) or 40 mg (0.4 ml) subcutaneously every 24 hours
• Dalteparin sodium - 2500 IU subcutaneously 2:00 before surgery - further - but 2500 IU subcutaneously
every 24
hours
• Bemiparin sodium - 2500 IU subcutaneously 2:00 before surgery - further - but 2500 IU subcutaneously
every 24
hours
10) The fight against multiple organ failure syndrome (a wide range of drugs in
according to organ disorders)
11) Improving microcirculation (use of pentoxifylline or dipyridamole)
12) Anti-mediator therapy.
antioxidants (vitamin E, N-acetylcysteine, glutathione), corticosteroids (dexamethasone), lysophilin,
phosphodiesterase inhibitors (amrinone, milrinone, pentoxifylline) and adenosine deaminases
(dipyridamole),
adenosine and alpha-blockers.
13) Surgical treatment with the removal of the focus of infection.
14) Extracorporeal blood purification (detoxification) is a promising direction in the correction
homeostasis disorders in severe patients. For this purpose, apply: hemodialysis, ultrafiltration,
hemofiltration, hemodiafiltration, plasmapheresis

17. A woman in labor (37 weeks) with preeclampsia in the 1st stage of
labor experienced an attack of seizures. BP 200 / 120 mm Hg. Fetal
heartbeat rhythmic deaf 90 beats in 1 minute. During internal obstetric
examination - the cervix is smoothed, the opening of the uterine cervix is
6 cm, the amniotic sac is intact, the head of the fetus is presentation,
pressed to the entrance to the small pelvis.
1.Diagnosis
Eclampsia - an attack of seizures, fetal distress.
2.Diagnosis
Eclampsia is diagnosed with an attack of generalized tonic-clonic seizures in a woman with pre
eclampsia. High risk of eclampsia is indicated by: severe headache, high hypertension
(diastolic blood pressure> 120 mmHg), nausea, vomiting, visual impairment, pain in the right
hypochondrium and / or
epigastric region. The examination is carried out after the termination of the attack by the court.
Neobkhidni methods
examination: consultation of a neurologist and optometrist with a mandatory examination of the fundus.
Laboratory tests: a clinical blood test (platelets, hematocrit, hemoglobin, time
coagulation), total protein, the level of albumin, glucose, urea, creatinine, transaminases, electrolytes,
calcium, magnesium, fibrinogen and its degradation products, prothrombin and prothrombin hour, analysis
urine, daily proteinuria. ongoing monitoring of blood pressure, determination of hourly urine ou tput.
3. Diff. diagnosis with diseases that cause seizures (vascular disease
CNS, intracerebral hemorrhages / aneurysms, GM tumors, arteriovenous malformations, infections -
meningitis or encephalitis, epilepsy, hypoNa, hyperK, the effect of drugs - theophylline).
4.Tactics.
Delivery is carried out immediately after the elimination of an attack of seizures against the background of
continuous administration of sulfate
magnesium and antihypertensive therapy by cesarean section.
5. Means, dosing.
With the development of prolonged apnea, ventilation with a nasofacial mask immediately begins with a
100% supply
oxygen.
In parallel with the measures taken to restore adequate gas exchange,
peripheral vein catheterization and the introduction of anticonvulsants (magnesium sulfate -
4 g bolus for 5 minutes intravenously, then maintenance therapy 1-2 g / h) under careful
control of blood pressure and heart rate. If the attacks continue, another 2 g of magnesium sulfate (8 ml
25%
solution) for 3-5 minutes. Instead of an extra bolus of magnesium sulfate, you can use
diazepam intravenously (10 mg) or thiopental sodium (450-500 mg) for 3 minutes.
If diastolic blood pressure remains at a high level (> 110 mmHg), antihypertensive therapy is performed.
As a hypotensive agent in patients, clonidine can be used: 0.5-1 ml of a 0.01% solution intravenously or
intramuscularly.
The drugs of choice for infusion therapy until delivery is isotonic saline
solutions (Ringer, NaCl 0.9%) (B). The condition for adequate infusion therapy is strict control.
volume of injected fluid and urine output. Diuresis should be at least 60 ml / h. The rate of fluid injection
should not exceed 85 ml / h. or hourly diuresis + 30 ml / h (s)

18. A woman in labor (38 weeks) with preeclampsia in the 2nd stage of
labor had convulsions, loss of consciousness. BP 160/110 mm Hg, Pulse
96 in 1 minute. The fetal head in the pelvic cavity. Fetal heartbeat
rhythmic muffled 100 beats in 1 minute.
1.Diagnosis:
Eclampsia - a seizure, fetal distress.
2. Duration:
Control Ps, BP, BH, Laboratory tests: blood test (platelets, hematocrit, hemoglobin, time
coagulation), total protein, albumin, glucose, urea, creatinine, transaminases, electrolytes,
the level of calcium, magnesium, fibrinogen and its degradation products , prothrombin and prothrombin
time,
urinalysis, daily proteinuria.
3. The differential diagnosis is carried out with epilepsy and other convulsive disorders (acute
cerebrovascular accident, encephalitis, meningitis, rupture of cerebral aneurysm, hysteria,
uremic coma). Differential diagnosis is based on the assessment of the following data: appearance
eclampic court in the second half of pregnancy in the presence of urinary retention, proteinuria, edema and
vascular hypertension.
4. Tactics
Delivery is carried out urgently. In the presence of conditions in childbirth through natural ways impose
obstetric forceps with adequate pain relief. If the obstetric situation does not allow
immediate delivery through the natural birth canal, perform a cesarean sect ion.
Delivery is carried out immediately after the elimination of an attack of seizures against the background of
continuous administration of sulfate
magnesium and blood pressure. Provided the seizure continues, emergency delivery is carried out after the
transfer
patient on mechanical ventilation.
• Treatment begins on the spot.
• Open an intensive care unit or hospitalize a pregnant woman in the anesthesiology department and
intensive care.
• Pregnant laid on a flat surface in position on the left side, quickly released
airways, opening the mouth and pushing the lower jaw forward, in parallel evacuate the contents
the oral cavity. If possible, if spontaneous breathing is maintained, an air duct is introduced and carried out
inhalation of oxygen.
• Forced ventilation with a nasal-facial mask with a supply of 100% oxygen in positive mode
pressure at the end of exhalation. If convulsions recur or the patient remains in a coma, enter
muscle relaxants and transfer the patient to mechanical ventilation (mechanical ventilation) in the mode of
moderate
hyperventilation.
• catheterize the central vein if it is necessary to control CVP, to control hourly urine output
catheterize - the bladder. According to indications - transnasal catheterization of the stomach.
• Catheterization of the peripheral vein, the introduction of anticonvulsants (magnesium sulfate is
administered in /
in a bolus for 5-100 min., 4 g of magnesium sulfate (16 ml of a 25% solution) is introduced, then
supporting
therapy 1-2 g / h, the maintenance dose is 2 g / hour (8 ml of a 25% solution), the daily dose is 24-30 g /
day)
under close monitoring of blood pressure and heart rate.
• Delivery is urgent. If there are conditions in childbirth through natural routes
impose obstetric forceps on the background of adequate analgesia. If the obstetric situation does not allow
conduct immediate delivery through the natural birth canal, perform a cesarean operation
section. Delivery is carried out immediately after the elimination of an attack of seizures aga inst the
background of continuous administration
magnesium sulfate and blood pressure. Provided the seizure continues, emergency delivery is carried out
after
transfer of the patient to mechanical ventilation.
5. Preparations, dosages.
After liquidation by the court, infusion therapy - solutions of hydroxyethyl starch (stabizol, reftan, 6%) in
a volume of 10-15 ml / kg, crystalloids

19. A pregnant woman with regular labor for 8 hours and vaginal
bleeding, which began 1 hour ago, admitted to the maternity ward.
Regarding pregnancy, the doctor not observed and was not examined.
Objectively: the skin is pale, BP 90/50 mm Hg, Ps - 102 in 1 min.
Contraction after 3-4 minutes for 25-30 seconds. The fetal heart rate of
100 beats / min., deaf. During a vaginal examination of the woman in
labor (39 weeks): opening the uterine cervix by 4 cm, the amniotic
membrane is not damaged, the spongy tissue is palpated through the
uterine cervix—allocations of bright red color with clots of 500 ml.
1. Unfavorable condition.
Placenta previa, marginal previa (the placenta is located in the lower segment below
present part and partially or completely overlaps the internal pharynx of the cervix)
2. Obstetric examination:
A. Cautious external obstetric examination: • high location o f the underlying part; • tone
the uterus is not elevated; • auscultation in the region of the lower segment can be determined by placental
noise • may
incorrect fetal position, or pelvic presentation. B. Examination of the cervix and vagina c
mirrors exclusively in a deployed operating environment: • eliminates other sources
bleeding (rupture of varicose nodes of the vagina, pseudo -erosion and cervical cancer).
B. Vaginal examination exclusively in a full operating room:
a. with the cervix closed • through the arch palpitations are palpitations, tissue pastiness, pulsation of blood
vessels;
high standing of the present part and the inability to palpate it;
b. when the cervix is opened at least 4-6 cm, the following is detected: • placental tissue - complete
presentation (placenta praevia totalis) • fruitful membranes and placenta tissue - lateral presentation
(placenta praevia lateralis) • fruitful membranes and the edge of the placenta - marginal presentation
(placenta praevia
marginalis) • rustling of the membranes - low attachment of the placenta.
In case of significant bleeding, clarification of the nature of the presentation does not make sense, since
obstetric tactics are determined by the volume of blood loss and the state of the pregnant.
4) Ultrasound examination has a high informative value in determining localization.
placenta and presentation.
3. Differential diagnosis is carried out with diseases that are accompanied by bleeding
from the genital tract:
• premature detachment of a normally located placenta (unlike placenta previa,
bleeding with severe pain, ultrasound data) • uterine rupture (bleeding with
severe pain, ultrasound data) • rupture of varicose nodes of the vagina (examination of the vagina
in the mirrors) • cancer and cervical erosion (examination of the cervix in the mirrors).
4. Tactics.
With blood loss of more than 250 ml, regardless of the degree of presentation, an urgent cesarean section.
5. Drugs.
Infusion is 200-300 ml / min.
Ringer's Ring, Acesol, Trisol - 10 ml / kg
Reftan 10 ml / kg
Freshly frozen plasma 5 ml / kg
Er. weight 5 ml / kg
After stabilization of blood pressure at a safe level, further infusion is carried out
slower - 150-100-50 ml / min, controlling CVP, blood pressure, diuresis, saturation.
If necessary, blood transfusion, suitable for group and Rh

20. Childbirth at 42 weeks of gestation ended with the use of low forceps
for fetal distress. Five minutes after the delivery of the placenta, the
woman started to have chills, she was agitated, there was a sudden
pallor of the skin, sharp chest pain, and noisy breathing. Blood pressure
80/50 mm Hg, heart rate 120 beats per 1 min, body T 38.60 С, SpO2
85%.
1.Restore emergency.
Cardiopulmonary shock, amniotic fluid embolism
2. Necessary examination methods for this pathology.
Laboratory signs - signs of hypocoagulation and increased ESR.
Additional research methods:
• ECG - sinus or paroxysmal tachycardia, myocardial hypoxia, acute pulmonary heart
• radiological changes are characterized by a picture of interstitial drainal pneumonitis (
“Butterfly” with densification along the entire basal zone and enlightenment of the lung tissue along the
periphery).
3. What diseases should be used for differential diagnosis?
Pulmonary embolism, myocardial infarction, Mendelssohn syndrome - acid-aspiration hyperergic
pneumonitis,
cerebral hemorrhage, eclampsia, bronchial asthma, uterine rupture,
premature detachment of a normally located placenta, fat embolism,
pulmonary edema, spontaneous pneumothorax.
4. Determine the tactics of emergency care.
Priority Activities:
1) When circulatory arrest - conducting cardiopulmonary resuscitation.
2) With an increase in signs of respiratory failure - intubation of the trachea and mechanical ventilation
with 100% oxygen with
positive pressure at the end of exhalation + 5 cm of water
3) Puncture and catheterization of the subclavian or internal jugular vein with mandatory control of CVP.
Collect 5 ml of blood to study the coagulogram and the presence o f amniotic fluid elements.
4) Bladder catheterization with a permanent catheter.
5. Indicate the dose and frequency of use of necessary medications.
Bronchodilators: aminophylline 240-480 mg, no-spa 2 ml, alupent, brikanil 0.5 mg dropwise, atropine 0.7-1
-
Membrane stabilizers: prednisone up to 300 mg, ascorbic acid 500 mg, troxevasin 5 ml, etamsylate
Na 250-500 mg, Essential 10 ml, cytochrome-C 10 mg, cyto-poppy 35 mg.
- Narcotic analgesics: Promedol 20-40 mg (morphine 10 mg).
- protease inhibitors: trasilol 400 thousand units, kontrikal 100 thousand units, gordoks, antagozan.
- antihistamines: diphenhydramine 10-20 mg (suprastin 20 mg, tavegil 2 ml).
- the use of heparin intravenously in a dose of 500-700 U / h.
1) If CVP <8 cm water. Art. - correction of hypovolemia by introducing colloids and crystalloids into
2: 1 ratio at a rate of 5 to 20 ml / min. depending on the level of blood pressure. In case of occurrence
bleeding in the composition of infusion therapy include freshly frozen plasma. Do not use 5%
albumen.
2) When CVP> 8 cm of water. Art. inotropic support is performed: dopamine (5 - 10 mcg / kg / min.) or
dobutamine (5
- 25 mcg / kg / min.). Isotropic therapy begins with minimal doses, and in the absence of effect - gradually
they are enlarged. It is advisable to use the combined introduction of dopamine (2-5 mcg / kg / min) and
dobutamine
(10 mcg / kg / min.).
3) The fight against coagulopathy.
4) Prevention of the development of infectious complications.

21. During an urgent cesarean section due to premature detachment of a

typically located placenta after removal of the fetus and placenta, the
woman's saturation suddenly decreased to 75%, a sharp pale skin, heart
tachycardia 110 beats per 1 min, chills. After a short period, bleeding
from the uterus and laparotomy wound began.
1. Set an emergency.
Amniotic fluid embolism. Early postpartum hemorrhage, hemorrhagic shock
(Ch-trauma to the uterus or delayed part of the placenta in the uterine cavity)
2. Necessary examination methods for this pathology.
1. Evaluation of the condition of the woman in childbirth: complaints, AO, pulse rate, color of the skin and
mucous membranes, the amount of urine,
the presence and stage of hemorrhagic shock.
2. Urgent laboratory examination:
• determination of the level of hemoglobin, hematocrit;
• coagulogram (platelet count, prothrombin index, fibrinogen level, time
blood coagulation)
• determination of blood type and Rh factor;
• biochemical examination according to indications.
3. What diseases should be used for differential diagnosis?
• hypotension or atony of the uterus (in 90% of cases);
• delay of parts of the placenta or membranes
• traumatic damage to the birth canal;
• bleeding disorders (afibrinogenemia, fibrinolysis)
• primary blood diseases.
4. Determine the tactics of emergency care.
1. Determination of the amount of blood loss. The most appropriate is the assessment of blood loss using
weighing.
2. Call for help
3. ABC - diagnosis (assessment of the respiratory tract, cardiovascular system - pulse, blood pressure, heart
rate)
4. The rule of 3 catheters:
• oxygen supply (10-15 l / min)
• catheterization of 2 peripheral veins with catheters
• catheterization of the bladder;
5. Position - on the back with raised lower limbs.
6. Ensuring the warming of women.
7. Urgently start infusion therapy
Infusion is 200-300 ml / min.
Ringer's Ring, Acesol, Trisol - 10 ml / kg
Reftan 10 ml / kg
Freshly frozen plasma 5 ml / kg
Er. weight 5 ml / kg
After stabilization of blood pressure at a safe level, further infusion is carried out
slower - 150-100-50 ml / min, controlling CVP, blood pressure, diuresis, saturation.
If necessary, blood transfusion, suitable for group and Rh.
Bronchodilators: aminophylline 240-480 mg, no-spa 2 ml, alupent, brikanil 0.5 mg dropwise, atropine 0.7-1
-
Membrane stabilizers: prednisone up to 300 mg, ascorbic acid 500 mg, troxevasin 5 ml, etamsylate
Na 250-500 mg, Essential 10 ml, cytochrome-C 10 mg, cyto-poppy 35 mg.
- Narcotic analgesics: Promedol 20-40 mg (morphine 10 mg).
- protease inhibitors: trasilol 400 thousand units, kontrikal 100 thousand units, gordoks, antagozan.
- antihistamines: diphenhydramine 10-20 mg (suprastin 20 mg, tavegil 2 ml).
- the use of heparin intravenously in a dose of 500-700 U / h.
1) If CVP <8 cm water. Art. - correction of hypovolemia by introducing colloids and crystalloids into
2: 1 ratio at a rate of 5 to 20 ml / min. depending on the level of blood pressure. In case of occurrence
bleeding in the composition of infusion therapy include freshly frozen plasma. Do not use 5%
albumen.
2) When CVP> 8 cm of water. Art. inotropic support is performed: dopamine (5 - 10 mcg / kg / min.) or
dobutamine (5
- 25 mcg / kg / min.). Isotropic therapy begins with minimal doses, and in the absence of effect - gradually
they are enlarged. It is advisable to use the combined introduction of dopamine (2-5 mcg / kg / min) and
dobutamine
(10 mcg / kg / min.).
3) The fight against coagulopathy.
4) Prevention of the development of infectious complications.
8. Abdominal compression of the aorta, not pneumatic anti-shock panties.
10. Establishing the cause of bleeding:
Atony, hypotension - administration of uterotonics (Oxytocin 10 IU / 500 ml of physiological saline with
60 drops / min), external massage of the uterus, manual examination of th e uterus.
the use of uterotonics of the second - 3rd line (ergometrine, prostaglandins, carbetocin),
in case of continued bleeding. The use of balloon tamponade and tranexam appointment
acid (1 g, repeat after 30 minutes if necessary),
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if bleeding continues
↓
- with a blood loss of 1.5% or more of body weight - laparotomy (use of organ-preserving
technologies - ligation of the main vessels (stepwise partial uterine devascularization),
compression sutures on the uterus, bilateral ligation of the internal iliac (hypogastric)
hysterctomy without appendages of the uterus
22. The maternity ward received a pregnant woman at 37 weeks of
gestation with complaints of lack of fetal movement within 3 days. As for
pregnancy, the doctor was not observed. Ultrasound is diagnosed with
complete placenta previa and antenatal fetal death. During cesarean
section, uterine bleeding and a postoperative wound bleeding occurred.
Lee-White coagulation time is more than 12 s, spontaneous clot lysis is
fast, APTT is 80 sec, platelets are 80 × 10 9 l, prothrombin time is 18
sec, thrombin time is 140 sec, fibrinogen is 1.5 g / l.
1. Set an emergency.
Obstetric hemorrhage with placenta previa, DIC
2. The necessary examination methods for this pathology:
a) vaginal examination: eliminates other sources of bleeding (varicose rupture
vaginal nodes, pseudo-erosion and cervical cancer, uterine rupture), b) ultrasound
3.Diagnosis with:
uterine rupture (bleeding with severe pain, ultrasound data) rupture of varicose nodes
vagina (examination of the vagina in the mirrors) with cancer and cervical erosion (examination of the
cervix in the mirrors).
4. Assistance: 5. Doses and multiplicity
blood loss determination
If necessary, CAB resuscitation measures
Oxygen therapy 6-10 l / min
BB access - 2 veins
volume recovery
Condition monitoring (AO, pulse oximetry, diuresis)
Stopping bleeding (Emergency - compression of the abdominal aorta, bimanual compression of the uterus ,
balloon tamponade. Medicated i / m administration of 10 units of oxytocin, kta aminocaproic 6% 100 ml
or 5-10 ml of 1% aminomethylbenzoic acid with intervals of at least 4 hours per need, 1-2 mg of vitamin K.
Surgical: relaparotomy and hysterectomy without appendages; internal iliac ligation
arteries by a specialist who has this operation.)
Infusion therapy: Ringer-lactate 10-15 ml / kg, gelofusin 10 ml / kg, freshly frozen plasma 5-10-15
ml / kg (depending on the volume of blood loss), erythrocyte mass 10-20 ml / kg, albumin 200+ ml
The introduction of platelet concentrate 1 unit per 10 kg (1 unit = 50 ml)
Contrical (or other drugs in equivalent doses) is administered to prisoners depending on the stage
DIC-syndrome by drip infusion for 1 - 2:00
Trazilol, OD 300000 - 500000
Kontrikal, OD - 100000 - 300000
Gordoks, OD - 1,000,000 - 4,000,000
2. Recovery of coagulation factors by the introduction of plasma cryoprecipitate (600 Units - IV stage)
If possible, it is recommended that the introduction of male recombinant factor VIIa (NovoSeven) - 60 - 90
mcg
/ kg (1 - 2 doses)

23. A woman in labor has placenta retention in the uterus; manual

removal of the placenta was performed. After this operation, the woman
suddenly started anxiety, coughing, sharp chest pains, shortness of
breath, chills. The skin is pale, blood pressure 85/50 mm Hg, pulse - 112
in 1 min.
1. Set an emergency.
Amniotic fluid embolism
2. Necessary examination methods for this pathology.
AS (hypocoagulation and increased ESR) ECG (sinus tachycardia, signs of myocardial hypoxia, acute
pulmonary heart), Ro (picture of interstitial drainal pneumonitis -
"Butterfly" with a seal pattern in the basal zone and its enlightenment on the periphery).

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3. What diseases should be used for differential diagnosis?
Pulmonary embolism, myocardial infarction, Mendelssohn syndrome - acid-aspiration hyperergic
pneumonitis,
cerebral hemorrhage, eclampsia, bronchial asthma, uterine rupture,
premature detachment of a normally located placenta, fat embolism,
pulmonary edema, spontaneous pneumothorax.
4. Determine the tactics of emergency care.
1. Transition to mechanical ventilation with positive pressure at the end of exhalation + 5 cm of water. Art.
2. Catheterization of 2-3 veins.
3. Catheterization of the bladder.
4. Call reserve donors.
5. Indicate the dose and frequency of use of necessary medication s.
- Bronchodilators: aminophylline 240-480 mg, no-spa 2 ml, alupent, brikanil 0.5 mg dropwise, atropine
0.7-1 -
Membrane stabilizers: prednisone up to 300 mg, ascorbic acid 500 mg, troxevasin 5 ml, etamsylate
Na 250-500 mg, Essential 10 ml, cytochrome-C 10 mg, cyto-poppy 35 mg.
- Narcotic analgesics: Promedol 20-40 mg (morphine 10 mg).
- protease inhibitors: trasilol 400 thousand units, kontrikal 100 thousand units, gordoks, antagozan.
- antihistamines: diphenhydramine 10-20 mg (suprastin 20 mg, tavegil 2 ml).
- the use of heparin intravenously in a dose of 500-700 U / h.
- When CVP <8 cm of water. B - correction of hypovolemia by introducing colloids and crystalloids in a
ratio of 2:
1 at a rate of 5 to 20 ml / min. depending on the level of blood pressure. In case of bleeding in the
composition
infusion treatments include freshly frozen plasma (C).
- When CVP> 8 cm of water. Art. inotropic support is performed: dopamine (5 - 10 mcg / kg / min.) or
dobutamine (5 -
25 mcg / kg / min.). Isotropic therapy begins with minimal doses, and in the absence of effect - gradually
they are enlarged.

24. A pregnant woman (gestational age 34 weeks) admitted to the

department of pregnancy pathology due to premature detachment of a
typically located placenta. Ultrasound revealed a small retro placental
hematoma. The woman complained of sharp chest pain, chills, a sense
of fear. Objectively: the skin is pale, noisy breathing, blood pressure
95/50 mm Hg, pulse - 116 in 1 min.
1. Set an emergency.
Amniotic fluid embolism
2. Necessary examination methods for this pathology.
AS (hypocoagulation and increased ESR) ECG (sinus tachycardia, signs of myocardial hypoxia, acute
pulmonary heart), Ro (picture of interstitial drainal pneumonitis -
"Butterfly" with a seal pattern in the basal zone and its enlightenment on the periphery).
3. What diseases should be used for differential diagnosis?
Pulmonary embolism, myocardial infarction, Mendelssohn syndrome - acid-aspiration hyperergic
pneumonitis,
cerebral hemorrhage, eclampsia, bronchial asthma, uterine rupture,
premature detachment of a normally located placenta, fat embolism,
pulmonary edema, spontaneous pneumothorax.
4. Determine the tactics of emergency care.
1. Transition to mechanical ventilation with positive pressure at the end of exhalation + 5 cm of water. Art.
2. Catheterization of 2-3 veins.
3. Catheterization of the bladder.
4. Call reserve donors.
5. Terminological delivery by caesarean section
5. Indicate the dose and frequency of use of necessary medications.
- Bronchodilators: aminophylline 240-480 mg, no-spa 2 ml, alupent, brikanil 0.5 mg dropwise, atropine
0.7-1 -
Membrane stabilizers: prednisone up to 300 mg, ascorbic acid 500 mg, troxevasin 5 ml, etamsylate
Na 250-500 mg, Essential 10 ml, cytochrome-C 10 mg, cyto-poppy 35 mg.
- Narcotic analgesics: Promedol 20-40 mg (morphine 10 mg).
- protease inhibitors: trasilol 400 thousand units, kontrikal 100 thousand units, gordoks, antagozan.
- antihistamines: diphenhydramine 10-20 mg (suprastin 20 mg, tavegil 2 ml).
- the use of heparin intravenously in a dose of 500-700 IU / h. Heparin can be administered with glucose
and
reopoliglyukin (in this case, anticoagulation and antithrombotic effects are potentiated).
- When CVP <8 cm of water. B - correction of hypovolemia by introducing colloids and crystalloids in a
ratio of 2:
1 at a rate of 5 to 20 ml / min. depending on the level of blood pressure. In case of bleeding in the
composition
infusion treatments include freshly frozen plasma (C).
- When CVP> 8 cm of water. Art. inotropic support is performed: dopamine (5 - 10 mcg / kg / min.) or
dobutamine (5 -
25 mcg / kg / min.). Isotropic therapy begins with minimal doses, and in the absence of effect - gradually
they are enlarged. It is advisable to use the combined introduction of dopamine (2-5 mcg / kg / min) and
dobutamine
(10 mcg / kg / min.

25. A pregnant woman delivered to the perinatal center with partial

placenta previa. Gestational age 35 weeks. From relatives, it knew that
blood loss is about 1.2 liters (1.5% of body weight). Bleeding continues.
The woman is weak. The skin is pale. BP 90/50 mm Hg, pulse - 112 in 1
min.
1. Set an emergency.
Partial placenta previa, hemorrhagic shock II century.
2. Necessary examination methods for this pathology.
Anamnesis, AS, coagulation, external obstetric examination (in the expanded operating room),
ultrasound. AT
In this case, an obstetric examination does not make sense, due to the rapid deterioration of the pregnant
woman’s condition and
fetus.
3. What diseases should be used for differential diagnosis?
- Premature detachment of a normally located placenta (unlike
placenta previa, bleeding with severe pain, ultrasound data)
- Uterine rupture (bleeding with severe pain, ultrasound data)
- Rupture of varicose nodes of the vagina (examination of the vagina in the mirrors)
- Cancer and cervical erosion (examination of the cervix in the mirrors).
4. Determine the tactics of emergency care.
In the case of small blood loss (up to 250 ml), the absence of signs of hemodynamic impairment,
fetal distress, lack of labor, fetal lung immaturity with
pregnancy up to 37 weeks - a wait-and-see tactic.
In this case, an urgent delivery by caesarean section, hemotransfusion therapy.
5. Indicate the dose and frequency of use of necessary medications.
Infusion is 200-300 ml / min.
Ringer's Ring, Acesol, Trisol - 10 ml / kg
Reftan 10 ml / kg
Freshly frozen plasma 5 ml / kg
Er. weight 5 ml / kg
After stabilization of blood pressure at a safe level, further infusion is carried out
slower - 150-100-50 ml / min, controlling CVP, blood pressure, diuresis, saturation.
If necessary, blood transfusion, suitable for group and Rh.

26. Maternal hypotension in the uterus occurred in the early postpartum

period. Blood loss was 1.5 L (1.8% of body weight). The uterus
periodically relaxes, and bleeding resumes. Blood secreted from the birth
canal does not clot. The skin is pale. BP 90/40 mm Hg, pulse - 120 in 1
min.
1. Set an emergency.
Uterine hypotension, hemorrhagic shock of the II century, DIC
2. Necessary examination methods for this pathology.
AS (platelet count, hemoglobin, hematocrit) + bleeding time,
coagulation express - test, coagulogram, group and Rh factor, biochemical analysis
blood, examination of the birth canal, manual examination of the uterus.
3. What diseases should be used for differential diagnosis?
Thrombocytopathy (von Willebrand disease, Glanzmann thrombasthenia
and acquired medicinal thrombocytopathy, idiopathic thrombocytopenic purpura), rupture
uterus, rupture of the cervix, eversion of the uterus, malignant neoplasms.
4. Determine the tactics of emergency care.
1) Catheterization of peripheral (or / and central).
2) Stool of the bladder.
3) The introduction of uterotonic agents: oxytocin and / or ergometrine.
4) Manual examination of the uterus under intravenous anesthesia (assessment of uterine integrity,
especially the left wall, the removal of blood bundles, the remains of the placenta and membranes).
5) Overview of the birth canal and suturing of gaps.
6) In the case of continued bleeding - misoprostol 800 mcg rectally or \ and carboprost.
7) Temporary bimanual compression of the uterus.
11) Recovery of bcc and blood loss.
12) Surgical intervention (in case of continued bleeding after our actions) in the amount
hysterectomy without appendages, and if necessary - ligation of the internal iliac arteries.
13) In the case of continued bleeding after hysterectomy - tight abdominal tamponade
cavity and vagina (do not suture the abdominal cavity until bleeding stops).
5. Indicate the dose and frequency of use of necessary medications.
Kontrikal or Trazizol (20 - 60 thousand. Up to 500 tons. UNITS, depending on the stage of ICE)
NovoSeven - 60-90 mcg / kg (1-2 doses)
10 units of oxytocin i / m or iv in 400 ml of physiological solution, 60 drops / min.
0.2 mg ergometrine every 15 min, max 1.0 mg.
Misoprostol 800 mcg rectally or Karboprost 0.25 mg IM, repeated every 15 minutes, but not more than
2 mg
Infusion is 200-300 ml / min.
Ringer's Ring, Acesol, Trisol - 10 ml / kg
Reftan 10 ml / kg
Freshly frozen plasma 5 ml / kg (jet injection heated to 37 *) + cryoprecipitate 200 PIECES
Er. weight 5 ml / kg
After stabilization of blood pressure at a safe level, further infusion is carried out
slower - 150-100-50 ml / min, controlling CVP, blood pressure, diuresis, saturation

27. Pregnant delivery by cesarean section for fetal distress against

gestational pyelonephritis. The postoperative period complicated by
endometritis. Objectively: blood pressure 80/50 mm Hg, pulse - 120 in 1
min., BH 25 in 1 min, diuresis 30 ml / h, petechial rash on the skin.
Clinical blood test: Hb 75 g / l, white blood cells - 15 109 / l, stab
neutrophils - 25%, platelets - 150 109 / l.
1. Set an emergency.
Sepsis. Septic shock?
2. Necessary examination methods for this pathology.
AS, BCh blood, the pathogen hung on a nutrient medium, CAS, stool control, monitoring of blood
pressure, FM, ECG
(determination of metabolic disorders of the myocardium), thermometry, ultrasound OBP (in order to
detect abscesses)
3. What diseases should be used for differential diagnosis?
-/-
4. Determine the tactics of emergency care.
1. Immediate hospitalization in the intensive care unit.
2. Correction of hemodynamic disturbances through inotropic therapy and adequa te
infusion therapy with constant monitoring of hemodynamics.
3. Maintaining adequate ventilation and gas exchange (IVL)
4. Surgical rehabilitation of the site of infection;
5. Normalization of bowel function and early enteral nutrition.
6. Timely correction of metabolism under constant laboratory control.
7. Antibacterial therapy under constant microbiological control.
8. Anti-mediator therapy.
With endomyometritis, it does not respond to conservative treatment (24-48 hours) - removal of the uterus;
5. Indicate the dose and frequency of use of necessary medications.
- derivatives of hydroxyethyl starch (Venofundin, reftan, KhNPP-steril) and crystalloids (0.9% solution
sodium chloride, Ringer's solution) in a ratio of 1: 2 - 10 ml / min for 15-20 minutes, further in
keeping pace.
- freshly frozen plasma of 600 - 1000 ml.
- dopamine in a dose of 5 - 10 mcg / kg / min. or dobutamine, which is administered at a rate of 5 to 20 mcg
/ kg / min.,
sympathomimetic therapy is supplemented by the administration of norepinephrine hydrotartrate at a rate of
0.1 - 0.5 mg
/ kg / min At the same time, reducing the dose of dopamine to the "renal" (2 - 4 μg / kg / min.)
- hydrocortisone - 200-300 mg per day (with the ineffectiveness of previous measures)
- AB therapy (empirically to determine the type of pathogen) semisynthetic penicillins,
cephalosporins II generation + aminoglycosides + imidazoles) combined double
antibiotic therapy (clindamycin + aminoglycosides), monoantibiotic therapy (cephalosporins III
generations, carbopenems, ureidopenicillins, aminopenicillin, fluoroquinolones of the fourth generation)

28. A 40-year-old pregnant woman has a stomach ulcer. In the

gestational age of 11 weeks, she developed a clinic of acute
gastrointestinal bleeding. In shock, a pregnant woman hospitalized in the
surgical department.
1. Set an emergency.
VhSh, gastrointestinal bleeding, hemorrhagic shock.
2. Necessary examination methods for this pathology.
Anamnesis, palpation of OBP, AS, CAS, coagulogram, ankala for occult blood , FGDS, ultrasound, X-ray,
CT.
3. What diseases should be used for differential diagnosis?
Acute appendicitis. Acute pancreatitis. Acute cholecystitis. Acute intestinal obstruction.
4. Determine the tactics of emergency care.
1) Support for the passage of the VDP. Catheterization of the veins.
2) transfusion therapy to replenish bcc.
3) Measures aimed at maintaining pregnancy (antispasmodics, vitamin therapy, hormonal
drugs (gestagens).
4) Endoscopy with an attempt to stop the bleeding, if it fails then -
5) Surgical intervention - suturing of the perforated hole or resection of the stomach or bilateral
stem vagotomy.
6) In the presence of diffuse peritonitis, termination of pregnancy.
5. Indicate the dose and frequency of use of necessary medications.
Omeprazole or pantoprazole in an injection of 80 mg (2 amp.), Then - in a continuous infusion of 8 mg / h
for 3 days
(also after endoscopic cessation of bleeding).
Infusion is 200-300 ml / min.
Ringer's Ring, Acesol, Trisol - 10 ml / kg
Reftan 10 ml / kg
Freshly frozen plasma 5 ml / kg
Er. weight 5 ml / kg
After stabilization of blood pressure at a safe level, further infusion is carried out
slower - 150-100-50 ml / min, controlling CVP, blood pressure, diuresis, saturation
Progesterone 10-25 mg / day.

29. Pregnant 30 years old, second full-term pregnancy hospitalized in the

perinatal center with active labor and complaints of suffocation,
palpitations, rapid fatigue. For anamnesis: frequent tonsillitis, acute
respiratory viral infections, from 16 years old rheumatism in the inactive
phase, mitral stenosis of the II degree, circulatory failure II A degree.
Contractions in 1-2 minutes for 35-40 seconds. Fetal heartbeat rhythmic
154 beats in 1 min. In vaginal examination: the cervix is fully dilated, the
amniotic membrane is intact, the fetal head presented with a large
segment at the entrance to the small pelvis, the of the sacropromontory
is not reached.
1. Set an emergency.
Acute heart failure (acute left ventricular heart failure).
2. Necessary examination methods for this pathology.
AS CAS, coagulogram, AO, saturation, ECG, Echo, X-ray analysis of OGK.
3. What diseases should be used for differential diagnosis?
AD, myocardial infarction, amniotic fluid embolism, pulmonary embolism.
4. Determine the tactics of emergency care.
Peripheral catheterization.
Heart rate control, heart rate, saturation, blood pressure.
We deliver with the exception of the AI period (accelerated delivery by imposing obstetric
forceps) or Caesarean section.
5. Indicate the dose and frequency of use of necessary medications.
Sublingual nitroglycerin 1-2 tabs (0.3-0.6 mg) at intervals of 5 minutes. 3-4 times with simultaneous iv
infusion of 20 mg per 200 ml of saline solution of 5-7 drops per min.
Pentamine 5% po1ml in 9 ml of physical solution on / in titrated in 1-2 ml under the control of blood
pressure.
Furosemide 20-80mg iv
Prednisolone 60-120mg (in the absence of an increase in blood pressure)
Diphenhydramine 1% 1-2 ml iv
Morphine sulfate 3-5 mg iv for 3 minutes, Promedol 25 1-2 ml, fentanyl 0.005% 2 ml.
Dopamine 0.5-2 μg / kg per 1 min
Digoxin 0.025% 1-2 ml

30. A 24-year-old woman admitted to the gynecological department for

artificial abortion of pregnancy in term of 7 weeks. A history of one birth,
four abortions, the latter ended in acute endometritis. During the
instrumental abortion, the curette penetrated the uterine cavity to a depth
of more than 12 cm, bleeding increased, and removal of the fetal egg not
completed.
1. Set emergency:
Perforation of the uterus
2. Necessary examination methods for this pathology
Anamnesis (penetration of instruments to a depth exceeding the expected length of the uterine cavity)
measurement of blood pressure, heart rate, heart rate, temperature;
ZAK (anemia, in some cases leukocytosis, elevated ESR) ultrasound (detected fluid in an ectopic
space) Coagulogram, group and Rh factor of the blood.
3. What diseases should be used for differential diagnosis?
Malignant and benign neoplasms, abnormalities of the uterus.absec fıbroıd ,cyst,
4. Determine the tactics of emergency care.
Peripheral vein catheterization + urinary catheter placement
hemodynamic control
Infusion therapy (volume, rate of administration of solutions) depends on the stage of hemorrhagic shock,
anesthesia, hemostatics
Immediate surgical intervention (lower middle laparatomy, organ revision
abdominal cavity, supravaginal amputation of the uterus without appendages (or suturing perforation
holes).
5. Indicate the dose and frequency of use of necessary medications.
Premedication: Sibazon 0.5% 2 ml atropine sulfate 0.1% 0.5 ml
Analgin 50% - 2.0+ diphenhydramine 1% - 1.0 v \ m 3 r / day
Ketanov 10 mg / m 2p / d,
Promedol 2% - 1 ml / m with analgin inefficiency
Hemostatic agents - calcium chloride or gluconate 10% -10ml intravenously; aminocaproic
acid 5% 100 ml w / w cr. Vicasol solution 1% -1ml intramuscularly 2 times a day; Dist Dicinon 2-4
ml intravenously
Crystalloids (fiz.rozchin, ringer Ringer) -7-10ml \ kg
Synthetic colloids (Reftan, Gelofusin) 10-15 ml / kg
Proserin 0.05% 1.0x 2 times a day IM
Antibiotic therapy - Cefatoxime 1.0 -3 r / d iv

31. In a 36-year-old woman, profuse blood spotting from the vagina

observed for two weeks. Such a violation of the menstrual cycle arose for
the first time. A history: polycystic ovarian syndrome, infertility, IVF, and
one pregnancy, which ended in childbirth. Objectively: BMI 35, blood
pressure 130/90 mm Hg, Ps 78 in 1 min, Hb 120 g / l. During a
gynecological examination: the cervix is cylindrical, the blood is plentiful,
the uterus is normal size, the appendages of the uterus on both sides are
slightly enlarged painless.

dysfuctıonal uterıne bleedıng

cbc hb decreased rbc decreased

beta hcg
tyhroıd fuctıon test
ddx: ectepıc pregnancy
patogenıc cause
fıbroıds
uterıne sarcoma
treatment : ıv fluıd rınger solutıon
amınovapronuc acıd , trexanıc asıd
oral contraceprıces

32. A 22-year-old woman admitted to the gynecological department with

complaints of pain in the lower abdomen, which arose suddenly during
classes in a fitness club. From the anamnesis: last menstruation two
weeks ago, there were no pregnancies. She denies gynecological
diseases. The skin is pale pink, blood pressure 120/80 mm Hg, pulse 80
in 1 min, body T 36.7 C. The abdomen on palpation is painful, a negative
symptom of Shchetkin-Blumberg. In the vaginal examination: the uterus
and right appendages are not enlarged, sharply painful appendages on
the left. The vaginal fornix is deep.

Torsıon of ovary

Addıctıonal test

Ultrasounf ,ct,mrı
Ovary cyct, appencıtısı, pıd,ectopıc pregnancy

Treatment: analgesıc morphunes

Surgery,laparoscopy

33. A 27-year-old woman who was in the gynecological department with

suspected ectopic pregnancy suddenly lost consciousness. In the
anamnesis: the menstrual cycle is regular, one childbirth, suffered acute
gonorrheal salpingitis, does not use contraceptives. Objectively: the skin
is pale, moist, blood pressure 80/50 mm Hg, pulse 120 in 1 min, the
abdomen is tense, painful on palpation in the lower parts, there is also a
positive symptom of Shchetkin-Blumberg. A gynecological examination is
difficult due to muscle tension in the anterior abdominal wall; the
posterior vaginal fornix is sharply painful, bulging.

Hemarrhagıc shock due to rupture of ectopıc pregnancy

Addıctıona methots

Ultrasound, cbc,hb dec,rbc dec

Level of gonotoprın levels

Curretage

Ddx :fıbroıds ,pıd,neoplasm,polyp,ovaryn cyct ,splenıc rupture ,

Treatment: cab

Gıve catheterızatıon

Colloıd and crystalloıd

Emergency laparatomy

34. A 37-year-old woman has abundant bleeding for two weeks, which
began seven days earlier than the next menstrual period. The patient
associates this with the stress suffered the day before. Two months ago,
in the same situation, she underwent a diagnostic curettage of the walls
of the uterine cavity. The result of the histological examination is a simple
atypical endometrial hyperplasia. Somatically healthy. She is Para 2;
there were no abortions. Gynecological diseases denied. BP 120/80 mm
Hg, pulse 76 in 1 min, BMI - 25, Hb 115 g / l. Has no bad habits.

Menometturrhage

Addıtıonal methods : ultrasound ,hystenoscopy,mrı,ct scan,pelvıc exam,

Ddx: polyps,fıbroıds ,coagulatıons dısorder,

Treatment :surgery,dılatatıon and curretage

35. A teenager of 14 years with abundant blood flow was admitted to the
gynecological department for two weeks during the next menstruation.
Menarche at 13 years old; the menstrual cycle is irregular. They were
repeatedly treated on this occasion and moderate anemia. Objectively:
the skin is pale pink, moist, blood pressure 120/70 mm Hg, Ps 82 per 1
min, the abdomen is soft, painless, menstrual flow abundant, Hb 110 g /
l. Ultrasound of the uterus and appendages of the pathology was not
detected. Conducted symptomatic therapy is ineffective, bleeding
continues.

Juvelıne uterıne bleedıng

cbc hb decreased rbc decreased

beta hcg
tyhroıd fuctıon test
ddx: ectepıc pregnancy
patogenıc cause
fıbroıds
uterıne sarcoma
treatment : ıv fluıd rınger solutıon
amınovapronuc acıd , trexanıc asıd
oral contraceprıces

36. A 38-year-old woman complains of severe cramping pains in the

lower abdomen, profuse blood discharge from the genital tract. In the
anamnesis: the menstrual cycle is regular 28 days, during one year of
menstruation, plentiful for seven days, the last menstruation three weeks
ago. Childbirth 2, spontaneous abortion - 1, she does not use
contraception, she was not pregnancy. On speculum examination, it
found that pink tissue with a diameter of 3 cm visualized in the external
os. The body of the uterus is not enlarged, dense, painful. Uterine
appendages are not enlarged, painless. The vaginal vault is deep.

Cervıcal ectopıc

37. A woman came to the gynecological department complaining of a

delay in menstruation for two weeks, small blood discharge from the
genitals, pain in the lower abdomen, more on the left, vomiting,
weakness. In anamnesis: chronic salpingitis. In a bimanual examination:
the uterus is slightly enlarged, softened, the appendages on the left are
enlarged, painful on palpation. The posterior vaginal fornix is bulging.
The reaction to chorionic gonadotropin is positive. An ultrasound
examination: of the fetal sac in the uterus was not found. The left
fallopian tube is enlarged, the contents in the cavity are inhomogeneous.
Free fluid in the cul-de-sac.

Hemarrhagıc shock due to rupture of ectopıc pregnancy

Addıctıona methots

Ultrasound, cbc,hb dec,rbc dec

Level of gonotoprın levels

Curretage

Ddx :fıbroıds ,pıd,neoplasm,polyp,ovaryn cyct ,splenıc rupture ,

Treatment: cab

Gıve catheterızatıon

Colloıd and crystalloıd

Emergency laparatomy

38. A 38-year-old patient delivered urgently, with complaints of weakness

and pain in the lower abdomen, which radiates to the rectum. Complaints
appeared suddenly after intercourse. The last menstrual period two
months ago. The skin is pale, pulse - 102 in 1 min., Body temperature
36.9 0 C, blood pressure - 90 \ 60 mm Hg. The abdomen is tense, painful
in the lower parts; the symptoms of peritoneal irritation are positive.
During vaginal examination: the uterus is slightly enlarged, appendages
on the right are sausage-shaped 3x6 cm, painful on palpation, the
posterior vaginal fornix bulge. The uterine appendices on the left are
unchanged.

Juvelıne uterıne bleedıng

cbc hb decreased rbc decreased

beta hcg
tyhroıd fuctıon test
ddx: ectepıc pregnancy
patogenıc cause
fıbroıds
uterıne sarcoma
treatment : ıv fluıd rınger solutıon
amınovapronuc acıd , trexanıc asıd
oral contraceprıces

39. A 47-year-old woman referred to the doctor of the women's

consultation. She has complaints of pain in the lower abdomen, which
bothered her for 15 days. Within five days, the patient took no-spa,
diclofenac, amoxicillin. There was no improvement. History: medium-
sized nodular uterine leiomyoma, cervical ectropion. Objectively: body
temperature 37.80 C, blood pressure 120/80 mm Hg, Ps 88 in 1 min. The
abdomen is painful upon palpation in the lower abdomen; the symptoms
of peritoneal irritation are positive in the iliac regions. A gynecological
examination revealed that the uterine body enlarged as in an 8-week
pregnancy, tuberous due to myomatous nodes, sharply painful in the
area of one of them. Uterine appendages not enlarged. In the clinical
analysis of blood Hb 110 g / l, white blood cells 11x10 9 / l, ESR 20 mm /
hour.

Infected fıbroıd wıth perıtonıtıs

Addıtıonal methots :pelvıc exam,ultraound,mrı,

Ddx:adenomysosıs,ectopıc pregnancy,endometrıod polyp,endometrıol

carcınoma ,endometrıosıs

Treatment :anelgesıs for paın

Emergency laparatomy,uterıne artey embolısm

40. A 29-year-old woman was hospitalized in the gynecological

department complaining of severe pain in the lower abdomen, which
arose suddenly, nausea, vomiting, chills. There was no history of
pregnancy, chronic salpingo-oophoritis with frequent exacerbations.
Objectively: the general state of moderate severity, body temperature
38.50 C, abdomen sharply painful in all departments, positive symptoms
of peritoneal irritation. Gynecological examination to the left of the uterus
revealed a tumor-like formation with fuzzy contours due to adhesions
with adjacent organs. The posterior vaginal vault is overhanging. Vaginal
discharge purulent. Clinical blood test: hemoglobin 110 g / l, white blood
cells 16x109 / l, stab neutrophils 25%, ESR 30 mm / hour.

Perıtonıtıs Secondary of recurrent pelvıc ınflammatıon dısease

Addıtıonal methots :ultrasound,ct,blood culture,urıne test

Ddx:appendıatıs,endometrıoısıs,ovarıan torsıon,adrenal tumors

Treratment : analgetıcs ,emegercy laparactomy,broad spectrum

antobıotıcs

41. A 29-year-old patient complains of acute pain in the lower abdomen,

nausea, and vomiting. Objectively: blood pressure - 120 \ 80 mm Hg,
pulse - 108 in 1 min., body temperature 380 C. The tongue is densely
lined with white coating, the abdomen is evenly swollen, sharply painful
in the lower sections. Symptom Shchetkina-Blyumberg positive. Vaginal
examination: the body of the uterus is not enlarged, mobile, painless. To
the right of the uterus, a formation of 7 x 7 cm is palpated, of a tight-
elastic consistency, sharply painful. Left appendages are not detected.

Pelvıc ınflamatory dısease complıcated wıth perıtonıtıs

Addıtıonal methots :ultrasound,ct,blood culture,urıne test

Ddx:appendıatıs,endometrıoısıs,ovarıan torsıon,adrenal tumors

Treratment : analgetıcs ,emegercy laparactomy,broad spectrum

antobıotıcs

42. Thirty-six years old woman, sixth pregnant was admitted. The labor
activity lasts since 4 hours ago. The fetus's position is transverse; the
fetal head palpated on the left, buttocks - on the right. Five liters of
amniotic fluid poured out two hours ago. A fetal arm sticks out of the
vagina. The fetal heart rate is not determined. On vaginal examination:
the cervix is fully open, the amniotic sac is absent, the fetal shoulder and
arm presentation in the pelvic cavity.

Antenatal dıscharge of amnıotıc fluıd wıth shoulder presentatıon

Addıtıonal dıagnosıs : ultrasound,leopolds manouvers,dıgıtal cervıcal

exam

Treatment : cs

43. A 32-year-old pregnant woman was hospitalized in the gynecological

department with cramping pains in the lower abdomen and uterine
bleeding with a gestational age of 10 weeks. Objectively: the general
condition is severe, the skin is pale, heart rate is 100 beats/min, blood
pressure is 95/50 mm Hg, body t is 36.0. The abdomen is soft, painful
over the bottom. Symptoms of peritoneal irritation are negative. In a
vaginal examination: the uterine body is increased to 8 weeks of
pregnancy, painful, the cervix admit two fingers. Uterine appendages are
not enlarged. The vaginal arches are deep. No infiltrates found in the
pelvis. Abundant blood discharge with clots.

Ineutable ıncomplete abortıon

Addıtıonal :cbc hb dec, rbc dec,

Ddx: complete abortıon ,ıneretable abortıon,ıncomplete abortıon

,theatenede abortıon

Treatment : dsc

44. In the third stage of the fourth urgent birth, no signs of separation of
the placenta. The uterus is relaxed—the Krede-Lazarevich method used
to remove the placenta. Suddenly, the woman felt a sharp pain in her
abdomen, lost consciousness. A soft, bright red formation, on which the
placenta is locating, hangs from the vagina.

45. A mother with a mitral valve insufficiency after a cesarean section on

day 1 complained of coughing, chest pain, aggravated by breathing.
Noteworthy is cyanosis of the skin of the face, rapid and shallow
breathing, heart rate of 120 beats/min, blood pressure 95/50 mm Hg,
body t 38.0. The abdomen is soft, painless. The wound dressing is dry.
The uterus is dense, painless, the uterine fundus 4 cm below the navel—
Lochia bloody moderate.

Cardıopulmonary shock

Addıtıonal cbc,ecg,angıography ,x ray

Ddx: acute coranary syndrome,hemorragıc shock ,systemıc ınfalamtory

response syndrome

Treatment : ıv fluıd ,blood tranfusıon,epınefrın ,dopamıne ,collogen

,crystaloıd

46. In the first period of urgent birth, a woman in labor is excited.

Contractions of a convulsive nature, painful, the uterus practically does
not relax, is overstretched, painful on palpation. Contraction ring at the
navel. The palpation of the fetus is difficult due to uterine tension.
Arrhythmic fetal heartbeat clearly 180 beats in 1 minute. Within 2 hours
with the full opening of the cervix, the advancement of the fetal head
does not occur. Urine excreted with a catheter - with blood. Vaginal
discharge bloody moderate.

Rısk of uterıne

47. The first period of urgent delivery lasts 10 hours; the amniotic fluid
flowed 3 hours ago. The woman in labor was anxious, agitated,
complained of sharp abdominal pain. Uterus painful on palpation
acquired an asymmetric shape. The fetus is palpated outside the uterus.
The fetal heart rate is not heard. Vaginal discharge bloody moderate

Early dıscharge of amnıotıcs fluıd .

48. On the 2nd day after an emergency cesarean section, a woman

presented with the following threatening symptoms: temperature up to
39.3 °C, heart rate - 110 beats per 1 minute, Respiration Rate -26 in 1
minute. Laboratory: platelets - 90 * 109/l, elevated levels of C-reactive
protein, circulating microorganisms in the blood culture, test for
endotoxin is positive.

Septıc shock

49. The woman in labor is 35 years old. In the history of 1 birth, there
were no abortions: weight 80 kg, height 164 cm. The second urgent
physiological birth ended in the birth of a healthy baby weighing 3800.0
g, height 54 cm. After the delivery of the placenta, uterine bleeding
increased; blood loss was 400 ml and continues. The uterus is soft,
shrinks when massaged, becomes dense—the fundus of the uterus - at
the level of the navel.

Atony of uterus

50. Pregnant 36 years old delivered unconscious. Pregnancy 35 weeks,

was not registered for pregnancy in the antenatal clinic,. It is known that
even before pregnancy, there was a periodic increase in blood pressure,
the last week's swelling of the limbs, and face. According to her husband,
the pregnant woman suddenly fell unconscious; there were cramps.
Objectively: clonic convulsions of the extremities, bitten tongue, blood
pressure 200/120 mm Hg The uterus is in good shape. Fetal heart rate
deaf rhythmic 70 beats in 1 minute

eclampsıs