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"description": "<p><span id=\"docs-internal-guid-1960a8f1-7fff-6a6b-b94c-0d161ba0d17e\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Угрожающий аборт - это вагинальное кровотечение без раскрытия зева шейки матки, происходящее в течение этого периода времени, и указывающее на возможность спонтанного аборта у женщины с подтвержденной внутриматочной беременностью жизнеспособным плодом.</span></span></p>",
"etiology": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Спонтанная угроза прерывания беременности малого срока у 50% пациенток связана с хромосомными аномалиями эмбриона. После 16 недели угрожающий выкидыш является следствием генетических дефектов в 10% случаев. Чем меньше срок гестации, тем выше вероятность, что угрожающий аборт перейдет в самопроизвольный выкидыш. Инфекция способна вызвать нарушение развития плодного яйца и угрожающий аборт при хроническом эндометрите, вирусном инфицировании во время вынашивания ребенка. Опасность выше на раннем сроке, пока не сформирована плацента, выполняющая роль защитного фильтра.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Выделяют факторы, которые достоверно увеличивают риск угрожающего аборта. Они связаны с эндогенными состояниями, особенностями образа жизни будущей матери. Большое значение имеют перенесенные острые и хронические заболевания, а также действие внешних раздражителей и патогенов. Эти факторы учитывают при постановке женщины на учет у акушера-гинеколога и ведении беременности:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Возраст матери. У женщин 20-30 лет угрожающий аборт возникает в 9-15%, после 30 лет этот показатель увеличивается до 20%, а у 45-летних - до 80%. Молодые девушки до 18 лет также часто сталкиваются с развитием угрозы прерывания гестации из-за незрелой гипоталамо-гипофизарной системы, физиологической дисфункции яичников.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Эндокринные заболевания матери. Патология щитовидной железы, некомпенсированный сахарный диабет, синдром поликистозных яичников вызывают эндокринные изменения, ухудшающие состояние эндометрия, выработку гормонов желтого тела яичников. Ожирение приводит к изменению синтеза стероидных гормонов, что ведет к их дисбалансу.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Потери беременности в анамнезе. У женщин с привычным невынашиванием риск составляет 30%. Если в анамнезе были нормальные роды и отсутствуют спонтанные выкидыши, то риск прерывания гестации у беременной всего 5%.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Прием лекарственных средств. Использование лекарственных препаратов с тератогенным действием (ретиноиды, антикоагулянты), большие дозы нестероидных противовоспалительных средств подавляют синтез простагландинов и ухудшают имплантацию эмбриона, что позже может вызвать угрозу выкидыша.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Действие токсических веществ. Угроза прерывания гестации может возникать у женщин, работающих во вредных условиях, на опасном производстве. Токсичным действием на эндометрий и плод обладают алкоголь при систематическом употреблении, курение 10 сигарет в день, употребление кокаина. Дозозависимым эффектом обладает кофе, безалкогольные напитки с кофеином. Опасность представляет употребление 4-5 чашек крепкого напитка или 100 мг кофеина в сутки.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Аутоиммунные заболевания. Антифосфолипидный синдром, системная красная волчанка связаны с образованием антител к фосфолипидам и другим структурам клеток. У женщины повышается склонность к микротромбозам. Тромбы формируются в сосудах эндометрия, что нарушает питание зародыша, приводит к угрожающему аборту или гибели плодного яйца.</span></li>\r\n</ul>\r\n<p> </p>\r\n<p><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\"> </span></p>",
"pathogenesis": "<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Механизм развития угрожающего выкидыша связан с усилением сократительной способности матки. В случае инфекции нарушается кровоток в сосудах, питающих зародыш, возникает их спазм. Эмбрион не получает нужного количества питательных веществ и кислорода. На этой стадии может произойти его гибель. Спазм микрососудов приводит к их разрыву, появляется небольшое кровотечение в стенку матки, формируется ретрохориальная гематома. Она отслаивает плодное яйцо от эндометрия. Если кровотечение вовремя не остановить, угрожающий аборт переходит в выкидыш в ходу. Потеря беременности в 1 и начале 2 триместра происходит без разрыва плодных оболочек.</span></p>",
"diagnostics": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При появлении характерных жалоб необходимо обратиться к акушеру-гинекологу для осмотра и диагностики. После подтверждения диагноза может потребоваться госпитализация для лечения и динамического наблюдения. Обследование беременной включает:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Осмотр на кресле. Физикальное обследование показывает, что шейка матки плотно закрыта, но во влагалище может быть небольшое количество коричневых выделений. Бимануальное исследование не доставляет боль, своды влагалища свободны. При пальпации матка остается невозбудимой, мягкой, но ощущается небольшая болезненность. Яичники не пальпируются.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Лабораторная диагностика. Необходима для оценки функции яичников и мониторинга беременности. Берется кровь на ХГЧ, для подтверждения прогрессирующей беременности анализ проводят в динамике с интервалом в несколько дней. Определяют уровень прогестерона. По показаниям может быть назначен анализ на эстрогены.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">УЗИ малого таза. «Золотым стандартом» диагностики угрожающего выкидыша является УЗИ трансвагинальным датчиком, точность методики выше, чем при обследовании трансабдоминально. По данным УЗИ определяют признаки жизнеспособности плода. В полости матки визуализируется плодное яйцо, у эмбриона или плода определяется сердцебиение. При сомнительных результатах исследование повторяют дважды разными специалистами с интервалом 7-10 дней.</span></li>\r\n</ul>\r\n<p> </p>\r\n<p><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\"> </span></p>",
"treatment": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Беременная с кровотечением и угрозой выкидыша на малом сроке должна быть экстренно госпитализирована в отделение гинекологии. Ей назначается лечебно-охранительный режим, не рекомендуется вставать с постели. В некоторых учреждениях в качестве дополнительного способа терапии практикуют поднятие ножного конца кровати на 5 см. Назначается медикаментозная сохраняющая терапия:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Препараты прогестерона. Используют дидрогестерон или микронизированный прогестерон. Их назначают для поддержания функции плаценты по индивидуальной схеме. Женщинам, у которых в прошлом были прерывания на небольшом сроке, препараты назначаются превентивно до появления признаков угрозы.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Эстрогены. Включают в схему лечения с 6 недели гестации, если по результатам анализов выявлен их дефицит. Необходимы для улучшения действия прогестерона. Дозировка подбирается индивидуально.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Снятие тонуса матки. Для купирования боли и мышечного спазма у беременных разрешено применять дротаверин, папаверин. Их назначают внутримышечно, позже переходят на таблетированные формы. Выраженным токолитическим действием обладает раствор магния сульфата. Его используют для уменьшения тонуса матки, снижения артериального давления и улучшения питания плода.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Гемостатическая терапия. Для остановки кровотечения используют этамзилат натрия в форме раствора внутримышечно или внутривенно. Разрешены к применению аминокапроновая и транексамовая кислота.</span></li>\r\n</ul>\r\n<p> </p>\r\n<p><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\"> </span></p>",
"prevention": "<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Профилактика угрожающего самопроизвольного аборта заключается в прегравидарной подготовке, санации очагов инфекции в организме. Женщинам необходимо за 2 месяца до зачатия начинать принимать фолиевую кислоту и витамин Е.</span></p>",
"clinical_picture": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Беременная начинает ощущать чувство дискомфорта внизу живота, которое постепенно переходит в тянущую, ноющую боль. Боль локализуется нечетко над лобком, может отдавать в крестец, поясницу, промежность. При угрожающем аборте ощущения не переходят в схватки, в противном случае это говорит о прогрессировании патологии и развивающемся выкидыше.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Выделения из половых путей на начальном этапе могут отсутствовать. Это характерно для формирования небольшой гематомы позади плодного яйца, которая не опорожняется в полость матки. Если происходит его отслойка по краю, то беременная замечает кровянистые мажущие или сукровично-кровянистые выделения на белье, которые выглядят как прожилки темной крови с примесью слизи. При угрозе выкидыша они не трансформируются в массивное кровотечение алой или темной кровью. Выделения появляются несколько раз в сутки, постепенно их количество под влиянием терапии уменьшается. Если этого не происходит, предполагают прогрессирование патологии.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Нарушение общего самочувствия не характерно. Боль внизу живота не снижает работоспособность беременной, но появляется желание прилечь, отдохнуть. Часто это помогает уменьшить интенсивность неприятных ощущений. Усиление боли провоцируют нервные переживания, физическая нагрузка или отсутствие полноценного отдыха. Половые отношения также могут стать фактором прогрессирования угрожающего аборта.</span></p>",
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},
"code": "O22.4",
"name": "Геморрой во время беременности",
"icd_name": "Геморрой во время беременности",
"gender": 0,
"age_min": 15,
"age_max": 50,
"cause": [
"0"
],
"periodicity": 1,
"slug": "o22.4_gemorroy_vo_vremya_beremennosti",
"lead": "варикозное расширение сосудов геморроидального сплетения, возникновение или обострение которого спровоцировано гестацией",
"description": "",
"etiology": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Геморрой при беременности обусловлен патологическими изменениями в геморроидальных венах на фоне изменившихся условий функционирования организма. В большинстве случаев заболевание возникает в период гестации, реже уже существующая патология клинически дебютирует или обостряется из-за происходящих в организме физиологических изменений. По мнению специалистов в сфере современной проктологии, развитию геморроя у беременных способствуют:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Влияние прогестерона. Под действием гормона снижается тонус гладкомышечных волокон, разрыхляется соединительная ткань. Из-за расслабления стенки венозных сосудов и ослабления эластичных волоконных компонентов в геморроидальном сплетении депонируется кровь, формируются типичные кавернозные тельца. Ситуацию усугубляет снижение перистальтики, приводящее к запорам.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Застойные явления. По мере развития беременности постепенно увеличивается уровень внутрибрюшного давления, что приводит к нарушению работы пищеварительных органов и оттока крови. Растущая матка сдавливает нижнюю полую вену, вызывая застой крови в нижних конечностях, половых органах, геморроидальном сплетении. Под влиянием повышенного давления венозные сосуды расширяются.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Изменение образа жизни. Часть женщин воспринимают беременность как болезненное состояние и намеренно уменьшают физическую активность. На фоне гиподинамии снижается общий тонус и ухудшается моторика кишечника, что усиливает запоры, вызванные действием прогестерона. При натуживании внутрибрюшное давление еще больше повышается, кавернозные синусы прямой кишки переполняются кровью.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Роды. Пусковым моментом в манифестации геморроя могут стать нагрузки при родовой деятельности. Во время потуг происходит повышение внутрибрюшного давления, при опускании головки в малый таз сдавливаются прямокишечные вены. Ослабленные участки сосудистой стенки выбухают. Кроме того, при прорезывании головки возможно смещение кнаружи существующих геморроидальных узлов и их разрыв.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Дополнительными провоцирующими факторами становятся увеличение объема циркулирующей крови, изменения в свертывающей и противосвертывающей системах крови, усиленный синтез различных медиаторов. После родов геморрой, возникший в период гестации, подвергается инволюции или продолжает прогрессировать. Важную роль в развитии болезни после беременности играет конституциональная предрасположенность в виде расстройств иннервации и субклинической дисплазии соединительной ткани с нарушением структуры коллагена и несостоятельностью средней оболочки венозных сосудов.</span></p>",
"pathogenesis": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Существует универсальный механизм развития геморроя при беременности, не зависящий от непосредственной провоцирующей причины и обусловленный анатомическими особенностями ректальных кавернозных телец. В отличие от обычных прямокишечных вен сосуды геморроидального сплетения имеют прямые артериовенозные анастомозы, соединяющие завитковые артерии и кавернозные вены. Гиперплазия кавернозных телец наблюдается при усилении притока артериальной крови на фоне повышения уровня внутрибрюшного давления и ухудшении венозного оттока вследствие сдавливания беременной маткой нижней полой и воротной вен.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Расслабление гладкомышечного слоя венозной стенки и размягчение соединительнотканных волокон под влиянием прогестерона способствуют быстрому формированию мешотчатых (узловатых) образований при беременности. Варикоз сильнее выражен у женщин с наследственными коллагенопатиями. При прогрессировании процесса с разрушением связок Паркса и мышц Трейца, поддерживающих аппарат внутреннего геморроидального сплетения, образовавшиеся узлы могут выпячиваться, а затем воспаляться и ущемляться. Слизистая, покрывающая их стенку, травмируется, изъязвляется, начинает кровоточить.</span></p>",
"diagnostics": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При бессимптомном течении или незначительной выраженности симптоматики геморрой при беременности зачастую становится случайной находкой во время планового осмотра или проявляется клинически во время родов. У пациенток с характерными симптомами заболевание не представляет каких-либо сложностей в диагностическом плане. Наружные и выпавшие узлы выявляются уже на этапе визуального осмотра и пальпации промежности. Наиболее информативными методами диагностики внутреннего геморроя при беременности являются:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Пальцевое исследование прямой кишки. При пальпации рельеф слизистой изменен. В ее складках определяются тугоэластичные образования с широким основанием и гладкой поверхностью, которые при надавливании спадаются, а при покашливании и натуживании выбухают, становятся напряженными.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Аноскопия. Во время визуального осмотра с помощью аноскопа оценивается состояние зубчатой линии, анальных крипт, эпителиальной оболочки. Выявляются внутренние узлы, определяется их локализация, размеры, структура. В ходе аноскопии прямая кишка осматривается на глубину 8-12 см.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Ректороманоскопия. Данный метод подтверждает и дополняет данные аноскопического исследования. Выполняется в обязательном порядке для исключения процессов, локализующихся в дистальных отделах сигмовидной кишки и сопровождающихся кровянистыми выделениями из анального отверстия.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Дополнительные исследования. При необходимости с помощью сфинктерометрии и электромиографии оценивается запирательная функция ануса. В качестве дополнительных лабораторных методов показаны общий анализ крови, позволяющий оценить влияние геморроя на анемию при беременности, и коагулограмма, показатели которой изменяются при тромбозе геморроидальных узлов.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>",
"treatment": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Немедикаментозные методы</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Выбор врачебной тактики зависит от наличия и выраженности клинической симптоматики, остроты течения заболевания. Комплексный подход к ведению беременных с геморроем предполагает коррекцию диеты, обеспечение гигиенического ухода, выполнение специального комплекса упражнений, медикаментозное и хирургическое лечение. Специалисты в сфере акушерства выделяют три группы пациенток. Первую составляют больные с бессимптомным течением геморроя. Таким женщинам рекомендовано динамическое наблюдение и профилактика дальнейшего прогрессирования болезни. </span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Ведущей является диетотерапия с достаточным потреблением воды, направленная на предупреждение запора и размягчение каловых масс.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Допустимо употребление кисломолочных продуктов, растительных масел, нежирного мяса, яиц, круп, фруктов, ягод, свеклы, капусты, моркови, тыквы, других овощей, содержащих клетчатку. Запрещены свежий хлеб, сдоба, мучное, жирное мясо, солености, копчености, маринады, грибы, бобовые, манная и рисовая каши, крепкие бульоны, фрукты с вяжущим эффектом (айва, груша), продукты, усиливающие брожение (виноград, редис, чеснок, лук), крепкий чай, кофе. Эффективны ЛФК, дозированные прогулки, уход за перианальной областью после дефекации. Возможно назначение растительных препаратов со слабительным эффектом.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Медикаментозная терапия</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Вторая группа включает больных с начальными стадиями геморроя при наличии показаний к консервативной медикаментозной терапии. Подбор конкретного препарата определяется клиническим вариантом и особенностями течения заболевания. В дополнение к перечисленным выше лечебным и профилактическим мероприятиям беременным назначают теплые сидячие ванны с отварами вяжущих растений и следующие группы медикаментов:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Комбинированные свечи, мази. Ингредиенты, входящие в их состав, эффективно устраняют зуд и боль, препятствуют инфицированию тканей, способствуют уменьшению отеков и заживлению эрозий. Они также обладают гемостатическим, подсушивающим, антиоксидантным, регенерирующим действием.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Флеботоники и флебопротекторы. Повышают тонус гладкомышечной мускулатуры кавернозных синусов, делают менее проницаемой сосудистую стенку, восстанавливают микроциркуляцию. Благодаря повышению устойчивости геморроидальных вен к высокому внутрибрюшному давлению узлы уменьшаются в размерах.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Антикоагулянты. Рекомендованы при повышенной кровоточивости. Ускоряют рассасывание существующих тромбов и предотвращают формирование новых. Обладают противовоспалительным, противоотечным эффектом. Регенеративно воздействуют на соединительную ткань. С осторожностью применяются в конце беременности.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Возможно назначение средств для улучшения микроциркуляции и реологии крови, витаминно-минеральных комплексов с высоким содержанием аскорбиновой кислоты и рутина. Чтобы размягчить стул, снять местное раздражение, устранить воспаление используют микроклизмы с маслами и отварами лекарственных трав (объем жидкости — до 40 мл). При инфицировании и наличии боли применяют антибиотики и нестероидные противовоспалительные средства.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Хирургическое лечение</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Пациенткам с частыми обострениями геморроя, выпадением узлов, интенсивным болевым синдромом, осложненным течением заболевания рекомендовано оперативное лечение. При беременности предпочтительны малоинвазивные техники:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">латексное лигирование;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">радиоволновое иссечение;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">инъекционная склеротерапия;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">фотокоагуляция;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">электрокоагуляция;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">дезартеризация расширенных кавернозных синусов или комбинация процедур.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При внешнем тромбозе выполняется тромбэктомия (эвакуация тромботического сгустка). Женщинам с тяжелым рецидивирующим течением болезни, обильными анемизирующими кровотечениями показаны радикальные операции при геморрое — подслизистая, открытая, закрытая геморроидэктомия, трансанальная резекция слизистой по Лонго. По возможности вмешательства проводят на ранних сроках беременности или переносят на послеродовый период.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Беременных больных с геморроем обычно наблюдают амбулаторно. Неотложная госпитализация выполняется при ущемлении и некрозе узлов, возникновении массивного геморроидального кровотечения. Наличие геморроя не оказывает влияния на выбор способа родоразрешения. Беременность обычно завершается естественными родами. Кесарево сечение проводится при наличии акушерских показаний.</span></p>\r\n<p><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\"> </span></p>",
"prevention": "<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">С профилактической целью беременным женщинам, имеющим субклинические признаки соединительнотканной дисплазии и склонным к запорам, рекомендованы регулярное наблюдение у акушера-гинеколога, умеренная двигательная активность, рацион с повышенным содержанием пищевых волокон и растительных жиров, достаточное потребление воды, ограничение употребления продуктов, способных оказывать закрепляющих эффект.</span></p>",
"clinical_picture": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Геморрой во время беременности может протекать в двух формах:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">острой;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">хронической.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Для острой формы характерно внезапное образование тромба в венах прямой кишки, что вызывает жгучие боли, особенно после процесса дефекации. Образуются плотные наружные узлы, диаметр которых может достигать 2-3 см, кожа под ними отекает и краснеет.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Через 5-10 дней острая форма переходит в хроническую − узлы размягчаются и набухают только при натуживании. Процесс сопровождается неприятными ощущениями в области заднего прохода и зудом.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">В фекальных массах появляется кровь, иногда в довольно больших количествах, геморроидальные узлы могут выпадать из заднего прохода, самостоятельно вправляясь через какое-то время. Боли при этом может не быть, может возникать чувство неполного опорожнения кишечника, дискомфорт, вздутие живота. Ходьба и сидение становятся болезненными.</span></p>\r\n<p><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\"> </span></p>",
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