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"lead": "вариант гестоза, который возникает после 20-й недели гестационного срока, характеризуется полиорганными нарушениями с преимущественным поражением ЦНС, предшествует эклампсии",
"description": "<p><span id=\"docs-internal-guid-ded959ea-7fff-9eca-8135-1fd0cfedb763\"><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;\">Преэклампсия — это возникающее в период беременности заболевание, для которого характерно повышение кровяного давления и наличие белка в моче. Преэклампсия является одним из наиболее частых осложнений беременности.</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;\">Этиология расстройства, как и других форм гестозов, на сегодняшний день окончательно не установлена. Вероятным фактором, способствующим развитию преэклампсии, считается патологическая реакция организма предрасположенной женщины на физиологическую перестройку при беременности. </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;\">Причины развития патологии:</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;\">Наследственная. Роль генетических факторов в развитии преэклампсии подтверждается ее более частым диагностированием у пациенток, чьи матери страдали гестозами. </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;\">Иммунная. Проникновение в материнский кровоток чужеродных антигенов плода сопровождается ответной выработкой антител. Осаждение образовавшихся иммунных комплексов в различных тканях запускает сложные защитные механизмы, которые проявляются активацией клеток эндотелия и острым эндотелиозом.</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;\">Плацентарная. Некоторые авторы связывают преэклампсию с нарушением инвазии цитотрофобласта. В результате не происходит трансформация гладкомышечного слоя маточных артерий, что в последующем приводит к их спазму, ухудшению межворсинчатого кровотока, гипоксии и, как следствие, повреждению эндотелия.</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;\">Кортико-висцеральная. Сторонники теории рассматривают преэклампсию как невротическое расстройство гемодинамики, вызванное нарушением взаимоотношений между корой и подкорковыми отделами. Такой подход объясняет провоцирующую роль тяжелых стрессов и подтверждается функциональными изменениями на ЭЭГ.</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;\">Непосредственными причинами развития преэклампсии являются неправильно подобранная терапия водянки беременных и нефропатии, несоблюдение пациенткой врачебных рекомендаций, высокая терапевтическая резистентность более легких вариантов гестозов.</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;\">Ключевым звеном в механизме развития преэклампсии является генерализация острого эндотелиоза и вазоконстрикции, изначально локализованных в плаценте, с вовлечением в патологический процесс тканей головного мозга. Сосудистая дисфункция приводит к повреждению клеточных мембран, нарушению метаболизма нейронов с возникновением гиперчувствительности и повышенной возбудимости нервных клеток. Поражение надсегментарных подкорковых структур сопровождается полисистемными вегетативными расстройствами, выявляемыми более чем у 90% больных с тяжелыми формами гестозов.</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;\">Параллельно у беременных и рожениц с преэклампсией развивается пирамидная недостаточность, которая свидетельствует о расстройстве на уровне корковых отделов и проявляется сухожильно-периостальной гиперрефлексией, анизорефлексией, возникновением патологических рефлексов, повышением судорожной готовности. Последними поражаются стволовые отделы мозга. Деструктивные процессы, вызванные расстройствами микроциркуляции, также происходят в других органах — печени, почках, легочной ткани. Ситуация усугубляется характерными для гестозов коагулопатическими нарушениями.</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 первичном обращении пациентки с характерными жалобами рекомендован план обследования с выявлением специфических маркеров гестозов:</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;\">Контроль артериального давления. Показано суточное мониторирование с автоматическим измерением АД при помощи специального прибора. У больных с преэклампсией АД обычно превышает 180/110 мм рт. ст. с пульсовой амплитудой более 40 мм рт. ст. Индекс артериальной гипертензии составляет 50% и выше.</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;\">Оценка системы гемостаза. Для гестозов характерна коагулопатия потребления и активация фибринолитической системы. Рекомендуется исследовать содержание фибриногена, продуктов его деградации (РФМК), антитромбина III, эндогенного гепарина, оценивать АЧТВ, протромбин (MHO), тромбиновое время.</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;\">Общий анализ мочи. Важным признаком преэклампсии считается протеинурия. Содержание белка в моче превышает 5 г/л, могут обнаруживаться зернистые цилиндры, лейкоцитурия. Часовой диурез часто снижается до 40 мл и менее. Для оценки тяжести поражения почек определяется суточное количество протеина в моче.</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;\">ТКДГ сосудов головного мозга. Применяется для объективной оценки церебрального кровотока. В ходе транскраниальной допплерографии подтверждается наличие признаков повышения мозгового перфузионного давления и уменьшения сосудистой резистентности, характерных для преэклампсии.</span></li>\r\n</ul>\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;\">С учетом возможных акушерских осложнений пациентке показаны УЗИ матки и плаценты, допплерография маточно-плацентарного кровотока, КТГ, фетометрия, фонокардиография плода. Дифференциальная диагностика проводится с заболеваниями головного мозга (тромбозом синусов твердой оболочки, менингитом, опухолями, инсультом), бессудорожными формами эпилепсии, отслойкой сетчатки. Беременную консультируют анестезиолог-реаниматолог, терапевт, невропатолог, окулист, кардиолог, нефролог.</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>",
"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;\">1. Сохранение беременности и родоразрешение при преэклампсии. Родоразрешение — наиболее эффективный и единственный патогенетически обоснованный метод лечения.</span></p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">При умеренной преэклампсии беременную следует госпитализировать, чтобы уточнить диагноз и провести тщательный мониторинг ее состояния и плода, но при этом возможно продолжение вынашивания до 37 недель. При ухудшении состояния матери и плода показано родоразрешение.</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">При тяжелой преэклампсии нужно сначала стабилизировать состояние матери, а затем решать вопрос о родоразрешении, желательно после проведения профилактики респираторного дистресс-синдрома плода, если беременность менее 34 недель.</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\"><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;\">2. Антигипертензивная 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;\">Цель лечения — поддерживать АД в пределах, которые сохраняют на нормальном уровне показатели маточно-плодового кровотока и снижают риск развития эклампсии.</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;\">Антигипертензивную терапию следует проводить, постоянно контролируя состояние плода, потому что снижение плацентарного кровотока провоцирует у него прогрессирование функциональных нарушений. Критерием начала антигипертензивной терапии является АД ≥ 140/90 мм рт. ст.</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;\">Основные лекарственные средства, используемые для лечения АГ в период беременности:</span></p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Метилдопа (допегит) — антигипертензивный препарат центрального действия, α2-адреномиметик (препарат первой линии);</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Нифедипин — блокатор кальциевых каналов (препарат второй линии);</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">β-адреноблокаторы: метопролол, пропранолол, соталол, бисопролол;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">По показаниям: верапамил, клонидин, амлодипин.</span></li>\r\n</ul>",
"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 преэклампсии предполагает регулярные осмотры в женской консультации, мониторинг давления и лабораторных показателей у пациенток с водянкой беременных, нефропатиями, тщательное выполнение всех врачебных назначений, нормализацию режима сна и отдыха, психоэмоциональный покой, контроль прибавки веса, обогащенный белком рацион с низким содержанием соли.</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;\">Обычно расстройство возникает на фоне предшествующей нефропатии. К существующим отекам артериальной гипертензии, умеренно выраженной астеновегетативной симптоматике (головокружению, слабости, недостаточному сну, метеотропности, эмоциональной лабильности) присоединяются признаки поражения ЦНС и повышения внутричерепного давления. Пациентка жалуется на интенсивную головную боль, тяжесть в затылке, усталость, выглядит заторможенной, вялой, безучастной, иногда отвечает невпопад. Отмечается повышенная сонливость или бессонница, дрожание вытянутых пальцев рук, потливость ладоней и стоп.</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;\">У 25% женщин с клиникой преэклампсии выявляются зрительные расстройства — ощущение затуманенности зрения, мелькание искр или мушек, боязнь света, двоение в глазах, выпадение отдельных полей зрения. Возможно появление тошноты, рвоты, болей в эпигастрии и правой подреберной области. В тяжелых случаях возникают мышечные подергивания, бред, галлюцинации, петехиальная сыпь, свидетельствующая о нарушении свертываемости крови. Преэкламптическое состояние является сравнительно коротким, длится не более 3-4 суток, после чего купируется правильной терапией либо переходит в эклампсию.</span></p>",
"image": null,
"image_alt": null,
"standard_type": 0,
"danger": 40,
"published": 1,
"parent": 6961,
"block_rubric": 159,
"standards": [
5157
]
},
{
"id": 13271,
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"code": "N96",
"name": "Привычный выкидыш",
"icd_name": "Привычный выкидыш",
"gender": 2,
"age_min": 15,
"age_max": 49,
"cause": [
3
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"periodicity": 1,
"slug": "n96_privychnyy_vykidysh",
"lead": "Нарушение здоровья, относящееся к группе невоспалительные болезни женских половых органов",
"description": "Привычный выкидыш — это самопроизвольное прерывание беременности (при сроке до 22 недель беременности), повторяющееся при каждой последующей беременности. ",
"etiology": "<p>Причины привычного выкидыша включают в себя: </p>\r\n<ul>\r\n<li>дефекты анатомического строения матки; </li>\r\n<li>недоразвитие плодного яйца; </li>\r\n<li>воспалительные заболевания и опухоли матки; </li>\r\n<li>эндокринные заболевания; </li>\r\n<li>генетическую детерминацию; </li>\r\n<li>хронические инфекции и интоксикации; </li>\r\n<li>вирусные инфекции, перенесенные в первые недели беременности; </li>\r\n<li>гиповитаминозы; применение противоопухолевых, гормональных, противозачаточных препаратов; </li>\r\n<li>неблагоприятные факторы внешней среды. </li>\r\n</ul>",
"pathogenesis": "<p>Механизм привычного выкидыша различен. В ряде случаев сначала возникают сокращения матки, вызывающие отслойку плодного яйца. В других случаях сокращениям матки предшествует гибель плодного яйца (при токсикозах, острых и хронических инфекционных болезнях беременной и др.). Иногда отслойка и гибель плодного яйца и сокращения матки происходят одновременно. </p>",
"diagnostics": "<p>У 5%-15% женщин с привычным абортом определяется клинически значимое повышение титра антифосфолипидных антител. </p>\r\n<p>При планировании следующей беременности супругам необходимо: </p>\r\n<ul>\r\n<li>сделать спермограмму; </li>\r\n<li>пройти гинекологическое УЗИ; </li>\r\n<li>сделать гистероскопию; </li>\r\n<li>исследовать анализы крови на гормоны (определение уровня прогестерона), а также на наличие вирусных и половых инфекций; </li>\r\n<li>исследовать иммунный статус; </li>\r\n<li>исследовать кариотип (выявление носительства хромосомных аномалий, в том числе унаследованные тромбофилии); </li>\r\n<li>исследовать свертывающую систему крови (определение АчТВ, антитромбин 3, Д-димер, агрегация тромбоцитов, МНО, протромбиновое время – признаки гиперкоагуляции). </li>\r\n</ul>\r\n<p>При необходимости может быть назначен ряд дополнительных исследований. </p>",
"treatment": "<p>При несостоятельности шейки и внутреннего маточного зева применяют пластические операции с целью устранения деформации, разрывов и т. п. При несостоятельности шейки функционального характера используют операции, сущность которых заключается в суживании области внутреннего зева при помощи швов из найлоновой тесьмы. Швы удаляют на 36—38-й неделе беременности, наступившей после наложения швов. </p>\r\n<p>У женщин, страдающих привычным выкидышем на почве инфантилизма, недостаточности функции яичников, воспалительных заболеваний половых органов, следует проводить лечение до наступления беременности. В подобных случаях рекомендуется курс лечения эстрогенами и прогестероном в соответствии с индивидуальным менструальным циклом (не менее 3 циклов) в сочетании с влагалищно-крестцовой диатермией и воротником по Щербаку (15 процедур, чередуя их через день). </p>\r\n<p>Лечение во время беременности женщин, страдающих привычным выкидышем, должно носить выраженный профилактический характер (режим питания, труда и отдыха, пребывание на свежем воздухе, психотерапия и пр.). При наступлении беременности рекомендуется назначать прогестерон внутримышечно в течение 10 дней в начале 2, 4, 7-го месяцев беременности. </p>\r\n<p>При угрозе прерывания беременности — немедленная госпитализация и лечение, как и при первичном самопроизвольном аборте. После исчезновения симптомов угрожающего выкидыша беременная должна оставаться в стационаре еще 10—15 дней, затем ее выписывают для амбулаторного наблюдения. </p>\r\n<p>При гормональной терапии угрожающего выкидыша большое значение имеет определение экскреции прегнандиола и эстрогенов, позволяющее проводить более рациональное лечение. При пониженном количестве прегнандиола целесообразно назначение прогестерона; если же экскреция прегнандиола в пределах нормы, прогестерон противопоказан, так как при этом опасность наступления выкидыша увеличивается. При низком уровне экскреции прегнандиола и эстрогенов ряд авторов указывает на хорошие результаты от применения диэтилстильбэстрола. </p>\r\n<p> </p>",
"prevention": "<p>Главные принципы профилактики: </p>\r\n<ol>\r\n<li>Выявление женщин, входящих в группу риска развития невынашивания беременности. </li>\r\n<li>Целенаправленное обследование супружеской пары до беременности и рациональная их подготовка. </li>\r\n<li>Систематический контроль над возможным возникновением инфекционных осложнений и адекватная противовоспалительная, антибактериальная и иммунотерапия. </li>\r\n<li>Своевременное диагностирование шеечной недостаточности посредством мануальной оценки и проведения ультразвукового исследования с помощью трансвагинального датчика до 24 недель беременности, а при многоплодии — до 26-27 недель. </li>\r\n<li>Проведение рациональной терапии сопутствующих экстрагенитальных заболеваний. </li>\r\n<li>Профилактика и своевременное лечение нарушений тромбофилического генеза и плацентарной недостаточности с ранних сроков беременности. </li>\r\n</ol>\r\n<p> </p>",
"clinical_picture": "<p>Чаще всего выкидыш происходит в первые 2 месяца беременности, а при истмико-цервикальной недостаточности — после 14-й недели беременности. Появляются схваткообразные боли в нижних отделах живота и/или в поясничной области и кровянистые выделения или кровотечение из половых путей. Через некоторое время все эти симптомы выкидыша могут полностью прекратиться, после чего возобновиться снова. При привычном невынашивании характерно прерывание трех и более беременностей в сроке до 22 недель. <br class=\"SCXW70246934\" /> </p>",
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