Dynamic observation of groups of dispensary registration of gynecological patients. Organization of preventive care and dispensary observation of pregnant women and gynecological patients

LEARNING PURPOSE: learn five groups of medical examination of gynecological patients. To study the indications for hospitalization of gynecological patients.

STUDENT SHOULD KNOW:

1. Clinical examination is the main method of dynamic observation.

2. Five-group medical examination system.

3. Groups of dispensary observation of gynecological patients.

4. Order No. 572n of the Ministry of Health of the Russian Federation. “On approval of the procedure for providing medical care in the field of Obstetrics and Gynecology (with the exception of the use of ART).

5. Indications for hospitalization of gynecological patients.

6. Indications for hospitalization of gynecological patients with various dental diseases.

7. Indications for the stay of gynecological patients in day hospitals.

8. List of minor gynecological operations and manipulations to be performed in a day hospital.

9. Dynamic observation of women after termination of pregnancy.

10. Dynamic observation of women using various methods of contraception.

11. The role of women's consultation in the prevention of gynecological diseases.

12. The role of antenatal clinic in the diagnosis of gynecological diseases.

13. The role of women's consultations in the treatment of gynecological patients.

14. Organization of gynecological care in rural areas.

15. Features of clinical examination in rural areas.

16. Principles of organization of dental care for gynecological patients in the antenatal clinic, polyclinic.

The student must be able to:

collect anamnesis in gynecological patients;

Conduct an examination of the external genital organs and examination with the help of mirrors;

Conduct a bimanual, vaginal-abdominal examination;

Evaluate the data of laboratory research methods (analyzes of smears, blood, urine);

Evaluate the data of ultrasound of the pelvic organs.

TESTS

1. The purpose of the antenatal clinic is:

A) dispensary observation of pregnant women

B) dispensary observation of gynecological patients

C) medical obstetric and gynecological care

D) the provision of outpatient medical and preventive obstetric and gynecological care aimed at maintaining reproductive health, improving women's health, and preventing maternal mortality.

2. The tasks of the antenatal clinic for the provision of gynecological care are:

A) conducting qualified diagnostics, treatment and rehabilitation of gynecological diseases using modern technologies

B) carrying out preventive measures to prevent gynecological and oncological diseases.

C) carrying out sanitary and educational work

D) work on family planning, contraception, abortion prevention

E) providing women with social and legal protection in accordance with the legislation on the protection of motherhood and infancy

E) ensuring continuity in the examination and treatment of women with obstetric-gynecological and other medical and preventive institutions

G) all of the above are correct

3. Specify accounting documents for the observation of gynecological patients:

A) outpatient medical card (form 25\y)

B) dispensary observation control card (form 030\y)

B) doctor's note

D) doctor's work diary

4. The structure of a preventive gynecological examination includes everything except:

A) identifying complaints

B) examination of the mammary glands

C) a special gynecological examination

D) cytological examination of the cervix by papanicolaou

D) colposcopy

5. Gynecological diseases are diagnosed when:

A) self-referral of women to the antenatal clinic

B) during preventive examinations

C) when examining women at home (on call or active visiting a doctor)

D) all answers are correct

6. Patients should be under dispensary observation in the conditions of the antenatal clinic:

A) after surgical treatment of ectopic pregnancy;

B) with violation of the menstrual cycle;

C) with uterine fibroids, the size of which corresponds to a pregnancy for a period of less than 12 weeks;

D) with chronic inflammation of the uterine appendages;

D) all of the above groups.

7. Emergency hospitalization in a gynecological hospital is indicated in all the cases listed below, except:

A) torsion of the pedicle of the ovarian tumor;

B) the birth of a submucosal myomatous node;

C) atypical hyperplasia of the endometrium;

D) acute purulent inflammation of the uterine appendages;

E) ectopic pregnancy, disturbed by the type of tubal abortion.

Sample answers to test control

1-g; 2-g; 3- a, b; 4-d; 5 g; 6-d; 7-in

Situational tasks

Task number 1.

Patient K., 20 years old, went to the antenatal clinic for registration, considers herself pregnant, as there is a delay in menstruation for 10 days, the day before at home she took a pregnancy test - positive. When examining complaints of minor periodic pain in the lower abdomen for 2 days.

From the anamnesis: menstruation since the age of 12, without features. Sexual life from the age of 18. Currently married. This pregnancy is the second, the first in 2005. She ended with a medical abortion at 8 weeks of gestation. Suffering from chronic bilateral salpingo-oophoritis, metroendometritis, for which she was repeatedly treated in a hospital and in a antenatal clinic.

Objectively: the condition is satisfactory, the skin and visible mucous membranes are of physiological color. Temperature 36 degrees. Pulse 76 beats/min., rhythmic. BP 120/80 mmHg On the part of the respiratory and cardiac pathologies were not detected. The tongue is wet. The abdomen is not swollen, takes part in the act of breathing, soft painless. There are no symptoms of peritoneal irritation.

Vaginal examination: on examination, the external genitalia are formed correctly.

P.S: the vaginal mucosa is cyanotic, the cervix is ​​without visible pathology.

P.V.: uterus of normal size, softened, painless. The right appendages are not defined. On the left, slightly enlarged appendages are palpable, of a doughy consistency, slightly painful. The vaults are deep, painless. The parameters are free.

The woman was referred for ultrasound on cito. According to ultrasound: signs of uterine pregnancy is not determined. A tubo-ovarian formation is noted in the region of the appendages on the left. There is no free fluid in the posterior fornix.

The doctor of the antenatal clinic was diagnosed with a progressive tubal pregnancy on the left.

What is the further tactics of the antenatal clinic doctor?

Sample answer: the doctor of the antenatal clinic must urgently hospitalize the patient for surgical treatment.

MODULE 2: "Menstrual cycle, menstrual disorders", "Women's reproductive system",

TOPIC 2.1.: "NEUROENDOCRINE REGULATION OF WOMAN'S REPRODUCTIVE FUNCTION"

Purpose of the lesson: To study the classification, etiology, pathogenesis, methods of diagnosis and treatment of menstrual dysfunction.

The student must know:

I. Questions of basic disciplines

1. Endocrine structures and their role in the regulation of the reproductive system

Hypothalamic-pituitary system

gonads

Thyroid

adrenal glands

Other endocrine organs and hormones

2. The role of neurotransmitters in the regulation of reproductive function

3. The role of prostaglandins in the regulation of reproductive function

4. Neurohumoral regulation of the reproductive system during its formation, functioning and decay

5. Normal menstrual cycle

II. Issues set out in the lecture material and literature

1. Scheme of the regulation of the reproductive function of a woman.

2. Age periods of the female body.

3. Classification of menstrual dysfunction.

4. Etiology and pathogenesis of menstrual dysfunction.

5. Amenorrhea (definition, classification).

6. Definition of concepts primary and secondary amenorrhea.

7. Diagnostic algorithm for primary amenorrhea.

8. Diagnostic algorithm for secondary amenorrhea.

9. Principles of treatment of amenorrhea.

10. Syndrome of sclerocystic ovaries (Stein-Leventhal).

11. Adrenogenital syndrome.

12. Sheehan's syndrome.

13. Diagnostic algorithm for galactorrhea.

14. Chiari-Frommel syndrome.

15. Algodysmenorrhea (etiology, pathogenesis, clinic, treatment).

The student must be able

Collection of anamnesis in gynecological patients

Examination of the external genital organs and examination with the help of mirrors.

Bimanual vaginal-abdominal examination

Take smears for colpocytology

Evaluation of data from laboratory research methods (analyzes of smears, blood, urine)

Evaluation of ultrasound data of the pelvic organs

Evaluation of laparoscopy data.

Evaluation of hysteroscopy data

· To diagnose

Develop a treatment plan

Maintaining medical records

TESTS

1. Duration of a normal menstrual cycle:

2. Features of a normal menstrual cycle are:

A) ovulation

B) the formation of a corpus luteum in the ovary

C) the predominance of gestagens in the second phase of the cycle

3. The hypothalamus produces the following hormones:

a) gonadotropins

B) estrogen

B) gestagens

D) releasing factors

4. In the interaction of the hypothalamus, pituitary gland and ovaries in the regulation of the menstrual cycle:

A) one link (overlying) stimulates the function of another link (lower)

B) the underlying link inhibits or regulates the function of the overlying

C) the function of the links is synchronous

D) turning off one link disrupts the entire system as a whole

5. Estrogens are secreted:

A) cells of the inner lining of the follicle

B) corpus luteum

B) adrenal cortex

6. FSH stimulate:

A) growth of follicles in the ovary

B) the production of corticosteroids

C) TSH production in the thyroid gland

7. In its action on the body, estrogens:

A) block oxytocin receptors

B) stop (weaken) proliferative processes in the endometrium

C) cause secretory transformations in the endometrium

8. Estrogens:

A) promote peristalsis of the uterus and tubes

B) enhance the processes of ossification

C) stimulate the activity of cellular immunity

9. Gestagens:

A) lower blood cholesterol levels

B) determine the development of primary and secondary sexual characteristics

B) increase the tone of the uterus

10. Gestagens:

A) have a hyperthermic effect on the body

B) slow down the flow of urine

B) increase the secretion of gastric juice

11. Androgens are formed:

A) in the ovary (interstitial cells, stroma, internal theca)

B) in the reticular zone of the adrenal cortex

12. Functional diagnostic tests (tfd) allow you to determine:

A) biphasic menstrual cycle

B) the level of estrogen saturation of the body

B) the presence of ovulation

D) the usefulness of the luteal phase of the cycle

13. An increase in rectal temperature in the second phase of the ovulatory menstrual cycle is due to:

A) the action of ovarian progesterone on the thermoregulatory center in the hypothalamus

B) the action of progesterone, which reduces heat transfer

C) intensification of biochemical processes in the uterus

14. An anovulatory menstrual cycle with a short-term persistence of a mature follicle is characterized by:

A) symptom of "pupil" (+++)

B) single-phase basal temperature

C) in scraping of the endometrium in the second phase of the cycle, the late phase of proliferation

15. Primary algomenorrhea is caused by:

A) infantilism

B) retrodeviation of the uterus

C) high production of prostaglandins

16. The fullness of the luteal phase of the menstrual cycle is evidenced by:

A) an increase in basal temperature in the first phase of the cycle

B) proliferative processes in the endometrium in the second phase of the cycle

17. With menopausal syndrome in premenopausal women, symptoms are observed:

A) vegetative-vascular

b) metabolic endocrine

B) neuropsychiatric

18. The secretion phase in the endometrium can be complete only if:

A) complete phase of proliferation

B) ovulation has occurred

C) a full-fledged corpus luteum functions

19. Amenorrhea is the absence of menstruation during:

A) 4 months

B) 5 months

B) 6 months

20. Anovulatory dysfunctional uterine bleeding must be differentiated:

A) with pregnancy (progressive)

B) with the onset of spontaneous miscarriage

B) with submucosal uterine fibroids

Clinical examination of gynecological patients is carried out in the following groups (order No. 50):

D1 - dispensary healthy at a professional examination once a year with a mandatory smear for atypical cells at any age.
D2 - practically healthy.

• 1. Prolapse of the genitals.
• 2. Fibromatosis of the uterus.
• 3. N.M.Ts. after an abortion, more than 2 months, (anti-inflammatory therapy, absorbable therapy, physio).
• 4. Infertility.
• 5. Women who have had inflammation of the appendages, currently residual effects (after exacerbation, NMD).
• 6. IUD - 1-2 times a year with cytology.
• 7. Persistent stage of endometritis with the onset of menopause.
• 8. Tumors of the ovary - after surgical treatment.
• 9. Patients after surgery for uterine fibroids.
• 10. Changes after hydatidiform mole.
• 11. Infertility, older than 35 years, because this group often disappears from sight, and at this time, ovarian cystoma, uterine fibroids appear, which are also the cause of infertility.
• 12. Patients after treatment for cervical pathology: erosion, etc.
• 13. Every woman after a medical abortion within 1 month.

D31 - chronic diseases in the stage of compensation.
D32 - who have had acute illnesses.
D33 - chronic diseases in the stage of decompensation.

D3a - compensated flow:

• 1. A group of patients after surgery for uterine fibroids for the first 6 months.
• 2. A group of patients after surgery for an ovarian tumor for the first 6 months.
• 3. A group of patients after inpatient treatment for inflammation of the appendages.
• 4. A group of patients with endometriosis in need of hormonal treatment.
• 5. Patients with moderate climacteric syndrome.
• 6. Patients with a high risk of chorionepithelioma.
• 7. Patients after surgical treatment for the pathology of the cervix (erosion - the first 6 months).

Observed once a quarter.
D3b - decompensated flow:

• 1. Cervical pathology requiring surgical treatment
• 2. Uterine fibroids requiring surgical treatment.
• 3. Cysts and ovarian cystomas.
• 4. Acute inflammatory processes of the genitals or exacerbation of chronic ones.
• 5. Infertility requiring surgical and inpatient treatment.
• 6. Patients in the stage of subcompensation of mole.
• 7. Severe forms of climacteric syndrome.
• 8. Patients with severe pain syndrome who need surgical treatment due to their somatic status, but have contraindications to surgery:
  a) prolonged infiltrates after surgery;
  b) frequent recurrences of inflammation of the uterine appendages, pain syndrome with endometriosis.

Observed once a week:
Quality control of medical care for gynecological patients is carried out by the chief physician (head) of the antenatal clinic. For this purpose, within a month, the medical documentation of about 50% of patients admitted by an obstetrician-gynecologist is reviewed, an examination of the maintenance of the “Dispensary Monitoring Control Cards” and “Outpatient Medical Records” is carried out. At the same time, compliance with the regularity of examinations, the volume of preventive, diagnostic and therapeutic measures taken, the presence of epicrises, as well as the effectiveness of the treatment, are assessed.

For the purpose of early detection of malignant neoplasms, it is recommended to conduct annual preventive examinations of women, which include examination and palpation of the mammary glands, examination and palpation of the abdomen, regional lymph nodes, examination in the mirrors of the cervix and vagina, bimanual examination of the uterus and appendages, digital examination of the rectum for older women. 40 years or with complaints.

If oncopathology is suspected, the obstetrician-gynecologist sends the woman for a consultation to the oncologist at the place of residence, who then monitors her.

There are several types of health: Somatic - the current state of the organs and systems of the body, Physical - the level of growth and development of organs and systems, Mental - the state of the psychological sphere, Moral - the value system of behavior in society, a set of motivations of the need-informative sphere of activity

From the point of view of medical practice, the definition of health should meet the following criteria: Have a personal value that is significant for a person; Characterize in the body what is opposite to the disease; Provide the possibility of its quantitative measurement; Have a morphophysiological substrate that is accessible to study and influence.

A healthy lifestyle is a type of life activity that is aimed at maintaining and strengthening health. The lifestyle includes: increased physical activity, the presence or absence of bad habits, nutrition, neuro-emotional state, daily routine, personal hygiene, level of medical literacy, level of medical activity

Today, maintaining the health of the population is a state task. Implementation of the Health project: promoting a healthy lifestyle, combating smoking and alcoholism, improving oncological care, equipping outpatient clinics, introducing birth certificates, increasing cash payments to primary care workers, additional medical examination Organization of “Health Centers” for the population in Russia 502 centers operate in the regions, an Internet site is working on the website of the Ministry of Health, work has begun on compiling a health passport.

The purpose of medical examination is to create a unified system that provides assessment and dynamic monitoring of a woman's health. Clinical examination is understood as: active detection of sick women in the early stages of the disease, dynamic monitoring and complex treatment, implementation of measures to improve working and living conditions, prevent the development and spread of diseases, and strengthen working capacity.

Prevention is the main direction of health care, medical examination is the method by which this preventive direction is carried out. Clinical examination includes observation of certain groups of healthy women in order to carry out preventive, sanitary and hygienic and social measures, ensure proper physical development and maintain health, and monitor patients suffering from long-term chronic forms of diseases.

Of the healthy, dispensary observation is subject to female workers in accordance with the list of industries and professions for which preliminary examinations are mandatory upon admission and periodic examinations for the purpose of labor safety and prevention of occupational diseases, service workers, students, schoolchildren, athletes, etc., and also persons who are ill for a long time and often, suffering from chronic diseases in the stage of compensation and decompensation

The selection of patients subject to dispensary observation is carried out by doctors: With the current appeal to outpatient clinics for any reason: for information, advice, sanatorium card, etc. During preventive medical examinations of certain contingents of persons When analyzing records, obtaining information from hospitals, processing various documents.

Efficiency of prophylactic examination It is ensured by establishing an accurate diagnosis of the disease - the main one, for which the patient will be under dispensary observation and concomitant ones. Therapeutic measures should be aimed at the complete recovery of the individual, taking into account all the changes in the body Comprehensive examination, both during registration and subsequently Periodicity of observation to prevent the progression of the process Consultation of doctors of various specialties, since the disease can cause changes in various organs and systems

Women's clinics and specialized dispensaries participate in annual preventive examinations of the population, carry out dispensary observation of all identified patients, carry out the necessary medical and diagnostic measures, evaluate the effectiveness of dispensary observation, carry out sanitary and hygienic and educational work among the population, carry out continuity with territorial treatment and prevention institutions.

Preventive gynecological examinations are subject to all women over 18 years of age living in the area of ​​activity of the antenatal clinic For the adult population, annual examinations by an obstetrician-gynecologist are mandatory continuity of care, coordinates actions Medical care must be effective, safe, meet the needs of the patient and society, and easily adapt to changing circumstances.

At the first stage of clinical examination, gynecological patients who need treatment, systematic examinations and examinations are identified, they are filled with the "Medical card of the outpatient" f.025 and the control card of dispensary observation f.030. After the end of treatment, the card is transferred to the cell of the month for which the next visit is scheduled. The duration, frequency, terms of visits are determined for each patient individually, depending on the clinical manifestations of the disease, age and other factors.

The rest of the women are considered practically healthy. Some practically healthy women may experience some deviations in the state of the genital organs, but they do not complain, do not need treatment and systematic monitoring, their ability to work is not impaired and there is no threat to health. For these women, only preventive examinations and some recommendations are needed. Special documentation for them does not start and they are not diagnosed

Practically healthy women include: - with the prolapse of the walls of the vagina and uterus of the 1st degree; past inflammatory process of the appendages without exacerbation and dysfunction.

The provision of outpatient care to women with gynecological diseases is regulated by orders of the Ministry of Health of the Russian Federation and the authorities of the Irkutsk region. Order of the Ministry of Health of Russia dated “On the improvement of obstetric and gynecological care in outpatient clinics” and order 786 of the city “On approval of patient management protocols” of the Main Directorate of the Administration of the Irkutsk Region regulate the procedure and completeness of examination and treatment of patients with a wide variety of pathologies. In the relevant sections, according to the diagnosis, a list of diagnostic procedures used in establishing a diagnosis, examination by doctors of other specialties, a list of diagnostic procedures carried out in the process of observation and treatment, medical and recreational activities, the frequency of repeated examinations, indications for inpatient treatment, criteria for deregistration are given.

Gynecological diseases subject to dispensary observation Children's gynecological diseases Infectious pathology in gynecology (genital herpes, bacterial vaginosis, urogenital trichomoniasis, urogenital chlamydia, female genital tuberculosis) Inflammatory diseases of the pelvic organs Benign diseases of the cervix ovarian insufficiency, postovariectomy syndrome, severe climacteric syndrome, postmenopausal osteoporosis) Hyperplastic processes and benign tumors of the uterus, appendages and mammary glands Infertile marriage Urogenital disorders (genital prolapse and urinary incontinence)

Registration of documentation for a dispensary patient: An epicrisis of a patient taken for dispensary registration, in which, after the examination, a diagnosis is made, indications for medical examination are determined, anamnesis, complaints and objective examination data are reflected. The dispensary observation plan is attached, it reflects the purpose of the examinations, the treatment of the disease, the frequency of examinations. The plan is agreed with the patient, the date and signature is put, the consent of the patient In case of deregistration, or at the end of the calendar year, an epicrisis and a plan for the next year are written

Examination during a professional examination includes: anamnesis, general physical examination, palpation of the mammary glands, examination using mirrors, cytology of smears "PAP-test" Referral for ultrasound of the pelvic organs Referral for mammography: 1 time in 2 years, after 50 years 1 time per year. With a high risk of cancer from the age of 35, ultrasound of the mammary glands with complaints up to 40 years Colposcopy (order 50) is not a screening method, carried out according to the results of a cytological examination

Basic principles for monitoring women using COCs Annual gynecological examination, including colposcopy and cytological examination of the cervix. Examination of the mammary glands, mammography once a year in premenopause. Regular measurement of blood pressure: with an increase in diastolic blood pressure to 90 mm Hg. Art. - discontinuation of COC use In a special examination according to indications (with the development of side effects, the appearance of complaints) In case of menstrual dysfunction - exclusion of pregnancy and transvaginal ultrasound scanning of the uterus and appendages

Monitoring of patients using the IUD During the first week after the introduction of the IUD, sex life and intense physical activity are not recommended. Control examination of the doctor is carried out after 7-10 days and ultrasound in order to clarify the location of the IUD in the uterine cavity. Subsequent examinations should be carried out after 1 month, in the future at least 1 time in 6 months, then annually with a bacterioscopic examination of the discharge of the cervix, ultrasound according to indications. NB!!! The patient should be taught to check for the presence of threads after menstruation so as not to miss the expulsion of the IUD.

Ectopia of the cervix Ectopia of the cervix - displacement of the boundaries of the cylindrical epithelium on the vaginal part of the cervix. In ICD-10, cervical ectopia is not included. In the colposcopic nomenclature adopted in Rome (1990), ectopia is referred to item 1 “normal colposcopic findings”. The uncomplicated form of cervical ectopia does not have specific manifestations. Does not require treatment. Dispensary observation is indicated for the purpose of timely detection of deviations in the clinical course: examinations once a year with colposcopy and bacteriological examination. COC contraception is not contraindicated.

Complicated form of cervical ectopia In complicated forms, ectopia is combined with inflammatory processes of the cervix, dysplasia of varying severity. Bacterioscopic, bacteriological methods, PCR are used. Differential diagnosis is carried out with cervical cancer, true erosions of the cervix

Complicated cervical ectopia Treatment goals for cervical ectopia: Elimination of concomitant inflammation Correction of hormonal and immune disorders Correction of vaginal microbiocenosis Destruction of pathologically altered cervical tissue Examination of the cervix and colposcopy is carried out no earlier than 4-6 weeks after surgical treatment

Ectropion Ectropion - eversion of the mucous membrane of the cervical canal Treatment goals for ectropion: restoration of the anatomy and architectonics of the cervix Elimination of concomitant inflammation Correction of the vaginal microbiocenosis Surgical treatment on an outpatient basis with a release from work for 1-2 days, with reconstructive plastic surgery performed in a hospital , the patient is given a sick leave for 7-10 days Control examination after 6-8 weeks

Cervical leukoplakia Cervical leukoplakia is a pathological process associated with keratinization of stratified squamous epithelium (a synonym for cervical dyskeratosis) ICD code for cervical leukoplakia Extended colposcopy allows you to clarify the size and nature of the lesion Targeted biopsy and curettage of the cervical canal with histological examination is the main diagnostic method Differential diagnosis with cervical cancer, consultation of an oncologist in case of a combination of LSM and CIN3, consultation of an endocrinologist in case of complex hormonal disorders Treatment of concomitant inflammatory diseases of the genital organs, destruction of pathologically altered tissue of the cervix (in the presence of CIN1-2) including colposcopic and cytological examination, testing for HPV - 1 time in 6 months for 2 years, with satisfactory results - transfer to the usual screening regimen

Treatment goals Removal of atypical epithelium Antiviral therapy CIN2-3 immunomodulatory therapy should be treated with amputation, conization, or destruction. The choice of the scope of the operation depends on the age of the woman, the nature and extent of the process, CIN1 is determined individually, observation is shown every 6 months for 2 years. After destructive treatments, examination and colposcopy after 6-8 weeks, then 1 time in 3 months during the first year and 2 times a year thereafter

Exo-endocervicitis Under the term exocervicitis understand inflammation of the vaginal part of the cervix. Endocervicitis is an inflammation of the mucous membrane of the cervical canal of the cervix. Differential diagnosis from cervical ectopia, cervical cancer, specific cervicitis (gonorrhea, syphilis, tuberculosis)

Treatment goals: Relief of the inflammatory process by etiotropic treatment Elimination of predisposing factors (the presence of atrophic colpitis in menopause) Treatment of concomitant diseases Drug treatment: etiotropic therapy and restoration of normal vaginal microbiocenosis Surgical treatment in combination with other diseases of the cervix (dysplasia, elongation, cicatricial deformity, etc.) e.) Patients are at risk for STIs and cancer of the cervix. Dispensary observation after adequately carried out treatment 1 time per year.

Inflammatory diseases of the pelvic organs The minimum criteria for PID according to WHO: Soreness on palpation in the lower abdomen Soreness in the appendages Painful traction of the cervix If these signs are present and there is no other cause of the disease, all sexually active young women of reproductive age should be treated! !!

PID Additional WHO criteria (to increase specificity of diagnosis): Body temperature above 38 Abnormal discharge from the cervix or vagina Leukocytosis, changes in the leukocyte count, increased ESR and C-reactive protein levels Laboratory evidence of cervical infection caused by STIs

PID Defining criteria: Pathological confirmation of endometritis on endometrial biopsy, Thickening of the fallopian tubes, presence of free fluid in the abdominal cavity or a tubo-ovarian mass on ultrasound, Deviations consistent with PID detected at laparoscopy.

PID-stages of treatment: Etiotropic therapy - broad-spectrum antibiotics Immunomodulatory therapy in the chronic phase Physiotherapy and spa treatment Contraception Dispensary observation 3 months after recovery or stable remission

Treatment of hyperplastic processes in the endometrium First stage - therapeutic and diagnostic curettage of the uterine mucosa under the control of hysteroscopy Second stage - therapeutic measures aimed at preventing relapse (COCs, gestagens, antigonadotropins, GnRH agonists, depot forms of gestagens) Diet combined with drugs that regulate carbohydrate metabolism Upon completion of hormone therapy - control hysteroscopy with endometrial biopsy. In women with infertility, the next stage is ovulation induction Observation once a year with ultrasound

Retention cysts - screening and primary prevention To prevent the recurrence of functional cysts, the restoration of the menstrual cycle is indicated, taking into account the hormonal status. If chronic inflammatory processes that provoke cyst recurrence are detected, anti-inflammatory treatment is indicated.

Tumors of the ovaries The second stage lasts the first 2 years, regular examinations with ultrasound every 6 months The third stage of the year after the operation. Gynecological examinations and ultrasound every 4-6 months Fourth stage - observation is carried out every six months with ultrasound of the pelvic organs

Endometriosis Endometriosis is a benign disease characterized by the growth of tissue outside the uterine cavity, which has a morphological similarity to the endometrium and undergoes cyclic changes according to the menstrual cycle.

Endometriosis Differential diagnosis with: Uterine myoma Chronic endometritis Hyperplastic processes in the endometrium Ovarian tumors Metrophlebitis Malignant formations of the genital organs Tuboovarian formations of inflammatory etiology Differential diagnosis of endometriosis of the cervix is ​​carried out with Cervical carcinoma Chronic endocervicitis Cervical cysts with hemorrhagic contents According to indications - consultations of specialists: urologist, gastroenterologist, psychiatrist

Endometriosis Treatment goals: relief of clinical symptoms, removal of endometriosis foci, restoration of reproductive function Treatment of endometriosis mainly consists of a combination of surgical and hormonal therapy Drug therapy is carried out in the antenatal clinic enzymatic activity, stimulation of tissue repair Support for vaginal normobiocenosis Restoration of a two-phase menstrual cycle after the end of drug treatment Observation in the antenatal clinic at 1 year after the end of treatment 1 time in 3 months during organ-preserving operations with ultrasound control

Uterine fibroids Uterine fibroids are benign solid tumors of monoclonal origin arising from smooth muscle cells of the myometrium and containing varying amounts of connective tissue. Uterine leiomyoma is formed due to poorly controlled proliferation of individual smooth muscle cells in combination with vasodilation and excessive extracellular collagen deposition ICD-10 D 25-D 25.3

Uterine fibroids The plan for managing a patient with uterine fibroids depends on the location and size of the node, the age of the patient, reproductive plans, and symptoms of fibroids. Clinical minimum, Colposcopy, transvaginal ultrasound, Diagnostic curettage or aspirate from the uterine cavity, Consultations of related specialists to identify concomitant pathology, Observation 2-4 times a year

Uterine fibroids Screening and primary prevention - ultrasound once a year Expectant management is justified in patients with uterine myoma who are not interested in maintaining reproductive function (premenopausal and postmenopausal) without clinical manifestations of the disease and the absence of tumor growth Dynamic monitoring is carried out 1 time in 6 months with ultrasound and analysis blood

Uterine fibroids Indications for surgical treatment: Rapid growth of uterine fibroids (along the largest node) Acute malnutrition in the myomatous node Suspicion of sarcoma Growth of the myomatous node in postmenopause Large uterine myoma (14-16 weeks of pregnancy) "Nursing" myomatous node Violation of the function of neighboring organs Unfavorable node locations: submucosal, cervical, intraligamentary, subserous pedunculated

Uterine fibroids - UAE Advantages of UAE compared to surgical treatment: preservation of the uterus, no intraoperative blood loss, simultaneous effect on all myomatous nodes, lower risk of complications, shorter disability (1-2 weeks) Follow-up after UAE: after 3.6 months Ultrasound FSH in a month Contraindications to UAE: subserous node

Infertility Infertility (infertility) - the inability of spouses of childbearing age to conceive a child with regular sexual activity without contraception for 12 months ICD, 46 male infertility The frequency of infertility in marriage ranges from 8 to 29%

Screening and primary prevention Prevention of infertility is to improve the quality of medical care, as well as the general culture of the population. Reducing the number of abortions and their complications Timely diagnosis and treatment of STIs Promotion of a healthy lifestyle Stress management Refusal of unreasonable surgical interventions on the pelvic organs Timely planning of childbearing function Development of child and adolescent gynecology and andrology Improvement of endoscopic surgery Improvement of hormonal therapy for endocrine disorders

Infertility diagnostics: Rapid (up to 3-6 months) determination of the cause of infertility: gynecological examination, ultrasound monitoring of follicle growth, STIs, assessment of the condition of the fallopian tubes, direct visualization of the pelvic organs Exclusion of male and immunological infertility

Infertility treatment In the absence of a positive effect from the traditional treatment for 2 years, and in patients older than 35 years - no more than a year, it is advisable to use the methods of ASSISTED REPRODUCTIVE TECHNOLOGIES (IVF, ICSI). pregnancy, in addition, when a history of the birth of children with malformations is indicated, stillbirth, habitual miscarriage, late menarche, delayed sexual development, with severe pathozoospermia in the husband.

GYNECOLOGICAL PATIENTS

Order of the Ministry of Health of the Russian Federation of November 1, 2012 No. №572 n

"On approval of the procedure for rendering
medical care by profile
obstetrics and gynecology (for
except for the use
assisted reproductive
technologies)"

The main task of primary health care
health care for gynecological patients
is prevention, early detection and
treatment of the most common
gynecological diseases, as well as the provision
emergency medical care
conditions, sanitary and hygienic
education for prevention
abortion, reproductive health,
formation of a stereotype of a healthy image
life, using effective
outreach models
(patient schools, round tables with
patients, health days).

Preventive medical examinations for women

As part of primary health care
assistance, preventive
medical check-ups for women
for early detection of gynecological
diseases, pathologies of the mammary glands,
sexually transmitted infections, HIV infection, selection of contraceptive methods,
preconceptional and pregravid
preparation.

When carrying out preventive
examinations of women are carried out:
cytological screening for the presence
atypical cells of the cervix,
2. mammography,
3. Ultrasound of the pelvic organs.
1.

According to the results of preventive examinations of women, health status groups are formed:

Group I - practically healthy women who do not need
in dispensary observation;
Group II - women at risk of pathology
reproductive system;
Group III - women in need of additional
examination on an outpatient basis for clarification
(establishment) of the diagnosis at the first time
chronic disease or in the presence of an existing
chronic disease, as well as those in need of treatment
on an outpatient basis;
Group IV - women in need of additional
examination and treatment in a hospital;
Group V - women with newly diagnosed
diseases or observed for chronic
disease and having indications for rendering
high-tech medical care.

Health group management

Women assigned to groups I and II of the state of health,
preventive examinations are recommended at least once
in year.
If there is a risk of pathology
reproductive system in a woman of childbearing age
guided by an obstetrician-gynecologist
childbearing with subsequent selection of methods
contraception.
Women assigned to III, IV, V groups of the state
health, depending on the identified diseases
an individual treatment program is drawn up, with
necessary, a dispensary is established for them
observation by an obstetrician-gynecologist on site
residence.

1 dispensary group - women with
chronic diseases,
benign tumors and
hyperplastic processes of the reproductive
system and mammary gland, background
diseases of the cervix;
2 dispensary group - women with
congenital anomalies of development and position
genitals;
3 dispensary group - women with
dysfunction of the reproductive system
(miscarriage, infertility).

Dispensary observation groups:

Structure of medical examination
Diagnosis
Examination by doctors of other specialties
List of diagnostic procedures,
carried out in the process of observation and
treatment
Therapeutic and recreational activities
Frequency of re-examinations
Indications for inpatient treatment
Deregistration Criteria

10. Structure of medical examination

Documentation
Dispensary patient card
Control card F-30

11. Documentation

NOSOLOGY
Pathology of the cervix
Hyperplastic processes of the endometrium
endometriosis
uterine fibroids
Inflammatory diseases of women
genitals
Family planning

12. NOSOLOGY

A - a mandatory minimum of examinations
gynecological patients
Anamnesis.
General physical examination
respiratory, circulatory,
digestion, urinary system,
mammary glands.

Colposcopy.
Bimanual vaginal
study.

13. A - mandatory minimum examination of gynecological patients

Microscopic examination of discharge
female genital organs for aerobic and
facultative anaerobic microorganisms,
smear cytology (PAP test).
Ultrasound examination (hereinafter referred to as ultrasound)
genitals (1 time per year, then - according to indications),
Ultrasound of the mammary glands (1 time per year, then - on
testimony).
Mammography (at the age of 35-36 the first
mammography, at 35-50 years old - 1 time in 2 years,
over 50 years old - once a year).

14. A - mandatory minimum examination of gynecological patients

Pathology of the cervix
background diseases.
1. Hyperplastic processes
- endocervicosis: simple, proliferating, healing.
-polyps:
simple, proliferating, healing.
-papilloma,
- leukoplakia (simple)
- endometriosis.

15. Pathology of the cervix

2. Inflammatory changes:
- true erosion,
- cervicitis.
3. Post-traumatic:
- breaks
- ectropions,
- cicatricial changes.

16. Pathology of the cervix

precancerous diseases.
- dysplasia:
weakly expressed
I
moderately pronounced
expressed.
- leukoplakia with cell atypia
- erythroplakia,
- adenomatosis.

17. Pathology of the cervix

List of diagnostic
procedures
Oncocytology
Colposcopy
Targeted biopsy of the cervix
With dysplasia - diagnostic
curettage of the cervical
channel

18. List of diagnostic procedures

Therapeutic
Events
Stages of treatment:
Etiotropic and
anti-inflammatory.
1.
Local effect on the neck
uterus:
- chemical ("Solkovagin") 4 weeks.
74-90%.
- cryosurgery (necrosis 2.5 mm, time 25 min.)
Relapses 42%
2.

19. Therapeutic and recreational activities

- Surgical (knife amputation
cervix, cervical plastic).
- Electrosurgical (DEK, DEE)
cicatricial deformity
cervical canal, n.m.f.
Efficiency 95-97%.

20.

- Laser surgery.
epithelialization by 46 days.
Efficiency 98.9%
- Radiosurgical method
(surgitron). radio wave
impact. Efficiency
high.

21.

RADIO WAVES TREATMENT
cervix pathologies
Radio wave surgery is
atraumatic incision method and
coagulation of soft tissues without their destruction
using high frequency
electrical waves emitted from
variable power and constant
a frequency of 3.8 - 4.0 MHz.

22. RADIO WAVE TREATMENT OF CERVICAL PATHOLOGY

Indications for use:
- erosion,
- ectopia of the cervix,
- cicatricial deformity of the neck
postpartum breaks,
- eroded ectropion,
- cervical hypertrophy,
- cervical endometriosis,
- cervical leukoplakia,
- chronic cervicitis,
- dysplasia of the cervix of the 1st degree.

23. Indications for use:

EFFICIENCY
USING THE METHOD
minimal destruction of underlying tissues,
minimal bleeding during surgery;
no black scab is formed, because not
charring of tissues occurs;
no deep necrosis of underlying tissues
(in comparison with electrocoagulation);
slight swelling of the tissues, resulting in
further there is no increased wound
detachable;
Virtually no pain during surgery
and in the postoperative period;
sterilizing effect of emitted radio waves,
high cosmetic effect.

24. EFFICIENCY OF USING THE METHOD

Therapeutic
Events
Stimulation of processes
regeneration of MPE of the cervix,
regulation of endocrine and
immune system.
3.

25. Therapeutic and recreational activities

Frequency of repeated
inspections
Examination of the cervix in the mirrors
Oncocytological control 1 time in 3
months

26. Frequency of re-examinations

Deregistration Criteria
The absence of clinical and morphological
changes on observation:
- background diseases - 6 months.
- precancerous diseases - 12 months.

27. Deregistration criteria

Information Support
quarterly

- recovered.
Cases of malignant diseases
cervix III-IV st.

28. Information support quarterly

Hyperplastic processes
endometrium
Diagnosis of pathology of the endometrium
In the presence of uterine bleeding -
hemostasis
"D" observation within 1 year after
end of treatment.
Prevention of endometrial cancer

29. Hyperplastic processes of the endometrium

(A) gynecological examination
sick
Anamnesis. General physical
survey.
Study with mirrors.
Colposcopy.
vaginal
study.
Oncocytology of smears from the cervix (PAPtest).

30. (A) examination of gynecological patients

List of diagnostic procedures
Ultrasound of the uterus and ovaries
Oncocytology of the endometrium
Hysteroscopy
Separate diagnostic
scraping

31. List of diagnostic procedures

Examination by doctors of others
specialties
Therapist
Hematologist
Other specialists by indications

32. Examination by doctors of other specialties

Therapeutic
Events
prostaglandin synthetase inhibitors,
fibrinolysis inhibitors,
antianemic therapy,
estrogen progestogens, or
progestogens to regulate the cycle at 6
months (duphaston 10 mg from 6 to 25 days
cycle).

33. Therapeutic and recreational activities

Frequency of repeated
inspections
When bleeding - 1 time per week.
Then, 1 time in 2 weeks - 2 months.
After the normalization of the cycle - 1 time per
3 months throughout the year with a fence
oncocytology of the endometrium.

34. Frequency of re-examinations

Deregistration Criteria
Persistent normalization of menstruation
cycle during the year.
Normal morphological control.
Persistent menopause.

35. Deregistration criteria

Information Support
quarterly
The number taken on the "D" account, of which
- recovered.
Cases of endometrial cancer
IV Art.

36. Information support quarterly

uterine fibroids
Submucosal uterine fibroids
Interstitial uterine fibroids
Subserous uterine fibroids

37. Uterine fibroids

List of diagnostic
procedures
Ultrasound of the uterus and appendages
If necessary:
hysteroscopy or HSG
separate diagnostic
scraping

38. List of diagnostic procedures

Therapeutic
Events
Asymptomatic fibroids and after
conservative myomectomy:
- Hormone therapy (gestagens,
antigestagens), physiotherapy, SCL.
Symptomatic myoma: operational
treatment (according to indications).

39. Therapeutic and recreational activities

Frequency of repeated
inspections
At discharge from the hospital after 10 days
and when leaving for work.
Then at least once every 6 months.

40. Frequency of re-examinations

Deregistration Criteria
With conservative treatment or after
organ-preserving operations removal from
accounting is not recommended until the end of life.
After radical operations - after 6
months

41. Deregistration criteria

Information Support
quarterly
The number taken on the "D" account, of which
- recovered.
Cases of uterine sarcoma.

42. Information support quarterly

Inflammatory diseases
female genital organs
Chronic salpingo-oophoritis.
Hydrosalpinx.
chronic inflammatory disease
uterus.
Endocervicitis.
Bartholin gland cyst.
Vulvovaginitis

43. Inflammatory diseases of the female genital organs

Establish a diagnosis.
In case of an acute process, direct to
hospital treatment.
Rehabilitation after
acute process.
Carrying out anti-relapse
treatment for a chronic process

44. Inflammatory diseases of the female genital organs

List of diagnostic
procedures
Category A
Thermometry.
Clinical blood test.
Biochemical blood test (C-
reactive protein)
Bacterioscopy for flora and degree
purity.
Testing for STIs.
Ultrasound of the uterus and appendages.
Hysteroscopy.

45. List of diagnostic procedures

Therapeutic
Events
In an acute process, treatment under conditions
hospital.
After station. treatment - early
rehabilitation (local, physiotherapy).
In a chronic process
dissolution therapy,
antibiotic therapy, blockers
prostaglandins, physiotherapy,
immunotherapy, mud therapy, gin massage.

46. ​​Therapeutic and recreational activities

Frequency of repeated
inspections
1-2 times in the first month until
recovery
Then 1 time in 3 months.
Upon discharge from the hospital before
exit to work.

47. Frequency of re-examinations

Deregistration Criteria
If there are no recurrences within 1
of the year.
After surgical treatment,
recovery.

48. Deregistration criteria

Information Support
quarterly
The number taken on the "D" account, of which
- recovered.
Cases of recurrence of inflammatory
diseases.

49. Information support quarterly

Barren marriage
A fruitless marriage is an absence
pregnancy in spouses of childbearing
age within 1 year of regular
sexual life without the use of any
contraceptives.
According to epidemiological data
research,
frequency of infertile couples ranges from 8 to
15%,

50. Barren marriage

female infertility
female infertility associated with
lack of ovulation
Tubal-peritoneal infertility
Female uterine infertility
origin
Female cervical infertility
origin
Other forms of female infertility.

51. Female infertility

List of diagnostic procedures
Clinical - anamnestic data
Clinical - laboratory examination:
- gynecological status,
- TFD,
- infectious disease examination
chlamydia, gonorrhea, mycoplasma,
trichomonas and viral
(herpetic and cytomegalovirus).
Ultrasound examination of the uterus and
ovaries.
Evaluation of the patency of the fallopian tubes
(hydroultrasound, HSG)

52. List of diagnostic procedures

Hormonal examination
- with the preserved rhythm of menstruation
for 2-5 d.c. prolactin, testosterone,
cortisol and TSH, T3, T4.
- with a disturbed rhythm of menstruation,
in addition, the levels of gonadotropins
(FSH, LH),

Combined endoscopic
examination (chromo-laparoscopy and
hysteroscopy).

53. List of diagnostic procedures

Hormonal examination
- with the saved rhythm of menstruation for 2-5
d.c. prolactin, testosterone, cortisol and TSH,
T3, T4.
- with a disturbed rhythm of menstruation, except
this levels of gonadotropins (FSH, LH),
androgens (T, DHEA-S), estradiol.

54. List of diagnostic procedures

Immunological examination
- postcoital test (test
Shuvarsky), ASAT.
Diagnosis of male infertility

Clinical examination of gynecological patients

Clinical examination- active dynamic monitoring of the health status of the population, including a set of preventive, diagnostic, therapeutic and health-improving measures.

Initially, the principles and methods of D. were used to combat socially dangerous diseases - tuberculosis, syphilis, trachoma, etc. Subsequently, the dispensary method was used to monitor pregnant women, children, workers in leading industries and agriculture. production, patients suffering from chronic diseases.

The purpose of D. is the formation, preservation and strengthening of the health of the population, the prevention of diseases, the reduction of morbidity, disability, mortality, and the achievement of active longevity. D. is included as an integral part of a wide system of measures for the prevention of diseases carried out by the state, society, and health care. National efforts are aimed at improving working conditions, living and resting, ensuring a rational balanced diet, combating physical inactivity, smoking, alcohol consumption, ᴛ. ᴇ. to the formation of a healthy lifestyle. In this set of measures, an important role is assigned to the health care system, which uses a dispensary method that synthesizes prevention and treatment, aimed at detecting diseases in the earliest stages and preventing them through systematic medical monitoring of the health of the population.

Clinical examination includes: an annual medical examination with laboratory and instrumental studies to detect diseases in the early stages, as well as an examination of people with risk factors for developing diseases; additional examination of those in need using modern diagnostic methods; determination of the state of health of each person; implementation of a complex of medical and recreational measures for patients and persons with risk factors and subsequent systematic monitoring of their health.

The use of all existing diagnostic methods for mass examinations within the framework of D. seems to be hardly justified, since, along with low economic efficiency, this would lead to an overload of medical institutions and to a negative reaction of the population to excessively frequent analyzes, functional and other studies. For this reason, a relatively narrow range of laboratory and instrumental studies has been defined, which, nevertheless, makes it possible to identify or suspect the presence of the most common diseases of medical and social significance.

The district therapist (both territorial and shop area) annually examines the entire adult attached population. A preliminary pre-medical examination is carried out, ĸᴏᴛᴏᴩᴏᴇ includes measurement of height and body weight, blood pressure, determination of hearing and vision acuity, pneumotachometry. Gynecological examination of women with a mandatory cytological examination is carried out from the age of 18; electrocardiography - from 15 to 40 years 1 time in 3 years, after 40 years - annually; measurement of intraocular pressure - annually after 40 years; women - mammography 1 time in 2 years after 40 years. Chest fluorography is differentiated, but at least once every 3 years, with a high incidence of tuberculosis in the relevant territory - annually.