Method of diagnosing ruptures of ligaments of symphysis pubis during pregnancy and in postpartum period. RU patent 2423911.

FIELD: medicine.

SUBSTANCE: invention relates to medicine and can be used for timely detection and treatment of failure of ligament apparatus of symphysis pubis in obstetric- gynecological and trauma practice. In the beginning of pregnancy factors of risk of symphysis pubis ruptures are determined: narrow pelvis, post-trauma pelvis deformities, exostoses, presence of expressed contractures of hip joints and hip joint endoprosthesis, previous pelvis trauma, kyphoscoliosis, fractures of thoracolumbar part of spine, pelvic pain in previous pregnancies and labours, rupture of symphysis pubis ligaments and gait disturbance during previous pregnancies and labours, large fetus, presence of scar on uterus from previous operation of cesarean section, incorrect position and fetus presentation, defects of its development. If at least one factor is present pregnant women are put into a risk group and clinical and ultrasonic examinations are performed in dynamics: at early pregnancy, in the middle of pregnancy and 7-10 days before labour. If in the middle of pregnancy or 7-10 days before labour pelvic pain syndrome grows, and/or ultrasonic examination shows increase of symphysis pubis diastasis to 9 mm and more, overdistension of symphysis pubis is determined and it is recommended to carry out delivery by cesarean section. On 1-3 day after delivery, both natural and by cesarean section, control clinical and X-ray examination of pubic bones in 2 projections and/or magnetic-resonance or computer tomography are carried out.

EFFECT: method ensures objective estimation of state of symphysis pubis ligaments during pregnancy and in postpartum period, Increases efficiency of diagnostics.

3 ex

The invention relates to medicine and can be used to identify the risk of gaps articulation in pregnancy, childbirth and the puerperium.

Frequency of pathological changes of the joints of the pelvis during pregnancy and after childbirth, particularly articulation according to the literature ranges from 0.12 to 56%. Such large fluctuations can be explained by a lack of attention to the pathology of patients and doctors (obstetricians-gynecologists, surgeons, traumatologists-orthopedists), and that often breaks joint proceed with mild symptoms, they remain unrecognized.

The severity of the clinical picture depends on the degree of divergence of bones. According to the adopted in the literature classification expansion articulation can be of three classes: I degree - 5-9 mm, II degree - 10-20 mm, III degree - more than 20 mm (almost breaks joint). The severity of the symptoms varies from mild discomfort to the expressed pain syndrome (1, 2).

In obstetric practice doctors are guided by complaints pregnant women or new mothers and sent for consultation to a surgeon or consulting a traumatologist for diagnosis. So if there is a discrepancy bones of the first degree pregnant and parturients complaints usually do not present and the doctor is focused on clinical data on examination of pregnant women and mothers. In the second degree complain of pain in the and sacroiliac joints, gait disturbance, for the third time degree of divergence bones strong pains in the field of junction and region sacroiliac joints, the inability to make vigorous movement of the limbs and turn on its side.

Diagnosis of pregnant women are usually installed on clinical data: pain in mating, ileo-sacral mating, gait disturbance, and use x-ray (3) and, in rare cases, ultrasound examination, (MRI) or computer (CT) imaging. Pregnant women are recommended to limit the prolonged stay on their feet, and it is shown wearing the prenatal bandage.

However, some clinical data do not give a clear idea about the offset articulation and appointed conservative treatment is not always effective, it's not always possible to give recommendations to the choice of rational method of delivery (naturally or by caesarean section). X-ray method of the study, although it provides the opportunity to the most reliably diagnosed gap articulation, is contraindicated during pregnancy, ultrasound, MPT, CT appointed already in extreme cases.

In the postpartum period with complaints of child-birth, are examined by clinical signs, and the final diagnosis is x-ray of the pelvis or use (MRI), CT (CT) imaging.

However, clinical examination and x-rays of the pelvis (front projection), is often late for 3-5 days and more, since the emergence of pain in the junction and the sacrum, gait disturbance (may take some time to themselves parturients and doctors, midwives pay attention almost before or after discharge from the hospital, so missed the early periods, which can conduct effective conservative treatment, and there is a need surgical treatment. In addition, when x-ray of the pelvis in the direct projection is not always detected bias in the vertical plane of articulation, and a shift in the Sacro-iliac mating, and MRI, CT only specifies the diagnosis for the required surgery.

There is a method of diagnostics of risk ruptures of ligaments joint in pregnancy and the postpartum period, including the identification of risk factors ligament rupture articulation, clinical examination, the use of radiological methods of diagnostics (7).

However, the known factors is not always possible to objectively identify the pathological changes joint in pregnancy and after childbirth and to choose a rational method of delivery, use x-rays during pregnancy is contraindicated, as ultrasound, MRI, CT appointed already in extreme cases. Postpartum examination articulation (on clinical grounds, x-ray of the pelvis or magnetic resonance (MRI), computer tomography (CT) imaging) is carried out only on the complaints of mothers and often only in 5 and more day.

The objective - an objective assessment of the ligaments articulation, risk identification ruptures of ligaments joint in pregnancy and the postpartum period, increase of efficiency of diagnostics.

The method of diagnostics ruptures of ligaments joint in pregnancy and the postpartum period, which includes determination in early pregnancy, risk factors, clinical examination and use in the postpartum period radiology procedures, according to the invention in early pregnancy define the following risk factors: a narrow pelvis, posttraumatic deformations of the pelvis, exostosis, the presence of severe stiffness of hip joints, the presence of endoprosthesis of the hip joint, the previous pelvic trauma, kyphoscoliosis, fractures spine, pelvic pain in the previous pregnancies, ligaments articulation and gait disturbance during the previous pregnancies and childbirth, presumed large fruit, the presence of uterine scar from a previous cesarean section, the correct position and presentation of the fetus, malformations of the fetus, and if at least one factor pregnant referred to the group of risk of tearing articulation. Appoint a survey of clinical and ultrasound in the dynamics: in the early stages of pregnancy, in the middle of the pregnancy and for 7-10 days before delivery. If in the middle of the pregnancy or for 7-10 days before childbirth increases pelvic pain syndrome and/or ultrasound shows increase in the diastasis articulation to 9 mm and more define articulation and recommend births by caesarean section. At 1-3 days after birth, both natural and by caesarean section to control clinical and x-ray examination bones in 2 projections and/or or CT.

Torn ligaments a joint in most cases occur in the horizontal plane (basin width), because the rear complex of the sacroiliac joint is represented by three powerful chords (front, middle, back). Deliveries are usually held at a horizontal position of the body. When the direction of acting force and to the pelvic bones from the inside outwards to the right and to the left from the centre of the pelvis, that is focused on the gap articulation. Possible bias bones in vertical and anteroposterior direction. In normal width articulation is 6-8 mm (age 18-20), then decreases with age. Sometimes it is permissible up to a width of 9 mm when pain and violation of gait, when standing, walking, bending the body in turning torso in a prone position (1, 4, 5). Possible gaps and sacroiliac joints (6).

The authors have defined the most significant factors influencing the discrepancy a joint in pregnancy: a narrow pelvis, posttraumatic deformations of the pelvis, exostosis, the presence of severe stiffness of hip joints, the presence of endoprosthesis of the hip joint, the previous pelvic trauma, kyphoscoliosis, fractures spine, pelvic pain during the previous pregnancies, ligaments articulation and gait disturbance during the previous pregnancies and childbirth, presumed large fruit, the presence of scar on the uterus from a previous cesarean section, the correct position and presentation of the fetus, malformations of the fetus. Clinical studies confirm that there is at least one factor of pregnancy must be included in the risk group of potential rupture junction and carry out clinical and ultrasound examination in dynamics of pregnancy up to 3 times and examine the state of articulation to identify gaps articulation, including «hidden damage immediately after birth at 1-3 days of using clinical and radiographic, 2 projections, examination, and, if unobservable inputs (for example, is detected clinically ligaments, and on the radiograph offset width not detected) conduct or a CT scan to identify a clear zone and nature of damage to the ligaments.

Was studied 113 pregnant and parturient women with breaks bones. Age from 19 to 43 years. Every woman in history where at least one risk factor. Divergence bones all women began during pregnancy, and 57 of them during delivery gap occurred not only ligaments articulation, but also the sacroiliac joint.

At receipt on the account of obstetrician-gynecologist identifies risk factors for pregnant: narrow pelvis, posttraumatic deformations of the pelvis, exostosis, the presence of severe stiffness of hip joints, the presence of endoprosthesis of the hip joint, the previous pelvic trauma, kyphoscoliosis, fractures spine, pelvic pain during the previous pregnancies, ligaments articulation and gait disturbance during the previous pregnancies and childbirth, presumed large fruit, the presence of uterine scar from a previous cesarean section, the correct position and presentation of the fetus, vices development of the fetus. When identifying at least one risk factor obstetrician includes pregnant-risk group, shall send to the doctor for advice consulting a traumatologist in the conduct of clinical and ultrasound examination in dynamics: in the early stages of pregnancy, in the middle of the pregnancy and for 7-10 days before delivery. If in the middle or for 7-10 days prior to delivery will be increase of pelvic pain syndrome and/or ultrasound will show increases diastasis articulation to 9 mm, is regarded as articulation and trauma issues recommendations and, together with a midwife gynecologist prepare pregnant to conduct births by caesarean section. In the period prior to delivery for prevention recommend pregnant wearing a bandage exciting thighs, the bed alternate with special exercises (LFC), take preventive drugs calcium and vitamins of group B. After childbirth as a natural and by caesarean section at 1-3 days of puerperas monitor the condition of the articulation. To confirm the diagnosis, provide clinical and x-ray examination and/or need an MRI or CT. X-ray examination carried out in 2 projections (direct and axial) and suspicion on the vertical instability displacements in mating height, optional with functional tests, i.e conduct x-ray standing alternately, the one and the other leg. For the detection of shifts in the anteroposterior direction perform axial () projection, ray apparatus is placed into the entrance to the small pelvis side of the head. When the underlying diagnosis is unclear appoint or CT. When identifying or break articulation doctor appoints indications conservative or surgical treatment.

This improves the efficiency of diagnosis, as comprehensively addressed the problem of objective examination of pregnant women and parturient women, early warning breaks articulation and implementation of effective treatment.

Example 1. Patient M, 25 years old, was under the supervision of the Institute of MME Ekaterinburg. Diagnosis: pregnancy 16 weeks.

Clinical examination in early pregnancy identified risk factor is a narrow pelvis. The patient is included in the risk group. The clinical and ultrasound examination in dynamics in terms of pregnancy: 16 weeks 20 weeks and 7 days prior to childbirth showed that by the middle of pregnancy pains in junction, which are gradually increased towards the end of pregnancy. Oseltamivir recommended wearing prenatal bandage supplementation of calcium and vitamins. Ultrasonic examination within 7 days prior to delivery has been shown to increase diastasis articulation to 10 mm ( - the risk of rupture of ligaments joint). The patient recommended births by caesarean section. After delivery on the 3rd day with the objective of monitoring conducted an x-ray examination in two projections (direct, front-back). Diastasis joint remained within 10 mm, pain in junction no. Recommended for the prevention of wear symphyseal tritor bandage Dosi or pelvic girdle «Trochanter-gurter» by Otto Booch for 8 weeks and radiological control once a month. After 2 months of diastasis in mating amounted to 7 mm Exodus recovery.

Example 2. Patient P., 31. Diagnosis 30 weeks of pregnancy. Aims of the women's clinic at the reception in .

In a survey of pregnant revealed that she had previously had injury to the pelvis. The survey showed that the presence of pain in the field of junction and the sacrum, walking and climbing out of bed, if you turn the body in the bed, clinically identified a discrepancy bones, tissue swelling. An ultrasound revealed a discrepancy junction 12 mm ( - the risk of rupture of ligaments joint). The patient oseltamivir recommended to restrict stay on their feet, wearing prenatal bandage supplementation of calcium and vitamins. Repeated examination. For 10 days prior to delivery, clinical and ultrasound examination revealed: in the field of articulation and sacrum pain increased, diastasis articulation increased to 18 mm Appointed the use of analgesics. The patient recommended births by caesarean section and after childbirth for examination articulation. After the delivery of the 2-nd day clinical and radiological examination of the pelvis in 2 projections. The size of diastasis amounted to 16 mm The patient immediately appointed intensive conservative treatment: the wearing of the pelvic girdle 2.5 months, bed rest, 1 month, physiotherapy (electrophoresis dipyrone and by a standard method), therapeutic exercise, medication calcium and vitamins. Inspection of patients 3 months after birth showed a decrease diastasis joints up to 6 mm and good anatomical and functional results. Exodus recovery.

Example 3. The patient, 32 years. Entered the trauma Department on the 10th day after the urgent largest fruit of labor rapid) with a diagnosis of ligaments articulation.

The anamnesis of the patient attended risk factors gap junction - large fruit. In the second half of pregnancy were observed pain that the patient did not pay attention; on the advice of the orthopaedist-traumatologist was not.

Spent x-ray examination in 2 projections direct, seat, front-rear, axial(kaudalnaya) and for the diagnosis - magnetic resonance scan revealed a vast zone of damage: ligaments junction with 31 mm and ligaments of the sacroiliac joint right up to 5 mm

Due to the instability of pelvic ring conducted operative treatment: osteosynthesis joints device for external fixation. On the 7th day was discharged from the traumatology Department. The device with the pelvis lifted after 8 weeks. After 6 months marked by a good and functional result. Diastasis junction - 4 mm, the Outcome is the cure.

The positive effect of the proposed method:

- ability to dynamically control before and after birth,

- opportunity of an estimation of a condition and revealing of ligament damage articulation at early and late stages of pregnancy and after childbirth,

- ability to define a zone, the nature and scope of ligament damage and sacroiliac joints,

- absolutely harmless for pregnant women, rather precise,

- allows to objectify the obtained data,

- gives the opportunity to perform preventive and curative measures (tips trauma on conservative and operative treatment),

- allows to recommend the obstetrician-gynecologist possible methods of delivery (natural or by caesarean section).

The proposed method can be widely used for the timely detection and treatment of such pathology as a failure of the ligamentous apparatus articulation in obstetric and trauma practice, it directs the attention of doctors for possible damage mating, timely preventive measures can significantly reduce the share of surgical interventions for damage joint in pregnancy and childbirth.

Literature

1. Vanina L.V. On a classification of changes in the joints of the pelvis pregnant and parturient women / Obstetrics and gynecology - 1954. - №5. - P.45-48.

2. .. and tear on the joints of the pelvis / in the book: Manual of obstetrics and gynecology. - 1964. - .223-227.

3. Zhordania I.PH. Textbook of obstetrics. Meters, - 1955. - .471.

4. Mineev K.P., K.K. treatment of serious injuries of the pelvis and spine. - Ulyanovsk, 1996. - .83.

5. Korolyuk I.P. Atlas of the skeleton (the standard options, errors of interpretation). Meters, - 1996. - P.97.

6. K.K., Mineev K.P., Mineev K.K. Treatment of breaks in the pelvic ring after delivery / abstracts of all-Russian scientific-practical conference «Pressing questions of diagnostics and treatment of combined trauma», 20-22 November 1996 - Prokopevsk, 1996. P.47 - 48.

7. Chernukha EA, Anan'ev E.V. Dysfunction articulation Journal of the Russian society of obstetricians-gynecologists, 2006, 3 (electronic resource on the Internet www.ag-info.ru/jroag/2006-3/1).

Method of diagnostics of risk ruptures of ligaments joint in pregnancy and the postpartum period, including determination in early pregnancy, risk factors, clinical examination and use in the postpartum period of radiological methods of diagnostics, characterized in that in early pregnancy define the following risk factors: a narrow pelvis, posttraumatic deformations of the pelvis, exostosis, the presence of severe stiffness of hip joints, the presence of endoprosthesis of the hip joint, the previous pelvic trauma, kyphoscoliosis, fractures spine, pelvic pain in the previous pregnancies, ligaments articulation and gait disturbance during the previous pregnancies and childbirth, presumed large fruit, the presence of uterine scar from a previous cesarean section, the correct position and presentation of the fetus, malformations of the fetus, and if at least one factor pregnant referred to the group of risk of potential rupture articulation and provide clinical and ultrasound tests in the dynamics: in the early stages of pregnancy, in the middle of the pregnancy and for 7-10 days before delivery, if in the middle of pregnancy or for 7-10 days before delivery occurs increase pelvic pain syndrome and/or ultrasound shows increase in the diastasis articulation to 9 mm or more, determine articulation and recommend births by caesarean section, and at 1-3 days after birth, both natural and by caesarean section, to control clinical and x-ray examination bones in 2 projections and/or magnetic resonance or computer tomography.