Development centre of medical education tashkent medical academy

:)


Download 0.69 Mb.
Page1/13
Date conversion20.04.2018
Size0.69 Mb.
  1   2   3   4   5   6   7   8   9   ...   13
MINISTRY OF PUBLIC HEALTH OF THE REPUBLIC OF UZBEKISTAN

DEVELOPMENT CENTRE OF MEDICAL EDUCATION
TASHKENT MEDICAL ACADEMY



«Affirms»

Prorector for educational work

Tashkent medical Akademy

Prof. Teshayev O.R.

THE MANUAL



ON THE PRACTICAL TRAINING OF PATHOLOGICAL OBSTETRICS

FORMED BY INTEGRATED METHODOLOGICAL SYSTEM
The manual

for teachers and students of the medical universities

Tashkent-2012

Edited by Head of the Department of Obstetrics and Gynecology, Professor TMA Ayupova FM and associate professor Shukurova FI

Compiled by:
          
Zhabbarova JK Professor of Obstetrics and Gynecology, TMA
Babazhanova GS - Professor, Department of Obstetrics and Gynecology, TMA
Bekbaulieva G.N.-d.m.n., assistant professor of obstetrics and gynecology TMA
Nigmatova GM - MD, assistant professor of obstetrics and gynecology TMA
Abdullayev LM - MD, assistant professor of obstetrics and gynecology TMA
Saidzhalilova DD - d.m.n, assistant professor of obstetrics and gynecology TMA
Ayupova DA - PhD, Ass. Department of Obstetrics and Gynecology, TMA
Khodjaeva DN - K.m.n., Ass. Department of Obstetrics and Gynecology, TMA
Sherbaeva DB - Ass. Department of Obstetrics and Gynecology, TMA
Muminova ZA - Ass. Department of Obstetrics and Gynecology, TMA

Reviewed by:


1. Nazhmutdinova DK-Head of Department. Obstetrics and gynecology GP TMA, MD, PhD
2. Sultans SN-director of scientific practical center A and D MH Uzbekistan,
       MD, PhD

The manual was approved:
at a meeting of SSC TMA Minutes № 10 of June 6, 2008

Approved at the meeting of the Academic Council of TMA

 Minutes № 12 of 25 June 2008
Scientific Secretary Ph.D., Professor G.S.Rahimbaeva

INTRODUCTION

Currently, Uzbekistan is a new system of education, focused on entry into the world educational space. This process is accompanied by significant changes in educational theory and practice of educational work: a transition to advanced innovative educational technology, the widespread use of interactive teaching methods. Continues to work to improve the educational and methodological expertise of university faculty. In this regard, each HIGH SCHOOL be science-based regulatory model learning system that can provide the fundamental unity of profiling and specialized disciplines. It is such a common technical system (EMS) of the university as a whole and each department separately. Under the EMC implied normative model design and implementation of the educational process, the theoretically calculated according to the identified its objectives, principles, functions, and special logic and didactic training sessions parameters (both lecture and practical). EMC objectives are: unification of teaching, reducing the dependence on the skills and talents of the teacher, the increasing importance and proportion of independent work of students, strengthening the policy of intensification and the computerization of the educational process, the development of creative abilities of students. Teaching science is almost established that the learning process can not be constructed scientifically and efficiently, while psycho-educational laws have not been translated into the language of the rules and criteria for the organization of the learning process. EMC is a technology teacher, guide the work of each teacher for optimal achievement of goals. General principles for the formulation of specific EMS training are basic elements of teaching and methodical control mechanism, being dynamic, ie constantly developed and specified.

To this end, the department staff to write this teaching aid.
It is intended for teachers and medical students.

CONTENTS
Vaginal bleeding in early (threatening, incomplete, complete abortion is not held-miscarriage) and late pregnancy. Premature by-puff normally situated placenta. Placenta previa. Causes, clinical features, early recognition and emergency .........................................................................

Vaginal bleeding after delivery: the reasons (anomalies of the placenta is attached tion, hypotension, and atony of the uterus, the delay of the next, tearing of the cervix and perineum). Rapid initial assessment, methods to stop bleeding, resuscitation, measures

Unsatisfactory progress of labor. Passive and active phase of labor. Classification. The etiology, clinical features and diagnosis of different types of anomalies of labor. Obstetric and prevention tactics. Rodostimulyatsiya oxytocin WHO recommends ................................................................

Narrow pelvis, etiology, types, classification, diagnosis. The disproportion of the fetal head and the mother's pelvis. Dystocia. Causes and clinical symptoms functionally narrow pelvis. Complications for mother and fetus, their…………………………………………………………

Malposition, causes, diagnosis, tactics ............................................................................................

 Vaginal bleeding during labor: uterine rupture. Classification, etiology-logy and pathogenesis, clinical features, diagnosis, principles of treatment, prevention. Re-morragichesky shock. DIC - syndrome .........................................................................................................................................

Rodorazreshayuschih surgery: cesarean section, forceps, vacuum - the extraction of the fetus, fetal extraction of pelvic end ......................................... .................................................................

Emergency conditions and problems of the newborn. Resuscitation of newborn. Intrauterine infection of the fetus. The concept of the TORCH - infections. Ways of intrauterine infection. Diagnosis, treatment and obstetric tactics .....................................................................................

 Transmission of HIV from mother to fetus. Integration of prevention of HIV transmission from mother to child in an effective perinatal care. Pre-and post-test counseling for HIV. Antenatal care of HIV-positive pregnant, administering antiretroviral drugs. Choosing SPO-soba delivery (elective caesarean section), safe practices of the Veda birth. Safe infant feeding practices. Special care for infants of HIV-positive mothers. Prevention of obstetric complications. Preventing HIV infection in the workplace ...................................................................................


Pathology of the postpartum period. Secondary postpartum haemorrhage, thrombus boemboliya. Problems chest. Postpartum depression ...................................................................
High fever after delivery. Infection in the postpartum period. Modern ideas. Classification, the spread of infection. Modern ideas of the infectious agent. Diagnostics. Principles of treatment. Obstetrical peritonitis, causes, diagnosis, treatment. Prevention. High-risk groups, prevention outpatient ......................................................................................................................................


Topic: Vaginal bleeding in early (threatening, incomplete, complete abortion, miscarriage frustrated) and late pregnancy. Premature detachment of normally situated placenta. Placenta previa. Causes, clinical features, early recognition and first aid.
1st place of training, equipping,
- Department of Obstetrics and Gynecology, the audience;
- Dummy pelvis, female pelvis, doll fetus;
- Standard Model of pregnancy
- The classic model of labor;
- Gynecological simulator ZOE;
- Childbirth simulator Noelle;
- Simulator newborn Newborn;
- A set of slides on the topics of discipline;
- Methods of work in small groups: a method of "round table" problem solving, "pen in the middle of the table", "swarm", etc.;
- Training and supervision of practical skills in OSKE (by objective structured clinical examination).
- Video recorder;
- Personal computer (Pentium-IV);
- A set of slides with typical states by ultrasound scanning of pregnant women and gynecologic patients;
- A set of video blogs "VJOG" (USA), highlighting recent advances in diagnosis and treatment of obstetric and gynecological conditions;
- A set of movies and video with a demonstration of typical obstetrician-cal and gynecological procedures and operations.

- Educational videos;

- Educational software;
- Multi media training and testing;
- The use of e-mail and INTERNET;
- Business games and case studies;
- Centre for skills training;
- Offices and laboratories maternity complex;
- Delivery room;
- The department of pathology of pregnancy;
- A set of tests;
- A set of slides, overhead projector;
- Measuring tape, a stethoscope;
- Tools used during delivery;
- Outline the main stages of the diagnostic process;
- Step by step implementation of clinical skills;
- Stories of women giving birth with the pathological process of delivery.
2.Prodolzhitelnost study subjects
Number of hours, 5 hours
3.Tsel classes
- Examine the reasons causing bleeding in late pregnancy;
- To study the etiology and pathogenesis of premature detachment of normally situated placenta;
- To consider the classification of premature detachment of normally situated placenta;
- To analyze the clinical features and diagnosis of premature detachment of normally situated placenta;
- Learn the principles of management and treatment in pregnancy and childbirth in premature detachment of normally situated placenta;
- To study the etiology and pathogenesis of placenta previa;
- To consider the classification of placenta previa;
- To analyze the clinical features and diagnosis of placenta previa;
- Learn the principles of management and treatment in pregnancy and birth with placenta previa.
Tasks
The student should know:
- Understanding of the main causes of bleeding in late pregnancy;
- The causes, mechanism of PP and PONRP.
The student should be able to:

Find out the characteristic clinical symptoms of PP and PONRP, methods of diagnosis and differential diagnosis of these conditions, to learn about the impact of this disease on the child and on the principles of treatment and prevention.

4.Motivatsiya
Vaginal bleeding in late pregnancy occurs in about 4% of pregnant women. If you notice bleeding, the doctor must establish its cause. The first rule previa and premature detachment of the placenta - obstetric complications, the most dangerous for a pregnant woman and the fetus. With previa and premature detachment of the placenta due to 50% of bleeding in late pregnancy. Prognosis depends on prompt diagnosis of these complications. The need to study the topic, its importance in the study of the course and professional orientation is to improve and upgrade the knowledge of students, future GPs on bleeding in early and late stages of pregnancy. Identify women at high risk of bleeding in the later stages of pregnancy and HIV prevention activities during and beyond pregnancy. Help students learn practical skills at SVP, Northeast Asia and first aid on-dogos pitalnom level.
Intra 5.Mezhpredmetnye and communication
Teaching of the subject is based on the knowledge of the students basic anatomical mission, topographic anatomy, histology, normal and abnormal physiology, endocrinology and microbiology ..
Acquired during the course knowledge will be used during the passage of surgery, endocrinology, internal medicine, pathology of obstetrics, gynecology, hematology, health, pediatrics, anesthesiology.
6.Soderzhanie classes
6.1.Teoreticheskaya part
Bleeding in the first trimester.
Bleeding is one of the main problems of the modern acoustic sherstva. For years, obstetric hemorrhage is at the forefront of maternal mortality. This topic discusses bleeding occurring in the early and late stages of pregnancy.
The main causes of bleeding in the first trimester of pregnancy, STIs are:
 Spontaneous abortion / miscarriage
 trophoblastic disease
 Cervical Pregnancy

 The pathology of the cervix (cervical polyps, decidual polyps, cancer of the cervix).

 Ectopic Pregnancy
Spontaneous abortions (abortions).
Spontaneous abortion (miscarriage) is an abortion during the first 22 weeks. Distinguish early abortion (before 12 weeks gestation) and late (13 to 22 weeks of pregnancy). If a miscarriage is repeated two more times, then one speaks of habitual abortion.
The frequency of miscarriage is 2-8% of the total number of pregnancies.
The causes of miscarriages are often unclear. Important in their pathogenesis have delayed sexual development (infantile) preceding abortion services (especially the first pregnancy interruption) dysfunction of the endocrine glands, isthmic-cervical insufficiency, intrauterine adhesions, acute and chronic infectious diseases and intoxication Rh factor; genital tumors bodies and other physical factors (injuries, weight lifting) have an effect only if the predisposing causes.
Diagnostics.
In involuntary abortion two major signs are: pain and bleeding.
Spontaneous abortions are characterized by their gradual course (stage miscarriage) threatening miscarriage, started a miscarriage, abortion in progress, incomplete and complete spontaneous miscarriage.
Threatened miscarriage: bleeding can be very poor, aching, or missing or are aching, dull character in the abdomen. Such a condition is reversible, and the successful treatment of pregnancy is developing normally in the future.
Started miscarriage: bleeding may be slow, pain are colicky. Threatened miscarriage and started flowing amid quite satisfactory. Emergency measures to stop the bleeding in these cases is usually not required. Hospitalization is shown in the hospital, where it is decided the question of the maintenance of pregnancy and further treatment. Pregnancy is still possible to save, but the prognosis is worse than threatened abortion.

Abortion in progress: excessive bleeding, pain are cramping in nature, changing the general condition, which depends on the magnitude of blood loss. Require emergency hospitalization. Continuation of the pregnancy in this case it is impossible, in the hospital performed curettage of the uterine cavity and compensation of blood loss (depending on its size).

With incomplete spontaneous abortion bleeding dark red, with clots, can be significant. All this is accompanied by cramping abdominal pain. Emergency treatment is curettage of the uterus, blood loss compensation.
Complete spontaneous miscarriage occurs more frequently in the early stages of pregnancy. The uterus contracts, the cervical canal is closed and the bleeding stops, because the fertilized egg completely stood out from the uterus. Emergency care is required. Complete abortion is possible up to 6 weeks of pregnancy, after 6 weeks - usually incomplete. In the hospital conducted diagnostic curettage of the uterus to make sure if there was a residue of the ovum.
Missed miscarriage (late abortion) - the fetus is dead, but there is a discharge of tissue cervix is ​​closed. Usually shows no mid-tones dechnyh fruit, no increase in uterine size.
Septic abortion - Incomplete abortion infection.
      Pathophysiology of miscarriage:
 Large genetic abnormalities
 Internal environmental factors
 The mother: anomalies, leiomyoma, Cervical insufficiency
 luteal phase defect
 Immunological factors
 External environmental factors
o The use of substances (tobacco, alcohol, drink)
o Radiation
o Infection
o occupational chemical exposure
 * Late maternal age
Clinical picture:
 delay menstruation, pregnancy symptoms
 Positive βHGG
 Vaginal bleeding
 βHGG falls or remains unchanged
 Cramping pain in the lower abdomen and lower back
 waste products of conception
Placenta previa

Placenta previa call her attachment to the lower uterine segment, that is the way the fetus is born. Placenta previa increases the risk of severe bleeding, often life-threatening pregnancy. There are three types of placenta previa. As the pregnancy progresses, smoothing and cervical dilatation form of placenta previa may vary. With full placenta previa inner mouth completely closed. Kind of complete previa considered central placenta previa, when its focus is on the inner jaw. In case of partial placenta previa is closed only a part of the internal os. Thus for the inner jaw, along with placental tissue determined the fetal membranes. At the low location of the placenta is located near the edge of the internal os (within 2 cm).

Prevalence is approximately 1 in 200 pregnancies. Placenta previa, found in II trimester of pregnancy, self disappears by the end of pregnancy is more than 90% of cases. This is due to the growth of trophoblast toward the bottom of the uterus.
The etiology of placenta previa is unknown. It is believed that the main role in the pathogenesis of endometrial changes play related to the prior-yuschimi childbirth and abortion, as well as circulatory disorders of the decidua.
Risk Factors
 Age (pregnant at age 35 placenta previa occurs three times more often than at the age of 25 years).
 A large number of births.
 The scar on the uterus.
 Placenta praevia in history.
 Smoking.
 Multiple pregnancy.
The clinical picture
Typical symptoms - sudden painless bleeding from position O paths. Approximately one third of patients bleeding occurs before the 30th week of pregnancy, the other third - after the 36th. Among the remaining cases, bleeding occurs more frequently in the 34th week of pregnancy. In most cases, the bleeding itself stops later - resumes. All four cases of placenta previa bleeding occurs on the background of uterine contractions without the long tension. One-third of patients the wrong position and fetal presentation. DIC is rare.
Diagnostics

In 95% of cases of placenta previa can diagnose with the aid of ultrasound. Initially produce abdominal ultrasound with a full bladder. For suspected placenta praevia bladder emptied and repeat the study. Then perform a vaginal ultrasound to clarify the location of the placenta to the uterine cervix, especially if the placenta is attached to the back wall of the uterus. To confirm the diagnosis, you can use an MRI. Vaginal examination for the diagnosis of placenta previa is rarely required. Resort to it when, after ultrasound diagnosis remains unclear (for example, a partial placenta previa), and the woman does not stop bleeding from the genital tract. Because of the risk of major bleeding in the study produce operating, if there is enough blood.

Clinical management of
With heavy bleeding that threatens the mother's life, regardless of the length of pregnancy, emergency cesarean delivery. In the absence of severe bleeding and pregnancy 36 weeks or more after the confirmation of fetal lung maturity spend delivery on schedule. Delivery is preferable to an emergency.
Rodorazreshayuschih usually by Caesarean section. In case of partial placenta previa and mature cervix possible birth vaginally. If the placenta is located on the front wall of the uterus, for cesarean section may be heavy bleeding. Therefore, make a longitudinal incision in the lower uterine segment with the transition to the body of the uterus. If the lungs of the fetus or immature gestation less than 36 weeks and there is no bleeding, a conservative treatment. It includes the following activities. Limitation of physical activity. Abstinence from sexual activity and douching. Maintaining a hemoglobin level of 100 g / l. The introduction of anti-Rh0 (D)-immune globulin to women with Rh-negative blood. Tocolytic therapy (made with caution.) Drug choice dialing - magnesium sulfate. Harvesting of blood products.
Outpatient treatment in the following cases.
 pregnant realizes the gravity of his condition.
 At home possible under the above restrictions.
 pregnant is under constant supervision, you can quickly get her to hospital.

 When you reach the 36th week of pregnancy of view regularly assess fetal lung cavity.


 delivery carried out immediately after the positive test results.
Complications
 Hemorrhagic shock.
 Complications of cesarean section.
 The complications of transfusion therapy.

 When placenta previa can be observed its increment. The risk is particularly high in the presence of a uterine scar. The increment of the placenta can cause massive bleeding, in which there is a need for hysterectomy.

Forecast. Maternal mortality placenta previa is close to zero. Perinatal mortality is 10%. The main cause of death of children - prematurity. Placenta previa is a high risk of birth defects.
Other causes of obstetric hemorrhage in late pregnancy.
Among the causes of bleeding following the main danger to the mother and the fetus is especially previa vessels. For vaginal bleeding sometimes take hematuria.
Previa vessels - a condition in which a segment of umbilical cord vessels coming in embryonic membranes, is located above the inner throat.
 vessel rupture causes bleeding from the genital tract and intra-uterine hypoxia.
 In order to determine the origin of blood flowing from the genital tract, conduct sample Apt.
 If the fetus is alive, hold an emergency C-section.
 When previa vascular fetal death occurs in more than 50% of cases.
Abruption NORMALLY
Location of the placenta
Premature detachment of the placenta called the partial or complete separation of normally situated placenta from the uterine wall, which took place before the birth of the fetus - in pregnancy or childbirth.
The frequency of this pathology varies over a wide range from 0.05 to 0.5%.
Etiology and risk factors. The etiology of placental abruption is unknown. It is believed to be important in the pathogenesis of this disease is vascular pathology of the placenta. Risk factors for placental abruption include.
 Pre-eclampsia and hypertension.
 Premature detachment of the placenta in the history of (risk of recurrence is achieved 10%).
 A large number of births.
 Age (risk increases with age).
 Trauma.
 Smoking.
 Addiction, especially cocainism.
 The use of alcohol.
 Premature rupture of membranes.

 Quick rupture of membranes with polyhydramnios and rapid birth of the first fetal twins.

 Uterine fibroids, especially when placing the node in the placental site.
Predisposing causes of PONRP include:
1. In spiral arteries clots occur in the intervillous space appear fibrin deposits, which leads to the formation of red and white heart attack placenta. A large number of heart attacks violates placental circulation and cause subsequent detachment of the placenta. Such changes are observed in severe pre-eclampsia in the second half of pregnancy (45% of cases occur in the pre-eclampsia), hypertension, kidney disease, accompanied by hypertension, acute infectious diseases
2. Inflammatory and degenerative changes in the uterine and placental-those that cause communication failure between chronic inflammatory diseases of the uterus, submucosal fibroids nodes, perenashivanie pregnancy, etc.
3. Excessive stretching of the uterus, leading to a thinning of its walls and increased placental site (polyhydramnios, multiple pregnancy, large fetus).
Rarer causes:
- Trauma
- Neuro-psychological factors
Pathogenesis PONRP due to ruptured blood vessels that lead to the disruption of blood circulation in the intervillous space, bleeding and hematoma formation retroplatsentarnoy.
Diagnostics
1. The diagnosis is usually made on the basis of clinical symptoms, which include vaginal bleeding, abdominal pain, tension and tenderness of the uterus.
a. Vaginal bleeding is observed in 80% of premature placental abruption, in 20% of cases formed retroplacental hematoma.
b. Pain - a common symptom of premature detachment of the placenta. In most cases, it appears suddenly, is constant, is located in the abdomen and lower back.
a. Soreness and tension of the uterus is usually seen in heavier cases.

In the formation, the hematoma retroplatsentarnoy uterus increases. This can be detected by repeated measurement abdominal circumference and height of standing uterus.

on Amniotic fluid can be stained with blood.
is, can develop hemorrhagic shock.
Well. Often, there are signs of fetal hypoxia.
s. Premature detachment of the placenta can cause premature birth.
Laboratory studies
a. Marked proteinuria.
b. Show signs of DIC.
1) Placental abruption leads to massive release of tissue thromboplastin.
2) Blood clots in the first retroplatsentarnoy hematoma, and then in the bloodstream. Develop compensatory fibrinolysis.
3) Phase fibrinolysis manifested by reduced levels of fibrinogen, pro-thrombin, factors V and VIII, and platelet counts.
4) increase the content of the PDF, which have anticoagulant-schee action.
5) Within 8 hours after the onset of placental abruption developed hypofibrinogenemia.
It was reported that the premature detachment of the placenta increases in serum levels of markers of tumor CA-125.
Ultrasound
Depending on the location of release subchorionic hematoma (placental abruption at 20 weeks of gestation), retroplatsentarnoy hematoma (after 20 weeks of gestation) and preplatsentarnuyu hematoma (rare). The most difficult runs premature detachment of the placenta to form retroplatsentarnoy hematoma. Ultrasound helps to diagnose placental abruption in about 15% of cases.
Clinical classification of placental abruption
1. Lightweight (40%).
 The volume of blood loss from the genital tract does not exceed 100 ml. In the formation of a hematoma retroplatsentarnoy no external bleeding.
 uterine tone slightly elevated.
 fetal heart rate in the normal range.
 a pregnant satisfactory. Basic physiological energy parameters and indicators of coagulation were normal.
2. Moderate (45%).

 The volume of blood loss from the genital tract is 100-500 ml. In the formation of a hematoma retroplatsentarnoy no external bleeding.

 increased uterine tone. Can uterine tenderness in Palpa-tion.
 The character of the fetal heart. There are signs of fetal hypoxia, sometimes - no heartbeat.
 A pregnant tachycardia, orthostatic hypotension, and low pulse pressure.
 May lower fibrinogen levels to 150-250 mg%.
3. Heavy (15%).
 The volume of blood loss from the genital tract is more than 500 ml. When retroplatsentarnoy hematoma external bleeding may be absent.
 Uterus dramatically tense and painful on palpation.
 fetus usually dies.
 Pregnant develop hemorrhagic shock.
 Most joins DIC.
Clinical management of
Easy abruptio placenta
a. When satisfactory pregnant woman and fetus spend carefully monitored. At the slightest deterioration of the pregnant woman or the fetus shown immediate delivery.
b. Around the clock monitoring of the fetus.
a. Control the coagulation parameters in detecting violations immediately begin their treatment.
If the fruit was immature, appoint tocolytic therapy.
Moderate to severe premature detachment of the placenta
a. Through careful control of the pregnant woman and the fetus.
b. Shock treatment described below
a. Treat DIC. Heparin is contraindicated. After delivery, the content of coagulation factors usually normalized after 24 h, and the platelet count - within 4 days.
1) To improve the content of coagulation factors administered cryoprecipitate and fresh frozen plasma. A single dose of fresh frozen plasma fibrinogen level increases by about 10 mg%. 1 dose of cryoprecipitate contains about 250 mg of fibrinogen. For the normalization of the coagulation system requires about 4 g of fibrinogen (ie 15-20 doses of cryoprecipitate).

2) If the platelet count is less than 50 000 ml-1, platelet transfusions. A single dose of platelets increases the platelet count in the 5000-10 000 ml-1. In the treatment of DIC is administered at least 4-6 doses.

, has conducted an oxygen inhalation.
etc. To control diuresis set urinary catheter.
Timing and methods of delivery
1. In mild premature detachment of the placenta, if the state of a pregnant stable, allowed independent labor. In other cases, an emergency delivery.
2. If there was a premature detachment of the placenta at birth, state of mother and fetus is satisfactory, BCC made up and delivery proceeds normally, accelerate their course is not required.
3. For rodostimulyatsii and declining revenues in the blood thromboplastin produce amniotomy.
4. In some cases delivery stimulate oxytocin.
5. Preferably delivery vaginally.
6. Caesarean section is performed in the following cases.
a. Intrauterine hypoxia in the absence of conditions for rapid delivery through the birth canal.
b. Severe premature detachment of the placenta from the threat to the life of the mother.
a. The immaturity of the cervix.
Complications
1. Hemorrhagic shock.
2. DIC.
3. Extensive haemorrhage in the wall of the uterus - the uterus Kuvelera (developed in 8% of cases).
4. Ischemic necrosis of the internal organs (hypovolemia), acute tubular necrosis, necrosis of the liver, pituitary gland, lung, renal cortex and adrenal glands.
Forecast. Premature detachment of the placenta are severe obstetric complications. Perinatal mortality rate of 30%.
The methodology of the business game
"Handle the middle of the table"
1.Voprosy, printed on separate sheets.
2.Chistye sheets of paper, pens.
3.Rabochaya notebook.
Progress:
1.All students of the draw are divided into 3 groups.
2.Kazhdaya subgroup sits at a separate table, preparing a clean sheet of paper and a pen.

3.On written sheet date, the group number, department, FI Student-participants in this subgroup (the name of the business game).

4.Predlagaetsya task: to answer a specific question the whole subgroup.
5.Kazhdy student writes on a piece of his name and one answer sheet and sends neighbor, and my pen moves to the middle.
6.Pedagog controls the group and the involvement of everyone.
Total correct version is written in the notebook.
7.Studenty who gave the correct answers are maximal score of 100% of the theoretical part of the rating-0, 8b.
Students zanyavschie 2nd-85, 9% rating. Zanyavschie 3rd-70, 9% rating. Neotvetivschie otvetivschie or wrong 0 b.
8.Na answer sheet lecturer puts mark and signature.
9.Poluchenny students score counted in the scoring for the current session.
10.V lower empty part of the magazine a mark on the business of the game warden to sign.
11.Raboty students saved teacher.
6.2.Analiticheskaya part
Case studies:
1.Zhaloby patient on arching abdominal pain, dizziness. In the history of cesarean section due to eclampsia. The gestational age 32-33 weeks, swelling of the legs, AD-150/100. Suddenly, there was a pregnant sharp pain in his stomach and stopped feeling fetal movements. On palpation the abdomen uterus firm, part of the fruit is not defined, the fetal heart is not listening.
What is the diagnosis?
A: premature detachment of normally situated placenta.
Clinical management: cesarean section

2. Last menstrual period was 8 months ago. A month ago, swelling of the lower extremities, blood pressure rose to 150/100 mm. Hg A hundred-tsionare 3 days after receipt of the pain originated in the abdomen, from the genital tract appeared spotting. Skin and visible mucous pink. Pulse 90 per minute, blood pressure 160/100 mm. Hg 102cm belly., WMM 37cm. Palpation of the uterus is tense, illness-nenna on the front wall. Labors there is no fetal heartbeat muffled.

I. What is the diagnosis?

A: premature detachment of normally situated placenta
II. Clinical management: cesarean section.
3. Patient 24 years old was admitted to hospital in connection with the appearance of the genital tract bleeding. Sex life of 19 years, the marriage first. In the history of two pregnancies, one pregnancy ended in abortion, another miscarriage. Last menstrual period was 8 months ago. At 6 weeks of pregnancy demonstrated symptoms threatened abortion.
Within 2 weeks of treatment at the hospital. 2 days ago there were spotting. Palpation of the uterus is soft, strained
GMR-30cm, abdominal circumference 89cm. Fruit in the transverse position. Fetal heartbeat rhythmic 136 beats per minute.
What is the diagnosis?
Answer: placenta previa
II. Clinical management: symptomatic therapy
4. Pregnant 27 years old, was taken to a maternity hospital by ambulance 30 minutes after the sudden onset of bleeding.
Scarlet liquid blood appeared during the act of defecation. For a period of 37-38 weeks of pregnancy and labor pains are not. At the time of admission to the hospital bleeding stopped, blood loss was 200 ml. In the history of the first two pregnancies artificially interrupted in the early stages, the last abortion complicated by endometritis. General condition is satisfactory, pulse 80 per minute blood pressure 110/70. Uterus correct ovoid shape. Fetal position Longitudinal predlezhit head high above the entrance to the pelvis. Fetal heart rate 140 beats rhythmically. per minute.
The diagnosis?
Answer: placenta previa
Clinical management: cesarean section

5. New mother came to the hospital about vaginal bleeding started 2 hours. ago, when a labor contractions. By the time of receipt of blood loss was 50 mL. There were 5 of these pregnancies resulted in two pregnancies urgent delivery, 3 pregnancy medical abortion. On palpation painless uterus fetal position Longitudinal ritmichnoe.140 heart beats. per minute.

The diagnosis?
Answer: placenta previa
Clinical management: cesarean section
6. New mother 32 years translated into obstetric clinic from the department of pathology where was pregnant for 20 days on the re-bleeding from the genital tract. Two hours ago, with the onset of labor contractions appeared slight bleeding. Pregnancy of 36 weeks. At 33 weeks gestation during the night suddenly had bleeding. Pregnant was hospitalized.
OJ-100cm, GMR-32cm, the longitudinal position of the fetus in the bottom of a large part determined by the running. Rhythmic heartbeat of the fetus above the navel. Allocation bloody spotting.
The diagnosis?
Answer: placenta previa
7. New mother 29 years taken to hospital with minor bleeding from the genital tract, severe abdominal pain, appeared at 6 hours after the onset of regular contractions. Deliveries on time. Pregnant for 2 years suffering from hypertension. In the history of two pregnancies, one ended with urgent delivery, another medical abortion. Abdomen oval, painful on palpation, in the bottom left where the protrusion is determined. Longitudinal position of the fetus, the presenting head at the entrance to a large segment of the pelvis. According to the woman in labor vaginal examination is in the second stage of labor.
The diagnosis?
Answer: PONRP
Clinical management: cesarean section

8. 27 years old woman in labor on a stretcher transferred to the maternity ward of the department of pathology of pregnant women, which was 20 days at the re-bleeding from the genital tract. Two hours ago, at term went into labor at the same time there was spotting, which adopted soon bleeding patterns. Blood loss was 500 ml. When deployed operating produced vaginal examination: cervix flattened, opening the throat to 4 cm in the throat defined placental tissue.

The diagnosis?
Answer: placenta previa
Clinical management: cesarean section
6.3. Graphic organizer: Making graphic organizer
"Clusters" on "placenta previa"
(Cluster - beam bunch) way to map the information - gathering ideas around a main factor for determining the meaning and focus of the assembly.
Encourages mainstreaming knowledge helps freely and openly engage in the thought process of the new association presentation on the topic.
6.4.Prakticheskaya part
                                          Rules transfusion
Objective: To determine the blood group.
Performs step (steps):
Events number does not hold nil
(0 points) Fully
correctly
performed
(20 points)
1. Indications for transfusion
make your selection transfusion environment (check the date blank)
check the blood group donor in two series of standard sera 0 20
2. check the patient's blood group in two series of standard serum, determine compatibility ABO system 0 20
3. determine Rh compatibility in vitro with zhelatinolem (t48S 10 min) 0 20
4. with the start of transfusion spend 3x biological sample 0 20
5. Set the start and end-gemot ransfuzii
spend thermometry during and after the transfusion, blood transfusion filling sheet 0 20
Total 0100
7.Formy control of knowledge, skills and abilities
-Oral;
-Written;
Testing;
Solution situational problems;
And demonstration of skills mastered.
8.Kriterii assessment monitoring
Number suc-BAE-bridge
 in% of valuation is the standard one student

1% From 96-100, personally

 "5" full correct answer to the questions on the etiology-ology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of the disease. To sum up and make decisions, creative thinking, self-analyzes, case studies resolves correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decisions and summarizes and analyzes. Medical history, partograph fills correctly.
91-95% from two-person
 "5" full correct answer to the questions on the etiology-ology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of the disease. Think creatively, independently is analyzed, case studies decides correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decision. Medical history, filled with partograph one grammatical error.
86-90% from three-person
 "5" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis, treatment and prevention of this disease is completely covered, but have 1-2 errors in the response. Own analyzes, inaccuracies in solving situational problems, but with the right approach. Actively involved in interactive games, make the right decisions. Medical history, partograph fills with 2-3 grammatical errors.
4 81-85% It is well

"4" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis, treatment and prevention of this disease is completely covered, but there are 2-3 inaccuracies, errors. Into practice, understands the essence of the question, says confidently, is a faithful representation. Situational problems solved correctly, but the justification answer sufficiently. Actively involved in interactive games, take the right decision. Medical history, partograph fills with 2-3 grammatical errors, inaccuracies in the description.

5 76-80% It is well
"4" Correct, but incomplete coverage of the issue. The student knows the etiology, pathogenesis, classification, clinic of the disease, but not completely disassembled diagnosis, treatment and prevention of this disease. Understands the issue, says confidently. There is an exact representation. Actively participate in the games. On case studies gives partial solutions. Medical history, partograph fills with 3-4 grammatical errors, inaccuracies in the description.
6 71-75% It is well
"4" Correct, but incomplete coverage of the issue. The student knows the etiology and pathogenesis of the disease, but not completely disassembled diagnosis, treatment and prevention of this disease. Understand the subject matter is covered in confidence, has accurate representation. On case studies gives partial solutions. Medical history, partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
7 66-70% Udo-vle-create-state
 "3", the correct answer to a half set of issues. Student knows the etiology of the disease, but do not pay out the classification of the disease clinic, confused in the treatment and prevention. Understands the issue, said confidently, has accurate representations only on specific issues topic. Situational problems solved correctly, but there is no justification of the answer. Medical history, partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
8 61-65% Udo-vle-create-state

 "3", the correct answer to a half set of issues. Errors in the etiology, pathogenesis, poorly versed and confused in the treatment and prevention of this disease. Says uncertainly, has the only views on certain issues topic. Making mistakes in solving situational problems. Medical history and partnership gram fills with errors.

9 55-60% Udo-vle-create-state
 "3" error response by half set of issues. Student makes an error in the etiology of this disease, poorly versed and confused in other matters relating to the disease. Says uncertainly has a partial view on the subject. Situational problems solved incorrectly. Medical history and partograph fills with errors.
10 50-54% Unsatisfactory-vle-create-state "2" The correct answer is 1/3 of the questions. Student does not know the etiology of the disease, and poorly versed entangled in other issues related to the disease. Situational problems solved correctly if the right approach. Medical history and partograph fills with errors.
11 46-49% Unsatisfactory-vle-create-state "2" the correct answer to one fourth of the questions. Student does not know the etiology of the disease, and poorly versed entangled in other issues related to the disease. Situational problems solved correctly if the right approach. Medical history and partograph fills with errors.
12 41-45% Unsatisfactory-vle-create-state "2" Lighting fifth of the questions with errors. Student does not know the etiology of this disease, little versed in other matters related to the disease. Gives an incomplete and partially incorrect answers to questions on the classification of the clinical disease. Situational problems solved correctly if the right approach. More than half of the patient's history and the partograph filled with errors.

13 36-40% Unsatisfactory-vle-create-state "2" Lighting 1/10 of the questions at the wrong approach. Does not know the etiology of the disease, and poorly versed entangled in other issues related to the disease. Gives an incomplete and partially incorrect answers to questions on the classification of the clinical disease. Situational problems solved correctly if the right approach. Bole half medical history and partograph fills with gross errors.

14 31-35% Unsatisfactory-vle-create-state "2" to the questions not answers. Does not know and does not understand the other issues related to the disease. Does not know how to fill out and used to describe the disease and thorium partograph.
9. Typical flow chart of lesson
Stages of work, time-name The content of the
Teachers Students
1etap. Introduction to the training session
(5min) 1.1.Soobschaet topic, purpose, and planned training results. Familiar with the plan, features of the training session.
1.2.Nazyvaet: key categories and concepts from the data subject tion, a list of books for self-study
1.3.Soobschaet indicators and criteria of educational work in class
Listen, record,
specify, ask the question.
Stage 2.
Primary
(235 min) 2.1.Provodit updating knowledge through блиц-опроса/вопросно-ответной forms / brainstorming, etc.
2.2. Consistently describes the steps
 on the organization of the educational process according to the structure of practical training.
Meet
Abstracts with ethyl.
Working in groups, will present the results of the group work
Stage 3.
The Final-Resultant-regulating (60 min)
3.1.Delaet opinion on the subject, attention was concentrated on the main students, according to the importance of the work done for future careers.
3.2. Commends the work of groups (some of students) summarizes vzaimootsenki. Analyzes and evaluates the degree of achievement of lesson.

 3.3. Gives the task for independent work, informing schaet and criteria evaluation. Self-evaluation,

interaction assessment.
Ask the question.
Write down the job.
10.Kontrolnye questions
1.Nazovite main causes of bleeding in late pregnancy
2.Gde placenta is normal.
3.Main etiological factors of placenta previa.
4.Osnovnye PONRP etiological factors.
5 .. When there is bleeding due PONRP.
6.When is normal placenta
7.Nazovite major symptoms of placenta previa.
8.Nazovite vital signs PONRP.
9.Kakoe bleeding characteristic of placenta previa?
10.Kakoe bleeding observed in PONRP?
11.How additional research methods to help the diagnosis of placenta previa?
12.Kak additional methods to help diagnose PONRP?
13.Chto palpated during vaginal study in PP?
14.Taktika doctor for bleeding in the II half of pregnancy.
15.Kakie methods used to stop bleeding during PP?
16.Metody bleeding due PONRP during pregnancy.
17.Kakie methods can be used to stop bleeding with partial placental abruption during labor?
18.Kakie measures are recommended for bleeding in the I stage of labor due to incomplete placenta previa?
19.Taktika doctor at full PONRP.
20.Taktika physician in central placenta previa.
21.Kakie main reasons lead to PONRP?
22.Kakie clinical symptoms characteristic PONRP?
23.Kak determined severity PONRP?
24.Vliyanie PONRP on the fetus?
25.Kakova PONRP hospital with internal bleeding?
26.Kakova clinic PONRP with external bleeding?
27.K which causes complications PONRP?
28.Chto you understand by the term "queen Kyuvelera"?
29.Kakova tactics doctor GPs in the prehospital setting for PONRP?
30.Akusherskaya tactics PONRP doctor at the hospital?
33.Kakie factors contribute to placenta previa?
34.Kakoy main leading symptom of placenta previa?
35.Kakie types of placenta previa you know?
36.Chto such a complete placenta previa?

37.Chto a lateral and marginal placenta previa?

38 .. What is the main leading symptom of placenta previa?
39.Kakie types of placenta previa you know?
11. Recommended Reading
                           Summary:
1. Abramchenko, VV Epidural anesthesia in obstetrics: a guide for physicians / 2006. - 229 p.
2. Abramchenko, VV Pregnancy and delivery of high risk: a guide for physicians / - M. Med. Inform, 2004. - 400 p.
3. Abramchenko, VV Cesarean section in perinatal medicine: a guide for physicians / 2005. - 126.
4. Abramchenko, VV Postoperative intensive care in obstetrics / Literature, 2000. - 88.
5. Abramchenko, VV Pharmacotherapy of preterm labor / 2006. - 448.
6. Abramchenko, VV Purulent-septic infection in obstetrics and ginekologii.rukovodstvo / 2005. - 459
7. Abramchenko, VV Postoperative intensive care in obstetrics / - St. Petersburg: Spec. Literature, 2000. - 88.
8. Abramchenko, VV Clinical perinatology / IntelTek, 2004. - 424 p.
9. Ailamazyan, EK Midwifery: a textbook for honey. Universities / 2003 - 528.
10. Topical issues of Obstetrics, Gynecology and Reproductive / Ed. EV KOKHANEVICH. - Moscow: Triad-X, 2006. - 480.
11. Obstetrics. Ed. GM Savelyeva. - M.: Medicine, 2000. - 816 p.
12. Obstetric and gynecological care: Hands-on. for doctors / Ed. VI Kulakov. - Moscow: MEDpress, 2000. - 512 p.
13. Obstetrics. Clinical lectures: a manual for schools with a CD / Ed. OV Makarova. - Moscow: GEOTAR Media, 2007. - 640.

14. Obstetrics. Directory of the University of California / Ed. Nisvandera K., A. Evans: Lane. from English. - M.: Practice, 1999. - 704 p.

15. Barashnev, YI Perinatal neurology / Y. Barashnev. - M.: "Triad - X", 2005. - 670 p.
16. Bodyazhina, VI Akushersvo. The manual for the media. prof. Education / VI Bodyazhina. - Rostov-on-Don: Phoenix, 2003. - 480.
17. Resurrection, SL Fetal assessment. CTG. Doplerometriya. Biophysical profile: a manual for the system of postgraduate medical. Education / SL Resurrection. - Minsk: The Book House, 2004. - 304.
18. Gazhonova, VE Ultrasound in Gynecology / VE Gazhonova. - Moscow: MEDpress-inform, 2005. - 264.
19. Gluhovets, BI Ascending infection of placental / BI Gluhovets. - Moscow: MEDpress-inform, 2006. - 240.
20. Humeniuk, EG Obstetrics: Physiology of pregnancy: study guide / EG Humeniuk. - Petrozavodsk: IntelTek, 2004. - 170 p.
21. Demidov, VN Pelvic ultrasound in women. Adnexal cysts and benign ovarian tumors: a practical guide / V. Demidov. - Moscow: Academy of Medical Sciences, 1999, vol. II. - 100 p.
22. Duda VI Obstetrics: a textbook for high schools in the specialty "General Medicine" / - Minsk: High School, 2004. - 639 p.
23. Duda VI Physiological OB / - Minsk: 2000. - 447 p.
24. Duda VI Operative obstetrics: a manual / Minsk Interpresservis, Book House, 2002. - 512 p.
25. Zhilyaev, NI Obstetrics: phantom course / - Kiev, 2002. - 239 p.
26. Zhilyaev, NI Operative Obstetrics: Ouch. Manual / Kiev 2004. - 468 p.
27. Zhilyaev, NI Operative surgery in obstetrics and gynecology / 2004.

28. Selected lectures on obstetrics and gynecology / Ed. AK Strizhakova etc. - Rostov-on-Don: Phoenix, 2000. - 512 p.

29. Clinical recommendations. Obstetrics and Gynecology: from scientific-Danie / Ed. VI Kulakov. - Moscow: GEOTAR Media, 2006. - 512 p.
30. Clinical lectures on obstetrics and gynecology / Ed. AN Strizhakova etc. - M.: Medicine, 2000. - 379 p.
31. Clinical evaluation of laboratory tests in women: study guide / Moscow Medical and Dental. University. NA Semashko. - M: 2005. - 96 p.
32. Kulakov, VI Preterm birth / VI Kulakov, LE Ants. - M.: Medicine, 2002. - 176.
33. Kulakov, VI Intensive care in obstetrics and gynecology (efferent methods) / - M: MIA, 1998. - 206 p.
34. Drugs used in obstetrics and gynecology / Ed. Acad. RAMS VI Kulakov, Acad. RAMS VN Serov. 2006. - 375 p.
35. Emergency care in obstetrics and gynecology. Brief leadership stvo - Moscow GEOTAR - Media, 2007. - 52.
36. Perinatology Basics: A tutorial / Ed. MP Shabalov. - Moscow: MEDpress-inform, 2002. - 576 p.
37. Practical skills in obstetrics and gynecology: a manual / LY Suprun, TS Divakova and others. - Minsk: New Knowledge, 2002. - 166 p.
38. Rational pharmacotherapy in obstetrics and gynecology: Hands-on. for practitioners / Ed. VI Kulakov, VN Serov. - M.: 2005.
39. Guide Out - patient care in obstetrics and gynecology / Ed. VE Radzinsky. M: GEOTAR - Media, 2007.
40. Guide to practical training in obstetrics / Ed. VE Radzinsky. - M.: MIA, 2004. - 576 p.
41. Saveliev, GM Obstetrics: a textbook for schools / GM Savelyev, RI Shalina. - Moscow: GEOTAR Media, 2008. - 656 p.

42. Sidelnikov, VM AG Antonov Premature birth. A premature baby / VM Sidelnikov, AG Antonov. -M. "GEOTAR" 2006.

43. Smirnov, A. Pregnancy without problems / AN Smirnov. - Moscow: Atris Press, 2002. - 208.
44. Smirnov, LM Obstetrics and Gynecology: Textbook / LM Smirnov. - M.: Medicine, 1999. - 368 p.
45. Handbook of obstetrics, gynecology and perinatology: uch.posobie for doctors / Ed. GM Savelevoy.2006. - 720.
46. Trifonov, E. Obstetrics and gynecology: a manual for med._vuzov / EV Trifonov. - Moscow: VLADOS, 2005. - 175 p.
47. Filippova, GG Psychology of motherhood: a manual / GG Filippov. - Moscow: Publishing House of the Institute of Psychiatry, 2002. - 240.
48. Chernukha, EA Prolonged and prolonged pregnancy. Guide for Physicians / EA Chernukha. - M.: "GEOTAR - Media", 2007. - 207.
49. Chernukha, EA TK Puchko breech presentation. Guide for Physicians / EA Chernukha, TK Beam. - M.: "GEOTAR - Media", 2007. - 173 p.
50. Shmagel, KV Immune pregnant women / KV Shmagel, VA Cherries. - Moscow: Medical Book, 2003. - 226 p.
51. Tskhai, VB Perinatal obstetrics: a manual for honey. Universities / VB Tskhai. - Atlanta: Med. Academy of RAMS, Moscow, Honey. book, 2003.
52. Amniotic and extraembryonic structures in normal and complicated pregnancy / Ed. VE Radzinsky. 2004. - 393 p.
53. Congenital, perinatal and neonatal infections: Per. from English. / Ed. A.Grinou, J. Osborne, S. Sutherland. - M.: Medicine, 2000. - 287.
54. Kulakov VI, Murashko LE Premature birth. M. Medicine, 2002.
55. Serov VN etc. Eclampsia: A Guide for Physicians / V.N.Serov etc. - M.: MIA, 2002. 463 - with

56. VM Sidelnikov Habitual loss beremennosti.-M.: Triad-X, 2002.

57. Disseminated intravascular coagulation in obstetrics AD Makatsaria etc. - M.: Triad-X, 2002. - 496.
58. Schechtman, MM, GM Burduli Diseases of the respiratory system and blood circulation in beremennyh.-M.: Triad-X, 2002. - 230C.
59. Shifman EM Pre-eclampsia, eclampsia, NELLP syndrome / Inteltek, 2002.
More:
60.Uchebnoe grant for the development of practical skills surgical / Edited by prof. Atalieva AE, prof. Babadjanova BD Tashkent 2003. C102-115
61.Algoritmy diagnosis and treatment of surgical / Edited by Academician Karimov Sh.I.Tashkent 2003. From 39-64
62.Uchebnoe benefit surgical disciplines for students Me-ditsinskih institutes / Edited by Academician Karimov Sh.I.Tashkent -2003 Part II Obstetrics and ginekologiya.S 64-19013. Practical skills in obstetrics and gynecology / Me-tod.posobie / / Tashkent 2008.
63.Akushersky soft tissue injuries of the birth canal, Kulakov VI, Butova E.A.2004.
64.Akusherstvo. National rukovodstvo._2004.
65.Infektsii in Obstetrics and Gynecology How VK Seagull 2006
66.Hirurgicheskaya technique cesarean secheniya_Strizhakov A.N._2007.
67.Ratsionalnaya pharmacotherapy in obstetrics and ginekologii.2007
Chan_Gynecology_and_obstetrics.2004
68.Rukovodstvo for outpatient care in obstetrics and gynecology, Kulakov V.I.2005.
70.Sidorova_I.S._Rukovodstvo_po_akusherstvu_ (Medicina, 2006) (ru) (1033s

71.Posobie for practical development of Obstetrics Voronin (KV) 2007.

72.Kirienko AI, Matyushenko AA, Andriyashkin VV Ostryi tromboflebit/2005
AN 73.Ivanyan - Intrauterine growth ploda/2007
74.DVS_sinrom _v_akusherstve.2004
75.Neonatologiya (Bazhanov NP). - T. I. - 2004
76.Prikaz MZ № 500 "On the reorganization of maternity hospitals to improve the efficiency of perinatal care and the prevention of nosocomial infections."
77.Partogramma/Sherbaeva DB, Ayupova FM, FI Shukurov / Metod.rekomendatsii. Tashkent-2005. 28C
78.Uchebnaya birth history / Sherbaeva DB, Ayupova FM, FI Shukurov / Metod.rekomendatsii. Tashkent-2005. 13C
79.Prakticheskie skills in obstetrics and gynecology / Me-tod.posobie / / Tashkent 2008.
80.Klinicheskoe guide the management of patients with bleeding during delivery and the postpartum period. Tashkent. 2008
81.Bond A. I. et al. Expectant management of abruptio placentae before 35 weeks gestation. Am. J. Perinatol. 6:121, 1989.
82.Cotton D. et al. The conservative aggressive management of placenta previa. Am. J. Obstet. Gynecol. 137:687, 1980.
80.Internet sites:
http://www.studmedic.narod.ru/, http://med.siteedit.ru/,
http://www.rukovodstvo-po-akusherstvu.-uchebnoe-posobie.html, http://www.materinstvo.ru, http://mama.ru.http://www.art-med.ru,, http://www.doctor.ru, http://www.rodim.ru, http://mamka.ru
http://medagent.ru, http://www.art-med.ru, http://www.medsan.ru,
http://mediki.spb.ru, http://medinstitut.e2e.ru, http://www.medstudy.narod.ru
http://www.obgyn.ru, http://www.medsno.ru, http://medrusnet.euro.ru

www.medtext.ru, www.medpoisk.ru, www.medicum.nnov.ru/student/
http://6years.net/, http://preryvanie-beremennosti.pharmabort.ru/
http://med4net.ru/, http://www.med-life.ru/, http://www.pregnant.ru/
http://www.roddom.ru, http://www.medpoisk.ru/, http://www.medlinks.ru


  1   2   3   4   5   6   7   8   9   ...   13
:)


The database is protected by copyright ©hestories.info 2017
send message

    Main page

:)