Microbiological feature

It must be said that the microbiological feature of the GDH in obstetrics, gynecology and neonatology is the polymicrobial etiology of these diseases. Conditionally pathogenic enterobacteria (E.coli, Klebsiella spp., Proteus spp.) Dominate among the pathogens of the uvogenital tract in pregnant women and puerperas, often in association with obligate anaerobes of the bacteroid family – Prevotella spp. and anaerobic cocci. In recent years, the role of enterococci in the aetiology of the GDV in obstetrics and neonatology has increased, which is apparently due to the resistance of these bacteria to cephalosporins, widely used in obstetric practice.
In inflammatory diseases of the female genital organs, the ascending pathway of infection prevails. Invasion of the microbes that inhabit the vagina into the internal genital organs can occur during various surgical interventions, the introduction of intrauterine contraceptives, the implementation of invasive diagnostic methods. With the development of the GDH after childbirth, in most cases the vaginal microflora penetrates into the internal genital organs. An important role is played by the degree of colonization by the microorganisms of the vagina and the cervical canal: massive contamination contributes to the development of the infection process. Thus, a high degree of colonization of the vagina with aerobic and anaerobic bacteria before abdominal delivery increases the risk of postoperative purulent-inflammatory complications, in particular, endometritis, peritonitis after cesarean section. The factors contributing to the activation of the microflora of the vagina and the subsequent development of the infectious process include reduction of systemic and local immunity, changes in hormonal status, and irrational administration of antimicrobial drugs that disrupt the natural relationship of microorganisms in the vaginal microcenosis.
The general patterns of the dynamics of the etiological structure of the GDH allow us to say that in each hospital there is a certain epidemiological situation, biological features of pathogens and their sensitivity to antibiotics, and therefore local monitoring of the species composition and antibiotic resistance of the secreted microorganisms is necessary, determining the choice of drugs for the prevention and treatment of the disease .
The use of antibacterial drugs in obstetric practice has a number of features that should be considered for the effective treatment of infectious and inflammatory diseases in pregnant women and puerperas. Antibacterial therapy of the GDH in obstetrics and gynecology can be effective only taking into account their clinic, etiology, pathogenesis and a number of features that occur in the body of pregnant women and determine the correct choice and adequate use of antibacterial drugs.

First of all, you should know whether the drug has embryotoxic and teratogenic effects. The presence of such properties is a contraindication for the use of medicinal substances in obstetrics. Of great importance is the transplacental transition of antibiotics. The level of the drug, which is created in the tissues of the fetus and in the amniotic fluid when it is introduced into the maternal organism, determines the possibility for its therapeutic use during intrauterine infection and chorioamnionitis.

Non-embryotoxic drugs

Group III includes drugs that do not have an embryotoxic effect – penicillins, cephalosporins, macrolides. These antibiotics can be considered the drugs of choice in the treatment of infectious diseases in pregnant women.
Physiological changes occurring in the body of women during pregnancy have a significant impact on the pharmacokinetics of drugs, including antibiotics. A decrease in the amount of albumin in the blood, an increase in renal clearance, a decrease in absorption from the gastrointestinal tract, and a number of other factors that appear during pregnancy, lead to a decrease in the period of excretion of drugs. The above helps to reduce the concentration of antibacterial substances in the blood and organs compared to non-pregnant ones, this is most pronounced in the third trimester of pregnancy. The individual characteristics of the body, as well as the properties of the drug, have a significant impact on the pharmacokinetics of antibiotics during pregnancy. This is of great diagnostic importance and determines the need for dose adjustment and the mode of administration of the antibiotic.

Often, the content of antibacterial drugs in the blood during gestation exceeds their minimum bacteriostatic concentration for pathogens. However, in some cases, the average therapeutic concentrations of antibiotics in the treatment of infections in pregnant women may be ineffective, and therefore there is a need to increase the dose. Without the risk of pronounced adverse reactions, large doses of antibiotics can be used, having a wide range between therapeutic and toxic effects, such as penicillins, cephalosporins. If the specified range is small, then drugs are prescribed only in the average therapeutic dose. In case of a severe disease, ineffectiveness of the treatment, when there is a need to increase the dose of antibiotics, in order to avoid their embryotoxic action, it is advisable to determine the content of drugs in the blood of pregnant women.

Postpartum Pharmacokinetics of Antibiotics

In the postpartum period, the pharmacokinetics of antibiotics do not significantly change. In the early postpartum period there is an increase in the half-life of some antibacterial drugs, the volume of distribution and the renal clearance of these antibiotics are increased. In puerperas, antibiotics are found in uterine lochia and milk.

Antibacterial drugs for use in obstetric practice, as indicated above, should not have any teratogenic or embryotoxic properties; as far as possible, with maximum efficacy, be of low toxicity, with a minimum incidence of side effects. A number of modern antibiotics fully meet these requirements, in particular, inhibitor-protected penicillins, cephalosporins and macrolides. As you know, penicillins penetrate the placenta, but they are quite safe. There is a fairly large amount of observation in pregnant women who received them in the first trimester, but even in this case there were no serious anomalies, this group of drugs can be used in the postpartum period without stopping breastfeeding. Cephalosporins easily cross the placenta, so their use in the first trimester is still not recommended. The conducted preclinical studies did not reveal any mutagenic or teratogenic effect in the preparations of these groups.
Due to the wide range of pathogens that cause inflammation in the female genital organs, the choice of an effective antibiotic is crucial. Treatment in many cases is carried out with a combination of broad-spectrum drugs, preferably intracellularly penetrating, and anti-anaerobic drugs.
Dosage forms and pharmacokinetic properties of antimicrobial drugs allow you to use the principle of “step therapy”, that is, to begin the course with parenteral administration of drugs, and finish taking the tablets of the antibiotic.

Modern antibiotic therapy

Modern antibiotic therapy of individual nosological forms begins with empirical treatment, when antibiotics are administered immediately after the diagnosis of the disease, taking into account possible pathogens and their sensitivity to drugs. When choosing a drug for initial therapy, data from the literature on its spectrum of action on microorganisms, pharmacokinetic features, etiological structure of this inflammatory process, and structure of antibiotic resistance are taken into account. Before starting therapy, one should receive material from the patient for microbiological examination.
From the first days of the disease, it is advisable to prescribe an antibiotic or a combination of antibiotics that best cover the spectrum of possible pathogens. To do this, it is necessary to use combinations of synergistically acting antibiotics with an action spectrum that complements each other, or one drug with a broad spectrum of action. In case of positive dynamics of the disease, based on the results of microbiological research, it is possible to switch to drugs of a narrower spectrum of action. After isolating the pathogen and determining its sensitivity to antimicrobial drugs in the absence of clinical effect from the initiated empirical therapy, it is advisable to continue the treatment with the drug to which, according to the analysis, the causative agent of the disease is sensitive. Purposeful monotherapy is often more effective, it is more profitable and economically. Such tactics of antibiotic therapy is used in the treatment of the GDH in obstetrics and gynecology.

The combination of antibacterial drugs is indicated in the treatment of diseases of polymicrobial etiology in order to reduce the possibility of the development of antibiotic resistance of certain types of bacteria, to take advantage of the combined effect of antibiotics, including reducing the dose of drugs used and their side effects. However, it should be borne in mind that combination therapy is usually less economically advantageous than monotherapy.

Antibacterial therapy of the GDH in obstetrics and gynecology should be systemic, and not local. With systemic treatment, it is possible to create the necessary concentration of antibiotics in the blood and the lesion focus, maintaining its required time. Local use of antibacterial drugs does not allow to achieve this effect, which in turn can lead to the selection of resistant strains of bacteria and the lack of effectiveness of local antibiotic therapy.

Prescribing antibacterial drugs

In the appointment of antibacterial drugs for the treatment of the GDH in pregnant women should consider the duration of pregnancy. In the first trimester, at the stage of organogenesis, the fetus is most sensitive to the action of medicinal substances and therefore during this period of pregnancy only harmless drugs are prescribed that do not adversely affect the fetus. In the first and second trimester of pregnancy, the spectrum of antibiotics used for treatment can be expanded. In the postpartum period, antibacterial drugs of various groups can be used, provided that the breastfeeding is suspended.
The duration of antibiotic use is determined by the nature and severity of the disease. Unreasonably long-term antibiotic therapy increases the frequency of side effects of drugs, including the development of dysbiosis, antibiotic-associated diarrhea [3]. In most cases, antibiotics can be canceled 2–3 days after the temperature normalizes. If within 48–72 hours after the start of antibiotic therapy there is no positive dynamics of the disease, the issue of changing antibacterial drugs should be resolved (even in the absence of bacteriological examination results). However, it must be certain that the removal or surgical debridement of the foci of infection (according to indications) has been fully performed (for example, hysterectomy and drainage of the abdominal cavity during obstetric peritonitis; operation for purulent mastitis; instrumental emptying of the uterus during an infected abortion, etc.) . As you know, the causes of the ineffectiveness of antibiotic therapy can be the resistance of the pathogen to this drug, insufficient penetration of the antibiotic into the focus of inflammation, impaired immune status of the woman.

Summarizing the above, it is necessary to emphasize that antibacterial drugs are an important, often the main component of the complex therapy of infectious diseases in obstetric practice; their rational and reasonable use in most cases determines the effectiveness of the treatment, favorable obstetric and neonatal outcomes.

Treatment of Morton’s Neuroma

At the initial stages of the development of the disease is carried out conservative treatment. The first recommendations of the attending physician are: unloading of the feet, periodic use of the metatarsal pads and lifts, wearing shoes with a retrocapital support. The essence of these methods is to reduce the pressure on the nerve trunk. The use of custom-made orthopedic insoles increases the effectiveness of conservative treatment. With their help, it is possible, firstly, to reduce the load on the front area of the foot and restore the state of the transverse arch to normal; secondly, to reduce the pressure of bones and ligaments on the damaged nerve, which allows you to stop the progression of the disease; thirdly, to eliminate the inflammatory process in the nerve fibers and tissues, which significantly reduces or completely eliminates pain; fourthly, to restore the structure of the foot, thereby ensuring the correct gait.
If the pain syndrome is not pronounced, it is possible to use multicomponent compresses with dimexidum, nonsteroidal anti-inflammatory drugs and local anesthetics in combination with muscle relaxants and manual therapy. With insufficient effect, injections of glucocorticosteroids are performed in the interplusar space on the back of the foot, which in half of the cases leads to an improvement in the course of the disease, and in one third of the cases – to complete recovery. If a patient has a deforming arthrosis, it is possible to prescribe chondroprotectors for prophylactic treatment.
In the case of resistance to conservative methods of treatment, patients are offered surgical treatment. In this case, there are several different approaches to the treatment of Morton syndrome surgically.
The most common operation performed under local anesthesia is the removal of the neuroma. Since it is part of the nerve, its hypertrophied and inflamed area is excised. In most cases, this eliminates the pain syndrome, but, as a rule, a small area of unexpressed numbness remains on the foot, which is almost always not felt until the patient touches it. Motor and support functions of the foot do not suffer. The rehabilitation process averages 2-4 weeks, during which the patient is recommended to reduce the load on the foot.
Some surgeons believe that excision of the inflamed area of the nerve as a primary surgical method is too radical. The operation of dissection (release) of the transverse ligament between the metatarsal bones will eliminate the nerve compression. One of the advantages of this method is the absence of sensory disorders. In the event that this operation does not lead to success, excision of the neuroma is possible.
Osteotomy of the 4th metatarsal bone is the least used method of surgical treatment of the pathology under consideration. The essence of the intervention is that due to the displacement of the head of the 4th metatarsal bone after osteotomy (artificial fracture), nerve decompression is achieved. This manipulation is performed under x-ray control through an incision or puncture of the skin, not exceeding 2 mm.
Analysis of the effectiveness of surgical treatment of Morton’s neuroma showed excellent results (complete absence of pain syndrome and other symptoms) in 45% of cases, good results (significant reduction of pain syndrome and almost complete regression of neurological symptoms) – in 32%, in 15% of cases the outcome was satisfactory ( pain syndrome decreased slightly, neurological symptoms persist), in 8% – unsatisfactory (the operation did not bring any improvement). The low effectiveness of surgical interventions is associated with the formation of a true amputation neuroma in the proximal part of the interplusomer nerve….

Diagnosis of Morton’s Neuroma

Clinical diagnosis of this pathological condition is simple. First of all, it is based on the characteristic localization of pain. During palpation of the 3rd interplusar gap for 30–60 s, the patient, as a rule, begins to experience numbness and a burning sensation. Movement disorders are uncharacteristic. Sensory disturbances confirm neural damage.
Speaking of instrumental studies of Morton’s metatarsalgia, it should be noted that magnetic resonance imaging, unfortunately, does not always confirm the clinical diagnosis and in some cases gives questionable results. Performing computed tomography of the foot rarely gives any information due to the lack of mineral deposits in this soft tissue formation. However, due to X-ray methods, it is sometimes possible to determine the bone bite in the place of compression of the neuroma.
Ultrasound examination is one of the leading methods for diagnosing the condition of soft-tissue structures of the foot. However, in our country, the use of ultrasound for the diagnosis of diseases of the peripheral nerves is not sufficiently developed.
The regression of pain syndrome after the treatment and diagnostic blockade of the interplusal nerve with a solution of a local anesthetic is a convincing indication in favor of neuroma.
Pain in the foot and fingers is often observed in clinical practice, in most cases it is caused by deformity of the foot, which occurs in various pathological conditions, in particular with flat-footed or chronic Achilles tendinitis. However, with significant deformity of the feet, a pronounced pain syndrome does not always develop, as, for example, in patients with hereditary spastic paraplegia.
Differential diagnosis of Morton’s Neuroma is conducted with diseases such as synovitis of the metatarsophalangeal joint, stress fractures of the metatarsal bones and metatarsophalangeal joint arthritis, osteonecrosis of the metatarsal heads, neoplastic lesions of bones, lumbar spine disease, radiating pain in the intertarsal gaps.

The mechanism of development of Morton’s neuroma

The mechanism of development of Morton’s neuroma is not well understood, but a number of hypotheses have been proposed. When studying the morphological material, it was concluded that, with this pathology, a thickening occurs on the tarsal tibial nerve, and the researcher believed that this is not a true neuroma, but a pseudoneuroma similar to that which develops in the trunk of the median nerve above its compression site carpal tunnel syndrome. Later, changes that ranged from thickening of the wall to complete obliteration of the lumen of the artery supplying the nerve and adjacent tissues in this area of the foot were described, the conclusion about the ischemic nature of the pathological process was made. At present, it is believed that the starting moment is repeated, multiple microtraumas and nerve compression, which passes between the 3rd and 4th metatarsal bones, as a result of which the transversal interlumbus ligament is thickened, the separation
its on fiber and the formation of edema. The so-called pathological interlaryus ligament of the foot leads to constant compression and displacement of the medial plantar nerve and its accompanying vessels, causing its ischemia. Modern studies have shown that the average size of neuroma is 0.95–1.45 cm in length, and 0.15–0.65 cm in width, that is, it is an elongated, spindle-shaped formation.

Treatments for Morton’s Neuroma

The article describes Morton’s neuroma, presents a clinic of the disease with a description of the nature of the pain syndrome and neurological symptoms. The measures for the prevention and conservative treatment of Morton’s neuroma are described, including the use of orthopedic insoles and other orthopedic aids.

Tunnel or compression syndromes / neuropathies are one of the most common groups of diseases of the peripheral nerves and constitute, according to different authors, from 25% to 40% of all diseases of the peripheral nervous system.
In the scientific literature there is information about two diseases of the foot, which are associated with the name of the American surgeon Thomas George Morton (1835-1903). The first is Morton’s foot, otherwise, the syndrome of insufficiency of the first metatarsal bone, in which the second toe of the foot is longer than the first, which is a factor predisposing to the formation of the hammer-like second toe. The second is Morton’s neuroma, a manifestation of tunnel syndrome in which the nerve that passes between the heads of the 3rd and 4th metatarsal bones suffers. This disease has many synonyms: metatarsalgiya Morton, plantar interdigital neuroma, interplusus neuroma, foot neuroma.
In 1876, Thomas Morton first described the syndrome observed in 12 patients with an “unusual and painful lesion of the 4th metatarsophalangeal joint”. In studying this pathology, Morton suggested that mechanical compression of the nerve with the heads of the metatarsal bones is the main mechanism for the development of the disease.
Compression neuropathies are currently believed to be a polyetiologic disease. In their formation play an important role as a genetic predisposition, and the impact of exogenous and endogenous factors. Among the many etiological factors that cause the development of tunnel neuropathies, it is necessary to highlight the main ones that play a major role in the formation of Morton’s neuroma. These include: transverse flatfoot, wearing close shoes (including shoes
with high heels and narrow nose), acute traumatic injuries and hematomas at the site of localization of nerve fibers, irregular gait with turning the foot inwards, obliterating diseases of the lower extremity vessels, overweight, increased load on the front foot, infectious and autoimmune diseases, changes in the structure of the nerve, lipomas of various types.

Diet №8

Diet № 8 – one of the most popular types of diets, which is used by people suffering from obesity. It provides a portion meal. Thus, a person eats at least six times a day, but the products should not contain more than 100 grams of fat, 150 g of carbohydrates and 100 g of protein.

This is a compromise diet for many. As a rule, most nutritionists tend to remove excess carbohydrates from the human body, resulting in weight loss. Doctors who developed this diet, say that it is enough to use the main rules of the diet, and excess weight will go away.

Important advice! Do not try to choose your own diet on the Internet. This is a futile exercise, for which you will spend a lot of time, and it will not end in your favor. It is better not to regret the funds and ask for help from an experienced nutritionist or trainer. Do not forget that each person is individual, and the nutrition program should be prescribed based on your personal needs.

The diet is based on the concept: we spend more calories, but use less carbohydrates. Thus, all excess fat deposits go away. The body eventually regains its beautiful forms and relief. If you adhere to the basic laws of diet, you will be able to get rid of excess weight. It is proved that people observing the principles of diet number 8, show high results of weight loss after the first weeks.

Thus, we come to the conclusion that a diet is more a system of proper nutrition, rather than a restriction on any food. Nutritionists do not just tell you what you need to do to get rid of excess weight, but also teach you how to eat right. Due to the fact that the intake of carbohydrates is sharply restricted in the diet, the body takes its own fat reserves to get the energy it needs.

The main purpose of diet number 8 is not to starve the body, but to reduce the amount of carbohydrates in the diet, removing from the diet starchy foods that are characterized by nutritional value. The use of a minimum amount of carbohydrates will provide the body with all the useful substances.

This diet provides a full meal. Products are selected with high demands, they should be rich in all the necessary macronutrients and vitamins. In general, the diet consists of fruits and vegetables. It is not recommended to eat vegetables, which contain starch. It is also necessary to refuse the use of spices, as they provoke the appearance of appetite. The diet provides cooking dishes without salt and pepper. Alcoholic drinks, soda and sweets need to be excluded from the diet in principle!

It is important to observe the body’s water balance. A healthy person should drink at least two liters of water a day. Tea, juices and mineral water are not included in the list. An exception can be considered hydrocarbonate mineral water