RU2293561C1 - Method for predicting acute appendicitis in pregnant women - Google Patents

Abstract

FIELD: medicine, surgery, surgical gynecology.

SUBSTANCE: one should perorally introduce xymedon at the dosage of 0.5 g to be repeated in 30 min. Then, intravenously one should inject 30 ml provocation-diagnostic curative composition, not more, that consists of aqueous solution of nicotinic acid and polyglucin taken at the following ratio of components, weight%: nicotinic acid 0.05-0.1, polyglucin 0.1-1.8, water - the rest. In case of pain one should diagnose appendicitis. The innovation provides the decrease of incorrect diagnostics in case of acute appendicitis in pregnant women at earlier stages of development along with normalizing action upon gravid uterus.

EFFECT: higher accuracy and efficiency of diagnostics.

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Description

The invention relates to medicine, namely to methods of differential diagnosis, preventive therapy and prevention of postoperative complications in purulent-inflammatory processes in the abdominal organs, for example, in acute appendicitis in pregnant patients.

The well-known difficulty in recognizing acute appendicitis, especially in pregnant women. A clinic that develops, for example, with premature termination of pregnancy or its threat, is able, under certain conditions, to stimulate the picture of acute appendicitis. The same condition can occur with incomplete uninfected miscarriages, perforation of the uterus during criminal abortion and other pathological conditions of the organ (Dekhtyar E.G. Acute appendicitis in women. M., 1965, 194 p .; Kalitievsky PF Diseases of the appendix. M., 1970, 202 pp .; Kasymov, Sh.Kh. Some clinical and laboratory indicators in the diagnosis of various forms of acute appendicitis (Abstract of Cand. Diss. Tashkent, 1973).

Traditionally, the diagnostic program boils down to collecting an anamnesis, objective research, paraclinical methods, such as studying the composition of peripheral blood (elevated ESR, leukocytosis, shift of the leukoformula to the left), panoramic x-ray of the abdominal organs, novocaine blockade of the uterine cervix according to Lorin-Epstein, electromyography of changes muscles of the anterior abdominal wall. Ultrasound, chromothermography, rectal, vaginal, measurement of electric skin resistance, hysterography, etc. (Salishchev V.E. Surgery issues. M, 1952, 316 p .; Serov B.N et al. Practical obstetrics: A guide for doctors. M .: Medicine, 1997, 512 pp.). However, these methods often do not provide the necessary information for the diagnosis of acute appendicitis, as indicated by numerous authors. The greatest difficulties in the diagnosis of acute appendicitis arise in the early phases of their development - vasoconstriction, functional disorders, when there are no macroscopic, and often microscopic, changes. Diagnostic errors are possible at other stages of the inflammation of the process, when the pain is significantly reduced or detected with difficulty (Kochnev, O.S. Emergency surgery of the gastrointestinal tract. Kazan, 1984, 288 pp .; M. Bondarenko et al. Clinical surgery., 1993. - No. 6. - P.5-7; Pozolkova NM, Semenova BC // Actual issues of obstetrics and gynecology. Moscow-Surgut, 1996. - P.123-128).

Summing up the numerous data available on this issue in the literature and personal observations, we came to the conclusion that the main, cardinal sign of acute appendicitis is pain: intensity, localization, character, and radiation. The value of this symptom in the form in which it is most often determined, especially in the second half of pregnancy, decreases sharply (Ivanov G. I. Appendicitis in pregnant women. M.-: Medicine, 1968. - P.96). Pain is always a determining criterion for establishing a diagnosis in the choice of tactics - "To operate or not to operate!".

Informative methods are laparocentesis and laparoscopy, the disadvantages of which are their invasiveness with the danger of infection and injury to internal organs. The methods are technically complicated, not always feasible and also do not give 100 percent confidence in the correct diagnosis (Filin V.I., Elkin M.A. Emergency and emergency surgical care in Leningrad. L., 1978; Kulik I.P. et al. West Surgery. - 1996.- No. 3. - P.31-33).

The clinical features of acute appendicitis in pregnant women are explained by physiological changes and topographic and anatomical changes in the abdominal cavity, which is most pronounced in the 2nd half of pregnancy. Stretching the abdominal wall, reducing its elasticity, reduces or completely eliminates muscle tension. The value of the classical symptoms of Shchetkin-Blumberg, Sitkovsky, Kera is lost (Uteshev NS. Et al.: Acute appendicitis. M., 1975). With uncertain localization of pain in people of critical age, obese, pregnant, manual techniques are offered with a change in the patient’s body position, such as the position on the left side, knee-elbow (Izmailov G.A. Features of the diagnosis of inflammatory diseases of the abdominal organs in elderly and senile patients West Surgery. - 1973. - No. 7). These techniques have low information content and complexity.

With a not entirely clear clinical picture with appendicitis and inflammatory diseases of the genitals, it is considered advisable for differential diagnostic purposes to perform intra-pelvic novocaine blockade according to L.G. Shkolnikov - V.V. Selivanov, N.Ya. Romanenko (On closed liver injury. - Surgery, 1978. - No. 7. - S.51-54). If the pain in the right iliac region after the blockade persists, then we are talking about appendicitis. A similar differential technique was widely used until the 60s of the XX century to exclude renal and intestinal colic and other functional disorders of the urinary and digestive organs with appendicitis. However, the accumulated clinical material showed that the blockade can be carried out only for therapeutic purposes with a clearly established diagnosis. With an unclear disease, novocaine blockade is fraught with consequences, sometimes it not only obscures the clinic of the underlying disease, but can lead to complications such as organ puncture, allergies, collapse, etc. Attitude to novocaine blockades is currently restrained and they are carried out according to strict indications, as evidenced by our clinical observations and reports in the literature (Schmitt V., Khartig V., Kuzin MI. General Surgery. M., 1985; Gostishchev V.K. Operational purulent surgery. M., 1996; Kuleshov EV, Kuleshov S.E. Diabetes mellitus and surgical diseases. M., 1996, Petrov S.V. General surgery. St. Petersburg, 1999). Novocainic blockade is deprived of selectivity of action, it is aimed at relieving spasm in organs without their differentiation, i.e. the spasm is removed simultaneously in all organs localized in this innervated area. Other similar methods of treatment include the introduction of various antispasmodic drugs, such as no-spa, papaverine, atropine (Ivanov G.I. Appendicitis in pregnant women. M: Medicine, 1968. - 175 p .; Uteshev N.S. et al. Acute appendicitis. M: Medicine. 1978. - 159 p.), As well as tocolytics - means that relax the muscles of the uterus (Mashkovsky MD Medicines. M: Medicine, 2002). Antispasmodics, as already indicated, are aimed at relieving spasm in the organs, at reducing pain in the affected and intact organs in the absence of selectivity of action.

However, the use of antispasmodics has the following significant disadvantages:

- low diagnostic value due to the lack of selectivity of action;

- do not have a desensitizing property;

- the unidirectionality of the pharmacological effects, namely the elimination of pathologically supported spasm of smooth muscles of the organs;

- the possibility of the genesis of collapse;

- contraindication of the introduction of a number of antispasmodic drugs, such as atropine, due to pronounced side effects (tachycardia, dry mouth, etc.);

- Frequent allergic reactions are observed;

- leads to the erasure of clinical manifestations, which not only worsens the recognition of the underlying disease, but also exacerbates its course;

- does not have regenerative and antiphlogic ability.

In addition, these methods are not acceptable in the postoperative period. They are not very effective in treating developing complications (premature termination of pregnancy, flatulence, suppuration of a wound, inconsistency of sutures, delayed stool and urination), especially in their prevention. They do not have regenerative ability, which is significantly reduced in this group of patients, which leads to the formation of fragile postoperative scar. There is a significant risk of eventation, which is facilitated by increased intraperitoneal pressure.

You should pay attention to the fact of a decrease in the content of nicotinic acid in the blood of pregnant women. The US National Research Council recommends an increase in niacin equivalents of 3 mg per day for 3–6 and 6–9 months of pregnancy in accordance with an increase in calorie intake. Therefore, the introduction of nicotinic acid can be considered scientifically sound, without fear of hypervitaminosis.

However, after taking nicotinic acid in patients, redness of the skin of the face, upper half of the body and less often of the lower part, dizziness, feeling of heat, rush of blood to the head may occur. Typically, an angioneurotic reaction passes on its own after 8-12 minutes and does not aggravate the patient’s condition, which is also indicated in the literature (Vitamins. Edited by M. I. Smirnov. M .: Medicine, 1974. - P.364). As a rule, an angioneurotic reaction with a feeling of heat in the abdomen and lower back in patients with no acute diseases of the abdominal organs appeared at the 4-5th minute after the administration of nicotinic acid, was short (on average 8-10 minutes), mild and painless in the treatment of more than 500 patients with various pathologies of the abdominal and chest organs, bones, joints and soft tissues.

Among the shortcomings of nicotinic acid, one of the side effects should also have a hypotensive effect with its rapid intravenous administration (Mashkovsky M.D. Medicines. M .: Medicine, 2002).

Known plasma substitute polyglucin - a sterile 6% solution of the molecular weight fraction of partially hydrolyzed dextran (with a relative molecular weight of 60,000 ± 10,000) in an isotonic sodium chloride solution (Mashkovsky MD Medicines. 2002. - T.2. - P.131). Due to the high osmotic pressure, the drug retains fluid in the bloodstream, thus exerting a hemodynamic effect, and when used locally prevents the formation of adhesions.

Methods of treating various diseases with preparations containing polyglucin are described.

So, the method of treatment of purulent-inflammatory complications of the abdominal cavity in patients in the postoperative period (Application No. 92009639 A, 16.12.1992, A 61 K 31/74, A 61 K 35/14, A 61 N 5/10) is that the patient in the postoperative period is administered antibacterial drugs intravenously or intramuscularly. Immediately after their administration, transfusion of low molecular weight solutions of dextran (reopoliglyukin, polyglyukin, reomacrodex), previously irradiated with low-wave x-rays at a dose of 0.1-25 g, is carried out.

The method allows to improve the results of treatment, reduce the severity of the disease and reduce the treatment time by 2 times. This is achieved due to the fact that the introduction into the body of low molecular weight solutions of dextran irradiated with x-ray radiation immediately after the administration of antibiotics increases their biological activity and also stimulates the immune system. The economic effect is reduced by reducing the number of injected antibacterial drugs and reducing the number of bed days.

Another way to restore the interstitial department of the uterine tubes of a woman (Application No. 2000127767 A, 03.11.2000, A 61 N 7/00), consists in a single cryotherapy on the uterine corner after preliminary sedation additionally repeatedly affects the mucous membrane of the uterus with low-frequency radiation of ultrasonic energy through the stream liquid antibacterial drug (tetracyclines, macrolides, fluoroquinolones) and polyglucin, which causes the property to prevent the formation of adhesions, reduce tissue swelling, improve microcirculation radiation and regeneration processes in the impact zone and, as a result, restore the patency of the fallopian tubes.

There is a method of treating peritonitis (Patent No. 2092111 C1, 06/28/1993, A 61 B 17/00, A 61 M 27/00, A 61 M 31/00, A 61 K 31/725). In the proposed method, after the elimination of the main cause of peritonitis, surgical removal of the abdominal antiseptics is performed. Then, a mixture containing polyglucin, heparin, novocaine, kanamycin, kontrikal is continuously drip injected into the abdominal cavity through a microirrigator.

A method of treating postoperative purulent-inflammatory complications in the abdominal cavity (Patent No. 2034545, C1, 12/06/1992, A 61 K 31/74, A 61 K 35/14, B 61 N 5/10) is that the patient in the postoperative period, antibacterial drugs are administered intravenously or intramuscularly. Immediately after their administration, transfusion of low molecular weight solutions of dextran (reopoliglyukin, polyglukin, reomacrodex) is performed once.

A method of treating trophic ulcers and long-term non-healing purulent wounds (Patent No. 2160135 C2, 07.17.1998, A 61 N 5/06, A 61 K 38/43) involves irradiating blood with a low-intensity helium-neon laser through a light guide in combination with local application of a suspension of drugs (pepsin, ascorbic acid, hydroperite, methyluracil, polyglucin).

The above analogues provide for the use of polyglucin in significant quantities (from 400 to 2000 ml) for the treatment and prevention of various diseases as a means of increasing and stabilizing blood pressure. Of the disadvantages of these analogues, it should be noted that polyglucin leads to:

- to increase blood pressure, which is especially dangerous in people with already existing hypertension;

- repeated administration of polyglucin increases the risk of allergic reactions, which is most likely in the proposed complex medicinal compositions.

In addition, the restructuring of the reactivity of a pregnant woman in the direction of increasing sensitivity to drugs creates an unfavorable allergic background for the implementation of active antispasmodic therapy (Petrovsky G.A., Panashchenko A.D. Clinical Pharmacology. Kiev: Health, 1965). Therefore, in the treatment of pregnant women, it is necessary to take this fact into account and resort to pharmaceuticals with an additional desensitizing effect.

Numerous studies have shown that one of the aspects of pregnancy is changes in the coagulation and anticoagulation system of the blood. Even hypo- or afibrinogenemia with the occurrence of uterine bleeding can be observed (Baksheev N.S. Uterine bleeding in obstetrics. Kiev: Health, 1966). Therefore, the inclusion of agents that correlate blood coagulation, such as Xymedon, is well founded.

Xymedon N- (β-hydroxyethyl) -4,6-dimethyldihydropyrimidone-2), by order of the Ministry of Health of the Russian Federation No. 287 of December 17, 1993, was included in the Register of Medicinal Products Allowed for Clinical Use. Long-term use of Xymedon in the clinic has shown its high therapeutic efficacy in a number of surgical and therapeutic diseases (traumatic tissue injuries, ulcers, pneumonia). Xymedon in therapeutic doses does not cause toxic effects and no allergic reactions have been reported with its use. The drug has a pronounced general sensitizing effect (Izmaylov S.G. et al. Xymedon in clinical practice. Nizhny Novgorod: Publishing House of NGMA. - 2001).

The aim of the invention is a new method for the diagnosis of acute appendicitis in pregnant women.

The proposed method allows more efficient (selective) to diagnose and relieve possible complications of acute appendicitis in pregnant women.

The goal is achieved by successive combined fractional oral administration of xymedon followed by intravenous fractional administration of small doses of a provocative diagnostic therapeutic composition - an aqueous solution of nicotinic acid with polyglucin, prolonging and potentiating the main pharmacological effect of nicotinic acid. In this case, nicotinic acid causes an increase in pain in the inflamed appendix with simultaneous relaxation of the muscles of the uterus with the elimination of pain in its projection. Xymedon is also prescribed in the postoperative period in recommended dosages inside until the patient is discharged from the hospital. In this case, an increase in the regenerative ability of the immune defense forces is achieved, as well as a prevention of the possibility of premature termination of pregnancy.

The proposed provocative diagnostic therapeutic composition of prolonged action contains nicotinic acid and a plasma substitute, for example, polyglucin in the following components, respectively, in wt.%:

A nicotinic acid 0.05-0.1 Polyglukin 0.1-1.8 Water rest.

The proposed provocative diagnostic therapeutic composition NIKOPOL (abbreviated name from the initial letters of the active ingredients of the composition) consists of highly effective chemical and biological pharmacological agents that provide a normalizing effect on the motor function of the gastrointestinal tract, pregnant uterus with simultaneous moderate intensification of the pain syndrome with its more distinct localization in the area of the inflammatory focus.

Our own observations allowed us to state one important, previously unknown phenomenon - to intensify the pain syndrome in latent, latent inflammatory processes that are difficult or completely not detected before the introduction of nicotinic acid. At the same time, under its influence, the muscles of the pregnant uterus are relaxed with the elimination of pain caused by impaired contractile function of the organ. Such a differentiated effect gave us the scientific justification for the inclusion of nicotinic acid in the combined provocative diagnostic therapeutic composition - NICOPOL. At recommended therapeutic dosages, nicotinic acid is not toxic.

The provocative effect of nicotinic acid of the inflammatory process, which we discovered, for example, acute appendicitis in pregnant women, especially in doubtful, difficult to diagnose cases, is the basis of the proposed method. The described phenomenon can be explained by a higher degree of nicotinic acid irritation of the nerve endings in the area of the pathological focus in the inflammatory process, i.e. increasing their selective sensitivity to the administered vitamin PP.

In contrast to analogues, polyglucin was chosen as a prolongator of the main action of nicotinic acid and a means to level out possible unwanted hemodynamic changes. Giving durance to the mechanism of exposure to nicotinic acid comes from our goal.

Thus, the well-known 6% solution of polyglucin of the middle molecular fraction of partially hydrolyzed dextran (glucose polymer) in an isotonic sodium chloride solution, which is a plasma-replacing drug, has a hemodynamic effect. Polyglukin increases blood pressure, which makes it useful for the prevention of hypotension at the time of administration of nicotinic acid. Due to the high osmotic pressure, polyglucin retains fluid in the bloodstream, thereby prolonging the circulation and pharmacological effect of the drug. So, the feasibility of including polyglucin in the composition of the proposed medicinal composition is theoretically justified, which is confirmed by our own clinical observations.

Our early studies in the experiment and clinic proved the normalizing effect of xymedon on the kinetics of the gastrointestinal tract in patients in the postoperative period with diseases of the abdominal organs (RF patent No. 2159616, MKI A 61 K 31/505). A method of treating wounds of the digestive tract (S.G. Izmailov et al. 2000). However, in the work (RF Patent No. 2159616) there is no data on the effect of the drug on the contractile activity of the pregnant uterus in the presence of acute abdominal pathology, as well as on the motility of the gastrointestinal tract. Therefore, the difference of our invention is the use of xymedon in acute inflammatory diseases of the abdominal organs in pregnant women under conditions of increased intra-abdominal pressure. The drug has a normalizing effect on the functional activity of the uterus. Pregnancy is not a contraindication to the use of Xymedon.

The positive pharmacological properties of Xymedon are potentiated by nicotinic acid - vitamin PP, the inclusion of which in the proposed method is scientifically justified. Niacin, a drug often used in the clinic, has a wide spectrum of action (antiallergic, desensitizing, antitoxic, improves carbohydrate metabolism, vasodilator, etc.), which allows it to be prescribed for a variety of diseases: the genitourinary system (Drugs used in urological practice. Edited by V.A. Chernov, Moscow: Medicine, 1972. - 188 p .; Mazmanyan, Ts. G. Handbook of pharmacotherapy of genitourinary diseases. Tashkent, 1977. - 208 p.), Non-healing wounds for a long time (Medicinal products the drugs allowed for use in the USSR. M: Medicine, 1979. - 352 p.), atherosclerosis (Zapadnyuk V.I. Geriatric pharmacology. Kiev: Zdorovya, 1997. - 168 p.). A therapeutic effect was obtained with persistent vomiting of pregnant women (Petrovsky G. A., Panashchenko A. D. Clinical pharmacology. Kiev: Zdorovya, 1965. - P.359). It is also known that vitamin PP reduces the activity of uterine stimulants (I. Muravyov et al. Incompatibility of medicinal substances. M: Medicine, 1978. - P.205).

It should be noted that the achieved effect of the proposed composition - NICOPOL, is not the result of the sum of the effects of the ingredients contained in it, but the resulting effect is unexpected. It is much higher in degree and spectrum of action. This result was obtained by potentiating the action of the components, moreover, with the exception of the manifestation of undesirable side effects of the proposed composition.

The preparation of the proposed provocative diagnostic therapeutic composition was carried out according to the accepted weight-volume methods of the State Pharmacopoeia by simple mixing of the components (Pharmacist Handbook, edited by T.I. Tenzova. - M .: Medicine, 1973. - 384 p.).

The use of a provocative diagnostic therapeutic composition and a method for detecting acute appendicitis in pregnant women was carried out as follows. After the initial examination with the obligatory involvement of an obstetrician-gynecologist and establishing a presumptive diagnosis, the patient took 0.5 g of xymedon inside, which was repeated after 30 minutes. At the end of a detailed clinical, laboratory and instrumental examination, it is mandatory to include 30 ml of the proposed provocative diagnostic therapeutic composition in a bed in one of the cubital veins, including determining the Zakharyin-Ged skin hyperesthesia zone, uterine excitability, rectal temperature, pain localization, and white blood counts. fixing the time of administration. As soon as the patient subjectively felt mild abdominal pain, which, in the presence of an inflammatory focus, was detected in the 2-3rd minute, intravenous infusion of the composition was stopped. The duration of the pain of the reaction was within 20-30 minutes, more often after administration of 15-20 ml of the composition. In the absence of a purulent-inflammatory focus in the abdominal cavity after administration of 30 ml of the composition, the pain completely subsided in all regions of the abdomen, lower back and other areas. After the introduction of the proposed provocative therapeutic diagnostic composition, a second clinical, laboratory and instrumental examination was performed. Thus, in the presence of inflammation of the vermiform appendix, pain already appeared or intensified in the right ileal or mesogastric region on the 2nd or 3rd minute of the injection, where a weakly expressed abdominal wall deflection was detected by palpation. In a number of observations, such symptoms of peritoneal irritation as Shchetkina-Blumberg, coughing, tapping (table) were manifested. On palpation and subjectively, as already indicated, the zone of greatest pain or its appearance shifted to the right half of the abdomen and became weakly expressed or with complete disappearance in the projection of the uterus. In a bimanual study, the excitability of the uterus was insignificant or not detected at all. Rectal temperature tended to increase significantly by 0.5-0.7 ° C.

The study of leukoformula at 35-40 minutes indicated a significant shift to the left. A dynamic study of peripheral blood, carried out every hour, allows you to get a regular, rapidly growing tendency to increase the number of white blood cells. Significant leukocytosis (12-16) · 10 ⁹ / L with pronounced stab shift (more than 5 stab forms), an altered number of lymphocytes and increased ESR are characteristic of appendicitis, in contrast to a prematurely interrupted pregnancy. The rapid increase in the first hours (hourly) of the number of leukocytes, a significant shift of the blood count to the left to young forms, and the stab shift is scientifically justified by the fact that after the introduction (after 15 minutes) of nicotinic acid, the manifestation of the so-called latent leukocytosis occurs, i.e. it becomes possible to determine the true leukocytosis. The hourly increase in the number of stab neutrophils found in this case is also a reliable objective diagnostic reference point.

The study of skin sensitivity (Zakharyin-Ged hyperalgesia zone) showed, first of all, an increase in the frequency of its detection (from 50 to 95%) and an expansion of the zones of hyperesthesia (corresponding to segments D ₃ -D ₁₂ ) and a significant increase in its degree, which is due to the intensification of the excitatory process in segments of the spinal cord.

Appendectomy was predominantly performed under local infiltration anesthesia according to A.V. Vishnevsky with preliminary intramuscular administration of a 50% solution of dipyrone (2 ml). Particular attention was paid to thorough layered, precision suturing of the surgical wound of the anterior abdominal wall with a careful attitude to tissues. In view of the increased tension of the tissues of the abdominal wall, the decrease in the volume of the abdominal cavity due to the enlarged uterus, certain difficulties in adapting the edges of the wound developed. At the same time, bulging of intestinal loops through the wound was observed, which further complicated the technique of closing the wound, making it extremely dangerous. In order to exclude possible damage to organs, to facilitate and less traumatic suturing of the wound, we successfully used special original design wound adaptive reposition devices. Wound drainage was performed strictly according to indications (presence of exudate in the abdominal cavity, technical difficulties, etc.). Patients in the experimental group from the first days after surgery received inside xymedon 0.5 g 3 times a day before meals.

Under our supervision, there were 17 patients admitted to surgical hospitals with a diagnosis of inflammation of the appendix and pregnancy. The experimental group consisted of 9 patients. Control served similar patients, the diagnosis of appendicitis in which was carried out by traditional methods. Erroneous diagnosis of acute appendicitis in the experimental group was found much less frequently and was minimal (in 1 case) compared with the control (in 4 cases). The reason for the erroneous diagnosis in pregnant women in the experiment was associated diseases (pyelitis, urolithiasis, cholecystitis).

An example of the successful application of the proposed provocative diagnostic therapeutic composition in the clinic.

Patient Z., 30 years old, was admitted on July 20, 2000 to a surgical clinic with a direct diagnosis of "acute appendicitis", a pregnancy of 25-26 weeks. Subjectively notes cramping pains in the lower abdomen and in the right mesogastric region with irradiation in the lower back. Pain is associated with pregnancy. She is ill on the 3rd day, on the eve she was examined at the antenatal clinic where she was offered a referral to the obstetric and gynecological department with a diagnosis of the threat of premature termination of pregnancy. Twice was vomiting. Before pregnancy, twice noted mild pain in the right iliac region. The general condition of the patient is satisfactory. The tongue is moist, slightly coated with a white coating. Heart rate 90 per minute. A / D 110/70 mm Hg. The temperature in the armpit is 37.6 ° C, in the rectum 38.7 ° C. The abdomen is slightly painful in hypogastria and in the right half. Symptoms of Shchetkin-Blumberg, Rowzing, Sitkovsky, Pasternatsky are negative. In a vaginal examination, the uterus is enlarged to 25 weeks of pregnancy, painful. The examination was carried out according to the proposed method with giving inside 0.5 g of Xymedon and internal administration of a provocative diagnostic therapeutic composition. Upon repeated examination, subjectively and objectively, the pains were localized in the right mesogastrium, where the defense and symptom of peritoneal irritation began to be determined. No pain was detected below the abdomen. 3 hours after admission under local anesthesia, a phlegmonous altered appendix was removed from the pararectal incision. The wound with the help of a wound adaptation-reposition apparatus is sewn up tightly. No complications after surgery were noted. Discharged 10 days after surgery home.

Patients in the experimental group were operated on early after admission (after 2-3 hours), in the control they in some cases (10) reached 30 hours. Establishing the exact location of the cecum displaced by the uterus made it possible to use a more rational type of surgical access to the vermiform inflamed process (Volkovich-Dyakonov, para-transrectal).

The postoperative period in the experimental group proceeded without complications. In no case was the case of premature termination of pregnancy, which occurred in 3 cases of the control group. As a rule, on day 2-3, experienced patients had independent stool; urinary retention is not marked. In the control, respectively, a delay in stool and urination was observed; in 3 cases, allergy was noted (rash, swelling of the face, itching). There was no postoperative mortality in the experiment, in the control - 0.1% (development of peritonitis due to untimely diagnosis of appendicitis).

There were no complications from the applied provocative diagnostic medical treatment, including allergic reactions of the composition against the background of xymedonotherapy.

The results of clinical intravenous use of the proposed provocative diagnostic therapeutic composition in pregnant women with acute appendicitis with preliminary oral and fractional administration of xymedon allow us to consider this diagnostic scheme highly effective. The use of xymedon inside after surgery before discharge from the hospital reduces the risk of premature termination of pregnancy, lowering the excitability of the uterus. Achievement of the differential diagnostic goal - an accurate diagnosis of acute appendicitis in pregnant women - is the discovery of new properties, potentiation of the action of components, and not just their total effect.

The proposed pharmacological agents are available, the scheme of their use is real, safe.

Differential diagnosis of acute appendicitis in pregnant women using a provocative diagnostic therapeutic composition Survey data Appendicitis in pregnant women Premature Abortion Before introduction After introduction Before introduction After introduction Pain localization In hypogastric lower back In the right iliac or hypochondrium In hypogastrium and lumbar region Complete disappearance (85%) or sharp weakening Irradiation of pain 50% in the epigastrium, in the lower back In 80% of the epigastrium 90% of the lower back, epigastrium, sacrum 15% in the lower back, sacrum Nature of pain 65% persistent moderate 100% amplified More cramping 95% disappear Nausea, vomiting Often Becoming less common Often Disappears Body temperature, ° C 36.5-37.2 75% higher than 37.8 37.0-39 37.4-39.2 Rectal temperature, ° С 37.6-38.3 38.1-39.4 38.2-40.6 38,4-40,8 A / D, mm Hg (M) 115/70 112/65 120/80 115/75 Heart rate 70-84 78-86 80-90 88-100 Zones of Zakharyin-Ged Skin hyperesthesia D ₈ -D ₁₁ D ₉ -D ₁₂ D ₁₀ -D ₁₂ D ₈ -D ₁₁

Digital rectum examination, anterior wall soreness In 30% In 70% Seldom Seldom Bimanual examination of the uterus, its excitability Seldom More frequent Often Becoming less common Symptom Shchetkina-Blumberg Missing or weak In 65% In 100% IN 2% Symptom Promptova, (+) Seldom Seldom Often Seldom ESR accelerated In 60% In 85% Moderately Moderately Leukocytosis with neutrophilic shift of the formula to the left Expressed in 70% Expressed in 92% Moderate Moderate

Claims (1)

A method for diagnosing acute appendicitis in pregnant women, characterized in that the oral administration of xymedon at a dose of 0.5 g, which is repeated after 30 minutes, after which a provocative diagnostic therapeutic composition consisting of an aqueous solution of nicotinic acid is administered at a dose of not more than 30 ml and polyglucin taken in the following ratio of components, wt.%: A nicotinic acid 0.05-0.1 Polyglukin 0.1-1.8 Water Rest with the appearance of pain, appendicitis is diagnosed.