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Management of labor/ delivery with pre existing hypertension 1 страница
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Time and mode of delivery:
• No PE – delivery at term
• Superimposed PE – delivery depending on severity of PE.
• The most preferable mode of delivery for women with CHP is delivery through maternal passage (per vias naturales). Careful control of arterial blood pressure is necessary in any labor with CHP.
• Epidural anesthesia is indicated for patients with moderate and severe hypertension.
• In case of moderate or severe hypertension forceps delivery may be preformed for substitution of expulsive pains and prevention of cerebral complications (disorders of cerebral blood circulation, retinal detachment).
• Cesarean section is performed by obstetric indication (placental abruption, asphyxia of the fetus), as well as in conditions, threatening the life of mother (disorders of cerebral blood circulation, retinal detachment).
Pregnancy and Arterial Hypotension
It is generally accepted to speak about arterial hypotension in case of decrease of arterial blood pressure down to 100/60 mmHg. Arterial hypotension can be the basic manifestation of illness or one of the signs of other disease. Therefore primary and symptomatic hypotension is distinguished.
Primary arterial hypotension is a vascular neurosis, neurocirculatory dystonia of a hypotonic type.
Compensated and subcompensated stages of primary arterial hypotension are distinguished.
Compensated arterial hypotension includes cases manifested only by decrease of blood pressure.
To subcompensated stage the cases refer, manifested by various subjective and objective symptoms, apart from decrease of blood pressure. Patients with decompensated arterial hypotension complain of headache, dizziness, general asthenia, weak heartbeats, sweating, sleep disturbance, decrease of working capacity, memory impairment. Chill of hands and feet is marked. Hypotonic crises, syncopes are frequent. A characteristic objective sign is acrocyanosis. In connection with a bad general state of health, irritability, emotional lability, apathy, depressions often develop.
Hypotensive crises proceed as collaptoid states, the arterial blood pressure decreases up to 80/50 mmHg. Bad headaches, nausea, vomiting, sharp weakness are possible. The asthenic body-build is characteristic of women with arterial hypotension. Anemia, varicosity are often concomitant diseases in such cases.
Effect of Arterial Hypotension on Course of Pregnancy
EPH-gestosis is one of the most often complications of pregnancy in patients with arterial hypotension. The incidence of gestosis in pregnant with hypotension is about 25%. The diagnostics is very difficult, because on a background of hypotension the absolute level of blood pressure in cases with preeclampsia is not so significant — 130/90 mm Hg, but it is accompanied with a typical symptomatology. Besides it exceeds the initial level of arterial pressure by 30 mm and over, and is considered to be a manifestation of preeclampsia.
More often than in healthy pregnants, early forms of gestoses are observed proceeding severely particularly in patients with vegetoasthenic syndrome. Miscarriages and premature labor are observed in patients with arterial hypotension by 3-5 times more often than in group of healthy women. The disturbances of blood circulation in the uteroplacental system connected with hypotension, pathology of veins are accompanied by development of intrauterine fetal hypoxia and hypotrophy, development of syndrome of arrested development of fetus. The rate of perinatal mortality and birth of children with hypotrophy in such patients is 2 times higher than in those with a normal blood pressure.
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Labor in pregnant women with arterial hypotension is complicated by anomalies of labor pains, premature rupture of amniotic membranes, asphyxia and hypoxia of the fetus, disturbances of contractile activity of uterus in the 3rd stage of labor and in early puerperal period. Hypotonic bleedings, as well as bleedings connected with decrease of blood coagulation, are of particular danger in such cases. In puerpera with arterial hypotension the signs of shock develop faster; decompensation occurs more often and quicker, and yields to treatment with difficultly.
Effect of Pregnancy on Course of Arterial Hypotension
The effect of pregnancy on course of arterial hypotension is more often marked by decrease of systolic and diastolic pressure. In the majority of patients the worsening of the course of arterial hypotension is observed from the first trimester of pregnancy, the frequency of vegetovascular disturbances being increased in the late terms of gestation.
Management of Pregnancy and Labor at Arterial Hypotension
The arterial hypotension, even decompensated, is not a contraindication for carrying of a pregnancy and labor. All women with arterial hypotension should be regularly checked up in maternity welfare clinic. Three preventive hospitalizations (at non-complicated course of pregnancy and arterial hypotension) are recommended: in term before 12 weeks, at 22-26 weeks of pregnancy and 37-38 weeks, i. e. two weeks prior to labor. At preventive hospitalization a restorative, sedative, metabolic therapy, as well as treatment aimed at improvement of uteroplacental circulation and prophylaxis of intrauterine growth retardation, hypoxia and asphyxia of the fetus and newborn are administered. Ultrasound examination of pregnant is made in term of 9-11, 16-21 and 32-36 weeks of pregnancy. In term of 32-34 wk cardiotocography of the fetus, radio-Doppler examination by indication are made.
At compensated hypotension any special treatment is usually not required. At subcompensated stage of primary arterial hypotension out-patient treatment is indicated and in the absence of effect — treatment at the in-patient department. Non-drug treatment, i. e. curative gymnastics, hydrotherapeutic procedures, massage is effective. Normalization of sleep with the help of sedative preparations, antihistamine drugs is necessary. The diet rich in vitamins, microelements is administered.
With the purpose of increase of vascular wall tone, β -adrenoceptor agonist fetanol (0. 005 g 2-3 times a day for 2 weeks) should be administered. Its efficiency is based on expulsion of blood deposited in the liver into the bloodstream. On decrease of arterial pressure and reduction of cardiac output izadrin is usually administered in a dose of 0. 005 g under the tongue 3 times a day during 10-14 days.
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At hypotonic crises 0. 5 ml of 5 % ephedrin solution subcutaneously, and then 1 ml of 10 % solution of caffeine or 1-2 ml of cordiamin should be administered. At collapse some pregnant may be administered prednisolone (30 ml intramuscularly or intravenously).
Labor in patients with arterial hypotension is conducted through maternal passages in the presence of neonatologist in accordance with a developing obstetrical situation. Prophylaxis of anomaly of labor pains, intrauterine hypoxia of the fetus, hypo- and atonic hemorrhage should be carried out. The third stage of labor should be conducted with a needle in the vein and obstetrical hands ready to enter the uterine cavity.
Pregnancy and Tuberculosis
The most common form of tuberculosis is the process in the lungs. In 50 % of women it proceeds asymptomatically, in others the main manifestations of the disease are a subfebrile condition, cough, perspiration and a slight weight gain. Other forms of tuberculosis, such as meningitis, affection of kidneys, bones are encountered in pregnant women extremely rarely. Genital tuberculosis is accompanied by female sterility.
The incidence of tuberculosis during pregnancy depends on prevalence of disease in the given population and region.
Effect of Tuberculosis on Pregnancy
Usually tuberculosis does not produce any appreciable effect on the course of pregnancy. However at subcompensated and compensated forms a complicated course of pregnancy is marked. Thus, the first place by frequency is taken by miscarriages and premature birth. They are mainly observed at severe forms of tuberculosis accompanied by expressed intoxication. The reason of premature birth is specific infection, intoxication, hypoxia. A constant strain at bad cough, general weakness of organism also contribute to occurrence of premature birth. Late and early gestoses in pregnant with tuberculosis are observed much more often than in healthy pregnant women, and frequency of severe forms among them (preeclampsia of II and III degree) is high. The transition of tuberculous bacilli from mother to fetus through placenta is rarely observed. However due to intoxication of mother’s organism, disturbances of uteroplacental blood flow an intrauterine hypoxia and hypotrophy of the fetus are frequently observed.
Effect of Pregnancy on Tuberculosis
Pregnancy causes exacerbation of the process, most frequently at hematogenous disseminated, infiltrative and fibrous-cavernous pulmonary tuberculosis. Exacerbation of the process is more often observed in the first months of pregnancy and immediately after labor.
At tuberculous process in the phase of pulmonary consolidation the exacerbation during pregnancy is commonly not observed.
At the end of pregnancy and in postpartum period the progressive pulmonary tuberculosis is possible in women, who worked much, were chronically overtired during pregnancy and badly fed. A combination of these factors with decrease of immunity causes exacerbation of tuberculous process.
Conducting Pregnancy at Tuberculous Process
Until recently tuberculosis was one of the most frequent indications for abortion. However a timely revealing and systematic treatment (in TB prophylactic centre and in a hospital) allows to maintain pregnancy in women, ill with tuberculosis.
The indications for abortion are the following:
· a general destructive process in the lungs, badly yielding to treatment;
· an active form of spinal and pelvic tuberculosis, especially with formation of abscess or fistula, at tuberculosis of coxofemoral, knee, talocrural articulation;
· bilateral renal tuberculosis;
· active forms of tuberculosis, when the treatment undertaken before pregnancy or during it has appeared ineffective and duration of gestation is less than 28 weeks;
· exacerbation of the process during the previous pregnancy;
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· a two-year period after the suffered miliary tuberculosis or meningitis;
· concomitant kidney diseases, diabetes mellitus, cardiopulmonary failure.
The abortion should be made in early terms (till 12 weeks) as a single-stage operation (curettage of the uterine cavity or vacuum aspiration). The question of abortion is solved finally by tuberculosis specialist (phthisiatrician), therefore at establishing the diagnosis of pregnancy in woman with any form of tuberculosis it is necessary to hospitalize her at the in-patient phthisiology department.
In the late term pregnancy is terminated in the life-threatening cases.
The examination during pregnancy to reveal tuberculosis is necessary in groups of risk. To these refer pregnant women with tuberculosis in the family or life history, having such clinical signs as weakness, sweating, subfebrile temperature, cough. These women undergo a Mantoux test with estimation of dermal reaction in 48 and 72 h. A positive result does not mean availability of active pathological process; it indicates the necessity of further examination (culture of sputum for Mycobacterium tuberculosis and radiography of the chest). An x-ray examination of the chest in pregnant women is carried out with careful shielding of the abdomen area (fetus thus is exposed to the minimal irradiation). The diagnosis is established on the basis of revealing Mycobacterium tuberculosis in sputum.
Management of Pregnancy
At continuation of pregnancy the complex in-patient treatment during the first three months of pregnancy should be carried out, the next months the treatment should be given in tubercular dispensary. Preference is given to isoniazid and ethambutol. At very serious forms or in the presence of resistance to the specified preparations the application of rifampicinum is allowable, however in the first trimester of pregnancy the treatment with this preparation is undesirable. All persons contacting the woman carrying mycobacterium of tuberculosis are subjected to obligatory inspection and observation in antituberculous dispensary. In term of 36-38 weeks of pregnancy the repeated course of in-patient treatment to prepare for labor is indicated.
Management of Labor
Methods of delivery in women with tuberculosis are chosen by obstetric indication and criteria; labor is conducted in specialized departments or separate wards. Expectant management is applied at labor with the use of respiratory gymnastics; physiological and psychological preparation should be made. Prevention and treatment of occurring obstetrical complications is carried out. For acceleration of delivery and exclusion of expulsive efforts forceps delivery can be used.
If the woman received antituberculous therapy at the end of pregnancy or by the moment of labor, the histological research of placenta is necessary.
Breast feeding can be permitted to women in whom Mycobacterium tuberculosis is not revealed; otherwise newborns are isolated and fed artificially.
Contamination of the fetus is possible at inhalation of the infected amniotic fluid or contents of maternal passages during labor. The infection of children is encountered extremely rarely, and newborns, as a rule, are practically healthy. They should be inoculated against Calmette-Guerin bacillus (BCG) during first 6 weeks of life.
Pregnancy and Bronchial Asthma
Bronchial asthma is the commonest lung disease in pregnant. In majority of cases bronchial asthma is an allergic disease. Intrinsic (infectious-allergic) and atonic (noninfectious-allergic) forms of asthma are distinguished. Infectious-allergic bronchial asthma develops on a background of previous infectious diseases of respiratory tract (pneumonia, rhinopharyngitis, bronchitis, quinsy, tonsillitis); the antigen is a microorganism. The allergen of the atonic form of bronchial asthma may be various organic and inorganic factors: pollen, street or home dust, feather, wool and dandruff of animals and man, alimentary allergens, medicinal substances (antibiotics, especially penicillin, vitamin В6, acetylsalicylic acid, pyrazolone derivative, etc. ), industrial chemical substances (more often formalin, pesticides, inorganic salts of heavy metals, etc). In occurrence of atonic bronchial asthma the hereditary predisposition is of importance.
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Effect of Bronchial Asthma on Pregnancy
Pregnant women with bronchial asthma more often have early and late forms of gestoses, as compared to healthy pregnant. Premature and small-for-date children, antenatal death of the fetus may happen, though rarely, in patients with bronchial asthma. Rare cases of antenatal and neonatal fetal death refer to an exceptionally severe course of bronchial asthma and inadequate treatment during asthmatic states, as severe attacks of hypoxia, undergone by woman, result in critical hypoxemia of the fetus.
Effect of Pregnancy on the Course of Bronchial Asthma
In 20 % of pregnant women suffering from bronchial asthma remission is maintained during pregnancy or improvement occurs. In more than 70% of women pregnancy results in worsening of the course of bronchial asthma, thus moderate and severe forms of disease with daily repeated attacks of suffocation, periodic asthmatic states, unstable effect of medical treatment predominate.
Attacks of dyspnea in some women develop at the beginning of pregnancy, in others — in its second half. Bronchial asthma can primarily occur during pregnancy. The occurrence of asthma in pregnant women results from changed reactivity of organism, in particular, sensitivity to endogenous prostaglandin, causing bronchospasm in women suffering from asthma. Asthma occurred during pregnancy can disappear after birth, but can also remain as a chronic disease.
Conducting Pregnancy and Labor in Patients with Bronchial Asthma
Nowadays there are no criteria allowing to prognose the condition of the patient with bronchial asthma during pregnancy, and it makes the decision of problem about possibility of pregnancy continuation very difficult.
The attacks of bronchial asthma during labor are rare, especially at preventive administration of bronchial spasmolytics in this period (aminophylline, ephedrin) or glucocorticoid preparations (prednisolone, hydrocortisone).
Bronchial asthma is not contraindicated to pregnancy. Only at recurrent asthmatic attacks and phenomena of cardiopulmonary decompensation, artificial abortion or premature delivery may be indicated.
Pregnant suffering from bronchial asthma should be under common supervision of obstetrician-gynaecologist and therapeutist-pulmonologist. Medical treatment is provided at the out-patient department; if it is not effective, hospitalization is indicated.
Irrespective of form of bronchial asthma 3 stages of its development are distinguished: 1) preasthma; 2) attacks of suffocation, which may be of a mild, moderate and severe form; 3) attack of asthma.
The treatment of bronchial asthma consists in controlling attacks of asphyxia. In mild cases the application of inhalations or tablets of bronchial spasmolytic preparations is sufficient. Adrenoceptor agonists are: izadrin (novodrin, vuspiran) for inhalation or in tablets by 0. 005 g under the tongue; or alupent (metaproterenol) in a dose of 0. 02 g under the tongue or 1-2 inhalations. Alupent in pills acts during 1-2 hours and can be used regularly for prevention of attacks. A mixture of euphylline (3 gr), marsh mallow syrup (40 ml), 12 % ethyl alcohol (360 ml) is used in a dose of 1 tablespoonful per one intake. The pills of theophedrine or antasthmane, solutan in drops can be used, but these preparations contain phenobarbital and belladonna, which are contraindicated for pregnant, therefore their systematic application with the purpose of prophylaxis of attacks is not allowed. At mild attacks of asphyxia the hot drink, mustard plasters or cups are administered. If the listed agents do not help, 1 ml of a 5 % ephedrin solution or 1 ml of a 0. 05 % alupent solution subcutaneously may be introduced. Adrenalin and atropine are contraindicated for pregnant women, they should be better avoided. At more serious attacks of asphyxia 10 ml of 2. 4 % solution of euphylline with 40 % solution of glucose should be injected intravenously; or 10-15 ml of euphylline with 1 ml of ephedrin in 200-300 ml of 5 % glucose solution should be introduced slowly drop-by-drop. At cardiac insufficiency strophanthin or corglycon should be added. Simultaneously oxygen should be given to the patient. If the attack was caused by infection, antibiotics should be administered, preferably ampicillin in a dose of 0. 5 g 4 times orally.
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Treatment of asthmatic state should be provided only in hospital (in-patient department). A combination of 10 ml of a 2. 4 % euphylline solution and 10 ml of a 5 % glucose solution should be intravenously drop-by-drop; if necessary corglycon or strophanthin may be added. A large amount of liquid is necessary to prevent dehydration and for liquation of sputum, therefore the amount of glucose and 0. 9 % sodium chloride should be increased up to 2 litres. At inadequate effect 30 mg of prednisolone can be introduced intramuscularly or intravenously, repeating the injection every 3 hours till control of asthmatic state, with a gradual increase of intervals between injections. Drop-by-drop injection can be repeated in 8-12 hours. During the interval 10 ml of plasma or 50 ml of a 20 % albumin solution should be introduced. At metabolic acidosis 200 ml of a 4 % sodium bicarbonate solution should be injected. 2-4 ml of cordiamin subcutaneously is administered for stimulation of respiratory center. Continual oxygenation through the nasal catheter should be provided, periodically — in mixture with nitrous oxide. If there is no effect of treatment during 1–1. 5 hours and the condition is not improved, the auscultatory picture of “silent lung” is kept, the anaesthesiologist begins artificial ventilation of the lungs with an active dilution and suction of sputum. The antihistaminic medications (dimedrol, suprastin, pipolphen, tavegil) are indicated only at mild forms of atonic asthma. At infectious form of illness they are contraindicated, as they condense secretions of bronchial glands. A repeated injection of 100 ml of dry plasma or 50 ml of a 20 % albumin solution promotes binding of all mediators of allergic reaction. Intal may be used after the 3rd month of pregnancy at atonic form of disease; in severe forms of disease and in asthmatic state Intal is not indicated.
Treatment with antibiotics or sulfonamides is necessary for patients with an infectious form of asthma at exacerbations of inflammatory process in the lungs and bronchial tubes and at catarrhal diseases. Regular administration of small doses of euphylline, izadrin, alupent is possible. As expectorant drugs it is necessary to use terpinhydrate, marsh mallow, sodium bicarbonate, inhalations of trypsin, hemotrypsin. As sedatives valerian, elenium, seduxen, diazepam may be used.
A diet excluding food with high allergenic action (citruses, eggs, nuts) and nonspecific alimentary irritants (pepper, mustard, spicy and salty dishes) is of great importance. In some cases it is necessary to change a job, if there is occupational hazard playing a role of allergens (chemicals, antibiotics, etc. ).
Labor in pregnant with bronchial asthma is conducted through maternal passages according to individual obstetric situation.
Pregnancy and Acute Respiratory Disease, Influenza
Acute respiratory disease and influenza are common infectious diseases, which occur in obstetrical practice. During flu epidemics 40 % of population fall ill; lethal outcome of flu and acute respiratory disease (ARD) makes up 0. 6% of population.
Influenza is a sharp viral disease spread by respiratory ways. The basic serologic types of flu virus are A, B, and C. Viruses penetrate through the upper respiratory ways, affect the cylindrical epithelium of respiratory passages. Permeability of vascular wall increases that results in disturbance of microcirculation and hemorrhagic complications (petechial skin rash on the mucous membranes of mouth, eyes, hemoptysis, nosebleeds, hemorrhagic pneumonia). Flu decreases immunological resistance, thus being a reason of exacerbation of chronic infections in organism.
The incubation period is 12-24 hours. The onset of the disease is acute: body temperature rises till 38-40°. There is fever, headache, weakness, muscular pains (in the loin, arms, legs, chest), pain in the eyes, adynamy. Dizziness and vomiting can occur. Such signs as tickling in throat, stuffiness in nose, difficult nasal breathing, rhinitis occur very quickly. These are accompanied by phenomena of tracheobronchitis, pneumonia, which can be an immediate reason of death. Furthermore influenza can cause such complications, as myocarditis, otitis, sinusitis.
The diagnosis of influenza is based on revealing the virus in nasopharynx secretion or on the data of a four-times increase of titre of specific antibodies in serum of blood, taken twice: during the first 6 days of disease and on the 10-14th day.
The differential diagnosis is made with acute respiratory disease of other etiology.
Effect of Influenza and Acute Respiratory Infection on the Course of Pregnancy
In women, who had influenza and ARD during pregnancy, spontaneous abortions (early and late), premature birth, congenital anomalies of fetus are frequently observed. Influenza is a reason of fetopathies and embryopathies (depending on term of gestation, at which influenza occurred). The frequency of perinatal mortality due to past influenza or ARD is increased.
Labor in the acute period of disease, more often premature, produces an unfavorable effect on the fetus and newborn. Children are born with a low body mass, signs of physical and functional underdevelopment, frequent attacks of secondary asphyxia; the intrauterine pneumonia is diagnosed in them. The fetus infected by virus of influenza quite often dies in labor, just after the beginning of labor pains.
Especially dangerous complication is the occurrence of puerperal septic diseases, which frequency sharply increases on a background of suppression of immune and protective properties due to the past viral infection. In postpartum period pyelonephritis, cystitis, mastitis frequently develop.
Effect of Pregnancy on the Course of Influenza and Acute Respiratory Infection
During the last months of pregnancy women are less resistant to infections because of features of hormonal and immunological changes characteristic of gestational process, and that is why they are especially subjected to catarrhal and viral diseases. At pregnant severe and complicated forms of flu develop more often. Under the influence of viral infection the substantial changes in the immune system of organismtake place, which are manifested by exacerbation of chronic, latent course of infection. An infectious-toxic action of flu virus is instrumental in the origin of hypovitaminosis, hyperacidosis that can result in disturbance of the course of gestation process. Special danger is presented by such complication as pneumonia, which can be the reason of death of pregnant, woman in childbirth, puerperant.
Management of Pregnancy and Labor at Acute Respiratory Infection and Influenza
Influenza and ARI are not an absolute contraindication for continuation of pregnancy. However at occurrence of these diseases in early term of gestation (about 12 weeks) the woman is usually recommended to interrupt pregnancy in view of high risk of development of congenital anomalies of the fetus, and also of necessity of application of anti-inflammatory and antiviral preparations, which can be contraindicated in early period of gestation.
If pregnancy is kept nevertheless, such women call for special approach to conducting pregnancy and labor.
The treatment of pregnant woman, who has fallen ill with influenza, is provided at home. Plentiful alkaline drink, antipyretic and analgetic agents (indomethacin, acetylsalicylic acid, analgin), vitamins C, A, B, Е are recommended. Expectorants, vasoconstrictive agents for improvement of respiration through nose (farmazolin, halazolin), hot and cold inhalation of essential oils (sage, eucalyptus, fennel oils) are administered. Expectorants include: mixture of thermopsis, marsh mallow root.
At a complicated course of influenza, i. e. development of tracheitis, bronchitis, hospitalization at the in-patient department is indicated and administration of antibacterial, infusion, symptomatic therapy. Patients at the in-patient department are administered γ -globulin (3-5 ml intramuscularly), nasal inhalation of dry antigrippal serum with sulfanilamides and semisynthetic penicillin 3 times a day, prednisolone by 30-50 mg intramuscularly a day. At the development of severe complications the problem of artificial abortion by medical indication is solved.
The delivery of such women is more often conducted through maternity passages. In postpartum period the prophylaxis of septic puerperal complications is carried out.
Pregnancy and Viral Hepatitis
Several variants of acute viral hepatitis are distinguished:
· viral hepatitis A (VHА)
· viral hepatitis B (VHВ)
· viral hepatitis C (VHС)
· viral hepatitis D (VHD)
· viral hepatitis Е (VHЕ).
Laboratory signs of disease: the increase of level of transaminase, alanine aminotransferase, aspartate aminotransferase. Recovery occurs in 4-6 weeks. Jaundice is manifested by icteric color of eyes, oral mucous membrane, skin, by discoloration of faeces, urine gets a dark, saturated color.
Effect of Pregnancy on the Course of Viral Hepatitis
It is known that pregnancy due to features of hormonal and immunological alteration incident to gestational process leads to exacerbation of extragenital diseases, especially acute ones, such as viral hepatitis. The course of viral hepatitis in pregnancy is more severe than in nonpregnant patients.
Viral hepatitis in the second half of pregnancy proceeds more severely than in the first one. In the 2nd and 3rd trimester of pregnancy there are an increased risk of incidence and development of acute hepatic (liver) failure followed by encephalopathy and coma. The lethality of pregnant with hepatitis is up to 10 %, while in nonpregnant it is 1-4%.
Contraindication for Pregnancy
Arresting of pregnancy in acute stage of viral hepatitis is dangerous for mother due to increased risk of worsening of hepatitis and development of its chronic or prolonged form. Thus, pregnancy may be arrested in a convalescent stage.
Viral Hepatitis A (VHA) with Pregnancy
An acute viral hepatitis A is most investigated at pregnancy. The causative agent of illness is hepatitis A virus, referring to a type of enteroviruses. The source of infection is a person infected with HАV. The infection spreads by a fecal-oral type. The patient is infectious at the end of incubatory period and in a preicteric stage. The duration of incubatory period makes up 7-50 days, more often — 15-30 days. The preicteric (prodromal) period proceeds from 2 to 14 days.
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