BLEEDING IN GENUS.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

BLEEDING IN GENUS. At physiological births, the blood loss in the consecutive and early postpartum period does not exceed 0.5% of the body weight (physiological blood loss). The blood loss, corresponding to 0.6% of body weight and more, is considered pathological. Bleeding in the period of opening the cervix and the period of fetal ejection may be due to a partial premature placental abruption of the placenta presentation, rupture of the uterus. In the consecutive and early postpartum period, bleeding is associated with hypo- and atonic state of the uterus, partial dense attachment or increment of the placenta; It can arise from violations of hemostasis (congenital or acquired), ruptures of the body and cervix, vagina and perineum.

Bleeding associated with a decrease in the tone (hypotonia) of the myometrium in the consecutive and early postpartum periods is called hypotonic; With loss of tonus (atony) of myometrium - atonic. These bleedings can be observed with dystrophic, cicatricial, inflammatory changes in the myometrium in connection with previous births, abortions (especially complicated), operations on the uterus, endometritis, chorioamnionitis. Bleeding is facilitated by underdevelopment of the uterus, hypofunction of the ovaries, overgrowth of the myometrium in large fetuses, polyhydramnios, multiple pregnancies. Hypo- and atony of the myometrium may occur due to excessive labor activity, prolonged delivery, severely forced by their management, under the influence of a number of drugs used for the stimulation of labor and anesthesia, as well as in delivery operations (imposition of obstetric forceps, extraction of the fetus from the pelvic End, etc.). The contractile function of the myometrium in the postpartum period of labor can be reduced due to a disruption in the process of separation of the placenta (with its tight attachment or increment), delay in the uterus of the separated afterbirth and its parts.

According to the clinical picture, there are two variants of hypotonic bleeding. The first is characterized by a slight initial blood loss, repeated small bleeding, in the intervals between which the tone of the myometrium is temporarily restored in response to conservative treatment. The patient initially adapts to the progressive hypovolemia, the blood pressure remains normal, the tachycardia is not clearly expressed , the skin is pale. Inadequate treatment, the breach of the contractile function of the myometrium progresses, the volume of blood loss increases. If the blood loss is 25-30% of the circulating blood volume or more, the condition deteriorates sharply, the symptoms of hemorrhagic shock and disseminated intravascular coagulation syndrome increase. In the second variant of hypotonic bleeding, it is plentiful from the moment of onset, the uterus is flabby (atonic), reacts badly to funds that increase its tone and contractile activity, as well as to external massage and manual examination. Rapidly progressing hypovolemia, symptoms of hemorrhagic shock and disseminated intravascular coagulation syndrome.

Often, bleeding in the consecutive period is associated with a violation of the placenta due to its partial tight attachment or partial increment. Dense attachment of the placenta is formed by thinning the basal decidual (falling off) shell of the uterus, as a result of which the villi of the placenta penetrate it deeper than usual (but do not reach the myometrium). Usually this is noted on individual placental sites (partial dense attachment of the placenta). The causes of dense attachment of the placenta are postponed abortions and complicated labor , inflammatory diseases of female genital organs, etc. The process of separation of the placenta in the consecutive period in this case is disrupted, occurs unevenly (placental-free areas alternate with areas on which the placenta is tightly attached). This leads to a violation of the retraction of the uterus, the outflow of blood from the gaping vessels of the placental platform, free of the placenta.

The increment of the placenta occurs as a result of the penetration of its villi to the myometrium or into its thickness. The increase in the placenta is facilitated by the implantation of the fetal egg in the neck and uterine cervix, endometrial atrophy due to surgical interventions (caesarean section, manual separation of the afterbirth with previous births, scraping of the uterine mucosa), endometritis, submucosal uterine myoma ,

Depending on the penetration depth of the villi, the placenta distinguishes three variants of its increment. Placenta accreta (placenta): the placenta naps are in contact with the myometrium without penetrating into it and not disturbing its structure; Placenta increta (ingrown placenta): the placenta naps penetrate into the myometrium and break its structure; Placenta percreta (germinating placenta): the villi germinate the myometrium all the way down to the visceral peritoneum. With full increment, the placenta is soldered to the myometrium throughout its entire length, with partial - only in separate areas, which leads to uterine bleeding in the postpartum period of childbirth.

Partial increment and partial dense attachment of the placenta contribute to the development of uterine hypotension, which in turn leads to increased uterine bleeding. With a partial increase in the placenta, hemorrhagic shock rapidly develops, a syndrome of disseminated intravascular coagulation. Signs of separation of the placenta in the consecutive period with increment and dense attachment of the placenta are absent.

When bleeding in the consecutive period of childbirth and the early postpartum period, to exclude ruptures of the cervix and vagina, it is necessary to examine them with the help of vaginal mirrors (ruptures sutured after the discharge of the afterbirth). If the bleeding has occurred with the delay of the afterbirth or its parts in the uterus, it is urgent under general anesthesia to perform manual removal of the placenta (with its tight attachment), followed by the isolation of the afterbirth or the manual removal of parts of the afterbirth that are not associated with the uterine wall. With a dense attachment of the placenta well exfoliates from the wall of the uterus. Attempting to manually detach the placenta with its increment leads to heavy bleeding, the placenta tears off, not separating completely from the uterine wall. In this case, it is necessary immediately to stop further attempts to separate it and urgently perform an operation: supravaginal amputation of the uterus (in the absence of the syndrome of disseminated intravascular coagulation) or extirpation of the uterus (with the development of this syndrome).

After the manual removal of the placenta and its isolation from the uterus, the manual removal of the lingering afterbirth and its parts, it is necessary to perform a manual examination of the uterus - inserted into her cavity by hand to check the fullness of the emptying of the uterus and the condition of its walls.

Scraping of the uterine cavity at the puerperas, if suspected of delaying parts of the afterbirth, is very traumatic for the postpartum uterus. This operation can lead to a breakdown in the contractile function of the uterus, a violation of thrombus formation in the vessels of the placental site and infection. In a modern clinic, after removal of the placenta or its parts, an ultrasound is performed, in which the fullness of the emptying of the uterus is determined.

In hypotonic bleeding in the early postpartum period, not associated with a delay in the uterus of the afterbirth or parts of it, means are shown that increase the tone and contractile activity of the myometrium (methylergometrine, oxytocin , prostaglandin preparations, etc.), external uterine massage. If the parenteral administration of funds that stimulate the muscles of the uterus and the external massage of the uterus are ineffective, it is necessary to proceed immediately to a manual examination of the uterus and careful external internal massage (the fingers of the hand inserted into the uterus are clenched into the fist, the other hand massaging the uterus from the outside).

In the absence of the effect of the use of funds that stimulate the musculature of the uterus, a manual examination of the uterus and external internal massage, it shows supravaginal amputation of the uterus (in the absence of the syndrome of disseminated intravascular coagulation) or extirpation of the uterus (with the development of this syndrome).

Simultaneously with activities aimed at stopping bleeding, it is necessary to carry out replenishment of blood loss and other measures to restore impaired vital functions.

When bleeding during delivery outside the obstetric hospital, it is urgent to deliver the patient to the maternity hospital. Transportation is carried out on stretchers. When bleeding in the consecutive and early postpartum period, to temporarily stop it during transportation, you should press the abdominal aorta with your fist. Before the start of transportation, it is necessary to provide constant access to the venous system and intravenously administer 1 ml (5 units) of oxytocin or 1 ml (5 units) of gipotocin (with uterine hypotension), ascorbic acid (2 to 3 ml of a 5% solution), analeptic drugs (1 Ml of a cordiamine or 3 ml of a 1.5% solution of ethyzole). Simultaneously, when the uterus is hypotensive intramuscularly, it is advisable to administer 1 ml of a 0.02% ergometrine maleate solution. Required infusion of blood substitution solutions, which continues in the process of transportation.

Prevention of hypotonic (atonic) hemorrhage in childbirth consists in the rational and careful management of them (regulation of labor, exclusion of methods of severe forced delivery, correct management of the post-natal period). The duration of the follow-up period should not exceed 20 - 30 minutes. At the end of this time, the probability of independent separation of the placenta decreases sharply, and the possibility of hypotonic bleeding increases. In order to prevent bleeding in childbirth, the following measures are suggested: at the time of the fetal head eruption, 1 ml of 0.02% methylergometrine is injected intramuscularly; Active-expectant management of the postpartum period of labor: in the absence of signs of separation after 20-25 minutes after the birth of the fetus, 1 ml of oxytocin is administered intravenously in 20 ml of a 40% solution of glucose, if after 10-15 minutes the latter is not separated, proceed to its manual Removal (the appearance of bleeding in the absence of signs of separation of the aftereffect serves as an indication for this operation, regardless of the time elapsed after the birth of the fetus).