Prerequisites for late postpartum hemorrhage. Early and late postpartum hemorrhage: causes and treatment

16.04.2020

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Bleeding in the early postpartum period is bleeding that occurs in the first 2 hours after delivery.

Hypotension of the uterus is a weakness in the contractility of the uterus and its insufficient tone.

Atony of the uterus is a complete loss of tone and contractility of the uterus, which does not respond to drug and other stimulation.

Epidemiology

Classification

See subchapter "Bleeding in the successive period".

Etiology and pathogenesis

Bleeding in the early postpartum period may be due to the retention of parts of the placenta in the uterine cavity, hypo- and atony of the uterus, impaired blood coagulation, rupture of the uterus.

The causes of hypo- and atonic bleeding are violations of the contractility of the myometrium due to childbirth (gestosis, somatic diseases, endocrinopathies, cicatricial changes in the myometrium, etc.).

The causes of bleeding in violations of the hemostasis system can be both congenital and acquired defects of the hemostasis system that are present before pregnancy (thrombocytopenic purpura, von Willebrand disease, angiohemophilia), and various types of obstetric pathology that contribute to the development of disseminated intravascular coagulation and bleeding during childbirth and the early postpartum period. The development of thrombohemorrhagic blood coagulation disorders is based on the processes of pathological activation of intravascular blood coagulation.

Clinical signs and symptoms

Bleeding caused by retention of parts of the placenta is characterized by abundant blood secretions with clots, large size of the postpartum uterus, its periodic relaxation and abundant discharge of blood from the genital tract.

With hypotension of the uterus, bleeding is characterized by wavyness. Blood is released in portions in the form of clots. The uterus is flabby, its contractions are rare, short. Blood clots accumulate in the cavity, as a result of which the uterus enlarges, loses its normal tone and contractility, but still responds to ordinary stimuli with contractions.

The relatively small size of fractional blood loss (150-300 ml) provides a temporary adaptation of the postpartum woman to the developing hypovolemia. BP remains within the normal range. There is a pallor of the skin, increasing tachycardia.

With insufficient treatment in the early initial period of uterine hypotension, the severity of violations of its contractile function progresses, therapeutic measures become less effective, the volume of blood loss increases, symptoms of shock increase, and DIC syndrome develops.

Uterine atony is an extremely rare complication. With atony, the uterus completely loses its tone and contractility. Its neuromuscular apparatus does not respond to mechanical, thermal and pharmacological stimuli. The uterus is flabby, poorly contoured through abdominal wall... The blood flows out in a wide stream or in large clots. The general condition of the postpartum woman is progressively worsening. Hypovolemia progresses rapidly, hemorrhagic shock, DIC syndrome develops. With continued bleeding, the mother may die.

In the practical activities of an obstetrician-gynecologist, the division of bleeding into hypotonic and atonic is conditional due to the complexity of differential diagnosis.

In violation of the hemostatic system, the clinical picture is characterized by the development of coagulopathic bleeding. In conditions of deep deficiency of coagulation factors, the formation of hemostatic thrombi is difficult, blood clots are destroyed, and the blood is liquid.

With bleeding due to retention of parts of the placenta, the diagnosis is based on data from a thorough examination of the placenta and membranes after the birth of the placenta. If there is a defect or doubt about the integrity of the placenta, manual examination of the postpartum uterus and removal of the retained parts of the placenta are indicated.

The diagnosis of hypotonic and atonic bleeding is made based on the results of the physical examination and the clinical presentation.

The diagnosis of coagulopathic bleeding is based on indicators of hemostasis (absence of platelets, the presence of high molecular weight fractions of fibrin / fibrinogen degradation products).

Differential diagnosis

Bleeding resulting from the retention of parts of the placenta in the uterine cavity should be differentiated from bleeding associated with hypotension and uterine atony, impaired blood coagulation, rupture of the uterus.

Hypotension and uterine atony are usually differentiated from traumatic injuries of the soft birth canal. Heavy bleeding with a large, relaxed, poorly contoured uterus through the anterior abdominal wall indicates hypotonic bleeding; bleeding with a dense, well-contracted uterus indicates damage to the soft tissues of the birth canal.

The differential diagnosis for coagulopathies should be carried out with uterine bleeding other etiology.

Bleeding due to retained parts of the placenta

If parts of the placenta are retained in the uterus, their removal is indicated.

Hypotension and uterine atony

In case of violation of the contractility of the uterus in the early postpartum period with blood loss exceeding 0.5% of body weight (350-400 ml), all means of combating this pathology should be used:

■ emptying bladder a soft catheter;

■ external massage of the uterus;

■ application of cold to the lower abdomen;

■ the use of funds that enhance the contraction of the myometrium;

■ manual examination of the walls of the postpartum uterus;

■ terminals for parameters according to Baksheev;

■ if the measures taken were ineffective, laparotomy and extirpation of the uterus were justified.

With continued bleeding, pelvic vessel embolization or ligation of the internal iliac arteries is indicated.

Timely infusion therapy and compensation of blood loss, the use of drugs that improve the rheological properties of blood and microcirculation, and prevent the development of hemorrhagic shock and coagulopathic disorders, are of great importance in the treatment of hypotonic bleeding.

Uterotonic therapy

Dinoprost IV drip 1 ml (5 mg) in 500 ml of 5% dextrose solution or 500 ml of 0.9% sodium chloride solution, once

Methylergometrine, 0.02% solution, intravenous 1 ml, once

Oxytocin IV drip 1 ml (5 ED) in 500 ml of 5% dextrose solution or 500 ml of 0.9% sodium chloride solution, once.

Hemostatic

and blood replacement therapy

Albumin, 5% solution, intravenous drip 200-400 ml 1 r / day, the duration of therapy is determined individually

Aminomethylbenzoic acid IV 50-100 mg 1-2 r / day, the duration of therapy is determined individually

Aprotinin IV drip 50,000-100,000 U up to 5 r / day or 25,000 U 3 r / day (depending on the specific drug), the duration of therapy is determined individually

Hydroxyethyl starch, 6% or 10% solution, intravenous drip 500 ml 1-2 times / day, duration of therapy is determined individually

Bloody discharge from the genital tract more than 400 ml in volume. The color of the discharge varies from scarlet to dark red, depending on the cause of the bleeding. May be present blood clots... Blood flows out in jerks, intermittently. Bleeding occurs immediately after the baby is born or after a few minutes, depending on the cause.
Dizziness, weakness, pallor of the skin and mucous membranes, tinnitus.
Loss of consciousness.
Decline blood pressure, frequent, barely perceptible pulse.
Prolonged absence of placenta discharge (child seat) - more than 30 minutes after the birth of the child.
"Lack" of parts of the placenta when viewed after birth.
The uterus is flabby on palpation (feeling), it is determined at the level of the navel, that is, it does not contract or decrease in size.

Forms

There are 3 degrees of severity of the mother's condition, depending on the volume of blood lost:

mild degree (the volume of blood loss is up to 15% of the total circulating blood volume) - there is an increase in the mother's pulse, a slight decrease in blood pressure;
medium degree (volume of blood loss 20-25%) - blood pressure is reduced, pulse is frequent. Dizziness, cold sweat occurs;
severe degree (volume of blood loss 30-35%) - blood pressure is sharply reduced, the pulse is frequent, barely perceptible. Consciousness is clouded, the amount of urine produced by the kidneys decreases;
extremely severe degree (the volume of blood loss is more than 40%) - blood pressure is sharply reduced, pulse is frequent, barely perceptible. Consciousness is lost, there is no urination.

The reasons

The reasons for the discharge of blood from the genital tract in successive period are:

(violation of the integrity of the tissues, vagina, (tissues between the entrance to the vagina and the anus);
(pathological attachment of the placenta):
- dense attachment of the placenta (attachment of the placenta in the basal layer of the uterine wall (deeper than the decidual (where attachment should normally occur) layer of the uterine mucosa;
- placenta accreta (attachment of the placenta to the muscle layer of the uterine wall);
- ingrowth of the placenta (the placenta grows into the muscle layer by more than half of its thickness);
- germination of the placenta (the placenta grows into the muscle layer and is introduced into the outermost layer of the uterus - the serous layer);

hypotension of the uterus (the muscle layer of the uterus contracts weakly, which prevents bleeding, separation and excretion of the placenta);
hereditary and acquired defects of the blood coagulation system.

The reasons for the discharge of blood from the genital tract in the early postpartum period are:

hypotension or atony of the uterus (the muscle layer of the uterus contracts weakly or does not contract at all);
retention of parts of the placenta (parts of the placenta did not separate from the uterus in the third stage of labor);
(violation of the blood coagulation system with intravascular formation of blood clots (blood clots) and bleeding).

The factors leading to the occurrence of the above-described complications of pregnancy can be:

severe (complication of the course of pregnancy, accompanied by edema, increased blood pressure and impaired renal function);
(violation of uteroplacental blood flow at the level of the smallest vessels);
(fruit weight is more than 4000 grams).

During childbirth:

irrational use of uterotonics (drugs that stimulate uterine contractions);
:
- weakness of labor (uterine contractions do not lead to the opening of the cervix, movement of the fetus along the birth canal);
- violent labor activity.

Diagnostics

Analysis of the anamnesis of the disease and complaints - when (how long ago) there were spotting from the genital tract, their color, the number that preceded their occurrence.
Analysis of the obstetric and gynecological history (past gynecological diseases, surgery, pregnancy, childbirth, their features, outcomes, features of the course of this pregnancy).
General examination of the pregnant woman, determination of her blood pressure and pulse, palpation (feeling) of the uterus.
External gynecological examination - with the help of hands and palpation, the doctor determines the shape of the uterus, the tension of its muscle layer.
Examination of the cervix in the mirrors - the doctor examines the cervix for injuries, ruptures using a vaginal mirror.
Ultrasound examination (ultrasound) of the uterus - the method allows you to determine the presence of parts of the placenta (children's place) and the location of the umbilical cord, the integrity of the walls of the uterus.
Manual examination of the uterine cavity allows you to clarify the presence of unselected parts of the placenta. The doctor inserts his hand into the uterine cavity and feels its walls. If the remaining parts of the placenta are found, they are manually removed.
Inspection of the released placenta (placenta) for integrity and the presence of tissue defects.

Treatment of bleeding in the sequential and early postpartum period

The main goal of treatment is to stop the life-threatening bleeding of the mother.

Conservative treatment, regardless of the period of bleeding, should be aimed at:

treatment of the underlying disease that caused the bleeding;
stopping bleeding with the help of fibrinolysis inhibitors (drugs acting to stop the natural dissolution of blood clots);
combating the consequences of blood loss (intravenous administration of aqueous and colloidal solutions to increase blood pressure).

Intensive therapy in the intensive care unit is necessary in the event of a serious condition of the pregnant woman and the fetus. If necessary, it is performed:

transfusion of blood components (with a significant amount of blood loss caused by detachment);
mechanical ventilation of the mother's lungs (with the inability to maintain adequate respiratory function on their own).

If the cause of bleeding is prolonged or retention of parts of the placenta, hypotension or atony of the uterus (weak muscle contraction or its absence), then:

manual examination of the uterine cavity (the doctor examines the uterine cavity with his hand for the presence of unselected parts of the placenta);
manual separation of the placenta (the doctor separates the placenta from the uterus by hand);
massage of the uterus (the doctor with a hand inserted into the uterine cavity massages its walls, thereby stimulating its contraction and stopping bleeding);
the introduction of uterotonics (drugs that help to contract the uterus).

If the blood loss exceeds 1000 ml, conservative therapy should be stopped and the following measures should be taken:

ischemia of the uterus (the imposition of clamps on the vessels that feed the uterus);
hemostatic (hemostatic) sutures on the uterus;
embolization (introduction into a vessel of particles that prevent blood flow) of the uterine arteries.

Surgery to remove the uterus is performed in the interests of saving a woman's life if it is impossible to stop uterine bleeding.

If the cause of bleeding is, then restorative operations (suturing,) are performed.

Complications and consequences

Couveler's uterus - multiple hemorrhages into the thickness of the uterine wall, soaking with blood.
- severe disorders of the blood coagulation system with the occurrence of multiple blood clots (blood clots) and bleeding.
Hemorrhagic shock (progressive violation of vital functions of the nervous system, circulatory system and respiration against the background of loss of a significant amount of blood).
Sheehan's syndrome () - ischemia (lack of blood supply) of the pituitary gland (an endocrine gland that regulates the work of most of the body's endocrine glands) with the development of a failure of its function (lack of hormone production).
Death of the mother.

Prevention of bleeding in the follow-up and early postpartum period

Prevention of obstetric bleeding includes several methods:

pregnancy planning, timely preparation for it (detection and treatment of chronic diseases before pregnancy, prevention of unwanted pregnancy);
timely registration of a pregnant woman with a antenatal clinic (up to 12 weeks of pregnancy);
regular visits (once a month in the 1st trimester, once every 2-3 weeks in the 2nd trimester, once every 7-10 days in the 3rd trimester);
removal of increased muscle tension of the uterus during pregnancy with the help of tocolytics (drugs that reduce the muscle tension of the uterus);
timely detection and treatment (complication of the course of pregnancy, accompanied by edema, increased blood pressure and impaired renal function);
adherence to a pregnant diet (with a moderate content of carbohydrates and fats (excluding fatty and fried foods, flour, sweet) and a sufficient protein content (meat and dairy products, legumes)).
Physiotherapy exercises for pregnant women (minor physical activity 30 minutes a day - breathing exercises, walking, stretching).
Rational management of childbirth:
- assessment of indications and contraindications for labor through the vaginal birth canal or using a caesarean section;
- adequate use of uterotonics (drugs that stimulate uterine contractions);
- exclusion of unreasonable palpation of the uterus and stretching of the umbilical cord in the subsequent period of labor;
- conducting an epizio- or perineotomy (dissection by a doctor of the woman's perineum (tissue between the entrance to the vagina and the anus) as a prevention of perineal rupture);
- examination of the released placenta (placenta) for integrity and the presence of tissue defects;
- the introduction of uterotonics (drugs that stimulate the muscle contractions of the uterus) in the early postpartum period.

Bleeding in succession (in the third stage of labor) and in the early postpartum periods can occur as a result of a violation of the processes of separation of the placenta and the release of the placenta, a decrease in the contractile activity of the myometrium (hypo- and atony of the uterus), traumatic injuries of the birth canal, disturbances in the hemo-coagulation system.

Blood loss up to 0.5% of body weight is considered physiologically acceptable during childbirth. The volume of blood loss over this indicator should be considered pathological, and blood loss from 1% or more is classified as massive. Critical loss blood - 30 ml per 1 kg of body weight.

Hypotonic bleedingdue to such a state of the uterus, in which there is a significant decrease in its tone and a significant decrease in contractility and excitability. With hypotonia of the uterus, the myometrium reacts inadequately to the strength of the stimulus to mechanical, physical and drug effects. In this case, there may be periods of alternating decrease and restoration of the tone of the uterus.

Atonic bleedingis the result of a complete loss of tone, contractile function and excitability of the neuromuscular structures of the myometrium, which are in a state of paralysis. At the same time, the myometrium is unable to provide sufficient postpartum hemostasis.

However, from a clinical point of view, the division of postpartum hemorrhages into hypotonic and atonic should be considered conditional, since medical tactics primarily depends not on what kind of bleeding it is, but on the massiveness of blood loss, the rate of bleeding, and the effectiveness conservative treatment, the development of disseminated intravascular coagulation.

What provokes bleeding in the successive and early postpartum periods

Although hypotonic bleeding always develops suddenly, it cannot be considered unforeseen, since in each specific clinical observation certain risk factors for the development of this complication are identified.

Physiology of postpartum hemostasis

The hemochorial type of placentation determines the physiological volume of blood loss after placenta separation in the third stage of labor. This blood volume corresponds to the volume of the intervillous space, does not exceed 0.5% of the woman's body weight (300-400 ml of blood) and does not negatively affect the condition of the postpartum woman.

After separation of the placenta, an extensive, abundantly vascularized (150-200 spiral arteries) subplacental site opens, which creates a real risk of rapid loss of a large blood volume. Postpartum hemostasis in the uterus is provided both by contraction of the smooth muscle elements of the myometrium and thrombus formation in the vessels of the placental site.

Intensive retraction of the muscle fibers of the uterus after separation of the placenta in the postpartum period contributes to compression, twisting and retraction of the spiral arteries into the muscle. At the same time, the process of thrombus formation begins, the development of which is facilitated by the activation of platelet and plasma factors of blood coagulation, and the influence of the elements of the ovum on the process of hemocoagulation.

At the beginning of thrombus formation, loose clots are loosely associated with the vessel. They are easily torn off and washed out by the blood stream during the development of uterine hypotension. Reliable hemostasis is achieved 2-3 hours after the formation of dense, elastic fibrin thrombi, firmly connected to the vessel wall and closing defects, which significantly reduces the risk of bleeding in the event of a decrease in uterine tone. After the formation of such blood clots, the risk of bleeding decreases with a decrease in the tone of the myometrium.

Therefore, an isolated or combined violation of the presented components of hemostasis can lead to the development of bleeding in the successive and early postpartum periods.

Disorders of postpartum hemostasis

Disturbances in the hemocoagulation system can be caused by:

changes in hemostasis that were present before pregnancy;
disorders of hemostasis due to complications of pregnancy and childbirth (antenatal death of the fetus and its long delay in the uterus, preeclampsia, premature placental abruption).

Violations of the contractility of the myometrium, leading to hypo- and atonic bleeding, are associated with various reasons and can occur both before the onset of labor and occur during childbirth.

In addition, all risk factors for the development of uterine hypotension can be conditionally divided into four groups.

Factors due to the peculiarities of the patient's socio-biological status (age, socio-economic status, profession, addictions and habits).
Factors due to the premorbid background of a pregnant woman.
Factors due to the characteristics of the course and complications of this pregnancy.
Factors associated with the characteristics of the course and with complications of these births.

Therefore, the following can be considered the prerequisites for a decrease in the tone of the uterus even before the onset of labor:

Age 30 and older is the most threatened by uterine hypotension, especially for primiparous women.
The development of postpartum hemorrhage in female students is facilitated by great mental stress, emotional stress and overstrain.
The parity of childbirth does not have a decisive influence on the frequency of hypotonic bleeding, since pathological blood loss in primiparous primiparous women is observed as often as in multiparous women.
Dysfunction of the nervous system, vascular tone, endocrine balance, water-salt homeostasis (myometrial edema) due to various extragenital diseases (presence or exacerbation of inflammatory diseases; pathology of the cardiovascular, bronchopulmonary systems; diseases of the kidneys, liver, thyroid diseases, sugar diabetes), gynecological diseases, endocrinopathies, disorders of fat metabolism, etc.
Dystrophic, cicatricial, inflammatory changes in the myometrium, which caused the replacement of a significant part of the muscle tissue of the uterus with connective tissue, due to complications after previous births and abortions, operations on the uterus (presence of a scar on the uterus), chronic and acute inflammatory process, uterine tumors (uterine myoma).
Insufficiency of the neuromuscular apparatus of the uterus against the background of infantilism, anomalies in the development of the uterus, ovarian hypofunction.
Complications of this pregnancy: breech presentation of the fetus, FPI, threatened abortion, previa or low placenta. Severe forms of late gestosis are always accompanied by hypoproteinemia, increased permeability of the vascular wall, extensive hemorrhages in the tissue and internal organs... Thus, severe hypotonic bleeding in combination with gestosis is the cause of death in 36% of women in labor.
Overstretching of the uterus due to a large fetus, multiple pregnancy, polyhydramnios.

Most frequent reasons violations of the functional ability of the myometrium, arising or aggravated during childbirth, are as follows.

Depletion of the neuromuscular apparatus of the myometrium due to:

overly intense labor (rapid and rapid labor);
discoordination of labor;
a protracted course of labor (weakness of labor);
irrational administration of uterotonic drugs (oxytocin).

It is known that in therapeutic doses, oxytocin causes short-term, rhythmic contractions of the body and the fundus of the uterus, does not significantly affect the tone of the lower segment of the uterus, and is rapidly destroyed by oxytocinase. In this regard, to maintain the contractile activity of the uterus, its long-term intravenous drip is required.

Prolonged use of oxytocin for labor stimulation and labor stimulation can lead to a blockade of the neuromuscular apparatus of the uterus, as a result of which its atony develops and further immunity to drugs that stimulate contractions of the myometrium. The risk of amniotic fluid embolism increases. The stimulatory effect of oxytocin is less pronounced in multiparous women and women in labor over 30 years of age. At the same time, hypersensitivity to oxytocin was noted in patients with diabetes mellitus and with pathology of the diencephalic region.

Operative delivery. The frequency of hypotonic bleeding after operative delivery is 3-5 times higher than after vaginal delivery. At the same time, hypotonic bleeding after surgical delivery can be due to various reasons:

complications and diseases that caused the operative delivery (weakness of labor, placenta previa, gestosis, somatic diseases, clinically narrow pelvis, abnormalities of labor);
stress factors in connection with the operation;
the influence of painkillers that reduce the tone of the myometrium.

It should be noted that with operative delivery, not only the risk of hypotonic bleeding increases, but also prerequisites for the occurrence of hemorrhagic shock are created.

Damage to the neuromuscular apparatus of the myometrium due to the entry into the vascular system of the uterus of thromboplastic substances with elements of the ovum (placenta, membranes, amniotic fluid) or products of the infectious process (chorioamnionitis). In a number of cases, the clinical picture caused by amniotic fluid embolism, chorioamnionitis, hypoxia and other pathology may have a blurred, abortive character and is manifested primarily by hypotonic bleeding.

The use of drugs during childbirth that reduce the tone of the myometrium (painkillers, sedatives and antihypertensive drugs, tocolytics, tranquilizers). It should be noted that when prescribing these and other drugs during childbirth, as a rule, their relaxing effect on the tone of the myometrium is not always taken into account.

In the sequential and early postpartum period, a decrease in the function of the myometrium under the other circumstances listed above can be caused by:

rough, forced management of the successive and early postpartum period;
dense attachment or accretion of the placenta;
delay in the uterine cavity of parts of the placenta.

Hypotonic and atonic bleeding can be caused by a combination of several of these reasons. Then the bleeding takes on the most formidable character.

In addition to the listed risk factors for the development of hypotonic bleeding, their occurrence is also preceded by a number of disadvantages in the management of pregnant women at risk both in the antenatal clinic and in the maternity hospital.

Complicating prerequisites in childbirth for the development of hypotonic bleeding should be considered:

discoordination of labor activity (more than 1/4 of observations);
weakness of labor (up to 1/5 of observations);
factors leading to overstretching of the uterus (large fetus, polyhydramnios, multiple pregnancies) - up to 1/3 of observations;
high traumatism of the birth canal (up to 90% of observations).

The opinion about the inevitability of death in obstetric bleeding is deeply mistaken. In each case, a number of preventable tactical errors associated with insufficient observation and untimely and inadequate therapy are noted. The main errors leading to the death of patients from hypotonic bleeding are the following:

incomplete examination;
underestimation of the patient's condition;
inadequate intensive care;
belated and inadequate replacement of blood loss;
loss of time when using ineffective conservative methods of stopping bleeding (often repeatedly), and as a result - delayed operation - removal of the uterus;
violation of the technique of the operation (long-term operation, injury to neighboring organs).

Pathogenesis (what happens?) During bleeding in the successive and early postpartum periods

Hypotonic or atonic bleeding, as a rule, develops in the presence of certain morphological changes in the uterus that precede this complication.

In the histological examination of uterine preparations removed due to hypotonic bleeding, in almost all cases there are signs of acute anemia after massive blood loss, which are characterized by pallor and dullness of the myometrium, the presence of sharply dilated gaping blood vessels, the absence of blood cells in them or the presence of leukocyte accumulations due to redistribution of blood.

A significant number of preparations (47.7%) revealed pathological chorionic villus ingrowth. At the same time, among the muscle fibers, chorionic villi covered with syncytial epithelium and single cells of the chorionic epithelium were found. In response to the introduction of elements of the chorion, foreign to muscle tissue, lymphocytic infiltration occurs in the connective tissue layer.

The results of morphological studies indicate that in a large number of cases, uterine hypotension is functional in nature, and bleeding was preventable. However, as a result of traumatic management of childbirth, prolonged delivery stimulation, repeated

manual entry into the postpartum uterus, intensive massage of the "uterus on a fist" among the muscle fibers there are a large number of erythrocytes with elements of hemorrhagic impregnation, multiple micro-tears of the uterine wall, which reduces the contractility of the myometrium.

Chorioamnionitis or endomyometritis in childbirth, found in 1/3 of observations, has an extremely unfavorable effect on the contractility of the uterus. Among the incorrectly located layers of muscle fibers in the edematous connective tissue, abundant lymphocytic infiltration is noted.

Edematous swelling of muscle fibers and edematous loosening of the interstitial tissue are also characteristic changes. The persistence of these changes indicates their role in the deterioration of the contractile ability of the uterus. These changes are most often the result of a history of obstetric and gynecological diseases, somatic diseases, gestosis, leading to the development of hypotonic bleeding.

Consequently, the often inferior contractile function of the uterus is due to morphological disorders of the myometrium, which arose as a result of the transferred inflammatory processes and the pathological course of this pregnancy.

And only in isolated cases, hypotonic bleeding develops due to organic diseases of the uterus - multiple fibroids, extensive endometriosis.

Symptoms of Bleeding in Succession and Early Postpartum Periods

Bleeding in the successive period

Hypotension of the uterus often begins already in the successive period, which at the same time has a longer course. Most often, in the first 10-15 minutes after the birth of the fetus, there is no intense contractions of the uterus. On external examination, the uterus is flabby. Its upper border is at the level of the navel or much higher. It should be emphasized that the sluggish and weak contractions of the uterus during its hypotension do not create the proper conditions for the retraction of muscle fibers and the rapid separation of the placenta.

Bleeding during this period occurs if there is a partial or complete separation of the placenta. However, it is usually not permanent. The blood is released in small portions, often with clots. When the placenta is separated, the first portions of blood accumulate in the uterine cavity and in the vagina, forming clots that are not secreted due to the weak contractile activity of the uterus. Such an accumulation of blood in the uterus and in the vagina can often create a false impression of the absence of bleeding, as a result of which the corresponding treatment measures may be started late.

In some cases, bleeding in the subsequent period may be due to a delay in the detached placenta due to the infringement of its part in the uterine horn or cervical spasm.

Cervical spasm occurs due to a pathological reaction sympathetic division the pelvic plexus in response to trauma to the birth canal. The presence of the placenta in the uterine cavity with normal excitability of its neuromuscular apparatus leads to increased contractions, and if there is an obstacle to the allocation of the placenta due to cervical spasm, then bleeding occurs. Removal of cervical spasm is possible by using antispasmodic drugs, followed by the release of the placenta. Otherwise, manual isolation of the placenta with revision of the postpartum uterus should be performed under anesthesia.

Violations of the discharge of the placenta are most often caused by unreasonable and gross manipulations with the uterus with a premature attempt to isolate the placenta or after the introduction of large doses of uterotonic drugs.

Bleeding due to abnormal attachment of the placenta

The decidua is a functional layer of the endometrium changed during pregnancy and in turn consists of the basal (located under the implanted ovum), capsular (covers the ovum) and parietal (the rest of the decidua lining the uterine cavity) sections.

In the basal decidua, compact and spongy layers are distinguished. The basal lamina of the placenta is formed from the compact layer located closer to the chorion and the cytotrophoblast of the villi. Individual chorionic villi (anchor villi) penetrate into the spongy layer, where they are fixed. With the physiological separation of the placenta, it is detached from the uterine wall at the level of the spongy layer.

Violation of the separation of the placenta is most often due to its dense attachment or accretion, and in more rare cases, ingrowth and germination. These pathological conditions are based on a pronounced change in the structure of the spongy layer of the basal decidua, or its partial or complete absence.

Pathological changes in the spongy layer can be caused by:

previous inflammatory processes in the uterus after childbirth and abortion, specific lesions of the endometrium (tuberculosis, gonorrhea, etc.);
hypotrophy or atrophy of the endometrium after surgery (cesarean section, conservative myomectomy, curettage of the uterus, manual separation of the placenta in previous childbirth).

It is also possible to implant the ovum in areas with physiological endometrial hypotrophy (in the isthmus and cervix). The likelihood of pathological attachment of the placenta increases with malformations of the uterus (septum in the uterus), as well as in the presence of submucous myomatous nodes.

Most often, there is a dense attachment of the placenta (placenta adhaerens), when the chorionic villi firmly grow together with the pathologically altered underdeveloped spongy layer of the basal decidua, which entails a violation of the separation of the placenta.

There is a partial dense attachment of the placenta (placenta adhaerens partialis), when only individual lobes have a pathological nature of attachment. Less common is the complete dense attachment of the placenta (placenta adhaerens totalis) - over the entire area of \u200b\u200bthe placental site.

Placenta accreta is due to the partial or complete absence of the spongy layer of the decidua due to atrophic processes in the endometrium. In this case, the chorionic villi adjoin directly to the muscular membrane or sometimes penetrate into its thickness. Distinguish between partial placenta accreta (placenta accreta partialis) and full accreta (placenta accreta totalis).

Much less common are such formidable complications as the ingrowth of villi (placenta increta), when chorionic villi penetrate into the myometrium and disrupt its structure, and the germination (placenta percreta) of villi into the myometrium to a considerable depth, up to the visceral peritoneum.

With these complications, the clinical picture of the process of separation of the placenta in the third stage of labor depends on the degree and nature (complete or partial) of violation of attachment of the placenta

With partial dense attachment of the placenta and with partial augmentation of the placenta due to its fragmented and uneven separation, bleeding always occurs, which begins from the moment the normally attached portions of the placenta are separated. The degree of bleeding depends on the violation of the contractile function of the uterus at the site of attachment of the placenta, since part of the myometrium in the projection of the unseparated parts of the placenta and in the nearby parts of the uterus does not contract to the extent required to stop bleeding. The degree of weakening of contraction varies widely, which determines the clinical picture of bleeding.

The contractile activity of the uterus outside the placenta attachment is usually maintained at a sufficient level, as a result of which bleeding for a relatively long time may be insignificant. In some women in labor, a violation of the contraction of the myometrium can spread to the entire uterus, causing it to be hypo- or atony.

With full dense attachment of the placenta and complete accretion of the placenta and the absence of its forced separation from the uterine wall, bleeding does not occur, since the integrity of the intervillous space is not violated.

Differential diagnosis of various pathological forms of attachment of the placenta is possible only during its manual separation. In addition, these pathological conditions should be differentiated from the normal attachment of the placenta in the tubal corner of the two-horned and doubled uterus.

With tight attachment of the placenta, as a rule, it is always possible to completely separate and remove all lobes of the placenta by hand and stop the bleeding.

In the case of placenta accreta, when trying to manually remove it, profuse bleeding occurs. The placenta is torn off in pieces, it is not completely separated from the uterine wall, part of the placenta lobes remains on the uterine wall. Atonic bleeding, hemorrhagic shock, DIC syndrome develop rapidly. In this case, only removal of the uterus is possible to stop bleeding. A similar way out of this situation is also possible with the ingrowth and germination of villi into the thickness of the myometrium.

Bleeding due to retention of parts of the placenta in the uterine cavity

In one of the options, postpartum bleeding, which usually begins immediately after the release of the placenta, may be due to the retention of its parts in the uterine cavity. These can be lobules of the placenta, parts of the membrane that interfere with the normal contraction of the uterus. The reason for the delay of parts of the placenta is most often a partial increase in the placenta, as well as improper management of the third stage of labor. A careful examination of the placenta after birth, most often without any particular difficulty, reveals a defect in the tissues of the placenta, membranes, the presence of ruptured vessels located along the edge of the placenta. Identification of such defects or even doubt about the integrity of the placenta serves as an indication for an urgent manual examination of the postpartum uterus with the removal of its contents. This operation is performed even if there is no bleeding when the placenta defect is detected, since it will necessarily appear later.

It is unacceptable to perform curettage of the uterine cavity, this operation is very traumatic and disrupts the processes of thrombus formation in the vessels of the placental site.

Hypo- and atonic bleeding in the early postpartum period

In most cases, in the early postpartum period, bleeding begins as hypotonic, and only later does uterine atony develop.

One of clinical criteria the difference between atonic and hypotonic bleeding is the effectiveness of measures aimed at enhancing the contractile activity of the myometrium, or the lack of effect from their use. However, such a criterion does not always allow us to clarify the degree of impairment of the contractile activity of the uterus, since the ineffectiveness of conservative treatment may be due to a severe violation of hemocoagulation, which becomes a leading factor in a number of cases.

Hypotonic bleeding in the early postpartum period is often the result of ongoing uterine hypotension observed in the third stage of labor.

It is possible to identify two clinical variants of uterine hypotension in the early postpartum period.

Option 1:

bleeding from the very beginning, profuse, accompanied by massive blood loss;
the uterus is flabby, sluggishly responds to the introduction of uterotonic agents and manipulations aimed at increasing the contractility of the uterus;
hypovolemia progresses rapidly;
hemorrhagic shock and disseminated intravascular coagulation develop;
changes in the vital organs of the postpartum woman become irreversible.

Option 2:

initial blood loss is small;
there are recurrent bleeding (blood is released in portions of 150-250 ml), which alternate with episodes of temporary restoration of uterine tone with cessation or weakening of bleeding in response to conservative treatment;
there is a temporary adaptation of the postpartum woman to the developing hypovolemia: blood pressure remains within normal values, there is some pallor of the skin and slight tachycardia. So, with a large blood loss (1000 ml or more) for a long time, the symptoms of acute anemia are less pronounced, and a woman copes with this condition better than with rapid blood loss in the same or even less amount, when collapse can develop faster and death occurs.

It should be emphasized that the patient's condition depends not only on the intensity and duration of bleeding, but also on the general initial condition. If the forces of the postpartum woman's body are depleted, and the reactivity of the body is reduced, then even a slight excess of the physiological norm of blood loss can cause a severe clinical picture in the event that a decrease in BCC (anemia, gestosis, diseases of cardio-vascular system, violation of fat metabolism).

With insufficient treatment in the initial period of uterine hypotension, violations of its contractile activity progress, and the response to therapeutic measures weakens. At the same time, the volume and intensity of blood loss increases. At a certain stage, the bleeding increases significantly, the condition of the woman in labor worsens, the symptoms of hemorrhagic shock rapidly increase, and the disseminated intravascular coagulation syndrome joins, soon reaching the hypocoagulation phase.

Correspondingly, the indicators of the hemocoagulation system change, indicating a pronounced consumption of coagulation factors:

the number of platelets, the concentration of fibrinogen, the activity of factor VIII decreases;
increased consumption of prothrombin and thrombin time;
fibrinolytic activity increases;
degradation products of fibrin and fibrinogen appear.

With slight initial hypotension and rational treatment hypotonic bleeding can be stopped within 20-30 minutes.

With severe hypotension of the uterus and primary disorders in the hemocoagulation system in combination with disseminated intravascular coagulation syndrome, the duration of bleeding increases and the prognosis worsens due to the significant complexity of treatment.

With atony, the uterus is soft, flabby, with poorly defined contours. The fundus of the uterus reaches the xiphoid process. The main clinical symptom is continuous and profuse bleeding. The larger the area of \u200b\u200bthe placental site, the more profuse the blood loss in atony. Hemorrhagic shock develops very quickly, the complications of which (multiple organ failure) are the cause of death.

Pathological examination reveals acute anemia, hemorrhages under the endocardium, sometimes significant hemorrhages in the pelvic region, edema, congestion and atelectasis of the lungs, dystrophic and necrobiotic changes in the liver and kidneys.

Differential diagnosis of bleeding in case of uterine hypotension should be carried out with traumatic damage to the tissues of the birth canal. In the latter case, bleeding (of varying intensity) will be observed with a dense, well-contracted uterus. Existing damage to the tissues of the birth canal is detected during examination with the help of mirrors and is eliminated accordingly with adequate anesthesia.

Treatment of Bleeding in Succession and Early Postpartum Periods

Follow-up management for bleeding

It is necessary to adhere to the expectant-active tactics of the follow-up period.
The physiological duration of the subsequent period should not exceed 20-30 minutes. After this time, the probability of spontaneous separation of the placenta decreases to 2-3%, and the possibility of bleeding increases dramatically.
At the time of the eruption of the head, 1 ml of methylergometrine per 20 ml of a 40% glucose solution is injected intravenously to the woman in labor.
Intravenous administration of methylergometrine causes a prolonged (within 2-3 hours) normotonic contraction of the uterus. In modern obstetrics, methylergometrine is the drug of choice for prophylaxis during childbirth. The time of its introduction should coincide with the moment of emptying of the uterus. It makes no sense to inject methylergometrine intramuscularly to prevent and stop bleeding due to the loss of the time factor, since the drug begins to be absorbed only after 10-20 minutes.
Bladder catheterization is performed. In this case, there is often an increase in the contraction of the uterus, accompanied by the separation of the placenta and the release of the placenta.
Intravenous drip begins to inject 0.5 ml of methylergometrine together with 2.5 IU of oxytocin in 400 ml of 5% glucose solution.
Simultaneously start infusion therapy to adequately replenish pathological blood loss.
Determine the signs of placenta separation.
When signs of separation of the placenta appear, the placenta is isolated using one of the known methods (Abuladze, Krede-Lazarevich).

Repeated and repeated use of external techniques for isolating the placenta is unacceptable, since this leads to a pronounced violation of the contractile function of the uterus and the development of hypotonic bleeding in the early postpartum period. In addition, with the weakness of the ligamentous apparatus of the uterus and its other anatomical changes, the rough use of such techniques can lead to eversion of the uterus, accompanied by severe shock.

In the absence of signs of placental separation, after 15-20 minutes with the introduction of uterotonic drugs or in the absence of effect from the use of external methods for isolating the placenta, it is necessary to manually separate the placenta and isolate the placenta. The appearance of bleeding in the absence of signs of placental separation is an indication for this procedure, regardless of the time that has passed after the birth of the fetus.
After separation of the placenta and removal of the placenta, the inner walls of the uterus are examined to exclude additional lobules, remnants of placental tissue and membranes. At the same time, parietal blood clots are removed. Manual separation of the placenta and the release of the placenta, even not accompanied by large blood loss (average blood loss 400-500 ml), lead to a decrease in the BCC by an average of 15-20%.
If signs of placental accreta are detected, attempts to manually remove it should be stopped immediately. The only treatment for this pathology is the extirpation of the uterus.
If the tone of the uterus is not restored after the manipulation, uterotonic agents are additionally administered. After the uterus contracts, the hand is withdrawn from the uterine cavity.
In the postoperative period, the state of the uterine tone is monitored and the administration of uterotonic drugs is continued.

Treatment of hypotonic bleeding in the early postpartum period

The main sign that determines the outcome of childbirth in postpartum hypotonic bleeding is the amount of blood lost. Among all patients with hypotonic bleeding, the volume of blood loss is mainly distributed as follows. Most often, it ranges from 400 to 600 ml (up to 50% of observations), less often - up to Uz of observations, blood loss ranges from 600 to 1500 ml, in 16-17% blood loss is from 1500 to 5000 ml or more.

Treatment of hypotonic bleeding is primarily aimed at restoring sufficient contractile activity of the myometrium against the background of adequate infusion-transfusion therapy. If possible, the cause of hypotonic bleeding should be established.

The main tasks in the fight against hypotonic bleeding are:

the fastest possible stop of bleeding;
prevention of the development of massive blood loss;
restoration of the BCC deficit;
prevention of blood pressure lowering below the critical level.

In the event of hypotonic bleeding in the early postpartum period, it is necessary to adhere to a strict sequence and phasing of measures to stop bleeding.

The scheme of dealing with uterine hypotension consists of three stages. It is designed for ongoing bleeding, and if the bleeding was stopped at a certain stage, then the action of the scheme is limited to this stage.

First step.If the blood loss has exceeded 0.5% of the body weight (on average 400-600 ml), then the first stage of the fight against bleeding is started.

The main tasks of the first stage:

stop bleeding, preventing more blood loss;
to provide adequate time and volume infusion therapy;
keep accurate records of blood loss;
avoid a deficit of blood loss compensation of more than 500 ml.

Measures of the first stage of the fight against hypotonic bleeding

Emptying the bladder with a catheter.
Dosed gentle external massage of the uterus for 20-30 s after 1 min (during massage, gross manipulations should be avoided, leading to a massive flow of thromboplastic substances into the mother's bloodstream). External massage of the uterus is carried out as follows: through the anterior abdominal wall, the bottom of the uterus is covered with the palm of the right hand and circular massaging movements are performed without the use of force. The uterus becomes dense, blood clots that have accumulated in the uterus and prevent it from contracting, are removed by gentle pressure on the fundus of the uterus and massage continues until the uterus is completely contracted and the bleeding stops. If, after the massage, the uterus does not contract or contracts, and then relaxes again, then proceed to further activities.
Local hypothermia (application of an ice pack for 30-40 minutes with an interval of 20 minutes).
Puncture / catheterization of great vessels for infusion-transfusion therapy.
Intravenous drip of 0.5 ml of methyl ergometrine with 2.5 U of oxytocin in 400 ml of 5-10% glucose solution at a rate of 35-40 drops / min.
Replenishment of blood loss in accordance with its volume and the body's response.
At the same time, a manual examination of the postpartum uterus is performed. After the treatment of the external genital organs of the postpartum woman and the hands of the surgeon, under general anesthesia, with a hand inserted into the uterine cavity, the walls of the uterus are examined to exclude trauma and lingering remnants of the placenta; remove blood clots, especially parietal, which prevent uterine contraction; conduct an audit of the integrity of the walls of the uterus; a malformation of the uterus or a tumor of the uterus should be excluded (the myomatous node is often the cause of bleeding).

All manipulations on the uterus must be carried out carefully. Rough interventions on the uterus (massage on a fist) significantly disrupt its contractile function, lead to the appearance of extensive hemorrhages into the thickness of the myometrium and contribute to the entry of thromboplastic substances into the bloodstream, which negatively affects the hemostasis system. It is important to assess the contractile potential of the uterus.

In a manual study, a biological test for contractility is performed, in which 1 ml of a 0.02% methylergometrine solution is injected intravenously. If there is an effective contraction, which the doctor feels with his hand, the result of the treatment is considered positive.

The effectiveness of manual examination of the postpartum uterus is significantly reduced depending on the increase in the duration of the period of uterine hypotension and the volume of blood loss. Therefore, it is advisable to perform this operation at an early stage of hypotonic bleeding, immediately after the absence of the effect of the use of uterotonic drugs has been established.

Manual examination of the postpartum uterus has another important advantage, as it allows timely detection of uterine rupture, which in some cases can be hidden by the picture of hypotonic bleeding.

Examination of the birth canal and suturing of all tears of the cervix, vaginal walls and perineum, if any. A catgut transverse suture is applied to the posterior wall of the cervix close to the internal pharynx.
Intravenous administration of a vitamin-energy complex to increase the contractile activity of the uterus: 100-150 ml of 10% glucose solution, ascorbic acid 5% - 15.0 ml, calcium gluconate 10% - 10.0 ml, ATP 1% - 2.0 ml, cocarboxylase 200 mg.

One should not rely on the effectiveness of repeated manual examination and massage of the uterus if the desired effect was not achieved during the first application.

To combat hypotonic bleeding, such methods of treatment are unsuitable and insufficiently justified as the imposition of clamps on the parametrium in order to compress the uterine vessels, clearing the lateral parts of the uterus, tamponade of the uterus, etc. In addition, they do not belong to pathogenetically justified methods of treatment and do not provide reliable hemostasis, their use leads to loss of time and delayed use indeed necessary methods stopping bleeding, which contributes to an increase in blood loss and the severity of hemorrhagic shock.

Second phase.If the bleeding has not stopped or has resumed again and is 1-1.8% of the body weight (601-1000 ml), then you should proceed to the second stage of the fight against hypotonic bleeding.

The main tasks of the second stage:

stop the bleeding;
prevent more blood loss;
avoid deficit of blood loss compensation;
maintain the volumetric ratio of injected blood and blood substitutes;
to prevent the transition of compensated blood loss to decompensated;
normalize the rheological properties of blood.

Measures of the second stage of the fight against hypotonic bleeding.

Into the thickness of the uterus through the anterior abdominal wall 5-6 cm above the uterine pharynx, 5 mg of prostin E2 or prostanone is injected, which promotes long-term effective contraction of the uterus.
5 mg of Prostin F2a diluted in 400 ml of crystalloid solution is injected intravenously. It should be remembered that long-term and massive use of uterotonic drugs may be ineffective with continued massive bleeding, since the hypoxic uterus ("shock uterus") does not respond to injected uterotonic substances due to the depletion of its receptors. In this regard, the primary measures for massive bleeding are replenishment of blood loss, elimination of hypovolemia and correction of hemostasis.
Infusion-transfusion therapy is carried out at the rate of bleeding and in accordance with the state of compensatory reactions. Blood components are injected, plasma-substituting oncotically active drugs (plasma, albumin, protein), colloidal and crystalloid solutions, isotonic to blood plasma.

At this stage of the fight against bleeding with blood loss approaching 1000 ml, the operating room should be deployed, donors should be prepared and prepared for emergency gluttony. All manipulations are performed under adequate anesthesia.

With the restored BCC, intravenous administration of a 40% solution of glucose, korglikon, panangin, vitamins C, B1 B6, cocarboxylase hydrochloride, ATP, as well as antihistamines (diphenhydramine, suprastin) is indicated.

Stage three.If the bleeding has not stopped, blood loss has reached 1000-1500 ml and continues, the general condition of the postpartum woman has worsened, which manifests itself in the form of persistent tachycardia, arterial hypotension, then it is necessary to proceed to the third stage, stopping postpartum hypotonic bleeding.

A feature of this stage is surgery to stop hypotonic bleeding.

The main tasks of the third stage:

stopping bleeding by removing the uterus until hypocoagulation develops;
prevention of a deficit of blood loss compensation of more than 500 ml while maintaining the volume ratio of injected blood and blood substitutes;
timely compensation of respiratory function (IVL) and kidneys, which allows to stabilize hemodynamics.

Measures of the third stage of the fight against hypotonic bleeding:

In case of unstoppable bleeding, the trachea is intubated, mechanical ventilation is started, and gluttony is started under endotracheal anesthesia.

Removal of the uterus (extirpation of the uterus with fallopian tubes) is performed against the background of intensive complex treatment with the use of adequate infusion-transfusion therapy. This volume of surgery is due to the fact that the wound surface of the cervix may be a source of intra-abdominal bleeding.
In order to ensure surgical hemostasis in the area of \u200b\u200bsurgery, especially against the background of disseminated intravascular coagulation (DIC), the internal iliac arteries are ligated. Then the pulse pressure in the vessels of the small pelvis drops by 70%, which contributes to a sharp decrease in blood flow, reduces bleeding from damaged vessels and creates conditions for the fixation of blood clots. Under these conditions, the extirpation of the uterus is performed in "dry" conditions, which reduces the total amount of blood loss and reduces the ingress of thromboplastin substances into the systemic circulation.
During the operation, the abdominal cavity should be drained.

In exsanguinated patients with decompensated blood loss, the operation is performed in 3 stages.

First step. Laparotomy with temporary hemostasis by applying clamps to the main uterine vessels (ascending part of the uterine artery, ovarian artery, round ligament artery).

Second phase. Operational pause when all manipulations are abdominal cavity stop for 10-15 minutes to restore hemodynamic parameters (increase in blood pressure to a safe level).

Stage three. Radical stop of bleeding - extirpation of the uterus with fallopian tubes.

At this stage of the fight against blood loss, active multicomponent infusion-transfusion therapy is required.

Thus, the main principles of combating hypotonic bleeding in the early postpartum period are as follows:

start all activities as early as possible;
take into account the initial state of health of the patient;
strictly observe the sequence of measures to stop bleeding;
all treatment measures carried out should be comprehensive;
exclude repeated use of the same methods of combating bleeding (repeated manual entry into the uterus, shifting clamps, etc.);
apply modern adequate infusion-transfusion therapy;
use only the intravenous route of administration of drugs, since under the current circumstances the absorption in the body is sharply reduced;
promptly resolve the issue of surgical intervention: the operation should be carried out before the development of thrombohemorrhagic syndrome, otherwise it often no longer saves the postpartum woman from death;
prevent blood pressure from falling below a critical level for a long time, which can lead to irreversible changes in vital organs (cerebral cortex, kidneys, liver, heart muscle).

Internal iliac artery ligation

In some cases, it is not possible to stop bleeding at the site of the incision or pathological process, and then it becomes necessary to bandage the main vessels feeding this area, at some distance from the wound. In order to understand how to perform this manipulation, it is necessary to recall the anatomical features of the structure of those areas where the vessels will be ligated. First of all, one should dwell on the ligation of the main vessel supplying blood to the woman's genitals, the internal iliac artery. Abdominal part the aorta at the level of the LIV vertebra is divided into two (right and left) common iliac arteries. Both common iliac arteries run from the middle outward and downward along the inner edge of the psoas major muscle. In front of the sacroiliac joint, the common iliac artery divides into two vessels: the thicker, external iliac artery, and the thinner, internal iliac artery. Then the internal iliac artery goes vertically downward, to the middle along the posterolateral wall of the pelvic cavity and, reaching the large sciatic foramen, is divided into anterior and posterior branches. From the anterior branch of the internal iliac artery depart: the internal genital artery, the uterine artery, the umbilical artery, the lower urinary artery, the middle rectal artery, the lower gluteal artery, which supply blood to the pelvic organs. From back branch The following arteries branch off the internal iliac artery: the ilio-lumbar, lateral sacral, obturator, superior gluteal arteries, which supply blood to the walls and muscles of the pelvis.

Ligation of the internal iliac artery is most often performed when the uterine artery is damaged during hypotonic bleeding, rupture of the uterus or extended extirpation of the uterus with appendages. A cape is used to determine the location of the internal iliac artery. Approximately 30 mm to the side of it, the border line is crossed by the internal iliac artery, which descends into the pelvic cavity with the ureter along the sacroiliac joint. To ligate the internal iliac artery, the posterior parietal peritoneum is dissected from the cape downward and outward, then using forceps and a grooved probe, the common iliac artery is bluntly separated and, going downward along it, the place of its division into the external and internal iliac arteries is found. Above this place, a light cord of the ureter stretches from top to bottom and from outside to inside, which is easy to recognize by its pink color, the ability to contract (peristalize) when touched and produce a characteristic popping sound when slipping out of the fingers. The ureter is retracted medially, and the internal iliac artery is immobilized from the connective tissue membrane, tied with catgut or lavsan ligature, which is brought under the vessel using a blunt-pointed Deschamp needle.

The Deschamp needle should be brought in very carefully so as not to damage its tip to the accompanying internal iliac vein, which runs in this place from the side and under the artery of the same name. It is advisable to apply the ligature at a distance of 15-20 mm from the place of division of the common iliac artery into two branches. It is safer if not the entire internal iliac artery is ligated, but only its anterior branch, but its isolation and threading under it is technically much more difficult to perform than ligation of the main trunk. After the ligature is brought under the internal iliac artery, the Deschamp needle is pulled back and the thread is tied.

After that, the doctor attending the operation checks the pulsation of the arteries in the lower extremities. If there is pulsation, then the internal iliac artery is pinched and a second knot can be tied; if there is no pulsation, then the external iliac artery is ligated, so the first knot must be untied and the internal iliac artery must be looked for again.

Continued bleeding after ligation of the iliac artery is due to the functioning of three pairs of anastomoses:

between the ilio-lumbar arteries extending from the posterior trunk of the internal iliac artery and the lumbar arteries branching from the abdominal part of the aorta;
between the lateral and median sacral arteries (the first departs from the posterior trunk of the internal iliac artery, and the second is an unpaired branch of the abdominal aorta);
between the middle rectal artery, which is a branch of the internal iliac artery, and the superior rectal artery, which extends from the inferior mesenteric artery.

With proper ligation of the internal iliac artery, the first two pairs of anastomoses function, providing sufficient blood supply to the uterus. The third pair is connected only in case of inadequately low ligation of the internal iliac artery. Strict bilateral anastomoses allow one-sided ligation of the internal iliac artery in case of rupture of the uterus and damage to its vessels on one side. AT Bunin and AL Gorbunov (1990) believe that when the internal iliac artery is ligated, blood enters its lumen through the anastomoses of the ilio-lumbar and lateral sacral arteries, in which the blood flow acquires the opposite direction. After ligation of the internal iliac artery, anastomoses begin to function immediately, but the blood passing through small vessels loses its arterial rheological properties and, in terms of its characteristics, approaches venous. In the postoperative period, the anastomoses system provides an adequate blood supply to the uterus, sufficient for the normal development of subsequent pregnancy.

Prevention of bleeding in the successive and early postpartum periods

Timely and adequate treatment of inflammatory diseases and complications after surgical gynecological interventions.

Rational management of pregnancy, prevention and treatment of complications. When registering a pregnant woman with an antenatal clinic, it is necessary to identify a high-risk group, if possible, for the development of bleeding.

A full examination should be carried out using modern instrumental (ultrasound, dopplerometry, echographic functional assessment of the state of the fetoplacental system, CTG) and laboratory research methods, as well as consult pregnant women with related specialists.

During pregnancy, it is necessary to strive to maintain the physiological course of the gestational process.

In women at risk for bleeding preventive actions on an outpatient basis, they consist in organizing a rational regimen of rest and nutrition, conducting health procedures aimed at increasing the neuropsychic and physical stability of the body. All this contributes to a favorable course of pregnancy, childbirth and the postpartum period. The method of physiopsychoprophylactic preparation of a woman for childbirth should not be neglected.

Throughout pregnancy, careful monitoring of the nature of its course is carried out, possible violations are detected and eliminated in a timely manner.

All pregnant groups at risk for the development of postpartum hemorrhage for the implementation of the final stage of complex antenatal preparation 2-3 weeks before delivery should be hospitalized in a hospital, where a clear plan of labor management is developed and an appropriate follow-up examination of the pregnant woman is carried out.

During the examination, the state of the fetoplacental complex is assessed. With the help of ultrasound, the functional state of the fetus is studied, the location of the placenta, its structure and size are determined. An assessment of the state of the patient's hemostasis system deserves serious attention on the eve of delivery. In advance, you should also prepare blood components for possible transfusion, using the methods of autodonation. In the hospital, it is necessary to select a group of pregnant women to perform a caesarean section in a planned manner.

To prepare the body for childbirth, prevent abnormalities in labor and prevent increased blood loss closer to the expected date of birth, it is necessary to prepare the body for childbirth, including with the help of prostaglandin E2 preparations.

Qualified management of childbirth with a reliable assessment of the obstetric situation, optimal regulation of labor, adequate pain relief (prolonged pain depletes the body's reserve forces and disrupts the contractile function of the uterus).

All childbirth should be carried out under cardiac monitoring.

In the process of conducting labor through the natural birth canal, it is necessary to monitor:

the nature of the contractile activity of the uterus;
matching the size of the presenting part of the fetus and the mother's pelvis;
the advancement of the presenting part of the fetus in accordance with the planes of the pelvis in different phases of labor;
condition of the fetus.

In the event of anomalies in labor, they should be eliminated in a timely manner, and in the absence of an effect, the issue should be resolved in favor of prompt delivery for appropriate indications on an emergency basis.

All uterotonic drugs must be prescribed in a strictly differentiated manner and according to indications. In this case, the patient must be under the strict supervision of doctors and medical personnel.

Correct management of the sequential and postpartum periods with the timely use of uterotonic drugs, including methylergometrine and oxytocin.

At the end of the second stage of labor, 1.0 ml of methylergometrine is injected intravenously.

After the baby is born, the bladder is emptied with a catheter.

Close observation of the patient in the early postpartum period.

When the first signs of bleeding appear, it is necessary to strictly adhere to the phasing of measures to combat bleeding. A clear and specific distribution is an important factor in providing effective care for massive bleeding. functional responsibilities among all medical personnel of the obstetric department. All obstetric facilities should have sufficient supplies of blood components and blood substitutes for adequate infusion-transfusion therapy.

On October 12, 13 and 14, Russia is hosting a large-scale social action for free blood clotting test - “INR Day”. The action is timed to coincide with the World Thrombosis Day.

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Lecture 8

BLEEDING IN PERSONAL AND EARLY

POST-NATURAL PERIOD

1. Bleeding in the successive period.

2. Bleeding in the early postpartum period.

3. Pathogenesis of bleeding.

4. Therapy.

5. Literature.

In modern obstetrics, bleeding remains one of the main causes of maternal mortality. They not only complicate the course of pregnancy, childbirth and the postpartum period, but also lead to the development of neuroendocrine pathology in the remote period of a woman's life.

Every year 127,000 women die from bleeding worldwide. This accounts for 25% of all maternal mortality. In Russia, bleeding is the leading cause of death of patients and accounts for 42% of deaths associated with pregnancy, childbirth and the postpartum period. Moreover, in 25% of cases, bleeding is the only reason for an unfavorable pregnancy outcome.

Causes of mortality:

· Belated inadequate hemostasis;

· Incorrect infusion-transfusion tactics;

· Violation of the stages and sequence of obstetric care.

Physiologically proceeding pregnancy is never accompanied by bleeding. At the same time, the hemochorial type of human placentation predetermines a certain amount of blood loss in the third stage of labor. Let's consider the mechanism of normal placentation.

The fertilized egg enters the uterine cavity at the morula stage, surrounded on all sides by trophoblast. Trophoblast cells have the ability to secrete a proteolytic enzyme, due to which the ovum, in contact with the uterine mucosa, attaches to it, dissolves the underlying areas of the decidual tissue, and within 2 days, nidation occurs. The proteolytic properties of the cytotrophoblast increase with the development. The destruction of the decidua on the 9th day of ontogenesis leads to the formation of lacunae containing maternal blood poured out of the destroyed vessels. From the 12-13th day, connective tissue begins to grow into the primary villi, and then vessels. Secondary and then tertiary villi are formed. Gas exchange and the provision of the fetus will depend on the correct formation of villi. nutrients... The main organ of pregnancy, the placenta, is being formed. Its main anatomical and physiological unit is placenton.Its constituent parts are cotylidone and curunculus. Cotilidon - this is the fruiting part of the placenton, it consists of a stem villi with numerous branches containing fruit vessels. Most of them are localized in the superficial - compact layer of the endometrium, where they float freely in intervillous spaces filled with maternal blood. To ensure the fixation of the placenta to the wall of the uterus, there are “anchor” villi that penetrate into the deeper, spongy layer of the endometrium. There are significantly fewer of them than the main villi and it is they that break during the separation of the placenta from the wall of the uterus in the successive period. The loose spongy layer is easily displaced with a sharp decrease in the uterine cavity, while the number of opened anchor villi is not large, which reduces blood loss. With normal placentation, the chorionic villi never penetrate the basal layer of the endometrium. The endometrium will revive from this layer in the future.

Thus, normal placentation guarantees the woman in the future the normal functioning of the most important organ - the uterus.

From the maternal surface, each cotyledon corresponds to a certain area of \u200b\u200bthe decidua - kuruncul.At its bottom, a spiral artery opens, supplying the lacuna with blood. They are separated from each other by incomplete septa - septa. Thus, the cavities of the intervillous spaces, the curuncles, are communicated. The total number of spiral arteries reaches 150-200. From the moment of the formation of the placenta, the spiral arteries approaching the intervillous space, under the influence of trophoblast, lose their muscle elements and lose the ability to vasoconstriction, not responding to all vasopressors. Their lumen increases from 50 to 200 microns, and by the end of pregnancy up to 1000 microns. This phenomenon is called "physiological denervation of the uterus" This mechanism is necessary to maintain the blood supply to the placenta at a constant optimal level. With an increase in systemic pressure, the blood supply to the placenta does not decrease.

The process of trophoblast invasion is completed by the 20th week of pregnancy. By this time, the uteroplacental circuit contains 500-700 ml of blood, the fetal-placental circuit - 200-250 ml.

In the physiological course of pregnancy, the uterus-placenta-fetus system is closed. Maternal and fetal blood does not mix and does not pour out. Bleeding occurs only in case of a violation of the connection between the placenta and the uterine wall, normally occurs in the III stage of labor, when the volume of the uterus decreases sharply. The placental site does not contract throughout pregnancy and childbirth. After the expulsion of the fetus and the outflow of posterior waters, intrauterine pressure sharply decreases. In a small area of \u200b\u200bthe placental site within the spongy layer, the anchor villi rupture, and bleeding begins from the exposed spiral arteries. The area of \u200b\u200bthe placental site is exposed, which is a vascularized wound surface. In this zone, 150-200 spiral arteries open, the end sections of which do not have a muscular wall, and create the danger of large blood loss. At this moment, the myotamponade mechanism begins to operate. Powerful contractions of the muscle layers of the uterus lead to mechanical closure of the mouths of bleeding vessels. In this case, the spiral arteries are twisted and pulled into the thickness of the uterine muscle.

At the second stage, the mechanism of thrombotamponade is implemented. It consists in the intense formation of clots in the pinched spiral arteries. The processes of blood coagulation in the area of \u200b\u200bthe placental site are provided with a large amount of tissue thromboplastin formed during placental abruption. The rate of clot formation is 10-12 times higher than the rate of thrombus formation in the systemic circulation.

Thus, in the postpartum period, hemostasis is carried out at the first stage by an effective myotamponade, which depends on the contraction and retraction of myometrial fibers, and a full-fledged thrombotamponade, which is possible under the normal state of the postpartum hemostasis system.

For the final formation of a dense thrombus and its relatively reliable fixation on the vessel wall, it takes 2 hours. In this regard, the duration of the early postpartum period, during which there is a risk of bleeding, is determined by this time interval.

In the normal course of the subsequent period, the volume of lost blood is equal to the volume of the intervillous space and does not exceed 300-400 ml. Taking into account the thrombus formation of the placental bed, the volume of external blood loss is 250-300 ml and does not exceed 0.5% of the woman's body weight. This volume does not affect the state of the postpartum woman, and therefore in obstetrics there is the concept of "physiological blood loss".

This is the normal mechanism of placentation and the course of the successive and early postpartum period. With placentation mechanisms, the leading symptom is bleeding.

Disorders of the placentation mechanism

The reasons for the violation of the placentation mechanism are pathological changes in the endometrium that occurred before pregnancy:

1. Chronic inflammatory processes in the endometrium (acute or chronic endomyometritis).

2. Dystrophic changes myometrium, resulting from frequent abortions, miscarriages with curettage of the walls of the uterine cavity, especially complicated by subsequent inflammatory complications.

3. Dystrophic changes in the myometrium in multiparous.

4. Inferiority of the endometrium in infantilism.

5. Changes in the endometrium in pregnant women with uterine fibroids, especially with submucosal localization of nodes

6. Inferiority of the endometrium with abnormalities in the development of the uterus.

Bleeding during the subsequent stage of labor

Disruption of the processes of separation of the placenta

Tight attachment of the placenta

True placenta accreta

Hypotonic state of the uterus

Location of the placenta in one of the uterine corners

Rupture of the uterus, soft birth canal

Ø Infringement of the separated placenta

Ø DIC syndrome

Ø Irrational management of the sequential period (stretching the umbilical cord - eversion of the uterus, untimely use of uterotonics).

With changes in the endometrium, the essence of which is the thinning or complete absence of the spongy layer, four variants of pathological attachment of the placenta are possible.

1. Placentaadhaerens - false rotation of the placenta. It occurs in the case of a sharp thinning of the spongy layer of the endometrium. Separation of the placenta is possible only with mechanical destruction of the villi within the compact layer. Anchor villi penetrate into the basal layer, and are localized near the muscle layer. The placenta, as it were, "sticks" to the wall of the uterus, and the absence of a spongy layer leads to the fact that after emptying the uterus, there is no disruption of the connection between the placenta and the uterine wall.

2. Placentaaccraeta - true rotation of the placenta. In the complete absence of the spongy layer of the endometrium, the chorionic villi, invading the basal layer, penetrate into the muscle tissue. In this case, the destruction of the myometrium does not occur, but the separation of the placenta from the wall of the uterus by hand is impossible.

3. Placentaincraeta – deeper invasion of chorionic villi, accompanied by their penetration into the thickness of the myometrium with destruction of muscle fibers. Occurs with complete atrophy of the endometrium, as a result of severe septic postpartum, post-abortion complications, as well as endometrial defects arising from surgical interventions on the uterus. At the same time, the basal layer of the endometrium loses its ability to produce antienzymes, which normally prevent the penetration of chorionic villi deeper than the spongy layer. An attempt to remove such a placenta results in massive endometrial injury and fatal bleeding. The only way to stop it is to remove the organ along with the ingrown placenta.

4. Placentapercraeta - is rare, chorionic villi grows the wall of the uterus to the serous cover and destroys it. The villi are exposed, and profuse intra-abdominal bleeding begins. Such a pathology is possible when the placenta is attached in the area of \u200b\u200bthe scar, where the endometrium is completely absent, and the myometrium is almost not expressed, or when the ovum is inserted in the rudimentary uterine horn.

If a violation of the attachment of the placenta occurs in some part of the placental site - this is a partial abnormal attachment of the placenta. After the birth of the fetus, normal processes of placental separation begin in unchanged areas, which is accompanied by blood loss. The larger the area of \u200b\u200bthe exposed placental site, the larger it is. The placenta sags on an unseparated, abnormally attached, area, does not allow the uterus to contract, and there are no signs of placenta separation. The absence of myotamponade leads to bleeding in the absence of signs of placental separation. This is a sequential bleeding, the method of stopping it is the operation of manual separation and isolation of the placenta. The operation is performed under general anesthesia. The operation lasts no more than 1-2 minutes, but it requires a quick introduction of the patient into anesthesia, because everything happens against the background of unstoppable bleeding. During the operation, it is possible to determine the type of placentation pathology and the depth of the villus invasion into the uterine wall. In Pl adharens, the placenta is easily separated from the uterine wall, because you are working within the functional layer of the endometrium. With Pl accraeta, it is not possible to separate the placenta in this area - areas of tissue hang from the wall of the uterus, and the bleeding increases and begins to take on a profuse character. With Pl incraeta, attempts to remove the placental tissue lead to the formation of defects, niches in the uterine muscle, bleeding becomes threatening. With a partial dense attachment of the placenta, one should not persist in attempts to separate the non-separating parts of the placenta and proceed to surgical methods of treatment. Attempts should never be made to isolate the placenta in the absence of signs of placental separation in conditions of subsequent bleeding.

The clinical picture in cases of total dense attachment of the placenta is extremely rare. In the subsequent period, the violation of the integrity of the intervillous spaces does not occur, there are no signs of placenta separation and bleeding. In this situation, the waiting time is 30 minutes. If during this time there are no signs of placental separation, there is no bleeding, the diagnosis of total dense attachment of the placenta becomes obvious. Tactics - active separation of the placenta and the allocation of the placenta. The type of placental abnormality is determined during the operation. In this case, the blood loss exceeds physiological, because the separation occurs within the compact layer.

BLEEDING IN THE SUBSEQUENT PERIOD.

DELAY OF THE CHILD PLACE AND ITS PARTS IN THE UTERINE CAVITY

Bleeding that occurs after the birth of the fetus is called successive bleeding. It occurs when a child's seat or parts of it are delayed. In the physiological course of the subsequent period, the uterus after the birth of the fetus decreases in volume and sharply contracts, the placental site decreases in size and becomes smaller than the size of the placenta. During successive contractions, the muscle layers of the uterus are retracted in the region of the placental site, due to this, the spongy layer of the decidua is ruptured. The separation of the placenta is directly related to the strength and duration of the retraction process. The maximum duration of the subsequent period is normally no more than 30 minutes.

Postpartum hemorrhage.

According to the time of occurrence, they are divided into early ones - arising in the first 2 hours after childbirth and late - after this time and until the 42nd day after childbirth.

Early postpartum hemorrhage.

The causes of early postpartum bleeding can be:

and. hypo- and atony of the uterus

b. birth canal injuries

in. coagulopathy.

Hypotension of the uterus- this is a condition in which the tone and contractility of the uterus are sharply reduced. Under the influence of measures and means that stimulate the contractile activity of the uterus, the muscle of the uterus contracts, although often the strength of the contractile reaction does not correspond to the strength of the impact.

Atony of the uterus - this is a condition in which the drugs that stimulate the uterus have no effect on it. The neuromuscular apparatus of the uterus is in a state of paralysis. Atony of the uterus is rare, but causes massive bleeding.

The reasons for the development of uterine hypotension in the early postpartum period. Muscle fiber loses its ability to contract normally in three cases:

1. Excessive hyperextension: this is facilitated by polyhydramnios, multiple pregnancy and the presence of a large fetus.

2. Excessive muscle fiber fatigue. This situation is observed with a prolonged course of labor, with irrational use of large doses of tonomotor drugs, with rapid and impetuous labor, as a result of which exhaustion occurs. Let me remind you that rapid should be considered in primiparous labor lasting less than 6 hours, in multiparous - less than 4 hours. Rapid labor is considered to last, respectively, less than 4 hours in the first and less than 2 hours in the multiparous.

3. The muscle loses its ability to contract normally in case of structural changes of a cicatricial, inflammatory or degenerative nature. Postponed acute and chronic inflammatory processes involving the myometrium, uterine scars of various origins, uterine fibroids, numerous and frequent curettage of the walls of the uterine cavity, in multiparous women and with small intervals between births, in women in labor with manifestations of infantilism, anomalies in the development of the genital organs.

The leading syndrome is bleeding, in the absence of any complaints. An objective examination reveals a decrease in the tone of the uterus, determined by palpation through the anterior abdominal wall, a slight increase due to the accumulation of clots and liquid blood in its cavity. External bleeding, as a rule, does not correspond to the volume of blood loss. When the uterus is massaged, liquid dark blood with clots is poured through the anterior abdominal wall. The general symptoms depend on the BCC deficiency. When it decreases more than 15%, manifestations of hemorrhagic shock begin.

There are two clinical variants of early postpartum hypotonic bleeding:

1. Bleeding from the very beginning profuse, sometimes jet. The uterus is flabby, atonic, the effect of the treatment is short-lived.

2. The initial blood loss is small. The uterus periodically relaxes, blood loss increases gradually. Blood is lost in small portions - 150-200 ml each, which allows the body of the postpartum woman to adapt within a certain period of time. This option is dangerous in that the relatively satisfactory state of health of the patient disorients the doctor, which can lead to inadequate therapy. At a certain stage, bleeding begins to grow rapidly, the condition deteriorates sharply and the DIC syndrome begins to develop intensively.

Differential diagnosis hypotonic bleeding is performed with traumatic injuries of the birth canal. In contrast to hypotonic bleeding with trauma to the birth canal, the uterus is dense, well contracted. Examination of the cervix and vagina using mirrors, manual examination of the walls of the uterine cavity confirm the diagnosis of ruptures of the soft tissues of the birth canal and bleeding from them.

There are 4 main groups of methods for combating bleeding in the early postpartum period.

1. Methods aimed at restoring and maintaining the contractile activity of the uterus include:

The use of drugs of the oxytotic series (oxytocin), ergot drugs (ergotal, ergotamine, methylergometrine, etc.). This group of drugs gives a fast, powerful, but rather short-term contraction of the uterine muscles.

Massage the uterus through the anterior abdominal wall. This manipulation should be carried out dosed, carefully, without excessively rough and prolonged exposure, which can lead to the throwing of thromboplastic substances into the mother's bloodstream and lead to the development of DIC syndrome.

Coldness on the lower abdomen. Prolonged cold irritation reflexively maintains the tone of the uterine muscles.

2. Mechanical irritation of the reflex zones of the vaginal vaults and the cervix:

Tamponade of the posterior vaginal fornix with ether.

Electrotonization of the uterus, performed with the presence of equipment.

The listed reflex effects on the uterus are performed as additional, auxiliary methods that complement the main ones, and are carried out only after the operation of manual examination of the walls of the uterine cavity.

The operation of manual examination of the walls of the uterine cavity refers to the methods of reflex action on the uterine muscle. This is the main method that should be performed immediately after a complex of conservative measures.

Tasks that are solved during the operation of manual examination of the uterine cavity:

n exclusion of trauma to the uterus (complete and incomplete rupture). In this case, they urgently switch to surgical methods of stopping bleeding.

n removal of the remnants of the ovum lingering in the uterine cavity (lobules of the placenta, membranes).

n Removal of blood clots accumulated in the uterine cavity.

n The final stage of the operation is a fist massage of the uterus, which combines mechanical and reflex methods of affecting the uterus.

3. Mechanical methods.

Hand pressing of the aorta is referred to.

Terminal parameters according to Baksheev.

It is currently used as a temporary measure to gain time in preparation for surgical techniques to stop bleeding.

4. Surgical operative methods. These include:

n clamping and ligation of the main vessels. They are used in cases of technical difficulties when performing a caesarean section.

n hysterectomy - amputation and extirpation of the uterus. Serious, crippling operations, but, unfortunately, the only correct measures with massive bleeding, allowing reliable hemostasis. In this case, the choice of the scope of the operation is individual and depends on the obstetric pathology that caused the bleeding and the patient's condition.

Supravaginal amputation of the uterus is possible with hypotonic bleeding, as well as with true rotations of the placenta with a high placental area. In these cases, this volume allows you to remove the source of bleeding and ensure reliable hemostasis. However, when, as a result of massive blood loss, the clinic of disseminated intravascular coagulation has developed, the scope of the operation should be expanded to a simple extirpation of the uterus without appendages with additional double drainage of the abdominal cavity.

Extirpation of the uterus without appendages is indicated in cases of cervical-isthmus location of the placenta with massive bleeding, with PONRP, Couveler's uterus with signs of disseminated intravascular coagulation (DIC), as well as with any massive blood loss accompanied by disseminated intravascular coagulation.

Dressing Art Iliaca interna. This method is recommended as an independent, preceding or even replacing hysterectomy. This method is recommended as the final stage in the fight against bleeding in patients with extensive disseminated intravascular coagulation syndrome after extirpation of the uterus and the absence of sufficient hemostasis.

With any bleeding, the success of the measures taken to stop bleeding depends on timely and rational infusion-transfusion therapy.

TREATMENT

Treatment for hypotonic bleeding is complex. It begins without delay, while measures are taken to stop bleeding and replenish blood loss. Medical manipulations should begin with conservative ones, if they are ineffective, then immediately proceed to operational methods, up to celiac disease and removal of the uterus. All manipulations and measures to stop bleeding should be carried out in a strictly defined order without interruption and be aimed at increasing the tone and contractility of the uterus.

The system for combating hypotonic bleeding includes three stages.

First step: Blood loss exceeds 0.5% of body weight, averaging 401-600 ml.

The main task of the first stage is to stop bleeding, to prevent large blood loss, to prevent a deficit in blood loss compensation, to maintain the volume ratio of injected blood and blood substitutes equal to 0.5-1.0, 100% compensation.

First stage activities combating bleeding boil down to the following:

1) emptying the bladder with a catheter, therapeutic dosed massage of the uterus through the abdominal wall for 20-30 seconds. after 1 min., local hypothermia (ice on the stomach), intravenous administration of crystalloids ( saline solutions, concentrated glucose solutions);

2) simultaneous intravenous administration of methylergometrine and oxytocin, 0.5 ml each. in one syringe, followed by drip introduction of these drugs in the same dose at a rate of 35-40 'drops. in min. within 30-40 minutes;

3) manual examination of the uterus to determine the integrity of its walls, removal of parietal blood clots, two-handed massage of the uterus;

4) examination of the birth canal, suturing of ruptures;

5) intravenous administration of a vitamin-energy complex to increase the contractile activity of the uterus: 100-150 ml. 40% glucose solution, 12-15 U of insulin (subcutaneously), 10 ml. 5% solution of ascorbic acid, 10 ml. calcium gluconate solution, 50-100 mg. cocarboxylase hydrochloride.

In the absence of effect, confidence in the cessation of bleeding, as well as with blood loss equal to 500 ml, blood transfusion should be started.

If the bleeding has not stopped or resumed in the ovum, they immediately proceed to the second stage of the fight against hypotonic bleeding.

With continued bleeding, proceed to the third stage.

Stage three: blood loss exceeding masses body i.e. 1001-1500 ml.

The main tasks of the third stage of the fight against hypotonic bleeding: removal of the uterus before development hypocoagulation, prevention of deficit of compensation blood loss more than 500 ml., preservation of the volumetric ratio of injected blood and blood substitutes: 1, timely compensation of respiratory function (IVL) and kidneys, which allows you to stabilize hemodynamics. Reimbursement of blood loss by 200.

Stage three activities .

With unstoppable bleeding, intubation anesthesia with mechanical ventilation, gluttony, temporary stopping of bleeding in order to normalize hemodynamic and coagulation indicators (the imposition of clamps on the corners of the uterus, the base of the wide isthmic part of the tubes, own ligaments of the ovaries and round ligaments of the uterus).

The choice of the scope of the operation (amputation or extirpation of the uterus) is determined by the pace, duration, volume blood loss, state of systems hemostasis. With development DIC syndrome only extirpation of the uterus should be performed.

I do not recommend applying the position Trendelenburg, which dramatically impairs lung ventilation and function cordially- vascular system, repeated manual examination and vyskab shower uterine cavity, transposition of terminals, simultaneous administration of large amounts of drugs tonomotor actions.

Tamponade of the uterus and suture according to Lositskaya as methods of dealing with postpartum hemorrhage are withdrawn from the arnale of funds as a dangerous and disorienting doctor about the true value blood loss and the tone of the uterus, in connections , with which operational intervention turns out to be belated.

Pathogenesis of hemorrhagic shock

The leading place in the development of severe shock belongs to the disproportion between the BCC and the capacity of the vascular bed.

BCC deficiency leads to a decrease in venous return and cardiac output. The signal from the vamoreceptors of the right atrium enters the vasomotor center and leads to the release of catecholamines. There is peripheral vasospasm mainly in the venous part of the vessels, because it is in this system that 60-70% of blood is contained.

Redistribution of blood. In postpartum women, this is done by releasing blood from the uterine circuit into the bloodstream, containing up to 500 ml of blood.

Redistribution of fluid and the transition of extravascular fluid into the bloodstream - autohemodilution. This mechanism compensates for blood loss up to 20% of the BCC.

In cases where blood loss exceeds 20% of the BCC, the body is unable to restore the correspondence between the BCC and the vascular bed at the expense of its reserves. The blood loss goes into the decompensated phase and the blood circulation is centralized. To increase venous return, arterio-venous shunts are opened, and blood, bypassing the capillaries, enters the venous system. This type of blood supply is possible for organs and systems: skin, subcutaneous tissue, muscles, intestines, and kidneys. This entails a decrease in capillary perfusion and tissue hypoxia in these organs. The volume of venous return increases slightly, but to ensure adequate cardiac output, the body is forced to increase the heart rate - in the clinic, along with a slight decrease in systolic blood pressure with increased diastolic blood pressure, tachycardia appears. The stroke volume increases, the residual blood in the ventricles of the heart decreases to a minimum.

For a long time in this rhythm, the body cannot work and tissue hypoxia occurs in organs and tissues. A network of additional capillaries is revealed. The volume of the vascular bed increases sharply with a deficiency of the BCC. The resulting discrepancy leads to a drop in blood pressure to critical values, at which tissue perfusion in organs and systems practically stops. Under these conditions, perfusion is retained in vital organs. With a decrease in blood pressure in large vessels to 0, blood flow in the brain and coronary arteries remains.

In conditions of a secondary decrease in the BCC and low blood pressure due to a sharp decrease in the stroke volume in the capillary network, a “sludge syndrome” (“mud”) occurs. There is a gluing of shaped elements with the formation of microclots and thrombosis of the microvasculature. The appearance of fibrin in the stream activates the fibrinolysis system - plasminogen is converted into plasmin, which breaks down fibrin strands. The permeability of the vessels is restored, but again and again the formed clots, absorbing blood factors, lead the blood coagulation system to depletion. Aggressive plasmin, not finding a sufficient amount of fibrin, begins to break down fibrinogen - in the peripheral blood, along with the products of fibrin degradation, products of fibrinogen degradation appear. DIC passes into the stage of hypocaagulation. Almost devoid of clotting factors, the blood loses its ability to coagulate. In the clinic, bleeding occurs with non-clotting blood, which, against the background of multiple organ failure, leads the body to death.

Diagnosis of obstetric hemorrhagic shock should be based on clear and accessible criteria that would allow us to capture the moment when a relatively easily reversible situation decompensates and approaches irreversible. To do this, two conditions must be met:

n blood loss should be accurately and reliably determined

n there should be an objective individual assessment of the patient's response to this blood loss.

The combination of these two components will make it possible to choose the correct algorithm of actions to stop bleeding and draw up an optimal program of infusion-transfusion therapy.

In obstetric practice, the exact definition of blood loss is of great importance. This is due to the fact that any childbirth is accompanied by blood loss, and bleeding is sudden, profuse and requires quick and correct action.

As a result of numerous studies, average volumes of blood loss have been developed in various obstetric situations. (slide)

When delivering through the vaginal birth canal, a visual method for assessing blood loss using measuring containers. This method, even with experienced specialists, gives 30% errors.

Determination of blood loss by hematocrit presented by Moore's formulas: In this formula, it is possible to use another indicator instead of the hematocrit indicator - the hemoglobin content, the true values \u200b\u200bof these parameters become real only 2-3 days after reaching full blood dilution.

Nelson's formula is based on the hematocrit index. It is reliable in 96% of cases, but informative only after 24 hours. You need to know the initial hematocrit.

There is an interdependence between indicators of blood density, hematocrit and blood loss (slide)

When determining intraoperative blood loss, the gravimetric method is used, which involves weighing the operating material. Its accuracy depends on the intensity of blood saturation of the surgical linen. The error is within 15%.

In obstetric practice, the visual method and Libov's formula are most acceptable. There is a certain relationship between body weight and BCC. For women, the BCC is 1/6 of body weight. Physiological blood loss is considered to be 0.5% of body weight. This formula is applicable to almost all pregnant women, except for obese patients with severe gestosis. Blood loss 0.6-0.8 refers to pathological compensated, 0.9-1.0 - pathological decompensated and more than 1% - massive. However, such an assessment is applicable only in combination with clinical data, which are based on the assessment of signs and symptoms of developing hemorrhagic shock using indicators of blood pressure, pulse rate, hematocrit, and Altgover index calculation.

The Altgover index is the ratio of heart rate to systolic blood pressure. Normally, it does not exceed 0.5.

The success of measures to combat bleeding is due to the timeliness and completeness of measures to restore myotamponade and ensure hemostasis, but also to the timeliness and well-designed program of infusion-transfusion therapy. Three main components:

1.volume infusion

2.composition of infusion media

3. rate of infusion.

The infusion volume is determined by the volume of blood loss recorded. With blood loss of 0.6-0.8% of body weight (up to 20% of the BCC), it should be 160% of the volume of blood loss. At 0.9-1.0% (24-40% BCC) - 180%. With massive blood loss - more than 1% of body weight (more than 40% of the BCC) - 250-250%.

The composition of infusion media becomes more complicated as blood loss increases. With a 20% BCC deficiency, colloids and crystalloids in a 1: 1 ratio, blood is not transfused. At 25-40% of the BCC - 30-50% of blood loss is blood and its preparations, the rest is colloids: crystalloids - 1: 1. With blood loss of more than 40% of the BCC - 60% - blood, the ratio of blood: FFP is 1: 3, the rest is crystalloids.

The rate of infusion depends on the magnitude of systolic blood pressure. With blood pressure less than 70 mm Hg. Art. - 300 ml / min, at rates of 70-100 mm Hg - 150 ml / min, then - the usual rate of infusion under the control of CVP.

Prevention of bleeding in the postpartum period

1. Timely treatment of inflammatory diseases, the fight against abortion and recurrent miscarriage.

2. Correct management of pregnancy, prevention of gestosis and complications of pregnancy.

3. Correct management of childbirth: a competent assessment of the obstetric situation, optimal regulation of labor. Pain relief during labor and timely resolution of the issue of operative delivery.

4. Prophylactic administration of uterotonic drugs from the moment the head is inserted, careful observation in the postpartum period. Especially in the first 2 hours after childbirth.

Mandatory emptying of the bladder after childbirth, ice on the lower abdomen after the birth of the placenta, periodic external massage of the uterus. Careful registration of lost blood and assessment of the general condition of the postpartum woman.

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Bleeding that occurs in the first 2 hours of the postpartum period is most often caused by a violation of the contractile ability of the uterus - its hypo- or atonic state. Their frequency is 3-4% of the total number of births.

The term "atony"denote a condition of the uterus in which the myometrium completely loses its ability to contract. Hypotensioncharacterized by a decrease in tone and insufficient ability of the uterus to contract.

Etiology. The reasons for the hypo- and atonic state of the uterus are the same, they can be divided into two main groups: 1) conditions or diseases of the mother, causing hypotension or atony of the uterus (gestosis, diseases of the cardiovascular system, liver, kidneys, respiratory tract, central nervous system, neuroendocrine disorders, acute and chronic infections, etc.); all extreme conditions of the postpartum woman, accompanied by impaired perfusion of tissues and organs, including the uterus (trauma, bleeding, severe infections); 2) reasons contributing to the anatomical and functional inferiority of the uterus: anomalies in the location of the placenta, retention in the uterine cavity of parts of the placenta, premature detachment of the normally located placenta, malformations of the uterus, increment and tight attachment of the placenta, inflammatory diseases of the uterus (endomyometritis), uterine fibroids, multiple pregnancy, large fetus, destructive changes in the placenta. In addition, such additional factors as abnormalities of labor, leading to a prolonged or rapid and rapid course of labor, can predispose to the development of hypotension and atony of the uterus; untimely discharge of amniotic fluid; quick extraction of the fetus during obstetric operations; prescribing large doses of drugs that reduce the uterus; overly active management of the III stage of labor; unreasonable use (with an unseparated placenta) of such techniques as the method of Abuladze, Genter, Krede-Lazarevich; external massage of the uterus; stretching the umbilical cord, etc.

The clinical picture. There are two clinical variants of bleeding in the early postpartum period.

First option:immediately after the birth of the placenta, the uterus loses its ability to contract; she is atonic, does not respond to mechanical, temperature and drug stimuli; bleeding from the first minutes is profuse, quickly leads the mother to a state of shock. Atony of the uterus, which arose initially, is a rare phenomenon.

Second option:the uterus periodically relaxes; under the influence of funds that stimulate the muscles, its tone and contractility are temporarily restored; then the uterus becomes flabby again; wave-like bleeding; periods of its strengthening alternate with an almost complete stop; blood is lost in portions of 100-200 ml. The body of the postpartum woman temporarily compensates for such blood loss. If assistance is provided to the postpartum woman on time and in sufficient volume, the tone of the uterus is restored and the bleeding stops. If obstetric care is delayed or carried out haphazardly, the body's compensatory capabilities are depleted. The uterus ceases to respond to stimuli, hemostasis disorders join, the bleeding becomes massive, hemorrhagic shock develops. The second variant of the clinical picture of bleeding in the early postpartum period occurs much more often than the first.

Treatment. Methods of dealing with hypotonic and atonic bleeding are divided into drug, mechanical and operational.

Assisting with the onset of hypotonic bleeding consists in a set of measures that are carried out quickly and clearly, without wasting time on the repeated use of ineffective means and manipulations. After emptying the bladder, proceed to external massage of the uterus through the abdominal wall. At the same time, drugs are administered intravenously and intramuscularly (or subcutaneously) that reduce the muscles of the uterus. As such agents, you can use 1 ml (5 units) of oxytocin, 0.5-1 ml of 0.02% methylergometrine solution. It must be remembered that ergot preparations in case of an overdose can have a depressing effect on the contractile activity of the uterus, and oxytocin can lead to a violation of the blood coagulation system. Do not forget about local hypothermia (ice on the stomach).

If these measures do not lead to a lasting effect, and the blood loss has reached 250 ml, then it is necessary, without delay, to proceed with a manual examination of the uterine cavity, remove blood clots, and revise the placental site; if a delayed lobe of the placenta is detected, remove it, check the integrity of the walls of the uterus. If performed in a timely manner, this operation provides a reliable hembstatic effect and prevents further blood loss. The lack of effect during manual examination of the uterine cavity in most cases indicates that the operation was performed late.

During the operation, the degree of impairment of the motor function of the uterus can be determined. With the preserved contractile function, the force of contraction is felt by the operator's hand, with hypotension, weak contractions are noted, and with atony of the uterus, there are no contractions, despite mechanical and medicinal effects. When hypotension of the uterus is established during the operation, the uterus is massaged on a fist (carefully!). Caution is necessary to prevent violations of the functions of the blood coagulation system in connection with the possible entry into the mother's bloodstream of a large amount of thrombotic plate.

To consolidate the effect obtained, it is recommended to impose a transverse suture on the cervix according to Lositskaya, place a tampon moistened with ether in the posterior fornix of the vagina, inject 1 ml (5 U) oxytocin or 1 ml (5 mg) of prostaglandin F 2 o into the cervix.

All measures to stop bleeding are carried out in parallel with infusion-transfusion therapy, adequate blood loss.

In the absence of an effect from timely treatment (external massage of the uterus, the introduction of uterine-reducing agents, manual examination of the uterine cavity with a gentle external-internal massage) and ongoing bleeding (blood loss over 1000 ml), it is necessary to immediately proceed to celiac disease. In case of massive postpartum hemorrhage, the operation should be undertaken no later than 30 minutes after the onset of hemodynamic disturbances (with a blood pressure of 90 mm Hg). An operation undertaken after this period, as a rule, does not guarantee a favorable outcome.

Surgical methods to stop bleeding are based on ligation of the uterine and ovarian vessels or removal of the uterus.

Supravaginal amputation of the uterus should be resorted to in the absence of the effect of vascular ligation, as well as in cases of partial or complete placental augmentation. Extirpation is recommended in cases where uterine atony occurs as a result of an increase in placenta previa, with deep ruptures of the cervix, in the presence of infection, and also if the pathology of the uterus is the cause of a blood clotting disorder.

The outcome of the fight against bleeding largely depends on the sequence of activities and a clear organization of the assistance provided.

Treatment of late gestosis. The volume, duration and effectiveness of treatment depend on the correct definition of the clinical form and the severity of the course of gestosis.

Edema of pregnant women(with diagnosed pathological weight gain and transient edema of the 1st degree of severity) can be carried out in a antenatal clinic. In the absence of the effect of therapy, as well as in the case of detection of edema of I and III degrees, pregnant women are subject to hospitalization.

Treatment consists in creating a calm environment, prescribing a protein-plant-based diet. Salt and fluid restriction is not required; fasting days are held once a week: cottage cheese up to 500 g, apples up to 1.5 kg. It is advised to take herbal diuretics (kidney tea, bearberry), vitamins (including tocopherol acetate, vitamin C, rutin). The use of drugs that improve uteroplacental and renal blood flow (aminophylline) is recommended.

Relief of nephropathy I and II degreerequires an integrated approach. It is carried out only under stationary conditions. A therapeutic and protective regime is created, which is supported by the appointment of a decoction or tincture of valerian and motherwort and tranquilizers (sibazon, nozepam). The sedative effect of tranquilizers can be enhanced by the addition of antihistamines (diphenhydramine, suprastin).

The diet does not require strict fluid restriction. Food should be rich in complete proteins (meat, boiled fish, cottage cheese, kefir, etc.), fruits, vegetables. Fasting days are spent once a week (apple-curd, kefir, etc.).

The intensity of antihypertensive therapy depends on the severity of gestosis. With nephropathy I degree, you can limit yourself to enteral or parenteral administration of no-shpa, aminophylline, papaverine, dibazol; with nephropathy II degree, methyldofu, clonidine are prescribed.

For many years, magnesium sulfate has been successfully used for the treatment of nephropathy - an ideal remedy for the treatment of preeclampsia, providing a pathogenetically based sedative, hypotensive and diuretic effect. It inhibits platelet function, is an antispasmodic and calcium antagonist, enhances the production of prostacyclin, and affects the functional activity of the endothelium. D.P. Brovkin (1948) proposed the following scheme for intramuscular administration of magnesium sulfate: 24 ml of a 25% solution is injected three times after 4 hours, the last time - after 6 hours.Currently, with grade I nephropathy, smaller doses of magnesium sulfate are used: twice a day 10 ml of a 25% solution is injected intramuscularly. With nephropathy II degree, preference is given to the intravenous route of administration of the drug: the initial hourly dose of magnesium sulfate is 1.25-2.5 g of dry matter, the daily dose is 7.5 g.

To improve the uteroplacental blood flow, optimize microcirculation in the kidneys, infusion therapy is prescribed (rheopolyglucin, glucose-novocaine mixture, hemodesis, isotonic saline solutions, in case of hypoproteinemia - albumin). The total amount of infused solutions is 800 ml.

The complex of medicinal products includes vitamins C, B r B 6, E.

The effectiveness of treatment depends on the severity of the nephropathy: in the first degree, as a rule, the therapy is effective; at And the degree requires great effort and time. If within 2 weeks. it is not possible to achieve a lasting effect, then it is necessary to prepare the pregnant woman for delivery.

Grade III nephropathy reliefperformed in an intensive care unit or ward. This stage of gestosis, along with preeclampsia and eclampsia, refers to severe forms of gestosis. There is always a threat of its transition to the next phases of toxicosis development (preeclampsia, eclampsia) and danger to the life of the fetus. Therefore, therapy should be intensive, pathogenetically grounded, complex and individual.

In the course of treatment, doctors (obstetrician and resuscitator) set and solve the following main tasks:

1) provide a protective regime;

2) eliminate vascular spasm and hypovolemia;

3) prevent or treat fetal hypoxia.

A woman should be kept in bed. She is prescribed small tranquilizers: Chlosepide (Elenium), Sibazon (Seduxen), Nosepam (Tazepam), etc. Antihistamines (Diphenhydramine, Pipolfen, Suprastin) are added to enhance the sedative effect.

Removal of vascular spasm and elimination of hypovolemia are carried out in parallel. Typically, treatment begins with intravenous drip of magnesium sulfate and rheopolyglucin. Depending on the initial level of blood pressure, 30-50 ml of 25% magnesium sulfate is added to 400 ml of rheopolyglucin (at MAP 110-120 mm Hg - 30 ml, 120-130 mm Hg - 40 ml, over 130 mm Hg. - 50 ml). The average rate of solution introduction is 100 ml / h. Intravenous administration of magnesium sulfate requires careful monitoring of the patient: to prevent a sharp drop in blood pressure, monitor possible suppression of neuromuscular transmission (check knee reflexes), monitor breathing (possibly suppression of the respiratory center). In order to avoid undesirable effects, after achieving a hypotensive result, the infusion rate can be reduced to a maintenance dose of 1 g of magnesium sulfate dry matter for 1 hour.

Treatment with magnesium sulfate is combined with the appointment of antispasmodics and vasodilators (no-shpa, papaverine, dibazol, aminophylline, methyldopa, ap -resin, clonidine, etc.).

If necessary, use ganglion blocking drugs (pentamine, hygronium, imekhin, etc.).

To eliminate hypovolemia, in addition to rheopolyglucin, hemodez, crystalloid solutions, glucose and glucose-novocaine mixture, albumin, reogluman, etc. are used. The choice of drugs and the volume of infusion depends on the degree of hypovolemia, colloid-osmotic composition and osmolarity of the blood, the state of central hemodynamics, function kidneys. The total amount of infused solutions for grade III nephropathy is 800-1200 ml.

The inclusion of diuretics in the complex therapy of severe forms of gestosis should be careful. Diuretics (lasix) are prescribed for generalized edema, high diastolic blood pressure with the replenished volume of circulating plasma, as well as in the case of acute left ventricular failure and pulmonary edema.

Cardiac drugs (korglucon), hepatotropic drugs (Essentiale) and vitamins Bj, B 6, C, E are a necessary part of the treatment of severe OPG-gestosis.

The whole complex of therapeutic agents contributes to the correction of hypovolemia, a decrease in peripheral arteriospasm, the regulation of protein and water-salt metabolism, an improvement in microcirculation in the vital organs of the mother, and has a positive effect on the uteroplacental blood flow. The addition of trental, sygetin, cocarboxylase, oxygen inhalation, and hyperbaric oxygenation sessions improve the condition of the fetus.

Unfortunately, against the background of the existing pregnancy, one cannot count on the complete elimination of severe nephropathy, therefore, carrying out intensive therapy, it is necessary to prepare the patient for careful childbirth for her and child. In order to avoid serious complications that can lead to the death of the mother and the fetus, in the absence of a clear and lasting effect, the treatment period is 1-3 days. /

Relief of preeclampsia,along with complex intensive care (as in grade III nephropathy), it includes the provision of emergency assistance to prevent the development of seizures. This assistance consists in the urgent intravenous administration of the neuroleptic droperidol (2-3 ml of 0.25% solution) and diazepam (2 ml of 0.5% solution). Sedation can be enhanced by intramuscular injection of 2 ml of 1% solution of promedol and 2 ml of 1% solution of diphenhydramine. Before the introduction of these drugs, you can give a short-term masked nitrous-fluorothane anesthesia with oxygen.

If complex intensive treatment is effective, then gestosis from the stage of preeclampsia passes into the stage of nephropathy of II and III degrees, and the patient's therapy continues. If there is no effect after 3-4 hours, it is necessary to decide on the delivery of a woman.

Eclampsia relief

Easing the HELLP syndrome.The effectiveness of complex intensive therapy for HELLP syndrome is largely determined by its timely diagnosis. As a rule, it is required to transfer patients to mechanical ventilation, control laboratory parameters, assess the blood coagulation system, and diuresis. The therapy aimed at stabilizing the hemostasis system, eliminating hypovolemia, and antihypertensive therapy is of fundamental importance. There are reports of high efficacy in the therapy of HELLP-syndrome of plasmapheresis with transfusion of fresh frozen plasma, immunosuppressants and corticosteroids.

Labor management. Childbirth aggravates the course of gestosis and aggravates fetal hypoxia. This should be borne in mind when choosing the time and method of delivery.

Eclampsia relief,is to provide emergency care and intensive complex therapy, common for the treatment of severe forms of gestosis. First aid for the development of seizures is as follows:

1) the patient is placed on a flat surface and her head is turned to the side;

2) with a mouth dilator or a spatula, carefully open the mouth, pull out the tongue, free the upper respiratory tract from saliva and mucus;

3) start assisted ventilation with a mask or transfer the patient to artificial ventilation;

4) Sibazon (seduxen) - 4 ml of a 0.5% solution is injected intravenously and the administration is repeated an hour later in an amount of 2 ml, droperidol - 2 ml of a 0.25% solution or dipracin (pipolfen) - 2 ml of a 2.5% solution;

5) start drip intravenous administration of magnesium sulfate.

The first dose of magnesium sulfate should be shock: at the rate of 5 g of dry matter per 200 ml of rheopolyglucin. This dose is administered over 20-30 minutes under the control of a decrease in blood pressure. Then they switch to a maintenance dose of 1-2 g / h, carefully monitoring blood pressure, respiratory rate, knee reflexes, the amount of urine excreted and the concentration of magnesium in the blood (if possible).

Complex therapy of preeclampsia complicated by convulsive syndrome is carried out according to the rules for the treatment of grade III nephropathy and preeclampsia with some changes. Colloid solutions should be used as infusion solutions because of the low colloidal osmotic pressure in such patients. The total volume of infusion should not exceed 2-2.5 l / day. Strict control of hourly urine output is required. One of the elements of the complex therapy of eclampsia is immediate delivery.

POLYWATER. Low water

Amniotic fluid is a liquid medium that surrounds the fetus and is intermediate between it and the mother's body. During pregnancy, amniotic fluid protects the fetus from pressure, makes it possible to move relatively freely, and contributes to the formation of the correct position and presentation. During childbirth, the amniotic fluid balances the intrauterine pressure, the lower pole of the fetal bladder is a physiological irritant to the receptors of the internal pharynx region. Amniotic fluid, depending on the duration of pregnancy, is formed from various sources. In the early stages of pregnancy, the entire surface of the amnion performs a secretory function, later exchange is carried out to a greater extent through the amniotic surface of the placenta. Other areas of water exchange are the lungs and kidneys of the fetus. The ratio of water and other components of amniotic fluid is maintained due to constant dynamic regulation of metabolism, and its intensity is specific for each component. A complete exchange of amniotic fluid is carried out in 3 hours.

The volume and composition of amniotic fluid depend on the gestational age, fetal weight and placenta size. As pregnancy progresses, the volume of amniotic fluid increases from 30 ml at week 10 to a maximum at week 38 and then decreases by week 40, amounting to 600-1500 ml at the time of urgent delivery, on average 800 ml.

Etiology. Polyhydramnios can accompany various complications of pregnancy. Most often, polyhydramnios is detected in pregnant women with chronic infection. For example, such as pyelonephritis, inflammatory diseases of the vagina, acute respiratory infection, specific infections (syphilis, chlamydia, mycoplasmosis, cytomegalovirus infection). Polyhydramnios is often diagnosed in pregnant women with extragenital pathology (diabetes mellitus, Rh-conflict pregnancy); in the presence of multiple pregnancies, fetal malformations (damage to the central nervous system, gastrointestinal tract, polycystic kidney disease, skeletal anomalies). Distinguish between acute and chronic polyhydramnios, which often develops in the II and III trimesters of pregnancy.

The clinical picture. Symptoms are quite pronounced with acutely developing polyhydramnios.There is a general malaise, painful sensations and heaviness in the abdomen and lower back. Acute polyhydramnios due to the high standing of the diaphragm may be accompanied by shortness of breath, impaired cardiac activity.

Chronic polyhydramniosusually does not have clinical manifestations: the pregnant woman adapts to the slow accumulation of amniotic fluid.

Diagnostics is based on the assessment of complaints, the general condition of pregnant women, external and internal obstetric examination and special examination methods.

Complaintspregnant women (if any) are reduced to loss of appetite, shortness of breath, malaise, a feeling of heaviness and pain in the abdomen, lower back.

When objective researchthere is a pallor of the skin, a decrease in the subcutaneous fat layer; in some pregnant women, the venous pattern on the abdomen is enhanced. The abdominal circumference and the height of the uterine fundus do not correspond to the gestational age, significantly exceeding them. The uterus is sharply enlarged, tense, of a tight-elastic consistency, spherical in shape. When palpating the uterus, fluctuation is determined. The position of the fetus is unstable, often transverse, oblique, possibly breech presentation; on palpation, the fetus easily changes its position, parts of the fetus are palpable with difficulty, sometimes they are not determined at all. The presenting part is located high and is running. The fetal heartbeat is poorly audible, deaf. Sometimes excessive motor activity of the fetus is expressed. The vaginal examination data helps to diagnose polyhydramnios: the cervix is \u200b\u200bshortened, the internal pharynx opens slightly, and a tense fetal bladder is determined.

Of the additional research methods, informative and therefore mandatory is ultrasound scanning,allowing to make fetometry, determine the estimated weight of the fetus, clarify the gestational age, establish the volume of amniotic fluid, identify fetal malformations, establish the localization of the placenta, its thickness, stage of maturation, compensatory capabilities.

With diagnosed polyhydramnios, it is necessary to conduct research in order to identify the cause of its occurrence. Although this is not always possible, this should be strived for. Prescribe all studies aimed at identifying (or clarifying the severity) of diabetes mellitus, isosensitization for the Rh factor; specify the nature of malformations and the state of the fetus; detect the presence of a possible chronic infection.

Differential diagnosis is carried out with polyhydramnios, cystic drift, ascites and giant ovarian cystoma. In this case, ultrasound scanning is of invaluable help.

Features of the course of pregnancy. The presence of polyhydramnios indicates a high degree of risk for both the mother and the fetus.

The most common complication is miscarriagepregnancy. With acute polyhydramnios, which often develops before 28 weeks, a miscarriage occurs. With chronic polyhydramnios in some women, pregnancy can continue, but more often it ends in premature birth. Another complication, which is often combined with the threat of termination of pregnancy, is the premature rupture of the membranes due to their degenerative changes.

The rapid outflow of amniotic fluid can lead to the prolapse of the umbilical cord or small parts of the fetus, contribute to the premature detachment of the normally located placenta.

Pregnant women with polyhydramnios often develop syndrome of compression of the inferior vena cava.Women in the supine position begin to complain of dizziness, weakness, ringing in the ears, and flashing of flies before their eyes. When turning to the side, the symptoms disappear, since the compression of the inferior vena cava stops and the venous return to the heart increases. With the syndrome of compression of the inferior vena cava, the blood supply to the uterus and the fetoplacental complex worsens, which affects the state of the intrauterine fetus.

Often during pregnancy, complicated by polyhydramnios, fetal malnutrition is observed.

Pregnancy and childbirth management. Pregnant women with suspected polyhydramnios are subject to hospitalization to clarify the diagnosis and identify the cause of its development. After confirming the diagnosis, they choose the tactics of further pregnancy management.

If, during the examination, fetal abnormalities are found that are not compatible with life, the woman is prepared to terminate the pregnancy through the natural birth canal. If an infection is detected, adequate antibiotic therapy is carried out, taking into account the effect of drugs on the fetus. In the presence of isoserological incompatibility of the blood of the mother and the fetus, pregnancy is carried out in accordance with the adopted tactics. After revealing diabetes mellitus, treatment is carried out aimed at its compensation.

In recent years, there has been a tendency to influence the amount of amniotic fluid by acting on the fetus. Indomethacin, received by a woman at a dose of 2 mg / kg per day, reduces fetal urine output and thereby reduces the amount of amniotic fluid. In some cases, amniocentesis is used with the evacuation of excess water.

Unfortunately, therapeutic measures aimed at reducing the amount of amniotic fluid are not always effective.

In parallel with the pathogenetically justified therapy, it is necessary to influence the fetus, which is often in a state of chronic hypoxia with malnutrition against the background of insufficiency. To do this, use agents that improve uteroplacental blood circulation. Prescribe antispasmodics, drugs that improve the rheological properties of blood (rheopolyglucin, trental, curantil), acting on metabolic processes (riboxin, cytochrome C), antioxidants (tocopherol acetate, unitiol). Oxybarotherapy gives good results.

Childbirth in the presence of polyhydramnios is complicated. Weakness of labor is often observed. Polyhydramnios leads to overstretching of the muscle fibers of the uterus and to a decrease in their contractility. Obstetric care begins with opening the fetal bladder. Amniotomy must be performed carefully, with an instrument, and amniotic fluid must be released slowly to avoid placental abruption and prolapse of the umbilical cord and small parts of the fetus. In 2 hours after opening the fetal bladder, in the absence of intensive labor, birth-stimulating therapy should be started. For the prevention of bleeding in the sequential and early postpartum periods "with the last push" of the expulsion period, it is necessary to administer intravenous methylergometrine or oxytocin. If the woman in labor received

rhodostimulation using intravenous administration of uterine-reducing agents, then it is continued in the sequential and early postpartum periods.

Low water.If the amount of amniotic fluid at full-term pregnancy is less than 600 ml, then this is considered oligohydramnios. It is very rare.

Etiology. Until now, the etiology of oligohydramnios is not clear. In the presence of oligohydramnios, fetal growth retardation syndrome is often observed, perhaps in this situation there is an inverse relationship: in a hypotrophic fetus, renal function is impaired, and a decrease in hourly urine output leads to a decrease in the amount of amniotic fluid. With low water due to lack of space, fetal movements are limited. Often, adhesions form between the skin of the fetus and the amnion, which, as the fetus grows, stretch out in the form of strands and threads. The walls of the uterus fit tightly to the fetus, bend it, which leads to curvature of the spine, malformations of the limbs.

The clinical picture. Symptoms of oligohydramnios are usually not pronounced. The condition of the pregnant woman does not change. Some women experience painful fetal movements.

Diagnostics. Based on the discrepancy between the size of the uterus and the gestational age. In this case, it is necessary to conduct an ultrasound examination, which helps to establish the exact amount of amniotic fluid, to clarify the duration of pregnancy, to determine the size of the fetus, to identify possible malformations, to conduct a medical and genetic examination by chorionic biopsy.

The course of pregnancy. Low water often leads to miscarriage. There is hypoxia, hypotrophy, fetal anomalies.

Childbirth often takes on a protracted course, since dense membranes, tightly stretched over the presenting part, prevent the opening of the internal pharynx and the advancement of the presenting part. Obstetric care begins with opening the fetal bladder. Having opened it, it is necessary to widely dilute the shells so that they do not interfere with the opening of the internal pharynx and the advancement of the head. 2 hours after amniotomy, with insufficiently intensive labor activity, birth-stimulating therapy is prescribed.

Successive and early postpartum periods are often accompanied by increased blood loss. One of the measures to prevent bleeding is the prophylactic administration of methylergometrine or oxytocin at the end of period II.