6607 0

Bleeding in early postpartum period - It is bleeding that arose in the first 2 h after childbirth.

The hypotension of the uterus is the weakness of the contractile ability of the uterus and its insufficient tone.

Atony of the uterus is a complete loss of tone and the contractile ability of the uterus, which does not respond to medication and other stimulation.

Epidemiology

Classification

See sublap "Bleeding in the last period".

Etiology and pathogenesis

Bleeding in the early postpartum period may be due to the delay in the parts of the placenta in the uterine cavity, hypo- and atonius of the uterus, a violation of the coagulation system of blood, the gap of the uterus.

The causes of hypo-and atonic bleeding are violations of the contractile ability of myometrium due to childbirth (gestosis, somatic diseases, endocrinopathy, scar changes in myometrium, etc.).

The causes of bleeding in violations of the hemostasis system can be both congenital and acquired hemostasis system defects (thrombocytopenic purpura, Willebrand disease, angiohemophilia) and various types of obstetric pathology that contribute to the development of DVS-syndrome and the emergence of bleeding in childbirth and early postpartum period. The development of violations of blood coagulation of blood clotting is the processes of pathological activation of intravascular blood coagulation.

Clinical signs and symptoms

Bleeding caused by the delay of the placenta parts is characterized by abundant blood discharges with clots, large sizes of postpartum uterus, periodic relaxation and abundant blood outlets from sex tract.

In the hypotension, the uterus bleeding is characterized by wave-likeness. Blood is highlighted by portions in the form of clots. The uterus is flabby, reduce its rare, short. The blood clots are accumulated in the cavity, as a result of which the uterus increases, loses normal tone and contractile ability, but still responds to conventional stimuli abbreviations.

The relatively small dimensions of fractional blood loss (150-300 ml) provide temporary adaptation of the parental to developing hypovolemia. Hell remains within normal values. Palloth notes skin Pokrov, increasing tachycardia.

With insufficient treatment in the early initial period of the uterine hypotension, the severity of the violations of its contractile function progresses, medical events It becomes less effective, the volume of blood loss increases, the symptoms of shock increase are growing, develops in DVS syndrome.

Atonia uterus is an extremely rare complication. When atony, the uterus completely loses the tone and contractile ability. The neuro-muscular apparatus does not respond to mechanical, thermal and pharmacological stimuli. The uterus is flabby, poorly contoured through abdominal wall. Blood flows into a wide stream or stands out in large clots. The general condition of the parental is progressively deteriorating. Hypovolemia is rapidly progressing, hemorrhagic shock, DVS syndrome, develops. With continuing bleeding, the death of a parental may occur.

In the practical activity of the obstetrician-gynecologist, the division of bleeding on hypotonic and atonic is conditional in connection with the complexity of differential diagnosis.

In disruption of the hemostasis system, the clinical picture is characterized by the development of coagulopathic bleeding. In a deep deficit of coagulation factors, the formation of hemostatic thromboms is difficult, blood clot is destroyed, the blood is liquid.

When bleeding, due to the delay of the placenta parts, the diagnosis is based on the data of a thorough inspection of the placenta and the shells after the birth of the last. If there is a defect or doubt, the placenta is shown a manual examination of the postpartum uterus and removing the delayed placenta parts.

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

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

Differential diagnosis

Bleeding, resulting from the delay of the parts of the placenta in the uterine cavity, should be differentiated with bleeding associated with hypotension and an atonius of the uterus, a violation of the coagulation system of blood, the uterus break.

The hypotension and the atron of the uterus usually differentiate from traumatic damage to the soft tripes. Strong bleeding with a large, relaxed, poorly contoured through the front abdominal wall, the uterus indicates hypotonic bleeding; Bleeding with a dense, well-cutting uterus indicates damage to the soft tissues of the genital tract.

Differential diagnosis in coagulopathy should be carried out with uterine bleeding of other etiology.

Bleeding due to the delay of the placenta parts

When a delay in the uterus parts of the placenta shows their removal.

Hypotension and Atony Uterine

With a violation of the contractile ability of the uterus in the early postpartum period during blood loss, exceeding 0.5% body weight (350-400 ml), all means of combating this pathology should be used:

■ emptying bladder with soft catheter;

■ outer massage of the uterus;

■ application of cold to lower abdomen;

■ use of means that enhance the reduction of myometrium;

■ manual examination of the walls of the postpartum uterus;

■ terminals for a parameter of Bakshev;

■ With the ineffectiveness of the activities carried out, laparotomy and extirpation of the uterus are substantiated.

With continuing bleeding, the embolization of the vascular of the small pelvis or the gleaming of the internal ileum arteries is shown.

Important in the treatment of hypotonic bleeding, the initiation of the treatment and reimbursement of blood loss, the use of funds that improve the rheological properties of blood and microcirculation, preventing the development of hemorrhagic shock and coagulopathic disorders.

Ustronic therapy

Dinor-grinding / in drip 1 ml (5 mg) in 500 ml of 5% p-ra dextrose or 500 ml of 0.9% R-RR sodium chloride, one-time

Methyl ergometrine, 0.02% rr, V / in 1 ml, one-time

Oxytocin V / in drip 1 ml (5 units) in 500 ml of 5% p-ra dextrose or 500 ml of 0.9% p-ra sodium chloride, one-time.

Hemostatic

and bloodstream therapy

Albumin, 5% rr, in / in drip 200- 400 ml 1 p / day, the duration of therapy is determined individually

Aminometilbenzoic acid in / at 50-100 mg 1-2 p / day, the duration of therapy is determined individually

Aprotinin V / in drip 50 000- 100,000 units of up to 5 p / day or 25 000 foods 3 p / day (depending on the specific LAN), the duration of therapy is determined individually

Hydroxyethyl stroke, 6% or 10% rr, V / in drip 500 ml 1-2 p / day, the duration of therapy is determined individually

Affected features of physiology, hormonal regulation, biochemical processes of the reproductive system of men and women. Separately, questions of contraception, diseases of men's sex glands and eggs, infertility and decline in fertility are considered. A separate chapter is devoted to sexual dysfunction in men and women.

3 290 R




The directory covers a wide range of problems (from hormonal contraception and sterilization to gynecological oncology), the diversity of pathological conditions faced in their practical activity a gynecologist, methods of their diagnosis and treatment. Along with this, the informational saturation of the book assumes that it will be able to get a full-fledged certificate and the thematic recommendations of the doctors of other specialties.

1 640 R




In the clinical part of the book, all major endocrine disorders found in gynecological practice are considered; They are combined into syndromes (for example, discharge syndromes from nipples, androgenation, amenorrhea, postmenopausal osteoporosis, etc.) or discussed separately (for example, endometriosis), some of the heads are discussed not yet enough aspects of gynecological endocrinology (for example, pathology thyroid gland).

2 620 R




The book provides modern theoretical ideas about etiology, pathogenesis, gestosis pathorphology based on the generalization of these world literature and the results of their own studies. Pathogenetic therapy and prevention of gestosis are substantiated on the basis of theoretical ideas.

1 690 R




This leadership presents information on the etiology and pathogenesis of most intrauterine infections, their diagnosis, maintaining pregnant women with various pregnancy trimesters infections, in childbirth and postpartum period, testimony to interrupt pregnancy.

850 R




Saves time when preparing for accreditation. Ready algorithms for passing accreditation.

2 590 R




Hysteroscopy: Indications, Contraindications, Preparation for Research, Equipment, Methods of conducting. Hysteroscopic picture normally. Options for hysteroscopic pattern with intrauterine pathology. Treatment of basic forms of intrauterine pathology.

1 690 R




This is the leadership of the Atlas on the pathology of pregnancy, obstetric pathology and, which is important, in congenital malformations and the most common inherited hereditary diseases in children. One of the few atlases along congenital vices in children, which presents a rich clinical material, and, especially valuable, it is remarkably illustrated with high-quality photos.

2 790 R




The algorithms of medical actions are presented in the diagnosis, treatment and prevention of these infections that will allow Akuster-gynecologist to quickly make reasonable clinical solutions. Particular attention is paid to the organization of work on the prevention of infectious diseases in obstetric hospital, prevention, early diagnosis and treatment of the complications arising.

2 890 R




The book contains a wide range of modern laboratory studies and clinical and diagnostic significance of their changes in different diseases, conditions and syndromes. Indicators and markers of research are grouped by type: "sharp phase" proteins, mineral, pigment, lipid and other exchanges; Enzymes, hormones, markers of infections, oncomarkers, etc.

776 R




The monograph is designed to doctors to urologists, microbiologists, clinical pharmacologists, gynecologists, as well as researchers working in this field of science.

3 099 R




Treatment schemes are combined with a description of drugs, the most common errors and methods of preventing and correction. Separate sections of the book are devoted to endocrine, inflammatory and infectious diseases female genital sphere, mammary pathology, application of various methods of contraception

2 290 R




A special emphasis was made on the analysis of the logic of consistent analysis and the use of additional UP-Methods (CDC modes, ed, 3D, elastography and elastometry) in addition to the standard seroshkali study of the tissues of the mammary glands. The necessity of a multi-parameter approach to ultrasonic assessment of the state of the glands is substantiated. The application of the Bi-Rads system is shown in the final-summing assessment of the risks of malignancy of the breast

3 190 R




Deals with the treatment of infertility of women in late reproductive age. The book contains information about the peculiarities of the treatment of infertility, including against the background of diseases such as the mioma of the uterus and genital endometriosis, as well as programs of auxiliary reproductive technologies in women of late reproductive age, on the principles of conducting patients during pregnancy and childbirth. A separate chapter is devoted to new cellular technologies in reproductive medicine.

1 880 R




New information about the relationship of microcenosis indicators, general and local immunity in inflammatory diseases of the genital organs is highlighted. Much attention is paid to the diagnosis and tactics of maintaining the most common in the gynecological practice of diseases, the problem of inconvenient pregnancy of infectious genesis, the development of intrauterine infection.

1 850 R




Modern principles of diagnosis and treatment are formulated, as well as algorithms for conducting patients with hormonal disorders in the reproductive system. The purpose of this book is to summarize and present the latest data in the field of endocrine gynecology for practical doctors of various profiles.

2 290 R




The book outlines the basics of cardiotockography and pathophysiology of the fetus, the rules for using terminology, lists common errors associated with the equipment and interpretation of cardiotocograms, given clinical trial data and the corresponding clinical scenarios. This edition added a chapter on testing the competence of specialists who increase their qualifications

2 790 R




The clinical characteristics of the drugs used for anesthesia in pregnant women and fencers are presented in detail. Your attention is paid to the anesthesiological support of the operation. cesarean section and anesthesia with small obstetric operations, as well as complications of anesthesiological manual. The problem of intensive therapy in the uterine postpartum bleeding, late hundreds and other urgent states in obstetrics is considered.

2 390 R




Practical guide In terms of outpatient polyclinic assistance include materials on the most important sections of obstetrics and gynecology, gynecological endocrinology and oncogynecology. The issues of etiology, pathogenesis and diagnosis of pathological conditions in the light of the recent achievements of domestic and foreign authors are considered in detail. Modern methods of prevention and therapy in obstetrics and gynecology are presented.

2 190 R




The book details the issues of general and oncological gynecology, reproductive endocrinology and infertility, contraception and planning of family, children's and teenage gynecology, yorkiology, etc. In some chapters, psychological aspects of gynecology are revealed, the problems of homemade cruelty and sexual violence.

2 790 R




The book details the basics of reproduction, normal obstetrics, diagnosis and tactics of conducting various complications during pregnancy and childbirth, urgent states in obstetrics. Attention is paid to extragenital diseases (including surgical) during pregnancy. A separate chapter is devoted to resuscitation of newborns and care for children from high-risk groups.

2 690 R




Currently, there are cases when a student is already a month after passing state exams enter the clinic and must perform a pediatrician function. For many years he studied Pediatrics, but only 10 days of them - ophthalmology; At the same time, the doctors working with children are significantly more responsible in contrast to doctors working with adult patients, for the state of the visual system of the newborn - immature, gentle, developing, very vague, rich in congenital disposable and unreasonable pathology, anomalies.

1 590 R




The book examined the basic principles of patients with complaints about pain, the most common causes of pain and the most common ways to deal with it are given numerous examples from practice. A separate section is devoted to invasive methods of treating pain under fluoroscopic control.

2 890 R




Practical guide may be useful specialists encountered with the problems of diagnosis, treatment and rehabilitation of septic patients, including patients with diseases of the reproductive system.

790 R




The book is written by doctors of different specialties for gynecological obstetricians. It is set out modern ideas about anemia, prevalence different species This disease and their influence on the state of the reproductive system of women.

1 890 R




In this "Atlas", all aspects of the study are clearly structured and intelligible - from the rules for organizing the workflow to the thinnest nuances of colposcopic paintings with various diseases of the cervix. This is a brief, but the maximum full course of colposcopy, a guide for a doctor.

2 790 R




Practical guidance may be useful obsuchar gynecologists, pediatricians, family doctors and other specialists who face with the problems of lactation, hypoglactics, lactostasis and other pathological conditions arising during lactation, as well as contraceptive issues in nursing mothers.

1 290 R




The book discusses the features and options for the flow of migraine in women and strategic approaches to the treatment and prevention of this disease in different periods of their lives. The book is intended for neurologists, obstetricians-gynecologists, therapists, doctors common practice and other professionals who are directly involved in the treatment of women with migraine attacks.

1 590 R




Particular attention is paid to the method of ultrasound study of the anatomical structures of the fetus in early pregnancy, the role of echography during screening for frequent chromosomal syndromes, as well as multiple pregnancy. The second part of the book is devoted to a detailed ultrasound study of organs and fetal systems (central nervous system, face and area of \u200b\u200bneck, chest, heart and main vessels, gastrointestinal tract, urinary system, skeleton), placenta and umbilical umbilical systems and in pathological conditions. The algorithms for the diagnosis of some genetic, including chromosomal, syndromes are considered.

4 990 R




Testimony, contraindications to this operation; The conditions in which it is advisable to produce. The problems of optimal surgical and anesthesiological support of the operation, the prevention and treatment of postoperative complications, intensive therapy and the resuscitation of newborns after abdominal delivery are considered.

1 990 R




The task of this publication is to familiarize the doctors with the specifics of Eco programs in some gynecological and endocrine diseases. The book is designed for the doctors of obstetrician-gynecologists as a common profile and working in Eco clinics, endocrinologists, specialists who are passing and improving their qualifications.

1 790 R




The book discusses ambiguous situations associated with the presence of intrauterine pathology, thyroid diseases and HIV infection. Expanding the testimony to use the auxiliary reproduction methods to achieve pregnancy led to the fact that more than a third of patients with various gynecological, endocrine and other diseases are required "non-standard" solutions in preparation for IVF programs and during treatment

1 890 R




Clinical methods diagnostics. Laboratory diagnostic methods. Instrumental diagnostic methods. Surgical treatment methods. Contraception. Pathology of the reproductive system in children's and adolescence. Endocrine disorders in the reproductive period. Breakfit marriage. Clinical forms inflammatory diseases of the small pelvis organs.

2 790 R




Specialists who worked on the book are confident that after familiarization with the readers presented with readers, there will be no questions about the treatment of violations by the reproductive system. The book "Sugar diabetes and reproductive system" will be useful for reproductologists, gynecologists, diabetologists and endocrinologists.

2 190 R




In full, illuminated diseases and pathological conditionsassociated with pregnancy, childbirth and postpartum period. In addition, diseases, including infectious, most significant in terms of their impact on the health of the mother and child, are presented with modern methods of treating and preventing these diseases. Separately considered the causes of the emergence and methods of combating prenatal and postpartum bleeding.

4 590 R




2 190 R




The most fully published data on the treatment of skin diseases and sexually transmitted infections. The first part presents detailed information about general principles Therapies of skin and venereal diseases. In the 2nd Tome of the leadership, treatment methods are described (with the basics of clinic and etiopathogenesis) of skin diseases - more than 500 nosological forms

3 890 R




The manual consists of two parts, which outlines theoretical and clinical issues of medical genetics. The first part presents the latest data on theoretical issues of medical genetics. Information about the organization and functions of genome, genes and chromosomes are set out in a form understandable for doctors, but without unnecessary simplification. The second part presents the issues of clinical genetics, namely methods of diagnosing hereditary diseases (from clinical level before DNA sequencing and RNA)

3 590 R




The book is devoted to the pathogenesis, prevention and treatment of a number of life-degrading states in modern perinatology: massive obstetric bleeding due to primary impairment in the hemostasis system; anaphyactoid pregnant syndrome; prenatal observation and pregnancy.

2 790 R




The manual contains over 1,400 echograms and 264 clips, which are fragments of real ultrasound research. Comments are given to each clip with access, the scanning plane and the description of the visualization zone. For self-education presented tests of test control and visual tasks with answers for self-control.

2 990 R




The book contains information on the regulatory and legal provision of outpatient obstetric and gynecological care, the organization of work of women's consultation, the day stay hospital, on the peculiarities of organizing children's gynecological assistance, the prevention, diagnosis and treatment of the most common diseases occurring in girls and women of all age groups.

3 499 R




Addressed to all doctors obstechememic gynecologists participating in the medical process: from outpatient to specialized high-tech service, including heads of medical organizations and their deputies planning and engaged in the procurement of drugs (LS)

2 099 R




Contains descriptions of drugs of the Russian pharmaceutical cabinet and section "Parapharmaceutical", which includes dietary supplements, medical products, therapeutic nutrition and therapeutic cosmetics. Information pages of manufacturers contain contact information, a list of drugs, their classification and other information.

2 399 R




Dedicated to one of the main problems of modern gynecology - infertility associated with endometriosis. The main task of the book was to highlight all existing discussion issues. In the non-standard key of the Conterarsions (Sections "Pro", "Et Contra", "point of view") provide information on the prevalence, etiology and pathogenesis of infertility due to endometriosis, from the persuasion of evidence, the global experience of diagnosis, conservative and surgical treatment methods is summarized.

1 699 R




The study manual presents fundamental data on the main indicators of cardiotockography, their pathophysiological and clinical characteristics are presented, and their diagnostic value is given. The technique of applying cardiotockography during pregnancy and childbirth is described. The technique of automated cardiotocogram analysis is setl.

1 690 R




Illustrated Atlas Guide for Colposcopy and the pathology of the cervix, which presents a colposcopic picture in a combination with histopathology, which ensures a complete understanding of the morphological picture and clinical diagnosis. The book contains updated information about the central role of the human papilloma virus in the development of cervical cancer and HPV vaccines for its prevention.

3 199 R




Eco in HIV-infected patients. Algorithm for preliminary examination and preparation of HIV-infected patients to conduct ECO programs. Algorithm of the Embryological Laboratory in the treatment of HIV-infected patients.

1 790 R




Questions of theory and practice of ultrasound diagnostics of ectopic pregnancy. Attention is paid to the significance of the risk factors, modern diagnostic algorithms during pregnancy unknown localization. All the well-known ultrasound signs of ectopic pregnancy are considered in detail, depending on its localization, as well as the degree of urgency of the clinical situation.

2 290 R




There are questions of prenatal diagnosis and pregnancy under various types of twins. The features of the screening of chromosomal pathology of the fetus are described in multiple pregnancy, as well as the tactics of pregnancy when identifying a chromosomal disease or a malformation of one of the fruits

2 399 R




In your hands, a book that gives answers to the questions faced by medical workers when they seek to conduct scrupulous, rational and effective medical advice.

2 390 R




Methods for the examination of the mammary glands: self-examination, surveillance, electrical selectionomammography, radiothermometry, as well as traditional methods of clinical examination. We consider the features of malicious radiological digital technologies - ultrasound computer tomography (UKT), magnetic resonance (MRI), laser volumemmography.

1 190 R




Quick guide on key issues of diagnosis of diseases of the internal organs. All sections are presented in the form of a visual material - short structural logic schemes (algorithms). The content of the book is subordinate to the Unified Scheme, which greatly facilitates the possibilities of operational work with a book and a quick search for a symptom or syndrome.

539 R




Management includes a detailed consideration of their issues, including an analysis of the reasons for inefficient medical measures related to primary or acquired resistance.

1 590 R




The study guide presents modern information about epidemiology, etiopathogenesis, diagnosis and treatment of infertility due to immune responses against spermatozoa

1 190 R




Information on how large the diversity of the forms of brain lesions in children, how these lesions differ from the brain pathology in adults and what is the role of infections, hypoxia, generic injury and other factors in their origin. Text accompany more than 450 color illustrations (photos, schemes and graphics)

2 190 R




Ultrasound, echiberography, MSCT, MRI, PET / CT. Vagina and Vulva. Anatomy of the vagina and vulva. Congenital disorders. Atresia vagina. Infected virgin pole. Vagina partition. Benign neoplasms. Leiomioma Vagina. Hemangioma vulva. Paraganglioma vagina. Malignant neoplasms. Cancer Vagina. Leiomiosarcoma Vagina.

4 290 R




Pelvis. Ultrasound examination: technology and anatomy. Hysterosalpingography. Infusion sonoipeography. Computed tomography: research technology and anatomy. Magnetic resonance Tomography: research technology and anatomy. Positron-Emission Tomography / Computed Tomography: Research Technology and Visualization Features

4 290 R




First of all, we are talking about benign diseases and prevention of RMG. All drugs offered for the treatment of diseases of dairy glazes are considered from the point of view of evidence-based medicine and existing procedures for rendering medical careClinical recommendations. The book presents modern scientific-practical approaches to the diagnosis, treatment and prevention of non-spoken diseases of dairy glasses, assessing risk factors, attention is focused on the introduction of mammographic screening as one of the most important methods of timely detection of cancer.

1 890 R




Diseases gOOD SYSTEM and their relationship with urogenital infections. According to etiology, the pathogenesis of both the most common - cystitis, urethritis, prostatites, and more rare pathology, accompanied by the disorganization of the epithelium, - urethra polyps, bladder leukoplakia.

1 390 R




Chronic pains in the lower abdomen are a frequent complaint of the patients. One of the most unpleasant and depressing factors is an uncertain cause of pelvic pains. The book allows you to comprehensively approach the diagnosis and more successful treatment of chronic pelvic pain syndrome.

1 290 R




The rational treatment schemes are given. Separate sections of the book are devoted to the correction of pain syndrome, infectious complications in oncurology and clinical studies. Modern treatment regimens are combined with a description of drugs, analyzing the most common mistakes, as well as ways to prevent and correction

1 290 R




All aspects of the Ultrasonic Screening Protocol in II of the TRIMETR pregnancy are considered in detail. Special attention is paid to ultrasonic fetometry, evaluation of placenta, accumulating waters and umbilical cord. Detail presented issues of ultrasonic anatomy of the fetus in the II trimester of pregnancy during normal development and various congenital vices. A separate chapter is devoted to echographic markers of chromosomal anomalies in the fetus.

Modern antibiotic therapy of infections of the lower urinary tract in women in schemes and tables




The publication is devoted to modern approaches to antibacterial therapy of uncomplicated infections of the lower urinary tract. Presented an algorithm for the diagnosis of acute cystitis, features of the treatment of infections of the lower urinary tract in pregnant women.

990 R




Modern provisions Ultrasound diagnostics in gynecology based on consensus of international groups of experts on the morphological ultrasound analysis of uterus, deep endometriosis, endometrial tumors and ovaries.

3 099 R




Fundamental provisions of screening research in 30-34 weeks of pregnancy. All aspects of the Ultrasound Screening Protocol in the third trimester of pregnancy are considered in detail. Special attention is paid to ultrasound fetometry

3 280 R




The collection of clinical protocols includes the main nosological forms and clinical situations encountered in the practical work of obstetric hospital doctors. Protocols are compiled on the basis of current regulatory documents of the Ministry of Health of the Russian Federation

1 190 R




The collection of clinical protocols includes the main nosological forms and clinical situations in the practical work of the doctors of women's consultations and gynecological hospitals. Protocols are compiled on the basis of current regulatory documents of the Ministry of Health of the Russian Federation

1 090 R




Dedicated to the pathogenesis, etiology, diagnosis and treatment of polycystic ovary syndrome (SPE), as the most frequently found in women of the reproductive age of the endocrine disease. Given detailed description The characteristics of the physiology of the female reproductive system. Considerable attention is paid to differential diagnosis Sleep and morphological changes in ovaries.

1 150 R




Standed out modern concepts pathogenesis of endometrioid disease. Named indications for the use of special research methods, the technique of various methods is presented. surgical treatment and options for the conservative phase of therapy.

1 350 R




The book uses the traditional for the series "secrets" the form of filing material in the form of questions and answers. The summary of the issues included a brief information about theoretical foundations of ultrasound, but the main volume of the publication occupy practical recommendations By its use in diagnosis. At the same time, specific issues related to certain diseases and pathological conditions are considered, some of which are rarely discussed in special periodicals and monographs.

2 899 R




The features of the development of the embryo and the fetus are detailed depending on the trimester of pregnancy. The data on the formation of its emerging bodies and systems are presented. Complications are also described that arise in different periods of pregnancy, their risk factors, etiology, pathogenesis, classification, diagnosis, treatment and prevention.

1 690 R




The methods of emergency esophagogastroduodenoscopy, colonoscopy, bronchoscopy and laparoscopy, endoscopic pattern of various urgent pathology of the gastrointestinal tracker, the abdominal cavity and small pelvis, as well as the main operational interventions performed through the endoscope in children of various age groups are described.

1 999 R




The leadership describes almost all congenital heart defects, which can be diagnosed by the fetus, as well as treatment of arrhythmias in the fetus and conducting screening ultrasound research in the first trimester of pregnancy. A separate chapter is devoted to the review of the probable outcomes of each of the congenital heart defects. The data is based on a study of almost 4000 fruits with heart anomalies.

3 520 R




Recommendations for the implementation of biopsies with ultrasound guidance, using ultrasound to provide access to various bodies and structures, in diagnostic and medical intervention procedures, installation of drainage, as well as during son-systemography. Such key procedures as a biopsy of the thyroid and mammary glands, surface lymph nodes, sonoipeography, skeletal-muscular and other interventions are covered in detail.

2 750 R




The optimal tactics of conducting patients with gynecological and urological pathologies, which are accompanied by chronic pelvic pains, using modern radiation and endoscopic methods are presented. The main recommendations for the management of patients with chronic pelvic pain syndrome are proposed.

652 R




Aspects of hysteroscopy, fluorescent diagnostics, hysterorestectoscopy with intrauterine pathology endometrial are covered.

1 180 R




Presented data O. modern treatment inflammatory diseases, endocrine and reproductive violations. The head dedicated to the uterus, a new information on etiology, pathogenesis and methods of treating this disease are presented.

990 R




Information on such issues as contraception, sexual dysfunction, endometrial hyperplastic processes, postmenopausal osteoporosis, obesity and reproductive system, genital herpetic infection, uterine mioma, applied aspects of the functional morphology of the perinee and pelvic dna, gynecological endocrinology.

1 410 R




Contains information on children's and teenage gynecology, the main techniques of diagnosis and treatment, the decision-making algorithms in health care. Violations of the development of the reproductive system. Dynamics of puberty physiology. Methods of teenage girls survey.

2 690 R




In detail the information of classical obstetrics about the physiological and complicated course of pregnancy and childbirth, obstetric operations. Modern data on pathogenesis, treatment and prevention of most common pregnancy complications are presented.

1 260 R




Management contains modern and topical information on the diagnosis and treatment of basic breast diseases. It addressed the main aspects of mammology. Management reflecting the agreed position on topical issues of modern diagnosis and therapy of the diseases of the mammary glands.

3 199 R




Information on the basic characteristics of the state of female reproductive health and presents comparative global medical records. The authors identified priority factors affecting the function of reproduction in women and formulated the options for its improvement. The main clinical aspects of obstetric and gynecological pathologies are considered taking into account modern scientific data on their effective treatment and prophylaxis.

1 099 R




The main reasons for interrupting pregnancy, diagnosis, preparation tactics for pregnancy and basic principles of conducting and treatment during pregnancy is presented. Much attention is paid to such aspects as endocrine causes of pregnancy loss, including when sensitizing hormones.

2 150 R




880 R




The main genetic forms of thrombophilia and the mechanisms for the development of thrombosis and thromboembolism are described when previor. Pathogenetic mechanisms for the occurrence of thrombohemorrhagic complications in patients with disseminated intravascular coagulation syndrome, with dysplasia connective tissue, with malignant neoplasms.

2 350 R




Etiology, pathogenesis, clinic, diagnosis and treatment of sex glands caused by endocrine disorders are described. Modern data on the clinic, diagnosis and treatment of polycystic ovarian syndrome are summarized. Call issues related to pathogenesis, clinics, diagnosis and treatment of patients with climacteric syndrome and post-surveying syndrome.

1 990 R




Modern data on etiology, molecular pathogenesis, surgical and drug treatment of ovarian cancer. Genetic and epigenetic disorders change the epithelium of the ovaries, and a number of markers are revealed, which serve both diagnostic and prognostic factors under this disease.

1 090 R




Ultrasound, MRI, PET / CT. Uterus. Introduction and review of the anatomy of the uterus. Age changes. Atrophy endometrial. Congenital disorders. Anomalies for the development of muller ducts. Hypoplasia / Agnesia of the uterus. Single uterus. Uterus Didelphys. Curry uterus. Intrauterine partition. Saddle-like uterus. Uterine development anomalies associated with the effects of diethyl beastrol. Congenital cysts of uterus. Inflammation / infection

3 390 R




Not only malignant and benign neoplasms, but also background precancerous diseases, as well as bubble skid and trophoblastic disease are described. For each localization of tumors (milk iron, the uterine tube, the cervix, the body of the uterus, the ovary) in detail the clinic, diagnosis and possibility of surgical, dosage and radiation treatment.

750 R




The issues related to the modern principles of diagnosis, the peculiarities of clinical course, treatment and prevention of the most common in the obstetric practice of internal organs are considered.

The book discussed in detail epidemiology, risk factors, etiology, pathogenesis, as well as features of clinical manifestations and modern possibilities for the diagnosis of bacterial vaginosis. New variants of etiotropic and pathogenetic therapy, as well as the prevention of bacterial vaginosis are described.

2 440 R




Modern infertility data and outdoor genital endometriosis. The algorithms for the surgical treatment of external genital endometriosis and protocols for the use of argonoplasma coagulation are presented for the first time.

1 190 R




Demonstration of real anatomy and an accessible description of surgical techniques, the most important operational technical subtleties that are so necessary for the work of practicing surgeons.

11 900 R




The issues of preventing and correction of errors in the neoplasms of the ovaries at the treatment stages before entering a specialized oncological clinic are considered. The appropriateness of the use of a complex of morphological, morphometric and immunohistochemical studies to predict the recurrence of the ovarian border tumor is shown. The recommendations of the optimal monitoring for healing women, the possibilities of timely diagnosis and therapeutic measures during the recurrence of the tumor were proposed.

940 R




Modern data on etiology, pathogenesis, clinical flow, diagnosis and treatment of benign and border tumors of ovarian. The material is set out in accordance with the International Classification of Health Conditions and Problems.

Postpartum bleeding. Classification

Definition 1.

Postpartum bleeding is a loss of more than 0.5 liters of blood through the generic paths after childbirth and more than one liter after cesarean sections.

The blood loss in 500 ml in most cases is set to approximately, entails the underestimation of the true painting of blood loss. The physiological conditionally is considered to be blood loss up to 0.5% of the body weight of a woman.

Bleeding can develop after normal and pathological clans.

Strong blood loss leads to

• development of acute anemia in the woman in labor;
• violation of the functioning of vital organs (lungs, brain, kidneys);
• spasm of vessels of the front proportion of pituitary glands and the development of Shihan's syndrome.

Classification of bleeding in the postpartum period from the time of occurrence:

• early bleeding is manifested during the day after delivery;
• in the early postpartum period - two hours after childbirth;
• later, bleeding is manifested after 24 hours after delivery;
• in the late postpartum period - up to 42 days after childbirth.

The classification of the World Health Organization allocates the following types of bleeding:

• primary postpartum;
• secondary postpartum;
• delayed branch and placenta isolate.

Bleeding in the early postpartum period

Definition 2.

Bleedings arising in the early postpartum period are called pathological blood discharge from the genital organs of a woman within the first two hours after delivery. It is found in 2-5% of childbirth.

The main causes of the bleeding of the early postpartum period:

• hypotension and atony of the uterus;
• pathology of the coagulation system of blood, violation of hemostasis, coagulopathy;
• injuries of soft tissues of the generic canal;
• eranny drug administration of drugs (long-term reception of spasmolytic and tocolic drugs, anticoagulants, decagnegantes, massive solutions infusion).

Bleeding in late postpartum period

In the late postpartum period of bleeding occurs in two hours and within 42 days after childbirth. Most often late bleeding After childbirth, they appear in 7-12 days after delivery.

With a normal involution and normal state of the parental, the royal blood discharge in the postpartum period continues up to 3-4 days, they are dark and in moderate quantities. Survicious allocations are observed before the week.

The causes of late postpartum bleeding are diverse:

• violations of the epithelization processes of endometrial and involution of the uterus;
• benign or malignant diseases of the uterus (cervical cancer, submucosic uterine myoma);
• delay in the parts of the placenta in the uterus;
• reduced contractile ability of the uterus;
• incomplete rupture of the uterus;
• postpartum infections;
• failure of the scar after cesarean section;
• chorionepitheloma;
• placental polyp;
• congenital coagopathologists;
• delay in the uterus parts of the placenta;
• rejection after the birth of dead tissues;
• the discrepancy between the edges of the wound after cesarean section.

Clinical manifestations of late bleeding:

• blood discharge from the uterus, abundant or scanty, develop gradually, can be periodic or permanent;
• pains around the abdomen or lower belly - nunning, grapple-shaped, permanent or emerging periodically;
• when infected, sweating increases, headache, chills appears, the body temperature rises.

In case of massive bleeding, the DVS syndrome or hemorrhagic shock is developing. In the presence of an infectious process, tachycardia appear, the blood discharges acquire an unpleasant smell, pain at the bottom of the abdomen, the pledges of the fever.

For the prevention of postpartum bleeding, it is necessary to identify women at risk of bleeding:

• with an interpretation of the uterus;
• multiplying;
• abortion abortion;
• having congenital coagulopathy and inflammatory diseases of the genitals;
• with preeclampsia.

Bleeding in the last and early postpartum periods

What is bleeding in the last and early postpartum periods -

Bleeding in the last time (in the third period of birth) and in the early postpartum periods It may arise as a result of a violation of the processes of separation of the placenta and the selection of the lane, the reduction of the contractile activity of the myometrium (hypo- and atony of the uterus), traumatic damage to the generic pathways, violations in the hemo coagulation system.

Blood lodge up to 0.5% of body weight is considered physiologically admissible in childbirth. The volume of blood loss more than this indicator should be considered pathological, and the blood loss from 1% and is more qualified as massive. Critical loss Blood - 30 ml per 1 kg of body weight.

Hypotonic bleedingdue to the state of the uterus, in which there is a significant reduction in its tone and a significant decrease in contractile ability and excitability. In case of hypotension, myometriy reacts inadequately by the power of irritant on mechanical, physical and drug influences. This may occur periods of alternating reduction and restoration of the tone of the uterus.

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

However, from a clinical point of view, the division of postpartum bleeding on hypotonic and atonic should be considered conditional, since the medical tactics primarily depends not on what bleeding is, but from the massiveness of the bloodsture, the temperature of the bleeding, the effectiveness of conservative treatment, the development of the DVS syndrome.

What provokes / reasons for bleeding in the last and early postpartum periods:

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

• Physiology of postpartum hemostasis

The hemochorial type of placenta predetermines the physiological volume of blood loss after the branch of the placenta in the third period of childbirth. This volume of blood corresponds to the volume of intervalistic space, does not exceed 0.5% of the body weight of the woman (300-400 ml of blood) and is not reflected negatively in the state of the parent.

After separation of the placenta, it opens extensive, richly vascularized (150-200 spiral arteries) Subplascent, which creates a real risk of rapid loss of a large volume of blood. Postpartum hemostasis in the uterus is provided both by reducing the smooth muscle elements of myometrium and thrombosis in the placental vessels.

Intensive retraction of muscle fibers of the uterus after separating the placenta in the postpartum period contributes to the compression, twisting and retracting into the thickness of the muscle of spiral arteries. At the same time, the process of thrombosis is beginning, the development of which contributes to the activation of platelet and plasma factors of blood coagulation, and the influence of the elements of the fetal egg on the process of hemocoagulation.

At the beginning of the thrombosis, loose bunches are fragile with a vessel. They are easily removed and washed away with blood flow when developing uterine hypotension. Reliable hemostasis is achieved after 2-3 hours after the dense, elastic fibrin tombes are formulated, firmly associated with the vessel wall and closing their defects, which significantly reduces the risk of bleeding in the event of a decrease in the uterus tone. After the formation of such thrombus, the danger of bleeding decreases with a decrease in the toon of the myometrium.

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

• Violations of postpartum hemostasis

Violations in the hemochaguance system may be due to:

• changes to hemostasis before pregnancy;
• the hemostasis disorders in connection with the complications of pregnancy and childbirth (the antenatal death of the fetus and its long-term delay in the uterus, premature, premature detachment of the placenta).

Disturbances of the contractile ability of myometrium, leading to hypo-and atonic bleeding, are associated with different reasons and may occur both before the start of childbirth and occur during the delivery process.

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

• Factors caused by the peculiarities of the socio-biological status of the patient (age, socio-economic situation, profession, harmful addictions and habits).
• Factors caused by a premorbid background of pregnant.
• Factors caused by the features of flow and complications of this pregnancy.
• Factors associated with the features of the flow and complications of data data.

Consequently, the prerequisites for a decrease in the tone of the uterus before the start of childbirth can be considered the following:

• Age 30 years and older is the most threatened uterine hypotension, especially for primible women.
• The development of postpartum bleeding among students contributes large mental loads, emotional stress and overvoltage.
• The frequency of hypotonic bleeding parity does not have a decisive influence, since the pathological blood loss in primary originarian women is also observed as often as repeatedly.
• Violation of the function of the nervous system, vascular tone, endocrine balance, water-salt homeostasis (edema of myometrium) due to various extragenital diseases (the presence or aggravation of inflammatory diseases; pathology of cardiovascular, bronchopulmonary systems; diseases of the kidneys, liver, thyroid disease, sugar diabetes), gynecological diseases, endocrinopathies, violation of body metabolism, etc.
• Dystrophic, scar, inflammatory changes in myometrium, which caused the substantial part of the muscle tissue of the junction, due to complications after the previous birth and abortion, operations in the uterus (the presence of a scar in the uterus), a chronic and acute inflammatory process, uterine tumors (uterus mioma).
• The insufficiency of the neuromuscular apparatus of the uterus against the background of infantilism, the anomalies of the development of the uterus, the pitipofunction of the ovaries.
• Complications of the present pregnancy: Pelvic presence of the fetus, FPN, the threat of pregnancy interrupt, presence or low location of the placenta. The severe forms of late gestosis are always accompanied by hypoproteinemia, an increase in the permeability of the vascular wall, extensive hemorrhages in the tissue and internal organs. So, severe hypotonic bleeding in combination with gestosis are the cause of death in 36% of the feminine.
• Coloring the uterus due to a large fetus, multiple pregnancy, multi-way.

The most frequent causes of violation of the functional ability of myometrium, arising or aggravating in the process of birth are the following.

The depletion of the neuromuscular device of myometrium in connection with:

• overly intense generic activities (quick and rapid genera);
• discordination generic activity;
• the protracted flow of labor (weakness of labor);
• irrational administration of uterotonic drugs (oxytocin).

It is known that in the therapeutic doses, oxytocin causes short-term, rhythmic contraction of the body and the bottom of the uterus, does not have a significant effect on the tone of the lower segment of the uterus and quickly destroys oxytocinase. In this regard, its long-term intravenous drip administration is required to maintain the contractile activity of the uterus.

The long-term use of oxytocin for generage and relaxation can lead to the blockade of the neuromuscular uterus machine, resulting in its atony and further immunity to the means stimulating the reductions of the myometrium. The danger of embolism is increasing with spicy waters. The stimulating effect of oxytocin is less pronounced among more important women and women in the years older than 30 years. At the same time, sustainedness to oxytocin in patients with diabetes and with the pathology of the diancephal region.

Operational delivery. The frequency of hypotonic bleeding after the operational delivery is 3-5 times higher than after childbirth through natural generic paths. At the same time, hypotonic bleeding after operational delivery may be due to various reasons:

• complications and diseases served as the cause of operational delivery (weakness of generic activities, the prelation of placenta, prestal, somatic diseases, clinically narrow pelvis, native anomalies);
• stress factors due to the operation;
• the effect of painkillers that reduce the tone of myometrium.

It should be paid to the fact that with the operational delivery, not only increases the risk of developing hypotonic bleeding, but also creates prerequisites for the occurrence of hemorrhagic shock.

Defeat of the neuromuscular device of myometrium due to admission to vascular system Matters of thromboplastic substances with elements of a fetal egg (placenta, shells, accumulating waters) or infectious process products (chorioamnionitis). In some cases, the clinical picture caused by embolism by the accumulating waters, chorioamnionitis, hypoxia and other pathology may have erased, abortive character and manifests itself primarily by hypotonic bleeding.

Application in the process of generics of drugs that reduce the tone of myometrium (analgesic drugs, sedative and hypotensive drugs, tocolitics, tranquilizers). It should be noted that when the appointment of these and other drugs, during childbirth, as a rule, they do not always take into account their relaxing effect on the miometry tone.

In the last and early postpartum period, the decrease in the function of myometrium, with other circumstances, may be caused by:

• rude, forced leading of the entry and early postpartum period;
• dense attachment or increment of the placenta;
• delay in the uterus of the parts of the last.

Hypotonic and atonic bleeding can be caused by a combination of several listed causes. Then bleeding takes the most terrible character.

In addition to the listed risk factors for the development of hypotonic bleeding, their occurrence is also preceded by a number of shortcomings in conducting pregnant risk groups both in women's consultation and in the maternity hospital.

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

• discordination of generic activities (more than 1/4 observations);
• weakness of labor activities (up to 1/5 of observations);
• factors leading to the formation of uterus (large fruit, multi-way, multipleness) - up to 1/3 of observations;
• high injuries of generic pathways (up to 90% of observations).

The opinion on the unexpectedness of death in obstetric bleeding is deeply erroneous. In each particular case, a number of preventable tactical errors associated with insufficient observation and late and inadequate therapy are observed. The main errors, leading to the death of patients from hypotonic bleeding, are the following:

• incomplete examination;
• underestimation of the patient's condition;
• defective intensive therapy;
• late and inadequate replenishment of blood loss;
• time loss when using ineffective conservative ways to stop bleeding (often re-), and as a result - a late operation - the removal of the uterus;
• violation of the technique of operation (long operation, injury of neighboring organs).

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

Hypotonic or atonic bleeding is usually developing with certain preceding the complication of morphological changes in the uterus.

For histological research Pomes remote due to hypotonic bleeding, in almost all observations, there are signs of acute anemia after massive blood loss, which are characterized by pallor and dullness of myometrium, the presence of sharply extended gaping blood vessels, the absence of uniform elements of blood or the presence of leukocyte clusters due to the redistribution of blood.

In a significant number of drugs (47.7%), the patological rustling of the chorion village was revealed. At the same time, among muscle fibers, chorion vapors were found coated with sycitial epithelium, and single cells of the chorial epithelium. In response to the introduction of chorion elements, alien for muscle tissue, lymphocytic infiltration arises in the interlayer connectingly.

The results of morphological studies suggest that in a large number of cases of hypotension, the uterus is functional in nature, and the bleeding was prevented. However, as a result of traumatic guiding, long-term relatives, repeated

manual occurrences in the postpartum uterus, intensive massage "Matters on a fist" among muscle fibers there are a large number of erythrocytes with hemorrhagic impregnation elements, multiple micrographs of the uterus wall, which reduces the contractile ability of the myometrium.

Extremely adversely affect the contractile ability of the uterus chorioamnionit or endomyometrite in childbirth, found in 1/3 of observations. Among the incorrectly arranged muscle fibers in the emulsion tissue, abundant lympholooccitar infiltration is observed.

Characteristic changes are also the edema swelling of muscle fibers and the edema bursting of the interstitial tissue. The constancy of these changes indicates their role in the deterioration of the contractile ability of the uterus. These changes are most often due to obstetric and gynecological diseases in history, somatic diseases, gestosis leading to the development of hypotonic bleeding.

Therefore, often an infallible contractile function of the uterus is due to morphological disorders of the myometrium, which arose due to transferred inflammatory processes and the pathological flow of real pregnancy.

And only in single observations, hypotonic bleeding develops due to organic uterine diseases - multiple misa, extensive endometriosis.

Symptoms of bleeding in the last and early postpartum periods:

Bleeding last period

The uterus hypotension often begins in the last period, which has a longer current. Most often in the first 10-15 minutes after the birth of the fetus, there is no intensive cuts of the uterus. With an external study of the uterus, a flabby. Its upper border is at the navel level or significantly higher. It should be emphasized that the sluggish and weak contractions of the uterus during its hypotension do not create proper conditions for the retraction of muscle fibers and the rapid branch of the placenta.

Bleeding in this period occurs if partial or complete placenta compartment occurred. However, it is usually not permanent. Blood is highlighted in small portions, more often with clots. When separating the placenta, the first portions of blood accumulate in the uterine cavity and in the vagina, forming a bunch, which are not distinguished due to the weak contractile activity of the uterus. Such a cluster of blood in the uterus and in the vagina often can create a false idea of \u200b\u200bthe absence of bleeding, as a result of which the relevant therapeutic measures can be initiated with a delay.

In some cases, bleeding in the last period may be due to the delay in the separated placenta due to the infringement of its part in the rog of the uterus or the cervical spasm.

Spazm of the cervix arises due to the pathological reaction sympathetic department Pelvic nervous plexus in response to the injury of the tricky ways. The presence of a placenta in the uterus in the normal excitability of its neuromuscular apparatus leads to a strengthening of abbreviations, and if there is an obstacle to the selection of the last due to the spasm of the cervix, the bleeding occurs. The removal of the spasm of the cervix is \u200b\u200bpossible by applying antispasmodic preparations with the subsequent release of the last. Otherwise, followed by anesthesia manual selection The last with the revisions of the postpartum uterus.

Violations of the selection of the lane are most often due to unreasonable and rude manipulations with the uterus with a premature attempt to discharge the last or after the introduction of large doses of uterotonic drugs.

Bleeding due to pathological attachment placenta

The decidual shell is a functional layer of endometrial changed during pregnancy and in turn consists of a basal (located under the implanted fetal egg), capsular (coats the fruit egg) and the parietal (the rest of the decidual shell, lining the uterus) departments.

In the basal decidual shell differ compact and sponge layers. From the compact layer, located closer to the chorion, and the cytotrofoblast porsyl is formed by a basal plate of the placenta. Separate chorion navigations (anchor vests) penetrate the sponge layer, where they are fixed. In the physiological separation of the placenta, it takes place from the wall of the uterus at the level of the spongy layer.

The violation of the placenta separation is most often due to its dense attachment or increment, and in more rare cases by rustling and germination. The basis of these pathological conditions is a pronounced change in the structure of the spongy layer of the basal decidual shell or partial or its complete absence.

The pathological changes of the spongy layer may be due to:

• transferred previously inflammatory processes in the uterus after childbirth and abortion, specific lesions of the endometrium (tuberculosis, gonorrhea, etc.);
• hypotrophy or endometrial atrophy after surgical interventions (cesarean cross section, conservative momectomy, scraping of the uterus, manual separation of the placenta in previous births).

Implantation of the fetal eggs in areas with physiological hypotrophyroid endometrium is also possible (in the variety and cervical cervical). The probability of pathological attachment of the placenta increases with the vices of the uterus (partition in the uterus), as well as in the presence of submembratous myomatous nodes.

Most often there is a dense attachment of the placenta (Placenta Adhaerens), when the chorion vapors are firmly strange with a pathologically changed underdeveloped spongy layer of the basal decidual shell, which entails a violation of the placenta separation.

The partial tight attachment of the placenta (Placenta Adhaerens Partialis) is distinguished when only individual shares have a pathological nature of attachment. Less often meets the complete density attachment of the placenta (Placenta Adharens Totalis) - throughout the area of \u200b\u200bthe placental area.

The increment of the placenta (PLACENTA ACCRETA) is due to the partial or complete absence of the sponge layer of the decidual shell due to atrophic processes in the endometrium. At the same time, the chorion vapors are adjusted directly to the muscle shell or sometimes penetrate into its thickness. There are partial placenta increments (Placenta Accreta Partialis) and full increment (Placenta Accreta Totalis).

Significantly, such terrible complications are significantly less common (Placenta Increta), when the chorion vapors penetrate the myometrium and violate its structure, and germination (PLACENTA Percreta) to the miometry to a significant depth, up to visceral peritoneum.

With these complications, the clinical picture of the placenta separation process in the third period of generation depends on the degree and nature (full or partial) disorders of the attachment of the placenta

With a partial dense attachment of the placenta and with a partial increment of the placenta due to its fragmentary and uneven compartment, there is always a bleeding, which begins with the time of separation of the normally attached placenta sections. The degree of bleeding depends on the violation of the contractile function of the uterus at the place of attachment of the placenta, since part of the myometrium in the projection of the inseparable parts of the placenta and in the nearby portions of the uterus is not reduced to the proper extent, as required to stop bleeding. The degree of reducing the reduction varies widely, which determines the clinic of bleeding.

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

With the full density attachment of the placenta and the fully increment of the placenta and the absence of the violent separation from the wall of the uterus, the bleeding does not occur, since the integrity of intervalic space is not disturbed.

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 tubular corner of the cough and twin uterus.

With a dense attachment of the placenta, as a rule, always manages to completely separate and remove all the shares of the placenta and stop the bleeding.

In the event of an increment of the placenta when trying to produce its manual compartment, abundant bleeding occurs. The placenta is cut off with pieces, completely from the wall of the uterus is not separated, part of the placenta shares remains on the wall of the uterus. Athron bleeding, hemorrhagic shock, DVS syndrome, are rapidly developed. In this case, only removal of the uterus is possible to stop bleeding. A similar way out of the current situation is also possible during rustling and sprouting the vicest in the thickness of the myometrium.

Bleeding due to the delay of the parts of the last in the uterine cavity

In one of the options, postpartum bleeding, which begins, as a rule, immediately after the selection of the last, may be due to the delay in its parts in the uterine cavity. It may be a loss of placenta, part of the shell, which impede the normal reduction in the uterus. The reason for the latency of the parts is most often partial increment of the placenta, as well as the incorrect maintenance of the third birth period. With a thorough examination of the last after birth, the defect of the placenta tissues, shells, the presence of broken vessels located along the edge of the placenta is revealed without much difficulty. Detection of such defects or even doubt in the integrity of the lane serves as an indication of the urgent manual study of the postpartum uterus with the removal of its contents. This operation is performed even if there is no bleeding with a defect defect, since it will definitely appear later.

It is unacceptable to produce the scraping of the uterine cavity, this operation is very traumatic and disrupts the processes of thrombosis in the vessels of the placental site.

Hypo- and atonic bleeding in the early postpartum period

In most observations in the early postpartum period, bleeding begins as hypotonic, and only in the subsequent developing atony of the uterus.

One of clinical criteria The differences of atonic bleeding from hypotonic is the effectiveness of measures aimed at strengthening the contractile activity of myometrium, or the lack of effect on their application. However, such a criterion does not always allow to clarify the degree of violation of the contractile activity of the uterus, since the ineffectiveness of conservative treatment may be due to a severe violation of the hemochaguance, which becomes the leading factor in a number of cases.

Hypotonic bleeding in the early postpartum period is often a consequence of continuing uterine hypotension observed in the third period of birth.

It is possible to allocate two clinical options for the uterus hypotension in the early postpartum period.

Option 1:

• bleeding from the very beginning abundant, accompanied by massive blood loss;
• the uterus is flabby, sluggishly reacts to the introduction of uterotonic means and manipulations aimed at improving the contractile ability of the uterus;
• hypovolemia quickly progresses;
• hemorrhagic shock and DVS syndrome are developing;
• changes in vital bodies of the parental are irreversible.

Option 2:

• initial blood loss small;
• repeating bleeding (blood is highlighted by portions of 150-250 ml), which alternate with the episodes of temporary restoration of the uterine tone with the cessation or weakened bleeding in response to conservative treatment;
• there is a temporary adaptation of the parent's for developing hypovolemia: blood pressure remains within normal values, there is some pallor of skin and minor tachycardia. Thus, with a large blood loss (1000 ml or more) over a long time, the symptoms of acute anemia are less pronounced, and the woman copes with a similar state better than when a rapid blood loss in the same or even smaller quantities when a collapse can develop and death can be developed faster.

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

In case of insufficient treatment, in the initial period of the hypotension, the uterus of the violation of its contractile activity is progress, and the reaction to therapeutic measures weakens. At the same time, the volume and intensity of blood loss increases. At a certain stage, the bleeding is significantly enhanced, the state of the feminine is deteriorating, the symptoms of hemorrhagic shock are rapidly increasing and joins the DVS syndrome, reaching the phase of hypocoagulation.

The indicators of the hemochaguing system are changed, indicating the pronounced consumption of coagulation factors:

• the number of platelets is reduced, fibrinogen concentration, factor activity VIII;
• protromine and thrombin time consumption increase;
• fibrinolytic activity increases;
• fibrin and fibrinogen degradation products appear.

With insignificant initial hypotension and rational treatment Hypotonic bleeding can be stopped for 20-30 minutes.

With severe uterine hypotension and primary disorders in the hemokoagulation system, in combination with the combination of KV-syndrome, the duration of bleeding increases and the forecast is worse due to the considerable complexity of treatment.

Under Atony, the uterus is soft, flaky, with poorly defined contours. The bottom of the uterus comes to a sword-shaped process. Basic clinical symptom It is continuous and abundant bleeding. The larger the area of \u200b\u200bthe placental site, the more abundant blood loss in atony. Hemorrhagic shock is developing very quickly, complications of which (polyorgan deficiency) and cause fatal outcome.

With a pathologist study, acute anemia, hemorrhage under endockard, sometimes significant hemorrhages in the field of small pelvis, swelling, full-blooded and atelectasis of the lungs, dystrophic and necrobiotic changes in the liver and kidneys.

Differential diagnosis of bleeding in the hypotension of the uterus should be carried out with traumatic damage to the body channels. In the latter case, bleeding (different intensity) will be observed with a dense, well reduced uterus. The existing damage to the tissues of the generic channel is detected when inspection using mirrors and eliminate appropriately with adequate anesthesia.

Treatment of bleeding in the last and early postpartum periods:

Leading the late period when bleeding

• An expectancy-active launching tactic should be followed.
• The physiological duration of the lateral period should not exceed 20-30 minutes. After this time, the probability of independent separation of the placenta decreases to 2-3%, and the possibility of the development of bleeding increases sharply.
• At the time of rubbering head, the feminine is intravenously administered with 1 ml of methyl ergometr on a 20 ml of 40% glucose solution.
• Intravenous administration of methyl ergometrine causes a long (for 2-3 hours) the normal contraction of the uterus. In modern obstetrics, methyl ergometrine is a drug to choose to conduct medicine prevention in childbirth. The time of its introduction should coincide with the moment of emptying of the uterus. Intramuscularly to introduce methyl ergometrin for prevention and stopping bleeding does not make sense due to the loss of time factor, since the drug begins to be absorbed only after 10-20 minutes.
• Perform the catheterization of the bladder. At the same time, it often increasing the increase in the uterus, accompanied by the placenta separation and the selection of the last.
• An intravenously begins to enter 0.5 ml of methyl ergometric, together with 2.5 erux oxytocin in 400 ml of 5% glucose solution.
• At the same time start infusion therapy For adequate replenishment of pathological blood loss.
• Determine the signs of the branch of the placenta.
• With the appearance of signs of separation, the placenta is released with one of the known methods (Abuladay, Credit-Lazarevich).

It is unacceptable for the re-repeated use of external receptions of the selection of the lane, as 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 binder of the uterus and its other anatomical changes, the coarse use of such techniques can lead to a twist of the uterus accompanied by heavy shock.

• In the absence of signs of separation of the placenta after 15-20 minutes, with the introduction of uterotonic drugs or in the absence of an effect on the use of external methods of selection of the latch, it is necessary to make a manual separation of the placenta and the selection of the last. The appearance of bleeding in the absence of signs of separation of the placenta serves as an indication of this procedure, regardless of the time after the birth of the fetus.
• After separation of the placenta and the removal of the lane, the inner walls of the uterus are examined to eliminate additional fractions, the remains of placental fabric and shells. Simultaneously remove cloth bunches of blood. The manual separation of the placenta and the selection of the last, not even accompanied by a large blood loss (the average blood loss of 400-500 ml), lead to a decrease in the BCC by an average of 15-20%.
• When identifying signs of increment, the placenta attempts to its manual separation should be immediately discontinued. The only method of treating this pathology is the extirpation of the uterus.
• If the tone of the uterus after the manipulation is not restored, it is additionally introduced by uterotonic means. After the uterus decreases, the hand is removed from the uterus.
• In the postoperative period, control over the state of the uterus tone and continue the introduction of uterotonic drugs.

Treatment of hypotonic bleeding in the early postpartum period

The main feature determining the outcome of genera in postpartum hypotonic bleeding is the volume of lost blood. 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 before the observation of blood loss is from 600 to 1500 ml, in 16-17% of blood loss from 1500 to 5000 ml and more.

Treatment of hypotonic bleeding is primarily aimed at restoring sufficient contractual activity of myometrium against the background of adequate infusion-transfusion therapy. If possible, it is necessary to establish the cause of hypotonic bleeding.

The main tasks in the fight against hypotonic bleeding are:

• major stopping bleeding;
• preventing the development of massive blood loss;
• restoration of the BCC deficiency;
• prevent reduction arterial pressure Below the critical level.

In the event of hypotonic bleeding in the early postpartum period, it is necessary to adhere to the strict sequence and the stages of the events held to stop bleeding.

The scheme of combating hypotension of the uterus consists of three stages. It is designed for continuing bleeding, and if the bleeding was able to stop at a certain stage, the effect of the scheme is limited to this step.

First stage.If blood loss exceeded 0.5% of the body weight (on average 400-600 ml), then proceed to the first step of combating bleeding.

The main tasks of the first stage:

• stop bleeding, not allowing greater blood loss;
• provide adequate in time and volume of infusion therapy;
• carry out accurate records of blood loss;
• do not allow a deficiency of reimbursement of blood loss more than 500 ml.

Events of the first step of combating hypotonic bleeding

• Emptying bladder catheter.
• The dosage of the careful outer massage of the uterus is 20-30 s after 1 min (with massage, coarse manipulations leading to the massage flow of thromboplastic substances in the blood flow of the mother should be avoided). The outer massage of the uterus is carried out as follows: Through the front abdominal wall, the bottom of the uterus is covered with palms of the right hand and produce circular massaging movements without the use of force. The uterus becomes dense, blood clot, accumulated in the uterus and preventing it with reduction, remove with cautious pressing on the bottom of the uterus and continue massage until the uterus is completely reduced and bleeding will not stop. If, after the massage, the uterus is not reduced or shrinking, and then relaxed again, they go to further events.
• Local hypothermia (applying an ice bubble for 30-40 minutes with an interval of 20 minutes).
• Puncture / catheterization of trunk vessels for infusion-transfusion therapy.
• Intravenous drip administration of 0.5 ml methyl ergometrine with 2.5 ergoxitocin in 400 ml of 5-10% glucose solution at a speed of 35-40 drops / min.
• Replenishment of blood loss in accordance with its volume and the reaction of the body.
• At the same time, a manual study of the postpartum uterus is produced. After processing the outdoor genital bodies of the parental and the hands of the surgeon, under general anesthesia, hand introduced into the uterine cavity, examine it the walls to exclude injury and delayed the rest of the last; Remove blood clots, especially intricate, preventing the reduction in the uterus; conduct a revision of the integrity of the walls of the uterus; The vicoity of the uterus or the uterus tumor should be excluded (myomatous node is often the cause of bleeding).

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

With a manual study, a biological sample is performed on a reduction in which 1 ml of 0.02% methyl ergometrine solution is administered intravenously. If there is an effective reduction that the doctor feels his hand, the result of treatment is considered positive.

The effectiveness of the hand-held examination of the postpartum uterus is significantly reduced depending on the increase in the duration of the uterine hypotension period and the volume of blood loss. Therefore, it is advisable to perform this operation at an early stage of hypotonic bleeding at an early stage, immediately after the lack of effect from the use of uterotonic means is established.

A manual study of the postpartum uterus has another important advantage, as it makes it possible to reveal the uterus break, which in some cases the picture of hypotonic bleeding can be hidden.

• Inspection of the generic paths and sewing of all the gaps of the cervix, the walls of the vagina and the crotch, if any. The ketgutic transverse seams are imposed on the rear wall of the cervix close to the inner zev.
• Intravenous administration of the vitamin and 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.

Do not count on the effectiveness of the re-manual study and the massage of the uterus, if during the first application it was not achieved due effect.

To combat hypotonic bleeding, such treatment methods such as the imposition of clamps per parameteric for compressing the uterine vessels, terminaling of the lateral portions of the uterus, tamponade of the uterus, etc. In addition, they do not belong to pathogenetically reasonable treatment methods and do not provide reliable hemostasis, their use leads to loss of time and late use really required methods Stop bleeding, which contributes to the increase in blood loss and severity of hemorrhagic shock.

Second phase.If bleeding was not stopped or resumed again and is 1-1.8% of body weight (601-1000 ml), then one should go to the second step of combating hypotonic bleeding.

The main tasks of the second stage:

• stop the bleeding;
• prevent greater blood loss;
• avoid deficiency of blood loss;
• maintain the volumetric ratio of blood injected and blood substitutes;
• prevent compensated blood loss in decompensated;
• normalize the rheological properties of blood.

Events of the second phase of combating hypotonic bleeding.

• In the edge of the uterus through the front abdominal wall at 5-6 cm above the uterine zoom, 5 mg is introduced in 4 mg of E2 or proposed, which contributes to a long-term efficient reduction in the uterus.
• Intravenously drip 5 mg in 400 ml of crystalloid mortar diluted in 400 ml of crystalloid solution. It should be remembered that the long and massive use of uterotonic tools may be ineffective with continuing massive bleeding, since the hypoxic uterus ("shock uterus") does not respond to injected lobster substances in connection with the depletion of its receptors. In this regard, the primary measures for massive bleeding are the replenishment of blood loss, elimination of hypovolemia and hemostasis correction.
• Infusion-transfusion therapy is carried out at a temperature of bleeding and in accordance with the state of compensatory reactions. Blood components are introduced, plasma-substituting oncotically active drugs (plasma, albumin, protein), colloid and crystalloid solutions, isotonic blood plasma.

At this stage of combating bleeding with blood loss, approaching 1000 ml, you should deploy operational, prepare donors and be prepared for emergency exercise. All manipulations are carried out under adequate anesthesia.

With restored OCC shown intravenous administration 40% solution of glucose, corgal cryligar, Pangin, Vitamins C, B1 B6, Cocarboxylase hydrochloride, ATP, as well as antihistamine preparations (DIDEDROL, Supratin).

Third stage.If bleeding was not stopped, the blood loss reached 1000-1500 ml and continues, the general state of the parental worsened, which manifests itself in the form of a rack of tachycardia, arterial hypotension, then it is necessary to start the third stage, stopping postpartum hypotonic bleeding.

A feature of this stage is an operational intervention in order to stop hypotonic bleeding.

The main tasks of the third stage:

• stop bleeding by removing the uterus until the development of hypocoagulation;
• prevention of a deficiency of reimbursement of blood loss of more than 500 ml while maintaining the volumetric ratio of injected blood and blood substitutes;
• timely compensation of respiratory function (IVL) and kidney, which allows you to stabilize hemodynamics.

Events of the third stage of combating hypotonic bleeding:

With unexpected bleeding, they intubate the trachea, the IVL begin and proceed to waste under endotracheal anesthesia.

• Removal of the uterus (extirpation of the uterus with royal pipes) Perform on the background of intensive comprehensive treatment using adequate infusion transfusion therapy. Such a volume of operation is due to the fact that the wound surface of the uterus cervix may be a source of intra-abdominal bleeding.
• In order to provide surgical hemostasis in the area of \u200b\u200boperational intervention, especially against the background of the engine, the internal ileum arteries are suspended. Then the pulse pressure in the nest pelvis vessels drops by 70%, which contributes to a sharp decrease in blood flow, reduces bleeding from damaged vessels and creates conditions for fastening the thrombus. Under these conditions, the extirpation of the uterus is carried out in "dry" conditions, which reduces the overall size of blood loss and reduces the injection of thromboplast substances into systemic blood flow.
• During the operation, the abdominal cavity should be drained.

Drafted patients with decompensated blood loss, the operation is carried out in 3 stages.

First stage. Lapotomy with temporary hemostasis by imposing terminals for trunk uterine vessels (ascending part uterine artery, ovarian artery, round ligament artery).

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

Third stage. Radical bleeding stop - extirpation of uterus with uterine pipes.

At this stage of the struggle against blood loss, active multicomponent infusion transfusion therapy is necessary.

Thus, the basic principles of combating hypotonic bleeding in the early postpartum period are the following:

• all events start as early as possible;
• take into account the initial health status of the patient;
• strictly observe the sequence of measures to stop bleeding;
• all therapeutic measures carried out must be comprehensive;
• eliminate the reuse of the same methods of combating bleeding (repeated manual entry into the uterus, shifting clamps, etc.);
• apply modern adequate infusion transfusion therapy;
• use only intravenous method the introduction of drugs, since in the current circumstances, the absorption in the body is sharply reduced;
• timely decide the question of operational intervention: The operation should be carried out before the development of thrombohemorrhagic syndrome, otherwise it often does not save the pledges from the deadly outcome;
• to prevent reduction in blood pressure below the critical level for a long time, which can lead to irreversible changes in vital organs (large brain, kidney, liver, heart muscle).

Binding of internal ileal artery

In some cases, it is not possible to stop bleeding at the area of \u200b\u200bthe cut or pathological process, and then the need arises in the dressing of the main vessels that feed this site at some distance from the wound. In order to understand how to perform this manipulation, it is necessary to remind the anatomical features of the structure of those areas where vascular ligation will be produced. First of all, it should be stopped on the dressing of the main vessel supplying the genital organs of a woman, an internal ileal artery. Abdominal Aorts at the level of the vertebra Liv is divided into two (right and left) common iliac artery. Both general iliac artery are directed from the middle of the outside and the book on the inner edge of the large lumbar muscle. In front of the sacrator, the overall iliac artery is divided into two vessels: thicker, outdoor iliac artery, and a thinner, internal iliac artery. Then the internal iliac artery goes vertically down, to the middle of the posterior wall of the cavity of the small pelvis and, reaching a large sedlication hole, is divided into the front and rear branches. From the front branch of the inner iliac artery: internal genital artery, uterine artery, umbilical artery, lower urochroom artery, middle recycling artery, lower berry artery, supplying the blood organs of a small pelvic. From rear branch The internal ileal artery moves the following artery: iliac-lumbar, lateral sacral, locking, upper berical, carrying out blood supply to the walls and muscles of the small pelvis.

The dressing of the internal ileum artery is most often produced by damage to the uterine artery during hypotonic bleeding, the breaking of the uterus or extended extirpation of the uterine with appendages. To determine the location of the internal iliac artery uses a cape. Approximately 30 mm away from it the borderline crosses the inner iliac artery, descending into the cavity of a small pelvic with a ureter along the sacratsoy-iliac joint. To ligate the inner iliac artery, the rear parietal peritoneum dissect from the cape a book and outward, then with the help of a tweezers and a groove probe, a stupid way is separated by a general iliac artery and, descending on it, they find the place of its division on the outdoor and internal iliac artery. Above this place stretches from top to bottom and outside the light of the bright ureter, which is easy to learn about pink color, the ability to shrink (peristalistic) when touched and publish a characteristic clapping sound when slipping out of fingers. The ureter is distinguished by medially, and the inner iliac artery is immobilized from the connective tissue of the shell, tied by a ketguade or lavsano ligature, which is supplied under the vessel with the help of a stupid needle of the dechann.

To bring the needle of Deshans very carefully, so as not to damage it by the tip of the concomitant inner iliac venu, passing at this site on the side and under the eponymous artery. It is desirable to impose a ligature at a distance of 15-20 mm from the place of dividing the total iliac artery into two branches. Susty, if not all the inner iliac artery is tied up, but only its front branch, but its allocation and summing up the threads are technically more difficult for it than to ligate the main trunk. After summing up the ligature under the inner iliac artery, the Escharan is pulling back, and the thread is tied.

After that, the doctor present on the operation checks the pulsation of the arteries on lower limbs. If there is a pulsation, the internal iliac artery is shifted and the second node can be tied; If the pulsation is absent, then, it means, the outer iliac artery is ligated, so the first node must be unleashed and again to look for an internal iliac artery.

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

• between the ileum-lumbar arteries that are separated from the rear trunk of the internal ileum artery, and lumbar arteries that are branched off from the abdominal part of the aorta;
• between lateral and median sacral arteries (the first departs from the rear trunk of the inner iliac artery, and the second is the unpaired branch of the abdominal part of the aorta);
• between the average rectifying artery, which is the branch of the inner iliac artery, and the upper straightformer artery, departing from the lower mesenteric artery.

With the correct dressing 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 the case of inadequately low ligation of the internal ileal artery. Strict bilateralness of the anastomoses allows one to carry out a one-sided dressing of the internal iliac artery when the uterine breaks and damage to its vessels on the one hand. A. T. Bunin and A. L. Gorbunov (1990) believe that when the internal iliac artery is lining, the blood enters it through the anastomoses of the ileum-lumbar and lateral sacratsum arteries, in which the flow of blood acquires the opposite direction. After the dressing of the internal ileal artery, the anastomoses immediately begin, but the blood passing through small vessels, loses its arterial rheological properties and is approaching venous in its characteristics. In the postoperative period, the anastomosis system ensures adequate blood supply to the uterus, sufficient for the normal development of subsequent pregnancy.

Prevention of bleeding in the last and early postpartum periods:

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

Rational maintenance of pregnancy, prevention and treatment of the complications arising. When making a pregnant woman registered in the women's consultation, it is necessary to allocate a group of high risk in the possibility of developing bleeding.

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

During pregnancy, it is necessary to strive to preserve the physiological flow of the gestational process.

In women, the risk group for bleeding preventive actions in outpatient conditions Enclosed in organizing a rational regime of recreation and nutrition, conducting health procedures aimed at increasing the neuropsychic and physical stability of the body. All this contributes to the favorable course of pregnancy, childbirth and postpartum period. Do not neglect the method of physiopsychophylactic woman preparation for childbirth.

Throughout the pregnancy, careful monitoring of its flow is carried out in a timely manner and eliminate possible violations.

All pregnant risk groups for the development of postpartum bleeding to implement the final stage of complex prenatal preparation 2-3 weeks before delivery should be hospitalized to the hospital, where a clear plan of childbirth is developed and appropriate addresses pregnant.

In the process of examination, the condition of the fetoplacentar complex is estimated. With the help of ultrasound, the functional state of the fetus is studied, the location of the placenta, its structure and dimensions determine. Evaluation of the state of the patient hemostasis system deserves serious attention. In advance, the blood components should also be prepared for possible transfusion, while using outodonorming methods. In the hospital, it is necessary to highlight the group of pregnant women to perform cesarean section in a planned manner.

To prepare the body for childbirth, the prevention of the anomalies of generic activities and prevent the increased blood loss, closer to the intended date of delivery, it is necessary to prepare the body for childbirth, including using the drugs of Prostaglandin E2.

A qualified guidance of childbirth with a reliable assessment of the obstetric situation, the optimal regulation of generic activities, adequate anesthesia (long-term pain depletes the backup forces of the body and disrupts the contractile function of the uterus).

All childbirth should be conducted under cardiomonitorial control.

In the process of conducting birth through natural generics, it is necessary to follow:

• character contractual activity uterus;
• compliance with the size of the preemptive part of the fetus and the pelvis;
• promotion of the preemptive part of the fetus in accordance with the pelvic planes in various phases of labor;
• the state of the fetus.

In the event of anomalies of generic activity, they should be eliminated in a timely manner, and in the absence of the effect, it is decided to resolve the issue in favor of operational delivery in accordance with the relevant testimony in an emergency order.

All uterotonic drugs must be prescribed strictly differentiated and by readings. At the same time, the patient should be under the strict control of doctors and medical personnel.

Proper maintenance of lateral and postpartum periods with the timely use of uterotonic drugs, including methyl ergometrine and oxytocin.

At the end of the second period of genera, 1.0 ml of methyl ergometrine is introduced intravenously.

After the birth of the child, the bladder catheter is empty.

Careful observation of the patient in the early postpartum period.

When the first signs of bleeding, it is necessary to strictly adhere to the stratitude of the measures to combat bleeding. An important factor in the provision effective help With massive bleeding, a clear and specific distribution of functional duties among the entire medical personnel of the obstetric department is. All boring institutions should have sufficient stocks of blood components and blood substitutes for adequate infusion-transfusion therapy.

What doctors should be contacted if you have bleeding in the last and early postpartum periods:

Does something bothers you? Do you want to learn more detailed information about bleeding in the last and early postpartum periods, its causes, symptoms, methods of treatment and prevention, course the course of the disease and observance of the diet after it? Or do you need an inspection? You can make an appointment to the doctor - Clinic Euro.lab always at your service! The best doctors will examine you, learn external signs and will help determine the disease in symptoms, you will advise you and provide the necessary assistance and make a diagnosis. you also can call a doctor. Clinic Euro.lab Opened for you around the clock.

How to contact the clinic:
Phone of our clinic in Kiev: (+38 044) 206-20-00 (multichannel). The secretary of the clinic will select you a convenient day and an hour of visiting to the doctor. Our coordinates and travel scheme are indicated.

Bleeding last period

The causes of bleeding in the third birth period are:

1) violation of separation and selection of the lastness of the uterus;

2) injuries of soft tissues of tribal tract;

3) hereditary and acquired hemostasis disorders.

A special role in the delayed branch of the placenta is played by various types of pathological attachment of the placenta to the wall of the uterus: a dense attachment (Placenta Adhaerens)full or partial (Fig. 60), true increment (PLACENTA ACCRETA)full or partial. The complete increment of the placenta is extremely rare.

The most commonly occurred pathological attachment of the placenta, its dense attachment, when there is a pathological change in the spongy layer of the decidual shell, in which the placenta is separated from the physiological genus. As a result of inflammatory or different

Fig. 60.Partial dense attachment of the placenta

dystrophic changes The sponge layer of Rubtsovo is reborn, because of the tissue rupture in it in the III period of birth is impossible, and the placenta is not separated.

In some cases, the change in the decidual shell is expressed significantly, the compact layer is undeveloped, spongy and basal layers are atrophy, there is no fibrinoid degeneration zone. In such circumstances, Kelheidones (one or more) placenta will directly go to the muscle layer of the uterus (Placenta Accreta)or sometimes penetrate into its thickness. In this case, we are talking about true increment. Depending on the degree of rustling, the vehicle in the muscular membrane is distinguished placenta Increta,when she germinates muscular layer, I. placenta Percreta.- germination of navy muscles and serous layer of the uterus. The probability of the increment of the placenta increases when it is arranged in the postoperative scar, or in the lower segment of the uterus, as well as in the defects of the uterus, the uterine neoplasms.

Recognition of the forms of pathological attachment of the placenta is possible only with a manual study of the uterus in order to separate the placenta. If there is a dense attachment of the placenta, it is usually possible to remove all its shares by hand. With the true increment of the placenta, it is impossible to separate the placenta from the wall of the uterus without disturbing the integrity of the uterus. Often, the true increment of the placenta is established in the pathorphological and histological examination of the uterus.

The breakdown and selection of the post may be caused by the place of attachment of the placenta: in the lower uterine segment, in the corner or on the side walls of the uterus, on the partition, where muscles are less complete, and sufficient contractual activity required to separate the placenta cannot develop.

The cause of bleeding may be not only a violation of the placenta separation, but also a violation of the selection of the lane, which is observed in the discordination of the cutting of the uterus. At the same time, a delay of the already separated placenta in the uterus is possible due to infringement of it in one of the uterine angles or in the lower segment due to their abbreviation and spasm. The uterus often acquires the shape of the "hourglass", which makes it difficult to highlight the last.

This pathology is observed with improper postpartum period. Untimely, unnecessary manipulations,

caustit of the uterus or coarse control over the placenta separation, uterus massage, attempts to squeezing the penis-lazarevich, in the absence of signs of the placenta separation, attraction for umbilical cord, the introduction of large doses of uterotonic drugs may violate the physiological flow of the 3rd generation period. With premature squeezing of the uterus, the retroplated hematoma is squeezed with a hand, which in the norm contributes to the placenta separation.

Clinical picture.In disruption of the placenta and selection of the post, bleeding from the genital tract appears. Blood flows out as if jolts, temporarily suspending, sometimes the blood accumulates into the vagina, and then released by clots; bleeding is enhanced by applying outdoor methods of separation of the placenta. Blood delay in the uterus and in the vagina creates a false idea of \u200b\u200bthe absence of bleeding, as a result of which measures aimed at identifying and stopping are delayed. With an external study of the uterus, there are no signs of the separation of the termination. The general state of the feminine is determined by the degree of blood loss and can change quickly. In the absence of timely assistance, hemorrhagic shock develops.

Bleeding is sometimes due to injury of soft tissues of the tribute. Such more often are observed when breaking or bundle tissue of the cervical cervix, when they fall in the sprigs of cervical vessels. Bleeding at the same time starts immediately after the birth of a child, it may be massive and contribute to the development of hemorrhagic shock and the death of the guinea, if it is not recognized in a timely manner. Rales in the clitoris area where there is a large network of venous vessels is also often accompanied by strong bleeding. It is also possible to bleeding from the walls of the vagina, from the damaged veins. The ruptures of the perineum or walls of the vagina rarely cause massive bleeding if the large vessels of the branch are not damaged a. Vaginalis.or a. Pudenda.The exceptions are high gaps of the vagina, penetrating the vaults.

In the absence of signs of the placenta separation within 30 minutes, against the background of the introduction of reduction funds, a manual separation of the placenta is produced and the selection of the lapse under anesthesia (Fig. 61).

If you suspect the true increment of the placenta, it is necessary to stop attempting to separate it and make amputation, extirpation or resection of the germination site.

Fig. 61.Manual placenta compartment and post

Carefully examine the walls of the uterus to identify additional fractions, residues of placental tissue and shells. At the same time, blood clots are removed. After removal of the last, the uterus is usually reduced, tightly wrapped the hand. If the uterus tone is not restored, it is additionally introduced with uterotonic drugs, an outer-ended dosage massage of the uterus on a fist is produced.

If you suspect the true increment of the placenta, it is necessary to stop separating it and make an amputation or extirpation of the uterus. The consequences of excessive zeal when trying to remove the placenta can be massive bleeding and uterine break.

Diagnostics.Main clinical manifestations: bleeding occurs immediately after the birth of a child; Despite the bleeding, the uterus is dense, well shortening, the blood flows out of the genital paths of a liquid bright color.

Treatment.Therapeutic activities should be clearly aimed at separating the placenta and the allocation of the pen.

Sequence of measures during bleeding in the third birth period

1. The catheterization of the bladder.

2. Puncture or catheterization of the elbow vein.

3. Definition of signs of the placenta separation:

1), with positive features, they allocate the post of credential-Lazarevich or Abuladay;

2) In the absence of an effect from the use of external methods of selection of the lane, it is necessary to produce a manual separation of the placenta and the selection of the last.

3) In the absence of the effect, the lower-consuming laparotomy is shown, the introduction of the reducing uterus of funds in the myometry, interming for the uterine vessels. With continuing bleeding against the background of the introduction of the reducing uterus, plasma for the correction of hemostasis is shown by the extirpation of the uterus after the dressing of the internal ileum arteries.

4. Bleeding from the gaps of the cervix, the clitoris, the perineum and vagina stops by restoring the integrity of the tissues.

bleeding in the early postpartum period

The causes of bleeding, which begins after the birth of the last, there are bursting of uterus or soft tissues of generic pathways, hemostasis defects, as well as the delay of the parts of the last in the uterine cavity (slices of placenta, shell), which prevents the normal reduction in the uterus and contributes to bleeding. Diagnosis is carried out on the basis of a thorough inspection of the last immediately after birth in order to determine the defect of tissues. When the defect is detected by the placenta tissues, shells, as well as vessels located along the edge of the placenta and cut off at the place of their transition to the shell (it is possible that the presence of a broken down slices, delayed in the uterine cavity), or the occurrence of doubt in the integrity of the lane must urgently make a manual examination of the uterus and Delete its contents.

Hypotonic and atonic bleeding.Frequent causes of bleeding in the early postpartum period are hypotension and atony of the uterus. Under the hypothey of the uterus, this condition is understood at which a significant reduction in its tone and a decrease in contractile ability occur; The muscles of the uterus react to various stimuli, but the degree of reactions are inadequate than irritation. The hypotension of the uterus is a reversible state. When atony, the uterine, myometrium completely loses the tone and contractile ability. Atony of the uterus is extremely rare, but it can be a source of massive bleeding. Causes of hypotension and atony uterus: malformations of the uterus, mioma, dystrophic changes of muscles, erase the uterus during pregnancy and childbirth (multiplexing, multi-way, large fruit), rapid or delayed childbirth in the weakness of generic activity, the presence of an extensive placental platform, especially

lower segment, elderly or young age, neuroendocrine failure. Heavy forms of hypotension and massive bleeding are usually combined with a violation of hemostasis proceeding by the type of DVS syndrome. Massive bleeding can be a manifestation of polyorgan deficiency. At the same time, against the background of microcirculatory failure in the muscles of the uterus, ischemic and dystrophic changes, hemorrhages characterizing the development of shock uterine syndrome.

Clinical picture.The main symptom of the uterus hypotension is bleeding. When inspection, the uterus is flabby, big size. When conducting an outdoor massage of the uterus, blood clots are distinguished from it, after which the uterus is restored, but then hypotension is possible again. Under Atonia, the uterus is soft, test, the contours are not defined. The bottom of the uterus comes to a sword-shaped process. There is continuous and abundant bleeding. The clinical picture of hemorrhagic shock is developing rapidly.

Diagnosticsno difficulties. Initially, blood is allocated with clots, subsequently she loses the ability to coagulate. At Atony, the uterus does not respond to mechanical irritation, while under hypotension, weak reductions are noted in response to mechanical stimuli.

Bleeding stops are carried out against the background of infusion-transfusion therapy (Table 16) and includes the following.

1. Emptying bladder.

2. With blood loss, exceeding 350 ml, an outer massage of the uterus is produced through the front abdominal wall. At the same time introduces uterotonic drugs. On the low part Belly put a bubble with ice.

3. With the continuing bleeding and blood loss, more than 400 ml under anesthesia produce a manual examination of the uterus, as well as a dosage outfit internal massage of the fist on a fist, while intravenously introduced uterotonic preparations with prostaglandins. After the uterus is reduced, the hand is removed from the uterus.

4. In continuing bleeding, the volume of which was 1000-1200 ml, the question of the operational treatment and removal of the uterus should be resolved. It is impossible to count on the re-administration of uterotonic drugs, a manual examination and massage of the uterus, if the first time they were ineffective. Time loss when repetition of these methods

dov leads to an increase in blood loss and deterioration of the state of the parental, the bleeding acquires a massive character, hemostasis is disturbed, hemorrhagic shock develops, and the prognosis for the patient becomes unfavorable.

Table 16.

Protocol infusion-transfusion therapy of obstetric bleeding

In the process of preparation for the operation, a number of events are used: presses of the abdominal aorta to the spine through the front abdominal wall, the imposition of terminals for Baksheyev on the cervix; The side walls are superimposed by 3-4 ABORTICANGA, the uterus is shifted down.

If the operation is performed quickly during bloodwall, not exceeding 1300-1500 ml, and complex therapy allowed stabilizing the functions of vital systems, it is possible to limit the overall amputation of the uterus. With the continuing bleeding and development of the engine, the hemorrhagic shock shows the extirpation of the uterus, the drainage of the abdominal cavity, the supply of internal ileal arteries. Perspective is the method of stopping bleeding by embolization of the uterine vessels.

Prevention of bleeding in the postpartum period

1. Timely treatment of inflammatory diseases, the fight against abortions and the usual unbearab.

2. Proper pregnancy, prevention of gestosis and complications of the course of pregnancy.

3. Proper guidance: a competent assessment of the obstetric situation, the optimal regulation of generic activity. The anesthesia of childbirth and the timely solution of the issue of the operational delivery.

4. Preventive administration of uterotonic preparations Since the cutting of the head, careful observation in the postpartum period. Especially in the first 2 h after childbirth.

5. Mandatory emptying of the bladder after the birth of a child, ice on the abdomen after the birth of the lane, periodic outer massage of the uterus. Careful accounting of losing blood and evaluation general status Row birth.