With atonic bleeding in the early postpartum period. Postpartum haemorrhage: earlier and later
The features of physiology, hormonal regulation, biochemical processes of the reproductive system of men and women are touched upon. Issues of contraception, diseases of the male gonads and testes, infertility and decreased fertility are considered separately. A separate chapter is devoted to sexual dysfunction in men and women.
3 290 R
The handbook covers a wide range of problems (from hormonal contraception and sterilization to gynecological oncology), the variety of pathological conditions that a gynecologist encounters in his practice, methods of their diagnosis and treatment. Along with this, the information richness of the book suggests that doctors of other specialties will be able to get full information and topical recommendations in it.
1 640 R
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2 620 R
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1 690 R
This guide provides information on the etiology and pathogenesis of most intrauterine infections, their diagnosis, management of pregnant women with various infections by the trimesters of pregnancy, during childbirth and postpartum period, indications for termination of pregnancy.
850 R
Saves time when preparing for accreditation. Ready algorithms for accreditation.
2 590 R
Hysteroscopy: indications, contraindications, preparation for research, equipment, methods of conducting. The hysteroscopic picture is normal. Variants of a hysteroscopic picture for intrauterine pathology. Treatment of the main forms of intrauterine pathology.
1 690 R
This is an atlas guide to the pathology of pregnancy, obstetric pathology and, importantly, to congenital malformations and the most common hereditary diseases in children. One of the few atlases on congenital malformations in children, which presents a rich clinical material, and, what is especially valuable, it is wonderfully illustrated with high-quality photographs.
2 790 R
Algorithms of medical actions in the diagnosis, treatment and prevention of these infections are presented, which will allow the obstetrician-gynecologist to quickly make informed clinical decisions. Particular attention is paid to the organization of work on the prevention of infectious diseases in the obstetric hospital, prevention, early diagnosis and treatment of complications that have arisen.
2 890 R
The book contains a wide list of modern laboratory research and the clinical and diagnostic value of their changes in various diseases, conditions and syndromes. Indicators and markers of research are grouped by types: "acute phase" proteins, mineral, pigment, lipid and other metabolism; enzymes, hormones, markers of infections, tumor markers, etc.
776 R
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3 099 R
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2 290 R
Particular emphasis is placed on the analysis of the logic of sequential analysis and the use of additional ultrasound techniques (modes of CDC, ED, 3D, elastography and elastometry) in addition to the standard gray-scale examination of breast tissue. The necessity of a multiparametric approach to the ultrasound assessment of the state of the glands is substantiated. The application of the BI-RADS system in the final summarizing risk assessment of malignant neoplasms of the mammary gland is shown
3 190 R
Dedicated to the treatment of infertility in women in late reproductive age. The book contains information about the peculiarities of infertility treatment, including against the background of diseases such as uterine fibroids and genital endometriosis, as well as programs of assisted reproductive technologies in women of late reproductive age, and the principles of managing such 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 indicators of microcenosis, general and local immunity in inflammatory diseases of the genital organs is highlighted. Much attention is paid to the diagnosis and management tactics of the most common diseases in gynecological practice, the problem of miscarriage of infectious genesis, and the development of intrauterine infection.
1 850 R
The modern principles of diagnosis and treatment are formulated, and algorithms for the management of patients with hormonal disorders in the reproductive system are presented. The purpose of this book is to summarize and present the latest data in the field of endocrine gynecology for practitioners in various fields.
2 290 R
The book outlines the basics of cardiotocography and fetal pathophysiology, rules for using terminology, lists common errors associated with equipment and interpretation of cardiotocograms, provides data from clinical trials and relevant clinical scenarios. This edition has added a chapter devoted to testing the competence of specialists who improve their qualifications
2 790 R
The clinical characteristics of drugs used for anesthesia in pregnant women and women in labor are presented in detail. special attention is paid to the anesthetic support of the caesarean section and anesthesia in minor obstetric operations, as well as to the complications of anesthesia. The problem of intensive care in uterine postpartum bleeding, late gestosis and other emergency conditions in obstetrics is considered.
2 390 R
A practical guide to outpatient care includes materials on the most important sections of obstetrics and gynecology, gynecological endocrinology and gynecological oncology. The issues of etiology, pathogenesis and diagnosis of pathological conditions are considered in detail in the light of the latest achievements of domestic and foreign authors. The modern methods of prevention and therapy in obstetrics and gynecology are presented.
2 190 R
The book covers in detail the issues of general and oncological gynecology, reproductive endocrinology and infertility, contraception and family planning, pediatric and adolescent gynecology, urogynecology, etc. The psychological aspects of gynecology, the problems of domestic cruelty and sexual violence are revealed in separate chapters.
2 790 R
The book covers in detail the basics of reproduction, normal obstetrics, diagnosis and management of various complications during pregnancy and childbirth, emergency conditions in obstetrics. Attention is paid to extragenital diseases (including surgical ones) during pregnancy. A separate chapter is devoted to the resuscitation of newborns and the care of children from high-risk groups.
2 690 R
Currently, there are cases when a student, already a month after passing state exams, goes to the clinic and must perform the function of a pediatrician. For many years he studied pediatrics, but only 10 days of them - ophthalmology; At the same time, doctors who work with children are assigned a much greater responsibility, unlike doctors who work with adult patients, for the state of the visual system of a newborn - immature, tender, developing, very vulnerable, rich in congenital removable and irreparable pathology, anomalies.
1 590 R
The book discusses the basic principles of managing patients with pain complaints, the most common causes of pain and the most common ways to deal with it, and numerous examples from practice. A separate section is devoted to the invasive methods of pain management under fluoroscopic control.
2 890 R
Practical guidance can be useful for specialists who face the problems of diagnosis, treatment and rehabilitation of septic patients, including patients with diseases of the reproductive system.
790 R
The book was written by doctors of various specialties for obstetricians and gynecologists. It sets out modern views about anemia, the prevalence of various types of this disease and their impact on the state of the reproductive system of women.
1 890 R
In this Atlas, all aspects of the study are clearly structured and clearly explained - from the rules for organizing the workflow to the finest nuances of colposcopic pictures in various diseases cervix. This is a short, but the most complete course of colposcopy, a guide for a doctor.
2 790 R
Practical guidance can be useful for obstetricians-gynecologists, pediatricians, family doctors and other specialists who are faced with the problems of lactation, hypogalactia, lactostasis and other pathological conditions that occur during lactation, as well as contraception issues in nursing mothers.
1 290 R
The book examines the features and options for the course of migraine in women and strategic approaches to the treatment and prevention of this disease at different periods of their lives. The book is intended for neurologists, obstetricians-gynecologists, therapists, general practitioners and other specialists who are directly involved in the treatment of women with migraine attacks.
1 590 R
Particular attention is paid to the technique ultrasound examination anatomical structures of the fetus in early pregnancy, the role of echography in screening for frequent chromosomal syndromes, as well as multiple pregnancies. The second part of the book is devoted to a detailed ultrasound examination of fetal organs and systems (central nervous system, face and neck region, chest, heart and great vessels, gastrointestinal tract, genitourinary system, skeleton), placenta and umbilical cord in normal and pathological conditions. Algorithms for the diagnosis of some genetic, including chromosomal, syndromes are considered.
4 990 R
Indications, contraindications for this operation; the conditions in which it is advisable to produce it. Problems of optimal surgical and anesthetic support of the operation, prevention and treatment are considered. postoperative complications, intensive care and resuscitation of newborns after abdominal delivery.
1 990 R
The objective of this publication is to familiarize doctors with the specifics of IVF programs for certain gynecological and endocrine diseases. The book is intended for general practitioners and obstetricians-gynecologists, as well as those working in IVF clinics, endocrinologists, specialists undergoing training and improving their qualifications.
1 790 R
The book examines the ambiguous situations associated with the presence of intrauterine pathology, thyroid diseases and HIV infection. The expansion of indications for the use of assisted reproduction methods in order to achieve pregnancy has led to the fact that more than a third of patients with various gynecological, endocrine and other diseases require “non-standard” solutions when preparing for IVF programs and during the treatment itself
1 890 R
Clinical diagnostic methods. Laboratory diagnostic methods. Instrumental diagnostic methods. Surgical methods treatment. Contraception. Pathology of the reproductive system in childhood and adolescence. Endocrine disorders in the reproductive period. Fruitless marriage. Clinical forms of inflammatory diseases of the pelvic organs.
2 790 R
The specialists who worked on the book are sure that after reading the information presented, readers will not have any questions about the treatment of disorders of the reproductive system. Book " Diabetes and the reproductive system ”will be useful for reproductive specialists, gynecologists, diabetologists and endocrinologists.
2 190 R
Diseases and pathological conditions associated with pregnancy, childbirth and the postpartum period are fully covered. In addition, diseases are described, including infectious diseases, the most significant in terms of their impact on the health of mothers and children, and modern methods of treatment and prevention of these diseases are given. The causes of occurrence and methods of dealing with prenatal and postpartum hemorrhages are considered separately.
4 590 R
2 190 R
The data on the treatment of skin diseases and sexually transmitted infections are published in the most complete volume. The first part provides detailed information on the general principles of treatment of skin and sexually transmitted diseases. The second volume of the manual describes methods of treatment (with the basics of clinical picture and etiopathogenesis) of skin diseases - more than 500 nosological forms
3 890 R
The manual is divided into two parts, which outline the theoretical and clinical aspects of medical genetics. The first part presents the latest data on theoretical issues of medical genetics. Information about the organization and functions of the genome, genes and chromosomes is presented in a form understandable for doctors, but without undue simplification. The second part presents the issues of clinical genetics, namely, methods for diagnosing hereditary diseases (from the clinical level to DNA and RNA sequencing)
3 590 R
The book is devoted to the pathogenesis, prevention and treatment of a number of life-threatening conditions in modern perinatology: massive obstetric bleeding caused by primary disorders in the hemostatic system; anaphylactoid syndrome of pregnant women; antenatal care and pregnancy management.
2 790 R
The manual contains over 1400 echograms and 264 clips, which are fragments of real ultrasound examinations. Each clip is provided with comments indicating access, scanning plane and description of the visualization zone. For self-education, test control questions and visual tasks with answers for self-control are presented.
2 990 R
The book contains information on the regulatory support of outpatient obstetric and gynecological care, the organization of the antenatal clinic, the day hospital, the specifics of organizing children's gynecological care, the prevention, diagnosis and treatment of the most common diseases encountered in girls and women of all age groups.
3 499 R
Addressed to all obstetrician-gynecologists involved in the treatment process: from outpatient to specialized high-tech service, including managers medical organizations and their deputies who plan and carry out the procurement of medicines (drugs)
2 099 R
Contains descriptions of pharmaceuticals on the Russian pharmaceutical market and the section "Parapharmaceuticals", which includes dietary supplements, medical products, medical food and medical 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 the existing controversial issues. In a non-standard way of contraversions (sections “Pro”, “Et contra”, “Point of view”), information on the prevalence, etiology and pathogenesis of infertility caused by endometriosis is presented, from the standpoint of evidence, the world experience in diagnostics, conservative and surgical methods of treatment is summarized.
1 699 R
The tutorial presents the basic data on the main indicators of cardiotocography, outlines their pathophysiological and clinical characteristics, and also gives their diagnostic value. The technique of using cardiotocography during pregnancy and childbirth is described. The technique of automated analysis of the cardiotocogram is described.
1 690 R
An illustrated atlas guide to colposcopy and cervical pathology, which presents the colposcopic picture in conjunction with histopathology, which provides a complete understanding of the morphological picture and clinical diagnosis. The book provides an update on the central role of human papillomavirus in cervical cancer and HPV vaccines for its prevention.
3 199 R
IVF in HIV-infected patients. Algorithm for preliminary examination and preparation of HIV-infected patients for IVF 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 importance of disease risk factors, modern diagnostic algorithms in pregnancy of unknown localization. All 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
The issues of prenatal diagnosis and management of pregnancy in different types of twins are presented. The features of screening the chromosomal pathology of the fetus in multiple pregnancies, as well as the tactics of pregnancy management when detecting a chromosomal disease or malformation in one of the fetuses are described.
2 399 R
In your hand is a book that answers the questions that healthcare professionals face when seeking to deliver rigorous, rational, and effective medical advice.
2 390 R
Methods of examination of the mammary glands: self-examination, questioning, electrical impedance tomomammography, radiothermometry, and traditional methods clinical examination. The features of dose-free radiological digital technologies are considered - ultrasound computed tomography (UST), magnetic resonance imaging (MRI), laser tomomammography.
1 190 R
A short guide to key issues in the diagnosis of diseases of internal organs. All sections are presented in the form of visual material - short structural logic diagrams (algorithms). The content of the book is subordinated to a single scheme, which greatly facilitates the possibility of operational work with the book and the quick search for a symptom or syndrome.
539 R
The guidance includes detailed consideration of their issues, including an analysis of the causes of ineffective treatment interventions associated with primary or acquired resistance.
1 590 R
The tutorial presents modern information about the epidemiology, etiopathogenesis, diagnosis and treatment of infertility caused by immune responses against sperm
1 190 R
Information about how great the variety of forms of brain lesions in children is, how these lesions differ from brain pathology in adults, and what is the role of infections, hypoxia, birth trauma and other factors in their origin. The text is accompanied by over 450 color illustrations (photographs, diagrams and graphics)
2 190 R
Ultrasound, echohysterography, MSCT, MRI, PET / CT. Vagina and vulva. Anatomy of the vagina and vulva. Congenital disorders. Vaginal atresia. Infected hymen. Vaginal septum. Benign neoplasms. Leiomyoma of the vagina. Hemangioma of the vulva. Paraganglioma of the vagina. Malignant neoplasms. Vaginal cancer. Leiomyosarcoma of the vagina.
4 290 R
The pelvis. Ultrasound examination: technology and anatomy. Hysterosalpingography. Infusion sonohysterography. Computed tomography: research technology and anatomy. Magnetic resonance imaging: 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 breast cancer prevention. All drugs offered for the treatment of diseases of the mammary glands are considered from the point of view of evidence-based medicine and current procedures for the provision of medical care, clinical guidelines. The book presents modern scientific and practical approaches to the diagnosis, treatment and prevention of non-cancerous diseases of the mammary glands, assessment of risk factors, focuses on the introduction of mammographic screening as one of the most important ways to timely detect cancer.
1 890 R
Diseases genitourinary system and their relationship with urogenital infections. According to the etiology, pathogenesis of both the most common - cystitis, urethritis, prostatitis, and a more rare pathology, accompanied by disorganization of the epithelium, - urethral polyps, bladder leukoplakia.
1 390 R
Chronic pain in the lower abdomen is a common complaint of patients. One of the most unpleasant and depressing factors is the undefined cause of pelvic pain. The book allows for a comprehensive approach to the diagnosis and more successful treatment of chronic pelvic pain syndrome.
1 290 R
Rational treatment regimens are presented. Separate sections of the book are devoted to the correction of pain syndrome, infectious complications in oncourology and clinical trials. Modern treatment regimens are combined with a description of drugs, analysis of the most common mistakes, as well as ways to prevent and correct them
1 290 R
All aspects of the ultrasound screening protocol in the II trimester of pregnancy are considered in detail. Particular attention is paid to ultrasound fetometry, assessment of the placenta, amniotic fluid and umbilical cord. The issues of ultrasound anatomy of the fetus in the II trimester of pregnancy with normal development and various congenital defects are presented in detail. A separate chapter is devoted to echographic markers of chromosomal abnormalities in the fetus.
Modern antibiotic therapy of lower urinary tract infections in women in diagrams and tables
The publication is devoted to modern approaches to antibiotic therapy of uncomplicated lower urinary tract infections. An algorithm for the diagnosis of acute cystitis, features of the treatment of lower urinary tract infections in pregnant women is presented.
990 R
Modern provisions of ultrasound diagnostics in gynecology based on the consensus of international expert groups on morphological ultrasound analysis of the uterus, deep endometriosis, endometrial and ovarian tumors.
3 099 R
Fundamental provisions of the screening study at 30-34 weeks of gestation. All aspects of the ultrasound screening protocol in the third trimester of pregnancy are considered in detail. Particular 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. The protocols were drawn up on the basis of the 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 encountered in the practice of doctors of antenatal clinics and gynecological hospitals. The protocols were drawn up on the basis of the 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 (PCOS), as the most common endocrine disease in women of reproductive age. A detailed description of the physiological features of the female reproductive system is given. Considerable attention is paid to differential diagnosis PCOS and morphological changes in the ovaries.
1 150 R
The modern concepts of the pathogenesis of endometrioid disease are outlined. Indications for the use of special research methods are named, the technique of various methods is described surgical treatment and options for the conservative phase of therapy.
1 350 R
The book uses the traditional form of the "Secrets" series of presenting material in the form of questions and answers. The issues covered include brief information about the theoretical foundations of ultrasound, but the bulk of the publication is occupied by practical recommendations for its use in diagnostics. At the same time, specific, practical 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 fetus, depending on the trimester of pregnancy, are described in detail. Data on the formation of its developing organs and systems are presented. Complications that occur during different periods of pregnancy, their risk factors, etiology, pathogenesis, classification, diagnosis, treatment and prevention are also described.
1 690 R
The methods of emergency esophagogastroduodenoscopy, colonoscopy, bronchoscopy and laparoscopy, the endoscopic picture of various urgent pathologies of the gastrointestinal tract and tracheobronchial tree, abdominal and pelvic organs, as well as the main surgical interventions performed through an endoscope in children of different age groups are described.
1 999 R
The guide describes almost all congenital heart defects that can be diagnosed in the fetus, as well as the treatment of fetal arrhythmias and screening ultrasound in the first trimester of pregnancy. A separate chapter is devoted to an overview of the likely outcomes of each of the congenital heart defects. The data is based on a study of nearly 4,000 fetuses with heart abnormalities.
3 520 R
Recommendations for performing biopsies with ultrasound guidance, using ultrasound to provide access to various organs and structures, during diagnostic and therapeutic interventional procedures, installing drains, and also during sonohysterography. Key procedures such as biopsy of the thyroid and mammary glands, superficial lymph nodes, sonohysterography, musculoskeletal and other interventions are described in detail.
2 750 R
The article presents the optimal management tactics for patients with gynecological and urological pathologies accompanied by chronic pelvic pain using modern radiation and endoscopic methods. Basic recommendations for the management of patients with chronic pelvic pain syndrome are proposed.
652 R
The aspects of hysteroscopy, fluorescence diagnostics, hysteroresectoscopy in intrauterine endometrial pathology are highlighted.
1 180 R
The data on the modern treatment of inflammatory diseases, endocrine and reproductive disorders are presented. The chapter on uterine fibroids provides new information on the etiology, pathogenesis, and treatment of this disease.
990 R
It contains information on such issues as contraception, sexual dysfunction, endometrial hyperplastic processes, postmenopausal osteoporosis, obesity and the reproductive system, genital herpes infection, uterine myoma, applied aspects of the functional morphology of the perineum and pelvic floor, gynecological endocrinology.
1 410 R
Contains information on issues of pediatric and adolescent gynecology, basic methods of diagnosis and treatment, decision-making algorithms in healthcare. Disorders of the development of the reproductive system. Dynamics of the physiology of puberty. Methods of examination of adolescent girls.
2 690 R
The information of classical obstetrics about the physiological and complicated course of pregnancy and childbirth, obstetric operations is presented in detail. The paper presents modern data on the pathogenesis, treatment and prevention of the most common complications of pregnancy.
1 260 R
The guide contains up-to-date and up-to-date information on the diagnosis and treatment of major breast diseases. It covers the main aspects of mammology. A guide reflecting an agreed position on topical issues of modern diagnostics and therapy of breast diseases.
3 199 R
Information on the main characteristics of the state of female reproductive health and comparative world medical indicators. The authors highlighted the priority factors influencing the reproductive function in women and formulated 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 prevention.
1 099 R
The main reasons for termination of pregnancy, diagnostics, tactics of preparation for pregnancy and the basic principles of management and treatment during pregnancy are stated. Much attention is paid to such aspects as endocrine causes of pregnancy loss, including in the case of sensitization to hormones.
2 150 R
880 R
The main genetic forms of thrombophilia and the mechanisms of thrombosis and thromboembolism in the presence of thrombophilic conditions are described. The pathogenetic mechanisms of thrombohemorrhagic complications in patients with disseminated intravascular coagulation syndrome, connective tissue dysplasia, and malignant neoplasms are considered.
2 350 R
The etiology, pathogenesis, clinical picture, diagnosis and treatment of diseases of the gonads caused by endocrine disorders are described. The current data on the clinical picture, diagnosis and treatment of polycystic ovary syndrome are summarized. Issues related to the pathogenesis, clinical picture, diagnosis and treatment of patients with climacteric syndrome and postvariectomy syndrome are highlighted.
1 990 R
Current data on etiology, molecular pathogenesis, surgical and drug treatment of ovarian cancer. Genetic and epigenetic disorders alter the ovarian epithelium, and a number of markers are identified that serve as both diagnostic and prognostic factors for this disease.
1 090 R
Ultrasound, MRI, PET / CT. Uterus. Introduction and overview of the anatomy of the uterus. Age changes... Endometrial atrophy. Congenital disorders. Anomalies in the development of Müllerian ducts. Hypoplasia / agenesis of the uterus. One-horned uterus. Double uterus (uterus didelphys). Bicornuate uterus. Intrauterine septum. Saddle uterus. Anomalies in the development of the uterus associated with exposure to diethylstilbestrol. Congenital cysts of the uterus. Inflammation / infections
3 390 R
Described not only malignant and benign neoplasms, but also background precancerous diseases, as well as cystic drift and trophoblastic disease. For each localization of tumors (mammary gland, fallopian tube, cervix, uterine body, ovary), the clinic, diagnosis and possibilities of surgical, drug and radiation treatment are detailed.
750 R
The issues related to modern principles of diagnostics, features of the clinical course, treatment and prevention of diseases of internal organs most common in obstetric practice are considered.
The book examines in detail the epidemiology, risk factors, etiology, pathogenesis, as well as the features of clinical manifestations and modern possibilities for diagnosing bacterial vaginosis. New variants of etiotropic and pathogenetic therapy, as well as prevention of bacterial vaginosis are described.
2 440 R
Current data on infertility and external genital endometriosis. For the first time, algorithms for the surgical treatment of external genital endometriosis and protocols for the use of argon plasma coagulation are presented.
1 190 R
Demonstration of real anatomy and an accessible description of surgical techniques, the most important operational and technical subtleties that are so necessary for the work of practicing surgeons.
11 900 R
The issues of preventing and correcting errors in ovarian neoplasms at the stages of treatment before admission to a specialized oncological clinic are considered. The expediency of using a complex of morphological, morphometric and immunohistochemical studies for predicting the recurrence of a borderline ovarian tumor is shown. Recommendations for optimal monitoring of cured women, the possibility of timely diagnosis and therapeutic measures in case of tumor recurrence are proposed.
940 R
Modern data on etiology, pathogenesis, clinical course, diagnosis and treatment of benign and borderline ovarian tumors. The material is presented in accordance with the International Classification of Diseases and Related Health Problems.
Lecture number 4
Pathological course of childbirth and the postpartum period
PM.02 Participation in treatment, diagnostic and rehabilitation processes
MDK 02.01 SP in obstetrics and in pathology of the reproductive system in men and women
By specialty
Nursing
Bleeding during the subsequent stage of labor
Causes of bleeding in the subsequent period of labor:
- Decreased tone of the uterus.
- Violation of the contractile activity of the uterus.
- Placental attachment anomalies: incomplete placenta previa.
- Placental anomalies: low attachment or location in one of the tubal corners of the uterus.
- Irrational management of the sequential period: massaging the uterus, pressing on its bottom, pulling on the umbilical cord is unacceptable.
Clinical symptoms bleeding in the subsequent stage of labor:
1) If bleeding reaches 350 ml (or 0.5% of the woman's body weight) and it continues, this is pathological bleeding. The severity of bleeding depends on the size of the detached part of the placenta and on the place of attachment of the placenta.
2) Pale skin, tachycardia, tachypnea, hypotension.
3) The uterus is enlarged, spherical, sharply tense if the blood does not come out, but accumulates in the uterine cavity.
Diagnostics of the delayed placenta:
1) To understand whether the placenta has separated or not, you can use the described signs of placenta separation:
- schroeder's sign: after separation of the placenta, the uterus rises above the navel, becomes narrow and deviates to the right;
- alfeld's sign: the exfoliated placenta descends to the inner os of the cervix or into the vagina, while the outer part of the umbilical cord is lengthened by 10-12 cm;
- mikulich's sign: after separation of the placenta and its lowering, the woman in labor has a need to push;
- klein's sign: when the woman in labor is straining, the umbilical cord is lengthened. If the placenta is separated, then after pushing the umbilical cord does not tighten;
- küstner-Chukalov sign: when the obstetrician presses over the pubic symphysis with a detached placenta, the umbilical cord will not retract.
If childbirth proceeds normally, then the afterbirth will separate no later than 30 minutes after the expulsion of the fetus.
Diagnostics of the delay of parts of the placenta:
1) Examination of the placenta and membranes after birth: if there are irregularities, roughness and deepening, then this is a defect of the placenta.
Treatment for delayed placenta and its parts in the uterine cavity:
1) Conservative method:
Injection of 1 ml (5 U) oxytocin to enhance the contractions
In cases of separation of the placenta from the uterus, but its retention in the cavity, external methods of isolating the placenta from the uterus are used: the methods of Bayer-Abuladze, Krede-Lazarevich, etc.
2) Operative method: if conservative measures do not give an effect, and blood loss has exceeded physiological limits, then immediately proceed to the operation of manual separation and isolation of the placenta (performed by a doctor)
After the uterus is emptied, contractors are injected, the abdomen is cold on them.
Antibiotics
With blood loss of more than 0.7% of body weight - infusion therapy.
Prevention of delay of parts of the placenta:
1) Rational management of childbirth and the postpartum period.
2) Prevention of abortion and inflammatory gynecological diseases.
Bleeding in the early postpartum period
Bleeding in the early postpartum period - bleeding from the genital tract that occurred in the first 4 hours after the birth of the placenta.
Causes of bleeding in the early postpartum period:
1) Delay in the uterine cavity of parts of the child's place.
2) Atony or hypotension of the uterus.
3) Injury of the soft tissues of the birth canal.
Hypotonic bleeding (Greek hypo- + tonos tension) - uterine bleeding, the cause of which is a decrease in the tone of the myometrium.
Causes of hypotonic bleeding:
1) Depletion of the body's forces, the central nervous system as a result of prolonged painful labor.
2) Severe gestosis, GB.
3) Anatomical inferiority of the uterus.
4) Functional inferiority of the uterus: overstretching of the uterus due to multiple pregnancies, multiple pregnancies.
5) Presentation and low attachment of the child's seat.
Clinic of hypotonic bleeding:
1) Massive bleeding from the uterus: blood flows out in a stream or in large clots.
2) Hemodynamic disorders, signs of anemia.
3) The picture is gradually developing hemorrhagic shock.
Diagnosis of hypotonic bleeding:
1) The presence of bleeding.
2) Objective data of the state of the uterus: on palpation, the uterus is large, relaxed.
Treatment for hypotonic bleeding:
1) Measures to stop bleeding: carried out simultaneously by all personnel without interruption
Emptying the bladder with a catheter.
Oxytocin or Ergometrine 1ml IV.
External massage of the uterus. If during the massage the uterus does not contract or contracts poorly, then proceed to:
Manual examination of the walls of the uterine cavity. If this is ineffective, laparotomy. If the bleeding has stopped, the increase in uterine tone is conservative.
2) Fight against hemodynamic disorders.
3) Gluttony and removal of the uterus.
4) Surgical methods:
Ligation of uterine vessels. If that doesn't help, then
Amputation (removal of the body of the uterus) or extirpation (removal of both the body and cervix) of the uterus.
Prevention of bleeding in the early postpartum period:
1) Identification and hospitalization in an obstetric hospital before delivery of pregnant women with pathology.
Birth force anomalies
Anomalies of the birth forces are a fairly common complication of the birth act. The consequences of abnormalities in the contractile activity of the uterus during labor can be very dangerous for both the mother and the fetus.
Causes of anomalies generic activity:
Maternal pathology: somatic and neuroendocrine diseases; complicated pregnancy; pathological change in the myometrium; overstretching of the uterus; genetic or congenital myocyte pathology, in which the excitability of the myometrium is sharply reduced.
Pathology of the fetus and placenta: malformations nervous system fetus; aplasia of the fetal adrenal glands; placenta previa and its low location; accelerated, belated maturation.
Mechanical obstacles to fetal advancement: narrow pelvis; tumors of the small pelvis; malposition; incorrect head insertion; anatomical stiffness of the cervix;
Non-simultaneous (asynchronous) readiness of the body of the mother and the fetus;
Iatrogenic factor.
There are conditions in which the risk of postpartum bleeding is higher than in their absence. Analysis of statistical information showed that such bleeding occurs more often in the following situations.
- Postpartum hemorrhage, abortion, miscarriages in the past. This means that the woman is prone to bleeding, which means the risk will be higher.
- Late toxicosis. In the case of preeclampsia, high blood pressure and impaired renal function are present, as a result of which the vessels become more fragile and easily destroyed.
- Big fruit. Due to the pressure of such a fetus during childbirth, the walls of the uterus can be injured, which is manifested by bleeding after the baby is born. In addition, the uterus is overstretched and therefore contracts worse.
- Polyhydramnios (a large amount of amniotic fluid). The mechanism is about the same as with a large fruit.
- Multiple pregnancy. Here it is similar.
- Leiomyoma of the uterus. it benign tumorwhich gives the clinic bleeding. And childbirth can provoke it.
- A scar on the uterus. After operations (more often a cesarean section), a scar remains, which is a weak link in the wall of the uterus. Therefore, after the birth of a child, a rupture may occur in this place.
- DIC syndrome. As a result of this phenomenon, the blood coagulation function is impaired. After childbirth, trauma and bleeding are always observed, but with DIC, the bleeding does not stop.
- Thrombocytopathy. These are acquired or congenital diseases where platelets involved in blood clotting cannot perform their duties due to the presence of defects in them.
The mechanism of development of postpartum hemorrhage
After the baby is born, the intrauterine pressure drops sharply and the empty uterus also contracts sharply (postpartum contractions). The size of the placenta does not correspond to such a contracted uterus and it begins to separate from the walls.
The duration of the separation of the placenta and its discharge directly depends on the contraction of the uterus. Normally, evacuation occurs approximately 30 minutes after birth. Delayed evacuation of the placenta indicates a high chance of postpartum bleeding.
When the placenta is separated from the walls of the uterus, the vessels are damaged. A delay in the exit of the placenta indicates a weak contraction. This means that the vessels cannot narrow and the bleeding does not stop. Also, the cause of bleeding may be incomplete separation of the placenta from the walls due to its accretion or pinching of parts in the uterus.
Postpartum bleeding in the event of injury to soft tissues, it occurs only when they break. With blood diseases, the vessels are not able to withstand even minor damage. And since during childbirth, damage to the vessels always occurs, then the bleeding after birth will continue for a long time, which requires immediate action to stop the blood.
Types of postpartum bleeding
In obstetric practice, it is customary to distinguish two main types of bleeding:
- Bleeding in the early postpartum period - this means that blood is released in the first 2 hours after birth. The most dangerous, since it is difficult to eliminate the cause of the occurrence.
- In the late postpartum period - after 2 hours and up to 1.5-2 months.
Well, since this is bleeding, the separation occurs due to the appearance. That is, bleeding due to:
- weak contraction of the uterus,
- delayed separation and excretion of parts of the placenta,
- blood diseases,
- injury to the uterus.
They also determine sharp bleeding, which begins immediately after the birth of a child in large quantities (blood loss reaches more than 1 liter per minute) and the pressure drops rapidly. Another type is characterized by the release of blood in small portions with a gradual increase in blood loss. It stops and starts.
Causes of bleeding after childbirth
In general, bleeding is the release of blood from the vessels. This phenomenon is observed when the vessels are damaged, their integrity is violated from the inside, or the systems are unable to stop the blood. Therefore, the main causes of PPH are 4 main groups.
Weak uterine contraction
Since the bulk of the vessels is in the uterus, when it contracts, the vessels narrow and the blood stops. With insufficient contraction of the uterus, the vessels do not narrow and blood continues to be secreted. This occurs when the uterus is overstretched with a large fetus, with polyhydramnios, overwork of a woman, an overflowing bladder, or the rapid birth of a child.
When using antispasmodics, prolonged and exhausted labor, the muscles of the uterus are overexcited and exhaled, which leads to a drop in its tone.
All sorts of inflammation of the uterus, cancer and endocrine diseases lead to a deterioration in the ability of the muscles of the uterus to effectively contract.
Mental disorders (severe anxiety, fear for the child's condition) or strong pain may also lead to insufficient contraction of the uterus.
Birth injury
Damage to the uterus with a large fetus occurs against the background of rapid childbirth, the use of obstetric forceps, a narrow pelvis in a pregnant woman, or with polyhydramnios. Such injuries include rupture of the uterus, cervical canal, perineum, and clitoris.
Violation of placenta discharge
The impossibility of complete separation of the placenta from the walls and its discharge or the retention of parts (umbilical cord, fetal membranes) of this organ in the uterus.
Blood diseases
These include hemophilia, thrombocytopenia, and coagulopathy. Substances that are involved in stopping bleeding are damaged, or are absent altogether. Under normal conditions, these disorders may not appear, but childbirth becomes the impetus for the onset of bleeding.
There may also be an option when bleeding has arisen due to the divergence of the seams. This can be suspected by an operation performed, for example, a cesarean section, where sutures are always applied. Also, the development of infectious complications at the suture site can weaken the thread and, under load, lead to its rupture.
Postpartum hemorrhage symptoms
How does it look clinical picture postpartum hemorrhage? How can you tell them apart? It has its own characteristics, depending on the cause of bleeding and on the period of occurrence.
Early signs of postpartum hemorrhage (first 2 hours)
Practice shows that the loss of blood in a volume of about 250-300 ml does not pose any danger or harm to life. Since the body's defenses compensate for this loss. If the blood loss is more than 300 ml, it is considered bleeding.
Delayed separation or discharge of parts of the placenta
The main symptom is the occurrence of bleeding immediately after the beginning of the evacuation of parts of the placenta. Blood flows either in a continuous stream, or, which occurs more often, is secreted in separate portions.
The blood is usually dark in color with an admixture of small clots. Sometimes it happens that the opening of the cervical canal of the uterus closes and, as it were, the bleeding stops. But in reality, the situation is the opposite or even worse. The fact is that in this case, blood accumulates inside the uterus. The uterus increases in size, contracts poorly, and if you massage, a large blood clot comes out and bleeding resumes.
The general condition of the mother is gradually deteriorating. This is manifested by the following signs:
- pallor of the skin and visible mucous membranes,
- gradual decrease in blood pressure,
- rapid pulse and breathing.
It is also possible to pinch parts of the placenta in the area of \u200b\u200bthe fallopian tube. This can be determined by finger examination, during which a protrusion will be felt.
Weak uterine contraction
After the baby is born, the uterus should normally contract, which will lead to vasoconstriction and prevent the development of bleeding. In the absence of such a process for the above reasons, stopping the blood is very problematic.
Distinguish between hypotension and uterine atony. Hypotension is manifested by a weak contraction of the uterus, which is not enough for vasoconstriction. Atony is a complete lack of work of the uterus. Accordingly, such bleeding is called hypotonic and atonic. Blood loss can range from 60 ml to 1.5 liters. and more.
The uterus loses its normal tone and contractility, but is still able to respond by contraction to the administration of drugs or physical stimuli. Blood is not released constantly, but in waves, that is, in small portions. The uterus is weak, its contractions are rare and short. And after massaging, the tone is relatively quickly restored.
Sometimes large clots can form, which clog the entrance to the uterus and, as it were, the bleeding stops. This leads to an increase in its size and a worsening of the woman's condition.
Prolonged hypotension, rare, but can turn into atony. Here, the uterus does not respond to any stimuli, and bleeding is characterized by a continuous strong current. The woman feels even worse and there may be a sharp drop in blood pressure and even death.
Bleeding due to blood disorders
A characteristic sign of such bleeding is the normal tone of the uterus. At the same time, rare blood without clots flows out, there are no signs of any injury or damage. Another symptom that indicates a blood disorder is the formation of hematomas or hemorrhages at the injection site. The blood that has flowed out does not coagulate for a long time or does not coagulate at all, since it is absent for this in the required amount necessary substances.
Hemorrhages can be not only at injection sites, but also in internal organs, stomach, intestines, that is, anywhere. With an increase in the volume of blood loss, the risk of death increases.
In the case of disseminated intravascular coagulation (depletion of clotting substances), this leads to the formation of blood clots and blockage of most of the small vessels in the kidneys, adrenal glands, liver, and other organs. If proper medical care is not provided, then tissues and organs will simply begin to deteriorate and die off.
All this is manifested by the following symptoms:
- hemorrhages under the skin and mucous membranes,
- profuse bleeding at injection sites, surgical wounds, uterus,
- the appearance of dead skin areas,
- hemorrhages in internal organs, which is manifested by a violation of their functions,
- signs of damage to the central nervous system (loss, depression of consciousness, etc.).
Bleeding due to trauma
A common manifestation in such a situation will be rupture of the soft tissues of the genital tract. In this case, characteristic signs are observed:
- the onset of bleeding immediately after the birth of the child,
- blood is bright red
- the uterus is dense to the touch,
- upon examination, the place of the rupture is visualized.
When the perineal tissue is torn, there is little blood loss and it does not pose any threat. However, if the cervix or clitoris ruptures, the bleeding can be serious and life-threatening.
Signs of bleeding in the late period (2 hours to 2 months)
Usually, such bleeding makes itself felt about 7-12 days after birth.
Blood can be released once and strongly or in small amounts, but several times and bleeding can last a couple of days. The uterus may be soft, or it may be tight, painful, and not painful. It all depends on the reason.
The retention of parts of the placenta creates a favorable background for the multiplication of bacteria and the development of infection, which will then manifest itself as characteristic symptoms of the inflammatory process.
Diagnosis of postpartum hemorrhage
What is the diagnosis of postpartum hemorrhage? How do doctors determine the type of bleeding? In reality, diagnosis and treatment are carried out simultaneously because this condition poses a threat to the patient's life. Especially when there is profuse bleeding, the diagnosis generally fades into the background, since the most important thing is to stop the blood. But now we will talk specifically about diagnostics.
Here, the main task is to find the cause of the bleeding. The diagnosis is based on the clinical picture, that is, when the bleeding began, what is the color of the blood, the presence of clots, the number, nature, and so on.
The first thing to look at is the timing of the bleeding. That is, when it arose: immediately after childbirth, a few hours later, or in general, for example, on the 10th day. This is an important point. For example, if bleeding immediately after childbirth, then there may be a problem with a blood disorder, tissue rupture, or insufficient muscle tone in the uterus. And other options automatically disappear.
The nature and amount of bleeding are the second most important signs. When analyzing these symptoms, one can talk about the possible cause, the extent of the damage, how severe the bleeding is and make predictions.
The clinical picture only allows us to suspect possible reason... But in most cases, doctors can make a diagnosis from experience. In doubtful cases, a gynecological examination is performed to confirm the diagnosis. In this case, you can:
- assess the tone and ability to contract the uterus,
- determine the soreness, shape and density of the uterus,
- detect the source of bleeding, the place of tissue rupture in trauma, stuck or attached parts of the placenta.
Delayed afterbirth
Usually, the afterbirth is always examined after any birth. Then special tests are used, which are necessary to detect defects in the placenta.
If it was found that parts of the placenta remained in the uterine cavity, a manual examination is performed. It is performed when there is a suspicion of violation of the integrity of the placenta, regardless of whether there is bleeding or not. Since the external discharge of blood may not be visible. This method is also used to search for possible defects after surgical procedures.
The procedure looks like this:
- One hand is inserted into the uterine cavity, and the other is placed on the outside of the abdomen for control.
- With the same hand that is inside, an examination and assessment of the condition of the walls of the uterus, mucous membrane for the presence of placental residues is carried out.
- Further, the soft parts, flat foci of the mucous membrane are removed.
- If scraps of tissue are found that stretch to the wall of the uterus, then the external hand is massaged that area. If these are the remnants of the placenta, then they are easily separated.
- After that, the uterus is massaged with both hands clenched into a fist, oxytocin is injected to increase the contraction of the organ and plus antibiotics to prevent infection.
Weak uterine contraction
A gynecological examination allows a diagnosis in this case. In this case, the uterus will be weak, there are almost no contractions. But if you stimulate with drugs (oxytocin) or massage the uterus, then the tone is relatively increased.
Also, to confirm the diagnosis of postpartum hemorrhage, factors that can lead to such a condition are taken into account (overstretching of the uterus with a large fetus, the discrepancy between the size of the fetus and the width of the pelvis to the woman, polyhydramnios, etc.).
Birth injury
Diagnosing ruptured bleeding is not difficult. This happens with prolonged childbirth, polyhydramnios and a discrepancy between the size of the fetus and the parameters of the woman's pelvis. And if bleeding occurs against the background of these factors, then doctors suspect this type of bleeding in the first place. To confirm the fact of injury and detect the area of \u200b\u200bbleeding, a gynecological examination is performed using mirrors.
Blood diseases
Here the diagnosis is simple in one case, and very difficult in the other. When a pregnant woman is admitted to the hospital, standard blood tests are performed, where a low level of clotting substances (platelets, fibrinogen) can be detected. That is, those that are easy to identify.
But it may be that the reason lies in a congenital defect of the coagulation system. Then the diagnosis is difficult. To confirm such a disease, it is necessary to pass special expensive tests and a genetic test.
There were cases where the patient had postpartum bleeding, which was very difficult to stop. And the doctors couldn't find the reason. And only after stopping the woman admitted that she had a congenital blood disease. Therefore, you need to tell all the information to your doctor.
Another important aspect of diagnosis is urgent laboratory research:
- For hemoglobin. It is necessary to detect anemia after bleeding. Since in this case the body always spends hemoglobin, and in case of its lack, organs and tissues receive an insufficient amount of oxygen. If a lack of hemoglobin was found, then appropriate therapy is carried out.
- Coagulogram. This is a determination of the amount of substances that are involved in blood clotting.
- Blood group and Rh factor. They are necessary for transfusion of the correct type of blood in case of severe bleeding.
Postpartum hemorrhage treatment
What actions are taken by doctors during bleeding? What does healthcare delivery look like? Heavy bleeding is life-threatening. Therefore, everything is done quickly and clearly according to the instructions, and the choice of tactics depends on the cause of the bleeding. The main task is first to stop bleeding, and then eliminate its cause.
Urgent care
The algorithm of actions looks like this:
- A catheter is placed on one of the veins in order to quickly administer pharmacological drugs. This action is also due to the fact that with a large blood loss, blood pressure drops and the veins collapse. As a result, it will be difficult to hit them.
- The bladder is emptied of urine using a urinary catheter. This will relieve pressure on the uterus and improve uterine contraction.
- The volume of lost blood, blood pressure, and the severity of the situation are assessed. With a loss of more than 1 liter. blood to compensate for blood loss, intravenous drip infusion of saline is used. In the latter case, donor blood transfusion is used, and at low pressure, appropriate drugs are injected.
- Funds are introduced to enhance the contraction of the uterus. This will compress the vessels and slightly stop the flow of blood. But for the duration of the drug's action.
- An instrumental examination of the uterine cavity is performed.
- Further, medical care depends on the cause and tactics are selected individually according to the situation.
Treatment of a weak uterine contraction
Treatment of postpartum hemorrhage in this case is based on combating hypotension and preventing the development of atony. That is, it is necessary to stimulate and resume the normal functioning of the muscles of the uterus. There are 4 ways to do this:
Medication. We have already mentioned it. This is the very first and most frequently used method. Special drugs are injected intravenously or into the cervical region, which enhance the contraction. Side effects in case of overdose are worsening of organ contraction, increase or decrease in blood pressure.
Mechanical. Massage is used here. First, light massaging is carried out from the abdomen for about 60 seconds until the moment of contraction. Then the hand is pressed on top of the uterus to release a blood clot. This promotes better contraction. If this turned out to be ineffective, then one hand is inserted into the uterus, the other lies on the stomach, and an external internal massage is done. After that, sutures are applied to the cervical canal to contract the uterus and stop the blood.
Physical. This includes methods that tone the uterus using electric current or cold. In the first case, electrodes are placed on the stomach in the pelvic region and a light current is applied. This procedure is painless. In the second case, an ice bag is placed on the lower abdomen for 30-40 minutes. or use a tampon that has been dipped in ether for anesthesia. When ether evaporates, the surrounding tissues are abruptly cooled, and the cold causes contraction and constricts the vessels.
Tamponade of the uterus. This method is rarely used, in case of ineffectiveness of the previous ones and in preparation for surgery. Here, gauze wipes are used and injected into the uterine cavity to form blood clots. But there is a great risk of an infectious complication.
Another temporary method of stopping bleeding can be used by pressing the abdominal aorta to the spine with a fist, since the uterine vessels extend from the aorta.
Surgical treatments
When the hypotension of the uterus has passed into atony and it is impossible to stop the bleeding by the above methods, then they turn to surgical intervention. Atony is when the uterus no longer responds to any stimuli, and bleeding can only be stopped by invasive means.
First, the patient is put under general anesthesia. The essence of the operation is based on cutting the abdomen and gaining access to the uterus and vessels that are involved in its blood supply, followed by removal of this organ. The operation is carried out in 3 stages:
- Pinched vessels. Here, clamps are used on the uterine and ovarian arteries. If the woman's condition is normalized, then proceed to the next stage.
- Vascular ligation. The uterus is removed from the surgical wound, the desired arteries are found by the characteristic pulsation, tied with threads and cut off. After this, there is a sharp shortage of blood in the uterus, which leads to its contraction. This procedure is used as a temporary measure when the doctor does not know how to extirpate (remove) the uterus. But you need to remove it. A doctor who knows how to do this operation comes to the rescue.
- Extirpation of the uterus. The most radical method of dealing with such bleeding. That is, the organ is completely removed. This is the only way to save a woman's life.
Treatment for blood disease
Since in this case there are often no substances necessary for coagulation, the best way would be a donor blood transfusion. This is due to the fact that the necessary substances will be in the donated blood.
Direct intravenous administration fibrinogen, which is involved in the formation of blood clots. A special substance is also used that reduces the work of the anticoagulant system. All these activities maximize the provision of the body with everything necessary to stop bleeding.
Trauma treatment
In this case, the main cause of bleeding will be soft tissue rupture, which means that the therapy will be based on suturing the damaged tissue. The procedure must be performed after removing the placenta.
Treatment for retained parts of the placenta
The remnants of the placenta are removed either by hand or with the help of instruments. Which method the doctor chooses depends on the period of bleeding.
If blood loss occurs immediately after birth or on the first day, then they resort to manual separation. The second method is used in case of bleeding on days 5-6, since the uterus has already significantly decreased in size.
General anesthesia is mandatory. With the manual method, the hand enters the uterine cavity and parts of the placenta are separated from its walls. The rest is pulled out by the other hand by the umbilical cord and removed. With the inner hand, check the wall of the uterus again for the presence of the remaining parts of the placenta.
With the instrumental department, in fact, everything is the same, only here the uterine cavity is scraped. First, the cervix is \u200b\u200bexpanded with special mirrors, and then a surgical spoon is inserted, the walls are scraped out and the remains are removed.
After treatment and elimination of the cause, correction of pathological conditions arising from blood loss is carried out. With a small blood loss (about 500-700 ml), saline solutions are dripped. If the volume is more than 1 liter, donor blood is transfused. In the case of anemia (low hemoglobin level), iron preparations are prescribed, since it is from it that hemoglobin is formed.
Possible complications of postpartum hemorrhage
With severe postpartum bleeding and untimely provision of proper care, hemorrhagic shock may occur. It is a life-threatening complication when blood pressure drops sharply. The consequence of the body's defensive reaction to a lack of blood.
All remaining blood goes to the main organs (brain, heart, lungs). Because of this, all other organs and tissues suffer from a lack of blood supply. There is a failure of the liver, kidneys and then their failure. The defense mechanism wears out, the blood returns back, which leads to a lack of blood in the brain and, as a result, to death.
With hemorrhagic shock, the countdown goes on for seconds, so therapy should be carried out immediately. Immediately stop bleeding by any means, use artificial ventilation. Drugs are injected that increase blood pressure, normalize metabolism and donate blood, since a lack of blood is the cause of this condition.
How to prevent the development of postpartum hemorrhage
Doctors are directly involved in prevention. Even at the first admission to the antenatal clinic, a full examination of the pregnant woman is carried out for the presence of factors that increase the chance of postpartum bleeding and determine the risk of its occurrence.
For example, one of the risks is placenta previa (incorrect attachment). Therefore, for prevention, it is recommended to have a baby through a cesarean section.
After childbirth, a thorough examination of the genital tract is carried out. The woman is actively monitored for 2 hours. If risk factors are present, oxytocin is dripped after birth to keep the uterus in good shape.
After the woman in labor is discharged from the hospital, and this is not earlier than 15-20 days, a systematic examination by the doctors of the antenatal clinic will be carried out. Since sometimes such women have serious complications: disruptions in the hormonal balance (amenorrhea, postpartum death of the pituitary gland, atrophy of the genitals). Detection of early symptoms will enable effective treatment.
Take good care of your health and more often come to consultations with specialists in order to identify the problem in advance and solve it by discussing the appropriate tactics with your doctor.
Attention! This article is posted for informational purposes only and under no circumstances is scientific material or medical advice and can not serve as a substitute for an in-person consultation with a professional doctor. For diagnostics, diagnosis and treatment prescription, please contact qualified doctors!
Number of reads: Date of publication:Bleeding in the successive and early postpartum period is the most dangerous complication of childbirth.
Epidemiology
The frequency of bleeding in the successive period is 5-8%.
BLEEDING IN THE SUBSEQUENT PERIOD
Causes of bleeding in the subsequent period of labor:
- violation of the separation of the placenta and the discharge of the placenta (partial dense attachment or ingrowth of the placenta, infringement of the separated placenta in the uterus);
- hereditary and acquired defects of hemostasis;
Disruption of placenta separation and discharge of placenta
Violation of the separation of the placenta and discharge of the placenta is observed when:
- pathological attachment of the placenta, tight attachment, ingrowth of chorionic villi;
- hypotension of the uterus;
- anomalies, structural features and attachment of the placenta to the wall of the uterus;
- infringement of the placenta in the uterus;
Etiology and pathogenesis
Anomalies, structural features and attachment of the placenta to the wall of the uterus, often contribute to a violation of the separation and excretion of the placenta.
For the separation of the placenta, the area of \u200b\u200bcontact with the surface of the uterus matters.
With a large attachment area, a relatively thin or leathery placenta (placenta membranacea), the small thickness of the placenta prevents its physiological separation from the walls of the uterus. The placenta, in the form of lobes, consisting of two lobes, with additional lobules, are separated from the wall of the uterus with difficulty, especially with hypotension of the uterus.
Violation of the separation of the placenta and discharge of the placenta may be due to the placenta attachment; in the lower uterine segment (with a low position and presentation), in the corner or on the lateral walls of the uterus, on the septum, above the myomatous node. In these places, the muscles are defective and cannot develop the contraction forces necessary to separate the placenta. Infringement of the placenta after separation of the placenta occurs when it is retained in one of the uterine corners or in the lower segment of the uterus, which is most often observed with discoordinated contractions in the successive period.
Violation of the discharge of the born placenta can be iatrogenic if the postpartum period is mismanaged.
An untimely attempt to isolate the placenta, massage of the uterus, including according to Crede-Lazarevich, stretching the umbilical cord, the introduction of large doses of uterotonic drugs violate the physiological course of the third period, the correct sequence of contractions of various parts of the uterus. One of the reasons for the violation of the separation of the placenta and the discharge of the placenta is the hypotension of the uterus.
With uterine hypotension, sequential contractions are either weak or absent long time after the birth of the fetus. As a result, both the separation of the placenta from the uterine wall and the discharge of the placenta are disturbed; at the same time, infringement of the placenta in one of the uterine corners or the lower uterine segment of the uterus is possible. The successive period is characterized by a protracted course.
Clinical picture
The clinical picture of a violation of the separation of the placenta and the discharge of the placenta depends on the presence of areas of the separated placenta. If the placenta is not separated throughout, then clinically determine the absence of signs of placenta separation for a long time and the absence of bleeding.
Partial separation of the placenta is more common, when one or another area is separated from the wall, and the rest remains attached to the uterus. In this situation, muscle contraction at the level of the detached placenta is not enough to compress the vessels and stop bleeding from the placental site. The main symptoms with a partial separation of the placenta are the absence of signs of placenta separation and bleeding. Bleeding occurs a few minutes after the baby is born. Liquid blood, mixed with clots of various sizes, flows out in jerks, unevenly. Retention of blood in the uterus and in the vagina often creates a false idea about the cessation or absence of bleeding, as a result of which measures aimed at stopping it may be delayed. Sometimes blood accumulates in the uterine cavity and in the vagina, and then it is secreted in clots after external detection of signs of placenta separation. On external examination, there are no signs of separation of the placenta. The fundus of the uterus is at the level of the navel or higher, deviated to the right. The general condition of a woman in labor depends on the degree of blood loss and changes rapidly. In the absence of timely assistance, hemorrhagic shock occurs. The clinical picture of a violation of the discharge of a restrained placenta is the same as in violation of the separation of the placenta from the uterine wall (also accompanied by bleeding).
Diagnostics
Complaints about bleeding of varying intensity. Laboratory tests for bleeding in the subsequent period:
- clinical blood test (Hb, hematocrit, erythrocytes);
- coagulogram;
- with massive blood loss, CBS, blood gases, plasma lactate level
- blood chemistry;
- plasma electrolytes;
- Analysis of urine;
Physical examination data:
- no signs of placental separation (Schroeder, Kustner-Chukalov, Alfelts);
- with manual separation of the placenta with physiological and dense attachment of the placenta (placenta adhaerens), infringement, as a rule, you can remove all lobes of the placenta by hand.
With true chorion ingrowth, it is impossible to separate the placenta from the wall without violating its integrity. Often, the true ingrowth of the placenta is established only with a histological examination of the uterus removed due to the alleged hypotension and massive bleeding in the postpartum period.
Instrumental methods... It is possible to accurately determine the variant of pathological attachment with targeted ultrasound during pregnancy and manual separation of the placenta in the subsequent period.
Birth canal injuries
Bleeding from ruptures of the soft tissues of the birth canal is pronounced when the vessels are damaged. Ruptures of the cervix are accompanied by bleeding in violation of the integrity of the descending branch of the uterine artery (with lateral ruptures of the cervix). With low attachment of the placenta and pronounced vascularization of the tissues of the lower segment of the uterus, even small injuries of the cervix can lead to massive bleeding. With vaginal injuries, bleeding occurs from ruptures of varicose veins, a. vaginalis or its branches. Bleeding is possible with high ruptures involving the fornices and the base of the wide uterine ligaments, sometimes a. uterinae. With perineal ruptures, bleeding occurs from the branches of a. pudendae. Ruptures in the area of \u200b\u200bthe clitoris, where the network of venous vessels is developed, is also accompanied by severe bleeding.
Diagnostics
Diagnosis of bleeding from soft tissue ruptures is not difficult, with the exception of damage to deep branches a. vaginalis (bleeding can simulate uterine). Discontinuity a. vaginalis may indicate hematomas of the soft tissues of the vagina.
Differential diagnosis
In differential diagnosis, the following signs of bleeding from soft tissue ruptures are taken into account:
- bleeding occurs immediately after the birth of the child;
- despite bleeding, the uterus is dense, well contracted;
- the blood does not have time to coagulate and flows out of the genital tract in a liquid stream of bright color.
Defects of hemostasis
Features of bleeding with defects in hemostasis - the absence of clots in the blood flowing from the genital tract. Treatment and management of pregnant women with pathology of the third stage of labor The goal of treatment is to stop bleeding, which is carried out by:
- separation of the placenta and discharge of the placenta;
- suturing of tears of soft tissues of the birth canal;
- normalization of hemostasis defects.
The sequence of measures for delayed separation of the placenta and the absence of bleeding from the genitals:
- catheterization of the bladder (often causes increased contractions of the uterus and separation of the placenta);
- puncture or catheterization of the ulnar vein, intravenous administration of crystalloids for the purpose of adequate correction of possible blood loss;
- the introduction of uterotonic drugs 15 minutes after expulsion of the fetus (oxytocin intravenous drip 5 units in 500 ml of 0.9% sodium chloride solution);
- with the appearance of signs of separation of the placenta - allocation of the placenta by one of the accepted methods (Abuladze, Krede-Lazarevich);
- in the absence of signs of placenta separation within 20-30 minutes against the background of the introduction of reducing agents, produce manual separation placenta and placenta discharge. If epidural anesthesia was used during childbirth, manual removal of the placenta and the release of the placenta are performed before the end of the anesthetic. If anesthesia was not used during childbirth, this operation is performed against the background of intravenous anesthetics (propofol). After removal of the placenta, the uterus usually contracts, I tightly wrap my arm. If the tone of the uterus is not restored, uterotonic drugs are additionally administered, bimanual compression of the uterus is performed by inserting the right hand into the anterior fornix of the vagina;
- if you suspect a true ingrowth of the placenta, it is necessary to stop the attempt to separate in order to avoid massive bleeding and perforation of the uterus.
The sequence of measures for bleeding in the third stage of labor:
- catheterization of the bladder. Puncture or catheterization of the ulnar vein with the connection of intravenous infusions;
- determination of signs of separation of the placenta (Schroeder, Kustner-Chukalov, Alfelts);
- with positive signs of separation of the placenta, an attempt is made to isolate the afterbirth according to Krede-Lazarevich, first without anesthesia, then against the background of anesthesia;
- in the absence of effect from external methods of allocation of the placenta, it is necessary to perform manual separation of the placenta and the allocation of the placenta.
IN postoperative period it is necessary to continue the intravenous administration of uterotonic drugs and from time to time gently, without excessive pressure, perform external massage of the uterus and squeeze out blood clots from it. Bleeding due to ruptures of the cervix, clitoris, perineum and vagina is stopped by immediate suturing and restoration of tissue integrity. On the breaks of the soft birth canal, sutures are applied after the release of the placenta. The exception is the rupture of the clitoris, the restoration of the integrity of which is possible immediately after the birth of the child. Visible bleeding from the vessels of the perineal wound after episiotomy is stopped by the imposition of clamps, and after removal of the placenta from the uterus - by suturing. If a hematoma of soft tissues is detected, they are opened and sutured. When a bleeding vessel is identified, it is ligated. Hemostasis is normalized, and in case of bleeding caused by hemostasis disorder, its correction is performed.
Prevention
Rational management of childbirth; the use of regional anesthesia. Careful and correct management of the third stage of labor. Exclusion of unreasonable stretching of the umbilical cord of the uterus.
BLEEDING IN THE EARLY POSTNATAL PERIOD
Epidemiology
The frequency of bleeding in the early postpartum period is 2.0-5.0% of the total number of births. By the time of occurrence, early and late postpartum hemorrhages are distinguished. Early or primary bleeding is considered to be postpartum hemorrhage that occurs within 24 hours after delivery, after this period it is classified as late or secondary.
Bleeding within 2 hours after delivery occurs for the following reasons:
- delay of parts of the placenta in the uterine cavity;
- hereditary or acquired defects of hemostasis;
- hypotension and atony of the uterus;
- trauma of the soft birth canal;
- eversion of the uterus (see the chapter on injuries);
To determine a generalized understanding of the etiology of bleeding, the 4T scheme can be used:
- "tissue" - a decrease in the tone of the uterus;
- "tone" - a decrease in the tone of the uterus;
- "trauma" - ruptures of the soft birth canal and uterus;
- "blood clots" - a violation of hemostasis.
Retention of parts of the placenta in the uterine cavity
The retention of parts of the placenta in the uterine cavity prevents its normal contraction and clamping of the uterine vessels. The reason for the retention of parts of the placenta in the uterus can be a partial tight attachment or an increase in the afterbirth lobules. The delay of the membranes is most often associated with improper management of the postpartum period, in particular, with excessive forcing of the birth of the placenta. The retention of the membranes is also observed during their intrauterine infection, when it is easy to break their integrity. It is not difficult to determine the retention of parts of the placenta in the uterus after birth. When examining the placenta, a defect in the tissues of the placenta, the absence of membranes, and torn membranes are revealed.
Finding parts of the placenta in the uterus can lead to infection or bleeding, both in the early and late postpartum period. Sometimes massive bleeding occurs after discharge from the maternity hospital on the 8-21st day of the postpartum period (late postpartum bleeding). Identification of a defect in the placenta (placenta and membranes), even in the absence of bleeding, is an indication for manual examination and emptying of the uterine cavity.
Classification
Uterine hypotonia - a decrease in the tone and contractility of the muscles of the uterus. Reversible state. Atony of the uterus is a complete loss of tone and its contractile ability. At present, it is considered inappropriate to divide bleeding into atonic and hypotonic. The definition of "hypotonic bleeding" is accepted.
The clinical picture of the main symptoms of uterine hypotension;
- bleeding;
- decrease in the tone of the uterus;
- symptoms of hemorrhagic shock.
Blood with hypotension of the uterus is first released with clots, usually after external massage of the uterus. The uterus is flabby, the upper border can reach the navel and above. The tone can recover after external massage, then decrease again, bleeding resumes. In the absence of timely assistance, the blood loses its ability to clot. In accordance with the amount of blood loss, symptoms of hemorrhagic shock appear (pallor of the skin, tachycardia, hypotension, etc.).
Diagnostics
Diagnosis of hypotonic bleeding is not difficult. Differential diagnosis should be carried out with trauma to the uterus and genital tract.
Treatment
The goal of treatment is to stop bleeding. Stopping bleeding with hypotension should be carried out simultaneously with measures to correct blood loss and hemostasis.
With blood loss in the range of 300-400 ml after confirming the integrity of the placenta, perform external massage of the uterus, simultaneously inject uterotonic drugs (oxytocin 5 U in 500 ml of NaCl 0.9% solution) or carbetocin 1 ml (intravenously slowly), misoprostol (mirolite) 800-1000 μg per rectum once. An ice pack is placed on the lower abdomen.
In case of blood loss of more than 400.0 ml or in the presence of a defect in the placenta, under intravenous anesthesia or ongoing epidural anesthesia, a manual examination of the uterus is performed, if necessary, bimanual compression of the uterus. In the process of helping to stop bleeding, you can press the abdominal aorta to the spine through abdominal wall... This reduces blood flow to the uterus. Subsequently, the tone of the uterus is checked by external methods and uterotonics are continued intravenously.
With bleeding of 1000-1500 ml or more, a woman's pronounced reaction to less blood loss, embolization of the uterine vessels or laparotomy is necessary. The most optimal at the present time, in the presence of conditions, should be considered when embolization of the uterine arteries according to the generally accepted method. In the absence of conditions for embolization of the uterine arteries, laparotomy is performed.
As an intermediate method in preparation for surgery, a number of studies suggest intrauterine tamponade with a hemostatic balloon. The algorithm for using a hemostatic balloon is presented in the appendix. With profuse uterine bleeding, one should not waste time on the introduction of a hemostatic balloon, but proceed with a laparotomy, or, if possible, with UAE. In laparotomy, at the first stage, with experience or a vascular surgeon, the internal iliac arteries are ligated (the technique of ligation of the internal iliac arteries is presented in the appendix). If there are no conditions, then sutures are applied to the uterine vessels or the uterus is compressed using hemostatic sutures according to one of the methods B-Lynch, Pereira, Hayman. Cho, V.E. Radzinsky (for the technique, see the Appendix). When the lower segment is overstretched, tightening sutures are applied to it.
The effect of suturing lasts 24-48 hours. With continued bleeding, the uterus is extirpated. Laparotomy uses an apparatus to reinfuse blood from the incisions and abdomen. Timely implementation of organ-preserving methods allows you to achieve hemostasis in most cases. In conditions of ongoing bleeding and the need to switch to radical intervention, they help to reduce the intensity of bleeding and the total amount of blood loss. Conservation methods for stopping postpartum hemorrhage are mandatory. Only the lack of effect from the above measures is an indication for radical intervention - extirpation of the uterus.
Organ-preserving methods of surgical hemostasis in the majority do not lead to the development of complications. After ligation of the internal iliac and ovarian arteries, the blood flow in the uterine arteries is restored in all patients by 4-5 days, which corresponds to physiological values.
Prevention
Oxytocin is administered intravenously at the end of the second stage of labor in patients at risk for bleeding due to uterine hypotension.
With hereditary and congenital defects of hemostasis, a plan for the management of childbirth is planned in conjunction with hematologists. The principle of therapeutic measures is the introduction of fresh frozen plasma and glucocorticoids.
Patients at risk of bleeding should be warned of the possibility of bleeding during labor. With massive bleeding, extirpation of the uterus is possible. If possible, instead of ligating the vessels and removing the uterus, embolization of the uterine arteries is performed. Transfusion of your own blood from the abdominal cavity is highly advisable. In case of rupture of the uterus and soft birth canal, suturing is performed, in case of violation of hemostasis - correction.
Therapies
In childbirth, physiological blood loss is 300-500 ml - 0.5% of body weight; for caesarean section - 750-1000 ml.; with a planned cesarean section with hysterectomy - 1500 ml; for emergency hysterectomy - up to 3500 ml.
Massive obstetric bleeding is defined as a loss of more than 1000 ml of blood, or\u003e 15% of the circulating blood volume, or\u003e 1.5% of body weight.
Severe life-threatening bleeding is considered:
- loss of 100% of the circulating blood volume within 24 hours, or 50% of the circulating blood volume in 3 hours;
- blood loss at a rate of 15 ml / min, or 1.5 ml / kg per minute (over 20 minutes);
- instantaneous blood loss of more than 1500-2000 ml, or 25-35% of the circulating blood volume.
Determination of the volume of blood loss
Visual assessment is subjective. The underestimation is 30-50%. Volume less than average is overestimated and large volume losses are underestimated. In practice, it is of great importance to determine the amount of blood lost:
- the use of a measuring container makes it possible to take into account the outflow of blood, but does not allow measuring the remaining blood in the placenta (approximately 153 ml). Inaccuracy is possible when mixing blood with amniotic fluid and urine;
- gravimetric method - determining the difference in the mass of the operating material before and after use. Wipes, balls and diapers should be of standard size. The method is not free from error when mixing amniotic fluid. The error of this method is within 15%.
- acid-hematinic method - calculating the volume of plasma using radioactive isotopes, using labeled erythrocytes, the most accurate, but more complicated and requires additional equipment.
Due to the difficulty of accurately determining blood loss, the body's response to blood loss is of great importance. Accounting for these components is essential for determining the volume of infusion required.
Diagnostics
Due to an increase in the volume of circulating blood and SV, pregnant women are able to tolerate significant blood loss with minimal changes in hemodynamics until the late stage. Therefore, in addition to taking into account the lost blood, indirect signs of hypovolemia acquire special importance. In pregnant women, compensatory mechanisms persist for a long time, and they are able, with adequate therapy, to endure, in contrast to non-pregnant women, significant blood loss.
The main symptom of decreased peripheral blood flow is a capillary filling test, or white spot symptom. It is performed by pressing the nail bed, raising the thumb or other part of the body for 3 seconds until a white coloration appears, indicating the cessation of capillary blood flow. After the end of the pressure, the pink color should be restored in less than 2 seconds. An increase in the recovery time of the pink color of the nail bed for more than 2 seconds is noted in case of microcirculation disorder.
A decrease in pulse pressure and shock index is an earlier sign of hypovolemia than systolic and diastolic blood pressure, measured separately.
Shock index - the ratio of the heart rate to the value of systolic blood pressure, which changes with a blood loss of 1000 ml or more. Normal values \u200b\u200bare 0.5-0.7. Decreased urine output with hypovolemia often precedes other signs of circulatory disorders. Adequate diuresis in a patient not receiving diuretics indicates sufficient blood flow in the internal organs. To measure the rate of urine output, 30 minutes are enough:
- insufficient diuresis (oliguria) - less than 0.5 ml / kg per hour;
- reduced urine output - 0.5-1.0 ml / kg per hour;
- normal urine output - more than 1 ml / kg per hour.
Respiratory rate and state of consciousness should also be assessed prior to mechanical ventilation.
Intensive management of obstetric bleeding requires coordinated action, which should be rapid and, if possible, simultaneous. It is carried out together with an anesthesiologist - resuscitator against the background of measures to stop bleeding. Intensive therapy (resuscitation) is carried out according to the ABC scheme: airways (Aigway), breathing (Breathing), blood circulation (Cigculation).
After the assessment of breathing, an adequate supply of oxygen is ensured: intra-nasal catheters, masked spontaneous or mechanical ventilation. After assessing the patient's breathing and the start of oxygen inhalation, notification and mobilization are made for the upcoming joint work of obstetricians - gynecologists, midwives, operating nurses, anesthesiologists-resuscitators, nurses-anesthetists, an emergency laboratory, a blood transfusion service. Vascular surgeon and angiography specialists are called in if necessary. At the same time, a reliable venous access is provided. Peripheral catheters 14Y (315 ml / min) or 16Y (210 ml / min) are used.
With collapsed peripheral veins, venesection or catheterization of the central vein is performed. In hemorrhagic shock or blood loss of more than 40% of the circulating blood volume, catheterization of the central vein (preferably the internal jugular vein) is indicated, preferably with a multi-lumen catheter, which provides additional intravenous access for infusion and allows control of central hemodynamics. In conditions of impaired blood coagulation, access through the cubital vein is preferable.When installing a venous catheter, it is necessary to take a sufficient amount of blood to determine the initial parameters of the coagulogram, hemoglobin concentration, hematocrit, platelet count, and conduct tests for compatibility in case of possible blood transfusion. Bladder catheterization should be performed and minimal monitoring of hemodynamic parameters should be provided: ECG, pulse oximetry, non-invasive blood pressure measurement. All measurements should be documented. Blood loss must be considered. In the intensive care of massive bleeding, the leading role belongs to infusion therapy
The goal of fluid therapy is to recover:
- the volume of circulating blood;
- tissue oxygenation;
- hemostasis systems;
- metabolism.
With an initial violation of hemostasis, therapy is aimed at eliminating the cause. During infusion therapy, a combination of crystalloids and colloids is optimal, the volume of which is determined by the amount of blood loss.
The rate of introduction of solutions is of great importance. The critical pressure (60-70 mm Hg) should be reached as soon as possible. Adequate values \u200b\u200bof blood pressure figures are achieved with an ITT\u003e 90 mm Hg. In conditions of decreased peripheral blood flow and hypotension, no invasive measurement blood pressure may not be accurate, in which case invasive blood pressure measurement is preferred.
The initial replenishment of the circulating blood volume is carried out at a rate of 3 liters for 515 minutes under the control of ECG, blood pressure, saturation, capillary filling test, blood CBS and diuresis. Further therapy can be carried out either discretely at 250-500 ml for 10-20 minutes with an assessment of hemodynamic parameters, or with constant monitoring of central venous pressure. Negative values \u200b\u200bof central venous pressure indicate hypovolemia, however, they are possible with positive values \u200b\u200bof central venous pressure, therefore, the response to volumetric load, which is carried out by infusion at a rate of 1020 ml / min for 10-15 minutes, is more informative. An increase in central venous pressure of more than 5 cm of water. Art. indicates heart failure or hypervolemia, a slight increase in central venous pressure values, or its absence indicate hypovolemia. To obtain sufficient left heart filling pressure to restore tissue perfusion, sufficient high values central venous pressure (10-12 cm water column and above)
The criterion for adequate replenishment of the fluid deficit in the circulation is central venous pressure and hourly urine output. Until the central venous pressure reaches 12-15 cm of water. Art. and the hourly urine output will not become\u003e 30 ml / h, the patient needs I.T.
Additional indicators of the adequacy of fluid therapy and tissue blood flow are:
- saturation of mixed venous blood, target values \u200b\u200bof 70% or more;
- positive test of capillary filling;
- physiological values \u200b\u200bof blood CBS. Lactate clearance: it is desirable to reduce its level by 50% within 1 hour; IT. continue until the lactate level is less than 2 mmol / l;
- sodium concentration in urine less than 20 mol / l, urine / plasma osmolarity ratio more than 2, urine osmolarity more than 500 mOsm / kg - signs of ongoing renal perfusion disorders.
In intensive care, hypercapnia, hypocapnia, hypokalemia, hypocalcemia, fluid overload, and excessive correction of acidosis with sodium bicarbonate should be avoided. Restoration of the oxygen transport function of the blood.
Indications for blood transfusion:
- concentration of hemoglobin 60-70 g / l;
- blood loss of more than 40% of the circulating blood volume;
- unstable hemodynamics.
In patients with a body weight of 70 kg, one dose of erythrocyte mass increases the hemoglobin concentration by approximately 10 g / l, hematocrit - by 3%. To determine the required number of doses of erythrocyte mass (n) with ongoing bleeding and a hemoglobin concentration of 60-70 g / l, an approximate calculation is convenient using the formula:
N \u003d (100x / 15,
Where n is the required number of doses of erythrocyte mass,
- the concentration of hemoglobin.
For blood transfusion, it is advisable to use a system with leukocyte filters, which helps to reduce the likelihood of immune reactions caused by leukocyte transfusion. An alternative to transfusion of erythrocyte mass: intraoperative hardware reinfusion of blood (transfusion of erythrocytes collected during the operation and washed out). A relative contraindication for its use is the presence of amniotic fluid. To determine the Rh-positive blood factor in newborns, Rh-negative postpartum women need to enter an increased dose of human immunoglobulin anti-Rh Rho [D], since when using this method, fetal erythrocytes may enter.
Correction of hemostasis. During the treatment of a patient with bleeding, the function of the hemostasis system is most often affected by the influence of infusion drugs, with coagulopathy of dilution, consumption, and loss. Dilution coagulopathy is of clinical importance when more than 100% of the circulating blood volume is replaced, manifested by a decrease in the content of plasma coagulation factors. In practice, dilutional coagulopathy is difficult to distinguish from DIC. To normalize hemostasis, use the following drugs.
Fresh frozen plasma. The indications for transfusion of fresh frozen plasma are:
- APTT\u003e 1.5 from baseline with ongoing bleeding;
- bleeding of III-IV class (hemorrhagic shock).
The initial dose is 12-15 ml / kg, repeated doses are 5-10 ml / kg. The rate of transfusion of fresh frozen plasma is not less than 1000-1500 ml / h, when the coagulation parameters are stabilized, the rate is reduced to 300-500 ml / h. It is desirable to use fresh frozen plasma, which has undergone leukoreduction. Cryoprecipitate containing fibrinogen and factor VIII is indicated as an additional agent for the treatment of hemostatic disorders with a fibrinogen content of 1 g / l.
Thromboconcentrate. The possibility of platelet transfusion is considered in the following cases:
- platelet count less than 50,000 / mm3 against a background of bleeding;
- platelet count less than 20-30,000 / mm3 without bleeding;
- with clinical manifestations of thrombocytopenia or thrombocytopathy (petechial rash). One dose of platelet concentrate increases the platelet count by approximately 5000 / mm3. Usually 1 U / 10 kg is used (5-8 bags).
Antifibrinolytics. Tranexamic acid and aprotinin inhibit plasminogen activation and plasmin activity. The indication for the use of anti-fibrinolytics is pathological primary activation of fibrinolysis. To diagnose this condition, a test for lysis of an euglobulin clot with streptokinase activation or a 30-minute lysis with thromboelastography is used.
Antithrombin III concentrate. With a decrease in the activity of antithrombin III less than 70%, the restoration of the anticoagulant system is shown using the transfusion of fresh frozen plasma or antithrombin III concentrate. The activity of antithrombin III must be maintained within 80-100%. Recombinant activated factor VIIa was developed for the treatment of bleeding episodes in patients with hemophilia A and B. As an empirical hemostatic, the drug is successfully used in various conditions associated with uncontrolled severe bleeding. Due to the insufficient number of observations, the role of recombinant factor VII A in the treatment of obstetric bleeding has not been finally determined. The drug can be used after standard surgical and medications stopping bleeding.
Application conditions:
- Hb\u003e 70 g / l, fibrinogen\u003e 1 g / l, platelets\u003e 50,000 / mm3;
- pH\u003e 7.2 (correction of acidosis);
- warming the patient (desirable but not required).
Possible application protocol (by Sobeschik and Breborovich);
- the initial dose is 40-60 mcg / kg intravenously;
- with continued bleeding - repeated doses of 40-60 mcg / kg 3-4 times in 15-30 minutes.
- when a dose of 200 mcg / kg is reached, no effect is necessary to check the conditions for use;
- only after the correction can the next dose of 100 μg / kg be administered.
Adrenomimetics. Used for bleeding for the following indications:
- bleeding during regional anesthesia and sympathetic blockade;
- hypotension when installing additional intravenous lines;
- hypodynamic, hypovolemic shock.
In parallel with the replenishment of the circulating blood volume, a bolus administration of 5-50 mg of ephedrine, 50-200 μg of phenylephrine or 10-100 mg of epinephrine is possible. It is better to titrate the effect by intravenous infusion:
- dopamine - 2-10 mg / (kg min) or more, dobutamine - 2-10 μg / (kg min), phenylpherin - 1-5 μg / (kg x min), epinephrine - 1-8 μg / min.
The use of these drugs aggravates the risk of vascular spasm and organ ischemia, but is justified in a critical situation.
Diuretics Loop or osmotic diuretics should not be used in the acute period during IT. The increase in urine output caused by their use will reduce the value of monitoring urine output or replenishing the circulating blood volume. Moreover, stimulation of diuresis increases the likelihood of developing acute pyelonephritis. For the same reason, the use of solutions containing glucose is undesirable, since noticeable hyperglycemia can subsequently cause osmotic diuresis. Furosemide (5-10 mg intravenously) is indicated only to accelerate the onset of mobilization of fluid from the extracellular space, which should occur approximately 24 hours after bleeding and surgery.
Maintaining temperature balance. Hypothermia disrupts platelet function and reduces the rate of reactions of the blood coagulation cascade (10% for each degree Celsius decrease in body temperature). In addition, the state of the cardiovascular system worsens, oxygen transport (displacement of the Hb-Ch dissociation curve to the left), and elimination of drugs by the liver. It is imperative to warm both the intravenous fluids and the patient. The central temperature must be kept close to 35 °.
Operating table position. In case of blood loss, the horizontal position of the table is optimal. The reverse position of the Trendelenburg is dangerous due to the possibility of an orthostatic reaction and a decrease in MV, and in the Trendelenburg position, the increase in SV is short-lived and is replaced by its decrease due to an increase in afterload. Therapy after stopping bleeding. After stopping the bleeding, I.T. continue until adequate tissue perfusion is restored.
Objectives:
- maintenance of systolic blood pressure over 100 mm Hg. (with the previous hypertension more than 110 mm Hg);
- maintaining the concentration of hemoglobin and hematocrit at a level sufficient for oxygen transport;
- normalization of hemostasis, electrolyte balance, body temperature (\u003e 36 °);
- restoration of diuresis more than 1 ml / kg per hour;
- increased SV;
- the reverse development of acidosis, a decrease in lactate concentration to normal.
Prevention, diagnosis and treatment of possible manifestations of multiple organ failure are carried out. With further improvement of the condition to moderate, the adequacy of the replenishment of the circulating blood volume can be checked using the orthostatic test. The patient lies quietly for 2-3 minutes, then the blood pressure and heart rate are noted. The patient is asked to stand up (standing up is more accurate than sitting down in bed). If symptoms of cerebral hypoperfusion appear, that is, dizziness or lightheadedness, the test should be discontinued and the patient should be put to bed. If these symptoms are absent, heart rate indicators are noted 1 min after lifting. The test is considered positive with an increase in heart rate of more than 30 beats / min or the presence of symptoms of cerebral perfusion. Due to the slight variability, changes in blood pressure are not taken into account. Orthostatic test reveals a 15-20% deficit in circulating blood volume. It is unnecessary and dangerous for hypotension in a horizontal position and signs of shock.
BLEEDING IN THE SUBSEQUENT PERIOD
The causes of bleeding in the III stage of labor are:
1) violation of separation and discharge of the placenta from the uterus;
2) trauma to the soft tissues of the birth canal;
3) hereditary and acquired disorders of hemostasis.
Various types of pathological attachment of the placenta to the wall of the uterus play a special role in delaying the separation of the placenta: (placenta adhaerens),full or partial (Fig. 60), true increment (placenta accreta),full or partial. Complete placental accreta is extremely rare.
The most common pathological attachment of the placenta, its dense attachment, when there is a pathological change in the spongy layer of the decidua, in which, during physiological childbirth, the placenta separates from the uterine wall. As a result of inflammatory or various
Fig. 60.Partial tight attachment of the placenta
dystrophic changes, the spongy layer of the scar is reborn, due to which rupture of tissues in it in the III stage of labor is impossible, and the placenta is not separated.
In some cases, the change in the decidua is significantly pronounced, the compact layer is undeveloped, the spongy and basal layers atrophy, and the zone of fibrinoid degeneration is absent. In such conditions, cathelidones (one or more) of the placenta are directly adjacent to the muscular layer of the uterus. (placenta accreta)or sometimes they penetrate into its thickness. This is a true increment. Depending on the degree of ingrowth of villi into the muscular membrane of the uterus, placenta increta,when it grows into the muscle layer, and placenta percreta- germination by villi of the entire thickness of the muscle and the serous layer of the uterus. The likelihood of placenta accreta increases when it is located in the area of \u200b\u200bthe postoperative scar or in the lower segment of the uterus, as well as with uterine malformations, uterine neoplasms.
Recognition of forms of pathological attachment of the placenta is possible only with manual examination of the uterus in order to separate the placenta. In the presence of a dense attachment of the placenta, it is possible, as a rule, to remove all its lobes by hand. With true placental augmentation, it is impossible to separate the placenta from the uterine wall without violating the integrity of the uterus. Often, the true increment of the placenta is established by pathomorphological and histological examination of the uterus.
Violation of the separation and discharge of the placenta can be caused by the place of attachment of the placenta: in the lower uterine segment, in the corner or on the lateral walls of the uterus, on the septum, where the musculature is less complete, and sufficient contractile activity necessary for the separation of the placenta cannot develop.
The cause of bleeding can be not only a violation of the separation of the placenta, but also a violation of the discharge of the placenta, which is observed with discoordination of uterine contractions. In this case, a delay of the already separated placenta in the uterus is possible due to its infringement in one of the uterine corners or in the lower segment due to their contraction and spasm. The uterus often takes the shape of an "hourglass", which makes it difficult to isolate the placenta.
The specified pathology is observed with improper management of the postpartum period. Untimely, unnecessary manipulations,
combat seizure of the uterus or rough control over the separation of the placenta, massage of the uterus, attempts to squeeze the placenta according to Krede-Lazarevich in the absence of signs of placental separation, attraction to the umbilical cord, the introduction of large doses of uterotonic drugs can disrupt the physiological course of the third stage of labor. With premature compression of the uterus by hand, a retroplacental hematoma is squeezed out, which normally contributes to the separation of the placenta.
The clinical picture.In case of violation of the separation of the placenta and the discharge of the placenta, bleeding from the genital tract appears. The blood flows out as if by jerks, temporarily stopping, sometimes blood accumulates in the vagina, and then clots; bleeding increases with the use of external methods of separating the placenta. Retention of blood in the uterus and in the vagina creates a false idea of \u200b\u200bthe absence of bleeding, as a result of which the measures aimed at identifying and stopping it are delayed. With an external examination of the uterus, there are no signs of separation of the placenta. The general condition of a woman in labor is determined by the degree of blood loss and can change rapidly. In the absence of timely assistance, hemorrhagic shock develops.
Bleeding is sometimes caused by trauma to the soft tissues of the birth canal. These are more often observed with ruptures or stratification of the tissues of the cervix, when branches of the cervical vessels fall into them. In this case, bleeding begins immediately after the birth of the child, it can be massive and contribute to the development of hemorrhagic shock and death of the woman in labor, if it is not recognized in a timely manner. Tears in the clitoris, where there is a large network of venous vessels, are also often accompanied by severe bleeding. It is also possible bleeding from the walls of the vagina, from damaged veins. Tears of the perineum or vaginal walls rarely cause massive bleeding unless the large vessels of the branch are damaged. a. vaginalisor a. pudenda.The exception is high vaginal tears that penetrate the vaults.
In the absence of signs of separation of the placenta within 30 minutes against the background of the introduction of reducing agents, the placenta is manually separated and the placenta is isolated under anesthesia (Fig. 61).
If you suspect a true increment of the placenta, it is necessary to stop trying to separate it and to amputate, extirpate or resect the site of germination.
Fig. 61.Manual removal of the placenta and separation of the placenta
The walls of the uterus are carefully examined to identify additional lobules, remnants of placental tissue and membranes. At the same time, blood clots are removed. After removal of the placenta, the uterus usually contracts, wrapping tightly around the arm. If the tone of the uterus is not restored, then uterotonic drugs are additionally administered, an external-internal dosed massage of the uterus is performed on the fist.
If you suspect a true increase in the placenta, it is necessary to stop separating it and amputate or extirpate the uterus. Excessive diligence when trying to manually remove the placenta can result in massive bleeding and rupture of the uterus.
Diagnostics.The main clinical manifestations: bleeding occurs immediately after the birth of the child; despite the bleeding, the uterus is dense, well contracted, blood flows out of the genital tract in a liquid stream of bright color.
Treatment.Therapeutic measures should be clearly directed to the separation of the placenta and the allocation of the placenta.
The sequence of measures for bleeding in the III stage of labor
1. Catheterization of the bladder.
2. Puncture or catheterization of the ulnar vein.
3. Determination of signs of placenta separation:
1) with positive signs, the placenta is isolated according to Krede-Lazarevich or Abuladze;
2) in the absence of effect from the use of external methods of allocation of the placenta, it is necessary to perform manual separation of the placenta and the allocation of the placenta.
3) in the absence of effect, a lower midline laparotomy, the introduction of uterine-reducing agents into the myometrium, ligation of the uterine vessels is indicated. With continued bleeding against the background of the introduction of uterine-contracting agents, plasma for the correction of hemostasis, extirpation of the uterus is shown after ligation of the internal iliac arteries.
4. Bleeding from ruptures of the cervix, clitoris, perineum and vagina is stopped by restoring tissue integrity.
bleeding in the early postpartum period
The causes of bleeding, which begins after the birth of the placenta, are ruptures of the uterus or soft tissues of the birth canal, defects in hemostasis, as well as retention of parts of the placenta in the uterine cavity (lobules of the placenta, membranes), which prevents the normal contraction of the uterus and promotes bleeding. Diagnostics is carried out on the basis of a thorough examination of the placenta immediately after birth in order to determine the tissue defect. If a defect is found in the tissues of the placenta, membranes, as well as vessels located along the edge of the placenta and torn off at the place of their transition to the membranes (there may be a torn off additional lobule lingering in the uterine cavity), or if there is any doubt about the integrity of the placenta, it is necessary to urgently conduct a manual examination of the uterus and delete its contents.
Hypotonic and atonic bleeding.Common causes of bleeding in the early postpartum period are uterine hypotension and atony. Hypotension of the uterus is understood as a condition in which there is a significant decrease in its tone and a decrease in contractility; the muscles of the uterus respond to various stimuli, but the degree of reactions is inadequate to the strength of the irritation. Uterine hypotonia is a reversible condition. With atony of the uterus, the myometrium completely loses its tone and contractility. Uterine atony is extremely rare, but it can be a source of massive bleeding. Causes of uterine hypotension and atony: malformations of the uterus, fibroids, dystrophic changes in muscles, overstretching of the uterus during pregnancy and childbirth (multiple pregnancy, polyhydramnios, large fetus), rapid or prolonged labor with weak labor, the presence of an extensive placental site, especially in
lower segment, old or young age, neuroendocrine insufficiency. Severe forms of hypotension and massive bleeding, as a rule, are combined with impaired hemostasis, proceeding as DIC-syndrome. Massive bleeding can be a manifestation of multiple organ failure. At the same time, against the background of microcirculatory insufficiency in the muscles of the uterus, ischemic and dystrophic changes, hemorrhages, characterizing the development of shock uterus syndrome, develop.
The clinical picture.The main symptom of uterine hypotension is bleeding. On examination, the uterus is flabby and large. When performing an external massage of the uterus, blood clots are released from it, after which the tone of the uterus is restored, but then hypotension is again possible. With atony, the uterus is soft, pasty, its contours are not determined. The fundus of the uterus reaches the xiphoid process. Continuous and profuse bleeding occurs. The clinical picture of hemorrhagic shock develops rapidly.
Diagnosticsis not difficult. At first, blood is released with clots, later it loses its ability to clot. With atony, the uterus does not respond to mechanical stimuli, while with hypotension, weak contractions are noted in response to mechanical stimuli.
Measures to stop bleeding are carried out against the background of infusion-transfusion therapy (Table 16) and includes the following.
1. Emptying the bladder.
2. With blood loss exceeding 350 ml, external massage of the uterus is performed through the anterior abdominal wall. At the same time, uterotonic drugs are administered. On the lower part belly put an ice pack.
3. With continued bleeding and blood loss of more than 400 ml under anesthesia, manual examination of the uterus is performed, as well as dosed external-internal massage of the uterus on the fist, at the same time uterotonic drugs with prostaglandins are injected intravenously. After the uterus has contracted, the hand is removed from the uterus.
4. With continued bleeding, the volume of which was 1000-1200 ml, the issue of surgical treatment and removal of the uterus should be resolved. You cannot rely on repeated administration of uterotonic drugs, manual examination and massage of the uterus if they were ineffective the first time. The loss of time in repeating these methods
dov leads to an increase in blood loss and a deterioration in the condition of the postpartum woman, bleeding becomes massive, hemostasis is disturbed, hemorrhagic shock develops, and the prognosis for the patient becomes unfavorable.
Table 16
Protocol for infusion-transfusion therapy of obstetric bleeding
In the process of preparing for the operation, a number of measures are used: pressing the abdominal aorta to the spine through the anterior abdominal wall, applying Baksheev's clamps to the cervix; 3-4 abortions are applied to the side walls, the uterus is shifted down.
If the operation is performed quickly with blood loss not exceeding 1300-1500 ml, and complex therapy has stabilized the functions of vital systems, it is possible to limit ourselves to supravaginal amputation of the uterus. With continued bleeding and the development of DIC syndrome, hemorrhagic shock, extirpation of the uterus, drainage of the abdominal cavity, and ligation of the internal iliac arteries are shown. A promising method is to stop bleeding by embolization of uterine vessels.
Prevention of bleeding in the postpartum period
1. Timely treatment of inflammatory diseases, the fight against abortion and recurrent miscarriage.
2. Correct management of pregnancy, prevention of gestosis and complications of pregnancy.
3. Correct management of childbirth: a competent assessment of the obstetric situation, optimal regulation of labor. Pain relief during labor and timely resolution of the issue of operative delivery.
4. Prophylactic administration of uterotonic drugs from the moment the head is inserted, careful observation in the postpartum period. Especially in the first 2 hours after childbirth.
5. Mandatory emptying of the bladder after the birth of the child, ice on the lower abdomen after the birth of the placenta, periodic external massage of the uterus. Careful recording of lost blood and assessment general condition postpartum women.