Lecture 8

BLEEDING IN THE SUBSEQUENT AND EARLY

POSTPARTUM

1. Bleeding in the afterbirth period.

2. Bleeding in the early postpartum period.

3. Pathogenesis of bleeding.

4. Therapy.

5. Literature.

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

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

Causes of mortality:

belated inadequate hemostasis;

Incorrect infusion-transfusion tactics;

Violation of the stages and sequence of obstetric care.

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

The fertilized egg enters the uterine cavity in the morula stage, surrounded on all sides by the trophoblast. Trophoblast cells have the ability to secrete a proteolytic enzyme, due to which the fetal egg, in contact with the uterine mucosa, attaches to it, dissolves the underlying areas of the decidual tissue, and nidation occurs within 2 days. With nidation, the proteolytic properties of the cytotrophoblast increase. Destruction of the decidua on the 9th day of ontogenesis leads to the formation of lacunae containing maternal blood poured out of the destroyed vessels. From the 12-13th day, the connective tissue begins to grow into the primary villi, and then the vessels. Secondary and then tertiary villi are formed. Gas exchange and the provision of nutrients to the fetus will depend on the correct formation of the villi. The main organ of pregnancy is formed - the placenta. Its main anatomical and physiological unit is placenton. Its constituent parts are cotylidon and curuncle. Cotylidone- this is the fruiting part of the placenton, it consists of a stem villus with numerous branches containing fruiting vessels. Their main mass is localized in the superficial - compact layer of the endometrium, where they swim freely in the intervillous spaces filled with maternal blood. To ensure the fixation of the placenta to the wall of the uterus, there are "anchor" villi that penetrate into the deeper - spongy layer of the endometrium. They are much smaller than the main villi and it is they that are torn in the process of separation of the placenta from the uterine wall in the afterbirth period. The loose spongy layer is easily displaced with a sharp decrease in the uterine cavity, while the number of opened anchor villi is not large, which reduces blood loss. In normal placentation, chorionic villi never penetrate the basal layer of the endometrium. From this layer, the endometrium will be reborn in the future.

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

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

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

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

At the second stage, the mechanism of thrombotamponade is realized. It consists in the intensive formation of clots in the clamped spiral arteries. The processes of blood coagulation in the area of ​​the placental site are provided by a large amount of tissue thromboplastin formed during placental abruption. The rate of formation of clots in this case exceeds the rate of thrombus formation in the systemic circulation by 10-12 times.

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

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

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

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

Violations of the mechanism of placentation

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

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

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

3. Dystrophic changes in the myometrium in multiparous women.

4. Inferiority of the endometrium in infantilism.

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

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

Bleeding in the postpartum period

Violation of the processes of separation of the placenta

Tight attachment of the placenta

True placental accreta

Hypotonic condition of the uterus

The location of the placenta in one of the uterine angles

Rupture of the uterus, soft birth canal

Ø Infringement of the separated placenta

Ø DIC

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

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

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

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

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

4. Placentapercraeta- rare, chorionic villi germinate the wall of the uterus to the serous cover and destroy it. The villi are exposed, and profuse intra-abdominal bleeding begins. Such a pathology is possible when the placenta is attached in the area of ​​the scar, where the endometrium is completely absent, and the myometrium is almost not expressed, or when the fetal egg is nided in the rudimentary horn of the uterus.

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

The clinical picture in cases of total dense attachment of the placenta is extremely rare. In the succession period, there is no violation of the integrity of the intervillous spaces, there are no signs of separation of the placenta and bleeding. In this situation, the waiting time is 30 minutes. If during this time there are no signs of placental separation, there is no bleeding, the diagnosis of total dense attachment of the placenta becomes obvious. Tactics - active separation of the placenta and the allocation of the placenta. The type of anomaly of placentation is determined during the operation. In this case, blood loss exceeds physiological, because. separation occurs within the compact layer.

BLEEDING IN THE SUBSEQUENT PERIOD.

RETENTION OF THE CHILD'S PLACE AND ITS PARTS IN THE UTERINE CAVITY

Bleeding that occurs after the birth of the fetus is called bleeding in the afterbirth period. It occurs when a child's place or its parts are delayed. With the physiological course of the succession period, the uterus after the birth of the fetus decreases in volume and contracts sharply, the placental site decreases in size and becomes smaller than the size of the placenta. During subsequent contractions, retraction of the muscular layers of the uterus occurs in the area of ​​​​the placental site, due to this, a rupture of the spongy layer of the decidua occurs. The process of separation of the placenta is directly related to the strength and duration of the retraction process. The maximum duration of the follow-up period is normally no more than 30 minutes.

Postpartum bleeding.

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

Early postpartum hemorrhage.

The causes of early postpartum hemorrhage can be:

a. hypo- and atony of the uterus

b. birth canal injury

in. coagulopathy.

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

Uterine atony- this is a condition in which stimulants of the uterus do not have any effect on it. The neuromuscular apparatus of the uterus is in a state of paralysis. Atony of the uterus is rare, but causes massive bleeding.

Causes of uterine hypotension in the early postpartum period. A muscle fiber loses its ability to contract normally in three cases:

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

2. Excessive fatigue of the muscle fiber. This situation is observed during the prolonged course of the birth act, with the irrational use of large doses of tonomotor drugs, with fast and rapid childbirth, as a result of which exhaustion occurs. I remind you that fast should be considered in primiparous labor lasting less than 6 hours, in multiparous - less than 4 hours. Childbirth is considered to be rapid if it lasts less than 4 hours for the first and less than 2 hours for the multiparous, respectively.

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

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

There are two clinical variants of early postpartum hypotonic bleeding:

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

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

Differential Diagnosis hypotonic bleeding is carried out with traumatic injuries of the birth canal. In contrast to hypotonic bleeding in trauma of the birth canal, the uterus is dense, well reduced. Examination of the cervix and vagina with the help of mirrors, manual examination of the walls of the uterine cavity confirm the diagnosis of soft tissue ruptures of the birth canal and bleeding from them.

There are 4 main groups of methods to combat bleeding in the early postpartum period.

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

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

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

Cold in the lower abdomen. Prolonged cold irritation reflexively maintains the tone of the uterine muscles.

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

Tamponade of the posterior vaginal fornix with ether.

Electrotonization of the uterus, is performed in the presence of equipment.

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

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

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

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

n removal of the remnants of the fetal egg, lingering in the uterine cavity (placental lobules, membranes).

n removal of blood clots that have accumulated in the uterine cavity.

n the final stage of the operation is the massage of the uterus on the fist, which combines mechanical and reflex methods of influencing the uterus.

3. Mechanical methods.

Refer to manual pressing of the aorta.

Clamping of parameters according to Baksheev.

It is currently used as a temporary measure to buy time in preparation for surgical methods to control bleeding.

4. Surgical operational methods. These include:

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

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

Supravaginal amputation of the uterus is possible with hypotonic bleeding, as well as with true rotations of the placenta with a highly located placental site. In these cases, this volume allows you to remove the source of bleeding and provide reliable hemostasis. However, when a DIC syndrome developed as a result of massive blood loss, the scope of the operation should be expanded to a simple extirpation of the uterus without appendages with additional double drainage of the abdominal cavity.

Extirpation of the uterus without appendages is indicated in cases of cervical isthmus location of the placenta with massive bleeding, with PONRP, Kuveler's uterus with signs of DIC, as well as with any massive blood loss accompanied by DIC.

Dressing Art Iliaca interna. This method is recommended as an independent, preceding or even replacing hysterectomy. This method is recommended as the final stage in the fight against bleeding in advanced DIC after hysterectomy and lack of sufficient hemostasis.

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

TREATMENT

Treatment for hypotonic bleeding is complex. It is started without delay, at the same time, measures are taken to stop bleeding and replenish blood loss. Therapeutic manipulations should begin with conservative ones, if they are ineffective, then immediately move on to surgical methods, up to ablation and removal of the uterus. All manipulations and measures to stop bleeding should be carried out in a strictly defined order without interruption and be aimed at increasing the tone and contractility of the uterus.

The system for combating hypotonic bleeding includes three stages.

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

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

Activities of the first stage bleeding control are as follows:

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

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

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

4) examination of the birth canal, stitching of gaps;

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

In the absence of effect, confidence in the cessation of bleeding, as well as in case of blood loss equal to 500 ml, one should proceed to blood transfusion.

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

With continued bleeding proceed to the third stage.

Third stage: blood loss exceeding masses body i.e. 1001-1500 ml.

The main tasks of the third stage of the fight against hypotonic bleeding: removal of the uterus before development hypocoagulation, compensation shortfall warning blood loss more than 500 ml., preservation of the volume ratio of injected blood and blood substitutes: 1, timely compensation of respiratory function (IVL) and kidneys, which allows stabilizing hemodynamics. Compensation for blood loss by 200 .

Activities of the third stage .

For uncontrolled bleeding, intubation anesthesia with mechanical ventilation, abdominal surgery, temporary stop of bleeding in order to normalize hemodynamic and coagulation indicators (the imposition of clamps on the corners of the uterus, the bases of the broad ligaments, isthmic part of the tubes, own ligaments of the ovaries and round ligaments of the uterus).

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

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

Uterine tamponade and suture according to Lositskaya, as methods of combating postpartum hemorrhage, were withdrawn from the arena of funds as a dangerous and misleading doctor about the true value blood loss and uterine tone connections, with which operational intervention is belated.

The pathogenesis of hemorrhagic shock

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

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

Redistribution of blood. In a puerperal, this is carried out due to the release of blood from the uterine circuit into the bloodstream, containing up to 500 ml of blood.

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

In cases where blood loss exceeds 20% of the BCC, the body is not able to restore the compliance of the BCC and the vascular bed at the expense of its reserves. Blood loss passes into the decompensated phase and centralization of blood circulation occurs. To increase venous return, arteriovenous shunts are opened, and blood, bypassing the capillaries, enters the venous system. This type of blood supply is possible for organs and systems: skin, s / c fiber, muscles, intestines, and kidneys. This entails a decrease in capillary perfusion and hypoxia of the tissues of these organs. The volume of venous return slightly increases, but to ensure adequate cardiac output, the body is forced to increase the heart rate - in the clinic, along with a slight decrease in systolic blood pressure with increased diastolic tachycardia appears. The stroke volume increases, the residual blood in the ventricles of the heart decreases to a minimum.

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

In conditions of a secondary decrease in BCC and low blood pressure due to a sharp decrease in stroke volume in the capillary network, a "sludge syndrome" ("scum") occurs. Bonding of formed elements occurs with the formation of microclots and thrombosis of the microvasculature. The appearance of fibrin in the bloodstream activates the fibrinolysis system - plasminogen turns into plasmin, which breaks the fibrin strands. The patency of the vessels is restored, but again and again formed clots, absorbing blood factors, lead the blood coagulation system to exhaustion. Aggressive plasmin, not finding a sufficient amount of fibrin, begins to break down fibrinogen - along with fibrin degradation products, fibrinogen degradation products appear in the peripheral blood. DIC enters the stage of hypocoagulation. Virtually devoid of clotting factors, the blood loses its ability to coagulate. In the clinic, bleeding with non-clotting blood occurs, which, against the background of multiple organ failure, leads the body to death.

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

n blood loss should be determined as accurately and reliably as possible

n there must be an objective individual assessment of the response of a given patient to a given blood loss.

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

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

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

In case of delivery through the natural birth canal, a visual method for assessing blood loss using measuring containers. This method, even for experienced specialists, gives 30% errors.

Determination of blood loss by hematocrit represented by Moore formulas: In this formula, it is possible to use another indicator instead of hematocrit - hemoglobin content, the true values ​​of these parameters become real only 2-3 days after the blood is completely diluted.

The Nelson formula is based on the hematocrit. It is reliable in 96% of cases, but informative only after 24 hours. It is necessary to know the initial hematocrit.

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

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

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

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

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

1. infusion volume

2. composition of infusion media

3. rate of infusion.

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

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

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

Prevention of bleeding in the postpartum period

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

2. Proper management of pregnancy, prevention of preeclampsia and complications of pregnancy.

3. Proper management of childbirth: competent assessment of the obstetric situation, optimal regulation of labor activity. Anesthesia of childbirth and timely resolution of the issue of operative delivery.

4. Prophylactic administration of uterotonic drugs starting from the moment of insertion of the head, careful monitoring in the postpartum period. Especially in the first 2 hours after childbirth.

Mandatory emptying of the bladder after the birth of a child, ice on the lower abdomen after the birth of the placenta, periodic external massage of the uterus. Careful accounting of lost blood and assessment of the general condition of the puerperal.

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2. Gynecology / Ed. G.M. Savelieva, V.G. Breusenko.-M., 2004

3. Obstetrics. Ch. 1,2, 3 / Ed. V.E. Radzinsky.-M., 2005.

4. Obstetrics from ten teachers / Ed. S. Campbell.-M., 2004.

5. Practical skills in obstetrics and gynecology / L.A. Suprun.-Mn., 2002.

6. Smetnik V.P. Non-operative gynecology.-M., 2003

1. Bohman Ya.V. Guide to oncogynecology.-SPb., 2002
2. Practical guide for an obstetrician-gynecologist / Yu.V. Tsvelev et al. - St. Petersburg, 2001
3. Practical gynecology: (Clinical lectures) / Ed. IN AND. Kulakov and V.N. Prilepskaya.-M., 2002
4. Guide to practical exercises in gynecology / Ed. Yu.V. Tsvelev and E.F. Kira.-SPb., 2003
5. Khachkuruzov S.G. Ultrasound examination during early pregnancy.-M., 2002
6. Guide to endocrine gynecology / Ed. EAT. Vikhlyaeva.-M., 2002.

Lecture #4

Pathological course of childbirth and the postpartum period

PM.02 Participation in medical diagnostic and rehabilitation processes

MDC 02.01 SP in obstetrics and pathology of the reproductive system in men and women

By specialty

nursing

Bleeding in the postpartum period

Causes of bleeding in the postpartum period:

- Decreased tone of the uterus.

- Violation of the contractile activity of the uterus.

- Anomalies of placenta attachment: incomplete placenta previa.

- Anomalies in the location of the placenta: low attachment or location in one of the tubal corners of the uterus.

- Irrational management of the afterbirth period: massaging the uterus, pressing on its bottom, pulling on the umbilical cord is unacceptable.

Clinical symptoms of bleeding in the postpartum period:

1) If the bleeding has reached 350 ml (or 0.5% of the mother's body weight) and it continues, this is pathological bleeding. The strength of bleeding depends on the size of the exfoliated part of the placenta and on the site 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.

Diagnosis of afterbirth delay:

1) To understand whether the separation of the placenta has occurred or not, you can use the described signs of separation of the placenta:

- Schroeder sign: after separation of the placenta, the uterus rises above the navel, becomes narrow and deviates to the right;

- sign of Alfeld: the exfoliated placenta descends to the internal pharynx of the cervix or into the vagina, while the outer part of the umbilical cord lengthens by 10-12 cm;

- sign of Mikulich: after separation of the placenta and its lowering, the woman in labor has a need to push;

- Klein sign: when straining a woman in labor, the umbilical cord lengthens. If the placenta has separated, then after an attempt the umbilical cord is not tightened;

- sign of Kyustner-Chukalov: when the obstetrician presses over the pubic symphysis with the separated placenta, the umbilical cord will not be retracted.

If the birth proceeds normally, then the placenta will separate no later than 30 minutes after the expulsion of the fetus.

Diagnosis of delayed parts of the placenta:

1) Examination of the placenta and membranes after birth: if there are irregularities, roughness and depressions, then this is a defect in the placenta.

Treatment for retention of the placenta and its parts in the uterine cavity:

1) Conservative method:

Injection of 1 ml (5 units) of oxytocin to increase the aftereffects

In cases of separation of the placenta from the uterus, but its retention in the cavity, external methods are used to isolate the placenta from the uterus: Bayer-Abuladze, Krede-Lazarevich methods, etc.

2) Operative method: if conservative measures do not give an effect, and the blood loss has exceeded the physiological limits, then immediately proceed to the operation of manual separation and removal of the placenta (performed by a doctor)

After emptying the uterus, contracting agents are introduced, cold on them in the abdomen.

Antibiotics.

With blood loss of more than 0.7% of body weight - infusion therapy.

Prevention of the 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 to 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 forces of the body, the central nervous system as a result of prolonged painful childbirth.

2) Severe preeclampsia, GB.

3) Anatomical inferiority of the uterus.

4) Functional inferiority of the uterus: overstretching of the uterus due to multiple pregnancy, multiple pregnancy.

5) Presentation and low attachment of a child's seat.

Clinic of hypotonic bleeding:

1) Massive bleeding from the uterus: blood flows out in a jet or large clots.

2) Hemodynamic disorders, signs of anemia.

3) The picture of hemorrhagic shock gradually develops.

Diagnosis of hypotonic bleeding:

1) The presence of bleeding.

2) Objective data on the state of the uterus: on palpation, the uterus is large, relaxed.

Treatment of 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 the tone of the uterus is conservative.

2) The fight against hemodynamic disorders.

3) Chestectomy and removal of the uterus.

4) Surgical methods:

Ligation of the vessels of the uterus. If that doesn't help, then

Amputation (removal of the body of the uterus) or extirpation (removal of both the body and the 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.

Anomalies of tribal forces

Anomalies of the birth forces are a fairly common complication of the birth act. The consequences of anomalies in the contractile activity of the uterus during childbirth can be very dangerous for both the mother and the fetus.

Causes of labor anomalies:

Maternal pathology: somatic and neuroendocrine diseases; complicated course of pregnancy; pathological change in the myometrium; overdistension of the uterus; genetic or congenital pathology of myocytes, in which the excitability of the myometrium is sharply reduced.

Pathology of the fetus and placenta: malformations of the nervous system of the fetus; fetal adrenal aplasia; placenta previa and its low location; accelerated, delayed maturation.

Mechanical obstacles to the advancement of the fetus: narrow pelvis; pelvic tumors; malposition; incorrect insertion of the head; anatomical rigidity of the cervix;

Non-simultaneous (non-synchronous) readiness of the body of the mother and fetus;

iatrogenic factor.

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

term "atony" indicate the state of the uterus, in which the myometrium completely loses its ability to contract. Hypotension characterized by a decrease in tone and insufficient ability of the uterus to contract.

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

clinical picture. Two clinical variants of bleeding in the early postpartum period can be observed.

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

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

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

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

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

During the operation, you can determine the degree of violation of the motor function of the uterus. With preserved contractile function, the force of contraction is felt by the operating hand, with hypotension, weak contractions are noted, and with atony of the uterus, there are no contractions, despite mechanical and medicinal effects. When hypotension of the uterus is established during the operation, a (carefully!) massage of the uterus on the fist is performed. Caution is necessary to prevent violations of the functions of the blood coagulation system due to the possible entry into the mother's bloodstream of a large amount of thromboplastin.

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

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

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

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

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

The outcome of the fight against bleeding largely depends on the sequence of measures taken and the precise organization of the assistance provided.

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

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

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

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

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

The intensity of antihypertensive therapy depends on the severity of preeclampsia. With nephropathy of the first degree, it is possible to confine oneself to enteral or parenteral administration of no-shpa, aminofillin, papaverine, dibazol; with nephropathy of the II degree, methyldopa, clonidine are prescribed.

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

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

The complex of therapeutic agents includes vitamins C, B r B 6 , E.

The effectiveness of treatment depends on the severity of nephropathy: with grade I, as a rule, therapy is effective; at I degree, great efforts and time are required. If within 2 weeks it is not possible to achieve a lasting effect, then it is necessary to prepare the pregnant woman for delivery.

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

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

1) ensure a protective regime;

2) eliminate vascular spasm and hypovolemia;

3) prevent or treat fetal hypoxia.

A woman must comply with bed rest. She is prescribed small tranquilizers: chlozepid (elenium), sibazon (seduxen), nozepam (tazepam), etc. Antihistamines (diphenhydramine, pipolfen, suprastin) are added to enhance the sedative effect.

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

Magnesium sulfate treatment is combined with the appointment of antispasmodics and vasodilators (no-shpa, papaverine, dibazol, eufillin, methyldopa, apressin, clonidine, etc.).

If necessary, use ganglioblokiruyuschie drugs (pentamine, gigronium, imekhin, etc.).

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

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

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

The whole complex of therapeutic agents helps to correct hypovolemia, reduce peripheral arteriospasm, regulate protein and water-salt metabolism, improve microcirculation in the vital organs of the mother, and has a positive effect on uteroplacental blood flow. The addition of trental, sigetin, cocarboxylase, inhalation of oxygen, sessions of hyperbaric oxygenation improve the condition of the fetus.

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

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

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

Legion of eclampsia

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

Birth management. Childbirth aggravates the course of preeclampsia and exacerbates fetal hypoxia. This should be remembered when choosing the time and method of delivery.

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

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

2) with a mouth expander or spatula, the mouth is carefully opened, the tongue is pulled out, and the upper respiratory tract is freed from saliva and mucus;

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

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

5) start drip intravenous administration of magnesium sulfate.

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

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

POLYHYDROLOGY. LOW WATER

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

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

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

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

Chronigic polyhydramnios usually has no clinical manifestations: the pregnant woman adapts to the slow accumulation of amniotic fluid.

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

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

At objective research there is pallor of the skin, a decrease in the subcutaneous fat layer; in some pregnant women, the venous pattern on the abdomen increases. The circumference of the abdomen and the height of the uterine fundus do not correspond to the gestational age, significantly exceeding them. The uterus is sharply enlarged, tense, hard-elastic consistency, spherical shape. When feeling the uterus, fluctuation is determined. The position of the fetus is unstable, often transverse, oblique, possibly breech presentation; on palpation, the fetus easily changes its position, parts of the fetus are palpated with difficulty, sometimes they are not defined at all. The presenting part is located high, running. The fetal heartbeat is poorly audible, muffled. Sometimes expressed excessive motor activity of the fetus. Diagnosis of polyhydramnios is helped by data from a vaginal examination: the cervix shortens, the internal os opens slightly, and a strained fetal bladder is determined.

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

When diagnosed with polyhydramnios, it is necessary to conduct research in order to identify the causes of its occurrence. Although this is not always possible, it should be striven for. Assign all studies aimed at identifying (or clarifying the severity) of diabetes mellitus, isosensitization by the Rh factor; clarify the nature of malformations and the state of the fetus; identify the presence of a possible chronic infection.

Differential diagnosis is carried out with polyhydramnios, hydatidiform drift, ascites and giant ovarian cystoma. Ultrasound scanning is invaluable in this regard.

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

The most common complication is miscarriage pregnancy. In acute polyhydramnios, which often develops before the 28-week period, a miscarriage occurs. With chronic polyhydramnios, in some women, pregnancy can be carried to term, but more often ends in premature birth. Another complication, which is often combined with the threat of termination of pregnancy, is the premature rupture of the membranes due to their degenerative changes.

Rapid discharge of amniotic fluid can lead to prolapse of the umbilical cord or small parts of the fetus, contribute to premature detachment of a normally located placenta.

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

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

Management of pregnancy and childbirth. Pregnant women with suspected polyhydramnios are subject to hospitalization to clarify the diagnosis and identify the cause of its development. Having confirmed the diagnosis, choose tactics for further management of pregnancy.

If during the examination anomalies of fetal development that are incompatible with life are found, the woman is prepared for termination of pregnancy through the natural birth canal. When an infection is detected, adequate antibiotic therapy is carried out, taking into account the effect of drugs on the fetus. In the presence of isoserological incompatibility of the blood of the mother and fetus, pregnancy is carried out in accordance with the accepted tactics. Having identified diabetes mellitus, they carry out treatment aimed at its compensation.

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

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

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

Childbirth in the presence of polyhydramnios proceeds with complications. Often there is a weakness of labor activity. Polyhydramnios leads to overstretching of the muscle fibers of the uterus and to a decrease in their contractility. Obstetric care begins with the opening of the fetal bladder. Amniotomy must be performed carefully, with an instrument, and amniotic fluid should be released slowly to avoid placental abruption and prolapse of the umbilical cord and small parts of the fetus. 2 hours after the opening of the fetal bladder, in the absence of intensive labor activity, labor-stimulating therapy should be started. To prevent bleeding in the afterbirth and early postpartum periods "with the last attempt" of the period of exile, intravenous methylergometrine or oxytocin must be administered. If the mother received

labor stimulation with the help of intravenous administration of means that reduce the uterus, then it is continued in the afterbirth and early postpartum periods.

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

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

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

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

The course of pregnancy. Oligohydramnios often leads to miscarriage. There is hypoxia, malnutrition, anomalies in the development of the fetus.

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

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

Only 14% of births proceed without complications. One of the pathologies of the postpartum period is postpartum hemorrhage. There are many reasons for this complication. It can be both diseases of the mother, and complications of pregnancy. There are also postpartum hemorrhages.

Early postpartum hemorrhage

Early postpartum hemorrhage is bleeding that occurs within the first 2 hours after the birth of the placenta. The rate of blood loss in the early postpartum period should not exceed 400 ml or 0.5% of the woman's body weight. If the blood loss exceeds the indicated figures, then they speak of pathological bleeding, but if it is 1 percent or more, then this indicates massive bleeding.

Causes of early postpartum hemorrhage

Causes of early postpartum hemorrhage may be related to maternal illness, complications of pregnancy and/or childbirth. These include:

• long and difficult childbirth;
• stimulation of contractions with oxytocin;
• overstretching of the uterus (large fetus, polyhydramnios, multiple pregnancy);
• woman's age (over 30 years);
• blood diseases;
• rapid childbirth;
• the use of painkillers during childbirth;
• (for example, fear of surgery);
• dense attachment or increment of the placenta;
• retention of part of the placenta in the uterus;
• and / or rupture of the soft tissues of the birth canal;
• malformations of the uterus, a scar on the uterus, myomatous nodes.

Early postpartum hemorrhage clinic

As a rule, early postpartum hemorrhage occurs as hypotonic or atonic (with the exception of injuries of the birth canal).

Hypotonic bleeding

This bleeding is characterized by rapid and massive blood loss, when the puerperal loses 1 liter of blood or more in a few minutes. In some cases, the blood loss occurs in waves, alternating between good uterine contraction and no bleeding, and sudden relaxation and flaccidity of the uterus with increased bleeding.

Atonic bleeding

Bleeding that develops as a result of untreated hypotonic bleeding or inadequate therapy of the latter. The uterus completely loses its contractility and does not respond to irritants (tweezing, external massage of the uterus) and therapeutic measures (Kuveler's uterus). Atonic bleeding is profuse in nature and can lead to the death of the puerperal.

Therapeutic measures for early postpartum hemorrhage

First of all, it is necessary to assess the condition of the woman and the amount of blood loss. Ice must be placed on the stomach. Then inspect the cervix and vagina and, if there are tears, suture them. If bleeding continues, a manual examination of the uterus (mandatory under anesthesia) should be started and after emptying the bladder with a catheter. During manual inspection of the uterine cavity, all the walls of the uterus are carefully examined by hand and the presence of a rupture or fissure of the uterus or residual placenta / blood clots is detected. The remains of the placenta and blood clots are carefully removed, then a manual massage of the uterus is performed. At the same time, 1 ml of a contracting agent (oxytocin, methylergometrine, ergotal, and others) is injected intravenously. To consolidate the effect, you can enter 1 ml of uterotonic into the anterior lip of the cervix. If there is no effect from manual control of the uterus, it is possible to insert a tampon with ether into the posterior fornix of the vagina or apply a transverse catgut suture to the posterior lip of the cervix. After all procedures, the volume of blood loss is replenished with infusion therapy and blood transfusion.

Atonic bleeding requires immediate surgery (extirpation of the uterus or ligation of the internal iliac arteries).

Late postpartum hemorrhage

Late postpartum hemorrhage is bleeding that occurs 2 hours after delivery and later (but not more than 6 weeks). The uterus after childbirth is an extensive wound surface that bleeds for the first 2 to 3 days, then the discharge becomes sanious, and then serous (lochia). Lochia lasts 6 to 8 weeks. In the first 2 weeks of the postpartum period, the uterus actively contracts, so by 10-12 days it disappears behind the womb (that is, it cannot be palpated through the anterior abdominal wall) and, with a bimanual examination, reaches sizes that correspond to 9-10 weeks of pregnancy. This process is called uterine involution. Simultaneously with the contraction of the uterus, the cervical canal is also formed.

Causes of late postpartum hemorrhage

The main causes of late postpartum hemorrhage include:

• retention of parts of the placenta and / or membranes of the fetus;
• blood clotting disorders;
• subinvolution of the uterus;
• blood clots in the uterine cavity with a closed cervical canal (caesarean section);
• endometritis.

Clinic of late postpartum hemorrhage

Bleeding in the late postpartum period begins suddenly. Often it is very massive and leads to a sharp anemia of the puerperal and even to hemorrhagic shock. Late postpartum hemorrhage should be distinguished from increased bleeding during breastfeeding (the uterus begins to contract due to increased production of oxytocin). A characteristic sign of late bleeding is increased spotting of a bright red color or changing the pad more often than every 2 hours.

Treatment of late postpartum hemorrhage

In the event of late postpartum hemorrhage, if possible, ultrasound of the pelvic organs should be performed. On ultrasound, the uterus is determined, larger than the prescribed size, the presence of blood clots and / or remnants of the membranes and placenta, the expansion of the cavity.

With late postpartum hemorrhage, it is necessary to curettage the uterine cavity, although a number of authors do not adhere to this tactic (the leukocyte shaft in the uterine cavity is disturbed and its walls are damaged, which can later lead to the spread of infection outside the uterus or). After surgical arrest of bleeding, complex hemostatic therapy continues with the introduction of reducing and hemostatic agents, replenishment of circulating blood volume, blood and plasma transfusion, and antibiotics.

Bleeding in the afterbirth and early postpartum periods

What is Bleeding in the afterbirth and early postpartum periods -

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

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

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

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

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

What provokes / Causes of Bleeding in the afterbirth and early postpartum periods:

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

• Physiology of postpartum hemostasis

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

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

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

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

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

• Postpartum hemostasis disorders

Violations in the hemocoagulation system may be due to:

• pre-pregnancy changes in hemostasis;
• disorders of hemostasis due to complications of pregnancy and childbirth (antenatal death of the fetus and its prolonged retention in the uterus, preeclampsia, premature detachment of the placenta).

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

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

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

Therefore, the following can be considered prerequisites for reducing the tone of the uterus even before the onset of childbirth:

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

The most common causes of dysfunction of the myometrium, arising or aggravated during childbirth, are the following.

Depletion of the neuromuscular apparatus of the myometrium due to:

• excessively intense labor activity (fast and rapid childbirth);
• discoordination of labor activity;
• protracted course of childbirth (weakness of labor activity);
• irrational administration of uterotonic drugs (oxytocin).

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

Prolonged use of oxytocin for labor induction and labor stimulation can lead to blockade of the neuromuscular apparatus of the uterus, resulting in its atony and further resistance to agents that stimulate myometrial contractions. The risk of amniotic fluid embolism increases. The stimulating effect of oxytocin is less pronounced in multiparous women and women in labor over 30 years of age. At the same time, hypersensitivity to oxytocin was noted in patients with diabetes mellitus and pathology of the diencephalic region.

Operative delivery. The frequency of hypotonic bleeding after operative delivery is 3-5 times higher than after vaginal delivery. In this case, hypotonic bleeding after operative delivery can be due to various reasons:

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

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

The defeat of the neuromuscular apparatus of the myometrium due to the entry into the vascular system of the uterus of thromboplastic substances with elements of the fetal egg (placenta, membranes, amniotic fluid) or products of the infectious process (chorioamnionitis). In some cases, the clinical picture caused by amniotic fluid embolism, chorioamnionitis, hypoxia and other pathologies may have an erased, abortive character and is manifested primarily by hypotonic bleeding.

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

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

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

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

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

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

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

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

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

Pathogenesis (what happens?) During Bleeding in the afterbirth and early postpartum periods:

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

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

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

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

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

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

Characteristic changes are also edematous swelling of muscle fibers and edematous loosening of the interstitial tissue. The constancy of these changes indicates their role in the deterioration of uterine contractility. These changes are most often the result of a history of obstetric and gynecological diseases, somatic diseases, preeclampsia, leading to the development of hypotonic bleeding.

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

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

Symptoms of bleeding in the afterbirth and early postpartum periods:

Bleeding in the aftermath

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

Bleeding in this period occurs if there is a partial or complete separation of the placenta. However, it is usually not permanent. Blood is secreted in small portions, often with clots. When the placenta separates, the first portions of blood accumulate in the uterine cavity and in the vagina, forming clots that are not released due to the weak contractile activity of the uterus. Such accumulation of blood in the uterus and in the vagina can often create a false impression that there is no bleeding, as a result of which appropriate therapeutic measures can be started late.

In some cases, bleeding in the afterbirth period may be due to retention of the separated placenta due to infringement of its part in the uterine horn or cervical spasm.

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

Disturbances in the discharge of the placenta are most often due to unreasonable and gross manipulations with the uterus during a premature attempt to release the placenta or after the administration of large doses of uterotonic drugs.

Bleeding due to abnormal attachment of the placenta

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

The decidua basalis is divided into compact and spongy layers. The basal plate of the placenta is formed from the compact layer located closer to the chorion and the cytotrophoblast of the villi. Separate villi of the chorion (anchor villi) penetrate the spongy layer, where they are fixed. With the physiological separation of the placenta, it is separated from the uterine wall at the level of the spongy layer.

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

Pathological changes in the spongy layer may be due to:

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

It is also possible to implant a fetal egg in areas with physiological hypotrophy of the endometrium (in the isthmus and cervix). The likelihood of pathological attachment of the placenta increases with malformations of the uterus (uterine septum), as well as in the presence of submucosal myomatous nodes.

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

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

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

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

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

With partial dense attachment of the placenta and with partial accretion of the placenta due to its fragmentary and uneven separation, bleeding always occurs, which begins from the moment of separation of normally attached areas of the placenta. The degree of bleeding depends on the violation of the contractile function of the uterus at the site of attachment of the placenta, since part of the myometrium in the projection of the unseparated parts of the placenta and in the surrounding areas of the uterus does not contract to the proper extent, as is required to stop the bleeding. The degree of weakening of the contraction varies widely, which determines the bleeding clinic.

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

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

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

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

In the case of placenta accreta, when trying to produce its manual separation, profuse bleeding occurs. The placenta is torn off in pieces, it is not completely separated from the uterine wall, part of the placental lobes remains on the uterine wall. Rapidly developing atonic bleeding, hemorrhagic shock, DIC. In this case, only the removal of the uterus is possible to stop the bleeding. A similar way out of this situation is also possible with the ingrowth and germination of villi into the thickness of the myometrium.

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

In one embodiment, postpartum hemorrhage, which begins, as a rule, immediately after the release of the placenta, may be due to the delay of its parts in the uterine cavity. These may be placental lobules, parts of the membrane that prevent the normal contraction of the uterus. The reason for the delay of parts of the afterbirth is most often a partial accretion of the placenta, as well as improper management of the third stage of labor. With a thorough examination of the placenta after birth, most often, without much difficulty, a defect in the tissues of the placenta, membranes, the presence of torn vessels located along the edge of the placenta is detected. The identification of such defects or even doubt about the integrity of the placenta is an indication for urgent manual examination of the postpartum uterus with the removal of its contents. This operation is performed even if there is no bleeding with a defect in the placenta, since it will definitely appear later.

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

Hypo- and atonic bleeding in the early postpartum period

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

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

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

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

Option 1:

• bleeding from the very beginning is profuse, accompanied by massive blood loss;
• the uterus is flabby, sluggishly responds to the introduction of uterotonic drugs and manipulations aimed at increasing the contractility of the uterus;
• rapidly progressing hypovolemia;
• hemorrhagic shock and DIC develop;
• changes in the vital organs of the puerperal become irreversible.

Option 2:

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

It should be emphasized that the patient's condition depends not only on the intensity and duration of bleeding, but also on the general initial condition. If the forces of the body of the puerperal are exhausted, and the reactivity of the body is reduced, then even a slight excess of the physiological norm of blood loss can cause a severe clinical picture if there has already been an initial decrease in BCC (anemia, preeclampsia, diseases of the cardiovascular system, impaired fat metabolism).

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

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

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

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

In case of severe hypotension of the uterus and primary disorders in the hemocoagulation system in combination with DIC, the duration of bleeding increases accordingly and the prognosis worsens due to the significant complexity of treatment.

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

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

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

Treatment of Bleeding in the afterbirth and early postpartum periods:

Follow-up management for bleeding

• It is necessary to adhere to the expectant-active tactics of maintaining the afterbirth period.
• The physiological duration of the subsequent period should not exceed 20-30 minutes. After this time, the probability of spontaneous separation of the placenta decreases to 2-3%, and the possibility of bleeding increases dramatically.
• At the time of the eruption of the head, the woman in labor is intravenously injected with 1 ml of methylergometrine per 20 ml of a 40% glucose solution.
• Intravenous administration of methylergometrine causes long-term (within 2-3 hours) normotonic contraction of the uterus. In modern obstetrics, methylergometrine is the drug of choice for drug prophylaxis during childbirth. The time of its introduction should coincide with the moment of emptying the uterus. Intramuscular injection of methylergometrine to prevent and stop bleeding does not make sense due to the loss of the time factor, since the drug begins to be absorbed only after 10-20 minutes.
• Perform bladder catheterization. In this case, there is often an increase in uterine contraction, accompanied by the separation of the placenta and the release of the placenta.
• Intravenous drip begin to inject 0.5 ml of methylergometrine together with 2.5 IU of oxytocin in 400 ml of 5% glucose solution.
• At the same time, infusion therapy is started to adequately compensate for pathological blood loss.
• Determine the signs of separation of the placenta.
• When signs of separation of the placenta appear, the placenta is isolated using one of the known methods (Abuladze, Krede-Lazarevich).

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

• In the absence of signs of separation of the placenta after 15-20 minutes with the introduction of uterotonic drugs or in the absence of the effect of the use of external methods for extracting the placenta, it is necessary to manually separate the placenta and remove the placenta. The appearance of bleeding in the absence of signs of separation of the placenta is an indication for this procedure, regardless of the time elapsed after the birth of the fetus.
• After separation of the placenta and removal of the placenta, the internal walls of the uterus are examined to exclude additional lobules, remnants of placental tissue and membranes. At the same time, parietal blood clots are removed. Manual separation of the placenta and separation of the placenta, even without large blood loss (average blood loss 400-500 ml), lead to a decrease in BCC by an average of 15-20%.
• If signs of placenta accreta are detected, attempts to manually separate it should be stopped immediately. The only treatment for this pathology is hysterectomy.
• If the tone of the uterus after the manipulation is not restored, uterotonic agents are additionally administered. After the uterus contracts, the hand is removed from the uterine cavity.
• In the postoperative period, the state of uterine tone is monitored and the administration of uterotonic drugs is continued.

Treatment of hypotonic bleeding in the early postpartum period

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

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

The main tasks in the fight against hypotonic bleeding are:

• the fastest possible stop of bleeding;
• prevention of massive blood loss;
• restoration of the BCC deficit;
• preventing a decrease in blood pressure below a critical level.

If hypotonic bleeding occurs in the early postpartum period, it is necessary to adhere to a strict sequence and staging of measures taken to stop bleeding.

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

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

The main tasks of the first stage:

• stop bleeding, preventing more blood loss;
• provide adequate infusion therapy in terms of time and volume;
• to accurately record blood loss;
• not to allow a shortage of compensation for blood loss of more than 500 ml.

Measures of the first stage of the fight against hypotonic bleeding

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

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

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

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

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

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

You should not count on the effectiveness of repeated manual examination and uterine massage if the desired effect was not achieved during their first application.

To combat hypotonic bleeding, such methods of treatment as the imposition of clamps on the parameters to compress the uterine vessels, clamping of the lateral sections of the uterus, uterine tamponade, etc. are unsuitable and insufficiently substantiated. In addition, they do not belong to pathogenetically substantiated methods of treatment and do not provide reliable hemostasis, their use leads to loss of time and belated use of really necessary methods to stop bleeding, which contributes to an increase in blood loss and the severity of hemorrhagic shock.

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

The main tasks of the second stage:

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

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

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

At this stage of the fight against bleeding with a blood loss approaching 1000 ml, you should deploy the operating room, prepare donors and be ready for emergency abdominoplasty. All manipulations are carried out under adequate anesthesia.

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

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

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

The main tasks of the third stage:

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

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

With unstopped bleeding, the trachea is intubated, mechanical ventilation is started, and abdominal surgery is started under endotracheal anesthesia.

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

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

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

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

Third stage. Radical stop of bleeding - extirpation of the uterus with fallopian tubes.

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

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

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

Ligation of the internal iliac artery

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

Ligation of the internal iliac artery is most often performed when the uterine artery is damaged during hypotonic bleeding, uterine rupture, or extended extirpation of the uterus with appendages. To determine the location of the passage of the internal iliac artery, a cape is used. Approximately 30 mm away from it, the boundary line is crossed by the internal iliac artery, which descends into the cavity of the small pelvis with the ureter along the sacroiliac joint. To ligate the internal iliac artery, the posterior parietal peritoneum is dissected from the cape downwards and outwards, then, using tweezers and a grooved probe, the common iliac artery is bluntly separated and, going down along it, the place of its division into the external and internal iliac arteries is found. Above this place stretches from top to bottom and from outside to inside a light strand of the ureter, which is easily recognizable by its pink color, the ability to contract (peristaltic) when touched and make a characteristic popping sound when slipping out of the fingers. The ureter is retracted medially, and the internal iliac artery is immobilized from the connective tissue membrane, tied with a catgut or lavsan ligature, which is brought under the vessel using a blunt Deschamps needle.

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

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

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

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

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

Prevention of bleeding in the afterbirth and early postpartum periods:

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

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

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

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

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

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

All pregnant risk groups for the development of postpartum hemorrhage for the implementation of the final stage of comprehensive prenatal preparation 2-3 weeks before delivery should be hospitalized in a hospital where a clear plan for the management of childbirth is developed and an appropriate additional examination of the pregnant woman is carried out.

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

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

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

All births should be carried out under cardiac monitoring.

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

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

If anomalies of labor activity occur, they should be eliminated in a timely manner, and if there is no effect, the issue should be resolved in favor of operative delivery according to relevant indications on an emergency basis.

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

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

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

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

Careful monitoring of the patient in the early postpartum period.

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

Which doctors should be contacted if you have Bleeding in the afterbirth and early postpartum periods:

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