Www.vnmu.edu.ua
Vinnitsa Nathional Medical University named after N.I. Pyrogov
Head of Obstetrics and Gynaecology department № 2 PhD, prof. Bulavenkо О.V.__________
the «____» ____________of 20___ year
METHODICAL RECOMMENDATIONS
FOR THE STUDENT’S OF STOMATOLOGICAL FACULTY
FOR PREPARING TO PRACTICAL CLASS
| Subject | Obstetrics |
|Module 1. |Physiological and pathological course of pregnancy, childbirth and the |
| |postpartum period. Perinatal complications. |
| | |
|Semantic module 1. |Physiological and pathological course of pregnancy, childbirth and the |
| |postpartum period. Perinatal complications. |
| | |
|Subject lessons | Obstetric bleeding during the first trimester of pregnancy. Ectopic |
| |pregnancy. Obstetric hemorrhage during the second half of pregnancy, |
| |childbirth and the postpartum period. Resuscitation during hemorrhage in |
| |obstetrics. Operative obstetrics. Maternity injuries. |
|Year of study |4 |
|Faculty |Dental |
|Author |Assistant, Goncharenko O.M. |
Vinnitsa 2013
1. Topicality. This topic is relevant for future physicians as family medicine and obstetrician-gynecologists and for dentists because patients in these categories doctors quite often pregnant women. Knowing the topic helps to reduce maternal mortality and perinatal morbidity. Knowledge algorithm of actions physician in obstetric hemorrhage patients' lives.
2. Specific objectives:
1. Know the classification of obstetric hemorrhage.
2. To analyze the etiology and pathogenesis of ectopic pregnancy.
3. Classify ectopic pregnancy depending on the location.
4. Explain clinic and symptoms of ectopic pregnancy.
5. Be able to identify the symptoms of internal bleeding and hemodynamic disorders.
6. Learn to evaluate the results of puncture of the abdominal cavity through the posterior fornix (differentiate blood from the veins and the abdominal cavity).
7. Know the basic principles of diagnosis and diagnostical errors in ectopic pregnancy.
8. Make a plan of examination of patients with ectopic pregnancy.
9. Read and evaluate the results of clinical and laboratory examination of patients with ectopic pregnancy.
10. Conduct differential diagnosis in a patient with ectopic pregnancy and other nosological forms.
11. Know the basic principles of treatment of ectopic pregnancy.
12. Know the tactics hospital and physician placenta previa and abruption placenta.
13. Differentiate causes of bleeding during pregnancy.
14. To be able to diagnose placenta previa or premature its detachment.
15. Identify and describe the degree of placenta previa.
16. Make and justify individual plan of delivery in placenta previa and abruption in the placenta.
17. To be able to assess the amount of blood loss.
3. Basic knowledge, skills necessary for studying the topic (interdisciplinary integration)
|The names of the preceding disciplines |The skills |
|Department of Human Anatomy |Apply knowledge of the anatomical structure of the female genital organs, blood|
| |supply of the uterus and fallopian tubes, uterine ligaments. |
|Normal physiology |The phases of the menstrual cycle (uterine and ovarian cycle). |
|Physiopathology |Pathophysiological changes in the uterus and fallopian tubes, which can lead to|
| |ectopic pregnancy, premature detachment of normally placed плаценти та |
| |передлежання плаценти. |
|Endocrinology |Female hormones, their place fusion bonds on the phase of the menstrual cycle. |
|General Surgery |Determination of blood group and Rh membership, conduct tests on individual |
| |(group and Rh) and biological compatibility in blood transfusions. |
4. Tasks for independent work in preparation for employment.
List of key terms that students must master in preparation for the Session:
|Term |Definition |
|1. Physiological blood loss during childbirth |- This is 0.5% of body weight women. |
| | |
|2. Ectopic Pregnancy |- Pregnancy, when the fertilized egg is implanted and develops |
| |outside the uterus |
| | |
|3. symptom Kulyenkampfa |- Signs of peritoneal irritation in the absence of local muscular |
| |strain in the lower abdomen. |
| | |
| | - Sharp pain posterior vaginal vault |
|4. symptom "Douglas Creek" | |
| |- Cut the fallopian tube; |
|5. . Salpinhotomiya | |
| |- Removal of the fallopian tubes |
|6. . Salpinhoektomiya | |
| |- The location of the placenta in the lower uterine segment below the|
|7. Placental |presenting part, blocking all or part of the internal cervical os |
| | |
| |- A placental abruption located outside the lower segment of the |
| |uterus during pregnancy or in the first - second stage of labor. |
|8. Premature detachment of placenta - |- Bleeding, which occurred in the first 24 hours after birth |
| |- Bleeding that occurs - after 24 hours to 6 weeks after childbirth |
| | |
| | |
|9. Early postpartum hemorrhage | |
| | |
|10. Late postpartum hemorrhage | |
Theoretical question for the class:
1. What is bleeding?
2. Classification of bleeding.
3. What bleeding occurring during the first half of pregnancy?
4. Tactics treatment of bleeding and half of pregnancy.
5. What bleeding occurring during the second half of pregnancy?
6. Tactics treatment of bleeding the second half of pregnancy
8. Diagnosis of bleeding during childbirth. Tactics doctor.
9. Early postpartum hemorrhage methods to stop bleeding.
10. Late postpartum hemorrhage. Algorithm actions doctor.
11. Methods of stops obstetric hemorrhage.
12. Basic principles of treatment of obstetric hemorrhage.
13. Methods for determining the degree of blood loss.
14. Indications for hysterectomy in obstetric hemorrhage.
15. Rehabilitation of women recovering from obstetric hemorrhage.
Practical work (tasks) to be performed in class:
1. To determine the degree of blood loss during childbirth.
2. To chart the treatment of bleeding and second half of pregnancy.
3. Work out on a mannequin tactics physician in obstetric hemorrhage.
4. Make a table of methods stop postpartum bleeding.
5. To chart treatment of obstetric hemorrhage.
6. Develop a scheme of rehabilitation of women who had bleeding.
5. Organization of the content of educational material (described educational material are structural logic, tables, figures, reflecting the content of the main themes of class).
Among the various types of obstetric pathology uterine bleeding occupy one of the leading causes of maternal mortality. The most dangerous bleeding occur in late pregnancy or during labor and early postpartum period. This kind of disease requires urgent skilled care. Physician of any specialty should be able to organize activities against bleeding. No pathology in obstetrics requires so much knowledge, patience and skill as bleeding.
Classification of obstetric hemorrhage:
Bleeding in the first half of pregnancy:
- Spontaneous abortion;
- Puhyrnyy skidding;
- Ectopic pregnancy (including cervical pregnancy).
Bleeding in early pregnancy:
- Placenta previa;
- Premature detachment of the placenta;
- Uterine rupture.
Bleeding during childbirth:
First period:
- Premature detachment of the placenta;
- Placenta previa;
- Uterine rupture;
- Laceration of the cervix.
Second period:
- Premature detachment of the placenta;
- Uterine rupture.
Third period:
- Pathology of attachment of the placenta;
- Delay, pinched placenta;
- Rupture of soft tissue generic ways.
Postpartum hemorrhage:
- Hypotonic bleeding;
- Delay parts litter;
- Rupture of soft tissue generic ways;
- Uterine rupture;
- Embolism amniotic waters;
- Koahulopatychna bleeding.
Bleeding that is not associated with pregnancy:
- Polyp of the cervix;
- Cervical cancer.
Bleeding in the first half of pregnancy
Ectopic Pregnancy
Ectopic pregnancy is pregnancy, when the fertilized egg is implanted and develops outside the uterus.
Implantation and development of a fertilized egg outside the uterus represents a major threat to the health and lives of women and untimely provision of quality medical care can lead to tragic complications.
The frequency of ectopic pregnancy in relation to the number of gynecological patients, according to different authors, from 11.8 to 26%. According to the Institute of M.V. Sklifosofsky, the incidence of this disease over the past 25 years - 26%.
In recent years there has been a slight increase in the frequency of ectopic pregnancy, it can be explained by the change of the nature and frequency of pro-inflammatory processes of the female genital organs, hormonal interrelation in women in connection with the use of contraceptives, enlarged equation of the number of abortions and complications from them, improving diagnosis in ectopic pregnancy and others.
Modern classification identifies common and rare forms of ectopic pregnancy. The most common form is localization in the fallopian tube (up to 98.5% of cases).
Tubal pregnancy is divided into pregnancy in the fallopian tube ampullar section (43% of cases), in istmical department (53.8%), and interstitial department (2.8%).
Possible transitional forms of tubal pregnancy: tubal-peritoneal, tubal, ovarian, fimbrial (0,4%).
Over the course of tubal pregnancy is divided into:
- Progressive;
- Impaired (tubal abortion, rupture of the fallopian tubes);
- Missed abortion.
The rare form of ectopic pregnancy include:
1. Ovary (0.1-0.2% of cases), which is divided into intrafollicular and ovarian forms.
Intrafollicular - ectopic pregnancy is when the follicle rupture after sperm penetrates into its cavity and there fertilizes the mature egg.
Ovarian - when the fertilized egg is fertilized and inoculated on the surface of the ovary. Maybe ovarian pregnancy occurs more often than is recognized, so during surgery this pathology is regarded as bleeding from the broken corpus luteum.
Developed in case of fertilization in the oral follicle. The frequency of ovarian pregnancy is 0.5-1% of all ectopic pregnancies and ranks second in frequency after tubal pregnancy. The only risk factor for ectopic pregnancy, this option is the use of intrauterine contraceptive devices.
Diagnosis.
Clinical signs are the same as in tubal pregnancy. When impaired ovarian pregnancy possible clinical hemorrhagic shock. In 75% of cases of ovarian pregnancy mistakenly put diagnosed ovarian apoplexy.
For diagnostic helps ultrasound of the pelvic organs, especially the transvaginal probe when visualized fetal egg in the ovary and positive qualitative reaction for HCG.
Signs of ovarian pregnancy with ultrasound:
- Fallopian tube on the side of the stricken unchanged;
- Fetal egg is in the projection of the ovary;
- Fetal egg is connected to the uterus own ovarian ligament;
- Among membranes visualized ovarian tissue.
Treatment.
Surgical treatment includes removal of the ovum and wedge resection of the ovary.
In the case of massive destruction and significant intra-ovarian bleeding perform ovariectomy.
2. Pregnancy in a rudimentary uterine horn (0.9%). From an anatomical point of view, this location should be attributed to uterine pregnancy, but clinical signs of this pregnancy occurs as pipe and ends usually break uterine horn and heavy bleeding.
3. Peritoneal, or abdominal, pregnancy (0.003%).
There are primary and secondary abdominal pregnancy.
During the primary abdominal pregnancy implantation fertilized egg occurs in the peritoneum, omentum and other organs.
Secondary ectopic pregnancy is formed as a result of tubal pregnancy when the fertilized egg unit comes with pipes and secondarily inoculated in the abdominal cavity, sometimes in such cases abdominal pregnancy can develop to later periods. The most frequent localization of abdominal pregnancy is rectal, uterine cavity.
Maternal mortality in abdominal pregnancy at 7-8 times higher than in the tube, and 90 times higher than in the uterine.
Diagnosis.
Clinical manifestations depend on the duration of pregnancy:
1. In the first and early second trimester, they differ little from the symptoms of tubal pregnancy.
2. In later periods are pregnant complain of pain during Fetal Movements, feeling stir in the epigastric region or sudden cessation of Fetal Movements.
3. When physical investigated easily palpable soft parts of the fetus and uterus separately small size. Abdominal pregnancy as diagnosed in the absence of uterine contractions after oxytocin.
4. For diagnosis using ultrasound. If ultrasound uninformative, the diagnosis confirmed by X-ray, CT and MRI. The X-ray abdomen, removed in the lateral projection, rendered shadow skeleton of the fetus, which is superimposed on the shadow ridge mother.
Treatment.
Given the high risk of maternal mortality, immediately after the diagnosis of conduct surgical treatment. During the surgical treatment of isolated and tie up vessels that supply blood to the placenta, and possibly remove it. If this is not possible due to heavy bleeding, apply a tampon. Tampons are removed in 24-48 hours.
When you select these vessels can not, spend ligation and cut the umbilical cord and placenta leave.
Postoperative period.
In case the placenta after surgery in the abdominal cavity, its status was assessed by ultrasound and determination of (-subunit of hCG. In these cases, a very high risk of intestinal obstruction, fistulas, sepsis. The use of methotrexate is contraindicated, as it is accompanied by severe complications, especially sepsis.
The cause of sepsis is massive necrosis of the placenta.
4. Ectopic pregnancy between ligamentous (intraligamentous) (0.1%).
Sometimes the fertilized egg is implanted in the tube begins to develop in the direction of parametrial space, immersed between leaves of the broad ligament of the uterus.
5. Pregnancy in the mesentery of the uterus.
6. Cervical pregnancy - is one of the rare and severe variants of ectopic pregnancy when implantation of the fertilized egg held in the cervical canal.
Diagnosis.
1. Medical history, including gynecological. Pay attention to the number of abortions and post-abortion course period, deferred inflammatory diseases of the internal genitalia, including the cervix.
2. Examination of the cervix in the mirror. Visualization cyanotic barrel cervix.
3. Careful bimanual gynecologic examination. Together with cervix as "hourglass".
4. Ultrasonography of the pelvic organs.
Ultrasound signs of cervical pregnancy:
- The absence of a fertilized egg in the uterus;
- Hyperechoic endometrium (decidual tissue);
- Heterogeneity of biometrics;
- Uterus as hourglass;
- Extension of the cervical canal;
- The fertilized egg into the cervical canal;
- Placental tissue in the canal of the cervix;
- Closed internal uterine os.
Differential diagnosis.
Cervical pregnancy is differentiated from spontaneous abortion, uterine, cervical cancer, uterine submucous deposition on the stem, trophoblastic tumor previa and placenta low. Ultrasound can clearly to distinguish, identify differences between cervical pregnancy and other obstetrical and gynecological pathology.
Treatment.
1. If diagnosed cervical pregnancy - a categorical refusal of scraping the walls of the uterus, which can lead to profuse bleeding.
2. Method of treatment of cervical pregnancy - surgery (hysterectomy).
3. After confirming the diagnosis of cervical pregnancy determine blood group and Rh-factor, establish venous catheter receiving informed written consent of the patient to perform hysterectomy. From the department of Transfusion need to order the same blood group of fresh frozen plasma, fresh red cell mass, preparing drugs hydroxyethyl starch.
Causes and mechanisms of ectopic pregnancy.
Prior to the development of this pathology leading causes of that delay normal ovum transport through the pipe.
1. The main cause of dysfunction of the fallopian tube is different anatomical changes in its wall or in the surrounding tissues and organs, which are often the result of various inflammatory processes.
The first place among the causes occupy inflammation of female genitals, leading to tissue damage pipes. A special role is played by a specific infection. An important place is given to abortion as a cause of pathological changes in the tubes and ovaries.
Inflammation and degeneration of the mucosa leading to bonding the inner walls of the pipe together with the formation of adhesions, ki ¬ sion that essentially gives the patency of tubes. The inflammatory process also damages the muscle membrane and contractile function gives the pipe. Damage serous membrane inflammation leads to the formation of adhesions and zroschuvan pipe surrounding organs, the formation of kinks, closed abdominal end of the tube. At the same time significantly damaged nerve apparatus pipes (varicose, tortuosity, fragmentation of nerve fibers), which also gives the functional state of the pipe.
2. The source of infection of the uterus is often the appendix or other parts of the intestine. Related to this is the greater frequency of right-sided tubal pregnancy. Appendectomy in anamnesis- risk factor for ectopic pregnancy.
3. Operative intervention in other pelvic organs may also be etiological factors of ectopic pregnancy because after surgery often formed adhesions and fusion that alter anatomical relationships in the pelvis, but also affect the normal peristaltic movements of the pipe. Tumors of the uterus and ovaries, endometriosis of tubes, infantilism fallopian tubes, ovarian dysfunction and other endocrine disorders can cause tubal pregnancy.
Risk Factors.
1. Inflammatory diseases of uterus and appendages of the uterus in anamnesis.
2. Scar - commissural changes pelvic due to previous operations on the internal reproductive organs, pelvioperitonit, abortion.
3. Hormonal ovarian function.
4. Genital infantilism.
5. Endometriosis.
6. Long-term use of intrauterine contraceptive devices.
7. Assisted reproductive technology.
Clinical course.
Possible variants of clinical course of ectopic pregnancy:
- Progressive pregnancy (not broken)
- Broken ectopic pregnancy by type of tubal abortion and development of hematoma,
- Broken ectopic pregnancy by type of pipe rupture.
In unruptured ectopic pregnancy in women the changes that are inherent in normal uterine pregnancy in the early period. In developing ovarian corpus luteum, and uterine decidua appears that macroscopic no different from that in uterine pregnancy. Only microscopic elements determined absence of a fertilized egg. The uterus softens and increases slightly in size. Functioning chorion produces human chorionic gonadotropin, which is defined in the research. In women having the same changes as in a normal pregnancy. There are questionable and probable signs of pregnancy: missed period (15-20% of cases of ectopic pregnancy no delay) nahrubayut breast appears colostrum, there are disorders of the nervous system (irritability, drowsiness, mood instability), pigmentation the face, belly white line, nipples. Appears cyanosis of mucous membrane of the vagina and cervix. In the lining of the uterus appears decidual tissue. May occur early gestosis pregnant. Vaginal examination marked softening of the uterus, especially the isthmus, but after 6 weeks pregnant uterus behind in size. Specific features of Horwitz-Gegar, Henter, Gubareva, but no signs of Snegirev and Piskachek.
Should pay attention to anamnesis. In unruptured ectopic pregnancy can sometimes disturb slight pain in the projection appendages. Complete blood count was normal. When conjoined research noteworthy soft, supple texture tumor formation, painful and pulsating palpation side of the uterus. Symptoms of unruptured ectopic pregnancy is limited, but it is enough to ask about the diagnosis and the patient hospitalized immediately for examination and dynamic care. The physician must remember that progressive ectopic pregnancy at any time may disrupt the emergence of massive bleeding into the abdominal cavity, with grave consequences for the health of the patient.
To clarify the diagnosis used additional methods: ultrasound diagnosis, endoscopic diagnosis (laparoscopy, culdoscopy), aiming culdocentesis. After setting the final diagnosis the patient needs immediately operation : conservative-plastic surgery on the tube.
Ectopic pregnancy interrupted course of 4-6 weeks of pregnancy by type of tubal abortion (internal rupture of fetal receptacle) or pipe rupture. Violation pipe ruptured blood vessels starts bleeding into the abdominal cavity, which leads to anemia and hemorrhagic shock. The closer the pregnancy develops in the tube to the uterus, the more there is a pipeline rupture and massive bleeding.
Diagnosis usually is simple. In such cases, there is a picture of massive internal bleeding. The patient feels pregnant. Among the total health suddenly there are sharp pains in the lower abdomen, especially in one of the iliac plots give the anus, back, lower limbs. Often brief fainting, dizziness, nausea, and vomiting.
Appears desire to defecate. The patient is pale, the pupils dilated, her face cold sweat, his lips are pale, with a bluish tinge. In the history of the same characteristics as that of unruptured ectopic pregnancy.
Pulse is frequent, low volume and tension. The maximum and minimum blood pressure lowered. It is noted dyspnea. Appears frenikus syndrome. The abdomen is swollen. Percussion and palpation of his sharply painful. Identify symptoms of peritoneal irritation. If bleeding continues, the picture peritoneal shock increases, anemia progresses.
In blood uniformly reduced red blood cells and hemoglobin, anemia normochromic and hypochromic then prevailing character. From the short-lived white blood leukopenia and thrombocytopenia. Accelerated ESR. Gynecological survey should be carried out very carefully. In most cases, bleeding from the vagina immediately after abortion no because decidua no time to exfoliate. When viewed in the mirror cervix tsyanotychna, eyes closed. Vaginal study sharply painful. Especially painful displacement of the cervix. The uterus is slightly enlarged in size, soft, sharply painful on palpation. Sometimes it seems that the uterus floats in a fluid - a symptom of "floating uterus." In one of the side arches are defined appendages without clear contours. Rear arch curved, palpation it sharply painful. Therefore, research should be done very carefully.
Diagnosis of ectopic pregnancy interrupted without difficulty. Differential diagnosis should be made with spontaneous abortion in terms of small uterine pregnancy, ovarian apoplexy, acute pelviope-rytonitom, perforated gastric and duodenal ulcers and more. Additional methods: ultrasound diagnosis, culdocentesis (for blood), scraping the uterine walls with microscopy (decidual tissue without chorionic villi) diagnostic laparoscopy. Once the diagnosis of ectopic pregnancy is interrupted, the patient should immediately to operate with adequate transfusion (appropriate to reinfusion, if after a pipeline rupture was not more than 12 hours).
Tubal abortion occurs more frequently than rupture the pipe. Clinical case of tubal abortion develops slowly. In tubal abortion occurs inside the gap fetal containers. The blood that gets into the abdominal cavity drains into the space to form an ectopic ectopic hematoma. Sometimes blood flows from the tube slowly in small portions to form around her blood cast - perytubarnu hematoma. The clinical picture depends on the intensity of bleeding. Typically, due to the slow development of the disease, the clinical picture is not typical, symptoms are not clear, the general condition of the patient remains satisfactory for a long time.
Therefore, diagnosis is often difficult.
Diagnosis.
Clinical features.
1. Signs of pregnancy:
- Delay menstruation;
- Breast engorgement;
- Change of taste, smell and other sensations characteristic of pregnancy;
- Early signs of preeclampsia (nausea, vomiting, and others.)
- Positive immunological response to pregnancy (hCG in serum and urine).
2. Menstrual disorders - mazhuschie blood dolls discharge from the genital tract:
- After a delay of menstruation;
- The beginning of the next menstrual period;
- Before the expected menstruation;
3. Pain:
- Unilateral colicky or persistent pain in the abdomen;
- A sudden intense pain in the lower abdomen;
- Peritoneal signs in the lower abdomen, varying degrees of severity;
- Irradiation of pain in rectum crotch area and buttocks.
4. Signs of intraperitoneal bleeding (when excited PX):
- Blunting percussion in flank abdomen;
- Positive symptom of Kulencamfa (signs of peritoneal irritation in the absence of local muscular strain in the lower abdomen);
- Horizontal patient positive bilateral "frenikus" symptom and vertically - dizziness, loss of consciousness;
- If significant hemoperitoneum - symptom of Shetkin-Blumberg;
- A progressive decline in hemoglobin, erythrocytes, hematocrit according to the analysis of blood.
5. Violation of the general condition (in the case of impaired PV):
- Weakness, dizziness, fainting, cold sweat, collapse, hemodynamic disorders;
- Nausea, vomiting reflex;
- Flatulence, single in-diarrhea.
These gynecological examination:
- Cyanosis of vagina and cervix;
- Uterine size smaller than the expected duration of pregnancy;
- Unilateral increase and tenderness of the uterus;
- Overhanging vault of the vagina (if hemoperitoneum);
- Sharp pain posterior vaginal vault ("Douglas Creek");
- Pain in the displacement of the cervix.
Specific laboratory tests:
- Qualitative or quantitative test for hCG. Qualitative determination of hCG in urine is possible in any - any institution of public health, while the quantitative analysis of (-hCG in serum (lower level of the expected life of physiological pregnancy) performed in hospitals of III level.
Instrumental methods examination.
Ultrasound:
- No gestational egg in the uterus;
- Visualization of the embryo outside the uterus;
- Detection of formation of inhomogeneous structures in the projection tubes;
- A significant amount of free fluid in Douglas space.
Laparoscopy - a visual setting of ectopic pregnancy in the form:
- Thickening of the uterine tube purplish - bluish color;
- Rupture of the fallopian tube;
- Bleeding from the ampullar hole or gap space fallopian tube;
- Presence in the abdomen and blood in Douglas space in the form of convolution, or in liquid form;
- The presence of abdominal elements of a fertilized egg.
Diagnostic scraping the walls of the uterus:
- Lack scraped items fertilized eggs;
- The presence of decidual tissue scraped.
Diagnostic scraping the walls of the uterus is performed in the absence of ultrasound apparatus and provided informed consent for this patient manipulation.
In the case of small time delay menstruation, women interested in maintaining uterine pregnancy symptoms and the absence of intra-abdominal bleeding must select a wait tactics, focusing on clinical signs, ultrasound in dynamic monitoring and (-hCG level in serum.
Puncture of the abdominal cavity through the posterior vaginal vault.
Conducted in the absence of ultrasound apparatus for diagnosing tubal abortion. The presence of punctate liquid blood - a sign of PV.
In case of clinical signs of intra-abdominal bleeding puncture through the posterior vaginal vault is not performed - delay start time of laparotomy.
TABLE 1. Diagnostic characteristics of various forms of tubal pregnancy.
|Signs of pregnancy |Positive |Positive |Positive |
|Overall condition of |Satisfactory |Periodically worse, intermittent loss of |Collaptoid condition |
| patient | |consciousness, prolonged periods of |clinic massive |
| | |satisfactory |bleeding and progressive |
| | | |deterioration |
|Pain |Missing |Character attacks, recurrent |Since appears as an acute attack |
|Allotment |Missing or minor blood dolls |Blood dolls allocation |Missing or minor blood |
| | |dark, with appear after an attack of pain | |
|Vaginal |The uterus does not match |Same pain |Same symptoms |
|examination |delay term monthly, along with the uterus |with displacement of the uterus, |"Floating uterus" |
| |determined |formation without clear contours, rear |tenderness of the uterus and |
| |formation retortopodibnoyi form painless, vault |arches |Application of the affected |
| |free |smoothened |hand, hanging back set |
|Additional methods of |Ultrasound determination of (-hCG, laparoscop |Culdocentesy |Not held |
|examination | |Laparoscopy | |
To clarify the diagnosis used additional methods: ultrasound diagnosis, endoscopic diagnosis (laparoscopy, culdoscopy), aiming culdocentesis. After setting the final diagnosis of the patient should be operated on immediately: conservative-plastic surgery on the tube.
Differential diagnosis.
Diagnosis of ectopic pregnancy is quite simple in patients with amenorrhea, signs of pregnancy, pain in the lower abdomen and bleeding. But we need to exclude the following states:
1. Torsion of ovarian cyst or acute appendicitis.
2. Interruption of uterine pregnancy.
3. Hemorrhage in the corpus luteum.
Treatment of ectopic pregnancy:
I. Operational
Operations that are used in case of tubal pregnancy:
1. Salpingotomy (tubotomy). Running longitudinal salpingostomy. After removing of the fertile egg, salpingostomy certainly not sewed. If the chorionic villi do not germinate in the muscle membrane fallopian tube confined her curettage.
2. Segmental resection of the fallopian tube. Remove segment of the fallopian tube where an egg was implanted, and then perform bypass the two ends of the pipe. If you can not perform salpingo-salpingo anastomosis can tie up both ends and impose anastomosis later.
3. Salpigectomy. This operation is performed in the case of impaired tubal pregnancy, accompanied by massive bleeding. Operation and blood transfusion in this case simultaneously.
II. Conservative treatment of ectopic pregnancy.
Treatment of unruptured ectopic pregnancy with methotrexate
Indications for use of methotrexate in the case of PV.
To avoid the introduction of methotrexate in normal uterine pregnancy or miscarriage that failed, he was appointed only in the following cases:
1. Elevated levels of (-subunit of hCG in serum after organ-preserving surgery on the fallopian tube, which is made on the unruptured ectopic pregnancy.
2. Stabilization or increase the level of (-subunit of hCG in serum within 12-24 hours after a separate diagnostic curettage or vacuum aspiration, if the size of the gestational sac in the uterus does not exceed 3.5 cm
3. Determination of transvaginal ultrasound probe gestational sac diameter of 3.5 cm in the uterus when the level of (-subunit of hCG of 1500 IU / L in the absence of gestational sac in the uterus.
Table 2. The use of methotrexate in the PB
|Day |Therapeutic and diagnostic procedures |
|1 |Determining the level of (-subunit of hCG in serum |
|2 |Complete blood grouping and Rh factor in the blood of women, the activity of liver enzymes |
|5 |Metrotreksat 75-100 ml intramuscular |
|8 |Determining the level of (-subunit of hCG in serum |
If the (-subunit of hCG in serum decreased less than 15% on the eighth day, metrotreksat re-injected in the same dose.
If the (-subunit of hCG in serum increased more than 15% of patients have a weekly determine the level of (-subunit of hCG as long as this level is not less than 10 IU / l.
Bleeding in the second half of pregnancy
Placental
The most common cause of bleeding in the second half of pregnancy is placenta previa (0,2-0,8%).
Placenta previa - pregnancy complication in which the placenta is located in the lower uterine segment below the presenting part, blocking all or part of the internal cervical os. At physiological pregnancy lower edge of the placenta is below 7 cm to the internal os. Placenta previa occurs in 0,2-0,8% of total births.
Reasons:
At risk of placenta previa include women who have had:
- Endometritis to the following scar degenerative changes of the endometrium;
- Abortion, especially complicated inflammatory processes;
- Benign tumors of the uterus, including submucous myoma node;
- Effect on the endometrium chemicals;
- Women with hypoplastic uterus.
Classification of placenta previa
1. Complete previa - the placenta completely covers the internal os;
2. Incomplete previa - the placenta partially covers the internal os:
a) the presentation side - inner eye overridden by 2/3 of its area;
b) marginal previa - the inner eye right edge of the placenta.
3. Low implantation of placenta - placenta in the lower segment below 7 cm from the internal os without overlapping.
In connection with the migration of the placenta or placenta growth species may change with increasing gestational age.
Degree presentation clarifies the disclosure of the cervix by 5-6 cm
Clinic:
Any bleeding in pregnancy 20-25 weeks in the absence of morphological changes of the cervix should be considered as a possible placenta previa.
Uterine bleeding - the only clinical manifestation of placenta previa. Air bleeding does not always correspond to the presentation and much more related to the nature of the contractile activity of the uterus.
Most bleeding placenta previa occurs after 28 - 29 weeks of pregnancy, because in this period is the formation of the lower uterine segment-first, or the beginning of labor activity when disturbed relationship between the lower segment shrinking, and not able to skorotly-ties placenta.
Bleeding placenta previa with undulating character.
Pregnancy and childbirth
Immediate hospitalization, in the presence of intense bleeding immediate- cesarean delivery.
With minor bleeding and premature pregnancy woman remains in the hospital to accouchement or to establish migration placenta by ultrasound.
The best method of delivery in placenta previa CoP-zhayetsya caesarean section routinely.
Of delivery through the birth canal can be done when a woman entered the hospital in labor, without hemorrhage, with partial placenta previa, in the absence of any other complicating things (large fruit, narrow pelvis, etc.). In such cases, you should immediately cut through the membranes and delivery lead expectant that the presence of bleeding change tactics quickly.
In the presence of a dead fetus in his head can impose a skin-head pliers and hang loads not exceeding 400 g
If you have bleeding even when dead fetus should apply operational tactics. Real imposition of obstetric forceps in previa of placenta or fetal extraction for pelvic end contraindicated due to extreme vulnerability of the lower segment.
The third stage of labor is active with the operation manual placental abruption, placenta peredlehla mostly because there is a partial or even intimate attachment placenta accreta.
Treatment
The therapeutic approach depends on the amount of bleeding, the patient's status and fetal character previa, gestational age, fetal lung maturity.
Principles of patients with placenta previa:
1. In the case of small blood loss (250 mL), the absence of symptoms of hemorrhagic shock, fetal distress, lack of labor activity, immaturity of the lungs of the fetus during pregnancy to 37 weeks - the waiting game.
2. Upon termination of bleeding - ultrasound, preparative fetus's lungs. Purpose expectantly tactics - prolongation of pregnancy to term viability of the fetus.
3. In case of progressive bleeding becomes uncontrollable (250 ml), followed by symptoms of hemorrhagic shock, fetal distress, regardless of gestational age, fetal (live, distress, dead) rush delivery.
Premature detachment of normal placenta (0,02-0,07%)
Premature detachment of placenta - placental abruption is located outside the lower segment of the uterus during pregnancy or in the first - the second stage of labor.
Classes:
1. Complete detachment (detachment whole placenta).
2. Partial detachment:
- Boundary
- Central
Variants of the clinical course:
1. Slight delamination clinically diagnosed before birth litter
2. Local delamination size from one-fourth of the placenta usually has an acute onset, local pain, uterine hypertonicity, signs of fetal hypoxia (or intrauterine fetal death), signs of internal, sometimes external bleeding.
3. Placental abruption a large surface (or full) has a picture of pain and hemorrhagic shock: pressure drop, rapid pulse, cold sweats, uterine hypertonicity, the inability to determine the parts of the fetus, intrauterine fetal death.
Premature detachment of the placenta in pregnant women may be at the subsequent pathology (causes that contribute to):
- Gestosis;
- Kidney disease;
- Isoimmune conflict between mother and fetus;
- Hyperextension of uterus (polyhydramnios, multiple pregnancy, large fetus);
- Diseases of the vascular system;
- Diabetes mellitus;
- Connective tissue disease;
- Inflammation of the uterus, placenta;
- Abnormalities or tumors of the uterus (submucosal, intramural fibroids).
The immediate cause may be:
- Physical injury;
- Trauma;
- Sudden volume reduction amniotic fluid;
- Absolutely or relatively short umbilical cord;
- Pathology of contractile activity of the uterus.
Clinical symptoms:
1. Pain: acute pain in the projection of the localization of the placenta, which then spreads to the entire uterus, waist, back and becomes diffuse. The pain is most pronounced in the central detachment and may not be expressed at the regional detachment. When placental abruption, which is located at the rear, the pain can mimic renal colic.
2. Hypertonicity uterus until tetany, which is not removed antispasmodics, tokolitykamy.
3. Bleeding from the vagina can vary depending on the severity and nature (marginal or central retinal detachment) from small to massive. If formed retroplacental hematoma, external bleeding may be absent.
Diagnosis:
2. External obstetric examination:
- Hypertonicity of the uterus;
- Uterus enlarged, can be deformed to a local vypyachuvannyam if the placenta is on the front wall;
- Tenderness;
- Difficulty or inability to palpation and auscultation of fetal heart;
- Symptoms of fetal distress or death.
3. Internal midwifery research:
- Tension plodnoho bladder;
- When the outpouring of amniotic fluid - perhaps their color blood;
- Bleeding from the uterus of varying intensity.
4. Ultrasound examination (echo negative fireplace between the uterus and placenta), but this method can not be an absolute diagnostic criterion as hypoechoic area can be visualized in patients without delamination.
In the absence of external bleeding diagnosis of abruption placenta based on increased uterine tone, local pain, deterioration of the fetus. Blood from retroplacental hematoma penetrates the uterine wall and forms Kuveler uterus (uterine-placental apoplexy), which loses its ability to contract, leading to the development of bleeding from massive blood loss due to coagulopathy and hypotension.
Treatment:
1. If progressive abruption placenta during pregnancy or in the first stage of labor, when symptoms of hemorrhagic shock, DIC, signs of fetal distress, regardless of gestational age - Urgent Cesarean delivery. If the symptoms Kuveler uterus - hysterectomy without appendages.
2. Restoring volume bleeding, treatment of hemorrhagic shock and disseminated intravascular coagulation (see related records).
3. If neprohresuyuchoho placental abruption possible dynamic monitoring in premature pregnancy up to 34 weeks (the therapy for fetal lung maturation), in settings where there is around the clock skilled obstetrician-gynecologist, anesthesiologists, neonatologists. A monitor surveillance of pregnant women and the fetus, CTG, ultrasound dynamics.
Tactics in placental abruption end I or II periods:
- Immediate amniotomy if the amniotic bubble round;
- At home peredledanni fetus - blending obstetrical forceps;
- In the breech - the extraction of the fetus for pelvic end;
- Transverse position of the other twins fetus performed obstetric twist with yekstraktsiyeyu fetus leg. In some cases, the more reliable will cesarean section;
- Manual removal of placenta and afterbirth;
- Contractors - in / 10 units of oxytocin, with no effect of 800 micrograms of misoprostol (rectal);
- Careful dynamic monitoring in the postpartum period;
- Restore volume bleeding, treatment of hemorrhagic shock and disseminated intravascular coagulation (see related records).
Treatment: only with a slight placental abruption possible (allowed) to a wait tactic immediately rozitnuvshy membranes that sometimes prevents further placental abruption.
In all other cases, immediate delivery is recommended by blending operations obstetrical forceps (if conditions) or (more often) by Caesarean section. After emptying the uterus physician must decide whether conservation authority.
Removal of the uterus is due to:
1) loss of ability to uterine contraction due to the impregnation of the wall with blood;
2) entering the circulation of blood in the uterine wall Soaked with substances such as blood and tissue thromboplastin, which leads to the development of DIC.
Premature detachment of normally located placenta may result ¬ stimulates the development of DIC. Coagulation disorders mainly arises due ingress into the bloodstream substances such as thromboplastin and fibrinolysin from the damaged area myometrium and fibrin deposition in retroplacental hematomas.
Bleeding in childbirth (in III-rd stage of labor)
PATHOLOGY attachment and separation of placenta
The causes of obstetric hemorrhage in the III-rd (sequence) stage of labor is a violation of detachment and separation of the placenta, namely:
- Delay in parts of the placenta or membranes;
- Pathology of attachment of the placenta;
- Pinching placenta.
It should be noted that the common cause of bleeding in the sequence period is the delay of the placenta in the uterus or its parts, additional shares. In turn cause delays in the uterus litter and its parts can be factors that reduce uterine tone and its contractile ability, abnormalities of structure and location of the placenta, as well as violations of the process of detachment.
The normal myometrium is reduced, and the placenta gradually exfoliate, but in some cases can be intimate attachment of the placenta or its increment when the chorionic villi sprout in the basal layer or even deeper (and perhaps in serous layer of the uterus), which may be one reason for the bleeding.
Types of violations of attachment of the placenta: full, partial or increment germination placenta.
Causes of placenta accreta:
- After inflammation;
- Due to postoperative scar on the uterus;
- Abortion in history;
- Uterine fibroids;
- Malformation of the uterus;
- Increased proteolytic activity chorion.
Degrees of placenta accreta:
placenta adhaerens - increment in which the chorionic villi penetrate the basal layer of the decidua;
placenta accreta - chorionic villi penetrate all the basal layer of the decidua to the muscle layer of the uterus;
placenta increta - chorionic villi penetrate deep into the muscle layer of the uterus;
placenta percreta - nap germinate muscular and serosal layer of the uterus.
Clinical manifestations:
1. No signs of separation of the placenta within 30 minutes without significant blood loss - pathology attachment or germination placenta.
2. Bleeding begins immediately after the birth of the litter - the delay part of the placenta or membranes
3. Bleeding occurs when a baby is born without placenta - placenta jamming, partial placenta accreta.
Obstetric management of pathology attachment and separation of the placenta:
- Actively-caring expectant tactics;
-Duration of the third stage of labor is 10 to 30 minutes.
To establish that the separation of the placenta lacks 3.2 features, and if it is not born, it is necessary to use external devices discharge manure, which itself separated.
- When the amount of blood loss to 0.5% of body weight and bleeding that lasts deterioration mothers in the absence of external bleeding should conduct manual separation of the placenta and the allocation of litter;
- If within 30-40 minutes no signs of separation of the placenta, and external or internal bleeding, you should install a previous diagnosis of placenta accreta and genuine attempt separation of the placenta only when gross operating. In establishing the diagnosis of placenta accreta genuine attempt to forcibly separating it causes increased bleeding and perforation of the uterus. Haemorrhage in this case can only operational method - hysterectomy;
- Establishment of a defect in his litter survey is an indication for manual revision uterine walls irrespective of bleeding.
Bleeding associated with delayed pathology attachment or strangulation placenta.
Algorithm of care:
1. Catheterization of peripheral or central vein, depending on the size and condition of bleeding women.
2. Emptying the bladder.
3. Check for signs of placenta and afterbirth manual selection methods;
4. When pinched litter external massage of the uterus, external techniques remove droppings.
5. In case of delay parts of the placenta or membranes - manual examination of the uterus during intravenous anesthesia;
6. In the case of the mechanism of separation of the placenta and the absence of bleeding - waiting for 30 min. (In pregnant women at risk - 15 min.) Manual separation of the placenta and the allocation of manure.
7. When the bleeding - immediate manual separation of the placenta and afterbirth allocation under / in anesthesia.
8. Introduction uterotonichnyh vehicles - 10 -20 IU oxytocin / in 400 ml saline / drip.
9. If true placenta accreta or germination - laparotomy, hysterectomy without appendages;
10. Estimate of blood loss (Appendix № 1) and recovery values BCC (see treatment of hemorrhagic shock).
Bleeding in the postpartum period
Postpartum hemorrhage - a blood loss of 0.5% or more of body weight after the birth of the fetus.
Causes of postpartum hemorrhage in the postpartum period:
- Impaired motor function of the uterus (hypotonia, atonia);
- Impaired blood clotting;
- Injury maternal passages
- Delay parts litter in the uterus.
Risk factors of postpartum hemorrhage:
- Burdened obstetric history (bleeding in previous births, abortions, spontaneous abortions);
- Preeclampsia;
- Large fruit;
- Polyhydramnios;
- Multiple pregnancy;
- Uterine fibroids;
- Scar on the uterus.
- Chronic DIC;
- Tromotsytopatiyi;
- Antenatal zyhybel fetus.
Types of postpartum hemorrhage:
1. Primary (early) postpartum arising in the early postpartum period or within 24 hours after birth.
2. Secondary (late) postpartum bleeding that occurs after 24 hours and up to 6 weeks postpartum.
Early (primary) postpartum hemorrhage
Causes of early postpartum hemorrhage:
- Hypotonia or atony of the uterus (90% of cases);
- Delay in parts of the placenta or membranes;
- Traumatic injury ancestral ways;
- Blood clotting (afibrynohenemiya, fibrinolysis);
Hypo-and uterine atony
Uterine bleeding in the first hours postpartum period most commonly associated with disruption uterus activity (hypo-and atonic condition). If hypotension uterus loses its normal tone and contractile ability, but the mechanical, physical and pharmacological stimuli usually corresponds to the reduction. For atony characterized by the absence rate and a sharp reduction in uterine tone, which does not respond to the above stimuli. It may also be koahulopatychna bleeding (in violation of blood coagulation function), but it is less common and is usually secondary.
The causes hypotonic bleeding can be divided into two groups:
- Causes extragenital character;
- Obstetric causes.
Causes of hypotension or uterine atony:
- Impaired functional abilities myometrium (late mellitus, endocrinopathies, somatic disease, uterine tumors, scar on the uterus, large fetus, polyhydramnios, multiple pregnancy and others);
- Overstimulation followed by exhaustion of the myometrium (long or prolonged labor, operative delivery end, the use of drugs that lower the tone of the myometrium (antispasmodics, tocolitics, hypoxia during labor, etc.);
- Impaired contractile function myometrium due to violation of biochemical processes, correlations of neurohumoral factors (estrogen, acetylcholine, oxytocin, cholinesterase, progesterone, prostaglandins).
- Disrupting the attachment, separation and separation of the placenta and afterbirth;
- Idiopathic (not installed).
Clinical hypotonic bleeding varied - from large blood ¬ leak a few minutes to periodic bleeding every 20-30 minutes.
Bleeding can be 2 - species:
- Bleeding begins immediately after birth, massive (several minutes> 1000 mL), hypotonic uterus is not shrinking fast developing hypovolemia, hemorrhagic shock;
- Bleeding occurs when uterine blood is released in small portions, blood loss increases gradually. Characteristically duty hypotension uterine tone with the restoration, suspension and continuation of bleeding.
Volume of aid and its completeness depends on the amount and intensity of blood leaks and the initial state of childbirth: conservative methods of ZU-Pinky should begin prevention in women at risk of bleeding for the appearance, and for therapeutic purposes - if OK from 0.5 % to 1-1.2% of body weight mothers.
Assistance should be performed as follows:
a) emptying of the bladder;
b) external massage of the uterus (20-ZO s after 1 min);
c) introduction of uterotonichnyh - in / oxytocin 5 units or 0.5-1.0 ml 0.02% metylerhometrynu, or 5 mg of prostaglandin F2α and E2 in 250 ml of saline solution of sodium chloride, efficient administration of prostaglandins in the cervix or in the body of the uterus through the abdominal wall followed / drip (35-40 drops / min) injection of 10 IU oxytocin per 250 ml of saline solution of sodium chloride;
e) manual examination of the uterus and uterine massage on his fist;
e) review of maternal passages and stitching breaks;
g) blending terminals on the parameters of the method of Baksheev M.S., seam on neckstion of uterine Mikhailenko or Lositsky can be used to prepare for surgery.
Along with the above measures should be carried infusion therapy, administer glucocorticoids, vasopressors.
When hemorrhage 1.5% of body weight and prolonged bleeding should use surgery to the extent hysterectomy, and if necessary - ligation of internal iliac arteries.
Postpartum secondary (late) bleeding
The main causes of late after maternal bleeding:
- Delay in parts of the placenta or afterbirth;
- Discharge of necrotic tissue after birth;
- Differences stitches and the wound of the uterus (after cesarean section or uterine rupture).
Often late postpartum bleeding occurs 7-12 days after birth.
Algorithm of care:
1. Estimate of blood loss methods available (see above).
2. Catheterization of peripheral or central vein.
3. Instrumental inspection of the uterine cavity under / in anesthesia.
4. Intravenous uterotonikiv (10-20 IU oxytocin in saline-400.0 or 0.5 mg metylerhometrynu).
5. If continued bleeding - misoprostol 800 mcg rectally
6. Restoring volume BCC
7. When blood loss> 1.5% of body weight - laparotomy, hysterectomy, subject to continued bleeding - internal iliac artery ligation specialist who owns this transaction.
Clotting of blood (postnatal afibrynohenemiya, fibrinolysis):
- Restore volume CBV;
- Correction of hemostasis (see treatment ICE syndrome).
- Diagnosis and treatment of anemia;
2. During labor:
- Anesthesia delivery;
- Avoidance of prolonged labor;
- Active management of the third period of delivery;
- The use of drugs uterotonichnyh uterus in the third stage of labor.
- Routine inspection and assessment of the integrity of the placenta and membranes;
- Prevention of injury during childbirth.
3. After birth:
- Inspection and review of maternal passages;
- Careful supervision for 2 hours after birth;
- In pregnant women at risk / in drip 20 units of oxytocin within 2 hours after birth.
Methods for determination of blood loss
1. Method of Libov
Volume of blood loss is determined after weighing napkins impregnated with blood
where B - weight of napkins, 15% and 30% - the value error on amniotic fluid disinfectants.
2. Formula of Nelson
The ratio of total blood loss calculated by following way:
3. Determination of the density of blood loss and blood hematocrit
|The density of blood , |Hematocrit |Volume of blood loss, ml |
|кg/ml | | |
|1057-1054 |44-40 |to 500 |
|1053-1050 |38-32 |1000 |
|1049-1044 |30-22 |1500 |
|Less1044 |Less 22 |More 1500 |
4. Shock index of Alhover
Normally Alhovera index = 1.
The magnitude of the index, you can draw conclusions about the magnitude of blood loss
|Shock index of Alhover |Volume of blood loss (% of BCC) |
|0,8 and less |10% |
|0,9-1,2 |20% |
|1,3-1,4 |30% |
|1,5 та більше |40% |
Note: Index Alhovera not informative in patients with hypertension
5. Hematocrit method of Moore
To determine the approximate amount of blood loss in pregnant women may use a modified formula Moore:
0.42 – Htf
HF = M 75 • 0,42
Where: KO - blood loss (ml), M - pregnant weight (kg); Htf - actual patient hematocrit (L / L)
Eddition table № 2
Basic principles of recovery bec
Infusion-transfusion therapy obstetric hemorrhage
|Volume of blood loss |Infusion environment |
|% BCC |% of body weight|Ringer-lactate |Helofuzyn |Fresh frozen plasma |Albumin (10 – |Erythrocytic |Platelet |
| | | | | |20%) |weight | |
|To 25% |Tо 1,5% |1 - 2 l |1 - 2 l | | | | |
|(до1,25 l) | | | | | | | |
|To 50% |Tо 3,0% |2 l |2 - 2,5 l |1 х 250 ml | |1 х 250 ml | |
|(до 2,5 l) | | | | | | | |
|To 65% (to 3,25 l) |Tо 4,0% |2 l |2 - 2,5 l |1-3 х 250 ml |0,25-1 l |1-3 х 250 ml | |
|Tо 75% |Tо 4,5% |2 l |2 - 2,5 l |3-5 х 250 ml |0,25-1 l |3-6 х 250 ml | |
|(tо 3,75 l) | | | | | | | |
|> 75% |> 4,5% |2 l |2 - 2,5 l |5 х 250 ml and more |0,5 - 1 l |6 х 250 ml and |For nessesery |
| | | | | | |more | |
Basic principles of treatment of obstetric hemorrhage:
1) stop bleeding;
2) determine the stage of compensated blood loss;
3) restore the BCC;
4) normalization tone vasculature;
5) correction of blood rheology and its structural, biochemical, electrolyte composition, KLS, colloid-osmotic properties;
6) desintoxication;
7) desensitization;
8) correction functions coagulation, anticoagulant, fibrinolytic and protease systems;
9) the regulation of vital organs;
10) prevention of infectious complications.
Situational tasks
Problem number 1.
Patient 20 years old, married got 2 years ago. Since pregnancy is not sterehlasya. Menstruation for 17 years without a certain rhythm. Last menstrual period was 6 weeks then ¬ m. Sexuality regular. On the way to work there was pain in the lower abdomen, as discolored ¬ prytomnila. Ambulances delivered to the gynecological department in distress: the skin and mucous membranes pale, AT - 80/40 mm Hg. t pulse 112 beats / min. Periodically neprytomnyuye.
What is the diagnosis?
What should I do?
Problem number 2.
Patient 29 years old, sexually active lives 5 years. During this time there was one spontaneous abortion at 10 weeks gestation. Now married again. Over 2 years of pregnancy does not occur. Last menstruation came late for 8 days. When doing work with some tension arose acute pain in the lower abdomen, weakness, nausea, dizziness. A few minutes later appeared vomiting. Over the past two days notice slight bleeding from the vagina. The patient appealed to the antenatal clinic. The examination revealed uterine enlargement and enlarged and painful in-law contributions uterus. Suspected ectopic pregnancy, sick and sent to the gynecological hospital in an ambulance.
What is the diagnosis?
Make a plan for evaluation and treatment of the patient.
Problem number 3.
Patient '30 entered the hospital complaining of pain in the lower abdomen, dark little bloody vaginal discharge for 5 days. In the morning robot unconscious. From history revealed that the last menstrual period was 2 months ago. Considers herself pregnant.
What is necessary for accurate diagnosis?
What is the recommended treatment?
Problem number 4.
Pregnant delivered in maternity ambulance assistance ¬ gi. Pale, pulse - 100 bpm. / Min, AT - 100/60 mm Hg. century. Sharp pain around the stomach for hours. Pregnancy is full-term, 2 weeks ago pregnant was in the hospital about gestosis. When the feeling stress ¬ weighted uterus, painful. The heartbeat of the fetus does not listen. Vaginal study: royal eye closed, no bleeding.
Diagnosis. What to do?
Problem number 5.
With the onset of labor at 38 weeks of pregnancy in women in plural bleeding from the vagina. The study found: cervix revealed by 8 cm on one side for 1/3 palpable rough fabric, on the other hand - the amniotic sac. In women in active labor ward activity.
Diagnosis. What to do?
Problem number 6.
Pregnant at row 22 weeks at the planned ultrasound examination diagnosed placenta previa.
What further management of this case?
Problem number 7.
In the admissions department hospital ambulance brought a woman at row 27-28 weeks with complaints of bright bleeding from the vagina that appeared amidst total well being. From the history of pregnancy V, the previous 3 ended medical abortion and en dometrytom after the last abortion.
Diagnosis. Dyfdiahnoz. What to do?
7. Recommended Reading.
1. Haystruk A.N, Haystruk N.A, Moroz O.V. Urgent conditions in obstatrics. The textbook for students of medical skills, High society institutions. - Vinnitsa: "Book-Vega," 2009. - 576 p.
2. Urgent conditions in obstetrics and gynecology / Ed. prof. Stepankovsky G.K., Ventskovsky B.M. - K.: Health, 2000.
3. Stepankovsky G.K., Mihailenko O.T. Obstetrics. - K.: Health, 2000.
4. Chernuha E.A., Maternity department. - M., 2001.
5. Obstetrical bleeding. Urgant aids: Training. Handbook / G.I. Gerasimov, Kolhushkyna T.N., Mogeyko L.F. - Mn.: Higher. H.Q., 1997. - 66 p.
6. Zilber A.P., Schiffman E.M. Obstetrics eye of anesthesiologist / Critical studies of medicine, Medicine: T.Z. - Petrozavodsk: Izd. PSU, 1997. - 397 p.
7. Stepankovsky G.K., Mihailenko O.T. Gynecology. - Kyiv, Health, 1999.
8. Gryaznov I.M.,\ Ectopic pregnancy. - M., 1980.
9. Kulakov V.I. and et al. Operational lead of researches. Gl. 16. - M., 1990. P. 16.
10. Strizhakova AN, Bunin AG, Medvedev MV Ultrasound diagnosis in clinical akusherskoy. - M., 1990.
11. Obstetrical bleeding / V. I. Kulakov, VN Serov, AM Abubakyrova, I. Baranov. - Moscow: Triada-X, 1998. - 96 p.
12. Prevention and intensive therapy of massive uterine bleeding in obstetrics (guidelines). Ministry of Health of Ukraine., - K., 2000. - 32.
Author: Goncharenko O.M., assistant
Approved at the meeting of the department "___" _________________ 20___, protocol № __________.
Reviewed by department meeting "___" _________________ 20___,
protocol № __________.
-----------------------
Volume of blood loss = V / 2 x 15% (less than 1000 ml blood loss)
or by 30% (with blood loss more than 1000 ml)
0,036 х original blood volume
----------------------------------------- х hematocrit
weight
24
Output volume of blood (ml/кg) = ------------------------------------ х100
0,86 х initial hematocrit
HR
Shock index of Alhover = ---------
BP s,
Wheࢩ[?]ࢪ[?]ࣁ[?]ࣂ[?]ࣃ[?]࣐[?]࣑[?]࣒[?]࣓[?]ࣞ[?]ࣟ[?]ࣩ[?]࣪[?]࣫[?]ࣳ[?]ࣽ[?]ࣾ[?]ँ[?]ऌ[?]छ[?]ऺ[?]ॽ[?]ॾ[?]ঁ[?]ই[?][?][?]ত[?]ৄ[?]ে[?][?]ো[?]ৌ[?][?]ড়[?]ঢ়[?][?]য়[?]৳[?]৴[?]ৼ[?][?]ਅ[?]ਆ[?]ਇ[?]ਉ[?][?]ਖ[?]ਗ[?]ਘ[?]ਙ[?]ਤ[?][?]ੇ[?]ੈ[?]쇍ꚲꚲꚲꚲꚲꚲꚲꚲ솲ꚲꚗ讲늦늦늦늦늦닁늦늦讦讲讲讲讲ᘖ깨猙䌀愀洀ै猀ैᔜ䅨癇ᘀ嵨ꭱ䌀愀洀ै猀ैᘖ嵨ꭱ䌀愀re HR-heart rate
BP s – systolic blood pressure
KV VCB = (n) x (GT (n) - GT (f)) / GT (n)
KV-hemorrhage
BCC (n) - normal CBV
GT (n) - normal hematocrit (women -42)
HT (f) - the actual hematocrit determined after stopping the bleeding and stabilize hemodynamics.
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.