Ministry of Health of Uzbekistan
TASHKENT MEDICAL ACADEMY
Obstetric hemorrhage in the second half of pregnancy
(The text of the lecture)
For the 4th year students of medical and
medical and pedagogical faculties
Tashkent 2013
Obstetric hemorrhage in the II half of pregnancy
PURPOSE.
To familiarize students with the basic causes of bleeding in the II half of pregnancy,
etiology and pathogenesis, symptoms, methods ¬ DAMI relief and prevention in
outpatient services.
Show that PONRP takes first place among the causes of maternal mortality and
perinatal pathology, in connection with which every doctor is not necessary to know ¬
high-risk factors and prevention, emergency care for bleeding in pregnancy.
PLAN.
1. Introduction. Relevance. Frequency.
2. Classification of obstetric hemorrhage.
3. PONRP, etiology, classification, symptomatology.
4. Diagnostics. Mode of delivery. Complications.
5. Emergency care and prevention of complications.
6. Risk group of pregnant women for PONRP, methods
prevention.
7. Placenta previa. Diagnostics. rendering
emergency care.
Premature detachment of normally situated placenta
Premature detachment of normally situated placenta is a division of ¬ placenta
attached to the upper segment of the uterus during pregnancy or whi ¬ in I and II
stage of labor. Depending on the size of compartment ¬ loivshegosya plot distinguish
partial and full premature otsloy ¬ ku placenta. Clinical manifestations of
complications developed if otslai ¬ Vaeth 1/4-1/3 placenta and more.
Complication may be due to pre-eclampsia, extragenital pathology primarily kidney
(pyelonephritis), diabetes, cardio-vascular disease and other disorders that have the
most adverse effects on the peripheral circulatory ¬ Treatment or is the background
for the development of hypertensive syndrome. Reports of such etiological factors of
premature placental abruption, as trauma and short umbilical cord malodokazatelny.
They should be seen as provoking an already existing pathomorphological
background.
It should be emphasized that the changes of peripheral blood formation in
preeclampsia are not only in the utero-placental blood ¬ stream, but also in the vital
organs - the liver, kidneys, brain, lungs, dysfunction which essentially determine the
symptoms and complications of pregnancy.
The deterioration of the micro circulation in the placenta reduces the elasticity of the
vascular wall, increasing its permeability. This sposobs ¬ tvuet rupture arterial
capillaries, forming micro hematoma, post ¬ merging gradually destroying the basal
plate decidual tissue, exciting between villous space and form in placental abruption
ever increasing retroplatsentarnoy hematoma. Effused with placental abruption blood
diffusely inhibits myometrium up to the visceral peritoneum. Multiple hemorrhages in
the thickness of the uterus, edematous swelling of the muscle tissue and the stroma in
relation to pre-eclampsia leads to damage of the neuromuscular system mat ¬ ki,
violation of its contractility. Blood soaking through the uterus becomes mottled
appearance, becomes atonic. This is called the states of coc ¬ uteroplacental apoplexy
or uterus Kuvelera by author, first described a similar picture (Couvelaire A. 1912).
With all the variety of clinical manifestations of premature compartment ¬ Loic
normally located placenta are two types of the course of this complication: 1) the
development of generalized bleeding wounds ¬ it through postpartum uterine atony
and consumption coagulopathy ¬ tion with the activation of fibrinolysis system 2)
with severe functional ¬ tional failure of vital organs (brain, liver, kidneys, lay ¬
KIE), with no bleeding or there is the possibility ¬ sion it relatively easy to stop.
Sometimes both options ¬ clinical course who are mixed. The development of a
clinical picture depends on the previous background. Placental abruption,
accompanied ¬ yuschayasya severe renal failure, pulmonary, stroke, often develops in
the recovery or under-treatment of late toxicity and usually occurs during preg ¬
nancy (often premature). Placental abruption with massive bleeding ¬ tion often
occurs during childbirth, during the opening of uterine os to 2 cm
With significant activation of fibrinolysis, promote bleeding prognosis premature
detachment of normally located placenta ¬ zhennoy doubtful. However, it should be
recognized that the placental abruption, not accompanied by the activation of
fibrinolysis, forecasting an even more unfavorable. In this case, much stronger
violation ¬ blood flow, and thus leads to irreversible changes in the vital organs. To
factor in the forecast, as relative ¬ syatsya for relatively successful treatment of
pathological fibrosis ¬ rinoliza (thanks powerful antifibrinolytic drugs) and at the
same time a small efficacy fibrinolizinom.
Prevent premature detachment of normally situated placenta can only terminate a
pregnancy in a timely manner in case of its long-term complications of hypertension
and current severe physical illness. If it is possible to continue the pregnancy, the
better the utero-placental circulation reach, using drugs contribute ¬ own
normalization of platelet aggregation state and rheology ¬ erties of blood, including
the reduction of its viscosity, always high ¬ Coy preeclampsia due to the loss of
plasma and the relative increase in erythrocytes.
The clinical course of premature detachment of normally located ¬ zhennoy placenta
depends on the blood coagulation system (activation or no activation of fibrinolysis),
the degree of detachment, the severity of comorbidities (hypertension).
Premature detachment of normally situated placenta occurs more frequently in
nulliparous women with previous births ¬ is rarely observed. However, the constant
backdrop to the development of detachment is oc ¬ hypertensive complications of
pregnancy, usually for a long time the current ¬ ing, combined with a particular
medical condition. Of somato ¬ České diseases often associated with pregnancy, renal
failure, hyper ¬ pertonicheskaya disease, endocrinopathies, including diabetes,
obesity and other metabolic diseases. In the course of pregnancy complicated by preeclampsia, often progressing thrombocytopenia. At the same time ¬ me hematocrit
and hemoglobin concentration, erythrocyte count is much higher than that of women
with placenta previa. Pregnant women who are premature detachment of normally
situated placenta is also much more common in intrauterine growth retardation.
Acute complication, usually against hypertension varying severity and duration occur
rapidly worsening pain, initially ¬ initially localized in the area of the uterus, where
the placenta, and gradually extended to the rest of its departments. Pain syndrome is
more common in cases of detachment to form retroplatsentarnoy hematoma and
uteroplacental apoplexy and can not be expressed (poorly defined) at the end of the
blood out.
Develops hyper tone of the uterus: it is tense, painful at Pal ¬ dissipation, enlarged,
sometimes asymmetrical. These symptoms are also more common in
retroplatsentarnoy bruising and less pronounced with a significant external bleeding.
Develop symptoms of intrauterine fetal hypoxia or fruit very quickly dies. ¬ there is a
definite dependence between the degree of placental abruption, volume retroplatsen ¬
tare hematoma and the degree of tension of the uterus, the fetus. According to the data
¬ nym G.Sber (1980), the appearance of hyper uterine tone indicates that the value
retroplatsentarnoy hematoma reached more than 150 ml, and points to the risk of fetal
death. In cases of intrauterine fetal death retroplatsentarnoy hematoma volume usually
reaches 500 ml or more. When retroplatsentarnoy hematoma volume of 1000 ml or
more are necessarily identified ¬ koagulopaticheskogo clinical signs of the syndrome.
Vaginal bleeding may be profuse, small or absent altogether. As the volume of blood
loss to the clan resolutions are rarely up to 1000 ml due to plugging of the retro
placental hematoma, the general condition of patients by developing hyper ¬
yuscheysya volemii at this stage, little disturbed, and clinical manifestations ¬ tion of
blood loss may be mild: skin and visible ¬ mye mucous membranes normal color,
blood pressure can fall short, and then rise again, but the more common constant high
arterial hypertension <170/100-180/110 mmHg and more, in connection with
hypertension. That develops moderate ¬ hikardiya.
Clinical symptoms of placental abruption can with ¬ putstvovat signs of severe
deficiency of vital organs due to pre-eclampsia: oligoanuria, cerebral blood ¬
voobrascheniya, often in the form of symptom complex of pre-eclampsia or coma,
etc. These symptoms can be so pronounced that are lead ¬ schimi, disguise placental
abruption, especially if there is not at ¬ ruzhnoe bleeding
By increasing the time interval from the time of delivery, placental abruption before
clinical symptoms may appear incremental consumption coagulopathy with
thrombocytopenia: petechial rash on the face and upper limbs, bruising at the
injection sites, long ¬ tion bleeding from the injection site, etc.
Excessive bleeding usually occurs after the birth of flat ¬ yes (extraction for caesarean
section) and is caused by a double violation of hemostasis in the uterus, it atony in
combination with acute coagulopathy. ¬ ka mat soaked with blood, loses its ability to
contract. Gaping vessels placental site are a constant source of bleeding, blood flows,
unable to clot, which contains a very small amount as a result of their prolonged
procoagulant previous intravascular consumption. Increased fibrinolytic activity, and
Cindy ¬ rum ICE rapidly into IIJ-IV phase. Bleeding can be very strong, takes a
generalized and indomitable character: profuse bleeding from the uterus of soft tissue
wounds, the wound, venous puncture sites, etc. Common hematoma The detection of
small hemorrhages in ¬ ruzhivayut parametrial tissue, fallopian tubes, ligamentous
apparatus ¬ those cancer around the injection site on the skin of the neck, trunk,
limbs, etc. Duration of the symptoms of coagulopathy during treatment reaches 3-6
hours a rapidly progressive shock, the severity of which increased ¬ tering due to the
development of hypo volemii, chronic disorders with degeneration of parenchymal
organs due to preeclampsia.
Diagnosis abruption normally located pla ¬ cents can be very simple, but may have
difficulty if the detachment camouflage comorbidity. Correct diagnosis allows the
appearance of bleeding polo ¬ O paths during pregnancy or in early labor amid
varying degrees of hypertension, the development of a hyper tone of the uterus,
disorders ¬ tion life of the fetus.
Diagnosis is difficult in cases when there is no external bleeding ¬ tion, and the
patient's condition serious, not only due to placental abruption occurred, but extensive
damage to vital organs (coma, anuria, etc.). Diagnosis of placental abruption in these
cases ¬ teas help symptoms such as increased tension, stress, lo ¬ locally uterine
tenderness, an increase in its volume, signs of fetal life.
Considerable potential in the diagnosis of premature detachment of normally situated
placenta ultrasound study reveals ¬ tion, which allows to determine the initial stages
of this disease. Between the wall of the uterus and the placenta appears echo negative
area, indicating the presence of a hematoma.
Premature detachment of normally situated placenta should be differentiated from
threatening uterine rupture. In patients in whom there was a rupture of the uterus, is
often described burdened obstetric and gynecological history. During pregnancy, they
have complicated pain in the form of permanent or long-term occasional pain in the
abdomen, lower back, in the area of the scar on the uterus or without clear localization
¬ tion.
Important components of the treatment of premature detachment of normally situated
placenta is to ensure constant contact with us and ve ¬ perform transfusion-infusion
therapy, the introduction of tools to facilitate the restoration of peripheral
hemodynamics, treatment and prevention of functional impairment of vital organs,
etc. From the point of view of patients with premature detachment of normal ¬ mally
located placenta is impractical to divide premature detachment of the placenta to the
partial and complete. The appearance of clinical symptoms of placental abruption in a
hyper tone of disability of the fetus, bleeding, etc. always indicate serious
complications irrespective of the placenta by 1/4 - 1/3 full, and thus eliminate the
need for its urgent intervention .
PRACTICES.
First pregnancy 19 years 36 weeks. admitted with complaints of abdominal pain and
bleeding from the genital tract, which began 30 min ¬ chickpeas ago. Blood pressure
160/100, protein in the urine, 3.3 g / l, swelling of face, trunk, and legs. Hb 80 g / l, ¬
serdtsebi enie fetus dull. Rhythmical. In an emergency order was in Caesar ¬ section.
2200.0, the girl recovered in asphyxia, animated. PONRP diagnosis is confirmed, the
third placenta detached from the edge, no changes in the uterus. Total blood loss 1L,
made blood transfusion and infusion of plasma ¬ us. The cause of this disease was
severe preeclampsia. Premature birth, timely operation took place, the child is alive.
6.1. Multiparous 38 years enrolled in hemorrhagic shock: BP 70/40 pulse was 120
beats per 1min., Weak filling. Uterus dramatically tense, the fruit is not defined, the
heartbeat is not listening. The patient was brought ¬ the neighbors, houses have 4
children, my husband went to Russia for the goods. From the words of the evening,
the patient had pain in the stomach, but she was suffering, because there was no one
to leave the kids. In the morning it was really bad, she called her neighbor. The
patient immediately transferred to the operating room: the two veins ¬ is pouring
blood and blood products. Produced by / c removed the dead fetus, free lying placenta
and 1.5 kg of blood clots (a 3 liter of blood). The rear wall of the uterus dark purple
bluish color, inhibit blood. This is the "queen Kyuvelera." In connection with
hemorrhage into the myometrium occurs atony and bleeding from the placental site, is
not to cut out the vessels. Therefore performed amputation of the uterus, blood loss,
along with the operation of up to 3.5-4 m. From vessels tied translational em ¬ liquid
blood that is not being phased out - it's ICE syndrome - koagulopaticheskoe bleeding
develops in connection with a large loss of blood, and also due to the fact that more
than 6 hours blood clots were retro placental and under great pressure, intrauterine
platelet masses began to arrive in the gaping vessels, circulating platelet Plate
promoted the formation of blood clots inside the capillary in all parenchymal organs
(shock lung, shock kidney, liver shock - remember to pat. Anatomy), even the parietal
peritoneum is covered with hemorrhages, POE ¬ that circulate in the blood vessels
remains liquid blood - like water from water comes out of it is cut and ligated vessels.
Pain ¬ tion of FFP transfused to 120ml of 8 donors, periodically stopped by ICE, but
clumps of loose and easily lysed. additional hemostasis. 2n transfused red blood cells
from the donor. stabilized blood pressure 100/70 mm Hg ., within 12 hours of doctors
fought for his life sick. 3 days later, the patient began a massive transfusion
syndrome: hemolysis and oligouriya. Translated into reg. hospital ¬ division of the
artificial kidney, and later on the 40th day of renal function recovered. On the day of
discharge at 43-D day patient suddenly skoncha ¬ varied from pulmonary embolism.
Here it is necessary to know that dialysis was performed by heparin when finished
connecting research ¬ artificially kidney was necessary to monitor blood coagulation,
as occurs hyper coagulation, and that was the cause of death of the patient. cases show
that the late arrival of the patient to the hospital contributed to the development of the
uterus and Kyuvelera DIC. Heroic amplification ¬ lence doctors and relatives hardly
helped to cope with DIC ¬ nism but further sad outcome. Therefore it is necessary to
raise public awareness among the public about the fact that at the slightest pain in the
abdomen of a pregnant, an urgent need to hospitalize the patient to the hospital, where
specialists will specify the cause of pain - or a P0NRP or premature birth or other
pathology and render timely assistance.
Thus PONRP - is threatening pathology of the mother and the fetus. Naib ¬ Leia
difficult to diagnose placental abruption at the center. Nesvoev ¬ strap treatment of
patients in hospitals have deadly conse ¬ tviyam until death. Easier to prevent
pathology than to fight it, so in the outpatient general practitioner should allocate
pregnant women with high risk factors for PONRP, monitoring and treatment of,
antenatal hospitalization to avoid maternal mortality and reduce the incidence of
surgical interventions.
Placenta praevia
Placenta previa (placenta praevia) - attachment of the placenta in the lower uterine
segment with partial or complete overlap of its internal cervical os. Distinguish
between full, or central ¬ tion (placenta praevia tjtalis s. Centralis), and incomplete
(placenta rgaevia partialis) placenta previa. With full placenta previa completely
covers the inner mouth, the area of incomplete internal os ¬ him down only a part
(lateral previa-placenta praevia lateralis) or the edge of the placenta (marginal previa placenta praevia marginalis). Attachment of the placenta in the lower uterine segment
¬ th, but without capturing the internal os is called low attachment of the placenta. In
cases of placenta previa is 5-6 times higher than in general during pregnancy develops
its increment (placenta accreta). Even higher frequency of dense attachment of the
placenta (placenta adhaerens). Frequent complications of placenta previa with a very
unfavorable prognosis ¬ more unlikely is a partial cervical placentation (placenta
cervicalis).
The frequency of placenta previa is 0.4 - 0.6% of the total number of births.
In the etiology of placenta previa are important distrofiches ¬ Kie, inflammatory
scarring endometrium that inhibit implantation of the ovum in the uterine wall.
Confirm the importance of these factors by high rate of obstetric and gynecological
burdened ¬ cal history in pregnant women with placenta previa. Placenta previa rarely
develops in the first pregnancy of women who have it may be due to malnutrition of
the endometrium in relation to the general and genital infantilism.
In recent years, with the development of ultrasound (SPL) placenta previa started to
learn from a new angle. ¬ dock was shown the ability to migrate the placenta during
pregnancy. The frequency of placenta previa in the II trimester is 8-10 times higher
than the beginning of the birth, and that the placenta previa in II or III trimesters
gradually migrates from the neck up to the body of the uterus.
Placental migration mechanism is not completely clear. Suggested carrying ¬ Kolk
assumptions. Migration of the placenta associated with changes in archi ¬ tectonics of
the lower segment of the uterus during pregnancy. The influence of this factor on the
migration of the placenta, from our point of view finds support in C.Mittelstaedt et al
1979). Authors on the outside ¬ placenta previa, which was located on the front or
back wall of the uterus, in the II trimester of pregnancy in 98 pregnant women. By the
beginning of birth placenta previa persisted for most women who have placenta was
implanted on the back wall of the uterus, whereas at its location on the front of the
presentation is almost always eliminated ¬ nyalos.
There is also the hypothesis of "dynamic placenta", according to which ¬ swarm
during pregnancy there is a microscopic abruptio pla ¬ cents, which is re-attached to
other parts of the uterus. As a result of this gradual ¬ area decreases uterine wall, the
placenta of the cover ¬: it becomes a more compact. Availability Perma ¬-component
processes of placental abruption with hemorrhage found histologically Placenta
previa: detected diffuse hyperplasia end villi, edge thrombosis and marginal necrosis
of decidual tissue (Naeye R., 1978).
Predlezhashey abruption placenta, accompanied by bleeding in late pregnancy is
associated with the formation of the lower uterine segment at the end of pregnancy
and during labor: maloelastichnaya placental tissue, unable to stretch after stretch of
the uterine wall, partially detached and exfoliate. At the same time opened the
intervillous space and starts bleeding. Observations showed that the bleeding with
placenta previa develops not only closer to the on ¬ chalu birth, but in earlier periods:
first, due to the fact previa vetvis ¬ chorion (I trimester) and then, form and branching
ho ¬ Rion placenta. Usually in cases of previa branching chorionic preg ¬ variables
women are under observation for a long time with a diagnosis threaten ¬ schego
abortion. Meanwhile, the cause of bleeding in the previous period ¬ ti Pregnancy is a
"dynamic placenta", ie constant branching mikrootsloyka chorion, and then the
placenta, resulting in their migration.
Thus, the clinic placenta previa describes one ve ¬ duschy symptom - a recurring
vaginal bleeding during pregnancy, bleeding may be significant in dilitelnym an
amount of blood lost, appears spontaneously in a period of 12 to 40 weeks.
pregnancy. After 26-28 weeks. pregnancy bleeding can be carried-induced physical
activity, sexual intercourse, defecation, vaginal examination. Placenta previa often
described the non-threat of pregnancy, stages of pregnancy, in which there is a threat
of miscarriage (from 6 to 33 weeks), suggest that threatening ¬ yuschy abortion can a
life backdrop for the presentation formed pla ¬ cents, and vice versa, previa branching
chorionic may contribute to threatened abortion.
A characteristic feature of placenta previa is a common development in pregnant
hypertensive syndrome: 1/3 - 1/4 of them in late pregnancy developed persistent
hypotension during initial normotonii. Placenta praevia occurs more frequently in
pregnant women older than 30 years who have had abortions or childbirth.
Repeated bleeding in pregnancy complicated by placenta previa, reflected on red
blood. In this pathology observed the lowest hemoglobin and red blood cells as com ¬
pared with other complications of pregnancy, leading to bleeding ¬ pits. Placentation
in the lower uterine segment is reflected in the growth of BCC with ¬. Placenta previa
have a high perinatal mortality ¬ sion of children (10-15%). This is due to the fact that
with this patho ¬ energy is often a premature birth, abnormal fetal presentation and
position.