BUKOVINIAN STATE MEDICAL UNIVERSITY
“Approved”
on methodological meeting
of Department of Obstetrics and Gynecology
with course of Infant and Adolescent Gynecology
“___”______________________ 201_ year
protocol #
T.a. The Head of the department
Professor
________________ O. Andriyets
METHODOLOGICAL INSTRUCTION
for practical lesson
“Bleeding in obstetrics. Obstetric hemorrhages. Hemorrhagic shock in obstetrics. Syndrome
of disseminated intravascular blood coagulation in obstetrics. Extrauterine pregnancy.”
MODULE 4: Obstetrics and gynecology
CONTEXT MODULE 9: Pathological flow of pregnancy, labor and puerperium
Subject: Obstetrics and Gynecology
6th year of studying
2nd medical faculty
Number of academic hours – 6
Methodological instruction developed by:
ass.prof. Andriy Berbets
Chernivtsi – 2010
I. Scientific and methodical background of the topic
Although vaginal bleeding in the first trimester is a relatively common occurrence, it must be
considered serious until all potential abnormal causes have been effectively ruled out. The
precipitating cause may not readily present itself and may take some investigation to identify.
Ectopic pregnancy should always be considered.
II. Aim:
A student must know:
1. Etiology of development obstetrical bleedings.
2. Terminology, used characterize clinical symptoms of obstetrical bleedings.
3. Ways of formation of amniotic fluid embolism during pregnancy and labor.
4. Bleedings during labor
5. Classification of obstetrical bleedings.
6. Placental presentation.
7. Clinic, diagnosis and treatment placental presentation.
8. Classification of premature detachment of a normally located placenta.
A student should be able to:
1. Collect general and specific obstetrical anamnesis.
2. Make up a plan of examination and treatment of different forms of obstetrical
bleedings.
III. Recommendations to the student
Obstetrical bleedings
Bleedings in the first half of pregnancy:
- spontaneous abortion;
- hydatidiform mole;
- extrauterine pregnancy ( including cervical pregnancy);
Bleedings in the second half of pregnancy:
- placental presentation (placenta praevia);
- premature detachment of normally located placenta;
- hysterorrhexis.
Bleedings during labor:
I period:
- premature detachment of normally located placenta;
- placental presentation;
- hysterorrhexis;
- laceration of the neck of the uterus.
II period:
- premature detachment of normally located placenta;
- hysterorrhexis.
III period:
- pathologic implantation of placenta;
- suppression, strangulation of placenta;
- laceration of soft tissues of maternal passages.
Postpartum bleeding:
- hypotonic bleeding;
- retention of the afterbirth’s fragments;
- laceration of soft tissues of maternity passages;
- hysterorrhexis,
-
amniotic fluid embolism,
coagulopathetic hemorrhage.
Bleedings unconnected with pregnancy:
- uterine cervix polyp;
- carcinoma of uterine cervix.
Classification
-
threat of abortion;
the abortion which has started;
abortion in process;
incomplete accidental abortion;
complete accidental abortion;
missed miscarriage.
Diagnostic criteria
Symptoms of abortion:
- pain-syndrome: pain associated with contraction of the uterus;
- increased tension of the uterus;
- hemorrhage of different intensity;
- structural changes in the uterine cervix.
Differential diagnosis of abortion stages is based on the 2 latter symptoms. By the threat of
abortion, hemorrhage and structural changes in the uterine cervix are absent.
Bleedings during accidental abortion, in the beginning of abortion, in the course of abortion
and by incomplete accidental abortion.
Clinic:
- pain of intermittent character;
- hemorrhage of different intensity
-
Diagnosis:
assessment of the gravida’s general condition;
speculum examination of the uterine cervix, bimanual examination;
evaluation of the blood less amount.
Treatment
-
instrumental uterus emptying under intravenous anaesthesia (with an obligatory examination of
the received material);
medications contracting uterus (10 units of oxytocin by intravenous droppery or 0,5 mg of
methylergobrevin intravenously or intramuscularly);
if hemorrhage proceeds-800 mkg of misoprostol rectally;
recovery of the amount of blood loss as indicated;
antibacterial therapy as indicated.
Placental presentation
Placental presentation is a complication of pregnancy when placenta is located in the lower segment
of the uterus lower than the presenting part of the fetus blocking totally or partially the inner pupil
of the uterine cervix. During physiological pregnancy the lower edge of the placenta lacks 7 sm to
reach the inner pupil. Placental presentation occurs in 0,2-0,8% of general delivery.
Classification of placental presentation
1. Complete presentation-placenta completely blocks the inner pupil.
2. Incomplete presentation-placenta blocks the inner pupil incompletely:
a) lateral presentation- the inner pupil is covered on 2\3 of its area;
b) regional presentation- the end of placenta reaches the inner pupil.
3. Lower implantation of placenta- the location of placenta in the lower segment, 7 sm lowerer
than inner pupil without its blocking. Due to the migration of placenta or its expansion this kind of
presentation can change during pregnancy progression.
Diagnostic criteria.
Risk group of placental presentation includes women which underwent:
- endometritis with the following scarry dystrophic changes of endometrium;
- abortions excessively complicated with inflammatory processes;
- benign tumours of the uterus, in particular, submucous myomates nodes;
- influence of chemical preparations on endometrium;
- women with hypoplastic uterus.
Clinical symptoms
A pathognomonic symptom is an obligatory hemorrhage which can periodically recur throughout
the term of pregnancy from 12 to 40 weeks, occurs spontaneously or after physical overwork, takes
a dangerous character:
- with the onset of uterus contraction at any term of gestation;
- isn’t accompanied by pain;
- isn’t accompanied by the rise of uterine tension.
Seriousness of the condition is determined by the amount of blood loss:
- it is massive at the complete presentation;
- variable from small to massive at the incomplete presentation.
Anematizing as the result of recurrent bleeding. By this pathology the content of hemoglobin and
erythrocytes is the lowest if compared to the other complications of pregnancy accompanied by
bleedings. Irregular location of the fetus is frequent: oblique, transversal, pelvic presentation,
irregular position of the head. Premature delivery is possible.
Diagnosis
1. Medical history (anamnesis)
2. Clinic manifestations – appearance of recurrent blledings which are not accompanied by pain or
increased uterus tension.
Obstetrical examination:
a) external examination:
- high position of the presenting part;
- oblique, transversal position of the fetus;
- uterine tension is not increased;
b) internal examination (made only in the conditions of a full-scale operating room):
- doughy tissues of the vault, pastiness, pulsation of vessels;
- impossibility to pulpate the presenting part because of the vault.
In case of hemorrhage a more precise definition of the presentation character has no sense because
obstetrical tactics is determined by the amount of blood loss and the gravida’s condition.
Ultrasound scanning is very important for the definition of placental location and correct diagnosis.
Placental presentation with bleeding is an urgent indication for in-patient hospitalization
Algorhythm of examination at admittance of a pregnant with bleeding to in-patient
department.
-
verification of the anamnesis;
evaluation of the general state and the amount of blood loss;
general clinic examination (blood group, Rhesus factor, general blood count, coagulogram);
external obstetrical examination;
examination of the uterine cervix and vagina in the full-scale operating-room by vaginal specula
to exclude such causes of bleeding as polyp of uterine cervix, cervical carcinoma, laceration of
the varicose node, assessment of the discharge- additional methods of examination (USD)
according to the indications if urgent delivery is not necessary.
Treatment
The tactics of management depends on the amount of blood loss, state of the gravida and the fetus,
characteristics of the presentation, the term of pregnancy, maturity of the fetus’s lungs.
Principles of treating patients with placental presentation:
1. In case of little bleeding (up to 250 ml), the absence of hemorrhagic shock signs, distress of
the fetus and labor activity, immaturity of the fetus’s lungs at the term no more than 37
weeks of gestation – the tactics of anticipation.
2. At the arrest of the bleeding – US examination, preparation of the fetus’s lungs. The target
of expectancy tactics is prolongation of gestation to the term of the fetus’s viability.
3. In case of progressive bleeding which becomes uncontrolled (more than 250 ml),
accompanied by hemorrhagic shock signs, the fetus’s distress, regardless of the term and the
fetus’s condition (alive, distressed dead)- urgent delivery.
Clinic variants:
1. Blood loss (less than 250 ml), symptoms of hemorrhagic shock, the fetus’s distress are absent,
the term of pregnancy is less than 37 weeks of gestation:
- hospitalization;
- tocolytic therapy according to the indications;
- acceleration of the fetus’s lungs maturity up to 34 weeks of gestation (6 mg of dexamethazone in
the interval of 12 hours for 2 days);
- monitor examination of the gravida’s and fetus’ condition.
If the bleeding increases for more than 250 ml – Cesarean delivery.
2. Significant blood loss (more than 250 ml) at premature pregnancy – regardless of the
presentation stage – urgent Cesarean section.
3. Bloodloss (less than 250 ml) at mature pregnancy:
In the conditions of a full-scale operating room the stage of presentation is verified.
- in case of partial placental presentation and possibility to reach amnionic membranes and
cephalic fetus presentation with active uterine contractions – amniotomy is performed. After the
arrest of bleeding the childbirth is conducted through natural maternal passages. After the
childbirth – 10 units of oxytocin by intramuscular injection, a thorough observation of the
uterine contraction and the character of discharge from vagina. If hemorrhage recurs – Cesarean
delivery should be performed.
-
At complete or incomplete placental presentation and irregular fetus position (pelvic, oblique
or transversal) – Cesarean delivery is indicated;
At incomplete presentation and dead fetus – amniotomy is possible; at hemostasia – labor
should take place through maternal passages.
4. Blood loss (more than 250 ml) at mature pregnancy – regardless of the stage of presentation –
urgent Cesarean delivery.
5. Complete presentation, diagnosed by USD, without hemorrhage – hospitalization before the term
of labor, Cesarean section at 37-38 weeks of gestation.
At an early postpartum period – a thorough observation of the parturient. If hemorrhage recurs on
Cesarean delivery and the amount of blood loss is more than 1% to the body mass – urgent
relaparotomy, uterus extirpation without appendayes, in case of necessity – ligation of inner
glomerular arteries by a specialist well-experienced at performing such operations.
Blood loss restoration, hemorrhagic shock and DIC syndrome management are performed
according to the indications.
Premature detachment of normally located placentaIs a detachment of the placenta located behind the lower uterine segment during pregnancy or in the
first-second (I-II) periods of delivery.
Classification
-
1. Complete detachment (detachment of total placenta).
2. Partial detachment:
marginal;
central
Clinicodiagnostic criteria of premature detachment of a normally located placenta:
- gestosis;
- renal diseases;
- isoimmune conflict between the mother and the fetus;
- uterine hyperdistension (hydramnios, multiple pregnancy, a big fetus);
- vascular system diseases;
- diabetes mellitus;
- connective tissue pathology;
- uterine and placental inflammatory processes;
- anomalies of development or tumours of the uterus (submucous, intramural myomas).
The direct cause may be:
- a physical trauma;
- a psychic trauma;
- an abrupt reduction of the amniotic fluid volume;
- an absolutely or relatively short umbilical cord;
- pathology of the uterine contractile activity.
Clinical symptoms:
1. Pain syndrome: acute pain in placental projection irradiating in the total uterine body, loin,
back and turning diffusive. The pain is mostly acute by central detachment and it may be
slight by marginal detachment. By detachment of placenta located on the posterior wall, the
pain can imilate renal colic.
2. Uterine hypertension up to tetany, which can’t be released by spasmolytics, tocolytics.
3. Vaginal bleedings can vary from slight to massive depending on acuteness and character
(marginal or central detachment). If retroplacental hematoma is being formed, external
bleeding can be absent.
Diagnosis
-
1. The assessment of a gravida’s state will depend on the size of detachment, the amount of
blood loss, the appearance of hemorrhagic shock symptoms or DIC-syndrome.
2. External obstetric examination:
uterine hypertension;
the enlarged uterine can be deformed with a local diverticulum if the placenta is on the frontier
wall position;
tenderness by palpation;
difficulties or impossibility of palpation and auscultation of the fetus’ palpitation;
appearance of the fetus’ distress symptoms or fetal death.
3. Internal obstetric examination:
tension of the bag of waters;
there may be a colouring with blood by the rupture of amniotic fluid sac;
uterine4 bleedings of different intensity
4. US-examination (echo-negative focus between the uterus and the placenta), but this method
can’t be an absolute diagnostic criterion because hypoechogenic zone can be visualized in
patients without detachment.
If there is no external bleeding, diagnosis of premature placental detachment is based on the
increased uterine tension, local painfulness and change of the fetus’ condition to the worse.
Blood from retroplacental hematoma saturales the uterine wall and forms Kuveler’s uterus
(uterine-placental apoplexy) which loses the ability to contract resulting in the development of
bleedings with massive blood loss at the expense of coagulopathy and hypotonia.
Treatment
Ungrounded late delivery leads to fetal motability, Kuveler’s uterus formation, massive blood loss,
hemorrhagic shock and DIC-syndrome, gravida’s reproductive failure.
1. In case of progressive premature placental detachment during pregnancy or in the first
period of delivery, when hemorrhagic shock symptoms, DIC-syndrome, fetus’s distress
signs appear-regardless of gestation term – urgent Cesarean delivery. In the presence of
Kuveler’s uterus signs – extirpation of the uterus without appendages.
2. Restoration of the blood loss amount, treatment of hemorrhagic shock and DIC – syndrome
(see corresponding protocols).
3. In case of unprogressive placental detachment there should be dynamic observation at
immature pregnancy up to 34 weeks of gestation (therapy for fetus’ lungs maturation) in
hospitals with day- and night duty by skilled physicians, obstetricians, gynecologists,
anesthesiologists, neonatologists. Monitor observation of the gravida’s and her fetus’ state,
CRI, USD are made.
Peculiarities of Cesarean section:
-
amniotomy prior to the operation (provided there are necessary conditions);
obligatory revision of uterine walls (especially external surface) with the aim to eliminate the
possibility of uterine – placental apoplexy;
in case of Kuveler’s uterus diagnosis – extirpation of the uterus without appendages;
if the area of apoplexy is not large – 2-3 foci of a small diameter of 1-2 sm, or one focus – up to
3 sm) and if the uterus can contract, if there is no bleeding and no signs of DIC-syndrome and if
it is necessary to preserve a reproductive function ( first labor, fetal mortality) – the
consultation has to decide the question of protecting the uterus. Surgeons have to observe the
uterus state for some time (10-20 min) by open abdominal cavity and if there is no hemorrhage,
the abdominal cavity is drained to control hemostasis. This tactics is allowed, in exceptional
-
cases, only in hospitals with day-and-night duty by an obstetrician-gynecologist, an
anesthesiologist;
in early postpartum period- a thorough observation of the parturient.
Tactics by placental detachment in the end of I or II periods
- urgent amniotomy if the amniotic bladder is intact;
- by cephalic presentation – application of obstetrical forceps;
- by pelvic presentation – fetal extraction at the pelvic end;
- if one fetus of the twins is in the transverse presentation – obstetric podalic version is
performed. In some cases delivery by Cesarean section is more reliable.
- manual placental separation and expulsion of the afterbirth;
- contractile methods – 10 units of oxytocin intravenously, if there is no effect – 800 mkg of
misoprostol (rectally);
- thorough dynamic observation in postpartum period;
- restoration of the blood loss amount, hemorrhagic shock and DIC-syndrome management.
Amniotic fluid embolism
I. Causes of intrauterine high blood pressure:
- hyperactive labor;
- rapid labor;
- oxytocin injections in big dosages;
- hydramnios;
- a big fetus;
- multiple pregnancy;
- pelvic presentation;
- uterine cervical distonia;
- prolonged gestation;
- late break of the water bag;
- gross manipulations during delivery (Kristeller’s method and other)
II. Causes of uterine vessels hiatus:
- hypovolemia of any origin;
- premature placental detachment;
- placental presentation;
- manual separation and expulsion of the afterbirth from the uterine cavity;
- Cesarean section;
- Uterine hypotension.
Clinical picture depends on the amount and composition of the fluid in the blood vessels of the
mother.
Diagnosis of amniotic fluid embolism is based on the assessment of clinical symptoms, laboratory
tests and auxiliary methods of investigation,
Cinical signs:
- anxiety;
- nervousness, excitement;
- shivering and hyperthermia;
- cough;
- sudden pallor or cyanosis;
- acute pain in the chest;
- dyspnea, noisy respiration;
- AP lowering;
- tachycardia,
- coagulopathetic hemorrhage from maternal passages or other traumatized sites;
-
-
-
coma;
convulsions;
death in consequence of ventricular fibrillation in the course of several minutes.
Laboratory signs – signs of hypocoagulation and ESR rise (B)..
Auxiliary methods of examination:
ECG – sinus tachycardia, myocardium hypoxia, acute pulmonary heart (SIQ III P-pulmonale)
Roentgenologic changes reveal themselves immediately or some hours after embolism and have
a clinical picture of interstitial confluent pneumonitis (“a butterfly” with consolidation
throughout total area at the root of the lung and lumen of the lung tissue picture at periphery).
Differential diagnosis is made with the following pathology:
myocardial infarction: pain irradiating in the left hand, rhythm disturbances, ECG changes
which are not always visible on the fresh infarction;
- lung artery thromboembolism: abruptness, various facial cyanosis, dyspnea, headache, pain in
the chest. It often occurs by compromised veins (varicosity, thrombophlebitis, phlebitis) right
gram on the ECG;
- air embolism (by rough violation of intravenuous infusion technique);
- Mendelson’s syndrome (bronchospasm as a response to the appearance of acidic stomach
content in the upper respiratory tracts) – acid – aspiratory hyperergic pneumonitis. As a rule, it
occurs bi initial narcosis with unemptied stomach, when vomiting masses appear in the
respiratory tracts: anoxia during 5 minutes – death of the brain.
Urgent therapy by amniotic fluid embolism is performed by a team of physicians including
an obstetrician-gynecologist and anesthesiologist. Consultations of a cardiologist, a
neuropathologist and a vascular surgeon are essential.
Therapeutic tactics:
1. Urgent parturition in the course of pregnancy or delivery;
2. Management of cardio-pulmonary shock or cardio-pulmonary resuscitation.
3. Coagulopathy correction.
4. Timely and complete surgical intervention by hemorrhage.
5. Prevention and therapy of polyorganic insufficiency.
First –rate measures:
1. At the arrest of circulation – performance of cardio-pulmonary resuscitation.
2. If signs of respiratory insufficiency increase - trachea intubation and APV.
3. Punction and catheterization of subclavian jugular vein with obligatory control of CVP. To
take 5 ml of blood for the investigation of coagulogram and presence of amniotic fluid
elements.
4. Urinary bladder catheterization with an indwelling catheter.
Monitoring of viable functions should include:
- AP measurement every 15 minutes;
- CVP;
- RHB;
- RR (respiration rate);
- Pulsoxemetry;
- ECG;
- Hour-to hour diuresis and routine analysis of the urine;
- Thermometry;
- Chest organs roentgenology;
- Routine blood test, Ht, thrombocytes;
- Coagulogram;
- Acid-basic state and blood gases;
- Biochemical blood test and electrolytes content.
1.
2.
3.
4.
5.
-
Further therapy:
If CVP is <8 sm of water column then – correction of hypovolemia by colloids and
crystalloids injections in the proportion of 2:1 at the rate 5-20 ml/min regarding the AP
level. If bleeding occurs – chilled plasma is added to the infusive therapy 5% albumin
mustn’t be used.
If CVP is >8 sm of water column then – inotropic support is performed: dofamin (5-10
mkg/kg/min). Isotropic therapy is initiated with minimal dosages and if there is no effect –
the dosages are gradually increased. Combined dofamine (2-5 mkg/kg/min) and dobutamine
(10 mkg/kg/min) injections are desirable.
Simultaneously with sympathomimetic therapy glucocorticoids are used:: prednisolone up
to 300-400 mg or hydrocortisone – 1000-1500 mg.
Control of coagulopathy.
Prevention of injectious complications.
Criteria of intensive therapy effectiveness:
increase of cardiac ejaction;
abolition of arterial hypotension;
elimination of peripheric vasoconstriction signs;
normalization of diuresis >30 ml/hour
normalization of hemostasis indeces;
decrease of respiratory failure signs.
Bleeding in the afterbirth and postpartum periods
Postpartum bleeding is blood loss of 0,5% or more in relation to the body mass after parturition.
Risk factors of postpartum hemorrhage
- aggravated obstetric anamnesis (bleedings at previous labor, abortions, spontaneous abortion);
- hestosis;
- a big fetus;
- hydramnion;
- multiple pregnancy;
- uterine myoma;
- cicatrix on the womb;
- chronic DIC – syndrome;
- thrombocytopathy;
- antenatal fetal mortality.
Hemorrhage in postpartum (third) period of labor
Causes:
- partial placental or membrane retention;
- placental implantation pathology;
- placental strangulation.
The amount of blood loss depends on the kind of placental implantation damage: total, partial
detachment or adherent placenta.
Clinical manifestations:
1. Signs of placental separation are absent during 30 minutes without significant blood loss –
pathology of placental detachment or adherence.
2. Hemorrhage initiates immediately at afterbirth labor – retention of placental fragments or
membranes;
3. Hemorrhage initiates after the childbirth without placental separation – placental
strangulation, partial placental adherence.
Hemorrhage associated with placental retention, pathologic detachment or strangulation
Algorhythm of management:
1. Catherization of the peripheric or central vein regarding the amount of blood loss and the
woman’s state.
2. Urine bladder emptying.
3. Checking-up the signs of placental separation and afterbirth removal by manual methods.
4. In case of afterbirth strangulation – external massages of the uterus, external methods of the
afterbirth removal.
5. If placental fragments or membranes have been retained – manual examination of uterine
cavity under intravenous narcosis.
6. If the mechanism of placental presentation fails and there is no hemorrhage – anticipation in
the course of 30 minutes (with the group of pregnants – 15 minutes) manual separation of
placenta and removal of the afterbirth.
7. If hemorrhage occurs – urgent manual placental separation and removal of the afterbirth
under intravenous narcosis.
8. Uterotonics injections – 10-20 units of oxytocin intravenously on 400 ml of physiologic salt
solution by intravenous droppery.
9. In case of genuine detachment or adherence of the placenta – laparotomy, extirpation of the
uterus without appendages.
10. Assessment of the blood loss amount and recovery of the BCV (blood circulation volume)
amount.
Early (primary) postpartum hemorrhage
Causes of early postpartum hemorrhage:
- hypotension or atony of the uterus (in 90% of patients);
- retention of placental fragments or membranes;
- traumatic damages of the maternal passages;
- disorder of blood coagulability (afibrinogenemia, fibrinolysis);
- primary blood diseases.
Causes of uterine hypotension or atony
- functional failures of myometrium (late hestosis, endocrinopathies, somatic diseases, uterine
tumours, a cicatrix on the womb, a big fetus, hydramnios, multiple pregnancy and others);
- overexcitation with the following failure of myometrium function (protracted or prolonged
labor), operation in the end of delivery, administration of medicaments lowering myometrium
tension (spasmolytics, tocolytics, hypoxia at delivery, and so on);
- failure of a contractive function of myometrium due to disorder of biochemical processes,
correlation of neurohumoral factors (estrogens, acetylcholine, oxytocin, cholinesterase,
progesterone, prostaglandins);
- disturbances of placental and afterbirth implantation, separation and removal processes;
- idiopathetic (haven’t been established).
Major clinicolaboratory manifestations:
Hemorrhage occurs in two kinds:
- hemorrhage initiates immediately after the childbirth, it’s massive (>1000 ml in the course of
few minutes); the uterus remains hypotonic, doesn’t contract, hypovolemia develops rapidly,
then hemorrhagic shock;
- hemorrhage initiates after the uterine contraction, blood runs out in small portions, blood loss
increases gradually. Alternation of uterine hypotony with tonus recovery, arrest and recurrence
of bleeding are characteristic.
Algorhythm of management:
1. General examination of the women in childbirth:
- assessment of blood loss amount by available methods (appendage №1);
- assessment of the parturient’s state: complaints, AP, heart rate, colour of the skin and mucous
membranes, urine amount, if there is hemorrhagic shock and its stage;
2. Urgent laboratory tests:
- evaluation of hemoglobin and hematocryt level;
- coagulogram (the amount of thrombocytes, prothrombin index, fibrinogen factor, blood
coagulation time);
- blood group and rhesus factor;
- biochemical tests according to indications.
3. Peripheric or central vein catherization regarding the amount of blood loss and the woman’s
condition.
4. Urine bladder evacuation.
5. Beginning or continuation of urotonics injections: 10-20 units of oxytocyn intravenously on 400
ml of physiologic salt solution.
6. manual examination of uterine cavity under intravenous anesthesia (assessment of uterine walls
intactness, removal of blood clots or residue of placenta or membranes).
7. Examination of the maternal passages and restoration of their intactness.
8. External uterine massage.
9. In case the hemorrhage continues, 800 mkg of misoprostol are additionally injected rectally.
10. Restoration of BCV (blood circulating volume) and blood loss.
11. If hemorrhage takes up again and the blood loss amount is 1,5% and more in relation to the
body weight – surgical management: uterine extirpation without appendages, in case the
hemorrhage continues – ligation of internal glomerular arteries by a specialist having a good
command of the operation.
12. During preparation for surgery with the aim to decrease the amount of blood loss – temporary
bimanual external and internal compression of the uterus.
13. If the hemorrhage continues after uterine extirpation – powerful tamponade of the abdominal
cavity and the vagina (the abdominal cavity isn’t stitched till the hemostasis).
Postpartum secondary (late) hemorrhage
Major causes for late postpartum hemorrhages:
- retention of placental fragments or afterbirth;
- expulsion of necrotic tissues after delivery;
- disjunctional separation of sutures and uterine wound (after Cesarean section or hysterorrhexis).
Postpartum hemorrhage most frequently occurs on the 7-12th days after labor.
Algorhythms of medical care:
1. Assessment of blood loss by available methods.
2. Catherization of peripheric and central vein.
3. Instrumental revision of uterine cavity under intravenous anesthesia.
4. Intravenous injections of uterotonics (oxytocin 10-20 units on physiologic salt solution –
400 or 0,5 mkg methylergometrine).
5. In case the hemorrhage proceeds – misoprostol 800 mkg rectally.
6. Restoration of the blood loss circulation volume.
7. If the blood loss is >1,5% to the body mass – laparotomy, uterine extirpation, if the
hemorrhage continues – ligation of internal glomerular arteries by a specialist well-trained
in the operation.
Blood coagulation disturbances (postpartum afibrinogenemia, fibrinolysis):
- restoration of the blood circulation volume;
- correction of hemostasis (see DIC – syndrome treatment).
Prevention of postpartum hemorrhages.
1. In the course of pregnancy:
- estimating risk factors of hemorrhage;
- diagnosis and treatment of anemia;
- hospitalization at the maternity home being home being ready to help the gravida from the high
risk group in the incidence of hemorrhage who has in the history:
-antenatal hemorrhage; hemorrhages in previous deliveries, whith hydramnion, multiple pregnancy,
a big fetus.
Predisposal factors to hemorrhages in postpartum period
Previous pregnancies
Factors which occur in
the course of pregnancy
Factors which occur in the
course of delivery
Unigravida (primipara,
primigravida)
Complete placental
presentation
Induction of labor
More than 5 labor in the
history
Placental separation
Protracted or prolonged
labor
Pathology of placental
separation or expulsion
hydramnion
Precipitated labor
Operations on the uterus in the
history including Cesarean
section
Prolonged or difficult
childbirth in the history
Background diseases:
cardiovascular, diabetes
mellitus, blood coagulation
pathology
Anemia
Uterine myoma
Multiple pregnancy
Urgent Cesarean section
Intrauterine fetal
mortality
Difficult preeclampsia,
eclampsia
Application of obstetrical
forceps
hepatitis
Conditions associated
with anemia
DIC - syndrome
General or epidural
anesthesia
chorionamnionitis
2. In the course of delivery:
- labor pain relief;
- elimination of prolonged labor;
- active management of the third period of delivery;
- usage of uterotonic medicamentations I the third period of delivery;
- routine examination and assessment of placental and membranes intactness;
- traumatism prevention in the course of delivery.
3. After the parturium:
- observation and examination of the maternal passages;
- thorough care during 2 hours after the delivery;
- pregnant women from the risk group undergo intravenuous 20 units of oxytocin droppery during 2
hours after the childbirth.
Hemorrhagic shock in obstetrics
Hemorrhagic shock is a condition of severe hemodynamic and metabolic disturbances resulting
from blood loss and characterized by inability of the blood circulation system to provide viable
organs with adequate perfusion due to the lack of correspondence between the circulating blood
amount and the vascular bed volume
The threat of hemorrhagic shock appears when the blood loss is 15-20% of the circulatory blood
volume or 750-1000 ml. Hemorrhage exceeding 1500 ml (25-30% from the circulatory blood
volume or 1,5% in relation to the body mass) in regarded massive.
Causes of hemorrhagic shock risk in obstetrics
1. Hemorrhage at early terms of gestation:
- abortion;
- extrauterine pregnancy;
- hydatidiform mole
2. Hemorrhage at late terms of gestation or delivery:
- premature placental detachment;
- placental presentation;
- hysterorrhexis (uterine rupture);
- amniotic fluid embolism
3. Postpartum hemorrhage:
- hypo- or atony of the uterus;
- retention of the afterbirth or its fragments in the uterine cavity;
- maternal passages rupture
4. Hepatic insufficiency
5. Hemostasis system pathology
Hemorrhagic shock. Classification according to the clinical course and the damage rate
Shock damage rate
Shock stage
Blood loss amount
1
compensated
% BCV
15-20
%body mass
0,8-1,2
2
subcompensated
21-30
1,3-1,8
3
4
decompensated
irreversible
31-40
>40
1,9-2,4
>2,4
Shock severity rate criteria
Index
Shock stage
Blood loss , ml
<750
750-1000
1000-1500
1500-2500
>2500
Blood loss
(%BCV)
Pulse, beat/min
Systolic AP, mm
mercuric column
Shock index
CVP, mm water
column
White spot test
<15%
15-20%
21-30%
31-40%
>40%
<100
N
100-110
90-100
110-120
70-90
120-140
50-70
>140 or<40*
<50**
0,54-0,8
60-80
0,8-1
40-60
1-1,5
30-40
1,5-2
0-30
>2
≤0
N(2 sec)
2-3 sec
>3 sec
>3 sec
>3 sec
Hematocrit
0,38-0,42
0,30-0,38
0,25-0,30
0,20-0,25
<0,20
14-20
20-25
25-30
30-40
>40
Respiration rate
Diuresis rate ,
ml/hour
Mental status
50
30-50
Calm
quiet
Slight
anxiety
25-30
5-15
0-5
Anxiety
Nervousne
confused
moderate
ss fear or consciousness
nervousness confused or coma
conscious
ness
Note: *- on main arteries,
** - cannot be determined by Korotkov’s method
Difficulties of determining the blood loss amount in obstetrics are caused by a significant
hemodilution of the leaking blood with amniotic fluid as well as the retention of a big amount of
blood in the vagina or uterine cavity. For a tentative determination of the blood loss amount in
pregnant women a modificated Moore’s formula can be used:
0,42-Htf
BL=M*75*----------0,42
where: BL – blood loss (ml);
M – body mass of the gravida (kg);
Htf – factual hematocrit of the gravida (l/l)
NB! Arterial hypotension is regarded late and unreliable clinical symptom of obstetric hemorrhagic
shock. Due to physiologic hypervolemic autohemodilution AP in pregnant women may be stable
until the blood loss volume reaches 30%. Hypovolemia compensation in pregnant is, provided, at
first rate, at the expense of symptoadrenal system activation, which reveal itself in vasospasm and
tachycardia. Oliguria joins in early.
Hemorrhagic shock intensive therapy. General principles of acute blood loss therapy:
1. Urgent hemostasia by conservative or surgical methods depending on the causes of
hemorrhagic development (see the protocol ‘Obstetric hemorrhages’)
2. Circulation blood volume recovery.
3. Maintenance of adequate gas exchange.
4. Management of organ dysfunction and prophylaxis of polyorganic insufficiency.
5. Correction of metabolic disorder.
Immediate actions by hemorrhage shock.
1. Assessment of viable functions (pulse, arterial pressure, respiration rate and character,
mental status).
2. A duty obstetrician-gynecologist in charge or assistant of chief doctor should be informed
about hemorrhage and hemorrhage shock initiation, the personnel should be mobilized.
3. The patient’s feet or the foot end of the bed are raised (trendelenburg position) to increase
venous turnover to the heart.
4. The gravida is turned to the left side to avoid the development of aortocaval syndrome, to
reduce aspiration risk by vomiting and to provide a free passage for respiratory tracts.
5. Catheterization of one – two peripheric veins by catheters of big diameter (NN 14-16 G). If
it possible to reach some peripheric veins, then haste shouldn’t be made with central veins
catherization because in the course of their catherization serious complications are sure to
arise. If shock of 3-4 stage develops - catheterization of 3 veins should be made one of
them should be central at that. During catherization preference in given to venesection v.
brachiales or punction and catherization after Seldinger v. jugularis interna.
6. 10 ml of blood is taken to determine blood group and Rhesus – factor, cross-compatibility,
hemoglobin and hematocrit content, prior to the infusion of solutions Lee-White test is
performed.
7. 100% oxygen inhalation is performed at the rate of 6-8 l/min thtough nasofacial mask or
nasal cannula.
Further activity to eliminate hemorrhagic shock
1. Crystalloid (0,9% solution of sodium chloride, Ringer’s solution, oth.) and colloids (helofusin)
are jet-infused intravenously. If shock develops to the second or third stage, the tempo of infusion is
200-300 ml/min. On AP stabilization at the safe level further infusion is performed at the rate 2 l of
solution per hour. Hemorrhagic shock management is more effective if infusive therapy has been
started at the very onset, no later than 30 min after the appearance of first signs of shock.
Infusive-transfusive therapy of obstetric blood loss
Blood loss volume
% BCV
To 25% (to
1,25 l)
To 50% (to
2,5 l)
To 65% (to
3,25 l)
To 75% (to
3,75 l)
>75%
% from
body
mass
To
1,5%
To
3,0%
To
4,0%
To
4,5%
>4,5%
Infusive media
Ringer
lactate
Helofuzi
n
Cool
plasma
1-2 l
1-2 l
2l
2-2,5 l
1*250 ml
2l
2-2,5 l
2l
2-2,5 l
2l
2-2,5 l
1-3*250
ml
3-5 *250
ml
5*250 ml
and more
Albumi
n 1020%
Erythrocyte
mass
Thromboconcent
rate
1*250 ml
0,25-1 l
1-3*250 ml
0,25-1 l
3-6*250 ml
0,5-1 l
6*250 ml
and more
In case of
necessary
usage
2. The bleeding can be arrested by conservative or surgical methods depending on
the
cause of hemorrhage.
3. The women should be warmed but not over-warmed, because peripheric microcirculation
improves at that, decreasing blood supply to the viable organs. Taking into account a big
number of solutions injected, they are warmed up to 36˚ Centigrade.
4. Urine bladder is catheterized.
5. 100% oxygen inhalation is continued at the rate 608 l/min, if necessary – APV.
If low PaO2 remains (<75 mm merc. Column) – FiO2 is increased ultimately to 0,6 (higher FiO2
for more than 48 hours can result in acute lungs damage). If lung pliability is preserved – positive
pressure is raised in the end of expiration.
High – frequency of APV is used.
Heart ejection and hemoglobin level are estimated. If necessary alkalosis and hypophosphatemia
are corrected which eliminates the replacement of oxyhemoglobin dissociation curve.
Syndrome of disseminated intravascular blood coagulation in obstetrics
Disseminated intravascular blood coagulation is a pathologic syndrome at the basis of which there
is an activation of vascular-thrombocytic or coagulative hemostasis (external or internal), in the
consequence of that blood, at first, coagulates in microcirculatory bed, blocks it with fibrin and
cellular units and by depletion of the potential of coagulative and anticoagulative system loses
coagulative ability, which reveals itself in profuse hemorrhage and development of polyorganic
failure.
1. Risk causes of DIC – syndrome in obstetrics:
- amniotic fluid embolism;
- shock (hemorrhagic, anaphylactic, septic);
- placental detachment;
- severe stage of preeclampsia;
- eclampsia;
- sepsis;
- septic abortion;
- syndrome of massive hemotransfusion;
- transfusion of incompatible blood;
- intrauterine fetal death;
- extrauterine pregnancy;
- cesarean section;
- extragenital diseases of the gravida (heart failure, malignant tumours, diabetes mellitus, serious
diseases of kidneys and liver).
2. DIC – syndrome classification:
According to the clinical course:
- acute;
- subacute;
- chronic;
- relapsing.
According to the clinical stages of the course
I – hypercoagulation
II – hypocoagulation without generalized activation of fibrinolysis;
III – hypocoagulation with generalized activation of fibrinolysis;
IV – total blood incoagulability.
I stage – hypercoagulation.
Depending on the clinic and seriousness of the main disease course, at this stage of DIC –
syndrome there can be evident clinical signs of acute respiratory distress – syndrome (ARDS),
beginning with mild stages and ending with most severe ones, at which even application of modern
methods of respiratory support fail to provide an adequate gas exchange in the lungs. Consequences
of hypercoagulation can be:
- appearance or progression of fetoplacental insufficiency;
- severe aggrevation of gestosis;
- decrease of uterine-placental blood flow, formation of infarction zones in the placenta and
higher probability of its detachment;
- anemia intensification;
- development of respiratory insufficiency at the expence of acute respiratory distress – syndrome
progression;
- hemodynamics distress with the development of circulation centralization symptoms;
- encephalopathy development.
3. Diagnosis
DIC – syndrome
stages
I hypercoagulation
Clinicolaboratory manifestations
Blood from the uterus coagulates at the 3-rd minute and
faster. Coagulation of venous blood is normal.
Chronometrical hypercoagulation.
II – hypocoagulation
M
without
generalized
activation of fibrinolysis
III – hypocoagulation with
generalized activation of
fibrinolysis
Uterine blood coagulates slowly in the course of more than
10 min. Petechial type of hemophilia
IV – total blood
incoagulability
Total hemorrhage. Uterine and venous blood doesn’t
coagulate. Potential hypercoagulation is absent.
Chronometrical hypocoagulation is expressed.
Uterine blood doesn’t coagulate. Venous blood coagulates
rather slowly, the clot lyses quickly. A mixed type of
hemophilia.
Appearance of activated thrombin factors in the blood leads to shortening of coagulation time (Lee
– White test, activated blood coagulation time, activated partial thrombin time, thrombin time,
activated time of recalcification. Appearance of hemorrhages at this stage is not associated with
blood coagulation failure.
II stage – hypocoagulation without generalized activation of fibrinolyses. Depending on the major
nosologic form of the disease a clinical picture, characteristic to this stage, can be rather various.
Petechial type of bleeding, prolonged hemophilia from the sites of injections, postoperative wound
and uterus, which is conditioned by the initial discord in the coagulative system – are typical. Blood
coagulates quickly at this stage, but the clot is very fragile due to the great numbers of products
from fibrin degradation which possess anticoagulant properties.
III stage – hypocoagulation with a generalized fibrinolysis activation.
All patients have got petechial macular type of hemorrhage: ecchymoses, petechial on the skin and
mucous membranes, bleeding from the sites of injections and formation of hematomas at there
place, prolonged uterine hemorrhage, postoperative wounds, bleeding into the abdominal cavity
retroperitoneal area as a consequence of hemostasis disorder. In the result of ischemia and failure of
capillary permeability of the intestine walls and stomach there develops gastrointestinal
hemorrhage. The blood which runs out can form clots but they lyse very quickly.
Signs of polyorganic insufficiency syndrome appear.
Thrombocytopenia with thrombocytopathy develops. Hypocoagulation occurs in the
consequence of blocking fibrogen transition into fibrin with great numbers of products from fibrin
degradation. Anemia is associated with intravascular hemolysis.
IV stage – total blood incoagulability.
Patients’ condition is extremely severe or terminal at the expense of polyorganic failure syndrome:
arterial hypotension which is difficult to correct, critical disorder of respiration and gas exchange,
impaired consciousness up to comatose state, oligo- and anuria against the background of massive
bleeding. Hemophilia of a mixed type: profusive bleeding from tissues, gastrointestive tract,
tracheobronchial tree, macrohematuria.
Coagulation time according to Lee - White
A conic dry test-tube is filled with 1 ml of blood (it’s better when blood runs out of the needle
independently), and the time of coagulation is estimated at the temperature of 37˚C.
6. Management.
1. Treatment of the major disease which caused DIC – syndrome (surgical intrusion, medicamental
and infusive therapy).
2. Intravenous jet-injection of 700-1000 ml of heated to 37˚C, chilled plasma which contains
antithrombin III. If the hemorrhage doesn’t eliminate, additional injection of 1000 ml chilled
plasma is necessary. On the following second-third day chilled plasma is used in the dosage of 400600 ml/a day. Antithrombin in the dasage of 100 units/kg is injected every 3 hours if possible.
3. Regarding the rate of hypercoagulation stage transition into the stage of hypocoagulation and
impossibility to make a precise laboratory diagnosis of DIC – syndrome stage (mostly because of
urgent situation), routine heparin usage should be refused from.
4. Proteolyses inhibitors injections are indicated beginning from the II stage. Contrical (or other
preparations in equivalent dosages) is injected regarding the stage of DIC – syndrome by
intravenous infusion droppery for 1-2 hours.
Recommended dosages of proteolysis inhibitors depending on the stage of DIC syndrome.
Preparations
Phases of DIC
Trasilol, unit
I
-
Contrical, unit
-
Gordox, unit
-
II
5000100000
2000060000
200000600000
III
100000300000
60000100000
6000001000000
IV
300000-500000
100000-300000
10000004000000
5. Restoration of blood coagulative factors by cryoprecipitate plasma injection (200 units – II stage,
400 units – III stage, 600 units – IV stage).
6. Thromboconcentrate is used when thrombocytes have decreased less than 50*109/l
7. Local hemostasis from the wound surface is performed in all cases. It is accomplished by various
methods and techniques: coagulation, vascular ligation, wound tamponada, usage of local
hemostatic methods.
8. Management of polyorganic disorder – syndrome.
9. In extreme urgent cases there are recommendations for warm donor’s blood transfusion in the
half dosage of the total blood loss.
Extrauterine pregnancy
Extrauterine pregnancy is an implantation of the conceptus outside the endometrical cavity. Most
frequent location of EP are uterine tubes.
Risk factors.
1. Inflammatory diseases of the uterus and uterine appendages in the history
2. Cicatrical – adhesive changes of small pelvis organs as a consequence of prior operations
on inner genitals, pelvioperitonitis, abortions.
3. Distress of ovarian hormonal functions.
4. Genital infantilism.
5. Endometriosis.
6. Long usage of intrauterine contraceptives.
7. Subsiduary reproductive technologies.
Diagnosis
Clinical symptoms:
1. Pregnancy signs:
- suppression of menses;
- mammary glands swelling;
- changes of taste, olfaction and other sensations typical for pregnancy;
- early gestosis signs (sickness, vomiting, oth.);
- positive immunologic reactions on gestation (HCG in blood serum and urine).
2. Disordered menstrual cycle – smeary bloody discharge from the genitals:
- after menstrual retention;
- with the onset of the following menstruation;
- before the onset of anticipated menstruation.
3. Pain – syndrome:
- unilateral menstrual cramps or continuous pain in the lower abdomen;
- abrupt intensive pain in lower abdomen
- peritoneal symptoms in lower abdomen pronounced in various degrees;
- pain irradiation into rectum, perineum and loin.
4. Symptoms of intraabdominal hemorrhage (in case of EP disorder):
- loss of resonance in abdominal flanks;
- positive Kulenkampf’s syndrome (there are signs of abdominal irritation when there is no local
muscular tension in lower parts of abdomen;
- in horizontal position of the patient there is a positive bilateral “frenicus” symptom, and in vertical
position – vertigo (dizziness), loss of consciousness;
- in case of significant hemoperitoneum there is a Shchotkin – Bloomberg symptom;
- progressive decrease of hemoglobin, erythrocytes, hematocrits indeces according to the blood test
data.
5.General state distress ( in case of EP disorder):
- asthenia (weakness), vertigo (dizziness), loss of consciousness, cold sweat, collapse,
hemodynamic disorders;
- sickness, reflex vomiting;
- meteorism, single diarrhea.
Gynecologic examination data
- cyanosis of vaginal mucous membrane and uterine cervix;
- uterine size is smaller than is expected at the term;
- unilateral enlargement and tenderness of uterine appendages;
- overhanging vaults of vagina (in case of hemoperitoneum);
- sharp pain a posterior vault of the vagina (Dougla’s cry);
- tenderness by uterine cervix displacement.
Specific laboratory examination:
- qualitative or quantative HCG test. Sualitative HCG assessment in urine is possible in any medical
setting, whereas quantitative β – HCG analysis in blood serum (level less than expected term of
physiologic pregnancy) is made in medical institutions of III level.
Instrumental investigations methods USD:
- absence of a fertilized ovum in the uterine cavity;
- embryo visualization outside uterine cavity;
- revealing of heterogenous structure formations in the area of uterine tubes projection;
- significant quantity of free fluid in Dougla’s area;
Laparoscopy – visual diagnosis of extrauterine pregnancy in the state of:
- retort – like enlargement of purple – coloured uterine tube;
- uterine tube laceration
- rupture of blood in clots or liquid in the abdominal cavity and Dougla’s area;
- presence of a fertilized ovum elements in the abdominal cavity.
Diagnostic curettage of uterine cavity walls:
Absence of the fertilized ovum elements in the scraping;
Presence of decidual tissue in the scraping.
Diagnostic curettage of uterine cavity walls is performed when USD
apparatus is not available and after the informed patient has given her concent to have this
manipulation.
If the term of menstrual cesassion is short, the woman wants to preserve her uterine gestation and
there are no signs of intraperitoneal hemorrhage it is necessary to choose the tactics of expectancy
with orientation on clinical symptoms, USD in the dynamics of observation and β – HCG level in
blood serum.
Peritoneal cavity punction through the posterior uterine vault
It is performed if USD apparatus is not available for diagnosis of tubal abortion. Presence of thin
blood in the punctuate is one of the EP symptoms. If there are clinical signs of intraperitoneal
hemorrhage – punction of the abdominal cavity through the posterior vault of the uterine isn’t
performed – a delay for the time to begin laparotomy.
Clinical signs
Pregnancy
signs
General state
of the patient
Diagnostic signs of various forms of tubal pregnancy.
Progressive
Tubal abortion
Uterine tube laceration
extrauterine pregnancy
positive
positive
positive
satisfactory
Periodically worsens, losses
of consciousness for a short
time, long period of
satisfactory state
pain
absent
discharge
Absent or thin watery
blood
Uterine doesn’t
correspond to the term
of menstrual cessation,
alongside the uterus a
retort like formation
reveals, which is
painless, vaults are free
USD, β – HCG level
determination,
laparoscopy
Kind of fits, which
periodically recur
Blood discharge of dark
colour, after pain attack
The same, tenderness at the
uterine displacement,
formations without distinet
contours, posterior vault is
smoothened
Vaginal
observation
Subsidiary
methods of
examination
Culdocentesis, laparoscopy
Colaptoid state,
massive blood loss
clinic, progressive
aggravation of
symptoms
Appears as a severe
attack
Absent or thin watery
blood
The same, “swimming”
uteru’s symptoms
tenderness of the uterus
and appendages from
the damaged side
overhanging at the
posterior vault
Are not performed
Differential diagnosis
Ectopic pregnancy diagnosis is rather simple in patients with amenorrhea, pregnancy signs, pain in
the lower abdomen and hemorrhage. But the following conditions should be excluded:
1. ovarian cyst torsion or acute appendicitis
2. abortion of the uterine pregnancy
3. hemorrhage into the yellow body.
EP management
Principles of managing patients with ectopic pregnancy:
1. suspected extrauterine pregnancy is a quideline for urgent hospitalization.
2. early diagnosis helps to reduce the number of complications and enables to make use of
alternative therapeutic methods.
3. once the diagnosis of extrauterine pregnancy has been made – urgent surgery should be
performed (laparoscopy, laparotomy). Operative treatment of extrauterine pregnancy is
optimal. In practice of nowadays the usage of conservative methods for extrauterine
pregnancy therapy is also possible.
4. In case of a pronounced clinical picture of impaired ectopic pregnancy, hemodynamic
disorders, hypovolemia, the gravida is immediately hospitalized for urgent surgical intrusion
by laparoscopy as soon as possible.
5. At prehospital stage in case of impaired extrauterine pregnancy the volume of urgent
medical aid is determined according to the general condition of the ill woman and the
amount of blood loss.
6. Severe condition of the ill woman, presence of marked hemodynamic disorders (hypotony,
hypovolemia, hematocrit less than 30%) are absolute guidelines for surgical intrusion by
laparotomy with extirpation of the gravida’s uterine tube and antishock therapy.
7. A complex approach to the management of pregnant with extrauterine gestation is used,
which include:
a) operative treatment;
b) management of hemorrhage, hemorrhagic shock, blood loss;
c) postoperative period management;
d) reproductive function rehabilitation.
8. Operative treatment is performed by both laparotomic and laparoscopic approaches.
The advantages of laparoscopic methods are:
- reduction of the operative time;
- reduction of the postoperative period;
- reduction of the stay in hospital;
- reducing the number of scarring changes of anterior abdominal wall;
- cosmetic effect.
9. Performance of organoprotective surgery at extrauterine pregnancy is accompanied by the risk
of developing trophoblast persistence during postoperative period, which is the result of its
incomplete removal from the uterine tube and abdominal cavity. Most effective method for
prevention of this complication is thorough toilet of the abdominal cavity with 2-3 l of physiologic
salt solution and one metotrexat injection in the dosage of 75-100 mg intramuscular during the first
, second day after the operation.
Operations performed in case of tubal pregnancy
1. Salpingostomy.
2. Segmental resection of a uterine tube.
3. Salpingectomy.
Conservative EP treatment
Progressive EP treatment with methotrexate can be accomplished only in medical institutions of the
third level where there is potential to estimate β-subunit HCG in blood serum and USD and make
USD with transvaginal sensor.
Guidelines for methotrexate injection in case of EP.
Methotrexate injection should be avoided by normal uterine pregnancy or missed miscarriage; it is
indicated only in the following cases:
1. Increased level of β-subunit HCG in blood serum following organoprotective surgery on
uterine tube, which was performed for progressive extrauterine pregnancy.
2. Stabilization or increase of β-subunit HCG level in blood serum during 12-24 hours after
separate diagnostic curettage or vacuum-aspiration, if the fertilized ovum size in the site of
uterine appendages is no more than 3,5 sm.
3. Revealing a fertilized ovum with a diameter no more than 3,5 sm in the site of uterine
appendages with USD transvaginal sensor in case β-subunit HCG level is more than 1500
ME/l when there is no fertilized ovum in the uterine cavity.
Methotrexate injection by EP.
Day
1-st
Therapeutic-diagnostic measures
Assessment of β-subunit HCG level in blood serum
2-nd
Routine blood test, determination of the blood group and Rhesus
factor of the woman, liver ferment activity.
5 -th
Methotrexate 75-100 ml intramuscular
8-th
Assessment of β-subunit HCG level in blood serum
If β-subunit HCG level in serum increased less than in 15% on the 8-th day, methotrexate is
injected again in the same dosage. If β-subunit HCG level in serum increased in more than 15%, the
gravida is being observed, β – subunit HCG level is assessed every week till the time this level is
less than 10 ME/l.
Ovarian pregnancy – develops when the ovum is fertilized in the follicule cavity. Frequency of
ovarian pregnancy is 0,5-1% to all extrauterine pregnancies and takes the second place in
frequency after tubal pregnancy. The only risk factor of this variant of extrauterine pregnancy is
intrauterine contraceptives usage.
Diagnosis.
Clinical signs are the same as during tubal pregnancy. At disturbed ovarian pregnancy there is a
possibility of hemorrhagic shock. In 75% cases of ovarian pregnancy it is incorrectly diagnosed as
ovarian apoplexy. USD of small pelvis organs is helpful in making diagnosis, especially by means
of transvaginal sensor, when the fertilized ovum is visualized in the site of ovary as well as positive
qualitative reaction on HCG.
Ovarian pregnancy signs by USD:
- uterine tube on the affected side is intact;
- the fetal sac occupies the position of the ovary;
- the ovary and the sac are connected to the uterus by the uteroovarian ligament;
- ovarian tissue is visualized in the sac wall.
Treatment.
Surgical treatment includes removal of the fertilized ovum and clinoid resection of the ovary.
Massive impairment of the ovary and significant intraperitoneal hemorrhage are indications for
ovariotomy.
Cervical pregnancy is the rarest in incidence and most severe variant of extrauterine pregnancy,
when the implantation of a fertilized ovum imbedded in the cervical canal of the uterus.
Diagnosis.
1. A precedent history (anamnesis) including gynecologic. Attention is paid to the number of
abortions and course of the postabortion period, previcus inflammations of inner genitals
including uterine cervix.
2. Uterine cervix examination with specula. Cyanotic barrel-like uterine cervix is visualized.
3. Careful bimanual gynecologic examination. The uterine together with the cervix looking
like a “sand-glass”.
4. Small pelvis organs observation by USD.
Ultrasound signs of cervical pregnancy
- absence of a fertilized ovum in the fetal sac (uterine cavity);
- hypoechogenic endometrium (decidual tissue);
- heterogeneity of biometry;
- “a sand-glass” – like uterine;
- extasia of the cervical canal of the uterus;
- the fertilized ovum is in the cervical canal of the uterus;
- placental tissue is in the cervical canal of the uterus;
- a closed intrauterine pupil.
Differential diagnosis
Cervical pregnancy should be differentiated with spontaneous abortion, myoma, cervical
carcinoma, procidentia of the submucous myoma on peduncle, presentation and lower placental
location USD is very helpful in making differential diagnosis, revealing differences between
cervical pregnancy and other obstetric-gynecologic pathology.
Management.
1. Once the diagnosis of cervical pregnancy been made – there should be a point-blank refusal
to curettage of walls in the uterine cavity, which could have resulted in profuse hemorrhage
development.
2. The method of cervical pregnancy management is surgery (uterus extirpation).
3. When the diagnosis has been confirmed,-the blood group and Rhesus factor are estimated, a
venous catheter is installed, a written concent of the informed patient for uterine extirpation
should be received. In the transfusiologic unit chilled plasma of the same blood group and
recently prepared erythrocytic mass should be ordered, preparations of hydrooxyethyl starch
should be made.
Abdominal pregnancy.
It accounts for 0,003% of all ectopic pregnancies. Primary and secondary abdominal pregnancies
are distinguished. Primary pregnancy is regarded to be the one that has implanted on the peritoneal
surface. Secondary pregnancy develops when the impregnated ovum has implanted in the
abdominal cavity after tubal abortion. Motherly mortality rate by abdominal pregnancy is 7-8 times
higher than by tubal one and 90 times higher than by uterine pregnancy.
Diagnosis.
Clinical manifestations depend on the term of gestation:
1. In the first and in the beginning of the second trimester they slightly differ from the
symptoms of tubal pregnancy.
2. At later terms pregnant women complain of tenderness during fetal movements, feeling
movements in the epigastral side or a sudden pause of fetal movements.
3. Physical examination may reveal a very easily palpated fetus and a separate small uterine.
Abdominal pregnancy is also diagnosed when there are no uterine contractions after
oxytocin injection.
4. USD is also helpful for diagnosis. If USD data are not informative, the diagnosis is
confirmed by X-ray, CT and MRI. A cross-table lateral X-ray of the maternal abdomen
shows shadowy fetal skeleton overlying. The maternal vertebral.
Treatment.
Having in mind a high risk of maternal mortality, once the diagnosis has been made, surgery is
urgent. During operative treatment the vessels are exposed and ligated, which carry blood to the
placenta and extirpate it if possible. If it is impossible because of excessive bleeding, the placenta is
tamponed. The tampons are removed in 24-48 hours. If exposure of the vessels can’t be performed,
the umbilical cord is ligated and separated while the placenta remains.
Postoperative period.
If placenta after surgery is in the abdominal cavity, its condition is evaluated by means of USD and
assessment of β-subunit HCG level. The risk of intestinal obstruction, adhesions and sepsis is very
high in these cases. Methotrexate injections are contraindicated because of concomitant severe
complications, sepsis, first of all. The cause of sepsis is massive necrosis of the placenta.
IV. Control questions and tasks
1. General classification of obstetrical bleedings.
2. Classification of the bleedings in the first half of pregnancy.
3. Clinicodiagnostic criteria of abortion.
4. What is the placental presentation?
5. Classification of placental presentation.
6. What clinical symptoms of placental presentation do you now?
7. Algorhythm of examination at admittance of a pregnant with bleeding to in-patient.
8. What is the premature detachment of normally located placenta?
9. Classification of the premature detachment of normally located placenta.
10. Hemorrhage in postpartum period of labor.
11. What is the hemorrhagic shock?
12. What causes of hemorrhagic shock do you now?
13. Infusive-transfusive therapy of obstetric blood loss
V.Tasks and tests
1. At the puerpera of 26 years old, for 4 day after labour the incessant parent bleeding began. The
haemorrhage has made 400 ml. The common state is worsened - a body temperature 36, 7о С, pulse
of 94 beets / mines, the AP of 90/70 mm.Hg. The uterus is intense, morbid, its bottom is at a level
of a umbilicus. The diagnosis is : "Delivery in time. A bleeding of the 4th day of puerperal term. ".
It is necessary:
A *Tool revision of a cavity of the uterus
B Manual inspection of a cavity of the uterus and erasion of the delayed parts of a placenta
C Outside massage of a uterus after bleeding urinary bladder
D To enter drugs reducing a uterus
E Supravaginal ablation of a uterus
2. Secundapara of 25 years. In the third period of delivery the bleeding has appeared. The
attributes of placenta’ detachment are absent. At manual detachment ofplacenta it was revealed
that a placenta is fixed, with growing into a myometrium. Tactics of the doctor?
A Laparotomy, a hysterectomy
B Application of uterotonic agents
C A hemotransfusion
D Laparotomy, supravaginal amputation of uterus
E Tool secretion of an afterbirth
3. The woman delivered twins has early postnatal hypotonic uterine bleeding reached 1.5\% of her
bodyweight. The bleeding is going on. Conservative methods to arrest the bleeding have been
found ineffective. The conditions of patient are pale skin, acrocyanosis, oliguria. The woman is
confused. The pulse rate is 130 beats per min, BP – 75/50 mm Hg. What is the further treatment?
A *Uterine extirpation
B Supravaginal uterine amputation
C Uterine vessels ligation
D Inner glomal artery ligation
E To put clamps on the uterine cervix
4. The 36 weeks of gestation pregnant woman was admitted to the obstetric in-patient department.
She has previous history of arterial hypertension, now complains of a headache, aching pains in the
lower abdomen and bloody discharge from vagina. The main clinical features are blood pressure
180/100 mm Hg and hypertonic uterus. During investigation about 300 ml of dark blood was
discharged from vagina. The fetal heartbeats are not heard. What is the diagnosis?
A *premature placental separation
B Placental presentation
C premature delivery threat
D uterine rupture
E Embolism caused by amniotic fluid
VI. List of recommended literature
1. Danforth's Obstetrics and gynaecology. - Seventh edition.- 1994.
2. Obstetrics and gynaecology. Williams & Wilkins Waverly Company. - Third Edition.- 1998.
3. Basic Gynecology and Obstetrics. - Norman F. Gant, F. Gary Cunningham. -1993.
4. Clinical Obstetrics of Fetus and Mother – E. Albert Reece&John Hobbins. – Third Edition. –
Blackwell publishing. – 2007.
5. Obstetrics Illustrated. – Kevin P. Hanretty. – Sixth Edition. – Churchill Livingstone. - 2003.
6. Manual on Obstetrics. – Arthur T. Evans. – Seventh Edition. - Lippincott Williams & Wilkins. –
2007.
7.Акушерство= Obstetrics: Підручник/І.Б.Венцківська, Г.Д.Гордєєва, О.А.Бурка та ін.; Ред.
Венцківська І.-Рекомендовано МОЗ України для студентів ВМНЗ ІУ рівня акредитації.-К.:
Медицина, 2008.-336 с.: іл. (Англ. мовою).