HEMORRHAGES DURING PREGNANCY
ECTOPIC PREGNANCY Ectopic pregnancy is one in which the products of conception develop outside the uterine cavity. By far ...
 
The musculature is of two layers, an inner circular and an outer longitudinal, and peristaltic movements are particularly ...
Ectopic implantation may be fortuitous or the result of a tubal abnormality which obstructs or delays the passage of the f...
<ul><li>Risk factors. </li></ul><ul><li>Inflammatory diseases of the uterus and uterine appendages in the history </li></u...
 
 
 
 
 
 
 
 
 
 
Diagnosis Clinical symptoms: 1. Pregnancy signs: - suppression of menses; - mammary glands swelling; - changes of taste, o...
<ul><li>2. Disordered menstrual cycle – smeary bloody discharge from the genitals: </li></ul><ul><li>- after menstrual ret...
4. Symptoms of intraabdominal hemorrhage (in case of EP disorder): - loss of resonance in abdominal flanks; - positive Kul...
5.General state distress ( in case of EP disorder): - asthenia (weakness), vertigo (dizziness), loss of consciousness, col...
<ul><li>Gynecologic examination data </li></ul><ul><li>cyanosis of vaginal mucous membrane and uterine cervix; </li></ul><...
SYMPTOMS AND SIGNS PAIN  in the lower abdomen is always present and may be either constant or cramp-like. It may be referr...
INTERNAL BLOOD LOSS   can be severe and rapid and the usual signs of collapse and shock will appear. Acute internal bleedi...
DIFFERENTIAL DIAGNOSIS 1. Salpingitis. 2. Miscarriage. 3. Appendicitis. 4. Torsion of pedicle of ovarian cyst. 5. Rupture ...
SALPINGITIS Swelling and pain are bilateral, fever is higher and a pregnancy test is usually negative. There may be a puru...
<ul><li>MISCARRIAGE (threatened or </li></ul><ul><li>incomplete) </li></ul><ul><li>Bleeding is the dominant clinical featu...
<ul><li>APPENDICITIS </li></ul><ul><li>The area of tenderness is higher and may be </li></ul><ul><li>localised in the righ...
<ul><li>TORSION OF PEDICLE OF </li></ul><ul><li>OVARIAN CYST </li></ul><ul><li>The mass so formed can usually be felt </li...
<ul><li>RUPTURE OF CORPUS LUTEUM </li></ul><ul><li>It is virtually impossible to distinguish this, by </li></ul><ul><li>ex...
 
 
TREATMENT <ul><li>If haemorrhage and shock are present, restore the blood volume by the transfusion of red </li></ul><ul><...
<ul><li>Laparotomy </li></ul>
ABDOMINAL PREGNANCY <ul><li>Clinical Features </li></ul><ul><li>1. There is a history of'threatened miscarriage </li></ul>...
<ul><li>Diagnosis  is difficult. </li></ul><ul><li>1. Palpation is unreliable even when fetal limbs are easily felt. </li>...
<ul><li>Treatment </li></ul><ul><li>Once diagnosed or strongly suspected, it is better to perform laparotomy in the intere...
Obstetrical bleedings
<ul><li>Bleedings in the first half of pregnancy: </li></ul><ul><li>accidental abortion; </li></ul><ul><li>hydatidiform mo...
<ul><li>Bleedings in the second half of pregnancy: </li></ul><ul><li>placental presentation; </li></ul><ul><li>premature d...
<ul><li>Bleedings during labor: </li></ul><ul><li>I period: </li></ul><ul><li>premature  detachment of normally located pl...
<ul><li>II period: </li></ul><ul><li>premature  detachment of normally located placenta; </li></ul><ul><li>hysterorrhexis....
<ul><li>III period: </li></ul><ul><li>pathologic implantation of placenta; </li></ul><ul><li>suppression, strangulation of...
<ul><li>Postpartum bleeding: </li></ul><ul><li>hypotonic bleeding; </li></ul><ul><li>retention of the afterbirth’s fragmen...
<ul><li>Bleedings unconnected with pregnancy: </li></ul><ul><li>uterine cervix  polyp; </li></ul><ul><li>carcinoma of uter...
<ul><li>Classification </li></ul><ul><li>threat of abortion; </li></ul><ul><li>the abortion which  has started; </li></ul>...
<ul><li>Clinicodiagnostic criteria </li></ul><ul><li>Symptoms of abortion: </li></ul><ul><li>pain-syndrome: pain associate...
<ul><li>Bleedings during accidental abortion, in the beginning of abortion, in the course of abortion and by incomplete ac...
<ul><li>Diagnosis: </li></ul><ul><li>assessment of the gravida’s general condition; </li></ul><ul><li>speculum examination...
<ul><li>Treatment </li></ul><ul><li>instrumental uterus emptying under intravenous anaesthesia (with an obligatory examina...
Placental presentation   <ul><li>Placental presentation is a complication of pregnancy when placenta is located in the low...
<ul><li>Classification of placental presentation </li></ul><ul><li>Complete presentation - placenta completely blocks the ...
 
<ul><li>Clinicodiagnostic criteria. </li></ul><ul><li>Risk group of placental presentation includes women which underwent:...
<ul><li>Clinical symptoms </li></ul><ul><li>A pathognomonic symptom is an obligatory hemorrhage which can periodically rec...
<ul><li>Seriousness of the condition is determined by the amount of blood loss: </li></ul><ul><li>it is massive at the com...
<ul><li>Diagnosis </li></ul><ul><li>1. Medical history (anamnesis) </li></ul><ul><li>2. Clinic manifestations – appearance...
<ul><li>Principles of treating patients with placental presentation: </li></ul><ul><li>In case of little bleeding (up to 2...
<ul><li>Clinic variants: </li></ul><ul><li>1.  Blood loss (less than 250 ml), symptoms of hemorrhagic shock, the fetus’s d...
<ul><li>  3.  Bloodloss (less than 250 ml) at mature pregnancy: </li></ul><ul><li>After the arrest of bleeding  the childb...
<ul><li>4.  Blood loss (more than 250 ml) at mature pregnancy  – regardless of the stage of presentation – urgent  Cesarea...
<ul><li>Premature detachment of normally located placenta </li></ul><ul><li>Is a detachment of the placenta located behind...
<ul><li>Classification </li></ul><ul><li>Complete detachment (detachment of total placenta). </li></ul><ul><li>Partial det...
<ul><li>Clinicodiagnostic criteria of premature detachment of a normally located placenta: </li></ul><ul><li>gestosis; </l...
<ul><li>The direct cause may be: </li></ul><ul><li>a physical trauma; </li></ul><ul><li>a psychic trauma; </li></ul><ul><l...
<ul><li>Clinical symptoms: </li></ul><ul><li>Pain syndrome: acute pain in placental projection irradiating in the total ut...
<ul><li>Diagnosis </li></ul><ul><li>External obstetric examination: </li></ul><ul><li>uterine hypertension; </li></ul><ul>...
<ul><li>Internal obstetric examination: </li></ul><ul><li>tension of the bag of waters; </li></ul><ul><li>there may be a c...
<ul><li>US-examination  (echo-negative focus between the uterus and the placenta), but this method can’t be an absolute di...
<ul><li>Treatment </li></ul><ul><li>In case of progressive premature placental detachment during pregnancy or in the first...
<ul><li>Restoration of the blood loss amount, treatment of hemorrhagic shock and DIC – syndrome (see corresponding protoco...
<ul><li>Peculiarities of Cesarean section:   </li></ul><ul><li>obligatory revision of uterine walls (especially external s...
<ul><li>Tactics by placental detachment in the end of I or II periods </li></ul><ul><li>urgent amniotomy if the amniotic b...
<ul><li>Bleeding in the afterbirth and postpartum periods </li></ul><ul><li>Postpartum bleeding is blood loss of 0,5% or m...
<ul><li>Degrees of fused placenta: </li></ul><ul><li>placenta adhaerens  —  the chorion villi penetrate into the basal lay...
False fused placenta   True fused placenta
<ul><li>Risk factors of postpartum hemorrhage </li></ul><ul><li>aggravated obstetric anamnesis (bleedings at previous labo...
<ul><li>Hemorrhage in postpartum (third) period of labor </li></ul><ul><li>Causes: </li></ul><ul><li>partial placental or ...
<ul><li>Clinical manifestations: </li></ul><ul><li>Signs of placental separation are absent during 30 minutes without sign...
<ul><li>Algorhythm of management: </li></ul><ul><li>If placental fragments or membranes have been retained – manual examin...
<ul><li>Early (primary) postpartum hemorrhage </li></ul><ul><li>Causes of early postpartum hemorrhage: </li></ul><ul><li>h...
<ul><li>Causes of uterine hypotension or atony </li></ul><ul><li>functional failures of myometrium (late hestosis, endocri...
<ul><li>Causes of uterine hypotension or atony </li></ul><ul><li>functional failures of myometrium (late hestosis, endocri...
<ul><li>Postpartum secondary (late) hemorrhage </li></ul><ul><li>Major causes for late postpartum hemorrhages: </li></ul><...
<ul><li>Algorhythms of medical care: </li></ul><ul><li>Assessment of blood loss by available methods. </li></ul><ul><li>Ca...
<ul><li>Hemorrhagic shock in obstetrics </li></ul><ul><li>Hemorrhagic shock is a condition of  severe hemodynamic and meta...
<ul><li>Causes of hemorrhagic shock risk in obstetrics </li></ul><ul><li>1. Hemorrhage at early terms of gestation: </li><...
<ul><li>Causes of hemorrhagic shock risk in obstetrics </li></ul><ul><li>1. Hemorrhage at early terms of gestation: </li><...
<ul><li>Hemorrhagic shock. Classification according to the clinical course and the damage rate </li></ul>% body mass % BCV...
<ul><li>Hemorrhagic shock intensive therapy. General principles of acute blood loss therapy: </li></ul><ul><li>Urgent hemo...
 
<ul><li>Syndrome of disseminated intravascular blood  coagulation in obstetrics </li></ul><ul><li>Disseminated intravascul...
<ul><li>Risk causes of DIC – syndrome in obstetrics: </li></ul><ul><li>- amniotic fluid embolism; </li></ul><ul><li>- shoc...
<ul><li>DIC – syndrome classification: </li></ul><ul><li>According to the clinical course: </li></ul><ul><li>acute; </li><...
<ul><li>According to the clinical stages of the course </li></ul><ul><li>I  – hypercoagulation </li></ul><ul><li>II  – hyp...
<ul><li>I stage – hypercoagulation. </li></ul><ul><li>Consequences of hypercoagulation can be: </li></ul><ul><li>appearanc...
 
<ul><li>II stage – hypocoagulation without generalized activation of fibrinolyses. </li></ul><ul><li>Petechial type of ble...
<ul><li>III stage – hypocoagulation with a generalized fibrinolysis activation. </li></ul><ul><li>All patients have got pe...
<ul><li>IV stage – total blood incoagulability. </li></ul><ul><li>Patients’ condition is extremely severe or terminal at t...
 
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Hemorhages during pregnancy

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Hemorhages during pregnancy

  1. 1. HEMORRHAGES DURING PREGNANCY
  2. 2. ECTOPIC PREGNANCY Ectopic pregnancy is one in which the products of conception develop outside the uterine cavity. By far the commonest site is the fallopian tube. The fallopian tube is about 10 cm long. The diameter of the lumen varies from 1 mm in the interstitial portion to about 5 mm at the fimbriated end.
  3. 4. The musculature is of two layers, an inner circular and an outer longitudinal, and peristaltic movements are particularly strong during and after ovulation. The mucosa is arranged in plications or folds which become much more complete and plentiful as the infundibulum is approached.
  4. 5. Ectopic implantation may be fortuitous or the result of a tubal abnormality which obstructs or delays the passage of the fertilised ovum.
  5. 6. <ul><li>Risk factors. </li></ul><ul><li>Inflammatory diseases of the uterus and uterine appendages in the history </li></ul><ul><li>Cicatrical – adhesive changes of small pelvis organs as a consequence of prior operations on inner genitals, pelvioperitonitis, abortions. </li></ul><ul><li>Distress of ovarian hormonal functions. </li></ul><ul><li>Genital infantilism. </li></ul><ul><li>Endometriosis. </li></ul><ul><li>Long usage of intrauterine contraceptives. </li></ul><ul><li>Subsiduary reproductive technologies. </li></ul>
  6. 17. 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).
  7. 18. <ul><li>2. Disordered menstrual cycle – smeary bloody discharge from the genitals: </li></ul><ul><li>- after menstrual retention; </li></ul><ul><li>- with the onset of the following menstruation; </li></ul><ul><li>before the onset of anticipated menstruation. </li></ul><ul><li>3. Pain – syndrome: </li></ul><ul><li>- unilateral menstrual cramps or continuous pain in the lower abdomen; </li></ul><ul><li>- abrupt intensive pain in lower abdomen </li></ul><ul><li>- peritoneal symptoms in lower abdomen pronounced in various degrees; </li></ul><ul><li>- pain irradiation into rectum, perineum and loin. </li></ul>
  8. 19. 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.
  9. 20. 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.
  10. 21. <ul><li>Gynecologic examination data </li></ul><ul><li>cyanosis of vaginal mucous membrane and uterine cervix; </li></ul><ul><li>uterine size is smaller than is expected at the term; </li></ul><ul><li>unilateral enlargement and tenderness of uterine appendages; </li></ul><ul><li>overhanging vaults of vagina (in case of hemoperitoneum); </li></ul><ul><li>sharp pain a posterior vault of the vagina (Dougla’s cry); </li></ul><ul><li>tenderness by uterine cervix displacement. </li></ul>
  11. 22. SYMPTOMS AND SIGNS PAIN in the lower abdomen is always present and may be either constant or cramp-like. It may be referred to the shoulder if blood tracks to the diaphragm and stimulates the phrenic nerve, and it may be so severe as to cause fainting. The pain is caused by distension of the gravid tube, by its efforts to contract and expel the ovum, and by irritation of the peritoneum by leakage of blood. VAGINAL BLEEDING occurs usually after the death of the ovum and is an effect of oestrogen withdrawal. It is dark brown and scanty and its irregularity may lead the patient to confuse it with the menstrual flow and thus, inadvertently, give a misleading history. In about 25% of cases tubal pregnancy presents without any vaginal bleeding.
  12. 23. INTERNAL BLOOD LOSS can be severe and rapid and the usual signs of collapse and shock will appear. Acute internal bleeding is the most dramatic and dangerous consequence of tubal pregnancy, but it is less common than the condition presenting by a slow trickle of blood into the pelvic cavity.
  13. 24. DIFFERENTIAL DIAGNOSIS 1. Salpingitis. 2. Miscarriage. 3. Appendicitis. 4. Torsion of pedicle of ovarian cyst. 5. Rupture of corpus luteum or follicular cyst. 6. Perforation of peptic ulcer.
  14. 25. SALPINGITIS Swelling and pain are bilateral, fever is higher and a pregnancy test is usually negative. There may be a purulent discharge from the cervix.
  15. 26. <ul><li>MISCARRIAGE (threatened or </li></ul><ul><li>incomplete) </li></ul><ul><li>Bleeding is the dominant clinical feature and </li></ul><ul><li>usually precedes pain. The bleeding is red </li></ul><ul><li>rather than brown and the pain is crampy or </li></ul><ul><li>colicky. The uterus is larger and softer and the </li></ul><ul><li>cervix patulous or dilated. Products of </li></ul><ul><li>conception may be recognised on vaginal </li></ul><ul><li>examination. </li></ul>
  16. 27. <ul><li>APPENDICITIS </li></ul><ul><li>The area of tenderness is higher and may be </li></ul><ul><li>localised in the right iliac fossa. There may be </li></ul><ul><li>a swelling if an appendix abscess was formed </li></ul><ul><li>but is not so deep in the pelvis as a tubal </li></ul><ul><li>swelling. Fever is greater and the patient may </li></ul><ul><li>appear toxic. A pregnancy test will usually be </li></ul><ul><li>negative although pregnancy and appendicitis </li></ul><ul><li>can, of course, co-exist. </li></ul>
  17. 28. <ul><li>TORSION OF PEDICLE OF </li></ul><ul><li>OVARIAN CYST </li></ul><ul><li>The mass so formed can usually be felt </li></ul><ul><li>separate from the uterus, while a tubal </li></ul><ul><li>pregnancy usually feels attached. Tenderness </li></ul><ul><li>may be marked, and intraperitoneal bleeding </li></ul><ul><li>may produce fever. Signs and symptoms of </li></ul><ul><li>pregnancy are absent but there is a history of </li></ul><ul><li>repeated sudden attacks of pain which pass off. </li></ul>
  18. 29. <ul><li>RUPTURE OF CORPUS LUTEUM </li></ul><ul><li>It is virtually impossible to distinguish this, by </li></ul><ul><li>examination, from a tubal pregnancy, but </li></ul><ul><li>such a severe reaction is rare. </li></ul>
  19. 32. TREATMENT <ul><li>If haemorrhage and shock are present, restore the blood volume by the transfusion of red </li></ul><ul><li>cells or a volume expander and proceed with operation. The patient's condition will </li></ul><ul><li>improve as soon as the bleeding is controlled. </li></ul>
  20. 33. <ul><li>Laparotomy </li></ul>
  21. 34. ABDOMINAL PREGNANCY <ul><li>Clinical Features </li></ul><ul><li>1. There is a history of'threatened miscarriage </li></ul><ul><li>with irregular bleeding. </li></ul><ul><li>2. Continued abdominal discomfort is felt and </li></ul><ul><li>fetal movements are painful. </li></ul><ul><li>3. Fetal abnormality is common and fetal </li></ul><ul><li>mortality is high. </li></ul>
  22. 35. <ul><li>Diagnosis is difficult. </li></ul><ul><li>1. Palpation is unreliable even when fetal limbs are easily felt. </li></ul><ul><li>2. Ultrasound may show the fetus outwith the uterus and an abnormal fetal attitude due to lack of liquor. </li></ul>
  23. 36. <ul><li>Treatment </li></ul><ul><li>Once diagnosed or strongly suspected, it is better to perform laparotomy in the interests of </li></ul><ul><li>the mother. The fetus is removed, the cord tied and the abdomen closed. No attempt is made </li></ul><ul><li>to detach the placenta unless it is clear that bleeding can be controlled. </li></ul><ul><li>If the condition is diagnosed around the time of fetal viability then delivery may be deferred </li></ul><ul><li>to improve the prognosis for the fetus. This approach requires careful supervision and </li></ul><ul><li>laparotomy may be required at any time. </li></ul>
  24. 37. Obstetrical bleedings
  25. 38. <ul><li>Bleedings in the first half of pregnancy: </li></ul><ul><li>accidental abortion; </li></ul><ul><li>hydatidiform mole; </li></ul><ul><li>extrauterine pregnancy ( including cervical pregnancy); </li></ul>
  26. 39. <ul><li>Bleedings in the second half of pregnancy: </li></ul><ul><li>placental presentation; </li></ul><ul><li>premature detachment of normally located placenta; </li></ul><ul><li>hysterorrhexis. </li></ul>
  27. 40. <ul><li>Bleedings during labor: </li></ul><ul><li>I period: </li></ul><ul><li>premature detachment of normally located placenta; </li></ul><ul><li>placental presentation; </li></ul><ul><li>hysterorrhexis; </li></ul><ul><li>laceration of the neck of the uterus. </li></ul>
  28. 41. <ul><li>II period: </li></ul><ul><li>premature detachment of normally located placenta; </li></ul><ul><li>hysterorrhexis. </li></ul>
  29. 42. <ul><li>III period: </li></ul><ul><li>pathologic implantation of placenta; </li></ul><ul><li>suppression, strangulation of placenta; </li></ul><ul><li>laceration of soft tissues of maternal passages. </li></ul>
  30. 43. <ul><li>Postpartum bleeding: </li></ul><ul><li>hypotonic bleeding; </li></ul><ul><li>retention of the afterbirth’s fragments; </li></ul><ul><li>laceration of soft tissues of maternity passages; </li></ul><ul><li>hysterorrhexis, </li></ul><ul><li>amniotic fluid embolism, </li></ul><ul><li>coagulopathetic hemorrhage. </li></ul>
  31. 44. <ul><li>Bleedings unconnected with pregnancy: </li></ul><ul><li>uterine cervix polyp; </li></ul><ul><li>carcinoma of uterine cervix. </li></ul>
  32. 45. <ul><li>Classification </li></ul><ul><li>threat of abortion; </li></ul><ul><li>the abortion which has started; </li></ul><ul><li>abortion in process; </li></ul><ul><li>incomplete accidental abortion; </li></ul><ul><li>complete accidental abortion; </li></ul><ul><li>missed miscarriage. </li></ul>
  33. 46. <ul><li>Clinicodiagnostic criteria </li></ul><ul><li>Symptoms of abortion: </li></ul><ul><li>pain-syndrome: pain associated with contraction of the uterus; </li></ul><ul><li>increased tension of the uterus; </li></ul><ul><li>hemorrhage of different intensity; </li></ul><ul><li>structural changes in the uterine cervix. </li></ul>
  34. 47. <ul><li>Bleedings during accidental abortion, in the beginning of abortion, in the course of abortion and by incomplete accidental abortion. </li></ul><ul><li>Clinic: </li></ul><ul><li>pain of intermittent character; </li></ul><ul><li>hemorrhage of different intensity </li></ul>
  35. 48. <ul><li>Diagnosis: </li></ul><ul><li>assessment of the gravida’s general condition; </li></ul><ul><li>speculum examination of the uterine cervix, bimanual examination; </li></ul><ul><li>evaluation of the blood less amount. </li></ul>
  36. 49. <ul><li>Treatment </li></ul><ul><li>instrumental uterus emptying under intravenous anaesthesia (with an obligatory examination of the received material); </li></ul><ul><li>medications contracting uterus (10 units of oxytocin by intravenous droppery or 0,5 mg of methylergobrevin intravenously or intramuscularly); </li></ul><ul><li>if hemorrhage proceeds-800 mkg of misoprostol rectally; </li></ul><ul><li>recovery of the amount of blood loss as indicated; </li></ul><ul><li>antibacterial therapy as indicated.. </li></ul>
  37. 50. Placental presentation <ul><li>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. </li></ul>
  38. 51. <ul><li>Classification of placental presentation </li></ul><ul><li>Complete presentation - placenta completely blocks the inner pupil. </li></ul><ul><li>Incomplete presentation - placenta blocks the inner pupil incompletely: </li></ul><ul><li>a) lateral presentation - the inner pupil is covered on 23 of its area; </li></ul><ul><li>b) marginal presentation - the end of placenta reaches the inner pupil. </li></ul><ul><li>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. </li></ul>
  39. 53. <ul><li>Clinicodiagnostic criteria. </li></ul><ul><li>Risk group of placental presentation includes women which underwent: </li></ul><ul><li>endometritis with the following scarry dystrophic changes of endometrium; </li></ul><ul><li>abortions excessively complicated with inflammatory processes; </li></ul><ul><li>benign tumours of the uterus, in particular, submucous myomates nodes; </li></ul><ul><li>influence of chemical preparations on endometrium; </li></ul><ul><li>women with hypoplastic uterus. </li></ul>
  40. 54. <ul><li>Clinical symptoms </li></ul><ul><li>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: </li></ul><ul><li>- with the onset of uterus contraction at any term of gestation; </li></ul><ul><li>- isn’t accompanied by pain; </li></ul><ul><li>- isn’t accompanied by the rise of uterine tension. </li></ul>
  41. 55. <ul><li>Seriousness of the condition is determined by the amount of blood loss: </li></ul><ul><li>it is massive at the complete presentation; </li></ul><ul><li>variable from small to massive at the incomplete presentation. </li></ul><ul><li>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. </li></ul>
  42. 56. <ul><li>Diagnosis </li></ul><ul><li>1. Medical history (anamnesis) </li></ul><ul><li>2. Clinic manifestations – appearance of recurrent blledings which are not accompanied by pain or increased uterus tension. </li></ul><ul><li>Obstetrical examination: </li></ul><ul><li>a) external examination: </li></ul><ul><li>high position of the presenting part; </li></ul><ul><li>oblique, transversal position of the fetus; </li></ul><ul><li>uterine tension is not increased; </li></ul><ul><li>b) internal examination (made only in the conditions of a full-scale operating room): </li></ul><ul><li>- doughy tissues of the vault, pastiness, pulsation of vessels; </li></ul><ul><li>- impossibility to pulpate the presenting part because of the vault. </li></ul><ul><li>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 </li></ul>
  43. 57. <ul><li>Principles of treating patients with placental presentation: </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  44. 58. <ul><li>Clinic variants: </li></ul><ul><li>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 : </li></ul><ul><li>- hospitalization; </li></ul><ul><li>- tocolytic therapy according to the indications; </li></ul><ul><li>- 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); </li></ul><ul><li>- monitor examination of the gravida’s and fetus’ condition. </li></ul><ul><li>If the bleeding increases for more than 250 ml – Cesarean delivery. </li></ul><ul><li>2. Significant blood loss (more than 250 ml) at premature pregnancy – regardless of the presentation stage – urgent Cesarean section. </li></ul>
  45. 59. <ul><li> 3. Bloodloss (less than 250 ml) at mature pregnancy: </li></ul><ul><li>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. </li></ul><ul><li>At complete or incomplete placental presentation and irregular fetus position (pelvic, oblique or transversal) – Cesarean delivery is indicated; </li></ul><ul><li>At incomplete presentation and dead fetus – amniotomy is possible; at hemostasia – labor should take place through maternal passages . </li></ul>
  46. 60. <ul><li>4. Blood loss (more than 250 ml) at mature pregnancy – regardless of the stage of presentation – urgent Cesarean delivery . </li></ul><ul><li>5. Complete presentation, diagnosed by USD, without hemorrhage – hospitalization before the term of labor, Cesarean section at 37-38 weeks of gestation. </li></ul>
  47. 61. <ul><li>Premature detachment of normally located placenta </li></ul><ul><li>Is a detachment of the placenta located behind the lower uterine segment during pregnancy or in the first-second (I-II) periods of delivery. </li></ul>
  48. 62. <ul><li>Classification </li></ul><ul><li>Complete detachment (detachment of total placenta). </li></ul><ul><li>Partial detachment: </li></ul><ul><li>marginal; </li></ul><ul><li>central. </li></ul>
  49. 63. <ul><li>Clinicodiagnostic criteria of premature detachment of a normally located placenta: </li></ul><ul><li>gestosis; </li></ul><ul><li>renal diseases; </li></ul><ul><li>isoimmune conflict between the mother and the fetus; </li></ul><ul><li>uterine hyperdistension (hydramnios, multiple pregnancy, a big fetus); </li></ul><ul><li>vascular system diseases; </li></ul><ul><li>diabetes mellitus; </li></ul><ul><li>connective tissue pathology; </li></ul><ul><li>uterine and placental inflammatory processes; </li></ul><ul><li>anomalies of development or tumours of the uterus (submucous, intramural myomas). </li></ul>
  50. 64. <ul><li>The direct cause may be: </li></ul><ul><li>a physical trauma; </li></ul><ul><li>a psychic trauma; </li></ul><ul><li>an abrupt reduction of the amniotic fluid volume; </li></ul><ul><li>an absolutely or relatively short umbilical cord; </li></ul><ul><li>pathology of the uterine contractile activity. </li></ul>
  51. 65. <ul><li>Clinical symptoms: </li></ul><ul><li>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. </li></ul><ul><li>Uterine hypertension up to tetany, which can’t be released by spasmolytics, tocolytics. </li></ul><ul><li>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. </li></ul>
  52. 66. <ul><li>Diagnosis </li></ul><ul><li>External obstetric examination: </li></ul><ul><li>uterine hypertension; </li></ul><ul><li>the enlarged uterine can be deformed with a local diverticulum if the placenta is on the frontier wall position; </li></ul><ul><li>tenderness by palpation; </li></ul><ul><li>difficulties or impossibility of palpation and auscultation of the fetus’ palpitation; </li></ul><ul><li>appearance of the fetus’ distress symptoms or fetal death. </li></ul>
  53. 67. <ul><li>Internal obstetric examination: </li></ul><ul><li>tension of the bag of waters; </li></ul><ul><li>there may be a colouring with blood by the rupture of amniotic fluid sac; </li></ul><ul><li>uterine4 bleedings of different intensity </li></ul>
  54. 68. <ul><li>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. </li></ul>
  55. 69. <ul><li>Treatment </li></ul><ul><li>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. </li></ul>
  56. 70. <ul><li>Restoration of the blood loss amount, treatment of hemorrhagic shock and DIC – syndrome (see corresponding protocols). </li></ul><ul><li>In case of unprogressive placental detachment there should be dynamic observation </li></ul>
  57. 71. <ul><li>Peculiarities of Cesarean section: </li></ul><ul><li>obligatory revision of uterine walls (especially external surface) with the aim to eliminate the possibility of uterine – placental apoplexy; </li></ul><ul><li>in case of Kuveler’s uterus diagnosis – extirpation of the uterus without appendages; </li></ul><ul><li>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. </li></ul>
  58. 72. <ul><li>Tactics by placental detachment in the end of I or II periods </li></ul><ul><li>urgent amniotomy if the amniotic bladder is intact; </li></ul><ul><li>by cephalic presentation – application of obstetrical forceps; </li></ul><ul><li>by pelvic presentation – fetal extraction at the pelvic end; </li></ul><ul><li>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. </li></ul><ul><li>manual placental separation and expulsion of the afterbirth; </li></ul><ul><li>contractile methods – 10 units of oxytocin intravenously, if there is no effect – 800 mkg of misoprostol (rectally); </li></ul><ul><li>thorough dynamic observation in postpartum period; </li></ul><ul><li>restoration of the blood loss amount, hemorrhagic shock and DIC-syndrome management. </li></ul>
  59. 73. <ul><li>Bleeding in the afterbirth and postpartum periods </li></ul><ul><li>Postpartum bleeding is blood loss of 0,5% or more in relation to the body mass after parturition. </li></ul>
  60. 74. <ul><li>Degrees of fused placenta: </li></ul><ul><li>placenta adhaerens — the chorion villi penetrate into the basal layer of the decidual membrane; </li></ul><ul><li>placenta accreta — the chorion villi penetrate through the whole basal layer of the decidual membrane to the muscular layer of the uterus; </li></ul><ul><li>placenta increta — the chorion villi penetrate into the depth of the uterine muscular layer; </li></ul><ul><li>placenta percreta — the villi penetrate the muscular and serous uterine layers. </li></ul>
  61. 75. False fused placenta True fused placenta
  62. 76. <ul><li>Risk factors of postpartum hemorrhage </li></ul><ul><li>aggravated obstetric anamnesis (bleedings at previous labor, abortions, spontaneous abortion); </li></ul><ul><li>hestosis; </li></ul><ul><li>a big fetus; </li></ul><ul><li>hydramnion; </li></ul><ul><li>multiple pregnancy; </li></ul><ul><li>uterine myoma; </li></ul><ul><li>cicatrix on the womb; </li></ul><ul><li>chronic DIC – syndrome; </li></ul><ul><li>thrombocytopathy; </li></ul><ul><li>antenatal fetal mortality. </li></ul>
  63. 77. <ul><li>Hemorrhage in postpartum (third) period of labor </li></ul><ul><li>Causes: </li></ul><ul><li>partial placental or membrane retention; </li></ul><ul><li>placental implantation pathology; </li></ul><ul><li>placental strangulation. </li></ul>
  64. 78. <ul><li>Clinical manifestations: </li></ul><ul><li>Signs of placental separation are absent during 30 minutes without significant blood loss – pathology of placental detachment or adherence. </li></ul><ul><li>Hemorrhage initiates immediately at afterbirth labor – retention of placental fragments or membranes. </li></ul><ul><li>Hemorrhage initiates after the childbirth without placental separation – placental strangulation, partial placental adherence. </li></ul>
  65. 79. <ul><li>Algorhythm of management: </li></ul><ul><li>If placental fragments or membranes have been retained – manual examination of uterine cavity under intravenous narcosis. </li></ul><ul><li>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. </li></ul><ul><li>If hemorrhage occurs – urgent manual placental separation and removal of the afterbirth under intravenous narcosis. </li></ul><ul><li>Uterotonics injections – 10-20 units of oxytocin intravenously on 400 ml of physiologic salt solution by intravenous droppery. </li></ul><ul><li>In case of genuine detachment or adherence of the placenta – laparotomy, extirpation of the uterus without appendages. </li></ul>
  66. 80. <ul><li>Early (primary) postpartum hemorrhage </li></ul><ul><li>Causes of early postpartum hemorrhage: </li></ul><ul><li>hypotension or atony of the uterus (in 90% of patients); </li></ul><ul><li>retention of placental fragments or membranes; </li></ul><ul><li>traumatic damages of the maternal passages; </li></ul><ul><li>disorder of blood coagulability (afibrinogenemia, fibrinolysis); </li></ul><ul><li>primary blood diseases. </li></ul>
  67. 81. <ul><li>Causes of uterine hypotension or atony </li></ul><ul><li>functional failures of myometrium (late hestosis, endocrinopathies, somatic diseases, uterine tumours, a cicatrix on the womb, a big fetus, hydramnios, multiple pregnancy and others); </li></ul><ul><li>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); </li></ul><ul><li>failure of a contractive function of myometrium due to disorder of biochemical processes, correlation of neurohumoral factors (estrogens, acetylcholine, oxytocin, cholinesterase, progesterone, prostaglandins); </li></ul><ul><li>disturbances of placental and afterbirth implantation, separation and removal processes; </li></ul><ul><li>idiopathetic (haven’t been established). </li></ul>
  68. 82. <ul><li>Causes of uterine hypotension or atony </li></ul><ul><li>functional failures of myometrium (late hestosis, endocrinopathies, somatic diseases, uterine tumours, a cicatrix on the womb, a big fetus, hydramnios, multiple pregnancy and others); </li></ul><ul><li>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); </li></ul><ul><li>failure of a contractive function of myometrium due to disorder of biochemical processes, correlation of neurohumoral factors (estrogens, acetylcholine, oxytocin, cholinesterase, progesterone, prostaglandins); </li></ul><ul><li>disturbances of placental and afterbirth implantation, separation and removal processes; </li></ul><ul><li>idiopathetic (haven’t been established). </li></ul>
  69. 83. <ul><li>Postpartum secondary (late) hemorrhage </li></ul><ul><li>Major causes for late postpartum hemorrhages: </li></ul><ul><li>retention of placental fragments or afterbirth; </li></ul><ul><li>expulsion of necrotic tissues after delivery; </li></ul><ul><li>disjunctional separation of sutures and uterine wound (after Cesarean section or hysterorrhexis). </li></ul><ul><li>Postpartum hemorrhage most frequently occurs on the 7-12th days after labor. </li></ul>
  70. 84. <ul><li>Algorhythms of medical care: </li></ul><ul><li>Assessment of blood loss by available methods. </li></ul><ul><li>Catherization of peripheric and central vein. </li></ul><ul><li>Instrumental revision of uterine cavity under intravenous anesthesia. </li></ul><ul><li>Intravenous injections of uterotonics (oxytocin 10-20 units on physiologic salt solution – 400 or 0,5 mkg methylergometrine). </li></ul><ul><li>In case the hemorrhage proceeds – misoprostol 800 mkg rectally. </li></ul><ul><li>Restoration of the blood loss circulation volume. </li></ul><ul><li>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. </li></ul>
  71. 85. <ul><li>Hemorrhagic shock in obstetrics </li></ul><ul><li>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 </li></ul>
  72. 86. <ul><li>Causes of hemorrhagic shock risk in obstetrics </li></ul><ul><li>1. Hemorrhage at early terms of gestation: </li></ul><ul><li>- abortion; </li></ul><ul><li>- extrauterine pregnancy; </li></ul><ul><li>- hydatidiform mole </li></ul><ul><li>2. Hemorrhage at late terms of gestation or delivery: </li></ul><ul><li>- premature placental detachment; </li></ul><ul><li>- placental presentation; </li></ul><ul><li>- hysterorrhexis (uterine rupture); </li></ul><ul><li>- amniotic fluid embolism </li></ul><ul><li>3. Postpartum hemorrhage: </li></ul><ul><li>- hypo- or atony of the uterus; </li></ul><ul><li>- retention of the afterbirth or its fragments in the uterine cavity; </li></ul><ul><li>- maternal passages rupture </li></ul><ul><li>4. Hepatic insufficiency </li></ul><ul><li>5. Hemostasis system pathology </li></ul>
  73. 87. <ul><li>Causes of hemorrhagic shock risk in obstetrics </li></ul><ul><li>1. Hemorrhage at early terms of gestation: </li></ul><ul><li>- abortion; </li></ul><ul><li>- extrauterine pregnancy; </li></ul><ul><li>- hydatidiform mole </li></ul><ul><li>2. Hemorrhage at late terms of gestation or delivery: </li></ul><ul><li>- premature placental detachment; </li></ul><ul><li>- placental presentation; </li></ul><ul><li>- hysterorrhexis (uterine rupture); </li></ul><ul><li>- amniotic fluid embolism </li></ul><ul><li>3. Postpartum hemorrhage: </li></ul><ul><li>- hypo- or atony of the uterus; </li></ul><ul><li>- retention of the afterbirth or its fragments in the uterine cavity; </li></ul><ul><li>- maternal passages rupture </li></ul><ul><li>4. Hepatic insufficiency </li></ul><ul><li>5. Hemostasis system pathology </li></ul>
  74. 88. <ul><li>Hemorrhagic shock. Classification according to the clinical course and the damage rate </li></ul>% body mass % BCV >2,4 >40 irreversible 4 1,9-2,4 31-40 decompensated 3 1,3-1,8 21-30 subcompensated 2 0,8-1,2 15-20 compensated 1 Blood loss amount Shock stage Shock damage rate
  75. 89. <ul><li>Hemorrhagic shock intensive therapy. General principles of acute blood loss therapy: </li></ul><ul><li>Urgent hemostasia by conservative or surgical methods depending on the causes of hemorrhagic development (see the protocol ‘Obstetric hemorrhages’) </li></ul><ul><li>Circulation blood volume recovery. </li></ul><ul><li>Maintenance of adequate gas exchange. </li></ul><ul><li>Management of organ dysfunction and prophylaxis of polyorganic insufficiency. </li></ul><ul><li>Correction of metabolic disorder. </li></ul>
  76. 91. <ul><li>Syndrome of disseminated intravascular blood coagulation in obstetrics </li></ul><ul><li>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. </li></ul>
  77. 92. <ul><li>Risk causes of DIC – syndrome in obstetrics: </li></ul><ul><li>- amniotic fluid embolism; </li></ul><ul><li>- shock (hemorrhagic, anaphylactic, septic); </li></ul><ul><li>- placental detachment; </li></ul><ul><li>- severe stage of preeclampsia; </li></ul><ul><li>- eclampsia; </li></ul><ul><li>- sepsis; </li></ul><ul><li>- septic abortion; </li></ul><ul><li>- syndrome of massive hemotransfusion; </li></ul><ul><li>- transfusion of incompatible blood; </li></ul><ul><li>- intrauterine fetal death; </li></ul><ul><li>- extrauterine pregnancy; </li></ul><ul><li>- cesarean section; </li></ul><ul><li>- extragenital diseases of the gravida (heart failure, malignant tumours, diabetes mellitus, serious diseases of kidneys and liver). </li></ul>
  78. 93. <ul><li>DIC – syndrome classification: </li></ul><ul><li>According to the clinical course: </li></ul><ul><li>acute; </li></ul><ul><li>subacute; </li></ul><ul><li>chronic; </li></ul><ul><li>relapsing. </li></ul>
  79. 94. <ul><li>According to the clinical stages of the course </li></ul><ul><li>I – hypercoagulation </li></ul><ul><li>II – hypocoagulation without generalized activation of fibrinolysis; </li></ul><ul><li>III – hypocoagulation with generalized activation of fibrinolysis; </li></ul><ul><li>IV – total blood incoagulability. </li></ul>
  80. 95. <ul><li>I stage – hypercoagulation. </li></ul><ul><li>Consequences of hypercoagulation can be: </li></ul><ul><li>appearance or progression of fetoplacental insufficiency; </li></ul><ul><li>severe aggrevation of gestosis; </li></ul><ul><li>decrease of uterine-placental blood flow, formation of infarction zones in the placenta and higher probability of its detachment; </li></ul><ul><li>anemia intensification; </li></ul><ul><li>development of respiratory insufficiency at the expence of acute respiratory distress – syndrome progression; </li></ul><ul><li>hemodynamics distress with the development of circulation centralization symptoms; </li></ul><ul><li>encephalopathy development. </li></ul>
  81. 97. <ul><li>II stage – hypocoagulation without generalized activation of fibrinolyses. </li></ul><ul><li>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. </li></ul>
  82. 98. <ul><li>III stage – hypocoagulation with a generalized fibrinolysis activation. </li></ul><ul><li>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. </li></ul>
  83. 99. <ul><li>IV stage – total blood incoagulability. </li></ul><ul><li>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. </li></ul>
  84. 101. THANK YOU !

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