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Karimova Nilufar Nabidjanovna, candidate of medical sciences, associate professor of the Department of Obstetrics and Gynecology, Bukhara State Medical Institute E-mail: [email protected] Tursunova Nodira Isroilovna, assistant of department Oncology, Tashkent Medical Academy E-mail: [email protected]
PRESENT AND FUTURE OF REPRODUCTIVE SYSTEM AFTER MASSIVE OBSTETRIC BLEEDING
Abstract: The aim of the research was to study the effectiveness of modern principles of stopping postpartum obstetric bleeding. From 127 cases of bleeding in 101 women (79.5%) the childbirth were with the operational method. With the development of blood loss was rendered stepwise ways to stop bleeding. During hemostasis of the bleeding, ligatures were imposed on the ovarian arteries and the ascending branch of the uterine artery for isch-emicization of the uterus, which was effective in 30 (30%) women, and in 114 (89.7%) women managed to achieve organ-sparing tactics.
Keywords: obstetric bleeding, hypotonia of the uterus, Cesarean section.
Among the various obstetric complications arising in obstetricians is to save the woman's life with hysterectomy, and childbirth and the early postpartum period, bleeding con- then to prevent immediate and remote complications [8; 9]. tinues to occupy one of the leading places [1; 2]. In the This prompted us to analyze the immediate and long-term
results of assisting 127 women with acute massive obstetric blood loss in our clinic over the past 5 years.
The aim of our work was to evaluate the immediate and long-term results of massive postpartum bleeding. Analysis of the mortality of pregnant women and woman in labor from bleeding indicates certain defects in the organization of the therapeutic and prophylactic process in antenatal clinics and maternity homes, and every seventh of them suffers from bleeding, which in 50% is caused by hypo- or atony of the uterus in the postpartum period. Postpartum hemostasis is a complex and multicomponent process [8; 9; 10].
The aim of our research was to study the effectiveness of modern principles of stopping postpartum obstetric bleeding and restoring the reproductive system.
Materials and methods: Over the past 3 years (20142017), 6.400 pregnant women were given birth in the city maternity hospital in Bukhara, more than half of them were threatened with bleeding. Massive blood loss (over 1000 ml) occurred in 127(1.9%) women.
A detailed analysis of 127 histories of childbirth, wich complicated by massive blood loss, showed that primiparous women made up 64.1% and multiparous was 35.9%. At delivery through the natural birth canal, blood loss exceeding 1000 ml occurred in 26(20.4% of bleeding) women, with planned Cesarean section - in 43(33.8%), in case of emergency - in 58(45.6%).
population of women of reproductive age in 15.5% obstetric complications (atonic bleeding, pathology of the placenta, scar on the uterus, rupture / perforation of the uterus, severe pre-eclampsia) caused radical operations [3; 4]. One of the factors affecting the growth in the frequency of obstetric hemorrhage at the present days is the increase the numbers of abdominal delivery. The frequency of bleeding during abdominal delivery increased by 3-5 times, compared with spontaneous birth [5]. In some cases, surgery is complicated by even more massive bleeding, mainly due to a decrease in the contractile function of the myometrium. Saving a woman's life in critical situations is the main task of obstetricians, since obstetric hemorrhages are the main cause of maternal mortality, accounting for 20-25% in pure form, 42% as a competing cause, and up to 78% as a background cause [1; 3]. At the same time, pathological blood loss in childbirth and the postpartum period has an adverse effect on the subsequent health of the woman [6; 7]. In obstetric practice, bleeding continues to be the most serious problem, as among the causes of maternal mortality they constitute 20-25% [2; 4; 5].
The most common causes of bleeding at Caesarean section are hypo- and atonic states of the uterus and DIC (dissemination intravascular coagulation) syndrome [6; 7]. Hypotonia of the uterus is accompanied by 1.8% of all Cesarean section operations. In case of massive bleeding the main task of
Medical science
Figure 1. Analysis of childbirth, wich complicated by massive blood loss
An analysis of the course of pregnancy revealed that 29(22.8%) were threatened with abortion, 23(18.1%) had high hydration and signs of intrauterine infection of the fetus, 31(24.4%) had mild preeclampsia, each second anemia, with half of the patients having a combination of two or more pregnancy complications. The average age of the patients was 23.1 ± 0.9 years.
The strategic stages of treatment of massive bleeding were selected:
- Correct assessment of the quantitative and qualitative components of blood loss;
- Timely and adequate infusion - transfusion therapy;
- Timely and adequate surgical treatment (organ preservation tactics);
- Permanent hardware and laboratory monitoring of vital functions and homeostasis.
In modern obstetrics, methods of dealing with hypotonic and atonic bleeding can be divided into 3 groups: drug, mechanical and operational.
Statistical analysis of the data was carried out using the standard Statistica software package (version 7.0, Statsoft Inc., USA). Survival analysis (using the Kaplan-Mayer method) and evaluating the reliability of differences were performed using a log-rank test using the "Survival" program. Differences were considered reliable at p < 0.05.
Results: For bleeding after vaginal delivery (26 cases; 20.4% of the number of bleeding), we used the drug method (utero-tonic agents), oxytocin 5 units. intravenously - in 12 (9.4%) patients. Manual examination of the walls of the postpartum
uterus, with bimanual compression, was performed in 9-7%, administration of misoprostol 800-1000 ^g per rectum in 2-1.5%.
Removal of the uterus with the ineffectiveness of conservative therapy was performed in 1 (0.7%) women. The deliveries were operational in 101 women, 79.5% of the 127 cases of bleeding. With the development of blood loss was phased ways to stop bleeding.
During hemostasis of the bleeding, ligatures were imposed on the ovarian arteries and the ascending branch of the uterine artery for ischemicization of the uterus, which was effective in 30(30%) women.
As a next measure, hemostatic compression stitches on the uterus were used. The principle of their application is - the insertion in the same plane of sagital or transverse subserous blanket absorbable sutures with compression of the uterus. A thick thread is used on the piercing atraumatic needle. This method proved to be effective in 49 puerperas, which is 38.7%.
From the remaining 43 women in 30(23.6%) patients of the most effective organ-sparing intervention was ligation of the internal iliac arteries. It is necessary to note that these manipulations are performed only by highly qualified specialists, sometimes with the participation of vascular surgeons. The uterus was removed in 13(10.2%) women. Today, we can call the removal of an organ to stop bleeding "the operation of despair", when other ways of preserving the life of the puerperal woman have already shown their futility. Thus, in 114(89.7%) women we managed to implement organ-preserving tactics.
The next step in the treatment of obstetric hemorrhage is the intravenous administration of fresh frozen donor plasma,
the infusion of hydroxyethylated starch (HES) preparations, proteolysis inhibitors and calloid - crystalloid preparations, taking into account the volume of hemorrhage.
The recovery time of menstrual and generative function after childbirth varies widely and largely depends on the conditions of labor, the amount of blood loss in the postpartum period and lactation. After uncomplicated labor in young primiparous women, there is observed earlier (5-6 weeks after delivery) the resumption of menstrual cycles. However, acute blood loss during childbirth leads to disruption of the hypothalamic-pituitary-ovarian system and affects the formation of menstrual and generative functions. The first menstruation after childbirth were moderate in 45%, abundant in 22.2% and scarce in 12.8% of women, 30.3% of women suffered from amenorrhea, in 66% menstruation was irregular, in 34% - regular. Ovulatory cycles are observed in about 40% of non-lactating and in 20% of lactating women. Of the women we examined, 20% did not protect against pregnancy,
the rest used various methods of contraception. Studies have shown that the timing of the resumption of menstrual function in women who have undergone abnormal bleeding occurs much later, sometimes absent. Pathological labor, being a major stress for the body, as it is accompanied by abundant blood loss, adversely affects the central nervous system, directly the menstrual function, which requires the use of hormone replacement and antianemic therapy.
Conclusion: Thus, the use of a modern approach to stopping postpartum hemorrhage and the introduction into clinical practice of adequate surgical tactics make it possible to practically abandon organ-bearing interventions and to achieve the preservation of the menstrual and reproductive functions in patients.
Conflicts of interest: The authors received no financial support for their research, and they report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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