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40Акушерство и Гинекология
УДК: 618.3-06 +616-005.1-08
MODERN ASPECTS OF THE TREATMENT OF HEMORRHAGIC SHOCK IN OBSTETRIC BLEEDING
KHAMIDOVA NIGORA RUSTAMOVNA
Doctoral candidate of the Department of Obstetrics and Gynecology No. 2 of the Bukhara State Medical Institute named after Abu Ali ibn Sino, Uzbekistan, Bukhara ORCID ID 0000-0002-2125-5251
TUKSANOVA DILBARISMATOVNA Bukhara State Medical Institute named after Abu Ali Ibn Sino, Head of the Department of Obstetrics and Gynecology, Dsc, Bukhara, Republic of Uzbekistan. ORCID ID 0000-0002-7626-0410 NEGMATULLAEVA MASTURA NURULLAEVNA Bukhara State Medical Institute named after Abu Ali Ibn Sino, professor of the Department of Obstetrics and Gynecology, Dsc, Bukhara, Republic of Uzbekistan. ORCID ID 0000-0001-7698-0533
ABSTRACT
The purpose of the study is to study the experience of treating hemorrhagic shock in an obstetric hospital and assess its effectiveness. Intensive treatment of hemorrhagic shock in obstetrics should be aimed at eliminating the source of bleeding and replenishing the circulating blood volume, taking into account the stage of the process. Timely assessment of blood loss, severity of shock and the need for adequate intensive care with the inclusion of blood transfusion, transfusion of fresh frozen plasma prevent the development of DIC and hemic hypoxia, which contributes to the reduction of multiorgan disorders, the disability of patients and the prevention of disastrous fatal outcomes.
Key words: obstetric hemorrhage, hemorrhagic shock, shock index, pregnancy
СОВРЕМЕННЫЕ АСПЕКТЫ ЛЕЧЕНИЯ ГЕМОРРАГИЧЕСКОГО ШОКА ПРИ АКУШЕРСКИХ КРОВОТЕЧЕНИЯХ
ХАМИДОВА НИГОРА РУСТАМОВНА
Докторант кафедры акушерства и гинекологии №2 Бухарского Государственного медицинского института имени Абу Али ибн Сино, Узбекистан, г.Бухара
ОИСЮ Ю 0000-0002-2125-5251 ТУКСАНОВА ДИЛБАР ИСМАТОВНА заведующая кафедрой «Акушерство и гинекологии», Бухарский Государственный медицинский институт имени Абу Али Ибн Сино, город Бухара Республика Узбекистан. ОЯСЮ Ю 0000-0002-7626-0410 НЕГМАТУЛЛАЕВА МАСТУРА НУРУЛЛАЕВНА профессор кафедры акушерство и гинекологии, Бухарский Государственный медицинский институт имени Абу Али Ибн Сино, город Бухара Республика Узбекистан.
ОИСЮ Ю 0000-0001-7698-0533 АННОТАЦИЯ
Цель исследования изучение опыта лечения геморрагического шока в акушерском стационаре и оценка ее эффективность. Интенсивная терапия геморрагического шока в акушерстве должна быть направлена на устранение источника кровотечения и восполнение объема циркулирующей крови с учетом стадии процесса. Своевременная оценка объема кровопотерия, степени тяжести шока и необходимости адекватной интенсивной терапии с включением гемотрансфузии, переливание свежезамороженной плазмы препятствуют развитию ДВС-синдрома и гемической гипоксии, что способствует снижению полиорганных нарушений, инвалидизации пациенток и предотвращению плачевных фатальных исходов.
Ключевые слова: акушерские кровотечения, геморрагический шок, шоковый индекс, беременность
АКУШЕРЛИК КОН КЕТИШЛАРИДАГИ ГЕМОРРАГИК ШОКНИ ДАВОЛАШНИНГ ЗАМОНАВИЙ УСУЛЛАРИ
ХАМИДОВА НИГОРА РУСТАМОВНА
Акушерлик ва гинекология №2 кафедраси докторанти, Бухоро давлат тиббиёт институти, Бухоро, Узбекистон
ORCID Ю 0000-0002-2125-5251 ТУКСАНОВА ДИЛБАР ИСМАТОВНА Акушерлик ва гинекология №2 кафедраси мудири, Бухоро давлат тиббиёт институти, Бухоро, Узбекистон
О^С1Ю Ю 0000-0002-7626-0410 НЕГМАТУЛЛАЕВА МАСТУРА НУРУЛЛАЕВНА Акушерлик ва гинекология №2 кафедраси профессори, Бухоро давлат тиббиёт институти, Бухоро, Узбекистон
О^С1Ю Ю 0000-0001-7698-0533 АННОТАЦИЯ
Тадцицотнинг мацсади акушерлик стационарида геморрагик шокни даволаш тажрибасини урганиш ва унинг самарадорлигини бацолаш цисобланади. Интенсив терапия биринчи уринда цон кетиш манбасини бартараф этиш ва йуцотилган цон урнини тулдиришга царатилган булади. Кетган цон мицдори, шокнинг огирлик даражасига уз вацтида тугри бацо бериш гемотрансфузия, тоза музлатилган плазмани цуйиш орцали ДВС синлром ва гипоксия ривожланишига тусцинлик цилади. Бу эса полиорган етишмовчилик, беморларнинг ногиронлиги ва улим цолатларининг камайишига олиб келади.
Калит сузлар: акушерлик цон кетишлар, геморрагик шок, шок индекси, цомиладорлик
Электронный научный журнал «Биология и интегративная медицина» №3 - май-июнь (43) 2020
Massive obstetric bleeding is known to be one of the leading causes of maternal mortality and disability in women - [1, 2]. Among the various obstetric complications arising in childbirth and the early postpartum period, bleeding continues to occupy one of the leading places. In recent years, according to the WHO, annually bleeding associated with pregnancy is observed in 14 million women, of which 128 thousand usually die within the first 4 hours after giving birth. The introduction of new methods to combat massive bleeding is not always acceptable in obstetric hospitals of different levels and does not lead to a decrease in their frequency - [3, 10].
There are many methods for predicting massive bleeding, at the same time, the reliability and effectiveness of their use is insufficient [4,9], which necessitates the continuation of scientific research in this direction.
The severity of blood loss depends on the individual tolerance of blood loss, premorbid background, obstetric pathology and delivery method. Factors predisposing to bleeding in the subsequent and early postpartum periods are abortions, numerous pregnancies, a uterine scar, abnormalities of the uterus, preeclampsia and eclampsia, obesity, multiple pregnancy, large fetus, polyhydramnios, various extra genital diseases mothers, the use of tocolytics, a dead fetus, a hemostatic defect (von Will brand disease, etc.) - [6, 7].
Currently, obstetric hemorrhages continue to pose a threat to the life of women in childbirth and puerperia's. Hemorrhagic shock in women during the perinatal period causes acute and massive bleeding, which leads to a sharp decrease in the volume of circulating blood (BCC), ejection fraction (EF) and tissue hypo perfusion. The development of hemorrhagic shock is promoted by chronic circulatory and metabolic disorders caused by extra genital pathology, preeclampsia and other pregnancy complications - [5, 8].
In the pathogenesis of hemorrhagic shock, the mismatch of decreasing during bleeding bcc and vascular bed capacity is of great importance. A decrease in venous return to the heart due to a deficiency of bcc leads to a decrease in stroke and minute volume of the heart, blood pressure (BP).
It should be borne in mind that due to the insufficient increase in BCC in pregnant women with preeclampsia, obesity, and heart diseases, hemorrhagic shock can develop with moderate blood loss. Which is due to the insufficient increase in BCC in pregnant women with preeclampsia, obesity, and heart diseases, hemorrhagic shock can develop with moderate blood loss.
Purpose of the study: studying the experience of treating hemorrhagic shock in an obstetric hospital and evaluating its effectiveness.
Material and methods
This study was conducted at the Department of Obstetrics and Gynecology, Bukhara Medical Institute, in the city maternity complex. An analysis of the treatment of hemorrhagic shock in 20 women was carried out, in the average age of patients was 36.1 ± 2.4 years, who were treated in the maternity hospital. Of the prim parous of them were 3 (15%) people, 2 (10%) had a second birth, 6 (30%) - a third, and 9 (45%) - a fourth. Parity is prim parous 3 (15%), multiparous - 17 (85%). In all cases, it developed against the background of various extra genital and gynecological diseases. The diagnosis of hemorrhagic shock was made on the basis of subjective sensations, clinical and additional research methods.
All observed patients underwent a complete clinical examination in a maternity hospital. A general blood test was performed according to the generally accepted method. All women underwent biochemical blood tests: the total protein, bilirubin, and urea were determined.
The study of the blood coagulation system (fibrinogen, D-dimers, prothrombin index (PTI), coagulation time according to Lee-White) was carried out according to the capabilities of the existing laboratory service of this medical institution.
The severity of hemorrhagic shock was assessed by the general condition, determination of blood pressure (BP), heart rate (HR), respiration (BH), body temperature, central venous pressure (CVP), hemoglobin oxygen saturation (SP02) using a pulse oximeter, hourly urine output.
The following criteria were followed to evaluate the stages of hemorrhagic shock. Hemorrhagic shock of I st - corresponds to a blood loss of 15% of BCC (<1000 ml). The clinical picture shows pallor of the skin and mucous membranes, moderate tachycardia up to 100 beats / min, moderate oliguria (less than 50 ml/h). Systolic blood pressure is not lower than 100 mm RT. Art., CVP - below 5 cm of water. Art. Hemorrhagic shock of the II degree - is established with a blood loss of 15-25% of BCC (10001500ml). In this case, a spasm of peripheral vessels cannot compensate for a small cardiac output, blood pressure of 100/60 mm RT. Art. the amplitude of the pulse pressure decreases, severe tachycardia (120-130 beats/min), shortness of breath, acrocyanosis against the background of pallor of the skin, cold sweat, anxiety, deafness of heart sounds, decrease in CVP to 0 mm of water. Art. Diuresis 20-30 ml/hour. The shock index -1. Hemorrhagic shock of the III degree - develops with blood loss exceeding 25-40% of BCC (1500-2000ml). The main role in the pathogenesis of irreversible shock is paresis of capillaries, plasma loss, aggregation of blood cells, and increasing metabolic acidosis. Pulse more than 120 beats. in minutes HELL from 100 to 60 mm RT. Art., inhibited state, confused consciousness, sharp pallor, acracyanosis, cold sweat. Shortness of breath at rest, frequent breathing with rhythm disturbance, restless behavior. Diuresis - oliguria 5-20 ml/h. The shock index is 1.3-1.4.
External respiratory disorders intensify, extreme pallor or marbling of the skin, anuria, stupor, loss of consciousness is noted. Hemorrhagic shock of the IV degree - develops with blood loss exceeding more than 2000 ml (more than 40% of BCC). Pulse more than 140 beats. in minutes GARDEN - less than 60 mm. Hg. Art. determined by labor, diastolic-0. Extreme pallor of the skin, cold sweat. Severe shortness of breath, weakened breathing with rhythm disturbance. Lack of consciousness. Multiple organ failure, anuria. '
"Algover's shock index" was calculated - the ratio of heart rate (HR) to the value of systolic blood pressure. Normally, this indicator is 0.5. Statistical processing of the results was performed using Student's test using the Stat Graf software package and Microsoft Excel version for Windows.
Results and discussion
In our studies, the following data were obtained, analyzing in detail the causes of obstetric pathology leading to hemorrhagic shock, we can say that the main part is uterine hypotension (PPH) - 2 (10%), placenta pathology: premature detachment of normally located placenta-4 (20%), placenta previa and ingrowth: placenta accreta- 2 (10%), traumatic injuries of the uterus-1 (10%), acute eversion of the uterus-1 (5%). Preeclampsia and premature rupture of the membranes were equal amounts - 6 (30%), coagulopathy - 4 (20%).
It should be noted that the surgical intervention itself, carried out to stop bleeding, is also accompanied by blood loss, especially against the background of DIC, which exacerbates the course of hemorrhagic shock.
Studies have shown that hemorrhagic shock of I degree in 10 (50%) women, II degree in 6 (30%), III degree in 2 (10%) and IV degree-2 (10%).
During intensive therapy of hemorrhagic shock, they sought to urgently stop bleeding, to quickly eliminate violations of the parameters of
the circulating blood volume and central and systemic hemodynamics by timely, adequate infusion-transfusion therapy.
Since profuse bleeding and hemorrhagic shock contribute to the development of DIC, DIC in one stage or another has occurred in all cases. Therefore, the complex of intensive care necessarily included measures to prevent and combat coagulopathy by transfusion of FFP, protease inhibitors and prothromplex -600. We monitored the determination of the parameters of fibrin degradation products — D-dimer. The fight against respiratory failure and its prevention also became necessary measures in terms of treatment.
During ITT, the volume of injected fluid depended on the volume of blood loss or the stage of hemorrhagic shock. Infusion therapy was started with colloidal solutions (reftan, stabizol).
Fresh frozen plasma (FFP) has a favorable effect in the treatment of hemorrhagic shock, since it contains all coagulation factors. FFP was transfused both for the purpose of replenishing the BCC and for combating DIC and its prevention. In stage II of hemorrhagic shock, 300-450 ml of FFP was used, in stage III and IV, 600-800 ml of FFP and more. Protease inhibitors were also introduced (contracal at 80,000 AE, gordox at 300,000 units).
Since a decrease in hematocrit below 25% leads to a violation of the oxygen-transport function of the blood, with blood loss of 1-1.5% of body weight (800-1200 ml), the issue of transfusion of blood components was resolved.
All patients were withdrawn from hemorrhagic shock. However, in the early days of the recovery period, their condition remained serious. Treatment continued in the intensive care unit.
Conclusion
Thus, timely diagnosis of bleeding that has begun should be carried out using a standard approach, starting from a step-by-step action and
further solving problems as they are identified. It is necessary to simultaneously dynamically evaluate the patient's condition. Intensive care for hemorrhagic shock in obstetrics should be aimed at eliminating the source of bleeding and replenishing the volume of circulating blood, taking into account the stage of the process. Timely assessment of the volume of blood loss, the severity of shock, and the need for adequate intensive care including blood transfusion, transfusion of freshly frozen plasma impede the development of DIC and hemic hypoxia, which helps to reduce multiple organ dysfunctions, disable patients and prevent fatal outcomes.
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