Bleeding in the second half of pregnancy. obstetric bleeding

Causes of uterine bleeding

Much less often, the cause of this pathology can be the so-called extragenital diseases (not associated with the genitals). Uterine bleeding can occur with liver damage, with diseases associated with impaired blood clotting (for example, von Willebrand disease). In this case, in addition to uterine, patients are also concerned about nosebleeds, bleeding gums, bruising with minor bruises, prolonged bleeding with cuts, and others. symptoms.

Symptoms of uterine bleeding

Unlike normal menstruation, uterine bleeding is characterized by the following features:
1. An increase in the volume of excreted blood. Normally, during menstruation, 40 to 80 ml of blood is released. With uterine bleeding, the volume of blood lost increases, amounting to more than 80 ml. This can be determined if there is a need to change hygiene products too often (every 0.5 - 2 hours).
2. Increased bleeding time. Normally, during menstruation, the discharge lasts from 3 to 7 days. With uterine bleeding, the duration of bleeding exceeds 7 days.
3. Violation of the regularity of discharge - on average, the menstrual cycle is 21-35 days. An increase or decrease in this interval indicates bleeding.
4. Bleeding after intercourse.
5. Bleeding in postmenopause - at an age when menstruation has already stopped.

Thus, it is possible to distinguish the following symptoms uterine bleeding:

• Menorrhagia (hypermenorrhea)- excessive (more than 80 ml) and prolonged menstruation(more than 7 days), while their regularity is preserved (occur after 21-35 days).
• metrorrhagia- Irregular bleeding. Occur more often in the middle of the cycle, and are not very intense.
• Menometrorrhagia- Prolonged and irregular bleeding.
• Polymenorrhea- menstruation occurring more often than 21 days later.

Types of uterine bleeding

Depending on the cause of occurrence, uterine bleeding is divided into:

• Dysfunctional bleeding(may be ovulatory and anovulatory).
• organic bleeding- associated with the pathology of the genital organs or systemic diseases (for example, diseases of the blood, liver, etc.).
• Iatrogenic bleeding- occur as a result of taking non-hormonal and hormonal contraceptives, blood thinners, due to the installation of intrauterine devices.

Juvenile uterine bleeding

Treatment, depending on the condition, may be symptomatic - the following agents are used:

• hemostatic drugs: dicynone, vikasol, aminocaproic acid;
• uterine contractions (oxytocin);
• iron preparations;
• physiotherapy procedures.

To prevent re-bleeding, courses of vitamins, physiotherapy, and acupuncture are prescribed. After stopping the bleeding, estrogen-gestagenic agents are prescribed to restore the normal menstrual cycle. Of great importance in the recovery period is hardening and physical exercises nutrition, treatment of chronic infections.

Uterine bleeding in the reproductive period

During pregnancy, on early dates uterine bleeding may be a manifestation of miscarriage or ectopic pregnancy. In the later stages of bleeding due to placenta previa, hydatidiform mole. During childbirth, uterine bleeding is especially dangerous, the amount of blood loss can be large. A common cause of bleeding during childbirth is placental abruption, atony or hypotension of the uterus. AT postpartum period bleeding occurs due to parts of the membranes remaining in the uterus, uterine hypotension, or bleeding disorders.

Often, the causes of uterine bleeding in the childbearing period can be various diseases of the uterus:

• myoma;
• endometriosis of the body of the uterus;
• benign and malignant tumors of the body and cervix;
• chronic endometritis (inflammation of the uterus);
• hormonally active ovarian tumors.

Bleeding associated with pregnancy and childbirth

An ectopic pregnancy can develop in the fallopian tubes, cervix. At the first signs of bleeding, accompanied by subjective symptoms of pregnancy against the background of even a slight delay in menstruation, it is necessary to urgently seek medical help.

In the second half of pregnancy, bleeding poses a great danger to the life of the mother and fetus, so they require urgent medical attention. Bleeding occurs with placenta previa (when the placenta is not formed by back wall uterus, and partially or completely blocks the entrance to the uterus), detachment of a normally located placenta or uterine rupture. In such cases, the bleeding may be internal or external, and require an emergency caesarean section. Women who are at risk of such conditions should be under close medical supervision.

During childbirth, bleeding is also associated with placenta previa or placental abruption. In the postpartum period, common causes of bleeding are:

• reduced uterine tone and its ability to contract;
• parts of the placenta remaining in the uterus;
• blood clotting disorders.

Uterine bleeding with menopause

Dysfunctional uterine bleeding

• acute and chronic inflammation of the genital organs (ovaries, appendages, uterus);
• endocrine diseases (thyroid dysfunction, diabetes mellitus, obesity);
• stress;
• physical and mental overwork;
• climate change.

Very often, dysfunctional bleeding is the result of artificial or spontaneous abortions.

Dysfunctional uterine bleeding can be:
1. Ovulatory - associated with menstruation.
2. Anovulatory - occur between periods.

With ovulatory bleeding, there are deviations in the duration and volume of blood released during menstruation. Anovulatory bleeding is not associated with the menstrual cycle, most often occurs after a missed period, or less than 21 days after the last menstruation.

Ovarian dysfunction can cause infertility, miscarriage, so it is extremely important to consult a doctor in a timely manner if there is any menstrual irregularity.

Breakthrough uterine bleeding

In such cases, you should consult a doctor to review the dose of the drug used. Most often, if breakthrough bleeding occurs, it is recommended to temporarily increase the dose of the drug taken. If the bleeding does not stop, or becomes more abundant, an additional examination should be carried out, as the cause may be various diseases of the reproductive system. Also, bleeding can occur when the walls of the uterus are damaged by an intrauterine device. In this case, it is necessary to remove the spiral as soon as possible.

Which doctor should I contact for uterine bleeding?

Unfortunately, uterine bleeding can be a sign not only of a long-term chronic disease of the internal genital organs of a woman, which requires a planned examination and treatment, but also of emergency symptoms. The term emergency means acute diseases in which a woman needs urgent qualified medical care to save her life. And if such help is not provided for emergency bleeding, the woman will die.

Accordingly, it is necessary to contact a gynecologist at a polyclinic for uterine bleeding when there are no signs of an emergency. If uterine bleeding is combined with signs of an emergency, then you should immediately call an ambulance or on your own transport to as soon as possible get to the nearest hospital gynecological department. Consider in which cases uterine bleeding should be considered as an emergency.

First of all, all women should know that uterine bleeding at any stage of pregnancy (even if the pregnancy is not confirmed, but there is a delay of at least a week) should be considered as an emergency, since bleeding is usually provoked by life-threatening fetus and future mothers with conditions such as placental abruption, miscarriage, etc. And in such conditions, a woman should be provided with qualified assistance to save her life and, if possible, save the life of the gestating fetus.

Secondly, a sign of an emergency should be considered uterine bleeding that began during or some time after intercourse. Such bleeding may be due to pathology of pregnancy or severe trauma to the genital organs during previous intercourse. In such a situation, the help of a woman is vital, because in her absence, the bleeding will not stop, and the woman will die from blood loss that is incompatible with life. To stop bleeding in such a situation, it is necessary to suture all tears and injuries of the internal genital organs or to terminate the pregnancy.

Thirdly, an emergency should be considered uterine bleeding, which turns out to be profuse, does not decrease with time, is combined with severe pain in the lower abdomen or lower back, causes a sharp deterioration in well-being, blanching, decreased pressure, palpitations, increased sweating, possibly fainting. A common characteristic of an emergency in uterine bleeding is the fact of a sharp deterioration in a woman's well-being, when she cannot perform simple household and daily activities (she cannot stand up, turn her head, it is difficult for her to speak, if she tries to sit up in bed, she immediately falls, etc.) , but literally lies in a layer or even is unconscious.

What tests and examinations can a doctor prescribe for uterine bleeding?

Moreover, at the first stage, various examinations are carried out to assess the condition of the uterus, since uterine bleeding is most often caused by the pathology of this particular organ. And only if, after the examination, the pathology of the uterus was not detected, methods of examining the work of the ovaries are used, since in such a situation, bleeding is due to a disorder of the regulatory function of the ovaries. That is, the ovaries do not produce required amount hormones in different periods menstrual cycle, and therefore, as a response to hormonal imbalance, bleeding occurs.

So, with uterine bleeding, first of all, the doctor prescribes the following tests and surveys:

• General blood analysis ;
• Coagulogram (indicators of the blood coagulation system) (enroll);
• Gynecological examination (make an appointment) and examination in mirrors;
• Ultrasound of the pelvic organs (make an appointment).

A coagulogram allows you to evaluate the work of the blood coagulation system. And if the parameters of the coagulogram are not normal, then the woman should consult and undergo the necessary treatment with hematologist (make an appointment).

A gynecological examination allows the doctor to feel with his hands various neoplasms in the uterus and ovaries, to determine the presence of an inflammatory process by changing the consistency of the organs. And examination in the mirrors allows you to see the cervix and vagina, identify neoplasms in the cervical canal, or suspect cervical cancer.

Ultrasound is a highly informative method that allows you to identify inflammatory processes, tumors, cysts, polyps in the uterus and ovaries, endometrial hyperplasia, and endometriosis. That is, in fact, ultrasound can detect almost all diseases that can cause uterine bleeding. But, unfortunately, the information content of ultrasound is not sufficient for a final diagnosis, since this method only provides an orientation in the diagnosis - for example, ultrasound can detect uterine myoma or endometriosis, but to establish the exact localization of a tumor or ectopic foci, determine their type and assess the state of the organ and surrounding tissues - it is impossible. Thus, ultrasound, as it were, allows you to determine the type of existing pathology, but to clarify its various parameters and find out the causes this disease other testing methods must be used.

When a gynecological examination is performed, examination in the mirrors, ultrasound and a general blood test and a coagulogram are made, it depends on which pathological process was detected in the genitals. Based on these examinations, the doctor may prescribe the following diagnostic manipulations:

• Separate diagnostic curettage (sign up);
• Hysteroscopy (make an appointment);
• Magnetic resonance imaging (make an appointment).

If fibroids or other tumors of the uterus have been detected, the doctor prescribes hysteroscopy in order to examine the cavity of the organ and see the neoplasm with the eye.

If endometriosis has been identified, the doctor may prescribe magnetic resonance imaging in order to clarify the location of ectopic foci. In addition, if endometriosis is detected, the doctor may prescribe a blood test for the content of follicle-stimulating, luteinizing hormones, testosterone in order to clarify the causes of the disease.

If cysts, tumors or inflammation in the ovaries have been identified, additional examinations are not carried out, since they are not needed. The only thing that the doctor can prescribe in this case is laparoscopic surgery (make an appointment) to remove neoplasms and conservative treatment for the inflammatory process.

In the event that the results Ultrasound (make an appointment), gynecological examination and examination in the mirrors, no pathology of the uterus or ovaries was revealed, dysfunctional bleeding is assumed due to a violation hormonal balance in the body. In such a situation, the doctor prescribes the following tests to determine the concentration of hormones that can affect the menstrual cycle and the appearance of uterine bleeding:

• Blood test for cortisol (hydrocortisone) levels;
• Blood test per level thyroid-stimulating hormone(TSH, thyrotropin);
• Blood test for the level of triiodothyronine (T3);
• Blood test for thyroxine level (T4);
• Blood test for the presence of antibodies to thyroperoxidase (AT-TPO);
• Blood test for the presence of antibodies to thyroglobulin (AT-TG);
• Blood test for the level of follicle-stimulating hormone (FSH);
• Blood test for luteinizing hormone (LH) levels;
• Blood test for prolactin level (sign up);
• Blood test for estradiol levels;
• Blood test for dehydroepiandrosterone sulfate (DEA-S04);
• Blood test for testosterone levels;
• A blood test for the level of sex hormone-binding globulin (SHBG);
• Blood test for the level of 17-OH progesterone (17-OP) (enroll).

Treatment of uterine bleeding

Methods for stopping bleeding depend on age, their cause, and the severity of the condition. One of the main methods of surgical control of bleeding is a separate diagnostic curettage - it also helps to identify the cause of this symptom. For this, scraping of the endometrium (mucous membrane) is sent for histological examination. Curettage is not carried out when juvenile bleeding(only if heavy bleeding does not stop under the influence of hormones, and threatens life). Another way to stop bleeding is hormonal hemostasis (the use of large doses of hormones) - estrogenic or combined oral contraceptives Mirena). If intrauterine pathology is detected, chronic endometritis, endometrial polyps, uterine fibroids, adenomyosis, endometrial hyperplasia are treated.

Hemostatic agents used in uterine
bleeding

• dicynone;
• etamsylate;
• vikasol;
• calcium preparations;
• aminocaproic acid.

Dicynon for uterine bleeding

The drug begins to act within 5-15 minutes after intravenous administration. Its effect lasts 4-6 hours.

Dicynon is contraindicated in the following cases:

• thrombosis and thromboembolism;
• malignant blood diseases;
• hypersensitivity to the drug.

What to do with prolonged uterine bleeding?

The main signs of anemia:

• severe weakness;
• dizziness;
• lowering blood pressure;
• increased heart rate;
• pale skin;

Folk remedies

Bleeding in late pregnancy - a series of bleeding that opens after the 28th week of pregnancy. In most cases, they are a sign of a formidable complication and require emergency medical care. The causes of bleeding in the second half of pregnancy are most often associated with pathologies of the placenta. At the same time, there are also situations when bleeding is absolutely not related to the pregnancy itself, but only a doctor can differentiate the diagnosis correctly.

Note: very rarely, bleeding opens in the 2nd trimester due to complications associated with pregnancy. Its cause usually lies in the fall of a woman or a strong blow to the stomach, in contrast to the 3rd trimester, when this happens against the backdrop of formidable pathologies.

Causes of bleeding in late pregnancy

In the later stages, bleeding can be provoked by such causes:

• placenta previa;
• detachment of a normally located placenta (premature);
• uterine rupture;
• bleeding from the vessels of the fetus.

Late term bleeding due to placenta previa: symptoms, causes, treatment

This condition is characterized by an atypical location of the placenta in the uterine cavity. Placenta previa means that during ultrasound diagnostics, the doctor notices its abnormal location in the lower segment of the uterus, at a time when it should be on its side wall or in the bottom. The placenta in this case partially or completely covers the internal pharynx. There are 2 options for presentation: incomplete and complete, as well as a low location of the placenta (below 5 cm from the pharynx).

Important: this disease is the causehigh perinatal mortality of children, as it often leads to premature birth. As a result, children are born prematurely, with respiratory distress syndrome, etc. It also increases the risk of hemorrhagic shock and death in the mother.

This severe complication can form as a result of pathological changes in the endometrium or disturbances in the normal implantation of the fetal egg.

In particular, there are such provoking factors of placenta previa and associated late bleeding:

• abnormalities in the structure of the uterus;
• second, third, etc. childbirth;
• abortion;
• underdevelopment of the uterus;
• multiple pregnancy;
• perforation of the uterus;
• uterine fibroids;
• diagnostic curettage;
• C-section.

Clinically, placenta previa is manifested by bleeding of varying profusion without pain, which can suddenly stop and also suddenly resume. The second symptom is fetal hypoxia - due to hemodynamic disturbances, the child in the womb does not receive the necessary amount of nutrients and develops oxygen starvation.

Depending on where the placenta is located in the uterus, bleeding can begin both during childbearing (full presentation) and during delivery (incomplete, low attachment). A low-lying placenta is indicated by a postpartum examination of the placenta, on which a small distance is noticed between the rupture of the membranes and the placenta itself.

Important: treatment of this condition and the accompanying bleeding in late pregnancy should be carried out exclusively in a hospital, and it can be surgical or medical.

Conservative therapy is appropriate for mild bleeding, normal blood pressure and satisfactory blood test results.

Except the strictest bed rest, the patient is also prescribed:

• preparations for the prevention of fetal hypoxia;
• blood transfusions (erythrocyte mass, fresh frozen plasma);
• medicines for withdrawal increased tone uterus;
• funds for the normalization of uteroplacental blood flow;
• vitamins C, E, K.

Delivery in a patient with bleeding in placenta previa (complete and incomplete) is always carried out operatively in the form of a caesarean section. A direct indication for him is massive blood loss, immaturity birth canal at mother.

Sometimes a pregnant woman with incomplete placenta previa is allowed to go into labor. If she has normal labor activity, there is an opening of the cervix by 3 fingers, then the doctor opens the fetal bladder. Due to this, the fetal head descends into the small pelvis and mechanically presses the area of ​​placental abruption, which stops the bleeding.

For a complete algorithm for the treatment of bleeding in placenta previa, see the diagram:

Causes, symptoms and treatment of bleeding from uterine rupture

Bleeding in late pregnancy may develop as a result of uterine rupture. This complication is formed due to such reasons:

• history of caesarean section (scar on the uterus);
• cystic skid;
• chorioepithelioma.

Very often, uterine rupture occurs due to a fresh scar on it, which did not have time to fully heal after the first pregnancy.

note: the optimal interval between pregnancies should be 2.5 - 4 years, especially if the first child was born by caesarean section. The scar on the uterus should fully heal before the next pregnancy, which takes at least 2-3 years.

When the uterus ruptures, internal and external bleeding occurs. A woman complains of acute pain in the abdomen, spotting during pregnancy (bright scarlet). These symptoms indicate that a picture of hemorrhagic shock is developing. The mechanism of uterine rupture is quite simple: it stretches excessively, its walls become thinner, and the area of ​​​​the attachment site of the placental site increases, resulting in a rupture of the muscle layer.

The condition is very dangerous, therefore, it requires immediate first aid measures.

To stop bleeding and treat pathology, it is used:

• laparotomy,
• suturing the gap or complete amputation of the uterus,
• replenishment of the volume of lost blood.

Bleeding from premature detachment of a normally located placenta

This is a condition in which a normally located placenta is shed before the birth of the fetus during pregnancy or in childbirth before the 3rd period, when it should normally occur. This pathological process is always accompanied by external, internal or combined bleeding. It can cause death of both the fetus and the mother as a result of hemorrhagic shock due to blood loss and multiple organ failure that has developed due to it.

The causes of such bleeding in late pregnancy can be:

• rapid discharge of amniotic fluid;
• hypovitaminosis of various types;
• disturbance in placental circulation;
• eclampsia;
• hypotonic and hypertonic disease;
• short umbilical cord;
• large fruit;
• external obstetric turn;
• severe gestosis;
• endomyometritis;
• polyhydramnios;
• amniocentesis;
• anomalies in the development of the uterus;
• trauma (fall);
• thyrotoxicosis;
• late rupture of membranes;
• prolongation of pregnancy;

There are two types of placental abruption:

• complete, when the entire placenta exfoliates completely;
• partial, in which only part of the afterbirth is separated from the wall of the uterus along its center or edge, and may have a non-progressive and progressive course.

At the placental level, there are changes in the endothelium and an increase in the permeability of the vascular wall.

The most dangerous situation develops with progressive detachment, which does not give external bleeding. The blood that accumulates between the placenta and the wall of the uterus forms a hematoma, and it quickly increases. The uterus stretches, and blood begins to penetrate into its muscular layer and placenta. As a result, the walls of the uterus are saturated with blood, which is why cracks form on them. Blood penetrates into the periuterine tissue and into the abdominal cavity. The uterus itself acquires a bluish color with hemorrhages on its surface. Such a complication of bleeding during premature detachment of a normally located placenta is called - "Kuveler's uterus", by the name of the author who first described it.

Symptoms accompanying bleeding in late pregnancy with this pathology:

• with localization in the abdomen;
• bleeding;
• increased tone of the uterus;
• fetal hypoxia in the acute stage.

Medical tactics and the necessary treatment depend on the area of ​​detachment, the level of blood loss, the condition of the woman herself and the fetus, and the gestational age. If this complication occurred during pregnancy, then they resort to a caesarean section on an emergency basis, regardless of what trimester and what condition the fetus is in.

In the case when the “Kuveler’s uterus” is diagnosed during the operation, 2 options are possible further action: the first is the extirpation of the uterus with massive bleeding. Preservation of the uterus became real after the advent of high technology in modern medicine. If there is a vascular surgeon in the team and special equipment for intraoperative reinfusion of autologous blood, it is possible to save the patient's uterus, but at the same time, the internal iliac arteries are ligated.

In the case of a stable condition of a woman and a fetus with a gestational age of up to 34 weeks, the absence of massive bleeding (according to ultrasound, a small retroplacental hematoma without progression is allowed), severe anemia, expectant management can be used.

The woman and the fetus must be under constant medical supervision, which includes such activities as:

• dopplerometry;
• cardiotocography;
• strict bed rest;
• taking antispasmodics;
• taking antiplatelet agents;
• taking multivitamins;
• anemia therapy;
• transfusion of fresh frozen plasma (if indicated).

Bleeding from fetal vessels

This pathology occurs in 1 case per 5000 pregnancies. Bleeding from the vessels of the umbilical cord may develop with their atypical sheath attachment. It is quite difficult to make this diagnosis.

Tearing of the vessels of the umbilical cord or membranes of the fetus is manifested by the following symptoms:

• an increase in the fetal heart rate, which will gradually be replaced by its decrease;
• acute fetal hypoxia;
• a woman has bright scarlet bleeding without pain and increased uterine tone.

This pathology has a very high risk of antenatal fetal death. Only a doctor is competent to decide whether to keep the pregnancy and how to perform delivery.

Bloody discharge during pregnancy not related to pregnancy itself: causes and treatment

It is worth mentioning that there are a number of reasons that can also cause bleeding in the expectant mother, but they are not related to the pregnancy itself. Such secretions provoke a variety of factors, and in order to determine them, it is important to immediately consult a doctor for help after the first signs of bleeding appear.

Bleeding on late stages pregnancy can cause:

• ectopia of the cervix;
• polyp of the cervix;
• cervical cancer.

Bleeding with ectopia and erosion of the cervix during pregnancy

Such a combination is not pleasant, but it often goes unnoticed for a pregnant woman. Spotting will appear, which the doctor associates directly with erosion, may occur during the first stage of labor. When opening an eroded cervix, the risk of its rupture during childbirth increases significantly. But during pregnancy, this pathology is not cauterized as usual, as this complicates the course of future childbirth, but is treated conservative methods. This tactic will avoid infection of the wound surface on the cervix.

Bloody discharge with a cervical polyp

Very rarely they provoke bleeding during pregnancy, but this fact is still known. Treatment consists of removing the polyp and prescribing hemostatic drugs.

Bleeding in cervical cancer

This combination is not common in pregnant women, since the disease itself develops after the age of 40, with a history of abortion, childbirth and promiscuity. When bleeding is discovered due to cervical cancer, they resort exclusively to surgical treatment. During the intervention, the woman is delivered and the uterus is completely removed.

CHAPTER 24

Bleeding during pregnancy and childbirth, especially massive, is one of the serious complications that can be life-threatening for the mother and fetus. Especially adverse bleeding in III trimester pregnancy.

The most common causes of bleeding in the second half of pregnancy and childbirth:

placenta previa;

Premature detachment of a normally located placenta;

Rupture of the vessels of the umbilical cord during their sheath attachment.

In addition, the causes of bleeding in the second half of pregnancy may be those that essentially appear at any stage of pregnancy: erosion and polyps, cancer of the cervix and vagina; rupture of varicose veins of the vagina.

With detachment of a normally located and placenta previa, bleeding can be extremely severe. Delayed care for abruption of a normally located and placenta previa is one of the causes of maternal and perinatal morbidity and mortality.

PLACENTA PRESENTATION

placenta previa ( placenta praevia) - the location of the placenta in the lower segment of the uterus in the area of ​​​​the internal pharynx ( prae- before and via- on a way).

The placenta can cover the internal os in whole or in part.

The frequency of placenta previa depends on the gestational age. Before 24 weeks, placenta previa is more common (up to 28%). After 24 weeks, its frequency decreases to 18% and before childbirth - to 0.2-3.0%, as the placenta moves upward ("migration of the placenta").

The degree of placenta previa is determined by the dilatation of the cervix and may change throughout labor.

During pregnancy distinguish:

Complete placenta previa, when it completely covers the internal os (Fig. 24.1, a);

Incomplete (partial) presentation, when the internal pharynx is partially blocked or the placenta reaches it with its lower edge (Fig. 24.1, b, c);

Low placenta previa, when it is located at a distance of 7 cm or less from the internal pharynx (Fig. 24.1, d).

Placenta previa during pregnancy is determined by ultrasound. According to transvaginal echography, four degrees of placenta previa are currently distinguished (Fig. 24.2):

I degree - the placenta is located in the lower segment, its edge does not reach the internal pharynx, but is located at a distance of at least 3 cm from it;

II degree - the lower edge of the placenta reaches the internal os of the cervix, but does not overlap it;

III degree - the lower edge of the placenta overlaps the internal os, moving to the opposite part of the lower segment, its location on the anterior and posterior walls of the uterus is asymmetrical;

IV degree - the placenta is symmetrically located on the anterior and posterior walls of the uterus, blocking the internal os with its central part.

For a long time, the classification of the degree of placenta previa provided for its localization during childbirth with the opening of the cervix by 4 cm or more. At the same time, they singled out:

Central placenta previa ( placenta praevia centralis) - the internal pharynx is blocked by the placenta, the fetal membranes within the pharynx are not determined (see Fig. 24.1, a);

Lateral placenta previa ( placenta praevia lateralis) - part of the placenta lies within the internal pharynx and next to it are the fetal membranes, usually rough (Fig. 24.1, b);

Marginal placenta previa ( placenta praevia marginalis) - the lower edge of the placenta is located at the edges of the internal pharynx, only the fetal membranes are located in the pharyngeal region (Fig. 24.1, c).

Currently, placenta previa, both during pregnancy and during childbirth, is diagnosed using ultrasound. This allows you to deliver a pregnant woman before bleeding. In this regard, the above classification has lost its relevance, but for an idea of ​​the degree of placenta previa, it has a certain meaning.

In etiology placenta previa changes in the uterus and features of the trophoblast matter.

The uterine factor is associated with dystrophic changes in the uterine mucosa, as a result of which placentation conditions are violated. Chronic endometritis leads to dystrophic changes in the uterine mucosa; a significant number of births and abortions in history, especially with postpartum or postoperative endometritis; scars on the uterus after caesarean section or myomectomy, smoking.

Fetal factors contributing to placenta previa include a decrease in the proteolytic properties of the fetal egg, when its nidation in upper divisions uterus is not possible.

Under unfavorable conditions for nidation of the fetal egg, deviations in the development of the chorion are observed - atrophy of its villi occurs in the area decidua capsularis. At a possible location decidua capsularis a branched chorion is formed.

Due to reasons not fully known, in the early stages of pregnancy, a branched chorion is relatively often formed in the lower sections of the fetal egg. As the body of the uterus increases, the formation and stretching of the lower segment at the end of the II and III trimester, the placenta can move (migrate) up to 7-10 cm. At the time of displacement of the placenta, small bleeding from the genital tract may occur.

With placenta previa, due to insufficient development of the uterine mucosa, a dense attachment of the placenta or its true increment is possible.

clinical picture. The main symptom of placenta previa is bleeding from the genital tract, which appears suddenly among full health, more often at the end of the II-III trimesters or with the appearance of the first contractions. With massive blood loss, hemorrhagic shock develops. The greater the degree of placenta previa, the earlier bleeding occurs. The blood flowing from the genital tract is bright scarlet. Bleeding is not accompanied by pain. It often recurs, leading to anemia in pregnant women. Against the background of anemia, relatively small blood loss can contribute to the development of hemorrhagic shock.

Bleeding is caused by detachment of the placenta from the uterine wall during the formation of the lower segment, when there is a contraction of muscle fibers in the lower sections of the uterus. Since the placenta does not have the ability to contract, as a result of displacement relative to each other of the lower segment of the uterus and the placenta, its villi are torn off from the walls of the uterus, exposing the vessels of the placental site. In this case, maternal blood flows out (Fig. 24.3). Bleeding can stop only at the end of muscle contraction, vascular thrombosis and termination of placental abruption. If uterine contractions resume, bleeding occurs again.

The intensity of bleeding can be different, it depends on the number and diameter of damaged uterine vessels.

Blood from the vessels of the placental site flows through the genital tract without forming hematomas, so the uterus remains painless in all departments, its tone does not change.

Since the beginning labor activity one of the factors in the occurrence of bleeding in placenta previa is the tension of the membranes in the lower pole of the fetal egg, which hold the edge of the placenta, and it does not follow the contraction of the lower uterine segment. The rupture of the membranes helps to eliminate their tension, the placenta moves along with the lower segment, and bleeding can stop. An additional factor in stopping bleeding with incomplete placenta previa may be its pressing by the fetal head descending into the pelvis. With complete placenta previa, a spontaneous stop of bleeding is impossible, since the placenta continues to exfoliate from the uterine wall as the cervix smoothes.

The general condition of a pregnant woman with placenta previa is determined by the amount of blood loss. It is necessary to take into account the blood that can accumulate in the vagina (up to 500 ml).

The condition of the fetus depends on the severity of anemia or hemorrhagic shock with blood loss. With heavy bleeding, acute hypoxia develops.

The course of pregnancy. When placenta previa is possible:

The threat of termination of pregnancy;

Iron-deficiency anemia;

Incorrect position and breech presentation of the fetus due to an obstacle to inserting the head to the entrance to the small pelvis;

Chronic hypoxia and fetal growth retardation as a result of placentation in the lower segment and relatively low blood flow in this part of the uterus.

Diagnostics. The main diagnostic method for both placenta previa and its variant is ultrasound. The most accurate method is transvaginal echography.

Clinical signs of placenta previa include:

Bright scarlet bleeding with a painless uterus;

High standing of the presenting part of the fetus;

Incorrect positions or breech presentation of the fetus.

Vaginal examination with placenta previa is not recommended, as it can lead to further placental abruption, increasing bleeding. In the absence of an ultrasound vaginal examination carried out with extreme caution. During the study, spongy tissue is palpated between the presenting part and the fingers of the obstetrician. Vaginal examination is carried out with a deployed operating room, which allows an emergency caesarean section in case of heavy bleeding.

Management of pregnancy and childbirth with placenta previa, it is determined by the gestational age, the presence of blood discharge and their intensity.

InIItrimester pregnancy with placenta previa according to the results of ultrasound and in the absence of blood discharge, the patient is observed in the antenatal clinic. The examination algorithm does not differ from the generally accepted standard, with the exception of the additional determination of hemostasis indicators in the blood. Pregnant women are advised to exclude physical activity, travel, and sexual activity. Regularly (after 3-4 weeks) ultrasound should be performed to track the migration of the placenta.

When bleeding occurs, the woman is hospitalized. Further tactics are determined by the amount of blood loss and the localization of the placenta. With massive blood loss, a small caesarean section is performed; with minor bleeding - therapy aimed at maintaining pregnancy under the control of hemostasis. Treatment consists in the appointment of bed rest, the introduction of antispasmodics. Depending on the indicators of hemostasis, replacement (fresh frozen plasma), deaggregation (curantil, trental) therapy or the use of drugs aimed at activating hemostasis and improving microcirculation (dicynone) is carried out. At the same time, antianemic therapy is carried out. Ultrasound control over the location of the placenta.

ATIIItrimester pregnancy with placenta previa without blood discharge, the issue of hospitalization is decided individually. If the patient lives near the maternity hospital and can get to it in 5-10 minutes, then she can be observed by the doctors of the antenatal clinic until 32-33 weeks. If the place of residence of the pregnant woman is significantly removed from the medical institution, she must be hospitalized earlier.

With abundant bleeding, urgent delivery is indicated -

abdominal and caesarean section in the lower uterine segment, regardless of the gestational age.

In the absence of blood discharge, it is possible to prolong pregnancy up to 37-38 weeks, after which, with any variant of placenta previa, in order to prevent massive bleeding, a caesarean section is performed in a planned manner. During caesarean section, especially when the placenta is located on the anterior wall of the uterus, bleeding may increase up to massive, which is caused by a violation of the contractility of the lower segment, where the placental site is located. The cause of bleeding can also be the dense attachment or accretion of the placenta, which is often observed in this pathology.

When the placenta is located on the anterior wall experienced doctor can perform a caesarean section in the lower segment of the uterus. In this case, it is necessary to make an incision on the uterus and placenta and continue it to the side without exfoliating the placenta from the uterine wall. Quickly remove the fetus and subsequently separate the placenta from the uterine wall by hand.

A novice doctor can perform a corporal caesarean section to reduce blood loss.

If massive bleeding occurs during caesarean section, which is not stopped after suturing the incision on the uterus and administering uterotonic agents, dressing is necessary iliac arteries. In the absence of effect, one has to resort to extirpation of the uterus.

In the presence of angiographic installation, embolization is performed uterine arteries immediately after the extraction of the fetus in order to prevent massive bleeding. It is especially useful for timely ultrasound diagnosis of placental rotation during pregnancy. If this is detected on the operating table, catheterization of the uterine arteries is performed before the abdominal surgery and after the fetus is removed -

their embolization. Embolization of the uterine arteries makes it possible to perform an organ-preserving operation in case of true increment (ingrowth) of the placenta: excise part of the lower segment and suture the defect, preserving the uterus. If vascular embolization is not possible, then during ingrowth, to reduce blood loss, the uterus should be extirpated without separating the placenta.

During operative delivery, the device for intraoperative autologous blood reinfusion collects blood for subsequent reinfusion.

With incomplete placenta previa, the absence of bleeding with the onset of labor, it is possible to conduct labor through the natural birth canal, opening the membranes in a timely manner, which prevents further placental abruption. The same is facilitated by the head descending into the pelvis, which presses the exposed area of ​​​​the placental site to the tissues of the uterus. As a result, the bleeding stops, and further childbirth takes place without complications. With weak contractions or with a movable head above the entrance to the pelvis after amniotomy, it is advisable intravenous administration oxytocin (5 units per 500 ml isotonic solution sodium chloride). The appearance or increase in bleeding after opening the fetal bladder is an indication for operative delivery by caesarean section.

In case of incomplete presentation, absence of bleeding and premature birth, non-viable (developmental defects incompatible with life) or dead fetus after amniotomy and a movable head above the entrance to the small pelvis, it is possible to use Ivanov-Gauss skin-head forceps. In case of their ineffectiveness, a caesarean section is performed.

In the past, pedunculation of the fetus was used to stop abruption of the placenta when the cervix was not fully dilated (Brexton Hicks rotation). This complex and dangerous operation for the mother and fetus was designed for the fact that after turning the fetus on the leg, the buttocks would press the placenta against the tissues of the uterus, as a result of which the bleeding could stop.

With placenta previa in the early postoperative or postpartum period, uterine bleeding is possible due to:

Hypotension or atony of the lower uterine segment;

Partial tight attachment or ingrowth of the placenta;

Rupture of the cervix after childbirth through the natural birth canal.

To prevent violations of uterine contractility at the end of the second stage of labor or during caesarean section after the extraction of the fetus, uterotonic agents are administered: oxytocin or prostaglandin (enzaprost) intravenously for 3-4 hours.

After childbirth through the natural birth canal, the cervix must be examined in the mirrors, since placenta previa contributes to its rupture.

Regardless of the method of delivery, the presence of a neonatologist is necessary, since the fetus can be born in a state of asphyxia.

Due to the significant risk of developing purulent-inflammatory diseases in postoperative period the mother is shown intraoperative (after clamping the umbilical cord) prophylactic administration of broad-spectrum antibiotics to her, which is continued in the postoperative period (5-6 days).

PREMATURE DEPARTMENT OF A NORMALLY LOCATED PLACENTA

Detachment of a normally located placenta before the birth of the fetus is considered premature: during pregnancy, in the first and second stages of childbirth.

Premature detachment of a normally located placenta is often accompanied by significant internal and / or external bleeding. Mortality is 1.6-15.6%. The main cause of death of a woman is hemorrhagic shock and, as a result, multiple organ failure.

The frequency of premature detachment has now increased due to the often occurring cicatricial changes in the uterus (caesarean section, myomectomy).

In early pregnancy, detachment of a normally located placenta often accompanies abortion.

Depending on the area of ​​detachment, partial and complete are distinguished.

With partial detachment of the placenta, part of it exfoliates from the uterine wall, with complete detachment - the entire placenta. Partial detachment of a normally located placenta can be marginal, when the edge of the placenta exfoliates, or central - respectively, the central part. Partial placental abruption can be progressive or non-progressive. (Fig. 24.4, a, b, c)

Etiology Premature detachment of a normally located placenta has not been definitively established. Placental abruption is considered a manifestation of a systemic, sometimes latent pathology in pregnant women.

There are several etiological factors: vascular (vasculopathy), hemostasis disorder (thrombophilia), mechanical. Vasculopathy and thrombophilia are relatively often (more often than in the population) observed in conditions such as preeclampsia, arterial hypertension, glomerulonephritis, in which detachment develops relatively often.

Changes in blood vessels in premature placental abruption consist in endothelial damage, the development of vasculitis and vasculopathy with a change in vascular permeability, and ultimately a violation of the integrity of the vascular wall.

Changes in hemostasis can be both a cause and a consequence of premature placental abruption. Antiphospholipid syndrome (APS), genetic defects in hemostasis (factor V Leidena mutation, antithrombin III deficiency, protein C deficiency, etc.) predisposing to thrombosis are of great importance. Thrombophilia, which develops with APS, genetic defects in hemostasis, contributes to inferior trophoblast invasion, placentation defects, detachment of a normally located placenta.

Violations of hemostasis can also be a consequence of premature detachment of the placenta. An acute form of DIC develops, which in turn contributes to massive bleeding. This is especially common with central detachment, when pressure rises in the area of ​​blood accumulation and conditions are created for the penetration of placental tissue cells with thromboplastic properties into the maternal circulation.

Premature detachment of a normally located placenta is possible with a sharp decrease in the volume of the overstretched uterus, frequent and intense contractions. The placenta, which is not capable of contraction, cannot adapt to the changed volume of the uterus, as a result of which the connection between them is disrupted.

Thus, premature placental abruption is predisposed to:

during pregnancy- vascular extragenital pathology (arterial hypertension, glomerulonephritis); endocrinopathy (diabetes mellitus); autoimmune conditions (APS, systemic lupus erythematosus); allergic reactions on dextrans, blood transfusions; preeclampsia, especially against the background of glomerulonephritis;

during childbirth- outpouring of amniotic fluid with polyhydramnios; hyperstimulation of the uterus with oxytocin; the birth of the first fetus with multiple pregnancy; short umbilical cord; delayed rupture of the membranes.

Violent detachment of the placenta is possible as a result of a fall and trauma, external obstetric turns, amniocentesis.

Pathogenesis. Rupture of blood vessels and bleeding begins in decidua basalis. The resulting hematoma violates the integrity of all layers of the decidua and exfoliates the placenta from the muscular layer of the uterus.

In the future, non-progressive and progressive detachment is possible. If placental abruption occurs in a small area and does not spread further, then the hematoma thickens, partially resolves, and salts are deposited in it. Such a detachment does not affect the condition of the fetus, the pregnancy progresses. An area of ​​partial detachment of a normally located placenta is found when examining the placenta after childbirth (Fig. 24.5).

With progressive detachment, it can increase rapidly. The uterus is stretched. Vessels in the area of ​​detachment are not clamped and the flowing blood can continue to exfoliate the placenta, and then the membranes and flow out of the genital tract (Fig. 24.4). If the blood does not find a way out during the ongoing placental abruption, then it accumulates between the wall of the uterus and the placenta, forming a hematoma (Fig. 24.4, b). Blood penetrates both into the placenta and into the thickness of the myometrium, which leads to overstretching and impregnation of the walls of the uterus, irritation of the myometrial receptors. Stretching of the uterus can be so significant that cracks form in the wall of the uterus, extending to the serous membrane and even on it. The entire wall of the uterus is saturated with blood, it can penetrate into the periuterine tissue, and in some cases through a rupture of the serous membrane and into the abdominal cavity. The serous cover of the uterus at the same time has a cyanotic color with petechiae (or with petechial hemorrhages). This pathological condition is called uteroplacental apoplexy. It was first described by A. Couvelaire (1911) and was named "Couvelaire's uterus". With the uterus of Kuveler after childbirth, the contractility of the myometrium is often disturbed, leading to hypotension, progression of DIC, and massive bleeding.

Clinical picture and diagnosis. Premature detachment of a normally located placenta characteristic symptoms:

Bleeding;

Abdominal pain;

Hypertension of the uterus;

Acute fetal hypoxia.

Symptoms of premature placental abruption and their severity are determined by the size and location of the abruption.

Bleeding with premature detachment of the placenta can be external; internal; mixed (internal and external) (Fig. 24.4).

External bleeding often appears with marginal placental abruption. In this case, bright blood is released. Blood from a hematoma located high at the bottom of the uterus is usually dark in color. The amount of blood loss depends on the area of ​​detachment and the level of hemostasis. With external bleeding, the general condition is determined by the amount of blood loss. With internal bleeding, which, as a rule, occurs with a central detachment, the blood does not find a way out and, forming a retroplacental hematoma, impregnates the uterine wall. The general condition is determined not only by internal blood loss, but also by pain shock.

Abdominal pain due to imbibition of the uterine wall by blood, stretching and irritation of the peritoneum covering it.

The pain syndrome is observed, as a rule, with internal bleeding, when there is a retroplacental hematoma. The pain can be extremely intense. With premature detachment of the placenta, located on the back wall of the uterus, there are pains in the lumbar region. With a large retroplacental hematoma, a sharply painful "local swelling" is determined on the anterior surface of the uterus.

Uterine hypertonicity observed with internal bleeding and is caused by retroplacental hematoma, blood imbibition and overstretching of the uterine wall. In response to a constant stimulus, the uterine wall contracts and does not relax.

Acute fetal hypoxia is a consequence of uterine hypertonicity and impaired uteroplacental blood flow, as well as placental abruption. The fetus may die when detaching 1/3 of the surface or more. With complete detachment, instantaneous death of the fetus occurs. Sometimes intrapartum fetal death becomes the only symptom of placental abruption.

According to the clinical course, mild, moderate and severe degrees of placental abruption are distinguished.

For mild degree characterized by detachment of a small area of ​​the placenta and minor discharge from the genital tract. The general condition does not suffer. With ultrasound, a retroplacental hematoma can be determined, but if blood is released from the external genital organs, then the hematoma is not detected.

After childbirth, you can find an organized clot on the placenta.

With marginal detachment of 1/3-1/4 of the surface of the placenta ( medium degree severity) a significant amount of blood with clots is released from the genital tract. With central detachment and the formation of a retroplacental hematoma, abdominal pain, uterine hypertonicity appear. If the detachment occurred during childbirth, then the uterus does not relax between contractions. With a large retroplacental hematoma, the uterus may have an asymmetric shape and, as a rule, is sharply painful on palpation. The fetus experiences acute hypoxia and, without timely delivery, it dies.

At the same time, symptoms of shock develop, which basically contains symptoms of both hemorrhagic and pain.

Severe degree involves placental abruption 1/2 or more area. Sudden onset of abdominal pain due to internal bleeding sometimes there is external bleeding. Shock symptoms develop relatively quickly. On examination and palpation, the uterus is tense, asymmetrical, with swelling in the area of ​​retroplacental hematoma. Symptoms of acute hypoxia or fetal death are noted.

The severity of the condition, the amount of blood loss is further aggravated by the development of thrombohemorrhagic syndrome, due to penetration into the mother's bloodstream a large number active thromboplastins formed at the site of placental abruption.

Diagnostics placental abruption is based on the clinical picture of the disease; ultrasound data and changes in hemostasis.

When diagnosing, the following important symptoms of PONRP should be noted: spotting and abdominal pain; hypertonicity, soreness of the uterus; lack of relaxation of the uterus in the pauses between contractions during childbirth; acute hypoxia of the fetus or its antenatal death; symptoms of hemorrhagic shock.

At vaginal examination during pregnancy, the cervix is ​​preserved, the external os is closed. In the first stage of labor, the fetal bladder during placental abruption is usually tense, sometimes there is a moderate amount of blood discharge in clots from the uterus. When opening the fetal bladder, amniotic fluid mixed with blood is sometimes poured out.

If placental abruption is suspected, ultrasound should be performed as early as possible. Longitudinal and transverse scanning allows you to determine the place and area of ​​placental abruption, the size and structure of the retroplacental hematoma. If there is a slight detachment of the placenta along the edge and there is external bleeding, i.e. blood flows out, then with ultrasound, the detachment may not be detected.

Hemostasis indicators indicate the development of DIC.

Differential Diagnosis performed with histopathic rupture of the uterus, placenta previa, rupture of the umbilical cord vessels.

It is extremely difficult to differentiate premature detachment of a normally located placenta from histopathic uterine rupture without ultrasound, since their symptoms are identical: abdominal pain, tense, unrelaxed uterine wall, acute fetal hypoxia. Ultrasound reveals an area of ​​exfoliated placenta. If not, then differential diagnosis is difficult. However medical tactics it does not differ, namely, an emergency delivery is necessary.

Detachment of the placenta previa is easily established, since in the presence of blood discharge from the genital tract, other characteristic symptoms are absent. With ultrasound, it is not difficult to determine the location of the placenta.

It is very difficult to suspect a rupture of the umbilical cord vessels with their sheath attachment. Bright scarlet blood is secreted, acute hypoxia is noted, and antenatal fetal death is possible. Local pain and hypertonicity are absent.

Tactics of conducting with premature detachment of the placenta is determined:

The amount of detachment;

The degree of blood loss;

The condition of the pregnant woman and the fetus;

The duration of pregnancy;

The state of hemostasis.

During pregnancy with a pronounced clinical picture of detachment of a normally located placenta, emergency delivery by caesarean section is indicated, regardless of the gestational age and the condition of the fetus. During the operation, the uterus is examined to detect hemorrhage into the muscular wall and under the serous membrane (Cuveler's uterus). With Kuveler's uterus, according to the principles of classical obstetrics, hysterectomy was always performed before, since a hematoma in the uterine wall reduces its ability to contract and causes massive bleeding. Currently, in highly specialized medical institutions, where it is possible to provide emergency care with the participation of a vascular surgeon, as well as the possibility of using a device for intraoperative reinfusion of autologous blood and collecting the patient's blood, ligation of the internal iliac arteries is performed after delivery ( a. ilica interna). In the absence of bleeding, the operation is completed, the uterus is preserved. With continued bleeding, it is necessary to perform a hysterectomy.

If the condition of the pregnant woman and the fetus is not significantly impaired, there is no pronounced external or internal bleeding (small non-progressive retroplacental hematoma according to ultrasound), anemia, with a gestational age of up to 34 weeks, expectant management is possible. The management of a pregnant woman is carried out under the control of ultrasound, with constant monitoring of the condition of the fetus (Doppler, cardiotocography). Therapy involves bed rest and consists in the introduction of antispasmodics, antiplatelet agents, multivitamins, antianemic drugs. Transfusion of fresh frozen plasma is allowed according to indications.

In childbirth in case of premature detachment of the placenta and a pronounced clinical picture of the disease, a caesarean section is performed.

With a mild form of detachment, satisfactory condition women in labor and the fetus, normal uterine tone, childbirth can be carried out through the natural birth canal. Early amniotomy is necessary, since the outflow of amniotic fluid leads to a decrease in bleeding, the flow of thromboplastin into the maternal circulation, and accelerates labor, especially with a full-term fetus. Childbirth should be carried out under constant monitoring of hemodynamics in the mother, contractile activity of the uterus and fetal heartbeat. A catheter is installed in the central vein and, according to indications, infusion therapy is carried out. With weakness of labor activity after amniotomy, uterotonics can be administered. Epidural anesthesia is advisable. At the end of the second stage of labor after the eruption of the head, oxytocin is prescribed to enhance uterine contractions and reduce bleeding.

With the progression of detachment or the appearance of pronounced symptoms in the second stage of labor, tactics are determined by the condition of the woman in labor and the fetus, the location of the presenting part in the small pelvis. With the head located in the wide part of the pelvic cavity and above, a caesarean section is shown. If the presenting part is located in the narrow part of the pelvic cavity and below, then obstetric forceps are applied with head presentation, and with pelvic presentation, the fetus is extracted by the pelvic end.

In the early postpartum period after separation of the placenta, a manual examination of the uterus is performed. To prevent bleeding, enzaprost is administered in an isotopic solution of sodium chloride intravenously by drip for 2-3 hours.

Violation of coagulation in the early or late postpartum period is an indication for the transfusion of fresh frozen plasma, platelet mass, according to indications, hemotransfusion is performed. In rare situations, with massive blood loss, phenomena of hemorrhagic shock, it is possible to transfuse fresh donor blood. In order to stop bleeding in the early postpartum period, it is advisable to ligate the internal iliac arteries and, if appropriate equipment is available -

embolization of the uterine arteries.

outcome for the fetus. With premature detachment of the placenta, the fetus, as a rule, suffers from acute hypoxia. If obstetric care is provided untimely and not fast enough, then antenatal death occurs.

SCHEME OF EXAMINATION OF PREGNANT WOMEN ADMITTING HOSPITAL WITH BLOODY DISCHARGE IN LATE PREGNANCY

Patients with bloody secretions entering the obstetric institution are: assessing the general condition; collection of anamnesis; external obstetric examination; listening to the heart sounds of the fetus; examination of the external genital organs and determination of the nature of blood discharge. Ultrasound is indicated (with massive blood loss it is performed in the operating room).

Currently, due to the widespread introduction of ultrasound in the practice of antenatal clinics, placenta previa is known in advance. With established placenta previa and bleeding after admission, the patient is transferred to the operating room. In other situations, with massive bleeding, it is first necessary to exclude premature detachment of the placenta.

If premature detachment is not confirmed by external obstetric and ultrasound examination, examination of the cervix and vaginal walls in the mirrors is necessary to exclude erosion and cervical cancer; cervical polyps; rupture of varicose veins; injury.

If this pathology is detected, appropriate treatment is carried out.

Vaginal examination during childbirth is performed for:

Determining the degree of cervical dilatation;

Detection of blood clots in the vagina, in the posterior fornix, which helps to determine the true blood loss;

Carrying out amniotomy when solving the management of childbirth through the natural birth canal.

A vaginal examination is performed with an expanded operating room, when, with increased bleeding, it is possible to urgently perform a cerebrosection and a caesarean section.

Blood loss is determined by weighing diapers, sheets and taking into account blood clots in the vagina.

Rarely give significant bleeding, more often it is minor bleeding. A decidual polyp is an overgrowth of decidual tissue, and its excess descends into the cervical canal. Such a polyp most often disappears on its own, or it can be removed by gently unscrewing it. A bleeding polyp should be removed, but without curettage of the uterine cavity, with hemostatic therapy, and pregnancy-preserving therapy.

Cervical cancer.

Cervical cancer in a pregnant woman is extremely rare, since most often this pathology develops in women over 40 years old, in women with large quantity childbirth and abortion in history, in women who often change sexual partners. Cervical cancer is usually diagnosed with a mandatory examination of the cervix during pregnancy 2 times - when a pregnant woman enters the register, when issuing maternity leave. Cervical cancer looks like exophytic (cauliflower type) and endophytic growths (barrel-shaped cervix). Most often, this woman had underlying diseases of the cervix. In case of cervical cancer, depending on the gestational age, an operative delivery is performed, followed by hysterectomy - for long periods, removal of the uterus for short gestations with the consent of the woman. No conservative methods of stopping bleeding in cervical cancer are used!

Obstetric bleeding refers to bleeding associated with an ectopic pregnancy. If earlier a woman died from bleeding during an ectopic pregnancy, then her death was considered as a gynecological pathology, now it is considered as an obstetric pathology. As a result of the localization of pregnancy in the isthmic tubal angle of the uterus, in the interstitial section, there may be a rupture of the uterus, and give a clinic of ectopic pregnancy.

Bleeding in the second half of pregnancy. The main causes of obstetric bleeding in the second half of pregnancy:

placenta previa

Premature abruption of a normally located placenta (PONRP)

Rupture of the uterus.

At present, after the advent of ultrasound, and they began to diagnose placenta previa before the onset of bleeding, the main group of maternal mortality is women with PONRP.

Placenta previa and premature detachment of a normally located placenta.

Placenta previa is 0.4-0.6% of the total number of births. There are complete and incomplete placenta previa. The risk group for the development of placenta previa are women with inflammatory, dystrophic diseases, genital hypoplasia, uterine malformations, and ischemic-cervical insufficiency.

Normally, the placenta should be located in the fundus or body of the uterus, along the back wall, with the transition to the side walls. The placenta is located much less frequently along the anterior wall, and this is protected by nature, because the anterior wall of the uterus undergoes much greater changes than the posterior one. In addition, the location of the placenta on the back wall protects it from accidental injury.

Differential diagnosis between placenta previa, ponrp and uterine rupture.