Obstetric bleeding

Obstetric bleeding - bleeding in the second half of pregnancy, during and after childbirth. Early postpartum haemorrhage - bleeding that occurred in the first 2 hours, late - more than 2 hours after childbirth.

ICD-10 code

• O44.1 Placenta previa with bleeding
• O45.0 Premature placental abruption with bleeding disorders
  • O45.8 Other premature placental abruption
  • O45.9 Premature placental abruption, unspecified
• О46.0 Prenatal bleeding with impaired coagulation
  • О46.8 Other prenatal bleeding
  • О46.9 Prenatal bleeding, unspecified
• O67.0 Bleeding during labor with blood clotting disorder
  • Other bleeding during labor
  • O67.9 Bleeding during delivery, unspecified
• O69.4 Births complicated by the presentation of the vessel (vasa praevia)
  • О71.0 Rupture of the uterus before the onset of labor
  • O71.1 Rupture of the uterus during labor
  • O71.2 Postpartum uterine evacuation
  • Obstetric rupture of the cervix uteri.
  • Obstetric rupture of the upper part of the vagina only.
  • A71.7 Obstetrical pelvic hematoma
• O72.0 Bleeding in the third stage of labor
  • O72.1 Other bleeding in the early postpartum period
  • O72.2 Late or secondary postpartum hemorrhage
• O75.1 Shock during or after childbirth and delivery

Causes Obstetric bleeding

Causes of obstetric hemorrhages

The causes of bleeding during pregnancy and childbirth are premature detachment of the normally and low-lying placenta, placenta previa, rupture of the uterus, membrane attachment of the umbilical cord. Causes of bleeding in the III period of labor and early postpartum period - hypotension and atony of the uterus, defects of the placenta, tight attachment and rotation of the placenta, trauma of the birth canal, eversion of the uterus, impaired blood clotting. It was proposed to determine the causes of postpartum bleeding as 4 "T":

• tone,
• the cloth,
• injury,
• thrombin.

Every year, around 125,000 women die from bleeding related to childbirth. Maternal mortality from obstetric hemorrhages in the Russian Federation in 2001-2005 was 63 to 107 per 100 thousand live births, or 15.8-23.1% in the structure of maternal mortality.

Physiological blood loss in childbirth is considered within 300-500 ml or 0.5% of body weight. The blood loss during caesarean section is 750-1000 ml, with the planned cesarean section with a hysterectomy - 1500 ml, with an emergency hysterectomy - up to 3500 ml.

Massive obstetric hemorrhage is defined as the loss of more than 1000 ml of blood, or more than 15% of BCC, or more than 1.5% of body weight. Severe, life-threatening bleeding is considered:

• loss of 100% BCC for 24 hours, or 50% BCC for 3 hours,
• blood loss at a rate of 150 ml / min, or 1.5 ml / (kghmin) (over a period of more than 20 minutes),
• single-stage blood loss more than 1500-2000 ml, or 25-35% BCC.

[1], [2]

Pathogenesis

Physiological changes in late pregnancy

Compensatory changes in hemodynamics, respiratory system, gas exchange, occurring at the end of pregnancy, affect the diagnosis and intensive care with massive bleeding.

During pregnancy, an increase in BCC by 30-50% occurs. The volume of plasma and the number of erythrocytes increase disproportionately, creating a physiological hemodilution of CB increases by 30-50%, mainly in the I and II trimesters due to stroke volume and to a lesser extent - in the III trimester, due to the increase in heart rate by 15-20%, CVP and DZLK vary, despite a significant increase in intravascular volume. This occurs as a result of a decrease in the total peripheral and pulmonary vascular resistance. The greatest decrease occurs in vascular resistance and an increase in blood flow in the vessels of the uterus and kidneys.

Oncotic pressure on average decreases to 18 mm Hg (by 14%). The risk of OL in the course of infusion therapy is increased because of a decrease in the oncotic pressure / DZLK gradient.

During pregnancy, there is an increase in all four chambers of the heart, a thickening of the wall of the left ventricle. There is a predisposition to the development of ventricular and supraventricular rhythm disorders. More than 90% of healthy pregnant women have signs of tricuspid regurgitation, one-third note minor mitral regurgitation. The sizes of the left atrial and ventricular chambers gradually return to normal values 2 weeks after delivery, and the wall thickness of the left ventricle is 24 weeks later.

Changes in the system of the respiratory system also occur. Increasing oxygen consumption by 20% is the result of increased metabolic needs of the mother and fetus. An increase in minute ventilation and respiratory volume by 40% leads to compensated respiratory alkalosis with a decrease in pCOO2 to 27-32 mm. Gt; Art. A significant change in pH does not occur due to a decrease in the kidney concentration of bicarbonate in the plasma to 18-21 mmol / l. Reducing plasma bicarbonate concentrations may limit buffer capacity during pregnancy. These changes should be borne in mind when interpreting blood COC data from a patient with shock. It is suggested that physiological hyperventilation during pregnancy is caused by an increase in the content of progesterone in the blood, whose concentration rapidly decreases after delivery.

Pathogenesis

The blood loss of more than 15% of bcc leads to a number of compensatory reactions involving stimulation of the sympathetic nervous system due to reflexes from the baroreceptors of the sinocarotid zone, large intramedullary arteries, activation of the hypothalamic-pituitary-adrenal system with the release of catecholamines, angiotensin, vasopressin, ADH. This leads to a spasm of arterioles, an increase in the tone of venous vessels (an increase in venous return and preload), an increase in the frequency and strength of heartbeats, a decrease in the excretion of sodium and water in the kidneys. Due to the fact that the hydrostatic pressure in the capillaries is reduced to a greater extent than in the interstitium, from the first hour to 40 hours after the blood loss, the intercellular fluid is slowly transferred to the vascular bed (transcapillary replenishment). Reduction of blood flow in organs and tissues leads to changes in the CBS of arterial blood - an increase in the concentration of lactate and an increase in the deficiency of bases (BE). In order to maintain a normal pH under the influence of acidemia on the chemoreceptors of the respiratory center in the brain stem, minute ventilation increases, leading to a decrease in pACO2.

With blood loss more than 30% of bcc there is a decompensation, expressed in arterial hypotension, that is, a decrease in systolic blood pressure of less than 90 mm. Gt; Art. At the same time, with previous hypertension, this level can be 100 mm Hg, and with severe gestosis - even normal systolic BP. Further release of stress hormones causes glycogenolysis, lipolysis with moderate hyperglycemia and hypokalemia. Hyperventilation no longer provides a normal pH of the arterial blood, as a result of this, acidosis develops. Further decrease in tissue blood flow leads to an increase in anaerobic metabolism with an increase in lactic acid production. As a result of progressive metabolic lactic acidosis, a decrease in pH in tissues occurs and vasoconstriction is blocked. Arterioles dilate, and the blood fills the microcirculatory bed. There is worsening of CB, damage of endothelial cells with subsequent DVS-syndrome can develop.

With blood loss of more than 40% BCC and a systolic blood pressure lower than 50 mmHg due to CNS ischemia, there is an additional stimulation of the sympathetic nervous system with the formation of the so-called second plateau AD for a while. Without vigorous intensive therapy, the shock goes to an irreversible stage, characterized by widespread cell damage, PON, deterioration of myocardial contractility up to cardiac arrest. It is believed that after the rise of blood pressure and the restoration of blood flow, more severe organ damage is observed than in the period of hypotension. Due to the activation of neutrophils, their release of oxygen radicals, release of inflammatory mediators from ischemic tissues, damage to cell membranes, increased permeability of the pulmonary endothelium with possible development of ARDS, mosaic intra-lobular liver damage with an immediate increase in the level of transaminases in plasma. Possible spasm of arteriolar-producing renal glomeruli with the development of acute tubular necrosis and arthritis. The supply of energy substrates to the heart and brain can be disrupted due to a decrease in the release of glucose by the liver, a violation of hepatic ketone production and inhibition of peripheral lipolysis.

Symptoms Obstetric bleeding

Symptoms of obstetric hemorrhages

Signs of hypovolemic shock outside pregnancy are manifested when blood loss is 15-20% BCC. Practical application of the scheme of severity of hypovolemic shock during pregnancy and in the early postpartum period can be difficult, as patients due to increased bcc and CB, young age and good physical form are able to withstand significant blood loss with minimal changes in hemodynamics to a very late stage. Therefore, in addition to accounting for lost blood, indirect signs of hypovolemia play a special role.

The main sign of a decrease in peripheral blood flow is a capillary filling test, or a "white spot" symptom. Perform it by pressing the nail bed, raising the thumb or other part of the body for 3 seconds before the appearance of white staining, indicating the termination of capillary blood flow. After the end of the pressure, the pink color should be restored in less than 2 seconds. The increase in the recovery time of the pink color of the nail bed is noted for more than 2 seconds if microcirculation is disturbed.

Decrease in pulse pressure is an earlier sign of hypovolemia than systolic and diastolic blood pressure, assessed separately.

Shock index - the ratio of heart rate to the value of systolic blood pressure. The normal values are 0.5-0.7.

Values of hemoglobin concentration and hematocrit are often used to determine the magnitude of blood loss. A marked decrease in the concentration of hemoglobin and hematocrit means a lot of blood loss and requires immediate action to find the source and stop bleeding. After bleeding in a volume of 1000 ml, or 15% of bcc, or 1.5% of body weight, there is no significant fluctuation, for at least 4 hours. For the subsequent changes in hemoglobin and hematocrit, it takes up to 48 hours. Intravenous infusion may lead to an earlier decrease in the concentration of hemoglobin and hematocrit.

Decreased diuresis with hypovolemia often precedes other signs of circulatory disorders. Adequate diuresis in a patient who does not receive diuretics, speaks about sufficient blood flow in internal organs. To measure the tempo diuresis 30 minutes is enough.

• Insufficient diuresis (oliguria) - less than 0.5 ml / (kghh).
• Decreased diuresis - 0,5-1 ml / (kghh).
• Normal diuresis - more than 1 ml / (kghh).

Obstetric bleeding is divided into 4 classes, depending on the magnitude of blood loss. It is necessary to be oriented in clinical signs, corresponding to blood loss, for an approximate evaluation and determination of the volume of necessary infusion.

Patients with a bleeding class 1 rarely meet the deficit of BCC. When bleeding Class 2, there are often complaints of unexplained anxiety, a feeling of cold, lack of air, or poor health. The earliest symptoms are mild tachycardia and / or tachypnea.

Increasing the respiratory rate - a nonspecific response to a decrease in BCC and a relatively early sign of an easy deficit - often goes unnoticed. Patients with hemorrhage of the 2nd class have orthostatic changes in blood pressure, peripheral circulation disorders in the form of a positive capillary filling test. Another sign of bleeding of the 2nd class is a decrease in the pulse BP to 30 mm. Gt; Art. And less.

Bleeding of the 3rd class is characterized by signs of hypovolemic shock expressed by hypotension, tachycardia and tachypnea. Violations of the peripheral circulation are more pronounced. Skin can be cold and wet.

With bleeding of the 4th grade, the patients are in deep shock, there may be no pulsation in the peripheral arteries, not determined by blood pressure, oliguria or anuria. In the absence of adequate volume-substituting infusion therapy, one can expect the development of circulatory collapse and cardiac arrest.

Diagnostics Obstetric bleeding

Determination of the volume of blood loss

Various methods are used to estimate the magnitude of blood loss. The widely used visual assessment is subjective and leads to an underestimation of the average, often occurring blood loss by 30-50%. At the same time, the amount less than the average is overestimated, and a large amount of blood loss is significantly underestimated. Quantitative methods are more perfect, but they are not free of shortcomings. Using a measuring container makes it possible to take into account spilled blood, but does not allow to measure the remaining in the placenta (about 153 ml). Inaccuracy is possible when mixing blood with amniotic fluid and urine.

Gravimetric method - determination of the difference in the weight of the material before and after use. Napkins, balls and diapers should be standard size. The method is not free from error in the presence of amniotic fluid.

The most accurate acid-hematin method is the determination of the plasma volume with the help of radioactive isotopes, the use of labeled erythrocytes, but it is more complicated and requires additional equipment.

[3], [4], [5], [6]

Treatment Obstetric bleeding

Intensive care with massive obstetric hemorrhage

Massive obstetric hemorrhage is a complex problem requiring coordinated actions, which must be rapid and, if possible, simultaneous. Intensive therapy (reanimation aid) is carried out according to the ABC scheme airways (Airway), breathing (Breathing) and blood circulation (Circulation).

After assessing the patient's breathing and starting oxygen inhalation, they alert and mobilize for the upcoming joint work of obstetrician-gynecologists, midwives, operating nurses, anesthesiologists-resuscitators, anesthetists, an emergency laboratory, and a blood transfusion service. If necessary, cause a vascular surgeon and specialists in angiography.

The most important step is to ensure reliable venous access. Preferably, two peripheral catheters are used - 14G (315 ml / min) or 16G (210 ml / min). However, even a functioning 20G catheter (65 ml / min) allows further assistance to be provided. With the asleep peripheral veins, Venezuelan vision or catheterization of the central vein is indicated.

When installing a venous catheter, you need to take a sufficient amount of blood to determine the initial parameters of the coagulogram, hemoglobin concentration, hematocrit, platelet count, and compatibility tests for possible blood transfusion.

It is necessary to make a catheterization of the bladder and to provide minimal monitoring of hemodynamic parameters of ECG, pulse oximetry, noninvasive blood pressure measurement. All changes should be documented. It is necessary to consider blood loss.

Methods of obstetrical obstetrics

When the bleeding stops during pregnancy, emergency delivery and use of drugs that enhance myometrium tone are shown. If inefficiency goes to the following measures:

• selective embolization of uterine arteries (if possible),
• hemostatic suture by B-Lynch, or haemostatic "square" seam according to Cho, and / or ligation of uterine arteries,
• ligation of the main vessels (a hypogastnca),
• hysterectomy.

To stop bleeding after childbirth should be applied in the order listed:

• external massage of the uterus,
• uterotonics,
• manual examination of the uterus,
• suturing ruptures of the birth canal.

After a manual examination, it is possible to use an intrauterine balloon tamponade (tamponade test). In the absence of effect, the application of all the above operative (including angiographic) methods of stopping bleeding is indicated.

Artificial ventilation

As a testimony for ventilation, the general anesthesia usually begins when the bleeding stops operatively. In a critical situation - when ODN phenomena occur, a disturbance of consciousness is shown by mechanical ventilation.

• Application of ventilation:
• prevents aspiration in the suppression of consciousness,
• improves oxygenation,
• is a curative measure for ODN,
• contributes to the correction of metabolic acidosis,
• reduces the work of breathing, increasing oxygen consumption by 50-100% and reducing cerebral blood flow by 50%.

General anesthesia includes antacid prophylaxis (omeprazole 20 mg and metoclopramide 10 mg intravenously), preoxygenation, rapid sequential induction with pressure on the cricoid cartilage and intubation of the trachea. Anesthesia is provided with ketamine at a reduced dose of 0.5-1 mg / kg or etomidate 0.3 mg / kg, relaxation with suxamethonium chloride of 1-1.5 mg / kg followed by the use of nondepolarizing muscle relaxants. In patients with severe shock, with maximum stimulation of the sympathetic nervous system, ketamine may have a depressant effect on the myocardium. In this situation, the drug of choice is etimidate, which ensures the stability of hemodynamics. Until sufficient compensation is made for BCC, drugs that cause peripheral vasodilation should be avoided. The course of anesthesia is usually supported by the fractional administration of small doses of ketamine and narcotic analgesics.

When ventilation is performed, a patient with a shock to prevent alveolar collapse leading to ventilation-perfusion disorders and hypoxemia needs to adjust the PEER.

If regional anesthesia is initiated before massive bleeding, it can be continued until successful hemorrhage stops, hemodynamic stability. In an unstable situation, an early transition to general anesthesia is indicated.

[7], [8], [9], [10], [11]

Features of infusion therapy

With the infusion therapy, priority is to restore and maintain:

• BCC,
• sufficient oxygen transport and oxygenation of tissues,
• system of hemostasis,
• body temperature, acid-base and electrolyte balance.

When replenishing BCC, the advantages of colloids or crystalloids are not determined. Crystalloids, in comparison with colloids, more efficiently compensate extracellular water, moving at the same time by 80% in the interstitial space. Colloidal solutions retain intravascular volume and microcirculation more efficiently, increase CB, delivery of oxygen and AD with about 3 times less infusion volumes than crystalloids. All synthetic colloids in clinically valid in vitro studies act on hemostasis, causing a tendency to hypocoagulation in descending order of dextrans, hydroxyethyl starch 200 / 0.5, hydroxyethyl starch 130 / 0.42, 4% modified gelatin. Dextrans are currently not recommended for use. When replenishing the bcc against the background of hemorrhage, hydroxyethyl starch 130 / 0.42 and 4% modified gelatin are preferred.

Albumin with hemorrhagic shock has limited application, shown:

• as an additional tool in achieving a maximum dose of synthetic colloids,
• with hypoalbuminemia less than 20-25 g / l.

A rational approach is balanced therapy with crystalloids and colloids. With blood loss of up to 30% BCC (bleeding of 1st or 2nd class) and stopped bleeding, replacement with crystalloids in triplicate volume in relation to blood loss will be adequate. If bleeding continues or blood loss is 30% of BCC and more (bleeding of 3rd or 4th grade), a combination of crystalloids and colloids that have minimal effect on hemostasis is necessary. A possible option of initial compensation for BCC in bleeding of the 3rd-4th grade with a blood loss of 30-40% BCC may be infusion of 2 liters of crystalloids and 1-2 liters of colloids. To accelerate the infusion, special devices may be needed.

Initial compensation of BCC is carried out at a speed of 3 liters within 5-15 minutes under the control of ECG, blood pressure, saturation, capillary filling test, blood catarrh and diuresis. It is necessary to aim at systolic blood pressure indices over 90 mmHg or with prior hypertension more than 100 mm. Gt; Art. In conditions of a decrease in peripheral blood flow and hypotension, a noninvasive measurement of blood pressure may be inaccurate or erroneous (up to 25% of observations). The most accurate method is the invasive measurement of blood pressure, which also makes it possible to study the gases and arterial blood vessels of the arterial blood. The heart rate and blood pressure do not reflect the state of the tissue blood flow, the restoration of which is the ultimate goal of the infusion therapy. Normal parameters for pulse oximetry, capillary filling test, diuresis testify to the adequacy of the infusion therapy being performed. Deficiency of bases less than 5 mmol / l, lactate concentration less than 4 mmol / l - signs of shock, their normalization indicates the restoration of tissue perfusion. The hourly urine output less than 0.5 ml / (kghh) or less than 30 ml / h, after the initial compensation of BCC can talk about insufficient tissue flow. The concentration of sodium in the urine is less than 20 mmol / l, the ratio of osmolarity of urine / plasma of more than 2, osmolality of urine more than 500 mOsm / kg indicate a decrease in renal blood flow and prenatal renal failure. But restoration of the rate of urine output may be slower in relation to recovery of blood pressure and tissue perfusion in severe gestosis, the development of arterial hypertension. Diuresis is a relative reflection of the tissue blood flow, the assessment of the condition of which must be confirmed by other signs (capillary filling test, pulse oximetry, blood CBC).

With hemorrhagic shock or blood loss more than 40% of bcc is shown the central vein catheterization, which provides:

• additional intravenous infusion,
• control of central hemodynamics during infusion therapy. A catheter (better multi-lumen) can be inserted into one of the central veins

The method of choice is the catheterization of the internal jugular vein, but with hypovolemia, its identification may be difficult. In conditions of disruption of blood clotting, access through the cubital vein is preferred.

Negative values of CVP speak of hypovolemia. The latter is possible and with positive values of CVP, therefore, the response to the volume load, which is carried out by infusion at a rate of 10-20 ml / min for 10-15 min, is more informative. Increasing CVP more than 5 cm H2O or DZLK greater than 7 mmHg indicates heart failure or hypervolemia, a slight increase in the values of CVP, DZLK or its absence indicates hypovolemia.

With hemorrhagic shock, venous tone is increased, and the capacity of the venous bed is reduced, so replacing the loss of BCC can be a difficult task. A rapid intravenous infusion of the first 2-3 l (within 5-10 min) is considered safe. Further therapy can be done either discretely for 250-500 ml for 10-20 min with an assessment of hemodynamic parameters, or with constant monitoring of CVP. To obtain sufficient pressure to restore tissue perfusion, filling the left parts of the heart may require rather high values of CVP (10 cm of water and higher). In rare cases, while maintaining low tissue blood flow with positive values of CVP, the contractility of the left ventricle should be evaluated. In other areas of medicine, for this purpose, catheterization of the pulmonary artery, which is extremely rarely used in obstetrics and has a number of serious complications, is used as a standard technique. Alternatives are pulse-line analysis for radial artery catheterization, assessment of central hemodynamics and intrathoracic vollemic parameters in transpulmonary thermodilution (RISCO technique), transesophageal echocardiography.

To assess tissue perfusion, lactate clearance and saturation of mixed venous blood are used. The clearance of lactate requires the determination of CBS blood two or more times. If there is no decrease in lactate concentration by 50% during the first hour of intensive care, additional efforts should be made to improve systemic blood flow. Intensive therapy should be continued until the lactate is reduced to less than 2 mmol / l. In the absence of normalization of lactate concentration within 24 hours, the forecast is doubtful.

Saturation of mixed venous blood reflects the balance between oxygen delivery and consumption and correlates with cardiac index. It is necessary to strive for the values of saturation of mixed venous blood (blood saturation from the central vein) equal to 70% or more.

[12], [13], [14], [15], [16], [17], [18]

Peculiarities of therapy of cracked loss in severe gestosis

In patients with severe gestosis, during pregnancy often there is no protective increase in BCC. Antihypertensive drugs used for treatment may affect the ability to compensatory vascular spasm in the event of bleeding. Also, the likelihood of AL development during the infusion therapy is higher due to increased capillary permeability, hypoalbuminemia, and left ventricular dysfunction.

Recovery of the oxygen transport function of blood

Oxygen transport is a product of CB and oxygen content in the arterial blood. Normally oxygen transport exceeds VO2 at rest by 3-4 times. The critical level of oxygen transport is below which VO2 is not provided and tissue hypoxia occurs. The oxygen content in the arterial blood is composed of oxygen bound to hemoglobin and dissolved in the plasma. Therefore, to increase the oxygen content in the arterial blood and its transport can be:

• an increase in CB,
• an increase in the saturation of hemoglobin with oxygen,
• by increasing the concentration of hemoglobin.

Transfusion of the erythrocyte mass allows a significant increase in the oxygen content in the arterial blood, and usually it is carried out at a hemoglobin concentration of less than 60-70 g / l. Transfusion of erythrocyte mass is also indicated with blood loss of more than 40% BCC or preservation of instability of hemodynamics against the background of continuing bleeding and infusion of 2 liters of crystalloids and 1-2 l of colloids. In these situations, a reduction in hemoglobin concentration of less than 60 g / L or lower can be expected.

In a patient weighing 70 kg, a single dose of erythrocyte mass increases hemoglobin concentration by about 10 g / l, hematocrit - by 3%. To determine the required number of doses of erythrocytic mass (n) with continuing hemorrhage and hemoglobin concentration less than 60-70 g / l, an approximate calculation by the formula is convenient:

N = (100- [Hb]) / 15,

Where n is the required number of doses of erythromass, [Hb] is the concentration of hemoglobin.

For transfusion it is desirable to use a system with a leukocyte filter, which helps to reduce the likelihood of immune reactions caused by the transfusion of leukocytes.

Alternatives to Erythrocyte Mass Transfusion. As an alternative to transfusion of erythrocyte mass, the following methods are proposed: autodonorality, acute normo- and hypervolemic hemodilution.

Another possibility is intraoperative hardware blood reinfusion, which consists of collecting blood during an operation, washing out red blood cells and then transfusing the autologous red blood cell suspension. Relative contraindication for its use is the presence of amniotic fluid. For their removal, a separate operating suction is used to remove water, washing red blood cells with twice the volume of the solution, the use of a leukocyte filter for the return of erythrocytes. In contrast to amniotic fluid, the entry of fetal erythrocytes into the composition of an autologous suspension of red blood cells is possible. Therefore, in determining the Rh-positive blood factor in a newborn, the Rh-negative puerperium requires the introduction of an increased dose of human immunoglobulin, the Rhre [D] antiresus.

Maintenance of the coagulation system of blood

During the treatment of patients with bleeding, the functions of the hemostatic system most often can be violated due to:

• effects of drugs for infusion,
• coagulopathy of dilution,
• DIC-syndrome.

Coagulopathy of dilution is of clinical importance when replacing more than 100% of BCC and is manifested, first of all, by a decrease in the concentration of plasma clotting factors. In practice, it is difficult to distinguish it from DVS-syndrome, the development of which is possible:

• with placental abruption, especially in conjunction with intrauterine fetal death,
• embolism with amniotic fluid,
• hemorrhagic shock with acidosis, hypothermia.

The phase of hypocoagulation of the DIC syndrome manifests itself by a rapid decrease in the concentration of coagulation factors and the number of platelets clotting factors less than 30% of the norm, prothrombin time and APTT are increased more than 1.5 times from the baseline level. Clinically, the diagnosis is confirmed by the absence of clot formation in the bleeding blood with continued bleeding.

Initially, the state of hemostasis can be estimated with the help of Lee-White coagulation time, in which 1 ml of venous blood is placed in a small tube 8-10 mm in diameter. Every 30 seconds, the test tube should be tilted 50 °.

Determine the moment when the blood level ceases to occupy a horizontal position. It is better to sample at 37 ° C. The norm is 4-10 minutes. After the formation of the clot, one can observe its retraction or lysis. In the future, the diagnosis and treatment of DIC syndrome should be carried out with laboratory monitoring of coagulogram indices and determination of coagulation factor activity, including antithrombin III, thromboelastograms, platelet concentrations and aggregation.

Freshly frozen plasma (FFP)

Indication for transfusion FFP - substitution of plasma clotting factors in the following situations:

• prothrombin time and APTT increased more than one and a half times from the initial level with continuing bleeding,
• with bleeding of the 3 rd grade, it may be necessary to begin transfusion of the FFP until the coagulogram values are obtained.

It should be taken into account that the defrosting takes about 20 min. The initial dose is 12-15 ml / kg, or 4 pack FFP (approximately 1000 ml), repeated doses - 5-10 ml / kg. There is evidence that doses of FFP over 30 ml / kg are effective in the hypocoagulation phase of the DIC syndrome. The speed of transfusion of FFP should be at least 1000-1500 ml / h, with the stabilization of coagulation indicators, the rate is reduced to 300-500 ml / h. The purpose of the use of FFP is the normalization of prothrombin time and APTTV. It is desirable to use FFP that has undergone leukoremedia.

A cryoprecipitate containing fibrinogen and coagulation factor VIII is shown as an additional treatment for hemostasis disorders with a fibrinogen level of more than 1 g / L. The usual dose is 1-1.5 units per 10 kg of body weight (8-10 packets). The goal is to increase the concentration of fibrinogen more than 1 g / l.

Thrombose concentrate

The possibility of platelet transfusion should be considered when clinical manifestations of thrombocytopenia / thrombocytopathy (petechial rash), as well as the number of platelets:

• less than 50х10 ⁹ / l against bleeding,
• less than 20-30х10 ⁹ / l without bleeding.

One dose of thromboconcentrate increases the content of platelets by approximately 5x10 ⁹ / l. Usually apply 1 unit per 10 kilograms of body weight (5-8 packets).

Antifibrinolytics

Tranexamic acid and aprotinin inhibit plasminogen activation and plasmin activity. Indication for the use of antifibrinolytic agents is a pathological primary activation of fibrinolysis. To diagnose this condition, a test for lysis of the euglobulin clot with activation of streptokinase or a 30-minute lysis with thromboelastography is used.

[19], [20], [21], [22], [23]

Antithrombin III Concentrate

With a decrease in antithrombin III activity of less than 70%, restoration of the anti-inverting system by transfusion of FFP or an antithrombin III concentrate is indicated. Its activity should be maintained at 80-100%.

The recombinant factor VIla was developed to treat bleeding in patients with hemophilia A and B. However, as an empirical hemostat, the drug was effectively used in various conditions associated with severe, uncontrolled bleeding. Due to the insufficient number of observations, the role of the recombinant factor VIla in the treatment of obstetric hemorrhages has not been finally determined. The drug can be used after standard surgical and medicamentous means of stopping bleeding. Conditions of use:

• the concentration of hemoglobin is more than 70 g / l, fibrinogen is more than 1 g / l, the number of platelets is more than 50х10 ⁹ / l,
• pH - more than 7.2 (correction of acidosis),
• Warming up the patient (preferably, but not necessarily).

Possible application protocol:

• the initial dose is 40-60 μg / kg intravenously,
• with the continuation of bleeding, repeated doses of 40-60 μg / kg 3-4 times through 15-30 minutes,
• when the dose reaches 200 mcg / kg and there is no effect, check the conditions for use and make a correction, if necessary,
• only after the correction, the following dose (100 μg / kg) can be administered.

Maintenance of temperature, acid-base and electrolyte balance

Each patient with hemorrhagic shock should measure the central temperature with an esophageal or pharyngeal sensor. At a central temperature of 34 ° C, atrial rhythm disturbances, including atrial fibrillation, are possible, and at 32 ° C the probability of FH appears. Hypothermia disrupts platelet function and reduces the rate of response of the blood clotting cascade by 10% for every 1 ° C decrease in body temperature. In addition, there is a worsening of the state of the cardiovascular system, oxygen transport (displacement of the curve of dissociation of oxyhemoglobin to the left), elimination of medicines by the liver. Therefore, it is extremely important to warm both intravenous solutions and the patient. The central temperature should be maintained at a level of more than 35 ° C.

With the transfusion of erythromass, the supply of extracellular potassium may be associated. Also, the low pH of canned red blood cells can aggravate metabolic acidosis. The consequences of acidemia include displacement of the curve of dissociation of oxyhemoglobin to the right, a decrease in the sensitivity of adrenoreceptors, an additional violation of blood coagulation. Usually correction of acidosis occurs with improvement of perfusion of organs and tissues. Nevertheless, severe acidosis with a pH of less than 7.2 can be corrected with sodium bicarbonate.

With massive transfusion with plasma and erythromass, a significant amount of citrate is received, which absorbs ionized calcium. Prevention of transient hypocalcemia should be performed by intravenous injection of 5 ml of calcium gluconate after each packet of FFP or erythrocyte mass.

With intensive care, hypercapnia, hypokalemia, fluid overload and excessive correction of acidosis of sodium with hydrocarbonate should be avoided.

Position of the operating table

With hemorrhagic shock, the horizontal position of the table is optimal. The reverse Trendelenburg position is dangerous due to the possibility of an orthostatic reaction and a decrease in the MK, while in the Trendelenburg position the increase in SW is short-lived and is replaced by its decrease due to an increase in afterload.

Adrenomimetics

Adrenomimetics are used for shock, bleeding during the action of regional anesthesia and sympathetic blockade, when time is needed to install additional intravenous lines, with hypodynamic hypovolemic shock.

The humoral factors released during tissue ischemia can have a negative inotropic effect in severe shock. The condition for the use of adrenomimetics in hypodynamic shock is an adequate replacement for bcc.

In parallel with replenishment of BCC, intravenous administration of ephedrine 5-50 mg, if necessary, again. It is also possible to use 50-200 μg phenylephrine, 10-100 μg adrenaline. Titration effect of adrenomimetics is better by intravenous infusion of dopamine - 2-10 μg / (kghmin) or more, dobutamine - 2-10 μg / (kghmin), phenylephrine - 1-5 μg / (kghmin), epinephrine - 1-8 μg / ( kgmmin). The use of drugs carries the risk of aggravation of vascular spasm and ischemia of organs, but may be justified in a critical situation.

[24], [25], [26]

Diuretics

Loop or osmotic diuretics should not be used in an acute period during intensive care. Increased urination caused by their use, will reduce the value of monitoring diuresis when replenishing the BCC. Moreover, stimulation of diuresis increases the likelihood of developing arterial hypertension. For the same reason, the use of glucose-containing solutions is undesirable, since appreciable hyperglycemia can subsequently cause osmotic diuresis. Furosemide (5-10 mg intravenously) is indicated only to accelerate the onset of fluid mobilization from the intercellular space, which should occur approximately 24 hours after bleeding and surgery.

[27]

Postoperative therapy of obstetric hemorrhages

After stopping bleeding, intensive therapy is continued until adequate tissue perfusion is restored. Goals of the therapy:

• maintenance of systolic blood pressure more than 100 mm Hg (with previous hypertension more than 110 mm Hg),
• maintaining the concentration of hemoglobin and hematocrit at a level sufficient for transport of oxygen,
• normalization of hemostasis, electrolyte balance, body temperature (more than 36 ° C),
• diuresis more than 1 ml / (kghh),
• increase in CB,
• reverse the development of acidosis, reduce the concentration of lactate to normal.

Prophylaxis, diagnosis and treatment of possible manifestations of PNS are carried out.

Criteria for cessation of ventilation and transfer of the patient to independent breathing:

• resolved the problem that caused the ventilation (bleeding stopped and restored blood flow in tissues and organs),
• oxygenation is adequate (p O2 is more than 300 for PEEP 5 cm H2O and FiO2 0.3-0.4),
• hemodynamics is stable, there is no arterial hypotension, infusion of adrenomimetics is discontinued,
• patient in consciousness, performs commands, discontinued sedation,
• restored muscle tone,
• there is an inspiration attempt.

Extubation of the trachea is performed after observing the adequacy of self-breathing of the patient for 30-120 minutes.

With further improvement of the condition to the moderate, the adequacy of BCC supplementation can be checked using an orthostatic test. The patient calmly lies for 2-3 minutes, then the indicators of blood pressure and heart rate are noted. The patient is offered to get up (the option with getting up is more accurate than sitting on the bed). When symptoms of cerebral hypoperfusion, te vertigo or pre-occlusive condition appear, stop the test and put the patient. If these symptoms are not present, a minute later, the indicators of blood pressure and heart rate. The test is considered positive with an increase in heart rate of more than 30 or the presence of symptoms of cerebral hypoperfusion. Because of significant variability, changes in blood pressure are not taken into account. Orthostatic test allows to reveal the deficit of BCC 15-20%. It is unnecessary and dangerous for hypotension in the horizontal position or signs of shock.