#1
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âíóòðèáðþøíîå êðîâîòå÷åíèå âî âðåìÿ áåðåìåííîñòè
Áåðåìåííîñòü II 34-35 íåäåëè. Âàðèêîçíàÿ áîëåçíü âåí í/ê.  àíàìíåçå 2004ã ñðî÷íûå ðîäû á/î. Àíàìíåç ãèíåêîëîãè÷åñêèé íå îòÿãîùåí.
Ïîñòóïèëà ñ ïîäîçðåíèåì íà îòñëîéêó ïëàöåíòû: ïîÿâèëèñü áîëè â íèæíèõ îòäåëàõ æèâîòà, ñëàáîñòü, ñíèæåíèå äâèãàòåëüíîé àêòèâíîñòè ïëîäà. Ïðè îáñëåäîâàíèè ïàòîëîãèè íå âûÿâëåíî (ëàáîðàòîðíî), äàííûõ çà îòñëîéêó íåò. Ãåìîäèíàìèêà ñòàáèëüíàÿ. Ñîñòîÿíèå ïëîäà (ÓÇÈ) óäîâëåòâîðèòåëüíîå.Çà âðåìÿ íàáëþäåíèÿ îòìå÷àåòñÿ óñèëåíèå áîëåâîãî ñèíäðîìà, âûíóæäåííîå ïîëîæåíèå: íà ëåâîì áîêó ñ ïðèâåäåííûìè ê æèâîòó êîëåíÿìè. Ïðè ïîâòîðíîé ÄÌ- ÃÄÍ II, ÊÒà â äèíàìèêå: ñíèæåíèå STV äî 3, ÀÄ 80/50, ïîÿâèëàñü òàõèêàðäèÿ 96, â ñâÿçè ñ ÷åì ðåøåíî ðîäîðàçðåøèòü ÊÑ. Èíòðàîïåðàöèîííî: â áðþøíîé ïîëîñòè 1000 êðîâè ñî ñãóñòêàìè, êåñàðåâî á/î. Ïðè ðåâèçèè:èñòî÷íèê êðîâîòå÷åíèÿ-ëåâûé ìàòî÷íûé ñîñóäèñòûé ïó÷îê(âåòêà ìàòî÷íîé àðòåðèè). Äåôåêò çàäíåãî ëèñòêà øèðîêîé ñâÿçêè ìàòêè îò 5 ñì íàä âíóòðåííèì çåâîì è óõîäèò â äóãëàñ, ìíîãî êðîâîèçëèÿíèé, òêàíü ðûõëàÿ, äèôôóçíî êðîâèò, ó íèæíåãî êðàÿ äåôåêòà ïîäïàÿí ñàëüíèê. Âûïîëíåíà ÍÀÌ, äðåíèðîâàíèå Ãèñòîëîãèÿ á/î. Ðåáåíîê èçâëå÷åí ÷åðåç 38 ìèí ïîñëå ïîÿâëåíèÿ ïðèçíàêîâ â/óòðîáíîãî ñòðàäàíèÿ-1-5-6-7 áàëëîâ, 2640, íà ÈÂË. Çà 10 äíåé ìíîãî âñåãî ïåðåäóìàëà, â ëèòåðàòóðå òîëüêî êðîõè (ïîäåëèëñÿ èíôîðìàöèåé ïàòàíàòîì), ïîÿâèëèñü íåêîòîðûå ñîîáðàæåíèÿ ïî ýòîìó ïîâîäó...íî íå î÷åíü â íèõ óâåðåíà. Î÷åíü íàäåþñü, êîëëåãè, íà âàøó ïîìîùü. Ê òîìó æå, äóìàþ, ÷òî âñåì ïðàêòèêóþùèì àêóøåðàì ýòîò ñëó÷àé áóäåò î÷åíü èíòåðåñåí. Ïèøó êðàòêî, îòâå÷ó íà âñå âîïðîñû. Çàðàíåå áëàãîäàðþ. |
#2
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Êàêîé âîçðàñò ïàöèåíòêè ? Äàííûå óçè äî ýòîãî ñðîêà ãåñòàöèè?
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#3
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Íîãàìè íå ïèíàëè â æèâîò?
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#4
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Æåíùèíå 30 ëåò.Ãèíåêîëîãè÷åñêèé àíåìíåç íå îòÿãîùåí, ìåíñòðóàöèè ðåãóëÿðíûå, ÷åðåç 28 ïî 4-5 äíåé, áåçáîëåçíåííûå.
Áîëåâîé ñèíäðîì âîçíèê íà ôîíå õîðîøåãî ñàìî÷óâñòâèÿ, òðàâì íå áûëî. ÓÇÈ â ñðîêàõ 12-13 íåäåëü, 22 íåäåëè, ïàòîëîãèè íå âûÿâëåíî, ïëîä ñîîòâåòñòâóåò ãåñòàöèîííîìó ñðîêó. Ñàìîå èíòåðåñíîå, ÷òî áûëà îñìîòðåíà õèðóðãîì áóêâàëüíî ïåðåä ðîäîðàçðåøåíèåì, äîêòîð õèðóðãè÷åñêîé ïàòîëîãèè íå âûÿâèë. Íî, íà ëàïàðîòîìèþ ïîøëè âìåñòå. Ïåðâàÿ ìûñëü, ÷òî ýòî ñåëåçåíêà. Íî îòñëîéêó áûëî íåëüçÿ ïîëíîñòüþ èñêëþ÷èòü, ïîýòîìó ïåðâûì äåëîì îñìîòðåëè ìàòêó... |
#5
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Èíòåðåñíûé ñëó÷àé. Î÷åíü ïîõîæå íà ðàçðûâ ìàòêè ïî ðóáöó, íî ãèñòîëîãèÿ õîòü ÷òî-òî ïîêàçàëà áû.
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#6
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Spontaneous haemoperitoneum during the 3rd trimester of pregnancy resulting from tear or rupture of a uterine or ovarian vessel is a rare yet catastrophic event. Hodgkinson and Christensen in 1950 reported an overall mortality rate of 49%.[3] These figures reflect the difficulties faced by the obstetricians prior to the modern resuscitative, anaesthetic and operative technique. Ever since there has been a fall in the maternal mortality rate to 3.6%.[4]
Aetiology of the condition is unknown though at times arteriovenous malformation or uterine artery aneurysm may be present. The congenital malformation, arterial degeneration and inflammatory process are causes of aneurysm, which can be aggravated by haemodynamic stress of pregnancy and labour. Presenting symptoms seen are of sudden onset of abdominal pain without vaginal bleeding associated with signs of acute abdomen and hypovolaemia. Foetal distress is a rare finding.[1] An accurate diagnosis is rarely made prior to laparotomy because of a host of other surgical and obstetrical conditions that can present with a similar clinical picture. Differential diagnosis includes -Abruptio placentae -Rupture uterus -Abdominal pregnancy -Perforated appendicitis -Rupture of splenic/hepatic artery aneurysms. Placental abruption is the most common differential diagnosis for rupture of the utero-ovarian vessels. The diagnosis of which is aided by establishing the presence of haemoperitoneum in case of a vessel rupture. Active preoperative resuscitation is crucial. Exploratory laparotomy and control of haemorrhage is the only option. Caesarean is often needed in order to locate the site of the haemorrhage. If the source of bleeding is not identified then other causes of haemoperitoneum should be ruled out and managed accordingly. Obstetricians should be aware of this rare aetiology of shock, which can present either antenatal or in labour. REFERENCES 1.Steinberg LH, Goodfellow C, Rankin L. Spontaneous rupture of uterine artery in pregnancy. British Journal of Obstetrics and Gynecology Feb. 1993; 100 : 184. |
#7
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Âû ïèøåòå, ÷òî ó æåíùèíû âàðèêîçíàÿ áîëåçíü íèæíèõ êîíå÷íîñòåé.  çàêëþ÷åíèÿõ óçè íå óêàçûâàåòñÿ íà âàðèêîçíîå ðàñøèðåíèå âåí ìàëîãî òàçà?
Ïî÷åìó áûëà ñäåëàíà àìïóòàöèÿ, à íå ýêñòèðïàöèÿ? |
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#8
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Ïðè ïîñòóïëåíèè äåëàåòñÿ óçè è íå âèäíî ãåìàòîìû?????
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#9
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Íåò,â çàêëþ÷åíèÿõ ÓÇè òàêèõ äàííûõ íå áûëî, õîòÿ âèçóàëüíî ðàñøèðåíèå âåí â ìàëîì òàçó èìååòñÿ, íî â ïðåäåëàõ ðàçóìíîãî. À íàñ÷åò îáúåìà îïåðàöèè: ãåìîñòàç áûë äîñòèãíóò, ïóñòü è ñ íåêîòîðûìè òðóäíîñòÿìè, ïðîøèâàíèåì ñîñóäèñòîãî ïó÷êà.
Íî êîëëåãèàëüíî ðåøèëè, ÷òî íåëüçÿ èñêëþ÷èòü òðîôîáëàñòè÷åñêóþ áîëåçíü è íóæíà ãèñòîëîãèÿ. Ýòî(ÍÀÌ) áûë ìåíåå òðàâìàòè÷íûé âàðèàíò äëÿ ìîëîäîé æåíùèíû. Ãèñòîëîãè÷åñêîå èññëåäîâàíèå ïðîâåäåíî ïðèöåëüíî( ñ ïàòàíàòîìîì ðàáîòàåì â î÷åíü òåñíîì êîíòàêòå ñ îöåíêîé êëèíèêè), ìåæäó ëèãàòóð: ïàòîëîãèè ñîñóäîâ íåò, äàæå íè÷åãî íå íàòÿíóòü |
#10
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"Äåôåêò çàäíåãî ëèñòêà øèðîêîé ñâÿçêè ìàòêè îò 5 ñì íàä âíóòðåííèì çåâîì è óõîäèò â äóãëàñ" - ýòî òðàâìà. Âåðîÿòíî ÷åðåç âëàãàëèùå â çåðêàëàõ ñìîòðåëè? ìîãóò áûòü êðîâîèçëèÿíèÿ íà çàäíåì ñâîäå. Íó èëè ÷åðåç ïðÿìóþ êèøêó.
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#11
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òðàâìà èñêëþ÷åíà, îñìîòðîâ íå áûëî
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#12
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Æåíùèíà íåêîòîðûå îáñòîÿòåëüñòâà ìîæåò ñêðûâàòü.
Ëèáî ýòî êàêàÿ òî ïàòîëîãèÿ ñîåäèíèòåëüíîé òêàíè? òîãäà äîëæíû áûòü ñòèãìû - îïóùåíèå ïî÷åê, ïðèðîùåííàÿ ìî÷êà óõà, äîïîëíèòåëüíàÿ õîðäà, õîíäðîïàòèÿ ëþáàÿ è ò.ä. Ìåõàíèçì âîçíèêíîâåíèÿ äåôåêòà íà ìÿãêîé ñêëàäêå áðþøèíû (êàêîé ÿâëÿåòñÿ øèðîêàÿ ñâÿçêà) êðîìå, êàê òðàâìîé îáúÿñíèòü î÷åíü ñëîæíî, äà åù¸ ïîÿâëåíèå äåôåêòà íà ìàòî÷íîé àðòåðèè êðîâîòå÷åíèå âåäü èç íå¸? àíåâðèçìà? ýòîæ íàäî êàê ñîâïàëî òî. "Ïðè ïîñòóïëåíèè äåëàåòñÿ óçè è íå âèäíî ãåìàòîìû?????" åù¸ è õèðóðã îñòðûé æèâîò èñêëþ÷èë. Òàêèå äåëà, íî âû â ýòîì íå îäèíîêè ìû â íåðàáî÷åå âðåìÿ âîîáùå ÓÇÈ ñäåëàòü íå ìîæåì. |
#13
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ß îñòàíîâèëàñü íà òîì, ÷òî ýòî ðàçðûâ øèðîêîé ñâÿçêè ìàòêè ( â ãèíåêîëîãèè ñ-ì Àëëåíà-ìàñòåðñà).  ìîíîãðàôèè Òèìîôååâà "ïàòîëîãèÿ ëå÷åíèÿ" åñòü óïîìèíàíèå î ñëó÷àÿõ ðàçðûâà øèðîêîé ñâÿçêè âî âðåìÿ ôèçèîëîãè÷åñêè ïðîòåêàþùåé áåðåìåííîñòè. Äðóãèì îáúÿñíèòü íåâîçìîæíî...
À ãåìàòîìû,êàê òàêîâîé , êëàññè÷åñêè íå áûëî-ïðîñòî êðîâîèçëèÿíèÿ è ïîâðåæäåííàÿ òêàíü ñâÿçêè, êðîâü ñâîáîäíî âûõîäèëà â áðþøíóþ ïîëîñòü. Êñòàòè, áûëî ÓÇÈ ÎÁÏ äî îïåðàöèè-áåç ïàòîëîãèè, æèäêîñòè â áðþøíîé ïîëîñòè íåò... À âû ãîâîðèòå, êàê ìîæíî íå óâèäåòü ãåìàòîìó... |
#14
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"Ëèáî ýòî êàêàÿ òî ïàòîëîãèÿ ñîåäèíèòåëüíîé òêàíè? òîãäà äîëæíû áûòü ñòèãìû - îïóùåíèå ïî÷åê, ïðèðîùåííàÿ ìî÷êà óõà, äîïîëíèòåëüíàÿ õîðäà, õîíäðîïàòèÿ ëþáàÿ è ò.ä." Áðåä êàêîé-òî....
Ñòîèò, íàâåðíîå, ïðîñìîòðåòü: Acta Obstet Gynecol Scand. 2010 Oct;89(10):1368-9. Spontaneous rupture of broad ligament and uterine vessels during pregnancy. Huisman CM, Boers KE. J Obstet Gynaecol. 2005 Jul;25(5):511-2. Spontaneous uterine artery rupture: a rare cause of abdominal pain in pregnancy. O'Connell MP, Prendiville W. Department of Obstetrics and Gynaecology, Coombe Women's Hospital, Dolphin's Barn, Dublin 8, Republic of Ireland. |
#15
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Ìá ñòîèëî îãðàíè÷èòüñÿ óøèâàíèåì äåôåêòà øèðîêîé ñâÿçêè ? ê òîìó æå ðàñïîëîæåííîãî íà óðîâíå âíóòðåííåãî çåâà , åñëè áûëà èìáèáèöèÿ òêàíåé íà óðîâíå êðåñòöîâîìàòî÷íûõ ñâÿçîê ñòðàííî , ÷òî ïîñëå âûïîëíåíèÿ íàì êðîâîòå÷åíèå âîîáùå óäàëîñü îñòàíîâèòü.
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