• Evaluation of clinical efficiency of immediate methods of administry of radiation by platcent pathology

Evaluation of clinical efficiency of immediate methods of administry of radiation by platcent pathology

HEALTH OF WOMAN. 2018.9(135):88–94; doi 10.15574/HW.2018.135.88
Golyanovsky O. V., Ivankova I. M., Khimenko M. V.
Shupyk National Medical Academy of Postgraduate Education, Kiev

The frequency of delivery by caesarean section increases in all countries of the world. At the same time, the frequency of cardiovascular diseases grows, performed in the lower segment of the uterus, and the placenta praevia frequency in the lower segment of the uterus increases. Placenta pathology (placenta previa / placenta accreta / increta / percreta) is one of the main causes of massive bleeding that are dangerous for life (45%). In case of development of obstetric blood loss exceeding 1.5% of the body weight, surgical stopping of bleeding is necessary (Order of the Ministry of Health of Ukraine No. 205).The most common treatment for such bleeding is to conduct a hysterectomy without uterine appendages. There is an urgent need to improve the methods of stopping bleeding in CR in cases of placenta prevailing and true placenta increment by preserving the reproductive organ, preventing the development of MOB, reducing intraoperative blood loss.

The objective: to assess the clinical effectiveness of improved methods of abdominal delivery on the pathology of placentation.

Materials and methods. The object of the study was women of reproductive age with a cesarean section in history and placenta previa.As part of a prospective study, 157 pregnant women were examined and delivered by re-caesarean section, which were divided into 2 groups. In the I group (main group) there were 107 pregnant women with pathology of the placentation (hereinafter, the main group of pregnant women was divided into two subgroups: 57 pregnant women were included in the Ia group, who showed signs of abnormally invasive placenta (AIP) against the background of placental presentation and I and B group – pregnant women with a scar on the uterus, placenta previa without signs of true placenta increment (AIP or pl. accret / increta / per); and in group II (control), 50 pregnant women with a scar on the uterus without signs of abnormally invasive placenta (AIP) were made.and in group II (control), 50 pregnant women with a scar on the uterus without signs of abnormally invasive placenta (AIP) were made. Our task was to develop an algorithm for delivery of pregnant women with placental pathology and to assess the effectiveness of abdominal delivery, which we suggested in the first subgroup of women with AIP and to compare how the main indicators differed, primarily the amount of blood loss,and other complications compared with the IB subgroup without AIP and with the control group (group II), in which women had no placentation pathology, but in which there was a scar on the uterus after the previous cesarean section.

Results. A planned CR in the main group (in the absence of bleeding and other urgent indications) was performed in the period of 37–38 weeks of pregnancy in 86 pregnant women of the main group (80.4%) and in 43 pregnant women of the control group (86.0%) – p>0.05. But a significant significant difference in the planned CR was between the Ia and Ib subgroups – 79.0% and 62.0%, respectively (p<0.05).With regard to the volume of surgical intervention when performing CR, a high percentage of surgical interventions performed in case of placentation pathology was noted in 90 pregnant women (84.1%). The number of radical surgical interventions with expansion of the operation volume in the main group was performed significantly more, which is primarily due to a significant amount of AIP with deep invasion of the placenta into the myometrium – pl. increta / percreta – 25 women (23.4%). It should be noted that in 32 cases of AIP (pregnant Ia subgroups), diagnosed with prenatally partial pl. ascreta and in 10 – with pl. increta, organ-sparing operations were carried out according to the method developed by us with the use of benthic and corporeal KR and drug prevention (carbetocin, tranexamic acid) and technical support (tissue APC).A total of 42 organ-preserving operations were performed in pregnant women of the Ia subgroup according to AIP, which accounted for 73.7% of the total number of pregnant women with a true increment of the placenta. In all cases of AIP (Ia subgroup) – 57 cases (53.3% of the main group) and 12 pregnant women (11.2%) with a complete prevalence of the placenta, a lower-middle or middle laparotomy was performed due to the possible need for expansion of the surgical volume interventions. In all other cases (38 – 35.5%), that is, in the absence of a true increment of the placenta, a Joel-Cohen or Pfannenshtiel laparotomy was performed; as well as in 48 (96.0%) cases of CR in the control group. The difference in study groups is significant (p<0.01).

Conclusion. The analysis of the effectiveness of the use of improved methods of caesarean section in pregnant women with pathology of placentation (organ preserving technique CR, bottom CR), including ligation of the main vessels of the uterus, the integrated use of technical support (PX-scalpel and APC tissue) and drug support (carbetocin and TC), allows in most cases, to preserve the uterus, reliably reduces the average amount of intraoperative blood loss, the number of massive obstetric bleeding (MOB),the intensity of postoperative pain, improves the quality of postoperative pain, reduces the length of stay of women in the obstetric hospital.

Key words: cesarean section, obstetric hemorrhage, abnormally invasive placenta.

REFERENCES

1. Sidelnikova VM. (2009). Aktualnyie problemyi nevyinashivaniya beremennosti: tsikl klinicheskih lektsii. М:138.

2. Fleіshman AN. (2012). Medlennyie kolebaniya gemodinamiki. Teoriya, prakticheskoe primenenie v klinicheskoi meditsine i profilaktike. Novosibirsk:222.

3. Heller DS. (2013). Placenta Accreta and Percreta. Surgical Pathology 6:181–197. https://doi.org/10.1016/j.path.2012.10.003; PMid:26838709

4. Khan RU, El-Refaey H. (2015). Pathophysiology of postpartum hemorrhage and third stage of labor. A textbook of postpartum hemorrhage. SapiensPublishing:156.

5. Clark SL, Koonings PP, Phelan JP. (1985). Placenta previa/accreta and prior cesarean section. Obstet. Gynecol. 66;1:89–92. PMid:4011075

6. Frolova OG, Tokova ZZ, Volgina VF. (2006). Mediko-sotsialnyie aspektyi nevyinashivaniya beremennosti. Akusherstvo i ginekologiya 4:7–11.

7. Shunji S, Sachi T, Shutaro Y, Gen I, Tomoko O. (2014). Fetal Circulatory Responses to Maternal Blood Loss. Gynecologic and Obstetric Investigation. 51;3:157–159.

8. Mehasseb MK, Konje JC. (2015). Placental abnormalities. A textbook for postpartum hemorrhage. – Sapience publishing:800.

9. Wladimiroff JW. (2013). Cerebral and umbilical arterial blood flow velocity waveforms in normal and growth-retarded pregnancies. Obstet. Gynec. 69;5:705–709.

10. Milovanov AP, Dimova EA. (2011). Spornyie voprosyi patogeneza vrastaniya v stenku matki. Arhiv patologii 73;2:54–57.

11. Golianovskyi OV, Kaminskyy̆ VV. (2010). Masyvni akusherski krovotechi. K, «Triumf»:232.

12. Saveleva GM, Suhih GT, Manuhina IB. (2013). Ginekologiya: natsionalnoe rukovodstvo. Kratk. izd. M, GEOTAR-Media:704.

13. Ajlamazian EK. (2007). Neotlozhnaya pomosch pri ekstremalnyih sostoyaniyah v akusherskoi praktike: rukovodstvo. SPb, SpetsLit:400.

14. Radzinskiy VE. (2011). Akusherskaya agressiya. M, Status Praesens:688.