ECTOPIC PREGNANCY. An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes. Risk factors include previous pelvic inflammatory disease or use of an intrauterine device. Clinical presentation includes amenorrhea, abdominal pain, and vaginal bleeding. Diagnosis is made through pregnancy tests, ultrasound, and clinical examination. Treatment options include surgery such as salpingectomy or salpingotomy. Conservative treatment with methotrexate may also be used. Complications can include hemorrhage and shock.

1. OBSTETRIC BLEEDING.
ECTOPIC PREGNANCY.
BLEEDING OCUURS DURING
PREGNANCY, LABOUR,
PUERPERIUM.
TRANSFUSION AND SHOCK

2. The most common reasons of
significant bleeding in early
pregnancy are :
-Cervical erosions
-Cervical polyps
-Invasive cervical carcinoma
-Traumatic lesions of the vagina and cervix
-Ectopic pregnancy: tubal , abdominal, ovarian,
cervical pregnancy
-Spontaneous Abortion
-Hydatidiform mole

3. ECTOPIC PREGNANCY
 E P - any pregnancy occurring outside the uterine
cavity.
 E P – predisposing factors: previous history of pelvic
inflammatory disease, subfertility, presence of intra-
uterine device
 E P- classification
-Unruptured ; -Interrupting
-Tubal abortion; - uterine tube rupture

4. ECTOPIC PREGNANCY

5. Sponsored
Medical Lecture Notes – All Subjects
USMLE Exam (America) – Practice

6. ECTOPIC PREGNANCY
 TUBAL
 ABDOMINAL
 OVARIAN
 CERVICAL
 TUBAL
 ABDOMINAL
 OVARIAN
 CERVICAL

7. ECTOPIC PREGNANCY.

8. ECTOPIC PREGNANCY. CLINICAL
PRESENTATION.
 Amenorrhoea
 Low abdominal pain
 Uterine bleeding
The abdominal pain precedes the onset of vaginal
bleeding, rapidly becomes generalized as blood loss
extends into peritoneal cavity.
Subdiaphragmatic irritation by blood gives the shoulder
tip pain.
Shocked woman with hypotension, tachycardia and
signs of peritonism, abdominal distension, rebound
tenderness.
Anaemia

9. DIAGNOSIS OF ECTOPIC
PREGNANCY

10. ECTOPIC PREGNANCY.
DIAGNOSIS.
 POSITIVE PREGNANCY TEST
 ULTRASOUND SCAN OF THE PELVIS
 CLINICAL EXAMINATION
 PUNCTION OF THE POSTERIOR FORNIX (needle
aspiration of Douglas)
 CURETAGE FOR HISTOPATHOLOGY (decidual reaction)
Diagnosis of acute EP rarely presents a problem: urgent cross-
matching, laparotomy, removal of the damaged tube .
Diagnosis of tubal pr. In the subacute phase more difficult

11. ECTOPIC PREGNANCY.

12. ECTOPIC PREGNANCY.

13. SURGICALLY TREATMENT OF
ECTOPIC PREGNANCY
 Saipingectomy – if the tube is badly damaged
 Salpingotomy – the conservative operation – the
removing the pregnance and reconstitution the tube
 Tubal compression (EP occurs in the fimbrial end)
 Laparoscopy
 Laparothomy
 Hysterectomy with adequate haemostasis (cervical
pregnancy)

14. SURGICALLY TREATMENT OF
ECTOPIC PREGNANCY

15. CONSERVATIVE THERAPY EP
 METHOTRECSATIS 75-100 mg. i/m under the
control β-Hhg and USA
Differential diagnosis
• Early pregnancy
• Incomplete abortion
• Acute salpingitis
• Appendicitis, pelvic peritonitis
• Rupture of an ovarian cyst

16. Cervical pregnancy
 Differential diagnosis with
With cervical stage of
Spontaneous abortion.
 In 50% cases it is
necessary to do
hysterectomy with
adequate haemostasis

17. Late-pregnancy Bleeding
Late-pregnancy bleeding occurs in 2% to 3% of patients.
The most common source of significant bleeding is :
 Placenta previa
 Premature separation of the normally implanted
placenta.
 Invasive cervical carcinoma
 Lacerations of vaginal septa (during delivery)
 Preterm Labor

18. PLACENTA PREVIA
The term placenta previa describes the condition
in which the placenta is implanted in the lower
pole of the uterus; usually a portion of the
placenta precedes the presenting part of the
fetus.
ETIOLOGY:
 early or late fertilization,
 the receptivity and no adequacy of the endometrium,
 multiple pregnancy,
 scar from a uterine incision after operations.

19. Placenta previa. Classification.
Total placenta previa - the entire internal
cervical os is covered by placenta.
Partial placenta previa - only a portion of
the os is covered by placenta.
Low-lying placenta or a low implantation -if
the placenta is implanted near the internal
cervical os

20. Placenta previa.
Classification.

21. Clinical Course of PLACENTA
PREVIA
Painless bleeding is the hallmark of placenta
previa.
During late pregnancy the lower pole of the uterus
becomes somewhat thinner, and the softening cervix
begins to dilate, some separation at the placental
margin results, and maternal bleeding occurs from the
intervillous space.
The patient experiences no pain and the uterus remains
soft.
The bleeding may occur while the patient is resting in bed
or during any type of activity. The blood is bright.
Preterm delivery is the greatest threat to the infant.

22. Painless bleeding in the third
trimester of pregnancy,
regardless of whether it is
heavy or minimal, must be
considered to be due to
placenta previa until this
complication is ruled out.

23. Indirect Methods of Diagnosis PP
Indirect methods of diagnosis are applicable if
the initial hemorrhage has stopped.
Prolonged observation in the hospital will be
needed.
The most helpful and commonly used method
of placental localization is ultrasound.
If placenta previa is diagnosed , a plan of
management can be formulated.

24. Definitive Diagnosis PP
The definitive antepartum diagnosis of
placenta previa is made by palpation
of the placenta on vaginal
examination.
It is to be performed only if preparations
for immediate cesarean section, have
been made (in operation room).

25. Management (PP)
 the patient should be placed at bedrest in an area
of high-intensity care ( the labor-delivery suite);
 an intravenous catheter should be inserted;
 blood drawn for typing, cross- matching, and
haemogram;
 infusion fluids started;
 the history of previous bleeding, and the past
obstetric and medical history should be obtained;
 physical examination should be complete (On
examination of the abdomen the uterus is usually found to be
soft, normal in tone, and nontender. The fundus is usually
higher than expected, since the presenting part is held high
by the placenta. Breech, oblique, and transverse lies are
common , and the fetal heart tones are usually found easily).

26.  The vaginal examination should be
conducted in an operating room
(major surgery can be performed).

27. Concepts of Therapy PP
If placenta previa is found, treatment
should be instituted at that time:
 amniotomy for minor degrees of
placenta previa,
 cesarean section for the remainder.

28. If the cervix is found to be dilated 3 cm or more and the
placenta does not cover any of the internal os, rupture
of the membranes permits the presenting part to
advance against the placenta, and hence to tamponade
it against the bleeding maternal sinuses. If this does
not control the bleeding and labor does not ensue and
progress, cesarean section is indicated ( the type of
cesarean section that should be performed in patients
with placenta previa - classic or lower segment with
vertical or transverse incision).
Personnal must include a circulating nurse, one
physician assistant, an anesthetist or anesthesiologist,
and someone to provide immediate care for the baby( a
high-risk infant).
A vein must be kept open with a large-bore catheter, and
fluids should be running.

29. Complications PP:
 Maternal disease and death (antepartum
hemorrhage may be fatal),
 Prolonged hypotension may produce
cerebral or renal damage,
 Sheehan's syndrome
 Atonic uterus
 Postpartum hemorrhage
 Placentae accreta, increta, and percreta
 Sepsis
 Operative trauma

30. PREMATURE SEPARATION OF PLACENTAPREMATURE SEPARATION OF PLACENTA
(ABRUPTIO PLACENTAE)(ABRUPTIO PLACENTAE)
Abruptio placentaeAbruptio placentae is - the partialis - the partial
or complete detachment of theor complete detachment of the
placenta from a site of normalplacenta from a site of normal
implantation in the corpus uteri atimplantation in the corpus uteri at
any time before delivery of theany time before delivery of the
infant.infant.
The detachment may be:The detachment may be:
complete or partial, mild,complete or partial, mild,
moderate, or severe abruptiomoderate, or severe abruptio
placentae (AP)placentae (AP)

32. Bleeding from the placental siteBleeding from the placental site
may dissect beneath themay dissect beneath the
membranes and find as external,membranes and find as external,
or revealed or concealedor revealed or concealed
bleeding.bleeding.
The clinical signs vary according toThe clinical signs vary according to
the degree of detachment:the degree of detachment:
 In the marginal type they areIn the marginal type they are
usually trivial,usually trivial,
 complete detachment may becomplete detachment may be
quickly fatalquickly fatal

34. Spontaneous premature separation of the placentaSpontaneous premature separation of the placenta
occurs :occurs :
 in multipara than in primigravid patients,in multipara than in primigravid patients,
 in patients over the age of 35,in patients over the age of 35,
 Preeclampsia clearly predisposes a patient toPreeclampsia clearly predisposes a patient to
this complication,this complication,
 Predisposes underlying extragenital diseasesPredisposes underlying extragenital diseases
( renovascular, arterial hypertension)( renovascular, arterial hypertension)
 Trauma is the cause in some cases.Trauma is the cause in some cases.
 The rapid reduction of uterine size afterThe rapid reduction of uterine size after
rupture of the membranes in hydramniosrupture of the membranes in hydramnios
In second stage of labor the placental separationIn second stage of labor the placental separation
has been reported as the result of spinalhas been reported as the result of spinal
anesthesia, oxytocineanesthesia, oxytocine
In some cases the placental separation has beenIn some cases the placental separation has been
delayed for hours or days with the suddendelayed for hours or days with the sudden
onset of severe fetal distress and fetal death.onset of severe fetal distress and fetal death.

35. Pathology APPathology AP
Spontaneous rupture of blood vessels atSpontaneous rupture of blood vessels at
the placental bedthe placental bed may resultmay result fromfrom
changes in the uterine vasculature, bychanges in the uterine vasculature, by
pregnant hypertension.pregnant hypertension.
HypovolemiaHypovolemia from the loss of of blood -from the loss of of blood -
results inresults in shockshock..
The blood may flow beneath the placenta,The blood may flow beneath the placenta,
shearing it, may separate theshearing it, may separate the
membranes from the uterine wall andmembranes from the uterine wall and
appear in the vagina, or it mayappear in the vagina, or it may
extravasate between the muscle fibersextravasate between the muscle fibers
of the myometrium. This increasesof the myometrium. This increases
uterine tone, and uterine relaxation isuterine tone, and uterine relaxation is
incomplete.incomplete.

36. Areas of ecchymosis are common, it is -Areas of ecchymosis are common, it is -
utero­placental apoplexyutero­placental apoplexy oror CouvelaireCouvelaire
uterus.uterus. Large quantities of thromboplastinLarge quantities of thromboplastin
are released into the maternal circulationare released into the maternal circulation
as a result of myometrial damage andas a result of myometrial damage and
retroplacental clotting ; in severe casesretroplacental clotting ; in severe cases
this produces disseminated intravascularthis produces disseminated intravascular
clotting. Much of this clotting is reducedclotting. Much of this clotting is reduced
by the circulating fibrinolysin, but theby the circulating fibrinolysin, but the
laying down of fibrin . The consumptionlaying down of fibrin . The consumption
coagulopathy that results may causecoagulopathy that results may cause
increased bleeding from the uterus, asincreased bleeding from the uterus, as
well as from other organs.well as from other organs.
Renal disturbance are developted -Renal disturbance are developted -
vascular spasm resulting from shock,vascular spasm resulting from shock,
intravascular clotting (oliguria,intravascular clotting (oliguria,
proteinuria, acute tubular necrosis, orproteinuria, acute tubular necrosis, or
acute cortical necrosis).acute cortical necrosis).

37. The effects on the fetus AP:The effects on the fetus AP:
Marginal separationMarginal separation may havemay have
no apparent effect;no apparent effect;
complete or almost completecomplete or almost complete
abruption is the result ofabruption is the result of
fetal distress and fetal death.fetal distress and fetal death.

38. Mild Abruptio Placentae:Mild Abruptio Placentae:
1.1. Lower abdominal discomfort andLower abdominal discomfort and
tenderness.tenderness.
2.2. Dark vaginal bleeding .Dark vaginal bleeding .
3.3. The maternal vital signs areThe maternal vital signs are
unchanged.unchanged.
4.4. Leopold's maneuvers: the uterusLeopold's maneuvers: the uterus
may fail to relax completely betweenmay fail to relax completely between
contractions.contractions.
5.5. It is no evident effect on the fetus.It is no evident effect on the fetus.

39. Moderate Abruptio Placentae(¼-⅔)Moderate Abruptio Placentae(¼-⅔)
1.1. Continuous abdominal (uterine)Continuous abdominal (uterine) painpain ,,
followed byfollowed by dark vaginal bleedingdark vaginal bleeding..
2.2. External bleeding is usually moderate( upExternal bleeding is usually moderate( up
to 1000 ml).to 1000 ml).
3.3. Evidence of shock (cold clammy skin,Evidence of shock (cold clammy skin,
tachycardia, hypotension, oliguria).tachycardia, hypotension, oliguria).
4.4. The fetus may show evidence ofThe fetus may show evidence of
embarrassment (the fetal heart may beembarrassment (the fetal heart may be
difficult to hear)difficult to hear)
5.5. The uterus is clearly tender , or partialThe uterus is clearly tender , or partial
contraction, the uterus dos nt to relaxcontraction, the uterus dos nt to relax
between contractions.between contractions.
6.6. Clotting defects and renal sequelae occur.Clotting defects and renal sequelae occur.

40. Severe Abruptio PlacentaeSevere Abruptio Placentae
1.1. Uterine pain is agonizing (tearing,Uterine pain is agonizing (tearing,
knife-like, and unremitting).knife-like, and unremitting).
2.2. The uterus is continuously boardlikeThe uterus is continuously boardlike
and tender.and tender.
3.3. External bleeding is usuallyExternal bleeding is usually
moderate, or there may be nomoderate, or there may be no
external bleeding.external bleeding.
4.4. The fetus is almost invariablyThe fetus is almost invariably
stillborn.stillborn.
5.5. Shock ensues with astonishingShock ensues with astonishing
speed.speed.
6.6. Oliguria and consumptionOliguria and consumption
coagulopathy should be expected.coagulopathy should be expected.

42. TREATMENT APTREATMENT AP
• If the gestation period is more than 37 weeksIf the gestation period is more than 37 weeks, ,, ,
thethe membranes should be rupturedmembranes should be ruptured..
• Continued bleeding, failure of the uterus to relaxContinued bleeding, failure of the uterus to relax
between contractions, and fetal distress arebetween contractions, and fetal distress are
indications forindications for cesarean section.cesarean section.
• TheThe ultimate meansultimate means is byis by ligation of the hypo­ligation of the hypo­
gastric arteries or by hysterectomygastric arteries or by hysterectomy..
• IfIf shock is presentshock is present ,, central venous or pulmonarycentral venous or pulmonary
wedge pressure monitoring should be started atwedge pressure monitoring should be started at
once.once.
• Tests for fibrinogen and circulating fibrinolysinTests for fibrinogen and circulating fibrinolysin
must be set up immediately.must be set up immediately.
• The clotting status must be determined andThe clotting status must be determined and
correctedcorrected..
• A vein must be kept open with a large­boreA vein must be kept open with a large­bore
catheter, and fluids should be running.catheter, and fluids should be running. EmergencyEmergency
blood transfusionblood transfusion

45. DIFFERENTIAL DIAGNOSIS OF
BLEEDING IN LATE PREGNANCY
Placenta previa Abruptio placenta
External
bleeding
Mild to
catostrophic
None to moderate
Color of
bl…
Bright None, dark
Back pain None None to moderate

46. Shock Uncommon Very common
Myomerial.
Tone
Normal Hypertonic localizde
or diffuse
Uterinetender None tenderness Marked and diffuse

47. Fetal status Nearly always
alive,
Fetal distress or
death
Frequently alive,
usually dead
Presentation Breech, oblique,
transverse. High
station of pr.
part
Normal distribution
Coagolopathy Very rare Very common

48. BLEEBING OCUURS DURINGBLEEBING OCUURS DURING
THE THIRD STAGE OF LABOUR,PUERPERIUM.THE THIRD STAGE OF LABOUR,PUERPERIUM.
TRANSFUSION AND SHOCKTRANSFUSION AND SHOCK
If heavyIf heavy vaginal bleedingvaginal bleeding occursoccurs duringduring
the third stage of laborthe third stage of labor, or if the, or if the
placenta has not been delivered withinplacenta has not been delivered within
30 minutes of birth of the newborn, the30 minutes of birth of the newborn, the
anesthesiologist should be summonedanesthesiologist should be summoned
and preparations toand preparations to remove theremove the
placenta manuallyplacenta manually should be made.should be made.
In placenta accreta the placenta isIn placenta accreta the placenta is
abnormally adherent,abnormally adherent, the decidua isthe decidua is
underdeveloped, and the physiologicunderdeveloped, and the physiologic
cleavage plane through the spongycleavage plane through the spongy
layer of the decidua is not present.layer of the decidua is not present.

49. When the villi extend throughWhen the villi extend through
the myometrium, the conditionthe myometrium, the condition
is calledis called placenta increta.placenta increta.
When they reach or evenWhen they reach or even
penetrate the uterine serosa, itpenetrate the uterine serosa, it
is termedis termed placenta percreta.placenta percreta.

50. ABNORMAL PLACENTAE ADHERENCEABNORMAL PLACENTAE ADHERENCE

51. Abnormal adherence of the placenta isAbnormal adherence of the placenta is
most often associated with suchmost often associated with such
conditions:conditions:
 placenta previa,placenta previa,
 previous cesarean section orprevious cesarean section or
curettage,curettage,
 intrauterine synechiae,intrauterine synechiae,
 multiparity.multiparity.

52. TACTICSTACTICS
1.1. massage, remove the placentamassage, remove the placenta
manuallymanually
2.2. intravenous administration ofintravenous administration of
oxytocinoxytocin..
IfIf bleeding continuesbleeding continues, the safest treatment, the safest treatment
is:is:
3.3. to institute prompt blood replacementto institute prompt blood replacement
4.4. attempts at curettageattempts at curettage
5.5. proceed with hysterectomy.proceed with hysterectomy.

55. SHOCKSHOCK
Chock is a state of generalizedChock is a state of generalized
circulatory failurecirculatory failure ..
The main characteristics isThe main characteristics is
inadequate tissue perfusion with:inadequate tissue perfusion with:
 diminished circulatory volume,diminished circulatory volume,
 an abnormally enlarged vascularan abnormally enlarged vascular
space,space,
 cardiac failure.cardiac failure.

56. TheThe clinical manifestations of shockclinical manifestations of shock varyvary
according to the severity of the condition:according to the severity of the condition:
1.1. Blood pressure and pulse rate areBlood pressure and pulse rate are
important diagnostic indices forimportant diagnostic indices for
shock.shock.
2.2. Orthostatic changes are moreOrthostatic changes are more
reliable. Postural changes alone arereliable. Postural changes alone are
insufficient grounds for the diagnosisinsufficient grounds for the diagnosis
of shock.of shock.
3.3. Inadequate tissue perfusion such asInadequate tissue perfusion such as
confusion, oliguria.confusion, oliguria.

57. Laboratory StudiesLaboratory Studies
 blood typing and cross-matching,blood typing and cross-matching,
 complete blood count,complete blood count,
 coagulation studies: platelet count,coagulation studies: platelet count,
prothrombin time, partialprothrombin time, partial
thromboplastin time, fibrinogen, andthromboplastin time, fibrinogen, and
tests for split products of fibrin ,tests for split products of fibrin ,
 serum chemistry analysis (i.e.,serum chemistry analysis (i.e.,
electrolytes, glucose, calcium, andelectrolytes, glucose, calcium, and
creatinine levels),creatinine levels),
 arterial blood gas determinationsarterial blood gas determinations
 urinalysis.urinalysis.
 an electrocardiograman electrocardiogram

58. Correlation of Clinical Findings and MagnitudeCorrelation of Clinical Findings and Magnitude
of Volume Deficit in Hemorrhagic Shockof Volume Deficit in Hemorrhagic Shock
Severity of
shock
Clinical Findings Reduction of blood
volume
Mild Mild evidence of peripheral
vasoconstriction with cool
hands and feet.
Minimal tachycardia
Slight decrease in blood
presser
15-25%
750-1250 ml

59. Moderate Tachycardia 100-120,
Decrease in puls pressure ,
pallor
Systolic blood pressurer
90-100 mg Hg
Oliguria
25-35%
1250-1750 ml
Severe Tachycardia over 120,
mental stupor
Exreme pallor, cold
extremities
Systolic blood pressurer
below 60 mg Hg
Anuria
Up to 50%
2500ml

60. ManagementManagement
Definitive treatment -medical or surgical.Definitive treatment -medical or surgical.
Appropriate medical treatment beforeAppropriate medical treatment before
emergency surgery is indicated foremergency surgery is indicated for
stabilization with blood transfusion.stabilization with blood transfusion.
A large-gaugeA large-gauge intravenous lineintravenous line should be usedshould be used
to obtain blood for laboratory studies and toto obtain blood for laboratory studies and to
provide a reliable route for subsequentprovide a reliable route for subsequent
therapy.therapy.
Insertion of a central venous pressureInsertion of a central venous pressure as aas a
second line for more accurate hemodynamicsecond line for more accurate hemodynamic
evaluation is usually indicated.evaluation is usually indicated.
Urinary catheterUrinary catheter should be inserted to monitorshould be inserted to monitor
renal perfusion.renal perfusion.
Restoration of tissue oxygenationRestoration of tissue oxygenation is theis the
ultimate goal of treatment for shockultimate goal of treatment for shock
(ventilation, oxygen).(ventilation, oxygen).

61. The keystone of treatment to increase cardiacThe keystone of treatment to increase cardiac
filling pressures is volume replacement.filling pressures is volume replacement. IfIf
filling pressures fail to respond to rapidfilling pressures fail to respond to rapid
infusion of crystalloid fluids (1-2 liters/hour),infusion of crystalloid fluids (1-2 liters/hour),
colloid fluids should be added. Erythrocytecolloid fluids should be added. Erythrocyte
transfusion contributes to volumetransfusion contributes to volume
replacement, and is frequently indicated inreplacement, and is frequently indicated in
shock.shock.
Crystalloid fluidsCrystalloid fluids are solutions that contain onlyare solutions that contain only
water and small molecules such as glucose andwater and small molecules such as glucose and
electrolytes.electrolytes.
Colloid fluidsColloid fluids contain larger molecules that crosscontain larger molecules that cross
vascular membranes more slowly than dovascular membranes more slowly than do
crystalloids. In plasma, colloids help tocrystalloids. In plasma, colloids help to
maintain oncotic pressure, help to preventmaintain oncotic pressure, help to prevent
edema. Infusion of large volumes ofedema. Infusion of large volumes of
crystalloids without colloid replacement maycrystalloids without colloid replacement may
lead to pulmonary edema.lead to pulmonary edema.

62. Plasma colloidsPlasma colloids are usually replacedare usually replaced
with albumin or plasma proteinwith albumin or plasma protein
fraction, fresh frozen plasma andfraction, fresh frozen plasma and
blood also contain significantblood also contain significant
amounts of colloid.amounts of colloid.
After adequate volume replacement,After adequate volume replacement,
low-dose dopaminelow-dose dopamine (1-5 jug/min) can(1-5 jug/min) can
increase cardiac output and dilate theincrease cardiac output and dilate the
coronary, mesenteric, and renalcoronary, mesenteric, and renal
arteries without causing significantarteries without causing significant
peripheral vasoconstriction.peripheral vasoconstriction.
Severe acidosis (blood pH less thanSevere acidosis (blood pH less than
7.2) should be corrected with sodium7.2) should be corrected with sodium
bicarbonate.bicarbonate.

63. Complications of shock:Complications of shock:
 myocardial infarction,myocardial infarction,
 stroke,stroke,
 pituitary necrosis,pituitary necrosis,
 renal cortical necrosis,renal cortical necrosis,
 transfusion reaction,transfusion reaction,
 acidosis,acidosis,
 dilutional coagulopathy,dilutional coagulopathy,
 acute tubular necrosis,acute tubular necrosis,
 adult respiratory distressadult respiratory distress
syndrome (shock lung)syndrome (shock lung)

64. INFUSIAL, TRANSFUSIAL THERAPY (ITT)
DURING
OBSTETRICS BLEEDINGS
Reduction of
blood
volume
Qualitative composition of ITT Volume
ITT (%
of
reducti
on of
blood
volume
)
0,6–0,8%
(400-600 ml.)
Crystalloid fluids are solutions that
contain only water and small
molecules such as glucose and
electrolytes (5% dextrose in
lactated Ringer's solution)
100%

65. 0,8-1%
(600-750 ml.)
1
/3
Volume - Colloid fluids,
2
/3
Volume – Crystalloid fluids
Colloid fluids contain larger molecules
that cross vascular membranes more
slowly. In plasma, colloids help to
maintain oncotic pressure, and thus
help to prevent edema: plazma,
crioprecipitates,
hydroxiaethylkrachmal – refortane
150 %
1 – 2%
(750-1500
ml.)
¼ Volume - red cell mass,
½ Volume - Colloid fluids,
¼ Volume – Crystalloid fluids
250%
2% and >
(1500 ml and
>)
2
/3
Volume- Transfusion of blood
products ,
1
/6
Volume - Crystalloid fluids,
1
/6
Volume – Colloid fluids
250%

66. CLINICAL FINDINGS
HYPOVOLEMIC SHOCK
Order 676 MH Ukrain

67. Degree
of hypo
vole
mia
Reduc
tion of
Blood
volume
Blood
lost
(ml)
% blood
lost fro
weight
Clinical Findings
I Crisis
of
Makro
circu
lation
10%
-20
%
500,0-
1000,
0
1,0 –
1,5%
Tachycardia
100-110 beats
per min.
Systolic blood
pressurer –
100 mmHg
Respiratory rate
18 – 20 per
min.
Paleness
Diures –up 30
ml/ hr.
CVPr–80-100

68. II Crisis
of
Mikro
circu
lation
20-
30%
1000,0
1500,0
1,5 –
2,0
%
Tachycardia
up to120
Systolic bl.
Pres.<100
mmHg
Resp. rate 24-
30per min.
CVPr–< 60.
Oliguria

69. III Crisis
of
Coagu
lation
30-
40%
1500,0
2000,0
2,0 –
2,5
%
Tachycardia
up to 140
Systolic bl.
Pres.<
70mmHg
Coma
CVPr–< 40
Anuria, DIC-
syndrom

70. IY Extre
mely
Severe
40%
and >
>2000,0 > 2,5% Tachycardia
>140
Systolic bl.
Pres.< 50
mm Hg
CVPr -0
Anuria, DIC-
syndrom

72. LATE GESTOSIS.LATE GESTOSIS.
HYPERTENSIVE DISODERS OFHYPERTENSIVE DISODERS OF
PREGNANCYPREGNANCY..
DETERMINATION, FACTORS OF RISK OFDETERMINATION, FACTORS OF RISK OF
DEVELOPMENTDEVELOPMENT
OF LATE GESTOSIS (LG).OF LATE GESTOSIS (LG).
A gestosisA gestosis is the syndrome of adaptation of ais the syndrome of adaptation of a
woman to pregnancy. LG arises up only duringwoman to pregnancy. LG arises up only during
the period of pregnancy, it complicates thethe period of pregnancy, it complicates the
pregnancy, and disappears at once or soonpregnancy, and disappears at once or soon
after delivery.after delivery.
Late gestosis is the polyorganic insufficiency,Late gestosis is the polyorganic insufficiency,
which clinically develops after 20th weeks ofwhich clinically develops after 20th weeks of
pregnancy and finishes after delivery.pregnancy and finishes after delivery.

73. ReasonsReasons which predetermine the violation ofwhich predetermine the violation of
adaptation are:adaptation are:
• genetically weakness of the systems of organism,genetically weakness of the systems of organism,
(hypoksia, infections, intoxications, diseases in a(hypoksia, infections, intoxications, diseases in a
childhood, teens);childhood, teens);
• psychological and social desorders of woman,psychological and social desorders of woman,
stressing situations of the nervous system ;stressing situations of the nervous system ;
• chronic extragenital diseases: cardiovascularchronic extragenital diseases: cardiovascular
diseases (hypertensive illness, vascular blooddiseases (hypertensive illness, vascular blood
pressure low, and rheumatic heart-diseases);pressure low, and rheumatic heart-diseases);
diabetes mellitus, renal diseases (nephrite,diabetes mellitus, renal diseases (nephrite,
pyelonephritis) and other;pyelonephritis) and other;
• chronic intoxications (smoking and other);chronic intoxications (smoking and other);
• allergic reactions;allergic reactions;
• immunological violations;immunological violations;
• complications during the period of real pregnancy.complications during the period of real pregnancy.

74. Forms of gestosis:Forms of gestosis:
 early gestosisearly gestosis —— arises up in the firstarises up in the first
half of pregnancy (usually in the firsthalf of pregnancy (usually in the first
three months), as a rule thesethree months), as a rule these
symptoms disappear with forming ofsymptoms disappear with forming of
placenta;placenta;
 rare forms of gestosisrare forms of gestosis — arise up both— arise up both
in the first and in the second half ofin the first and in the second half of
pregnancy;pregnancy;
 late gestosislate gestosis —— clinically shows up inclinically shows up in
the second half of pregnancy (morethe second half of pregnancy (more
frequently in last 2-3 month 's).frequently in last 2-3 month 's).

75. For all forms of gestosis thereFor all forms of gestosis there
are general signs, namely:are general signs, namely:
 a gestosis is observed only during pregnancy;a gestosis is observed only during pregnancy;
 the functional changes of CNS are inherent to allthe functional changes of CNS are inherent to all
forms of gestosis,forms of gestosis,
 vasculomotor violations are manifested in the formsvasculomotor violations are manifested in the forms
of hypertension (late gestosis) or hypotension (earlyof hypertension (late gestosis) or hypotension (early
gestosis) and tachycardia;gestosis) and tachycardia;
 renal desorders (decline of diuresis);renal desorders (decline of diuresis);
 metabolic violations;metabolic violations;
 a gestosis more frequently appears during the firsta gestosis more frequently appears during the first
pregnancy;pregnancy;
 presence of polyorganic pathologypresence of polyorganic pathology
Frequency of LG from 1,4 to 23,2% among allFrequency of LG from 1,4 to 23,2% among all
pregnant, the heavy forms of LG develop only at 8-pregnant, the heavy forms of LG develop only at 8-
10% patients.10% patients.

76. A gestosis is not the independent disease, it isA gestosis is not the independent disease, it is
adequate to consider this clinical display aadequate to consider this clinical display a
impossibility of adaptations mechanisms ofimpossibility of adaptations mechanisms of
maternal organism to the necessity ofmaternal organism to the necessity of
developing fetus. This impossibility will bedeveloping fetus. This impossibility will be
realized through different degrees ofrealized through different degrees of
perfusive-diffusive insufficiency in the systemperfusive-diffusive insufficiency in the system
mother- placenta-fetus.mother- placenta-fetus.
Preeclampsia is called the disease of theories,Preeclampsia is called the disease of theories,
illnesses of adaptation.illnesses of adaptation.
Presently there are about 30 different theoriesPresently there are about 30 different theories
of development of LG:of development of LG:
haemodynamic, increased vasoconstrictor tone,haemodynamic, increased vasoconstrictor tone,
endocrinology, immunological,..endocrinology, immunological,..

77. TheThe starting mechanisms of LGstarting mechanisms of LG
are:are:
 the general spasm of vessels,the general spasm of vessels,
 redistribution of liquid, reduced bloodredistribution of liquid, reduced blood
volume, hemoconcentration,volume, hemoconcentration,
 violation of the aggregate state of bloodviolation of the aggregate state of blood
 the increase of permeability of vascularthe increase of permeability of vascular
wall,wall,
 development of system insufficiency ofdevelopment of system insufficiency of
blood circulation of woman' s organism.blood circulation of woman' s organism.
 Hypoxia is the result of these changes.Hypoxia is the result of these changes.

78. CLASSIFICATION OF LG.CLASSIFICATION OF LG.
 Hypertension during pregnancyHypertension during pregnancy
 Chronic HypertensionChronic Hypertension
 Gestational HypertensionGestational Hypertension
 Edemata during pregnancy.Edemata during pregnancy.
 Proteinuria during pregnancy.Proteinuria during pregnancy.
 Preeclampsia mildPreeclampsia mild
 Preeclampsia moderatePreeclampsia moderate
 Preeclampsia severePreeclampsia severe
 EclampsiaEclampsia

80. Clean gestosisClean gestosis develops at the end of the IIIdevelops at the end of the III
trimester of pregnancy and has clinicaltrimester of pregnancy and has clinical
signs of gestosis without somaticsigns of gestosis without somatic
pathology.pathology.
Combined gestosisCombined gestosis (to 70% all LG) develops(to 70% all LG) develops
at a background of extragenital diseasesat a background of extragenital diseases
(more frequently such as hypertension,(more frequently such as hypertension,
hypotension, renal and liver diseases andhypotension, renal and liver diseases and
other pathology).other pathology).
Features of combined gestosis are:Features of combined gestosis are:
 early beginning (to 25th-30th w.);early beginning (to 25th-30th w.);
 heavy development;heavy development;
 absence of classic triad of preeclampsia .absence of classic triad of preeclampsia .

82. AA hypertensionhypertension is the increase of systoleis the increase of systole
pressure up to 140mm., a diastole to 90 mm.pressure up to 140mm., a diastole to 90 mm.
(either higher at two measurings in a state of(either higher at two measurings in a state of
rest with an interval no less than 4 hours), orrest with an interval no less than 4 hours), or
increase of arterioly pressure up to 160/110increase of arterioly pressure up to 160/110
mm. after 20 weeks of pregnancy.mm. after 20 weeks of pregnancy.
PreeclampsiaPreeclampsia is hypertension arising up after 20is hypertension arising up after 20
weeks of pregnancy, in combination withweeks of pregnancy, in combination with
proteinuria.proteinuria.
ProteinuriaProteinuria isis maintenance of albumen in urinemaintenance of albumen in urine
0,3 g/l in the middle portion of urine, collected0,3 g/l in the middle portion of urine, collected
twice with an interval at 4 hours, or 0,3g/ltwice with an interval at 4 hours, or 0,3g/l
albumen during the day.albumen during the day.

83. Classification of hypertension ofClassification of hypertension of
pregnant (1999)pregnant (1999)
Hypertension
pregnant
Systole BP
mm.
Diastole BP
1 degree (mild) 140-159 90-99
2 degrees (moderate) 160-179 100-109
3 degrees (severe) > 180 > 110
Isolated systoles BP > 140 >90

84. Diagnostic criteria ofDiagnostic criteria of PreeclampsiaPreeclampsia
(eclampsia)(eclampsia)
Diagnosis Diastol.
BPmmHg
Proteinuria
g/day
Other symptoms
Preeclampsia
mild
90-99 0,3
Preeclampsia
moderate
100-109 0,3-5,0 Edemata of legs.
Head pain.
Preeclampsia
severe >110 >5
Anasarca.
Head pain.
Pain in an epigastrium.
Hyperreflexia.
Olyguria 500ml/d.).
Coagulopathya
Eclampsia >90 >0,3 Attack of
cramps.

85. Presence of cerebral symptoms (headPresence of cerebral symptoms (head
pain, nausea, vomiting, shroud beforepain, nausea, vomiting, shroud before
eyes, «flashing of beauty-spot») in theeyes, «flashing of beauty-spot») in the
clinic ofclinic of preeclampsia makes itpreeclampsia makes it
necessary to diagnose the severe formnecessary to diagnose the severe form
of preeclampsiaof preeclampsia and accordingly toand accordingly to
change the tactic of treatment.change the tactic of treatment.

86. On the part of the mother theOn the part of the mother the
following complications are morefollowing complications are more
frequently:frequently:
 eclampsia;eclampsia;
 syndrome of polyorganic insufficiency ;syndrome of polyorganic insufficiency ;
 cerebral hemorrhage;cerebral hemorrhage;
 cerebral edema ;cerebral edema ;
 pulmonary edema, cardiovascular insufficiency;pulmonary edema, cardiovascular insufficiency;
 hemorrhage and removing of retina;hemorrhage and removing of retina;
 premature removing of normally locatedpremature removing of normally located
placenta (abruptio placenta);placenta (abruptio placenta);
 renal insufficiency;renal insufficiency;
 a syndrome DIC;a syndrome DIC;
 premature labour;premature labour;

87. Complications from the side ofComplications from the side of
fetus and placenta are:fetus and placenta are:
 premature removing of normally locatedpremature removing of normally located
placentaplacenta
 fetal growth retardation;fetal growth retardation;
 distress of fetus;distress of fetus;
 asphyxia of new-born;asphyxia of new-born;
 syndrome of respiratory disorders;syndrome of respiratory disorders;
 perinatal mortality.perinatal mortality.

88. AnAn eclampsiaeclampsia is characterized by development ofis characterized by development of
tonic-clonic cramps (convulsions) duringtonic-clonic cramps (convulsions) during
pregnancy on the background of preeclampsiapregnancy on the background of preeclampsia
An eclampsiaAn eclampsia is the clinical display of theis the clinical display of the
expressed syndrome of polyorganicexpressed syndrome of polyorganic
insufficiency with the primary defeat of CNS. Itinsufficiency with the primary defeat of CNS. It
is met in 0,2-0,5% cases of all pregnancies andis met in 0,2-0,5% cases of all pregnancies and
is fraught by a highlower of newborn (30-40%)is fraught by a highlower of newborn (30-40%)
and maternal (3-4%) mortinatality.and maternal (3-4%) mortinatality.
The attack of crampsThe attack of cramps proceeds on the averageproceeds on the average
from 1 to 3 minutes and consists of a fewfrom 1 to 3 minutes and consists of a few
phases which change one other.phases which change one other.

89. The first phase (pre-convulsive)The first phase (pre-convulsive) ——
lasts 20-30sec. and is characterizedlasts 20-30sec. and is characterized
by appearance of shaking of eyelids,by appearance of shaking of eyelids,
twitch of mimic muscles, muscles oftwitch of mimic muscles, muscles of
fingers of hands. The eyeballs offingers of hands. The eyeballs of
patient are revolved or displacedpatient are revolved or displaced
upwards and/or aside, the look isupwards and/or aside, the look is
fixed in one point, pupils narrow andfixed in one point, pupils narrow and
in the tears appear eyes. Breathingin the tears appear eyes. Breathing
superficial.superficial.

90. Second phase (tonic cramps)Second phase (tonic cramps) — lasts 10-— lasts 10-
20 sec., and sometimes to 60 sec. and20 sec., and sometimes to 60 sec. and
can result in an asphyxia. The head ofcan result in an asphyxia. The head of
patient is thrown back, all musclespatient is thrown back, all muscles
become taut and a body bends. A personbecome taut and a body bends. A person
is pale, teeth are squeezed, the cornersis pale, teeth are squeezed, the corners
of mouth are tomentous, eyes areof mouth are tomentous, eyes are
goggled, pupils narrow and the white ofgoggled, pupils narrow and the white of
a eyeballs are visible (eyes are «rolled»a eyeballs are visible (eyes are «rolled»
up). A pulse is not felt and breathing isup). A pulse is not felt and breathing is
halted. The stop of breathing ishalted. The stop of breathing is
explained by tonic reduction ofexplained by tonic reduction of
practically all musculature.practically all musculature.

91. Third phase (clonic cramps)Third phase (clonic cramps) — lasts 30-60— lasts 30-60
sec., and sometimes from 1 to 10 minessec., and sometimes from 1 to 10 mines
and is characterized by clonic reductionsand is characterized by clonic reductions
and weakening of all groups of musclesand weakening of all groups of muscles
of person, trunk and extremities. Clonicof person, trunk and extremities. Clonic
cramps spread from top to bottom on allcramps spread from top to bottom on all
muscles Face is of purple-dark bluemuscles Face is of purple-dark blue
color, the tongue sticks out of the mouth.color, the tongue sticks out of the mouth.
Neck veins swell and become taut. ANeck veins swell and become taut. A
pulse is not felt, breathings laboured orpulse is not felt, breathings laboured or
absent. Involuntary secretion of urineabsent. Involuntary secretion of urine
and excrement, biting of the tongue, isand excrement, biting of the tongue, is
possiblepossible..

92. Fourth phase (coma or phase of permission)Fourth phase (coma or phase of permission) ——
lasts from a few minutes to a few hours. Alasts from a few minutes to a few hours. A
patient begins to breathe noisily, slowly andpatient begins to breathe noisily, slowly and
deeply and does not come to senses. Adeeply and does not come to senses. A
person is cyanotic, the temperature of bodyperson is cyanotic, the temperature of body
can rise (to 38,5-41°), that considerablycan rise (to 38,5-41°), that considerably
worsens the prognosis. Foamy salvation,worsens the prognosis. Foamy salvation,
sometimes with the admixture of bloodsometimes with the admixture of blood
because of the biting tongue can bebecause of the biting tongue can be
observed during the cramp attack. After theobserved during the cramp attack. After the
attack of cramps a patient gradually comes toattack of cramps a patient gradually comes to
consciousness, complains about head pain,consciousness, complains about head pain,
general weakness retrograde amnesiageneral weakness retrograde amnesia

93. THE TACTIC IS ACTIVE, WITHTHE TACTIC IS ACTIVE, WITH
DELIVERY AT THE NEAREST 24DELIVERY AT THE NEAREST 24
HOURS FROM THE MOMENT OFHOURS FROM THE MOMENT OF
ESTABLISHMENT OF DIAGNOSIS.ESTABLISHMENT OF DIAGNOSIS.
TACTIC OF DELIVERY.TACTIC OF DELIVERY.
1.1. Amniotomy in case of prepared family ways.Amniotomy in case of prepared family ways.
2.2. In most ways, appropriative induction ofIn most ways, appropriative induction of
labourlabour
3.3. At the unready neck of uterus and absence ofAt the unready neck of uterus and absence of
effect from preparation of PG, in the case ofeffect from preparation of PG, in the case of
progress of hypertension, threat ofprogress of hypertension, threat of
development of eclampsia, worsening of thedevelopment of eclampsia, worsening of the
state of fetus, delivery is rotined by operationstate of fetus, delivery is rotined by operation
caesarean sections.caesarean sections.

95. Indications to the planned cesareanIndications to the planned cesarean
section :section :
 severe progressive preeclampsia orsevere progressive preeclampsia or
worsening of the state of fetus (withworsening of the state of fetus (with
immature family ways);immature family ways);
 eclampsiaeclampsia
 comacoma
 standard obstetric indicationsstandard obstetric indications
 removing of retinaremoving of retina
 abruptio placentaabruptio placenta
 anuriaanuria
 HELLP- syndrome, DICHELLP- syndrome, DIC

96. After liquidation of cramps the conductAfter liquidation of cramps the conduct
correction of metabolic violations,correction of metabolic violations,
water-electrolyte balance,water-electrolyte balance,
proteometabolism.proteometabolism.
TTreatment is continued in accordancereatment is continued in accordance
with the state of patient. Magnesiawith the state of patient. Magnesia
therapy proceeds no less than 48therapy proceeds no less than 48
hours.hours.

98. BASIC DIRECTIONS OF THERAPY OFBASIC DIRECTIONS OF THERAPY OF
LG.LG.
Treatment of hypertnsia is conducted atTreatment of hypertnsia is conducted at
the increase of diastole BP of from 110the increase of diastole BP of from 110
mm. ,together with magnesia therapy formm. ,together with magnesia therapy for
warning of encephalopathy and stroke.warning of encephalopathy and stroke.
BP is reduced to the safe level: 150/90-BP is reduced to the safe level: 150/90-
160/100 mmHg, not below!160/100 mmHg, not below! Fall-off rapidFall-off rapid
BP can cause worsening of the state ofBP can cause worsening of the state of
mother and fetus.mother and fetus.

99. Hypotensions preparationsHypotensions preparations ::
METHYLDOFA,METHYLDOFA, NIFEDIPIN, KLONIDIN,NIFEDIPIN, KLONIDIN,
EUPHYLLIN,EUPHYLLIN, PAPAVERIN,PAPAVERIN, NOSPANI.NOSPANI.
For prophylaxis eclamptic convulsions we canFor prophylaxis eclamptic convulsions we can
apply the sulfate of magnesium (preparation ofapply the sulfate of magnesium (preparation of
choice for treatment of cramps).choice for treatment of cramps).
Magnesia therapy:Magnesia therapy:
Starting doseStarting dose – 4 g (І6ml 25% sulfate of– 4 g (І6ml 25% sulfate of
magnesium) slowly, during 15 mins (in themagnesium) slowly, during 15 mins (in the
case of eclampsia - 5 mines). The startingcase of eclampsia - 5 mines). The starting
dose of sulfate of magnesium is brought intodose of sulfate of magnesium is brought into
0,9% sol. of natrium chloride (in a sterile0,9% sol. of natrium chloride (in a sterile
small bottle with 34 ml.)small bottle with 34 ml.)
Magnesia therapy conduct during 24-48 h.Magnesia therapy conduct during 24-48 h.

100. Infusion therapy of LGInfusion therapy of LG
Basic terms of adequate infusion therapy:Basic terms of adequate infusion therapy:
 control of the entered, drink liquid and diuresis;control of the entered, drink liquid and diuresis;
 diuresis no less than 50 ml./ hour;diuresis no less than 50 ml./ hour;
 the volume of the entered liquid must correspond tothe volume of the entered liquid must correspond to
the physiological necessities of organism (30-35the physiological necessities of organism (30-35
ml/kg/dayly), taking into account the volume ofml/kg/dayly), taking into account the volume of
unphysiological losses (bleeding);unphysiological losses (bleeding);
 speed (rate) must not exceed introduction of liquidspeed (rate) must not exceed introduction of liquid
85 ml/hour;85 ml/hour;
 preparation of choice:preparation of choice: (physiological(physiological solution,solution,
hydroxiethylcrachmal – REFORTAN or STABISOL,hydroxiethylcrachmal – REFORTAN or STABISOL,
crystalloids );crystalloids );
 it is necessary to includeit is necessary to include fresh-frozen plasma forfresh-frozen plasma for
normalization of correlation anticoagulants –normalization of correlation anticoagulants –
procoagulants, for the prophylaxis of bleedingprocoagulants, for the prophylaxis of bleeding

101. For strengthening of sedative effectFor strengthening of sedative effect
of the conducted therapy, if it isof the conducted therapy, if it is
required by the state of patient, withrequired by the state of patient, with
the purpose of decline of diastolethe purpose of decline of diastole
pressure it is possible to applypressure it is possible to apply
SEDUXEN, DROPERIDOL.SEDUXEN, DROPERIDOL.
A gestosis is not cured, it is possibleA gestosis is not cured, it is possible
to attain only it s remission !to attain only it s remission !

102. FIRST MEDICAL AIDFIRST MEDICAL AID
AT ECLAMPSIA.AT ECLAMPSIA.
Primary purposes of the first medicalPrimary purposes of the first medical
aid:aid:
 stopping of cramps;stopping of cramps;
 restoring of ability of respiratoryrestoring of ability of respiratory
waways.ys.

103. Tasks of intensive therapyTasks of intensive therapy
after liquidation of cramps:after liquidation of cramps:
 prophylaxis repeated attacks of cramps;prophylaxis repeated attacks of cramps;
 liquidation of hypoxia, acidosisliquidation of hypoxia, acidosis
(respiratory, metabolic);(respiratory, metabolic);
 prophylaxis the aspiration syndrome;prophylaxis the aspiration syndrome;
 immideatly delivery.immideatly delivery.

104. REHABILITATIONREHABILITATION
Supervision of a woman who hadSupervision of a woman who had
preeclampsia-eclampsia, after the leaving ofpreeclampsia-eclampsia, after the leaving of
maternity hospital (rehabilitation): duration ofmaternity hospital (rehabilitation): duration of
clinical supervision after preeclampsia is 6clinical supervision after preeclampsia is 6
month , eclampsia – 1 year.month , eclampsia – 1 year.
Volume and terms of inspection:Volume and terms of inspection:
 general analysis of urine - in 1, 3, 6, 9 and 12general analysis of urine - in 1, 3, 6, 9 and 12
months after delivery;months after delivery;
 clinical analysis of blood - in 1 and 3 month;clinical analysis of blood - in 1 and 3 month;
 ophtalmoscopia - in 1, 3 and 12 months;ophtalmoscopia - in 1, 3 and 12 months;
 ECG - in 1 month;ECG - in 1 month;
 measuring of BP - at every visit to a doctor.measuring of BP - at every visit to a doctor.