Injuries of an abdominal cavity during pregnancy

Description:

Stupid injury of a stomach — the main reason for death of mother and a fruit at pregnancy.

Classification of an abdominal injury.
· Open injuries.
---On character of a hurting subject:
– put with cold weapon: chipped, cut, chopped, fragmentary, hurt;
– fire: bullet, shot, fragmental.
---On the nature of defeat of an abdominal wall:
– not getting;
– getting.
---Damage of parenchymatous bodies:
– superficial wounds of the capsule;
– the wounds of the capsule and a parenchyma which are not reaching area of a sosudistosekretorny leg;
– wounds of the capsule and a parenchyma with injury of a sosudistosekretorny leg;
– crush (gunshot wound) or cutting off of a part of body.
---Damage of hollow bodies:
– wound of a serous cover;
– the wound getting into a gleam of body;
– through wound;
– crush or crossing of body.
· The closed (stupid) injury.
---Localization of a bruise (damage):
– abdominal wall;
– abdominal organs;
– retroperitoneal space and its bodies.
---Internal injury:
– intra belly;
– retroperitoneal.
---A type of the damaged body:
– parenchymatous;
– hollow;
– blood vessel;
– retroperitoneal hemorrhage (hematoma).
---Damages of parenchymatous bodies:
– superficial gaps no more than 1 cm in depth (3 cm for a liver);
– the central gaps passing through area of gate;
– subcapsular hematomas (peripheral and central);
– separation or crush of body or its part.
---Damage of hollow bodies:
– anguish (serous or mucous membrane);
– gap;
– separation or crush.
· Effects of an abdominal injury.
---Formation of a hematoma.
---Peritonitis.
---Bleeding (outside or intra belly).
---Intra belly abscesses.
---Retroperitoneal phlegmon.
---Fistulas (intestinal, bilious, pancreatic, uric).

In classification of hysterorrheses the mechanical injury is allocated as one of the reasons in spite of the fact that an external injury — an unusual occurrence in genesis of hysterorrheses.

Symptoms of Injuries of an abdominal cavity during pregnancy:

Sensitivity and reaction to damages at mother and a fruit are various. Any injuring action from the outside is capable to break pregnancy development, to cause damage or pre-natal death of a fruit, and also to lead to the change of a homeostasis of mother which is shown MONDAY. Anatomo-topografichesky features of an arrangement of bodies of a small pelvis promote emergence of the combined damages, complicating diagnosis and complicating the choice of rational tactics at pregnancy. Clinical manifestations of injuries of abdominal organs and retroperitoneal space will be less expressed especially in the III trimester of pregnancy. Symptoms of irritation of a peritoneum can be vague (doubtful) or not be defined. Stretching of parietal layers of a peritoneum as result of development of a uterus, especially in the III trimester of pregnancy, reduces amount of touch nerve fibrils in a stomach. It leads to increase in a threshold of peritoneal excitability at intra belly bleeding or other pathological process. Izz shifts of bodies with a growth of a uterus of pain can be localized in atypical places.

Existence of bloody allocations from a genital tract, lack of stirs of a fruit, the raised tone of a uterus can testify to an injury of a uterus, a fruit and placenta. The premature beginning of patrimonial activity after an injury of a stomach can begin at uterus contusions, placental detachment, a premature rupture of a membrane.

The shock which arose in response to mechanical influence, first of all — a hypovolemic pathophysiological symptom complex in which development, in addition to nervnoreflektorny reactions, the significant role belongs to blood loss, an emotional stress, disturbances of gas exchange and intoxication. In response to a severe mechanical injury the organism will mobilize the defense reactions which are available at its order for preservation of a homeostasis. Shock — step by step the developing pathological process which begins with the moment of action of the factor of aggression (leading to system disturbance of blood circulation) and when progressing disturbances comes to an end with irreversible damages and the death of the patient.

Allocate a number of consecutive stages.

· Stage of a preshok.
· Early (reversible) stage of shock.
· Intermediate (progressive) stage of shock.
· Refractory (irreversible) stage of shock.

At shock hypercoagulation always develops and there is a formation of the intravascular blood clots which are formed preferential in a microcirculator bed. At the same time a number of factors of coagulation (thrombocytes, fibrinogen, the V factor, the VIII factor, a prothrombin) is consumed that leads to considerable delay of coagulability of blood. Along with this process in already formed clots enzymatic process of disintegration of fibrinogen with formation of products of its degradation which possess powerful fibrinolitic action begins.

Blood absolutely ceases to turn that happens the reason of considerable bleedings from places of punctures, edges of a wound and a mucous membrane of the alimentary system. An important role in disturbances of hemocoagulation is played by decrease in concentration of antithrombin III and a protein With therefore correction of their deficit is reasonable.

The progressing decrease in content of fibrinogen and thrombocytes in combination with increase in maintenance of products of degradation of fibrinogen and soluble fibrin-monomers, and also the corresponding clinical symptomatology has to be the basis for the diagnosis of the IDCS and the beginning of special therapy.
The developing IDCS aggravates disturbances of regional blood circulation. Thereof process the long hypoxia of a number of vitals develops that leads to disturbance of biopower processes and all types of exchange in an organism. PON syndrome develops.

Pathogeny of development of a syndrome of PON.
· Macrocirculation.
- Decrease in OTsK.
- Reduction of venous return.
- Decrease in cordial emission.
- Increase in vascular resistance.
- Decrease in perfusion of bodies and fabrics.
· Microcirculation.
- Increase in viscosity of blood.
- Development of hypercoagulation — the I stage of the IDCS.
- Aggregation of thrombocytes and other uniform elements of blood.
- Increase in permeability of vessels.
· System disturbances of perfusion.
- Decrease in oxygen capacity of blood.
- Decrease in kislorodotransportny function of blood.
- Decrease in delivery of oxygen to fabrics against the background of increase in his requirement.
- The local fabric hypoxia leading to development of acidosis.
- Functional disturbances of activity of bodies and fabrics with the subsequent development of alteration and formation of PON (cardiovascular insufficiency, acute respiratory insufficiency, acute pechyonochnopochechny insufficiency, an immunodeficiency, consecutive infections).

The traumatic shock observed at pregnant women has the expressed differences from nonpregnant that is caused by features of cardiovascular system, a hemodynamics and system of a hemostasis at pregnant women.

The blood circulatory system at pregnant women is not only under the regulating influence of neurohumoral and neuroendocrinal factors, but also reflex impulses from a zone of uteroplacental blood circulation. At pregnant women observe changes in system of a hemostasis. So, by the end of pregnancy there is an increase
amounts of fibrinogen. Since the II trimester of pregnancy, activity of pro-coagulants and thrombocytes increases and also the anticoagulating potential of blood decreases. Shortening of AChTV is established that demonstrates increase in maintenance of the factors of an internal link of system of a hemostasis characterizing activity of factors of II, V, VII, IX, X, XI, XII. Increase in structural properties of a blood clot is demonstrated by increase in an indicator of "ma" (amplitude) and an index of thromboplastic potential of a tromboelastogramma.

Aggregation activity of thrombocytes practically does not change, the platelet stickness slightly increases.

Thus, in process of pregnancy development blood coagulation potential gradually increases. By the time of childbirth increase in prothrombin activity, further increase in quantity of thrombocytes, concentration of fibrinogen and proconvertin is also at the time of delivery noted. Fibrinolitic activity practically does not change. Normalization of system of a hemostasis occurs to 3–6 weeks after the delivery.

At pregnant women with the stupid injury of a stomach which led to a hysterorrhesis, PONRP and pre-natal death of a fruit a large number of fabric factors of a placenta, OV can get to a blood stream. It attracts danger of emergence of the developed picture of the IDCS and massive koagulopatichesky bleeding.

At shock during pregnancy the fruit has a hypoxia, decrease in cordial emission, vasoconstriction in system of a pulmonary artery, centralization of blood circulation with receipt of bulk of blood in a brain and a myocardium.

Bleedings in pleural or in an abdominal cavity at pregnant women can lead to a lethal outcome both mother, and a fruit. For adequate compensation of blood loss it is necessary to determine blood loss volume.

Ways of scoping of blood loss.
· Gravimetric method.
· M. A. Libov's formula.

Blood loss volume = (the mass of the linen moistened кровью´К)/2,
where K=15 of % of mass of the linen moistened with blood at blood loss to 1000 ml, or K=30 of % of mass of the linen moistened with blood at blood loss more than 1000 ml.
· Formula M. I. Borovsky.
Blood loss volume = (1000'vyazkost blood)+ (60´Ht) –6060.
· Nelson formula.
Volume of blood (ml/kg)= [24 / (0,86'Ht)] ´100;
Blood loss volume =0,036'objyom krovi'massa tela'ht.
· V. A. Kulavsky's formula.
Blood loss volume = [(1–Ht the patient) ´0,2'massa sick] / is normal of Ht
· Shock index of Algovera-Burri (tab. 51-1).
Shock index = ChSS / system ABP,
· Definition of deficit of OTsK and volume of blood loss on clinical manifestations of shock.

The reasons of Injuries of an abdominal cavity during pregnancy:

The most frequent reasons of a stupid injury of a stomach during pregnancy — road accident, home accidents, falling.

To 60% of all stupid injuries of a stomach at pregnancy results from road and transport incidents.

Treatment of Injuries of an abdominal cavity during pregnancy:

The purpose of treatment of pregnant women with injuries — preservation of life and health of mother and a fruit.

INDICATIONS TO HOSPITALIZATION.
Getting injured — the indication to hospitalization even at satisfactory condition of the pregnant woman. As even without internal injury of a thorax and an abdominal cavity of mother and in the absence of injury of a uterus within three days after an injury at a contusion of a uterus premature patrimonial activity on any duration of gestation can begin.

NON-DRUG TREATMENT.
Non-drug treatment is carried out in two directions:
· akusherskoginekologichesky — a psychoprophylaxis of premature births;
· surgical — non-drug therapy of damages at not heavy changes (a change of a head of a beam bone in the typical place, an outside anklebone of a shin, etc.) consists in the closed manual reposition and an immobilization of an extremity plaster splints, etc.

Use of laser therapy, various physiotherapeutic and other methods of treatment carry out in two directions.

DRUG TREATMENT.
Drug treatment is also carried out in two directions: akusherskoginekologichesky and surgical.

At treatment of pregnant women with an injury, initial efforts have to be directed to the fastest stabilization of a condition of the woman with use of available methods of the resuscitation help and an intensive care. After performance of the specified actions the main attention can be directed to treatment of a fruit. Therapy of the complications revealed at a fruit demands cross-disciplinary approach with involvement of obstetricians-gynecologists, neonatolog and surgeons. Best "key" to rescue and survival of a fruit — effective treatment of mother.

Using medicamentous drugs for treatment of a traumatic disease and preservation of pregnancy, it is necessary to consider pharmacokinetics of drugs, lack of teratogenic and embriotoksichesky action; compatibility of various drugs, and also it is necessary to use drugs of the prolonged action with care. However, carrying out a number of diagnostic procedures and use during pregnancy of some drugs (including "not recommended by the instruction" for reception) during this period not always comes to the end with the child's birth with anomalies of development or other manifestations of teratogenic activity. The decision on continuation of pregnancy is made by the woman who obtained exhaustive information.

The general resuscitation actions same, as well as at other patients. At a stable condition of the pregnant woman with an injury treatment is appointed taking into account influence of methods and medicines on a fruit. All results of inspections and appointment have to be carefully reflected in the history of a disease as cases of injuries often are followed by judicial proceedings.

General resuscitation actions.

· Breath maintenance. At disturbance of passability of respiratory tracts and an apnoea the patient is intubated and begin IVL. The intubation of a trachea is shown also at a loss of consciousness (in order to avoid aspiration of contents of a stomach) and considerable injuries of a thorax.

· Blood circulation maintenance. Indications for cardiopulmonary resuscitation same, as at nonpregnant.

Serdechnolyogochny resuscitation is carried out carefully not to injure a pregnant uterus.

· Treatment of shock. Prevention of a syndrome of the lower vena cava.

· Assessment of a condition of the pregnant woman. Whenever possible collect the anamnesis and conduct careful physical examination, laboratory and tool researches, including a X-ray analysis. It helps to estimate weight of visible damages, and also to reveal the hidden damages. At changes carry out an immobilization by means of tires. At suspicion of an injury of uric ways establish an uric catheter and carry out a retrograde tsistografiya. Exclude a hemoperitoneum. At a palpation of a stomach estimate the sizes, a tone and morbidity of a uterus.

For definition of a condition of a neck of uterus, presentation, an integrity of a bag of waters and an exception of bleeding of a genital tract conduct vaginal examonation.

· Assessment of a condition of a fruit. After the 25-26th week of pregnancy continuous KTG is shown. This research is important not only for assessment of a condition of a fruit. The first manifestation of hypovolemic shock mother quite often has a pre-natal hypoxia registered by means of KTG. It is caused by reduction of placental blood circulation owing to the compensatory vasoconstriction providing maintenance of OTsK. For specification of gestational age of a fruit and diagnosis of defeat of a placenta carry out ultrasonography. For definition of a maturity of lungs of a fruit ratios of lecithin and sphingomyelin (the foam test) in OV received by amniocentesis carry out quality standard. At severe injuries and injuries of a stomach surely investigate blood on existence of fetalis erythrocytes.

· Prevention of tetanus. If data on vaccination against tetanus are absent, or from the moment of the last vaccination there passed more than 5 years, enter tetanic anatoxin in a dose of 0,5 ml intramusculary, with the subsequent introduction of two more doses of anatoxin. In cases of extensive damage of fabrics (at the getting wounds and a deep necrosis of fabrics), except anatoxin, enter antitetanic immunoglobulin in a dose 250-500 ME intramusculary once. In especially hard cases appoint antimicrobic therapy.

· Posthumous Cesarean section. At fast or inevitable death of mother it is necessary to prepare everything for delivery. In literature many cases of posthumous KS are described. Viability of a fruit depends on the term which passed from the moment of a blood circulation stop at mother. It should not exceed 4–6 min. though cases of extraction of live fruits later after a blood circulation stop at the pregnant woman are described more than 10 min. If at the woman there came the blood circulation stop, cardiopulmonary resuscitation is continued before extraction of a fruit. Cases of successful cardiopulmonary resuscitation of mother after KS are noted. If time of approach of death is unknown, then delivery is made only at a live fruit. At an unstable condition of pregnant KS it is contraindicated as it can provoke a blood circulation stop (in particular, at the expense of blood loss). At efficiency of cardiopulmonary resuscitation of KS postpone and carry out prevention of a pre-natal hypoxia.

TREATMENT OF MASSIVE BLOOD LOSS AND HEMORRHAGIC SHOCK.

Main objective of therapy of shock — optimization of transport of oxygen.

Medical actions have to be directed on:
· elimination of the reason of shock (bleeding stop);
· recovery of OTsK;
· increase in contractility of a myocardium and regulation of a vascular tone;
· elimination of a hypoxia of bodies and fabrics;
· correction of the broken exchange processes;
· treatment of various complications.

The central place in treatment of hemorrhagic shock is taken by infusion-transfusion therapy, auxiliary — an oxygenotherapy and carrying out a discrete plasma exchange by a standard technique.

Necessary conditions of performing infusional therapy — respect for staging of treatment and control of the vital functions of an organism (especially behind system of a hemostasis).

Treatment of the hypovolemic shock caused by blood loss is directed to the termination of losses of plasma and blood, bystry recovery of OTsK, elimination of deficit of intersticial liquid and correction of volume of the circulating erythrocytes.

Bystry recovery of OTsK is reached infusion of colloidal solutions — drugs of starch and a dextran. As colloidal solutions use plasma, albumine drugs, dextrans, gelatin and the hydrohydroxyethylated starch: 6 and 10% ХАЕС-стерил© (hydroxyethylstarch), ONKOHAS, 6%

Voluven©; (hydroxyethylstarch). The specified solutions, without having ability to transfer oxygen, nevertheless, improve haemo transport function of blood thanks to increase in OTsK, cordial emission, increase of a circulation time of the erythrocytes which remained in a vascular bed. Besides, solutions of starch improve rheological properties of blood and recover a blood stream in microvessels.

Considering development of a hypoglycemia at massive blood loss inclusion in the infusional transfusion program of solutions of the concentrated carbohydrates (10% and 20%) is reasonable. Administration of solutions of glucose promotes not only to recovery of energy resources, but also exponentiates hemodynamic effect of solutions of hydrooxyethylstarch. The transfusion of freshly frozen plasma in a dose not less than 15 ml/kg of body weight is necessary for correction of hemocoagulative potential and recovery of oncotic balance. The last contains both labile, and stable factors of coagulation and a fibrinolysis in their natural physiological ratio. The timely beginning of a transfusion of donor freshly frozen plasma in necessary volume, allows to compensate quickly a hypocoagulative stage of the IDCS and to prevent development of a syndrome of PON. At the same time, in order that it is fuller to stop processes of disturbance of hemocoagulation, it is necessary to use inhibitors of proteolytic proteases. One of the most important properties of inhibitors of proteases — their ability to regulate relationship between systems of coagulation, a fibrinolysis and kininogenez. These drugs increase resistance of fabrics to air hunger.

At activation of a fibrinolysis and development of koagulopatichesky bleedings with formation of consumption coagulopathies it is necessary to block effect of plasmin. Traneksaminovy acid has such property.

Transaminum in a dose of 500-700 mg competitively inhibits receptors of plasmin and plasminogen, thereby interfering with fixing of the last to fibrin that prevents fibrinogen degradation. Recovery of globular volume needs to be carried out under control of concentration indicators. Sufficient it is possible to consider the maintenance of Hb of ³80 g/l, Hb of ³25%. The aspiration to reach higher rates leads to emergence of a syndrome of massive hemotransfusions with possible development of posttransfusion complications. The specified infusion-transfusion program is carried out against the background of glucocorticoid therapy (Prednisolonum not less than 10 mg/h on body weight kg) also by administrations of inhibitors of proteolysis (not less than 10 000 ME/h).

In recent years the recombinant activated factor of VII — the drug Novoseven© is recognized as the universal hemostatic which is effectively stopping and warning the most various spontaneous and postoperative hemorrhages [эптаког an alpha (activated)]. The recommended drug dose for intravenous jet administration — 60–90 mkg/kg.

At the following stage continue administration of freshly frozen plasma in calculation of 10 mg/kg or proteinaceous drugs (albumine, a protein). Correction of electrolytic disturbances is carried out by solutions like asparaginate kaliymagniya.

Normalization of microcirculation is carried out introduction of dezagregant (trental, аспизол and др). For regulation of metabolic processes recommend administration of ATP (drug of the choice should be considered неотон© (phosphocreatinine) in a dose of 6 g/days).

SURGICAL TREATMENT.

The most often surgical treatment at pregnant women should be carried out at a stupid injury of a stomach. In process of increase in the sizes of a uterus the risk of its damages and a fruit at a stomach injury increases. The most serious consequences for mother and a fruit have the injuries received at car accidents.

Effects for a fruit.

On early durations of gestation owing to shock-absorbing action of OV the stomach injury seldom is followed by damage of a fruit. It is shown that in this period the stupid injury of a stomach does not increase risk of a misbirth. At the full-term pregnancy when the head of a fruit is in an entrance to a small pelvis, the stupid injury of a stomach can lead to a fracture of bones of a skull, intracraneal hemorrhage and death of a fruit.

Effects for mother.

Intra belly bleeding. The ruptures of a liver, spleen and large vessels leading to massive intra belly bleeding are characteristic of an automobile injury. In this regard, to all pregnant women with a severe stupid injury of a stomach for timely diagnosis of a hemoperitoneum appoint кульдоцентез (in early durations of gestation) or diagnostic peritoneal lavage (in late terms). Through a section of a front abdominal wall above a navel enter a catheter for peritoneal dialysis and, directing it towards a small pelvis, wash out an abdominal cavity Ringer's solution with a lactate of 1000 ml. Washing waters subject to a research. At doubtful result lavage is repeated. At a stupid injury of a stomach in the I trimester of pregnancy if it is impossible to exclude intra belly bleeding or an internal injury, carry out also diagnostic laparoscopy. In II and the III trimester of pregnancy performance of a diagnostic laparoscopy is also possible, but on these terms preference is given to a monitoring laparoscopy. Contraindications to carrying out a laparoscopy consider sharp abdominal distention, existence of multiple hems on a front abdominal wall, and also the critical condition of the pregnant woman caused by shock, injury of a breast, brain as pneumoperitoneum volume significantly influences not only FVD, but also hemodynamics indicators. Imposing of a big pneumoperitoneum is absolutely contraindicated at suspicion on a rupture of a diaphragm as it will quickly lead to a tension pneumothorax and death of mother and a fruit.

For diagnosis of free liquid (blood, exudate, intestinal contents, urine, transudate) in an abdominal cavity at pregnant women with a stupid injury of a stomach, additional tool researches, since neinvaziny methods apply. Ultrasonography of a stomach authentically reveals liquid (blood) in an abdominal cavity and in a pericardium cavity, however in 25% of observations it does not allow to find the isolated damages of parenchymatous bodies. The X-ray analysis method can also help to reveal free liquid in an abdominal cavity (as emergence of pristenochny tape-like shadows in lateral channels also expansion of interloopback intervals radiological is expressed). KT — the objective diagnostic method which is most precisely revealing the nature of damages of parenchymatous bodies. However this method of a research quite long is also not shown at serious condition of the pregnant woman. In such cases for an exception of intra belly bleeding and an internal injury preference is given to invasive methods of a research: to a laparocentesis, kuldoskopiya, laparoscopy.

At suspicion on a rupture of the bladder and urethras estimate results of its catheterization and on indications carry out a X-ray contrast tsistografiya, an uretragrafiya. At confirmation of this diagnosis carry out the emergency operational treatment.

Detection of blood in an abdominal cavity — the absolute indication to the emergency surgical intervention, a stop of bleeding and sewing up of the injured internals. Optimum quick access — a median laparotomy with a navel bypass at the left. The volume and types of the carried-out operative measures at an internal injury at pregnant women same, as well as at other patients. However maintaining tactics in the postoperative period is various and depends on duration of gestation, duration of operational treatment, existence of purulent peritonitis, age of the pregnant woman, existence of the accompanying pathology, estimated complications in the postoperative period. The main strategic direction at stomach injuries at pregnant women on early terms (I and II trimesters) — preservation and prolongation of pregnancy.

In the presence of purulent peritonitis carry out adequate sanitation of an abdominal cavity and its broad drainage. Carry out complex treatment of peritonitis. Antibacterial and other medicamentous therapy is selected rationally taking into account the term of a gestation and lack of teratogenic influence of drug on a fruit.

In II and III trimesters of pregnancy, in the absence of injury of a uterus and placental detachment more than for 30%, perform the operations directed to a final stop of bleeding (sewing up of parenchymatous bodies, a resection, etc.).

At placental detachment more than for 30% and at duration of gestation more than 26 weeks are made by KS.

In the presence of purulent peritonitis and lack of signs of the progressing placental detachment of KS do not carry out, and carry out complex treatment of peritonitis. If in this situation because of placental detachment there is a threat of life of a fruit, then carry out operation KS, sanitation and drainage of an abdominal cavity, with obligatory adequate antibacterial therapy in the postoperative period. In late durations of gestation the uterus can prevent audit of an abdominal cavity, however KS seldom happens it is necessary.

Injury of a uterus. The hysterorrhesis occurs less than at 1% of the pregnant women who got injured on a stomach in a car accident. If the blow is necessary directly to the area of a uterus, then its gap occurs almost always, even on early durations of gestation (hysterorrheses on the term of 12 weeks are described). At massive bleeding the emergency surgical intervention is shown. At an extensive rupture or damage of large vessels of a uterus its extirpation is shown. Except a gap, the stupid injury of a stomach can cause premature births, premature izlity OV and damage of a placenta.

Damage of a placenta. PONRP develops at pregnant women with a severe injury of a stomach rather often (7–66% of cases). As showed researches, the main reason for death of a fruit at road accident — death of mother. At a trip in the car pregnant women have to use seat belts. At accident belts can injure a uterus, however the risk of it is not comparable with advantage — the prevention of death of the woman. PONRP is possible at a long prelum of the lower vena cava when as a result какойлибо injuries the pregnant woman is forced to be in a dorsal decubitus long.

The abdominal pain and increase in a tone of a uterus are characteristic of PONRP bleeding from a genital tract. In 20% of cases of outside bleeding does not happen. Symptoms of the pre-natal hypoxia of a fruit connected with the hidden placental detachment can be recorded at KTG. Placental detachment can be delayed (up to 5 days after an injury). In this regard to pregnant women with heavy damages during 48 h carry regularly out determination of level of fibrinogen. Normal at pregnant women it is raised. Content of fibrinogen lower than 250 mg of % (norm for nonpregnant) can be a precursory symptom of placental detachment. For an exception of a retroplacental hematoma carry out ultrasonography.

Feto-materinsky transfusion. At a stupid injury of a stomach, irrespective of existence or lack of placental detachment, chorion vorsina can be damaged. At the same time blood of a fruit gets to intervillous space, and from there — to mother's blood stream. The feto-maternal transfusion which can cause anemia of a fruit and the newborn, a pre-natal hypoxia and death of a fruit, and also mother's isosensitization erythrocyte Ag of a fruit develops. The diagnosis is confirmed at detection of fetalis erythrocytes in the smear of maternal blood painted according to Kleykhauer-Betke. This research of a smear allows to estimate also weight of a feto-maternal transfusion and to calculate a dose of anti-Rh0(D) - immunoglobulin (immunoglobulin of the person an anti-Rhesus factor of Rho [D]) for introduction to pregnant women with rezusotritsatelny blood.

TACTICS OF MAINTAINING PREGNANT WOMEN WITH THE INJURY.

At a severe injury of any localization and duration of gestation more than 25-26 weeks continuous KTG and careful observation during 48 h for PONRP exception are shown. At a stomach injury observation of the pregnant woman and continuous KTG spend longer period. Detection also serves as the indication for more long observation in blood of mother of fetalis erythrocytes.

The getting stomach wounds. Injury of abdominal organs and death of the pregnant woman at the getting wounds observe seldom as internals are protected by a pregnant uterus. Prevalence of injuries of abdominal organs, apart from a uterus, at the getting stomach wounds (including fire) makes 19%. Wounds and death of a fruit observe more often — 60–90% and 40–70% of cases respectively.

Gunshot wounds. As abdominal organs are injured seldom, the lethality is low. If inlet opening of the wound channel is located below an uterine fundus, and at roentgenoscopy it is revealed that the bullet is in a projection of a uterus and the movement of a fruit are absent, carry out conservative treatment. During the developing of peritonitis or symptoms of an internal injury the laparotomy is shown. At wound of a uterus make bandaging of the bleeding vessels. At hit of a bullet in a cavity of the uterus the fruit most often perishes. If the uterus does not stir audit of an abdominal cavity, and a condition of the pregnant woman stable, KS is not required. If the fruit died, delivery is carried out after surgical intervention. The risk of an amnionitis at the getting wound of a uterus is small. If the fruit is live, KS make if at pregnancy preservation the risk of complications at a fruit is higher, than at premature births.

Chipped wounds. At the wound which is not getting into an abdominal cavity (confirmed by means of a X-ray analysis after introduction of contrast to the wound channel), observation is shown. At the getting wound of lower parts of a stomach usually there is an injury of a uterus; much more rare — abdominal organs. At absence of damage of abdominal organs and a stable condition of the pregnant woman, carry out conservative treatment. At the getting wound of upper parts of a stomach, the laparotomy and audit of abdominal organs is shown.

TERMS AND METHODS OF DELIVERY.

In each case the question of terms and methods of delivery is solved individually.

In the first trimester of pregnancy at women with a severe injury when at treatment used a broad set of medicines (including possessing embriotoksichesky action) it is reasonable, after stabilization of a condition of the patient, abortion in a planned order. At emergence of clinical manifestations of the begun abortion, an operative measure (a uterus scraping) is carried out in the emergency order.

In II and III trimesters of pregnancy terms and a method of delivery directly depend on the developed obstetric situation. Operation KS is carried out in the emergency order at the progressing placental detachment (more than 30%). At hysterorrheses radical surgical intervention — a hysterectomy is shown. Pregnancy is prolonged in the absence of indications for the emergency surgical intervention. The delivery method at the full-term pregnancy will depend on character traumatized and existence of the accompanying gestation complications.

At the beginning of patrimonial activity or an otkhozhdeniya of OV delivery in natural patrimonial ways is reasonable.

At diagnosis of pre-natal death of a fruit, the choice of a method of delivery will depend on the term of the gestation and character which was traumatized. At the uterus sizes to 17 weeks of pregnancy fetal egg is deleted in one step, under control of a hemostasis. This operation is performed after preliminary preparation of a neck of uterus hydrophilic laminarias during 12 h. At the uterus sizes more than 17 weeks and absence of heavy extragenital pathology, it is reasonable to use the program of the induced childbirth.