Rupture of a neck of a uterus
Rupture of a neck of a uterus — traumatic violation of integrity of walls of body at the time of delivery or invasive interventions. It is shown by bleeding of various intensity with release of bright red blood in potuzhny and early posledovy the periods. Major importance for diagnostics is played by audit of walls of a neck with use of wide mirrors. At detection of a gap surgery which volume is defined by a damage rate and the accompanying complications is shown. Usually the neck of a uterus is taken in through vaginal access. Upon transition of a gap to walls of a uterus or detection of a hematoma in parametralny cellulose band operation is carried out.
Rupture of a neck of a uterus
The majority of primipara has side anguishes (cracks) of edges of an external uterine pharynx which sizes do not exceed 1 cm. Such damages are not pathological, are followed by the insignificant volume of bloody allocations and do not need an ushivaniye. After their healing the external pharynx of a uterus becomes slit-like that demonstrates the postponed childbirth. The uterus neck injury with more than centimetric gap, according to various data, is observed in 6-15% of childbirth and is one of widespread obstetric injuries. Usually it arises at the women who are giving rise for the first time is much more rare – at povtornorodyashchy. As not diagnosed gap serves as the cause of many gynecologic diseases, special survey for an exception of this pathology is shown to all women in childbirth.
Reasons of a rupture of a neck of a uterus
There are several groups of the factors capable to cause such trauma of patrimonial ways. The risk of injury of a neck in the course of childbirth significantly increases at a rigidnost or a loosening of its fabrics to which can lead:
- Inflammatory diseases. At a chronic tservitsit soyedinitelnotkanny Strom of body of an infiltrirovan it is also condensed because of what disclosure of a uterine pharynx worsens.
- Age changes. At primipara 30 years in tissues of a neck are more senior the amount of elastic fibers decreases that reduces their tensile strength.
- Cicatricial deformation. The tensile properties of fabrics worsen owing to formation of soyedinitelnotkanny hems after the gaps postponed earlier and medical manipulations (a diatermokoagulyation, cryodestruction, laser vaporization, a konization, etc.).
- Distotion of a uterus neck. Because of the dicoordinated patrimonial activity of edge of body instead of smoothing and relaxation are condensed, become thick and rigidny.
- Prelying of a placenta. The attachment and development of an afterbirth in lower uterine a segment and area of a pharynx leads to a loosening of tissues of neck of a uterus that increases risk of their gap.
- Rapid childbirth. At rough patrimonial activity the fruit passes through insufficiently maleficiated and opened uterus neck, injuring edges of her pharynx.
- Incomplete disclosure of a pharynx. Problems with smoothing of a neck of a uterus can arise at weakness of patrimonial activity, insufficient volume or premature izlitiya of amniotic waters. The body is also damaged at stimulation of attempts before its full disclosure.
- Hypoxia of fabrics. Durability of a neck decreases at violation of its food because of long squeezing between a head of the child and a bone ring. Such state arises at women in labor with a narrow basin more often.
The probability of a trauma also increases at excess loads of edges of an external pharynx. Can lead to a gap:
- Childbirth by a large fruit. The circle of a head of the child weighing more than 4 kg in most cases exceeds the sizes to which the external pharynx can stretch. The similar situation arises at the child's birth with hydrocephaly.
- Razgibatelny provision of a fruit. In such cases not only the physiological mechanism of childbirth is broken or they become impossible, but also patrimonial ways are more often injured.
- Surgical manipulations. The neck of a uterus is injured when imposing obstetric nippers, using a vacuum extractor, extraction of the child the pelvic end, etc. Out of childbirth gaps can be observed at rough carrying out invasive manipulations.
The mechanism of traumatic injury of a neck of a uterus is based on discrepancy between ability of fabrics to stretching and considerable loadings which arise in labor. At first elastic fibers well cope with the efforts created by a fruit head, tools for obstetric aid or the obstetrician's hand. At restretching fabric becomes thinner, and blood vessels which feed it are pressed. There is a hypoxia leading to development of dystrophic processes. Finally integrity of fabrics is broken.
The gap usually is radial longitudinal, is more rare — star-shaped. In certain cases the necrosis happens so expressed that is followed by full rejection of a forward lip. If the unprepared neck of a uterus is affected by considerable loadings, the full circular separation of its vaginal part is possible. In some cases at late spontaneous abortions and premature birth the so-called "central" gap with formation of the false course in a back wall of a neck of a uterus with a diameter of 1,5-2,0 cm over the uninjured external pharynx is observed.
At assessment of type and characteristics of damage consider the mechanism of its formation, the sizes and existence of complications. Depending on the reasons which caused violation of integrity of a neck of a uterus distinguish gaps:
- Spontaneous — arisen spontaneously in the course of patrimonial activity against the background of a rigidnost or excessive stretching.
- Violent — provoked by rodorazreshayushchy vaginal interventions for acceleration of process of childbirth.
Taking into account the size gaps happen three degrees:
- The I degrees — one - or bilateral injury of a neck of a uterus up to 2 cm long.
- The II degrees — the sizes of a gap exceed 2 cm, however it not less than on 1 cm does not reach the vagina arch.
- The III degrees — the gap reaches the vaginal arches and passes to them.
- Ruptures of the III degree.
- The gaps passing for an internal uterine pharynx.
- Gaps in which the peritoneum or surrounding a uterus of parametriya is involved.
- Circular separation of a neck of a uterus.
Symptoms of a rupture of a neck of a uterus
In case of small damages by the sizes to 1 cm the clinical symptomatology usually is absent. The main manifestation of a rupture of a neck of a uterus is bleeding. Sometimes its signs can be observed already during exile when the born parts of a fruit are covered with bright red blood. However usually bleeding arises or the miometriya amplifies after the child's birth, despite good sokratitelny activity. At the same time blood from a vagina flows a stream or is emitted in a significant amount. Less often it contains many clots. If the gap arose against the background of big razmozzheniye at long squeezing of fabrics, bleeding are observed not always as vessels manage to trombirovatsya. In similar cases and at damage of sites without large vessels of blood it is usually allocated a little that increases the importance of postnatal survey of a neck in mirrors.
At damage of a cervical and vaginal branch of a uterine artery the rupture of a neck of a uterus can be complicated by profuzny bleeding. Because of considerable blood loss skin and mucous women in childbirth turn pale, the woman complains of weakness, dizziness, cold sweat, can faint. At untimely assistance at the patient the hemorrhagic shock posing a threat for life develops. The deep damages reaching the vaginal arch can be followed by a rupture of a uterus and massive hemorrhage in parametry. At the passed and not taken in rupture of a neck the risk of development of a parametritis, postnatal endometritis, and significantly increases in the subsequent — an ektropiona, a chronic endotservitsit, an erosion, neoplaziya. The remote consequences are cicatricial deformation of a neck, istmiko-tservikalny insufficiency with pregnancy not incubation, formation of a cervical and vaginal fistula.
Postnatal bleedings arise both at ruptures of a neck of a uterus, and at other pathological states. Therefore for the correct diagnosis carry out:
- External obstetric research. After the delivery the uterus was well reduced. At the emptied bladder its bottom is located below a navel.
- Survey in mirrors. By means of wide mirrors, bullet or gemorroidalny nippers audit of a neck with extension of edges of a pharynx and survey of all folds is carried out.
At identification of a rupture of the 3rd degree uterus walls for an exception of their damage manually are examined. Differential diagnostics is carried out with a rupture varikozno of expanded veins of a vagina, postnatal hypotonia and an atoniy uterus, a delay to her cavities of covers of a fruit or segments of a placenta, development of the DVS-syndrome. If necessary involve the anesthesiologist, the therapist, the surgeon in diagnosis and maintaining the woman in childbirth.
Treatment of a rupture of a neck of a uterus
At detection of a pathological gap integrity of body is restored surgically. The choice of surgery depends on extent of damages and existence of complications. The damaged site is taken in transvaginalno the resolving material, the seam is imposed on all thickness of fabric except for an endotserviks. If the gap passing for an internal pharynx, or hemorrhage into parametry is found the laparotomy during which the bleeding stop is carried out is recommended, the hematoma is removed. In the postoperative period protivoanemichesky medicines are shown. For prevention of infectious complications usually appoint a short course of antibacterial therapy.
Forecast and prevention
The forecast at uncomplicated gaps favorable. In the presence of complications results depend on timeliness and adequacy of treatment. A key role in prevention of gaps is played by correctness of conducting childbirth and reasonable use of methods of an operational rodorazresheniye in the presence of the corresponding indications. In exceptional cases at high probability of a gap because of a rigidnost, narrow conical shape of a neck or need of an urgent rodorazresheniye at incomplete disclosure of a pharynx the trakhelotomiya (operation on a section of walls of the tservikalny channel) can preventively be carried out.