- violations of the anatomical integrity of the tissues of the cervix or the body of the uterus, caused by the effects of mechanical, chemical, thermal, radiation and other factors. Damage to the uterus is usually accompanied by bleeding, pain in the lower abdomen; the formation of fistulas is possible. In the future, such injuries can lead to miscarriage or infertility. Damage to the uterus is detected by gynecological examination, cervicoscopy, hysteroscopy, ultrasound, diagnostic laparoscopy. Treatment tactics (conservative or operative) depend on the type of damaging factor and the nature of the injury.
Damage to the uterus - various kinds of injuries leading to the formation of anatomical defects and dysfunction of the organ. Most often occur during medical interventions and childbirth, but can occur outside of these events. Uterine injuries in gynecology include bruises, ruptures, perforations, fistulas, radiation, chemical and thermal injuries. Damage to the uterus often requires emergency assistance, since it is accompanied by bleeding, painful shock, infection, and in the future can lead to serious reproductive disorders. Birth injuries are considered in detail by us separately, since they have their own causes and characteristics. With regard to injuries of the internal genitals associated with bruises, intrauterine manipulations, operations or sexual intercourse, they account for approximately 0.5% of all causes of hospitalization in gynecological hospitals.
Injuries such as rupture of the cervix or uterine body are more likely to occur during childbirth, but can also occur during induced abortion or diagnostic curettage. Birth trauma is usually associated with the birth of a large fetus, rapid labor, cicatricial deformity or stiffness of the cervix, the use of obstetric aids in childbirth (the imposition of obstetric forceps, vacuum extraction of the fetus and fetal destruction operations, etc.). The reason for the rupture of the uterus, as a rule, becomes the failure of the scar left after a cesarean section, myomectomy, and suturing of the uterus. In these cases, rupture of the uterus along the scar is possible during the next pregnancy and labor.
Damage to the uterus, such as ruptures, is sometimes observed when foreign objects with a sharp end are introduced into the vagina. Traumatic necrosis of the cervix develops as a result of compression of the cervix between the walls of the woman's pelvis and the head of the fetus. A similar situation can occur with a narrow pelvis, weak labor, cicatricial deformity of the cervix. Perforation of the uterus is associated with iatrogenic causes - erroneous or rude actions of the medical staff during abortion, probing of the uterine cavity, RFE, hysteroscopy, the introduction of an intrauterine contraceptive and other intrauterine procedures. Various pathological conditions can also contribute to the perforation of the uterine wall: postoperative scars, endometrial cancer, endometritis, etc.
Uterine bruises are more common in pregnant women; they can be caused by a fall, hit to the abdomen with a blunt object, or a car accident. Abdominal, vesicouterine, ureteral-uterine fistulas can occur due to birth trauma, surgical interventions with secondary wound healing, iatrogenic damage to the bladder or ureters during gynecological operations, the collapse of malignant tumors, radiation exposure, etc.
Thermal and chemical damage to the uterus is rare. Thermal injuries usually occur from douching with too hot solutions. Chemical damage to the uterus can be caused by the use of cauterizing substances (silver nitrate, acetic or nitric acid), as well as the deliberate introduction of chemicals into the uterine cavity for the purpose of criminal abortion.
The risk of such damage to the uterus increases in pregnant women in proportion to the increase in gestational age. Isolated bruises of the uterus can provoke spontaneous abortion at any time, premature placental abruption or premature birth. These complications are usually indicated by bloody discharge from the genital tract, abdominal pain, increased uterine tone. In case of damage to the chorionic villi, fetal-maternal transfusion may develop, in which the blood of the fetus enters the bloodstream of the pregnant woman. This condition is dangerous by the development of fetal anemization, fetal hypoxia, and intrauterine death. In severe blunt trauma to the abdomen, ruptures of the liver, spleen, uterus are also possible, and therefore massive intra-abdominal bleeding develops.
To determine the severity of the injury, the condition of the pregnant woman and the fetus, in addition to traditional physical and laboratory tests, a gynecological examination, ultrasound of the uterus and fetus, CTG are performed. In order to detect blood in the pelvic cavity, culdocentesis or peritoneal lavage is performed.
Treatment of uterine injuries and their consequences is carried out taking into account the severity of the injury and the gestational age. With mild bruises and early gestation, dynamic observation with ultrasound control and CTG monitoring can be carried out. At a gestational age close to full-term, the question of early delivery is raised. If blood is found in the abdominal cavity, an emergency laparotomy is performed, bleeding stops and the damaged organs are sutured. Feto-maternal transfusion may require intrauterine blood transfusion.
Minor cervical ruptures may be asymptomatic. With extensive and deep defects, bloody discharge of a bright red color appears: blood can flow out in a trickle or stand out with clots. Cervical ruptures are usually recognized clinically or by examining the cervix in mirrors. With such injuries, catgut sutures are applied to the cervix. If such damage to the uterus was not detected in time or correctly sutured, in the future they can be complicated by the formation of hematoma in the parametrium, cervicitis, postpartum endometritis, ectropion and erosion of the cervix.
Rupture of the uterus is accompanied by acute cutting pain in the abdomen, pallor of the skin and mucous membranes, falling blood pressure, cold sweat. If the rupture occurs in the active phase of labor, then labor stops. There are signs of intra-abdominal bleeding and bleeding from the genital tract. Parts of the fetus are defined directly under the anterior abdominal wall. The general condition of the patient is extremely difficult. Damage to the uterus by the type of rupture is diagnosed on the basis of a general objective and external obstetric examination, ultrasound, cardiotocography. In this case, immediate delivery by cesarean section, revision of the uterus and abdominal cavity is indicated. Possible surgical options are tear closure, supravaginal amputation, or radical removal of the uterus.
When the uterine wall is perforated with a surgical instrument, intra-abdominal or mixed bleeding develops. At the same time, patients feel a sharp pain in the lower abdomen, complain of bloody discharge, dizziness and weakness. With massive internal bleeding, arterial hypotension, tachycardia, and pallor of the skin are noted. Along with damage to the uterus, injury to the bladder or intestines can occur. The most common complication of uterine perforation is peritonitis.
Perforation of the uterine wall can be recognized even during intrauterine manipulation by characteristic features (feeling of "failure" of the instrument, visualization of intestinal loops, etc.). The diagnosis in this case is confirmed by the data of hysteroscopy, transvaginal ultrasound of the pelvic organs. The main method of treatment of perforating injuries of the uterus is surgical (tear suturing, subtotal or total hysterectomy).
Abdominal fistulas connect the uterine cavity with the anterior abdominal wall and are external. The outlet opening of the fistulous tract often opens in the area of the suture or postoperative scar. The presence of a fistula is supported by inflammatory infiltration of the fistulous tract. It is manifested by the periodic release of blood and pus through the cutaneous opening of the fistula. Fistulas are found during examination and hysteroscopy. Treatment - excision of the fistulous passage and suturing of the uterus.
The main signs of a vesicouterine fistula are cyclical menouria (Yussif's symptom), the discharge of urine from the vagina, the symptom of "laying" the urine stream when blood clots form in the bladder, and secondary amenorrhea. Uretero-uterine fistulas are manifested by urine leakage from the vagina, lower back pain, fever due to hydroureteronephrosis. Genitourinary fistulas are detected during examination of the vagina in the mirrors, cystoscopy, hysterography. Treatment - surgical closure of fistulas (fistuloplasty), plastic ureter.
Uterine-intestinal fistulas may result from perforation of the uterus with damage to the intestine, breakthrough into the intestine of an abscess that developed after conservative myomectomy or cesarean section. The course of intestinal-uterine fistulas of inflammatory genesis is recurrent. Before the breakthrough of the abscess into the large intestine, pains in the lower abdomen, hyperthermia, chills, tenesmus increase. Mucus and pus appear in the stool. After emptying the abscess, the patient's condition improves. However, due to the fact that the fistulous opening quickly undergoes obliteration, pus soon again accumulates in the abscess cavity, which causes a new exacerbation of the disease.
For diagnostics, examination of the vagina using mirrors, combined gynecological ultrasound, rectovaginal examination, sigmoidoscopy, fistulography, CT and MRI of the pelvis are used. The tactics for this kind of pathology are only surgical; includes "intestinal" and "gynecological" stages. The details of the intervention are determined by the operating gynecologist and proctologist. Excision of necrotic tissue and restoration of intestinal integrity is usually combined with supravaginal amputation or extirpation of the uterus.
In the acute period after damage to the uterus of this kind, the clinic of endomyometritis develops. Worried about an increase in body temperature, pain in the lower abdomen, sometimes - bloody discharge caused by the rejection of the necrotically altered uterine mucosa. Such injuries can be complicated by peritonitis and sepsis. After healing of thermal and chemical injuries, cicatricial changes in the cervix, atresia of the cervical canal, and intrauterine synechiae can form. In the long-term period, the development of hypomenstrual syndrome or amenorrhea, infertility is likely.
Diagnostics is based on clarifying the anamnesis (identifying the fact of the introduction of hot solutions or chemicals into the vagina), examination data of the cervix in the mirrors, gynecological ultrasound. Treatment is detoxification and antibacterial therapy. With the development of peritonitis, laparotomy, sanitation and drainage of the abdominal cavity are carried out; with extensive necrotic damage to the uterus - extirpation of the organ. In the future, to restore the patency of the cervical canal, it is bougienated. In Asherman's syndrome, hysteroscopic separation of synechia is shown.
- violations of the anatomical integrity of the tissues of the cervix or the body of the uterus, caused by the effects of mechanical, chemical, thermal, radiation and other factors. Damage to the uterus is usually accompanied by bleeding, pain in the lower abdomen; the formation of fistulas is possible. In the future, such injuries can lead to miscarriage or infertility. Damage to the uterus is detected by gynecological examination, cervicoscopy, hysteroscopy, ultrasound, diagnostic laparoscopy. Treatment tactics (conservative or operative) depend on the type of damaging factor and the nature of the injury.
Damage to the uterus - various kinds of injuries leading to the formation of anatomical defects and dysfunction of the organ. Most often occur during medical interventions and childbirth, but can occur outside of these events. Uterine injuries in gynecology include bruises, ruptures, perforations, fistulas, radiation, chemical and thermal injuries. Damage to the uterus often requires emergency assistance, since it is accompanied by bleeding, painful shock, infection, and in the future can lead to serious reproductive disorders. Birth injuries are considered in detail by us separately, since they have their own causes and characteristics. With regard to injuries of the internal genitals associated with bruises, intrauterine manipulations, operations or sexual intercourse, they account for approximately 0.5% of all causes of hospitalization in gynecological hospitals.
Injuries such as rupture of the cervix or uterine body are more likely to occur during childbirth, but can also occur during induced abortion or diagnostic curettage. Birth trauma is usually associated with the birth of a large fetus, rapid labor, cicatricial deformity or stiffness of the cervix, the use of obstetric aids in childbirth (the imposition of obstetric forceps, vacuum extraction of the fetus and fetal destruction operations, etc.). The reason for the rupture of the uterus, as a rule, becomes the failure of the scar left after a cesarean section, myomectomy, and suturing of the uterus. In these cases, rupture of the uterus along the scar is possible during the next pregnancy and labor.
Damage to the uterus, such as ruptures, is sometimes observed when foreign objects with a sharp end are introduced into the vagina. Traumatic necrosis of the cervix develops as a result of compression of the cervix between the walls of the woman's pelvis and the head of the fetus. A similar situation can occur with a narrow pelvis, weak labor, cicatricial deformity of the cervix. Perforation of the uterus is associated with iatrogenic causes - erroneous or rude actions of the medical staff during abortion, probing of the uterine cavity, RFE, hysteroscopy, the introduction of an intrauterine contraceptive and other intrauterine procedures. Various pathological conditions can also contribute to the perforation of the uterine wall: postoperative scars, endometrial cancer, endometritis, etc.
Uterine bruises are more common in pregnant women; they can be caused by a fall, hit to the abdomen with a blunt object, or a car accident. Abdominal, vesicouterine, ureteral-uterine fistulas can occur due to birth trauma, surgical interventions with secondary wound healing, iatrogenic damage to the bladder or ureters during gynecological operations, the collapse of malignant tumors, radiation exposure, etc.
Thermal and chemical damage to the uterus is rare. Thermal injuries usually occur from douching with too hot solutions. Chemical damage to the uterus can be caused by the use of cauterizing substances (silver nitrate, acetic or nitric acid), as well as the deliberate introduction of chemicals into the uterine cavity for the purpose of criminal abortion.
The risk of such damage to the uterus increases in pregnant women in proportion to the increase in gestational age. Isolated bruises of the uterus can provoke spontaneous abortion at any time, premature placental abruption or premature birth. These complications are usually indicated by bloody discharge from the genital tract, abdominal pain, increased uterine tone. In case of damage to the chorionic villi, fetal-maternal transfusion may develop, in which the blood of the fetus enters the bloodstream of the pregnant woman. This condition is dangerous by the development of fetal anemization, fetal hypoxia, and intrauterine death. In severe blunt trauma to the abdomen, ruptures of the liver, spleen, uterus are also possible, and therefore massive intra-abdominal bleeding develops.
To determine the severity of the injury, the condition of the pregnant woman and the fetus, in addition to traditional physical and laboratory tests, a gynecological examination, ultrasound of the uterus and fetus, CTG are performed. In order to detect blood in the pelvic cavity, culdocentesis or peritoneal lavage is performed.
Treatment of uterine injuries and their consequences is carried out taking into account the severity of the injury and the gestational age. With mild bruises and early gestation, dynamic observation with ultrasound control and CTG monitoring can be carried out. At a gestational age close to full-term, the question of early delivery is raised. If blood is found in the abdominal cavity, an emergency laparotomy is performed, bleeding stops and the damaged organs are sutured. Feto-maternal transfusion may require intrauterine blood transfusion.
Minor cervical ruptures may be asymptomatic. With extensive and deep defects, bloody discharge of a bright red color appears: blood can flow out in a trickle or stand out with clots. Cervical ruptures are usually recognized clinically or by examining the cervix in mirrors. With such injuries, catgut sutures are applied to the cervix. If such damage to the uterus was not detected in time or correctly sutured, in the future they can be complicated by the formation of hematoma in the parametrium, cervicitis, postpartum endometritis, ectropion and erosion of the cervix.
Rupture of the uterus is accompanied by acute cutting pain in the abdomen, pallor of the skin and mucous membranes, falling blood pressure, cold sweat. If the rupture occurs in the active phase of labor, then labor stops. There are signs of intra-abdominal bleeding and bleeding from the genital tract. Parts of the fetus are defined directly under the anterior abdominal wall. The general condition of the patient is extremely difficult. Damage to the uterus by the type of rupture is diagnosed on the basis of a general objective and external obstetric examination, ultrasound, cardiotocography. In this case, immediate delivery by cesarean section, revision of the uterus and abdominal cavity is indicated. Possible surgical options are tear closure, supravaginal amputation, or radical removal of the uterus.
When the uterine wall is perforated with a surgical instrument, intra-abdominal or mixed bleeding develops. At the same time, patients feel a sharp pain in the lower abdomen, complain of bloody discharge, dizziness and weakness. With massive internal bleeding, arterial hypotension, tachycardia, and pallor of the skin are noted. Along with damage to the uterus, injury to the bladder or intestines can occur. The most common complication of uterine perforation is peritonitis.
Perforation of the uterine wall can be recognized even during intrauterine manipulation by characteristic features (feeling of "failure" of the instrument, visualization of intestinal loops, etc.). The diagnosis in this case is confirmed by the data of hysteroscopy, transvaginal ultrasound of the pelvic organs. The main method of treatment of perforating injuries of the uterus is surgical (tear suturing, subtotal or total hysterectomy).
Abdominal fistulas connect the uterine cavity with the anterior abdominal wall and are external. The outlet opening of the fistulous tract often opens in the area of the suture or postoperative scar. The presence of a fistula is supported by inflammatory infiltration of the fistulous tract. It is manifested by the periodic release of blood and pus through the cutaneous opening of the fistula. Fistulas are found during examination and hysteroscopy. Treatment - excision of the fistulous passage and suturing of the uterus.
The main signs of a vesicouterine fistula are cyclical menouria (Yussif's symptom), the discharge of urine from the vagina, the symptom of "laying" the urine stream when blood clots form in the bladder, and secondary amenorrhea. Uretero-uterine fistulas are manifested by urine leakage from the vagina, lower back pain, fever due to hydroureteronephrosis. Genitourinary fistulas are detected during examination of the vagina in the mirrors, cystoscopy, hysterography. Treatment - surgical closure of fistulas (fistuloplasty), plastic ureter.
Uterine-intestinal fistulas may result from perforation of the uterus with damage to the intestine, breakthrough into the intestine of an abscess that developed after conservative myomectomy or cesarean section. The course of intestinal-uterine fistulas of inflammatory genesis is recurrent. Before the breakthrough of the abscess into the large intestine, pains in the lower abdomen, hyperthermia, chills, tenesmus increase. Mucus and pus appear in the stool. After emptying the abscess, the patient's condition improves. However, due to the fact that the fistulous opening quickly undergoes obliteration, pus soon again accumulates in the abscess cavity, which causes a new exacerbation of the disease.
For diagnostics, examination of the vagina using mirrors, combined gynecological ultrasound, rectovaginal examination, sigmoidoscopy, fistulography, CT and MRI of the pelvis are used. The tactics for this kind of pathology are only surgical; includes "intestinal" and "gynecological" stages. The details of the intervention are determined by the operating gynecologist and proctologist. Excision of necrotic tissue and restoration of intestinal integrity is usually combined with supravaginal amputation or extirpation of the uterus.
In the acute period after damage to the uterus of this kind, the clinic of endomyometritis develops. Worried about an increase in body temperature, pain in the lower abdomen, sometimes - bloody discharge caused by the rejection of the necrotically altered uterine mucosa. Such injuries can be complicated by peritonitis and sepsis. After healing of thermal and chemical injuries, cicatricial changes in the cervix, atresia of the cervical canal, and intrauterine synechiae can form. In the long-term period, the development of hypomenstrual syndrome or amenorrhea, infertility is likely.
Diagnostics is based on clarifying the anamnesis (identifying the fact of the introduction of hot solutions or chemicals into the vagina), examination data of the cervix in the mirrors, gynecological ultrasound. Treatment is detoxification and antibacterial therapy. With the development of peritonitis, laparotomy, sanitation and drainage of the abdominal cavity are carried out; with extensive necrotic damage to the uterus - extirpation of the organ. In the future, to restore the patency of the cervical canal, it is bougienated. In Asherman's syndrome, hysteroscopic separation of synechia is shown.
Damage to the cervix is a violation of its integrity during childbirth. The most common radial lateral rupture of the cervix.
Damage to the cervix (rupture) occurs both spontaneously and due to surgical intervention (violent).
Spontaneous ruptures can be caused by:
Violent ruptures occur during operations that accelerate childbirth, namely:
There are three degrees of cervical rupture:
Complicated and uncomplicated ruptures of the cervix are also distinguished.
Uncomplicated breaks are grade 1-2.
Complicated include:
There are a number of reasons leading to rupture of the cervix:
1. Dystrophic and inflammatory diseases of the cervix:
2. Prolonged compression of the cervix between the woman's pelvic ring and the fetal head;
3. Strong stretching of the edges of the uterine os with:
Complicated forms of damage to the cervix occur in the following cases:
The main method of treating damage to the cervix is surgery. Suturing of ruptures of the cervix is carried out in all cases, except for superficial ones, which are not accompanied by bleeding cracks. In the case of severe bleeding, squeeze the placenta and proceed to suturing. The tears are sutured under strict asepsis. The doctor exposes the cervix using vaginal mirrors, then grabs it with special forceps for the front and back lips, pulls it out and pulls it to the side opposite to the location of the existing tears. The doctor performs the imposition of the first suture on the upper corner of the wound, while the entire thickness of the tissue of the vaginal part of the cervix is captured in the suture, excluding the mucous membrane of the cervical canal. When it is impossible to impose the first suture on the upper corner of the wound, one or two sutures are applied closer to the upper corner in the area of rupture, then the threads are tightened and the uppermost corner of the injury is sewn up. A seam on each side is made at a distance of 0.5-1 cm from the edge to avoid cutting the seam while tightening it.
Suturing the gap entails stopping bleeding, and also prevents the occurrence of parametritis. Unsecured ruptures can lead to the development of erosions, endocervicitis and ectropions of the cervix.
In case of a complicated rupture, passing to the parametrium and accompanied by the formation of hematomas, celiac disease is used to stop bleeding, remove the hematoma and suture the rupture.
1. Infectious complications:
2. Hematomas in parametria;
3. Violations of the integrity of the walls of the uterus;
4. Hemorrhagic shock.
Methods for preventing damage to the cervix include:
1. Preparation and planning of pregnancy: exclusion of the possibility of unwanted pregnancy, diagnosis and adequate complete treatment of chronic diseases before pregnancy. It is not recommended to plan the conception of a child before two years after the operation on the uterus.
2. Timely (up to 12 weeks of pregnancy) registration of a woman in an antenatal clinic.
3. Regular visits to the doctor: in the first trimester - once a month, in the second - once every two to three weeks, in the third - once every seven to ten days.
4. Taking vitamins;
5. Adequate sleep;
6. Elimination of excessive physical exertion and stress;
7. Rejection of bad habits.
8. Compliance with a rational and balanced diet: avoiding spicy, fried and canned foods, eating foods high in fiber.
9. Rational management of childbirth, which means:
Injuries (tears) of the cervix are more likely to occur during childbirth, but the cervix can also be damaged during an induced abortion. Damage to the uterus (perforation) most often occurs during an induced abortion and can be performed with a dilator, probe, curette, collet abortion, or vacuum excochleator tube (Fig. 49).
Clinical presentation and diagnosis. Rupture of the cervix is accompanied by bleeding. The diagnosis is made by examining the cervix using mirrors. Perforation of the uterus can be accompanied by pain, shock, internal bleeding. The main symptom is the feeling of the instrument falling through, that is, its penetration to a depth exceeding the length of the uterine cavity established by probing. The diagnosis is clarified by probing the uterine cavity.
Treatment. Surgical. Separate catgut sutures are applied to the rupture of the cervix.
If the uterus is damaged, gastrointestinal surgery, revisions of all abdominal organs and suturing of the uterus wound are shown, and sometimes the removal of the uterus if the damage is too extensive. If the uterus is perforated with a probe at the very beginning of the abortion, if the patient is in a satisfactory condition and there are no symptoms of internal bleeding, conservative treatment is possible, and if the condition worsens, emergency laparotomy and suturing of the perforation are indicated.
Perforation of the uterus, produced in another medical institution or with out-of-hospital intervention, is always an indication for carrying out gastrointestinal surgery.
Fistula is a persistent pathological message, often in the form of a narrow channel. Fistulas communicating with the female reproductive system are divided into genitourinary and intestinal-genital (Fig. 50). Among the urogenital fistulas, there are urethrovaginal, vesicovaginal, vesicouterine, ureteral-vaginal and ureteral-uterine fistulas.
Genital fistulas most often form between the genitals and the rectum, but other parts of the large and small intestines can also participate in their formation.
Causes of fistulas: 1) birth trauma (with pathological childbirth); 2) surgical trauma (during obstetric and gynecological operations); 3) complications of inflammatory processes of the appendages (breakthrough of abscesses); 4) malignant tumors with decay; 5) radiation damage to neighboring organs; 6) trauma (not related to childbirth or surgery). In obstetric practice, the cause of fistula formation is the prolonged standing of the head in one plane of the pelvis and the pressing of soft tissues to the bones of the pelvis, which can occur with a narrow pelvis, a large fetus, and weakness in labor. Obstetric operations (the application of forceps, embryotomy, vacuum extraction, extraction by the pelvic end) can be accompanied by extensive ruptures of soft tissues and adjacent organs, followed by the formation of fistulas. The resulting damage can sometimes go unnoticed, and in some cases, even with the elimination of the damage, complete healing does not occur.
When the pyosalpinx breaks through into the intestine or bladder, the abscess can be emptied and the symptoms of acute inflammation can be stopped, but after that a fistula can form between the fallopian tube and the intestine or bladder. In malignant tumors, fistulas arise as a result of the spread of the process to neighboring organs and as a result of the disintegration of the tumor.
The clinical picture. The clinic of fistulas depends on their localization. The most common symptoms are involuntary discharge of urine, feces, or gas passing through the vagina. Long-term fistulas cause irritation, itching and pain in the external genital area. A complication of the fistula can be an ascending infection of the urinary tract, as well as the uterus, vagina, and uterine appendages. Constant putrefactive discharge, the outflow of urine, feces and gases oppress the patient, deprive her of her ability to work. Often, with fistulas, menstrual function is disturbed.
Diagnostics. The diagnosis is established on the basis of the patient's complaints, anamnestic data, as well as the results of examination of the external genitalia and the vagina. To clarify the localization of the fistula, additional research methods are used: cystoscopy, cystography, excretory urography, fistulography (the introduction of a contrast agent into the fistulous tract).
Prevention. Since most often fistulas are a consequence of birth trauma, among the preventive measures, the most important is the rational management of childbirth, the provision of correct obstetric care during childbirth, which is directly related to the problem of training qualified nurses. Prevention of postoperative fistulas is reduced to careful handling of tissues, correct assessment of the anatomical relationships of organs during surgery. Prevention of fistulas in malignant tumors consists in the prevention and early detection of tumors.
Treatment. With genitourinary and urogenital fistulas, treatment is a complex problem.
In case of acute trauma to neighboring organs during childbirth or during gynecological operations, immediate restoration of their integrity is required. If a fistula has formed, attempts are made to conservatively heal it (small fistulas can heal spontaneously). With urogenital fistulas, a permanent catheter is inserted into the urethra (the patient's position in bed should be on the stomach or on the back, depending on the location of the fistula), tampons with Vishnevsky's ointment or 5% syntomycin emulsion are brought to the site of injury.
In case of irritation of the external genital organs, sedentary warm baths with a decoction of chamomile or a solution of potassium permanganate 1:10 000 are recommended. Such management of patients promotes healing of the fistula and suppression of the inflammatory reaction in the surrounding tissues.
Fistula can also be removed surgically. Fistula surgeries are complex. Preparing the patient for surgery consists in adhering to a diet (excluding spicy food), drinking plenty of fluids, taking care of the external genitals, douching the vagina with disinfectant solutions, and conducting antibacterial therapy. Eliminate fistulous passages by splitting and layer-by-layer suturing of tissues. Postoperative care is very important in ensuring the success of the operation. Constant monitoring of the functioning of the catheter is required. If it becomes clogged with salts or blood clots, it must be rinsed or replaced. Bed mode, gentle diet (only liquid food) for 5-7 days. At the same time, general care should be carried out (for the oral cavity, skin, etc.).
If the fistula has arisen on the basis of a breakthrough of the abscess of the fallopian tube or ovary, surgery is indicated (removal of the focus of infection). In case of tuberculous etiology of the fistula, specific anti-tuberculosis treatment is carried out, after which the question of the operation is resolved.
Fistulas resulting from the disintegration of tumors or radiation therapy are subject to symptomatic treatment (disinfectant solutions, the introduction of tampons with antiseptic emulsions and ointments).
The onset of labor ahead of time, an abnormally narrow pelvis in a woman in labor, discharge of water without the development of labor and other pathologies of delivery cause a rupture of the cervix. This is a very dangerous injury that requires treatment.
To understand why ruptures occur, you need to understand what is the basis for pathology. The main cause of neck cracks is considered to be incomplete opening before childbirth. The abnormal condition provokes difficulties in delivery.
Why does the cervix rupture during childbirth:
Nonviolent ruptures of the cervix are caused by factors that the woman in labor cannot spontaneously influence. But there are those that become the result of improper medical care, they are considered to be violent. This is the use of obstetric forceps (they are prohibited for use), a vacuum extractor, as well as pulling the child by the pelvic end.
Deep cracks can also involve the vagina, a perineal rupture is possible as a complication. The most common are lateral tears, which soon scar, but make themselves felt in subsequent births.
The reason for the rupture of the cervix often lies in the lack of professionalism of obstetricians. The presence of two or more factors provoking pathology increases the likelihood of a problem.
Tears are of two types: spontaneous and violent. The elasticity of tissues with age, as well as due to certain circumstances (abortions, operations, scars from childbirth) decreases, from this there is a rupture of the cervix.
Expectant mothers who are overdue are also at risk. In babies, after 42 weeks, the skull begins to harden, which is difficult to pass through the cervical canal without injury. If the woman in labor has clamped the cervix of the baby during childbirth, mechanical extraction of the fetus is used, where cracks cannot be dispensed with.
Rapid childbirth without the onset of cervical sprain does not pass without a trace. Too long delivery provokes a long pinching of the organ between the mother's pelvic bones and the head of the fetus. As a result, the woman's cervix is torn. Women in labor with placenta previa are most susceptible to the manifestation of pathology.
The violent causes of a lacerated uterus lie in the mechanical extraction of the fetus with a weak opening of the internal pharynx or uterine spasm. Tearing is possible when turning the baby by hand. In such situations, severe bleeding occurs that is difficult to stop.
Depending on the severity and depth of tears, there is a classification. The degree of rupture of the cervix is determined according to the symptomatology and the area of the lesion.
Types of pathology:
The third degree of pathology is characterized by the layering of the wound not only on the vagina, but also on the internal pharynx. This is very dangerous for a woman's life, because profuse bleeding opens.
If the cervix is not severely torn during childbirth, up to 1 cm, this happens without symptoms, since the pain threshold is already at its peak at this point. Perceptible signs of abnormal opening are recognized only with deep wounds.
Symptoms:
It is extremely difficult to identify the pathology, because in the last stage of childbirth, discharge with blood almost always appears. Therefore, you can ignore the symptoms. Childbirth after a rupture of the cervix is accompanied by bleeding, which is constantly increasing, especially at the final stage - the expulsion of the placenta. In the postpartum period, the intensity of blood loss will depend on the tone of the uterine muscles. With atony of the uterus, the organ becomes vague and flabby, the uterine fundus rises abnormally high.
The most accurate way to check an organ for cracks is to examine a woman on a gynecological chair using mirrors. Vaginal instruments are inserted inside, the front and back lips are parted, then the folds of the cervix are carefully examined.
It is important to adhere to the rules of sterilization and antiseptic processing, as well as the technique of inserting mirrors, so as not to harm the health of a woman in the postpartum period. The manual method of palpation of the genitals will be informative.
Other diagnostic methods:
After identifying a generic pathology, it is required to eliminate it to restore integrity. Postpartum rupture of the cervix is sutured immediately after the birth of the placenta.
Reconstructive measures for cervical dissection are carried out at the end of the delivery process. If the bleeding is too intense, first aid is provided in this situation: obstetricians do not wait for the placenta to exit and squeeze it out manually. Then stitches are quickly applied.
As soon as the pathology has been identified, they begin to suture the cervix after childbirth. Self-absorbable sutures (catgut) are usually used. The procedure is performed under mask general anesthesia. Intravenous anesthesia is also used. If too complex tears have formed, reaching the edge of the throat, suturing of the cervix is carried out after opening the peritoneum. The operation is performed under general anesthesia. Such situations are extremely rare.
What does a ruptured cervix look like after childbirth:
A woman in labor may experience a painful shock, so the skin turns pale and the pulse quickens. The obstetrician must react quickly and suture the cervix.
To penetrate the cervical canal, the lips are opened and stretched to the sides using forceps and mirrors. The first suture is performed on the upper edge of the wound, capturing the vaginal cervical tissue. For this manipulation, catgut number 3 or 4 is used with a cutting needle curved at the end. The entry and exit of the needle into the fabric is done no closer than half a centimeter. If the neck is sutured, the bleeding will stop.
The tears are not always sewn, sometimes they are left to grow together on their own. When the cervix is not sutured, there is a high likelihood of parametritis, endocervicitis, erosion. Shallow cracks are usually left that are not hazardous.
Treatment for a ruptured cervix during childbirth is more than just suturing. A woman must follow the recommendations of doctors for some time without breaking the regime. During the recovery period, you need sexual rest for several months. Do not lift anything heavier than a child. Physical activity will have to be abandoned.
How long does the cervix heal after childbirth? It takes at least 2 months to fully recover. Perceptible relief will begin to come gradually a couple of weeks after the baby is born.
The consequences of a ruptured cervix during childbirth correlate with the severity of the cracks and with the professionalism of first aid. It is necessary to identify the pathology in time and eliminate it by applying catgut sutures. It happens that tears are missed, this provokes complications unfavorable for the woman in labor.
Consequences of unsealed tears:
Is it possible to give birth after a ruptured cervix? Women with this pathology are allowed to give birth. The problem lies in the quality of the bearing. A second pregnancy after a ruptured cervix will be constantly at risk of termination, especially if the tissue is not scarred correctly. There is a high likelihood of a spontaneous abortion.
How is the second birth after a ruptured cervix? As a rule, there are fewer genital trauma, because the tissues were already stretched during the first experiment. Obstetricians, if there is a likelihood of wound formation, make an incision on their own.
To prevent the occurrence of injuries, it is required to adhere to the recommendations even during the gestation period. The correct course of delivery is also important.
Tips for avoiding cervical tears:
To prevent tearing, an incision is made. It is believed that the smooth edges of a medical incision heal faster and grow together better. After suturing, it is recommended to visit a gynecologist after a few weeks to make sure that the tissue is repairing normally.
Rupture of the cervix is a dangerous birth pathology that must be eliminated in time. Many doctors themselves provoke its occurrence. This is the use of forceps, a vacuum extractor on the fetus. Such manipulations injure the organ, as wounds occur. To prevent this from happening, it is necessary to prepare the cervical muscles for childbirth, as well as obey the advice of the participants in the labor act, then everything will pass without injury.
