HEMORRHAGES HEMORRHAGES DURING PREGNANCYDURING PREGNANCY

ECTOPIC PREGNANCYEctopic pregnancy is one in which the products of conception develop outside the uterinecavity. By far the commonest site is the fallopian tube.The fallopian tube is about 10 cm long. The diameter of the lumen varies from 1 mm in theinterstitial portion to about 5 mm at the fimbriated end.

The musculature is of two layers, an inner circular and an outer longitudinal, and peristaltic

movements are particularly strong during and after ovulation. The mucosa is arranged in

plications or folds which become much more complete and plentiful as the infundibulum is

approached.

Ectopic implantation may be fortuitous or the result of a tubal abnormality which obstructsor delays the passage of the fertilised ovum.

Risk factors.Inflammatory diseases of the uterus and

uterine appendages in the historyCicatrical – adhesive changes of small

pelvis organs as a consequence of prior operations on inner genitals, pelvioperitonitis, abortions.

Distress of ovarian hormonal functions.Genital infantilism.Endometriosis.Long usage of intrauterine

contraceptives.Subsiduary reproductive technologies.

Diagnosis

Clinical symptoms:

1. Pregnancy signs:

- suppression of menses;

- mammary glands swelling;

- changes of taste, olfaction and other sensations typical for pregnancy;

- early gestosis signs (sickness, vomiting, oth.);

- positive immunologic reactions on gestation (HCG in blood serum and urine).

2. Disordered menstrual cycle – smeary bloody discharge from the genitals:

- after menstrual retention;

- with the onset of the following menstruation;-before the onset of anticipated menstruation.

3. Pain – syndrome:

- unilateral menstrual cramps or continuous pain in the lower abdomen;

- abrupt intensive pain in lower abdomen

- peritoneal symptoms in lower abdomen pronounced in various degrees;

- pain irradiation into rectum, perineum and loin.

4. Symptoms of intraabdominal hemorrhage (in case of EP disorder):

- loss of resonance in abdominal flanks;

- positive Kulenkampf’s syndrome (there are signs of abdominal irritation when there is no local muscular tension in lower parts of abdomen;

- in horizontal position of the patient there is a positive bilateral “frenicus” symptom, and in vertical position – vertigo (dizziness), loss of consciousness;

- in case of significant hemoperitoneum there is a Shchotkin – Bloomberg symptom;

- progressive decrease of hemoglobin, erythrocytes, hematocrits indeces according to the blood test data.

5.General state distress ( in case of EP disorder):

- asthenia (weakness), vertigo (dizziness), loss of consciousness, cold sweat, collapse, hemodynamic disorders;

- sickness, reflex vomiting;

- meteorism, single diarrhea.

Gynecologic examination datacyanosis of vaginal mucous membrane and uterine cervix;uterine size is smaller than is expected at the term;unilateral enlargement and tenderness of uterine appendages;overhanging vaults of vagina (in case of hemoperitoneum);sharp pain a posterior vault of the vagina (Dougla’s cry);tenderness by uterine cervix displacement.

SYMPTOMS AND SIGNS

PAIN in the lower abdomen is always present and may be either constant or cramp-like.It may be referred to the shoulder if blood tracks to the diaphragm and stimulates thephrenic nerve, and it may be so severe as to cause fainting. The pain is caused by distensionof the gravid tube, by its efforts to contract and expel the ovum, and by irritation of theperitoneum by leakage of blood.

VAGINAL BLEEDING occurs usually after the death of the ovum and is an effect ofoestrogen withdrawal. It is dark brown and scanty and its irregularity may lead the patient toconfuse it with the menstrual flow and thus, inadvertently, give a misleading history. In about25% of cases tubal pregnancy presents without any vaginal bleeding.

INTERNAL BLOOD LOSS can be severe and rapid and the usual signs of collapse andshock will appear.Acute internal bleeding is the most dramatic and dangerous consequence of tubal pregnancy,but it is less common than the condition presenting by a slow trickle of blood into the pelviccavity.

DIFFERENTIAL DIAGNOSIS

1. Salpingitis.2. Miscarriage.3. Appendicitis.4. Torsion of pedicle of ovarian cyst.5. Rupture of corpus luteum or follicular cyst.6. Perforation of peptic ulcer.

SALPINGITISSwelling and pain are bilateral, fever is higherand a pregnancy test is usually negative.There may be a purulent discharge from thecervix.

MISCARRIAGE (threatened orincomplete)Bleeding is the dominant clinical feature andusually precedes pain. The bleeding is redrather than brown and the pain is crampy orcolicky. The uterus is larger and softer and thecervix patulous or dilated. Products ofconception may be recognised on vaginalexamination.

APPENDICITISThe area of tenderness is

higher and may belocalised in the right iliac

fossa. There may bea swelling if an appendix

abscess was formedbut is not so deep in the

pelvis as a tubalswelling. Fever is greater and

the patient mayappear toxic. A pregnancy

test will usually benegative although pregnancy

and appendicitiscan, of course, co-exist.

TORSION OF PEDICLE OFOVARIAN CYSTThe mass so formed can

usually be feltseparate from the uterus,

while a tubalpregnancy usually feels

attached. Tendernessmay be marked, and

intraperitoneal bleedingmay produce fever. Signs

and symptoms ofpregnancy are absent but

there is a history ofrepeated sudden attacks of

pain which pass off.

RUPTURE OF CORPUS LUTEUM

It is virtually impossible to distinguish this, by

examination, from a tubal pregnancy, but

such a severe reaction is rare.

TREATMENT

If haemorrhage and shock are present, restore the blood volume by the transfusion of red

cells or a volume expander and proceed with operation. The patient's condition will

improve as soon as the bleeding is controlled.

Laparotomy

ABDOMINAL PREGNANCY

Clinical Features1. There is a history

of'threatened miscarriagewith irregular bleeding.2. Continued abdominal

discomfort is felt andfetal movements are painful.3. Fetal abnormality is

common and fetalmortality is high.

Diagnosis is difficult.

1. Palpation is unreliable even when fetal limbs are easily felt.

2. Ultrasound may show the fetus outwith the uterus and an abnormal fetal attitude due to lack of liquor.

Treatment

Once diagnosed or strongly suspected, it is better to perform laparotomy in the interests of

the mother. The fetus is removed, the cord tied and the abdomen closed. No attempt is made

to detach the placenta unless it is clear that bleeding can be controlled.

If the condition is diagnosed around the time of fetal viability then delivery may be deferred

to improve the prognosis for the fetus. This approach requires careful supervision and

laparotomy may be required at any time.

Obstetrical bleedings

Bleedings in the first half of pregnancy:

accidental abortion; hydatidiform mole; extrauterine pregnancy

( including cervical pregnancy);

Bleedings in the second half of pregnancy:

placental presentation; premature detachment of

normally located placenta; hysterorrhexis.

Bleedings during labor:

I period: premature detachment of

normally located placenta; placental presentation; hysterorrhexis; laceration of the neck of the

uterus.

II period: premature detachment of

normally located placenta; hysterorrhexis.

III period: pathologic implantation of

placenta; suppression, strangulation of

placenta; laceration of soft tissues of

maternal passages.

Postpartum bleeding: hypotonic bleeding; retention of the afterbirth’s

fragments; laceration of soft tissues of

maternity passages; hysterorrhexis, amniotic fluid embolism, coagulopathetic hemorrhage.

Bleedings unconnected with pregnancy:

uterine cervix polyp; carcinoma of uterine cervix.

Classification threat of abortion; the abortion which has started; abortion in process; incomplete accidental abortion; complete accidental abortion; missed miscarriage.

Clinicodiagnostic criteria

Symptoms of abortion: pain-syndrome: pain associated

with contraction of the uterus; increased tension of the uterus; hemorrhage of different intensity; structural changes in the uterine

cervix.

Bleedings during accidental abortion, in the beginning of abortion, in the course of abortion and by incomplete accidental abortion.

Clinic: pain of intermittent character; hemorrhage of different intensity

Diagnosis: assessment of the gravida’s

general condition; speculum examination of the

uterine cervix, bimanual examination;

evaluation of the blood less amount.

Treatment instrumental uterus emptying under intravenous

anaesthesia (with an obligatory examination of the received material);

medications contracting uterus (10 units of oxytocin by intravenous droppery or 0,5 mg of methylergobrevin intravenously or intramuscularly);

if hemorrhage proceeds-800 mkg of misoprostol rectally;

recovery of the amount of blood loss as indicated;

antibacterial therapy as indicated..

Placental presentation

Placental presentation is a complication of pregnancy when placenta is located in the lower segment of the uterus lower than the presenting part of the fetus blocking totally or partially the inner pupil of the uterine cervix.

Classification of placental presentation

1. Complete presentation - placenta completely blocks the inner pupil.

2. Incomplete presentation - placenta blocks the inner pupil incompletely:

a) lateral presentation - the inner pupil is covered on 2\3 of its area;

b) marginal presentation - the end of placenta reaches the inner pupil.

3. Lower implantation of placenta - the location of placenta in the lower segment, 7 sm lowerer than inner pupil without its blocking. Due to the migration of placenta or its expansion this kind of presentation can change during pregnancy progression.

Clinicodiagnostic criteria.

Risk group of placental presentation includes women which underwent:

endometritis with the following scarry dystrophic changes of endometrium;

abortions excessively complicated with inflammatory processes;

benign tumours of the uterus, in particular, submucous myomates nodes;

influence of chemical preparations on endometrium;

women with hypoplastic uterus.

Clinical symptoms

A pathognomonic symptom is an obligatory hemorrhage which can periodically recur throughout the term of pregnancy from 12 to 40 weeks, occurs spontaneously or after physical overwork, takes a dangerous character:

- with the onset of uterus contraction at any term of gestation;

- isn’t accompanied by pain; - isn’t accompanied by the rise of uterine

tension.

Seriousness of the condition is determined by the amount of blood loss:

it is massive at the complete presentation; variable from small to massive at the

incomplete presentation. Anematizing as the result of recurrent

bleeding. By this pathology the content of hemoglobin and erythrocytes is the lowest if compared to the other complications of pregnancy accompanied by bleedings. Irregular location of the fetus is frequent: oblique, transversal, pelvic presentation, irregular position of the head. Premature delivery is possible.

Diagnosis

1. Medical history (anamnesis)

2. Clinic manifestations – appearance of recurrent blledings which are not accompanied by pain or increased uterus tension.

Obstetrical examination:

a) external examination:

high position of the presenting part;

oblique, transversal position of the fetus;

uterine tension is not increased;

b) internal examination (made only in the conditions of a full-scale operating room):

- doughy tissues of the vault, pastiness, pulsation of vessels;

- impossibility to pulpate the presenting part because of the vault.

In case of hemorrhage a more precise definition of the presentation character has no sense because obstetrical tactics is determined by the amount of blood loss and the gravida’s condition. Ultrasound scanning is very important for the definition of placental location and correct diagnosis. Placental presentation with bleeding is an urgent indication for in-patient hospitalization

Principles of treating patients with placental presentation:

In case of little bleeding (up to 250 ml), the absence of hemorrhagic shock signs, distress of the fetus and labor activity, immaturity of the fetus’s lungs at the term no more than 37 weeks of gestation – the tactics of anticipation.

At the arrest of the bleeding – US examination, preparation of the fetus’s lungs. The target of expectancy tactics is prolongation of gestation to the term of the fetus’s viability.

In case of progressive bleeding which becomes uncontrolled (more than 250 ml), accompanied by hemorrhagic shock signs, the fetus’s distress, regardless of the term and the fetus’s condition (alive, distressed dead)- urgent delivery.

Clinic variants:

1. Blood loss (less than 250 ml), symptoms of hemorrhagic shock, the fetus’s distress are absent, the term of pregnancy is less than 37 weeks of gestation:

- hospitalization;

- tocolytic therapy according to the indications;

- acceleration of the fetus’s lungs maturity up to 34 weeks of gestation (6 mg of dexamethazone in the interval of 12 hours for 2 days);

- monitor examination of the gravida’s and fetus’ condition.

If the bleeding increases for more than 250 ml – Cesarean delivery.

2. Significant blood loss (more than 250 ml) at premature pregnancy – regardless of the presentation stage – urgent Cesarean section.

3. Bloodloss (less than 250 ml) at mature pregnancy:

After the arrest of bleeding the childbirth is conducted through natural maternal passages. After the childbirth – 10 units of oxytocin by intramuscular injection, a thorough observation of the uterine contraction and the character of discharge from vagina. If hemorrhage recurs – Cesarean delivery should be performed.

At complete or incomplete placental presentation and irregular fetus position (pelvic, oblique or transversal) – Cesarean delivery is indicated;

At incomplete presentation and dead fetus – amniotomy is possible; at hemostasia – labor should take place through maternal passages.

4. Blood loss (more than 250 ml) at mature pregnancy – regardless of the stage of presentation – urgent Cesarean delivery.

5. Complete presentation, diagnosed by USD, without hemorrhage – hospitalization before the term of labor, Cesarean section at 37-38 weeks of gestation.

Premature detachment of normally located placenta

Is a detachment of the placenta located behind the lower uterine segment during pregnancy or in the first-second (I-II) periods of delivery.

Classification

1. Complete detachment (detachment of total placenta).

2. Partial detachment: marginal; central.

Clinicodiagnostic criteria of premature detachment of a normally located placenta:

gestosis; renal diseases; isoimmune conflict between the mother and the fetus; uterine hyperdistension (hydramnios, multiple pregnancy,

a big fetus); vascular system diseases; diabetes mellitus; connective tissue pathology; uterine and placental inflammatory processes; anomalies of development or tumours of the uterus

(submucous, intramural myomas).

The direct cause may be: a physical trauma; a psychic trauma; an abrupt reduction of the amniotic

fluid volume; an absolutely or relatively short

umbilical cord; pathology of the uterine contractile

activity.

Clinical symptoms:

1. Pain syndrome: acute pain in placental projection irradiating in the total uterine body, loin, back and turning diffusive. The pain is mostly acute by central detachment and it may be slight by marginal detachment. By detachment of placenta located on the posterior wall, the pain can imilate renal colic.

2. Uterine hypertension up to tetany, which can’t be released by spasmolytics, tocolytics.

3. Vaginal bleedings can vary from slight to massive depending on acuteness and character (marginal or central detachment). If retroplacental hematoma is being formed, external bleeding can be absent.

Diagnosis

External obstetric examination: uterine hypertension; the enlarged uterine can be deformed with a

local diverticulum if the placenta is on the frontier wall position;

tenderness by palpation; difficulties or impossibility of palpation and

auscultation of the fetus’ palpitation; appearance of the fetus’ distress symptoms or

fetal death.

Internal obstetric examination: tension of the bag of waters; there may be a colouring with blood by the

rupture of amniotic fluid sac; uterine4 bleedings of different intensity

US-examination (echo-negative focus between the uterus and the placenta), but this method can’t be an absolute diagnostic criterion because hypoechogenic zone can be visualized in patients without detachment.

Treatment

1. In case of progressive premature placental detachment during pregnancy or in the first period of delivery, when hemorrhagic shock symptoms, DIC-syndrome, fetus’s distress signs appear-regardless of gestation term – urgent Cesarean delivery. In the presence of Kuveler’s uterus signs – extirpation of the uterus without appendages.

2. Restoration of the blood loss amount, treatment of hemorrhagic shock and DIC – syndrome (see corresponding protocols).

3. In case of unprogressive placental detachment there should be dynamic observation

Peculiarities of Cesarean section: obligatory revision of uterine walls (especially

external surface) with the aim to eliminate the possibility of uterine – placental apoplexy;

in case of Kuveler’s uterus diagnosis – extirpation of the uterus without appendages;

if the area of apoplexy is not large – 2-3 foci of a small diameter of 1-2 sm, or one focus – up to 3 sm) and if the uterus can contract, if there is no bleeding and no signs of DIC-syndrome and if it is necessary to preserve a reproductive function ( first labor, fetal mortality) – the consultation has to decide the question of protecting the uterus.

Tactics by placental detachment in the end of I or II periods urgent amniotomy if the amniotic bladder is intact; by cephalic presentation – application of obstetrical

forceps; by pelvic presentation – fetal extraction at the pelvic end; if one fetus of the twins is in the transverse presentation –

obstetric podalic version is performed. In some cases delivery by Cesarean section is more reliable.

manual placental separation and expulsion of the afterbirth;

contractile methods – 10 units of oxytocin intravenously, if there is no effect – 800 mkg of misoprostol (rectally);

thorough dynamic observation in postpartum period; restoration of the blood loss amount, hemorrhagic shock

and DIC-syndrome management.

Bleeding in the afterbirth and postpartum periods

Postpartum bleeding is blood loss of 0,5% or more in relation to the body mass after parturition.

Degrees of fused placenta: placenta adhaerens — the chorion villi penetrate

into the basal layer of the decidual membrane; placenta accreta — the chorion villi penetrate

through the whole basal layer of the decidual membrane to the muscular layer ofthe uterus;

placenta increta — the chorion villi penetrate into the depth of the uterine muscular layer;

placenta percreta — the villi penetrate the muscular and serous uterine layers.

False fused placenta True fused placenta

Risk factors of postpartum hemorrhage aggravated obstetric anamnesis (bleedings at

previous labor, abortions, spontaneous abortion); hestosis; a big fetus; hydramnion; multiple pregnancy; uterine myoma; cicatrix on the womb; chronic DIC – syndrome; thrombocytopathy; antenatal fetal mortality.

Hemorrhage in postpartum (third) period of labor

Causes: partial placental or membrane retention; placental implantation pathology; placental strangulation.

Clinical manifestations: Signs of placental separation are absent

during 30 minutes without significant blood loss – pathology of placental detachment or adherence.

Hemorrhage initiates immediately at afterbirth labor – retention of placental fragments or membranes.

Hemorrhage initiates after the childbirth without placental separation – placental strangulation, partial placental adherence.

Algorhythm of management: If placental fragments or membranes have been retained –

manual examination of uterine cavity under intravenous narcosis.

If the mechanism of placental presentation fails and there is no hemorrhage – anticipation in the course of 30 minutes (with the group of pregnants – 15 minutes) manual separation of placenta and removal of the afterbirth.

If hemorrhage occurs – urgent manual placental separation and removal of the afterbirth under intravenous narcosis.

Uterotonics injections – 10-20 units of oxytocin intravenously on 400 ml of physiologic salt solution by intravenous droppery.

In case of genuine detachment or adherence of the placenta – laparotomy, extirpation of the uterus without appendages.

Early (primary) postpartum hemorrhage

Causes of early postpartum hemorrhage: hypotension or atony of the uterus (in 90%

of patients); retention of placental fragments or

membranes; traumatic damages of the maternal

passages; disorder of blood coagulability

(afibrinogenemia, fibrinolysis); primary blood diseases.

Causes of uterine hypotension or atony functional failures of myometrium (late hestosis,

endocrinopathies, somatic diseases, uterine tumours, a cicatrix on the womb, a big fetus, hydramnios, multiple pregnancy and others);

overexcitation with the following failure of myometrium function (protracted or prolonged labor), operation in the end of delivery, administration of medicaments lowering myometrium tension (spasmolytics, tocolytics, hypoxia at delivery, and so on);

failure of a contractive function of myometrium due to disorder of biochemical processes, correlation of neurohumoral factors (estrogens, acetylcholine, oxytocin, cholinesterase, progesterone, prostaglandins);

disturbances of placental and afterbirth implantation, separation and removal processes;

idiopathetic (haven’t been established).

Causes of uterine hypotension or atony functional failures of myometrium (late hestosis,

endocrinopathies, somatic diseases, uterine tumours, a cicatrix on the womb, a big fetus, hydramnios, multiple pregnancy and others);

overexcitation with the following failure of myometrium function (protracted or prolonged labor), operation in the end of delivery, administration of medicaments lowering myometrium tension (spasmolytics, tocolytics, hypoxia at delivery, and so on);

failure of a contractive function of myometrium due to disorder of biochemical processes, correlation of neurohumoral factors (estrogens, acetylcholine, oxytocin, cholinesterase, progesterone, prostaglandins);

disturbances of placental and afterbirth implantation, separation and removal processes;

idiopathetic (haven’t been established).

Postpartum secondary (late) hemorrhage

Major causes for late postpartum hemorrhages: retention of placental fragments or afterbirth; expulsion of necrotic tissues after delivery; disjunctional separation of sutures and

uterine wound (after Cesarean section or hysterorrhexis).

Postpartum hemorrhage most frequently occurs on the 7-12th days after labor.

Algorhythms of medical care:

1. Assessment of blood loss by available methods.

2. Catherization of peripheric and central vein.

3. Instrumental revision of uterine cavity under intravenous anesthesia.

4. Intravenous injections of uterotonics (oxytocin 10-20 units on physiologic salt solution – 400 or 0,5 mkg methylergometrine).

5. In case the hemorrhage proceeds – misoprostol 800 mkg rectally.

6. Restoration of the blood loss circulation volume.

7. If the blood loss is >1,5% to the body mass – laparotomy, uterine extirpation, if the hemorrhage continues – ligation of internal glomerular arteries by a specialist well-trained in the operation.

Hemorrhagic shock in obstetrics

Hemorrhagic shock is a condition of severe hemodynamic and metabolic disturbances resulting from blood loss and characterized by inability of the blood circulation system to provide viable organs with adequate perfusion due to the lack of correspondence between the circulating blood amount and the vascular bed volume

Causes of hemorrhagic shock risk in obstetrics

1. Hemorrhage at early terms of gestation:

- abortion;

- extrauterine pregnancy;

- hydatidiform mole

2. Hemorrhage at late terms of gestation or delivery:

- premature placental detachment;

- placental presentation;

- hysterorrhexis (uterine rupture);

- amniotic fluid embolism

3. Postpartum hemorrhage:

- hypo- or atony of the uterus;

- retention of the afterbirth or its fragments in the uterine cavity;

- maternal passages rupture

4. Hepatic insufficiency

5. Hemostasis system pathology

Causes of hemorrhagic shock risk in obstetrics

1. Hemorrhage at early terms of gestation:

- abortion;

- extrauterine pregnancy;

- hydatidiform mole

2. Hemorrhage at late terms of gestation or delivery:

- premature placental detachment;

- placental presentation;

- hysterorrhexis (uterine rupture);

- amniotic fluid embolism

3. Postpartum hemorrhage:

- hypo- or atony of the uterus;

- retention of the afterbirth or its fragments in the uterine cavity;

- maternal passages rupture

4. Hepatic insufficiency

5. Hemostasis system pathology

Hemorrhagic shock. Classification according to the clinical course and the damage rate

Shock damage

rateShock stage

Blood loss amount

% BCV% body mass

11 compensated 15-2015-20 0,8-1,20,8-1,2

22 subcompensated 21-3021-30 1,3-1,81,3-1,8

33 decompensated 31-4031-40 1,9-2,41,9-2,4

44 irreversible >40>40 >2,4>2,4

Hemorrhagic shock intensive therapy. General principles of acute blood loss therapy:

1. Urgent hemostasia by conservative or surgical methods depending on the causes of hemorrhagic development (see the protocol ‘Obstetric hemorrhages’)

2. Circulation blood volume recovery.

3. Maintenance of adequate gas exchange.

4. Management of organ dysfunction and prophylaxis of polyorganic insufficiency.

5. Correction of metabolic disorder.

Syndrome of disseminated intravascular blood coagulation in obstetrics

Disseminated intravascular blood coagulation is a pathologic syndrome at the basis of which there is an activation of vascular-thrombocytic or coagulative hemostasis (external or internal), in the consequence of that blood, at first, coagulates in microcirculatory bed, blocks it with fibrin and cellular units and by depletion of the potential of coagulative and anticoagulative system loses coagulative ability, which reveals itself in profuse hemorrhage and development of polyorganic failure.

Risk causes of DIC – syndrome in obstetrics:

- amniotic fluid embolism;

- shock (hemorrhagic, anaphylactic, septic);

- placental detachment;

- severe stage of preeclampsia;

- eclampsia;

- sepsis;

- septic abortion;

- syndrome of massive hemotransfusion;

- transfusion of incompatible blood;

- intrauterine fetal death;

- extrauterine pregnancy;

- cesarean section;

- extragenital diseases of the gravida (heart failure, malignant tumours, diabetes mellitus, serious diseases of kidneys and liver).

DIC – syndrome classification: According to the clinical course: acute; subacute; chronic; relapsing.

According to the clinical stages of the course

I – hypercoagulation

II – hypocoagulation without generalized activation of fibrinolysis;

III – hypocoagulation with generalized activation of fibrinolysis;

IV – total blood incoagulability.

I stage – hypercoagulation.

Consequences of hypercoagulation can be: appearance or progression of fetoplacental

insufficiency; severe aggrevation of gestosis; decrease of uterine-placental blood flow, formation of

infarction zones in the placenta and higher probability of its detachment;

anemia intensification; development of respiratory insufficiency at the expence

of acute respiratory distress – syndrome progression; hemodynamics distress with the development of

circulation centralization symptoms; encephalopathy development.

II stage – hypocoagulation without generalized activation of fibrinolyses.

Petechial type of bleeding, prolonged hemophilia from the sites of injections, postoperative wound and uterus, which is conditioned by the initial discord in the coagulative system – are typical. Blood coagulates quickly at this stage, but the clot is very fragile.

III stage – hypocoagulation with a generalized fibrinolysis activation.

All patients have got petechial macular type of hemorrhage: ecchymoses, petechial on the skin and mucous membranes, bleeding from the sites of injections and formation of hematomas at there place, prolonged uterine hemorrhage, postoperative wounds, bleeding into the abdominal cavity retroperitoneal area as a consequence of hemostasis disorder. In the result of ischemia and failure of capillary permeability of the intestine walls and stomach there develops gastrointestinal hemorrhage. The blood which runs out can form clots but they lyse very quickly.

IV stage – total blood incoagulability.

Patients’ condition is extremely severe or terminal at the expense of polyorganic failure syndrome: arterial hypotension which is difficult to correct, critical disorder of respiration and gas exchange, impaired consciousness up to comatose state, oligo- and anuria against the background of massive bleeding. Hemophilia of a mixed type: profusive bleeding from tissues, gastrointestive tract, tracheobronchial tree, macrohematuria.

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