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},
"code": "N85.5",
"name": "Выворот матки",
"icd_name": "Выворот матки",
"gender": 2,
"age_min": 40,
"age_max": 100,
"cause": [
"0"
],
"periodicity": 1,
"slug": "n85.5_vyvorot_matki",
"lead": "тяжелое состояние, при котором тело матки выворачивается наизнанку и выдается через шейку матки во влагалище за пределы половой щели, обычно после родов",
"description": "",
"etiology": "<p> </p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li style=\"list-style-type: none; font-size: 6.5pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre; margin-left: -18pt;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">К вывороту матки может привести несколько причин:</span></p>\r\n</li>\r\n<li><span id=\"docs-internal-guid-a3156a1a-7fff-4ee2-5152-cbccd2095fd9\"><span style=\"background-color: transparent; font-size: 7pt; white-space: pre-wrap; font-family: Verdana;\">атония матки (отсутствие мышечного напряжения матки после родов) с одновременным увеличением внутрибрюшного давления (кашель, чихание, давление на живот);</span></span></li>\r\n<li><span id=\"docs-internal-guid-a3156a1a-7fff-4ee2-5152-cbccd2095fd9\"><span style=\"background-color: transparent; font-size: 7pt; white-space: pre-wrap; font-family: Verdana;\">потягивание за пуповину при еще не отделившейся плаценте (детское место);</span></span></li>\r\n<li><span id=\"docs-internal-guid-a3156a1a-7fff-4ee2-5152-cbccd2095fd9\"></span><span style=\"font-size: 7pt; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">грубом выполнении приема Креде-Лазаревича (врач руками надавливает на матку), способствующего отделению плаценты;</span></li>\r\n<li><span style=\"font-size: 7pt; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">выделение новообразования матки (полипа, миоматозного узла) на короткой ножке.</span></li>\r\n<li style=\"list-style-type: none; font-size: 6.5pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre; margin-left: -18pt;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Факторами риска самопроизвольного выворота матки являются:</span></p>\r\n</li>\r\n<li><span style=\"background-color: transparent; font-size: 7pt; white-space: pre-wrap; font-family: Verdana;\">донное прикрепление плаценты (плацента располагается в дне матки (самом верхнем и широком ее сегменте));</span></li>\r\n<li><span style=\"background-color: transparent; font-size: 7pt; white-space: pre-wrap; font-family: Verdana;\">наличие большого подслизистого миоматозного узла (доброкачественного новообразования мышечного слоя матки) в области дна матк</span></li>\r\n</ul>\r\n<p> </p>",
"pathogenesis": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">В норме последовый период длится не более получаса. Задержка последа в матке больше, чем на 30 минут, снижает ее способность к сокращению, ведет к гипотонии. Через 20-25 минут могут предприниматься попытки ускорить отделение детского места при помощи наружных приемов Гентера, Креде-Лазаревича или за конец пуповины. При плотном прикреплении плаценты и развившейся атонии матки эти методы не дают желаемого результата и приводят к смещению дна матки в направлении влагалища или полному вывороту слизистым слоем наружу за пределы родовых путей. Иногда этот процесс сопровождается выпадением влагалища.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Вывернутая матка тянет за собой придатки и яичники, что приводит к раздражению нервных пучков, брюшины и развитию болевого шока. У женщины бледнеет кожа, снижается артериальное давление, но при этом сердце не ускоряет ритм, характерна брадикардия. Причиной непрекращающегося кровотечения становится гипотония миометрия и зияние сосудов. Это усугубляет картину шокового состояния, ведет к истощению системы коагуляции. Если выворот не вправить, через 6-8 часов присоединяется инфекция, а еще позже развивается некроз.</span></p>",
"diagnostics": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Диагностика выворота проводится по типичной клинической картине. После родов во влагалище определяется мягкое круглое опухолевидное образование красного цвета. При полном вывороте матка появляется снаружи половой щели. Если послед после выворота не отделен, это облегчает диагностику. На дне матки визуально заметна плацента с прикрепленным остатком пуповины.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При частичном вывороте установить диагноз в родах помогает двуручное исследование. Пальпация через переднюю стенку живота определяет на месте половых органов воронкообразное углубление. Манипуляция болезненна, доставляет женщине неприятные ощущения. Состояние женщины после родов с выворотом может быть тяжелым, поэтому другие методы диагностики не используются. Лабораторные анализы, подсчет пульса и измерение артериального давления необходимы для оценки степени тяжести состояния и определения уровня необходимой помощи.</span></p>",
"treatment": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Лечение проводится экстренно в родзале роддома врачом акушер-гинекологом. Необходимо присутствие ассистента и двух акушерок, а также врача-анестезиолога для наркотического обезболивания и проведения реанимационных мероприятий. Цель терапии выворота – репозиция органа и устранение симптомов шока. Также проводится профилактика инфекционных осложнений.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Консервативная терапия</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Если женщине во время родов внутривенно вводились утеротоники, инфузию немедленно прекращают, чтобы не дать сократиться матки до ее вправления. Медсестра обеспечивает венозный доступ, назначаются коллоидные и кристаллоидные растворы для коррекции водно-солевого баланса, уменьшения последствий кровопотери. Используются следующие группы препаратов:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Наркотические анальгетики. Необходимы для качественного и быстрого обезболивания манипуляции по вправлению выворота матки и последующего отделения плаценты. Применяются после родов внутримышечно в течение 1-3 суток при выраженном болевом синдроме.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Антибиотики. Назначаются для профилактики инфекционных осложнений и развития эндометрита. Применяют цефалоспорины 2-3 поколения в сочетании с метронидазолом, который подавляет анаэробную микрофлору. Продолжительность лечения до 5 суток.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Препараты крови. После массивной кровопотери, при развитии ДВС-синдрома для восполнения факторов свертывания применяют свежезамороженную плазму, тромбоцитарную массу или отдельные компоненты свертывающей системы. Цельная кровь при ДВС-синдроме не используется.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Хирургическая помощь</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Коррекцию выворота проводят под общей анестезией после уменьшения признаков шока. Сначала проверяют возможность отделения плаценты. Если она плотно прикреплена, проводят вправление и только после этого ручное отделение. В противном случае возникает кровотечение, которое невозможно остановить из-за гипотонии. Для облегчения манипуляции производят рассечение задней губы шейки. Выворот вправляют осторожным введением тела органа в обратную сторону или применяют метод Джонсона, при котором сначала матку смещают в полость живота и после этого выворачивают.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При неудачном вправлении выворота производят лапаротомию. Во время операции сочетают методику репозиции по Джонсону и дополняют ее процедурой Хантингтона. Если выворот матки сопровождается спазмом шейки, манипуляция становится невозможной. Ее заменяют операцией Холтейна, при которой процедура Хантингтона дополняется разрезом контракционного кольца на шейке.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">После коррекции выворота на низ живота укладывается грелка со льдом, назначаются утеротоники (раствор окситоцина внутривенно для улучшения сократимости матки, снижения риска кровотечения). Некоторые врачи для профилактики повторного выворота после родов накладывают компрессионные швы, вводят вагинальный баллон.</span></p>",
"prevention": "<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Планирование беременности и подготовка к ней (выявление и лечение хронических заболеваний женщины до беременности, исключение нежелательной беременности). Рекомендуется планировать беременность не ранее, чем через 2 года после операций на матке.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Своевременная постановка беременной на учет в женской консультации (до 12 недель беременности).</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Регулярное посещение акушера-гинеколога (1 раз в месяц в 1 триместре, 1 раз в 2-3 недели во 2 триместре, 1 раз в 7-10 дней в 3 триместре).</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Рациональное и сбалансированное питание беременной (употребление продуктов с высоким содержанием клетчатки (овощи, фрукты, зелень), отказ от жареной, консервированной, слишком горячей и острой пищи).</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Полноценный сон.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Прием витаминов и успокаивающих средств (при необходимости).</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Отказ от курения, употребления алкоголя и наркотиков.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Исключение чрезмерных физических и психоэмоциональных нагрузок.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Рациональное ведение последового периода родов:</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Исключение потягивания за пуповину;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Избегание чрезмерного давления на матку;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Правильное применение приема Креде-Лазаревича;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Назначение утеротоников (препаратов, стимулирующих сокращение мышечного слоя матки).</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Выполнение ультразвукового исследования (УЗИ) органов малого таза для обнаружения полипов, миоматозных узлов (доброкачественные образования матки) и своевременное их лечение.</span></li>\r\n</ul>\r\n<p> </p>",
"clinical_picture": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p><span style=\"background-color: transparent; font-family: Verdana; font-size: 7pt; white-space: pre-wrap;\">Признаки выворота появляются в последовом или раннем послеродовом периоде. Отделение плаценты может задерживаться на срок до получаса. Если приемы выделения последа достигли цели, выворот может начаться с усиления кровотечения. </span></p>\r\n<p><span style=\"background-color: transparent; font-family: Verdana; font-size: 7pt; white-space: pre-wrap;\">Женщина ощущает теплую вытекающую кровь на промежности и ягодицах, резкую боль в животе, которая не стихает. Следом возникают признаки шока. Сильно кружится голова, появляется общая слабость, которая является следствием резкого снижения артериального давления. Возникает озноб, мелкая мышечная дрожь. </span></p>\r\n<p><span style=\"font-size: 7pt; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Из-за раздражения брюшины нет рефлекторной тахикардии, сердце замедляет ритм. Кожа стремительно бледнеет, появляется холодный липкий пот. Губы становятся сухими, мучает сильная жажда. Могут возникнуть тошнота и рвота, которые являются плохими прогностическими признаками. Дыхание учащается. При тяжелой степени шока кожные покровы приобретают синюшный оттенок. Роженица дышит часто, но поверхностно.</span></p>",
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