The term "attachments" reflects the strength of the connection of the chorion villi with the decidual membrane of the uterine wall. With a normal attachment, the villus of the chorion is located in the functional layer of the decidual membrane of the uterine wall. In some cases, the placenta is attached to the deeper layers of the uterine wall.
Most often there is a false increment of - dense attachment of the placenta (placenta adherens), in which the villi of the chorion are located in the basal layer of the decidua, due to the atrophy of the spongy layer of the falling shell. There is also a real increase in the placenta due to the partial or total absence of the spongy layer of the decidua, as a result of which the villus of the chorion reaches the uterus (placenta accreta), grows through (placenta increta) or grows into the muscular and serous layers of the uterus (placenta percreta). The increment of the placenta is complete or partial, depending on which area of the placenta has occurred its increment.
The cause of this severe pathology is often frequent abortions, pathological births, endometritis, which lead to dystrophic changes in the mucous membrane of the uterus. On the other hand, chorionic villi sometimes penetrate deeper into the uterine wall due to increased activity of proteolytic enzymes.
The clinic of partial non-real increment of the placenta is manifested by bleeding from the uterus in the absence of signs of separation of the placenta. With full placenta increment, bleeding is absent.
The tactics of the doctor in the third stage of labor should be expectant-active. Expectant tactics consist in the fact that before the appearance of signs of separation of the placenta, the obstetrician does not interfere with the course of the consecutive period. This is due to the fact that the uterus gradually and rhythmically contracting, the placenta is separated without compromising integrity. Intervention in this period (external uterus massage, pulling on the umbilical cord) can disrupt the normal course of placental abruption.
Over a consistent period, the general condition of the parturient is monitored (pulse, arterial pressure, skin and mucous membrane color, temperature), for her well-being, the amount of blood given out is counted. Usually within 30 minutes - an hour (more often in 5-15 minutes) there are signs of separation of the placenta. In the absence of signs of separation of the placenta and blood loss of greater physiological need to move to active management of the III period. An operation is performed - a manual examination of the uterine cavity. When a partial increase in the placenta is found to the uterus, the placenta is manually removed under anesthesia. Before the operation, the obstetrician processes the hands, the operating field. With his left hand pushing the labia, the right arm is conical and introduces the umbilical cord into the uterine cavity. Finds the edge of the placenta and gradually bluntly separates the placenta from the walls of the uterus with blunt movements. Then the latter is removed by pulling on the umbilical cord with the second hand, and by hand, which is in the uterine cavity, conduct a revision of its walls - a manual examination of the uterine cavity, removal of the remains of placental tissue and membranes. With tight attachment it is possible to perform. In the absence of bleeding and signs of separation of the placenta in the III stage of labor for 2 hours in the primipara and 1 hour in re-births, the diagnosis is made of the full increment of the placenta and attempt to manually separate it from the uterine wall. With a false increment, this can not be done, but with the present (there is no way to separate the placenta from the uterus wall) - no. In this case, surgical treatment is performed (laparotomy and supravaginal amputation of the uterus). It should be remembered that in women with an increment of the placenta there may be a rupture of the uterus, caused by the thinning of its walls. Careless handling of the uterus, especially when trying to remove the placenta in parts in cases of its increment, leads to the development of massive bleeding, hemorrhagic shock, DIC syndrome.