Consequences of thermal and chemical burns, frostbite, wounds. Consequences of thermal and chemical burns, frostbite, wounds Post-burn scars ICD code 10
Rough scars on the face or body today no longer adorn real men and, especially, women. Unfortunately, the capabilities of modern medical cosmetology do not allow us to completely get rid of scar defects, only offering to make them less noticeable. The process of scar correction requires persistence and patience.
“Run” and “scar” are synonymous words. Scar is a common, everyday name for a scar. Scars on the body are formed due to the healing of various skin injuries. Exposure to mechanical (trauma), thermal (burns) agents, skin diseases (post-acne) lead to disruption of the physiological structure of the skin and its replacement with connective tissue.
Sometimes scars behave very insidiously. With normal physiological scarring, the skin defect shrinks and turns pale over time. But in some cases, scarring is pathological: the scar becomes bright purple in color and increases in size. In this case, immediate assistance from a specialist is necessary. The problem of scar correction is dealt with jointly by dermatocosmetologists and plastic surgeons.
Scar formation.
In its formation, the scar goes through 4 successively replacing each other stages: I - stage of inflammation and epithelization.It takes from 7 to 10 days from the moment the injury occurs. Characterized by a gradual decrease in swelling and inflammation of the skin. Granulation tissue is formed, bringing the edges of the wound closer together; there is no scar yet. If infection or divergence of the wound surface does not occur, the wound heals by primary intention with the formation of a barely noticeable thin scar. In order to prevent complications at this stage, atraumatic sutures are applied that spare the tissue, and daily dressings are performed with local antiseptics. Physical activity is limited to avoid divergence of wound edges. II - stage of formation of a “young” scar.
Covers the period from the 10th to the 30th day from the moment of injury. It is characterized by the formation of collagen-elastin fibers in granulation tissue. The scar is immature, loose, easily extensible, bright pink in color (due to increased blood supply to the wound). At this stage, secondary wound trauma and increased physical activity should be avoided. III - stage of formation of a “mature” scar.
Lasts from the 30th to the 90th day from the date of injury. Elastin and collagen fibers grow into bundles and line up in a certain direction. The blood supply to the scar decreases, causing it to thicken and turn pale. At this stage there are no restrictions on physical activity, but repeated trauma to the wound can cause the formation of a hypertrophic or keloid scar. IV - stage of final scar transformation.
Starting from 4 months after injury and up to a year, the final maturation of the scar occurs: the death of blood vessels, tension of collagen fibers. The scar thickens and turns pale. It is during this period that the doctor understands the condition of the scar and further tactics for its correction.
It is not possible to get rid of scars once and for all. With the help of modern techniques, you can only make a rough, wide scar cosmetically more acceptable. The choice of technique and the effectiveness of treatment will depend on the stage of formation of the scar defect and the type of scar. The rule applies: the sooner you seek medical help, the better the result will be.
A scar is formed as a result of a violation of the integrity of the skin (surgery, trauma, burn, piercing) as a result of the processes of closing the defect with new connective tissue. Superficial damage to the epidermis heals without scar formation, i.e. Cells of the basal layer have good regenerative ability. The deeper the damage to the skin layers, the longer the healing process and the more pronounced the scar. Normal, uncomplicated scarring leads to the formation of a normotrophic scar: flat and the same color as the surrounding skin. Disruption of the course of scarring at any stage can lead to the formation of a rough pathological scar.
Types of scars.
Before choosing a treatment method and the optimal timing of a particular procedure, you should determine the type of scars.Normotrophic scars usually do not cause much distress to patients. They are not so noticeable, because their elasticity is close to normal, they have a pale or flesh-colored color and are at the level of the surrounding skin. Without resorting to radical treatment methods, such scars can be safely eliminated using microdermabrasion or chemical surface peeling.
Atrophic scars can occur as a result of acne or poor-quality removal of moles or papillomas. Stretch marks (striae) are also this type of scar. Atrophic scars are located below the level of the surrounding skin and are characterized by tissue sagging resulting from decreased collagen production. Lack of skin growth leads to the formation of pits and scars, creating a visible cosmetic defect. Modern medicine has in its arsenal many effective ways to eliminate even fairly extensive and deep atrophic scars.
Hypertrophic scars are pink in color, limited to the damaged area and protrude above the surrounding skin. Hypertrophic scars may partially disappear from the surface of the skin within two years. They are highly treatable, so you shouldn’t expect them to disappear spontaneously. Small scars can be treated with laser resurfacing, dermabrasion, and chemical peeling. Positive results are achieved by the introduction of hormonal drugs, diprospan and kenalog injections into the scar area. Electro- and ultraphonophoresis with conractubex, lidase, and hydrocortisone give a lasting positive effect in the treatment of hypertrophic scars. Surgical treatment is possible, in which scar tissue is excised. This method gives the best cosmetic effect.
Keloid scars have a sharp border and protrude above the surrounding skin. Keloid scars are often painful, and there is itching and burning in the areas where they form. This type of scar is difficult to treat, and recurrence of keloid scars of even larger sizes is possible. Despite the complexity of the task, aesthetic cosmetology has many examples of successful solutions to the problem of keloid scars.
Features of keloid scars.
The success of treatment of any disease largely depends on a correct diagnosis. This rule is no exception in the case of eliminating keloid scars. It is possible to avoid mistakes in treatment tactics only by clearly defining the type of scar; in terms of external manifestations, keloid scars often resemble hypertrophic scars. A significant difference is that the size of hypertrophic scars coincides with the size of the damaged surface, while keloid scars extend beyond the boundaries of the injury and can exceed the size of the traumatic skin damage in area. Common places for keloid scars to occur are the chest area, ears, and less commonly, joints and the face. Keloid scars go through four stages in their development.Epithelization stage. After injury, the damaged area is covered with a thin epithelial film, which within 7-10 days thickens, becomes rough, becomes pale in color and remains in this form for 2-2.5 weeks.
Swelling stage. At this stage, the scar enlarges, rises above the adjacent skin, and becomes painful. Over the course of 3-4 weeks, the painful sensations weaken, and the scar acquires a more intense reddish color with a cyanotic tint.
Compaction stage. The scar thickens, dense plaques appear in some places, and the surface becomes lumpy. The external appearance of the scar is a keloid.
Softening stage. At this stage, the scar finally acquires a keloid character. It is pale in color, soft, mobile and painless.
When choosing treatment tactics, they are based on the age of the scars. Keloid scars from 3 months to 5 years of existence (young keloids) are actively growing, are distinguished by a smooth shiny surface, red in color with a cyanotic tint. Scars older than 5 years (old keloids) turn pale and acquire a wrinkled, uneven surface (sometimes the central part of the scar sinks).
Keloid scars can be caused by surgical interventions, vaccinations, burns, insect or animal bites, or tattoos. Such scars can occur even without traumatic injury. In addition to significant aesthetic discomfort, keloid scars give patients unpleasant sensations of itching and pain. The reason for the development of this particular type of scars, and not hypertrophic ones, has not yet been established by doctors.
A little about scarring.
Information about scars will be incomplete if we ignore such procedures as scarification or scarification - the artificial application of decorative scars to the skin. For some, this newfangled trend of body art is a way to disguise existing scars, for others it is an attempt to give their appearance masculinity and brutality. Unfortunately, young people's thoughtless passion for such procedures, as well as other artificial damage to the skin (tattoos, piercings) leads to irreversible consequences. Fashion passes, but scars remain forever.RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2014
Radiation-related skin and subcutaneous tissue disease, unspecified (L59.9), Keloid scar (L91.0), Complication of surgery and medical intervention, unspecified (T88.9), Open head wound, unspecified (S01.9), Open wound other and unspecified part of the abdomen (S31.8), Open wound of another and unspecified part of the shoulder girdle (S41.8), Open wound of another and unspecified part of the pelvic girdle (S71.8), Open wound of the unspecified part of the chest (S21.9) , Open wound of unspecified part of forearm (S51.9), Open wound of unspecified part of neck (S11.9), Avulsion of scalp (S08.0), Sequelae of other specified injuries of upper extremity (T92.8), Sequelae of other specified injuries of head (T90.8), Sequelae of other specified injuries of the lower extremity (T93.8), Sequelae of other specified injuries of the neck and torso (T91.8), Sequelae of complications of surgical and therapeutic interventions, not elsewhere classified (T98.3), Consequences thermal and chemical burns and frostbite (T95), Scar conditions and fibrosis of the skin (L90.5), Cellulitis of the trunk (L03.3), Chronic skin ulcer, not elsewhere classified (L98.4), Ulcer of the lower extremity, not classified in other sections (L97)
Combustiology
General information
Brief description
Recommended
Expert Council of the Republican State Enterprise at the Republican Exhibition Center "Republican Center for Health Development"
Ministry of Health and Social Development of the Republic of Kazakhstan
dated December 12, 2014, protocol No. 9
Consequences of thermal burns, frostbite and wounds is a symptom complex of anatomical and morphological changes in the affected areas of the body and surrounding tissues, limiting the quality of life and causing functional disorders.
The main outcomes of the above conditions are scars, long-term non-healing wounds, wounds, contractures and trophic ulcers.
Scar- this is a connective tissue structure that arises at the site of skin damage by various traumatic factors to maintain homeostasis of the body.
Scar deformities- a condition with limited scars, scar masses localized on the head, torso, neck, limbs without restriction of movements, leading to aesthetic and physical inconveniences and restrictions.
Contracture- this is a persistent restriction of joint movements caused by changes in surrounding tissues due to the influence of various physical factors, in which the limb cannot be completely bent or straightened in one or more joints.
Wound- this is damage to tissues or organs, accompanied by a violation of the integrity of the skin and underlying tissues.
Long-term non-healing wound- a wound that does not heal within a period that is normal for wounds of this type or location. In practice, a long-term non-healing wound (chronic) is considered to be a wound that has existed for more than 4 weeks without signs of active healing (the exception is extensive wound defects with signs of active repair).
Trophic ulcer- a defect in the integumentary tissues with a low tendency to heal, with a tendency to recur, which arose against the background of impaired reactivity due to external or internal influences, which in their intensity go beyond the adaptive capabilities of the body. A trophic ulcer is a wound that does not heal for more than 6 weeks.
I. INTRODUCTORY PART
Protocol name: Consequences of thermal and chemical burns, frostbite, wounds.
Protocol code:
ICD-10 code(s):
T90.8 Consequences of other specified head injuries
T91.8 Consequence of other specified injuries of the neck and torso
T92.8 Consequence of other specified injuries of the upper limb
T93.8 Consequence of other specified injuries of the lower extremity
T 95 Consequences of thermal and chemical burns and frostbite
T95.0 Consequences of thermal and chemical burns and frostbite of the head and neck
T95.1 Consequences of thermal and chemical burns and frostbite of the torso
T95.2 Consequences of thermal and chemical burns and frostbite of the upper limb
T95.3 Consequences of thermal and chemical burns and frostbite of the lower limb
T95.4 Consequences of thermal and chemical burns, classified only according to the area of the affected area of the body
T95.8 Consequences of other specified thermal and chemical burns and frostbite
T95.9 Consequences of unspecified thermal and chemical burns and frostbite
L03.3 Cellulitis of the trunk
L91.0 Keloid scar
L59.9 Disease of the skin and subcutaneous tissue associated with radiation
L57.9 Skin changes caused by chronic exposure to non-ionizing radiation, unspecified
L59.9 Radiation-associated disease of the skin and subcutaneous tissue, unspecified
L90.5 Scar conditions and fibrosis of the skin
L97 Ulcer of lower extremity, not elsewhere classified
L98.4 Chronic skin ulcer, not elsewhere classified
S 01.9 Open head wound, unspecified
S 08.0 Scalp avulsion
S 11.9 Open wound of the neck, unspecified
S 21.9 Open chest wound, unspecified
S 31.8 Open wound of another and unspecified part of the abdomen
S 41.8 Open wound of other and unspecified part of the shoulder girdle and shoulder
S 51.9 Open wound of an unspecified part of the forearm
S 71.8 Open wound of another and unspecified part of the pelvic girdle
T88.9 Complications of surgical and therapeutic interventions, unspecified.
T98.3 Consequences of complications of surgical and therapeutic interventions, not classified elsewhere.
Abbreviations used in the protocol:
ALT - Alanine aminotransferase
AST - Aspartate aminotransferase
HIV - human immunodeficiency virus
ELISA - enzyme immunoassay
NSAIDs - non-steroidal anti-inflammatory drugs
CBC - complete blood count
OAM - general urine analysis
Ultrasound - ultrasound examination
UHF therapy - ultra high frequency therapy
ECG - electrocardiogram
ECHOKS - transthoracic cardioscopy
Date of protocol development: 2014
Protocol users: combustiologists, orthopedic traumatologists, surgeons.
Classification
Clinical classification
Scarring classified according to the following criteria:
By origin:
Post-burn;
Post-traumatic.
By growth pattern:
Atrophic;
Normotrophic;
Hypertrophic;
Keloids.
Wounds divided depending on the origin, depth and extent of the wound.
Types of wounds:
Mechanical;
Traumatic;
Thermal;
Chemical.
There are three main types of wounds:
Operating rooms;
Random;
Firearms.
Accidental and gunshot wounds Depending on the wounding object and the mechanism of injury, they are divided into:
Chipped;
Cut;
Chopped;
Bruised;
Crushed;
Torn;
Bitten;
Firearms;
Poisoned;
Combined;
Penetrating and not penetrating into body cavities. [7]
Contractures classified depending on the type of tissue that caused the disease. Contractures are primarily classified according to the degree of restriction of movement in the damaged joint.
After burns, skin-scar contractures (dermatogenic) most often occur. According to the severity, post-burn contractures are divided into degrees:
I degree (mild contracture) - limitation of extension, flexion, abduction ranges from 1 to 30 degrees;
II degree (moderate contracture) - limitation from 31 degrees to 60 degrees;
III degree (severe or severe contracture) - limitation of movement more than 60 degrees.
Classification of trophic ulcers by etiology:
Post-traumatic;
Ischemic;
Neurotrophic;
Lymphatic;
Vascular;
Infectious;
Tumor.
Trophic ulcers are classified according to their depth:
I degree - superficial ulcer (erosion) within the dermis;
II degree - an ulcer reaching the subcutaneous tissue;
III degree - an ulcer that penetrates into the fascia or subfascial structures (muscles, tendons, ligaments, bones), into the cavity of the articular capsule or joint.
Classification of trophic ulcers by area affected:
Small, up to 5 cm2 in area;
Medium - from 5 to 20 cm2;
Extensive (giant) - over 50 cm2.
Diagnostics
II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
List of basic and additional diagnostic measures
Basic (mandatory) diagnostic examinations performed on an outpatient basis:
Additional diagnostic examinations performed on an outpatient basis:
Coagulogram (determination of clotting time, duration of bleeding).
The minimum list of examinations that must be carried out when referring for planned hospitalization:
Blood coagulogram (determination of clotting time, duration of bleeding);
Blood group determination
Determination of Rh factor;
Bacterial culture from wounds (if indicated).
X-ray according to indications (affected area);
Basic (mandatory) diagnostic examinations carried out at the hospital level: According to indications, upon discharge, control tests:
Additional diagnostic examinations carried out at the hospital level:
Biochemical blood test (glucose, total bilirubin, alanine aminotransferase, aspartate aminotransferase, urea, creatinine, total protein);
Bacterial culture from wounds according to indications;
Diagnostic measures carried out at the stage of emergency care: not carried out.
Diagnostic criteria
Complaints: For the presence of post-traumatic or burn scars with functional disorders, pain or causing aesthetic discomfort. For the presence of wounds of various origins, their pain, limitation of movements in the joints.
Anamnesis: A history of trauma, frostbite or burns, as well as concomitant diseases that caused pathological changes in tissues.
Physical examination:
If there are wounds describes their origin (post-traumatic, post-burn), the age of the wound, the nature of the edges (smooth, torn, crushed, callous), their length and size, depth, bottom of the wound, mobility of the edges and adhesion to the surrounding tissues.
In the presence of granulations described:
Character;
The presence and nature of the discharge.
When describing contractures their origin is indicated:
Post-burn;
Post-traumatic.
Localization, degree and nature of changes in the skin (description of scars, if any, color, density, growth pattern - normotrophic - without rising above the surrounding tissues, hypertrophic - rising above the surrounding tissues), the nature of the limitation of movements, flexion, extension and the degree of limitation of movements. [8]
When describing scars indicate them:
Localization;
Origin;
Prevalence;
Character, mobility;
The presence of an inflammatory reaction;
Areas of ulceration.
Laboratory research:
UAC(with long-term non-healing wounds, trophic ulcers, especially giant ones): moderate decrease in hemoglobin, increase in ESR, eosinophilia,
Coagulogram: increase in fibrinogen level to 6 g/l.
Biochemical blood test: hypoproteinemia.
Indications for consultation with specialists:
Consultation with a neurosurgeon or neurologist in the presence of a neurological deficit due to the progression of the underlying or concomitant disease.
Consultation with a surgeon in the presence of exacerbation of concomitant pathology.
Consultation with an angiosurgeon for concomitant vascular damage.
Consultation with a urologist in the presence of concomitant urological pathology.
Consultation with a therapist in the presence of concomitant somatic pathology.
Consultation with an endocrinologist in the presence of concomitant endocrinological diseases.
Consultation with an oncologist to rule out cancer.
Consultation with a phthisiatrician to exclude tuberculous etiology of diseases.
Differential diagnosis
Differential diagnosis of contractures
Table 1 Differential diagnosis of contractures
|
Sign |
Post-burn contracture | Post-traumatic contracture | Congenital contracture |
| Anamnesis | burns | Post-traumatic wounds, fractures, tendon and muscle damage | Congenital malformation (cerebral palsy, amniotic bands, etc.) |
| The nature of the skin | Presence of scars | Ordinary | Ordinary |
| How long ago did contracture appear? | After 3-6 months. after a burn | In 1-2 months. after an injury | From birth |
| X-ray picture | Picture of arthrosis, bone hypotrophy | Picture of osteoarthritis, improperly healed fracture, narrowing and homogeneous darkening of the joint space | Underdevelopment of joint elements |
Table 2 Differential diagnosis of wounds and pathologically changed tissues
|
Sign |
Scarring | Long-term non-healing granulating wounds | Trophic ulcers |
| The nature of the skin | Dense, hyperpigmented, with a tendency to grow | The presence of pathological granulations without a tendency to close the wound defect | Adhesive to the underlying tissues, with callous edges and a tendency to recur |
| Duration of appearance of wounds | Immediately after physical exposure for a period of 3 to 12 months without the presence of a wound surface or with limited areas of ulceration | From 3 weeks or more after the injury | For a long time without the presence of a traumatic agent |
Treatment abroad
Get treatment in Korea, Israel, Germany, USA
Get advice on medical tourism
Treatment
Treatment goals:
Increased range of motion in damaged joints;
Elimination of aesthetic defects;
Restoring the integrity of the skin.
Treatment tactics
Non-drug treatment
Diet - 15 table.
General regimen, in the postoperative period - bed.
Drug treatment
Table 1. Medicines used in the treatment of the consequences of burns, frostbite, and wounds of various etiologies(except for anesthesiological support)
Post-burn scars and contractures
|
№ |
Drug, release forms | Dosing | Duration of use |
| Local anesthetic drugs: | |||
| 1 | Procaine | 0.25%,0.5%, 1%, 2%. No more than 1 gram. | 1 time upon admission of a patient to a hospital or when contacting an outpatient clinic |
| Antibiotics | |||
| 2 |
Cefuroxime Or Cefazolin Or Amoxicillin/clavulanate Or Ampicillin/sulbactam |
1.5 g IV 3g IV |
1 time 30-60 minutes before the skin incision; additional administration possible during the day |
| Opioid analgesics | |||
| 3 |
Tramadol solution for injection 100 mg/2 ml 2 ml in ampoules 50 mg in capsules, tablets Metamizole sodium 50% |
50-100 mg. IV, through the mouth. maximum daily dose 400 mg. 50% - 2.0 intramuscularly up to 3 times |
1-3 days. |
| Antiseptic solutions | |||
| 4 | Povidone-iodine | Bottle 1 liter | 10 - 15 days |
| 5 | Chlorhexedine | Bottle 500 ml | 10 - 15 days |
| 6 | Hydrogen peroxide | Bottle 500 ml | 10 - 15 days |
| Dressings | |||
| 7 | Gauze, gauze bandages | meters | 10 - 15 days |
| 8 | Medical bandages | Pieces | 10 - 15 days |
| 9 | Elastic bandages | Pieces | 10 - 15 days |
Medicines for wounds, trophic ulcers, extensive post-burn wounds and wound defects
|
№ |
Name of the drug (international name) | Quantity | Duration of use |
| Antibiotics | |||
| 1 |
Cefuroxime, powder for solution for injection 750 mg, 1500 mg Amoxicillin/clavulanate, powder for solution for injection 1.2g |
5-7days | |
| Analgesics | |||
| 2 | Tramadol solution for injection 100 mg/2 ml 2 ml in ampoules 50 mg in capsules, tablets | 50-100 mg. intravenously, through the mouth. maximum daily dose 400 mg. | 1-3 days |
| 3 | Metamizole sodium 50% | 50% - 2.0 intramuscularly up to 3 times | 1-3 days |
| 4 | 1500 - 2000 cm/2 | ||
| 5 | Hydrogel coatings | 1500 - 2000 cm/2 | |
| 6 | 1500 - 2000 cm/2 | ||
| 7 | Allogeneic fibroblasts | 30 ml with a cell count of at least 5,000,000 | |
| 8 | 1500 - 1700 cm/2 | ||
| Ointments | |||
| 9 | Vaseline, ointment for external use | 500 gr. | |
| 10 | Silver sulfadiazine, cream, ointment for external use 1% | 250 - 500 gr. | |
| 11 | Combined water-soluble ointments: chloramphenicol/methyluracil, ointment for external use | 250 - 500 gr. | |
| Antiseptic solutions | |||
| 12 | Povidone-iodine | 500 ml | |
| 13 | Chlorhexedine | 500 ml | |
| 14 | Hydrogen peroxide | 250 ml | |
| Dressings | |||
| 15 | Gauze, gauze bandages | 15 meters | |
| 16 | Medical bandages | 5 pcs | |
| 17 | Elastic bandages | 5 pcs | |
| Infusion therapy | |||
| 18 | Sodium chloride solution 0.9% | Bottle ml. | |
| 19 | Glucose solution 5% | Bottle ml. | |
| 20 | SZP | ml | |
| 21 | Red blood cell mass | ml | |
| 22 | Synthetic colloidal preparations | ml | |
Drug treatment provided on an outpatient basis:
For post-burn scars and contractures. Onion extract liquid, sodium heparin, allantoin, gel for external use
For trophic ulcers
Antibiotics: Strictly according to indications, under the control of bacterial culture from the wound.
Antiplatelet agents
Pentoxifylline - solution for injection 2% - 5 ml, tablets 100 mg.
Drug treatment provided at the inpatient level:
Scar contractures and deformities
Antibiotics:
Cefuroxime, powder for solution for injection 750 mg, 1500 mg
Cefazolin, powder for solution for injection 1000 mg
Amoxicillin/clavulanate, powder for solution for injection 1.2g,
Ampicillin/sulbactam, powder for solution for injection 1.5g - 3g
Ciprofloxacin, solution for infusion 200 mg/100 ml
Ofloxacin, solution for infusion 200 mg/100 ml
Gentamicin, solution for injection 80 mg/2 ml
Amikacin, powder for solution for injection 0.5 g
List of additional medicines(less than 100% probability of application).
Non-steroidal anti-inflammatory drugs:
Ketoprofen - solution for injection in ampoules of 100 mg.
Diclofenac solution for IM, IV administration 25 mg/ml
Ketorolac solution for intravenous, intramuscular administration 30 mg/ml
Metamizole sodium 50% - 2.0 i/m
Low molecular weight heparins
Nadroparin calcium release form in syringes 0.3 ml, 0.4 ml, 0.6
Enoxaparin solution for injection in syringes 0.2 ml, 0.4 ml, 0.6 ml
Solutions for infusion therapy
Sodium chloride - isotonic sodium chloride solution 400ml.
Dextrose - glucose 5% solution 400ml.
Antiplatelet agents
Pentoxifylline - solution for injection 2% - 5ml.
Acetylsalicylic acid tablets 100 mg
Drug treatment provided at the emergency stage: not provided, hospitalization is planned.
Other types of treatment:
Compression therapy;
Balneological treatment (hydrogen sulfide applications, radon);
Mechanotherapy;
Ozone therapy;
Magnetotherapy;
Application of immobilization devices (splints, soft bandages, plaster cast, circular plaster cast, brace, orthosis) in the early stages after surgery.
Other types of treatment provided on an outpatient basis:
Magnetotherapy;
Compression therapy;
Balneological treatment;
Mechanotherapy.
Other types of services provided at the stationary level:
Hyperbaric oxygenation.
Other types of treatment provided at the emergency stage: not carried out, hospitalization is planned.
Surgical intervention:
In the absence of positive dynamics of the main surgical interventions, or as an addition to them, transplantation of cultured allogeneic or autologous skin cells is possible, as well as the use of biodegradable dressings [2]
Surgical intervention provided on an outpatient basis: not performed.
Surgical intervention provided in an inpatient setting
For post-burn, post-traumatic scars and contractures:
Plastic surgery with local tissues; in the presence of linear scars, contractures with formed “sail-shaped scar cords”, in the presence of limited skin defects.
Plastic surgery with flaps on the feeding pedicle; In the presence of scars, tissue defects in the area of large joints, when tendons and bone structures are exposed along the length, in case of tissue defects in the hands and on the supporting surfaces of the feet, for the purpose of reconstructing defects in the head, neck, torso, and pelvic area.
Free plastic surgery with flaps on vascular anastomoses; In the presence of scars, tissue defects in the area of large joints, when bone structures are exposed along the length, in case of tissue defects in the hands and on the supporting surfaces of the feet, for the purpose of reconstructing defects in the head, torso, and pelvic area.
Plastic flaps with axial blood supply; In the presence of tissue defects with exposure of joints, bone structures, defects of supporting surfaces (hands, feet).
Combined skin grafting; In the presence of scars or tissue defects in the area of large joints, when tendons and bone structures are exposed, in case of tissue defects in the hands and on the supporting surfaces of the feet, for the purpose of reconstructing defects in the head, neck, torso, and pelvic area.
Plastic surgery with estension flaps (through the use of endoexpanders); In the presence of extensive cicatricial lesions of the skin.
Use of external fixation devices; In the presence of bone fractures, arthrogenic contractures, correction of the length or shape of bone structures.
Transplantation or relocation of muscles and tendons; If there are defects along the muscles or tendons.
Endoprosthetics of small joints. When articular components are destroyed and other treatment methods have not been successful.
Long-term non-healing ulcers and scars:
Free autodermoplasty; in the presence of limited or extensive skin defects.
Surgical treatment of granulating wounds: in the presence of pathologically altered tissues.
Skin allotransplantation; in the presence of extensive skin defects, extensive ulcers of various origins.
Xenotransplantation in the presence of limited or extensive skin defects, for the purpose of preoperative preparation.
Transplantation of cultured skin cells in the presence of extensive skin defects, extensive ulcers of various origins.
Combined transplantation and the use of growth factors in the presence of extensive skin defects, extensive ulcers of various origins.
Plastic surgery with local tissues: in the presence of limited skin defects.
Plastic surgery with pedicle flaps: In the presence of scars or tissue defects in the area of large joints, when tendons and bone structures are exposed, in case of tissue defects in the hands and on the supporting surfaces of the feet, for the purpose of reconstructing defects in the head, neck, torso, and pelvic area .
Preventive measures:
Sanitation of residual wounds and scars;
Reducing the area of the scar;
Absence of inflammatory processes in the wound;
For wounds and trophic ulcers:
Healing of a wound defect;
Restoring the integrity of the skin
Drugs (active ingredients) used in treatment
| Allantoin |
| Allogeneic fibroblasts |
| Amikacin |
| Amoxicillin |
| Ampicillin |
| Acetylsalicylic acid |
| Biotechnological wound dressings (acellular material or material containing living cells) (xentransplantation) |
| Vaseline |
| Hydrogen peroxide |
| Gentamicin |
| Heparin sodium |
| Hydrogel coatings |
| Dextrose |
| Diclofenac |
| Ketoprofen |
| Ketorolac |
| Clavulanic acid |
| Onion bulb extract (Allii cepae squamae extract) |
| Metamizole sodium (Metamizole) |
| Methyluracil (Dioxomethyltetrahydropyrimidine) |
| Nadroparin calcium |
| Sodium chloride |
| Ofloxacin |
| Pentoxifylline |
| Fresh frozen plasma |
| Film collagen coatings |
| Povidone - iodine |
| Procaine |
| Synthetic wound coverings (Foamed polyurethane, combined) |
| Sulbactam |
| Sulfadiazine silver salt |
| Tramadol |
| Chloramphenicol |
| Chlorhexidine |
| Cefazolin |
| Cefuroxime |
| Ciprofloxacin |
| Enoxaparin sodium |
| Red blood cell mass |
Groups of drugs according to ATC used in treatment
Hospitalization
Indications for hospitalization, indicating the type of hospitalization.
Emergency hospitalization: No.
Planned hospitalization: Patients who have suffered frostbite, thermal burns of various origins with long-term wounds or trophic ulcers, scars, contractures are eligible.
Information
Sources and literature
- Minutes of meetings of the Expert Council of the RCHR of the Ministry of Health of the Republic of Kazakhstan, 2014
- 1. Yudenich V.V., Grishkevich V.M. Guidelines for the rehabilitation of burnt patients, Moscow medicine, 1986. 2.S. Kh. Kichemasov, Yu. R. Skvortsov Skin grafting with flaps with axial blood supply for burns and frostbite. St. Petersburg 2012 3.G. Chaby, P. Senet, M. Veneau, P. Martel, JC Guillaume, S. Meaume, et al. Dressings for the treatment of acute and chronic wounds. Systematic review. Archives of Dermatology, 143 (2007), p. 1297-1304 4.D.A. Hudson, A. Renshaw. An algorithm for the release of burn contractures of the extremities/ Burns, 32. (2006), pp. 663–668 5.N.M. Ertaş, H. Borman, M. Deniz, M. Haberal. Double opposing rectangular advancement elongates tension line as much as Z-plasty: an experimental study in the rat inguinal. Burns, 34 (2008), pp. 114–118 6 T. Lin, S. Lee, C. Lai, S. Lin. Treatment of axillary burn scar contractures using opposite running Y-V plasty. Burns, 31 (2005), pp. 894–900 7 Suk Joon Oh, Yoojeong Kim. Combined AlloDerm® and thin skin grafting for the treatment of postburn dyspigmented scar contracture of the upper extremity. Journal of Plastic, Reconstructive & Aesthetic Surgery. Volume 64, Issue 2, February 2011, Pages 229–233. 8 Michel H.E. Hermans. Preservation methods of allografts and their (lack of) influence on clinical results in partial thickness burns // Burns, Volume 37. - 2011, P. - 873–881. 9 J. Leon-Villapalos, M. Eldardiri, P. Dziewulski. The use of human deceased donor skin allograft in burn care // Cell Tissue Bank, 11 (1). - 2010, P. - 99–104. 10 Michel H.E. Hermans, M.D. Porcine xenografts vs. (cryopreserved) allografts in the management of partial thickness burns: Is there a clinical difference? Burns Volume 40, Issue 3, May 2014, pp. 408–415. 11 Alekseev A. A., Tyurnikov Yu. I. Application of the biological dressing “Xenoderm” in the treatment of burn wounds. // Combustiology. - 2007. - No. 32 - 33. - http://www.burn.ru/ 12 Ryu Yoshida, Patrick Vavken, Martha M. Murray. Decellularization of bovine anterior cruciate ligament tissues minimizes immunogenic reactions to alpha-gal epitopes by human peripheral blood mononuclear cells. // The Knee, Volume 19, Issue 5, October 2012, pp. 672–675. 13 Celine Auxenfansb, 1, Veronique Menetb, 1, Zulma Catherinea, Hristo Shipkov. Cultured autologous keratinocytes in the treatment of large and deep burns: A retrospective study over 15 years. Burns, Available online 2 July 2014 14 J.R. Hanft, M.S. Surprenant. Healing of chronic foot ulcers in diabetic patients treated with a human fibroblast derived dermis. J Foot Ankle Surg, 41 (2002), p. 291. 15 Steven T Boyce, Principles and practices for treatment of cutaneous wounds with cultured skin substitutes. The American Journal of Surgery. Volume 183, Issue 4, April 2002, Pages 445–456. 16 Mitryashov K.V., Terekhov S.M., Remizova L.G., Usov V.V., Obydeinikova T.N. Evaluation of the effectiveness of the use of skin epidermal growth factor in the treatment of burn wounds in a “wet environment”. Electronic journal - Combustiology. 2011, No. 45.
Information
III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION
List of protocol developers with qualification information:
1. Abugaliev Kabylbek Rizabekovich - JSC "National Scientific Center of Oncology and Transplantology", chief specialist of the department of reconstructive plastic surgery and combustiology, candidate of medical sciences, chief freelance specialist in combustiology of the Ministry of Health and Social Development of the Republic of Kazakhstan
2. Mokrenko Vasily Nikolaevich - State Public Enterprise at the RVC “Regional Center for Traumatology and Orthopedics named after Professor Kh.Zh. Makazhanova" of the Health Department of the Karaganda region, head of the burn department
3. Khudaibergenova Mahira Seidualievna - JSC National Scientific Center of Oncology and Transplantology, chief expert clinical pharmacologist of the department for examination of the quality of medical services
Disclosure of no conflict of interest: No.
Reviewers:
Sultanaliev Tokan Anarbekovich - Advisor to the Chief Surgeon of JSC National Scientific Center of Oncology and Transplantology, Doctor of Medical Sciences, Professor
Indication of the conditions for reviewing the protocol: Review of the protocol after 3 years and/or when new diagnostic/treatment methods with a higher level of evidence become available.
Attached files
Attention!
- By self-medicating, you can cause irreparable harm to your health.
- The information posted on the MedElement website and in the mobile applications "MedElement", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Guide" cannot and should not replace a face-to-face consultation with a doctor. Be sure to contact a medical facility if you have any illnesses or symptoms that concern you.
- The choice of medications and their dosage must be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and condition of the patient’s body.
- The MedElement website and mobile applications "MedElement", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Directory" are exclusively information and reference resources. The information posted on this site should not be used to unauthorizedly change doctor's orders.
- The editors of MedElement are not responsible for any personal injury or property damage resulting from the use of this site.
Pronounced skin pigmentation Certain localization of initial lesions (deltoid muscle area, chest, earlobe) Pregnancy Puberty.
Pathomorphology
Histological examination reveals elongated convoluted bundles of eosinophilically stained hyalinized collagen, thinning of the dermal papillae and decreased elasticity of the fibers. Morphological basis
consists of excessively growing immature connective tissue with a large number of atypical giant fibroblasts that have been in a functionally active state for a long time. IN
keloids
few capillaries, mast and plasma cells.
Keloid: Signs, Symptoms
Clinical picture
Pain Soreness Hyperesthesia Itching Hard, smooth scars raised above the surface of the skin with clear boundaries At the beginning of the disease, there may be pallor or slight erythema of the skin The scar occupies a larger area than the original damage Even after years
continue to grow and can form claw-like outgrowths.
Symptoms of keloid scars
Keloid and hypertrophic scars are accompanied by redness (hyperemia) and painful sensations after pressing on the scar. In this place, the tissues are highly sensitive. The scars begin to itch. Keloids develop in two stages:
- Active is characterized by the dynamic growth of keloid tissue. This is accompanied by itching, numbness of the affected areas and tissue soreness. This stage begins with epithelization of the wound and lasts up to a year.
- During the inactive period, the final formation of a scar occurs. It is called stabilized, acquiring normal skin color. The resulting scar does not cause concern to the owner, but on open areas of the body it looks unaesthetic.
There are two types of keloids. True ones rise above the skin and have a whitish or pink color. The scars are dense, with a smooth shiny surface with a minimal content of capillaries.
The formation of keloids is accompanied by the following symptoms:
- hyperemia (redness) in the scar area;
- painful sensations when pressing;
- increased sensitivity in the area of affected tissues;
- itching when scratching.
The development of keloids goes through two stages - active and inactive.
During the active stage, dynamic growth of keloid tissue occurs, which causes physical discomfort in the patient: itching, soreness and/or numbness of the affected tissues. This stage begins from the moment of epithelization of the wound and can last up to 12 months.
The inactive stage ends with the final formation of the scar. Such a keloid is otherwise called stabilized, since its color resembles the natural color of the skin, and the scar itself does not cause much concern, except for its unaesthetic appearance, especially on open areas of the body.
Keloid: Diagnosis
There are true (spontaneous) and false keloids.
Differential diagnosis
Hypertrophic scars Dermatofibroma Infiltrating basal cell carcinoma (confirmed by biopsy).
Conservative treatment
Keloid scar - how to get rid of it with conservative treatment? First, a diagnosis is made and a biopsy is prescribed to exclude a malignant neoplasm.
Treatment begins with conservative techniques. They help well if the scars are not yet old, formed no more than a year ago.
During compression, pressure is applied to the affected area. The growth of the keloid is stopped by compression. The nutrition of scar tissue is blocked, its blood vessels are compressed. All this helps stop the growth.
Ointment for keloid scars is only an auxiliary method. It is rarely used as an independent remedy. Ointments are usually prescribed as additional drugs that have antibacterial, anti-inflammatory and blood circulation-restoring effects.
Various techniques are used for cosmetic correction of acne keloid: dermabrasion, peelings. All of them are aimed at changing the appearance of scars.
Mesotherapy and other cosmetic methods are carried out only for the upper skin layer, in order to avoid the growth of connective tissue. Correction is indicated only for old scars.
In other cases, three main conservative methods are most often used to remove them. The first way to remove a keloid scar is treatment with silicone plates.
They begin to be used immediately after the first wound healing. Silicone sheets are mainly indicated for people who have a tendency to form keloids.
The essence of the technique is based on squeezing capillaries. As a result, collagen synthesis decreases and tissue hydration ceases. A special patch with plates is used daily for 12-24 hours. The course of therapy is from 3 to 18 months. Compression is a variation of this method.
Second method: treatment of keloid scars with corticosteroids is indicated for local use. An injection is made into the bulge, which includes a suspension of triamcinolone acetonide. It is allowed to inject from 20 to 20 milligrams of the drug per day, 10 mg is spent on each scar.
The purpose of the injections is to reduce collagen production. At the same time, the division of fibroblasts that produce it decreases, and the amount of collagenase increases.
Treatment is most effective for non-old scars. In this case, small doses are sufficient for therapy.
After a month, the course of treatment is repeated until the scars are even with the surface of the skin.
The third main method of how to get rid of keloid scars is called cryodestruction. This is a destructive effect on scar tissue with liquid nitrogen. As a result, a crust appears on the treated area.
Healthy tissue forms underneath. After the process is completed, the crust falls off on its own, leaving an almost imperceptible mark. The cryodestruction method is effective only for new keloid and hypertrophied scars.
Aggressive removal of keloid scars is done in two ways - surgically or using a laser. In the first case, during the operation, not only the overgrown tissue is excised, but also the affected area of skin.
The surgical method has its drawbacks - there is a high probability of the formation of new keloid scars.
This risk is somewhat reduced by removing the affected area of skin. However, relapses occur in 74-90 percent of cases. Surgery is indicated only in cases where conservative treatment has proven ineffective.
With the help of laser therapy, keloid scars that minimally affect the surrounding tissue are removed or cauterized. Correction is used in complex treatment and combined with corticosteroid and local methods. With laser therapy, relapses are much less common - 35-43 percent.
Treatment of keloid on the ear occurs according to a certain scheme. First, diprospan or kenologist-40 is prescribed.
Injections are made into the scar tissue. A month after the start of treatment, laser therapy using Bucca rays is performed.
The patient wears a special compression clip on the ear (at least 12 hours daily).
At the end of therapy, phono- and electrophoresis with collagenase or lidase is prescribed to consolidate the effect. At the same time, ointments and gels are prescribed (Lioton, Hydrocotisone, etc.).
If after this the growth of scar tissue does not stop, then close-focus radiotherapy is added to the treatment. In severe and complex cases, methotrexate is given.
A keloid scar after a cesarean section can be treated in many ways. In some cases, deep chemical peeling can help get rid of keloid scars.
First, the scar is treated with fruit acids. After this, chemicals are applied.
This method is ineffective, but also the most cost-effective.
For the treatment of keloid scars after removal of a mole or cesarean section, plates and gels containing silicone are prescribed. There are many anti-scar products with a collagenase base.
Hyaluronidase preparations are used. Hormone-based products with vitamins and oils help eliminate keloid scars.
To remove mature scars, physiotherapy is prescribed: phonoelectrophoresis. These are effective and painless procedures. In extreme cases, plastic surgery or laser resurfacing is done. A more gentle method is microdermabrasion. During the procedure, microparticles of aluminum oxide are used.
There are many ways to treat keloid scars using traditional methods. The scars are not completely removed, but they become less visible.
Plant-based products are used. For example, take 400 g of sea buckthorn oil and mix it with 100 g of beeswax.
The solution is heated in a water bath for 10 minutes. Then a gauze pad is dipped into the mixture and applied to the scar.
The procedure is carried out twice a day. The course of treatment is three weeks.
To remove scars, compresses are made with camphor, in which the bandage is moistened. Then it is applied to the scar. The compress is done daily for a month. Only after this will the result be visible.
You can make a tincture from delphinium. The roots of the plant are greatly crushed. Alcohol and water are added to them, mixed in equal proportions. The container is removed for two days in a dark place. Then a gauze pad is soaked in the liquid and applied to the keloid scar.
You can make your own ointment based on Japanese styphnolobia. A couple of glasses of plant beans are crushed and mixed with badger or goose fat in equal proportions.
The mixture is infused for 2 hours in a water bath. Then, at intervals of a day, it is heated twice more.
After this, the mixture is boiled, stirred and transferred to a ceramic or glass jar.
Keloid scars do not pose a threat to health or life, but can cause nervous disorders due to the unaesthetic appearance of the body. In the early stage, neoplasms are much easier to treat than in the advanced version.
According to statistics, keloid scars are not very common - only 10 percent of cases. Women are most susceptible to this disease. To prevent scars, you must follow all doctor's instructions and not self-medicate.
The nature of keloid is not fully understood, so to date no universal treatment method has been developed. The doctor chooses the methods individually for each patient, depending on the clinical picture of the disease.
Treatment methods can be divided into conservative and aggressive (radical).
It is preferable to start with conservative ones, especially if the scars are young - no older than one year. Three methods are recognized as the most effective:
- use of silicone coating/gel;
- corticosteroid injection therapy;
- cryotherapy.
Application of silicone plates
You should start using silicone plates in the form of a patch immediately after the initial healing of the wound in people who are predisposed to the development of keloids.
The mechanism of this technique is based on squeezing capillaries, reducing collagen synthesis and hydration (moistening) of the scar. The patch must be used from 12 to 24 hours a day.
The treatment period is from 3 months to 1.5 years.
A variation of this treatment method can be considered compression (squeezing), as a result of which the growth of the keloid stops, nutrition is blocked and the vessels of the scar are compressed, which leads to a stop in its growth.
Corticosteroid injections
This technique is used locally. A suspension of triamcinolone acetonide is injected into the scar using an injection.
You can administer 20-30 mg of the drug per day - 10 mg for each scar. Treatment is based on reducing collagen synthesis.
At the same time, the division of fibroblasts that produce collagen is inhibited, and the concentration of collagenase, the enzyme that breaks down collagen, increases.
Treatment in small doses is effective for fresh keloid scars. After 4 weeks, the treatment is repeated until the scars are compared with the surface of the skin. If there is no therapeutic effect, a triamcinolone suspension containing 40 mg/ml is used.
Treatment with steroids can cause complications:
Treatment
Lead tactics
Local injections of HA are most effective. Pressure on the damaged area prevents the development of
Bandages are used that create a pressure of up to 24 mm Hg over the injury site. Art. , for 6–12 months. The bandage can be removed for no more than 30 minutes/day. Radiation therapy in combination with GC - if other treatment methods are ineffective.
Surgical treatment
indicated only for extensive lesions and ineffectiveness of local treatment with GC. A high frequency of relapses is noted, so surgical treatment is recommended no earlier than 2 years after formation.
with immediate preventive treatment (as with emerging
Drug therapy
On one day, the drug can be injected into 3 scars (10 mg for each scar) The needle should be inserted in different directions for better distribution of the drug The effectiveness of the method is higher with fresh keloid scars Treatment is repeated every 4 weeks until the scars are compared with the surface of the skin If there is no effect, you can use triamcinolone suspension containing 40 mg/ml for surgical excision.
keloids
You can use a mixture of triamcinolone solution (5–10 mg/ml) with local anesthetics. To prevent relapses after surgery, injections of HA into the area of scar excision after 2–4 weeks and then 1 time per month for 6 months.
Course and prognosis
Under the influence of triamcinolone
decrease over 6–12 months, leaving flat, light scars.
ICD-10 L73. 0 Acne keloid L91. 0 Keloid scar.
Tags:
Did this article help you? Yes -0 No -0 If the article contains an error Click here 47 Rating:
Prevention
To reduce the risk of relapses after surgical operations to remove a keloid, it is customary to carry out preventive measures already in the process of forming a new scar (on days 10-25).
All therapeutic (conservative) methods are used as preventive measures. After surgery, you should constantly use sunscreen with a high level of protection.
Infiltration after surgery is one of the most common complications after surgery. It can develop after any operation - if you had your appendix removed, a hernia removed, or even just given an injection.
Therefore, it is important to monitor your condition very carefully after surgery. It is quite simple to cure such a complication if it is diagnosed in time. But if you delay it, it can develop into an abscess, and this is already fraught with a breakthrough of the abscess and blood poisoning.
What is it?
The term itself is a merger of two Latin words: in - “in” and filtratus - “strained”. Doctors call this word a pathological process when particles of cells (including blood cells), blood itself, and lymph accumulate inside tissues or any organ. Outwardly, it looks like a dense formation, but simply a tumor.
There are 2 main forms of this phenomenon - inflammatory (this is usually a complication after surgery) and tumor. Inside the second formation is not innocent blood and lymph, but tumor cells, and very often cancer cells. Sometimes doctors call infiltration the area on the body where an anesthetic, antibiotic or other substances are injected during treatment. This type is called “surgical”.
The inflammatory process can begin even before surgery. Particularly often diagnosed is appendiceal infiltrate, which develops almost in parallel with inflammation of the appendix. It occurs even more often than a complication after appendicitis surgery. Another “popular” option is a tumor in the mouth of children, the cause is fibrous pulpitis.
Varieties
Inflammatory infiltrate is the main type of this pathology, which often appears after surgery. There are several types of such inflammation, depending on which cells inside the tumor are most numerous.
- Purulent (polymorphonuclear leukocytes collected inside).
- Hemorrhagic (red blood cells).
- Round cell, or lymphoid (lymphoid cells).
- Histiocytic-plasma cell (plasma elements and histiocytes inside).
Inflammation of any nature can develop in several directions - either resolve over time (within 1-2 months), or turn into an unsightly scar, or develop into an abscess.
Scientists consider infiltration of a postoperative suture to be a special type of inflammatory disease. This disease is especially insidious - it can “pop up” a week or two after the operation, and after 2 years. The second option happens, for example, after a cesarean section, and the risk that the inflammation will develop into an abscess is quite high.
Reasons
No one is immune from the appearance of purulent, hemorrhagic and other formations after surgery. The complication occurs in both small children and adult patients, after banal appendicitis and after surgery to remove the uterus(paracervical and other tumors).
Experts name 3 main reasons for this phenomenon - trauma, odontogenic infections (in the oral cavity) and other infectious processes. If you see a doctor because a postoperative suture is inflamed, there are a number of other reasons:
- the wound became infected;
- postoperative drainage was performed incorrectly (usually in overweight patients);
- due to the fault of the surgeon, the layer of subcutaneous fatty tissue was damaged and a hematoma appeared;
- suture material has high tissue reactivity.
If the scar becomes inflamed only a few months or years after surgical procedures, the suture material is to blame. This pathology is called ligature (ligature is a dressing thread).
Pathology can also be provoked by a patient’s tendency to allergies, weak immunity, chronic infections, congenital diseases, etc.
Symptoms
Postoperative complication does not develop immediately - usually on the 4-6th day after hour X (surgical intervention). Sometimes later - after one and a half to two weeks. The main signs of incipient inflammation in a wound are:
- low-grade fever (increases by only a few notches, but it is impossible to bring it down);
- when pressing on the inflamed area, pain is felt;
- if you press very hard, a small pit appears, which gradually straightens;
- the skin in the affected area swells and turns red.
If the tumor occurs after surgery to remove an inguinal hernia, other symptoms may also appear. About a pathological accumulation of cells in the abdominal cavity they will say:
- aching pain in the peritoneum;
- intestinal problems (constipation);
- hyperemia (strong blood flow to sore spots).
With hyperemia, swelling occurs and boils appear, the heart rate increases, and the patient suffers from headaches.
What is post-injection infiltrate?
Infiltration after an injection is one of the most common complications after injection, along with hematomas. It looks like a small dense lump in the place where the needle with the medicine was inserted. The predisposition to such a mini-complication is usually individual: for some, a thickening appears on the skin after each injection, while others have never encountered such a problem in their entire life.
The following reasons can provoke such a reaction of the body to a banal injection:
- the nurse performed antiseptic treatment poorly;
- the syringe needle is too short or blunt;
- the injection site is chosen incorrectly;
- injections are made constantly in the same place;
- the medicine is administered too quickly.
Such a sore can be cured with regular physiotherapy, an iodine mesh or compresses with diluted dimexide. Traditional methods will also help: compresses from cabbage leaves, aloe, burdock. For greater effectiveness, you can lubricate the lump with honey before applying the compress.
Diagnostics
Diagnosing such postoperative pathology is usually not difficult. When making a diagnosis, the doctor relies primarily on the symptoms: temperature (what and how long it lasts), the nature and intensity of the pain, etc.
Most often, a tumor is determined by palpation - it is a dense formation with uneven and fuzzy edges, which responds with pain when palpated. But if surgical manipulations were performed on the abdominal cavity, then the seal may be hidden deep inside. And during a finger examination, the doctor simply will not find it.
In this case, more informative diagnostic methods come to the rescue - ultrasound and computed tomography.
Another mandatory diagnostic procedure is a biopsy. Tissue analysis will help to understand the nature of inflammation, find out which cells have accumulated inside, and determine whether any of them are malignant. This will allow you to find out the cause of the problem and correctly draw up a treatment plan.
Treatment
The main goal in the treatment of postoperative infiltration is to relieve inflammation and prevent the development of an abscess. To do this, you need to restore blood flow in the sore spot, relieve swelling and eliminate pain. First of all, conservative therapy is used:
- Treatment with antibiotics (if the infection is caused by bacteria).
- Symptomatic therapy.
- Local hypothermia (artificial decrease in body temperature).
- Physiotherapy.
- Bed rest.
Effective procedures are considered to be UV irradiation of the wound, laser therapy, mud therapy, etc. The only contraindication for physiotherapy is purulent inflammation. In this case, heating and other procedures will only accelerate the spread of infection and may cause an abscess.
When the first signs of an abscess appear, a minimally invasive intervention is first used - drainage of the affected area (under ultrasound control). In the most difficult cases, the abscess is opened in the usual way, using laparoscopy or laparotomy.
Treatment of postoperative sutures with complications is also traditionally carried out using conservative methods: antibiotics, novocaine blockade, physiotherapy. If the tumor has not resolved, the suture is opened, cleaned and sutured again.
Infiltrate after surgery can form in a patient of any age and health condition. By itself, this tumor usually does not cause any harm, but it can serve as the initial stage of an abscess - severe purulent inflammation. Another danger is that sometimes the pathology develops several years after a visit to the operating room, when the scar becomes inflamed. Therefore, it is necessary to know all the signs of such a disease and, at the slightest suspicion, consult a doctor. This will help avoid new complications and additional surgical interventions.
Article for the site "Health Recipes" prepared by Nadezhda Zhukova.
* By clicking on the “Send” button I agree with
Source: zdorovieiuspex.ru
Includes: conditions warranting observation, hospitalization or other obstetric care for the mother, or caesarean section before the onset of labor
Excludes: listed conditions with obstructed labor (O65.5)
- double uterus
- bicornuate uterus
Medical care for the mother for:
- uterine body polyp
- uterine fibroid
Excludes: maternal care for cervical tumors (O34.4)
Medical care for a mother with a scar from a previous cesarean section
Excludes: vaginal delivery after previous caesarean section NOS (O75.7)
Suturing the cervix with a circular suture with or without mention of cervical insufficiency
Shirodkar suture with or without mention of cervical insufficiency
Medical care for the mother for:
- cervical polyp
- previous cervical surgery
- stricture and stenosis of the cervix
- cervical tumors
Providing medical care to the mother for:
- strangulation of the pregnant uterus
- prolapse of the pregnant uterus
- retroversion of the pregnant uterus
Medical care for the mother for:
- previous vaginal surgery
- dense hymen
- vaginal septum
- vaginal stenosis (acquired) (congenital)
- vaginal stricture
- vaginal tumors
Excludes: maternal medical care for vaginal varicose veins during pregnancy (O22.1)
Medical care for the mother for:
- fibrosis of the perineum
- previous surgery on the perineum and vulva
- rigid perineum
- vulvar tumors
Excludes: maternal medical care for varicose veins of the perineum and vulva during pregnancy (O22.1)
Medical care for the mother for:
- cystocele
- pelvic floor plastic surgery (and medical history)
- saggy belly
- rectocele
- rigid pelvic floor
In Russia International Classification of Diseases 10th revision ( ICD-10) was adopted as a single normative document for recording morbidity, reasons for the population’s visits to medical institutions of all departments, and causes of death.
ICD-10 introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. No. 170
The release of the new revision (ICD-11) is planned by WHO in 2022.
Source: mkb-10.com
Postoperative uterine scar requiring medical care for the mother
Definition and general information [edit]
A scar (scars) is a dense formation consisting of hyalinized connective tissue rich in collagen fibers, resulting from the reparative regeneration of tissue when its integrity is violated.
A uterine scar is an area of the uterus in which previous surgical interventions were performed (cesarean section, myomectomy, reconstructive plastic surgery)
According to various authors, 12-16% of pregnant women have a scar on the uterus after cesarean section, and every third abdominal birth is subsequently repeated. The prevalence of cesarean section in the Russian Federation over the past 30 years (since 1980) has increased 3 times and is 22-23%. The number of pregnant women with a uterine scar after myomectomy is increasing. If it is performed using laparoscopic or laparotomic access in the presence of an interstitial component, a scar is also formed. The incidence of failed scars after myomectomy reaches 21.3%.
Prosperous scar on the uterus.
Incompetent scar on the uterus.
a) Localization of the scar on the uterus after cesarean section:
- in the lower uterine segment;
— partly in the lower segment, partly in the body (after an isthmic-corporal incision on the uterus);
b) Scar on the uterus after myomectomy before and during pregnancy:
- without opening the uterine cavity;
- with opening of the uterine cavity;
— a scar on the uterus after removal of the subserous-interstitial node;
- a scar on the uterus after removal of cervical fibroids.
c) Scar on the uterus after perforation of the uterus [during intrauterine interventions (abortion, hysteroscopy)].
d) A scar on the uterus after an ectopic pregnancy, located in the interstitial part of the fallopian tube, in the cervix after removal of the cervical pregnancy.
e) Scar on the uterus after reconstructive plastic surgery (Strassmann operation, removal of the rudimentary uterine horn, plastic surgery of the isthmus for an incompetent scar on the uterus after cesarean section).
A scar on the uterus is formed as a result of cesarean section, after myomectomy, uterine perforation, tubectomy. Scarring is a biological mechanism for healing damaged tissue. Healing of the dissected uterine wall can occur through both restitution (full regeneration) and substitution (incomplete). With complete regeneration, wound healing occurs due to smooth muscle cells (myocytes), with substitution - due to bundles of coarse fibrous connective tissue, often hyalinized.
Postoperative uterine scar requiring medical care for the mother: Diagnosis[edit]
Informative methods for diagnosing the condition of a scar on the uterus in a non-pregnant woman are hysterography, or better yet, hysteroscopy, ultrasound examination (ultrasound).
Hysterography performed on the 7-8th day of the menstrual cycle, but not earlier than 6 months after the operation in frontal and lateral projections. The method allows you to study changes in the inner surface of the postoperative scar on the uterus. The failure of a postoperative scar is indicated by: a change in the position of the uterus in the pelvis (significant displacement of the uterus anteriorly, jagged and thinned contours of the inner surface of the uterus in the area of the intended scar, “niches” and defects in its filling).
Hysteroscopy is performed on the 4-5th day of the menstrual cycle, when the functional layer of the endometrium is completely rejected, and the underlying tissue is visible through the thin basal layer. Scar failure is usually indicated by local retractions or thickening in the scar area. The whitish color of scar tissue and the absence of blood vessels indicate a pronounced predominance of the connective tissue component, and retractions indicate thinning of the myometrium as a result of inadequate regeneration. A non-visualized uterine scar and a scar with a predominance of muscle tissue indicate its anatomical and morphological usefulness.
Ultrasound examination. Echoscopic signs of uterine scar failure include: an uneven contour along the posterior wall of a full bladder, thinning of the myometrium, discontinuity of the scar contours, a significant number of echo-dense inclusions (connective tissue). With two-dimensional ultrasound, pathological changes in the area of the uterine scar are detected much less frequently than with hysteroscopy (56% and 85%, respectively). But with the advent of the Doppler method and 3D reconstruction, the information content of ultrasound for assessing the condition of the uterine scar has increased significantly, since it has become possible to assess the hemodynamics of the scar (the development of the vascular network). The results of additional methods for diagnosing the condition of the uterine scar outside pregnancy are entered into the outpatient chart and taken into account when deciding on the possibility of planning a subsequent pregnancy.
If there is an incompetent scar on the uterus at the stage of pregnancy planning, in order to prevent its rupture during a subsequent pregnancy, reconstructive surgery is indicated - plastic surgery of the uterine isthmus, which is performed in a gynecological hospital by a highly qualified gynecological surgeon using laparotomic or laparoscopic access.
Careful selection of pregnant women for spontaneous childbirth.
Careful cardiotocographic and ultrasound monitoring during spontaneous labor.
Adequate pain relief during spontaneous labor.
Excision of an incompetent scar on the uterus during a repeat caesarean section.
Postoperative uterine scar requiring medical care for the mother: Treatment[edit]
Management of pregnant women with a uterine scar after cesarean section
A thorough history taking, including information about a previous caesarean section based on an extract from the obstetric hospital.
Information about studies of the uterine scar conducted outside and during pregnancy.
Parity: whether there was spontaneous labor before surgery; the number of pregnancies between the operation and the real pregnancy, how they ended (abortion, miscarriage, non-developing pregnancy).
The presence of living children, whether there were stillbirths and deaths of children after previous births.
b) Physical examination
Palpation examination of the scar on the anterior abdominal wall and on the uterus; measuring the size of the pelvis and the estimated weight of the fetus; assessment of the condition of the birth canal and the body’s readiness for childbirth at 38-39 weeks of gestation.
c) Instrumental research methods
Ultrasound of the fetus using Doppler ultrasound of the vessels of the umbilical cord, aorta, middle cerebral artery of the fetus and placenta, starting from the end of the second trimester of pregnancy.
Cardiac monitoring of the fetus.
Ultrasound of the uterine scar every 7-10 days after 37 weeks of pregnancy.
The management tactics for pregnant women with a significant uterine scar do not differ from the generally accepted ones.
An ultrasound must be performed as early as possible. The main purpose of this study is to determine the place of attachment of the fertilized egg in the uterus. If it is located in the area of the isthmus on the anterior wall of the uterus (in the area of the scar after cesarean section in the lower uterine segment), from a medical point of view it is advisable to terminate the pregnancy, which is performed using a vacuum aspirator; since the proteolytic properties of the chorion, as pregnancy progresses, can lead to inferiority of even a wealthy uterine scar, to placenta previa and ingrowth of the placenta into the scar and to uterine rupture. The question of maintaining or terminating a pregnancy is within the competence of the woman herself. In case of uncomplicated pregnancy and the presence of a scar on the uterus, the next comprehensive examination is carried out at 37-38 weeks of gestation in a hospital where the pregnant woman is expected to give birth (level III obstetric hospitals).
Delivery of pregnant women with a scar on the uterus after cesarean section
The question of the method of delivery must be agreed upon with the pregnant woman. The obstetrician’s task is to explain to her in detail all the benefits and risks of both a repeat cesarean section and spontaneous birth. The final decision is made by the woman herself in the form of written informed consent to one of the methods of delivery. In the absence of absolute indications for a planned cesarean section, preference should be given to childbirth through the birth canal, and its spontaneous onset.
Conducting childbirth through the natural birth canal is permissible if a number of conditions are met:
- one history of caesarean section with a transverse incision on the uterus in the lower segment;
— absence of extragenital diseases and obstetric complications that served as indications for the first operation;
— the presence of a strong scar on the uterus (according to the results of clinical and instrumental studies);
— localization of the placenta outside the scar on the uterus;
- cephalic presentation of the fetus;
— correspondence between the sizes of the mother’s pelvis and the fetal head;
— availability of conditions for emergency delivery by cesarean section: highly qualified medical personnel; the possibility of performing an emergency caesarean section no later than 15 minutes after the decision to operate is made.
Indications for repeated abdominal birth in the presence of a scar on the uterus after cesarean section:
— a scar on the uterus after a corporal caesarean section;
— incompetent scar on the uterus according to clinical and echoscopic signs;
— scar on the uterus after isthmus surgery;
- placenta previa in the scar;
- two or more scars on the uterus after cesarean sections in the lower uterine segment;
During a repeat cesarean section, a prerequisite is the excision of the incompetent scar on the uterus, which significantly reduces the risk of complications during subsequent pregnancies.
Management of childbirth in women with a uterine scar after myomectomy
When choosing a method of delivery in women with a uterine scar after myomectomy, the nature, volume and method (laparotomy or laparoscopic) of the operation performed are of decisive importance. The risk of uterine rupture along the scar after myomectomy during spontaneous labor is determined by the depth of the tumor in the myometrium.
Indications for cesarean section after myomectomy outside pregnancy:
- a scar on the uterus after removal of the interstitial or subserous-interstitial nodes located on the posterior wall of the uterus;
— a scar on the uterus after removal of cervical fibroids;
— a scar on the uterus after removal of intraligamentary fibroids;
— scars on the uterus after removal of several large interstitial-subserous nodes;
- complicated obstetric history;
- breech presentation of the fetus;
— FPI (fetoplacental insufficiency);
- the age of the first-time mother is over 30 years;
— scar after myomectomy performed by laparoscopic approach.
When pregnant women with a scar on the uterus after myomectomy give birth outside of pregnancy and there are no indications for cesarean section, spontaneous birth is preferable.
A scar on the uterus after a myomectomy performed during pregnancy is an indication for a cesarean section.
Delivery of pregnant women with a scar on the uterus after reconstructive plastic surgery, uterine perforation and ectopic pregnancy
Indications for caesarean section:
— scar on the uterus after metroplasty (Strassmann operation, removal of the rudimentary uterine horn with opening of the uterine cavity, plastic surgery of the isthmus for an incompetent scar on the uterus after cesarean section);
— a scar after perforation of the uterus, located in the area of the isthmus along the posterior wall;
- a scar after removal of a cervical pregnancy, pregnancy in the rudimentary uterine horn, or the stump of a previously removed tube.
After vaginal delivery with a uterine scar, it is necessary to conduct a control manual examination of the walls of the uterine cavity.
Prevention of uterine scar failure
Creating optimal conditions for the formation of a healthy scar on the uterus during operations on the uterus: suturing the incision on the uterus with separate muscular-muscular sutures or a continuous suture (but not reverse) using synthetic absorbable suture threads (Vicryl, Monopril, etc.).
Prevention, timely diagnosis and adequate treatment of postoperative complications.
Objective assessment of the condition of the uterine scar before pregnancy.
Source: wikimed.pro
Childbirth with a scar on the uterus, ICD code 10
A scar (cicatrix) is a dense formation consisting of hyalinized connective tissue rich in collagen fibers, resulting from tissue regeneration when its integrity is violated.
A uterine scar is the area of the uterus in which surgical interventions were performed [cesarean section (CS)], myomectomy, reconstructive plastic surgery).
It should be noted that the concept of “uterine scar after cesarean section”, adopted in our country, is not entirely successful, since often the scar is not detected during a repeat operation. Foreign authors usually use the terms “previous caesarean section” and “previous myomectomy”.
ICD-10 CODE
O34.2 Postoperative uterine scar requiring maternal medical care.
O75.7 Vaginal delivery after previous caesarean section.
O71.0 Uterine rupture before labor begins.
O71.1 Uterine rupture during childbirth.
O71.7 Obstetric pelvic hematoma.
O71.8 Other specified obstetric injuries.
O71.9 Obstetric trauma, unspecified.
According to various authors, a scar on the uterus after cesarean section is observed in 4–8% of pregnant women, and about 35% of abdominal births in the population are repeated. The prevalence of cesarean section in Russia over the last decade has increased 3 times and is 16%, and according to foreign authors, about 20% of all births in developed countries end in cesarean section.
There are no statistical indicators of the number of pregnant women with a scar on the uterus after myomectomy and reconstructive plastic surgery, but at present, due to the development of uterine fibroids at an earlier age, the rapid growth of the tumor in women of reproductive age and its large size, which prevents the onset and pregnancy pregnancy, myomectomy was included in the complex of preconception preparation. When women with uterine fibroids become pregnant, obstetricians and gynecologists also perform myomectomy more often than 10–15 years ago. Thus, the number of pregnant women with a uterine scar after myomectomy is constantly increasing.
There are distinguished between wealthy and incompetent scars on the uterus. There is also a classification depending on the cause of the uterine scar.
·Scar on the uterus after cesarean section.
- In the lower uterine segment.
— Corporal scar on the uterus.
— Isthmic-corporal scar on the uterus.
·Uterine scar after conservative myomectomy before and during pregnancy.
- Without opening the uterine cavity.
- With the opening of the uterine cavity.
— Scar on the uterus after removal of the subserous-interstitial node.
— Scar on the uterus after removal of intraligamentary fibroids.
· Scar on the uterus after perforation of the uterus [during intrauterine interventions (abortion, hysteroscopy)].
· A scar on the uterus after an ectopic pregnancy, located in the interstitial part of the fallopian tube, at the junction of the rudimentary uterine horn with the main uterine cavity, in the cervix after removal of a cervical pregnancy.
· Scar on the uterus after reconstructive plastic surgery (Strassmann operation, removal of the rudimentary uterine horn).
A scar on the uterus forms after a cesarean section, conservative myomectomy, uterine perforation, tubectomy, etc.
Scarring is a biological mechanism for healing damaged tissue. Healing of the dissected uterine wall can occur through both restitution (full regeneration) and substitution (incomplete regeneration). With complete regeneration, wound healing occurs thanks to smooth muscle cells (myocytes), and with substitution - bundles of coarse fibrous connective tissue, often hyalinized.
CLINICAL PICTURE OF UTERINE RUPTURE BY SCAR
Uterine ruptures due to dystrophic changes in the myometrium or the presence of scar tissue occur without a pronounced clinical picture (incorrectly called “asymptomatic”). Despite the erased and unexpressed nature of the disease, the symptoms do exist and need to be known.
If there is a postoperative scar on the uterus, ruptures can occur both during pregnancy and during childbirth.
According to the clinical course, the same stages are distinguished as with mechanical ones - threatening, beginning and completed uterine ruptures.
Symptoms of uterine rupture along a scar during pregnancy
Symptoms of threatening uterine rupture along a scar during pregnancy are caused by reflex irritation of the uterine wall in the area of spreading scar tissue:
·nausea;
·vomit;
pain:
- in the epigastric region with subsequent localization in the lower abdomen, sometimes more on the right (simulate symptoms of appendicitis),
- in the lumbar region (simulate renal colic);
pain, sometimes local, in the area of the postoperative scar during palpation, where it can be felt
deepening
Symptoms of the onset of uterine rupture along the scar during pregnancy are determined by the presence of a hematoma in the wall of the uterus due to the appearance of tears in its wall and blood vessels. Symptoms of a threatening rupture include:
·hypertonicity of the uterus;
signs of acute fetal hypoxia;
Possible bleeding from the genital tract.
Symptoms of completed uterine rupture during pregnancy: to the clinical picture of threatening and
When ruptures begin, symptoms of pain and hemorrhagic shock are associated:
general condition and well-being deteriorate;
weakness and dizziness appear, which may initially be of reflex origin, and subsequently
be caused by blood loss;
· obvious symptoms of abdominal bleeding and hemorrhagic shock - tachycardia, hypotension, pallor of the skin.
If a rupture occurs in scar tissue devoid of a large number of vessels, bleeding into the abdominal cavity may be moderate or insignificant. In such cases, symptoms associated with acute fetal hypoxia come to the fore.
Uterine ruptures along the scar during childbirth
Ruptures of the uterus along the scar during childbirth occur in the presence of postoperative scars on the uterus or dystrophic changes in it, in multiparous women.
Threatening uterine rupture during childbirth is characterized by the following symptoms:
·nausea;
·vomit;
epigastric pain;
· various variants of disruption of the contractile activity of the uterus - incoordination or weakness of labor, especially after the rupture of amniotic fluid;
· painful contractions that do not correspond to their strength;
· restless behavior of the woman in labor, combined with weak labor;
Delayed fetal advancement when the cervix is fully dilated.
When the uterine rupture begins along the scar in the first stage of labor due to the presence of a hematoma in the uterine wall, the following appear:
constant, non-relaxing tension of the uterus (hypertonicity);
Pain on palpation in the area of the lower segment or in the area of the intended scar, if any;
signs of fetal hypoxia;
· bloody discharge from the genital tract.
· for most women in labor, the time interval from the onset of symptoms of the onset of rupture to the moment
what has happened is counted in minutes.
The clinical picture of a completed uterine rupture along the scar is similar to that observed during pregnancy - mainly these are signs of hemorrhagic shock and antenatal fetal death.
A vaginal examination is characterized by the identification of a high-standing movable head, previously pressed or standing tightly at the entrance to the pelvis.
If uterine rupture along the scar occurs in the second stage of labor, then the symptoms are not clearly expressed:
weak but painful attempts, gradually weakening until they stop;
pain in the lower abdomen, sacrum;
· bloody discharge from the vagina;
Acute fetal hypoxia with possible fetal death.
Sometimes uterine rupture along the scar occurs with the last attempt. At the same time, diagnosing a gap can be very difficult. The child is born spontaneously, alive, without asphyxia. The placenta separates on its own, the placenta is born, and only subsequently do the symptoms associated with hemorrhagic shock, seemingly “unreasonable” hypotension, and sometimes epigastric pain gradually increase. The diagnosis can only be clarified by manual examination of the uterus or by laparoscopy.
Incomplete uterine rupture can occur at any stage of labor.
Diagnosis of pregnancy complications in women with a uterine scar is based on a careful collection of medical history, physical examination and laboratory data.
A thorough history collection should include obtaining information about a previous cesarean section (indications), the time of the CS, the presence of spontaneous labor before and after surgery, the number of pregnancies between the operation and the current pregnancy, their results (abortion, miscarriage, non-developing pregnancy), about the presence of living children, cases of stillbirth and death of children after previous births, about the course of the current pregnancy.
You should palpate the scar on the anterior abdominal wall and the uterus, measure the size of the pelvis and determine the estimated weight of the fetus. At 38–39 weeks of gestation, the pregnant woman’s body’s readiness for childbirth is assessed.
·General blood test.
·General urine analysis.
·Biochemical blood test (determining the concentration of total protein, albumin, urea, creatinine, residual nitrogen, glucose, electrolytes, direct and indirect bilirubin, alanine aminotransferase activity, aspartate aminotransferase and alkaline phosphatase).
·Coagulogram, hemostasiogram.
· Hormonal status of FPC (concentration of placental lactogen, progesterone, estriol, cortisol) and assessment of a-fetoprotein content.
· Ultrasound of the fetus with Doppler analysis of the vessels of the umbilical cord, fetal aorta, fetal middle cerebral artery and placenta is indicated from the end of the second trimester of pregnancy.
·Cardiomonitoring of the fetal condition.
· Ultrasound of the uterine scar every 7–10 days.
DIAGNOSIS OF UTERUS SCAR CONDITION OUTSIDE OF PREGNANCY
All women with a uterine scar after a cesarean section should be registered at the dispensary immediately after discharge from the hospital. The main purpose of clinical observation is early diagnosis and treatment of late complications of surgery (genital fistulas, tubo-ovarian formations) and prevention of pregnancy during the first year after surgery. During lactation, for the purpose of hormonal contraception, linestrenol (gestagen) is used, which does not have a negative effect on the newborn. After the end of lactation, estrogen progestogen contraceptives are prescribed.
In the complex of measures to prepare for the next pregnancy, assessing the condition of the uterine scar plays an important role. Hysterography, hysteroscopy and ultrasound examination (US) are considered informative methods for determining the condition of the uterine scar in a non-pregnant woman.
Hysterography is performed on the 7th or 8th day of the menstrual cycle (but not earlier than 6 months after surgery) in frontal and lateral projection. Using this method, you can study changes in the inner surface of a postoperative scar on the uterus. The following signs of incompetent postoperative scar are identified: change in the position of the uterus in the pelvis (significant displacement of the uterus anteriorly), jagged and thinned contours of the inner surface of the uterus in the area of the intended scar, “niches” and filling defects.
Hysteroscopy is performed on the 4th or 5th day of the menstrual cycle, when the functional layer of the endometrium is completely sloughed off and the underlying tissue is visible through the thin basal layer. When the scar fails, retractions or thickening in the scar area are usually noted. The whitish color of the scar tissue and the absence of blood vessels indicate a pronounced predominance of the connective tissue component, and retractions indicate thinning of the myometrium as a result of inadequate regeneration. The prognosis for pregnancy and vaginal delivery is controversial. A non-visualized uterine scar and a scar with a predominance of muscle tissue serve as a sign of its anatomical and morphological usefulness. These women may become pregnant 1–2 years after surgery.
Ultrasound signs of uterine scar failure include an uneven contour along the posterior wall of a full bladder, thinning of the myometrium, discontinuity of the scar contours, and a significant amount of hyperechoic inclusions (connective tissue). With two-dimensional ultrasound, pathological changes in the area of the uterine scar are detected much less frequently than with hysteroscopy (in 56 and 85% of cases, respectively). However, thanks to Doppler measurements and three-dimensional reconstruction, which can be used to assess hemodynamics in the scar (development of the vascular network), the information content of ultrasound assessment of the condition of the uterine scar has increased significantly.
The results of additional methods for diagnosing the condition of the uterine scar outside pregnancy are entered into the outpatient chart and are taken into account when deciding on the possibility of planning a subsequent pregnancy.
A differential diagnosis is necessary between a true threat of miscarriage and the presence of an incompetent scar on the uterus (Table 52-6). It is also necessary to carry out a differential diagnosis of acute appendicitis and renal colic. The diagnosis is clarified in a hospital setting based on clinical symptoms, ultrasound data, and the effect of therapy. If there is an incompetent scar on the uterus, the pregnant woman should be in the hospital until delivery. In this case, a daily clinical assessment of the condition of the pregnant woman, the fetus and the uterine scar is carried out. Ultrasound is repeated every week. If clinical or ultrasound symptoms of uterine scar failure increase, surgical delivery is indicated for health reasons on the part of the mother, regardless of the gestational age.
Table 52-6. Differential diagnosis of threatened miscarriage and failure of the uterine scar after cesarean section in the lower uterine segment
INDICATIONS FOR CONSULTATION WITH OTHER SPECIALISTS
Consultation with an anesthesiologist is indicated if it is necessary to provide anesthesia for surgical delivery or for the purpose of pain relief during labor.
·Pregnancy 32 weeks. Head presentation of the fetus. An incompetent scar on the uterus after a cesarean section in 2002. Hydrops of pregnancy. Anemia of the first degree.
·Pregnancy 38 weeks. Head presentation of the fetus. A scar on the uterus after a cesarean section in 2006. Placental insufficiency. ZRP I degree. Combined gestosis of moderate severity 8 points against the background of arterial hypertension.
·Pregnancy 37 weeks. Scars on the uterus after myomectomy and minor cesarean section in 2000. An elderly primigravida.
·Pregnancy 36 weeks. Breech presentation of the fetus. Scar on the uterus after a corporal cesarean section in 1999. Anemia.
COMPLICATIONS OF GESTATION IN THE PRESENCE OF A UTERUS SCAR
The course of pregnancy in the presence of a scar on the uterus after cesarean section has a number of clinical features. In these patients, a low location or presentation of the placenta, true rotation of the placenta, abnormal position of the fetus are more often noted, and when the placenta is localized in the area of the scar on the uterus, PN often develops.
One of the most common complications of the gestation process in pregnant women with a uterine scar is the threat of miscarriage. Symptoms of threatened miscarriage in the first trimester of pregnancy do not have an etiological connection with the presence of a scar on the uterus. Conservation therapy is prescribed according to the established diagnosis (insufficient progesterone synthesis, hyperandrogenism, APS, etc.). Treatment on an outpatient basis is possible, but if there is no effect, hospitalization is necessary to clarify the diagnosis and correct the therapy. If isthmic-cervical insufficiency is detected, surgical correction of this pathology in this group of patients is not indicated, since the presence of a scar on the uterus in combination with the threat of miscarriage can lead to uterine rupture along the scar. Treatment of this complication includes antispasmodic therapy, administration of magnesium sulfate, bed rest, and the use of an unloading vaginal pessary. Treatment of other pregnancy complications in women with an operated uterus is not fundamentally different from the generally accepted one.
MANAGEMENT OF PREGNANT WOMEN WITH A UTERUS SCAR
During pregnancy (in the first trimester), a general examination is carried out, and, if necessary, consultations with related specialists. An ultrasound is required, the main purpose of which is to determine the location of attachment of the fertilized egg in the uterus. If it is located in the area of the isthmus on the anterior wall of the uterus (in the area of the scar after cesarean section in the lower uterine segment), it is advisable to terminate the pregnancy, which is performed using a vacuum aspirator. This tactic is due to the fact that the proteolytic properties of the chorion, as pregnancy progresses, can lead to inferiority of even a wealthy scar on the uterus and its rupture, and the outcome of this pregnancy is only a repeat cesarean section. However, there are no absolute contraindications to prolonging pregnancy in this case, and the question of terminating the pregnancy is decided by the woman herself. The next screening examination, including ultrasound and study of the hormonal status of the fetoplacental complex (FPC), is carried out at 20–22 weeks of pregnancy and its purpose is to diagnose fetal malformations, compliance of its size with the gestational age, signs of placental insufficiency (PI), especially with the location of the placenta in the scar area. For the treatment of PN, hospitalization is indicated. In case of an uncomplicated course of pregnancy and a significant scar on the uterus, the next comprehensive examination is carried out at 37–38 weeks of gestation in a hospital, where the pregnant woman is expected to deliver the baby.
During childbirth, antispasmodic, sedative and antihypoxic drugs, drugs that improve uteroplacental blood flow are necessarily used.
DELIVERY OF PREGNANT WOMEN WITH A UTERUS SCAR
Delivery of pregnant women with a scar on the uterus after cesarean section
Most obstetricians have a basic postulate when delivering a pregnant woman with a uterine scar after a cesarean section: one cesarean section is always a cesarean section. However, both in our country and abroad, it has been proven that in 50–80% of pregnant women with an operated uterus, childbirth through the birth canal is not only possible, but also preferable. The risk of a repeat cesarean section, especially for the mother, is higher than the risk of spontaneous labor.
Spontaneous birth in pregnant women with a uterine scar after cesarean section
Carrying out childbirth through the natural birth canal in the presence of a scar on the uterus after a cesarean section is permissible if a number of conditions are met.
· One history of caesarean section with a transverse incision on the uterus in the lower segment.
· Absence of extragenital diseases and obstetric complications that served as indications for the first operation.
· The consistency of the uterine scar (according to the results of clinical and instrumental studies).
· Localization of the placenta outside the uterine scar.
· Head presentation of the fetus.
· Correspondence between the sizes of the mother's pelvis and the fetal head.
· Availability of conditions for emergency delivery by cesarean section (highly qualified medical personnel, the ability to perform an emergency cesarean section no later than 15 minutes after the decision to operate is made).
The question of the method of delivery must be agreed upon with the pregnant woman. The obstetrician should explain to her in detail all the benefits and risks of both a repeat cesarean section and a vaginal birth. The final decision must be made by the woman herself in the form of written informed consent to one of the methods of delivery. In the absence of absolute indications for a planned cesarean section, preference should be given to childbirth through the birth canal, and if it begins spontaneously.
Childbirth in the presence of a scar on the uterus, as a rule, proceeds according to the standard mechanism characteristic of primiparous or multiparous women. The most common complications of childbirth in women with a uterine scar are untimely rupture of amniotic fluid, labor anomalies (which should be considered as a threat of uterine rupture), clinical discrepancy between the sizes of the mother’s pelvis and the fetal head (due to a more frequent location of the fetal head than in the population). posterior view), the appearance of signs of threatening uterine rupture. During childbirth, continuous cardiac monitoring of the condition of the fetus is necessary, with a clinical assessment of the nature of labor and the condition of the uterine scar. Childbirth should be carried out with the operating room deployed, with the infusion system connected. In addition to clinical (palpation) assessment of the condition of the uterine scar during spontaneous labor, ultrasound can be used, with the help of which, in addition to assessing the condition of the uterine scar in the first stage of labor, the appearance and position of the fetus, the location of the fetal head in relation to the planes of the mother’s pelvis are clarified, and cervicometry is performed. (ultrasound registration of the opening of the uterine pharynx), thereby reducing the number of vaginal examinations, which is useful in terms of preventing infectious complications in women in labor with a high probability of surgical delivery.
Pain relief for labor in women with a uterine scar is carried out according to generally accepted rules, including the use of epidural analgesia. The method of anesthesia during childbirth depends on the nature of the extragenital or other obstetric pathology.
A scar on the uterus after a cesarean section is not considered a contraindication to the use of other obstetric and anesthetic aids during childbirth, such as labor induction or labor stimulation. If the second stage of labor is prolonged or fetal hypoxia has begun, delivery must be accelerated by dissecting the perineum. In case of acute fetal hypoxia and the head located in a narrow part of the pelvic cavity, the birth can be completed by applying obstetric forceps or a vacuum extractor.
Manual examination of the uterus immediately after childbirth is considered mandatory in the absence of ultrasound guidance.
Symptoms of uterine rupture may appear a considerable time after delivery, so it is advisable to repeat an ultrasound 2 hours after birth in order to diagnose dissecting retrovesical hematomas, which are the result of undiagnosed uterine rupture.
Indications for cesarean section in the presence of a scar on the uterus after cesarean section:
·Uterine scar after corporal caesarean section.
· Incompetent scar on the uterus according to clinical and ultrasound signs.
· Placenta previa.
· Two or more scars on the uterus after cesarean sections.
·A woman’s categorical refusal to give birth through the birth canal.
Management of childbirth in women with a uterine scar after myomectomy
When choosing a method of delivery in women with a uterine scar after myomectomy, the nature and extent of the operation performed are of decisive importance. The incidence of failed scars after myomectomy reaches 21.3%. The risk of uterine rupture along the scar after myomectomy during spontaneous labor depends on the depth of the tumor in the myometrium (interstitial, subserous-interstitial, subserous or submucosal fibroids) before surgery, the surgical technique, and the location of the scar on the uterus. Indications for surgical delivery are absolute and relative. The absolute indications for cesarean section after myomectomy outside pregnancy are given below.
·A scar on the uterus after removal of an interstitial or subserous-interstitial node located on the posterior wall of the uterus.
·Scar on the uterus after removal of intraligamentary fibroids.
· Scars on the uterus after removal of several large interstitial subserous nodes.
When pregnant women with a scar on the uterus after myomectomy give birth outside of pregnancy and there are no absolute indications for a cesarean section, it is preferable to deliver vaginally. In the presence of a burdened obstetric history, post-term pregnancy, breech presentation of the fetus, PN, and the age of the primigravida over 30 years, the indications for cesarean section after myomectomy are expanded.
A scar on the uterus after a myomectomy performed during pregnancy is an indication for a cesarean section.
Management of childbirth in women with a uterine scar after reconstructive plastic surgery
·After metroplasty, preference should be given to cesarean section in order to prevent maternal injuries during spontaneous birth.
·After removing the rudimentary uterine horn without opening its main cavity, childbirth through the natural birth canal is possible.
Management of childbirth in women with a uterine scar after uterine perforation
Childbirth after uterine perforation during intrauterine interventions is a complex and responsible task. The location of the perforation in relation to the walls of the uterus is of great importance. The location of the scar in the isthmus region and along the posterior wall of the uterus is considered prognostically unfavorable. When managing such births, uterine ruptures, hypotonic bleeding, and pathology of placental separation are possible, especially in women with a complicated course of the operation itself and the postoperative period.
The obstetric prognosis is more favorable in cases where the scar is located along the anterior wall of the uterus, and the operation was limited to only suturing the perforation without additional dissection of the uterine wall. In the absence of complicating circumstances, birth through the birth canal is possible, followed by a control manual examination of the walls of the uterine cavity.
Management of childbirth in women with a uterine scar after ectopic pregnancy
The choice of delivery method after an ectopic pregnancy depends on the extent of the surgery and the age of the woman. Surgical interventions for cervical pregnancy, pregnancy in the rudimentary uterine horn (if it has a connection with the main cavity), interstitial part of the fallopian tube, or the stump of an earlier removed tube are indications for cesarean section.
PREDICTION AND PREVENTION OF GESTATIONAL COMPLICATIONS
Pregnant women with a uterine scar are considered a risk group for the development of the following obstetric and perinatal complications: spontaneous abortion, uterine rupture along the scar, premature birth, preterm birth, PN, hypoxia and intrauterine fetal death, birth trauma of the mother and fetus, high maternal and perinatal mortality. To prevent these complications, careful clinical monitoring of the pregnant woman is necessary, timely detection of complications and their treatment in multidisciplinary obstetric hospitals. Prevention of complications is based on widespread promotion of preconceptional preparation for women with a uterine scar, which includes the following activities.
·Informing about the risks associated with the presence of a uterine scar.
— Risk for the mother: uterine rupture along the scar, bleeding, maternal mortality, purulent-septic complications; miscarriage.
— Risk for the fetus and newborn: prematurity, birth trauma, neonatal complications of varying severity.
· Diagnosis and treatment of concomitant gynecological and extragenital diseases before pregnancy.
·Inspection for sexually transmitted infections (STIs) and sanitation of foci of infection.
TREATMENT OF COMPLICATIONS DURING CHILDREN AND THE POSTPARTUM PERIOD
The most serious complication during childbirth is uterine rupture along the scar. When managing vaginal delivery in women with a uterine scar, preference should be given to overdiagnosis of uterine rupture rather than underestimation of such a serious complication. It is considered extremely difficult to assess the first symptoms of the onset of uterine rupture based on the scar. Diagnosis of uterine rupture is carried out taking into account the clinical picture: pain in the epigastric region, nausea, vomiting, tachycardia, local pain, blood discharge from the genital tract, shock, etc. Signs of deterioration in the condition of the fetus, weakening of the contractile activity of the uterus can be symptoms of an incipient rupture, and often first. Additional diagnostic methods (ultrasound, tococardiography) are invaluable during childbirth.
A distinction is made between complete rupture and incomplete uterine rupture (dissection, spreading of the scar), when the peritoneum remains intact. The tactics for uterine rupture are to perform an emergency cesarean section. The extent of surgical intervention depends on the extent of the injury: in case of uterine rupture only in the area of the scar after the fetus is removed, the scar is excised and the uterus is sutured, and in case of uterine rupture complicated by the formation of intraligamentary hematomas, it is extirpated. In subsequent pregnancies, surgical delivery is indicated.
Indications for caesarean section during childbirth are expanded in case of negative dynamics of the fetal condition, the appearance of clinical signs of impending uterine rupture, and the absence of conditions for careful spontaneous completion of labor.
PREVENTION OF UTERUS RUPTURE BY SCAR
Prevention of uterine rupture along the scar involves the following measures.
· Creation of optimal conditions for the formation of a healthy scar on the uterus during the first caesarean section (uterine incision according to Derfler) and other operations on the uterus: suturing the incision on the uterus with separate muscular-muscular sutures using synthetic absorbable suture threads (vicryl, monopril, etc.) .
·Prediction, prevention, timely diagnosis and adequate treatment of postoperative complications.
·Objective assessment of the condition of the uterine scar before pregnancy and during gestation.
·Screening examination during pregnancy.
·Careful selection of pregnant women for vaginal delivery.
·Careful cardiotocographic and ultrasound monitoring during spontaneous labor.
·Adequate pain relief during spontaneous labor.
· Timely diagnosis of threatening and/or incipient uterine rupture.
