Medical Academy named after S.I. Georgievsky of «Crimean Federal University named after V.I. Vernadsky» Department of obstetrics and gynecology №2

LECTURE: «"ACUTE" IN GYNECOLOGICAL PRACTICE».

-"Acute" abdomen – is a symptomocomplex, shown by the expressed painful syndrome in an abdominal cavity, presence of vegetative disturbances, increase of temperature, tachycardia. To the phenomena of an "acute" abdomen in gynecology can result the following gynecologic diseases: 1. Inflammatory diseases of internal genitals:  Endomeometritis.  Salpingo-.  Pelvioperitonitis. 2. Benign tumors of genitals:  Perforation of .  Leg torsion of ovarian cyst.  Necrosis or torsion of myomatous node. 3. Ovarian apoplexy. 4. Ectopic pregnancy. 5. Traumatic disturbances of internal genitals (рerforation of the during abortion, diagnostic curettage of the uterus). 6. Malignant tumors of internal genitals. Ectopic pregnancy – pregnancy in which the fertilized egg implantation occured outside the uterus.

Classification. • 1. According to ICD-10: • abdominal pregnancy; • tubal pregnancy: - рregnancy in the ; - rupture the fallopian tube due to pregnancy; - tube abortion; • оvarian pregnancy; • оther forms of ectopic pregnancy: - cervical; - сombined; - іn the corner of uterus; - intraligamental; - іn the mesentery of the uterus; • еctopic pregnancy unspecified. 2. Over the course: • progressive; • interrupted (tubal abortion, rupture of the fallopian tube); • missed abortion.

Causes are:  inflammatory processes in appendages of the uterus;  sexual ;  disturbance of contractile activity of the uterine tubes;  endocrine disturbances;  tumors;  hyperactivity of trophoblast;  scar-commissural changes in pelvic operations previously deferred due to the internal reproductive organs, pelvioperitonitіs, abortion;  еndometriosis;  long-term use of intrauterine contraceptive devices;  assisted reproductive technology.

Anatomy of the uterine tube

The fallopian tube is about 10 cm long. The diameter of the lumen varies from 1mm in the interstitial portion to about 5 mm at the fimbria part. Histology of uterine tube  The musculature consists of two layers, an inner circular and an outer longitudinal, and peristaltic movements are strong during and after .  The mucosa consists of a single layer of ciliated and secretory cells, resting on a thin basement membrane. - Owing to inflammatory diseases in the lumen of a tube there are adhesions, strangulations and broken peristaltic movements. Quite often in women who were treated concerning infertility, partial permeability of tubes is restored, but peristaltic is broken, that is the reason of occurrence fallopian pregnancy.

- At presence of sexual infertility the uterine tubes are long, twisted, their peristaltic is defective. Through such tube the ovum has not time to penetrate into the put term in a cavity of the uterus. Pathogenesis.

 Implantation of fetal ovum occurs where it appears by the that moment when trophoblast begins the fermentative activity.  Chorion villi take root into a wall of a tube, thus its muscular layer is hypertrophies.  The uterine tube accepts the fusiform, for 4-5 weeks pregnancy is aborted; seldom it proceeds over 8 weeks.  If the wall of fetal cistern inverted in the lumen of a tube is ruptured, fetal ovum starts to perish, it is exfoliated from walls of a tube and owing to peristalsis is gradually thrown out in the abdominal cavity through the ampulla end. There is a fallopian abortion, which is accompanied by bleeding various intensity. Thus blood through a tube acts in the abdominal cavity and through the uterus outside as blood discharge.

 As fallopian abortion the pregnancy developing in an ampulla part of a tube is more often aborted, and it is often accompanied by not plentiful bleeding.

Clinical manifestation: progressive ectopic pregnancy  Signs of pregnancy: - Delayed ; - Breast engorgement; - Change the taste, the smell and other sensational characteristic of pregnancy; - Early signs of toxemia (nausea, vomiting, etc.)  Gynecological examination: - Cyanosis of the mucous membrane of the vagina and ; - Uterine size is smaller than the expected term of pregnancy; - Unilateral enlargement and tenderness of ;  - Positive immunological response to pregnancy (hCG in serum and urine). Rupture of the uterine tube

 Same signs of progressive ectopic pregnancy.  This occurs mainly from the narrow isthmus before 8 weeks, or later from the interstitial portion of the tube.

 The symptomatology of the tube rupture is typical.

 Suddenly there is a pain in the lower abdomen (constant or cramp-like), in a groin, irradiates to the rectum, perineum, sacrum, also in a shoulder and scapular (a phrenicosymptom caused by irritation of diaphragmatic nerve), сontinuation:

 weakness, dizziness, cold sweat, decrease of arterial pressure, loss of consciousness, weak rapid pulse, nausea, vomiting (reflexive), pallor of integuments and mucous membranes, cyanosis of a naso-labial triangle - hemorrhage is likely to be severe.  The abdomen is more painful at palpation from that side where has taken place rupture of a tube; Schyotkin-Blumberg’s symptom is weakly positive, positive Kulenkampf ’s symptom (signs of peritoneal irritation in the absence of local muscle tension in the lower abdomen).

сontinuation:  The body temperature is normal, at percussion loss of resonance in slope places is defined.  In process of increase hemorrhage severe hemorrhagic shock develops, collapse.  May be flatulence, diarrhea single.  At PV insignificant bloody discharge are found out. The uterus is slightly increased, softened and more mobile than usually - «a swimming uterus». In the field of appendages can be palpated tumor-like formation. The posterior fornix is impressed or protruded. Acute morbidity of the posterior fornix of vagina is marked («cry of Douglas») and pain during displacement of the cervix (Promptov’ symptom). Following signs can help in diagnosis of ectopic pregnancy:  Laffon's sign — consecutive shift of pain feelings: at first in suprabrachial part, then shoulder, then pain spreads into back part, scapulars, under sternum.  Elecker's sign — abdominal-ache presence, that is followed by its irradiation into shoulder and scapulars on tubal rupture side.  Gertsfield's sign — urging to urination appears during tubal rupture moment.  Kulenkampf's sign — intensive pain during percussion of anterior abdominal wall.

At vaginal research such signs are determined:  Landau's sign — intensive pain during speculum or fingers inserting into vagina.  Golden's sign — uterine cervix pallor.  Bolt's symptom — acute pain during an attempt to displace uterine cervix.  Gudell's sign — soft consistence of cervix.  Promptov's sign — woman feels acute pain during an attempt to displace uterus up by inserted into vagina and rectum fingers. At appendicitis examination per rectum causes pain in rectouterine pouch.  Goffman's sign — uterus displacement into contrary from altered tubal side. During examination uterus easily comes into normal position, and when examination is over it returns into its previous position.

At long blood presence in abdominal cavity its partial resorbtion takes place and transformed bilirubin deposits in skin cells. That's why there appear such signs:  Gofshteter's sign — presence of blue-green or blue-black colouring of skin in navel region.  Kuschtalov's sign — yellow skin colouring of palms and soles, specially in fingers area

Tubal abortion  The same signs of progressive ectopic pregnancy.  At abortion of pregnancy as fallopian abortion attacks of pain in the bottom of the abdomen, bloody discharge take place. Frequently there are short- term syncopes.  It is palpated slightly increased soft uterus and tumor- like formation in the region of appendages, painful at palpation, limited in mobility. In some cases impression of the lateral and the posterior fornix of vagina is defined. Morbidity at displacement of the cervix and at palpation of the posterior fornix of vagina more poorly are expressed, than at rupture of a tube. Investigations  Qualitative and quantitative test for HCG - must be performed at all reproductive age women who present with pain, bleeding or collapse.

In a normal pregnancy, the β-HCG level doubles every 48-72 hours until it reaches 10,000-20,000mIU/mL. In ectopic pregnancies, β-HCG levels usually increase less. Mean serum β- HCG levels are lower in ectopic pregnancies than in healthy pregnancies. No single serum β-HCG level is diagnostic of an ectopic pregnancy. Serial serum β-HCG levels are necessary to differentiate between normal and abnormal pregnancies and to monitor resolution of ectopic pregnancy once therapy has been initiated.

 Ultrasound (no ovum in the uterus, the embryo visualization outside the uterine cavity, revealing the formation of heterogeneous structure in the projection of the fallopian tubes, a significant amount of free fluid in Douglas space).

 Culdocentesis - this means passing a needle through the posterior fornix into the pouch of Douglas. Intraperitoneal blood does not readily clot and if such blood is obtained it is an indication for surgical treatment - performed in the absence of ultrasound.

 Laparoscopic investigation.

 Diagnostic curettage of walls of the uterus (no elements of ovum and the presence of decidual tissue) – is performed in the absence of ultrasound.

Tubal pregnancy – treatment:  Immediate hospitalization. Each woman with suspicion on ectopic pregnancy should be hospitalized and must stay in stationary until clinical confirmation or refuse of suspicion on ectopic pregnancy.  Surgical operation ( or ) - salpingectomy or plastic of a tube (tubotomy, salpingostomy).Laparotomy has usually be required where there is extensive intra-peritoneal bleeding.

After surgery with preservation of the tube for the prevention of persistent trophoblast requires a careful toilet of abdomen by 2 to 3 liters of 0,9% NaCl and single dose of methotrexate at a dose 75-100 mg i/m in the first, the second day after surgery.  Infusion therapy (volume, speed of solution) depends on the stage of hemorrhagic shock. Conservative treatment Indications for use of methotrexate in case of EP:  Elevated levels of β-subunit of hCG in serum after organ-preserving surgery on the fallopian tube, which is made in the progressive ectopic pregnancy.  Stabilized or increased level of β-subunit of hCG in serum within 12-24 hours after separate diagnostic curettage or vacuum aspiration if the size of the ovum in the uterus does not exceed 3.5 cm.

 Determination by transvaginal ultrasound probe of gestational sac with diameter less than 3.5 cm in the uterus in case of β- subunit of hCG of 1500 IU/L shows absence of the ovum in the uterus .  Methotrexate is the standard medical treatment for unruptured ectopic pregnancy.

The optimal candidates for Methotrexate treatment of ectopic pregnancy are: •hemodynamically stable, willing and able to comply with posttreatment follow-up, have a human chorionic gonadotropin beta-subunit (hCG) concentration ≤5000 mIU/mL (some recommend limiting Methotrexate protocol to bHCG <2000 mIU/ml •ectopic pregnancy fully visualized on ultrasound: o embryo size under 3 cm; o tubal serosa intact (no rupture); o no fetal heart activity; • normal lab testing (see screening below). • no active bleeding. continuation:  The dose of methotrexate used to treat ectopic pregnancy (50 mg/m2 or 1 mg/kg), followed by checking the level of hCG.  Methotrexate can be given systemically (intravenously, intramuscularly, or orally) or by direct local injection into the ectopic pregnancy sac transvaginally or laparoscopically. Intramuscular administration is most common.  If the β-subunit of hCG in serum decreased less than 15% on the eighth day, methotrexate re-enter the same dose.  If the β-subunit of hCG in serum increased more than 15%, the patient watched weekly determining the level of β- subunit of hCG as long as this level is not less than 10 IU/l. Single Dose (preferred protocol)

1.Contraception until bHCG returns to 5 mIU/ml or less 2.Methotrexate 50 mg/m2 IM for 1 dose (some protocols have used IV or PO). 3.bHCG monitoring as below (days 4, 7 and then weekly until bHCG 0 mIU/ml). 1.Repeat Methotrexate dose if bHCG does not drop 15% between days 4 to 7. 4. Outcomes. 1.Success rate: 88.1% if starting bHCG <1000 mIU/ml (>1 dose needed in 14% of cases). 2.Adverse effects: 31.3%. Multiple Dose (older protocol)

1.Contraception until bHCG returns to 5 mIU/ml or less. 2.bHCG monitoring as below. 3.Alternate agents up to 4 doses of each drug 1.Methotrexate 1 mg/kg PO or IV on days 1, 3, 5, and 7. 2.Leucovorin 0.1 mg/kg on days 2, 4, 6, and 8. 4.Outcomes. 1.Success rate: 92.7%. 2.Adverse effects: 41.2%.

Monitoring  Inadequate bHCG response requires intervention  Methotrexate may be repeat dosed in Protocol 1  Indicated for inadequate bHCG decrease between days 4-7  Surgical intervention if failed protocol  Indicated if bHCG increasing despite 2 or more doses of Methotrexate or  Signs of hemodynamic instability  Follow Quantitative bhCG  First Week: Draw bHCG days 4 and 7  Anticipate 25% bHCG decrease between days 1 and 7  Anticipate 15% bHCG decrease between days 4 and 7  If inadequate decrease, repeat Methotrexate protocol above  Subsequent Weeks: Draw bHCG weekly  Anticipate drop to 5 mIU/ml by 3-4 weeks  Serum Progesterone may also be followed  Anticipate drop to 1.5 mg/ml by 2-3 weeks Ovarian pregnancy:  Developed in case of fertilization in the cavity of the follicle.  The frequency is 0.5-1 % of all ectopic pregnancies.  Risk factor - use of intrauterine contraceptive devices.  Clinical signs are the same as in tubal pregnancy. In case of disturbed ovarian pregnancy the clinical hemorrhagic shock is possible.  Diagnosis - ultrasound (fallopian tube on the side of the stricken unaltered; ovum is in the projection of the ; the fertilized egg to the uterus connected to their connections ovary; among membranes visualized ovarian tissue) and positive qualitative reaction to HCG. Treatment - surgical removal of the ovum and wedge resection of the ovary. In case of massive ovarian lesions and severe bleeding - ovariectomy.

Cervical pregnancy - when the fertilized egg implantation occurred in the cervical canal.  Diagnosis: - Visualization of cyanotic barrel cervix per speculum. - During bimanual examination - uterus with cervix as "hourglass". - Ultrasonography (the absence of a fertilized egg in the uterus; endometrial hyperechogenicity (decidua tissue); uterus as hourglass; extension of the cervical canal; the fertilized egg into the cervical canal; placental tissue in the cervical canal; closed internal uterine os).  Treatment of cervical pregnancy - surgical (hysterectomy).

Abdominal pregnancy:  There are primary (implantation of a fertilized egg in the abdomen) and secondary (formed when a fertilized egg is in the abdomen after tubal abortion) abdominal pregnancy.  Maternal mortality in abdominal pregnancies 7-8 times higher than in the tube, and 90 times higher than in the uterine. Diagnosis:  Clinical manifestations in the first and early second trimester are not very different from the symptoms of tubal pregnancy.  At a later date are pregnant complain of pain during fetal movements, feeling stir in the epigastric region or sudden cessation of fetal movements.  In physical investigation: the easily palpable soft parts of the fetus and uterus alone small size.  Abdominal pregnancy as diagnosed in the absence of uterine contractions after oxytocin.  For diagnosis are used ultrasound, X-ray , CT and MRI.

 Treatment - surgical.  During the surgical treatment of isolated and tie up vessels that supply blood to the placenta, and possibly remove it. If this is not possible due to heavy bleeding, placenta need to backfill. Tampons are removed in 24-48 hours.  In case of the placenta after surgery in the abdominal cavity, her condition is assessed by ultrasound and determination of β-subunit of hCG. In these cases, there is a very high risk of intestinal obstruction, fistulas, sepsis.  The use of methotrexate is contraindicated, since it is accompanied by serious complications, especially sepsis. The cause of sepsis is massive necrosis of the placenta. Intraligamentary pregnancy

• If tubal pregnancy, chorion villi don't grow into the abdominal cavity, but into side of broad ligament of the uterus, separating it, embryo comes into space between leaves of lig. latum uteri and continues to develop between them. • Embryo, protected by leaves of the broad ligament, can develop to late terms or even to full-term, however more frequently interruption of such pregnancy in 2-3 months term takes place. • At its interrupting a big haematoma accumulates, and if the leaves of the broad ligament are ruined in the result of chorion villi penetrating, bleeding into abdominal cavity can appear.

Apoplexy of –  It is suddenly come hemorrhage accompanying with disturbance of integrity of ovarian tissue and bleeding in the abdominal cavity.  Among all reasons of intraabdominal bleedings of 0,5-2,5% falls on apoplexy of ovaries.  The bleeding from ovary precedes formation of a hematoma, which causes sharp pains owing to increasing of intraovarian pressure. Then follows rupture of ovarian tissue that results in bleeding even at a small perforation in an ovary. Rupture of ovary arises owing to stagnant hyperemia, varicosity or sclerosing of vessels, and also sclerous changes in stroma. Change of vessels and tissues of ovary grows out pathological process, more often inflammations of appendages of the uterus.  Provoking factors of ovary apoplexy can be: a trauma, physical pressure, the rough sexual intercourse, trauma of the abdomen, operative intervention, mechanical pressing of the vessels by pelvis tumor.  Ovarian apoplexy can come in various phases of a , but it is more often observed during the period of ovulation (i.e. for 14 day of a 28-days menstrual cycle) and in a stage of vascularization of yellow body. It is more often observed in women of 20-25 years, there is more often a rupture of the right ovary. Clinical picture:

 It is allocated two forms of ovarian apoplexy depending on expressiveness of this or that clinical symptomatology – painful and anemic.  Ovarian apoplexy usually sharply begins with occurrence of sudden, sometimes very strong pains in the bottom of the abdomen, with primary localization on the side of injured ovary.  At examination the pressure of a peritoneal wall, positive Schyotkin-Blumberg’s symptom is marked. At percussion of the abdomen the free liquid in the abdomen cavity can be defined.  At a plentiful bleeding there is a frenicus-symptom and the phenomena of a collapse. Quite often an attack of pain is accompanied by nausea and vomitting.  Bimanual research gives a possibility to set gynecological nature of the disease. Pain of vaginal fornixes is present. Displacement of cervix causes strong pain. Uterus is of normal size, and pain is determined in ovaries region from one side.  Injured ovary of softish consistence, sharply painful, enlarged, vaults of a vagina are sharply painful - «cry of Douglas». Palpation of the uterus is complicated because of acute morbidity at presence of significant hemorrhage in the peritoneal cavity and irritations of the peritoneum. THE DIFFERENTIAL DIAGNOSIS:

 With fallopian pregnancy. Apoplexy comes suddenly, frequently in the middle of a menstrual cycle, there are no signs of pregnancy. The external bleeding is not present. Biological reactions to pregnancy are negative.  With appendicitis. As for differential diagnostics with acute appendicitis, one must remember, that in appendicitis more frequently pain initiate at the epigastric region, there are nausea and vomiting and no signs of internal bleeding. At abdominal examination muscular defancel and positive Schotkin- Blumberg's symptom are observed. At appendicitis the temperature is increased, in blood are leukocytes. Treatment.  If the bleeding is insignificant (pulse and arterial pressure is in norm), i.e. it is possible to be limited by conservative actions (rest, cold on a bottom of the abdomen, hold haemostatics) at the painful form.  At significant bleeding operation – laparotomy or laparoscopy (resection, ovaryrhaphy or coagulation of ovary is shown).

 Torsion of a leg of ovarian tumour – quick motions, pregnancy, labor, stormy bowel peristalsis can cause torsion. In the result of torsion trophies о tumor tissue disturb, degenerative changes and necrosis with wall rupture in it.  it is divided on a degree on partial and full, on time – acute and gradual.  It is allocated anatomic and surgical leg of a tumor.  The anatomic leg includes: a proper ligament of the ovary, a suspensory ligament of the ovary, vessels and nerves which are taking place in these ligaments (a. ovarica, r. ovaricus a. uterine etc.), mesoovarium.  The surgical leg includes above the listed anatomic formations, and also parts of bodies or other anatomic formations involved in torsion (uterine tube, intestine, omentum, etc.). Treatment –

 surgical (removal of a tumor together with a leg, i.e. the clip is imposed below a place of torsion irrespective of the fact what anatomic formations have got in torsion).

 The leg of a tumor cannot be untwisted in avoidance of thrombohemorrhagic and infectious complications. Оvarian cyst rupture: Necrosis of myomatous node:

Necrosis of subserous myomatous nodes is most frequently occurred. It is possible at disturbance of blood circulation in a tumor in postnatal, in postabortive period, at presence of a long leg – torsion of a leg of myomatous node. Clinical picture:  Acute pains in the bottom of the abdomen, pressure of muscles of an anterior peritoneal wall, increase of temperature, leukocytosis.  At vaginal examination is defined presence of myomatous nodes in the uterus, one of which is sharply painful at palpation. Further to aseptic necrosis is almost always joined the infection penetrating into a node by hematogenic or lymphogenic way, and in some cases – from intestine (more often from an appendix). Treatment – operative, make amputation or extirpation of the uterus. Conservative myomectomy can be made as exception in young childless women in conditions of antibacterial therapy. Torsion fibroids legs: Uterine perforation: PYOSALPINX RUPTURE:  An abscess rupture takes place spontaneously or in the result of physical trauma.  Clinic. Before abscess perforation there is always patient's health change to the worse — pain reinforces, temperature rises, peritoneum irritation symptoms are intensifying. Just after rupture there appears an acute pain which has a cutting character through the abdomen, collapse, nausea, vomiting, stomach is strained and strongly painful. General patient's state becomes worse, the face features sharpen, breathing becomes frequent and superficial. In the result of bowels paresis abdomen becomes flatulent, peristalsis disappears and meteorism develops.

 Diagnosis. During stomach percussion one can find blunting of sound in lateral departments because of exudate presence in abdominal cavity.  During bimanual examination uterus and ovaries palpation is impossible because of acute pain and tension of front abdominal wall and vaginal fornixes bulgeng. Pelvic peritonitis may develop in the result of pyosalpinx rupture. Specification of the diagnosis can be made by means of ultrasonic research and culdocentesis.  Treatment. Operative cure with ablating of altered ovaries and following drainage of abdominal cavity is necessary. Laparotomy should be made by lower-middle incision, because this access gives a possibility to make a revision of abdominal cavity organs and its wide drainage, and if it is necessary — peritoneal dialysis. Operative intervention is inevitable anyways, however before operation it is necessary to make detoxicaton and start antibiotics.

Pelvioperitonitis:

 Can be partial (perisalpingitis, perioopharitis, ) or diffuse, extending on parietal and visceral peritoneum of a small pelvis.  The term "pelvioperitonitis" is concerned to an inflammation of all peritoneum of a small pelvis. Pathogens of disease are usually the pathogenic and conditional-pathogenic microflora causing inflammatory diseases of the bottom departments of a pelvis.  Pelvioperitonitis is usually developed again, owing to penetration of microorganisms on uterine tube at , and this canaliculate way is primary for gonococci, a little bit less often for pyogenic microbes. The primary focus of infection can be not only in the uterine tubes, but also in ovaries, uterus, fat of a small pelvis, an appendix and other bodies, from which infection acts by lymphogenic or hematogenic way.

 Pelvioperitonitis can arise at suppuration of postuterine hematomas, cyst or cystoma, torsion of a "leg" of cyst with the subsequent contamination, perforation of pyosalpinx.  It is allocated serofibrinous and purulent pelvioperitonitis. The acute stage of serofibrinous process is characterized by disturbances of microcirculation, hyperemia, edema of peritoneum, occurrence of serous exudate to which fibrin is added, albumins and segmentonuclear leukocytes. There are dystrophic changes in the peritoneum. On a measure of calm down of inflammatory process there is a restriction of infectious process by limits of a small pelvis that promoted by formation of comissures between parietal peritoneum of a small pelvis, uterus, appendages, big omentum, loops of intestine.

 Deposition of a plenty of fibrin and rather fast delimitation of a process typically for purulent pelvioperitonitis. Clinical picture:

 High body temperature, increase of pulse, bad state of health, strong pain in the bottom of the abdomen, chilling, fever, swelling of the abdomen, pressure of muscles of an anterior peritoneal wall, positive Schyotkin-Blumberg’s symptom. Peristalsis of intestine is weakened, tongue is dry, nausea, hiccup, vomitting. It is increased ESR (erythrocyte sedimentation rate), expressed leukocytosis, shift of leukocytic formulas to the left.

 At gynecologic examination: in the first days only rigidity and morbidity of the posterior vault of the vagina are marked, the next days in this area exudates is revealed, cecum cupulare of the posterior vault. Palpation of the uterus is sharply painful, it is impossible precisely to palpate because of sharp morbidity of the anterior peritoneal wall. Treatment:

 It is based on principles of complex therapy of acute inflammatory process.  Full rest, cold on the bottom department of the abdomen, antibacterial therapy (semisynthetic penicillins, cephalosporin, amynoglycosides) in a combination with metronidazole for treatment of anaerobic infections, infusion and disintoxicational therapy (intravenous drop infusion of rheopolyglucinum, refortan, infesol, solution of glucose, isotonic solution sodium of chloride, plasma of blood, albuminous preparations).  It is appointed antihistaminic preparations (dimedrol, suprastin, etc.), nonsteroid anti-inflammatory and anesthetizing preparations, correction of a acidic-alkaline condition and aqueous-electrolytic metabolism (alkaline solutions, preparations of potassium) is carried out.  For restoration of intestine peristalsis methylsulfate is applied, hypertonic rectal injections, heparin in small dozes for improvement of microcirculation.

 In case of occurrence of an abscess in rectouterine space make a puncture of the posterior vault for evacuation of pus with the subsequent infusion of antibiotics in area of a small pelvis. For the best evacuation (evacuations of pus) make drainage through the posterior vault of the vagina. At correct treatment later 1-2 days the general condition is improveed, intensity of clinical displays is gradually reduced, hemic parameters are improved.

 At absence of effect from spent therapy – it is necessary surgical treatment, which volume depends on a stage of disease.

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