Volume 02 Issue 04-2022
7
International Journal of Medical Sciences And Clinical Research
(ISSN
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2771-2265)
VOLUME
02
I
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04
Pages:
07-15
SJIF
I
MPACT
FACTOR
(2022:
5.
705
)
OCLC
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1121105677
METADATA
IF
–
5.654
Publisher:
Oscar Publishing Services
Servi
ABSTRACT
The review article provides detailed information on the problem of soft tissue ruptures during vaginal delivery in
women with diabetes and gestational mellitus. The epidemiological data of various authors on the incidence of
gestational diabetes mellitus, which have been studied in many countries, are presented. And the main part of the
article describes the etiological features of soft tissue ruptures during vaginal delivery in pregnant women with
diabetes and gestational mellitus, complication and prevention of postpartum sepsis.
KEYWORDS
Gestational diabetes, diabetes mellitus, perineal rupture, fetal macrosomia, sepsis.
INTRODUCTION
The process of childbirth is accompanied by a
significant stretching of the birth canal of a woman, as
a result of which various degrees of damage to the
tissues of the vagina, perineum and cervix may
appear, which is physiological and represent
abrasions, cracks and microtraumas with an
Research Article
CURRENT STATE OF THE PROBLEM OF SOFT TISSUES RUPTURE
DURING VAGINAL BIRTH IN WOMEN WITH DIABETES AND
GESTATIONAL MELLITUS
Submission Date:
April 20, 2022,
Accepted Date:
April 25, 2022,
Published Date:
April 30, 2022
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume02Issue04-02
Zufarova Shakhnoza Alimjanovna
Doctor Of Medical Sciences, Professor, Director Of The Republican Center For Reproductive Health Population
Of The Ministry Of Health Of The Republic Of Uzbekistan
Kholmatova Shirin Shukhrat Qizi
Gyneologist Republican, Center For Reproductive Health Population Of The Ministry Of Health Of The Republic
Of Uzbekistan
Kamalov Telman Tulaganovich
Doctor Of Medical Sciences, Head Of Department, Purulent Complication Of Diabetes Mellitus Republican
Practical Medical Center Of Endocrinology, Uzbekistan
Journal
Website:
https://theusajournals.c
om/index.php/ijll
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 02 Issue 04-2022
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International Journal of Medical Sciences And Clinical Research
(ISSN
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Pages:
07-15
SJIF
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asymptomatic course, and rapid self-regeneration in
the first 24 hours after childbirth. However, in cases
of tissue overstretching or due to surgical
intervention, ruptures of the cervix, vaginal walls,
perineum can occur, up to injuries that threaten the
life of a woman and lead to her disability, in particular
uterine rupture [Sacks DA 2012; Riethmuller D 2018].
According to the International Diabetes Federation, in
2021 the number of patients with diabetes in the
world has reached 537 million people.
An increase in the number of pregnant women with
DM and GDM, a high incidence of complications of
pregnancy, childbirth, and an increase in the number
of pathologies in newborns with GDM of more than
80% caused the scientific and practical interest of
obstetrician-gynecologists in gestational diabetes
mellitus (GDM) [Ushakova O.V. 2014; Shakhnazaryan
A.A. 2013; McIntyre HD. 2016; Metzger B.E. 2010].
Given the risks of DM, maternal and fetal outcomes at
birth may be affected by complications of DM. These
include: violations of the contractile activity of the
uterus, due to diabetes - in 20% of the studied, and
anomalies in labor activity, observed in 7-20% of cases
[Anim-Somuah M. 2011].
Prevalence, etiology, and risk factors for soft tissue
tears during vaginal delivery in women with diabetes
and gestational diabetes
Every year in the world, according to the World Health
Organization, more than 350 thousand women die as
a result of complications that occurred during
pregnancy and in the postpartum period. The
indicator of the result of the act of pregnancy for the
mother and child is determined by the timing, course
and complications of pregnancy [Soimenova O.I.
2014].
Diabetes mellitus (DM) is a pathology of the
endocrine system, in which hyperglycemia is observed
at a chronic level, arising from a violation of the
production and pathway of insulin action. DM that
occurs during pregnancy is defined as gestational
diabetes mellitus (GDM) [Bondar I.A., 2014; Dedov I.I.,
2013; McIntyre HD 2018].
There are differing data on the etiology of GDM, for
example, some sources report that GDM is a transient
disorder of glucose utilization that develops during
pregnancy [Ailamazyan E.K., 2014; Bashmakova N.V.,
2012; Goncharova E.V., 2015; Dhulkotia J.S., 2010], as
well as according to another source, previously
undiagnosed and identified during pregnancy, type 1
or 2 diabetes can be the cause of GDM.
From 2 to 5% of pregnant women are with diabetes
mellitus and 87.5% of them suffer from GDM, type 1
diabetes - 7.5%, type 2 diabetes - 5%, but current data
indicate an increase in patients with type 2 diabetes [
Ruyatkina L.A., 2015; Sievenpiper JL., 2012].
Modern women choose to give birth at a more
mature age, which results in an increase in the
number of women with pathologies of the endocrine
system, the probability of a pregnant woman 35+ of
developing GDM is 8 times higher than in a woman
under 25 [Petrov A.V., 2014; Saprina T.V., 2012;
Laughon SK., 2012; Sugiyama T., 2011]. Therefore, it
must be taken into account that with GDM, risks are
possible for both the mother and the fetus
[Arzhanova O.N., 2011; Deryabina E.G., 2013;
Zukhurova N.K., 2010; Logutova L.S., 2013; Mikhalev
E.V., 2015].
Complications from the woman:
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1) complications resulting from diabetes - diabetic
ketoacidosis,
retinopathy,
nephropathy,
hypoglycemia;
2) complications after surgery - spontaneous abortion,
premature
birth,
gestational
hypertension,
polyhydramnios, shoulder dystocia.
As a result of obstetric interventions, the most
extensive ruptures and injuries of the birth canal
develop (use of obstetric forceps, vacuum extractor).
Thanks to the research, experts were able to identify
risk factors for perineal injuries in primiparous and
multiparous puerperas. The first include: the age of
the woman, the size of the fetus, the use of oxytocin
to enhance the birth process, a protracted 2nd stage
of labor (less than 30 minutes and more than an hour
can increase the likelihood of ruptures). [Bychkov I.V.
2013].
The National Guidelines for Obstetrics cites data on
infectious complications that occur in 19.3% of cases,
despite advances in the treatment of perineal injuries.
This leads to suppuration, divergence of the suture
material, tightening by secondary tension. To date,
most authors agree that the causative agents of most
postpartum pathologies are non-spore-forming
anaerobes, they cause colpitis and vulvoganitis, which
further contribute to the traumatization of the
perineum and soft tissues. [Shornikov A.B. 2013].
In the treatment of inflammatory processes, drugs
with a wide range of effects are used, since the
microbial
picture
from
the
area
of
\u200b\u200binflammation sometimes does not
characterize the main pathogen. Special attention
should be paid to new diagnostic technologies
(naflora smears from the vagina) and therapy for risk
groups, which can reduce the risk of infection
[Pokrovsky V.I. 2012; Bishchekova B.N. 2017].
The risk group for DM includes: - family predisposition;
- malformations of the fetus; - polyhydramnios; -
glycosuria; - perinatal fetal death; - late toxicosis. The
clinical symptoms include diabetes mellitus in
pregnant women include: - dry mouth; - pustular skin
lesions; - darkening in the eyes; - thirst; - polyuria; -
polydipsia; - skin itching; - dramatic weight loss
[Smirnova O.M. 2011].
Classification and pathogenetic basis of soft tissue
ruptures during vaginal delivery in women with
diabetes and gestational diabetes
To this day, the causes, pathogenesis and mechanisms
of trauma during the dissection of the perineum into
the functional component of the pelvic floor remain
unknown. Complications that worsen the quality of
life faced by patients make this problem quite acute.
The beginning of the pathogenic link in injuries of the
perineum is a violation of the venous outflow, then
due to the compression of the arteries, ischemia will
be noted, in the classification of which there are 3
degrees of ruptures of the soft tissues of the
perineum [Kulakov V.I. 2012, Radzinsky V.E. 2016,
Toktar L.R. 2012]:
I degree
─
the presence of a violation of the integrity
of the posterior commissure, injury to the posterior
wall of the vagina and skin of the perineum, but there
is no damage to the muscles and fascia of the pelvic
floor;
II degree
─
the integrity of the skin, the walls of the
vagina and the muscles of the pelvic floor is violated,
but the wall of the rectum and the external sphincter
of the anus remain undamaged;
III degree
─
the external sphincter is damaged,
trauma to the anterior wall of the rectum is possible
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(complete and incomplete rupture according to
Malinovsky).
Postpartum high-quality rehabilitation of women with
perineal ruptures is very important, since the trauma
will contribute to the development of various
infections
that
can
lead
to
severe
septic
complications, the anatomical integrity of the
perineum and pelvic floor may be impaired due to
secondary wound , and this, in turn, can lead to
followed by an atypical arrangement of organs,
disability, up to disability [Kravchuk L.A. 2014].
Ruptures are determined after the birth of the
placenta, when examining the perineum and vagina,
the main sign of injury is bleeding.
During pregnancy, a decrease in glucose tolerance, a
decrease in insulin sensitivity, is considered
characteristic, however, the breakdown of insulin
increases and the number of free fatty acids in the
blood increases. The level of free fatty acids
increases, for the energy costs of the mother in order
to preserve glucose for the fetus during the lipolytic
action of placental lactogen [Ametov A.S. 2015].
Due to diabetes, pregnant women may face serious
complications associated not only with the health of
the woman herself, but also affect the health of the
fetus. It is necessary to follow the measures for
planning pregnancy, to approach this issue rationally
in order to prevent and prevent the development of
complications and achieve the maximum comfortable
course of pregnancy [Mkrtumyan, A.M. 2008].
Preparation for pregnancy of a woman with diabetes
mellitus begins half a year before the planned
conception, with a medical examination and
consultation with an endocrinologist to establish the
degree of compensation for diabetes mellitus,
determine the complications associated with
diabetes, the degree of complications, if any, and
familiarize yourself with the methods of self-control
and come to the conclusion in matters of gestation
[Arkhangelsky V.I. 2013].
Necessary actions that a woman must perform before
pregnancy:
1) Receive specific training in diabetes management
and blood sugar management
2) A woman should be able to correctly set the dose
of insulin using a glucometer to maintain a normal
glucose level
3) Diet in preparation for conception
4) Passing a comprehensive examination before
pregnancy
The risk of developing diabetes in the fetus increases
in the presence of this pathology in both parents
[Sumin S.A. 2015].
The parameters under which it is recommended to
terminate the pregnancy: age over 37 years, the level
of glycated hemoglobin - 13% and ketoacidosis in the
initial period of pregnancy [Sumin S.A. 2015].
Modern trends in the treatment and diagnostic tactics
of soft tissue ruptures during vaginal delivery in
women with diabetes and gestational mellitus
Often with ruptures of the perineum, damage to the
labia minora and labia majora, the vestibule of the
vagina, and the clitoris is observed, which are
corrected with catgut interrupted sutures. Abundant
blood loss can be when suturing the clitoris. The
peculiarity of suturing a part of the external opening
of the urethra is that a metal catheter is first inserted
into the bladder. Vaginal injuries are often violent or
spontaneous. Spontaneous ruptures occur due to the
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individual structure of the pelvic organs, for example,
with a narrow, short and underdeveloped vagina, and
is accompanied by trauma to all parts of the birth
canal. Extensive injuries of the vagina are more often
of a violent nature, they appear due to improper use
of instruments, obstetric forceps, fetal vacuum
eruption, etc. [Ivanyan A.G. 2014].
To date, there are many methods of suturing, but
their essence is that suturing begins close to the edge
of the wound (up to 1.0 cm), muscles are sutured with
dip sutures, synthetic absorbable sutures are used
when suturing the vagina, and the final stage is skin
tightening. Another method was proposed by I.V.
Bychkov et al. (2013), which, in their opinion, is the
most effective and has minimal difficulties in the
postoperative period. The technique is as follows: in
the hymen area, one interrupted suture is
superimposed shallowly, the mucosa remains intact,
then the muscles are sutured with separate sutures at
an interval of one and a half centimeters, the skin is
sutured with cosmetic sutures [Baev O.R. 2012;
Bychkov I.V. 2013].
Inflammatory diseases of the genitals increase the
likelihood of soft tissue ruptures by 32.2% according to
Rumyantseva Z.S. et al., which necessitates the
treatment of inflammatory processes in the
pregravidon period [Ishchenko A.I. 2014].
In the works of H.J. Landy (2011) noted that an
increase in the number of perineal damage occurs
with a long period of fetal expulsion and the use of
reducing agents [Landy H.J. 2011; Buyanova S.N.
2015].
Epidural anesthesia significantly increases the
likelihood of using the episiotomy method, when, as a
conscious control by attempts of puerperas, on the
contrary, it reduces the likelihood of injury
[Ailamazyan E.K. 2017].
Infectious complications in the postpartum period are
not uncommon and result from several causes.
However, it is worth noting that the decrease and
suppression of immunity in the period after childbirth
is absolutely physiological. During pregnancy and
during the recovery period after childbirth, the div
undergoes great changes, in particular, a decrease in
the immunity coefficient by an average of 3-10% is
observed, which is also manifested by a decrease in
the activity of lymphocytes. Cellular and humoral
parameters of immunity decrease in insignificant
numbers, which does not require treatment
[Ankirskaya A.S. 2013].
Aspects of rehabilitation and prevention of soft tissue
ruptures during vaginal delivery in women with
diabetes and gestational diabetes
Since the end of the 20th century, it has become
widely used in the world to prevent deep ruptures of
soft tissues - episiotomy or pereneotomy. A feature
of the methods is the dissection of the perineum,
which allows you to increase the size of the vulvar
ring up to 5-6 cm, this greatly facilitates the process
and prevents perineal ruptures. This method of
surgical dissection has a number of advantages, for
example, the wound has a linear character and
smooth edges, which will promote tissue healing
without crushing; Under favorable conditions, wound
healing occurs by primary intention. Effective
prevention of ruptures is the exact technique of
delivery to remove the fetal head, shoulder girdle,
anterior and posterior handles [Berashevich G.I.
2016].
Episiotomy and perineotomy are techniques used to
facilitate childbirth, prevent ruptures and shorten the
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second stage of labor. Thanks to the dissection of the
perineum, it becomes possible to prevent its rupture.
With surgical dissection, the rehabilitation of women
is more favorable, the wound heals faster, it is
possible to achieve an anatomically more holistic
restoration of structures, etc.
In addition, it is recommended to perform dissections
in the following conditions: hypoxia, premature birth,
as there is a possibility of compression jof the head of
the premature fetus by the pelvic floor muscles. As a
rule, this is always a complex of indications in relation
to the mother and fetus, in particular, a large fetus,
atypical insertion of the head, inactive labor, breech
presentation.
Prevention of ruptures in the first place will be the
preparation of the cervix for childbirth, that is, it is
necessary to observe the maturity of the structures, it
is especially important for women who are nulliparous
and women with a predisposition to overbearing the
fetus. Taking into account and observing the correct
technique of childbirth, the imposition of obstetric
forceps, with the timely use of drugs that relax the
myometrium of the uterus and analgesics, cervical
ruptures are not observed.
In order to accelerate the healing and resorption of
sutures, specialists prescribe physiotherapeutic
methods of treatment.
The use of BIOLuch (the first 5 postpartum days),
which improves microcirculation in the area of the
seams and perineum, has shown high efficiency.
Thanks to this method of physiotherapy, healing is
accelerated and sutures dissolve, and special rays of a
certain spectrum provide thermal and other types of
influence on tissues. The use of BIOLuch reduces pain
in the area of the scar, in turn, the scar on the
perineum becomes almost invisible.
Another method that has shown its effectiveness is
electrotherapy. It is based on the effective
administration of a pharmacological preparation and
the effect of galvanic current (electrophoresis), high
efficiency lies in the activation of higher nerve
centers, mediated reflexively through the excitation
of skin receptors.
Electrophoresis has enough advantages in the
treatment of purulent-inflammatory complications
and long-term complications after perineal dissection.
The method is also used for better resorption of scars.
Preparations administered by electrophoresis are 10
times smaller in quantity, but retain high therapeutic
efficacy, compared to the usual route of
administration.
Under the influence of direct current, ions penetrate
into tissue cells, in the skin, where a drug depot is
created, in which it retains its pharmacological activity
for several days, slowly and evenly enters the
bloodstream, spreads throughout the div, having a
therapeutic effect on tissues and cells. most sensitive
to this drug. [Zalikhanov Z. M. 2020].
With the help of electrophoresis, it is possible to
administer various kinds of drugs: analgesics,
antibiotics, etc. Electrophoresis is indicated for
patients with purulent-inflammatory diseases and to
accelerate the tightening of the scar. In addition,
electrophoresis has shown its effective effect on
microelements, thanks to it there is a good
dissociation of elements in water (copper, iodine,
magnesium and calcium), which improves the
regulation of metabolic processes in the div. For
example, calcium ions are involved in the regulation of
smooth muscle tone, blood clotting and contribute to
the recovery mechanisms of the div after blood loss
during childbirth. However, this physiotherapeutic
procedure is contraindicated in women with cicatricial
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adhesions of the small pelvis, since calcium
contributes to the thickening of adhesions. An
alternative is electrophoresis using iodine to dissolve
abdominal adhesions. Electrophoresis of ichthyol,
lidase and aloe is used to soften scars and adhesions.
CONCLUSION
This article analyzes the literature, reflecting the
current views of soft tissue ruptures during vaginal
delivery in women with diabetes and gestational
mellitus, as well as modern methods of treatment and
prevention.
Despite the high level of medical diagnosis and
treatment of soft tissue ruptures during vaginal
delivery, every 4-5 women are prone to postpartum
infectious complications, which in turn cause
suppuration and rupture of the perineal sutures,
wound healing by secondary intention.
A characteristic sign of the threat of rupture of the
birth canal in women is the presence of a history of
spontaneous injuries of the perineum. Prevention of
soft tissue rupture is the timely implementation of the
optimal surgical method - episiotomy. Bilateral
asymmetric episiotomy is necessary for women giving
birth for the first time, whose fetal weight exceeds
3900 g. In this case, with posterior occipital
presentation and anterior presentation, using
obstetric forceps and vacuum extraction. The use of
this technique allows to reduce the frequency of early
complications by almost 3 times, in the late
postpartum period - by 2 times. This method allows
you to speed up the recovery period by 1.5 times,
which minimizes the need for rehabilitation.
To identify risk factors and reduce obstetric perineal
trauma, regular medical examination of women is
necessary, which will allow to identify the risk group
for repeated perineal injuries in women of
reproductive age with a history of obstetric perineal
trauma, timely diagnosis, prevention and treatment of
pregnancy complications associated with violation of
the vaginal biocenosis is also necessary. competent
management of childbirth (non-aggressive, gentle),
the use of episiotomies strictly according to
indications.
Summarizing the above, the most common
complication of childbirth are perineal injuries,
namely, soft tissue ruptures during vaginal delivery.
According to modern medical literature, early and late
complications of the birth act, determined by perineal
injuries, are clearly defined. These include
complications that occur in a third of cases, this is
prolapse of the pelvic floor muscles, with further
possible prolapse of the walls of the vagina, bladder,
rectum, prolapse of the uterus. The most serious and
formidable are septic complications, anomalies in the
position of internal organs - gaping of the genital slit
(20% of cases) secondary healing, infertility, habitual
miscarriage,
isthmic-cervical
insufficiency,
anus
fissures (60% of cases), rectal and vesicovaginal
fistulas, moderate bleeding, infection of the sutures.
Thus, at the present stage, the scientific and practical
interest in this issue is caused by the presence of
conflicting data on the pathogenetic mechanism of
the occurrence and effectiveness of the treatment of
soft tissue ruptures during vaginal delivery in women
with diabetes and gestational mellitus, as well as the
need to improve the quality of life of women after
childbirth.
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