AFTERHISTORY OF THE SURGICAL TREATMENT OF POSTPARTUM PERINEAL RUPTURES

KH.N. MUSAEV, M.M. MAMEDOV, N.N. AKHUNDOVA

Azerbaijan Medical University, Research Institute of Obstetrics and Gynecology, Baku,AZERBAIJAN

Materials and methods. We have analyzed 237 reports of birth for 2000-2008 obtained from the Institute of Obstetrics and Gynecology regarding women at age 18-36, that had perineal ruptures. 144 (60.8%) cases had perineal ruptures of 1^st, 87 (34,2%) – of 2^nd , and 12 (5,0%) – of 3^rd degree. We observed the increase in the frequency of ruptures in primiparas, mainly due to older women. 1^st degree ruptures were sutured obstetricians under local anesthesia by nodal catgut sutures. Usually there were inserted from 3 to 5 sutures. Postoperative wound care was performed by means daily irrigation with a potassium permanganate solution (1:1000). Sutures were removed on the 5-6^th days. 113 (78.5%) of 144 women with 1^st degree perineal ruptures had primary wound healing in birth reports. Various pyo-inflammatory complications in the postoperative wound of the perineum were observed in 31 (21.5%) patients. Results of treatment in-103 (71.5%) women were studied after a year, of them 56 (54.4%) were examined by us personally and 47 (45.6%) – asked to the sent questionnaire. The analysis showed that in 61 (59.2%) cases, women complained of pains during defecation. 56 of women examined by us had not changes in the external genital organs. During combined digital investigation of rectum and vagina in 8 secundiparas thinning of the rectovaginal septum was detected. All the patients were exposed to sigmoidoscopy and identification of anal reflex. All the patients had normal anal.

Sphincterotomy was carried out by sphincterometer-fixator. The main group of women that had 1^st degree postpartum perineal ruptures in 34 (79.1%) cases had a normal indicators of anal sphincter tone (500-550) and maximum force (750-810). In 9 women (20.9%) the tone was at the average of 420 g, and maximum force – 680 gr. These indicators are lower limits of the norm and from the clinical point of view, the anal sphincter function was within norm. 41 (87 2%) of 47 women that answered questionnaires had no complaints. 6 (12.8%) patient complained of tendency to constipation. During the examination, in 3 women there was detected 1^st degree rectocele and in one patient chronic anal fissure.

Results of the investigation. We studied the results of treatment of 3^rd degree perineal ruptures in 12 women (5.0%). 3^rd degree perineal ruptures without the solution of continuity of the rectal wall were found in 7 parturient women. Solution of the continuity of the rectal wall were stated in 5 (41.7%) cases. Suturing of the rupture covered the elimination of the defect of the rectal wall, external sphincter, and repair perineal tissues. During the study of operation reports, no cases of rehabilitation of the integrity of the muscles raising the anus were noted. Suppuration of postoperative wound was observed in 9 (75.0%) parturients. Suppuration was in all the five cases with the solution of continuity of the rectal wall. 10 (83.3%) of 12 women with 3^rd degree perineal ruptures were examined. 2 patients complained of gas incontinence, 3 – of incontinence of gas and loose stool and 3 of incontinence for gas and stool. All 12 women had pains during bowel movements with 1-6 months after parturition. 3 patients had no perineum. They had the following diseases of rectum and sigmoid: hemorrhoids – 2; proctosigmoiditis - 5; 2^nd degree rectocele - 1. The sphincter tone of 3 patients was from 120 to 150 grams, and maximum force - from 200 to 240, and corresponded to the 2^nd degree. Complete incontinence for gas and stool was observed in 3 patients with missing perineum.

Conclusion. Analysis of birth report allowed determined the following key aspects in the development of diseases of the perineum of non-tumor etiology: 1 - the overwhelming majority of parturient women - 141 (76.6%) of 237 that were examined and answered a special questionnaire, complained of severe pains during bowel movements, and hand to use laxatives and cleansing enema, 2 - more than the quarter of the patients (25.3%) had pyoinflammatory complications of the postoperative wound; 3 – 1^st and 2^nd perineal ruptures may be accompanied by weakening of the contractile force of the external sphincter; 4 - 12.5% ​​of examined women had various degrees of anal incontinence; 5. during the study of operation reports, no cases of rehabilitation of the integrity of the muscles raising the anus were noted.

THE NATURE OF MORPHOLOGICAL CHANGES IN POSTERIOR VAGINAL WALL DURING RECTOCELE

KH.N. MUSAEV, I.A.GASANOV, S.AALIYEVA

Azerbaijan Medical University, Baku,AZERBAIJAN

In order to study the optimal timing of the anterior rectocele levatoropalsty, we studied the nature morphological of disorders of a flap posterior vaginal wall in 20 patients, divided into two groups subject to the extent and duration of the disease. 1^st group included 10 women with at least 10 year anamnesis, mainly with 2^nd degree rectocele, the women in the 2^nd group had 3^rd degree rectocele for more than 10 years.

Results of histochemical analysis of all the layers of posterior vaginal wall revealed major changes consisting of morphological triad “fibrosis –dicelatosis -reduction and thrombosis of the microcirculation." Comparative quantitative analysis of morphologic indicators of the vaginal wall revealedstatistically significant greater thickness of the surface epitheliumin patients of the 2^ndGroup with more than 10 year anamnesis, while proliferative activity of the epithelium was two times less than in the patients of the 1^st group. Density microcirculation grid and the density of arteriolar-venular anastomoses in patients of the 2^ndgroup had decreasetendencyas compared with norm and patients of the 1^st group, with the majority of micro-vessels andbypasses lost their adequate morphofunctional properties, exposed to massive fibrosis, obstructive thrombosis, total or partial obliteration. Indicators of dystrophy, such as intensity of edema, with average values ​​of 1,8 ± 0,13 c.u. in the 1^st group and 3,2 ± 0,23 c.u. in the 2^ndgroup, the intensity of inflammatory infiltration (0,8 ± 0,08 c.u. in 1^stand 1,4 ± 0,12 c.u. in 2^ndgroup), the intensity of the degranulation in mast cells (2,0 ± 0, 15c.u. and 3,4 ± 0,25c.u. respectively), the number of histochemicalglucosaminoglycans(1,8 ± 0,15 c.y and 3,4 ± 0,25 c.u/), the intensity fibrosis (2,8 ± 0,19 c.u. and 3,8 ± 0,16 c.u.), sclerosis (2,6 ± 0,18 c.u and 3,6 ± 0,23 c.u), keratosis (2,4 ± 0,2 c.u. and 3,6 ± 0,3 c.u) were quantitatively evaluated. As can be seen from the data, the average values ​​of their patients with the duration of the disease more than 10 years were 1.5 - 2 times higher than respective indicators of the morphometric studies of the posterior vaginal wall of women with less than 10-year anamnesis.

All the above allows to make conclusion on the advisability of early surgerican intervention in 2^nd and 3^rd degree rectocele patient with maintained full tissues ofrectovaginal septum at a young age and with not more than 10-year anamnesis to avoid complications in the nearestpostsurgical period and recurrence of the disease in future.

Date: 2014-12-28; view: 899