1. Studiul metodelor de tratament medicamentoas ce urmaresc sistar ea hemoragiei uterine. 2. Identificarea principalelor patologii ce dete… [614991]

&2175,%8$,܉3(5621$/Ă
– 35 –

CAPITOLUL IV
2%,(&7,98//8&5Ă5,, :
1. Studiul metodelor de tratament medicamentoas ce urmaresc sistar ea hemoragiei uterine.
2. Identificarea principalelor patologii ce dete UPLQăKHPRUDJLL uterine.
3. Studiul procedurilor invazive utilizate în tratamentul hemora giilor uterine.
4.$QDOL]D LQIOXHQ܊HL IDFWRULORU GH ULVF ܈L D DQWHFHGHQWHORU SHUVR QDOH SDWRORJLFH DVXSUD
patologiei actuale.
5. Instituirea tratamentului adjuvant în cazul hemoragiilor uter ine prin metode specifice
LQGLYLGXDOL]DWHvQI XQF܊LHGHSDWRORJLH
6. Importan ܊a tratamentului hormonal aplicat în prelungirea perioadei liber e de simptome,
pentru cazurile selec ܊ionate.
– 36 –

CAPITOLUL V
0$7(5,$/,܇0(72'Ă
Am realizat un studiu retrospec tiv pe 224 de paciente internate in perioada septembrie
2016 – februarie 2017 în Spitalul Judetean de urgent ă

6I$SRVWRO$QGUHL

&RQVWDQ ta, Sec܊ia de
Obstetrica-Ginecologie, FDUHDXSUH]HQWDWVkQJHUDUHSHFDOHYDJLQDOă
3HQWUXDUHDOL]DDFHDVWăOXFUDUHDPVHOHFWDWSDFLHQWHOHFDUHDX SUH]HQWDWVkQJHUDUHvQ
FDQWLWDWHDSUHFLDELOăVLPSWRPIUHFYHQWDVRFLDWFXRSDWRORJLH GHIRQGFDUHDIRVWUH]ROYDWă de
cele mai multe ori vQGHFXUVXOLQWHUQăULL actuale.
Am folosit ca materia OGHOXFUXIRLOHGHREVHUYD܊LH܈L SURWRFRDOHOHRSH UDWRULLGLQD UKLYD
spitalului.
Criterii de includere: v kUVWă , mediul de provenien ܊ă, paritatea, PRWLYHOH LQWHUQăULL
simptome asociate hemoragiei, p RVLELOLWăWLOH GH WUDWDPHQW PHGLFDPHQWRDVHFKLUXUJLFDOH ,
antecedente personale patologice.
$PPRQLWRUL]DWXUPăWRULLSDUDPHWULL
xEficacitatea tratamentului hemostatic
xEvROX܊LDVLPSWRPDWRORJLHLSUH]HQWH la internare
x5H]XOWDWHOHH[DLQăULL ecografice
xPatologii identificate în urma examenului histo-patologic
xTipurLGHLQWHUYHQ܊LLFKLUXUJLFDOH ܈LHYROX܊LDSRVWRSHUDWRULH
x&RQVWDQWHOHYLWDOHD OHSDFLHQWHORU܈LQHFHVDUXOGHUHHFKLOLEUDU HKLGURHOHFWUROLWLFă
– 37 –

CAPITOLUL VI
5(=8/7$7(,',܇6&8,,܉
Figura 7.15HSDUWLаLDSDFLHQWHORUGLQORWXO VWXGLDWvQIXQFаLHGHPHGLXO GHSURYHQLHQаă
0HGLXO GH SURYHQLHQ܊ă HVWH XQ SD UDPHWUX GHVWXO GH LPSRUWDQW ĠLQ kQG FRQW GH
accesibilitatea pacientei la consultul de specialitate. Astfel, din totalul de 224 de cazuri studiate,
142(63%) provin din mediul urban iar restul de 82 de paciente pr ovin din mediul rural.
$PFRQVWDWDWRLQFLGHQ܊DFUHVFXWăDFDQFHUHORUGHFROXWHULQVL cancerelor endometriale la
pacientele din mediul rural. Cresterea inciden ܊ei neoplasmelor în rândul pacientelor din mediul
rXUDOSRDWHILFRUHODWăFXDEVHQĠDFRQVXOWDĠLLORUSHULRGLFHODP HGLFXOVSHFLDOLVWFkW܈ i neinformarea
asupra SRVLELOLWă܊ ii screeningului pentru cancerul de col uterin.
)LEURPDWR]D XWHULQă DUH R LQFLGHQ܊ă FUHVFXWă OD SDFLHQWHOH GLQ DPEHOH PHGLL GH
SURYHQLHQ܊ăvQVăDPREVHUYDWIDSWXOFăXQQXPăUPDLPDUHGHSD FLHQWHFXILEURPXWHULQGLQ
142; 63%
82; 37% ZĞƉĂƌƚŝƜŝĂƉĂĐŝĞŶƚĞůŽƌĚŝŶůŽƚƵůƐƚƵĚŝĂƚŠŶ
ĨƵŶĐƜŝĞĚĞŵĞĚŝƵůĚĞƉƌŽǀĞŶŝĞŶƜĉ
Urban
Rural
– 38 –

PHGLXOUXUDOSUH]LQWăRIRUPDDY DQVDWăGHERDOă'HVFRSHULUHDv QVWDGLXDYDQVDWDILEU omatozei
XWHULQHODGLQWUHSDFLHQWHHVWHLQUHOD܊LHGLUHFWăFXDEVHQ܊ DLQVWLWXLULLSUHFRFHDWUDWDPHQWXOXL
medicamentos, acestea neprezen tându-se în timp util la medic.
Tabelul 7.1. 5HSDUWL܊LDSDFLHQWHORUvQIXQF܊LHGHSDWRORJLHSHFDWHJRULDGH YkUVWă 7-30 de ani
5HSDUWL܊LDSDFLHQWHORUvQIXQF܊LHGHSDWRORJLHSHFDWHJRULDGH YkUVWă -30 de ani
Patologie 1XPăUGHFD]XUL
2EVWHWULFDOă 30
*LQHFRORJLFă,QIODPDWRULH 12
*LQHFRORJLFD+RUPRQDOă 17
7XPRUDOă%HQLJQă 1
Total 60
Majoritatea SDFLHQWHORUFXYkUVWDFXSULQVăvQWUH -30 ani studiate de mine au prezentat
SDWRORJLHGHWLSREVWHWULFDOGDU܈LSDWRORJLHGHRULJLQHKRUPRQ DOă,QFLGHQ܊DPDUHDSDWRORJLHL
REVWHWULFDOHVROGDWăFXKHPRUDJLH XWHULQăFRUHVSXQGHFXSHULRDG DGHIHUWLOLWDWHPD[LPăDIHPHLL
SUREOHPHOHOHJDWHGHVDUFL QăDYkQGFDX]HPXOWLSOH
Dintre cele 17 GHSDFLHQWHFXGLVIXQF܊LHKRUPRQD ODSUH]LQWăGHILFLW3URJHVW HURQLFFH
GHWHUPLQăDQRYXOD܊LHVLv QFRQVHFLQ܊ăDSDULWLHPHQR -metroragiilor.
)HPHLOHvQSHULRDGDUHSURGXFWLYăVXQWSUHGLVSXVHODDSDUL܊LDLQ IHF܊LLORUGHWUDFWJHQLWDOvQ
XUPDFRQWDFWHORUVH[XDOHQHSURW HMDWH8QQXPDUGHFD]XULVXI HUăGHFHUYLFLWăFURQLFăFX
VkQJHUDUH3DWRORJLDWXPRUDOăEHQLJQDHVWHUDUăDPFRQVWDWDWX QVLQJXUFD]SDFLHQWDSUH]HQWkQG
dureri intense pelvi- DEGRPLQDOH܈LVkQJHUDUHYDJLQDODLPSRUWDQWăLDUODHFRJUDILHD IRVWFRQVWDWDWă
SUH]HQ܊DXQXLFKLVWRYDULDQYROXPLRV de 5/4cm la nivelul ovarului stâng.
– 39 –

)LJXUD5HSDUWLаLDSDFLHQWHORUv QIXQFаLHGHSDWR ORJLHSHFDWHJRULDGHYkUVWă -30 de ani
ÌQFD]XLVWLFDVWXGLDWăGHPLQHvQLQWHUYDOXOGHYkUVWă -30 de ani domina patologia
REVWHWULFDOă܈LFHDGH QDWXUăKRUPRQDOD
Gravidele internate pentru hemorag LHXWHULQăVXQWvQSURFHQWGH܈LDXDYXWGUHSW
GLDJQRVWLFHVDUFLQăHFWRSLFăVLDPHQLQ܊DUHGHDYRUWÌQXUPDDQ DPQH]HLODDFHVWHSDFLHQHDXIRVW
FRQVHPQD܊LXQLLIDFWRULGHULVFSUHFXPIXPDWXOVDXLQIHF܊LLUHF XUHQWHJHQLWDOH&D]XULFXWRWXO
SDUWLFXODUH VXQW VDUFLQLOH PRODUH DX ULVF FUHVFXW ܈L QHFHVLWă DGPLQLVWUDUHD REOLJDWRULH GH
Methotrexat.
O pondere mare de 28 FXSULQGHSDWRORJLDKRU PRQDOăFHGHWHUPLQăPHQR -metroragii. La
DFHVWHSDFLHQWHWLQHUHVHWHQWHD]ăLQSULPSODQDGPLQLVWUDUHDF RQWUDFHSWLYHORURUDOHFRPELQDWHÌQ
FD]XULVHOHF܊LRQDWHVHYDDGPLQ VWUDGRDU3URJHVWHURQ3HVWHMX matate dintre aceste paciente au
antecedente de chisturi ovariene.
(VWH QHFHVDUă LQYHVWLJDUHD JORED Oă D SDFLHQWH SHQWUX D H[FOXGH SDWRORJLL DVRFLDWH
,PSRUWDQ܊DGR]ăULLKRUPRQDOHOD SDFLHQWHDXIRVWLGHQWLILFD WHGLVIXQ܊LLKRUPRQDOHWLURLGLHQH –
GXSă W ratamentul recomandat bine condus simptomatologia s-a remis. Ec hilibrul hormonal
50%
20%
28%
2% ZĞƉĂƌƚŝƜŝĂƉĂĐŝĞŶƚĞůŽƌŠŶĨƵŶĐƜŝĞĚĞƉĂƚŽůŽŐŝĞ
ƉĞĐĂƚĞŐŽƌŝĂĚĞǀąƌƐƚĉϭϳ -30 de ani
3DWRORJLH2EVWHWULFDOă
3DWRORJLH*LQHFRORJLFă
Inflamatorie
3DWRORJLH*LQHFRORJLFă
+RUPRQDOă
3DWRORJLH7XPRUDOă%HQLJQă
– 40 –

UHVWDELOLWHVWHIRDUWHLPSRUWDQWDWkWSHQWUXUH]ROYDUHDGLVIXQ F܊LLORUFDQWLWDWLYHDOHPHQVWUXD܊LHLFkW
܈LSHQWUXSURJUDPDUHDXQHLVDUFLQL
&HUYLFLWHOHFURQLFHGHWHUPLQăDSDUL܊LDFROXOXLOH]LRQDO܈LVkQJ HUDUHSHFDOHYDJLQDOă sunt
întalnite in procent de 20 ODSDFLHQWHOHVWXGLDWH,QL܊LDOVHDGPLQLVWUHD]ăWUDWDPHQWXO KHPRVWDWLF
SDUWLFXODUL]DWILHFDUXLFD]LDUXOWHULRUVXQWQHFHVDUHLQYHVWL JD܊LLVXSOLPHQWDUHSHQWUXVWDELOLUHD
DJHQWXOXLHWLRORJLF܈LDSOLFDUHDWUDWDPHQWXOXLDQWLELRWLF܊LQWL W
ÌQORWXOGHSDFLHQWHVWXGLDWHGHPLQHFXYkUVWDFXSULQVăvQWUH -30 de ani am observat
DEVHQ܊DSDWRORJ iei tumorale maligne, un lucru î PEXFXUăWRUGDWă ILLQGIUHFYHQ܊DDWkWGHPDUHD
ratei de transmitere a HPV-ului(Human Papill RPD9LUXVFHGHWHUPLQă DSDUL܊LD cancerului de col
uterin.
7DOHOXO5HSDUWLаLDSDFLHQWHOR UvQIXQFаLHGHSDWRORJLHSH FDWHJRULDGHYkUVWă -40 de ani
5HSDUWL܊LDSDFLHQWHORUvQIXQF܊LHGHSDWRORJLHSHFDWHJRULDGHY kUVWă -40 de ani
Patologie 1XPăUGHFD]XUL
2EVWHWULFDOă 50
*LQHFRORJLFă,QIODPDWRULH 2
*LQHFRORJLFD+RUPRQDOă 17
7XPRUDOă%HQLJQă 8
7XPRUDOă0DOLJQă 6
Total 83
Din totalul de 83 GHSDFLHQWHFXYkUVWDFXSULQVăvQWUH܈LGHDQLSULPHD]ă SDFLHQWHOH
FXKHPRUDJLHXWHULQăGHFDX]ăREVWHWULFDOăÌQXOWLPHOHGHFDGH V-DFRQVWDWDWRWHQGLQ܊ăGHFUH܈WHUH
a vârstei primiparelor, astfel încât am identificat cresterea n umarului de cazuri cu patologie
REVWHWULFDOă vQ UkQGXO SDFLHQWHOR U FX YkUVWD FXSULQVă vQWUH  VL  GH DQL $P REVHUYDW
FRQVHPQDUHD $33DOHSDFLHQWHORUvQIL܈HOHVWXGLDWHFDUHUHOHYă IDSWXO Fă DFHVWHD DXGLIHULWH
SDWRORJLLDVRFLDWHSUHH[LVWHQWHFXLPSDFWDVXSUDVWăULLDFW uale.
– 41 –

$PREVHUYDWLQFLGHQ܊DPDUHDSDWRORJLHLKRUPRQDOHFHDGHWHUPLQ DWDSDUL܊LDVkQJHUăULORU
DQRUPDOHSHFDOHYDJLQDOăOD dintre pacientele analizate.
3DWRORJLDJLQHFRORJLFDLQIODPDWRULHHVWHSUH]HQWăODSDFLHQWH DFHVWHDDYkQGUHFLGLYH
frecvente în ultimul an – vQDFHVWHFD]XULSRDWHILOXDWăvQFRQVLGHUDUHDGPLQLVWUDUHDLP SURSULHD
PHGLFD܊LHDWkWSDFLHQWHLFkW ܈LWUDWDUHDSDUWHQHUXOXL
&RPSDUDWLYFXLQWHUYDOXOGHYkUVWăVWXGLDWDQWHULRUODSDFLHQW HOHLQWUH -40 ani observ o
FUH܈WHUHDDSDUL܊LHLSDWRORJLHLWXPRUDOHEHQLJQHSDFLHQWHOHDF X]kQGKHPRUDJLLLPSRUWDQWHGDWRULWă
fibromatozei uterine.
8QQXPăUGHSDFLHQWHVXIHUăGHFDQFHUGH col uterin, fiind descoperite în stadii diferite.
'RDUSDFLHQWHSUH]LQWăXQVWDGLXLQFLSLHQWDOEROLLFXV ângerari ocazionale de tip spotting.
5HVWXOSDFLHQWHORUVHSUH]LQWăODPHGLFvQVWDGLXDYDQVDWQHFHV LWkQGLQWHUYHQ܊LHFKLUXUJLFDOD
UHVSHFWLYKLVWHUHFW RPLHWRWDOă
Figura 7.3.5HSDUWLаLDSDFLHQWHORUvQIXQFаLHGH SDWRORJLHSHFDWHJRULDGH YkUVWă -40 de ani
60%
2%
21%
10%
7% ZĞƉĂƌƚŝƜŝĂƉĂĐŝĞŶƚĞůŽƌŠŶĨƵŶĐƜŝĞĚĞƉĂƚŽůŽŐŝĞƉĞ
ĐĂƚĞŐŽƌŝĂĚĞǀąƌƐƚĉϯϭ -40 de ani
3DWRORJLH2EVWHWULFDOă
3DWRORJLH*LQHFRORJLFă,QIODPDWRULH
3DWRORJLH*LQHFRORJLFă+RUPRQDOă
3DWRORJLH7XPRUDOă%HQLJQă
3DWRORJLH7XPRUDOă0DOLJQă
– 42 –

În figura 7.3 VHREVHUYăSUHGRPLQDQ܊DSDWRORJLHLREVWHWULFDOHFHGHWHUPLQăKH PRUDJLH
uterLQăPDLH[DFWSHVWHMXPDWDWH % ) dintre pacientele analizate cu vârsta cuprinsa între 31 si
DQL$QDOL]kQGIL܈HOHDFHVWRUSDFLHQWHDPREVHUYDWGLDJQRVWL FHPXOWLSOHGHVDUFLQLHFWRSLFH܈L
DPHQLQ܊ăULGHDYRUW
Un procent de 21 GLQORWXOVWXGLDWSUH]LQWăWXOEXUăULGHRULJLQHKRUPRQDOăIL LQGWUDWDWH
FXPHGLFD܊LHKRUPRQDOă FODVLFăFHFRQVWăvQDGPLQLVWUDUHDGHS rogesteron, iar în cazurile cu
UHFLGLYăLQGHFXUVGHOXQLGXSD RSULUHDPHGLFD܊LHLVWUDWHJLD WHUDSHXWLFăFRQVWăvQSODVDUHD
VLVWHPXOXLLQWUDXWHU LQFXHOLEHUDUHOHQWă GHOHYRQRJHVWUHO6,8 -LNG).
Dezideratul imediat al terapiei hormonale este oprirea hemoragi ei, iar pe termen lung
rezolvarea dezechelibrului hormona O܈LSRVLELOLWDWHDPHQ܊LQHULL VDUFLQLLIăUăSUREOHPH
ÌQDFHVWăILJXUăVHREVHUYăSURFHQWHPLFLGHSDFLHQWH cu patologie tumorala benigna(10%)
܈LSDWRORJLHWXPRUDOăPDOLJQD %).
Tabelul 7.5HSDUWLаLDSDFLHQWHORUvQIXQFаLH GHSDWRORJLHSHFDWHJRULD GHYkUVWă -55 de ani
5HSDUWL܊LDSDFLHQWHORUvQIXQF܊LHGHSDWRORJLHSHFDWHJRULDGH YkUVWă -55 de ani
Patologie 1XPăUGHFD]XUL
*LQHFRORJLFă,QIODPDWRULH 2
*LQHFRORJLFD+RUPRQDOă 8
7XPRUDOă%HQLJQă 33
7XPRUDOă0DOLJQă 10
Total 53
ÌQWDEHOXOVHREVHUYăLQFLG HQ܊DPLFDDKHPRUDJLLORUXWHULQ HGHWHUPLQDWHSDWRORJLD
LQIODPDWRULHvQVIHUDJLQHFRORJLFDvQQXPăUGHFD]XULÌQORW XOVWXGLDWDPLGHQWLILFDWGLQWRWDOXO
SDFLHQWHORUIHPHLFXKHPRUDJLHXWHULQăGHFDX]ăKRUPRQDOăÌQ DFHVWLQWHUYDOGHYkUVWăGRPLQă
SDWRORJLDWXPRUDOăEHQLJQăvQVSH܊ăILEURPXOXWHULQDVWIHO de paciente prezentând hemoragie
– 43 –

XWHULQăLPSRUWDQWăvQXUPDDFHVWHLSDWRORJLL3DWRORJLDWXPRUDO ăPDOLJQăHVWHvQWkOQLWăOD 10
paciente din lotul studiat.
Figura 5HSDUWLаLDSDFLHQWHORUvQIXQF аLHGHSDWRORJLH SHFDWHJRULDGHYkUVWă -55 de ani
ÌQ ILJXUD  VH REVHUYă GLVWULEX܊LD SURFHQWXDOă D SDWRORJLHL OD SDFLHQWHOH FX YkUVWD
FXSULQVăvQWUHVLGHDQLFH DXSUH]HQWDWKHPRUDJLHXWHULQ ă
În acest LQWHUYDOGHYkUVWăSDWRORJLDFHDPDLIUHFYHQWăvQUkQGXOSDFLHQ WHORUGLQORWXO
VWXGLDWGHPLQHHVWHSDWRORJLDWXPRUDOăPDOLJQD –f i b r o mDWR]DXWHULQăvQSURSRU܊LHGH %.
Forma anatomo- FOLQLFă vQ FD]XO SDFLHQWHORU GLQ ORWXO VWXGLDW GH PLQH HVWH IRU PD FX PHQ o-
PHWURUDJLLQXDPFRQVWDWDWDOWHIRUPHGHILEURPDWR]ăXWHULQă SULQWUHFDUHFHOHFXQHFURELR]ă
DVHSWLFăVHSWLFăVDXGHILEURPXWHULQPDOLJQL]DW$SDUL܊LDILEU RPXOXLXWHULQODSDFLHQWHOHVWXGLDWH
GHPLQHFRUHVSXQGHFXLQWHUYDOXOGHLQFLGHQWăPD[LPăGHDSDUL܊L HDDFHVWHLSDWRORJLLFLWDWvQ
OLWHUDWXUDGHVSHFLDOLWDWH܈LvQVWXGLLOHFOLQLFH
ÌQUkQGXOSDFLHQWHORUGLQORWXOV WXGLDWFXYDUVWDFXSULQVăLQWU HVLGHDQLDPvQWDOQLW
SUH]HQWăSDWRORJLHLW umorale maligne în procent de 19 $SDUL܊LDWXPRULORUPDOLJQHQXUHVSHFWă
RGLVWULEX܊LHRPRJHQăvQIXQFWLH GHYkUVWăvQXOWLPHOHGHFDGH FHOPDLIUHFYHQWSRDWHILREVHUYDWă
aparitia cancerului de col uterin la diferite vârste, din ce în ce mai tinere.
4%
15%
62%
19% ZĞƉĂƌƚŝƜŝĂƉĂĐŝĞŶƚĞůŽƌŠŶĨƵŶĐƜŝĞĚĞƉĂƚŽůŽŐŝĞƉĞ
ĐĂƚĞŐŽƌŝĂĚĞǀąƌƐƚĉϰϭ -55 de ani
3DWRORJLH*LQHFRORJLFă,QIODPDWRULH
3DWRORJLH*LQHFRORJLFă+RUPRQDOă
3DWRORJLH7XPRUDOă%HQLJQă
3DWRORJLH7XPRUDOă0DOLJQă
– 44 –

3DWRORJLDKRUPRQDOăGHWHUPLQăKHPRUDJLLXWHULQHOD % din pacienteledin lotul studiat
de mine.
'LQ DFHDVWă ILJXUD UHLHVH IDSWXO Fă SDWRORJLD LQIODPDWRULH FRPS OLFDWă FH GHWHUPLQă
hemoragii î QVIHUDJHQLWDOăHVWHUDUăO DSDFLHQWHOHGLQORWXOVWX diat, fiind în procent de doar 4%.
7DEHOXO5HSDUWLаLDSDFLHQWHO RUvQIXQFаLHGHSDWRORJLHSH FDWHJRULDGHYkUVWă -76 de ani
5HSDUWL܊LDSDFLHQWHORUvQIXQF܊LHGHSDWRORJLHSHFDWHJRULDGH YkUVWă -76 de ani
Patologie 1XPăUGHFD]XUL
Prolaps total recidivant 1
*LQHFRORJLFă,QIODPDWRULH 3
*LQHFRORJLFD+RUPRQDOă 6
7XPRUDOă%HQLJQă 8
7XPRUDOă0DOLJQă 10
Total 28
+HPRUDJLLOHXWHULQHODSDFLHQWHOHFXYkUVWDFXSULQVăvQWUH -76 de ani au survenit cel mai
frecvent în urma patologiei tumorale maligne. În acest interval de vârsta pacientele sunt
predispuse la apari ܊LDWXPRULORUPDOLJQHGDWILLQGIDSWXOFDVXQWDVRFLD܊LPDLPXO ܊LIDFWRULGHULVF
Din totalul de 10 cazuri, 3 paciente au diagnosticul de cancer de col uterin ( având ca factor de
ULVFIXPDWXO܈LLQIHF܊LDFURQLFDFX+XPDQ3DSLOORPD9LUXVLDU SDFLHQWH VXIHUăGHFDQFHU
HQGRPHWULDO$QDPQH]DVLH[DPHQXO FOLQLFUHOHYăDVRFLHUHDIDFWR ULORUGHULVFSUHFXPREH]LWDWHD܈L
KLSHUSOD]LDHQGRPHWUL DOăSUH]HQ܊LvQFD]XOSDFLHQWHORUFXKHPRU DJLHXWHULQăvQXUPDFDUFLQRPXOXL
endometrial.
$PLGHQWLILFDWFD]XULFXKHPRUDJLHXWHULQăGHFDX]ăWXPRUDOă EHQLJQăGLQWUHFDUHvQ
FD]XULGLDJQRVWLFXOHVWHGHSROLSR] ăHQGRPHWULDOă LDUILEURPDWR ]DXWHULQăDSDUHODSHUVRDQH
&RQIRUPUH]XOWDWHORU GLIHULWHORUVWXGLLSROLSR]DHQGRPHWULDOă DSDUHvQSRSXOD܊LDJHQHUDOă
la 7,5-GLQWUHIHPHLLDUPLFăSDUWHGLQWUHDFHVWHDSUH]LQWăVLPSWR PHVSHFLILFHFDUHOHFRQGXF
– 45 –

ODPHGLFSUHFXPVkQJHUDULDQRUPDOHJHQLWDOHVDXVHFUH܊LLYDJLQ DOHDQRUPDOH$FWLYLWDWHDEROLL܈L
GLPHQVLXQLOHIRUPD܊LXQLLWXPRUDOHQX VXQWFRUHODWHFXDSDUL܊LDV LPSWRPHORUVLJUDYLWDWHDDFHVWRUD
9kVWDvQDLQWDWăHVWHXQIDFWRU GHULVFLPSRUWDQWvQDSDUL܊LDSR OLSLORUHQGRPHWULDOL
Doar 3SDFLHQWH GLQ ORWXO VWXGLDW GH PLQH SUH]LQWă KHPRUDJLH XWHULQă v QDIHFWLXQLORU
inflamatorii din sfera JHQLWDOă LDU R SDFLHQWă SUH]LQW ă SURODSV UHFLGLYDQW WRWDO FX D SDUL܊LD
hemoragiei uterine.
3DWRORJLDKRUPRQDOăvQSHULRDGDFOLPDWHULFăDPLQWDOQLW -o la 6 paciente, conform tabelului
GHPDLVXV'H]HFKLOLEUXOKRUPRQDOFRQVWăvQDSDULWLDKLSHUVWUR JHQHPLHL ODPHQRSDX]ăGDWRULWă
DFWLYLWă܊LLUDPDVHDJODQGHORUFHVHFUHWăHVWURJHQSHXQWHUHQ SULYDWGHSURJHVWHURQGH]HFKLOLEUX
ce apare frecvent la femeile obeze.
)LJXUD5HSDUWLаLDSDFLHQWHORU vQIXQFаLHGHSDWRORJLHSHF DWHJRULDGHYkUVWă -76 de ani
/D SDFLHQWHOH vQ PHQRSDX]ă KHPRUDJLD XWHULQă DUH GUHSW FDX]H I UHFYHQWH SDWRORJLD
WXPRUDOăPDOLJQăIUHFYHQ܊DGHDSDUL܊LHDFDUFLQRDPHORUFUHVFkQ GRGDWDFXYkUVWDÌQILJXUD
HVWHQRWDWăLQFLGHQ܊DPDOLJQLWă ܊LORUvQSURFHQWGHSHQWUXD FHVWLQWHUYDO GHYkUVWă
4%
%
%
%7%
22%
30%
37% ZĞƉĂƌƚŝƜŝĂƉĂĐŝĞŶƚĞůŽƌŠŶĨƵŶĐƜŝĞĚĞƉĂƚŽůŽŐŝĞƉĞ
ĐĂƚĞŐŽƌŝĂĚĞǀąƌƐƚĉϱϲ -76 de ani
Prolaps recidivant total
3DWRORJLH*LQHFRORJLFă,QIODPDWRULH
3DWRORJLH*LQHFRORJLFă+RUPRQDOă
3DWRORJLH7XPRUDOă%HQLJQă
3DWRORJLH7XPRUDOă0DOLJQă
– 46 –

2LQFLGHQ܊ăFUHVFXWăvQDFHDVWăSHULRDGăRDX܈LWXPRULOHEHQLJ QHDOFăWXLQGGLQ
WRWDOXOFD]XULORUVWXGLDWHF XYkUVWDFXSULQVăvQWUH -40 de ani.
'H]HFKLOLEUHOHKRUPRQDOHGLQSHULRDGD FOLPDWHULFăVHVROGHD]ă F XGHFD]XULGH
hemoragii ut HULQH 2 LPSRUWDQ܊ă GHRVHELWă v Q DSDUL܊LD DFHVWRU GH]HFKLOLEUH R DUH
KLSHUHVWURJHQHPLDFHDSDUHFDXUPD UHDWHUHQXOXLIDYRUL]DQWOD PHQRSDX]ăFHSUHVXSXQHVFDGHUHD
GUDPDWLFDDSURJHVWHURQXOXLFHQXSRDWHFRQWUDEDODQVDVHFUH܊LD FRQWLQXDGHHVWURJHQFKLDUGDFă
DFHDVWDHVWHvQFDQWLWDWHPLFă' LQDOWSXQFWGHYHGHUHKHPRUD JLLOHXWHULQHGHRULJLQHKRUPRQDOă
SRWILGHFHODWHODSDFLHQWHOH FHIRORVHVFWUDWDPHQWVXEVWLWXWLY HVWURJHQLFSHRSHULRDGăLQGHOXQJDWă
܈LvQGR]HQHDGHFYDWHv QWLPSXOPHQRSDX]HL
PatologiDJLQHFRORJLFăLQIODPDWRULHDIHFWHD]ăGRDUGLQWUHSDFLHQWHOH GLQORWXOVWXGLDW
GHPLQHFHVHDIOăODPHQRSDX]ă&RQVWDWIDSWXOFăKHPRUDJLLOH XWHULQHGHRULJLQHLQIODPDWRULHQX
VXQWFDUDFWHULVWLFHIHPH LORUFXYkUVWăvQDLQWDWă
Un caz particular de hemor DJLHXWHULQăLOFRQVWLWXLHSURODSVXOJHQLWDOWRWDOUHFLGLYDQW
SDFLHQWDUHVSHFWLYăDYkQGDQW HFHGHQWHPXOWLSOHGHDIHF܊LXQLvQ VIHUDJHQLWDOă܈LQXQXPDL&HOPDL
LPSRUWDQWIDFWRUGHULVFFDUHD FRQGXVODDSDUL܊LDDIHF܊LXQLLD FWXDOHHVWHPXOWLSDULWDWHDvQIL܈D
SDFLHQWHLILLQGvQVFULVHQD܈WHULQDWXUDOH în antecedente).
– 47 –

Figura 7.6. Fumatul ca factor de risc asociat patologiilor din lotul studiat
8QVWXGLXUHDOL]DWvQDSHFLD]ăIDSWXOFăXQVIHUWG LQSRSXOD܊LD5RPDQLHLHVWH
IXPăWRDUH )XPDWXO v܈v ODVă DPSUHQWD DVXSUD vQWUHJXOXL RUJDQLVP  LQFOXVLY vQ VIHUD JHQLWDOă
,PSRUWDQ܊ăIXPDWXOXLDVXSUDWHPHLVWXGLDWHGHPLQHHVWHGHDLQ IOXHQ܊DQH gativ procesul natural
GH FRDJXODUH FDOLWDWHD YDVHORU GH VkQJH DF܊LXQHD IXPDWXOXL DV XSUD GH]YROWăULL SURFHVHORU
WXPRUDOH܈LQXvQXOWLPXOUkQGLPSDFW XOIXPDWXOXLDVXSUDHFKLOL EUXOXLKRUPRQDO
ÌQFD]XLVWLFDVWXGLDWăGHPLQHDPREVHUYDWXQQXPăUFUHVFXW de fumatoare, mai exact 85
din totalul de 224, în procent de 38%. Fumatul are un impact ma jor in dezvoltarea tumorilor
PDOLJQH܈LHVWHXQIDFWRUDVRFLDWEROLORUFDUGLR -vasculare.
Pacientele din lotul studiat de mine care au dezvoltat tumori m aligne sunt fumatoare sau
IRVWHIXPDWRDUHDVWIHOFRQVWDWRFRUHOD܊LHGLUHFWăvQWUHH[SXQ HUHDODIDFWRUXOGHULVFIXPDWXO܈ i
DSDUL܊LDWXPRULLPDOLJQHÌQFD]XOSDFLHQWHORUFHDXVXIHULWXQ DYRUWVSRQWDQVDXLPLQHQ܊ăGHDYRUW
DPFRQVWDWDWSUH]HQ܊DIDFWRUXOXLGHULVFIXPD tul la jumatate dintre acestea.
139; 62% 85; 38% Fumatul ca factor de risc asociat patologiilor
din lotul studiat
Nefumatoare Fumatoare
– 48 –

Tabelul 7.5. Simptome asociate hemoragiilor uterine
Simptome asociate hemoragiilor uterine
Durere Etaj Abdominal Inferior 134
9ăUVăWXUL 4
ContraF܊LLXWHULQHG ureroase(CUD) 18
+HPDWXULH0DFURVFRSLFă 2
Cefalee 10
)HEUă 9
Dismenoree ܈Ldispareunie 60
&HOPDLIUHFYHQWVLPSWRPLQWkOQLWDOăWXULGHVăQJHUDUHHVWHGXU HUHD&DUDFWHUXOGXUHULL Ьi
ORFDOL]DUHDDOăWXULGHDQDPQH]D ܈LH[SORUăULSDUDFOLQLFHRULHQW HD]ăGLDJQRVWLFXO'LVSDUHXQLDHVWH
LQWkOQLWăLQWRDWH cazurile analizate.
Hemoragiile disf XQF܊LRQDOHDVRFLD]ăIUHFYHQWGLVPHQRUHH'HDVHPHQHDGLVPHQRUH HD
HVWHRELHFWLYDWăvQHQGRPHWULR] HILEURDPHXWHULQSROLSL Ьi în unele cervicite cronice.
Pacientele cu sar FLQăHFWRSLFăDXSUH]HQWDWVLYăUVDWXULFkW܈LRSDFLHQWăFXI LEURPXWHULQ
ce asocia ܈LGLDJQRVWLFXOGHFROHFLVWLWă
ContracЮiile uterine dureroase sunt caracteristice placentei p UDHYLDDFHDVWDILLQGLQVWUkQVă
OHJDWXUăFXUXSWXUDSUHPDWXUăGH PHPEUDQHVLQD܈WHUHSUHPDWXUă
+HPDWXULDPDFURVFRSLFăDIRVWD VRFLDWăFXXQKHPDWRPSHULWRQHDO SRVW -cistorafie în cazul
XQHLOHKX]HFXSODJăGHKLVFHQ WăGXSăRSHUD܊LHFH]DULDQă
Cefaleea este un simpto m nespecific, des întâlnit în cazul sind romului hemoragic.
În cadrul diagnosticelor asociate de tip septic precum colecist ita sau pneumoniile se
REVHUYăDSDUL ЮLDIHEUHL)HEUDHVWHXQIHQRPHQFRQVXPSWLYFDUHLQUăXWă܊H܈ te prognosticul unei
hemoragii.
– 49 –

Figura 7.7. Simptome asociate hemoragiilor uterine
Din Figura 7.7. UHLHVHIDSWXOFăGXUHUHDHVWHVLPSWRPXOFHOPDL obiectivat alaturi de
hemoragie, ce apare la mai mult de jumatate dintre cazurile ana lizate, urmat de dismenoree ܈i
dispareunie.
'XUHUHDGLQHWDMXODEGRPLQDOLQIHULRUUHVLP܊LWăGHGLQWUHS DFLHQWHOHGLQ lotul studiat
este de intensitate mare, necesitând administrarea de antialgic e in doze înalte. Majoritatea
SDFLHQWHORU DX SUH]HQWDW GXUHUH vQ HYROX܊LD EROLL FH D FHGDW O D PHGLFD܊LD DGPLQLVWUDWă OD
domiciliu.În cazul pacientelor cu dezechilibre hormonale c H DX SUH]HQWDW KHPRUDJLH XWHULQă
GXUHUHDSRDWHILSUH]HQWăVDXD EVHQWăQHILLQGRFDUDFWHULVWLFă DDFHVWRUSDWRORJLL
'LVPHQRUHHD܈LGLVSDUHXQLDVXQWVLPSWRPH nespecifice, ce sunt întâlnite frecvent în sfera
JLQHFRORJLFăÌQXUPDLQYHVWLJD܊LLORUVXSOLPHQWDUHVHSXQHGLDJ QRVWLFXOGHFHUWLWXGLQH$SDUL܊LD
DFHVWRUVLPSWRPHODGLQSDFLHQWHOHGLQORWXOVWXGLDWHVWHF RUHODWăFXGLJQRVWLFHVHYHUHVDX
SDWRORJLLFDUHDXIRVW UH]ROYDWHFXXVXULQ܊ă
Celelate simptome ce LQVR܊HVF hemoragia XWHULQă au o inciden ܊amDLVFD]XWă Simptome
QHVSHFLILFHSUHFXPFHIDOHH܈LIHEUDDSDUODGLQFD]XULvQVR ܊LQGVLQGURPXOKHPRUDJLF܈L
56%
2%
8%
1%
4%
4%
25% ^ŝŵƉƚŽŵĞĂƐŽĐŝĂƚĞŚĞŵŽƌĂŐŝŝůŽƌƵƚĞƌŝŶĞ
Durere Etaj Abdominal Inferior
9ăUVăWXUL
ŽŶƚƌĂĐƜŝŝhƚĞƌŝŶĞƵƌĞƌŽĂƐĞ;hͿ
+HPDWXULH0DFURVFRSLFă
Cefalee
)HEUă
ŝƐŵĞŶŽƌĞĞcŝŝƐƉĂƌĞƵŶŝĞ
– 50 –

LQIODPDWRU 7UDWDPHQWXO DIHF܊LXQLL GH ED]ă D DYXW HIHFW SR]LWLY  ܈L DVXSUD DFHVWRU VLPSWRPH
asociate, care au disparut d upa rezolvarea patologiei GHFODQ܈DWRDUH
&RQWUDF܊LLOHXWHULQHGXUHURDVHDSDUvQGLQFD]XULODSDFLHQ WHOHFXSODFHQWDSUDHYLDvQ
DFHVWHFD]XULVHDGPLQLVWUHD]ăXWHURWRQLFHFXVFRSXOGHDSUHOX QJLFkWPDLPXOWSRVLELOVDUFLQD
vQVăGHFHOHPDLPXOWHRULDFHVWOXFUXQXHVWHSRVLELOVLVHUH FXUJHODRSHUD܊LDFH]DULDQă
8Q FD] SDUWLFXODU HVWH DVRFLHUHD KHPRUDJLHL XWHULQH FX KHPDWXUL H PDFURVFRSLFă
RELHFWLYDWăODRSDFLHQWăODX]ăFXSODJDGHKLVFHQWăvQ]LXD SRVW -RSHUD܊LHFH]DULDQăÌQDFHDVWă
VLWXD܊LHV -DSUDFWLFDWFLVWRUDILD܈L histerectomia de necesitate.
9ăUVăWXULOHDSDUODGLQFD]XU LOHORWXOXLVWXGLDWvQFRUHOD܊ LHFXVLQGURPXOKHPRUDJLF܈L
intensitatea durerii.
Tabelul 7.6. Localizarea durerii la pacientele din lotul studiat
Localizarea Durerii la pa cientele din lotul studiat
Pelvi-Abdominal 86
Perineale 14
Lombo-Abdominale 34
1HVSHFLILFă 90
Total 224
'HVHRUL KHPRUDJLD HVWH FRPELQD Wă FX VLQGURP DOJLF SURQXQĠDW FD UH FKLDU ܈L în
hemoragiile scazute cantitativ poate provoaca consumul rapid a l mecanismelor de FRPSHQVDUHúL
SURWHFĠLH
Durerea pelvi- DEGRPLQDOăGRPLQăSDWRORJLDGHWLSJLQHFRORJLFILLQGLQWDOQLWă LQWRDWH
cazurile de fibrom uterin, tumori ovariene, neoplasm endometria l , c a n c e r d e c o l u t e r i n Ьi
HQGRPHWULR]ă6kQJHUDULOHGLQ OăX]LDLPHGLDWăDVRFLD]ă dureri pelvi-abdominale.Am identificat
durerea pelvi- DEGRPLQDOăODGHFD]XUL'XUHUHDSHOYLQăDFXWăXQLODWHUDOăH VWHLQWDOQLWă in
sarcinile ectopice fiind con WLQXăVDXFROLFDWLYă
– 51 –

Durerea lombo- DEGRPLQDOăDPLQWDOQLW -o la 34 de paciente, frecvent in asociere cu
GLVSOD]LDFHUYLFDOăDYRUWXOVSRQW DQVDUFLQDPRODUăVLFHUYLFLW DFURQLFăKHPRUDJLFă .
Afec܊unileLQIODPDWRULL FH DVRFLD]ă FHUYLFLWHOH FRPSOLFDWH SUHFXP VL VROX܊ iile de
continuitate de diferite etiologii pot determina apari Юia durerii in zona SHULQHDOăDVRFLDWăFXSUXULW
܈LIHEUă,QOăX]LDLPHGLDWăDPLQWăOQLWUXSWXULGHFDQDOPRDOH FDUHDVRFLD]ăGXUHULLPSRUWDQWH
perineale. ÌQORWXOVWXGLDWVXQWSDFLHQWH FXGXUHUHORFDOL]DWăSUHSRQGH UHQWODQLYHOSHULQHDO
Figura 7.8. Localizarea durerii la pacientele din lotul studiat
În figura 7.8. VHREVHUYăFHOHPDLIUHFYHQWHORFDOL]DUL ale durerii la nivel pelvi-abdominal
la 39% dintre pacientele din lotul studiat, LDUQHVSHFLILFăHVWHGXUHUHDvQGLQWUHFD]XUL
Durerea pelvi- DEGRPLQDOăHVWHDFX]DWăIUHFYHQWILLQG vQUHOD܊LHGLUHFWăFXSDW RORJLDWXPRUDOă
EHQLJQăLQVSH ЮăILEURPXOXWHULQ$GPQLVWUDUHDDQWLDOJLFHORUHVWHREOLJDWRULH , având scopul de a
asigura confortul pacientei cât ܈idH D SHUPLWH HIHFWXDUHD LQWHUYHQ܊ iilor de specialitate sub
controlul eficace al durerii.
Ca frecven ܊ă, localizarea durerii la nivel pelvi- DEGRPLQDO HVWH XUPDWă GH localizarea
lombo-DEGRPLQDOăDGXUHULLSUH]HQWăOD 15% din cazurile studiate, i ar 6% dintre pacientele
ORWXOXLDQDOL]DWSUH]LQWăGXUHULODQLYHOXO zonei perineale.
39%
6%
15%
40% Localizarea durerii la pacientele din lotul studiat
Pelvi-Abdominal
Perineale
Lombo-Abdominale
1HVSHFLILFă
– 52 –

Figura 7.9.. Tratament Hemostatic Vitamina K administrat pacientelor din lotul studiat
Etamsilatul este un derivat de acid benzensulfonic, hemostatic general nespecific, ce are
UROXOGHDFUH܈WHUH]LVWHQ܊DFDSLODUă܈LDJUHJDUHDWURPERFLWHOR U)RORVLUHDSUHSDUDWXOXLHVWHGH
HOHF܊LHvQFD]XOPHQR -PHWURUDJLLORULDUvQFD]GHXUJH QĠăGăUH]XOWD WHEXQHvQGR]ă GH2-3
fiole(250mg/2ml)fiola, de 3 ori pe zi, intravenos sau intramusc ular.
S-a administrat etamsilat vQ FRPELQD܊LH FX ILWRPHQDGLRQă OD  de paciente cu uter
fibromatos, dintre care 18 p DFLHQWHDXUăVSXQVODWUDWDPHQWSULQRSULUHDVkQJHUăULL+HPRUD Jia nu
putut fi st DSkQLWăOD p a c i e n t e c u f i b r o m u t e r i n d i n l o t u l s t u d i a t d e m i n e , a s t f e l î n c a t au
necesitat histerectomie pentru realizarea hemostazei. Ca înlocu itor al etamsilatului poate fi folosit
FDUED]RFURPXOvQVăH tamsilatul este de preferat, stu GLLOHDUăWkQGXQUăVSXQVW HUDSHXWLFVXSHULRUvQ
cazul meno-metroragiilor.
În cazul pacientelor cu menoragii semnificative s-a efectuat un studiu restrans pe 76 de
paciente cu aceste acuze, în care a fost administrat acidul tra nexamic(antifibrinolotic) pacientelor
GLQORWXOUHVSHFWLYFHDFRQGXVO DGLPLQXDUHDIOX[XOXLVDQJXLQ FXID܊DGHSHULRDGDDQWHULRDUă
32 10 12 12 2 4 4 2 2 2 10 30
0 5 10 15 20 25 30 35UTER FIBROMATOS METROPATIE ÎN CLIMAX DE/EfZsKZd CANCER DE COL UTERIN NEOPLASM ENDOMETRIAL WK>/Whcd/EK> sKZd^WKEdE (1'20(75,7Ă+(025$*,&ĂCHISTADENOCARCINOM 6$5&,1$(&723,&Ă&(59,&,7Ă&521,&Ă+(025$*,&Ă,DKZ'///^&hEf/KE>Ksh>dKZ// dƌĂƚĂŵĞŶƚƵůŚĞŵŽƐƚĂƚŝĐǀŝƚĂŵŝŶĂ<ĂĚŵŝŶŝƐƚƌĂƚ
pacientelor din lotul studiat
– 53 –

WUDWDPHQWXOXLÌQVăFRVWXULOHULGLFDWHDOHDFHVWXLSUHSDUDWLPS LHGLFăXWLOL]DUHDSHVFDUăODUJăFX
WRDWHFăUHGXFHVHPQLILFDWLYPHQRUDJLD܈LFRPSOLFD܊LLOHSHWHUP HQOXQJFXPDUILDQHPLD
3DFLHQWHOHFXPHWURSDWLHKHPRUDJLFăGLVIXQF܊LRQDOăGLQORWXOXL VWXGLDWGHPLQHDXIRVW
WUDWDWHFXSUHSDUDWHKRUPRQDOHWLPSvQGHOXQJDWODLQWHUQDUHDD FWXDOăILLQGQHFHVDUăDGPLQLVWUDUHD
GHHWDPVLODW܈LI itomenadion ă
&HOHGHSDFLHQWHFXPHWURSDWLH KHPRUDJLFăGLVIXQF܊LRQDOăDX IRVWLQYHVWLJDWHLPDJLVWLF
SULQHFRJUDILHWUDQVYDJLQDOăDVWIHOV -DHYLGHQ܊LDWRFDX]ăRUJDQLFăODSDFLHQWH3ULQWUHFDX]HOH
RUJDQLFHGHVFRSHULWHvQGHFXUVXO LQWHUQăULLDFWXDOHODSDFLHQWH OHGLQORWXOVWXGLDWVHQXPăUăSROLSLL
HQGRPHWULDOLGHIHFWHGHFRD JXODUH܈LILEURPVXEPXFRV
Prezen܊a de vitamina K1 sau f LWRPHQDGLRQă HVWHHVHQĠLDOăSHQWUXIRUPDUHDvQFDGUXO
RUJDQLVPXOXLGHSURWURPELQ ăIDFWRU9,,IDFWRUXO,; Ьi factorul X, ܈i a inhibitorilor de coagulare,
proteina C ܈iSURWHLQD6$FĠLXQHDILWRPHQDGLRQ HLHVWHPDLUDSLGăPDLLQWHQV ăúLPDLSUHOXQJLWă
decît a celorlalte vitamine K. 9LWDPLQD.DIRVWDGPLQLVWUDWăWXWXURUSDFLHQWHORUFXKHPRUDJLH 
XWHULQăGHFDX]ăJLQHFRORJLFă
ÎQ FD]XO DPHQLQ܊ăULL GH DYRUW FHO H  SDFLHQWH LQWHUQDWH DX EHQ HILFLDW GH WHUDSLD
PHGLFDPHQWRDVăKHPRVWDWLFăFXHWDPVLODW܈LILWRPHQDGLRQăDODWXU LGHPHGLFD܊LHDQWLVSDVWLFă
VkQJHUDUHDSHFDOHYDJLQDOăFkW܈LGXUHULOHSHOYL -abdominale au fost controlate succes, sarcina
ILLQGPHQ܊LQXWăIăUăSHULFRO
$FHVWHSDFLHQWHDXSULPLW܈LWUDWDPHQWKRUPRQDOFXSURJHVWDWLYH ÌQXUPDDQDPQH]HLDP
FRQVWDWDWFăPDLPXOWGHMXPDWDWHGLQWUHSDFLHQWHOHFXDPHQ܊DUH GHDYRUWDXVXIHULWvQWUHFXWXQ
avort spontan, aceste pacien WHILLQGVXEVXSUDYHJKHUHDVWULFWăDVSHFLDOL܈WLORU3ULQWUHID FWRULL
IDYRUL]DQ܊LDLDPHQLQ܊ăULLGHDYRUWDPFRQVWDWDWRIUHFYHQ܊ăFU HVFXWăODSDFLHQWHOHGLQORWXOVWXGLDW
DXWHUXOXLFLFDWULFLDOVDUFLQLLJHPHODUHLQIHF܊LLFURQLFHvQ VIHUDJHQLWDOăWXPRU i benigne anexiale
VDX XWHULQH ܈L IXPDWXO ÌQ DEVHQ ܊ă IDFWRULORU GH ULVF SHQWUX DP HQLQ܊DUH GH DYRUW ܈L DYRUWXUL
VSRQWDQHVWXGLLUHFHQWHVXJHUHD] ăFăIDFWRULLvQFULPLQD܊LvQDS DUL܊LDDYRUWXULORUVSRQWDQHUHFXUHQWH
SRWILDOWHUăULDOHH[SUHVLHLJHQHL+/$ -*܈i Ly-Th1 sau tratamentul prelugit cu antiagregante sau
anticoagulante.
– 54 –

'XSăDGPLQLVWUDUHDLQWUDYHQRDVă WLPSXOGHvQMXPăWăĠLUHSODVPDW LFăDOI itomenadionei este
de 2 -RUH'XSă -RUHGHODDGPLQLVWUDUHSURWURPELQDFUHúWHVXILFLHQWSHQWUXS URGXFHUHD
hemostazei.
În cancerul de col uterin s-a practicat ini ܊ial administrarea hemostaticelor, efectul acestora
ILLQGVFă]XWODFHOH de paciente, ulterior s-a efetuat FXUDRQFRORJLFăSDUWLFXODUL]DWăILHFDUXL
stadiu de cancer de col uterin.
Patologia RQFRORJLFăIUHFYHQăvQSHULRDGDFOLPDWHULFăHVWHQHRSODVPXOHQG RPHWULDOFHOH
SDFLHQWHGLQORWXOVWXGLDWDXEHQHILFLDWGHDGPLQLVWUDUHDGHYL WDPLQD.SHSDUFXUVXOLQWHUQăULLFD
adjuvant în oprirea hemoragiei ute rine în completarea tratament ului elaborat. Examenul histo-
SDWRORJLF D DUăWDW DVRFLHUHD  KLSHUSOD]LHL HQGRPHWULDOH OD DPEH OH SDFLHQWH DFHVWD ILLQG FX
FHUWLWXGLQHROH]LXQHSUROLIHUDWLYăSUHFDQFHURDVă
&HOHFD]XULGHHQGRPHWULWăKHPRUDJLFăDXEHQHILFLDWDOăWXULG HWUDWDPHQWXOKHPRVWDWLF
medicame QWRV GH DVRFLHUHD DQWLELRWLFRWHUDS LHL ܈L WUDWDPHQWXOXL DQWLDOJL F ÌQ DQWHFHGHQWHOH
SHUVRQDOHSDWRORJLFHDOHFHORU FD]XULHVWHFRQVHPQDWăHQGRPHW ULR]DDFHDVWDILLQGH[SOLFD܊LD
EROLLDFWXDOHHQGRPHWULWDHVWH RFRPSOLFD܊LHDHQGRPHWULR]HL FHDGLQXUPăVH poate ulcera. În
XUPDXOFHUD܊LHLHQGRPHWULR]HLV HSRWJUHIDJHUPHQLSDWRJHQL
ÌQFD]XOKHPRUDJLLORUXWHULQHLPSRUWDQWHGHWHUPLQDWHGHSUH]HQ܊ DSROLSLORUODQLYHOXO
cROXOXL XWHULQ VH DGPLQLVWUHD]ă ILWRPHQDGLRQă &RQGXLWD WHUDSHXW LFă DVRFLD]ă HIHWXDUHD
chiurHWDMXOXLXWHULQKHPRVWDWLF܈LELRSVLFDOăWXULGHSROLSHFWRPLH ([DPHQXOKLVWR -patologic al
IRUPD܊LXQLL SROLSRLGH HVWH LPSRUWDQW ܈L JKLGHD]ă DWLWXGLQHD WHU DSHXWLFă XUPăWRDUH HWLRORJLD
SROLSXOXL SRDWH IL HQGRPHWULR]L Fă OH]LXQH SUROLIHUDWLYă EHQLJQ ă VDX PDOLJQă ÌQ XUPD
LQYHVWLJD܊LLORUSROLSR]DDIRVW EHQLJQăvQFD] XOFHORUSDFLHQ WH
Hemoragiile disfunc ܊ionale ovulatorii par ܊ial cRQWURODWHSULQWHUDSLDKRUPRQDOă si acid
tranexamic, au beneficiat la un moment dat de administrarea eta msilatului pentru stoparea
hemoragiei, pacientele urmând sa fie investigate suplimentar. $FLGXO WUDQH[DPLF GHWHUPLQă
KHPRVWD]DSULQHIHFWXODQWLILEULQROLWLF&RQWUDLQGLFD܊LLOHDGPL QLVWUăULLDFHVWXLDVXQWKHPRUDJLL
LQWUDFDYLWDUHSULPXOWULPHVWU XVHVDUFLQă,5VHYHUă
– 55 –

Cevicita cr RQLFăKHPRUDJLFăHVWHRSDWRORJLHIUHFYHQWvQWkOQLWăPXOWLSOL IDFWRULHWLRORJLFL
ILLQGLPSOLFD܊LvQDSDUL܊LDDFHVWHLDSULQWUHFDUHLQIHFWLLOHFX WUDQVPLWHUHVH[XDOHSHQWUXFDUHQXD
IRVWLQVWLWXLWXQWUDWDPHQW܊LQWLW GDU܈LFDQFHUXOGHFROXWHUL Q
PrimulSDV HVWH HIHWXDUHD XQXL WHVW %DEH܈- Papanicolau implicit UHFROWDUHD VHFUH܊LHL
YDJLQDOHSHQWUXH[DPHQXOPLFURELRORJLFODSDFLHQWHOHODFDUHK HPRUDJLD HVWH DFWLYă VH YRU
administra hemostatice de tipul vitamina K. În lotul studiat a m identificat 8 paciente FXFHUYLFLWă
FURQLFăKHPRUDJLFăGHHWLRORJLHPDOLJQă
Tabelul 7.7.Tratamentul Hormonal adminis trat pacientelor din lotul studiat
3HQWUX DERUGDUHD WHUDSHXWLFă D ILEURPXOXL XWHULQ SULPXO SDV vO  UHSUH]LQWă WHUDSLD
KRUPRQDOăFXSURJHVWDWLYH܈LG anazol(agent sistemic cu activitate DQWLHVWURJHQLFă3URJHVWDWLYHOH
sunt administrate pe termen lung prin forma dispozitivu OXL FX HOLEHUDUH SUHOXQJLWă GH
lHYRQRJHVWUHO$JRQL܈WLLGH*Q -5KSRWILDGPLQLVWUD܊LSHRSHULRDGăYDULDELOăSUHRSHUDWRUvQ FD]XO
SDFLHQWHORUFDUHQHFHVLWăKLVW HUHFWRPLHODFDUHPLMORDFHOHWHU HSHXWLFHDSOLFDWHDQWHULRUDXH܈XDW
Cele 34 de paciente din lotul studiat cu diagnosticul de fibrom uterin au urmat timp îndelungat
WHUDSLHKRUPRQDOăFXSURJHVWHURQvQVăPHQR -PHWURUDJLLOHDXFRQWLQXDWVDDSDUăODXQPRPHQW
dat.7UDWDPHQWXOFXSURJHVWHURQHVWHI RORVLWSHQWUXSUHYHQ܊LDUHFLGL YHORUKHPRUDJLLORUXWHULQH܈L
nu pentru tratamentul acum al acestora.
0HWURSDWLDKHPRUDJLFăGLVIXQ܊LRQDOăHVWHIRDUWHIUHFYHQWăvQUk QGXOSDFLHQWHORUDIHFWkQG
toate intervalele de vârsta di QSUHPHQRSDX]ă3URJHVWDWLYHOH PRQRID]LFHDXIRVWIRORVLWHFXTratamentul Hormonal administrat pacientelor din lotul studiat
Uter Fibromatos (Danazol/ Progestative) 34
Metropatie +HPRUDJLFă'LVIXQF ЮLRQDOă
-Progestative
– Estrogeni28
10
13
AmeniQ܊DUHGHD vort(Progesteron) 10
– 56 –

succes pentru oprirea hemoragiei uterine la 10 paciente din lot ul studiat cu metropatie
KHPRUDJLFă GLVIXQF܊LRQDOă ÌQ FD]XO DFHVWRU SDFLHQWH KHPRUDJLD D IRVW GH LQWHQVLWDWH PHGLH
asociindu-se a GPLQLVWUăULLGHSURJHVWDWLYH܈LW HUDSLDDQWLDQHPLFăLPSUHXQăFX YLWDPLQRWHUDSLH
5HDF܊LLDGYHUVHPLQRUHFDXXUPDUHDWUDWDPHQWXOXLFXSURJHVWDWL YHDXDSDUXWODSDFLHQWH
DFHVWHDSUH]HQ܊kQGRXVRDUăFUH܈W HUHDWHQVLXQLLDUWHULDOH
Metropatiile KHPRUDJLFHGLVIXQF܊LRQDOHFHDXGHWHUPLQDWDSDUL܊LDXQHLKHPRUD JLLFXGHELW
mare au fost tratate de prim DLQWHQ܊LHFXDGPLQLVWUDUHDGHHVWRJHQLFRQMXJD܊LSUHPDULQvQ GR]ă
de 14mg i.v. la 4 ore. 6WXGLLOHFOLQLFHDXDUăWDWFăVHREĠLQFRQFHQWUDĠLLVDQJYLQH DVH PăQăWRDUH
SULQWRDWHFăLOHGHDGPLQLVWUDUH .
(YROX܊LDDIRVWEXQăGRDUvQFD]XODSDFLHQWHGLQORWXOVWXGL DWFDUHQXDXSUH]HQWDW
UHFXUHQ܊HSHSDUFXUVXOLQWHUQăULL&HOHSDFLHQWHFDUHDXSUH] HQWDWUHFXUHQ܊HKHPRUDJLFHDX
beneficiat de tehnica de d LVWUXF܊LHDEOD܊LH HQGRPHWULDOă DFHVWHD QHJkQG GRULQ܊D XQHL VDU FLQL
YLLWRDUH'LQWRWDOXOGHSDFLHQWHWUDWDWHFXHVWURJHQLSH UVRDQHDXSUH]HQWDWUHDF܊LLDGYHUVH
X܈RDUHSUHFXPFHIDOHH܈LJUHD܊ăYHUWLM
În lotul studiat de mine 10 paciente internate DXSUH]HQWDWDPHQLQ܊DUHGHDYRUWVDUFLQDD
IRVWSDVWUDWăODWRDWHSDFLHQWHOHFXDFHDVWăSDWRORJLH$XIRVW DGPLQLVW rate cu succes progestative
( uWURJHVWUDQDOăWXULGHDQWL VSDVWLFH܈LUHHFKLOLEUDUHKLGUR -HOHFWUROLWLFă8QQXPăUGHSDFLHQWH
au necesita WDGPLQLVWUDWHDGHWRFROLWLFHSHQWUXGLPLQXDUHDVLPSWRPDWRORJLH LGXUHURDVHDSăUXWăFD
XUPDUHDFRQWUD܊LLORUXWHULQHGXUHURDVH3LHUGHULOHVDQJXLQHDX IRVWvQFDQWLWDWHPLFăVDXPHGLH
VWDELOL]DUHDSDFLHQWHORUQXDQHFHVLWDWWUDQVIX]LLGHVkQJHVDX GHULYD܊L .
– 57 –

Figura 7.10. Tratamentul hormonal administrat pacientelor din lotul studiat
Conform figurii 7.10 administrarea tratamentului hormonal s-a ef ectuat în 51% din cazuri
SHQWUXXWHUILEURPDWRV7UDW DPHQWXOFXDJRQL܈WLGH*Q -Rh a fost administrat pacientelor la care
WHUDSLDVLPSOăFXSURJHVWDWLYHDH܈XDW 0HFDQLVPHOHGHDFĠLXQHD OGDQD]ROXOXLQXVXQWSHGH plin
cunoscute; o serie de studii au investigat diferite verigi fizi opatologice posibil atacate de danazol
sunt:
– Reducerea fluxului arterial uterin,- Atrofierea endometrului – WUDWDPHQWGHOXQJDGXUDWă
– Reducerea nivelurilor circulante ale E2 – Danazolul a f RVWLQFULPLQDWD DFĠLRQD SULQ
VFăGHUHDFRQFHQWUDĠLHLVHULFHDKRUPRQLORUHVWURJHQL
– Efecte androgenice – 'DQD]ROXO VH OHDJă úL WUDQVORFKHD]ă UHFHSWRULL DQGURJHQLFL HO
GHSODVHD]ăWHVWRVWHURQXOGHSHJ OREXOLQDFDUHOHDJăKRUPRQLLVH [XDOL6+%*UHGXFH
Uter fibromatos (
ĂŶĂnjŽůͬWƌŽŐĞƐƚĂƚŝǀĞͿ
51% ŵĞŶŝŶƜĂƌĞĚĞĂǀŽƌƚ;
WƌŽŐĞƐƚĞƌŽŶͿ
15%

Estrogeni
19%
WƌŽŐĞƐƚĂƚŝǀĞ
15% Metropatie
,ĞŵŽƌĂŐŝĐĉ
ŝƐĨƵŶĐƜŝŽŶĂůĉ
39% dZdDEdh>,KZDKE>D/E/^dZdW/Ed>KZ
/E>Kdh>^dh/d
hƚĞƌĨŝďƌŽŵĂƚŽƐ;ĂŐŽŶŝƕƚŝĚĞ'Ŷ -ZŚͿ
ŵĞŶŝŶƜĂƌĞĚĞĂǀŽƌƚ;WƌŽŐĞƐƚĞƌŽŶͿ
ƐƚƌŽŐĞŶŝ
WƌŽŐĞƐƚĂƚŝǀĞ
– 58 –

OHJDUHDWHVWRVWHURQXOXLGH6+%* $UHúLHIHFWHDQGURJHQLFHSHUL IHULFHILHSULQDFĠLXQH
GLUHFWăILHSULQPHWDEROLĠLLVăL
O parte din pacientele lotului s tudiat au tratate cu Progestero n pe termen lung în vederea
SUHYHQ܊LHLUHFLGLYHORUVXEIRUPDGHGLVSR]LWLYLQWUDXWHULQFX HOLEHUDUHOHQWăGH/HYRQRJHVWUHO
5HDFĠLLDGYHUVHKHPRUDJLLOHLQWHUPHQVWUXDOHúLVHQVLELOLWDWHD VkQLORU . Cu toate acestea, DIU cu
levonoJHVWUHODVLJXUăRVDWLVIDFĠLHPDLPDUHIDĠăGHWHUDSLDSURJHVWH URQLFăFODVLFă&RVWXULOH
WUDWDPHQWXOXLVXQWPDLPDULGDUVHDPRUWL]HD]ăvQWLPSvQWUXF kW',8FXOHYRQRUJHVWUHOVHLQVHUă
RGDWăODDQL
Studii în domeniu au comparat DIU cu levono JHVWUHO FX UH]HFĠLD WUDQVFHUYLFDOă D
HQGRPHWUXOXL7&5(DDUăWDWU H]XOWDWHLQIHULRDUHDOH',8 -LNG (reducerea fluxului menstrual cu
IDĠăGHOD7&5(FXRUDWăPDLVFă]XWăGHDPHQRUHHvQ VFKLPEQXV -DXJăVLWGLIHUHQĠH
vQWUHVDWLVIDFĠLDSDFLHQWHORUIDĠăGHFHOHGRXăWHUDSLL3DFLHQ WHOHFX',8 -/1*DXDYXWUHDFĠLL
adverse legate de administrarea progestativelor, ce nu s- DXUHJăVLWODFHOHFX7&5( Concluzie:
DIU-/1*QXVXQWODIHOGHHILFDFHFX7&5(DXXQUDQGDPHQWPDLPLF GDUDXRVDWLVIDFĠLH
HJDOăGLQSDUWHDSDFLHQWHORU
Compararea DIU- /1*FXKLVWHUHFWRPLDFHOHGRXăVXQWHJDOHvQWHUPHQL de calitatea
YLHĠLL&RVWXULOHJO REDOHDXIRVWGHRULPD LPDULODKLVWHUHF WRPLHIDĠăGHJUXSXO',8 -LNG.
În ansamblu, DIU- /1* SDUH D IL ELQH WROHUDWă LHIWLQă VDWLVIăFăWRDUH vQ WHUPHQL G H 
FDOLWDWHDYLHĠLL
&HOHPDLLPSRUWDQWHH[DPLQăULSDUDFOLQLFHHIHFW uate pacientelor cu fibrom uterin din lotul
studiat sunt: ecografia trans- YDJLQDOăFKLXUHWDMXWHULQIUDF ܊LRQDWKHPRVWDWLF ܈LELRSWLFH[ DPHQHGH
ODERUDWRU6WUDWHJLDWHUDSHXWLFăDIRVWDGDSWDWăILHFDUXLFD] GHSULPDLQWHQ܊LHILLQGWUDWDPHQWXO
medicamento V FX SUHSDUDWH KRUPRQDOH &X PLFL H[FHS܊LL SDFLHQWHOH DX QHFHV LWDW WUDWDPHQW
antianemic.
(VWURJHQLLDXIRVWDGPLQLVWUD܊LvQSURSRU܊LHGHSDFLHQWHORU FXPHWURSDWLHKHPRUDJLFă
GLVIXQF܊LRQDOă(VWURJHQLLVXQWU H]HUYD܊LSDFLHQWHORUvQDFWLYL WDWHJHQLWDOăIH PHLOHODPHQRSDX]ă
DYkQGFRQWULQGLFD܊LHDEVROXWă7 RDWHSDFLHQWHOHDXIRVWLQYHVWL JDWHHFRJUDILFSHQWUXH[OXGHUHD
XQHLVDUFLQLVDXDXQHLIRUPD܊L XQLWXPRUDOHXWHULQHvQDLQWHDvQ FHSHULLWUDWDPHQWXOXLFXHVWURJHQL
– 59 –

GR]DUHDȕ -HCG-ului a fost de asemenea u WLOăvQH[SOXGHUHDXQHLVDUFLQL3ULQDQDOL]DUHDIRLORUGH
REVHUYD܊LHDPLGHQWLILFDWSUH]HQ܊DIDFWRULORUGHULVFvQFULPLQD ܊LFHLPDLIUHFHYHQWFDUHDXFRQGXV
ODSDWRORJLDDFWXDOă)DFWRULLGHULVFLGHQWLILFD܊LODSDFLHQWH OHORWXOXLVWXGLDWFXKHPRUDJLHXWHULQă
GLVIXQF܊LRQDOăVXQWIXPDWXO܈LD IHF܊LXQLJLQHFRORJLFHKRUPRQDO HvQDQWHFHGHQWH6WXGLLOHFOLQLFH
vQGRPHQLXDXDUăWDWIUHFYHQ܊DFUHVFXWă܈LDDOWRUIDFWRULGHU LVFLPSRUWDQWLvQDIDUăGHFHL
PHQ܊LRQDWLPDLVXVFHOPDLIUHFYHQWILLQGREH]LWDWHD3HVWH MXP ăWDWHGLQSDFLHQWHOHWUDWDWHFX
preparate hormonale estrogenice au necesitat tratament de linia a doua, minim invaziv, pentru
sistarea hemoragiei.
Progestativele au fost administrate pacientelor din lotul studi at în vederea opririi
hemoragiei provocat HGHPHWURSDWLDKHPRUDJLFăGLVI XQF܊LRQDOă3UHSDUDWHOHKRUPRQDO HSHED]ă
de progesteron au fost urmate de succes în oprirea hemoragiei u terine la toate pacientele
VHOHF܊LRQDWH&D܈LvQFD]XOHVW URJHQXOXLSURJHVWHURQDUHFRQW UDLQGLFD܊LHDEVROXWăGHDGPLQL strare
vQVDUFLQă
&RQIRUPVWXGLLORUGHVSHFLDOLWDWHSUHYHQ܊LDUHFLGLYHORUGHKHPR UDJLH XWHULQăvQFD]XO
PHWURSDWLLORU KHPRUDJLFH GLVIXQF܊LRQDOH VH SRDWH UHDOL]D SULQ U H]HF܊LH HQGRPHWULDOă
SHUKLVWHURVFRSLFăFXUH]XOWDWHVXSHULRDUHLPSODQWăULLGHVLVWH PLQWUDXWHULQFXHOLEHUDUHOHQWăGH
levonogestrel.
Un procent de 15% corespunde ane PLQ܊ăULORUGHDYRUWWUDWDWHFXS rogesteron. Conduita
WHUDSHXWLFăvQDFHVWHFD]XULHVWHPL[WăDVRFLLQGSUHSDUDWHORU KRUPRQDOHDQWLVSDVWLFH܈LDQWLDOJLFH
Î n c a z u r i l e î n c a r e KHPRUDJLDXWHULQăHVWHLPSRUWDQWăVHYRUDGPLQLVWUDWKHPRVWDWLF HGHWLSXO
YLWDPLQD . ܈L DGPLQLVWUDUH GH VROX܊LL PDFURPROHFXODUH LDU OD QH YRLH WUDQVIX]LL GH VkQJH
(WLRSDWRJHQLDDYRUWXOXLVSRQWDQH VWHYDVWăDPHQLQ܊DUHGHDYRUW HVWHXQVHPQDOGHDODUPă
ceQHFHVLWă R PXOWLWXGLQH GH LQYHVWLJD܊LL GH VSHFLDOLWDWH SHQWUX D  GHVFRSHUL VXEVWUDWXO
morfopatologic.
– 60 –

Tabelul 7.8. Tratament hemostatic cu uterotonice
8QQXPăUGH de pacient HDXSUH]HQWDWVkQJHUăULLQOHKX]LDLPHGLDWăODMXPăWDWHGLQWU H
DFHVWHSDFLHQWHFDX]DGHWHUPLQDQ WăILLQGKLSRWRQLDDWRQLDXWHUL QD
5HIHULWRUODIDFWRULLGHULVFSHQWUXDWRQLDXWHULQăSRVW -partum, în lotul de paciente analizat
DPLQGHQWLILFDWSDFLHQWHFXSROLKLGUDPQLRV܈LIăWPDFURVRPF DUHDXSUH]HQWDWDWRQLHXWHULQă
$WRQLDXWHULQăHVWHRFRQGL܊LHJUDYDFDUHQHFHVLWăLQVWLWXLUHDW Uatamentului specific de urgen ܊ă.
+HPRUDJLLLPSRUWDQWHvQSRVWSDUWXPDXDSăUXWODSDFLHQWHGLQ ORWXOVWXGLDWFXQRVFXWHFX
ERDODYRQ:LOOHEUDQG'XSDFRQWUR OXOPDQXDODOFDYLWă܊LLXWHULQ HDXIRVWH[WUDVHUHVWXULSODFHQWDUH
la 3 paciente ce au acuzat hemoragie postpartum. În cazul rupt urLORUGHSăUWLPRLDVRFLDWHVH
HIHFWXHD]ăVXWXUDDFHVWRUD începând de la unghiul s uperior al leziunilor ܈Lcontinuând distal.
&RQGXLWDPHGLFDOăFRQVWăvQDGPLQ LVWUDUHDXWHURWRQLFHORULQYHG HUHDUHDOL]ăULLKHPRVWD]HL
6HDGPLQLVWUHD]ă ca prima linie terapeut LFăRFLWRFLQăvQSHY UIvQPOVHUIL]LRORJLF܈L
prostaglandine (15-me til prostaglandina F2 Į PJLPDFHDVWăVWUDWHJLHWHUDSHXWLFăDIRVW
DSOLFDWăODSDFLHQWHFXKHPRUDJLHSRVWSDUWXP
La 2 paciente s-a asociat admin istrarea de metilergmetril(0,5mg i.v lentGR]ăPD[LPD
mg)܈i prostaglandine (15-metil prostaglandina F2 Į0,25mg i.m).
$OăWXULGHPHGLFD܊LDXWHURWRQLFăVHDGPLQLVWUHD]ăDFLGW ranexamic 1g i.v lent în 10 minute
LDUvQXUPăWRDUHOHKVHSRDWHDG PLQLVWUDJ܈LVHYDHIHFWXD PDVDMXO uterin.Tratament hemosta tic cu Uterotonice
Hemoragii post-partum 10
Avort incomplet 4
(QGRPHWULWă3RVW -partum 2
3ODFHQWă3UDHYLD 12
IminenЮă'H5XSWXUă8WHULQă 2
(QGRPHWULWă3RVWDSDUWXP 2
– 61 –

ÌQIXQF܊LHGHYROXPXOGHVkQJHSLH UGXW܈LGHVWDWXVXOSDFLHQWH VHYDUHVWDELOLYROXPXOGH
VkQJHSLHUGXWSULQDGPLQLVWUDUHDGHVROX܊LLFULVWDORLGH܈LWUDQ VIX]LLGHVkQJH3DFLHQWHOHQHFHVLWă
R[LJHQRWHUDSLHSHPDVFăGHELWGH -OPLQXW܈LDGPLQLVWUD re de calciu gluconic. Protocolul utilizat
în cazul pacientelor care au pierdut peste 2000 ml de sânge cup rinde 4-XQLWăWLGHFRQFHQWUDW
HULWURFLWDUFULRSUHFLSLWDWXQ LWăWLODQHYRL HXQLWDWHGHF RQFHQWUDWGHSODFKHWH
ÌQFLXGDPăVXULORUWHUDSHXWLFHD plicate celor 10 paciente din lotul studiat cu hemoragii
postpartum, 6 dintre acestea au ne cesitat efectuarea histerecto miei de hemostaza.
Pentru restabil LUHDYROXPXOXLVDQJXLQDXIRVWXWLOL]DWHVROX܊LL cristDORLGHFRORLGH܈L sânge.
3ODVPăSURDVSăWăFRQJHODWă -PONJFFDQGWLPSLLGHFRDJXODUH VXQWSHVWHQRUPDOXO0DVă 
WURPRELWDUăXNJFDQG7!FULRSUHFLSLWDWXNJFFDQG ILEULQRJHQXOHVWH!PJGO
Terapia frac ЮLRQDWDSODVPăIDFWRULGHFRDJXODUH7(
Tratamentul cu uterotonice a IRVWDGPLQLVWUDWODSDFLHQWHFXKHPRUDJLHXWHULQăGDWRUDWă
DYRUWXOXLLQFRPSOHWHIHFWXDWDIODWHvQWULPHVWUXGHVDUFLQă 7HUDSLDFRQVWăvQDGPLQLVWUDUHDGH
(UJRPHWPDOHDW GH HUJRPHWULQă HIHFXDUHD FKLXUHWDMXOXL XWHULQ HYDFXDWRU ܈L KHPRVWDWLF
administUDUHGHDQWLELRWLFHvQVFRSSURILO DFWLF܈LPHGLFD ܊LHDQWLDOJLFă 
ÌQ XUPD LQYHVWLJD܊LLORU HIHFWXDWH vQ GHFXUVXO LQWHUQăULL DFWXDO H XQD GLQWUH SDFLHQWHOH
WUDWDWHDIRVWGLDJQRVWLFDWăFX RIRUPD܊LXQHEHQLJQăODQLYHO RYDULDQ3ULQLQWHUPHGLXOHFRJUDILHL
eIHFWXDWHSDFLHQWHLvQYkUVWăGHGHDQLDIRVWGHVFRSHULWXQ FKLVWHQGRPHWULR]LFVWkQJDFHDVWă
neavând un istoric ginecologic se mnificativ. Celelalte paciente cu diagnosticul de avort incomplet
HIHFWXDWVHDIODXvQWULPHVWUXO GHVDUFLQăSURFHGXUDWHUDSHX WLFăILLQGDFHHD܈L
'LQORWXOVWXGLDWSDFLHQWHDX GH]YROWDWHQGRPHWULWăSRVWSDUWX PvQD -a respectiv a 6-a zi
GHOHKX]LH/DH[DPHQXOFOLQLFSDFLHQWHOHDXSUH]HQWDWIHEUăV WDUHJHQHUDOăDOWHUDWă܈LORKLL
maronii,fetide. La ecografie au fost ident LILFDWHSUH]HQ܊DDEFHVHORU ܈LUHVWXULORUFRWLOHGRQDUH
Tratamentul administrat acestor paciente cuprinde: e UJRPHW DQWLLQIODPDWRULL ܈L
DQWLELRWHUDSLHFXVSHFWUXODUJȕ -ODFWDPLGHDPLQRJOLFR]LGHPHWURQLGD]RO3DFLHQWHOHVXQW܊LQXWH
VXEREVHUYD܊LHLDUGXSă ]LOHGHDIHEULOLWDWHV -DHIHFWXDWFKLXUHWDMXWHULQHYDFXDWRUHYROX܊LD
XOWHULRDUăILLQGEXQă
– 62 –

8WHURWRQLFHOHDXIRVWDGPLQLVWUDW H܈LvQFD]XODGRXDSDFLHQWH FXLPLQHQ܊ăGHUXSWXUă
XWHULQă7RDWHLQIRUPD܊LLOHFXOHV HGLQDQDPQH]DDFHVWRUSDFLHQW HFRURER rate cu statusul actual, au
condus la decizia de efectuare a h isterectomiei. Cele 2 pacient e aveau uter cicatricial, una dintre
HOHILLQGPXOWLSDUă LDUFHDODOWăDYkQGRV DUFLQăJHPHODUă
Cele 12 paciente din lotul studi at de mine cu placenta praevia au neFHVLWDWRSHUD܊LD
FH]DULDQăvQXUPDKHPRUDJLHLGHLQWHQVLWDWHFUHVFXWăVDXGDWRU LWăSDWRORJLLORUXWHULQHDVRFLDWH
SUHFXPILEURPDWR]DXWHULQăVDXVLQHFKLLOHXWHULQH
7UDWDPHQWXOXWHURWRQLFDIRVWDGPLQLVWUDWFHORUSDFLHQWHFX SODFHQWDSUDHYLDDOăWXULG e
FDOFLXJOXFRQLFGH[DPHWD]RQăDQWLLQIODPDWRULLVLWHUDSLHSURI LODFWLFăDQWLELRWLFăÌQDFHVWHFD]XUL
SLHUGHUHDYROHPLFăVDQ JXLQăHVWHLPSRUWDQWăV -DXDGPLQLVWUDWVROX܊LLFULVWDORLGH܈LWUDQVIX]LLGH
VkQJH8QQXPăUGHSDFLHQWHFXSODFHQWDSUHDYLDDXQHFHVLWDW WHUDSLHIUDF܊LRQDWăFXSODVPă
SURDVSăWăFRQJHODWăIDFWRULGH FRDJXODUHWURPERFLWH܈LHULWUR FLWH
Figura 7.11. Tratament hemostatic cu uterotonice
33%
13%
7%
40%
7% Tratament hemostatic hormonal cu uterotonice
,ĞŵŽƌĂŐŝŝƉŽƐƚͲƉĂƌƚƵŵ
Avort incomplet
(QGRPHWULWăSRVWSDUWXP
3ODFHQWă3UDHYLD
,PLQHQ܊ă'H5XSWXUă8WHULQă
– 63 –

Uterotonicele sunt folosite în 33% din cazuri pentru management ul hemoragiilor post-
partum. $FHVWHWLSXULGHKHPRUDJLLQHFHVLWăRDWHQ܊LHVSRULWăDPHGLFXO XLFDUHWUHEXLHVăHYDOXH]H
SURPSWXUPDWRDUHOHFRQGLWLLSDWRORJLFHDWRQLDXWHULQăWUDXPDWL VPGHSăUWLPRLUXSWXULYDJLQDOH
care se pot propaga la segmentul in ferior), resturi tisulare in trautHULQH܈LHYHQLPHQWHWURPERWLFH
Un studiu clinic randomizat realiz DWvQ7DLZDQFRPSDUăHILFLHQ܊DP isoprostolului versus
2FLWRFLQăvQWLPSXOGHOLYUHQ܊HL܈ LGXSăDFHDVWDSHQWUXGLPLQXDU HDKHPRUDJLLORUSRVW -partum.
Acest studiu s- DHIHFWXDWSHXQQXPăUGHGHSDFLHQWHFDUHDXQăVFXWSULQR SHUD܊LHFH]DULDQă
IăUăDQVWH]LHJHQHUDOă&RQIRUPDFHVWXLDDGP inistrarea de m LVRSURVWROVXEOLQJXDOGHWHUPLQăR
VFDGHUHVHPQLILFDWLYPDLPDUHDSLHUGHULORUGHVkQJHODSDFLHQW HOHORWXOXL$ID܊ăGHSDFLHQWHOH
lotului B t UDWDWHFXRFLWRFLQăP DLDOHVvQWLPSXORS HUD܊LHLFkW܈LGXSă RUH2FLWRFLQDDUHHIHFWQHW
VXSHULRUvQSUHYHQ܊LDXQHL KHPRUDJLLLPSRUWDQWH
&RPSDUkQGYDORULOHKHPDWRFULWXOXLvQDLQWH܈LGXSDLQWHUYHQ܊LH DFHVWHDDXIRVWVLPLODUHOD
ambele grupuri analiza WH'LIHUHQ܊HVWDWLVWLFHQHVHPQLI LFDWLYHDXIRVW܈LvQFD]XODS DUL܊LHLIHEUHLÌQ
grupul tratat cu o FLWRFLQăDXDSăUXWUHDF܊LLDGYHUVHIUHFYHQWHGHWLSXOJUH܊ăFH IDOHHDPH܊HDOă
comparativ cu grupul tratat cu m LVRSURVWROXQGHFDUHDF܊LHDGYHUVăIUHFYHQWă apare gustul metalic.
Conform figurii 7.11 FHD PDL IUHFYHQWă SDWRORJLH FDUH QHFHVLWă DGPLQLVWUDUHD
uterotonicelor în lotul s tudiat de mine este pla FHQWDSUDHYLDvQSURSRU܊LHGH %.
'HPXOWHRULDFHDVWăSDWRORJLH SXQHvQSHULFROYLD܊DSDUWXULHQW HL܈LFR nduce spre sechele
IXQF܊LRQDOH SUHFXP VWHULOLWD WHD FH HVWH GREkQGLWă SRVW -histerectomie. Conform unui studiu
publicat în Londra s-a evaluat eficacitatea unei tehnici altern ative chirurgicale pentru a evita
KLVWHUHFWRPLDGHQHFHVLWDWH $FHDVWăWHKQLFăGHQXPLWă -P presupune incizia uterului la nivelul
LQVHU܊LHL VXSHULRDUH D SODFHQWHL H[WUDJHUHD IăWXOXL GHYDVFXOD UL]D܊LH SHOYLFă SDU܊LDOă H[FL]LD
PLRPHWUXOXLFXSODFHQWD܈LUHF RQVWUXF܊LDSHUHWHOXLXWHULQ
Majoritatea avorturile spont ane sunt sporadice, boala DERUWLYăDIHFWkQGPDLSXWLQH
GLQSRSXOD܊LDJHQHUDOăHWLRORJLDH VWHFRPSOH[ă܈LFRQWURYHUVDW ă
Diagnoscticul de avort incomplet efectuat este prezent la 13% d in pacientele tratate cu
XWHURWRQLFH FRQGXLWD WHUDSHXWLFD PHGLFDPHQWRDVă DVRFLD]ă DQWLE LRWHUDSLH ܈L UHHFKLOLEUDUH
– 64 –

KHPRGLQDPLFăVROX܊LLPDFURPROHFXODUHVkQJH܈LSUHSDUDWHGLQV kQJHÌQXUPDGHWHUPLQăULL5K –
XOXLQXDIRVWQHFHVDUăDGPLQLVWUDUHDGH,JDQWL -D, pacientele analizate fiind Rh pozitive.
8QSURFHQWGHGLQWUHSDFLHQWHDXIRVWGLDJQRVWLFDWHFXHQGRP HWULWăSRVW -partum, în
primele zile de lehuzie. Paraclinic în mod specific markerii LQIODPDWRULVXQWFUHVFX܊LSURWHLQD&
UHDFWLYăILEULQRJHQ96+$UVHQDOXOWHUDSHXWLFDGPLQLVWUDWHVW HIRUPDWGLQDQWLELRWLFHFXVSHFWUX
ODUJXWHURWRQLFHPHGLFD܊LHDQ WLLQIODPDWRDUH܈LDQWLDOJLFă
Tabel 7.9. Chiuretajul XWHULQKHPRVWDWLFЮLELRSVLFH IHFWXDWSDFLHQWHORUGLQORWXOVW XGLDW
Chiuretajul uterin a fost efectuat în cazul în care alte mijloc e terapeutice aplicate
pacientelor din lotul studiat nu au fost VXILFLHQWHSHQWUXDRSUL KHPRUDJLDJHQLWDOă
&HOHPDLPXOWHGLQWUHSDFLHQWHOHFăURUDOH -DIRVWDSOLFDWăSURFHGXUDVXIHUăGHILEURP
XWHULQDPFRQVWDWDWFD]XULF XDFHDVWăSDWRORJLHÌQFD]XOF HORUSDFLHQWHFXDYRUWVSRQWDQ
chiuretajul uterin are rol PXOWLSOXKHPRVWDWLFHYDFXDWRU܈LvQSUHYHQ܊LDDSDUL܊LHLFRPSO LFD܊LLORU
septice.
ÌQFD]XOFHORUSDFLHQWHFXGL VSOD]LHFHUYLFDOăUROXOFKLXUH WDMXOXLXWHULQQXVHUH]XPăOD
KHPRVWD]ăDYkQGGHDVHPHQHDVF RSXOGHDDQDOL]DPDWHULDOXOUHF ROWDW܈LGHDL dentifica etiologia
DIHF܊LXQLLDFWXDOH0DWHULDOXOELRORJLFUHFROWDWYDILDQDOL]DW GHFăWUHDQDWRPR -patolog, iar în
IXQF܊LHGHUH]XOWDWHOH RE܊LQXWHVHYDDGRSW DFRQGXLWDWHUDSHXW LFăVSHFLILFăChiuretajul uter in hemostatic ܈i biopsic efectuat pacien telor din lotul studiat
Uter fibromatos 18
0HWURSDWLHKHPRUDJL FăGLVIXQFWLRQDOă 6
Metropatie în climax 4
Hiperplazie e QGRPHWULDOă 2
Polip acuЬat în col 6
Avort spontan 10
(QGRPHWULWăKHPRUDJLFă 2
6DUFLQăPRODUă 2
Displazie cervical ă 12
– 65 –

6HRE܊LQHKHPRVWD]ăHILFLHQWăFXDMXWRUXOFKLXUHWDMXOXLXWHULQ ODXQQXPăUGHGH
SDFLHQWHGLQORWXODQDOL]DWFHVXIHUăGHGLIHULWHSDWRORJLLGLQ WUHFDUHPHWURSDWLLOHKHPRUDJLFH
GLVIXQF܊LRQDOH܈LFHOHGLQFOLPD[SHQWUXFDUHV -DXHIHFWXDWXQQXPăUGHFKLXUHWDMHvQVFRSSXU
hemostatic), iar celelate condi ܊LLSUHFXPVDUFLQăPRODUăFD]XULHQGRPHWULWăKHPRUDJLFă
FD]XULSROLSDFX܈DWvQFRO FD]XUL܈LKLSHUSOD]LHHQGRPHWUL DOăFD]XULEHQHILFLD]ăGHVFRSXO
multiplu-KHPRVWDWLF܈LELRSVLFDOFKLXUHWDMXOXLXWHULQ
Figura 7.12. Chiuretaj uterin hemostatic si biopsic
6WXGLLQGIL܈HOHSDFLHQWHORUDPREV HUYDWXQQXPăUPDUHGHFD]XUL GHILEURPXWHULQFHDX
EHQHILFLDWGHFKLXUHWDMXWHULQL QVFRSKHPRVWDWLF܈LELRSVLFR FXSkQGXQSURFHQWGHGLQ
WRWDOXO FKLXUHWDMHORU XWHULQH UHDOL]DWH $FHDVWă SURFHGXUă HVWH  IUHFYHQWă GDWRULWă FRQWUROXOXL
insuficient a hemoragiei uterine prin tratament medicamentos în cazul fibroamelor uterine
agresive.
În figura 7.12 VHREVHUYăXQSURFHQWGHH JDOvQWUHFKLXUHWDMHORUXWHULQH HIHFWXDWH
SHQWUXPHWURSDWLHKHPRUDJLFăGL VIXQFWLRQDOă܈LSROLSDFX܈DWLQ FRO
29%
10%
7%
3%
10%
16%
3%
3%
19% ŚŝƵƌĞƚĂũƵůƵƚĞƌŝŶŚĞŵŽƐƚĂƚŝĐƕŝďŝŽƉƐŝĐĞĨĞĐƚƵĂƚ
pacientelor din lotul studiat
Uter Fibromatos
0HWURSDWLH+HPRUDJLFă'LVIXQFWLRQDOă
Metropatie În Climax
+LSHUSOD]LH(QGRPHWULDOă
WŽůŝƉĐƵƕĂƚ2ŶŽů
Avort Spontan
(QGRPHWULWă+HPRUDJLFă
6DUFLQă0RODUă
Displazie Cervicala
– 66 –

8QQXPăUOLPLWDWGHFD]XULFHDXIRVWLQWHUQDWHSHQWUXKHPRUDJL HXWHULQăDXGLDJQRVWLFH
SUHFXP VDUFLQă PRODUă KLSHUSOD ]LH HQGRPHWULDOă ܈L HQGRPHWULWă  KHPRUDJLFă )LHFDUH GLQWUH
DFHVWHSDWRORJLLDXRLQFLGHQ܊ăVFD]XWăGHFRPSDUDWLYFX UHVWXODIHF܊LXQLORUFHGHWHUPLQă
KHPRUDJLHXWHULQăSHQWUXFDUHV -a efectuat chiuretaj utrin.
Din totalul chiuretajelor uterine, 19% au fost efectuate in caz ul displaziilor cervicale în
YHGHUHDGLPLQXăULLVD XVLVWăULLKHPRUDJLHLLDUSHGHDOWăSDUW HSHQWUXHOXFLGDUHD etiologiei, de cele
PDLPXOWHRULDFHDVWDILLQGWXPRUDOăPDOLJQă
7UDWDPHQWXOGHHOHF܊LHHVWHFKLXUHWDMXOXWHULQSHQWUXGLQWU HSDFLHQWHOHORWXOXLVWXGLDW
FHDXIRVWLQWHUQDWHSHVHF܊LDGHREVWHWULFă -ginecologie cu diagnosticul de avort spontan. În urma
procedurii, s- DSURGXVKHPRVWD]ăHILFLHQWă܈LH YDFXDUHDPDWHULDOXOXLELRORJLF FXSRWHQ܊LDOVHSWLF
Un procent de 7% dintre pacientele analizate cu diagnosticul de metropatie în climax au
UăVSXQVIDYRUDELOFKLXUHWDMXOXLXW HULQVLWHUDSLHLFRPSOHPHQWDU HKHPRUDJLDXWHULQăVLVWkQGX -se.
Tabelul 7.10. +LVWHUHFWRPLH VXEWRWDOăWRWDOă F X DQH[HFWRPLH HIHFWXDWă SDFLHQW HORU GLQ ORWXO
studiat
7UDWDPHQWXOFKLUXUJLFDOHVWHRSURFHGXUăGHXOWLPăLQWHQ܊LHvQ PDQDJHPHQWXOKHPRUDJLLORU
uterine. +LVWHUHFWRPLD D IRVW HIHFWXDWă vQ FD]XO SDFLHQWHORU FDUH QX DX UDVSXQV IDYRUDELO OD
administrarea tratamentului medicamentos, dovedindu- VHDILVROX܊LDVDOYDWRDUHvQDFHVWHVLWXD܊LL+LVWHUHFWRPLHVXEWRWDOăWRWDOăF XDQH[HFWRPLHHIHFWXDWăSDFLHQW HORUGLQORWXOVWXGLDW
Uter fibromatos 16
Neoplasm endometrial 2
IminenЮăGeUXSWXUăXWHULQă 2
3ODJă'HKLVFHQWăSRVW2& 2
Chistadenocarcinom 2
Hemoragii uterine din OăX]LDLPHGLDWă 6
Prolaps genital total 2
– 67 –

)LEURPXOXWHULQHVWHRSDWRORJLH IUHFYHQWăvQUkQGXOSDFLHQWHOR UGLQORW ul studiat, un QXPăU
de 16 paciente necesitând histerec tomie pentru oprirea hemoragie i uterine rebele la
administrareatratamentului medicamentos. S-a efectuat histerectom ie totala cu anexectomie la un
QXPăU GH  SDFLHQWH FX ILEURP XWHULQ LDU OD  SDFLHQWH V -a practicat histerectomia
VXEWRWDOăSHQWUXFRQVHUYDUHDI XQF܊LHLUHSURGXFWLYH7HUDSLDFK LUXUJLFDOăUDGLFDOăHVWHSUHIHUDWăvQ
cazul paciente ORUFXYkUVWăvQDLQ WDWăODPHQRSDX]ă
8Q QXPăU GH  FD]XUL GLQWUH SDFLHQWHOH DQDOL]DWH DX GLDJQRVWLFX O GH QHRSODVP
endometrial, pentru care s- D HIHFWXDW KLVWHUHFWRPLD WRWDOă FX DQH[HFWRPLH vQ FRPSOHWDUHD
tratamentului oncologic. Cele 2 pa ciente au antecedente personal e patologice de hiperplazie
HQGRPHWULDOăGHVFRSHULWăvQSHUL RDGDGHFOLPD[ SHQWUXFDUHDX XUPDWWUDWDPHQWKRUPRQDO
ÌQFD]XOXQRUVDUFLQL FRPSOLFDWHvQVLWXD܊LLUDUHVHSRDWHSUR GXFHUXSWXUDXWHULQăSHXQ
teren favorizant) aceasta fiind R FRQGL܊LH JUDYă FH SXQH vQ SHULFRO YLD܊ă SDUWXULHQWHL SULQ
KHPRUDJLDXWHULQăLPSUHVLRQDQWăXQHRULLPSRVLELOGHRSULWÌQ ORWXODQDOL]DWDPLGHQWLILFDW
SDFLHQWHFXLPLQHQ܊ăGHUXSWXUăXWHULQăSHQWUXFD]XULOHDPLQWL WHV-a practicat histerectomia de
necesitate. Ca antecedente persona le fiziologice, aceste pacient e sunt multipare.
3HXQIRQGGHXWHUFLFDWULFLDO܈L vQXUPDQHUHVSHFWăULLLQGLFD܊ LLORUPHGLFXOXLSDFLHQWHGLQ
ORWXOVWXGLDWDXVXIHULWvQXUPDRSHUD܊LHLFH]DULHQHRFRPSOLFD ܊LHFXSRWHQ܊LDOYLWDO܈LDQXPH
GHKLVFHQ܊DSOăJLL6 -DLQWHUYHQLWGHXUJHQ܊ăSHQWUXVLVWDUHDKHPRUDJLHLXWHULQHSULQ HIHFWXDUHD
histerectomiei totale. 8WHUXOFLFDWULFLDOH VWHRFRQGL܊LHSDWRORJLFăGREkQGLWăFHOPDL IUHFYHQWvQ
urma chiuretajelor uterine repetate.
Din lotul VWXGLDWODXQQXPăUGHSDFLHQ WHFXGLDJQRVWLFXOGHFKLVWDGH QRFDUFLQRPV -a
SUDFWLFDWKLVWHUHFWRPLDWRWDOăFXDQH[HFWRPLHvQYHGHUHDFRPSOH WăULLWUDWDPHQWXOXLRQFRORJLF܈L
opririi hemoragiei genitale.
ÌQFDGUXOOăX]LHLLPHGLDWHSRWDSăUHDKHPRUDJLLXWHU ine grave ca urmare a hipotoniei
XWHULQHFHQXUăVSXQGODDGPLQLVWUDUHDXWHURWRQLFHORUÌQORWX OVWXGLDWDPLGHQWLILFDWFD]XULFX
DFHDVWăSDWRORJLHFHDXQHFHVLWDWHIHFWXDUHDKLVWHUHFWRPLHLWRW DOHFXVFRSKHPRVWDWLF Aceste
SDFLHQWHDXDYXWRVDUFLQăFX ULVFFHDPDLLPSRUWDQWăSDWRORJLH ILLQGSODFHQWDSUDHYLDSHQWUX
care s-DHIHFWXDWRSHUD܊LDFH]DULDQăIăU ăKLVWHUHFWRPLH DWLWXGLQHFRQ VHUYDWRDUH
– 68 –

ÌQORWXOVWXGLDWDPLGHQWLILFDWSDFLHQWHFXSURODSVJHQLWDOW RWDOFHDXQHFHVLWDWLQWHUYHQ܊LD
chirurgicDOăvQYHGHUHDRSULULLKHPRUDJLHLXWHULQHUHFLGLYDQWHÌQDFHDV WăVLWXD܊LHV -a practicat
KLVWHUHFWRPLDWRWDOăFXDQH[HFWRPLH
Figura 7.12. +LVWHUHFWRPLHVXEWRWDOăWRWD OăFXDQH[HFWRPLHHIHFWXDWăSDFLHQW HORUGLQORWXO
studiat

SRVW2& SRVWRSHUDаLHFH]DULDQă
Din totalul histerectomiilor efectuate pacientelor din lotul st udiat, un procent de 50%
UHYLQHSDFLHQWHORUFXGLDJQRVWLFXOGHILEURPXWHULQ)LEURPXO XWHULQHVWHRSDWRORJLHWXPRUDOă
EHQLJQăIUHFYHQWăFDUDFWHUL]DWă SULQKHPRUDJLHXWHULQă܈LSUH] HQ܊DGXUHULL
+LVWHUHFWRPLDHVWHSUHIHUDWăvQFD]XOvQFDUHFHOHODOWHPLMORDF HWHUDSHXWLFHDSOLFDWHSUHFXP
WHUDSLDPHGLFDPHQWRDVă܈LPLRPHFWRPLD nu au rezolvat simpomatologia.
50%
7%
7
76%
6
6%
%6%
6%
19%
6% ,ŝƐƚĞƌĞĐƚŽŵŝĞƐƵďƚŽƚĂůĉͬƚŽƚĂůĉĐƵĂŶĞdžĞĐƚŽŵŝĞ
ĞĨĞĐƚƵĂƚĉƉĂĐŝĞŶƚĞůŽƌĚŝŶůŽƚƵůƐƚƵĚŝĂƚ
Uter Fibromatos
Neoplasm Endometrial
,PLQHQ܊ă'H5XSWXUă8WHULQă
3ODJă'HKLVFHQWăSRVW2&
Chistadenocarcinom
+HPRUDJLLXWHULQHGLQOăX]LD
LPHGLDWă
Prolaps Genital Total
– 69 –

Un procent de 19% dintre histerectomiile efectuate, se atribuie hemoragiilor uterine din
OăX]LDLPHGLDWăFDUHQXDXUDV SXQVODDGPLQLVWUDUHDWUDWDPHQWXO XLPHGLFDPHQWRV6HUHFRPDQGă
FDLQWHUYHQ܊LDFKLUXUJLFDOăVăVHSUDFWLFHvQUHJLPGHXUJHQ܊ă GHRDUHFHvQDFHVWHFD]XULKHPRUDJLD
XWHULQăDUHXQGHELWFUHVFXWLDUWHPSRUL]DUHDLQWHUYHQ܊LHLFKL UXUJLFDOHSRDWHFRQGXFHODLQVWDODUHD
܈RFXOXLKLSRYROHPLF܈LH[LWXV
6DUFLQLOHFXULVFvQFD]XOSODFHQWHLSODHYLDDXEHQHILFLDWGH RSHUD܊LDFH]DULDQăÌQDFHVWH
cazuri s-DLQWHUYHQLWGHXUJHQ܊ăGDWăILLQGGHFRPSHQVDUHDFDUGLR -circulatorie în urma hemoragiei
uterine masive, în regim conservator s- D HIHFWXDW RSHUD܊LD FH]DULDQă FX SăVWUDUHD  XWHUXOXL
$WLWXGLQHDFRQVHUYDWRULHPHQ܊LQHIHUWLOLWDWHDIHPHLLvQVăQXH VWH JUHYDWăGHULVFXULFHOPDL
LPSRUWDQWILLQGKHPRUDJLDXWHULQ ăLQSRVWSDUWXPFHLPSXQHKLVWH UHFWRPLHGHQHFHVLWDWHvQDEVHQ܊D
UăVSXQVXOXLODDGPLQLVWUDUHDGHXWHU otonice.
&RQGL܊LLSDWRORJLFHFHDXGHWHUPLQDWKHPRUDJLHXWHULQăSUHFXP SURODSVJHQLWDOWRWDO
FKLVWDGHQRFDUFLQRP SODJă GHVKLVFHQWăSRVW 2& ܈L LPLQHQ܊ă GH U XSWXUă XWHULQă DX QHFHVLWDW
HIHFWXDUHDKLVWHUHFWRPLHLIL HFDUHGLQWUHDFHDVWHDvQSURSRU܊L HGH 6%.
Dintre histerectomiile efectuate în cadrul pacientelor din lotu l studiat, un procent de 7%
din acestea revin pacientelo r cu neoplasm endometrial.
6FRSXOKLVWHUHFWRPLHL WRWDOHFXDQH[HFWRPLHHVWHGXEOXDWkWKH PRVWDWLFFkW܈LFXUDWLY
facând parte din standardul terapiei oncologice aplicate acestei malatii. Neoplasmul endometrial
HVWH R ERDOă VSHFLILFă IHPHLORU OD PHQRSDX]ă FX DQWHFHGHQWH GH KLSHUSOD]LH HQGRPHWULDOă
3DFLHQWHOHGLQORWXOVWXGLDWFDUHDXEHQHILFLDWGHDFHDVWăSURF HGXUăFKLUXUJLFLFDOăvQ scop curativ
܈L KHPRVWDWLF DX XUPDW vQ WUHFXW WUDWDPHQW KRUPRQDO SHQWUX KLS HUSOD]LD HQGRPHWULDOă IăUă
UH]XOWDWHIDYRUDELOHDVWIHOvQFkWvQXUPDHIHFWXăULLFKLXUHWDM XOXLXWHULQKHPRVWDWLF܈LELRSVLF
constatându-se apa UL܊LDQHRSODVPXOXLHQGRPHWULDO
– 70 –

Tabelul 7.11. Altetratamente chirurgicale aplicate pacientelor din lotul studiat
(5$' HOHFWURUH]HF аLHFXDQVăGLDGHUPLFă
8QQXPăUGHSDFLHQWHGLQORW XOVWXGLDWFXGLDJQRVWLFXOGHSO DFHQWDSUDHYLDDXQHFHVLWDW
RSHUD܊LHFH]DULDQăHIHFWXDWă între 34-37 GHVDSWăPkQLGDWRULWăKHPRUDJLHLXWHULQH ce nu a putut fi
FRQWURODWăvQXUPDDGPLQLVWUăULLWUDWDPHQWXOXLPHGLFDPHQWRV .ÌQYHGHUHDPDWXUăULLSXOPRQDUHD
QRXQăVFX܊LORUVHYRUDGPLQ LVWUDFRUWLFRVWHURL]L
'HFL]LD WHUDSHXWLFă HVWH MXVWLILFDWă GH VWDUHD JHQHUDOă DOWHUDWă D S D F L H Q W H O R U  & H O P D L 
LPSRUWDQWIDFWRUFDUHDFRQGXVOD VWDWXVXODFWXD ODOSDFLHWHORU HVWHKHPRUDJLDXWHULQăLPSRUWDQWă
FDQWLWDWLYÌQXUPDHYDOXăULLSDUDPHWULORUELRORJLFLV -a constatat Rh +, astfel încât nu a fost
QHFHVDUăDGPLQLVWUD rea de Ig anti D pacientelor din lotul studiat cu diagnosticul de placenta
SUDHYLDFDUHDXEHQHILFLDWGHRSHUD܊LHFH]DULDQă
(5$'HOHFWURUH]HF܊LDFXDQVăGLDGHUPLFăHVWHRSURFHGXUăHIHFW XDWăGHFăWUHVSHFLDOLVW
pacientelor cu suspiciune de neoplazie la QLYHOXOFROXOXLXWHULQFHSUH]LQWăKHPRUDJLHvQFDQWLWDWH
PRGHUDWă$FHDVWăPDQHYUăFKLUXUJLFDOăGHUHFROWDUHD܊HVXWXOXL DIHFWDWGHODQLYHOXOFROXOXL
XWHULQDUHVFRSXOWHUDSHXWLFGHD vQGHSăUWD]RQDFXULVFGDU܈L VFRSXORE܊LQHULLGLDJQRVWLFXOXL
histopatologic de certiturdine.
$FHDVWăSURFHGXUăV -a efectuat pentru metroragie în climax la 6 paciente din lotul studiat.
Dintre pacientele lotului s tudiat cu diagnosticul de FHUYLFLWăFURQLFăKHPRUDJLFăDXEHQHILFLDWAlte tratamente chirurgicale ap licate pacientelor din lotul stu diat
Operatie c H]DULDQă3ODFHQWD3UDHYLD 12
ERAD
-Metroragie în climax
-&HUYLFLWăFURQLFăKHPRUDJLFă6
10
Salpingostomie 12
Ovarectomie XQLODWHUDOă 2
'LVWUXF܊LH /Abla܊ie(QGRPHWULDOă 9
– 71 –

de eleFWURUH]HF܊LHFXDQVăGLDGHUPLFă XUPkQGFDSLHVDUH]HFDWăVăILH VXSXVăH[DPHQXOXLKLVWR –
patologic.
În tabloul clinic al unei sarcini extraut HULQHDYDQVDWHGRPLQă hemoragia H[WHULRUL]DWăSULQ
vagin, iar vQFD]XOORWXOXLVWXGLDWDPLGHQ WLILFDWSDFLHQWHFXVDUFLQă H[WUDXWHULQăORFDOL]DWăOD
QLYHOXO WURPSHL XWHULQH $FHVWHD DX QHFHVLWDW LQWHUYHQ܊LH FKLUX UJLFDOă FX VFRSXO HYDFXăULL
FRQ܊LQXWXOXLWURPSHLXWHU LQHSULQVDOSLQJRVWRPLH
,PSODQWDUHDRXOXLODQLYHOXOWU RPSHORUXWHULQHFRQGXFHODUXSWX UDWURPSHLvQDEVHQ܊D
LQWHUYHQ܊LHLFKLUXUJLFDOH܈LDSDUL܊LDFRQVHFXWLYăDKHPRSHULWR QHXOXLLPSOLFLWDDEGRPHQXOXLDFXW
chirurgical. În lotul studiat de mine, sarcinile extrauterine s unt localizate la nivelul trompelor
XWHULQHILLQGFHDPDLIUHFYHQWă ]RQăGHLPSODQWDUHH[WUDXWHULQă DRXOXL
Un număUGHSDFLHQWHDXQHFHVLWDWH[WLUSDUHDXQXLVLQJXURYDUDIHFW DWGHIRUPD܊LXQL
tumorale GHGLPHQVLXQLFUHVFXWH)RUPD܊L XQLOHFKLVWLFHDXIRVWGHVFRSHUL WHSULQHIHFWXDUHDXQHL
ecografii trans-vaginale.
'XSăRSHULRDGăGHOXQLvQFDUHSDFLHQWHOHDXXUP at tratament medicamentos hormonal,
IRUPD܊LXQLOHWXPRUDOHFkW܈ i simptomatologia nu au regresat(ceea ce exclude diagnosticul de chist
RYDULDQ IXQF܊LRQDO IăFkQG QHFHVDUă RYDUHFWRPLD FH DUH scopul de a preciza diagnosticul
KLVWRSDWRORJLFDOIRUPD܊LXQLORUWXPRUDOH܈LGHDUHPLWHKHPRUDJ LDUHFLGLYDQWă
3DFLHQWHOHGLQORWXOVWXGLDWFXGLDJQRVWLFXOGHPHWURUDJLLKHPR UDJLFHGLVIXQF܊LRQDOHFDUH
VHDIOăvQSHULPHQRSDX]ăDXIRVWWUDWDWHSULQGLVWUXF܊LHDEOD܊ LHHQGRPHWULDOă3UHFL]H]IDSWXOFă
SDFLHQWHOHGLQDFHDVWăFDWHJRULHQHDJăGRULQ܊DXQHLVDUFLQLYLL WRDUH/DFRQWUROXOSHULRGLFDOFHORU
SDFLHQWHFXPHWURUDJLHK HPRUDJLFăGLVIXQF܊LRQDOăV -DFRQVWDWDWDEVHQ܊ăPHWURUDJLLORUFXR
HYROX܊LHEXQă .
– 72 –

Figura 7.13. Altetratamente chirurgicale aplicate pacientelor din lotul studiat
(5$' HOHFWURUH]HFаLDFXDQVăGLDGHUPLFăDin totalul tratamentelor chirurgicale efectuate conform figuri i 7.12., 23% dintre aceastea
s-DXHIHFWXDWvQYHGHUHDRSULULLKHPRUDJLHLFXSRWHQ܊LDOYLWDOGL QSODFHQWDSUDHYLD2SHUD܊LLOHGH
FH]DULDQă HIHFWXDWH FX DFHVWH RFD]LL DX IRVW GHFL]LD WHUDSHXWL Fă VDOYDWRDUH vQ FD]XO DFHVWRU
SDFLHQWHFkW܈LDQRX -QăVFX܊LORU
Opera܊LDFH]DULDQăvQFD]XOSDFLHQWHORUFXGLDJQRVWLFXOGHSODFHQWă praevia cu risc crescut
VHHIHFWXHD]ăLQWRWGHDXQDVXEDQHVWH]LHJHQHUDOă%HQHILFLLOHD QHVWH]LHLJHQHUDOHVXQWGXEOH
permit un abord chirurgical r DSLGFăW܈L DGPLQLVWUDUHDvQDFHOD܈LWLPSDWUDQVIX]LLORUGHVkQ JH܈L
FRORL]LORUÌQDOWHVLWXD܊LLFOLQLFHDWXQFLFkQGSODFHQWDSUDH YLDQXDIHFWHD]ăVHPQLILFDWLYVWDWXVXO
KHPRGLQDPLFDOSDFLHQWHORUVH SRDWHUHFXUJHODQD܈WHUHSHFDOH YDJLQDOă
În procent de 23% sunt salpingostomiile, proceduri terapeutice e fectuate în vederea
HYDFXăULLVDUFLQLORUH[WUDXWHULQHORFDOL]DWHODQLYHOXOWURPSHO RUXWHULQH(VWHLPSRUWDQWVăVH
H[FOXGăRVDUFLQăPRODU ăLQDFHVWHFD]XULGDWRULWăFRQGXLWHLW HUDSHXWLFHGLIHULWH
^ĂůƉŝŶŐŽƐƚŽŵŝĞ
23% KǀĂƌĞĐƚŽŵŝĞ
ƵŶŝůĂƚĞƌĂůĉ
3% 'LVWUXF܊LH$EOD܊LH
(QGRPHWULDOă
18%Operatie
&H]DULDQă3ODFHQW
a Praevia)
23%DĞƚƌŽƉĂƚŝĞŠŶĐůŝŵĂdž
12%
&HUYLFLWăFURQLFă
KHPRUDJLFă
20%ERAD
26% ALTE TRATAMENTE CHIRURGICALE APLICATE
W/Ed>KZ/E>Kdh>^dh/d
– 73 –

Conform articolelor publicate în reviste de specialitate, cu to ate ca abordul chirurgical
HVWHPLQLPLQYD]LYvQPDUHDPDMRULWDWHDFD]XULORUvQFDSHUVLVW ăRUDWăFUHVFXWăDVHFKHOHORUGHWLS
VWHULOLWDWHFKLDU܈LvQID܊DDERUGXOXLODSDURVFRSLFFDUHHVWH QHWVXSHULRUODSDURWRPLHL'LQSXQFWGH
vedere al pierderilor de sânge, ac estea sunt mai mici la laparosc opii, necesitatea de analgetice
postoperator fiind mai redusã ia r recuperarea postoperatorie a p acientelor este mai rapidã.
2SDUWHVHPQLILFDWLYăGLQWUHWUDWDPHQWHOHFKLUXUJLFDOHDSOLFDWH ORWXOXL studiat sunt tehnicile
(5$'vQSURFHQWGH(OHFWURUH]HF܊LDFXDQVăGLDGHUPLFăHVW HRSURFHGXUăHIHFWXDWăvQVFRS
GLDJQRVWLF܈LFXUDWLYSHQWUXOH]LXQLOHVXVSHFWHGHODQLYHOXOF ROXOXLXWHULQ3DFLHQWHOHFDQGLGDWH
SHQWUX DFHDVWă SURFHGXUă DX GLVSOD]LH X܈RDUă VDX PRGHUDWă LGHQW LILFDWă SULQ WHVWXO %DEH܈-
3DSDQLFRODX ܈L VH XUPăUH܈WH SU LQ LQWHUPHGLXO SURFHGXULL (5$' R E܊LQHUHD XQHL KLVWRORJLL
complete.
Un procent de 12% dintre ERAD co respund pacientelor cu metropa tie in climax, iar 20%
cervicitelor cronice h HPRUDJLFH5H]HF܊LLOHFXDQVăGLDGHUPLFăVHSUDFWLFăVXEFROSRV FRS܈LDX
UROXOGLDJQRVWLFFHYDGHFLGHFRQGXLWDWHUDSHXWLFă
ÌQFD]XOSDFLHQWHORUFXFHUYLFLWăFURQLFăKHPRUDJLFăVHXUPDUH܈ WHSDVWUDUHDIHUWLOLWă܊LLGDW
ILLQG IDSWXO Fă (5$' HVWH R SURFHGXUă PLQLP LQYD]LYă FH FRQVHUY ă XWHUXO VL DQH[HOH /D
XUPDULUHDSDFLHQWHORUGXSDDFHDVWăSRFHGXUăV -DHYLGHQ܊LDWQHRSOD]LHFHUWăFHHDFHDLPSXV
efectuarea tratamentului oncol ogic, implicit histerectomia.
Ovarectomia s-a practicat in 3% din cazuri, prin pr RFHGXUăODSDURVFRSLFăÌQDFHVWHFD]XUL
KHPRUDJLD XWHULQă VXUYLQH FHO P DL IUHFYHQW vQ XUPD XQXL GH]HFKL OLEUX KRUPRQDO SURGXV GH
chisturile ovariene.
3ULQDERUGXOODSDURVFRSLFVHSRWLGHQWLILFDHYHQWXDOHOHFRPSOLF D܊LLSUHFXPKHPRSHULWRQHX
VDXSHULWRQLWăFD XUPDUHDSURFHV XOXLLQIHF܊LRVH[WLQVGHODQLY HOXORYDUHORUVLWURPSHORUXWHULQH
În cazurile studiate DFHVWHFRPSOLFD܊LLQXDXDSăUXWX UPăWRUXOSDVILLQGH[DPHQXOD QDWRPR –
patologic al ovarului extirpat.
7HKQLFD GH GLVWUXF܊LHDEOD܊LH HQGRPHWULDOă FRUHVSX nde unui procent de 18% dintre
LQWHUYHQ܊LLOH FX VFRS FXUDWLY DSOLFDWH SDFLHQWHORU GLQ ORWXO VW XGLDW 'XSă  VăSWăPDQL GH OD
HIHFWXDUHDSURFHGXULLSDFLHQWHOH DXIRVWUHLQYHVWLJDWHDFHVWHD DYkQGRHYROX܊LHEXQă
– 74 –

Cele 9 paciente tratate prin acest procedeu DXIRVWVHOHFWDWHSULQvQWUXQLUHDXUPăWRDUHORU
FRQGL܊LL REOLJDWRULL DEVHQ܊D VDUFLQLL ܈L D GRULQ܊HL DFHVWHLD v Q YLLWRU SUHPHQRSDX]ă DEVHQ܊D
FRQGL܊LLORU PDOLJQH DEVHQ܊D SROLS LORU HQGRPHWULDOL VDX ILEURPX OXL XWHULQ VXEPXFRV $FHVWH
FULWHULLGHVHOHF܊LHULJXURDVHVWUDWLILFăXQQXPăUGHVWXOGHPL FGHSDFLHQWH$QWHULRUHIHWXăULL
GLVWUXF܊LHLDEOD܊LH L HQGRPHWULDOH V -D DGPLQLVWUDW 'DQD]ROSURJHVWDWLY GH VLQWH]ă WLPS GH 
VăSWDPkQL FRQGXLWă FH Gă UH]XOWD WH QHW VXSHULRDUH vQ FRPSDUD܊L H FX WHKQLFLOH VLPSOH IDUă
administrarea acestui preparat. S-a constatat oprirea hemoragie i uterine, eficacitatea tehnicii fiind
JDUDQWDWă&RQIRUPVWXGLLORUHIHFWXDWHvQGRPHQLXDFHDVWăSURF HGXUăDUHRUDWăGHH܈HFPLFăGH
doar 7,2%.
5HDF܊LLOHDGYHUVHFRQVWDWDWHODDFHVWHSDFLHQWHVXQWPLQRUHFH IDOHHEXIHXULWUDQVSLUD܊LL
XVFDFLXQH YDJLQDOă 7HKQLFD GH DEO D܊LHGLVWUXF܊LH GH HQGRPHWUX H V W H S U H I H U D W ă G D W R U L W ă 
FRPSOLFD܊LLORUSX܊LQHWLPSRSHUDWR UVFXUWUHOXDUHDUDSLGăDD FWLYLWă܊LORUQRUPDOH DOHSDFLHQWHORU
Figura 7.14. Alte tratamente farmacologice administrate pacientelor din lotul studiat120
87
13 224
68
050100150200250
Antibioterapie Preparate pe
ED]ăGH)LHU 0HGLFD܊LH
DQWLKLSHUWHQVLYăŶƚŝĂůŐŝĐĞ AntiinflamatoareůƚĞƚƌĂƚĂŵĞŶƚĞĨĂƌŵĂĐŽůŽŐŝĐĞĂĚŵŝŶŝƐƚƌĂƚĞƉĂĐŝĞŶƚĞůŽƌ
din lotul studiat
Antibioterapie 3UHSDUDWHSHED]ăGH)LHU 0HGLFD܊LHDQWLKLSHUWHQVLYă
ŶƚŝĂůŐŝĐĞ Antiinflamatoare
– 75 –

Dintre pacientele lotului studi at 120 au necesitat administrare a de antibiotice. Pacientele
FXXQSURFHVVHSWLFDFWLYvQVIHUDJHQLWDOăDXIRVWWUDWDWHFX DQWLELRWLFHFXVSHFWUXODUJ3UR cedurile
FKLUXUJLFDOHHIHFWXDWHSDFLHQWHORUGLQFD]XLVWLFDVWXGLDWăvQY HGHUHDUH]ROYăULLSDWRORJLLORUFHDX
GHWHUPLQDWDSDUL܊LDKHPRUDJLLORUXWHULQHDXIRVWHIHFWXDWHVXE SURWHF܊LHDQWLELRWLFă
2DWHQ܊LHGHRVHELWăvQYHGHUHDDSOLFăULLXQHLVWUDWHJLLWHUDSHX WLFHRSWLPHDIRVWGHVWLQDWă
FD]XULORUGHQD܈WHULSU LQRSHUD܊LHFH]DULDQă
$QHPLDKLSRFURPăPLFURFLWDUăHVWHXQHIHFWGLUHFWDOKHPRUDJLLO RUXWHULQHDFXWHVDX
FURQLFH 7UDWDPHQWXO DQHPLHL YL]HD]ă VFDGHUHD PRUELGLWăWLL ܈L D  FRPSOLFD܊LLORU vQ FDGUXO
sindromului hemoragic.
'LQWRWDOXOGHGHSDFLHQWHDQHPLFHGRDUDXIRVWWUDWDWHF X)LHUHOHPHQWDOvQGR]ăGH
150-200 mg/zi per os. Cele 27 de p aciente din lotul studiat car e nu au tolerat administrarea pe
FDOHRUDOăDXIRVWWUDWDWHSHQWUXDQHPLHIHULSULYăFX)LHUSDUH QWHUDOVDXFRPSOH[JOXFRQDW -sodiu-
fier. În cazul pacientelor cu status hemodinamic depreciat s-au efetuat trasfuzii de sânge izo-grup
izo-5K܈LGHULYDWHDGPLQLVWUDUHD XQHLXQLWă܊LGHVk QJHFUH܈WHKHP RJORELQDFXJJO
2DWHQ܊LHGHRVHELWăHVWHDGUHVDWăJUDYLGHORUGHRDUHFHDQHPLDS UHH[LVWHQWăSUH]HQWăULLOD
VSLWDOLQIOXHQ܊HD]ăGLUHFWVWDUHDPDPHL܈LLQGLUHFWVWDUHDIăWX OXL6WXGLLOHFOLQLFHGHVSHFLDOLWDWH
DVXSUDJUDYLGHORUFXDQHPLHIHULSULYăDUDWăRIUHFYHQ܊ăFUHVFXW ăDDSDUL܊LHLFRPSOLFD܊LLORUPDWHUQH
܈LIHWDOH
&HOHPDLIUHFYHQWHFRPSOLFD܊LL VXQWDFFLGHQWHKHPRUDJLFHLQIH F܊LLVHYHUHDQRPDOLLDOH
WUDYDOLXOXLvQFD]XOJUDYLGHORULDUIUHFYHQ܊DQD܈WHULORUSU HPDWXUH܈LDVXIHUL܊HLIHWDOHFUH܈WH
FRQVLGHUDELOvQFD]XOIH܊LORU
Antihipertensivele au fost administrate pacientelor internate, dozele nefiind modificate pe
SDUFXUVXOLQWHUQăULLILLQGUHVS HFWDWHYGR]HOHWHUDSLHLGHED]D
Antialgicele au fost administrate tuturor pacientelor din lotul studiat, sindrom dureros
vQVR܊LQG DSURDSH vQWRWGHXQD KHPRU DJLD XWHULQă WHUDSLD ILLQG L QGLYLGXDOL]DWă vQ IXQF܊LH GH
DPSOLWXGLQHDGXUHULLGHODDQWLD OJLFHX܈RDUHSkQăODPRUILQă
– 76 –

Antiiflamatoarele au rol important în tratamentul hemoragiilor uterine din patologia
JLQHFRORJLFă $FHVWHD VXQW IRORVLWH SH VFDUă ODUJă FX SUHGLOHF܊ LH OD SDFLHQWHOH FX SURFHVH
LQIODPDWRULLLQIHFWLRDVHODQLYHOXOFROXOXLXWHULQPHWURSDWLL KHPRUDJLFHGLVIXQF܊LRQDOHIRUPD܊LXQL
WXPRUDOHEHQLJQH܈LVDUFLQăH[WUDXWHULQă
Figura 7.15.&RPRUELGLWăаLDVRFLDWHGLDJQRV WLFXOXLGHED]ăDOSDFLHQWHORUGL QORWXOVWXGLDW
ÌQXUPDLQYHUWLJD܊LLORUGHVSHFLDOLWDWHDOHSDFLHQWHORULQWHUQD WHvQVHF܊LDGH2EVWHWULFD –
*LQHFRORJLHDPFRQVWDWDWXQQXPDUPDUHGHSDFLHQWHFXDQHPLHQ RUPRFURPăPLFURFLWDUă$P
REVHUYDWUHOD܊LDUHOD܊LDGLUHFWăvQWUHKHPRUDJLDXWHULQăUHFXUH QWăVDXvQFDQWLWDWHPDUH܈LFHOH 187
de paciente care au dezvoltat anemia.
$FHVWHSDFLHQWHDXIRVWWUDWDWHFXSUHSDUDWHSHED]ăGHILHUDG PLQLVWUDWHRUDOVDXSDUHQWHUDO
vQIXQF܊LHGH JUDYLWDWH)HPHLOHvQVăUFLQDWH FDUHQXDXXUPDWS URILOD[LDDGPLQLVWUDULLGH)H
87 2 13 5 1 1 2 10 3 15
0 1 02 03 04 05 06 07 08 09 0 1 0 0AnemieƐƚŵƌŽŶƕŝĐ HTA+HSDWLWă&URQLFă&X9LUXV%*DVWULWă(UR]LYăPneumonie&LUR]ă+HSDWLFă,QIHFWLH8ULQDUă7XOEXUăUL'H&RDJXODUH/ŶĨĞĐƜŝŝ'ĞŶŝƚĂůĞ ŽŵŽƌďŝĚŝƚĉƜŝĂƐŽĐŝĂƚĞĚŝĂŐŶŽƐƚŝĐƵůƵŝĚĞďĂnjĉĂů
pacientelor din lotul studiat
– 77 –

suplimentar 20- PJ]LDXGH]YROWDWRDQHPLHVHYHUă1HFHVDUXOGHILHUWUHEXL HDGPLQLVWUDW܈LvQ
WLPSXODODSWăULL
Pacientele sunt urmarite prin efectuarea analizelor de laborato r, implicit hemoleucograma
FRPSOHWDSHQWUXDYHULILFDLP EXQăWă܊LUHDYDORULL KHPDWRFULWXOXL 'LQWRWDOXOSDFLHQWHORUFXDQHPLH
FăURUDOH -au fost ad PLQLVWUDWHSUHSDUDWHSHED]ăGHILHURSDFLHQWăQXDDYXWRHY ROX܊LHEXQă
DFHDVWDVXIHULQG܈LGHLQVXILFLHQ܊ăUHQDOăFURQLFăÌQDFHDVWă VLWXD܊LHV -DDGPLQLVWUDWHULWURSRHWLQă
XPDQăUHFRPELQDWăvQXUPDVXVSLF LXQLLGHILFLWXOX LGHHULWURSRHW LQăUH]XOWDWDO GLVIXQ܊LHLUHQDOH
'R]DGHHULWURSRHWLQăDGPLQLVWU DWăHVWHGH8,NJVHRULSH VăSWăPkQă
&XDVWPEURQ܈LFDXIRVWGLDJQRVWLFDWHSDF iente, acest diagnostic necesitând RDWHQ܊LH
GHRVHELWă vQ DGPLQLVWUDUHD WUDWDPHQWXOXL DQWLDOJLF LQGHRVHEL X WLOL]DUH a morfinei care este
FRQWUDLQGLFDWă
8QQXPăUGHSDFLHQWHGLQORWXO VWXGLDWVXQWKLSHUWHQVLYHDF HVWHDSUH]LQWăKHPRUDJLH
XWHULQăGHFDX]ăJLQHFRORJLFăILLQGVXEWUDWDPHQWVSHFLILFÌQ DQDPQH]ăHVWHFRQVHPQDWIDSWXOFD
aceste paciente au obezitate, iar 8 paciente hipertensive au diagnosticul de fibrom uterin,
patologie FHDGHWHUPLQDWDSDUL܊LDPHQR -metroragiilor.
([LVWăRUHOD܊LHGLUHFWăvQWUHID FWRULLGHULVF܈LDSDUL܊LDILE URPXOXLXWHULQFHOPDLLPSRUWDQW
aspect este considerat dezechilibrul secretiei hormonale iar fa ctori suplimentari sunt obezitatea si
KLSHUWHQVLXQHDDUWHULDOă
'LQWUHSDFLHQWHOHORWXOXLVWXGL DWVXQWFXQRVFXWHFXKHSDWLWă FURQLFăFXYLUXV%XOWHULRU
WUDWDPHQWXOXLDGPLQLVWUDWvQGHFXUVXOLQWHUQăULLDFWXDOHVLQGUR PXOKHPRUDJL c a fost oprit.
Ca urmare a consumului cronic de antiinflamatoare nesteroidiene pentru simptomatologia
GXUHURDVăFHDFRPSDQLD]ăPHQR -PHWURUDJLLOHSDFLHQWHFXXWHUILEURPDWRVDXGH]YROWDWJDVWUL Wă
HUR]LYă'LDJQRVFWLFXOVXSOLPHQWDUDIRVWVWDELOLWvQGHFXUVXO LQWHUQăULLDFWXDOHSDFLHQWHOHDXIRVW
LQYHVWLJDWHSHVHF܊LDGHJDVWUR -enterologie unde s- DHIHFWXDWHQGRVFRSLDGL JHVWLYăVXSHULRDUă
2 SDFLHQWă LQWHUQDWă  SHQWUX KHPRUDJLH XWHULQă DFX]kQG GXUHUL D EGRPLQDOH UHEHOH OD
administrarea în ambulator de an WLDOJLFH HVWH GLDJQRVWLFDWă vQ GHFXVXO LQWHUQăULL DFWXDOH FX
SQHXPRQLH܈LQHRSODVPHQGRPHWULDO
– 78 –

3URFHVXO QHRSOD]LF HYROXWLY GHWHUPLQă vQ PRG FHUW R VFăGHUH D E XQHL IXQF܊LRQăUL D
VLVWHPXOXL LPXQLWDU DO JD]GHL PHFDQLVPHOH GH DSăUDUH ILLQG GHS ăVLWH SRW DSăUHD LQIHF܊LL
oportuniste, în acest caz s- DGHVFRSHULWDSDU L܊LDXQHLSQHXPRQLL
'HRELFHLKHPRUDJLDXWHULQăFHDSDUHvQFDGUXOPHWURSDWLHLKHP RUDJLFHGLVIXQF܊LRQDOH
HVWHOLPLWDWăILLQGELQHFRQWURODWăFXDMXWRUXOWHUDSLHLKRUPR QDOHÌQVăH[LVWăH[FHS܊LL de exemplu
SULQWUHFD]XULOHVWXGLDWHGHPLQHDPGHVFRSHULWSDFLHQWHFXP HWURSDWLHGLVIXQF܊LRQDOăFDUHDX
DYXWRKHPRUDJLHUHEHOăODWUDWDPHQWXOLQL܊LDOPHGLFDPHQWRV܈L DXQHFHVLWDWvQILQDODSOLFDUHD
histerectomiei de necesitate.
Consider un factor deo VHELW GH LPSRUWDQW vQ DFHVWH FD]XUL SUH]HQ܊D FLUR]HL KHSDWLFH
GHFRPSHQVDWHFHDFRQGXVO DWXOEXUăULGHFRDJXODUH
,QIHF܊LDXULQDUăHVWHXQGLDJQRVWLFIUHFYHQWvQVăvQFRQWH[WXO XQHLKHPRUDJLLvQVIHUD
JHQLWDOăSRDWHFRPSOLFDVLPSWRPDWRORJLDGXUHURDVăDVRFLDWă&HO HFD]XULDXUăVSXQVELQHOD
tratamentul cu antibiotice.
/DVHF܊LXQHDGHDQWHFHGHQWHSHUV RQDOHSDWRORJLFHGLQWUHSDFLH QWHOHORWXOXLVWXGLDWGH
PLQH DX FRQILUPDW SUHH[LVWHQ܊D WXOEXUăULORU GH FRDJXODUH ÌQ FD ]XO SHUWXUEăULL PHFDQLVPHORU
fizioORJLFHDOHFDVFDGHLFRDJXOăULLSRWILvQWkOQLWHGHILFLWHFRQJHQ LWDOHVDXGREkQGLWHDOHIDFWRULORU
de coagulare.
3XUSXUDWURPERFLWRSHQLFăLGLRSDWLF ăHVWHDOGRLOHDGLDJQRVWLFD OXQHLSDFLHQWHLQWHUQDWH
SHQWUX PHWURSDWLH KHPRUDJLFă GLVIXQF܊LRQDOă $FHDVWă IRUPă GH W URPERFLWRSHQLH HVWH GH WLS
SHULIHULFUH]XOWDWăvQXUPDFUH܈WHULLGLVWUXF܊LHLSODFKHWHORU SULQPHFDQLVPLPXQ([DFHUEDUHD
sindromului hemoragic în cazul ac estei paciente poate survine î n contextul unei cauze
VXSUDDGăXJDWHFXPDUILVLQGURPXODQHP ic, sepsis sau sindrom inflamator. În plan biologic testele
GH FRDJXODUH VXQW vQ OLPLWH QRUPD OH GDU SH GH DOWă SDUWH WURPE RFLWHOH VXQW VHYHU VFă]XWH
PPF܈LWLPSXOGHVkQJHUDUH HVWHDOXQJLWYDORULOHQRUPDO HILLQG -4 ').
Dintre pacientele l otului studiat,  VXIHUă GH PDODGLD 9RQ :LOOHEUDQG R DIHF܊LXQH
KHPRUDJLFăFRQVWLWX܊LRQDOăWUDQVPLVă DXWR]RPDOGRPLQDQWILLQGG LDJQRVWLFDWHFXDPHQLQ܊DUHGH
avort.&RQIRUPVWXGLLORUGLQXOWLPLLDQL DFHDVWăERDOăDUHRSUHYDOHQ ܊ăGHDSUR[LPDWLYvQ
SRSXOD܊LDJHQHUDOăFHHDFHRSODVHD]ăvQSULPXOUkQGFDIUHFYH Q܊ăvQDLQWHDKHPRILOLLORU)DFWRUXO
– 79 –

YRQ :LOOHEUDQG LQWHUYLQH vQ SULPD  ID]D D KHPRVWD]HL ܈L DUH UROX O GH SURWHLQă SXUWăWRDUH D
factorului VIII.
ÌQXUPDLQYHVWLJD܊LLORUGHVSHFL DOLWDWHQXDIRVWGHFHODWăRF DX]ăRUJDQLFăGHFOD܈DWRDUH
pentru meno- PHWURUDJLLOHUHFXUHQWHDOHDFHVWRUSDFLHQWHGLQORWXOVWXGLDW VHSRDWHOXDvQGLVFX܊LH
FRUHOD܊LDGLUHFWăvQWUHERDOD9RQ:LOOHEUDQG܈LDSDUL܊LDVkQJHU ăULORUDQRUPDOH Pentru oprirea
hemoragiei, tratamentul acestor paciente include administrarea de concentrat de factor VIII-
:LOOHEUDQGGR]ăGH -8,NJUHSHWDWHODK*KLGXULOHUHFRPDQGă܈LDOWHWHUDSLL vQIRUPH
X܈RDUHGHERDOă DDAVP (1 deamino-8- DUJLQLQăYDVRSUHVLQăLYGR]ăGHPFJNJUHSHWDWOD
12 ore.
2EXQăSDUWHGLQWUHSDFLHQWHOHGLQORWXOVWXGLDWFHDFX]ăKHPRU DJLHXWHULQăDXDOGRLOHD
GLDJQRVWLFLQIHF܊LHvQVIHUDJHQLWDOă,QIHF܊LLOHJLQHFRORJLFH QHWratate la timp pot conduce la
VWHULOLWDWHSULQIRUPDUHDDGHUHQ ܊HORUODQLYHOXODQH[HORU
&RPSOLFD܊LLOHVHSWLFHVXQWQXPHURDVHDYkQGRLPSRUWDQ܊ăGHRVHE LWăvQWLPSXOVDUFLQLLGLQ
IHULFLUH LQFLGHQ܊D LQIHF܊LLORU JHQLWDOH LQ WLPSXO VDUFLQLL QX H VWH IRDUWH mare. Pacientele din
FDX]XLVWLFDVWXGLDWăGHPLQHDVRFLD]ăDFHDVWăSDWRORJLHvQDIDU DVDUFLQLLvQQXPDUGHLDU
paciente post- RSHUD܊LH FH]DULDQă &HOH  SDFLH QWH FX HYROX܊LH FRPSOLFDWă QX D X UHVSHFWDW
LQGLFD܊LLOHPHGLFXOXLRLJLHQăSUHFDUăDGXVODLQIHF܊LDSODJL LFDUHDIRVWWUDVPLVă de la tegument
spre straturile profunde , astfel rezultând QHFHVLWDWHDUHLQWHUYHQ܊LHL܈LHIHWXDUHDKLVWHUHFWRPLHL
ÌQDIDUDVDUFLQLLLQIHF܊LLOHJHQLWDOHSRWFRPSOLFDIRUPD܊LXQLOH WXPRUDOHSUHH[LVWHQWHvQ
special la niv HOXORYDUHORUXQGHHYROX܊LDSUR FHVXOXLVHSWLFSRDWHGHWHUPLQD FKLDUDEGRPHQDFXW
FKLUXUJLFDOFHQHFHVLWăLQWHUYHQ܊LHFKLUXUJLFDOăGHXUJHQ܊DSUL QODSDURWRPLH
– 80 –

CONCLUZII
1. În cazurile de KHPRUDJLHXWHULQă în care nu este pus ăvQSHULFROYLD܊D pacientei, abordarea
WHUDSHXWLFăVHIDFHSDVFXSDVLQFHSkQGFXWUDWDPHQWXOPHGLFDP HQWRVSHQWUXDFRQWLQXDFX
procedurile invazive.
2.ÌQFD]XOPHQRPHWURUDJLLORUIăUăRFDX]ăRUJDQLFăGHFHODELOăVH HIHFWXHD]DRPRQLWRUL]DUH
PLQX܊LRDVăDSDFLHQWHLVH administreaza preparate hormonale.
3. Medicamentele hemostatice care au fost utilizate în vederea sistăULLKHPRUDJLLORUXWHULQHVXQW
HWDPVLODWXO܈LI itomenadiona.
4. Medicamentele uterotonice folosite cu succes vQ SDWRORJLD REVWHWULFDOă VXQW R citocina,
prostaglDQGLQHOH܈LP etilergometril.
5.*UDYLWDWHDKHPRUDJLHLXWHULQHSULQDPSORDUH܈LULWPUDSLGLPSXQ HDGPLQLVWUDUHDGHGHULYDWH
de sânge atunci când nu s- D UHX܈LW RSULUHD DFHVWHLD SULQ DGPLQLVWUDUHD GH PHGLFDPHQWH
hemostatice.
6.0HWURSDWLLOHKHPRUDJLFHGLVIXQF܊LRQDOHIăUăRFDX]ăRULJDQLFăG HFHODWăVXQWFXUDELOHGXSD
H܈HFXOWHUDSLHLKRUPRQDOHSULQHI HFWXDUHDGLVWUXF܊LHLDEOD܊LHL HQGRPHWULDOH .
– 81 –

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