Bubble skeleton is the hydrophilic degeneration of chorion villi
, which are transformed into a grove-like formation consisting of transparent vesicles resembling grape or white currant brushes.
In the course of sharply enlarged villi, bubble-like extensions from the millet grain to the cherry are formed. The diameter of the bubbles rarely exceeds 25 mm. The vesicles are filled with opalescent or yellowish liquid, in which it is possible to determine amino acids, albumins and globulins, chorionic gonadotropin;they do not contain blood vessels, only very rarely can there be single patches of formed capillaries.
The main signs of hurion infection, detectable by microscopic examination: cystic and edematous degeneration of the stroma, absence of vascular vascularization, hypertrophy of trophoblastic epithelium( both syncytia and langansa layer).
The incidence of bladder skidding, according to various authors, ranges in a very wide range - from 0.02 to 0.8% of all pregnancies.
The size of the lesio
n of the villous shell varies, and as a result, a complete bladder drift is discerned, when rebirth captures all the villi;a partial bladder drift when only a part of the villi regenerates. Full bladder skidding develops in the first months of pregnancy
, when the chorion on the entire periphery of the egg is supplied with villi, partial - after 3 months of pregnancy. With full bladder drift, the fetus dies and subsequently resolves, with partial - the pregnancy can continue and result in the birth of a live fetus. With partial bladder drift, labor usually occurs prematurely, but can sometimes be timely. A bladder skid of one of the placenta in a multiple pregnancy may not extend to the second. The causes of bubble skidding have not been fully established
Currently, there are three hypotheses that attempt to explain the etiology of this disease: about the infectious origin - the degeneration of the chorionic villi occurs under the influence of either viruses or toxoplasm;about hormonal origin - the reason for a bubble drift is the lack of estrogen;on the genetic origin of the bladder drift as a result of impaired development of the fetal egg due to chromosomal aberrations.
Bubble skip occurs 3 times more often in re-pregnant. It is observed in girls and adolescents, early ripened, and even in girls under 10 years, as well as in women in the pre-menopausal period, especially in multi-female women. There are numerous reports of cases of bladder skipping in women 50-56 years of age. At the age of 40-50 years, 33% of all cases of blistering drifts occur. In the same woman, pregnancy can result in a bladder drip repeatedly. Bubble skidding as a complication of ectopic pregnancy can develop in the tube.
The doctor, and sometimes the patient, pay attention to the unreasonably rapid increase in the volume of the uterus, which considerably exceeds the dimensions corresponding to the delay in menstruation. As a rule, before 6-8 weeks of pregnancy, the uterus grows slowly, then a sudden jump occurs, in 18% of the patients the uterus is not increased. Bleeding during bladder drifts of
are more likely to be mild, but repetitive, usually begin with 2 months of pregnancy. The total weight of the bubble drift can reach 4 kg. Bleeding increases by the time of the expulsion of the drift, which is more often in the 4-5th month of pregnancy.
With partial bladder drift, his birth occurs at a later date, sometimes the pregnancy is worn out and even overdone. Cases of a delay in the cumming of the uterus until 14 and 17 months are described.
During the bleeding, the particles of the bladder drift are often excreted. In rare cases, hemorrhage does not happen until the 6-7th month of pregnancy, sometimes before the onset of labor. Cases of fatal bleeding are described.
The consistency of the uterus becomes tight-elastic, places are identified excessive softening( in normal pregnancy, the consistency of the uterus is testy).
With large uterus sizes, it is impossible to find part of the fetus, its movement and palpitation are not determined.
In 30-40% of cases develop luteal cysts - many filled with transparent fluid cysts, the walls of which consist of a thin layer of lutein cells. An important feature of them is the reverse development after removal of the bladder drift. Very rarely luteal cysts appear 4-5 weeks after the birth of a bladder drift. In the presence of luteal cysts, the chorionic gonadotropin is significantly longer defined.
Often, the bladder skid is complicated by a toxicosis of pregnancy - vomiting of varying severity, salivation, nephropathy, eclampsia, which can occur even in the 3-4th month of pregnancy. In 60-84% of patients with pancreatic skipping, proteinuria is found, the protein in these cases has a fetal origin.
Invasion of the uterine wall with altered villi leads to the formation of destructive bladder skidding or destructive chorio-adenoma. In violation of the integrity of the peritoneal cover of the uterus, a picture of the acute abdomen may develop. The diagnosis of destructive bladder drift is usually established on the operating table. Tow( 1966) believes that destructive bladder drift is a villous chorionepithelioma.
There is destruiruyuschaya chorionadenoma, according to various authors, in 9-28% of all cases of cystic skidding. Destructive bladder skidding can develop in the event of a long delay in the remnants of a bladder drift in the uterus.
At usual, and more often at destruirujushchem a bubble drift can be metastasises in walls of a vagina, a vulva, lungs, a brain. Sometimes metastatic lesions are detected after removal of the bladder drift.
Treatment of metastases occurs most often spontaneously, sometimes they can cause serious complications and even death, which depends on their location. Such metastases shortly after removal of the bladder drift or after a long period of time may be the cause of the development of heterotopic chorioepithelialomas. Metastatic dissemination of cramps is very rare.
In connection with the probability of a part of patients with the transformation of a bubble drift into a chorionepithelium, studies are being conducted aimed at detecting histological signs that would help to isolate patients with the greatest risk of malignancy of the trophoblast.
Eston and Bagshawe( 1972) concluded that there was no correlation between the degree of differentiation of the bladder skidding tissue and the subsequent development of chorionepithelioma. Diagnosis of bladder skidding
in women's clinics and clinics is set only in 2%, often - only when vaginal discharge from the vesicles. Isolation of vesicles is observed in 11% of patients, usually before expulsion or at the beginning of the expulsion of the bladder drift.
Even prolonged blood clotting is not a reliable sign of bladder skidding, as it is also observed with prolonged miscarriage. It is advisable to collect all the excretions on gauze pads;If you can find the bubbles, the diagnosis is beyond doubt.
Bubble drift should be differentiated from multiple pregnancies, acute polyhydramnios, pregnancy in the myomatous uterus, miscarriage with a hemorrhage into the uterine cavity.
In case of multiple pregnancies, uterus growth is slower, its consistency is not tight-elastic, but dough-like, no bleeding.
Acute polyhydramnios, as a rule, develops in the second half of pregnancy, with it a symptom of fluctuation is determined.
For the differentiation of bladder skipping and pregnancy in the myomatous uterus, hormonal examination is performed. When combining myoma and pregnancy, the titer of the chorionic gonadotropin is lowered even in comparison with a normal pregnancy of the same period. In the case of bladder skipping, the content of chorionic gonadotropin in the urine is significantly increased in most patients. In normal pregnancy, the maximum concentration of this hormone is observed in 7-11 weeks of pregnancy and is not more than 20 000 L.E.( frog units) in 1 L of urine. According to our data, when a bubble drift in 1 liter of urine is determined from 25 000 to 300 000 L. Ye. Chorionic gonadotropin.
In rare cases, when the tissue of the bladder drift is necrotic, but remains in the uterus, the reaction to this hormone may even be negative.
A more complex but more precise immunological method for determining chronic gonadotropin( Wide, Gemzell, 1962) can be used in the modifications of EI Kotlyarskaya, KR Roganova, and AA Molodyk. According to KRRoganova( 1960), the maximum concentration of chorionic gonadotropin is determined at 9-11 weeks of gestation and is no more than 80,000 IU per 1 liter of urine.
In 1970, an enzymatic method for the diagnosis of bladder skidding was proposed based on the determination of the biochemical method of oxytocinase( with a bubble drift, its activity is significantly lower in comparison with normal pregnancy).When bubble drift, the activity of hyaluronidase in the blood serum increases 3.6 times in comparison with healthy pregnant women "and 7.2 times with non-pregnant ones."
When determining the diagnosis of bladder drift, the therapeutic tactics will be different depending on the size of the uterus. " Treatment of bladder skidding
If the size of the uterus does not exceed 12 weeks of pregnancy, bladder drip should be removed with a blunt curette after the cervical canal is expanded, it is also possible to remove it digitally. For large uterine sizes and slight bleeding in order to accelerate the expulsion of the bladder drift, one should use the reducing agents( pituitrin or oxytocin in 0.5 ml every half hour, up to 3 ml, quinine - 0.15 g in 15 minutes up to 8 times,calcium chloride, thiamine injection, etc.)
The isolation of the bladder drift without intervention occurs in 50 to 70% of patients, and abbreviated agents may accelerate this process. Blade and LS Persianinov( 1962) recommend bleeding,caused by a bubble drift, first try a tight tampondu vagina or colpeirinter for the purpose of increasing uterine motility and spontaneous expulsion of the drift.
With continued bleeding after expulsion of the bladder drift, cautious scraping with a blunt curette is made. If there is no bleeding, scraping should be performed the next day, since in this case the perforation of the uterine wall is reduced.
With significant bleeding, it is necessary to rapidly expand the cervical canal with Gegar dilators and remove the bladder drift as much as possible by the finger method. With large uterine sizes, unpreparedness of the birth canal and massive bleeding, the method of choice may be a small cesarean section. It is permissible after removing a part of the bladder drift to facilitate its expulsion by careful pressure on the uterus according to the method of Kreda.
When resuming bloody discharge( usually 1 to 2 weeks), it is necessary to re-scrape the stitch of the uterine cavity. The increase in temperature is not a contraindication for the removal of a pancreatic drift, on the contrary, this circumstance makes it necessary to accelerate the active intervention. Of the complications associated with bladder drift, the greatest danger is the development of chorioepithelioma
.Based on recent studies, it can be argued that malignancy of bladder drift occurs in 4% of cases.
It is necessary to remember the possibility of the development of chorionepithelioma in patients who have undergone a bubble drift after a long latent period that can last up to 19 years.
Lethal outcome from bleeding was rare and does not appear to occur at the present time. Complications of an infectious nature are more common. There are cases of septic diseases and thromboses.
In 28.7% of women who underwent a bladder drift, infertility is observed, in 13,8% - amenorrhea. Due to the fact that malignancy of the bladder drift occurs only in 4% of patients, it is advisable to prophylactic treatment with methotrexate only to those women who are at risk of developing chorionepithelioma, that is, the absence of a progressive decrease in the titer of the chorionic gonadotropin after removal of the bladder drift. If you can not determine the titre of the hormone, women who have a positive reaction to chorionic gonadotropin in a month after removing the bladder drip should be treated with 1 - 2 courses of methotrexate, in the same way as in chorionic epithelioma. In our opinion, it is possible to resolve pregnancy to women who have undergone a gall bladder in six months.