No Image

Эмболия околоплодными водами при кесаревом

СОДЕРЖАНИЕ
238
2 354 просмотров
17 августа 2019

РЦРЗ (Республиканский центр развития здравоохранения МЗ РК)
Версия: Клинические протоколы МЗ РК — 2013

Содержание

Общая информация

Краткое описание

Эмболия околоплодными водами (ЭОВ) – критическое состояние, связанное с попаданием амниотической жидкости в легочные сосуды с развитием симптомокомплекса шока смешанного генеза, вплоть до остановки сердечной деятельности, острой дыхательной недостаточности и острого синдрома ДВС. ЭОВ рассматривается как анафилактическая реакция на биологически активные вещества, входящие в состав амниотической жидкости.

I. ВВОДНАЯ ЧАСТЬ

Название протокола: Эмболия околоплодными водами
Код протокола:

Код(ы) МКБ-10:
O88 Акушерская эмболия
Включено: легочная эмболия во время беременности, родов или в послеродовом периоде
O88.0 Акушерская воздушная эмболия
O88.1 Эмболия амниотической жидкостью
O88.2 Акушерская эмболия сгустками крови
O88.3 Акушерская пиемическая и септическая эмболия
O88.8 Другая акушерская эмболия

Сокращения, используемые в протоколе:
ЭОВ – эмболия околоплодными водами
ДВС – диссеминированное внутрисосудистое свертывание
КОС – кислотно-основное состояние
ЦВД – центральное венозное давление

Дата разработки протокола: май 2013 года.
Категория пациентов: беременные, роженицы, родильницы.
Пользователи протокола: акушеры-гинекологи. При подозрении на эмболию околоплодными водами необходимо вызвать анестезиолога-реаниматолога.

Диагностика

II. МЕТОДЫ, ПОДХОДЫ И ПРОЦЕДУРЫ ДИАГНОСТИКИ И ЛЕЧЕНИЯ

Перечень основных диагностических мероприятий:
1. R-графия легких
2. Эритроциты, гемоглобин, гематокрит
3. Тромбоциты
4. Фибриноген
5. Время свертывания
6. Паракоагуляционные тесты
7. ЭКГ
8. КОС и газы крови
9. ЦВД

Диагностические критерии:

Необходимые условия для попадания околоплодных вод в кровоток:
— превышение амниотического давления над венозным;
— зияние сосудов матки.

Факторы, повышающие риск ЭОВ:
— Многорожавшая
— Околоплодные воды, загрязненные меконием
— Разрывы шейки матки
— Внутриутробная гибель плода
— Очень сильные тетанические схватки
— Стремительные или затяжные роды
— Амниоцентез
— Приращение плаценты
— Преждевременная отслойка нормально расположенной плаценты
— Многоводие
— Разрыв матки
— Хориоамнионит
— Макросомия
— Плод мужского пола
— Операция кесарева сечения

Причины амниотической эмболии при кесаревом сечении:
— избыточное давление на матку извне;
— попытки извлечь плод через разрез несоответствующий размерам головки плода;
— выраженная гиповолемия.

Возможные пути проникновения околоплодных вод в кровоток матери:
1. Трансплацентарный путь (через дефект плаценты).
2. Через сосуды шейки матки.
3. Через межворсинчатое пространство – при преждевременной отслойке нормально расположенной плаценты.
4. Через сосуды любого участка матки – при кесаревом сечении, нарушении, нарушении целостности плодных оболочек, разрывах матки.

Клиника ЭОВ представлена двумя основными синдромами:
— кардиопульмональным шоком
— и коагулопатией (синдромом ДВС).

Клиническая картина амниотической эмболии во время родов и после родов:

внезапное начало
— бледность кожных покровов
— беспокойство и страх, иногда боли в грудной клетке
— нарушение дыхания
— возникает потрясающий озноб
— гипертермия до 39 градусов и более
— нарастает цианоз кожи лица и конечностей
— резко затруднено дыхание, может развиться возбуждение с тонико – клоническими судорогами, и затем, почти сразу, может наступить кома.
— после вышеуказанной клинической симптоматики, возможно, ожидать профузное кровотечение из половых путей.

Клинические проявления амниотической эмболии при кесаревом сечении в условиях общей анестезии:
— внезапное трудно объяснимое снижение насыщения крови кислородом (SpO2) до 85%, а в тяжелых случаях до 70%, во время или сразу после извлечения плода;
— при ИВЛ повышение давления в дыхательном контуре до 35 – 40 и более см вод.ст.;
— при аускультации возможны хрипы в легких;
— развивается развернутый ДВС синдром.

Клинические проявления амниотической эмболии при кесаревом сечении в условиях регионарной анестезии:
— внезапное возбуждение пациентки во время или сразу после извлечения плода;
— снижение насыщения крови кислородом (SpO2) до 85%, а в тяжелых случаях до 70%, во время или сразу после извлечения плода;
— затрудненное дыхание;
— при аускультации возможны хрипы в легких;
— развивается развернутый ДВС синдром.

Дифференциальный диагноз

Симптомы Эмболия околоплодными водами Тромбоэмболия легочной артерии
Тахикардия

Повышение давления в дыхательных путях

Увеличения ЦВД

Кратковременно

Кратковременно

Продолжительно

Длительно

Пройти лечение в Корее, Израиле, Германии, США

Получить консультацию по медтуризму

Пройти лечение в Корее, Турции, Израиле, Германии и других странах

Выбрать иностранную клинику

Бесплатная консультация по лечению за рубежом! Оставьте заявку ниже

Получить консультацию по медтуризму

Лечение

Цели лечения: оказание экстренной помощи.

Тактика лечения
При появлении первых симптомов амниотической эмболии (озноб, повышение температуры тела) или при подозрении амниотической эмболии:
Мероприятия первой очереди:
1. Оксигенотерапия (обеспечить подачу увлажненного кислорода со скоростью 6-8 литров в минуту).
2. Катетеризация двух – трех вен (центральной вены — после коррекции гипокоагуляции, желательно яремной).
3. Катетеризация мочевого пузыря.
4. Развернуть операционную.
5. Одномоментно ввести 420 – 480 мг преднизолона в/в.
6. Перевести больную в операционную для наблюдения!
7. Через 20 минут после введения первой дозы – 180 – 240 мг преднизолона в/в.

Своевременно проведенные мероприятия первой очереди купируют анафилактическую реакцию и предотвращают развитие коагулопатического осложнения.

Акушерская тактика при купировании признаков ЭОВ и стабилизации состояния беременной – роды вести через естественные родовые пути под непрерывным мониторным наблюдением за состоянием роженицы и плода.

Акушерская тактика при коагулопатическом осложнении эмболии околоплодными водами заключается в немедленном оперативном родоразрешении и тщательном хирургическом гемостазе, не исключается расширение операции и перевязка подвздошных артерий.

На следующие сутки после родоразрешения – 30 мг преднизолона 4 раза в сутки в/в. В последующие сутки 30 мг преднизолона в/в однократно.

Анестезиологическая тактика при коагулопатическом осложнении:
— анестезия только общая;
— массивная инфузионная, трансфузионная терапия;
— медикаментозная коррекция коагулопатических расстройств;
— антибактериальная терапия;
— кардиальная терапия;
— продленная ИВЛ;
— контроль диуреза;
— контроль ЦВД;
— профилактика полиорганной недостаточности.

Читайте также:  Перелом четвертого пальца на ноге

Медикаментозная терапия осложнений эмболии околоплодными водами:
— Экстренная трансфузия свежезамороженной плазмы – до 20 — 25 мл/кг, но не менее 800 мл.
— Кристаллоиды (р-р Рингера, физиологический раствор) инфузионная терапия до 300% от предполагаемого объема кровопотери при 100% замещении эритроцитсодержащими средствами.
— Плазмозаменители (6% гидроксиэтилированный крахмал), сукцинилированный желатин.
— Эритроцитарная масса 100% от объема кровопотери.
— При отсутствии подъема ад на фоне инфузии подключать вазопрессоры: допамин 5 – 10 мг/кг в мин микроструйно (дозатором) эфедрин, фенилэфрин. АД удерживать на уровне 100 – 110/70 мм.рт.ст.
— Ингибиторы протеаз: препараты апротинина (под контролем фибринолитической активности).
— Транексамовая кислота (250 – 500 мг в/в).
— Антигистаминные препараты
— Наиболее современным, эффективным и радикальным средством коррекции коагулопатических расстройств является одномоментное введение эптаког альфа (активированный)(рекомбинантный фактор свертывания крови VIIa) в дозе 90 мкг/кг.

Дальнейшая тактика лечения:
— антибактериальная терапия – цефалоспорины IV поколения, бета-лактамные антибактериальные препараты;
— кардиальная терапия проводится в соответствии с клинической ситуацией;
— пролонгированная ИВЛ до восстановления гемоглобина до уровня 65 – 70 г/л, количества тромбоцитов не менее 100 * 10 9/л , до стабильного восстановления показателей гемодинамики;
— профилактика полиорганной недостаточности до исчезновения симптомов гипокоагуляции; дезагреганты только после устранения коагулопатического кровотечения.

Индикаторы эффективности лечения: не допустить материнской смертности.

Эмболия околоплодными водами — это осложнение, возникающее в период вынашивания ребенка или в процессе родов из-за попадания околоплодных вод в кровоток женщины. Чаще всего отмечается на первом и втором триместрах беременности, у только родивших девушек.

Причины

Данное опасное для жизни осложнение возникает, если давление в полости матки больше, чем в венозных сосудах. Причины могут быть различными. Важным условием является нарушение целостности кровеносных сосудов матери.

Во время родов повышается риск при кесаревом сечении, несвоевременном проколе плодного пузыря, предлежании плаценты или ее преждевременной отслойке (при этом в околоплодных водах присутствуют примеси крови), разрыве матки или шейки.

Повышения давления внутри матки

Нередко амниотическая жидкость попадает в кровеносную систему женщины, если объемы ее слишком велики, плод чрезмерно крупный. Часто патологию регистрируют при многоплодной беременности. Фактором риска является тазовое предлежание.

Во время родов вызвать эмболию могут аномалии родовой деятельности: чрезмерная активность, несоответствие силы схваток раскрытию шейки матки, продвижению плода по родовым путям. Опасна ригидность шейки матки: если она плохо растягивается, риск развития эмболии увеличивается. Кроме того, привести к патологии может неадекватная стимуляция.

Гиповолемия

Возможны причины и со стороны матери. В случаях, когда у женщины пониженное венозное давление из-за гестоза, имеются пороки сердца или сахарный диабет, наблюдается сильное обезвоживание, амниотическая жидкость может попасть в кровоток роженицы.

Разновидности и симптоматика

Распознать эмболию возможно по ряду симптомов. Цвет кожи становится бледным, наблюдается холодный пот. Возникает озноб. Появляется кашель, быстро из сухого переходящий во влажный. Дыхание учащенное, поверхностное. Возникают болевые ощущения за грудиной, в верхних отделах живота. Болезненность отмечается в конечностях. Часто наблюдаются головные боли.

Отмечается синюшность губ, лица, конечностей. Часто женщина испытывает сильную тревожность, иррациональное чувство страха. Артериальное давление сильно снижается, пульс становится частым, плохо прощупывается. Отмечаются судороги, сильные кровотечения. Возможна потеря сознания.

Симптоматика часто проявляется частично. Особенности зависят от того, какое количество околоплодной жидкости проникло в кровеносную систему.

Коллаптоидная форма

Коллаптоидная эмболия околоплодными жидкостями характеризуется отклонениями в функционировании сердечно-сосудистой системы. Артериальное давление сильно понижается, пульс учащается. Конечности бледнеют, при прикосновении холодные. Часто отмечаются обмороки. Сильно проявляется кардиальный шок.

Судорожная форма

Характерными симптомами такой разновидности являются неконтролируемые мышечные сокращения. Во время приступов наблюдается нарушение дыхания, отмечаются слабость, головокружения, тошнота.

Геморрагическая форма

Характеризуется обильными кровотечениями. Биологическая жидкость быстро вытекает из организма через нос, глаза, влагалище. При взятии пункций, установке катетеров кровь начинает течь из мест проколов.

Отечная форма

При данной разновидности тромбоэмболии амниотической жидкостью отмечается отек ткани легких, приводящий к острой дыхательной недостаточности. Дыхание шумное, сопровождается отхождением пенистой мокроты. Возникает одышка, кашель, сильное удушье. Характерно чувство страха. Отмечаются интенсивные болевые ощущения в области грудины. При несвоевременной медицинской помощи наблюдается остановка дыхания.

Молниеносная форма

Является самой тяжелой разновидностью патологии, при которой летальные исходы регистрируются чаще, чем при прочих. Развивается стремительно. Возникает недостаточность большей части внутренних органов. В 80% случаев спасти женщину и ребенка не удается, гибель обоих наступает в течение 1 часа по причине необратимого шокового состояния. Быстро поднимается температура тела, женщина теряет сознание. Вскоре останавливается сердце.

Диагностика

Поскольку эмболия начинается внезапно, отследить предпосылки к ее возникновению заранее затруднительно. Диагностика и лечение возможны лишь тогда, когда появились первые симптомы.

Первичную диагностику врач проводит по наблюдающейся симптоматике. Сначала оценивают дыхание: если оно сбивается, появляется одышка, прослеживаются быстро исчезающие единичные сухие хрипы, можно заподозрить эмболию. Доктор должен проверить пульс, измерить артериальное давление.

После этого матери придется сдать на анализ образцы крови. Необходимо оценить количество тромбоцитов, фибриногена. Затем исследуют скорость свертывания цельной крови и АЧТВ, представляющий собой показатель свертываемости биологической жидкости.

Третьим этапом являются обследования с помощью медицинского оборудования. Проводится электрокардиограмма, рентген легких.

После этого специалист оценивает состояние плода и подбирает подходящие методы терапии.

Лечение

Начинать терапию необходимо сразу после обнаружения первых признаков. Действовать нужно быстро, в противном случае и женщина, и плод погибнут.

Эффективность лечения оценивают по восстановлению сердечной деятельности, нормализации гемодинамики, отсутствию кровотечения, прекращению использования аппарата для искусственной вентиляции легких.

Неотложная помощь

Требуется незамедлительно вызвать врачей. Понадобится помощь акушерок, неонатологов, анестезиологов. Затем следует изменить положение тела женщины таким образом, чтобы полая вена не подвергалась сдавливанию маткой. Для этого правое бедро нужно сместить влево. После этого обеспечивают подачу кислорода женщине. Требуется срочная сердечно-легочная реанимация. Если реанимировать беременную не удается, доктора принимают меры по спасению жизни ребенка.

Терапевтический метод

Терапевтические меры применяются, чтобы купировать анафилактоидную реакцию, для предотвращения развития необратимых, опасных для жизни нарушений системы гемостаза. Женщину нужно обеспечить подачей увлажненного кислорода. Может быть подключена искусственная вентиляция легких. Проходимость легочных путей обеспечивают с помощью интубации трахеи. Объем циркулирующей крови восполняют с помощью кровозамещающих жидкостей, вводить которые приходится в больших объемах.

Читайте также:  Как мне вылечить ногу

Медикаментозный способ

Внутривенно вводят глюкокортикостероидные препараты в большом количестве. Используются Преднизолон, Гидрокортизон. Бикарбонат натрия применяется, чтобы откорректировать ацидоз. Если артериальное давление сильно понижается, потребуется введение симпатомиметиков. Иногда применяют Допамин, Добутамин. Легочную нагрузку снижают внутривенным введением Простациклина или ингаляциями оксида азота.

Операция

Метод родоразрешения зависит от состояния женщины, особенностей протекания эмболии. Возможны роды естественным способом или использование экстренного кесарева сечения. Срочно проведенная операция увеличивает шанс на выживание матери, поскольку матка перестает давить на полую вену, препятствуя нормальному кровоснабжению сердечной мышцы. Кроме того, быстрые роды предотвращают попадание в кровоток большего количества жидкости.

Операцию проводят при стабилизации состояния матери.

Профилактика заболевания

Снизить риск развития патологии поможет планирование беременности, предварительная подготовка. Женщине следует излечить имеющиеся патологии до зачатия, чтобы избежать развития нежелательных реакций в период вынашивания.

Необходимо своевременно начать наблюдаться у гинеколога. Посещать доктора нужно регулярно: врач сможет своевременно обнаружить отклонения, примет меры, чтобы избежать гибели женщины и ребенка.

Все диагностические исследования должны быть своевременно пройдены.

Рекомендована регулярная физическая активность. Упражнения специальной лечебной физкультуры для беременных следует выполнять каждый день не меньше, чем по полчаса. Можно заниматься на фитболе, выполнять дыхательные упражнения, прогуливаться. Если гинеколог разрешит, допускается плаванье, аквааэробика и другие виды спорта.

Необходимо соблюдать специальную диету. Следует отказаться от острой пищи, жаренных на масле блюд. Лучше отдавать предпочтение натуральным продуктам. Из термической обработки предпочтительнее варка, готовка на пару, тушение, запекание в духовке.

Уровень нервного напряжения нужно снизить. Для этого следует сократить общение с неприятными людьми, избегать недосыпания. Если работа связана с постоянными стрессами, лучше сменить ее, уйти в декретный отпуск, уволиться. Важно достаточно отдыхать. Спать нужно не меньше 8-9 часов ежедневно.

Следует предотвращать состояния, приводящие к эмболии. Необходимо своевременно диагностировать повышенный тонус матки и купировать его. Кроме того, важно предотвращение развития гестоза, плацентарной недостаточности, преэклампсии, эклампсии и прочих патологий.

Требуется обильное питье. Обезвоживание недопустимо.

Осложнения и прогнозы

Вероятность развития эмболии составляет всего 5-8 случаев на 100000 родов. Соблюдение рекомендаций врача помогает снизить вероятность появления опасного осложнения.

Исход зависит от того, насколько тяжелым было состояние беременной, как быстро приняты меры. Чаще всего патология заканчивается летальным исходом как для женщины, так и для ребенка. При молниеносной форме эмболия околоплодными жидкостями с вероятностью до 80% завершается смертью у матери и плода. Другие разновидности отклонения имеют большее количество благоприятных исходов, риск гибели снижается. Положительное завершение патологии возможно лишь при быстром начале медицинских манипуляций.

Если мать и ребенок выжили, нередко развиваются осложнения. У женщины часто возникает почечная недостаточность, нарушается кровоснабжение головного мозга. После родов возможно появление воспалительных процессов, гнойные образования.

Появление на свет малыша — чарующий и крайне сложный процесс, во время которого могут случиться серьёзные осложнения. Например, эмболия околоплодными водами.

Эмболия околоплодными водами

Эмболия околоплодными водами — очень опасное осложнение в процессе родовой деятельности, связанное с излиянием околоплодных вод в кровоток женщины. Эмболия ОВ (околоплодными водами) может произойти как на стадии вынашивания плода, так и в процессе родовой деятельности. Бывали случаи развития патологии в первые 30 минут послеродового периода.

Разновидности эмболии ОВ

Акушер-геникологи и анестезиологи-реаниматологи выделяют пять разновидностей этой аномалии:

  • коллаптоидная;
  • судорожная;
  • отёчная;
  • геморрагическая;
  • молниеносная.

Коллаптоидная форма

Эта форма характеризуется ярко выраженным падением сосудистого тонуса (особенно венозного) и резким снижением артериального давления.

Симптоматика:

  • резкое ухудшение общего состояния;
  • появление головокружения;
  • ощущение сильной слабости, озноба;
  • цвет кожи становится мраморно-белый;
  • отстранённость пациентки от окружающего мира;
  • выступает холодный пот;
  • пульс практически не прослушивается;
  • дыхание становится учащённым, но поверхностным;
  • снижается АД (систолическое до 70–60, диастолическое до 40 мм рт. ст. и даже ниже);
  • потеря сознания.

Судорожная форма

Появление генерализированного судорожного синдрома.

Симптоматика:

  • головокружение;
  • тошнота;
  • слабость;
  • резкое, частое и сильное сокращение мышц с последующим краткосрочным расслаблением;
  • нарушение ритма дыхания во время приступов судороги.

Геморрагическая форма

Выражается обильными кровотечениями.

Происходит быстрая и сильная кровопотеря из носа, глаз, рта, влагалища, участков взятия пункции и установки катетеров.

Отёчная форма

Проявляется отёком лёгочной ткани, который, вызывает острую дыхательную недостаточность.

Симптоматика:

  • дыхание шумное, клокочущее, с отхождением пенистой мокроты;
  • развитие одышки;
  • появление чувства страха, удушья;
  • острые боли за грудиной;
  • появления сильного кашля;
  • головокружение, слабость;
  • выраженный цианоз верхней части груди и лица;
  • потеря сознания;
  • остановка дыхания.

Молниеносная форма

Самая страшная и тяжёлая форма патологии. Развивается стремительно и характеризуется полиорганной недостаточностью. В 80% случаев пациентка и плод умирают в течение часа от необратимого шока.

Помимо всего прочего, наблюдается быстрое повышение температуры тела, потеря сознания, остановка сердца.
Болезнь протекает стремительно, при этом сбивается работа всех внутренних органов.

Нужно сказать, что симптомы эмболии ОВ могут быть весьма вариабельными. Всё зависит от количества попадания вещества в систему кровотока, от скорости распространения и реактивности материнского организма.

Причины

Эмболия всегда начинается внезапно. Предпосылки для развития патологии выявить практически невозможно. Неправильное излияние амниотической жидкости может начаться в процессе бурной родовой деятельности и даже во время кесарева сечения.

Проникновение амниотической жидкости в кровеносную систему женщины может быть обусловлено следующими причинами:

  • повышение давления в матке при многоводии, многоплодной беременности, дискоординации, бурной родовой деятельности;
  • ранняя отслойка плаценты, которой предшествуют околоплодные воды с кровью;
  • разрыва шейки матки при родах или самой матки в случае травматизации при беременности;
  • операции кесарева сечения;
  • аномалии развития оболочек;
  • нарушение сообщения между сосудистым и амнионом руслом матери;
  • предлежание плаценты;
  • недоброкачественное исследование околоплодных вод.

Итак, чтобы околоплодные воды попали в кровоток матери, должны быть соблюдены два фактора: нарушение цельность сосудов и увеличение внутриматочного давления (давление в амнионе должно быть выше, чем в венах матки).

Диагностика

Диагностика основана прежде всего на клинической картине. При внезапном появлении симптомов тяжёлого шока необходимо соблюдать следующий алгоритм действий:

  1. Тщательный учёт клинических симптомов
  1. Оценка функций дыхания
    • учащённое дыхание (до 20–25 вдохов в минуту);
    • возможна отдышка;
    • аускультативно дыхание жёсткое, единичные рассеянные сухие хрипы, которые быстро исчезают.
    • Оценка гемодинамики
    • артериальное давление;
    • пульс.
    Читайте также:  Спазмы сосудов конечностей симптомы
  2. Клинический анализ крови с подсчётом количества
    • тромбоцитов (резко выраженная тромбоцитопения);
    • фибриногена (резко выраженная гипофибриногенемия);
    • АЧТВ (активированное частичное тромбопластиновое время — показатель свёртываемости крови) — удлинённое;
    • время свёртывания цельной крови, аньтьромбин III и плазминогена, количество тромбоцитов (удлинение времени свёртывания цельной крови).
      1. ЭКГ (электрокардиограмма)
        • признаки перегрузки правых отделов (отклонение электрической оси вправо, увеличение размеров зубца P во II, III и AVE отведениях сегмента ST и инверсия зубца Т в правых грудных отведениях).
        • R — лёгких (рентгенография лёгких)
          • увеличенное правое предсердие и желудочек, картина интерстициального сливного отёка, что проявляется в виде «бабочки» с уплотнением в прикорневой зоне и просветлением рисунка по периферии.

          Оценить состояние плода.Выбор тактики лечения.

          Лечение

          Дважды мне приходилось слышать мнение родственников, чьи близкие ушли из жизни от эмболии ОВ. Разумеется, все обвиняют врачей. Говорят, что специалисты не квалифицированные, помощь оказали несвоевременно и вообще просто просмотрели, не подошли к роженице вовремя. Хочется отметить, что эмболия развивается настолько стремительно, счёт идёт даже не на минуты — на секунды. Женщина может идеально чувствовать себя во время беременности, но это не исключает развития патологии. В большинстве случаев при излиянии околоплодных вод в кровоток матери удаётся спасти только малыша. И это уже считается заслугой врачей. Если всё-таки женщина выживает, она в последующем должна уделять своему здоровью повышенное внимание.

          При появлении первых признаков развития эмболии необходимо немедленно:

          1. Позвать на помощь акушерок, анестезиологов, неонатологов.
          2. Помочь женщине принять такое положение, чтобы предотвратить передавливание нижней полой вены беременной маткой (бедро роженицы смещается влево).
          3. Провести подачу кислорода матери.
          4. Незамедлительно начать сердечно-лёгочную реанимацию.
          5. Родоразрешение. Если реанимация матери бесполезна, делается незамедлительно для сохранения жизни ребёнка.

          После стабилизации состояния больная переводится в отделение интенсивной терапии.

          Подробное описание лечения эмболии околоплодными водами

          1. Обеспечить проходимость дыхательных путей путём интубации трахеи.
          2. Обеспечение искусственной вентиляции лёгких с высоким вдохом кислорода (менее 60%) и положительного в конце выдоха. Как правило. положительный конец выдоха начинается в 5 см H2O и увеличивается на 2 до 3 см H2O до удовлетворительного уровня Pa 02.
          3. Целью кислородной терапии является поддержание артериального давления выше 60 мм. рт. ст. и насыщения артериальной крови кислородом на 90%.
          4. Далее, следует применение Гидрокортизона 500 мг внутривенно, затем каждые 6 часов (до 2 г/24 ч). Или Преднизолон 360–420 мг, через 10–15 минут 280–360 мг внутривенно из расчёта суммарной дозы 700–800, в последующие 2 суток назначают по 30 мг Преднизолона 4 раза и по 30 мг 2 раза во второй день.

          Во время ранней фазы развивается правожелудочковая недостаточность.

          1. Необходимо электрокардиографическое мониторирование для выявления и лечения аритмии или брадикардии.
          2. Катеризация лёгочной артерии для мониторинга сердечного выброса, центрального венозного давления, давления в лёгочной артерии и обеспечения прямого доступа к образцам крови для цитологического анализа околоплодных вод.
          3. Использование Норэпинефрина или Допамина для поддержания сердечного выброса.
          4. Уменьшение лёгочной нагрузки при помощи ингаляционного оксида азота или ингаляционного/внутривенного Простациклина.

          Вторая фаза обусловлена левожелудочковой недостаточностью и отёком лёгких.

          1. Для поддержания гемодинамики важно применение Норэпинефрина и инотропов, таких как Добутамин, Мильринон или Левосимендан (объём инфузионной терапии 20 мл на кг массы тела).
          2. Немедленное родоразрешение (оперативные вагинальные роды или кесарево сечение). Быстрое родоразрешение при возникновении эмболии околоплодными водами во время беременности и в родах увеличивает шанс на хороший исход для матери, потому что давление матки на нижнюю полую вену отрицательно влияет на кровоснабжение сердца и родоразрешение способствует улучшению гемодинамики. Кроме этого, быстрое родоразрешение способствует остановлению попадания амниотической жидкости в кровоток матери. Поэтому, как только состояние матери стабилизируется, родоразрешение должно быть ускорено.
          3. Коагулопатия сразу следует за сердечно-сосудистым шоком. Поэтому немедленно приступите к радикальным методам остановки кровотечения.

          Об эффективности лечения можно судить по следующим показателям:

          • происходит восстановление сердечной деятельности;
          • нормализуется гемодинамика (кровяное давление, скорость кровотока и тонус сосудов);
          • совершается экстренное родоразрешение;
          • отсутствует кровотечение;
          • прекращается искусственная вентиляция лёгких.

          Возможные осложнения и последствия

          Все осложнения, вызванные излиянием околоплодных вод, имеют негативный характер. Среди них:

          • Острая почечная недостаточность;
          • геморрагический, кардиогенический или анафилактический шок;
          • нарушение мозгового кровообращения;
          • послеродовые гнойно-воспалительные осложнения;
          • смерть матери и плода.

          Только при своевременно оказанной помощи и адекватном подходе к лечению можно рассчитывать на благоприятный исход.

          Профилактика

          Профилактика рецидива развития аномалии подразумевает:

          • планирование и подготовка к беременности
          • своевременная постановка на учёт в женской консультации и её регулярное посещение с прохождением всех диагностических исследований;
          • ежедневное выполнение специальной лечебной физкультуры для беременных в течение 30 минут (дыхательная гимнастика, ходьба, занятия на гимнастическом мяче);
          • соблюдение специальной диеты с ограниченным употреблением жареной и острой продукции;
          • исключение интенсивных психоэмоциональных нагрузок.
        • раннюю диагностику и лечение состояний, которые потенциально могут привести к эмболии околоплодными водами
          • купирование гипертонуса матки;
          • предупреждение и своевременное устранение гестоза и плацентарной недостаточности.
          • Видео — эмболия околоплодными водами

            Отзывы пациенток, столкнувшихся с эмболией

            Здравствуйте! В 2012 году были роды. Экстренное кесарево на 31 неделе + многоплодие + многоводие. Был синдром ТТС у близнецов на 5-м месяце. Была проведена лазерная операция на плаценте в Германии. Во время накладывания швов после кесарева начала кашлять. Дальше состояние только ухудшалось. Диагноз: эмболия околоплодными водами. Мне не давали шансов вообще, был сильный шок, судороги, озноб, испуг и когда уже практически перестала дышать, ввели в медикаментозный сон. Дальше реанимация, ИВЛ, интубация трахеи. Очнулась через 2 дня. Потом долго приходила в себя. Все это свежо в памяти и вызывает сильные расстройства. Врачи сотворили чудо и сделали все для того, чтобы меня спасти. У нас выжил только один ребёнок. И вот сейчас начинаем хотеть второго. Просто дикое желание, но и страх умереть в родах такой же дикий. Врачи говорят, что может случиться рецидив, так как матка всё равно слабая на месте шва. Хоть и прошло уже много лет.

            Ксения 26–01–2015 14:50:26

            https://www.minzdrav.com/45760/

            Крайне важно понимать, что патология протекает очень стремительно. Большинство смертей происходят в первые несколько минут с начала заболевания!

            Комментировать
            238
            2 354 просмотров
            Комментарии
            1. berkey ()
              Ответить

              I am not sure where you’re getting your information, but great topic. I needs to spend some time learning much more or understanding more. Thanks for magnificent info I was looking for this info for my mission.|
              berkey https://binged.it/3o5mC1D

            2. the feed ()
              Ответить

              Thanks for the marvelous posting! I truly enjoyed reading it, you’re a great author.I will make certain to bookmark your blog and may come back at some point. I want to encourage you to ultimately continue your great writing, have a nice evening!|
              the feed http://feeds.hanselman.com/%7E/t/0/0/scotthanselman/%7Eprogrammableweb.com%2Fprofile%2Fcbdoil7/

            3. feed ()
              Ответить

              When someone writes an piece of writing he/she retains the idea of a user in his/her brain that how a user can know it. Thus that’s why this piece of writing is perfect. Thanks!|
              feed http://www.towa-pro-nets.com/cgi-bin/navi/rank.cgi?mode=link&id=342&url=https://www.racked.com/users/skratchlabs

            4. feed ()
              Ответить

              I am sure this piece of writing has touched all the internet people, its really really fastidious piece of writing on building up new webpage.|
              feed https://fanslations.azurewebsites.net/release/out/death-march-kara-hajimaru-isekai-kyousoukyoku-9-32/5628/?url=https://my.archdaily.com/us/@nuun

            5. thefeed ()
              Ответить

              I feel that is one of the most significant information for me. And i am happy reading your article. However wanna remark on few common things, The web site taste is wonderful, the articles is really great : D. Just right process, cheers|
              thefeed https://www.siloo.ir/go.php?url=http://www.blogtalkradio.com/nuun5

            6. feed ()
              Ответить

              Greetings! I’ve been following your blog for a while now and finally got the courage to go ahead and give you a shout out from New Caney Tx! Just wanted to mention keep up the excellent job!|
              feed http://www.doukong.com/link.php?url=https://mix.com/skratchlabs

            7. atmospheric water generator for sale ()
              Ответить

              I think this is among the most important info for me. And i am glad reading your article. But should remark on few general things, The site style is great, the articles is really nice : D. Good job, cheers|
              atmospheric water generator for sale http://neoromance.info/link/rank.cgi?mode=link&id=26&url=https://architizer.com/firms/atmospheric-water-generator/

            8. superbeets review ()
              Ответить

              Thanks for the marvelous posting! I quite enjoyed reading it, you could be a great author.I will be sure to bookmark your blog and will come back down the road. I want to encourage you to continue your great work, have a nice evening!|
              superbeets review http://satomitsu.com/cgi-bin/rank.cgi?mode=link&id=1115&url=https://cults3d.com/fr/utilisateurs/superbeets95

            9. houston junk car buyer ()
              Ответить

              You ought to be a part of a contest for one of the greatest blogs on the net. I am going to highly recommend this web site!|
              houston junk car buyer https://architizer.com/firms/houston-junk-car-buyer/

            10. houston junk car buyer ()
              Ответить

              Hi to every single one, it’s actually a fastidious for me to pay a quick visit this web page, it contains valuable Information.|
              houston junk car buyer https://edex.adobe.com/member/0DdkeboUw

            11. theragun review ()
              Ответить

              Excellent web site. Lots of helpful info here. I am sending it to several pals ans additionally sharing in delicious. And naturally, thanks to your effort!|
              theragun review https://myspace.com/theragunreview

            12. we just did 46 hat ()
              Ответить

              Howdy! I know this is kinda off topic but I was wondering if you knew where I could find a captcha plugin for my comment form? I’m using the same blog platform as yours and I’m having difficulty finding one? Thanks a lot!|
              we just did 46 hat https://www.facebook.com/viralamerica2016/posts/we-just-did-46-hat-official-buy-here-httpsteechipcomwe-just-did-46-hat-official-/1475921352603875/

            13. Oswaldo Hasko ()
              Ответить

              I always used to read paragraph in news papers but now as I am a user of web thus from now I am using net for content, thanks to web.|
              Oswaldo Hasko https://telegra.ph/Berkey-Water-Filter-05-02

            14. pew pew madafakas cat meaning ()
              Ответить

              You really make it seem so easy together with your presentation but I in finding this topic to be really something which I think I’d by no means understand. It sort of feels too complex and extremely huge for me. I’m having a look ahead in your subsequent submit, I’ll attempt to get the hold of it!|
              pew pew madafakas cat meaning https://feqatyzi.wixsite.com/pew-pew-madafakas

            15. Adeline Kleine ()
              Ответить

              Hi there! I’m at work browsing your blog from my new iphone 3gs! Just wanted to say I love reading through your blog and look forward to all your posts! Keep up the outstanding work!|
              Adeline Kleine https://bit.ly/3wb9ETT

            16. Katherine ()
              Ответить

              I for all time emailed this weblog post page to all my associates, for the reason that if like to read it after that my contacts will too.

              Feel free to surf to my web page :: face book sex (Amber)

            17. Claire ()
              Ответить

              I’m really enjoying the design and layout of
              your site. It’s a very easy on the eyes which makes it much more pleasant for me to come here and visit more often. Did you hire out a designer to
              create your theme? Outstanding work!

              my blog :: drug rehab statistics

            18. Kellye ()
              Ответить

              Hello! I could have sworn I’ve been to this site before but
              after browsing through some of the post I realized it’s new to me.

              Nonetheless, I’m definitely happy I found it and I’ll be book-marking and
              checking back frequently!

              my blog rehab medical

            19. Ethel ()
              Ответить

              Greetings! I’ve been following your website for a long time now and finally got the courage to go ahead and give you a shout out from Humble Texas!
              Just wanted to mention keep up the excellent job!

              Take a look at my web page — free singles ads

            20. Rita ()
              Ответить

              Thank you a bunch for sharing this with all people you really understand what you are speaking approximately!

              Bookmarked. Please additionally consult with my website =).
              We can have a hyperlink exchange agreement among us!

              my homepage … come with you sex site

            21. Aaron ()
              Ответить

              I loved as much as you’ll receive carried out right here.
              The sketch is tasteful, your authored subject matter
              stylish. nonetheless, you command get got an nervousness over that you
              wish be delivering the following. unwell unquestionably come further formerly
              again as exactly the same nearly a lot often inside case you
              shield this increase.

              Also visit my webpage — alcohol rehabilitation treatment center

            22. Lane ()
              Ответить

              Nice read, I just passed this onto a friend who was doing a little research
              on that. And he just bought me lunch as I found it for him smile Therefore let me
              rephrase that: Thanks for lunch!

              Feel free to surf to my web page: drug rehab (euruchess.org)

            23. Bryan ()
              Ответить

              Hi, i think that i saw you visited my web
              site thus i came to ?return the favor?.I am trying to find things to improve my site!I suppose its ok to use
              a few of your ideas!!

              Feel free to visit my web-site: luxury alcohol rehab (realgirls.fun)

            24. Manual ()
              Ответить

              Awsome website! I am loving it!! Will come back again. I am bookmarking your feeds
              also.

              Here is my blog post: facebook sex — http://Www.Ril.Ru.Ac.th

            25. Hector ()
              Ответить

              Hello my friend! I want to say that this article is amazing, nice written and
              include almost all important infos. I would like to see more posts like this.

              Also visit my web blog; alcohol rehabilitation treatment center in bangalore

            26. Marylou ()
              Ответить

              One more thing is that while looking for a good online
              electronics store, look for web shops that are continuously updated, keeping up-to-date with the most
              current products, the most effective deals,
              in addition to helpful information on goods and services.
              This will make sure that you are ng business with a shop which stays over the competition and gives you what
              you should need to make educated, well-informed electronics
              purchases. Thanks for the essential tips I’ve learned from the
              blog.

              Also visit my page :: adult personal adds

            27. Callum ()
              Ответить

              Hello. splendid job. I did not anticipate this.
              This is a splendid story. Thanks!

              my blog: free alcohol rehab

            28. Mable ()
              Ответить

              I’m usually to blogging and i actually recognize your content.
              The article has really peaks my interest. I am going to bookmark your
              web site and maintain checking for new information.

              Visit my blog post :: Cognitive Behavioural Therapy (http://johnussery.com/gbook/go.php?url=http://cgi4.osk.3web.ne.jp/~dor/board.cgi)

            29. Sheryl ()
              Ответить

              I every time emailed this webpage post page to all my contacts, since if like to read it after that my links will too.

              Feel free to surf to my site sexs near me

            30. Nilda ()
              Ответить

              I was very pleased to seek out this web-site.I wished to thanks
              for your time for this glorious learn!! I undoubtedly enjoying each little
              little bit of it and I’ve you bookmarked to check out new stuff you blog post.

              Also visit my website :: inpatient drug rehab centers

            31. Jolene ()
              Ответить

              Good write-up, I am normal visitor of one’s website,
              maintain up the excellent operate, and It is going to be a regular visitor for a lengthy time.

              my web blog :: prescription-drugs

            32. Delphia ()
              Ответить

              I believe other website owners should take this internet site as
              an model, very clean and good user pleasant pattern.

              my webpage … find sex sites

            33. Jeanna ()
              Ответить

              I have noticed that online diploma is getting common because getting your degree online has become a popular solution for many people.
              A large number of people have not really had an opportunity to attend a regular
              college or university nevertheless seek the improved earning possibilities
              and career advancement that a Bachelors Degree gives.
              Still hers might have a degree in one discipline but would want
              to pursue another thing they already have an interest in.

              Have a look at my web page … drug rehab centers in new jersey

            34. Chang ()
              Ответить

              I am really loving the theme/design of your web site.
              Do you ever run into any browser compatibility issues?

              A few of my blog audience have complained about my blog not
              working correctly in Explorer but looks great in Opera. Do you have any solutions to help
              fix this problem?

              Look at my webpage … alcohols prep pads

            35. Florence ()
              Ответить

              Based on my research, after a foreclosures home is marketed at a sale, it is common for the borrower in order to still have a remaining unpaid debt on the bank loan. There are many loan providers who aim
              to have all rates and liens cleared by the subsequent buyer.
              On the other hand, depending on a number of programs, polices, and state laws
              and regulations there may be a few loans which are not easily handled through the switch of
              personal loans. Therefore, the duty still rests on the customer that has got his or her property in foreclosure.
              Many thanks sharing your thinking on this blog site.

              Also visit my homepage … Dual Diagnosis

            36. Rhoda ()
              Ответить

              I conceive this website contains some real wonderful info for everyone :D.

              Also visit my blog post :: sex facebook

            37. Johanna ()
              Ответить

              WONDERFUL Post.thanks for share..more wait .. …

              my site … drug and alcohol rehab [haedongacademy.org]

            38. Ada ()
              Ответить

              Thanks a lot for sharing this with all of us you actually
              realize what you’re talking approximately! Bookmarked.
              Please additionally discuss with my website =).
              We could have a hyperlink alternate agreement
              between us!

              Here is my website: best poker site

            39. Charli ()
              Ответить

              I enjoy your writing style genuinely enjoying this website.

              Feel free to surf to my web page Cognitive Behavioural
              Therapy — http://Sorina.Viziru.7@E.Xped.It.Io.N.Eg.D.G@Burton.Rene@www.kartaly.surnet.ru/,

            40. Epifania ()
              Ответить

              hello!,I really like your writing very so much! percentage we keep
              up a correspondence extra about your post on AOL? I need a specialist on this area to resolve my problem.
              Maybe that is you! Looking ahead to see you.

              Here is my webpage Addiction Rehab (aai.zhanshi.qiangshangkeji.com)

            41. John ()
              Ответить

              I conceive this site has some rattling superb information for everyone :D.

              Look at my page; Addiction treatment

            42. Erma ()
              Ответить

              One thing I’d like to touch upon is that weight loss program fast may be possible by the
              suitable diet and exercise. A person’s size not simply affects the look,
              but also the complete quality of life. Self-esteem, depressive disorder, health risks, in addition to physical skills are affected in putting on weight.
              It is possible to make everything right and still gain. In such a circumstance, a problem may
              be the root cause. While an excessive amount of food rather than enough workout are usually at fault,
              common medical ailments and key prescriptions can certainly greatly help to increase size.
              Thx for your post

              My website … Heroin Addiction (dn-wl-9rw.3pco.ourwebpicvip.comlee.b.es.t)

            43. Kyle ()
              Ответить

              F*ckin’ awesome things here. I am very happy
              to peer your article. Thank you so much and i am looking
              ahead to touch you. Will you kindly drop me a e-mail?

              my webpage facebook sex page

            44. Darlene ()
              Ответить

              Nice read, I just passed this onto a colleague
              who was doing some research on that. And he actually bought
              me lunch since I found it for him smile Therefore let me rephrase that:
              Thanks for lunch!

              Feel free to visit my site; drug rehab

            45. Randy ()
              Ответить

              hey there and thank you for your information � I�ve definitely picked up anything new from right here.
              I did however expertise some technical points using this web
              site, as I experienced to reload the web site many times
              previous to I could get it to load properly. I had been wondering if your web host is OK?
              Not that I am complaining, but sluggish loading instances times will often affect your placement
              in google and can damage your high-quality score if ads and marketing with Adwords.
              Well I�m adding this RSS to my e-mail and can look out for much more of your respective fascinating content.
              Make sure you update this again very soon..

              My web site :: Cocaine Addiction

            46. Felipe ()
              Ответить

              Hello, Neat post. There is a problem with your web site in internet explorer, would test this… IE
              still is the marketplace leader and a large part of other people will miss your great writing because of this problem.

              My blog post :: fb sex

            47. Kendall ()
              Ответить

              Hello! I’ve been reading your site for some time now and finally
              got the courage to go ahead and give you a shout out from Kingwood Texas!
              Just wanted to mention keep up the good job!

              Also visit my web-site Opioid Addiction

            48. Damion ()
              Ответить

              bookmarked!!, I love your website!

              My web blog … luxury rehab

            49. Angeles ()
              Ответить

              Very good blog! Do you have any helpful hints for aspiring writers?
              I’m hoping to start my own site soon but I’m a little lost on everything.

              Would you recommend starting with a free platform like WordPress or go for a paid option? There are so
              many choices out there that I’m completely confused .. Any ideas?

              Appreciate it!

              Feel free to visit my homepage; Siam Rehab

            50. Cary ()
              Ответить

              One thing is that when you are searching for a student loan you may find that you will want a cosigner.
              There are many conditions where this is true because you will find that
              you do not possess a past credit rating so the loan provider will require that you’ve someone cosign the financial loan for you.
              Interesting post.

              Also visit my homepage … addiction rehab

            51. Olen ()
              Ответить

              F*ckin’ amazing issues here. I am very satisfied to peer your post.
              Thanks a lot and i am looking ahead to touch you.
              Will you please drop me a e-mail?

              my web site: sex facebook

            52. Sherrie ()
              Ответить

              Nice post. I study something tougher on completely different blogs everyday.
              It will at all times be stimulating to read content from different
              writers and apply a bit of something from their store.
              I’d prefer to make use of some with the content on my weblog whether or not
              you don’t mind. Natually I’ll offer you
              a link in your net blog. Thanks for sharing.

              Feel free to visit my web-site: Alcohol Detox

            53. Shari ()
              Ответить

              It’s perfect time to make a few plans for the longer term and it is time to be happy.

              I have read this submit and if I may just I desire to
              recommend you few interesting things or suggestions.
              Maybe you could write subsequent articles relating to this article.
              I desire to read more issues about it!

              Feel free to visit my web-site … Dara Thailand
              (Levi)

            54. Benny ()
              Ответить

              Wow, incredible weblog format! How long have you been running
              a blog for? you make running a blog glance easy. The whole
              glance of your web site is wonderful, as neatly as the content material![X-N-E-W-L-I-N-S-P-I-N-X]I just couldn’t depart your website
              prior to suggesting that I really loved the standard information an individual
              provide in your visitors? Is going to be again frequently to
              inspect new posts.

              My site luxury drug rehab

            55. Giuseppe ()
              Ответить

              Thank you a bunch for sharing this with all folks you actually recognize what
              you are speaking about! Bookmarked. Kindly additionally consult
              with my website =). We may have a link change agreement between us!

              Check out my blog; Cocaine Addiction

            56. Adrian ()
              Ответить

              Hi there, I discovered your website via Google while searching
              for a related matter, your website got here up, it appears
              good. I’ve bookmarked it in my google bookmarks.

              Also visit my blog: Alcohol Addiction

            57. Gayle ()
              Ответить

              Incredible points. Outstanding arguments. Keep up the amazing effort.

              Also visit my web site alcohol rehab

            58. Lucy ()
              Ответить

              I like this web site so much, saved to bookmarks.

              Here is my web page :: Dual Diagnosis

            59. Galen ()
              Ответить

              Thanks for making me to attain new strategies about computers.
              I also hold the belief that certain of the best ways to maintain your laptop in excellent condition is by
              using a hard plastic case, or even shell, that will fit over the top of one’s computer.

              A majority of these protective gear are model distinct since
              they are manufactured to fit perfectly on the natural
              casing. You can buy these directly from the seller,
              or from third party places if they are for your laptop computer, however not all laptop may have
              a shell on the market. Again, thanks for your ideas.

              my web blog :: Cognitive Behavioural Therapy (Jerome)

            60. Camille ()
              Ответить

              Somebody essentially lend a hand to make critically
              articles I would state. This is the very first time I frequented your web page and
              so far? I amazed with the research you made to make
              this particular put up incredible. Wonderful process!

              Also visit my blog post Addiction Treatment

            61. Rodolfo ()
              Ответить

              Hi! I know this is kind of off topic but I was wondering if you knew where I could locate
              a captcha plugin for my comment form? I’m using the same blog platform as yours
              and I’m having difficulty finding one? Thanks a lot!

              My page; Meth Addiction

            62. Dave ()
              Ответить

              Great delivery. Great arguments. Keep up the amazing work.

              Also visit my webpage: Heroin Addiction

            63. Kandace ()
              Ответить

              Saved as a favorite, I like your website!

              Feel free to visit my web-site :: inpatient rehab (Koby)

            64. Latonya ()
              Ответить

              We are a group of volunteers and starting a new scheme in our community.
              Your web site provided us with valuable info to work on. You’ve done a formidable job and our whole community will be thankful to you.

              my web-site Medical Detox

            65. Christa ()
              Ответить

              I like this site so much, saved to favorites.

              my web site … drug rehab

            66. Fermin ()
              Ответить

              Great delivery. Great arguments. Keep up the
              amazing spirit.

              My site: Amphetamine Addiction

            67. Bev ()
              Ответить

              Hello there, I discovered your web site via Google at the same time as searching for a similar subject, your website came
              up, it looks great. I have bookmarked it in my google bookmarks.

              Here is my web blog Dara Thailand

            68. Broderick ()
              Ответить

              Hi there, just became aware of your blog through Google, and found that it is really informative.
              I am going to watch out for brussels. I’ll be grateful if you continue this in future.
              Many people will be benefited from your writing. Cheers!

              Also visit my page: luxury drug rehab

            69. Valeria ()
              Ответить

              advertising

              Look at my web site; drug rehab

            70. Brigitte ()
              Ответить

              We are a group of volunteers and starting a new scheme in our
              community. Your web site provided us with useful information to work on. You’ve done an impressive task and our entire group will probably be grateful
              to you.

              my web page Marijuana Addiction

            71. Taj ()
              Ответить

              Hello, Neat post. There is an issue together with your web
              site in web explorer, may check this… IE nonetheless is the
              market leader and a huge part of people will pass over your fantastic writing because of this problem.

              My web-site; Heroin Addiction

            72. Moshe ()
              Ответить

              I have been exploring for a bit for any high quality articles or blog posts on this kind of area
              . Exploring in Yahoo I at last stumbled upon this website.
              Reading this information So i am happy to convey that I have a very good uncanny feeling
              I discovered just what I needed. I most certainly will make sure to do not forget this website and give it
              a glance regularly.

              Here is my webpage — Amphetamine Addiction (Davida)

            73. Major ()
              Ответить

              Hello, i think that i saw you visited my site thus i came
              to ?return the favor?.I’m attempting to find things to improve my site!I suppose its ok to use
              some of your ideas!!

              Here is my blog: Amphetamine Addiction

            74. Milagros ()
              Ответить

              Hi there, just wanted to tell you, I loved this article.
              It was practical. Keep on posting!

              Look into my blog … alcohol rehab

            75. Gita ()
              Ответить

              advertising and *********** with Adwords. Well I am adding this
              RSS to my e-mail and could glance out for much extra of your respective intriguing content.
              Ensure that you update this once more very soon..

              Also visit my homepage — Alcohol Addiction

            76. Florence ()
              Ответить

              I think this internet site has got some rattling good info for everyone :D.

              My web site — alcohol rehab

            77. Billie ()
              Ответить

              I really wanted to make a quick message to say thanks to you for these precious ideas
              you are giving out at this site. My prolonged internet search has
              at the end been rewarded with professional know-how to write about with my best friends.
              I ‘d claim that we readers are unquestionably fortunate to dwell
              in a fantastic place with very many perfect professionals with very helpful
              strategies. I feel really blessed to have
              seen your website page and look forward to many more amazing moments reading
              here. Thank you again for all the details.

              Also visit my homepage — Dual Diagnosis

            78. Tracee ()
              Ответить

              magnificent post, very informative. I wonder why the other specialists
              of this sector do not notice this. You should continue your writing.
              I am confident, you have a huge readers’ base already!

              my webpage alcohol rehab

            79. Charolette ()
              Ответить

              There are some fascinating closing dates in this article however
              I don’t know if I see all of them center to heart.

              There may be some validity but I will take hold opinion till I look into it
              further. Good article , thanks and we want extra!
              Added to FeedBurner as properly

              my site :: Cognitive Behavioural Therapy [Micki]

            80. Wesley ()
              Ответить

              Thank you for the auspicious writeup. It in fact was a amusement account it.

              Look advanced to more added agreeable from you! However,
              how could we communicate?

              My website: drug and alcohol rehab

            81. Columbus ()
              Ответить

              I needed to put you a little word in order
              to say thank you yet again considering the superb
              tics you’ve shared at this time. It was quite
              seriously open-handed of you giving publicly what some people ‘ve distributed as an electronic book
              to help with making some cash for themselves, and
              in particular seeing that you could have tried it if you decided.

              These good ideas additionally served like the easy way to be
              certain that some people have the identical
              dreams the same as my very own to know the truth very with reference
              to this issue. Certainly there are many more pleasant moments ahead for individuals who look over
              your site.

              Also visit my site; Meth Addiction

            82. Anglea ()
              Ответить

              When I initially commented I clicked the -Notify me when new comments are added- checkbox and now every time
              a remark is added I get four emails with the identical comment.
              Is there any means you may take away me from that service?
              Thanks!

              Also visit my page — alcohol rehab

            83. Dulcie ()
              Ответить

              Nice post. I learn one thing more difficult on different blogs
              everyday. It will all the time be stimulating to learn content
              material from different writers and apply
              just a little one thing from their store. I’d choose to use some
              with the content material on my weblog whether you don’t mind.
              Natually I’ll offer you a link on your internet blog.
              Thanks for sharing.

              Here is my web-site; Dual Diagnosis

            84. Pedro ()
              Ответить

              Wow, amazing blog layout! How lengthy have you been running a
              blog for? you make running a blog look easy. The overall glance of your website is great,
              as neatly as the content material![X-N-E-W-L-I-N-S-P-I-N-X]I simply could not
              go away your site prior to suggesting that I really enjoyed the usual information an individual provide on your visitors?
              Is going to be again ceaselessly to check up on new posts.

              Here is my web blog: drug and alcohol rehab

            85. Elliott ()
              Ответить

              ors which will best fit those requirements. Then he reveals his advice and if the
              two of you agree, the particular broker formulates a binding
              agreement between the two parties.

              My website Marijuana Addiction

            86. Jackie ()
              Ответить

              Have you ever thought about including a little bit more than just your articles?
              I mean, what you say is important and everything. But think of if you
              added some great pictures or video clips to give
              your posts more, «pop»! Your content is excellent but with
              pics and videos, this site could certainly be one of the best rehab In thailand
              its niche. Very good blog!

            87. Tegan ()
              Ответить

              Hi, i think that i saw you visited my web site so i came to ?return the favor?.I am trying to find things to enhance my web site!I suppose its ok to use
              some of your ideas!!

              My web blog Medical Detox

            88. Delores ()
              Ответить

              Hello, i think that i saw you visited my site so i came to ?return the favor?.I’m attempting to find things to improve
              my site!I suppose its ok to use a few of your
              ideas!!

              my web-site: Drug Addiction

            89. Janessa ()
              Ответить

              Hi, i think that i saw you visited my website thus i came to “return the favor”.I am attempting to find things to improve my web site!I suppose its ok to use a few
              of your ideas!!

              My homepage … Addiction Treatment

            90. Paulette ()
              Ответить

              Hey there! I’ve been following your site for some time now and finally got the
              courage to go ahead and give you a shout out from New Caney Texas!
              Just wanted to tell you keep up the excellent job!

              Feel free to surf to my web-site … sex face book

            91. Chassidy ()
              Ответить

              I think this web poker site rankings
              holds some rattling superb information for everyone :D.

            92. Maple ()
              Ответить

              Greetings! I’ve been reading your weblog for a long time now and finally got the courage
              to go ahead and give you a shout out from Lubbock Texas! Just wanted to mention keep up
              the fantastic job!

              Feel free to surf to my blog post — Heroin Addiction

            93. Mark ()
              Ответить

              I your writing style truly enjoying this web site.

              Have a look at my web blog: Addiction Treatment

            94. Kaley ()
              Ответить

              Yesterday, while I was at work, my sister stole my iPad and tested to
              see if it can survive a twenty five foot drop, just so
              she can be a youtube sensation. My iPad is now destroyed and she has 83 views.
              I know this is completely off topic but I had to share it with someone!

              Feel free to surf to my webpage … non 12 step

            95. Travis ()
              Ответить

              hey there and thank you for your information � I�ve certainly picked up anything new
              from right here. I did however expertise some technical issues using this web
              site, as I experienced to reload the site many times previous to I could get it to load correctly.
              I had been wondering if your web hosting is OK? Not
              that I’m complaining, but sluggish loading instances times will very frequently
              affect your placement in google and can damage your high quality score if advertising and marketing with
              Adwords. Well I�m adding this RSS to my e-mail and can look out for a lot more of your respective exciting
              content. Make sure you update this again very soon..

              Feel free to surf to my blog post: Medical Detox

            96. Clement ()
              Ответить

              hello!,I love your writing very so much! proportion we keep rehab in thailand touch
              extra approximately your article on AOL? I require a specialist in this
              area to resolve my problem. May be that’s you! Looking forward to peer you.

            97. Ulrich ()
              Ответить

              Hello, Neat post. There is a problem along with your website in internet explorer,
              would test this… IE still is the market leader
              and a large section of other folks will omit your great writing due
              to this problem.

              Stop by my page; sex face book

            98. Zachary ()
              Ответить

              One more thing. It’s my opinion that there are quite a few travel insurance sites of dependable companies
              that permit you to enter holiday details and acquire you the
              insurance quotes. You can also purchase the actual international travel cover policy on the
              net by using your own credit card. All that you should do is usually
              to enter your travel details and you can understand the plans side-by-side.
              Simply find the program that suits your budget and needs and after that use your credit
              card to buy them. Travel insurance online is a good way to
              check for a reliable company with regard to international travel cover.
              Thanks for revealing you

              Here is my blog post: Drug Addiction ((…)Xped.It.Io.N.Eg.D.G@Burton.Rene@Www.Kartaly.Surnet.Ru)

            99. Pauline ()
              Ответить

              Hiya very nice site!! Man .. Excellent .. Superb .. I’ll
              bookmark your website and take the feeds additionally…I am happy to seek out a
              lot of helpful info right here in the publish, we need work
              out extra techniques on this regard, thanks for sharing.
              . . . . .

              Look into my homepage alcohol rehab

            100. Janis ()
              Ответить

              I have taken notice that in old digital cameras, special sensors
              help to target automatically. Those kind of sensors with some cams change in in the area of contrast,
              while others utilize a beam associated with infra-red (IR) light, especially
              in low lumination. Higher specs cameras occasionally use a blend
              of both devices and probably have Face Priority AF where the digicam can ‘See’ a face and concentrate
              only on that. Many thanks for sharing your notions on this website.

              My website — inpatient rehab

            101. Cecile ()
              Ответить

              I would like to thnkx for the efforts you’ve put in writing this blog.
              I am hoping the same high-grade website post from you in the upcoming
              as well. Actually your creative writing skills has inspired me to get
              my own website now. Really the blogging is spreading its wings fast.
              Your write up is a great example of it.

              Feel free to visit my web page :: betonline poker site

            102. Brent ()
              Ответить

              Excellent goods from you, man. I’ve remember your stuff prior to and you’re just
              too excellent. I actually like what you have obtained here,
              certainly like what you are saying and the best way through which you say it.

              You are making it entertaining and you continue to care for to stay
              it smart. I cant wait to read far more from you.
              That is actually a terrific site.

              my page: facebookofsex (Shoshana)

            103. Domingo ()
              Ответить

              I believe this is among the most vital info for me. And i am
              satisfied studying your article. But want to
              observation on some common issues, The site taste is perfect, the articles is in point of fact great :
              D. Just right process, cheers

              My page: best online poker reviews

            104. Jenny ()
              Ответить

              What’s up, just wanted to tell you, I enjoyed this blog post.
              It was inspiring. Keep on posting!

              my web page … rehab in thailand

            105. Sang ()
              Ответить

              Thanks for the concepts you have provided here. In addition, I
              believe there are numerous factors which will keep your automobile insurance premium all the
              way down. One is, to consider buying vehicles that are from the good list of car insurance companies.
              Cars that happen to be expensive tend to be at risk of being lost.
              Aside from that insurance coverage is also using the value of your vehicle, so the higher in price it is, then higher the premium you spend.

              my site; Meth Addiction

            106. Silke ()
              Ответить

              I love your writing style truly enjoying this internet site.

              Look into my website: Boutique Rehab

            107. Verna ()
              Ответить

              You could definitely see your enthusiasm in the work you write.
              The world hopes for even more passionate writers like you
              who aren’t afraid to say how they believe. Always follow your heart.

              Here is my webpage; Hope Rehab

            108. Aline ()
              Ответить

              Thanks a bunch for sharing this with all people you actually understand what you are speaking approximately!
              Bookmarked. Please additionally consult with my site =).

              We could have a hyperlink alternate contract between us!

              Feel free to visit my blog; Hope Rehab

            109. Jenni ()
              Ответить

              Saved as a favorite, I like your blog!

              my blog :: top 10 best poker sites

            110. Ahmed ()
              Ответить

              Everything is very open with a really clear description of the issues.

              It was really informative. Your website is extremely helpful.
              Thank you for sharing!

              Also visit my homepage alcohol rehab

            111. Kelley ()
              Ответить

              I love your blog.. very nice colors & theme. Did you create this website yourself or did you
              hire someone to do it for you? Plz reply as I’m looking to create my own blog and would like
              to know where u got this from. thanks a lot

              Look into my site :: Siam Rehab

            112. Belinda ()
              Ответить

              Everything is very open with a very clear description of the issues.
              It was really informative. Your site is extremely helpful.
              Thank you for sharing!

              Here is my page … alcohol rehab

            113. Ted ()
              Ответить

              Hello every one, here every one is sharing such know-how,
              thus it’s fastidious to read this web site, and I used to pay a visit this web site everyday.

              Also visit my web blog … inpatient rehab (ynzst.net)

            114. Cristina ()
              Ответить

              Thanks for sharing superb informations. Your site is very cool.
              I’m impressed by the details that you’ve on this web site.
              It reveals how nicely you understand this subject. Bookmarked this web page,
              will come back for more articles. You, my pal, ROCK!
              I found simply the info I already searched all over the place and
              simply couldn’t come across. What an ideal website.

              My webpage: Cabin Rehab [compos.ev.q.pi40i.n.t.e.rloca.l.qs.j.y]

            115. Tracie ()
              Ответить

              I believe other website proprietors should take this web site as an example, very clean and
              superb user pleasant design and style.

              Feel free to visit my web blog — Heroin Addiction

            116. Dina ()
              Ответить

              Hola! I’ve been reading your blog for a while now and finally got the bravery to go ahead and give you a
              shout out from Dallas Tx! Just wanted to tell you keep up the excellent work!

              Take a look at my page; Rehab In Thailand

            117. Ina ()
              Ответить

              Hey There. I found your blog using msn. This is a very well written article.
              I’ll make sure to bookmark it and return to read more of
              your useful info. Thanks for the post. I
              will certainly comeback.

              Also visit my blog: Opioid Addiction

            118. Dulcie ()
              Ответить

              I cling on to listening to the reports speak about receiving free online
              grant applications so I have been looking around for the most excellent
              site to get one. Could you tell me please, where could
              i get some?

              Feel free to visit my site drug rehab

            119. Mallory ()
              Ответить

              Thanks for your useful post. Through the years, I have been able to understand that the
              particular symptoms of mesothelioma are caused by a build up of fluid between the lining in the
              lung and the breasts cavity. The condition may start in the chest
              region and get distributed to other parts of the body. Other symptoms of pleural mesothelioma include weight loss, severe respiration trouble, throwing up,
              difficulty swallowing, and bloating of the face and neck areas.
              It ought to be noted that some people with the disease never experience almost any serious signs
              or symptoms at all.

              Here is my web blog :: Drug Addiction

            120. Ermelinda ()
              Ответить

              advertising

              Also visit my web-site … Robby

            121. Crystal ()
              Ответить

              One thing I’d like to discuss is that weightloss program fast can be achieved by
              the perfect diet and exercise. Ones size not just affects appearance, but
              also the complete quality of life. Self-esteem, depression, health
              risks, along with physical abilities are impacted in extra weight.
              It is possible to just make everything right whilst still having
              a gain. If this happens, a condition may be the perpetrator.
              While a lot food instead of enough workout are usually at fault,
              common health conditions and popular prescriptions could greatly increase size.
              Thanks for your post

              Here is my blog post … top 10 poker sites

            122. Dillon ()
              Ответить

              Fantastic site. Lots of useful info here. I’m sending it to some friends ans also sharing in delicious.
              And certainly, thanks for your sweat!

              my homepage: addiction rehab [http://www.ozportal.tv]

            123. Lisa ()
              Ответить

              Incredible points. Outstanding arguments. Keep up the amazing
              effort.

              Also visit my blog Medical Detox

            124. Booker ()
              Ответить

              Thanks for your post. I also think that laptop computers are becoming more and more popular right
              now, and now are usually the only form of computer employed in a
              household. This is due to the fact that at the same time that they are becoming more and more very affordable, their processing power is growing to the point where they can be as
              powerful as pc’s out of just a few years ago.

              My site — Alcohol Addiction

            125. Ernesto ()
              Ответить

              Wow, amazing weblog layout! How lengthy have you ever been blogging for?
              you make running a blog look easy. The total look of your web site is wonderful,
              as well as the content material![X-N-E-W-L-I-N-S-P-I-N-X]I just
              couldn’t leave your web site prior to suggesting that I really enjoyed the standard info
              a person provide in your visitors? Is going
              to be again incessantly to check out new posts.

              My web site: Dara Thailand

            126. Kimber ()
              Ответить

              One more thing. I do believe that there are numerous travel
              insurance sites of trustworthy companies than enable you to enter your vacation details to get you the prices.
              You can also purchase the particular international travel insurance policy on the
              web by using the credit card. All you need to do would be
              to enter all travel specifics and you can view the plans side-by-side.
              You only need to find the system that suits your financial budget and needs and use your credit
              card to buy it. Travel insurance on the internet
              is a good way to begin looking for a reputable company for international holiday insurance.
              Thanks for revealing you

              my site :: Alcohol Addiction

            127. Leonor ()
              Ответить

              Hi all, here every one is sharing such know-how, thus it’s
              fastidious to read this web site, and I used to pay a quick visit this weblog every day.

              Feel free to visit my site :: alcohol rehab

            128. Dylan ()
              Ответить

              Hi there are using WordPress for your blog platform?
              I’m new to the blog world but I’m trying to get started and create my
              own. Do you need any coding expertise to make your own blog?
              Any help would be really appreciated!

              Look into my webpage alcohol rehab

            129. Denis ()
              Ответить

              Touche. Sound arguments. Keep up the amazing work.

              Also visit my web blog: Cognitive Behavioural Therapy

            130. Casimira ()
              Ответить

              This is very interesting, You’re a very skilled
              blogger. I have joined your feed and look forward to
              seeking more of your wonderful post. Also,
              I’ve shared your website in my social networks!

              Look into my blog post — Wilhemina

            131. Sienna ()
              Ответить

              Touche. Great arguments. Keep up the amazing effort.

              my blog — Siam Rehab

            132. Mathias ()
              Ответить

              Howdy! Someone in my Facebook group shared this site
              with us so I came to give it a look. I’m definitely loving the information. I’m book-marking and will be
              tweeting this to my followers! Outstanding blog
              and amazing design and style.

              Also visit my blog :: Alcohol Addiction

            133. Anglea ()
              Ответить

              you are in point of fact a just right webmaster.
              The site loading pace is amazing. It seems that you’re doing any unique trick.

              Furthermore, The contents are masterwork. you’ve performed a excellent
              process in this topic!

              Take a look at my blog post :: Alcohol Addiction

            134. Duane ()
              Ответить

              I believe other website proprietors should take this web site
              as an example, very clean and wonderful user friendly layout.

              My page Amphetamine Addiction (Halina)

            135. Dominik ()
              Ответить

              What’s up, just wanted to say, I liked this article.
              It was practical. Keep on posting!

              My webpage :: best online poker reviews

            136. Elouise ()
              Ответить

              Howdy! I know this is kind of off topic but
              I was wondering which blog platform are you using for this
              site? I’m getting fed up of WordPress because I’ve had issues with hackers drug and alcohol rehab I’m looking
              at options for another platform. I would be awesome if you could point
              me in the direction of a good platform.

            137. Madeleine ()
              Ответить

              Wow, marvelous weblog structure! How lengthy have you ever been blogging for?

              you made running a blog glance easy. The whole glance of
              your website is excellent, as smartly as the content material![X-N-E-W-L-I-N-S-P-I-N-X]I just could not go away your website
              before suggesting that I really loved the standard information an individual supply for your guests?
              Is going to be back often to inspect new posts.

              Also visit my site: Evie

            138. Reina ()
              Ответить

              One other thing to point out is that an online business administration training course is
              designed for people to be able to well proceed to bachelors degree programs.
              The Ninety credit certification meets the lower bachelor college degree requirements when you earn the associate of arts in BA online, you will get access to up to date technologies in this particular
              field. Several reasons why students want to get their associate degree in business is
              because they are interested in this area and want to receive the general training necessary
              just before jumping into a bachelor college diploma program.

              Many thanks for the tips you provide with your blog.

              My website — drug rehab

            139. Eunice ()
              Ответить

              I’m impressed, I must say. Actually hardly ever do I encounter a
              weblog that’s each educative and entertaining,
              and let me tell you, you might have hit the nail on the head.
              Your idea is excellent; the issue is something that not
              enough persons are talking intelligently about. I am very completely satisfied that I stumbled throughout this
              in my search for something relating to this.

              my blog … Heroin Addiction

            140. Regina ()
              Ответить

              Hi! This is kind of off topic but I need some guidance from
              an established blog. Is it very difficult to set up your own blog?

              I’m not very techincal but I can figure things out
              pretty fast. I’m thinking about creating my own but I’m not sure where to begin. Do you have any tips or suggestions?
              Cheers

              Check out my web page; Best Personal Loan For Good Credit

            141. Harley ()
              Ответить

              Thank you for your whole labor on this web page. Kim really loves setting aside time for investigation and it’s obvious why.
              My spouse and i know all concerning the compelling way you give very useful things on your website
              and therefore cause participation from the others on the situation and our favorite child
              is in fact understanding a great deal. Have fun with the rest of the new year.

              You are doing a tremendous job.[X-N-E-W-L-I-N-S-P-I-N-X]I
              am extremely inspired with your writing skills as well as with the layout in your
              weblog. Is this a paid subject matter or did you customize it your self?
              Anyway stay up the nice high quality writing, it is uncommon to peer a great weblog like this
              one these days.

              Feel free to surf to my site :: top poker sites — Judy,

            142. Ewan ()
              Ответить

              Hi there every one, here every one is sharing these kinds
              of know-how, so it’s nice to read this website, and I used to pay a visit this web
              site everyday.

              Check out my page: kkpoker review

            143. Ngan ()
              Ответить

              Hello there, I discovered your blog by the use of Google while looking apr for a personal loan a comparable matter, your
              web site got here up, it appears to be like good. I have bookmarked it in my google
              bookmarks.

            144. Pasquale ()
              Ответить

              I wanted to send you this little bit of observation in order to thank you so much as before
              on your amazing opinions you’ve shown above.
              This is quite pretty generous of people like you to deliver
              freely exactly what many people would made available for an e-book to end up making
              some bucks for their own end, even more so considering the fact that
              you could possibly have done it in the event you desired.
              The inspiring ideas as well served to be the great way to be aware that some
              people have similar passion just like my own to figure out significantly more with respect to this condition. I know there are a lot more
              fun occasions ahead for many who find out your blo.

              Take a look at my blog :: upoker review

            145. Claribel ()
              Ответить

              Excellent read, I just passed this onto a colleague who was doing a
              little research on that. And he actually bought
              me lunch because I found it for him smile So let me rephrase that: Thanks for lunch!

              Feel free to surf to my webpage Heroin Addiction

            146. Shenna ()
              Ответить

              t more. Thanks

              Feel free to visit my website: Ice Addiction

            147. Elden ()
              Ответить

              I’m really enjoying the design and layout of your blog.
              It’s a very easy on the eyes which makes it much more pleasant for me
              to come here and visit more often. Did you hire out a designer to create your
              theme? Excellent work!

              Here is my webpage http://www.abacus21.Com

            148. Roscoe ()
              Ответить

              Also a thing to mention is that an online business administration diploma is designed for students to be able to
              without problems proceed to bachelor degree programs. The 90 credit certification meets the other
              bachelor education requirements and once you earn your current associate of arts in BA online, you
              should have access to up to date technologies in such a field.
              hy students are able to get their associate degree in business is because they may be interested in the field
              and want to receive the general schooling necessary previous to jumping right bachelor education program.
              Thx for the tips you really provide as part of your blog.

              My webpage inpatient rehab

            149. Regina ()
              Ответить

              Great delivery. Outstanding arguments. Keep up the good effort.

              Also visit my site: sex face book

            150. Gretta ()
              Ответить

              Hello there, I discovered your site via Google even as looking
              for a related subject, your website got here up, it seems to be good.
              I have bookmarked it in my google bookmarks.

              Also visit my web-site Alcohol Withdrawal

            151. Meridith ()
              Ответить

              I like this blog so much, saved to my bookmarks.

              My web page … facebook of sex

            152. Madge ()
              Ответить

              Wow, amazing weblog layout! How lengthy have you ever been running a blog for?
              you made blogging look easy. The total look of your site is wonderful, let alone
              the content material![X-N-E-W-L-I-N-S-P-I-N-X]I simply couldn’t
              leave your web site before suggesting that I actually loved the standard
              info an individual provide on your visitors?
              Is gonna be back steadily in order to inspect new posts.

              Feel free to surf to my blog … Dara Rehab

            153. Jenifer ()
              Ответить

              Normally I do not learn article on blogs, however I would like to say that this write-up very pressured me to try and do so!
              Your writing taste has been surprised me. Thanks, quite great article.

              my webpage :: Dawn Rehab

            154. Emil ()
              Ответить

              Write more, thats all I have to say. Literally, it seems as though you relied on the video to make your point.
              You definitely know what youre talking about, why throw away your intelligence on just posting videos to your weblog when you
              could be giving us something enlightening to read?

              My web site: Drug Addiction

            155. Nelle ()
              Ответить

              I have realized some significant things through your site post.

              One other subject I would like to express is that there are numerous games in the marketplace designed particularly for toddler age small children. They contain pattern identification, colors, animals, and styles.
              These commonly focus on familiarization in lieu of memorization. This makes a child
              engaged without having a sensation like they are studying. Thanks

              Feel free to surf to my page Alcohol Addiction (http://Www.ozportal.tv)

            156. Connor ()
              Ответить

              I all the time emailed this website post page to all my friends,
              because if like to read it after that my friends will too.

              My blog … drug rehab

            157. Clayton ()
              Ответить

              Right now it seems like Drupal is the top blogging platform
              available right now. (from what I’ve read) Is that what you’re using
              on your blog?

              Here is my blog :: Drug Addiction

            158. Isabella ()
              Ответить

              After study just a few of the weblog posts in your web site now,
              and I actually like your way of blogging. I bookmarked it to my
              bookmark website record and will be checking back soon. Pls try my website as
              properly and let me know what you think.

              Feel free to surf to my homepage alcohol rehab

            159. Winona ()
              Ответить

              Hey there! I’ve been following your web site for a while now
              and finally got the bravery to go ahead and give you a shout out from
              Huffman Texas! Just wanted to tell you keep up the excellent
              work!

              Here is my site — sex on facebook; Jorg,

            160. Celeste ()
              Ответить

              Nice read, I just passed this onto a friend who was doing a little research
              on that. And he actually bought me lunch as I found it for him smile Thus let me
              rephrase that: Thanks for lunch!

              Feel free to surf to my web blog: sex face book

            161. Christiane ()
              Ответить

              We are a group of volunteers and opening a new
              scheme in our community. Your site offered us with valuable info
              to work on. You have done a formidable activity and our
              entire group shall be thankful to you.

              Feel free to visit my webpage: Amphetamine Addiction

            162. Lucie ()
              Ответить

              What’s up, just wanted to tell you, I liked this post. It was
              inspiring. Keep sex on facebook
              posting!

            163. Bessie ()
              Ответить

              Very nice post. I simply stumbled upon your weblog and
              wished to mention that I’ve truly enjoyed surfing around your
              blog posts. In any case I’ll be subscribing on your rss feed and I am
              hoping you write once more soon!

              Also visit my website: Cocaine Addiction

            164. Karolyn ()
              Ответить

              I like your writing style truly loving this internet site.

              Also visit my web page :: facebook of sex — Caitlin,

            165. Kasey ()
              Ответить

              Nice read, I just passed this onto a colleague who was doing a little
              research on that. And he just bought me lunch as I found it for him smile So let me rephrase that:
              Thank you for lunch!

              Feel free to visit my site alcohol rehab

            166. Les ()
              Ответить

              Hello, i think that i saw you visited my weblog thus i came to ?return the
              favor?.I am attempting to find things to enhance my website!I suppose its ok to use a few
              of your ideas!!

              Take a look at my web page Cocaine Addiction

            167. Silvia ()
              Ответить

              Hello! I’ve been reading your site for a while now
              and finally got the bravery to go ahead and give you a shout out from Lubbock Tx!
              Just wanted to tell you keep up the good work!

              Visit my blog post; addiction rehab

            168. Veta ()
              Ответить

              I like this weblog so much, saved to my bookmarks.

              Feel free to surf to my web blog; Dara Rehab

            169. Modesta ()
              Ответить

              I feel this is one of the so much vital information for me.
              And i am glad studying your article. However should commentary on some
              common things, The site style is great, the articles is truly
              nice : D. Excellent job, cheers

              My web-site :: https://sdsforward.ru

            170. Concetta ()
              Ответить

              Thanks for the advice on credit repair on this particular site.
              The things i would tell people is usually to give up the mentality they will buy today and fork out later.
              Being a society we all tend to repeat this for many issues.
              This includes trips, furniture, and items we
              would like. However, you’ll want to separate your current
              wants out of the needs. When you are working to raise your credit
              ranking score make some sacrifices. For example you are
              able to shop online to save money or you can click on second hand outlets instead of highly-priced department stores regarding clothing.

              My page … Alcohol Withdrawal

            171. Bret ()
              Ответить

              Superb post but I was wanting to know if you could write
              a litte more on this subject? I’d be very
              grateful if you could elaborate a little bit more.
              Cheers!

              My homepage … Cabin Rehab

            172. Pasquale ()
              Ответить

              I conceive other website owners should take this website as an example,
              very clean and superb user friendly pattern.

              My webpage Marijuana Addiction

            173. Jorge ()
              Ответить

              I know this if off topic but I’m looking into starting
              my own weblog and was wondering what all is required to get setup?
              I’m assuming having a blog like yours would cost a pretty
              penny? I’m not very internet savvy so I’m not 100% sure.
              Any recommendations or advice would be greatly appreciated.
              Thank you

              My site — Dawn Rehab

            174. Candelaria ()
              Ответить

              Excellent read, I just passed this onto a friend who was doing some research
              on that. And he just bought me lunch because I found it for him smile Thus let me rephrase that:
              Thanks for lunch!

              My web blog — Bad credit personal loans Online

            175. Glenda ()
              Ответить

              I your writing style truly enjoying this internet site.

              Here is my page — Ezra

            176. Donte ()
              Ответить

              Hi! I’ve been reading your site for a long time now and finally got
              the courage to go ahead and give you a shout out from New Caney Texas!
              Just wanted to mention keep up the good job!

              My website; Cognitive Behavioural Therapy

            177. Florene ()
              Ответить

              I always emailed this webpage post page to all my friends,
              for the reason that if like to read it next my friends will too.

              Stop by my web site :: rehab in thailand

            178. Indiana ()
              Ответить

              hi!,I love your writing very a lot! percentage we be in contact more approximately your article on AOL?
              I require an expert in this area to unravel my problem.
              May be that’s you! Taking a look forward to see you.

              my web blog: Dara Rehab

            179. Bernadine ()
              Ответить

              Wonderful work! This is the type of information that should
              be shared around the net. Shame on Google for not positioning this post
              higher! Come on over and visit my website . Thanks =)

              my homepage … Alcohol Detox [realgirls.fun]

            180. Janna ()
              Ответить

              Sweet blog! I found it while surfing around on Yahoo News.
              Do you have any tips on how to get listed in Yahoo News?

              I’ve been trying for a while but I never seem to get
              there! Thanks

              my blog post … drug and alcohol rehab

            181. Bernard ()
              Ответить

              magnificent post, very informative. I wonder why the other specialists of this
              sector do not notice this. You should continue
              your writing. I am confident, you have a huge readers’ base already!

              Feel free to visit my site sex on facebook

            182. Alysa ()
              Ответить

              Thank you a bunch for sharing this with all of us you actually understand what you’re speaking about!
              Bookmarked. Please also seek advice from my site =).
              We may have a link change agreement among us!

              Here is my website … Meth Addiction

            183. Alycia ()
              Ответить

              We are a group of volunteers and opening a brand new scheme
              in our community. Your site offered us with valuable info to work on. You have performed an impressive process and our entire group
              will probably be grateful to you.

              Also visit my webpage; Opioid Addiction

            184. Ezequiel ()
              Ответить

              I enjoy you because of all your valuable work
              on this site. Betty enjoys doing research and it’s really easy
              to understand why. We all notice all regarding the lively form you give very helpful tricks on your website
              and therefore foster response from other
              people on the area of interest then my simple princess is certainly understanding so much.
              Enjoy the remaining portion of the year. Your conducting a w job.

              Also visit my blog post — Alcohol Detox [Vito]

            185. Harris ()
              Ответить

              What’s up all, here every one is sharing these know-how, thus it’s good
              to read this web site, and I used to pay a quick visit this blog all the time.

              Here is my web page — rehab in thailand

            186. Tracy ()
              Ответить

              Thanks for revealing your ideas listed here. The other point is that any time a problem appears with a
              laptop or computer motherboard, people should not consider the risk regarding repairing the item
              themselves because if it is not done right it can lead to permanent damage to all the laptop.
              It’s usually safe to approach your dealer of a laptop for the repair of motherboard.
              They’ve already technicians who may have an expertise in dealing with pc motherboard complications and can make right prognosis and accomplish repairs.

              My web page — Cabin Rehab

            187. Leonor ()
              Ответить

              This is the fitting weblog for anybody who wants to seek out out about this topic.
              You notice so much its almost laborious to argue with you (not that I actually
              would want…HaHa). You definitely put a brand new spin on a
              topic thats been written about for years. Great stuff,
              simply nice!

              My web site; Alphonso

            188. Erin ()
              Ответить

              It’s really a cool and useful piece of info.
              I am glad that you simply shared this useful information with
              us. Please stay us informed like this. Thank you for sharing.

              My web site … rehab in thailand

            189. Jeana ()
              Ответить

              You really make it seem so easy with your presentation but I find this
              topic to be actually something which I think I would never understand.
              It seems too complex and extremely broad for me. I’m looking forward
              for your next post, I’ll try to get the hang of it!

              Feel free to visit my blog: Heroin Addiction

            190. Erna ()
              Ответить

              Thanks for your write-up. What I want to point out is that
              while looking for a good on the internet electronics shop, look for
              a site with comprehensive information on critical factors such as the personal privacy statement, safety details, payment guidelines, and
              other terms and also policies. Usually take time to browse the help
              along with FAQ sections to get a far better idea of how the shop will work, what they are able to do for you,
              and exactly how you can take full advantage of the features.

              Also visit my site: Cocaine Addiction

            191. Krystyna ()
              Ответить

              Everything is very open with a clear explanation of the issues.
              It was really informative. Your site is useful. Thank you for sharing!

              Here is my web page — Siam Rehab (Paul)

            192. Hildred ()
              Ответить

              Everything is very open with a clear explanation of the
              challenges. It was definitely informative. Your site is very
              helpful. Thanks for sharing!

              My web page :: Cocaine Addiction (images.anythingabout.net)

            193. Archie ()
              Ответить

              I was wondering if you ever thought of changing the
              page layout of your site? Its very well written; I love what youve got to say.

              But maybe you could a little more in the way of content so people could connect with it better.
              Youve got an awful lot of text for only having 1
              or two images. Maybe you could space it out better?

              my webpage … Dara Rehab (https://realgirls.fun)

            194. Damian ()
              Ответить

              Hi there, I found your website by way of Google at the same time as looking for a similar matter, your website came up,
              it appears good. I have bookmarked it in my google bookmarks.

              Feel free to surf to my web blog: Opioid Addiction

            195. Rochell ()
              Ответить

              What’s up all, here every person is sharing these
              kinds of knowledge, thus it’s nice to read this web site, and I used to pay a quick visit
              this webpage everyday.

              my homepage non 12 step

            196. Adrian ()
              Ответить

              As I website possessor I believe the content matter here is rattling
              magnificent , appreciate it for your efforts. You should keep it up forever!

              Good Luck.

              Here is my homepage top ten poker sites

            197. Alberto ()
              Ответить

              I do agree with all the ideas you’ve presented in your post.
              They are very convincing and will definitely work.

              Still, the posts are very short for newbies. Could
              you please extend them a bit from next time? Thanks for the
              post.

              Check out my webpage: Dual Diagnosis

            198. Hayden ()
              Ответить

              Good day! This is my first comment here so I
              just wanted to give a quick shout out and tell you I really enjoy reading through your blog posts.
              Can you recommend any other blogs/websites/forums that deal
              with the same subjects? Appreciate it!

              my page: addiction rehab

            199. Yolanda ()
              Ответить

              Write more, thats all I have to say. Literally, it seems as
              though you relied on the video to make your point. You obviously know what youre talking about,
              why waste your intelligence on just posting videos to your blog when you could be giving us something enlightening to read?

              My site — Dwight

            200. Carla ()
              Ответить

              I wanted to compose you that very small observation to be able to
              thank you very much yet again over the amazing
              methods you’ve shared in this case. It’s quite seriously open-handed of people
              like you to provide unreservedly all a number of us might have distributed as an e book to get some cash for their own end, most notably
              given that you might well have tried it in case you considered
              necessary. Those advice additionally acted to be the great way to comprehend other
              people online have the identical dream like my very own to grasp much more with regard to this condition. I’m sure there are several more pleasant
              instances ahead for folks who look over your blo.

              Here is my blog post — Siam Rehab

            201. Kevin ()
              Ответить

              er an hour. It’s among the easiest laptop upgrade methods one can consider.
              Thanks for discussing your ideas.

              my web page: Meth Addiction

            202. Daisy ()
              Ответить

              There are some attention-grabbing deadlines on this article but
              I don’t know if I see all of them heart to heart.
              There may be some validity however I will take maintain opinion until I look into it further.
              Good article , thanks and we would like more! Added to FeedBurner as properly

              Feel free to visit my page :: Marijuana Addiction

            203. Candice ()
              Ответить

              I should say also believe that mesothelioma cancer is a unusual form of many forms
              of cancer that is commonly found in those people
              previously familiar with asbestos. Cancerous cells form within the mesothelium, which is a shielding
              lining that covers almost all of the body’s body organs.
              These cells commonly form inside the lining on the lu

              Have a look at my site: Heroin Addiction (Garnet)

            204. Leopoldo ()
              Ответить

              Hello there, I discovered your web site via Google while searching for a comparable topic, your web site got here up, it seems good.

              I have bookmarked it in my google bookmarks.

              my web blog :: Dara Thailand

            205. Verlene ()
              Ответить

              We’re a group of volunteers and opening a new scheme in our community.
              Your website provided us with valuable info to work on.
              You’ve done a formidable process and our entire neighborhood can be grateful to you.

              my website — drug rehab (https://8owic0.icu/hope-rehab-the-google-strategy)

            206. Keira ()
              Ответить

              Hey! This post couldn’t be written any better! Reading through this post reminds me of my good old room
              mate! He always kept chatting about this. I will forward this page to him.
              Pretty sure he will have a good read. Many thanks for
              sharing!

              Stop by my website … Medical Detox

            207. Reda ()
              Ответить

              Hello, i think that i saw you visited my site so
              i came to ?return the favor?.I’m attempting to find
              things to improve my site!I suppose its ok to use a few of your ideas!!

              My blog post Eugenio

            208. Imogene ()
              Ответить

              An additional issue is that video gaming has become
              one of the all-time most significant forms of fun for people of various age groups.
              Kids engage in video games, and adults do, too. Your XBox 360 is
              one of the favorite gaming systems for many who love to have a
              huge variety of games available to them, drug and alcohol rehab who like to play live with all over the
              world. Many thanks for sharing your opinions.

            209. Jame ()
              Ответить

              Hi, i think that i saw you visited my website thus i came to ?return the favor?.I am attempting to find things to improve my
              web site!I suppose its ok to use a few of your ideas!!

              Have a look at my blog :: Alcohol Addiction

            210. Debbie ()
              Ответить

              wonderful post, very informative. I wonder why the other specialists of this sector do not notice this.
              You should continue your writing. I’m confident, you’ve a great
              readers’ base already!

              my web page … Drug Addiction

            211. Micah ()
              Ответить

              Pretty nice post. I just stumbled upon your weblog
              and wanted to say that I have really enjoyed browsing your blog posts.
              In any case I will be subscribing to your rss feed and I
              hope you write again very soon!

              Look into my website — Marijuana Addiction; Della,

            212. Sheri ()
              Ответить

              Hello there, I found your blog via Google whilst looking for a comparable topic,
              your site got here up, it appears good. I have bookmarked it in my google
              bookmarks.

              Review my web blog … Drug Addiction (realgirls.fun)

            213. Lilia ()
              Ответить

              I enjoy your writing style really loving this
              website.

              my website; Boutique Rehab

            214. Mark ()
              Ответить

              Thanks for the thoughts you write about through
              this website. In addition, a lot of young women who become pregnant will not even aim to get Medical Detox care insurance because they
              have anxiety they wouldn’t qualify. Although a few states now require that insurers offer coverage regardless of pre-existing
              conditions. Premiums on these types of guaranteed plans are
              usually bigger, but when with the high cost of health care
              it may be any safer strategy to use to protect a person’s financial future.

            215. Hwa ()
              Ответить

              Wow, awesome weblog structure! How long have you
              ever been running a blog for? you make blogging glance easy.
              The overall glance of your site is fantastic, let alone the content material![X-N-E-W-L-I-N-S-P-I-N-X]I just couldn’t depart your web site prior to suggesting that I actually enjoyed the usual info a person supply to your
              visitors? Is going to be again ceaselessly to investigate cross-check new posts.

              my web-site … Dual Diagnosis

            216. Stephaine ()
              Ответить

              Touche. Solid arguments. Keep up the great effort.

              Here is my web site :: drug rehab

            217. Vernon ()
              Ответить

              Wow, incredible weblog structure! How lengthy have you been blogging for?

              you make running a blog look easy. The overall glance of your
              website is excellent, as well as the content material![X-N-E-W-L-I-N-S-P-I-N-X]I just could
              not go away your site prior to suggesting that I really enjoyed the standard info an individual provide for your guests?
              Is gonna be again often in order to inspect new posts.

              Here is my web page refer.ash1.ccbill.com

            218. Steve ()
              Ответить

              Hello there, I found your web site via Google at
              the same time as looking for a comparable subject, your web
              site came up, it appears to be like good. I have bookmarked it in my google bookmarks.

              my web site :: Cabin rehab

            219. Casey ()
              Ответить

              I all the time emailed this website post page to all my
              friends, since if like to read it afterward my friends will too.

              My web-site: Hope Rehab

            220. Wilhemina ()
              Ответить

              Thanks a lot for sharing this with all people you really realize what you are speaking approximately!

              Bookmarked. Kindly additionally discuss with my site =).

              We can have a hyperlink trade contract between us!

              Visit my website :: Dawn Rehab

            221. Anton ()
              Ответить

              Thanks for your submission. Another thing is that just being a
              photographer consists of not only problems in capturing
              award-winning photographs and also hardships in getting the best photographic camera suited to
              your needs and most especially hardships in maintaining the caliber of your camera.

              This is certainly very true and obvious for those photography addicts that are in capturing a nature’s fascinating
              scenes — the mountains, the actual forests, the actual wild or maybe
              the seas. Visiting these exciting places unquestionably requires a video camera that
              can meet the wild’s nasty landscapes.

              My web page; Heroin Addiction

            222. Adelaida ()
              Ответить

              I like this blog so much, saved to favorites.

              Feel free to surf to my blog post: inpatient rehab

            223. Eulah ()
              Ответить

              We’re a group of volunteers and starting a new scheme in our community.
              Your website offered us with valuable information to work on. You have done a formidable job and
              our entire community will be grateful to you.

              My site: Dara Rehab

            224. Aidan ()
              Ответить

              Thanks for your article. I would also like to say
              that a health insurance dealer also works well with the benefit of the coordinators
              of a group insurance plan. The health broker is given an index of benefits
              searched for by someone or a group coordinator. What any broker
              does indeed is look for individuals as well as coordinat

              Also visit my blog post … Alcohol Detox

            225. Edison ()
              Ответить

              Hi there every one, here every one is sharing these familiarity,
              so it’s fastidious to read this weblog, and I used to pay a quick visit this blog daily.

              Feel free to surf to my web page — Medical Detox

            226. Darryl ()
              Ответить

              Hi there everybody, here every person is sharing these kinds of knowledge,
              thus it’s pleasant to read this website, and I used to pay a visit this website everyday.

              Also visit my website :: Medical Detox

            227. Guy ()
              Ответить

              Great delivery. Outstanding arguments. Keep up the amazing effort.

              my web blog; Dara Rehab (Marquita)

            228. Wilford ()
              Ответить

              Thank you a bunch for sharing this with all of us you actually understand
              what you’re talking approximately! Bookmarked. Please also
              talk over with my website =). We could have a link alternate agreement among us!

              My page … drug rehab

            229. Abby ()
              Ответить

              I want to express my appreciation for your kindness
              supporting men and women who should have assistance with in this concept.
              Your personal commitment to getting the message acro had become pretty informative and has continuously
              allowed folks much like me to arrive at their objectives.
              Your own invaluable help and advice implies a whole lot a person like me and far more to
              my colleagues. Thanks a ton; from everyone of us.

              Check out my web blog — luxury drug rehab

            230. Angeline ()
              Ответить

              affiliate marketing for natural health and
              wellness
              health blog membership sites
              affiliate marketing for alternative health bloggers
              online jobs for stay-at-home moms

              Look into my page — pharmacy affiliate marketing case studies for beginners

            231. mibEffiff ()
              Ответить

              purchasing cialis online It is not uncommon for patients on Clomid to develop ovarian cysts and persistent luteal phase problems and in the absence of a pregnancy a pelvic scan would be valuable to confirm this problem and in so doing to avoid future use of Clomid in the dosages that you have used

            232. mibEffiff ()
              Ответить

              watermelon and ginger natural viagra As for the Milk Thistle

            233. iHGUySBUo ()
              Ответить

              For those not suited to an ambulatory device e comparatif viagra prix levitra Antrals and IVF Success for Female Age 35- 37 at Advanced Fertility Center of Chicago Women 35 to 37 years old have slightly lower success than the younger women Slightly higher rates of cycle cancellation are also seen The median antral follicle count at age 35- 37 was 17 Age 38- 40 antral follicle counts and IVF success

            234. Hildegarde ()
              Ответить

              What’s up, constantly i used to check blog posts here in the early hours in the break of day,
              since i enjoy to learn more and more.

              Feel free to surf to my web page xiety disponible sin receta en España

            235. Minda ()
              Ответить

              I am really delighted to glance at this web site posts which contains plenty of helpful data,
              thanks for providing these information.

              Here is my web page — Sibyl

            236. Drew ()
              Ответить

              Hello everyone, it’s my first pay levofloxacin a precio asequible en Argentina visit
              at this web page, and paragraph is genuinely fruitful in favor of me, keep up posting such articles.

            237. Morgan ()
              Ответить

              Hurrah, that’s what I was searching for, what
              a material! present here at this website, thanks admin of this site.

              Also visit my web-site :: Tyrell

            238. Ivory ()
              Ответить

              Hi, this weekend is fastidious for me, since this moment i
              am reading this fantastic informative post here
              at my home.

              My web-site: Wie kann ich colospa in der Schweiz bekommen?

            Это интересно
            No Image Варикоз
            24 190 комментариев
            No Image Варикоз
            34 886 комментариев
            No Image Варикоз
            26 404 комментария
            Adblock
            detector