Postpartum bleeding is bleeding from the birth canal that occurs in the early or late postpartum period. Postpartum bleeding is most often a consequence of the main obstetric complication. The severity is determined by the amount of blood loss. Bleeding is diagnosed by examination of the birth canal, examination of the uterine cavity, ultrasound. Treatment requires infusion-transfusion therapy, administration of uterotonic agents, suturing of ruptures, sometimes extirpation of the uterus.
ICD 10
O72 Postpartum bleeding
General information
The danger of postpartum bleeding is that it can lead to a rapid loss of a large volume of blood and the death of the woman in labor. Abundant blood loss is facilitated by the presence of intense uterine blood flow and a large wound surface after childbirth. Normally, a pregnant woman’s body is ready for physiologically permissible blood loss during childbirth (up to 0.5% of body weight) due to an increase in intravascular blood volume. In addition, postpartum bleeding from the uterine wound is prevented by increased contraction of the uterine muscles, compression and displacement into deeper muscle layers of the uterine arteries with simultaneous activation of the blood clotting system and thrombosis in small vessels.
Early postpartum bleeding occurs in the first 2 hours after delivery, late ones can develop in the period from 2 hours to 6 weeks after the birth of the child. The outcome depends on the volume of blood lost, the rate of bleeding, the effectiveness of conservative therapy, and the development of DIC syndrome. Prevention is an urgent task of obstetrics and gynecology.
Causes
Postpartum bleeding often occurs due to a violation of the contractile function of the myometrium: hypotension (decreased tone and insufficient contractile activity of the uterine muscles) or atony (complete loss of uterine tone, its ability to contract, lack of response of the myometrium to stimulation). The causes of such postpartum bleeding are fibroids and uterine fibroids, scarring processes in the myometrium; excessive stretching of the uterus during multiple pregnancy, polyhydramnios, prolonged labor with a large fetus; the use of drugs that reduce the tone of the uterus.
Postpartum bleeding can be caused by a delay in the uterine cavity of the remnants of the placenta: placenta lobules and parts of the fetal membranes. This prevents the normal contraction of the uterus, provokes the development of inflammation and sudden postpartum bleeding. Partial increment of the placenta, improper management of the third period of labor, discoordinated labor activity, cervical spasm leads to a violation of the separation of the afterbirth.
Factors provoking can be hypotrophy or atrophy of the endometrium due to previously performed surgical interventions – cesarean section, abortions, conservative myomectomy, curettage of the uterus. The occurrence may contribute to a violation of hemocoagulation in the mother, due to congenital anomalies, taking anticoagulants, the development of DIC syndrome.
Often, postpartum bleeding develops with injuries (ruptures) or dissection of the genital tract during childbirth. There is a high risk of postpartum bleeding with gestosis, presentation and premature detachment of the placenta, the threat of termination of pregnancy, fetoplacental insufficiency, pelvic presentation of the fetus, the presence of endometritis or cervicitis in the mother, chronic diseases of the cardiovascular and central nervous system, kidneys, liver.
Symptoms of postpartum bleeding
Clinical manifestations of postpartum bleeding are caused by the amount and intensity of blood loss. With an atonic uterus that does not respond to external therapeutic manipulations, postpartum bleeding is usually abundant, but it can also have a wave-like character, sometimes subside under the action of drugs that contract the uterus. Arterial hypotension, tachycardia, pallor of the skin are objectively determined.
The volume of blood loss up to 0.5% of the body weight of a woman in labor is regarded as physiologically permissible; with an increase in the volume of blood lost, they talk about pathological postpartum bleeding. The amount of blood loss exceeding 1% of body weight is considered massive, above that – critical. With critical blood loss, hemorrhagic shock and DIC syndrome may develop with irreversible changes in vital organs.
In the late postpartum period, a woman should be alerted by intense and prolonged lochia, bright red discharge with large blood clots, unpleasant odor, pulling pains in the lower abdomen.
Diagnosis of postpartum bleeding
Modern clinical gynecology evaluates the risk of postpartum bleeding, which includes monitoring during pregnancy of hemoglobin levels, the number of erythrocytes and platelets in the blood serum, the time of bleeding and blood clotting, the state of the blood coagulation system (coagulograms). Hypotension and uterine atony can be diagnosed during the third period of labor by flabbiness, weak contractions of the myometrium, and a longer course of the postpartum period.
Diagnosis is based on a thorough examination of the integrity of the separated placenta and fetal membranes, as well as examination of the birth canal for injury. Under general anesthesia, the gynecologist carefully performs a manual examination of the uterine cavity for the presence or absence of ruptures, remaining parts of the afterbirth, blood clots, existing malformations or tumors that prevent the contraction of the myometrium.
An important role in preventing late postpartum bleeding is played by pelvic ultrasound on 2-3 days after delivery, which allows detecting the remaining fragments of placental tissue and fetal membranes in the uterine cavity.
Treatment of postpartum bleeding
In case of postpartum bleeding, it is paramount to establish its cause, stop extremely quickly and prevent acute blood loss, restore the volume of circulating blood and stabilize the blood pressure level. In the fight against postpartum bleeding, an integrated approach is important with the use of both conservative (medical, mechanical) and surgical methods of treatment.
To stimulate the contractile activity of the uterine muscles, catheterization and emptying of the bladder, local hypothermia (ice on the lower abdomen), gentle external massage of the uterus, and in the absence of a result, intravenous administration of uterotonic agents (usually methylergometrine with oxytocin), injections of prostaglandins into the cervix. To restore the BCC and eliminate the consequences of acute blood loss during postpartum bleeding, infusion-transfusion therapy with blood components and plasma-substituting drugs is carried out.
If ruptures of the cervix, vaginal walls and perineum are detected during the examination of the birth canal in mirrors, they are sutured under local anesthesia. In case of violation of the integrity of the placenta (even in the absence of bleeding), as well as hypotonic postpartum bleeding, an urgent manual examination of the uterine cavity is performed under general anesthesia. During the revision of the walls of the uterus, manual separation of placenta remnants and membranes, removal of blood clots is performed; the presence of ruptures of the uterine body is determined.
In case of rupture of the uterus, an emergency laparotomy, suturing of the wound or removal of the uterus is performed. When signs of placental increment are detected, as well as with uncupable massive postpartum bleeding, subtotal hysterectomy (supravaginal amputation of the uterus) is indicated; if necessary, it is accompanied by ligation of the internal iliac arteries or embolization of the uterine vessels.
Surgical interventions are carried out simultaneously with resuscitation measures: compensation of blood loss, stabilization of hemodynamics and blood pressure. Their timely implementation before the development of thrombohemorrhagic syndrome saves the woman in labor from death.
Prevention
Women with an unfavorable obstetric and gynecological history, disorders of the coagulation system, taking anticoagulants, have a high risk of postpartum bleeding, therefore they are under special medical supervision during pregnancy and are sent to specialized maternity hospitals.
In order to prevent postpartum bleeding, women are injected with drugs that promote adequate uterine contraction. All women in labor spend the first 2 hours after delivery in the maternity ward under the dynamic supervision of medical personnel to assess the volume of blood loss in the early postpartum period.
