Postpartum hemorrhage is defined as blood loss in excess of 400 mL at the time of vaginal delivery

OBSTETRIC HEMORRHAGES

Prepared by professor S.N.Heryak

Ternopol medical state univercity

by I.Y. Gorbachevsky

 

The main causes in the first trimester of pregnancy:

l     Spontaneous abortion

l     Ectopic pregnancy

l     Hytadidiform Mole

Abortion is the termination of a pregnancy before viability, typically defined as 22 weeks from the first day of the last normal menstrual period or a fetus weighing less than 500 g and its height is less than 25 cm

Clinical classification of spontaneous abortion:

l     Threatened – doesn’t provoke bleedong

l     Initial

l     Inevitable

l     Completed

l     Incomplete

l     Missed

Reasons for spontaneous abortion

1.     Maternal 

l     Infections – Listeria, Mycoplasma hominis, Ureaplasma urealyticum, Toxoplasmosis,Rubella, Cytomegalovirus.

l     Endocrine factors - luteal phase inadequacy, HyperthyroidismDiabetes Mellitus

l     Environmental factors

l     Uterine abnormalities

 2.  Paternal - chromosomal abnormality in either parent.

3. Fetal - genetic abnormalities of the conceptus, approximately half of which are autosomal trisomies

Threatened abortion

Signs – lover abdominal pain.

In bimanual examination – cervix is closed, enlargement of the uterus corresponds with gestational period

Management – conservative

Initial abortion

Signs – lover abdominal pain, bloody vaginal discharge.

In bimanual examinationcervix is closed, enlargement of the uterus corresponds with gestational period

Management – conservative:

               Bed rest

               Sedative drugs – Valeriannae, Persen, Novopaside.

               Spasmolitics – No-Spani, Papaverini hydrochloride

               Analgetics – Analgin, Baralgin

               Progesterone – Utrogestan – 100 mg twice a day, Duphastone – 10 mg 2-3 times a day, Progesterone 10-25 mg in a day, Endometrin – 100mg 2 times a day

               Chorionic Gonadotropin Hormone

               Vitamines – vit. E 200 mg per os, folic acid – 0,4 mg in a day

Inevitable abortion

Signs – cramp abdominal pain thanks to uterine contractions, bloody vaginal discharge till profuse hemorrhage.

 In bimanual examination – cervix is dilated, products of conception are presented on cervical channel,  enlargement of the uterus doesn’t correspond with gestational period – smaller

Management –surgical – uterine curettage.

Complete abortion

Signs - lover abdominal pain, bloody vaginal discharge.

In bimanual examination – cervix is dilated or closed, enlargement of the uterus doesn’t correspond with gestational period – smaller.

Management –surgical – uterine curettage

 

Incomplete abortion

Signs – lover abdominal pain, bloody vaginal discharge.

   In bimanual examination – cervix is dilated, enlargement of the uterus doesn’t correspond with gestational period – smaller, some products of conception should be expelled out.

Management –surgical – uterine curettage

 

ECTOPIC PREGNANCY

 

l     Implantation outside of the uterine cavity is termed as ectopic pregnancy

l     !Ectopic pregnancy is the leading cause of maternal mortality in the first trimester

 

Etiology of ectopic pregnancy

1.Mechanical Factors - prevent or retard passage of the fertilized ovum into the uterine cavity include the following.

l     1.  Salpingitis,

l     2.  Peritubal adhesions subsequent to postabortal or puerperal infection

l     3.  Developmental abnormalities of the tube, especially diverticula,  hypoplasia.

l     4.  Previous ectopic pregnancy.

l     5.  Previous operations on the tube, either to restore patency

l     6.  Multiple previous induced abortions.

l     7.  Tumors that distort the tube, such as uterine myomas, adnexal masses.

2.Functional Factors - that delay passage of the fertilized ovum into the uterine cavity.

l     1.  External migration of the ovum

l     2.  Menstrual reflux

l     3.  Altered tubal motility

l     4. Cigarette smoking at the time of conception

3.Increased Receptivity of Tubal Mucosa to Fertilized Ovum.

4.Assisted Reproduction.   

5.Failed Contraception.

Classification of ectopic pregnancy

According to localization:

l     Tubal – isthmic, interstitial,ampullary 

l     Ovarian

l     Abdominal

l     Broad-Ligament pregnancy

l     Cervical

According to clinical duration:

l     Progressive

l     Ruptured - Tubal rupture, Tubal abortion

Clinical signs of ectopic pregnancy

l     Presence of Presumptive and Probable signs of pregnancy

l     Irregular dark brown vaginal bleeding

l     Pain – from light to severe

l     Syncope

l     Dizziness

l     Urge to defecate

l     Signs of internal hemorrhage - peritoneal irritation, shock

Pelvis examination:

l     Unilateral or bilateral exquisite tenderness especially on motion of the cervix

l     Adnexal mass

l     Enlarged uterus

l     Tenderness and painful of the posterior fornix

CULDOCENTESIS – puncture of posterior fornix, bloody fluid that

   does not clot result of  hemoperitoneum resulting from an ectopic pregnancy

Management:

Surgical:

l     linear salpingostomy

l     segmentai resection

l     Salpingectomy

Medical - Methotrexate,  folinic acid antagonist: if the gestation is less than 6 weeks, the tubal mass is not more than 3.5 cm in diameter, and the fetus is not alive

Signs of cervical pregnancy

l     uterine bleeding without cramping after a period of amenorrhea

l     softened cervix disproportionally enlarged to a size equal to or larger than the corpus

l     complete confinement and firm attachment of the products of conception to the endocervix, snug internal cervical os.

Management – Hysterectome, embolization of uterine artery

HYDATIDIFORM MOLE - Is an abnormal conceptus with loss of villus vascularity and without an embryo or fetus.

l     Most of symptoms are presented thanks to markedly elevated hCG levels

Signs of Molar pregnancy

l     Vaginal bleeding with molar elements

l     Preeclampsia

l     In pelvic exam - uterus larger than expected, Ovarian enlargement due to bilateral theca lutein cysts

l     Ultrasonography – “snow-storm” appearance

Treatment – vacuum aspiration, utreine curretage

 

BLEEDING IN THE SECOND HALF OF PREGNANCY

 The main causes of bleeding in the second half of pregnancy are:

Vulva

Varicose veins

Tears or lacerations

Vagina

Tears or lacerations

Cervix

Polyp

Glandular tissue (normal)

Cervicitis

Carcinoma Intrauterine

Placenta previa

Abruptio placentae

Vasa previa

PLACENTA PREVIA

Placenta previa refers to an abnormal loca­tion of the placenta over, or in close prox­imity to, the internal cervical os. Placenta previa can be categorized as:

¨     complete or total -  if the entire cervical os is covered;

¨     par­tial -  if the margin of the placenta extends across part but not all of the internal os;

¨     marginal , if the edge of the placenta lies adjacent to the internal os;

¨     low lyingif the placenta is located near but not directly adjacent to the internal os.

The etiology of placenta  previa is not under­stood, but abnormal vascularization has long been proposed as a mechanism for this abnormal placement of the placenta. In some cases, such as in twin pregnancy or if it is hydropic, the placenta may extend to the region of the internal cervical os because of its size alone. Increasing maternal age, increasing parity, and previous cesarean delivery are factors commonly associated with placenta previa, although recent evi­dence suggests that age alone is not an important factor.

Clinical signs: Painless bleeding, Ultrasonography has been of enormous benefit in localizing the placenta, Careful vaginal examination – in labor.

Management of placenta previa during pregnancy

l       Initial hospitalization with hemodynamic stabilization, followed by expectant management until fetal  maturity has occurred.

l       Bed rest

l       Vitamins – for increasing of vascular strenght: Rutin, Ascorutin, Ca

l       Bloodstoping agents – Vicasol, Dicinon, Tranexam

l       Smasmolytics in the case of pregnancy interruption

Management of placenta previa in labor

l     Complete – cesarean section;

l     Partial, marginal, low lying - artificial rupture of the membranes and oxytocin induction of labor. 

   If the hemorrhage exceeds 250-300ml – immediate cesarean section

ABRUPTIO PLACENTAE

Whereas placenta previa refers to the abnormal location of the placenta, abruptio placentae, often called placental abruption, refers to the premature separation of the normally implanted placenta from the uter­ine wall.

Etiology. Placental abruption occurs when there is hemorrhage into the decidua basalis, leading to premature placental separation and fur­ther bleeding. The cause for this bleeding is not known.

Clinical findings and Diagnosis. 

The signs and symptoms can vary considerable. External bleeding can be profuse or there may be no external bleeding (concealed hemorrhage) but the placenta is completely sheared off and the fetus dead. Besides, common findings are uterine tenderness, back pain, fetal distress, uterine hypertonus or high-frequently contractions, idiopathic preterm labor, and a dead fetus.

Because the separation of the placenta from the uterus interferes with oxygénation of the fetus, a nonreassuring fetal status is quite common in cases of significant placental abruption. Thus, in any patient in whom placental abruption is suspected, electronic fetal monitoring should be included in the initial management.

Coagulation abnormalities may also be found, thereby compounding the patient's already compromised status. Placental abrup­tion is the most common cause of consump­tive coagulopathy in pregnancy and is mani­fested by hypofibrinogenemia as well as by increased levels of fibrin degradation prod­ucts. The platelet count can also be decreased, and prothrombin time and partial thromboplastin time can be increased as well. Such coagulopathy is a result of intravascular and retroplacental coagulation. The intravas­cular fibrinogen is converted to fibrin by way of the extrinsic clotting cascade. Thus not only is serum fibrinogen decreased but platelets and other clotting factors are thereby also depleted.

Ultrasound is of little benefit in diag­nosing placental abruption, except to exclude placenta previa as a cause for the hemorrhage. Relatively large retroplacental clots may be detected on ultrasound exami­nation, but the absence of ultrasonographically identified retroplacental clots does not rule out the possibility of placental abrup­tion, and conversely, a retroplacental echogenic area can be seen in patients with­out placental abruption. The diagnosis rests on the classic clinical presentation of vagi­nal bleeding, a tender uterus, and frequent uterine contractions with some evidence of fetal distress. The extravasation of blood into the uterine muscle causes contractions such that the resting intrauterine pressure, when measured with an intrauterine pres­sure catheter, is often elevated; this sign can be helpful in making the diagnosis. The entire uterus has a purplish or bluish appearance, owing to such extravasation of blood (Couvelaire uterus). 

Management of a patient with placental abruption when the fetus is mature is hemodynamic stabilization and delivery. Appropriate facilities and staff for cesarean section must be continuously available whenever placental abruption is suspected  Careful attention to blood component therapy is crit­ical, and the coagulation status must be fol­lowed closely. Unless there is evidence of fetal distress or hemodynamic instability, vaginal delivery by oxytocin induction of labor is preferable to a cesarean delivery, although the maternal or fetal status may require that abdominal delivery be performed. When the fetus is not mature and the placental abrup­tion is limited and not associated with pre­mature labor or fetal or maternal distress, observation with close monitoring of both fetal and maternal well-being may be consid­ered while awaiting fetal maturity. In the case of Couvelaire uterus total hysterectomy is performed because of danger of uterine hypotony and disseminated intravascular clotting syndrome.

 

HEMORRHAGE IN THE THIRD STAGE OF LABOR AND EARLY PUERPERAL PERIOD

 

Postpartum hemorrhage is defined as blood loss in excess of 400 mL at the time of vaginal delivery.

Postpartum hemorrhage before delivery of the placenta is called third-stage hemorrhage.

Postpartum hemorrhage after delivery of placenta during the first two hours is called as hemorrhage in early puerperal stage.

Hemorrhage after placental separation is stopped thanks to:

·        uterine contractions – caliberes of ruptured vessels decreases during uterine contractions;

·        formation of thrombs, especially in the region of placental site;

·        torsion of thin septs in which vessels are situated.

 

Causes of Postpartum Hemorrhage:

·        uterine atony,

·        genital tract trauma,

·        bleeding from the placental site (retained placental tissue, low placental implantation, placental adherence, uterine inversion)

·        coagulation disorders.

 

The main causes of third-stage bleeding are genital tract trauma and bleeding from placental site.

The main causes of hemorrhage in early puerperal stage are all of the above causes of Postpartum hemorrhage.

 

Predisposing factors and causes of immediate postpartum hemorrhage:

Uterine atony:

1. Overdistended uterus – multiple fetuses, Hydramnios, distention with clots.

2. Anesthesia or analgesia – halogenated agents, conducted analgesia with hypertension.

3. Exhausted myometrium – rapid labor, prolonged labor, oxytocin or prostaglandin stimulation.

4. Chrionamnionitis.

4. Previous uterine atony.

Genital tract trauma:

1. Complicated vaginal delivery.

2. Cesarean section or hysterectomy, forceps or vacuum.

3. Uterine rupture; risk increased by: previously scarred uterus, high parity, hyperstimulation, obstructed labor, intrauterine manipulation.

4. Large episiotomy, including extensions.

5. Lacerations of the perineum, vagina or cervix.

 

Bleeding form placental implantation cite:

1. Retained placental tissue – avulsed cotyledon, succentuariate lobe

2.Abnormally adherent – accreta, increta, percreta. 

Coagulation defects – intensifies other causes:

1. Placental abruption.

2. Prolonged retention of dead fetus.

3. Amnionic fluid embolism.

4. Saline-induced abortion.

5. Sepsis with endotoxemia.

6. Severe intravescular hemolysis.

7. Massive transfusions.

8. Severe preeclampsia or eclampsia.

9. Congenital coagulopathies.

 

Clinical findings and diagnosis

The two most common causes of immediate hemorrhage are hypotonic myometrium (uterine atony) and lacerations of the vagina and cervix. Retention of part or all of the placenta, a less common cause, may produce either immediate or delayed hemorrhage (or both).

Uterine atony is called as total absence of uterine contractions into the external irritation. Uterine hypotony is called as presence of inadequate uterine contractions on the external irritation. In the pauses between uterine contractions a uterus is soft. But  blood form clots in the case of uterine hypo- or atony. These clots are stored in the uterine cavity that’s why a uterus is enlarged in sizes. 

The differentiation between bleeding from uterine atony and from lacerations is tentatively based on the condition of the uterus. If bleeding persists despite a firm, well-contracted uterus, the cause of the hemorrhage most probably lacerations. Bright red blood also suggests lacerations. To ascertain the role of lacerations as a cause of bleeding, careful inspection of the vagina, cervix, and uterus is essential.

Placental accreta is any implantation of the placenta in which there is abnormally firm adherence to the uterine wall. As a consequence of partial or total absence of the decidua basalis and imperfect development of the fibrinoid layer (Nitabush’s membrane):

·          the placental villi are attached into the basal layer - placenta adhaerens;

·          the placental villi are  attached to the myometrium - placenta accreta;

·          extensive growth of placental tissue into the uterine muscle itself – placenta increta;

·          complete invasion through the sickness of the uterine muscle to the serosa or beyond – placenta percreta.

 Complete or total placenta accreta will not cause bleeding because the placenta remains attached, but partial ( the abnormal adherence involves a few to several cotyledons) or focal ( the abnormal adherence involves a single cotyledon) type may cause profuse bleeding, as the normal part of the placenta separates and the myometrium cannot contract sufficiently to occlude the placental site vessels.

The abnormal placental adherence is diagnosed by:

1. Absence of the signs of placental separation during 30 minutes.

Signs of placental separation:

·        the uterus rises in the abdomen;

·        the shape of the uterus changes from discoid to globular

·        the umbilical cord lengthens.

2. External bleeding – in the case of partial adherence, absence of the bleeding – in the case of total placenta accreta.

3. Manual removal of the placenta confirms the diagnosis of different types of abnormal placental adherence. In the case of partial placental adhaerence it stops bleeding, but in the case of placenta accreta, increta and percrata it increases bleeding. Attempts at manual removal are futile. That’s why in these cases manual removal of the placenta should be stopped immediately and hysterectomy should be performed.

 

Coagulation disorders are recognized thanks to coagulation studies and inspection for clot formation. 

 

MANAGEMENT OF THE PATIENTS IN THE THIRD-STAGE BLEEDING

 

UTERINE ATONY

Modern contractile drugs – Pabal –i/v 1ml - 1ìë (100 mkg carbetocin)

 

2.     Massage of the uterine corpus: one hand gently massages the uterus from the abdomen while the other is inserted so that the cervix is cradled in the fingers and thumb to allow maximal compression and massage.

3.  Manual exploration of the uterine cavity under the general anesthesia, bimanual uterine compression.

4.  Aorta compression to the spinal column.

5.  Ligation of uterine arteries, ovarian arteries, a. iliaca interna

6.  Compressive B-Lynch sutures into the uterus

 

GENITAL TRACT TRAUMA – ligation and suturing of all ruptures of the vagina, cervix and perineum. In the case of uterine rupture – hysterectomy should be performed.

 

BLEEDING FROM PLACENTAL IMPLANTATION CITE

1) placental separation signs are absent – manual separation and removal of the placenta and exploration of the uterine cavity, uterine massage, uterine contracting drugs are prescribed;

2)  complete and partial placenta adhaerens - manual separation and removal  of the placenta;

3) placenta accreta, increta and percreta – hysterectomy. With more extensive involvement, however, hemorrhage becomes profuse as manual removal of the placenta is attempted.

 

Attention ! Irrespective of the apparent cause, whenever there is any suggestion at the delivery or postpartum of excessive blood loss from the genital tract, immediate steps must be taken to identify the presence of uterine atony, retained placental fragments, and trauma.

1.     At least one or, in the presence of frank hemorrhage, two intravenous infusion systems of large caliber must be established right away to permit rapid administration of aqueous electrolyte solutions and blood as nedded

2.     An operating room and a surgical team, including an anesthesiologist, must be immediate available.

 

COAGULATION DEFECTS

The treatment of coagulation defects is aimed at correcting the coagulation defects and include infusion of:

·     platelet concentrate – increases platelet count by about 20 000 to 25 000;

· cryoprecipitate – supplies fibrinogen, factor VIII, and factor XIII (3 to 10 times more concentrated than the equivalent volume of fresh plasma);

· fresh-frozen plasma – supplies all factors except platelets (1 g of fibrinogen);

· packed red blood cells

·     Prothrombin complex concentrate

·  Novoseven - Recombinant VII clotting factor

·     Proteolytic enzymes inhibitors – KONTRYCAL, GORDOX