The birth of a baby is a joyful event that you don’t want to overshadow with anxious thoughts. But knowledge about the complications that can accompany childbirth is necessary - first of all, in order not to get confused at a critical moment and to meet them fully armed. After all, the calmer a woman behaves, and the better she understands her condition, the greater the likelihood of a successful birth outcome for both mother and child. In this article we will talk about one of the most dangerous complications - bleeding. It can develop during childbirth, in the early postpartum period, and even in the last weeks of pregnancy. The onset of bleeding poses a serious danger to the health (and sometimes to the life) of the mother and the unborn child.
Bleeding early in pregnancy
It is estimated that one in three women will bleed during pregnancy. Most often appears at the beginning of pregnancy. In the first trimester, bleeding is usually caused by:
- implantation of the fertilized egg into the wall of the uterus.
- date of menstruation. It happens that during pregnancy, light bleeding occurs at the moment when your period should begin. It may be that you experience abdominal pain or other symptoms that accompany your period;
- cervical disease such as erosion or polyp. Then the most common bleeding is after sexual intercourse or a gynecological examination;
- hormonal deficiency, usually a lack of progesterone. To find out, you should take a blood test to determine its level. If the result confirms the suspicion, the pregnant woman needs to take duphaston or lutein (usually until the 16th week of pregnancy);
- ectopic pregnancy, when the embryo implants outside the uterine cavity, most often in the fallopian tubes. This is a condition that threatens the health and even life of a woman. If you experience abdominal pain, usually on one side, see your doctor as soon as possible. Symptoms occur between the fourth and eighth weeks of pregnancy;
- Molar pregnancy, which is a rare complication. This means excessive growth of the tissues from which the placenta develops, which interferes with the development of the embryo. An ultrasound should be performed to confirm the diagnosis.
- miscarriage, i.e. termination of pregnancy before 22 weeks. What could indicate them? Heavy and prolonged bleeding, painful cramps in the abdomen, a feeling of pressure in the lower abdomen. In such a situation, it is necessary to go to the hospital as soon as possible. Every third pregnancy ends in miscarriage by 12 weeks.
Why is bleeding dangerous?
Why do obstetric hemorrhages remain so dangerous today, despite all the achievements of modern medicine, the development of resuscitation techniques and a fairly large arsenal of means to replenish blood loss?
Firstly, bleeding is always a secondary complication of an existing obstetric problem. In addition, it very quickly becomes massive, that is, in a relatively short period of time the woman loses a large volume of blood. This, in turn, is explained by the intensity of uterine blood flow, which is necessary for the normal development of the fetus, and the extensiveness of the bleeding surface. What can be more successfully turned off by hand when the valve is broken: a single stream of water from a tap or a fan shower? Approximately the same can be said about bleeding, for example, from a damaged artery in the arm and bleeding during childbirth. After all, this is precisely the situation in which doctors find themselves trying to save a woman in labor, when blood is gushing from a large number of small damaged vessels of the uterus.
Of course, a pregnant woman’s body “is preparing for the normal small loss of blood during childbirth. Blood volume increases (although this primarily meets the needs of the developing fetus, which needs more and more nutrition every day). The blood coagulation system is put on “combat readiness,” and when bleeding occurs, all of its forces, without exception, “rush into battle.” At the same time, the increased clotting ability of the blood develops into complete depletion - coagulopathy; there are no elements (special proteins) left in the blood that can form a blood clot and “close the hole.” The so-called DIC syndrome develops. All this is aggravated by severe metabolic disorders due to the main obstetric complication (uterine rupture, premature placental abruption or tight attachment, etc.). And until this particular primary complication is corrected, it is unlikely to cope with the bleeding. In addition, a woman’s strength is often exhausted due to pain and physical stress.
Bleeding during pregnancy: 3rd trimester
Bleeding in the third trimester is associated with abnormalities of the placenta. This:
- Placenta previa, that is, the location of the placenta on the fundus of the uterus. This usually occurs between 28 and 32 weeks of pregnancy. It usually goes away on its own, but women should exercise caution for the rest of the pregnancy. It's better to go to the hospital and observe.
- Premature abruption of the properly seated placenta, which can occur as a result of a sudden increase in blood pressure or a blood clotting disorder in the mother, as well as abdominal trauma. Placental abruption is a condition in which the placenta is partially or completely separated from the wall of the uterus.
- The release of the mucus plug covering the cervix, which may be stained with blood.
Obstetric hemorrhage is the leading cause of maternal mortality worldwide , killing 127,000 women each year, accounting for 25% of all maternal deaths. In the Russian Federation, maternal mortality from obstetric hemorrhage in the structure of its causes is 14-17%, consistently occupying 2nd place after mortality associated with abortion. Relative to the total number of births, the frequency of obstetric hemorrhage ranges from 2.7 to 8% , with 2-4% associated with uterine hypotension. On average, 1 woman per day in Russia dies from causes related to pregnancy and childbirth, and every seventh of them is from bleeding. The use of Zhukovsky's balloon tamponade is possible not only when bleeding has already begun, but also as a preventive measure.
Postpartum hemorrhage (PPH) is considered the most dangerous postpartum complication for the mother . It is well known that if proper medical care is not provided, PPH has the shortest time to death among all obstetric emergencies - only 2 hours; this means that late identification of the disease and lack of appropriate treatment for PPH are critical factors that can lead to poor outcome.
PPH is not an independent diagnosis, but only a symptom of many disorders of postpartum hemostasis, when, when observing vaginal bleeding, obstetricians cannot immediately determine the cause of the complication. Once the treating physician recognizes this acute and uncertain condition requiring urgent action, the only sure-fire, tried-and-true course of action is to aggressively and promptly implement a sequence of procedures aimed at treating PPH.
Selecting the best and most effective treatment tools and techniques is undoubtedly of paramount importance. The sequence of measures for uterine bleeding in the early postpartum period
. Review of standards for the treatment of postpartum hemorrhage Materials prepared by Zhukovsky Ya. G.
Main reasons
Bleeding that occurs in the first 2 hours of the postpartum period is called early postpartum hemorrhage. Its causes are, most often, retention of parts of the placenta in the uterine cavity, hypotension or atony of the uterus, a violation of the blood coagulation system, and uterine rupture. When parts of the placenta are retained in the uterine cavity, the postpartum uterus becomes large and blood clots are released from the genital tract. Diagnosis is based on a thorough examination of the placenta and membranes after the birth of the placenta. If there is a defect in the placenta or there is doubt about its integrity, manual examination of the postpartum uterus and removal of placental remnants is indicated. The most common cause of early postpartum hemorrhage is a violation of the contractility of the myometrium - hypotension and atony of the uterus. Hypotony of the uterus is a decrease in its tone and insufficient contractility. Uterine atony is a condition in which the uterus completely loses the ability to contract and does not respond to medications and other types of stimulation. The causes of hypo- and atonic bleeding are disturbances in the functional state of the myometrium at the onset of labor due to gestosis, diseases of the cardiovascular system, kidneys, liver, central nervous system, endocrinopathies, scar changes in the myometrium, uterine tumors, hyperextension of the uterus due to multiple pregnancy, polyhydramnios, large fetus. The functional state of the myometrium may be impaired during prolonged labor, the use of drugs that reduce uterine tone, or prolonged use of contractile drugs. Anomalies of placenta attachment, retention of the placenta and its parts in the uterine cavity, and premature detachment of a normally located placenta are also important.
Clinic of hypotonic and atonic bleeding
Clinically, there are 2 types of early postpartum hemorrhage:
- the bleeding immediately takes on a massive, profuse character. The uterus is atonic, flabby, does not respond to external massage, manual examination of the uterine cavity, or to the introduction of contractile agents. Hypovolemia, hemorrhagic shock, and disseminated intravascular coagulation syndrome quickly develop;
- bleeding is wavy. The uterus periodically relaxes and releases blood in portions of 150-300 ml. In response to the introduction of contractile agents, external massage of the uterus, myometrial contractility and tone are temporarily restored, and bleeding stops. Due to the fragmentation of blood loss, a woman’s condition may be compensated for a certain period of time.
If assistance is provided on time and in sufficient volume, the tone of the uterus is restored and bleeding stops. If timely assistance is not provided, the body's compensatory capabilities are depleted, bleeding intensifies, hemostasis disorders occur, and hemorrhagic shock and disseminated intravascular coagulation develop.
Treatment of hypotonic and atonic bleeding
Methods of combating hypotonic and atonic bleeding in the early postpartum period are divided into medicinal, mechanical and surgical. After emptying the bladder, apply a cold pack on the stomach and begin external massage of the uterus through the anterior abdominal wall. At the same time, 5 units (1 ml) of oxytocin and 1 ml of a 0.02% solution of methylergometrine in 20 ml of a 40% glucose solution are administered intravenously. If this does not lead to a lasting effect, they immediately begin manual examination of the walls of the postpartum uterus under intravenous anesthesia. At the same time, they are convinced that there are no parts of the placenta in the uterus, and a violation of the integrity of the uterus is excluded; have a powerful reflex effect on myometrial contractility with two-handed massage. The operation is highly effective in the early stages of bleeding. A good hemostatic effect is achieved by introducing prostaglandins into the cervix. You should pay attention to the tablet drug containing prostaglandins - misoprostol. All measures to stop bleeding are carried out in parallel with adequate infusion and transfusion therapy. If there is no effect from manual examination of the uterus, this most often indicates a coagulopathic nature of the bleeding. It must be remembered that it is unacceptable to re-use manipulations that were ineffective the first time they were performed. The lack of effect of timely conservative therapy and ongoing bleeding are indications for laparotomy and the use of surgical methods to stop bleeding. The effectiveness of “intermediate” measures between the conservative and surgical stages, including the introduction of an intrauterine balloon or compression of the abdominal aorta, cannot be underestimated. Tamponade of the uterine cavity, described by a group of foreign authors, allows in some cases to avoid surgical treatment. In our country, the method of balloon tamponade of the uterus using the Optimiss intrauterine catheter has become widespread. According to V.E. Radzinsky et al. (2008), in case of massive obstetric bleeding, tamponade with an intrauterine balloon as a way to stop it is effective in 90% of cases. Therefore, the use of an intrauterine balloon as a method of stopping bleeding or as a temporary measure that reduces the rate of blood loss and gives time to prepare for surgical intervention, according to leading domestic obstetricians, should be considered mandatory. The surgical stage also has a clear algorithm of actions. When the uterus is exposed, prostaglandins are injected into the muscle. If the volume of blood loss is more than 1500 ml, ligation of the internal iliac arteries is indicated first. If blood loss is 1000-1500 ml or in the absence of conditions for ligation of the iliac arteries, it is necessary to ligate the uterine vessels, followed by the application of hemostatic compression sutures. The literature describes a technique for the simultaneous use of compression hemostatic sutures on the uterus and an intrauterine hemostatic balloon. If the lower segment is overstretched, tightening sutures are applied. If bleeding continues, hysterectomy is performed. If possible, instead of ligating the vessels and removing the uterus, embolization of the uterine vessels is performed
Late postpartum bleeding
Late postpartum hemorrhage occurs 2 hours or more after the end of labor. Their causes may be uterine hypotension, retention of parts of the placenta in the uterine cavity, disorders in the blood coagulation system, trauma to the birth canal, and diseases of the blood system. Hypotonic bleeding occurs on the first day after birth. The pathogenesis and clinical picture are similar to those of early postpartum hypotonic bleeding. When part of the placenta is retained in the uterine cavity, the size of the uterus is increased, its consistency is soft, and the cervical canal is passable for 1-2 fingers. A manual examination of the uterine cavity is carried out and parts of the placenta are removed, hemostatic and antibacterial therapy is carried out, and uterine contractions are prescribed. Bleeding in the late postpartum period can be caused by injuries to the birth canal due to improper suturing technique. In this case, hematomas of the vagina or perineum are formed. In this case, it is necessary to remove all previously applied sutures, ligate the bleeding vessel, and connect the edges of the wound. These manipulations are performed under general anesthesia.
Bleeding during pregnancy: what to do?
Bleeding during pregnancy requires caution and various measures. What to do? Much depends on its abundance. If the bleeding is small and has subsided, rest and, preferably, take a horizontal position. Then write down the date of the attack and tell your doctor about it at your next visit. Any bleeding during pregnancy that is accompanied by mild contractions, even minor, should be reported to your doctor or midwife within 72 hours of its onset.
If bleeding during pregnancy is more severe, contact your doctor monitoring your pregnancy. If it is accompanied by severe contractions, reminiscent of menstrual pain, you need to go to the hospital or call an ambulance. Most bleeding during pregnancy ends on its own and does not have an adverse effect on the course of pregnancy. But even then, the situation requires you to see a doctor because there is no rule: slight bleeding during pregnancy should not indicate that everything is fine, but heavy bleeding definitely indicates that the pregnancy is at risk.
Features of labor management
If bleeding occurs during childbirth, work is carried out in several directions simultaneously. The anesthesiologist begins infusion of special blood replacement solutions and blood products through large veins. Thanks to this, substances and proteins responsible for blood clotting enter the bloodstream. To improve blood clotting, fresh frozen plasma is started to be infused, then, depending on the volume of blood loss, red blood cells are poured into another vein, sometimes these blood products are injected in parallel into different vessels. The patient is also given hemostatic drugs and painkillers. Obstetricians determine the cause of bleeding and the type of surgery to be performed.
To maintain normal oxygen supply to tissues, inhalation of humidified oxygen through a mask is used.
The patient is connected to a monitor that constantly monitors her blood pressure, heart rate, blood oxygen saturation (saturation) and continuously takes an ECG. Simultaneously with the above measures, the patient is quickly put under anesthesia for further surgical treatment and the woman is transferred to artificial ventilation with a breathing apparatus. Practice has proven that blood transfusions in patients under anesthesia are safer than in conscious patients.
Of course, transfusion of blood and solutions will be successful only when the initial complication that caused the bleeding is eliminated. Therefore, the task of obstetricians is to identify this complication and determine a plan for treatment procedures, be it manual examination of the uterus, emergency caesarean section, removal of the uterus, etc.
After the bleeding has stopped, the woman is transferred to the intensive care ward of the maternity hospital or to a specialized intensive care unit of the hospital under the constant supervision of medical personnel.
Remember that bleeding in pregnant women can occur not only during childbirth in a hospital, but also at home. When obstetric hemorrhage occurs, time becomes decisive, and in the case of childbirth outside the hospital, it, alas, works against us. Therefore, when planning a trip somewhere in the last weeks of pregnancy or a home birth, calculate in advance how long it will take you to end up in the hospital. Remember that with obstetric hemorrhage, a condition very quickly develops when, despite intensive therapy and external clamping of the abdominal aorta (and this is very difficult to do in pregnant women), the ambulance team and even the medical helicopter team may not be able to transport the patient to hospital is alive, since the main method of treatment against the background of intensive care remains surgery.
Treatment of postpartum hemorrhage
The primary task in case of postpartum hemorrhage is to establish the cause of its occurrence, as well as to stop it as quickly as possible. Then it is necessary to prevent acute blood loss, which is possible, and restore the volume of blood necessary for a healthy woman’s body, which circulates in the pelvis to a stable level of blood pressure.
When fighting postpartum hemorrhage, it is very important to understand the need for an integrated approach and the use of all possible and necessary means: mechanical and medicinal measures, surgical methods to influence treatment.
To stimulate contractile activity and muscle activity, it is necessary to perform catheterization to empty the bladder as much as possible. It is necessary to carry out local hypothermia with ice placed on the lower abdomen and gentle massage of the uterus. If there is still no result, then it is necessary to resort to the introduction of uterotonic agents, injections of which must be made into the cervix.
To restore blood volume, as well as eliminate various consequences of blood loss, it is customary to carry out infusion-transfusion therapy using blood components and plasma-substituting drugs.
If ruptures of the cervix, vaginal walls or perineum are detected when examining the birth canal in the speculum, such wounds are sutured using local anesthesia.
Symptoms of postpartum hemorrhage
Manifestations that indicate postpartum hemorrhage are determined by the intensity and amount of blood lost. Under the condition of an antonic uterus, which does not react to external influences and any therapeutic manipulations, the bleeding will be quite profuse, but can acquire a wave-like character, subsiding and resuming blood loss from the body again. Such subsidence can be caused by exposure to drugs that can contract the uterus.
The physiologically acceptable amount of blood loss may be 0.5% of the mother’s body weight. If the volume increases, this indicates pathological uterine bleeding during childbirth. Bleeding can be determined by blood pressure, pale skin tone and tachycardia.
If the amount of blood loss exceeds 1% of the mother’s body weight, then the blood loss becomes massive. If it is above this indicator, then it is critical. In case of critical bleeding, hemorrhagic shock develops, as well as disseminated intravascular coagulation syndrome, which in total leads to irreversible changes in the vital organs of the woman in labor and can lead to death.
During the late postpartum period, a woman should monitor her health as closely as possible and be wary of intense bloody discharge, which has an unpleasant odor and is accompanied by nagging pain in the lower abdomen.
Placenta previa
We are talking about a unique organ that is formed in women during pregnancy. It provides a close connection between the emerging small organism and its mother. Through this formation, substances necessary for its development are supplied to the fetus and metabolic products are removed. The placenta also performs other important functions. For example, it produces hormones responsible for preparing the mammary glands for lactation.
This organ is located in the uterus, normally on its back wall or slightly above. However, sometimes placenta previa is detected. This is the case when it occupies the wrong position - on the front wall. This position for the placenta is dangerous, since it is in this part of the uterus that undergoes the greatest changes. As a result, there is a risk of injury to the placenta, as well as its premature detachment.
Full presentation is especially dangerous. Childbirth here occurs through a caesarean section, since the natural passages (exit from the uterus) are blocked by the placenta. During pregnancy, this condition causes repeated external bleeding. It begins in the second half of the gestation period. The color of the discharge is bright red.
Sometimes there is an incomplete presentation. The position of the placenta in this case is lateral with a transition to the anterior region of the uterus. If bleeding occurs during the labor period during partial presentation, the amniotic sac is opened. Once the discharge stops, childbirth can occur naturally. If the bleeding cannot be stopped, a caesarean section is performed.
Placenta previa is a rare but dangerous complication. Previously, it could even end in the death of the woman in labor. However, now a tragic outcome is practically excluded. Modern research methods, in particular ultrasound, allow early detection of the considered pregnancy defect. If a pathology is detected, measures are taken to further ensure the successful course of the gestation process.
Diagnosis and treatment
The doctor will conduct an examination, take a smear from the vagina, and prescribe an ultrasound of the pelvis. The woman also needs to donate blood for general and biochemical analysis and group determination. Based on the results, the gynecologist will prescribe further treatment.
In case of a miscarriage, you will need to clean the uterus; if an ectopic pregnancy is detected, then a diagnostic laparoscopy is performed. If the cause of bleeding is the threat of miscarriage, then the woman will be prescribed medications to maintain pregnancy and bed rest, and hospitalization is possible.
Causes of postpartum hemorrhage
The process of development of postpartum hemorrhage can occur as a result of dysfunction of myometrial contraction, which can manifest itself in hypotonia - decreased muscle tone and insufficient activity in the uterus, atony - loss of the ability of the uterus to contract, decreased tone of the uterus and lack of response of the myometrium to external stimulation.
Among the main causes of postpartum hemorrhage are fibroids and uterine fibroids. Scar processes in the myometrium, polyhydramnios, and excessive uterine distension in the case of multiple pregnancies can also become causes of this condition. Less commonly, the causes may be prolonged labor with a fairly large baby, or taking medications that can reduce the tone of the uterus.
Bleeding of the uterus can occur due to retention of the placenta in the cavity in the form of remnants of the placenta and particles of the fetal membrane. Such an afterbirth can interfere with normal and complete contraction of the uterus, which means it will provoke inflammation and postpartum bleeding. The separation of the placenta may be disrupted due to partial accretion of the placenta inside the woman’s body, improper behavior in the third stage of labor, cervical spasms and uncoordinated labor.
Most often, the factors causing postpartum hemorrhage can be atrophy or hypotrophy of the endometrium, which occurs as a result of previous surgical interventions such as cesarean section, uterine curettage, early abortions, conservative myomectomy.
Postpartum bleeding can occur after injuries or tears to the soft tissue of a woman's genital tract, which she may receive during childbirth. A fairly high risk of postpartum hemorrhage may occur with premature placental abruption, preeclampsia, or threatened miscarriage. There is such a risk in the presence of previa, placental insufficiency, cervicitis or endometritis, chronic heart, liver or kidney diseases.
