Puerperal bleeding

Description:

Puerperal bleeding – the bleeding from patrimonial ways arising in early or in a late puerperal period. Puerperal bleeding most often serves as an effect of the main obstetric complication. Weight of puerperal bleeding is defined by blood loss size. Bleeding is diagnosed at survey of patrimonial ways, inspection of a cavity of the uterus, ultrasonography. Treatment of puerperal bleeding demands performing infusion-transfusion therapy, introduction of uterotonichesky means, sewing up of gaps, sometimes – hysterectomies.
Danger of puerperal bleeding consists that it can lead to bystry loss of large volume of blood and the death of the woman in labor. Plentiful blood loss is promoted by existence of an intensive uterine blood-groove and a big wound surface after the delivery. Normal the organism of the pregnant woman is ready to physiologically inconsequential loss of blood in labor (to 0,5% of body weight) due to increase in intravascular volume of blood. Besides, puerperal bleeding from a uterine wound is warned by the strengthened reduction of muscles of a uterus, compression and shift in deeper muscular layers of uterine arteries with simultaneous activation of coagulant system of blood and a thrombogenesis in small vessels.
Early puerperal bleedings arise in the first 2 hours after the delivery, late can develop in the period from 2 hours to 6 weeks after the child's birth. The outcome of puerperal bleeding depends on the volume of the lost blood, the speed of bleeding, efficiency of the carried-out conservative therapy, development of the IDCS. Prevention of puerperal bleeding is an urgent problem of obstetrics and gynecology.

Reasons of puerperal bleeding:

Puerperal bleeding often arises because of disturbance of sokratitelny function of a myometrium: hypotonias (decrease in a tone and insufficient sokratitelny activity of muscles of a uterus) or atonies (total loss of a tone of a uterus, its ability to reduction, lack of reaction of a myometrium to stimulation). As the reasons of such puerperal bleedings serve fibromas and hysteromyomas, cicatricial processes in myometriums; excess stretching of a uterus at polycarpous pregnancy, a hydramnion, long childbirth by a large fruit; use of the drugs reducing a uterus tone.
Puerperal bleeding can be caused by a delay in a cavity of the uterus of the remains of an afterbirth: segments of a placenta and parts of fetal membranes. It interferes with normal reduction of a uterus, provokes development of an inflammation and sudden puerperal bleeding. The partial increment of a placenta, the wrong maintaining the third period of childbirth, the dicoordinated patrimonial activity, a spasm of a neck of uterus leads to disturbance of department of an afterbirth.
As the factors provoking puerperal bleeding the hypotrophy or an atrophy of an endometria owing to earlier carried out operative measures - Cesarean section, abortions, a conservative myomectomy, a uterus scraping can serve.
Developing of puerperal bleeding can be promoted by the disturbance of hemocoagulation at mother caused by congenital anomalies, reception of anticoagulants, development of DVS - a syndrome.
Quite often puerperal bleeding develops at injuries (gaps) or a section of a genital tract at the time of delivery. The high risk of puerperal bleeding is available at a gestosis, presentation and premature placental detachment, threat of abortion, fetoplacental insufficiency, pelvic presentation, existence for mother of an endometritis or a cervicitis, chronic diseases cardiovascular and TsNS, kidneys, a liver.

Symptoms of puerperal bleeding:

Clinical displays of puerperal bleeding are caused by quantity and intensity of a loss of blood. At the atonichny uterus which is not reacting to external medical manipulations, puerperal bleeding, as a rule, plentiful, but can have also wavy character, times to calm down under the influence of the drugs reducing a uterus. Objectively arterial hypotonia, tachycardia, pallor of skin is defined.
Blood loss volume to 0,5% of body weight of the woman in labor is regarded as physiologically admissible; at increase in volume of the lost blood speak about pathological puerperal bleeding. The blood loss size exceeding 1% of body weight is considered massive, over it is critical. At critical blood loss hemorrhagic shock and the IDCS with irreversible changes in vitals can develop.
In a late puerperal period intensive and long lokhiya, allocations of bright red color with big clots, an unpleasant smell, nagging pains in the bottom of a stomach have to guard the woman.

Diagnosis:

The modern clinical gynecology carries out assessment of risk of puerperal bleeding which includes monitoring during pregnancy of level of hemoglobin, quantity of erythrocytes and thrombocytes in blood serum, a bleeding time and a blood coagulation, a condition of coagulant system of blood (koagulogramma).
Hypotonia and atony of a uterus can be diagnosed in the course of the third period of childbirth on flabbiness, weak reductions of a myometrium, longer current of the afterbirth period.
Diagnosis of puerperal bleeding is based on careful inspection of integrity allocated a placenta and fetal membranes, and also survey of patrimonial ways regarding an injury. Under the general anesthesia the gynecologist carefully carries out a manual research of a cavity of the uterus on existence or lack of gaps, rests of an afterbirth, clots, the available malformations or tumors interfering reduction of a myometrium.
An important role in the prevention of late puerperal bleeding is played by the performing ultrasonography of bodies of a small pelvis for the 2-3rd days after the delivery allowing to find the remained fragments of placental fabric and fetal membranes in a cavity of the uterus.

Treatment of puerperal bleedings:

At puerperal bleeding establishment of its reason, extremely bystry stop and prevention of acute blood loss, recovery of volume of the circulating blood and stabilization of level of arterial pressure is paramount. In fight against puerperal bleeding an integrated approach using as conservative (medicamentous, mechanical), and surgical methods of treatment is important.
For stimulation of sokratitelny activity of muscles of a uterus carry out catheterization and bladder emptying, a local hypothermia (ice on a stomach bottom), the sparing outside massage of a uterus, and in the absence of result - intravenous administration of uterotonichesky means (usually, methylergometrine with oxytocin), injections of prostaglandins to a neck of uterus.
For recovery of OTsK and elimination of effects of acute blood loss at puerperal bleeding carry out infusion-transfusion therapy by components of blood and plasma substituting drugs.
At detection of ruptures of a neck of uterus, walls of a vagina and crotch during survey of patrimonial ways in mirrors they are taken in under a local anesthesia. At disturbance of integrity of a placenta (even in absence of bleeding), and also at hypotonic puerperal bleeding conduct urgent manual examination of a cavity of the uterus under the general anesthesia. During audit of walls of a uterus carry out manual department of the remains of a placenta and covers, removal of clots; define existence of ruptures of a body of the womb.
In case of a hysterorrhesis carry out the emergency laparotomy, sewing up of a wound or removal of a uterus. At detection of signs of an increment of a placenta, and also at not stopped massive puerperal bleeding the hysterectomy is shown (if necessary with bandaging of internal ileal arteries or embolization of uterine vessels).
Operative measures at puerperal bleeding carry out along with the resuscitation actions: compensation of blood loss, stabilization of a hemodynamics and ABP. Their timely carrying out before development of a trombogemorragichesky syndrome saves the woman in labor from death.

Prevention:

The women with the adverse obstetric and gynecologic anamnesis, disturbances of coagulant system accepting anticoagulants have high risk of development of puerperal bleeding therefore are under special medical control in process of conducting pregnancy and go to specialized maternity homes.
For the purpose of prevention of puerperal bleeding to women administer the drugs promoting adequate reduction of a uterus. After the delivery all women in labor spend the first 2 hours in delivery room under dynamic observation of medical personnel for blood loss volume assessment in an early puerperal period.