Hypotonic bleeding in the early postpartum period

The significance of the problem caused by obstetric hemorrhage is due to the fact that this pathology is the main and immediate cause of death of 60-70% of women. It follows that postpartum bleeding is at one of the most important places in the system of maternal mortality. By the way, it is noted that the leading role among obstetric hemorrhages is occupied by hypotonic bleeding, which opened after childbirth in the first 4 hours.

Possible causes of

The main causes of possible hypotonic bleeding may be: atony and hypotension of the uterus, poor blood coagulation, part of the child's place that left the uterine cavity, trauma of soft tissues in the birth canal.

What is hypotension of the uterus

Hypotension of the uterus is a condition in which the tone and its ability to contract sharply decreases. Thanks to the measures produced and under the influence of the means that excite the contractile function, the muscle begins to contract, although often the force of the contractile reaction is not equal to the force of the action. For this reason, hypotonic bleeding also develops.

Atony

An atony of the uterus is a condition in which the means directed to the excitation of the uterus are not able to exert any influence on it. The apparatus of the neuromuscular system of the uterus is in a state of paralysis. This condition does not happen often, but can cause severe bleeding.

Provoking factors of bleeding

The causes of bleeding hypotonic and atonic character can be different. One of the main reasons is the weakening of the organism, i.e.the central nervous system weakens due to prolonged and painful births, persistent labor activity weakens, in addition, the cause can be rapid delivery and the use of oxytocin. Also for reasons include severe gestosis( nephropathy, eclampsia) and hypertension. Postpartum hypotonic bleeding is very dangerous.

The next reason may be the inferiority of the uterus at the anatomical level: poor development and malformations of the uterus;various fibroids;presence of scars on the uterus after the operations made earlier;diseases caused by inflammation or abortion, which replaced the connective tissue with a significant proportion of the muscle.

In addition, the effects of hypotonic bleeding in the early postpartum period are: uterine dysfunction, i.e.its strong stretching as a result of polyhydramnios, the presence of not one fetus, if the fetus is large;previa and low attachment of the placenta.

Hypotension or atony

Bleeding hypotonic and atonic character may result from a combination of several of the above reasons. In this case, bleeding takes a more dangerous character. Proceeding from the fact that with the first symptoms it can be difficult to find a difference between hypotonic bleeding and atonic, it will be correct to use the first definition, and diagnose atony of the uterus if the performed measures are ineffective.

What is the reason for the stop of bleeding

The bleeding stopped due to the fact that placental abruption and the birth of the placenta have occurred are usually explained by two main factors: myometrium retraction and thrombus formation in the vessels of the placenta site. The increased retraction of the myometrium leads to the contraction and curling of the venous vessels, and the spiral arteries are also drawn into the uterus. After this, thrombosis begins in the vessels of the uterus, which is facilitated by the process of blood coagulation. The process of formation of thrombi can last for a long time, sometimes several hours.

Women in childbirth who are at high risk for early postpartum hypotonic bleeding should be carefully anesthetized because contractions that are accompanied by severe pain lead to disruption of the CNS and the necessary interrelations between the subcortical structures and, accordingly, the cerebral cortex. As a result, it is possible to violate the generic dominant, which is accompanied by equivalent changes in the uterus.

Clinically, such bleeding is manifested in that it can often begin in the postpartum period, and then go into the bleeding of the early postpartum period.

Clinical options for hypotension

MA Repin( 1986) conducted the selection of two clinical options for hypotension of the uterus. According to this theory, in the first variant the bleeding is profuse from the very beginning, the blood loss is enormous. The uterus becomes flabby, atonic, shows a weak response to the introduction of funds that contribute to its reduction. Rapidly developing hypovolemia, hemorrhagic shock begins and often there is a syndrome of disseminated intravascular coagulation( DIC syndrome).

In the second version, the theory of blood loss is minor, the clinical picture is typical of the hypotonic state of the uterus: repeated blood loss alternates with a short-term regeneration of the myometrium tone and temporary stoppage of bleeding as a result of conservative treatment( such as the administration of contractile agents, external uterine massage).As a result of relatively small repeated blood loss, a temporary addiction of the woman to progressive hypovolemia begins: the arterial pressure decreases insignificantly, the appearance of pallor of the skin and visible mucous membranes is observed, an insignificant tachycardia appears.

As a result of compensated fractional blood loss, the onset of hypovolemia often goes unnoticed by medical personnel. When treatment at the initial stage of hypotension of the uterus was ineffective, its impaired contractile function begins to progress, the reactions to the therapeutic effect become short-lived, the volume of blood loss increases. At some stage, bleeding begins to increase significantly, leading to a sharp deterioration in the patient's condition and all signs of hemorrhagic shock and DIC syndrome begin to develop.

The definition of the effectiveness of the first phase should be relatively fast. If for 10-15 minutes.the uterus will decrease badly, and hypotonic bleeding in the postpartum period will not stop, then immediately perform a manual examination of the uterus and apply a uterine massage on the fist. Proceeding from the practical experience of obstetrics, timely manual examination of the uterus, cleaning it from accumulated blood clots, and then made her massage on the fist, help ensure correct uterine hemostasis and prevent severe blood loss.

Significant information that causes the need for appropriate examination by the hand of the uterus in the event of hypotonic bleeding in the early postpartum period, leads M. A. Repin in his own monograph "Bleeding in Obstetrical Practice"( 1986).According to her observations, in the deceased from him, the approximate time from bleeding to manual examination of the uterine cavity averages 50-70 minutes. In addition, the fact that there is no effect from this operation and the invariability of the hypotonic state of the myometrium not only indicate that the performed operation was delayed, but also about the unlikely forecast of stopping bleeding even with the use of other conservative methods of treatment.

The method of clamping by NS Baksheev

During the activities of the second stage, it is necessary to use techniques that contribute to at least the slightest reduction in blood flow to the uterus, which can be achieved with the help of digital aortic compression, parameterization of terminals, dressing of the main vessels, etc. For todayday among a variety of these methods, the most popular method is the locking by NS Baksheyev, thanks to which in many cases it was possible to stop hypotonic uterine bleeding, which in St.th turn helped to do without surgery to remove the uterus.

By the method of NS Baksheev used in the case when the volume of blood loss is not too large( not more than 700-800 ml).The duration of the presence of terminals on the parameters should not be more than 6 hours. In cases when, in the presence of superimposed terminals, the bleeding does not stop, even in small quantities, it is necessary to puzzle in time the question of how to remove the uterus. This operation is called supravaginal amputation or extirpation of the uterus. The surgery for removal of the uterus, made on time, is the most reliable method to stop hypotonic bleeding after childbirth.

Timely and necessary measures of

This is associated with the risk of bleeding disorders. Thus, in the fight against hypotension of the uterus, as well as for the restoration of hemodynamics, it is necessary to carefully monitor the nature of the blood clots in the patient that flows out of the genital tract, as well as the occurrence of petechial skin hemorrhages, especially at the injection site.

If the slightest symptoms of hypofibrinogenemia appear, proceed to the immediate introduction of drugs that increase the coagulating properties of the blood. When in this case the question arises of the necessity of an operation to remove the uterus, it is necessary to carry out extirpation, and not amputation of the uterus. This is explained by the fact that probably the remaining stump of the cervix can serve as a continuation of the flickering pathological process if there is a bleeding disorder of the blood. A stop of hypotonic bleeding should be timely.