Obstetrical bleedings
MINISTRY OF PUBLIC HEALTH OF UKRAINE
National Pirogov Memorial Medical University, Vinnytsya
CHAIR OF OBSTETRICS and Gynecology №1
Methodological instruction
on the practical class
“Obstetric hemorrhages. Hemorrhagic shock in obstetrics. Syndrome of disseminated intravascular blood coagulation in obstetrics. Extrauterine pregnancy.”
I. Scientific and methodical grounds of the theme
Although vaginal bleeding in the first trimester is a relatively common occurrence, it must be considered serious until all potential abnormal causes have been effectively ruled out. The precipitating cause may not readily present itself and may take some investigation to identify. Ectopic pregnancy should always be considered.
II. Aim:
A student must know:
1. Etiology of development obstetrical bleedings.
2. Terminology, used characterize clinical symptoms of obstetrical bleedings.
3. Ways of formation of amniotic fluid embolism during pregnancy and labor.
4. Bleedings during labor
5. Classification of obstetrical bleedings.
6. Placental presentation.
7. Clinic, diagnosis and treatment placental presentation.
8. Classification of premature detachment of a normally located placenta.
A student should be able to:
1. Collect general and specific obstetrical anamnesis.
2. Make up a plan of examination and treatment of different forms of obstetrical bleedings.
III. Recommendations to the student
Obstetrical bleedings
Bleedings in the first half of pregnancy:
- accidental abortion;
- hydatidiform mole;
- extrauterine pregnancy ( including cervical pregnancy);
Bleedings in the second half of pregnancy:
- placental presentation;
- premature detachment of normally located placenta;
- hysterorrhexis.
Bleedings during labor:
I period:
- premature detachment of normally located placenta;
- placental presentation;
- hysterorrhexis;
- laceration of the neck of the uterus.
II period:
- premature detachment of normally located placenta;
- hysterorrhexis.
III period:
- pathologic implantation of placenta;
- suppression, strangulation of placenta;
- laceration of soft tissues of maternal passages.
Postpartum bleeding:
- hypotonic bleeding;
- retention of the afterbirth’s fragments;
- laceration of soft tissues of maternity passages;
- hysterorrhexis,
- amniotic fluid embolism,
- coagulopathetic hemorrhage.
Bleedings unconnected with pregnancy:
- uterine cervix polyp;
- carcinoma of uterine cervix.
Classification
- threat of abortion;
- the abortion which has started;
- abortion in process;
- incomplete accidental abortion;
- complete accidental abortion;
- missed miscarriage.
Clinicodiagnostic criteria
Symptoms of abortion:
- pain-syndrome: pain associated with contraction of the uterus;
- increased tension of the uterus;
- hemorrhage of different intensity;
- structural changes in the uterine cervix.
Differential diagnosis of abortion stages is based on the 2 latter symptoms. By the threat of abortion, hemorrhage and structural changes in the uterine cervix are absent.
Bleedings during accidental abortion, in the beginning of abortion, in the course of abortion and by incomplete accidental abortion.
Clinic:
- pain of intermittent character;
- hemorrhage of different intensity
Diagnosis:
- assessment of the gravida’s general condition;
- speculum examination of the uterine cervix, bimanual examination;
- evaluation of the blood less amount.
Treatment
- instrumental uterus emptying under intravenous anaesthesia (with an obligatory examination of the received material);
- medications contracting uterus (10 units of oxytocin by intravenous droppery or 0,5 mg of methylergobrevin intravenously or intramuscularly);
- if hemorrhage proceeds-800 mkg of misoprostol rectally;
- recovery of the amount of blood loss as indicated;
- antibacterial therapy as indicated.
Placental presentation
Placental presentation is a complication of pregnancy when placenta is located in the lower segment of the uterus lower than the presenting part of the fetus blocking totally or partially the inner pupil of the uterine cervix. During physiological pregnancy the lower edge of the placenta lacks 7 sm to reach the inner pupil. Placental presentation occurs in 0,2-0,8% of general delivery.
Classification of placental presentation
1. Complete presentation-placenta completely blocks the inner pupil.
2. Incomplete presentation-placenta blocks the inner pupil incompletely:
a) lateral presentation- the inner pupil is covered on 2\3 of its area;
b) regional presentation- the end of placenta reaches the inner pupil.
3. Lower implantation of placenta- the location of placenta in the lower segment, 7 sm lowerer than inner pupil without its blocking. Due to the migration of placenta or its expansion this kind of presentation can change during pregnancy progression.
Clinicodiagnostic criteria.
Risk group of placental presentation includes women which underwent:
- endometritis with the following scarry dystrophic changes of endometrium;
- abortions excessively complicated with inflammatory processes;
- benign tumours of the uterus, in particular, submucous myomates nodes;
- influence of chemical preparations on endometrium;
- women with hypoplastic uterus.
Clinical symptoms
A pathognomonic symptom is an obligatory hemorrhage which can periodically recur throughout the term of pregnancy from 12 to 40 weeks, occurs spontaneously or after physical overwork, takes a dangerous character:
- with the onset of uterus contraction at any term of gestation;
- isn’t accompanied by pain;
- isn’t accompanied by the rise of uterine tension.
Seriousness of the condition is determined by the amount of blood loss:
- it is massive at the complete presentation;
- variable from small to massive at the incomplete presentation.
Anematizing as the result of recurrent bleeding. By this pathology the content of hemoglobin and erythrocytes is the lowest if compared to the other complications of pregnancy accompanied by bleedings. Irregular location of the fetus is frequent: oblique, transversal, pelvic presentation, irregular position of the head. Premature delivery is possible.
Diagnosis
1. Medical history (anamnesis)
2. Clinic manifestations – appearance of recurrent blledings which are not accompanied by pain or increased uterus tension.
Obstetrical examination:
a) external examination:
- high position of the presenting part;
- oblique, transversal position of the fetus;
- uterine tension is not increased;
b) internal examination (made only in the conditions of a full-scale operating room):
- doughy tissues of the vault, pastiness, pulsation of vessels;
- impossibility to pulpate the presenting part because of the vault.
In case of hemorrhage a more precise definition of the presentation character has no sense because obstetrical tactics is determined by the amount of blood loss and the gravida’s condition. Ultrasound scanning is very important for the definition of placental location and correct diagnosis. Placental presentation with bleeding is an urgent indication for in-patient hospitalization
Algorhythm of examination at admittance of a pregnant with bleeding to in-patient department.
- verification of the anamnesis;
- evaluation of the general state and the amount of blood loss;
- general clinic examination (blood group, Rhesus factor, general blood count, coagulogram);
- external obstetrical examination;
- examination of the uterine cervix and vagina in the full-scale operating-room by vaginal specula to exclude such causes of bleeding as polyp of uterine cervix, cervical carcinoma, laceration of the varicose node, assessment of the discharge- additional methods of examination (USD) according to the indications if urgent delivery is not necessary.
Treatment
The tactics of management depends on the amount of blood loss, state of the gravida and the fetus, characteristics of the presentation, the term of pregnancy, maturity of the fetus’s lungs.
Principles of treating patients with placental presentation:
1. In case of little bleeding (up to 250 ml), the absence of hemorrhagic shock signs, distress of the fetus and labor activity, immaturity of the fetus’s lungs at the term no more than 37 weeks of gestation – the tactics of anticipation.
2. At the arrest of the bleeding – US examination, preparation of the fetus’s lungs. The target of expectancy tactics is prolongation of gestation to the term of the fetus’s viability.
3. In case of progressive bleeding which becomes uncontrolled (more than 250 ml), accompanied by hemorrhagic shock signs, the fetus’s distress, regardless of the term and the fetus’s condition (alive, distressed dead)- urgent delivery.
Clinic variants:
1. Blood loss (less than 250 ml), symptoms of hemorrhagic shock, the fetus’s distress are absent, the term of pregnancy is less than 37 weeks of gestation:
- hospitalization;
- tocolytic therapy according to the indications;
- acceleration of the fetus’s lungs maturity up to 34 weeks of gestation (6 mg of dexamethazone in the interval of 12 hours for 2 days);
- monitor examination of the gravida’s and fetus’ condition.
If the bleeding increases for more than 250 ml – Cesarean delivery.
2. Significant blood loss (more than 250 ml) at premature pregnancy – regardless of the presentation stage – urgent Cesarean section.
3. Bloodloss (less than 250 ml) at mature pregnancy:
In the conditions of a full-scale operating room the stage of presentation is verified.
- in case of partial placental presentation and possibility to reach amnionic membranes and cephalic fetus presentation with active uterine contractions – amniotomy is performed. After the arrest of bleeding the childbirth is conducted through natural maternal passages. After the childbirth – 10 units of oxytocin by intramuscular injection, a thorough observation of the uterine contraction and the character of discharge from vagina. If hemorrhage recurs – Cesarean delivery should be performed.
- At complete or incomplete placental presentation and irregular fetus position (pelvic, oblique or transversal) – Cesarean delivery is indicated;
- At incomplete presentation and dead fetus – amniotomy is possible; at hemostasia – labor should take place through maternal passages.
4. Blood loss (more than 250 ml) at mature pregnancy – regardless of the stage of presentation – urgent Cesarean delivery.
5. Complete presentation, diagnosed by USD, without hemorrhage – hospitalization before the term of labor, Cesarean section at 37-38 weeks of gestation.
At an early postpartum period – a thorough observation of the parturient. If hemorrhage recurs on Cesarean delivery and the amount of blood loss is more than 1% to the body mass – urgent relaparotomy, uterus extirpation without appendayes, in case of necessity – ligation of inner glomerular arteries by a specialist well-experienced at performing such operations.
Blood loss restoration, hemorrhagic shock and DIC syndrome management are performed according to the indications.
Premature detachment of normally located placenta-
Is a detachment of the placenta located behind the lower uterine segment during pregnancy or in the first-second (I-II) periods of delivery.
Classification
1. Complete detachment (detachment of total placenta).
2. Partial detachment:
- marginal;
- central
Clinicodiagnostic criteria of premature detachment of a normally located placenta:
- gestosis;
- renal diseases;
- isoimmune conflict between the mother and the fetus;
- uterine hyperdistension (hydramnios, multiple pregnancy, a big fetus);
- vascular system diseases;
- diabetes mellitus;
- connective tissue pathology;
- uterine and placental inflammatory processes;
- anomalies of development or tumours of the uterus (submucous, intramural myomas).
The direct cause may be:
- a physical trauma;
- a psychic trauma;
- an abrupt reduction of the amniotic fluid volume;
- an absolutely or relatively short umbilical cord;
- pathology of the uterine contractile activity.
Clinical symptoms:
1. Pain syndrome: acute pain in placental projection irradiating in the total uterine body, loin, back and turning diffusive. The pain is mostly acute by central detachment and it may be slight by marginal detachment. By detachment of placenta located on the posterior wall, the pain can imilate renal colic.
2. Uterine hypertension up to tetany, which can’t be released by spasmolytics, tocolytics.
3. Vaginal bleedings can vary from slight to massive depending on acuteness and character (marginal or central detachment). If retroplacental hematoma is being formed, external bleeding can be absent.
Diagnosis
1. The assessment of a gravida’s state will depend on the size of detachment, the amount of blood loss, the appearance of hemorrhagic shock symptoms or DIC-syndrome.
2. External obstetric examination:
- uterine hypertension;
- the enlarged uterine can be deformed with a local diverticulum if the placenta is on the frontier wall position;
- tenderness by palpation;
- difficulties or impossibility of palpation and auscultation of the fetus’ palpitation;
- appearance of the fetus’ distress symptoms or fetal death.
3. Internal obstetric examination:
- tension of the bag of waters;
- there may be a colouring with blood by the rupture of amniotic fluid sac;
- uterine4 bleedings of different intensity
4. US-examination (echo-negative focus between the uterus and the placenta), but this method can’t be an absolute diagnostic criterion because hypoechogenic zone can be visualized in patients without detachment.
If there is no external bleeding, diagnosis of premature placental detachment is based on the increased uterine tension, local painfulness and change of the fetus’ condition to the worse. Blood from retroplacental hematoma saturales the uterine wall and forms Kuveler’s uterus (uterine-placental apoplexy) which loses the ability to contract resulting in the development of bleedings with massive blood loss at the expense of coagulopathy and hypotonia.
Treatment
Ungrounded late delivery leads to fetal motability, Kuveler’s uterus formation, massive blood loss, hemorrhagic shock and DIC-syndrome, gravida’s reproductive failure.
1. In case of progressive premature placental detachment during pregnancy or in the first period of delivery, when hemorrhagic shock symptoms, DIC-syndrome, fetus’s distress signs appear-regardless of gestation term – urgent Cesarean delivery. In the presence of Kuveler’s uterus signs – extirpation of the uterus without appendages.
2. Restoration of the blood loss amount, treatment of hemorrhagic shock and DIC – syndrome (see corresponding protocols).
3. In case of unprogressive placental detachment there should be dynamic observation at immature pregnancy up to 34 weeks of gestation (therapy for fetus’ lungs maturation) in hospitals with day- and night duty by skilled physicians, obstetricians, gynecologists, anesthesiologists, neonatologists. Monitor observation of the gravida’s and her fetus’ state, CRI, USD are made.
Peculiarities of Cesarean section:
- amniotomy prior to the operation (provided there are necessary conditions);
- obligatory revision of uterine walls (especially external surface) with the aim to eliminate the possibility of uterine – placental apoplexy;
- in case of Kuveler’s uterus diagnosis – extirpation of the uterus without appendages;
- if the area of apoplexy is not large – 2-3 foci of a small diameter of 1-2 sm, or one focus – up to 3 sm) and if the uterus can contract, if there is no bleeding and no signs of DIC-syndrome and if it is necessary to preserve a reproductive function ( first labor, fetal mortality) – the consultation has to decide the question of protecting the uterus. Surgeons have to observe the uterus state for some time (10-20 min) by open abdominal cavity and if there is no hemorrhage, the abdominal cavity is drained to control hemostasis. This tactics is allowed, in exceptional cases, only in hospitals with day-and-night duty by an obstetrician-gynecologist, an anesthesiologist;
- in early postpartum period- a thorough observation of the parturient.
Tactics by placental detachment in the end of I or II periods
- urgent amniotomy if the amniotic bladder is intact;
- by cephalic presentation – application of obstetrical forceps;
- by pelvic presentation – fetal extraction at the pelvic end;
- if one fetus of the twins is in the transverse presentation – obstetric podalic version is performed. In some cases delivery by Cesarean section is more reliable.
- manual placental separation and expulsion of the afterbirth;
- contractile methods – 10 units of oxytocin intravenously, if there is no effect – 800 mkg of misoprostol (rectally);
- thorough dynamic observation in postpartum period;
- restoration of the blood loss amount, hemorrhagic shock and DIC-syndrome management.
Amniotic fluid embolism
I. Causes of intrauterine high blood pressure:
- hyperactive labor;
- rapid labor;
- oxytocin injections in big dosages;
- hydramnios;
- a big fetus;
- multiple pregnancy;
- pelvic presentation;
- uterine cervical distonia;
- prolonged gestation;
- late break of the water bag;
- gross manipulations during delivery (Kristeller’s method and other)
II. Causes of uterine vessels hiatus:
- hypovolemia of any origin;
- premature placental detachment;
- placental presentation;
- manual separation and expulsion of the afterbirth from the uterine cavity;
- Cesarean section;
- Uterine hypotension.
Clinical picture depends on the amount and composition of the fluid in the blood vessels of the mother.
Diagnosis of amniotic fluid embolism is based on the assessment of clinical symptoms, laboratory tests and auxiliary methods of investigation,
Cinical signs:
- anxiety;
- nervousness, excitement;
- shivering and hyperthermia;
- cough;
- sudden pallor or cyanosis;
- acute pain in the chest;
- dyspnea, noisy respiration;
- AP lowering;
- tachycardia,
- coagulopathetic hemorrhage from maternal passages or other traumatized sites;
- coma;
- convulsions;
- death in consequence of ventricular fibrillation in the course of several minutes.
Laboratory signs – signs of hypocoagulation and ESR rise (B)..
Auxiliary methods of examination:
- ECG – sinus tachycardia, myocardium hypoxia, acute pulmonary heart (SIQ III P-pulmonale)
- Roentgenologic changes reveal themselves immediately or some hours after embolism and have a clinical picture of interstitial confluent pneumonitis (“a butterfly” with consolidation throughout total area at the root of the lung and lumen of the lung tissue picture at periphery).
Differential diagnosis is made with the following pathology:
- myocardial infarction: pain irradiating in the left hand, rhythm disturbances, ECG changes which are not always visible on the fresh infarction;
- lung artery thromboembolism: abruptness, various facial cyanosis, dyspnea, headache, pain in the chest. It often occurs by compromised veins (varicosity, thrombophlebitis, phlebitis) right gram on the ECG;
- air embolism (by rough violation of intravenuous infusion technique);
- Mendelson’s syndrome (bronchospasm as a response to the appearance of acidic stomach content in the upper respiratory tracts) – acid – aspiratory hyperergic pneumonitis. As a rule, it occurs bi initial narcosis with unemptied stomach, when vomiting masses appear in the respiratory tracts: anoxia during 5 minutes – death of the brain.
Urgent therapy by amniotic fluid embolism is performed by a team of physicians including an obstetrician-gynecologist and anesthesiologist. Consultations of a cardiologist, a neuropathologist and a vascular surgeon are essential.
Therapeutic tactics:
1. Urgent parturition in the course of pregnancy or delivery;
2. Management of cardio-pulmonary shock or cardio-pulmonary resuscitation.
3. Coagulopathy correction.
4. Timely and complete surgical intervention by hemorrhage.
5. Prevention and therapy of polyorganic insufficiency.
First –rate measures:
1. At the arrest of circulation – performance of cardio-pulmonary resuscitation.
2. If signs of respiratory insufficiency increase - trachea intubation and APV.
3. Punction and catheterization of subclavian jugular vein with obligatory control of CVP. To take 5 ml of blood for the investigation of coagulogram and presence of amniotic fluid elements.
4. Urinary bladder catheterization with an indwelling catheter.
Monitoring of viable functions should include:
- AP measurement every 15 minutes;
- CVP;
- RHB;
- RR (respiration rate);
- Pulsoxemetry;
- ECG;
- Hour-to hour diuresis and routine analysis of the urine;
- Thermometry;
- Chest organs roentgenology;
- Routine blood test, Ht, thrombocytes;
- Coagulogram;
- Acid-basic state and blood gases;
- Biochemical blood test and electrolytes content.
Further therapy:
1. If CVP is 8 sm of water column then – inotropic support is performed: dofamin (5-10 mkg/kg/min). Isotropic therapy is initiated with minimal dosages and if there is no effect – the dosages are gradually increased. Combined dofamine (2-5 mkg/kg/min) and dobutamine (10 mkg/kg/min) injections are desirable.
3. Simultaneously with sympathomimetic therapy glucocorticoids are used:: prednisolone up to 300-400 mg or hydrocortisone – 1000-1500 mg.
4. Control of coagulopathy.
5. Prevention of injectious complications.
Criteria of intensive therapy effectiveness:
- increase of cardiac ejaction;
- abolition of arterial hypotension;
- elimination of peripheric vasoconstriction signs;
- normalization of diuresis >30 ml/hour
- normalization of hemostasis indeces;
- decrease of respiratory failure signs.
Bleeding in the afterbirth and postpartum periods
Postpartum bleeding is blood loss of 0,5% or more in relation to the body mass after parturition.
Risk factors of postpartum hemorrhage
- aggravated obstetric anamnesis (bleedings at previous labor, abortions, spontaneous abortion);
- hestosis;
- a big fetus;
- hydramnion;
- multiple pregnancy;
- uterine myoma;
- cicatrix on the womb;
- chronic DIC – syndrome;
- thrombocytopathy;
- antenatal fetal mortality.
Hemorrhage in postpartum (third) period of labor
Causes:
- partial placental or membrane retention;
- placental implantation pathology;
- placental strangulation.
The amount of blood loss depends on the kind of placental implantation damage: total, partial detachment or adherent placenta.
Clinical manifestations:
1. Signs of placental separation are absent during 30 minutes without significant blood loss – pathology of placental detachment or adherence.
2. Hemorrhage initiates immediately at afterbirth labor – retention of placental fragments or membranes;
3. Hemorrhage initiates after the childbirth without placental separation – placental strangulation, partial placental adherence.
Hemorrhage associated with placental retention, pathologic detachment or strangulation
Algorhythm of management:
1. Catherization of the peripheric or central vein regarding the amount of blood loss and the woman’s state.
2. Urine bladder emptying.
3. Checking-up the signs of placental separation and afterbirth removal by manual methods.
4. In case of afterbirth strangulation – external massages of the uterus, external methods of the afterbirth removal.
5. If placental fragments or membranes have been retained – manual examination of uterine cavity under intravenous narcosis.
6. If the mechanism of placental presentation fails and there is no hemorrhage – anticipation in the course of 30 minutes (with the group of pregnants – 15 minutes) manual separation of placenta and removal of the afterbirth.
7. If hemorrhage occurs – urgent manual placental separation and removal of the afterbirth under intravenous narcosis.
8. Uterotonics injections – 10-20 units of oxytocin intravenously on 400 ml of physiologic salt solution by intravenous droppery.
9. In case of genuine detachment or adherence of the placenta – laparotomy, extirpation of the uterus without appendages.
10. Assessment of the blood loss amount and recovery of the BCV (blood circulation volume) amount.
Early (primary) postpartum hemorrhage
Causes of early postpartum hemorrhage:
- hypotension or atony of the uterus (in 90% of patients);
- retention of placental fragments or membranes;
- traumatic damages of the maternal passages;
- disorder of blood coagulability (afibrinogenemia, fibrinolysis);
- primary blood diseases.
Causes of uterine hypotension or atony
- functional failures of myometrium (late hestosis, endocrinopathies, somatic diseases, uterine tumours, a cicatrix on the womb, a big fetus, hydramnios, multiple pregnancy and others);
- overexcitation with the following failure of myometrium function (protracted or prolonged labor), operation in the end of delivery, administration of medicaments lowering myometrium tension (spasmolytics, tocolytics, hypoxia at delivery, and so on);
- failure of a contractive function of myometrium due to disorder of biochemical processes, correlation of neurohumoral factors (estrogens, acetylcholine, oxytocin, cholinesterase, progesterone, prostaglandins);
- disturbances of placental and afterbirth implantation, separation and removal processes;
- idiopathetic (haven’t been established).
Major clinicolaboratory manifestations:
Hemorrhage occurs in two kinds:
- hemorrhage initiates immediately after the childbirth, it’s massive (>1000 ml in the course of few minutes); the uterus remains hypotonic, doesn’t contract, hypovolemia develops rapidly, then hemorrhagic shock;
- hemorrhage initiates after the uterine contraction, blood runs out in small portions, blood loss increases gradually. Alternation of uterine hypotony with tonus recovery, arrest and recurrence of bleeding are characteristic.
Algorhythm of management:
1. General examination of the women in childbirth:
- assessment of blood loss amount by available methods (appendage №1);
- assessment of the parturient’s state: complaints, AP, heart rate, colour of the skin and mucous membranes, urine amount, if there is hemorrhagic shock and its stage;
2. Urgent laboratory tests:
- evaluation of hemoglobin and hematocryt level;
- coagulogram (the amount of thrombocytes, prothrombin index, fibrinogen factor, blood coagulation time);
- blood group and rhesus factor;
- biochemical tests according to indications.
3. Peripheric or central vein catherization regarding the amount of blood loss and the woman’s condition.
4. Urine bladder evacuation.
5. Beginning or continuation of urotonics injections: 10-20 units of oxytocyn intravenously on 400 ml of physiologic salt solution.
6. manual examination of uterine cavity under intravenous anesthesia (assessment of uterine walls intactness, removal of blood clots or residue of placenta or membranes).
7. Examination of the maternal passages and restoration of their intactness.
8. External uterine massage.
9. In case the hemorrhage continues, 800 mkg of misoprostol are additionally injected rectally.
10. Restoration of BCV (blood circulating volume) and blood loss.
11. If hemorrhage takes up again and the blood loss amount is 1,5% and more in relation to the body weight – surgical management: uterine extirpation without appendages, in case the hemorrhage continues – ligation of internal glomerular arteries by a specialist having a good command of the operation.
12. During preparation for surgery with the aim to decrease the amount of blood loss – temporary bimanual external and internal compression of the uterus.
13. If the hemorrhage continues after uterine extirpation – powerful tamponade of the abdominal cavity and the vagina (the abdominal cavity isn’t stitched till the hemostasis).
Postpartum secondary (late) hemorrhage
Major causes for late postpartum hemorrhages:
- retention of placental fragments or afterbirth;
- expulsion of necrotic tissues after delivery;
- disjunctional separation of sutures and uterine wound (after Cesarean section or hysterorrhexis).
Postpartum hemorrhage most frequently occurs on the 7-12th days after labor.
Algorhythms of medical care:
1. Assessment of blood loss by available methods.
2. Catherization of peripheric and central vein.
3. Instrumental revision of uterine cavity under intravenous anesthesia.
4. Intravenous injections of uterotonics (oxytocin 10-20 units on physiologic salt solution – 400 or 0,5 mkg methylergometrine).
5. In case the hemorrhage proceeds – misoprostol 800 mkg rectally.
6. Restoration of the blood loss circulation volume.
7. If the blood loss is >1,5% to the body mass – laparotomy, uterine extirpation, if the hemorrhage continues – ligation of internal glomerular arteries by a specialist well-trained in the operation.
Blood coagulation disturbances (postpartum afibrinogenemia, fibrinolysis):
- restoration of the blood circulation volume;
- correction of hemostasis (see DIC – syndrome treatment).
Prevention of postpartum hemorrhages.
1. In the course of pregnancy:
- estimating risk factors of hemorrhage;
- diagnosis and treatment of anemia;
- hospitalization at the maternity home being home being ready to help the gravida from the high risk group in the incidence of hemorrhage who has in the history:
-antenatal hemorrhage; hemorrhages in previous deliveries, whith hydramnion, multiple pregnancy, a big fetus.
Factors conductive to hemorrhages in postpartum period
|Previous pregnancies |Factors which occur in the course of |Factors which occur in the course of |
| |pregnancy |delivery |
|Unigravida (primipara, primigravida) |Complete placental presentation |Induction of labor |
|More than 5 labor in the history |Placental separation |Protracted or prolonged labor |
|Pathology of placental separation or expulsion |hydramnion |Precipitated labor |
|Operations on the uterus in the history |Multiple pregnancy |Urgent Cesarean section |
|including Cesarean section | | |
|Prolonged or difficult childbirth in the |Intrauterine fetal mortality |Application of obstetrical forceps |
|history | | |
|Background diseases: cardiovascular, diabetes |Difficult preeclampsia, eclampsia | |
|mellitus, blood coagulation pathology | |chorionamnionitis |
|Anemia |hepatitis |DIC - syndrome |
|Uterine myoma |Conditions associated with anemia |General or epidural anesthesia |
2. In the course of delivery:
- labor pain relief;
- elimination of prolonged labor;
- active management of the third period of delivery;
- usage of uterotonic medicamentations I the third period of delivery;
- routine examination and assessment of placental and membranes intactness;
- traumatism prevention in the course of delivery.
3. After the parturium:
- observation and examination of the maternal passages;
- thorough care during 2 hours after the delivery;
- pregnant women from the risk group undergo intravenuous 20 units of oxytocin droppery during 2 hours after the childbirth.
Hemorrhagic shock in obstetrics
Hemorrhagic shock is a condition of severe hemodynamic and metabolic disturbances resulting from blood loss and characterized by inability of the blood circulation system to provide viable organs with adequate perfusion due to the lack of correspondence between the circulating blood amount and the vascular bed volume
The threat of hemorrhagic shock appears when the blood loss is 15-20% of the circulatory blood volume or 750-1000 ml. Hemorrhage exceeding 1500 ml (25-30% from the circulatory blood volume or 1,5% in relation to the body mass) in regarded massive.
Causes of hemorrhagic shock risk in obstetrics
1. Hemorrhage at early terms of gestation:
- abortion;
- extrauterine pregnancy;
- hydatidiform mole
2. Hemorrhage at late terms of gestation or delivery:
- premature placental detachment;
- placental presentation;
- hysterorrhexis (uterine rupture);
- amniotic fluid embolism
3. Postpartum hemorrhage:
- hypo- or atony of the uterus;
- retention of the afterbirth or its fragments in the uterine cavity;
- maternal passages rupture
4. Hepatic insufficiency
5. Hemostasis system pathology
Hemorrhagic shock. Classification according to the clinical course and the damage rate
|Shock damage rate |Shock stage |Blood loss amount |
| | |% BCV |%body mass |
|1 |compensated |15-20 |0,8-1,2 |
|2 |subcompensated |21-30 |1,3-1,8 |
|3 |decompensated |31-40 |1,9-2,4 |
|4 |irreversible |>40 |>2,4 |
Shock damage rate criteria
|Index |Shock stage |
| | |
|Blood loss , ml |2500 |
|Blood loss (%BCV) |40% |
|Pulse, beat/min |140 or3 sec |>3 sec |>3 sec |
|Hematocrit |0,38-0,42 |0,30-0,38 |0,25-0,30 |0,20-0,25 |40 |
|Diuresis rate , ml/hour |50 |30-50 |25-30 |5-15 |0-5 |
|Mental status |Calm quiet |Slight anxiety |Anxiety moderate |Nervousness fear |confused |
| | | |nervousness |or confused |consciousness |
| | | | |consciousness |or coma |
Note: *- on main arteries,
** - cannot be determined by Korotkov’s method
Difficulties of determining the blood loss amount in obstetrics are caused by a significant hemodilution of the leaking blood with amniotic fluid as well as the retention of a big amount of blood in the vagina or uterine cavity. For a tentative determination of the blood loss amount in pregnant women a modificated Moore’s formula can be used: 0,42-Htf
BL=M*75*-----------
0,42
where: BL – blood loss (ml);
M – body mass of the gravida (kg);
Htf – factual hematocrit of the gravida (l/l)
NB! Arterial hypotension is regarded late and unreliable clinical symptom of obstetric hemorrhagic shock. Due to physiologic hypervolemic autohemodilution AP in pregnant women may be stable until the blood loss volume reaches 30%. Hypovolemia compensation in pregnant is, provided, at first rate, at the expense of symptoadrenal system activation, which reveal itself in vasospasm and tachycardia. Oliguria joins in early.
Hemorrhagic shock intensive therapy. General principles of acute blood loss therapy:
1. Urgent hemostasia by conservative or surgical methods depending on the causes of hemorrhagic development (see the protocol ‘Obstetric hemorrhages’)
2. Circulation blood volume recovery.
3. Maintenance of adequate gas exchange.
4. Management of organ dysfunction and prophylaxis of polyorganic insufficiency.
5. Correction of metabolic disorder.
Immediate actions by hemorrhage shock.
1. Assessment of viable functions (pulse, arterial pressure, respiration rate and character, mental status).
2. A duty obstetrician-gynecologist in charge or assistant of chief doctor should be informed about hemorrhage and hemorrhage shock initiation, the personnel should be mobilized.
3. The patient’s feet or the foot end of the bed are raised (trendelenburg position) to increase venous turnover to the heart.
4. The gravida is turned to the left side to avoid the development of aortocaval syndrome, to reduce aspiration risk by vomiting and to provide a free passage for respiratory tracts.
5. Catheterization of one – two peripheric veins by catheters of big diameter (NN 14-16 G). If it possible to reach some peripheric veins, then haste shouldn’t be made with central veins catherization because in the course of their catherization serious complications are sure to arise. If shock of 3-4 stage develops - catheterization of 3 veins should be made one of them should be central at that. During catherization preference in given to venesection v. brachiales or punction and catherization after Seldinger v. jugularis interna.
6. 10 ml of blood is taken to determine blood group and Rhesus – factor, cross-compatibility, hemoglobin and hematocrit content, prior to the infusion of solutions Lee-White test is performed.
7. 100% oxygen inhalation is performed at the rate of 6-8 l/min thtough nasofacial mask or nasal cannula.
Further activity to eliminate hemorrhagic shock
1. Crystalloid (0,9% solution of sodium chloride, Ringer’s solution, oth.) and colloids (helofusin) are jet-infused intravenously. If shock develops to the second or third stage, the tempo of infusion is 200-300 ml/min. On AP stabilization at the safe level further infusion is performed at the rate 2 l of solution per hour. Hemorrhagic shock management is more effective if infusive therapy has been started at the very onset, no later than 30 min after the appearance of first signs of shock.
|Blood loss volume |Infusive media |
|% BCV |% from body |Ringer lactate|Helofuzin |Cool |Albumin 10-20%|Erythrocyte mass |Thrombo- |
| |mass | | |plasma | | |concent |
| | | | | | | |rate |
|To 25% (to 1,25 l) |To 1,5% |1-2 l |1-2 l | | | | |
|To 50% (to 2,5 l) |To 3,0% |2 l |2-2,5 l |1*250 ml | |1*250 ml | |
|To 65% (to 3,25 l) |To 4,0% |2 l |2-2,5 l |1-3*250 ml |0,25-1 l |1-3*250 ml | |
|To 75% (to 3,75 l) |To 4,5% |2 l |2-2,5 l |3-5 *250 ml |0,25-1 l |3-6*250 ml | |
|>75% |>4,5% |2 l |2-2,5 l |5*250 ml and more |0,5-1 l |6*250 ml |In case of necessary |
| | | | | | |and more |usage |
Infusive-transfusive therapy of obstetric blood loss
2. The bleeding can be arrested by conservative or surgical methods depending on the cause of hemorrhage.
3. The women should be warmed but not over-warmed, because peripheric microcirculation improves at that, decreasing blood supply to the viable organs. Taking into account a big number of solutions injected, they are warmed up to 36˚ Centigrade.
4. Urine bladder is catheterized.
5. 100% oxygen inhalation is continued at the rate 608 l/min, if necessary – APV.
If low PaO2 remains (1000 ml. Technical |
|complications during operation. |
|Concomitant pathology absence of |
|endovideosurgical equipment |
|Significant changes the tube; |
|defect of the wall>4 sm, |
|peritubal hematoma. |
|Realization of reproductive |
|function. |
Algorhythm of EP surgery
Conservative EP treatment
Progressive EP treatment with methotrexate can be accomplished only in medical institutions of the third level where there is potential to estimate β-subunit HCG in blood serum and USD and make USD with transvaginal sensor.
Guidelines for methotrexate injection in case of EP.
Methotrexate injection should be avoided by normal uterine pregnancy or missed miscarriage; it is indicated only in the following cases:
1. Increased level of β-subunit HCG in blood serum following organoprotective surgery on uterine tube, which was performed for progressive extrauterine pregnancy.
2. Stabilization or increase of β-subunit HCG level in blood serum during 12-24 hours after separate diagnostic curettage or vacuum-aspiration, if the fertilized ovum size in the site of uterine appendages is no more than 3,5 sm.
3. Revealing a fertilized ovum with a diameter no more than 3,5 sm in the site of uterine appendages with USD transvaginal sensor in case β-subunit HCG level is more than 1500 ME/l when there is no fertilized ovum in the uterine cavity.
|Day |Therapeutic-diagnostic measures |
|1-st | Assessment of β-subunit HCG level in blood serum |
|2-nd | Routine blood test, determination of the blood group and Rhesus factor of the woman, liver ferment|
| |activity. |
|5 -th |Methotrexate 75-100 ml intramuscular |
|8-th |Assessment of β-subunit HCG level in blood serum |
Methotrexate injection by EP.
If β-subunit HCG level in serum increased less than in 15% on the 8-th day, methotrexate is injected again in the same dosage. If β-subunit HCG level in serum increased in more than 15%, the gravida is being observed, β – subunit HCG level is assessed every week till the time this level is less than 10 ME/l.
Ovarian pregnancy – develops when the ovum is fertilized in the follicule cavity. Frequency of ovarian pregnancy is 0,5-1% to all extrauterine pregnancies and takes the second place in frequency after tubal pregnancy. The only risk factor of this variant of extrauterine pregnancy is intrauterine contraceptives usage.
Diagnosis.
Clinical signs are the same as during tubal pregnancy. At disturbed ovarian pregnancy there is a possibility of hemorrhagic shock. In 75% cases of ovarian pregnancy it is incorrectly diagnosed as ovarian apoplexy. USD of small pelvis organs is helpful in making diagnosis, especially by means of transvaginal sensor, when the fertilized ovum is visualized in the site of ovary as well as positive qualitative reaction on HCG.
Ovarian pregnancy signs by USD:
- uterine tube on the affected side is intact;
- the fetal sac occupies the position of the ovary;
- the ovary and the sac are connected to the uterus by the uteroovarian ligament;
- ovarian tissue is visualized in the sac wall.
Treatment.
Surgical treatment includes removal of the fertilized ovum and clinoid resection of the ovary.
Massive impairment of the ovary and significant intraperitoneal hemorrhage are indications for ovariotomy.
Cervical pregnancy is the rarest in incidence and most severe variant of extrauterine pregnancy, when the implantation of a fertilized ovum imbedded in the cervical canal of the uterus.
Diagnosis.
1. A precedent history (anamnesis) including gynecologic. Attention is paid to the number of abortions and course of the postabortion period, previcus inflammations of inner genitals including uterine cervix.
2. Uterine cervix examination with specula. Cyanotic barrel-like uterine cervix is visualized.
3. Careful bimanual gynecologic examination. The uterine together with the cervix looking like a “sand-glass”.
4. Small pelvis organs observation by USD.
Ultrasound signs of cervical pregnancy
- absence of a fertilized ovum in the fetal sac (uterine cavity);
- hypoechogenic endometrium (decidual tissue);
- heterogeneity of biometry;
- “a sand-glass” – like uterine;
- extasia of the cervical canal of the uterus;
- the fertilized ovum is in the cervical canal of the uterus;
- placental tissue is in the cervical canal of the uterus;
- a closed intrauterine pupil.
Differential diagnosis
Cervical pregnancy should be differentiated with spontaneous abortion, myoma, cervical carcinoma, procidentia of the submucous myoma on peduncle, presentation and lower placental location USD is very helpful in making differential diagnosis, revealing differences between cervical pregnancy and other obstetric-gynecologic pathology.
Management.
1. Once the diagnosis of cervical pregnancy been made – there should be a point-blank refusal to curettage of walls in the uterine cavity, which could have resulted in profuse hemorrhage development.
2. The method of cervical pregnancy management is surgery (uterus extirpation).
3. When the diagnosis has been confirmed,-the blood group and Rhesus factor are estimated, a venous catheter is installed, a written concent of the informed patient for uterine extirpation should be received. In the transfusiologic unit chilled plasma of the same blood group and recently prepared erythrocytic mass should be ordered, preparations of hydrooxyethyl starch should be made.
Abdominal pregnancy.
It accounts for 0,003% of all ectopic pregnancies. Primary and secondary abdominal pregnancies are distinguished. Primary pregnancy is regarded to be the one that has implanted on the peritoneal surface. Secondary pregnancy develops when the impregnated ovum has implanted in the abdominal cavity after tubal abortion. Motherly mortality rate by abdominal pregnancy is 7-8 times higher than by tubal one and 90 times higher than by uterine pregnancy.
Diagnosis.
Clinical manifestations depend on the term of gestation:
1. In the first and in the beginning of the second trimester they slightly differ from the symptoms of tubal pregnancy.
2. At later terms pregnant women complain of tenderness during fetal movements, feeling movements in the epigastral side or a sudden pause of fetal movements.
3. Physical examination may reveal a very easily palpated fetus and a separate small uterine. Abdominal pregnancy is also diagnosed when there are no uterine contractions after oxytocin injection.
4. USD is also helpful for diagnosis. If USD data are not informative, the diagnosis is confirmed by X-ray, CT and MRI. A cross-table lateral X-ray of the maternal abdomen shows shadowy fetal skeleton overlying. The maternal vertebral.
Treatment.
Having in mind a high risk of maternal mortality, once the diagnosis has been made, surgery is urgent. During operative treatment the vessels are exposed and ligated, which carry blood to the placenta and extirpate it if possible. If it is impossible because of excessive bleeding, the placenta is tamponed. The tampons are removed in 24-48 hours. If exposure of the vessels can’t be performed, the umbilical cord is ligated and separated while the placenta remains.
Postoperative period.
If placenta after surgery is in the abdominal cavity, its condition is evaluated by means of USD and assessment of β-subunit HCG level. The risk of intestinal obstruction, adhesions and sepsis is very high in these cases. Methotrexate injections are contraindicated because of concomitant severe complications, sepsis, first of all. The cause of sepsis is massive necrosis of the placenta.
IV. Control questions and tasks
1. General classification of obstetrical bleedings.
2. Classification of the bleedings in the first half of pregnancy.
3. Clinicodiagnostic criteria of abortion.
4. What is the placental presentation?
5. Classification of placental presentation.
6. What clinical symptoms of placental presentation do you now?
7. Algorhythm of examination at admittance of a pregnant with bleeding to in-patient.
8. What is the premature detachment of normally located placenta?
9. Classification of the premature detachment of normally located placenta.
10. Hemorrhage in postpartum period of labor.
11. What is the hemorrhagic shock?
12. What causes of hemorrhagic shock do you now?
13. Infusive-transfusive therapy of obstetric blood loss
V.Tasks and tests
1. At the puerpera of 26 years old, for 4 day after labour the incessant parent bleeding began. The haemorrhage has made 400 ml. The common state is worsened - a body temperature 36, 7о С, pulse of 94 beets / mines, the AP of 90/70 mm.Hg. The uterus is intense, morbid, its bottom is at a level of a umbilicus. The diagnosis is : "Delivery in time. A bleeding of the 4th day of puerperal term. ". It is necessary:
A *Tool revision of a cavity of the uterus
B Manual inspection of a cavity of the uterus and erasion of the delayed parts of a placenta
C Outside massage of a uterus after bleeding urinary bladder
D To enter drugs reducing a uterus
E Supravaginal ablation of a uterus
2. Secundapara of 25 years. In the third period of delivery the bleeding has appeared. The attributes of placenta’ detachment are absent. At manual detachment ofplacenta it was revealed that a placenta is fixed, with growing into a myometrium. Tactics of the doctor?
A Laparotomy, a hysterectomy
B Application of uterotonic agents
C A hemotransfusion
D Laparotomy, supravaginal amputation of uterus
E Tool secretion of an afterbirth
3. The woman delivered twins has early postnatal hypotonic uterine bleeding reached 1.5\% of her bodyweight. The bleeding is going on. Conservative methods to arrest the bleeding have been found ineffective. The conditions of patient are pale skin, acrocyanosis, oliguria. The woman is confused. The pulse rate is 130 beats per min, BP – 75/50 mm Hg. What is the further treatment?
A *Uterine extirpation
B Supravaginal uterine amputation
C Uterine vessels ligation
D Inner glomal artery ligation
E To put clamps on the uterine cervix
4. The 36 weeks of gestation pregnant woman was admitted to the obstetric in-patient department. She has previous history of arterial hypertension, now complains of a headache, aching pains in the lower abdomen and bloody discharge from vagina. The main clinical features are blood pressure 180/100 mm Hg and hypertonic uterus. During investigation about 300 ml of dark blood was discharged from vagina. The fetal heartbeats are not heard. What is the diagnosis?
A *premature placental separation
B Placental presentation
C premature delivery threat
D uterine rupture
E Embolism caused by amniotic fluid
VI. List of recommended literature
1. Danforth's Obstetrics and gynaecology. - Seventh edition.- 1994.
2. Obstetrics and gynaecology. Williams & Wilkins Waverly Company. - Third Edition.- 1998.
3. Basic Gynecology and Obstetrics. - Norman F. Gant, F. Gary Cunningham. -1993.
4. Clinical Obstetrics of Fetus and Mother – E. Albert Reece&John Hobbins. – Third Edition. – Blackwell publishing. – 2007.
5. Obstetrics Illustrated. – Kevin P. Hanretty. – Sixth Edition. – Churchill Livingstone. - 2003.
6. Manual on Obstetrics. – Arthur T. Evans. – Seventh Edition. - Lippincott Williams & Wilkins. – 2007.
7.Акушерство= Obstetrics: Підручник/І.Б.Венцківська, Г.Д.Гордєєва, О.А.Бурка та ін.; Ред. Венцківська І.-Рекомендовано МОЗ України для студентів ВМНЗ ІУ рівня акредитації.-К.: Медицина, 2008.-336 с.: іл. (Англ. мовою).
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