Obstetrics and gynecology. Uterine bleeding during pregnancy (lecture notes)

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Obstetrics and gynecology. Uterine bleeding during pregnancy (lecture notes)

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Lecture number 18. Uterine bleeding during pregnancy

The most common cause of bleeding from the genital tract during pregnancy is its premature termination - spontaneous miscarriage (abortus spontaneus) or artificial miscarriage (abortus artificialis).

Premature termination of pregnancy

Abortion (abortus - "miscarriage") - termination of pregnancy during the first 28 weeks. Termination of pregnancy after 28 weeks (up to 38 weeks) is called preterm birth (partus praematurus).

Spontaneous abortion. It is the most common obstetric pathology, occurring more often in the 3rd month in approximately 2-8% of pregnant women. The reasons for spontaneous abortion are quite complex and ambiguous. A miscarriage can be the result of not one, but several causes (endocrine disorders, underdevelopment of the uterus, the consequences of inflammatory diseases, infections, etc.), acting simultaneously or sequentially. Disturbances in the development of the reproductive system and various dysfunctions of the hypothalamus-pituitary-ovarian system are the most common causes of spontaneous abortion. Impaired ovarian function leading to miscarriage can occur due to induced abortions, inflammatory diseases of the female genital organs, and dysfunction of the endocrine glands. Complications arising in connection with induced abortions lead to miscarriage: trauma to the basal layer of the endometrium, isthmus and cervix. Infectious diseases in acute form (influenza, measles, rubella, scarlet fever, infectious hepatitis, etc.) often lead to termination of pregnancy. One of the reasons for miscarriage (spontaneous abortion and premature birth) is isthmic-cervical insufficiency of an organic nature (trauma during abortion, pathological birth). Functional isthmic-cervical insufficiency associated with endocrine disorders is observed less frequently. Often the causes of miscarriage are malformations of the uterus, neoplasms of the genital organs (uterine fibroids, ovarian cystomas) with the appropriate size and location, as well as concomitant neuroendocrine and other disorders. Chronic intoxication (nicotine, gasoline, lead, mercury, aniline compounds, etc.) often leads to fetal death and miscarriage.

Clinic and course. During an abortion, the fertilized egg gradually peels off from the walls of the uterus, which is accompanied by damage to the vessels of the decidua. In this case, bleeding occurs, the severity of which depends on the degree of detachment of the ovum and the diameter of the damaged vessels. Under the influence of the contractile activity of the myometrium, the exfoliated fertilized egg is expelled from the uterine cavity, less often as a whole, more often in parts. Contractions of the uterus, promoting the expulsion of the fertilized egg, are felt as cramping pain. The following stages of abortion are distinguished: threatened abortion, started abortion, ongoing abortion, incomplete abortion, complete abortion, delayed (failed) abortion.

Slight pulling pains, a feeling of heaviness in the lower abdomen in the absence of bleeding indicate a threat of abortion. The size of the uterus corresponds to the gestational age. The external os is closed. The abortion that has begun is characterized by the appearance of cramping pains and small bloody discharge due to the detachment of some part of the fetal egg from the uterine wall. The size of the uterus corresponds to the gestational age, the cervical canal is closed. With a threatening and incipient abortion, pregnancy can be maintained.

Abortion in the course is characterized by the fact that contractions intensify and become painful, bleeding increases. The cervix shortens, the cervical canal opens, the fetal egg, exfoliated from the walls of the uterus, is pushed out of it. Bleeding becomes severe and often reaches an alarming degree. Preservation of pregnancy is impossible, the fetal egg is removed as a matter of urgency.

Incomplete abortion is characterized by the fact that not all of the fetal egg is expelled from the uterus, but only the fetus and part of the membranes depart. The remaining parts of the ovum interfere with a good contraction of the uterus. The cervical canal is somewhat open, the size of the uterus is less than the gestational age. Bleeding continues and can be very heavy.

Complete abortion in early pregnancy is much less common than in later periods. With a complete abortion, no elements of the fetal egg remain in the uterus, it contracts, the cervical canal closes and the bleeding stops.

Modern methods of diagnosis and treatment allow in 80-90% of cases to detect the cause of premature termination of pregnancy and prescribe adequate therapy that will help maintain pregnancy.

Currently, for the treatment of threatening abortion, a complex etiotropic, pathogenetic and symptomatic effect is used.

For this purpose, sedative therapy is carried out, which helps to reduce emotional excitability, relieve anxiety and anxiety in a pregnant woman. The appointment of antispasmodic and tocolytic agents causes a decrease in the contractile activity of the uterus. Antiplatelet agents, angioprotectors, anticoagulants contribute to the normalization of microcirculation and rheological properties of blood. With insufficient function of the corpus luteum and the production of progesterone, replacement therapy with progesterone analogues is carried out. Glucocorticoid hormones are prescribed for autoimmune disorders and hyperandrogenism. Antimicrobial and immunostimulating drugs are indicated when infectious processes occur.

The use of complex methods of therapy helps to reduce the contractile activity of the uterus and normalize impaired uteroplacental circulation. At the same time, these women make up a certain percentage of the risk group for the development of chronic fetoplacental insufficiency, possibly premature birth and premature detachment of a normally located placenta.

Bleeding in the early postpartum period. Bleeding from the birth canal that occurs in the first 4 hours after delivery is called early postpartum bleeding.

Bleeding after childbirth can be caused by various reasons:

1) retention of part of the placenta in the uterine cavity;

2) hypotension or atony of the uterus;

3) rupture of the soft tissues of the birth canal;

4) dysfunction of the blood coagulation system (hypo- and afibrinogenemia).

Hypotension of the uterus - This is a pathological condition characterized by a sharp decrease in the tone and contractility of the uterus. As a result of ongoing activities and drug therapy that stimulate the contractile function of the uterus, the myometrium is reduced, but often the strength of the contractile reaction is inadequate to the strength of the effect.

Uterine atony - this is a formidable complication that can accompany labor. At the same time, drugs and ongoing activities do not have any effect on the uterus. The state of the neuromuscular apparatus of the myometrium is regarded as paralysis. Atony of the uterus occurs very rarely, but causes profuse bleeding.

Causes hypotonic and atonic bleeding are diverse:

1) violation of the neurohumoral regulation of the contractile function of the uterine muscles as a result of the exhaustion of the forces of the body of the puerperal and especially her nervous system during prolonged and complicated childbirth;

2) severe forms of preeclampsia (nephropathy, eclampsia), hypertension;

3) anatomical features of the uterus: infantilism and malformations of the uterus (double, bicornuate uterus), tumors (myoma) of the uterus, scars on the uterus after surgery, extensive inflammatory and degenerative changes after past inflammatory diseases or abortions;

4) functional inferiority of the uterus, prolonged overstretching of the uterus with polyhydramnios, multiple pregnancies, large fetuses;

5) rapid emptying of the uterus during operative delivery, especially after the application of obstetric forceps, is often accompanied by hypotonic bleeding due to the fact that the uterus does not have time to contract due to rapidly changing conditions;

6) presentation and low attachment of the placenta, especially in the presence of an extensive placental area;

7) adhesive processes in the abdominal cavity, especially adhesions of the uterus with adjacent organs, interfere with the normal contractile activity of the uterine muscles.

The cause of hypo- and atonic bleeding may be a combination of several causes.

Clinic. The leading symptom of hypotonic bleeding is massive bleeding from the uterus in the postpartum period. In addition, symptoms develop due to hemodynamic disturbances and acute anemia. A clinical picture of hemorrhagic shock appears.

The condition of the woman in these cases is due to the massiveness and duration of bleeding. Physiological blood loss during childbirth does not exceed 0,5% of a woman's body weight (but not more than 450 ml). In women with anemia, preeclampsia, diseases of the cardiovascular system, even a slight excess of the physiological norm of blood loss can cause a severe clinical picture.

The severity of clinical manifestations depends on the intensity of bleeding. With significant blood loss (1000 ml or more) that has occurred for a long time, the symptoms of acute anemia are less pronounced than with rapid blood loss, even in a smaller volume, when collapse can develop faster and death occurs.

Diagnostics. The diagnosis of hypotension is made based on existing uterine bleeding and data from its objective examination. With uterine hypotension, pathological bleeding is inconsistent. Blood is released in portions, often in the form of clots. The uterus is flabby, rarely contracts, contractions are rare and short-lived. The uterus is enlarged in size due to blood clots accumulated in it; in some cases, it is poorly defined through the anterior abdominal wall. When performing an external massage, it contracts, and then it relaxes again, and bleeding continues.

With atony, the uterus completely loses its tone and contractility, does not respond to mechanical and pharmacological stimuli. The uterus is flabby, poorly palpated through the abdominal wall. Blood flows out in a wide stream or is released in large clots.

It is necessary to make a differential diagnosis between hypotonic bleeding and traumatic injuries of the birth canal. With an injury to the birth canal, the contractility of the uterus is not disturbed, the uterus is dense. Inspection of the cervix and vaginal walls in the mirrors, manual examination of the walls of the uterus indicate the presence or absence of ruptures of the soft tissues of the birth canal.

With hypo- and afibrinenemia, the uterus is usually in good shape. The blood is liquid, without clots. To diagnose hypo- and afibrinogenemia during bleeding in the early postpartum period, a blood clot dissolution test can be performed. To conduct a test, 2 ml of blood is taken from a vein in a test tube from a healthy woman in labor. After 2-3 minutes, blood clotting occurs. The same amount of blood from the patient's vein is placed in the second tube. In this case, the blood does not clot. If you pour this blood into the first test tube, then the clot formed in it begins to dissolve.

Treatment. If a placental defect is suspected and detected, a manual examination of the uterus is performed, and remnants of placental tissue are removed. At the same time, myotonics are administered. In case of hypotonic bleeding, a set of therapeutic measures aimed at stopping the bleeding and replenishing blood loss is immediately carried out. If conservative treatment is ineffective, surgical treatment must be started immediately. These may include transection and hysterectomy. All actions to stop bleeding are aimed at strengthening the contractility of the uterus and are carried out in a certain order:

1) emptying the bladder using catheterization;

2) the introduction of uterine contracting agents (1 ml of oxytocin intravenously slowly);

3) external massage of the uterus: with the palm of the right hand through the anterior abdominal wall, they cover the bottom of the uterus and make light circular massaging movements. In this case, the uterus becomes dense. With gentle pressure on the bottom of the uterus, blood clots that prevent contraction are removed from its cavity. Massage is continued until the uterus is completely contracted and bleeding stops. If, after the massage, uterine contraction does not occur or does not occur completely, and then the uterus relaxes again, then proceed to further measures;

4) an ice pack on the lower abdomen;

5) if the bleeding has not stopped, a manual examination of the uterus is performed, it is massaged on the fist. The external genital organs and hands of the doctor are treated with disinfectants and under general anesthesia the uterine cavity, its walls are examined by hand in order to exclude the presence of trauma and retained placental remnants. Remove existing blood clots that prevent uterine contraction. If after this the contraction of the uterus is insufficient, then it is massaged on the fist. The fist is located in the region of the bottom of the uterus, with the other hand through the anterior abdominal wall, a light massage of the uterus is performed, with an increase in tone, the uterus tightly covers the fist, the bleeding stops. The hand is carefully removed from the uterus. Rough manipulations with the use of force can lead to multiple hemorrhages in the myometrium. Simultaneously with the massage of the uterus on the fist, agents that reduce the uterus (oxytocin, prostaglandins) are injected;

6) to enhance the effect of stopping bleeding, a transverse catgut suture can be applied to the posterior lip of the cervix according to V. A. Lositskaya;

7) introduction of a tampon moistened with ether into the posterior fornix of the vagina.

The lack of effect from all the measures taken indicates in favor of the presence of atonic bleeding, which requires emergency surgical intervention. In order to preserve the uterus, if circumstances permit, after opening the abdominal cavity, catgut ligatures are applied to the uterine and ovarian arteries on both sides, wait some time. In some cases, this leads to uterine contraction (hypoxia of the myometrium leads to reflex contraction), bleeding stops, and the uterus is preserved. If this does not happen, especially if there are signs of coagulopathy, then the bleeding cannot be stopped. In such a situation, the only method of saving the life of the puerperal is amputation or extirpation of the uterus.

Author: Ilyin A.A.

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