Prevention of bleeding in the postpartum period. Postpartum hemorrhage: earlier and later

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Bleeding in early postpartum period- bleeding that occurs in the first 2 hours after birth.

Hypotony of the uterus - weakness contractility uterus and its insufficient tone.

Uterine atony is a complete loss of tone and contractility of the uterus, which does not respond to medication and other stimulation.

Epidemiology

Classification

See subchapter “Bleeding in the afterbirth period.”

Etiology and pathogenesis

Bleeding in the early postpartum period can be caused by retention of parts of the placenta in the uterine cavity, hypo- and atony of the uterus, a violation of the blood coagulation system, and uterine rupture.

The causes of hypo- and atonic bleeding are disturbances in the contractility of the myometrium due to childbirth (preeclampsia, somatic diseases, endocrinopathies, scar changes in the myometrium, etc.).

The causes of bleeding due to disorders of the hemostatic system can be both congenital and acquired defects of the hemostatic system existing before pregnancy (thrombocytopenic purpura, von Willebrand disease, angiohemophilia), as well as various types of obstetric pathology that contribute to the development of disseminated intravascular coagulation syndrome and the occurrence of bleeding during childbirth and the early postpartum period. The development of blood coagulation disorders of a thrombohemorrhagic nature is based on the processes of pathological activation of intravascular coagulation.

Clinical signs and symptoms

Bleeding caused by retained parts of the placenta is characterized by copious bleeding with large clots postpartum uterus, periodic relaxations and copious discharge of blood from the genital tract.

With uterine hypotension, bleeding is characterized by waves. Blood is released in portions in the form of clots. The uterus is flabby, its contractions are rare and short. Blood clots accumulate in the cavity, as a result of which the uterus enlarges, loses normal tone and contractility, but still responds to normal stimuli with contractions.

Relatively small amounts of fractional blood loss (150-300 ml) provide temporary adaptation of the postpartum woman to developing hypovolemia. BP remains within limits normal values. Pallor of the skin and increasing tachycardia are noted.

With insufficient treatment in the early initial period of uterine hypotension, the severity of violations of its contractile function progresses, therapeutic measures become less effective, the volume of blood loss increases, symptoms of shock increase, and DIC develops.

Uterine atony is an extremely rare complication. With atony, the uterus completely loses its tone and contractility. Its neuromuscular system does not respond to mechanical, thermal and pharmacological stimuli. The uterus is flabby, poorly contoured through abdominal wall. Blood flows out in a wide stream or is released in large clots. The general condition of the postpartum woman is progressively deteriorating. Hypovolemia rapidly progresses, hemorrhagic shock and disseminated intravascular coagulation develop. If the bleeding continues, the death of the mother may occur.

In the practical work of an obstetrician-gynecologist, the division of bleeding into hypotonic and atonic is conditional due to the complexity of differential diagnosis.

In case of disruption of the hemostasis system clinical picture characterized by the development of coagulopathic bleeding. In conditions of severe deficiency of coagulation factors, the formation of hemostatic blood clots is difficult, blood clots are destroyed, and the blood is liquid.

For bleeding caused by retained parts of the placenta, the diagnosis is based on a thorough examination of the placenta and membranes after the birth of the placenta. If there is a defect or doubt about the integrity of the placenta, manual examination of the postpartum uterus and removal of retained parts of the placenta are indicated.

The diagnosis of hypotonic and atonic bleeding is made based on the results of a physical examination and clinical picture.

The diagnosis of coagulopathic bleeding is based on hemostasis indicators (absence of platelets, presence of high molecular weight fractions of fibrin/fibrinogen degradation products).

Differential diagnosis

Bleeding resulting from retention of parts of the placenta in the uterine cavity should be differentiated from bleeding associated with hypotension and atony of the uterus, a violation of the blood coagulation system, and uterine rupture.

Hypotony and atony of the uterus are usually differentiated from traumatic injuries of the soft birth canal. Heavy bleeding with a large, relaxed, poorly contoured uterus through the anterior abdominal wall, this indicates hypotonic bleeding; bleeding with a dense, well-contracted uterus indicates damage to the soft tissues of the birth canal.

Differential diagnosis for coagulopathies should be made with uterine bleeding of another etiology.

Bleeding due to retained parts of the placenta

If parts of the placenta are retained in the uterus, their removal is indicated.

Hypotony and atony of the uterus

If the contractility of the uterus is impaired in the early postpartum period with blood loss exceeding 0.5% of body weight (350-400 ml), all means of combating this pathology should be used:

■ emptying Bladder soft catheter;

■ external massage of the uterus;

■ applying cold to the lower abdomen;

■ use of agents that enhance myometrial contraction;

■ manual examination of the walls of the postpartum uterine cavity;

■ terminals for parametrium according to Baksheev;

■ if the measures taken are ineffective, laparotomy and hysterectomy are justified.

If bleeding continues, embolization of the pelvic vessels or ligation of the internal iliac arteries is indicated.

Important in the treatment of hypotonic bleeding, timely initiation of infusion therapy and compensation of blood loss, the use of agents that improve the rheological properties of blood and microcirculation, preventing the development of hemorrhagic shock and coagulopathic disorders are beneficial.

Uterotonic therapy

Dinoprost IV drip 1 ml (5 mg) in 500 ml 5% dextrose solution or 500 ml 0.9% sodium chloride solution, once

Methylergometrine, 0.02% solution, iv 1 ml, once

Oxytocin IV drip 1 ml (5 units) in 500 ml of 5% dextrose solution or 500 ml of 0.9% sodium chloride solution, once.

Hemostatic

and blood replacement therapy

Albumin, 5% solution, iv drip 200-400 ml once a day, duration of therapy is determined individually

Aminomethylbenzoic acid IV 50-100 mg 1-2 times a day, duration of therapy is determined individually

Aprotinin IV drip 50,000-100,000 units up to 5 times a day or 25,000 units 3 times a day (depending on the specific drug), the duration of therapy is determined individually

Hydroxyethyl starch, 6% or 10% solution, 500 ml IV drip 1-2 times a day, duration of therapy is determined individually

Bleeding in the afterbirth (in the third stage of labor) and in the early postpartum periods may occur as a result of disruption of the processes of separation of the placenta and discharge of the placenta, decreased contractile activity of the myometrium (hypo- and atony of the uterus), traumatic damage to the birth canal, and disturbances in the hemocoagulation system.

Blood loss of up to 0.5% of body weight is considered physiologically acceptable during childbirth. A volume of blood loss greater than this indicator should be considered pathological, and blood loss of 1% or more is classified as massive. Critical blood loss is 30 ml per 1 kg of body weight.

Hypotonic bleeding is caused by a condition of the uterus in which there is a significant decrease in its tone and a significant decrease in contractility and excitability. With uterine hypotension, the myometrium reacts inadequately to the strength of the stimulus to mechanical, physical and medicinal influences. In this case, periods of alternating decrease and restoration of uterine tone may be observed.

Atonic bleeding is the result of a complete loss of tone, contractile function and excitability of the neuromuscular structures of the myometrium, which are in a state of paralysis. In this case, the myometrium is unable to provide sufficient postpartum hemostasis.

However, from a clinical point of view, the division of postpartum hemorrhage into hypotonic and atonic should be considered conditional, since medical tactics primarily depends not on what kind of bleeding it is, but on the massiveness of blood loss, the rate of bleeding, the effectiveness of conservative treatment, and the development of disseminated intravascular coagulation syndrome.

What provokes / Causes of Bleeding in the afterbirth and early postpartum periods:

Although hypotonic bleeding always develops suddenly, it cannot be considered unexpected, since each specific clinical observation reveals certain risk factors for the development of this complication.

• Physiology of postpartum hemostasis

The hemochorionic type of placentation determines the physiological volume of blood loss after separation of the placenta in the third stage of labor. This volume of blood corresponds to the volume of the intervillous space, does not exceed 0.5% of the woman’s body weight (300-400 ml of blood) and does not negatively affect the condition of the postpartum woman.

After separation of the placenta, an extensive, richly vascularized (150-200 spiral arteries) subplacental area opens, which creates a real risk quick loss large volume of blood. Postpartum hemostasis in the uterus is ensured both by contraction of the smooth muscle elements of the myometrium and thrombus formation in the vessels of the placental site.

Intense retraction of the muscle fibers of the uterus after separation of the placenta in the postpartum period contributes to compression, twisting and retraction of the spiral arteries into the thickness of the muscle. At the same time, the process of thrombus formation begins, the development of which is facilitated by the activation of platelet and plasma coagulation factors, and the influence of the elements of the fetal egg on the hemocoagulation process.

At the beginning of thrombus formation, loose clots are loosely bound to the vessel. They easily come off and are washed out by the blood flow when uterine hypotension develops. Reliable hemostasis is achieved 2-3 hours after the formation of dense, elastic fibrin blood clots, firmly connected to the vessel wall and covering their defects, which significantly reduces the risk of bleeding in the event of decreased uterine tone. After the formation of such blood clots, the risk of bleeding decreases with a decrease in myometrial tone.

Consequently, an isolated or combined violation of the presented components of hemostasis can lead to the development of bleeding in the afterbirth and early postpartum periods.

• Disorders of postpartum hemostasis

Disturbances in the hemocoagulation system can be caused by:

• changes in hemostasis that existed before pregnancy;
• disorders of hemostasis due to complications of pregnancy and childbirth (antenatal death of the fetus and its prolonged retention in the uterus, gestosis, premature placental abruption).

Disorders of myometrial contractility, leading to hypo- and atonic bleeding, are associated with various causes and can occur both before the onset of labor and occur during childbirth.

In addition, all risk factors for the development of uterine hypotension can be divided into four groups.

• Factors determined by the characteristics of the patient’s socio-biological status (age, socio-economic status, profession, addictions and habits).
• Factors determined by the premorbid background of the pregnant woman.
• Factors determined by the peculiarities of the course and complications of this pregnancy.
• Factors associated with the characteristics of the course and complications of these births.

Consequently, the following can be considered prerequisites for a decrease in uterine tone even before the onset of labor:

• Ages 30 years and older are the most at risk for uterine hypotension, especially for primiparous women.
• The development of postpartum hemorrhage in female students is facilitated by high mental stress, emotional stress and overexertion.
• Parity of birth does not have a decisive influence on the frequency of hypotonic bleeding, since pathological blood loss in primigravidas is observed as often as in multiparous women.
• Dysfunction nervous system, vascular tone, endocrine balance, water-salt homeostasis (myometrial edema) in connection with various extragenital diseases (presence or exacerbation inflammatory diseases; pathology of the cardiovascular and bronchopulmonary systems; kidney diseases, liver diseases, thyroid diseases, diabetes mellitus), gynecological diseases, endocrinopathies, lipid metabolism disorders, etc.
• Dystrophic, cicatricial, inflammatory changes in the myometrium, causing the replacement of a significant part muscle tissue connective uterus, due to complications after previous births and abortions, operations on the uterus (presence of a scar on the uterus), chronic and acute inflammatory processes, tumors of the uterus (uterine fibroids).
• Insufficiency of the neuromuscular apparatus of the uterus against the background of infantilism, abnormal development of the uterus, and ovarian hypofunction.
• Complications of this pregnancy: breech presentation of the fetus, FPN, threatened miscarriage, previa or low location of the placenta. Severe forms Late gestosis is always accompanied by hypoproteinemia, increased permeability of the vascular wall, extensive hemorrhages in the tissues and internal organs. Thus, severe hypotonic bleeding in combination with gestosis is the cause of death in 36% of women in labor.
• Overdistension of the uterus due to a large fetus, multiple pregnancy, polyhydramnios.

The most common causes of impaired functional ability of the myometrium that arise or worsen during childbirth are the following.

Depletion of the neuromuscular apparatus of the myometrium due to:

• excessively intense labor (quick and rapid labor);
• discoordination of labor;
• protracted labor (weakness of labor);
• irrational administration of uterotonic drugs (oxytocin).

It is known that in therapeutic doses, oxytocin causes short-term, rhythmic contractions of the body and fundus of the uterus, does not have a significant effect on the tone of the lower segment of the uterus and is quickly destroyed by oxytocinase. In this regard, to maintain the contractile activity of the uterus, its long-term intravenous drip administration is required.

Long-term use of oxytocin for induction and labor stimulation can lead to blockade of the neuromuscular apparatus of the uterus, resulting in the development of atony and subsequent immunity to drugs that stimulate myometrial contractions. The risk of amniotic fluid embolism increases. The stimulating effect of oxytocin is less pronounced in multiparous women and women over 30 years of age. At the same time, hypersensitivity to oxytocin was noted in patients with diabetes mellitus and with pathology of the diencephalic region.

Surgical delivery. The frequency of hypotensive bleeding after surgical delivery is 3-5 times higher than after vaginal delivery. In this case, hypotensive bleeding after surgical delivery can be due to various reasons:

• complications and diseases that caused surgical delivery (weakness of labor, placenta previa, gestosis, somatic diseases, clinically narrow pelvis, anomalies of labor);
• stress factors in connection with the operation;
• the influence of painkillers that reduce myometrial tone.

It should be noted that operative delivery not only increases the risk of developing hypotonic bleeding, but also creates the preconditions for the occurrence of hemorrhagic shock.

Damage to the neuromuscular apparatus of the myometrium due to the entry into the vascular system of the uterus of thromboplastic substances with elements of the fertilized egg (placenta, membranes, amniotic fluid) or products infectious process(chorioamnionitis). In some cases, the clinical picture caused by amniotic fluid embolism, chorioamnionitis, hypoxia and other pathology may be blurred, abortive in nature and manifested primarily by hypotonic bleeding.

Use during childbirth medicines, reducing myometrial tone (painkillers, sedatives and antihypertensive drugs, tocolytics, tranquilizers). It should be noted that when prescribing these and other medications during childbirth, as a rule, their relaxing effect on myometrial tone is not always taken into account.

In the afterbirth and early postpartum period, a decrease in myometrial function under other of the above circumstances can be caused by:

• rough, forced management of the afterbirth and early postpartum period;
• dense attachment or placenta accreta;
• retention of parts of the placenta in the uterine cavity.

Hypotonic and atonic bleeding can be caused by a combination of several of these reasons. Then the bleeding takes on its most dangerous character.

In addition to the listed risk factors for the development of hypotonic bleeding, their occurrence is also preceded by a number of shortcomings in the management of pregnant women at risk both in the antenatal clinic and in the maternity hospital.

Complicating prerequisites for the development of hypotonic bleeding during childbirth should be considered:

• discoordination of labor (more than 1/4 of observations);
• weakness of labor (up to 1/5 of observations);
• factors leading to hyperextension of the uterus (large fetus, polyhydramnios, multiple pregnancy) - up to 1/3 of observations;
• high traumatism of the birth canal (up to 90% of observations).

The opinion that death due to obstetric hemorrhage is unpreventable is deeply erroneous. In each specific case, a number of preventable tactical errors associated with insufficient observation and untimely and inadequate therapy are noted. The main errors leading to the death of patients from hypotonic bleeding are the following:

• incomplete examination;
• underestimation of the patient's condition;
• inadequate intensive care;
• delayed and inadequate replacement of blood loss;
• loss of time when using ineffective conservative methods of stopping bleeding (often repeatedly), and as a result - a belated operation - removal of the uterus;
• violation of surgical technique (long operation, injury to neighboring organs).

Pathogenesis (what happens?) during Bleeding in the afterbirth and early postpartum periods:

Hypotonic or atonic bleeding, as a rule, develops in the presence of certain morphological changes in the uterus that precede this complication.

In histological examination of preparations of uteruses removed due to hypotonic bleeding, almost all observations show signs of acute anemia after massive blood loss, which are characterized by pallor and dullness of the myometrium, the presence of sharply dilated gaping blood vessels, the absence of blood cells in them or the presence of leukocyte accumulations due to blood redistribution.

A significant number of specimens (47.7%) revealed pathological ingrowth of chorionic villi. At the same time, chorionic villi covered with syncytial epithelium and single cells of chorionic epithelium were found among the muscle fibers. In response to the introduction of elements of the chorion, foreign to muscle tissue, lymphocytic infiltration occurs in the connective tissue layer.

The results of morphological studies indicate that in a large number of cases, uterine hypotension is functional in nature, and bleeding was preventable. However, as a result of traumatic labor management, prolonged labor stimulation, repeated

manual entry into the postpartum uterus, intensive massage of the “uterus on a fist”, a large number of red blood cells with elements of hemorrhagic impregnation, multiple microtears of the uterine wall are observed among the muscle fibers, which reduces the contractility of the myometrium.

Chorioamnionitis or endomyometritis during childbirth, found in 1/3 of cases, have an extremely adverse effect on the contractility of the uterus. Among the irregularly located layers of muscle fibers in the edematous connective tissue, abundant lympholeukocyte infiltration is noted.

Characteristic changes are also edematous swelling of muscle fibers and edematous loosening of the interstitial tissue. The persistence of these changes indicates their role in the deterioration of uterine contractility. These changes are most often a consequence of a history of obstetric and gynecological diseases, somatic diseases, and gestosis, leading to the development of hypotonic bleeding.

Consequently, often defective contractile function of the uterus is caused by morphological disorders of the myometrium, which arose as a result of inflammatory processes and the pathological course of this pregnancy.

And only in isolated cases does hypotonic bleeding develop as a result of organic diseases of the uterus - multiple fibroids, extensive endometriosis.

Symptoms of Bleeding in the afterbirth and early postpartum periods:

Bleeding in the afterbirth period

Hypotony of the uterus often begins already in the afterbirth period, which at the same time has a longer course. Most often, in the first 10-15 minutes after the birth of the fetus, no intense contractions of the uterus are observed. On external examination, the uterus is flabby. Its upper border is at the level of the navel or significantly higher. It should be emphasized that sluggish and weak contractions of the uterus with its hypotension do not create the proper conditions for retraction of muscle fibers and rapid separation of the placenta.

Bleeding during this period occurs if partial or complete separation of the placenta has occurred. However, it is usually not permanent. Blood is released in small portions, often with clots. When the placenta separates, the first portions of blood accumulate in the uterine cavity and vagina, forming clots that are not released due to the weak contractile activity of the uterus. Such accumulation of blood in the uterus and vagina can often create a false impression that there is no bleeding, as a result of which appropriate therapeutic measures may be started late.

In some cases, bleeding in the afterbirth period may be due to retention of the separated placenta due to incarceration of part of it in the uterine horn or cervical spasm.

Cervical spasm occurs due to a pathological reaction of the sympathetic part of the pelvic nerve plexus in response to injury to the birth canal. The presence of the placenta in the uterine cavity with normal excitability of its neuromuscular system leads to increased contractions, and if there is an obstacle to the release of the placenta due to spasm of the cervix, bleeding occurs. Removing cervical spasm is possible by using antispasmodic drugs followed by release of the placenta. Otherwise, under anesthesia, manual removal of the placenta with inspection of the postpartum uterus should be performed.

Disturbances in the discharge of the placenta are most often caused by unreasonable and rough manipulations of the uterus during a premature attempt to discharge the placenta or after the administration of large doses of uterotonic drugs.

Bleeding due to pathological attachment of the placenta

The decidua is a functional layer of the endometrium that changes during pregnancy and in turn consists of the basal (located under the implanted fertilized egg), capsular (covers the fertilized egg) and parietal (the rest of the decidua lining the uterine cavity) sections.

In the basal decidua there are compact and spongy layers. The basal lamina of the placenta is formed from the compact layer located closer to the chorion and the cytotrophoblast of the villi. Individual chorionic villi (anchor villi) penetrate into the spongy layer, where they are fixed. During the physiological separation of the placenta, it is separated from the wall of the uterus at the level of the spongy layer.

Violation of the separation of the placenta is most often caused by its tight attachment or accretion, and in more rare cases, ingrowth and germination. At the heart of these pathological conditions there is a pronounced change in the structure of the spongy layer of the basal decidua or its partial or complete absence.

Pathological changes in the spongy layer can be caused by:

• previously suffered inflammatory processes in the uterus after childbirth and abortion, specific lesions of the endometrium (tuberculosis, gonorrhea, etc.);
• hypotrophy or atrophy of the endometrium after surgical interventions (caesarean section, conservative myomectomy, uterine curettage, manual separation of the placenta in previous births).

It is also possible to implant the fertilized egg in areas with physiological endometrial hypotrophy (in the area of ​​the isthmus and cervix). The likelihood of pathological attachment of the placenta increases with malformations of the uterus (septum in the uterus), as well as in the presence of submucosal myomatous nodes.

Most often, there is a tight attachment of the placenta (placenta adhaerens), when the chorionic villi firmly grow together with the pathologically altered underdeveloped spongy layer of the basal decidua, which entails a violation of the separation of the placenta.

There is a partial dense attachment of the placenta (placenta adhaerens partialis), when only individual lobes have a pathological nature of attachment. Less common is complete dense attachment of the placenta (placenta adhaerens totalis) - over the entire area of ​​the placental area.

Placenta accreta is caused by the partial or complete absence of the spongy layer of the decidua due to atrophic processes in the endometrium. In this case, the chorionic villi are adjacent directly to the muscular layer or sometimes penetrate into its thickness. There are partial placenta accreta (placenta accreta partialis) and complete placenta accreta totalis.

Much less common are such serious complications as ingrowth of villi (placenta increta), when chorionic villi penetrate into the myometrium and disrupt its structure, and ingrowth (placenta percreta) of villi into the myometrium to a considerable depth, right up to the visceral peritoneum.

With these complications, the clinical picture of the process of separation of the placenta in the third stage of labor depends on the degree and nature (complete or partial) of disruption of the placenta.

With partial tight attachment of the placenta and with partial placenta accreta due to its fragmented and uneven separation, bleeding always occurs, which begins from the moment the normally attached areas of the placenta are separated. The degree of bleeding depends on the disruption of the contractile function of the uterus at the placenta attachment site, since part of the myometrium in the projection of the unseparated parts of the placenta and in nearby areas of the uterus does not contract to the proper extent, as required to stop bleeding. The degree of contraction weakening varies widely, which determines the clinical picture of bleeding.

The contractile activity of the uterus outside the placenta insertion usually remains at a sufficient level, as a result of which bleeding for a relatively long time may be insignificant. In some women in labor, a violation of myometrial contraction can spread to the entire uterus, causing hypo- or atony.

With complete tight attachment of the placenta and complete placenta accreta and the absence of its forced separation from the uterine wall, bleeding does not occur, since the integrity of the intervillous space is not violated.

Differential diagnosis of various pathological forms of placenta attachment is possible only during its manual separation. In addition, these pathological conditions should be differentiated from the normal attachment of the placenta in the tubal angle of the bicornuate and double uterus.

If the placenta is tightly attached, as a rule, it is always possible to completely separate and remove all parts of the placenta by hand and stop the bleeding.

In the case of placenta accreta, heavy bleeding occurs when attempting to manually separate it. The placenta comes off in pieces and is not completely separated from the wall of the uterus; some of the placenta lobes remain on the wall of the uterus. Atonic bleeding, hemorrhagic shock, and disseminated intravascular coagulation syndrome develop rapidly. In this case, to stop the bleeding, only removal of the uterus is possible. A similar way out of this situation is also possible with the ingrowth and growth of villi into the thickness of the myometrium.

Bleeding due to retention of parts of the placenta in the uterine cavity

In one option, postpartum bleeding, which usually begins immediately after the discharge of the placenta, may be due to the retention of its parts in the uterine cavity. These may be lobules of the placenta, parts of the membrane that prevent normal contraction of the uterus. The reason for the retention of parts of the placenta is most often partial placenta accreta, as well as improper management of the third stage of labor. Upon careful examination of the placenta after birth, most often, without much difficulty, a defect in the tissues of the placenta, membranes, and the presence of ruptured vessels located along the edge of the placenta are revealed. Identification of such defects or even doubt about the integrity of the placenta serves as an indication for an urgent manual examination of the postpartum uterus with removal of its contents. This operation is performed even if there is no bleeding when a defect in the placenta is detected, since it will certainly appear later.

It is unacceptable to perform curettage of the uterine cavity; this operation is very traumatic and disrupts the processes of thrombus formation in the vessels of the placental area.

Hypo- and atonic bleeding in the early postpartum period

In most cases, in the early postpartum period, bleeding begins as hypotonic, and only subsequently does uterine atony develop.

One of the clinical criteria for distinguishing atonic bleeding from hypotonic is the effectiveness of measures aimed at enhancing the contractile activity of the myometrium, or the lack of effect from their use. However, such a criterion does not always make it possible to clarify the degree of disturbance of the contractile activity of the uterus, since the ineffectiveness of conservative treatment may be due to a severe disorder of hemocoagulation, which becomes the leading factor in a number of cases.

Hypotonic bleeding in the early postpartum period is often a consequence of ongoing uterine hypotension observed in the third stage of labor.

It is possible to distinguish two clinical variants of uterine hypotension in the early postpartum period.

Option 1:

• bleeding is profuse from the very beginning, accompanied by massive blood loss;
• the uterus is flabby, reacts sluggishly to the introduction of uterotonic agents and manipulations aimed at increasing the contractility of the uterus;
• Hypovolemia progresses rapidly;
• hemorrhagic shock and disseminated intravascular coagulation syndrome develop;
• changes in the vital organs of the postpartum woman become irreversible.

Option 2:

• initial blood loss is small;
• there are repeated bleedings (blood is released in portions of 150-250 ml), which alternate with episodes of temporary restoration of uterine tone with cessation or weakening of bleeding in response to conservative treatment;
• temporary adaptation of the postpartum woman to developing hypovolemia occurs: blood pressure remains within normal values, there is some pallor of the skin and slight tachycardia. Thus, with large blood loss (1000 ml or more) over a long period of time, the symptoms of acute anemia are less pronounced, and the woman copes with this condition better than with rapid blood loss in the same or even smaller quantities, when collapse and death can develop faster.

It should be emphasized that the patient’s condition depends not only on the intensity and duration of bleeding, but also on the general initial condition. If the postpartum woman’s body strength is depleted and the body’s reactivity is reduced, then even a slight excess physiological norm blood loss can cause a severe clinical picture if there was already a decrease in blood volume initially (anemia, gestosis, diseases of cardio-vascular system, lipid metabolism disorder).

With insufficient treatment in the initial period of uterine hypotension, disturbances in its contractile activity progress, and the response to therapeutic measures weakens. At the same time, the volume and intensity of blood loss increases. At a certain stage, the bleeding increases significantly, the condition of the woman in labor worsens, the symptoms of hemorrhagic shock quickly increase and disseminated intravascular coagulation syndrome develops, soon reaching the hypocoagulation phase.

The indicators of the hemocoagulation system change accordingly, indicating a pronounced consumption of coagulation factors:

• the number of platelets, fibrinogen concentration, and factor VIII activity decreases;
• prothrombin consumption and thrombin time increase;
• fibrinolytic activity increases;
• degradation products of fibrin and fibrinogen appear.

With minor initial hypotension and rational treatment, hypotonic bleeding can be stopped within 20-30 minutes.

In case of severe uterine hypotension and primary disorders in the hemocoagulation system in combination with disseminated intravascular coagulation syndrome, the duration of bleeding increases and the prognosis worsens due to the significant complexity of treatment.

With atony, the uterus is soft, flabby, with poorly defined contours. The fundus of the uterus reaches the xiphoid process. Main clinical symptom is continuous and heavy bleeding. The larger the area of ​​the placental area, the greater the blood loss during atony. Hemorrhagic shock develops very quickly, the complications of which (multiple organ failure) are the cause of death.

A postmortem examination reveals acute anemia, hemorrhages under the endocardium, sometimes significant hemorrhages in the pelvic area, edema, congestion and atelectasis of the lungs, dystrophic and necrobiotic changes in the liver and kidneys.

Differential diagnosis of bleeding due to uterine hypotension should be carried out with traumatic injuries to the tissues of the birth canal. In the latter case, bleeding (of varying intensity) will be observed with a dense, well-contracted uterus. Existing damage to the tissues of the birth canal is identified during examination with the help of speculum and eliminated accordingly with adequate pain relief.

Treatment of Bleeding in the afterbirth and early postpartum periods:

Management of the succession period during bleeding

• You should adhere to expectant-active tactics for managing the afterbirth period.
• The physiological duration of the afterbirth period should not exceed 20-30 minutes. After this time, the probability of spontaneous separation of the placenta decreases to 2-3%, and the possibility of bleeding increases sharply.
• At the moment of eruption of the head, the woman in labor is administered intravenously 1 ml of methylergometrine per 20 ml of 40% glucose solution.
• Intravenous administration of methylergometrine causes long-term (for 2-3 hours) normotonic contractions of the uterus. In modern obstetrics, methylergometrine is the drug of choice for drug prophylaxis during childbirth. The time of its administration should coincide with the moment of uterine emptying. Intramuscular administration of methylergometrine to prevent and stop bleeding does not make sense due to the loss of the time factor, since the drug begins to be absorbed only after 10-20 minutes.
• Bladder catheterization is performed. In this case, there is often increased contraction of the uterus, accompanied by separation of the placenta and discharge of the placenta.
• Intravenous drip administration of 0.5 ml of methylergometrine along with 2.5 units of oxytocin in 400 ml of 5% glucose solution is started.
• At the same time, infusion therapy is started to adequately replenish pathological blood loss.
• Determine the signs of placenta separation.
• When signs of placental separation appear, the placenta is isolated using one of the known methods (Abuladze, Crede-Lazarevich).

Repeated and repeated use of external methods for releasing the placenta is unacceptable, as this leads to a pronounced disruption of the contractile function of the uterus and the development of hypotonic bleeding in the early postpartum period. In addition, with weakness of the ligamentous apparatus of the uterus and its other anatomical changes, the rough use of such techniques can lead to inversion of the uterus, accompanied by severe shock.

• If there are no signs of placenta separation after 15-20 minutes with the introduction of uterotonic drugs or if there is no effect from the use of external methods for releasing the placenta, it is necessary to manually separate the placenta and release the placenta. The appearance of bleeding in the absence of signs of placental separation is an indication for this procedure, regardless of the time elapsed after the birth of the fetus.
• After separation of the placenta and removal of the placenta, the internal walls of the uterus are examined to exclude additional lobules, remnants of placental tissue and membranes. At the same time, parietal blood clots are removed. Manual separation of the placenta and discharge of the placenta, even if not accompanied by large blood loss (average blood loss 400-500 ml), lead to a decrease in blood volume by an average of 15-20%.
• If signs of placenta accreta are detected, attempts to manually separate it should be stopped immediately. The only treatment for this pathology is hysterectomy.
• If the tone of the uterus is not restored after the manipulation, additional uterotonic agents are administered. After the uterus contracts, the hand is removed from the uterine cavity.
• In the postoperative period, the state of uterine tone is monitored and the administration of uterotonic drugs is continued.

Treatment of hypotonic bleeding in the early postpartum period

The main feature that determines the outcome of labor during postpartum hypotonic hemorrhage is the volume of lost blood. Among all patients with hypotonic bleeding, the volume of blood loss is mainly distributed as follows. Most often it ranges from 400 to 600 ml (up to 50% of observations), less often - before Uzbek observations, blood loss ranges from 600 to 1500 ml, in 16-17% blood loss ranges from 1500 to 5000 ml or more.

Treatment of hypotonic bleeding is primarily aimed at restoring sufficient contractile activity of the myometrium against the background of adequate infusion-transfusion therapy. If possible, the cause of hypotonic bleeding should be determined.

The main tasks in the fight against hypotonic bleeding are:

• stop bleeding as quickly as possible;
• prevention of the development of massive blood loss;
• restoration of the BCC deficit;
• preventing blood pressure from falling below a critical level.

If hypotonic bleeding occurs in the early postpartum period, it is necessary to adhere to a strict sequence and phasing of the measures taken to stop the bleeding.

The scheme for combating uterine hypotension consists of three stages. It is designed for ongoing bleeding, and if the bleeding was stopped at a certain stage, then the effect of the scheme is limited to this stage.

First stage. If blood loss exceeds 0.5% of body weight (on average 400-600 ml), then proceed to the first stage of the fight against bleeding.

The main tasks of the first stage:

• stop bleeding without allowing more blood loss;
• provide infusion therapy adequate in time and volume;
• carry out accurate accounting of blood loss;
• do not allow a deficit of blood loss compensation of more than 500 ml.

Measures of the first stage of the fight against hypotonic bleeding

• Emptying the bladder with a catheter.
• Dosed gentle external massage of the uterus for 20-30 seconds every 1 minute (during massage, rough manipulations leading to a massive entry of thromboplastic substances into the mother’s bloodstream should be avoided). External massage of the uterus is carried out as follows: through the anterior abdominal wall, the fundus of the uterus is covered with the palm of the right hand and circular massaging movements are performed without using force. The uterus becomes dense, blood clots that have accumulated in the uterus and prevent its contraction are removed by gently pressing on the fundus of the uterus and massage is continued until the uterus contracts completely and bleeding stops. If after the massage the uterus does not contract or contracts and then relaxes again, then proceed to further measures.
• Local hypothermia (applying an ice pack for 30-40 minutes at intervals of 20 minutes).
• Puncture/catheterization of great vessels for infusion-transfusion therapy.
• Intravenous drip administration of 0.5 ml of methyl ergometrine with 2.5 units of oxytocin in 400 ml of 5-10% glucose solution at a rate of 35-40 drops/min.
• Replenishment of blood loss in accordance with its volume and the body’s response.
• At the same time, a manual examination of the postpartum uterus is performed. After treating the external genitalia of the mother and the surgeon’s hands, under general anesthesia, with a hand inserted into the uterine cavity, the walls of the uterus are examined to exclude trauma and lingering remnants of the placenta; remove blood clots, especially parietal ones, which prevent uterine contractions; carry out an audit of the integrity of the walls of the uterus; a malformation of the uterus or a tumor of the uterus should be excluded (myomatous node is often the cause of bleeding).

All manipulations on the uterus must be carried out carefully. Rough interventions on the uterus (massage on the fist) significantly disrupt its contractile function, lead to extensive hemorrhages in the thickness of the myometrium and contribute to the entry of thromboplastic substances into the bloodstream, which negatively affects the hemostatic system. It is important to assess the contractile potential of the uterus.

During a manual examination, a biological test for contractility is performed, in which 1 ml of a 0.02% solution of methylergometrine is injected intravenously. If there is an effective contraction that the doctor feels with his hand, the treatment result is considered positive.

The effectiveness of manual examination of the postpartum uterus decreases significantly depending on the increase in the duration of the period of uterine hypotension and the amount of blood loss. Therefore, it is advisable to perform this operation at an early stage of hypotonic bleeding, immediately after the lack of effect from the use of uterotonic drugs has been established.

Manual examination of the postpartum uterus has another important advantage, as it allows timely detection of uterine rupture, which in some cases may be hidden by the picture of hypotonic bleeding.

• Inspection of the birth canal and suturing of all ruptures of the cervix, vaginal walls and perineum, if any. Apply a catgut transverse suture to back wall cervix close to the internal os.
• Intravenous administration of a vitamin-energy complex to increase the contractile activity of the uterus: 100-150 ml of 10% glucose solution, ascorbic acid 5% - 15.0 ml, calcium gluconate 10% - 10.0 ml, ATP 1% - 2.0 ml, cocarboxylase 200 mg.

You should not count on the effectiveness of repeated manual examination and massage of the uterus if the desired effect was not achieved the first time they were used.

To combat hypotonic bleeding, such treatment methods as applying clamps to the parametrium to compress the uterine vessels, clamping the lateral parts of the uterus, uterine tamponade, etc. are unsuitable and insufficiently substantiated. In addition, they are not pathogenetically based methods of treatment and do not provide reliable hemostasis, their use leads to loss of time and delayed use of truly necessary methods to stop bleeding, which contributes to increased blood loss and the severity of hemorrhagic shock.

Second phase. If the bleeding has not stopped or has resumed again and amounts to 1-1.8% of body weight (601-1000 ml), then you should proceed to the second stage of the fight against hypotonic bleeding.

The main tasks of the second stage:

• stop the bleeding;
• prevent greater blood loss;
• avoid a shortage of blood loss compensation;
• maintain the volume ratio of injected blood and blood substitutes;
• prevent the transition of compensated blood loss to decompensated;
• normalize the rheological properties of blood.

Measures of the second stage of the fight against hypotonic bleeding.

• 5 mg of prostin E2 or prostenon is injected into the thickness of the uterus through the anterior abdominal wall 5-6 cm above the uterine os, which promotes long-term effective contraction of the uterus.
• 5 mg of prostin F2a diluted in 400 ml of crystalloid solution is administered intravenously. It should be remembered that long-term and massive use of uterotonic agents may be ineffective if massive bleeding continues, since the hypoxic uterus (“shock uterus”) does not respond to the administered uterotonic substances due to the depletion of its receptors. In this regard, the primary measures for massive bleeding are replenishment of blood loss, elimination of hypovolemia and correction of hemostasis.
• Infusion-transfusion therapy is carried out at the rate of bleeding and in accordance with the state of compensatory reactions. Blood components, plasma-substituting oncotically active drugs (plasma, albumin, protein), colloid and crystalloid solutions isotonic to blood plasma are administered.

At this stage of the fight against bleeding, with blood loss approaching 1000 ml, you should open the operating room, prepare donors and be prepared for emergency transsection. All manipulations are carried out under adequate anesthesia.

When the bcc is restored, intravenous administration of a 40% solution of glucose, korglykon, panangin, vitamins C, B1, B6, cocarboxylase hydrochloride, ATP, and antihistamines(diphenhydramine, suprastin).

Third stage. If the bleeding has not stopped, blood loss has reached 1000-1500 ml and continues, the general condition of the postpartum woman has worsened, which manifests itself in the form of persistent tachycardia, arterial hypotension, then it is necessary to proceed to the third stage, stopping postpartum hypotonic bleeding.

A feature of this stage is surgical intervention to stop hypotonic bleeding.

The main tasks of the third stage:

• stopping bleeding by removing the uterus before hypocoagulation develops;
• prevention of a shortage of compensation for blood loss of more than 500 ml while maintaining the volume ratio of administered blood and blood substitutes;
• timely compensation of respiratory function (ventilation) and kidneys, which allows stabilizing hemodynamics.

Measures of the third stage of the fight against hypotonic bleeding:

In case of uncontrolled bleeding, the trachea is intubated, mechanical ventilation is started and transection is started under endotracheal anesthesia.

• Removal of the uterus (extirpation of the uterus with fallopian tubes) is performed against the background of intensive complex treatment using adequate infusion and transfusion therapy. This volume of surgery is due to the fact that the wound surface of the cervix can be a source of intra-abdominal bleeding.
• In order to ensure surgical hemostasis in the surgical area, especially against the background of disseminated intravascular coagulation syndrome, ligation of the internal iliac arteries is performed. Then the pulse pressure in the pelvic vessels drops by 70%, which contributes to a sharp decrease in blood flow, reduces bleeding from damaged vessels and creates conditions for the fixation of blood clots. Under these conditions, hysterectomy is performed under “dry” conditions, which reduces the overall amount of blood loss and reduces the entry of thromboplastin substances into the systemic circulation.
• During surgery, the abdominal cavity should be drained.

In exsanguinated patients with decompensated blood loss, the operation is performed in 3 stages.

First stage. Laparotomy with temporary hemostasis by applying clamps to the main uterine vessels (ascending part of the uterine artery, ovarian artery, round ligament artery).

Second phase. An operational pause, when all manipulations in the abdominal cavity are stopped for 10-15 minutes to restore hemodynamic parameters (increase in blood pressure to a safe level).

Third stage. Radical stopping of bleeding - extirpation of the uterus with fallopian tubes.

At this stage of the fight against blood loss, active multicomponent infusion-transfusion therapy is necessary.

Thus, the basic principles of combating hypotonic bleeding in the early postpartum period are the following:

• start all activities as early as possible;
• take into account the patient’s initial health status;
• strictly follow the sequence of measures to stop bleeding;
• all treatment measures taken must be comprehensive;
• exclude the repeated use of the same methods of combating bleeding (repeated manual entries into the uterus, repositioning of clamps, etc.);
• apply modern adequate infusion-transfusion therapy;
• use only the intravenous method of administering medications, since under the current circumstances, absorption in the body is sharply reduced;
• resolve the issue of surgical intervention in a timely manner: the operation must be carried out before the development of thrombohemorrhagic syndrome, otherwise it often no longer saves the postpartum woman from death;
• do not allow blood pressure to drop below a critical level for a long time, which can lead to irreversible changes in vital organs (cerebral cortex, kidneys, liver, heart muscle).

Ligation of the internal iliac artery

In some cases, it is not possible to stop the bleeding at the site of the incision or pathological process, and then it becomes necessary to ligate the main vessels supplying this area at some distance from the wound. In order to understand how to perform this manipulation, it is necessary to recall anatomical features the structure of those areas where ligation of vessels will be performed. First of all, you should focus on ligating the main vessel that supplies blood to the woman’s genitals, the internal iliac artery. The abdominal aorta at the level of the LIV vertebra is divided into two (right and left) common iliac arteries. Both common iliac arteries run from the middle outward and downward along the inner edge of the psoas major muscle. Anterior to the sacroiliac joint, the common iliac artery divides into two vessels: the thicker, external iliac artery, and the thinner, internal iliac artery. Then the internal iliac artery goes vertically downward, to the middle along the posterolateral wall of the pelvic cavity and, reaching the greater sciatic foramen, divides into anterior and posterior branches. From the anterior branch of the internal iliac artery depart: the internal pudendal artery, uterine artery, umbilical artery, inferior vesical artery, middle rectal artery, inferior gluteal artery, supplying blood to the pelvic organs. From posterior branch The following arteries depart from the internal iliac artery: iliopsoas, lateral sacral, obturator, superior gluteal, which supply blood to the walls and muscles of the pelvis.

Ligation of the internal iliac artery is most often performed when the uterine artery is damaged during hypotonic bleeding, uterine rupture or extended extirpation of the uterus and appendages. To determine the location of the internal iliac artery, a promontory is used. Approximately 30 mm to the side of it, the boundary line is crossed by the internal iliac artery, which descends into the pelvic cavity with the ureter along the sacroiliac joint. To ligate the internal iliac artery, the posterior parietal peritoneum is dissected from the promontory downwards and outwards, then using tweezers and a grooved probe, the common iliac artery is bluntly separated and, going downwards, the place of its division into the external and internal iliac arteries is found. Above this place stretches from top to bottom and from outside to inside a light cord of the ureter, which is easily recognized by its pink color, ability to contract (peristalt) when touched and make a characteristic popping sound when slipping from the fingers. The ureter is retracted medially, and the internal iliac artery is immobilized from the connective tissue membrane, ligated with a catgut or lavsan ligature, which is brought under the vessel using a blunt-tipped Deschamps needle.

The Deschamps needle should be inserted very carefully so as not to damage the accompanying internal iliac vein with its tip, which passes in this place from the side and under the artery of the same name. It is advisable to apply the ligature at a distance of 15-20 mm from the site of division of the common iliac artery into two branches. It is safer if not the entire internal iliac artery is ligated, but only its anterior branch, but isolating it and placing a thread under it is technically much more difficult than ligating the main trunk. After placing the ligature under the internal iliac artery, the Deschamps needle is pulled back and the thread is tied.

After this, the doctor present at the operation checks the pulsation of the arteries in the lower extremities. If there is pulsation, then the internal iliac artery is compressed and a second knot can be tied; if there is no pulsation, then the external iliac artery is ligated, so the first knot must be untied and the internal iliac artery again looked for.

The continuation of bleeding after ligation of the iliac artery is due to the functioning of three pairs of anastomoses:

• between the iliopsoas arteries, arising from the posterior trunk of the internal iliac artery, and the lumbar arteries, branching from the abdominal aorta;
• between the lateral and median sacral arteries (the first arises from the posterior trunk of the internal iliac artery, and the second is an unpaired branch of the abdominal aorta);
• between the middle rectal artery, which is a branch of the internal iliac artery, and the superior rectal artery, which arises from the inferior mesenteric artery.

With proper ligation of the internal iliac artery, the first two pairs of anastomoses function, providing sufficient blood supply to the uterus. The third pair is connected only in case of inadequately low ligation of the internal iliac artery. Strict bilaterality of anastomoses allows for unilateral ligation of the internal iliac artery in case of uterine rupture and damage to its vessels on one side. A. T. Bunin and A. L. Gorbunov (1990) believe that when the internal iliac artery is ligated, blood enters its lumen through the anastomoses of the iliopsoas and lateral sacral arteries, in which the blood flow takes the opposite direction. After ligation of the internal iliac artery, anastomoses immediately begin to function, but the blood passing through small vessels loses its arterial rheological properties and its characteristics approach venous. In the postoperative period, the anastomotic system provides adequate blood supply to the uterus, sufficient for normal development subsequent pregnancy.

Prevention of bleeding in the afterbirth and early postpartum periods:

Timely and adequate treatment inflammatory diseases and complications after surgical gynecological interventions.

Rational management of pregnancy, prevention and treatment of complications that arise. When registering a pregnant woman at the antenatal clinic, it is necessary to select a group high risk if bleeding is possible.

A full examination should be carried out using modern instrumental (ultrasound, Doppler, echographic functional assessment of the state of the fetoplacental system, CTG) and laboratory research methods, as well as consult pregnant women with related specialists.

During pregnancy, it is necessary to strive to maintain the physiological course of the gestational process.

In women at risk for the development of bleeding, preventive measures in an outpatient setting include organizing a rational rest and nutrition regimen, conducting health procedures aimed at increasing the neuropsychic and physical stability of the body. All this contributes favorable current pregnancy, childbirth and the postpartum period. The method of physiopsychoprophylactic preparation of a woman for childbirth should not be neglected.

Throughout pregnancy, careful monitoring of the nature of its course is carried out, and possible violations are promptly identified and eliminated.

All pregnant women at risk for the development of postpartum hemorrhage must be hospitalized in a hospital for the final stage of comprehensive prenatal preparation 2-3 weeks before birth, where a clear plan for the management of labor is developed and appropriate additional examination of the pregnant woman is carried out.

During the examination, the condition of the fetoplacental complex is assessed. Ultrasound is used to study functional state fetus, determine the location of the placenta, its structure and size. On the eve of delivery, an assessment of the state of the patient’s hemostatic system deserves serious attention. Blood components for possible transfusion should also be prepared in advance, using autodonation methods. In the hospital, it is necessary to select a group of pregnant women to perform a caesarean section as planned.

To prepare the body for childbirth, prevent labor anomalies and prevent increased blood loss closer to the expected date of birth, it is necessary to prepare the body for childbirth, including with the help of prostaglandin E2 preparations.

Qualified management of childbirth with a reliable assessment of the obstetric situation, optimal regulation of labor, adequate pain relief (prolonged pain depletes the body's reserve forces and disrupts the contractile function of the uterus).

All deliveries should be carried out under cardiac monitoring.

During the process of vaginal delivery, it is necessary to monitor:

• the nature of contractile activity of the uterus;
• correspondence between the sizes of the presenting part of the fetus and the mother’s pelvis;
• advancement of the presenting part of the fetus in accordance with the planes of the pelvis in various phases of labor;
• condition of the fetus.

If anomalies of labor occur, they should be eliminated in a timely manner, and if there is no effect, the issue should be resolved in favor of operative delivery according to appropriate indications on an emergency basis.

All uterotonic drugs must be prescribed strictly differentiated and according to indications. In this case, the patient must be under the strict supervision of doctors and medical personnel.

Proper management of the afterbirth and postpartum periods with timely use of uterotonic drugs, including methylergometrine and oxytocin.

At the end of the second stage of labor, 1.0 ml of methylergometrine is administered intravenously.

After the baby is born, the bladder is emptied with a catheter.

Careful monitoring of the patient in the early postpartum period.

When the first signs of bleeding appear, it is necessary to strictly adhere to the stages of measures to combat bleeding. An important factor in providing effective care for massive bleeding is a clear and specific distribution of functional responsibilities among all medical personnel of the obstetric department. All obstetric institutions must have sufficient supplies of blood components and blood substitutes for adequate infusion and transfusion therapy.

Which doctors should you contact if you have bleeding in the placenta and early postpartum periods:

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There are conditions in which the risk of postpartum hemorrhage is higher than without it. Analysis of statistical information showed that such bleeding occurs more often in the following situations.

• Postpartum hemorrhages, abortions, spontaneous miscarriages that happened in the past. This means that a woman is prone to bleeding, which means the risk will be higher.
• Late toxicosis. In the case of preeclampsia, there is high blood pressure and impaired kidney function, as a result of which the vessels become more fragile and easily destroyed.
• Big fruit. Due to the pressure of such a fetus during childbirth, the walls of the uterus can be injured, which is manifested by bleeding after the birth of the child. In addition, the uterus is overstretched and therefore contracts worse.
• Polyhydramnios (large amount of amniotic fluid). The mechanism is approximately the same as with a large fetus.
• Multiple pregnancy. It's similar here.
• Leiomyoma of the uterus. This benign tumor, which gives a bleeding clinic. And childbirth can provoke it.
• Scar on the uterus. After operations (usually cesarean section), a scar remains, which is a weak link in the wall of the uterus. Therefore, after the birth of the child, a rupture may occur in this place.
• DIC syndrome. As a result of this phenomenon, the blood clotting function is disrupted. After childbirth, injury and bleeding are always observed, but with disseminated intravascular coagulation the bleeding does not stop.
• Thrombocytopathies. These are acquired or congenital diseases where platelets involved in blood clotting cannot perform their duties due to the presence of defects in them.

Mechanism of development of postpartum hemorrhage

After the birth of a child, intrauterine pressure drops sharply and the empty uterus also contracts sharply (postpartum contractions). The size of the placenta does not correspond to such a contracted uterus and it begins to separate from the walls.

The duration of separation of the placenta and its release directly depends on the contraction of the uterus. Normally, evacuation occurs approximately 30 minutes after birth. Delayed placental evacuation indicates a high chance of postpartum hemorrhage.

When the placenta is separated from the walls of the uterus, the blood vessels are damaged. Delayed delivery of the placenta indicates a weak contraction. This means that the vessels cannot narrow and the bleeding does not stop. Also, the cause of bleeding may be incomplete separation of the placenta from the walls due to its adherence or pinching of parts in the uterus.

Postpartum hemorrhage in case of injury to soft tissues occurs only when they rupture. With blood diseases, blood vessels are unable to withstand even minor damage. And since vascular damage always occurs during childbirth, bleeding after birth will continue for a long time, which requires immediate action to stop the bleeding.

Types of postpartum hemorrhage

In obstetric practice, it is customary to distinguish two main types of bleeding:

• Bleeding in the early postpartum period means that blood is released in the first 2 hours after birth. The most dangerous, since it is difficult to eliminate the cause.
• In the late postpartum period - after 2 hours and up to 1.5-2 months.

Well, since this is bleeding, the separation occurs due to its appearance. That is, bleeding due to:

• weak contraction of the uterus,
• delayed separation and release of parts of the placenta,
• blood diseases,
• injury to the uterus.

They also determine sudden bleeding, which begins immediately after the birth of the child in large quantities (blood loss reaches more than 1 liter per minute) and the pressure quickly drops. Another type is characterized by the release of blood in small portions with a gradual increase in blood loss. It stops and then starts.

Causes of bleeding after childbirth

In general, bleeding is the release of blood from the vessels. This phenomenon is observed when blood vessels are damaged, their integrity is compromised from the inside, or the systems are unable to stop bleeding. Therefore, the main causes of postpartum hemorrhage are 4 main groups.

Weak uterine contraction

Since the main number of vessels is in the uterus, when it contracts, the vessels narrow and the blood stops. If the uterus contracts insufficiently, the vessels do not narrow and blood continues to be released. This occurs when the uterus is overstretched by a large fetus, with polyhydramnios, the woman is overworked, the bladder is full, or the child is born quickly.

When using antispasmodics, prolonged and exhausted labor, the muscles of the uterus become overexcited and exhausted, which leads to a drop in its tone.

Various types of inflammation of the uterus, cancer and endocrine diseases lead to a deterioration in the ability of the uterine muscles to contract effectively.

Mental disorders (severe excitability, fear for the condition of the child) or severe pain can also lead to insufficient contraction of the uterus.

Birth injury

Damage to the uterus occurs due to a large fetus against the background rapid labor, use of obstetric forceps, narrow pelvis in a pregnant woman or with polyhydramnios. Such injuries include rupture of the uterus, cervical canal, perineum and clitoral area.

Impaired passage of the placenta

The inability to completely separate the placenta from the walls and its release or the retention of parts (umbilical cord, membranes) of this organ in the uterus.

Blood diseases

These include hemophilia, thrombocytopenia, coagulopathy. Substances that are involved in stopping bleeding are damaged or absent altogether. Under normal conditions, these disorders may not appear, but childbirth becomes an impetus for the onset of bleeding.

There may also be an option when the bleeding occurred due to the divergence of the stitches. This can be suspected by an operation performed, for example, a caesarean section, where stitches are always applied. Also, the development of infectious complications at the suturing site can weaken the thread and, under stress, lead to its rupture.

Symptoms of postpartum hemorrhage

What does the clinical picture of postpartum hemorrhage look like? How can you tell them apart? There are some peculiarities here, depending on the cause of bleeding and the period of occurrence.

Signs of postpartum hemorrhage in the early period (first 2 hours)

Practice shows that blood loss of about 250-300 ml does not pose any danger or harm to life. Since the body's defenses compensate for this loss. If blood loss is more than 300 ml, this is considered bleeding.

Delayed separation or release of parts of the placenta

The main symptom is the occurrence of bleeding immediately after the evacuation of parts of the placenta begins. Blood flows either in a continuous stream, or, which occurs more often, is released in separate portions.

The blood is usually dark in color and contains small clots. Sometimes it happens that the opening of the cervical canal of the uterus closes and the bleeding seems to stop. But in fact the situation is the opposite or even worse. The point is that in in this case blood accumulates inside the uterus. The uterus increases in size, contracts poorly, and if you massage it, a large blood clot comes out and bleeding resumes.

The mother's general condition is gradually deteriorating. This is manifested by the following symptoms:

• pallor of the skin and visible mucous membranes,
• gradual decrease in blood pressure,
• increased heart rate and breathing.

It is also possible that parts of the placenta become pinched in the area of ​​the fallopian tube. This can be determined by digital examination, during which a protrusion will be felt.

Weak uterine contraction

After the birth of a child, the uterus should normally contract, which will lead to vasoconstriction and prevent the development of bleeding. In the absence of such a process for the above reasons, stopping the bleeding is very problematic.

A distinction is made between hypotension and uterine atony. Hypotension is manifested by weak contraction of the uterus, which is not enough to narrow the blood vessels. Atony is complete absence work of the uterus. Accordingly, such bleeding is called hypotonic and atonic. Blood loss can range from 60 ml to 1.5 l. and more.

The uterus loses its normal tone and contractility, but is still able to respond with contractions to the administration of drugs or physical stimuli. Blood is not released constantly, but in waves, that is, in small portions. The uterus is weak, its contractions are rare and short. And after massaging, the tone is restored relatively quickly.

Sometimes large clots can form, which block the entrance to the uterus and, as it were, the bleeding stops. This leads to an increase in its size and a deterioration in the woman’s condition.

Prolonged hypotension is rare, but can develop into atony. Here the uterus no longer reacts to any irritants, and the bleeding is characterized by a continuous strong flow. The woman feels even worse and may experience a sharp decrease in blood pressure and even death.

Bleeding due to blood diseases

A characteristic sign of such bleeding is normal uterine tone. In this case, rare blood without clots flows out, there are no signs of any injury or damage. Another symptom indicating blood diseases is the formation of hematomas or hemorrhages at the injection site. The blood that has leaked out does not clot for a long time or does not clot at all, since the necessary substances for this are not available in the required quantity.

Hemorrhages can occur not only at injection sites, but also in internal organs, stomach, intestines, that is, anywhere. As the volume of blood loss increases, the risk of death increases.

In the case of DIC (depletion of clotting substances), this leads to the formation of blood clots and blockage of most small vessels in the kidneys, adrenal glands, liver and other organs. If proper medical care is not provided, tissues and organs will simply begin to deteriorate and die.

All this is manifested by the following symptoms:

• hemorrhages under the skin and mucous membranes,
• heavy bleeding at injection sites, surgical wounds, uterus,
• the appearance of dead skin areas,
• hemorrhages in internal organs, which is manifested by a violation of their functions,
• signs of damage to the central nervous system (loss, depression of consciousness, etc.).

Bleeding due to injury

A frequent manifestation in such a situation will be rupture of the soft tissues of the genital tract. In this case, characteristic signs are observed:

• the onset of bleeding immediately after the birth of the baby,
• bright red blood
• the uterus is dense to the touch,
• upon examination, the location of the rupture is visualized.

When the perineal tissue ruptures, there is slight blood loss and does not pose any threat. However, if the cervix or clitoris ruptures, the bleeding can be serious and life-threatening.

Signs of bleeding in the late period (from 2 hours to 2 months)

Typically, such bleeding makes itself felt approximately 7-12 days after birth.

Blood can be released once and heavily or in small quantities, but several times and the bleeding can last a couple of days. The uterus can be soft, or it can be dense, painful and not painful. It all depends on the reason.

Retention of parts of the placenta creates a favorable background for the proliferation of bacteria and the development of infection, which will then manifest itself as characteristic symptoms of the inflammatory process.

Diagnosis of postpartum hemorrhage

What does the diagnosis of postpartum hemorrhage look like? How do doctors determine the type of bleeding? In reality, diagnosis and treatment are carried out simultaneously because this condition poses a threat to the patient’s life. Especially when there is heavy bleeding, diagnosis generally fades into the background, since the most important thing is to stop the bleeding. But now we will talk specifically about diagnostics.

Here the main task is to find the cause of bleeding. The diagnosis is based on the clinical picture, that is, when the bleeding began, what the color of the blood is, the presence of clots, quantity, nature, and so on.

The first thing you pay attention to is the time of bleeding. That is, when it occurred: immediately after birth, a few hours later, or generally, for example, on the 10th day. This important point. For example, if there is bleeding immediately after childbirth, then the problem may be a blood disease, tissue rupture, or insufficient muscle tone of the uterus. And other options automatically disappear.

The nature and amount of bleeding are the second most important signs. By analyzing these symptoms, you can speculate about the possible cause, the extent of the damage, how severe the bleeding is, and make predictions.

The clinical picture allows only to suspect possible reason. But in most cases, based on experience, doctors can make a diagnosis. In doubtful cases, to confirm the diagnosis, carry out gynecological examination. In this case you can:

• assess the tone and ability to contract the uterus,
• determine the soreness, shape and density of the uterus,
• detect the source of bleeding, the site of tissue rupture due to injury, stuck or attached parts of the placenta.

Placenta retention

Usually the placenta is always examined after any birth. Then special tests are used, which are necessary to detect defects in the placenta.

If it is discovered that parts of the placenta remain in the uterine cavity, a manual examination is performed. It is carried out if there is a suspicion of a violation of the integrity of the placenta, regardless of whether there is bleeding or not. Since external bleeding may not be visible. More this method used to search for possible defects after surgical procedures.

The procedure looks like this:

• One hand is inserted into the uterine cavity, and the other is placed on the outside of the abdomen for control.
• With the hand that is inside, the condition of the walls of the uterus and mucous membrane is examined and assessed for the presence of placental remnants.
• Next, the soft parts, flat foci of the mucous membrane are removed.
• If scraps of tissue are found that stretch to the wall of the uterus, then massage that area with the outer hand. If these are the remains of the afterbirth, then they are easily separated.
• Afterwards, the uterus is massaged with both hands clenched into a fist, oxytocin is administered to increase the contraction of the organ, plus antibiotics to prevent infection.

Weak uterine contraction

In this case, a gynecological examination allows making a diagnosis. In this case, the uterus will be weak, there will be almost no contractions. But if you stimulate it with drugs (oxytocin) or massage the uterus, the tone increases relatively.

Also, to confirm the diagnosis of postpartum hemorrhage, factors that can lead to such a condition are taken into account (overdistension of the uterus by a large fetus, discrepancy between the size of the fetus and the width of the woman’s pelvis, polyhydramnios, etc.).

Birth injury

Diagnosis of bleeding from tissue rupture is not difficult. This happens during prolonged labor, polyhydramnios, and a discrepancy between the size of the fetus and the parameters of the woman’s pelvis. And if bleeding occurs against the background of these factors, then doctors this type bleeding is suspected first. To confirm the fact of injury and detect the area of ​​bleeding, a gynecological examination is performed using speculum.

Blood diseases

Here the diagnosis is simple in one case, but very difficult in another. When a pregnant woman is admitted to the hospital, standard blood tests are performed, where low levels of clotting substances (platelets, fibrinogen) can be detected. That is, those that are easy to identify.

But it may be that the reason lies in a congenital defect of the coagulation system. Then making a diagnosis is difficult. To confirm such a disease, it is necessary to undergo special, expensive tests and conduct a genetic test.

There were cases where the patient experienced postpartum bleeding, which was very difficult to stop. And the doctors couldn't find the reason. And only after stopping the woman admitted that she had a congenital blood disease. Therefore, you need to tell all the information to your doctor.

Another important aspect of diagnosis is urgent laboratory testing:

• For hemoglobin. It is necessary to detect anemia after bleeding. Since in this case the body always spends hemoglobin, and in case of its shortage, organs and tissues receive an insufficient amount of oxygen. If a lack of hemoglobin is detected, then appropriate therapy is carried out.
• Coagulogram. This is a determination of the amount of substances that are involved in blood clotting.
• Blood type and Rh factor. They are necessary to transfuse the right type of blood in case of severe bleeding.

Treatment of postpartum hemorrhage

What actions do doctors take during bleeding? What does health care delivery look like? Excessive bleeding is life-threatening. Therefore, everything is done quickly and clearly according to the instructions, and the choice of tactics depends on the cause of the bleeding. The main task is to first stop the bleeding and then eliminate its cause.

Urgent Care

The algorithm of actions looks like this:

• A catheter is placed in one of the veins to quickly administer pharmacological drugs. This action is also due to the fact that with large blood loss, blood pressure drops and the veins collapse. As a result, they will be difficult to hit.
• The bladder is cleared of urine using a urinary catheter. This will remove pressure on the uterus and improve its contraction.
• The volume of lost blood, blood pressure, and the severity of the situation are assessed. If you lose more than 1 liter. blood, intravenous drip infusion of saline solutions is used to compensate for blood loss. In the latter case, they resort to transfusion of donor blood, and in case of low pressure, appropriate medications are administered.
• Agents are introduced to enhance uterine contractions. This will compress the blood vessels and slightly stop the flow of blood. But for the duration of the drug's effect.
• Held instrumental examination uterine cavity.
• Further, medical care depends on the cause and tactics are selected individually according to the situation.

Treatment of weak uterine contractions

Treatment of postpartum hemorrhage in this case is based on combating hypotension and preventing the development of atony. That is, it is necessary to stimulate and resume the normal functioning of the muscles of the uterus. There are 4 ways to do this:

Medication. We have already mentioned it. This is the very first and most commonly used method. Special drugs are injected intravenously or into the cervical area to enhance contraction. Side effects in case of overdose are worsening of organ contractions and an increase or decrease in blood pressure.

Mechanical. Massage is used here. First, light massage is performed on the abdominal side for about 60 seconds until contraction occurs. Then they apply pressure from above with their hand on the area of ​​the uterus to release a blood clot. This promotes better contraction. If this turns out to be ineffective, then one hand is inserted into the uterus, the other lies on the stomach, and an external-internal massage is performed. Afterwards, sutures are placed on the cervical canal to contract the uterus and stop the bleeding.

Physical. This includes methods that increase the tone of the uterus using electric current or cold. In the first case, electrodes are placed on the stomach in the pelvic area and a light current is applied. This procedure is painless. In the second case, an ice bag is placed on the lower abdomen for 30-40 minutes. or use a swab moistened with ether for anesthesia. When the ether evaporates, the surrounding tissues are sharply cooled, and the cold causes contraction and constricts the blood vessels.

Uterine tamponade. This method is rarely used, in case of ineffectiveness of the previous ones and in preparation for surgery. Here, gauze pads are used and inserted into the uterine cavity to form blood clots. But there is a high risk of infectious complications.

Another temporary way to stop bleeding can be to press the abdominal aorta to the spine with a fist, since the uterine vessels extend from the aorta.

Surgical methods of treatment

When uterine hypotension has turned into atony and it is impossible to stop the bleeding using the above methods, then surgical intervention is resorted to. Atony is when the uterus no longer responds to any irritants, and bleeding can only be stopped by invasive means.

First, the patient is introduced into general anesthesia. The essence of the operation is based on cutting the abdomen and gaining access to the uterus and the vessels that participate in its blood supply, followed by removal of this organ. The operation is carried out in 3 stages:

• Pinching of blood vessels. Here, clamps are used on the uterine and ovarian arteries. If the woman’s condition returns to normal, then move on to the next stage.
• Ligation of blood vessels. The uterus is removed from the surgical wound, the necessary arteries are found by the characteristic pulsation, tied with thread and circumcised. After this, a sharp lack of blood in the uterus occurs, which leads to its contraction. This procedure used as a temporary measure when the doctor does not know how to perform uterine extirpation (removal). But it must be removed. A doctor who knows how to perform this operation comes to the rescue.
• Extirpation of the uterus. The most radical method of combating such bleeding. That is, the organ is completely removed. This is the only way to save a woman's life.

Treatment for blood diseases

Since in this case the substances necessary for coagulation are often absent, then the best way There will be a blood transfusion. This is due to the fact that the donor blood will contain the necessary substances.

Direct intravenous administration of fibrinogen is used, which is involved in the formation of blood clots. A special substance is also used that reduces the functioning of the anticoagulant system. All these measures maximally contribute to providing the body with everything necessary to stop bleeding.

Treatment for injury

In this case, the main cause of bleeding will be rupture of soft tissues, which means therapy will be based on suturing the damaged tissues. The procedure must be carried out after removal of the placenta.

Treatment for retained placenta

Remains of the placenta are removed either by hand or using tools. Which method the doctor chooses depends on the period of bleeding.

If blood loss occurs immediately after birth or on the first day, then resort to manual separation. The second method is used in case of bleeding on days 5-6, since the uterus has already significantly decreased in size.

General anesthesia is required. With the manual method, the hand enters the uterine cavity and parts of the placenta are separated from its walls. The remnants are pulled with the other hand by the umbilical cord and removed. With the inner hand, the uterine wall is checked again for the presence of remaining parts of the placenta.

With instrumental separation, essentially everything is the same, only here the uterine cavity is curetted. First, the cervix is ​​dilated with special mirrors, and then a surgical spoon is inserted, the walls are scraped out and the remains are removed.

After treatment and elimination of the cause, correction of pathological conditions arising due to blood loss is carried out. For minor blood loss (about 500-700 ml), physiological solutions are dripped. If the volume is more than 1 liter, pour donor blood. In case of anemia (low hemoglobin level), iron supplements are prescribed, since it is from it that hemoglobin is formed.

Possible complications of postpartum hemorrhage

If postpartum bleeding is severe and proper care is not provided in a timely manner, hemorrhagic shock may occur. This is a life-threatening complication when blood pressure drops sharply. A consequence of the body’s protective reaction to a lack of blood.

All remaining blood goes to the main organs (brain, heart, lungs). Because of this, all other organs and tissues suffer from a lack of blood supply. Failure of the liver, kidneys and then their failure occurs. The protective mechanism wears out, blood returns back, which leads to a lack of blood in the brain and, as a result, death.

With hemorrhagic shock, the countdown is in seconds, so therapy must be carried out immediately. Immediately stop the bleeding by any means, use artificial ventilation. Drugs are administered that increase blood pressure, normalize metabolism, and donated blood is transfused, since a lack of blood is the cause of this condition.

How to prevent the development of postpartum hemorrhage

Doctors are directly involved in prevention. Even at the first admission to the antenatal clinic, a full examination of the pregnant woman is carried out for the presence of factors that increase the chance of postpartum hemorrhage and the risk of its occurrence is determined.

For example, one of the risks is placenta previa (incorrect attachment). Therefore, for prevention, the birth of a child through cesarean section is recommended.

After childbirth, the genital tract is carefully examined. The woman is actively monitored for 2 hours. If risk factors are present, oxytocin is given after birth to keep the uterus in good shape.

After the woman in labor is discharged from the hospital, and this is no earlier than 15-20 days later, a systematic examination will be carried out by doctors at the antenatal clinic. Because sometimes such women experience serious complications: disruptions in hormonal balance (amenorrhea, postpartum death of the pituitary gland, atrophy of the genital organs). Detection of early symptoms will enable effective treatment.

Take care of your health and come for consultations with specialists more often in order to identify the problem in advance and solve it by discussing the appropriate tactics with your doctor.

Attention! This article is posted for informational purposes only and under no circumstances constitutes scientific material or medical advice and should not serve as a substitute for an in-person consultation with a professional physician. For diagnostics, diagnosis and treatment, contact qualified doctors!

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• Bloody discharge from the genital tract more than 400 ml in volume. The color of the discharge varies from scarlet to dark red depending on the cause of the bleeding. Blood clots may be present. Blood flows out in spurts, intermittently. Bleeding occurs immediately after the baby is born or after a few minutes, depending on the cause.
• Dizziness, weakness, pallor of the skin and mucous membranes, tinnitus.
• Loss of consciousness.
• Decreased blood pressure, frequent, barely perceptible pulse.
• Long-term absence of placenta (baby place) release - more than 30 minutes after the birth of the child.
• “Lack of” parts of the placenta when examining it after birth.
• The uterus is flabby on palpation (palpation), determined at the level of the navel, that is, it does not contract or decrease in size.

Forms

There are 3 degrees of severity of the mother’s condition depending on the volume of blood lost:

• mild degree (volume of blood loss up to 15% of the total volume of circulating blood) - there is an increase in the mother’s pulse, a slight decrease in blood pressure;
• average degree (volume of blood loss 20-25%) – blood pressure is reduced, pulse is frequent. Dizziness and cold sweat occur;
• severe (volume of blood loss 30-35%) - blood pressure is sharply reduced, the pulse is frequent, barely noticeable. Consciousness is clouded, the amount of urine produced by the kidneys decreases;
• extremely severe (volume of blood loss more than 40%) - blood pressure is sharply reduced, the pulse is frequent, barely perceptible. Consciousness is lost, there is no urination.

Causes

Causes of bleeding from the genital tract in the afterbirth period are:

• (violation of the integrity of tissues, vagina, (tissues between the entrance to the vagina and the anus);
• (pathological attachment of the placenta):
  • dense attachment of the placenta (attachment of the placenta in the basal layer of the uterine wall (deeper than the decidual (where attachment should normally occur) layer of the uterine mucosa;
  • placenta accreta (attachment of the placenta to the muscular layer of the uterine wall);
  • placenta accreta (the placenta grows into the muscle layer by more than half its thickness);
  • placenta germination (the placenta grows through the muscular layer and penetrates into the outermost layer of the uterus - serous);

• hypotension of the uterus (the muscular layer of the uterus contracts weakly, which prevents the bleeding from stopping and the separation and release of the placenta);
• hereditary and acquired defects of the blood coagulation system.

Causes of bleeding from the genital tract in the early postpartum period are:

• hypotension or atony of the uterus (the muscular layer of the uterus contracts weakly or does not contract at all);
• retention of parts of the placenta (parts of the placenta did not separate from the uterus in the third stage of labor);
• (disturbance of the blood coagulation system with intravascular formation of thrombi (blood clots) and bleeding).

Factors leading to the above-described pregnancy complications may be:

• severe (complication of pregnancy, accompanied by edema, increased blood pressure and impaired renal function);
• (disruption of uteroplacental blood flow at the level of the smallest vessels);
• (fetal weight more than 4000 grams).

During childbirth:

• irrational use of uterotonics (drugs that stimulate uterine contractions);
• :
  • weakness of labor (uterine contractions do not lead to dilation of the cervix and movement of the fetus along the birth canal);
  • vigorous labor activity.

Diagnostics

• Analysis of the medical history and complaints - when (how long ago) appeared bloody issues from the reproductive tract, their color, quantity, what preceded their appearance.
• Analysis of obstetric and gynecological history (transferred gynecological diseases, surgical interventions, pregnancy, childbirth, their features, outcomes, features of the course of this pregnancy).
• General examination of the pregnant woman, determination of her blood pressure and pulse, palpation (feeling) of the uterus.
• External gynecological examination - using hands and palpation, the doctor determines the shape of the uterus and the tension of its muscle layer.
• Examination of the cervix in speculum - the doctor uses a vaginal speculum to examine the cervix for injuries and ruptures.
• Ultrasound examination (ultrasound) of the uterus - this method allows you to determine the presence of parts of the placenta (baby place) and the location of the umbilical cord, the integrity of the walls of the uterus.
• Manual examination of the uterine cavity allows you to clarify the presence of unremoved parts of the placenta. The doctor inserts his hand into the uterine cavity and feels its walls. If remaining parts of the placenta are found, they are removed manually.
• Inspection of the released placenta for integrity and presence of tissue defects.

Treatment of bleeding in the afterbirth and early postpartum period

The main goal of treatment is to stop bleeding that threatens the mother’s life.

Conservative treatment, regardless of the period of bleeding, should be aimed at:

• treatment of the underlying disease that caused the bleeding;
• stopping bleeding using fibrinolysis inhibitors (drugs that stop the natural dissolution of blood clots);
• combating the consequences of blood loss (intravenous administration of aqueous and colloidal solutions to increase blood pressure).

Intensive care in an intensive care unit is necessary in the event of a serious condition of the pregnant woman and fetus. If necessary, do:

• transfusion of blood components (with a significant amount of blood loss caused by detachment);
• mechanical ventilation of the mother's lungs (if she is unable to maintain adequate respiratory function on her own).

If the cause of bleeding is prolonged or retention of parts of the placenta, hypotension or atony of the uterus (weak or absent muscle contraction), then the following is performed:

• manual examination of the uterine cavity (the doctor examines the uterine cavity with his hand for the presence of unremoved parts of the placenta);
• manual separation of the placenta (the doctor separates the placenta from the uterus with his hand);
• massage of the uterus (the doctor, with a hand inserted into the uterine cavity, massages its walls, thereby stimulating its contraction and stopping bleeding);
• administration of uterotonics (drugs that promote uterine contraction).

If blood loss exceeds 1000 ml, conservative therapy must be stopped and the following measures must be taken:

• ischemia of the uterus (clamping of the vessels supplying the uterus);
• hemostatic (hemostatic) sutures on the uterus;
• embolization (introduction of particles into the vessel that obstruct blood flow) of the uterine arteries.

An operation to remove the uterus is performed in the interests of saving a woman’s life if it is impossible to stop uterine bleeding.

If the cause of bleeding is, then reconstructive operations are performed (suturing,).

Complications and consequences

• Kuveler's uterus - multiple hemorrhages into the thickness of the uterine wall, soaking it with blood.
• – severe disruption of the blood coagulation system with the occurrence of multiple thrombi (blood clots) and bleeding.
• Hemorrhagic shock (progressive disruption of the vital functions of the nervous system, circulatory and respiratory systems due to the loss of a significant amount of blood).
• Sheehan syndrome () is ischemia (lack of blood supply) of the pituitary gland (an endocrine gland that regulates the functioning of most endocrine glands of the body) with the development of insufficiency of its function (lack of hormone production).
• Death of mother.

Prevention of bleeding in the afterbirth and early postpartum period

Prevention of obstetric hemorrhage includes several methods:

• pregnancy planning, timely preparation for it (detection and treatment of chronic diseases before pregnancy, prevention of unwanted pregnancy);
• timely registration of a pregnant woman at the antenatal clinic (up to 12 weeks of pregnancy);
• regular visits (once a month in the 1st trimester, once every 2-3 weeks in the 2nd trimester, once every 7-10 days in the 3rd trimester);
• relieving increased muscle tension of the uterus during pregnancy with the help of tocolytics (drugs that reduce muscle tension of the uterus);
• timely detection and treatment (complications of pregnancy, accompanied by edema, increased blood pressure and impaired renal function);
• adherence to a pregnant diet (with a moderate content of carbohydrates and fats (excluding fatty and fried foods, flour, sweets) and sufficient protein (meat and dairy products, legumes)).
• Therapeutic exercise for pregnant women (minor physical activity 30 minutes a day - breathing exercises, walking, stretching).
• Rational management of childbirth:
  • assessment of indications and contraindications for vaginal delivery or cesarean section;
  • adequate use of uterotonics (drugs that stimulate uterine contractions);
  • exclusion of unreasonable palpation of the uterus and pulling of the umbilical cord in the afterbirth period;
  • performing episio- or perineotomy (dissection by a doctor of a woman’s perineum (tissue between the entrance to the vagina and the anus) as a preventative measure for perineal rupture);
  • examination of the released placenta for integrity and presence of tissue defects;
  • administration of uterotonics (drugs that stimulate muscle contractions of the uterus) in the early postpartum period.

Bleeding in the afterbirth and early postpartum period is the most dangerous complication of childbirth.

Epidemiology
The frequency of bleeding in the afterbirth period is 5-8%.

BLEEDING DURING THE FOLLOW-UP PERIOD
Causes of bleeding in the afterbirth period:
- violation of the separation of the placenta and the release of the placenta (partial tight attachment or accreta of the placenta, strangulation of the separated placenta in the uterus);

- hereditary and acquired hemostasis defects;

Violation of separation of the placenta and placenta discharge
Violation of placental separation and placenta discharge is observed when:
- pathological attachment of the placenta, tight attachment, ingrowth of chorionic villi;
- uterine hypotension;
- anomalies, structural features and attachment of the placenta to the wall of the uterus;
- strangulation of the placenta in the uterus;

Etiology and pathogenesis
Anomalies, features of the structure and attachment of the placenta to the wall of the uterus, often contribute to the disruption of separation and discharge of the placenta.

For separation of the placenta, the area of ​​contact with the surface of the uterus is important.

With a large area of ​​attachment, a relatively thin or leathery placenta (placenta membranacea), the insignificant thickness of the placenta prevents its physiological separation from the walls of the uterus. Placentas, shaped like lobes, consisting of two lobes, with additional lobules, are separated from the uterine wall with difficulty, especially with uterine hypotension.

Violation of the separation of the placenta and the discharge of the placenta may be due to the placenta’s attachment site; in the lower uterine segment (with a low location and presentation), in the corner or on the side walls of the uterus, on the septum, above the myomatous node. In these places, the muscles are defective and cannot develop the force of contraction necessary to separate the placenta. Strangulation of the placenta after separation of the placenta occurs when it is retained in one of the uterine angles or in the lower segment of the uterus, which is most often observed during discoordinated contractions in the placenta.

Impaired discharge of the birth placenta can be iatrogenic if the postpartum period is not managed correctly.

An untimely attempt to release the placenta, massage of the uterus, including according to Crede-Lazarevich, pulling the umbilical cord, administration of large doses of uterotonic drugs disrupt the physiological course of the third period, the correct sequence of contractions various departments uterus. One of the reasons for impaired separation of the placenta and discharge of the placenta is uterine hypotension.

With uterine hypotension, afterbirth contractions are either weak or absent for a long time after the birth of the fetus. As a result, both the separation of the placenta from the uterine wall and the release of the placenta are disrupted; in this case, it is possible that the placenta may be strangulated in one of the uterine angles or the lower uterine segment of the uterus. The succession period is characterized by a protracted course.

Clinical picture
The clinical picture of impaired separation of the placenta and discharge of the placenta depends on the presence of areas of separated placenta. If the placenta does not separate throughout, then clinically determine the absence of signs of placental separation for a long time and the absence of bleeding.

More common is partial separation of the placenta, when one or another section is separated from the wall, and the rest remains attached to the uterus. In this situation, muscle contraction at the level of the separated placenta is not enough to compress the vessels and stop bleeding from the placental site. The main symptoms of partial separation of the placenta are the absence of signs of placental separation and bleeding. Bleeding occurs a few minutes after the baby is born. The blood is liquid, mixed with clots of various sizes, and flows out in spurts and unevenly. Retention of blood in the uterus and vagina often creates a false impression of the cessation or absence of bleeding, as a result of which measures aimed at stopping it may be delayed. Sometimes blood accumulates in the uterine cavity and vagina, and then is released in clots after external signs of placental separation are detected. On external examination there are no signs of separation of the placenta. The fundus of the uterus is at the level of the navel or above, deviated to the right. The general condition of the woman in labor depends on the degree of blood loss and changes quickly. In the absence of timely assistance, hemorrhagic shock occurs. The clinical picture of impaired discharge of the strangulated placenta is the same as in the case of impaired separation of the placenta from the uterine wall (also accompanied by bleeding).

Diagnostics
Complaints of bleeding of varying intensity. Laboratory research for bleeding in the afterbirth period:
- clinical analysis blood (Hb, hematocrit, erythrocytes);
- coagulogram;
- in case of massive blood loss, CBS, blood gases, plasma lactate level
- biochemical analysis blood;
- electrolytes in plasma;
- Analysis of urine;

Physical examination data:
- absence of signs of placental separation (Schroeder, Küstner-Chukalov, Alfelts);
- when manually separating the placenta with physiological and tight attachment of the placenta (placenta adhaerens), strangulation, as a rule, you can remove all lobes of the placenta by hand.

With true chorionic ingrowth, it is impossible to separate the placenta from the wall without violating its integrity. Often, true placenta accreta is established only by histological examination of the uterus, which was removed due to suspected hypotension and massive bleeding in the postpartum period.

Instrumental methods. It is possible to accurately determine the type of pathological attachment with targeted ultrasound during pregnancy and manual separation of the placenta in the afterbirth period.

Birth canal injuries
Bleeding from ruptures of the soft tissues of the birth canal can be severe when the blood vessels are damaged. Cervical ruptures are accompanied by bleeding when the integrity is broken descending branch uterine artery (with lateral ruptures of the cervix). With low placental attachment and pronounced vascularization of the tissues of the lower segment of the uterus, even minor injuries to the cervix can lead to massive bleeding. In case of vaginal injuries, bleeding occurs from ruptures of varicose veins, a. vaginalis or its branches. Bleeding is possible with high tears involving the fornix and base of the broad uterine ligaments, sometimes a. uterinae. When the perineum ruptures, bleeding occurs from the branches of a. pudendae. Tears in the clitoral area, where the network is developed venous vessels, is also accompanied by severe bleeding.

Diagnostics
Diagnosis of bleeding from soft tissue ruptures is not difficult, with the exception of damage to the deep branches of a. vaginalis (bleeding can simulate uterine bleeding). About the gap a. vaginalis may indicate hematomas of the soft tissues of the vagina.

Differential diagnosis
In differential diagnosis, the following signs of bleeding from soft tissue ruptures are taken into account:
- bleeding occurs immediately after the birth of the child;
- despite the bleeding, the uterus is dense and well contracted;
- the blood does not have time to clot and flows out of the genital tract in a liquid stream of bright color.

Hemostasis defects
Features of bleeding with hemostasis defects are the absence of clots in the blood flowing from the genital tract. Treatment and tactics of management of pregnant women with pathology of the third stage of labor The goal of treatment is to stop bleeding, which is carried out by:
- separation of the placenta and placenta discharge;
- suturing ruptures of soft tissues of the birth canal;
- normalization of hemostasis defects.

Sequence of measures in case of retained placenta and absence of blood discharge from the genitals:
- bladder catheterization (often causes increased uterine contractions and separation of the placenta);
- puncture or catheterization of the ulnar vein, intravenous administration of crystalloids in order to adequately correct possible blood loss;
- administration of uterotonic drugs 15 minutes after expulsion of the fetus (oxytocin IV drip 5 units in 500 ml of 0.9% sodium chloride solution);
- when signs of placenta separation appear, release the placenta using one of the accepted methods (Abuladze, Crede-Lazarevich);
- in the absence of signs of placenta separation within 20-30 minutes against the background of the introduction of contracting agents, manual separation of the placenta and placenta discharge is performed. If epidural anesthesia was used during childbirth, manual separation of the placenta and release of the placenta is performed before the anesthetic wears off. If pain relief was not used during childbirth, this operation is performed against the background of intravenous painkillers (propofol). After removal of the placenta, the uterus usually contracts, tightly clasping the arm. If the tone of the uterus is not restored, additional uterotonic drugs are administered, bimanual compression of the uterus is performed, right hand in the anterior vaginal fornix;
- if true placenta accreta is suspected, the attempt at separation must be stopped to avoid massive bleeding and perforation of the uterus.

Sequence of measures for bleeding in the third stage of labor:
- catheterization of the bladder. Puncture or catheterization of the ulnar vein with the connection of intravenous infusions;
- determination of signs of placental separation (Schroeder, Küstner-Chukalov, Alfelts);
- if there are positive signs of separation of the placenta, an attempt is made to isolate the placenta according to Crede-Lazarevich, first without anesthesia, then against the background of pain relief;
- if there is no effect from external methods of releasing the placenta, it is necessary to manually separate the placenta and release the placenta.

In the postoperative period, it is necessary to continue the intravenous administration of uterotonic drugs and from time to time, carefully, without excessive pressure, perform external massage of the uterus and squeeze out blood clots from it. Bleeding due to ruptures of the cervix, clitoris, perineum and vagina is stopped by immediate suturing and restoration of tissue integrity. Sutures are placed on breaks in the soft birth canal after the placenta is released. The exception is ruptures of the clitoris, the integrity of which can be restored immediately after the birth of the child. Visible bleeding from the vessels of the perineal wound after episiotomy is stopped by applying clamps, and after removing the placenta from the uterus - by suturing. If a soft tissue hematoma is detected, it is opened and sutured. If a bleeding vessel is identified, it is ligated. Hemostasis is normalized. In case of bleeding caused by impaired hemostasis, it is corrected.

Prevention
Rational management of childbirth; use of regional anesthesia. Careful and correct management of the third stage of labor. Elimination of unreasonable pulling on the umbilical cord of the uterus.

BLEEDING IN THE EARLY POSTPARTUM PERIOD
Epidemiology
The incidence of bleeding in the early postpartum period is 2.0-5.0% of the total number of births. Based on the time of occurrence, early and late postpartum hemorrhage are distinguished. Postpartum hemorrhage that occurs within 24 hours after birth is considered early or primary; after this period it is classified as late or secondary.

Bleeding within 2 hours after birth occurs for the following reasons:
- retention of parts of the placenta in the uterine cavity;
- hereditary or acquired hemostasis defects;
- hypotension and atony of the uterus;
- injuries of the soft birth canal;
- uterine inversion (see chapter on traumatism);

To determine a general understanding of the etiology of bleeding, you can use the 4T diagram:
- “tissue” - decreased uterine tone;
- “tone” - decreased tone of the uterus;
- “trauma” - ruptures of the soft birth canal and uterus;
- “blood clots” - impaired hemostasis.

Retention of parts of the placenta in the uterine cavity
The retention of parts of the placenta in the uterine cavity prevents its normal contraction and compression of the uterine vessels. The reason for the retention of parts of the placenta in the uterus may be partial tight attachment or accretion of placenta lobules. The retention of membranes is most often associated with improper management of the postpartum period, in particular, with excessive acceleration of the birth of the placenta. Retention of the membranes is also observed during intrauterine infection, when their integrity is easily damaged. It is not difficult to determine the retention of parts of the placenta in the uterus after its birth. When examining the placenta, a defect in the placental tissue, absence of membranes, and torn membranes are revealed.

The presence of parts of the placenta in the uterus can lead to infection or bleeding, both in the early and late postpartum period. Sometimes massive bleeding occurs after discharge from hospital. maternity hospital on days 8-21 of the postpartum period (late postpartum hemorrhage). Detection of a defect in the placenta (placenta and membranes), even in the absence of bleeding, is an indication for manual examination and emptying of the uterine cavity.

Classification
Uterine hypotension is a decrease in the tone and contractility of the uterine muscles. Reversible condition. Uterine atony is a complete loss of tone and contractility. Currently, it is considered inappropriate to divide bleeding into atonic and hypotonic. The definition of “hypotonic bleeding” is accepted.

Clinical picture: main symptoms of uterine hypotension;
- bleeding;
- decreased uterine tone;
- symptoms of hemorrhagic shock.

With uterine hypotension, blood is first released with clots, usually after external massage of the uterus. The uterus is flabby, the upper border can reach the navel and above. The tone may be restored after external massage, then decrease again, bleeding resumes. In the absence of timely assistance, blood loses its ability to clot. In accordance with the amount of blood loss, symptoms of hemorrhagic shock arise (pallor of the skin, tachycardia, hypotension, etc.).

Diagnostics
Diagnosis of hypotonic bleeding is not difficult. Differential diagnosis should be made with trauma to the uterus and genital tract.

Treatment
The goal of treatment is to stop bleeding. Stopping bleeding in case of hypotension should be carried out simultaneously with measures to correct blood loss and hemostasis.

If blood loss is within 300-400 ml after confirming the integrity of the placenta, an external massage of the uterus is performed, while uterotonic drugs are administered (oxytocin 5 units in 500 ml NaCl solution 0.9%) or carbetocin 1 ml (slow IV), misoprostol (mirolut) 800-1000 mcg per rectum once. An ice pack is placed on the lower abdomen.

If blood loss exceeds 400.0 ml or if there is a placenta defect, under IV anesthesia or ongoing epidural anesthesia, a manual examination of the uterus is performed, and, if necessary, bimanual compression of the uterus. To help stop bleeding, the abdominal aorta can be pressed against the spine through the abdominal wall. This reduces blood flow to the uterus. Subsequently, the tone of the uterus is checked using external methods and uterotonics continue to be administered intravenously.

In case of bleeding of 1000-1500 ml or more, a woman’s pronounced reaction to less blood loss, embolization of the uterine vessels or laparotomy is necessary. The most optimal option at present, if conditions exist, should be considered embolization of the uterine arteries using the generally accepted method. If there are no conditions for embolization of the uterine arteries, laparotomy is performed.

As an intermediate method in preparation for surgery, a number of studies suggest intrauterine tamponade with a hemostatic balloon. The algorithm for using a hemostatic balloon is presented in the Appendix. If there is heavy uterine bleeding, you should not waste time on inserting a hemostatic balloon, but proceed to laparotomy, or, if possible, to UAE. During laparotomy, at the first stage, if there is experience or a vascular surgeon, the internal iliac arteries are ligated (the technique for ligating the internal iliac arteries is presented in the Appendix). If there are no conditions, then sutures are placed on the uterine vessels or the uterus is compressed using hemostatic sutures according to one of the methods of B-Lynch, Pereira, Hayman. Cho, V.E. Radzinsky (see appendix for technique). If the lower segment is overstretched, tightening sutures are placed on it.

The effect of suture lasts 24-48 hours. If bleeding continues, hysterectomy is performed. During laparotomy, a machine is used to reinfuse blood from the incisions and abdominal cavity. Timely implementation of organ-preserving methods allows achieving hemostasis in most cases. In conditions of ongoing bleeding and the need to proceed to radical intervention, they help reduce the intensity of bleeding and the total volume of blood loss. Implementation of organ-preserving methods to stop postpartum hemorrhage is a prerequisite. Only the lack of effect from the above measures is an indication for radical intervention - hysterectomy.

Organ-preserving methods of surgical hemostasis do not lead to the development of complications for the majority. After ligation of the internal iliac and ovarian arteries, blood flow in the uterine arteries is restored in all patients by 4-5 days, which corresponds to physiological values.

Prevention
Patients at risk for bleeding due to uterine hypotension are given intravenous oxytocin at the end of the second stage of labor.
In case of hereditary and congenital hemostasis defects, a labor management plan is outlined together with hematologists. Principle therapeutic measures consists of administering fresh frozen plasma and glucocorticoids. Information for the patient

Patients at risk of bleeding should be warned about the possibility of bleeding during childbirth. In case of massive bleeding, hysterectomy is possible. If possible, instead of ligating blood vessels and removing the uterus, embolization of the uterine arteries is performed. It is very advisable to transfuse your own blood from the abdominal cavity. In case of ruptures of the uterus and soft birth canal, suturing is performed, and in case of hemostasis disturbance, correction is performed.

Therapy methods
During childbirth, physiological blood loss is 300-500 ml - 0.5% of body weight; for caesarean section - 750-1000 ml; for planned caesarean section with hysterectomy - 1500 ml; for emergency hysterectomy - up to 3500 ml.

Major obstetric hemorrhage is defined as the loss of more than 1000 ml of blood, or >15% of circulating blood volume, or >1.5% of body weight.

Severe life-threatening bleeding is considered to be:
- loss of 100% of circulating blood volume within 24 hours, or 50% of circulating blood volume in 3 hours;
- blood loss at a rate of 15 ml/min, or 1.5 ml/kg per minute (for more than 20 minutes);
- immediate blood loss of more than 1500-2000 ml, or 25-35% of the circulating blood volume.

Determination of blood loss volume
Visual assessment is subjective. The underestimation is 30-50%. Less than average volume is overestimated, and large volume losses are underestimated. In practice great importance has a definition of the volume of blood lost:
- using a measuring container makes it possible to take into account the blood that has been shed, but does not allow you to measure the remaining blood in the placenta (approximately 153 ml). Inaccuracy is possible when blood is mixed with amniotic fluid and urine;
- gravimetric method - determining the difference in the mass of surgical material before and after use. Napkins, balls and diapers must be standard size. The method is not free from errors when mixing amniotic fluid. The error of this method is within 15%.
- acid-hematine method - calculation of plasma volume using radioactive isotopes, using labeled red blood cells, the most accurate, but more complex and requires additional equipment.

Due to the difficulty of accurately determining blood loss, the body's response to blood loss is of great importance. Taking these components into account is fundamental to determining the volume of infusion required.

Diagnostics
Due to an increase in circulating blood volume and CO, pregnant women are able to tolerate significant blood loss with minimal changes in hemodynamics up to late stage. Therefore, in addition to taking into account lost blood, indirect signs of hypovolemia are of particular importance. Pregnant women retain compensatory mechanisms for a long time, and they are able, with adequate therapy, to endure, unlike non-pregnant women, significant blood loss.

The main sign of decreased peripheral blood flow is the capillary refill test, or symptom white spot. It is performed by pressing the nail bed, eminence of the thumb or other part of the body for 3 seconds until a white color appears, indicating the cessation of capillary blood flow. After finishing pressing, the pink color should be restored in less than 2 seconds. An increase in the recovery time of the pink color of the nail bed of more than 2 seconds is noted when microcirculation is impaired.

A decrease in pulse pressure and shock index is an earlier sign of hypovolemia than systolic and diastolic blood pressure assessed separately.

Shock index is the ratio of heart rate to systolic blood pressure, which changes with blood loss of 1000 ml or more. Normal values ​​are 0.5-0.7. Decreased urine output during hypovolemia often precedes other signs of circulatory impairment. Adequate diuresis in a patient not receiving diuretics indicates sufficient blood flow in the internal organs. To measure the rate of diuresis, 30 minutes is enough:
- insufficient diuresis (oliguria) - less than 0.5 ml/kg per hour;
- reduced diuresis - 0.5-1.0 ml/kg per hour;
- normal diuresis - more than 1 ml/kg per hour.

Respiratory rate and state of consciousness should also be assessed before performing mechanical ventilation.

Intensive care of obstetric hemorrhage requires coordinated actions, which should be rapid and, if possible, simultaneous. It is carried out jointly with an anesthesiologist and resuscitator against the background of measures to stop bleeding. Intensive therapy (resuscitation) is carried out according to the ABC scheme: airways (Aigway), breathing (Breathing), blood circulation (Cigculation).

After assessing breathing, adequate oxygen supply is ensured: intranasal catheters, spontaneous mask or artificial ventilation. After assessing the patient’s breathing and starting oxygen inhalation, obstetricians - gynecologists, midwives, operating nurses, anesthesiologists-resuscitators, nurse anesthetists, an emergency laboratory, and a blood transfusion service are notified and mobilized for the upcoming joint work. If necessary, a vascular surgeon and angiography specialists are called. At the same time, reliable venous access is ensured. Use peripheral catheters 14Y (315 ml/min) or 16Y (210 ml/min).

For collapsed peripheral veins, venesection or catheterization is performed central vein. In case of hemorrhagic shock or blood loss of more than 40% of the circulating blood volume, catheterization of the central vein (preferably the internal jugular vein), preferably with a multilumen catheter, is indicated, which provides additional intravenous access for infusion and allows monitoring of central hemodynamics. In conditions of blood coagulation disorders, access through the cubital vein is preferable. When installing a venous catheter, it is necessary to take a sufficient amount of blood to determine the initial parameters of the coagulogram, hemoglobin concentration, hematocrit, platelet count, and conduct compatibility tests for possible blood transfusion. Bladder catheterization should be performed and minimal monitoring of hemodynamic parameters should be provided: ECG, pulse oximetry, non-invasive blood pressure measurement. All measurements should be documented. Blood loss must be taken into account. IN intensive care massive bleeding, the leading role belongs to infusion therapy

The goal of infusion therapy is to restore:
- volume of circulating blood;
- tissue oxygenation;
- hemostasis systems;
- metabolism.

In case of an initial violation of hemostasis, therapy is aimed at eliminating the cause. During infusion therapy, the optimal combination of crystalloids and colloids, the volume of which is determined by the amount of blood loss.

The speed of administration of solutions is important. Critical pressure (60-70 mmHg) should be achieved as quickly as possible. Adequate blood pressure values ​​are achieved when I.T. >90 mm Hg. In the setting of decreased peripheral blood flow and hypotension, noninvasive blood pressure measurement may be inaccurate; in these cases, invasive blood pressure measurement is preferred.

Initial replacement of circulating blood volume is carried out at a rate of 3 liters for 515 minutes under the control of ECG, blood pressure, saturation, capillary refill test, CBS of blood and diuresis. Further therapy can be carried out either in discrete doses of 250500 ml over 10-20 minutes with assessment of hemodynamic parameters, or with continuous monitoring of central venous pressure. Negative values ​​of central venous pressure indicate hypovolemia, however, they are also possible with positive values ​​of central venous pressure, therefore the response to volume load, which is carried out by infusion at a rate of 1020 ml/min for 10-15 minutes, is more informative. An increase in central venous pressure of more than 5 cm of water. Art. indicates heart failure or hypervolemia; a slight increase in central venous pressure values, or its absence, indicates hypovolemia. To obtain sufficient filling pressure in the left chambers of the heart to restore tissue perfusion, fairly high values ​​of central venous pressure (10-12 cm H2O and higher) may be required.

The criterion for adequate replenishment of fluid deficiency in the circulation is central venous pressure and hourly diuresis. Until the central venous pressure reaches 12-15 cm of water. Art. and hourly urine output does not become >30 ml/h, the patient requires I.T.

Additional indicators of the adequacy of infusion therapy and tissue blood flow are:
- saturation of mixed venous blood, target values 70% or more;
- positive test filling capillaries;
- physiological values Blood CBS. Lactate clearance: it is desirable to reduce its level by 50% within 1 hour; IT. continue until lactate level is less than 2 mmol/l;
- sodium concentration in urine less than 20 mol/l, urine/blood plasma osmolarity ratio more than 2, urine osmolarity more than 500 mOsm/kg - signs of ongoing impaired renal perfusion.

During intensive care, avoid hypercapnia, hypocapnia, hypokalemia, hypocalcemia, fluid overload, and overcorrection of acidosis with sodium bicarbonate. Restoring the oxygen transport function of the blood.

Indications for blood transfusion:
- hemoglobin concentration 60-70 g/l;
- blood loss of more than 40% of the circulating blood volume;
- unstable hemodynamics.

In patients weighing 70 kg, one dose of packed red blood cells increases the hemoglobin concentration by approximately 10 g/l and the hematocrit by 3%. To determine the required number of doses of red blood cells (n) with ongoing bleeding and a hemoglobin concentration of 60-70 g/l, an approximate calculation using the formula is convenient:

N=(100x/15,

Where n is the required number of doses of red blood cells,
- hemoglobin concentration.

During blood transfusion, it is advisable to use a system with leukocyte filters, which helps reduce the likelihood of immune reactions caused by leukocyte transfusion. An alternative to red blood cell transfusion: intraoperative hardware reinfusion of blood (transfusion of red blood cells collected during surgery and washed). A relative contraindication for its use is the presence of amniotic fluid. To determine the Rh-positive blood factor in newborns, the Rh-negative mother must be administered an increased dose of human anti-Rhesus immunoglobulin Rho[D], since using this method may introduce fetal red blood cells.

Correction of hemostasis. During the treatment of a patient with bleeding, the function of the hemostatic system is most often affected by the influence of drugs for infusion, with coagulopathy of dilution, consumption, and loss. Dilution coagulopathy has clinical significance when replacing more than 100% of the circulating blood volume, it is manifested by a decrease in the content of plasma coagulation factors. In practice, dilutional coagulopathy is difficult to distinguish from disseminated intravascular coagulation syndrome. To normalize hemostasis, the following drugs are used.

Fresh frozen plasma. Indications for transfusion of fresh frozen plasma are:
- APTT >1.5 from the initial level with ongoing bleeding;
- bleeding of III-IV class (hemorrhagic shock).

The initial dose is 12-15 ml/kg, repeated doses are 5-10 ml/kg. The transfusion rate of fresh frozen plasma is at least 1000-1500 ml/h; when coagulation parameters stabilize, the rate is reduced to 300-500 ml/h. It is advisable to use fresh frozen plasma that has undergone leukoreduction. Cryoprecipitate containing fibrinogen and factor VIII is indicated as an additional agent for the treatment of hemostatic disorders with a fibrinogen content of 1 g/l.

Thromboconcentrate. The possibility of platelet transfusion is considered in the following cases:
- platelet count less than 50,000/mm3 due to bleeding;
- platelet count less than 20-30,000/mm3 without bleeding;
- at clinical manifestations thrombocytopenia or thrombocytopathy (petechial rash). One dose of platelet concentrate increases platelet levels by approximately 5000/mm3. Usually 1 unit/10 kg (5-8 packets) is used.

Antifibrinolytics. Tranexamic acid and aprotinin inhibit plasminogen activation and plasmin activity. The indication for the use of anti-fibrinolytics is pathological primary activation of fibrinolysis. To diagnose this condition, use the euglobulin clot lysis test with activation by streptokinase or 30-minute lysis with thromboelastography.

Antithrombin III concentrate. When the activity of antithrombin III decreases to less than 70%, restoration of the anticoagulation system is indicated by transfusion of fresh frozen plasma or antithrombin III concentrate. Antithrombin III activity must be maintained within 80-100%. Recombinant activated factor VIIa was developed for the treatment of bleeding episodes in patients with hemophilia A and B. As an empirical hemostatic agent, the drug has been successfully used in a variety of conditions associated with uncontrolled severe bleeding. Due to the insufficient number of observations, the role of recombinant factor VII A in the treatment of obstetric hemorrhage has not been definitively determined. The drug can be used after standard surgical and medications stop bleeding.

Conditions of use:
- Hb >70 g/l, fibrinogen >1 g/l, platelets >50,000/mm3;
- pH >7.2 (correction of acidosis);
- warming the patient (preferably, but not required).

Possible application protocol (according to Sobeszczyk and Breborowicz);
- initial dose - 40-60 mcg/kg intravenously;
- with ongoing bleeding - repeated doses of 40-60 mcg/kg 3-4 times every 15-30 minutes.
- when the dose reaches 200 mcg/kg and there is no effect, it is necessary to check the conditions for use;
- only after correction can the next dose of 100 mcg/kg be administered.

Adrenergic agonists. Used for bleeding according to the following indications:
- bleeding during regional anesthesia and sympathetic blockade;
- hypotension when installing additional intravenous lines;
- hypodynamic, hypovolemic shock.

In parallel with replenishing the volume of circulating blood, a bolus injection of 5-50 mg of ephedrine, 50-200 mcg of phenylephrine or 10-100 mcg of epinephrine is possible. It is better to titrate the effect by intravenous infusion:
- dopamine - 2-10 mcg/(kg/min) or more, dobutamine - 2-10 mcg/(kg/min), phenylfarine - 1-5 mcg/(kg x min), epinephrine - 1-8 mcg/min.

The use of these drugs increases the risk of vascular spasm and organ ischemia, but is justified in a critical situation.

Diuretics. Loop or osmotic diuretics should not be used in acute period during IT. Increased urine output caused by their use will reduce the value of monitoring urine output or volume replenishment. Moreover, stimulation of diuresis increases the likelihood of developing acute pyelonephritis. For the same reason, the use of solutions containing glucose is undesirable, since noticeable hyperglycemia can subsequently cause osmotic diuresis. Furosemide (5-10 mg IV) is indicated only to accelerate the onset of fluid mobilization from the interstitial space, which should occur approximately 24 hours after bleeding and surgery.

Maintaining temperature balance. Hypothermia impairs platelet function and reduces the rate of reactions of the blood coagulation cascade (10% for every degree Celsius decrease in body temperature). In addition, the condition of the cardiovascular system, oxygen transport (shift of the Hb-Ch dissociation curve to the left), and elimination of drugs by the liver worsen. It is essential to warm both the IV fluids and the patient. The central temperature should be kept close to 35°.

Position of the operating table. In case of blood loss, the horizontal position of the table is optimal. The reverse Trendelenburg position is dangerous due to the possibility of an orthostatic reaction and a decrease in MV, and in the Trendelenburg position, the increase in CO is short-lived and is replaced by its decrease due to an increase in afterload. Therapy after bleeding has stopped. After stopping the bleeding, I.T. continue until adequate tissue perfusion is restored.

Goals:
- maintaining systolic blood pressure more than 100 mm Hg. (with previous hypertension more than 110 mm Hg);
- maintaining the concentration of hemoglobin and hematocrit at a level sufficient for oxygen transport;
- normalization of hemostasis, electrolyte balance, body temperature (>36°);
- restoration of diuresis more than 1 ml/kg per hour;
- increase in CO;
- reverse development of acidosis, decrease in lactate concentration to normal.

They carry out prevention, diagnosis and treatment of possible manifestations of multiple organ failure. With further improvement of the condition to moderate, the adequacy of replenishment of circulating blood volume can be checked using an orthostatic test. The patient lies quietly for 2-3 minutes, then blood pressure and heart rate are noted. The patient is asked to stand up (the option of standing up is more accurate than sitting down in bed). If symptoms of cerebral hypoperfusion appear, that is, dizziness or lightheadedness, the test should be stopped and the patient should be placed in bed. If specified symptoms no, 1 minute after getting up, heart rate readings are recorded. The test is considered positive when the heart rate increases to more than 30 beats/min or symptoms of cerebral perfusion are present. Due to the small variability, changes in blood pressure are not taken into account. An orthostatic test can reveal a deficit in circulating blood volume of 15-20%. It is not necessary and dangerous if there is hypotension in a horizontal position and signs of shock.