POSTPARTUM BLEEDING
• Postpartum bleeding over 1000 ml and accompanying symptoms.
Early Postpartum bleeding
► Bleeding before 24 hours. Most postpartum hemorrhages fall into this group.
Uterine Atony
0 Bleeding from the implantation site of the placenta due to insufficient uterine contractility following delivery.
0 The most common cause of maternal mortality and early postpartum hemorrhage due to bleeding is uterine atony.
0 Etiology:
- Excessive distension of the uterus (hydramnios, multiple pregnancy, fetal macrosomia)
- Grand multiparity
- Rapid (precipitate) or prolonged action
- History of previous uterine atony
- Use of uterine relaxant agents (terbutaline, magnesium, halothane anesthesia, conduction analgesia)
- Induction and augmentation of labor with oxytocin or prostaglandin
- Chorioamnionitis
0 Treatment: After exclusion of uterine rupture and placental retention, bimanual massage and/or compression is applied. Subsequently, medical uterotonic treatment is applied. In cases where there is no response, bacri balloon application, uterine compression sutures (B-lynch sutures), uteroovarian vessel ligation, hypogastric artery ligation, angiographic uterine artery embolization can be performed. If there is no response, hysterectomy is performed.
0 Uterotonics used in medical treatment:
- Oxytocin rapid infusion (contraindicated in hypotension)
- Methyl ergonovine (contraindicated in hypertension) (E-91J
- Prostaglandin F2 alpha (carboprost)
- Prostaglandin E1 (misoprostol)
- Prostaglandin E2 (dinoprostone)
Lower Genital Tract (cervix, vagina, perineum) lacerations
0 It should be suspected in case of vaginal bleeding despite adequate contraction and contraction of the uterus.
Lower genital tract lacerations
Grade 1 laceration-------- Laceration of vaginal epithelium or perineal skin only
2nd degree laceration-------- Laceration involving perineal muscles (bulbospongiosis and superficial transverse perineal muscle)
Grade 3 laceration-------- Laceration involving the anal sphincter;
- 3a: < 50% external anal sphincter laceration
- 3b: > 50% external anal sphincter laceration
- 3c: Laceration of external anal sphincter + internal anal sphincter
Grade 4 laceration ------- Laceration involving the perineal body, the entire anal sphincter complex, and the anorectal mucosa1
Among the risk factors for 0 3rd and 4th degree lacerations; median episiotomy, nulliparity, persistent occiput posterior presentation, operative delivery, Asian race, short perineal length, and macrosomia. Mediolateral episiotomy is protective.
0 Primary is repaired. If it is insufficient, measures such as compression, hypogastric artery ligation, embolization are taken.
Uterine Rupture
0 It is a rare complication and may be complete or incomplete. While all uterine layers are ruptured in complete rupture; In incomplete rupture, only the visceral peritoneum is intact.
0 The most common cause of uterine rupture is separation of the previous cesarean section scar. The risk also varies according to the uterine incision patterns during cesarean section.
cesarean scars and rupture risks: (risk increases with incisions involving the upper segment)
Classical incision------4-9%
T incision--------4-9%
lower segment vertical-----1-7%
Belonging segment transverse ----0.2-1.5%
previous lower segment uterine rupture scar---6%
previous upper segment uterine rupture scar ----32%
0 Risk factors:
- Previous cesarean section {highest risk factor}
- Previous myometrial surgeries (curettage, perforation, myomectomy, metroplasty)
- Overstretched uterus (hydramnios, multiple pregnancy, etc.) Muitiparity
- Hyperstimulation (especially prolonged use of oxytocin in multiparous patients), PGE1 use
- Difficult childbirth
- Intrauterine manipulation (internal version-extraction)
- focal weakness in the myometrium; Connective tissue diseases such as uterine anomalies, leiomyoma, adenomyosis, choriocarcinoma and Ehlers Danlos syndrome.
Clinical: Classical findings in spontaneous rupture developing in labor are suprapubic pain and tenderness, sudden disappearance of labor pains, regression of the fetal part presenting with impaired fetal heartbeat, and vaginal bleeding. Subsequently, signs of hypovolemic shock and hemoperitoneum may develop.
The most common finding in the cases is severe deceleration in fetal heart beats.
0 Prognosis and Treatment: The risk of fetal mortality is 50-75% and if the fetus is alive at the time of rupture, the only chance is emergency laparotomy. Survivors are at risk for hypoxic ischemic encephalopathy. Maternal mortality due to rupture is rare (0.2%). Hysterectomy is the preferred treatment. The rupture can be repaired in cases with a desire to have children; however, the chance of recurrence of rupture in the next pregnancy is 20%.
Uterine Inversion
0 It is a rare painting. Among the risk factors, fundal implantation of the placenta, uterine atony, placenta! umbilical cord traction and placental adhesion anomalies without separation are included.
0 There is acute pain and shock (30%) and life-threatening bleeding. The uterus can be seen protruding from the vagina. The treatment is emergency manual replacement accompanied by tocolysis, surgical replacement or hysterectomy if it is not possible (push in the uterus).
Placenta Implantation Disorders
0 Variations in which trophoblastic tissues invade the myometrium at different depths. In these cases there is little or no decidua basalis and no physiological separation line (Nitabuch layer) along the spongy layer of the decidua. Therefore, the cotyledons are firmly attached to the myometrium.
- P. accreta: The villi adhere to the superficial myometrium (80%); is the most common type.
- P. increta: The villi invade the myometrium (15%).
- P. percreta: The villi completely penetrate the myometrium and reach the serosa (5%).
etiology
- Placenta previa (1/3 of cases)
- Caesarean section history (1/4 of the cases)
- History of curettage (1/4 of the cases)
- Multiparity
- advanced maternal age; The risk increases 3 times over the age of 35
- Cigarette
Clinical and diagnosis: Antepartum hemorrhage is common, usually due to the accompanying placenta previa. Color flow Doppler ultrasonography has a very high diagnostic value. If the diagnosis is in doubt, MRI can be used in addition to ultrasonography.
Treatment: The placenta is tried to be removed, in case of heavy bleeding, postpartum hysterectomy may be required.
coagulopathy
0 The most common causes are von Willebrand disease and ITP.
0 Acquired causes are anticoagulation and consumption coagulopathy.
Late Postpartum Bleeding
► Bleeding after 24 hours before 12 weeks
► Etiology:
0 Placental fragment retention (most common cause); Risk factors include stillbirth, premature birth and a history of cesarean section.
0 Infections (endometritis)
0 Coagulopathy (von Willebrand disease)
0 Subinvolution of placenta
cord prolapse and cord presentation
• Following the opening of the fetal membranes, the presence of the umbilical cord in the lower uterine segment, next to the presenting fetal part (hidden) or in front of the birth canal is called cord prolapse.
• If the umbilical cord is between intact membranes in the cervical os and the fetal head, it is called cord presentation.
• Risk factors include malpresentation, hydramnios, prematurity (<34 weeks), pelvic tumors, inferior placenta, head-pelvic incompatibility, occiput posterior position, multiple pregnancy, rupture of membranes during prematurity. Among malpresentations, the most common risk factor is transverse situs (20%), followed by foot (15%). The risk also increases in breech presentations.
• Perinatal mortality is 20% in cord prolapse. When the umbilical cord prolapses, emergency cesarean section should be performed to reduce perinatal morbidity and mortality.
BIRTH INJURIES IN THE NEWBORN
• Cranial injuries: Skull fractures, mandible fractures, intracranial hemorrhages, epidural hemorrhages, subdural hemorrhages, cerebral palsy.
► Intracranial hemorrhages; It is more common in premature babies. While it is least observed in spontaneous deliveries and elective cesarean sections; It is more common in operative deliveries and emergency cesarean sections in active labor.
► The risk factor that increases the risk of cerebral palsy the most is preterm birth (between 23-27 weeks).
• Spinal cord injuries: Caused by excessive stretching. Facial paralysis, brachial plexus injury,
• Bone fractures: Clavicle, humerus, femur, mandible fractures
• Muscle injuries: Torticollis
• Soft tissue injuries: Subcapsular hepatic hematoma, scrotal hematoma
Shoulder dystocia
• It is the situation where the time between the birth of the head and the birth of the body lasts longer than 60 seconds. 75% of the cases occur in fetuses over 4000 g and the risk increases as the fetus weight increases.
• Risk factors:
► Obesity
► Multiparity
► Diabetes mellitus
► Exceeding term (postterm pregnancy)
► History of shoulder dystocia; recurrence risk 1-13%
• Prevention: Most are unpredictable and unavoidable. However, if the estimated birth weight is ?: 4500 g in women with diabetes and ?: 5000 g in non-diabetic women, elective cesarean section should be performed.
• Management scheme in shoulder dystocia:
► A wide episiotomy should be opened.
► The first thing to do is Mc Robert maneuver and suprapubic compression (N�J3J. Fundal compression alone should not be done.
► The second group of maneuvers that can be performed in case of failure are: Woods screw maneuver (rotating the shoulder 180 degrees), delivery of the posterior shoulder and Rubin maneuver (reducing the distance between each twin shoulder by pushing the fetal shoulder towards the anterior surface of the rib cage).
► What to do if no result is obtained; fracture of the clavicle, Zavanelli maneuver (pushing the head back in) and symphysiotomy.
AMNION fluid EMBOLI
• Risk factors:
► Advanced maternal age, placenta previa, abruptio placentae, preeclampsia, forceps vacuum or cesarean delivery, meconium stained amnion, precipitated labor, postterm pregnancy, labor induction, lacerations in the great pelvic veins, polyhydramnios
► Hypertonus due to oxytocin is the condition that increases the risk of amniotic fluid embolism the least; because strong contractions prevent the amniotic fluid from entering the uterine veins.
• Clinical: Hypotension, pulmonary edema, ARDS, cardiopulmonary arrest, cyanosis, coagulopathy (DIC), dyspnea, convulsions
Amniotic Fluid Embolism Diagnostic Criteria
Sudden onset of hypotension and respiratory failure
Documentation of overt disseminated intravascular coagulation not associated with bleeding
Onset of symptoms at birth or within 30 minutes of delivery of the placenta
Fever not 38 degrees or higher
Diagnosis; It is a clinical diagnosis and the definitive diagnosis is made only with the presence of fetal cells in the maternal circulation and maternal mortality is 60-90%.