Late postpartum hemorrhage

Introduction to late postpartum hemorrhage Late postpartum hemorrhage refers to a large amount of bleeding in the uterus that occurs during the calving period after 24 hours of delivery, and the amount of bleeding exceeds 500 ml. The most common morbidity occurred 1 to 2 weeks after birth, and it is also late for 6 weeks after birth, also known as puerperal bleeding. Due to the increase of pregnancy pathological conditions and social factors, the importance of fetal attention and maternal fear and other factors, the cesarean section rate gradually increased, postoperative complications also increased, the level of surgery during cesarean section and late postpartum hemorrhage The rate has a certain relationship. basic knowledge The proportion of illness: 0.34% Susceptible population: pregnant women Mode of infection: non-infectious Complications: Hemorrhagic shock

Causes of late postpartum hemorrhage

(1) Causes of the disease

1. Improper treatment of uterine incision in cesarean section is one of the important causes of late postpartum hemorrhage. In recent years, due to the increase of pregnancy pathological conditions and social factors, the importance attached to the fetus and maternal fear and other factors The effect, cesarean section rate gradually increased, postoperative complications also increased, the level of the surgeon during cesarean section and the late postpartum hemorrhage rate have a certain relationship.

(1) improper selection of uterine incision: the incision should be selected in the lower part of the uterus, avoiding too high or too low, the incision is too high, located at the junction of the uterus and the lower part, the thickness of the upper and lower edges of the cutting edge is uneven, misaligned or misaligned, Can cause poor healing of the uterine incision; the incision is too low, close to the cervix, more cervical connective tissue, poor blood supply, can also cause poor healing of the uterine incision, and easily cause tearing of the incision when the fetal head is born.

(2) Inappropriate incision method: When incision, use a scalpel or scissors to cut or cut the whole process, causing the arch wall of the uterine wall to break, and bleeding, affecting healing.

(3) When the fetal head is incision, the incision is torn: when the fetal head is out, the action is rough or in the case of a huge child. In the case of a deformed child, the placenta is prone to incision tearing. Because the uterus is moved by the sigmoid colon, the uterus is right-handed, so the left incision The angle is easily torn, involving the uterine artery, and massive hemorrhage occurs. At this time, the surgeon is nervous, and repeatedly sutures the hemostasis at the torn site, which can cause blood vessel disorder in the uterine horn wound, easy to be necrotic, split, and bleeding.

(4) Improper suture: the needle spacing is too tight, the suture is too tight, which can affect the local blood circulation, so that the incision is not well healed. In addition, when the suture is sutured into the muscular layer, it also affects the healing of the uterus incision. one of the reasons.

2. Infection before the delivery of premature rupture of membranes, prolonged labor, repeated vaginal examination, artificial rupture of the membrane, water sac induction or use of air bags to promote cervical ripening and other vaginal operators, the mother itself has severe anemia during pregnancy, severe pregnancy-induced hypertension, In the pathological situation such as diabetes, combined with vaginal hygiene after childbirth, fear of pain does not clean the perineum, can occur intravaginal and intrauterine infection, resulting in poor uterine incomplete or poor wound healing and late postpartum hemorrhage.

3. Uterine incomplete intrauterine infection and a small amount of placental membrane residual can cause uterine insufficiency.

4. Placenta polyps during delivery If the placenta, residual membrane, residual tissue necrosis in the uterus, mechanized, surface fibrin deposition, the formation of polyps.

5. Other endometritis, uterine submucosal fibroid infection, choriocarcinoma, can also cause late postpartum hemorrhage (Figure 1).

(two) pathogenesis

At the time of delivery, the placenta and fetal membranes are not carefully examined, especially when there are para-placenta or sail-shaped placenta, a small amount of placental membrane residue leads to the incomplete restoration of the placenta, the uterus can not be properly contracted, the uterine contraction is poor, and the residual local thrombus falls off. The sinusoids are open and late postpartum hemorrhage occurs. Partial or all of the placental polyps fall off, causing late sinus opening at the attachment site to cause late postpartum hemorrhage.

Late postpartum hemorrhage prevention

Do a good job of pregnancy care, properly handle the delivery process, can significantly reduce the incidence of late postpartum hemorrhage.

History of postpartum hemorrhage, multiple history of induced abortion, placental retention and twins, excessive amniotic fluid, prolonged labor, increased vigilance, good prenatal care and delivery, postpartum monitoring, and detailed maternal, coordination, prevention The occurrence of postpartum hemorrhage.

Correctly handle the second and third stages of labor, the shoulder should be slow, protect the perineum to avoid tearing of the soft birth canal, observe the contractions and vaginal bleeding after delivery, and press the uterus to promote blood discharge.

Strict cesarean section indications, strengthen the promotion of normal physiological delivery methods, reduce the impact of social factors, for those with cesarean section indications, the uterus incision is selected in the lower part of the uterus, first cut a small mouth, and then tear it by hand The length, the fetal head should be gentle, choose the appropriate suture, the needle distance should not be too dense, stop bleeding thoroughly, antibiotics to prevent infection after surgery.

Late postpartum hemorrhage complications Complications, hemorrhagic shock

The main complications are hemorrhagic shock and infection.

Late postpartum hemorrhagic symptoms Common symptoms Postpartum blood in postpartum, postpartum, lochia, odor, lochia, unclean, repeated bleeding, postpartum fever, thrombus, decidual membrane, residual membrane, early bankruptcy, blood gas, bloody lochia, prolonged duration

1. The third stage of placenta residue is improperly treated, and the placenta is delivered prematurely. If there is a large placental defect or the placenta remains in the uterine cavity, it cannot be found in time, and the residual placental tissue is degenerated, necrotic, and mechanized. Placental polyps, when the necrosis is detached, the basal part of the blood vessels rupture and hemorrhage, the clinical manifestations are often red prolonged time, repeated hemorrhage or even sudden hemorrhage, hemorrhagic shock, mostly occurred about 10 days after delivery, gynecological examination found that the uterus is incomplete. The cervix is slack, sometimes the residual tissue is blocked by the cervix, and the patient may be accompanied by fever. B-mode ultrasonography shows that the endometrial line is unclear, there is a strong light group echo in the uterine cavity, and sometimes the dark interval is mixed, and the uterine cavity is scraped. The pathological examination of the object has a villus tissue.

2. Residual membranes can also cause late postpartum hemorrhage, but the main manifestations are persistent red lochia for too long, large bleeding is rare, gynecological examination reveals poor uterine insufficiency, B-mode ultrasound shows that the endometrial line is unclear, there are intrauterine Small glare echoes, pathological examination of uterine cavity scraping has fetal membrane tissue.

3. The residual decidual tissue of the decidua is more than 1 week after delivery and is discharged with the lochia. The uterine malformation such as double uterus, double uterus, etc., the decidua is easily peeled off and remains for a long time, affecting the uterus, easy to secondary uterus Endometritis, leading to late postpartum hemorrhage, occurs in about 2 weeks postpartum, clinical manifestations are not easy to distinguish with residual fetal membranes, B-mode ultrasound examination shows that the endometrial line is unclear, there may be fine light echo or liquid in the uterine cavity In the dark area, the pathological examination of the uterine cavity scraping only saw the degeneration of the decidual cells and red blood cells, but no fluff.

4. Placenta attachment site uterine incomplete or endometrial repair incomplete uterus placenta attachment site blood vessels after the placenta discharge, there is thrombosis, followed by thrombosis, transparent changes, vascular epithelial thickening, stenosis, blockage, placenta The endometrium at the edge of the attachment site grows inward, and the residual gland and intima of the deep aponeurosis re-growth, so that the endometrium is repaired normally. This process takes 6-8 weeks. If the infection occurs in this part, the thrombus falls off and blood Reopening of the sinus can cause massive hemorrhage, which often occurs 2 to 3 weeks after delivery. Gynecological examination shows that the uterus is enlarged, soft, the cervix is slack, and sometimes a large number of blood clots are blocked. The massaged uterus has old blood and clots, B-mode ultrasound. Examination showed that the endometrial line was unclear, there was no history of residual placental membrane in the third stage of labor, no tissue echo in the uterine cavity, no placental villi in the scrape, and the lumen of the aponeurosis or muscle layer remained different. The membrane repair process is blocked, and there is an inflammatory reaction in the regenerating endometrium and muscle layer.

5. Uterine incision rupture after cesarean section is more common in the lower end of the transverse section of the lower uterine section of the uterus, causing the incision to split:

(1) Incision infection: the lower incision of the lower uterus is close to the vagina, the operation of blood loss and postoperative bleeding, premature rupture of membranes, prolonged labor and other causes of incision and surrounding infection, tissue necrosis, blood vessels open and massive bleeding, after the incision is split Aggravating infection, the two are causal, mutual influence makes the incision difficult to heal, such as aseptic operation is not strict and easier.

(2) Inappropriate incision selection: When the incision is too low, due to the proximity to the external cervix, the tissue structure is mostly connective tissue, and the healing ability is poor. When the incision position is too high, it is located at the anatomical opening, and the upper edge of the incision is the palace. Body tissue, contraction force and contraction force is strong, the fetus is thickened and shortened after delivery, the lower edge is cervical tissue, the contraction force is poor, thin and long, and the suture is difficult to cause poor healing due to poor pregnancy. More right-handed rotation, easy to be left to the left is easy to damage the left uterine blood vessels.

(3) Improper suture: the margin of the margin is poor, the operation is rude, the vascular suture of the active hemorrhage is not tight, especially the blood vessels at the corners of the incision are not sewn and the hematoma is formed; the suture is too loose or knotted. Pine can not effectively compress the blood vessels, the suture is tied tightly to cut the blood vessels and tissues, the sutured tissue is too much or too thin, the gut is too thick and the knot is too much, and the whole layer of the uterus penetrates and sutures will affect the healing of the incision. Causes bleeding.

Incision dehiscence often manifests as a painless massive vaginal bleeding that occurs suddenly around 3 weeks after surgery, and recurrent attacks. In a short period of time, the patient is in a state of shock. When examined, there are blood clots in the vagina and cervical canal, and the external cervix is loose. Sometimes In the lower incision of the uterus, touch the depression, protrusion or blood clot. At this time, do not forcibly tear or touch the "foreign object", otherwise it may cause uncontrollable bleeding.

6. Other placental site trophoblastic tumor, uterine submucosal fibroids, endometrial polyps, intrauterine foreign body, cervical erosion, cervical malignant tumors, etc., may cause late postpartum hemorrhage, diagnosis depends on gynecological examination, blood or urine HCG determination , X-ray or CT examination, B-mode ultrasound examination and pathological examination of uterine cavity scraping.

7. More manifestations of postpartum lochia are not clean, smelly, repeated or sudden vaginal bleeding, can lead to anemia, shock and even life-threatening (Figure 2).

Late postpartum hemorrhage

Peripheral hemoglobin, red blood cell reduction is positive cell positive pigment anemia, white blood cells are elevated.

1. B-ultrasound can prompt intrauterine mixed echo (blood clot or tissue), local hematoma formation in the lower incision of the uterus, severe cases have pelvic and abdominal effusion.

2. Diagnosis of the placenta or fetal membrane tissue.

Diagnosis and diagnosis of late postpartum hemorrhage

diagnosis

For a history of multiple abortions, a history of placental adhesions, a history of postpartum hemorrhage, or prolonged labor during labor, emergency, twins, dystocia, intrauterine procedures, para-placenta, contoured placenta, placental defects, or postpartum hemorrhage Be vigilant.

1. Diagnosis can be made based on medical history, clinical manifestations, signs and auxiliary examinations.

2. Diagnostic criteria

(1) Uterine bleeding occurred during the calving period after 24 hours of delivery, which showed that the postpartum lochia was not clean, the blood color changed from dark to red, accompanied by odor at the time of infection, repeated bleeding, low or medium blood volume, and a large amount of bleeding may be accompanied by blood clots. The patient has a shock when he has been bleeding for a long time.

(2) There is a history of lower abdominal pain, low fever or low postpartum fever.

(3) The uterus is slightly larger and softer. When there is infection, there is tenderness in the uterus or incision. The hematoma in the incision can form a mass, the cervix is loose, and sometimes the residual placental tissue can be touched.

(4) Blood routine shows anemia and infection.

(5) B-ultrasound examination showed residual tissue in the uterine cavity or hematoma in the lower part of the uterus after cesarean section, poor healing or tumor lesions in the uterus. The diagnosis of postpartum hemorrhage is not difficult to make. The key point and difficulty of diagnosis is to find the cause of bleeding. According to the treatment, it can stop bleeding quickly. Therefore, there are four major causes of postpartum hemorrhage: uterine contraction, placental factors, soft birth canal injury and blood coagulation. Mechanism disorders are used for differential diagnosis.

Differential diagnosis

1. Patients with uterine contraction and fatigue have a history of uterine contraction fatigue during labor, postpartum hemorrhage is mostly dark red blood, blood clots are visible, blood is rare; massage the bottom of the palace, the uterus is soft or even like a bag, after the massage, a large amount of blood can flow out of the vagina. There was no abnormality in the soft birth canal examination; the amount of bleeding after the contraction was strengthened.

2. Placental retention, partial adhesion, partial implantation and other placental abnormalities caused by abnormal postpartum hemorrhage, more common in the placenta after the delivery of the fetus, no signs of placenta stripping; abdominal examination sometimes in the inferion of the placenta in the lower part of the uterus to form a narrow ring, free to peel the placenta It was found that the placenta was stuck to the uterine wall or difficult to separate.

3. Soft birth canal laceration occurs after the baby is delivered, the bleeding is bright red, no blood clots but self-coagulation; the uterine contraction is found to be good, and the soft birth canal examination can clearly identify the location and severity of the laceration.

4. Coagulation dysfunction can have chronic systemic hemorrhage before delivery. Patients can have multiple sites such as uterus, soft birth canal, and blood. It is difficult to diagnose blood coagulation function according to platelet count.

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