Postpartum hemorrhage

Introduction Postpartum hemorrhage means that the amount of bleeding exceeds 500 ml within 24 hours after delivery, and 80% occurs within 2 hours after delivery. Late postpartum hemorrhage refers to a large amount of uterine bleeding that occurs during the calving period after 24 hours of delivery, which is more common in 1-2 weeks after delivery. Postpartum hemorrhage is a serious complication during childbirth and is one of the four causes of maternal death. Bleeding in China has been the first cause of maternal death in recent years, especially in remote and backward areas. The incidence of postpartum hemorrhage accounts for 2% to 3% of the total number of births. The actual incidence is higher due to the subjective factors of measuring and collecting the amount of bleeding.

Cause

There are four major causes of postpartum hemorrhage. The uterine contraction fatigue accounts for about 50% of postpartum hemorrhage, the soft birth canal tear accounts for about 20%, the placental residue or retention accounts for 5% to 10%, and coagulation dysfunction causes very few postpartum hemorrhage.

Uterine contraction

Under normal circumstances, the uterine muscle fibers immediately contract after the placenta is discharged, so that the original sinusoidal pressure is compressed, the blood flow is stagnant, and the thrombosis can quickly reduce the amount of bleeding. The hemostasis function of the muscle fibers is the most important, and any effect on the contraction of the uterine muscle fibers And the factors of the contraction function can cause postpartum uterine contraction and fatigue bleeding.

(1) Systemic factors: such as maternal physique weakness, acute and chronic medical history, long-term labor loss, nervous use of sedatives or deep anesthesia.

(2) Local factors: 1 excessive expansion of the uterine muscle wall, excessive expansion of muscle fibers, affecting muscle fiber contraction, such as excessive amniotic fluid, multiple pregnancy, giant children, huge placenta, -thalassemia, fetal edema syndrome. 2 more maternal repeated pregnancy and delivery, uterine muscle fiber damage, connective tissue relatively increased degeneration. 3 uterine dysplasia or surgical scars. 4 placental factors affect uterine contractions. Such as placenta previa placenta early stripping, decidual necrosis, myometrial osmotic bleeding, placental hematoma. 5 bladder, rectal overfill can affect uterine contractions.

2. Soft birth canal tear

During pregnancy, the soft birth canal is rich in blood vessels and congested. If a soft birth canal laceration occurs during childbirth, the amount of blood loss can be very large. Especially when the laceration involves the upper cervix and uterus of the vagina, hemostasis is often difficult, and the cause of soft birth canal tearing occurs. There are several aspects:

(1) Urgent production: due to excessive productivity or excessive maternal exertion during emergency delivery, the perineum has not been fully expanded, and the delivery of the fetus can cause heavier soft birth canal laceration.

(2) Huge fetus: The prenatal assessment of the size of the fetus is insufficient. No perineal incision or incision is not enough to cause a soft birth canal laceration.

(3) Obstetric surgery: If the forceps are turned to the fetal head and the shoulder is difficult to produce, it can cause perineal vagina, cervix or even lower uterine laceration and lead to postpartum hemorrhage.

(4) The elasticity and stretchability of the perineum itself: such as congenital dysplasia of the perineum vulvovaginal inflammation, white lesions and so on.

(5) Hematoma formation: if the injury involves the blood vessels and the mucosa of the birth canal, the skin remains intact or the suture is not completely sutured when the wound is sutured, or the cervix and vaginal foramen rupture extend upward to cause the blood vessels in the broad ligament to tear and form a hematoma. At this time, there may be less external bleeding, but there may be a lot of bleeding in the hematoma leading to shock.

3. Placenta residue or retention

Factors that affect the normal dissection or delivery of the placenta can result in residual or residual placenta. If the placenta is not completely peeled off or completely implanted, bleeding will not occur. Only after partial peeling or peeling, staying in the uterine cavity will affect the contraction and contraction of the uterus, so that the intrauterine sinus can not be closed and cause bleeding. There are placental leaflets or Residual placenta remains, which can also cause bleeding. With the increase in cesarean section rate and abortion rate, the chances of placental adhesion and implantation are also increased, which is a factor affecting normal placental stripping and delivery. In addition, if the third stage of labor is improperly treated, the uterus is prematurely compressed, the umbilical cord is pulled, the uterine contraction is weak, the placenta attachment surface is too large (such as twins), and it is not easy to be peeled off. The uterine fibroids and deformities affect the uterus contraction, and the bladder is overfilled to compress the lower uterus. The placenta can not be discharged, the placenta is incarcerated, the reason may be abnormal or improper use of uterine contraction agent, thus causing uterine contraction, the uterine contraction ring occurs, the placenta is blocked above it to form the placenta incarceration, due to the placenta Incarceration blockage of the cervix, blood deposition in the uterine cavity, the formation of recessive bleeding, and sometimes there may be a large number of external bleeding.

4. Coagulopathy

Coagulopathy in the obstetrics range, mainly occurs in severe placental abruption, high pregnancy, intrauterine stillbirth retention, amniotic fluid embolism, etc., due to systemic bleeding disorders, such as thrombocytopenia accounted for 50%, soft birth canal tear About 20%, placental residual or retention accounted for 5% to 10%, coagulation dysfunction caused by postpartum hemorrhage is rare.

an examination

Related inspection

Blood routine obstetrics B super obstetric examination postpartum examination urine routine

Blood, urine routine.

Learn about infections and anemia. Intrauterine secretion culture or smear examination. Check to see if there are any residues in the official cavity, and the healing of the uterine incision. If there is a uterine cavity scraping or removal of the uterus specimens.

Differential diagnosis

1, soft birth canal injury: mainly depends on the history of childbirth and careful gynecological examination, if there is a hematoma formation, B-ultrasound identification.

2, choriocarcinoma: blood, urine pregnancy immunoassay positive, X-ray chest X-ray and CT examination showed chest and brain metastasis lesions, pathological examination of the dissection can be identified.

3. Mainly differentiated from genital tumor hemorrhage. The bleeding volume exceeds 500ml within 24 hours after delivery, followed by hemorrhagic shock and prone to infection.

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