Bleeding conditions in obstetrics

The severity of the bleeding condition in pregnancy or peripartum depends on the nature, intensity and extent of the bleeding. The most common causes are:
 * 1) Before birth:
 * 2) * placenta praevia;
 * 3) * placental abruption;
 * 4) * extrauterine pregnancy.
 * 5) During childbirth:
 * 6) * uterine rupture;
 * 7) * premature recanalization of hemostatic coagulum (increased pressure, increased plasmin activity);
 * 8) * failure of hemostatic procedures (ligature).
 * 9) After birth:
 * 10) * physiological vascular closure disorder;
 * 11) * placental residue;
 * 12) * hypotonic uterus;
 * 13) * afibrinogenemia;
 * 14) * transboundary injured birth canal.

According to the pathophysiological process leading to bleeding, we divide the causes of bleeding conditions into: Coagulation failure can occur on the basis of a hereditary defect (hereditary coagulopathy - hemophilia and other hereditary defects in the plasma-coagulation system) or it is a congenital coagulopathy (autoimmune disease, thrombocytopenia, liver failure, drugs - heparin, oral anticoagulants, antiaggregants, dilution of plasma and platelets after bleeding and volume replacement, DIC). The mechanical causes of bleeding include transboundary tissue damage, placental residues and uterine hypotonia.
 * 1) coagulopathy;
 * 2) bleeding due to mechanical reasons.

Dilutional coagulopathy
Dilutional coagulopathy occurs as a result of volume replacement during heavy bleeding, it is alleviated by the administration of fresh frozen plasma in the replacement. Disorders of hemostasis cause:
 * dilution below 10-20&thinsp;% activity of coagulation factors;
 * dilution of platelets below 10-20&thinsp;thousand/mm3;
 * inhibition of procoagulant activity caused by dilution (in the physiological state there is a relative predominance of procoagulant activity);
 * hypoxic-reperfusion syndrome and isolated fibrinogen supplementation predispose to a possible transition to DIC.

Rupture of ectopic pregnancy
Complications associated with ectopic pregnancy are the most frequently occurring abdominal emergency in gynecology. Ectopic pregnancy is most often located in the fallopian tube (95-97&thinsp;%). If the trophoblast erodes the entire tubal wall, the fallopian tube ruptures. It has a stormy course. There is a risk of massive bleeding into the peritoneal cavity, as the blood practically does not clot (fibrinogen precipitates upon contact with the peritoneum). Symptoms of fallopian tube rupture include sudden pain in the lower abdomen, peritoneal irritation, collapse. Hemoperitoneum, cardiopulmonary decompensation, and shock state develop rapidly. Exceptionally, the blastocyst nidus and begins to develop in the cervix uteri, this pregnancy tends to have the most severe course (repeated, difficult-to-treat bleeding occurs, life-saving hysterectomy is often required).

Pathological placement of the placenta
The cause of bleeding in the third trimester and during childbirth can be a pathologically located placenta. Placenta praevia threatens the life of both the mother and the fetus (mother with bleeding, fetus with hypoxia). The main symptoms of pathological placement of the placenta are:
 * 1) Bleeding:
 * 2) * the main symptom that most often accompanies bed rest;
 * 3) * usually also as the first symptom at the end of the 1st trimester.
 * 4) Abortion':
 * 5) * can arise because the placenta does not find as much room to grow in the lower segment, the production of hCG decreases and the corpus luteum may disappear, but more often the miscarriage does not occur and the pregnancy continues;
 * 6) * if the pregnancy continues, in the second trimester, the lower segment begins to grow, which leads to partial separation of the bed and bleeding again;
 * 7) * repeated blood loss leads to anemization of the mother;
 * 8) * the closer to delivery, the more contractions (dilation of the throat), the more frequent and stronger the bleeding.
 * 9) More frequent occurrence of pathological fetal positions':
 * 10) * the placenta prevents the head from entering the pelvis;
 * 11) * if we find a pathological position towards the end of the pregnancy, we should rule out the en route bed.
 * 12) Pathological placement of the placenta can sometimes be completely ``asymptomatic''.

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