Bleeding during pregnancy, childbirth and postpartum

In the past, bleeding during pregnancy and childbirth was one of the most common causes of maternal death. Nowadays, it is the same, but with a much lower incidence difference, which is why you always need to think about bleeding.

Characteristics of blood loss

 * sudden, mostly violent and large
 * the possibility of a wrong estimate (devices that can determine blood loss more accurately)
 * resuscitation in pregnancy - complications of aortocaval compression and abdominal compartment syndrome
 * higher risk of hemorrhagic shock
 * leakage of blood into the small pelvis ⇒ formation of retroperitoneum

Life-threatening bleeding
This is high blood loss, which represents a loss of 50% of blood volume within 3 hours. We consider blood loss greater than 1500 ml to be life-threatening bleeding.

Placenta praevia
Possible causes :


 * higher number of caesarean sections ,
 * congenital developmental defects of the uterus ,
 * the occurrence of placenta praevia in the past.

The main symptom is incipient bleeding due to separation of the placenta. We diagnose it using ultrasound. Magnetic resonance imaging helps us determine the type of placenta praevia.

Vasa praevia
The main symptom is immediate bleeding after the outflow of amniotic fluid. It is due to a violation of the blood vessels located in the amniotic membranes. This complication is associated with pathological cardiotocographic recording and possible subsequent fetal mortality.

Abruption of the placenta
Placental abruption, or premature separation of the placenta, is a serious condition that can endanger the life of both mother and child. In case of placental abruption, the only option for delivery is an acute caesarean section.

Distribution of placental abruption:


 * marginal abruption of the placenta - violation of the marginal placental veins, separation mostly of the fetal membranes rather than the placenta itself
 * retroplacental abruption of the placenta - violation of the spinal arteries ⇒ formation of a retroplacental hematoma.

Liver rupture
Liver rupture is most likely to occur in women with preeclampsia. There is sudden epigastric pain or pain located in the upper abdomen. It may be accompanied by nausea and vomiting. When Glisson's capsule is broken, bleeding into the abdominal cavity occurs and hemorrhagic shock develops.

Rupture of the uterus
Although uterine rupture is not so often encountered, it is a very dangerous situation with lethal peripartum complications and perinatal mortality. Threatening rupture of the uterus can be detected with a deepening Brandl's furrow .

Risks of formation :


 * cesarean births,
 * births after previous intervention on the uterine wall - e.g. myomectomy.

Caesarean section
Nowadays, caesarean section can save many lives of women and newborns, but it is still a major abdominal operation and the complications associated with it. After removing the fetus, it is necessary to close the uterine cavity without waiting. Complications of caesarean section see. Cesarean section.

Retention of the placenta
Placenta retention occurs during cervical spasm. There is no natural separation of the placenta. The woman is therefore at risk of higher blood loss. The solution to retention of the placenta is its manual removal under general anesthesia - i.e. manual lysis of the placenta.

Birth injury
In the case of a birth injury, larger blood vessels may also be damaged. This can cause supralevator or infralevator hematomas or other more serious complications. After delivery, an examination with birth mirrors is necessary. We must also think about the possible occurrence of more than one source of bleeding.

Hypotonia and atony of the uterus
Hypotonia and atony of the uterus are among the most common causes of higher blood loss after childbirth .

Risk factors :


 * multiple pregnancy,
 * multiparity,
 * placenta praevia
 * precipitous or, on the contrary, protracted birth,
 * congenital developmental defects of the uterus, etc.

Uterine inversion
In the case of uterine inversion, the uterine fundus is absorbed into the uterine cavity and may even protrude in front of the external gate.

Placentation disorders - placenta accreta, increta, percreta.
In addition to placenta praevia, or pathologically placed placentas, we distinguish three more types of placentas, which are characterized by their growth into the individual layers of the uterus. Placenta accreta anchors superficially to the myometrium. The placenta incrleta grows through the myometrium. Placenta percreta spreads through the myometrium and into surrounding structures. In the first case, it is possible to preserve the uterus, for the remaining two types of placentas, delivery is carried out by caesarean section followed by hysterectomy.

Gestational hydremia
During pregnancy, the increase in circulating blood volume is up to 1.5 liters higher than in an adult. However, the increased increase in volume does not cover the increase in the volume of erythrocytes, which gets out of proportion - this is pregnancy hydremia.

Due to the higher blood volume, pregnant women therefore tolerate higher blood loss better than others. Often, with higher blood loss, there is no change in blood pressure or heart rate.

related articles

 * Pregnancy
 * Birth
 * Six weeks

Resources

 * MEDICAL TRIBUNE,. Placenta accreta, increta and percreta - Part one: Team care starts with prevention  [online]. STAFFORD, Irene, ©2008. Last revision 2022, [cit. 2022-02-10]. < https://www.tribune.cz/archiv/placenta-accreta-increta-a-percreta-cast-prvni-tymova-pece-zacina-jiz-prevenci/ >.


 * WIKISCRIPT,. Uterine inversion  [online]. Prouzová, Michaela, ©2021. Last revision 2021, [cit. 2022-02-10]. < https://www.wikiskripta.eu/w/Inverze_delohy >.


 * WIKISCRIPT,. Birth injuries  [online]. Bajerová, Michaela, ©2021. Last revision 2021, [cit. 2022-02-10]. < https://www.wikiskripta.eu/w/Poraněn%C3%AD_za_porodu >.


 * PORODNICE.CZ,. The most common causes of postpartum hemorrhage  [online]. Porodnice.cz, ©2022. Last revision 2022, [cit. 2022-02-10]. < http://studenti.porodnice.cz/nejcastejsi-princiny-krvaceni-po-porodu >.