Late postpartum hemorrhage

The reasons. Physiological childbirth are accompanied by bleeding within 250 ml, which occurs during the period of detachment and allocation of the placenta. In the next 2-3 days after birth bleeding from the uterus still in progress, but to a much lesser degree. This is mainly due to the retraction of the muscle fibers, which contributes to the compression of the lumen of the blood vessels. Then highlight acquire the bleeding is severe character; and finally, by the end of the first or early in the second week of the selection (lochia) become serous. By this time (9-10-th day after birth) the whole surface of the cervix is covered by the epithelium (C. S. Gruzdev, I. I. Yakovlev).
Thus, when a normal, physiological during the postnatal period spotting happen within the first three to four days last. The presence of bleeding after the specified term, often turning into major bleeding, and bleeding after 10-day and later should be regarded as an indicator of the pathological course of the postnatal period. To these signs, the doctor must be treated with great attention.
Bleeding often observed in the first week and more frequently on the second and third weeks postpartum period.
The origin of late postnatal bleeding most often associated with a delay in the uterine cavity parts of the placenta, shells or compact layer falling shell.
In the basis of these violations, of course, lie morphological changes in tissues of the uterus on the grounds of previous traumatic and inflammatory processes involving degeneration of the blood vessels and the changes in the peripheral nervous system. In the event of such kind of bleeding are of importance mainly innate inferiority muscles of the uterus and its net-fibrous framework (L. N. Chernyshev).
Bleeding can also occur from delays in the uterus of blood clots, in particular, old clots formed in the result of a partial detachment of the placenta during pregnancy on the grounds of spasm of muscles in the area of internal throat (bottom).
Thus, according to P. Century Pakhomova, late postpartum hemorrhage in 49% of cases occurred in connection with the delay parts of the placenta, and 51% were the cause of their inflammatory changes of the mucous membrane and muscle layer of the uterus.
The process of regeneration of the mucous membrane of the uterus after delivery is much slower in place placental site (own observations). Based on this, we can presume that stranded in the uterus remains of the falling shell slow recovery of the mucous membrane and support krovotechenie. In these cases the uterus seems enlarged and in its oral always found many old and fresh blood clots.
Unfortunately, many doctors not give due importance to the fact of the delay of the decidual tissue and are considered only with a delay integral parts of the placenta, which, from our point of view, absolutely wrong. The study M. M. Ginzburg fully confirms our observations. The author believes that the occurrence of late postnatal bleeding is due not only to limp back development of mucosal vessels, but the main way to delay parts of the placenta and cease (decidual) shell.
The cause of late postpartum haemorrhage are much less common diseases that cause venous congestion in the wall of the uterus (diseases of the cardiovascular system and so on), degenerative changes and fragility walls of the uterine vessels (With hypovitaminosis, and others), endocrine disorders, diseases of blood system, etc. are Rarely the reason for the late postpartum haemorrhage are chorionepithelioma, submucosal or intramural fibromatous node and cervical cancer.
Late postpartum hemorrhage in most cases occur suddenly and are intensive. Bleeding may be single and very rich or repeated, load and with poor, but continuing for many days.
Power bleeding is not always proportional to the amount of stranded in the uterus residues placental and blood clots. Profuse bleeding may be, and in the absence of a delay of particles of the placenta. The amount of bleeding, undoubtedly, is determined largely by the neurohormonal factors governing the contractile function of the uterus, as well as the ability of blood to clot and thrombus formation. This fact can be explained by the failure of repeated curettage of the uterus in some cases, postpartum haemorrhage.
The value of the uterus usually does not match the time current elapsed after birth. The uterus may be hard or soft consistence, painful or painless with the feeling, the cervical canal, may be closed or go for the thumb.
The body temperature is dramatically high, low or normal. The pulse may be rapid or normal. All depends on the nature and extent of the process. The delay in the uterine cavity parts of the placenta and blood clots creates a favorable ground for the development of infection; this may develop postpartum diseases, including sepsis.
In assessing the severity of injury and the choice of methods of treatment taking into account temperature, pulse, the degree of blood loss in childbirth, the patient's General condition, the power of rootdelay at the moment. Blood tests, ROE, blood culture, research urine contribute to a correct assessment of the clinical picture.

Treatment. To judge about the delay parts of the placenta in late postpartum bleeding on the grounds of examination of uterine cavity; external methods of research are insufficient. In any case, the presence of bleeding requires medical intervention, and the choice of method of treatment is determined by the presence of signs of infection. Here it is necessary to note two important things: 1) normal temperature is not proof of absence of infection and 2) strong degree of blood loss, life-threatening the patient, forces to intervene actively and in the presence of infection. When choosing treatment methods can be discussed or finger, or about instrumental remove the rear parts of the placenta, clots and other But both methods require great caution in their implementation. When manually (finger) method to avoid unnecessary injuries (kneading, compression), the uterus in the Department of placental tissue or remove blood clots, and at the instrumental method to beware of perforation of the uterus.
A number of eminent clinicians - C. S. Gruzdev, R. Century Kiparski and others - were against curettage of the uterus, given the possibility of following adverse effects;
1) violation of the history of demarcation zones (leukocyte shaft), which contributes to the spread of infection beyond the uterus through the blood and lymphatic vessels;
2) injuries of soft tissues of the uterus that are inevitably connected with the damage receptor apparatus; not excluded the possibility of perforation of the uterus;
3) the occurrence of hard stop uterine bleeding.
In addition, scraping does not guarantee that the delayed part of the ovum and blood clots will be deleted. This provision, in our opinion, largely applies to the use of the digital method of residue removal of the placenta.
Especially dangerous scraping in cases where there are clear signs of infection spread beyond the uterus. As profuse bleeding occurring in these cases, requires active intervention for health reasons, some authors recommend even to remove the uterus with the original source of infection and thereby create a good natural drainage.
At a delay of all of the placenta and permeability of the cervix finger destruction has an advantage over the instrumental; in such cases, the curette is applicable only for the final inspection of the uterine cavity. When the delay of the parts of the placenta, even when well-reduced the uterus, in the first days after birth recommended scraping (L. I., Bublichenko).
Complications in the postpartum period for manual removal of the placenta and its parts are observed less frequently than in the instrumental method, and especially in cases when, following manual removal of the placenta was used scraping. It is written entirely to remote consequences. Therefore, the method of choice has to be manual examination, only in the later stages of the postnatal period shown instrumental method.
Contrary results came P. A. Gusakov (1927), published the results after scraping taken to remove the rear parts and even the whole of the placenta. It turned out that after instrumental remove them, even in infected cases, there was complete recovery of patients; in the manual removal of the placenta, the author observed deaths.
Many years of personal experience makes us inclined in favor of the instrumental residue removal of placenta with simultaneous scraping postpartum uterine; conducting this operation may careful, without undue injury to the uterus and are widely using this method when indicated, we did not lose a single patient and did not see serious complications later on.
Prevention. In order to avoid the occurrence of late postpartum haemorrhage is necessary, first, always check the placenta, shell and ensure they are safe, and, secondly, from the first day of the postnatal period to monitor the uterine contractions that it is not delayed blood clots. The uterine contractions and removal from the body clots facilitate timely emptying of the bladder, daily bowel movements, the use of the first day after birth lung irritation hand of the uterus bottom and squeezing her blood clots, as well as the purpose for the best contractions of medicinal substances (the ergot drugs and other). In the following days, the massage of the uterus is contraindicated, because you cannot be quite sure in the absence of infection in the uterus; if the infection even with gentle pumping tissues of the uterus will contribute to the rapid spread of microorganisms. When prolonged (sluggish) the reduction of the uterus great service can have a hot vaginal shower; small particles placenta, membranes and blood clots usually depart on their own.
If these measures bleeding does not stop (often due to the delay of significant segments of the placenta), with open mouth, you can try gently to remove particles placenta great curette. In the presence of overt infection that have fallen outside of the uterus, and minor bleeding should refrain from active actions; in such cases shows anti-inflammatory and tonic treatment, and the use of the bactericidal and bacteriostatic agents.
The presence of infection, it is recommended to apply an ice pack (on the abdomen in place projection of the uterus), the appointment of medical substances that reduce the uterus, autohemotherapy, transfusion of small doses of the blood, the use of antibiotics or sulfa drugs, etc. Active way of action is valid only if heavy bleeding occurs, life-threatening the patient.