Obstetric hemorrhage

DIC syndrome: from diagnosis to treatment

Disseminated intravascular coagulation (DIC syndrome) is a critical condition requiring emergency measures. In subacute and chronic forms, laboratory tests show hemostatic hyperactivity, decreased activity of natural antithrombins, hyperfibrinogenemia, and the appearance of high- and low-molecular-weight FDP (fibrin degradation product) fragments.

Acute and subacute phase therapy consists of four stages:

1. Etiotropic treatment: elimination of the cause. In obstetrics, this is most often urgent delivery and arrest of bleeding.
2. Hemodynamic correction: infusion-transfusion therapy combined with mechanical ventilation to restore blood circulation.
3. Restoration of coagulation: intravenous bolus administration of fresh frozen plasma (FFP) warmed to 37 °C. Repeated infusions are performed every 2, 4, 6, or 8 hours. Slow drip infusion is ineffective.
4. Inhibition of fibrinolysis: infusion therapy combined with the administration of tranexamic acid.

Important nuance: in acute DIC syndrome (associated with premature placental abruption or amniotic fluid embolism), stage I is extremely short-lived. Given the presence of a wound surface in stages II and III, the administration of unfractionated heparin is inappropriate as it will increase blood loss. It is prescribed strictly 12–24 hours after surgery. In the chronic form, antiplatelet agents and vasodilators are used to normalize microcirculation, while low-molecular-weight heparins (enoxaparin sodium, nadroparin calcium) are used in stage I.

Idiopathic thrombocytopenic purpura (Werlhof's disease)

The pathology threatens the mother with preeclampsia, miscarriage, placental insufficiency, and severe hemorrhages (including premature placental abruption and postpartum hemorrhages). For the fetus, the main danger is intracranial hemorrhage caused by neonatal thrombocytopenia.

Management tactics are developed jointly with a hematologist:

• If the platelet count is above $40 \times 10^9$/L and there are no hemorrhages, specific therapy is not needed; expectant management and vaginal delivery are indicated.
• Corticosteroids are prescribed 1–2 weeks before delivery (10 mg/day, increased to 30–40 mg in case of bleeding). If resistant to them, immunoglobulin therapy is used.
• If bleeding develops, transfusion of FFP and washed red blood cells is indicated. Platelet transfusion is strictly contraindicated.
• Cesarean section is justified if treatment is ineffective and hemorrhagic manifestations increase towards the end of pregnancy—this significantly reduces the risk of newborn brain trauma.

Von Willebrand disease in obstetric practice

This hereditary autosomal dominant disorder is associated with a deficiency of von Willebrand factor (part of the factor VIII complex), leading to increased permeability and fragility of the vascular wall, as well as a decrease in its contractility. The diagnosis is confirmed by prolonged aPTT and bleeding time (more than 15–20 minutes).

During pregnancy, patients' condition may paradoxically improve due to the physiological increase in blood clotting factors. However, the risk of massive blood loss during delivery (both spontaneous and via Cesarean section) or during artificial abortion remains high.

Drug of choice is intravenous administration of plasma cryoprecipitate. Its administration is initiated at the onset of labor or 24 hours before planned surgery, and then repeated 3 days after delivery. FFP serves as an alternative if the drug is unavailable.

Historical background and instrumental methods

The fight against obstetric hemorrhage has a long history. In the 16th century, the first Cesarean section procedures in France were accompanied by colossal maternal mortality from hemorrhage and infections because the uterine wound was left open for a long time. In Russia, Nestor Maksimovich Maksimovich-Ambodik made a huge contribution. He published the foundational work "The Art of Midwifery", introduced teaching in Russian, and was the first in the country to use obstetric forceps. The forceps themselves were invented in England by the Chamberlen family, who kept the secret (selling only one part of the instrument to France, rendering it useless), and Palfijn was officially recognized as the inventor in 1723.

To assess anatomical risks and pathologies in modern obstetrics, the following methods are used:

• X-ray pelvimetry: allows the detection of a contracted pelvis. On the anteroposterior radiograph, the transverse diameter of the pelvis and the fronto-occipital diameter of the fetal head are measured; on the lateral radiograph, the true conjugate (conjugata vera) is measured. The sacral index is also calculated. The study is performed at the end of pregnancy, when fetal radiosensitivity is physiologically reduced.
• Fetoscopy: surgical interventions (division of amniotic bands, umbilical cord coagulation) are performed strictly in the operating room under general anesthesia and additional ultrasound guidance. A very rare complication of the procedure is hemorrhage.

Class and exam questions

What else to study on this topic

• Clinical stages and diagnostic methods of DIC syndrome
• Peculiarities of using low-molecular-weight heparins (enoxaparin, nadroparin)
• Indications and technique for performing X-ray pelvimetry
• Complications of fetoscopy and methods for their prevention
• Neonatal neurosonography: approaches and evaluation of results

Other topics in the "Obstetrics" section

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