Etiology: the “4 Ts” rule
To systematize the causes of postpartum hemorrhage, the international “4 Ts” classification is used:
- Tissue (Tissue): retention of placental fragments or membranes in the uterine cavity, preventing its normal contraction.
- Tone (Tone): myometrial hypotonia or atony — the most frequent causes.
- Trauma: lacerations of the soft birth canal or the uterus itself.
- Thrombin (Thrombin): blood coagulation disorders, including congenital defects and acquired DIC syndrome.
Diagnosis and first aid
The key sign of hypotonia is a flaccid uterus, the fundus of which may be palpated at the level of the umbilicus. With blood loss up to 500 ml, management includes:
- External massage of the uterus to remove clots.
- Administration of uterotonics (Oxytocinum, Carbetocinum, or Misoprostolum).
- Application of cold to the lower abdomen.
If blood loss exceeds 500 ml, manual exploration of the uterine cavity under anesthesia is mandatory.
Surgical methods of hemostasis
If conservative therapy is ineffective and blood loss reaches 1,500 ml, surgical intervention is initiated:
- Compression sutures: for example, the B-Lynch suture, which provides longitudinal compression of the uterus, pressing the walls against each other.
- Intrauterine balloon tamponade: insertion of a balloon filled with warm liquid (39–41 °C) for direct pressure on the vessels.
- Vascular control: ligation of the uterine or internal iliac arteries, or uterine artery embolization.
Briefly: answers to topical questions
What are the dosages, frequency, and routes of administration of uterotonics (oxytocin, carbetocetone, misoprostol) in postpartum hemorrhage?
In postpartum hemorrhage, intravenous or rectal administration of uterotonic drugs is used.
- Oxytocin (Oxytocinum) — 5 IU in 500 ml of isotonic sodium chloride solution intravenously.
- Carbetocin (Carbetocinum) — 1 ml slowly intravenously.
- Misoprostol (Misoprostolum) — 800–1000 mcg per rectum once.
Repeat administration of oxytocin is strictly prohibited if it proved ineffective the first time.
What clinical and hemodynamic criteria determine the severity grades of hemorrhagic shock in obstetrics?
To determine the stage of hemorrhagic shock, clinical indicators and the shock index are evaluated.
The following stages are distinguished:
- Compensated stage — blood loss greater than 15% of circulating blood volume (CBV). Characterized by increased heart rate, increased minute ventilation of the lungs, and arteriolar spasm.
- Decompensated stage — blood loss greater than 30% of CBV. Manifested by arterial hypotension (systolic blood pressure less than 50 mm Hg with a loss of more than 40% of CBV).
Additionally, general condition, pulse, respiratory rate and depth, as well as diuresis are monitored.
What is the complete obstetric management and staging of surgical intervention for diagnosed placenta accreta?
When true placental attachment (placenta accreta) is detected, attempts at manual separation must be stopped immediately.
The surgical intervention algorithm includes the following stages:
- Midline laparotomy and performance of fundal cesarean section (fetus is delivered without disturbing the placenta).
- Temporary balloon occlusion of the common iliac or uterine arteries.
- Excision of the affected uterine tissue area along with the embedded placenta en bloc within healthy myometrium.
- Metroplasty (reconstruction of the uterine wall).
If organ-preserving surgery is ineffective, hysterectomy is indicated.
Which specific congenital coagulopathies and acquired hemostatic defects (the “Thrombin” factor) most frequently cause postpartum hemorrhage?
The sources do not specify which hemostatic defects are the most frequent causes of postpartum hemorrhage. They indicate that congenital or acquired hemostatic defects may be the cause.
Among the specific conditions cited in the sources, the following are confirmed:
- von Willebrand disease — a congenital hemorrhagic diathesis.
- Werlhof's disease — idiopathic thrombocytopenic purpura, accompanied by hemorrhagic syndrome and bleeding in the placental and early postpartum periods.
DIC syndrome can accompany massive obstetric hemorrhage.
T-T-T-T: Tissue (retained fragments), Tone (hypotonia), Trauma (lacerations), Thrombin (coagulopathy).
Class and exam questions
What is the difference between uterine hypotonia and atonia?
Hypotonia is a reversible decrease in myometrial tone. Atony is a complete loss of contractility, an irreversible and extremely dangerous condition.
Can manual exploration of the uterine cavity be repeated in case of bleeding?
No, manual exploration and massage are performed strictly once. Repeating ineffective measures leads to wasted time and the development of coagulopathy.
What to do if placenta accreta is suspected?
It is necessary to immediately stop attempts at placental separation, as excessive efforts will lead to uterine perforation and massive bleeding.
What else to study on this topic
- Technique for performing bimanual uterine compression.
- Signs of placental separation (Schroeder, Küstner-Chukalov, Alfeld).
- Features of the management of the placental stage for the prevention of bleeding.
- Pathogenesis of DIC syndrome in massive obstetric blood loss.
- Technique of placing the B-Lynch suture and other types of compression sutures.
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