Labor complications

Thrombotic complications in obstetrics

Thrombosis is one of the most severe complications. Its pathophysiological basis is Virchow's triad, the severity of which is significantly amplified in complicated courses of pregnancy and labor.

Key risk factors are divided into several groups:

• Extragenital pathology: hypertension, kidney disease, rheumatic heart valve disease, and the presence of artificial heart valves.
• Obstetric issues: preeclampsia, as well as purulent-septic processes in postpartum women.
• Thrombophilia (genetic and acquired): plays a crucial role. This includes antiphospholipid syndrome, factor V Leiden and prothrombin mutations, antithrombin III deficiency, and protein C and S deficiencies.
• Mode of delivery: cesarean section increases the risk of thrombosis to 2.2–3.0% compared to 0.08–1.2% in vaginal delivery.
• Additional factors: age over 35, high parity, obesity, prolonged immobilization, and a history of thrombosis.

Superficial vein thrombophlebitis: clinical presentation and management

Superficial thrombophlebitis manifests as skin erythema, local hyperthermia, and painful induration along the affected vessel. The gold standard for diagnosis is lower extremity vascular ultrasound (Doppler ultrasonography, angiosonography). This method is completely safe for pregnant women, performed quickly, and highly informative.

Management tactics are determined in conjunction with a surgeon and strictly depend on the level of the lesion:

1. Conservative therapy (for lesions of the calf and lower third of the thigh): local application of cold in the first three days, ointment applications (sodium heparin, troxerutin, phenylbutazone), elevation of the legs, and elastic compression. Pharmacotherapy includes venotonics, antiplatelet agents, microcirculation-improving drugs, and anti-inflammatory agents. Anticoagulants during pregnancy are indicated only in cases of proven pathological hypercoagulation or a history of thromboembolism.
2. Surgical treatment: necessary for ascending thrombophlebitis of the great saphenous vein due to the high risk of thromboembolism. Ligation of the saphenofemoral junction is performed (Trojanov–Trendelenburg operation).

To prevent venous stasis and blood reflux during pushing, elastic bandaging of the legs is mandatory both during labor and in the postpartum period.

Intrauterine synechiae and their consequences

Intrauterine adhesions (synechiae) frequently develop in patients with a complicated postpartum or post-abortion period. To prevent their formation, "blind" curettage for retained placental tissue or ovum is strictly prohibited—targeted hysteroscopy is indicated for the gentle removal of the pathological focus.

If synechiae have already formed, they are hysteroscopically dissected under strict ultrasound guidance (or laparoscopy in cases of significant obliteration). To prevent recurrences, the following are used:

• Mechanical barriers: insertion of a Foley catheter for 1 day, an intrauterine device (Lippes loop) for at least 1 month, or special anti-adhesion gels.
• Medical support: high-dose estrogen-progestin therapy for 3–6 months for adequate endometrial regeneration.

The poorest prognosis for the recovery of reproductive function and the highest risk of recurrence are observed in intrauterine adhesions of tuberculous etiology. Pregnancy following treatment proceeds with high risks: about 1/3 of cases end in spontaneous abortion, 1/3 in preterm labor, and in the remaining third, placental pathology is diagnosed (placenta accreta or placenta previa).

Uterine septum

This is a congenital malformation in which the uterine cavity is divided into two hemi-cavities by a septum of varying length. The anomaly is detected in 2–3% of women in the general population and accounts for 48–55% of all female genital malformations.

The main clinical manifestation of the pathology is miscarriage (infertility is less common). The risk of fetal loss in the first trimester reaches 28–60%, decreasing to approximately 5% in the second trimester. In obstetric practice, the presence of a septum is frequently associated with preterm labor and impaired uterine contractility during delivery.

Class and exam questions

What else to study on this topic

• Pathogenesis of antiphospholipid syndrome (APS) in obstetrics
• Genetic thrombophilias: Factor V Leiden mutation and protein C/S deficiency
• Surgical technique of the Trendelenburg operation
• Differential diagnosis of tuberculous uterine lesions
• Management of labor in uterine contractile dysfunction

Other topics in the "Additional Topics" section

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