Postpartum complications

Bleeding in the early postpartum period

Massive uterine hemorrhage is one of the most formidable complications occurring immediately after the delivery of the placenta. In clinical practice, several key causes of its development are distinguished:

• Polyhydramnios. With excessive accumulation of amniotic fluid (echography shows an increase in the vertical pocket, for example, up to 10 cm), severe overdistension of the uterus occurs. In the placental and early postpartum periods, this leads to a decrease in the contractile capacity of the myometrium, resulting in uterine atony or hypotonia. An additional factor for hemorrhage is partial morbidly adherent placenta.
• HELLP syndrome. This severe complication of preeclampsia causes profuse coagulopathic hemorrhage. The pathogenesis is based on the depletion of the platelet pool (their level drops below 90–100×10⁹/L) due to microthrombus formation and endothelial damage, which triggers acute disseminated intravascular coagulation (DIC).
• Acute hepatitis B. At the peak of the infectious process, accompanied by pronounced intoxication and metabolic disorders, the probability of massive blood loss during and after labor is extremely high.

Infections and the historical background of combating them

Historically, postpartum infections (specifically, childbed fever or sepsis) were the leading cause of maternal morbidity and mortality.

• An immense contribution to the prevention of sepsis was made by the physician I. Semmelweis, who was the first to propose handwashing with a chlorine lime solution. The introduction of the basics of antisepsis made it significantly expanding the indications for operative delivery (cesarean section).
• In the first half of the 20th century in the USSR, an effective obstetric care system was established. The creation of antenatal clinics for dispensary observation and the introduction of pre-hospital monitoring made it possible to sharply reduce maternal mortality from postpartum infections, obstetric hemorrhages, and eclampsia.
• Today, sepsis remains on the list of severe systemic complications of preeclampsia, requiring close attention from obstetrician-gynecologists and intensivists.

Management of puerperae with viral infections

The presence of hepatotropic viruses or HIV in the mother dictates strict rules for postpartum management and the choice of feeding method:

• HIV infection. The main rule is the complete avoidance of breastfeeding. Putting the baby to the breast is not recommended, as this repeatedly increases the risk of virus transmission to the infant. Immediately after birth, the infant is transferred exclusively to formula feeding.
• Hepatitis A. Proceeds uneventfully; there is no risk of antenatal transmission of the pathogen to the fetus. Most women do not require active drug therapy, and vaginal delivery is preferred.
• Hepatitis B. Management is carried out jointly by an obstetrician-gynecologist and an infectious disease specialist in a specialized hospital. Vertical transmission of the virus occurs mainly during labor. While with HBsAg carrier status the risk of infection is about 10%, in acute hepatitis in the third trimester it reaches 70%. To prevent infection, newborns undergo passive-active immunization.

Complications of severe preeclampsia and HELLP syndrome

Preeclampsia and its extreme manifestation—HELLP syndrome (developing in 4–12% of patients with severe preeclampsia)—can lead to fatal consequences requiring intensive care after delivery.

1. Liver involvement. Blood flow blockage in the intrahepatic sinusoids leads to fibrin deposition and hepatocyte degeneration. Overdistension of Glisson's capsule causes pain in the epigastrium and right hypochondrium. The most dangerous complication is subcapsular hepatic hematoma. It can rupture under the slightest mechanical impact (increased intraabdominal pressure during labor, application of the Kristeller maneuver), leading to massive intraabdominal hemorrhage.
2. Hemolysis. A cardinal symptom. Destroyed erythrocyte fragments (schistocytes > 0.27%) are found in the blood, along with elevated levels of unconjugated bilirubin (> 12 g/L) and lactate dehydrogenase (> 600 IU/L).
3. Multiple organ dysfunction syndrome. In the postpartum period, acute renal failure, pulmonary edema, cerebral ischemia or edema may manifest, up to cerebral coma and hepatic encephalopathy.

Class and exam questions

What else to study on this topic

• Pathogenesis and laboratory criteria of HELLP syndrome (schistocytes, LDH, bilirubin).
• The impact of acute and chronic hepatitis B on the course of pregnancy and the fetus.
• Causes and diagnosis of polyhydramnios (exclusion of malformations and TORCH infections).
• History of the development of operative obstetrics (contribution of J. Simpson, G. Rein, F. Kehrer).
• Complications of severe preeclampsia affecting the central nervous system, kidneys, and lungs.

Other topics in the "Obstetrics" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.