Pathological duration of pregnancy, labor

and postpartum period

Prepared by N. Bahniy
The main causes of hemorrhages in
the first half of pregnancy
Spontaneous abortion
Ectopic pregnancy
Hytadidiform Mole
 Abortion is the
termination of a
pregnancy before
viability, typically defined
as 22 weeks from the first
day of the last normal
menstrual period or a
fetus weighing less than
500 g and its height is
less than 25 cm.
Classification of abortions
 Spontaneous
 Induced
Clinically:
 Threatened
 Initial
 Inevitable
 Completed
 Incomplete
 Missed
 Causes of spontaneous abortions
1. Maternal
 Infections – Listeria, Mycoplasma hominis, Ureaplasma
urealyticum, Toxoplasmosis,Rubella, Cytomegalovirus.
 Endocrine factors - luteal phase inadequacy,
HyperthyroidismDiabetes Mellitus
 Environmental factors
 Uterine abnormalities
2. Paternal - chromosomal abnormality in either parent.
3. Fetal - genetic abnormalities of the conceptus,
approximately half of which are autosomal trisomies.
Threatened abortion

Signs – lover abdominal pain.

In bimanual examination – cervix
is closed, enlargement of the
uterus corresponds with
gestational period

Management – conservative.
Initial abortion

Signs – lover abdominal pain,

bloody vaginal discharge.
In bimanual examination –
cervix is closed,
enlargement of the uterus
corresponds with
gestational period

Management – conservative.
Inevitable abortion
Signs – cramp abdominal pain
thanks to uterine contractions,
bloody vaginal discharge till
profuse hemorrhage.
In bimanual examination – cervix
is dilated, products of conception
are presented on cervical
channel, enlargement of the
uterus doesn’t correspond with
gestational period – smaller
Management –surgical – uterine
curettage.
Complete abortion – all products of
conception are expelled out of uterus
Signs - lover abdominal pain,
bloody vaginal discharge.
In bimanual examination –
cervix is dilated or closed,
enlargement of the uterus
doesn’t correspond with
gestational period – smaller.

Management–uterine curettage
 Incomplete abortion – retention of
some conceptus inside the uterus
Signs – lover abdominal pain,
bloody vaginal discharge.
In bimanual examination –
cervix is dilated, enlargement of
the uterus doesn’t correspond
with gestational period –
smaller, some products of
conception should be expelled
out.
Management–uterine curettage
Missed Abortion - retention of a failed
intrauterine pregnancy for an extended
period.
 Absence of uterine
growth and may have lost
some of the early
symptoms of pregnancy,
presented of dark bloody
discharge
 Although unusual, DIC
can occur.
Management –surgical –
uterine curettage
 Conservative treatment in the case of
threatened and initial abortion
 Bed rest
 Sedative drugs
 Spasmolitics – No-Spani,
Papaverini hydrochloride
 Analgetics – Analgin, Baralgin
 Progesterone – Utrogestan,
Duphastone,Endomerin
 Chorionic Gonadotropin
Hormone
 Vitamines – vit. E
 Hemostatics – Tranexamic
acid
 Stages of uterine curettage
Anesthesia - paracervical block or
general.
 Bimanual examination
 Disinfection of perineal region
 Speculum insertion
 Grasping the cervix for anterior lip
with a toothed tenaculum.
 Uterine probing- to identify the
status of the internal os and to
confirm uterine size and position.
 Dilation of the cervix by Hehar’s
dilators
 Uterine curettage by sharp curette
 ECTOPIC PREGNANCY

 Implantation outside
of the uterine cavity
is termed as ectopic
pregnancy
 !Ectopic pregnancy
is the leading cause
of maternal mortality
in the first trimester
Etiology of ectopic pregnancy
1.Mechanical Factors - prevent or retard passage of the fertilized ovum into
the uterine cavity include the following.
 1. Salpingitis,
 2. Peritubal adhesions subsequent to postabortal or puerperal infection
 3. Developmental abnormalities of the tube, especially diverticula,
hypoplasia.
 4. Previous ectopic pregnancy.
 5. Previous operations on the tube, either to restore patency
 6. Multiple previous induced abortions.
 7. Tumors that distort the tube, such as uterine myomas, adnexal masses.
2.Functional Factors - that delay passage of the fertilized ovum into the
uterine cavity.
 1. External migration of the ovum
 2. Menstrual reflux
 3. Altered tubal motility
 4. Cigarette smoking at the time of conception
3.Increased Receptivity of Tubal Mucosa to Fertilized Ovum.
4.Assisted Reproduction.
5.Failed Contraception.
Classification of ectopic pregnancy

According to localization:
 Tubal – isthmic, interstitial,ampullary
 Ovarian
 Abdominal
 Broad-Ligament pregnancy
 Cervical
According to clinical duration:
 Progressive
 Ruptured - Tubal rupture, Tubal abortion
Clinical signs of Ectopic Pregnancy
 Presence of Presumptive
and Probable signs of
pregnancy
 Irregular dark brown vaginal
bleeding
 Pain – from light to severe
 Syncope
 Dizziness
 Urge to defecate
 Signs of internal hemorrhage
- peritoneal irritation, shock
Pelvic examination in ectopic pregnancy

 Unilateralor bilateral exquisite tenderness

especially on motion of the cervix
 Adnexal mass
 Enlarged uterus
 Tenderness and painful of the posterior
fornix
Signs of internal
hemorrhages which
provoke hypovolemic
shock are the more
prominent the more
closely fertilized
ovum localized near
the uterus
Culdocentesis – is the simplest technique for
identifying hemoperitoneum

Bloody fluid that

does not clot result
of hemoperitoneum
resulting from an
ectopic pregnancy
Management of ectopic pregnancy
Surgical:
 linear salpingostomy
 segmentai resection
 Salpingectomy

Medical - Methotrexate,
folinic acid antagonist: if
the gestation is less than
6 weeks, the tubal mass
is not more than 3.5 cm in
diameter, and the fetus is
not alive
Signs of cervical pregnancy
 uterine bleeding without
cramping after a period of
amenorrhea
 softened cervix
disproportionally enlarged
to a size equal to or
larger than the corpus
 complete confinement
and firm attachment of
the products of
conception to the
endocervix, snug internal
cervical os.
MANAGEMENT CERVICAL
PREGNANCY

 HYSTERECTOMY
 EMBOLIZATION
of A. UTERINAE
Hydatidiform Mole
 Is an abnormal
conceptus with
loss of villus
vascularity and
without an embryo
or fetus.
 Most of symptoms
are presented
thanks to markedly
elevated hCG levels.
Signs of Hydatidiform
Mole
 Vaginal bleeding with molar
elements
 Preeclampsia
 In pelvic exam - uterus
larger than expected,
Ovarian enlargement due to
bilateral theca lutein cysts
 Ultrasonography – “snow-
storm” appearance
Treatment – vacuum
aspiration, utreine
curretage
BLEEDING IN THE SECOND HALF OF
PREGNANCY - PLACENTA PREVIA
 Definition: abnormal location of the placenta over, or
in close proximity to, the internal cervical os.
Placenta previa can be categorized as:
 complete or total - if the entire cervical os is covered;
 partial - if the margin of the placenta extends across
part but not all of the internal os;
 marginal , if the edge of the placenta lies adjacent to the
internal os;
 low lying - if the placenta is located near but not directly
adjacent to the internal os till 6 cm.
Etiology of placenta previa - abnormal vascularization
Clinical findings and Diagnosis

 Painless bleeding
 Ultrasonography
has been of
enormous benefit in
localizing the
placenta.
 Careful vaginal
examination – in
labor.
Management of patients with placenta
previa during pregnancy
Initial hospitalization with hemodynamic
stabilization, followed by expectant management
until fetal maturity has occurred.
 Bed rest
 Vitamins – for increasing of vascular strenght:
Rutin, Ascorutin, Ca
 Bloodstoping agents – Vicasol, Dicinon,
Tranexam
 Smasmolytics in the case of pregnancy
interruption
Management of patients with placenta
previa in labor
 Complete – cesarean
section;
 Partial, marginal, low
lying - artificial rupture of
the membranes and
oxytocin induction of
labor.
If the hemorrhage
exceeds 250-300ml –
immediate cesarean
section
PLACENTAL ABRUPTION
- premature separation of the normally implanted placenta from the
uterine wall.

 Etiology: when there is hemorrhage into the decidua

basalis, leading to premature placental separation and
further bleeding. The cause for this bleeding is not
known.
Patients at risk:
 Maternal hypertension
 Multiply pregnancy
 Polyhidramnios
 External trauma
 Preterm prematurely ruptured membranes
 Cigarette smoking
 Cocaine abuse
 Uterine leiomyoma,
 Clinical findings and Diagnosis
 External bleeding can be profuse or
there may be no external bleeding
(concealed hemorrhage)
 Uterine tenderness
 Back pain
 Fetal distress
 Uterine hypertonus or high-
frequently contractions
 Dead fetus when placenta is totally
shared.
 Coagulation disorders
 Ultrasonography can help in
diagnosis
Management of Placental Abruption

 When the fetus is mature - hemodynamic

stabilization and delivery by cesarean section.
In the second stage of labor – immediate
delivery by forceps application, vacuum, total
breech extraction.
 When the fetus is immature and blood loss is <
250 ml – very close observation, coupled with
facilities for immediate intervention, can be
practiced.
Couvelaire uterus –
Uteroplacental Apoplexy
Differential characteristics between placenta previa and
abruptio placentae
Characteristics Placenta previa Abruptio Placenta
Magnitude of blood loss Variable Variable
Duration Often ceases within 1-2 Usually continues
hours
Abdominal discomfort None Can be severe, pain
Absent Tachycardia, then
Fetal heart rate pattern bradycardia; loss of
on electronic monitoring variability; decelerations
frequently
present; intrauterine
demise not rare

Coagulation defects Rare Associated, but

infrequent; DIG often
severe when present
Cocaine use

Associated history None Abdominal trauma;

maternal hypertension;
HEMORRHAGE IN THE THIRD STAGE OF
LABOR AND EARLY PUERPERAL PERIOD
 Postpartum hemorrhage is defined as blood
loss in excess of physiologic blood loss at the
time of vaginal delivery – 0,5% from body
weight.
 Postpartum hemorrhage before delivery of the
placenta is called third-stage hemorrhage.
 Postpartum hemorrhage after delivery of
placenta during the first two hours is called as
hemorrhage in early puerperal stage.
Mechanisms of Hemorrhage stopping after placental
separation

 uterine contractions – calibers of ruptured

vessels decreases during uterine
contractions;
 formation of thrombs, especially in the
region of placental site;
 torsion of thin septs in which vessels are
situated.
Causes of Postpartum Hemorrhage

 uterine atony
 genital tract trauma
 bleeding from the placental site (retained
placental tissue, low placental implantation,
placental adherence, uterine inversion)
 coagulation disorders
Predisposing factors for uterine atony

1. Overdistended uterus – multiple fetuses,

Hydramnios, distention with clots.
2. Anesthesia or analgesia – halogenated agents,
conducted analgesia with hypertension.
3. Exhausted myometrium – rapid labor, prolonged
labor, oxytocin or prostaglandin stimulation.
4. Chorionamnionitis.
4. Previous uterine atony.
 Uterine atony - total absence of uterine
contractions into the external irritation.
 Uterine hypotony - inadequate uterine
contractions on the external irritation. In the
pauses between uterine contractions a uterus is
soft.
 But blood form clots in the case of uterine
hypo- or atony. These clots are stored in the
uterine cavity that’s why a uterus is enlarged in
sizes.
 CONTRICTILE DRUGS
Ergometrine/
15-methyl
Oxytocin Methyl-
Prostaglandin F2α
ergometrine
Dose and route IV: Infuse 20 units in IM or IV (slowly): 0.2 IM: 0.25 mg
1 L IV fluids at 60 mg
drops per minute
IM: 10 units
Continuing dose IV: Infuse 20 units in Repeat 0.2 mg IM 0.25 mg every 15
1 L IV fluids at 40 after 15 minutes minutes
drops per minute If required, give 0.2
mg IM or IV (slowly)
every 4 hours
Maximum dose Not more than 3 L of 5 doses (Total 1.0 8 doses (Total 2 mg)
IV fluids containing mg)
oxytocin
Precautions/ Do not give as an IV Pre-eclampsia, Asthma
Contrain-dications bolus hypertension, heart
disease
 PABAL – I/V BOLUS

ОXYTOCIN ANALOG
 1мл – 100 мкг
карбетоцину
 Діє через 3 хв
 1 ін’єкція на 6 годин
MISOPROSTOL

Acts in 30min and last

4-6 hours
FIGO – 1000мкг

Hemorrhages
prevention !!!!
Tranexamic acid
Antifibrinilytic

 50 mg/ml

 15-20 mg/kg
REMESTIP - VASOKONSTRICTOR
 0,2 -1, 0 MG every 4-
6 hours i/v bolus
Effect - 5-10 min
 Ligation of uterine arteries, ovarian
arteries, a. iliaca interna

 Hysterectomy
Antishock garment
Predisposing factors for Genital tract trauma

1. Complicated vaginal delivery.

2. Cesarean section or hysterectomy, forceps or
vacuum.
3. Uterine rupture; risk increased by: previously
scarred uterus, high parity, hyperstimulation,
obstructed labor, intrauterine manipulation.
4. Large episiotomy, including extensions.
5. Lacerations of the perineum, vagina or cervix.
Diagnosis and management of
Genital Tract Trauma
 Diagnosis – speculum
inspection
 Management -
ligation and suturing
of all ruptures of the
vagina, cervix and
perineum. In the case
of uterine rupture –
hysterectomy should
be performed
 Bleeding from placental implantation cite

1. Retained placental tissue – avulsed

cotyledon, succentuariate lobe

2. Abnormally adherent – accreta, increta,

percreta.
 Abnormal placenta adherent- any implantation of the placenta in
which there is abnormally firm adherence to the uterine wall thanks to
partial or total absence of the decidua basalis and imperfect
development of the fibrinoid layer (Nitabush’s membrane):

 placental villi are attached into

the basal layer - placenta
adhaerens;
 placental villi are attached to the
myometrium - placenta accreta;
 extensive growth of placental
tissue into the uterine muscle
itself – placenta increta;
 complete invasion through the
sickness of the uterine muscle to
the serosa or beyond – placenta
percreta.
 Classification of abnormal placental
adherence
 Complete or total placenta
accreta will not cause bleeding
because the placenta remains
attached
 Partial ( the abnormal adherence
involves a few to several
cotyledons)
 Focal (the abnormal adherence
involves a single cotyledon) type
may cause profuse bleeding, as
the normal part of the placenta
separates and the myometrium
cannot contract sufficiently to
occlude the placental site vessels.
Clinical findings, Diagnosis, Management

1. Absence of the signs of placental

separation during 30 minutes.

2. External bleeding – in the case of partial

adherence, absence of the bleeding – in
the case of total placenta accreta.
 In the case of placental
adherence bleeding stop,
but in the case of
placenta accreta, increta
and percrata increase.
That’s why in these cases
manual removal of the
placenta should be
stopped immediately and
hysterectomy should be
performed
 DIC - syndrome

 Prothrombin complex
concentrate

Recombinant VII clotting factor

 Fresh frozen plasma
80-90 mg/kg

 Proteolytic enzymes
inhibitors – KONTRYCAL,
GORDOX
Preeclampsia

Is defined as the development of

hypertension with proteinuria or
edema (or both).
 Assessment of different stages of PIH
severity
Mild Moderate Severe
Symptom of preeclampsia preeclampsia preeclampsia
evaluation

Edema Light, on + abdomen Considerabl

lower e
extremitas

Diastolic blood pressure 90-99 mm 100-110 mm > 110 mm

Hg Hg Hg

Proteinuria in a 24hours < 0,3 g / L 0,3-5 g / L 5 g/ L

collection sample
ECLAMPSIA

Is characterized typically by those

same abnormalities as severe
preeclampsia with the addition of
convulsions.