Atony of the uterus

The increased weakness of the muscular strength of the uterus, which in most cases is the cause of prolonged bleeding that accompanies a woman after childbirth, has its own medical term - atony of the uterus.

With normal muscle tone, the uterus immediately after the delivery is pulled together the spiral capillaries of the placental bed, which helps prevent extensive bleeding from the circulatory system, which is fairly tightly penetrating the tissues of the uterus. To support the relief of this problem, muscular contraction of the uterus is also called for. Advantageously, this process also avoids profuse bleeding from the spiral arteries of the placental bed. Blood coagulation in this situation has a mediocre effect. If the contractile force of the musculature of the uterus is broken - atony of the uterus is diagnosed.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Causes of atony of the uterus

At its core, atony of the uterus is the loss of the ability of the muscles of the uterus to contract, which plunges this female organ almost into a state of paralysis. Physicians share a complete and partial absence of the tone of the uterus. It is worth noting that under certain conditions the pathology under consideration can lead to the death of the mother in childbirth.

Medical workers are designated patients who fall into the risk zone for the onset of atony of the uterus, although there are cases of severe uterine bleeding in women who were not at risk.

So what are the categories of women attributed to problematic women in labor for the risk of postpartum hemorrhage and the likely causes of atony of the uterus:

• Women gave birth to a lot, as a result of increased stretching of muscle tissue.
• Polyhydramnios in pregnant women.
• If an ultrasound examination shows a large fetus.
• Artificial initiation of the onset of labor or an overdose of oxytocin. Excessive introduction uterotonikov, medicines called to cause artificial abortion or to activate labor activity during natural childbirth.
• Hemorrhagic shock.
• Prolonged process of obstetrics or, on the contrary, rapid resolution of labor.
• The cause of atony of the uterus can be the use during childbirth through cesarean section of general anesthesia. Especially this applies to drugs that have a relaxing effect on the muscles of the uterus.
• Congenital pathology of hematopoiesis, for example, thrombocytopenic purpura (hemorrhagic manifestations in the form of hemorrhages under the skin and bleeding).
• If a woman has a weak labor activity.
• Gestosis or late toxicosis in a woman during the period of gestation.
• The administration of magnesium sulfate significantly increases the risk of bleeding and increased bleeding.
• An individual characteristic of the woman's organism, manifested in a tendency to atony.
• Accumulation of a significant number of blood clots in the uterine cavity after the departure of the afterbirth.
• Placenta previa is a pathology that is characterized by abnormal attachment of the placenta to the walls in the lower parts of the uterus.
• Complicated birth.
• Untimely exit from the uterine cavity afterburn.
• Injury of the uterine walls during labor.
• A woman has postoperative scars.
• Genetically justified defectiveness of the neuromuscular system of the uterus, which is manifested by immaturity in development, low levels of hormones of the fetoplacental complex, reduced ovarian function.
• Inflammatory process, which caused pathological changes in myometrium.
• Benign or malignant tumors.
• Premature detachment of the normally located placenta.
• Disturbance of homeostasis equilibrium.
• Decreased vascular tone.
• Failure in the balance of the endocrine system.
• Embolism - blockage of the lumens of the vessels by the embolus, that is brought with the current of the blood particle, in this case it can be amniotic fluid.
• Pain shock.

[11], [12], [13]

Symptoms of atony of the uterus

Uterine bleeding is an integral part of the generic process. For the next four hours after birth, as doctors have established, the newly mummy loses an average of half a liter of this life-giving fluid (enough severe blood loss). And it fits into the norm! Immediately after the appearance of the baby in the light, a mother-in-waiting is placed on the abdomen, in which ice is placed. It is such a cryocompress that helps a healthy woman to compress the blood vessels faster, which stops further bleeding, and in a shorter period of time, uterine contraction occurs.

Over the next few days the contraction of the uterus continues until the moment when the organ will reach the dimensions corresponding to its parameters before conception. If this is not observed - this is the main symptoms of atony of the uterus. Severe hemorrhage, if you do not take emergency measures to stop this pathology, can lead to severe anemia or even death.

A healthy woman at a physical level feels the uterine contraction. It is especially clear in the first few days after the birth of the day. Immediately at the moment of feeding, the woman feels a slight weight in the lower abdomen, and it is quite natural to observe blood clots emerging from the uterus.

The situation is more complicated when atony of the uterus leads to latent internal bleeding. Especially it is dangerous if this process remains unnoticed for a long period of time. This clinical picture is the precursor of the subsequent strong, already external, bleeding. How not absurd it sounds, but doctors state that a much larger percentage of death is not due to the coping of heavy bleeding, but to ineffective attempts to stop the weak bloody discharge.

The main symptoms of atony of the uterus, which should alert the obstetrician, the host of delivery and the woman's postpartum period:

• Bleeding from the uterus is variable, of varying intensity.
• The liquid is released not in a homogeneous state, but with more dense clots.
• When palpation, the uterus is soft.
• Dimensional parameters of the uterus are increased due to the fact that it accumulates blood.
• Parameters of the uterus diminish badly.
• The level of spontaneous excitability of the uterus decreases.
• Its susceptibility to various pathogens (mechanical, pharmacological, thermal or chemical plan) decreases.
• In the nervous apparatus of the uterus, there is a state borderline between life and death of the cell (the inhibitory phase of parabiosis).
• Visually, one can ascertain the pallor of the patient.
• There is an increase in heart rate.

The physical and psychological state of a woman largely depends on the intensity of bleeding, the stability of hemodynamics, the qualifications and experience of the doctor. And the most important thing is the timeliness of the medical care provided.

Diagnosis of atony of the uterus

The main sign of this disease is a different intensity of bleeding, which begin in the process or after the passage of labor. But, based on the diagnosis of only this factor, it is not necessary, since the flow of blood from the birth can speak not only of bleeding as a sign of the disease, but also as a natural process that invests in the obstetrical norm. Simply during the passage of labor, blood can accumulate in the uterine space (this is due to the individual features of the structural structure of this female organ or its dystrophy due to other factors). Liquid volumes can reach up to one liter.

Therefore, to exclude such bleeding, the obstetrician-gynecologist conducts palpation of the abdomen to determine the true size of the uterus, since the liquid additionally stretches the walls.

Due to the fact that the volume of circulating blood during the period of gestation of the baby increases, very often the diagnosis of atony of the uterus passes in the postpartum period after serious blood loss. To confirm their guesses, the obstetrician-gynecologist feels the maternity's belly, when atony it is soft. Similarly, the doctor must at least "by sight" estimate the amount of blood lost. This is done for a period of at least an hour after obstetric care. If a health worker has a suspicion of atony of the uterus, the period during which the doctor more closely examines the postpartum symptoms of the parturient woman is lengthened.

When viewed with a gynecological mirror of the birth canal, the doctor can observe tissue ruptures affecting the vagina, cervix, perineum. The reaction of uterine tissues to pharmacological reactivity and spontaneous excitability is checked. In the case of atony of the uterus, these manifestations are smoothed out and become less noticeable. The gynecologist also checks the status of the function of hemocoagulation - a complex system of interaction of blood proteins, fibrins and platelets, which provides reliable protection of the woman's body from strong high-volume blood loss with minor injuries. Violation of this shaky balance can lead to a decrease in the level of platelets, prothrombin and fibrinogen in the mother's blood. At the same time, fibrinolytic activity increases with a decrease in prothrombin time. When examining the blood of a woman with atony of the uterus, the obstetrician-gynecologist can observe the differentiation of the products of the decomposition of fibrinogen and fibrin. Against the background of these changes, the rapid development of DIC syndrome (disseminated intravascular coagulation) characterized by a disruption of the blood clotting factor due to the massive release of thromboplastic substances from the tissue cells is seen.

In the case of untimely diagnosis of atony of the uterus and the lack of timely adequate treatment, the volume of blood loss increases substantially, and can lead to irreversible changes in the maternal organism. With further progression of this pathology, a woman dies of hemorrhagic shock or profuse blood loss.

[14], [15], [16], [17], [18], [19]

Treatment of atony of the uterus

Tactics like therapy, and prevention of atony of the uterus are quite similar. To preventive methods during obstetrics it is difficult to carry radical measures.

The main measures taken to stop bleeding can be classified according to the functional orientation into three types:

• To prevent the development or sooner to stop the already developing disease, the prevention or treatment of atony of the uterus begins with the invasion of oxytocin, a sufficient concentration of which allows to accelerate the contractile activity of the uterus, preventing the development of atony.

Oxytocin belongs to the pharmacological group of drugs - the hormones of the posterior lobe of the pituitary gland. Advantageously, this drug is administered for intramuscular administration. If, after such a form of administration, the therapeutic effect does not occur or is poorly manifested, the attending physician in the prescribing sheet may change the form of the input to the intravenous intake of oxytocin into the maternity body. In this case, the drug should be injected very slowly, drip (at a rate of 125-165 ml / h). Dosage of the solution is attributed from 1 to 3 IU, for deliveries with caesarean section, oxytocin is injected directly into the uterus by an initial injection in the amount of five IU. If the pathology is complicated enough, the dosage can be increased to 5 - 10 IU. This drug is not used in concentrated form, since such an amount of active substance can lead to arterial hypertension, therefore in treatment therapy only a solution is used.

The drug is categorically contraindicated for administration in the case of diagnosis by ultrasound, which is usually performed just before the expected delivery, mismatch between the size of the pelvis and the size of the baby, as well as the "wrong" position of the fetus (transverse or obliquely). Do not use oxytocin if there is a real threat of rupture of the uterus.

Analogues of oxytocin are such medications as clostilbegite, triderm, hydrocortisone, nazonex, morning, norethin, methylergobrevin, methylergometrinclimodien, ginepristone and others.

The meteorin is injected by the nurse into the muscle or vein, but very slowly, since a rapid intravenous injection of the drug may trigger the onset of hypertension. This medicine is a very powerful drug, the therapeutic effect of which can be observed after a few minutes. The dosage of the drug depends on many factors, including the period of obstetrics.

If there is a second phase of childbirth (when the shoulder of the newborn appears in the perineum of the woman in labor), metergin is fed into the vein in the amount of 0.1 to 0.2 mg, but not later than the moment when the child has completely gone out. When conducting cesarean section using general anesthesia, the drug is applied at a rate of 0.2 mg.

If there is a clinical need for re-treatment, the drug can be re-introduced two hours after the first injection.

In the case of cesarean section, metergin is taken immediately after the extraction of the baby intravenously in an amount of 0.05-0.1 mg or intramuscularly 0.2 mg.

This drug is prescribed and taken only if the woman is in the hospital under the vigilant supervision of the treating doctor.

It is inadmissible to administer this medicine if the woman is only carrying her baby, in the first phase of childbirth (before the appearance of the baby's head), as well as in the case of nephropathy, sepsis, arterial hypertension, a disease associated with pathological narrowing of the peripheral vessels before the beginning of feeding the newborn baby. With great caution should be appointed with dysfunction of the kidneys and liver and in the case of stenosis of the mitral valve.

• Manipulation techniques are also used to activate uterine contraction and reduce bleeding. In the light of these activities, a uterus massage is performed, after which the woman's tummy is tightly tightened with a bandage or bandage. Massage is often used as a preparatory stage for other therapeutic activities. Tight rewinding in modern medicine is rarely used.
• In case of suspicion or diagnosis of atony of the uterus, the doctor resorts to surgical techniques to stop this problem.

Laparotomy (laparotomia mediana) or abdominal cortex is performed. This procedure is appointed if the bleeding has not stopped the two previous methods. After opening the peritoneal cavity, the obstetrician-gynecologist performs a ligation of the uterine arteries, in especially severe cases, a situation may occur when the surgeon decides to remove the uterus.

In case of severe bleeding, the medical staff should be ready to put the catheter into a large vein and carry out volumetric diffusion with pre-prepared donor blood (at the observation stage the pregnant woman in the women's consultation must determine the blood group of the woman and make compatibility tests immediately before birth).

The choice of tactics for treatment of atony of the uterus is purely individual and depends on many different indicators, having analyzed which the right decision can only be made by a qualified specialist, taking into account the plans of the parturient woman for future procreation.

Prevention of atony of the uterus

Preventive measures in the prevention of this pathology are akin to the therapeutic treatment of this disease, but there are still differences. Prevention of atony of the uterus includes several items:

• Qualification of obstetrician - gynecologist, who takes delivery, should be sufficient to ensure that he gives obstetrics at a sufficiently high level: do not press on the abdomen, performing palpation of the uterus. In order not to cause atony of the uterus, it is not necessary to pull and pull the umbilical cord during the delivery.
• If a woman is in her health at risk for this disease, she is given oxytocin in a certain period of labor, allowing more active development of the uterus to contract, stopping bleeding blood vessels.
• Before the birth, during the period of the baby's birth, a qualified hematologist develops a sheet of sequential actions for the introduction of glucocorticoids (steroid hormones produced by the adrenal cortex) and donor plasma, which takes effect if the woman gives birth to profuse bleeding.

In order not to allow the need to connect atony therapy of the uterus, especially radical, it is better to prepare the female organism for delivery in advance and carry out preventive measures in the course of their course.

Prognosis of atony of the uterus

How much humanity exists, so many women have to go through childbirth. Still some hundred years ago, the death rate among women in childbirth was quite high, and only modern medicine has learned to cope with many pathologies that are manifested in a pregnant woman during her childbearing or directly in the course of childbirth itself. Atony of the uterus is one of the diseases from which no woman is insured. Therefore, only the high professionalism of the medical team of the host of delivery and the attitude of the mother to the birth of her child can make a prognosis of atony of the uterus favorable.

Otherwise, if the woman did not register with a woman's consultation and did not undergo the necessary examinations (establishing her anamnesis, blood type and test compatibility), or an obstetrician-gynecologist who does not have enough experience, the situation can be deplorable, even fatal for woman.

A woman who is a mother giving life to a new person in this exciting moment can lose her life. And the cause of this outcome can be atony of the uterus, manifested by virtue of the confluence of certain factors in the postpartum period. What can I advise future mothers in the light of this article? First of all, the outcome of the birth of the baby depends on the health, lifestyle and attitude to the pregnancy of the future young mother. If she was initially healthy and followed all the recommendations of the doctor during the entire pregnancy, then she should only advise, in advance, to determine the clinic in which she would like to see the birth of her baby. Selecting this specialized medical institution, it is worth inquiring about the level of qualification of her medical staff in those women in labor who have already passed this way in this maternity ward. If a woman has health problems, the more it is to take care of a good clinic and that doctor who will help your baby to appear on this world. Thus, the risk of obtaining a diagnosis of atony of the uterus will be significantly reduced. And even if the bleeding happened, an experienced team of doctors will do everything to solve this problem as quickly as possible, while preserving the health of the baby and his mother!