Abnormal Uterine Involution May Lead to Atony and Postpartum Hemorrhage: A Hypothesis, With Review of the Evidence.

Uterine involution has 2 major components-(1) involution of vessels; and (2) involution of myometrium. Involution of vessels was addressed by Rutherford and Hertig in 1945; however, involution of myometrium has received little attention in the modern literature. We suggest that the pathophysiology of myometrial involution may lead to uterine atony and postpartum hemorrhage. The myometrium dramatically enlarges due to gestational hyperplasia and hypertrophy of myocytes, caused by hormonal influences of the fetal adrenal cortex and the placenta. After delivery, uterine weight drops rapidly, with physiologic involution of myometrium associated with massive destruction of myometrial tissue. The resulting histopathology, supported by scientific evidence, may be termed "postpartum metropathy," and may explain the delay of postpartum menstrual periods until the completion of involution. When uterine atony causes uncontrolled hemorrhage, postpartum hysterectomy examination may be the responsibility of the perinatal pathologist.Postpartum metropathy may be initiated when delivery of the baby terminates exposure to the hormonal influence of the fetal adrenal cortex, and may be accelerated when placental delivery terminates exposure to human chorionic gonadotrophin (HCG). This hypothesis may explain why a prolonged third stage of labor, and delays in management, are risk factors for severe hemorrhage due to uterine atony.

Smooth muscle 22α deficiency impairs oxytocin-induced uterine contractility in mice at full-term pregnancy.

Smooth muscle 22α (SM22α, namely Transgelin), as an actin-binding protein, regulates the contractility of vascular smooth muscle cells (VSMCs) by modulation of the stress fiber formation. However, little is known about the roles of SM22α in the regulation of uterine contraction during parturition. Here, we showed that contraction in response to oxytocin (OT) was significantly decreased in the uterine muscle strips from SM22α knockout (Sm22α-KO) mice, especially at full-term pregnancy, which may be resulted from impaired formation of stress fibers. Furthermore, serious mitochondrial damage such as the mitochondrial swelling, cristae disruption and even disappearance were observed in the myometrium of Sm22α-KO mice at full-term pregnancy, eventually resulting in the collapse of mitochondrial membrane potential and impairment in ATP synthesis. Our data indicate that SM22α is necessary to maintain uterine contractility at delivery in mice, and acts as a novel target for preventive or therapeutic manipulation of uterine atony during parturition.

INVESTIGACIÓN DE LA INCIDENCIA Y COMPLICACIONES DEL PERIPARTO DE EMERGENCIA HISTERECTOMÍA / 9 INVESTIGATION OF INCIDENCE AND COMPLICATIONS OF EMERGENCY PERIPARTUM HYSTERECTOMY

Introduction: The emergency peripartum hysterectomy is a high-risk surgery, which is mostly performed after vaginal delivery or Cesarean section. Given the importance of complications and mortality of pregnant mothers for the health system, the present study aimed to investigate the incidence and complications of emergency peripartum hysterectomy in general and teaching hospitals of Zahedan University of Medical Sciences. Materials and Methods: In this cross-sectional descriptive-analytic study, after obtaining the Ethics Committee approval, the medical record of patients with emergency peripartum hysterectomy admitted to Ali ibn Abitaleb hospital of Zahedan for pregnancy termination during 2017-2018 were investigated. were studied. After evaluating demographic characteristics, including age, education, and occupation, causes, and complications of emergency hysterectomy were investigated. Finally, data were analyzed by SPSS software. Results: Out of 2438 cases, 50 cases of hysterectomy were investigated. The mean age of mothers and the average number of pregnancies was 31.06±5.21 and 5.72±2.31, respectively. In this study, 35 cesarean sections (70%) and 15 normal vaginal delivery (30%) were recorded, with only 2% leading to emergency hysterectomy. The most common causes of emergency hysterectomy included placenta accreta (28%), uterine atony (24%), and uterine rupture (20%). The complications also included fever (24%), coagulopathy (14%), and wound infection (12%). Conclusion: Placenta accreta and uterine atony are the most important causes of hysterectomy. The most common complications of emergency hysterectomy are fever, coagulopathy, and wound infections. A decrease in elective caesarean delivery and further encouraging to natural vaginal delivery could significantly reduce the incidence of peripartum hysterectomy and maternal mortality.

[Risk factors of evolution of postpartum hemorrhage towards severe postpartum hemorrhage: A case-control study]. / Factores de riesgo de la evolución de la hemorragia posparto a hemorragia posparto severa: estudio de casos y controles.

OBJECTIVE: To describe the incidence and risk factors for evolution of postpartum haemorrhage towards severe. MATERIAL AND METHODS: Epidemiologic, observational, analytical, case-control study was done from total data of deliveries in Complexo Hospitalario de Ourénse between January 1st 2004 and June 30th 2014. Mann-Whitney U test was used to determine the differences between cases and controls. The statistical analyses were made with the informatic programs Spss 15.0 y Epidat 3.0. We considered statistical significance for p < 0.05. RESULTS: The initial size of the sample was 17,116 deliveries from which we selected 150 patients with the diagnosis of postpartum haemorrhage. The incidence for HPSe form all deliveries was 3.3% reaching 36% of the total of postpartum haemorrhages. 79.63% of HPSe showed symptoms withing the first 24h postpartum, but we found that 20.37% debuted as secondary postpartum haemorrhages. BMI ≥ 35, hypertensive gestational manifestations, labor's second phase ≥ 120 minutes and weight at birth > 4000 g presented statistical significance as risk factor for evolution to severe postpartum haemhorrage. The relative risk for evolution towards HPSe was 2.81 for instrumental delivery and 3.55 for cesarean section. The most prevalent etiology was uterine atony. CONCLUSION: The incidence of HPSe in our hospital is low, as well as secondary maternal mortality. The major risk factor for the appearance of the clinical symptoms is cesarean section, followed, in less proportion by instrumental delivery. It is possible for the HPSe to make its appearance delayed after delivery, usually secondary to infrequent and non well-known clinical presentations.

Hemorragia obstétrica manejada con balón de Bakri / Obstetric hemorrhage management with the Bakri SOS balloon

Antecedentes: La Organización Mundial de la Salud reporta que existen en el mundo 536.000 muertes maternas al año, de las cuales 140.000 son originadas por hemorragia obstétrica, representando el 25% del total de dichas muertes. En México, se considera la segunda causa de muerte materna, con una tasa de mortalidad de 14,3 por 100.000 nacidos vivos. Objetivo: Conocer el porcentaje de éxitos de las pacientes con hemorragia obstétrica tratadas con balón de Bakri en el Instituto Nacional de Perinatología. Material y métodos: Se analizó una serie de casos, durante 2 años (2009-2011) en pacientes complicadas con hemorragia obstétrica, las cuales recibieron manejo conservador con balón de Bakri. Se encontró a 19 pacientes y se describieron los antecedentes obstétricos, personales, control prenatal, atención obstétrica, parámetros de laboratorios y desenlace perinatal. Resultados: El porcentaje de éxito con el balón de Bakri fue del 95% y solo el 5% se consideró fallido, ameritando histerectomía obstétrica. La pérdida hemática promedio fue 1.290 cc, con diferencia de 4 g/dl en los controles de hemoglobina pre- y posquirúrgicos. Dos días promedio de estancia en unidad de cuidados intensivos. El peso promedio de los recién nacidos fue 2.580 g y el 63% fue de sexo femenino. No se reportaron complicaciones por el uso del balón de Bakri. Se realizó una fórmula para estimar el llenado de balón en cc = 41 + (11 × semanas de gestación). Conclusión: El uso del balón de Bakri puede ser útil en el manejo conservador ante una hemorragia obstétrica con una tasa considerable de éxito y sin reportes de complicación debida al uso

Background: The World Health Organization reports that 536,000 maternal deaths occur per year, of which 140,000 are caused by obstetric hemorrhage, representing 25% of all maternal deaths. In Mexico, obstetric hemorrhage is the second cause of maternal death, with a mortality rate of 14.3/100,000 newborns. Objective: To describe the success rate in obstetric hemorrhage patients treated with the Bakri SOS balloon in the National Institute of Perinatology. Material and methods: From 2009- 2011, data were collected from obstetric hemorrhage patients (n = 19) who were treated conservatively with the Bakri SOS balloon in the Institute. Data on obstetric and personal history, prenatal care, obstetric care, laboratory values and perinatal outcomes were obtained. Results: The success rate with the Bakri SOS balloon was 95%, with a failure rate of only 5%; these patients required further hysterectomy. The mean blood loss was 1,290 cc, with a difference of 4 g of hemoglobin before and after surgery. The mean length of stay in the intensive care unit was 2 days. The mean birth weight was 2,580 g, and 63% of the neonates were females. There were no incidents or complications with the use of the Bakri SOS balloon. The formula to estimate balloon filling was cc = 41 + (11 × gestational age). Conclusion: The Bakri SOS balloon can be helpful to treat obstetric hemorrhage and has high success rates and no complications

Complete tamponade system for management of severe postpartum vaginal haemorrhage due to uterine atony.

A 30-year-old, 39 weeks pregnant, multiparous woman with single fetus, attended our obstetric clinic with complete cervical dilation in intractable mentum anterior presentation. The fetus was delivered by caesarean section with vertical uterine incision under general anaesthesia and lithotomy position. After surgery, examination of the vagina revealed multiple, serious tears with severe haemorrhage. Vaginal bleeding could not be controlled by sutures and concurrently uterine atony developed, which could not be controlled with medical treatment. Owing to intractable bleeding from uterus and vagina, a complete tamponade system was used. After the instillation of the uterine balloon with 500 mL and vaginal balloon with 300 mL liquid, the bleeding was controlled. The estimated blood loss was 3200 mL. The vaginal wound healed well during the postoperative 2 weeks. A complete tamponade system may be an effective treatment method for treatment of postpartum haemorrhage owing to vaginal lacerations and uterine atony.

Exaggerated placental site, consisting of implantation site intermediate trophoblasts, causes massive postpartum uterine hemorrhage: case report and literature review.

Every year, 14 million cases of obstetric hemorrhage occur worldwide, causing 127,000 maternal deaths. About 75% of postpartum hemorrhage cases are due to atonic uterus, which is loss of uterine muscular tone or strength for contraction of the uterus after delivery. The prediction of atonic uterus is therefore important for the prevention of postpartum maternal death. However, prediction of occurrence of atonic uterus is difficult before delivery, because the precise pathophysiological mechanism to trigger this condition remains unclear. Here, we present a case of severe postpartum hemorrhage due to atonic uterus. A 35-year-old woman gave a birth by vaginal delivery to a healthy boy. However, due to intractable massive hemorrhage after the removal of the retained placenta, we performed supravaginal hysterectomy as the best option for survival. Pathological examination showed that implantation site intermediate trophoblasts (ISITs) formed unusually large clumps in the decidua, diagnosed as exaggerated placental site (EPS). EPS is thought to be a condition consisting of an excessive number of ISITs. ISITs are differentiated from a trophoblast lineage in the process of placenta formation. ISITs anchor the placenta to the maternal tissue and are considered to maintain pregnancy, but the postpartum role of these cells remains unclear. Excessive infiltration of ISITs, namely EPS, may cause postpartum atonic uterus. In this article, we also reviewed the literatures on EPS. The present case and other reported cases indicate that EPS causes mass formation in the uterus, continuous uterine bleeding, and massive hemorrhage, resulting in hysterectomy.

Fatal postpartum air embolism due to uterine inversion and atonic hemorrhage.

We report a case of a 19-year-old woman who developed a persistent uterine hemorrhage after spontaneous delivery of a healthy child. Emergency laparotomy was indicated and then begun under stable circulatory conditions. Cardiac arrest occurred during the course of massive manual compression and packing of the uterus. After successful resuscitation, a supracervical hysterectomy was performed. During the suturing of the remaining cervix, a second cardiac arrest followed. The procedure was completed under constant external heart massage. Resuscitation was terminated due to the persistence of widened pupils. An autopsy was ordered by the public prosecutor as the manner of death was declared to be unascertained. An X-ray and a CT scan prior to the autopsy showed extensive gas embolism in both arterial and venous vessels extending from the pelvic region to the head. During the autopsy, gas was collected by aspirometer from the right ventricle of the heart. The autopsy showed no additional relevant findings, and gas analysis confirmed the suspicion of air embolism. The histological examination of the excised uterus especially in the corpus/fundus revealed an edema of the local smooth muscle cells and dilated vessels showing no sign of thrombogenesis. Upon evaluation of the clinical records, it became evident that, in addition to uterine atony, there had been a complete uterine inversion. This inversion was manually repositioned. After this maneuver, manual compression was performed. The air embolism, thus, was a complication of the manual repositioning of the uterine inversion. There is no evidence for other possible entries of the detected gas. In order to perform an effective exploration, the availability of all clinical records should be mandatory for medico-legal investigations of unexpected postpartum deaths.

Sutura de B-Lynch: experiencia en el desarrollo de una nueva técnica quirúrgica / B-Lynch suture for postpartum hemorrhage: a new surgical technique

Antecedentes: La hemorragia postparto (HPP) continúa siendo una de las patologías más prevalentes en la morbimortalidad materna en todo el mundo, especialmente en los países subdesarrollados. Distintos protocolos de manejo y técnicas se han desarrollado en los últimos años para su control. La sutura de B-Lynch surge como una herramienta útil y reproducible. Objetivo: Demostrar los beneficios de la técnica para el control de la HPP. Método: Serie de 5 casos en los que se realizó la sutura de B-Lynch en el Servicio de Obstetricia y Ginecología del Hospital Carlos Van Buren. Se identifican 5 casos en los que se realizó la técnica. Resultados: En los 5 casos se logró exitosamente controlar la HPP y preservar el útero. Una de las pacientes logró un embarazo posterior exitoso. Conclusión: Nuestros resultados permiten afirmar que la técnica de B-Lynch es segura, útil y reproducible en el manejo de la HPP.

Background: The postpartum haemorrhage (PPH) continues to be a prevalent problem affecting maternal morbimortality all over the world, particularly in non-developed countries. Different protocols of management and new techniques have been developed through these last years to control and treat PPH. The B-Lynch suture appears to be a useful and reproductible tool. Objectives: To show the benefits of the technique in the management of PPH. Method: A retrospective review of five cases in which B-Lynch suture was made, with the postoperatory controls and histeroscopics evaluations. Results: In all cases, successfully PPH was controlled and the uterus preserved. In one patient a successfully pregnancy and delivery was achieved. Conclusion: The B-Lynch suture is secure, useful and reproducible technique in the management of PPH.

[B lynch suture for post partum heamorrhage due to uterine atony]. / Zastosowanie szwu lyncha typu b w leczeniu krwotoku poporodowego w przebiegu atonii macicy.

Uterine atony and concomittant massive haemorrhage is one of the most dangerous complications of labour. Conventional, conservative treatment approach comprising of oxytocics such as oxytocin, methergin or prostaglandins may fail in some cases, mandating surgical techniques, including hysterectomy. B Lynch compression uterine suture may be a safe and effective method of treatment in post partum heamorrhage and in most of cases may replace more complicated techniques. In this article, together with referring the technical aspects of this procedure, we present a case of successful treatment.

[Pathomorphological changes in the uterine wall in gestosis]. / Patomorfologicheskie izmeneniia stenki matki pri gestoze.

With the purpose of studying a morphological substrate of the uterine contractile function disorder in gestosis, an investigation was conducted designed to study biopsy specimens of the uterine wall having been taken during the cesarean section in 80 parturient women. The womb of those parturient women having mild and severe gestosis complicated by uterine inertia (40 observations) or premature dethachement of the normally situated placenta (8 cases) was studied together with that of controls (32 cases). The indentified micro-circulatory disturbances and alterative changes in the myometrium structures in gestosis are regarded as one of the generalized blood circulation disorders, hemostasis (dissaminated intravascular blood coagulation) and systemic abnormalities of metabolism presenting as a multiorgan failure developing in the pathology under consideration. Microcirculatory disturbances and hypoxia-related dystrophic changes in the smooth myoblasts and connective tissue leading to its fibrosis--all these constitute a morphological substrate of changes in the contractile function of the womb.

[Fatal course of peracute fatty liver of pregnancy]. / Letaler Verlauf einer perakuten Schwangerschaftsfettleber.

A fatal case of acute fatty liver of pregnancy (AFLP) is reported. After admission, the patient was delivered within 3 hours. Routine laboratory investigation revealed acute liver insufficiency with advanced coagulopathy. Despite substitution therapy, the severe coagulation defect progressed to lethal intracerebral bleeding. Advanced AFLP can only be satisfactorily diagnosed in time, if non-specific symptoms or icterus lead to studies of blood chemistry, especially liver function tests, coagulation parameters (including platelet count, fibrinogen, AT III), blood glucose and renal function (including uric acid). This will enable an adequate management of the patient. The clinical problem of AFLP still remains that of early diagnosis.