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Delayed postpartum hemorrhage
Delayed postpartum hemorrhage A seven year study at St. Luke’s Hospital
JAIME
GORODOVSKY,
EDWARD
N.
GEORGE
WULFF,
St. Louis,
M.D.*
FLOREK,
M.D. JR.,
M.D.
Missouri
B L E E D I N G after the termination of labor is defined as postpartum hemorrhage, and when this occurs more than 24 hours after delivery of the placenta it is classified as a delayed postpartum hemorrhage. Usually the danger of immediate heavy bleeding may be discounted if there has been no serious hemorrhage within the first few hours following delivery. However, days and even weeks later, there may be episodes of more or less severe vaginal bleeding, frequently requiring active intervention. It is a relatively frequent complication, and is often seen after a completely normal labor and uneventful delivery.
curettage, an incidence of one in 226 deliveries. Hofmeister and Sauerg reported 41 cases in 20,836 deliveries, an incidence of one in 198 deliveries. Etiology Many factors are known to incite this delayed hemorrhage, such as ( 1) retained fragments in the uterus, placental secundines and placental polyps; (2) soft tissue injury; (3) myomas; (4) subinvolution of the placental site; (5) estrogen withdrawal after suppression of lactation; and (6) coital trauma. Stoeckel15 and Wolfe and Pedowitzl’ believe that detachment of thrombi from the placental site is the cause of this bleeding. Wolfe reported upon 2 cases of manual removal of the placenta, and these patients developed postpartum hemorrhage and required curettage. In the first of these 2 cases, upon microscopic examination, there were distended vessels with poor thrombus formation, and, in the second case, organization of the thrombus was delayed. Gainey, Nicolay, and Lapi frequently found early recanalization of the normally thrombosed vessels to be an etiological factor. McSweeney and Hassett13 report a case of cesarean section in which the patient died after developing severe hemorrhage on the twentythird postpartum day. Autopsy revealed large, open placental sinuses. Doolittle* believed that low-grade intrauterine infection
Incidence The occurrence of this complication is not rare and the reported cases in the literature attest to this fact. Lester and Bartholomewll mention an incidence of one case in 147 deliveries. Wolfe and Pedowitz18 had one case in 1,005 deliveries; these were due only to the retained secundines, proved histologically. Gainey, Nicolay, and Lap? reviewed 5,429 deliveries; of this number, 24 patients had postpartum hemorrhage that required
From the Department of Obstetrics and Gynecology, St. Luke’s Hosjital. Presented at the Quarterly Meeting the St. Louis Gynecological Society, April 11, 1963. *Present address: Insurgentes SW No. 42140301, Mexico 11, D.F.
of
612
Volume Number
88 5
Delayed
Table I. General pregnancies postpartum
characteristics of 46 which were followed by delayed hemorrhage
Primiparas Multiparas
16 30
38 plus weeks 36 to 38 weeks 20 to 36 weeks
38 6 2
Uncomplicated pregnancies Complicated pregnancies Bleeding Toxemia (mild)
36 10
6 4
must always be considered a possible cause of this bleeding. Hite and Hesseltiner suggested that postpartum bacterial invasion occurs in these cases, and they found multiple bacteria, such as staphylococci, nonhemolytic streptococci, and anaerobic bacteria of several types on postpartum intrauterine cultures. Kerr9 and Novak’* mention that retrodisplacement of the uterus may cause pelvic congestion with secondary hemorrhage. Bachmeyer and Stolll reported 421 cases of delayed postpartum hemorrhage of 36,732 deliveries, and suggested two possible causes; first, the presence of placental hormones which act upon the placental site and produce muscle block with consequent subinvolution of the placental site and hemorrhage; and, second, the presence of trophoblastic cells within the uterine vessels which produce erosion of the vessel wall. Their first theory is supported by Csapo’s’ animal experiments showing the local blocking effect of the placenta on the uterine muscle. A possible theory of the fibrinolytic effect was evidently ruled out by Kullander and KaIICnl” in their experiments with in vitro decidual cultures obtained from cases of abortion and cesarean section. In these cultures he could find no evidence of fibrinolytic effect. Gainey, Nicolay, and Lap? believe that in many instances the same factors are present in postpartum hemorrhage, whether caused by retained secundines or subinvolution of the placental site, and whether they occur a few hours after deliv-
postpartum
hemorrhage
613
ery or even a few weeks post partum. Williams,17 studying the histology of the placental site, showed that an adequate thrombus formation occurs only after 24 hours; therefore, any bleeding which occurs immediately after the third stage of labor has to be related to a poor contraction of the uterine muscle upon the large placental sinuses. It seems, therefore, that postpartum hemorrhage has to be divided into an early and a late stage. In the late stage the factors involved are different, since we are dealing with the reopening or recanalization of uterine vessels on the placental site. Present
study
Obstetrical case histories at St. Luke’s Hospital, St. Louis, Missouri, were reviewed from 1955 through 1961, during which time there was a total of 10,824 deliveries. During these 7 years 46 patients were found to have had late postpartum hemorrhage and required readmission for medical or surgical treatment. This represents an incidence of 1 case per 235 deliveries, which compares closely with the incidence in previously reported series. The average age of the patients in this series was 26 years, the youngest being 17 and the oldest 41 years. Sixteen patients were primiparas. Full-term pregnancies occurred in 38 patients, while 8 had premature deliveries (20 to 38 weeks). Two were delivered of stillborn babies. Ten pa-
Table II. General
characteristics of 46 deliveries which were followed by delayed postpartum hemorrhage
Delivery
Spontaneous Forceps Low or mid Breech
19 27 26
1
Placenta
Spontaneous separation Ergot Oxytocin drip Manual removal Blood
43 38 5 3
loss
Less than 300 cc. More than 300 C.C.
38 8
614
Gorodovsky,
Florek,
and
Wulff
.Am.
Table III.
Time interval between delivery and readmission in 46 cases of delayed postpartum hemorrhage Less
than one month 1 week or less 1 to 2 weeks 3 to 4 weeks More than one month 1 to 2 months 2 to 3 months Over 3 months
38 3 25
10 8 5 2 1
.March 1, 1961 J. Oh. & C;yrwc.
and this consisted of bed rest, oxytocin, blood replacement, and fluids. The average time spent in the hospital upon readmission was 3.6 days. The histology of 25 specimens removed at curettage revealed retained, degenerating, and necrotic placental tissue in 19 cases, degenerating decidua with no villi in 12 cases, normal endometrium in 2 cases, and insufficient tissue for a diagnosis to be made in 2 cases. Comment
tients had complicated pregnancies; prenatal bleeding episodes occurred in 6 patients and 4 had mild toxemia (Table I). Spontaneous deliveries occurred in 19 patients. Twenty-five patients were delivered by low forceps and one by midforceps, and one delivery was a frank breech with forceps applied to the aftercoming head. The placenta was delivered spontaneously in 43 patients, while in 3 patients the placenta was removed manually. Only 8 patients had an estimated blood loss of more than 300 C.C. (Table II). In 42 patients the postpartum course was uneventful, 2 patients had an unexplained temperature elevation above 38’ C. on 2 successive days, and 2 other patients developed endometritis with painful uteri, temperature elevation, and foul-smelling lochia. The time between delivery and the onset of symptoms averaged 21 days, with the longest being 96 days. Twenty-eight patients were readmitted within 2 weeks after delivery, 10 patients within 2 to 4 weeks after delivery, and 8 patients after an interval of more than one month (Table III). Upon readmission 10 patients were in shock because of acute blood loss, with lowered blood pressures and pulse rates varying from 100 to 160 per minute. The hemoglobin level varied from 8.0 to 11.8 Gm., and the hematocrit from 24 to 35 per cent. Fifteen patients received blood transfusions, including the 10 patients in shock. Thirty-five patients had surgical treatment consisting of curettage only; no hysterectomies were done. Conservative therapy was given to 11 patients,
Certainly a significant percentage of the cases of delayed postpartum hemorrhage is related to retained secundines and might be prevented. In our series of 46 cases of postpartum hemorrhage, retained placental tissue was the cause of the bleeding in 19 patients, or 41 per cent of the total. Hawkins” performs routine manual esploration of the uterus after delivery and in his series only one of 3,000 patients returned with postpartum hemorrhage. Lounsbury,l” who used more active treatment, did routine curettage after delivery on 715 patients and found retained secundines in 7.8 per cent. Routine manual or instrumental exploration of the uterus would certainly prevent late postpartum hemorrhage in a large number of cases; however, this would also represent unnecessary trauma for the vast majority of the patients. The above-mentioned authors are reporting their experiences from wellequipped hospitals with a well-trained house staff, and they had no complications after routine exploration of the uterine cavity. However, this procedure done routinely might lead to serious complications in less experienced hands and under less ideal surroundings. More attention should be given, therefore, to the third stage of labor and also to the placenta itself after its expression. In delayed detachment of the placenta, massage and traumatization of the uterus should be avoided, and gentle manual exploration of the uterine cavity should be performed. Careful inspection of the placenta must be done routinely. If there is any unusual irregularity of the maternal surface of the placenta or if the peripheral vessels
Volume 88 Number 5
Delayed
on the fetal surface are not intact, indicating a possible accessory lobe, manual exploration of the uterus is indicated. Careful observation of the third stage, and routine inspection of the placenta and membranes might, therefore, prevent postpartum hemorrhage in a large percentage of cases. Conclusion The prevention of delayed postpartum bleeding is easier than the treatment. The most effective treatment is curettage. The bleeding will stop following this procedure, whether it was caused by retained secundines or subinvolution of the placental site.
Curettage, but usually
postpartum
hemorrhage
therefore, is not only therapeutic.
615
diagnostic
Summary 1. Over a period of 7 years ( 1955 through 1961), 46 patients were admitted with delayed postpartum bleeding, an incidence of one in 235 deliveries. 2. Placental fragments were retained in 54 per cent of the cases of curettage. 3. Prevention of this complication should stress close inspection of the delivered placenta and active intervention if there is abnormal bleeding or suggestive fragmentation of the placenta.
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Bachmeyer, H., and Stall, P.: Deutsche med. Wchnschr. 85: 1789. 1960. Csapo, A., and Kuriyama, H.: AM. J. 0~s~. & GYNEC. 82:592, 1961. Dieckmann, W. J.: AM. J. OBST. & GYNEC. 54: 415, 1947. Doolittle, H. H.: Obst. & Gynec. 9: 422, 1957. Gainey, H. L., Nicolay, K. S., and Lapi, A.: AM. J. OBST. & GYNEC. 69: 558, 1955. Hawkins, R. J.: AM. J. OBST. & GYNEC. 69: 1094, 1955. Hite, K. E., and Hesseltine, C. H.: AM. J. OBST. & GYNEC. 53: 233, 1947. Hofmeister, F. J., and Sauer, J. P.: AM. J. OBST. & GYNEC. 75: 1120, 1958. Kerr, J. M.: Operative Obstetrics, Baltimore, 1937, William Wood & Company, p. 761. Kullander, S., and KPllen, B.: Acta obst. et gynec. scandinav. 40: I, 1961.
11. 12. 13. 14.
15. 16. 17. 18.
Lester, W. M., and Bartholomew, R. A.: AM. J. OBST. & GYNEC. 72: 1214, 1956. Lounsbury, J. B.: AM. J. OBST. & GYNEC. 74: 233, 1957. McSweeney, D. J., and Hassett, A. J.: New England J. Med. 230: 254, 1948. Novak, E.: Textbook of Gynecology, Baltimore, 1948, Williams & Wilkins Company, p. 600. Stoeckel, W.: Lehrbuch der Geburtshilfe, Jena, 1923, Gustav Fischer, p. 766. Treanor, T. A.: AM. J. OBST. & GYNEC. 83: 37, 1962. Williams, J. W.: J. A. M. A. 97: 523, 1931. Wolfe, S., and Pedowitz, P.: AM. J. OBST. & GYNEC. 53: 84. 1947.
8505 Delmar Blvd. St. Louis 24, Missouri
Discussion DR. orrhage
THOMAS M. of sufficient
MIER. Late postpartum hemseverity to require readmis-
sion to the hospital occurs once in about 500 deliveries. Although such rare causes of bleeding as a degenerating myoma or a small spurter in the episiotomy may be found to be the cause of the bleeding, by far the majority of cases can be divided almost equally into two groups. In the first group curettage reveals adherent placental fragments. Hemorrhage is controlled by removal
of these fragments. The second group, in which no placental tissue can be identified upon curettage, has been called to our attention by Dr. Rutherford and Dr. Hertig in 1945, and by Dr. Gainey of Kansas City in 1955, and has been referred to as noninvolution of the placental site in distinction to subinvolution of the rest of the uterus. The microscopic picture of subinvolution of the uterus has been described as an increased
616
Gorodovsky,
Florek,
and
Wulff
amount of elastic tissue around the blood vessels and muscle bundles together with the degenerated and obliterated vessels. However, study of the very few specimens removed because of delayed postpartum hemorrhage has failed to reveal any anatomical change that is not also prcsem in the postpartum uterus removed for other reasons. There has been no clue as to the etiology of this condition in relation to infection, parity, or difficulties of placental separation. Of the two cases that seem to meet the criteria of this condition that I have seen, one of them revealed, upon curettage, an area of adenomyosis in what I thought to be the placental site. Regeneration of the endometrium of the placental site occurs through ,growth of the surviving stumps of the endometrial glands. If the trophoblastic elements are restrained from growing into the region of the basal portion of these glands by a layer of canalized fibrin, the gland stubs remain intact to serve as a hub from which the new rndometrium grows to resurface the area. If the stumps of the glands have been destroyed, the resurfacing of the placental area is delayed until the endometrium grows in from the sides. This leaves the venous sinuses exposed, and sloughing of their unprotected, very thin walls results in profuse bleeding. The problem is not one of noninvolution of the uterus, itself, but one which involves epithelization of the placental site. In the reported cases endometrial glands arc not conspicuous in the curettings in spite of the fact that myometrial elements are ordinarily present. Any condition that destroys the gland stubs may delay cpithelization and hence give rise to this very formidable type of delayed postpartum hemorrhage. DR. ALFRED F. SUDHOLT, JR. After the child has been delivered, if the placenta has not already separated, I do a careful manual removal of the placenta and follow this with a thorough inspection of the uterine c.ivity. The patient is not redraped and I do not change gloves. If the placenta separates spontaneously, then I explore the uterine cavity before repairing the episiotomy. Sometimes it is necessary to remove pieces of membrane that are left behind by the manual removal. The removal of the membranes can easily be accomplished by covering the fingers with gauze and wiping the uterine cavity clean. Inspection of the cervix, either by manual palpation or by direct vision, is then accom-
March 1, 1964 Am. J. Obst. & Gym.
plished. Following this, a thorough inspection of the vagina is carried out to locate lacerations of the vagina other than in the episiotomy site. If any lacerations are found, they are repaired before the episiotomy is sutured. The episiotomy repair is the last procedure. This is always done after the placenta has been removed to prevent breakdown of the episiotomy site. Since using this routine, I have felt it unnecessary to continue the use of ergonovine maleate, post partum. In approximately 3,000 cases, labor has been treated in this manner, and in these only 5 cases of postpartum bleeding have occurred. These were due to subinvolution of the placental site caused by endometritis. The patients all required blood transfusion and curettage. The pathological findings were endometritis and degenerating dccidual tissue. DR. CAN. J. DREYER. This subject of delayed postpartum hemorrhage is of special interest to me since I was forced to remove one of these furiously bleeding uteri in order to save a life, some 8 or 9 years ago. I do believe that the complication is considerably more frequent than Dr. Mier states, my impression unfortunately being only an impression and not statistically supported. But on our srrvGce at St. h4ary’s Hospital, where we deliver some 400 babies per month, it seems there is almost weekly or twice-monthly one of these unfortunate returnees. Desiring to decrease the frequency of this problem in my personal practice, I have, for the last 8 years, been manually exploring and gauze-wiping the uterine cavity after the third stage, a procedure viewed with disdain and even horror by some of my friends, but lately becoming more generally accepted and respectable. The point I wish to make is that this maneuver not only diminishes the frequency of immediate hemorrhage, but drastically reduces the incidcnce of delayed hemorrhage from so-called subinvolution or retained secundines, because I can recall only one case of this in my practice when the maneuver was performed. In cases not so treated, because of local or pudendal anesthesia, or in cases of natural birth, the incidence remains elevated. DR. MA-IT H. BACKER, JR. Like others here present I have examined many placentas immediately postpartum and must confess I am not consistently able to tell whether or not the entire placenta has been expelled. One is impressed,
Volume 88 Number 5
however, with how promptly the patient becomes quite dry if the uterus is firm and empty, and no laceration exists. In cases of doubt, or certainly when the patient continues to have uterine bleeding, exploration of the endometrial cavity should be helpful. With patients delivered under regional (pudendal and caudal) anesthesia, however, the uterus is oftentimes too contracted to permit manual exploration without superimposing deep general anesthesia. In such cases I have found the insertion of a curved ring forceps into the endometrial cavity of the firmly contracted uterus, with the other hand guiding the fundus abdominally, a very rewarding procedure in terms of recovering pieces of placental tissue and/or membranes. It is also our practice to have patients report for the first postpartum visit 4 weeks after delivery. Patients who still have lochia rubra at this time will almost invariably be found to have retained membranes or placental tissue in the endometrial cavity, They usually also have a patulous cervix. We remove these secudines by means of an ovum forceps and light curet-
Delayed
postpartum
hemorrhage
617
tage, using no anesthesia or a few whiffs of trichlorethylene. After the uterus is thus emptied, bleeding stops promptly and uterine involution is hastened. This is especially helpful to patients who are anxious to revert, as soon as possible, to a normal menstrual pattern to facilitate the earlier practice of rhythm. DR. WULFF (Closing). Active prophylactic management of the third stage of labor by routine manual removal of the placenta and/or manual exploration of the uterine cavity is advocated by many authors, although, as noted in Dr. Sudholt’s experience, even this seemingly radical routine procedure has not eliminated delayed bleeding with its often necessary surgical intervention. Too often we neglect the proper inspection of the placenta, cervix, and vagina. As Dr. Florek pointed out, retained secundines are found in the large majority of these bleeding cases and we must teach that prevention of this condition undoubtedly can reduce its incidence. We must be aware of this possibility at the time of delivery and constantly alert to its etiological factors.
JAIME
GORODOVSKY,
EDWARD
N.
GEORGE
WULFF,
St. Louis,
M.D.*
FLOREK,
M.D. JR.,
M.D.
Missouri
B L E E D I N G after the termination of labor is defined as postpartum hemorrhage, and when this occurs more than 24 hours after delivery of the placenta it is classified as a delayed postpartum hemorrhage. Usually the danger of immediate heavy bleeding may be discounted if there has been no serious hemorrhage within the first few hours following delivery. However, days and even weeks later, there may be episodes of more or less severe vaginal bleeding, frequently requiring active intervention. It is a relatively frequent complication, and is often seen after a completely normal labor and uneventful delivery.
curettage, an incidence of one in 226 deliveries. Hofmeister and Sauerg reported 41 cases in 20,836 deliveries, an incidence of one in 198 deliveries. Etiology Many factors are known to incite this delayed hemorrhage, such as ( 1) retained fragments in the uterus, placental secundines and placental polyps; (2) soft tissue injury; (3) myomas; (4) subinvolution of the placental site; (5) estrogen withdrawal after suppression of lactation; and (6) coital trauma. Stoeckel15 and Wolfe and Pedowitzl’ believe that detachment of thrombi from the placental site is the cause of this bleeding. Wolfe reported upon 2 cases of manual removal of the placenta, and these patients developed postpartum hemorrhage and required curettage. In the first of these 2 cases, upon microscopic examination, there were distended vessels with poor thrombus formation, and, in the second case, organization of the thrombus was delayed. Gainey, Nicolay, and Lapi frequently found early recanalization of the normally thrombosed vessels to be an etiological factor. McSweeney and Hassett13 report a case of cesarean section in which the patient died after developing severe hemorrhage on the twentythird postpartum day. Autopsy revealed large, open placental sinuses. Doolittle* believed that low-grade intrauterine infection
Incidence The occurrence of this complication is not rare and the reported cases in the literature attest to this fact. Lester and Bartholomewll mention an incidence of one case in 147 deliveries. Wolfe and Pedowitz18 had one case in 1,005 deliveries; these were due only to the retained secundines, proved histologically. Gainey, Nicolay, and Lap? reviewed 5,429 deliveries; of this number, 24 patients had postpartum hemorrhage that required
From the Department of Obstetrics and Gynecology, St. Luke’s Hosjital. Presented at the Quarterly Meeting the St. Louis Gynecological Society, April 11, 1963. *Present address: Insurgentes SW No. 42140301, Mexico 11, D.F.
of
612
Volume Number
88 5
Delayed
Table I. General pregnancies postpartum
characteristics of 46 which were followed by delayed hemorrhage
Primiparas Multiparas
16 30
38 plus weeks 36 to 38 weeks 20 to 36 weeks
38 6 2
Uncomplicated pregnancies Complicated pregnancies Bleeding Toxemia (mild)
36 10
6 4
must always be considered a possible cause of this bleeding. Hite and Hesseltiner suggested that postpartum bacterial invasion occurs in these cases, and they found multiple bacteria, such as staphylococci, nonhemolytic streptococci, and anaerobic bacteria of several types on postpartum intrauterine cultures. Kerr9 and Novak’* mention that retrodisplacement of the uterus may cause pelvic congestion with secondary hemorrhage. Bachmeyer and Stolll reported 421 cases of delayed postpartum hemorrhage of 36,732 deliveries, and suggested two possible causes; first, the presence of placental hormones which act upon the placental site and produce muscle block with consequent subinvolution of the placental site and hemorrhage; and, second, the presence of trophoblastic cells within the uterine vessels which produce erosion of the vessel wall. Their first theory is supported by Csapo’s’ animal experiments showing the local blocking effect of the placenta on the uterine muscle. A possible theory of the fibrinolytic effect was evidently ruled out by Kullander and KaIICnl” in their experiments with in vitro decidual cultures obtained from cases of abortion and cesarean section. In these cultures he could find no evidence of fibrinolytic effect. Gainey, Nicolay, and Lap? believe that in many instances the same factors are present in postpartum hemorrhage, whether caused by retained secundines or subinvolution of the placental site, and whether they occur a few hours after deliv-
postpartum
hemorrhage
613
ery or even a few weeks post partum. Williams,17 studying the histology of the placental site, showed that an adequate thrombus formation occurs only after 24 hours; therefore, any bleeding which occurs immediately after the third stage of labor has to be related to a poor contraction of the uterine muscle upon the large placental sinuses. It seems, therefore, that postpartum hemorrhage has to be divided into an early and a late stage. In the late stage the factors involved are different, since we are dealing with the reopening or recanalization of uterine vessels on the placental site. Present
study
Obstetrical case histories at St. Luke’s Hospital, St. Louis, Missouri, were reviewed from 1955 through 1961, during which time there was a total of 10,824 deliveries. During these 7 years 46 patients were found to have had late postpartum hemorrhage and required readmission for medical or surgical treatment. This represents an incidence of 1 case per 235 deliveries, which compares closely with the incidence in previously reported series. The average age of the patients in this series was 26 years, the youngest being 17 and the oldest 41 years. Sixteen patients were primiparas. Full-term pregnancies occurred in 38 patients, while 8 had premature deliveries (20 to 38 weeks). Two were delivered of stillborn babies. Ten pa-
Table II. General
characteristics of 46 deliveries which were followed by delayed postpartum hemorrhage
Delivery
Spontaneous Forceps Low or mid Breech
19 27 26
1
Placenta
Spontaneous separation Ergot Oxytocin drip Manual removal Blood
43 38 5 3
loss
Less than 300 cc. More than 300 C.C.
38 8
614
Gorodovsky,
Florek,
and
Wulff
.Am.
Table III.
Time interval between delivery and readmission in 46 cases of delayed postpartum hemorrhage Less
than one month 1 week or less 1 to 2 weeks 3 to 4 weeks More than one month 1 to 2 months 2 to 3 months Over 3 months
38 3 25
10 8 5 2 1
.March 1, 1961 J. Oh. & C;yrwc.
and this consisted of bed rest, oxytocin, blood replacement, and fluids. The average time spent in the hospital upon readmission was 3.6 days. The histology of 25 specimens removed at curettage revealed retained, degenerating, and necrotic placental tissue in 19 cases, degenerating decidua with no villi in 12 cases, normal endometrium in 2 cases, and insufficient tissue for a diagnosis to be made in 2 cases. Comment
tients had complicated pregnancies; prenatal bleeding episodes occurred in 6 patients and 4 had mild toxemia (Table I). Spontaneous deliveries occurred in 19 patients. Twenty-five patients were delivered by low forceps and one by midforceps, and one delivery was a frank breech with forceps applied to the aftercoming head. The placenta was delivered spontaneously in 43 patients, while in 3 patients the placenta was removed manually. Only 8 patients had an estimated blood loss of more than 300 C.C. (Table II). In 42 patients the postpartum course was uneventful, 2 patients had an unexplained temperature elevation above 38’ C. on 2 successive days, and 2 other patients developed endometritis with painful uteri, temperature elevation, and foul-smelling lochia. The time between delivery and the onset of symptoms averaged 21 days, with the longest being 96 days. Twenty-eight patients were readmitted within 2 weeks after delivery, 10 patients within 2 to 4 weeks after delivery, and 8 patients after an interval of more than one month (Table III). Upon readmission 10 patients were in shock because of acute blood loss, with lowered blood pressures and pulse rates varying from 100 to 160 per minute. The hemoglobin level varied from 8.0 to 11.8 Gm., and the hematocrit from 24 to 35 per cent. Fifteen patients received blood transfusions, including the 10 patients in shock. Thirty-five patients had surgical treatment consisting of curettage only; no hysterectomies were done. Conservative therapy was given to 11 patients,
Certainly a significant percentage of the cases of delayed postpartum hemorrhage is related to retained secundines and might be prevented. In our series of 46 cases of postpartum hemorrhage, retained placental tissue was the cause of the bleeding in 19 patients, or 41 per cent of the total. Hawkins” performs routine manual esploration of the uterus after delivery and in his series only one of 3,000 patients returned with postpartum hemorrhage. Lounsbury,l” who used more active treatment, did routine curettage after delivery on 715 patients and found retained secundines in 7.8 per cent. Routine manual or instrumental exploration of the uterus would certainly prevent late postpartum hemorrhage in a large number of cases; however, this would also represent unnecessary trauma for the vast majority of the patients. The above-mentioned authors are reporting their experiences from wellequipped hospitals with a well-trained house staff, and they had no complications after routine exploration of the uterine cavity. However, this procedure done routinely might lead to serious complications in less experienced hands and under less ideal surroundings. More attention should be given, therefore, to the third stage of labor and also to the placenta itself after its expression. In delayed detachment of the placenta, massage and traumatization of the uterus should be avoided, and gentle manual exploration of the uterine cavity should be performed. Careful inspection of the placenta must be done routinely. If there is any unusual irregularity of the maternal surface of the placenta or if the peripheral vessels
Volume 88 Number 5
Delayed
on the fetal surface are not intact, indicating a possible accessory lobe, manual exploration of the uterus is indicated. Careful observation of the third stage, and routine inspection of the placenta and membranes might, therefore, prevent postpartum hemorrhage in a large percentage of cases. Conclusion The prevention of delayed postpartum bleeding is easier than the treatment. The most effective treatment is curettage. The bleeding will stop following this procedure, whether it was caused by retained secundines or subinvolution of the placental site.
Curettage, but usually
postpartum
hemorrhage
therefore, is not only therapeutic.
615
diagnostic
Summary 1. Over a period of 7 years ( 1955 through 1961), 46 patients were admitted with delayed postpartum bleeding, an incidence of one in 235 deliveries. 2. Placental fragments were retained in 54 per cent of the cases of curettage. 3. Prevention of this complication should stress close inspection of the delivered placenta and active intervention if there is abnormal bleeding or suggestive fragmentation of the placenta.
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Bachmeyer, H., and Stall, P.: Deutsche med. Wchnschr. 85: 1789. 1960. Csapo, A., and Kuriyama, H.: AM. J. 0~s~. & GYNEC. 82:592, 1961. Dieckmann, W. J.: AM. J. OBST. & GYNEC. 54: 415, 1947. Doolittle, H. H.: Obst. & Gynec. 9: 422, 1957. Gainey, H. L., Nicolay, K. S., and Lapi, A.: AM. J. OBST. & GYNEC. 69: 558, 1955. Hawkins, R. J.: AM. J. OBST. & GYNEC. 69: 1094, 1955. Hite, K. E., and Hesseltine, C. H.: AM. J. OBST. & GYNEC. 53: 233, 1947. Hofmeister, F. J., and Sauer, J. P.: AM. J. OBST. & GYNEC. 75: 1120, 1958. Kerr, J. M.: Operative Obstetrics, Baltimore, 1937, William Wood & Company, p. 761. Kullander, S., and KPllen, B.: Acta obst. et gynec. scandinav. 40: I, 1961.
11. 12. 13. 14.
15. 16. 17. 18.
Lester, W. M., and Bartholomew, R. A.: AM. J. OBST. & GYNEC. 72: 1214, 1956. Lounsbury, J. B.: AM. J. OBST. & GYNEC. 74: 233, 1957. McSweeney, D. J., and Hassett, A. J.: New England J. Med. 230: 254, 1948. Novak, E.: Textbook of Gynecology, Baltimore, 1948, Williams & Wilkins Company, p. 600. Stoeckel, W.: Lehrbuch der Geburtshilfe, Jena, 1923, Gustav Fischer, p. 766. Treanor, T. A.: AM. J. OBST. & GYNEC. 83: 37, 1962. Williams, J. W.: J. A. M. A. 97: 523, 1931. Wolfe, S., and Pedowitz, P.: AM. J. OBST. & GYNEC. 53: 84. 1947.
8505 Delmar Blvd. St. Louis 24, Missouri
Discussion DR. orrhage
THOMAS M. of sufficient
MIER. Late postpartum hemseverity to require readmis-
sion to the hospital occurs once in about 500 deliveries. Although such rare causes of bleeding as a degenerating myoma or a small spurter in the episiotomy may be found to be the cause of the bleeding, by far the majority of cases can be divided almost equally into two groups. In the first group curettage reveals adherent placental fragments. Hemorrhage is controlled by removal
of these fragments. The second group, in which no placental tissue can be identified upon curettage, has been called to our attention by Dr. Rutherford and Dr. Hertig in 1945, and by Dr. Gainey of Kansas City in 1955, and has been referred to as noninvolution of the placental site in distinction to subinvolution of the rest of the uterus. The microscopic picture of subinvolution of the uterus has been described as an increased
616
Gorodovsky,
Florek,
and
Wulff
amount of elastic tissue around the blood vessels and muscle bundles together with the degenerated and obliterated vessels. However, study of the very few specimens removed because of delayed postpartum hemorrhage has failed to reveal any anatomical change that is not also prcsem in the postpartum uterus removed for other reasons. There has been no clue as to the etiology of this condition in relation to infection, parity, or difficulties of placental separation. Of the two cases that seem to meet the criteria of this condition that I have seen, one of them revealed, upon curettage, an area of adenomyosis in what I thought to be the placental site. Regeneration of the endometrium of the placental site occurs through ,growth of the surviving stumps of the endometrial glands. If the trophoblastic elements are restrained from growing into the region of the basal portion of these glands by a layer of canalized fibrin, the gland stubs remain intact to serve as a hub from which the new rndometrium grows to resurface the area. If the stumps of the glands have been destroyed, the resurfacing of the placental area is delayed until the endometrium grows in from the sides. This leaves the venous sinuses exposed, and sloughing of their unprotected, very thin walls results in profuse bleeding. The problem is not one of noninvolution of the uterus, itself, but one which involves epithelization of the placental site. In the reported cases endometrial glands arc not conspicuous in the curettings in spite of the fact that myometrial elements are ordinarily present. Any condition that destroys the gland stubs may delay cpithelization and hence give rise to this very formidable type of delayed postpartum hemorrhage. DR. ALFRED F. SUDHOLT, JR. After the child has been delivered, if the placenta has not already separated, I do a careful manual removal of the placenta and follow this with a thorough inspection of the uterine c.ivity. The patient is not redraped and I do not change gloves. If the placenta separates spontaneously, then I explore the uterine cavity before repairing the episiotomy. Sometimes it is necessary to remove pieces of membrane that are left behind by the manual removal. The removal of the membranes can easily be accomplished by covering the fingers with gauze and wiping the uterine cavity clean. Inspection of the cervix, either by manual palpation or by direct vision, is then accom-
March 1, 1964 Am. J. Obst. & Gym.
plished. Following this, a thorough inspection of the vagina is carried out to locate lacerations of the vagina other than in the episiotomy site. If any lacerations are found, they are repaired before the episiotomy is sutured. The episiotomy repair is the last procedure. This is always done after the placenta has been removed to prevent breakdown of the episiotomy site. Since using this routine, I have felt it unnecessary to continue the use of ergonovine maleate, post partum. In approximately 3,000 cases, labor has been treated in this manner, and in these only 5 cases of postpartum bleeding have occurred. These were due to subinvolution of the placental site caused by endometritis. The patients all required blood transfusion and curettage. The pathological findings were endometritis and degenerating dccidual tissue. DR. CAN. J. DREYER. This subject of delayed postpartum hemorrhage is of special interest to me since I was forced to remove one of these furiously bleeding uteri in order to save a life, some 8 or 9 years ago. I do believe that the complication is considerably more frequent than Dr. Mier states, my impression unfortunately being only an impression and not statistically supported. But on our srrvGce at St. h4ary’s Hospital, where we deliver some 400 babies per month, it seems there is almost weekly or twice-monthly one of these unfortunate returnees. Desiring to decrease the frequency of this problem in my personal practice, I have, for the last 8 years, been manually exploring and gauze-wiping the uterine cavity after the third stage, a procedure viewed with disdain and even horror by some of my friends, but lately becoming more generally accepted and respectable. The point I wish to make is that this maneuver not only diminishes the frequency of immediate hemorrhage, but drastically reduces the incidcnce of delayed hemorrhage from so-called subinvolution or retained secundines, because I can recall only one case of this in my practice when the maneuver was performed. In cases not so treated, because of local or pudendal anesthesia, or in cases of natural birth, the incidence remains elevated. DR. MA-IT H. BACKER, JR. Like others here present I have examined many placentas immediately postpartum and must confess I am not consistently able to tell whether or not the entire placenta has been expelled. One is impressed,
Volume 88 Number 5
however, with how promptly the patient becomes quite dry if the uterus is firm and empty, and no laceration exists. In cases of doubt, or certainly when the patient continues to have uterine bleeding, exploration of the endometrial cavity should be helpful. With patients delivered under regional (pudendal and caudal) anesthesia, however, the uterus is oftentimes too contracted to permit manual exploration without superimposing deep general anesthesia. In such cases I have found the insertion of a curved ring forceps into the endometrial cavity of the firmly contracted uterus, with the other hand guiding the fundus abdominally, a very rewarding procedure in terms of recovering pieces of placental tissue and/or membranes. It is also our practice to have patients report for the first postpartum visit 4 weeks after delivery. Patients who still have lochia rubra at this time will almost invariably be found to have retained membranes or placental tissue in the endometrial cavity, They usually also have a patulous cervix. We remove these secudines by means of an ovum forceps and light curet-
Delayed
postpartum
hemorrhage
617
tage, using no anesthesia or a few whiffs of trichlorethylene. After the uterus is thus emptied, bleeding stops promptly and uterine involution is hastened. This is especially helpful to patients who are anxious to revert, as soon as possible, to a normal menstrual pattern to facilitate the earlier practice of rhythm. DR. WULFF (Closing). Active prophylactic management of the third stage of labor by routine manual removal of the placenta and/or manual exploration of the uterine cavity is advocated by many authors, although, as noted in Dr. Sudholt’s experience, even this seemingly radical routine procedure has not eliminated delayed bleeding with its often necessary surgical intervention. Too often we neglect the proper inspection of the placenta, cervix, and vagina. As Dr. Florek pointed out, retained secundines are found in the large majority of these bleeding cases and we must teach that prevention of this condition undoubtedly can reduce its incidence. We must be aware of this possibility at the time of delivery and constantly alert to its etiological factors.