Identification of biochemical changes in intractable postpartum hemorrhage and evaluation of the different methods used in management

ABSTRACT

To find out the possible causes for inability of the smooth muscle fibers of the uterus to contract in cases with postpartum hemorrhage in response to ecbolics and evaluation of the different methods used in management. This study included 200 women, 100 of them delivered and developed postpartum hemorrhage [the study group] which was divided into two subgroups, the first subgroup included 75 women that responded to conservative and medical methods of treatment of postpartum hemorrhage, the second subgroup included 25 women who did not respond. The other 100 women delivered and not developed postpartum hemorrhage [the control group]. The cases included in this study were [of atonic postpartum hemorrhage], of all parities, without rupture uterus, retention of the placenta, genital tract laceration or blood coagulation defects. Blood samples [10 cm each] were taken from each patient for determination of hemoglobin percentage, complete blood analysis, random blood sugar, urea and creatinine, serum sodium and potassium and coagulation profile. Another sample [10 cm] was taken for nitric oxide assay and determination of plasma lipid peroxides. The routine medical managements used for treatment of postpartum hemorrhage were done for all cases. Surgical managements were done for the non-responding cases. In relation to the risk factors for development of postpartum hemorrhage, the study group was more anemic, with more antepartum hemorrhage, more malpresentation, more multiple pregnancies, more polyhydramnious and more manipulation outside the hospital than the control group and the differences were statistically significant. There was more prolonged labor and prolonged rupture of membranes in the study group than in the control group but there was no difference in relation to the mode of delivery. There was significant difference in relation to the level of plasma lipid peroxides [P value<0.01] and serum nitric oxide [P value<0.001] between the study group and the control group. The level of plasma lipid peroxides and serum nitric oxide was elevated in the intractable subgroup more than in the responding one and the difference was statistically significant [P<0.001]. Twenty five cases did not respond to the medical methods used for treatment [the intractable subgroup], they were of high parity, more anemic and of more medical disorders than the responding subgroup [75 cases responded for medical methods] and the differences were statistically significant. The surgical methods [conservative one] succeeded in 19 cases of 25 who failed to respond to medical treatment with a percentage of 76%. The remaining 6 cases, hysterectomy was done and succeeded in 3 cases only with a percentage of 50%. The other 3 cases died later on from pulmonary embolism, renal failure and DIC. Elevation of the level of free radicals as plasma lipid peroxides and serum nitric oxide was more markedly evident in the cases that failed to respond to the medical methods and ecbolic drugs used in control of postpartum hemorrhage [Intractable cases]. This elevation in free radicals, most probably, was due to cellular injuries of the uterine muscle fibers as a result of hypoxia and anoxia resulting from failure of correction of blood loss rabidly in cases of postpartum hemorrhage. Thus early and rapid correction of blood loss especially by fresh blood can prevent this vicious circle and prevent cellular injury in cases of postpartum hemorrhage. It is advisable not to rush to do urgent hysterectomy without performing the other conservative surgical methods for controlling of postpartum hemorrhage, as they succeeded in more than 75% of cases