Rational use of tranexamic acid in complex treatment for bleeding during pregnancy

Author: Sozinova A.V., obstetrician-gynecologist, has been in continuous practice since 2001.

Retrochorial (gravid) hematoma is an accumulation of blood clots in the space between the wall of the uterus and the fertilized egg, or rather, the shell of the egg - the chorion, due to its rejection from the uterine wall. The chorion in the future, after 16 weeks, is transformed into the placenta, which means it performs the same functions as the latter. Retrochorial hematoma occurs in the first trimester of pregnancy.

As a rule, this pathology is a consequence of the threat of miscarriage, but can be formed as a result of destruction of the walls of the uterine vessels by chorionic villi during the growth of the chorion. A vicious circle results: a growing hematoma aggravates the threat of miscarriage, and a continuing threat stimulates the growth of the hematoma.

Causes

The reasons for the formation of retrochorial hematoma are similar to the factors that cause the threat of miscarriage:

• mechanical impact on the uterus (injuries, bruises);
• hormonal disorders (lack of progesterone);
• genetic abnormalities of the fetal egg (gross malformations);
• stress;
• heavy physical activity;
• inflammatory and tumor diseases of the uterus (endometritis, endometriosis, fibroids);
• sexually transmitted infections;
• occupational hazards (noise, vibration, radiation);
• early and late toxicosis;
• sudden jumps in blood pressure;
• infantilism and abnormalities of the genital organs;
• drinking alcohol and drugs, smoking;
• systemic diseases (systemic lupus erythematosus, collagenosis and others);
• chronic somatic diseases (diabetes mellitus, cardiovascular pathology and others);
• diseases of the blood coagulation system;
• disturbed ecology.

They also include diseases associated with vascular pathology, including the vessels of the uterus.

What causes the threat?

There are quite a lot of factors that cause the threat of miscarriage. The main ones are:

• Hormonal changes . Of course, the change in hormonal levels during pregnancy itself is considered normal, but in some cases it can be unfavorable. The most serious problem is a lack of the hormone progesterone, since it is what prevents the uterus from contracting randomly, and therefore prevents spontaneous miscarriage. Progesterone deficiency occurs due to dysfunction of the corpus luteum, disorders of the thyroid gland or pituitary gland. The situation is also considered dangerous when, with a normal level of progesterone, the level of the male hormone androgen is increased.
• Genetic disorders . Usually it is this factor that provokes miscarriages in the first weeks of gestation. Due to chromosome mutations, the normal development of the child becomes impossible; the woman’s body itself rejects the fetus, thus preventing the birth of a child with severe health problems and non-viable. The immune system of a pregnant woman can also cause the threat of miscarriage - it reacts to the child as a foreign body and rejects it. In such situations, future parents should definitely consult a geneticist.
• STIs (predominantly sexually transmitted infections): chlamydia, herpes, cytomegalovirus, mycoplasmosis, ureaplasmosis. These diseases are very unfavorable for the child and the pregnant woman. In the fetus, they can cause serious developmental disorders, interfere with the correct formation of internal organs at the first stage, their further growth and performance of functions.
• Infectious and inflammatory diseases (influenza, ARVI, hepatitis, rubella, sore throat, pneumonia, etc.) can also lead to termination of pregnancy due to elevated temperature, oxygen deprivation, and intoxication of the body. During pregnancy, you need to communicate with patients as little as possible and avoid crowded places.
• Diseases of the genital organs : fibroids, endometriosis, developmental abnormalities, consequences of injuries, adhesions - all this often interferes with the development and normal growth of the fetus. Therefore, the expectant mother should be observed and examined in specialized clinics by experienced specialists throughout her pregnancy.
• Stressful situations . It’s not for nothing that doctors recommend that expectant mothers monitor their psychological state. Sometimes this factor can become a trigger for miscarriage. Do not take events happening around you to heart at any stage of pregnancy.
• Invasive examination , that is, collection of amniotic fluid for further research in a genetic laboratory, as well as cordocentesis, that is, collection of blood from the baby’s umbilical vein. Such examinations are prescribed, for example, when there are serious suspicions that the fetus has chromosomal abnormalities or genetic diseases.
• Injuries, falls, overwork of a woman during pregnancy.
• Alcohol, smoking, etc.
• Thrombophilia is a blood clotting disorder, increased likelihood of blood clots.
• Rhesus conflict . In situations where the mother's blood is Rh negative and the father's blood is positive, the child may develop Rh positive. Then the mother’s body begins to produce antibodies that fight (as it “seems to them”) with the foreign body.

What symptoms indicate a threat of miscarriage?

Painful sensations . A woman may feel pain in the lower abdomen, in the lumbar region. Sometimes the pain radiates to the side on the right or left. The nature of the pain is varied - pulling, stabbing, cutting. Also, the pain can be cramping in nature and does not depend on whether the woman is sitting, standing or lying down. After sleep or rest, the pain does not go away, remains the same or even increases.

The appearance of discharge . Bloody discharge causes anxiety. They can be scanty, spotting, and then develop into heavy bleeding. In cases where a woman consults a doctor immediately after discovering slight bleeding, there remains a fairly good chance of maintaining the pregnancy and eliminating the threat. Heavy bleeding almost always leads to the loss of the fetus, moreover, it becomes a threat to the life and health (in particular, to the reproductive function) of the woman herself.

Increased uterine tone . This condition can occur constantly or occur periodically. A woman usually feels the tone herself when the uterus tenses and contracts. With such a symptom, you should definitely consult a doctor, especially if the tone is accompanied by pain or bleeding.

How can an ultrasound detect a threat of miscarriage?

Ultrasound examination reveals only indirect signs of a threat, but they are also very important for diagnosing a pathological condition:

• Uterine tone. A condition where the tone is localized only along the anterior or posterior wall of the uterus should not cause serious concern, but only become a reason for more careful monitoring of the pregnant woman. This condition may be transient and disappear without pain or pathological discharge. Full tone of the uterus (hypertonicity), that is, when it becomes completely tense (“turns to stone”), requires treatment.
• Fetal heartbeat disturbances. The fetal heart rate can be determined as early as the 5th week of gestation. For a period of 8 weeks or more, a heart rate of 120–160 beats per minute is considered normal. A deviation in the heart rate value up or down should alert the doctor.
• Chorionic hyperplasia. The placenta subsequently develops from the chorion. Accordingly, its underdevelopment will lead to the fact that the placenta will not be able to fully nourish the fetus.
• Retrochorial (extrathecal) hematoma. When the fertilized egg partially detaches from the chorion, vascular damage and bleeding occur. Thus, a hematoma is formed, the further development of which leads to termination of pregnancy. Timely detection of such pathology and proper treatment will help maintain pregnancy. Typically, a hematoma is detected during the first ultrasound screening, while the woman herself may not notice any pain or discomfort.
• Reduction in the length of the cervix with an enlarged internal os.

Symptoms of retrochorial hematoma

As a rule, this disease is an incidental finding during a routine ultrasound examination. The woman makes no complaints and feels satisfactory. But sometimes retrochorial hematoma is accompanied by signs of a threatened miscarriage.

How does a hematoma come out?

The main manifestation is dark red or brownish bloody discharge from the genital tract. Their intensity is insignificant (from spotting to moderate) and depends on the size of the hematoma and the duration of pregnancy.

Dark red discharge with retrochorial hematoma, confirmed by ultrasound, is a favorable rather than a dangerous sign. They indicate emptying of the retrochorial hematoma.

Dangerous discharge from a hematoma

The appearance of bright red discharge is considered an unfavorable symptom, especially in combination with pain in the lower abdomen. This indicates either an increase in the size of the hematoma and an increased threat of interruption, or that the hematoma is fresh, just formed, and it requires immediate treatment.

In addition, the woman is bothered by aching or nagging pain that is localized in the lower abdomen or lumbar region. Usually the pain is constant, but it can also occur periodically, intensifying after physical exertion and other factors.

In some cases, a retrochorial hematoma occurs without any bleeding at all, and its presence is established after childbirth by detecting an old area of ​​hemorrhage on the placenta.

Resorption of the hematoma lasts from 2 to 4-5 weeks.

Therapy for hematoma

Unfortunately, in especially severe cases - if the situation threatens the life and health of the mother or child - the pregnancy is terminated. For a hematoma, drug treatment is prescribed. In addition, a woman must strictly follow all the doctor’s recommendations, namely:

• refuse sexual intercourse for a while;
• do not lift heavy objects, avoid physical activity;
• protect yourself from severe stress and negative environmental influences (if possible);
• lead a calm lifestyle, reduce mental and physical stress at work and at home;
• drink enough fluids;
• diversify the menu with fruits and vegetables, placing special emphasis on foods rich in vitamins B, C, E.

Taking good care of yourself will help you maintain your long-awaited pregnancy, carry and give birth to a healthy baby.

All information is for informational purposes only. If you have any health problems, you need to consult a specialist.

Diagnostics

The main diagnostic method for retrochorial hematoma is ultrasound of the uterus and ovum.

During this procedure, the following signs are detected:

• local thickening of the uterine wall, which indicates an increase in uterine tone (short-term hypertonicity is possible when performing an ultrasound with a vaginal sensor, in which case it is necessary to repeat the ultrasound with a transabdominal sensor, that is, through the anterior abdominal wall. Continued muscle tone indicates a threat of termination of pregnancy);
• change in the shape of the fetal egg due to pressure on it from a thickened area of ​​the myometrium (the fertilized egg takes on a scaphoid or teardrop shape);
• detection of retrochorial hematoma, clarification of its size, location and increase or decrease during repeated examination.

In addition, the following laboratory tests are required:

• general blood and urine tests;
• blood for clotting (platelets, bleeding time, fibrinogen, prothrombin and other factors);
• vaginal smear for flora;
• blood chemistry;
• screening for sexually transmitted diseases;
• hormone research (according to indications);
• CTG and Dopplerometry of the fetus in late pregnancy.

Types of hematomas during pregnancy

Classification of hematomas during pregnancy takes into account the location and severity of the pathology.

Based on their location, there are 6 types of pathology; below we will consider them in more detail.

Retrochorial hematoma

This is a pathology that appears before 16 weeks. It occurs as a result of the threat of interruption, detachment of the embryo from the chorion and damage to blood vessels.

The chorion is the membrane of the embryo, which is necessary for removing carbon dioxide, obtaining nutrients and oxygen, and protecting against infections. It is covered with villi, which ensure metabolism, which allows the baby to fully develop. In the future, the placenta is formed from this formation.

It manifests itself as bloody discharge, pain in the lower abdomen, radiating to the lumbar region and perineum. But there may also be an asymptomatic course, when the doctor discovers the pathology during a routine ultrasound.

The prognosis depends on the size of the hematoma during early pregnancy, the rate of increase, and localization. If the size of the formation is small, it does not grow, the risk is minimal. But a rapid increase in volume indicates that the detachment is progressing: this is a dangerous condition. Bruising puts pressure on the child’s tissues and impairs blood supply.

Tactics are aimed at stopping the progression of detachment. If treatment is started in a timely manner, it is possible to save the child. Antispasmodics, hormonal and sedatives, and vitamins are prescribed.

Retroplacental

The mechanism of pathology is associated with placental abruption. Since the baby's place is fully formed by 16 weeks, this type of disorder is diagnosed only after this period. If the cause is not eliminated and the bleeding is not stopped, retroplacental bruising leads to premature birth.

A pregnant woman with this diagnosis is hospitalized and given intensive therapy with hormonal drugs, antispasmodics, vitamins, and sedatives.

Subchorionic

This is one of the types of retrochorial hematoma. Formed around the chorion. The subchorionic form can lead to fetal death and premature birth. This outcome is possible with a rapid increase in the volume of hemorrhage. The damaging factor is both the loss of blood by the woman and the compression of the baby.

Treatment of subchorionic type is carried out in a hospital. Using ultrasound, doctors monitor the dynamics. Even a stable size of the formation can cause malnutrition of the fetus. This leads to oxygen starvation and malnutrition. The consequences of these disorders can negatively affect the baby's development.

Retroamniotic

It is formed as a result of damage to the vessels that are located between the wall of the uterus and the amnion - the fetal bladder. The amniotic sac is a sac that contains amniotic fluid and the baby. Its function is to protect the baby from injury and ensure communication between the baby’s organisms.

The baby is protected by the amnion, so bruising is not dangerous for him. But if bleeding begins with a retroamniotic hematoma during pregnancy, the prognosis is disappointing. When treatment is started on time, the progression of the disease stops, and the danger to the baby and mother is eliminated.

Subamniotic

With the subamniotic type of pathology, there is no danger to the life of the baby and mother. The clot gradually dissolves and is eliminated from the body, leaving no consequences. A pregnant woman with a subamniotic form of the disease is carefully monitored so that it does not change into another form and become dangerous.

Intrauterine

And with an intrauterine form, there is a threat to both mother and child: uterine rupture is possible, which will lead to massive bleeding, rejection of the fertilized egg, and death of the baby. In this case, inpatient treatment with the use of antispasmodics, hemostatic agents and sedatives is necessary.

If the volume of the clot is small, then in most cases intrauterine hemorrhage does not in any way affect the course of the interesting situation. The baby develops according to the term.

The following classification takes into account the severity of hematoma symptoms during early pregnancy.

Light form

This type of hematoma during pregnancy is practically asymptomatic: there are no discharges or complaints. It is recommended to limit physical activity, eliminate stress, maintain sexual rest, and get proper rest. If these recommendations are followed, the disease does not progress, the condition of the pregnant woman remains satisfactory, and there is no danger to her life or the life of the baby.

Average

The average severity of hematoma during pregnancy is characterized by pain in the lower abdomen, reminiscent of menstrual pain. Small amounts of bloody discharge appear. Antispasmodics and sedatives are added to the treatment regimen. Other restrictions must also be observed to avoid complications. Then the prognosis is favorable: the disease does not progress.

Heavy

The most unfavorable form of hematoma during early pregnancy. The symptoms are clear: severe pain that spreads to the lower back, legs, and resembles contractions. Possible decrease in blood pressure, weakness, dizziness, even fainting. Bloody discharge gradually intensifies. Their color may vary. If the discharge is brown, it means that it is old blood, the danger has passed. A bright red color indicates that the disease is progressing. The bruising increases, the risk of an unfavorable outcome remains.

Therapy is carried out in a hospital. Hormonal agents, hemostatic drugs, and vitamins are used.

Treatment of retrochorial hematoma

Treatment of women with retrochorial hematoma is carried out by an obstetrician-gynecologist.

Therapeutic measures continue throughout the entire period of threatened miscarriage (about a month), and are also repeated at dangerous periods (12-14, 20-24, 28-32, 36-38 weeks).

First of all, to relax the muscle tone of the uterus and relieve signs of a threatened miscarriage, bed rest is prescribed, with the legs elevated, which allows normalizing blood circulation in the uterus and emptying the hematoma, provided it is localized in the fundus of the uterus.

Prohibited:

• sex life;
• lifting weights;
• exercise stress.

For this and not only this purpose, the doctor will suggest hospitalization to the patient.

A pregnant woman is recommended to adjust her diet: exclude foods that cause gas (legumes, cabbage), harden stool or increase intestinal motility (chocolate, coffee, coarse fiber). The intestines overflowing with gases put pressure on the pregnant uterus and aggravate the threat of interruption, increasing the size of the hematoma.

It is imperative to maintain psycho-emotional peace; for this, sedatives are prescribed:

• tincture of motherwort, valerian or peony;
• novopassit.

To relax the uterine tone, antispasmodics are used:

• papaverine;
• no-shpa;
• Magne-B6.

In the early stages, the doctor prescribes hormonal medications and individually (!) selects the required dosage and timing of administration:

• morning;
• duphaston.

To improve uteroplacental blood flow, the following is prescribed:

• vitamin E;
• folic acid;
• chimes, actovegin (strictly as prescribed by the doctor);

To stop or prevent bleeding at the site of the hematoma, hemostatic agents are used:

• dicinone;
• ascorutin;
• vikasol.

What treatment is prescribed to a woman if a threat of miscarriage is detected?

Numerous studies in the field of gynecology and genetics indicate that a threatened pregnancy under 12 weeks should not be maintained at all costs. As mentioned earlier, at such short periods, a woman’s body often rejects embryos with genetic pathologies.

The doctor assesses the patient’s condition, prescribes an early ultrasound, and prescribes treatment. Then all that remains is to wait for a positive outcome, but at the same time be prepared for the fact that it will not come to childbirth. Even if a miscarriage occurs, there is no need to despair and talk about a serious pathology of the reproductive system. For the next pregnancy, you will need to prepare, undergo additional examinations, possibly hormonal or other therapy - as prescribed by the doctor.

At later stages, treatment of threatened miscarriage is carried out in a hospital - day or full-time. A woman may be prescribed IVs, injections, physiotherapy and other procedures, depending on the symptoms and ultrasound readings.

What is the treatment of the threat in the early stages - 3-12 weeks?

Typically, at such short notice, if there is a threat of miscarriage, the following measures will be required to prevent it:

• Adjustment of lifestyle. Sometimes this means bed rest, sometimes it simply means limiting physical activity. Doctors often prescribe sick leave to pregnant women, since stress, strain and anxiety associated with work only aggravate the situation.
• Sexual abstinence.
• Prescription of sedative (calming) drugs. Typically, women are prescribed valerian, motherwort tincture and other relatively safe drugs.
• Prescribing medications aimed at regulating stool (for example, glycerin suppositories).
• Prescription of drugs containing magnesium. They have a calming effect and normalize intestinal function.
• Hormonal therapy. Women are often prescribed the drugs Duphaston or Utrozhestan (contain progesterone). Such medications are especially necessary if, during pregnancy planning, menstrual irregularities were observed, miscarriages had previously occurred, infertility treatment was carried out, and so on. The dosage, frequency and duration of taking the drugs are determined by the doctor on an individual basis.

Also, a woman whose pregnancy is at risk undoubtedly needs psychological support from loved ones.

Treatment of threatened pregnancy in the second trimester

All of the above appointments can continue into the second trimester. Treatment can be supplemented with the following:

• Magnesium therapy. Women are often prescribed magnesium in the form of droppers with slow administration in order to relieve tension in the uterus. This therapy is safe and its effectiveness has long been proven. In addition to its relaxing effect on the uterus, magnesium helps prevent or relieve swelling.
• Indomethacin rectal suppositories. Contraindications: gastric or duodenal ulcers, colitis, gastritis, thrombocytopenia. Contraindications related to the condition of the fetus - intrauterine growth retardation, kidney development anomaly, chorionic inflammation, heart defects, oligohydramnios, uneven blood supply (in case of twins).
• Applying sutures to the cervix in cases where its length deviates from the norm.
• Prescription of antispasmodics (no-spa, rectal suppositories with papaverine).

Effective treatment and removal of the threat of miscarriage does not mean that the woman’s observation can be transferred to normal mode. It is necessary to maintain close attention to her condition and promptly take action at the slightest suspicion of a new threat. In many ways, the success of pregnancy depends on the woman herself, on how carefully she listens to her own body and to the doctor’s advice.

Sometimes the threat persists throughout pregnancy. This often happens after IVF or artificial insemination. But the capabilities of modern medicine make it possible to maintain such pregnancies - women give birth to healthy children, although they have to experience many difficulties.

As you can see, the treatment of a threat can be very different, and when prescribing to a doctor, it is important to take into account all the individual characteristics of the woman’s condition and the development of the fetus. For many years, specialists in St. Petersburg have been helping women successfully become pregnant and preserving the pregnancies of their patients in the face of threats. But first of all, we do everything to prevent the threat - we conduct examinations, prescribe the optimal dosage of vitamins, give recommendations for adjusting the diet, and so on.

Possible consequences of threatened abortion

Statistics show that 50% of women at least once during their pregnancy faced the threat of termination, and not every case ended sadly. If we talk about the consequences of a threat to the fetus, it is worth highlighting the following:

• Fetal hypoxia (oxygen starvation). Acute and prolonged hypoxia can negatively affect the development of a child’s brain, causing cerebral palsy and other serious pathologies.
• Slow growth rates of the fetus (according to ultrasound, the number of gestational weeks does not coincide with the number of obstetric weeks).
• Infection of the fetus in utero.

As a rule, if a woman follows the recommendations of her doctor and undergoes scheduled and unscheduled ultrasound screenings, this helps maintain the pregnancy and prevent any pathologies in the baby.

Every woman during pregnancy first of all needs to think about herself and the child, and not about work, household chores, shopping and the like. Proper nutrition, calmness, walks in the fresh air, positive emotions - all these are prerequisites for a successful pregnancy and the birth of a healthy baby.

Why does a hematoma occur in early pregnancy?

There are quite a few reasons for the formation of a hematoma. This may be due to genetics, hormonal disorders, infectious or chronic inflammatory diseases, excessive physical or nervous stress, and even sexual intercourse.

The process of formation of a retrochorial hematoma itself looks something like this: under the influence of various external or internal factors, the fertilized egg begins to separate from the walls of the uterus, the blood vessels in this place rupture, and a space with a blood clot is formed at the site of rejection, which is called a hematoma.

Scientific studies have found that approximately 65% ​​of patients with retrochorial hematoma had a history or were discovered during an examination of a pathology such as thrombophilia. However, in reality, it is rarely possible to establish the true cause of detachment of the ovum and, accordingly, the formation of a hematoma.

General information

Retrochorial hematoma is an accumulation of blood in the retrochorial space, accompanied by partial rejection of the fertilized egg. If previously hematoma was considered a predictor of future placental insufficiency, in modern obstetrics there is a growing tendency to attribute it to the primary manifestation of this pathology. Hemorrhage occurs in the first trimester of pregnancy in the fifth to eleventh week. The incidence is 1.3-3%; 18% of cases of bleeding in early gestation are associated with hematoma. Subchorionic hematomas, even with adequate treatment, often lead to spontaneous abortion, and as pregnancy progresses, they significantly increase the likelihood of developing obstetric and perinatal complications.

Retrochorial hematoma