Uterine atony, commonly known as atony of the uterus, is a life-threatening disorder that can develop following childbirth. It happens when the uterus stops contracting after the baby is delivered, and it can result in postpartum hemorrhage, a potentially fatal condition.
The uterine muscles typically contract or tighten to deliver the placenta following childbirth. Additionally, the blood vessels that were connected to the placenta are compressed by the contractions. Bleeding is lessened by compression. The uterine muscles may not contract hard enough to stop the blood vessels from bleeding uncontrollably. Hemorrhage, or severe bleeding, results from this.
Epidemiology
At least 75% of postpartum hemorrhage cases and 1 in 40 complicated births in the US are caused by the uterus not contracting effectively after delivery. Seventy to eighty percent of PPH cases are caused by uterine atony. This happens when the myometrium contracts less firmly. The postgravid uterus lacks the necessary compression for hemostasis because it is flaccid or floppy.
Anatomy
Pathophysiology
Normal uterine contraction
Uterine contractions, also referred to as the “involution” process, are a sequence of well-coordinated contractions that the uterus experiences following childbirth.
By compressing the blood vessels supplying the placenta, these contractions are essential for sealing blood vessels and avoiding excessive bleeding.
Contraction and muscle tone
Smooth muscle fibers in the uterus contract and relax in a manner that maintains normal muscle tone. The hormone oxytocin, which is generated by the hypothalamus and secreted by the pituitary gland, stimulates contractions of the uterus.
Causes of uterine atony
Poor muscle tone resulting from a breakdown of the regular mechanisms of contraction can be the cause of uterine atony. Factors responsible for uterine atony are:
Uterine distension, which occurs in cases of multiple pregnancies or large babies, is one factor that leads to uterine atony.
Extended labor may result in tired muscles.
Placental fragments that were retained prevented the contraction from happening correctly.
Infections of the uterus affect regular muscle function.
Role of oxytocin
One of the main hormones in uterine contraction is oxytocin. It continues to function during the postpartum phase and promotes the uterus to contract while in labor. Uterine atony may be caused by insufficient oxytocin release or response.
Postpartum hemorrhage (PPH)
Postpartum hemorrhage, which occurs when the uterus is unable to contract normally, can be fatal if left untreated. Hypovolemic shock brought on by excessive bleeding can impair organ perfusion and essential bodily processes.
Etiology
Prolonged labor, unexpected labor, uterine distension (polyhydramnios, multi-fetal gestation, fetal macrosomia), chorioamnionitis, fibroid uterus, prolonged oxytocin use, and appropriate infusions of magnesium sulfate are the risk factors for uterine atony. Sporadic or diffuse ineffective uterine contraction is also linked to a variety of etiologies, such as uterine inversion, an increased fibrin degradation product (coagulopathy), and placental disorders (morbidly adherent placenta, abruption placentae, and placenta previa). Additionally, class III obesity, or a body mass index (BMI) above 40, is known to be an indicator of risk for postpartum uterine atony.
Genetics
Prognostic Factors
The recurrence risk in a subsequent pregnancy for women with a prior PPH can reach 15%. Class III obesity is associated with a higher risk of recurrence. The risk of recurrence is partially dependent on the underlying cause.
Clinical History
2.1 Clinical history
Recent labour or childbirth
Existence of risk factors: uterine atony in prior pregnancies, large baby, extended labor, multiple pregnancies, etc.
       2.2 Vital Signs
Severe blood loss can cause a drop in blood pressure.
Rapid heartbeats, or tachycardia, are frequently caused by the body’s reaction to hypovolemia.
Unable to pee
Loss of consciousness
Being tired or dizzy
Physical Examination
Uterine Palpation: Following delivery, the uterus may feel swollen and enlarged rather than firm and contracted, as would be expected.
Vaginal Bleeding: Uncontrollably heavy vaginal bleeding may be noticeable.
Signs of Shock: Pallor, clammy skin, cool skin, and altered mental status are a few signs that the patient may exhibit.
Examination of the abdomen: Examining for bruises or distention in the abdomen. Uterine size, consistency, and tenderness can all be evaluated by palpation. Examining the abdomen for peritonitis symptoms and intestinal sounds.
Examination of the pelvis: visual examination for hematomas or perineal cuts.
Digital evaluation to determine the tone of the uterus and detect any residual reproductive products.
Assessment of vaginal bleeding: Calculating blood loss (considering the
weight of materials soaked in blood). Evaluation of the consistency and color of vaginal bleeding.
Ultrasound evaluation: Ultrasound evaluation can be carried out to check for the presence of placental fragments, any retained products, and atony signs.
Laboratory investigations: measurements of hematocrit and hemoglobin to check for anemia. The coagulation profile of disseminated intravascular coagulation (DIC) is a cause for concern.
Assessment of response to intervention: assessment of the outcome of the first treatments, such as uterotonic medication administration and uterine massage.
Age group
Associated comorbidity
Associated activity
Acuity of presentation
Timing: Usually, uterine atony manifests itself in the first 24 hours following delivery, during the immediate postpartum phase. It can appear soon after giving birth and progress quickly.
Excessive bleeding: Uncontrollably heavy vaginal bleeding is a hallmark sign.
Bleeding can be constant and is frequently bright red in color.
Examination of the uterus: The uterus is a soft, enlarged organ when palpated. The uterus is not as firm as one would anticipate from a typical postpartum contraction.
Hypovolemic shock: Hypovolemic shock can result from sudden and significant blood loss. Tachycardia, a drop in blood pressure, and symptoms of lowered perfusion (cold extremities, pale skin) are examples of clinical features.
Clinical deterioration: The patient might experience a sharp decline in health.
If treatment is not received, early symptoms like increased bleeding can develop into severe shock.
Nature of emergency: One classifies uterine atony as a medical emergency.
It takes immediate action to stop serious complications, such as maternal death.
Monitoring: It is essential to continuously monitor important indications like oxygen saturation, heart rate, and blood pressure. For early detection, postpartum bleeding and uterine tone must be continuously assessed.
Differential Diagnoses
When the endometrial surface everts into the vagina and is permitted by uterine atony, the typical physical findings are invisible in the presence of uterine eversion. Usually, this happens after a vaginal delivery. The typical findings of an enlarged, boggy uterus are not present. Instead, an intra-vaginal mass with a cherry color—the endometrium—must be quickly reinserted into the uterine cavity. This prevents the condition from recurring by restoring uterine tone. Various differential diagnoses include:
Retained plasma tissue: Bleeding may continue if the placenta is not completely removed.
Imaging studies or clinical examinations may be used to determine this.
Pain in the Genital Tract: Significant bleeding can result from tears or abrasions of the perineum, vaginal, or perineum. A comprehensive pelvic exam can detect trauma that happens during labor.
Rupture of the uterus: a rare but dangerous consequence in which there is possible severe bleeding due to uterine tears. It is generally connected to uterine anomalies or prior uterine surgery.
Coagulopathy: Postpartum hemorrhage can be exacerbated by blood clotting disorders such as deficiencies of clotting factors or disseminated intravascular coagulation (DIC).
Inversion of the Uterus: This happens when the uterus ruptures, compressing blood vessels and causing bleeding as a result. A physical examination may be used to diagnose uterine inversion.
Aneurysm or Rupture of the Uterine Artery: Although uncommon, severe bleeding can occur from an aneurysm or uterine artery rupture.
Accreta, Increta, or Percreta placenta: Persistent bleeding may result from the placenta adhering abnormally to the uterine wall. Advanced imaging may be necessary to diagnose these conditions.
Uterine subinvolution: Prolonged bleeding after giving birth may result from a delayed return of the uterus to its standard size and tone.
Infection: Tenderness in the uterus and increased bleeding can be symptoms of postpartum infections, such as endometritis.
Drug-Related Bleeding: Excessive bleeding may be caused by some medications, including anticoagulants and drugs that affect blood clotting.
Vascular deformities: Postpartum hemorrhage is an uncommon side effect of aberrant blood vessel formations in the uterus.
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
The goal of the step-by-step treatment paradigm for uterine atony is to stabilize the patient, stop the bleeding, and restore uterine tone. Depending on the severity of the ailment and the outcome of early interventions, this paradigm might change.
Prenatal readiness
Blood should be screened and typed if the woman is at a medium risk of experiencing an intrapartum hemorrhage. Previous uterine surgery, multiple gestations, grand multiparity, prior PPH, macrosomia, large fibroids, anemia, macrosomia, prolonged second stage, body mass index higher than 40, chorioamnionitis, oxytocin administration for more than 24 hours, and magnesium sulfate administration are among the women with a medium risk factor for uterine atony-related postpartum hemorrhage. High-risk individuals ought to be classified and cross-matched with other high-risk PPH individuals. Accreta or placental previa, bleeding diathesis, and two or more medium-risk factors for uterine atony are examples of high-risk criteria.
Prevention of Intrapartum
This involves managing the third stage of labor as best as possible. To actively manage the third stage, uterine massage and continuous low-level traction on the umbilical cord are recommended. While waiting until placenta delivery is reasonable, a simultaneous oxytocin infusion is beneficial.
Quick Recognition: Recognize the symptoms of uterine atony as soon as possible. These include signs of shock, a soft and enlarged uterus, and heavy bleeding.
Massage of the uterus: Initiate the massage of the uterus to induce contractions.
During a massage, the lower uterine segment is supported with one hand while the uterine fundus is compressed firmly with the other.
Uterotonic medications: To improve uterine contractions, give uterotonic drugs.
It is common practice to administer oxytocin intravenously or intramuscularly.
Misoprostol, carboprost, and methylergonovine are further options.
by Stage
by Modality
Chemotherapy
Radiation Therapy
Surgical Interventions
Hormone Therapy
Immunotherapy
Hyperthermia
Photodynamic Therapy
Stem Cell Transplant
Targeted Therapy
Palliative Care
Procedures for Emergencies:
Make sure the hospital has well-defined procedures in place for handling obstetric emergencies, such as uterine abortion. Regularly practice drills and simulations to help staff members become familiar with emergency protocols.
Quick Reaction Group: Establish a quick response team that can be called upon in the event of uterine atony.
Obstetricians, anesthetists, nurses, and other essential staff members might be on this team.
Easily Accessible Uterotonic Drugs: Keep uterotonic drugs readily available, such as misoprostol, carboprost, methylergonovine, and oxytocin.
Equipment for Uterine Massage: Sterile gloves and lubricant are essential pieces of equipment for uterine massage.
Make sure the healthcare professionals have received the appropriate uterine massage training.
Kits for Intrauterine Balloon Tamponade: Whenever conservative measures prove ineffective, keep kits for intrauterine balloon tamponade handy.
Use of uterotonic agents
Oxytocin: The hormone that the pituitary gland produces is synthesized as oxytocin. It affects the uterine smooth muscle cells, which in turn causes uterine contractions.
Methylergonovine: An ergot alkaloid called methylergonovine causes blood vessels to constrict and induces uterine contractions.
Carboprost: A synthetic prostaglandin called carboprost helps regulate bleeding by inducing contractions in the uterus.
Misoprostol: A prostaglandin analog that induces uterine contractions is misoprostol.
Dinoprostone (Prostaglandin E2): Dinoprostone is a prostaglandin that can be used to stimulate uterine contractions.
Tranexamic acid: As an antifibrinolytic, tranexamic acid helps stop blood clots from breaking down, which lessens bleeding.
Surgical intervention
If medication fails to treat excessive bleeding, surgical procedures are employed.
Techniques for Tamponade:
Bladder drainage through uterine packing with gauze (coupled with vaginal packing to guarantee its retention, resulting in uterovaginal packing) and Foley catheter insertion. Rolled gauze ribbons are a quick and easy way to achieve tight and uniform uterine packing quickly and efficiently.
Bakri balloon with Foley catheter insertion to aid in bladder drainage (with vaginal packing to ensure its retention).
Methods of Surgical Management
Curettage of the uterus for retained products.
O’Leary uterine artery ligation, with the option to extend the ligation to the tubo-ovarian vessels.
B-Lynch and other compression sutures are generally saved for clinical situations in which manual uterine compression results in hemorrhage arrest.
Hypogastric artery ligation (Gyn/Onc performed)
Hysterectomy
The goal of the step-by-step approach to managing uterine atony is to stabilize the patient, restore uterine tone, and control bleeding. Depending on the severity of the ailment and how the initial interventions were received, the phases of management may change. The following summarizes the typical stages of uterine abortion management:
Initial Identification and Evaluation: Identify uterine atony symptoms and signs as soon as possible—clinical evaluation of vital signs, uterine tone, and postpartum hemorrhage.
Determining possible causes and risk factors.
Prompt Interventions: Take prompt action to stop bleeding and induce uterine contractions.
Uterine massage: Manually stimulating the uterus to increase contractions is known as uterine massage. Giving uterotonic drugs—like oxytocin—to cause contractions in the uterus.
Bimanual compression: The uterus is compressed manually to reduce bleeding.
Secondary Interventions: Move on to more sophisticated measures if the first interventions prove insufficient.
Intrauterine balloon tamponade: Pressuring and controlling bleeding within the uterus with a balloon. It may be necessary to try higher dosages or different uterotonic drugs like carboprost or methylergonovine.
Surgical Interventions: To treat uterine atony in severe cases, surgical options may be taken into consideration.
Ligating or clamping the uterine arteries to lower blood flow is known as uterine artery ligation.
Suturing the uterus to compress blood vessels is known as uterine compression sutures (e.g., B-Lynch or Hayman sutures).
Hysterectomy: uterine excision; typically used as a last resort.
Hemodynamic Support: Prevent shock-related complications by stabilizing the patient’s hemodynamic status. Intravenous resuscitation of fluids in cases of hypovolemia—transfusions of blood to keep tissue perfusion and treat anemia.
Post-Intervention Care and Monitoring: Keep a close eye on how the patient is responding to interventions and give them continuing support. Important signs, such as oxygen saturation, heart rate, and blood pressure,are continuously monitored. Uterine tone evaluation and continuous monitoring of postpartum hemorrhage assessment.
Postpartum Monitoring
Make sure you provide complete postpartum care and take care of any lingering problems.
Close observation is needed to look for any problems. Emotional and mental health assessment. Patient education regarding symptoms of complications after giving birth and when to see a doctor.
Uterine atony, commonly known as atony of the uterus, is a life-threatening disorder that can develop following childbirth. It happens when the uterus stops contracting after the baby is delivered, and it can result in postpartum hemorrhage, a potentially fatal condition.
The uterine muscles typically contract or tighten to deliver the placenta following childbirth. Additionally, the blood vessels that were connected to the placenta are compressed by the contractions. Bleeding is lessened by compression. The uterine muscles may not contract hard enough to stop the blood vessels from bleeding uncontrollably. Hemorrhage, or severe bleeding, results from this.
At least 75% of postpartum hemorrhage cases and 1 in 40 complicated births in the US are caused by the uterus not contracting effectively after delivery. Seventy to eighty percent of PPH cases are caused by uterine atony. This happens when the myometrium contracts less firmly. The postgravid uterus lacks the necessary compression for hemostasis because it is flaccid or floppy.
Normal uterine contraction
Uterine contractions, also referred to as the “involution” process, are a sequence of well-coordinated contractions that the uterus experiences following childbirth.
By compressing the blood vessels supplying the placenta, these contractions are essential for sealing blood vessels and avoiding excessive bleeding.
Contraction and muscle tone
Smooth muscle fibers in the uterus contract and relax in a manner that maintains normal muscle tone. The hormone oxytocin, which is generated by the hypothalamus and secreted by the pituitary gland, stimulates contractions of the uterus.
Causes of uterine atony
Poor muscle tone resulting from a breakdown of the regular mechanisms of contraction can be the cause of uterine atony. Factors responsible for uterine atony are:
Uterine distension, which occurs in cases of multiple pregnancies or large babies, is one factor that leads to uterine atony.
Extended labor may result in tired muscles.
Placental fragments that were retained prevented the contraction from happening correctly.
Infections of the uterus affect regular muscle function.
Role of oxytocin
One of the main hormones in uterine contraction is oxytocin. It continues to function during the postpartum phase and promotes the uterus to contract while in labor. Uterine atony may be caused by insufficient oxytocin release or response.
Postpartum hemorrhage (PPH)
Postpartum hemorrhage, which occurs when the uterus is unable to contract normally, can be fatal if left untreated. Hypovolemic shock brought on by excessive bleeding can impair organ perfusion and essential bodily processes.
Prolonged labor, unexpected labor, uterine distension (polyhydramnios, multi-fetal gestation, fetal macrosomia), chorioamnionitis, fibroid uterus, prolonged oxytocin use, and appropriate infusions of magnesium sulfate are the risk factors for uterine atony. Sporadic or diffuse ineffective uterine contraction is also linked to a variety of etiologies, such as uterine inversion, an increased fibrin degradation product (coagulopathy), and placental disorders (morbidly adherent placenta, abruption placentae, and placenta previa). Additionally, class III obesity, or a body mass index (BMI) above 40, is known to be an indicator of risk for postpartum uterine atony.
The recurrence risk in a subsequent pregnancy for women with a prior PPH can reach 15%. Class III obesity is associated with a higher risk of recurrence. The risk of recurrence is partially dependent on the underlying cause.
2.1 Clinical history
Recent labour or childbirth
Existence of risk factors: uterine atony in prior pregnancies, large baby, extended labor, multiple pregnancies, etc.
       2.2 Vital Signs
Severe blood loss can cause a drop in blood pressure.
Rapid heartbeats, or tachycardia, are frequently caused by the body’s reaction to hypovolemia.
Unable to pee
Loss of consciousness
Being tired or dizzy
Uterine Palpation: Following delivery, the uterus may feel swollen and enlarged rather than firm and contracted, as would be expected.
Vaginal Bleeding: Uncontrollably heavy vaginal bleeding may be noticeable.
Signs of Shock: Pallor, clammy skin, cool skin, and altered mental status are a few signs that the patient may exhibit.
Examination of the abdomen: Examining for bruises or distention in the abdomen. Uterine size, consistency, and tenderness can all be evaluated by palpation. Examining the abdomen for peritonitis symptoms and intestinal sounds.
Examination of the pelvis: visual examination for hematomas or perineal cuts.
Digital evaluation to determine the tone of the uterus and detect any residual reproductive products.
Assessment of vaginal bleeding: Calculating blood loss (considering the
weight of materials soaked in blood). Evaluation of the consistency and color of vaginal bleeding.
Ultrasound evaluation: Ultrasound evaluation can be carried out to check for the presence of placental fragments, any retained products, and atony signs.
Laboratory investigations: measurements of hematocrit and hemoglobin to check for anemia. The coagulation profile of disseminated intravascular coagulation (DIC) is a cause for concern.
Assessment of response to intervention: assessment of the outcome of the first treatments, such as uterotonic medication administration and uterine massage.
Timing: Usually, uterine atony manifests itself in the first 24 hours following delivery, during the immediate postpartum phase. It can appear soon after giving birth and progress quickly.
Excessive bleeding: Uncontrollably heavy vaginal bleeding is a hallmark sign.
Bleeding can be constant and is frequently bright red in color.
Examination of the uterus: The uterus is a soft, enlarged organ when palpated. The uterus is not as firm as one would anticipate from a typical postpartum contraction.
Hypovolemic shock: Hypovolemic shock can result from sudden and significant blood loss. Tachycardia, a drop in blood pressure, and symptoms of lowered perfusion (cold extremities, pale skin) are examples of clinical features.
Clinical deterioration: The patient might experience a sharp decline in health.
If treatment is not received, early symptoms like increased bleeding can develop into severe shock.
Nature of emergency: One classifies uterine atony as a medical emergency.
It takes immediate action to stop serious complications, such as maternal death.
Monitoring: It is essential to continuously monitor important indications like oxygen saturation, heart rate, and blood pressure. For early detection, postpartum bleeding and uterine tone must be continuously assessed.
When the endometrial surface everts into the vagina and is permitted by uterine atony, the typical physical findings are invisible in the presence of uterine eversion. Usually, this happens after a vaginal delivery. The typical findings of an enlarged, boggy uterus are not present. Instead, an intra-vaginal mass with a cherry color—the endometrium—must be quickly reinserted into the uterine cavity. This prevents the condition from recurring by restoring uterine tone. Various differential diagnoses include:
Retained plasma tissue: Bleeding may continue if the placenta is not completely removed.
Imaging studies or clinical examinations may be used to determine this.
Pain in the Genital Tract: Significant bleeding can result from tears or abrasions of the perineum, vaginal, or perineum. A comprehensive pelvic exam can detect trauma that happens during labor.
Rupture of the uterus: a rare but dangerous consequence in which there is possible severe bleeding due to uterine tears. It is generally connected to uterine anomalies or prior uterine surgery.
Coagulopathy: Postpartum hemorrhage can be exacerbated by blood clotting disorders such as deficiencies of clotting factors or disseminated intravascular coagulation (DIC).
Inversion of the Uterus: This happens when the uterus ruptures, compressing blood vessels and causing bleeding as a result. A physical examination may be used to diagnose uterine inversion.
Aneurysm or Rupture of the Uterine Artery: Although uncommon, severe bleeding can occur from an aneurysm or uterine artery rupture.
Accreta, Increta, or Percreta placenta: Persistent bleeding may result from the placenta adhering abnormally to the uterine wall. Advanced imaging may be necessary to diagnose these conditions.
Uterine subinvolution: Prolonged bleeding after giving birth may result from a delayed return of the uterus to its standard size and tone.
Infection: Tenderness in the uterus and increased bleeding can be symptoms of postpartum infections, such as endometritis.
Drug-Related Bleeding: Excessive bleeding may be caused by some medications, including anticoagulants and drugs that affect blood clotting.
Vascular deformities: Postpartum hemorrhage is an uncommon side effect of aberrant blood vessel formations in the uterus.
The goal of the step-by-step treatment paradigm for uterine atony is to stabilize the patient, stop the bleeding, and restore uterine tone. Depending on the severity of the ailment and the outcome of early interventions, this paradigm might change.
Prenatal readiness
Blood should be screened and typed if the woman is at a medium risk of experiencing an intrapartum hemorrhage. Previous uterine surgery, multiple gestations, grand multiparity, prior PPH, macrosomia, large fibroids, anemia, macrosomia, prolonged second stage, body mass index higher than 40, chorioamnionitis, oxytocin administration for more than 24 hours, and magnesium sulfate administration are among the women with a medium risk factor for uterine atony-related postpartum hemorrhage. High-risk individuals ought to be classified and cross-matched with other high-risk PPH individuals. Accreta or placental previa, bleeding diathesis, and two or more medium-risk factors for uterine atony are examples of high-risk criteria.
Prevention of Intrapartum
This involves managing the third stage of labor as best as possible. To actively manage the third stage, uterine massage and continuous low-level traction on the umbilical cord are recommended. While waiting until placenta delivery is reasonable, a simultaneous oxytocin infusion is beneficial.
Quick Recognition: Recognize the symptoms of uterine atony as soon as possible. These include signs of shock, a soft and enlarged uterus, and heavy bleeding.
Massage of the uterus: Initiate the massage of the uterus to induce contractions.
During a massage, the lower uterine segment is supported with one hand while the uterine fundus is compressed firmly with the other.
Uterotonic medications: To improve uterine contractions, give uterotonic drugs.
It is common practice to administer oxytocin intravenously or intramuscularly.
Misoprostol, carboprost, and methylergonovine are further options.
Oxytocin: The hormone that the pituitary gland produces is synthesized as oxytocin. It affects the uterine smooth muscle cells, which in turn causes uterine contractions.
Methylergonovine: An ergot alkaloid called methylergonovine causes blood vessels to constrict and induces uterine contractions.
Carboprost: A synthetic prostaglandin called carboprost helps regulate bleeding by inducing contractions in the uterus.
Misoprostol: A prostaglandin analog that induces uterine contractions is misoprostol.
Dinoprostone (Prostaglandin E2): Dinoprostone is a prostaglandin that can be used to stimulate uterine contractions.
Tranexamic acid: As an antifibrinolytic, tranexamic acid helps stop blood clots from breaking down, which lessens bleeding.
If medication fails to treat excessive bleeding, surgical procedures are employed.
Techniques for Tamponade:
Bladder drainage through uterine packing with gauze (coupled with vaginal packing to guarantee its retention, resulting in uterovaginal packing) and Foley catheter insertion. Rolled gauze ribbons are a quick and easy way to achieve tight and uniform uterine packing quickly and efficiently.
Bakri balloon with Foley catheter insertion to aid in bladder drainage (with vaginal packing to ensure its retention).
Methods of Surgical Management
Curettage of the uterus for retained products.
O’Leary uterine artery ligation, with the option to extend the ligation to the tubo-ovarian vessels.
B-Lynch and other compression sutures are generally saved for clinical situations in which manual uterine compression results in hemorrhage arrest.
Uterine atony, commonly known as atony of the uterus, is a life-threatening disorder that can develop following childbirth. It happens when the uterus stops contracting after the baby is delivered, and it can result in postpartum hemorrhage, a potentially fatal condition.
The uterine muscles typically contract or tighten to deliver the placenta following childbirth. Additionally, the blood vessels that were connected to the placenta are compressed by the contractions. Bleeding is lessened by compression. The uterine muscles may not contract hard enough to stop the blood vessels from bleeding uncontrollably. Hemorrhage, or severe bleeding, results from this.
At least 75% of postpartum hemorrhage cases and 1 in 40 complicated births in the US are caused by the uterus not contracting effectively after delivery. Seventy to eighty percent of PPH cases are caused by uterine atony. This happens when the myometrium contracts less firmly. The postgravid uterus lacks the necessary compression for hemostasis because it is flaccid or floppy.
Normal uterine contraction
Uterine contractions, also referred to as the “involution” process, are a sequence of well-coordinated contractions that the uterus experiences following childbirth.
By compressing the blood vessels supplying the placenta, these contractions are essential for sealing blood vessels and avoiding excessive bleeding.
Contraction and muscle tone
Smooth muscle fibers in the uterus contract and relax in a manner that maintains normal muscle tone. The hormone oxytocin, which is generated by the hypothalamus and secreted by the pituitary gland, stimulates contractions of the uterus.
Causes of uterine atony
Poor muscle tone resulting from a breakdown of the regular mechanisms of contraction can be the cause of uterine atony. Factors responsible for uterine atony are:
Uterine distension, which occurs in cases of multiple pregnancies or large babies, is one factor that leads to uterine atony.
Extended labor may result in tired muscles.
Placental fragments that were retained prevented the contraction from happening correctly.
Infections of the uterus affect regular muscle function.
Role of oxytocin
One of the main hormones in uterine contraction is oxytocin. It continues to function during the postpartum phase and promotes the uterus to contract while in labor. Uterine atony may be caused by insufficient oxytocin release or response.
Postpartum hemorrhage (PPH)
Postpartum hemorrhage, which occurs when the uterus is unable to contract normally, can be fatal if left untreated. Hypovolemic shock brought on by excessive bleeding can impair organ perfusion and essential bodily processes.
Prolonged labor, unexpected labor, uterine distension (polyhydramnios, multi-fetal gestation, fetal macrosomia), chorioamnionitis, fibroid uterus, prolonged oxytocin use, and appropriate infusions of magnesium sulfate are the risk factors for uterine atony. Sporadic or diffuse ineffective uterine contraction is also linked to a variety of etiologies, such as uterine inversion, an increased fibrin degradation product (coagulopathy), and placental disorders (morbidly adherent placenta, abruption placentae, and placenta previa). Additionally, class III obesity, or a body mass index (BMI) above 40, is known to be an indicator of risk for postpartum uterine atony.
The recurrence risk in a subsequent pregnancy for women with a prior PPH can reach 15%. Class III obesity is associated with a higher risk of recurrence. The risk of recurrence is partially dependent on the underlying cause.
2.1 Clinical history
Recent labour or childbirth
Existence of risk factors: uterine atony in prior pregnancies, large baby, extended labor, multiple pregnancies, etc.
       2.2 Vital Signs
Severe blood loss can cause a drop in blood pressure.
Rapid heartbeats, or tachycardia, are frequently caused by the body’s reaction to hypovolemia.
Unable to pee
Loss of consciousness
Being tired or dizzy
Uterine Palpation: Following delivery, the uterus may feel swollen and enlarged rather than firm and contracted, as would be expected.
Vaginal Bleeding: Uncontrollably heavy vaginal bleeding may be noticeable.
Signs of Shock: Pallor, clammy skin, cool skin, and altered mental status are a few signs that the patient may exhibit.
Examination of the abdomen: Examining for bruises or distention in the abdomen. Uterine size, consistency, and tenderness can all be evaluated by palpation. Examining the abdomen for peritonitis symptoms and intestinal sounds.
Examination of the pelvis: visual examination for hematomas or perineal cuts.
Digital evaluation to determine the tone of the uterus and detect any residual reproductive products.
Assessment of vaginal bleeding: Calculating blood loss (considering the
weight of materials soaked in blood). Evaluation of the consistency and color of vaginal bleeding.
Ultrasound evaluation: Ultrasound evaluation can be carried out to check for the presence of placental fragments, any retained products, and atony signs.
Laboratory investigations: measurements of hematocrit and hemoglobin to check for anemia. The coagulation profile of disseminated intravascular coagulation (DIC) is a cause for concern.
Assessment of response to intervention: assessment of the outcome of the first treatments, such as uterotonic medication administration and uterine massage.
Timing: Usually, uterine atony manifests itself in the first 24 hours following delivery, during the immediate postpartum phase. It can appear soon after giving birth and progress quickly.
Excessive bleeding: Uncontrollably heavy vaginal bleeding is a hallmark sign.
Bleeding can be constant and is frequently bright red in color.
Examination of the uterus: The uterus is a soft, enlarged organ when palpated. The uterus is not as firm as one would anticipate from a typical postpartum contraction.
Hypovolemic shock: Hypovolemic shock can result from sudden and significant blood loss. Tachycardia, a drop in blood pressure, and symptoms of lowered perfusion (cold extremities, pale skin) are examples of clinical features.
Clinical deterioration: The patient might experience a sharp decline in health.
If treatment is not received, early symptoms like increased bleeding can develop into severe shock.
Nature of emergency: One classifies uterine atony as a medical emergency.
It takes immediate action to stop serious complications, such as maternal death.
Monitoring: It is essential to continuously monitor important indications like oxygen saturation, heart rate, and blood pressure. For early detection, postpartum bleeding and uterine tone must be continuously assessed.
When the endometrial surface everts into the vagina and is permitted by uterine atony, the typical physical findings are invisible in the presence of uterine eversion. Usually, this happens after a vaginal delivery. The typical findings of an enlarged, boggy uterus are not present. Instead, an intra-vaginal mass with a cherry color—the endometrium—must be quickly reinserted into the uterine cavity. This prevents the condition from recurring by restoring uterine tone. Various differential diagnoses include:
Retained plasma tissue: Bleeding may continue if the placenta is not completely removed.
Imaging studies or clinical examinations may be used to determine this.
Pain in the Genital Tract: Significant bleeding can result from tears or abrasions of the perineum, vaginal, or perineum. A comprehensive pelvic exam can detect trauma that happens during labor.
Rupture of the uterus: a rare but dangerous consequence in which there is possible severe bleeding due to uterine tears. It is generally connected to uterine anomalies or prior uterine surgery.
Coagulopathy: Postpartum hemorrhage can be exacerbated by blood clotting disorders such as deficiencies of clotting factors or disseminated intravascular coagulation (DIC).
Inversion of the Uterus: This happens when the uterus ruptures, compressing blood vessels and causing bleeding as a result. A physical examination may be used to diagnose uterine inversion.
Aneurysm or Rupture of the Uterine Artery: Although uncommon, severe bleeding can occur from an aneurysm or uterine artery rupture.
Accreta, Increta, or Percreta placenta: Persistent bleeding may result from the placenta adhering abnormally to the uterine wall. Advanced imaging may be necessary to diagnose these conditions.
Uterine subinvolution: Prolonged bleeding after giving birth may result from a delayed return of the uterus to its standard size and tone.
Infection: Tenderness in the uterus and increased bleeding can be symptoms of postpartum infections, such as endometritis.
Drug-Related Bleeding: Excessive bleeding may be caused by some medications, including anticoagulants and drugs that affect blood clotting.
Vascular deformities: Postpartum hemorrhage is an uncommon side effect of aberrant blood vessel formations in the uterus.
The goal of the step-by-step treatment paradigm for uterine atony is to stabilize the patient, stop the bleeding, and restore uterine tone. Depending on the severity of the ailment and the outcome of early interventions, this paradigm might change.
Prenatal readiness
Blood should be screened and typed if the woman is at a medium risk of experiencing an intrapartum hemorrhage. Previous uterine surgery, multiple gestations, grand multiparity, prior PPH, macrosomia, large fibroids, anemia, macrosomia, prolonged second stage, body mass index higher than 40, chorioamnionitis, oxytocin administration for more than 24 hours, and magnesium sulfate administration are among the women with a medium risk factor for uterine atony-related postpartum hemorrhage. High-risk individuals ought to be classified and cross-matched with other high-risk PPH individuals. Accreta or placental previa, bleeding diathesis, and two or more medium-risk factors for uterine atony are examples of high-risk criteria.
Prevention of Intrapartum
This involves managing the third stage of labor as best as possible. To actively manage the third stage, uterine massage and continuous low-level traction on the umbilical cord are recommended. While waiting until placenta delivery is reasonable, a simultaneous oxytocin infusion is beneficial.
Quick Recognition: Recognize the symptoms of uterine atony as soon as possible. These include signs of shock, a soft and enlarged uterus, and heavy bleeding.
Massage of the uterus: Initiate the massage of the uterus to induce contractions.
During a massage, the lower uterine segment is supported with one hand while the uterine fundus is compressed firmly with the other.
Uterotonic medications: To improve uterine contractions, give uterotonic drugs.
It is common practice to administer oxytocin intravenously or intramuscularly.
Misoprostol, carboprost, and methylergonovine are further options.
Procedures for Emergencies:
Make sure the hospital has well-defined procedures in place for handling obstetric emergencies, such as uterine abortion. Regularly practice drills and simulations to help staff members become familiar with emergency protocols.
Quick Reaction Group: Establish a quick response team that can be called upon in the event of uterine atony.
Obstetricians, anesthetists, nurses, and other essential staff members might be on this team.
Easily Accessible Uterotonic Drugs: Keep uterotonic drugs readily available, such as misoprostol, carboprost, methylergonovine, and oxytocin.
Equipment for Uterine Massage: Sterile gloves and lubricant are essential pieces of equipment for uterine massage.
Make sure the healthcare professionals have received the appropriate uterine massage training.
Kits for Intrauterine Balloon Tamponade: Whenever conservative measures prove ineffective, keep kits for intrauterine balloon tamponade handy.
Oxytocin: The hormone that the pituitary gland produces is synthesized as oxytocin. It affects the uterine smooth muscle cells, which in turn causes uterine contractions.
Methylergonovine: An ergot alkaloid called methylergonovine causes blood vessels to constrict and induces uterine contractions.
Carboprost: A synthetic prostaglandin called carboprost helps regulate bleeding by inducing contractions in the uterus.
Misoprostol: A prostaglandin analog that induces uterine contractions is misoprostol.
Dinoprostone (Prostaglandin E2): Dinoprostone is a prostaglandin that can be used to stimulate uterine contractions.
Tranexamic acid: As an antifibrinolytic, tranexamic acid helps stop blood clots from breaking down, which lessens bleeding.
If medication fails to treat excessive bleeding, surgical procedures are employed.
Techniques for Tamponade:
Bladder drainage through uterine packing with gauze (coupled with vaginal packing to guarantee its retention, resulting in uterovaginal packing) and Foley catheter insertion. Rolled gauze ribbons are a quick and easy way to achieve tight and uniform uterine packing quickly and efficiently.
Bakri balloon with Foley catheter insertion to aid in bladder drainage (with vaginal packing to ensure its retention).
Methods of Surgical Management
Curettage of the uterus for retained products.
O’Leary uterine artery ligation, with the option to extend the ligation to the tubo-ovarian vessels.
B-Lynch and other compression sutures are generally saved for clinical situations in which manual uterine compression results in hemorrhage arrest.
Hypogastric artery ligation (Gyn/Onc performed)
Hysterectomy
The goal of the step-by-step approach to managing uterine atony is to stabilize the patient, restore uterine tone, and control bleeding. Depending on the severity of the ailment and how the initial interventions were received, the phases of management may change. The following summarizes the typical stages of uterine abortion management:
Initial Identification and Evaluation: Identify uterine atony symptoms and signs as soon as possible—clinical evaluation of vital signs, uterine tone, and postpartum hemorrhage.
Determining possible causes and risk factors.
Prompt Interventions: Take prompt action to stop bleeding and induce uterine contractions.
Uterine massage: Manually stimulating the uterus to increase contractions is known as uterine massage. Giving uterotonic drugs—like oxytocin—to cause contractions in the uterus.
Bimanual compression: The uterus is compressed manually to reduce bleeding.
Secondary Interventions: Move on to more sophisticated measures if the first interventions prove insufficient.
Intrauterine balloon tamponade: Pressuring and controlling bleeding within the uterus with a balloon. It may be necessary to try higher dosages or different uterotonic drugs like carboprost or methylergonovine.
Surgical Interventions: To treat uterine atony in severe cases, surgical options may be taken into consideration.
Ligating or clamping the uterine arteries to lower blood flow is known as uterine artery ligation.
Suturing the uterus to compress blood vessels is known as uterine compression sutures (e.g., B-Lynch or Hayman sutures).
Hysterectomy: uterine excision; typically used as a last resort.
Hemodynamic Support: Prevent shock-related complications by stabilizing the patient’s hemodynamic status. Intravenous resuscitation of fluids in cases of hypovolemia—transfusions of blood to keep tissue perfusion and treat anemia.
Post-Intervention Care and Monitoring: Keep a close eye on how the patient is responding to interventions and give them continuing support. Important signs, such as oxygen saturation, heart rate, and blood pressure,are continuously monitored. Uterine tone evaluation and continuous monitoring of postpartum hemorrhage assessment.
Postpartum Monitoring
Make sure you provide complete postpartum care and take care of any lingering problems.
Close observation is needed to look for any problems. Emotional and mental health assessment. Patient education regarding symptoms of complications after giving birth and when to see a doctor.
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