Uterine atony
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adnan Ezici, M.D[2]
Overview
Historical Perspective
In 1953, Du Vigneaud et al. were the first to discover the aminoacid sequence of oxytocin and its biochemical synthesis. Following his discoveries about polypeptide hormones, The Nobel Prize for chemistry was awarded to Vincent du Vigneaud in 1955.[1][2]
Classification
There is no established system for the classification of uterine atony.
Pathophysiology
It is thought that the uterine atony is caused by inadequate contraction of the myometrium following the delivery. Physiologically, contraction of the myometrium occurs in response to oxytocin, therefore, mediates the uterine hemostasis by mechanically compressing the blood vessels supplying the placenta.[3]
Causes and Risk Factors
Common risk factors in the development of uterine atony include:[4][5][6]
- Uterine overdistention
- Intrinsic factors
- Advanced maternal age
- Obesity
- Maternal race/ethnicity (Hispanic and non-Hispanic white)
- Previous postpartum hemorrhage
- Anemia
- Preeclampsia
- Fibroids
- Delivery-related factors
- Prolonged labor
- Precipitate labor
- Prolonged use of oxytocin
- Induction of labor
- Manual removal of placenta
- Chorioamnionitis
- Administration of magnesium sulfate
- Administration of inhaled anesthetic agents
Differentiating Uterine Atony from other Diseases
Uterine atony must be differentiated from other diseases that cause postpartum hemorrhage, such as retained placental tissue, obstetric lacerations, placenta accreta spectrum (placenta accreta, increta, and percreta), uterine inversion, maternal coagulation defects, and disseminated intravascular coagulation (DIC)[7]
- Detection of the uterine atony might be challenging in the presence of uterine inversion which causes the absence of typical findings of uterine atony such as soft and boggy uterus. The specific finding of uterine inversion is a visible protruding mass through the vagina.[3]
Epidemiology and Demographics
Uterine atony is responsible for up to 80% of cases of postpartum hemorrhage, and approximately 25% of maternal deaths are due to postpartum hemorrhage, which is the leading cause of maternal deaths.[4][8]
Screening
There is insufficient evidence to recommend routine screening for uterine atony. However, identifying the risk factors might provide a better prediction of women at risk for uterine atony, therefore, planning and preparation might be provided more sufficiently.[4]
Natural History, Complications, and Prognosis
- Previous history of postpartum hemorrhage increases the risk of recurrence by up to 15% in the next pregnancy.[3]
- Common complications of uterine atony include:[9][10][3]
- Postpartum anemia
- Hypovolemic shock
- Disseminated intravascular coagulation (DIC)
- Transfusion-associated morbidities (transfusion-related acute lung injury (TRALI), transfusion-associated volume overload)
- Acute respiratory distress syndrome (ARDS)
- Uterine necrosis
Diagnosis
Diagnostic Study of Choice
For the diagnostic definition of postpartum hemorrhage, click here.
History and Symptoms
- A detailed prenatal history is important for the detection of risk factors in the development of uterine atony.[3]
- The hallmark of postpartum hemorrhage is hypovolemia. For more symptoms of postpartum hemorrhage, click here.
Physical Examination
Abdominal examination by palpation is one of the main methods of physical examination in the diagnosis of uterine atony. Palpation of the uterus might be either direct (following the cesarean delivery) or indirect (bimanual examination after the vaginal delivery).[3]
- The presence of a soft, large and boggy uterus on physical examination is highly suggestive of uterine atony.[11]
- In case of focal localized atony of the uterine lower segments with normal contraction of uterine fundus, it might be challenging to detect the uterine atony with abdominal examination. Thus, manual exploration of the uterine cavity or ultrasound imaging might be useful in suspected cases.
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References
- ↑ Prata N, Bell S, Weidert K (2013). "Prevention of postpartum hemorrhage in low-resource settings: current perspectives". Int J Womens Health. 5: 737–52. doi:10.2147/IJWH.S51661. PMC 3833941. PMID 24259988.
- ↑ Ragnarsson U (July 2007). "The Nobel trail of Vincent du Vigneaud". J Pept Sci. 13 (7): 431–3. doi:10.1002/psc.864. PMID 17554806.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Gill P, Patel A, Van Hook JW. PMID 29630290. Missing or empty
|title=(help) - ↑ 4.0 4.1 4.2 Wetta LA, Szychowski JM, Seals S, Mancuso MS, Biggio JR, Tita AT (July 2013). "Risk factors for uterine atony/postpartum hemorrhage requiring treatment after vaginal delivery". Am J Obstet Gynecol. 209 (1): 51.e1–6. doi:10.1016/j.ajog.2013.03.011. PMC 3788839. PMID 23507549.
- ↑ Oyelese Y, Ananth CV (March 2010). "Postpartum hemorrhage: epidemiology, risk factors, and causes". Clin Obstet Gynecol. 53 (1): 147–56. doi:10.1097/GRF.0b013e3181cc406d. PMID 20142652.
- ↑ Breathnach F, Geary M (April 2009). "Uterine atony: definition, prevention, nonsurgical management, and uterine tamponade". Semin Perinatol. 33 (2): 82–7. doi:10.1053/j.semperi.2008.12.001. PMID 19324236.
- ↑ "ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage". Obstet Gynecol. 108 (4): 1039–47. October 2006. doi:10.1097/00006250-200610000-00046. PMID 17012482.
- ↑ Fukami T, Koga H, Goto M, Ando M, Matsuoka S, Tohyama A, Yamamoto H, Nakamura S, Koyanagi T, To Y, Kondo H, Eguchi F, Tsujioka H (2019). "Incidence and risk factors for postpartum hemorrhage among transvaginal deliveries at a tertiary perinatal medical facility in Japan". PLoS One. 14 (1): e0208873. doi:10.1371/journal.pone.0208873. PMC 6326562. PMID 30625154.
- ↑ Bienstock JL, Eke AC, Hueppchen NA (2021). "Postpartum Hemorrhage". N Engl J Med. 384 (17): 1635–1645. doi:10.1056/NEJMra1513247. PMID 33913640 Check
|pmid=value (help). - ↑ Kaya B, Tuten A, Daglar K, Onkun M, Sucu S, Dogan A, Unal O, Guralp O (May 2015). "B-Lynch uterine compression sutures in the conservative surgical management of uterine atony". Arch Gynecol Obstet. 291 (5): 1005–14. doi:10.1007/s00404-014-3511-2. PMID 25315382.
- ↑ Quiñones JN, Uxer JB, Gogle J, Scorza WE, Smulian JC (March 2010). "Clinical evaluation during postpartum hemorrhage". Clin Obstet Gynecol. 53 (1): 157–64. doi:10.1097/GRF.0b013e3181cd5d36. PMID 20142653.