Lochia bardale
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lochia types stages postpartum discharge clinical features
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Lochia (ሎኪያ / Bardale)
Lochia is the vaginal discharge that follows childbirth (delivery). It results from the autolysis of the placental implantation site on the endometrial surface as the uterus involutes back to its pre-pregnancy state. The word "bardale" is the Amharic/Ethiopian term commonly used to refer to this postpartum discharge.
Composition
Lochia contains:
- Blood and blood clots
- Mucus
- Decidual tissue (shed uterine lining)
- Necrotic material from the placental site
- Cervical and vaginal secretions
It has a characteristic sour, disagreeable odor (similar to menstrual discharge but more distinct).
Three Stages of Lochia
| Stage | Duration | Color | Description |
|---|---|---|---|
| Lochia Rubra (Red) | Days 1-4 to 5 | Bright red | Contains blood and large clots; heaviest flow |
| Lochia Serosa (Serous) | Days 5-9 (next ~4 days) | Pinkish-brown / pale serous | Becomes more watery and paler; decreasing volume |
| Lochia Alba (White) | Day 9 onward (up to 3 weeks) | Yellowish-grey, yellowish-white, or turbid | Minimal blood; creamy-white discharge |
Total duration is normally 2 to 3 weeks (up to 6 weeks in some women). After a cesarean section, the volume is generally less than after a vaginal delivery.
Physiology
During uterine involution, the placental site on the endometrium autolyzes and the uterus sheds this material as lochia. This process is accompanied by:
- Progressive uterine contraction and involution (uterus returns to ~100-120 g by 6 weeks)
- Re-epithelialization of the endometrial surface after about 10 days
- A temporary leukocytosis (WBC can reach 20,000/µL in the first 24 hours postpartum)
Breastfeeding promotes uterine contraction via oxytocin release, which can accelerate involution and reduce lochia duration.
Abnormal Lochia (Warning Signs)
Normal lochia should be monitored carefully. The following features are abnormal and require evaluation:
| Sign | Possible Cause |
|---|---|
| Foul-smelling (purulent) lochia | Postpartum endometritis (uterine infection) |
| Heavy, prolonged bright red bleeding beyond day 5 | Subinvolution of uterus, retained placental fragments |
| Fever + foul lochia + uterine tenderness | Puerperal sepsis |
| Sudden resumption of heavy red bleeding after it had lightened | Secondary postpartum hemorrhage |
Postpartum endometritis presents with: fever, malodorous lochia, uterine tenderness, abdominal pain, leukocytosis, and tachycardia. It is a polymicrobial infection and requires prompt antibiotic therapy.
Clinical Significance (Forensic Medicine)
Lochia is one of the key signs of recent delivery in a living woman:
- Presence of lochia rubra confirms delivery within the past 4-5 days
- Lochia serosa: delivery ~5-9 days prior
- Lochia alba: delivery ~9 days to 3 weeks prior
- Combined with uterine size, cervical changes, and a positive pregnancy test (positive for ~1-2 weeks post-delivery), lochia helps establish the timing of recent delivery.
Sources:
- The Essentials of Forensic Medicine and Toxicology, 36th ed. - Signs of Recent Delivery
- Textbook of Family Medicine, 9e - The Puerperium
- Guyton and Hall Textbook of Medical Physiology - Involution of the Uterus After Parturition
Types of abortion
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Types of Abortion
Abortion is defined as the expulsion or extraction of a fetus or embryo weighing 500 g or less, OR before 20-28 weeks of gestation (varies by definition), OR measuring 25 cm or less crown-to-heel length.
A. Classification by Cause
1. Spontaneous (Natural) Abortion
Occurs due to natural causes, without any deliberate intervention. Incidence: 5-20% of all recognized pregnancies (average ~10%).
Common causes:
- Fetal abnormalities (accounts for ~50% of all abortions) - chromosomal errors, maldevelopment
- Maternal infections (malaria, typhoid, syphilis, rubella, etc.)
- Uterine abnormalities (fibroids, Asherman syndrome)
- Hormonal/endocrine disorders
- Immunological factors (antiphospholipid syndrome)
- Accidental trauma
2. Induced (Artificial) Abortion
Deliberate termination of pregnancy. Subdivided into:
- Justifiable (Therapeutic): Performed legally for medical indications (e.g., maternal health risk, fetal abnormality)
- Criminal: Performed unlawfully without proper medical indication
B. Clinical Classification (Types Based on Presentation)
| Type | Cervical Os | Key Features |
|---|---|---|
| Threatened | Closed | Vaginal bleeding ± mild cramping; fetus still viable |
| Inevitable | Dilated / Open | Bleeding + severe pain + uterine contractions; expulsion cannot be stopped |
| Incomplete | Dilated | Some products of conception (POC) passed, but part retained (usually placenta) |
| Complete | Closed (after) | All POC fully expelled; bleeding and pain subside |
| Missed | Closed | Fetal death in utero, no expulsion; uterus fails to grow |
| Septic | Variable | Any abortion complicated by uterine infection |
| Habitual / Recurrent | - | Three or more consecutive spontaneous abortions |
Detailed Notes on Each Type
1. Threatened Abortion
- Vaginal bleeding through a closed cervical os before 20 weeks
- Mild lower abdominal pain or cramping may be present
- Pregnancy is still viable - may or may not progress to inevitable abortion
- Management: Bed rest, pelvic rest, progesterone support; serial hCG + ultrasound monitoring
2. Inevitable Abortion
- Bleeding + dilated cervical os, with or without rupture of membranes
- Severe uterine contractions present
- Expulsion of the fetus cannot be prevented
- Management: Uterine evacuation (suction curettage or medical management)
3. Incomplete Abortion
- Part of the products of conception has been expelled, but some (usually the placenta/membranes) are retained in utero
- Continuous bleeding from the placental site; patient may present with severe anemia
- Cervical os is dilated
- Management: Surgical evacuation (suction/sharp curettage) + ergometrine to promote uterine contraction
4. Complete Abortion
- All products of conception are expelled spontaneously
- Bleeding and pain decrease after expulsion
- Cervical os closes
- Management: Expectant; confirm with ultrasound (empty uterus)
5. Missed Abortion (Silent/Delayed Abortion)
- Fetus dies in utero but is not expelled - retained for weeks/months
- History: normal pregnancy symptoms initially, then slight brown spotting that stops, then amenorrhea
- Uterus does not enlarge (size < dates)
- Brown discharge per vaginum after several weeks
- Products may undergo carneous (fleshy) degeneration - forming a carneous mole or blood mole
- Risk of disseminated intravascular coagulation (DIC) if retained for weeks
- Management: Medical (misoprostol) or surgical evacuation
6. Septic Abortion
- Any abortion (spontaneous or induced) complicated by intrauterine infection
- Features: fever, foul-smelling offensive discharge, uterine tenderness, pelvic pain, tachycardia, leukocytosis
- Often polymicrobial (common after criminal/unsafe abortions)
- Can progress to septicemia, septic shock, and multiorgan failure
- Management: IV broad-spectrum antibiotics + uterine evacuation
7. Habitual / Recurrent Abortion
- Defined as 3 or more consecutive spontaneous pregnancy losses
- Requires thorough workup: uterine anatomy, genetic karyotyping (both partners), thrombophilia screen (antiphospholipid antibodies), hormonal evaluation
- Causes: antiphospholipid syndrome, uterine anomalies, chromosomal translocations, luteal phase defect
C. Classification by Ultrasound
| Ultrasound Finding | Diagnosis |
|---|---|
| Gestational sac present, fetal pole present, no cardiac activity | Embryonic/fetal demise |
| Gestational sac >16-45 mm, no fetal pole | Anembryonic pregnancy (Blighted ovum) |
| Intrauterine POC still present | Incomplete abortion |
| Empty uterine cavity (after bleeding) | Complete abortion |
Summary Table
| Type | OS | Bleeding | Pain | POC Passed | USG |
|---|---|---|---|---|---|
| Threatened | Closed | Mild | Mild | No | Viable fetus |
| Inevitable | Open | Heavy | Severe | No | Viable fetus (still) |
| Incomplete | Open | Heavy | Moderate | Partial | POC retained |
| Complete | Closed | Diminishing | Resolved | Yes (all) | Empty uterus |
| Missed | Closed | Brown spotting | None | No | No cardiac activity |
| Septic | Variable | + offensive | + | Variable | Variable |
Sources:
- P.C. Dikshit Textbook of Forensic Medicine and Toxicology - Classification of Abortion
- Swanson's Family Medicine Review - Spontaneous Abortion
- Berek & Novak's Gynecology - Abnormal Intrauterine Pregnancy
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