Obstetrical hemorrhage

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

## Overview

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Obstetrical hemorrhage refers to heavy bleeding during pregnancy, labor, or the puerperium. Bleeding may be vaginal and external, or, less commonly but more dangerously, internal, into the abdominal cavity. Typically bleeding is related to the pregnancy itself, but some forms of bleeding are caused by other events. Obstetrical hemorrhage is a major cause of maternal mortality.

## Classification

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### Antepartum Hemorrhage

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#### Early Pregnancy Bleeding

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The most common bleeding event is the loss of a pregnancy, a miscarriage, medically also called an abortion. Bleeding from an early miscarriages may be similar to that of a heavy menstruation, but later on, a pregnancy loss may be accompanied but excessive or prolonged bleeding. A physician may propose to perform a D&C for treatment. An ectopic pregnancy may lead to bleeding, often internally, that could be fatal if untreated.

#### Late Pregnancy Bleeding

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The primary consideration is the presence of a placenta previa, a condition that usually needs to be resolved by delivering the baby via cesarian section. Also a placental abruption can lead to obstetrical hemorrhage, some times concealed.

#### Bleeding During Labor

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Beside placenta previa and placental abruption, uterine rupture can occur as a very serious condition leading to internal or external bleeding. Bleeding from the fetus is rare, usually not heavy, but always very serious for the baby.

### Postpartum Hemorrhage

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Trauma from the delivery may tear tissue and vessels leading to significant postpartum bleeding. Uterine atony refers to the inability of the uterus to contract and may lead to continuous bleeding. Retained placental tissue and infection may contribute to uterine atony (Bleeding from the birth canal >500mL after vaginal delivery and >1000mL after cesarean section delivery).

### Unrelated Bleeding

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Pregnant patients may have bleeding from the reproductive tract due to trauma, including sexual assault, neoplasm, most commonly cervical cancer, and hematologic disorders.

## Causes

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### Common Causes

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* Abruptio placentae
* Cervical laceration
* Chorioamnionitis
* Disorders of coagulation
* Drugs\- Oxytocin
* Excessive uterine distension
* Multiparity
* Placenta accreta
* Placenta previa
* Rapid or prolonged labor
* Retained placenta
* Thrombocytopenia
* Uterine inversion
* Uterine rupture
* Vaginal hematoma

## Diagnosis

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The success of modern obstetrics is based to a good degree on the ability to recognize risk patients for obstetrical hemorrhage and their appropriate management.

### Ultrasound

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* Obstetric ultrasonography

## Treatment

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### Medical Therapy

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* Blood transfusion and pharmacological support

### Surgery

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* Surgical obstetrics

## Related Chapters

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* Gynecologic hemorrhage
* Antepartum haemorrhage

## References

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* v
* t
* e

Pathology of pregnancy, childbirth and the puerperium (O, 630-676)

Pregnancy with abortive outcome|

Ectopic pregnancy \- Hydatidiform mole \- Miscarriage

Oedema, proteinuria and
hypertensive disorders|

Pregnancy-induced hypertension \- Pre-eclampsia \- Eclampsia \- Gestational diabetes

Other, predominantly
related to pregnancy|

Hyperemesis gravidarum \- Gestational pemphigoid \- Intrahepatic cholestasis of pregnancy

Maternal care related to the
fetus and amniotic cavity and
possible delivery problems|

Polyhydramnios \- Oligohydramnios \- Chorioamnionitis \- Premature rupture of membranes \- Amniotic band syndrome \- Placenta praevia \- Braxton Hicks contractions \- Antepartum haemorrhage \- Placental abruption

Complications of
labour and delivery|

Premature birth \- Postmature birth \- Cephalopelvic disproportion \- Dystocia (Shoulder dystocia) - Fetal distress \- Vasa praevia \- Uterine rupture \- hemorrhage \- Placenta accreta \- Umbilical cord prolapse \- Amniotic fluid embolism

Maternal complications
in the weeks after childbirth|

Puerperal fever \- Peripartum cardiomyopathy \- Postpartum thyroiditis \- Galactorrhea \- Postpartum depression

Complications related to the fetus|

Fetal intervention \- Fetal surgery

Other|

Maternal death

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