Obstetrical hemorrhage

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.

Early pregnancy bleeding

In ICD-10, early pregnancy bleeding (code O20.9) refers to obstetrical hemorrhage before 20 completed weeks of gestational age.^[1][2]

First trimester bleeding, is obstetrical hemorrhage in the first trimester (0 weeks-12 weeks of gestational age). First trimester bleeding is a common occurrence and estimated to occur in approximately 25% of all (clinically recognized) pregnancies.^[3][4]

Differential diagnosis of first trimester bleeding is as follows, with the mnemonic AGE IS Low (during first trimester):

• Abortion (spontaneous), that is, miscarriage. One study came to the result that the risk of miscarriage during the course of the pregnancy with just spotting during the first trimester was 9%, and with light bleeding 12%, compared to 12% in pregnancies without any first trimester bleeding. However, heavy first trimester bleeding was estimated to have a miscarriage risk of 24%.^[5]
• Gestational trophoblastic neoplasia
• Ectopic pregnancy, which implies a pregnancy outside the uterus, commonly in the tube, and may lead to bleeding, internally, that could be fatal if untreated. In cases where there is a heavy bleeding and an obstetric ultrasonography comes to the result of pregnancy of unknown location (no visible intrauterine pregnancy), is has been estimated that approximately 6% have an underlying ectopic pregnancy.^[6]
• Implantation bleeding
• Chorionic hematoma
• Spotting
• Lower GU tract causes
  • Vaginal bleed
  • Cervical bleed

Antepartum bleeding

Antepartum bleeding (APH), also prepartum hemorrhage, is bleeding during pregnancy from the ^[7] 24th week (sometimes defined as from the 20th week^[7][8]) gestational age to term. The primary consideration is the presence of a placenta previa that is a low lying placenta, a condition that usually needs to be resolved by delivering the baby via cesarean section. Also a placental abruption (in which there is premature separation of the placenta) can lead to obstetrical hemorrhage, some times concealed.

Bleeding during labor

Besides 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. This condition is called as Vasa Previa. Occasionally this condition can be diagnosed by ultrasound. There are also tests to differentiate maternal blood from fetal blood which can help in determining the source of the bleed.^[9]

Postpartum bleeding

Bleeding after delivery, or postpartum bleeding, is the loss of greater than 500 ml of blood following vaginal delivery, or 1000 ml of blood following cesarean section. Other definitions of post partum bleeding are haemodynamic instability, drop of haemoglobin of more than 1 g % or requiring blood transfusion.

Unrelated bleeding

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

See also

• Gynecologic hemorrhage
• Non-pneumatic anti-shock garment

References