Obstetrical hemorrhage Classification and external resources
ICD-10	O20, O46, O67, O72

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

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

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

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.

After delivery (Postpartum)

Postpartum hemorrhage is the loss of ≥500mL of blood, and is the most common cause of death of the delivering mother within the developed world.^[1] Causes of postpartum hemorrhage are generally broken down into four categories, commonly called "The Four T's":

• Trauma from the delivery may tear tissue and vessels leading to significant postpartum bleeding.
• Uterine atony (Tone) 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.
• Tissue refers to any cellular debris from the placenta or fetus that may be left in the uterus, causing the uterus to not contract.
• Thrombin refers to some failure of clotting, such as with diseases known as coagulopathies.

Unrelated bleeding

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

Management

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. Key in this are methods of examination, including obstetric ultrasonography, surgical obstetrics, blood transfusion, and pharmacological support.

In developing countries, deaths from obstetrical hemorrhage are very high. It has been recognized that to reduce morbidity and death, it is necessary to prevent obstetric hemorrhage and reduce the impact of hemorrhage when it does occur through early diagnosis and timely, appropriate management. Three simple technologies have been used to prevent and manage post-partum hemorrhage. These are: use of misoprostol prophylactically immediately after childbirth, which has been shown to prevent post-partum hemorrhage by 50% ^[2] a blood drape, which collects and measures blood loss, allowing for early recognition of hemorrhage ^[3] and the non-pneumatic anti-shock garment which can be used to stabilize and resuscitate a woman, and keep her alive while she is being transported for further treatment or waiting at a facility for care ^[4].

See also

• Gynecologic hemorrhage
• Antepartum haemorrhage

Footnotes

1. ^ Anderson JM, Etches D. (15). "Prevention and Management of Postpartum Hemorrhage". American Family Physician 75 (6): 875–882. PMID 17390600. Retrieved on 2007-12-01. [A discussion of postpartum hemorrhage, including how to identify, manage and prevent it. Lay summary]. 
2. ^ Derman RJ, Kadkany BS, Goudar SS, Geller SE, Naik VA, Bellad MB, et el. Oral misoprostol in preventing postpartum hemorrhage in resource-poor communities: a randomized controlled trial. The Lancet 2006; 368:1248-53.
3. ^ Patel A, Gouder SS, Geller S, Kodkany BS, Edlavitch SA, Wagh K, et al. Drape estimation versus visual assessment for estimating postpartum hemorrhage. International Journal of Gynaecology and Obstetrics 2006; 93:220-4.
4. ^ Miller S, Turan JM, Dau K, Fathalla M, Mourad M, Sutherland T, et al. Use of the non-pneumatic anti-shock garment (NASG) to reduce blood loss and time to recovery from shock for women with obstetric haemorrhage in Egypt. Global Public Health 2007; 2:110-24.