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Obstetrical bleeding also known as obstetrical hemorrhage and maternal hemorrhage, refers to heavy bleeding during pregnancy, labor, or the postpartum period. Bleeding may be vaginal 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.

The most frequent cause of maternal mortality worldwide is severe hemorrhage with 8.7 million cases occurring in 2015[1] and 83,000 of those events resulting in maternal death[2]. Between 2003 and 2009, hemorrhage accounted for 27.1% of all maternal deaths globally.[3]

Early pregnancy

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In ICD-10, early pregnancy bleeding (code O20.9) refers to obstetrical hemorrhage before 20 completed weeks of gestational age.[4][5]

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.[6][7]

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.[5][6]

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

Other causes of early pregnancy bleeding may include:

  • Postcoital bleeding, which is vaginal bleeding after sexual intercourse that can be normal with pregnancy 
  • Iatrogenic causes, or bleeding due to medical treatment or intervention, such as sex steroids, anticoagulants, or intrauterine contraceptive devices[10]

Later pregnancy

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Main article: Antepartum bleeding

Antepartum bleeding (APH), also prepartum hemorrhage, is bleeding during pregnancy from the 24th week[12] (sometimes defined as from the 20th week[13][12]) gestational age to term (40th week). The primary consideration is the presence of a placenta previa which is a low lying placenta at or very near to the internal cervical os. This condition occurs in roughly 4 out of 1000 pregnancies[14] and 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, sometimes concealed. This pathology is of important consideration after maternal trauma such as a motor vehicle accident or fall.

Other considerations to include when assessing antepartum bleeding are: sterile vaginal exams that are performed in order to assess dilation of the patient when the 40th week is approaching. As well as cervical insufficiency defined as a midtrimester (14th-26th week) dilation of the cervix which may need medical intervention to assist in keeping the pregnancy sustainable.[15]

During labor

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Besides placenta previa and placental abruption, uterine rupture can occur, which is a very serious condition leading to internal or external bleeding. Bleeding from the fetus is rare, but may occur with two conditions called vasa previa and velamentous umbilical cord insertion where the fetal blood vessels lie near the placental insertion site unprotected by Wharton's jelly of the cord[16]. 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.

After delivery

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Main article: 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 postpartum bleeding are hemodynamic instability, drop of hemoglobin of more than 10%,[17] or requiring blood transfusion. In the literature, primary postpartum hemorrhage is defined as uncontrolled bleeding that occurs in the first 24 hours after delivery while secondary hemorrhage occurs between 24 hours and six weeks.[18]

Risk factors

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In rare cases, inherited bleeding disorders, like hemophilia, von Willebrand disease (vWD), or factor IX or XI deficiency, may cause severe postpartum hemorrhage, with an increased risk of death particularly in the postpartum period.[18] The risk of postpartum hemorrhage in patients with vWD and carriers of hemophilia has been found to be 18.5% and 22% respectively. This pathology occurs due to the normal physiological drop in maternal clotting factors after delivery which greatly increases the risk of secondary postpartum hemorrhage.[19]

Another bleeding risk factor is thrombocytopenia, or decreased platelet levels, which is the most common hematological change associated with pregnancy induced hypertension. If platelet counts drop less than 100,000 per microliter the patient will be at a severe risk for inability to clot during and after delivery.[20]

Medical tests

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If a small amount of bleeding is seen in early pregnancy a physician may request:

  • A quantitative human chorionic gonadotropin (hCG) blood test to confirm the pregnancy or assist in diagnosing a potential miscarriage[21]
  • Transvaginal pelvic ultrasonography to confirm that the pregnancy is not outside of the uterus[21]
  • Blood type and Rh test to rule out hemolytic disease of the newborn[21]

For bleeding seen in later pregnancy tests may include:

Unrelated bleeding

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Pregnant patients may have bleeding from the reproductive tract due to trauma, including sexual trauma, neoplasm, most commonly cervical cancer, and hematologic disorders. Molar pregnancy also called hydatiform mole is a type of pregnancy where the sperm and the egg have joined within the uterus but instead of making an embryo it creates a cyst resembling a grape-like cluster. Bleeding can be an early sign of this tumor developing.[23]

References

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  1. ^ GBD 2015 Disease and Injury Incidence and Prevalence, Collaborators. (8 October 2016). "Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.". Lancet (London, England). 388 (10053): 1545–1602. PMC 5055577 . PMID 27733282. doi:10.1016/S0140-6736(16)31678-6.
  2. ^ GBD 2015 Mortality and Causes of Death, Collaborators. (8 October 2016). "Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015.". Lancet (London, England). 388(10053): 1459–1544. PMC 5388903 . PMID 27733281. doi:10.1016/s0140-6736(16)31012-1
  3. ^ Say, Lale; et al. (June 2014). "Global causes of maternal death: a WHO systematic analysis". The Lancet Global Health. 2 (6): e323–e333. doi:10.1016/S2214-109X(14)70227-X. PMID 25103301. {{cite journal}}: Explicit use of et al. in: |last= (help)
  4. ^ page 436 in: 2013 ICD-10-CM Draft Edition, by Carol J. Buck, Elsevier Health Sciences, 2013. ISBN 9781455774883
  5. ^ 2014 ICD-10-CM Diagnosis Code O20.9 from 2014 ICD-10-CM/PCS Medical Coding Reference].
  6. ^ Pregnancy, Bleeding. eMedicineHealth. URL: http://www.emedicinehealth.com/pregnancy_bleeding/article_em.htm. Accessed on: April 12, 2009
  7. ^  Elective Abortion at eMedicine
  8. ^ Hasan, R.; Baird, D. D.; Herring, A. H.; Olshan, A. F.; Jonsson Funk, M. L.; Hartmann, K. E. (2009). "Association Between First-Trimester Vaginal Bleeding and Miscarriage". Obstetrics & Gynecology. 114 (4): 860–867. doi:10.1097/AOG.0b013e3181b79796
  9. ^ Kirk, E.; Bottomley, C.; Bourne, T. (2013). "Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location". Human Reproduction Update. 20 (2): 250–61. PMID 24101604. doi:10.1093/humupd/dmt047
  10. ^ Brenner, Paul (September 1996). "Differential diagnosis of abnormal uterine bleeding". American Journal of Obstetrics and Gynecology. 175 (3 Pt 2): 766–769. doi:10.1016/S0002-9378(96)80082-2. PMID 8828559.
  11. ^ Ricardo Gómez, Roberto Romero, Jyh Kae Nien, Luis Medina, Mario Carstens, Yeon Mee Kim, Tinnakorn Chaiworapongsa, Jimmy Espinoza & Rogelio González (August 2009). "Idiopathic vaginal bleeding during pregnancy as the only clinical manifestation of intrauterine infection". The Journal of Maternal-Fetal & Neonatal Medicine. 18: 31–37.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ^ a b  patient.info » PatientPlus » Antepartum Haemorrhage Last Updated: 5 May 2009
  13. ^ The Royal Women’s Hospital > antepartum haemorrhage Retrieved on Jan 13, 2009
  14. ^ Soyama H, Miyamoto M, Ishibashi H, Takano M, Sasa H, Furuya K (2016) Relation between Birth Weight and Intraoperative Hemorrhage during Cesarean Section in Pregnancy with Placenta Previa. PLoS ONE 11(11): e0167332. doi:10.1371/journal.pone.0167332 
  15. ^ Berghella, MD, Vincenzo (July 2017). "Cervical insufficiency". UpToDate.
  16. ^ Charles J Lockwood, MD, MHCM Karen Russo-Stieglitz, MD (July 2017). "Velamentous umbilical cord insertion and vasa previa". UpToDate.{{cite web}}: CS1 maint: multiple names: authors list (link)
  17. ^ Atukunda EC, Mugyenyi GR, Obua C, Atuhumuza EB, Musinguzi N, Tornes YF, et al. (2016) Measuring Post-Partum Haemorrhage in Low-Resource Settings: The Diagnostic Validity of Weighed Blood Loss versus Quantitative Changes in Hemoglobin. PLoS ONE 11(4): e0152408. https://doi.org/10.1371/journal.pone.0152408
  18. ^ a b Global burden of maternal haemorrhage in the year 2000 Carmen Dolea1, Carla AbouZahr2 , Claudia Stein1 Evidence and Information for Policy (EIP), World Health Organization, Geneva, July 2003
  19. ^ Kadir, R. A. and Aledort, L. M. (2000), Obstetrical and gynaecological bleeding: a common presenting symptom. Clinical & Laboratory Haematology, 22: 12–16. doi:10.1046/j.1365-2257.2000.00007.x
  20. ^ Aldred, Heather E. (1997). Pregnancy and birth sourcebook. health reference series. pp. 598–599. ISBN 9780780802162.
  21. ^ a b c R. Phillip Heine, MD; Geeta K. Swamy, MD (August 2009). "Vaginal Bleeding During Early Pregnancy". Merck Manual.{{cite web}}: CS1 maint: multiple names: authors list (link)
  22. ^ a b c R. Phillip Heine, MD; Geeta K. Swamy, MD (August 2009). "Vaginal Bleeding During Late Pregnancy". Merck Manual.{{cite web}}: CS1 maint: multiple names: authors list (link)
  23. ^ Aldred, Heather E. (1997). Pregnancy and birth sourcebook. Omnigraphics. pp. 547–551. ISBN 9780780802162.
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