Obstetrical bleeding is

bleeding Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...

pregnancy Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but ca ...

that occurs

before Before is the opposite of after, and may refer to: * ''Before'' (Gold Panda EP), 2009 * ''Before'' (James Blake EP), 2020 * "Before" (song), a 1996 song by the Pet Shop Boys * "Before", a song by the Empire of the Sun from ''Two Vines'' * "Befo ...

, during, or after childbirth. Bleeding before childbirth is that which occurs after 24 weeks of pregnancy. Bleeding may be vaginal or less commonly into the abdominal cavity. Bleeding which occurs before 24 weeks is known as

early pregnancy bleeding Early pregnancy bleeding (also called first trimester bleeding) refers to vaginal bleeding before 14 weeks of Gestational age (obstetrics), gestational age. If the bleeding is significant, hemorrhagic shock may occur. Concern for shock is increase ...

. Causes of bleeding before and during childbirth include

cervicitis Cervicitis is inflammation of the uterine cervix. Cervicitis in women has many features in common with urethritis in men and many cases are caused by sexually transmitted infections. Non-infectious causes of cervicitis can include intrauterine d ...

placenta previa Placenta praevia is when the placenta attaches inside the uterus but in a position near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated wi ...

placental abruption Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerou ...

and

uterine rupture Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth. Symptoms, while classically including increased pain, vaginal bleeding, or a change in contractions, are not always present. Disability or death of the ...

. Causes of bleeding after childbirth include poor contraction of the uterus,

retained products of conception Retained placenta is a condition in which all or part of the placenta or membranes remain in the uterus during the third stage of labour. Retained placenta can be broadly divided into: * failed separation of the placenta from the uterine lining * p ...

, and bleeding disorders. About 8.7 million cases of severe maternal bleeding occurred in 2015 resulting in 83,000 deaths. Between 2003 and 2009, bleeding accounted for 27% of maternal deaths globally.

Later pregnancy

Antepartum bleeding Antepartum bleeding, also known as antepartum haemorrhage (APH) or prepartum hemorrhage, is genital bleeding during pregnancy after the 28th week of pregnancy up to delivery. It can be associated with reduced fetal birth weight. Use of aspirin b ...

(APH), also prepartum hemorrhage, is bleeding during pregnancy from the 24th weekpatient.info » PatientPlus » Antepartum Haemorrhage
Last Updated: 5 May 2009 (sometimes defined as from the 20th week)

gestational age In obstetrics, gestational age is a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period (LMP), or the corresponding age of the gestation as estimated by a more accurate method if available. Suc ...

up to the birth of the baby. The primary consideration is the presence of a

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 and usually needs to be resolved by delivering the baby via

cesarean section Caesarean section, also known as C-section or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen, often performed because vaginal delivery would put the baby or mo ...

. Also a placental

abruption Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 Gestational age (obstetrics), weeks of pregnancy. Symptoms may include vaginal bleeding, lower ...

(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.

During labor

Besides placenta previa and placental abruption,

can occur, which is a very serious condition leading to internal or external bleeding. Bleeding from the

fetus A fetus or foetus (; plural fetuses, feti, foetuses, or foeti) is the unborn offspring that develops from an animal embryo. Following embryonic development the fetal stage of development takes place. In human prenatal development, fetal deve ...

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. 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

Abnormal bleeding after delivery, or postpartum hemorrhage, is the loss of greater than 500 ml of blood following vaginal delivery, or 1000 ml of blood following cesarean section. Other definitions of excessive postpartum bleeding are hemodynamic instability, drop of hemoglobin of more than 10%, 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.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

Risk factors

In rare cases, inherited bleeding disorders, like

hemophilia Haemophilia, or hemophilia (), is a mostly inherited genetic disorder that impairs the body's ability to make blood clots, a process needed to stop bleeding. This results in people bleeding for a longer time after an injury, easy bruising, ...

von Willebrand disease Von Willebrand disease (VWD) is the most common hereditary blood-clotting disorder in humans. An acquired form can sometimes result from other medical conditions. It arises from a deficiency in the quality or quantity of von Willebrand factor ( ...

(vWD), or

factor IX Factor IX (or Christmas factor) () is one of the serine proteases of the coagulation system; it belongs to peptidase family S1. Deficiency of this protein causes haemophilia B. It was discovered in 1952 after a young boy named Stephen Christmas w ...

or XI deficiency, may cause severe postpartum hemorrhage, with an increased risk of death particularly in the postpartum period. 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. 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.

Medical tests

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 * Transvaginal pelvic ultrasonography to confirm that the pregnancy is not outside of the uterus * Blood type and Rh test to rule out

hemolytic disease of the newborn Hemolytic disease of the newborn, also known as hemolytic disease of the fetus and newborn, HDN, HDFN, or erythroblastosis foetalis, is an alloimmune condition that develops in a fetus at or around birth, when the IgG molecules (one of the five ...

For bleeding seen in later pregnancy tests may include: * Complete blood count (CBC) and blood type and screen * Ultrasound to determine placental location * Kleihauer-Betke (KB) test especially if there was maternal trauma

Unrelated bleeding

Pregnant patients may have bleeding from the reproductive tract due to trauma, including sexual trauma, neoplasm, most commonly

cervical cancer Cervical cancer is a cancer arising from the cervix. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Early on, typically no symptoms are seen. Later symptoms may include abnormal ...

, and

hematologic disorder Hematologic diseases are disorders which primarily affect the blood & blood-forming organs. Hematologic diseases include rare genetic disorders, anemia, HIV, sickle cell disease & complications from chemotherapy or transfusions. Myeloid * Hemog ...

s. Molar pregnancy (also called hydatiform mole) is a type of pregnancy where the sperm and the egg have joined within the uterus, but the result is a cyst resembling a grape-like cluster rather than an embryo. Bleeding can be an early sign of this tumor developing.

References

External links

{{DEFAULTSORT:Obstetrical Hemorrhage Medical emergencies Complications of labour and delivery Health issues in pregnancy Women's health