Obstetrical bleeding

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Obstetrical bleeding
Other names: Maternal bleeding, obstetrical hemorrhage, maternal hemorrhage
TypesLate pregnancy, during labor, postpartum[1]
CausesLate pregnancy: Cervicitis, placenta previa, placental abruption, uterine rupture[1][2]
After childbirth: Poor contraction of the uterus, retained products of conception, bleeding disorders[1]
TreatmentIntravenous fluids, blood products[3]
MedicationRhIG, corticosteroids, oxytocin[3][4]
Frequency8.7 million (2015)[5]
Deaths83,000 (2015)[6]

Obstetrical bleeding is bleeding in pregnancy that occurs after 24 weeks of pregnancy, during childbirth, or after childbirth.[1] Bleeding which occurs before 24 weeks is known as early pregnancy bleeding.[2] Bleeding is generally vaginal and less commonly into the abdominal cavity.[7] Complications may include premature delivery and fetal death.[1]

Causes of bleeding before and during childbirth include cervicitis, placenta previa, placental abruption, and uterine rupture.[1][2] Causes of bleeding after childbirth include poor contraction of the uterus, retained products of conception, and bleeding disorders.[1] Before childbirth the cause can be assessed with a sterile speculum exam and ultrasound.[3]

Treatment of significant bleeding involved providing intravenous fluids and blood products.[3] RhIG is recommended for those who are Rh negative.[3] In those less than 34 weeks pregnant, corticosteroids are also recommended.[3] Other efforts depend on the underlying cause.[3] After delivery oxytocin or methylergonovine may be used.[4]

About 8.7 million cases of severe maternal bleeding occurred in 2015,[5] resulting in 83,000 death.[6] Between 2003 and 2009, bleeding accounted for 27% of maternal deaths globally.[8] Bleeding before childbirth occurs in about 2% to 5% of pregnancies.[1]

Late pregnancy

Late pregnancy bleeding, also known as antepartum bleeding (APH) or prepartum bleeding, is bleeding during pregnancy from the 24th week[9] (sometimes defined as from the 20th week[10][9]) gestational age up to the birth of the baby.[2] 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 [11] pregnancies 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.[12]

During labor

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.[13] 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%,[14] 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.[15]

Risk factors

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.[15] 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.[16] 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.[17]


For bleeding seen in later pregnancy tests may include:

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 [18]
  • Transvaginal pelvic ultrasonography to confirm that the pregnancy is not outside of the uterus[18]
  • Blood type and Rh test to rule out hemolytic disease of the newborn[18]

Differential diagnosis

Pregnant women 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 the result is a cyst resembling a grape-like cluster rather than an embryo. Bleeding can be an early sign of this tumor developing.[19]

See also


  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Walfish, M.; Neuman, A.; Wlody, D. (December 2009). "Maternal haemorrhage". British Journal of Anaesthesia. 103: i47–i56. doi:10.1093/bja/aep303. PMID 20007990.
  2. 2.0 2.1 2.2 2.3 Stables, Dorothy; Rankin, Jean (2010). Physiology in Childbearing: With Anatomy and Related Biosciences. Elsevier Health Sciences. pp. 423–429. ISBN 978-0702044113. Archived from the original on 2021-08-29. Retrieved 2020-09-20.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Sakornbut, E; Leeman, L; Fontaine, P (15 April 2007). "Late pregnancy bleeding". American family physician. 75 (8): 1199–206. PMID 17477103.
  4. 4.0 4.1 Sperling, Rhoda (2020). Obstetrics and Gynecology. John Wiley & Sons. ISBN 978-1-119-45007-8. Archived from the original on 29 August 2021. Retrieved 4 November 2020.
  5. 5.0 5.1 Vos, Theo; Allen, Christine; Arora, Megha; Barber, Ryan M.; Bhutta, Zulfiqar A.; Brown, Alexandria; Carter, Austin; Casey, Daniel C.; Charlson, Fiona J.; Chen, Alan Z.; Coggeshall, Megan; Cornaby, Leslie; Dandona, Lalit; Dicker, Daniel J.; Dilegge, Tina; Erskine, Holly E.; Ferrari, Alize J.; Fitzmaurice, Christina; Fleming, Tom; Forouzanfar, Mohammad H.; Fullman, Nancy; Gething, Peter W.; Goldberg, Ellen M.; Graetz, Nicholas; Haagsma, Juanita A.; Hay, Simon I.; Johnson, Catherine O.; Kassebaum, Nicholas J.; Kawashima, Toana; Kemmer, Laura (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. 388 (10053): 1545–1602. doi:10.1016/S0140-6736(16)31678-6. PMC 5055577. PMID 27733282. {{cite journal}}: Unknown parameter |displayauthors= ignored (help)
  6. 6.0 6.1 Wang, Haidong; Naghavi, Mohsen; Allen, Christine; Barber, Ryan M.; Bhutta, Zulfiqar A.; Carter, Austin; Casey, Daniel C.; Charlson, Fiona J.; Chen, Alan Zian; Coates, Matthew M.; Coggeshall, Megan; Dandona, Lalit; Dicker, Daniel J.; Erskine, Holly E.; Ferrari, Alize J.; Fitzmaurice, Christina; Foreman, Kyle; Forouzanfar, Mohammad H.; Fraser, Maya S.; Fullman, Nancy; Gething, Peter W.; Goldberg, Ellen M.; Graetz, Nicholas; Haagsma, Juanita A.; Hay, Simon I.; Huynh, Chantal; Johnson, Catherine O.; Kassebaum, Nicholas J.; Kinfu, Yohannes; Kulikoff, Xie Rachel (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. 388 (10053): 1459–1544. doi:10.1016/S0140-6736(16)31012-1. PMC 5388903. PMID 27733281. {{cite journal}}: Unknown parameter |displayauthors= ignored (help)
  7. Chen, C; Lee, SM; Kim, JW; Shin, JH (July 2018). "Recent Update of Embolization of Postpartum Hemorrhage". Korean journal of radiology. 19 (4): 585–596. doi:10.3348/kjr.2018.19.4.585. PMID 29962865.
  8. Say, Lale; Chou, Doris; Gemmill, Alison; Tunçalp, Özge; Moller, Ann-Beth; Daniels, Jane; Gülmezoglu, A Metin; Temmerman, Marleen; Alkema, Leontine (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. ISSN 2214-109X. PMID 25103301.
  9. 9.0 9.1 "Antepartum Haemorrhage APH; bleeding from birth canal". patient.info. Archived from the original on 28 June 2018. Retrieved 4 November 2020.
  10. The Royal Women’s Hospital > antepartum haemorrhage Archived 2010-01-08 at the Wayback Machine Retrieved on Jan 13, 2009
  11. 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. PMC 5130260. PMID 27902772.
  12. Berghella, MD, Vincenzo (July 2017). "Cervical insufficiency". UpToDate. Archived from the original on 2018-08-08.
  13. Charles J Lockwood, MD, MHCM, Karen Russo-Stieglitz, MD (July 2017). "Velamentous umbilical cord insertion and vasa previa". UpToDate. Archived from the original on 2018-08-08.
  14. Atukunda EC, Mugyenyi GR, Obua C, Atuhumuza EB, Musinguzi N, Tornes YF, Agaba AG, Siedner MJ (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. doi:10.1371/journal.pone.0152408. PMC 4822885. PMID 27050823.
  15. 15.0 15.1 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
  16. Kadir RA, Aledort LM (October 2000). "Obstetrical and gynaecological bleeding: a common presenting symptom". Clinical and Laboratory Haematology. 22 Suppl 1: 12–6, discussion 30–2. doi:10.1046/j.1365-2257.2000.00007.x. PMID 11251653.
  17. Aldred, Heather E. (1997). Pregnancy and birth sourcebook. health reference series. ISBN 9780780802162.
  18. 18.0 18.1 18.2 18.3 18.4 18.5 Heine PR, Swamy GK (August 2009). "Vaginal bleeding during early pregnancy". Merck Manual. Archived from the original on 2018-10-09.
  19. Aldred, Heather E. (1997). Pregnancy and birth sourcebook. Omnigraphics. ISBN 9780780802162.

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