Obstetrical hemorrhage
From Wikipedia, the free encyclopedia
| 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.
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[edit] 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 by excessive or prolonged bleeding. A physician may propose to perform a D&C for treatment. An ectopic pregnancy may lead to bleeding, internally, that could be fatal if untreated.
[edit] 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 cesarean section. Also a placental abruption can lead to obstetrical hemorrhage, some times concealed.
[edit] 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.
[edit] After delivery
| Cause | Incidence |
|---|---|
| Uterine atony | 70% |
| Trauma | 20% |
| Retained tissue | 10% |
| Coagulopathy | 1% |
Hemorrhage 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. It is the most common cause of perinatal maternal death in the developed world and is a major cause of maternal morbidity worldwide.[1]
Causes of postpartum hemorrhage are uterine atony, trauma, retained placenta, and coagulopathy, commonly referred to as the "four Ts":[1]
- Tone: uterine atony is the inability of the uterus to contract and may lead to continuous bleeding. Retained placental tissue and infection may contribute to uterine atony.
- Trauma: trauma from the delivery may tear tissue and vessels leading to significant postpartum bleeding.
- Tissue: retention of tissue from the placenta or fetus may lead to bleeding.
- Thrombin: a bleeding disorder occurs when there a failure of clotting, such as with diseases known as coagulopathies.
[edit]
Pregnant patients may have bleeding from the reproductive tract due to trauma, including sexual assault, neoplasm, most commonly cervical cancer, and hematologic disorders.
[edit] Management
The success of modern obstetrics is based 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 reduces risk of post-partum hemorrhage by 50%,[2] a blood drape that 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]
[edit] California's OB hemorrhage guidelines
A detailed stepwise management protocol has been introduced by the California Maternity Quality Care Collaborative.[5] It describes 4 stages of obstetrical hemorrhage after a delivery and its application reduces maternal mortality.[6]
- Stage 0: normal - treated with fundal massage and oxytocin.
- Stage 1: more than normal bleeding - establish large-bore intravenous access, assemble personnel, increase oxytocin, consider use of methergine, perform fundal massage, prepare 2 units of packed red cells.
- Stage 2: bleeding continues - check coagulation status, assemble response team, move to operating room, place intrauterine balloon, administer additional uterotonics (misoprostol, carboprost tromethamine), consider: uterine artery embolization, dilatation and curettage, and laparotomy with uterine compression stitches or hysterectomy.
- Stage 3: bleeding continues - activate massive transfusion protocol, mobilize additional personnel, recheck laboratory tests, perform laparotomy, consider hysterectomy.
[edit] See also
[edit] References
- ^ a b c Anderson JM, Etches D (March 2007). "Prevention and management of postpartum hemorrhage". American Family Physician 75 (6): 875–82. PMID 17390600.
- ^ 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.
- ^ 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.
- ^ 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.
- ^ [1] CMQCC guidelines, accessed August 10, 2009
- ^ Barbieri RL. "Planning reduces the risk of maternal death. This tool helps". OBG Management (2009) 21 (8):8-10.
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