Hemorragia Obstétrica

Obstetric Hemorrhage

Subtopics

1. Causes
2. Symptoms
3. Diagnosis
4. Treatment
5. Prevention

Causes

Obstetric hemorrhage, also known as postpartum hemorrhage, is excessive bleeding after childbirth. It occurs due to several underlying factors:

• Uterine Atony: This is the most common cause of obstetric hemorrhage, accounting for approximately 70 percent of cases. Uterine atony occurs when the uterus fails to contract properly after delivery, leading to bleeding.
• Birth Canal Trauma: Lacerations, hematomas, inversions, and ruptures caused by the passage of the baby through the birth canal and poor perineal repair can cause bleeding. Such trauma accounts for around 20 percent of obstetric hemorrhages.
• Retained Placental Remains: If pieces of the placenta remain inside the uterus after birth, this can lead to ongoing bleeding. Retained tissue contributes to 10 percent of obstetric hemorrhages.
• Coagulopathies: Certain blood disorders that impair normal blood clotting processes can cause bleeding. Coagulopathies account for 1 percent of obstetric hemorrhages.

Other contributing factors include placental problems such as placenta previa, placental abruption, and retained placenta, which increase the risk of hemorrhage by three to seven times compared with an average risk. An overdistended uterus also increases the likelihood of postpartum hemorrhage when the uterus is stretched beyond its capacity during labor and delivery.

Symptoms

Symptoms of obstetric hemorrhage include severe vaginal bleeding, dizziness, feeling faint, blurred vision, rapid heart rate, and difficulty breathing. These symptoms are indicative of blood loss that can restrict blood flow to vital organs, leading to shock if left untreated.

Treatment

The primary treatment for obstetric hemorrhage involves addressing the underlying cause through various methods such as:

• Controlling Uterine Contraction: This may involve administering medications like methylergonovine or prostaglandins [prostaglandins like carboprost or misoprostol] to promote uterine contractions.
• Removal of Retained Placental Remains: If pieces of the placenta remain inside the uterus, they must be removed surgically.
• Blood Transfusion: In cases where excessive blood loss occurs, patients may require emergency blood transfusions to prevent complications such as shock, anemia, and fatigue.

Prevention

To minimize the risk of obstetric hemorrhage, several strategies should be implemented:

• Active Management of Third Stage of Labor: This includes active management of the third stage of labor (AMTSL), which involves administering a uterotonic drug immediately after delivery, controlled cord traction, early cord clamping, and sometimes manual removal of the placenta. This approach significantly reduces postpartum hemorrhage by approximately 68 percent.
• Prophylactic Administration of Oxytocin: Preventive administration of oxytocin (Pitocin) is effective in reducing rates of postpartum hemorrhage by 40 percent.
• Delayed Cord Clamping: Delaying cord clamping for about 60 seconds after birth can help prevent bleeding, especially in preterm infants and low-resource settings. However, early cord clamping within one minute of birth is currently recommended.
• Patient Selection: Identifying patients with risk factors such as a history of postpartum hemorrhage or prolonged third stage of labor, episiotomy, fetal macrosomia, multiparity, or a previous cesarean section, and providing appropriate management to minimize their risk of obstetric hemorrhage.

Diagnosis

Recognition and diagnosis of obstetric hemorrhage require thorough clinical examination, including symptoms evaluation and assessment of blood loss using visual assessment or weighing surgical compresses. Rapid diagnostic tests may include complete blood count (CBC), coagulation studies, and monitoring the shock index—a parameter that estimates blood loss and guides the need for blood transfusion. Ultrasound scans can also be used in specific situations, such as placental location assessment in women with a previous cesarean section or suspected parametrial invasion.