Skip to main content
SpringerLink
Log in

Pregnancy-Associated Bleeding

  • Chapter
  • First Online:
Management of Bleeding Patients

  • 1506 Accesses

Abstract

In no other time during a person’s life is loss of up to 5 % of the circulating blood volume considered “natural” other than at the time of childbirth. Although pregnancy-associated bleeding is often physiologic, hemorrhage is among the leading causes of pregnancy-related death in women worldwide, especially in developing regions of the world. Blood loss during pregnancy can approximate that lost during major trauma and can lead to disseminated intravascular coagulopathy. Virtually all organ systems, including the cardiovascular and hematologic systems, are altered during gestation and an understanding of these changes is critical to management of the bleeding gravida. This chapter provides a review of physiologic changes in pregnancy that impact bleeding and hemostasis, risk factors for bleeding during pregnancy and delivery, and key pregnancy-related diagnoses that place women at especially high risk for massive hemorrhage. Additionally, the role of massive transfusion protocols in obstetrical and gynecological care will be discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 89.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323–33.

    Article  PubMed  Google Scholar 

  2. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol. 2015;125(1):5–12.

    Article  PubMed  Google Scholar 

  3. Wilkinson H. Trustees, Medical A. Saving mothers’ lives. Reviewing maternal deaths to make motherhood safer: 2006-2008. BJOG. 2011;118(11):1402–3. discussion 3-4.

    Article  PubMed  Google Scholar 

  4. Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol. 2008;199(1):36.e1–5; discussion 91-2.e7–11.

    Article  Google Scholar 

  5. Mabie WC, DiSessa TG, Crocker LG, Sibai BM, Arheart KL. A longitudinal study of cardiac output in normal human pregnancy. Am J Obstet Gynecol. 1994;170(3):849–56.

    Article  CAS  PubMed  Google Scholar 

  6. Clark SL, Cotton DB, Lee W, Bishop C, Hill T, Southwick J, et al. Central hemodynamic assessment of normal term pregnancy. Am J Obstet Gynecol. 1989;161(6 Pt 1):1439–42.

    Article  CAS  PubMed  Google Scholar 

  7. Clark SL, Hankins GD. Preventing maternal death: 10 clinical diamonds. Obstet Gynecol. 2012;119(2 Pt 1):360–4.

    Article  PubMed  Google Scholar 

  8. Zivný J, Kobilková J, Neuwirt J, Andrasová V. Regulation of erythropoiesis in fetus and mother during normal pregnancy. Obstet Gynecol. 1982;60(1):77–81.

    PubMed  Google Scholar 

  9. PRITCHARD JA. Changes in the blood volume during pregnancy and delivery. Anesthesiology. 1965;26:393–9.

    Article  CAS  PubMed  Google Scholar 

  10. Metcalfe J, Romney SL, Ramsey LH, Reid DE, Burwell CS. Estimation of uterine blood flow in normal human pregnancy at term. J Clin Invest. 1955;34(11):1632–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. McAuliffe F, Kametas N, Costello J, Rafferty GF, Greenough A, Nicolaides K. Respiratory function in singleton and twin pregnancy. BJOG. 2002;109(7):765–9.

    Article  PubMed  Google Scholar 

  12. Omo-Aghoja L. Maternal and fetal Acid-base chemistry: a major determinant of perinatal outcome. Ann Med Health Sci Res. 2014;4(1):8–17.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Monga M. Maternal cardiovascular, respiratory and renal adaptations to pregnancy. In: Creasy RK, editor. Creasy & Resnik’s maternal-fetal medicine: principles and practice. 6th ed. Philadelphia, PA, USA: Saunders Elsevier; 2009. p. 104–5.

    Google Scholar 

  14. Bremme KA. Haemostatic changes in pregnancy. Best Pract Res Clin Haematol. 2003;16(2):153–68.

    Article  PubMed  Google Scholar 

  15. Erez O, Novack L, Beer-Weisel R, Dukler D, Press F, Zlotnik A, et al. DIC score in pregnant women--a population based modification of the International Society on Thrombosis and Hemostasis score. PLoS One. 2014;9(4), e93240.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Gynecologists ACoOa, Pregnancy TFoHi. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122–31.

    Article  Google Scholar 

  17. Rana P, Kazmi I, Singh R, Afzal M, Al-Abbasi FA, Aseeri A, et al. Ectopic pregnancy: a review. Arch Gynecol Obstet. 2013;288(4):747–57.

    Article  PubMed  Google Scholar 

  18. Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011;118 Suppl 1:1–203.

    PubMed  Google Scholar 

  19. Creanga AA, Shapiro-Mendoza CK, Bish CL, Zane S, Berg CJ, Callaghan WM. Trends in ectopic pregnancy mortality in the United States: 1980-2007. Obstet Gynecol. 2011;117(4):837–43.

    Article  PubMed  Google Scholar 

  20. Kirk E, Bourne T. The nonsurgical management of ectopic pregnancy. Curr Opin Obstet Gynecol. 2006;18(6):587–93.

    Article  PubMed  Google Scholar 

  21. Cohen A, Almog B, Satel A, Lessing JB, Tsafrir Z, Levin I. Laparoscopy versus laparotomy in the management of ectopic pregnancy with massive hemoperitoneum. Int J Gynaecol Obstet. 2013;123(2):139–41.

    Article  PubMed  Google Scholar 

  22. Hou JL, Wan XR, Xiang Y, Qi QW, Yang XY. Changes of clinical features in hydatidiform mole: analysis of 113 cases. J Reprod Med. 2008;53(8):629–33.

    PubMed  Google Scholar 

  23. Duryea EL, McIntire DD, Leveno KJ. The rate of preterm birth in the United States is affected by the method of gestational age assignment. Am J Obstet Gynecol. 2015;213(2):231.e1–5.

    Article  Google Scholar 

  24. Tikkanen M. Placental abruption: epidemiology, risk factors and consequences. Acta Obstet Gynecol Scand. 2011;90(2):140–9.

    Article  PubMed  Google Scholar 

  25. Mendez-Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol. 2013;209(1):1–10.

    Article  PubMed  Google Scholar 

  26. Jelen K, Dolezal A. Mechanical reaction of the frontal abdominal wall to the impact load during gravidity. Neuro Endocrinol Lett. 2003;24(1-2):15–20.

    PubMed  Google Scholar 

  27. Pearlman MD, Tintinallli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol. 1990;162(6):1502–7. discussion 7-10.

    Article  CAS  PubMed  Google Scholar 

  28. Chames MC, Pearlman MD. Trauma during pregnancy: outcomes and clinical management. Clin Obstet Gynecol. 2008;51(2):398–408.

    Article  PubMed  Google Scholar 

  29. Reddy UM, Abuhamad AZ, Levine D, Saade GR, Participants FIWI. Fetal imaging: Executive summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Am J Obstet Gynecol. 2014;210(5):387–97.

    Article  PubMed  Google Scholar 

  30. Crane JM, Van den Hof MC, Dodds L, Armson BA, Liston R. Maternal complications with placenta previa. Am J Perinatol. 2000;17(2):101–5.

    Article  CAS  PubMed  Google Scholar 

  31. Wortman AC, Twickler DM, McIntire DD, Dashe JS. Bleeding complications in pregnancies with low-lying placenta. J Matern Fetal Neonatal Med. 2016;29(9):1367–71.

    Article  PubMed  Google Scholar 

  32. Onwere C, Gurol-Urganci I, Cromwell DA, Mahmood TA, Templeton A, van der Meulen JH. Maternal morbidity associated with placenta praevia among women who had elective caesarean section. Eur J Obstet Gynecol Reprod Biol. 2011;159(1):62–6.

    Article  PubMed  Google Scholar 

  33. Publications Committee SM-FM, Belfort MA. Placenta accreta. Am J Obstet Gynecol. 2010;203(5):430–9.

    Article  Google Scholar 

  34. Gynecologists ACoOa. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol. 2006;108(4):1039–47.

    Article  Google Scholar 

  35. Diagnosis and management of postpartum hemorrhage. ACOG technical bulletin number 143—July 1990. Int J Gynaecol Obstet. 1991;36(2):159–63.

    Google Scholar 

  36. Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus physiological management of third stage of labour. BMJ. 1988;297(6659):1295–300.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. Lancet. 1998;351(9104):693–9.

    Article  CAS  PubMed  Google Scholar 

  38. Calişkan E, Meydanli MM, Dilbaz B, Aykan B, Sönmezer M, Haberal A. Is rectal misoprostol really effective in the treatment of third stage of labor? A randomized controlled trial. Am J Obstet Gynecol. 2002;187(4):1038–45.

    Article  PubMed  Google Scholar 

  39. Derman RJ, Kodkany BS, Goudar SS, Geller SE, Naik VA, Bellad MB, et al. Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial. Lancet. 2006;368(9543):1248–53.

    Article  CAS  PubMed  Google Scholar 

  40. Raghavan S, Geller S, Miller S, Goudar SS, Anger H, Yadavannavar MC, et al. Misoprostol for primary versus secondary prevention of postpartum haemorrhage: a cluster-randomised non-inferiority community trial. BJOG. 2015.

    Google Scholar 

  41. Antony KM, Dildy GA. Postpartum hemorrhage: the role of the Maternal-Fetal Medicine specialist in enhancing quality and patient safety. Semin Perinatol. 2013;37(4):246–56.

    Article  PubMed  Google Scholar 

  42. Bowen LW, Beeson JH. Use of a large Foley catheter balloon to control postpartum hemorrhage resulting from a low placental implantation. A report of two cases. J Reprod Med. 1985;30(8):623–5.

    CAS  PubMed  Google Scholar 

  43. Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding. Int J Gynaecol Obstet. 2001;74(2):139–42.

    Article  CAS  PubMed  Google Scholar 

  44. Marasinghe JP, Du Plessis J, Epitawela D, Umstad MP. Management of postpartum haemorrhage with uterine balloon tamponade: The way forward. Aust N Z J Obstet Gynaecol. 2015;55(4):315–7.

    Article  PubMed  Google Scholar 

  45. Martin E, Legendre G, Bouet PE, Cheve MT, Multon O, Sentilhes L. Maternal outcomes after uterine balloon tamponade for postpartum hemorrhage. Acta Obstet Gynecol Scand. 2015;94(4):399–404.

    Article  PubMed  Google Scholar 

  46. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol. 1997;104(3):372–5.

    Article  CAS  PubMed  Google Scholar 

  47. Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of postpartum hemorrhage. Obstet Gynecol. 2002;99(3):502–6.

    CAS  PubMed  Google Scholar 

  48. Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol. 2000;96(1):129–31.

    CAS  PubMed  Google Scholar 

  49. Matsubara S, Yano H, Ohkuchi A, Kuwata T, Usui R, Suzuki M. Uterine compression sutures for postpartum hemorrhage: an overview. Acta Obstet Gynecol Scand. 2013;92(4):378–85.

    Article  PubMed  Google Scholar 

  50. Bailit JL, Grobman WA, Rice MM, Reddy UM, Wapner RJ, Varner MW, et al. Morbidly adherent placenta treatments and outcomes. Obstet Gynecol. 2015;125(3):683–9.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M. Incidence and risk factors for placenta accreta/increta/percreta in the UK: a national case-control study. PLoS One. 2012;7(12), e52893.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Thurn L, Lindqvist PG, Jakobsson M, Colmorn LB, Klungsoyr K, Bjarnadóttir RI, et al. Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries. BJOG. 2015.

    Google Scholar 

  53. Mehrabadi A, Hutcheon JA, Liu S, Bartholomew S, Kramer MS, Liston RM, et al. Contribution of placenta accreta to the incidence of postpartum hemorrhage and severe postpartum hemorrhage. Obstet Gynecol. 2015;125(4):814–21.

    Article  PubMed  Google Scholar 

  54. Fox KA, Shamshirsaz AA, Carusi D, Secord AA, Lee P, Turan OM, et al. Conservative management of morbidly adherent placenta: expert review. Am J Obstet Gynecol. 2015.

    Google Scholar 

  55. Clausen C, Lonn L, Langhoff-Roos J. Management of placenta percreta: a review of published cases. Acta Obstet Gynecol Scand. 2014;93(2):138–43.

    Article  PubMed  Google Scholar 

  56. Clausen C, Stensballe J, Albrechtsen CK, Hansen MA, Lönn L, Langhoff-Roos J. Balloon occlusion of the internal iliac arteries in the multidisciplinary management of placenta percreta. Acta Obstet Gynecol Scand. 2013;92(4):386–91.

    Article  PubMed  Google Scholar 

  57. Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M. The management and outcomes of placenta accreta, increta, and percreta in the UK: a population-based descriptive study. BJOG. 2014;121(1):62-70; discussion -1.

    Google Scholar 

  58. Stotler B, Padmanabhan A, Devine P, Wright J, Spitalnik SL, Schwartz J. Transfusion requirements in obstetric patients with placenta accreta. Transfusion. 2011;51(12):2627–33.

    Article  PubMed  Google Scholar 

  59. Shamshirsaz AA, Fox KA, Salmanian B, Diaz-Arrastia CR, Lee W, Baker BW, et al. Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach. Am J Obstet Gynecol. 2015;212(2):218.e1–9.

    Article  Google Scholar 

  60. Clark SL. Amniotic fluid embolism. Obstet Gynecol. 2014;123(2 Pt 1):337–48.

    Article  PubMed  Google Scholar 

  61. Clark SL, Hankins GD, Dudley DA, Dildy GA, Porter TF. Amniotic fluid embolism: analysis of the national registry. Am J Obstet Gynecol. 1995;172(4 Pt 1):1158–67. discussion 67-9.

    Article  CAS  PubMed  Google Scholar 

  62. Sperry JL, Ochoa JB, Gunn SR, Alarcon LH, Minei JP, Cuschieri J, et al. An FFP:PRBC transfusion ratio >/=1:1.5 is associated with a lower risk of mortality after massive transfusion. J Trauma. 2008;65(5):986–93.

    Article  PubMed  Google Scholar 

  63. Brown LM, Aro SO, Cohen MJ, Holcomb JB, Wade CE, Brasel KJ, et al. A high fresh frozen plasma: packed red blood cell transfusion ratio decreases mortality in all massively transfused trauma patients regardless of admission international normalized ratio. J Trauma. 2011;71(2 Suppl 3):S358–63.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  65. Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GD. The role of massive transfusion protocols in obstetrics. Am J Perinatol. 2013;30(1):1–4.

    PubMed  Google Scholar 

  66. Gynecologists ACoOa. Obstetric Hemorrhage Bundle www.acog.org/-/media/Districts/District-II/PDFs/SMI/v2/HemorrhagePowerPointExText.pdf?la=en2014 [

  67. Cortet M, Deneux-Tharaux C, Dupont C, Colin C, Rudigoz RC, Bouvier-Colle MH, et al. Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. Br J Anaesth. 2012;108(6):984–9.

    Article  CAS  PubMed  Google Scholar 

  68. Charbit B, Mandelbrot L, Samain E, Baron G, Haddaoui B, Keita H, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost. 2007;5(2):266–73.

    Article  CAS  PubMed  Google Scholar 

  69. Karlsson O, Jeppsson A, Hellgren M. Major obstetric haemorrhage: monitoring with thromboelastography, laboratory analyses or both? Int J Obstet Anesth. 2014;23(1):10–7.

    Article  CAS  PubMed  Google Scholar 

  70. de Lange NM, van Rheenen-Flach LE, Lancé MD, Mooyman L, Woiski M, van Pampus EC, et al. Peri-partum reference ranges for ROTEM(R) thromboelastometry. Br J Anaesth. 2014;112(5):852–9.

    Article  PubMed  Google Scholar 

  71. Lavigne-Lissalde G, Aya AG, Mercier FJ, Roger-Christoph S, Chauleur C, Morau E, et al. Recombinant human FVIIa for reducing the need for invasive second-line therapies in severe refractory postpartum hemorrhage: a multicenter, randomized, open controlled trial. J Thromb Haemost. 2015;13(4):520–9.

    Article  CAS  PubMed  Google Scholar 

  72. Mallaiah S, Barclay P, Harrod I, Chevannes C, Bhalla A. Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage. Anaesthesia. 2015;70(2):166–75.

    Article  CAS  PubMed  Google Scholar 

  73. Wikkelsø AJ, Edwards HM, Afshari A, Stensballe J, Langhoff-Roos J, Albrechtsen C, et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial. Br J Anaesth. 2015;114(4):623–33.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynecology, Baylor College of Medicine/Texas Children’s Hospital, 6651 Main St., Ste F1020, Houston, TX, USA

    Karin A. Fox

Authors
  1. Karin A. Fox
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Karin A. Fox .

Editor information

Editors and Affiliations

  1. Departments of Pathology & Immunology, Pediatrics, and Medicine, Baylor College of Medicine Division of Transfusion Medicine & Coagulation Texas Children’s Hospital, Houston, Texas, USA

    Jun Teruya

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Fox, K.A. (2016). Pregnancy-Associated Bleeding. In: Teruya, J. (eds) Management of Bleeding Patients. Springer, Cham. https://doi.org/10.1007/978-3-319-30726-8_9

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-30726-8_9

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-30724-4

  • Online ISBN: 978-3-319-30726-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation