Emergencies associated with pregnancy and delivery: peripartum hemorrhage

Abstract

Introduction: Peripartum hemorrhage is one of the leading causes of maternal death worldwide (25%).

Methods: Selective literature review, including international guidelines, for assessment of the causes and optimal management of this condition.

Results: The major causes of hemorrhage are uterine atony, placenta previa, and abruptio placentae. The diagnosis of hemorrhage is suspected from its clinical manifestations and confirmed by ultrasonography. In placenta previa, the placenta is implanted in the lower uterine segment and may cover the internal cervical os. Placenta previa is more common in older and multiparous mothers, as well as in mothers who have previously undergone a cesarean section. Placental abruption is defined as separation of the placenta from the uterine wall before delivery of the infant. The risk factors for this condition include preeclampsia, advanced maternal age, and trauma. When it presents with manifestations of acute blood loss, premature abruption placentae must be diagnosed rapidly and treated without delay to save the life of the mother and child. A rare, but highly lethal, cause of bleeding is amniotic fluid embolism, which manifests itself with sudden and unexplained peripartum respiratory distress and cardiovascular collapse. Amniotic fluid embolism is associated with high fetal and maternal mortality (20% and 60% to 80%, respectively) even when it is optimally treated.

Discussion: Peripartum hemorrhage is an important source of maternal and fetal morbidity and mortality. The prognosis for both mother and child can be markedly improved if the risk factors for hemorrhage are recognized and the problem is treated rapidly and appropriately when it arises.

Keywords: amniotic fluid embolism; maternal mortality; placenta previa; preterm abruption of placenta; third-trimester hemorrhage; uterine atony.

Abdominal sonography in placenta previa totalis. No evidence of placenta accreta or increta with good demarcation of the uterine wall. The dotted line shows the position of the cervix, the placenta is circled.

Transabdominal sonographic scan of premature marginal placental abruption with partly hypoechoic, partly echodense blood coagulum. Circled in yellow: hematoma associated with premature abruption; orange line shows the site of the normal placenta position.

Figure 3

Procedure for acute amniotic fluid embolism