Management of obstetric hemorrhage: Obstetric management

Obstetric hemorrhage (OH) is the leading cause of maternal mortality worldwide. In the UK, mortality rates are relatively low, with 10 deaths per 100 000 maternities recorded in the latest Confidential Enquiry (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK – MBRRACE-UK) 2010–2012[1]. However, morbidity remains high, and timely recognition and management is of the utmost importance.

Antepartum hemorrhage (APH) is defined as bleeding from the genital tract after 24 weeks’ gestation and affects approximately 3–4% of all pregnancies. The most common cause of APH is the presence of placenta previa, where the placenta is abnormally located in the lower uterine segment, covering or partially covering the internal os. As pregnancy progresses, especially as the lower segment forms or the cervix dilates, the woman is prone to episodes of bleeding that may be profuse. Another common cause of APH is placental abruption, when the placenta prematurely separates either partially or totally. It may be a single episode or recurrent, small or large, and the features may be typical and multiple (bleeding and pain, tender and woody Couvelaire uterus with stillbirth) or atypical and isolated (bleeding, premature labor, fetal growth restriction, abnormal CTG). However, the cause of many cases of APH is often unknown.