Bleeding During Pregnancy and Delivery
Maternal bleeding, or bleeding during pregnancy and delivery, can mean a number of things. It is possible that maternal bleeding is a.) a symptom of early pregnancy, b.) a sign of a more serious condition, or c.) an emergency situation (maternal hemorrhaging).
Bleeding as an early sign of pregnancy
Some women experience light bleeding, or spotting, early in their pregnancies. This is often due to implantation bleeding or cervical bleeding, both of which generally pose no serious threat to the mother or baby (1, 2). However, because it may be difficult to know for sure that one of these is the cause of bleeding, it is important to consult a medical professional if there is any bleeding during pregnancy.
As the fertilized egg implants in the uterine lining, some women may experience spotting (a few drops of blood every now and then). This is called implantation bleeding, and it can occur in the first 1-2 weeks after conception (1). Often, women mistake implantation bleeding for a light period and do not yet know they are pregnant.
Early in pregnancy, additional blood vessels develop in the cervical area. As a result, the cervix may bleed more easily after sexual intercourse or a procedure such as a pap smear (2).
When bleeding in early pregnancy signals a more serious condition
It is important not to dismiss bleeding during pregnancy because even minor bleeding during pregnancy can be a warning sign of a condition requiring immediate medical attention. Here are some examples:
An ectopic pregnancy occurs when the fertilized ovum is implanted outside of the uterus. Two in every 100 pregnant women in the U.S. will experience an ectopic pregnancy (4). Generally, they occur in the uterine/fallopian tube, but the ovum can also implant in the ovary, abdominal cavity, or cervix. Often, women who have ectopic pregnancies will experience symptoms before realizing they are pregnant. In addition to vaginal bleeding, these symptoms can include pelvic, abdominal, and shoulder pain (5). Occasionally, abdominal ectopic pregnancies can result in a living infant, although the likelihood of deformity is as high as 40 percent, and the chance of survival past one week post-partum is only about 50 percent (6). Because a fertilized egg generally cannot survive outside of the uterus, and because ectopic pregnancy can be very dangerous to the mother (it is the most common pregnancy-related cause of death in the first trimester), treatment usually entails removal of the fetus. This can be done through the use of medication or in a surgical procedure. Unless it is diagnosed and treated quickly, ectopic pregnancy can also result in loss of a fallopian tube (4, 5).
A hydatidiform mole (also known as a molar pregnancy) is the result of an abnormal conception that leads to minimal fetal development, but excessive placental development (7). The placental tissue forms a mass in the uterus made up of small cysts. Symptoms of a hydatidiform mole include (7):
- Vaginal bleeding in the first trimester, which may be clotted or watery and brown
- Vaginal expulsion of grape-like pieces of the mole
- Abnormal uterine growth
- Severe nausea/vomiting
- High blood pressure
- Swelling in the feet, ankles, and legs
Treatment for a hydatidiform mole generally involves removal of the abnormal tissue with a dilation and curettage (D&C) procedure (8). Most hydatidiforms are benign, although they can very occasionally lead to carcinoma. This is a fast-growing and potentially fatal cancer, but chemotherapy treatment has high success rates. Other complications include preeclampsia, thyroid problems, and recurrent molar pregnancies (9).
Miscarriage can be defined as a pregnancy that ends before the fetus is viable; in other words, before it could potentially survive outside of the womb. 8-20 percent of pregnancies end in miscarriage, and 90 percent of these miscarriages occur before eight weeks of gestation (10). There are many causes of miscarriage, including (1):
- Hormonal imbalance
- Genetic abnormalities
- Incompetent or insufficient cervix
- Trauma during pregnancy
Symptoms vary, depending on how far along a woman is in her pregnancy (10):
- Miscarriages before the 6th week: Similar to a heavy period
- Miscarriages between six and 12 weeks: Moderate discomfort and blood loss
- Miscarriages after 12 weeks: Can involve more severe pain, similar to contractions
Although miscarriages are sometimes inevitable, some may be preventable with proper treatment. If a woman is spotting beyond the implantation bleeding period, this may be a sign of a “threatened miscarriage.” It is usually managed with bed rest and supportive care. If a woman miscarries, she may require a procedure called “dilation and curettage” to clean the uterine walls and remove unexpelled content. In certain situations, doctors may also administer prostaglandins or intravenous oxytocin to stimulate labor. It is important to note that in addition to physical care, counseling may be necessary to cope with the loss of a pregnancy (1).
A chorionic hematoma is a pool of blood between the chorion, which is a membrane that surrounds the embryo, and the uterine wall. This is caused by separation of the chorion from the uterus. Subchorionic hematomas are the most common kind, and they occur between the chorion and the endometrium (the inner membrane of the uterus) (11). Doctors sometimes prescribe progesterone or dydrogesterone to women with subchorionic hematomas in order to prevent a miscarriage. They may also advise patients with larger hematomas to go on bed rest (12). With appropriate treatment and close monitoring, they usually will be able to deliver a healthy, full-term baby.
Incompetent cervix/cervical insufficiency
An incompetent cervix also called an insufficient cervix or weakened cervix, is a serious medical condition that occurs when the cervix begins to dilate prematurely (in the 2nd trimester). This can be caused by many different factors, including (13):
- Congenital conditions
- Exposure to Diethylstilbestrol (a synthetic estrogen)
- Prior obstetric trauma
- Prior procedures such as cervical biopsy, loop electrosurgical excision procedure (LEEP), and dilation & curettage (D&C)
Women may experience these warning signs and symptoms of an incompetent cervix (13):
- Light vaginal bleeding
- A change in vaginal discharge
- A sensation of pelvic pressure
- A backache
- Mild abdominal cramps
- Shortening or opening of the cervix prematurely
Doctors usually prescribe bed rest for patients with cervical insufficiency, plus a cerclage (a surgery in which the cervix is stitched closed; the stitches are removed near the end of pregnancy), and the hormone progesterone (14, 15).
An incompetent cervix can lead to a miscarriage or premature birth. To avoid premature birth and injury, it’s critical that medical professionals properly identify, diagnose, monitor, and treat patients with cervical insufficiency. Premature birth and hypoxic-ischemic encephalopathy (HIE) may put the baby at risk for a number of birth injuries and disabilities, such as:
- Cerebral palsy
- Intellectual disabilities
- Periventricular leukomalacia (PVL)
- Developmental delays
To learn more about the long-term effects of these conditions, their treatment options, and how they can be caused by malpractice, please click the links above.
Maternal bleeding during late pregnancy can be a cause for major concern. Maternal hemorrhaging around the time of delivery can indicate potential danger and, if treated improperly, can result in injury and/or death. There are several types of maternal hemorrhages that can occur during delivery, each with their own set of risk factors, symptoms, treatment plans, and potential consequences.
Antepartum hemorrhage: Bleeding in the second half of pregnancy
The Journal of Perinatal Medicine defines an antepartum hemorrhage (APH) as “bleeding from the genital tract in the second half of pregnancy.” Definitions often vary, but most commonly an antepartum hemorrhage can occur anytime between the halfway-point of gestation and the beginning of labor (16).
Causes of antepartum hemorrhage
Antepartum hemorrhage can arise from a variety of pregnancy complications, meaning that certain women are at greater risk for APH than others. Some typical causes of antepartum hemorrhage can include (16):
Signs of antepartum hemorrhage
It is critical that medical staff monitor a mother throughout each stage of her pregnancy. Certain signs appearing during the second half of the pregnancy can indicate the presence of an antepartum hemorrhage. Signs of an antepartum hemorrhage may include (16):
- Bleeding, either accompanied by pain or not
- Uterine contractions or irritability
- Malpresentation (e.g. breech presentation, face presentation, or failure of the fetal head to engage)
- Signs of fetal distress (for example decreased fetal movement, cramping, etc.)
Associated complications of an antepartum hemorrhage
The occurrence of an antepartum hemorrhage can negatively impact the mother and the baby, especially if it is managed improperly. Complications often associated with antepartum hemorrhage can be broken up into two categories:
- Maternal complications associated with antepartum hemorrhage (16):
- Premature labor
- Kidney injury
- Postpartum hemorrhage
- Fetal complications associated with antepartum hemorrhage (16):
In order to avoid these complications, it is crucial that medical staff accurately manage patients who suffer from antepartum hemorrhage. Physicians should carefully assess the mother’s blood loss and the well-being of the mother and baby before creating an appropriate treatment plan. Appropriate antepartum monitoring and testing typically includes nonstress tests (NSTs) (using a fetal monitor), ultrasounds (to assess the anatomy and amniotic fluid volume), and biophysical profiles (BPPs) (ultrasound which tests for fetal well-being) (16).
Disseminated intravascular coagulation (DIC): excessive bleeding
Disseminated intravascular coagulation (DIC) is a rare blood condition in which the blood begins to clot excessively, eventually leading to heavy bleeding when the body’s clotting proteins are used up. This condition may be triggered during pregnancy and can cause serious harm to the mother and baby (17).
Causes of disseminated intravascular coagulation (DIC)
DIC is not a spontaneous condition; it is always accompanied by a trigger. Many of these triggers are common pregnancy complications such as (17):
Signs of disseminated intravascular coagulation (DIC)
There are certain conditions that often occur with DIC, and can lead physicians to check patients for DIC. These include (17):
- Severe bleeding
- Oozing of blood from the skin
- Hypotension (low blood pressure)
- Altered mental state
- Cool extremities
- Acute renal failure
- Hepatic dysfunction
- Acute lung injury
- Neurologic dysfunction
Associated complications of DIC
The after-effects of DIC can be profound and are dependent on the underlying cause and its management. DIC may cause the following maternal complications and injuries (17):
- Acute kidney injury
- Cardiac tamponade: Pressure on the heart due to the surrounding build up of blood.
- Intracerebral hematoma: Burst blood vessel of the brain.
- Maternal mortality
Fetal-maternal hemorrhage: blood transfer between mother and baby
During pregnancy, a small amount of blood is passed back and forth between a mother and her baby. When the amount of blood transferred from the baby to the mother is excessive, it is known as a fetal-maternal hemorrhage (FMH), sometimes also referred to as fetomaternal hemorrhage. An FMH can be very dangerous for the baby (18).
Causes of fetal-maternal hemorrhage
Fetal-maternal hemorrhages can be the result of trauma to the placenta or surrounding areas, or they can be completely spontaneous. Trauma-related hemorrhages may result from poorly administered invasive tests such as amniocentesis and chorionic villus biopsies. Spontaneous FMH, which makes up the majority of reported cases of FMH has no known etiology (18).
Signs of fetal-maternal hemorrhage
During a fetal-maternal hemorrhage, the mother usually does not exhibit any signs, since the transfer of blood is not normally detrimental to her well-being. Occasionally the mother may exhibit minute warning signs consistent with those observed after a blood transfusion, such as (18):
Because the fetus is more heavily impacted by the transfer of blood, close monitoring of fetal status may reveal the signs of a fetal-maternal hemorrhage. Some fetal signs of fetal-maternal hemorrhage are (18):
- Decreased fetal movement
- Sinusoidal fetal heart rate pattern
- Low biophysical profile score
- Fetal anemia
Associated fetal complications of fetal-maternal hemorrhage
The implications of a fetal-maternal hemorrhage on the outcome of the baby are dependent on many factors, including the severity of the bleed and the decided upon treatment method. If the hemorrhage is treated improperly, and/or becomes too severe, the baby is at risk to develop conditions such as (18):
- Neonatal brain damage
- Respiratory distress syndrome (RDS)
- Pulmonary hypertension
- Renal dysfunction
- Fetal anemia
Amniotic fluid embolism (AFE): bleeding during childbirth
An amniotic fluid embolism (AFE) is an extremely rare condition that can occur during delivery when the amniotic fluid enters the mother’s bloodstream. Once this occurs, it may cause serious damage to the mother and her baby (19).
Risk factors for an amniotic fluid embolism
There are several factors linked to the occurrence of AFE during pregnancy; however, their predictive value is questionable due to the rarity of this condition. AFE is generally considered to be a spontaneous occurrence. The roughly-defined risk factors are (19):
- Traumatic labor
- Older maternal age
- Instrumental delivery
- Cesarean section
- Placenta previa
- Placental abruption
- Grand multiparity (> 5 pregnancies)
- Fetal distress
- Medical induction of labor
Signs of an amniotic fluid embolism
The signs of AFE generally show up just before or during the labor and delivery process. The signs are very severe and may lead to detrimental outcomes on their own. The common signs of AFE are (19):
- Cardiogenic shock: When the body does not pump enough blood.
- Hypoxemia: Low levels of oxygen in the blood
- Respiratory failure
- Coma or seizures
Complications of an amniotic fluid embolism
Due to AFE’s rare nature and it’s sudden, severe onset, the outcomes for both mother and baby may be poor if it not timely treated. AFE may result in maternal and fetal mortality, although higher levels of fetal survival have come as a result of quick delivery. Some maternal survivors of AFE may suffer from neurological injury.
Management of AFE aims to control the symptoms (such as hypoxemia), to prevent any further damage to the patient, and promptly deliver the fetus (within 3 to 5 minutes) to ensure adequate oxygen levels and avoid HIE (19).
Postpartum hemorrhage (PPH): bleeding after delivery
A postpartum hemorrhage occurs when a woman bleeds heavily after the delivery of her baby. Some blood is expected after birth; however, when the bleeding is heavy and does not stop, it is considered a hemorrhage and can be very dangerous for the mother (20).
Causes of postpartum hemorrhage
Bleeding after delivery can be caused by a number of factors. Some of the most common direct causes of postpartum hemorrhages are (20):
- Uterine atony: Uterine atony occurs when the uterus does not effectively contract after delivery of a baby. Conditions like placenta previa and placental abruption can increase the risk of uterine atony, and of postpartum hemorrhage by extension.
- Trauma around the time of labor: Bleeding from trauma during or near the labor process can lead to postpartum hemorrhage. This bleeding can be the result of complications like uterine rupture or lacerations from delivery or surgical intervention.
- Coagulopathy: Women who have inherited or acquired blood disorders that impact blood clotting ability may suffer from postpartum hemorrhage due to their body’s inability to stop delivery-related bleeding.
Risk factors for postpartum hemorrhage
Women who are at high risk for postpartum hemorrhaging should be identified early in pregnancy, and their labor and delivery should be managed in a safe and appropriate way depending on their level of risk. Some factors that put women at greater risk for postpartum hemorrhage are (20):
- Retained placenta: The placenta does not exit the womb within 30 minutes of birth.
- Failure to progress during the second stage of labor
- Instrumental delivery
- Placental abruption
- Placenta accreta: A condition in which the placenta attaches deeply into the uterine wall.
- Placenta previa
- Large for gestational age newborn
- Preeclampsia and related disorders
- Induction of labor
- Prolonged labor
Signs of postpartum hemorrhage
It is crucial that physicians recognize the signs of postpartum hemorrhage as soon as possible, as continued bleeding can be dangerous for the mother. The common signs of postpartum hemorrhage are (20):
- A great degree of observable or recorded blood loss
- Low blood pressure
- Lightheadedness and weakness
- Increase in heart rate, often into tachycardic range
- Restlessness or lethargy
Associated complications of postpartum hemorrhage
When postpartum hemorrhaging is severe or is not properly monitored and treated by medical staff, it can be very dangerous and lead to negative outcomes. Some of the most common associated complications of postpartum hemorrhaging include (20):
- Severe blood loss
- Damage to major organs
- Hypovolemic shock: A condition that occurs when more than 20% of blood is lost. It can lead to severe organ dysfunction.
- Maternal mortality
- Septicemia: A form of blood poisoning often due to an infection within the bloodstream.
Treatment for a postpartum hemorrhage depends heavily on the cause of bleeding, and on the amount of blood loss. Generally, women with postpartum hemorrhage are monitored, given fluids, and are appropriately treated for the cause of their hemorrhage.
Legal help for maternal bleeding injuries
If you or a loved one were injured as the result of a mismanaged maternal bleed or hemorrhage, call the award-winning birth injury attorneys at ABC Law Centers. With over 100 years of joint legal experience, our team has the education, qualifications, results, and accomplishments necessary to succeed. We’ve handled cases involving dozens of different complications and instances of medical malpractice, and we charge no legal fees unless we win your case. From our home base in Detroit, Michigan, we handle cases from all over the country.
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