What are the management options for bleeding during pregnancy?

Management of Bleeding During Pregnancy

The management of bleeding during pregnancy requires a systematic approach based on gestational age, severity, and underlying cause, with immediate assessment of maternal hemodynamic stability and fetal viability as the first priority.

Initial Assessment

• Assess maternal hemodynamic stability immediately, including vital signs to determine if the patient is in shock 1
• Evaluate the extent of bleeding using a combination of patient physiology, response to initial resuscitation, and shock index 1
• Avoid digital pelvic examination until placenta previa, low-lying placenta, and vasa previa have been excluded by ultrasound in second and third trimester bleeding 2
• Ultrasound is the mainstay for diagnosis before performing digital examination in pregnant patients with vaginal bleeding 2

First Trimester Bleeding (< 13 weeks)

Common Causes

• Threatened miscarriage, complete/incomplete miscarriage, ectopic pregnancy, and gestational trophoblastic disease 3, 4

Management

• Perform transabdominal and transvaginal ultrasound with Doppler to assess for intrauterine pregnancy, ectopic pregnancy, or nonviable pregnancy 2
• If hemodynamically unstable with heavy bleeding:
  • Establish IV access with large-bore catheters (14-16 gauge) 1, 5
  • Initiate fluid resuscitation with crystalloids 1
  • Consider blood transfusion if significant anemia is present 1
• For women with bleeding disorders:
  • Obtain coagulation factor levels 6
  • Consider fibrinogen replacement targeting levels ≥1.5 g/L in case of vaginal bleeding in women with fibrinogen disorders 7

Second and Third Trimester Bleeding

Common Causes

• Placenta previa, placental abruption, vasa previa, uterine rupture

Management

• Perform ultrasound to rule out placenta previa before digital examination 2
• For patients with portal hypertension and varices:
  • Consider non-selective beta-blockers (NSBBs) for primary or secondary prophylaxis of variceal bleeding, with propranolol favored in pregnancy 7
  • For active variceal hemorrhage, provide immediate resuscitation, stabilization, and emergent endoscopic therapy 7
  • Initiate octreotide (avoid terlipressin due to risk of uterine contractions) 7
  • Use cephalosporins for antibiotic prophylaxis in acute variceal bleeding 7
• For women with bleeding disorders:
  • Plan for delivery at a center with hemostasis expertise 6
  • Anticipate need for hemostatic agents 6

Management Based on Specific Conditions

Portal Hypertension and Varices

• Screen for varices within 1 year prior to conception if possible 7
• Esophageal variceal ligation (EVL) is preferred for medium or large esophageal varices with high-risk bleeding stigmata 7
• For recurrent esophageal bleeding or bleeding from gastric varices, consider cyanoacrylate with or without coiling 7
• Transjugular intrahepatic portosystemic shunt may be used as rescue therapy for uncontrolled gastroesophageal variceal bleeding 7

Congenital Fibrinogen Disorders

• For vaginal bleeding during pregnancy, provide fibrinogen replacement targeting fibrinogen level ≥1.5 g/L until cessation of bleeding 7
• In women with dysfibrinogenemia type 3B, start thromboprophylaxis at the beginning of gestation 7
• For pregnancy loss in afibrinogenemia and severe hypofibrinogenemia, consider surgical management with fibrinogen replacement targeting levels ≥1.5 g/L for 3 days 7

Anticoagulation Considerations

• For pregnant women requiring anticoagulation, subcutaneous application of LMWH or UFH is favored over oral anticoagulation 7
• In women with mechanical heart valves at high risk of thromboembolism, consider adding low-dose aspirin, 75-100 mg/day 7

Delivery Planning for Women with Bleeding Risk

• For women with fibrinogen disorders:
  • In women with fibrinogen levels <1 g/L in the third trimester, schedule delivery with laboratory and blood bank support 7
  • Maintain fibrinogen level ≥1.5 g/L for neuraxial anesthesia and cesarean section 7
• For women with portal hypertension:
  • Consider assisted vaginal delivery to minimize straining and shorten the second stage of labor 7
  • For cesarean delivery, correct coagulopathy/thrombocytopenia and consider MRI/US to map intra-abdominal/pelvic varices 7

Postpartum Management

• Monitor for postpartum hemorrhage, which occurs in 5%-45% of women with cirrhosis 7
• For women with bleeding disorders, continue clinical monitoring for 72 hours 7
• Consider early use of fibrinogen replacement and tranexamic acid in case of postpartum bleeding in women with fibrinogen disorders 7
• For women with dysfibrinogenemia type 3B, continue thromboprophylaxis for 6 weeks after birth 7

Special Considerations

• Administer anti-D immunoglobulin to all rhesus D-negative pregnant trauma patients 5
• In Rh-negative pregnant trauma patients, quantify maternal-fetal hemorrhage by tests such as Kleihauer-Betke to determine need for additional doses of anti-D immunoglobulin 5
• Screen for domestic violence in every woman who sustains trauma 5