CLINICAL SCIENCE SESSION (CSS)

OBSTETRICAL
HEMORRHAGE
DISUSUN OLEH
ANITA MUBAROKAH, S.Ked

PEMBIMBING
Dr. Firmansyah, Sp. OG

Obstetrics is

bloody business.

Although

medical advances have dramatically reduced the

dangers of childbirth, death from hemorrhage
still remains a leading cause of maternal

mortality.

Hemorrhage was a direct cause of more than 17

percent

of

4200

pregnancy-related

maternal

deaths in the United States as ascertained from

the Pregnancy Mortality Surveillance System of
the Centers for Disease Control and Prevention
(Gerberding, 2003).

OVERVIEW
IMPLICATIONS
AND
CLASSIFICATION

Fatal

hemorrhage

is

most

likely

in

circumstances in which blood or components

are not available immediately.

Generally speaking, obstetrical hemorrhage may
be antepartumsuch as with placenta previa or
placental abruption, or more commonly it is

postpartumfrom uterine atony or genital tract

lacerations.

INCIDENCE AND PREDISPOSING

CONDITIONS
The exact incidence of obstetrical hemorrhage is
not known because of its imprecise definition as
well as difficulty in its recognition and thus its
diagnosis.

ANTEPARTUM HEMORRHAGE
Slight vaginal bleeding is common during active
labor. This bloody show is the consequence of
effacement and dilatation of the cervix, with
tearing

of

small

vessels.

Uterine

bleeding,

however, coming from above the cervix, is cause

for concern.

CONT....
It may follow some separation of a placenta
implanted in the immediate vicinity of the cervical
canal-placenta previa.

It may come from separation of a placenta located

elsewhere in the uterine cavity-placental abruption

 Rarely, there may be velamentous insertion of the

umbilical cord, and involved placental vessels may
overlie the cervix-vasa previa

CONT....
The source of uterine bleeding is not always
identified.
bleeding

In

that

typically

circumstance,

begins

symptoms and then stops.

with

antepartum

few,

if

any,

POSTPARTUM HEMORRHAGE
Common causes include bleeding from the
placental implantation site, trauma to the
genital tract and adjacent structures, or both.

1. Definition
Traditionally, postpartum hemorrhage has been
defined as the loss of 500 mL of blood or more
after completion of the third stage of labor.
This is problematic because half of all women
delivered vaginally shed that amount of blood or
more when losses are measured quantitatively.

2. Hemostasis at the Placental Site

Near term, it is estimated that at least 600
mL/min of blood flows through the intervillous
space. This flow is carried by the spiral arteries.
With separation of the placenta, these vessels are
avulsed. Hemostasis at the placental implantation
site is achieved first by
myometrium

that

contraction of the

compresses

number of relatively large vessels.

this formidable

This is followed by subsequent

obliteration

clotting

and

of their lumens. Thus, adhered

pieces of placenta or large blood clots that prevent

effective

myometrial

contraction

hemostasis at the implantation site.

can

impair

3. Clinical Characteristics
Postpartum bleeding may begin before or after
placental separation. Instead of sudden massive
hemorrhage, there usually is steady bleeding. At any
given instant, it appears to be only moderate, but
may persist until serious hypovolemia develops.
Especially with hemorrhage after placental delivery,
constant seepage can lead to enormous blood loss.

4. Diagnosis
The

differentiation

between

bleeding

from

uterine atony and that from genital tract

lacerations

is

tentatively

determined

by

predisposing risk factors and the condition of

the uterus. If bleeding persists despite a firm,
well-contracted

uterus,

the

cause

of

hemorrhage most likely is from lacerations.

the

Bright red blood also suggests arterial blood from

lacerations. To confirm that lacerations are a

cause of bleeding, careful inspection of the vagina,

cervix, and uterus is essential.

CAUSES OF
OBSTETRICAL
HEMORRHAGE

Placental Abruption

Placental separation from its implantation

site before delivery has been variously called

placental abruption, abruptio placentae, and
in Great Britain, accidental hemorrhage.

The bleeding of placental abruption

typically insinuates itself between the

membranes and uterus, ultimately escaping
through the cervix, causing external
hemorrhage

Cont
Less often, the blood does not escape externally
but is retained between the detached placenta
and the uterus, leading to concealed hemorrhage

1. Significance and Frequency

Abruption severity often depends on how quickly
the woman is seen following symptom onset. With
delay, the likelihood of extensive separation
causing fetal death is increased remarkably.
The frequency with which placental abruption is
diagnosed varies because of different criteria, but
the

reported

deliveries.

frequency

averages

in

200

2. Perinatal Morbidity and Mortality

Although the rates of fetal death from abruption
have declined, they remain especially prominent as
stillbirth rates from other causes have decreased.

3. Etiology and Associated Factors

a. Age, Parity, Race, and Familial Factors
b.Hypertension
c. Prematurely Ruptured Membranes and Preterm
Delivery

d.Smoking
e.Cocaine.
f. Thrombophilias.
g.Traumatic Abruption.
h.Leiomyomas

4. Recurrent Abruption
A woman who has suffered a placental abruption
especially that caused fetal deathhas a high
recurrence rate.
Management of a pregnancy subsequent to an
abruption

is

thus

difficult

because

another

separation may suddenly recur, even remote from

term.

5. Pathology
Placental abruption is initiated by hemorrhage into
the decidua basalis. The decidua then splits,
leaving a thin layer adhered to the myometrium.
Consequently, the process in its earliest stages
consists

of

the

development

of

decidual

hematoma that leads to separation, compression,

and ultimate destruction of the placenta adjacent
to it.

a. Concealed Hemorrhage
There is an effusion of blood behind the
placenta, but its margins still remain adhered
The placenta is completely separated, yet the
membranes retain their attachment to the
uterine wall
Blood gains access to the amnionic cavity after
breaking through the membranes
The fetal head is so closely applied to the lower
uterine segment that blood cannot make its way
past.

b. Chronic Placental Abruption

c. Fetal-to-Maternal Hemorrhage
Bleeding with placental abruption is almost always
maternal. This is logical because the separation is
within the maternal decidua.

In this circumstance, fetal bleeding results from a

tear or fracture in the placenta rather than from
the placental separation itself.

6. Clinical Diagnosis
The signs and symptoms of placental abruption
can vary considerably.

Sonography infrequently confirms the diagnosis

of placental abruption at least acutely, because the
placenta and fresh clot have similar sonographic
appearances.

Cont
Syok
Koagulopati Konsumtif
Gagal Ginjal
Sindrom Sheehan
Uterus Couvelaire

7. Management
Treatment

for

placental

abruption

varies

depending on gestational age and the status of the

mother and fetus. With a fetus of viable age, and
if vaginal delivery is not imminent, then emergency
cesarean delivery is chosen by most clinicians.

a. Expectant Management in Preterm Pregnancy.

Delaying
b. Tocolysis
c. Cesarean Delivery
d. Vaginal Delivery
- Labor
- Amniotomy
- Oxytocin
h. Timing of Delivery after Severe Placental
Abruption.

TERIMA KASIH