Pregnancy-associated bleeding

In no other time during a person's life is loss of up to 5% of the circulating blood volume considered "natural" other than at the time of childbirth. Although pregnancy-associated bleeding is often physiologic, hemorrhage is among the leading causes of pregnancy-related death in women worldwide, especially in developing regions of the world. Blood loss during pregnancy can approximate that lost during major trauma and can lead to disseminated intravascular coagulopathy. Virtually all organ systems, including the cardiovascular and hematologic systems, are altered during gestation, and an understanding of these changes is critical to management of the bleeding gravida. This chapter provides a review of physiologic changes in pregnancy that impact bleeding and hemostasis, risk factors for bleeding during pregnancy and delivery, and key pregnancy-related diagnoses that place women at especially high risk for massive hemorrhage. Additionally, the role of massive transfusion protocols in obstetrical and gynecological care will be discussed.