Obstetric Hemorrhage Causes and Treatments

Obstetric hemorrhages are the most prevalent cause of maternal death. Losing a certain amount of blood after giving birth is expected, with 500 milliliters of blood loss typically accompanying vaginal birth and 1,000 milliliters common after c-section. Obstetric hemorrhages involve a much greater amount of lost blood, which can send the body into shock as blood pressure drops dramatically. If untreated, it may cause death. Affecting between one and five percent of women who give birth, the condition typically occurs within a day after delivery but can take place as far out as 12 weeks.

Among the causes of obstetric hemorrhages is antepartum bleeding, which involves placenta previa or placental abruption. The latter occurs when the placenta separates from the uterus’ inner wall before birth. Placental abruption not only cuts off nutrient and oxygen supply to the baby, often necessitating early delivery but results in heavy bleeding.

The placenta usually attaches to the top or side of the uterus’ inner wall. When placenta previa occurs, the placenta attaches lower down in the uterus, with a portion of the placental tissue covering the cervix. As a result, heavy bleeding may occur when giving birth or after delivery.

Obstetric hemorrhages often take the form of postpartum hemorrhage (PPH), and this commonly has to do with uterine contractions. Following birth, the uterus contracts, pushing the placenta, which supplies the baby with oxygen and food, out. The contractions place compressive pressure on the bleeding vessels, where the placenta is attached to the uterus. In cases where the contractions don’t have enough strength (uterine atony), the blood vessels bleed freely, and hemorrhage results. Alternatively, bleeding may continue if small pieces of placenta remain attached to the uterus.

Another risk factor for PPH is an overdistended uterus, an excessive uterus enlargement related to a large infant (above 8.8 pounds), or excessive amniotic fluid. Having more than one baby, such as twins or triplets, is also a risk factor. Overdistention of the uterus is an issue, and more than one placenta also increases bleeding risks. Preeclampsia or gestational hypertension, related to high blood pressure during pregnancy, can also cause excess bleeding. Infection, prolonged labor, and the use of drugs to induce labor are also PPH risk factors.

Less common conditions, such as blood clotting disorders and tears in uterine blood vessels or cervix or vaginal tissues, may also be involved. Placenta accreta, occurring once in every 2,500 births, involves the placenta being attached abnormally to the uterus inside and is most common when the placenta attaches over a past cesarean scar. With Placenta increta, placental tissues invade the uterine muscle, while placenta percreta involves placental tissues passing through the uterine muscle, potentially causing a rupture.

Treatment of postpartum hemorrhage centers on finding the source of the bleeding and treating it as fast as possible. Uterine contractions may be simulated either through medication or manual massage, and placental pieces removed from the uterus if necessary. A Foley catheter or Bakri balloon can also compress bleeding within the uterus. In cases where diagnostics such as ultrasound are insufficient, laparotomy surgery may be performed. This involves opening the abdomen and seeking the cause of bleeding.

A last resort measure involves a hysterectomy or removing the uterus surgically. In addition, IV fluids and blood and blood products may be rapidly deployed to prevent shock, with the patient receiving oxygen through a mask.

Cervical Cancer – Causes, Diagnosis, and Prevention

Cervical cancer centers on the uterus’ narrow lower end, which connects to the birth canal (vagina). Typically developing slowly, cervical cancer begins in the cells of the cervix. Cell changes are known as dysplasia, with abnormal cells gradually populating the cervical tissue. Not removing or eliminating such cells may spread into deeper portions of the cervix and surrounding tissue.

The cervix has two major parts, with the ectocervix being the outer portion viewable through a gynecologic exam. This is made up of squamous cells, or thin, flat cells. By contrast, the inner endocervix is made up of glandular cells that are column-shaped and produce mucus, and it is this part that connects the vagina with the uterus. Also known as the transformation zone, the squamocolumnar junction forms the border between the endocervix and ectocervix, and most cervical cancers start here.

Around 90 percent of cervical cancers are covered with cell carcinomas, forming within the ectocervix, with most of the remainder known as cervical adenocarcinomas and developing in the endocervix’s glandular cells. In cases of adenosquamous carcinoma (or mixed carcinoma), cervical cancer features both types of cells, and in extremely rare cases, it can develop in other cervical cells.

Preventing cervical cancer starts with administering human papillomavirus (HPV) vaccine, which addresses the HPV types responsible for vaginal, vulvar, and cervical cancers. This FDA-approved vaccine, Gardasil, is administered as early as age nine but is most common in the preteen years of 11 to 12. For those who start before age 15, a two-dose schedule is recommended at six to 12-month intervals. For those to begin after turning 15, a three-shot series is recommended.

If not vaccinated, the HPV vaccine is advisable for all women up to age 26. While some adult women, from age 27 through 45, take the vaccine, its benefits diminish, as a majority of women have already had some exposure to HPV by their late 20s.

Among the steps women can take to minimize HPV risks are delaying sexual intercourse until the late teens (or later), practicing safe sex, and limiting the number of sexual partners. Smoking cessation may also have a positive effect in preventing the disease.

There are three basic tests and procedures that screen for cervical cancer. The HPV test involves removing a sample of cells from the cervix, which are examined for the human papillomavirus linked with the cancer. Often combined with the former procedure, the Pap test involves examining the same sample for cell changes that can potentially develop into cancers.

Finally, visual inspection with acetic acid (VIA) involves applying diluted white vinegar to the cervix. Typically employed in places with limited medical options, this helps identify abnormalities as they turn white with exposure to vinegar.

Treating cervical cancer often involves removing cancerous tissue surgically, with chemotherapy and radiation used in conjunction to shrink or eliminate the tumor. A paper published in Gynecologic Oncology in 2023 points to the immunotherapy drug pembrolizumab, in conjunction with chemotherapy, as an effective way of reducing mortality risks among patients who have metastatic or recurrent cervical cancer. This approach harnesses the immune system’s natural cancer-fighting properties and thus is better tolerated, with fewer side effects, among many patients.