Management of Bleeding During Pregnancy

Initial Assessment and Stabilization

Assess maternal hemodynamic stability immediately, including vital signs to determine if the patient is in shock, according to Praxis Medical Insights 1
Evaluate the extent of bleeding using a combination of patient physiology, response to initial resuscitation, and shock index, as recommended by Praxis Medical Insights 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, as suggested by Praxis Medical Insights 2
Ultrasound is the mainstay for diagnosis before performing digital examination in pregnant patients with vaginal bleeding, according to Praxis Medical Insights 2

Perform transabdominal and transvaginal ultrasound with Doppler to assess for intrauterine pregnancy, ectopic pregnancy, or nonviable pregnancy in the first trimester, as recommended by Praxis Medical Insights 2
For women with bleeding disorders in the first trimester, consider fibrinogen replacement targeting levels ≥1.5 g/L in case of vaginal bleeding, as suggested by the Journal of Thrombosis and Haemostasis 3, 4

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, as recommended by Hepatology 5, 6
For active variceal hemorrhage, provide immediate resuscitation, stabilization, and emergent endoscopic therapy, according to Hepatology 5
Initiate octreotide (avoid terlipressin due to risk of uterine contractions) for variceal bleeding, as suggested by Hepatology 5, 6
Use cephalosporins for antibiotic prophylaxis in acute variceal bleeding, as recommended by Hepatology 5

For pregnant women requiring anticoagulation, subcutaneous application of LMWH or UFH is favored over oral anticoagulation, according to the European Heart Journal 7, 8
In women with mechanical heart valves at high risk of thromboembolism, consider adding low-dose aspirin, 75-100 mg/day, as suggested by Chest 9
For women with fibrinogen disorders, schedule delivery with laboratory and blood bank support if fibrinogen levels are <1 g/L in the third trimester, as recommended by the Journal of Thrombosis and Haemostasis 3, 4
Maintain fibrinogen level ≥1.5 g/L for neuraxial anesthesia and cesarean section in women with fibrinogen disorders, according to the Journal of Thrombosis and Haemostasis 3, 4

Monitor for postpartum hemorrhage, which occurs in 5%-45% of women with cirrhosis, as reported by the Journal of Hepatology 6
For women with bleeding disorders, continue clinical monitoring for 72 hours postpartum, as recommended by the Journal of Thrombosis and Haemostasis 3, 4
Consider early use of fibrinogen replacement and tranexamic acid in case of postpartum bleeding in women with fibrinogen disorders, as suggested by the Journal of Thrombosis and Haemostasis 3, 4