Obstetric Emergencies: Haemorrhage and Pre-eclampsia
Obstetrics and Gynaecology — Obstetric Emergencies, NMC MBBS licence examination syllabus (Nepal Medical Council).
Obstetric emergencies: two patients, one set of observations
A young woman compensates beautifully — right up until she does not.
Obstetric emergencies are unusual in medicine for two reasons. There are two patients, and the one you can examine is usually healthy — young, fit, with no comorbidity and an expanded blood volume. That combination produces a specific and dangerous pattern: she compensates extremely well, then decompensates abruptly.
So the observations that would reassure you in a 70-year-old mean something different here. A normal blood pressure in a bleeding pregnant woman is not evidence that the bleeding is modest; it is evidence that her compensatory reserve has not yet been exhausted. This chapter is largely about reading those signals correctly, and about the small number of actions that must happen before the diagnosis is complete.
🩺 Where this lives: Postpartum haemorrhage remains one of the leading direct causes of maternal death worldwide, and the great majority of those deaths are considered preventable. What kills is rarely a failure of knowledge about the four Ts — it is delay: delay in recognising how much blood has been lost, delay in calling for help, delay in getting blood products moving. In settings where transfusion and theatre are not immediately available, that delay compounds. Recognising early and escalating early is the intervention.
💡 A note on doses. This chapter gives none. Magnesium sulphate, uterotonic and antihypertensive regimens are protocol-driven, differ between national guidelines, and are given under time pressure. Learn the principles and the sequence here; take every number from your local protocol.
Why pregnant patients mislead you
Two practical consequences follow. First, tachycardia is the early sign and hypotension is very late — the same principle as the shock chapter, but more extreme, because the reserve is larger. Second, after about 20 weeks a supine woman compresses her own inferior vena cava with the gravid uterus, so left lateral tilt is part of resuscitation, not a comfort measure. A collapsed pregnant woman lying flat may not respond to anything else until she is tilted.
Bleeding before delivery
💡 Exam angle: no digital vaginal examination until placenta praevia has been excluded by ultrasound. This is one of the few absolute prohibitions in clinical medicine, and it appears in questions constantly — a woman with painless bright red bleeding, and an option offering vaginal examination as the next step. Examining a praevia can provoke torrential haemorrhage. Speculum examination may be performed once praevia is excluded.
DISTINGUISHING FEATURES, AND WHY
PLACENTA PRAEVIA — placenta over or near the internal os
Bleeding is from the placental edge as the lower segment
forms and stretches, so it is PAINLESS and the uterus
stays soft. The loss you see reflects the loss there is.
ABRUPTION — placenta separates from the uterine wall
Blood collects behind the placenta and irritates the
myometrium → PAIN and a hard, tender uterus.
Because blood is trapped behind the placenta, the
visible loss UNDERSTATES the true loss — which is why
shock appears out of proportion to what is seen.
Both threaten the fetus. Both require senior obstetric
involvement, resuscitation and fetal assessment.
ALSO CONSIDER: vasa praevia (fetal vessels — small
maternal loss with rapid fetal compromise) and local
causes such as cervical lesions, which do not excuse
skipping the assessment above.
Bleeding after delivery
MANAGING POSTPARTUM HAEMORRHAGE
CALL FOR HELP EARLY — obstetric, anaesthetic, haematology,
and activate the major haemorrhage pathway. This is the
step whose absence appears in most maternal death reviews.
RESUSCITATE
Large-bore access, bloods including crossmatch and
clotting, warmed fluids and blood products guided by
protocol. Tranexamic acid early in obstetric haemorrhage.
STOP THE BLEEDING — mechanical first, because it is
immediate and free:
Rub up the fundus — bimanual uterine massage
EMPTY THE BLADDER — a full bladder prevents the
uterus contracting, and catheterisation is
repeatedly forgotten
Uterotonic drugs per protocol
Examine for tears and retained tissue
Escalate to balloon tamponade, surgical measures
such as compression sutures or vessel ligation,
and hysterectomy as a last resort
MEASURE THE LOSS PROPERLY. Visual estimation
systematically UNDER-estimates, often by half. Weigh
swabs and use collection drapes where available.
The single most useful bedside habit in postpartum haemorrhage: feel the uterus. A soft, boggy uterus means atony — rub it up and give uterotonics. A firm, well-contracted uterus with continued bleeding means the cause is not tone, and you should be looking for a tear or retained tissue instead of giving more uterotonic.
Pre-eclampsia and eclampsia
KEY PRINCIPLES
IT IS A MULTISYSTEM DISORDER of placental origin, not a
blood pressure problem with proteinuria attached.
SEVERE FEATURES that demand urgent action
Severe hypertension · severe headache · visual changes
Epigastric or right upper quadrant pain · vomiting
Clonus and brisk reflexes · reduced urine output
Low platelets · deranged liver enzymes · pulmonary oedema
HELLP SYNDROME
Haemolysis, Elevated Liver enzymes, Low Platelets.
May present with epigastric pain and vomiting and be
mistaken for gastritis — in a pregnant woman, epigastric
pain is pre-eclampsia until proven otherwise.
MAGNESIUM SULPHATE
The drug for preventing and treating eclamptic seizures.
NOT diazepam, NOT phenytoin — this is examined.
Monitor for toxicity: loss of deep tendon reflexes is an
early sign, then respiratory depression. Reduced urine
output raises the risk because magnesium is renally
excreted. Calcium gluconate is the antidote.
CONTROL SEVERE HYPERTENSION to prevent maternal stroke —
labetalol, nifedipine or hydralazine per protocol.
DELIVERY is the definitive treatment, timed against
gestation and severity, with steroids for fetal lung
maturity where prematurity allows.
IT DOES NOT END AT DELIVERY. Eclampsia occurs postpartum,
sometimes days later. Continue monitoring and warn the
woman what to report.
Other emergencies to recognise
🔍 Presentations that must not be missed
Ectopic pregnancyAny woman of reproductive age with abdominal pain, collapse or unexplained shock needs a pregnancy test. A ruptured ectopic can present with shoulder-tip pain from diaphragmatic irritation and shock disproportionate to the visible loss. This is the pregnancy test that gets forgotten in a general emergency department.
Sepsis in pregnancy and the puerperiumPhysiological tachycardia masks it, and it progresses rapidly. Sources include chorioamnionitis, endometritis, urinary tract, wound and mastitis. Treat by the sepsis chapter's principles, with a lower threshold.
Venous thromboembolismPregnancy is prothrombotic and VTE is a leading direct cause of maternal death. Breathlessness or pleuritic pain in a pregnant or recently delivered woman warrants active exclusion, not reassurance.
Cord prolapseAn obstetric emergency: relieve pressure on the cord, position the woman to reduce compression, and deliver urgently. Time matters in minutes.
Shoulder dystociaRecognised when the head delivers and the shoulders do not. Managed by a defined sequence of manoeuvres — call for help and follow the drill rather than pulling.
Amniotic fluid embolismRare, sudden cardiovascular collapse with coagulopathy around delivery. Largely supportive management; recognition is the contribution.
Clinical reasoning: four presentations
🔍 Case 1 — the examination that must not happen
PresentationA woman at 32 weeks has sudden painless bright red vaginal bleeding. Uterus soft and non-tender. Observations are normal. A colleague prepares to perform a digital vaginal examination to assess the cervix.
TrapReflex examination of a bleeding patient.
ReasoningPainless bleeding with a soft uterus suggests placenta praevia. Digital examination can dislodge the placenta from the os and provoke catastrophic haemorrhage.
AnswerNo digital examination. Resuscitate as needed, obtain urgent ultrasound to locate the placenta, involve senior obstetric help, assess the fetus, and give anti-D if she is rhesus negative. Normal observations do not indicate a small bleed.
🔍 Case 2 — the firm uterus
PresentationTwenty minutes after a forceps delivery there is steady heavy bleeding. The uterus is firm and well contracted. Two doses of uterotonic have been given with no change.
Key clueA well-contracted uterus that keeps bleeding.
ReasoningIf tone were the problem the uterus would be soft. A firm uterus with ongoing loss points to trauma — a vaginal or cervical tear, plausible after instrumental delivery — or retained tissue.
AnswerStop escalating uterotonics and examine for tears under adequate analgesia and lighting, with senior help. Check the placenta is complete. Resuscitate and activate the major haemorrhage pathway in parallel.
🔍 Case 3 — the epigastric pain
PresentationA woman at 35 weeks reports two days of epigastric pain and vomiting. She is treated for gastritis. Blood pressure 158/104, urinalysis shows protein, platelets 88, ALT raised.
TrapEpigastric pain in pregnancy read as a gastrointestinal complaint.
ReasoningEpigastric or right upper quadrant pain in pre-eclampsia arises from hepatic capsular stretch. With hypertension, proteinuria, thrombocytopenia and raised transaminases, this is HELLP syndrome.
AnswerUrgent obstetric involvement, magnesium sulphate for seizure prophylaxis, control of severe hypertension, and planning for delivery. In a pregnant woman, epigastric pain is pre-eclampsia until proven otherwise.
🔍 Case 4 — the forgotten test
PresentationA 27-year-old presents to a general emergency department with lower abdominal pain and syncope. Pulse 118, BP 96/60, abdomen tender. She says her periods are irregular and she is "probably not pregnant".
Key clueA woman of reproductive age with pain and shock.
ReasoningA ruptured ectopic pregnancy presents exactly like this, with intraperitoneal blood loss and shock disproportionate to any external bleeding. Patient report is not a substitute for a test.
AnswerUrgent pregnancy test as part of the initial assessment, resuscitation, and immediate gynaecological involvement if positive. A pregnancy test in any woman of reproductive age with abdominal pain or collapse is a habit worth building.
Commonly confused
Confusion
The distinction
Why it matters
Normal observations vs stable patient
Pregnant women compensate then crash
Tachycardia is early; hypotension is very late.
Praevia vs abruption
Painless soft uterus versus painful hard uterus
One forbids vaginal examination; both threaten the fetus.
Visible loss vs actual loss
Abruption conceals blood; estimation under-reads
Shock out of proportion is the clue.
Soft vs firm uterus in PPH
Soft means tone; firm means trauma or tissue
Stops you giving uterotonics for a tear.
Epigastric pain vs gastritis
In pregnancy, think pre-eclampsia and HELLP
Delays diagnosis of a rapidly progressive disease.
Magnesium vs diazepam for eclampsia
Magnesium sulphate is the drug
A frequently examined and clinically important choice.
Delivery vs resolution
Eclampsia occurs postpartum
Monitoring continues after the baby is born.
Rapid revision
MUST-KNOW FACTS
1. Two patients — but resuscitating the mother is how you help the fetus.
2. Pregnancy raises blood volume, so compensation is excellent and collapse abrupt.
3. Tachycardia is early; hypotension is a LATE sign.
4. After 20 weeks, LEFT LATERAL TILT is part of resuscitation.
5. Blood loss is systematically UNDER-estimated by visual assessment.
6. Antepartum haemorrhage = bleeding after 24 weeks.
7. Praevia: PAINLESS, soft uterus, visible loss proportionate.
8. Abruption: PAINFUL, hard tender uterus, loss may be CONCEALED.
9. NO digital vaginal examination until praevia is excluded.
10. Give anti-D to rhesus-negative women with antepartum bleeding.
11. PPH causes — the four Ts: TONE, TISSUE, TRAUMA, THROMBIN.
12. Atony (tone) is by far the commonest cause.
13. Feel the uterus: soft = atony; firm and bleeding = trauma or tissue.
14. Empty the bladder — a full bladder prevents uterine contraction.
15. Tranexamic acid early in obstetric haemorrhage.
16. Call for help early — delay is what appears in maternal death reviews.
17. Pre-eclampsia is MULTISYSTEM, not just blood pressure and protein.
18. Severe features: headache, visual change, epigastric pain, clonus,
low platelets, deranged LFTs, oliguria.
19. HELLP: Haemolysis, Elevated Liver enzymes, Low Platelets.
20. Epigastric pain in pregnancy is pre-eclampsia until proven otherwise.
21. MAGNESIUM SULPHATE for eclamptic seizures — not diazepam, not phenytoin.
22. Magnesium toxicity: lost reflexes first, then respiratory depression;
calcium gluconate is the antidote.
23. Delivery is the only cure — but eclampsia can occur POSTPARTUM.
24. Pregnancy test in ANY woman of reproductive age with pain or collapse.
25. Pregnancy is prothrombotic — VTE is a leading direct cause of maternal death.
💡 Exam angle: the reliable threads are (a) normal observations not reassuring in an obstetric bleed, (b) no vaginal examination before excluding praevia, (c) the firm uterus pointing away from atony, (d) epigastric pain meaning HELLP, and (e) magnesium sulphate rather than a conventional anticonvulsant. Notice how many are the same shape as the rest of this stream — a reassuring finding that is not reassuring at all.
Syllabus points
Pregnancy physiology and why it masks deterioration
Left lateral tilt as part of resuscitation
Antepartum haemorrhage: praevia versus abruption
Why vaginal examination is prohibited before ultrasound
Postpartum haemorrhage and the four Ts
Managing postpartum haemorrhage and estimating loss
Pre-eclampsia as a multisystem disorder
Severe features and HELLP syndrome
Magnesium sulphate and its toxicity
Delivery, and why eclampsia occurs postpartum
Ectopic pregnancy, sepsis and thromboembolism
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