HAEMATEMSSIS IN PREGNANCY Prof. M.C.Bansal. MBBS.,MS.,MICOG., MICOG. Ex Principal & Controller , Jhalawar medical College & hospital, Jhalawar. MGMC & hospital Sitapura , jaipur.
Terminology ( definitions ) Haematemesis is the vomiting of blood due to bleeding from upper gestro intestinal tract. If severe enough it may give rise to melaena –the passage of black tarry stool., occurs when blood if loss is > 50 ml. Vomiting with small amount of altered blood ( coffee ground blood ) is common and of little worry. Coffee ground vomit is due to small amount of blood change into acid haematin by gastric acid. Fresh blood vomit occurs when large blood vessel bleed and is acute in on set . this is often associated with cardio vascular compromise.
Presentation Haematemesis with or without malaena There may be symptoms of dizziness , abdominal or retrosternal pain. There may be sign of shock or cardiovascular compromise .
Severity of HaematemesisSeverity Haemoglobin Pulse rate Blood Endoscopy PressureMild Normal Normal normal Not indicatedModerate >10 gm % > 100bpm Normal Elective endoscopy if possible with in 24 hrsSevere ,10 gm % > 1oo bpm Systolic BP < Urgent , if 100 evidence of on going bleeding despite resuscitation
Causes of Haematemesis ingeneral patientsSite Common Less common < 5%oesophagus Mallory- weiss tear 10% Oesophageal varices Oesophagitis 5-10 %Stomach Gastric ulcer 20% Gastric Tumor Gastric erosionDuodenum Duodenal ulcer35% Duodenitis Duodenal erosionDis ordered Warferin Chronic liver diseasesHaematemesis Heparin therapyMiscelaneous Swallowed blood from mouth ,nose and throat.
Specific Condition causingHaematemesis in Pregnancy. Pregnant women can have Haematemesis due to common reasons However their are certain conditions are to be considered which are more common in pregnancy and puerparium.1.Mallory –Weiss tear e.g. a mucosal tear at oesophago-gastric junction due to forceful vomiting.2. Oesophagitis with or without Hiatus hernia.3. Gastric / duodenal ulcer or erosion.4. injudicious use of NSAIDs.
Management of Haematemesis (A) History taking-History and examination will give the most likely source of haematemesis.1. If vomitings occurred before bleeding , it may be due to a mallory- weiss tear .2.Significant reflux symptoms may point towards oesophagitis with or without an associated hiatus hernia.3. those with ch.Peptic ulcer will give history of dyspepsia or treatment taken for ulceration. Peptic ulcer disease usually become silent during pregnancy but their perforation incidences increase significantly.
Management------ 4.Histry of habituation of alcohol and physical signs of cirrhosis of liver may indicate varices , although fertility may be significantly reduced in such women.(B) . Full blood count ,clotting, urea, electrolytes and liver function tests along with blood grouping and cross match.(C) .Intra venous fluids ( crystalloid / colloids ) , resuscitative measures., blood transfusion if severe. (D). Nil by mouth , if moderate to severe. (E)Give appropriate antacid medication. (F) Gastro-enterologist review.
Swallowed blood Bleeding from nose , gums , mouth and throat may be swallowed and later vomited , masquerading as blood loss from further down the GIT. Except in epistaxis such bleeding will be small. Careful questioning and examination will often elucidate the source and prevent the need of endoscopy. Pregnancy is associated with gingivitis and bleeding gums, but it is rarely severe enough to cause blood vomit.
Hiatus hernia & RefluxOesophagitis Hiatus hernia is common finding cases of epigastric pain in pregnancy. Owing to the increased intra abdominal pressure and relaxant effect of progesterone on smooth muscles in pregnancy ,the incidence of both hiatus hernia and reflux oesophagitis is increased. This causes retrosternal discomfort , water wash and haematemesis (some times Treatment includes small frequent meals, upright position after meals, raise the head end of bed , appropriate acid suppression.
Mallory- Weiss Tear A mucosal tear at oesophagigastric junction due to forceful vomiting can result in haematemesis. 70-85 % pregnant women do have nausea and vomiting in early pregnancy but usually will not cause mucosal tear and blood vomit . Hyper emesis however cause intractable vomiting , which usually occurs in 8-12 weeks’ gestation . Incidence is very low ( 0.5- 2 % ). Due to sustained nature of vomiting , there is increased risk of delicate mucosa. Treatment is to control vomiting and occasionally Mallory –Weiss tear need injection of sclerotherapy at endoscopy . H. pylori infection if present also need its eradication.
Oesophageal Varices Varices develop as a result of portal hypertension ., commonly due to cirrhosis of liver(alcoholic ) and portal vein thrombosis. Bleeding from varices is often brisk , requiring prompt resuscitation and endoscopic therapy (bending /sclerotherapy ) Physiological changes that occur in pregnancy can exacerbate the pre existing liver disease. To avoid complications, known cirrhotics should be prepared for pregnancy with endoscopic eradication of varices . B –blocker anti hypertensive drugs are relatively contra indicated in pregnancy.
Stomach—1, gastric Ulcer. There is no particular association between pregnancy and peptic ulcer. Symptoms prior to haematemesis includes epigastric pain more so immediately after food and anorexia. Association with NSAID’s ,H.pylori.(60%). These ulcer usually do not perforate during pregnancy, but incidence increases in puerparium. H.pylory eradication treatment and avoiding self medication with NSAID’s will be the best approach to manage these cases.
Stomach—2.Acute Gastritis In acute gastritis bleeding may be from mucosal erosion, tear , ulcer , hence it is small in amount. Patient often complains of nausea, dyspepsia epigastric pain and vomiting. NSAID’S are common to cause bleeding from erosive gastritis. Alcohol, irritant food, ingestion of corrosive liquids by depressive personality , mental tension and over anxiousness are the other contributory factors. Acute tropical infections leading to gastritis include dengue, yellow fever , variola and black water fever. Qunine derivatives commonly used for treating malaria do cause acute gastritis . Avoiding the gastric mucosa irritants and antacids will suffice to treat them.
Stomach—3. Rarities Angiodysplasia.—idiopathic or associated with aortic stenosis or Osler –Weber- Rendu syndrome( autosomal dominant inheritance , characterized by angiodysplastic lesions in mucosal membrane.) Dieulafoy’s lesion –bleeding vessel with no surrounding ulceration.
Duodenal Disordes—1. Duodenal Duodenal ulcers are often asymptomatic beforeUlcer bleeding occurs owing to the ulcer eroding the vessel present in its bed. Classically the pain if present , is epigastric radiates to back and is worse some hours after eating. 73-95 % are associated with H. pylori infection. Its treatment includes a proton pump inhibitor and 2 antibiotics (tetracycline and metro diazoles), As with gastric ulcer it may bleed profusely and initial treatment include quick resuscitation and endoscopy .
Duodenal—2. Duodenitis. Inflammation of duodenum can also lead to haematemesis , but less severe . Once again H.pylori should be exclude and if present , it needs its eradication by appropriate and adequate therapy.
Haematemesis---Liver Causes Portal Hypertension Portal veinObstructionCause of portal, vein thrombosis is not know in 8-15 % cases, it can complicate in Eclampsi a.Malignancy, systemic infection and myelo proliferatve disease are the other causes.Patient may present with haematemesis from oesophageal varices , hepatosplenomegaly and pain in right upper quadrant.Bleeding is better tolerated and there is no toxic encephalopathy in these case as in cirrhotic patients.Treatment is endoscopic ablation of varies.
Cirrhosis / chronic liverdisease Cirrhotic patients are relatively infertile due to deranged metabolism of steroid hormone. Haematemesis may occur from oesophageal and or gastric varices, Bleeding is often made worse by associated thrombocytopenia an vit K deficiency or coagulation abnormalities.
Disordered haemostasis Many medical conditions can lead to disordered haemostasis. , some or which are associated with pregnancy. Commonest being the treatment with coumarin ( warfarin ) or heparin, used in cases of DVT , Pulmonary embolism , Prosthetic valves in valvular heart disease etc.
Thrombocytopenia Low platelets count are found in 7-8 % of pregnant women , most of time it is simply a mild degree gestational thrombocytopenia and does not cause haematemesis as platelet count seldom go down to critical low level (< 50000/cmm). HELLP syndrome, eclampsia , missed abortion, IUFD , Accidental Hemorrhage ,DIC and Molar pregnancy may cause haematemesis. Concomitant diseases with pregnancy like leukemias ,familial or idiopathic thrombocytopenia may some time cause haematemesis.
Disseminated intravascularCoagulopathy In DIC , there is wide spread activation of coagulation cascade leading to platelet and many clotting factor’s consumption. Obstetrical causes include abruptio placenta ,amniotic fluid embolism ,post partum hemorrhage, retained dead tissue of fetus in uterus and septicemia. Haematemesis is uncommon complication in pregnancy associated DIC as DIC is usually short lived in these situations.
Inherited Haematologicalconditions Von wiilebrand’s disease dominant or recessive leads to defective platelet function and thus it leads to epistaxis , bruising and bleeding after minor trauma However haematemesis or other types of GI bleeding is rare.
Miscellaneous causes Scurvy usually causing swollen bleeding gums , anemia and coetaneous patechial hemorrhage. Drugs – NSAIDS AND anti coagulants .