1. HAEMATEMSSIS IN PREGNANCY
Prof. M.C.Bansal.
MBBS.,MS.,MICOG., MICOG.
Ex Principal & Controller ,
Jhalawar medical College & hospital, Jhalawar.
MGMC & hospital Sitapura , jaipur.

2. 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.

3. 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 .

4. Severity of Haematemesis
Severity Haemoglobin Pulse rate Blood Endoscopy
Pressure
Mild Normal Normal normal Not indicated
Moderate >10 gm % > 100bpm Normal Elective
endoscopy if
possible with in
24 hrs
Severe ,10 gm % > 1oo bpm Systolic BP < Urgent , if
100 evidence of on
going bleeding
despite
resuscitation

5. Causes of Haematemesis in
general patients
Site Common Less common < 5%
oesophagus Mallory- weiss tear 10% Oesophageal varices
Oesophagitis 5-10 %
Stomach Gastric ulcer 20% Gastric Tumor
Gastric erosion
Duodenum Duodenal ulcer35% Duodenitis
Duodenal erosion
Dis ordered Warferin Chronic liver diseases
Haematemesis Heparin therapy
Miscelaneous Swallowed blood from
mouth ,nose and throat.

6. Specific Condition causing
Haematemesis 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.

10. 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.

11. 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.

12. 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.

13. Hiatus hernia & Reflux
Oesophagitis
 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.

14. 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.

15. 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.

16. Oesophageal varices ( photo
graph)

17. 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.

18. 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.

19. 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.

20. Duodenal Disordes—1. Duodenal
 Duodenal ulcers are often asymptomatic before
Ulcer
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 .

21. 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.

22. Haematemesis---Liver Causes
Portal Hypertension Portal
veinObstruction
Cause 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.

23. Cirrhosis / chronic liver
disease
 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.

24. 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.

25. 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
leukemia's ,familial or idiopathic thrombocytopenia
may some time cause haematemesis.

26. Disseminated intravascular
Coagulopathy
 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.

27. Inherited Haematological
conditions
 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.

28. Miscellaneous causes
 Scurvy usually causing swollen bleeding gums
, anemia and coetaneous patechial
hemorrhage.
 Drugs – NSAIDS AND anti coagulants .