= Solution
\b[Classify the bleeding by anatomical source and by its relation to <pregnancy>, childbirth and <menstruation>; treatment must address that source.] The amount of visible genital <haemorrhage> does not measure all the loss: a ruptured <ectopic pregnancy> or concealed <placental abruption> can cause major internal <blood loss>. Initial assessment of severe bleeding concerns the circulation, <anaemia> and the need for resuscitation while the cause is established. Bleeding from the <urethra> or <rectum> must first be distinguished from genital bleeding.
\b[Local sources outside the uterine cavity.] The <vulva> and <vagina> may bleed from lacerations after childbirth or other trauma, an inflamed lesion, a foreign body, a vascular lesion or <cancer>. Examination localizes the loss; treatment is local compression and repair of a significant laceration, removal of the foreign body, cause-directed treatment of <infection>, or specialist management of the lesion. A <cervical polyp>, <cervical ectropion>, <cervicitis> or <cervical cancer> can cause bleeding from the <cervix>, often noticed between periods or after intercourse. A suitable <polyp> can be removed and examined; inflammation requires its cause to be established, while a suspicious lesion requires diagnostic assessment rather than indiscriminate cauterization. After menopause, thin, fragile vulvovaginal tissues can also bleed; this does not remove the need to investigate a suspicious lesion. These are different conditions, not one disease called “uterine <haemorrhage>”. <Vaginal Bleeding by Merck Manual>[Etiology, examination and cause-directed treatment of vulvar, vaginal and cervical bleeding]{ref}
\b[Bleeding from the <endometrium>.] Heavy or irregular <menstruation> may accompany <ovulatory dysfunction>, <uterine fibroids>, <endometrial polyps>, <adenomyosis>, a <coagulopathy>, medication effects or <endometrial cancer>. Modern assessment includes the menstrual and drug history, a full <blood count>, and selected <ultrasound>, <hysteroscopy> or tissue sampling according to the suspected cause. Where appropriate, menstrual bleeding can be reduced with <tranexamic acid> or hormonal treatment; an intracavitary <polyp> or <uterine fibroid> may instead need targeted removal. Persistent postmenopausal bleeding must not simply be treated as an ordinary period. <Heavy menstrual bleeding by NICE>[NG88 §§1.2–1.5: assessment, blood count, selected investigation and medical or surgical treatment]{ref}
\b[Early <pregnancy>.] A <miscarriage> may bleed while <pregnancy> tissue separates or remains in the <uterus>. In a stable, confirmed case, expectant, medical or surgical management may be appropriate; heavy continuing loss or <infection> changes the urgency. <Ectopic pregnancy> requires a separate plan: selected stable cases may be monitored or treated medically, but rupture with haemorrhagic collapse requires urgent operative control, not treatment of the <vagina> as though it were the principal source. A <hydatidiform mole> is another <pregnancy>-related source of abnormal bleeding; current management includes removal by suction evacuation and subsequent <human chorionic gonadotropin> surveillance for persistent disease. <Gestational Trophoblastic Disease Treatment by NCI>[Hydatidiform moles: bleeding, evacuation and biochemical follow-up]{ref} <Bleeding During Pregnancy by ACOG>[Early pregnancy loss, ectopic pregnancy and the distinction between vaginal and internal bleeding]{ref} <Ectopic pregnancy and miscarriage by NICE>[NG126, management of tubal ectopic pregnancy and diagnostic precautions]{ref}
\b[Later <pregnancy> and labour.] <Placenta praevia> commonly produces relatively painless bleeding, whereas <placental abruption> more often causes pain and uterine tenderness; these are useful patterns, not infallible rules. Management depends on the mother's circulation, the <fetus>, the placental lesion and the stage of <pregnancy>, with urgent delivery when required. A blind digital cervical examination is inappropriate before a possible <placenta praevia> has been excluded. Ruptured <vasa praevia> causes fetal rather than maternal bleeding and demands a different interpretation. A small <blood>-stained mucous “show” during cervical change is not equivalent to these pathological losses. <Antepartum Haemorrhage by the Royal College of Obstetricians and Gynaecologists>[Green-top 63, history, examination and management; exclusion of placenta praevia before digital examination]{ref} <Placenta praevia, placenta accreta and vasa praevia by the Royal College of Obstetricians and Gynaecologists>[Vasa praevia and fetal bleeding]{ref}
\b[After delivery.] The principal categories are failure of <uterine contraction>, retained <placental tissue>, trauma and disordered <coagulation>. For <uterine atony>, the aim is to restore contraction with uterine massage and an appropriate <uterotonic>. Retained tissue, a genital laceration or <uterine inversion> requires correction of that particular cause; a <coagulopathy> requires haemostatic support. With <placenta accreta spectrum>, attempted forcible separation can provoke severe <haemorrhage>. Current care combines resuscitation with cause-directed measures, and can require <tranexamic acid>, balloon tamponade, embolisation or <surgery> when initial measures fail. Later postpartum bleeding also raises retained tissue and <endometritis>. <Heavy bleeding after birth by RCOG>[Causes and treatment, including retained placenta, uterine contraction, trauma and escalation]{ref}
\b[The 1865 distinction.] An answer of the period could distinguish menstrual loss, local lesions, <pregnancy>-related <haemorrhage> and post-delivery failure of contraction through the history and physical examination. Compression, local plugging, removal of an accessible lesion and obstetric intervention were among the available approaches; their use was debated. The 1864 discussion of <placenta praevia> documents such disagreement. Modern imaging, <blood> banking, the present drug regimens and current operative pathways must not be attributed to that practice. Nor should historical astringents or depletion be substituted for identifying the source. <Midwifery in the Edinburgh Medical Journal (September 1864)>[pp. 262–268, discussion of placenta praevia and competing methods of management]{ref}
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