🩸 Antepartum Hemorrhage (APH)

🔷 Introduction

Antepartum hemorrhage (APH) is defined as bleeding from the genital tract after 20 weeks of gestation and before the birth of the baby(modern guidelines allow flexibility down to 24 weeks ).

🔑 Why 20 Weeks?

The 20-week mark is generally chosen because:

• Before 20 weeks → Threatened abortion or miscarriage.
• After 20 weeks → Fetus is potentially viable, and bleeding is classified as APH.

 It poses significant challenges to both the obstetrician and anesthesiologist due to the risks of maternal hypovolemia, fetal distress, emergency delivery, and hemorrhagic shock.

🔷 Causes of Antepartum Hemorrhage

🔹 Major Causes (80-90%)

🔹 Other Causes

• Vasa previa
• Local lesions (cervical polyp, carcinoma, infections)
• Uterine rupture
• Trauma

🔷 Classification of APH Severity

🔷 Clinical Features

🔷 Initial Management

• Resuscitate mother first: ABC approach
• Position: Left lateral tilt to avoid aortocaval compression
• IV access: 2 large-bore cannulas
• Bloods: CBC, crossmatch, coagulation profile, fibrinogen
• Monitoring: ECG, BP, O₂ sat, urine output
• Ultrasound to determine placental location and fetal status
• CTG: Continuous fetal monitoring
• Anti-D if Rh-negative mother

🔷 Anesthetic Considerations in APH

🔹 Goals

• Maintain maternal hemodynamic stability
• Optimize fetal oxygenation
• Prepare for massive hemorrhage
• Anticipate emergency cesarean delivery

🔷 Anesthesia for Placenta Previa (Painless APH)

• Stable patient with minor bleeding: Regional anesthesia acceptable
• Active bleeding or hemodynamic instability: General anesthesia preferred
• Be prepared for massive obstetric hemorrhage
• Consider arterial line, central line, cell salvage

🔷 Anesthesia for Placental Abruption (Painful APH)

• Commonly associated with DIC, shock, fetal distress
• General anesthesia is preferred
• Use Rapid Sequence Induction (RSI) due to aspiration risk
• Correct coagulopathy before regional anesthesia
• Tranexamic Acid (TXA): 1 g IV early

🔷 Specific Monitoring

• Arterial line: Beat-to-beat BP, blood sampling
• CVP line: Fluid and vasopressor guidance
• Foley catheter: Hourly urine output (target >0.5 mL/kg/hr)
• Temperature probe: Prevent hypothermia

🧪 Hemorrhage Management in APH

• Activate Massive Transfusion Protocol if bleeding >1500 mL or ongoing
• Maintain PRBC : FFP : Platelets = 1:1:1
• Monitor coagulation using ROTEM or TEG
• Use warm fluids, warming blankets, and infusion warmers
• Medications:
• TXA 1 g IV over 10 min
• Uterotonics after delivery
• Calcium and fibrinogen concentrate as needed

🏥 Postoperative Care

• ICU/HDU monitoring
• Continue fluid and blood component therapy
• Monitor for AKI, DIC, ARDS
• Pain control with PCA or Epidural
• Psychological support if fetal demise occurred

💡 Special Situations

🔹 Vasa Previa

• Fetal vessels traverse membranes near os
• Bleeding usually fetal → High risk of fetal exsanguination
• Requires emergency cesarean

🔹 Uterine Rupture

• Associated with previous cesarean scar
• Presents with sudden abdominal pain, bleeding, fetal distress
• Requires immediate laparotomy

💊 Drug Considerations

📚 MCQ Pearls